Associations of serum kisspeptin levels with metabolic and reproductive parameters in men.

Central kisspeptin action is well known in reproductive regulation; however, its peripheral action is not well understood. This study aimed to 1) compare serum or cerebrospinal fluid (CSF) kisspeptin levels between different body mass index (BMI) groups 2) compare the levels of kisspeptin between serum and CSF, and 3) determine correlations between serum or CSF kisspeptin levels with clinical, metabolic, and reproductive parameters. There were 40 male subjects undergoing operations with lumbar puncture anesthesia. Subgroup analysis was performed to compare between the normal (n = 12), overweight (n = 10), and obese groups (n = 17). One lean subject was recruited for correlation analysis. Serum kisspeptin levels were significantly higher in the obese group when compared to the normal weight and overweight groups even after adjusting for age or diastolic blood pressure (DBP) (p < 0.05 all). Serum leptin levels were significantly higher in the obese group when compared to the normal weight and overweight groups (p < 0.05 all). CSF kisspeptin levels were below the minimum detectable concentration for the assay (<0.06 ng/mL). Serum kisspeptin was positively correlated with body weight, BMI, plasma insulin, the homeostatic model assessment for insulin resistance (HOMA-IR), and serum leptin but was negatively correlated with plasma LH (p < 0.05 all). In conclusion, serum kisspeptin was related to obesity, leptin, insulin, and insulin resistance, while CSF kisspeptin was below the limits of detection. Thus, peripheral kisspeptin might have a role in metabolic regulation.

Risk Factors of Post-operative Sore Throat and Hoarseness.

Objective: To identify the risk factors of post-operative sore throat (POST) with and without hoarseness (PH) after general anesthesia. Material and Method: A retrospective cohort case-controlled study was done at Siriraj Hospital, Mahidol University, Bangkok, Thailand. Two thousand six hundred anesthetic records from between July 2013 and January 2014 were retrieved. Inclusion criteria were complete records of patients older than 18 years and elective surgery under general anesthesia longer than 30 minutes using endotracheal intubation (ETT) or Laryngeal mask airway (LMA). All patients went through complete post-operative evaluation. Results: Two thousand five hundred three cases were analyzed. Incidences of POST and PH were 41 and 19.7% respectively, mostly graded as mild symptoms. When severity of POST was increased, the incidence of PH also increased significantly (p<0.001). Both POST and PH were strictly related to insertion of ETT. The use of LMA instead of ETI reduced the incidences of POST and PH effectively. In female patients, reduction of ETT from size 7.5 to 7 reduced incidences of POST significantly. Conclusion: The use of LMA reduced the incidences of both POST and PH. This conclusion is limited to selected cases and not applicable to all. Further studies should focus on possible factors to decrease the incidence of POST and PH after endotracheal intubation, which could increase patient satisfaction.

A Randomized Placebo-Controlled Trial of Oral Ramosetron for Prevention of Post Operative Nausea and Vomiting after Intrathecal Morphine in Patients Undergoing Gynecological Surgery.

BACKGROUND: The incidence of postoperative nausea and vomiting (PONV) after intrathecal morphine is high. Ramosetron is a 5-HT3 antagonist that has been shown to reduce PONV in general anesthesia. The objective of this study was to evaluate the efficacy of Ramosetron in preventing PONV MATERIAL AND METHOD: 165 patients undergoing elective gynecological surgery under spinal anesthesia were randomly allocated to two groups: the Ramosetron group (0.1 mg orally, n = 82), and the placebo group (oral corn starch, n = 83). The incidence of PONV severity of nausea and use of rescue antiemetic during the first 24 hour after surgery were evaluated. RESULTS: The incidence of PONV was significantly lower in the Ramosetron group compared with the placebo group (24.4% vs. 44.6%, number needed to treat (NNT) = 5.0). The severity of nausea was significantly lower in the Ramosetron group compared with the placebo group (20.7% vs. 39.8%, NNT = 6.0) in the 24 hour period. CONCLUSION: Oral Ramosetron 0.1 mg was more effective than placebo in PONV prevention and reduced the incidence of moderate to severe nausea after intrathecal morphine in the first 24 hour after gynecological surgery.

