A Randomized Comparison of Effects of Budesonide Spray and K-Y Gel as an Endotracheal Tube Cuff Lubricant on Incidence of Postoperative Sore Throat.

PURPOSE: Postoperative sore throat (POST) is a frequent postoperative complication. Preinduction budesonide inhalation is effective in POST prevention. However, it requires inhaler equipment and patient cooperation. Budesonide spraying on the endotracheal (ETT) cuff is simple and can be performed on most patients requiring endotracheal intubation. This study aims to compare the effects of budesonide spray and K-Y gel as an ETT cuff lubricant on the incidence and severity of POST. DESIGN: Randomized and triple-blinded study. METHODS: One hundred patients undergoing elective noncardiac surgery were randomly allocated into the budesonide group (n = 50) and the K-Y gel group (n = 50). In the budesonide group, 200 mcg of budesonide was sprayed on the cuff of the ETT. For the K-Y gel group, the ETT cuff was lubricated with K-Y gel. A visual analog scale was used to assess the severity of POST at 2, 6, and 24 hours after surgery. Other complications of tracheal intubation and adverse effects of budesonide were also recorded. FINDINGS: Compared to the K-Y gel group, the budesonide group had a significantly lower overall incidence of POST (30% versus 54%, P = .032) and reduced the risk of POST by 24% (relative risk reduction = 24%, 95% CI, 5.23-42.77, P = .012) as well as the incidence of hoarseness (8.6% vs 34%, P = .001) and cough (0% vs 8%, P = 0.041). No incidence of drug-related side effects was reported in both groups. CONCLUSIONS: Spraying budesonide on the ETT cuff significantly reduces the incidence and severity of POST.

Anesthesia-related complications of caesarean delivery in Thailand: 16,697 cases from the Thai Anaesthesia Incidents Study.

BACKGROUND: Maternal complications related to anesthesia are low in comparison with the results from obstetric factors in developing countries. The purposes of the present study were to determine the incidence of maternal mortality related to anesthesia, to analyze the causes and to suggest measures to improve anesthetic safety for the parturients. MATERIAL AND METHOD: The present study was part of a multi-center study conducted by the Royal College of Anesthesiologists of Thailand aimed at surveillance of anesthesia-related complications in Thailand. The authors conducted a prospective survey of hospital records from all of the cases in and outside the operating room receiving general anesthesia in 18 centers between March 1, 2003 and February 28, 2004. All the forms were checked and verified by three-peer review then included in the analysis, using descriptive statistics. RESULTS: Sixteen thousand six hundred ninety seven cases were included. The incidence of anesthetic complication in parturients was 35.9: 10,000 (95% CI 27.4, 46.1). Incidence ofthe four most common anesthetic related adverse events in caesarean section were desaturation 13.8 (95% CI 8.7, 20.7), cardiac arrest 10.2 (95% CI 5.9, 16.3), awareness 6.6 (95% CI 3.3, 11.8), and death related anesthesia 4.8 (95% CI 2.17, 9.4). Of these, seven (17.5%) had preeclampsia/eclampsia and 46 (76.7%) presented for emergency caesarean delivery. General anesthesia was used in 41 patients (68.4%) and spinal in eighteen (30%). There were eight maternal deaths including five with general anesthesia, giving a case fatality rate of 0.1% of general anesthetics or 0.3% of caesarean deliveries. CONCLUSION: The authors found that inexperience, inadequate knowledge, inadequate care, and patient conditions were the major contributory factors. Most of them were preventable and correctable. Additional training and quality assurance can improve and prevent these serious adverse events.

The Thai Anesthesia Incident Monitoring Study (Thai AIMS): an analysis of perioperative complication in geriatric patients.

