Soontarinka S, M.D.,* KongPrai S, Bsc. (Nursing)* *Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkoknoi, Bangkok 10700
Numjaitaharn S, B.Sc. (Nursing),* Thienthong S, M.D.,** Tharnprisan P, B.Sc. (Nursing),* Chouwajaroen P, B.Sc. (Nursing)* *Nursing Division, Srinagarind Hospital, **Department of Anesthesiology, Faculty of Medicine, Khon Kaen University
Heparin Requirement for Anticoagulation in Open Heart Surgery in Songklanagarind Hospital
Chanchayanon T, M.D.,* Wasinwong W, M.D.,* Ua-kritdathikarn T, M.D.,* Rougkleang J, M.D.,** Dilukrattanapijit N, B.N.,* Apisittiwong Y, B.N.* *Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110 **Division of Cardiovascular Thoracic Surgery, Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110
Chularojmontri T, M.D.,* Wasinwong W, M.D.,* Nimmaanrat S, M.D.,* Pinsuwan S, Ph.D,# Langkatawornwong S.# *Faculty of Medicine, #Faculty of Pharmacy, Prince of Songkla University, HatYai, Songkla 90110, Thailand
Manuwong S, M.D.,* Prapaitrakool S, M.D.,* Nandhasri P, M.A. (Chemistry),** Chansom C, BSc.,** Seeyakul K, MSc.*** *Department of Anesthesiology, **Division of Research Center, ***Division of Apply Thai Traditional Medicine, Faculty of Medicine, Thammasat University Hospital
Factors Affect Sore Throat after Tracheal Intubation
Kanjanajongkol C, M.D.,* Vichitchote K, B.N.S.,* Aiengim M, B.N.S.* *Division of Anesthesia Prachuab-khiri-khan Hospital, Prachuabkhirikhan Province 7700
Quality Assessment and Risk Factors of Postoperative Pain in Children
Suraseranivongse S, M.D.,* Khuvichitsuwan P, M.D.,* Sriverachai P, M.D.,* Boonthitikul S, BN.** Homchan W, BN.** *Department of Anesthesiology, **Department of Nursing, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
Akavipat P, M.D., FRCAT.,* Maunsaiyat P, M.N.S.,* Thotham N, B.Sc. (Nursing).* *Department of Anesthesiology, Prasat Neurological Institute, Bangkok 10400
Reintubation in the Recovery Room, Songklanagarind Hospital : Incidence, Causes and Complication
Rujirojindakul P, M.D., FRCAT.,* Ua-kritdathikarn T, M.D., FRCAT.,* Wanasuwannakul T, M.D., FRCAT.,* Loetwiriyakul W, M.D., FRCAT.* *Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
Comparison of Ibuprofen with Placebo for Post-Operative Pain Control after Cesarean Section.
Sanyasiri A, M.D.,* Chanvej L, M.D.* *Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkla, 90110
Suhattaya Boonmak M.D.,* Polpun Boonmak M.D.,* Juthaluk Suwantinprapa M.D.,* Viriya Thincheelong Bsc. (Nursing)*
*Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
Yimyaem PR, M.D.,* Kritsanaprakornkrit W, M.D.,* Piyawaradej P, M.D.,* Sirarat S, M.D.*
*Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002
A Preliminary Report of Glutamine in Attenuating Inflammation from Cardiopulmonary Bypass.
Purintarapiban B, B.N.,* Tantivitayatan K, M.D.,* Ngodngamthaweesuk M, M.D.,* Datcharoen A, B.sc.(Nursing)* *Anesthesiology Department, ** Surgery Department, Faculty of Medicine, Ramathibodi Hospital, Mahidol University 10400 ***Golden Jubilee Medical Center, Mahidol University 73170
Effect of Pretreatment with Dexamethasone for Prevention of Pain on Injection of Propofol
Hintong T, M.D.,* Phanpaisan C, M.D.* *Department of Anesthesiology, Faculty of Medicine, Chiangmai University, Chiangmai 50200
Microbial Contamination on Anesthetic Monitorings at Srinagarind Hospital
Kingsangwal P, B.N.,* Bamrung J, B.N.S.,* Boonmak P, M.D.,* Thananun M, Bsc. (Nursing),* Nonlhaopol D, Bsc. (Nursing),* Muknumporn T, Bsc. (Nursing)* *Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, Thailand
Neurologic Complications after Spinal Anesthesia in Maharaj Nakorn Chiang Mai Hospital
Piyada Boonsong M.D.,* Somchai Wongpunkamol M.D.,* Yodying Punjasawadwong M.D.* Narut Ruananukun M.D.*
*Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200
Somchai Amornyotin M.D.,* Pranee Phomthong B.N.,* Wachira Reunreung B.N.,*
*Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University
Treacher Collins Syndrome : An Alternative Airway Management
Ruenreong Leelanukrom M.D., MPA,* Petch Wacharasint M.D.*
*Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, Rama IV Road, Bangkok 10330, Thailand
Akavipat P, M.D., FRCAT.* Dumrongbul K, B.Sc.(nursing)* Pannak S, B.N.S.* *Division of Anesthesiology, Prasat Neurological Institute, Bangkok. Thailand 10400
Laeni N, M.D.,* Loetwiriyakul W, M.D.,* Chaibandit C, M.D.,* Ruengjira-urai R, B.N.,* Phakam P, B.N.* *Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkla, 90110
R. Yimyaem P, M.D.,* Thienthong S, M.D.,* Krisanaprakonkrit W, M.D.* *Department of Anesthesiology, Faculty of medicine, Khonkaen University, Khonkaen, 40002
Bradycardia in Anesthetized Children : Experience over an 8-Year Period at Songklanagarind Hospital
Witthaya Loetwiriyakul M.D.,* Mayuree Vasinanukorn M.D.,* Thida Ua-kritdathikarn M.D.*
* Department of Anesthesia, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkla 90110
Malasai P, B.Sc. (Nursing),* Kamhom R, B.Sc. (Nursing),* Palachewa K, B.Sc. (Nursing),* Krisanaprakornkit W, M.D.,* Thienthong S, M.D.* *Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002
Anesthesia in Endovascular Aortic Repair
Sindhvananda W, M.D, MPH.* * Department of Anesthesiology, Chulalongkorn University, Bangkok 10330, Thailand
Ischemic Stroke Following Spinal Anesthesia for ORIF with Plate at Left Tibia
Yoosamran B., M.D.* *Division of Anesthesiology, Hat yai Hospital, Hat yai, Songkhla, 90110
Air Embolism with ARDS Following Manual Pressure Infusor
Nonthasoot C, M.D. * *Division of Anesthesiology, Lampang Hospital Lampang 52000
Comparison of Contamination on Blood Pressure Cuff between Measurements
Nonlhaopol D, Bsc. (Nursing),* Kingsangwal P, Bsc. (Nursing),* Satitkarnmance T, M.D.,*Bamrung J, B.N.S.,* Thananum M, Bsc. (Nursing),* Jeerarareunsak W, Bsc. (Nursing),*
Mooknumporn T, Bsc. (Nursing)*
*Department of Anesthesiology, Faculty of medicine, Khon Kaen University , Khon Kaen 40002
Background : Almost all patients receiving medical care will have their blood pressure taken. The blood pressure cuff is one of the most re-used pieces of medical equipment, and yet the cuff can be a real source cross-contamination and subsequent infection. The use of some sort of barrier was suggested so we used plastic wrap because it was inexpensive and readily available. If this technique could reduce the rate of contamination, its use should be adopted in everyday practice. Objective : To compare the contamination on the blood pressure cuff between blood pressure measurements with and Comparative study. Methods : The Ethics Committee of Khon Kaen University reviewed and approved our protocols. Then, 94 volunteers were enrolled for the study. Subjects were randomly allocated to two groups (n=474 to each group). Group 1 received blood pressure measurements without using the plastic wrap barrier, in the operating rooms 5 and 16 ; while Group 2 had the measurements performed using the plastic wrap barrier under the cuff, in the operating rooms 6 and 17. After each operation all of the inner surface of blood pressure cuffs were swabbed for culturing. Result : The rate of contamination on the blood pressure cuff without plastic wrap barrier was 76.59% while it was 14.89% when the barrier was used. Most of the contaminated bacteria was Staphylococcus coagulase negative. Conclusion : Applying plastic wrap around the upper arm before taking blood pressure reduces contact contamination from the blood pressure cuff between patients : the practice should be considered for widespread adoption.
Key words : Blood pressure cuff ; Contamination; plastic wrap
Phiphanmekhaphorn T, M.D.,* Tanwipong trakun T, M.D.,* Leelawattanakul R, M.D.*
*Department fo Anesthesiology, Faculty of Medicine, Chiangmai University , Chiangmai 50200
Background : To enhance the spread of spinal anesthesia, fentanyl may be administered intravenously (IV). This prospective study aims to investigate the effect of fentanyl administered IV on the spread of spinal anesthesia and assesses side effects of intravenous fentanyl. Methods : Forty patients were randomly assigned into two groups receiving either spinal anesthesia with isobaric bupivacaine 8 mg or isobaric bupivacaine 8 mg plus fentanyl intravenous. The level of the first peak of sensory block and motor block (modified Bromage scale) were recorded. Twenty minutes later, control group was administered normal saline 0.02 ml/kg interavenous whereas fentanyl group was administered fentanyl 1 microgram/kg intravenous. The level of second peak sensory block, motor block, side effect and duration of anesthesia were recorded. Results : The first peak dermatomal level of sensory block (cold and pinprick test) was T6 (T2-T12) and T9 (T3-L3) for control group compared with T8 (T3-L3) and T10 (T3-L3) for fentanyl group. After study drug administration, number of patients with sensory block enhancement in fentanyl group were 17 and 19 patients by cold and pinprick test significantly more than control group which were 8 and 7 patients respectively ((P<0.05). All patients have completely motor block. The incidence of hypotension, bradycardia and duration in PACU was not different in both group. Conclusion : The present study demonstrated that intravenous fentanyl can enhance the spread of spinal anesthesia whereas it does not increase the incidence of respiratory depression, sedation, nausea and vomiting, urinary retention, hypotension, bradycardia and duration in PACU.
Key words : Anesthesia ; regional, spinal, bupivacaine, fentanyl, intrathecal, Modified Bromage scale
Mortality Rate and The American Society of Anesthesiologists Physical Classification Yimrattanaboworn P, M.D., FRCAT.*
*Department of Anesthesiology, Buriram hospital, Buriram 31000
The occurrence of surgical outcome has been used to define anesthetic risk for a long time. Beside that preoperative clinical assessment classified by the American Society of Anesthesia (ASA) is one of those indicators. We performed a descriptive-retrospective study to determine the perioperative mortality rate classified by ASA from data base in computer, patients' records, and post anesthetic records during October 1 st , 2001 to September 30 th , 2003 at Buriram hospital. The records were done in all patients in term of the patients' characteristics, ASA physical status, anesthetic techniques and outcome of medical care within 72 hours after the operation. There were totally 53,k 393 anesthetic records. The average patients' age was 34.56 + 20.12 years. The majority of the patients had intraabdominal surgery (42.56%). The anesthetic techniques were general anesthesia with endotracheal tube (51.8%), general anesthesia with mask (21.0%) and spinal anesthesia (19.0%). The preoperative ASA physical status 1 was 72.06%, and ASA status 2 to 5 were 26.13%, 1.65%, 0.15% and 0.006% respectively. The perioperative mortalty rates classified by ASA physical status were 0.9 per 10,000 in status 1, 0.06% in status 2, 0.06% in status 3,78.75% in status 4 and 100% in status 5. The mortality rates associated with anesthesia in ASA physical status 1 0.9 and in status 2 was 2.8 per 10,000. Fundamentally, not only the perioperative mortality rate in associated with ASA physical status but other factors are also involved. All of the factors should be recognized for further improvement of perioperative and anesthetic care.
Key words : mortality rate, perioperative, ASA physical status
Raksakietisak M, M.D.,* Toomtong P, M.D.**
*Assistant Professor, **Associate professor, Department of Anesthesiology, Faculty of Medicine
Siriraj Hospital , Mahidol University , Bangkok 10700 , Thailand
Objective : To evaluate the surgical ICU workload by using simplified Therapeutic Intervention Scoring System 28 items (TISS 28) and to compare the outcome prediction (ICU stay longer than 24 hr) between TISS 28 and Sequential Organ Failure Assessment (SOFA). Design : Prospective cohort study. Setting : 14 surgical ICU beds at a university Hospital . Patients : Four hundred and seventy-two ICU patients (August-December 2004). Methods and measurements : The data included the patients'demographic, division of surgery, diagnosis, initial SOFA score and TISS scores in the first 24 hr, the prevalence of individual TISS items and ICU length of stay (LOS). The data were presented as mean, SD, median, percentage when appropriate. Areas Under Receiver Operating Characteristic (AUROC) curve were used to compare SOFA and TISS 28 for the outcome (LOS > 24 hr) prediction Results : The mean TISS 28 and SOFA scores were 23.8 + 8.6 and 2.0 + 1.0 respectively. The mean patients' age was 61.5 + 17.2 years. The emergency patients had higher TISS 28 and SOFA scores compared to elective patients (28.4 VS 22.8 and 4.0 VS 1.5, P < 0.05). Most patients (> 90%) received standard monitoring, laboratory investigation, multiple medications, wound dressing and hourly urine output measurement which were considered as non-active treatments. The active treatments were mechanical ventilation (51.9%), vasoactive drug (s) (33.0%), and pulmonary artery pressure monitoring (10.2%). TISS 28 had higher AURUC curve than SOFA for LOS > 24 hr (0.88 VS 0.77, P < 0.001). Conclusions : TISS 28 can be used as an effective tool to measure surgical ICU staff workload (for active and non-active treatments) and also a better predictor than SOFA for ICU LOS > 24 hr.
Thai J Anesthesiology 2006; 32(1) : 19-26.
Comparison of Double-lumen Intubation Between Normal Techique with Frova Intubation
Nisoong C, M.D., FRCAT*, Churnchongkolkul W, M.D. FRCAT*,
Punjasawadwong Y, M.D., FRCAT, M.Med.Sc (Clinical Epidemiology)*,
Nipitsukarn T. M.D., FRCAT*, Hongpromyati T, M.D., B.Econ., MBA*
*Department of Anesthesiology, Faculty of Medicine, Chiangmai University , Chiangmai 50200
Objective : To determine whether the use an Frova intubating introducer could facilitate the insertion of a double lumen tube (DLT). Method : Twenty ASA physical status I or II patients scheduled for elective intrathoracic surgery under DLT general anesthesia were randomly allocated to receive double lumen endotracheal intubation either with (a study group) or without (a control group) an Frova intubationg introducer. Result : The mean times for the successful DLT intubation were 13.2 and 10.8 seconds in the control group and the study group, respectively (P = 0.35). There were no difference in number of attempts, laryngoscopic views (grade I or II), complications between the two groups. The proportion of satisfactory grading excellent or good was higher in the study group (9/10) than in the control group (3/10). Conclusion : From a small set of this preliminary study, we failed to demonstrate the improvement of DLT intubation by the use of Frova intubation introducer in patients with low grade of laryngoscopic views (grade I or II). A further larger study may be needed to demonstrate the clinical advantages of the introducer aided DLT intubation, particularly in patients with higher difficult grades of the laryngoscopic view (grade III or IV).
Key word : double-lumen tube, intubation introducer
Thai J Anesthesiology 2006 ; 32(1) :27-32.
Factors Affecting in Competency of Advanced Cardiac Life Support in Anesthetic Residents
Udomphorn Y, M.D.,* Suraseranivongse S. M.D.*
*Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital , Mahidol University , Bangkok 10700
Background : ACLS skill is necessary for all healthcare personnel especially in the high-risk fields. Previous knowledge showed that a training course was important and there were many factors determinige the retention of ACLS knowledge and skill. Objective : To study a passing rate of Objective Structured Clinical Examinations (OSCE) in Siriraj anesthetic residents and factors that may be associated with a passing rate. Methods : All 3-year 50 anesthetic residents' OSCE scores and evaluation sheets were collected to this retrospective descriptive study. All residents passed ACLS course before the starting of an anesthetic training program and received a refresher course during their period of training. Demographic data including the difference in a time interval from the first course to the refresher course of the first to the third year residents were collected. Passing rate of OSCE and residency skills in every steps of ACLS examination were outcomes measurement. Results : The number of passed residents and the passing rate of second and third year residents were 12/16 (75%) and 14/20 (70%) which were significantly greater than first year residents 1/14 (701%), (p < 0.001). An experience during the training was a major factor affecting the passing rate. The most common mistakes in ACLS steps were primary C, primary A, primary B and secondary D (in the part of the treatment). Conclusion : The competency of ACLS skill in anesthetic residents was mainly determined by the clinical experience of cardiopulmonary resuscitation during an anesthetic training program.
Key words : ACLS, skill, residency training, retention of knowledge, audit
Thai J Anesthesiology 2006 ; 32(1) : 33-40.
Malignant Hyperthermia : A case report
Loapakdee R, M.D.*
*Division of Anesthesiology, Burirum 31000
This is a case report of 25 years old man with esophageal foreign body. He had direct laryngoscopy (DL) – esophagoscopy with foreign body removal. After rapid sequence induction with propofol and intubation with succinyl choline, masseter muscle was rigid but the intubation was successful in the first attempt. Then anesthesia was maintained with N 2 O : O 2 and halothane. Few minutes later the patient was tachycardic, had bigemini PVCs, and oxygen saturation decreased (SpO 2 88%). The body temperature was rising to 41 o C, and end-tidal CO 2 increased (ETCO, 67 mmHg). Malignant Hyperthermia was suspected. Only supportive treatments were given because there was no dantrolene. The patient died 5 hours after induction of anesthesia.
Thai J Anesthesiology 2006 ; 32(1) : 46-9.
Case Report : Respiratory Failure in Patient with Multiple Long Bone Fracture
Apichatibutra N, M.D.,* Srichu S, M.D.**
*Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital , Mahidol University , Bangkoknoi, Bangkok 107000
**Department of Anesthesiology, Faculty of medicine, H.R.H.Princess Sirintorn Medical Center , Ongkarak, Nakorn-nayak 26120
We report a case of 31 years old man with fat embolism syndrome ( FES ) after major surgery of multiple long bone fractures from a motorcycle accident. His first operation of dynamic hip screw on his left femur was uneventful. He developed marked dyspnea, hypoxemia and alteration of consciousness about twenty four hours after his second operation of plate and screws fixation on his left femoral shaft and intramedullary nailing of left tibia under general anesthesia three days after the first surgery. Multiple petechiae on his chest wall and jaundice were also found. His chest – X rays showed bilateral patchy infiltrations, arterial blood gas revealed severe hypoxemia along with a low pulmonary artery artery pressure. A diagnosis of FES was supported by this classical clinical presentation after excluding other possible etiology of acute pulmonary edema. He needed ventilatory support with PEEP to maintain oxygenation for 5 days and discharged on day 11. Physicians should be on high suspicious of FES in patients with multiple ling bone fractures especially when coming for intramedullary orthopedics procedure.
Thai J Anesthesiology 2006 ; 32 (1) : 50-3.
Thaisumit R, M.D.,* Rujirojindakul P, M.D,*
*Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University ,
Hat Yai, Songkhla, 90110
Introduction : Dextromethorphan, an antitussive agent, is a noncompetitive N-methyl-D-aspartate (NMDA) receptor antagonist which binds to receptor sites in the spinal cord and central nervous system, thereby blocking the generation of central pain sensations arising from peripheral nociceptive stimuli and enabling reduction in the amount of analgesics required for pain control. Studies have found that dextromethorphan attenuates the sensation of pain at doses of 30-90 mg without major side effects. Objective : To evaluate the effects of oral dextromethorphan (60 mg) on postoperative pain aftertotal abdominal hysterectomy Design : A double-blind randomized controlled trial. Materials and Methods : One hundred patients, ASA class I-II, age 18-65 years, scheduled for elective total abdominal hysterectomy under general anesthesia, were randomized to receive oral dextromethorphan 60 mg or a placebo at 1 hour before surgery. Following surgery, the patients then received patient-controlled analgesia with morphine for 48 hours postoperative as an analgesic. The dextromethorphan and placebo groups were compared in terms of total morphine consumption and pain scores (verbal numerical rating scales ; VNRS) hours postoperative. Results : There was no significant difference between dextromethorphan and placebo groups in terms of total morphine consumption at 48 hours. [32 (19-42.5) and 38 (21.5-46.25) : of the dextromethorphan group were significantly lower than the placebo group at every time of the study. Conclusion : Premedication with oral dextromethorphan 60 mg reduces the VNRS but does not reduce postoperative analgesic consumption after total abdominal hysterectomy.
Key words : preoperative dextromethorphan, postoperative pain, total abdominal
Hysterectomy, oral route
Acetaminophen Premedication for Post-operative Pain after Uterine Curettage
Procedure
Bamrungruk S, M.D.,* Chanvej L, M.D.,* Krataijan J, M.D.,* Lim A, M.Sc.**
*Division of Anesthesiology, Hatyai hospital, Hatyai, Songkla, 90110
**Department of Anesthesiology, ***Department of Epidemiology, Faculty of
medicine, Prince of Songkla University, Hatyai, Songkla, 90110
Background and objective : Acetaminophen is a well known analgesic for mild to moderate pain. After ambulatory uterine curettage pain is expected to be mild or moderate. However, systemic opioid is normally given to relieve pain which may delay recovery. Oral acetaminophen premedication given before the procedure should be suitable to relieve post operative pain. Material and Methods : Randomized, double blinded, control study was conducted. Two hundred and three outpatients age 18-60 years ASA class I-II undergoing curettage procedure were randomly allocated into 3 groups. The patients in group A 1000 (n = 73) received oral acetaminophen 1000 mg of acetaminophen, group A 500 (n = 68) received 500 mg of acetaminophen, the placebo group (PA) (n = 62) only placebo, all were given 30 minutes before starting the procedure. Total intravenous anesthesia with propofol and fentanyl was provided for all patients. The pain intensity was evaluated using verbal rating scale (VRS ; 0-10) at recovery time and 4, 8, 24 hours after premedication. Result : All three groups had mild pain intensity. There was no significant difference in pain intensity at recovery time and 8, 24 hours after premedication. However, pain intensity at 4 hours after premedication was significantly different since patients in group A1000 had a pain score lower than the placebo group (P = 0.02). Median (range) time required for the first dose of paracetamol was 420 (120-1470) minutes in group A1000, 450 (90-1170) minutes in group A500 and 270 (80-900) minutes in the placebo group (P=0.029) Conclusion : Acetaminophen in dosage of 500 and 1000 mg given as premedication is effective for post operative pain after uterine curettage procedure at 4 hour after premedication. In addition, a prolonged requirement of the first dose of paracetamol was found in paracetamol groups compared to the placebo group.
