Difficult intubation in the adult patients undergoing oropharygolaryngeal, neck, and maxillofacial procedures: Thai Anesthesia Incident Monitoring Study (Thai AIMS).

BACKGROUND: Difficult intubation is one of the common anesthetic related complications during the perioperative period. In the patients with pathology or disease involving the oropharyngolarynx, neck, or maxillo-facial region, they might have a potentially higher risk than the general population. OBJECTIVE: To determine the characteristics and the contributing factors of difficult intubation in the adult patients undergoing oropharyngolaryngeal, neck, and maxillofacial procedures, and the factors minimizing this incidence and the suggested corrective strategies. MATERIAL AND METHOD: All incident reports of difficult intubation in the adult patients who received general anesthesia for the procedure involving the oropharyngolarynx, neck, and maxillofacial region from the Thai Anesthesia Incident Monitoring Study (Thai AIMS) database were identified. The details of the reports, the contributing factors, the factors those minimizing the incident, and the suggestive corrective strategies were studied. RESULTS: There were 26 (1.3%) incident reports of difficult intubation from the database. This occurred in 35%, 58%, and 15% of the patients with Mallampati class 1-2, thyromental distance equal or more than 5 cm or 3 fingerbreadths, and combined both parameters, respectively. Forty two percent of cases were judged as an unplanned difficult intubation. Twenty-seven, 23, and 19 percent of the patients had tumor or carcinoma at the oropharyngolarynx, deep neck infection, and maxillofacial fracture, respectively. Nearly half of the adverse events accompanied with difficult intubation were desaturation. No immediate fatally and late outcome was reported. Patients' disease/anatomy was the major contributing factor that might relate to the incidence. Previous experience, experienced assistance, and high vigilance were the factors minimizing incidence. Suggestive corrective strategies were guideline practices, additional training, and improved supervision. CONCLUSION: Carefully preoperative airway assessment and additional attention focused on the pathology or disease were the principle tasks. Algorithms for both anticipated and unanticipated difficult airway as well as alternative airway equipments should be implemented.

Anesthesia-related cardiac arrest in children: the Thai Anesthesia Incidents Study (THAI Study).

BACKGROUND AND OBJECTIVE: The Thai Anesthesia Incidents study (THAI Study) is the first national study of anesthesia outcomes during anesthesia practice in Thailand. The authors extracted data of 25,098 pediatric cases from the THAI Study in order to examine the incidence, suspected causes, contributory factors, and suggested corrective strategies associated with anesthesia-related cardiac arrest. MATERIAL AND METHOD: A multi-centered prospective descriptive study was conducted among 20 hospitals across Thailand over a year between March 1, 2003 and February 28, 2004. Data of cardiac arrests in children aged 15 years and younger were collected during anesthesia, in the recovery room and 24 hours postoperative period, and reviewed independently by at least two reviewers. RESULTS: Incidence of anesthesia- related cardiac arrest was 5.1 per 10,000 anesthetics, with 46% mortality rate. Infants accounted for 61% of cases. Incidences of overall cardiac arrest and anesthesia-related arrest were significantly higher in infants than older children and in children with ASA physical status 3-5 than those with ASA physical status 1-2. Most of the anesthesia-related arrests occurred in the operating room (61%) during induction or maintenance of anesthesia (84%). Respiratory-related cardiac arrest was the most common suspected cause of anesthesia-related cardiac arrest. Improving supervision, additional training, practice guidelines, efficient blood bank, equipment maintenance, and quality assurance monitoring are suggested corrective strategies to improve the quality of care in pediatric anesthesia. CONCLUSION: The incidence of anesthesia-related cardiac arrest was 5.1:10,000 anesthetics. Major risk factors were children younger than 1 year of age and ASA 3-5. The identifications of airway management and medication-related problems as the main causes of anesthesia-related cardiac arrest have important implications for preventive strategies.

Multicentered study of model of difficult endotracheal intubation by incident reports from university and non-university hospitals.

