The Thai Anesthesia Incidents Study (THAI Study) of pulmonary aspiration: a qualitative analysis.

OBJECTIVES: To examine the risk factors, outcomes, and contributing factors associated with perioperative pulmonary aspiration. MATERIAL AND METHOD: Pulmonary aspiration incidents were extracted from the Thai Anesthesia Incidents Study (THAI Study) database conducted between March 1, 2003, and February 28, 2004, and analyzed using descriptive statistics. RESULTS: Thirty-two incidents of aspiration were reported. Passive regurgitation occurred more frequently than active vomiting. Aspiration occurred more commonly in elective rather than emergency surgery, with 59% of incidents taking place during the induction of anesthesia and intubation period. While a major immediate physiological disturbance was common, long term morbidity was not. Death ensued in 5 cases, most of which had significant co-morbidities. Most cases (62.5%) were appropriately treated. The majority of incidents occurred in ASA class 2 (56.3%), age group 15-64 years (59.4%), non obese (92.9%) and non-difficult intubation (71.9%). Most cases were incomplete fasted or had prolonged gastric emptying time. Nasogastric aspiration and rapid sequence induction with cricoid pressure were infrequently used (12.5, 25%). Factors reported as contributing to the incidents included failure of technique and error of judgement. Additional training, continuing medical education and quality assurance tended to minimize the incidents. CONCLUSION: Aspiration occurred commonly in patients with incomplete fasted or had prolonged gastric emptying time and underwent elective surgery. Additional training, continuing medical education and quality assurance tended to minimize the incidents.

Delayed detection of esophageal intubation: Thai Anesthesia Incidents Study (THAI Study) database of 163,403 cases.

INTRODUCTION: Even though esophageal intubation is a common event in anesthesia practice, frequently it is easily detected and resolved. However delayed detection of esophageal intubation (DDEI) can lead to many serious adverse events such as severe hypoxemia, cardiac arrhythmia, cardiac arrest and brain death. OBJECTIVES: To analyze the incidence of DDEI during general anesthesia with endotracheal intubation and to identify its risk factors, especially patients factors and anesthetic techniques, as well as suggested strategies to prevent it. DESIGN: Prospective observational study. MATERIAL AND METHOD: All reported DDEI incidents were identified from the Thai Anesthesia Incidents Study (THAI Study) database conducted between February 1, 2003, and January 31, 2004. Data were analyzed by using descriptive statistics. RESULTS: Forty four cases of DDEI were reported from total of 85,021 cases underwent general anesthesia with endotracheal intubation (5.2: 10,000). The incidence was highest in tertiary care hospital (11.6:10,000). Infant patients (< or = 1 year of age), emergency operation and technique of rapid sequence induction with cricoid pressure were identified as risk factors of DDEI. Detection of DDEI was mainly based on clinical examination. The incidents with extremely low SpO2 level were reported but most of them were adequately managed without long term consequences and only one patient suffered from severe permanent brain damage. CONCLUSION: The overall incidence of DDEI in Thailand was 5.2:10,000. Contributing factors included infant patients, emergency operation, and rapid sequence induction with cricoid pressure. Increased awareness and additional training are suggested as preventive strategies.

Cost-effectiveness of thoracic patient-controlled epidural analgesia using bupivacaine with fentanyl vs bupivacaine with morphine after thoracotomy and upper abdominal surgery.

OBJECTIVES: To compare the effectiveness and cost of thoracic patient-controlled epidural analgesia (TPCEA) using bupivacaine with fentanyl (BF) vs bupivacaine with morphine (BM) solution. MATERIAL AND METHOD: In a blinded, randomized controlled trial, 90 adult patients who were scheduled for thoracotomy or upper abdominal surgery were enrolled. All patients were anesthetized by a combined general/epidural technique. Intraoperative and postoperative analgesia was provided by TPCEA using bupivacaine 0.0625% with either fentanyl (group BF) or morphine (group BM) solution. The occurrence and severity of side effects, visual analogue scale (VAS) for pain at rest and during movement, patients' satisfaction score as well as charged cost of pain and side effect management were recorded for 48 hrs. RESULTS: Demographic data of both groups were not significantly different. No statistical differences were noted with respect to efficacy of pain relief between the 2 groups. Only 28.5% of the patients in group BM required supplemental systemic analgesia within 24 hours after epidural catheter removal compared with 51.4% in the group BE Patients' satisfaction and the severity of epidural analgesia related side effects, using itching and nausea/vomiting score, of both groups were not significantly different except the median nausea/ vomiting scores of group BM at 18 and 24 hours were statistically higher than those of group BF (P = 0.047 and 0.02, at 18 and 24 hour respectively) but not clinically different. The mean charged cost of medication used in group BM (470.64 +/- 160.54 baht) was lower than that in group BF (814.15 +/- 217.51 baht). CONCLUSION: TPCEA using BF and BM solution resulted in similar pain relief and side effect profiles but with higher charged cost of medication in group BF Morphine appears to be a more cost-effective choice than fentanyl for TPCEA after thoracotomy or upper abdominal surgery.

