Selective spinal anesthesia versus intravenous propofol in transrectal ultrasound-guided prostate biopsy.

BACKGROUND: Selective spinal anesthesia (SSA) focuses on the use of minimal doses of intrathecal agents with greater precision and selectivity so that return of function occurs rapidly. OBJECTIVE: The authors compared the efficacy of 1.25 mg of hyperbaric bupivacaine intrathecally with propofol anesthesia in terms of hemodynamic stability, surgical conditions and ability to bypass the post anesthetic care unit (PACU). MATERIAL AND METHOD: Seventy male patients, 45-85 years old, ASA physical status I-III, were randomly allocated into two groups. Group 1 (n=35) received intrathecal 1.25 mg hyperbaric bupivacaine plus patients cerebrospinal fluid 0.75 ml. Group 2 (n=35) received propofol 1-1.5 mg/kg IV bolus dose and 6-10 mg/kg/hr infusion to maintain surgical anesthesia. RESULTS: The patients in group 1 had adequate anesthesia and were able to walk and bypass the PACU (100%). The need of supplemental oxygen and airway maneuver; the incidence of hypotension and bradycardia were found only in group 2. The surgical conditions were rated as excellent 100% in group 1 and 57.1% in group 2. CONCLUSION: SSA is superior to propofol anesthesia in terms of hemodynamic stability, surgical conditions and recovery profiles. Even elderly patients were able to walk out from the operating theatre immediately after the procedure.

Evidence-based medicine in clinical curriculum.

INTRODUCTION: The teaching of evidence-based medicine (EBM) has now been incorporated as an integral part of medical curriculum at the Faculty of Medicine, Ramathibodi Hospital but there is little research into the effectiveness of the course. The purpose of this report is to evaluate the EBM skills of medical students and competency of the faculty member. MATERIALS AND METHODS: The EBM course was created by the EBM Working Group at the Faculty of Medicine, Ramathibodi Hospital for 3rd- to 6th-year medical students. The principles of EBM, clinical epidemiology and biostatistics were gradually instilled during the 4 years of medical school. Information technology infrastructure was also provided to facilitate critical appraisal skills. At the end of the Community Medicine clerkship, students anonymously evaluated aspects of the course regarding their EBM skills and faculty member competency with Likert scale questions. RESULTS: Medical students generally gave high evaluations to all aspects of the EBM course taught in the Community Medicine Department. For each of the evaluation questions, the means were higher for faculty member competency. CONCLUSIONS: The teaching of EBM course at the Faculty of Medicine, Ramathibodi Hospital is useful for medical students to enhance their critical thinking skills, and they seem to value the sessions positively.

An analysis of intraoperative recall of awareness in Thai Anesthesia Incidents Study (THAI Study).

OBJECTIVES: This study aimed to analyze intraoperative awareness using database of Thai Anesthesia Incidents Study (THAI Study) with regard to frequency, contributing factors, preventive and corrective strategies. MATERIAL AND METHOD: Details of intraoperative recall of awareness were recorded prospectively by attending anesthesiologists or nurse anesthetists in standardized record forms during February 1, 2003 to July 31, 2004. Participating hospitals included 7 university hospitals, 5 tertiary care hospitals, 4 secondary care hospitals, and 4 primary care hospitals. All data were analyzed to identify contributing factors, preventive and corrective strategies. RESULTS: Among 126078 general anesthetized cases, there were 99 cases of intraoperative recall of awareness. Awareness was found in female patients more than male patients (63% versus 37%). The majority of patients had ASA PS 1 and 2. Cardiac, obstetric, and lower abdominal surgery were involved in anesthesia awareness more than other type of surgery. Patients experiencing awareness reported sound (62%), pain (51%), feeling operated without pain (33%), and paralysis (25%). There was slight impact of anesthesia awareness in Thai patients (only 13% had temporary emotional stress and 13% had mild anxiety) despite small percentage of proper management by reassurance and psychiatric consultation (15%). The contributing factors included inadequate knowledge (67%), inadequate medication dosage (44%), and inadequate care from inexperience (11%). Awareness incidents were documented to be preventable in 36% of patients and partially preventable in 38% of patients. The corrective strategies included guideline practice (30%), additional training (28%), quality assurance activity (19%), and improved supervision (16%). CONCLUSION: The incidence of intraoperative recall of awareness in this study was 0.08%. Patients reported sound, pain, feeling operated without pain, and paralysis. Corrective strategies included guideline practice, additional training, quality assurance activity, and improved supervision.

Perioperative stroke and coma in Thai Anesthesia Incidents Study (THAI Study).

