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,Ma...
Problemi metodologici:II
• definizione di anestesia;pd+GA=?
• quale anestesia?LA vs oppioidi:
oppioidi solo
combinazioni
•...
Problemi metodologici:III
• le casistiche devono essere
comparabili;trattamenti condotti in
modo eguale; per es.analgesie
...
Mortality and morbidity of regional vs.general
anesthesia:a metaanalysis.(Sorensen et
al.,Anesthesiology,A1053,1991)

• Me...
Mortality and morbidity of regional vs.general
anesthesia:a metaanalysis.(Sorensen et
al.,Anesthesiology,A1053,1991

• par...
Choice of the anesthetic
technique
• choice of anesthetic technique is a complex
medical decision that depends on many fac...
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

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, Attenu...
Loick et al..High Thoracic Epidural Anesthesia, but Not
Clonidine, Attenuates the Perioperative Stress Response
Via Sympat...
Loick et al..High Thoracic Epidural Anesthesia, but Not
Clonidine, Attenuates the Perioperative Stress Response
Via Sympat...
Loick et al..High Thoracic Epidural Anesthesia,
but Not Clonidine, Attenuates the Perioperative
Stress Response Via Sympat...
Loick et al..High Thoracic Epidural Anesthesia,
but Not Clonidine, Attenuates the Perioperative
Stress Response Via Sympat...
Loick et al..High Thoracic Epidural Anesthesia,
but Not Clonidine, Attenuates the Perioperative
Stress Response Via Sympat...
Loick et al..High Thoracic Epidural Anesthesia,
but Not Clonidine, Attenuates the Perioperative
Stress Response Via Sympat...
Loick et al..High Thoracic Epidural Anesthesia,
but Not Clonidine, Attenuates the Perioperative
Stress Response Via Sympat...
Loick et al..High Thoracic Epidural Anesthesia,
but Not Clonidine, Attenuates the Perioperative
Stress Response Via Sympat...
Loick et al..High Thoracic Epidural Anesthesia,
but Not Clonidine, Attenuates the Perioperative
Stress Response Via Sympat...
Loick et al..High Thoracic Epidural Anesthesia,
but Not Clonidine, Attenuates the Perioperative
Stress Response Via Sympat...
Loick et al..High Thoracic Epidural Anesthesia, but Not
Clonidine, Attenuates the Perioperative Stress Response
Via Sympat...
Theorethical advantages of thoracic epidural
•
•
•
•

•
•

Larsson PT, Hjemdahl P, Olsson G, et al. Altered platelet funct...
Theorethical advantages of thoracic epidural
• This finding suggests that there is less myocardial
damage if high TEA supp...
Auroy Y,Narchi P,Messiah A. Serious Complications
Related to Regional Anesthesia: Results of a Prospective
Survey in Franc...
Auroy et al.Serious Complications Related to Regional
Anesthesia: Results of a Prospective Survey in
France.Anesthesiology...
Auroy et al.Serious Complications Related to Regional
Anesthesia: Results of a Prospective Survey in
France.Anesthesiology...
Auroy et al.Serious Complications Related to
Regional Anesthesia: Results of a Prospective
Survey in France.Anesthesiology...
Auroy et al.Serious Complications Related to
Regional Anesthesia: Results of a Prospective
Survey in France.Anesthesiology...
Auroy et al;summary of results
• 103,730 regional anesthetic procedures:sufficient prospective data for
investigators??

•...
Cardiac Arrest(da Auroy et al.Serious Complications Related to Regional
Anesthesia: Results of a Prospective Survey in Fra...
Cardiac Arrest(da Auroy et al.Serious Complications Related to Regional
Anesthesia: Results of a Prospective Survey in Fra...
Cardiac Arrest:epidural & peripheral nerve block(da Auroy et
al.Serious Complications Related to Regional Anesthesia: Resu...
Neurologic complications:(daAuroy et al.Serious Complications
Related to Regional Anesthesia: Results of a Prospective Sur...
Radiculopathy(da Auroy et al.Serious Complications Related to Regional
Anesthesia: Results of a Prospective Survey in Fran...
Neurol KO not associated with pain,paresthesias or
technivcal difficulties:(da Auroy et al.Serious Complications Related t...
Seizures (daAuroy et al.Serious Complications Related to Regional Anesthesia:
Results of a Prospective Survey in France.An...
Bupivacaine toxicity; daAuroy et al.Serious Complications
Related to Regional Anesthesia: Results of a Prospective Survey ...
Citotoxicity: daAuroy et al.Serious Complications Related to Regional
Anesthesia: Results of a Prospective Survey in Franc...
Auroy et al
• The incidence of complications reported in this
study is comparable with those found in various
other survey...
Auroy vs Caplan
• Caplan et al. retrospectively studied cases
of relatively young, healthy patients who
had cardiac arrest...
Citotoxicity;biblio
• 15: Drasner K, Sakura S, Chan VW, Bollen AW, Ciriales
R: Persistent sacral sensory deficit induced b...
Biboulet P, Aubas P, Dubourdieu J, Rubenovitch
J,Capdevila X, d'Athis F.Fatal and non fatal cardiac arrests
related to ane...
Biboulet et al.Fatal and non fatal cardiac arrests related to
anesthesia.General Anesthesia*Can J Anesth 2001 / 48 /
326-3...
Biboulet et al.Fatal and non fatal cardiac arrests
related to anesthesia.General Anesthesia*Can J
Anesth 2001 / 48 / 326-3...
Biboulet et al.Fatal and non fatal cardiac arrests
related to anesthesia.General Anesthesia*Can J
Anesth 2001 / 48 / 326-3...
Biboulet et al.Fatal and non fatal cardiac arrests
related to anesthesia.General Anesthesia*Can J
Anesth 2001 / 48 / 326-3...
Biboulet et al.Fatal and non fatal cardiac arrests
related to anesthesia.General Anesthesia*Can J
Anesth 2001 / 48 / 326-3...
Biboulet et al.Fatal and non fatal cardiac arrests
related to anesthesia.General Anesthesia*Can J
Anesth 2001 / 48 / 326-3...
Biboulet et al.Fatal and non fatal cardiac arrests
related to anesthesia.General Anesthesia*Can J
Anesth 2001 / 48 / 326-3...
•

