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unpublished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.
1
0,9
0,8
0,7
0,6
0,5
0,4
0,3
0,2
0,1
0

GA
epid+GA

glyc bas

glyc1h

glyc2

glycpost

1
0,9
0,8
0,7
0,6
0,5
0,4
0,3
0,2
0,1
0

GA
epid+GA

lactbas

lact1

lact2

lactpost

1
0,9
0,8
0,7
0,6
0,5
0,4
0,3
0,2
0,1
0

GA
epid+GA

FFA bas

FFA1

FFA 2

FFA post

Insulin
1
0,9
0,8
0,7
0,6
0,5
0,4
0,3
0,2
0,1
0

Cortisol
1
0,9
0,8
0,7
0,6
0,5
0,4
0,3
0,2
0,1
0

GA
epid+GA

lactbas

lact1

lact2

lactpost

Glucagon
1
0,9
0,8
0,7
0,6
0,5
0,4
0,3
0,2
0,1
0

GA
epid+GA

lactbas

lact1

lact2

lactpost

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

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 surgeryassociated 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

Loick et al..High Thoracic Epidural Anesthesia, but Not

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

• 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, crossclamp 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

• 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

• 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

• 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

Loick et al..High Thoracic Epidural Anesthesia, but Not
Pg o ng/ml
10000
1000
100

control

clonidine

TEA

10
Epi bas

NE bas

Cortisol

Cortisol

troponin

basal

ICU 24

T Icu 24

1

control
clonidine
TEA

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; 71:62530.<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

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

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 5month 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,

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

Auroy et al.Serious Complications Related to
Regional Anesthesia: Results of a Prospective
8
7

cardiac arrest
death
seizures
neurol.injury
radiculopathy
cauda equina
paraplegia

6
5
1/10.000

4
3
2
1
0

spinal

periph.reg

Total

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'

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

• 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

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

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—

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

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

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

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

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.

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 <

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

Anesth 2001 / 48 / 326-332

Anesth 2001 / 48 / 326-332
0,7
0,6
0,5

1/10.000

0,4

epid

spinl

caudal

ivra

plexus

3231

AG

9222

0

4145

3308

0,1

7656
2081

0,2

71826

0,3

cardiac arrest
death

nerve

•

•
•
•

Anesth 2001 / 48 / incidence
Over the six years of the study, the326-332 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

• 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>!

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

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

VS
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,
• CASISTICA DI 238 CASI ;MA Ac??
Casistica di AC:289
150 attribuiti all’anestesia
• FREQUENZA??
frequenza di 1.4 ± 0.45 per 10,000
• MORTALITà :50%
anestesie
• BRAIN DAMAGE 30%
mortalità del 26%.
Le cause di arresto cardiaco più frequenti
• EVENTI RESP 43%
sono state attribuite a farmaci (37%) e
• EVENTI CARDIOVASC 13%
cardioavscolari (32%) la depressione
cardiovascolare da alotano ,isolata o
• EQUIPMENT PROBL 13%
insieme con altri farmaci,era responsabile
• WRONG DRUG:3%
di circa i 2/3 di tutti gli AC legati ai
farmaci
• CLASSE asa 1 & 2:49%
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 .

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.

• 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

• 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.

Pollard JB. Cardiac arrest during spinal anesthesia:

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 anestheticinduced 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

Bachmann D, et al. The effects of
thoracic epidural anesthesia on
intraoperative visceral perfusion
and metabolism. Anesth Analg
1999; 88:402-6.

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.

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

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

Glantz et al. Perioperative myocardial ischemia in
cataract surgery patients: general versus local
anesthesia. Anesth Analg 2000; 91:1415-9.
25

Intraop & postop ischemia:31%!

20

num
dur(min)
ST dev(mm)
paz +isch.intraop
pz+ischpostop

15

isch events intra1
isch events postop

10

isch duration intraop(min)
isch dur postop(min)

5

ST dev intraop(mm)
S dev postop(mm)

0

peribulbar

All intraop events were associated
with
GA+peribulbar an increase in HR (+20% of baselin
, whereas the postop. ischemic changes
were independent of changes in HR in 10/ 22

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

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

• 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

• 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

• 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 ().

