Quality and patient safety in anesthesia service: Thai survey.

Background: The Royal College of Anesthesiologists of Thailand (RCAT) performed large-scale epidemiologic study of anesthesia-related complications and national incidents study in 2004 and 2007, respectively. Objectives: Evaluate the anesthesia service in Thailand with regard to status of quality and patient safety. Material and methods: A pre-planned structured questionnaire regarding demographic, administrative, preanesthetic, intraoperative postanesthetic variables and complications were requested to be filled in by nurse anesthetists attending the refresher course lecture of RCAT in February 2008. Descriptive statistics was used. Results: Three hundred fifty questionnaires were given and 341 respondents (97%) returned the questionnaires. Most of the respondents (90%) worked in government section. Thirty percent of respondents practiced in hospital without medical doctor anesthesiologist and 58% of nurse anesthetists worked in hospitals that have been accredited. Forty-six percent of respondents reported unavailability of a 24-hour recovery room. The questionnaires revealed of inadequacy of anesthesia personnel (64%), inadequate supervision during emergency condition (53%), inadequacy of patient information regarding anesthesia (57-69%), and low opportunity for patient to choose choice of anesthesia (19%). The commonly used monitoring were pulse oximeter (92% of respondents) and electrocardiography (63%). One-third (32%) of respondents had to provide of anesthesia for patients with insufficient NPO (non per oral) time. Common problems that the respondents experienced were miscommunication (49%), intraoperative cardiac arrest during the past year (35%), error related to infusion pump (24%) and medication error (8%). Fifty-five percent of respondents had to monitor at least one patient per month receiving spinal anesthesia. Conclusion: Suggested strategies for quality and patient safety improvement in anesthesia service are increasing personnel, increasing 24-hour recovery room, improvement of supervision, improvement of communication, compliance to guidelines and improvement of nurse anesthetist’s training regarding monitoring patient receiving spinal anesthesia and cardiopulmonary resuscitation.

The Thai Anesthesia Incident Monitoring Study (Thai AIMS) of oxygen desaturation in the post-anesthetic care unit.

OBJECTIVE: As part of the Thai Anesthesia Incident Monitoring Study (Thai AIMS), the present study was aimed to analyze the problems of oxygen desaturation in the post-anesthetic care unit in Thailand including clinical course, outcomes, contributing factors, and preventive strategies. MATERIAL AND METHOD: The authors prospectively collected incident reports of oxygen desaturation in the post-anesthetic care unit between January and June 2007 from 51 studied hospitals across Thailand Clinical characteristics, outcomes, and contributing factors were recorded. All data were analyzed to identify contributing factors and preventive strategies. RESULTS: Eighty-six of post-anesthetic oxygen desaturation incidents were reported Forty-six cases (53.5%) were diagnosed by pulse oximetry. Forty-eight cases (55.8%) were immediately detected within a minute upon arrival at the PACU. Thirty-one cases (36%) were caused by inadequate awakening. Eighty-two cases (95.3%) were anesthesia-related and preventable. The major clinical outcomes were re-intubation (51 cases; 59.3%), prolonged artificial ventilation (23 cases; 26.7%), unplanned ICU admission (16 cases; 18.6%), and prolonged hospital stay (3 cases; 3.5%). Sixty-three patients (73.3%) recovered completely within 24 hours but one died. Judgment error and lack of adequate patient evaluation were the two most common contributing factors that were minimized by high awareness and prior experience. Main strategies suggested to prevent the incidents included the development of specific guideline and quality assurance. These incidents did not effectively decrease when labor was increased. CONCLUSION: Post-anesthetic oxygen desaturation was frequently found during the transport period. It can cause morbidity and mortality. Anesthesia providers should be aware of these potential incidents and strictly follow guidelines.

The Thai Anesthesia Incidents Study (THAI study) of ambulatory anesthesia: II. Anesthetic profiles and adverse events.

