Prediction of massive transfusion in trauma patients in the surgical intensive care units (THAI-SICU study).

PURPOSE: After damage control surgery, trauma patients are transferred to intensive care units to restore the physiology. During this period, massive transfusion might be required for ongoing bleeding and coagulopathy. This research aimed to identify predictors of massive blood transfusion in the surgical intensive care units (SICUs). METHODS: This is an analysis of the THAI-SICU study which was a prospective cohort that was done in the 9-university-based SICUs in Thailand. The study included only patients admitted due to trauma mechanisms. Massive transfusion was defined as received ≥10 units of packed red blood cells on the first day of admission. Patient characteristics and physiologic data were analyzed to identify the potential factors. A multivariable regression was then performed to identify the significant model. RESULTS: Three hundred and seventy patients were enrolled. Sixteen patients (5%) received massive transfusion in the SICUs. The factors that significantly predicted massive transfusion were an initial sequential organ failure assessment (SOFA) ≥9 (risk difference (RD) 0.13, 95% confidence interval (CI): 0.03-0.22, p = 0.01); intra-operative blood loss ≥ 4900 mL (RD 0.33, 95% CI: 0.04-0.62, p = 0.02) and intra-operative blood transfusion ≥ 10 units (RD 0.45, 95% CI: 0.06 to 0.84, p = 0.02). The probability to have massive transfusion was 0.976 in patients who had these 3 factors. CONCLUSION: Massive blood transfusion in the SICUs occurred in 5%. An initial SOFA ≥9, intra-operative blood loss ≥4900 mL, and intra-operative blood transfusion ≥10 units were the significant factors to predict massive transfusion in the SICUs.

Processed electroencephalogram and evoked potential techniques for amelioration of postoperative delirium and cognitive dysfunction following non-cardiac and non-neurosurgical procedures in adults.

BACKGROUND: Postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) may complicate a patient's postoperative recovery in several ways. Monitoring of processed electroencephalogram (EEG) or evoked potential (EP) indices may prevent or minimize POD and POCD, probably through optimization of anaesthetic doses. OBJECTIVES: To assess whether the use of processed EEG or auditory evoked potential (AEP) indices (bispectral index (BIS), narcotrend index, cerebral state index, state entropy and response entropy, patient state index, index of consciousness, A-line autoregressive index, and auditory evoked potentials (AEP index)) as guides to anaesthetic delivery can reduce the risk of POD and POCD in non-cardiac surgical or non-neurosurgical adult patients undergoing general anaesthesia compared with standard practice where only clinical signs are used. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase and clinical trial registry databases up to 28 March 2017. We updated this search in February 2018, but these results have not been incorporated in the review. SELECTION CRITERIA: We included randomized or quasi-randomized controlled trials comparing any method of processed EEG or evoked potential techniques (entropy, BIS, AEP etc.) against a control group where clinical signs were used to guide doses of anaesthetics in adults aged 18 years or over undergoing general anaesthesia for non-cardiac or non-neurosurgical elective operations. DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by Cochrane. Our primary outcomes were: occurrence of POD; and occurrence of POCD. Secondary outcomes included: all-cause mortality; any postoperative complications; and postoperative length of stay. We used GRADE to assess the quality of evidence for each outcome. MAIN RESULTS: We included six randomized controlled trials (RCTs) with 2929 participants comparing processed EEG or EP indices-guided anaesthesia with clinical signs-guided anaesthesia. There are five ongoing studies and one study awaiting classification.Anaesthesia administration guided by the indices from a processed EEG (bispectral index) probably reduces the risk of POD within seven days after surgery with risk ratio (RR) of 0.71 (95% CI 0.59 to 0.85; number needed to treat for an additional beneficial outcome (NNTB) of 17, 95% CI 11 to 34; 2197 participants; 3 RCTs; moderate quality of evidence). Three trials also showed the lower rate of POCD at 12 weeks after surgery (RR 0.71, 95% CI 0.53 to 0.96; NNTB 38, 95% CI 21 to 289; 2051 participants; moderate-quality evidence), but it is uncertain whether processed EEG indices reduce POCD at one week (RR 0.84, 95% CI 0.69 to 1.02; 3 trials; 1989 participants; moderate-quality evidence), and at 52 weeks (RR 0.30, 95% CI 0.05 to 1.80; 1 trial; 59 participants; very low quality of evidence). There may be little or no effect on all-cause mortality (RR 1.01, 95% CI 0.62 to 1.64; 1 trial; 1155 participants; low-quality evidence). One trial suggested a lower risk of any postoperative complications with processed EEG (RR 0.51, 95% CI 0.37 to 0.71; 902 participants, moderate-quality evidence). There may be little or no effect on reduced postoperative length of stay (mean difference -0.2 days, 95% CI -2.02 to 1.62; 1155 participants; low-quality evidence). AUTHORS' CONCLUSIONS: There is moderate-quality evidence that optimized anaesthesia guided by processed EEG indices could reduce the risk of postoperative delirium in patients aged 60 years or over undergoing non-cardiac surgical and non-neurosurgical procedures. We found moderate-quality evidence that postoperative cognitive dysfunction at three months could be reduced in these patients. The effect on POCD at one week and over one year after surgery is uncertain. There are no data available for patients under 60 years. Further blinded randomized controlled trials are needed to elucidate strategies for the amelioration of postoperative delirium and postoperative cognitive dysfunction, and their consequences such as dementia (including Alzheimer's disease (AD)) in both non-elderly (below 60 years) and elderly (60 years or over) adult patients. The one study awaiting classification and five ongoing studies may alter the conclusions of the review once assessed.

