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2012 年至 2016 年麻醉期间意外事件的发生率:日本麻醉师学会对与麻醉相关事件的调查。

Incidence of accidental events during anesthesia from 2012 to 2016: survey on anesthesia-related events by the Japanese Society of Anesthesiologists.

机构信息

Okayama University Hospital, 2-5-1, Kitaku, Shikatacho, Okayama, Japan.

出版信息

J Anesth. 2021 Apr;35(2):206-212. doi: 10.1007/s00540-021-02898-9. Epub 2021 Feb 10.

Abstract

PURPOSE

The Japanese Society of Anesthesiologists (JSA) has conducted surveys on life-threatening accidental events during anesthesia and reported results since 1992. This report describes the incidence of these life-threatening accidental events in the survey period between 2012 and 2016.

METHODS

JSA conducts an annual survey on accidental events. Each participating facility reports life-threatening accidental events that occurred each year. Facilities accredited by the JSA can electronically report events using the JSA Perioperative Information Management System (JSA-PIMS) software program that interfaces with the electronic anesthesia record system.

RESULTS

The number of cardiac arrest events per 10,000 anesthesia cases gradually decreased from 2.97 in 2012 to 2.30 in 2016 (odds ratio OR 0.77 95% CI 0.68-0.88). The number of severe hypotension events per 10,000 anesthesia cases gradually decreased from 4.63 in 2012 to 4.24 in 2016 (OR 0.92, 95% CI 0.83-1.01). The number of severe hypoxia events per 10,000 anesthesia cases gradually decreased from 2.01 in 2012 to 1.59 in 2016 (OR 0.79, 95% CI 0.68-0.92). The number of life-threatening arrhythmia events per 10,000 anesthesia cases was 1.14 in 2012. Thereafter, it tended to decrease slightly to 0.88 in 2016 (OR 0.77, 95% CI 0.63-0.95).

CONCLUSION

The incidence of cardiac arrest during this period was 2.63/10,000, which was lower the incidence reported in other countries. While no change was observed in the incidence of severe hypotension over the survey period, the incidence of severe hypoxia and life-threatening arrhythmia decreased by 20-25% during those 5 years.

摘要

目的

日本麻醉师学会(JSA)自 1992 年以来一直在进行关于麻醉期间危及生命的意外事件的调查,并报告了调查结果。本报告描述了 2012 年至 2016 年调查期间这些危及生命的意外事件的发生率。

方法

JSA 每年进行一次意外事件调查。每个参与的医疗机构都报告每年发生的危及生命的意外事件。JSA 认证的医疗机构可以使用与电子麻醉记录系统接口的 JSA 围手术期信息管理系统(JSA-PIMS)软件程序电子报告事件。

结果

每 10000 例麻醉病例中心脏骤停事件的数量从 2012 年的 2.97 例逐渐减少到 2016 年的 2.30 例(比值比 OR 0.77,95%CI 0.68-0.88)。每 10000 例麻醉病例中严重低血压事件的数量从 2012 年的 4.63 例逐渐减少到 2016 年的 4.24 例(OR 0.92,95%CI 0.83-1.01)。每 10000 例麻醉病例中严重低氧血症事件的数量从 2012 年的 2.01 例逐渐减少到 2016 年的 1.59 例(OR 0.79,95%CI 0.68-0.92)。每 10000 例麻醉病例中危及生命的心律失常事件的数量为 2012 年的 1.14 例。此后,它略有下降,至 2016 年的 0.88 例(OR 0.77,95%CI 0.63-0.95)。

结论

在此期间,心脏骤停的发生率为 2.63/10000,低于其他国家的报告发生率。虽然在调查期间严重低血压的发生率没有变化,但严重低氧血症和危及生命的心律失常的发生率在这 5 年内下降了 20-25%。

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