[Analysis of fatal cases and irreversible CNS injuries as complications of anesthetic maintenance].
The authors made a retrospective analysis of the 1988-2007 forensic medical examinations. They selected 45 fatal cases and 9 cases of severe irreversible CNS injuries occurring within 30 days after surgery as absolute complications due to anesthetic maintenance and postoperative management. Among the victims there were 7 children and 47 adults. In each case concerned, an attempt was made to reveal all critical incidents and factors associated with an evolving fatal outcome and it was suggested that a poor outcome could be prevented. It was noted that the most critical incidents resulting in death or severe irreversible CNS injuries were associated with respiratory disorders. These incidents were most frequently observed in the induction of anesthesia when tracheal intubation was attempted and in the early period (within 2 hours) after surgery. The most common associated factors should include inadequate preparation of a patient for surgery, improper medical care in the early postoperative period, and unavailability of automatic monitoring systems. It was ascertained that there was a potential for the prevention of death in most cases (53/54).
Vinogradov
V L
VL
Likhvantsev
V V
VV
Lianenko
V A
VA
D000293:Adolescent; D000328:Adult; D000368:Aged; D000758:Anesthesia / Q000009:adverse effects* / Q000401:mortality*; D002493:Central Nervous System Diseases / Q000209:etiology / Q000401:mortality*; D002648:Child; D002675:Child, Preschool; D005260:Female; D049429:Forensic Pathology; D017052:Hospital Mortality; D006801:Humans; D007223:Infant; D008297:Male; D019300:Medical Errors / Q000401:mortality; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors; D012426:Russia; D055815:Young Adult