Factors Influencing Patients' Decision on Regional Anesthesia for Cesarean Section
Tantivitayatan K, M.D.,* Jarupongsa J, B.N.,* Sithamwilai W, B.Sc.,* Kitticharoenrerk
A, B.Sc.*
*Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital , Mahidol
University, Bangkok 10400
Recently there has been a breaking news throughout the country about cardiac arrests in regional anesthesia, especially for cesarean section. Whether the culprit is a local anesthetic agent or substandard care, we interviewed 87 parturients elected to undergo cesarean section at Ramathibodi Hospital during a 3-month period on factors involving their choices of anesthesia including impact of the news. The protocol was approved by Hospital Ethics Committee and patient informed consents were obtained. Sixty-seven parturients chose regional® while 20 chose general anesthesia (G). The patient characteristics were not statistically different between both (R VS G) groups : age (33.47 + 4.25 VS 33.25 + 5.23 years), body weight (68.78 + 8.55 VS 69.13 + 17.29 kg), gestational age (37.95 + 0.90 VS 37.75 + 0.63 wk), numbers of gravida, para and abortion, history of antenatal care, Buddhist religion, co-existing diseases, occupations, health insurances , and diagnoses. Over half were previous cesarean section and elderly primigravida. Only education in more college (86.5%) and past anesthetic history as regional anesthetic experiences (40%) in R group that differed from G group (60% and 10% with p < 0.02 and 0.004 respectively). Preoperative questions were asked concerning knowledge of anesthetic procedures and pain relief by regional anesthesia, talk on techniques through friends and family, anxiety about the operation, will to see a newborn delivery and breastmilk, anticipation of baby gender and reasons in coming for service. Postoperatively, they were interviewed on future pregnancy and choice of anesthesia, satisfaction for anesthetic and surgical services and impression on newborn delivery. The key question was changing technique if they heard the news. Results showed that the parturients who knew pain relief capability of regional anesthesia (82%) would choose this technique (p = 0.009) and almost all in both groups would like to have a look of newborn delivery. Hospital good services and recommendations were their main reasons for coming. Degrees of satisfaction ranged from much to very much. While they chose same anesthetic techniques for next delivery (97%), 30% in R group would change to general anesthesia on impact of the news. The influential parameters were represented by : choice of anesthesia = 0.02 (education) + 0.02 (prior anesthetic experience) + 0.14 (pain relief knowledge) + 0.1 (baby sight) + 0.49 (next choice) + 0.13 (news), r2 = 0.48. This study was concluded that patient education, prior experience in regional anesthesia, knowledge of postoperative pain relief and sight of the newborn played a significant role in decision making on the choice of anesthesia in cesarean section. However, the patients could be moved by negative health care information.
Key words : elective cesarean section, regional anesthesia, choice of anesthesia, satisfaction
Intravenous Ondansetron Prevents Intrathecal Morphine-Induced Pruritus in Patients
Undergoing Cesarean Delivery
Rodrak O, M.D.,* Chatmongkolchart S, M.D.*
*Department of Anesthesiology, Faculty of Medicine, Prince of Songkhla University ,
Hatyai, Songhkla 90110
Background : The additional of intrathecal morphine to local anesthetics is highly effective for the management of postoperative pain, however pruritus is a common side effect. The incidence is especially high in patients undergoing cesarean delivery. Objective : We investigated the efficacy of ondansetron in preventing intrathecal morphine-induced pruritus in patients undergoing cesarean delivery. Methods : In a randomized, double-blinded, placebo-controlled study, eighty-six parturients undergoing elective cesarean delivery with spinal anesthesia were studied. All parturients received 0.5% hyperbaric bupivacaine and 0.2 mg of morphine in trathecally. After a child birth, the patients were randomized to receive 8 mg of ondansetron or normal saline (placebo) intravenously, Both groups were evaluated postoperatively for the incidence and the severity of pruritus up to 24 hours. Results : The overall incidence of pruritus was significantly lower in the ondansetron group (53%) (P = 0.01). The postoperative pain score and time to flatus passage were not significantly different. There were no significant complications associated with ondansetron use. Conclusion : Ondansetron prophylaxis significantly reduced the incidence of intrathecal morphin-induced pruritus in patients undergoing cesarean delivery under spinal anesthesia.
Key words : intrathecal morphine, ondansetron, pruritus
Appropriate Blood Order for Elective Surgical Procedures in Songklanagarind
Hospital : Analyzed from the Types of Operation, Patients'Baseline Hematocrit and
Underlying Diseases.
Wanasuwannakul T, M.D.,* Vasinanukorn M, M.D.,* Lim A.**
*Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University ,
Hat Yai, Songkla 90110
**Epidemiology Unit, Faculty of Medicine, Prince of Songkla University , Hat Yai,
Songkla 90110
Introduction : Preoperative over ordering of blood can burden the physician and health care personnel and increases the cost of medical care. Objectives : To assess the appropriate units of blood ordered for elective surgery and the feasibility to develop a practice guideline. Methods : 4,567 anesthetic records of the patients undergoing elective surgery from January 2002 through June 2003 were audited. Group I (gr.I, n = 2,196) and Group II (gr.II, n = 2,371) had surgery during January to September 2002 and October 2002 to June 2003, respectively. The patients in both groups were categorized into subgroups according to the types of operation, baseline hematocrit (Hct) and underlying diseases. The units of blood ordered and transfused (means) in each subgroup in gr. I were calculated as a control in order to assess the error of blood ordered and transfused (in percent) in gr. II with the same subgroups. Results : 687 of 4,567 patients were transfused (15.04%). The patients in gr. I with Hct more than 30%, without underlying diseases, who underwent esophagectomy, renal pelvis and ureter operation, neck dissection, dissectomy, laminectomy for tumor removal, hip and femur surgery, Wertheim's operation, surgical staging and total abdominal hysterectomy + bilateral salpingo-oophorectomy (TAH + BSO), had the blood group matched (G/M) average 2-3 units per person but were actually transfused only 1 unit per person. When comparing this data to the same subgroups in gr. II, the patients who had actual transfusion more than 1 unit per person was less than 15%. The patients in gr. I who underwent breast, knee, cesarean section and gasless laparoscopic surgery had the average blood G/M of 1-2 units per person but none of the patients were transfused intraoperatively. When we examined the patients with same types of operation in gr. II who had only blood typed and screened (T/S) order, the error was zero. In patients with the Hct more than 30%, who had underlying diseases and had cholecystectomy (open or laparoscopic), transurethral procedures and ligation/division of patent ductus arteriosus (PDA) done, the average blood G/M was 1-2 units per person but none of the patients was transfused intraoperatively. This was applied to the patients in gr. II who had blood T/S ordered and we found the error of less than 25%. We could not analyze the data from the patients with underlying diseases who had Hct less than 30% because the numbers of the patients in each subgroup were very few. Conclusion : Patients without underlying ddiseases who has Hct more than 30%, who undergo esophagectomy, renal pelvis and ureter operations, neck dissection, dissectomy, laminectomy for tumor removal, hip and femur surgery, Wertheim's operation, surgical staging and TAH + BSO can have blood G/M scheduled for breast, knee, cesarean section, gasless laparoscopic surgery, cholecystectomy (open or laparoscopic), transurethral procedures and ligation / division of PDA can have only blood T/S ordered. The risk factors from blood transfusion and the patients' pathological conditions should also be considered for patient safety.
Effect of 2% Lidocaine Filling in the Endotracheal Tube Cuff on Postoperative Sore
Throat
Phongchiewboon A, M.D.,* Bunchungmongkol N, M.D.,* Aummeuwdejakorn S,
M.D.*
*Department of Anesthesiology, Faculty of Medicine, Chiang Mai University ,
Chiang Mai 50200
Postoperative sore throat is the common complaint of patients after endotracheal intubation.
Hypothesis and recent studies, usually with high concentration of local anesthetics, suggested that continuous application of local anesthesia at the contact area between the endotracheal tube cuff and trachea would reduce both the incidence and severity of postoperative sore throat by blocking the tracheal pain receptors with local anesthetic delivered via endotracheal tube (ETT) cuff. The objective of the study was to investigate the effectiveness of using conventional available 2% lidocaine filling in endotracheal cuff on reduction of the incidence and severity of postoperative sore throt One hundred and fifty patients, ASA physical status I and II, were randomly allocated into 3 groups where their ETT cuffs were filled with 2% lidocaine, saline or air in volume just sufficient to prevent retrograde leakage around the cuff while ventilating with the tidal volume of 10 ml./kg. Variables typically associated with postoperative sore throat, including endotracheal cuff design, endotracheal tube size, intubation technique, laryngoscope blade, airway placement, suctioning technique, and anesthetic technique were all controlled. Volume of the agents filled at intubation and extubation and cuff pressure measured at intubation and prior to extubation were all recorded. VAS (visual analog scale) and severity of sore throat at one hour and 24 houre following extubation, was used to assess the presence and severity of postoperative sore throat. Two patients in each study group (total 6 patients) were excluded due to failure to meet extubation criteria at the end of operations. Incidence of sore throat among 2% lidocaine group,saline group and air group were 3/48, 8/48 and 7/48 respectively. There was no statistical significant in both incidence and severity among groups. The volume and pressure in air group prior to extubation differed significantly from 2% lidocaine and saline groups. In conclusion, we failed to demonstrate the difference in postoperative sore throat among the 3 groups, 2% lidocaine, saline and air. Larger sample size is needed to elucidate the effectiveness of 2% lidocaine in reducing incidence and severity of postoperative sore throat due to lower incidence of postoperative sore throat in the population study.
Key words : Lidocaine, Endotracheal tube cuff, Postoperative sore throat
Relationship of Subjective and Objective Pain Intensity Assessment in Acute Post
Procedural Pain
Akavipat P, M.D.,FRCAT.,* Maunsaiyat P, M.N.S.*
*Division of Anesthesiology, Prasat Neurological Institute, Bangkok 10400
Background : The two most common methods of measuring pain behavior are through self-report and direct observation. Accuracy and reliability of pain measurement are necessary for diagnosis, evaluation and further management. Objective : To investigate the relationship between subjective pain intensity assessment ; Verbal Numerical Rating Scale (VNRS), Visual Analogue Scale (VAS), Verbal Rating Scale (VRS), Faces Scale (FS) and objective pain intensity assessment of behavior in acute post procedural pain. Methods : Systematic reviews were utilized from electronic databases (Pubmed, Google, Tripdatabase plus, the Cochrane collaboration) and index medicus with the key words of pain behavior, pain intensity, pain observation measures, patient self report, objective pain assessment and subjective pain assessment. The inclusion criteria were focused on study designed (random sampling controlled trial, case controlled trial), acute pain procedure, human population, statistical analysis (Pearson's correlation coefficient), period of time, language and methods of pain assessment. Data synthesis was non-quantitative method. Results : Data collection and critical appraisal of evidences were performed from 2,658 studies. The eight qualified evidenced were selected and analyzed. The findings indicate that subjective reports are moderately to well correlated with direct observations of pain behavior from medical personnel (r = 0.50-0.82, p<0.05 in 6 studies and poor correlated (r = 0.12-0.23, p<005 in 2 studies. Conclusion The appropriate pain measurement should be combined among the varieties of assessment methods for the benefit of patient. The limitation of age group, perception, knowledge and the response to pain should be discussed and recognized before implement.
Key word : self report pain assessment, Behavioral observation pain assessment, Acute pain
The Use of Oral Ramosetron for Prevention of Postoperative Nausea and Vomiting
Prapaitrakllo S, M.D.,* Manuwong S, M.D.,* Kongsayreepong S, B.Sc. (nursing),**
Pattaraarchachai J, M.S.P.H., Sc.D.***
*Department of Anesthesiology, Faculty of Medicine, Thammasart University **
Anesthesia Unit, Thammasart
University Hospital ***Gradstudy Program, Faculty of Medicine, Thammasart University, Patumthanee , Thailand
In a prospective, randomized, double blinded, placebo-controlled trial, we evaluated the efficacy of oral ramosetron 0.1 mg and metoclopramide 10 mg for the prevention of postoperative nausea and vomiting (PONV) in patients considered high risk for PONB after various types of surgery. One hundred and eighty patients ASA physical status I or II, aged 18-65 years who had at least 3 of 4 predictors of PONV (female gender, history of motion sickness or PONV, nonsmoking, and opioid use) were randomized to receive ramosetron 0.1 mg or metoclopramide 10 mg or placebo orally 1 h before the procedure. Standard general anesthetic technique and postoperative analgesia were employed. Significantly fewer patients who had received ramosetron experienced vomiting during the first 24 h compared with placebo (10% with ramosetron and 35% with placebo, P = 0.002, BB/t = 4) and fewer patients in ramosetron group required rescue antiemetice (20% with ramosetron and 43.3% with placebo, P = 0.010). There were no differences between metoclopramide and placebo. A complete response, defined as no nausea and no vomiting occurred in 60%, 25% and 41.7% in ramosetron, metoclopramide and placebo group respectively, there were no significant differences between ramosetron or metoclopramide compared with placebo. Patients who received ramosetron reported higher level of satisfaction in PONV
management and overall anesthesia service (P < 0.001 and P = 0.002 respectively. We conclude that prophylactic oral ramosetron 0.1 mg effectively reduces the incidence of postoperative vomiting and the need for rescue antiemetics in patients considered high risk for PONV and associates with a significantly more satisfaction.
Key words : ramosetron, oral preparation, postoperative, nausea, vomiting, antiemetics
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?. ????? 90110
???????????? : ??????????????????????????????????????? pethidine 0.5 ??./??. ????????????????????????????????????? lidocain 0.5 ??./??. ?????????????????????????????????????????? ?????????????? : ??????????????? ??????????? ??????????????? : ??????? 34 ??? (ASA I ??? II) ?????? pethidine ( ????? P) ???? lidocaine (????? L) ???????????????????????????????? ?????????? : ??????????????????? sensory ??? motor blockade ????????????? 2 ????? ???????????????????????????????????????????? 2 ????? ????????????????? ??????? 4 ??? ????????? pethidine ??????????????? ????????????????????????? ???????????????????????????????? visual analogue score (VAS) ????????????? 2 ????? ????????????????????????????????????????????????????????????????????????????????????????????? ????????????????????? pethidine ?????????????????????????? 4 ??? ??????????????????? 5 ??? ??? 1 ??? ???????????????? pethidine ??? lidocaine ???????? ?????????????????????????????????????????????????????????????????? 2 ????? ?????????????????????????????????????????? ???? : ?????? pethidine ????????????????????????????????????? lidocaine ??????????????????????????????????? ???????????? pethidine ???????????????????????????????????????????????????????????
Effect of Intraoperative Morphine on Postoperative Pain in the Post Anesthesia Care
Unit after abdominal Hysterectomy
Simajareuk S, M.Sc.,* Rakpong P, B.Sc.,* Pongjanyakul S, Dip.N.S.,* Tantanatewin
W, B.Sc.,* Thienthong S, M.D.*
*Department of Anesthesiology, Faculty of Medicine, Khon Kaen University ,
Khon Kaen 40003
Background : Morphine is an analgesic commonly used in general anesthesia. A proper dosage of morphine administration helps patients recover from anesthesia with less pain. Objective : To study the effect of intraoperative morphine administration on postoperative pain and the morphine requirement in the Post Anesthesia Care Unit (PACU) among patiens undergoing abdominal hysterectomy. Study design : Retrospective, descriptive study. Materials and Methods : Anesthetic and PACU records of patients who underwent abdominal hysterectomy under general anesthesia at Srinagarind Hospital were reviewed. Total morphine (mg) used during the surgery, during the hour in PACU and postoperative pain scores were recorded and analyzed. Data were presented as means and percentages. Results : One hundred and eighty-five patients were included. The mean operation time was 137 + 36.3 minutes ; the mean dose of intraoperative morphine was 8.5 mg (0.14 mg/kg). At admission to the PACU, 54 percent of patients had moderate to severe pain (NRS > 5). The data were also analyzed according to the different dosage of intraoperative morpine used. The proportion of patients with moderate to severe pain (NRS > 5) at admission was 69, 63, 47, 52 and 46 percent in the groups receiving 6, 7, 8, 9 and 10 mg of intraoperative morphine, respectively. The proportion of patients who required analgesic drug within 15 minutes after admission to the PACU progressively decreased as the intraoperative dosage of morphine increased, significant in groups receiving 6 vs 10 mg (p = 0.02). Conclusion : Patients who received more intraoperative morphine tend to have less postoperative pain and demand of analgesic in the PACU after abdominal hysterectomy.
Key words : Abdominal hysterectomy, Intraoperative morphine, Post Anesthesia Care Unit, Postoperative pain
Factors Influencing the Use of FLACC Scale by Nurse Anesthetists in Post Anesthetic Care Unit ; Srinagarind Hospital
Promkhote P, B.N.,* Horatanarang D, M.D.,* Mukumporn T, B.Sc. (Nursing),* Kamhom R, B.N.*
*Department of Anesthesiology, Faculty of Medicine, Khon Kaen University ,
Khon Kaen 40002
Background : Acute pain is a common postoperative problem, especially among pediatric patients (between 1 and 6 years of age) because children do not verbalize how they feel. As a consequence, pain assessment is done by observing behaviors. In the Post Anesthetic Care Unit (PACU) at Srinagarind Hospital , Khon Kaen University , the Face, Leg, Activities, Cry, Consolability (FLACC) scale is used for pain assessment, but the scale is not widely used among nurse anesthetists in the PACU : we were therefore interested in determining the reasons. Objective : To determine the factors influencing the use of FLACC scale by nurse anesthetists in the PACU. Design : Descriptive study with prospective data collection setting : PACU, Srinagarind Hospital , Khon Kaen University Methodology : Between April and May 2005, a three-part questionnaire comprising sections on attitude, practice and knowledge vis-à-vis pain assessment was distributed to all nurse anesthetists in the PACU. The nurses were asked to complete the questionnaire, which was then collected for analysis. The data were presented as percentage and mean. Results : All 37 of the hospital's nurse anesthetists consented to participation and all of the questionnaires were completed and returned. Three-quarters (78%) of the respondents agreed that every patient should be treated for pain, 76% considered post-operative pain in children a major problem needing attention, and 67% stated that untreated pain in children would have negative physical and psychological effects. In daily practice, only 51% of the nurses used the FLACC scale after giving pain medication to their patients, Forty percent used the FLACC scale routinely at PACU admission and discharge and 32% assessed pain regularly every 15 minutes. As for knowledge, 86% of respondents said that when patients cried, they were unsure whether the patients were in pain or distressed because of separation from their parents, 84% sometimes had problems using the FLACC scale when patient-behaviors did not match the scale exactly, and 76% thought that crying patients needed more nursing personnel. Conclusion : Although most of the nurse anesthetists in the PACU had a good attitude toward pain management in children, the rate of FLACC scale use in the PACU was not 100% (as should be) ; perhaps because of a lack of knowledge and/or shortage of staff. Education and personnel support might improve the quality of pain assessment and alleviation in the PACU.
Key word : FLACC scale, Post Anesthetic Care Unit, acute pain
Nurse Anesthetist in Assisting Anesthesiologist in Providing Anesthetics to a Patient Whose or with Family History Related to the Occurrence of Malignant Hyperthermia (MH).
Jommaronge P, B.N.,* Srichintai P, M.D.*
*Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital , Mahidol University , Bangkok 10400
Malignant hyperthermia (MH) is a pharmacogenetic disorderof skeletal muscle, manifested as a life-threatening hypermetabolic crisis after exposure to triggering anesthetics agent and possibly by other components or sensitivity to the anomaly of catecholamine resulting in abnormal secretion of calcium from sarcoplasmic reticulum (SR). This leads to severe contraction causing hypermetabolism, high feer and acute acidosis. It has an impact on highly mortality rate.
The author assisted an anesthesiologist to administer anesthesia to a 39 year old female patient whose family history is related to the occurrence of MH. Her elderly brother died from proven MG during anesthesia which was given for cholecystectomy due to cystic mass of gall bladder. The patient was diagnosed to have neurilemma at the second cervical spine (C 2 ) and herniated disc of the c-spine level 3-4 and 5-6. She was scheduled for laminedtomy with tumor removal maintenance anesthesia under GA.
The patient was visited by anesthesiologist and team for preoperative evaluation and preparation, advised for perioperative care to minimize any complication. In order to maintain anesthesia, N 2 O and oxygen fentanyl 100 microgram, pancuronium, midazolam was given together with propofol infusion o keep blood pressure range between 110-130/60-80 mmHg, and the end-tidal CO 2 was 30-35 mmHg. Estimated blood loss was about 200 milliliter. Crystalloid fluid replacement was about 2600 ml, Anesthesia time was about 6 hours. She was still intubated and observed closely in ICU. After the extubation was done, the patient was discharged from hospital within 8 days after the operation without any complication.
Post Operative Visual Loss after Cesarean Section
Suanya P, M.D.*
*Division of Anesthesiology, Vachiraphuket Hospital , Phuket 83000
A case of cortical blindness is reported in 34 year old pregnant woman. After cesarean section under general anesthesia, she became blindness with normal ophthalmologic examination and ocular light reflex. Magnetic resonance imaging showed subtle hypodensed lesions at both occipital lobes.
