Multicentered study of model of difficult endotracheal intubation by incident reports from university and non-university hospitals.

OBJECTIVE: To compare the characteristics, causative factors, outcomes, prevention, and suggested preventive strategies of difficult intubation between university (U) and general community (non-U) hospitals. MATERIAL AND METHOD: One thousand nine hundred and ninety-six reports were reviewed from Thai anesthesia incident monitoring study (Thai AIMS) conducted in 51 hospitals nationwide between January and June 2007. Thirty-four cases ofDI were reported from U hospitals and 69 cases from non-U hospitals. The described details on each report on dfficult intubation (DI) in adults undergoing general anesthesia were thoroughly reviewed by three reviewers to give their consensus opinions on causative factors, outcomes, contributing preventive factors, and strategies for corrections. Descriptive statistics were used for data analysis. RESULTS: Patient factors were the most common cause of DI (88% in U and 87% in non-U hospitals). Fifty percent of U and 51% of non-U DI cases were consequences of human errors, which were preventable and mostly based on knowledge (88% vs. 71%) and rules of practice (23% vs. 51%). Substitution of an intubating anesthesiologist, reducing the size of endotracheal tubes, and stylet guided technique were the three commonly used methods after DI. MacCoy laryngoscope, fiber optic-aided intubation, laryngeal mask airway and Frova introducer were commonly used as substitutes for the standard laryngoscope. Inadequate experience was the major problem of U hospitals, which required additional training to gain more skill. The most common problem ofDI in non-U hospitals was inadequate preanesthetic evaluation. Therefore, they required practice guidelines and experienced assistants in difFicult situations. CONCLUSION: Half of DI cases were preventable. DI cases in Non-U hospitals were mostly caused by inadequate preanesthetic evaluation. This indicates the necessities of providing practice guidelines and experienced assistants. In U hospitals, in-training practice of intubation should be performed under supervision. More advanced substitution techniques were applicable in U hospitals.

The Thai Anesthesia Incidents Study (THAI Study) of ambulatory anesthesia: Part I: Method, geographic distribution and population.

BACKGROUND: There is a continuing trend to have more elective surgical operations performed on an outpatient basis. OBJECTIVE: To determine the proportional distribution of anesthetic procedures performed in ambulatory elective surgery at different levels of hospitals across Thailand. MATERIAL AND METHOD: A prospective and descriptive study was conducted at 20 hospitals comprising seven universities, five regional, four general and four district hospitals across Thailand Consecutive outpatients who were undergoing elective surgical operation were included and their relevant data were selected and extracted for summary by using descriptive statistics. RESULTS: From the database of 118,027 anesthetics performed for elective surgical operation, 7,786 (6.6%) were outpatients. According to this, 7,016 (90.1%) were practiced in university hospitals, 656 (8.4%) in regional or tertiary hospitals, 71 (9%) in general or provincial hospitals, and 43 (0.6%) in district hospitals. The frequency of the ambulatory anesthesia was higher in hospitals in the central region, especially in university hospitals in Bangkok than in other regions. The majority of cases (86%) received their initial pre-anesthetic evaluation in the operating room while 12% were evaluated at the outpatient office. About 28% of the cases presented with pre-anesthetic abnormal conditions. The relatively common pre-anesthetic diseases were hypertension, diabetes mellitus, anemia, arrhythmia, and asthma. CONCLUSION: From the results of the present study, the authors have concluded that the rate of expansion of ambulatory anesthesia in Thailand is relatively slow, and varies according to the type of hospital and its geographic region. This indicates further studies should be formally conducted to determine factors affecting the practice of ambulatory surgery in Thailand. A large proportion of patients receive initial pre-anesthetic evaluation in the operating room on the day of surgery. This indicates that a system of pre-anesthetic evaluation should be set up for outpatients such as a pre-anesthetic care clinic should be set up for outpatients.

The Thai Anesthesia Incidents Study (THAI Study) of anesthetic equipment failure/malfunction: a qualitative analysis for risk factors.

BACKGROUND: Anesthesia equipment problems may contribute to anesthetic morbidity and mortality. In Thailand, the magnitude and pattern of these problems has not been established. We therefore analyzed the frequency, type and severity of equipment-related problems, and what additional efforts might be needed to improve safety. MATERIAL AND METHOD: The data were drawn from the Thai Anesthesia Incidents Study (THAI Study) between February 1, 2003 and July 31, 2004 in which anesthesia-related data (i.e. of perioperative problems and their severity) were recorded (by the attending anesthesiologist) from all anesthetic cases on a routine basis. We selected cases under general and regional anesthesia with anesthetic equipment failure/malfunction for descriptive analysis. RESULTS: The frequency of anesthetic equipment problems of the 202,699 recorded cases was approximated 0.04% or 1 : 2252. Two-thirds of the problems (63%) involved the anesthesia machine and of these incidents 73 and 41 percent involved system and human errors, respectively. One patient died and one suffered permanent morbidity. CONCLUSION: The incidence and severity of equipment problems was low. Aside from improvements to pre-operative equipment checks, vigilance, continuous quality improvement and quality assurance activities were suggested as strategies to reduce problems.

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.

Video-assisted thoracoscopic surgery (VATS) in the diagnosis and treatment of intrathoracic diseases at Ratchaburi Hospital.

OBJECTIVE: To review the authors' experience and benefit in diagnosis and management of intrathoracic diseases by Video-assisted thoracoscopic surgical procedures (VATS) using a non trocar technique. MATERIAL AND METHOD: Retrospective review of sixty-eight consecutive patients who underwent seventy-one VATS procedures between January 1997 and December 2004. Indications included recurrent or persistent pneumothorax (n = 21 patients), empyema thoracis (17), lung nodules or masses (8), clot haemothorax (6), pleural effusion (4), pleural thickening or masses (3), mediastinal masses or cysts (3), pericardial effusion (2), removal of bullets from the pleural cavity (2), bronchiectasis with hemoptysis (1) and inspection of diaphragmatic injury (1) (Table. 1). An alternative method of manipulating thoracoscopic instruments without using a trocar was described. RESULTS: Of the 71 VATS procedures in 68 patients, 62 (87.3%) procedures were successfully performed in 59 patients. Three of them underwent VATS bilaterally. (1 Tuberculous empyema and 2 spontaneous pneumothorax). Four patients requried conversion to thoracotomy due to bleeding in 1 who had excision lung bleb, extensive adhesion in 2 with chronic empyema thoracis and unlocated lesion in 1 with solitary pulmonary nodule (SPN). There were 5 postoperative complications: prolonged air leak for more than 7 days was seen in 4 patients. This complication occurred in a patient with spontaneous pneumothorax (3 patients) and bilateral tuberculous empyema at the left side (1 patient). Wound infection and mild effusion occurred in 1 patient with unilateral tuberculous empyema (no additional drainage was required). VATS in diagnostic procedures were effective in 90% (9 of 10 patients) and the procedures were 4 wedge excision, 3 pleural biopsies, 1 wedge excision for interstitial lung disease 1 inspection of diaphragmatic injury and 1 required conversion. Sixty one therapeutic procedures were effective in 50 patients (85.9%) (50 of 58 patients). None of them had a recurrence of pneumothorax after VATS procedures or other complications. Only small doses of analgesics were needed. There was no intraoperative mortality. The mean operative time was 67 minutes and the average postoperative hospital stay was 5.4 days for successful VATS group. CONCLUSION: VATS using of a non-trocar technique is a safe and effective method for diagnosis and treatment of intrathoracic diseases. Patients had benefit in reduced postoperative pain, short hospitalization, short recovery times and good cosmetic result.