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Reported anaesthetic complications during an 11-year period. A retrospective study.

Retrospectively 120 anaesthetic complications with potential medicolegal consequences were reviewed. Seven deaths occurred. Eighty percent of the complications were potentially avoidable. Of the complications 4.4% resulted in major morbidity and 82.3% in intermediate morbidity. Dental injuries were reported with an annual frequency of six. The use of pulse oximetry and/or capnography could possibly have prevented 18% of all complications apart from dental injuries. Ten cases were reported to the National Swedish Board of Health and Welfare; four cases resulted in disciplinary consequences. The influence of human factors on the development of complications is stressed.

Anesthesia↗

Poikilocapnic hypoxic ventilatory response in humans during 0.85 MAC isoflurane anesthesia.

Ventilatory responses to hypoxia (HVR) were investigated using poikilocapnic conditions (i.e. end-tidal CO2's allowed to seek it's own level) in 15 cardio-pulmonary healthy patients who were first studied awake and then at 0.85 MAC isoflurane. The influence of hypercapnia (HyperCapnic Ventilatory Response, HCVR) was also elucidated. Pneumotachography, capnography and airway occlusion pressures at 0.1 s (P degree 0.1) were used before and during both mild hypoxia (end-tidal O2 tension 8.7 kPa) and hypercapnia achieved by an inspired CO2 concentration of 5%. HCVR was attenuated by 60% during anesthesia (P < 0.01). In the awake state, five of the 15 patients decreased HVR during hypoxia as compared with during normoxia. This resulted in a VE that on average increased by 0.6 l.min-1 (P < 0.05) whereas P degree 0.1 was unchanged. In the anesthetized state, no case of decreased HVR was seen and hypoxia induced a mean VE increase (+/- s.d.) by 1.0 +/- 0.2 l.min-1 (P < 0.001) and a P degree 0.1 that on average was improved by 0.63 +/- 0.27 cm H2O (P < 0.01). It is suggested that when the aim is to evaluate the influence of volatile anesthetic agents on HVR and to quantitate its clinical relevance during and immediately after anesthesia, a poikilocapnic technique should be used. It is concluded that the poikilocapnic HVR to PEO2's of 8.7 kPa was maintained during 0.85 MAC isoflurane.

Adult↗

Hypoxic and hypercapnic ventilatory responses during isoflurane sedation and anaesthesia in women.

This study primarily examined the effect of three endtidal isoflurane concentrations (0.2, 1.0 and 1.4%) on the isocapnic hypoxic ventilatory response (HVR), as well as the hypercapnic ventilatory response (HCVR), in 18 women (ASA I) who were all in the follicular phase of their menstrual cycle. Capnography was used, together with pulseoximetry to indicate desired levels of hypoxia (SpO2 75-80%). This hypoxic challenge resulted, after 3-4 min, in a stable ventilation, and ventilation measurements were then taken during a 90 s period. The HCVR provocation (inhalation of 4.5% CO2 in air) and measurements were conducted using a similar time frame as for HVR. Isoflurane 0.2% did not affect any ventilatory parameter. Isoflurane 1.0 and 1.4% dose-dependently increased endtidal CO2 and respiratory rate, while tidal volumes decreased. Minute ventilation was not reduced. HVR, as well as HCVR, were both uninfluenced by isoflurane 0.2%. HVR was reduced by 60-70% at isoflurane 1.4% (P < 0.01), and was parallelled by a similar depression of HCVR (P < 0.01). The HVR during anaesthesia was accomplished by a respiratory rate response, while the increase in tidal volume, seen in the awake state, was abolished. The HCVR during anaesthesia was, on the other hand, the result of a dose-dependently depressed tidal volume response, without any increase in respiratory rate. In conclusion, isoflurane 0.2% did not affect the ventilatory response to mild isocapnic hypoxia, nor to mild hypercapnic challenge. During anaesthesia with isoflurane (1.0 and 1.4%), there was a parallel reduction of HVR and HCVR.

