Comparison of the Effectiveness of Nasal Cannula Versus Face Mask With Reservoir Bag in Postoperative Patients Undergoing General Anesthesia: A Prospective Randomized Controlled Trial.

BACKGROUND: High-concentration oxygen delivery via a face mask (FM) with a reservoir bag is a common practice to prevent postoperative hypoxemia; however, it may also lead to atelectasis and other respiratory complications. Lower concentrations delivered via nasal cannula (NC) may be equally effective in preventing postoperative hypoxemia. The present study aimed to compare peripheral oxygen saturation (SpO_2) delivered via NC versus FM with a reservoir bag in patients who have undergone general anesthesia (GA). METHODS: Eighty-four patients scheduled for GA were randomized to receive either oxygen via NC (NC group, n = 42) or FM with a reservoir bag (FM group, n = 42) for 30 minutes after GA at a postanesthesia care unit (PACU). All patients were assessed based on SpO_2 value, adverse events, and patient satisfaction (measured using a 100-mm visual analog scale). RESULTS: The overall difference between groups in the change of SpO_2 over 30 minutes at the PACU was -0.004 (95% confidence interval, -0.015 to 0.008; P = 0.527). SpO_2 during the first five minutes was lower in NC group, but the difference was not statistically significant. No desaturation occurred in either group, and there was no observed difference between groups in terms of adverse events. Patient satisfaction scores were also similar (P = 0.612). CONCLUSIONS: Oxygen supplementation via NC and via FM with a reservoir bag were equally effective in preventing postoperative hypoxemia after GA.

A comparison of the success rate of radial artery cannulation between the ultrasound-guided and conventional palpation techniques in elderly patients undergoing cardiothoracic surgery.

Background: Ultrasound-guided (USG) radial artery cannulation against the standard palpation technique increases the first attempt rate in both pediatric and adult patients. The objective of this study was to evaluate the benefits of USG versus the palpation technique in improving the first attempt rate in elderly patients. Methods: The patients over 65 years of age were randomized to the USG or Palpation group. The radial artery identification in the USG group was performed with the aid of the Sonimage HS 1. In the Palpation group, the radial artery was identified by manual palpation. The operators were cardiothoracic anesthesiologists. Overall success was defined as cannulation completed within 10 min. Results: Eighty patients (40 in each group) were recruited. The respective first attempt and overall success rate for the USG group were similar to the Palpation group (P > 0.999 and P = 0.732). The time to the first attempt and overall success were also similar (P = 0.075 and P = 0.636). The number of attempts, number of catheters used, and failure rates were similar between the groups (P = 0.935, P = 0.938, and P = 0.723). The number of successful cannulations within 10 min was similar for both the groups as categorized by the radial artery diameter (P = 0.169). Conclusions: The USG did not increase the first attempt or overall success rate of radial artery cannulation in the elderly patients undergoing cardiothoracic surgery. The time to first attempt and overall success were similar between both the groups. The number of attempts and number of catheters used were similar between both groups.

A fatal adverse effect of cefazolin administration: severe brain edema in a patient with multiple meningiomas.

Cefazolin is commonly administered before surgery as a prophylactic antibiotic. Hypersensitivity to cefazolin is not uncommon, and the symptoms mostly include urticaria, skin reaction, diarrhea, vomiting, and transient neutropenia, which are rarely life threatening. We present a rare case of fatal cefazolin hypersensitivity in a female who was diagnosed with multiple meningiomas and scheduled for craniotomy and tumor removal. Immediately after cefazolin IV administration, the patient developed acute hypertensive crisis, which resolved within 10 minutes after the treatment. This was followed by unexplained metabolic acidosis. The patient then developed severe brain edema 100 minutes later. The patient had facial edema when her face was exposed for the next 30 minutes. A computed tomography scan revealed global brain edema with herniation. She was admitted to the intensive care unit for symptomatic treatment and died 10 days after surgery from multiorgan failure. The serum IgE level was very high (734 IU/mL). Single-dose administration of cefazolin for surgical prophylaxis may lead to rare, fatal adverse reaction. The warning signs are sudden, unexplained metabolic acidosis, hypertensive crisis, tachycardia, and facial angioedema predominating with or without cutaneous symptoms like urticaria.

A Multi-center Thai University-based Surgical Intensive Care Unit Study (THAI-SICU Study): Incidence of Acute Myocardial Infarction and Associated Factors.

