Analysis of anaesthesia incidents during caesarean section reported to webAIRS between 2009 and 2022.

Autor:	Eley VA; Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.; Faculty of Medicine, The University of Queensland, Brisbane, Australia., Culwick MD; Australian and New Zealand Tripartite Anaesthetic Data Committee, Melbourne, Australia., Dennis AT; Department of Anaesthesia, The Royal Women's Hospital, Melbourne, Australia.; Faculty of Health, Deakin University, Geelong, Australia.; Departments of Critical Care, Obstetrics and Gynaecology, and Pharmacology, University of Melbourne, Melbourne, Australia.
Jazyk:	angličtina
Zdroj:	Anaesthesia and intensive care [Anaesth Intensive Care] 2023 Nov; Vol. 51 (6), pp. 391-399. Date of Electronic Publication: 2023 Sep 22.
DOI:	10.1177/0310057X231196915
Abstrakt:	Anaesthesia for caesarean section occurs commonly and places specific demands on anaesthetists. We analysed 469 narratives concerning anaesthesia for caesarean section, entered by Australian and New Zealand anaesthetists into the webAIRS incident reporting system between 2009 and 2022. As expected, compared with the remaining 8978 database entries, the 469 incidents were more likely to be emergency cases (relative risk (RR) 1.95), more likely to occur between 18:00 and 22:00 hours (RR 1.81) and between 22:00 and 07:59 hours (RR 4.40) and more likely to be undertaken using neuraxial anaesthesia (RR 9.18). Most incidents involved more than one event. The most commonly reported incidents included intraoperative neuraxial anaesthesia complications (180, 38%), medication errors or issues (136, 29%), equipment issues (49, 10%), obstetric haemorrhage (38, 8%), maternal cardiac arrests (28, 6%), endotracheal tube issues (28, 6%) and neonatal resuscitation (24, 5%). Inadequate neuraxial block, reported in 95 incidents, was the most common intraoperative neuraxial complication. Allergic reactions, reported in 30 incidents, were the most common medication issue, followed by 17 associated with oxytocin and 16 syringe swaps. Thirty-eight reports included significant maternal haemorrhage, with eight of those incidents including maternal cardiac arrest. There was one maternal death and eight incidents with neonatal deaths reported, affecting nine neonates. Problems with intraoperative neuraxial anaesthesia were the most commonly reported events. Implementation of specific strategies are encouraged to enhance preparation for conversion to general anaesthesia and to mitigate medication errors, particularly those relating to oxytocic use and neuraxial anaesthesia medications. Competing Interests: Declaration of conflicting interestsThe authors declared the following potential conflicts of interest: Martin Culwick is the medical director of the Australian and New Zealand Tripartite Anaesthetic Data Committee. The other authors have no conflicts of interest to declare.
Databáze:	MEDLINE
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