Multicentered study of model of anesthesia related adverse events in Thailand by incident report (The Thai Anesthesia Incidents Monitoring Study): results.

OBJECTIVE: The Thai Anesthesia Incidents Monitoring Study (Thai AIMS) was aimed to identify and analyze anesthesia incidents in order to find out the frequency distribution, clinical courses, management of incidents, and investigation of model appropriate for possible corrective strategies. MATERIAL AND METHOD: Fifty-one hospitals (comprising of university, military, regional, general, and district hospitals across Thailand) participated in the present study. Each hospital was invited to report, on an anonymous and voluntary basis, any unintended anesthesia incident during six months (January to June 2007). A standardized incident report form was developed in order to fill in what, where, when, how, and why it happened in both the close-end and open-end questionnaire. Each incident report was reviewed by three reviewers. Any disagreement was discussed and judged to achieve a consensus. RESULTS: Among 1996 incident reports and 2537 incidents, there were more male (55%) than female (45%) patients with ASA PS 1, 2, 3, 4, and 5 = 22%, 36%, 24%, 11%, and 7%, respectively. Surgical specialties that posed high risk of incidents were neurosurgical, otorhino-laryngological, urological, and cardiac surgery. Common places where incidents occurred were operating room (61%), ward (10%), and recovery room (9%). Common occurred incidents were arrhythmia needing treatment (25%), desaturation (24%), death within 24 hr (20%), cardiac arrest (14%), reintubation (10%), difficult intubation (8%), esophageal intubation (5%), equipment failure (5%), and drug error (4%) etc. Monitors that first detected incidents were EKG (46%), Pulse oximeter (34%), noninvasive blood pressure (12%), capnometry (4%), and mean arterial pressure (1%). CONCLUSION: Common factors related to incidents were inexperience, lack of vigilance, inadequate preanesthetic evaluation, inappropriate decision, emergency condition, haste, inadequate supervision, and ineffective communication. Suggested corrective strategies were quality assurance activity, clinical practice guideline, improvement of supervision, additional training, improvement of communication, and an increase in personnel.

Multicentered study of model of anesthesia related adverse events in Thailand by incident report (the Thai Anesthesia Incident Monitoring Study): methodology.

OBJECTIVE: Determine the appropriate model for incident study of adverse or undesirable events in more extensive levels from primary to tertiary hospitals across Thailand. MATERIAL AND METHOD: The present study was mainly a qualitative research design. Participating anesthesia providers are asked to report, on anonymous and voluntary basis, by completing the standardized incident report form as soon as they find a predetermined adverse or undesirable event during anesthesia, and until 24 hours after the operation. Data from the incident report will be reviewed by three peer reviewers and analyzed to identify contributing factors by consensus. CONCLUSION: The THAI anesthesia incidents monitoring study can be used as a model for the development of a local system to provide review and feedback information. This should help generate real improvement in the patient care.

Risk factors of intraoperative oxygen desaturation: a case-control study of 152,314 anesthetics.

BACKGROUND: The present study was part of the Thai Anesthesia Incidents Study (THAI Study) of anesthetic adverse outcomes. OBJECTIVE: To determine factors related to intraoperative oxygen desaturation (SpO2 < or =85% or < 90% for more than 3 min). MATERIAL AND METHOD: During a 12-month period (February 1, 2003 - January 31, 2004), a prospective multicentered registry of patients receiving anesthesia was conducted in 20 hospitals across Thailand Anesthesia personnel filled up patient-related, surgical-related, and anesthesia related variables and adverse outcomes including intraoperative oxygen desaturation. A case-control (1:4) study of patients with and without intraoperative oxygen desaturation in the THAI Study database was done. Univariate and multivariate analysis were used to identify factors related to intraoperative oxygen desaturation. A p-value < 0.05 was considered as significant. RESULTS: Among 152,314 patients without preanesthetic desaturation in the database, 328 cases of intraoperative oxygen desaturation were matched with 1312 control patients without desaturation. Variables that predict desaturation by multiple logistic regression were age less than 5 years old [OR 9.3 (95% CI 5.4-16.0)], ASA physical status 3, 4, 5 [OR 3.1 (95% CI 2.2-4.3)], history of upper respiratory tract infection [OR 10 (95% CI 1.9-51.6)], history of asthma [OR 2.9 (95% CI 1.0-9.5)], general anesthesia [OR 4.0 (95% CI 2.4-6.7)] duration of anesthesia 31-90 min [OR 1.9 (95% CI 1.2-3.0)], duration of anesthesia 91-150 min (OR 2.2 (95% CI 1.3-3.6)], and duration of anesthesia >150 min [OR 2.0 (95% CI 1.2-3.4)]. CONCLUSION: Knowing the risk factors of intraoperative oxygen desaturation helps improving personnel to improve preanesthetic conditions and facilitate early detection as well as prompt treatment of intraoperative oxygen desaturation.