A Multi-Center Thai University-Based Surgical Intensive Care Units Study (THAI-SICU Study): Outcome of ICU Care and Adverse Events.

Objective: Surgical intensive care units (SICUs) are special units for critically ill surgical patients both in the pre and postoperative period. There is little aggregated information about surgical patients who are admitted to the Thai surgical ICU. The objective of this report was to describe patient characteristics, outcomes of ICU care, incidence and outcomes of adverse events in the SICU in the participating SICUs. Material and Method: This multi-center, prospective, observational study of nine university-based SICUs was done. All admitted patients with ages >18 years old were included. Information about patient characteristics, underlying medical problems, indication and type of ICU admission, severity score as ASA physical status in operative patients, APACHE II score and SOFA score, adverse events of interest, ventilator days, ICU and 28 days mortality. The association of outcome and predictors was reported by relative risk (RR) with 95% confidence interval (95% CI). Statistical significant difference was defined by p<0.05. Results: During April 2011-January 2013 of total cohort time, a total of 4,652 patients from nine university-based SICUs were included in this study. Mode of patient age was 71-75 year old for both sexes. Median (IQR) of APACHE II scores and SOFA scores were 10 (7-10) and 2 (1-5), respectively. Seventy eight percent of patients were postoperative patients and 50% of them were ASA physical status III. The median of ICU stay was 2 (IQR 1-4) days. Each day of ICU increment was associated with increased 1.4 days of a hospital stay. Three percent of survived at discharge were clinically inappropriate discharge resulting in ICU readmission. Sixty-five percent were discharged home after ICU admission. ICU and 28 days mortality was 9.6% and 13.8%. The seven most common adverse events were sepsis (19.5%), acute kidney injury (AKI) (16.9%), new cardiac arrhythmias (6.2%), acute respiratory distress syndrome (ARDS) (5.8%), cardiac arrest (4.9%), delirium (3.5%) and reintubation within 72 hours (3.0%), respectively. Most of the adverse events occurred in the first five days, significantly less occurred after 15 days of ICU admission. The association between adverse events and 28 days mortality were significant for cardiac arrest (RR, 9.5; 95% CI, 8.6-10.4), respiratory failure [acute respiratory distress syndrome (ARDS) (RR, 4.6; 95% CI, 3.9-5.3), acute lung injury (ALI) (RR, 2.7; 95% CI, 2.1-3.6)], acute kidney injury (AKI) (RR, 4.2; 95% CI, 3.7-4.8), sepsis (RR, 3.6; 95% CI, 3.2-4.2), iatrogenic pneumothorax (RR, 3.2; 95% CI, 2.1-5.1), new seizure (RR, 3.1, 95% CI, 2.2-4.4), upper GI hemorrhage (RR, 3.0, 95% CI, 2.1-4.1), new cardiac arrhythmias (RR, 2.9; 95% CI, 2.4-3.5), delirium (RR, 2.1; 95% CI, 1.7-2.8), acute myocardial infarction (RR, 2.1; 95% CI, 1.4-3.1), unplanned extubation (RR, 2.1; 95% CI, 1.4-3.1), intra-abdominal hypertension (RR, 1.8; 95% CI, 1.2-2.7) and reintubation within 72 hours (RR, 1.5; 95% CI, 1.1-2.1). Conclusion: This is the first large study of surgical critical care in Thailand, which had a systematic patient follow-up program. Most of the patients were elderly. Adverse events were most frequent during the first 5 days of admission and were associated with ICU and 28 days mortality.