A low molecular weighed-heparin was administered for suspicious cerebral venous thrombosis. She showed to improve her clinical signs and symptoms after 2 months.
Normally, Cortical blindness is a rare complication in non-cardiovascular surgery. Cerebral venous thrombosis may play a role in pregnant woman.
Prevention and Treatment of Cardiac Arrest during Spinal or Epidural Anesthesia
Tritrakarn T, M.D.,* Chinachoti T, M.D.,* Visalyputra S, M.D.*
*Department of Anesthesiology, Siriraj Hospital , Mahidol University , Bangkok 10700 , Thailand
Cardiac arrest occurred in 24 cases of spinal anesthesia and 2 cases of epidural anesthesia in many hospitals in Thailand during 2002 to 2004
Cardiac arrest during spinal or epidural anesthesia (DADSEA) occurred in young and healthy patients and was unexpected. It has a catastrophic effect on patient, family, anesthesiologist and hospital. The occurrence may be much higher than previously perceived. It is different from cardiac arrest from other causes during anesthesia. Multiple factors and complicated mechanisms are proposed. Spinal or epidural anesthesia is the causative factor in blocking sympathetic nerves leading to unopposed parasympathetic activities, increase vagal tone, bradycardia, vasodilatation and decrease venous return. Patients with in herent high vagal tone, dehydration, hypovolemia, inadequate replacement of fluid or blood loss are more predisposed to CADSEA. Critical factor of sudden bradycardia and asystole are alleged to the activation of vasovagal reflex or Bezole-Jarisch reflex by reduction of venous return and pressure in cardiac chambers
Awareness of this occurrence and knowledge of the mechanism of cardiac arrest during spinal or epidural anesthesia are of the paramount importance in prevention and treatment of this devastating complication. Preoperative evaluation for the high risk patient (history of fainting or syncope, on beta blocker, bradycardia in young and healthy patient, uncorrected dehydration or hypovolemia) is essential in making proper choice of anesthesia. Adequate preloading of fluid before commencing spinal or epidural anesthesia, timely and appropriate fluid and blood replacement are necessary to fill in the vasodilated vessels and reduce drop in right sided filling pressure. Appropriate monitoring, awareness and vigilance of anesthesiologists play important role in early diagnosis and prompt treatment of bradycardia and hypotension before full cardiac arrest. Stepwise treatment of bradycardia with atropine, ephedrine and adrenaline is recommended. For severe bradycardia or asystole, full resuscitation dose of adrenaline and CPR should be promptly administered.
Spinal anesthesia is a valuable, safe and effective anesthetic technique. With a heightened level of awareness, early recognition and prompt aggressive treatment of bradycardia, safety of spinal anesthesia can be improved substantially.
Key words : spinal anesthesia, epidural anesthesia, bradycardia, asystole, cardiac arrest, vasovagal reflex, Bezold-Jarisch reflex
Combination off Dexamethason and Ondansetron for the Prevention of Postoperative Nausea and Vomiting in Patients Undergoing Dilatation and Curettage Under Sevoflurane Anesthesia
Triyasunant N, M.D.,* songsawat N, M.D.,* Visalayapputra S, M.D.,* Suksopee P, B.Sc.,* Sakulpacharoen N, B.Sc.*
*Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital , Mahidol University , Bangkok 10700 , Thailand
Background : There is a high incidence of postoperative nausea and vomiting (PONV) in patients undergoing dilatation and curettage under general anesthesia using sevoflurane. We evaluated whether the combination of dexamethasone and on dansetron could prevent the PONV in patients undergoing dilatation and curettage uuder sevoflurane anesthesia. Methods : In a prospective randomized controlled, double blind study, 76 patients (ASA I-II) scheduled to receive dilatation and curettage were randomly divided into two group. During preoperative period, patients in the treated group received dexamethasone 8 mg and ondansetron 4 mg intravenously while patients in the control group received placebo. A standardized general anesthesia using under mask technique was used with sevoflurane in N 2 O : O 2 . All episodes of PONV and visual analoque pain scores were evaluated during the recovery period, 3-6 hr, 6-12 hr and 12-24 hr of postoperative periods. Results : There was no difference in the episode of PONV during 24 hr of postoperative period (22.0% vs. 34.3%) p = 0.347. Conclusion : By using the combination of dexamethasone and ondansetron, the incidence of PONV is not statistically significant different from using placebo in patients undergoing curettage under sevoflurane anesthesia
The Success Rate of ProSeal™ LMA Insertion by Anesthetist Nurses
Tatiyanupunwong S, M.D.,* Chomsiri N, B.N.**
*Department of Anesthesiology, Faculty of Medicine, Thammasat University , Rangsit Campus, Pathumthani. 10120
**Division of Anesthesia. Thammasat Hospital , Pathumthani 10120
Background : ProSeal™ LMA is a new laryngeal mask airway in which glottis sealing is enhanced by a modified cuff. Moreover, a drainage tube in this device provides a bypass channel for regurgitated gastric content, prevents gastric insufflation, and allowa the passage of gastric tube. Objective : To assess the success rate of ProSeal™ LMA inserted by inexperienced anesthetist nurses. Method : The ProSeal ™ LMA was inserted into seventy, 17-65 years old anesthetized adults with ASA physical status 1-2 by manikin-only trained anesthetist nurses. Patients undergoing elective surgery were induced with fentanyl 1-2 m g/kg and propofol 2-3 mg/kg without neuromuscular blocking drugs. The ProSeal™ LMA was then inserted using an introducer tool. An orogastric tube was passed through the drain tube of the ProSeal™ LMA following the successful insertion. Nurses were allowed to practice three attempts at maximum. The success rate of insertion was monitored in term of numbers of attempt and required duration. Device removal and postoperative complications were also observed. In addition, the success rate of orogastric tube insertion was recorded Results : Overall total ProSeal™
LMA insertion success rate was 88%. Success rate on the first attempt was 74%, while that on the second attempt was 10%. Orogastric tube insertion was attempted in 67 cases and was successful in 57 cases (85%). Postoperative complications including sore throat (32%), dysphagia (12%), and dysphonia (8%) occurred in 24 cases (37%). Conclusion : The high success rate of ProSeal™ LMA inserted by manikin-only trained anesthetist nurses might be an alternative device for airway management in inexperienced nurses.
Key words : ProSeal™ LMA, anesthetist nurse, orogastric tube
Problems in Anaesthetic Trainees
Songarj P, M.D.,* Poopipatpab S, M.D.,* Aroonphrueksakool N, M.D.,* Phattharayuttwat S,
Ph.D.,** Toomtong P.M.D.,*
*Department of Anesthesiology and **Department of Psychiatry, Faculty of Medicine Siriraj
Hospital, Mahidol University , Bangkok 10700
Background : The three year anesthesiology training programme is a critical time for all anesthetic trainees because of the amount of hard work and learning. Trainees always have many problems to solve during a three year course such as a decrease in income and time to be with their families, changes in their social status, and planning for the future. All of these problems can affect the quality of life and facility for learning. This study was undertaken to identify the problems and factors that may affect their lives. Methods : We constructed an anonymous survey to explore in eight areas including general condition, financial, family, relationship with colleagues, job description, climate of learning, career planning and psychotherapy. Survey record forms were sent to four training centers in Thailand . The data was analysed with the descriptive statistics. Results : The response rate was 84.3% (91/108). This identified major concerns and problems in trainees which are as follows : moonlighting due to inadequate income (78%), workload during office hours (less time left for reading and other social activities) (54%), and the lack of self-confidence to the up and coming board examination (95%), and their working climate after graduation (58%). Conclusion : The major concerns and problems in trainees are inadequate income, too much workload during office hours, and the lack of self-confidence
Technique Adjusted Appropriate Endotracheal Cuff Pressure by Rebound Deflating of Syringe
Plunger.
Jumrustanasan Y, M.D.*
*Division of Anesthesiology, Sappasitthiprasong Hospital , Ubonrachathani 34000
Over endotracheal cuff pressure is common problem in anesthesia. Minimal occluding volume with just seal technique is inconvenience and palpation of the pilot balloon is inaccuracy. Method : Quasi experimental study one group with no control in 100 patients whom admitted at tertiary hospital for surgery under general anesthesia with endotracheal tube. Five providers adjusted endotracheal cuff pressure by using 10 cc. Of plastic syringe attached to the pilot balloon for over pressure relief, then measured with a manometer. Result : Eighty-one percents of the patients success to measure appropriate by Manometer (20-30 cm.H2O). Sex was significant correlated with endotracheal cuff pressure (P<0.05) but providers were not correlated. Conclusion : Debound deflating of syringe plunger technique is one method that can use for adjusted appropriate endotracheal cuff pressure. However, manometer is the equipment that is recommended for adjusted appropriate endotracheal cuff pressure.
Key words : Minimal occluding volume, Pilot balloon, Endotracheal cuff pressure, Manometer.
Surgeon Satisfaction with Anesthesia Services at Srinagarind Hospital
Putaprasit R, M.D., Sathikarnmanee T, M.D., Horatanaruang D, M.D., Suwanbunyarit J, M.D.,
Thananan M, B.Sc. (Nursing)
*Department of Anesthesiology, Faculty of Medicine, Khon Kaen University , Khon Kaen 40002
Background : Clinical quality improvement is an important part of hospital accreditation. The aim of the accreditation process is to ensure the best possible service to all persons. Vis-à-vis anesthesia service, the surgeon represents an internal customer. Surgeon's satisfaction of anesthesia services should be surveyed and the feedback used for quality improvement. Objective : To study the level of surgeon satisfaction to anesthesia services as provided at Srinagarind Hospital . Design : Descriptive study with prospective data collection. Method : We surveyed of all the surgeons including residents, who had more than one year's experience with anesthesia service provision at Srinagarind Hospital . A aquestionnaire with check boxes and open-ended questions was the information gathering tool used. Excluded were : surgeons who had not used the anesthesia service within the past year and elective residents from other institutions. The questionnaires were collected and analyzed and the data presented as presented as percentages and means. Results : The survey was carried out in 2004. One hundred and eighty six surgeons were included. The response rate was 91%. The average level of satisfaction with anesthesia service was 3.06 + 0.02 out of 4. Areas needing improvement were : 1) punctuality for the start of anesthesia ; 2) the unduly long time taken between cases ; and, 3) the difficulty in contacting oncall anesthesia personnel off hours. Conclusion : The level of surgeon satisfaction with anesthesia service in Srinagarind Hospital was acceptable ; however, some issues need improvement.
Key words : Surgeon satisfaction, anesthesia service
Effects of Patient Education During Antenatal Care on Preoperative Fasting for Emergency Cesarean Section.
Pisalayon M, B.N.,* Jarupongsa J, B.N.,* Jommarenge P, B.N.,* Tantivitayatan K, M.D., M.P.H.
(Public Health Administration)*
*Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital , Mahidol University , Bangkok 10400
Patient education during antenatal care regarding fasting had influence on NPO time of parturients who underwent emergency cesarean section at Ramathibodi Hospital . From July-December 2004, 150 parturients undergoing emergency cesarean section were equally allocated into the informed and non-in-formed groups and randomly interviewed. The study showed that the informed group prepared themselves better than the other group in terms of NPO practice (97.33% VS 57.33%, p < 0.05) and NPO time before operation (13.91 + 4.54 VS 11.23 + 5.51 hr respectively, p = 0.0025). After symptoms of labor pain, aminotic fluid leak and bloody show, the informed group fasted longer than non-informed group (9.15 + 0.21 VS 4.41 + 3.39 hr, p < 0.05). Patterns of information perception during antenatal care and patient compliance were reviewed and concluded with this study that anesthesiologists could contribute more to parturient cars as multidisciplinary, evidence-based and shared care.
Key words : education, fasting, parturients, cesarean section, emergency
Reintubation after General Anesthesia at Srinagarind Hospital
Sumret K, B.N.,* Chau-In W, M.D.,* Thananum M, B.Sc. (Nursing),* Nonlhaopol D, B.Sc. (Nursing),*
Boonmak P, M.D.,* Boonmak S, M.D.,* Jeerararuensak W, B.Sc. (Nursing)*
*Department of Anesthesiology, Faculty of Medicine, Khon Kaen University , Khon Kaen , 40002 , Thailand
Objective : To determine the incidence and risk factor of reintubation, a potentially preventable adverse event, we analyzed our quality assurance database to identify the causes of reintubation. Design : Descriptive, Prospective study. Methods : This study was part of a multi-center study conducted by the Thai Royal College of Anesthesiologists aimed at surveillance of anesthesia-related complications in Thailand . We collected data from all of the cases in and outside operating room receiving general anesthesia at Srinagarind Hospital , Faculty of Medicine, Khon Kaen University between February 2003, 1 and January 31, 2004 . The medical record of each patient requiring reintubation was obtained and reviewed to determine the causes and attributable risk of the reintubation. All the forms were checked and verified by three peer review then included in the analysis using descriptive statistics. Results : A total of 8,299 cases were included. The incidence of reintubation (after general anesthesia with endotracheal tube) was 31 (37.4 per 10,000 ; 95% CI 25.4, 53.0). The most common cause of reintubation was airway obstruction (77.5%) and most cases returned to normal. The mistakes were related to inappropriate decisions vis-à-vis the patient's physiological status. Contributing factors were inappropriate decision making (29%) and inexperience (26%). The suggested corrective strategies included quality assurance activities, additional training and improved supervision. Conclusion : The most common reason for reintubation after general anesthesia was airway obstruction post extubation, then prolong use of a respirator. To improve the quality of service, the anesthetic team should heighten awareness of the good practice guideline being made during extubation.
Key words : Reintubation ; General anesthesia ; Cause ; Incidence
Dilated Cardiomyopathy and Morbid Obesity in Cesarean Section : A case report
Yimrattanabowon P, M.D.
*Division of Anesthesiology, Burirum Hospital , Burirum 31000
The anesthetic management of a 30 years old woman undergoing repeated cesarean section was performed. A diagnosis of dilated cardiomyopathy had been made 2 years before admission. Her cardiac reserve was poor and she was morbid obesity. The general anesthesia was performed. We induced with Etomidate and intubated with Succinyl choline then maintained with Fentanyl, Sevoflurane and Esmeron. The patient's hemodynamic status was monitored with direct intraarterial blood pressure and pulmonary artery pressure. The patient's perioperative course was uneventful.
Mechanism of Cardiac Arrest during Spinal or Epidural Anesthesia
Tritrakarn T, M.D.,* Chinachoti T, M.D.,* Visalyaputra S, M.D.,* Pechpaisit N,M.D*
Siriwetchadarak R, M.D.*
*Department of Anesthesiology, Siriraj Hospital , Mahidol University , Bangkok 10700.
Cardiac arrest happened in 24 cases of spinal anesthesia and 2 cases of epidural anesthesia in December 2003 to August 2004. Seventeen patients were healthy and young (age below 40). Four aged 40-60 were healthy. Only 5 aged over 60 had concomitant diseases. Operations included cesarean section in 9, hip and lower extremity surgery in 14 and lower abdominal surgery in 4 patients. Cardiac arrest occurred within 5 to 45 min (mean 15.2 min) after performing spinal or epidural block. Either plain or heavy bupivacaine (Marcain®)was used in these cases. Cardiac arrest happened abruptly and refractory to cardiopulmonary resuscitation. Preceding symptoms and signs were bradycardia, hypotension, agitation, upward rolling of eye balls and convulsive – liked movement. Twelve patients recovered without any neurological deficit, 14 patients died in the operating room or in the postoperative period.
Cardiac arrest during spinal or epidural anesthesia in young and healthy patients in different from cardiac arrest from other causes. Multiple factors and mechanisms are proposed. Precipitating factors of sudden bradycardia and asystole are the activation of vasovagal reflex or Bezold-Jarisch reflex by reduction of venous return and increase in vagal tone. Spinal or epidural anesthesia is the causative factor in blocking sympathetic nerves leading to unopposed parasympathetic activities, increase vagal tone, bradycardia, vasodilation and decrease venous return. Patients with inherent high vagal tone, dehydration, hypovolemia, inadequate replacement of fluid or blood loss are more predisposed to the activation of the Bexole-Jarisch reflex.
Knowledge of the mechanism and frequency of occurrence are of the paramount importance in prevention and treatment of this devastating complication of anesthesia
Key words : Spinal anesthesia, epidural anesthesia, bradycardia, asystole, cardiac arrest, vasovagal reflex, Bezole-Jarisch reflex
Tracheal Intubation without Muscle Relaxant : a Comparison between Fentanyl-Lidocaine-Propofol and Fentanyy-Propofol-Succinylcholine, a Preliminary Report
Iamaroon A, M.D.,* Tangwiwat S, M.D.,* Mandee S, M.D.,* Anantachoty Y, M.D.,* Surachetpong S, B.Sc.* (nursing and midwife), Puangchan S, B.Sc.* (Nursing and midwife)
*Department of Anesthesiology, Faculty of medicine, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
To assess intubating conditions after administration of fentanyl-lidocaine-propofol compared with fentanyl-propofol-succinylcholine, 80 ASA I or II patients were randomized into two groups. All patients received midazolam 0.05 mg/kg IV before induction. The control group received atracurium 0.06 mg/kg, fentanyl 1.5 ug/kg, 0.9% normal saline (NSS), propofol 2 mg/kg, and succinylcholine 1.5 mg/kg IV. The study group received NSS, fentanyl 3 ug/kg, lidocaine 1.5 mg/kg propofol 2.5 mg/kg and NSS IV. Intubating conditions were graded according to jaw relaxation, ease of ventilation, vocal exposure, vocal cord position and patient responses. Intubating conditions were judged acceptable, when all scores were excellent or good. If any of the scores was poor. Intubating conditions were judged unacceptable. Hemodynamic response to tracheal intubation was recorded. Intubation was successful in all patients and there were no differences in ease of ventilation, exposure of vacal cords, cord position or patient responses. Jaw relaxation was more relaxed in the study group (87.5%) than in the control group (65%), P = 0.013. Excellent intubating conditions were observed in 52.5% and 57.5% of patients in the control and study group, respectively. All patients in the study group had acceptable intubating conditions, compared with 38 of 40 patients (95%) in the control group. However, there was no significant difference between groups ( P=0.49 ). Mean arterial pressure in the study group was greater decreased than the control group after induction and intubation. We conclude that tracheal intubation using fentanyl-lidocaine-propofol may be an alterantive to tracheal intubation with fentanyl-propofol-succinylcholine.
Key words : tracheal intubation, without muscle relaxant
A comparison of Hemodynamic Response of Laryngeal Mask Airway Insertion between Hypertensive and Normotensive Patients.
Wongpunkamol S, M.D.,* Chaiwong P, M.D.*
*Department of Anesthesiology, Faculty of Medicine, Chiangmai University , Chiangmai 50200
Objectives : To compare the hemodynamic response to laryngeal mask airway (LMA) insertion between hypertensive and normotensive patients. Patients and method : Forty patients (ASA I-II) were studied. Anesthesia was induced with fentanyl 1 mcg/kg IV and etomidate 0.3 mg/kg IV, followed by vecuronium 0.1 mg/kg to facilitate LMA insertion. Group A (n = 20) were hypertensive patients. Heart rate, arterial blood pressure and rate-pressure product (RPP) were measured before induction of anesthesia after LMA insertion. Results : Mean arterial pressure (MAP), heart rate (HR) and rate-pressure product (RPP) decreased after the induction of anesthesia and continued to be lower than baseline values, but not statistically significant. There were no significant differences in heart rate, MAP, and RPP between the two groups. Conclusion : The authors concluded in the pilot study that the hemodynamic responses to LMA insertion in hyperthensive patients were not changed as compared to normotensive patients. LMA insertion may be safely used in hypertensive patients.
Key word : Hemodynamic Response, Laryngeal Mask Airway
Postoperative Analgesic Effect of Morphine Plus Lidocaine for Brachial Plexus Block
Hintong T, M.D.,* Saringcarinkul A, M.D.,* Yampram C, M.D.**Department of Anesthesiology, Faculty of medicine, Chiangmai University , Chiangmai
50200
Background and objectives : Over two decades, results of studies evaluating the analgesic effect of opioid and local anesthetic combination in the brachial plexus block were inconclusive. The aim of this study was to compare the duration of analgesia produced by lidocaine alone or the combination of lidocaine and 0.1 mg.kg -1 morphine. Methods : In a randomized, prospective, double-blinded trial, 60 patients (ASAI-II), aged 16-70 years undergoing brachial plexus block (supraclavicular approach) for upper limb surgery were randomly allocated to 2 groups. Group C (n=30) were received 25 ml. Of 1.5% lidocaine with epinephrine 1 : 200,000 solution. Group M (n=30) were received the same solution as group C plus morphine 0.1 mg.kg.-1 The onset time, duration of sensory / motor block and duration of postoperative analgesia were noted. Results : There was no significant difference between groups in onset time of sensory and motor block. Duration of motor block in group M was significantly longer than group C (p<0.05) whereas the duration of sensory block was not. The median duration of postoperative analgesia was 3.67 hours (25 th – 75 th ) percentiles : 2.93 – 4.5 hours) in group M and 3.1 hours (25 th – 75 th percentiles : 2.18-4.5 hours) in group C which was not significantly different (P=0.84). Conclusion : The addition of morphine 0.1 mg.kg-1 to 25 ml. Of 1.5% lidocaine with epinephrine solution for the supraclavicular brachial plexus block does not improve the duration of postoperative analgesia but prolongs the duration of motor blockade.