BACKGROUND: There is a continuing trend to have more elective surgery performed on an outpatient basis. OBJECTIVE: To determine anesthetic profiles and adverse events in practice of ambulatory anesthesia for elective surgery in different levels of hospitals across Thailand. MATERIAL AND METHOD: A prospective descriptive study was conducted in 20 hospitals comprising seven university, five regional four general and four district hospitals across Thailand. Consecutive patients undergoing anesthesia for elective surgery were included. The included patients, classified as outpatients, were selected and extracted for summary of the result by using descriptive statistics. RESULTS: The authors reported 7786 outpatients receiving anesthesia for elective surgery. The majority of patients were in ASA class 1 and 2 (96.2%) while the rest were in ASA class 3 (3.8%). Nearly 90% of the ASA class 3 patients were in university hospitals. The majority of patients (83.1%) did not receive premedication. Diazepam was used more frequently (11.5% vs. 0.1%) than other drugs. Noninvasive blood pressure monitoring and pulse oximetry were used in greater than 90%, while electrocardiogram (EKG) was used in 67.2% and end tidal CO2 in only 6.8%. The three most common anesthetic techniques were general anesthesia (including inhalation anesthetics), total intravenous anesthesia (TIVA), and monitored anesthesia care (MAC). Regional anesthesia was performed in 12% of cases. The three most common regional anesthetic techniques were brachial plexus block (7.1%), spinal anesthesia (2.21%), and other peripheral nerve blocks (2.06%). Propofol was the most common drug for induction. Succinylcholine was used for intubation in 8.8%. The three most common nondepolaring neuromuscular blocking agents were atracurium, cisatracurium, and vecuronium. Fentanyl was the most common drug used among opioids. The three most common volatile anesthetics were sevoflurane, halothane, and isolurane. Lidocaine was the most frequently used in 29.76% of cases, while bupivacaine in 7.9% and ropivacaine only in 0.05%. The majority of the events relating to respiratory system were hypoxia or oxygen desaturation (18:10,000), reintubation (2.6:10,000) and difficult intubation (2.6:10,000), pulmonary aspiration (2.6:10,000), and esophageal intubation (1.3:10,000). Other adverse events included awareness (1.3:10,000), suspected myocardial infarction or ischemia (1.3:10,000), and drug error (1.3:10,000). Five patients (0.06%) received unplanned hospital admission. No patients developed cardiac arrest or died. CONCLUSION: The incidence of major adverse events was low in ambulatory anesthesia for elective surgery when compared to the incidence in general surgical population. The majority of the events occurred in the respiratory system. The authors did not find any complications relating to regional anesthesia. Despite a low incidence of adverse events in ambulatory anesthesia, anesthesia personnel who are responsible for ambulatory anesthesia should have adequate knowledge and skills in selection and preparation of the patients. Therefore, a system of preanesthesia evaluation is very important.

The Thai Anesthesia Incidents Study (THAI Study) of ambulatory anesthesia: Part I: Method, geographic distribution and population.

BACKGROUND: There is a continuing trend to have more elective surgical operations performed on an outpatient basis. OBJECTIVE: To determine the proportional distribution of anesthetic procedures performed in ambulatory elective surgery at different levels of hospitals across Thailand. MATERIAL AND METHOD: A prospective and descriptive study was conducted at 20 hospitals comprising seven universities, five regional, four general and four district hospitals across Thailand Consecutive outpatients who were undergoing elective surgical operation were included and their relevant data were selected and extracted for summary by using descriptive statistics. RESULTS: From the database of 118,027 anesthetics performed for elective surgical operation, 7,786 (6.6%) were outpatients. According to this, 7,016 (90.1%) were practiced in university hospitals, 656 (8.4%) in regional or tertiary hospitals, 71 (9%) in general or provincial hospitals, and 43 (0.6%) in district hospitals. The frequency of the ambulatory anesthesia was higher in hospitals in the central region, especially in university hospitals in Bangkok than in other regions. The majority of cases (86%) received their initial pre-anesthetic evaluation in the operating room while 12% were evaluated at the outpatient office. About 28% of the cases presented with pre-anesthetic abnormal conditions. The relatively common pre-anesthetic diseases were hypertension, diabetes mellitus, anemia, arrhythmia, and asthma. CONCLUSION: From the results of the present study, the authors have concluded that the rate of expansion of ambulatory anesthesia in Thailand is relatively slow, and varies according to the type of hospital and its geographic region. This indicates further studies should be formally conducted to determine factors affecting the practice of ambulatory surgery in Thailand. A large proportion of patients receive initial pre-anesthetic evaluation in the operating room on the day of surgery. This indicates that a system of pre-anesthetic evaluation should be set up for outpatients such as a pre-anesthetic care clinic should be set up for outpatients.

