Study of model of anesthesia related adverse event by incident report at King Chulalongkorn Memorial Hospital.

OBJECTIVE: As a site of the Thai Anesthesia Incidents Monitoring Study (Thai AIMS), the authors continued data collection of incident reports to find out the frequency, clinical course, contributing factors, factors minimizing adverse events, and investigation of model appropriate for possible corrective strategies in a Thai university hospital. MATERIAL AND METHOD: A standardized anesthesia incident report form that included close-end and open-end questions was provided to the attending anesthesia personnel of King Chulalongkorn Memorial Hospital between January I and December 31, 2007. They filled it on a voluntary and anonymous basis. Each incident report was reviewed by three reviewers. Any disagreement was discussed to achieve a consensus. RESULTS: One hundred sixty three incident reports were filled reporting 191 incidents. There were fewer male (44%) than female (56%) patients and they had an ASA physical status classification 1 (41%), 2 (43%), 3 (10%), 4 (4%) and 5 (2%). Surgical specialties that posed high risk of incidents were general, orthopedic, gynecological, otorhino-laryngological and urological surgery. Locations of incident were operating room (85%), ward (8%) and recovery room (2%). The common adverse incidents were oxygen desaturation (23%), arrhythmia needing treatment (14%), equipment malfunction (13%), drug error (9%), difficult intubation (6%), esophageal intubation (5%), cardiac arrest (5%), reintubation (4%), and endobronchial intubation (4%). Adverse events were detected by monitoring only (27%), by monitoring before clinical diagnosis (26%), by clinical diagnosis before monitoring (21%), and by clinical diagnosis only (26%). Incidents were considered to be from anesthesia related factor (73%), system factor (16%) and preventable (47%). CONCLUSION: Common factors related to incident were inexperience, lack of vigilance, haste, inappropriate decision, not comply with guidelines, and lack of equipment maintenance. Suggested corrective strategies were quality assurance activity, additional training, clinical practice guidelines, equipment maintenance, and improvement of supervision.

The Thai Anesthesia Incidents Monitoring Study (Thai AIMS) of adverse events after spinal anesthesia: an analysis of 1996 incident reports.

BACKGROUND: To study the incidents of complications, adverse events and anesthetic profiles ofspinal anesthesia from primary to tertiary hospitals across Thailand. MATERIAL AND METHOD: The present study is a descriptive research design. Participating anesthesia providers are requested to report the standardized incident reporting form as soon as they find the predetermined adverse or undesirable events during anesthesia until 24 hours after the operation. Data from the incident report were reviewed and analyzed to identify contributing factors and preventive strategies by consensus by three-peer reviewers. The objections were discussed and the decision was made in order to achieve general agreement. RESULTS: One hundred and sixty-seven cases adverse events after spinal anesthesia were reportedfrom fifty-one hospitals across Thailand. Eighty-five cases (50.9%) were male; eighty-two cases (49.1%) were female. Seventy cases (41.9%) occurred in patients whose age was more than 60 years. One hundred and thirty-one cases (78.4%) had ASA I and II, seventy cases (41.9%) occurred spontaneously whereas ninety-seven cases (58.1%) were considered as preventable. Most of the incidents (74.4%) were bradycardia (HR < 50 beats per minute). The others were hypotension (18.6%), respiratory complications (hypoxia and pulmonary edema) (5.4%), myocardial infarction (3.6%), and cardiac arrest (6.6%). Most of the incidents (88.6%) were detected by EKG pulse oximeter (64.7%), and NIBP (71.3%) respectively. Anesthetic factors and systemic factors that found to be involved in all cases were high spinal block, inadequate prehydration and delayed resuscitation. Most of the contributing factors were inappropriate decision making (45%), inexperienced performers (20%), inadequate preoperative evaluation and preparation (19%). The incidents should be minimized by having prior experience, high awareness and experienced assistants available. For immediate outcome that occurred within 24 hours, eighteen cases (10.8%) had major physiological change such as hypoxia, pulmonary edema, myocardial infarction or neurological deficit. Ten cases (6%) died within 24 hours and one case (0.6%) had cardiac arrest intra-operative period For long term outcome within 7 days, one hundred and fifty-seven reported cases (94%) had complete recovery; fourteen cases (8.4%) had prolonged hospital stay and ventilatory days. CONCLUSION: To minimize the adverse events after spinal anesthesia, the authors suggest corrective strategies which include established guideline practice, additional training, improved supervision and having quality assurance activity in each hospital.

Pain on injection of propofol: propofol LCT vs propofol MCT/LCT with or without lidocaine pretreatment.

BACKGROUND: Pain on injection was a disadvantage of propofol long-chain triglyceride (LCT) and reduces patient satisfaction. Based on a systematic review, the recommended method to attenuate this pain was a previous administration of lidocaine under tourniquet for 30-120 seconds before injection of propofol (pretreatment of lidocaine). Recently, propofol medium-chain triglyceride/long-chain triglyceride (MCT/LCT) emulsion was proposed for its ability to decrease pain on injection. The authors conducted a double-blind randomized controlled trial to compare the incidence and severity of pain on injection between the new propofol MCT/LCT and the propofol LCT with and without lidocaine pretreatment. MATERIAL AND METHOD: 360 adult patients with ASA physical status I-III who underwent general anesthesia were assigned into 4 groups by computer-generated randomization; Group I - pretreatment of lidocaine 1% and propofol LCT Group I - pretreatment oflidocaine 1% and propofol MCT/LCT Group III - pretreatment of saline and propofol MCT/LCT and Group IV- pretreatment of saline and propofol LCT mixed with lidocaine 1%. All groups received pretreatment under tourniquet for 60 seconds. Evaluators who were blinded to the injected drugs recorded pain intensity (none, mild, moderate and severe) after the first 30% of total induction dose ofpropofol was injected at a rate of 1 ml/s by questioning patients. Data was analyzed by using Kruskal-Wallis testfor ordinal data. Post hoc analysis was performed by using the Mann-Whitney U-test with Bonferroni's correction on pairwise comparisons and was considered significant with p value of less than 0.05. RESULTS: Patients in an individual group had insignificant differences in their demographic data. The incidences of pain in Group I, II, III and IV were 61.1%, 46.7%, 62.2% and 55.6% respectively with an average incidence of 56% (p = 0.006). There were 15.6%, 5.6%, 23.3% and 24.4% of patients in Group I, II, III and IV who rated pain intensity as severe. Pain on injection of propofol MCT/LCT with lidocaine pretreatment was less than propofol MCT/LCT alone (p = 0.001). CONCLUSION: The incidence of pain on injection of propofol MCT/LCT was not different from that caused by propofol LCT with pretreatment of lidocaine and the intensity of pain on propofol MCT/LCT injection decreased significantly when using lidocaine pretreatment. Therefore, the authors could conclude that an injection of new propofol MCT/LCT solution was an alternative in reducing pain sensation to propofol LCT with pretreatment of lidocaine. Additionally, pain of propofol MCT/LCT injection could be alleviated by pretreatment of lidocaine with a 60 seconds tourniquet time before the injection ofpropofol.