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.

A multi-center Thai university-based surgical intensive care units study (THAI-SICU study): methodology and ICU characteristics.

OBJECTIVE: Although there were two large intra-operative observational studies on Thai surgical patients (THAI and THAI-AIMS), there has been no available study on critically ill surgical patients regarding their adverse events and outcomes. A THAI-Surgical Intensive Care Unit (SICU) study has been established for monitoring the occurrence of these adverse events and outcomes in the SICU. The objective of this report is to describe the methodology of the THAI-SICU study and participating SICUs' characteristics as well as the early recruitment results on patients enrolled in the present study. MATERIAL AND METHOD: The present study is designed as a multi-center, prospective, observational study. This report describes the method of case record form development and summarizes their collected parameters as well as the adverse event surveillance variables. All of nine SICU characteristics are described regarding their management systems, physicians' and nurses' work patterns. The final group of enrolled patients is reported. RESULTS: A total of nine university-based SICUs were included in the present study. All participating hospitals are residency training centers. Four of the SICUs, fulltime directors are anesthesiologists. Only one hospital's SICU is directed by a surgeon. Two SICUs were closed ICUs, three were mandatory consulting units, one was an elective consultation unit and the remaining three ICUs had no directors. Most of the participating SICUs had heterogeneity of surgical specialty patients. Six SICUs had regular resident rotations and only two of the SICUs had critical care fellowship training. There were significant differences regarding the nursing workload among the ICUs. The patient to registered nurse ratio ranged from 0.9-2.0. After a total of 19.7 months of a recruitment period, the total number of patient admissions was 6,548 (1,894 patients were excluded). A total cohort of 4,654 patients was included for further analytical processes. CONCLUSION: There were differences in ICU management systems, physician and specialist coverage, nurse burdens, nurse sparing, and types of patients admitted in the university based SICUs. This presentation is the pioneer multi-center study on Thai SICUs in which adverse events and outcomes are reported.

Perioperative pulmonary aspiration: an analysis of 28 reports from the Thai Anesthesia Incident Monitoring Study (Thai AIMS).

OBJECTIVE: To study the patients' characteristics, outcomes, contributory factors, factors minimizing the incidence and suggested corrective strategies for perioperative pulmonary aspiration in Thailand. MATERIAL AND METHOD: This is a prospective descriptive research design. The relevant data was extracted from the incident reports on aspiration from 51 hospitals across Thailand during the study period between January 1 and June 30, 2007 from the Thai Anesthesia Incident Monitoring Study (Thai AIMS) database. Descriptive statistics was used. Each incident report was reviewed by three senior anesthesiologists. Any disagreement was discussed to achieve a consensus. RESULTS: From 1,996 incident reports, there were 28 reports (1.4%) that met the definition of pulmonary aspiration. Most of the incidents occurred in patients with ASA 1-2 (85.7%), during the official hour (64.3%) and the anesthesiologists were in charge (67.9%). Eleven incidents (39.3%) occurred during induction, seven (25%) during maintenance and seven (25%) during emergence phases. Anesthetic factors played an important role in 26 incidents (92.9%). All the incidents except one (96.4%) were considered human errors and 25 (89.2%) were preventable. Of the incidents caused by human errors, nine (32.1%) were caused by skill-based errors. Thirteen patients (46.4%) had major physiologic changes and 10 (35.7%) of them needed unplanned ICU admission. Ten patients (35.7%) needed prolonged ventilator support and two (7.14%) of them died. CONCLUSION: The contributing factors that might lead to the incidents were improper decision (75%), lack of experience (53.5%) and lack of knowledge (21.4%). Factors minimizing incident, were vigilance (85.7%), having experienced assistant (50%) and experience in that situation (25%). Suggested preventive strategies were guidelines practice in anesthetic management (67.8%), improvement of supervision (57.1%), additional training (42.8%) and quality assurance activity (28.6%).

