mortality and morbidity in anesthesia 2002

Mortalità e morbilità in anestesia:

Claudio Melloni

Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

Problemi metodologici:I

• la maggior parte delle complicanze avvengono>II giornata.(Hosking,Marsch,Christensen,Edwards,Mangano I & II,ecc,ecc....)

• come e perchè le complicanze sono legate al periodo intraop?

• la tecnica anestesiologica ha importanza solo se le complicanze sono innescate intraop. e si manifestano poi.....

Problemi metodologici:II

• definizione di anestesia;pd+GA=?

• quale anestesia?LA vs oppioidi:oppioidi solo

combinazioni

• intra vs postop

• standardizzazione della anestesia intraop

Problemi metodologici:III

• le casistiche devono essere comparabili;trattamenti condotti in modo eguale; per es.analgesie simili,andamento emodinamico simile,simile grado di stress,temperature simili......

Mortality and morbidity of regional vs.general anesthesia:a metaanalysis.(Sorensen et

al.,Anesthesiology,A1053,1991)• Medline-------articoli------bibliografia----

Medline-------articoli• no abstracts,no meeting reports,no

unpublished• classificazione:chirurgia,coorte o

casi,disegno sperimentale,dati deliberati vs osservaz,controlli paralleli o esterni,random vs.non random

• solo studi clinici controllati e randomizzati

Mortality and morbidity of regional vs.general anesthesia:a metaanalysis.(Sorensen et

al.,Anesthesiology,A1053,1991• parametri:• mortalità & morbilità cardiaca,• polmonare,• gastrointest,• infez,• neuropsicologica,• trombosi.

• analisi statistica:• non iterative random effects variance components

• risk difference• =diff assoluta nella freq di occorrenza fra il gruppo di controllo e

quello di trattamento

Choice of the anesthetic technique

• choice of anesthetic technique is a complex medical decision that depends on many factors, including patient characteristics (e.g., comorbidity, age), type of surgery performed, and risks of the anesthetic techniques. Assessment of the risks of the anesthetic technique should include consideration of technical factors (airway, establishment of regional blocks, invasive monitoring), anesthetic agent toxicities, incidence of critical intraoperative and postoperative events, and postoperative treatment of pain.

Lattermann et al.Epidural blockade suppresses lipolysis during major abdominal surgery.Reg.Anesth.Pain

Med.2002;27:469-75.

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0,91

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GAepid+GA\

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0,70,8

0,91

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GAepid+GA

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• Epid + GA decrease lypolysis during surgery to a lower value than GA

Loick HM,. Schmidt C, Van Aken H, Junker R,Erren M,Berendes E,Rolf N, Meißner A,Schmid C,Scheld HH, Möllhoff T.High Thoracic Epidural Anesthesia, but Not Clonidine, Attenuates the Perioperative Stress Response

Via Sympatholysis and Reduces the Release of Troponin T in Patients Undergoing Coronary Artery Bypass Grafting

Anesth Analg 1999; 88:701–9• In this prospective study, we evaluated whether high thoracic epidural anesthesia (TEA) or IV clonidine, in addition to general anesthesia, affects the cardiopulmonary bypass- and surgery-associated stress response and incidence of myocardial ischemia by their sympatholytic properties. Seventy patients scheduled for elective coronary artery bypass graft (CABG) received general anesthesia with sufentanil and propofol. TEA was randomly induced before general anesthesia and continued during the study period in 25 (anesthetized dermatomes C6-T10). Another 24 patients received IV clonidine as a bolus of 4 mg/kg before the induction of general anesthesia. Clonidine was then infused at a rate of 1 mg × kg-1 × h-1 during surgery and at 0.2–0.5 mg × kg-1 × h-1 postoperatively. The remaining 21 patients underwent general anesthesia as performed routinely (control). Hemodynamics, plasma epinephrine and norepinephrine, cortisol, the myocardial-specific contractile protein troponin T, and other cardiac enzymes were measured pre- and postoperatively. During the preoperative night and a follow-up of 48 h after surgery, five-lead electrocardiogram monitoring was used for ischemia detection. Both TEA and clonidine reduced the postoperative heart rate compared with the control group without jeopardizing cardiac output or perfusion pressure. Plasma epinephrine increased perioperatively in all groups but was significantly lower in the TEA group. Neither TEA nor clonidine affected the increase in plasma cortisol. The release of troponin T was attenuated by TEA. New ST elevations ³0.2 mV or new ST depression ³0.1 mV occurred in >70% of the control patients but only in 40% of the clonidine group and in 50% of the TEA group. We conclude that TEA (but not IV clonidine) combined with general anesthesia for CABG demonstrates a beneficial effect on the perioperative stress response and postoperative myocardial ischemia. Implications: Thoracic epidural anesthesia combined with general anesthesia attenuates the myocardial sympathetic response to cardiopulmonary bypass and cardiac surgery. This is associated with decreased myocardial ischemia as determined by less release of troponin T. These findings may have an impact on the anesthetic management for coronary artery bypass grafting.

Loick et al..High Thoracic Epidural Anesthesia, but Not Clonidine, Attenuates the Perioperative Stress Response


Anesth Analg 1999; 88:701–9

Loick et al..High Thoracic Epidural Anesthesia, but Not Clonidine, Attenuates the Perioperative Stress Response Via Sympatholysis and Reduces

the Release of Troponin T in Patients Undergoing Coronary Artery Bypass Grafting




Anesth Analg 1999; 88:701–9• TEA was performed successfully in all patients without any observed complications. The mean upper sensory blockade level extended to C5–6 (±1.5 segments), and the lower blockade extended to T10–11 (±3.5 segments). Biometric data, cross-clamp time, and length of surgery were similar among the groups (). The control and TEA groups attained comparable preoperative and intraoperative fluid balances, but patients in the clonidine group received more fluid before surgery and less fluid during the surgical procedure than control patients. It is probable that systemic clonidine administration before surgery resulted in an enlarged intravascular volume due to a vasodilating effect. During surgery, this effect could be partly counterbalanced by vasoactive substances, such as angiotensin and catecholamines. In contrast to TEA, clonidine did not cause a significant attenuation of epinephrine release. Patients receiving clonidine required more catecholamine support during weaning from CPB. This could have caused a venoconstriction and, therefore, less need for intravascular fluid. No patient received packed red blood cells for priming of the extracorporeal circuit.




• Baseline values were comparable among the groups, except for the central venous and mean pulmonary arterial pressures, which were slightly different (). In awake patients, both clonidine and TEA caused a decrease in heart rate, which was paralleled by a decrease in cardiac index and mean arterial pressure. Clonidine administration caused a small but significant decrease in systemic vascular resistance index and central venous, pulmonary arterial, and pulmonary artery occlusion pressure. These variables (except systemic vascular resistance index) showed slight increases after TEA induction.

• In all patients, heart rate increased after CPB and remained high during the study period (). However, in the TEA group, mean heart rate was increased to a lesser extent, whereas heart rate in the clonidine group differed significantly from the respective value of the control group only at 12 h after ICU admission. b-blockade, usually achieved with propranolol, was performed at least once in 23 patients (TEA: 7, clonidine: 9, control: 7), mostly immediately after surgery. b-blockers were administered if heart rate exceeded 110–120 bpm. No patient required continuous administration of b-blocker. A pacemaker was initiated in seven patients (TEA/clonidine: each two, control: three) because of intermittent bradycardia (<60 bpm). The cardiac index increased after surgery in all patients and remained high throughout the study period in all groups (). These changes were paralleled by a decrease in mean arterial pressure, which was most pronounced in the clonidine group. Although central venous and pulmonary arterial pressures increased slightly 12 and 24 h after surgery in the clonidine group, these variables did not change in the control and TEA groups. Pulmonary artery occlusion pressure and pulmonary vascular resistance index remained unchanged in all groups, whereas systemic vascular resistance index decreased postoperatively in all groups.

• .



Anesth Analg 1999; 88:701–9• No statistical differences among the groups were obtained with regard to the frequency of administration and dosage of different catecholamines and vasodilators during the weaning phase from CPB and during the postoperative period. However, there was a tendency for more frequent use of dopamine and epinephrine in the clonidine group, compared with the other groups



Anesth Analg 1999; 88:701–9• The surgical procedure resulted in an increase in the level of plasma epinephrine (). Both TEA and clonidine

caused less pronounced values compared with the control group. Likewise, postoperative norepinephrine levels were increased. In selected patients with comparable circadian measurement time points, the plasma levels of cortisol increased in all groups 24 h after ICU admission, with similar values among the groups. The serum concentration of troponin T was increased in all groups 24 h after ICU admission (, ). This increase was most pronounced in the control group, with significantly higher values compared with the TEA group. The muscle-related enzymes lactate dehydrogenase and hydroxy-butyrate-dehydrogenase increased 24 h after admission to the ICU. Postoperatively, hemoglobin in all groups decreased from approximately 13 g/dL at baseline to 10–11 g/dL after surgery. Plasma lactate was 0.7–0.8 mmol/L before surgery. It increased slowly over time in all groups and slightly exceeded our normal laboratory range (1.8 mmol/L) 12 h after ICU admission.

• New ST elevations ³0.2 mV or new ST depression £0.1 mV occurred in >70% of the control patients and in 40% of the clonidine group and 50% of the TEA group.

• Patients in the TEA group were tracheally extubated after 599 ± 159 min. This was significantly earlier than the extubation times in the control group (878 ± 549 min) or the clonidine group (936 ± 487 min).

• Visual analog scale values without or with exercise were comparable between the control and TEA groups (). In the clonidine group, VAS values were nearly halved compared with the other groups. Sedation scores were similar among the groups, with the exception of the 24-h value in the clonidine group, which was higher than that in the TEA group. The comfort score was rated between excellent and good and did not differ among the groups. The amounts of piritramid administered postoperatively were not different between the control and clonidine groups on the first postoperative day, but they were increased in the control groups on the second postoperative day. Likewise, the amount of sufentanil administered via the epidural catheter increased during the postoperative period.

Loick et al..High Thoracic Epidural Anesthesia, but Not Clonidine, Attenuates the Perioperative Stress Response



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Theorethical advantages of thoracic epidural

• Larsson PT, Hjemdahl P, Olsson G, et al. Altered platelet function during mental stress and adrenaline infusion in humans: evidence for an increased aggregability in vivo as measured by filtragometry. Clin Sci 1989; 76:369-76.<ldn>!

• Blomberg S, Emanuelsson H, Kvist H, et al. Effects of thoracic epidural anesthesia on coronary arteries and arterioles in patients with coronary artery disease. Anesthesiology 1990; 73:840-7.<ldn>!

• Blomberg S, Emanuelsson H, Ricksten SE. Thoracic epidural anesthesia and central hemodynamics in patients with unstable angina pectoris. Anesth Analg 1989; 69:558-62.<ldn>!

• Kock M, Blomberg S, Emanuelsson H, et al. Thoracic epidural anesthesia improves global and regional left ventricular function during stress-induced myocardial ischemia in patients with coronary artery disease. Anesth Analg 1990; 71:625-30.<ldn>!

• Liem TH, Booij LHDJ, Gielen MJM, et al. Coronary artery bypass grafting using two different anesthetic techniques. Part 3. Adrenergic responses. J Cardiothorac Vasc Anesth 1992; 6:162-7.<ldn>!

• 24: Kirnö K, Friberg P, Grzegorczyk A, et al. Thoracic epidural anesthesia during coronary artery bypass surgery: effects on cardiac sympathetic activity, myocardial blood flow and metabolism, and central hemodynamics. Anesth Analg 1994; 79:1075-81.<ldn>!

Theorethical advantages of thoracic epidural

• This finding suggests that there is less myocardial damage if high TEA supplements general anesthesia for CABG. Our findings correspond with previous studies that demonstrated a beneficial effect of high TEA on myocardial outcome . Several mechanisms may be responsible for this phenomenon: less myocardial stunning after CPB , a beneficial effect on myocardial oxygen metabolism , a vasodilating effect on constricted coronary vessels , and a diminishing effect on thrombus formation in the coronary vessels via less aggregability of platelets if adrenaline release is reduced . The principle mechanism seems to be the perioperative sympatholytic effect of the high TEA.

Auroy Y,Narchi P,Messiah A. Serious Complications Related to Regional Anesthesia: Results of a Prospective

Survey in France.Anesthesiology 87:479-86, 1997• Requests were sent to 4,927 French anesthesiologists in advance of a subsequent 5-month study period.

Participating anesthesiologists were asked for detailed reports of serious complications occurring during or after regional anesthetics performed by them during the study interval. Details regarding each complication then were obtained via a second questionnaire.

• Results: The number of responding anesthesiolgists was 736. The number of regional anesthetics performed was 103,730, corresponding to 40,640 spinal anesthetics, 30,413 epidural anesthetics, 21,278 peripheral nerve blocks, and 11,229 intravenous regional anesthetics. Reports of 98 severe complications were received, with follow-up information being obtained for 97. In 89 cases, complications were attributed fully or partially to regional anesthesia. Thirty-two cardiac arrests, seven of which were fatal, occurred during the study. Of these, 26 occurred during spinal anesthesia, with 6 being fatal, 3 occurred during epidural anesthesia, and 3 more occurred during peripheral blocks. The higher incidence of cardiac arrest during spinal anesthesia (6.4 ± 1.2 per 10,000 patients) compared with all other regional anesthesia (1.0 ± 0.4 per 10,000 patients) was statistically significant (P < 0.05). Of 34 neurologic complications (radiculopathy, cauda equina syndrome, paraplegia), 21 were associated either with paresthesia during puncture (n = 19) or with pain during injection (n = 2), suggesting nerve trauma or intraneural injection. Twelve patients who had neurologic complications after spinal anesthetics had no paresthesia during needle placement and no pain on injection. Of these 12 patients (7 with radiculopathy and 5 with cauda equina syndrome), 9 received intrathecal hyperbaric lidocaine, 5%. The incidence of neurologic injury was significantly greater after spinal anesthesia (6 ± 1 per 10,000 cases; P < 0.05) than after each of the other types of regional procedures (1.6 ± 0.5 per 10,000 cases for the weighted average). Seizures attributed to elevated serum levels of local anesthetics occurred in 23 patients, but none suffered a cardiac arrest.

• Conclusions: (1) The incidence of cardiac arrest and neurologic injury related to regional anesthesia were very low, but both were more than three SDs greater after spinal anesthesia than after other regional procedures. (2) Two thirds of the patients with neurologic deficits had either a paresthesia during needle placement or pain on injection. (3) Seventy-five percent of the neurologic deficits after nontraumatic spinal anesthesia occurred in patients who had received hyperbaric lidocaine, 5%.

Auroy et al.Serious Complications Related to Regional Anesthesia: Results of a Prospective Survey in

France.Anesthesiology 87:479-86, 1997

• Self reporting by participating anesthesiologists

• 736 /4,927 :14.9%

• 103,730 regional anesthetics during the 5-month study period:40,640 spinal anesthetics, 30,413 epidural anesthetics, 21,278 peripheral nerve blocks, 11,229 intravenous regional anesthetics.

•

Auroy et al.Serious Complications Related to Regional Anesthesia: Results of a Prospective Survey in


Auroy et al.Serious Complications Related to Regional Anesthesia: Results of a Prospective

Survey in France.Anesthesiology 87:479-86, 1997

Auroy et al.Serious Complications Related to Regional Anesthesia: Results of a Prospective

Survey in France.Anesthesiology 87:479-86, 1997

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Auroy et al;summary of results

• 103,730 regional anesthetic procedures:sufficient prospective data for investigators??

• 32 Cardiac arrest,28 radicular deficits,23 seizures,5 cauda equina,1 paraplegia,7 deaths

• More Ko following spinal; – cardiac arrest 6,4/10.000,(6/26 deaths)– neurol Ko 6/10.000– permanent cauda equina assoc with lidocaine 5%

• All 26 reported seizures were preceded by minor auditory symptoms and complaints of metallic taste;more frequent occurrence of seizures after peripheral block than after epidural anesthesia

Cardiac Arrest(da Auroy et al.Serious Complications Related to Regional

Anesthesia: Results of a Prospective Survey in France.Anesthesiology 87:479-86, 1997 • incidence of cardiac arrest was significantly greater with spinal

anesthesia (6.4 ± 1.2 per 10,000 patients) than with epidural anesthesia and peripheral nerve blocks combined (1.0 ± 0.4 per 10,000 patients; P < 0.05

• During the 26 cardiac arrests occurring with spinal anesthesia, 15 patients were treated only with closed-chest cardiac massage and ephedrine; one patient was treated only with epinephrine (0.5 mg); and 10 patients were treated with closed chest cardiac massage and epinephrine (3.4 ± 3.6 mg).

• Fatal outcome from cardiac arrest:6/26

• Risk of death after cardiac arrest was significantly associated with age and American Society of Anesthesiologists' (ASA) physical status class. The average age of survivors was 57 ± 20 yr, whereas the average age of nonsurvivors was 82 ± 7 yr. The difference in average ages was statistically significant (P < 0.05). Similarly, the breakdown of ASA physical status for survivors versus nonsurvivors was n = 13 versus n = 0 for ASA I; n = 5 versus n = 2 for ASA II; n = 2 versus n = 3 for ASA III; and n = 1 versus n = 0 for ASA IV.

