Efficacy of intravenous dexamethasone for the prevention of vomiting associated with intrathecal chemotherapy and ketamine sedation in children: a randomized, double-blinded, crossover, placebocontrolled trial.

Background: Chemotherapy-induced nausea and vomiting remains a significant problem for children with leukemia. There is limited evidence to support using prophylactic antiemetic prior to the administration of intrathecal chemotherapy. Objective: Determine whether vomiting and nausea associated with intravenous ketamine and intrathecal chemotherapy may be reduced by the addition of prophylactic dexamethasone in children. Method: A randomized, double-blinded, crossover, placebo-controlled trial was completed in 33 children receiving intrathecal chemotherapy with methotrexate and ketamine sedation at Pharmongkutklao Hospital. Patients were randomly assigned in a double-blinded fashion to receive one of two interventions during the first period, either an infusion of normal saline or intravenous dexamethasone at 0.25 mg/kg/dose. Each patient acted as his or her own control, and each patient was studied at two time-points. Results: Period effect, sequence effect, and carry over effect were not demonstrated. The absolute risk reduction of vomiting was significantly greater after infusion of dexamethasone than after placebo at 33.3 % (p=0.02). The number needed to treat was three to prevent one episode of vomiting. Fifteen patients in the treatment group reported nausea versus 26 patients in the placebo group (p= 0.007). In the group of patients treated with dexamethasone, five required antiemetic vs. 16 of those receiving placebo (p=0.02). There was no complication from dexamethasone. Conclusion: Intravenous dexamethasone reduced vomiting associated with intrathecal chemotherapy and ketamine sedation, without significant side-effects. It may be recommended a reasonable option before intrathecal chemotherapy.

Quality and patient safety in anesthesia service: Thai survey.

Background: The Royal College of Anesthesiologists of Thailand (RCAT) performed large-scale epidemiologic study of anesthesia-related complications and national incidents study in 2004 and 2007, respectively. Objectives: Evaluate the anesthesia service in Thailand with regard to status of quality and patient safety. Material and methods: A pre-planned structured questionnaire regarding demographic, administrative, preanesthetic, intraoperative postanesthetic variables and complications were requested to be filled in by nurse anesthetists attending the refresher course lecture of RCAT in February 2008. Descriptive statistics was used. Results: Three hundred fifty questionnaires were given and 341 respondents (97%) returned the questionnaires. Most of the respondents (90%) worked in government section. Thirty percent of respondents practiced in hospital without medical doctor anesthesiologist and 58% of nurse anesthetists worked in hospitals that have been accredited. Forty-six percent of respondents reported unavailability of a 24-hour recovery room. The questionnaires revealed of inadequacy of anesthesia personnel (64%), inadequate supervision during emergency condition (53%), inadequacy of patient information regarding anesthesia (57-69%), and low opportunity for patient to choose choice of anesthesia (19%). The commonly used monitoring were pulse oximeter (92% of respondents) and electrocardiography (63%). One-third (32%) of respondents had to provide of anesthesia for patients with insufficient NPO (non per oral) time. Common problems that the respondents experienced were miscommunication (49%), intraoperative cardiac arrest during the past year (35%), error related to infusion pump (24%) and medication error (8%). Fifty-five percent of respondents had to monitor at least one patient per month receiving spinal anesthesia. Conclusion: Suggested strategies for quality and patient safety improvement in anesthesia service are increasing personnel, increasing 24-hour recovery room, improvement of supervision, improvement of communication, compliance to guidelines and improvement of nurse anesthetist’s training regarding monitoring patient receiving spinal anesthesia and cardiopulmonary resuscitation.

Factors related to intraoperative oxygen desaturation in geriatric patients in a Thai university hospital.

