Multicentered study of model of difficult endotracheal intubation by incident reports from university and non-university hospitals.

OBJECTIVE: To compare the characteristics, causative factors, outcomes, prevention, and suggested preventive strategies of difficult intubation between university (U) and general community (non-U) hospitals. MATERIAL AND METHOD: One thousand nine hundred and ninety-six reports were reviewed from Thai anesthesia incident monitoring study (Thai AIMS) conducted in 51 hospitals nationwide between January and June 2007. Thirty-four cases ofDI were reported from U hospitals and 69 cases from non-U hospitals. The described details on each report on dfficult intubation (DI) in adults undergoing general anesthesia were thoroughly reviewed by three reviewers to give their consensus opinions on causative factors, outcomes, contributing preventive factors, and strategies for corrections. Descriptive statistics were used for data analysis. RESULTS: Patient factors were the most common cause of DI (88% in U and 87% in non-U hospitals). Fifty percent of U and 51% of non-U DI cases were consequences of human errors, which were preventable and mostly based on knowledge (88% vs. 71%) and rules of practice (23% vs. 51%). Substitution of an intubating anesthesiologist, reducing the size of endotracheal tubes, and stylet guided technique were the three commonly used methods after DI. MacCoy laryngoscope, fiber optic-aided intubation, laryngeal mask airway and Frova introducer were commonly used as substitutes for the standard laryngoscope. Inadequate experience was the major problem of U hospitals, which required additional training to gain more skill. The most common problem ofDI in non-U hospitals was inadequate preanesthetic evaluation. Therefore, they required practice guidelines and experienced assistants in difFicult situations. CONCLUSION: Half of DI cases were preventable. DI cases in Non-U hospitals were mostly caused by inadequate preanesthetic evaluation. This indicates the necessities of providing practice guidelines and experienced assistants. In U hospitals, in-training practice of intubation should be performed under supervision. More advanced substitution techniques were applicable in U hospitals.

A survey of awareness, opinion and reported use of clinical practice guidelines (CPG) of the Royal College of Anesthesiologists of Thailand.

BACKGROUND: Up to the present (2006), The Royal College of Anesthesiologists of Thailand (RCAT) has proposed and revised six practice guidelines. For guidelines to achieve their objectives, anyone who gets involved needs to be aware of the guidelines, be able to accept, and adhere to them. Although the authors did introduce their guidelines by several passive means, the authors have not yet ascertained what the result were. OBJECTIVE: The primary objective of the present study was to assess awareness, opinion, limitation, and reported use of guidelines. The secondary objective was to identify factors associated with variation, agreement, and reported use of guidelines. MATERIAL AND METHOD: A cross sectional, self-report survey study was conducted. An anonymous questionnaire including prepaid-addressed reply envelopes was mailed to 600 anesthesiologists and 1,300 nurse anesthetists, nationwide, based on the college's list. The questions covered respondents' general characteristics: awareness, agreement, and reported use of the existing guidelines; opinion on implementation media, which guidelines the members need, their local guidelines, and the impact of guidelines on their practice. All data were extracted and reported using descriptive statistics. Multiple logistic regression was done to identify factors associated with an agreement with and a reported use of the guidelines. RESULTS: The overall response rate was 33.4% and nurse anesthetists had a higher response than anesthesiologists. Forty-six percent of the respondents were aware of the existing guidelines. This result corresponded to percentage of those who had read the guidelines (41%). Among the six existing guidelines, the least two guidelines reported use of and agreement with, were those for labor analgesia and conscious sedation (23-28%, 24-28%). The guidelines for spinal anesthesia received the most response (46%). For respondents who had read the guidelines, most of them (80% to 94%) rated the level of agreement and reported use as good to excellent. The respondents also rated the announcement of the guidelines during the annual meeting of the Royal College of Anesthesiologists of Thailand as the best implementation strategy. Impracticability, inadequate dissemination, and un-cooperation among colleagues were the three most important obstacles of using the guidelines. In addition, the present study demonstrated three significant factors, anesthesiologists, regional hospitals, and general hospitals, as associated with reporting frequent use of and high agreement with the guidelines. CONCLUSION: The low level of awareness and reported use of the present guidelines among the members reflects poor implementation and dissemination. However the present study reveals some information that will guide the authors to introduce intensive and targeted interventions to encourage the members to comply and adhere to the guidelines designed to improve the quality of patients' care.

Clinical experiences of one--lung ventilation in adults using the Univent.

OBJECTIVE: To assess the clinical use and intraoperative problems of the Univent tube for one-lung ventilation (OLV). STUDY DESIGN: A cross-sectional descriptive study. MATERIAL AND METHOD: The records of 44 patients undergoing OLV with the Univent tube (Fuji System Corporation, Tokyo) at Chulalongkorn Memorial Hospital, Bangkok, Thailand from 1997 to 2003 were reviewed. The present study data included the techniques of the Univent blocker placement, frequencies of successful OLV being used as an alternative device after failed left-sided double lumen tube (LDLT), and related intraoperative problems during OLV. RESULTS: The blinded rotation method was used for 32 out of 44 cases of the Univent blocker placement, and the success rate of the correct sided placement on the needed bronchus was higher on the right (91.3%) than on the left (66.7%). Therefore, fiberoptic aided technique should be more appropriate for the left-sided blockade. Three successful intubations by the Univent after failed LDLT were found. Two of these had narrow glottic apertures, whereas the other had a stiff neck. Two successful patients after failed bronchial blockades by LDLT according to the anatomical deviation of the carina were demonstrated. However, clinical problems during OLV with the Univent tube were:--air trapping, inadequate OLV, herniated bronchial cuff and crossed contamination. CONCLUSION: The Univent tube can be an alternative to LDLT for OLV under the presence of available fiberoptic bronchoscopes, close monitoring and special precautions.

A placebo-controlled, randomized trial of droperidol versus metoclopramide for outpatients undergoing gynecological laparoscopy under conscious sedation.

This study compared the prophylactic antiemetic efficacy and the adverse effects of 0.5 mg droperidol, 5.0 mg metoclopramide, and placebo for outpatients undergoing gynecological laparoscopy under conscious sedation. One hundred and fifty outpatients were randomly allocated, in a randomized double-blind manner, into three groups to receive intravenous normal saline, 0.5 mg droperidol, and 5.0 mg metoclopramide before operation. Conscious sedation using intravenous pethidine, midazolam and local infiltration were given to each patient during the operation. Emetic symptoms were graded twice by the patients, at discharge time and the 24th post-operative hour. The difference of antiemetic effect of both study drugs failed to reach statistical significance. There was also no statistical difference of intra-operative hypoxemia, sedation score, and discharge time among the groups. Therefore, using 0.5 mg droperidol or 5.0 mg metoclopramide is not effective in providing antiemetic prophylaxis for outpatients undergoing gynecological laparoscopy under conscious sedation.