Fatal Air Embolism after Choroidal Melanoma Endoresection without Air Infusion: A Case Report.

BACKGROUND: The aim of this study was to report 2 cases of pulmonary air embolism developing several hours after choroidal melanoma endoresection without the use of air infusion during the surgery, with fatality in 1 patient. METHODS: The method of this study was case report. PARTICIPANTS: Two patients with large choroidal melanomas who collapsed several hours after endoresection without air infusion as a result of pulmonary air embolism. RESULTS: A 72-year-old man collapsed 4 h and 30 min after endoresection without air infusion. Computerized tomography angiography confirmed air embolism. The patient died after 86 min of cardiopulmonary resuscitation. A 41-year-old woman collapsed 5 h and 30 min after endoresection, performed without air infusion and with close monitoring, which included right internal jugular vein catheterization intraoperatively. Transthoracic and transesophageal echography, performed preoperatively, intraoperatively, and postoperatively, revealed air embolism only after collapse occurred. Imaging showed the embolism to be biventricular because of patent foramen ovale. The patient was treated promptly with extracorporeal membrane oxygenation and mechanical ventilation, which resulted in a full recovery. CONCLUSIONS: Air embolism can develop after endoresection for choroidal melanoma, despite avoiding air infusion. Further studies are needed to understand how this occurs. Special measures are indicated to detect this complication and to treat it promptly and effectively.

Systematic comparison of four point-of-care methods versus the reference laboratory measurement of hemoglobin in the surgical ICU setting: a cross-sectional method comparison study.

BACKGROUND: Transfusion decision during the perioperative period mostly relies on the point-of-care testing for Hb measurement. This study aimed systematically compared four point-of-care methods with the central laboratory measurement of hemoglobin (LHb) regarding the accuracy, precision, and assay practicality to identify the preferred point-of-care method during the perioperative period. METHODS: This cross-sectional method comparison study was conducted in the surgical intensive care unit at Ramathibodi Hospital, Thailand, from September 2015 to July 2016. Four point-of-care methods, i.e., capillary hematocrit (HctCap), HemoCue Hb201+, iSTAT with CG8+ cartridge, and SpHb from Radical-7 pulse co-oximeter were carried out when LHb was ordered. Pearson correlation and Bland-Altman analyses were performed to assess the accuracy and precision, while the workload, turnaround time, and the unit cost were evaluated for the method practicality. RESULTS: Thirty-five patients were enrolled, corresponding to 48 blood specimens for analyses, resulting in the measured hemoglobin of 11.2 ± 1.9 g/dL by LHb. Ranking by correlation (r), mean difference (bias) and 95% limit of agreement (LOA) showed the point-of-care methods from the greater to the less performance as followed, iSTAT-LHb pair (r = 0.941; bias 0.15 (95% LOA; - 1.41, 1.12) g/dL), HemoCue-LHb pair (r = 0.922; bias - 0.18 (95% LOA; - 1.63, 1.28) g/dL), SpHb-LHb pair (r = 0.670; bias 0.13 (95% LOA; - 3.12, 3.39) g/dL) and HctCap-LHb pair (r = 0.905; bias 0.46 (95% LOA; - 1.16, 2.08) g/dL). Considering the practicality, all point-of-care methods had less workload and turnaround time than LHb, but only HemoCue and HctCap had lower unit cost. CONCLUSION: This study identified HemoCue as the suitable point-of-care method for the sole purpose of Hb measurement in the surgical ICU setting, while iSTAT should be considered when additional data is needed.

Effects of pregabalin on post operative morphine consumption and pain after abdominal hysterectomy with/without salphingo-oophorectomy: a randomized, double-blind trial.

