A comparison of the success rate of radial artery cannulation between the ultrasound-guided and conventional palpation techniques in elderly patients undergoing cardiothoracic surgery.

Background: Ultrasound-guided (USG) radial artery cannulation against the standard palpation technique increases the first attempt rate in both pediatric and adult patients. The objective of this study was to evaluate the benefits of USG versus the palpation technique in improving the first attempt rate in elderly patients. Methods: The patients over 65 years of age were randomized to the USG or Palpation group. The radial artery identification in the USG group was performed with the aid of the Sonimage HS 1. In the Palpation group, the radial artery was identified by manual palpation. The operators were cardiothoracic anesthesiologists. Overall success was defined as cannulation completed within 10 min. Results: Eighty patients (40 in each group) were recruited. The respective first attempt and overall success rate for the USG group were similar to the Palpation group (P > 0.999 and P = 0.732). The time to the first attempt and overall success were also similar (P = 0.075 and P = 0.636). The number of attempts, number of catheters used, and failure rates were similar between the groups (P = 0.935, P = 0.938, and P = 0.723). The number of successful cannulations within 10 min was similar for both the groups as categorized by the radial artery diameter (P = 0.169). Conclusions: The USG did not increase the first attempt or overall success rate of radial artery cannulation in the elderly patients undergoing cardiothoracic surgery. The time to first attempt and overall success were similar between both the groups. The number of attempts and number of catheters used were similar between both groups.

Correlation and agreement of regional cerebral oxygen saturation measured from sensor sites at frontal and temporal areas in adult patients undergoing cardiovascular anesthesia.

Background: The function and viability of the brain depend on adequate oxygen supply. A decrease in cerebral blood supply causing cerebral desaturation may lead to many neurological complications. Direct measurement of regional cerebral oxygen saturation (rScO2) assists in early detection and management. Near-infrared spectroscopy (NIRS) has been introduced for measuring rScO2. A pair of sensors are attached to the right and left forehead. However, there are some situations where the forehead of the patient is not accessible for sensor attachment (e.g., neurosurgery involving the frontal area; a bispectral index (BIS) sensor already attached, or a wound to the forehead); therefore, alternate sites for sensor attachment are required. The temporal area was proposed as an alternate site. The objective of this study was to assess the correlation and agreement of rScO2 measured at the forehead vs. the temporal area. Methods: Adult patients undergoing cardiothoracic or vascular surgery were monitored for rScO2 using two pairs of ForeSight sensors. The first pair (A1 and A2) were attached to the right and left forehead, while the second pair (B1 and B2) were attached to the right and left temporal area. The rScO2 values measured from A1 vs. B1 and A2 vs. B2 were assessed for correlation and agreement using the Bland-Altman analysis. Results: Data from 19 patients with 14,364 sets of data were analyzed. The data from A1 vs. B1 and A2 vs. B2 showed moderate positive correlation (r = 0.627; P < 0.0001 and r = 0.548; P < 0.0001). The biases of A1 vs. B1 and A2 vs. B2 were -2.3% (95% CI [-2.5 to -2.2]; P < 0.0001) and 0.7% (95% CI [0.6-0.8]; P < 0.0001). The lower and upper limits of agreement of A1 vs. B1 were -17.5% (95% CI [-17.7 to -17.3]) and 12.8% (95% CI [12.6-13.0]). The lower and upper limits of agreement of A2 vs. B2 were -14.6% (95% CI [-14.8 to -14.4]) and 16.0% (95% [CI 15.8-16.3]). Conclusions: The rScO2 values measured from sensors at the frontal and temporal areas show a moderate correlation with sufficiently good agreement. The temporal area may be an alternative to the frontal area for cerebral oximetry monitoring.

Efficacy of early goal-directed therapy using FloTrac/EV1000 to improve postoperative outcomes in patients undergoing off-pump coronary artery bypass surgery: a randomized controlled trial.

