Tanyong Pipanmekaporn

Validity and reliability of the Thai version of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU).

Purpose The purpose of this study was to determine the validity and reliability of the Thai version of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), when compared to the diagnoses made by delirium experts. Patients and methods This was a cross-sectional study conducted in both surgical intensive care and subintensive care units in Thailand between February–June 2011. Seventy patients aged 60 years or older who had been admitted to the units were enrolled into the study within the first 48 hours of admission. Each patient was randomly assessed as to whether they had delirium by a nurse using the Thai version of the CAM-ICU algorithm (Thai CAM-ICU) or by a delirium expert using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Results The prevalence of delirium was found to be 18.6% (n=13) by the delirium experts. The sensitivity of the Thai CAM-ICU’s algorithms was found to be 92.3% (95% confidence interval [CI] =64.0%−99.8%), while the specificity was 94.7% (95% CI =85.4%−98.9%). The instrument displayed good interrater reliability (Cohen’s κ =0.81; 95% CI =0.64−0.99). The time taken to complete the Thai CAM-ICU was 1 minute (interquatile range, 1−2 minutes). Conclusion The Thai CAM-ICU demonstrated good validity, reliability, and ease of use when diagnosing delirium in a surgical intensive care unit setting. The use of this diagnostic tool should be encouraged for daily, routine use, so as to promote the early detection of delirium and its rapid treatment.

Incidence of and Risk Factors for Cardiovascular Complications After Thoracic Surgery for Noncancerous Lesions

OBJECTIVE The purpose of this study was to determine the incidence of and risk factors for cardiovascular complications after thoracic surgery for noncancerous lesions. DESIGN Retrospective cohort study. SETTING A tertiary medical center. PARTICIPANTS All consecutive patients undergoing either thoracotomy or thoracoscopy for noncancerous lesions between 2005 and 2011 were included. MEASUREMENTS AND MAIN RESULTS The primary outcomes were the incidence and types of cardiovascular complications such as cardiac arrhythmias, cardiac arrest, heart failure, and myocardial ischemia during hospitalization. A total of 719 patients were recruited, 60% of whom had infections. The incidence of cardiovascular complications after thoracic surgery was 6.7% (48 of 719), of which cardiac arrhythmia was the most common (25 of 48, 52%). The multivariate risk regression analysis showed that age>55 years (risk ratio [RR]=4.0; 95% confidence interval [CI]=2.1-7.5; p<0.01), diabetes mellitus (RR=3.0; 95% CI=1.7-5.3; p<0.01), coronary artery disease (RR=4.8; 95% CI=2.3-10.2; p<0.01), duration of surgery>180 minutes (RR=2.6; 95% CI=1.3-5.1; p<0.01), intraoperative hypotension (RR=2.6; 95% CI=1.6-4.3; p<0.01), and positive fluid balance>2,000 mL (RR=2.5; 95% CI=1.4-4.5; p<0.01) were independent risk factors for cardiovascular complications. CONCLUSIONS Knowledge of risk factors could help surgical teams to identify high risk patients and adjust modifiable risk factors including optimization of medical conditions, correction of intraoperative hypotension, and appropriate blood and fluid administration in order to reduce perioperative morbidity and mortality.

Association of positive fluid balance and cardiovascular complications after thoracotomy for noncancer lesions

Objective The purpose of this study was to explore the influence of positive fluid balance on cardiovascular complications after thoracotomy for noncancer lesions. Methods After approval from an institutional review board, a retrospective cohort study was conducted. All consecutive patients undergoing thoracotomy between January 1, 2005 and December 31, 2011 in a single medical center were recruited. The primary outcome of the study was the incidence of cardiovascular complications, which were defined as cardiac arrhythmia, cardiac arrest, heart failure, myocardial ischemia, and pulmonary embolism. Univariable and multivariable risk regression analyses were used to evaluate the association between positive fluid balance and cardiovascular complications. Results A total of 720 patients were included in this study. The incidence of cardiovascular complications after thoracotomy for noncancer lesions was 6.7% (48 of 720). Patients with positive fluid balance >2,000 mL had a significantly higher incidence of cardiovascular complications than those with positive fluid balance ≤2,000 mL (22.2% versus 7.0%, P=0.005). Cardiac arrhythmias were the most common complication. Univariable risk regression showed that positive fluid balance >2,000 mL was a significant risk factor (risk ratio =3.15, 95% confident interval [CI] =1.44–6.90, P-value =0.004). After adjustment for all potential confounding variables during multivariable risk regression analysis, positive fluid balance >2,000 mL remained a strong risk factor for cardiovascular complications (risk ratio =2.18, 95% CI =1.36–3.51, P-value =0.001). Causes of positive fluid balance >2,000 mL included excessive hemorrhage (48%), hypotension without excessive hemorrhage (29.6%), and liberal fluid administration (22.4%). Conclusion Positive fluid balance was a significant risk factor for cardiovascular complications. Strategies to minimize positive fluid balance during surgery for patients at high risk of cardiovascular complications include preparing adequate blood and blood products, considering appropriate hemoglobin level as a transfusion trigger, and adjusting the optimal dose of local anesthetic for intraoperative thoracic epidural analgesia.