Anesthesia-related complications of caesarean delivery in Thailand: 16,697 cases from the Thai Anaesthesia Incidents Study.

BACKGROUND: Maternal complications related to anesthesia are low in comparison with the results from obstetric factors in developing countries. The purposes of the present study were to determine the incidence of maternal mortality related to anesthesia, to analyze the causes and to suggest measures to improve anesthetic safety for the parturients. MATERIAL AND METHOD: The present study was part of a multi-center study conducted by the Royal College of Anesthesiologists of Thailand aimed at surveillance of anesthesia-related complications in Thailand. The authors conducted a prospective survey of hospital records from all of the cases in and outside the operating room receiving general anesthesia in 18 centers between March 1, 2003 and February 28, 2004. All the forms were checked and verified by three-peer review then included in the analysis, using descriptive statistics. RESULTS: Sixteen thousand six hundred ninety seven cases were included. The incidence of anesthetic complication in parturients was 35.9: 10,000 (95% CI 27.4, 46.1). Incidence ofthe four most common anesthetic related adverse events in caesarean section were desaturation 13.8 (95% CI 8.7, 20.7), cardiac arrest 10.2 (95% CI 5.9, 16.3), awareness 6.6 (95% CI 3.3, 11.8), and death related anesthesia 4.8 (95% CI 2.17, 9.4). Of these, seven (17.5%) had preeclampsia/eclampsia and 46 (76.7%) presented for emergency caesarean delivery. General anesthesia was used in 41 patients (68.4%) and spinal in eighteen (30%). There were eight maternal deaths including five with general anesthesia, giving a case fatality rate of 0.1% of general anesthetics or 0.3% of caesarean deliveries. CONCLUSION: The authors found that inexperience, inadequate knowledge, inadequate care, and patient conditions were the major contributory factors. Most of them were preventable and correctable. Additional training and quality assurance can improve and prevent these serious adverse events.

The Thai Anesthesia Incidents Study (THAI study) of ambulatory anesthesia: II. Anesthetic profiles and adverse events.