BACKGROUND: Early goal-directed therapy (EGDT) using FloTrac reduced length of stay (LOS) in intensive care (ICU) and hospital among patients undergoing coronary artery bypass graft (CABG) with a cardiopulmonary bypass. However, this platform in off-pump CABG (OPCAB) has received scant attention, so we evaluated the efficacy of EGDT using FloTrac/EV1000 as a modality for improving postoperative outcomes in patients undergoing OPCAB. METHODS: Forty patients undergoing OPCAB were randomized to the EV1000 or Control group. The Control group received fluid, inotropic, or vasoactive drugs (at the discretion of the attending anesthesiologist) to maintain a mean arterial pressure 65-90 mmHg; central venous pressure 8-12 mmHg; urine output ≥ 0.5 mL kg-1 h-1; SpO2 > 95%; and hematocrit ≥ 30%. The EV1000 group achieved identical targets using information from the FloTrac/EV1000. The goals included stroke volume variation < 13%; cardiac index (CI) of 2.2-4.0 L min-1 m-2; and systemic vascular resistance index of 1500-2500 dynes s-1 cm-5 m-2. RESULTS: The EV1000 group had a shorter LOS in ICU (mean difference - 1.3 d, 95% CI - 1.8 to - 0.8; P < 0.001). The ventilator time for both groups was comparable (P = 0.316), but the hospital stay for the EV1000 group was shorter (mean difference - 1.4 d, 95% CI - 2.1 to - 0.6; P < 0.001). CONCLUSIONS: EGDT using FloTrac/EV1000 compared to conventional protocol reduces LOS in ICU and hospital among patients undergoing OPCAB. Trial registration This study was retrospectively registered at www. CLINICALTRIALS: gov (NCT04292951) on 3 March 2020.

Efficacy of Intraoperative Hemodynamic Optimization Using FloTrac/EV1000 Platform for Early Goal-Directed Therapy to Improve Postoperative Outcomes in Patients Undergoing Coronary Artery Bypass Graft with Cardiopulmonary Bypass: A Randomized Controlled Trial.

PURPOSE: Early goal-directed therapy (EGDT) using the FloTrac system reportedly improved postoperative outcomes among high-risk patients undergoing non-cardiac surgery. This study's objective was to evaluate the FloTrac/EV1000 platform's efficacy for improving postoperative outcomes in cardiac surgery. PATIENTS AND METHODS: Eighty-six adults undergoing coronary artery bypass graft (CABG) with cardiopulmonary bypass (CPB) in 2 tertiary referral centers were randomized to the EGDT or Control group. The Control group was managed with standard care to achieve the following goals: mean arterial pressure 65-90 mmHg; central venous pressure 8-12 mmHg; urine output ≥0.5 mL·kg-1·h-1; oxygen saturation >95%; and hematocrit 26-30%. The EGDT group was managed to reach similar goals using information from the FloTrac/EV1000 monitor. The targets were stroke volume variation <13%; stroke volume index 33-65 mL·beat-1·m-2; cardiac index 2.2-4.0 L·min-1·m-2; and systemic vascular resistance index 1600-2500 dynes·s·cm-5·m-2. RESULTS: The intensive care unit (ICU) stay of the EGDT group was significantly shorter (mean difference -29.5 h; 95% CI -17.2 to -41.8, P < 0.001). The mechanical ventilation time was also shorter in the EGDT group (mean difference -11.3 h; 95% CI -2.7 to -19.9, P = 0.011). The hospital LOS was shorter in the EGDT group (mean difference -1.1 d; 95% CI -0.1 to -2.1, P = 0.038). CONCLUSION: EGDT using FloTrac/EV1000 can be applied in CABG with CPB to improve postoperative outcomes.

Comparative study of analgesia nociception index (ANI) vs. standard pharmacokinetic pattern for guiding intraoperative fentanyl administration among mastectomy patients.

