Abstract SNACC-23

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Adverse patient events related to surgery in the prone position; a 10 year audit of a QA/QI database

Kosse A, Reddy S, Abramowicz A
Montefiore Med.Ctr., AECoM, Bronx, NY, USA

Introduction: The inherent risk of surgery and anesthesia in the prone position is poorly quantified (1). Spine surgery is usually prone. Death rate within 60 days of spine surgery is 2.0 per 1000 adults (2). The 2004-2007 Scoliosis Research Society Database review of 108,419 cases identified 197 mortalities: 23 on the day of surgery but the day of death is known in 48% of cases. Our departmental QA/QI database was searched for adverse immediate perioperative events in prone surgery patients between Jan. 1, 2003 and March 15, 2014 to characterize their type, outcomes and risk factors.
Methods: The database recorded 3,484 adverse events in the last decade. With IRB approval, we queried for the terms “prone” (57 events, then “laminectomy” (additional 33). After excluding duplicates (8), non-prone (4) and pre-operative cancellation (5), 73 events were analysed (2.1% of all events). Anesthesia type, patient age, gender and ASA PS were recorded. The events were categorized as: hemodynamic, anaphylaxis/allergic reaction, respiratory, endotracheal tube-related, equipment-related, skin and eye injury, tongue injury, dental injury, POVL, intravenous access-related, neurological injury, intraoperative awareness, and other. The severity of the adverse event was deemed major if it required either interruption of surgery, an unplanned return to the supine position or an unplanned ICU admission (3).
The 5 deaths (6.8% of all the events) were respiratory (2), likely preventable and hemodynamic (3). Surgical bleeding contributed to one hemodynamic fatality, 1 patient suffered a fatal pulmonary embolism, and one had a cardiac arrest related to decompensated CHF. Five out of 6 endotracheal tube adverse events were related to tube kinking, obstruction; all were major. The most common adverse event was related to equipment, then minor events due to skin and corneal abrasions. Respiratory problems were most common in the non-spine patients: 1 death and 6 out of 8 severe events.
Discussion: In 2013, we performed 52,000 anesthetics yet only 3,484 adverse events were recorded in 10 years: 73 were related to prone surgery. The adverse events are primarily self-reported. There is no specific identifier for complications resulting from or related to patient position during surgery. The low total number of events reported and the high incidence of severe events in our cohort could be due to under-reporting of minor adverse events, quality indicators not specific to prone surgery complications and /or incomplete database search results. Our analysis indicates that most of the adverse events related to the prone position are spine surgery cases; they tend not to be respiratory. In the hospital setting, non-spine prone MAC and GA cases also carry a risk of severe adverse events.
1. Edgecombe H et al. Br J Anaesth.2008;100(2):165
2. Smith JS et al. Spine. 2012;37(23):1975-82
3. Lebude B et al. J Spinal Disord Tech. 2010;23(8):493-500

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