Educational video to improve the knowledge of health care providers in pain assessment of preschool children.

Objective: To evaluate the effect of pain assessment with preschool children educational video to assist healthcare providers’ ability to assess pain using CHEOPS and FLACC scores. Methods: A randomized controlled study was conducted in healthcare providers having less than one year experience in pediatric pain management. Participants were randomized into study group and control. Participant’s demographic data, existing experience and knowledge in pain assessment, pre-test and post-test’s corrected scores and time required were recorded. Results: One hundred healthcare providers were recruited. There were no differences between groups in pre-test score, the percentage of correct scoring in treatment decision and time required for assessment using CHEOPS and FLACC scores. Improvements in post-test scores were found in both groups with no statistical significance. However, the difference in time needed to compare the pre-post test results was lower in the control group. Twenty nine participants in the study group evaluated the educational video. They stated it to be informative, easy to understand and conveyed confidence about preschool pediatric pain assessment. Conclusion: A pain assessment education video is one of the media that can possibly be used for assisting pain assessment education. It could improve confidence and understanding in healthcare providers treating pain in preschool children.

Printed anesthetic-risk information and perioperative anxiety: a multi-center study.

Background: Currently, there is a considerable variation concerning the provision of preanesthetic-risk information, especially potential detrimental adverse outcomes. Objective: Determine the effects of printed anesthetic-risk information before surgery including patients’ anxiety, refusal of surgery, knowledge perception of adverse events and factors affecting anxiety. Methods: Patients in a university hospital, a tertiary care hospital, a secondary care hospital, and a neurological institute in Thailand, undergoing low-to-moderate risk surgery were randomly allocated to control group (C) and study group (S), where group C received printed general information in anesthesia, and group S received printed incidences of five anesthetic adverse events as sore throat, nausea/vomiting, tooth loss, not waking up after surgery, cardiac arrest. Spielberger State-Trait Anxiety Inventory Scale (STAIS, STAIT) for anxiety and Visual Analog Scale (VAS) for knowledge perception were recorded before and after information, and after surgery. Numbers of patients who refused surgery and needed anesthetic-risk information in the next surgery were also recorded. STAIS >45 were considered “high anxiety”. Results: Eight-hundred and twenty-four patients were analyzed (group C: 414, group S: 410). There was no difference in age, sex, ASA physical status, salary, education level, habitat, anesthetic experience and operative risk between groups. STAIS and STAIT, proportion of patients with high anxiety, proportion of patients who refused surgery were not different between groups. Patients in control group needed anesthetic-risk information in the next surgery more than study group (p<0.001). VAS for knowledge about five adverse events in study group were significantly higher than control group (p <0.001). Risk factors by the multivariate analysis included patients with high baseline trait anxiety and low income of less than 10,000 Baht/month. Conclusion: Printed anesthetic-risk nformation did not increase anxiety, but increased knowledge perception of the patients.

Time duration to safety sitting in parturient receiving spinal anesthesia for cesarean section with 0.5% Bupivacaine and morphine.

Background: Spinal anesthesia has been used for cesarean section for a long time. However, the proportion of post-cesarean paturients who were able to sit at the fourth hour still remains unclear. Objective: Investigate the proportion of post-cesarean paturients that were able to sit at the fourth hour following spinal anesthesia with 0.5% hyperbaric bupivacaine and morphine. Furthermore, investigate the optimum time to encourage ambulation, and the risk factors delaying time duration to sit. Methods: A prospective observational study was conducted in 240 patients with American Society of Anesthesiologists physical status classification I and II, and single pregnancy parturients undergoing cesarean section. The patients who had body mass index (BMI) >35, estimated blood loss >1000 mL, needed postoperative bed rest, or received postoperative sedation were excluded. Hyperbaric bupivacaine 8-11 mg and morphine 0.2-0.3 mg were used. The patients were evaluated at the fourth hour until they could sit without adverse events or complete the sixth hour. All patients were evaluated for risk factors delaying the time duration to sit. Results: Out of 240 patients, 77.0%, 90.9%, and 98.4% were able to sit at the fourth, fifth, and sixth hour, respectively. The risk factors that delayed time to sit were Bromage scale >1 and pain score >3 by the univariate analysis, and were Bromage scale >1 and pain score >3 by the multivariate analysis. Conclusion: Seventy-seven percent of the patients could sit at the fourth hour, and most patients (98%) could sit at the sixth hour. The risk factors that delayed the time duration to sit were Bromage score >1 and pain score >3.