Cardiac Arrest(da Auroy et al.Serious Complications Related to Regional

Anesthesia: Results of a Prospective Survey in France.Anesthesiology 87:479-86, 1997

• Two variables were statistically different regarding cardiac arrest in patients undergoing spinal anesthesia: (1) the time between onset of spinal blockade and occurrence of cardiac arrest was longer in nonsurvivors than in survivors (42 ± 19 min versus 17 ± 16 min, respectively; P < 0.05); and (2) total hip arthroplasty (THA) more frequently was the type of surgery in nonsurvivors than in survivors (5 of 6 THA among nonsurvivors compared with 2 of 20 non-THA surgeries in survivors; P < 0.05). During THA, three cardiac arrests happened at the time of cement insertion and were fatal. Blood loss at the time of cardiac arrest was 700 ml in nine cardiac arrest patients, with four arrests being fatal. Sedation was not performed nor was cyanosis or dizziness observed before any of the fatal cardiac arrests, although all cardiac arrests were reported to have been preceded by bradycardia.

• 3

Cardiac Arrest:epidural & peripheral nerve block(da Auroy et al.Serious Complications Related to Regional Anesthesia: Results of a Prospective Survey in


• 3 reversible cardiac arrest were reported with epidural anesthesia.

• 3 cardiac arrest were reported during peripheral nerve blocks. In each case, these appeared to be associated with inadequate analgesia. In two of the three cases, cardiac arrest also was associated with vasovagal responses, treated, and reversed. One fatal cardiac arrest resulted from a myocardial infarction. No neurologic sequelae were observed in the 25 patients who recovered from cardiac arrest.

Neurologic complications:(daAuroy et al.Serious Complications Related to Regional Anesthesia: Results of a Prospective Survey in


• All 34 neurologic complications presented within 48 h of surgery. Neurologic sequelae were considered permanent if they lasted more than 3 months. These occurred in five patients. Twenty-nine patients had transient sequelae, with recovery occurring between 48 h and 3 months.

• higher incidence of neurologic injury after spinal anesthesia (6 ± 1 per 10,000 cases) than after the other techniques combined (1.6 ± 0.5 per 10,000 cases): epidural anesthesia, peripheral nerve block, or intravenous regional anesthesia.

Radiculopathy(da Auroy et al.Serious Complications Related to Regional Anesthesia: Results of a Prospective Survey in France.Anesthesiology 87:479-86,

1997

• Radiculopathy was more frequently observed after spinal than after epidural anesthesia (). In 12 of 19 cases of radiculopathy after spinal anesthesia and in all cases of radiculopathy after epidural anesthesia (n = 5) and peripheral blocks (n = 4), needle puncture was associated either with paresthesia during puncture (n = 19) or with pain during injection (n = 2). In all cases, radiculopathy had the same topography as associated paresthesias. Anesthesiologists did not continue to inject when pain on injection occurred. All patients with neurologic deficits lasting more than 2 days were examined by a neurologist. All patients with cauda equina syndrome had a computed tomography (CT) scan to rule out a compressive etiology. In 12 patients in whom neurologic deficits occurred after spinal anesthesia, there was paresthesia or pain during injection. In these patients, hyperbaric bupivacaine, 0.5%, was used in 11 patients, whereas hyperbaric lidocaine, 5%, was used in one patient. All patients with radicular deficits after paresthesia recovered, although a permanent neurologic deficit occurred in one patient who had a paresthesia during placement of the spinal needle but no pain during the subsequent intrathecal injection of 15 mg of hyperbaric bupivacaine, 0.5%.

•

Neurol KO not associated with pain,paresthesias or technivcal difficulties:(da Auroy et al.Serious Complications Related to Regional


• Thirteen neurologic complications were not associated with pain, paresthesias, or technical difficulties. Twelve of these occurred after spinal anesthesia, with 9 of 12 patients having received hyperbaric lidocaine, 5%, intrathecally. Eight of the nine patients received a single dose of 75—100 mg of lidocaine. Two of the eight had permanent radiculopathy or cauda equina syndrome. One of the nine patients underwent continuous spinal anesthesia via an infusion of lidocaine, 5%. That patient received 350 mg of lidocaine over 5 h, and had permanent cauda equina syndrome. Three patients received 12—20 mg of hyperbaric bupivacaine, 0.5%, and had only transient neurologic deficit.

• One case of paraplegia occurred in a patient aged 62 years who underwent a combined technique: an uneventfully placed epidural block followed by general anesthesia. Lidocaine, 2%, without epinephrine was used. This patient had intraoperative hypovolemic arterial hypotension. Result of a CT scan of the lumbar spine, taken 1 day after surgery to rule out a compressing hematoma, was normal.

Seizures (daAuroy et al.Serious Complications Related to Regional Anesthesia:

Results of a Prospective Survey in France.Anesthesiology 87:479-86, 1997

• All 26 reported seizures were preceded by minor auditory symptoms and complaints of metallic taste. The more frequent occurrence of seizures after peripheral block than after epidural anesthesia was statistically significant (). In patients who suffered a seizure, a larger volume of lidocaine, 2%, or bupivacaine, 0.5%, was injected for peripheral nerve blocks (41 ± 14 ml) than for epidural anesthesia (15 ± 4 ml). This difference is statistically significant (P < 0.05). Although bupivacaine was injected in 14 of the 23 patients having seizures after epidural anesthesia or peripheral nerve blockade, it was never associated with cardiac arrest, either when used alone, or when used in combination with lidocaine. During intravenous regional anesthesia, three seizures were reported to have occurred after deflation of the tourniquet. In each of those patients, tourniquet inflation after injection of 30—45 ml of lidocaine, 0.5%, exceeded 40 min. In 23 patients, seizures were treated by intravenous administration of midazolam at the same time that supplemental face mask oxygen was provided. In three patients, thiopental was administered and followed by tracheal intubation.

Bupivacaine toxicity; daAuroy et al.Serious Complications

Related to Regional Anesthesia: Results of a Prospective Survey in France.Anesthesiology 87:479-86, 1997

• Although previous reports found that bolus intravenous injections of bupivacaine were associated with cardiotoxicity leading to cardiac arrest, no cardiac arrests were observed in our study in conjunction with bupivacaine. Similar absence of primary cardiac arrhythmia as a result of local anesthetics was recently reported.

Citotoxicity: daAuroy et al.Serious Complications Related to Regional


• Current controversies regarding the cytotoxicity of local anesthetics draw special attention to the 12 patients who developed radiculopathy or cauda equina syndrome after uneventful spinal anesthesia. In each of these patients, subarachnoid delivery occurred without paresthesia or pain on injection. In 9 of 12 patients, hyperbaric lidocaine, 5%, was used. Because we do not know the relative use of hyperbaric lidocaine, 5%, and hyperbaric bupivacaine, 0.5%, for spinal anesthesia by the 736 anesthesiologists who participated to our study, it is difficult to interpret this finding. However, hyperbaric bupivacaine, 0.5, was used more frequently than hyperbaric lidocaine, 5%, in patients who developed radiculopathy after spinal anesthesia and paresthesia or pain (11 vs. 1). Also, during the study period, the consumption of hyperbaric local anesthetics in France by anesthesiologists was 72,300 2-ml ampules of lidocaine, 5%, and 199,780 4-ml ampules of bupivacaine, 0.5%, permitting speculation that hyperbaric lidocaine, 5%, might have been used less often for spinal anesthesia and therefore might somehow have been associated with a higher incidence of the neurotoxicity that is rarely seen with that type of block, even though the dose and the technique are standard. This is probably the main difference between our findings and previous reports of cauda equina syndrome.

Auroy et al

• The incidence of complications reported in this study is comparable with those found in various other surveys of radicular deficits, cardiac arrest, and seizures after spinal or epidural blocks. Caplan et al. reported 14 cases of fatal cardiac arrest during spinal anesthesia. Sedation was found as a risk factor in 12 of those patients, whereas bradycardia was cited as an initial factor in 7. In contrast, in our patients sedation was not present in any patient before fatal cardiac arrest, and bradycardia preceded all cases of cardiac arrest. One possible explanation for this difference in critically serious events is that Caplan et al. retrospectively studied cases of relatively young, healthy patients who had cardiac arrest, severe neurologic sequelae, or death after regional anesthesia. In contrast, we prospectively studied randomly chosen patients in a population representative of wide-spread daily practice. A different recent survey reported neurologic complications after spinal anesthesia and epidural anesthesia in a Swedish University Hospital. This study, which was only in part prospective, found comparable rates of adverse neurologic sequelae after spinal anesthesia, but a higher rate of neurologic complications after epidural anesthesia.

Auroy vs Caplan

• Caplan et al. retrospectively studied cases of relatively young, healthy patients who had cardiac arrest, severe neurologic sequelae, or death after regional anesthesia

• Auroy prospectively studied randomly chosen patients in a population representative of wide-spread daily practice.

Citotoxicity;biblio• 15: Drasner K, Sakura S, Chan VW, Bollen AW, Ciriales R:

Persistent sacral sensory deficit induced by intrathecal local anesthetic infusion in the rat. ANESTHESIOLOGY 80:847-52, 1994<ldn>!

• 16: Sakura S, Chan VW, Ciriales R, Drasner K: The addition of 7.5% glucose does not alter the neurotoxicity of 5% lidocaine administered intrathecally in the rat. ANESTHESIOLOGY 82:236—40, 1995<ldn>!

• 17: Lambert LA, Lambert DH, Strichartz GR: Irreversible conduction block in isolated nerve by high concentrations of local anesthetics. ANESTHESIOLOGY 80:1082—93, 1994<ldn>!

• 18: Tarkkila P, Huhtala J, Tuominen M: Transient radicular irritation after spinal anaesthesia with hyperbaric 5% lignocaine. Br J Anaesth 74:328—9, 1995<ldn>!

Biboulet P, Aubas P, Dubourdieu J, Rubenovitch J,Capdevila X, d'Athis F.Fatal and non fatal cardiac arrests related to anesthesia.General Anesthesia*Can J Anesth 2001

/ 48 / 326-332• Purpose: The aim of this study was to assess the incidence and causes of cardiac arrests

related to anesthesia.• Methods: All patients undergoing anesthesia over a six year period were included in a

prospective study. The cardiac arrests encountered during anesthesia and the first twelve postoperative hours in the PACU or ICU were analysed. For each arrest, partially or totally related to anesthesia, the sequence of events leading to the accident was evaluated.

• Results: Eleven cardiac arrests related to anesthesia were identified among the 101,769 anesthetic procedures (frequency: 1.1/10,000 [0.44–1.72]). Mortality related to anesthesia was 0.6/10,000 [0.12–1.06]. Age over 84 yr and an ASA physical status > 2 were found to be risk factors of cardiac arrest related to anesthesia. The main causes of anesthesia related cardiac arrest were anesthetic overdose (four cases), hypovolemia (two cases) and hypoxemia due to difficult tracheal intubation (two cases). No cardiac arrests due to alveolar hypoventilation were noted during the postoperative periods in either PACU or ICU. At least one human error was noted in ten of the eleven cardiac arrests cases, due to poor preoperative evaluation in seven. All cardiac arrests totally related to anesthesia were classified as avoidable.

• Conclusion:Efforts must be directed towards improving preoperative patient evaluation. Anesthetic induction doses should be titrated in all ASA 3 and 4 patients. The prediction of difficult tracheal intubation, and if required, the use of awake tracheal intubation techniques, should remain a priority when performing general anesthesia.

Biboulet et al.Fatal and non fatal cardiac arrests related to anesthesia.General Anesthesia*Can J Anesth 2001 / 48 /

326-332

• Within the six years of the study, 101,769 anesthetics were performed: orthopedic (n = 45,852), pediatric (n = 19,851), urological (n = 16,325), otorhinolaryngological (n = 11,985) and maxillofacial surgery (n = 7,756). During this period, 24 cardiac arrests were identified, including 13 unrelated to anesthesia.

• Of the 11 anesthesia related cardiac arrests, 1.1/10,000 [0.44 – 1.72], three were considered totally, and eight partially related to anesthesia. Risk factors for anesthesia related cardiac arrest were age > 84 yr (P < 0.01), ASA 3 and 4 (P < 0.001). Emergency surgical conditions were not retained as a risk factor (, ). Five patients recovered following cardiac arrest. Anesthesia related mortality was 0.6/10,000 [0.12–1.06]. Cardiac arrests related to regional anesthesia were noted only during spinal anesthesia (

Biboulet et al.Fatal and non fatal cardiac arrests related to anesthesia.General Anesthesia*Can J

Anesth 2001 / 48 / 326-332

• The causes of cardiac arrest were related to anesthetic overdose (n = 4) primarily encountered during spinal anesthesia (n = 3), hypovolemia (n = 2), hypoxemia due to airway management difficulties (n = 2), and pacemaker malfunction (n = 1) (, ). In two cases, (patient #7 and #11), the exact cause of the cardiac arrest could not be determined. However, the arrest was retained as partially anesthesia related as an anesthetic overdose was identified in patient #7 and patient #11 was hypovolemic.


Anesth 2001 / 48 / 326-332• At least one human error was encountered in 10 of the 11 arrests.

Inadequate preoperative risk estimation was noted in 7/11 cardiac arrests: patient diseases were not controlled in four cases, intraoperative airway management difficulties were underestimated in two, and a probable thrombophlebitis was ignored in a bedridden obese patient. Intraoperative errors or misjudgments were noted in 10/11 cardiac arrests: inadequate fluid replacement (n = 7), anesthetic overdosage (n = 4), continuation of the surgical procedure despite an unstable hemodynamic state (n = 3), error in airway management technique choice (n = 2), insertion of methyl-metacrylate cement in a hypovolemic patient (n = 2), mobilization of a hypovolemic patient (n = 1), inadequate prevention of hypothermia (n = 1). The association of inadequate preoperative risk estimation and intraoperative errors were noted in 7/11 cardiac arrests. All cardiac arrests totally related to anesthesia were classified as avoidable.


Anesth 2001 / 48 / 326-332


Anesth 2001 / 48 / 326-332

0

0,1

0,2

0,3

0,4

0,5

0,6

0,7

1/10.000

AG epid spinl caudal ivra plexus nerve

cardiac arrestdeath

7182

6

4145

76562

08

1

330

8 922

2

323

1


Anesth 2001 / 48 / 326-332• Over the six years of the study, the incidence of anesthesia related cardiac arrest was 1.1/10,000 [0.44–1.72], and anesthesia related mortality was 0.6/10,000 [0.12–1.06]. This incidence was particularly high in ASA 3 and 4 patients: 7.8/10,000 cardiac arrest and 4.9/10,000 deaths related to anesthesia

• The three most frequent causes of cardiac arrest were overdose, hypovolemia and hypoxemia.

• Human error was noted in 91% of the arrests. • This study has pointed out that anesthesia-related cardiac arrests

are predominantly multifactorial, associating inadequate preoperative risk estimation, intraoperative errors or misjudgments, and poor preoperative patient condition.


Anesth 2001 / 48 / 326-332

• 1: Keenan RL, Boyan CP. Cardiac arrest due to anesthesia. A study of incidence and causes. JAMA 1985; 253:2373-7.<ldn>!

• 2: Tiret L, Desmonts JM, Hatton F, Vourc'h G. Complications associated with anaesthesia - a prospective survey in France. Can Anaesth Soc J 1986; 33:336-44.<ldn>!

• 3: Lunn JN, Delvin HB. Lessons from the confidential enquiry into perioperative deaths in three NHS regions. Lancet 1987; 12:1384-6.

• 4: Olsson GL, Hallén B. Cardiac arrest during anaesthesia. A computer aided study in 250 543 anaesthetics. Acta Anaesthesiol Scand 1988; 32:653-64.<ldn>!

• 5: Aubas S, Biboulet Ph, Daurès JP, du Cailar J. Incidence and aetiology of cardiac arrests occuring in operating and recovery rooms during 102,468 anaesthetics. (French) Ann Fr Anesth Réanim 1991; 10:436-42.

• 6: Tikkanen J, Hovi-Viander M. Death associated with anaesthesia and surgery in Finland in 1986 compared to 1975. Acta Anaesthesiol Scand 1995; 39:262-7.<ldn>!

• 7: Warden JC, Horan BF. Deaths attributed to anaesthesia in New South Wales 1984-1990. Anaesth Intensive Care 1996; 24:66-73.<ldn>!

Morray JP, Geiduschek JM, Ramamoorthy C,Haberkern CM,Hackel A, Caplan RA, Domino KB, Posner K,Cheney

FW.Anesthesia-related Cardiac Arrest in Children : Initial Findings of the Pediatric Perioperative Cardiac Arrest

(POCA) Registry Anesthesiology, 93:6-14, 2000• Background: The Pediatric Perioperative Cardiac Arrest (POCA) Registry was formed in 1994 in an attempt to

determine the clinical factors and outcomes associated with cardiac arrest in anesthetized children.• Methods: Institutions that provide anesthesia for children are voluntarily enrolled in the POCA Registry. A

representative from each institution provides annual institutional demographic information and submits anonymously a standardized data form for each cardiac arrest (defined as the need for chest compressions or as death) in anesthetized children 18 yr of age or younger. Causes and factors associated with cardiac arrest are analyzed.

• Results: In the first 4 yr of the POCA Registry, 63 institutions enrolled and submitted 289 cases of cardiac arrest. Of these, 150 arrests were judged to be related to anesthesia. Cardiac arrest related to anesthesia had an incidence of 1.4 ± 0.45 (mean ± SD) per 10,000 instances of anesthesia and a mortality rate of 26%. Medication-related (37%) and cardiovascular (32%) causes of cardiac arrest were most common, together accounting for 69% of all arrests. Cardiovascular depression from halothane, alone or in combination with other drugs, was responsible for two thirds of all medication-related arrests. Thirty-three percent of the patients were American Society of Anesthesiologists physical status 1—2; in this group, 64% of arrests were medication-related, compared with 23% in American Society of Anesthesiologists physical status 3—5 patients (P < 0.01). Infants younger than 1 yr of age accounted for 55% of all anesthesia-related arrests. Multivariate analysis demonstrated two predictors of mortality: American Society of Anesthesiologists physical status 3—5 (odds ratio, 12.99; 95% confidence interval, 2.9—57.7), and emergency status (odds ratio, 3.88; 95% confidence interval, 1.6—9.6).