• 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

• 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

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

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 perioperative mortality? Anaesthesia 52:203-6,

• 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,

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

• Yeager MP, Glass DD, Neff RK, BrinckJohnsen 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%

Ziser A,Plevak D,Wiesner RH,Rakela J,Offord KP,
Brown DL.Morbidity and Mortality in Cirrhotic Patients
Undergoing Anesthesia and Surgery.Anesthesiology,90:4253, 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.

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

•
•
•
•
•
•

•

Ziser et al .Morbidity and Mortality in Cirrhotic
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

•
•
•
•
•

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

80

+CIRROSI CRIPTOGENETICA E CERTI TIPI DI CHIR…

60
% 40
20
0

norm
P
AO
TR
IN
NS
TE
PO
HY G
ER
g
EM
di n
lee
asa GI b
per ct
up infe
op dip
pre e ins
bet
dia
D
CA
F
CH onia
eum
pn
PD
CO
F
CR nine
ati
cre s
ice
var
ites
asc in
um
e
alb
cor
T
hs
PT -Pug
i ld
Ch

norm
elevat
NO
SI

•
•
•
•
•
•
•
•
•

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

• 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

• 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 shortand 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

Mortality rates in cirhhotic patients operated upon for
various procedures
100

Open cholecyste

Araanha
Leonetti
Rice Um
hern
Ziser

10

1

normal

cirr PT 2.5+

cirr PT>2.5

Studi comparativi di outcome fra
peridurale e G.A, nei bambini
dati da Mc Neely(1991) in fundoplicatio
20
$*1000

gg o %
15

epid
G.A.

10
5
0

morbidità

O2 terap

gg osped

costo

•
•
•
•

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
dati da Bosenberg(1991)nella chirurgia per
atresia esofagiea
35
30
25
20
15
10
5
0

estubaz
ventilaz

G.A.

P.D.

•
•
•
•
•
•
•
•
•
•

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<1g

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/NIDDM
GA/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.


Andamento della cortisolemia

mmol/lt
400

valori espressi in variazione dai basali

300
200

GANIDDM
LANIDDM
GAnorm
LAnorm

100
0
-100
-200

induz

fine ch

60post

240post

andamento della glicemia
mmol/lt

variazioni rispetto ai valori basali

3
2,5
2
GANIDDM
LANIDDM
GAnorm
LAnorm

1,5
1
0,5
0
-0,5

induz

estraz

fine ch

30'post

60'post 120'post 240'post

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.
assorbimento del paracetamolo dopo
mg/lt
anestesia spinale per chir.ortopedica e
12 analgesia con ketorolac 30 mg o morfina 10
mg i.m.
10
8
ketor
morf

6
4
2
0

15'

30'

45'

60'

90'

120'

Postoperative pediatric urology
Pd.analgesia shortens hospital stay(Agarwal et
al.,Reg.Anesth.,1995,20,s48,)

140
120

hrs

100
80
60

epid
non epid.

%

40

gg

20
0

spasmo vesc

Ist pasto

Deg.postop

Advantages of epidural analgesia in upper
abdominal surgery
Borkowski et al.,Reg.Anesth.,1995,20,s49

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

9,00
8,00

i.v.PCA con morfina

7,00

VAS g.op.

6,00
5,00

funz.int.

4,00

VAS 1
VAS 2

VAS 3

soddis.

3,00
2,00
1,00
0,00

I.V.P
CA
P.D.

Analgesic techniques affects rate of
recovery after colonic surgery(Liu et
al,Reg.Anesth.,1995,20,s9)
100,00
hrs
90,00
80,00
70,00
60,00
50,00
40,00
30,00
20,00
10,00
0,00

PCA morf.
P.D.morf
p.d.bupi
p.d.bup+morf

h.Ist flatus

t.dimiss

Transsternal thymectomy patients
60,00
% o punti
50,00
40,00
p.d morf
p.d plac

30,00
20,00
10,00
0,00
FVC 1

FVC 2

FVC3

RR

pain 1

pain2

pain 6

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

20
%
15

*

10
5
0

card.

