Capabilities Toward Intravenous Patient-Controlled Analgesia: A Cross-Sectional Study of Registered Nurses Working in Two Tertiary Hospitals in China and Thailand.

BACKGROUND: An increased interest has been observed in the wide use of intravenous patient-controlled analgesia (IV-PCA) to control acute postoperative pain in both China and Thailand. The safety and efficacy of IV-PCA in patient care requires competent and capable staff nurses. This study aimed to appraise the capabilities of Thai and Chinese registered nurses regarding IV-PCA as a guide to develop educational programs. METHOD: A descriptive cross-sectional survey was conducted with 203 Chinese and 270 Thai registered nurses. An anonymous self-report questionnaire addressing 6 domains of capabilities toward IV-PCA was used to collect the data. Descriptive and inferential statistics were employed to analyze the data. RESULTS: The study found that the mean percentage scores (MPS) of the overall capability on IV-PCA of the Thai and Chinese nurse participants were 55.5 (mean [M] = 57.3, standard deviation [SD] = 4.9) and 62.6 (M = 58.7, SD = 13.0), respectively, which indicated very low and low levels. Barriers to the use and care of patients receiving IV-PCA after surgery according to the Thai and Chinese nurse participants included a lack of knowledge and systematic training regarding IV-PCA and a lack of first-hand experience in providing care for IV-PCA patients. CONCLUSION: The study results call for intensive and effective training and education concerning all domains for registered nurses involved with patients receiving IV-PCA.

A comparison of ondansetron and lidocaine in reducing injection pain of propofol: a randomized controlled study.

BACKGROUND: Direct stimulation of the afferent nerve endings in the venous endothelium is one explanation of propofol injection pain. Previous studies found that ondansetron can also block sodium channels. This effect is similar to that of lidocaine. OBJECTIVE: The primary outcome was the efficacy of ondansetron compared to lidocaine and placebo for the reduction of propofol injection pain. METHOD: This trial was conducted in 240 patients, American Society of Anesthesiologists classification I-III and aged between 18-65 years old, undergoing elective surgery, and having a 20-gauge intravenous catheter at the hand dorsum. Each group of 80 patients received 8 mg. of ondansetron in the O Group, 40 mg. of lidocaine in the L Group and normal saline in the C Group. The study medications were blindly administered to the patients through a 20-gauge intravenous catheter placed on the hand dorsum, and then 1 min later, the small dose of propofol (50 mg.) was infused via the syringe pump at a rate of 600 ml/hr. for 30 s. Following that, the syringe pump of propofol was temporarily stopped, and the patients were asked to rate their pain at the injection site. RESULT: The incidence of pain was lowest in the L group (66.2%) compared with the O (82.5%) and the C groups (85.0%) (P < 0.01). The median pain score in the L, O, and C groups were 2 (0-4), 4 (2-5), and 4.5 (2-6), respectively (P < 0.01). The incidences of no pain, mild, moderate, and severe pain were also significantly different in the L group (33.8%, 37.5%, 21.2%, and 7.5%, respectively) compared with those in the O group (17.5%, 31.2%, 31.2%, and 20.0%, respectively) and the C groups (15.0%, 22.5%, 40.0%, and 22.5%, respectively) (P < 0.01). CONCLUSION: Pretreatment with intravenous lidocaine, rather than ondansetron, can reduce the incidence and intensity of propofol-induced pain.

Predictors of death after receiving a modified Blalock-Taussig shunt in cyanotic heart children: A competing risk analysis.

OBJECTIVE: To determine risk factors affecting time-to-death ≤90 and >90 days in children who underwent a modified Blalock-Taussig shunt (MBTS). METHODS: Data from a retrospective cohort study were obtained from children aged 0-3 years who experienced MBTS between 2005 and 2016. Time-to-death (prior to Glenn/repair), time-to-alive up until December 2017 without repair, and time-to-progression to Glenn/repair following MBTS were presented using competing risks survival analysis. Demographic, surgical and anesthesia-related factors were recorded. Time-to-death ≤90 days and >90 days was analyzed using multivariate time-dependent Cox regression models to identify independent predictors and presented by adjusted hazard ratios (HR) and 95% confidence intervals (CI). RESULTS: Of 380 children, 119 died, 122 survived and 139 progressed to Glenn/repair. Time-to-death probability (95% CI) within 90 days was 0.18 (0.14-0.22). Predictors of time-to-death ≤90 days (n = 63) were low weight (<3 kg) (HR 7.6, 95% CI:2.8-20.4), preoperative ventilator support (HR 2.7, 95% CI:1.3-5.6), postoperative shunt thrombosis (HR 5.0, 95% CI:2.4-10.4), bleeding (HR 4.5, 95% CI:2.1-9.4) and renal failure (HR 4.1, 95% CI:1.5-10.9). Predictors of time-to-death >90 days (n = 56) were children diagnosed with pulmonary atresia with ventricular septal defect and single ventricle (compared to tetralogy of fallot) (HR 3.2, 95% CI:1.2-7.7 and HR 3.1, 95% CI:1.3-7.6, respectively), shunt size/weight ratio >1.1 vs <0.65 (HR 6.8, 95% CI:1.4-32.6) and longer duration of mechanical ventilator (HR 1.002, 95% CI:1.001-1.004). Shunt size/weight ratio ≥1.0 (vs <1.0) and ≥0.65 (vs <0.65) were predictors for overall time-to-death in neonates and toddlers, respectively (HR 13.1, 95% CI:2.8-61.4 and HR 7.8, 95% CI:1.7-34.8, respectively). CONCLUSIONS: Perioperative factors were associated with time-to-death ≤90 days, whereas particular cardiac defect, larger shunt size/weight ratio, and longer mechanical ventilation were associated with time-to-death >90 days after receiving MBTS. Larger shunt size/weight ratio should be reevaluated within 90 days to minimize the risk of shunt over flow.