BACKGROUND: The Analgesia Nociception Index (ANI) has been suggested as a non-invasive guide for analgesia. Our objective was to compare the efficacy of ANI vs. standard pharmacokinetic pattern for guiding intraoperative fentanyl administration. METHODS: This was a prospective, randomized, controlled study of adult female patients undergoing elective mastectomy under general anesthesia. The patients were randomized to the ANI-guided group receiving a loading dose of 75 µg of fentanyl followed by 25 µg when the ANI score was under 50. The Control group received the same loading dose followed by 25 µg every 30 min with additional doses when there were signs of inadequate analgesia (viz., tachycardia or hypertension). RESULTS: Sixty patients-30 in each group-were recruited. Although the actual mean ANI score was higher in the ANI-guided than in the Control group (mean difference 2.2; 95% CI: 0.3 to 4.0, P = 0.022), there was no difference in the primary outcome-i.e., intraoperative fentanyl consumption (mean difference - 4.2 µg; 95% CI: - 24.7 to 16.4, P = 0.686 and - 0.14 µg·kg- 1·h- 1; 95% CI: - 0.31 to 0.03, P = 0.105). No difference between groups was shown for either intraoperative blood pressure and heart rate, or for postoperative outcomes (i.e., pain scores, morphine consumption, or sedation scores) in the postanesthesia care unit. CONCLUSIONS: Intraoperative fentanyl administration guided by ANI was equivalent to that guided by a modified pharmacologic pattern. In a surgical model of mastectomy, the ANI-guided intraoperative administration of fentanyl had no impact on clinical outcomes. TRIAL REGISTRATION: The study was registered with ClinicalTrials.gov ( NCT03716453 ) on 21/10/2018.

1-1-8 one-step sevoflurane wash-in scheme for low-flow anesthesia: simple, rapid, and predictable induction.

BACKGROUND: Sevoflurane is suitable for low-flow anesthesia (LFA). LFA needs a wash-in phase. The reported sevoflurane wash-in schemes lack simplicity, target coverage, and applicability. We proposed a one-step 1-1-8 wash-in scheme for sevoflurane LFA to be used with both N2O and Air. The objective of our study was to identify time for achieving each level of alveolar concentration of sevoflurane (FAS) from 1 to 3.5% in both contexts. METHODS: We recruited 199 adults requiring general anesthesia with endotracheal intubation and controlled ventilation-102 in group N2O and 97 in group Air. After induction and intubation, a wash-in was started using a fresh gas flow of O2:N2O or O2:Air at 1:1 L·min- 1 plus sevoflurane 8%. The ventilation was controlled to maintain end-tidal CO2 of 30-35 mmHg. RESULTS: The rising patterns of FAS and inspired concentration of sevoflurane (FIS) are similar, running parallel between the groups. The FAS/FIS ratio increased from 0.46 to 0.72 within 260 s in group N2O and from 0.42 to 0.69 within 286 s in group Air. The respective time to achieve an FAS of 1, 1.5, 2, 2.5, 3, and 3.5% was 1, 1.5, 2, 3, 3.5, and 4.5 min in group N2O and 1, 1.5, 2, 3, 4, and 5 min in group Air. The heart rate and blood pressure of both groups significantly increased initially then gradually decreased as FAS increased. CONCLUSIONS: The 1-1-8 wash-in scheme for sevoflurane LFA has many advantages, including simplicity, coverage, swiftness, safety, economy, and that it can be used with both N2O and Air. A respective FAS of 1, 1.5, 2, 2.5, 3, and 3.5% when used with N2O and Air can be expected at 1, 1.5, 2, 3, 3.5, and 4.5 min and 1, 1.5, 2, 3, 4, and 5 min. TRIAL REGISTRATION: This study was retrospectively registered with ClinicalTrials.gov (NCT03510013) on June 8, 2018.

Emergency Surgery Mortality (ESM) Score to Predict Mortality and Improve Patient Care in Emergency Surgery.