The effect of prophylactic dexmedetomidine on hemodynamic disturbances to double-lumen endotracheal intubation: a prospective, randomized, double-blind, and placebo-controlled trial.

The purpose of this study was to determine the effect of dexmedetomidine on hemodynamic responses to DLT intubation compared to placebo and to assess the adverse effects related to dexmedetomidine. Sixty patients were randomly allocated to receive 0.7 μg/kg dexmedetomidine (n = 30) or normal saline (n = 30) 10 minutes before general anesthesia. Systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), heart rate (HR), and rate pressure product (RPP) between groups were recorded. During intubation and 10 minutes afterward (T1-T10), the mean SBP, DBP, MAP, HR, and RPP in the control group were significantly higher than those in the dexmedetomidine group throughout the study period except at T1. The mean differences of SBP, DBP, MAP, HR, and RPP were significantly higher in the control group, with the value of 15.2 mmHg, 10.5 mmHg, 14 mmHg, 10.5 beats per minute, and 2,462.8 mmHg min−1. Four patients in the dexmedetomidine group and 1 patient in the control group developed hypotension, while 2 patients in the dexmedetomidine group had bradycardia. Prophylactic dexmedetomidine can attenuate the hemodynamic responses to laryngoscopy and DLT intubation with minimal adverse effects. This trial is registered with ClinicalTrials.gov NCT01289769.

The Effectiveness of Intravenous Parecoxib on the Incidence of Ipsilateral Shoulder Pain After Thoracotomy: A Randomized, Double-Blind, Placebo-Controlled Trial

OBJECTIVES To determine the incidence of ipsilateral shoulder pain (ISP) with the therapeutic use of parecoxib compared with a placebo after thoracotomy. DESIGN A prospective, randomized, double-blind, placebo-controlled trial. SETTING A tertiary-care university hospital. PARTICIPANTS Adult patients undergoing an elective thoracotomy between June 2011 and February 2015. INTERVENTIONS Patients were allocated randomly into the parecoxib group (n = 80) and the control group (n = 80). In the parecoxib group, 40 mg of parecoxib was diluted into 2 mL and given intravenously 30 minutes before surgery and then every 12 hours postoperatively for 48 hours. In the control group, 2 mL of normal saline was given to the patients at the same intervals. MEASUREMENTS AND MAIN RESULTS A numerical rating scale was used to assess the intensity of ISP at 2, 6, 12, 24, 48, 72, and 96 hours after surgery. Intravenous morphine (0.05 mg/kg) was used as the rescue medication for ISP during the 96-hour period. Baseline characteristics of patients in both groups were comparable. Patients in the parecoxib group had a significantly lower incidence of ISP, both overall (42.5% v 62.0%, p = 0.014) and of moderate-to-severe ISP when compared with the control group (26.2% v 49.4%, p = 0.003). Parecoxib reduced the risk of ISP by a statistically significant 32% (risk ratio, 0.68; 95% confidence interval, 0.50-0.93, p = 0.016). There were no significant differences in the occurrence of adverse effects between the groups. CONCLUSIONS Intravenous parecoxib significantly can reduce the incidence and severity of ISP after thoracotomy.

A study into perioperative anaesthetic adverse events in Thailand (PAAd THAI): An analysis of suspected emergence delirium

The purpose of this study is to demonstrate the characteristics, contributing factors and recommended policy changes associated with emergence delirium. Relevant data were extracted from the PAAd Thai database of 2,006 incident reports which were conducted from 1 January to 31 December 2015. Details pertinent to the patient, surgery, anaesthetic and systematic factors were reviewed independently. Seventeen incidents of emergence delirium were recorded. Emergence delirium was common in the following categories: male (70.6%), over 65 years of age (53%), elective surgery (76%) and orthopedic surgery (35%). Physical restraint was required in 53% (9 of 17) of cases and 14 patients (82%) required medical treatment. One patient developed postoperative delirium and required medical treatment. The study led to the following recommendations: Development of a classification of practice guidelines and a screening tool, and training for restraint use.