Key Words : Brachial plexus block, postoperative analgesia, morphine, opioids
A Survey Research : Postoperative Pain in Children at Srinagarind Hospital
Horatanaruang D, M.D.,* Poomsawat S, B.Sc.* (Nursing), Srichaipanha S, B.Sc.* (Nursing),
Wongswadiwat M, M.D.,* Tantiyasawas V, M.D.**
Background : Postoperative pain in children is often under-treated. Several studies have reported that b20-50% of children have moderate to severe postoperative pain. A survey of postoperative pain experienced in children would be useful for improving patient care. Objective : To study the incidence of postoperative pain among pediatric patients at Srinagarind Hospital , Khon Kaen , Thailand . Design : Descriptive study with prospective data collection. Method : We surveyed the incidence of postoperative pain in pediatric patients (between 1 and 14 years of age) undergoing surgery at the Department of Surgery and Orthopedics, Srinagarind Hospital . All of the patients received standard care. Pain assessment was performed after surgery in the Post-Anesthetic Care Unit (PACU) every 15 minutes and at the ward every 4 hours, using the “Face, Legs, Activity, Cry, Consolability” scale (FLACC scale), in children between 1 and 6, and the Verbal Numeric Rating scale (VNR), in children between 6 and 14. A FLACC score of 2 or more or a VNR of 5 or more was considered as having significant postoperative pain. Nursing assessment using a numeric rating scale (0-10) was also employed. After 24 hours postoperatively, a parent's global rating was carried out using a visual analog scale (VAS). Results : We included 101 patients (60 males vs. 41 females) averaging 5.42 + 3.74 years of age, undergoing surgery in 2003-2004. The incidence of postoperative pain in the PACU at 15, 30, 45 and 60 minutes was 36% (95% CI = 27%-45%), 30% (95% CI=22%-39%), 21% (95% CI=14%-30%) and 16% (95% CI=10%-24%), respectively, vs. the incidence at the ward at 4, 8, 12, 16, 20 and 24 hours of 32% (95% CI = 23%-41%) 23% (95% CI = 16%-32%), 9% (95% CI = 5%-16%, 17% (95% CI = 11%-25%), 20% (95% CI = 13%-28%) and 16% (95% CI = 10%-24%), respectively. Thirty-six percent of the parents rated their children's pain as more than 5 out of 10 on the VAS (95% CI = 28%-46%). Conclusion : The incidence of postoperative pain in children from this study varied depending on the postoperative time frame and the average incidence was around 10-40%. Postoperative pain in pediatric patients should be recognized and managed.
Key words : Children, postoperative pain, survey
Patient knowledge Regarding Postoperative Spinal Anesthesia Complications And Practices in Recovery Room, Srinagarind Hospital
Limpkulwattanaporn P, B.Sc. (Nursing),* Yimyaem RP, M.D.,* Thananun M, B.N.,* Sathitkanmanee bA, B.N.,* Palachewa K, B.N.*
*Department of Anesthesiology, Faculty of Medicine, Khon Kaen University Khon kaen, 4002, Thailand
Background : Spinal anesthesia is a safe and widely used technique. Although it is not life-threatening, adverse reactions and complication effecting daily life can occur. Previous knowledge concerning to these adverse effects and the precautions performed after spinal anesthesia, can improve recovery and prevent exacerbation of compromised outcomes. Objective : To assess patient knowledge and understanding about the possible adverse effects, complications and post anesthetic care after spinal anesthesia. Methods : Subjects were selected from every type of operative procedures which undergoing spinal anesthesia at Srinagarind Hospital between June and September, 2004 (n = 171). All patients recovered well and had good consciousness. Subjects were interviewed after the full recovering in the Recovery Room. The data were analyzed using statistical methods for percentages and correlations (using the Pearson X 2 test). Results : The percentage of patients who ceived advice regarding the potential adverse effects and post-anesthetic care after spinal anesthesia was 88%. Most of the patients (80%) were given advice by the anesthetic team ; the others from a medical doctor, nurse or others from a medical doctor, nurse or other hospital staff-member. The ledge was 35% while 29% had a medium level. Over half of the patients (58%) well understand about prolonged muscle weakness and loss of sensation, while patients who lack of knowledge were significant for potential headache (38%), backache (63%), urinary retention (56%) and shivering (80%). Younger patients learned more effectively than the older. The number of patients receiving anti-anxiety medication before anesthesia was not correlated with the level of knowledge regarding to spinal anesthesia complications. Conclusion : Anesthetic staff plays an important role in giving health education about the possible complications of spinal anesthesia pre and post surgical procedure.
Key words : Patient knowledge ; Complications; Practice ; Spinal Anesthesia
A Re-visit of Basic Life Support Skills Among Anesthetic Residents
Manomayangkul K, M.D.,* Suraseranivongse S, M.D.*
*Department of Anesthesiology, Faculty of Medicine. Siriraj Hospital Bangkok 107000
Objectives : To investigate basic life support skill retention in anesthetic residents and associated factors. Methods : This retrospective descriptive study was conducted in the first, second and third year anesthetic residents during final Objective Structured Clinical Examinations. All residents received basic life support training prior to anesthesiology course and also received recertified course during training. The time interval since initial basic life support training to recertified course of the first, second and third year anesthetic residents were 6,18 and 30 months respectively.
Outcome measures included demographic data, passing score during performance of checking for responsiveness, calling for help, airway opening, checking breathing, checking carotid pulse, ventilation support, chest compression, ratio of compressions : ventilations and reassessment. Results : Fourteen of first year residents, fifteen of second year residents and twenty of third year residents were enrolled in this study. Passing rate of second year residents (86.7%) and third year residents (85%) were more than first year residents (43%). Time interval from initial basic life support to recertified course and Grade point average did not affect skill retention. The common faults were incorrect carotid pulse checking, incorrect reassessment, inadequate chest compression and wrong position of rescuer. Conclusion : Basic life support skill retention of second and third year residents were more than first year residents. Experience in cardiopulmonary resuscitation performance was associated with skill retention.
An Audit of Pain Management in the Post-Anesthesia Care Unit After Revision of the Pain Algorithm at Srinagarind Hospital
Huntula Y, Dip NS.,* Yimyaem RP, M.D.,* Thienthong S, M.D.,* Horatanaruang D, M.D.,* Kamhom R, B.Sc. (Nursing)*
*Department of Anesthesiology, Faculty of Medicine, Khon Kaen University , khon Kaen, 40002
Background : Pain in the Post-Anesthesia Care Unit (PACU) remains a common complaint although a pain algorithm has been implemented. In a 2003 survey at Srinagarind Hospital pain assessment was not performed in 27.2% of patients in the PACU. For quality improvement, the pain algorithm was revised. Objectives : To determine the rate of pain assessment in the PACU and the proportion of untreated patients after revision of the pain algorithm. Design : Descriptive study with retrospective data collection Setting : Post-Anesthesia Care Unit, Srinagarind Hospital Methods : The PACU records were reviewed. Patients included in this study were over 10 year of age and weighed 30 kg or more. Age, types of anesthesia, methods of pain assessment, pain scores and pain treatment were recorded. Results : Between September 1 and 30, 2004, 411 patients met the criteria for pain assessment, but 379 patients (92%) were as sessed. The highest rate of pain assessment with numeric rating scale (NRS) was 79% at 60 min after admission to the PACU and the 28% for the verbal rating scale (VRS) at the admission time. The two most common analgesic drugs used were morphine (72%) and fentanyl (27%).
Immediately after admission to the PACU, 234 patients (86%) were assessed for pain score with ability to use NRS by 222 patients (95%). Of the 53 patients with pain scores > 5, 11 (21%) did not receive any treatment (one refused treatment while the reasons for the other 10 (19%) were not recorded).
Before PACU discharge, pain assessment was performed on 284 patients (71%) with 275 patients (95%) were able to rate their pain using the NRS. Of the 52 patients who had pain scores > 5, 35 (67%) did not receive any treatment (seven refused treatment while the reasons for the other 28 (54%) were not documented). Conclusion : Pain assessment after implementation of a revised algorithm in the PACU was audited was recorded for 92% of patients. Those with pain scores > 5 received treatment ; however, before being discharged from the PACU, 67% of patients with pain scores > 5 did not receive any treatment. Pain management at the PACU needs further improvement.
Key words : Audit, pain algorithm, pain assessment, post-anesthesia care unit
A Case Report : Ventricular Tachycardia Following Lidocaine Local Injection for Flexible Endoscopic Sinus Chronic Sinusitis Surgery.
Piratana K, M.D.*
*Division of Anesthesiology, Sappasitthiprasong Hospital , Ubonrachatanee 34000.
Lidocaine is the most commonly used local anesthetic agent. A case is reported for the complication arising from systemic toxicity following lidocaine with epinephrine injection for bloodless field flexible endoscopic sinus surgery (FESS) and postoperative pain control of chronic sinusitis. Practitioners should be careful for the symptoms of toxicity following local anesthetic administration and particular care about the maximum calculating safe dose for patients.
Key words : lidocaine ; toxicity ; ventricular tachycardia.
Rofecoxib for Postoperative Pain Management after Arthroscopic Arthroscopic
Anterior Cruciate Ligament Reconstruction
Chumpathong S, M,D.,* Raksakietisak M, M.D.,* Apichatibutra N, M.D.,*
Keuprakone S, M.D.*
*Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol
University, Bangkok 10700, Thailand
Background : Nonsteroidal anti–inflammatory drugs (NSAIDs) have been recommended for management of post-operative pain and their opioid-sparing effect has been proved in various situation. One of the indications of specific cyclooxygenase-2 inhibitor NSAIDS, Rofecoxib, is to alleviate post-operative pain but the analgesic efficacy combined. We administered Rofecoxib in pre-emptive fashion to patients undergoing arthroscopic anterior cruciate ligament (ACL) reconstruction. Method : A double blind, randomized controlled trial was conducted. Forty patients scheduled for arthroscopic ACL reconstruction were enrolled in the study. They were allocated into 2 groups, 20 of each, receiving either oral 50 mg of Rofecoxib or placebo 1 hour preoperatively. Spinal anesthesia was perfomed with 0.5% heavy bupivacaine and morphine in every patients. Intravenous morphine via Patient Controlled Analgesia (PCA) was available for all patients. Time of first dose of morphine, total amount of morphine requirement, pain scores, adverse reactions were recorded during the first 24 hours. Result : The Rofecoxib group has significantly longer average time to the first analgesic requirement, 1004 minutes as compare to 720 minutes in the control group (p = 0.02). Accumulated intravenous morphine dose was significantly less in the Rofecoxib group than that in the control group, 3.75 mg vs 11.9 mg (p<0.0001). Pain scores were significantly lower in the Rofecoxib group than that in the control group (p = 0.0048). Conclusion : Preemptive Rofecoxib for arthroscopic ACL reconstruction combined with intrathecal anesthesia demonstrates an opioid sparing effect and is an effective pain management method by providing longer duration of analgesia and enhancing analgesic effects through the first 27- hour period without any adverse effects.
Key words : post-operative pain, Rofecoxib, arthroscopic surgery
The Effect of Preoperative High dose Gentamicin Infusion on the Action of Rocuronium
Lapisatepun W, M.D., F.P.C.A.T.,* Bunchungmongkol N, M.D., F.R.C.A.T.,* Junprasit S, M.D., F.R.C.A.T.*
* Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200
Drug interaction between high dose gentamicin (240 mg) as a prophylactic antibiotic and rocuronium (0.9 mg/kg) was studied prospectively in 20 patients undergoing appendectomy under balanced anesthesia. Ten patients received 240 mg of gentamicin infusion 5 minutes before anesthetic induction and the other 10 served as control. Onset time and clinical duration assessed by an accelerograph (TOF Watch®) were compared and no statistical differences were found. In conclusion, we failed to demonstrate the effect of high dose gentamicin on the action of rocuronium and suggest that a further equivalence study should be conducted to prove the null hypothesis.
Key words : Pharmacology : gentamicin, rocuronium
Influence of an Induction Technique on Intubating Conditions in Adult Patients After Rocuronium : a Comparison of Rropofol and Propofol-Ketamine for Rapid Sequence Induction of Anesthesia Kaewnopparat T,M.D.,* Uakritdathikarn
T, M.D.*
* Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Hatyai, Songkhla, 90110
Introduction : The effect of a neuromuscular blocking agent can be accelerated by many factors such as increased dose or priming technique. Hemodynamic factors such as cardiac output, circulation time and muscle perfusion have been shown to have an effect on the onset of blockade in previous studies. An induction agent which maintains blood pressure and cardiac output may an important factor in speeding up the onset of blockade and improving the intubating conditions of the patients. Objective : To compare intubating conditions and hemodynamic changes after induction with a propofol-ketamine combination or propofol alone, followed by rocuronium 0.6 mg/kg at 60 seconds. Materials and methods : One hundred adult patients with ASA class I-II and age of 15-65 years were randomly assigned to receive either propofol 1 mg/kg and ketamine 0.5 mg/kg in combination (PK group) or propofol 2 mg/kg (P group). The study was double-blinded, and anesthesia and timing of injections were standardized to the study drug and rocuronium 0.6 mg/kg. Tracheal intubation was attempted at 60 s after the relaxant and the intubating condition was graded as excellent, good, fair or poor by an experienced anesthetist. Results : There was no significant difference in the proportion of excellent intubating conditions between the PK group (60%) and the P group (62%) (p>0.05). Mean arterial pressure and heart rate were maintained at pre-induction levels in both groups. Conclusion : The study demonstrated the similar intubating condition usint rocuronium after induction with propofol-ketamine and propofol alone.
Key words : Induction technique, Rocuronium, Intubating condition, Propofol, Ketamine
Intratracheal Lidocaine vs Intravenous Lidocaine for Blunting Cordiovascular Response to Endotracheal Intubations
Kumpubhovichitra P, M.D.,* Kovitwanawong N,M.D.*
*Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Hatyai, Songkhla, 90110
Background and objectives : The alteration of hemodynamics caused by endotracheal intubation may cause significant morbidity such as myocardial infarction, myocardial failure or cerebral hemorrhage. Thus, several techniques include deep inhalation, high dose opioid, and antihypertensive drug administering were used to obtund the cardiovascular reflex. However, there were no studies comparing the effects between lidocaine intravenously and intratracheally. There fore , we compare the effects of lidocaine administration prior to intubation either intravenously or intrathacheally on the alteration of hemodynamics. Materials and method : Fifty patients, ASA I-II, scheduled for elective surgery under general anesthesia, were randomized into two groups. Each patient received 1.5 mg/kg of 2% lidocaine either intravenously (IV) or intrathacheally (IT) three minutes after the induction of anesthesia. The mean arterial pressure (MAP) and heart rate were recorded every minute until 5 minutes after intubation and every 5 minutes until the end of the operation. Results : After intubation, the MAP was 104.24 + 20 and 105.24 + 20 mmHg (p = 0.8) and the heart rate was 85.28 + 17 and 86.88 + 17 beats/minute (p = 0.77) in IV and IT group, respectively. The MAP was increased from baseline 12.14% and 12.43% in IV and IT group, respectively (p = 0.96). The increasing in heart rate was 5.53% and 13.98% in IV and IT group, respectively (p = 0.17). Conclusions : Administration of lidocaine prior to intubation either intratracheally or intravenously cause no significant difference in hemodynamic chang. However, administering lidocaine intravenously is considered more convenient and easier than intratracheally because the special equipment is not necessary.
Key words : intravenous, intratrachea, lidocaine, hemodynamic change, laryngotracheal anesthesia set
The Efficacy of Apneic Blind Nasal Intubation Technique Using an Intubating
Introducer
Churnchongkolkul W, M.D.,* Nisoong C, M.D.,* Punjasawadwong Y, M.D.,*
* Department of Anesthesiology, Faculty of Medicine, Chiang Mai University,
Chiang Mai 50200
This study was designed to evaluate the efficacy of apneic blind nasal intubation technique by using an intubating introducer (FROVA®) in the patients undergoing maxillofacial surgery at Maharaj Nakorn Chiang Mai Hospital. Thirty five, aged 15-60 years, ASA class 1-2, patients who were paralyzed, apneic and about to undergo bling nasotracheal intubation by using a flexible endotracheal tube for elective surgery were studied. Intubating introducer (FROVA®) was inserted via nasal route and advanced until tracheal ring click or hold up was occurred, then a flexible endotracheal tube was threaded over the introducer into the trachea. Demographic data, vital signs, intubation time and complication during intubation and post operative period were recorded. The success rate for blind apneic nasal intubation guided by an intubating introducer (FROVA®) was 34 out of 35 patients (97.15%). The success rate for first attempt was 28 out of 35 patients (80%). Average intubation time was 45.5+ 26.0 seconds. The incident of epistaxis during intubation was 14.3%. In postoperative period, sore throat and nares pain was 74.25% and 11.43% respectively. Intubating introducer (FROVA®) is a new airway device. In this study we have shown that blind nasal intubation with flexible endotracheal tube in apneic patients guided by this device appears to have a high success rate and low severe complication. This device may be very helpful for patients who have difficult intubation problem especially for the trismus patients. Although the success rate for first attempt intubation of this technique is lower than fiberoptic technique, we believe that this technique is an alternative intubating technique for the patients who have difficult intubation problem because of it’s simplicity, safety and high success rate.
Key words : Apneic blind nasal intubation, Intubating Introducer
Hypotension in Elderly Patients Undergoing Spinal Anaesthesia for TURP.
A Comparison of Two Different Spinal Solutions.
Chanchayanon T, M.D.,* Vasinanukorn M, M.D.,* Chanvej L, M.D.,* Jantharokorn
A, B.Sc.,* Juthasantikul W, B.Sc.,* Reangjiraurai R, B.Sc.,* Lim A, M.Sc.**
* Department of Anesthesiology, **Epidemiology unit, Faculty of medicine, Prince
of Songkhla University, Songkhla 90110
The use of conventional dose of bupivacaine for transurethral surgery is associated with a high incidence of hypotension, prolonged motor recovery and discharge time. It may be possible to minimize these undesirable outcomes by using either smaller dose of bupivacaine or small dose of bupivacaine combined with fentanyl. One hundred and forty two patients aged more than 65 years old undergoing transurethral resection of prostate gland (TUR-P) were randomly allocated into two groups receiving either spinal anesthesia with hyperbaric bupivacaine 5 mg plus fentanyl 20 mcg (group 1) or hyperbaric bupivacaine 8 mg (group 1) or hyperbaric bupivacaine 8 mg (group 2). We evaluated the efficacy of anesthesia and their effects on the incidence of hypotension, sensory level, motor blockade and other side effects. The maximal level of the sensory block in both groups was T9. Motor blockade was significantly more intense in group 2 at all times (P<0.05). The incidence of hypotension within 60 minutes was significantly lower in group 1 compared with group 2 (34.25% vs. 59.42%, p = 0.003). There was no other serious side effects. We concluded that the low dose of hyperbaric bupivacaine 5 mg in combination with fentanyl 20 mcg intrathecally could provide effective anesthesia, less intense motor blockade and lower incidence of hypotension compared with bupivacaine 8 mg in TUR-P.
Key words : Elderly, fentanyl, Intrathecal bupivacaine, TUR-P
Surgeons’ Satisfaction with Anesthesia Services in Songkhlanakarind Hospital.
Juthasantikul W, B.Sc.* Nursing, Junthalogon A, B.Sc. Nursing, *Chanchayanon
T, M.D.*
* Department of Anesthesiology, Faculty of Medicine, Songkhla University,
Hat Yai, Songkhla, 90110
Introduction : Satisfaction of surgeons, coworkers and internal customers of anesthetic team, is important in quality improvement. Objectives : To assess satisfaction of surgeons with anesthesia services and examine contributing factors. Methods : Data were collected using a questionnaire for surgeons between July-August 2004. Level of satisfaction was rated on 5-point scale. Results : Of 152 questionnaires sent, 93 were returned (61% response rate). The mean satisfaction score was highest during post anesthesia patients care at recovery room and ward within 48 hours (x = 4.25). The mean satisfaction score during preanesthetic patient care was 4.18. The mean satisfaction score regarding communication of health care team was 4.05. The lowest-mean satisfaction score was during patient care intraoperatively (x = 3.99). Suggestions for improvement included decrease time to perform procedure, start induction early in the morning, increase number of anesthesiologist. The contributing factors of satisfaction were surgeons’ position (staff, resident, intern) and surgeons’ experience. Conclusions : Surgeons’ satisfaction with anesthesia service and suggestion are important to improve anesthesia service to the best quality.
Key words : Satisfaction, Surgeons, Anesthesia, Anesthetic team.
Comparison the Effect of Clonidine and Diazepam Premedication to Decrease Pain on Propofol with Lidocaine Injection
Oofuvong M, M.D.,* Thongsuksai P, M.D.,** Nuanjan K, R.N.,* Jumpeepan
W, R.N.*
* Department of Anesthesiology, **Epidemiology Unit, Faculty of Medicine, prince of Songkla University, Songkhla 90110.
To determine whether oral clonidine reduces pain on jnjection of propofol to lidocaine as compare to oral diazepam. A prospective, randomized double-blind clinical study was conducted in 200 elective patients scheduled for surgery under general anesthesia. There were randomized into 2 groups. The clonidine group (100 patients) took 300 µg of clonidine whereas the diazepam group (100 patients) had 10 mg of diazepam orally 120 minutes before surgery. An intravenous catheter No. 18 was inserted on the dorsum of hands in all patients. Anesthesia was induced by propofol with lidocaine (lidocaine : propofol = 1 : 10) : 2 mg/kg at rate of 0.2 ml/s. Visual analogue scale (VAS) pain scores were assessed in increments from 0-10 every 15 seconds until the patients were asleep. Vecuronium 0.1 mg/kg intravenously was administered for endotracheal intubation and maintenance with morphine 0.1 mg/kg intravenously, halothane 0.5-1.5% and N2O/O2. The mean arterial pressure (MAP) and heart rate (HR) were recorded during the surgery. The results showed the incidence of moderate to severe VAS pain scores in the clonidine group (46%) were significantly lower than that in the diazepam group (63%) (P = 0.016). There was no statistically significant difference in the sedation score between the 2 groups. The MAP and HR in the clonidine group were significantly lower than that in the diazepam group (P < 0.001). The incidence of hypotension in the clonidine group was 17%, significantly higher than that in the diazepam group (P = 0.015). There was no statistically significant difference in the incidence of bradycardia between the 2 groups. We concluded that 5.6 µg/kg of oral clonidine significantly reduced pain on injection of propofol with lidocaine as compare to oral diazepam 0.2 mg/kg.
