Quality of Anesthesia Care in a University Hospital in Thailand.

BACKGROUND: Service quality is an important factor, which value differs between the patient's satisfaction and expectation. The patient's expectations are important factors for development. This service quality is a key part for improvement of our anesthesia service. In general, an improvement in service design and delivery helps to achieve higher levels of the service quality. OBJECTIVE: To evaluate the level of patient's expectation, patient's satisfaction and the quality of anesthesia care in a university hospital in Thailand MATERIAL AND METHOD: The patient satisfaction questionnaire, developed from service quality criteria and patient satisfaction questionnaire (PSQ-18), was applied to evaluate 467 in patients 24-72 hours after anesthesia care. The patients'expectation was also assessed A proportional stratified randomized allocation was done. The questionnaire consisted of three dimensions; 1) structure: reliability & empathy, 2) process: assurance & tangible and 3) result: responsiveness. Data expectation and satisfaction were analyzed with mean, standard deviation, t-test, ANOVA and normalized gain for the quality of anesthesia care. RESULTS: The patient's satisfaction in our anesthesia care is relatively high. The mean patient's satisfaction score is significantly higher than the mean patient's expectation in all dimensions. This study indicated that an anesthesia service in our hospital was a high quality service in the inpatient aspects. CONCLUSION: Patient's expectation and satisfaction with anesthesia services in our setting was relatively high. Although most patients never had been any expectation regarding anesthesia service, the information and the involvement in decision- making were the most requirements of the adult inpatients.

Maternal and neonatal outcomes in women with severe pre-eclampsia undergoing cesarean section: a 10-year retrospective study from a single tertiary care center: anesthetic point of view.

OBJECTIVE: This study is aiming to determine an actual incidence and characteristics of complications in cesarean section for severe pre-eclampsia (PE) by analysis of a large cohort from a single tertiary care center according to two choices of anesthesia. METHODS: Electronic medical records of pregnant women complicated with severe PE delivered by cesarean section from January 2002 to December 2011 were retrospectively reviewed. Medical records of their corresponding neonates were also identified and reviewed. RESULTS: A total of 701 women and 740 neonates (28 twin pairs) were identified. Anesthetic techniques were spinal anesthesia (SA) (88%) and general anesthesia (GA) (12%). Total maternal and neonatal deaths were 0.3% and 1.2%, respectively. Patients in GA group had a higher incidence of coagulopathy, immediate postpartum hemorrhage, intensive care unit admission, renal failure, respiratory complications, and death (p < 0.05). Neonates born from women in GA group had a higher incidence of lower birth weight, birth asphyxia, prematurity, neonatal intensive care admission, respiratory complications, and death (p < 0.05). CONCLUSION: Spinal anesthesia can be safely administered to severely pre-eclamptic parturients undergoing cesarean section. General anesthesia is associated with more untoward outcomes, as it has been chosen in patients with more severity of the disease.

Predictors for complications in pregnant women with heart disease, a retrospective study.

OBJECTIVE: Evaluate the CARPREG score in predicting cardiac, obstetric, and neonatal complications in pregnant women with heart disease. MATERIAL AND METHOD: This was a retrospective study between 2002 and 2011 at a tertiary care center and included 175 pregnant women with heart disease. Maternal and neonatal outcomes were assessed using Cardiac in Pregnancy Score (CARPREG), which included NYHA-class, systolic ejection fraction, left ventricular obstruction, and history of cardiac events. RESULTS: Rheumatic heart disease (n = 116, 66.3%) was the predominant cardiac problem. CARPREG score was 0, 1, > 1 in 65.1%, 24.6%, and 10.3% pregnancies, respectively. Maternal cardiac events occurred in 27.4%. CARPREG score > or = 1 was associated with an increased rate of cardiac events [odds ratio (OR) 6.76, 95% confidence interval (CI) 3.26 to 14.01]. Fetal complications occurred 24.4%. Neonatal birth weight < 2,500 g was associated with CARPREG score > or = 1 (OR 2.57, 95% CI 1.29 to 5.11). CONCLUSION: Maternal cardiac events can be predicted using CARPREG risk index. In Thai population, rheumatic heart disease was the most frequent form of cardiac problems in pregnant women.

Predictor of core hypothermia and the surgical intensive care unit.

