Simulation-based medical education in Thailand: a cross-sectional online national survey.

BACKGROUND: Simulation-Based Medical Education (SBME) is a teaching method commonly used in undergraduate medical education. Although Thai medical schools have developed a system that incorporates SBME, various aspects of that system require improvement. We surveyed medical school administrators, instructors, and students about SBME in their institutions and the obstacles involved in its implementation, as well as their experiences, expectations, and attitudes regarding the current system. METHODS: We conducted a cross-sectional online survey between August 2019 and July 2020 among administrators, instructors, and 6th-year medical students. A structured questionnaire was developed and distributed to volunteers as an online survey. We recorded details about the SBME system as well as participant characteristics, obstacles, experiences, expectations, and attitudes. We used descriptive statistics as appropriate. RESULTS: We received responses from 15 (68.2%) administrators, 186 instructors, and 371 (13.7%) sixth-year medical students. SBME was commonly used in teaching and evaluation but less so in research. It was mainly used to improve psychomotor tasks, knowledge, patient care, and communication skills. The expected outcomes were improvements in students' performance, knowledge, and practice. The clinical courses were longer and had fewer participants than the pre-clinical courses. Obstacles encountered included shortages of faculty and simulators, time and space limitations, inadequate faculty training, and insufficient financial support. The administrators surveyed had positive attitudes toward SBME. Medical students reported having experience with SBME and strongly agreed that it was beneficial; however, they expected fewer students per class and more learning time to be devoted to these methods. CONCLUSIONS: SBME in Thailand is focused on teaching and assessment. The system could be improved through better-trained faculty, greater available space, more simulators, and sufficient funding. There were also some aspects that failed to meet students' expectations and need to be addressed. However, participants expressed positive attitudes toward SBME. TRIAL REGISTRATION: TCTR20210524003 (Thai Clinical Trials Registry).

A Comparison of Pediatric Weight Estimation Methods for Emergency Resuscitation.

OBJECTIVES: Obtaining accurate pediatric weight is necessary during emergency resuscitation. Although several weight estimation methods exist, the most precise method has not been conclusively determined. This study aimed to evaluate the validity, reliability, and practicality of these tools. METHODS: A prospective observational study was conducted in healthy Thai children aged 6 months to 12 years. Correlations between estimated and actual weights were tested. Validity was assessed by mean bias (estimated weight minus actual weight) and accuracy (10% error). Practicality was evaluated by time usage and data derived from user questionnaires. RESULTS: Four hundred thirty participants with mean age of 6.7 years and mean weight of 26 kg were enrolled. A strong correlation between estimated weight and actual weight in all methods was demonstrated. Parental estimation was the most accurate tool in all age groups, with the lowest overall mean error (ME) of -0.83 kg and the highest accuracy of 88.7%. The Broselow tape was the second most accurate tool in ages younger than 1 year and 1-to-5-year age groups (ME = 0.23 and 0.50 kg; accuracy = 55.3% and 54.1%, respectively). The Mercy method was the second most accurate tool in the 6-to-10-year and 11-to-12-year age groups (ME = -2.47 and -2.77; accuracy = 54.6% and 67.9%, respectively). The Broselow tape had the highest score for practicality of use. CONCLUSIONS: Parental estimation was the most accurate method in every age group. The next best alternative is the Broselow tape in children aged 5 years or younger and the Mercy method in children aged older than 5 years.

Efficacy of surgical transversus abdominis plane block for postoperative pain relief following abdominal surgery in pediatric patients.

BACKGROUND: Transversus abdominis plane (TAP) block is a promising effective method for postoperative pain control after major abdominal surgery. Using a landmark technique, it is easily performed, but its popularity has decreased because of less efficacy due to inaccurate injection and the potential for intraperitoneal organ damage. Ultrasound-guided TAP block provides better results and less complications, but it requires experienced operators. Surgically administered TAP (sTAP) block is a simple technique and may cause less complications. This study was aimed to determine the efficacy of sTAP on postoperative pain control in pediatric patients following a major abdominal surgery, compared with local anesthetic infiltration and no block. METHODS: This stratified, randomized controlled trial was conducted in pediatric patients, below the age of 15 years, who underwent non-laparoscopic major abdominal surgery. Patients were allocated into three groups. The control group received no block; the LA group received 0.25% bupivacaine for local wound infiltration; and the sTAP group received 0.25% bupivacaine for TAP block performed by a surgeon before abdominal wall closure. Parameter records included the incidence of inadequate pain control, time to first analgesic, opioid requirement within 24 h, and complications of these techniques. RESULTS: Fifty-four patients were recruited. There was no significant difference in the incidence of inadequate pain control (P = 0.589). The median time to first analgesic was 380 min in the sTAP group compared with 370 and 420 min in the LA and control groups, respectively (95%CI = 193-567, 121-619, and 0-1012; P = 0.632). The median dose of total opioid requirement (calculated as fentanyl-equivalent dose) was 1.95, 2.05, and 2.04 µg·kg(-1) ·24 h(-1) in the sTAP, LA, and control groups, respectively (IQR = 0.65, 2.20; 0.59, 3.32; 0.38, 2.60; P = 0.723). No complications of sTAP block were detected. CONCLUSIONS: There was no significant advantage of the sTAP block over local infiltration or no intervention for postoperative pain control in pediatric patients undergoing non-laparoscopic major abdominal surgeries.

