Domino K B, Posner K L, Caplan R A, Cheney F W
Department of Anesthesiology, University of Washington School of Medicine, and the Virginia Mason Medical Center, Seattle 98195, USA.
Anesthesiology. 1999 Apr;90(4):1053-61. doi: 10.1097/00000542-199904000-00019.
Awareness during general anesthesia is a frightening experience, which may result in serious emotional injury and post-traumatic stress disorder. We performed an in-depth analysis of cases from the database of the American Society of Anesthesiologists Closed Claims Project to explore the contribution of intraoperative awareness to professional liability in anesthesia.
The database of the Closed Claims Project is composed of closed US malpractice claims that have been collected in a standardized manner. All claims for intraoperative awareness were reviewed by the reviewers to identify patterns of causation and standard of care. Logistic regression analysis was used to identify independent patient and anesthetic factors associated with claims for recall during general anesthesia compared to other general anesthesia malpractice claims.
Awareness claims accounted for 79 (1.9%) of 4,183 claims in the database, including 18 claims for awake paralysis, i.e., the inadvertent paralysis of an awake patient, and 61 claims for recall during general anesthesia, ie., recall of events while receiving general anesthesia. The majority of awareness claims involved women (77%), younger than 60 yr of age (89%), American Society of Anesthesiologists physical class I-II (68%), who underwent elective surgery (87%). Most (94%) claims for awake paralysis represented substandard care involving errors in labeling and administration, whereas care was substandard in only 43% of the claims for recall during general anesthesia (P < 0.001). Claims for recall during general anesthesia were more likely to involve women (odds ratio [OR] = 3.08, 95% confidence interval [CI] = 1.58, 6.06) and anesthetic techniques using intraoperative opioids (OR = 2.12, 95% CI = 1.20, 3.74), intraoperative muscle relaxants (OR = 2.28, 95% CI = 1.22, 4.25), and no volatile anesthetic (OR = 3.20, 95% CI = 1.88, 5.46).
Deficiencies in labeling and vigilance were common causes for awake paralysis. Claims for recall during general anesthesia were more likely in women and with nitrous-narcotic-relaxant techniques.
全身麻醉期间知晓是一种可怕的经历，可能导致严重的情感伤害和创伤后应激障碍。我们对美国麻醉医师协会封闭索赔项目数据库中的病例进行了深入分析，以探讨术中知晓对麻醉专业责任的影响。
封闭索赔项目数据库由以标准化方式收集的美国医疗事故结案索赔组成。所有术中知晓索赔均由评审人员进行审查，以确定因果关系模式和护理标准。与其他全身麻醉医疗事故索赔相比，采用逻辑回归分析来确定与全身麻醉期间回忆索赔相关的独立患者和麻醉因素。
在数据库的4183例索赔中，知晓索赔占79例（1.9%），包括18例清醒麻痹索赔，即清醒患者的意外麻痹，以及61例全身麻醉期间回忆索赔，即接受全身麻醉时对事件的回忆。大多数知晓索赔涉及女性（77%）、年龄小于60岁（89%）、美国麻醉医师协会身体状况分级为I-II级（68%）且接受择期手术的患者（87%）。大多数（94%）清醒麻痹索赔代表护理不达标，包括标签和给药错误，而全身麻醉期间回忆索赔中只有43%护理不达标（P<0.001）。全身麻醉期间回忆索赔更有可能涉及女性（优势比[OR]=3.08，95%置信区间[CI]=1.58，6.06）以及使用术中阿片类药物的麻醉技术（OR=2.12，95%CI=1.20，3.74）、术中肌肉松弛剂（OR=2.28，95%CI=1.22，4.25）和未使用挥发性麻醉剂（OR=3.20，95%CI=1.88，5.46）。
标签和警惕性不足是清醒麻痹的常见原因。全身麻醉期间回忆索赔在女性以及采用氧化亚氮-麻醉性镇痛药-肌肉松弛剂技术的患者中更常见。