• Conclusions: Anesthesia-related cardiac arrest occurred most often in patients younger than 1 yr of age and in patients with severe underlying disease. Patients in the latter group, as well as patients having emergency surgery, were most likely to have a fatal outcome. The identification of medication-related problems as the most frequent cause of anesthesia-related cardiac arrest has important implications for preventive strategies.

Morray et al.Anesthesia-related Cardiac Arrest in Children : Initial Findings of the Pediatric Perioperative

Cardiac Arrest (POCA) Registry Anesthesiology, 93:6-14, 2000

Morray et al.Anesthesia-related Cardiac Arrest in Children : Initial Findings of the Pediatric

Perioperative Cardiac Arrest (POCA) Registry Anesthesiology, 93:6-14, 2000

Morray et al.Anesthesia-related Cardiac Arrest in Children : Initial Findings of the Pediatric Perioperative Cardiac Arrest (POCA) Registry Anesthesiology, 93:6-14, 2000

VSMorray J, Geiduschek J, Caplan R, Posner K, Gild W, Cheney FW: A comparison of

pediatric and adult anesthesia malpractice claims. ANESTHESIOLOGY 78:461-7, 1993,

Casistica di AC:289 150 attribuiti all’anestesia frequenza di 1.4 ± 0.45 per 10,000

anestesie mortalità del 26%. Le cause di arresto cardiaco più frequenti

sono state attribuite a farmaci (37%) e cardioavscolari (32%) la depressione cardiovascolare da alotano ,isolata o insieme con altri farmaci,era responsabile di circa i 2/3 di tutti gli AC legati ai farmaci

33% dei pazienti appartenevano alla classe ASA 1—2

; ed in questo sottogruppo il 64% degli arresti erano relati alle medicazioni ,a confronto del 23% per i pazienti ASA 3—5. I neonati al di sotto dell’anno di età costituivano il 55% di tutti i casi di arresto legati all’anestesia .

• CASISTICA DI 238 CASI ;MA Ac??

• FREQUENZA??

• MORTALITà :50%

• BRAIN DAMAGE 30%

• EVENTI RESP 43%

• EVENTI CARDIOVASC 13%

• EQUIPMENT PROBL 13%

• WRONG DRUG:3%

• CLASSE asa 1 & 2:49%

Morray J, Geiduschek J, Caplan R, Posner K, Gild W, Cheney FW: A comparison of pediatric and adult

anesthesia malpractice claims. ANESTHESIOLOGY 78:461-7, 1993

Morray J, Geiduschek J, Caplan R, Posner K, Gild W, Cheney FW: A comparison of pediatric and adult

anesthesia malpractice claims. ANESTHESIOLOGY 78:461-7, 1993

• Background: Since 1985, the Committee on Professional Liability of the American Society of Anesthesiologists has evaluated closed anesthesia malpractice claims. This study compared pediatric and adult closed claims with respect to the mechanisms of injury, outcome, the costs, and the role of care judged to be substandard.

• Methods: Using a standardized form and method developed for analysis of closed claims, the American Society of Anesthesiologists Closed Claims Data Base was used to compare pediatric with adult anesthesia-related adverse events.

• Results: Of the 2,400 total claims, 238 (10%) were in the pediatric age group (15 yr of age or younger). The pediatric claims presented a different distribution of damaging events compared with that of adults. In particular, respiratory events were more common among pediatric claims (43% versus 30% in adult claims; P £ 0.01). The mortality rate was greater in the pediatric claims (50% versus 35% in adult claims; P £ 0.01), anesthetic care more often was judged less than appropriate (54% versus 44% in adult claims; P £ 0.01), the complications more frequently were thought to be preventable with better monitoring (45% versus 30% in adult claims; P £ 0.01), and the distribution of payments to the plaintiff was different (median payment, $111,234 versus $90,000 in adult claims; P £ 0.05). Many of the differences between pediatric and adult claims were explained by a higher prevalence of patient injury caused by inadequate ventilation in the pediatric claims (20% versus 9% in adult claims; P £ 0.01). In pediatric compared with adult inadequate ventilation claims, poor medical condition and/or obesity (6% versus 41%; P £ 0.01) were uncommon associated factors. Cyanosis (49%) and/or bradycardia (64%) often preceded cardiac arrest in pediatric claims related to inadequate ventilation, resulting in death (70%) or brain damage (30%) in previously healthy children. Although clinical clues suggested hypoxemia as a common mechanism of injury, the files did not contain enough information to explain the genesis of hypoxemia in these claims.

• Conclusions: Comparison of adult and pediatric closed claims revealed a large prevalence of respiratory related damaging events—most frequently related to inadequate ventilation. In the opinion of the reviewers, 89% of the pediatric claims related to inadequate ventilation could have been prevented with pulse oximetry and/or end tidal CO2 measurement. However, pulse oximetry appeared to prevent poor outcome in only one of seven claims in which pulse oximetry was used and could possibly have done so.

• total data base of 2,400 claims, accrued as of March 1991. Of these, 238 were pediatric claims (10%), defined as those involving patients 15 yr of age or younger.

• Damaging events relating to the respiratory system explained 43% of pediatric claims compared with 30% of adult claims (P £ 0.01, ). Inadequate ventilation was responsible for 20% of all pediatric claims compared with 9% of all adult claims (P £ 0.01). General anesthesia was used more frequently and regional anesthesia, less frequently, in pediatric than in adult inadequate ventilation claims (P £ 0.01, ).

• Pollard JB. Cardiac arrest during spinal anesthesia: Anesth Analg 2001; 92:252–6. <ldn>!

• 2: Ligouri G, Sharrock N. Asystole and severe bradycardia during epidural anesthesia in orthopedic patients. Anesthesiology 1997; 86:250–7. <ldn>!

• 3: Heidegger T, Kreienbuhl G. Unsuccessful resuscitation under hypotensive epidural anesthesia during elective hip arthroplasty. Anesth Analg 1998; 86:847–9. <ldn>!

• 4: Brown DL, Carpenter RL, Moore DC. Cardiac arrest During Spinal Anesthesia III (letter. Anesthesiology 1988; 68:971–2.

• 5: Geffin B, Shapiro L. Sinus bradycardia and asystole during spinal and epidural anesthesia: J Clin Anesth 1998; 10:278–85.<ldn>!

• 6: Lovstad RZ, Granhus G, Hetland S. Bradycardia and asystolic arrest during spinal anesthesia: Acta Anaesthesiol Scand 2000; 44:48–52.<ldn>!

Pollard JB. Cardiac arrest during spinal anesthesia: Anesth Analg 2001; 92:252–6

Ligouri G, Sharrock N. Asystole and severe bradycardia during epidural anesthesia in orthopedic patients.

Anesthesiology 1997; 86:250–7

Brown DL, Ransom DM, Hall JA, Leicht CH, Schroeder DR, Offord KP: Regional anesthesia and local anesthetic-

induced systemic toxicity: Seizure frequency and accompanying cardiovascular changes. Anesth Analg

81:321—8, 1995

Caplan RA, Ward RJ, Posner K, Cheney FW: Unexpected cardiac arrest during spinal anesthesia: A closed claims analysis of predisposing factors. ANESTHESIOLOGY

68:5-11, 1988

Dahlgren N, Tornebrandt K: Neurological complications after anaesthesia. A follow-up of 18 000 spinal and

epidural anesthetics performed over three years. Acta Anaesthesiol Scand 39:872-80, 1995

Kapral S, Gollmann G, Bachmann D, et al. The effects of

thoracic epidural anesthesia on intraoperative visceral perfusion and metabolism. Anesth Analg

1999; 88:402-6.

1:104; Olausson K, Magnusdottir H, Lurje

L, Wennerblom B, Emanuelsson H,

Ricksten SE. Anti-ischemic and anti-anginal effects of thoracic epidural anesthesia versus

those of conventional medical therapy in the treatment of severe refractory unstable angina pectoris. Circulation 1997;

96:2178-82.

:124; Scheini H, Virtanen T, Kentala E,

et al. Epidural infusion of

bupivacaine and fentanyl reduces perioperative

myocardial ischaemia in elderly patients with hip fracturesQa randomized controlled

trial. Acta Anaesthesiol Scand 2000; 44:1061-70.

Glantz L, Drenger B, Gozal Y. Perioperative myocardial ischemia in cataract surgery patients: general versus local

anesthesia. Anesth Analg 2000; 91:1415-9. • Patients having cataract surgery are usually elderly and have risk factors for ischemic

heart disease. We sought to determine the incidence of perioperative myocardial ischemia in patients having cataract surgery and compare the influence of local anesthesia (LA) and general anesthesia (GA). Eighty-one patients undergoing cataract surgery with at least two risk factors for ischemic heart disease were monitored continuously for 24 h by using electrocardiogram leads II and V5 and a Holter recorder (Medilog 4500, Oxford Ltd, UK). Patients were randomly allocated to two groups, either LA (n = 39) or GA (n = 42). In the LA group, a peribulbar block was performed, whereas a similar block was performed in the GA group after tracheal intubation. The study demonstrated that cataract patients suffered from a frequent incidence of perioperative myocardial ischemia (31%). There was no difference in the incidence rate between the groups: 12 of 39 in the LA group and 13 of 42 in the GA group (P = NS). However, the number of ischemic episodes was significantly increased in the GA group (18 vs 13 in the LA group) (P < 0.05), and there were significantly more intraoperatively in the GA group (8 vs 1) (P < 0.01). All intraoperative ischemic events were associated with tachycardia (³20% of baseline), whereas postoperative ischemic changes were mostly independent of heart rate. Only one of the ischemic patients (in the GA group) was admitted as a result of intractable chest pain. There were significantly less intraoperative episodes in the LA group, suggesting that LA may be safer than GA in patients during this

Glantz et al. Perioperative myocardial ischemia in cataract surgery patients: general versus local anesthesia. Anesth

Analg 2000; 91:1415-9.• LA (retrobulbar block) under sedation with IV midazolam (1–3 mg)

by using a mixture of bupivacaine 0.5% and lidocaine 4% (3 mL each)

• GA was induced with thiopental, fentanyl, and vecuronium and maintained with nitrous oxide and isoflurane in oxygen. Additional fentanyl was given as needed. After securing the endotracheal tube, a retrobulbar block was performed by the surgeon to decrease anesthetic requirement and to facilitate postoperative analgesia.

• Patients in both groups stayed 2 h in the postanesthesia care unit for closer monitoring, including continuous oxygen saturation recording, and noninvasive blood pressure recording (every 5 min). Afterwards, the patients were sent to the ward where these variables were checked once every shift.

Glantz et al. Perioperative myocardial ischemia in cataract surgery patients: general versus local

anesthesia. Anesth Analg 2000; 91:1415-9.

0

5

10

15

20

25

peribulbar GA+peribulbar

num

dur(min)

ST dev(mm)

paz +isch.intraop

pz+ischpostop

isch events intra1

isch events postop

isch duration intraop(min)

isch dur postop(min)

ST dev intraop(mm)

S dev postop(mm)

Intraop & postop ischemia:31%!

All intraop events were associated with an increase in HR (+20% of baseline)

, whereas the postop. ischemic changes were independent of changes in HR in 10/ 22 pts..

Barker JP, Vafidis GC, Robinson PN, Hall GM. Plasma catecholamine response to cataract surgery: a comparison between general and local anaesthesia. Anaesthesia 1991;

46:642-5.• study involving 20 elderly cataract patients that heart rate increased

significantly after the induction of GA compared with LA. Mean arterial blood pressure increased significantly in both groups after the induction of anesthesia, but decreased to lower than control values in the GA group during the rest of the study, whereas it remained moderately increased (10 mm Hg higher than control values) in the LA group. LA, in the same study, prevented the small increase in epinephrine, norepinephrine secretion, and glucose plasma level seen in the GA group. In addition, the same investigators have demonstrated the absence of excessive release of cortisol in the LA group compared with a significant increase (from 407 nmol/L to 801 nmol/L) in the GA group . In surgical patients, the hemodynamic changes strongly associated with myocardial ischemia are tachycardia

Hall GM, Peerbhoy D, Shenkin A, Parker CJR, Salmon P. The relationship of the functional

recovery after hip arthroplasty to the neuroendocrine and

inflammatory responses. Br J Anaesth 2001; 87:537-42.

• Cruickshank AM, Fraser WD, Burns HJG, Van Damme J, Shenkin A. Response of serum interleukin-6 in patients undergoing elective surgery of varying severity. Clin Sci 1990; 79:161-5.

• Kehlet H. Surgical stress response: does endoscopic surgery confer an advantage? World J Surg 1999; 23:801-7.

• Parker MJ, Urwin SC, Handoll HHG, Griffiths R: General versus spinal/epidural analgesia for hip fractures in adults, Issue 4 (Cochrane review). Oxford, The Cochrane Library, 1993. Update Software

O'Hara DA, Duff A,Berlin JA, ,Poses R, Lawrence VA,Huber E,Noveck H, Strom BL,Carson JL.The Effect of

Anesthetic Technique on Postoperative Outcomes in Hip Fracture Repair Anesthesiology 92:947-57, 2000

• This article is accompanied by an Editorial View. Please see: Baker SG: Randomized and nonrandomized clinical studies: Statistical considerations. ANESTHESIOLOGY 2000; 92: 928—30.

O'Hara et al.The Effect of Anesthetic Technique on Postoperative Outcomes in Hip Fracture

Repair Anesthesiology 92:947-57, 2000• Background: The impact of anesthetic choice on postoperative mortality and morbidity has not been determined

with certainty.• Methods: The authors evaluated the effect of type of anesthesia on postoperative mortality and morbidity in a

retrospective cohort study of consecutive hip fracture patients, aged 60 yr or older, who underwent surgical repair at 20 US hospitals between 1983 and 1993. The primary outcome was defined as death within 30 days of the operative procedure. The secondary outcomes were postoperative 7-day mortality, postoperative myocardial infarction, postoperative pneumonia, postoperative congestive heart failure, and postoperative change in mental status. Numerous comorbid conditions were controlled for individually and by several comorbidity indices using logistic regression.

• Results: General anesthesia was used in 6,206 patients (65.8%) and regional anesthesia in 3,219 patients (3,078 spinal anesthesia and 141 epidural anesthesia). The 30-day mortality rate in the general anesthesia group was 4.4%, compared with 5.4% in the regional anesthesia group (unadjusted odds ratio = 0.80; 95% confidence interval = 0.66—0.97). However, the adjusted odds ratio for general anesthesia increased to 1.08 (0.84—1.38). The adjusted odds ratios for general anesthesia versus regional anesthesia for the 7-day mortality was 0.90 (0.59—1.39) and for postoperative morbidity outcomes were as follows: myocardial infarction: adjusted odds ratio = 1.17 (0.80—1.70); congestive heart failure: adjusted odds ratio = 1.04 (0.80—1.36); pneumonia: adjusted odds ratio = 1.21 (0.87—1.68); postoperative change in mental status: adjusted odds ratio = 1.08 (0.95—1.22).

• Conclusions: The authors were unable to demonstrate that regional anesthesia was associated with better outcome than was general anesthesia in this large observational study of elderly patients with hip fracture. These results suggest that the type of anesthesia used should depend on factors other than any associated risks of mortality or morbidity.

•


Repair Anesthesiology 92:947-57, 2000

• retrospective cohort study of consecutive patients with hip fracture, aged 60 yr or older, who underwent surgical repair at 1 of 20 study hospitals between 1983 and 1993. Patients were excluded if they declined to receive blood transfusion, had metastatic cancer, or underwent a surgical procedure involving a site other than the hip because the data were collected for a study of blood transfusion and surgery.



• Primary Outcome: 30-day Mortality• Secondary Outcome: 7-day Mortality • Tertiary Outcomes: Morbidity • The morbidity outcomes were • postoperative myocardial infarction, • postoperative pneumonia• postoperative congestive heart failure (CHF)• postoperative confusion.

• Charlson ME, Pompei P, Ales KL, MacKenzie CR: A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation. J Chron Dis 40:373-83, 1987


Repair Anesthesiology 92:947-57, 2000• Statistical Analysis • For each outcome, we first assessed the unadjusted relations with type of anesthesia and potential confounders using an independent sample t

test or chi-square test. We calculated the unadjusted odds ratio for the effect of type of anesthesia instead of the relative risk, so it could be compared with the adjusted odds ratio generated by a logistic-regression model. The odds ratio should be the same for uncommon outcomes except confusion.

• Logistic regression was used to describe the effect of type of anesthesia on outcome after adjusting for potential confounders. Potential confounding variables included characteristics that met all of the following criteria: (1) a statistically significant univariate relation with outcome (P ³ 0.05), (2) presence in at least 5% of the population, and (3) no expected value less than 5 in the contingency-table analysis. All variables maintaining a P value of 0.10 or less were included in the final model. All variables included in the tables or described in the data collection section of the article were evaluated for inclusion in the models. We did not control for intraoperative or postoperative factors (i.e., intraoperative hypotension) that might influence mortality or morbidity because these might actually represent outcomes that occurred during or after the time anesthesia was administered.

• The ASA physical status score was missing in 348 (3.7%) patients. We present the unadjusted odds ratios for both the entire study population (N = 9,425) and the subset of the population with an available ASA physical status score (n = 9,067). Adjusted odds ratios are presented for the population with an available ASA physical status score because the ASA physical status is included in all the multivariate models. The results of logistic-regression models that included all patients (therefore not controlling for ASA physical status) were very similar and had no effect on the interpretation of the results, except where noted in the Results section.