*;signif
*

*
resp
kidney liver

card.

kidney

infect
infect

tot.compl

reop
tot.compl

Epid
i.v.PCA

Guinard et al,Anesthesiology,1995,82,377382.
• “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,1991,75,611618.
Complicanze fra blended e G.A. per chirurgia dell'aorta
addominale
60

resp

50

N.S.

40
30
20

card

10
0

G.A.
P.D.

renal
card

renal

GI

sepsi
sepsi

compl.magg

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

25,00
20,00

0-24 h

96-120

15,00

48-72
epis.ischem

da -2 a 0

10,00

paz con isch
dur isch

5,00
0,00

preop

-2 a 0

intraop

0-24

24-48

48-72

72-96

96-126

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

III

durata mediana degli episodi ischemici
20
15
min

10
5
0

dur preop

dur postop

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
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
al,BJA,1993,71,472.)

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

35,00
30,00
25,00
20,00
15,00
10,00
5,00
0,00

num ev.isch
durata isch
ST depr
paz
1

3

5

7

9

11

13

III:Myocardial ischemia and spinal analgesia in
al,BJA,1993,71,472.)
numero totale di eventi ischemici.durata in min e slivellamento
ST in mm(*100)il giorno dell'intervento

300
250
200
num.eventi
durata
sliv.ST

150
100
50
0

paz
1

3

5

7

9

11

13

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

160
140
120
100
80
60
40
20
0

*10!!
num.eventi
dur.isch
sliv.ST

giorno referenza

giorno op.

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.)

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

%
14
12
10
8
6
4
2
0

A.G
spin

aum isch

dim isch

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
140,00
120,00
100,00
80,00

p.d.
blended
A.G.

60,00
40,00
20,00
0,00

ml

PCA I

II

III

IV

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

• 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
•
•
•
•
•
•

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
Andamento temporale dei livelli plasmatici delle
catecolamine dopo p.d. toracica con lidocaina 2%.
700
600

*

500

*

400

*

*

*
epinefr
norepi

300
200
100
0

0

10

20

30

40

60

III:Effect of thoracic epidural anesthesia combined with
HR,MAP,CI,CPP(cor.perfus.press),SWM(segment.wall
motion TEE)giù,PAOP su rispetto al basale dopo
anest.p.d.toracica.
90,00
80,00
70,00
60,00
50,00
40,00
30,00
20,00
10,00
0,00

*

0

10

HR
MAP
PAOP
CI*10
CPP
SWM

*

20

30

40

60 min

IV:Effect of thoracic epidural anesthesia combined with

• 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

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)

Andamento temporale delle variabili
coagulative ed emoreologiche
300
250

Hct
piastr
prot(gr/lt)
album(gr/lt)
Fibrinog(*10)
vWillFact(%)

200
150
100
50
0

Preop Periop Postop Day1 DAY3 DAY6

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) I

• 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)II
•
•
•
•
•

monitoraggio:
sintomi
ECG
CPK
emodinamica invasiva per 48 h.

vascular surgery(Bode et al,Anesthesiology,1996,84,313)

III

18
16
14
12
G.A.
Spi
P.D.

10
8
6
4
2
0

Ko card

MI

angina

CHF

morte

vascular surgery(Bode et al,Anesthesiology,1996,84,313)

20
18
16
14
12
10
8
6
4
2
0

IV

Z

G.A.
Spi
P.D.