Unintended intraoperative awareness: An analysis of Perioperative Anesthetic Adverse Events in Thailand (PAAd Thai).

BACKGROUND: Despite the improvement of anesthetic-related modalities, the incidence of unintended intraoperative awareness remains at around 0.005-0.038%. OBJECTIVE: We aimed to describe the intraoperative awareness incidents that occurred across Thailand between January to December, 2015. METHODS: Observational data was collected from 22 hospitals throughout Thailand. The awareness category was selected from incident reports according to the Perioperative Anesthetic Adverse Events in Thailand (PAAd Thai) study database and descriptive statistics were analyzed. The awareness characteristics and the related factors were recorded. RESULTS: A total of nine intraoperative awareness episodes from 2000 incidents were observed. The intraoperative awareness results were as follows: experience of pain (38.1%), perception of sound (33.3%), perception of intubation (9.5%) and feeling of paralysis (14.3%). The observed factors that affect intraoperative awareness were anesthesia-related (100%), patient-related (55.5%), surgery-related (22.2%) and systematic process-related (22.2%). The contributing factors were situational inexperience (77.8%) and inappropriate patient evaluation (44.4%). An awareness of anesthetic performer (100%) and experience (88.9%) were defined as incident-mitigating factors. The suggested corrective strategies were quality assurance activity (88.9%), improved supervision (44.4%) and equipment utilization (33.3%), respectively. CONCLUSION: Nine intraoperative awareness incidents were observed, however the causes were preventable. The anesthetic component seems to be the most influential to prevent these events.

Deep neuromuscular blockade for endolaryngeal procedures: A multicenter randomized study.

OBJECTIVES/HYPOTHESIS: The aim of the present study was to compare the surgical condition between deep neuromuscular blockade (NMB) and moderate NMB. STUDY DESIGN: Multicenter, randomized, parallel intervention trial. METHODS: One hundred two patients underwent microscopic endolaryngeal surgery at four university hospitals. The patients were randomized into moderate NMB (train-of-four 1-2) (M group) or deep NMB (post-tetanic count 1-2) (D group) with moderate or high doses of rocuronium, respectively. Surgical rating conditions (SRCs) were evaluated during the surgery. Sugammadex was given to the M group at 2 mg/kg and the D group at 4 mg/kg. Perioperative clinical signs and conditions were recorded until discharge from the postanesthesia care unit. RESULTS: Clinically acceptable SRC was observed in 49 patients (100%) in the D group and 43 patients (89.6%) in the M group (P = .027). The frequency of notable vocal fold movement in the M group was significantly higher than the D group (70.8% vs. 32.7%). The patients in the M group required more additional doses of rocuronium (47.9%) than the D group (20.4%) to maintain full relaxation (P = .005). The median time (interquartile range) from administration of sugammadex to train-of-four ratio 0.9 in the D group was shorter than the M group (120 [109-180 minutes] vs. 180 minutes [120-240 minutes], P = .034). CONCLUSIONS: Deep NMB with high doses of rocuronium combined with 4 mg/kg of sugammadex for reversal during endolaryngeal surgery provided better SRC and anesthetic conditions than moderate NMB of rocuronium with 2 mg/kg of sugammadex. LEVEL OF EVIDENCE: 1b Laryngoscope, 130:437-441, 2020.