Incidence of Delayed Recovery from Femoral Nerve Block in Total Knee Arthroplasty.

OBJECTIVE: Femoral nerve block has been proven as an effective analgesia for total knee arthroplasty (TKA). Delayed recovery from nerve block can result in serious complication during postoperative period. This prospective, single-center, observational study investigated the incidence in delayed recovery from femoral nerve block more than 24 hours postoperatively. MATERIAL AND METHOD: Two hundred and forty patients with femoral nerve block as part of anesthesia plan for elective unilateral TKA were recruited into study. Participants were assessed for sensory or motor impairment lasting longer than 24 hours post operation. Factors associated with delayed recovery from femoral nerve block were analyzed. RESULTS: Five patients (incidence = 2.08%) reported sensory or motor impairment more than 24 hours post operation. All of the patients could ambulate within 4 days post operation without permanent nerve injury or serious complication. Higher dose of local anesthetic agent using for femoral nerve block showed association with the delayed recovery (p-value = 0.01). CONCLUSION: This study demonstrated 2.08% incidence in delayed recovery from femoral nerve block. High concentration and dose of local anesthetic agent may lead to fall during early ambulatory period.

Appropriate Size of Laryngeal Mask Airway in Thai Children: Is It Age or Weight that Better Correlated.

Background: Clinicians are divided regarding laryngeal mask airway (LMA) size selection for pediatric patients, primarily whether age or body weight is an appropriate predictor. Objective: Determine if body weight and/or age are reliable predictors in LMA size selection in Thai children. Material and Method: Retrospective review of patient medical records was conducted between October 1, 2012 and December 31, 2013. Seven hundred forty one patients, aged 0 to 8 years, were evaluated for the present study. Age and weight correlation for LMA size selection was determined. Appropriate LMA size was identified by successful LMA insertion after induction of anesthesia. Results: Our findings indicate that size 1 LMA for patients weighing less than 7 kilograms, size 1.5 LMA for patients weighing 7 to 11 kilograms, size 2 LMA for patients weighing 11 to 17 kilograms, and size 2.5 LMA for patients weighing 15 to 28 kilograms is appropriate. There was poor correlation between children's age and LMA size. Conclusion: LMA size selection should be based on patient's weight. Our findings revealed applicable and specific weight range for LMA selection in Thai pediatric patients

Direct Field Block with 40 ML of 0.125% Bupivacaine in Conjunction with Intrathecal Morphine for Analgesia after Cesarean Section: A Randomized Controlled Trial.

OBJECTIVE: To investigate the effect of direct field block with 40 ml of 0.125% bupivacaine on the top of intrathecal morphine on postoperative pain free period. MATERIAL AND METHOD: The present prospective randomized controlled trial was undertaken in 56 pregnant patients that underwent elective cesarean delivery at Siriraj Hospital. All patients were randomized into two groups to receive spinal block with intrathecal morphine as a control group, or direct field block on the top of spinal block with intrathecal morphine as a study group. The assessment ofpain score, 24-hour morphine usage, satisfaction score, pruritus, nausea and vomiting, sedation score, and motor power were recorded. RESULTS: Both groups had similar pain score. The number of subjects who had pain free period during the 24 hours in the direct field block group was seven of 28, while in the control group it was four of 28. Median time of pain free period was 2.10 hours in control group and 2.36 hours in direct field block group. There was no significant difference in 24-hour morphine consumption, satisfaction score, pruritus, nausea, vomiting, and sedation score. Motor power was fully recovered within six hours postoperative in both groups. CONCLUSION: Direct field block with 40 ml of 0.125% bupivacaine in conjunction with intrathecal morphine for cesarean section did not increase pain free period or decrease morphine consumption.

Two Doses of Tranexamic Acid Reduce Blood Transfusion in Complex Spine Surgery: A Prospective Randomized Study.

