Self-study and online interactive case-based discussion to improve knowledge of medical students in the COVID-19 era.

BACKGROUND: We aimed to determine whether a new online interactive learning method for fifth-year medical students could improve their knowledge of pre- and postoperative care during the COVID-19 era. METHODS: A retrospective cohort study was conducted from June 2020 to May 2022 during the pre- and postoperative care course for fifth-year medical students in a university hospital in southern Thailand. Students in the 2020 cohort received only a 60-minute lecture on spinal anesthesia via Zoom while a 3-step online interactive learning method was used for the 2021 cohort. Step 1: students performed self-study comprised of video lectures and case-based discussion one week before the online class with a pre-test submitted via Google forms. Step 2: an online interactive case-based discussion class was performed via Zoom by two experienced anesthesia staff and a post-test was submitted by the students via Google forms. Step 3: a small group discussion of course evaluation between 13 representatives of students and anesthesia staff was performed via Zoom. A comparison of the post-test and pre-test scores containing 20 multiple choice questions as well as the final exam scores before (2020) and after (2021) the new interactive learning was performed using a t-test. RESULTS: There were 136 and 117 students in the 2020 and 2021 academic years, respectively. The final mean (SD) exam scores for the 2020 and 2021 academic years were 70.3 (8.4) and 72.5 (9.0), respectively with a mean (95% confidence interval (CI)) difference of 2.2 (4.3, -0.02). In 2021, the mean (95% CI) difference between the post-test and pre-test scores was 5.8 (5.1, 6.5). The student representatives were satisfied with the new learning method and gave insightful comments, which were subsequently implemented in the 2022 academic year course. CONCLUSION: The new interactive learning method improved the knowledge of fifth-year medical students attending pre- and postoperative care course during the COVID-19 era. The final exam scores may not be suitable to represent the overall outcomes of the new interactive learning method. Using an online two-way communication method can improve the overall satisfaction and course adaptation during the COVID-19 era.

Ultrasonography measurement of glottic transverse diameter and subglottic diameter to predict endotracheal tube size in children: a prospective cohort study.

We aimed to determine the correlation between mid-glottic transverse diameter/subglottic diameter and outer diameter of endotracheal tube (ETT) by ultrasonography in children. Ninety-five patients aged 1-8 years who underwent general anesthesia were included. Ultrasonography of glottic/subglottic transverse diameter was performed by two investigators after patients were anesthetized and when the train of four showed ≤ 4. The subglottic diameter was measured at the mid cricoid cartilage. The mid-glottic transverse diameter was measured at the mid-point of true vocal fold triangle whereas the distance between arytenoids was considered as the glottic transverse diameter. Linear regression models and correlation coefficients (r) were used to determine the best formula of glottic/subglottic transverse diameter to predict the outer diameter of ETT. The predicted outer diameter of ETT formula for subglottic diameter, mid-glottic transverse diameter, and glottic transverse diameter were 5.7 + (subglotticmm/3) with an r of 0.45, 5.5 + (midglotticmm/2) with an r of 0.47, and 5.7 + (glotticmm/4) with an r of 0.46, respectively. The correlation between subglottic diameter and mid-glottic transverse diameter was 0.50. Subglottic/mid-glottic/glottic transverse diameter formulae had moderate correlations with the outer diameter of ETT. The glottic/mid-glottic transverse diameter can be used alternatively to predict the ETT size.Trial registration: Thai Clinical Trial Registry: TCTR20191022002 Registered 22/10/2019-Prospectively registered, https://www.thaiclinicaltrials.org/# TCTR20191022002.

Predicting difficult laryngoscopy in morbidly obese Thai patients by ultrasound measurement of distance from skin to epiglottis: a prospective observational study.

