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%).

The Thai Anesthesia Incident Monitoring study (Thai AIMS): perioperative arrhythmia.

BACKGROUND: The Royal College of Anesthesiologists of Thailand organized the first national sentinel incident reports of anesthesia related adverse events in 2007 on an anonymous and voluntary basis. The aims of the present study were to analyze incidence, risk factors, clinical course and outcome of perioperative arrhythmia and indicate the contributing factors and suggested corrective strategies in the database of the Thai Anesthesia Incidents Monitoring Study (Thai AIMS). MATERIAL AND METHOD: This study was a prospective descriptive multicentered study conducted between January 2007 and June 2007. Data was collected from 51 hospitals across Thailand. All cases whose arrhythmia was detected intra-operatively and within 24 hr postoperative period were analyzed by 3 independents anesthesiologists. Any disagreements were discussed to achieve a consensus. RESULTS: Four hundred and eighty-nine cases were enrolled as relevant arrhythmia cases. Bradycardia was the most common type (434 cases; 88.8%). Most of all events occurred intra-operatively (94.7%) and electrocardiography was the most common firstly detected monitoring equipment (95.5%). Arrhythmia occurred frequently in patients with hypertension and pre-operative heart rate < 60 beat per min. Intravenous anesthetics, central neural blockage and vagal reflex were considered to be the 3 most common suspected causes of arrhythmia requiring treatment. Most common outcomes were minor physiologic change with complete recovery physiologic change with complete recovery while 7% of incidents developed fatal outcome. The most common contributing factor was human factor (72.4%) especially in experience. An experienced anesthetic team with high awareness could be the minimizing factors. CONCLUSION: Arrhythmia accounted for 19.2% of 2,537 incidents of the Thai AIMS database. Bradycardia was the most common type of cardiac arrhythmia. Most arrhythmia was benign but might be fatal. Suggested corrective strategies such as guidelines practice, improvement of supervision and quality assurance activity.

The Thai Anesthesia Incident Monitoring Study (Thai AIMS) of oxygen desaturation in the post-anesthetic care unit.

OBJECTIVE: As part of the Thai Anesthesia Incident Monitoring Study (Thai AIMS), the present study was aimed to analyze the problems of oxygen desaturation in the post-anesthetic care unit in Thailand including clinical course, outcomes, contributing factors, and preventive strategies. MATERIAL AND METHOD: The authors prospectively collected incident reports of oxygen desaturation in the post-anesthetic care unit between January and June 2007 from 51 studied hospitals across Thailand Clinical characteristics, outcomes, and contributing factors were recorded. All data were analyzed to identify contributing factors and preventive strategies. RESULTS: Eighty-six of post-anesthetic oxygen desaturation incidents were reported Forty-six cases (53.5%) were diagnosed by pulse oximetry. Forty-eight cases (55.8%) were immediately detected within a minute upon arrival at the PACU. Thirty-one cases (36%) were caused by inadequate awakening. Eighty-two cases (95.3%) were anesthesia-related and preventable. The major clinical outcomes were re-intubation (51 cases; 59.3%), prolonged artificial ventilation (23 cases; 26.7%), unplanned ICU admission (16 cases; 18.6%), and prolonged hospital stay (3 cases; 3.5%). Sixty-three patients (73.3%) recovered completely within 24 hours but one died. Judgment error and lack of adequate patient evaluation were the two most common contributing factors that were minimized by high awareness and prior experience. Main strategies suggested to prevent the incidents included the development of specific guideline and quality assurance. These incidents did not effectively decrease when labor was increased. CONCLUSION: Post-anesthetic oxygen desaturation was frequently found during the transport period. It can cause morbidity and mortality. Anesthesia providers should be aware of these potential incidents and strictly follow guidelines.

Multicentered study of model of anesthesia related adverse events in Thailand by incident report (The Thai Anesthesia Incidents Monitoring Study): results.

