Analysis of Intraoperative Cardiac Arrests
Rather than studying perioperative mortality associated with anesthesia,
several studies have evaluated intraoperative fatal and nonfatal cardiac arrests
[22]
[69]
[70]
[71]
[72]
[73]
[74]
[75]
[76]
[77]
( Table
24-11
). In this situation, there are sufficient numbers of complications
to perform an analysis at a single institution. Keenan and Boyan[78]
studied the incidence and causes of cardiac arrest related to anesthesia at the Medical
College of Virginia during a 15-year period. There were a total of 27 cardiac arrests
during 163,240 procedures, for an incidence of 1.7 per 10,000 cases. Fourteen patients
died, for an incidence of 0.9 per 10,000 cases. Pediatric patients had a threefold
higher risk of arrest than adults did; emergency cases had a sixfold greater risk.
Specific errors in anesthesia management could be identified in 75% of cases, most
commonly inadequate ventilation and absolute overdose of an inhaled anesthetic.
The time of day did not appear to influence the rate of anesthesia-related cardiac
arrest. From an educational perspective, the investigators identified progressive
bradycardia preceding all but one arrest, suggesting that early identification and
treatment may prevent complications.
Olsson and Hallen[79]
studied
the incidence of intraoperative cardiac arrests at the Karolinska Hospital in Stockholm,
Sweden, from 1967 to 1984. A total of 170 arrests occurred in 250,543 anesthesia
procedures performed. Sixty patients died, resulting in a mortality rate of 2.4
per 10,000 procedures. After elimination of cases of inevitable death (e.g., rupture
of a cerebral aneurysm, trauma), the rate of mortality caused by anesthesia was 0.3
deaths per 10,000 procedures. The most common causes of anesthesia-related cardiac
arrest were inadequate ventilation (27 patients), asystole after succinylcholine
(23 patients), and postinduction hypotension (14 patients). The incidence of cardiac
arrest increased with increasing severity of comorbid disease, as assessed by the
ASA physical status classification. In evaluating the incidence of intraoperative
cardiac arrest over time, there was a considerable decline between 1967 and 1984,
coincident with the increased number of anesthesia specialists employed at the clinic.
Biboulet and colleagues[77]
studied
fatal and nonfatal cardiac arrests encountered during anesthesia and during the first
12 postoperative hours in the PACU or ICU in
TABLE 24-11 -- Cardiac arrest series when the denominator is more than 40,000 anesthetics
|
Study |
Years |
Total No. of Anesthetics |
Rate of Arrest |
|
Hanks and Papper[69]
|
1947–1950 |
49,728 |
1:2162 |
|
Ehrenhaft et al.[70]
|
1942–1951 |
71,000 |
1:2840 |
|
Bonica[71]
|
1945–1952 |
90,000 |
1:6000 |
|
Blades[72]
|
1948–1952 |
42,636 |
1:21,318 |
|
Hewlett et al.[73]
|
1950–1954 |
56,033 |
1:2061 |
|
Briggs et al.[74]
|
1945–1954 |
103,777 |
1:1038 |
|
Keenan and Boyan[78]
|
1969–1978 |
107,257 |
1:6704 (P) |
|
Cohen et al.[76]
|
1975–1983 |
112,721 |
1:1427 (C) |
|
Tiret et al.[61]
|
1978–1982 |
198,103 |
1:3358 (C) |
|
Tiret et al.[61]
|
1978–1982 |
198,103 |
1:11,653 (P) |
|
Keenan and Boyan[78]
|
1979–1988
*
|
134,677 |
1:9620 (P) |
|
Newland et al.[22]
|
1989–1999 |
72,959 |
1:14,493 (P) |
|
Newland et al.[22]
|
1989–1999 |
72,959 |
1:7299 (C) |
|
C, contributory cause; P, primary cause. |
|
Adapted from Brown DL: Anesthesia risk: A historical
perspective. In Brown DL (ed): Risk and Outcome
in Anesthesia, 2nd ed. Philadelphia, JB Lippincott, 1992. |
*Since
pulse oximetry was introduced in 1984, no "preventable respiratory" cardiac arrests
have occurred.
a single hospital in France. Eleven cardiac arrests related to anesthesia were identified
among 101,769 anesthesia procedures (1.1 per 10,000). The mortality rate related
to anesthesia was 0.6 per 10,000 cases. The major causes of death were anesthetic
overdose, hypovolemia, and hypoxemia; 10 of the 11 cases had at least one human error,
and all were classified as avoidable.
Newland and colleagues[22]
reported
anesthesia-related cardiac arrests from 72,959 procedures over a 10-year period in
a teaching hospital in the United States. They judged that 15 cardiac arrests of
a total of 144 were related to anesthesia (0.69 per 10,000 procedures), and in an
additional 10 cases, anesthesia was considered contributory, for a total rate of
1.37 per 10,000 procedures (95% CI: 0.52–2.22). The risk of death related
to anesthesia-attributable perioperative cardiac arrest was 0.55 per 10,000 procedures.
Most of the arrests were related to medication administration, airway management,
or technical problems of central venous access.
Cardiac arrests may be related to quality of care. The ability
to resuscitate patients from an intraoperative cardiac arrest may reflect the skills
of the care providers. Additional research is required to determine the validity
of such an approach.
