Results. Of 184 reports meeting inclusion criteria, 133 related to general anaesthesia: 46 events per million general anaesthetics [95% confidence interval (CI) 38 ‐54] or one per 22 000 (95% CI 1 per 26‐ 18 000). Anaesthesia events led to 16 deaths and three episodes of persistent brain damage: a mortality rate of 5.6 per million general anaesthetics (95% CI 2.8‐ 8.3): one per 180 000 (95% CI 1 per 352‐120 000). These estimates assume that all such cases were captured. Rates of death and brain damage for different airway devices (facemask, supraglottic airway, tracheal tube) varied little. Airway management was considered good in 19% of assessable anaesthesia cases. Elements of care were judged poor in three-quarters: in only three deaths was airway management considered exclusively good. Conclusions. Although these data suggest the incidence of death and brain damage from airway management during general anaesthesia is low, statistical analysis of the distribution of reports suggests as few as 25% of relevant incidents may have been reported. It therefore provides an indication of the lower limit for incidence of such complications. The review of airway management indicates that in a majority of cases, there is ‘room for improvement’.

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Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: Anaesthesia

Summary Problems with tracheal intubation are infrequent but are the most common cause of anaesthetic death or brain damage. The clinical situation is not always managed well. The Difficult Airway Society (DAS) has developed guidelines for management of the unanticipated difficult tracheal intubation in the non-obstetric adult patient without upper airway obstruction. These guidelines have been developed by consensus and are based on evidence and experience. We have produced flow-charts for three scenarios: routine induction; rapid sequence induction; and failed intubation, increasing hypoxaemia and difficult ventilation in the paralysed, anaesthetised patient. The flowcharts are simple, clear and definitive. They can be fully implemented only when the necessary equipment and training are available. The guidelines received overwhelming support from the membership of the DAS. Disclaimer: It is not intended that these guidelines should constitute a minimum standard of practice, nor are they to be regarded as a substitute for good clinical judgement.

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Difficult Airway Society guidelines for management of the unanticipated difficult intubation

Background This review examines the evidence from published data concerning the incidence of moderate-severe and of severe pain after major surgery, with three analgesic techniques; intramuscular (i.m.) analgesia, patient controlled analgesia (PCA), and epidural analgesia. Methods A MEDLINE search of the literature was conducted for publications concerned with the management of postoperative pain. Over 800 original papers and reviews were identified. Of these 212 papers fulfilled the inclusion criteria but only 165 provided usable data on pain intensity and pain relief. Pooled data on pain scores obtained from these studies, which represent the experience of a total of nearly 20 000 patients, form the basis of this review. Results Different pain measurement tools provided comparable data. When considering a mixture of three analgesic techniques, the overall mean (95% Cl) incidence of moderate-severe pain and of severe pain was 29.7 (26.4–33.0)% and 10.9 (8.4–13.4)%, respectively. The overall mean (95% Cl) incidence of poor pain relief and of fair-to-poor pain relief was 3.5 (2.4–4.6)% and 19.4 (16.4–22.3)%, respectively. For i.m. analgesia the incidence of moderate-severe pain was 67.2 (58.1–76.2)% and that of severe pain was 29.1 (18.8–39.4)%. For PCA, the incidence of moderate-severe pain was 35.8 (31.4–40.2)% and that of severe pain was 10.4 (8.0–12.8)%. For epidural analgesia the incidence of moderate-severe pain was 20.9 (17.8–24.0)% and that of severe pain was 7.8 (6.1–9.5)%. The incidence of premature catheter dislodgement was 5.7 (4.0–7.4)%. Over the period 1973–1999 there has been a highly significant (P Conclusions These results suggest that the UK Audit Commission (1997) proposed standards of care might be unachievable using current analgesic techniques. The data may be useful in setting standards of care for Acute Pain Services.

Effectiveness of acute postoperative pain management: I. Evidence from published data

Guidelines for cardiopulmonary resuscitation and emergency cardiac care.

Objective. Factors that contribute to adverse sedation events in children undergoing procedures were examined using the technique of critical incident analysis. Methodology. We developed a database that consists of descriptions of adverse sedation events derived from the Food and Drug Administration9s adverse drug event reporting system, from the US Pharmacopeia, and from a survey of pediatric specialists. One hundred eighteen reports were reviewed for factors that may have contributed to the adverse sedation event. The outcome, ranging in severity from death to no harm, was noted. Individual reports were first examined separately by 4 physicians trained in pediatric anesthesiology, pediatric critical care medicine, or pediatric emergency medicine. Only reports for which all 4 reviewers agreed on the contributing factors and outcome were included in the final analysis. Results. Of the 95 incidents with consensus agreement on the contributing factors, 51 resulted in death, 9 in permanent neurologic injury, 21 in prolonged hospitalization without injury, and in 14 there was no harm. Patients receiving sedation in nonhospital-based settings compared with hospital-based settings were older and healthier. The venue of sedation was not associated with the incidence of presenting respiratory events (eg, desaturation, apnea, laryngospasm, ∼80% in each venue) but more cardiac arrests occurred as the second (53.6% vs 14%) and third events (25% vs 7%) in nonhospital-based facilities. Inadequate resuscitation was rated as being a determinant of adverse outcome more frequently in nonhospital-based events (57.1% vs 2.3%). Death and permanent neurologic injury occurred more frequently in nonhospital-based facilities (92.8% vs 37.2%). Successful outcome (prolonged hospitalization without injury or no harm) was associated with the use of pulse oximetry compared with a lack of any documented monitoring that was associated with unsuccessful outcome (death or permanent neurologic injury). In addition, pulse oximetry monitoring of patients sedated in hospitals was uniformly associated with successful outcomes whereas in the nonhospital-based venue, 4 out of 5 suffered adverse outcomes. Adverse outcomes despite the benefit of an early warning regarding oxygenation likely reflect lack of skill in assessment and in the use of appropriate interventions, ie, a failure to rescue the patient. Conclusions. This study—a critical incident analysis—identifies several features associated with adverse sedation events and poor outcome. There were differences in outcomes for venue: adverse outcomes (permanent neurologic injury or death) occurred more frequently in a nonhospital-based facility, whereas successful outcomes (prolonged hospitalization or no harm) occurred more frequently in a hospital-based setting. Inadequate resuscitation was more often associated with a nonhospital-based setting. Inadequate and inconsistent physiologic monitoring (particularly failure to use or respond appropriately to pulse oximetry) was another major factor contributing to poor outcome in all venues. Other issues rated by the reviewers were: inadequate presedation medical evaluation, lack of an independent observer, medication errors, and inadequate recovery procedures. Uniform, specialty-independent guidelines for monitoring children during and after sedation are essential. Age and size-appropriate equipment and medications for resuscitation should be immediately available regardless of the location where the child is sedated. All health care providers who sedate children, regardless of practice venue, should have advanced airway assessment and management training and be skilled in the resuscitation of infants and children so that they can successfully rescue their patient should an adverse sedation event occur.

