Thewarug Werawatganon

Muscular Injury After Succinylcholine and Electroconvulsive Therapy

Both succinylcholine and seizures cause muscular injury during electroconvulsive therapy. We compared the muscular damage in two groups of patients. The psychiatric patient group received succinylcholine for electroconvulsive therapy. The surgical patient group received succinylcholine for endotracheal intubation. Serum myoglobin was measured as a marker for muscular injury and myalgic symptoms were also recorded. Serum myoglobin increased from baseline in both groups at 5 and 20 min. The surgical patients, however, had a higher myoglobin level than the psychiatric patients at 5 and 20 min after the administration of succinylcholine (P < 0.001). The median (range) of myoglobin concentration at 20 min in psychiatric patients was 32.6 (23.1–60.1) ng/mL, compared with 61.2 (31.6–1687.0) ng/mL in surgical patients. The incidence of myalgia was not different between the two groups. In conclusion, we unexpectedly conclude that the psychiatric patients who received electroconvulsive therapy had less effect of muscular damage associated with succinylcholine than the surgical patients did.

Quality and patient safety in anesthesia service: Thai survey.

Abstract Background: The Royal College of Anesthesiologists of Thailand (RCAT) performed large-scale epidemiologic study of anesthesia-related complications and national incidents study in 2004 and 2007, respectively. Objectives: Evaluate the anesthesia service in Thailand with regard to status of quality and patient safety. Material and methods: A pre-planned structured questionnaire regarding demographic, administrative, preanesthetic, intraoperative postanesthetic variables and complications were requested to be filled in by nurse anesthetists attending the refresher course lecture of RCAT in February 2008. Descriptive statistics was used. Results: Three hundred fifty questionnaires were given and 341 respondents (97%) returned the questionnaires. Most of the respondents (90%) worked in government section. Thirty percent of respondents practiced in hospital without medical doctor anesthesiologist and 58% of nurse anesthetists worked in hospitals that have been accredited. Forty-six percent of respondents reported unavailability of a 24-hour recovery room. The questionnaires revealed of inadequacy of anesthesia personnel (64%), inadequate supervision during emergency condition (53%), inadequacy of patient information regarding anesthesia (57-69%), and low opportunity for patient to choose choice of anesthesia (19%). The commonly used monitoring were pulse oximeter (92% of respondents) and electrocardiography (63%). One-third (32%) of respondents had to provide of anesthesia for patients with insufficient NPO (non per oral) time. Common problems that the respondents experienced were miscommunication (49%), intraoperative cardiac arrest during the past year (35%), error related to infusion pump (24%) and medication error (8%). Fifty-five percent of respondents had to monitor at least one patient per month receiving spinal anesthesia. Conclusion: Suggested strategies for quality and patient safety improvement in anesthesia service are increasing personnel, increasing 24-hour recovery room, improvement of supervision, improvement of communication, compliance to guidelines and improvement of nurse anesthetist’s training regarding monitoring patient receiving spinal anesthesia and cardiopulmonary resuscitation.

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.

Paramedian Spinal Anesthesia: Landmark vs. Ultrasound-guided Approaches

Background: Multiple attempts at needle redirection for paramedian spinal anesthesia can lead to significant complications, particularly in elderly patients. We hypothesized that ultrasound guidance may reduce the need for redirection (s), the associated discomfort, and complications in conventional landmark-guided paramedian spinal anesthesia. Methods: A total of 70 patients >65 years of age, undergoing total knee or hip arthroplasty, were randomly assigned to pre-procedural ultrasound-guided paramedian (PP) or conventional surface landmark-guided paramedian (CP) approach groups. The paramedian approach was performed at L3-4 in the lateral decubitus position. Results: The median number of needle redirection attempts was significantly lower in group PP (2 (interquartile range (IQR) 1-2)) than in group CP (4 (IQR 2-8.5)) (P<0.001). The median number of needle insertion attempts was also significantly lower in group PP than in group CP (P=0.003). All patients in group PP underwent successful needle insertion at the 3-4 lumbar intrathecal space, while 7 in group CP required multiple interspinous space insertions for success (P=0.006). No patient in group PP experienced significant complications related to spinal anesthesia. However, 5 (13.9%), 1 (2.8%), and 7 patients (19.4%) in group CP experienced transient radicular pain, paresthesia, and traumatic puncture, respectively. Conclusion: Application of pre-procedural ultrasound guidance in paramedian spinal anesthesia in elderly patients resulted in a significant decrease in the number of needle redirection and insertion attempts, as well as a reduction in related complications compared with the conventional paramedian technique.