Comparison of effectiveness between gas flow 1 and 2 l.min(-1) for general anesthesia in infants and children.

OBJECTIVES: To determine 1) Success rate of using fresh gas flow (FGF) 1 l.min(-1) compared to 2 l.min(-1) in pediatric patients 2) Necessity of using anesthetic agent analyzer 3) predicting volatile anesthetic concentration 4) cost difference. METHOD: Seventy-seven patients (age 10 days to 8 years) who underwent general anesthesia were randomly allocated into 2 groups: the control group (FGF 2 l.min(-1)) and the study group (FGF 1 l.min(-1)). Outcome measures included system leakage, SaO2, PECO2, FiO2, Fi and FeN2O, isoflurane dial setting, Fi and Fe isoflurane, isoflurane mass consumed and sodalime used. RESULTS: There was no difference between the groups regarding demographic data, duration of surgery and anesthesia. Success rate in using FGF 2 l.min(-1) was 100% and FGF 1 l.min(-1) was 92%. All failure cases (8%) were due to system leakage. The necessity of using a capnometer was similar at 5.3-7.7% in both groups. FiO2 was > or = 0.3 at any time. FiN2O and FeN2O were not different. Fi isoflurane was 13-15% lower than dial setting. Overall savings from using FGF 1 l/min was 37.8%. CONCLUSION: FGF 1 l.min(-1) could be safely used in most pediatric patients with lower cost. Capnometer was recommended, whereas FiO2 and Fi isoflurane could be clinically adjusted

Comparison of morphine given by an intravenous sliding scale or by intramuscular route for postoperative pain relief in pediatric patients: An interim analysis.

Objective: To assess the efficacy in pain relief, complication, practicality and patient’s compliance of morphine given by IV sliding scale (IV) compared to that given intramuscularly (IM) in children after surgery. Methods: One hundred and third-two children were randomly allocated to receive postoperative morphine via IM route (0.1 mg/kg) on a 6-h PRN basis or IV route on a sliding scale basis. Blood pressure, heart rate, respiratory rate, SaO2, nausea/vomiting, pain score using CHEOPS and patient’s compliance were recorded. A questionnaire was used to evaluate the satisfaction with and practicality of these techniques among nurses. Results: This study was terminated early and interim analysis was performed because 47% of the patients in the IM group refused treatment and only 32 patients remained for study (age 1.9-12y, ASA 1). The proportions of patients with moderate to severe pain (IM 73.3%, IV 76.5%), median of maximum CHEOPS score (IM 9, IV 10), average CHEOPS score (IM 6.01, IV 6.03), and morphine consumption (IM 0.157,IV 0.144 mg/kg/24h) of both groups were not statistically different. Neither respiratory depression nor desaturation was detected. Nurses preferred using the sliding scale technique due to better patient’s compliance. Conclusion: The IV sliding scale was superior to IM technique regarding patient’s compliance and nurses’ preference. The degree of pain relief obtained and complications of treatment were not different.

Quality assessment of anesthesia service at Siriraj Hospital.

As part of a quality assurance program, the quality of the anesthesia service at Siriraj Hospital was assessed by using a newly developed data collecting system to find the incidence of clinical indicators. During a 7-month period (June-December 2001), 14,036 anesthetics were included for evaluation. The mortality rate within 24 hours and CPR rate during anesthesia were equal at 20.6/ 10,000. Other clinical indicators were major anesthetic complications (mainly airway, respiratory and cardiovascular system) 144.8/10,000, drug mishaps and adverse drug reactions 6.4/10,000, anesthetic equipment related complications 3.5/10,000 and patient's dissatisfaction 30.6/10,000. Patterns of some complications were also reported. The implications of the results; comparison to international standard, prioritization of the problems, baseline information before intervention, recognition of complication patterns and guidance to future system management and research projects; were discussed. In conclusion, we demonstrated the effective data collecting system and its results and implication for quality assurance program.