Adverse Sedation Events in Pediatrics: A Critical Incident Analysis of Contributing Factors

An account is given of the 602 anaesthetic accidents reported to the Medical Defence Union of the United Kingdom over the eight-year period 1970-1977: these were reported from a total membership of 2,000 anaesthetists. It is known that reporting of minor accidents, for example damage to teeth, is very imcomplete, and that many deaths associated with surgery but due to disease processes rather than anaesthesia would not be reported either. It is thought, however, that the reporting by members of other accidents involving death and cerebral damage is likely to be complete, or nearly so. Cases of death and cerebral damage reported numbered 348 (60 per cent of the total) and the causes of these two major accidents were so closely similar that it was possible to deal with them together. This appears to be a suitable approach since cerebral damage can be as great, or greater, a catastrophe than death. In nearly half of this group of accidents there was discernibly faulty technique. Failure of postoperative care ( 10 per cent of the 348 cases) was another prominent and avoidable cause. Analysis of the faulty anaesthetic techniques which led to these major accidents showed that factors involved in tracheal intubation were preeminent, and that misuse of apparatus was also conspicuous. Over all error was deemed to be twice as common a cause of death and cerebral damage as was misadventure.

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Human misadventure in anaesthesia.

One hundred general surgical patients were subjected to a form of personality assessment (Eysenck and Eysenck, 1964) the day before operation. Anaesthesia was standardized using light general anaesthesia, a muscle relaxant and controlled ventilation. The day after surgery patients filled in a standardized postoperative questionnaire about complaints concerning their visit to theatre. The patients were more “neurotic” (had higher N scores) than the general population; they also had a higher lie (L) score, and this tended to increase with age. The N score was greater in those awaiting upper abdominal operations than in those awaiting other procedures, and greater in females than in males. Pain was the most conspicuous postoperative complaint, despite the use of conventional analgesia. Preoperative anxiety was also prominent, as were complaints related to the passage or presence of a nasogastric tube. There was a positive correlation between N score and complaints of anxiety, and between N score and total number of complaints, but not between N score and complaints of pain.

Psychometry and postoperative complaints in surgical patients

Pitfalls in anaesthetic practice

Vecuronium (initial dose 0.1 mg kg−1; incremental doses 0.04 mg kg−1) was given to 21 normal and 21 anephric patients. There were no gross difference between the two groups in the effect or in the duration of action of either initial or incremental doses, except in two anephric patients who were resistant to the agent. Reversal with neostigmine was satisfactory. In normal patients the initial dose of vecuronium was slower in onset of action than was atracurium 0.5 mg kg−1 (26 patients): the first two incremental doses of vecuronium were administered significantly earlier than the corresponding increments of atracurium (0.2 mg kg−1), but the duration of action of increments over-all was not greatly different. However, in anephric patients, except in the resistant patients, the behaviour of vecuronium was similar to that of atracurium (26 patients). A comparison with an initial dose of rubocurarine 0.5mg kg−1 given to 20 anephric patients and tubocurarine 0.6 mg kg−1 given to 21 normal and 20 anephric patients showed tubocurarine to be longer acting and considerably less predictable. This was particularly so in the anephric group, in which its action sometimes persisted after neostigmine had been given

Comparison of vecuronium, atracurium and tubocurarine in normal patients and in patients with no renal function

Summary

A study has been undertaken to compare the induction characteristics of the new intravenous anaesthetic agent 2,6 di-isopropyl phenol, newly prepared in a lipid emulsion (propofol) with those of thiopentone. Despite a significantly higher incidence of pain on injection and spontaneous movement, the new agent was felt to perform comparably to thiopentone as an induction agent. Unfortunately, propofol caused decreases in blood pressure which were significantly greater than those seen after thiopentone. This feature may prove to be a considerable hurdle to the general acceptance of propofol.

https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/pdf/10.1111/j.1365-2044.1985.tb10546.x

J. E. Utting

Papers

Human misadventure in anaesthesia.

Psychometry and postoperative complaints in surgical patients

Pitfalls in anaesthetic practice

Comparison of vecuronium, atracurium and tubocurarine in normal patients and in patients with no renal function

A comparison of the induction characteristics of thiopentone and propofol (2,6-di-isopropyl phenol).