• In addition to controlling for confounding in the logistic-regression model as described previously, we performed an analysis using propensity scores, which stratified patients based on their predicted probability of receiving general anesthesia. The first step in this analysis was to develop a predictive model for general anesthesia. Independent predictors (demographic characteristics, comorbid conditions, habits, preoperative physical findings, hospital) were entered into a logistic model. The C statistic was used to assess the adequacy of the ability of the predictive models to discriminate between those who received general versus regional anesthesia. The probability of receiving general anesthesia (the “propensity score”) was generated for each patient, based on the model, and patients were grouped into quintiles of predicted probability. Thus, within each of the five strata defined by predicted probability, all patients had a similar likelihood (based on clinical and demographic characteristics) of receiving general anesthesia, although some did and others did not actually receive general anesthesia. This stratification is an attempt to eliminate confounding by the variables that went into calculating the propensity score. The odds ratio for anesthesia type versus 30-day mortality was calculated, with a 95% confidence interval, separately within each of the five strata defined by the propensity scores. We used the Breslow—Day test among quintiles of predicted probability of receiving general anesthesia to assess homogeneity of odds ratios, and then calculated the common odds ratio using the Mantel—Haenzsel procedure. All analyses were performed using Statistical Analysis Software (SAS) version 6.12.



• original study cohort included 9,598 patients who underwent operative repair of a hip fracture. Patients who received local anesthesia (n = 14), a combination of regional and general anesthesia (n = 134), or whose type of anesthesia was unknown (n = 25), were excluded from this analysis. The final study population therefore included 9,425 patients. General anesthesia was used in 6,206 patients (65.8%). Of the remaining 3,219 patients, 3,078 received spinal anesthesia and 141 received epidural anesthesia. The mean age was 80.3 yr (SD = 8.7 yr) and 78.7% were women.



• The regional anesthesia group was older (17.4% were older than 90 yr vs. 12.5% of the general anesthesia group), and somewhat more sick. For example, the regional anesthesia group was more likely to have a history of cardiovascular disease (47.6 vs. 40.9%) and chronic obstructive lung disease (21.3 vs. 14.0%), and a greater percentage of patients had a higher score on the Sickness at Admission scale and a higher ASA physical status classification. The relative percentages of patients receiving regional anesthesia increased progressively (P < 0.001) beginning in 1988 (). There was considerable difference among study hospitals in the percentage of cases performed during general versus during regional anesthesia (P < 0.001), ranging from 12.6 to 97.3% (). Only 0.2% of the general anesthesia group and 1.6% of the regional anesthesia group underwent postoperative epidural anesthesia.


Repair Anesthesiology 92:947-57, 2000 • This study of 9,425 patients is the largest analysis that we

are aware of that evaluated the effect of the type of anesthesia on mortality and morbidity. As might be predicted from clinical practice, we found that older patients and those who are more ill were more likely to be administered regional anesthesia. However, after controlling for differences in patient characteristics, we found no association between type of anesthesia and mortality or morbidity. This finding suggests that unadjusted differences in outcome between general anesthesia and regional anesthesia are mainly a result of concomitant disease, and not any protective effect of one anesthetic technique versus another.

• Liu S, Carpenter RL, Neal JM: Epidural anesthesia and analgesia. Their role in postoperative outcome. ANESTHESIOLOGY 82:1474-506, 1995

• Bode RH, Lewis KP, Zarich SW, Pierce, ET, Roberts, M, Kowalchuk, GJ, Satwicz, PR, Gibbons, G, Hunter, JA, Espanola, CC, Nesto, RW: Cardiac outcome after peripheral vascular surgery. Comparison of general and regional anesthesia. ANESTHESIOLOGY 84:3-13, 1996<ldn>!

• Go AS, Browner WS: Cardiac outcomes after regional or general anesthesia. Do we have the answers? ANESTHESIOLOGY 84:1-2, 1996

O'Hara et al

• Our analysis also shows that regional anesthesia was used more frequently in recent years. In 1981—1982, the first year of our study, general anesthesia was used in 94.8% of patients. By 1993—1994, general anesthesia was used in only 49.6% of patients. The reasons for the increased use of regional anesthesia cannot be determined from these data. However, there was considerable variability in the use of regional anesthesia among institutions, ranging from 12.6 to 97.3%. This variation in practice is consistent with many other medical interventions. Importantly, we adjusted for year of surgery and hospital in the analysis.

O'Hara et al

• Many clinical factors influence the risk of mortality and morbidity after anesthesia. Studies have suggested increasing age, cardiovascular disease, pulmonary disease, diabetes mellitus, and poor general medical status are associated with an increased risk of death during anesthesia, regardless of anesthesia type. Indices that incorporate multiple medical problems, such as the Charlson comorbidity index, Sickness at Admission scale, and acute physiologic score from the APACHE II scale have also been shown to be associated with mortality after surgery. Predictors of postoperative ischemia include evidence of cardiovascular disease (including hypertension), symptoms of ischemia, and CHF and diabetes. Age older than 60 yr, male gender, obesity, diabetes mellitus, and history of chronic obstructive pulmonary disease, renal disease, and smoking are associated with increased risk of critical respiratory events after general anesthesia. The ASA physical status has been shown to predict perioperative mortality and morbidity.

Hole A, Terjesen T, Breivik H: Epidural versus general anaesthesia for total hip arthroplasty in elderly patients.

Acta Anaesth Scand 24:279-87, 1980

• 26: Rose DK, Cohen MM, DeBoer DP: Cardiovascular events in the postanesthesia care unit. ANESTHESIOLOGY 84:772-81, 1996<ldn>!

• 27: Wolters U, Wolf T, Stutzer H, Schroder T: ASA classification and perioperative variables as predictors of postoperative outcome. Br J Anaesth 77:217-22, 1996<ldn>!

• 28: Prause G, Ratzenhofer-Comenda B, Pierer G, Smolle-Juttner F, Glanzer H, Smolle J: Can ASA grade or Goldman's cardiac risk index predict peri-operative mortality? Anaesthesia 52:203-6, 1997<ldn>!

• Mangano DT, Browner WS, Hollenberg M, London MJ, Tubau JF, Tateo IM: Association of perioperative myocardial ischemia with cardiac morbidity and mortality in men undergoing noncardiac surgery. The Study of Perioperative Ischemia Research Group, N Engl J Med 323:1781-8, 1990<ldn>!

• 19: Goldman L: Cardiac risk in noncardiac surgery: An update. Anesth Analg 80:810-20, 1995

• 20: Goldman L, Caldera DL, Nussbaum SR, Southwick FS, Krogstad D, Murray B, Burke DS, O'Malley TA, Goroll AH, Caplan CH, Nolan J, Carabello B, Slater EE: Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med 297:845-50, 1977<ldn>!

• 21: Fleisher LA, Barash PG: Preoperative cardiac evaluation for noncardiac surgery: a functional approach. Anesth Analg 74:586-98, 1992<ldn>!

• 22: Detsky AS, Abrams HB, McLaughlin JR, Drucker DJ, Sasson Z, Johnston N, Scott JG, Forbath N, Hilliard JR: Predicting cardiac complications in patients undergoing noncardiac surgery. J Gen Intern Med 1:211-9, 1986<ldn>!

• 23: Larsen SF, Olesen KH, Jacobsen E, Nielsen H, Nielsen AL, Pietersen A, Jensen OJ, Pedersen F, Waaben J, Kehlet H: Prediction of cardiac risk in non-cardiac surgery. Eur Heart J 8:179-85, 1987<ldn>!

Bode RH, Lewis KP, Zarich SW, Pierce, ET, Roberts, M,

Kowalchuk, GJ, Satwicz, PR, Gibbons, G, Hunter, JA,

Espanola, CC, Nesto, RW: Cardiac outcome after peripheral vascular surgery. Comparison of general and regional anesthesia. ANESTHESIOLOGY 84:3-13,

1996

• Hole A, Terjesen T, Breivik H: Epidural versus general anaesthesia for total hip arthroplasty in elderly patients. Acta Anaesth Scand 24:279-87, 1980<ldn>!

• 29: Cook PT, Davies MJ, Cronin KD, Moran P: A prospective randomized clinical trial comparing spinal anesthesia using hyperbaric cinchocaine with general anaesthesia for lower limb vascular surgery. Anesth Intensive Care 14:373-80, 1986<ldn>!

• 30: Damask MC, Weissman C, Todd G: General versus epidural anesthesia for femoral popliteal bypass surgery. J Clin Anesth 2:71-5, 1990<ldn>!

• 31: Jayr C, Thomas H, Rey A, Farhat F, Lasser P, Bourgain JL: Postoperative pulmonary complications. Epidural analgesia using bupivacaine and opioids versus parenteral opioids. ANESTHESIOLOGY 78:666-76, 1993<ldn>!

• 32: Jellish WS, Thalji Z, Stevenson K, Shea J: A prospective randomized study comparing short- and intermediate-term perioperative outcome variables after spinal or general anesthesia for lumbar disk and laminectomy surgery. Anesth Analg 83:559-64, 1996<ldn>!

• 33: Shir Y, Raja SN, Frank SM: The effect of epidural versus general anesthesia on postoperative pain and analgesic requirements in patients undergoing radical prostatectomy. ANESTHESIOLOGY 80:49-56, 1994<ldn>!

• 34: Christopherson R, Beattie C, Frank SM, Noris EJ, Meinert CL, Gottlieb SO, Yates H, Rock P, Parker SD, Perler BA, Williams GM: Perioperative morbidity in patients randomized to epidural or general anesthesia for lower extremity vascular surgery. ANESTHESIOLOGY 79:422-34, 1993<ldn>!

• 35: Rosenfeld BA, Beattie C, Christopherson R, Norris EJ, Frank SM, Breslow MJ, Rock P, Parker SD, Gottlieb SO, Perler BA, Williams GM, Seidler A, Bell W: The effects of different anesthetic regimens on fibrinolysis and the development of postoperative arterial thrombosis. ANESTHESIOLOGY 79:435-43, 1993<ldn>!

• 36: Williams-Russo P, Sharrock NE, Haas SB, Insall J, Windsor RE, Laskin RS, Ranawat CS, Go G, Ganz SB: Randomized trial of epidural versus general anesthesia: Outcomes after primary total knee replacement. Clin Ortho Rel Res 331:199-208, 1996<ldn>!

• 37: Yeager MP, Glass DD, Neff RK, Brinck-Johnsen T: Epidural anesthesia and analgesia in high-risk surgical patients. ANESTHESIOLOGY 66:729-36, 1987<ldn>!

• Yeager MP, Glass DD, Neff RK, Brinck-Johnsen T: Epidural anesthesia and analgesia in high-risk surgical patients. ANESTHESIOLOGY 66:729-36, 1987<ldn>!

O'Hara et al

• The most important limitation of this retrospective observational cohort study is that it is possible that we were unable to identify and adjust for important prognostic differences between groups even though we controlled for ASA status, hospital, many individual diseases, and several comorbidity indices. A randomized clinical trial would eliminate this limitation but would need to be very large to adequately assess mortality and morbidity outcomes. For example, a trial in patients with hip fracture with 30-day mortality as the primary outcome (assuming 80% power, 4.8% mortality, and ability to detect 25% difference) would necessitate a sample size of approximately 13,000—14,000 patients. If the primary outcome for the trial was 7-day mortality (a time period some would argue is more likely to be related to anesthesia than 30-day mortality), 38,000 patients would be needed because mortality is much lower at 7 days than at 30 days. Alternatively, a smaller trial could be performed using a combined mortality and morbidity outcome.

• The precision of this study can be evaluated by evaluating the 95% confidence intervals. For fully adjusted 30-day mortality analysis, the 95% confidence interval of 0.84—1.38 means that the observed data are statistically compatible with an increase in risk of death no greater than 38% and a decrease in the risk of death no greater than 16%. This is equivalent to a difference in mortality from 4.03 to 6.6% when compared to a baseline of 4.8%, which suggests this study has reasonable power to detect clinically important differences in 30-day mortality. The study has less power to evaluate risk of myocardial infarction and pneumonia.

Ziser A,Plevak D,Wiesner RH,Rakela J,Offord KP, Brown DL.Morbidity and Mortality in Cirrhotic Patients

Undergoing Anesthesia and Surgery.Anesthesiology,90:42-53, 1999

• Methods: The authors retrospectively reviewed the records of all patients with the diagnosis of cirrhosis who underwent any surgical procedure under anesthesia at their institution between January 1980 and January 1991 (n = 733). Univariate and multivariate analyses were used to identify the variables associated with perioperative complications and short- and long-term survival.

• Results: The perioperative mortality rate (within 30 days of surgery) was 11.6%. The perioperative complication rate was 30.1%. Postoperative pneumonia was the most frequent complication. Multivariate factors that were associated with perioperative complications and mortality included male gender, a high Child-Pugh score, the presence of ascites, a diagnosis of cirrhosis other than primary biliary cirrhosis (especially cryptogenic cirrhosis), an elevated creatinine concentration, the diagnosis of chronic obstructive pulmonary disease, preoperative infection, preoperative upper gastrointestinal bleeding, a high American Society of Anesthesiologists physical status rating, a high surgical severity score, surgery on the respiratory system, and the presence of intraoperative hypotension.

• Conclusion: Risk factors have been identified for patients with cirrhosis who undergo anesthesia and surgery.

•

Ziser et al.Morbidity and Mortality in Cirrhotic Patients Undergoing Anesthesia and

Surgery.Anesthesiology,90:42-53, 1999

• PATIENTS with cirrhosis have a reduced life expectancy. Ginés et al. reported a median survival time of 8.9 yr for patients (mean age, 50.2 years) with newly diagnosed cirrhosis. The median survival time decreased to 1.6 yr in patients after the onset of the first major complication of cirrhosis (ascites, jaundice, encephalopathy, or gastrointestinal hemorrhage). Anesthesia and surgery are known to have decompensatory effects on patients with cirrhosis. Aranha et al. reported a 25% perioperative mortality rate for those patients with cirrhosis who underwent open cholecystectomy. Those patients who died frequently experienced postoperative bleeding, renal failure, and sepsis. We did this retrospective investigation to identify those factors that might be predictive of perioperative complications and death in patients with cirrhosis who were undergoing anesthesia and surgery.

Ziser et al .Morbidity and Mortality in Cirrhotic Patients Undergoing Anesthesia and

Surgery.Anesthesiology,90:42-53, 1999• January 1980- January 1991• Mayo Clinic.• The minimum follow-up period was 2.7 yr, and the maximum

follow-up time was 13.7 yr.• Only one surgical procedure considered • Patients who underwent orthotopic liver transplantation before or

during the study were excluded. • diagnosed primarily by liver biopsy(some . history of liver disease

with impaired liver function tests, + liver ultrasound or computed tomography scan suggesting the diagnosis of cirrhosis,

• or direct examination of a cirrhotic liver during abdominal surgery.



• Postop KO in 222 patients (30.1%):• Pneumonia:59 patients (8%) • ventilatory dependence: 57 patients (7.8%)• infection: 55 (7.5%)• new-onset or worsening ascites:49 patients

(6.7%)• cardiac arrhythmia :37 patients (5%).

Factors associated with perioperative complications in cirrhotic patients.(from Ziser et al .Morbidity and Mortality in Cirrhotic

Patients Undergoing Anesthesia and Surgery.Anesthesiology,90:42-53, 1999)

– male gender

– a high Child-Pugh score

• an elevated prothrombin time

• a low serum albumin level

• the presence of ascites

• the presence of varices

• a diagnosis of cirrhosis other than primary biliary cirrhosis

• an elevated serum creatinine concentration

• Higher ASA classification• emergency surgery• general anesthesia• cardiovascular operations• surgery for portal-systemic

shunt• splenectomy• digestive tract procedures• hip and pelvic surgery • A high surgical severity score • the presence of intraoperative

hypotension

Variables associated with complications in cirrhotic patients (DA Ziser et al .Morbidity and Mortality in Cirrhotic Patients Undergoing Anesthesia and


0

20

40

60

80

%

norm

norm

elevatNO

SI

+CIRROSI CRIPTOGENETICA E CERTI TIPI DI CHIR…



• Increased mortaility rate:• male gender• a high Child-Pugh score• an elevated prothrombin time• an elevated total bilirubin level• a low serum albumin level• the presence of ascites• the diagnosis of cryptogenic cirrhosis• an elevated serum creatinine concentration


Surgery.Anesthesiology,90:42-53, 1999• preoperative coexisting diseases that were associated with an increased

mortality rate:• chronic renal failure• chronic obstructive pulmonary disease,• pneumonia• congestive heart failure• ischemic heart disease• insulin-dependent diabetes mellitus• the presence of preoperative infection • Factors concerning anesthesia management that were associated with

an increase in the mortality rate :• a high ASA classification• emergency surgery.



• Those surgical procedures that were univariately associated with higher mortality rates included respiratory procedures, those cardiovascular procedures that required extracorporeal circulation, and biliary tract and liver procedures (). The occurrence of intraoperative hypotension was also statistically associated by univariate analysis with increased mortality rates.



• Multivariate analysis identified eight variables that were independently associated with a high short- and long-term mortality rates (P < 0.001). These multivariate associations included male gender, a high Child-Pugh score, the presence of ascites, a diagnosis of cryptogenic cirrhosis, an elevated creatinine concentration, preoperative infection, a high ASA physical status, and surgery on the respiratory system



• This retrospective investigation again documents a high perioperative mortality risk for patients with cirrhosis undergoing anesthesia and surgery. Aranha et al. reported an overall 25% perioperative mortality rate in patients with cirrhosis who underwent open cholecystectomy. They compared the mortality rates of three groups of patients having open cholecystectomy: noncirrhotic patients (1.1%), patients with cirrhosis with a prothrombin time less than 2.5 s greater than the control value (9.3%), and patients with cirrhosis with a prothrombin time more than 2.5 s greater than the control value (83%). Leonetti et al. reported a mortality rate of 8.3% for patients with cirrhosis who underwent umbilical hernia repair. They contrasted this rate of mortality with a mortality rate of 1.8% in noncirrhotic patients who had the same operation. Recently, Rice et al. reported a 28% perioperative mortality rate for patients with chronic liver failure who underwent nonhepatic surgery. Our investigation shows that 11.6% of patients with cirrhosis who received an anesthetic agent for any type of surgery (except liver transplantation) died within 30 days of surgery.