STUDY DESIGN: Prospective, double-blinded, randomized controlled study. OBJECTIVE: To determine whether the use of 2 doses of tranexamic acid (TXA) can reduce perioperative blood loss and blood transfusions in low-risk adult patients undergoing complex laminectomy. SUMMARY OF BACKGROUND DATA: Complex laminectomy (multilevel laminectomy or laminectomy and instrumentation) is a procedure with a medium risk of blood loss, which may require allogeneic blood transfusion. Previous studies of TXA showed its inconsistent effectiveness in reducing blood loss during spine surgery. The negative results may stem from ineffective use of a single dose of TXA during long and complex operations. METHODS: 80 adult (18-65 yr old) patients in Siriraj Hospital, Mahidol University, Thailand were enrolled and allocated into 2 groups (40 patients in each group) by computer-generated randomization. Patients with history of thromboembolic diseases were excluded. Anesthesiologists in charge and patients were blinded. Group I received 0.9% NaCl (NSS) or placebo and group II received 2 doses (15 mg/kg) of TXA. The first dose was administered before anesthesia induction and the second dose, after 3 hours. The assessed outcomes were the amount of perioperative blood loss and the incidence of blood transfusions. RESULTS: 78 patients were analyzed (1 patient in each group was excluded) with 39 patients randomized to each group. There were no differences in patient demographics and pre and postoperative hematocrit levels. The total blood loss in the control group (NSS) was higher [900 (160, 4150) mL] than in the TXA group [600 (200, 4750) mL]. Patients in the control group received more crystalloid, colloid, and packed red blood cell transfusions. Within 24 hours, we observed a 64.6% reduction of blood transfusions (43.5% vs.15.4%, P = 0.006). No serious thromboembolic complications occurred. CONCLUSION: 2 effective doses (15 mg/kg) of TXA can reduce blood loss and transfusions in low-risk adults undergoing complex spine surgery. LEVEL OF EVIDENCE: 1.

Plasma concentrations of bupivacaine after spinal anesthesia with single shot femoral nerve block and periarticular injection in total knee arthroplasty.

OBJECTIVE: To determine the plasma concentrations of bupivacaine and toxicity after periarticular injection (PAI) combined with spinal anesthesia and femoral nerve block (FNB). MATERIAL AND METHOD: Forty-three patients scheduled for unilateral total knee arthroplasty (TKA) were enrolled in the prospective observational study. The dose of bupivacaine for spinal anesthesia was adjusted by the attending anesthesiologist. The single-shot femoral nerve block (FNB) and periarticular injection (PAI) were performed with 20 ml of 0.5% bupivacaine and 20 ml of 0.25% bupivacaine respectively. Venous blood samples from antecubital vein were collected at 60 minutes after femoral nerve block and at the time before periarticular injection, then at 15, 30, 45, and 60 minutes afterwards. Plasma bupivacaine concentrations were analyzed, using a high performance liquid chromatography with tandem mass spectrometry. RESULTS: Ten males and 32 females, ASA I-II were included. The highest median plasma concentration was 586.22 ng/ml (min = 245.39, max = 1,614.36) at 45 minutes after periarticular injection. The maximum plasma bupivacaine concentration was 1,709.71 ng/ml at 60 minutes after periarticular injection. No clinical toxicity was encountered CONCLUSION: The plasma concentration of bupivacaine in patients performed periarticular injection with 20 ml of 0.25% bupivacaine after spinal anesthesia and single-shot femoral nerve block with 20 ml of 0.5% bupivacaine is below the plasma toxic level.

Postoperative sore throat: incidence, risk factors, and outcome.

BACKGROUND: Postoperative sore throat (POST) has been one of the most common complaints after anesthesia. In Siriraj Hospital, a high volume of general anesthesia is performed annually, but there was limited data regarding this complaint. OBJECTIVE: To describe the incidence of POST and to determine risk factors associated with the occurrence of POST MATERIAL AND METHOD: Three hundred eighty seven patients were prospectively studied. Demographic data, airway management, and intra-operative data were recorded. Sore throat occurrence and its intensity at postoperative 24 hours as well as patient satisfaction were assessed. RESULTS: The overall incidence of POST was 35.7% (95% confidence interval [CI] 30.9-40. 7%) with the mean intensity of 29.8 +/- 21.2. Operation of the neck was found to be an independent risk factor of 24-hour POST (odds ration [OR] 3.43, 95% confidence interval [CI] 1.88-6.25, p < 0.001), whereas in gynecological surgery the occurrence was significantly attenuated (OR 0.49, 95% CI 0.26-0.95, p = 0.035). CONCLUSION: POST was common after general anesthesia. Careful airway management might be the key to prevent this occurrence and to improve the quality of anesthetic care.