BACKGROUND: As a site of the Thai Anesthesia Incidents Study (THAI Study) of anesthetic adverse outcome, the authors continued the institutional data collection to determine the incidence of intraoperative oxygen desaturation of geriatric patients (age 65 years and over) and relative factors representing a Thai university hospital. MATERIAL AND METHOD: Between July 1, 2003 and March 31, 2007, an anesthesia registry was conducted at King Chulalongkorn Memorial Hospital. Anesthesiologists and anesthesia residents were requested to record perioperative variables and adverse outcomes including oxygen desaturation (SpO2 < or = 90% for 3 minutes or SpO2 < 85%) on a structured data record form. Univariable analysis was used to identify factors related to intraoperative oxygen desaturation. Multivariable generalized linear regression for risk ratio was used to investigate independent factors with significant association to intraoperative oxygen desaturation. A forward stepwise algorithm was chosen. A p-value < 0.05 was considered as statistically significant. RESULTS: Among 54,419 cases in the registry, 8,905 geriatric patients underwent non-cardiac surgery receiving anesthesia. Among these, 21 patients developed intraoperative oxygen desaturation with an incidence of 23.6 (95% CI 10, 30):10000 anesthetics. Variables that predict intraoperative oxygen desaturation by multivariable analysis were ASA physical status 3 [RR 4.6 (95% CI 1.6, 13.6)], ASA physical status 4-5 [RR 29.8 (95% CI 8.7, 102.8)], history of difficult airway [RR 13.1 (95% CI 1.7, 102.2)], recent respiratory failure [RR 6.0 (95% CI 1.2, 29.3)], and anesthetic agents used such as: pethidine [RR 6.2 (95% CI 1.9, 19.9)], and ketamine [RR 5.6 (95% CI 1.2, 25.9)]. CONCLUSION: The incidence of intraoperative oxygen desaturation of geriatric patients who underwent non-cardiac surgery in a Thai university hospital was 23.6:10000 anesthetics, which was comparable to others. The higher ASA physical status, history of difficult intubation and recent respiratory failure were risk factors of intraoperative oxygen desaturation. Pre-anesthetic evaluation particularly airway evaluation and identification of high-risk patients are crucial for prevention of oxygen desaturation.

Factors related to 24-hour perioperative cardiac arrest in geriatric patients in a Thai university hospital.

BACKGROUND: As a site of the Thai Anesthesia Incidents Study (THAI Study) of anesthetic adverse outcome, the authors continued the institutional data collection to determine the incidence and factors related to 24-hour perioperative cardiac arrest in geriatric patients (aged 65 years and over) representing a Thai university hospital. MATERIAL AND METHOD: Between July 1, 2003 and March 31, 2007, an anesthesia registry was conducted at King Chulalongkorn Memorial Hospital. Anesthesiologists and anesthesia residents were requested to record perioperative variables and adverse outcomes including 24-hour perioperative cardiac arrest on a structural data record form. Univariable analysis was used to identify factors related to 24-hour perioperative cardiac arrest. A multivariable generalized linear regression for risk ratio was used to investigate independent factors with significant association to 24-hour perioperative cardiac arrest. A forward stepwise algorithm was chosen. A p-value < 0.05 was considered as statistically significant. RESULTS: Among 54,419 cases in the registry, 8,905 geriatric patients underwent a non-cardiac surgery under anesthesia. Thirty-six patients experienced cardiac arrest. The incidence of intra-operative cardiac arrest, within 24 hours postoperative cardiac arrest, and overall 24-hours perioperative cardiac arrest were 18:10000 (mortality rate of 62.5%), 22.5:10000 (mortality rate of 90%), and 40.4:10000 (mortality rate of 77.8%), respectively. By multivariable analysis, age of 76-85 [RR 2.6 (95% CI: 1.2,5.4)], age > or = 86 [RR 4.4 (95% CI: 1.7, 11.8)], recent respiratory failure [RR 6.6 (95% CI: 1.9, 22.3)], ASA physical status 3-5 [RR 19.9 (95% CI: 4.6, 86)], emergency surgery [RR 2.8 (95% CI: 1.4, 5.6)], intrathoracic surgery [RR 3.7 (95% CI: 1.4, 9.9)], upper abdominal surgery [RR 2.8 (95% CI: 1.3, 5.7)], and administration of ketamine [RR 5.4 (95%CI: 1.8, 15.9)] were factors related to 24-hour perioperative cardiac arrest. CONCLUSION: The incidence of 24-hourperioperative cardiac arrest of geriatric patients in a Thai university in the present study was 40.4:10000 anesthetics, which was comparable to others with high mortality rate. Risk factors for 24-hour perioperative cardiac arrest were older age, ASA physical status 3-5, emergency surgery, intrathoracic surgery, upper abdominal surgery, recent respiratory failure, and administration of ketamine. Pre-anesthetic evaluation is important for finding the risks and optimal preparation for preventing perioperative cardiac arrest in these aging patients.

