围手术期肺误吸：泰国麻醉事件监测研究（泰国AIMS）28份报告的分析

Perioperative pulmonary aspiration: an analysis of 28 reports from the Thai Anesthesia Incident Monitoring Study (Thai AIMS).

作者信息

Klanarong Sireeluck, Suksompong Sirilak, Hintong Thanu, Chau-In Waraporn, Jantorn Prasatnee, Werawatganon Thewarug

机构信息

Department of Anesthesiology, Buddhachinaraj Hospital, Phitsanulok, Thailand.

出版信息

J Med Assoc Thai. 2011 Apr;94(4):457-64.

PMID:21591531

Abstract

OBJECTIVE

To study the patients' characteristics, outcomes, contributory factors, factors minimizing the incidence and suggested corrective strategies for perioperative pulmonary aspiration in Thailand.

MATERIAL AND METHOD

This is a prospective descriptive research design. The relevant data was extracted from the incident reports on aspiration from 51 hospitals across Thailand during the study period between January 1 and June 30, 2007 from the Thai Anesthesia Incident Monitoring Study (Thai AIMS) database. Descriptive statistics was used. Each incident report was reviewed by three senior anesthesiologists. Any disagreement was discussed to achieve a consensus.

RESULTS

From 1,996 incident reports, there were 28 reports (1.4%) that met the definition of pulmonary aspiration. Most of the incidents occurred in patients with ASA 1-2 (85.7%), during the official hour (64.3%) and the anesthesiologists were in charge (67.9%). Eleven incidents (39.3%) occurred during induction, seven (25%) during maintenance and seven (25%) during emergence phases. Anesthetic factors played an important role in 26 incidents (92.9%). All the incidents except one (96.4%) were considered human errors and 25 (89.2%) were preventable. Of the incidents caused by human errors, nine (32.1%) were caused by skill-based errors. Thirteen patients (46.4%) had major physiologic changes and 10 (35.7%) of them needed unplanned ICU admission. Ten patients (35.7%) needed prolonged ventilator support and two (7.14%) of them died.

CONCLUSION

The contributing factors that might lead to the incidents were improper decision (75%), lack of experience (53.5%) and lack of knowledge (21.4%). Factors minimizing incident, were vigilance (85.7%), having experienced assistant (50%) and experience in that situation (25%). Suggested preventive strategies were guidelines practice in anesthetic management (67.8%), improvement of supervision (57.1%), additional training (42.8%) and quality assurance activity (28.6%).

摘要

目的

研究泰国围手术期肺误吸患者的特征、结局、促成因素、降低发生率的因素及建议的纠正策略。

材料与方法

这是一项前瞻性描述性研究设计。相关数据取自泰国麻醉事件监测研究（Thai AIMS）数据库中2007年1月1日至6月30日研究期间泰国51家医院的误吸事件报告。采用描述性统计方法。每份事件报告由三位资深麻醉医师进行审核。如有分歧，则进行讨论以达成共识。

结果

在1996份事件报告中，有28份（1.4%）符合肺误吸的定义。大多数事件发生在ASA 1 - 2级患者中（85.7%），在正常工作时间内（64.3%）且由麻醉医师负责（67.9%）。11起事件（39.3%）发生在诱导期，7起（25%）发生在维持期，7起（25%）发生在苏醒期。麻醉因素在26起事件（92.9%）中起重要作用。除1起事件外，所有事件（96.4%）均被认为是人为失误，25起（89.2%）是可预防的。在人为失误导致的事件中，9起（32.1%）是由基于技能的失误引起的。13名患者（46.4%）出现了严重的生理变化，其中10名（35.7%）需要非计划入住重症监护病房。10名患者（35.7%）需要延长呼吸机支持时间，2名（7.14%）死亡。

结论

可能导致这些事件的促成因素包括决策不当（75%）、经验不足（53.5%）和知识欠缺（21.4%）。降低事件发生率的因素包括警惕性（85.7%）、有经验的助手（50%）和在该情况下的经验（25%）。建议的预防策略包括麻醉管理中的指南实践（67.8%）、加强监督（57.1%）、额外培训（42.8%）和质量保证活动（28.6%）。