Morisot P
Département d'Anesthésie-Réanimation, GH Cochin Port Royal, Paris.
Cah Anesthesiol. 1991;39(4):239-42.
We report a review of closed insurance claims for local and regional anaesthesia mishaps in the main private professional insurance companies. Twenty eight cases with extensive written documentation were discovered, spanning a 6 years interval between 1983 and 1989, involving 21 epidural, 6 spinal and 1 caudal anaesthesias, half with surgical and half obstetrical indication, and excluding all other blocks. Twenty four out of the 28 patients were relatively healthy. ASA I or II, only 4 ASA III. They fitted 4 items of our taxonomy of known complications: 15 cardiac arrests, 10 neurological damages, 1 systemic toxic reaction to local anaesthetic drug and 1 allergic reaction to dextran. The cardiac arrests resulted primarily from the 3 following or contributing factors: hypovolemia (in 3 cases), added sedation (7) and high or total spinal block following reinforcing doses (8). Twenty two had a poor outcome: 8 deaths, 7 severe neurological injuries, a baby was dead and another child had severe neurobehavioral sequellae. The author points out the limitation of this study--a biased sample of all adverse events and inability to derive an incidence. However some of these events reveal patterns of anaesthetic management which lead to poor outcomes.
我们报告了对主要私营专业保险公司中局部和区域麻醉事故的封闭保险索赔进行的一项综述。发现了28例有详尽书面记录的病例,时间跨度为1983年至1989年的6年,涉及21例硬膜外麻醉、6例脊髓麻醉和1例骶管麻醉,其中一半有外科手术指征,一半有产科指征,且排除了所有其他阻滞。28例患者中有24例相对健康,ASA分级为I或II级,只有4例为ASA III级。它们符合我们已知并发症分类法中的4项:15例心脏骤停、10例神经损伤、1例对局部麻醉药的全身毒性反应和1例对右旋糖酐的过敏反应。心脏骤停主要由以下3个后续或促成因素导致:血容量不足(3例)、额外使用镇静剂(7例)以及追加剂量后发生高位或全脊髓阻滞(8例)。22例预后不良:8例死亡、7例严重神经损伤、1名婴儿死亡,另一名儿童有严重神经行为后遗症。作者指出了本研究的局限性——所有不良事件的样本存在偏差,且无法得出发病率。然而,其中一些事件揭示了导致不良预后的麻醉管理模式。