•
•
•

Biboulet et al.Fatal and non fatal cardiac arrests
related to anesthesia.General Anesthesia*Can J
Anesth 2001 / ...
Biboulet et al.Fatal and non fatal cardiac arrests
related to anesthesia.General Anesthesia*Can J
Anesth 2001 / 48 / 326-3...
• 1: Keenan RL, Boyan CP. Cardiac arrest due to anesthesia. A study
of incidence and causes. JAMA 1985; 253:2373-7.<ldn>!
...
• 5: Aubas S, Biboulet Ph, Daurès JP, du Cailar J.
Incidence and aetiology of cardiac arrests occuring in
operating and re...
CM,Hackel A, Caplan RA, Domino KB, Posner K,Cheney
FW.
Anesthesia-related Cardiac Arrest in Children : Initial
Findings of...
Morray et al.Anesthesia-related Cardiac Arrest in
Children : Initial Findings of the Pediatric Perioperative
Cardiac Arres...
Morray et al.Anesthesia-related Cardiac Arrest
in Children : Initial Findings of the Pediatric
Perioperative Cardiac Arres...
Morray et al.Anesthesia-related Cardiac Arrest
in Children : Initial Findings of the Pediatric
Perioperative Cardiac Arres...
Morray et al.Anesthesia-related Cardiac Arrest
in Children : Initial Findings of the Pediatric
Perioperative Cardiac Arres...
Morray et al.Anesthesia-related Cardiac Arrest in Children : Initial Findings of the
Pediatric Perioperative Cardiac Arres...
Morray J, Geiduschek J, Caplan R, Posner K, Gild W,
Cheney FW: A comparison of pediatric and adult
anesthesia malpractice ...
Morray J, Geiduschek J, Caplan R, Posner K, Gild W,
Cheney FW: A comparison of pediatric and adult
anesthesia malpractice ...
• total data base of 2,400 claims, accrued as of
March 1991. Of these, 238 were pediatric claims
(10%), defined as those i...
• Pollard JB. Cardiac arrest during spinal
anesthesia: Anesth Analg 2001; 92:252–6. <ldn>!
• 2: Ligouri G, Sharrock N. Asy...
Pollard JB. Cardiac arrest during spinal anesthesia:
Anesth Analg 2001; 92:252–6
Ligouri G, Sharrock N. Asystole and severe bradycardia
during epidural anesthesia in orthopedic patients.
Anesthesiology 1...
Brown DL, Ransom DM, Hall JA, Leicht CH, Schroeder
DR, Offord KP: Regional anesthesia and local anestheticinduced systemic...
Caplan RA, Ward RJ, Posner K, Cheney FW: Unexpected
cardiac arrest during spinal anesthesia: A closed claims
analysis of p...
Dahlgren N, Tornebrandt K: Neurological complications
after anaesthesia. A follow-up of 18 000 spinal and
epidural anesthe...
Bachmann D, et al. The effects of
thoracic epidural anesthesia on
intraoperative visceral perfusion
and metabolism. Anesth...
anginal effects of
thoracic epidural
anesthesia versus
those of conventional
medical therapy in the
treatment of severe
re...
fentanyl reduces
perioperative
myocardial ischaemia
in elderly patients
with hip fracturesQa
randomized controlled
trial. ...
Glantz L, Drenger B, Gozal Y. Perioperative myocardial
ischemia in cataract surgery patients: general versus local
anesthe...
Glantz et al. Perioperative myocardial ischemia in cataract
surgery patients: general versus local anesthesia. Anesth
Anal...
Glantz et al. Perioperative myocardial ischemia in
cataract surgery patients: general versus local
anesthesia. Anesth Anal...
Barker JP, Vafidis GC, Robinson PN, Hall GM. Plasma
catecholamine response to cataract surgery: a comparison
between gener...
A, Parker CJR, Salmon P. The
relationship of the functional
recovery after hip arthroplasty to
the neuroendocrine and
infl...
• Cruickshank AM, Fraser WD, Burns
HJG, Van Damme J, Shenkin A.
Response of serum interleukin-6
in patients undergoing ele...
• Parker MJ, Urwin SC, Handoll HHG,
Griffiths R: General versus spinal/epidural
analgesia for hip fractures in adults, Iss...
O'Hara DA, Duff A,Berlin JA, ,Poses R, Lawrence
VA,Huber E,Noveck H, Strom BL,Carson JL.The Effect of
Anesthetic Technique...
O'Hara et al.The Effect of Anesthetic Technique
on Postoperative Outcomes in Hip Fracture
Repair Anesthesiology 92:947-57,...
O'Hara et al.The Effect of Anesthetic Technique
on Postoperative Outcomes in Hip Fracture
Repair Anesthesiology 92:947-57,...
O'Hara et al.The Effect of Anesthetic Technique
on Postoperative Outcomes in Hip Fracture
Repair Anesthesiology 92:947-57,...
• Charlson ME, Pompei P, Ales KL,
MacKenzie CR: A new method of
classifying prognostic comorbidity in
longitudinal studies...
O'Hara et al.The Effect of Anesthetic Technique
on Postoperative Outcomes in Hip Fracture
Repair Anesthesiology 92:947-57,...
O'Hara et al.The Effect of Anesthetic Technique
on Postoperative Outcomes in Hip Fracture
Repair Anesthesiology 92:947-57,...
O'Hara et al.The Effect of Anesthetic Technique
on Postoperative Outcomes in Hip Fracture
Repair Anesthesiology 92:947-57,...
O'Hara et al.The Effect of Anesthetic Technique
on Postoperative Outcomes in Hip Fracture
Repair Anesthesiology 92:947-57,...
O'Hara et al.The Effect of Anesthetic Technique
on Postoperative Outcomes in Hip Fracture
Repair Anesthesiology 92:947-57,...
O'Hara et al.The Effect of Anesthetic Technique
on Postoperative Outcomes in Hip Fracture
Repair Anesthesiology 92:947-57,...
O'Hara et al.The Effect of Anesthetic Technique
on Postoperative Outcomes in Hip Fracture
Repair Anesthesiology 92:947-57,...
O'Hara et al.The Effect of Anesthetic Technique
on Postoperative Outcomes in Hip Fracture
Repair Anesthesiology 92:947-57,...
O'Hara et al.The Effect of Anesthetic Technique
on Postoperative Outcomes in Hip Fracture
Repair Anesthesiology 92:947-57,...
O'Hara et al.The Effect of Anesthetic Technique
on Postoperative Outcomes in Hip Fracture
Repair Anesthesiology 92:947-57,...
• Liu S, Carpenter RL, Neal JM: Epidural
anesthesia and analgesia. Their role in
postoperative outcome. ANESTHESIOLOGY
82:...
• Go AS, Browner WS: Cardiac outcomes
after regional or general anesthesia. Do we
have the answers? ANESTHESIOLOGY
84:1-2,...
O'Hara et al
• Our analysis also shows that regional anesthesia
was used more frequently in recent years. In 1981
—1982, t...
O'Hara et al
• Many clinical factors influence the risk of
mortality and morbidity after anesthesia. Studies
have suggeste...
Hole A, Terjesen T, Breivik H: Epidural versus general
anaesthesia for total hip arthroplasty in elderly patients.
Acta An...
• 26: Rose DK, Cohen MM, DeBoer DP:
Cardiovascular events in the postanesthesia care
unit. ANESTHESIOLOGY 84:772-81,
1996<...
• Mangano DT, Browner WS, Hollenberg M,
London MJ, Tubau JF, Tateo IM: Association of
perioperative myocardial ischemia wi...
Gibbons, G, Hunter, JA,
Espanola, CC, Nesto, RW:
Cardiac outcome after peripheral
vascular surgery. Comparison of
general ...
• Hole A, Terjesen T, Breivik H: Epidural versus
general anaesthesia for total hip arthroplasty in
elderly patients. Acta ...
• Yeager MP, Glass DD, Neff RK, BrinckJohnsen T: Epidural anesthesia and
analgesia in high-risk surgical patients.
ANESTHE...
O'Hara et al
• The most important limitation of this retrospective
observational cohort study is that it is possible that
...
Ziser A,Plevak D,Wiesner RH,Rakela J,Offord KP,
Brown DL.Morbidity and Mortality in Cirrhotic Patients
Undergoing Anesthes...
Ziser et al.Morbidity and Mortality in Cirrhotic
Patients Undergoing Anesthesia and
Surgery.Anesthesiology,90:42-53, 1999
...
•
•
•
•
•
•