OBJECTIVES: To analyze perioperative stroke and coma using database of Thai Anesthesia Incidents Study (THAI Study) with regard to frequency, contributing factors, preventive and corrective strategies. MATERIAL AND METHOD: Details of perioperative neurological complications comprising stroke and coma in one year were recorded prospectively by attending anesthesiologists or nurse anesthetists in standardized record forms. All data were analyzed to identify contributing factors and preventive strategies. RESULTS: Among 172,592 anesthetics, there were 24 cases of coma, and 28 cases of stroke. Most cases of coma that eventually died (12/16 cases, 75%) had ASA physical status (ASA PS) ranging from 2E to 5E. Perioperative stroke was found mainly in patients with ASA PS 3 and most of the incidence (74%) occurred in patients who had no previous history of stroke. These patients already had pre-existing cardiovascular diseases and underwent high risk procedures. There were 54% of perioperative stroke cases that could be due to improper cardiovascular management and 42% due to improper emergency neurological management. CONCLUSION: The incidence of perioperative stroke and coma in this study was approximately 0.03%. The majority of cases had no prior stroke or coma, which suggested that a problem during perioperative period itself might predispose patients to these complications. Preventive strategies included quality assurance activity, improved communication, and practice guideline.

The Thai Anesthesia Incidents Study (THAI Study) on nerve injury associated with anesthesia.

OBJECTIVES: The Thai Anesthesia Incidents Study (THAI Study) database was used to identify the incidence, outcome and contributing factors of nerve injuries associated with anesthesia in Thai people. MATERIAL AND METHOD: A prospective multicenter study was conducted in 20 hospital in Thailand from February 1, 2003 to January 31, 2004. All patients underwent anaesthesia were monitored for nerve injuries during the first 24 hours. The details of nerve injuries were recorded and analysed. RESULTS: The overall incidence of nerve injuries associated with anesthesia was 1.6 per 10,000 patients. Considering on spinal and regional anesthesia, the incidence was 5.2 per 10,000 patients. Lumbosacral roots comprised 65.4% of the injuries, the brachial plexus nerve 11.5%, and femoral nerve 7.7%. Contributing factors included type and duration of surgery and regional anesthesia. CONCLUSION: The incidence of nerve injuries associated with anesthesia in Thailand was 1.5 per 10,000 patients. The spinal anesthesia was predominantly associated with injury of lumbosacral root.

The Thai Anesthesia Incidents Study (THAI Study) of anesthetic outcomes: II. Anesthetic profiles and adverse events.

BACKGROUND AND RATIONALE: The purposes of the Thai Anesthesia Incidents Study (THAI Study) of anesthetic outcomes were to survey patients, surgical, anesthetic profiles and determine factors related to adverse events. MATERIAL AND METHOD: A prospective descriptive study of occurrence screening was conducted in 20 hospitals comprised of 7 university, 4 general and 4 district hospitals across Thailand. Anesthesia personnel were required to fill up patient-related, surgical-related, anesthesia-related variables and adverse outcomes on a structured data entry form. The data were collected during the preanesthetic evaluation, intraoperative period and 24 hr postoperative period. Adverse events specific forms were used to record when they occurred. All data were keyed at data management unit with double entry technique and descriptive statistics was used in the first phase of this study. RESULTS: A total of 163403 consecutive cases were recorded during first 12 months. MD. anesthesiologists involved with 82%, 89%, 45% and 0.2% of cases in university hospitals, regional hospitals, general hospitals and district hospitals respectively. Nurse anesthetists took a major involvement in hospitals run by the Ministry of Public Health. Two-thirds of cases did not receive any premedication (67%) and midazolam was most frequent premedication administered (20%). Common monitoring were non invasive blood pressure (NIBP) (97%), pulse oximetry (96%), electrocardiography (80%), urine output (33%), airway pressure (27%) and capnometry (19%) respectively. The choices of anesthesia were general anesthesia (62%), spinal anesthesia (23%), total intravenous anesthesia (6%), monitor anesthesia care (4%), brachial plexus block (3%) and epidural anesthesia (1%). The adverse events were oxygen desaturation (31.9:10000), cardiac arrest (30.8:10000), death within 24 hr. (28.3:10000), difficult intubation (22.5:10000),re-intubation (19.4:10000), unplanned ICU admission (7.2:10000), coma/cva/convulsion (4.8:10000), equipment malfunction/failure (3.4:10000), suspected myocardial ischemia or infarction (2.7:10000), awareness during anesthesia (3.8:10000), late detected esophageal intubation (4.1:10000), failed intubation (3.1:10000), anaphylaxis or anaphylactoid reaction (2.1:10000), nerve injury (2:10000), pulmonary aspiration (2.7:10000), drug error (1.3:10000), hazard to anesthesia personnel (1.5:10000), unplanned hospital admission (0.1:10000), total spinal block (1.3:10000) and mismatch blood transfusion (0.18:10000) CONCLUSION: Respiratory adverse events were common anesthesia direct related events. High incidence of cardiac arrest and death within 24 hr highlighted concerns for prevention strategies. Incidents of adverse events can be used for institutional quality improvement, educational quality assurance and further research for patient safety in anesthesia.