The Thai Anesthesia Incident Monitoring Study (Thai AIMS) of postoperative central neurological complications.

OBJECTIVE: To analyze the incidents of central neurological complication in the Thai Anesthesia Incident Monitoring Study (Thai AIMS). MATERIAL AND METHOD: A prospective descriptive multi-centered study of incident reports was conducted in 51 hospitals across Thailand from January to June 2007. Voluntary and anonymous reports of any adverse events during the first 24 hrs of anesthesia were sent to the Thai AIMS data management unit. Three anesthesiologists reviewed the possible central neurological complication reports. Descriptive statistics was used RESULTS: There were 16 relevant incident reports of central neurological complications (7 cases of convulsion, 5 cases of cerebro-vascular accident and 4 cases of coma). Majority of patients appeared to be old with underlying co-morbidities undergoing major surgical procedures under general anesthesia and required more intensive intra-operative monitoring. These complications occurred commonly with patients of orthopedics, cardiac, urologic and neurosurgical surgery. The majority of cerebro-vascular accident (80%) and coma (75%) were considered preventable. CONCLUSION: Inappropriate decision making and inexperienced anesthesiologists were common contributing factors while suggested corrective strategies were quality assurance activity, clinical practice guidelines and improvement of supervision.

The Thai anesthesia incident monitoring study of perioperative allergic reactions: an analysis of 1996 incidents reports.

OBJECTIVES: Analyze the clinical course, management, outcome, and contributing factors of perioperative allergic reactions in the Thai Anesthesia Incident Monitoring Study (Thai AIMS). MATERIAL AND METHOD: A prospective descriptive multicenter study was conducted in 51 hospitals across Thailand Voluntary, anonymous reports of any adverse or undesirable events during the first 24 hours of anesthesia were sent to the Thai AIMS data management unit. Possible perioperative allergic reactions were extracted and examined independently by three peer reviewers. RESULTS: Forty-three reports of possible perioperative allergic reactions from the 2,537 incidents reported to the Thai AIMS (1.6%) were reviewed. There was a female predominance (1.9:1). The most common features were cutaneous manifestations (93%), arterial hypotension (20.1%), and bronchospasm (11.6%) respectively. The severity grades were 69.8% in grade I, 4.7% in grade II, and 25.6% in grade III. The three most suspected causative agents were neuromuscular blocking agents (39.5%, 30.2%-succinylcholine), antibiotics (27.9%), and opioids (18.6%) respectively. All but one responded well to treatment with complete recovery. One patient suffered acute myocardial infarction and had to stay at the hospital for longer than one week. None had further allergic reaction. CONCLUSION: Perioperative allergic reactions accounted for 1.6% of anesthetic adverse events. The most common features were cutaneous manifestations. A quarter of these were life-threatening but responded well to treatment. The most common suspected causative agent was succinylcholine.

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.

Incidence and risk factors of hypotension and bradycardia after spinal anesthesia for cesarean section.