•

Ziser et al .Morbidity and Mortality in Cirrhotic
Patients Undergoing Anesthesia and
Surgery.Anesthesiolog...
Ziser et al .Morbidity and Mortality in Cirrhotic
Patients Undergoing Anesthesia and
Surgery.Anesthesiology,90:42-53, 1999...
Factors associated with perioperative complications in
cirrhotic patients.(from Ziser et al .Morbidity and Mortality in Ci...
Variables associated with complications in cirrhotic
patients (DA Ziser et al .Morbidity and Mortality in Cirrhotic Patien...
Ziser et al .Morbidity and Mortality in Cirrhotic
Patients Undergoing Anesthesia and
Surgery.Anesthesiology,90:42-53, 1999...
Ziser et al .Morbidity and Mortality in Cirrhotic
Patients Undergoing Anesthesia and
Surgery.Anesthesiology,90:42-53, 1999...
Ziser et al .Morbidity and Mortality in Cirrhotic
Patients Undergoing Anesthesia and
Surgery.Anesthesiology,90:42-53, 1999...
Ziser et al .Morbidity and Mortality in Cirrhotic
Patients Undergoing Anesthesia and
Surgery.Anesthesiology,90:42-53, 1999...
Ziser et al .Morbidity and Mortality in Cirrhotic
Patients Undergoing Anesthesia and
Surgery.Anesthesiology,90:42-53, 1999...
Mortality rates in cirhhotic patients operated upon for
various procedures
100

Open cholecyste

Araanha
Leonetti
Rice Um
...
Dati di Jayr su Vaio
Studi comparativi di outcome fra
peridurale e G.A, nei bambini
dati da Mc Neely(1991) in fundoplicatio
20
$*1000

gg o %
1...
•
•
•
•

Quale rationale per scegliere
regionale vs generale?

esistono realmente dei vantaggi?
quali sono questi vantaggi...
Studi comparativi di outcome fra
peridurale e G.A, nei bambini
dati da Bosenberg(1991)nella chirurgia per
atresia esofagie...
•
•
•
•
•
•
•
•
•
•

Definire le complicanze legate
all’anestesia(Lagasse,Anesthesiology 1995)
morte intraop o <2 gg.
rico...
complicanze legate
all’anestesia(ARC’s)

• tutte le complicanze :
•
•
•
•
•
•
•

neurologiche
polmonari
cardiache(MI,aritm...
Metabolic control of noninsulin dependent diabetic
patients undergoing cataract surgery:comparison of local
and general an...
Metabolic control of noninsulin dependent diabetic
patients undergoing cataract surgery:comparison of local
and general an...
Metabolic control of noninsulin dependent diabetic
patients undergoing cataract surgery:comparison of local
and general an...
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 ...
Funzione gastrica postop:da Petring et
al.BJA,1995,74,257.
assorbimento del paracetamolo dopo
mg/lt
anestesia spinale per ...
Postoperative pediatric urology
Pd.analgesia shortens hospital stay(Agarwal et
al.,Reg.Anesth.,1995,20,s48,)

140
120

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

p.d.con bupi 0,1+fen...
Analgesic techniques affects rate of
recovery after colonic surgery(Liu et
al,Reg.Anesth.,1995,20,s9)
100,00
hrs
90,00
80,...
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
...
Yaeger:inizia la disputa
frequenza di complicanze in chirurgia maggiore a seconda della
tecnica anestesiologica:GA +PCA vs...
Guinard et al,Anesthesiology,1995,82,377382.
• “p.d. and i.v. fentanyl produce equivalent
effects during major surgery”
•
...
Baron et al,Anesthesiology,1991,75,611618.
Complicanze fra blended e G.A. per chirurgia dell'aorta
addominale
60

resp

50...
Yaeger vs Baron
• differenza nella chirurgia(addomino-toracica maggiore vs
aortica)
• differenza nel numero pazienti
• dif...
Incidenza di episodi ischemici
perioperatori
Ischemia periop.in 52 paz.monitorizzati con Holter(da Marsch,Anesthesiology,7...
Perioperative myocardial ischemia in patients undergoing
elective hip arthroplasty during lumbar regional
anesthesia.(Mars...
Perioperative myocardial ischemia in patients undergoing elective hip
arthroplasty during lumbar regional anesthesia.(Mars...
Perioperative myocardial ischemia in patients undergoing elective hip
arthroplasty during lumbar regional anesthesia.(Mars...
Myocardial ischemia and spinal analgesia in
patients with angina pectoris. (Christensen et
al,BJA,1993,71,472.)

• paz.con...
Myocardial ischemia and spinal analgesia in
patients with angina pectoris. (Christensen et
al,BJA,1993,71,472.);segue dall...
II:Myocardial ischemia and spinal analgesia in
patients with angina pectoris. (Christensen et
al,BJA,1993,71,472.)

numero...
III:Myocardial ischemia and spinal analgesia in
patients with angina pectoris. (Christensen et
al,BJA,1993,71,472.)
numero...
Maggiore incidenza di eventi ischemici nel giorno
dell’intervento rispetto ad un giorno successivo di
riferimento con atti...
Perioperative myocardial ischemia in patients undergoing
transurethral surgery:a pilot study comparing general
with spinal...
II:Perioperative myocardial ischemia in patients
undergoing transurethral surgery:a pilot study
comparing general with spi...
III:Perioperative myocardial ischemia in patients
undergoing transurethral surgery:a pilot study
comparing general with sp...
IV:Perioperative myocardial ischemia in patients undergoing
transurethral surgery:a pilot study comparing general with spi...
The effect of epidural versus general anesthesia on postoperative pain
and analgesic requirements in patients undergoing r...
II:The effect of epidural versus general anesthesia on postoperative
pain and analgesic requirements in patients undergoin...
III:The effect of epidural versus general anesthesia on
postoperative pain and analgesic requirements in patients undergoi...
Failure of epidural anesthesia to prevent
postoperative paralytic ileus.(Wallin et
al,Anesthesiology,1986,65,292)

