Anaesthesia/analgesia for manual removal of retained placenta.

BACKGROUND: As a retained placenta is a potential life-threatening obstetrical complication, effective and timely management is important. The estimated mortality rates from a retained placenta in developing countries range from 3% to 9%. One possible factor contributing to the high mortality rates is a delay in initiating manual removal of the placenta. Effective anaesthesia or analgesia during this procedure will provide adequate uterine relaxation and pain control, enabling it to be carried out effectively. OBJECTIVES: To assess the effectiveness and safety of general, regional, and local anaesthesia or analgesia during manual removal of a retained placenta. SEARCH METHODS: We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov and the World Health Organization's International Clinical Trials Registry Platform to 30 September 2019, and reference lists of retrieved studies. SELECTION CRITERIA: We sought randomised controlled trials (RCTs), quasi-randomised controlled trials, and cluster-randomised trials that compared different methods of preoperative or intraoperative anaesthetic or analgesic, administered during the manual removal of a retained placenta. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the study reports for inclusion, and risk of bias, extracted data and checked them for accuracy. We followed standard Cochrane methodology. MAIN RESULTS: We identified only one randomised controlled trial (N = 30 women) that evaluated the effect of paracervical block on women undergoing manual removal of a retained placenta compared with intravenous pethidine and diazepam. The study was conducted in a hospital in Papua New Guinea. The study was at high risk of bias of performance bias and detection bias, low risk of attrition bias, and an unclear risk of selection bias, reporting bias, and other bias. The included study did not measure this review's primary outcomes of pain intensity and adverse events. The study reported that there were no women, in either group, who experienced an estimated postpartum blood loss of more than 500 mL. We are uncertain about the providers' satisfaction with the procedure, defined as their perception of achieving good pain relief during the procedure (risk ratio (RR) 1.50, 95% confidence interval (CI) 0.71 to 3.16, one study, 30 women; very low quality evidence). We are also uncertain about the women's satisfaction with the procedure, defined as their perception of achieving good pain relief during the procedure (RR 0.82, 95% CI 0.49 to 1.37; one study, 30 women; very low quality evidence). The included study did not report on any of our other outcomes of interest. AUTHORS' CONCLUSIONS: There is insufficient evidence from one small study to evaluate the effectiveness and safety of anaesthesia or analgesia during the manual removal of a retained placenta. The quality of the available evidence was very low. We downgraded based on issues of limitations in study design (risk of bias) and imprecision (single study with small sample size, few or no events, and wide confidence intervals). There is a need for well-designed, multi-centre, randomised, controlled trials to evaluate the effectiveness and safety of different types of anaesthesia and analgesia during manual removal of a retained placenta. These studies could report on the important outcomes outlined in this review.

A Multi-center Thai University-based Surgical Intensive Care Unit Study (THAI-SICU Study): Incidence of Acute Myocardial Infarction and Associated Factors.

Introduction: To describe the incidence, characteristics and outcomes of acute myocardial infarction (AMI) and determine risk factor(s) of AMI in THAI-surgical intensive care unit (SICU). Material and Method: This study was multicenter prospective cohorts study that conducted data from 9 university-affiliated SICUs in Thailand between April 2011 and January 2013. We collected and evaluated data of AMI events. The patients were followed-up for up to 28 days after admitted to the SICUs. Results: The overall incidence of AMI in SICU was 1.4% (66 of 4,652 patients). Non-ST elevated MI was the most common electrocardiography (ECG) presentation (75%). The common clinical sign and symptom of AMI included ECG changes (53%) and elevation of cardiac enzymes (48.5%). Patients with AMI had significantly higher 28-day mortality rate (28.8% versus 13.6%, p<0.001) than those with non-MI. The Acute Physiologic and Chronic Health Evaluation (APACHE) II scores (RR 1.04, 95% CI 1.01-1.07, p = 0.003) and age >65 year (RR 2.54, 95% CI 1.36-4.75, p = 0.003) were significant risk factors of AMI. Conclusion: The incidence of AMI in the SICU was uncommon but led to significantly higher mortality rates. The APACHE II score and age ≥65 year were significant predictors of AMI in SICU.

Incidence of Cardiac Arrest and Related Factors in a Multi-Center Thai University-Based Surgical Intensive Care Units Study (THAI-SICU Study)

Objective: To describe the incidences, outcomes and determine the risk factor(s) of cardiac arrest in surgical intensive care unit (SICU). Material and Method: We collected data between April 2011 and January 2013. The case record form (CRF) included the CRF 1 (admission, daily screening and discharge data) and the CRF 2 for cardiac arrest events. The patients were followed-up until discharge from SICU or for up to 28 days after admission in SICU. Results: The incidence of cardiac arrest in SICU was 226 in 4,652 patients (4.9%). The APACHE II score at the day with cardiac arrest were 24.1. Initial monitor rhythm during cardiac was asystole (35.4%), bradycardia (22.6%) and pulseless electrical activity (14.6%). The main cause was poor patient condition before admission (51.3%). Most of the cardiac arrest patients (73.9%) had antecedents within 24 hour and the most common antecedents were hypotension, metabolic disturbances and sepsis and/or septic shock. The overall return of spontaneous circulation rate was 23.5%. At hospital discharge, the mortality rate (91.6%) was statistically different between the cardiac arrest and non-cardiac arrest group (p<0.001). The Acute Physiologic and Chronic Health Evaluation II score (APACHE II score) (Odds ratio, (OR 1.15, 95% CI 1.11-1.19, p<0.001), Sequential Organ Failure Assessment score (SOFA score) (OR 1.12, 95% CI 1.03-1.20, p = 0.005) and American Society of Anesthesiologists physical status physical status (ASA PS) ≥3 (OR 2.32, 95% CI 1.33-4.04, p = 0.003) were significantly risk factors for cardiac arrest. Conclusion: Cardiac arrest in the SICU was uncommon. Initial non-shockable rhythms were common and mostly had antecedents before cardiac arrest. The APACHE II score, SOFA score and ASA PS ≥3 were independent risk factors for cardiac arrest in SICU.