Mortality rates in cirhhotic patients operated upon for various procedures

1

10

100

normal cirr PT 2.5+ cirr PT>2.5

Araanha

Leonetti

Rice

Ziser

Open cholecystectomu

Umbilical hernia

Dati di Jayr su Vaio

Studi comparativi di outcome fra peridurale e G.A, nei bambini

0

5

10

15

20

morbidità O2 terap gg osped costo

dati da Mc Neely(1991) in fundoplicatio

epidG.A.

$*1000gg o %

Quale rationale per scegliere regionale vs generale?

• esistono realmente dei vantaggi?

• quali sono questi vantaggi,se ci sono?

• sono state considerate tutte le variabili nella scelta?

• sono stati eliminati i biasimi dell’osservatore?

Studi comparativi di outcome fra peridurale e G.A, nei bambini

0

5

10

15

20

25

30

35

G.A. P.D.

dati da Bosenberg(1991)nella chirurgia per atresia esofagiea

estubazventilaz

Definire le complicanze legate all’anestesia(Lagasse,Anesthesiology 1995)

• morte intraop o <2 gg.• ricovero osped o in ICU inaspettato opp. <1 g.• cefalea postpuntura durale(PDPH)• arresto resp intraop o <1 g.• infarto miocardico intraop o < 2 gg.• arresto cardiaco intraop o < 1 g.• cva intraop o < 2gg.• polmonite da aspiraz• EPA intraop o < 1gg• trauma oculare,dentario.nervi periferici intraop o

< 1 g

complicanze legate all’anestesia(ARC’s)

• tutte le complicanze :• neurologiche• polmonari• cardiache(MI,aritmie,CHF,angina nuova)• gastrointest.(emorragia,canalizzaz.....)• infettive(sepsi,MOF...)• trombotiche• ecc,ecc.(reintervento...)

Metabolic control of noninsulin dependent diabetic patients undergoing cataract surgery:comparison of local

and general anesthesia.(BJA,1995,74,500-505).• 40 pazienti anziani• chirurgia per cataratta• 4 gruppi di 10:GA/ NIDDM

LA/NIDDMGA/sani

LA/sani• GA:tps/vecu/iot/N2O/enflurane• LA:blocco retro-o peribulbare• pasto 2 h postop.in LA,dopo 4 h in GA.


and general anesthesia.(BJA,1995,74,500-505).

-200

-100

0

100

200

300

400

induz fine ch 60post 240post

Andamento della cortisolemia

GANIDDMLANIDDMGAnormLAnorm

valori espressi in variazione dai basalimmol/lt


and general anesthesia.(BJA,1995,74,500-505).

-0,5

0

0,5

1

1,5

2

2,5

3

induz estraz fine ch 30'post 60'post 120'post 240'post

andamento della glicemia

GANIDDMLANIDDMGAnormLAnorm

mmol/lt variazioni rispetto ai valori basali

McNeely,Anesthesiology,75,A689,1991.

• chirurgia antireflusso gastroesofageo

• 20 paz p.d.vs 20 G.a.

Controllo della tachicardia• Anesth.Analg. 1990,70,S74

• Crowley et al.

• interv di chir vascolare periferica ;epid vs GA

• G.A:fent/tiamylal/N2O/enflurane;morfina in PCA vs epid a T8 ;fent p.d.cont.

• HR + elevato nel postop dopo GA

• uso di betabloccanti + frequente intra e postop nei paz in GA

Funzione gastrica postop:da Petring et al.BJA,1995,74,257.

0

2

4

6

8

10

12

15' 30' 45' 60' 90' 120'

assorbimento del paracetamolo dopo anestesia spinale per chir.ortopedica e

analgesia con ketorolac 30 mg o morfina 10 mg i.m.

ketormorf

mg/lt

Postoperative pediatric urology

0

20

40

60

80

100

120

140

spasmo vesc Ist pasto Deg.postop

Pd.analgesia shortens hospital stay(Agarwal et

al.,Reg.Anesth.,1995,20,s48,)

epidnon epid.

gg

hrs

%

Advantages of epidural analgesia in upper abdominal surgery

soddis.

dimis

funz.int.

VAS 3VAS 2

VAS 1

VAS g.op.

0,00

1,00

2,00

3,00

4,00

5,00

6,00

7,00

8,00

9,00Borkowski et al.,Reg.Anesth.,1995,20,s49

I.V.PCAP.D.

p.d.con bupi 0,1+fent 5 microgr/ml

i.v.PCA con morfina

Analgesic techniques affects rate of recovery after colonic surgery(Liu et

al,Reg.Anesth.,1995,20,s9)

0,0010,0020,0030,0040,0050,0060,0070,0080,0090,00

100,00

h.Ist flatus t.dimiss

PCA morf.P.D.morfp.d.bupip.d.bup+morf

hrs

Transsternal thymectomy patients

0,00

10,00

20,00

30,00

40,00

50,00

60,00

FVC 1 FVC 2 FVC3 RR pain 1 pain2 pain 6

p.d morfp.d plac

% o punti

Yaeger:inizia la disputa

card. respkidney liver

infectreop

tot.compl

0

5

10

15

20

card. kidney infect tot.compl

frequenza di complicanze in chirurgia maggiore a seconda della tecnica anestesiologica:GA +PCA vs blended + pd.

Epidi.v.PCA

% *;signif** *

Guinard et al,Anesthesiology,1995,82,377-382.

• “p.d. and i.v. fentanyl produce equivalent effects during major surgery”

• emodinamica simile

• no diff.nei consumi di fentanil

• no diff.nei consumi di propofol(TIVA)

• no diff nei livelli plasmatici di glucosio,cortisolo,Adr e Nadr urinarie

• tecnica indistinguibile per “blinded” anestesista.

Baron et al,Anesthesiology,1991,75,611-618.

card

resp

renal GIsepsi

compl.magg

0

10

20

30

40

50

60

card renal sepsi

Complicanze fra blended e G.A. per chirurgia dell'aorta addominale

G.A.P.D.

N.S.

Yaeger vs Baron• differenza nella chirurgia(addomino-toracica maggiore vs

aortica)

• differenza nel numero pazienti

• differenza nel protocollo anestetico intraop e postop.

• differenze intrinseche fra p.d con oppioidi vs p.d. con L.A.

• non sarà l’analgesia postop a determinare le differenze nell’outcome?

Incidenza di episodi ischemici perioperatori

0,00

5,00

10,00

15,00

20,00

25,00

preop -2 a 0 intraop 0-24 24-48 48-72 72-96 96-126

Ischemia periop.in 52 paz.monitorizzati con Holter(da Marsch,Anesthesiology,76,518,1992)

epis.ischem

paz con isch

dur isch

da -2 a 0

0-24 h

48-72

96-120

Perioperative myocardial ischemia in patients undergoing elective hip arthroplasty during lumbar regional

anesthesia.(Marsch er al.,Anesthesiology,76,518,1992)

• età 74

• 11 con CAD,22 con fattori di rischio,19 senza

• monitoraggio Holter continuo da 24 h preop a 126 h postop

• anestesia regionale a T8,spinale o p.d.

Perioperative myocardial ischemia in patients undergoing elective hip arthroplasty during lumbar regional anesthesia.(Marsch er

al.,Anesthesiology,76,518,1992) II• 99 episodi ischemici significativi in 16 paz• solo 4% con angina• 44 episodi accompagnati da

tachicardia(>100/min) • rischio relativo di ischemia associato alla

CAD ;• complicanze cardiache correlate alla CAD

Perioperative myocardial ischemia in patients undergoing elective hip arthroplasty during lumbar regional anesthesia.(Marsch er

al.,Anesthesiology,76,518,1992) III

0

5

10

15

20

dur preop dur postop

durata mediana degli episodi ischemici

min

Myocardial ischemia and spinal analgesia in patients with angina pectoris. (Christensen et

al,BJA,1993,71,472.)

• paz.con angina pectoris stabile• monitoraggio Holter continuo• 24 ore pre ed intraop ,poi in III-IV

giornata a domicilio• anest.spinale con 25g ,bupi 17.5 mg• chirurgia

minore(orchiectomia,TURB,frattura caviglia,ernioplast.)

Myocardial ischemia and spinal analgesia in patients with angina pectoris. (Christensen et

al,BJA,1993,71,472.);segue dalla prec.

• il I evento ischemico il giorno dell’intervento si presenta 338 min più tardi della anest.spinale

• si associa con aumento della FC

II:Myocardial ischemia and spinal analgesia in patients with angina pectoris. (Christensen et

al,BJA,1993,71,472.)

0,00

5,00

10,0015,00

20,00

25,00

30,0035,00

paz1

3 5 7 9 11 13

numero totale,durata in min e slivellamento ST(*100) degli eventi ischemici nel giorno di referenza

num ev.ischdurata ischST depr

III:Myocardial ischemia and spinal analgesia in patients with angina pectoris. (Christensen et

al,BJA,1993,71,472.)

0

50

100

150

200

250

300

paz1

3 5 7 9 11 13

numero totale di eventi ischemici.durata in min e slivellamento ST in mm(*100)il giorno dell'intervento

num.eventiduratasliv.ST

Maggiore incidenza di eventi ischemici nel giorno dell’intervento rispetto ad un giorno successivo di riferimento con attività normale.Christensen IV

020406080

100120140160

giorno referenza giorno op.

num.eventidur.ischsliv.ST

*10!!

Perioperative myocardial ischemia in patients undergoing transurethral surgery:a pilot study comparing general

with spinal anesthesia.(Edwards et al,BJA,1995,74,368)

• Holter il pomeriggio prima dell’intervento e fino al giorno dopo

• confronto fra :

• A.G con fentanyl/etomidate/iot/vecu/enflurane/N2O 66% e spinale con bupi 14 mg.,blocco a T 10:

• e tre gruppi di rischio:malattia ischemica.solo fattori di rischio,senza fattori di rischio

• analgesia postop con morfina i.m.

• O2 postop per 24 h.

II:Perioperative myocardial ischemia in patients undergoing transurethral surgery:a pilot study

comparing general with spinal anesthesia. (Edwards et al,BJA,1995,74,368.)

III:Perioperative myocardial ischemia in patients undergoing transurethral surgery:a pilot study

comparing general with spinal anesthesia. (Edwards et al,BJA,1995,74,368.)

• tuttavia,anche se non ci sono state differenze nel carico di ischemia(“ischemic burden”),definito come durata di ischemia in min/durata del monitoraggio............

• 4 gravi Ko,tutte dopo AG,di cui 3 mortali:• MI dopo 4 gg

• MI dopo 25 gg

• ictus dopo 25 gg

• insuff cardiaca e morte dopo 12 h.

IV:Perioperative myocardial ischemia in patients undergoing transurethral surgery:a pilot study comparing general with spinal

anesthesia. (Edwards et al,BJA,1995,74,368.)

0

2

4

6

8

10

12

14

aum isch dim isch

i casi sono pochi,ma potrebbe esistere una differenza vera.......

A.Gspin

%

The effect of epidural versus general anesthesia on postoperative pain and analgesic requirements in patients undergoing radical

prostatectomy.(Shir et al,Anesthesiology,1994,80,49)T

• 3 gruppi :p.d.solo,p.d.+ A.G.,A.G solo(N2O,isof).

• prostatectomia retropubica radicale

• PCA fent 5 microgr/ml + 0.0625% bupiv

• VAS ogni 4 ore per 5 gg.

• bassi VAS nei gg.di trattamento,con pd>A.G. il I giorno

II:The effect of epidural versus general anesthesia on postoperative

pain and analgesic requirements in patients undergoing radical prostatectomy.(Shir et al,Anesthesiology,1994,80,49)T

0,00

20,00

40,00

60,00

80,00

100,00

120,00

140,00

PCA I II III IV

p.d.blendedA.G.

ml

III:The effect of epidural versus general anesthesia on

postoperative pain and analgesic requirements in patients undergoing radical prostatectomy.(Shir et al,Anesthesiology,1994,80,49)T• lo studio ha qualche manchevolezza

metodologica(dose di bupi inf.nel gruppo blended,morfina nel gruppo A.G all’inizio e non negli altri,inutilizzo del catetere p.d nel gruppo A.G....),ma dimostra che il blocco completo intraop delle afferenze al SNC è fondamentale nel diminuire il dolore postop.

Failure of epidural anesthesia to prevent postoperative paralytic ileus.(Wallin et

al,Anesthesiology,1986,65,292)

• 30 paz per colecistectomia elettiva

• A.G. vs blended(+ p.d con bupi 0.25% postop):analgesia postop con pentazocina.

• peristalsi valutata dalla progressione di markers radioopachi

• Non sono emerse differenze nel ritorno dell’attività propulsiva,nè nella progressione dei markers,nè nel ritorno di gas e defecazione.

Long term home self treatment with high thoracic epidural anesthesia in patients with severe coronary

artery disease.(Blomberg,S.G.,AA.,1994,79,413)

• 20 paz,con angina instabile refrattaria intrattabile,non candidati ad intervento

• p.d.toracica,prima di prova,poi tunnellizzata

• paz.istruiti nella automedicazione con bupivacaina,dopo nitrati sub.ling.

II:Long term home self treatment with high thoracic epidural anesthesia in patients with severe coronary


• indicazioni alla p.d.toracica:• pazienti con rischio chirurgico troppo elevato

• pazienti considerati inoperabili

• pazienti in attesa di bypass aortocoronarico

• paz.in attesa di stimolaz elettrica del midollo spinale

III:Long term home self treatment with high thoracic epidural anesthesia in patients with severe coronary


• sollievo dal dolore immediato

• valida qualità di vita e capacità funzionale

• progressiva diminuzione dei rifornimenti nel tempo

• durata:da 8 gg a 3.2 anni(media 186 gg)

• 4 paz curati:5 CABG ed 1 SCES,5 decessi;5 riposizionati

• problemi:2 occlusioni,3 riposizionamenti

• nessuna infezione

Effect of thoracic epidural anesthesia combined with general anesthesia on segmental wall motion assessed by transesophageal echocardiography.(Saada et al.,AA,1992,75,329)

• anestesia p.d toracica(inserz T6-T8) + A.G.(alfent/midaz/vecu)

• 26 paz per chirurgia aortica• TEE bidimensionale + emodinamica classica• prima A.G.poi p.d.con 12.5 ml di lidocaina 2%• plasmaexpander 10 ml/kg per 40 min pre

p.d.:efedrina al bisogno.

II:Effect of thoracic epidural anesthesia combined with general anesthesia on segmental wall motion assessed by transesophageal echocardiography.(Saada et al.,AA,1992,75,329)

0

100

200

300

400

500

600

700

0 10 20 30 40 60

Andamento temporale dei livelli plasmatici delle catecolamine dopo p.d. toracica con lidocaina 2%.

epinefrnorepi

* ** * *

III:Effect of thoracic epidural anesthesia combined with general anesthesia on segmental wall motion assessed by transesophageal echocardiography.(Saada et al.,AA,1992,75,329)

0,0010,0020,0030,0040,0050,0060,0070,0080,0090,00

0 10 20 30 40 60

HR,MAP,CI,CPP(cor.perfus.press),SWM(segment.wall motion TEE)giù,PAOP su rispetto al basale dopo

anest.p.d.toracica.

HRMAPPAOPCI*10CPPSWM

min

* *

IV:Effect of thoracic epidural anesthesia combined with general anesthesia on segmental wall motion assessed by transesophageal echocardiography.(Saada et al.,AA,1992,75,329)

• però il CI diminuisce solo nei pazienti con CAD!!

• NonCAD SWM scores < ai CAD,ma NCAD diminuiscono dopo TEA.

• tendenza al miglioramento delle SWM dopo TEA

• correzione dell’ipotensione con efedrina aumenta transitoriamente le SWM

Abnormalities in myocardial segmental wall motion during lumbar epidural anesthesia(Saada et

al.,Anesthesiology,1989,71,26)

Fibrinolytic and hemorheologic alterations during and after elective aortic graft surgery:implications for

postoperative management.(Freyburger et al,AA,1993,76,504)

• variabili fibrinolitiche ed emoreologiche in 15 paz

• chir.aortica protesica elettiva(dacron grafts)

• A.G. NLA e N2O

• diluiz con cristalloidi 10 ml/kg/h + albumina 12 ml/kg all’inizio della chir

• trasfus 903+/-240 ml intraop



• 50 u.i eparina all’inizio della chir;poi 300 IU/kg/die per aPTT>1.5 controllo

• viscosità misurata a differenti shear rates.

• structure index riflette la struttura tridimensionale degli aggregati



• in conclusione;• il fibrinogeno prima decresce poi aumenta:

• la fibrinolisi diminuisce

• nella I settimana postop esiste una tendenza all’iperviscosità

• esistono modificazione drammatiche nella eritroaggregazione,con rapide e reversibili modificazioni dei rouleaux eritrocitari.

