Lee Ji-Hyun, Kim Eun-Kyung, Song In-Kyung, Kim Eun-Hee, Kim Hee-Soo, Kim Chong-Sung, Kim Jin-Tae
Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea.
Paediatr Anaesth. 2016 Apr;26(4):409-17. doi: 10.1111/pan.12862. Epub 2016 Feb 20.
Analysis of critical incidents provides valuable information to improve the quality and safety of patient care. This study identified and analyzed pediatric anesthesia-related critical incidents including cardiac arrests in a tertiary teaching children's hospital.
All pediatric anesthesia-related critical incidents reported in a voluntary departmental reporting system between January 2008 and August 2013 were included in the analysis. A critical incident was defined as (i) any incident that altered patients' vital signs and affected the management of patients while they were under the care of an anesthesiologist, and (ii) human factor: where patient injury or accidents were as a result of human error. Changes in vital signs that recovered spontaneously were excluded.
During the 6-year study period, a total of 229 critical incidents were reported from 49,373 anesthetic procedures. The most frequently reported incidents were associated with the respiratory system (55%), with tracheal tube-related events accounting for 40.9% of respiratory incidents followed by laryngospasm (17.3% of respiratory incidents). Cardiac arrest occurred in 42 cases in this study (8.5 cases per 10,000 anesthetics). Cardiovascular problems were the major causes of cardiac arrest (66.7%), and incidents of cardiogenic shock and hemorrhage/hypotension contributed equally to the cardiac arrest induced by cardiovascular problems (each 16.7%). Human factor-related events accounted for 58.5% of all critical incidents of which 53.7% were respiratory events.
Despite recent improvements in safety of pediatric anesthesia, many preventable factors still remain that can lead to critical incidents.
对危急事件的分析可为提高患者护理质量和安全性提供有价值的信息。本研究在一家三级教学儿童医院中识别并分析了与儿科麻醉相关的危急事件，包括心脏骤停。
分析纳入了2008年1月至2013年8月期间在一个自愿性科室报告系统中报告的所有与儿科麻醉相关的危急事件。危急事件定义为：(i) 在麻醉医生护理患者期间，任何改变患者生命体征并影响患者管理的事件；(ii) 人为因素：患者受伤或发生事故是人为错误导致的。自发恢复的生命体征变化被排除。
在6年的研究期间，49373例麻醉手术中共报告了229起危急事件。报告最频繁的事件与呼吸系统相关(55%)，其中气管导管相关事件占呼吸系统事件的40.9%，其次是喉痉挛(占呼吸系统事件的17.3%)。本研究中有42例发生心脏骤停(每10000例麻醉中有8.5例)。心血管问题是心脏骤停的主要原因(66.7%)，心源性休克和出血/低血压事件对心血管问题导致的心脏骤停的贡献相同(各占16.7%)。人为因素相关事件占所有危急事件的58.5%，其中53.7%为呼吸系统事件。
尽管近年来儿科麻醉安全性有所提高，但仍存在许多可导致危急事件的可预防因素。
