Position for administering an epidural block using a photograph as a visual aid in cesarean section patients.

This randomized control trial was performed in 60 obstetric patients scheduled for cesarean section under regional anesthesia. They were randomly allocated into two groups. Group 1, the control group, were positioned by giving verbal instructions. Group 2, the visual-aided group, were positioned by giving verbal instructions plus showing them photographs of the standard position for an epidural block. The nurse anesthetist, who did not know the method used for positioning, was called into the operating room and readjusted the patient's position as necessary, and evaluated the previous positioning as; very good, good or unsatisfactory. The anesthesiologist, who also did not know which method had been used, palpated the patient's interspinous space before and after any adjustment by the nurse anesthetist and recorded the difference in the space width following adjustment, which was categorized into 3 grades; wider, no change, and narrower. The results showed a significantly better initial position using photographs (very good = 73.4%, good = 23.3%, and unsatisfactory = 3.3%) compared to the control group (very good = 3.3%, good = 46.7% and unsatisfactory = 50%), p < 0.0001. The adjustment of positioning which increased the interspinous width in the visual-aided group (30%) was significantly less than in the control group (56.7%). No change needed in positioning was more common in the study group (60%) than in the control group (36.6%). This meant that visual-aided positioning needed readjustment significantly less than those positioned by the conventional method. The average time used to identify the epidural space using the loss of resistance technique and the average number of needle insertions in the visual-aided group were less than in the control group, but this was not statistically significant. Successful epidural block in the visual-aided group (96.7%) was higher than in the control group (90%) but this was not statistically significant. We conclude that the photographs of the standard position for epidural block can be use as a visual aid to improve positioning in obstetric patients scheduled for cesarean section.

A survey of the anesthesia scavenging systems in a teaching hospital.

Pollution by anesthetic gases can be a problem in operating theaters. More than 90 per cent of this pollution can be reduced by using a scavenging system. Such systems increase the complexity, and thus the hazards of administering anesthesia. A case of pneumothorax prompted an investigation of the active scavenging systems currently used in a teaching hospital by using a pre-use check up protocol. Thirty-eight closed-reservoir active scavenging systems were included. Ten systems (26.3%) were assembled incorrectly. All systems passed a negative pressure relief valve test. Seventeen systems (44.7%) failed to pass a positive pressure relief valve test because high pressure (over 10 cmH2O) developed during an O2 flush, but direct measurement of the pressure at the scavenging interface revealed that these defects were caused by a problem with the adjustable pressure limiting (APL) valves, not with the positive pressure relief valves of the system. We suggest that routine pre-use check up together with regular maintenance of equipment should be emphasized and all personnel should be encouraged to learn more about safety precautions.

Siriraj’s oxygen system: Document for reference and maintenance.

This cross-sectional study was done during January to March 1999 by anesthesiolo-gists, engineers and technicians to investigate the whole oxygen system in Siriraj hospital. Four liquid oxygen containers supplied 15 buildings, were connected by main pipelines whose diameter were 1 1/4 to 2 1/2 inches. There were 2,511 oxygen outlets in the wards, operating suites, emergency rooms and intensive care units (ICU). The oxygen manifolds were installed in 10 buildings as reserved supply. The inappropriateness of oxygen source, piping systems, pressure gauges, manifolds, valves, alarm systems and outlets was found and recorded. These were potentialy hazardous to the patients, personnel and related equipment such as sophisticated ventilators in ICU. Lack of qualified personnel, emergency plan, proper knowledge and maintenance were contributing factors. All inappropriateness was correctable and could be prevented. We recommend the correction and maintenance plans together with acquisition of qualified engineer to improve the safety of medical oxygen service as well as the utility of equipment. The result could be used as reference and for maintenance purpose.

When should we order preoperative blood glucose, BUN, creatinine, or electrolytes: A systematic review and clinical practice guidelines.

The study were to apply a systematic review to answer the question whether routine preoperative investigation affected health outcomes; and to construct clinical practice guidelines for preoperative checking of blood glucose, BUN, creatinine and electrolytes. The guidelines were prepared for elective, non-cardiothoracic surgery in adult patients. Methods of the study were Medline search (1980-1998) and a search of studies published in Thailand. Criteria for high validity and reliability were applied to paper selection. The results of the systematic review were discussed among anesthesiologists and other specialists and the guidelines were drawn by consensus. Results from the systematic review suggested there were no randomized controlled trials to answer the question and no studies reported health outcomes. From this review and the consensus, we proposed guidelines which consisted of a history questionnaire, physical examination and indications for investigation. For the preoperative checking of blood glucose, the indications were: age > 60 years, obesity, diabetes, hypoglycemia, liver disease, alcoholism, severe infection, alteration of consciousness, hypothalamic, pituitary, pancreatic and adrenal disease, and steroid therapy. The common indications for both BUN/creatinine and electrolytes checking were: age > 60 years, undergoing TURP, TUR-BT and major KUB surgery, obesity, diabetes, hypertension, chronic renal failure, renal disease, liver disease, alcoholism, severe infection, severe vomiting or diarrhea, history of fluid, acid base or electrolyte disturbance, alteration of consciousness, hypothalamic, pituitary, pancreatic and adrenal disease, ADH abnormality and diuretic or digoxin therapy. The additional indications for electrolyte checking were: convulsion or muscle weakness, CNS disease with increased ICP and steroid therapy.

When should we order preoperative chest radiography: A systematic review and clinical practice guidelines.