BACKGROUND: There is a continuing trend to have more elective surgery performed on an outpatient basis. OBJECTIVE: To determine anesthetic profiles and adverse events in practice of ambulatory anesthesia for elective surgery in different levels of hospitals across Thailand. MATERIAL AND METHOD: A prospective descriptive study was conducted in 20 hospitals comprising seven university, five regional four general and four district hospitals across Thailand. Consecutive patients undergoing anesthesia for elective surgery were included. The included patients, classified as outpatients, were selected and extracted for summary of the result by using descriptive statistics. RESULTS: The authors reported 7786 outpatients receiving anesthesia for elective surgery. The majority of patients were in ASA class 1 and 2 (96.2%) while the rest were in ASA class 3 (3.8%). Nearly 90% of the ASA class 3 patients were in university hospitals. The majority of patients (83.1%) did not receive premedication. Diazepam was used more frequently (11.5% vs. 0.1%) than other drugs. Noninvasive blood pressure monitoring and pulse oximetry were used in greater than 90%, while electrocardiogram (EKG) was used in 67.2% and end tidal CO2 in only 6.8%. The three most common anesthetic techniques were general anesthesia (including inhalation anesthetics), total intravenous anesthesia (TIVA), and monitored anesthesia care (MAC). Regional anesthesia was performed in 12% of cases. The three most common regional anesthetic techniques were brachial plexus block (7.1%), spinal anesthesia (2.21%), and other peripheral nerve blocks (2.06%). Propofol was the most common drug for induction. Succinylcholine was used for intubation in 8.8%. The three most common nondepolaring neuromuscular blocking agents were atracurium, cisatracurium, and vecuronium. Fentanyl was the most common drug used among opioids. The three most common volatile anesthetics were sevoflurane, halothane, and isolurane. Lidocaine was the most frequently used in 29.76% of cases, while bupivacaine in 7.9% and ropivacaine only in 0.05%. The majority of the events relating to respiratory system were hypoxia or oxygen desaturation (18:10,000), reintubation (2.6:10,000) and difficult intubation (2.6:10,000), pulmonary aspiration (2.6:10,000), and esophageal intubation (1.3:10,000). Other adverse events included awareness (1.3:10,000), suspected myocardial infarction or ischemia (1.3:10,000), and drug error (1.3:10,000). Five patients (0.06%) received unplanned hospital admission. No patients developed cardiac arrest or died. CONCLUSION: The incidence of major adverse events was low in ambulatory anesthesia for elective surgery when compared to the incidence in general surgical population. The majority of the events occurred in the respiratory system. The authors did not find any complications relating to regional anesthesia. Despite a low incidence of adverse events in ambulatory anesthesia, anesthesia personnel who are responsible for ambulatory anesthesia should have adequate knowledge and skills in selection and preparation of the patients. Therefore, a system of preanesthesia evaluation is very important.

Prevention of post operative pain after abdominal hysterectomy by single dose etoricoxib.

OBJECTIVE: To test whether a reduction in post operative morphine consumption could be achieved by a single-dose of etoricoxib before induction of anesthesia. DESIGN: Randomized, double-blind, placebo-controlled study. MATERIAL AND METHOD: Two hours before surgery, patients undergoing transabdominal hysterectomy (under general anesthesia) were randomized to a single oral dose of 1) etoricoxib 120 mg (n = 17), 2) etoricoxib 180 mg (n = 17), or 3) placebo (n = 15). Intravenous morphine was given for patient-controlled analgesia (PCA) device. Morphine consumption, pain scores both at rest and on coughing, and side-effects were recorded at 1, 2, 4, 8 and 24 h after surgery. Patients' global evaluation of study medication was assessed at the end of the present study. RESULTS: Etoricoxib provided greater clinical benefit than the placebo in terms of mean morphine in milligram at 24 hour consumption (stardard deviation): a) 26.4 mg (SD of 11.2) for etoricoxib 120 mg; b) 27.2 mg (SD of 9.9) for etoricoxib 180 mg; and, c) 36.6 mg (SD of 8.9) for the placebo group. At 8 h post surgery, pain both at rest and on coughing in the active drug groups was significantly less than in the placebo, while pain on coughing was significantly less at 24 h. Patients reported better global satisfaction and less somnolence in the etoricoxib groups. CONCLUSION: Single dose etoricoxib 180 mg given before surgery provides the same analgesic effect as 120 mg for post operative pain after an abdominal hysterectomy.

Pediatric anesthesia adverse events: the Thai Anesthesia Incidents Study (THAI Study) database of 25,098 cases.

BACKGROUND: 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 THAI Study. OBJECTIVE: To report patient, surgical, and anesthetic profiles in order to determine the incidences of adverse events and their related factors. MATERIAL AND METHOD: A multi-centered prospective descriptive study was conducted among 20 hospitals across Thailand over a year from March 1, 2003 to February 28, 2004. Data in children aged 15 years and younger describing practices and adverse events were collected during anesthesia, in the recovery room and 24 hours postoperative period. RESULTS: Infants (0-1 year) had a significantly higher rate of adverse events compared with adults (4.6% versus 1.2%). Desaturation was the most common adverse event. The adverse events happened mostly during anesthesia (67%). Infants had significantly higher incidences of delayed detection of esophageal intubation, desaturation, reintubation, cardiac arrest, death, and drug error than older children and adults. Incidences of desaturation, reintubation, difficult intubation, coma/convulsion, cardiac arrest, and death were significantly higher in children with ASA physical status 3-5 than those with ASA physical status 1-2. CONCLUSION: Infants are prone to higher adverse events compared with older children and adults. Main adverse events were respiratory-related and they occurred mostly during anesthesia.