BACKGROUND: In morbidly obese patients, airway management is challenging since the incidence of difficult intubation is three times than those with a BMI within the healthy range. Standard preoperative airway evaluation may help to predict difficult laryngoscopy. Recent studies have used ultrasonography-measured distance from skin to epiglottis and pretracheal soft tissue at the level of vocal cords, and cut-off points of 27.5 mm and 28 mm respectively have been proposed to predict difficult laryngoscopy. The purpose of this study is to evaluate ultrasonography-measured distance from skin to epiglottis for predicting difficult laryngoscopy in morbidly obese Thai patients. METHODS: This prospective observational study was approved by the Ethics Committee of the Faculty of Medicine, Prince of Songkla University. Data were collected from January 2018 to August 2020. Eighty-eight morbidly obese patients (BMI ≥ 35 kg/m2) requiring general anesthesia with endotracheal intubation for elective surgery were enrolled in the Songklanagarind Hospital. Preoperatively, anesthesiologists or nurse anesthetists who were not involved with intubation evaluated and recorded measurements (body mass index, neck circumference, inter incisor distance, sternomental distance, thyromental distance, modified Mallampati scoring, upper lip bite test, and distance from skin to epiglottis by ultrasound. The laryngoscopic view was graded on the Cormack and Lehane scale. RESULTS: Mean BMI of the eighty-eight patients was 45.3 ± 7.6 kg/m2. The incidence of difficult laryngoscopy was 14.8%. Univariate analysis for difficult laryngoscopy indicated differences in thyromental distance, sternomental distance and the distance from skin to epiglottis by ultrasonography. The median (IQR) of thyromental distance in difficult laryngoscopy was 6.5 (6.3, 8.0) cm compared with 7.5(7.0, 8.0) cm in easy laryngoscopy (p-value 0.03). The median (IQR) of sternomental distance in difficult laryngoscopy was 16.8 (15.2, 18.0) cm compared with 16.0 (14.5, 16.0) cm in easy laryngoscopy (p-value 0.05). The mean distance from skin to epiglottis was 12.2 ± 3.3 mm Mean of distance from skin to epiglottis in difficult laryngoscopy was 12.5 ± 3.3 mm compared with 10.6 ± 2.9 mm in easy laryngoscopy (p-value 0.05). Multivariate logistic regression indicated the following factors associated with difficult laryngoscopy: age more than 43 years (A), thyromental distance more than 68 mm(B) and the distance from skin to epiglottis more than 13 mm(C). The scores to predict difficult laryngoscopy was calculated as 8A + 7B + 6C based on the data from our study. One point is given for A if age was more than 43 years old, 1 point is given for B if thyromental distance was less than 6.8 cm and 1 point is given for C if the distance from skin to epiglottis by ultrasonography was more than 13.0 cm. The maximum predicting score is 21, which indicates a probability of difficult laryngoscopy among our patients of 36.36%, odds 0.57, likelihood ratio 3.29 and area under the ROC curve of 0.77, indicative of a good predictive score. CONCLUSIONS: Age, thyromental distance and ultrasonography for the distance from skin to epiglottis can predict difficult laryngoscopy among obese Thai patients. The predictive score indicates the probability of difficult laryngoscopy.

Minimal effective dose of ultrasound-guided rectus sheath block to reduce oral analgesic requirement after ambulatory laparoscopic tubal resection: a randomized controlled superiority trial.

BACKGROUND: The effective dose during ultrasound-guided rectus sheath block (URSB) for reducing pain after laparoscopic tubal ligation is reported to be 100 mg of 0.25% bupivacaine. We examined the minimal effective dose of 0.25% bupivacaine for URSB on oral analgesic requirement after ambulatory single-port laparoscopic tubal resection. METHODS: A prospective, randomized controlled, superiority trial was conducted among patients who had been scheduled for ambulatory laparoscopic tubal resection between September 2015 and January 2019 at a tertiary care hospital in southern Thailand. Anesthesia was induced following protocol. The intervention group was allocated to receive a bilateral URSB using 10 ml of 0.25% bupivacaine on either side after intubation (total 50 mg) while the control group did not receive the sham block. Patients and assessors were blinded to the study intervention. All patients received a multimodal analgesia regimen as follows: fentanyl and ketorolac intraoperatively and fentanyl and oral acetaminophen at the post-anesthetic care unit. Postoperative oral analgesic requirement (acetaminophen and/or ibuprofen) at home was the primary outcome. Postoperative time to first analgesic requirement, oral analgesia (acetaminophen/ibuprofen), and pain score at 6 and 24 h were accessed via telephone interviews. Percentage, effect size (ES), and 95% confidence interval (CI) were presented. RESULTS: A total of 66 out of 79 eligible patients were analyzed (32 intervention, 34 control). Intraoperative fentanyl consumption was significantly lower in the intervention group (ES [95% CI]: 0.58 [0.08, 1.07] mcg, p = 0.022). Time to first oral analgesia in the intervention group was significantly longer than that of the control group (ES [95% CI]: 0.66 [0.14, 1.16] h, p = 0.012). The proportion of oral analgesia requirement at 24 h after surgery in the control group was significantly higher than that in the intervention group (97% vs 75%, p = 0.012). Pain scores at 6 and 24 h were similar in both groups although slightly lower in the intervention group (ES [95% CI]: 0.22 [-0.26, 0.71], p = 0.368 and 0.33 [-0.16, 0.81], p = 0.184, respectively). CONCLUSION: A dose of 0.25% bupivacaine 50 mg for URSB reduced the oral analgesic requirement at 24 h and prolonged the time to first analgesic requirement after ambulatory laparoscopic tubal resection. TRIAL REGISTRATION: Thaiclinicaltrials.org TCTR20150921002 . Registered on 18 September 2015.

Risk predictive tools of perioperative drug hypersensitivity reaction: A case-control study.

