[Risk management of anesthesia for head and neck surgery].

Control of the airway is fundamental for the safe anesthetic practice of head and neck surgery and careful assessment of airway must be undertaken preoperatively. Safe tracheal intubation method should be decided after the airway assessment. Special considerations are necessary for laser surgery, use of a nerve stimulator, and selecting the proper size and type of endotracheal tubes. Emergency anesthesia for neck and head surgery is most difficult. Experienced personnel and several kinds of devices for securing the airway should be gathered in the operating room before induction of anesthesia.

[Recent changes in the incidence of life-threatening events in the operating room: JSA surveys between 2001 and 2005].

BACKGROUND: In Japan, the number of medical staff charged with criminal liability has been increasing since 2000, and this medico-legal trend seems to be promoting topics of medical risk management in government, academic meetings and individual hospital. A survey conducted by the Japanese Society of Anesthesiologists (JSA) has been widely accepted among JSA-certified training hospitals, and its denominator has exceeded one million since 2001. The purpose of this investigation is to examine changes in the incidence of life-threatening events in the operating theater between 2001 and 2005 based on the data of the surveys. METHODS: JSA has conducted annual surveys of life-threatening and neurological events in the operating theater by sending and collecting confidential questionnaires to all JSA certified training hospitals. Cases of life-threatening events between 2001 and 2005 were analyzed. The recovery rates ranged from 76.2% (in 2005) to 91.6% (in 2002), and the annual patient numbers available for analysis ranged from 1,051,245 (in 2005) to 1,367,790 (in 2003) during the study period. The patients with ASA PS 1 or 2 were classified as having good physical status, and those with ASA PS 3 or 4 were classified as having poor physical status. Because mortalities (within 7 postoperative days) are more common in patients with poor physical status, in emergency patients, in neonate, in the elderly, and in patients undergoing cardiovascular surgery, the mortality rate in these patients were investigated. The recovery rate from cardiac arrest without any sequelae was also investigated. The causes of events were classified as follows: totally attributable to anesthetic management (AM), mainly to intraoperative pathological events (IP), to preoperative co-morbidity (PC), and to surgical management (SM). IP consists of pulmonary thromboembolism, acute coronary syndrome, anaphylaxis and so on. The incidence of cardiac arrest and mortality are indicated per 10,000 patients. Odds ratio and 95% confidential interval are shown in comparison with the incidence in 2001 to that in 2005. RESULTS: The incidences of cardiac arrest were 6.12 in 2001, 5.79 in 2002, 5.89 in 2003, 5.09 in 2004, and 4.24/10,000 patients in 2005, respectively (odds ratio 0.69; CI 0.62-0.78). The incidences of death within 7 postoperative days due to intraoperative life-threatening events were 6.41 in 2001, 6.31 in 2002, 6.61 in 2003, 5.88 in 2004, and 4.91/10,000 patients in 2005, respectively (OR 0.77; CI 0.69-0.85). The incidences of death in patients with poor physical status (from 35.48 to 26.87/10,000 patients; OR 0.76; CI 0.66-0.86), in emergency patients (from 37.25 to 30.55/10,000 patients; OR 0.82; CI 0.72-0.93), in neonates (from 70.09 to 31.70/10,000 patients; OR 0.45; CI 0.22-0.91) and in the elderly (from 11.03 to 8.75/10,000 patients; OR 0.79; CI 0.68 to 0.92) decreased. The incidence of death in patients undergoing cardiovascular surgery ranged between 61.22 and 76.88/10,000 patients, and has not shown any significant decline. The incidences of death due to IP (from 0.65 to 0.42/10,000 patients; OR 0.64; CI 0.44-0.92), PC (from 4.14 to 3.30/10,000 patients; OR 0.80; CI 0.70-0.91) and SM (from 1.49 to 1.02/10,000 patients; OR 0.68; CI 0.54-0.87) decreased. However, the incidence of death due to AM ranged between 0.07 and 0.11/10,000 patients, and has not shown any significant decline partly because of the small number of deaths from this cause. Although recent trends in life-threatening events seemed to be favorable, the recovery rate from cardiac arrest decreased from 40.3% in 2001 to 30.7% in 2005 (OR 0.66; CI 0.51-0.84). CONCLUSIONS: The incidence of life-threatening events in the operating room and mortality due to these events seemed to have decreased during the recent five years, probably because of progress in risk management in JSA-certified training hospitals. The decrease was obvious in the recent two years. However, the results should be interpreted cautiously, because the response rate to the questionnaire in 2005 was the lowest. To confirm this trend, we should perform a follow-up survey for 2006 and continue the survey. The reasons for the deterioration in the recovery rate from cardiac arrest should also be examined.