Routine preoperative investigation consumes much resource while Thailand suffers severe financial crisis. Objectives of the study were to apply a systematic review to answer the question whether routine preoperative investigation affected health outcomes; and to construct clinical practice guidelines for preoperative chest radiography (CXR). The guidelines were prepared for elective, non-cardiothoracic surgery in adult patients. Methods of the study were Medline search (1980-1998) and search from studies published in Thailand. Criteria for high validity and reliability were applied to paper selection. The results of the systematic review were discussed among anesthesiologists and other specialists and the guidelines were drawn by consensus. Results from the systematic review, there were no randomized controlled trials to answer the question and no studies reported health outcomes. Routine preoperative investigations yielded few positive results and were not very useful for patient care. From this review and the consensus, we proposed the guidelines, which consisted of a history questionnaire, physical examination and indication for investigation. For the preoperative CXR the indications were: age > 45 years, history of cardiovascular and respiratory diseases, autoimmune deficiency syndrome (AIDS), heavy smoking, chronic cough or fever, malignancy and findings of abnormal breath sounds on examination. This study recommends and prefers preoperative CXR as indicated by history and physical examination to routine.

When should we order preoperative electrocardiography: A systematic review and clinical practice guidelines.

Routine preoperative investigation consumes many resources at the time when Thailand is suffering a severe financial crisis. The objectives of the study were to apply a systematic review to answer the question if routine preoperative investigation affects health outcomes; and to construct clinical practice guidelines for preoperative electrocardiography (ECG). The guidelines were prepared for elective, non-cardiothoracic surgery in adult patients. Methods of the study were a Medline search (1980-1998) and a search of studies published in Thailand. Criteria for high validity and reliability were applied to paper selection. The results of the systematic review were discussed among anesthesiologists and other specialists and the guidelines were drawn by consensus. Results from systematic review found that there were no randomized controlled trials to answer the question and no studies reported health outcomes. Routine preoperative investigation yielded few positive results and were not very useful for patient care. From this review and consensus, we proposed the following guidelines: a history questionnaire, physical examination, and indication for investigation. For the preoperative ECG, the indications are: age > 45 years, history of hypertension, heart disease, palpitation or frequent syncope, diabetes, chronic cough for > 3 weeks or pulmonary disease, heavy smoking (> 10 pack /days for> 10 years), radiotherapy or chemotherapy. Preoperative ECG carried out according to these guidelines would be more cost-effective and routine preoperative investigation should be abandoned.

When should we order preoperative complete blood count and urinalysis: A systematic review and clinical practice guidelines.

Routine preoperative investigation is expensive especially at this time when Thailand is suffering a severe financial crisis. Objectives of the study were to apply a systematic review to answer the question whether routine preoperative investigation affected health outcomes; and to construct clinical practice guidelines for preoperative complete blood count (CBC) and urinalysis (UA). The guidelines were prepared for elective, non-cardiothoracic surgery in adult patients. Methods of the study were Medline search (1980-1998) and a search of studies published in Thailand. Criteria for high validity and reliability were applied to paper selection. The results of the systematic review were discussed among anesthesiologists and other specialists and the guidelines were drawn by consensus. Results from the systematic review found that there were no randomized controlled trials to answer the question and no studies reported health outcomes. Routine preoperative CBC and urinalysis yielded few clinically significant positive results and was not very useful for patient care. From this review and the consensus, we proposed a guidelines, which consisted of a history questionnaire, physical examination and indication for investigation. For the pre-operative CBC the indication were: age > 60 years, would have an operation that needed blood transfusion, had acute or chronic blood loss, malnutrition, pregnancy, heart disease, cancer, chronic renal failure, liver disease, severe infection, SLE, connective tissue disease, radiotherapy or chemotherapy. The guidelines for preoperative UA were: pregnancy, diabetes, abnormal urination, chronic renal failure, SLE or connective tissue disease. Preoperative CBC and UA requests according to these guidelines should be more cost-effective and routine preoperative investigation should be abandoned.

CPR in Siriraj Hospital: A preliminary report.

The determine the incidence and outcome of cardiopulmonary resuscitation (CPR), the availability of CPR equipments and personnel competence, we did a retrospective study by asking the head nurses of 117 wards in Siriraj Hospital. These were 53 adult wards, 24 pediatric wards and 40 combined wards. The total amount of patients in 3-month period was 183,874 patients which included 34,116 in-patients and 149,758 out-patients. Cardiac arrest occurred in 694 in-patients (2.03% of total patients) and 54 out-patients (0.04% of total patients). Among the 748 cardiac arrest patients, 685 received CPR (91.58% of cardiac arrest patients). Among these patients, 292 responded to CPR (42.67% of patients received CPR) and 393 died in spited of CPR (57.37% of patients received CPR). Patients in the Department of Internal Medicine had the highest incidence of CPR (47% of patients received CPR) whereas those in the Department of Radiology, Ophthalmology, Otorhinolaryngology had the lowest incidence (1%). The survival rates following CPR in the aforementioned departments were 32%, 0% and 20% respectively. Defibrillators were available in 24% of the wards. The completeness of airway equipments ranged from 60% to 90% of the wards. Electrocardiography, pulse oximeter and capnometry were available in 50%, 18% and 7% of the wards respectively. Subjective evaluation of nurses competence in performing CPR were as following: 86% of nurses from ICU were able to perform basic life support compare to 55% of nurses from emergency room and 31% of nurses from general wards. Fifty-five to sixty-two percent of ICU nurses could interpret ECG monitoring and 61% of nurses from 8 ICUs could used defibrillators. Delay time in doctor’s arrival for CPR more than 10 minutes was found in 54% of the wards. In order to improve the efficiency of CPR, we suggest that teaching and training of CPR should be mandatory and continuous, the guideline of CPR equipments should be recommended by the hospital’s experts and the hospital should provide more defibrillators to wards. The administration and communication system s should be reorganized to reduce the delay time in CPR.