BACKGROUND: 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 identify and analyze anesthesia incident in geriatric patients 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: This study was a prospective descriptive multicentered study conducted between January 1, 2007 and June 30, 2007. Incident reports from 51 hospital across Thailand were sent to data management unit on anonymous and voluntary basis. The authors extracted relevant data from the incident reports on geriatric patients (age 65 or more). The cases were reviewed by 3 anesthesiologists. Any disagreement was discussed and judged to achieve a consensus. Descriptive statistics was used. RESULTS: Among 407 incident reports and 559 incidents, there were more male (52.8%) than female (46.7%) patients with ASA PS 2, 3, 4 and 5 = 38.6%, 42.8%, 14.5% and 4.2% respectively. Surgical specialties that posed high risk of incidents were general, orthopedic, neurological, urologic and otorhiolaryngological surgery. Common places where incidents occurred were operating room (57.1%), ward (30.9%) and recovery room (12.0%). Common occurred incidents were arrhythmia needing treatment (30.0%), death within 24 hr (24.6%), desaturation (21.9%), cardiac arrest (16.2%) and reintubation (16.0%). The causes of the incidents were mostly attributed from patients underlying diseases and conditions. Most common outcomes were major physiologic changes with 26.5% fatal outcome at 7 days. The most common contributing factor was human factor (inappropriate decision and inexperience). Vigilance and having more experience could be the minimizing factors. CONCLUSION: Incidents in geriatric patients were similar to all age group patients with a higher incidents in death within 24 hr. The outcome were more serious resulting in 26.5% fatal outcome at 7 days. Quality assurance activity, clinical practice guidelines and improved supervision were suggested corrective strategies.

The Thai Anesthesia Incident Monitoring Study (Thai AIMS) of oxygen desaturation in the post-anesthetic care unit.

OBJECTIVE: As part of the Thai Anesthesia Incident Monitoring Study (Thai AIMS), the present study was aimed to analyze the problems of oxygen desaturation in the post-anesthetic care unit in Thailand including clinical course, outcomes, contributing factors, and preventive strategies. MATERIAL AND METHOD: The authors prospectively collected incident reports of oxygen desaturation in the post-anesthetic care unit between January and June 2007 from 51 studied hospitals across Thailand Clinical characteristics, outcomes, and contributing factors were recorded. All data were analyzed to identify contributing factors and preventive strategies. RESULTS: Eighty-six of post-anesthetic oxygen desaturation incidents were reported Forty-six cases (53.5%) were diagnosed by pulse oximetry. Forty-eight cases (55.8%) were immediately detected within a minute upon arrival at the PACU. Thirty-one cases (36%) were caused by inadequate awakening. Eighty-two cases (95.3%) were anesthesia-related and preventable. The major clinical outcomes were re-intubation (51 cases; 59.3%), prolonged artificial ventilation (23 cases; 26.7%), unplanned ICU admission (16 cases; 18.6%), and prolonged hospital stay (3 cases; 3.5%). Sixty-three patients (73.3%) recovered completely within 24 hours but one died. Judgment error and lack of adequate patient evaluation were the two most common contributing factors that were minimized by high awareness and prior experience. Main strategies suggested to prevent the incidents included the development of specific guideline and quality assurance. These incidents did not effectively decrease when labor was increased. CONCLUSION: Post-anesthetic oxygen desaturation was frequently found during the transport period. It can cause morbidity and mortality. Anesthesia providers should be aware of these potential incidents and strictly follow guidelines.

The Thai Anesthesia Incident Monitoring Study (Thai AIMS) of desaturation: an analysis of 1,996 incident reports.

BACKGROUND AND RATIONALE: The present study is a part of the Multicentered 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 frequency distribution, outcomes, contributory factors, and factors minimizing incident. MATERIAL AND METHOD: The present study is a prospective descriptive research design. The authors extracted relevant data from the incident reports on oxygen desaturation from the Thai AIMS database and analyzed during the study period between January and June 2007. RESULTS: From the relevant 445 incidents, most of the incidents (89%) occurred in patients receiving general anesthesia. The incidence in patients receiving regional anesthesia was 4.0%. The events mostly occurred in patients aged between 16-65 years (52.8%). Most of the events (76%) took place in the operating theater during the induction period (30.1%). More than 81% of the patients experienced severe oxygen desaturation (SpO2 < 85%). There were 55 patients (12.4%) who had unplanned ICU admission and 2 patients (0.4%) who had unplanned hospital admission. Factors that may relate to the incident involve combined factors (50.8%). Anesthetic factors were found to involve 38.4% of incidents. The common contributing factors that might lead to the incidents were inexperienced (57.5%), inappropriate decision (56.2%), and haste (23.8%). For factors minimizing incident, the important factors were vigilance (86.3%), experienced in that tropic (71.2%), and experienced assistance (54.8%). Quality assurance activity was the most common suggestive corrective strategy (79.1%). The others were improvement of supervision (47.2%) and guideline practice (46.5%). CONCLUSION: To lower the incidence of oxygen desaturation, the anesthesia personnel has to improve the anesthesia services by quality assurance activity, improvement of supervision, clinical practice guidelines, and additional training.