OBJECTIVE: We aimed to determine the risk factors of perioperative drug hypersensitivity reaction (DHR) and develop a predictive score for use in clinical practice. METHODS: A case-control study was conducted in patients who underwent anesthesia at a tertiary hospital in Thailand, between 2015-2018. DHR cases were graded clinically from 1 to 4 according to the World Federation of Societies of Anesthesiologists by two anesthesiologists. Controls were randomly matched with cases (ratio 2:1) by age group and month and type of surgery. Patient and anesthesia-related factors and agents given intraoperatively were recorded. A risk score was derived from the coefficients of the significant predictors of the final multivariate logistic regression model. Risk scores, adjusted odds ratios (OR) for perioperative DHR and 95% confidence intervals (CI) were determined. RESULTS: Overall, 325 cases and 650 controls were recruited. The severity of DHR was grade 1 (72.9%), grade 2 (24%), and grade 3 (3.1%). Our risk predictive tools for perioperative DHR provided a sensitivity of 62% and specificity of 65%. Predictive scores of subgroups of moderate to severe DHR showed high specificity (80%) but low sensitivity (47%). Common predictors of overall DHR and moderate to severe DHR were history of drug allergy to 2 or more drug categories (score 2.5-3.5), being allergic to analgesics (score 2.5-4.0), and intraoperative morphine use (score of 1). The sole predictor of high-risk perioperative DHR (score ≥3.5) was airway management with an endotracheal tube intubation (OR 5.6, 95% CI 2.2-14.4) whereas history of allergic rhinitis (OR 11.7, 95% CI 1.3-105.1) was a predictor of high-risk moderate to severe DHR (score ≥2.5). CONCLUSIONS: Our predictive tool for perioperative DHR provided a modest predictive ability. History of drug allergies, rhinitis, morphine use and endotracheal intubation were significant risk factors of DHR after adjusting for age and type of surgery.

Is ABO Blood Group a Predictive Factor for the Amount of Opioid Consumption in the First 24 Hours After Cesarean Section?

BACKGROUND: Cesarean section is the most common major surgery performed globally. Blood group O has been found as a factor affecting pain severity after cesarean section. We aimed to evaluate the predictive factors, including ABO blood group, for the amount of opioid consumption (measured as milligrams of morphine equivalent [MME]) within the first 24 hrs after cesarean section. METHODS: This retrospective study was done in 1530 pregnant women who had a cesarean section under the same regimen of spinal anesthesia (2.2 mL of 0.5% hyperbaric bupivacaine and morphine 0.2 mg). All were prescribed regular paracetamol and ibuprofen for postoperative pain control. Univariate and multinomial regression analyses were performed to identify the predictive factors for opioid consumption in the first 24 hrs postoperatively. RESULTS: About 2/5 of them (43.3%) received 0 mg MME, while 25.6%, 23.7% and 7.4% received 1-5, 6-10 and >10 mg MME, respectively. The majority have blood group O (40.6%), while 23.4%, 28% and 8% have blood group A, B and AB, respectively. After univariate and multinomial regression analyses, operation time, opioid consumption in PACU, maximum VNRS within the first 24 hrs and consumption of both paracetamol and ibuprofen were identified as predictive factors for postoperative opioid consumption. ABO blood group exhibited no correlation for opioid requirement postoperatively. CONCLUSION: ABO blood group is not a predictive factor for opioid requirement within the first 24 hrs following cesarean section. Duration of operation, opioid given in PACU, maximum VNRS on ward and consumption of both paracetamol and ibuprofen have been found to be predictive factors for postcesarean opioid requirement.

Does perioperative respiratory event increase length of hospital stay and hospital cost in pediatric ambulatory surgery?

OBJECTIVE: We examined the consequences of perioperative respiratory event (PRE) in terms of hospitalization and hospital cost in children who underwent ambulatory surgery. METHODS: This subgroup analysis of a prospective cohort study (ClinicalTrials.gov: NCT02036021) was conducted in children aged between 1 month and 14 years who underwent ambulatory surgery between November 2012 and December 2013. Exposure was the presence of PRE either intraoperatively or in the postanesthetic care unit or both. The primary outcome was length of stay after surgery. The secondary outcome was excess hospital cost excluding surgical cost. Financial information was also compared between PRE and non-PRE. Directed acyclic graphs were used to select the covariates to be included in the multivariate regression models. The predictors of length of stay and excess hospital cost between PRE and non-PRE children are presented as adjusted odds ratio (OR) and cost ratio (CR), respectively with 95% confidence interval (CI). RESULTS: Sixty-three PRE and 249 non-PRE patients were recruited. In the univariate analysis, PRE was associated with length of stay (p = 0.004), postoperative oxygen requirement (p <0.001), and increased hospital charge (p = 0.006). After adjustments for age, history of snoring, American Society of Anesthesiologists physical status, type of surgery and type of payment, preoperative planned admission had an effect modification with PRE (p <0.001). The occurrence of PRE in the preoperative unplanned admission was associated with 24-fold increased odds of prolonged hospital stay (p <0.001). PRE was associated with higher excess hospital cost (CR = 1.35, p = 0.001). The mean differences in contribution margin for total procedure (per patient) (PRE vs non-PRE) differed significantly (mean = 1,523; 95% CI: 387, 2,658 baht). CONCLUSION: PRE with unplanned admission was significantly associated with prolonged length of stay whereas PRE regardless of unplanned admission increased hospital cost by 35% in pediatric ambulatory surgery. TRIAL REGISTRATION: ClinicalTrials.gov registration number NCT02036021.