Adult↗

Isoflurane anaesthesia (0.6 MAC) and hypoxic ventilatory responses in humans.

In order to evaluate the difference between poikilo-capnic (no CO2 added to inspired gas) and iso-capnic (CO2 added to keep end-tidal CO2 constant) hypoxic ventilatory responses (HVR) awake and during 0.6 MAC isoflurane anaesthesia, seven cardio-pulmonary healthy patients were investigated. Pneumotachography and capnography were used before and during hypoxia (end-tidal O2 tension approx. 7 kPa). In the awake state, poikilo-capnic hypoxic challenges resulted in an increased HVR as indicated by a VE that on average increased by 1.4 +/- 1.0 (mean +/- s.d.) l.min-1, whereas the iso-capnic hypoxic challenges resulted in a VE increase that was 4.7 +/- 2.3 l.min-1 on average. In the anaesthetized state, the corresponding value during poikilocapnia was 1.3 +/- 0.8 l.min-1 (88% of the awake responses, n.s.) and during iso-capnia 2.3 +/- 1.4 l.min-1 (49% of the awake, P < 0.02). Awake HVR was achieved by greater tidal volumes during poikilocapnia as well as during isocapnic challenges, while respiratory rates were unchanged. In the anaesthetized state, during poikilocapnia, however, HVR was mediated by an increased respiratory rate, (from 17.5 +/- 1.7 breath.min-1 to 20.2 +/- 2.2) and during isocapnia by a combination of increased rate (from 17.1 +/- 1.9 breath.min-1 to 19.1 +/- 1.8) and tidal volume (from 496 +/- 80 to 560 +/- 83 ml). It is concluded that poikilocapnic HVR is maintained at 0.6 MAC isoflurane whereas iso-capnic HVR is depressed by 50%.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

Nitric oxide administration after the ventilator: evaluation of mixing conditions.

BACKGROUND: Because of the potential toxicity of nitric oxide (NO) and its oxidising product nitrogen dioxide (NO2), any system for the delivery of inhaled NO must aim at stable and predictable levels of NO and as low concentrations as possible of NO2. METHODS: In a laboratory set-up, we have evaluated mixing conditions in a system where NO is added after the ventilator with continuous flow. Mixing was studied by using carbon dioxide (CO2) as a tracer gas since capnography has a short response time (360 ms) in comparison with measurements of NO with electrochemical fuel cells (response time of 18 s). CO2 (in volumes corresponding to an ideal mixture of 1, 3 and 6%) was fed, after the ventilator, either into plain breathing tubing, into one or two soda lime absorbers, or into an empty and a soda lime-filled canister, at different ventilatory rates and different I:E ratios. Samples were drawn from the inspiratory limb close to the Y-piece. NO was added in the same way and in the same volume as the highest concentration of CO2. RESULTS: CO2 added to plain tubing resulted in peak levels up to five times the set levels, while addition to a mixing box with an empty and a soda lime-filled canister resulted in even mixing with gas concentrations close to the ideal. When NO was fed into plain tubing, low levels were measured at the Y-piece, indicating poor mixing. Gas supply to a mixing chamber resulted in even concentrations. CONCLUSION: Even and predictable levels of NO can be obtained with continuous flow of NO to the inspiratory limb, after the ventilator, if a mixing chamber is used. To obtain adequate mixing, the volume of the mixing box should be greater than the tidal volume.

Carbon Dioxide↗

Propofol anesthesia in spontaneously breathing children undergoing magnetic resonance imaging: comparison of two propofol emulsions.