Quality of post-operative pain control in infants and neonates.

Objective: To date, little information has been reported regarding the quality of pain control in infants and neonates. We identified the incidence and risk factors of postoperative pain, effects of fentanyl on extubation, optimal doses of fentanyl and respiratory complications. Methods: This descriptive study was conducted in infants and neonates who underwent major surgery, by retrospective chart review. Patients who were assessed as having pain by using the Neonatal Infant Pain Scale (NIPS) >10 times in 24 hours were included. Demographic data, type of surgery, timing of extubation and NIPS, including type of analgesia and doses of fentanyl given, were recorded. Pain was defined as NIPS >4 twice in 24 hours. Risk factors which included age group, type of surgery and type of postoperative analgesia were recorded. Results: Seventy-two neonates and 68 infants, ASA I-III were enrolled. The overall incidence of pain was 26.4% (infants, 44.1%; neonate, 9.7%). The age group was the significant factor affecting pain (adjusted odd ratio=7.84, 95% CI = 3.00, 20.84, p <0.001). Among patients who were still receiving fentanyl infusion or just ceased from receiving infusion within 30 minutes, 91.2% of infants and 58.3% of neonates were able to be extubated. The median time to extubation in infants was less than in neonates (0 vs. 16 min). Optimal doses of intravenous fentanyl in neonates were commenced at 0.3 mcg.kg-1 for intermittent use and 0.3 mcg.kg-1.h-1 for infusion. Apneic episodes were found in 2 patients. Conclusion: From this study, the quality of pain control in infants was not as good as neonates.

Anesthesia-related cardiac arrest in children: the Thai Anesthesia Incidents Study (THAI Study).

BACKGROUND AND OBJECTIVE: The Thai Anesthesia Incidents study (THAI Study) is the first national study of anesthesia outcomes during anesthesia practice in Thailand. The authors extracted data of 25,098 pediatric cases from the THAI Study in order to examine the incidence, suspected causes, contributory factors, and suggested corrective strategies associated with anesthesia-related cardiac arrest. MATERIAL AND METHOD: A multi-centered prospective descriptive study was conducted among 20 hospitals across Thailand over a year between March 1, 2003 and February 28, 2004. Data of cardiac arrests in children aged 15 years and younger were collected during anesthesia, in the recovery room and 24 hours postoperative period, and reviewed independently by at least two reviewers. RESULTS: Incidence of anesthesia- related cardiac arrest was 5.1 per 10,000 anesthetics, with 46% mortality rate. Infants accounted for 61% of cases. Incidences of overall cardiac arrest and anesthesia-related arrest were significantly higher in infants than older children and in children with ASA physical status 3-5 than those with ASA physical status 1-2. Most of the anesthesia-related arrests occurred in the operating room (61%) during induction or maintenance of anesthesia (84%). Respiratory-related cardiac arrest was the most common suspected cause of anesthesia-related cardiac arrest. Improving supervision, additional training, practice guidelines, efficient blood bank, equipment maintenance, and quality assurance monitoring are suggested corrective strategies to improve the quality of care in pediatric anesthesia. CONCLUSION: The incidence of anesthesia-related cardiac arrest was 5.1:10,000 anesthetics. Major risk factors were children younger than 1 year of age and ASA 3-5. The identifications of airway management and medication-related problems as the main causes of anesthesia-related cardiac arrest have important implications for preventive strategies.

Pediatric anesthesia adverse events: the Thai Anesthesia Incidents Study (THAI Study) database of 25,098 cases.

BACKGROUND: The Thai Anesthesia Incidents Study (THAI Study) is the first national study of anesthesia outcomes during anesthesia practice in Thailand. The authors extracted data of 25,098 pediatric cases from THAI Study. OBJECTIVE: To report patient, surgical, and anesthetic profiles in order to determine the incidences of adverse events and their related factors. MATERIAL AND METHOD: A multi-centered prospective descriptive study was conducted among 20 hospitals across Thailand over a year from March 1, 2003 to February 28, 2004. Data in children aged 15 years and younger describing practices and adverse events were collected during anesthesia, in the recovery room and 24 hours postoperative period. RESULTS: Infants (0-1 year) had a significantly higher rate of adverse events compared with adults (4.6% versus 1.2%). Desaturation was the most common adverse event. The adverse events happened mostly during anesthesia (67%). Infants had significantly higher incidences of delayed detection of esophageal intubation, desaturation, reintubation, cardiac arrest, death, and drug error than older children and adults. Incidences of desaturation, reintubation, difficult intubation, coma/convulsion, cardiac arrest, and death were significantly higher in children with ASA physical status 3-5 than those with ASA physical status 1-2. CONCLUSION: Infants are prone to higher adverse events compared with older children and adults. Main adverse events were respiratory-related and they occurred mostly during anesthesia.