OBJECTIVE: The Thai Anesthesia Incidents Monitoring Study (Thai AIMS) was aimed to identify and analyze anesthesia incidents in order to find out the frequency distribution, clinical courses, management of incidents, and investigation of model appropriate for possible corrective strategies. MATERIAL AND METHOD: Fifty-one hospitals (comprising of university, military, regional, general, and district hospitals across Thailand) participated in the present study. Each hospital was invited to report, on an anonymous and voluntary basis, any unintended anesthesia incident during six months (January to June 2007). A standardized incident report form was developed in order to fill in what, where, when, how, and why it happened in both the close-end and open-end questionnaire. Each incident report was reviewed by three reviewers. Any disagreement was discussed and judged to achieve a consensus. RESULTS: Among 1996 incident reports and 2537 incidents, there were more male (55%) than female (45%) patients with ASA PS 1, 2, 3, 4, and 5 = 22%, 36%, 24%, 11%, and 7%, respectively. Surgical specialties that posed high risk of incidents were neurosurgical, otorhino-laryngological, urological, and cardiac surgery. Common places where incidents occurred were operating room (61%), ward (10%), and recovery room (9%). Common occurred incidents were arrhythmia needing treatment (25%), desaturation (24%), death within 24 hr (20%), cardiac arrest (14%), reintubation (10%), difficult intubation (8%), esophageal intubation (5%), equipment failure (5%), and drug error (4%) etc. Monitors that first detected incidents were EKG (46%), Pulse oximeter (34%), noninvasive blood pressure (12%), capnometry (4%), and mean arterial pressure (1%). CONCLUSION: Common factors related to incidents were inexperience, lack of vigilance, inadequate preanesthetic evaluation, inappropriate decision, emergency condition, haste, inadequate supervision, and ineffective communication. Suggested corrective strategies were quality assurance activity, clinical practice guideline, improvement of supervision, additional training, improvement of communication, and an increase in personnel.

The Thai Anesthesia Incident Monitoring Study (Thai AIMS) of desaturation: an analysis of 1,996 incident reports.

BACKGROUND AND RATIONALE: The present study is a part of the Multicentered Study of Model of Anesthesia related Adverse Events in Thailand by Incident Report (The Thai Anesthesia Incident Monitoring Study or Thai AIMS). The objective of the present study was to determine the frequency distribution, outcomes, contributory factors, and factors minimizing incident. MATERIAL AND METHOD: The present study is a prospective descriptive research design. The authors extracted relevant data from the incident reports on oxygen desaturation from the Thai AIMS database and analyzed during the study period between January and June 2007. RESULTS: From the relevant 445 incidents, most of the incidents (89%) occurred in patients receiving general anesthesia. The incidence in patients receiving regional anesthesia was 4.0%. The events mostly occurred in patients aged between 16-65 years (52.8%). Most of the events (76%) took place in the operating theater during the induction period (30.1%). More than 81% of the patients experienced severe oxygen desaturation (SpO2 < 85%). There were 55 patients (12.4%) who had unplanned ICU admission and 2 patients (0.4%) who had unplanned hospital admission. Factors that may relate to the incident involve combined factors (50.8%). Anesthetic factors were found to involve 38.4% of incidents. The common contributing factors that might lead to the incidents were inexperienced (57.5%), inappropriate decision (56.2%), and haste (23.8%). For factors minimizing incident, the important factors were vigilance (86.3%), experienced in that tropic (71.2%), and experienced assistance (54.8%). Quality assurance activity was the most common suggestive corrective strategy (79.1%). The others were improvement of supervision (47.2%) and guideline practice (46.5%). CONCLUSION: To lower the incidence of oxygen desaturation, the anesthesia personnel has to improve the anesthesia services by quality assurance activity, improvement of supervision, clinical practice guidelines, and additional training.

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.

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.

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 anesthetic equipment failure/malfunction: a qualitative analysis for risk factors.

