Critical Incidents during Anesthesia and Early Post-Anesthetic Period: A Descriptive Cross-sectional Study

Abstract

Introduction: Critical incidents related to peri-operative anesthesia carry a risk of unwanted patient
outcomes. Studying those helps detect problems, which is crucial in minimizing their recurrence. We
aimed to identify the frequency of peri-anesthetic critical incidents.

Methods: This is a hospital-based descriptive cross-sectional study of voluntarily reported incidents,
which occurred during anesthesia or following 24 hours among patients subjected to non-cardiac
surgery within the calendar year 2019. Patient characteristics, anesthesia, and surgery types, category,
context, and outcome of incidents were recorded in an indigenously designed form. Incidents were
assigned to attributable (patient, anesthesia or surgery) factor, and were analyzed for the system,
equipment or human error contribution.

Results: Altogether 464 reports were studied, which consisted of 524 incidents. Cardiovascular
category comprised of 345 (65.8%) incidents. Incidents occurred in 433 (93%) otherwise healthy
patients and during 258 (55.6%) spinal anesthetics. Obstetric surgery was involved in 179 (38.6%)
incidents. Elective surgery and anesthesia maintenance phase included the context in 293 (63%)
and 378 (72%) incidents respectively. Majority incidents 364 (69.5%) were anesthesia-attributable,
with system and human error contribution in 196 (53.8%) and 152 (41.7%) cases respectively. All
recovered fully except for 25 cases of mortality, which were mostly associated with patient factors,
surgical urgency, and general anesthesia.

Conclusions: Critical incidents occur even in low-risk patients during anesthesia delivery. Patient
factors and emergency surgery contribute to the most serious incidents.