Trends in Anesthesia-related Death and Brain Damage
ABSTRACT The authors used the American Society of Anesthesiologists Closed Claims Project database to determine changes in the proportion of claims for death or permanent brain damage over a 26-yr period and to identify factors associated with the observed changes.
The Closed Claims Project is a structured evaluation of adverse outcomes from 6,894 closed anesthesia malpractice claims. Trends in the proportion of claims for death or permanent brain damage between 1975 and 2000 were analyzed.
Claims for death or brain damage decreased between 1975 and 2000 (odds ratio, 0.95 per year; 95% confidence interval, 0.94-0.96; P < 0.01). The overall downward trend did not seem to be affected by the use of pulse oximetry and end-tidal carbon dioxide monitoring, which began in 1986. The use of these monitors increased from 6% in 1985 to 70% in 1989, and thereafter varied from 63% to 83% through the year 2000. During 1986-2000, respiratory damaging events decreased while cardiovascular damaging events increased, so that by 1992, respiratory and cardiovascular damaging events occurred in approximately the same proportion (28%), a trend that continued through 2000.
The significant decrease in the proportion of claims for death or permanent brain damage from 1975 through 2000 seems to be unrelated to a marked increase in the proportion of claims where pulse oximetry and end-tidal carbon dioxide monitoring were used. After the introduction and use of these monitors, there was a significant reduction in the proportion of respiratory and an increase in the proportion of cardiovascular damaging events responsible for death or permanent brain damage.
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ABSTRACT: PRINTER-FRIENDLY VERSION AT ANESTHESIOLOGYNEWS.COM C o p y r i g h t © 2 0 1 0 M c M a h o n P u b l i s h i n g G r o u p u n l e s s o t h e r w i s e n o t e d . A l l r i g h t s r e s e r v e d . R e p r o d u c t i o n i n w h o l e o r i n p a r t w i t h o u t p e r m i s s i o n i s p r o h i b i t e d . This clinical review will not deal specifically with patient positioning. However, current clinical perspec-tive is that these changing sources of morbidity 4 need to be considered also in relation to the use of new air-way devices. For instance, we may consider the impact that new airway devices—such as video laryngoscopes and new intubating stylets (video-assisted, rigid/ semirigid)—have on the incidence of adverse events, in addition to the importance of positioning the patient properly when using each device. 5 In this review, we have categorized various positions proposed for airway management in different clinical settings. We briefly discuss evidence for any associated benefits and caveats, as well as the role of different air-way devices in different positions and clinical settings. Finally, we identify the anatomical and medical conditions of patients that, in different scenar-ios, lead to specific posi-tioning decisions. The discussion will be limited to positioning for airway management in adults. The sniffing position has been recommended as the optimal one for patient intubation and airway management. Historically, the defi-nition of this position is credited to an Irish-born anesthetist, Sir Ivan Magill, who described it as "sniffing the morning air" or "draining a pint of beer." The effectiveness of the sniffing position compared with other "head-neck extension" positions has not been clearly established. 6,7 The lack of scientific evi-dence to support one technique over the oth-ers is explored in this article. Differences in posi-tioning may be insignif-icant in the vast majority of patients and clinical scenarios that do not involve a difficult air-way. However, such dif-ferences may become critical in situations when even small adjust-ments in head and neck positioning improve visualization—that may other-wise have been impossible—of the glottis or periglot-tic structures. This review focuses on particularly challenging situ-ations in which the choice of one position over another may be critical for successful intubation and maintain-ing adequate oxygenation while managing the airway, and ultimately for patient outcomes. We stress the importance of teaching these techniques to providers in training, with the aim of improving the success rate among novices. Specifically, we discuss 3 different posi-tions and their usefulness in conjunction with different intubating devices and techniques. Examples of challenging clinical situations and differ-ent positioning options are described in the Table.