BACKGROUND: Emergency surgery has poor outcomes with high mortality. Numerous studies have reported the risk factors for postoperative death in order to stratify risk and improve perioperative care; nevertheless, a predictive model based upon these risk factors is lacking. OBJECTIVE: We aimed to identify the risk factors of postoperative mortality and to construct a new model for predicting mortality and improving patient care. METHODS: We included adult patients undergoing emergency surgery at Srinagarind Hospital between January 2012 and December 2014. The patients were randomized: 80% to the Training group for model construction and 20% to the Validation group. Patient data were extracted from medical records and then analyzed using univariate and multivariate logistic regression. RESULTS: We recruited 758 patients, and the mortality rate was 14.5%. The Training group comprised 596 patients, and the Validation group comprised 162. Based upon a multivariate analysis in the Training group, we constructed a model to predict postoperative mortality-an Emergency Surgery Mortality (ESM) score based on the coefficient of each risk factor from the multivariate analysis. The ESM score comprised 7 risk factors, i.e., coagulopathy, ASA class 5, bicarbonate <15 mEq/L, heart rate >100/min, systolic blood pressure <90 mmHg, renal comorbidity, and general surgery, for a total score of 11. An ESM score ≥4 was predictive of postoperative mortality with an AUC of 0.83. The respective sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, positive predictive value, negative predictive value, and accuracy for an ESM score ≥4 predictive of postoperative mortality was 70.2%, 94.9%, 13.8, 0.3, 69.4%, 95.1%, and 91.4%. The performance of the ESM score in the Validation group was comparable. CONCLUSIONS: An ESM score comprises 7 risk factors for a total score of 11. An ESM score ≥4 is predictive of postoperative mortality with a high AUC (0.83), sensitivity (70.2%), and specificity (94.9%). Four risk factors are preoperatively manageable for decreasing the probability of postoperative mortality and improving quality of patient care.

Validation of Open-Heart Intraoperative Risk score to predict a prolonged intensive care unit stay for adult patients undergoing cardiac surgery with cardiopulmonary bypass.

BACKGROUND: A prolonged stay in an intensive care unit (ICU) after cardiac surgery with cardiopulmonary bypass (CPB) increases the cost of care as well as morbidity and mortality. Several predictive models aim at identifying patients at risk of prolonged ICU stay after cardiac surgery with CPB, but almost all of them involve a preoperative assessment for proper resource management, while one - the Open-Heart Intraoperative Risk (OHIR) score - focuses on intra-operative manipulatable risk factors for improving anesthetic care and patient outcome. OBJECTIVE: We aimed to revalidate the OHIR score in a different context. MATERIALS AND METHODS: The ability of the OHIR score to predict a prolonged ICU stay was assessed in 123 adults undergoing cardiac surgery (both coronary bypass graft and valvular surgery) with CPB at two tertiary university hospitals between January 2013 and December 2014. The criteria for a prolonged ICU stay matched a previous study (ie, a stay longer than the median). RESULTS: The area under the receiver operating characteristic curve of the OHIR score to predict a prolonged ICU stay was 0.95 (95% confidence interval 0.90-1.00). The respective sensitivity, specificity, positive predictive value, and accuracy of an OHIR score of ≥3 to discriminate a prolonged ICU stay was 93.10%, 98.46%, 98.18%, and 95.9%. CONCLUSION: The OHIR score is highly predictive of a prolonged ICU stay among intraopera-tive patients undergoing cardiac surgery with CPB. The OHIR comprises of six risk factors, five of which are manipulatable intraoperatively. The OHIR can be used to identify patients at risk as well as to improve the outcome of those patients.

Comparative study of minimal fresh gas flow used in Lack-Plus and Lack's circuit in spontaneously breathing anesthetized adults.

BACKGROUND: The Lack's circuit is a co-axial Mapleson A breathing system commonly used in spontaneously breathing anesthetized adults but still requires high fresh gas flow (FGF). The Lack-Plus circuit was invented with the advantage of lower FGF requirement. The authors compared the Lack-Plus and Lack's circuit for the minimal FGF requirement with no rebreathing in spontaneously breathing anesthetized adults. METHODS: This was a randomized crossover study. We enrolled 24 adult patients undergoing supine elective surgery, with a body mass index ≤30 kg/m2 and an American Society of Anesthesiologists physical status I-II. They were randomly allocated to group 1 (LP-L) starting with Lack-Plus then switching to Lack's circuit or group 2 (L-LP) (with the reverse pattern). After induction and intubation, anesthesia was maintained with 50% N2O/O2 and desflurane (4%-6%) plus fentanyl titration to maintain an optimal respiratory rate between 10 and 16/min. Starting with the first circuit, all the patients were spontaneously breathing with a FGF of 4 L/min for 10 min, gradually decreased by 0.5 L/min every 5 min until FGF was 2.5 L/min. End-tidal CO2, inspired minimum CO2 (ImCO2), mean arterial pressure, and oxygen saturation were recorded until rebreathing (ImCO2 >0 mmHg) occurred. The alternate anesthesia breathing circuit was used and the measurements were repeated. RESULTS: The respective minimal FGF at the point of rebreathing for the Lack-Plus and Lack's circuit was 2.7±0.8 and 3.3±0.5 L/min, respectively, p<0.001. At an FGF of 2.5 L/min, the respective ImCO2 was 1.5±2.0 and 4.2±2.6 mmHg, respectively, p<0.001. CONCLUSION: The Lack-Plus circuit can be used safely and effectively, and it requires less FGF than Lack's circuit in spontaneously breathing anesthetized adults.