BACKGROUND: Anesthesia equipment problems may contribute to anesthetic morbidity and mortality. In Thailand, the magnitude and pattern of these problems has not been established. We therefore analyzed the frequency, type and severity of equipment-related problems, and what additional efforts might be needed to improve safety. MATERIAL AND METHOD: The data were drawn from the Thai Anesthesia Incidents Study (THAI Study) between February 1, 2003 and July 31, 2004 in which anesthesia-related data (i.e. of perioperative problems and their severity) were recorded (by the attending anesthesiologist) from all anesthetic cases on a routine basis. We selected cases under general and regional anesthesia with anesthetic equipment failure/malfunction for descriptive analysis. RESULTS: The frequency of anesthetic equipment problems of the 202,699 recorded cases was approximated 0.04% or 1 : 2252. Two-thirds of the problems (63%) involved the anesthesia machine and of these incidents 73 and 41 percent involved system and human errors, respectively. One patient died and one suffered permanent morbidity. CONCLUSION: The incidence and severity of equipment problems was low. Aside from improvements to pre-operative equipment checks, vigilance, continuous quality improvement and quality assurance activities were suggested as strategies to reduce problems.

The Thai Anesthesia Incidents Study (THAI Study) of perioperative death: analysis of risk factors.

BACKGROUND: National statistical data of mortality and morbidity related to anesthesia have not been reported. The need to comprehensively examine the cause of death as well as other adverse events prompted the first national study in Thailand. MATERIAL AND METHOD: In the Thai Anesthesia Incidents Study (THAI Study), a prospectively defined cohort of patients who underwent anesthesia from February 1, 2003 to January 31, 2004 (n=163,403) was studied. All consecutive patients who died intraoperatively or within the period of 24 hr after anesthesia were classified to determine a relationship with anesthesia by 3 independent reviewers. These data were further analysed to identify contributing factors. RESULTS: The incidence of 24-hr perioperative death, anesthesia directly related and anesthesia partially related death per 10,000 anesthetics was 28.2 (95% CI 25.7-30.8), 1.7 (95% CI 1.1-2.3) and 4.0 (95% CI 3.1-5.0) respectively. Of 462 deaths, 28 cases (6.5%), 66 cases (14.3%), 61 cases (3.3%), 399 cases (86.7%) and 104 cases (22.6%) were anesthesia directly related, anesthesia partially related, surgical related, patient disease related and system or management related to perioperative death. The common main causes of death were exangination (42.4%), traumatic brain injury (14.3%), sepsis (13.6%), heart failure (5.0%) and hypoxia (5.0%). CONCLUSION: This study shows incidence of 24-hr perioperative death of 1:354 which is comparable with other studies. Quality assurance activity, prevention of human failure and equipment failure, system improvement of perioperative care, availability of recovery room, intensive care unit, efficient blood bank and adequate number of MD. anesthesiologists are suggestive corrective strategies.

The Thai Anesthesia Incidents Study (THAI Study) of anesthesia personnel hazard.

OBJECTIVES: To determine the incidence, causes, management, outcomes and corrective strategies for personnel hazard in Thai Anesthesia Incidents Study (THAI Study). MATERIAL AND METHOD: Personnel hazard incidents were extracted from the Thai Anesthesia Incidents Study (THAI Study) database conducted between February 1, 2003 and January 31, 2004 and analysed using descriptive statistics. RESULTS: Twenty-four incidents of personnel hazard were recorded. Majority of incidents occurred in nurse anesthetist (54.2%). Five incidents exposed to patient blood but no infection reported afterwards. Nineteen incidents (79.2%) were injury without contact to patients blood or body fluid. Most of them were injured by broken ampoules. One case needed to leave from work for a while due to hand dysfunction. CONCLUSION: Personnel hazard incidence were quite low frequency because of under-report. One case of morbidity was reported. Universal precaution and post exposure prophylaxis tended to minimize the risk of infection.