Effects of a restrictive fluid regimen in pediatric patients undergoing major abdominal surgery.

OBJECTIVE: To investigate the effects of restrictive fluid regimen during major abdominal surgery in pediatric patients. BACKGROUND: In adults, a restrictive and goal-directed regimen as opposed to a liberal-fluid regimen results in better outcomes after various major surgical procedures. The different ratio of body fluid distribution in pediatric patients from those of adults may influence different needs of fluid. METHODS: This stratified, randomized, controlled trial was conducted in 25 pediatric patients (mean age <3 years) undergoing major abdominal surgery. Patients were allocated to two groups based on their perioperative fluid management. 'control group' received maintenance plus deficit plus interstitial space replacement plus ongoing loss, whereas 'restrictive group' had a similar treatment, but were given no interstitial space replacement. Intraoperative fluid resuscitation was guided by hemodynamics and base excess. Parameters recorded included hemodynamic variables, the volume and type of intravenous fluid, blood chemistry (including lactate, base excess, and electrolyte), chest X-ray, body weight, complications, and return of bowel function. RESULTS: Patients in control group needed significantly less additional fluid for resuscitation compared to restrictive group (0.62 ± 3.51 ml · kg(-1) · h(-1) vs 5.04 ± 4.16 ml · kg(-1) · h(-1) ; P = 0.012). In restrictive group, heart rates were higher (P = 0.012) and base excess showed more negative results (P = 0.049). There were no differences between the groups in terms of the total volume requirement, postoperative kidney function, chest X-ray, variation of body weight and the postoperative outcomes. CONCLUSIONS: Volume preload corresponding with an estimated interstitial space replacement was suitable for application to pediatric patients undergoing major abdominal surgery.

A Comparison of Pain Scales in Patients with Disorders of Consciousness Following Craniotomy.

OBJECTIVE: Evaluate the validity, reliability, and practicality of pain assessment tools in patients with disorders of consciousness who underwent craniotomy. MATERIAL AND METHOD: This prospective observational study cross-validated three pain scales, FLACC (Face, Legs, Activity, Cry, Consolability), rFLACC (Revised FLA CC), and NCS (Nociception Coma Scale), based on validity, reliability, and practicality. After translation, the three pain scales were tested for concurrent validity, construct validity, and interrater reliability in patients who experienced disorders of consciousness within 24 hours following craniotomy. Opinions regarding practicality were elicited via questionnaire from nurses who have used and are familiar with these pain scales. RESULTS: Fifty-eight patients were enrolled in the present study. Concurrent validity was supported by positive correlations among all scales, which ranged from r = 0.638 to r = 0.978. All scales yielded fair to moderate agreement (K = 0.380-0.626) with routine clinical decision to treat postoperative pain. Concurrent validity was much improved in the assessment of intubated patients. Construct validity was demonstrated by high scores (3-5) in higher pain situations before analgesic was given and low pain scores (0) in pain-free situations after analgesic was given. All scales had good interrater reliability (intraclass correlation = 0.7506-0.8810). CONCLUSION: All pain scales were found to be valid and reliable, especially in intubated patients. In terms ofpracticality, NCS was found to be the most acceptable by practitioners.

Predictors for complications in pregnant women with heart disease, a retrospective study.

