CAJ | 학술논문

目的：分析体外循环（ ECC）不安全事件的发生原因及对手术患者的影响，提高体外循环的安全性和效率。方法对开展心脏手术的10家医院2012年发生的ECC不安全事件进行分类、总结和分析。结果32621例ECC心脏手术共报告ECC相关不安全事件85例，其中耗材问题、装备故障、人为因素、气源问题分别为36、12、33和4例；导致患者不同程度损害11例，5例死亡，其中3例为不安全事件直接导致患者死亡。结论建立不安全事件的报告制度、建立涵盖ECC设备及人员要求制度、完善ECC各种操作常规，将有效控制、及时发现和处理ECC不安全事件。
목적：분석체외순배（ ECC）불안전사건적발생원인급대수술환자적영향，제고체외순배적안전성화효솔。방법대개전심장수술적10가의원2012년발생적ECC불안전사건진행분류、총결화분석。결과32621례ECC심장수술공보고ECC상관불안전사건85례，기중모재문제、장비고장、인위인소、기원문제분별위36、12、33화4례；도치환자불동정도손해11례，5례사망，기중3례위불안전사건직접도치환자사망。결론건립불안전사건적보고제도、건립함개ECC설비급인원요구제도、완선ECC각충조작상규，장유효공제、급시발현화처리ECC불안전사건。
Objective To evaluate the effects of adverse events during extracorporeal circulation ( ECC) on the outcome of pa-tients underwent cardiac surgery, and to improve the reliability, safety and effectiveness of ECC. Methods A survey in the patients underwent cardiac surgery with ECC was taken among 10 hospitals in 2012. Adverse events of ECC during cardiac surgery were studied. Results Eighty five ECC adverse events were detected in 32621 patients received cardiac surgery underwent ECC. The events concern-ing device loss function, machine malfunction, personal factor, gas provided were 36, 12, 33, and 4 cases respectively. 11 patients experienced different clinical injury. 5 patients died, and 3 of them died from critical events directly. Conclusion For decreasing the incidence of adverse events during ECC, and for early recognizing and treating these events, we have to establish the system of ECC e-vents report, complete the standards and guidelines, and update as necessary for perfusion practices on equipment requirement, qualifi-cation, competency, management of ECC.