Key words : Diazepam, lidocaine, oral clonidine, pain on injection, propofol
Factors Influencing Choices of Anesthesia for Cesarean Section – a Survey Research Krobbuaban B., M.D.,* Diregpoke S, B.N.,* Vapitak V,**
Sawasdivong N.
* Division of Anesthesiology, Chaiyaphum Hospital, Chaiyaphum.
Introduction : Choices of anesthesia for cesarean section are very important considering the safety of mother and newborn. Considerable variation exists comparing anesthetic practices for cesarean section. Objective : We assessed the anesthesia for cesarean section and the influence of hospital practice as well as physician’s specialty upon the anesthetic technique in Chaiyaphum province. Methods : This survey was conducted between October 1, 2002 to September 30, 2003 regarding the technique of anesthesia (regional or general) for cesarean section in all hospitals in Chaiyaphum province. The influence of practice (volume of deliveries, geographic location, presence of nurse anesthetists, presence of regional providers obstertrician / general practitioner, person who made decision for choice of anesthesia, patients’ preference and physician’s specialty (anesthesiologist) are explored by logistic regression. Result : The data of 2,132 cesarean section were analyzed. Anesthetic techniques were classified as ; general (89.8%), spinal (10.1%) and epidural anesthesia (0.1%). Surgeon mostly played a role in the decision making between regional and general anesthesia (73%). The influencing factors in the regression showed that anesthesia performed by nurse anesthetists, and surgeon’s decision significantly associated with the anesthetic technique for cesarean section. Conclusion : General anesthesia for cesarean section in Chaiyaphum province is highly popular. It was related to the hospital practice other than patients’ preference and physician’s specialty.
Postoperative Analgesic Effect of Rofecoxib after Transabdominal Hysterectomy
Bunchungmongkol N, M.D., F.R.C.A.T.*
Lapisatepun W, M.D., F.R..C.A.T.*
Pinthugat N, M.D., F.R.C.A.T.*
Parameetong S, M.D., F.R.C.A.T.*Full text
Effectiveness of Non-Temperature-Controlled Water Bath for Warming Packed Red Cells
Suhattaya Boonmak M.D., *
Polpun Boonmak M.D., *
Waraporn Chau-in M.D., *
Somyong Srichaipanha B. Sc.*Full text
Ginger for Prevention of Postoperative Nausea and Vomiting in Outpatiens undergoing Gynecologic Laparoscopic Procedure at Songklanagarind Hospital
Kovitwanawong N, M.D.,* Preechavai C, M.D., * Panichayupakaranant P, Ph.D.,**
*Department of Anesthesiology, Faculty of medicine, Prince of Songkla University,
Hatyai, Songkhla, 90110
**Department of Pharmacognosy and Pharmaceutical Botany, Faculty of Pharmaceutical
Sciences, Prince of Songkla University, Hatyai, Songkhla, 90112
Background and objectives : To study the efficacy of ginger in order to prevent nausea and vomiting in outpatients undergoing gynecologic laparoscopic procedure
Material and methods : 100 outpatients ASA I and II undergoing gynecologic laparoscopic procedure were randomly into 4 groups, n = 25 in each group. The patients in group A received 2 capsules of ginger (1 capsule contain 0.5 g of ginger powder) 1 hour before the procedure (preoperative) and 2 capsules of placebo 30 minutes before discharge from a recovery room (postoperative), group B received 2 capsules of placebo preoperatively and 2 capsules of ginger postoperatively, group C received 2 capsules of ginger preoperatively and postoperatively and group D received 2 capsules of placebo preoperatively and postoperatively. The frequency of nausea and vomiting were evaluated in the recovery room and at 24 hours after the procedure.
Results : There was a significant difference in the incidence of nausea between patients receiving ginger and a control group at 24 hours postoperatively, group A 2 (8%), group B1 (4%), group C7 (28%) and group D 10(40%). The incidence of nausea and vomiting in the recovery room and vomiting at 24 hours after the procedure was not significant.
Conclusions : Ginger is effective to prevent nausea in outpatients undergoing gynecologic laparoscopic procedure
Key words : ginger, gynecologic, laparoscopic procedure, postoperative nausea vomiting
Pain on Injection of Propofol Affects Patient Satisfaction
Tantivitayatan K, M.D.,* Jiarpinitnun J, B.Sc. (nursing)*
*Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol
University, Bangkok 10400
Objective : Propofol is recognized as an almost ideal anesthetic induction agent except pain on injection. The purpose of the current study was to investigate whether this side-effect affected patient satisfaction. Design: Prospective, observational study. Setting: Obstetric and gynecological operating theaters of the University Hospital. Patients : Female patients who underwent transabdominal hysterectomy, myomectomy, dilatation and curettage, Cesarean section, tubal ligation and so on.
Observations : Patients were given propofol (Pofol@) as an induction agent with or without other medications on judgement of each anesthesiologist and allocated into study(S) and control(C) groups respectively. Painful response was recorded and postoperative interview was performed in terms of preoperative memory, painful drug injection, future choice of anesthetic technique and degree of satisfaction.
Measurements and Main results: Patient characteristics in C (n = 132) VS S (n = 144): age 40.44+13.32 VS 40.84+13.74 years, weight 58.70+14.20 VS 57.20+12.16 kg, anesthetic time 76.40+55.85 VS 77.05+54.04 min, propofol dose 145.79+76.50 VS 119.34+45.54 mg (p < 0.05), pain on injection recall 73% VS 23% and similar degree of patient satisfaction in both groups (good to very good). Multiple regression implied anesthetic time, premedication and pain on injection recall influenced patient satisfaction but not to a strong association (r2 = 0.07). Other adjuncts to attenuate this side effect like lidocaine or fentanyl pretreatment could reduce the incidence to half with number needed to treat as 2 (95% CI = 1.74-2.34).
Conclusion : Study results partly support the hypothesis that pain on injection of propofol affects patient satisfaction with other main factors taken into consideration.
Key words : propofol; pain; injection; satisfaction; incidence
The Effect of Surgical Positioning on Cerebral Blood Flow Velocity Evaluated by
Transcranial Doppler Ultrasonography in Healthy Volunteers
Akavipat P, M.D.,* Suchartwatnachai P, M.D.,* Tanapornchaisit S, B.Sc. (Nursing)*
*Division of Anesthesiology, Prasat Neurological Institute, Bangkok 10440
Objective : To evaluate the effect of surgical positioning on blood flow velocity of the right middle cerebral artery in healthy Thai volunteers.
Methods : After ethical approval from Prasat Neurological Institute, Ministry of Public Health, thirty healthy volunteers were measured the blood pressure, heart rate as well as the systolic and mean blood flow velocities of the right middle cerebral artery by transcranial Doppler ultrasonography in normal supine position as basis and each surgical position as followings ; supine, standard sitting, left lateral, right lateral and prone position. The student t-test and ANOVA were used for the statistical analysis. (p value<0.05 considered significant)
Results : The systolic and mean blood flow velocity in normal supine position were 83.71+17.26 cm/sec and 55.36+15.83 cm/sec, surgical supine position were 83.58+19.33 cm/sec and 56.15+17.88 cm/sec, standard sitting position were 79.65+18.18 cm/sec and 55.96+13.24 cm/sec, left lateral position were 83.46+14.76 cm/sec and 51.05+15.98 cm/sec, right lateral position were 80.46+16.33 cm/sec and 52.46+18.23 cm/sec and prone position were 82.69+16.44 cm/sec and 54.35+16.17 cm/sec respectively.
Conclusion : There are no significant changes in the systolic and mean blood flow velocity of the right middle cerebral artery from various surgical position but significant decrease in mean blood pressure in left lateral position in healthy volunteers.
Key words : position, cerebral blood flow velocity, transcranial Doppler ultrasonography
The Use of Photograph as a Visual Aid in Positioning for Administration of a Spinal
Block.
Chaysang D, B.N.,* Lekprasert V, M.D.,* Pisalayon M, B.N.*
*Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital, Bangkok 10400
The use of spinal anesthesia has been increasingly popular due to several advantages as compared with general anesthesia. Patients normally recover from surgery faster, have less pain and spend less expense. In addition, opioids such as morphine can be administered into subarachnoid space to provide pain relief better than that of intravenous and intramuscular administration Since elderly often have coexisting diseases and impairment of major organ functions, general anesthesia in geriatric patients must be provided with great caution. This study was aimed to evaluate the usefulness of a photograph regarding patient positioning as a visual aid for a spinal block. The observational descriptive study was performed in 69 patients aging between 20-86 years who were undergoing hip or leg surgery, cesarean section, and transurethral resection of prostate under spinal block.
After understanding the photograph, the patient positioned him/herself with the help of nurse anesthetists. The investigator recorded the time spent for successful spinal block and the number of repositioning. The result showed no statistically significant difference of the time to successful spinal block and the number of repositioning (p = 0.8, 0.55 successively).
Key word : Anesthesia, Spinal Block, Positioning.
A Comparison Between Spinal Block, General Anesthesia with Bupivacaine Inguinal Field Block and General Anesthesia with Bupivacaine Instillation for Postoperative Pain Following Inguinal Herniorrhaphy in Adult.
Piratana K, M.D.,* Leesan U, B.N.,* Rachmanee A, B.N.,* Kengjuturat Y, B.N.,* Somnat Y, B.N.* Sangiumsak A, B.N.,* Galnade S, B.N.,* Jirachai V, B.N.,* Nontakote U, B.N.*
*Division of Anesthesiology, Sappasitthiprasong Hospital, Ubonrachathanee 34000
Objective : To compare the postoperative pain following inguinal herniorrhaphy.
Methods : Ninety, ASA I-III, aged 17-70 year patients with elective, unilateral, non-recurrent, indirect inguinal hernia undergoing Bassini repair were randomly allocated into3 groups. Group I received spinal anesthesia with 0.5% hyperbaric bupivacaine, group II received general anesthesia together with (SB) 0.25% bupivacaine inguinal field block (GA c BIFB) 20 ml before surgery and group III received general anesthesia with 0.25% bupivacaine instillation (GA c BI) 10 ml after herniorrhaphy before closure of the external fascia. General anesthesia via laryngeal mask airway (LMA) was performed with propofol 1.5-2.5 mg/kg and maintained with N2O / O2 / Sevoflurane. Outcome measurement : Postoperative pain scores (VAS 0-10 cm) were assessed at 0, 1/2, 1, 1 1/2 , 2, 3, 4 , 6, 8, 12 and 24 hours after surgery.
Results: Within 24 hours after surgery, average postoperative pain scores (mean VAS) in group I (SB) was 1.91 cm, group II (GA c BIFB) was 1.40cm and group III (GA c BI) was 1.83 cm and postoperative morphine requirement per patient in group I (SB) was 3.77 mg, group II (GA c BI) was 4.40 mg. There was no significant difference between patients who received the three treatment modalities.
Conclusion : The three anesthetic techniques for 24 hours postoperative pain control following inguinal herniorrhaphy in adult were no significant difference.
Key words : postoperative pain, Inguinal herniorrhaphy in adult, Spinal block, Inguinal field block. Wound instillation
Volunteers’ Satisfaction, Blood Pressure and skin Effect : a Results of Blood Pressure Measurement with and without Plastic Wrap under the Cuff
Kingsangwal P, B.N.,* Pragarngkamanan D, B.N.,* thananun M.B.N.,* Sinkuakool C, M.D.,*
Kritsanaprakornkit W, M.D,* Jangsem k, B.N.,* Nonlhaopol D, B.Sc. (nursing)*
*Department of Anesthesiology, Faculty of Medicine, Khon kaen University, Khon
Kaen 40002.
Chronic Undiagnosed Traumatic Diaphragmatic Hernia : A Case Report
Chintanapramote B, M.D.*
*Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Bangkok10700.
Traumatic diaphragmatic hernia (TDH) can occur in approximately 5% of hospitalized motor vehicle accident victims. Although most of such injuries are diagnosed at the time of initial trauma, approximately 10 % become clinically apparent only months or a year later. The TDH patient is at risk for surgical complication and hemodynamic instability.
Diagnosis and proper anesthetic management of TDH is essential in order to minimize such complications.
The anesthetic management of a patient with a chronic TDH presenting for herniorrhaphy is presented and discussed.
Unilateral Vocal Cord Paralysis Following Endotracheal Intubation : A Case Report Chimpalee R, M.D.*
*Division of Anesthesiology, Paholpolpayuhasena Hospital, Kanchanaburi 71000
A 54 years old male patient had chronic low back pain and operation of laminectomy with pedicular screw at L 3-4 and L 4-5. The surgical procedure was done under general anesthesia with endotracheal tube. The operation time was 3 hours and 50 minutes. Two weeks after the operation, he had hoarseness of voice.
The Otolaryngologist found that he had left vocal cord paralysis without any lesion and deformity. Further investigation was done without abnormal findings.
Complications of short-term intubation mentioned are sorethroat, laryngeal trauma such as vocal cord edema, arytenoids dislocation or subluxation, etc. However, vocal cord paralysis is a rarely complication. There are 2 types of vocal cord paralysis ; bilateral and unilateral vocal cord paralysis with different causes.
Halothane Hepatitis: A Case Report
Anusit J, M.D.*
*Chachoengsao Hospital, Chachoengsao 24000
A case of halothane hepatitis in a 49 years old male patient was reported. He had a disectomy operation more than 1 year ago with halothane with no problems. He came back for a second disectomy under general anesthesia. Same technique and halothane was used. He had jaundice, fever and diarrhea 4 days later. Hepatic enzymes were very high and he was sent to Chonburi hospital to find the cause of hepatitis and the treatment. He was sent to ICU because of unconsciousness, aspiration, and hypoxia the next day. Other causes of hepatitis were excluded and halothane hepatitis was diagnosed. After 11 day in ICU, he had been improved and was weaning from mechanical ventilator and extubated. Then he was referred back and admitted for 20 days at Chachoengsao hospital before being discharged.
Convulsion Post Spinal Block with Marcaine : Case Report
Anusit J, M.D.*
*Chachoengsao Hospital, Chachoengsao 24000
A case of convulsion, post spinal block with marcaine in a 28 years old, full term pregnant with primibreech was reported. A few minutes after admitting a spinal block with marcaine, she was unconsciousness with tonic convulsion. Then general anesthesia with endrotracheal tube was given and operation was continued. After finishing the operation, she complained of paresthesia at her thigh and buttock after 1 minute admitting spinal block and then she lost consciousness till extubation. She had no history of convulsion or head trauma. The level of anesthesia was about T4 level at the time she gained consciousness. She was discharged from the hospital 7 days later with normal symptoms. We could not find any causes of convulsion except the low cardiac output from spinal block.
Effect of Aloe Vera gel for Lubrication of Endotracheal Tube Cuff on Postoperative Sore Throat : A Randomized Controlled Trial
Changsam K, B.Sc.,* Thienthong S, M.D.,* Jariyavisuth S, Dip.N.Sc.,* Simajareuk S, M.Sc.,
Prakrankamanant D, B.Sc.,* Pongjanyakul S, Dip.N.S.,* Kirdpon W, Ph.D.**
*Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, Khon, 40002
**Department of Radiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002
Objective : To investigate the effect of Aloe Vera gel as an endotracheal tube lubricant on the Incidence of postoperative sore throat. Methods : Two hundreds and fifty patients, ASA class I-III, were randomly allocated before starting general anesthesia into 2 groups, Patients in group 1 and 2 received tracheal intubation without and with lubrication of endotracheal tube with Aloe Vera gel respectively. Outcome measurement : Postoperative sore throat and hoarseness were assessed within 24 hr after surgery. Results : Demographic data of the two groups were comparable, except for the duration of intubation which was longer in the non-lubricant group (134 vs 116 min, P = 0.01). The incidence of postoperative sore throat, as well as hoarseness, was not significantly different between the two groups (52% vs 63% and 37% vs 33%, respectively). No patients reported severe sore throat in this study. Conclusion : Lubrication of endotracheal tube with Aloe Vera gel does not decrease the incidence of postoperative sore throat and hoarseness.
Key words : Aloe Vera gel, postoperative sore throat, hoarseness, endotracheal intubation
Difficult Intubation in General Anesthesia in Siriraj Hospital
Chaiwat O, M.D.,* Chinachoti T, M.D.,* Tivirat S, B.N.,* Suwannanon P, B.N.*
Department Anesthesiology, Faculty of Medicine, Siriraj Hospital, Bangkok 10700.
Expectation to Anesthesia at Chaiyaphum Hospital : The Consumer’s View
Krobbuaban B, M.D.,* Homjan S, B.N.,* Diregpoke S, B.N.*
*Division of anesthesiology, Chaiyaphum Hospital, Chaiyaphum 36000
Introduction : The evaluation of quality of services by consumers is an essential component of continuous quality improvement in anesthesiology. Objective : To determine the view of internal and external consumers to anesthetic practice regarding expectation at Chaiyaphum hospital. Methods : The study use a combined quantitative and qualitative research design involved 16 surgeons, 27 scrub nurses, 35 surgical ward nurses, 87 patients and 67 patient’s relationships who scheduled for surgery. Data were collected using a questionnaire for internal consumer and indepht interview the patients and their ralation.
Descriptive data was described by frequency, percentage, mean and standard deviation. All qualitative data were determined with content analysis methods. Results : Both internal and external consumers expected to get the good quality of anesthetic care. Surgeons expected in pre-and postoperative management, smooth in traoperative care without any complications, In aspect of scrub nurses, communication and responsibility were determined. Nurses who worked in surgical ward expected the anesthesia should advice the patients for pre-and postoperative care, control postoperative pain and have 2 – way communication before transfer the patients to ward. The patients expected unawareness during surgery and care of postoperative pain. The patient’s relations expected to get information about surgery, anesthesia, course of disease plan of treatments including return to normal function. Conclusion : The expectation of customers is initiated the improvement in anesthetic practice with focusing to keep overall satisfaction.
Can Structured Instruction Improve the Success Rate of Pain Assessment in PACU?
Pongjanyakul S, Dip.N.S.,* Sathitkanmanee A, B.Sc. (Nursing).* Rakpong P, B.Sc. (Nursing),*
Jangsem K, B.Sc. (Nursing),* Krisanaprakornkit W, M.D., M.Sc.,* Theinthong S, M.D.*
*Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002
Purpose of the study : To compara the success rate of self-reported pain assessment in postanesthetic care unit (PACU) between conventional and structured instructions and exploring the correlation between numeric rating scale (NRS) and verbal rating scales (VRS). Methods : A randomized, contrlled trial study was performed in 110 patients, aged 10 to 70 years undergoing surgery at Srinagarind Hospital. Before starting general anesthesia, group 1 (n = 55) attended the conventional instruction and group 1 (n = 55) attended the structured instruction (an example of their pain intensity from recent intravenous cannulation). In the PACU, all extubated patients who had sedation score <3 were asked to rate their pain intensity using both VRS and NRS. The ability to rate their pain within 1 minute was defined as success. Results : All patients could report their pain using VRS. The success rate for reporting pain using NRS in group 2 was significantly higher than in group 1 (85.5% vs 63.6%,p = 0.01). There was good correlation between VRS and NRS (r = 0.69, p < 0.001). Discussion : By emphasizing and using the real example for pain assessment, the patients were able to understand more about their pain intensity. The high correlation between NRS and VRS was similar to the previous reports. Conclusion : The structured instruction can improve the success rate of self-reported pain assessment in the immediate postoperative setting. This should be included in routine preoperative visit in order to improve quality of patient care in the PACU.
Key words : PACU, pain assessment, structured instruction
Frova Using for Blind Nasal Intubation in Patient with Difficult Intubation : A Case Report
Kunchayangkul C., M.D.*
*Division of Anesthesiology, Nakornping Hospital Chiangmai 50180
A 53 years old male with right submandibular and sublingual abscess was generally anesthetized for incision and Drainage operation. After applying the laryngoscope we found that the direct laryngoscopic view was grade 4. Alternative methods such as Miller laryngoscope, decreased size of an endotracheal tube and blind nasal intubation were performed for this difficult intubation situation but failed.
Frova® (intubating introducer) is a new well designed, helpful equipment for difficult intubation. This special device is used for the placement of an endotracheal tube in situation where there is inadequate exposure of the glottis (grade 3 direct laryngoscope view) and for the exchange of an endotracheal tube.
It was inserted into a nasotracheal tube attemped to blind intubation. When maximum breathing sound was heard, we past Frova® into the trachea. Then the nasotracheal tube was rail-roaded. In addition, the position of the tube was confirmed by stethoscope and end tidal CO2. When the operation was over, the tube was retained to ward. Thirty five hours after the operation, we could extubated without any major complications.
Key words : Frova, intubating introducer blind nasal intubation, difficult intubation
Endotracheal Tube Fire During Tracheostomy : A Case Report
Srimanta T, M.D.
Division of Anesthesiology, Yasothon Hospital, Yasothon 35000
An endotracheal tube fire ignited while intubated patient underwent electrosurgical tracheostomy. In such an oxygen-rich environment, a spark or high temperature induced by electrosurgery can cause a polyvinyl chloride endotracheal tube to ignite. In this patient, the incision of the trachea by electrosurgery perforated the endotracheal tube cuff , resulting in a back-flow of oxygen around the tube and caused fire.