BACKGROUND: This study evaluated a propofol-based anesthesia regimen with spontaneous breathing in pediatric patients scheduled for magnetic resonance imaging (MRI). METHODS: In this prospective, randomized, double-blind study propofol formulated with long-chain triglycerides (LCT) and mixed medium-chain/long-chain triglycerides (MCT/LCT) were used. Ninety patients aged 2.4 months to 7.3 years were premedicated with intravenous midazolam. Lidocaine was injected prior to propofol to reduce injection pain. Anesthesia was induced and maintained by propofol. Glycopyrronium bromide was administered for saliva reduction. Hemodynamics, blood oxygen saturation and endtidal capnography were continuously monitored. All patients received additional oxygen. The aggregated propofol dose for induction and maintenance of anesthesia was analyzed for therapeutic equivalence. Incidence of injection pain, laboratory safety values, vital signs, and the adverse event profile were analyzed to compare tolerability and safety. RESULTS: Propofol anesthesia was safe and successful in all children. Both propofol formulations were equivalent regarding dose requirements (mean induction and maintenance doses for anesthesia 2.0-4.0 mg.kg(-1) and 6.0-8.8 mg.kg(-1).h(-1) respectively; aggregated doses 8-13.26 mg.kg(-1)). There were no differences in drug safety such as hemodynamics, spontaneous breathing, injection pain, and laboratory values. Duration of induction and of recovery from anesthesia were short and all examinations were completed with minimal interruption. CONCLUSIONS: Propofol-based short-term anesthesia was well suited for anesthesia during MRI procedures in the studied pediatric patients. There were no clinically relevant differences between the two propofol formulations.

Anesthesia, Intravenous↗

An inhaler device using liquid injection of isoflurane for short term anesthesia in piglets.

OBJECTIVES: To test a novel inhaler for administering isoflurane (ISO) anesthesia to piglets during castration and other surgical procedures of short duration. STUDY DESIGN: Prospective, randomized study. Animals Fifty-seven male piglets aged 6-10 days, body weight 1.1-3.5 kg. METHODS: An inhaler was developed which consisted of a mask, center body with open-close valve, vaporization chamber with wick and injection port, and a rebreathing bag. Liquid ISO required for induction of anesthesia and surgery was calculated, based on a desired alveolar ISO concentration of 1.82%. Dose was calculated using a square root of time model and metabolic size (B.W. 0.75). For practical use the calculated dose was expressed in relation to scale weight (kg). Isoflurane was delivered into the liquid injection port, followed by oxygen to fill the rebreathing bag and initiate vaporization. After the mask was fitted over the piglet's nose, the sliding open-close valve was opened to allow respiratory flow to move gases in and out of the inhaler and rebreathing bag. Fifty-seven male piglets received anesthesia prior to castration. Morbidity and mortality were assessed relative to unanesthetized litter mates. Induction, recovery and total anesthetic times were measured. End-tidal CO2 was measured immediately after mask removal by capnography. Costs of equipment and anesthetic agent were calculated. RESULTS: Mean induction time was rapid, 47.5 +/-8.7 seconds, generally with minimal or no struggling. Surgery usually lasted less than 30 seconds and was always completed prior to the 120 seconds allotted for induction and surgery. Anesthesia was adequate and recovery time was 122 +/- 44 seconds. Total time from start to standing was 260 +/- 51 seconds. The end-tidal CO2 was 5.2 +/- 1.1 kPa (39.4 +/- 8.4 mmHg). No morbidity or mortality was associated with either group. Inhaler construction costs were below $100, and liquid ISO cost ranged between $0.02 and $0.03 per piglet. CONCLUSION AND CLINICAL RELEVANCE: Isoflurane delivered in a novel inhaler has the potential to provide economical, safe, rapid anesthetic induction and safe, smooth recovery in piglets.

Administration, Inhalation↗

Alveolar dead space as a predictor of severity of pulmonary embolism.

