Watterson L M, Morris R W, Westhorpe R N, Williamson J A
Sydney Medical Simulation Centre, Royal North Shore Hospital, St Leonards, New South Wales, Australia.
Qual Saf Health Care. 2005 Jun;14(3):e9. doi: 10.1136/qshc.2002.004481.
Bradycardia in association with anaesthesia may have many potential causes and associated conditions, some rare and/or obscure. A prompt appropriate response is important as some homeostatic mechanisms may be impaired under anaesthesia.
To examine the role of a previously described core algorithm "COVER ABCD-A SWIFT CHECK", supplemented by a specific sub-algorithm for bradycardia, in the management of bradycardia occurring in association with anaesthesia.
The potential performance of this structured approach for each of the relevant incidents among the first 4000 reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual management as reported by the anaesthetists involved.
From the first 4000 incidents reported to AIMS, 265 reports which described bradycardia during anaesthesia were extracted and studied. Bradycardia was associated with hypotension in 51% of cases, cardiac arrest in 25% of cases and hypertension in one case. In 22% of reports apparent desaturation or an abnormality of ventilation was described. Bradycardia was caused by drug events (28%), airway related events (16%), autonomic reflexes (14%), and regional anaesthesia (9%). Airway and drug events caused 75% of cases involving children. It was considered that, correctly applied, the core algorithm COVER would have diagnosed 53 cases (20%) and led to corrective management in 45 (85%) of these; this included an important subset of airway and ventilation problems. Completion of COVER ABCD-A SWIFT CHECK followed by the specific sub-algorithm for bradycardia would have resulted in diagnosis and appropriate management in all but two cases. It would have led to earlier recognition of the problem and/or better management in 11 cases (4%) when compared with the actual management described in the reports.
Steps should be taken to manage bradycardia whilst associated conditions are managed concurrently. Analysis of cardiac rhythm should not be pursued to the exclusion of supportive therapy. The use of a structured approach in the management of bradycardia associated with anaesthesia is likely to improve management in the small percentage of cases in which the diagnosis of the cause may be missed or delayed.
与麻醉相关的心动过缓可能有许多潜在原因及相关情况，其中一些罕见和/或不明确。由于某些体内平衡机制在麻醉状态下可能受损，迅速做出恰当反应很重要。
研究先前描述的核心算法“COVER ABCD-A SWIFT CHECK”（辅以针对心动过缓的特定子算法）在处理与麻醉相关的心动过缓中的作用。
将这种结构化方法对向澳大利亚事件监测研究（AIMS）报告的前4000起相关事件中每起事件的潜在表现，与参与的麻醉师报告的实际处理情况进行比较。
从向AIMS报告的前4000起事件中，提取并研究了265份描述麻醉期间心动过缓的报告。心动过缓在51%的病例中与低血压相关，25%的病例中与心脏骤停相关，1例与高血压相关。在22%的报告中描述了明显的血氧饱和度下降或通气异常。心动过缓由药物事件（28%）、气道相关事件（16%）、自主反射（14%）和区域麻醉（9%）引起。气道和药物事件导致75%涉及儿童的病例。据认为，正确应用核心算法COVER可诊断出53例（20%），并使其中45例（85%）得到纠正处理；这包括气道和通气问题的一个重要子集。完成COVER ABCD-A SWIFT CHECK后接着采用针对心动过缓的特定子算法，除两例之外所有病例均可得到诊断和恰当处理。与报告中描述的实际处理情况相比，在11例（4%）病例中它可使问题得到更早识别和/或更好处理。
在处理相关情况的同时应采取措施处理心动过缓。不应为了分析心律而排除支持性治疗。在处理与麻醉相关的心动过缓时采用结构化方法，可能会改善在一小部分可能漏诊或延误病因诊断的病例中的处理情况。