Postoperative Pain Management for Neonates in Siriraj Hospital
Suraseranivongse S, M.D.,* Kongchon V, M.D.,* Pattana-alongkorn J, M.D.*
*Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital , Bangkok
10700, Thailand
Objectives : To evaluate pain measurement, management, efficacy and complications in neonates following surgery in Siriraj Hospital Method : Retrospective study conducted by reviewing all records in neonates underwent major surgery since 1 January 2001 to 31 December 2002 Setting : University Hospital Main outcome measures : Pain measurement, techniques of pain management and complications including extubation time Results : Of 44 neonates and 48 operations, pain was mostly measured by clinical assessment (79.2%). Efficacy of pain management could not be evaluated due to insufficient date. Techniques of pain management included intravenous infusion of fentanyl (47.9%), intermittent intravenous fentanyl (27.1%), continous epidural analgesia (12.5%), single short epidural analgesia (4.2%) and intravenous morphine (4.2%). Complications related to pain management were motor weakness (2.1%). Among 17 neonates who had fulfilled criteria for extubation, fifteen patients (88.2%) could be extubated. All 5 patients who received combined general and epidural anesthesia were able to extubated. Of 12 neonates who received only general anesthesia, 10 patients (83.3%) could be extubated. Conclusion : Clinical assessment was mostly used to evaluate pain in neonates. Intravenous infusion and in termittent intravenous fentanyl were preferred for postoperative pain relief.
Key word : postoperative pain, neonate
Can Electrocardiogram Electrodes Replace Bispectral Index Electrodes While
Monitoring Depth of Anesthesia?
Akavipat P, M.D., FRCAT.,* Damrongbul K, B.Sc. (Nursing),* Niemnak P, B.N.
*Department of Anesthesiology, Prasat Neurological Institute, Bangkok 10400
Objectives : To compare the feasibility of commercially available electrocardiogram (ECG) electrodes for the bispectral index (BIS) monitoring Methods : We evaluated the difference in signal quality index (SQI) and BIS values collected with two BIS monitors, using either ECG electrodes or BIS electrodes in the same patients before anesthesia, during light anesthesia, deep anesthesia and emergence period. Each type of electrode was placed in a bifrontal area and monitored throughout the procedure. Statistical analysis were evaluated by bias with 95% limits of agreement and visualized by Bland-Altman plot. Non parametric analysis was paired t-test. A P value less than 0.05 was considered statistically significant. Results : There were 390 parallel signal quality index and BIS values in this study. During anesthesia the mean SQI were 79.20 + 24.77 in ECG electrode group and 82.82 + 21.65 in BIS electrode group, which were not statistically different. The mean BIS values were 58.63 + 18.77 and 56.99 + 19.84 using ECG electrodes and BIS electrodes, respectively. The mean bias between BIS value was 1.65 with 95% limits of agreement between 0.91 and 2.38. Conclusions : The result showed that the commercial ECG electrodes could be used for monitoring depth of anesthesia while the mean bias and 95% limits of agreement of BIS value between ECG electrode and BIS electrode group were clinically acceptable.
Key words : monitoring ; electroencephalogram, signal quality index, bispectral index Anesthesia ; depth, equipment, electrodes
The Success of Medium-Flow Anesthesia Without Gas and Agent Monitoring
Pirayavaraporn S, M.D.,* Kumpong P, M.D.,* Tritrakan T, M.D.,* Areewattana A,
M.D.,* Issariyakul S, M.D.,* Wisitprechawut R, M.D.*
*Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital , Mahidol
University, Bangkok , 10700
Objective : To determine the success of using medium-flow anesthesia with fresh gas flow (FGF) 2 Ipm in adults without gas and agent monitoring. Method : Three hundred and six patients (age 16-70 years, ASA physical status 1-2) undergoing surgery under general anesthesia with controlled ventilation were randomly allocated into 2 groups. Both groups receieved FGF 2 Ipm with standard monitoring (NIBP, ECG, Pulse oximeter) together with gas and agent analyzer. However, in the study group the anesthetists were unaware of gas and agent analyzer which were monitored by another anesthetist. Outcome measurement including SpO2, EtCO2, FiO2, isoflurane diual setting, Fi isoflurane, Fe isoflurane, heart rate, noninvasive blood pressure (NIBP), body temperature and urine output (if operative time was longer than 3 hours or excessive blood loss was predicted) were recorded. Failure of using this technique was defined as 1) SpO2<95% for 1 minute 2) EtCO2 > 45 mmHg for more than 3 minutes 3) FiO2 < 0.30 or 4) awareness > 0.2%. Results : There was no fifference between the study and control groups regarding age, body weight, anesthetic technique, type of surgery, anesthesia time, operation time and medium-flow duration. The outcom measurement and the parameter in detecting failure of using medium-flow showed no difference. Conclusion : FGF 2 Ipm could be used successfully in adult patients neither using gas nor agent analyzer with lower cost than FGF 6 Ipm was used.
Key word : medium-flow anesthesia
A New Invented Connector Between Tracheostomy Tube and Breathing Circuit
Chowvanayotin S, M.D.,* Pranootnarabhal T, M.D.*
*Department of Anesthesiology, Faculty of Medicine Siriraj Hospital , Mahidol
University, Bangkok 10700
A connector between tracheostomy tube, face mask, endotracheal tube and breathing circuit was invented by using Cobb connector of the Bronchocath TM double lumen tube (Mallinckrodt medical company, Ireland ) and slip joint No. 8.0 mm. The connector, sterilized by ethylene oxide, has the opening to pass the suction tube and fiberoptic bronchoscope during oxygenation. It can decrease wound contamination when connected between tracheostomy tube and breathing circuit after the insertion of tracheostomy tube into the trachea during tracheostomy. Fiberoptic bronchoscopy and suction under general anesthesia can be done very easily via the opening side of the connector without interruption of the inhaled oxygen and anesthetic agents.
Incidence of Heparin Resistance Before Cardiopulmonary Bypass Machine at King
Chulalongkorn Memorial Hospital
Urusopone P, M.D.,* Sindhvananda W, M.D.,* Surapong K, M.D.*
*Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University ,
Bangkok 10330
Purpose : This study was a 1-year cross sectional study to investigate an incidence of heparin resistance before cardiopulmonary bypass machine at King Chulalongkorn Memorial Hospital . The duration of study has begun since October 2002, 1 until September 2003, 30. Method : All patients who underwent heart operations with cardiopulmonary bypass machine were included in this study. Heparinized blood was maintained with an initial intravenous 3 mg/kg of heparin sulfate. Coagulation study was monitored by activated coagulation time (ACT) using ACTALYTE TM . The base lin eACT (pre ACT) was investigated before anesthetizing the patients. The measured ACT (post ACT) was investigated at 5 minutes after heparinizing blood. Heparin resistance was defined that ACT was less than 400 seconds after 3 mg/kg of heparin sulfate administration. Factors possible indication risks for heparin resistance such as previous heparin, nitroglycerin, aprotinin administration, using intraaortic balloon pump, infactive endocarditis, etc. were recorded. Incidence of heparin resistance and correlations of the possible risk factors were analyzed. Res ult : Total samples were 520 patients. Age range started from 3 days to 90 years. The number of patients who had post ACT < 400 s were 179 patients (female = 85, male = 94). Previous heparin administration was, the first rank of risks, found in 80 patients (15.39%). Previous nitroglycerin administration was, the second rank, found in 28 patients (5.38%). There was no significant correlation between heparin resistance and all of the mentioned risk factors. Conclusion : The incidence of heparin resistance for 1-year survey at Kin Chulalongkorn Hospital was 34.40%.
Key word : heparin resistance, heparin sulfate, nitroglycerin
Laryngoscopic View in Sniffing Position Versus Simple Head Extension ; A
Comparative Study
Boonsong P, M.D.,* Wongpunkamol S, M.D.,* Punjasawadwong Y, M.D.,* Sukuprakarn W, M.D.*
*Department of Anesthesiology, Faculty of Medicine, Chiangmai University ,
Chiangmai 50200
The sniffing position is recommended for optimization of glottic visualization under direct laryngoscopy. However, no studies have confirmed its superiority over the simple head extension. One hundred and twenty patients undergoing elective surgery were randomized into two groups. Group A was the sniffing position group. The sniffing position was obtained by placement of 10 cm cushion under the patient's head. Group B was the simple head extension group. In group B there was no cushion placement. After propofol induction and paralysis with rocuronium, we recorded laryngoscopic view under direct laryngoscopy. Then the intubation of the trachea was performed. Laryngoscopic view was assessed by using the Cormack and Lehane classification. We found that laryngoscopic view distribution was not significantly modified between the two groups. In conclusion, the simple head extension position is as good as the sniffing position in full view of the glottic exposure.
Key words : laryngoscopic view, sniffing position, simple head extension
DLT Intubation with Frova ? Intubating Introducer in a Difficult Airway Patient
Nisoong C, M.D.,* Hongpromyati T, M.D.,* Nipitsukarn T, M.D.*
*Department of Anesthesiology, Faculty of Medicine, Chiangmai University , Chiangmai 50200
In the course of anesthetizing a patient for surgery of the airway, we have to control the effective airway while the operation is going on the same site. The use of Double Lumen Tube (DLT) makes the operation successful. To intubate the DLT, is a technique that required some skillfulness of the anesthesiologist, especially in the case of difficult airway. To put the DLT in place is one of the most difficult events. This report demonstrates the successful DLT intubation with “Frova ? ” intubating introducer in a difficult airway patient. The 41 years old male was scheduled for “Sleeve operation.” He was bronchoscoped and found endobronchial tumor of the main bronchus. The anesthetic record at that time reviewed difficult airway with laryngoscopic view grade IV. All the equipments and drugs were prepared for difficult airway before getting start. The patient was induced with 55 microgram of Fentanyl followed by Propofol 110 mg, then the mask was tried to assist ventilation adequately. Rocuronium 50 mg was injected and followed by mask ventilation for 60 seconds. The laryngoscope was applied to attempt DLT by a third year anesthetic resident. The laryngoscopic reviewed grade IV and the first attempt was failed. The patient was ventilated via mask with oxygen and halothane, the second attempt by an anesthetic staff was also failed (missed). The third attempt was done with the use of “Frova ? ” (Cook group company, USA ) but the DLT was put into the esophagus. After re-ventilating and the second attempting with Frova ? , the tracheal intubation was succeeded. The DLT was placed in position on the 4 th attempt within 8 seconds. Times used from the induction until the successful intubation were 6 minutes. The operation was done for 4 hours. Uneventfully after the operation, the DLT was changed to a single lumen tube with the aid of a tube exchanger. The patient was intubated for 2 days in ICU then he was extubated and discharged on the 8 th day after surgery. There was no serious complication with Frova ? intubating introducer. In summary, the anesthesiologist should try to get used to the instrument and its application properly in the normal airway patient. The intubation of DLT with Frova? in the difficult airway will become easier and more successful.
Comparison the Epidural and Spinal Anesthetic-related Variable Costs for Cesarean
Section at King Chulalongkorn Memorial Hospital
Sindhvananda W, M.D.,* Leelanukrom R, M.D.*
*Department of Anesthesiology, Faculty of Medicine Chulalongkorn University,
Bangkok 10330, Thailand
Purpose : Either epidural (EAA) or spinal (SAA) anesthesia and analgesia is safe for those uncomplicated mothers undergoing cesarean sections. In addition to the different procedure, differences in the outcomes of anesthesia and analgesia between these two techniques might make differences in the variable costs. Only the anesthetic-related variable costs for cesarean section were evaluated and compared between EAA and SAA. Method : One hundred and twenty uncomplicated mothers undergoing cesarean section in King Chulalongkorn Memorial Hospital were simply randomized into two groups ; Epidural and Spinal groups. In Epidural, 0.5% bupivacaine 20 mL plus 1: 200000 adrenalin was administered to the epidural space at L2-3 or L3-4 interspace using a 18G Touhy needle and an epidural catheter. Twice injections of morphine 5 mg ; after delivery and the next 12 hours were given via the catheter. In spinal, 0.5% hyperbaric bupivacaine 2.2-2.4 mL mixed with preservative-free morphine 0.2 mg was administered to the spinal canal using a 27G Quincke needle. Treatments of the adverse outcomes due to anesthesia and analgesia were set up. Numbers of the treatments for the adverse outcomes and the amount of medication were recorded and compared between two groups using chi-square and student t tests. The anesthetic-related variable costs were analyzed. A p-value <0.05 considered significant. Result : No significant difference in the number and the amount of medication for the adverse-outcome treatments between two groups. The anesthetic-related variable cost comprised of the technical cost, the anesthesia –outcome cost and the analgesia-outcome cost. Based on the cost reference of the hospital last updated in October 2003, the anesthetic-related variable costs of EAA and SAA were 1105.17 and 581.42 baht respectively. The costs of EAA : SAA ratio was 1 : 1.9. Conclusion : The anesthetic-related variable cost of EAA was higher than of SAA. The different value was 523.75 baht in which dominant differences were the cost of an epidural needle and catheter set and the cost due to failure of anesthesia. The anesthesia and analgesia outcomes did not seem to remarkably cause difference in the anesthetic-related variable cost.
Key word : Variable cost, epidural, spinal cesarean section
Relationship Between end Tidal CO2 Tension and Arterial CO2 Tension During Laparoscopic Cholecystectomy under General Anesthesia
Paibonworachat S, M.D.,* Punjasawadwong Y,M.D.,* Wongpim S,M.D.,* Teinwiboon S,M.D.,*
*Department of Anesthesiology,Faculty of Medicine, Chiangmai, University, Chiangmai 50200
During laparoscopic cholecystectomy, respiratory changes induced by pneumoperitoneum and head-up tilt may generate alveolar ventilation to perfusion ratio changes. The reliability of end-tidal carbon dioxide tension in predicting arterial carbon dioxide partial pressure may be affected. The purpose of this study was to evaluate P(a-ET) CO2 gradient during pneumoperitoneum and to determine factors that may be affected to P (a-ET) CO2 gradient.
The 25 (ASA 1-2) patients in this study comprised 20 women and 5 men aged 51.6 (+12.28)
Years. Intra – abdominal pressure was 12.9 (+1.08) mmHg. After abdominal insufflation, end tidal carbon dioxide tension and arterial carbon dioxide partial pressure significantly increased (p<0.05). However, the arterial carbon dioxide partial pressure – end tidal carbon dioxide partial pressure gradient (P (a-ET) CO2) were not significant change. There were no significant relationship between P(a-ET) CO2 gradient and PaCO2, age, body weight, smoking, duration of surgery, duration of anesthesia, duration of insufflation and intra-abdominal pressure.
In conclusion, end-tidal carbon dioxide partial pressure allows reliable monitoring of arterial carbon dioxide partial pressure in ASA 1-2 patients undergoing laparoscopic cholecystectomy, with intraabdominal insufflation, during general anesthesia with controlled ventilation
Effect of Sevoflurane and Isoflurane on Blood Glucose Level in Neurosurgery.
Suchartwatnachai P, M.D.,* Kaewsing P, B.Sc.*
*Department of Anesthesiology, Prasat Neurological Institute, Bangkok 10400
This research was designed to study the change and compare the blood glucose (BS) levels in neuro surgical patients under general anesthesia using sevoflurane or isoflurane. Forty patients were divided by complete random sampling into 2 groups. Both groups received non-glucose intravenous fluid during the pre and intra-operative period. Group I received not more than 2.5% sevoflurane. Group II received not more than 1.5% isoflurane. The inhalation agents were combined with 50-66% nitrous oxide in oxygen. Blood glucose concentration was measured by glucometer before and after induction of anesthesia, then every hour consecutively during anesthesia until the end of surgery. The Student t-test and Chi-square test were used for the statistical analysis.
The results showed that hypoglycemia (BS<70 mg%) was found in 5 patients in both groups after induction and 1 st hour of anesthesia. In group I, the blood glucose levels after induction and at 1st hour were significantly lower than that before induction, however, the blood glucose levels at 2nd , 3rd and 4th hour were significantly higher than that after induction. In group II, the blood glucose level at 3rd hour was significantly higher than before induction, after induction and at 1 st hour. There was no significant difference in the mean blood glucose levels between both groups at the same period of time. In conclusion, sevoflurane and isoflurane showed no difference in increasing the blood glucose levels at 2nd and 3rd hour in patients undergoing neurosurgery.
Key words : blood glucose, isoflurane, sevoflurane, neurosurgery
Glottic Visualization of “Sniffing Position” Compared with Neutral Head Position in Elective Surgical Patient
Krobbuaban B, M.D.,* Pitakpol S, B.N.,* Pisalpan S, B.N.,* Kumkeaw S, B.N.,* Serkphukhiew T, B.N.,* Prungchaiyaphum T, B.N.*
*Department of Anesthesiology, Chaiyaphum Hospital, Chaiyaphum 36000
Introduction : Correct positioning of the patient appears to be the crucial determining factor for obtaining a good glottic visualization. The “sniffing position” is widely recommended for direct laryngoscopy. However, the anatomic explanation of the advantage of this maneuver has been called into question. The neutral head position has been commonly used by nurse anesthetists in routine anesthesia procedures. No any other studies have claimed that the sniffing position superior to the neutral head position. The purpose of this study was to evaluate the head position was obtained by manipulation of patient’s occiput resting on the operating table. The patients were randomized as follows : Group A the sniffing position during the first laryngoscopy and the neutral head position during the second performance ; group B the neutral head position during the first laryngoscopy and the sniffing position during the second maneuver. Glottic exposure was assessed glottic visualization of sniffing position compared with that of neutral head position for tracheal intubation in normal practice. Methods : A prospective, randomized study with a cross-over design, included 500 patients scheduled for elective surgery under general anesthesia. The anesthetic procedure included two laryngoscopies with muscle paralysis performed by nurse anesthetists. During the second direct laryngoscopy, intubation of the trachea was completed. The sniffing position was obtained by placement of a 10 cm cushion under the patient’s head. The neutral by nurse anesthetists using the modified Cormack and Lehane classification. Results : The sniffing position improved glottic visualization (decreased the Cormack and Lehane grade) in 36.4% of patients and worsened it (increased the Cormack and Lehane grade) in 6.2% of patients, as compared to the other group. Conclusions : The sniffing position improved the laryngoscopic view.
Disposable Laryngeal Mask Airway for Blind Oral Endotracheal Intubation in Manikin Boonmak S, M.D.,* Boonmak P, M.D.*
*Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, Thailand
Objective : To assess the success rate of blind tracheal intubation with endotracheal tube through the disposable laryngeal mask airway on a manikin. Design : Descriptive study. Methods : Fifty-five volunteers (15 anesthesiologists, 25 nurse anesthetists, 15 nurse anesthetist trainees) were assigned to insert an endotracheal tube through the inserted disposable laryngeal mask airway on the manikin which optimal position was ready confirmed by fiberoptic bronchoscope. The success rate and time of the insertion were recorded, also difficulty of the insertion was graded by both intubator using and by observer using 3-point rating scale as well. Results : Blind tracheal intubation through the disposable laryngeal airway was successful in all intubators. The mean time for intubation ranged from 16.71 to 19.28 sec. (anesthesiologists group 17.95 + 3.70 sec., nurse anesthetists group 16.17 + 2.38 Sec., nurse anesthetist trainees group 19.28 + 3.03 sec.) and the intubation was graded as easy either assessed by the intubators 90.91 % or by the observer 92.73%. Conclusion : Blind tracheal intubation through the optimal position of disposable laryngeal mask airway using endotracheal tube is easy to performby personnel with high success rate. The technique may be useful for patients whose airway management is expected to be difficult.
Key words : disposable laryngeal mask airway, intubation
Leg Wrapping for Prevention of Spinal-Induced Hypotension During Lower Body Surgery In Elderly Patients at Srinagarind Hospital
Thincheelong W, B.Sc. (Nursing),* Chau-In W, M.D.,* Palachewa K, B.Sc. (Nursing),* Thananan M,
B.Sc. (Nursing).*
*Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, Thailand
Background : Spinal-induced hypotension remains a common and potentially serious complication despite sudden expansion of intravascular volume. The demonstrated failure of adequate intravascular volume expansion, to prevent hypotension in elderly patients, often requires external application of vasopressure. Objective : To evaluate whether elastic compression bandaging reduces hypotension from spinal anesthesia. Methods : Forty elderly patients, undergoing lower body surgery under spinal anesthesia of 2.8 to 3.2 ml of 0.5% hyperbaric bupivacaine, were randomly allocated before spinal injection to the leg wrapped group (W, n = 20) and the control group (C, n = 20). All patients received intravenous acetar solution (5-10 ml/kg over 20 min) before the spinal injection. Hypotension was defined as a decrease in SAP > 20% from baseline. Results : The incidence of hypotension in group W was 60% while it was 75% in the group C the difference, however, was not statistically significant (P>0.05). Hypotension occurred in 9 (53%) persons in group W and 8 (61.54%) in group C. The mean dose of ephedrine injected during anesthesia was 1.35 + 3.7 (95% CI 0.4, 3.1) and 2.85 + 5.0(95% CI 0.5, 5.2) mg, and the incidence of ephedrine injected was 15 and 35 percent in group W and group C, respectively. The elastic bandaging produced no complications. Conclusion : Wrapping the legs of elderly patients undergoing lower body surgery did not significantly lessen the rate of hypotension following spinal anesthesia. A larger sample size is needed to differentiate the groups as the intra-group standard deviation was large.
Key words : Anesthesia techniques : spinal ; complications : hypotension ; preventions : leg wrapping ; patients : elderly.
Reinforced Switch of Anesthetic Ventilator MCM 801.
Pongpan U, M.D.,* Kariya P, RN.,* Machaiwong S, Technician.*
*Division of Anesthesiology, Lampang Hospital, Lampang. 52000
The author presents the instrument which has been designed to reinforce switch of Anesthetic Ventilator MCM 801. The equipment is simple, inexpensive, lasting and available in general hospitals. The equipment has been used successfully for 1614 patients having surgical procedures under general anesthesia in Lampang Hospital during August 2001 October 2003.