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.

The Thai anesthesia incidents study (THAI Study) of perioperative death in geriatric patients.

BACKGROUND: The study was part of the Thai Anesthesia Incidents Study (THAI Study), a multi-centered study conducted by the Royal College of Anesthesiologists of Thailand, aiming to survey anesthetic related complications in Thailand. OBJECTIVE: Identify the incidence and factors related to perioperative death in geriatric patients. MATERIAL AND METHOD: During a 12 months period (March 1, 2003 - February 28, 2004), a prospective multicenter descriptive study conducted in 20 hospitals comprising of seven university, five tertiary, four general and four district hospitals across Thailand. Anesthesia personnel filled up patient-related data, surgical-related, and anesthesia related variables and adverse outcomes of geriatric patients (age > or =65 yr) on a structured data entry form. The data were collected during pre-anesthetic, intra-operative, and 24 hr post operative periods. RESULTS: The overall mortality was 39.3 per 10,000 anesthetics from the registry of 23,899 geriatric patients receiving anesthesia. Multiple regression analysis showed that higher American Society of Anesthesiologists (ASA) physical status grading (p < 0.001), emergency operation (p = 0.031) and current medications (p = 0.043) were factors related to 24 hr perioperative death in geriatric patients. Patient's underlying diseases and duration of operations were not significantly related to death. CONCLUSION: The present study showed an incidence of 24-hr perioperative death of 1:254 in geriatric patients receiving anesthesia, which is comparable to other countries. Mortality in elderly patients operated under anesthesia can be predicted by ASA physical status, current medications, and emergency condition.

An analysis of intraoperative recall of awareness in Thai Anesthesia Incidents Study (THAI Study).

OBJECTIVES: This study aimed to analyze intraoperative awareness using database of Thai Anesthesia Incidents Study (THAI Study) with regard to frequency, contributing factors, preventive and corrective strategies. MATERIAL AND METHOD: Details of intraoperative recall of awareness were recorded prospectively by attending anesthesiologists or nurse anesthetists in standardized record forms during February 1, 2003 to July 31, 2004. Participating hospitals included 7 university hospitals, 5 tertiary care hospitals, 4 secondary care hospitals, and 4 primary care hospitals. All data were analyzed to identify contributing factors, preventive and corrective strategies. RESULTS: Among 126078 general anesthetized cases, there were 99 cases of intraoperative recall of awareness. Awareness was found in female patients more than male patients (63% versus 37%). The majority of patients had ASA PS 1 and 2. Cardiac, obstetric, and lower abdominal surgery were involved in anesthesia awareness more than other type of surgery. Patients experiencing awareness reported sound (62%), pain (51%), feeling operated without pain (33%), and paralysis (25%). There was slight impact of anesthesia awareness in Thai patients (only 13% had temporary emotional stress and 13% had mild anxiety) despite small percentage of proper management by reassurance and psychiatric consultation (15%). The contributing factors included inadequate knowledge (67%), inadequate medication dosage (44%), and inadequate care from inexperience (11%). Awareness incidents were documented to be preventable in 36% of patients and partially preventable in 38% of patients. The corrective strategies included guideline practice (30%), additional training (28%), quality assurance activity (19%), and improved supervision (16%). CONCLUSION: The incidence of intraoperative recall of awareness in this study was 0.08%. Patients reported sound, pain, feeling operated without pain, and paralysis. Corrective strategies included guideline practice, additional training, quality assurance activity, and improved supervision.

An analysis of the drug error problem in the Thai Anesthesia Incidents Study (THAI Study).