Nausea, vomiting and pruritus induced by intrathecal morphine.

BACKGROUND: Presently, in Siriraj Hospital, intrathecal morphine is routinely used in spinal anesthesia for postoperative pain control in more than 600 cases per month with doses lower than 0.3 mg. However, the incidence of side effects is high. This retrospective data review was performed to identify incidence and risk factors of postoperative nausea, vomiting, and pruritus. MATERIAL AND METHOD: One thousand three hundred six anesthetic records were analyzed for incidence of nausea, vomiting, and pruritus after spinal anesthesia with intrathecal morphine in Siriraj Hospital between October 2010 and April 2011. Data extracted were age, gender, type of operations, dosage of spinal morphine, and frequency, and severity of adverse effects (nausea, vomiting, and pruritus). Odd ratios and multiple logistic regression analysis were used. RESULTS: Incidence of nausea, vomiting, and pruritus were 21.5, 14.8, and 59.5% respectively. No respiratory depression and urinary retention was reported There was statistically significant correlation in the incidence of nausea, vomiting, and pruritus with female gender, cesarean section, and intrathecal morphine dose (p < 0.001). Intrathecal morphine more than 0.2 mg resulted in an increase in severity of side effects. CONCLUSION: The intrathecal morphine is effective in postoperative pain control. However it induces high incidence of nausea, vomiting, and pruritus. Prevention of side effects and alternatives to intrathecal morphine need further research.

Plasma concentrations of bupivacaine after spinal anesthesia with single shot femoral nerve block in total knee arthroplasty.

BACKGROUND: Femoral nerve block is commonly established for postoperative analgesia in total knee arthroplasty but no evidence of plasma bupivacaine level has been reported. OBJECTIVE: Determine the plasma concentrations of bupivacaine in patients who had single-injection of femoral nerve block. MATERIAL AND METHOD: A prospective observational study was undertaken with 25 patients scheduled for unilateral total knee arthroplasty under spinal anesthesia and single shot femoral nerve block with 20 mL of 0.5% bupivacaine. Venous blood samples were collected at 0, 5, 10, 15, 30, 60, 90, and 120 minutes after femoral nerve block. Plasma bupivacaine levels were analyzed by high performance liquid chromatography with tandem mass spectrometry. RESULTS: Four males and 21 females, ASA I-II were enrolled in the present study. Mean age, body mass index, and serum albumin level were 69.9 +/- 5.95 years, 27 +/- 3.67 kg/m2, and 4.46 +/- 0.26 mg/dL, respectively. The median of peak plasma concentration was 538.35 ng/mL (min = 176.30, max = 1,383.99) at 60 minutes after femoral nerve block, while the maximal plasma concentration of bupivacaine was 1,883.39 ng/mL at 10 minutes. None showed signs or symptoms of bupivacaine toxicity. CONCLUSION: Peak plasma concentrations of bupivacaine were demonstrated at 60 minutes after a single shot femoral nerve block, and no signs or symptoms of bupivacaine toxicity were observed Therefore, single shot femoral nerve block with 20 mL of 0.5% bupivacaine is safe.

Periarticular injection with bupivacaine for postoperative pain control in total knee replacement: a prospective randomized double-blind controlled trial.

Background. Local periarticular injection with bupivacaine alone in TKA has not been studied. Thus, we aimed to examine the effectiveness of local periarticular injection with bupivacaine for post-operative pain control in TKA. Method. Sixty patients undergoing TKA by a single surgeon were randomly assigned into two groups in a double-blind, placebo-controlled study. In the injection group, patients received periarticular injections with 0.25% bupivacaine before wound closure; in the control group, patients received a 0.9% normal saline injection. Both groups received the same anesthetic procedure, post-operative pain control, and rehabilitation protocol. Results. There was a significant reduction in post-operative morphine consumption in the first six hours after the operation (mean 0.9 mg and 2.43 mg, P = 0.01), but there was no significant difference in post-operative morphine consumption between six hours and ninety-six hours after the operation, visual analogue scale (VAS) score, morphine side effects during the first 96 hours, length of hospital stay, or complications from morphine consumption. Conclusion. Local periarticular injection with bupivacaine alone before wound closer was shown to be an effective method to improve pain control after TKA with a few complications and ease of use.

