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.

Incidence and risk factors of hypotension and bradycardia after spinal anesthesia for cesarean section.

BACKGROUND: Hypotension or bradycardia after spinal anesthesia for cesarean section remain common and are serious complications. The current study evaluated factors associated to the incidences of hypotension or bradycardia in this context. MATERIAL AND METHOD: A prospective cross sectional study from November 1, 2004 to July 31, 2005 was conducted on 722 parturients undergoing cesarean section under spinal anesthesia. T-test and Chi-square test were used in univariate analysis to compare continuous data and categorical data respectively. Multivariate logistic regression was performed on the variables hypotension (systolic pressure decrease > 30% of baseline value) and bradycardia (heart rate < 60 bpm) p-value < 0.05 was considered significant. RESULTS: Incidence of hypotension and bradycardia were 52.6% and 2.5%. The probability of hypotension increased with estimated blood loss 500-1000 mL (odds ratio [OR] = 1.86; 95% CI 1.30-2.67, p = 0.001), estimated blood loss > 1000 mL (OR = 5.31; 95% CI 1.47-19.19, p = 0.011), and analgesia level > T4 (OR = 1.94; 95% CI 1.18-3.19, p = 0.009). Hypotension occurred despite left uterine displacement (OR = 1.56; 95% CI 1.11-2.19, p = 0.01). Risk factors associated with bradycardia were adding intrathecal morphine 0.2 mg (0.2 mL) (OR = 4.61; 95% CI 1.31-16.19, p = 0.017) to local anesthetics. CONCLUSION: The present results indicated that the incidence of hypotension after spinal anesthesia for cesarean section increased with amount of estimated blood loss > 500 mL and analgesic level > T4. Adding intrathecal morphine 0.2 mg (0.2 mL) to local anesthetics increased incidence of bradycardia.

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.

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.

Spinal versus epidural anesthesia for cesarean delivery in severe preeclampsia: a prospective randomized, multicenter study.

In this randomized, multicenter study we compared the hemodynamic effects of spinal and epidural anesthesia for cesarean delivery in severely preeclamptic patients. The epidural group (n = 47) received 2% lidocaine with epinephrine 1:400,000, 18-23 mL, followed by 3 mg of morphine after delivery. The spinal group (n = 53) received 2.2 mL of 0.5% hyperbaric bupivacaine plus 0.2 mg morphine. We hypothesized that the lowest MAP (mean arterial blood pressure, the primary outcome) during the delivery period would have to be at least 10 mm Hg less in the spinal group to be of clinical importance. We found that there was a statistically significant difference in MAP, with more patients in the spinal group exhibiting hypotension (P < 0.001). Although the incidence of hypotension (systolic arterial blood pressure, SAP < or =100 mm Hg) was more frequent in the spinal group than in the epidural group (51% versus 23%), the duration of significant hypotension (SAP < or =100 mm Hg) was short (< or =1 min) in both groups. There was more use of ephedrine in the spinal group than in the epidural group (median, 6 versus 0 mg) but hypotension was easily treated in all patients. Neonatal outcomes assessed by Apgar scores and the umbilical arterial blood gas analysis were similar in both groups. Adverse neonatal outcomes (5-min Apgar score < 7 and umbilical arterial blood pH < 7.20) were found in only 2 premature newborns (weight < 1500 g) who were born without maternal hypotension after regional anesthesia. We conclude that the results of this large prospective study support the use of spinal anesthesia for cesarean delivery in severely preeclamptic patients.

The Thai Anesthesia Incidents Study (THAI Study) of anesthetic outcomes: I. Description of methods and populations.