[The state of pediatric anesthesia in Japan: an analysis of the Japanese society of anesthesiologists survey of critical incidents in the operating room].

BACKGROUND: The Japanese Society of Anesthesiologists (JSA) survey of critical incidents in the operating room and other reports have shown that pediatric patients undergoing anesthesia are at an increased risk. Purpose was to examine the state of pediatric anesthesia in Japan. This might clarify the role of children's hospitals for pediatric anesthesia, and the relationship between critical incidents and volume of pediatric anesthetic procedures. METHODS: The JSA has conducted annual surveys of critical incidents in the operating room by sending to and collecting confidential questionnaires from all JSA Certified Training Hospitals. From 1999 to 2003, 342,840 pediatric (0-5 yr) anesthetic procedures were registered. During this period, only 15 cardiac arrests and 3 deaths within 7 postoperative days totally attributable to anesthetic management were reported. Therefore, we analyzed cardiac arrests and deaths due to all etiologies. The hospitals were classified as children's hospitals, university hospitals, and other hospitals, and the incidence of cardiac arrest, the recovery rate from cardiac arrest without any sequelae, and the mortality rate were compared according to types of the hospitals. The relationship between death due to intraoperative critical incidents and the volume of pediatric anesthetic procedures was examined using data from the 2003 survey, the recovery rate of which was 85.7%. In 2003, 739 JSA Certified Training Hospitals responded to the survey: 7 children's hospitals, 109 university hospitals, and 623 other hospitals. Among these hospitals, 707 and 270 hospitals conducted pediatric and newborn (<1 mo) anesthesia, respectively. In 2003, 4,630 newborn, 17,890 infant (<1 yr), and 60,524 child (1-5 yr) anesthetic procedures were registered. Odds ratios were determined to compare the risks among the hospital groups, and the 95% confidential interval (CI) was shown. The Chi square test was used to compare the background of patients with cardiac arrest. P values less than 0.05 were considered significant. RESULTS: In 2003, 95.7% and 36.5% of JSA Certified Training Hospitals which responded to the survey had conducted pediatric and newborn anesthesia, respectively. Children's hospitals, university hospitals, and other hospitals were responsible for 10.7%, 31.0%, and 58.3% of pediatric anesthetic procedures, respectively. Seven children's hospitals (100.0%), 54 university hospitals (50.5%), and 54 other hospitals (9.1%) conducted more than 201 annual pediatric anesthetic procedures, respectively, and these 115 hospitals conducted 62.5% of all pediatric anesthetic procedures in Japan. There was no significant difference between the overall mortality rate in hospitals with an annual pediatric anesthetic volume of less than 200 and that in hospitals with an annual pediatric anesthetic volume of more than 201 (5.46 versus 7.12/10,000 anesthetic procedures). However, the overall mortality rate was 4.87 times higher (95% confidential interval: 1.53-15.66) in hospitals with an annual pediatric anesthetic volume of more than 101 (7.91/10,000 anesthetic procedures) than in those with an annual pediatric anesthetic volume of less than 100 (1.62/10,000 anesthetic procedures). The situation was quite different when we focused on newborn anesthetic procedures : the overall mortality was 2.63 times higher (95% confidential interval : 1.19-5.84) in hospitals with an annual newborn anesthetic volume of less than 12 (126.6/ 10,000 anesthetic procedures) than those with an annual newborn anesthetic volume of more than 13 (48.5/10,000 anesthetic procedures). Between 1999 and 2003, the incidences of cardiac arrest in children's hospitals, university hospitals, and other hospitals were 9.54 (1.89 times higher than the other hospitals; CI 1.31-2.67), 10.30, and 5.11/10,000 anesthetic procedures, respectively. Among the children who developed cardiac arrest, the ratio of poor preoperative conditions with an American Society of Anesthesiologists physical status classification of more than 3 was significantly lower in the children's hospitals (68.9%) than the university hospitals (84.3%) and the other hospitals (84.0%). The recovery rate from cardiac arrest was 51.1% (2.49 times higher than the university hospitals; CI 1.23-5.06, and 3.05 times higher than the other hospitals ; CI 1.45-6.43), 29.6%, and 25.5%, respectively. The mortality rate was 9.54 (1.77 times higher than the other hospitals; CI 1.25-2.52), 8.87, and 5.38/10,000 anesthetic procedures in children's hospitals, university hospitals and other hospitals, respectively. CONCLUSION: Almost all JSA Certified Training Hospitals conducted pediatric anesthesia, although only 15.6% of them had an annual pediatric anesthetic volume of more than 200. It was suggested that general pediatric anesthesia was conduced safely in JSA Certified Training Hospitals, even if they had a low annual pediatric anesthetic volume. The exception was newborn anesthetic procedures : the mortality was high in hospitals with an annual newborn anesthetic volume of less than 12. Analysis of critical incidents in the operating room failed to show the superiority of children's hospitals in comparison with the university hospitals and other hospitals. Collecting and analyzing data including the patients without critical incidents are required for further analysis.

