Maximum Surgical Blood Order Schedule for Elective Neurosurgery in a University Teaching Hospital in Northern Thailand.

CONTEXT: Preoperative blood bank testing should optimize the trade-off between intraoperative transfusion delay and blood wastage. AIMS: This study aims to develop a maximal surgical blood order schedule (MSBOS) for elective neurosurgery. SETTINGS AND DESIGN: Prospective data in University Teaching Hospital, Northern Thailand. SUBJECTS AND METHODS: Blood transfusion data were collected on all adult patients satisfying inclusion/exclusion criteria in 2015. Patients were assigned to ten procedure groups (G): vascular: (1) Aneurysm/arteriovenous malformation, (2) Cerebrovascular bypass; tumor resection: (3) Meningioma, (4) Other, (5) Cerebellopontine angle, (6) Pituitary/craniopharyngioma, (7) Endoscopic pituitary; and miscellaneous: (8) Cranioplasty, (9) Spine, (10) Other. The crossmatch-transfusion ratio (C/T), transfusion probability (%T), and transfusion index (Ti) were calculated. MSBOS was generated by applying published criteria, subjected to clinical neurosurgical judgment. STATISTICAL ANALYSIS USED: Statistical Package for the Social Sciences, Vision 20. RESULTS: Of 377 patients, 95% underwent preoperative cross-and-match (C and M) testing for 1422 red blood cell (RBC) units, while 3% had no type and screen (T and S) nor C and M, and 2% had T and S only. Overall C/T was 6.6, with range from 4 for G3-53 for G8. Intraoperative %T was 27%. Intraoperative Ti was 0.6. Our MSBOS recommended T and S only for G2, G7, G8, G9, G10; C and M of 2 RBC units for G1, G4, G5, G6; and C and M 2-to-4 for G3. If this were followed in 2015, intraoperative blood needs would have been satisfied for ≥82% of patients, and substantial reductions achieved in blood banking fees. CONCLUSIONS: Our MSBOS may help optimize blood ordering and serve as an example for similar efforts for other surgical specialties.

Factors Associated with Operating-Room Extubation after Emergency Craniotomy.

Objective: To determine clinical factors and outcomes associated with operating-room extubation. Material and Method: Three hundred seventy three medical records of emergency craniotomy were reviewed. The author categorized by whether the patients underwent operating-room extubation (ORE) or not (nORE). Demographic and perioperative factors were reviewed for association with ORE, e.g. Glasgow coma scale score (GCS), brain edema, and duration of anesthesia. Outcomes included clinical status, and duration in intensive care unit and hospital stay. Results: Of the 373 patients, 130 (35%) had been extubated in the operating room. The strongest factors associated with ORE were no perioperative brain edema (adjusted odds ratio [OR] = 76.44 [95% confidence interval 9.46-617.50], p<0.001), high GCS score from 13 to 15 (adjusted OR = 3.74 [1.99-7.01], p<0.001), and better ASA physical class IE or IIE (adjusted OR = 2.09 [1.21-3.59], p = 0.008). The median lengths of time in the intensive care unit (ICU) were significantly shorter among OREs (3 days, range 2-5) than nOREs (4 days, range 3-8), p<0.001, as well as for duration of hospital stay (7 days, range 4-10 vs. 8 days, range 5-13, respectively, p = 0.008). Conclusion: After emergency neurosurgery, ORE is associated with absent cerebral edema, high GCS score, and better ASA status.

Plasma glucose level in elective surgical patients administered with 5% dextrose in 0.45% NaCl in comparison with those receiving lactated Ringer's solution.