II:Fibrinolytic and hemorheologic alterations during and after elective aortic graft surgery:implications for postoperative

management.(Freyburger et al,AA,1993,76,504)

III:Fibrinolytic and hemorheologic alterations during and after elective aortic graft surgery:implications for postoperative

management.(Freyburger et al,AA,1993,76,504)

0

50

100

150

200

250

300

Preop Periop Postop Day1 DAY3 DAY6

Andamento temporale delle variabili coagulative ed emoreologiche

Hctpiastrprot(gr/lt)album(gr/lt)Fibrinog(*10)vWillFact(%)

Haemodynamic effects and outcome analysis of hypotensive extradural anaesthesia in controlled hypertensive patients undergoing total hip arthroplasty.(Sharrock et al.BJA,1991,67,17)

• 1016 pazienti consecutivi sottoposti a p.d.lombare con blocco a T4 per ipotensione

• chirurgia protesica dell’anca• riduz della MAP al 50% • correzione emodinamica con infusione di

adrenalina(1-5 mg/h)• valutazione dello stato cerebrale dal contatto

verbale con il paziente

II:Haemodynamic effects and outcome analysis of hypotensive extradural anaesthesia in controlled hypertensive patients undergoing total hip

arthroplasty.(Sharrock et al.BJA,1991,67,17)

• 3 decessi nel postop• non differenze fra paz ipertesi e non,nè nei

livelli di ipotensione,nè nelle KO• 69 pazienti seguiti con emodinamica

invasiva;MAP,HR,PADP,SVR,LVSWI ridotti,ma SV e CO mantenuti

• in conclusione:ipotensione controllata al 50% dei valori basali ben tollerata in anestesia p.d. alta per total hip anche in pazienti ipertesi e coronaropatici.

Cardiac outcome after peripheral vascular

surgery(Bode et al,Anesthesiology,1996,84,3-13) II

• GA vs spi vs p.d.

• 425 paz per bypass fem-distale

• monitoraggio con PA cruenta radiale + PAP

• NTG i.v. per controllo pressione

• terapia idrca guidata da emodinamica

• analg.postop con morf o mep i.v.


surgery(Bode et al,Anesthesiology,1996,84,3-13)IIII

• monitoraggio:

• sintomi

• ECG

• CPK

• emodinamica invasiva per 48 h.

Cardiac outcome after peripheral vascular surgery(Bode et al,Anesthesiology,1996,84,3-

13)IIIIII

0

2

4

6

8

10

12

14

16

18

Ko card MI angina CHF morte

G.A.SpiP.D.

Cardiac outcome after peripheral vascular surgery(Bode et al,Anesthesiology,1996,84,3-

13)IVIV

0

2

4

68

10

12

14

16

1820

Z

PADPmax CVPmax ggRR ICUgg Osp.gg

G.A.SpiP.D.

CVP max ggICU


surgery(Bode et al,Anesthesiology,1996,84,3-13)VV

• Conclusioni:

• la morbilità e mortalità periop non differisce fra i tre tipi di anestesia,nè sono diversi i tempi di ricovero.

• attenzione alle conversioni da regionale

insuff. a G.A.!+ Ko!

Le ragioni per scegliere la anestesia regionale

• riduzione dello stress• riduzione delle perdite ematiche• riduzione delle Ko tromboemboliche• preservazione dello stato mentale• riduzione delle complicanze respiratorie• riduzione dei costi• accelerata convalescenza con ridotta

degenza• superiore analgesia postop.

Anestesia regionale:una scelta mirata?

• chirurgia dell’anca

• chirurgia della prostata,specie per via endoscopica

• chirurgia ,oncologica,del ginocchio

• cesareo

• chirurgia vascolare periferica

anestesia regionale e funzione G.I

• facilitazione dello svuotamento gastrico

• aumento dell’ attività elettrica intestinale

• riduzione del tempo di transito dell’ileo

• miglioramento del flusso ematico splancnico

Riduzione delle perdite ematiche

0

10

20

30

40

50

60

Keith Hole Modig Hendolin

% protesi d'anca elettiva

prostatect retropub

TURP

isterectomia

Riduzione delle complicanze tromboemboliche

0

10

20

30

40

50

60

70

80

Davis Modig Modig Jorgensen

reggen

protesi d'anca

prostatectomia

%

chir.ginocchio

chir.vasc

Riduzione delle complicanze respiratorie

• migliore conservazione della FRC

• minore frequenza di KO infettive

Riduzione delle complicanze cardiache

0,00

5,00

10,00

15,00

20,00

25,00

Reiz Cristopherson

reggen

p.d.MI<3mo.vasc.mag

g.urg

exitus,MI,angina,

resp.fail

Quale evidenza globale?

0

20

40

60

80

100

Report of National Confidential Enquiry into perioperative deaths 1990

G.A.Locale soloreg.soloGA+REGGA+localsedazsedaz+localsedaz+reg

e fra le diverse tecniche?

Complicanze nel cesareo(CEMD)

0

1

2

3

4

5

6

7

8

9

inalinduz falliot accidapparec

varie

1973-19751976-19781979-1981

inaliotmisusofarm

sub

inve

ce d

i p

d

casi

*****

Mortalità (<30 gg.) in chirurgia urgente di protesi d’anca

02

4

6

810

12

14

16

1820

Couderc Davis McKenzie Rackle

reggen**

*%

Lista delle abbreviazioni

• ASA:American Society of Anesthesiologists• ACOG:American College of Obstetricians

Gynecologists• CEMDEW(UK):Confidential Enquiry into

maternal deaths of England and Wales(poi United Kingdom)

• C/S ;cesareo• AG o GA;anestesia generale• Reg;regionale

Report on Confidential enquiries into maternal deaths in England and Wales 1970-1996

0

5

10

15

20

25

30

35

1970-72

73-75

76-78

79-81

82-84

85-87

88-90

91-93

94-96

97-99

Frequenza per milione di gravid.stimate

emb.polmipertens

anestemb.fluido amnioticoaborto

gravid.ectopicaemorragiasepsi

rottura uteroaltre cause dirette

Entrata in vigore della nuova classificazione

Morti materne associate con l’anestesia in milioni di gravidanze stimate per England & Wales

0

5

10

15

20

25

30

35

40

70-72

73-75

76-78

79-81

82-84

85-87

88-90

91-93

94-96

97-99

morti associatedirettamentefreq.per milione

% delle morti dirette

Maternal Mortality

0

5

10

15

20

25

30

35

40

45

1985-87 1988-90 1991-93 1994-96 1997-99

Triennium

Num

ber

Congenital

Acquired-Isch

Acquired-Other

Total

Maternal Mortality

10 9 9 10 10

95 8 6 5

4

42

2320

05

1015202530354045

1985-87 1988-90 1991-93 1994-96 1997-99

Triennium

Num

ber

Acquired-Other

Acquired-Isch

Congenital

Maternal Deaths

0

5

10

15

20

25

30

1985-87 1988-90 1991-93 1994-96 1997-99

Triennium

Num

ber of death

s

Pre-eclampsia

Eclampsia

Total

Rate

Maternal deaths

0

5

10

15

20

25

1985-87 1988-90 1991-93 1994-96 1997-99

Triennium

Num

ber Placental abruption

Placenta praevia

Post-partum haem

Total deaths

Breakdown of thromboembolism

0

2

4

6

8

10

12

14

16

18

1985-87 1988-90 1991-93 1994-96 1997-99

Num

ber

Miscarraige/ectopic

Antepartum

In labour

CS

Vaginal delivery

Deaths from pulmonary embolism

1985-871988-90

1991-931994-96

1997-99

30

2430

46

31

0

5

10

15

20

25

30

35

40

45

50N

um

ber

Da Parker,J,Schiffer,MA,Nelson,F.“Maternal and perinatal mortality”in Clinical management

of mother and newborn,GF Marx ed.,Springer,New York 1979,pag 241-274.

0

5

10

15

20

25

30

Num %

Maternal mortality,New York 1973-76;122 morti.

emb.polmprecl-eclampsiaanest

Da Parker

0

5

10

15

20

%

Maternal mortality,New York 1980

gravid.ectopica

ipertens

emb polm

accid cerebrovasc

anestesia

Tabella comparativa della mortalità materna attribuita

all’anestesia

0

2

4

6

8

10

12

14

%

New York 73-76N.Y 77-80N.Y 81-83Indiana 60-80E-W 64-66E-W 67-69E-W. 70-72E-W.73-75E-W.79-81E-W.82-84E_W.85-87UK 88-90

Pattern di mortalità materna associata all’anestesia

• New York,1979-81:– 13 casi:

• 12 GA:failed intub,asp of gastric content

• 1 epid(iniez accid di bupi)

• Indiana 60-80– aspiraz di gastric

content

– cardioresp arrest


• England-Wales 1970-78

• 68 da GA;• 40 inalazioni

• 28 problemi di iot

• 7 da reg.

• England & Wales 1985-87

• 7 da GA– 5 iot sbagliata(2 nel periodo

‘91-93)

– 1 inalaz

– 1 tubo iot piegato

• 1 da reg;– collasso cardiovasc da

blocco epid in paz con insuff aortica :


CAUSA 1973-75 1976-78 1985-88

Inalaz all’induzanest.

9 4 1

Inalaz durante iotdifficile

4 7 0

Ipossia da iotesofagea/fallita/tubo piegato

3 9 6

Errori di farmaci 4 3 0

Iniezsubaracn.durantetentata epid

2 1 0

Varie 7 4 1

Frequenza di iot fallite

• Hawthorne, L.; Wilson, R.; Lyons, G.; Dresner, M. Failed intubation revisited: 17-yr experience in a teaching maternity unit

• Br. J. Anaesth. 1996; 76:680-684.

• 16 anni di esperienza del St James

• 5802 GA per C/S

• 0.4% di iot fallite;1/300 1984,1/250 1994.

Frequenza di iot fallite(Tsen et al,Int J.Obset Anesth. 1998;7:147)

0

2

4

6

8

10

12

14

16

1990 1991 1992 1993 1994 1995

iot fallite

Cambiamento del Mallampati Score durante la

gravidanza(Piklington et al,BJA 1995;74:638)

0

10

20

30

40

50

60

%

1 2 3 4

12-set38 sett

score

Aumento delle iot difficili in ostetricia

0

0,2

0,4

0,6

0,8

1

1,2

1,4

1,6

1,8

%

score 3

chir genC/S (Pilk)C/S (Durban)ost (Carli)

Cause delle iot difficili

• Variazioni anatomiche

• fattori organizzativi:– inesperienza– urgenze fuori orario

– “stat” mentalità– panico

0

20

40

60

80

100

%

elettive

Iot fallite e tipo di C/S(Hawthorn,BJA 1996

% AGfallite

Ricorso non necessario alla AG

• Inadeguata educazione della paziente• abitudini chirurgiche• chiamata tardiva• controindicazioni sorpassate:

– preeclampsia– placenta praevia– febbre– mal.cardiache

Prevenzione delle C/S di urgenza(Morgan,Brit J Obstet

Gynecol 1990;97:420)

• visite preop congiunte 3 volte al dì

• analgesia peridurale raccomandata per tutte le madri a rischio di C/S

• comunicazione continua fra reparto di ostetricia e anestesia

• …risoluzione dei problemi organizzativi…...

Carrello per intubazione

• In sala op.• laringoscopi:manico normale,sottile ,corto• lame curve,rette,Bizzarri,ecc• Guedel,Copa• LMA di vari calibri• mandrino di gomma,con ventilazione• set crico tiroidotomia:Patil,Ravussin,ecc• fibroscopio……..• jet ventilation……...

Conclusioni sulla intubazione difficile

• Mettere a punto l’organizzazione;informazione,visite,educazione,Sellick…...

• valutare le vie aeree• adottare una pratica che sottolinei

l’ossigenazione ed il risveglio della madre• praticare regolarmente !• evitare l’AG.

Cause di mortalità anestetiche in gravide classificate come “varie”:

• reazioni allergica

• inadeguato antagonismo miorisoluzione

• sovraccarico e.v.

• asfissia postop

• errore di conduzione epid in cardiopatica

Valutazione dei fattori di rischio• Visita prenatale,vicino al termine

• fattori di rischio per C/s urgente possono essere valutati correttamente

nel 90% dei casi analgesia p.d. preventiva per evitare G.A.(Morgan et al.Anesthesia for emergency cesarean section.Br.J Obstet.Gynecol. 1990;97:420-

24).• Large study pf outpatient obstetric anesthesia clinic:(Hamza et al.Anesthesia

consultaion can decrease the need for general anesthesia for emergency cesarean section in parturients

with difficult airway.Br.J.Anesth 1995;74:A353.):10% hanno almeno u n fattore di rischio per IOT difficile p.d.preventiva, meno G.A.

Cause di mortalità ostetrica da anestesia

• Inalazione polmonare del contenuto gastrico

• impossibilità di intubare la trachea

• shock spinale

Hawkins JL,Koonin LM,Palmer SK,Gibbs CP.Anesthesia related deaths during obstetric delivery in the United States(Anesthesiology

1997;86:277-84).• Maternal deaths reported in USA 1979-

1990

• cause

• relation to anesthetic

• type of obstetric procedure

• associated maternal conditions.

Stime dei denominatori della casistica CDC USA

• C/S:19%:GA 41%,reg 55%(1979-84)

• C/S 24%:GA 16%,reg 84%:(1990-92)

:82% da CS;5% da vaginal anestesia/analgesia in travaglio 16% (1981);

• 37%(1992),anest.regionale.


1997;86:277-84).

02468

1012141618

%

79-81 82-84 85-87 88-90

num.tot=129

GAREGignotasedazione

Mortalità anestetica legata all’anestesia

• 4.3/milione di nati vivi( 1979—1981)

• 1.7/ milione di nati vivi (1988—1990).



CDC USA CEMDEW

Fatti salienti da CDC USA: la mortalità anestetica legata all’anestesia;cause e differenze

fra AG e reg.

• Il numero assoluto di morti materne da AG è rimasto stabile negli anni 1979-1990.

• I problemi di vie aeree sono la causa principale di mortalità da AG,mentre il numero assoluto di morti legate alla anest.reg. è in calo dal 1984,equamente divise fra tossicità da AL e anestesia spinale/perid alta.

• Tuttavia sono diminuite le morti da tossicità da AL da quando Food and Drug Administration ha tolto l’approvazione per la bupivacaina 0.75% in ostetricia.

Fatti salienti da CDC USA frequenza di fatalità per GA vs reg.

• GA 2.3 volte > reg (1979—1984)

• GA 16.7 volte > reg ( 1985—1990).

Complicanze della AG per C/S: CDC USA

• 20.0/milione GA ( 1979—1984)

• 32.3 morti/milione (1985—1990)

mortalità del CS in anest reg: CDC USA

• 8.6 /milioni di anest reg ( 1979—1984)

• 1.9 /milione ( 1985—1990).

Chadwick,HS,Posner,K,Kaplan,RA,Ward,RJ,Cheney FW.A comparison of obstetric and

nonobstetric anesthesia malpractice claims.Anesthesiology 1991;74:242-249.

• ASA closed claims project

• Malpractice claims against anesthesiologists

• ob vs non ob:190 vs 1351– ob cases 67% CS,33% vaginal– 65% associati a anest reg,;33% con GA– 2 claims per non disponibilità dell’anestesista!

ASA closed claims project

Malpractice claims against anesthesiologists

0

5

10

15

20

25

30

35

40

%

ob nonob

morte (materna)

danno cerebrale neonatale

cefalea

morte neonatale

dolore dur.anest

danno neurale

danno cerebrale paz.

distress emotivo

dolore dorso

Claims ostetrici:regionale vs GA.

0

5

10

15

20

25

30

35

40

45

%

reg GA

morte materna


cefalea

morte neonatale

dolore dur.anest

danno neurale

danno cerebrale paz

distress emoz

dolore dorso

*

*

**

Patogenesi del danno neonatale

• 45% attribuiti a cause anestetiche( 4 GA(1 broncospasmo,1 intub esofagea,i

aspir polm,1 ritardo abnest.) ,13 reg,9 convuls da iniez intravasc,1 eclampsia,1 ritardo disponibilità,3 spinali alte,);

• 37% a probl ostetrici o congeniti,

• 13% con probl di rianimaz.

Danno materno;CS vs vaginale

0

5

10

15

20

25

%

CS vag

morte materna


cefalea

morte neonatale

dolore dur.anest

danno neurale

danno cerebrale paz

distress emoz

dolore dorso

*

Eventi dannosi nei claims ostetrici

0

2

4

6

8

10

12

14

%

ob nonob

ventilaz inadeguata

iot difficile

aspiraz

intub esofag

broncospasmo

FiO2 inadeg

ostruz vie aeree

estubaz prematura

convuls

probl attrezz

errore farmacol

errore idrico..

perdite ematiche

errore trasf

*

*

*

Probl.resp

Probl cardiocirc

Inalazione polmonare

• 8% degli ob claims vs 2% dei non ob• 50% dei casi associati a iot difficile,intubazione

esofagea o inadeguata ventilazione.• 14/16 associati a GA;

– in 7 anestesia somministrata in maschera;– 6 casi con iot difficile o intubazione esofagea

• 2 casi associati alla reg;blocchi spinali,il I con tetrac 20 mg….;il II dopo tetrac 4 mg somministrata dall’ostetrico per il forcipe;iot tentata dall’ostetrico;inalazanestesisti-iot dopo 6-7 min. danno cerebrale.

Convulsioni

•

Problemi di attrezzature

• 5/11 strappo del catetere perid

• defibrillatore non operativo

• 5 probl di ventilatore:– connessione al respiratore del braccio esp;– errore di connessione del circuito– N2 nel circuito

Classificazione della severità del danno

• Temporaneo: 0:non ovvio 1: emotivo

solo;paura,dolore… 2:insignificante;lacerazion

e,contusione,senza ritardo della ripresa

3:minore:p.es ;caduta in ospedale,ritardo di ripresa

4:maggiore;danno cerebrale,neurologico,ritardo di ripresa

• Permanente 5:minore:danno ad

organi,non debilitante; 6:significativo;p.es;perdita

di un occhio, di un rene… sordità,

7:maggiore;paraplegia,cecità,danno cerebrale

8:grave;severo danno cerebrale,quadriplegia, cure a vita

9:morte.

