Factors related to 24-hour perioperative cardiac arrest in geriatric patients in a Thai university hospital.

BACKGROUND: As a site of the Thai Anesthesia Incidents Study (THAI Study) of anesthetic adverse outcome, the authors continued the institutional data collection to determine the incidence and factors related to 24-hour perioperative cardiac arrest in geriatric patients (aged 65 years and over) representing a Thai university hospital. MATERIAL AND METHOD: Between July 1, 2003 and March 31, 2007, an anesthesia registry was conducted at King Chulalongkorn Memorial Hospital. Anesthesiologists and anesthesia residents were requested to record perioperative variables and adverse outcomes including 24-hour perioperative cardiac arrest on a structural data record form. Univariable analysis was used to identify factors related to 24-hour perioperative cardiac arrest. A multivariable generalized linear regression for risk ratio was used to investigate independent factors with significant association to 24-hour perioperative cardiac arrest. A forward stepwise algorithm was chosen. A p-value < 0.05 was considered as statistically significant. RESULTS: Among 54,419 cases in the registry, 8,905 geriatric patients underwent a non-cardiac surgery under anesthesia. Thirty-six patients experienced cardiac arrest. The incidence of intra-operative cardiac arrest, within 24 hours postoperative cardiac arrest, and overall 24-hours perioperative cardiac arrest were 18:10000 (mortality rate of 62.5%), 22.5:10000 (mortality rate of 90%), and 40.4:10000 (mortality rate of 77.8%), respectively. By multivariable analysis, age of 76-85 [RR 2.6 (95% CI: 1.2,5.4)], age > or = 86 [RR 4.4 (95% CI: 1.7, 11.8)], recent respiratory failure [RR 6.6 (95% CI: 1.9, 22.3)], ASA physical status 3-5 [RR 19.9 (95% CI: 4.6, 86)], emergency surgery [RR 2.8 (95% CI: 1.4, 5.6)], intrathoracic surgery [RR 3.7 (95% CI: 1.4, 9.9)], upper abdominal surgery [RR 2.8 (95% CI: 1.3, 5.7)], and administration of ketamine [RR 5.4 (95%CI: 1.8, 15.9)] were factors related to 24-hour perioperative cardiac arrest. CONCLUSION: The incidence of 24-hourperioperative cardiac arrest of geriatric patients in a Thai university in the present study was 40.4:10000 anesthetics, which was comparable to others with high mortality rate. Risk factors for 24-hour perioperative cardiac arrest were older age, ASA physical status 3-5, emergency surgery, intrathoracic surgery, upper abdominal surgery, recent respiratory failure, and administration of ketamine. Pre-anesthetic evaluation is important for finding the risks and optimal preparation for preventing perioperative cardiac arrest in these aging patients.

Effectiveness of mouthpiece nebulization and nasal swab stick packing for topical anesthesia in awake fiberoptic nasotracheal intubation.

OBJECTIVE: To evaluate the effectiveness of using mouthpiece nebulization and nasal swab stick packing for topical anesthesia in awake fiberoptic nasotracheal intubation. MATERIAL AND METHOD: This was a prospective descriptive study of 30 patients with ASA I-II who underwent elective surgery and suspected of difficult intubation between March 2004 and June 2006. After 2% lidocaine 5 ml was nebulizated in a micronebulizer using oxygen 10 L/min as a driving gas through a standard mouthpiece and 10% cocaine 1 ml on cotton swab-stick was applied to the selected nostril for 15 min, fiberoptic nasotracheal intubation was done while the patient was awake. If the patient had severe gag or cough reflex, 1% lidocaine 5 ml per each time could be injected through the working channel of the fiberoptic bronchoscope. The descriptive statistics were calculated by using SPSS version 11.0. RESULTS: The success rate of awake fiberoptic nasotracheal was 100%. The mean duration of awake fiberoptic nasotracheal intubation was 119.0 +/- 76.8 sec. The responses of the patient to instrumentation during 4 periods, i.e.: passing the endotracheal tube into the nose, passing the bronchoscope into the pharynx-larynx, passing the bronchoscope into the trachea-carina and passing the endotracheal tube into the trachea were, as follows: no response in about 53.3%, 63.3%, 23.3%,and 13.3%; mild pain or reflex in about 46.7%, 10%, 70%, and 86.7%; moderate pain or reflex in about 0%, 3.3%, 6.7%, and 0%; and severe pain or reflex requiring more local anesthetic in about 0%, 23.3%, 0%, and 0%, respectively. Despite complete topical anesthesia in the majority of the patients, two patients required 5 ml more 1% lidocaine and five patients required 10 mL more of the drug through the fiberoptic bronchoscope. There was no serious complication such as hypoxemia, arrhythmia. Twenty-four patients (80%) were satisfied with mouthpiece nebulization and nasal swab packing because they felt safe, did not have pain, and were comfortable; only three patients (10%) were dissatisfied because of numbness of the tongue and difficulty in swallowing; two patients (6.7%) had no comment; and one patient (3.3%) was unable to evaluate due to unplanned tracheostomy. CONCLUSION: In the present study technique of topical anesthesia using 2% lidocaine 5 mL mouthpiece nebulization and 10% cocaine 1 mL soaked nasal swab stick packing is useful and safe for awake fiberoptic nasotracheal intubation in patients with suspected difficult intubation. 76.7% of the patient did not require more local anesthesia and 80% were satisfied with this technique.