• 30 pa...
Long term home self treatment with high thoracic
epidural anesthesia in patients with severe coronary
artery disease.(Blom...
II:Long term home self treatment with high thoracic
epidural anesthesia in patients with severe coronary
artery disease.(B...
III:Long term home self treatment with high thoracic
epidural anesthesia in patients with severe coronary
artery disease.(...
Effect of thoracic epidural anesthesia combined with
general anesthesia on segmental wall motion assessed by
transesophage...
II:Effect of thoracic epidural anesthesia combined with
general anesthesia on segmental wall motion assessed by
transesoph...
III:Effect of thoracic epidural anesthesia combined with
general anesthesia on segmental wall motion assessed by
transesop...
IV:Effect of thoracic epidural anesthesia combined with
general anesthesia on segmental wall motion assessed by
transesoph...
Abnormalities in myocardial segmental wall
motion during lumbar epidural anesthesia(Saada et
al.,Anesthesiology,1989,71,26...
Fibrinolytic and hemorheologic alterations during and
after elective aortic graft surgery:implications for
postoperative m...
Fibrinolytic and hemorheologic alterations during and
after elective aortic graft surgery:implications for
postoperative m...
Fibrinolytic and hemorheologic alterations during and
after elective aortic graft surgery:implications for
postoperative m...
II:Fibrinolytic and hemorheologic alterations during and after
elective aortic graft surgery:implications for postoperativ...
III:Fibrinolytic and hemorheologic alterations during and after
elective aortic graft surgery:implications for postoperati...
Haemodynamic effects and outcome analysis of hypotensive
extradural anaesthesia in controlled hypertensive patients
underg...
II:Haemodynamic effects and outcome analysis of hypotensive extradural
anaesthesia in controlled hypertensive patients und...
Cardiac outcome after peripheral vascular
surgery(Bode et al,Anesthesiology,1996,84,3-13) I

• GA vs spi vs p.d.
•
•
•
•
•...
Cardiac outcome after peripheral vascular
surgery(Bode et al,Anesthesiology,1996,84,3-13)II
•
•
•
•
•

monitoraggio:
sinto...
Cardiac outcome after peripheral
vascular surgery(Bode et al,Anesthesiology,1996,84,313)

III

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

...
Cardiac outcome after peripheral
vascular surgery(Bode et al,Anesthesiology,1996,84,313)

20
18
16
14
12
10
8
6
4
2
0

IV
...
Cardiac outcome after peripheral vascular
surgery(Bode et al,Anesthesiology,1996,84,3-13)V
• Conclusioni:
• la morbilità e...
•
•
•
•
•
•
•

Le ragioni per scegliere la anestesia
regionale

riduzione dello stress
riduzione delle perdite ematiche
ri...
Anestesia regionale:una scelta
mirata?
• chirurgia dell’anca
• chirurgia della prostata,specie per via
endoscopica
• chiru...
anestesia regionale e funzione
G.I
•
•
•
•

facilitazione dello svuotamento gastrico
aumento dell’ attività elettrica inte...
Riduzione delle perdite ematiche
60
50
%

protesi d'anca elettiva

40

prostatect retropub
isterectomia

30

TURP

20
10
0...
Riduzione delle complicanze
tromboemboliche
protesi d'anca

% 80
70

prostatectomia

60
50

chir.ginocchio

40

chir.vasc
...
Riduzione delle complicanze
respiratorie
• migliore conservazione della FRC
• minore frequenza di KO infettive
Riduzione delle complicanze
cardiache
exitus,
MI,angina,
resp.fail

25,00
20,00
15,00

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

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

G.A.
Loc...
e fra le diverse tecniche?
Complicanze nel cesareo(CEMD)
subinvece di pd

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

McK...
Lista delle abbreviazioni
• ASA:American Society of Anesthesiologists
• ACOG:American College of Obstetricians
Gynecologis...
Report on Confidential enquiries into maternal deaths in
England and Wales 1970-1996
Frequenza per milione di gravid.stima...
Morti materne associate con l’anestesia in milioni di
gravidanze stimate per England & Wales
40
35
30
morti associate
dire...
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...
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
...
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
...
Maternal deaths
25

Number

20
Placental abruption

15

Placenta praevia
Post-partum haem

10

Total deaths

5
0
1985-87

...
Breakdown of thromboembolism
18
16
14

Num ber

12

Miscarraige/ectopic
Antepartum

10

In labour
8

CS
Vaginal delivery

...
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...
Da Parker,J,Schiffer,MA,Nelson,F.“Maternal
and perinatal mortality”in Clinical management
of mother and newborn,GF Marx
ed...
Da Parker
Maternal mortality,New York 1980
20
15

gravid.ectopica
ipertens

% 10

emb polm
accid cerebrovasc

5
0

anestes...
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 8...
Pattern di mortalità materna
associata all’anestesia
• New York,1979-81:
– 13 casi:
• 12 GA:failed intub,asp
of gastric co...
Pattern di mortalità materna
associata all’anestesia
• England-Wales 197078
• 68 da GA;
• 40 inalazioni
• 28 problemi di i...
Pattern di mortalità materna associata
all’anestesia
CAUSA

1973-75

1976-78

1985-88

Inalaz all’induz
anest.
Inalaz dura...
Frequenza di iot fallite

• Hawthorne, L.; Wilson, R.; Lyons, G.;
Dresner, M. Failed intubation revisited: 17yr experience...
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...
Cambiamento del Mallampati Score durante la
gravidanza(Piklington et al,BJA 1995;74:638)
60
50
40
12-set
38 sett

% 30
20
...
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...
Cause delle iot difficili

• Variazioni anatomiche
• fattori organizzativi:
– inesperienza
– urgenze fuori orario
– “stat”...
Ricorso non necessario alla AG

•
•
•
•

Inadeguata educazione della paziente
abitudini chirurgiche
chiamata tardiva
contr...
Prevenzione delle C/S di urgenza(Morgan,Brit J Obstet
Gynecol 1990;97:420)

• visite preop congiunte 3 volte al dì
• analg...
Carrello per intubazione
•
•
•
•
•
•
•
•
•

In sala op.
laringoscopi:manico normale,sottile ,corto
lame curve,rette,Bizzar...
Conclusioni sulla intubazione difficile

• Mettere a punto
l’organizzazione;informazione,visite,educaz
ione,Sellick…...
• ...
Cause di mortalità anestetiche in gravide
classificate come “varie”:

•
•
•
•
•

reazioni allergica
inadeguato antagonismo...
Valutazione dei fattori di rischio
• Visita prenatale,vicino al termine
• fattori di rischio per C/s urgente possono esser...
Cause di mortalità ostetrica da anestesia

• Inalazione polmonare del contenuto
gastrico
• impossibilità di intubare la tr...
Hawkins JL,Koonin LM,Palmer SK,Gibbs
CP.Anesthesia related deaths during obstetric
delivery in the United States(Anesthesi...
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%...
Hawkins JL,Koonin LM,Palmer SK,Gibbs
CP.Anesthesia related deaths during obstetric
delivery in the United States(Anesthesi...
Mortalità anestetica legata all’anestesia
• 4.3/milione di nati
vivi( 1979—1981)

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

...
Fatti salienti da CDC USA: la mortalità
anestetica legata all’anestesia;cause e differenze
fra AG e reg.
• Il numero assol...
Fatti salienti da CDC USA frequenza di fatalità
per GA vs reg.