Bronchial Artery Embolization in Life-Threatening Hemoptysis: Outcome and Predictive Factors.

PURPOSE: To determine the outcome and predictive factors of clinical success of bronchial artery embolization in life-threatening hemoptysis. MATERIAL AND METHODS: We reviewed all bronchial artery embolization procedures performed for life-threatening hemoptysis between January 2008 and December 2018. The outcomes and predictive factors of clinical success following embolization were evaluated. RESULTS: One hundred and eighty-four bronchial artery embolization procedures performed in 145 patients were eligible for the study. The technical and clinical success rates of the procedures were 170/184 (92.4%) and 129/184 (70.1%), respectively. The unstable hemodynamics and prothrombin time/international normalized ratio >1.5 was associated with lower clinical success rate, while embolization of more than one vessel was associated with higher clinical success rate. CONCLUSION: Bronchial artery embolization is a safe and effective procedure for controlling bleeding in life-threatening hemoptysis. However, low clinical success rate was noted in patients with unstable hemodynamics and coagulopathy, while multiple vessel embolization was associated with higher clinical success.

Predictors of death after receiving a modified Blalock-Taussig shunt in cyanotic heart children: A competing risk analysis.

OBJECTIVE: To determine risk factors affecting time-to-death ≤90 and >90 days in children who underwent a modified Blalock-Taussig shunt (MBTS). METHODS: Data from a retrospective cohort study were obtained from children aged 0-3 years who experienced MBTS between 2005 and 2016. Time-to-death (prior to Glenn/repair), time-to-alive up until December 2017 without repair, and time-to-progression to Glenn/repair following MBTS were presented using competing risks survival analysis. Demographic, surgical and anesthesia-related factors were recorded. Time-to-death ≤90 days and >90 days was analyzed using multivariate time-dependent Cox regression models to identify independent predictors and presented by adjusted hazard ratios (HR) and 95% confidence intervals (CI). RESULTS: Of 380 children, 119 died, 122 survived and 139 progressed to Glenn/repair. Time-to-death probability (95% CI) within 90 days was 0.18 (0.14-0.22). Predictors of time-to-death ≤90 days (n = 63) were low weight (<3 kg) (HR 7.6, 95% CI:2.8-20.4), preoperative ventilator support (HR 2.7, 95% CI:1.3-5.6), postoperative shunt thrombosis (HR 5.0, 95% CI:2.4-10.4), bleeding (HR 4.5, 95% CI:2.1-9.4) and renal failure (HR 4.1, 95% CI:1.5-10.9). Predictors of time-to-death >90 days (n = 56) were children diagnosed with pulmonary atresia with ventricular septal defect and single ventricle (compared to tetralogy of fallot) (HR 3.2, 95% CI:1.2-7.7 and HR 3.1, 95% CI:1.3-7.6, respectively), shunt size/weight ratio >1.1 vs <0.65 (HR 6.8, 95% CI:1.4-32.6) and longer duration of mechanical ventilator (HR 1.002, 95% CI:1.001-1.004). Shunt size/weight ratio ≥1.0 (vs <1.0) and ≥0.65 (vs <0.65) were predictors for overall time-to-death in neonates and toddlers, respectively (HR 13.1, 95% CI:2.8-61.4 and HR 7.8, 95% CI:1.7-34.8, respectively). CONCLUSIONS: Perioperative factors were associated with time-to-death ≤90 days, whereas particular cardiac defect, larger shunt size/weight ratio, and longer mechanical ventilation were associated with time-to-death >90 days after receiving MBTS. Larger shunt size/weight ratio should be reevaluated within 90 days to minimize the risk of shunt over flow.

Premedication with oral paracetamol for reduction of propofol injection pain: a randomized placebo-controlled trial.

BACKGROUND: To compare the effect of premedication with 2 different doses of oral paracetamol to prevent pain at propofol intravenous injection. METHODS: We conducted a double-blind randomized controlled trial in which patients scheduled for induction of general anesthesia with intravenous propofol received either a placebo, 500 mg or 1000 mg of oral paracetamol (P500 and P1000, respectively) 1 h prior to induction. Two mg/kg of propofol was injected at a rate of 600 ml/hr. After 1/4 of the full dose had been injected, the syringe pump was paused, and patients were asked to rate pain at the injection site using a verbal numerical rating score (VNRS) from 0 to 10. RESULTS: Three hundred and twenty-four patients were included. Pain intensity was lower in both P500 and P1000 groups (median VNRS [interquartile range] = 2 [0-3] and 4 [2-5], respectively) than in the placebo group (8 [7-10]; P < 0.001)*. The rate of pain was lower in the P1000 group (70.4%) than in both the P500 and the placebo group (86.1 and 99.1%, respectively; P < 0.001)*. The respective rates of mild (VNRS 1-3), moderate (VNRS 4-6) and severe pain (VNRS 7-10) were 47.2, 23.2 and 0% in the P1000 group, 28.7, 50 and 7.4% in the P500 group, and 0, 22.2 and 76.9% in the placebo group (P < 0.001* for between group comparisons). Tolerance was similar in the 3 groups. CONCLUSIONS: A premedication with oral paracetamol can dose-dependently reduce pain at propofol intravenous injection. To avoid this common uncomfortable concern for the patients, this well-tolerated, available and cheap treatment appears as an option to be implemented in the current practice. TRIAL REGISTRATION: TCTR20150224002 . Prospectively registered on 24 February 2015.