OBJECTIVES: To analyze the problem of drug error related to anesthesia in Thailand including nature, contributing factors and preventive strategies. MATERIAL AND METHOD: We prospectively recorded anesthesia-related drug error incidents for 18 months in 20 studied hospitals in Thailand. Types of errors and their outcomes were recorded. All data were analyzed to identify contributing factors and preventive strategies. RESULTS: Forty-one drug error incidents were reported in 40 out of 202,699 anesthetized cases or 1: 4,943 in this study. The most common type of error was wrong drug (20 incidents; 48.8%). No relationship between anesthetic techniques and the incidents except for a combined general and epidural technique. The errors were most commonly occurred during induction of anesthesia (26 out of 41; 63.4%) and muscle relaxants were most commonly involved (13 out of 41; 31.7%). The majority of incidents (26 out of 41; 63.4%) caused no adverse effect. However 14 incidents (34.1%) caused transient mild to severe physiological effects, of which 13 had complete recovery but one died. Haste and lack of recheck were two common contributing factors which were minimized by high awareness and double check prior to drug administration. Main strategies suggested to prevent the incidents included specific guideline development whereas the incidents did not effectively decrease by increasing of manpower CONCLUSION: The incidence of drug error in our study was 1 : 4,943. It can cause morbidity and mortality during anesthesia. Practitioners should be aware of these potential incidents and strictly follow the guideline for drug administration.

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.

The Thai Anesthesia Incidents Study (THAI Study) of perioperative allergic reactions.

OBJECTIVES: To determine the incidence, risk factors, signs, symptoms and management of perioperative allergic reactions in the Thai Anesthesia Incidents Study (THAI Study). MATERIAL AND METHOD: Between February 1, 2003, and January 31, 2004, a descriptive, prospective, multicenter study was conducted in 20 hospitals across Thailand. All patients receiving anesthetic and medical agents were monitored for allergic reactions for the first 24 postoperative-hours. Signs and symptoms of suspected allergic reactions included skin reactions, wheezing and unexpected hypotension. The details of allergic reactions were reviewed and recorded. RESULTS: Allergic reactions occurred in 30 of the 163,403 patients included in this study. The reaction-incidence was approximately 1 in 5,500 cases of anesthesia. Forty-eight percent of the affected patients had a history of allergic reactions. The manifestations were skin reactions, hypotension and wheezing in 38, 22 and 19 percent of the overall symptoms, respectively. Reactions were mild, moderate and severe in 40, 23 and 37 percent of the patients, respectively. The three drugs most suspected of causing the reaction(s) were antibiotics (19%), muscle relaxants (17%) and propofol (15%). All of the affected patients recovered after treatment including the one who suffered cardiac arrest because of the allergic reaction. CONCLUSION: The incidence of perioperative allergic reactions was 1 in 5,500 cases of anesthesia. History of allergies was obtained from half of the patients and the most common sign was a skin reaction. The drugs most suspected of causing an allergic reaction were antibiotics. All of the patients responded well to rescue treatment.

Transfusion errors in the Thai Anesthesia Incidents Study (THAI Study): three cases.

Of 163,403 recorded cases of anesthesia in the Thai Anesthesia Incidents Study (THAI Study), transfusion errors occurred thrice. Case #1: a 68-year-old male, blood group A, undergoing hepatectomy, received two units of PRC and four units of FFP (all units were group A), but two of the FFP units were given to the wrong patient because the caregiver did not check the patient-identification on all of the blood bags. Case #2: a 42-year-old female, blood group A, undergoing emergency exploratory laparotomy, received 250 mL of group B-blood. Skin rashes, a clue for diagnosis of transfusion error were observed in the postoperative period. The error occurred because the caregiver did not check the patient-identification before starting the transfusion. Case #3: a 42-year-old female, blood group O, undergoing hysterectomy, received 430 mL of group AB-blood. More blood was requested in the ICU and it was discovered that the new bag was group O instead of AB. Mislabeling of the blood sample at the first blood request accounted for the error even though blood group O was recorded on the patient's OPD chart. The first two patients developed minor adverse reactions (grade 1) whereas the third developed a severe reaction (grade 3). All of the patients responded well to treatments. Accordingly, the system for preventing transfusion errors has been improved at both hospitals.