• GA 2.3 volte > reg
1984)

• GA 16.7 volte > reg
( 1985—1...
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...
ASA closed claims project
Malpractice claims against anesthesiologists
40
35

morte (materna)
danno cerebrale neonatale
ce...
Claims ostetrici:regionale vs GA.
45

*

40

morte materna
danno cerebrale neonatale
cefalea
morte neonatale
dolore dur.an...
Patogenesi del danno neonatale

• 45% attribuiti a cause anestetiche( 4 GA
(1 broncospasmo,1 intub esofagea,i aspir
polm,1...
Danno materno;CS vs vaginale
25
morte materna
danno cerebrale neonatale
cefalea
morte neonatale
dolore dur.anest
danno neu...
Eventi dannosi nei claims ostetrici
*

14
12

*

10
%

8
6 Probl.resp
4
Probl cardiocirc

2
0

ob

*
nonob

ventilaz inade...
Inalazione polmonare
• 8% degli ob claims vs 2% dei non ob
• 50% dei casi associati a iot difficile,intubazione
esofagea o...
Convulsioni
•
Problemi di attrezzature
• 5/11 strappo del catetere perid
• defibrillatore non operativo
• 5 probl di ventilatore:
– conn...
Classificazione della severità del danno
• Temporaneo:

• Permanente

∨ 0:non ovvio
∨ 1: emotivo
solo;paura,dolore…
∨ 2:in...
Severità del punteggio di
danno(SIS)
• Ob: SIS con mediana 3 vs non ob ,mediana
7
• massimi di SIS eguali
40
• distribuzio...
Dati relativi ai pagamenti
claims non ob claims ob

Claims ob
regionale generale

non pagati(%)
pagati(%)
pagamento median...
Conclusioni dai closed claims:1
• Danno cerebrale neonatale è il claim più
frequente,anche se solo il 50% è LEGATO
ALL’ANE...
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 di...
CEMDUK 1988–1990:II
•

It is particularly noteworthy that there has been a sharp
reduction in the percentage of direct mat...
CEMDUK 1988–1990:III
• In the last two triennia, there was a reduction in
the percentage of direct anaesthetic deaths (of ...
CEMDUK 1988–1990:IV
• Of the four deaths directly attributable to anaesthesia, all
had risk factors which were easily iden...
CEMDUK 1988–1990:V
• Every triennial report has identified a strong
link between maternal death and associated
disease or ...
Raccomandazioni finali CEMDUK 88-90
•
•
•
•
•

Capnografia per AG:
bloccanti recettori H2;
antiacidi liquidi non particola...
CEMDUK 1988–1990:VII
• This triennial report recommends that all maternity unit
staff should have a higher level of awaren...
Endler GC,Mariona FG,Sokol RJ,Stevenson
LB.Anesthesia related maternal mortality in
Michigan 1972-84.Am.J.Obstet.Gynecol.
...
Failed intubation drill (St Jame’s Unversity Hospital
maternity Unit)

• Una intubazione fallita è una iot che non può
ess...
Ricoveri in TI legati alla gravidanza

A total of 11 359 patients were admitted to 14 ICU
in the study period: 210 obstetr...
Sequele materne del parto;
dati di Crawford 1978-85.

• Birmingham,UK,11701 questionari su
30096 parti:
• dolore dorsale 1...
Scott DB, Hibbard BM. Serious non-fatal
complications associated with extradural block in
obstetric practice. British Jour...
Scott DB, Tunstall ME. Serious complications
associated with epidural/spinal blockade in
obstetrics. International Journal...
Mortality and morbidity in anesthesia 2002
Mortality and morbidity in anesthesia 2002
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Mortality and morbidity in anesthesia 2002
Mortality and morbidity in anesthesia 2002
Mortality and morbidity in anesthesia 2002
Mortality and morbidity in anesthesia 2002
Mortality and morbidity in anesthesia 2002
Mortality and morbidity in anesthesia 2002
Mortality and morbidity in anesthesia 2002
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Mortality and morbidity in anesthesia,2002

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Mortality and morbidity in anesthesia 2002