A fatal adverse effect of cefazolin administration: severe brain edema in a patient with multiple meningiomas.

Cefazolin is commonly administered before surgery as a prophylactic antibiotic. Hypersensitivity to cefazolin is not uncommon, and the symptoms mostly include urticaria, skin reaction, diarrhea, vomiting, and transient neutropenia, which are rarely life threatening. We present a rare case of fatal cefazolin hypersensitivity in a female who was diagnosed with multiple meningiomas and scheduled for craniotomy and tumor removal. Immediately after cefazolin IV administration, the patient developed acute hypertensive crisis, which resolved within 10 minutes after the treatment. This was followed by unexplained metabolic acidosis. The patient then developed severe brain edema 100 minutes later. The patient had facial edema when her face was exposed for the next 30 minutes. A computed tomography scan revealed global brain edema with herniation. She was admitted to the intensive care unit for symptomatic treatment and died 10 days after surgery from multiorgan failure. The serum IgE level was very high (734 IU/mL). Single-dose administration of cefazolin for surgical prophylaxis may lead to rare, fatal adverse reaction. The warning signs are sudden, unexplained metabolic acidosis, hypertensive crisis, tachycardia, and facial angioedema predominating with or without cutaneous symptoms like urticaria.

1-1-12 one-step wash-in scheme for desflurane low flow anesthesia: performance without nitrous oxide.

BACKGROUND: We reported a 1-1-12 wash-in scheme for desflurane-nitrous oxide (N2O) low flow anesthesia that is simple, rapid, and predictable. There remain some situations where N2O should be avoided, which limits the generalizability of this wash-in scheme. The objective of our study was to determine the performance of this scheme in contexts where N2O is not used. METHODS: We recruited 106 patients scheduled for elective surgery under general anesthesia. After induction and intubation, wash-in was started with a fresh gas flow of air:O2 1:1 L/min and a vaporizer concentration of desflurane of 12%. Controlled ventilation was then adjusted to maintain PACO2 at 30-35 mmHg. RESULTS: The alveolar concentration of desflurane (FAD) rose rapidly from 0% to 6% in 4 minutes in the same pattern as observed in our previous study in which N2O was used. An FAD of 7% was achieved in 6 minutes. An FAD of 1% to 7% occurred at 0.6, 1, 1.5, 2, 3, 4, and 6 minutes. The rise in heart rate during wash-in was statistically significant, although not clinically so. There was a slight but statistically significant decrease in blood pressure, but this had no clinical significance. CONCLUSION: Performance of the 1-1-12 wash-in scheme is independent of the use of N2O. Respective FADs of 1%, 2%, 3%, 4%, 5%, 6%, and 7% can be expected at 0.6, 1, 1.5, 2, 3, 4, and 6 minutes.

Transdermal fentanyl patch for postoperative analgesia in total knee arthroplasty: a randomized double-blind controlled trial.