BACKGROUND: Hypotension or bradycardia after spinal anesthesia for cesarean section remain common and are serious complications. The current study evaluated factors associated to the incidences of hypotension or bradycardia in this context. MATERIAL AND METHOD: A prospective cross sectional study from November 1, 2004 to July 31, 2005 was conducted on 722 parturients undergoing cesarean section under spinal anesthesia. T-test and Chi-square test were used in univariate analysis to compare continuous data and categorical data respectively. Multivariate logistic regression was performed on the variables hypotension (systolic pressure decrease > 30% of baseline value) and bradycardia (heart rate < 60 bpm) p-value < 0.05 was considered significant. RESULTS: Incidence of hypotension and bradycardia were 52.6% and 2.5%. The probability of hypotension increased with estimated blood loss 500-1000 mL (odds ratio [OR] = 1.86; 95% CI 1.30-2.67, p = 0.001), estimated blood loss > 1000 mL (OR = 5.31; 95% CI 1.47-19.19, p = 0.011), and analgesia level > T4 (OR = 1.94; 95% CI 1.18-3.19, p = 0.009). Hypotension occurred despite left uterine displacement (OR = 1.56; 95% CI 1.11-2.19, p = 0.01). Risk factors associated with bradycardia were adding intrathecal morphine 0.2 mg (0.2 mL) (OR = 4.61; 95% CI 1.31-16.19, p = 0.017) to local anesthetics. CONCLUSION: The present results indicated that the incidence of hypotension after spinal anesthesia for cesarean section increased with amount of estimated blood loss > 500 mL and analgesic level > T4. Adding intrathecal morphine 0.2 mg (0.2 mL) to local anesthetics increased incidence of bradycardia.

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.

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.

A survey of awareness, opinion and reported use of clinical practice guidelines (CPG) of the Royal College of Anesthesiologists of Thailand.

BACKGROUND: Up to the present (2006), The Royal College of Anesthesiologists of Thailand (RCAT) has proposed and revised six practice guidelines. For guidelines to achieve their objectives, anyone who gets involved needs to be aware of the guidelines, be able to accept, and adhere to them. Although the authors did introduce their guidelines by several passive means, the authors have not yet ascertained what the result were. OBJECTIVE: The primary objective of the present study was to assess awareness, opinion, limitation, and reported use of guidelines. The secondary objective was to identify factors associated with variation, agreement, and reported use of guidelines. MATERIAL AND METHOD: A cross sectional, self-report survey study was conducted. An anonymous questionnaire including prepaid-addressed reply envelopes was mailed to 600 anesthesiologists and 1,300 nurse anesthetists, nationwide, based on the college's list. The questions covered respondents' general characteristics: awareness, agreement, and reported use of the existing guidelines; opinion on implementation media, which guidelines the members need, their local guidelines, and the impact of guidelines on their practice. All data were extracted and reported using descriptive statistics. Multiple logistic regression was done to identify factors associated with an agreement with and a reported use of the guidelines. RESULTS: The overall response rate was 33.4% and nurse anesthetists had a higher response than anesthesiologists. Forty-six percent of the respondents were aware of the existing guidelines. This result corresponded to percentage of those who had read the guidelines (41%). Among the six existing guidelines, the least two guidelines reported use of and agreement with, were those for labor analgesia and conscious sedation (23-28%, 24-28%). The guidelines for spinal anesthesia received the most response (46%). For respondents who had read the guidelines, most of them (80% to 94%) rated the level of agreement and reported use as good to excellent. The respondents also rated the announcement of the guidelines during the annual meeting of the Royal College of Anesthesiologists of Thailand as the best implementation strategy. Impracticability, inadequate dissemination, and un-cooperation among colleagues were the three most important obstacles of using the guidelines. In addition, the present study demonstrated three significant factors, anesthesiologists, regional hospitals, and general hospitals, as associated with reporting frequent use of and high agreement with the guidelines. CONCLUSION: The low level of awareness and reported use of the present guidelines among the members reflects poor implementation and dissemination. However the present study reveals some information that will guide the authors to introduce intensive and targeted interventions to encourage the members to comply and adhere to the guidelines designed to improve the quality of patients' care.

