Pediatric kidney transplantation: Siriraj Hospital experience.

We reported six children with end stage renal disease (ESRD) who received kidney transplantation in our unit from 1996 to 2000. They were 5 boys and 1 girl and their mean age was 9.7 +/- 2.7 years (range 6.8 to 13.2). Etiologies of ESRD were congenital anomalies (3 patients), chronic glomerulonephritis (2 patients), and rapidly progressive glomerulonephritis (1 patient). Prior to the transplantation, chronic peritoneal dialysis was used in 5 patients, including one who had to switch to hemodialysis due to chronic exit site infection and 1 had preemptive kidney transplantation. All children received a kidney from living-related donors, 4 from their fathers, 1 from his mother, and 1 from his elder brother. Triple immunosuppressive drug therapy (prednisolone, azathioprine, and cyclosporine A) was initially given to all patients. Serum creatinine returned to normal within the first week in all patients and 4 patients were discharged home by the end of the second week post operation. Immediate complications included severe hypertension (all patients), ureteral leakage (2 patients), neutropenia (3 patients) and nephrotic syndrome (1 patient). Azathioprine was discontinued in 2 patients due to persistent neutropenia. Cyclosporine A was discontinued in 1 patient due to hepatotoxicity, this patient was maintained on mycophenolate mofetil and prednisolone. Serum creatinine levels at last follow-up (mean 24.3 +/- 19.0 months, range 8-55) were normal in 5 patients and slightly increased (1.5 mg/dl) in one. Five patients returned to school full time within 1 year after kidney transplantation. Height standard deviation score improved markedly as early as 6 months post transplant. The cost of maintenance of the immunosuppressive drugs was similar to adults, i.e. 6,859.1 +/- 1,151.8 Baht per month at 6 months post kidney transplantation. We concluded that kidney transplantation can be performed successfully in selected Thai children with very good results and similar cost of treatment as for adults.

Anesthesia and laparoscopic adrenalectomy for primary aldosteronism.

Adrenalectomy is the curative treatment of primary aldosteronism or Conn's syndrome. Laparoscopic adrenalectomy, a new method, should result in less pain and shorter hospitalization. We reported 25 patients who received anesthesia and laparoscopic adrenalectomy from 1995-1999. There were 17 females and 8 males. The mean age was 41.9 years (range 25-59). Ninety-six per cent had hypertension, 76 per cent had weakness of the extremities. When these patients sought medical care, their serum potassium and bicarbonate were 2.4 and 30.9 mEq/l respectively. Before operation, after treatment with spinorolactone, they were 4.3 and 24.4 mEq/l respectively. Associated diseases and cardiovascular abnormalities were reported. General anesthesia was the anesthetic technique of choice. Laparoscopic adrenalectomy was described in detail. Sixteen patients had adenomas on the left adrenal gland, 9 were on the right. Twenty-four patients had unilateral adrenalectomy, one had enucleation of the tumor. The size of the adenoma was 1.8 cm (range 1-3). There was no morbidity or mortality. All patients were discharged on the third postoperative day.

Surgery and anesthesia for pheochromocytoma--a series of 40 operations.

Pheochromocytoma is a catecholamine-producing tumor which can be life-threatening. A series of 40 operations in 39 pheochromocytoma patients at a tertiary hospital in Thailand from 1976 to 1997 was reported. The patients were 30 females and 9 males; aged 7-73 years. One man had 2 operations 5 years apart. The most common symptoms and signs were palpitation, headache and hypertension. Preoperative management consisted of control of blood pressure and restoration of intravascular volume by using prazosin, an alpha adrenergic blocker. New imaging techniques have improved the ability to localize the tumors; 20 were found in the right adrenal glands, 14 in the left, 1 patient had bilateral tumors, 4 in Organs of Zuckerkandl and 1 patient had metastatic liver nodules. The operative procedures were 39 laparotomies and 1 laparoscopic surgery. The surgical and anaesthetic procedures were presented, and nitroprusside was used to control intraoperative blood pressure. Removal of tumors was successful in all cases except for 1 mortality due to injury of the liver and massive blood loss. Other complications were postoperative pulmonary edema and renal vein thrombosis. One patient had MEN type 2 and five cases were malignant. Pheochromocytoma can be cured by surgery, but cooperation among surgeons, anesthesiologists and internists is very important.

Recovery after total intravenous anesthesia (TIVA) using propofol and inhalation anesthesia (IA) using halothane in day case surgery.