Severità del punteggio di danno(SIS)

• Ob: SIS con mediana 3 vs non ob ,mediana 7

• massimi di SIS eguali• distribuzione diversa……….

• Mediana + alta dopo GA; morte materna 47% dei claims in AG vs 12% dopo regionale

0

20

40%

minore(0-3)

obnon ob

Dati relativi ai pagamenti

claims non ob claims ob Claims obregionale generale

non pagati(%) 32 38 43 27

pagati(%) 59 53 48 63

pagamento mediano($) 85000 203000 91000 225000

range di pagamento($) 15000-6 milioni 675000-5.4 milioni 675-2.5 mil 750-5.4 mil

GA pagata il 63% vs 48% delle reg.

Conclusioni dai closed claims:1

• Danno cerebrale neonatale è il claim più frequente,anche se solo il 50% è LEGATO ALL’ANESTESIA!.

• Pagamento mediano per il danno cerebr. Neonatale:500.000 $ ,vs 120.000 $ dei danni ob;

Conclusioni dai closed claims:2

• Cefalea è il III problema: e risulta in pagamento il 56% delle volte……...

CEMDUK 1988–1990:I

The major finding of CEMDUK 1988–1990 is that the total number of direct and indirect deaths did not differ from the previous triennium. There was evidence of substandard care in almost 50% of all such deaths (in common with the previous triennium). Of the main causes of direct maternal deaths , thrombosis and thromboembolism and those resulting from hypertensive disorders of pregnancy, remain unchanged from the previous triennium but maternal deaths from haemorrhage have doubled since the 1985–1987 report.

CEMDUK 1988–1990:II

• It is particularly noteworthy that there has been a sharp reduction in the percentage of direct maternal deaths associated directly with anaesthesia. These data provided by CEMDUK do not however provide a true indication of the improvement in quality of anaesthesia. As Morgan observed in 1986 , between 1970–1972 and 1979–1981, there was a marked increase in the total number of Caesarean sections and an enormous increase in the number of legal abortions. It is likely that this trend has continued and so the number of anaesthetic deaths as a proportion of the number of anaesthetic interventions may have shown an even greater rate of decline.

CEMDUK 1988–1990:III• In the last two triennia, there was a reduction in

the percentage of direct anaesthetic deaths (of all maternal deaths) from 4.3 to 2.7%.

• In the period 1988–1990, there were four deaths directly attributable to anaesthesia. One death directly caused by anaesthesia was classified as a late death and in 10 patients, anaesthesia was a contributory factor.

CEMDUK 1988–1990:IV

• Of the four deaths directly attributable to anaesthesia, all had risk factors which were easily identifiable at an early stage: case 1, previous anaesthetic difficulties (high inflation pressure); case 2, anxiety and obesity; case 3, smoking, obesity, hypertension (treated with atenolol); case 4, obesity, smoking, anaemia and a past history of difficult tracheal intubation. Recognition by midwives and obstetricians of anaesthetic risk factors preferably during the antenatal period should lead to discussion of potential problems with an anaesthetist and result in a management plan which might avert catastrophies.

CEMDUK 1988–1990:V

• Every triennial report has identified a strong link between maternal death and associated disease or risk factors. Of the 10 deaths in the current report where anaesthesia was a contributory factor, two had pre–existing respiratory disease, two suffered severe haemorrhage and in six there was substandard postoperative care.

Raccomandazioni finali CEMDUK 88-90

• Capnografia per AG:• bloccanti recettori H2;• antiacidi liquidi non particolati prima della AG;• svuotamento gastrico prima della estubaz tracheale;• vie venose di largo calibro e monitoraggio PVC quando

c’è il rischio di o inizia emorragia• miglioramento degli standard di assistenza postop;• linee guida dipartimentali e precoce chiamata per aiuto

da parte di esperti…• uso prolungato della pulsossimetria nel postop per

allertare sulle complicanze polmonari.....

CEMDUK 1988–1990:VII

• This triennial report recommends that all maternity unit staff should have a higher level of awareness of potential problems and that early consultant involvement is essential when problems develop. The view of the Association of Anaesthetists of Great Britain and Ireland and of the Obstetric Anaesthetists Association is that this is achieved best by formal attachment to the maternity unit of a consultant obstetric anaesthetist who must be based on the labour ward with minimal other commitments when on duty. The anaesthetist thus becomes a member of the delivery suite team and takes an active part in the day to day work of the unit, including ward rounds and teaching.

Endler GC,Mariona FG,Sokol RJ,Stevenson LB.Anesthesia related maternal mortality in

Michigan 1972-84.Am.J.Obstet.Gynecol. 1988;159:187-83.

• Obesità

• chirurgia di emergenza

• ipertensione

Failed intubation drill (St Jame’s Unversity Hospital

maternity Unit) • Una intubazione fallita è una iot che non può

essere effettuata con una unica dose di succi• non somministrare una altra dose di succi• chiama tutto l’aiuto possibile• gira la paz sul lato sinistro,testa in basso• somministra O2 100%• se ventilazione difficile,rilascia la pressione sulla cricoide• supporta la ventilazione fino al ritorno della ventilazione

spontanea• discuti il trattamento ulteriore con il consulente.

Ricoveri in TI legati alla gravidanza

A total of 11 359 patients were admitted to 14 ICU in the study period: 210 obstetric patients were identified, representing 1.01% (median 0.89% (range 0.18–3.18%)) of all ICU admissions and 0.17% (0.04–0.6%) of total deliveries in the obstetric units concerned. Median age was 30 (16–45) yr and the median length of stay (LOS) in the ICU was 1 (1–34) days. Therapeutic interventions are shown in . A total of 205 (97.6%) patients had severity of illness data available. Admissions to ICU during pregnancy and childbirth are infrequent, often require minimal intervention and have low mortality, with wide variation between ICU. The SMR suggest good ICU performance and the ROC data indicate reasonable goodness of fit but the small overall numbers limit full statistical inference.

Sequele materne del parto;dati di Crawford 1978-85.

• Birmingham,UK,11701 questionari su 30096 parti:

• dolore dorsale 14%• cefalea 4%• parestesie mani 2.5%,arti inferiori 0,2 %

(associate ad anest.reg)• incontinenza vescicale da stress 15%,disuria

4%(associate a travagli prolungati e forcipe)

Scott DB, Hibbard BM. Serious non-fatal complications associated with extradural block in obstetric practice. British Journal of Anaesthesia

1990; 64:537-541. • 505000 blocchi extradurali,84% per travaglio e

16%per C/S(da 203 unità ostetriche ,1982-86,su 2580000 parti):

• 108 eventi;5 sequele permanenti• 60 reaz acute• 5 paralisi nn cranici,• 1 ematoma subdurale bilat dopo puntura durale accidentale• 38 neuropatie periferiche di un singolo nervo• 1 quadriplegia da trombosi di emangioma cervicale• 1 paraplegia di ndd.• 1 ascesso ed 1 ematoma subdurale evacuati con successo

Scott DB, Tunstall ME. Serious complications associated with epidural/spinal blockade in

obstetrics. International Journal of Obstetric Anesthesia 1995; 4:131-137.

• inchiesta fra anestesisti ostetrici

• 123000 blocchi/216816 parti

• 46 neuropatie isolate di un singolo nervo spinale

• 8 casi di ritenzione urinaria prolungata

Holdcroft A, Gibberd FB, Hargrove RL, Hawkins DF, Dellaportas CI. Neurological complications associated with pregnancy. British Journal of

Anaesthesia 1995; 75:522-526. • Tutti i 48066 parti della regione North West Thames in un anno:19

disturbi neurologici – 2 danno cerebrale ipossico:

– 1 dopo arresto da cardiomiopatia : decesso– 1 dopo emorragia con tetraparesi residua;

– 5 danni delle radici nervose;– Bell,cervicale,L5 da prolasso dicale, esacerbazione di sciatica preesistente, 1 fot

drop (spontaneous delivery under nitrous oxide analgesia of a large baby via a small pelvis)

– 3 paralisi nervi periferici:– popliteo laterale,– ulnare,– meralgia parestetica)

– 5 con concause mediche;– 2 da lesioni occupanti spazio,1 esacerbazione di sclerosi multipla,1 neuropatia

diabetica,1 meningite)

– 2 casi di dolore dorsale– 1 parestesia della distribuzione della radice nervosa

Schäfer RD.Anesthesiology89:1288-90, 1998

Rheinische Perinatal-Erhebung bei der

Ärztekammer Nordrhein/RPE.

Complicanze neurologiche relate all’anestesia regionale: 78 casi in (

Medline fino al 1998:Lee CC.Int J Obstet.Anest.

• ascesso epidurale• meningite• meningite asettica• aracnoidite• ematoma spinale• ematoma subdurale cranico• sindrome dell’arteria spinale anteriore• paralisi nn.cranici• danno diretto legato all’ago o catetere epidurale

Perché i problemi in ostetricia……..per l’anestesista…...

• Dovrebbe essere un momento di gioia• visibilità dell’anestesia regionale vs invisibilità

della testa fetale• scaricabarile dell’ostetrico nel parto

vaginale………….• preferenza accordata all’anestesia/analgesia

regionale per:– maggiore sicurezza– maggiore efficacia

Eziologia del danno neurologico in ostetricia

• Cause mediche intercorrenti;– ascesso o ematoma epidurale spontaneo– esacerbazione di:

• malattie del collagene• patologie vascolari• polineuropatie• neuriti postinfettive• sclerosi multipla

• discesa del feto nella pelvi:– compressione del tronco lombosacrale;

• nn.sciatico,femorale,otturatorio,lat.cutaneo,peroneo comune……..

• anestesia regionale per se

Eziologia delle paralisi materne

• Paralisi ostetriche agli arti inferiori:( Bademosi.Int J.Obstet Gynecol 1980)

• foot drop 88%(peroneo comune..)– posizione inappropriata dei reggigambe;– posizione inadeguata durante l’espulsione

• neuropatia femorale 27%• paraparesi spastica 15%:

– compromissione della irrorazione del midollo spinale;art di Adamkievicz &/o da branche dalle art.iliache int.

Altre cause non anestetiche di danno nervoso

• Prolungata compressione da parte della testa fetale

• lame del forcipe

• da posizione durante il parto

Complicanze neurologiche dell’anestesia regionale in

ostetricia• Kandel (1965);0 su 1000• Crawford(1972);0 su 1035• Holdcroft(1976);1 su 1000• Bleyaert(1979);0 su 3000• Abouleish(1981);3 su 1417• Crawfoed(1985);4 su 27000• Ong(1987);34 su 9403• Scott(1990);43 su 505000• Scott(1995):38 su 108133• Holdcroft(1995);1 su 13007• Puech(1999);1 su 10995

Meccanismi del danno neurologico legato all’anestesia

• Trauma diretto da ago,catetere,iniezione…

• neurotossicità da AL

Rischio di ematoma peridurale o spinale

• Travaglio di parto:• peridurali :1:500.000(Scott,BJA 1990)

• spinali;0

• interventi:– peridurali;1:190.000(CI 1/4060000-1/97000)

(Wolf-Tryba)– spinali :1/240000

Ong BY,Cohen MM,Esmail A,Cumming M,Kozody R,Palahniuk RJ.Paresthesias and motor dysfunction

after labor and delivery.AA,1987;66:18-22.

• Winnipeg Women Hospital,1975-83,23827 parti• Tipo di analgesia/anestesia

– nessuno 8198– analg.inalatoria 4766– anest. Epidurale 9403– AG 864– altre 381– non codif 215

– modalità del parto:• spont. vag. 53.4%• forcipe/vacuum 27.9%• C/S 18.6%

Paresthesias and motor dysfunction after labor and delivery

Incidenza di parestesia e disfunz motoria;18.9/10.000(45 casi)

0

5

10

15

20

25

30

35

40

/10.

000

multiparaprimiparavag spontforceps,vacuumno analganalg. Inalatepid soloGA

* ** *

Incidenza di parestesia dopo anest.epidurale

• Autore casi incid /10.000

• Crawford 2035 14.7

• Eisen 9532 16.8

• Abouleish 1417 42.3

• Lund 10000 5

• Bonica 3637 24.7

• ONG 9403 36.2

Incidenza di deficit motorio dopo anest.epidurale

• Autore casi incid /10.000• Dawkins 32718 14.7/2.1(trans/perm)• Crawford 2035 0• Aboulesih 1417 14.1• Bonica 3637 2.7• Lund 10000 1• Hellman 26127 0• Moore 6729 0• Bleyaert 3000 0 • Ong 9403 0.8

Rischio di ascesso epidurale

• Per travaglio:– da 1:500.000(Scott) a 1:27.000(Crawford)

• per anest.epidurale:– 1:75.000 tra 1987-95 da Acta Anesth.Scand.– 45 casi in Medline (Scneider ,com.WCA 2000.)

Altri problemi attribuiti all’anestesia

• Problemi associati alla PDPH:– 8 ematomi subdurali cranici(Medline 1966-90)– paralisi dei nn.cranici:diplopia,tinnitus,vertigo,ecc

• dorsalgia a lungo termine postpartum:– debole legame con la neurologia– può arrivare al 49% durante la gravidanza– non incremento per 1 anno dopo analg.peird(MacArthur ,AA)

– dorsalgia a lungo termine postpartum

Conclusioni sulle complicanze neurol. attribuibili al travaglio ed al parto:

• Non sono rare(incid stimata 1: 2530• frequentemente associate con un travaglio prolungato

o difficile• quelle che accompagnano l’anest/analg regionale:

– si accompagnano più spesso al travaglio prolungato o difficile;

• non costituiscono un fattore di rischio per complicanze particolari per se…...

• ma necessitano dei migliori standard di pratica!

Controllo e prevenzione

• Standard assistenziali• total quality management:

– valutazione del rischio/beneficio individuale;

– controllo delle pazienti

– audit delle complicanze

– insegnamento del team responsabile dell’assistenza peripartum

– informazione sulle possibilità delle complicanze

Anesthesia for Cesarean Section and Acid Aspiration Prophylaxis: A German Survey

Schneck, Hajo, MD; Scheller, Michaela, MD; Wagner, Richard, MD; von Hundelshausen,

Burkhard

MD; Kochs, Eberhard, MD Anesth Analg 1999; 88:63–6

We surveyed routine anesthetic practice and measures to prevent acid aspiration syndrome (AAS) in patients undergoing cesarean section (CS) throughout Germany. Of 1061 questionnaires, 81.9% were returned. For scheduled CS, general anesthesia was used in 63% of cases, and for urgent CS, it was used in 82% of cases. Regional anesthesia was used less often for both scheduled and urgent CS in smaller (£500 deliveries/yr; 28% and 16%, respectively) than in medium-sized (500–1000 deliveries/yr; 42% and 19%, respectively) or major obstetric departments (>1000 deliveries/yr; 45% and 21%, respectively). Among the regional techniques, epidural anesthesia (59%) was preferred more than spinal anesthesia (40%) in scheduled CS. In urgent CS, spinal anesthesia predominated (56% vs 42%). Pharmacological AAS prophylaxis is routinely used in 69% (68%) of departments before elective (urgent) CS under general anesthesia and in 52% under regional anesthesia. H2-blocking drugs are preferred for AAS prophylaxis over H2-blocker plus sodium citrate and sodium citrate alone. Both the incidence of and the mortality from AAS at CS are very low in Germany (<1 fatality per year). Nevertheless, AAS prophylaxis deserves more widespread use in obstetric anesthesia and in other patients at risk (e.g., children, outpatients). Implications: According to a countrywide survey, the use of regional anesthesia for cesarean section and pharmacological prophylaxis of acid aspiration syndrome is considerably less common in Germany than in the United States, United Kingdom, or other European countries.

Maternal injury files(Chadwick)• 356 cases: n. %• maternal death: 83 23• headache 64 18• nerve/spinal cord trauma 41 12• pain during anesth 37 10• back pain 34 10• brain damage 32 9• emotional distress 31 9• aspiration pneumonitis 20 6

PDPH

• Vedi mio testo inviato da word

Accidental dural puncture rates(Cowan IJOA 2001;10:1-16)• Incidence:0.25-0.5%

• reduced dural puncture;frequence

• experience

• non rotation of the needle

• choice of technique:lateral decubitus+loss of resist with saline+non rotation of needle

Dural puncture ko

• Pdph.80% FOLLOWING LARGE NEEDLES

• cranial nerve palsy;1-3.7%:abducens vestibulocochlear

• cranial subdural haematoma;1/500.000(Scott 1990)

• Any persitent postspinal headache or recurrence of it shlul alert the anesthesiologist………LOO IJOA 2000

Long term morbidity following dural puncture(Jeskin iJOA

2001;10:17-24.)• Case controled retrospective pèostal survey

• 194 mother with accidental dural punt.

• Low response rate

• 18% long term headache(3.6 years)

• following spoinal anesth 0.89% > 1 year

Sharrock:the role of anaesthesia care?