OBJECTIVE: Evaluate the CARPREG score in predicting cardiac, obstetric, and neonatal complications in pregnant women with heart disease. MATERIAL AND METHOD: This was a retrospective study between 2002 and 2011 at a tertiary care center and included 175 pregnant women with heart disease. Maternal and neonatal outcomes were assessed using Cardiac in Pregnancy Score (CARPREG), which included NYHA-class, systolic ejection fraction, left ventricular obstruction, and history of cardiac events. RESULTS: Rheumatic heart disease (n = 116, 66.3%) was the predominant cardiac problem. CARPREG score was 0, 1, > 1 in 65.1%, 24.6%, and 10.3% pregnancies, respectively. Maternal cardiac events occurred in 27.4%. CARPREG score > or = 1 was associated with an increased rate of cardiac events [odds ratio (OR) 6.76, 95% confidence interval (CI) 3.26 to 14.01]. Fetal complications occurred 24.4%. Neonatal birth weight < 2,500 g was associated with CARPREG score > or = 1 (OR 2.57, 95% CI 1.29 to 5.11). CONCLUSION: Maternal cardiac events can be predicted using CARPREG risk index. In Thai population, rheumatic heart disease was the most frequent form of cardiac problems in pregnant women.

Algorithmic prediction of anaesthesia manpower quantity needs: A multicentre study.

BACKGROUND: A shortage of anaesthetists affects health system globally. This is a study on task-force to develop a predictive model for the appropriate number of anaesthetic providers (Y). METHODS: A cross-sectional study was performed with randomisation from every health service region across Thailand. The decision-making criteria for manpower needed were written and provided guidance. The number of personnel was calculated from the sum of total time spent by all anaesthetic providers divided by duration of the service. Linear regression analysis was applied. RESULTS: In total 3774 patients were included from 18 hospitals. The factors that affect the anaesthetic providers' allocation needs were included in the predictive model, calculated as Y = 3.53 + [0.56 (standard centre) + 0.36 (advanced centre) + 1.03 (specialty centre)] + 0.07 (American Society of Anesthesiologists physical status IV and V) + 0.61 (advanced anaesthetic medication) + [0.61 (monitored anaesthesia care) + 0.17 (general anaesthesia)] - [0.27 (pre-anaesthetic duration within 31-60 minutes) + (0.61 (over 60 minutes)] - [0.85 (anaesthetic duration within 31-60 minutes) + 1.04 (within 61-120 minutes) + 1.32 (over 120 minutes)] - [0.16 (post-anaesthetic duration within 31-60 minutes) + 0.45 (within 61-90 minutes) + 0.74 (over 90 minutes)]. CONCLUSION: The anaesthesia manpower algorithm developed during this study can be used to calculate the number of anaesthetists per population to maintain health services.

Effect of wound infiltration with bupivacaine on postoperative analgesia in neonates and infants undergoing major abdominal surgery: a pilot randomized controlled trial.

PURPOSE: Postoperative pain management is essential in the perioperative care of neonates and infants but it requires a high level of care. Wound infiltration with bupivacaine, a long-acting local anesthetic, is a simple method with minimal complications. However, studies on the effectiveness of wound infiltration in neonates and infants are lacking. The purpose of this study was to investigate the effectiveness of wound infiltration with bupivacaine for postoperative analgesia in neonates and infants undergoing abdominal surgery. METHODS: A prospective, randomized controlled trial was conducted in 34 neonates and infants. The patients were randomized into two groups: the bupivacaine (B) group and the control (C) group. A standardized anesthetic protocol was used for each patient. Before wound closure, the surgical site of each patient in the B group was infiltrated with 2 mg/kg of bupivacaine, whereas no surgical site anesthetic infiltration was used in the C group. The neonatal infant pain scale (NIPS) score was used to evaluate postoperative pain, and fentanyl 0.5-1.5 µg/kg was administered when the NIPS score was ≥4. In regard to the fentanyl requirement, the NIPS score and the numbers of patients whose NIPS score was ≥4 were compared between the two groups. RESULTS: The median fentanyl dose requirements in the B group and C group were 1 and 0.5 µg/kg, respectively; and the difference was not statistically significant (p = 0.255). The postoperative NIPS scores in the two groups were not significantly different. In addition, there were no significant differences in the numbers of patients whose NIPS score was ≥4 at 6, 12, 18, and 24 h postoperatively. CONCLUSIONS: In neonates and infants, wound infiltration with bupivacaine had no significant effect on pain relief or fentanyl requirement during the first 24 h after major abdominal surgery.

National survey of pediatric anesthesia practice in Thailand.

