Analysis of Mishaps Developed in Operating Theater

Bae, Jung In; Cheun, Jae Kyu

Abstract

Sudden death is the sudden and unexpected cessation of respiration and functional circulgion. The term "sudden death" is synonymous with cardiopulmonary arrest or heart-lung arrest. Sudden death in the operating theater could be better called mishaps because human errors are believed to be a factor in a large number of sudden deaths which can be preventable. This study was undertaken to analyze the patients who had sudden death and to examine the element of errors. We had 35 cases of cardiac arrest out of 51,798 patients who received general anesthesia in our institution from 1987 to 1992. The 35 cases were classified according to the age, sex, ASA status, incidence, death, causes and outcome etc. The results are as follows; 1) The incidence of cardiac arrest was 0.008 percent. 2) 23 percent of cardiac arrest was encountered in the fifty-one to sixty age group. 3) There was no significant difference between the sexes. 4) Incidence of cardiac arrest increased as the ASA physical status increased, with the majority being observed in classes III and IV E. Increasing incidence of cardiac arrest was encountered in poor physical status. 5) Etiological factors in cardiac arrest were severe bleeding, excessively high concentration of inhalation anesthetics, respiratory failure, difficult intubation, accidental extubation, hidden CNS lesion, hypoxemia, airway kinking, esophageal intubation and volume overload. 6) The incidences of death were 46 percent in the operating theater and 14 percent postoperatively.