Prediction of uncuffed tracheal tube sizes in children and infants using age/weight-based formulae: A retrospective cross-sectional study.

INTRODUCTION: The age-based formula is commonly used to predict tracheal tube (TT) sizes although its inaccuracy has been reported to reach as high as 60%. We aim to determine a practical formula using age in months and weight in kilograms to predict uncuffed tracheal tube (TT) size in children and infants. METHODS: A retrospective cross-sectional study was conducted on data obtained from a prospective study on children aged less than 9 years who came for elective surgery and received general anesthesia with oroendotracheal tube intubation at Songklanagarind Hospital between September 2008 and December 2012. The uncuffed TT sizes were based on the age-based formulae and the discretion of the attending anesthesiologist. The age (in months), weight (in kg), and final TT size were measured. Univariate and multivariate linear regression analyses were used to find potential predictors of final uncuffed TT size and therefore the best formula. The correlation coefficient (r) for each model was calculated. The kappa statistic was used to measure the agreement between predicted and actual TT size. RESULTS: A total of 668 patients were recruited. The age/weight formulae for infants aged ≤12 months and children aged >12 months were 3.15 + (age [months] × 0.05) + (weight [kg] × 0.05) with r value of 0.75 (n = 216) and 3.83 + (age [months] × 0.017) + (weight [kg] × 0.017) with r value of 0.85 (n = 452), respectively. The formulae correctly predicted 69.0% and 65.0% of actual TT sizes for infants and children, respectively (both p < 0.001). The formulae for malnourished infants and children whose weights were less than the 3rd percentile for age were 2.70 + (weight [kg] × 0.21) (n = 43) and 3.59 + (age [months] × 0.012) + (weight [kg] × 0.056) (n = 105) with r values of 0.81 and 0.87, respectively. CONCLUSION: The age/weight formula can be used to estimate TT size in infants and children. In failure to thrive children, our formula for malnourished children and infants provided high correlation with final TT sizes.

Risk prediction tool for use and predictors of duration of postoperative oxygen therapy in children undergoing non-cardiac surgery: a case-control study.

BACKGROUND: We aimed to construct a prediction tool for postoperative oxygen therapy and determine predictors of duration of use among children undergoing non-cardiac surgery. METHODS: Data from this case-control study was obtained from a database of 9820 children aged < 15 years who underwent general anesthesia between January 2010 and December 2013 at a tertiary care hospital in southern Thailand. The primary outcomes were the use and duration (hours) of postoperative oxygen therapy (cases). Cases were matched with controls on age group and year of surgery in a ratio of 1:4. A negative binomial hurdle model was used to obtain significant predictors of any use and number of hours of oxygen therapy. A risk score was derived from the coefficients of the significant predictors. The risk score, adjusted odds ratio (OR) for any use and count ratio (CR) for duration of postoperative oxygen therapy and 95% confidence interval (CI) were determined. RESULTS: A total of 288 cases and 1152 controls were included. The median (inter-quartile range) duration of oxygen therapy delivered was 17 (9-22) hours. An optimal risk score for predictors of oxygen use was 12 (0-32) giving an area under the receiver operating characteristic curve of 0.93. Predictors of high risk need for oxygen therapy (score ≥ 12) were thoracic surgery (OR = 278, 95% CI = 44.6-1733) and having desaturation perioperatively (OR = 459.8, 95% CI = 169.7-1246). Intermediate risk factors (score 8-11) were having bronchospasm (OR = 92.4, 95% CI = 29.7-287.5) and upper airway obstruction/laryngospasm (OR = 61.5, 95% CI = 14.4-262.4) perioperatively. Significant predictors of duration of oxygen therapy were probably difficult airway (CR = 2.2, 95% CI = 1.4-3.5), history of delayed development (CR = 2.3, 95% CI = 1.5-3.6), airway (CR = 3.0, 95% CI = 1.6-5.8), orthopedic (CR = 2.1, 95% CI = 1.1-4.3), thoracic (CR = 4.9, 95% CI = 2.3-10.1) and abdominal surgery (CR = 4.2, 95% CI = 2.1-8.1), compared to eye surgery. CONCLUSIONS: Our risk prediction tool for the use of postoperative oxygen therapy provided a high predictive ability. Children who have thoracic surgery, desaturation, bronchospasm, upper airway obstruction or laryngospasm will most likely need postoperative oxygen therapy, regardless of other factors, while those with a probably difficult airway, history of delayed development, or thoracic/abdominal surgery will most likely need longer duration of oxygen therapy.