Comparison of Intubation Time with GlideScope® and McIntosh Laryngoscope in Obese Patients

Background: Difficult intubation is more frequent in obese than in lean patients. The GlideScope® is a videolaryngoscope that provides a laryngoscopic view equal to or better than a direct laryngoscope in non-obese patients. Objective: To compare the intubation time between the GlideScope® and the McIntosh laryngoscope in obese patients. Material and Method: The authors randomly allocated 46 obese patients (BMI >28 kg/m2) with the American Society of Anesthesiologists physical status I to III, scheduled for elective surgery under general anesthesia with oroendotracheal intubation into either the McIntosh group (Group M) or the GlideScope® group (Group G). The age range was 18 to 65 years old. Intubation was performed by anesthetic residents with experience in the use of the GlideScope® at least 10 times. The intubation time, the laryngoscopic view, the number of intubations and success rate, the number of optimizing maneuvers, vital signs, and complications from intubation were recorded. Results: The intubation time in Group G (31 seconds) was not different from Group M (29 seconds). There was a significant difference in laryngoscopic view between the two groups. The laryngoscopic view was grade 2 in Group M and was grade 1 in Group G (p = 0.007). All patients in Group G were successfully intubated in the first attempt. There were two patients in Group M who needed more than one attempt. One of these needed a second intubation and another one was successful on the third attempt with the GlideScope®. However, there was no statistical significance in the overall success rate. The heart rate, blood pressure and complications were not statistically different. Conclusion: The intubation time and the success rate between the McIntosh blade and GlideScope® in obese patients was not significantly different. Nevertheless, the GlideScope® provided a better laryngoscopic view than the McIntosh blade.

Target Controlled Infusion versus Sevoflurane/Desflurane Anesthesia for Laparoscopic Cholecystectomy: Comparison Postoperative Nausea/Vomiting and Extubation Time.

BACKGROUND: Target-controlled infusion (TCI) systems have been developed from manually controlled infusion systems and have rapidly increased in popularity, especially in laparoscopic surgery. Propofol is claimed to decrease nausea and vomiting. OBJECTIVE: To compare anesthetic techniques, propofol-TCI, desflurane, and sevoflurane, for better results in terms of postoperative nausea and vomiting (PONV) and extubation times. MATERIAL AND METHOD: The present study was prospective with informed consent from 75 patients, ASA 1-3 scheduled for laparoscopic cholecystectomy, and classified by anesthetic technique into three groups. The patients were induced by propofol target plasma concentration 6 µg/ml in Group P, or 1-2 mg/kg in Group S and Group D, fentanyl 2 µg/kg and vecuronium 0.1 mg/kg followed by propofol 2 to 5 µg/mI in group P, sevoflurane 0.5 to 3% in Group S, and desflurane 2 to 6% in Group D. RESULTS: The incidence of postoperative nausea and vomiting was least in Group P, both at the PACU (p < 0.001) and ward (p = 0.01). Extubation time excluding outlier were Group P 11.17 ± 1.19 minutes, Group D 13.96 ± 1.17 minutes, Group S 11.75 ± 1.34 minutes (p = 0.25). There were no statistical differences in the amount of fentanyl (p = 0.38) and fluid replacements (p = 0.05). CONCLUSION: Laparoscopic cholecystectomy under propofol with TCI is one option of anesthetic technique with a significantly lower incidence of PONV compared with both sevoflurane and desflurane otherwise there is no statistical difference in the extubation time. Propofol-TCI technique is suggested for laparoscopic and ambulatory surgery.

Completion and accuracy in charting of anesthetic records in Songklanagarind Hospital.

OBJECTIVE: To audit the completeness and accuracy in charting of anesthetic recorded by hand. MATERIAL AND METHOD: A retrospective descriptive study from 890 checklist forms. The classification of complete record as good level and incomplete record including level of fair, poor or no data. The frequency, percentage and the difference of completeness and accuracy in charting of anesthetic records were analyzed by Chi-squared test. RESULTS: The item of vital signs during anesthesia was one of 44 items that were 100% complete and accurate. The overall average of completeness and accuracy in terms of good, fair, poor quality, and no data was 94.5, 3.1, 0.4, and 2%, respectively. Twenty-two of 44 items had statistically significant difference between complete and incomplete records. CONCLUSION: The charting of anesthetic record remained incomplete and inaccurate in 43 from 44 items, except the item of vital signs. The average of good anesthetic record was 94.5%. The incomplete anesthetic records were caused by illegibility, incorrect data filling, no data, or incomplete detail of each item such as incorrect ASA classification, or problem list etc. Handwritten records should be carefully filled-in to increase completion so that the data could be used as legal evidence.

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.

Attitudes, beliefs, and expectations of gynecological patients toward postoperative pain and its managementt.

OBJECTIVE: To examine the attitudes, beliefs, and expectations of gynecological patients regarding postoperative pain and management. MATERIAL AND METHOD: A prospective study performed in 112 patients undergoing major gynecological surgery, using a preoperative questionnaire regarding expectations toward postoperative pain and management and a postoperative questionnaire regarding actual pain experience, attitudes, and beliefs about pain and management. RESULTS: The majority expected (92%) and experienced (89%) postoperative pain at moderate to very severe levels. The median visual analog scales (VAS) of expected and maximum experienced pain were 6.4 and 6 6, respectively. Ninety-eight percent reported at least moderate pain relief from the analgesics administered. Ninety-two percent were satisfied with their pain management. A significant number held misconceptions about postoperative pain and its management. CONCLUSION: Patients should be preoperatively advised regarding postoperative pain and management. Misunderstandings should be corrected to improve the quality and adequacy of postoperative pain management.