PURPOSE: To assess the efficacy of a transdermal fentanyl patch (TFP) (50 µg/hour) applied 10-12 hours before surgery versus placebo for postoperative pain control of total knee arthroplasty (TKA). MATERIALS AND METHODS: We enrolled 40 patients undergoing elective TKA under spinal anesthesia using isobaric or hyperbaric bupivacaine. Subjects were randomized to receive a TFP (Duragesic(®) 50 µg/hour) or placebo patch applied with a self-adhesive to the anterior chest wall 10-12 hours before spinal anesthesia. Every patient was given patient-controlled morphine for postoperative pain control. Patients were evaluated every 4 hours until 48 hours. RESULTS: Morphine consumption at 24 and 48 hours in the TFP group versus the placebo group was 15.40±12.65 and 24.90±20.11 mg versus 33.60±19.06 and 57.80±12.65 mg (P≤0.001). Numeric rating scale scores at rest and during movement over 48 hours were lower in the TFP group. Ambulation and nausea/vomiting scores were statistically greater, but not clinically significant in the TFP group. Sedation scores were low and not statistically significantly different between groups. There was no severe respiratory depression. CONCLUSION: TFP (50 µg/hour) applied 10-12 hours before surgery can effectively and safely decrease morphine consumption and pain scores during the first 48 hours after TKA surgery.

1-1-12 one-step wash-in scheme for desflurane-nitrous oxide low-flow anesthesia: rapid and predictable induction.

BACKGROUND: We propose a 1-1-12 wash-in scheme for desflurane-nitrous oxide (N2O) low-flow anesthesia. The objective of our study was to determine the time to achieve alveolar concentration of desflurane (FAD) at 1, 2, 3, 4, 5, and 6%. METHODS: We enrolled 106 patients scheduled for elective surgery under general anesthesia. After induction and intubation, wash-in was started with a fresh gas flow (FGF) of N2O : O2 1 : 1 L min(-1) and vaporizer concentration of desflurane (FD) of 12%. Ventilation was controlled to maintain PACO2 at 30-35 mmHg. RESULTS: The FAD rose rapidly from 0 to 4% in 2 min in a linear manner in 0.5 min increments. An FAD of 6% was achieved in 4 min in a linear fashion from FAD of 4% but in 1 min increments. An FAD of 1 to 6% occurred at 0.6, 1, 1.5, 2, 3, and 4 min. Heart rate during wash-in showed a statistically, albeit not clinically, significant pattern of increase. By contrast, blood pressure slightly decreased during this period. CONCLUSIONS: We developed a 1-1-12 wash-in scheme using a FGF of N2O : O2 1 : 1 L min(-1) and FD of 12% for desflurane-nitrous oxide low-flow anesthesia. A respective FAD of 1, 2, 3, 4, 5, and 6% can be expected at 0.6, 1, 1.5, 2, 3, and 4 min.

Development of an open-heart intraoperative risk scoring model for predicting a prolonged intensive care unit stay.

BACKGROUND: Based on a pilot study with 34 patients, applying the modified sequential organ failure assessment (SOFA) score intraoperatively could predict a prolonged ICU stay, albeit with only 4 risk factors. Our objective was to develop a practicable intraoperative model for predicting prolonged ICU stay which included more relevant risk factors. METHODS: An extensive literature review identified 6 other intraoperative risk factors affecting prolonged ICU stay. Another 168 patients were then recruited for whom all 10 risk factors were extracted and analyzed by logistic regression to form the new prognostic model. RESULTS: The multivariate logistic regression analysis retained only 6 significant risk factors in the model: age ≥ 60 years, PaO2/FiO2 ratio ≤ 200 mmHg, platelet count ≤ 120,000/mm(3), requirement for inotrope/vasopressor ≥ 2 drugs, serum potassium ≤ 3.2 mEq/L, and atrial fibrillation grading ≥ 2. This model was then simplified into the Open-Heart Intraoperative Risk (OHIR) score, comprising the same 6 risk factors for a total score of 7-a score of ≥ 3 indicating a likely prolonged ICU stay (AUC for ROC of 0.746). CONCLUSIONS: We developed a new, easy to calculate OHIR scoring system for predicting prolonged ICU stay as early as 3 hours after CPB. It comprises 6 risk factors, 5 of which can be manipulated intraoperatively.

A comparison of spinal isobaric levobupivacaine and racemic bupivacaine for lower abdominal and lower extremity surgery.

