Brazilian Journal of Anesthesiology
https://app.periodikos.com.br/journal/rba/article/doi/10.1590/S0034-70942003000600013
Brazilian Journal of Anesthesiology
Miscellaneous

Incidentes críticos em anestesia no Uruguai - dez anos após: estudo comparativo (1990-2000)

Critical anesthetic incidents in Uruguay - ten years after: comparative study (1990-2000)

Manuel da Fonte Bello; Gladys Miriam Lejbusiewicz Liberman; Gonzalo Manuel Barreiro Escudero

http://dx.doi.org/10.1590/S0034-70942003000600013 Braz J Anesthesiol, vol.53, n6, p.814-832, 2003
PDF
Downloads: 0
Views: 917

Resumo

JUSTIFICATIVA E OBJETIVOS: Descreve-se uma pesquisa sobre Incidentes Críticos (IC) em Anestesia. Os resultados encontrados em 2000 são comparados aos de 1990, na busca de variações de padrão de IC ao longo da década. MÉTODO: Foram utilizados 2 formulários diferentes. No primeiro (F1), constava uma lista pré-determinada de incidentes críticos para que os pesquisados apontassem com quais tinham tido algum tipo de contato para o estudo de freqüência relativa de cada incidente. No segundo (F2), solicitava-se a descrição de um incidente em particular, a critério do pesquisado. RESULTADOS: No F1 de 2000, foram assinalados 9.482 IC, em que os 13 mais freqüentes constituíram 50% de todas as ocorrências do período. Os resultados foram muito similares aos de 1990, já que dentre os mais freqüentes, 9 repetem-se em ambas as investigações. Os incidentes que alcançaram os primeiro e segundo lugares também se repetem: intubação difícil e disritmia cardíaca. Em F2 foram descritos 20% de IC com conseqüência mortal. Cinqüenta e quatro por cento das mortes deveram-se a 5 IC: parada cardíaca inesperada, tromboembolismo pulmonar, infarto agudo de miocárdio, aspiração de vômito e choque hipovolêmico. Quarenta e seis por cento dos IC foram de origem respiratória e 24% tiveram origem hemodinâmica. Destaca-se um aumento significativo de IC na recuperação e no pós-operatório imediato. A observação clínica do paciente foi responsável pela detecção de 63% dos IC. Comprova-se um aumento substancial dos IC relatados como imprevisíveis. CONCLUSÕES: Manteve-se a diversidade de incidentes críticos com diminuição dos fenômenos respiratórios. Este segue sendo o grupo mais freqüente. Há uma clara redução dos acidentes graves hipóxicos vinculados à intubação esofágica e óxido nitroso como gás único. Manteve-se a gravidade dos incidências hemodinâmicos.

Palavras-chave

ANESTESIOLOGIA, COMPLICAÇÕES, COMPLICAÇÕES, COMPLICAÇÕES, COMPLICAÇÕES

Abstract

BACKGROUND AND OBJECTIVES: A survey of Critical Incidents (CI) in Anesthesia is described. Year 2000 results are compared to those obtained in 1990 in search for CI pattern changes throughout this decade. METHODS: Two different forms were used: the first, F1, was a list of predetermined CI to determine the relative frequency of each incident. The second, F2, requested the description of a specific incident chosen by the respondent. RESULTS: In F1 forms, 9482 CI were recorded and the 13 most frequent CI accounted for 50% of events. Results were very similar to those found in 1990, since among the most frequent, 9 CI were repeated in both surveys. First and second most common incidents were also repeated: difficult intubation and arrhythmias. In form F2, 20% of CI had fatal consequences. Five CI accounted for 54% of deaths were due to 5 CI: unexpected cardiac arrest, pulmonary thromboembolism, acute myocardial infarction, vomiting aspiration and hypovolemic shock. Respiratory incidents accounted for 46% of CI, and 24% were due to hemodynamic causes. It is to be noted a significant CI increase during recovery and in the immediate postoperative period. Patients’ clinical observation accounted for 63% CI detection. A substantial increase in unpredictable events has been identified. CONCLUSIONS: CI diversity was maintained with decreased respiratory events, although these are still the most frequent. There is a sharp decrease in severe hypoxia accidents related to esophageal intubation and nitrous oxide as single gas. Hemodynamic incidents severity was maintained.