Predictors of intra-operative recall of awareness: Thai Anesthesia Incidents Study (THAI Study): a case-control study.

BACKGROUND: The authors determined predictors of intra-operative recall of awareness in the Thai Anesthesia Incidents Study (THAI Study). OBJECTIVE: To study a multi-centered registry of anesthesia in 20 hospitals across Thailand. MATERIAL AND METHOD: Structured data collection forms of patients who underwent general anesthesia and experienced intra-operative recall of awareness between March 1, 2003 and February 28, 2004, were reviewed by three independent anesthesiologists. One case of awareness was matched to four controls by age, gender, and level of hospitals. Univariate analysis (p < 0.1) and logistic regression (p < 0.05) identified characteristics associated with intra-operative recall of awareness. RESULTS: Eighty-one cases were matched with 324 controls in the nested case control study. From univariate analysis, risk factors were cardiac surgery, cesarean delivery, upper abdominal surgery, i.v. anesthetics, depolarizing muscle relaxant, non-depolarizing muscle relaxant, and nitrous oxide (p < 0.1). The predictors from multivariable logistic regression were cesarean delivery p < 0.001, OR 6.48 (95% CI 2.03, 20.71), and cardiac surgery p < 0.001, OR 10.37 (95% CI 3.37, 31.89). Decreased risk was associated with intra-operative use of nitrous oxide p = 0.02, OR 0.42 (95% CI 0.20, 0.88). CONCLUSION: In the THAI Study, predictors of intra-operative recall of awareness were cesarean delivery and cardiac surgery. Use of nitrous oxide attenuates the risk of awareness.

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.

History and evolution of western medicine in Thailand.

Background: Western medicine entered into the Kingdom of Siam for the first time in Ayutthaya Period. In 1686, Chevalier de Forbin, a French military officer described a surgical operation in which the stomach and intestine of a patient were restored into the abdomen and the surgical wound closed by suturing, without complication. Soon after this the relationship between Thailand and Europe was severed until it was renewed in the Bangkok Period. Thailand’s first hospital was built in the province of Petchaburi in 1878. The first hospital built by the government of Thailand was Siriraj Hospital in 1887; and the Red Cross Society was founded in 1893. King Chulalongkorn Memorial Hospital was established in 1914. Chulalongkorn University was established with the Faculty of Medicine in 1916. In 1942, the Ministry of Public Health was established to regulate medical services and public health of the people of Thailand. Objective: To introduce the history and development of western medicine in Thailand.

The incidence and risk factors of hypotension and bradycardia associated with spinal anesthesia.

OBJECTIVES: Hypotension and bradycardia after conduction of spinal anesthesia are common and may lead to intraoperative cardiac arrest or death. The present study was carried out to investigate the incidence and risk factors of hypotension and/or bradycardia in the patients receiving spinal anesthesia. MATERIAL AND METHOD: The authors prospectively studied 1,220 patients to identify the incidence of hypotension (> 30% decreased systolic blood pressure) and bradycardia (heart rate < 60 beats/min) after spinal anesthesia. Historical, clinical and physiologic data were correlated with the incidences by univariate analysis. Logistic regression with a forward stepwise algorithm was performed to identify independent variables. A p value < 0.05 was considered significant. RESULTS: Incidence of hypotension and bradycardia were 36.8% and 4.9% respectively. The risk factors of hypotension included increasing age (OR = 1.019 ; 95%CI 1.017-1.031); analgesia level > or = T4 dermatome (OR = 2.068; 95%CI 1.486-2.879); body mass index > or = 30 (OR = 1.534; 95%CI 1.120-2. 100); cesarean section (OR= 1.723; 95%CI 1.244-2.386 and prehydration fluid < 500 mL (OR 1.472; 95%CI 1.071-2.023). The risk factors of bradycardia were increasing age (OR = 1.042; 95%CI 1.023-1.061) and analgesic level > or = T4 dermatome (OR = 2.246; 95%CI 1.101-4.584). CONCLUSION: The incidence of hypotension and bradycardia may increase with increasing age and analgesic level > or = T4 dermatome. Three other factors related to hypotension after spinal anesthesia were body mass index > or = 30, cesarean section, and prehydration fluid of less than 500 mL.