Minimal effective weight-based dosing of ondansetron to reduce hypotension in cesarean section under spinal anesthesia: a randomized controlled superiority trial.

BACKGROUND: The weight-based dosing of ondansetron to reduce hypotension has never been investigated. The aim of this study is to determine the optimal dose of ondansetron required based on the patient's weight to reduce hypotension following spinal anesthesia for cesarean section. METHODS: In this prospective, triple-blinded, parallel group, randomized controlled trial, a total of 228 pregnant women were randomized to receive either normal saline (group NS) or ondansetron 0.05 mg/kg (group O1) or ondansetron 0.1 mg/kg (group O2) intravenously 5 min before induction of spinal anesthesia. The incidence of hypotension, mean arterial pressure, heart rate, vasopressor requirements, and blood loss between the three groups were compared. Maternal and neonatal complications were also assessed. Changes in blood pressure and heart rate were compared using the generalized estimating equations method. RESULTS: Thirteen patients were excluded from the analysis because of no intervention (n = 12) and protocol violation (n = 1). Two hundred and fifteen patients remained for the intention-to-treat analysis. The incidence of hypotension in groups NS (n = 72), O1 (n = 71), and O2 (n = 72) were 81.9%, 84.5%, and 73.6%, respectively (P = 0.23). The episodes of hypotension before delivery (first 14 min after spinal anesthesia) were significantly higher in group O1 compared to NS (5 vs 2, P = 0.02). The overall heart rates throughout the operations were not different among the three groups. The ephedrine requirements and amount of blood loss were also similar among the three groups. The metoclopramide requirement was significantly lower in group O2 compared to group NS (2.8% vs 16.7%, P = 0.01). There were no serious adverse events in terms of maternal or neonatal complications. CONCLUSIONS: Ondansetron 0.05 mg/kg or 0.1 mg/kg administered before spinal anesthesia did not reduce the incidence of hypotension in this study. TRIAL REGISTRATION: Thai Clinical Trials Registry, TCTR 20160323001 , 22 March 2016.

Attitudes of Medical Students Regarding Cancer Pain Management: Comparison Between Pre- and Post-Lecture Test Findings.

BACKGROUND: Medical practitioners' attitudes have a significant impact on quality of care for cancer pain patients. This study was conducted to determine if being given a lecture concerning cancer pain and its management could improve the attitudes of medical students. MATERIALS AND METHODS: A comparative study was conducted in 126 fifth-year medical students. Each student completed a pretest consisting of 3 questions about attitudes toward the optimal use of analgesics and 5 questions about attitudes toward prescribing opioids. Then they were given a 1.5-hour lecture, immediately following which they completed a post-test with the same questions. RESULTS: Analysis with either comparison between groups or by matching, the post-test showed significantly more positive attitudes (p<0.05) of the medical students in all 3 questions about optimal use of analgesics and 4 out of 5 questions about prescription of opioids. The post-test results showed significantly more negative attitudes concerning the most appropriate stage for patients with severe pain to receive maximal doses of analgesics. CONCLUSIONS: Conservative attitudes, especially concerns about addiction, have been associated with a reluctance in many physicians to prescribe opioids. This study found that cancer pain education can help to improve medical student attitudes. However, fear of addiction and tolerance was still evident so emphasis of this particular issue during a lecture is essential. Providing appropriate information by means of a lecture can improve the attitudes of medical students regarding cancer pain management. However, more information should be given to lessen fear of addiction and tolerance.

Excess costs and length of hospital stay attributable to perioperative respiratory events in children.

BACKGROUND: Knowledge of the excess hospital costs and prolonged length of stay attributable to perioperative respiratory event (PRE) in pediatric anesthesia is useful for hospital planning. In this study, we compared costs (excess hospital costs and indirect costs) and length of hospital stay between children who had PRE and did not have PRE for noncardiac surgery at a tertiary care hospital in southern Thailand. METHODS: A prospective matched cohort study was conducted in children aged <15 years who underwent general anesthesia between November 2012 and December 2013 at Songklanagarind Hospital. PRE children were matched with no PRE children (1:1) using a random selection procedure on outpatients/inpatients, type of surgery, surgical charge (baht), ASA physical status, age difference <9 years, and difference in time of surgery <6 months. Primary end points were excess hospital costs and number of days hospitalized after surgery. Number of days hospitalized after surgery, excess hospital costs and indirect costs regarding transportation, and income loss of parents between groups were compared using Wilcoxon signed rank test. Any hospital stay after surgery between groups was compared using McNemar χ test. A hurdle model was used to predict any hospital stay and number of days hospitalized after surgery. Multiple mixed-effects linear regression was used to identify predictors of adjusted excess hospital costs and indirect costs. RESULTS: A total 430 children were included (215 matched pairs). More PRE children required hospital stay after surgery (81% vs 72%, P = 0.004), and PRE children had a longer number of days hospitalized after surgery (median [interquartile ranges]: 1 [1-3.5] vs 1 [0-2]; P < 0.001) and incurred higher excess costs (P < 0.001) but not indirect costs (P = 0.23). In multivariate analysis, PRE was a significant predictor for hospital stay after surgery (odds ratio, 2.56; 95% confidence interval, 1.23-5.31), longer hospitalization (count ratio, 2.10 [1.31-3.35]), higher excess costs (cost ratio, 1.30 [1.12-1.53]), and indirect cost (cost ratio, 1.58 [1.20-2.08]) after adjusting for patient and anesthesia characteristics. Universal coverage (74%) was associated with 35% and 64% higher excess cost compared with the Comptroller General's Department (17%) and self-pay (7%), respectively (P = 0.003). CONCLUSIONS: The effects of PRE in pediatric anesthesia were hospital stay after surgery, 2 times longer hospitalization, 30% higher excess hospital costs, and 58% higher indirect cost among outpatients. Hospital policy to efficiently manage hospital beds and compensatory budget should be developed.