BACKGROUND: Achieving post operative pain management is difficult with the use of only opioids analgesia. Multimodal pain management is a method to improve post operative analgesia with minimal side effects. Pregabalin has an analgesic and opioids sparing effects in post operative analgesia. OBJECTIVE: The objective of the present study was to evaluate the effect of premedication with pregabalin 300 mg compared with lorazepam 0.5 mg on post operative morphine consumption in women undergoing abdominal hysterectomy with/without salphingo-oophorectomy. MATERIAL AND METHOD: Eighty ASA I-III, aged 18-65 year patients undergoing elective abdominal hysterectomy with/without salphingo-oophorectomy were randomized to receive either lorazepam 0.5 mg or pregabalin 300 mg 1 hr before surgery. Anesthesia was induced with thiopental (3-5 mg/kg) and atracurium (0.6 mg/kg) and maintained with sevoflurane with a fresh gas flow of 2 L/min (50% N2O in O2) and morphine 0.1-0.2 mg/kg. All patients received patient-controlled analgesia with morphine with a 1 mg incremental dose, 5-min lockout interval, and 4-hr limit of 40 mg post operative. Patients were studied at 0, 1, 4, 12 and 24 hours post operatively for verbal numerical rating scale (VNRS), morphine consumption, satisfaction score and side effects. RESULTS: The VNRS scores of the pregabalin group were significantly lower than the control group at 1, 4, 12 and 24 hours after surgery. The total morphine consumption at 24 hours post operatively of pregabalin group (7.11 +/- 5.57) was significantly lower than the control group (21.18 +/- 7.12) (p < 0.01). There were no differences between groups in somnolence and dizziness (p = 0.93) and nausea-vomiting (p = 0.11). The satisfaction score was higher in the pregabalin group. CONCLUSION: A 300 mg pregabalin administered 1 hr preoperatively before abdominal hysterectomy with/without salphingo-oophorectomy significantly reduced morphine consumption, VNRS pain score and improved satisfaction score at 24 hr post operatively without any significant differences in side effects. Pregabalin is an alternative combination to opioids as multimodal analgesia.

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.

The Thai Anesthesia Incident Monitoring Study (Thai AIMS) of desaturation: an analysis of 1,996 incident reports.

BACKGROUND AND RATIONALE: The present study is a part of the Multicentered Study of Model of Anesthesia related Adverse Events in Thailand by Incident Report (The Thai Anesthesia Incident Monitoring Study or Thai AIMS). The objective of the present study was to determine the frequency distribution, outcomes, contributory factors, and factors minimizing incident. MATERIAL AND METHOD: The present study is a prospective descriptive research design. The authors extracted relevant data from the incident reports on oxygen desaturation from the Thai AIMS database and analyzed during the study period between January and June 2007. RESULTS: From the relevant 445 incidents, most of the incidents (89%) occurred in patients receiving general anesthesia. The incidence in patients receiving regional anesthesia was 4.0%. The events mostly occurred in patients aged between 16-65 years (52.8%). Most of the events (76%) took place in the operating theater during the induction period (30.1%). More than 81% of the patients experienced severe oxygen desaturation (SpO2 < 85%). There were 55 patients (12.4%) who had unplanned ICU admission and 2 patients (0.4%) who had unplanned hospital admission. Factors that may relate to the incident involve combined factors (50.8%). Anesthetic factors were found to involve 38.4% of incidents. The common contributing factors that might lead to the incidents were inexperienced (57.5%), inappropriate decision (56.2%), and haste (23.8%). For factors minimizing incident, the important factors were vigilance (86.3%), experienced in that tropic (71.2%), and experienced assistance (54.8%). Quality assurance activity was the most common suggestive corrective strategy (79.1%). The others were improvement of supervision (47.2%) and guideline practice (46.5%). CONCLUSION: To lower the incidence of oxygen desaturation, the anesthesia personnel has to improve the anesthesia services by quality assurance activity, improvement of supervision, clinical practice guidelines, and additional training.

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.

Erythropoietin mimics the acute phase response in critical illness.

BACKGROUND: In a prospective observational study, we examined the temporal relationships between serum erythropoietin (EPO) levels, haemoglobin concentration and the inflammatory response in critically ill patients with and without acute renal failure (ARF). PATIENTS AND METHOD: Twenty-five critically ill patients, from general and cardiac intensive care units (ICUs) in a university hospital, were studied. Eight had ARF and 17 had normal or mildly impaired renal function. The comparator group included 82 nonhospitalized patients with normal renal function and varying haemoglobin concentrations. In the patients, levels of haemoglobin, serum EPO, C-reactive protein, IL-1beta, IL-6, serum iron, ferritin, vitamin B12 and folate were measured, and Coombs test was performed from ICU admission until discharge or death. Concurrent EPO and haemoglobin levels were measured in the comparator group. RESULTS: EPO levels were initially high in patients with ARF, falling to normal or low levels by day 3. Thereafter, almost all ICU patients demonstrated normal or low EPO levels despite progressive anaemia. IL-6 exhibited a similar initial pattern, but levels remained elevated during the chronic phase of critical illness. IL-1beta was undetectable. Critically ill patients could not be distinguished from nonhospitalized anaemic patients on the basis of EPO levels. CONCLUSION: EPO levels are markedly elevated in the initial phase of critical illness with ARF. In the chronic phase of critical illness, EPO levels are the same for patients with and those without ARF, and cannot be distinguished from noncritically ill patients with varying haemoglobin concentrations. Exogenous EPO therapy is unlikely to be effective in the first few days of critical illness.