We have read with great interest both the editorial of Dr. Lagasse1and the article of Li et al. ,2which were related to the epidemiology of anesthesia-related mortality in the United States. The study by Li et al. 2used the data from the National Vital Statistics System and the International Classification of Diseases codes (10th revision) to assess mortality related to anesthesia in the United States between 1999 and 2005. A similar study has been performed in France in 1999 and was correctly referenced by the authors.3The major advantage of such a methodology is the completeness of mortality data retrieved from the National Vital Statistics System. However, when trying to identify deaths related to anesthesia, and to describe the precise degree of imputation, some problems arise.First, the coding system is not detailed enough to capture the precise mechanism(s) that led to death and to ascertain a causal relationship. To assess more precisely the pathophysiological mechanism(s) that led to death, and subsequently to clarify the relation to anesthesia in the sequence of events, an expert analysis remains necessary, which may even be better replaced by a peer discussion with the anesthesiologist in charge of the case and who reported the death.Second, as Dr. Lagasse noticed in his Editorial, the 10th revision of International Classification of Diseases is curiously quite poor regarding anesthesia. Items are more numerous for anesthesia for pregnancy and labor than for anesthesia in general. They explore mainly the surgical time and are mostly limited to anesthetic medication side effects or overdose. What about aspiration occurring during an emergency procedure, for example? Also, what about hemorrhage and/or delayed blood transfusion? This could be one of the limitations of this method, as the authors have noticed themselves in the discussion section of the article. Maybe the use of specific keywords related to anesthesia practice, in addition of the selection of International Classification of Diseases codes as described, could enhance the sensibility of the filter. However, even adding these suggestions might not be powerful enough to capture all cases. In the experience of the Mortality Research Group of the French Society of Anesthesia and Intensive Care,3we have experienced that in some cases death certificates did not mention any specific International Classification of Diseases code or any previously determined specific keyword. The patients' files could be included in the survey only because researchers had chosen to select also death certificates in which a surgical (or invasive) procedure was mentioned.Third, although one could manipulate in many ways the method to select death certificates to detect all cases that have a relation to anesthesia, is it the real problem? The specificity of the filter will never reach 100 percent. We only assess the visible part of the iceberg. Maybe it would be more efficient to monitor the same indicator along time as the trend is likely a valuable marker, even if absolute data are very approximate. It could thus be very interesting to choose an indicator both strongly related to anesthesia and reproducible to assess over time the trend of anesthesia-related mortality through a national mortality database, rather than simply obtain punctual data through a great nationwide survey.*Military Teaching Hospital, Clamart, France. gsmopex@yahoo.fr

En 2006, plus de 10 400 deces par suicide ont ete enregistres en France metropolitaine. Les suicides sont aux trois quarts masculins. Le taux de suicide a baisse de 20 % en 25 ans, mais il a diminue trois fois moins vite que l'ensemble des morts violentes

Death certificates from the French national mortality database for the calendar year 1999 were reviewed to analyse cases in which airway complications had contributed to peri-operative death. Respiratory deaths (and comas) found in a previous national 1978-82 French survey (1:7960; 95% CI 1:12,700 to 1:5400) were compared with the death rate found in the present one: 1:48,200 (95% CI 1:140,000 to 1:27,500). In 1999, deaths associated with failure of the breathing circuit and equipment were no longer encountered and no death was found to be related to undetected hypoxia in the recovery unit. Deaths related to difficult intubation also occurred at a lower rate than in the previous report (1:46,000; 95% CI 1:386,000 to 1:13,000) in 1978-82 vs 1:176,000 (95% CI 1:714,000 to 1:46,000) in 1999, a fourfold reduction. In most cases, there were both inadequate practice and systems failure (inappropriate communication between staff, inadequate supervision, poor organisation). This large French survey shows that deaths associated with respiratory complications during anaesthesia have been strikingly reduced during this 15-year period.

Aspiration of gastric contents is a major complication in relation with the practice of anaesthesia. The present article is aimed at describing detailed data related to aspiration which were obtained during the French national survey on anaesthesia-related mortality conducted by both Star and CepiDC-Inserm. Information regarding methods of the survey and the main results has been previously published. In brief, the first part of the survey described the number and characteristics of anaesthetic procedures performed in 1996 (denominator). The second survey analysed deaths related to anaesthesia which were identified from death certificates of the calendar year 1999. Because of the numerical importance of aspiration among the causes of deaths, a secondary analysis was undertaken to assess into details factors leading to the occurrence of this complication. Eighty-three cases of death were found related to aspiration, i.e. one-fifth of deaths related completely or partially to anaesthesia, implying a death rate of one for 221,368 general anaesthetic procedures or 4.5 x 10(-6) (95% IC: 0.8 x 10(-6)-14 x 10(-6)). Patients involved were all in a severe clinical condition (ASA >= 3: 92%), very old and often scheduled for urgent abdominal surgery. Two cases of death occurred during colonoscopy but none in obstetric patients. Aspiration almost always occurred during induction of anaesthesia. Analysis of practice patterns disclosed significant deviations from recommendations. French anaesthetists should voluntarily move through a personal and active process toward an improvement of their practice to reduce the incidence of aspiration. (C) 2009 Elsevier Masson SAS. All rights reserved.