UNLABELLED: Inadvertent postoperative core hypothermia is associated with multiple physiological effects, especially in patients admitted to the intensive care unit (ICU). Despite previous reports of the relationship between patient, surgical, and anesthetic factors and immediate postoperative core hypothermia, this information might need to be reconsidered in the light of progress in surgery, anesthetic, and warming techniques. We designed this prospective study of 194 postgeneral surgical patients to assess the incidence, predictive factors, and outcome of core hypothermia (tympanic membrane core temperature [Tc] <36.0 degrees C) at the time of admission to the general ICU in a large tertiary university medical center from December 2000 to March 2001. The following variables were studied: age, sex, body weight, body surface area, preoperative body temperature, ASA physical status, history of diabetic neuropathy, emergency surgery, surgical subspecialty performing surgery, type of surgery, type of anesthesia (general, regional, or combined epidural and general), temperature monitoring, use of a forced air warming technique, amount of fluid and blood replacement, duration of anesthesia, duration of surgery, and the ambient operating room temperature. Other outcomes, i.e., length of ICU stay and mortality, were also assessed. The incidence of core hypothermia was 57.1%, 41.3%, and 28.3% according to the definition of Tc <36.0 degrees C, <35.5 degrees C, and <35.0 degrees C, respectively. Multiple logistic regression showed the following risk factors for core hypothermia: high ASA physical status (odds ratio, 2.87; 95% confidence interval [CI], 0.82-10.03 for ASA II; odds ratio, 8.35; 95% CI, 1.67-41.88 for ASA >II), magnitude of surgical procedure (odds ratio, 6.60; 95% CI, 1.66-26.19 for medium surgery; odds ratio, 22.23; 95% CI, 5.41-91.36 for major surgery), use of combined epidural and general anesthesia (odds ratio, 3.39; 95% CI, 1.05-10.88), and duration of surgery >2 h (odds ratio, 4.50; 95% CI, 1.48-13.68). Not using temperature monitoring seems to be a risk factor as well (odds ratio, 3.00; 95% CI, 0.87-10.12). Significant protective factors against core hypothermia were heavier body weight (odds ratio, 0.94; 95% CI, 0.89-0.98), higher preoperative body temperature (odds ratio, 0.31; 95% CI, 0.15-0.65), and warmer ambient operating room temperature (odds ratio, 0.67; 95% CI, 0.51-0.88). In conclusion, the incidence of core hypothermia (Tc <36.0 degrees C) at the time of admission to the general ICU is still frequent. To reduce the incidence, more efforts and concern should be taken to prevent core hypothermia, especially in the patient with high ASA physical status, undergoing more intensive and lengthy surgery, and using combined epidural and general anesthesia. IMPLICATIONS: In an effort to decrease the frequent incidence of core hypothermia at the time of admission to the general surgical intensive care unit, this prospective study showed that high ASA physical status, the use of a combined epidural and general anesthesia, surgery lasting longer than 2 h, and extensive surgery were the important risk factors, whereas heavier body weight, higher preoperative body temperature, and warmer ambient operating room temperature were important protective factors.

Adding droperidol to morphine patient-controlled analgesia: effect on nausea and vomiting.

This prospective, double-blind, randomized, controlled trial was performed to evaluate the antiemetic effectiveness and side effects of adding droperidol to morphine delivered via a patient-controlled analgesia (PCA) device in 94 women undergoing transabdominal hysterectomy with a standardized anesthetic regimen. They were randomly allocated to receive postoperative PCA as either bolus doses of morphine I mg or a combination of morphine 1 mg and 0.0625 mg droperidol with a lockout interval of 5 minutes and no continuous infusion. The incidence of nausea 6-18 hours postoperatively and 18-24 hours postoperatively was significantly lower in the morphine and droperidol group than in the morphine only group and its severity 2-6 hours, 6-18 hours, and 18-24 hours postoperatively was significantly lower. The number needed to treat to prevent nausea comparing the morphine only group at 6-18 and at 18-24 hours postoperatively were 4 and 4 (95% CI 2-27 and 2-11, respectively). The amount of morphine used 6-18 hours postoperatively in the droperidol group was lower than in the morphine only group. Although the incidence of vomiting and the amount of rescue antiemetics were lower in the morphine and droperidol group, the difference was not statistically significant. Postoperative pain scores were not different between the groups. No patients were oversedated. A series of extrapyramidal reactions were observed in one patient in the morphine and droperidol group. The drug and consumable item cost was not different between the groups. We conclude that droperidol added to morphine in PCA reduces nausea. The appropriate dose of droperidol should be further investigated to reduce the incidence of vomiting.

EMLA cream and intraperitoneal lidocaine decrease intraoperative pain during postpartum tubal sterilization.

UNLABELLED: We conducted a randomized, double blinded, placebo controlled trial to evaluate the effectiveness of EMLA cream together with intraperitoneal lidocaine for pain relief in postpartum tubal ligation. In a factorial designed study, 90 postpartum patients were randomly assigned to have 5 g of EMLA or placebo cream applied to the skin in 2 groups of 45 patients and to have intraperitoneal instillation of 20 ml of either 1 per cent, 2 per cent lidocaine or normal saline in 3 groups of 30 patients. A numerical rating pain score (0-10) was used during skin check, skin infiltration and uterine tube manipulation. The pain scores were significantly lower in the EMLA group as compared with the placebo group during the skin forceps check (p < 0.001) and during local skin infiltration (p < 0.05). The pain scores were also significantly lower during intraabdominal manipulation in the group using either 1 per cent or 2 per cent intraperitoneal lidocaine as compared with the group using normal saline (p < 0.001), but no difference was found between the groups using 1 per cent and 2 per cent lidocaine. IMPLICATIONS: Five g of EMLA cream applied to the skin together with 20 ml of 1 per cent lidocaine instilled into the abdominal cavity effectively decrease intraoperative pain in patients undergoing postpartum tubal sterilization under local anesthesia.