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. 2021 Apr;35(2):206-212.
doi: 10.1007/s00540-021-02898-9. Epub 2021 Feb 10.

Incidence of accidental events during anesthesia from 2012 to 2016: survey on anesthesia-related events by the Japanese Society of Anesthesiologists

Hiroshi Morimatsu  1 ; Accidental Event (Pulmonary Embolism) Working Group, Safety Committee of the Japanese Society of Anesthesiologists
Collaborators, Affiliations

Incidence of accidental events during anesthesia from 2012 to 2016: survey on anesthesia-related events by the Japanese Society of Anesthesiologists

Hiroshi Morimatsu et al. J Anesth. 2021 Apr.

Abstract

Purpose: The Japanese Society of Anesthesiologists (JSA) has conducted surveys on life-threatening accidental events during anesthesia and reported results since 1992. This report describes the incidence of these life-threatening accidental events in the survey period between 2012 and 2016.

Methods: JSA conducts an annual survey on accidental events. Each participating facility reports life-threatening accidental events that occurred each year. Facilities accredited by the JSA can electronically report events using the JSA Perioperative Information Management System (JSA-PIMS) software program that interfaces with the electronic anesthesia record system.

Results: The number of cardiac arrest events per 10,000 anesthesia cases gradually decreased from 2.97 in 2012 to 2.30 in 2016 (odds ratio OR 0.77 95% CI 0.68-0.88). The number of severe hypotension events per 10,000 anesthesia cases gradually decreased from 4.63 in 2012 to 4.24 in 2016 (OR 0.92, 95% CI 0.83-1.01). The number of severe hypoxia events per 10,000 anesthesia cases gradually decreased from 2.01 in 2012 to 1.59 in 2016 (OR 0.79, 95% CI 0.68-0.92). The number of life-threatening arrhythmia events per 10,000 anesthesia cases was 1.14 in 2012. Thereafter, it tended to decrease slightly to 0.88 in 2016 (OR 0.77, 95% CI 0.63-0.95).

Conclusion: The incidence of cardiac arrest during this period was 2.63/10,000, which was lower the incidence reported in other countries. While no change was observed in the incidence of severe hypotension over the survey period, the incidence of severe hypoxia and life-threatening arrhythmia decreased by 20-25% during those 5 years.

Keywords: Accidental events; Arrhythmia; Cardiac arrest; Hypotension; Hypoxemia.

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