Korean J Anesthesiol.
2011 Apr;60(4):260-265. 10.4097/kjae.2011.60.4.260.
Analysis of expert consultation referrals for anesthesia-related issues (December 2008-July 2010): KSA legislation committee report
- Affiliations
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- 1Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea.
- 2Department of Anesthesiology and Pain Medicine, Chosun University Hospital, Gwangju, Korea.
- 3Department of Anesthesiology and Pain Medicine, Seoul ST. Mary's Hospital, Catholic University of Korea, Seoul, Korea.
- 4Department of Anesthesiology and Pain Medicine, Kyungpook National University School of Medicine, Daegu, Korea.
- 5Department of Anesthesiology and Pain Medicine, National Police Hospital, Seoul, Korea.
- 6Department of Anesthesiology and Pain Medicine, Konkuk University Hospital, Seoul, Korea. dikei@kuh.ac.kr
- KMID: 2092286
- DOI: http://doi.org/10.4097/kjae.2011.60.4.260
Abstract
- BACKGROUND
Since 2009, database construction of anesthesia-related adverse events has been initiated through the legislation committee of the Korean Society of Anesthesiologists (KSA), based on expert consultation referrals provided by police departments, civil courts, and criminal courts.
METHODS
This study was a retrospective descriptive analysis of expert consultation referrals on surgical anesthesia-related cases between December 2008 and July 2010.
RESULTS
During the given period, 46 surgical anesthesia-related cases were referred to the KSA legislation committee for expert consultation. Because six cases were excluded due to insufficient data, 40 cases were included in the final analysis. Of 40 cases, 29 (72.5%) resulted in death. Respiratory events were most common in both surviving/disabled and dead patients (36.4 vs. 51.7%, respectively; P > 0.05). Overall, respiratory depression due to the drugs used for monitored anesthesia care (MAC) was the most common specific mechanism (25%), in which all but one case (profound brain damage) resulted in death. In all of these cases, surgeons or physicians provided MAC without the help of anesthesiologists.
CONCLUSIONS
Overall, the most common damaging mechanism was related to respiratory depression due to sedatives or anesthetics used for MAC. Almost all MAC injury cases are believed to be preventable with the use of additional or better monitoring and an effective response to initial physiological derangement. Thus, it is essential to establish practical MAC guidelines and adhere to these guidelines strictly to reduce the occurrence of severe anesthesia-related adverse outcomes.
MeSH Terms
Cited by 1 articles
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