Unintended intraoperative awareness: An analysis of Perioperative Anesthetic Adverse Events in Thailand (PAAd Thai).

BACKGROUND: Despite the improvement of anesthetic-related modalities, the incidence of unintended intraoperative awareness remains at around 0.005-0.038%. OBJECTIVE: We aimed to describe the intraoperative awareness incidents that occurred across Thailand between January to December, 2015. METHODS: Observational data was collected from 22 hospitals throughout Thailand. The awareness category was selected from incident reports according to the Perioperative Anesthetic Adverse Events in Thailand (PAAd Thai) study database and descriptive statistics were analyzed. The awareness characteristics and the related factors were recorded. RESULTS: A total of nine intraoperative awareness episodes from 2000 incidents were observed. The intraoperative awareness results were as follows: experience of pain (38.1%), perception of sound (33.3%), perception of intubation (9.5%) and feeling of paralysis (14.3%). The observed factors that affect intraoperative awareness were anesthesia-related (100%), patient-related (55.5%), surgery-related (22.2%) and systematic process-related (22.2%). The contributing factors were situational inexperience (77.8%) and inappropriate patient evaluation (44.4%). An awareness of anesthetic performer (100%) and experience (88.9%) were defined as incident-mitigating factors. The suggested corrective strategies were quality assurance activity (88.9%), improved supervision (44.4%) and equipment utilization (33.3%), respectively. CONCLUSION: Nine intraoperative awareness incidents were observed, however the causes were preventable. The anesthetic component seems to be the most influential to prevent these events.

Validity and reliability of quality of recovery-35 Thai version: a prospective questionnaire-based study.

BACKGROUND: The quality of patients' recovery following surgery and anesthesia has been a matter of focus and concern over the past decade. The Quality of Recovery-40 (QoR-40) questionnaire was developed and validated for post-anesthesia patient evaluation. The QoR-40, however, is English-based and was tested and validated in Caucasian patients, a population that is culturally and behaviorally different from the Thai population. The objective of this study was to translate and modify the original English-language QoR-40 into the Thai language and evaluate the Quality of Recovery-35 Thai version for measuring health outcomes in Thai patients after surgery and anesthesia. METHODS: Translation was performed according to internationally recognized translation standards to ensure the integrity of the translated version. Consistent with the recommendations of 25 anesthesiologists, five questions from the original QoR-40 were excluded. The 35-item questionnaire was then translated into the Thai language and renamed the Quality of Recovery-35 Thai version (Thai QoR-35). Overall, 43 outpatients and 53 inpatients rated their health and recovery status using three patient evaluation tools: 100-mm Visual Analogue Scale-Recovery (VAS-R), six-item Activities of Daily Living (ADL) questionnaire, and Thai QoR-35. RESULTS: Overall, 90 % of patients took <10 min to complete the Thai QoR-35 questionnaire. The Thai QoR-35 and VAS-R showed good convergent validity (r = 0.84, P < 0.001). Discrimination validity was supported by a significant difference in mean scores for recovery among the Thai QoR-35, VAS-R, and ADL when compared between outpatients and inpatients (P < 0.01) and also between baseline and postoperative values (P < 0.001). The Thai QoR-35 also demonstrated good reliability with high internal consistency at three time points (Cronbach's alpha = 0.88, 0.89, 0.91, respectively; P < 0.01) and a split-half reliability coefficient of 0.65 (P < 0.001). CONCLUSION: Thai QoR-35 is a valid, reliable tool for evaluating quality of recovery in Thai patients.

A survey of awareness, opinion and reported use of clinical practice guidelines (CPG) of the Royal College of Anesthesiologists of Thailand.

BACKGROUND: Up to the present (2006), The Royal College of Anesthesiologists of Thailand (RCAT) has proposed and revised six practice guidelines. For guidelines to achieve their objectives, anyone who gets involved needs to be aware of the guidelines, be able to accept, and adhere to them. Although the authors did introduce their guidelines by several passive means, the authors have not yet ascertained what the result were. OBJECTIVE: The primary objective of the present study was to assess awareness, opinion, limitation, and reported use of guidelines. The secondary objective was to identify factors associated with variation, agreement, and reported use of guidelines. MATERIAL AND METHOD: A cross sectional, self-report survey study was conducted. An anonymous questionnaire including prepaid-addressed reply envelopes was mailed to 600 anesthesiologists and 1,300 nurse anesthetists, nationwide, based on the college's list. The questions covered respondents' general characteristics: awareness, agreement, and reported use of the existing guidelines; opinion on implementation media, which guidelines the members need, their local guidelines, and the impact of guidelines on their practice. All data were extracted and reported using descriptive statistics. Multiple logistic regression was done to identify factors associated with an agreement with and a reported use of the guidelines. RESULTS: The overall response rate was 33.4% and nurse anesthetists had a higher response than anesthesiologists. Forty-six percent of the respondents were aware of the existing guidelines. This result corresponded to percentage of those who had read the guidelines (41%). Among the six existing guidelines, the least two guidelines reported use of and agreement with, were those for labor analgesia and conscious sedation (23-28%, 24-28%). The guidelines for spinal anesthesia received the most response (46%). For respondents who had read the guidelines, most of them (80% to 94%) rated the level of agreement and reported use as good to excellent. The respondents also rated the announcement of the guidelines during the annual meeting of the Royal College of Anesthesiologists of Thailand as the best implementation strategy. Impracticability, inadequate dissemination, and un-cooperation among colleagues were the three most important obstacles of using the guidelines. In addition, the present study demonstrated three significant factors, anesthesiologists, regional hospitals, and general hospitals, as associated with reporting frequent use of and high agreement with the guidelines. CONCLUSION: The low level of awareness and reported use of the present guidelines among the members reflects poor implementation and dissemination. However the present study reveals some information that will guide the authors to introduce intensive and targeted interventions to encourage the members to comply and adhere to the guidelines designed to improve the quality of patients' care.

An economic evaluation of bupivacaine plus fentanyl versus ropivacaine alone for patient-controlled epidural analgesia after total-knee replacement procedure: a double-blinded randomized study.

BACKGROUND AND OBJECTIVES: Total-knee replacement (TKR) surgery is one of the most painful orthopedic procedures after surgery. Opioid has been commonly combined with a local anesthetic to improve the quality of pain relief, but the treatment has opioid-related side effects. This study compared the cost effectiveness of patient-controlled epidural analgesia (PCEA) with 0.0625% bupivacaine plus fentanyl (BF) 3 microg/mL versus 0.15% ropivacaine alone (R) during the first 48 hours after TKR procedure. METHODS: This prospective randomized double-blinded study was performed on 70 patients who underwent unilateral TKR procedure and received either BF or R after surgery. Visual analog scale (VAS) pain score at rest and upon movement, side effects, and cost of treatment were compared. RESULTS: Overall pain at rest and upon movement between groups was not significantly different (P = 0.58, 95% CI = 4.4 to -7.8 and P = 0.8, 95% CI = 6.4 to -8.2, respectively). Patients in the BF group experienced more pruritus and had more vomiting episodes than those in the R group (P = .015), whereas no difference occurred in other side effects. Nevertheless, patient satisfaction with pain management was higher in the BF group compared with that in the R group. In addition, pain treatment with bupivacaine and fentanyl was 18% less costly compared with ropivacaine alone. CONCLUSIONS: Considering the economic evaluation, we conclude that PCEA with 0.0625% bupivacaine plus fentanyl 3 microg/mL is more cost effective and provides more patient satisfaction than PCEA with ropivacaine alone. However, use of epidural ropivacaine alone causes fewer opioid-related side effects, particularly pruritus and vomiting.