Introduction: To describe the incidence, characteristics and outcomes of acute myocardial infarction (AMI) and determine risk factor(s) of AMI in THAI-surgical intensive care unit (SICU). Material and Method: This study was multicenter prospective cohorts study that conducted data from 9 university-affiliated SICUs in Thailand between April 2011 and January 2013. We collected and evaluated data of AMI events. The patients were followed-up for up to 28 days after admitted to the SICUs. Results: The overall incidence of AMI in SICU was 1.4% (66 of 4,652 patients). Non-ST elevated MI was the most common electrocardiography (ECG) presentation (75%). The common clinical sign and symptom of AMI included ECG changes (53%) and elevation of cardiac enzymes (48.5%). Patients with AMI had significantly higher 28-day mortality rate (28.8% versus 13.6%, p<0.001) than those with non-MI. The Acute Physiologic and Chronic Health Evaluation (APACHE) II scores (RR 1.04, 95% CI 1.01-1.07, p = 0.003) and age >65 year (RR 2.54, 95% CI 1.36-4.75, p = 0.003) were significant risk factors of AMI. Conclusion: The incidence of AMI in the SICU was uncommon but led to significantly higher mortality rates. The APACHE II score and age ≥65 year were significant predictors of AMI in SICU.

Incidence of Cardiac Arrest and Related Factors in a Multi-Center Thai University-Based Surgical Intensive Care Units Study (THAI-SICU Study)

Objective: To describe the incidences, outcomes and determine the risk factor(s) of cardiac arrest in surgical intensive care unit (SICU). Material and Method: We collected data between April 2011 and January 2013. The case record form (CRF) included the CRF 1 (admission, daily screening and discharge data) and the CRF 2 for cardiac arrest events. The patients were followed-up until discharge from SICU or for up to 28 days after admission in SICU. Results: The incidence of cardiac arrest in SICU was 226 in 4,652 patients (4.9%). The APACHE II score at the day with cardiac arrest were 24.1. Initial monitor rhythm during cardiac was asystole (35.4%), bradycardia (22.6%) and pulseless electrical activity (14.6%). The main cause was poor patient condition before admission (51.3%). Most of the cardiac arrest patients (73.9%) had antecedents within 24 hour and the most common antecedents were hypotension, metabolic disturbances and sepsis and/or septic shock. The overall return of spontaneous circulation rate was 23.5%. At hospital discharge, the mortality rate (91.6%) was statistically different between the cardiac arrest and non-cardiac arrest group (p<0.001). The Acute Physiologic and Chronic Health Evaluation II score (APACHE II score) (Odds ratio, (OR 1.15, 95% CI 1.11-1.19, p<0.001), Sequential Organ Failure Assessment score (SOFA score) (OR 1.12, 95% CI 1.03-1.20, p = 0.005) and American Society of Anesthesiologists physical status physical status (ASA PS) ≥3 (OR 2.32, 95% CI 1.33-4.04, p = 0.003) were significantly risk factors for cardiac arrest. Conclusion: Cardiac arrest in the SICU was uncommon. Initial non-shockable rhythms were common and mostly had antecedents before cardiac arrest. The APACHE II score, SOFA score and ASA PS ≥3 were independent risk factors for cardiac arrest in SICU.

A multi-center Thai university-based surgical intensive care units study (THAI-SICU study): methodology and ICU characteristics.

OBJECTIVE: Although there were two large intra-operative observational studies on Thai surgical patients (THAI and THAI-AIMS), there has been no available study on critically ill surgical patients regarding their adverse events and outcomes. A THAI-Surgical Intensive Care Unit (SICU) study has been established for monitoring the occurrence of these adverse events and outcomes in the SICU. The objective of this report is to describe the methodology of the THAI-SICU study and participating SICUs' characteristics as well as the early recruitment results on patients enrolled in the present study. MATERIAL AND METHOD: The present study is designed as a multi-center, prospective, observational study. This report describes the method of case record form development and summarizes their collected parameters as well as the adverse event surveillance variables. All of nine SICU characteristics are described regarding their management systems, physicians' and nurses' work patterns. The final group of enrolled patients is reported. RESULTS: A total of nine university-based SICUs were included in the present study. All participating hospitals are residency training centers. Four of the SICUs, fulltime directors are anesthesiologists. Only one hospital's SICU is directed by a surgeon. Two SICUs were closed ICUs, three were mandatory consulting units, one was an elective consultation unit and the remaining three ICUs had no directors. Most of the participating SICUs had heterogeneity of surgical specialty patients. Six SICUs had regular resident rotations and only two of the SICUs had critical care fellowship training. There were significant differences regarding the nursing workload among the ICUs. The patient to registered nurse ratio ranged from 0.9-2.0. After a total of 19.7 months of a recruitment period, the total number of patient admissions was 6,548 (1,894 patients were excluded). A total cohort of 4,654 patients was included for further analytical processes. CONCLUSION: There were differences in ICU management systems, physician and specialist coverage, nurse burdens, nurse sparing, and types of patients admitted in the university based SICUs. This presentation is the pioneer multi-center study on Thai SICUs in which adverse events and outcomes are reported.