CVP max

PADPmax CVPmax

ggICU
ggRR

ICUgg

Osp.gg

surgery(Bode et al,Anesthesiology,1996,84,3-13)V
• 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
60
50
%

protesi d'anca elettiva

40

prostatect retropub
isterectomia

30

TURP

20
10
0
Keith

Hole

Modig

Hendolin

Riduzione delle complicanze
tromboemboliche
protesi d'anca

% 80
70

prostatectomia

60
50

chir.ginocchio

40

chir.vasc

30
20
10
0

Davis

Modig

Modig

Jorgensen

reg
gen

respiratorie
• migliore conservazione della FRC
• minore frequenza di KO infettive

cardiache
exitus,
MI,angina,
resp.fail

25,00
20,00
15,00

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

reg
gen

10,00
5,00
0,00

Reiz

Cristopherson

Quale evidenza globale?
Report of National Confidential Enquiry into
perioperative deaths 1990
100
80
60
40
20
0

G.A.
Locale solo
reg.solo
GA+REG
GA+local
sedaz
sedaz+local
sedaz+reg

Complicanze nel cesareo(CEMD)
subinvece di pd

*****
9
8
casi
7
6
5
misusofarm
4
inaliot
3
2
1
0
inalinduz
falliot
accid
varie
apparec

1973-1975
1976-1978
1979-1981

Mortalità (<30 gg.) in chirurgia
urgente di protesi d’anca
20
18
%
16
14
12
10
8
6
4
2
0
Couderc

*
reg
gen

*

Davis

McKenzie

Rackle

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
Frequenza per milione di gravid.stimate
35
30

emb.polm
ipertens

25

anest

20

emb.fluido amnio
aborto
gravid.ectopica
emorragia
sepsi
rottura utero
altre cause dirett

15
10
5
0

19 73- 76- 79- 82- 85- 88- 91- 94- 9770- 75 78 81 84 87 90 93 96 99
72

Entrata in vigore della nuova

Morti materne associate con l’anestesia in milioni di
gravidanze stimate per England & Wales
40
35
30
morti associate
direttamente
freq.per milione

25
20
15

% delle morti dirette

10
5
0

70- 73- 76- 79- 82- 85- 88- 91- 94- 9772 75 78 81 84 87 90 93 96 99

Num ber

M aternal Mortality
45
40
35
30

Congenital

25

Acquired-Isc

20

Acquired-Oth
Total

15
10
5
0
1985-87

1988-90

1991-93
Triennium

1994-96

1997-99

Maternal Mortality
45
40
35
30
25
20
15
10
5
0

23
4
9

4

20

2

5

8

6

5

10

9

9

10

10

1985-87

1988-90

1991-93

1994-96

1997-99

Triennium

Acquired-Oth
Acquired-Isch
Congenital

Number of deaths

Maternal Deaths
30
25
20

Pre-eclampsia
Eclam ps ia

15

Total

10

Rate

5
0
1985-87

1988-90

1991-93
Triennium

1994-96

1997-99

Maternal deaths
25

Number

20
Placental abruption

15

Placenta praevia
Post-partum haem

10

Total deaths

5
0
1985-87

1988-90

1991-93

Triennium

1994-96

1997-99

Breakdown of thromboembolism
18
16
14

Num ber

12

Miscarraige/ectopic
Antepartum

10

In labour
8

CS
Vaginal delivery

6
4
2
0
1985-87

1988-90

1991-93

1994-96

1997-99

Deaths from pulmonary embolism
50
45
40

Number

35
30
25
46

20
15

30
24

30

31

10
5
0
1985-87

1988-90

1991-93

1994-96

1997-99

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.
Maternal mortality,New York 1973-76;122 morti.
30
25
20
emb.polm
precl-eclampsia
anest

15
10
5
0

Num

%

Da Parker
Maternal mortality,New York 1980
20
15

gravid.ectopica
ipertens

% 10

emb polm
accid cerebrovasc

5
0

anestesia

Tabella comparativa della
mortalità materna attribuita
all’anestesia
14
12
10
%

8
6
4
2
0

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

Pattern di mortalità materna
associata all’anestesia
• England-Wales 197078
• 68 da GA;
• 40 inalazioni
• 28 problemi di iot

• 7 da reg.