Maternal satisfaction to epidural and spinal anesthesia for cesarean section.

BACKGROUND AND OBJECTIVE: The differences between epidural (EA) and spinal (SA) anesthesia that can affect maternal satisfaction are the procedures, quality of anesthesia and postoperative events. Dominantly, postoperative events such as postdural puncture headache, pruritus and nausea or vomiting after spinal anesthesia are claimed to be its disadvantages. However, maternal satisfactory perception to theses two techniques has not been revealed. The authors' purpose was to compare maternal satisfaction regarding the techniques and their outcomes between EA and SA by the developed valid and reliable tool. MATERIAL AND METHOD: Patients were randomly classified into two groups: epidural (Group E, n=56) and spinal (Group S, n = 58). Epidural and spinal anesthesia were administered with bupivacaine, 20 mL 0.5% with 1:200,000 epinephrine combined with two doses of 5 mg morphine and hyperbaric bupivacaine 2.2-2.4 mL 0.5% combined with 0.2 mg morphine respectively. Guidelines for treatment of intraoperative and postoperative events, which might be the confounding factors, were set up. Maternal satisfaction was evaluated by the 11-item, qualified, self-administered questionnaire comprised of 4 common factors. The score of 0-10 Visual analog scale was used to access the degree of satisfaction. Trained personnel performed data collections in the post-anesthesia care unit and ward. The means of the factor and total satisfaction scores were compared between the two groups by Mann Whitney U test. A p-value < 0.05 considered significant. RESULTS: There was no statistical difference in the factor scores between the two groups. The total satisfactory score was 89.48 +/- 9.31 and 90.03 +/- 11.26 in Group E and S respectively. No statistical difference of the total satisfaction score was detected. CONCLUSION: There was no difference in maternal satisfaction regarding to the techniques and the outcomes between EA and SA.

A questionnaire for measuring patient satisfaction to general anesthesia.

BACKGROUND AND OBJECTIVES: Measurement of patient satisfaction to general anesthesia needs a valid and reliable tool to cover all dimensions of satisfaction. However, there is no standard tool in a Thai version for measurement of this satisfaction. The objective of this study was to develop a valid and reliable tool for measurement of patient satisfaction to general anesthesia. METHOD: Review of the medical literature and patients' interviews were performed to generate the ideas and dimensions of satisfaction. Items were generated according to customer satisfaction. The pilot questionnaire was set and verified for content validity by item correlation. One item of low item correlation was deleted. The pilot study was performed by application of the pilot questionnaire to patients to detect problems on processes to derive responses and problems of the questionnaire. Another two items were excluded due to high missing responses. The results of reliability analysis were satisfactory. Revision of the pilot questionnaire was taken eventually into the final questionnaire. Then, the final questionnaire was processed to obtain Cronbach's alpha coefficient at King Chulalongkorn Memorial Hospital. Finally, retest for reliability was taken at Police General Hospital in order to prove its generalization. RESULTS: The constructed final questionnaire composed of ten items. All item correlations were higher than 0.5. Cronbach's alpha coefficients obtained in King Chulalongkorn Memorial Hospital and Police General Hospital were 0.8775 and 0.7571, respectively. CONCLUSION: The developed questionnaire was qualified for both validity and reliability. Also verified for the wide application in another hospital.

Parental presence during induction of anesthesia in children: a study on parental attitudes and children's cooperation.

Parental attitudes and children's cooperation towards parental presence during induction of anesthesia (PPIA) were studied in one hundred parents and one hundred children aged 1-10 years. The dimensions of parental attitudes were how much PPIA is beneficial or harmful to their child, whether their presence could help the anesthetist, whether the parents should be present and their feelings during induction of anesthesia. Before and after induction of anesthesia respectively, 83 per cent and 87 per cent of the parents thought their presence was mostly beneficial to their child, 77 per cent and 83 per cent thought their presence was least harmful, 64 per cent and 71 per cent believed their presence could help the anesthetist and 97 per cent of the parents agreed that parents should be present during induction of anaesthesia. From the children, perspective, 86 per cent of the children cooperated with induction. It was concluded that PPIA was well accepted by the parents and the majority of the children were cooperative.