Periarticular infiltration of 0.25% bupivacaine on top of femoral nerve block and intrathecal morphine improves quality of pain control after total knee arthroplasty: a randomized double-blind placebo controlled clinical trial.

OBJECTIVE: Find out if the addition of periarticular local anesthetic infiltration enhances the quality of postoperative pain control in patients with knee arthroplasty (TKA) in spinal anesthesia and intrathecal morphine plus single shot femoral nerve block (FNB). MATERIAL AND METHOD. Ninety-nine patients scheduled for TKA under spinal anesthesia were enrolled after written informed consent, and randomized into two groups with either periarticular injection of 20 ml 0.25% bupivacaine (B-gr n = 50) or isotonic saline solution (S-gr n = 49). All patients had intrathecal morphine 0.2 mg and single shot FNB with 20 ml bupivacaine 0.25% and were adjusted postoperative analgesic requirement via patient controlled analgesia with morphine. Effect of postoperative pain control and requirement of additional analgesics were recorded. RESULTS: Randomization created comparable groups. Periarticular infiltration of bupivacaine in addition to femoral nerve block and intrathecal morphine was efficient and superior to saline regarding pain control, morphine consumption, and patient's satisfaction. More patients in B-gr did not require any supplement morphine in the first 24 hours (26% compared to 12.2%, p < or = 0.01). In patients who required morphine, B-gr had longer pain free period (25 hours compared to 14.8 hours, p < 0.001) and needed lower dose of morphine (5.16 mg compared to 8. 67mg, p = 0.005). No significant side effects were recorded. CONCLUSION: Adding periarticular infiltration to femoral block and intrathecal morphine significantly enhances the quality of postoperative pain therapy in TKA patients. However combining three methods for analgesic therapy may be too much effort. Modifying infiltration techniques including continuous application needs further research.

Cardiac arrest after spinal anesthesia in Thailand: a prospective multicenter registry of 40,271 anesthetics.

BACKGROUND AND OBJECTIVES: As part of the Thai Anesthesia Incidents Study of anesthetic adverse outcomes, we evaluated the incidence and factors related to cardiac arrest during spinal anesthesia. METHODS: During a 12-mo period (March 1, 2003, to February 28, 2004), a prospective, multicenter registry of patients receiving anesthesia was initiated in 20 hospitals (7 university, 5 tertiary, 4 general, and 4 district hospitals) across Thailand. Anesthesia personnel reported patient-, surgery-, and anesthetic-related variables and adverse outcomes, including cardiac arrest during spinal anesthesia (defined as the time period from induction of spinal anesthesia until the end of operation). Adverse event specific forms were recorded within 24 h of an anesthetic procedure whenever a specific adverse event occurred. Univariate and multivariate analysis were used to identify factors related to cardiac arrest during spinal anesthesia. A P value <0.05 was considered significant. RESULTS: In the registry of 40,271 cases of spinal anesthesia, there were 11 cardiac arrests, corresponding to an incidence of 2.73 (95% CI: 1.12-4.34) per 10,000 anesthetics. The mortality rate was 90.9% among patients who arrested. Among 11 patients who arrested, there were 5 cases of cesarean delivery and 6 cases of extremity surgery, including hip surgery. In 4 patients (36.3%), the anesthetic contributed directly to the arrest (high sympathetectomy, local anesthetic overdose, or lack of electrocardiography monitoring), whereas some arrests were associated with specific events (cementing of prosthesis, massive bleeding, suspected pulmonary embolism, and suspected myocardial infarction). From multivariate analysis, the risks of cardiac arrest during anesthesia were shorter stature (odds ratio 0.944 [95% CI: 0.938-0.951], P < 0.001), longer duration of surgery (odds ratio 1.003 [95% CI: 1.001-1.005], P = 0.002), and spinal anesthesia administered by the surgeon (odd ratio 23.508 [95% CI: 6.112-90.415], P < 0.001), respectively. CONCLUSION: The incidence of cardiac arrest during spinal anesthesia was infrequent, but was associated with a high mortality rate. If the surgeon performed the spinal anesthetic, this was a significant factor associated with cardiac arrest. Increasing the number of anesthesiologists, improving monitoring guidelines for spinal anesthesia and improving the nurse-anesthetist training program may decrease the frequency of arrest and/or improve patient outcome.