OBJECTIVE: To determine whether the alveolar dead space volume (V(D)alv), expressed as a percentage of the alveolar tidal volume (V(D)alv/V(T)alv), can predict the degree of vascular occlusion caused by pulmonary embolism (PE). METHODS: Fifty-three subjects with suspected PE were prospectively studied. Pulmonary embolism was diagnosed in 33 by high-probability ventilation/perfusion (V/Q) scan (n = 19) or by pulmonary arteriography (PAG, n = 14). Pulmonary embolism was excluded by PAG in 20 subjects. The V(D)alv/V(T)alv was determined from volumetric capnography and arterial blood gas analysis, which permits measurement of the physiologic dead space, V(D)phys (mL) = [(PaCO2 - PeCO2)/PaCO2]. tidal volume. Airway dead space (V(D)aw) was subtracted to yield the alveolar dead space [(V(D)phys - V(D)aw) = V(D)alv (mL)]; the percentage of alveolar volume occupied by alveolar dead space per breath = V(D)alv/V(T)alv x 100%. Percentage perfusion defect was determined from V/Q scans by a radiologist blinded to other data. Regression analysis was performed to show correlation between V(D)alv/V(T)alv and defect on V/Q scan or systolic pulmonary arterial pressure (SPAP). RESULTS: For subjects with PE, the mean perfusion defect on lung scan was 38 +/- 22%; the mean V(D)alv = 208 +/- 115 mL, V(T)alv = 452 +/- 251 mL, and V(D)alv/V(T)alv = 43 +/- 18%. Regression of V(D)alv/V(T)alv vs perfusion defect yielded r2 = 0.41. Regression of V(D)alv/V(T)alv vs pulmonary artery pressures yielded r2 = 0.59. For subjects without PE, V(D)alv/V(T)alv = 27 +/- 14% and V(D)alv = 89 +/- 66 mL. CONCLUSIONS: The V(D)alv/V(T)alv correlates with the lung perfusion defect and the pulmonary artery pressures in subjects with PE. These findings show the potential for V(D)alv/V(T)alv to quantify the embolic burden of PE.

Adult↗

Clinical evaluation of a valveless non-absorber breathing system in spontaneously breathing canine patients.

A valveless non-absorber breathing system novel to veterinary anaesthesia is described. The performance of this system was evaluated in 35 anaesthetised spontaneously breathing dogs weighing between 2.1 and 56 kg. Fresh gas flows were reduced incrementally until rebreathing (defined as an increase in end-inspired carbon dioxide tension above 0.2 per cent) started to occur, as measured by capnography. A significant relationship (P < 0.0001) between critical fresh gas flow and bodyweight was determined, and a mean critical fresh gas flow rate of 145 +/- 21 ml/kg/minute was derived for 15 dogs weighing 10 kg or less (mean 6.7 +/- 2.6 kg) and one of 98 +/- 16 ml/kg/minute for the remaining 20 dogs weighing 11 kg or greater (mean 30.2 +/- 13.9 kg). The fresh gas requirements for each group were found to differ significantly (P < 0.0001), although the correlation between critical fresh gas flow and bodyweight was not significant (P = 0.054) in the dogs weighing 10 kg or less. It is suggested that the system may prove an economical and useful addition to the breathing systems currently used in canine anaesthesia.

Anesthesia↗

Effects of age and exercise on physiological dead space during simulated dives at 2.8 ATA.