Pain on injection of propofol: propofol LCT vs propofol MCT/LCT with or without lidocaine pretreatment.

BACKGROUND: Pain on injection was a disadvantage of propofol long-chain triglyceride (LCT) and reduces patient satisfaction. Based on a systematic review, the recommended method to attenuate this pain was a previous administration of lidocaine under tourniquet for 30-120 seconds before injection of propofol (pretreatment of lidocaine). Recently, propofol medium-chain triglyceride/long-chain triglyceride (MCT/LCT) emulsion was proposed for its ability to decrease pain on injection. The authors conducted a double-blind randomized controlled trial to compare the incidence and severity of pain on injection between the new propofol MCT/LCT and the propofol LCT with and without lidocaine pretreatment. MATERIAL AND METHOD: 360 adult patients with ASA physical status I-III who underwent general anesthesia were assigned into 4 groups by computer-generated randomization; Group I - pretreatment of lidocaine 1% and propofol LCT Group I - pretreatment oflidocaine 1% and propofol MCT/LCT Group III - pretreatment of saline and propofol MCT/LCT and Group IV- pretreatment of saline and propofol LCT mixed with lidocaine 1%. All groups received pretreatment under tourniquet for 60 seconds. Evaluators who were blinded to the injected drugs recorded pain intensity (none, mild, moderate and severe) after the first 30% of total induction dose ofpropofol was injected at a rate of 1 ml/s by questioning patients. Data was analyzed by using Kruskal-Wallis testfor ordinal data. Post hoc analysis was performed by using the Mann-Whitney U-test with Bonferroni's correction on pairwise comparisons and was considered significant with p value of less than 0.05. RESULTS: Patients in an individual group had insignificant differences in their demographic data. The incidences of pain in Group I, II, III and IV were 61.1%, 46.7%, 62.2% and 55.6% respectively with an average incidence of 56% (p = 0.006). There were 15.6%, 5.6%, 23.3% and 24.4% of patients in Group I, II, III and IV who rated pain intensity as severe. Pain on injection of propofol MCT/LCT with lidocaine pretreatment was less than propofol MCT/LCT alone (p = 0.001). CONCLUSION: The incidence of pain on injection of propofol MCT/LCT was not different from that caused by propofol LCT with pretreatment of lidocaine and the intensity of pain on propofol MCT/LCT injection decreased significantly when using lidocaine pretreatment. Therefore, the authors could conclude that an injection of new propofol MCT/LCT solution was an alternative in reducing pain sensation to propofol LCT with pretreatment of lidocaine. Additionally, pain of propofol MCT/LCT injection could be alleviated by pretreatment of lidocaine with a 60 seconds tourniquet time before the injection ofpropofol.

Comparison of 25 and 27 gauge needle in spinal anesthesia learning curve for anesthesia residency training.

BACKGROUND AND RATIONALE: Size of spinal needle may be a factor which influences the success rate of spinal anesthesia. OBJECTIVES: To compare learning curves of using 25G and 27G quincke spinal needle for spinal anesthesia. SETTING: Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital. DESIGN: Prospective randomized control trial. MATERIAL AND METHOD: Ten new first year anesthesia residents were randomized to 2 groups: Group I (n = 5) used 25G Quincke spinal needle, Group II (n = 5) used 27G Quincke spinal needle to perform 200 consecutive cases of spinal anesthesia. Number of success and failure was recorded by each individual resident anonymously. The learning curves of plotted by cumulative sum of success rate revealed an initial rapid improvement of success during the first 20 cases in both groups. The overall success rate of group I was 84% (95CI, 66.5-100) and group II was 87% (95%CI, 61.5-100); p = 0.89. The widest difference between the 2 learning curves at 20 attempts intervals was at the twentieth attempts with a success rate of 76.0% VS 65.0% in group I and group II respectively; p = 0.54. CONCLUSION: The learning curves of spinal anesthesia using 25G and 27G Quincke spinal needle showed rapid improvement of success rate at the first 20 spinal block and high overall success rate with no significant difference between the groups.

