The Thai Anesthesia Incident Monitoring study (Thai AIMS): an analysis of 21 awareness events.

OBJECTIVE: To demonstrate the characteristics, outcomes, and the circumstances associated with intraoperative recall of awareness. MATERIAL AND METHOD: Relevant data of intra-operative recall of awareness were extracted from the Thai Anesthesia Incident Monitoring study (Thai AIMS) database of 1996 incident reports and 2537 incidents which were conducted among 51 hospitals throughout Thailand from January to June, 2007. Details regarding patients, surgical, anesthetic and systematic factors were recorded in a structured data record form. The completed record forms were reviewed independently by three anesthesiologists. The descriptive statistic was analyzed by using SPSS software version 11.5 and demonstrated in number and percent. RESULTS: Twenty-one incidents (21/1996 = 1.05%) of intra-operative recall of awareness were reported. Awareness was predominantly found in females (76.2%) and with ASA physical status I (47.6%). Most of the patients recalled events during the maintenance period and reported sound (71.4%), pain (52.4%), feeling operated (38.1%), paralysis (33.3%), recognizing intubated (4.8%) and panic (4.8%). Anxiety (33.3%), temporary emotional stress (19%), and post traumatic stress (4.8%) were found during immediate outcome assessment but scarcely sustained on the hospital discharged date. The factors associated with the incidents were anesthetic related in the majority especially ineffective monitoring (100%), pre-medication abandonment (100%) and light anesthesia (71.5%). CONCLUSION: Intra-operative recall of awareness in the Thai AIMS was 1.05% of all incident reports. Most of the events were considered as anesthesia related. The suggested corrective strategies were quality assurance activity, effective monitoring and equipment maintenance.

The Thai Anesthesia Incident Monitoring Study (Thai AIMS) of postoperative central neurological complications.

OBJECTIVE: To analyze the incidents of central neurological complication in the Thai Anesthesia Incident Monitoring Study (Thai AIMS). MATERIAL AND METHOD: A prospective descriptive multi-centered study of incident reports was conducted in 51 hospitals across Thailand from January to June 2007. Voluntary and anonymous reports of any adverse events during the first 24 hrs of anesthesia were sent to the Thai AIMS data management unit. Three anesthesiologists reviewed the possible central neurological complication reports. Descriptive statistics was used RESULTS: There were 16 relevant incident reports of central neurological complications (7 cases of convulsion, 5 cases of cerebro-vascular accident and 4 cases of coma). Majority of patients appeared to be old with underlying co-morbidities undergoing major surgical procedures under general anesthesia and required more intensive intra-operative monitoring. These complications occurred commonly with patients of orthopedics, cardiac, urologic and neurosurgical surgery. The majority of cerebro-vascular accident (80%) and coma (75%) were considered preventable. CONCLUSION: Inappropriate decision making and inexperienced anesthesiologists were common contributing factors while suggested corrective strategies were quality assurance activity, clinical practice guidelines and improvement of supervision.

Clinical outcomes of failed extubation in a postoperative intensive care unit.

The causes and consequences of failed extubation in postoperative intensive care unit (ICU) patients were prospectively collected by clinical observation study in the surgical ICU Siriraj Hospital from 1st October 2000 to 31st March 2001. The failure rate was 1.7 per cent (9/477). Patients underwent the following types of surgery: abdominal surgery 66.67 per cent, orthopedic 22.22 per cent, and head-neck surgery 11.11 per cent. Reasons for reintubation were respiratory failure 55.56 per cent (5/9), inadequate cough reflex 22.22 per cent (2/9), congestive heart failure 11.11 per cent (1/9), and acute myocardial infarction 11.11 per cent (1/9). The consequences of failed extubation were worse outcomes:- the average length of stay in these patients increased from 3.67 days to 9.3 days. The mortality rate was 33.33 per cent. Tracheostomy was required in 55.56 per cent. From these observations we conclude that extubation should be performed at the appropriate time for each patient. This will differ according to the patient and his/her circumstances.

Comparison of different doses of epidural morphine for pain relief following cesarean section.

Although epidural opioid analgesia after cesarean section can provide excellent postoperative pain relief, serious complications may occur after epidural morphine. Therefore, we performed this study to compare the efficacy and side effects of three different doses of epidural morphine for analgesia following cesarean section. Ninety healthy pregnant women who underwent cesarean delivery were randomly assigned to receive either 2.5, 3 or 4 mg of epidural morphine for postoperative analgesia. Pain intensity at rest and on movement using a visual analogue scale (0-10) was regularly assessed for 48 hours, the time to first analgesic requirement, the total analgesic dose, patient satisfaction and side effects were recorded. Chi square and ANOVA tests were used for statistical analyses. We were unable to demonstrate any difference in pain relief, patient satisfaction, and side effects among the three groups. Epidural morphine provided sufficient pain relief for approximately 24 hours. About 27 per cent of the patients from each group were pain-free for up to 48 hours without further analgesics. Mild pruritus and nausea occurred in all three groups and there was no significant difference between them. No serious complications were observed. In conclusion low dose epidural morphine is effective in providing adequate analgesia following cesarean delivery.

Unplanned admission to Siriraj post-anesthetic intensive care unit.

OBJECTIVE: Notice of all surgical patients who need access to Siriraj post-anesthetic intensive care unit (ICU) must be given to the ICU in advance by the surgical team. However, there are some patients who present unexpectedly, and we would like to evaluate this unplanned ICU admission as a quality control. PATIENTS AND METHOD: We performed a self-reported study of the patients who were categorized as unplanned for ICU admission over a six-month period from June 1st to November 30th, 2001. We attempted to quantify these patients into small groups in order to learn what the reasons were, where they came from, and how big the anesthesia-related reasons can be. RESULTS: There were 520 admissions to the ICU during study period, and of those 80 were unplanned patients. The major source of these patients is from the operating theaters, followed by the recovery rooms and surgical wards. There were 65 patients admitted because of the cardiopulmonary problems, while 13 patients were admitted for close observations; surgical complications made up another 8 patients. Overall there were 36 unplanned patients because of anesthesia-associated complications. CONCLUSION: These results indicate that the patients who are admitted to the post-anesthetic ICU without prior planning can provide insights of ICU resource management, and the standards of perioperative management in the operating theatres. It definitely offers an opportunity to implement changes in our anesthetic practice. We will continue to monitor the impact of this important indicator.