Physiological dead space (Vds), end-tidal CO(2) (Pet(CO(2))), and arterial CO(2) (Pa(CO(2))) were measured at 1 and 2.8 ATA in a dry hyperbaric chamber in 10 older (58-74 yr) and 10 younger (19-39 yr) air-breathing subjects during rest and two levels of upright exercise on a cycle ergometer. At pressure, Vd (liters btps) increased from 0.34 +/- 0.09 (mean +/- SD of all subjects for normally distributed data, median +/- interquartile range otherwise) to 0.40 +/- 0.09 (P = 0.0060) at rest, 0.35 +/- 0.13 to 0.45 +/- 0.11 (P = 0.0003) during light exercise, and 0.38 +/- 0.17 to 0.45 +/- 0.13 (P = 0.0497) during heavier exercise. During these conditions, Pa(CO(2)) (Torr) increased from 33.8 +/- 4.2 to 35.7 +/- 4.4 (P = 0.0059), 35.3 +/- 3.2 to 39.4 +/- 3.1 (P < 0.0001), and 29.6 +/- 5.6 to 37.4 +/- 6.5 (P < 0.0001), respectively. During exercise, Pet(CO(2)) overestimated Pa(CO(2)), although the absolute difference was less at pressure. Capnography poorly estimated Pa(CO(2)) during exercise at 1 and 2.8 ATA because of wide variability. Older subjects had higher Vd at 1 ATA but similar changes in Vd, Pa(CO(2)), and Pet(CO(2)) at pressure. These results are consistent with an effect of increased gas density.

Adult↗

Ventilatory post-stimulus potentiation in patients with brain damage.

In normal humans when a brief hypoxic ventilatory stimulus is terminated abruptly by breathing 100% O2, ventilation during hyperoxia gradually declines to baseline prehypoxic levels without an undershoot. This has been interpreted as evidence of decay of short-term potentiation (STP), a mechanism located in the brainstem and not dependent upon higher center inputs. STP decay may be important in preventing periodic breathing by damping ventilatory responses to cyclic stimuli. Patients with brain damage commonly have periodic breathing that may be caused partly by impairment of STP activation. To test this 12 tracheostomized patients with severe brain damage (Glasgow score 9.9 +/- 0.6) were studied. Breathing stability was estimated by at least 6 h of capnography and from these records apnea index (AI, episodes/hour) and cyclic changes of end-tidal CO2 (c-PETCO2, cycles/hour) were derived. STP activation was examined by brief exposure to hypoxia (45 s, end-tidal O2 = 50 mm Hg) followed by hyperoxia. Forty-four hypoxic-hyperoxic runs were analyzed and compared with 19 normoxic-hyperoxic trials. At the end of the hypoxia ventilation (VI) increased 39.5 +/- 5.8% and PETCO2 decreased 2.7 +/- 0.6 mm Hg to 91.5 +/- 2.2% of baseline value. When hypoxia was terminated abruptly by hyperoxia VI dropped immediately to 63.2 +/- 7.2% of baseline, remaining for 35 s significantly lower than the corresponding values acquired during hyperoxia after normoxia. After hypoxia, apneas occurred in 19 of 44 hyperoxic runs. There was a negative relationship between nadir hyperoxic ventilation after hypoxia and both AI and c-PETCO2.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

Restoration of pulmonary perfusion by a serotonin antagonist.

R 41 468, a selective serotonin receptor blocking agent, was found to improve pulmonary perfusion in patients with venous air embolism, in patients with adult respiratory distress syndrome (ARDS), and in certain cases of impairment of the pulmonary circulation during prolonged major surgery accompanied by blood transfusion. Continuous monitoring of end-tidal (CO2 (FETCO2) by means of infra-red capnography combined with blood gas estimations were the principle methods of assessment used.

Adult↗

The Lack, Magill and Bain anaesthetic breathing systems: a direct comparison in spontaneously-breathing anaesthetized adults.

The performances of the Lack (Mapleson A), Magill (Mapleson A) and Bain (Mapleson D) anaesthetic breathing systems were compared in each of 20 anaesthetized adult patients breathing spontaneously with fresh gas flows of 70 ml kg-1 min-1. In every patient the Lack system caused the least rebreathing, as seen by the lowest inspired and end-expired CO2 tensions using capnography. The Magill caused more rebreathing than the Lack though less than the Bain. Comparative fresh gas flows for each system at the point where rebreathing started to occur were examined in 10 further patients. The Lack system required approximately 51 ml kg-1 min-1, the Magill 72 ml kg-1 min-1 while the Bain required 153 ml kg-1 min-1. Of the three systems the Lack is concluded to be the most efficient and economical system for spontaneous respiration in adults, with the additional advantages of convenient access to the exhaust valve, easy scavenging and low expiratory resistance. In addition, it also offers many useful advantages over the circle absorber system.