Quality assessment of postoperative pain management in pediatric surgical patients.

Objective: To evaluate the incidence of moderate to severe pain in children during 24 hours following surgery, including their risk factors, analgesic treatment and complications. Methods: A retrospective descriptive study was conducted at a university hospital from 1 March 2003 to 28 February 2004. Children aged 1-15 years, ASA 1-2, who underwent major operation at the Department of Surgery were recruited into the study. Postoperative pain was assessed by age-appropriated scales at least 10 times in the first 24 hours postoperatively. Their demographic data, type of operation, anesthetic technique, medication and complication were recorded. Results: Two hundred and thirty children, median age of 8 years (IQR 4-11 years) were recruited. They received surgical operations on various regions of the bodies, namely: groin/perineum, head/neck/face, extremity and abdomen/trunk with the following percentages: 24.3%, 10.9%, 3.5 % and 59.1%, respectively. Incidents of moderate to severe pain in the first 24 hours occurred in 100 patients (43.5 %). Their risk factors included age > 6 years old (adjusted OR 2.21) and inadequacy of analgesic treatment (adjusted OR 38.80). Pethidine IV and oral paracetamol on PRN basis were commonly prescribed with too long dosing interval. The common postoperative complication identified was nausea and vomiting (19.6%). No respiratory depression was detected. Conclusion: Postoperative pain in children was still under-treated. More attention should be provided to children > 6 years old. Proper prescription of analgesic dosing interval, frequent assessment and appropriate criteria for treatment on PRN basis tended to reduce pain.

Postoperative reintubation after planned extubation in Thai Anesthesia Incidents Study (THAI Study).

OBJECTIVE: To analyze precipitating causes, outcomes and corrective strategies especially anesthetic related factors associated with reintubation after planned extubation in anesthetic technique of general anesthesia with endotracheal intubation. DESIGN: Prospective observational study. MATERIAL AND METHOD: Incidents of reintubation after planned extubation were extracted from the Thai Anesthesia Incidents Study (THAI Study) database conducted between February 1, 2003, and January 31, 2004, and analyzed using descriptive statistics. RESULTS: The total of two hundred and thirty four patients of reintubation after planned extubation (RAP) at the end of general anesthesia was reviewed in this study. The incidence of RAP was 27:10,000 and the incidence in the university hospital was similar to the tertiary and secondary care hospital. The incidence was increased in extreme age group (age < 1 and > 70 year). One hundred and fifty eight cases of RAP (67.5%) occurred in operating theater and recovery room which included 83 cases occurring within 10 minutes after extubation. The two most common primary diagnoses were upper airway obstruction and hypoventilation. Three main precipitating factors were residual effect of neuromuscular blocking and anesthetic agents (53-57%), upper airway obstruction (31%) and unstable hemodynamics (26.3%). Nearly half of RAP incidents occurring in the operating theater and recovery room were successful reextubation within six hours and 58-72 % of these two subgroups were complete recovery. The chance for prevention was more than 80% by additional training and supervision. CONCLUSION: More than 90% of RAP occurred in operating theater and recovery room were completely or partially related to anesthetic process. Incidence of RAP could be decreased by quality assurance process of recording, reporting and modeling care process together with increase individual experience.

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.

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.

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 anesthetic outcomes: I. Description of methods and populations.

