Thitima Chinachoti

Cardiac arrest after spinal anesthesia in Thailand: a prospective multicenter registry of 40,271 anesthetics.

BACKGROUND AND OBJECTIVES: As part of the Thai Anesthesia Incidents Study of anesthetic adverse outcomes, we evaluated the incidence and factors related to cardiac arrest during spinal anesthesia. METHODS: During a 12-mo period (March 1, 2003, to February 28, 2004), a prospective, multicenter registry of patients receiving anesthesia was initiated in 20 hospitals (7 university, 5 tertiary, 4 general, and 4 district hospitals) across Thailand. Anesthesia personnel reported patient-, surgery-, and anesthetic-related variables and adverse outcomes, including cardiac arrest during spinal anesthesia (defined as the time period from induction of spinal anesthesia until the end of operation). Adverse event specific forms were recorded within 24 h of an anesthetic procedure whenever a specific adverse event occurred. Univariate and multivariate analysis were used to identify factors related to cardiac arrest during spinal anesthesia. A P value <0.05 was considered significant. RESULTS: In the registry of 40,271 cases of spinal anesthesia, there were 11 cardiac arrests, corresponding to an incidence of 2.73 (95% CI: 1.12–4.34) per 10,000 anesthetics. The mortality rate was 90.9% among patients who arrested. Among 11 patients who arrested, there were 5 cases of cesarean delivery and 6 cases of extremity surgery, including hip surgery. In 4 patients (36.3%), the anesthetic contributed directly to the arrest (high sympathetectomy, local anesthetic overdose, or lack of electrocardiography monitoring), whereas some arrests were associated with specific events (cementing of prosthesis, massive bleeding, suspected pulmonary embolism, and suspected myocardial infarction). From multivariate analysis, the risks of cardiac arrest during anesthesia were shorter stature (odds ratio 0.944 [95% CI: 0.938–0.951], P < 0.001), longer duration of surgery (odds ratio 1.003 [95% CI: 1.001–1.005], P = 0.002), and spinal anesthesia administered by the surgeon (odd ratio 23.508 [95% CI: 6.112–90.415], P < 0.001), respectively. CONCLUSION: The incidence of cardiac arrest during spinal anesthesia was infrequent, but was associated with a high mortality rate. If the surgeon performed the spinal anesthetic, this was a significant factor associated with cardiac arrest. Increasing the number of anesthesiologists, improving monitoring guidelines for spinal anesthesia and improving the nurse-anesthetist training program may decrease the frequency of arrest and/or improve patient outcome.

Two Doses of Tranexamic Acid Reduce Blood Transfusion in Complex Spine Surgery: A Prospective Randomized Study.

Study Design. Prospective, double-blinded, randomized controlled study. Objective. To determine whether the use of 2 doses of tranexamic acid (TXA) can reduce perioperative blood loss and blood transfusions in low-risk adult patients undergoing complex laminectomy. Summary of Background Data. Complex laminectomy (multilevel laminectomy or laminectomy and instrumentation) is a procedure with a medium risk of blood loss, which may require allogeneic blood transfusion. Previous studies of TXA showed its inconsistent effectiveness in reducing blood loss during spine surgery. The negative results may stem from ineffective use of a single dose of TXA during long and complex operations. Methods. 80 adult (18–65 yr old) patients in Siriraj Hospital, Mahidol University, Thailand were enrolled and allocated into 2 groups (40 patients in each group) by computer-generated randomization. Patients with history of thromboembolic diseases were excluded. Anesthesiologists in charge and patients were blinded. Group I received 0.9% NaCl (NSS) or placebo and group II received 2 doses (15 mg/kg) of TXA. The first dose was administered before anesthesia induction and the second dose, after 3 hours. The assessed outcomes were the amount of perioperative blood loss and the incidence of blood transfusions. Results. 78 patients were analyzed (1 patient in each group was excluded) with 39 patients randomized to each group. There were no differences in patient demographics and pre and postoperative hematocrit levels. The total blood loss in the control group (NSS) was higher [900 (160, 4150) mL] than in the TXA group [600 (200, 4750) mL]. Patients in the control group received more crystalloid, colloid, and packed red blood cell transfusions. Within 24 hours, we observed a 64.6% reduction of blood transfusions (43.5% vs.15.4%, P = 0.006). No serious thromboembolic complications occurred. Conclusion. 2 effective doses (15 mg/kg) of TXA can reduce blood loss and transfusions in low-risk adults undergoing complex spine surgery. Level of Evidence: 1