OBJECTIVE: To determine the effect of dextrose containing solution (5% dextrose in 0.45% NaCl) compared to non-dextrose containing solution (lactated Ringer's solution) on plasma glucose level in elective surgical patients. MATERIAL AND METHOD: A prospective randomized double-blind control trial was conducted on 60 patients aged 18-60, with ASA physical status I to II, who were scheduled for elective surgery at Maharaj Nakorn Chiang Mai Hospital, Thailand between October; 2007 and September; 2008. The patients received either lactated Ringer's solution (Group L), or 5% dextrose in 0.45% NaCl (Group D) in the morning of the operation day. Blood glucose levels were determined before intravenous fluid administration (T0), at the beginning (T1), after the 1st hr (T2), and at the end of surgery (T3). RESULTS: Mean duration of preoperative fast was almost 11 hrs in both groups; however, none of the patients had preoperative hypoglycemia. The blood sugar levels were significantly higher in the patients receiving 5% dextrose solution compared to the patients receiving lactated Ringer's solution at the beginning, after the 1st hr and at the end of surgery (p-value = 0.06, 0.018 and 0.036 respectively). There were some patients having hyperglycemia after receiving 5% dextrose in 0.45% NaCl during surgery. However, none of the average plasma glucose values in either group was considered as hyperglycemia. CONCLUSION: Though they fasted many hours before surgery, no patients were found to have hypoglycemia. The large volume of lactate Ringer's solution had minimal effect on the blood sugar levels compared to the levels in 5% dextrose in 0.45% NaCl group. Therefore, lactate Ringer's solution is probably the alternative choice of intravenous fluid for perioperative maintenance and can be used as replacement in healthy patients undergoing elective surgery.

Effect of scalp infiltration on postoperative pain relief in elective supratentorial craniotomy with 0.5% bupivacaine with adrenaline 1:400,000.

OBJECTIVE: Determine the effect of scalp infiltration on postoperative craniotomy pain with 0.5% bupivacaine with adrenaline 1:400,000. MATERIAL AND METHOD: A prospective randomized double blind control trial was conducted on 50 patients (18-65 years), who were ASA physical status I to III, and scheduled for elective intracranial surgery at Maharaj Nakorn Chiang Mai Hospital, Thailand between October 2006 and December 2007. The patients received wound infiltration before skin closure by either 0.5% bupivacaine with adrenaline 1.:400,000 (group B), or normal saline with adrenaline 1:400,000 (group S). RESULTS: The median pain score in the first 12 hours trended to be lower in the bupivacaine group than in the control, but the differences were not statistically significant apart from the score in the first hour (median pain score = 2, IQR = 3; p = 0.031). There were more pain-free patients in the bupivacaine group than in the control group at all time intervals during the first 12 hours. However, the difference was significant in the first hour (7 vs. 1; p = 0.034). Although the median (range) time interval between the end of surgery and first administration of tramadol was longer in the bupivacaine group, when compared to the control group, it was not statistically significant. CONCLUSION: Surgical wound infiltration, before skin closure, with 0.5% bupivacaine with adrenaline decreased the incidence and severity of postoperative pain in patients undergoing supratentorial craniotomy, but only for the first hour after surgery.

Incidence and risk factors of emergence agitation in pediatric patients after general anesthesia.

OBJECTIVE: To study the incidence and evaluate factors associated with emergence agitation (EA) in pediatrics after general anesthesia. MATERIAL AND METHOD: A prospective observational study was conducted in 250 pediatric patients aged 2-9 years, who received general anesthesia for various operative procedures in Maharaj Nakorn Chiang Mai Hospital between October 2006 and September 2007. The incidence of EA was assessed Difficult parental-separation behavior, pharmacologic and non-pharmacologic interventions, and adverse events were also recorded Univariate and multivariate analysis were used to determine the factors associated with EA. A p-value of less than 0.05 was considered significant. RESULTS: One hundred and eight children (43.2%) had EA, with an average duration of 9.6 +/- 6.8 minutes. EA associated with adverse events occurred in 32 agitated children (29.6%). From univariate analysis, factors associated with EA were difficult parental-separation behavior, preschool age (2-5 years), and general anesthesia with sevoflurane. However; difficult parental-separation behavior; and preschool age were the only factors significantly associated with EA in the multiple logistic regression analysis with OR = 3.021 (95% CI = 1.680, 5.431, p < 0.001) and OR = 1.857 (95% CI = 1.075, 3.206, p = 0.026), respectively. CONCLUSION: The present study indicated that the incidence of EA was high in PACU. Preschool children and difficult parental-separation behavior were the predictive factors of agitation on emergence. Therefore, anesthesia personnel responsible for pediatric anesthesia should have essential skills and knowledge to effectively care for children before, during, and after an operation, including implementing the methods that minimize incidence of EA.