Efficacy of pre- and postoperative oral dextromethorphan for reduction of intra- and 24-hour postoperative morphine consumption for transabdominal hysterectomy.

OBJECTIVE: We studied the effect of dextromethorphan (DEX), an N-methyl-D-aspartate receptor antagonist, on analgesic consumption and pain scores after abdominal hysterectomy. We aimed to compare the analgesic effectiveness and incidence of adverse side effects of oral DEX with placebo (P). DESIGN: This was a double-blinded, randomized, placebo-controlled study. SETTING AND PATIENTS: One hundred patients were randomized to two groups. Group DEX was given 30-mg tablets of oral DEX with their premedication and three more times in the first 24 hours after surgery. Group P received the placebo following the same schedule. Postoperative analgesic requirements were assessed using a patient-controlled analgesia system. Pain was assessed at rest using a visual analogue scale in the post-anesthetic care unit (PACU), 6 and 24 hours after surgery. RESULTS: Mean pain scores were significantly lower at the PACU (62.6 vs 75.7) as was the mean sum of all resting pain scores (144.5 vs 173.1). Mean morphine consumption was greatest in the DEX group (35.1 vs 33.0 mg; P < 0.05). The sedation scores, postoperative analgesic requirements, and incidence of side effects were similar between the P and DEX groups as were the mean pain scores. CONCLUSIONS: During PACU, however, there were two differences between the DEX and placebo groups: 1) a lower pain score at PACU; and 2) a prolonged time to the first use of morphine at PACU in the DEX group as compared with the placebo group. A low-dose DEX had a weaker though still measurable effect in this clinical trial compared with trials using higher doses.

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.

Unplanned intubation during anesthesia: review of 31 cases from the Thai Anesthesia Incidents Study (THAI study).

OBJECTIVES: To examine the causes, outcomes, and contributing factors associated with patients requiring unplanned emergency intubation for adverse respiratory events. METERIAL AND METHOD: Appropriate unplanned intubation incidents were extracted from the Thai Anesthesia Incidents Study (THAI Study) database conducted between February 1, 2003, and January 31, 2004, and analyzed using descriptive statistics. RESULTS: Thirty-one incidents of unplanned intubation were recorded, 21 of which were due to respiratory problems particularly after bronchoscopy with and without surgery of the upper airway. Six of the 21 cases (28.6%) were children under 10 years of age who suffered from papilloma of the larynx. Sixteen cases of the 31 cases (52%) of the unplanned intubations were due to inadequate ventilation; 13 cases (41%) due to laryngeal edema; 11 cases (36%) due to sedative agents. The other events were the result of unstable hemodynamics, severe metabolic acidosis, muscle relaxants, and intrapulmonary lesions. Eighteen cases of unplanned intubations (18/31) (58%) occurred in the Post-Anesthesia Care Unit, 5 cases (16%) in a ward, and 4 (13%) in the operating room. The reported contributing factors included inadequate experience, lack of supervision and the patient's condition. CONCLUSION: Major incidents of unplanned intubation occurred after bronchoscopy. Common contributing factors related to inadequate ventilation, airway obstruction, sedative agents and unstable hemodynamics. Quality assurance, additional training, and improved supervision tended to minimize the incidents.

Surveillance of anesthetic related complications at Srinagarind Hospital, Khon Kaen University, Thailand.