BACKGROUND AND RATIONALE: Since anesthesia, unlike medical or surgical specialties, does not constitute treatment, The Royal College of Anesthesiologists of Thailand host the Thai Anesthesia Incidents Study (THAI Study) of anesthetic outcomes to determine factors related to anesthesia related 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 personnels were required to fill up patient-related, surgical-related, anesthesia-related variables and adverse outcomes on a strutured data entry form. The data included preanesthetic evaluation intraoperative period and 24 hr postoperative period. Adverse events specific form was recorded when adverse events occurred. All data were keyed in 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 in one year. The mean (S.D.) of age, weight and height of patients were 38.6(2.3) yrs, 53.9(17.7) kgs and 153.4(22.7) cm respectively. There were more female (52.9%) than male (47. 1%) patients with ASA PS 1, 2, 3, 4, 5 = 50.8%, 36.3%, 10.7%, 2.0%, 0.2% respectively. Hypertension (11.6%), anemia (7.7%) and diabetes melitus (6.8%) were the three most common abnormalities in preanesthetic history taking. Mallampati score of 111870 patients grade 1, 2, 3, 4 were 54.0%, 39.7%, 5.6%, 0.7% and laryngoscopic grade 1, 2, 3, 4 of 74888 patients were 81.0%, 15.5%, 3.0% and 0.5% respectively. CONCLUSION: The first phase of THAI study epidemiological project can represent both the anesthesia and surgical profiles in Thailand. The collected data available should be useful for the improvement of the quality of anesthesia, guidelines for clinical practices, medical education and for further research.

Cross-validation of a self-report scale for postoperative pain in school-aged children.

The present study cross-validated self-report pain scales: Verbal Rating Scale (VRS), Facial Expression Scale (FACES), Color Analogue Scale (CAS) and Poker Chip Tool (PCT) in Thai children aged 5-12 years. The concordance with observational measure, Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) was also tested. Among 100 students, test-retest reliability of all self-report measures was moderate to good (K = 0.501-0.712) and only FACES yielded acceptable face validity(IC > 0.5). Validation in 87 patients, all scales showed construct and concurrent validity. FACES was the most preferred scale. Agreement of self-report measures and CHEOPS was better in the age group 5-8 years (K = 0.417-0.826) than 9-12 years (K = 0.231-0.529). In conclusion, FACES is a valid, reliable and practical tool. Self-report measures are more in concordance with CHEOPS in the younger age group.

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.

Cervical cord decompression and posterior cervical immobilization following anterior C1-C2 subluxation in a patient with MPS type IV (morquio syndrome) : A team approach.

We report a 23 month old gril who presented with right hemiparesis after falling for 6 months. She was also diagnosed with mucopolysaccharidosis type IV (Morquio syndrome) with C1-C2 subluxation. Anesthesia was uneventful after inhalation induction, manual in-line stabilization, intubation, external fixation of the cervical spine, followed by prone position and manual assisted ventilation. Postoperative pain was relieved using a tramadol infusion.

Postoperative pain assessment in ambulatory pediatric patients by parents.

OBJECTIVES: This study aimed to assess 1) agreement and correlation of postoperative pain scores rated by nurses and parents 2) the difference between the pain scores (CHEOPS and FLACC) as rated by nurses and parents 3) effects of parental education on pain rating 4) the ease with which parents could score CHEOPS and FLACC. METHODS: Sixty-nine children, age 1-12 years (median 3.7, IQR 2-6.85 years) underwent herniorrhaphy and hydrocoelectomy under general anesthesia and 69 parents, age 20-65 years (median 32, IQR 37.5-38.5 years) were enrolled in the study. Parents were trained how to score pain using CHEOPS and FLACC by using a videotape of children's pain behaviors. One of 2 nurses who were tested for inter-rater reliability (ICC > 0.9) rated the postoperative pain of a child in the recovery room at the same time with his parent by using CHEOPS and FLACC. RESULTS: Agreement (ICC) and Correlation Coefficient (r) between nurses and parents were 0.934-0.979 and 0.898-0.969 respectively (p < 0.001). ICC and r were not influenced by parental education. Pain scores rated by parents using either CHEOPS or FLACC showed no difference between the scoring systems (p = 0.544, 0.166). CONCLUSION: Thai parents could be easily trained how to use pain scales. Parental rating was not different from nurse rating. The agreement and correlation between parents and nurses were very high. The ease of using CHEOPS was not different from FLACC.

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.

Pediatric obstructive sleep apnea.

Obstructive sleep apnea in children is most commonly caused by adenotonsillar hypertrophy. Chronic longstanding hypoxia at night can lead to cardiovascular complications such as pulmonary hypertension and cor pulmonale. We reported a case of a four-year-old boy who had suffered from adenotonsillar hypertrophy and obstructive sleep disturbance for 3 years, resulting in right ventricular hypertrophy. Adenotonsillectomy was performed. Pre-operative awareness of potential omplications, good co-operation between pediatric cardiologist and pediatric anesthesiologist with post-operative monitoring in intensive care unit were essential for the success of surgical treatment.