• England & Wales 198587
• 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 :

Pattern di mortalità materna associata
all’anestesia
CAUSA

1973-75

1976-78

1985-88

Inalaz all’induz
anest.
Inalaz durante iot
difficile
Ipossia da iot
esofagea/fallita/tub
o piegato
Errori di farmaci

9

4

1

4

7

0

3

9

6

4

3

0

Iniez
subaracn.durante
tentata epid
Varie

2

1

0

7

4

1

Frequenza di iot fallite

• Hawthorne, L.; Wilson, R.; Lyons, G.;
Dresner, M. Failed intubation revisited: 17yr 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)

16
14
12
10
8

iot fallite

6
4
2
0

1990

1991

1992

1993

1994

1995

Cambiamento del Mallampati Score durante la
gravidanza(Piklington et al,BJA 1995;74:638)
60
50
40
12-set
38 sett

% 30
20
10
0

1

score

2

3

4

Aumento delle iot difficili in ostetricia
1,8
1,6
1,4

%

1,2
1

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

0,8
0,6
0,4
0,2
0

score 3

Cause delle iot difficili

• Variazioni anatomiche
• fattori organizzativi:
– inesperienza
– urgenze fuori orario
– “stat” mentalità
– panico

%

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

100
80
60
40
20
0

% AG
fallite
elettive

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,educaz
ione,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;97:42024).
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

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

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 19791990
• 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.

Hawkins JL,Koonin LM,Palmer SK,Gibbs
CP.Anesthesia related deaths during obstetric
delivery in the United States(Anesthesiology
1997;86:277-84).
num.tot=129
18
16
14
12
10
%
8
6
4
2
0

GA
REG
ignota
sedazione

79-81

82-84

85-87

88-90

Mortalità anestetica legata all’anestesia
• 4.3/milione di nati
vivi( 1979—1981)

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

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

• 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
1984)

• GA 16.7 volte > reg
( 1985—1990).

(1979—

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,Ch
eney 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
40
35

morte (materna)
danno cerebrale neonatale
cefalea
morte neonatale
dolore dur.anest
danno neurale
danno cerebrale paz.
distress emotivo
dolore dorso

30
25
% 20
15
10
5
0

ob

nonob

Claims ostetrici:regionale vs GA.
45

*

40

morte materna
cefalea
morte neonatale
dolore dur.anest
danno neurale
danno cerebrale paz
distress emoz
dolore dorso

35
30
%

25
20
15
10

*
*

*

5
0

reg

GA

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
25
morte materna
cefalea
morte neonatale
dolore dur.anest
danno neurale
danno cerebrale paz
distress emoz
dolore dorso

20
15
%

*

10
5
0

CS

vag

Eventi dannosi nei claims ostetrici
*

14
12

*

10
%

8
6 Probl.resp
4
Probl cardiocirc

2
0

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

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;inalaz→→→anestesisti→→iot dopo 6-7 min. →→danno cerebrale.

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:

• Permanente

∨ 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,ritar
do di ripresa

∨ 9:morte.

∨ 5:minore:danno ad
organi,non debilitante;
∨ 6:significativo;p.es;perdita
di un occhio, di un rene…
∨ sordità,
7:maggiore;paraplegia,cec
ità,danno cerebrale
∨ 8:grave;severo danno
cerebrale,quadriplegia,
cure a vita

Severità del punteggio di
danno(SIS)
• Ob: SIS con mediana 3 vs non ob ,mediana
7
• massimi di SIS eguali
40
• distribuzione diversa……….
20
ob
%

0
minore(03)

non ob

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

Dati relativi ai pagamenti
claims non ob claims ob

Claims ob
regionale generale

non pagati(%)
pagati(%)
pagamento mediano($)
range di pagamento($)

32

38

43

27

59

53

48

63

85000

203000

91000

225000

15000-6 milioni

675000-5.4 milioni

GA pagata il 63% vs 48% delle reg.

675-2.5 mil 750-5.4 mil

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 lengt
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 performan
and the ROC data indicate reasonable goodness of fit but the small ov
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

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