OBJECTIVE: To identify the incidence of common anesthetic complications in 2003 at Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Thailand and find the strategies for prevention. MATERIAL AND METHOD: The study was part of a multi-center study conducted by the Thai Royal College of Anesthesiologists to survey anesthetic related complications in Thailand in 2003. The authors collected data from all the cases receiving anesthesia service at Srinagarind Hospital between January 1 and December 31, 2003, to report the incidence of common anesthetic complications and to assess the need to improve the quality of service. This was a prospective, descriptive study. When any anesthetic complications occurred, they were reported by anesthesia personnel and anesthesiologists. The reporting forms comprised four categories of complications, viz.: respiratory, cardiovascular, neurological and others. Each category of complications has a guidebook for reference in order to correctly fill out the form. All the forms were verified by the principal author then included in the present study. RESULTS: A total of 10,607 patients were included and among these 268 incidents were recorded. The common incidents per 10,000 were desaturation (95.22), cardiac arrest (44.31), re-intubation (29.23), equipment failure (19.80) and difficult intubation (18.86). Main contributing factors were insufficient knowledge and inappropriate decisions. Suggested corrective strategies included quality assurance activities, additional training and improved supervision. CONCLUSION: Despite practical prevention guidelines being in place, the most common anesthesia incident at Srinagarind Hospital was respiratory incident. Continuing quality improvement is needed.

Translaryngeal retrograde wire-guided fiberoptic intubation for difficult airway: a case report.

The authors describe the special tracheal intubation technique used in two patients with a difficult airway. These are the translaryngeal retrograde wire-guided and fiberoptic intubation. The authors show how to use both to facilitate intubation. The authors modified the technique by passing a guide-wire in a retrograde manner from the trachea to the nose and then a fiberoptic laryngoscope within the endotracheal tube over the wire. The technique can be applied for use in any difficult airway situation.

The Thai Anesthesia Incidents Study (THAI Study) of oxygen desaturation.

OBJECTIVES: To examine incidents, contributory factors, treatment and outcomes associated with oxygen desaturation during anesthesia practice in Thailand. MATERIAL AND METHOD: Relevant data were extracted from the Thai Anesthesia Incidents Study (THAI Study) database between February 1, 2003 and January 31, 2004 and analyzed by using mainly descriptive statistics. RESULTS: Four hundred and ninety seven incidents of oxygen desaturation (SpO2 <90 for at least 3min or < or = 85%) were reported. The incidents were widely distributed throughout anesthesia phases. Most of the incidents (92.2%) occurred during general anesthesia, while 23 (4.6%) occurred after regional anesthesia. Anesthesia was the sole contributory factor in 280 patients (56.8%) and a combination of that with other factors in 126 (25.4%). The majority of the incidents (88.4%) was related to respiratory adverse events, whereas, 8% was related to circulatory ones. Sixteen incidents (3.2%) were related to anesthetic machine and equipment failure. Most of the incidents (60.0%) caused minor physiologic changes and were correctable. The management was considered adequate in the majority of patients. As a result, 77.5 % of the patients recovered completely, whereas, death ensued in 5.8%. The cases of death were associated with co-morbidity (ASA class 4 and 5) with an Odds ratio of 12.9 (95% CI:5.4,31.0). The common contributory factors were inexperience, wrong decision, inadequate knowledge and lack ofsupervision. The proposed corrective strategies included improvement in supervision, care improvement, additional training, clinical practice guideline and quality assurance activity. CONCLUSION: Incidents associated with oxygen desaturation were distributed throughout all phases of anesthesia. Most of them were preventable and correctable. Therefore, anesthesia care providers should be alert in looking for incidents, and manage them promptly before they were in serious adverse events.

The Thai Anesthesia Incidents Study (THAI Study) of difficult intubation: a qualitative analysis.