The Thai Anesthesia Incidents Study (THAI study) of morbidity after spinal anesthesia: a multi-centered registry of 40,271 anesthetics.

BACKGROUND: The present study was part of the Thai Anesthesia Incidents Study (THAI Study) of anesthetic adverse outcomes. OBJECTIVE: Study complications after spinal anesthesia. MATERIAL AND METHOD: During the 12 month period (March 1, 2003 - February 28, 2004), a prospective multicentered descriptive study was conducted in 20 hospitals comprised of seven university, five tertiary, four general and four district hospitals across Thailand Anesthesia personnel filled up patient-related, surgical-related, and anesthesia-related variables and adverse outcomes of all consecutive patients receiving anesthesia on a structured data entry form. The data were collected during pre-anesthetic, intra-operative, and 24 hr post operative period Adverse event specific forms were used to record when these incidents occurred. Data were reviewed by three independent reviewers and analyzed to identify contributing factors by consensus. RESULTS: This was registry of 40,271 spinal anesthetics from 172,697 anesthetics. The incidence of total spinal anesthesia, neurological complications, suspected myocardial ischemia, or infarction and oxygen desaturation per 10000 spinal anesthetics were 3.48 (95% CI 1.66-5.30), 1.49 (95% CI 0.30-2.68), 2.73 (95% CI 1.12-4.35), 0.99 (95% CI 0.39-2.56), and 6.46 (95% CI 3.98-8.94) respectively. This was not different to the incidence in other countries. Risk factors of oxygen desaturation were shorter in height [OR 0.95 (95% CI 0.92-0.97); p < 0.0011, higher ASA physical status [OR 3.37 (95% CI 1.98-5.72); p < 0.001], and use of propofol [OR 5.22 (95% CI 1.78-15.35); p = 0.003]. Other complications such as seizure, anaphylactic or anaphylactoid reaction, drug error, and pulmonary aspiration were scarce. There was no case of mismatched blood transfusion in the present study. CONCLUSION: Incidence of total spinal block, neurological complication, and suspected myocardial ischemia or infarction was uncommon. Risk factors of oxygen destruction were shorter in height, higher ASA physical status, and use of propofol. Some events were considered avoidable and preventable.

The Thai Anesthesia Incidents Study (THAI Study) of difficult intubation: a qualitative analysis.

OBJECTIVES: To examine the causes, outcomes and contributing factors including suggested corrective strategies associated with difficult intubation. MATERIAL AND METHOD: Difficult intubation and failed intubation incidents were extracted from the Thai Anesthesia Incidents Study (THAI Study) database conducted between February 1, 2003 to January 31, 2004 and analyzed by using descriptive statistics RESULTS: Two hundred and thirty-four cases of difficult intubation were recorded. Among those, 50 cases (21%) were failed intubation. The most common cause (95%) of incidents was due to patients difficult anatomy. Prediction of events was derived from physical examination (65%) and history taking (50%). Majority of incidents (44%) occurred in Mallampati II and III. Only 3 cases (1.3%) of morbid obesed and 3 cases (1.3%) of pregnant patients were attributed to the events. Most incidents (119 cases, 50.9%) were successfully managed by conventional techniques. The adverse effects included hypoxemia (54 cases, 23.1%), esophageal/ tracheal injury (40 cases, 17.1%) and prolonged ventilatory support (17 cases, 7.3%). One patient died from sepsis. The reported contributing factors included inadequate experience, lack of knowledge including inadequate preoperative evaluation and preparation. Additional training, quality assurance and protocol/algorithm tended to minimize the incidents. CONCLUSION: The majority of difficult intubation could be predicted. Proper preoperative evaluation and equipment preparation, appropriate technique including experienced anesthesia personnel could attenuate the morbidity and mortality.