Risk over time and risk factors of intraoperative respiratory events: a historical cohort study of 14,153 children.

BACKGROUND: The variation in the rate of intraoperative respiratory events (IRE) over time under anesthesia and the influence of anesthesia-related factors have not yet been described. The objectives of this study were to describe the risk over time and the risk factors for IRE in children at a tertiary care hospital in southern Thailand. METHODS: The surveillance anesthetic database and chart review of IRE of 14,153 children who received surgery at Songklanagarind Hospital during January 2005 to December 2011 were used to obtain demographic, surgical and anesthesia-related data. Incidence density of IRE per person-time was determined by a Poisson modelling. Risk of IRE over time was displayed using Kaplan Meier survival and Nelson-Aalen curves. Multivariate Cox regression was employed to identify independent predictors for IRE. Adjusted hazard ratios (HR) and their 95% confidence intervals (CI) were obtained from the final Cox model. RESULTS: Overall, IRE occurred in 315 out of 14,153 children. The number (%) of desaturation, wheezing or bronchospasm, laryngospasm, reintubation and upper airway obstruction were 235 (54%), 101 (23%), 75 (17%), 21 (5%) and 4 (1%) out of 315 IRE, respectively. The incidence density per 100,000 person-minutes of IRE at the induction period (61.3) was higher than that in the maintenance (13.7) and emergence periods (16.5) (p < 0.001). The risk of desaturation, wheezing and laryngospasm was highest during the first 15, 20 and 30 minutes of anesthesia, respectively. After adjusting for age, history of respiratory disease and American Society of Anesthesiologist (ASA) classification, anesthesia-related risk factors for laryngospasm were assisted ventilation via facemask (HR: 18.1, 95% CI: 6.4-51.4) or laryngeal mask airway (HR: 12.5, 95% CI: 4.6-33.9) compared to controlled ventilation via endotracheal tube (p < 0.001), and desflurane (HR: 11.0, 95% CI: 5.1-23.9) compared to sevoflurane anesthesia (p < 0.001). CONCLUSIONS: IRE risk was highest in the induction and early maintenance period. Assisted ventilation via facemask or LMA and desflurane anesthesia were anesthesia-related risk factors for laryngospasm. Therefore, anesthesiologists should pay more attention during the induction and early maintenance period especially when certain airway devices incorporated with assisted ventilation or desflurane are used.

Comparison of intelligence, weight and height in children after general anesthesia with and without perioperative desaturation in non-cardiac surgery: a historical and concurrent follow-up study.

PURPOSE: To determine whether perioperative desaturation (PD) in preschool children undergoing non-cardiac surgery is associated with subsequent impairment of intelligence or subsequent change in age-specific weight and height percentile. METHOD: A historical-concurrent follow-up study was conducted in children aged ≤ 60 months who underwent general anesthesia (GA) for non-cardiac surgery between January 2008 and December 2011 at Songklanagarind Hospital. Children who developed PD (PD group) and children who did not develop perioperative respiratory events (no-PRE group) were matched on sex, age, year of having index GA, type of surgery and choice of anesthesia. The children's age-specific weight and height percentile and intelligence quotient (IQ) scores by Standford Binet-LM or Wechsler Intelligence Scale for Children, 3rd edition 12-60 months after GA were compared using Student's t- test and Wilcoxon's rank sum test. Multivariate linear regression models for standardized IQ and multivariate mixed effects linear regression models for the change of age-specific weight and height percentile from the time of index GA to the time of IQ test were performed to identify independent predictors. The coefficients and 95% confidence intervals (CI) were displayed and considered significant if the F test p-values were < 0.05. RESULTS: Of 103 subjects in each group (PD vs no-PRE), there were no statistically significant differences in IQ (94.7 vs 98.3, p = 0.13), standardized IQ (-0.1 vs 0.1, p = 0.14) or age-specific weight percentile (38th vs 63th, p = 0.06). However, age-specific height percentile in the PD group at the time of IQ test was significantly lower (38th vs 50th, p = 0.02). In the multivariate analysis, PD was not a significant predictor for standardized IQ (coefficient: -0.06, 95% CI: -0.3, 0.19, p = 0.57), change in age-specific weight percentile (coefficient: 4.66, 95% CI: -2.63, 11.95, p = 0.21) or change in age-specific height percentile (coefficient: -1.65, 95% CI: -9.74, 6.44, p = 0.69) from the time of index GA to the time of IQ test after adjusting for family and anesthesia characteristics. CONCLUSION: Our study could not demonstrate any serious effect of PD on subsequent intelligence or on the change in age-specific weight and height percentile of children after non-cardiac surgery.

