Efficacy of the Enhanced Recovery After Surgery program for thoracic surgery in a developing country.

Purpose: Enhanced Recovery After Surgery (ERAS) is a strategy used to improve perioperative outcomes and reduce complications. However, data on the efficacy of ERAS in thoracic surgery in developing countries are limited. The current study aimed to validate the benefits of ERAS among patients at a single institution. Methods: This was a retrospective study of patients who underwent pulmonary resection at Vajira Hospital, Bangkok, Thailand, between 2016 and 2020. To compare outcomes, patients were divided into the pre-ERAS group (2016-2018) and the post-ERAS group (2019-2020) using propensity score matching (1:2) with the year 2019 as the cutoff for introducing ERAS protocols at our institution. Results: In total, 321 patients were included in the analysis (pre-ERAS group, n = 74; post-ERAS group, n = 247). After propensity score matching, 56 and 112 patients were classified under the pre- and post-ERAS groups, respectively. The post-ERAS group had significantly lower pain scores than the pre-ERAS group on postoperative days 1, 2, and 3, and a lower volume of intraoperative blood loss. In the multivariable analysis, the post-ERAS group had a shorter chest tube duration (mean difference = -1.62 days, 95% confidence interval = -2.65 to -0.31) and length of hospital stay (mean difference = -2.40 days, 95% confidence interval = -4.45 to -0.65) than the pre-ERAS group. Conclusion: The use of ERAS guidelines in pulmonary resection is beneficial. Although no significant differences were observed in postoperative complication rate, intensive care unit stay, and additional cost burden between the two groups, patients in the post-ERAS group had a shorter postoperative chest tube duration, shorter hospital stays, shorter operative time, lower postoperative pain score, and lower volume of intraoperative blood loss.

Perioperative outcomes of non-intubated versus intubated video-assisted thoracoscopic surgery in different thoracic procedures: a propensity score-matched analysis.

BACKGROUND: Non-intubated video-assisted thoracoscopic surgery (NIVATS) is increasingly performed in different types of thoracic procedures. Based on the anesthetic perspective, the outcomes of this method are limited. General anesthesia with intubation and controlled ventilation for video-assisted thoracoscopic surgery (IVATS) is a standard technique. The current study aimed to compare the pulmonary gas exchange between NIVATS and IVATS, with a focus on desaturation event. METHODS: This was a retrospective study conducted at Vajira Hospital. Data were collected from the hospital medical record database between January 9, 2019, and May 15, 2020. A propensity score-matched analysis was used to adjust the confounders by indications and contraindication between NIVATS and IVATS. The perioperative outcomes of VATS and NIVATS were compared by the regression analysis method. RESULTS: In total, 180 patients were included in the analysis. There were 98 and 82 patients in the NIVATS and IVATS groups, respectively. After a propensity score matching, the number of patients with similar characteristics decreased to 52 per group. None of the patients in both groups experienced desaturation. The lowest oxygen saturation of the NIVATS and IVATS groups did not significantly differ (96.5% vs. 99%, respectively; p = 0.185). The NIVATS group had a significantly higher ETCO2 peak than the IVATS group (43 vs. 36 mmHg, respectively; p < 0.001). According to the regression analysis, the NIVATS group had a significantly shorter anesthetic induction time (Mean difference (MD) = -5.135 min (95% CI = (- 8.878)- (-1.391)) and lower volume of blood loss (MD = -75.565 ml (95%CI = (- 131.08)-(- 20.65) but a higher intraoperative ETCO2 than the IVATS group (MD = 4.561 mmHg (95%CI = 1.852-7.269). Four patients in the NIVATS group required conversion to intubation due to difficulties encountered when using the surgical technique (7.7%, p = 0.041). Seven patients in the IVATS group, but none in the NIVATS group, presented with sore throat (13.5% vs. 0%, respectively; p = 0.006). Moreover, none of the patients in both groups experienced postoperative pneumonia, underwent reoperation, or died. CONCLUSIONS: The anesthetic and surgical outcomes of NIVATS were comparable to those of IVATS.

Randomized Double-Blind Controlled Trial Comparing 0.2 mg, 0.1 mg, and No Intrathecal Morphine Combined With Periarticular Injection for Unilateral Total Knee Arthroplasty.