OBJECTIVE: To assess current pediatric anesthesia practice for further education from Royal College of Anesthesiologists of Thailand. MATERIAL AND METHOD: A questionnaire was sent to 500 anesthetists in public hospitals in January 2010 to investigate preoperative data, intraoperative data, postoperative pain management, ambulatory anesthesia, and pediatric anesthesia training requirement. RESULTS: Response rate was 30.6%. Preoperative fasting and infective endocarditis (IE) prophylaxis were appropriate except that half the anesthesiologists preferred giving antibiotics in non-cyanotic heart diseases and ordering complete blood count as a routine investigation in healthy patients undergoing minor surgery. Premedication was preferred in children and adolescents. Parental presence during induction was most often selected in children (74.5%). Modified Ayre T-piece was the most popular breathing circuit used during induction while circle circuit was more likely used during maintenance period. Manual ventilation was preferred in neonates. Scavenging system was rarely used Intraoperative fluid was given based on Holliday & Segar Law (> 90%). Isotonic fluid without glucose was preferred for replacement of third space loss and hypotonic fluid with glucose was preferred for maintenance fluid. Transfusion trigger was inversely correlated with age. Postoperative pain scales were more often used in children and adolescents. Fentanyl was more popular in younger age group. Intermittent intravenous administration was the most preferred route. Age group of infants and older were predominantly accepted to be anaesthetized on an ambulatory basis. Pediatric advanced life support was seldom performed. Intermittent training was more popular than certified fellowship training. CONCLUSION: Routine investigation in healthy patients, IE prophylaxis in non-cyanotic patients, intraoperative fluid replacement, and pediatric advanced life support and postoperative pain management were the issues recommended for further education.

Anesthesia workforce capacity in Thailand: A multicenter study.

BACKGROUND: Workforce management in anesthesia services is crucial for service quality. However, the data associated with this are lacking. Therefore, this study was done to analyze workforce and workload and to compare differences among hospital clusters in Thailand. MATERIALS AND METHODS: We conducted a cross-sectional study in multilevel hospitals that were classified by location, the population cared for, and the categorization of physicians. Stratified randomization from all health service regions across Thailand was done. The profile of hospitals, number of anesthesia staffs, their capabilities, and ratio of anesthesia personnel to the service provided during the 5 workdays and 1 weekend period were analyzed. RESULTS: A total of 18 hospitals, ranging from secondary to super-tertiary referral centers, were included in the study. The mean number of personnel ranged from 2.0 ± 1.2 to 12.0 ± 0 for anesthesiologists and 7.5 ± 2.9 to 42.3 ± 19.3 for nurse anesthetists from each hospital cluster, which vary in terms of capabilities and the number of staff. The average number of anesthesia service units was 9.1 ± 4.2 to 31.9 ± 16.4, while the number of operating theaters was 6.9 ± 2.2 to 22.7 ± 8.3. However, the ratio of anesthesia personnel to one anesthesia service unit and the ratio of these personnel to an operating theater were not significantly different among the participating hospitals, with a mean of 0.94 ± 0.45 and 1.34 ± 0.38, respectively. CONCLUSION: The overall number of anesthesia service units was above the designated operating theater capacity, while the ratio of anesthesiologists was 0.8-1.3 and nurse anesthetists was 2.4-6.5 per 100,000 people on an average, with a disproportionate responsibility ratio of anesthesia personnel to anesthesia service units during that time.

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.

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.

Outcome of cardiopulmonary resuscitation in a 2300-bed hospital in a developing country.

OBJECTIVE: To evaluate the outcome and quality of in-hospital cardiopulmonary resuscitation (CPR), and factors affecting the outcome. SETTING: A 2300-bed university hospital in Thailand. METHOD: A 1-year prospective audit according to the Utstein style. RESULTS: A total of 639 cardiac arrests (370 male, 269 female, age 1 day-96 years, mean+/-S.D.=53.3+/-24.12 years) were included. Four hundred and thirty-three cardiac arrests (67.8%) occurred in non-monitored areas and 200 (31.3%) occurred in monitored areas. Five hundred and thirty-six cardiac arrests (84%) were witnessed. The majority of cardiac arrests occurred in medical patients (68.4%) and surgical patients (21.4%). The most common underlying causes of arrest were respiratory failure (24.7%) and septic shock (23.3%). Initial ECG rhythms were ventricular fibrillation 79 (12.4%), asystole 272 (42.6%) with pulseless electrical activity 225 (35.2%). Most patients received basic life support within 1 min (86.7%) and advanced life support (ALS) within 4 min (92.6%) but only 25% of patients received defibrillation within 3 min. Following resuscitation, 394 (61.7%) achieved restoration of spontaneous circulation and 44 patients (6.9%) survived to discharge. Only 162 post-arrest patients were treated in the critical care area. The initial survival rate was not associated with sex, age and time to ALS, but was significantly related to the monitored area. CONCLUSION: In our setting, survival to discharge is 6.9%. Initial survival rate was strongly associated with being in a monitored area. Defibrillators and the critical care areas were insufficient.