BACKGROUND AND RATIONALE: Since anesthesia, unlike medical or surgical specialties, does not constitute treatment, The Royal College of Anesthesiologists of Thailand host the Thai Anesthesia Incidents Study (THAI Study) of anesthetic outcomes to determine factors related to anesthesia related 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 personnels were required to fill up patient-related, surgical-related, anesthesia-related variables and adverse outcomes on a strutured data entry form. The data included preanesthetic evaluation intraoperative period and 24 hr postoperative period. Adverse events specific form was recorded when adverse events occurred. All data were keyed in 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 in one year. The mean (S.D.) of age, weight and height of patients were 38.6(2.3) yrs, 53.9(17.7) kgs and 153.4(22.7) cm respectively. There were more female (52.9%) than male (47. 1%) patients with ASA PS 1, 2, 3, 4, 5 = 50.8%, 36.3%, 10.7%, 2.0%, 0.2% respectively. Hypertension (11.6%), anemia (7.7%) and diabetes melitus (6.8%) were the three most common abnormalities in preanesthetic history taking. Mallampati score of 111870 patients grade 1, 2, 3, 4 were 54.0%, 39.7%, 5.6%, 0.7% and laryngoscopic grade 1, 2, 3, 4 of 74888 patients were 81.0%, 15.5%, 3.0% and 0.5% respectively. CONCLUSION: The first phase of THAI study epidemiological project can represent both the anesthesia and surgical profiles in Thailand. The collected data available should be useful for the improvement of the quality of anesthesia, guidelines for clinical practices, medical education and for further research.

Perioperative myocardial ischemia/infarction: study of incidents from Thai Anesthesia Incidence Study (THAI Study) of 163,403 cases.

OBJECTIVES: To analyze incidence, risk factors, clinical course, outcomes of PMI. Degree of anesthesia related to PMI, management, precipitating factors and corrective strategies. MATERIAL AND METHOD: PMI cases 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: Forty-five cases were recorded as PMI (Suspected myocardial ischemia/infarction) from 20 hospital study centers. The incidence was 2.7:10,000 of all anesthetic services (163,403 cases). PMI occurred more frequently in male, underlying disease of hypertension, diabetes mellitus, ischemic heart disease, ASA class >2, under general anesthesia and during operation. EKG change and hypotension were primary clinical symptoms. PMI caused high mortality (5 cases), high morbidity (6 cases of brain death), high medical cost and change of management plan. CONCLUSION: PMI was strongly impact to both anesthetic and surgical outcomes. Improve quality of anesthetic care for patient at risk and surgical risk reflected the whole anesthetic quality of care.

Anaesthetic experiences in three sets of conjoined twins in King Chulalongkorn Memorial Hospital.

We describe the anaesthetic management for magnetic resonance image scanning, angiography and surgical operations in three sets of conjoined twins (ischiopagus, throracopagus and pygopagus) in King Chulalongkorn Memorial Hospital during 1996-2002. The anaesthetic technique and associated problems are summarized.

Effectiveness of lubrication of endotracheal tube cuff with chamomile-extract for prevention of postoperative sore throat and hoarseness.

PURPOSE OF THE STUDY: To determine the efficacy of lubrication of the endotracheal tube cuff with Chamomile extract (Kamillosan M) before intubation on postoperative sore throat and hoarseness. MATERIAL AND METHOD: The authors randomly assigned 161 patients ASA (American Society of Anesthesiologists) physical status I, II elective surgical, orthopedic, gynecological or urological into 2 groups. The study group received 10 puffs of total 370 mg of Chamomile extract (Kamillosan M spray) lubricated at cuff of endotracheal tube while the control group did not receive any lubrication before intubation. Standard general anesthesia with tracheal intubation was given in both groups. Sore throat and hoarseness were recorded in post anesthetic care unit and at 24 h after operation. RESULTS: One hundred and sixty-one ASA physical status I, II elective surgical patients were recruited. Forty one out of 81 patients (50.6%) in the Chamomile group, scored no postoperative sore throat in the post-anesthesia care unit compared with 45 out of 80 patients (56.3%) in the control group p=0.386. Postoperative sore throat and hoarseness both in the postanesthesia care unit and at 24 h postoperation were not statistically different. There was no statistically significant relationship between sore throat or hoarseness and postoperative nausea or vomiting, ASA physical status, gender, history of smoking, grade of laryngoscopic view, number of intubation attempts, condition during intubation, use of oral airway and couching during extubation. CONCLUSION: Lubrication of endotracheal tube cuff with Chamomile extract spray before intubation can not prevent post operative sore throat and hoarseness.

