The Thai Anesthesia Incident Monitoring Study (Thai AIMS) of oxygen desaturation in the post-anesthetic care unit

Abstract

Objective: As part of the Thai Anesthesia Incident Monitoring Study (Thai AIMS), the present study was aimed to analyze the problems of oxygen desaturation in the post-anesthetic care unit in Thailand including clinical course, outcomes, contributing factors, and preventive strategies. Material and Method: The authors prospectively collected incident reports of oxygen desaturation in the post-anesthetic care unit between January and June 2007 from 51 studied hospitals across Thailand. Clinical characteristics, outcomes, and contributing factors were recorded. All data were analyzed to identify contributing factors and preventive strategies. Results: Eighty-six of post-anesthetic oxygen desaturation incidents were reported. Forty-six cases (53.5%) were diagnosed by pulse oximetry. Forty-eight cases (55.8%) were immediately detected within a minute upon arrival at the PACU. Thirty-one cases (36%) were caused by inadequate awakening. Eighty-two cases (95.3%) were anesthesia-related and preventable. The major clinical outcomes were re-intubation (51 cases; 59.3%), prolonged artificial ventilation (23 cases; 26.7%), unplanned ICU admission (16 cases; 18.6%), and prolonged hospital stay (3 cases; 3.5%). Sixty-three patients (73.3%) recovered completely within 24 hours but one died. Judgment error and lack of adequate patient evaluation were the two most common contributing factors that were minimized by high awareness and prior experience. Main strategies suggested to prevent the incidents included the development of specific guideline and quality assurance. These incidents did not effectively decrease when labor was increased. Conclusion: Post-anesthetic oxygen desaturation was frequently found during the transport period. It can cause morbidity and mortality. Anesthesia providers should be aware of these potential incidents and strictly follow guidelines.