Prospective study of hypotension after spinal anesthesia for cesarean section at Siriraj Hospital: incidence and risk factors, Part 2.

BACKGROUND: The incidence of hypotension after spinal anesthesia is highest in cesarean section. The authors' first retrospective study identified three risk factors that included two non-modifiable (patient's height and low baseline systolic blood pressure) and one modifiable risk factor (sensory analgesia equal to or higher than TS) associated with hypotension. OBJECTIVE: To create a prospective record of the event in the patients who received successful spinal anesthesia for cesarean section. MATERIAL AND METHOD: A prospective data collection, together with questionnaires that were completed by the responsible anesthetic team at the end of the operation for each consecutive patient. All parameters were coded and recorded in SPSS11.5. To assess the association between two categorical variables in a univariable analysis, chi-square test was used along with odds ratio (OR) and its 95% confidence interval (CI). Mutivariable analysis via multiple logistic regressions was employed to determine the effect of each independent variable. RESULTS: Eight hundred and seven full-term pregnant women received successful spinal anesthesia for cesarean section at Siriraj Hospital from July 1 to December 31, 2004. Hypotension was defined as lowest systolic < 100 mmHg and the pressure was lower to equal to or more than 20% of baseline. Incidence of hypotension was 65.1%. Age > 35 yr BMI > 35 were two non-modifiable risk factors that increased the incidence of hypotension in the crude odds ratio (OR) 1.62 and 2.83 respectively with narrow 95% confidence interval. The level of sensory analgesia equal to or higher than T5 was the only one modifiable risk factor that increased the incidence of hypotension with crude OR 1.55 and narrow 95% CI. CONCLUSION: Limitation of the dose of local anesthetic agent or addition of some opioids could reduce the incidence and severity of hypotension after spinal anesthesia for cesarean section.

The Thai Anesthesia Incident Monitoring Study (Thai AIMS) of post anesthetic reintubation: an analysis of 184 incident reports.

OBJECTIVE: The present study was a part of the Multi-centered Study of Model of Anesthesia related Adverse Events in Thailand by Incident Report (The Thai Anesthesia Incident Monitoring Study or Thai AIMS). The objective of the present study was to determine the outcomes, contributory factors and factor minimizing incident. MATERIAL AND METHOD: The present study was a descriptive research design. The authors extracted relevant data from the incident reports on reintubation after planned extubation after general anesthesia with endotracheal intubation from the Thai AIMS database during the study period January to June 2007. The cases were extensively reviewed by 3 reviewers for conclusion of anesthesia directly and indirectly related reintubation. Comparative analysis between two groups was done. RESULTS: A total 184 incidents of extubation failure according to the definition were extracted in which 129 cases (70.1%) were classified as directly related to anesthesia and 55 cases (29.9%) were indirectly related to anesthesia. Oxygen desaturation occurred in 85.9% of cases while 90.2% of patients was reintubated within 2 hours after extubation. Hypoventilation (58.1%) was the commonest cause which led to reintubation directly related to anesthesia while upper airway obstruction (39.6%) was the commonest cause in the indirectly related anesthesia group. The proportion of preventable incident was 99.2% and 54.5% in directly and indirectly related anesthesia groups, respectively. Human factors particularly including lack of experience and inappropriate decision-making were considered in 99.2%, are directly related to anesthesia reintubation group. CONCLUSION: Extubation failure and reintubation was mostly related to anesthesia. Most of directly related to anesthesia group were considered as preventable. Human factors were also claimed as contributing factors. Quality assurance activity and improvement of supervision to improve experience and competency of decision making were suggested corrective strategies.

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.

Prospective study of hypotension and bradycardia during spinal anesthesia with bupivacaine: incidence and risk factors, part two.