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.

The Thai Anesthesia Incidents Study (THAI Study) of anesthetic outcomes: II. Anesthetic profiles and adverse events.

BACKGROUND AND RATIONALE: The purposes of the Thai Anesthesia Incidents Study (THAI Study) of anesthetic outcomes were to survey patients, surgical, anesthetic profiles and determine factors related to 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 personnel were required to fill up patient-related, surgical-related, anesthesia-related variables and adverse outcomes on a structured data entry form. The data were collected during the preanesthetic evaluation, intraoperative period and 24 hr postoperative period. Adverse events specific forms were used to record when they occurred. All data were keyed at 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 during first 12 months. MD. anesthesiologists involved with 82%, 89%, 45% and 0.2% of cases in university hospitals, regional hospitals, general hospitals and district hospitals respectively. Nurse anesthetists took a major involvement in hospitals run by the Ministry of Public Health. Two-thirds of cases did not receive any premedication (67%) and midazolam was most frequent premedication administered (20%). Common monitoring were non invasive blood pressure (NIBP) (97%), pulse oximetry (96%), electrocardiography (80%), urine output (33%), airway pressure (27%) and capnometry (19%) respectively. The choices of anesthesia were general anesthesia (62%), spinal anesthesia (23%), total intravenous anesthesia (6%), monitor anesthesia care (4%), brachial plexus block (3%) and epidural anesthesia (1%). The adverse events were oxygen desaturation (31.9:10000), cardiac arrest (30.8:10000), death within 24 hr. (28.3:10000), difficult intubation (22.5:10000),re-intubation (19.4:10000), unplanned ICU admission (7.2:10000), coma/cva/convulsion (4.8:10000), equipment malfunction/failure (3.4:10000), suspected myocardial ischemia or infarction (2.7:10000), awareness during anesthesia (3.8:10000), late detected esophageal intubation (4.1:10000), failed intubation (3.1:10000), anaphylaxis or anaphylactoid reaction (2.1:10000), nerve injury (2:10000), pulmonary aspiration (2.7:10000), drug error (1.3:10000), hazard to anesthesia personnel (1.5:10000), unplanned hospital admission (0.1:10000), total spinal block (1.3:10000) and mismatch blood transfusion (0.18:10000) CONCLUSION: Respiratory adverse events were common anesthesia direct related events. High incidence of cardiac arrest and death within 24 hr highlighted concerns for prevention strategies. Incidents of adverse events can be used for institutional quality improvement, educational quality assurance and further research for patient safety in anesthesia.

Repair of extra-cranial internal carotid artery aneurysm with application of modified carotid shunt: a case report.

Aneurysms of the extracranial internal carotid artery (ICA) are uncommon. These lesions usually present with symptoms of transient ischemic attacks (TIA) from emboli and cranial nerve dysfunction from compression. The primary objective of treatment is to prevent a permanent neurologic deficit arising as a result of atheroembolism. The resection of an ICA aneurysm with restoration of flow is the preferred method of treatment. The authors present the case of a 32-year-old woman diagnosed with an ICA aneurysm. The patient underwent aneurysmectomy using an autologous saphenous vein graft with ICA blood flow being maintained using a carotid-to-carotid shunt, which was modifiedfrom an intravenous catheter set. This modified carotid shunt is easy to prepare for use and is of low cost. The authors do not expect this shunt to represent the standard commercially available shunt; but in some institutes, where commercial shunts are not available, this shunt may be suitably used.