Keywords

ANESTHESIOLOGY, COMPLICATIONS, COMPLICATIONS, COMPLICATIONS, COMPLICATIONS

Referencias

Knight III P, Bacon D. An unexplained death: hannah greener and chloroform. Anesthesiology. 2002;96:1250-1253.

Buck N, Devlin HB, Lunn JN. The Report of a Confidential Enquiry into Perioperative Deaths. 1987.

Newland M, Ellis S, Lydiatt C. Anesthestic-related cardiac arrest and its mortality: a report covering 72,959 anesthetics over 10 years from a US Teaching Hospital. Anesthesiology. 2002;97:108-115.

Biboulet P, Aubas P, Dubourdieu J. Fatal and no fatal cardiac arrests related to anesthesia. Can J Anesth. 2001;48:326-332.

Morray JP, Geiduschek JM, Ramamoorthy C. Anesthesia-related cardiac arrest in children. Anesthesiology. 2000;93:6-14.

Flanagan JC. The critical incident technique. Psychol.Bull. 1954;51:327-358.

Cooper JB, Newbower RS, Long CD. Preventable anesthetic mishaps: a study of human factors. Anesthesiology. 1978;49:399-406.

Barreiro G, Garat J. Incidentes críticos em anestesia. Rev Bras Anestesiol. 1992;42:357-376.

Cheney F, Weiskopf R. The American Society of Anesthesiologists closed claims project: what have we learned, how has it affected practice, and how will it affect practice in the future?. Anesthesiology. 1999;91:552-556.

Rutstein DD, Berenberg W, Chalmers TC. Measuring the quality of medical care: a clinical method. New Engl J Med. 1976;294:582-588.

Webb RK, Currie M, Morgan CA. The Australian incident monitoring study: an analysis of 2000 incident reports. Anaesth Intensive Care. 1993;21:520-528.

Clergue F, Auroy Y, Peguinot F. French survey of Anesthesia in 1996. Anesthesiology. 1999;91:1509-1520.

Runciman WB. Incident Monitoring. Clinical Anaesthesiology. 1996;10:333-356.

Bartolomé A, Gómez-Arnau JI. Incidentes Críticos en Anestesia. Tratado de Anestesia y Reanimación. 2001:23-45.

Posner K, Cheney W. Current Spectrum of Anesthetic Injury. Anesthesia & Perioperative Complications. 1999:752-759.

Caplan R, Vistica M, Posner K. Adverse anesthetic outcomes arising from gas delivery equipment: a closed claims analysis. Anesthesiology. 1997;87:741-745.

Litvan H, Jensen EW, Maestre ML. Comparison of an auditory evoked potentials index and a bispectral index versus clinical signs for determining the depth of anesthesia produced by propofol or sevoflurane. Rev Esp Anestesiol Reanim. 2000;47:447-457.

Johansen J, Sebel P, Fisher D. Development and clinical application of electroencephalographic bispectrum monitoring. Anesthesiology. 2000;93:1336-1344.

Reinerstein JL. Let’s talk about error: leaders should take responsability for mistakes. BMJ. 2000;320:730.

Garat J, Barreiro G. Parada cardiaca inesperado em anestesia. Rev Bras Anestesiol. 1993;43:119-127.

Barreiro G. Edema agudo de pulmón postobstructivo en anestesia. Anest. Analg Reanim. 2001;17:77-84.

Pasternak LR, Arens JF, Caplan R. Practice advisory for preanesthesia evaluation. a report by the American Society of Anesthesiologists task force on preanesthesia evaluation. Anesthesiology. 2002;96:485-496.

Gaba D. Anesthesiology as a model for patient safety in health care. BMJ. 2000;320:785-788.

Cheney F. Changing trends in anesthesia-related death and permanent brain damage. ASA Newsletter. 2002;66:6-8.

Lema M. America the suable. ASA Newsletter. 2002;66:1.

To err is human: Building a safer health system. Washington DC. BMJ. 2000;320:788-91.

Reason J. Human error: models and management. BMJ. 2000;320:768-770.

Small S. Reframing the question of human error: tools to navigate the next era in anesthesia safety. ASA Refresher Courses. 2001;29:229-233.

Bates DW. Using information technology to reduce rates of medication errors in hospitals. BMJ. 2000;320:788-791.

5ddc400c0e8825ae20f2c91e rba Articles
Links & Downloads
2352-2291 (Electrónico) 0104-0014 (Impreso)
Braz J Anesthesiol ©2024 Todos los derechos reservados.

Braz J Anesthesiol

Share this page
Page Sections