Caplan R A, Ward R J, Posner K, Cheney F W
Department of Anesthesiology, University of Washington, School of Medicine, Seattle 98195.
Anesthesiology. 1988 Jan;68(1):5-11. doi: 10.1097/00000542-198801000-00003.
Fourteen cases of sudden cardiac arrest in healthy patients who received spinal anesthesia were discovered in a preliminary review of 900 closed insurance claims for major anesthetic mishaps. All patients were resuscitated from the intraoperative cardiac arrest, but six suffered such severe neurologic injury that they died in hospital. Of the eight survivors, only one exhibited sufficient neurologic recovery to allow independence in daily self-care. In view of the unexpected nature of the cardiac arrests, as well as the ultimate severity of injury, these cases were analyzed in detail to determine whether there were recurring patterns of management that may have contributed to the occurrence or outcome of these anesthetic mishaps. Two patterns were identified. The first was the intraoperative use of sufficient sedation to produce a comfortable-appearing, sleep-like state in which there was no spontaneous verbalization. Cyanosis frequently heralded the onset of cardiac arrest in patients exhibiting this degree of sedation, suggesting that unappreciated respiratory insufficiency may have played an important role. The second pattern appeared to be an inadequate appreciation of the interaction between sympathetic blockade during high spinal anesthesia and the mechanisms of cardiopulmonary resuscitation. Prompt augmentation of central venous filing through the use of a potent alpha-agonist and positional change might have improved organ perfusion, shortened the duration of cardiac arrest, and lessened the degree of neurologic damage.
在对900例重大麻醉事故的封闭保险理赔申请进行初步审查时，发现了14例接受脊髓麻醉的健康患者发生心脏骤停的病例。所有患者均从术中心脏骤停中复苏，但有6例遭受了严重的神经损伤，最终在医院死亡。在8名幸存者中，只有1例神经功能恢复到足以使其能够独立进行日常自我护理。鉴于心脏骤停的意外性质以及最终的损伤严重程度，对这些病例进行了详细分析，以确定是否存在可能导致这些麻醉事故发生或结果的反复出现的处理模式。确定了两种模式。第一种是术中使用足够的镇静剂，使患者呈现出舒适的、类似睡眠的状态，在此状态下患者不会自发发声。在表现出这种程度镇静的患者中，发绀常常预示着心脏骤停的发生，这表明未被察觉的呼吸功能不全可能起到了重要作用。第二种模式似乎是对高位脊髓麻醉期间交感神经阻滞与心肺复苏机制之间的相互作用认识不足。通过使用强效α受体激动剂和改变体位迅速增加中心静脉血容量，可能会改善器官灌注，缩短心脏骤停持续时间，并减轻神经损伤程度。