Key words : Anesthetic Machine, General Anesthesia
Anaphylactoid Syndrome of Pregnancy : Case Report of a Patient who Survived without Neurologic impairment
Loetwiriyakun W, M.D.*
*Department of Anesthesiology, Faculty of Medicine Prince of Songkhla University Hatyai, Songkhla 90110
Anaphylactoid syndrome of pregnancy, previously known as amniotic fluid embolism, is an uncommon condition but a leading cause of pregnancyrelated deaths. It should be suspected in pregnant woman with acute severe hypoxia, hypotension, cardiac arrest and/or coagulopathy during labor, or immediately after delivery. This report discusses the case of a 41-year-old woman (gravida 2, para 1) at 34 weeks gestation who developed anaphylactoid syndrome of pregnancy during cesarean delivery and survived. She developed acute hypoxia, cardiovascular collapse and acute onset of coagulopathy (a cliical diagnosis, without pathological confirmation). The clinical features, pathophysiological changes and management are presented in the hope of improving awareness and thereby survival of woman with this condition.
Key words : amniotic fluid embolism, anaphylactoid syndrome of pregnancy
Rapid Tracheal Intubation with Atracurium : Comparison Between Timing and Priming Techniques
Ittichaikulthol W, M.D.,* Choorat J, M.D.,* Chanpradub S, M.D.,* Kitticharoenrerk A, BSc.,* Sithamwilai W, BSc.*
*Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400
The priming technique of non-depolarizing muscle relaxant has been advocated as a rapidsequence induction. However, the onset time is not similar to succinylcholine with undesirable clinical weakness. Timing technique utilizing a single bolus of non-depolarizing neuromuscular blocking drug followed by thiopentone has been advocated as an alternative. The purpose of this study is to compare the intubation condition between timing and priming techniques with atracurium in term of onset time and side effects. Sixty patients ASA I-II, age 15-60 years old undergoing elective surgery under general anesthesia were randomly divided into two groups. Exclusion criteria were the patients with cardiovascular disease, neuromuscular disease and difficult intobation. Both groups were premedicated with midazolam 7.5 mg orally 1-1 ? hours and fentanyl 1-2 mg/kg intravenously 3 minutes before induction. Time group (group 1) received atracurium 0.75 mg/kg intravenously 20 seconds prior to administration of thiopentone 3-5 mg/kg. Priming group (group 2) received atracurium one tenth of total dose (0.075 mg/kg). After 4 minutes, anesthesia was commenced with thiopentone 3-5 mg/kg and the remaining dose of atracurium. The intubation time (time from total dose of intravenous atracurium injection to intubation) was predetermined by the Dixon's up-and-down method (with 5 seconds as a step size) for each patient and started at 80 seconds for the first patient in each group. Result : There were no significant differences in demographic data between groups. The intubation time in group 1 was 65.7 + 2.18 seconds which was significantly shorter than 69.3+2.41 seconds in group 2. The hemodynamic data were similar in both groups. Clinical weakness prior to induction of anesthesia were 3.33% and 6.66% in group 1 and group 2 respectively, Conclusion : the timing technique with atracurium for tracheal intubation is statistically better than the priming technique in term of onset time with no significant adverse effects, although the result is not clinically significant.
Key words : tracheal intubation, timing technique, priming technique
Low-Dose Fentanyl Attenuates Circulating
Responses to Laryngoscopy and
Tracheal Intubation
Lapisatepun W, M.D., F.R.C.A.T.,* Bunchungmongkol N, M.D., F.R.C.A.T.,* Wongmuk P, M.D.*
* Department of Anesthesiology, Faculty
of Medicine, Chiangmai, University,
Chiangmai 50200
The effect of fentanyl 3 mcg/kg, using as an adjunct to thiopentone induction on the circulatory responses to tracheal intubation was studied in 20 normotensive, surgical patients. Patients were randomly allocated to receive either normal saline (group 1, n = 10) or fentanyl 3 mcg/kg (group 2, n = 10) 3 minutes before induction. Blood pressure and heart rate were recorded at baseline, before laryngoscopy, immediately after intubation and every 1 minute up to 3 mimutes. Following intubation, blood pressure significantly increased from baseline in group 1, whereas only systolic blood pressure did in group 2 immediately after intubation. There was also significant difference in blood pressure response between the to groups. In group 1, heart rate significantly increased from baseline 1 and was significantly greater than that in group 2 at 1 and 2 minutes after intubation. During recovery, no significant respiratory depression was observed in both groups. We conclude that fentanyl 3 mcg/kg can attenuate circulatory responses to tracheal intubation when used as an adjunct to thiopentone induction with no early postoperative respiratory depression.
Key words : Pharmacology : fentanyl Anesthetic technique : laryngoscopy Circulatory responses tracheal intubation, hypertension, tachycardia.
Protective Device for Oral Injury During
Tracheal Intubation
Phophichitra C, M.D.,* Tantivitayatan K, M.D.,* Panich A, M.D.*
* Department of Anesthesiology, Faculty of Medicine Ramathibode Hospital,
Bangkok 10400
The incidence of oral injury during endotracheal intubation reporting from Anesthesia Department, Ramathibodi Hospital, Mahidol University in the two-year period (2001-2002) was 0.46%. As small the number is, the injury has been involved in most closed claims. Therefore, the protective device for oral injury was invented and tested for its efficiency in 50 elective surgical patients who had no difficult airway. After demonstration, the medical personnels - nurse anesthetist students, nurse anesthetists, the 5th year medical students, residents and anesthesia staffs, could intubate the patients successfully with the device. Almost all but one showed no injuries. Since it is easy to use and affordable in comparison to the dental repair cost, it should be promoted in anesthesia practice.
Low Flow Anesthesia in Infants and Children : a Preliminary
Report
Suraseranivongse S, M.D.,* Montapaneewat T, Diploma in Nursing and Midwife
(Eqivalent to Bachelor in Nursing)*, Manon J, B.N.,* Chainchop P, B.Sc* (Nursing
and midwife), Noocharoen P, B.N.,* Wattanakul R, B.N.,* Phetttongkam A, B.Ed.*
(Nursing)
Objectives : To determine (1) success rate of using fresh gas flow 1 l/min in infants and children alyzer (3) predicting volatile anesthetic concentration during low flow anesthesia. Method : Thirty infants and children (age 10 d to 6 y, ASA I-II) underwent surgery lasted > 1 h under general anesthesia with controlled ventilation were enrolled. After intubation, fresh gas flow (FGF) 6 i/min was maintained for 15 min then reduced to 1 l/min. Failure of using low flow was defined as (1) leakage in the system (12) SpO2 < 95% (3) PECO2 > 46 mmHg. Outcome measures included leakage in the system, SpO2, PECO2, FiO2, FEN2O, isoflurane dial setting, Fi isoflurane, FE isoflurane, HR, MAP and body temperature. Results : Success rate in using low flow was 93.3% (28/30) due to leakage in the system. No patient had FiO2 < 0.3 but one patient had PECO2 of 46 mmHg without any clinical sign. Maximum temperature was 38.5oC which could be relieved by termination of warming devices. Inspired isoflurane concentration was 14.25% lower than dial setting. Larger size than precalculated of endotracheal tube were needed in 23% of patient (7/30) to avoid leakage. Patients recovered within 7.76 + 6.45 min after changing lowflow to high flow. Postintubation croup was detected in 1 patient. Conclusion : Fresh gas flow 1 l/min could be used safely in most infants and children. Oxygen and isoflurane could be clinically adjusted whereas monitoring with capnometer was necessary.
Epidural Anesthesia for Casearean Section
: An open Clinical Study
Comparison of 0.75% Ropivacaine and 0.5% Bupivacaine
Saigosoom W, B.Sc., M.D.,* Duangkae S, M.P.H.* Saratan P, M.D.*
* Department of Anesthesiology, Rajavithi Hospital, Bangkok 10400
A prospective, open clinical study was designed to compare
the epidural anesthetic efficacy of ropivacaine with bupivacaine in parturients
undergoing caesarean section at Rajavithi Hospital. Sixty ASA physical statue
I-II parturients were randomly allocated into two groups and received extradural
block at the L2-3 interspace with 20 ml of either 0.75% ropivacaine or 0.5%
bupivacaine. Onset and duration of sensory block (pin prick test), motor block
(modified Bromage scale), hemodynamic variables and neonatal outcome by Apgar
scores at 1 and 5 minute after birth were recorded.
The onset time of sensory block was significantly shorter and the duration
of analgesia was significantly longer in ropivacaine group (P < 0.05).
There were no statistically significant differences in the onset time of intensity
of motor blockade, maternal systolic blood pressure and neonatal outcome between
the two groups (P > 0.05)
These findings suggested that 0.75% ropivacaine provided more effective sensory
block than that of 0.5% bupivacaine for caesarean section. No other significant
differences emerged between the two group.
Key words : Local Anesthetics : Ropivacaine, Bupivacaine Anesthetic
Techniques :
Extradural Anesthesia : AObstetric
The Appropriateness of ICU Admission in Buriram Hospital
Yimrattanabowon P, M.D.*
* Department of Anesthesia Buriram Hospital Mang District, Buriram 31000
Introduction : There have been insufficient ICU beds in many
medical centers including Burirum hospital because of many critically ill
patients as well as inadequate equipment and resources. After implement best
practice on admission and discharge criteria in
the ICU, it shows to reduce the medical risk and hospital stay.
Objective : To evaluate the appropriateness of ICU admission at Buriram hospital.
Methods : Descriptive retrospective study from Burirum hospital records during
October 1st 2001 to September 30th 2002 were studied by using systematic random
sampling and descriptive statistics method (mean, 95% CI)
Results : There were totally 1,188 records, 40.98% of them were male, aged
44.29 years. Patients were admitted in Medical units 33.26%, Surgical units
21.61%, Ob-Gyn units 25.84% and Orthopedic 9.98%. The lengths of hospital
stay were 5.62 days. The critically ill patients were 27 records, with the
ratio of 2.27. (95% CI 1.36-3.09), only 8 of them were admitted in the ICU.
The inappropriate admissions were 1.17%. APACHE II scores, shock, respiratory
failure were used as a admission criteria.
Conclusion : The important tool to evaluate the adequacy of beds and the appropriateness
of admission is the ICU admission criteria. In Burirum hospital, most inpatients
were admitted appropriately. Only 29.63% of the critically ill patients were
admitted in the ICU may be from seasonal variation.
Key word : ICU admission criteria, APACHE II scores
Pain Relief During Propofol Injection
: 1.0 vs 1.5 mg/kg Thiopentone
Pretreatment
Chau-in W, M.D.,* Peanmanakit J, M.D.,* Nonlhaopol D, B.N.*
*Department of Anesthesiology, Srinagarind Hospital, Faculty of Medicine,
Khon Kaen University, Khon Kaen, 40002, Thailand.
Rational : Minimizing the pain from propofol injection is clinically important because it may influence patient's perception regarding the quality and acceptability of general anesthesia. Objective : To compare the perception of pain after a pretreatment dose of 1.0 vs 1.5 mg/kg of thiopentone prior to induction of general anesthesia with propofol. Materials and Methods : We included 274 non-premedicated, ASA class I or II patients scheduling for elective surgery in a randomized, double-blind trial. Patients were allocated into two groups : Group T 1.0 was pretreated with an injection of 4-ml of solution with 1.0 mg/kg of thiopentone and Group T 1.5 was pretreated with 1.5 mg/kg of thiopentone. We used a verbal rating scale to assess patient's injection pain while administering propofol. Results : The incidence of injection pain was 48% and 47% in Groups T 1.0 and T 1.5 respectively. The severity of pain experiencing mild, moderate and severe degree was similar in both groups : 34% vs 32%, 10% vs 10% and 2.9% vs 3.6% of patients in Groups T 1.0 and T 1.5 respectively. Conclusion : Thiopentone pretreatment reduced propofol injection pain in half of our patients ; there was, how ever, no significant difference between using 1.0 vs 1.5 mg/kg.
Comparison of Dexamethasone versus Droperidol
for Postoperative Nausea and Vomiting Following Diagnotic Laparoscopy under
General Anesthesia
Chau - In W, M.D.,* Bunsangcharoen P, M.D.,* Pongmetha S, M.D.,* Thananun
M, B.N.,* Malasi P, B.N.*
*Department of Anesthesiology, Srinagarind Hospital, Faculty of Medicine,
Khonkaen University
Postoperative nausea and vomiting (PONV) after laparoscopic surgery is a common complication. In this prospective, randomized, double-blind, controlled study, we evaluated the efficacy of intravenous droperidol and dexamethasone compared with a saline solution for antiemetic prophylaxis. Methods : Ninety patients, ASA I-II requiring general anesthesia for diagnostic laparoscopy were randomly assigned into three groups (30 each). After induction and intubation, the patients received deoperidol (0.02 mg/kg), dexamethasone (0.2 mg/kg) or saline solution, then were maintained under anesthesia using the balanced technique. Results : The incidence of early PONV in the droperidol and dexamethasone groups was less than that of in the saline group (P<0.05) whereas the incidence in the dexamethasone group was less that that of in the dexamethasone group was less than that of in the deoperidol group (P <0.05). However, the incidence of late PONV in the dexamethasone group was not significantly different from the deoperidol of saline groups (P=0.44). The overall indidence of PONV in the dexamethasone group was less than that of in the droperidol and saline groups (16.7 vs. 30 and 57.7 percents, respectively) but the incidence of severe PONV (N/V score grade 3) in the droperidol group was less than the dexamethasone and saline groups (0 vs. 3 and 3 percents, respectively). There was difference in the sedation score between droperidol and dexamethasone group at 30 min (P=0.01). Three percents of patients in the dexamethasone group received rescue antiemetics vs 6 percents in both the droperidol and saline groups. Conclusion : Dexamethasone is more effective in prophylaxis of early and late PONV than droperidol but do not reduce the severity of PONV.
Key words : diagnostic laparoscopy, postoperative nausea and vomiting (PONV), antiemetic drugs; dexamethasone
Isoflurane In Cesarean Section
Jirasiritham S, M.D.,* Tantivitayatan K, M.D.*
*Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital,
Mahidol University, Bangkok
The purpose was to study the effect of isoflurane in general anesthesia for cesarean section in terms of blood loss, APGAR scores, awareness and other complications. Seventy-eight elective and emergency parturients with ASA mostly I status, mean age 32.02+4.15 years, mean weight 68.55+8.67 kgs. inhaled 0.9% isoflurane for 13.78+4.12 mins before and 0.44% of that for 7.85+ 9.83 mins after delivery, Midazolam 1-3 mg was supplemented intravenously in most cases. No evidence of abnormal bleeding, neither APGAR scores nor incidence of awareness was found. Isoflurane in different concentrations for cesarean section was discussed.
Abstract : Efficacy of Low Dasage of Intrathecal Bupivacaine
with Fentanyl for Surgery
Chanchayanon T.,* Krataijan J.,* Preechavai P.,* Phakam P.,* Vittayanupagorn
N.*
*Department of Anesthesiology, Faculty of Medicine, Prince of Songkhla University,
Hatyai, Songkhla 90110
We evaluated the effect of 10 microgram of fentanyl added to bupivacaine on sensory and motor blockade, By using a double blinded study design, 90 patients undergoing general lower extremities, orthopedic and urologic surgery were randomized into two group : Group I, bupivacaine 7.5 mg and fentanyl 10 microgram; Group II, bupivacaine 12.5 mg only. The final volume of intrathecal injectate was adjusted to 2.5 mL with normal saline solution. Spinal anesthesia was administered with the 27-gauge Whitacre needle at the L2-3 interspace with the patient in the lateral position. Neural block was assessed by using pinprick and a modified Bromage scale. The degree of motor blockade and median level of the upper limit of the sensory blockade were similar in both groups. The efficacy of blockade in group II (93.33%) is higher than that of in group I (88.88%) but not statistically significant. The incidence of side effects was not significantly different between both groups except vomiting in group I (11.11%). We concluded that fentanyl 10 microgram with 7.5 mg of bupivacaine increased only the maximal sensory level but not the motor blockade. The low dosage of intrathecal bupivacaine with fentanyl is as good as the conventional use of bupivacaine alone.
Key words : Intrathecal bupivacaine, fentanyl, randomized control trial, spinal anesthesia
Comparison of Intravenous Regional Anesthesia with 0.2% Ropivacaine and 0.5%
Lidocaine for Hand/Forearm Surgery
Saringcarinkul A, M.D.,* Wongpankamol S, M.D.,* Shevasunt K, M.D.*
Department of Anesthesiology, Faculty of Medicine, Chiengmai University, Chiengmai 50200
Backgrounds : Ropivacine may offer some advantages over lidocaine for intravenous regional anesthesia (IVRA), but its anesthetic effectiveness and toxicity have been less documented. Methods : The IVRA with 0.2% ropivacaine 40 ml and 0.5% lidocaine 40 ml were compared in 40 patients for hand/forearm surgery. Tourniquet times of proximal and distal cuff as well as distal cuff inflation to pain were recorded. The principle sensation of radial, median, ulnar and musculocutaneous nerves were evaluated by verbal numeric score, whereas its motor function were examined by muscle power. After the deflation of distal cuff, signs of systemic toxicity such as lightheadedness, tinnitus, circumoral numbness, nausea and vomiting were observed. Results : there was no significant difference of motor blockade between the two groups. Sensory blockade decreased after IVRA in both groups, but the sensation of lidocaine group diminished more than the of ropiacine group. Tourniquet times of distal cuff inflation to pain were 31.60+16.31 minutes in lidocaine group and 29.95+11.38 minutes in ropivacaine group. Times from distal cuff deflation to wound pain were 10.25+8.61 and 14.45+21.84 minutes in lidocaine and ropivacaine groups suspectively, however there were no significant differences. There were 3 patients in lidocaine group who had tinnitus after tourniquet deflation. Conclusion 0.2% ropivacaine has similar efficiency as 0.5% lidocaine for intravenous regional anesthesia.
Key words : Bier's block, intravenous regional anesthesia ; ropivacaine ; lidocaine
Prevention of Skin Trauma from Blood Pressure
Measurement with Plastic Wrap Between the Cuff and the Skin.
Thananun M, B.N.,* Nonlhaopol D, B.Sc. (nursing),* Kingsungwal P, B.N.,*
Sinkuakool C, M.D.,* Jeerararuensak W, B.Sc. (nursing).*
*Department of Anesthesiology, Faculty of Medicine, Khon Kaen University,
Khon Kaen 40002.
Background : Every patient receiving anesthesia is monitored for vital signs, both in the operating room and recovery room. Blood pressure recording is one of the monitoring, which is done frequently every 1-15 minutes using automatic non-invasive blood pressure measurement. Blood pressure cuff inflation can cause tissue trauma such as skin creasing and petechiae. To prevent these complications, the hygienically food wrapping film (plastic wrap) could be applied around the upper arm before placing with the blood pressure cuff. Objectives : To compare the rate of skin trauma from non-invasive blood pressure measurement using the normal blood pressure cuff with and without plastic wrap under the cuff. Design : Randomized controlled trial. Setting : Operating and recovery room, Sringarind Hospital, Faculty of Medicine, Khon Kaen University. Subjects : After approval from the Ethic Committee, 224 patients gave consents to participate in the study. The patients were randomly allocated into 2 groups, 112 patients in each group. Patients in group 1 had plastic wrap under the blood pressure cuff. Patients in group 2, which is the control group, received normal blood pressure measurement. Measurements : Hewlett Packard monitor (Omnicare model 1996 Hewlett - Packard company, USA) was used for blood pressure measurement in both groups. Degree of skin trauma was recorded at the end of anesthesia in the operating room and at the end of anesthetic services in recovery room. Data analysis was done using Chisquare test and Logistic regression. Results : Baseline characteristics in terms of age, body weight, ASA classification, type of anesthesia and degree of skin moisture were comparable. It was found that the statistical significant related factors to the petechiae were the sex (p=.03), duration of anesthesia (p=.03) and the wrapping of plastic material used before wrapping the inflating pressure cuff (p<.001). Multivariate analysis found that female had more petechiae than male (OR = 2.8, 95% CI = 1.34-6.13), the younger patient age group 15-30 years and 31-52 years had more petechiae than the older age group more than 53 years (OR = 4.91, 95% CI = 1.38 - 17.3 and OR = 5.01, 95%CI = 1.54 - 16.30 respectively). And the group using blood pressure cuff without plastic wrap had a higher chance of having petechiae 12.3 times (OR = 12.3, 95% CI = 5.38-28.25) compare to the group with plastic wrap. Conclusions : The result of this study revealed that the use of plastic material wrapping the upper arm before the inflating pressure cuff could significantly lower the incidence of petechiae when measuring the blood pressure.
Comparison of Dose Requirement of Diluted
and Undiluted Propofol for Patients Undergoing ERCP
Amornyotin S, M.D.,* Suraseranivongse S, M.D.,* Sattawattharmrong Y, M.D.,**
Tensit K, M.D.,* Prakotsue K, M.D.,* Chalaynnawin W, B.N.*
* Department of Anesthesiology
** Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University,
Bangkok 10700
Two hundred and eighteen patients were assinged to one of three groups in a prospective, double blind, randomized manner. Group U, the control group, received undiluted propofol (10 mg/ml); Group D1, diluted propofol (5 mg/ml) ; Group D2, diluted propofol (2.5 mg/ml). All patients were topicalized with 2% viscous lidocaine and 10% lidocaine spray for topical anesthesia and pethidine 0.5 mg/kg, midazolam 0.05 mg/kg and propofol 1 mg/kg for premedication and induction Anesthesia was maintained with continuously intravenous infusion of titratable propofol. Blood pressure, heart rate, ECG, oxygen saturation at base line, after premedication, immediately and every 5 minutes after induction, total dose of propofol, duration of anesthesia and complications were recorded. The results of the study showed that total doses and dose requirement of propofol and complications in Group U were higher than that of Group D1 and D2 with a statistically significant level of p < 0.001. It can be concluded that diluted propofol is safe and effective for the patients who have been undergoing ERCP.