The aims of this study were to compare recovery by clinical tests, the Perceptual Speed Test (PST) and the Ball Bearing Test (BBT), home recovery, side effects and satisfaction of anesthesia between total intravenous anesthesia using propofol and inhalation anesthesia using halothane in day case surgery and to determine average cost per case of each technique from the provider's the perspective. Forty patients were randomly allocated into TIVA and IA groups. The anesthetic times were 42.1 +/- 26.47 minutes and 37.6 +/- 14.75 minutes respectively. Recovery was assessed by the time to orientation, sitting up, standing up and to success in obtaining baseline values of the PST & BBT. The observer was blinded to the anesthetic technique that the patient received. Recovery tests showed no difference between the two groups. The recovery times of TIVA and IA as assessed by the PST and BBT were 1.2 +/- 0.41 and 1.1 +/- 0.31 hour respectively. From a home questionnaire, both groups showed no difference in the first 2-3 hours of home recovery, incidence of side effects and satisfaction of anesthesia. When asked about the difficulty in getting home, no TIVA patients complained of sleepiness whereas 6/16 IA patient did (p = 0.018). The average cost per case of TIVA and IA was 642.15 and 363.15 bahts respectively.

Comparison of general and regional anesthesia for cesarean section: success rate, blood loss and satisfaction from a randomized trial.

OBJECTIVE: A prospective randomized trial was organized to compare the effectiveness of general and regional anesthesia for cesarean section (C/S). METHOD: Three hundred and forty-one patients were randomized into the general anesthesia group (GA), epidural anesthesia group (EA) and spinal anesthesia group (SA). The effectiveness of interest was success rate, blood loss and patient satisfaction. RESULT: We found that the success rates of EA and SA were lower than GA. Success in EA should be improved by using an epidural catheter to add more local anesthetic drug instead of a single shot; and the surgeon should allow more time for the block to work adequately. Success in SA should be improved by using bupivacaine instead of lidocaine. GA resulted in significantly more blood loss, lower postoperative hematocrit, and higher proportion of patients who had postoperative hematocrit < 30 per cent than EA and SA. The patients' satisfaction scores were not different among the 3 techniques. This meant that, given adequate explanation and perioperative care, Thai women were satisfied with regional anesthesia. CONCLUSION: Regional anesthesia is a better choice of anesthesia for C/S than general anesthesia. However, the availability of different techniques and ability to change the technique when needed were very useful and important. If GA is chosen, all safety procedures must be followed. Oxygen supplement and endotracheal intubation facilities must be available in all techniques. Guidelines of anesthesia for C/S at a national level should be agreed upon, including the type of personnel, monitoring equipment and postoperative care.

Effects of general and regional anesthesia on the neonate (a prospective, randomized trial).

Anesthetic methods used during cesarean section have advantages and disadvantages to both mothers and infants and may result in short and long term neonatal effects. OBJECTIVE: To determine the effects of general and regional anesthesia on the infants, a prospective, randomized trial was performed in Siriraj Hospital, Mahidol University. MATERIAL AND METHOD: 341 uncomplicated pregnant women who were to be delivered at term by Cesarean section were recruited and randomized to receive general anesthesia, GA (103); epidural anesthesia, EA (120) and spinal anesthesia, SA (118). The immediate fetal and neonatal effects were assessed by cord blood gas analysis and the infant's Apgar scores. The Neurologic and Adaptive Capacity Scores (NACS) was performed within 4 hours after birth by two pediatricians who were blind to the anesthetic method. RESULT: Maternal age, weight, height, duration of the operation and infants' birth weight were not different among the study groups. In the EA and SA group, maternal systolic blood pressure decreased more than 20 per cent from the baseline in more than half. The infants' Apgar scores at 1 and 5 minutes were 8.3 +/- 1.9; 8.2 +/- 1.6; 6.7 +/- 2.8, and 9.7 +/- 0.9; 9.8 +/- 0.7; 9.2 +/- 1.6 in EA, SA and GA group respectively. The adaptive capacity, active tone, passive tone, general assessment and primary reflexes of the NACS were not statistically different. CONCLUSION: Apgar scores of the infants whose mothers received general anesthesia were lower than infants whose mothers received regional anesthesia but the NACS were not statistically different among the three study groups.

Comparison of immediate recovery period among young, middle-aged and elderly patients.