Nalbuphine versus ondansetron for prevention of intrathecal morphine-induced pruritus after cesarean delivery.

UNLABELLED: In this prospective, randomized, double-blinded study, we compared the prophylactic efficacy of nalbuphine and ondansetron for the prevention of intrathecal morphine-induced pruritus after cesarean delivery. Two-hundred-forty parturients were randomly allocated into four groups. The N-4 group, O-4 group, O-8 group, and placebo group received IV 4 mg of nalbuphine, 4 mg of ondansetron, 8 mg of ondansetron, and 4 mL of normal saline, respectively, immediately after the baby was delivered. In the postanesthesia care unit, we found that the severity of pruritus score in the four groups was significantly different (P < 0.001). The prophylactic success rate for pruritus of the N-4, O-4, O-8, and placebo groups was 20%, 13%, 12%, and 6%, respectively (P < 0.001). The pruritus score between N-4 and placebo and O-4 and placebo was significantly different (P < 0.001 and P = 0.006, respectively). Treatment for pruritus was requested by patients in 25%, 47%, 51%, and 72% of patients in the N-4, O-4, O-8, and placebo groups, respectively (P < 0.001). There were no differences among groups in nausea/vomiting score, pain score, sedation score, or shivering score at 4, 8, and 24 h after surgery. Nalbuphine and ondansetron are more effective than placebo for the prevention of intrathecal morphine-induced pruritus after cesarean delivery. IMPLICATIONS: Nalbuphine and ondansetron are more effective than placebo for the prevention of intrathecal morphine-induced pruritus after cesarean delivery.

A randomized controlled study of three targets of propofol plasma concentration in patients undergoing uterine dilation and curettage.

AIM: To compare the efficacy and the complications of three target levels of propofol plasma concentration in patients undergoing uterine dilation and curettage. METHODS: Sixty-nine patients were randomly allocated to receive propofol target controlled infusion at different target concentrations of 4 (group I), 5 (group II) and 6 (group III) mcg/mL combined with 1 microg/kg of fentanyl and 66% of nitrous oxide. Patients' movement during the procedure, hemodynamic variables, oxygen saturation, end tidal carbon dioxide, time to sleep and awake, and bispectral index score were recorded. RESULTS: Seven patients in group I, one in group II, and none in group III (P < 0.05) moved grossly during the procedure. More patients in group III developed hypotension (5 vs 0 and 2 in group I and II, P < 0.05), but no difference was found regarding respiratory complication. No difference was found in time to sleep, but time to wake was longer in group III. CONCLUSION: Propofol infusion at the target concentration of 5 microg/mL was recommended for uterine dilation and curettage when it was administered with fentanyl 1 microg/kg and nitrous oxide 66% under close monitoring and appropriate respiratory management.

Parental presence during induction of anesthesia in children: a study on parental attitudes and children's cooperation.

Parental attitudes and children's cooperation towards parental presence during induction of anesthesia (PPIA) were studied in one hundred parents and one hundred children aged 1-10 years. The dimensions of parental attitudes were how much PPIA is beneficial or harmful to their child, whether their presence could help the anesthetist, whether the parents should be present and their feelings during induction of anesthesia. Before and after induction of anesthesia respectively, 83 per cent and 87 per cent of the parents thought their presence was mostly beneficial to their child, 77 per cent and 83 per cent thought their presence was least harmful, 64 per cent and 71 per cent believed their presence could help the anesthetist and 97 per cent of the parents agreed that parents should be present during induction of anaesthesia. From the children, perspective, 86 per cent of the children cooperated with induction. It was concluded that PPIA was well accepted by the parents and the majority of the children were cooperative.