[Surgical volume and mortality due to intraoperative critical incidents at Japanese Society of Anesthesiologists certified training hospitals: an analysis of the annual survey in 2002].

BACKGROUND: We have previously showed that surgical volume affects mortality due to intraoperative critical incidents among patients undergoing cardiac surgery, the surgery with the highest risk, using data obtained by the annual survey in 2001 conducted by the Japanese Society of Anesthesiologists (JSA). In this study, we investigated whether surgical volume affects mortality due to intraoperative critical incidents independent of the surgical site. METHODS: We investigated this relationship using data obtained from the 2002 annual survey conducted by the Subcommittee on Surveillance of Anesthesia-related Critical Incidents, JSA. Between January 1, 2002 and December 31, 2002, 1,987,988 patients were registered from 704 training hospitals certified by the JSA. Intraoperative critical incidents occurred in 2,844 patients. Of these, 804 patients died within 7 postoperative days. The overall mortality was 4.61 per 10,000 anesthetics. Hospitals were divided into 5 groups according to their annual surgical cases: Group A, fewer than 1,000 (62 hospitals); Group B, 1,000-1,999 (204 hospitals); Group C, 2,000-3,999 (288 hospitals); Group D, 4,000-5,999 (110 hospitals); Group E, more than 6,000 (40 hospitals). Hospitals were also divided into 2 groups according to mortality: Group 1, under 20.00 per 10,000 anesthetics (672 hospitals); Group 2, equal to or higher than 20.00 per 10,000 anesthetics (32 hospitals). Total number of deaths in Group 2 was 158. Mortality was expressed as the mean (95% confidence interval). Statistical analysis was performed using chi-square test and Fisher test. A p value of <0.05 was considered significant. RESULTS: The mortality rates in Groups A-E were 14.89 (8.48-21.3), 3.86 (3.05-4.67), 3.88 (3.19-4.57), 4.04 (3.20-4.88), and 3.12 (2.19-4.05) per 10,000 anesthetics, respectively. Average surgical cases and mortality in Group 1 were 2,789 (2,775-3,002) and 3.24 (2.90-3.58), respectively, while those in Group 2 were 1,672 (1,243-2,101) and 22.18 (30.58-45.94), respectively. If all patients in Group 2 (n=53,509) had been treated in the hospitals of Group 1, 139-143 deaths might have been avoided. CONCLUSIONS: Surgical volume was shown to affect mortality independent of the surgical site. Hospitals with low surgical volume should pay significant attention to improving surgical outcomes. These results also suggest that centralization or regionalization should be discussed from the perspective of socio-economical problems as well as patient safety.