We reported the immediate recovery period of 705 consecutive patients post general or head-neck-breast surgery, 590 were looked after in the recovery room (RR) and 115 were admitted into the intensive care unit (ICU) right after surgery. Group I were "young" (aged 15-45 years), group II were "middle aged" (46-60 years) and group III were "elderly" (> 60 years). Twenty-seven per cent of the elderly patients were sent to the ICU, whereas, 8.4 per cent of the young and 14.7 of the middle-aged group were looked after in the ICU. In RR patients, the young group were in better ASA class and had significantly fewer underlying diseases than the middle-aged and elderly groups; the most common of which were hypertension, diabetes and anemia. Elderly patients spent a significantly longer time in the RR than the young group but the risk of complication was not different. The most frequent complication was pain and elderly patients more frequently suffered from pain than the young group. Post-anesthetic recovery score (after Aldrete and Kroulik) was lower in the elderly on arrival and at 15, 30, 60 minutes in the RR but there was no clinical significance. In ICU patients, the 3 groups' intubation rates were not different and although the duration of intermittent positive pressure ventilation and duration of stay in the ICU were longest in the elderly group, there was no statistically significant difference. The mortality rate was highest in the elderly. We concluded that elderly patients had a worse immediate recovery period.

APACHE II in a postoperative intensive care unit in Thailand.

In order to evaluate the effectiveness of an intensive care unit (ICU), the case-mix has to be considered. This was a cohort study. By using Acute Physiology and Chronic Health Evaluation scores (APACHE II score), we evaluated the case-mix and mortality rate of 282 patients who were treated in our postoperative ICU. The overall mortality rate was 10.6 per cent. Higher Acute physiology scores and emergency surgery in the presence of chronic health status were related to higher mortality, but age was not. However, the original APACHE II model could not precisely predict the mortality of Thai patients. We used stepwise logistic regression to determine the predictors of death and found the prediction model to be -7.24 + 0.37 (APACHE II score) + 1.46 (postemergency surgery). The actual mortality for patients with APACHE II score > 15 in our ICU was higher than that predicted by the original APACHE II model. The causes of this difference might be difference in methodology, characteristics of ICU and the quality of care.

Cost-effectiveness analysis of patient-controlled analgesia, intramuscular q.i.d. injection and p.r.n. injection for postoperative pain relief.

We conclude that the intravenous PCA method is a cost-effective technique. Although the PCA device is expensive, the cost-effectiveness analysis should give explicit figures for physicians and the hospital administrators to decide whether they should use the PCA instead of the conventional method.

Patient-controlled analgesia in Thai patients.

We conclude that the intravenous PCA method is acceptable, easy to use, does not depend on the patients' level of education, and is safe for Thai patients. The average pain scores at 48 hours postoperation of the PCA group was significantly lower than for the conventional and the I.M. groups. Satisfaction was quite difficult to assess. Thai culture might influence how much pain is accepted and the patients had not experienced other techniques, so they could not make a comparison. The amount of morphine used by the PCA group was intermediate between that used by the other two groups.

Dental anaesthesia in Siriraj Hospital.

We reported the use of anaesthesia for dental treatment and surgery in 60 patients during September 1989 – December 1990. Most of the pathological indications comprised dental caries, impacted teeth, bone exostosis and infection in the oral cavity. Twenty percent of the patients came to our unit in order to avoid dental treatment under local infiltration with local anaesthetics. Forty-seven percent of patients had associated diseases and 21 percent had taken regular medication. The laboratory investigation is helpful only when was indicated by history and physical examination. A routine complete blood count should be replaced with hematocrit and a routine urine examination should be abandoned. The method of payment for treatment was cash out of pocket 64.9 percent, reimbursement 28.1 percent and financial assistances 7.1 percent, but the fee for anaesthesia had to be reduced because costs of anaesthesia were much more than local infiltration. General anaesthesia was used in 58 patients and intravenous sedation in 2 patients. Monitoring included pulse oximetry, automated blood pressure, EKG, stethoscopy, because the anaesthesiologist and the dentist had to share the airway and the patients had to be ambulatory within a few hours. Anaesthetic time was less than 90 minutes in 81.7 percent of the patients and recovery time was less than three hours in 73.3 percent of them. Only minor complications were noted in recovery time was 13.1 percent and nausea 11.7 percent. Ninety-six percent of the patients were satisfied with the result of treatment under anaesthesia. Therefore, while dental anaesthesia needs the presence of competent anaesthesiologists and close monitoring, it can help dentists in performing their work and overcoming the inconvenience of the patients.