BACKGROUND: The addition of intrathecal morphine (ITM) to neuraxial anesthesia during total knee arthroplasty (TKA) to achieve postoperative analgesia can elicit opioid-related side effects. The other methods of pain alleviation and side effect reduction, including multimodal analgesia, are challenging. This study aimed to determine the efficacy of various ITM dosages for primary unilateral TKA with periarticular injection (PI). METHODS: This randomized double-blind controlled trial was conducted at Vajira Hospital between April 2018 and March 2019. Patients undergoing TKA were randomized into 3 groups: no ITM (M0), ITM 0.1 mg (M1), and ITM 0.2 mg (M2). All patients received PI. Postoperative pain scores, side effects of ITM, and orthopedic outcomes were compared. RESULTS: The trial enrolled 102 patients: M0 (n = 32), M1 (n = 35), and M2 (n = 35). The postoperative pain scores and rescue analgesic consumption of groups M1 and M2 did not differ significantly within the first 24 hours and were significantly lower than those in group M0. Nausea and vomiting were observed more frequently 4 hours postoperatively in M2 than in groups M1 and M0 (77%, 51%, and 6%, respectively; P < .05), which required second-line antiemetic administration (29%, 9%, and 13%, respectively; P = .09). CONCLUSION: Postoperative pain control achieved with PI combined with ITM 0.1 mg after primary unilateral TKA was comparable to that achieved with ITM 0.2 mg. PI without ITM resulted in higher pain scores and rescue analgesic consumption. The frequency and severity of nausea and vomiting 4 hours postoperatively were also lower in patients administered 0.1 mg of ITM than those in patients administered 0.2 mg of ITM.

Nonintubated Video-Assisted Thoracoscopic Surgery Using Local Anesthesia for Catamenial Pneumothorax.

This report describes a case of successful catamenial pneumothorax repair using local anesthesia and sedation. A female patient presented with spontaneous pneumothorax with a persistent air leak. Preoperative computed tomography did not reveal any abnormality. Surgery was planned for exploration. In the intraoperative field, a pore was incidentally found in the diaphragm. Therefore, an apical lung wedge procedure was performed; the pore was resected at the diaphragm and covered with polypropylene mesh. The operation was performed using anesthesia with intravenous agents and an oxygen mask with a reservoir bag without endotracheal intubation. The patient was discharged 4 days postoperatively and was doing well at 1-month follow-up.

The Incidence, Characteristics and Outcomes of Pneumothorax in Thai Surgical Intensive Care Units (Thai-SICU Study).

Objective: To identify incidence, characteristics, and outcomes of pneumothorax among patients who specifically stayed in surgical intensive care units (SICUs). Material and Method: This was a multicenter prospective cohort study conducted in 9 University-affiliated SICUs in Thailand. Incidence of pneumothorax and its outcomes were evaluated from April 2011 to January 2013. Results: 4,652 patients who were admitted to SICU were enrolled. The incidence of pneumothorax was 0.5% (25 cases) in our study. Significant characteristics were found in the pneumothorax group, including: lower BMI, underlying malignancy and COPD, higher APACHE-II and SOFA score within 24 hours of first ICU admission, pulmonary infiltration pattern of chest imaging and usage of mechanical ventilation. In terms of outcome, there were higher SICU mortality and 28-day hospital mortality in pneumothorax than non-pneumothorax patients at 28.0% vs. 9.6%, p = 0.002 and at 44.0% vs. 13.6%, p<0.001, respectively. Conclusion: Patients admitted to surgical intensive care units who developed pneumothorax had higher risk of intensive care unit mortality and 28-day hospital mortality than non-pneumothorax patients, as well as a longer intensive care unit and hospital length of stays.

The Incidence, Characteristics, and Outcomes of Stroke and Seizure In Critically Ill Surgical Patients: A Multicenter Cohort Study of Thai Surgical Intensive Care Units (THAI-SICU Study).

Objective: To explore the incidence, characteristics, and outcomes of patients affected with new onset of stroke and seizure in the surgical intensive care unit (SICU). Material and Method: This study identified new onset of stroke and seizure in 4,652 patients admitted to our multicenter prospective cohort study, a collaboration of nine university-affiliated surgical ICUs in Thailand between April 2011 to January 2013. Results: The authors found new stroke and seizure events at 0.2% and 1%, respectively. The significant characteristics found in stroke and seizure patients included: reason for ICU admission, American Society of Anesthesiologists (ASA) physical status classification, and severity of patients at ICU admission (evaluated by APACHE-II and SOFA day score in first 24 hours of ICU admission). In terms of outcomes, there was higher ICU mortality in both stroke and seizure groups than in nonstroke and non-seizure groups (18% vs. 36% vs. 9%, p<0.001, respectively). In addition, ICU length of stay among stroke and seizure patients was also longer than non-stroke and non-seizure groups (6 (4-18) vs. 10 (4-16) vs. 2 (1-4) days, p<0.001, respectively). However, multivariable regression analysis showed a statistical significance only in longer duration of ICU stay in stroke (6.07 days; 95% CI: 3.34-8.80) and seizure (3.88 days; 95% CI: 2.15-5.62) when compared with nonstroke and non-seizure patients, adjusted by ASA, APACHE-II and SOFA score). Conclusion: From Thai-SICUs study, patients admitted to surgical ICU who developed new episodes of stroke and seizure had longer ICU length of stay when adjusted by their severity score.

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

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