Volume 1, No. 2 • Summer 1986

From the Literature: Deaths During General Anesthesia

Ralph A. Epstein, M.D.

Editor’s note: In each APSF Newsletter, a pertinent Publication from the anesthesia patient safety literature will be summarized. Suggestions for future issues are welcome.

ECRI Technology Assessment. Deaths during general anesthesia. 1. Health Care Tech. 1: 155 175, 1985.

“Deaths During General Anesthesia” is must reading for every anesthesiologist if only because it will be read by hospital administrators who control capital budgets. The article appears to be the collective product of the staff of the ECRI.

The article starts out with a very good description of the extent of preventable anesthetic mortality and a review of the underlying factors. Cooper’s study of anesthetic incidents is summarized and the experience of several insurance companies reviewed. The potential costs of insurance losses alone are remarkable. If one only counts the estimated 1000 preventable deaths, and multiplies that by the reported average of $100,000 loss per case of all types (excluding minor costs attributed to damage to teeth), the yearly loss is one-tenth of a billion dollars. One can reasonably assume that this estimate is very conservative of total potential cost.

The article’s analysis of what can be done to prevent unnecessary morbidity and mortality is not as strong as the description of the problem. For reasons not clear to this reviewer, the authors appear to accept the premise that it would be too costly to institute procedures (including use of modem equipment) to really address the problem; this despite the high cost of preventable losses. They state that since “few hospitals can afford to replace all their obsolete equipment . . . anesthetists must tolerate … deficiencies such as dangerously arranged controls and gauges.” Such complacent thinking in 1986 defies logic and makes one pause before criticizing the plaintiffs bar. Indeed, the courts are setting standards by case law while the profession debates their necessity.

The authors content themselves with suggesting the universal adoption of “two relatively inexpensive technologies:” circuit oxygen analyzers and circuit low pressure alarms. They, however, state that capnography “comes closest to being a fail-safe monitor for most problems that can cause anoxia and death” and that pulse oximetry “provides a more clinically useful measure than any anesthesia safety device now in common use” while failing to advocate their general use

The article is marred by errors which may be due to the authors not being aware of the most recent technology They correctly point out that battery exhaustion is a problem with circuit oxygen analyzers while failing to acknowledge the existence of line-operated devices. They are concerned that oxygen analyzers may not be turned on, while not reporting that with many modem anesthesia machined, the analyzer is automatically on when the machine is on. They warn against the confusion of multiple alarms, while not noting that integrated system with alarm priorities are becoming available

Finally, they consistently refer to circuit low pressure alarms as “disconnect alarm,” although this unfortunate misnomer may be the reason that far more reliable methods of detecting catastrophic disconnection such as capnography are not yet universally used.

Despite deficiencies, this is a valuable contribution because of the way it organizes a great deal of information and presents critical issues. It could well serve as a starting point for discussions within an anesthesia department concerning preventable deaths.

Abstracted by Ralph A. Epstein, M.D., Professor and Chairman, Dept. of Anesthesiology, University of Connecticut