  1. 1. Mortalità e morbilità in anestesia: Claudio Melloni Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  2. 2. 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.....
  3. 3. Problemi metodologici:II • definizione di anestesia;pd+GA=? • quale anestesia?LA vs oppioidi: oppioidi solo combinazioni • intra vs postop • standardizzazione della anestesia intraop
  4. 4. 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......
  5. 5. 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
  6. 6. 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
  7. 7. 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.
  8. 8. 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
  9. 9. 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
  10. 10. 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
  11. 11. Insulin 1 0,9 0,8 0,7 0,6 0,5 0,4 0,3 0,2 0,1 0
  12. 12. 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
  13. 13. 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
  14. 14. • Epid + GA decrease lypolysis during surgery to a lower value than GA
  15. 15. 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
  16. 16. Loick et al..High Thoracic Epidural Anesthesia, but Not Clonidine, Attenuates the Perioperative Stress Response Via Sympatholysis and Reduces the Release of Troponin T in Patients Undergoing Coronary Artery Bypass Grafting Anesth Analg 1999; 88:701–9
  17. 17. Loick et al..High Thoracic Epidural Anesthesia, but Not Clonidine, Attenuates the Perioperative Stress Response Via Sympatholysis and Reduces the Release of Troponin T in Patients Undergoing Coronary Artery Bypass Grafting Anesth Analg 1999; 88:701–9
  18. 18. Loick et al..High Thoracic Epidural Anesthesia, but Not Clonidine, Attenuates the Perioperative Stress Response Via Sympatholysis and Reduces the Release of Troponin T in Patients Undergoing Coronary Artery Bypass Grafting Anesth Analg 1999; 88:701–9
  19. 19. Loick et al..High Thoracic Epidural Anesthesia, but Not Clonidine, Attenuates the Perioperative Stress Response Via Sympatholysis and Reduces the Release of Troponin T in Patients Undergoing Coronary Artery Bypass Grafting Anesth Analg 1999; 88:701–9
  20. 20. Loick et al..High Thoracic Epidural Anesthesia, but Not Clonidine, Attenuates the Perioperative Stress Response Via Sympatholysis and Reduces the Release of Troponin T in Patients Undergoing Coronary Artery Bypass Grafting Anesth Analg 1999; 88:701–9
  21. 21. Loick et al..High Thoracic Epidural Anesthesia, but Not Clonidine, Attenuates the Perioperative Stress Response Via Sympatholysis and Reduces the Release of Troponin T in Patients Undergoing Coronary Artery Bypass Grafting Anesth Analg 1999; 88:701–9
  22. 22. 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 Anesth Analg 1999; 88:701–9 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
  23. 23. 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 • Baseline values were comparable among the groups, except Coronary Artery Bypass Grafting for the central venous and mean pulmonary arterial Anesth Analg 1999; 88:701–9 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
  24. 24. 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 • No statistical differences among the groups Anesth Analg 1999; 88:701–9 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
  25. 25. 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 • The surgical procedure resulted in an increase in Anesth Analg 1999; 88:701–9 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
  26. 26. Loick et al..High Thoracic Epidural Anesthesia, but Not Clonidine, Attenuates the Perioperative Stress Response Via Sympatholysis and Reduces the Release of Troponin T in Patients Undergoing Coronary Artery Bypass Grafting Anesth Analg 1999; 88:701–9 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
  27. 27. 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
  28. 28. 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
  29. 29. 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,
  30. 30. 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. •
  31. 31. Auroy et al.Serious Complications Related to Regional Anesthesia: Results of a Prospective Survey in France.Anesthesiology 87:479-86, 1997
  32. 32. Auroy et al.Serious Complications Related to Regional Anesthesia: Results of a Prospective Survey in France.Anesthesiology 87:479-86, 1997
  33. 33. Auroy et al.Serious Complications Related to Regional Anesthesia: Results of a Prospective Survey in France.Anesthesiology 87:479-86, 1997 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
  34. 34. 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
  35. 35. 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'
  36. 36. Cardiac Arrest(da Auroy et al.Serious Complications Related to Regional Anesthesia: Results of a Prospective Survey in France.Anesthesiology 87:479-86, 1997 • Two variables were statistically different regarding cardiac arrest in patients undergoing spinal anesthesia: (1) the time between onset of spinal blockade and occurrence of cardiac arrest was longer in nonsurvivors than in survivors (42 ± 19 min versus 17 ± 16 min, respectively; P < 0.05); and (2) total hip arthroplasty (THA) more frequently was the type of surgery in nonsurvivors than in survivors (5 of 6 THA among nonsurvivors compared with 2 of 20 non-THA surgeries in survivors; P < 0.05). During THA, three cardiac arrests happened at the time of cement insertion and were fatal. Blood loss at the time of cardiac arrest was 700 ml in nine cardiac arrest patients, with four arrests being fatal. Sedation was not performed nor was cyanosis or dizziness observed before any of the
  37. 37. Cardiac Arrest:epidural & peripheral nerve block(da Auroy et al.Serious Complications Related to Regional Anesthesia: Results of a Prospective Survey in France.Anesthesiology 87:479-86, 1997 • 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.
  38. 38. Neurologic complications:(daAuroy et al.Serious Complications Related to Regional Anesthesia: Results of a Prospective Survey in France.Anesthesiology 87:479-86, 1997 • 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.
  39. 39. 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
  40. 40. Neurol KO not associated with pain,paresthesias or technivcal difficulties:(da Auroy et al.Serious Complications Related to Regional Anesthesia: Results of a Prospective Survey in France.Anesthesiology 87:479-86, 1997 • 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—
  41. 41. 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
  42. 42. 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.
  43. 43. Citotoxicity: daAuroy et al.Serious Complications Related to Regional Anesthesia: Results of a Prospective Survey in France.Anesthesiology 87:479-86, 1997 • 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
  44. 44. 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
  45. 45. 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.
  46. 46. 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
  47. 47. 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.
  48. 48. 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 <
  49. 49. 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.
  50. 50. Biboulet et al.Fatal and non fatal cardiac arrests related to anesthesia.General Anesthesia*Can J 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
  51. 51. Biboulet et al.Fatal and non fatal cardiac arrests related to anesthesia.General Anesthesia*Can J Anesth 2001 / 48 / 326-332
  52. 52. Biboulet et al.Fatal and non fatal cardiac arrests related to anesthesia.General Anesthesia*Can J Anesth 2001 / 48 / 326-332
  53. 53. Biboulet et al.Fatal and non fatal cardiac arrests related to anesthesia.General Anesthesia*Can J Anesth 2001 / 48 / 326-332
  54. 54. Biboulet et al.Fatal and non fatal cardiac arrests related to anesthesia.General Anesthesia*Can J 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
  55. 55. • • • • Biboulet et al.Fatal and non fatal cardiac arrests related to anesthesia.General Anesthesia*Can J 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
  56. 56. Biboulet et al.Fatal and non fatal cardiac arrests related to anesthesia.General Anesthesia*Can J Anesth 2001 / 48 / 326-332
  57. 57. • 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>!
  58. 58. • 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>!
  59. 59. 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
  60. 60. Morray et al.Anesthesia-related Cardiac Arrest in Children : Initial Findings of the Pediatric Perioperative Cardiac Arrest (POCA) Registry Anesthesiology, 93:6-14, 2000
  61. 61. Morray et al.Anesthesia-related Cardiac Arrest in Children : Initial Findings of the Pediatric Perioperative Cardiac Arrest (POCA) Registry Anesthesiology, 93:6-14, 2000
  62. 62. Morray et al.Anesthesia-related Cardiac Arrest in Children : Initial Findings of the Pediatric Perioperative Cardiac Arrest (POCA) Registry Anesthesiology, 93:6-14, 2000
  63. 63. Morray et al.Anesthesia-related Cardiac Arrest in Children : Initial Findings of the Pediatric Perioperative Cardiac Arrest (POCA) Registry Anesthesiology, 93:6-14, 2000
  64. 64. 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 .
  65. 65. 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
  66. 66. 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.
  67. 67. • 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
  68. 68. • 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.
  69. 69. Pollard JB. Cardiac arrest during spinal anesthesia: Anesth Analg 2001; 92:252–6
  70. 70. Ligouri G, Sharrock N. Asystole and severe bradycardia during epidural anesthesia in orthopedic patients. Anesthesiology 1997; 86:250–7
  71. 71. 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
  72. 72. 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
  73. 73. 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
  74. 74. Bachmann D, et al. The effects of thoracic epidural anesthesia on intraoperative visceral perfusion and metabolism. Anesth Analg 1999; 88:402-6.