OBJECTIVE: To compare the characteristics, causative factors, outcomes, prevention, and suggested preventive strategies of difficult intubation between university (U) and general community (non-U) hospitals. MATERIAL AND METHOD: One thousand nine hundred and ninety-six reports were reviewed from Thai anesthesia incident monitoring study (Thai AIMS) conducted in 51 hospitals nationwide between January and June 2007. Thirty-four cases ofDI were reported from U hospitals and 69 cases from non-U hospitals. The described details on each report on dfficult intubation (DI) in adults undergoing general anesthesia were thoroughly reviewed by three reviewers to give their consensus opinions on causative factors, outcomes, contributing preventive factors, and strategies for corrections. Descriptive statistics were used for data analysis. RESULTS: Patient factors were the most common cause of DI (88% in U and 87% in non-U hospitals). Fifty percent of U and 51% of non-U DI cases were consequences of human errors, which were preventable and mostly based on knowledge (88% vs. 71%) and rules of practice (23% vs. 51%). Substitution of an intubating anesthesiologist, reducing the size of endotracheal tubes, and stylet guided technique were the three commonly used methods after DI. MacCoy laryngoscope, fiber optic-aided intubation, laryngeal mask airway and Frova introducer were commonly used as substitutes for the standard laryngoscope. Inadequate experience was the major problem of U hospitals, which required additional training to gain more skill. The most common problem ofDI in non-U hospitals was inadequate preanesthetic evaluation. Therefore, they required practice guidelines and experienced assistants in difFicult situations. CONCLUSION: Half of DI cases were preventable. DI cases in Non-U hospitals were mostly caused by inadequate preanesthetic evaluation. This indicates the necessities of providing practice guidelines and experienced assistants. In U hospitals, in-training practice of intubation should be performed under supervision. More advanced substitution techniques were applicable in U hospitals.

The Thai Anesthesia Incidents (THAI Study) of anesthetic risk factors related to perioperative death and perioperative cardiovascular complications in intracranial surgery.

OBJECTIVE: To evaluate the correlations between anesthetic risk factors and perioperative cardiovascular complications as well as perioperative death within 72 hours. MATERIAL AND METHOD: This case controlled took the data from the Thai Anesthesia Incidents Study (THAI Study), a prospective multi-centered registry of anesthesia in Thailand. The authors included all the patients who received intracranial surgery from 20 hospitals throughout Thailand. The present study was divided into two groups and focused on anesthetic factors that possibly related to perioperative cardiovascular complications or perioperative death. The statistical analysis were Chi Square test and logistic regression model with the statistical significance if p-value < 0.05 demonstrated in Odds ratio (OR) and 95% confidence interval. RESULTS: From the 7,430 patients, there were 63 patients (0.85%) with perioperative cardiovascular complication. The American Society of Anesthesiologists (ASA) physical status 3-5 (OR 5.77, 95% CI 2.33-14.27) and the absence of anesthesiologists (OR 2.19, 95% CI 1.06-4.54) had statistical correlation with the cardiovascular complication. Eighty-four patients (1.13%) who died within 72 hours post operatively were found. The ASA physical status 3-5 (OR 10.14, 95% CI 3.42-30.02), the emergency circumstance (OR 3.55, 95% CI 1.31-9.60), and the absence of endtidal carbondioxide monitor (OR 2.27, 95% CI 1.26-4.09) had statistical correlation with the perioperative death. CONCLUSION: Predictors of perioperative cardiovascular complications in intracranial surgical patients were ASA physical status 3-5 and absence of certified board anesthesiologists. Risk factors of perioperative death were ASA physical status 3-5, emergency condition, and absence or no monitoring of capnometer.

Risk factors of intraoperative oxygen desaturation: a case-control study of 152,314 anesthetics.

BACKGROUND: The present study was part of the Thai Anesthesia Incidents Study (THAI Study) of anesthetic adverse outcomes. OBJECTIVE: To determine factors related to intraoperative oxygen desaturation (SpO2 < or =85% or < 90% for more than 3 min). MATERIAL AND METHOD: During a 12-month period (February 1, 2003 - January 31, 2004), a prospective multicentered registry of patients receiving anesthesia was conducted in 20 hospitals across Thailand Anesthesia personnel filled up patient-related, surgical-related, and anesthesia related variables and adverse outcomes including intraoperative oxygen desaturation. A case-control (1:4) study of patients with and without intraoperative oxygen desaturation in the THAI Study database was done. Univariate and multivariate analysis were used to identify factors related to intraoperative oxygen desaturation. A p-value < 0.05 was considered as significant. RESULTS: Among 152,314 patients without preanesthetic desaturation in the database, 328 cases of intraoperative oxygen desaturation were matched with 1312 control patients without desaturation. Variables that predict desaturation by multiple logistic regression were age less than 5 years old [OR 9.3 (95% CI 5.4-16.0)], ASA physical status 3, 4, 5 [OR 3.1 (95% CI 2.2-4.3)], history of upper respiratory tract infection [OR 10 (95% CI 1.9-51.6)], history of asthma [OR 2.9 (95% CI 1.0-9.5)], general anesthesia [OR 4.0 (95% CI 2.4-6.7)] duration of anesthesia 31-90 min [OR 1.9 (95% CI 1.2-3.0)], duration of anesthesia 91-150 min (OR 2.2 (95% CI 1.3-3.6)], and duration of anesthesia >150 min [OR 2.0 (95% CI 1.2-3.4)]. CONCLUSION: Knowing the risk factors of intraoperative oxygen desaturation helps improving personnel to improve preanesthetic conditions and facilitate early detection as well as prompt treatment of intraoperative oxygen desaturation.