Postoperative analgesia for total knee replacement: comparing between pre-and postoperative "3-in-1" femoral nerve block.

BACKGROUND: Total Knee Replacement (TKR) produces severe postoperative pain. Pre- and postoperative single-shot "3-in-1" Femoral Nerve Block (FNB) were reported to improve analgesia and reduce morphine consumption post TKR. OBJECTIVE: To find out the most beneficial time for injection of single shot "3-in-1" FNB for TKR between preoperative and postoperative in a prospective controlled trial. MATERIAL AND METHOD: In a Randomized, double-blind Controlled Trial (RCT), 48 patients undergoing TKR received either pre- or postoperative "3-in-1" FNB using 30 mL of bupivacaine 0.25% after a standardized general anesthesia. Morphine consumption, Numeric Pain-Rating Scale (NPRS) at rest and during movement, tension in the back of the knee, nausea/vomiting, pruritus, sedation, and respiratory depression at 1, 4, 24 and 48 hr after TKR were compared RESULTS: There were no significant differences in 48-hr morphine consumption [46.5 (20.0) vs 45.0 (23.6) mg, p = 0.809], NPRS both at rest and during movement, tension in the back of knee, nausea/vomiting, pruritus, sedation, and respiratory depression at any time during 48-hr postoperative TKR between groups. CONCLUSION: Preoperative single-shot "3-in-1" FNB using 30 mL of bupivacaine 0.25% is not better than postoperative single-shot "3-in-1" FNB using the same drug in postoperative pain and morphine reduction in patients undergoing elective TKR under general anesthesia.

The Thai Anesthesia Incidents Study (THAI Study) of anesthetic outcomes: I. Description of methods and populations.

BACKGROUND AND RATIONALE: Since anesthesia, unlike medical or surgical specialties, does not constitute treatment, The Royal College of Anesthesiologists of Thailand host the Thai Anesthesia Incidents Study (THAI Study) of anesthetic outcomes to determine factors related to anesthesia related adverse events. MATERIAL AND METHOD: A prospective descriptive study of occurrence screening was conducted in 20 hospitals comprised of 7 university, 4 general and 4 district hospitals across Thailand. Anesthesia personnels were required to fill up patient-related, surgical-related, anesthesia-related variables and adverse outcomes on a strutured data entry form. The data included preanesthetic evaluation intraoperative period and 24 hr postoperative period. Adverse events specific form was recorded when adverse events occurred. All data were keyed in data management unit with double entry technique and descriptive statistics was used in the first phase of this study. RESULTS: A total of 163403 consecutive cases were recorded in one year. The mean (S.D.) of age, weight and height of patients were 38.6(2.3) yrs, 53.9(17.7) kgs and 153.4(22.7) cm respectively. There were more female (52.9%) than male (47. 1%) patients with ASA PS 1, 2, 3, 4, 5 = 50.8%, 36.3%, 10.7%, 2.0%, 0.2% respectively. Hypertension (11.6%), anemia (7.7%) and diabetes melitus (6.8%) were the three most common abnormalities in preanesthetic history taking. Mallampati score of 111870 patients grade 1, 2, 3, 4 were 54.0%, 39.7%, 5.6%, 0.7% and laryngoscopic grade 1, 2, 3, 4 of 74888 patients were 81.0%, 15.5%, 3.0% and 0.5% respectively. CONCLUSION: The first phase of THAI study epidemiological project can represent both the anesthesia and surgical profiles in Thailand. The collected data available should be useful for the improvement of the quality of anesthesia, guidelines for clinical practices, medical education and for further research.

A comparison of propofol and ketamine as induction agents for cesarean section.