OBJECTIVE: Hypotension and bradycardia during spinal anesthesia are common and may relate to severe adverse events such as cardiac arrest or death. The authors'first retrospective study identified three non-modfiiable factors including females, age more than 40 years, and type of operation. Level of blockage higher than T5 was the only one modifiable factor that could be confirmed That study was strongly limited by the nature of the retrospective anesthetic record reviewed study. MATERIAL AND METHOD: The authors prospectively studied the records of 2, 000 patients who received spinal anesthesia at Sriraj Hospital from 1 July 2004 to 31 December 2004. The collected parameters were patient demographic data (sex, age, body weight, height, ASA status), operative data (type of operation, emergency status, position and duration of operation), anesthetic data (type and dosage of local anesthetic agents used, intravenous fluid, vasoactive and sedative agents, highest sensory level of spinal blockage, usage and doses of spinal opioids). Recording forms of hypotension and bradycardia were completed by the responsible anesthetic team in each consecutive patient. RESULTS: Incidence of hypotension (20% or more decrease in systolic blood pressure) in the present study was 57.9%. The highest incidence was in cesarean section. Four non-modifiable risk factors could be identified which included females, age more than 50, body mass index more than 35 (OR = 2.1, 95% CI 1.01-4.29) and type of operation. Two modifiable risk factors included high dose of heavy bupivacaine (OR 1. 88, 95%CI 1. 3-2.74) and level of sensory blockage equal to or higher than T5 (OR 2.27, 95%CI 1.73-2.97). CONCLUSION: Usage of high dose of heavy bupivacaine and level of blockage higher than T5 were two modifiable risk factors associated with hypotension during spinal anesthesia. Avoidance of high block and lower dose of heavy bupivacaine can reduced the incidence and severity of hypotension after spinal anesthesia.

Incidence and risk factors of hypotension during spinal anesthesia for cesarean section at Siriraj Hospital.

OBJECTIVE: Spinal anesthesia is commonly used for cesarean section. Its major adverse effect is hypotension. The objective of this study is to determine the incidence and risk factors of hypotension during spinal anesthesia for cesarean section. MATERIAL AND METHOD: The authors retrospectively reviewed anesthetic records of 991 patients who received spinal anesthesia for cesarean section at Siriraj Hospital. Exclusion criteria were patients with pregnancy included hypertension, received combination of spinal block with other type of anesthesia. RESULTS: The incidence of hypotension (the lowest systolic blood pressure < or = 100 mm Hg) was 76.%. The parameter with increased incidence of hypotension included patient's height < 155 cm (adjusted odd ratio (OR) 1.93, 95%CI 1.19-3.14), baseline systolic blood pressure < or = 120 mmHg (OR 2.14, 95%CI 1.53-2.99) and analgesic level > or = T5 (OR 1.83, 95%CI 1.18-2.84). CONCLUSION: The risk factors associated with increased incidence of hypotension are the patient 's height, baseline systolic blood pressure and level of blockade.

Unplanned intubation during anesthesia: review of 31 cases from the Thai Anesthesia Incidents Study (THAI study).

OBJECTIVES: To examine the causes, outcomes, and contributing factors associated with patients requiring unplanned emergency intubation for adverse respiratory events. METERIAL AND METHOD: Appropriate unplanned intubation incidents 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: Thirty-one incidents of unplanned intubation were recorded, 21 of which were due to respiratory problems particularly after bronchoscopy with and without surgery of the upper airway. Six of the 21 cases (28.6%) were children under 10 years of age who suffered from papilloma of the larynx. Sixteen cases of the 31 cases (52%) of the unplanned intubations were due to inadequate ventilation; 13 cases (41%) due to laryngeal edema; 11 cases (36%) due to sedative agents. The other events were the result of unstable hemodynamics, severe metabolic acidosis, muscle relaxants, and intrapulmonary lesions. Eighteen cases of unplanned intubations (18/31) (58%) occurred in the Post-Anesthesia Care Unit, 5 cases (16%) in a ward, and 4 (13%) in the operating room. The reported contributing factors included inadequate experience, lack of supervision and the patient's condition. CONCLUSION: Major incidents of unplanned intubation occurred after bronchoscopy. Common contributing factors related to inadequate ventilation, airway obstruction, sedative agents and unstable hemodynamics. Quality assurance, additional training, and improved supervision tended to minimize the incidents.