Adolescent↗

Hyperventilation in patients who have sustained myocardial infarction after a work injury.

Patients who present with acute myocardial infarction after a work injury (AMI-WI) often report symptoms consistent with chronic hyperventilation which date back as far as the work injury itself, rather than to the AMI. The aim of the study was to test the hypothesis that hyperventilation significantly contributes to the symptoms of AMI-WI patients. The prevalence of hyperventilation was assessed by clinical capnography in 12 AMI-WI patients, 20 normal controls, 15 AMI patients whose AMI was conventional and not subsequent to a work injury (AMI-C) and 14 patients with post-traumatic stress disorder (PTSD). End-tidal carbon dioxide partial pressure (P(et)CO2) was measured at rest, after 1 min hyperventilation (FHPT), after recall of the relevant stressor (Think) and when the breathing was felt to be normal (MBIN). P(et)CO2 levels after FHPT were: 29.0 +/- 1.5 (mean +/- SD) mmHg for AMI-WI; 26.7 +/- 1.9 mmHg for PTSD; 32.1 +/- 4.1 mmHg for AMI-C and 33.7 +/- 1.4 mmHg for the controls (P < 0.05 and P < 0.01 for AMI-WI and PTSD, respectively, versus controls). After Think, the levels were 25.8 +/- 1.6 mmHg for AMI-WI, 24.6 +/- 1.4 mmHg for PTSD, 31.2 +/- 4.1 mmHg for AMI-C and 31.2 +/- 1.5 mmHg for normals (P < 0.05 and P < 0.01 for AMI-WI and PTSD, respectively, versus controls). For MBIN, values of P(et)CO2 were 26.8 +/- 1.7 mmHg and 26.7 +/- 1.5 mmHg for AMI-WI and PTSD versus 33.8 +/- 1.2 mmHg for normals, (P < 0.01 for both versus controls).(ABSTRACT TRUNCATED AT 250 WORDS)

Accidents, Occupational↗

Anaesthesia for neurosurgery in the sitting position: a practical approach.

Neurosurgery in the sitting position offers advantages for certain operations. However, the approach is associated with potential complications, in particular venous air embolism. As the venous pressure at wound level is usually negative, air can be entrained. This air may follow any of four pathways. Most commonly it passes through the right heart into the pulmonary circulation, diffuses through the alveolar-capillary membrane and appears in expelled gas. It may pass through a pulmonary-systemic shunt such as a probe patent foramen ovale (paradoxical air embolism); it may collect at the superior vena cava-right atrial junction. Rarely it may traverse through lung capillaries into the systemic circulation. Many monitors, such as the precordial Doppler; capnography, pulmonary artery catheter; transoesophageal echocardiography are useful for venous air embolism detection, with transoesophageal echocardiography being today's gold standard. Various manoeuvres, including neck compression and volume loading, are also useful in reducing the incidence of venous air embolism. Volume loading, in particular; is very helpful as it reduces the risk of hypotension. Other particular concerns to the anaesthetist are airway management, avoidance of pressure injuries, and the risk of pneumocephalus, oral trauma, and quadriplegia. Newer anaesthetic agents have made the choice of anaesthetic technique easier. An appreciation of the implications of neurosurgery in the sitting position can make the procedure safer

Anesthesiology↗

Locally developed guidelines reduce immediate complications from percutaneous dilatational tracheostomy using the Ciaglia Blue Rhino technique: a report on 200 procedures.

