Arbous M S, Grobbee D E, van Kleef J W, de Lange J J, Spoormans H H, Touw P, Werner F M, Meursing A E
Department of Anaesthesia, Leiden University Medical Center, Leiden, The Netherlands.
Anaesthesia. 2001 Dec;56(12):1141-53. doi: 10.1046/j.1365-2044.2001.02051.x.
From a prospectively defined cohort of patients who underwent either general, regional or combined anaesthesia from 1 January 1995 to 1 January 1997 (n = 869 483), all consecutive patients (n = 811) who died within 24 h or remained unintentionally comatose 24 h after anaesthesia were classified to determine a relationship with anaesthesia. These deaths (n = 119; 15%) were further analysed to identify contributing aspects of the anaesthetic management, other factors and the appropriateness of care. The incidence of 24-h peri-operative death per 10 000 anaesthetics was 8.8 (95% CI 8.2-9.5), of peri-operative coma was 0.5 (0.3-0.6) and of anaesthesia-related death 1.4 (1.1-1.6). Of the 119 anaesthesia-related deaths, 62 (52%) were associated with cardiovascular management, 57 (48%) with other anaesthetic management, 12 (10%) with ventilatory management and 12 (10%) with patient monitoring. Inadequate preparation of the patient contributed to 30 (25%) of the anaesthesia-related deaths. During induction of anaesthesia, choice of anaesthetic technique (n = 18 (15%)) and performance of the anaesthesiologist (n = 8 (7%)) were most commonly associated with death. During maintenance, the most common factors were cardiovascular management (n = 43 (36%)), ventilatory management (n = 12 (10%)) and patient monitoring (n = 12 (10%)). In both the recovery and the postoperative phases, patient monitoring was the most common factor (n = 12 (10%) for both). For cardiovascular, ventilatory and other anaesthetic management, human failure contributed to 89 (75%) deaths and organisational factors to 12 (10%). For inadequate patient monitoring, human factors contributed to 71 (60%) deaths and organisational factors to 48 (40%). Other contributing factors were inadequate communication (30 deaths (25%) for all four aspects of the anaesthetic management) and lack of supervision (particularly for ventilatory management). Inadequate care was delivered in 19 (16%) of the anaesthesia-related deaths with respect to cardiovascular management, in 20 (17%) with respect to ventilatory management, in 18 (15%) with respect to patient monitoring and in 23 (19%) with respect to other anaesthetic management.
从1995年1月1日至1997年1月1日接受全身麻醉、区域麻醉或联合麻醉的前瞻性定义队列患者（n = 869483）中，对所有在麻醉后24小时内死亡或在麻醉后24小时仍处于无意识昏迷状态的连续患者（n = 811）进行分类，以确定与麻醉的关系。对这些死亡病例（n = 119；15%）进行进一步分析，以确定麻醉管理的促成因素、其他因素以及护理的适宜性。每10000例麻醉中24小时围手术期死亡的发生率为8.8（95%CI 8.2 - 9.5），围手术期昏迷的发生率为0.5（0.3 - 0.6），与麻醉相关死亡的发生率为1.4（1.1 - 1.6）。在119例与麻醉相关的死亡病例中，62例（52%）与心血管管理相关，57例（48%）与其他麻醉管理相关，12例（10%）与通气管理相关，12例（10%）与患者监测相关。患者准备不足导致30例（25%）与麻醉相关的死亡。在麻醉诱导期间，麻醉技术的选择（n = 18（15%））和麻醉医生的操作（n = 8（7%））最常与死亡相关。在维持期间，最常见的因素是心血管管理（n = 43（36%））、通气管理（n = 12（10%））和患者监测（n = 12（10%））。在恢复和术后阶段，患者监测都是最常见的因素（两者均为n = 12（10%））。对于心血管、通气和其他麻醉管理，人为失误导致89例（75%）死亡，组织因素导致12例（10%）死亡。对于患者监测不足，人为因素导致71例（60%）死亡，组织因素导致48例（40%）死亡。其他促成因素包括沟通不足（麻醉管理的所有四个方面共30例（25%）死亡）和缺乏监督（特别是通气管理）。在与麻醉相关的死亡病例中，19例（1б%）在心血管管理方面护理不足，20例（17%）在通气管理方面护理不足，18例（15%）在患者监测方面护理不足，23例（19%）在其他麻醉管理方面护理不足。
