The Thai Anesthesia Incident Monitoring study (Thai AIMS): perioperative arrhythmia.

BACKGROUND: The Royal College of Anesthesiologists of Thailand organized the first national sentinel incident reports of anesthesia related adverse events in 2007 on an anonymous and voluntary basis. The aims of the present study were to analyze incidence, risk factors, clinical course and outcome of perioperative arrhythmia and indicate the contributing factors and suggested corrective strategies in the database of the Thai Anesthesia Incidents Monitoring Study (Thai AIMS). MATERIAL AND METHOD: This study was a prospective descriptive multicentered study conducted between January 2007 and June 2007. Data was collected from 51 hospitals across Thailand. All cases whose arrhythmia was detected intra-operatively and within 24 hr postoperative period were analyzed by 3 independents anesthesiologists. Any disagreements were discussed to achieve a consensus. RESULTS: Four hundred and eighty-nine cases were enrolled as relevant arrhythmia cases. Bradycardia was the most common type (434 cases; 88.8%). Most of all events occurred intra-operatively (94.7%) and electrocardiography was the most common firstly detected monitoring equipment (95.5%). Arrhythmia occurred frequently in patients with hypertension and pre-operative heart rate < 60 beat per min. Intravenous anesthetics, central neural blockage and vagal reflex were considered to be the 3 most common suspected causes of arrhythmia requiring treatment. Most common outcomes were minor physiologic change with complete recovery physiologic change with complete recovery while 7% of incidents developed fatal outcome. The most common contributing factor was human factor (72.4%) especially in experience. An experienced anesthetic team with high awareness could be the minimizing factors. CONCLUSION: Arrhythmia accounted for 19.2% of 2,537 incidents of the Thai AIMS database. Bradycardia was the most common type of cardiac arrhythmia. Most arrhythmia was benign but might be fatal. Suggested corrective strategies such as guidelines practice, improvement of supervision and quality assurance activity.

The Thai anesthesia incident monitoring study (Thai AIMS): an analysis of perioperative myocardial ischemia/infarction.

OBJECTIVES: To analyze the clinical course, outcome, contributing factors and factors minimizing the incidents of perioperative myocardial ischemia or infarction (PMI) from Thai AIMS study. MATERIAL AND METHOD: The present study was a prospective multicenter study. Data was collected from 51 hospitals in Thailand during a six-month period. The participating anesthesia provider completed the standardized incident report form of the Thai AIMS as soon as they found the PMI incident. Each incident was reviewed by three peer reviewers for clinical courses, contributing factors, outcome and minimizing factors of PMI. RESULTS: From the Thai AIMS incident report, the authors found 25 suspected PMI cases which was 0.9% of the 2,669 incidents reported in the present study. Most of the PMI occurred in elective cases (84%) and orthopedic procedures (56%). The majority of PMI was reported from the patients undergoing general anesthesia (72%). Suspected PMI occurred mostly during operations (56%). New ST-T segment change was detected in 92% of these patients. The most common immediate outcome of PMI was major physiological change (88%). The most common management effect of PMI was unplanned ICU admission (64%); the others were prolonged ventilatory support (12%) and prolonged hospital stay (16%). Four patients (16%) died after the suspected PMI. Most of the events occurred spontaneously and were unpreventable (80%). Patient factors (100%), anesthesia factors (72%), surgical factors (32%) and system factors (8%) were all judged as a precipitating factor for PMI. Human factors were the most common contributing factors which included poor preoperative evaluation, inexperience and improper decision. The three most common factors minimizing the adverse incidents included prior experienced, high awareness and experienced assistance. The recommended corrective strategies were guideline practice, quality assurance activity, improvement of supervision and additional training. CONCLUSION: Perioperative myocardial ischemia/infarction was infrequent but may be lethal. Patient factors were the most common precipitating cause. The morbidity and mortality could be reduced by high quality preoperative evaluation and preparation, early detection and appropriate treatment. Guideline practice, quality assurance activity, improvement of supervision and additional training were suggested corrective strategies.

Combined spinal-epidural analgesia and epidural analgesia in labor: effect of intrathecal fentanyl vs. epidural bupivacaine as a bolus.

OBJECTIVE: To compare the clinical effects of intrathecal fentanyl with conventional epidural bupivacaine bolus before the same continuous epidural infusion for labor analgesia. MATERIAL AND METHOD: Fifty parturients in active labor were randomized to receive subarachnoid fentanyl 25 mcg as part of a combined spinal epidural analgesia (CSE) or bupivacaine 0.25% 10 ml incrementally into the epidural space in the epidural group. After that, 0.0625% bupivacaine with fentanyl 2 mcg/ml was infused via epidural catheter in all women at a rate of 12 ml/h. Verbal numeric pain scores (VNPS), onset time to pain relief times of additional analgesia and other side effects were recorded. RESULTS: Mean (SD) onset time to the first pain free contraction was not significantly different (7.8 +/- 4.3 min in the CSE group, 10.2 +/- 5.1 min in epidural group, p = 0.085). Most of the patients in the CSE group required additional epidural bolus dose (80% compared to 48% in the Epidural group, p = 0.038). There was no difference in motor blockage at time of delivery or mode of delivery. Significantly more women in the CSE group had pruritus (68% VS none in the epidural group, p < 0.001), all had mild degree and did not require any treatment. There was no difference in other side effects. CONCLUSION: Intrathecalfentanyl as part of CSE did not produce statistically a significant faster onset compared to epidural bupivacaine bolus. Most of the patients in the CSE group required epidural bolus after intrathecal fentanyl with a higher incidence of pruritus.

Levobupivacaine versus racemic bupivacaine for extradural anesthesia for cesarean delivery.

BACKGROUND AND OBJECTIVES: Bupivacaine is available as a racemic mixture of dextrobupivacaine and levobupivacaine. Many studies show that dextrobupivacaine has a greater inherent central nervous system and cardiovascular toxicity than levobupivacaine. The aim of the present study was to investigate the clinical efficacy and safety of levobupivacaine compared with racemic bupivacaine for extradural anesthesia. METERIAL AND METHOD: The authors studied 61 patients undergoing elective cesarean delivery who received either 0.5% levobupivacaine (n = 31) or 0.5% bupivacaine (n = 30) extradurally, in a randomized, double blind study. RESULTS: The 2 groups were similar in terms of time to block suitable for surgery, duration of sensory block, time to T10 regression, time to onset and offset of motor block, verbal numeric pain scores at abdominal opening and at child birth. Mean (SD) dose of 0.5% levobupivacaine and 0.5% bupivacaine were 19.3 (4.6) ml and 17.3 (3.8) ml respectively, p = 0.069. CONCLUSION: Levobupivacaine produces an extradural block that is similar to bupivacaine, and is an alternative to bupivacaine for cesarean delivery patients.