  75. 75. 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.
  76. 76. fentanyl reduces perioperative myocardial ischaemia in elderly patients with hip fracturesQa randomized controlled trial. Acta Anaesthesiol Scand 2000; 44:1061-70.
  77. 77. 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
  78. 78. 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
  79. 79. 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
  80. 80. 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
  81. 81. 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.
  82. 82. • 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.
  83. 83. • 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
  84. 84. 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.
  85. 85. 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
  86. 86. O'Hara et al.The Effect of Anesthetic Technique on Postoperative Outcomes in Hip Fracture Repair Anesthesiology 92:947-57, 2000 • retrospective cohort study of consecutive patients with hip fracture, aged 60 yr or older, who underwent surgical repair at 1 of 20 study hospitals between 1983 and 1993. Patients were excluded if they declined to receive blood transfusion, had metastatic cancer, or underwent a surgical procedure involving a site other than the hip because the data were collected for a study of blood transfusion and surgery.
  87. 87. O'Hara et al.The Effect of Anesthetic Technique on Postoperative Outcomes in Hip Fracture Repair Anesthesiology 92:947-57, 2000 • • • • • • • • 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.
  88. 88. • 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
  89. 89. O'Hara et al.The Effect of Anesthetic Technique on Postoperative Outcomes in Hip Fracture Repair Anesthesiology 92:947-57, 2000 • Statistical Analysis • For each outcome, we first assessed the unadjusted relations with type of anesthesia and potential confounders using an independent sample t test or chi-square test. We calculated the unadjusted odds ratio for the effect of type of anesthesia instead of the relative risk, so it could be compared with the adjusted odds ratio generated by a logistic-regression model. The odds ratio should be the same for uncommon outcomes except confusion. • Logistic regression was used to describe the
  90. 90. O'Hara et al.The Effect of Anesthetic Technique on Postoperative Outcomes in Hip Fracture Repair Anesthesiology 92:947-57, 2000 • 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.
  91. 91. O'Hara et al.The Effect of Anesthetic Technique on Postoperative Outcomes in Hip Fracture Repair Anesthesiology 92:947-57, 2000 • 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 ().
  92. 92. O'Hara et al.The Effect of Anesthetic Technique on Postoperative Outcomes in Hip Fracture Repair Anesthesiology 92:947-57, 2000
  93. 93. O'Hara et al.The Effect of Anesthetic Technique on Postoperative Outcomes in Hip Fracture Repair Anesthesiology 92:947-57, 2000
  94. 94. O'Hara et al.The Effect of Anesthetic Technique on Postoperative Outcomes in Hip Fracture Repair Anesthesiology 92:947-57, 2000
  95. 95. O'Hara et al.The Effect of Anesthetic Technique on Postoperative Outcomes in Hip Fracture Repair Anesthesiology 92:947-57, 2000
  96. 96. O'Hara et al.The Effect of Anesthetic Technique on Postoperative Outcomes in Hip Fracture Repair Anesthesiology 92:947-57, 2000
  97. 97. O'Hara et al.The Effect of Anesthetic Technique on Postoperative Outcomes in Hip Fracture Repair Anesthesiology 92:947-57, 2000
  98. 98. O'Hara et al.The Effect of Anesthetic Technique on Postoperative Outcomes in Hip Fracture Repair Anesthesiology 92:947-57, 2000 • This study of 9,425 patients is the largest analysis that we are aware of that evaluated the effect of the type of anesthesia on mortality and morbidity. As might be predicted from clinical practice, we found that older patients and those who are more ill were more likely to be administered regional anesthesia. However, after controlling for differences in patient characteristics, we found no association between type of anesthesia and mortality or morbidity. This finding suggests that unadjusted differences in outcome between general anesthesia and regional anesthesia are
  99. 99. • 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>!
  100. 100. • Go AS, Browner WS: Cardiac outcomes after regional or general anesthesia. Do we have the answers? ANESTHESIOLOGY 84:1-2, 1996
  101. 101. 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
  102. 102. 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
  103. 103. Hole A, Terjesen T, Breivik H: Epidural versus general anaesthesia for total hip arthroplasty in elderly patients. Acta Anaesth Scand 24:279-87, 1980
  104. 104. • 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,
  105. 105. • 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,
  106. 106. 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
  107. 107. • 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
  108. 108. • Yeager MP, Glass DD, Neff RK, BrinckJohnsen T: Epidural anesthesia and analgesia in high-risk surgical patients. ANESTHESIOLOGY 66:729-36, 1987<ldn>!
  109. 109. 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%
  110. 110. 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.
  111. 111. 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
  112. 112. • • • • • • • Ziser et al .Morbidity and Mortality in Cirrhotic Patients Undergoing Anesthesia and Surgery.Anesthesiology,90:42-53, 1999 January 1980- January 1991 Mayo Clinic. The minimum follow-up period was 2.7 yr, and the maximum follow-up time was 13.7 yr. Only one surgical procedure considered Patients who underwent orthotopic liver transplantation before or during the study were excluded. diagnosed primarily by liver biopsy(some . history of liver disease with impaired liver function tests, + liver ultrasound or computed tomography scan suggesting the diagnosis of cirrhosis, or direct examination of a cirrhotic liver during
  113. 113. Ziser et al .Morbidity and Mortality in Cirrhotic Patients Undergoing Anesthesia and Surgery.Anesthesiology,90:42-53, 1999 • • • • • 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%).
  114. 114. 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
  115. 115. Variables associated with complications in cirrhotic patients (DA Ziser et al .Morbidity and Mortality in Cirrhotic Patients Undergoing Anesthesia and Surgery.Anesthesiology,90:42-53, 1999 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
  116. 116. Ziser et al .Morbidity and Mortality in Cirrhotic Patients Undergoing Anesthesia and Surgery.Anesthesiology,90:42-53, 1999 • • • • • • • • • 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
  117. 117. Ziser et al .Morbidity and Mortality in Cirrhotic Patients Undergoing Anesthesia and Surgery.Anesthesiology,90:42-53, 1999 • preoperative coexisting diseases that were associated with an increased mortality rate: • chronic renal failure • chronic obstructive pulmonary disease, • pneumonia • congestive heart failure • ischemic heart disease • insulin-dependent diabetes mellitus • the presence of preoperative infection • Factors concerning anesthesia management that
  118. 118. Ziser et al .Morbidity and Mortality in Cirrhotic Patients Undergoing Anesthesia and Surgery.Anesthesiology,90:42-53, 1999 • 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.
  119. 119. Ziser et al .Morbidity and Mortality in Cirrhotic Patients Undergoing Anesthesia and Surgery.Anesthesiology,90:42-53, 1999 • 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
  120. 120. Ziser et al .Morbidity and Mortality in Cirrhotic Patients Undergoing Anesthesia and Surgery.Anesthesiology,90:42-53, 1999 • 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
  121. 121. 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
  122. 122. Dati di Jayr su Vaio
  123. 123. 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
  124. 124. • • • • 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?
  125. 125. 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.
  126. 126. • • • • • • • • • • 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
  127. 127. 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...)
  128. 128. 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.
  129. 129. Metabolic control of noninsulin dependent diabetic patients undergoing cataract surgery:comparison of local and general anesthesia.(BJA,1995,74,500-505). 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
  130. 130. Metabolic control of noninsulin dependent diabetic patients undergoing cataract surgery:comparison of local and general anesthesia.(BJA,1995,74,500-505). 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
  131. 131. McNeely,Anesthesiology,75,A689,1991. • chirurgia antireflusso gastroesofageo • 20 paz p.d.vs 20 G.a.
  132. 132. • • • 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
  133. 133. 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'
  134. 134. 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
  135. 135. 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.
  136. 136. 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
  137. 137. 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
  138. 138. 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
  139. 139. 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.
  140. 140. 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
  141. 141. 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?
  142. 142. 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
  143. 143. 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.
  144. 144. 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
  145. 145. Perioperative myocardial ischemia in patients undergoing elective hip arthroplasty during lumbar regional anesthesia.(Marsch er al.,Anesthesiology,76,518,1992) III durata mediana degli episodi ischemici 20 15 min 10 5 0 dur preop dur postop
  146. 146. 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.)