The Thai Anesthesia Incidents Study (THAI Study) of oxygen desaturation.

OBJECTIVES: To examine incidents, contributory factors, treatment and outcomes associated with oxygen desaturation during anesthesia practice in Thailand. MATERIAL AND METHOD: Relevant data were extracted from the Thai Anesthesia Incidents Study (THAI Study) database between February 1, 2003 and January 31, 2004 and analyzed by using mainly descriptive statistics. RESULTS: Four hundred and ninety seven incidents of oxygen desaturation (SpO2 <90 for at least 3min or < or = 85%) were reported. The incidents were widely distributed throughout anesthesia phases. Most of the incidents (92.2%) occurred during general anesthesia, while 23 (4.6%) occurred after regional anesthesia. Anesthesia was the sole contributory factor in 280 patients (56.8%) and a combination of that with other factors in 126 (25.4%). The majority of the incidents (88.4%) was related to respiratory adverse events, whereas, 8% was related to circulatory ones. Sixteen incidents (3.2%) were related to anesthetic machine and equipment failure. Most of the incidents (60.0%) caused minor physiologic changes and were correctable. The management was considered adequate in the majority of patients. As a result, 77.5 % of the patients recovered completely, whereas, death ensued in 5.8%. The cases of death were associated with co-morbidity (ASA class 4 and 5) with an Odds ratio of 12.9 (95% CI:5.4,31.0). The common contributory factors were inexperience, wrong decision, inadequate knowledge and lack ofsupervision. The proposed corrective strategies included improvement in supervision, care improvement, additional training, clinical practice guideline and quality assurance activity. CONCLUSION: Incidents associated with oxygen desaturation were distributed throughout all phases of anesthesia. Most of them were preventable and correctable. Therefore, anesthesia care providers should be alert in looking for incidents, and manage them promptly before they were in serious adverse events.

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.

The Thai Anesthesia Incidents Study (THAI Study) of perioperative death: analysis of risk factors.

BACKGROUND: National statistical data of mortality and morbidity related to anesthesia have not been reported. The need to comprehensively examine the cause of death as well as other adverse events prompted the first national study in Thailand. MATERIAL AND METHOD: In the Thai Anesthesia Incidents Study (THAI Study), a prospectively defined cohort of patients who underwent anesthesia from February 1, 2003 to January 31, 2004 (n=163,403) was studied. All consecutive patients who died intraoperatively or within the period of 24 hr after anesthesia were classified to determine a relationship with anesthesia by 3 independent reviewers. These data were further analysed to identify contributing factors. RESULTS: The incidence of 24-hr perioperative death, anesthesia directly related and anesthesia partially related death per 10,000 anesthetics was 28.2 (95% CI 25.7-30.8), 1.7 (95% CI 1.1-2.3) and 4.0 (95% CI 3.1-5.0) respectively. Of 462 deaths, 28 cases (6.5%), 66 cases (14.3%), 61 cases (3.3%), 399 cases (86.7%) and 104 cases (22.6%) were anesthesia directly related, anesthesia partially related, surgical related, patient disease related and system or management related to perioperative death. The common main causes of death were exangination (42.4%), traumatic brain injury (14.3%), sepsis (13.6%), heart failure (5.0%) and hypoxia (5.0%). CONCLUSION: This study shows incidence of 24-hr perioperative death of 1:354 which is comparable with other studies. Quality assurance activity, prevention of human failure and equipment failure, system improvement of perioperative care, availability of recovery room, intensive care unit, efficient blood bank and adequate number of MD. anesthesiologists are suggestive corrective strategies.