Document Detail


The Australian Incident Monitoring Study. Problems with regional anaesthesia: an analysis of 2000 incident reports.
MedLine Citation:
PMID:  8273890     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
There were 160 incidents associated with regional anaesthesia amongst the first 2000 incidents reported to the Australian Incident Monitoring Study. They were categorised into 6 groups; epidural anaesthesia (83), spinal anaesthesia (42), brachial plexus blocks (14), intravenous local anaesthesia (4), ocular blocks (3), and local infiltration (14). The largest single cause of incidents involved circulatory problems; these occurred in all the groups except brachial plexus block (30 cases of hypotension, 7 of arrhythmias, 3 of cardiac arrest, 2 of hypertension and 1 of myocardial ischaemia). There were 24 drug errors, of which 10 involved the "wrong drug" and 4 "inappropriate use". With the exception of these, all the remainder involved problems specific to regional anaesthesia: 26 inadvertent dural punctures; 19 failed or inadequate blocks; 14 dural puncture headaches (all cured by blood patches); 10 inadvertent total or high spinal blocks (of which 7 required artificial ventilation); 5 blocks on the wrong side or in the wrong patient; 3 late hypoxic incidents and a variety of miscellaneous problems. Three-quarters of all incidents occurred in the presence of an anaesthetist and over 90% in patients of ASA Groups I-III. Rapid recognition by the anaesthetist prevented many potentially life threatening events, and the only death was as a result of surgical bleeding.
Authors:
M A Fox; R K Webb; R Singleton; G Ludbrook; W B Runciman
Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  Anaesthesia and intensive care     Volume:  21     ISSN:  0310-057X     ISO Abbreviation:  Anaesth Intensive Care     Publication Date:  1993 Oct 
Date Detail:
Created Date:  1994-02-03     Completed Date:  1994-02-03     Revised Date:  2006-08-28    
Medline Journal Info:
Nlm Unique ID:  0342017     Medline TA:  Anaesth Intensive Care     Country:  AUSTRALIA    
Other Details:
Languages:  eng     Pagination:  646-9     Citation Subset:  IM    
Affiliation:
Department of Anaesthesia & Intensive Care, University of Adelaide, South Australia.
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MeSH Terms
Descriptor/Qualifier:
Accidents / statistics & numerical data*
Anesthesia, Conduction / adverse effects*
Australia / epidemiology
Humans
Incidence
Risk Management / methods*

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine


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