OBJECTIVE: To compare the neonatal and maternal effects of propofol and ketamine as induction agents for elective cesarean section. DESIGN: Randomized, double-blind study. SETTING: Inpatient Obstetrics Department of Sappasitthiprasong Ubonratchatani Hospital, Ubonratchatani province, Thailand INTERVENTION: 2 groups of 50 patients each receiving either 2 mg/kg propofol or 1 mg/kg ketamine for the induction of anesthesia. RESULTS: The time from the induction to cord clamping (I-C), the time from the uterine incision to cord clamping (U-C), the hemodynamic changes, sleep'quality, dream, recall, awareness, Postoperative nausea & vomiting (PONV), and Apgar scores were studied In the ketamine group Systolic Blood Pressure and Diastolic Blood Pressure rose about 10-25% of the baseline after the induction, intubation, skin incision, and cord clamping (p < 0.001) while in the propofol group only the Heart Rate rose (p < 0.036) after the induction, the intubation, the skin incision, and cord clamping. Apgar scores, the I-C time, the U-C time, the age, the weight and total amount of methergin and oxytocin were not significantly different in both groups. No incidence of awareness, nightmare and ketamine's phychomimetic side effects was found The incidence of unpleasant light sleep, dreams and PONV was low. Most patients were willing to have the same anesthetic technique for the next cesarean section (81.3% of the propofol group & 86% of the ketamine group). CONCLUSION: Both propofol and ketamine can be used as alternative induction agents to thiopental. The addition of sevoflurane immediately after the induction, together with the use of midazolam and morphine after delivery shall prevent awareness and ketamine's phychomimetic side effects. However ketamine was cheaper and although Systolic Blood Pressure and Diastolic Blood Pressure were elevated they were within an acceptable range.

Intermittent apnea and total intravenous anesthesia for microscopic laryngeal surgery.

Intermittent apnea with inhalational anesthesia has been reported to improve the visualization of the larynx but it has some disadvantages from inhalational anesthetics. The authors evaluated the use of total intravenous anesthesia instead of inhalation anesthesia in 30 patients undergoing microscopic laryngeal surgery. Anesthesia was started with propofol, fentanyl and cisatracurium. The patients were ventilated with 100% oxygen and the period of intermittent apnea, guided by pulse oximetry and end tidal carbon dioxide monitoring, was started by removal of the endotracheal tube. This technique provided a good visualization and immobile field for the operation. The average duration of apnea was 258 +/- 107 sec. The number of periods of apnea ranged from 1 to 4. A few patients showed some sympathetic responses to surgical stimuli. In conclusion, intermittent apnea with total intravenous anesthesia, with appropriate precaution, could be used without any serious adverse outcome for microscopic laryngeal surgery.

Validity and reliability of cardiac output by arterial thermodilution and arterial pulse contour analysis compared with pulmonary artery thermodilution in intensive care unit.

Cardiac output measurement has a significat role in the critical care setting. The standard of measurement currently is via pulmonary arterial catheter but it has some technical difficulties and serious complications. The authors performed a new method of measurement that used a catheter in a femoral artery. The results of both methods performed simultaneously in 10 surgical intensive care patients every 2 hours for 24 hours were compared. There was high correlation between the two methods, r = 0.97. The average difference of the cardiac output values was 0.46 l/min with standard deviation 0.56 l/min.

Remifentanil vs morphine for patients in intensive care unit who need short-term mechanical ventilation.

This randomized, double-blind study compared the safety and efficacy of remifentanil (9 microg/ kg/h) with morphine (0.045 mg/kg/h plus a bolus dose of 0.025 mg/kg). One hundred and eighty nine Intensive Care Unit (ICU) patients with normal renal function or mild renal impairment requiring mechanical ventilation were included in this study. A pre-defined dosing algorithm permitted initial titration of the opioids to predetermine the optimal level of sedation and pain score. Supplementary infusion of midazolam (0.03 mg/kg/h) was given when additional sedation was required. The duration of optimal sedation during the maintenance phase was 82.7 per cent and 84.3 per cent of the total time in the remifentanil and morphine groups respectively. There were no statistically significant differences in the between-subject variability in the duration of optimal sedation between the two treatment groups. Midazolam was not required in approximately 75 per cent of all patients. The patients in the morphine group required twice the amount of midazolam required by the remifentanil group. The dosing algorithm facilitated rapid extubation in both groups. Remifentanil provided comparable hemodynamic stability to morphine, and was not associated with an increase in cardiovascular adverse event. Remifentanil is therefore considered to be effective and well tolerated in ICU patients.