BACKGROUND: Levobupivacaine is a new long-acting local anesthetic, which is the isolated S-enantiomer of racemic bupivacaine with less cardiovascular and central nervous system toxicity than bupivacaine. Reports using levobupivacaine for epidural or brachial plexus anesthesia suggested equivalent clinical efficacy to bupivacaine. However, inadequate information for spinal anesthesia was found OBJECTIVE: To study the onset of motor block and other anesthetic efficacy of intrathecally administered racemic bupivacaine compared with levobupivacaine. MATERIAL AND METHOD: A prospective randomized double blind study at Srinagarind Hospital included seventy patients aged 18-65 years, ASA I-II, scheduled for elective lower abdominal and lower extremity surgery under spinal anesthesia was done. Exclusion criteria were known hypersensitivity to amide local anesthetics, contraindication against spinal anesthesia, morbid obesity, or patient unable to understand the study protocol. The patients were divided into two groups. They received either 0.5% isobaric racemic bupivacaine 3 mL or 0.5% isobaric levobupivacaine 3 mL for spinal anesthesia. The measurement included vital signs, peak block height, motor and sensory blockade and side effects. RESULTS: There was no significant difference between the two groups in the quality of motor and sensory block (p-value > 0.05). The median of peak block height of racemic bupivacaine and levobupivacaine group was T9 (T6-T12) and T9 (T4-T12) respectively Afew adverse events were detected and treated carefully with no clinically significant difference between groups. CONCLUSION: The present study indicated that 15 mg of isobaric racemic bupivacaine and levobupivacaine for spinal anesthesia had equivalent peak block height and showed equally effective efficacy regarding to both the onset time and duration of motor and sensory blockade.

Less tachycardia in adults when using atropine 0.9 mg compared with 1.2 mg plus neostigmine 2.5 mg.

OBJECTIVE: Compare the increase in heart rate in adults after 0.9 vs. 1.2 mg of atropine plus neostigmine 2.5 mg as the non-depolarizing muscle relaxant reversal agent. MATERIAL AND METHOD: A randomized, double blind, controlled trial on 46 adults ASA I-II, undergoing elective gynecological or general surgery with balanced general anesthesia was performed. The subjects were randomized into two groups, After surgery, the study group received 0.9 mg of atropine, while the control group received 1.2 mg of atropine. Both groups received 2.5 mg of neostigmine simultaneously. RESULTS: The heart rate and blood pressure were taken at 0, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 15, 20, 25, and 30 min after the injection. The increase in heart rate and blood pressure between the two groups were compared. The heart rate (at 3, 4, 5, and 6 min) of patients in the study group increased significantly less than that of patients in the control group. There was no significant difference in blood pressure between groups and no side effects occurred. CONCLUSION: The authors conclude that 0.9 mg of atropine with 2.5 mg neostigmine can be safely used as the reversal agent for a non-depolarizing muscle relaxant, particularly in patients for whom any increase in heart rate would be harmful.

Surveillance of anesthetic related complications at Srinagarind Hospital, Khon Kaen University, Thailand.

OBJECTIVE: To identify the incidence of common anesthetic complications in 2003 at Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Thailand and find the strategies for prevention. MATERIAL AND METHOD: The study was part of a multi-center study conducted by the Thai Royal College of Anesthesiologists to survey anesthetic related complications in Thailand in 2003. The authors collected data from all the cases receiving anesthesia service at Srinagarind Hospital between January 1 and December 31, 2003, to report the incidence of common anesthetic complications and to assess the need to improve the quality of service. This was a prospective, descriptive study. When any anesthetic complications occurred, they were reported by anesthesia personnel and anesthesiologists. The reporting forms comprised four categories of complications, viz.: respiratory, cardiovascular, neurological and others. Each category of complications has a guidebook for reference in order to correctly fill out the form. All the forms were verified by the principal author then included in the present study. RESULTS: A total of 10,607 patients were included and among these 268 incidents were recorded. The common incidents per 10,000 were desaturation (95.22), cardiac arrest (44.31), re-intubation (29.23), equipment failure (19.80) and difficult intubation (18.86). Main contributing factors were insufficient knowledge and inappropriate decisions. Suggested corrective strategies included quality assurance activities, additional training and improved supervision. CONCLUSION: Despite practical prevention guidelines being in place, the most common anesthesia incident at Srinagarind Hospital was respiratory incident. Continuing quality improvement is needed.