  147. 147. Myocardial ischemia and spinal analgesia in patients with angina pectoris. (Christensen et al,BJA,1993,71,472.);segue dalla prec. • il I evento ischemico il giorno dell’intervento si presenta 338 min più tardi della anest.spinale • si associa con aumento della FC
  148. 148. II:Myocardial ischemia and spinal analgesia in patients with angina pectoris. (Christensen et 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
  149. 149. III:Myocardial ischemia and spinal analgesia in patients with angina pectoris. (Christensen et 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
  150. 150. 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.
  151. 151. 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.
  152. 152. II:Perioperative myocardial ischemia in patients undergoing transurethral surgery:a pilot study comparing general with spinal anesthesia. (Edwards et al,BJA,1995,74,368.)
  153. 153. 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.
  154. 154. 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
  155. 155. 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
  156. 156. 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
  157. 157. 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.
  158. 158. 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.
  159. 159. 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.
  160. 160. II:Long term home self treatment with high thoracic epidural anesthesia in patients with severe coronary artery disease.(Blomberg,S.G.,AA.,1994,79,413) • 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
  161. 161. III:Long term home self treatment with high thoracic epidural anesthesia in patients with severe coronary artery disease.(Blomberg,S.G.,AA.,1994,79,413) • • • • • • 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
  162. 162. 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.
  163. 163. II:Effect of thoracic epidural anesthesia combined with general anesthesia on segmental wall motion assessed by transesophageal echocardiography.(Saada et al.,AA,1992,75,329) 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
  164. 164. III:Effect of thoracic epidural anesthesia combined with general anesthesia on segmental wall motion assessed by transesophageal echocardiography.(Saada et al.,AA,1992,75,329) 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
  165. 165. IV:Effect of thoracic epidural anesthesia combined with general anesthesia on segmental wall motion assessed by transesophageal echocardiography.(Saada et al.,AA,1992,75,329) • però il CI diminuisce solo nei pazienti con CAD!! • NonCAD SWM scores < ai CAD,ma NCAD diminuiscono dopo TEA. • tendenza al miglioramento delle SWM dopo TEA • correzione dell’ipotensione con efedrina aumenta transitoriamente le SWM
  166. 166. Abnormalities in myocardial segmental wall motion during lumbar epidural anesthesia(Saada et al.,Anesthesiology,1989,71,26)
  167. 167. 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
  168. 168. Fibrinolytic and hemorheologic alterations during and after elective aortic graft surgery:implications for postoperative management.(Freyburger et al,AA,1993,76,504) • 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
  169. 169. Fibrinolytic and hemorheologic alterations during and after elective aortic graft surgery:implications for postoperative management.(Freyburger et al,AA,1993,76,504) • 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.
  170. 170. II:Fibrinolytic and hemorheologic alterations during and after elective aortic graft surgery:implications for postoperative management.(Freyburger et al,AA,1993,76,504)
  171. 171. 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
  172. 172. 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
  173. 173. 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.
  174. 174. 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.
  175. 175. Cardiac outcome after peripheral vascular surgery(Bode et al,Anesthesiology,1996,84,3-13)II • • • • • monitoraggio: sintomi ECG CPK emodinamica invasiva per 48 h.
  176. 176. Cardiac outcome after peripheral 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
  177. 177. Cardiac outcome after peripheral 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
  178. 178. Cardiac outcome after peripheral vascular 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!
  179. 179. • • • • • • • 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.
  180. 180. Anestesia regionale:una scelta mirata? • chirurgia dell’anca • chirurgia della prostata,specie per via endoscopica • chirurgia ,oncologica,del ginocchio • cesareo • chirurgia vascolare periferica
  181. 181. 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
  182. 182. Riduzione delle perdite ematiche 60 50 % protesi d'anca elettiva 40 prostatect retropub isterectomia 30 TURP 20 10 0 Keith Hole Modig Hendolin
  183. 183. 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
  184. 184. Riduzione delle complicanze respiratorie • migliore conservazione della FRC • minore frequenza di KO infettive
  185. 185. Riduzione delle complicanze 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
  186. 186. 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
  187. 187. e fra le diverse tecniche?
  188. 188. 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
  189. 189. 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
  190. 190. 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
  191. 191. 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
  192. 192. 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
  193. 193. 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
  194. 194. 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
  195. 195. 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
  196. 196. 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
  197. 197. 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
  198. 198. 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
  199. 199. 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 %
  200. 200. Da Parker Maternal mortality,New York 1980 20 15 gravid.ectopica ipertens % 10 emb polm accid cerebrovasc 5 0 anestesia
  201. 201. 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
  202. 202. 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
  203. 203. 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 :
  204. 204. 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
  205. 205. 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.
  206. 206. 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
  207. 207. 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
  208. 208. 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
  209. 209. 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
  210. 210. Ricorso non necessario alla AG • • • • Inadeguata educazione della paziente abitudini chirurgiche chiamata tardiva controindicazioni sorpassate: – – – – preeclampsia placenta praevia febbre mal.cardiache
  211. 211. 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…...
  212. 212. 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……...
  213. 213. 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.
  214. 214. 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
  215. 215. 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.
  216. 216. Cause di mortalità ostetrica da anestesia • Inalazione polmonare del contenuto gastrico • impossibilità di intubare la trachea • shock spinale
  217. 217. 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.
  218. 218. 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.
  219. 219. 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
  220. 220. 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
  221. 221. 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.
  222. 222. 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—
  223. 223. Complicanze della AG per C/S: CDC USA • 20.0/milione GA ( 1979—1984) • 32.3 morti/milione (1985—1990)
  224. 224. mortalità del CS in anest reg: CDC USA • 8.6 /milioni di anest reg ( 1979—1984) • 1.9 /milione ( 1985—1990).
  225. 225. 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!
  226. 226. 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
  227. 227. Claims ostetrici:regionale vs GA. 45 * 40 morte materna danno cerebrale neonatale 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
  228. 228. 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.
  229. 229. Danno materno;CS vs vaginale 25 morte materna danno cerebrale neonatale cefalea morte neonatale dolore dur.anest danno neurale danno cerebrale paz distress emoz dolore dorso 20 15 % * 10 5 0 CS vag
  230. 230. 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
  231. 231. 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.
  232. 232. Convulsioni •
  233. 233. 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
  234. 234. 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
  235. 235. 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
  236. 236. 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
  237. 237. 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;
  238. 238. Conclusioni dai closed claims:2 • Cefalea è il III problema: e risulta in pagamento il 56% delle volte……...
  239. 239. 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.
  240. 240. 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.
  241. 241. 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.
  242. 242. 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.
  243. 243. 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.
  244. 244. 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.....
  245. 245. 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.
  246. 246. 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
  247. 247. 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.
  248. 248. 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.
  249. 249. 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)
  250. 250. 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
  251. 251. 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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