Editor'Guidelines related to maintenance fluids in children have been recently implemented in the UK by the National Patient Safety Agency (NPSA)1National Patient Safety Agency Reducing the risk of hyponatraemia when administering intravenous infusions to children.Available from http://www.npsa.nhs.uk/display?contentId=5756Date: March 28, 2007Google Scholar and a recent editorial commenting on these changes included comparison with the French situation.2Stewart P New maintenance fluid guidelines for children: is 0.9% sodium chloride with 5% glucose a good choice?.Anaesthesia. 2007; 62: 322-324Crossref PubMed Scopus (3) Google Scholar Although ‘safe’ fluids have been available in France for a while, deaths still occur as a consequence of hyponatraemia as shown by this example extracted from the recent French survey on perioperative deaths.3Lienhart A Auroy Y Pequignot F et al.Survey of anesthesia-related mortality in France.Anesthesiology. 2006; 105: 1087-1097Crossref PubMed Scopus (436) Google Scholar A 4-yr-old, 15 kg, female child with no medical history (ASA I) was admitted for dental extraction. The anaesthetist in charge was trained to anaesthetize children. Anaesthesia was started at 10:30 a.m. using sevoflurane and sufentanil and tracheal intubation was performed. A peripheral venous access was maintained with dextrose 5%. At 1:00 p.m., the child vomited swallowed blood, cried, and complained of headache. Because vomiting continued, the nurse decided to continue infusion of dextrose 5% solution to counterbalance the effects of fasting. On the next morning (10:00 a.m. and 1:00 p.m.), the child was again examined by two anaesthetists because of persisting sedation. From surgery to the next day, the child had received 1200 ml of dextrose 5% and had had 12 episodes of vomiting. The child was then admitted to the paediatric medical unit at 2:00 p.m. and the child was said to be comatose (Glasgow coma score 6). A blood sample revealed hyponatraemia at 120 mmol litre−1 and haemoglobin concentration at 10.9 g dl−1. The infusion was modified to dextrose 5% +60 mmol litre−1 of sodium chloride over 24 h. In the evening, respiratory distress, a worsening coma, and unilateral mydriasis led to tracheal intubation and transfer in a paediatric ICU. A cerebral CT scan showed diffuse oedema while echocardiography disclosed a very dilated and hypokinetic left ventricle. The patient died several hours after arrival in the ICU. Search of contributory factors showed that local guidelines on fluid administration in children did not exist in this institution and prescription rules were not clear. Many decisions were also left to the nurse. Apart from these system failures, it is of note that none of the physicians or nurses involved evoked that symptoms could have been related to hypotonic infusion. We have found that the rate of deaths totally or partially related to anaesthesia for the age range 0–7 yr is 0.6 per 100 000 anaesthetics (95% CI: 0.12–3.2 per 10 000).3Lienhart A Auroy Y Pequignot F et al.Survey of anesthesia-related mortality in France.Anesthesiology. 2006; 105: 1087-1097Crossref PubMed Scopus (436) Google Scholar This translates into a rate of three deaths each year for this age group in our country, of which one is related to hyponatraemia-induced complications. Although the number of accidents is small, their impact is huge and unacceptable. This cannot be considered as a residual small number because the deficiencies observed are amenable to improvement. A solution containing Ringer's lactate and dextrose 1% also known as B66 is available in France, but was not used. This solution is now commercially available from several industrial manufacturers which should facilitate implementation of its use of such solutions in the UK. Although this wide availability should have also facilitated its use in France, a number of institutions and physicians are not aware of the risk associated with infusion of hypotonic solutions in children. The prescribing of i.v. fluids should be as rigorous as the prescribing of drugs.4Cunliffe M Potter F Hyponatraemia after postoperative fluid management in children (author reply).Br J Anaesth. 2006; 97: 898Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar This suggests that actions such as the one driven by the NPSA are to be commended and are also necessary in France.