Cleft Lip Cleft Palate and Craniofacial Deformities Care: An Anesthesiologist's Perspective at the Tawanchai Center.

BACKGROUND: The increasing number of pediatric patients with cleft lip-palate and craniofacial anomalies is a nuisance problem in the Northeast of Thailand. These patients have complicated problems including physical health, psychosocial, and poor quality of life; therefore, a multidisciplinary care team was established, named Tawanchai center. This study encouraged the improvement of the quality of holistic healthcare service system to improve the quality of life the patients and their families. Anesthesiologists are important personnel in the facilitation of the surgical team, and to help improve other activities including academic, service and research. OBJECTIVE: To relate the perspective of anesthesiologist according to the role they play in the multidisciplinary team. MATERIAL AND METHOD: The database of Anesthesiology department and annual report from the period between June 2005 to July 2015 were collected and reviewed. CONCLUSION: Highly-skilled and experienced anesthesiologist in the multidisciplinary patient care team play a vital role through the provision of advanced and specific knowledge to anesthesia management. The role of anesthesiologists should be researched to enhance the quality of anesthesia management, thereby contributing to national and international patient care team development.

Anesthetic Techniques and Perioperative Complications of Cleft Lip and Cleft Palate Surgery at Srinagarind Hospital.

BACKGROUND: Cleft lip (CL) and cleft palate (CP) are common craniofacial abnormalities with an incidence of around 1:800. Surgical are corrections often performed during the first year of life. These patients have risks for difficult intubation and various perioperative complications due to their young age and craniofacial abnormalities. OBJECTIVE: The purpose of the retrospective descriptive study is to report the data of anesthetic techniques and complications of repairing CLCP in Srinagarind Hospital. These results could improve the caring and services for these groups of patients. MATERIAL AND METHOD: Data was retrieved from anesthetic records of patients undergoing correction of CLCP from the period January 2005 to January 2009. Demographic data, clinical diagnosis, type operation, anesthetic technique, total opiod were analyzed using direct laryngoscopic view, grading intubation, method of intubation, and as well perioperative complications were also analyzed. RESULTS: A total of 469 anesthetic records were obtained. The most common type of CLCP was unilateral side (45.48%). The highest incidence of difficult intubation was found in the CP and unilateral CLCP subgroup (4.48% and 4.48%, respectively). All patients were successfully intubated with a stylet except one patient, in whom retrograde intubation was used. Perioperative complications included desaturation, reintubation, postoperative bleeding, and post-operative nausea and vomiting (PONV). And the highest incidence of PONV was found in the CP (8.95%). Correlation between fentanyl using and postoperative desaturation was statistically significant when multivariate analysis was used (OR = 1.2; p = 0.01). CONCLUSION: Patients with unilateral CLCP or CP had a higher risk for difficult intubation. Fortunately, all of the patients were successfully intubated with advanced anesthetists' skill. Long operative periods and a large dose of opioid could contribute to the postoperative desaturation and PONV.

Comparison of minimal fresh gas requirements of baby enclosed afferent reservoir and Jackson Rees anesthetic circuit for general anesthesia in spontaneously breathing children.

OBJECTIVE: The authors compared the baby enclosed afferent reservoir (Baby EAR) with the Jackson-Rees (JR) anesthesia circuit for the minimal fresh gas flow (FGF) requirement with no and clinically acceptable rebreathing in spontaneous breathing anesthesia among pediatric patients. MATERIAL AND METHOD: The present study was a randomized crossover study. Twenty patients, weighing 5 to 20 kg with ASA physical status I-II were enrolled. They were allocated to group 1 (EAR-JR) starting with Baby EAR then switching to JR or group 2 (JR-EAR), reversedpattern. After induction and intubation, anesthesia was maintainedwith a N2O/O2 combination with sevoflurane 1 to 3% and fentanyl. Starting with the first circuit, all patients were spontaneously ventilated with FGF 500 mL/kg/min for 10 minutes, and then gradually decreased by 50 mL/kg/min every five minutes. End-tidal CO2 (ETCO) and inspired minimum CO2 (imCO) were recorded until rebreathing (imCO2 >2 mmHg) occurred and continued until rebreathing was not clinically acceptable (imCO2 >6 mmHg). The anesthesia breathing circuit was switched and the procedure repeated. RESULTS: The minimal FGF at no rebreathing of Baby EAR and JR were 192.5±76.6 and 347.5±108.2 mL/kg/min; p<0.001. At acceptable rebreathing, the values were 117.5±46.7 and 227.6±90.6 mL/kg/min; p< 0. 001. CONCLUSION: Baby EAR can be used safely, effectively, and requires less FGF than JR in pediatric anesthesia in patients weighing 5 to 20 kg.