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.

Delayed detection of esophageal intubation: Thai Anesthesia Incidents Study (THAI Study) database of 163,403 cases.

INTRODUCTION: Even though esophageal intubation is a common event in anesthesia practice, frequently it is easily detected and resolved. However delayed detection of esophageal intubation (DDEI) can lead to many serious adverse events such as severe hypoxemia, cardiac arrhythmia, cardiac arrest and brain death. OBJECTIVES: To analyze the incidence of DDEI during general anesthesia with endotracheal intubation and to identify its risk factors, especially patients factors and anesthetic techniques, as well as suggested strategies to prevent it. DESIGN: Prospective observational study. MATERIAL AND METHOD: All reported DDEI incidents were identified from the Thai Anesthesia Incidents Study (THAI Study) database conducted between February 1, 2003, and January 31, 2004. Data were analyzed by using descriptive statistics. RESULTS: Forty four cases of DDEI were reported from total of 85,021 cases underwent general anesthesia with endotracheal intubation (5.2: 10,000). The incidence was highest in tertiary care hospital (11.6:10,000). Infant patients (< or = 1 year of age), emergency operation and technique of rapid sequence induction with cricoid pressure were identified as risk factors of DDEI. Detection of DDEI was mainly based on clinical examination. The incidents with extremely low SpO2 level were reported but most of them were adequately managed without long term consequences and only one patient suffered from severe permanent brain damage. CONCLUSION: The overall incidence of DDEI in Thailand was 5.2:10,000. Contributing factors included infant patients, emergency operation, and rapid sequence induction with cricoid pressure. Increased awareness and additional training are suggested as preventive strategies.

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.

Cross-validation of a self-report scale for postoperative pain in school-aged children.

The present study cross-validated self-report pain scales: Verbal Rating Scale (VRS), Facial Expression Scale (FACES), Color Analogue Scale (CAS) and Poker Chip Tool (PCT) in Thai children aged 5-12 years. The concordance with observational measure, Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) was also tested. Among 100 students, test-retest reliability of all self-report measures was moderate to good (K = 0.501-0.712) and only FACES yielded acceptable face validity(IC > 0.5). Validation in 87 patients, all scales showed construct and concurrent validity. FACES was the most preferred scale. Agreement of self-report measures and CHEOPS was better in the age group 5-8 years (K = 0.417-0.826) than 9-12 years (K = 0.231-0.529). In conclusion, FACES is a valid, reliable and practical tool. Self-report measures are more in concordance with CHEOPS in the younger age group.

The Thai Anesthesia Incidents Study (THAI Study) of pulmonary aspiration: a qualitative analysis.

OBJECTIVES: To examine the risk factors, outcomes, and contributing factors associated with perioperative pulmonary aspiration. MATERIAL AND METHOD: Pulmonary aspiration incidents were extracted from the Thai Anesthesia Incidents Study (THAI Study) database conducted between March 1, 2003, and February 28, 2004, and analyzed using descriptive statistics. RESULTS: Thirty-two incidents of aspiration were reported. Passive regurgitation occurred more frequently than active vomiting. Aspiration occurred more commonly in elective rather than emergency surgery, with 59% of incidents taking place during the induction of anesthesia and intubation period. While a major immediate physiological disturbance was common, long term morbidity was not. Death ensued in 5 cases, most of which had significant co-morbidities. Most cases (62.5%) were appropriately treated. The majority of incidents occurred in ASA class 2 (56.3%), age group 15-64 years (59.4%), non obese (92.9%) and non-difficult intubation (71.9%). Most cases were incomplete fasted or had prolonged gastric emptying time. Nasogastric aspiration and rapid sequence induction with cricoid pressure were infrequently used (12.5, 25%). Factors reported as contributing to the incidents included failure of technique and error of judgement. Additional training, continuing medical education and quality assurance tended to minimize the incidents. CONCLUSION: Aspiration occurred commonly in patients with incomplete fasted or had prolonged gastric emptying time and underwent elective surgery. Additional training, continuing medical education and quality assurance tended to minimize the incidents.

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.