Ciaglia Blue Rhino percutaneous dilatational tracheostomy is used as an aid to ventilatory weaning. It carries an immediate complication rate previously reported in 100 consecutive patients by Fikkers et al at 6% for "major" complications and 30% for "minor" complications. Mortality has been associated with the procedure. Our institution has performed dilatational percutaneous tracheostomy since 1998 and used the Blue Rhino technique since 2002. Consensus guidelines were developed following initial experiences. They focus on preoperative risk assessment including levels of ventilatory support and anatomical considerations, seniority of staff use of bronchoscopy and capnography and correction of coagulopathies. Following introduction of the guidelines we conducted an audit of the first 200 Ciaglia Blue Rhino tracheostomies performed. There was an immediate major complication rate of 3% and minor complication rate of 18%. No deaths occurred within 24 hours of the procedure. We conclude that applying our consensus guidelines produced an immediate complication rate for Ciaglia Blue Rhino percutaneous dilatational tracheostomy below published audits.

Adult↗

The Australian Incident Monitoring Study. The capnograph: applications and limitations--an analysis of 2000 incident reports.

The first 2000 incidents reported to the Australian Incident Monitoring Study were analysed with respect to the role of the capnograph. One hundred and fifty-seven (8%) were first detected by a capnograph and there were a further 18 (1%) in which capnography was contributory. Of the 1256 incidents which occurred in association with general anaesthesia 48% were "human detected" and 52% "monitor detected". The capnograph was ranked second and detected 24% of these monitor detected incidents; this figure would have been nearly 30% if a correctly checked, calibrated capnograph had always been used. The capnograph is a "front-line" monitor for oesophageal intubation, failure of ventilation, anaesthetic circuit faults, gas embolism, sudden circulatory collapse and malignant hyperthermia. It is a valuable "back-up" monitor when other monitors (e.g. low pressure alarm, pulse oximeter) are not in use, are being used incorrectly or fail. Such situations, in order of frequency of detection were: circuit-leak, overpressure of the breathing circuit, bronchospasm, leak of ventilator-driving-gas into the patient circuit, aspiration and/or regurgitation and hypoventilation. There were 20 reports of "failure", over two-thirds of which would not have occurred with appropriate checking and calibration. Seven were due to gas sampling problems and 6 to apnoea alarm failure. Two circuit leaks and 2 faulty unidirectional valves were not detected; on 3 occasions problems occurred due to power failure, calibration problems, or misinterpretation of an alarm.(ABSTRACT TRUNCATED AT 250 WORDS)

Accidents↗

The Australian Incident Monitoring Study. Blood pressure monitoring--applications and limitations: an analysis of 2000 incident reports.

Of the first 2000 incidents reported to the Australian Incident Monitoring Study, 1256 occurred in relation to general anaesthesia and 81 of the latter were first detected by blood pressure (BP) monitoring. A further 25 incidents not associated with general anaesthesia were first detected by blood pressure monitoring, giving a total of 106. In the monitor detection of incidents in relation to general anaesthesia, BP monitoring ranked fourth after oximetry, capnography and low pressure alarms. On the other hand, 38 incidents in which the problem was primarily one of significant change in BP were first detected by means other than the BP monitor (20 clinically, 12 by pulse oximetry and 6 by ECG). Early detection rates of hypotension were 60% for invasive methods, 40% for automated non-invasive (NIBP) devices and 30% for manual sphygmomanometry. There were 21 reports of BP monitor "failure"; the 11 of these which occurred with NIBPs involved unexplained false "low" or "high" readings and failure to detect profound hypotension, and led to considerable morbidity and at least one death. The 10 cases of invasive monitoring failure were predominantly due to mains power loss, hardware breakage or operator error. In a theoretical analysis of the 1256 GA incidents, it was considered that on its own, BP monitoring would have detected 919 (73%), but in the vast majority, by the time this detection has occurred, potential organ damage could not be excluded. It is recommended that BP be measured at regular intervals dictated by clinical requirements (usually at least every five minutes).(ABSTRACT TRUNCATED AT 250 WORDS)

Accidents↗