(Anesthesiology,1991,75,A868)

0

0,1

0,2

0,3

0,4

0,5

0,6

mortality rate

artroplastica di ginocchio e d'anca

81-8587-90

%aum.p.d.

aum.ter.intens

miglior monitoraggio

aum.invasività

aum.analg.postop

Mivacurium neuromuscular block at the adductor muscles of the larynx and adductor pollicis in humans.Plaud et al,Anesthesiology,1996,85,77-81)

0

50

100

150

200

250

maxblock

onset T1 75 T1 25-75%

miv 0.07 larynxmiv 0.07 APmiv 0.14 larynxmiv 0.14 AP

*

*

***

onset

%

sec

min

t1: 25% 75% 90% 25-75%

Anesthesia for High Risk pregnancy

Claudio Melloni

Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

Maternal deaths UK 1994-96

thrombosisPIHearly pregnhaemorrhageAFEAnaesthesiaothers

Maternal deaths UK 1997-99

thrombosisPIHafehaemorrhagesuicidesepsis

New trends in UK maternal mortality

• Mort.rate among most disadvantaged groups;20 *• Other than white :*2• Young<18• Increasing maternal age• Increasing parity• Obese• In vitro fertilization

Relative risk

• C/S 4,9> vag(C/S is an amalgamation of risk associated with the disorder for which surgery is indicated and the risk associated with the procedure itself….

• Elective C/S 2.3

• Emergent C/S 12.0

• Instrum,vag delivery risk 3,1 vs vag deliv

Maternal deaths due to anesthesia:CEMD

02

46

810

1214

1618

20

direct GA indirect

85-8788-9091-9394-96

Panchal et al.Maternal mortality during hospital admission for delivery:a retrospective analysis

using a state maintained database.Anesth.Analg.2001;93:134-41.

• Jan 1984-dec 1997• Maryland• DRG C/S and vag.deliv,hospital only,anonymous• Selected case controls• 822.591 admissions for delivery• 135 deaths

• Maternal deaths/100.000 5.92-29,6

RISK factors(/100.000)(from Panchal et al)

• Age;from 13,9<34 to 23,9>34• Caucasiona 7,6,african.americans 31,6,18,1 others• African americans 5 times more prob to die during pregancy

than caucasian• Social,cultural,economic,health care access,quality

factors;multiple diagnoses and severity of illness ++• C/S 5,3 +;60% of deaths associaTted with C/S• Minor teaching hospital 3,.1 +• Transfer from another hospital 6,2+

Maryland more common causes of maternal mortality

precl/eclamppostpartum hemorrhpulm Kocvs eventAFE/clotinsuff prenatal caretrauma

MARYLAND STATISTICS on Maternal deaths;african american vs caucasian

0

5

10

15

20

25

30

precl/eclamp pulm Ko AFE/clot AC.RENAL FAIL

african-americancaucasian


1997;86:277-84).

• Maternal deaths reported in USA 1979-1990

• cause

• relation to anesthetic

• type of obstetric procedure

• associated maternal conditions.

Hawkins et al.Anesthesia related deaths during obstetric delivery in the United

States(Anesthesiology 1997;86:277-84).

02468

1012141618

%

79-81 82-84 85-87 88-90

num.tot=129

GAREGignotasedazione


1997;86:277-84).

C S 82% parto vag 5% ignoto 13%

Mortalità ostetric a

C/S Mortality (from Hawkins…)

asp iraz3 3 %

p rob l d i in d u z /in tu b az2 2 %

ven tilaz in ad eg1 5 %

in su ff resp3 %

arres to ca rd d u ran te an es t2 2 %

AG :52% del totale

Oppioidi o sedativi parent

3%

ep id u ra le7 0 %

sp in a le3 0 %

Regionale25%

Causes of anesthesia related deathsCauses of anesthesia related deathsUSA 1979-1990(Hawkins et al.Anesthesiology 86;280:1997)USA 1979-1990(Hawkins et al.Anesthesiology 86;280:1997)

AG(67)AG(67)Reg(33)Reg(33)sedaz(4)sedaz(4)ignota(25)ignota(25)%% NN

Probl.vie aereeProbl.vie aeree 7373 -- 7575 4040 4949 6262

arresto card.intraoparresto card.intraop2222 66 -- 5252 2323 3030

tox da ALtox da AL 5151-- -- 1313 1717

spi/pd altaspi/pd alta 3636 -- -- 99 1212

iperdosaggioiperdosaggio -- 2525 -- 11 11

anafilassianafilassi -- -- 44 11 11

ignotaignota 55 66 -- 44 55 66

%% 100100 100100100100 100100100100129129

Number of deaths during cesarean sectionNumber of deaths during cesarean sectionUSA 1979-1990(Hawkins et al.Anesthesiology 86;280:1997)USA 1979-1990(Hawkins et al.Anesthesiology 86;280:1997)

1979-19841979-19841985-19901985-1990

GAGA 3333 3232

REGREG 1919 99

Fatality rates during cesareansection

Fatality rates during cesareansection

per million of Ga or REGper million of Ga or REG

1979-19841979-19841985-19901985-1990

G.A.G.A. 2020 32.332.3

REGREG 8.68.6 1.91.9

Fatality rate from CDC USA: GA vs reg.

• GA 2.3 * > reg (1979—1984)

• GA 16.7 * > reg ( 1985—1990).

Anesthesia related maternal mortality





CDC USA CEMDEW

Fatti salienti da CDC USA: la mortalità anestetica legata

all’anestesia;cause e differenze fra AG e reg.• Il numero assoluto di morti materne da AG è rimasto

stabile negli anni 1979-1990.• I problemi di vie aeree sono la causa principale di

mortalità da AG,mentre il numero assoluto di morti legate alla anest.reg. è in calo dal 1984,equamente divise fra tossicità da AL e anestesia spinale/perid alta.

• Tuttavia sono diminuite le morti da tossicità da AL da quando Food and Drug Administration ha tolto l’approvazione per la bupivacaina 0.75% in ostetricia.

Complications of AG for C/S: CDC USA

• 20.0/milione GA ( 1979—1984)

• 32.3 morti/milione (1985—1990)

CS mortality rate for reg.anesth: CDC USA

• 8.6 /milioni di anest reg ( 1979—1984)

• 1.9 /milione ( 1985—1990).

Environmental problems

• Personnel:– Skills– On duty– teamwork

• Hospital:– Maternity– Cardiac & neurosurgical services available– Radiology,interventional….– ICU– Blood bank….– Neonatal ICU– Lab

High risk obstetrics is a multidisciplinary problem

• Anesthesiologist;almost always involved

• Obstetrician;no experience in intensive care

• Intensivist;little knowledge of obs.physiopathology,delivery…

• Neonatologist;if any….

High Risk Obstetrics;a place for regional

• Good anesthetic choice may improve condition:– epid * PIH/preeclampsia

• Bad anesthetic choice may worsen condition;– GA & difficult intubation;highway to disaster

GA:pro & cons

• Fast• High success rate• Full control• Uterine

relaxation(halog)• Less hypotension• Protection of the

airway(…)

• Airway problems..• Aspiration• Hypertension during

laryngoscopy and oti• Cardiac depression• Resp depression• Nenatal depression• awareness

Regional anesthesia;pro & cons

• Awake• Psychological• Materno-foetal bonding• Mother caring for the

newborn immediately• No intubation• Less risk of pulm

aspiration• Postop analgesia• Maternal satisfaction

• Technically + difficult• Time consuming• Hypotension

Indications for GA(QCCH,Crowhurst 2001))

cord prolapsesev.fetal distressmaternal requestfailed regReg contraindicated

Maternal request for GA

• Anxiety

• Previous experience– Bad(with reg)– Good(with GA)– Backache

– None seen in the anesth.antenatal clinics

Anesthesia for emergency C/S

• Morgan et al.BJA 1990;97:420-24

• “need for emergency C/S anticipated in 87% (380 cases).Early establishment of epidural analgesia in labour allowed extension to adequate anaesthesia in 70%”

• Crowhurst(ESOA 2001);99% extension

Questions about emergencies

• If an epid is in place,how long it takes from top up to adequate block?

• Decision-delivery interval

• Fetal risk ;how much from GA and how much from reg?

• Other strategies benefiting the fetus

CESDI:Confidential Enquiry into Stillbirths and deaths in infancy,7th report,2000

• OB anesthesia focus group• 2 ob anesthesiologists• 2 obstetricians• 873 perinatal deaths;25(2,8%)anesth.contributing

factors identified:– maternal anaphylaxis1,– maternal bronchospasm and hypoxia 1,– failed/difficult oti 2– Delay with personnel 11– Delay in administering anesth 10

Optimising maternal-fetal physiology

• 1)Mat.O2 carrying capacity• 2)Mat.ventilation• 3)Mat circulation• 4)Uteroplacental blood flow• 5)Umbilical(fetal) blood flow

•1-4 can be optimized

Halper,SH et al.Effect of epidural vs parenteral opioid analgesia on the progress of labor.JAMA

1998;280:2105-2110

• Metanalysis

• “epidural analgesia has a favourable effect on funic pH and BE suggesting that the known reduction in maternal stress and sympathetic tone do improve the intrauterine environment ,despite the theorethical potential adverse effects…”

Decision-delivery interval

• The 30 min.rule

• Is this a standard that fetal distress cases be delivered within 30 min?

• Fetal hypoxia=scalp pH <7,2;serious disability when pH<7.00

• Correlation between DD interval and neonatal asphyxia?

DD interval….

• C/S ;DD interval shorter with GA(DD 23),but umb.cord artery pH better with reg(DD 50).

• Br Med J 322,June 2001

• McKenzie1334-35

Reliability.CSE *C/S

0

0,1

0,2

0,3

0,4

0,5

0,6

0,7

0,8

0,9

1

%

failure rate

QCH 1998Norris 1994Paech 1998Albright 1999

GA is not the choice for obs emergencies

• necessary only for true emergencies• Necessary only when:

– poor teamwork,poor communication,lack of reg skills

• Necessary only for some fetal conditions(tocolysis)• GA risk in pregnancy greater• GA not necessarily faster and faster my not be

better……….• Crowhurst,2001

Riley ET,Cohen, Sheila E,Macario A,Desai JB,Ratner E.Spinal Versus Epidural Anesthesia for

Cesarean Section: A Comparison of Time efficiency,Costs,Charges and

Complications .Anesth Analg 1995; 80:709–12• Retrospective study from their cases• C/S elective • epidural (n = 47) or spinal (n = 47) anesthesia• Patients who received epidural anesthesia had significantly longer total

operating room (OR) times than those who received spinal anesthesia (101 ± 20 vs 83 ± 16 min, [mean ± SD] P < 0.001); this was caused by longer times spent in the OR until surgical incision (46 ± 11 vs 29 ± 6 min, P < 0.001). Length of time spent in the postanesthesia recovery unit was similar in both groups. Supplemental intraoperative intravenous (IV) analgesics and anxiolytics were required more often in the epidural group (38%) than in the spinal group (17%) (P < 0.05). Complications were noted in six patients with epidural anesthesia and none with spinal anesthesia (P < 0.05). Average per-patient charges were more for the epidural group than for the spinal group. Although direct cost differences between the groups were negligible, there were more substantial indirect costs differences. We conclude that spinal block may provide better and more cost effective anesthesia for uncomplicated, elective cesarean sections.

Spinal faster than epid….( Riley et al, Spinal Versus Epidural Anesthesia for Cesarean Section: A Comparison of Time Efficiency, Costs, Charges, and Complications.Anesth

Analg 1995; 80:709–12)

0

20

40

60

80

100

120

min

OR-incis total OR time Pacu time

epidspi

Drug(opioids,anxyolitics) consumption;spinal vs peridural (Riley et al, Spinal Versus Epidural Anesthesia for Cesarean Section: A Comparison of Time Efficiency, Costs, Charges, and Complications.Anesth Analg

1995; 80:709–12)

0

5

10

15

20

25

30

35

40

%

intraop postop KO

epidspi

*

I catete intravasc1 catet intratecale1 perf dura3 insuff analg

*

Direct costs($):Spi vs epid

0

5

10

15

20

25

30

35

40

45

spi epid

kitneedledrugmorphfentnurses 13 mintot

Epid takes longer……..• Learning curve• the anesthesiologist must progress more slowly with the

epidural needle to avoid a dural puncture• the epidural catheter must be threaded and taped• a test dose must be given and the patient .observed for 3–5

min to exclude IV or intrathecal placement• the entire local anesthetic dose must be administered

incremental• onset of epidural anesthesia is slower than that of spinal

anesthesia.

Anesth prep time differed among groups( Glosten et al.Practical aspects of regional anesthesia for cesarean delivery,failure rates and

anesthetic preparation times-An observational study..Anesthesiology 1995;83:A977. ):

0

10

20

30

40

50

60

70

%

failure rate anest prep time anest successful anest unsuccess

GAEPISPIMin

Attitude in failed epidurals(Glosten et al.Practical aspects of regional anesthesia for cesarean delivery,failure rates and anesthetic preparation times-

An observational study..Anesthesiology 1995;83:A977. ):

ab sen t b lock 5 in ad eq b lock 1 2 ca te t m isp lac 2 (iv.) p a res tes ia 1 su b d u ra l 2 p a tien t an xie ty 1

ep id fa ilu res(2 4 /1 7 9 )

Repeat EPI 4SPI 11AG 9

Attitude in failed spinalsGlosten et al.Practical aspects of regional anesthesia for cesarean delivery,failure rates and anesthetic preparation times-An

observational study..Anesthesiology 1995;83:A977. ):

in ab ility to ob ta in C S F in traop p a in

S p i fa ilu res(3 /9 8 )

GA

USA changes in anesthesia for C/S( Hawkins et al,Obstetric anesthesia workforce survey-1992 versus 1981.Anesthesiology 1994;81:A1128)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1981 1992

EpidSpiGA

UK changes in obs.anesthesia(Brown et al.Int

J.Obstet.Anesth.1995;4:214)

0%

20%

40%

60%

80%

100%

1982 1987 1992

EpidSpiGA

Ben David B,Miller G,Gavriel R,Gurevitch A.Low dose bupivacaine-fentanyl spinal anesthesia for

cesarean delivery, Reg Anest PainMed.2000;25:235-39.

• 32 paz,20-40 anni• isobaric bupi 0.5% 10 mg vs 5 mg+fent 25

microgr• preload RL 500;intraop altri 800 ml• sitting,26 g pencil point;2 ml in 10-15 sec.• Poi supine + LLT• efedrina 5-10 mg as needed • tempo oper(dal’inizio della spi);<70 min

tutti,eccetto 1.

Ben David et al.Low dose bupivacaine-fentanyl spinal anesthesia for cesarean delivery, Reg Anest

PainMed.2000;25:235-39.

0

10

20

30

40

50

60

70

80

90

100

min,%,mg

time to peakblock

misur ipotens nausea/vomito

bupi 10 mgbupi 5 + fent 25 mu

0.01

0.001

0.00020.0002

Liv medio T3

Liv medio T4-5

0.05

Meno blocco motorio

Vercauteren MP,Coppejans HC,Hoffmann VH,Mertens E,Adriaensen A.Prevention of hypotension by a single 5 mg dose of

ephedrine during small dose spinal anesthesia in prehydrated cesarean delivery patients.AA 2000;90:324-327.

• Cimetidine p.o 900 mg 1 h prima della induzione• RL 1000 ml iniziato 10’ prima del trasferimento in S.OP• HES 6% 500 ml all’arrivo in sala op• Induzione di CSE• dec,.lat dx• bupi 6,6 mg+sufent 3.3 microgr intratecale• inserito catet pd• doppio cieco efedr 5 mg vs placebo• dec lat sn 15• O2 3lt/min per masch facciale

Vercauteren et al Prevention of hypotension by a single 5 mg dose of ephedrine during small dose spinal anesthesia in prehydrated

cesarean delivery patients.AA 2000;90:324-327.Results

0

10

20

30

40

50

60

70

80

altra efedr ipotens<90 vomito

efedr 5 mgplacebo

Livello T3 1 per ogni gruppo lidoc 2% 3 ml* p.d.

Parekh N,Husaini SWU,Russell IFCaesarean section for placenta praevia:a retrospective study

of anesthetic management.Br.J.Anaesth. 2000;84:723-30.

• Tutte le anest dal 1 genn 1984 al 31/12/1998.• 350 casi di plac previa:

– 60% Reg e 40% AG– plc accreta;7 casi; 4 REG e 3 AG:ma 2 reg convertite ad

AG…5 isterectomie.– Controllo della pA anche in corso di emorragia non

problematico– Ra associata a minori perdite ematiche.– “Questo studio retrospettivo non trova dati che

supportino il molto quotato detto che la Reg è controindicata per CS in presenza di plac previa….”.

Clinical impression from the above studies

• In the vast majority of the more developed countries Ga is used only in the sickest and emergency cases or where Reg is contraindicated ……..

• Moreovere,C/S /vaginal delivery ratio is increasing….

• Queen Charlotte UK;GA 4-5% 1993-2001(Crowhurst ,pers,comm.)

Scott-Beattie,W,Badner NH,Choi P.Epidural analgesia reduces pos toperative myocardial infarction:a

meta.analysis.Anesth.Analg. 2001;93:853-8.

• Metanalysis to determine the effect of postoperative epidural analgesia on postop cardiac mortality

• Only randomized controlled trials

• Postop epid analgesia 24 hr:

• Outcomes with MI and death.

Studies included in the search on postop.epidural anesthesia and outcome(cardiac).

The effects of postop. Epidural anesthesia on postop.myocardial infarction

Favorisce il trattamento

The effects of postop.epidural anesthesia on in hospital death.

Favorisce il trattamento

Epidural analgesia and cardiac outcome:

• Postoperative ischemia:– decreased incidence– Shorter duration of

– REDUCTION OF POSTOP MI :40%

Norris EJ et al Anesthesiology 2001;95:1054

• Double blind,double masked

• 168 pts for AA surg.

• 4 groups:

• TEA+GA+ivPCA

• TEA+GA+EPCA

• GA+EPCA

• GA+ivPCA

mortality and morbidity in anesthesia 2002

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