Incidence of difficult bag-mask ventilation in children: a prospective observational study.

BACKGROUND: Difficult airway (DA), including difficult bag-mask ventilation (DBMV), and difficult intubation (DI) is an important challenge for the pediatric anesthesiologist. While expected DBMV can be successfully managed with appropriate equipment and personnel, unexpected DBMV relies on the resources available and the experience of the anesthesiologist at the time of the emergency. The incidence and risk factors of unexpected DA in otherwise healthy children, including DBMV among pediatric patients are not known. The aim of this study was to expand the scientific knowledge of unexpected DBMV among pediatric patients. METHODS: Patients between the ages of 0 and 8 years, undergoing elective surgery requiring bag-mask ventilation BMV and intubation at the Montreal Children's Hospital were recruited in this prospective observational study. Data on the incidence of DBMV and risk factors were collected over a 3-year period. RESULTS: In a sample of 484 children, the incidence of unexpected difficult BMV was 6.6% (95% CI [4.6, 9.2]). The incidence of expected DA among the screened patients (N = 4865) was 0.5% (95% CI [0.3, 0.7]). In a logistic regression analysis, age (OR 0.98; 95%CI [0.97, 0.99]), undergoing otolaryngology (ENT) surgery (OR 2.92; 95% CI [1.08, 7.95]) and use of neuromuscular blocking agents (OR 3.49; 95%CI [1.50-8.11]) were independently associated with DBMV. The incidence of DI was 1.2%. No association between DBMV and DI was found (Fisher's exact test, P = 1.0). CONCLUSIONS: This is the first published report of the incidence of unexpected DBMV among healthy pediatric patients.

Comparison the incidence of emergence agitation between sevoflurane and desflurane after pediatric ambulatory urologic surgery.

OBJECTIVE: To compare the incidence and severity of emergence agitation, recovery profile, and adverse events between desflurane and sevoflurane anesthesia in unpremedicated pediatric ambulatory urologic surgery patients. MATERIAL AND METHOD: The study was conducted among 136 healthy children, aged six months to nine years, and randomized to two groups, sevoflurane and desflurane, during maintenance anesthesia with laryngeal mask airway. Recovery profile and perioperative adverse events were recorded. The emergence agitation (EA) was assessed using a 4-point scale by an anesthetist nurse in the recovery room who was blinded to the treatment. RESULTS: The incidences of EA between sevoflurane/desflurane were not significantly different at 36.8%/41.2%, p = 0.73, and neither was the median (IQR) of severity (2 (1, 3)/2 (1, 3), p = 0.4). The awakening time in the desflurane group was 6.4 +/- 4.0 minutes, faster than in the sevoflurane group of 10.6 +/- 7.6 minutes (p < 0.001). The number of children having intraoperative respiratory events was significantly higher in the desflurane group (17), compared to the sevoflurane group (7) (p = 0.043). CONCLUSION: The occurrence of EA and adverse events between sevoflurane and desflurane were not different, except that the overall of intraoperative respiratory events was higher in desflurane group.

Single dose of gabapentin for prophylaxis intrathecal morphine-induced pruritus in orthopedic surgery: a randomized controlled trial.

OBJECTIVE: Gabapentin has an antipruritus effect, which its efficacy in reducing pruritus induced by intrathecal morphine has not been well documented. The purpose of the present study was to know if a single smaller dose of gabapentin could decrease the intrathecal morphine-induced pruritus. MATERIAL AND METHOD: One hundred sixty eight patients from the 180 recruited patients fulfilled the trial requirement and were scheduled for orthopedic surgery under spinal anesthesia using 0.5% isobaric bupivacaine and 0.2 mg preservative-free morphine. The patients were divided into two groups, each of 84 subjects and received either gabapentin 600 mg or a placebo, two hours preoperatively, in a prospective, randomized, double-blind, placebo-controlled trial. The pruritus was evaluated at 1, 2, 3, 4, 6, 9, 12 and 24 hours after intrathecal morphine administration. Adverse events were noted. RESULTS: The overall incidence of pruritus was not significantly different between the two groups while the incidence and severity of pruritus was significantly decreased in the gabapentin group at four hours after intrathecal morphine injection (18 of 84 subjects, 21.4% vs. 35 of 84 subjects, 41.7%; p = 0.008 and 0.045 respectively). The urinary retention was significantly higher in the study group compared to the placebo group (50.0% (42 of 84 subjects) vs. 33.3% (28 of 84 subjects) p = 0.042). CONCLUSION: Preoperative gabapentin 600 mg did not significantly reduce the postoperative intrathecal morphine-induced pruritus.