Document Detail


A series of anesthesia-related maternal deaths in Michigan, 1985-2003.
MedLine Citation:
PMID:  17525583     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
BACKGROUND: Maternal Mortality Surveillance has been conducted by the State of Michigan since 1950, and anesthesia-related maternal deaths were most recently reviewed for the years 1972-1984. METHODS: Records for pregnancy-associated deaths between 1985 and 2003 were reviewed to identify 25 cases associated with a perioperative arrest or major anesthetic complication. Four obstetric anesthesiologists independently classified these cases, and disagreements were resolved by discussion. Precise definitions of anesthesia-related and anesthesia-contributing maternal death were constructed. Anesthesia-related deaths were reviewed to identify the chain of medical errors or care management problems that contributed to each patient death. RESULTS: Of 855 pregnancy-associated deaths, 8 were anesthesia-related and 7 were anesthesia-contributing. There were no deaths during induction of general anesthesia. Five resulted from hypoventilation or airway obstruction during emergence, extubation, or recovery. Lapses in either postoperative monitoring or anesthesiology supervision seemed to contribute to 5 of the 8 anesthesia-related deaths. Other characteristics common to these cases included obesity (n=6) and African-American race (n=6). CONCLUSIONS: The 8 anesthesia-related and seven anesthesia-contributing maternal deaths in Michigan between 1985 and 2003 illustrate three key points. First, all anesthesia-related deaths from airway obstruction or hypoventilation took place during emergence and recovery, not during the induction of general anesthesia. Second, system errors played a role in the majority of cases. Of concern, lapses in postoperative monitoring and inadequate supervision by an anesthesiologist seemed to contribute to more than half of the deaths. Finally, this report confirms previous work that obesity and African-American race are important risk factors for anesthesia-related maternal mortality.
Authors:
Jill M Mhyre; Monica N Riesner; Linda S Polley; Norah N Naughton
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Publication Detail:
Type:  Journal Article; Research Support, N.I.H., Extramural; Research Support, Non-U.S. Gov't    
Journal Detail:
Title:  Anesthesiology     Volume:  106     ISSN:  0003-3022     ISO Abbreviation:  Anesthesiology     Publication Date:  2007 Jun 
Date Detail:
Created Date:  2007-05-25     Completed Date:  2007-06-28     Revised Date:  2008-01-23    
Medline Journal Info:
Nlm Unique ID:  1300217     Medline TA:  Anesthesiology     Country:  United States    
Other Details:
Languages:  eng     Pagination:  1096-104     Citation Subset:  AIM; IM    
Affiliation:
Department of Anesthesiology, University of Michigan Health System, Ann Arbor 48109-0048, USA. jmmhyre@umich.edu
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MeSH Terms
Descriptor/Qualifier:
Adolescent
Adult
Algorithms
Anesthesia, Obstetrical / adverse effects*
Female
Humans
Maternal Mortality*
Medical Errors
Michigan / epidemiology
Population Surveillance / methods*
Pregnancy
Pregnancy Complications / epidemiology,  mortality*
Comments/Corrections
Comment In:
Anesthesiology. 2007 Jun;106(6):1082-4   [PMID:  17525579 ]
Anesthesiology. 2008 Jan;108(1):170; author reply 171   [PMID:  18156907 ]

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


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