T his article reports on studies performed by a group of clinicians and epidemiologists who have worked for a long time in several surveys from which data related to perioperative transfusion are presented here. These surveys were initially aimed at measuring anesthesia-related death and mortality in the perioperative setting. When gathering data we gained some interesting and evolving information related to transfusion.

The article of Lienhart et al. 1must be applauded. Because of the authors’ careful and high-quality methodology, this work—begun in 1996 and covering an entire nation—was able to estimate anesthesia-related mortality in France. This work confirms the critical role of cardiac disease, aging, emergency care and hemorrhage in mortality related to anesthesia.Perhaps more importantly, the authors illuminate the importance of human error. In at least 98% of cases, one episode of substandard practice was identified, and in more than half of the cases, four deviations from accepted practice were recorded. The authors acknowledge that their analysis probably underestimated the true incidence of such system error.Production pressure was a factor in 20% of the events, but despite their belief that errors may occur more frequently during urgent and stressful care, the authors do not mention the role, if any, of a night shift or call, the night of or the 48 h before the accident. Several recent articles have linked fatigue in anesthesia with medical errors,2,3but because anesthesia deaths are rare events (according to the survey, occurring in less than 1 of 100,000 cases) and despite a rigorous methodology, analysis were unable to demonstrate a link between night shifts and anesthetic or intensive care mortality.4Because of the authors’ sample size and their careful analysis, the study could have provided a unique opportunity to analyze the role of sleep deprivation5in the genesis of anesthesia accidents. It would have been of interest to know whether this could have played a role in mortality related to anesthesia.*Val-de-Grâce Military Hospital, Paris, France. georges.mion@club-internet.fr

Background/Aims: Mortality related to HCV and HBV infections was estimated in France.Methods: A random sample (n = 999) of death certificates was obtained from all death certificates listing HBV, HCV, hepatitis, liver disease, possible complication of cirrhosis, bacterial infection, HIV, or transplantation (n = 65,000) in France in 2001. Physicians who reported the deaths were sent a questionnaire to identify how many deaths were related to HBV/HCV infection. Completed forms were independently analyzed by a panel of hepatologists. Death rates were estimated according to national population census data.Results: Estimated annual number of deaths associated with HCV and HBV infection was 3618 and 1507, respectively (6.1 and 2.5 deaths per 100,000 inhabitants, respectively). Estimated number of deaths attributable to HCV or HBV infection was 2646 and 1327, respectively (4.5 and 2.2 deaths per 100,000 inhabitants, respectively). In the HCV infection group, 95 percent had cirrhosis; 33 percent had hepatocellular carcinoma (HCC). In the HBV infection group, 93 percent had cirrhosis; 35 percent had HCC. Eleven percent of deaths occurred in patients with HIV coinfection. Deaths related to HBV or HCV infection occurred at an earlier age in patients with a history of excessive alcohol consumption.Conclusions: In France, 4000-5000 deaths related to HCV and HBV infection occurred in 2001. Alcohol consumption and HIV infection were important co-factors. These data emphasize the need for ongoing, efficient public health programs that include screening, management, and counseling for HCV- and HBV-infected individuals. (C) 2007 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.

Background: This study describes a nationwide survey that estimates the number and characteristics of anesthesia-related deaths for the year 1999.Methods: Death certificates from the French national mortality database were selected from the international Classification of Diseases, Ninth Revision codes using a variable sampling fraction. Medical certifiers were sent a questionnaire (response rate, 97%), and the anesthesiologist in charge was offered a peer review (acceptance rate, 97%). Files were reviewed to determine the mechanism of each perioperative death and its relation to anesthesia. Mortality rates were calculated using the number of anesthetic procedures estimated from a national 1996 survey and compared with a previous (1978-1982) nationwide study.Results. Among the 4,200 certificates analyzed, 256 led to a detailed evaluation. The death rates totally or partially related to anesthesia for 1999 were 0.69 in 100,000 (95% confidence interval, 0.22-1.2 in 100,000) and 4.7 in 100,000 (3-1-6.3 in 100,000), respectively. The death rate increased from 0.4 to 55 in 100,000 for American Society of Anesthesiologists physical status I and IV patients, respectively. Rates increased with increasing age. Although concerns regarding aspiration of gastric contents remain, intraoperative hypotension and anemia associated with postoperative ischemic complications were the associated factors most often encountered. Deviations from standard practice and organizational failure were often found to be associated with death.Conclusion: In comparison with data from a previous nationwide study (1978-1982), the anesthesia-related mortality rate in France seems to be reduced 10-fold in 1999. Much remains to be done to improve compliance of physicians to standard practice and to improve the anesthetic system process.