OBJECTIVES: To examine the causes, outcomes and contributing factors including suggested corrective strategies associated with difficult intubation. MATERIAL AND METHOD: Difficult intubation and failed intubation incidents were extracted from the Thai Anesthesia Incidents Study (THAI Study) database conducted between February 1, 2003 to January 31, 2004 and analyzed by using descriptive statistics RESULTS: Two hundred and thirty-four cases of difficult intubation were recorded. Among those, 50 cases (21%) were failed intubation. The most common cause (95%) of incidents was due to patients difficult anatomy. Prediction of events was derived from physical examination (65%) and history taking (50%). Majority of incidents (44%) occurred in Mallampati II and III. Only 3 cases (1.3%) of morbid obesed and 3 cases (1.3%) of pregnant patients were attributed to the events. Most incidents (119 cases, 50.9%) were successfully managed by conventional techniques. The adverse effects included hypoxemia (54 cases, 23.1%), esophageal/ tracheal injury (40 cases, 17.1%) and prolonged ventilatory support (17 cases, 7.3%). One patient died from sepsis. The reported contributing factors included inadequate experience, lack of knowledge including inadequate preoperative evaluation and preparation. Additional training, quality assurance and protocol/algorithm tended to minimize the incidents. CONCLUSION: The majority of difficult intubation could be predicted. Proper preoperative evaluation and equipment preparation, appropriate technique including experienced anesthesia personnel could attenuate the morbidity and mortality.

Postoperative reintubation after planned extubation in Thai Anesthesia Incidents Study (THAI Study).

OBJECTIVE: To analyze precipitating causes, outcomes and corrective strategies especially anesthetic related factors associated with reintubation after planned extubation in anesthetic technique of general anesthesia with endotracheal intubation. DESIGN: Prospective observational study. MATERIAL AND METHOD: Incidents of reintubation after planned extubation were extracted from the Thai Anesthesia Incidents Study (THAI Study) database conducted between February 1, 2003, and January 31, 2004, and analyzed using descriptive statistics. RESULTS: The total of two hundred and thirty four patients of reintubation after planned extubation (RAP) at the end of general anesthesia was reviewed in this study. The incidence of RAP was 27:10,000 and the incidence in the university hospital was similar to the tertiary and secondary care hospital. The incidence was increased in extreme age group (age < 1 and > 70 year). One hundred and fifty eight cases of RAP (67.5%) occurred in operating theater and recovery room which included 83 cases occurring within 10 minutes after extubation. The two most common primary diagnoses were upper airway obstruction and hypoventilation. Three main precipitating factors were residual effect of neuromuscular blocking and anesthetic agents (53-57%), upper airway obstruction (31%) and unstable hemodynamics (26.3%). Nearly half of RAP incidents occurring in the operating theater and recovery room were successful reextubation within six hours and 58-72 % of these two subgroups were complete recovery. The chance for prevention was more than 80% by additional training and supervision. CONCLUSION: More than 90% of RAP occurred in operating theater and recovery room were completely or partially related to anesthetic process. Incidence of RAP could be decreased by quality assurance process of recording, reporting and modeling care process together with increase individual experience.

An analysis of the drug error problem in the Thai Anesthesia Incidents Study (THAI Study).

OBJECTIVES: To analyze the problem of drug error related to anesthesia in Thailand including nature, contributing factors and preventive strategies. MATERIAL AND METHOD: We prospectively recorded anesthesia-related drug error incidents for 18 months in 20 studied hospitals in Thailand. Types of errors and their outcomes were recorded. All data were analyzed to identify contributing factors and preventive strategies. RESULTS: Forty-one drug error incidents were reported in 40 out of 202,699 anesthetized cases or 1: 4,943 in this study. The most common type of error was wrong drug (20 incidents; 48.8%). No relationship between anesthetic techniques and the incidents except for a combined general and epidural technique. The errors were most commonly occurred during induction of anesthesia (26 out of 41; 63.4%) and muscle relaxants were most commonly involved (13 out of 41; 31.7%). The majority of incidents (26 out of 41; 63.4%) caused no adverse effect. However 14 incidents (34.1%) caused transient mild to severe physiological effects, of which 13 had complete recovery but one died. Haste and lack of recheck were two common contributing factors which were minimized by high awareness and double check prior to drug administration. Main strategies suggested to prevent the incidents included specific guideline development whereas the incidents did not effectively decrease by increasing of manpower CONCLUSION: The incidence of drug error in our study was 1 : 4,943. It can cause morbidity and mortality during anesthesia. Practitioners should be aware of these potential incidents and strictly follow the guideline for drug administration.