The Effect of Low Dose Bupivacaine and Fentanyl on Spinal
Anesthesia and Incidence of Hypotension During Elective Cesarean Section
Wongpunkamol S, M.D.,* Pinyopornpanit T, M.D.,* Sanguansuk J, M.D.,*
* Department of Anesthesiology, Faculty of Medicine, Chiangmai University,
Chiangmai
Objectives : To investigate the effect of low dose bupivacaine and fentanyl on the level of spinal anesthesia and the incidence of hypotension during cesarean section. Method : A randomized, double-blind, controlled trial was conducted in 80 parturients (age 21-41 years, ASA physical status I-II) Who were scheduled for elective cesarean section at Maharaj Nakornchiangmai hospital. The parturients were randomly allocated into 2 groups ; The control group (B) recelving 10 mg of 0.5% hyperbaric Bupivacaine and the study group (BF) receiving the combination of 0.5% hyperbaric Bupivacaine 7.5 mg + fentatnyl 25 mcg. The study profiles include no premedication, preload fluid with LRS 1000 ml and 3 L/MIN of oxygen via nasal canula throughout the study. The blockade was performed in right lateral position, interlaminar space of L3-4 with whitacre needle 25G, Result : There were no differences in anesthetic level, incidence of hypotension, nausea/vomiting, pruritus and apgar score at 1 and 5 min but the requirement of ephedrine to correct hypotension in the study group was significantly less than the Control group (p < 0.05). Conclusion : Although adding fentanyl to low dose bupivacaine does not provide difference in the level of block and incidence of hypotension, it may have a role in decreasing the severity of hypotension when considered from the amount of ephedrine used to correct hypotension.
Key Word : 1. Spinal anesthesia
2. Bupivacaine
3. Fentanyl
4. Hypotension
The Incidence of Microbial Contamination
in Anesthetic Equipments at Srinagarind Hospital
Boonmak P, M.D., Boonmak S, M.D., Chau-In W, M.D., Muknumporn T, BSc, (nursing)*
* Department of Anesthesiology, Faculty of Medicine, Khon Kaen University,
Thailand
Objective : To determine the incidence of microbial contamination in anesthetic equipments sterilized by technique following Department of Anesthesiology protocol. Design : Descriptive study Methods : We collected samples by swab culture technique from anesthetic equipments at Srinagarind hospital. All anesthetic equipments were sterilized by chemical or gseous method according to Department of Anesthesiology protocol. Six hundred and twenty samples (10 types of anesthetic equipment) were sterilized by chemical method and 135 samples (5 types of anesthetic equipment) were sterilized by gaseous method. The results were recorded as positive or negative finding. Results : The incidence of positive finding in the samples sterilization group, laryngoscope blade had the highest incidence of microbial contamination (14.51%) as well as Staphylococcus coagulase negative was proved in mostly positive findings (25.64%). There was no any positive finding in gaseous sterilization group. Conclusion : Technique of sterilization should be reconsidered because of high incidence of microbial contamination found in chemical method.
Keywords : anesthetic equipments, sterilization
A Comparative Study between Intercostal
Nerve Block Combined with Total Intravenous Anesthesia and General Anesthesia
Combined with Field Block in Augmentation Mammoplasty.
Borvornvanichyakul S, M.D.,* Takoonsawat P, M.D.,* Paiboonkasemsuthi P, M.D.,**
Worathamrong S, M.D.,** Pornsinsirirak K, M.D.,**
*Anesthesiologist, Yanhee General Hospital, Bangkok 10700
**Plastic Surgeon, Yanhee General Hospital, Bangkok 10700
Background : General anesthesia with endotracheal intubation (GA with ET) combined with field block in the technique commonly used in augmentation mammoplasty, however the incidence of side effects from this technique such as postoperative nausea and vomiting (PONV) as well as sore throat is persistently high. Intercostal nerve block (ICNB) combined with total intravenous anesthesia (TIVA) is an alternative that can be employed for this operation. Objective : To study the effectiveness and side effects of ICNB and TIVA comparing with GA with ET and field block in patients undergoing augmentation mammoplasty were studied. Group 1 : 80 patients were anesthesized with bilateral ICNB T2-6 (0.5% bupivacaine with adrenaline 1 : 200,000 ; 2 ml per segment) combined with TIVA (propofol, fentanyl and midazolam). Group 2 : 47 patients were anesthesized with GA with ET combined with field block. Results : The patients in group 1 had significantly less first 24 hour total narcotic consumption (pethidine 45.00 + 41.80 mg vs 67.02 + 61.92 mg), PONV (11.25% vs 48.94%) and sore throat (0% vs 10.64%) than the patients in group 2. Pain-free duration, postoperative shivering and patient's satisfaction were not different. None of patients in both groups experienced awareness. The complication from ICNB was nil. Conclusions : ICNB combined with TIVA was found to be superior to GA with field block in patients undergoing augmentation mammoplasty with respect to postoperative total narcotic consumption, PONV and sore throat. This technique is an appealing alternative to general anesthesia for patients undergoing augmentation mammoplasty.
Key words : intercostal nerve block, intercostal block, ICNB, ICB, mammoplasty, total intravenous anesthesia, TIVA
Determining the Appropriate Dosage of
Propofol by the Usage of Bispectral Index.
Akavipat P, M.D.,* Nakareseisoon P, M.D.,* Suchartwatnachai P, M.D.*
*Department of Anesthesiology, Prasat Neurological Institute, Bangkok 10400
Background : We determined the appropriate induction and maintenance dosages of propofol by the usage of bispectral index (BIS) in regarding to measure the depth of consciousness that relate directly to the adequacy of anesthesia. Methods : After the ethic approval from Prasat Neurological Institute and Ministry of Public Health, forty adult patients scheduled to undergo elective spinal surgery were enrolled. The anesthetic depth was controlled by the titration of propofol to keep BIS between 40-60. We recorded the demographic data, the amount and the duration of drug infusion to calculate the dosage. The data were analyzed as mean and standard deviation. Results : The induction and maintenance dosage of propofol were 2.04+ 0.54 mg/kg and 4.8+2.69 mg/kg/hr respectively. Conclusions : The amount of propofol administration can be reduced as compare to the recommended dosage by BIS monitoring of the adequacy of anesthesia.
Key words : Bispectral Index, propofol, depth of anesthesia
Hemodynamic and adverse Effects of Propofol/ketamine
Compare to
Propofol/fentanyl in Minor Gynecologic Patients
Phadungchaichote N, M.D.,* Ang-kanarwiriyarak S, M.D.,* Chanvej L, M.D.,*
Chongsuvivatwong V, M.D., Ph.D.,**
*Department of Anesthesiology, Faculty of medicine, Prince of Songkhla University,
Songkha 90110
**Epidemiology unit, Faculty of medicine, Prince of Songkhla, University,Songkhla
90110
A randomized double-blind study was conducted to compare hemodynamic and adverse effects of propofol/fentanyl (P/F) and propofol/ketamine (P/K) for total intravenous anesthesia (TIVA) in 112 ASA class 1, 2 patients scheduled for uterine curettage in Songkhlanagarind Hospital. After patients were given 2 mg/kg propofol during induction, the anesthesia was maintained with 8 mg/kg/hr propofol. The P/F group received fentanyl 1 mg/kg and the P/K group received ketamine 0.5 ma/kg for analgesia. In the P/F group, 55.4% had hypotension and 30.6% had bradycardia whereas 25% (p=0.001) and 10.7% (p=0.008) in the P/K group had hypotension and bradycardia respectively. The incidence of apnea and oxygen desaturation in the P/F were 19.6% and 42.9% respectively while in the P/K group, there were 3.6% (p=0.008) and 10.7% (p<0.0001) respectively. The P/F group had shorter time to awakening than the P/K group mean (SD); 4.86 (3.33) min vs 7.79 (5.7) min (p=0.002). there were no difference in other adverse effects, pain score, and analgesic requirement. In addition, no emergence phenomenon in the P/K group was detected.
Key word : adverse effect, hemodynamic minor gynecologic patients, propofol/ketamine,
propofol/fentanyl, randomized double-blind study
Prediction of Difficult Laryngoscopy with Combination
of Preoperative Airway
Assessments.
Ua-Kritdathikarn T, M.D.,* Saelim A, M.Sc.,** Chaimongkol E, B.N.S.,* Suwuthikul
N, B.N.S.*
*Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University.
Hatyai, Songkhla, 90110.
**Epidemiology unit, Faculty of Medicine, Prince of Songkla University, Hatyai,
Songkhla 90110.
Objectives : This prospective study aimed to predict difficult laryngoscopy with preoperative airway asessments. Patients and methods : Preoperative airway assessments were performed, after consents were obtained, in 500 patients undergoing elective surgery requiring tracheal intubation. Five methods, Mallampati classification, thyromental distance (TMD), interincisor gap (ICG), grinding and atlantooccipital joint extension (AOE), were used for airway assessment. Demographic data such as age, sex body mass index (BMI) were recorded. Measurements of these five airway assessments were done by two experience anesthetists. Difficult laryngoscopy was defined as grade 3 or 4 on the Cormack-Lehane scale. Each method of airway assessments and BMI were graded to score 1 or 2. Degree of predictability was assessed by sensitivity, specificity positive predictive value (PPV), and area under ROC curve. Results : Sensitivity of Mallampati classification, ICG, TMD, AOE, grinding and BMI are 47.22%, 16.67%, 27.78%, 25%, 2.78% and 36.11% respectively. Specificity of each test are 84.91%, 94.40%, 88.15%, 89.66%, 98.28% and 85.78%, respectively. The results of combination of Mallampati classification, ICG, TMD, AOE and grinding (score more than 5) are sensitivity of 66.67%, specificity of 69.4% and PPV of 14.46%/ The combination of these five airway assessments with BMI (score more than 6) result in increasing sensitivityto 83.33%, decreasing spicificity to 60.78% and PPV 14.15%. The combination of Mallampati classification, TMD and BMI (score more than 3), as compared with all six airway assessments, result in the same sensitivity (83.33%). However, increasing specificity (67.89%) and PPV (16.67%). Conclusion : Each of airway assessment, Mallampati classification, ICG, TMD, AOE and grinding have low sensitivity to predict difficult laryngoscopy. Therefore, it can not be used adequately to predict difficult laryngoscopy. However, the combination of Mallampati classification, TMD and BMI (score more than 3) has highest sensitivity and area under ROC curve. Thus, this combination test should be considered as a better screening method for predicting the difficult laryngoscopy.
Key word : Difficult laryngoscopy, Mallampati classification, Thyromental distance,
Interincisor
gap, Grinding (Chin protrusion), Atlantooccipital joint extension)
Low dose Intrathecally Bupivacaine for Cesarean Section
Chumnarnkitkosol P, M.D.,* Sirinan C, M.D.,* Samranjai P, M.D.,* Keawjareon
M,
M.D.,*
Sornnil A, B.S.c. (Nursing).*
Anesthesiology Department, Ramathibodi Hospital, Bangkok 10400
Hypotension is the most common adverse effect of spinal anesthesia for cesarean section. A number of strategies for preventing hypotension have been investigated. However, no method has proved entirely satisfactory. In a recent study, the use of small dose hyperbaric bupivacaine in well-hydrated patients is associated with a low incidence of hypotension. We randomized 80 parturients to a control trial to receive spinal anesthesia with either hyperbaric bupivacaine 7.5 mg (group I) or 10 mg (group II) with morphine 0.2 mg in both groups. We evaluated the adequacy of anesthesia and their effects on the incidence of hypotension, sensory level, motor blockade and surgical condition. The median of the upper limit of the sensory block at ten minutes testing time in both group was T4 equally. The incidence of hypotension in group I was 32.5% and in group II was 90%. Motor blockade was more intense in group II. One patient (2.5%) in each group was supplement with small dose of ketamine. Total ephedrine requirement in group I was significantly lower than group II (P<0.001). Surgical conditions were good in both groups. Patient's satisfaction was rated as good 92.5% in group I and 80% in group II. We concluded that hyperbaric bupivacaine 7.5 mg in combination with morphine 0.2 mg intrathecally provided adequate surgical anesthesia in cesarean section, with lower incidence of hypotension and vasopressor requirement .
Heart Rate Change During the Reversal of Neuromuscular
Blockade by 3
Dosages of Atropine
Limpamas B, M.D.,* Jearanorot A, M.D.,* Wasinwong W, M.D.,* Chanvej
L, M.D.,*
*Department of Anesthesiology, Faculty of Medicine, Prince of Songkhla University,
Songkhla 90110
Objective : To evaluate the change in heart rate during the reversal of neuromuscular blockade by using 3 dosages of atropine in a mixture with neostigmine. Methods : Sixty patients with ASA physical status I or II undergoing balanced general anesthesia were randomly allocated into 3 groups. Neostigmine 0.05 mg/kg mixed with atropine 0.01, 0.015, and 0.02 mg/kg were given intravenously in group A, B, and C respectively at the time of reversal of neuromuscular blockade. Results : In the first 5 minutes, all groups manifested with an initial increase in heart rate (P = 0.008, P = 0.007 and P = 0.008 respectively) however, group B and C showed more tachycardia than group A (P = 0.028 and P = 0.021 respectively) After 15 minutes, heart rate became stable and returned close to the baseline. Conclusion : In healthy patients, atropine 0.01 mg/kg is safe for the reversal of neuromuscular blockade since it affects the increase in heart rate very little as compare to the conventional dose of atropine.
Keywords : atropine, heart rate, neostigmine, neuromuscular blockade, reversal
Factors Related to Satisfaction of Being Thai Nurse Anesthetists
Charuluxananan S, M.D., MSc. FRCAT.,* Kyokong O, M.D., MSc. FRCAT.,*
Tamdee D, BN.S.**
*Department of Anesthesiology and Clinical Epidemiology Unit, Faculty of
Medicine, Chulalongkorn University
**Department of Public Health Nursing Faculty, of Nursing, Chiengmai University
Background and Rationale : Nowadays more than 1500 of nurse anesthetists are assisting anesthesiologists provide anesthesia service across Thailand, but there is no data about work characteristics and satisfaction of nurse anesthetists in Thailand. This study aims to survey factors related to overall satisfaction of being Thai nurse anesthetists Method : Salf-administered questionnaires comprising of part I : demographic data, workplace data and incomes, part II : questions about work characteristics such as knowledge, skill of anesthesia service, administrative capability, support from colleagues, conflict in workplace, chance of promotion etc. and part III : the overall satisfaction of being Thai nurse anesthetists and agree or disagree to be nurse anesthetist if it is possible to change were distributed to nurse anesthetists who were participant of refresher course lectures held by the Royal College of Anesthesiologists of Thailand. Results : Two hundred ninety participants (100% response rate) who worked in several parts of Thailand returened the questionnaires. The overall satisfaction of being Thai nurse anesthetists is moderate to high score (mean 3.68 + 0.89 from scale of 5). With multiple logistic regression analysis, the negative factors regarding the satisfaction of being nurse anesthetist were lack of anesthesiologist in the hospital (p = 0.007), being male gender nurse anesthetist (p = 0.009) and conflict with surgeon (p = 0.001). The positive factors related to satisfaction were family support (p = 0.001) and chance of being promoted for higher position or higher salary (p = 0.015). Twenty four percentages of respondents would not choose to be nurse anesthetists again if it is possible to change or choose. The negative factor for willingness to be nurse anesthetist again was administrative capability (p = 0.01) and positive factors were family support (p = 0.016) and overall satisfaction of being nurse anesthetist ( p <0.001). Conclusion : Overall satisfaction of being Thai nurse anesthetist was graded moderate to high score. Negative factors related to overall satisfaction of being nurse anesthetist were lack of anesthesiologist in the hospital, male gender, conflict with the surgeon while positive factors were family support and chance of being promoted for higher position or higher salary.
Keywords : satisfaction, nurse anesthetist, cnaracteristics.
Patient Satisfaction of Anesthetic Services at Srinagarind
Hospital.
Jeerararuensak W, B.Sc. (Nursing),* Chau-In W, M.D.,* Jariyawisuth S, B.N.,*
Mooknumporn T, B.Sc. (Nursing),* Jangsem K, B.Sc. (Nursing),*
Limpkulwattanaporn P, B.Sc. (Nursing),*
Pongjanyakul S, B.N.,* Promkhote P, B.N.*
*Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, Khon
Kaen 40002.
Background : Health Care Reform is intended to bring about better quality, patient-oriented
care. We studied the level of patient satisfaction with anesthetic services
as an indicator for improvement of clinical quality. Objectives : To determine
the level of patient satisfaction with anesthetic services including information,
courtesy and quality. Setting : Operating rooms, post anesthetic care units
and surgical wards at Srinagarind Hospital, Faculty of Medicine, Khon Kaen University,
Thailand. Methods : This was a descriptive study and included 407 purposive
samplings of patients coming to the operating rooms. Within 24 to 48 hours after
surgery, each patient was interviewed for general information and an evaluation
of satisfaction (questionnaire). Results : On the whole, patient satisfaction
with anesthetic services was very good. The patients felt that they were adequately
informed of the anesthetic techniques, potential complications and pre-and post-operative
symptomatology. Service was satisfactorily courteous and sympathetic. Patients
assured that the anesthetic team would care for them in a regular and timely
fashion pre-and post-operatively. Conclusions : Despite the generally good level
of patient satisfaction with anesthetic services, formulating a standard preoperative
visit including information about anesthetic techniques, pre-and post-operative
symptomatoloyg and potential complications would enhance the psychosocial aspect.
Keyword : Patient satisfaction, anesthetic services
Survey of Knowledge and Opinions Concerning Quality in
Anesthesia Service
Among Thai Anesthesia Personnels
Charuluxananan S, M.D. MSc. FRCAT.,* Rodanant O, M.D. FRCAT.,**
Charoernraj P, M.D., FRCAT.,**
Somboonviboon W, M.D., FRCAT.,** Kyokong O, M.D., MSc. FRCAT.*
*Department of Anesthesiology and Clinical Epidemiology Unit, Faculty of
Medicine, Chulalongkorn University
**Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University
Objectives : To determine knowledge and opinions concerning quality in anesthesia service among Thai anesthesia personnel Methods : Constructed questionnaires comprising of 3 parts (part 1 : demographic and work place data, part 2 : 18 questions about personnels, equipments and monitors, anesthesia practice and anesthesia related adverse events and part 3:2 open end questions 1) 3 most common anesthesia related adverse events in the past 3 months before answering the questionnaires and 2) 3 most important anesthesia related adverse events to avoid) were distributed for self administering in the annual scientific congress of the Royal College of Anesthesiologists of Thailand and collected within the same day Results : Five hundred and eighty two respondents (97%) who were anesthesiologists (12.5%) and nurse anesthetists (73.4%) came from various parts of Thailand. The knowledge and opinions about quality of anesthesia care in term of personnels, equipments and monitors, anesthesia practice of the respondents were high. More than 90% of respondents agreed that there should be anesthesiologist in every hospital that provide anesthesia service or every hospital with at least 120 beds. More than 95% of respondents agreed that there must be disconnect alarm and reserved oxygen tank in anesthesia machine. The knowledge about epidemiologic data concerning anesthesia related adverse events was low. The 3 most important anesthesia related adverse events to avoid were cardiac arrest, cardiovascular problems (ie : arrhythmia, myocardial ischemia) and difficult intubation or ventilation Conclusion : Thai anesthesia personnels have tended to focus on quality in anesthesia care. Their knowledge and opinions about standare of anesthesia and clinical practice guidelines was high except anesthesia related adverse events.
Keywords : knowledge, opinions, quality, standard, anesthesia service
Alternatives of Patients between Inhalation and Intravenous
Induction of
Anesthesia
Kampan S, B.Sc. Nursing, MPA.*
Department of Anesthesiology Rajavithi, Payathai Bangkok 10400
This research attempted to study the patients' alternatives between inhalation
and intravenous induction of anesthesia in terms of determinant factors like
age, level of education, income and occupation. The result had showed that the
majority of the patients chose inhalation 58%, while 17% chose intravenous and
the rest let anesthesiologist make a decision. The independent variables that
determined the patients' alternatives were age and level of education.
Minidose Bupivacaine-Fentanyl Intrathecally in Transurethral
Surgery
Chumnarnkitkosol P, M.D.,* Sirinan C, M.D.,* Tontisirin N, M.D.,* Intasang A,
M.D.,* Datcharoen A, B.S.c*
*Department of Anesthesiology, Ramathibodi Hospital Faculty of Medicine, Mahidol
University, Bangkok, Thailand.
The use of conventional dose of bupivacaine for transurethral surgery is associated
with a high incidence of hypotension, prolonged motor recovery and discharge
time. It may be possible to minimize these unwanted outcome by using either
smaller dose of bupivaciane or minidose of bupivacaine combined with fentanyl.
Eighth six patients undergoing transurethral surgery were randomized into two
groups receiving spinal anesthesia with hyperbaric bupivacaine 5 mg plus fentanyl
10 mcg (group I) and hyperbaric bupivacaine 7.5 mg (group II). We evaluated
the adequacy of anesthesia and their effects on the incidence of hypotension,
sensory level, motor blockade, discharge time, and surgical condition. The median
of the upper limit of the sensory block at the ten minutes testing time in both
groups was T6 equally. Motor blockade was significantly more intense in group
II (p=.008). The incidence of hypotension was minimal, four patients (9.5%)
in group I and two patients (4.5%) in group II were treated with only single
dose of 0.25 mg metaraminol. Surgical condition was rated as good 97.6% (41/42)
in group I and 100% in group II. PACU time was not different significantly,
30.8 + 2.5 minutes in group I and 32.3 + 6.9 minutes in group II (P = 0.203).
Patients' satisfaction were rated as good 97.6% (41/42) in group I and 97.7%
(43/44) in group II. We concluded that the minidose of hyperbaric bupivacaine
5 mg in combination with fentanyl 10 mcg intrathecally provided adequate surgical
anesthesia in transurethral surgery, with less intense motor blockade and minimal
incidence of hyptension.
Intrathecal Pethidine Versus Bupivacaine Combined with
Morphine for
Caesarean Section.
Srimuangthon S, M.D.,* Kanchanatawan P, M.D.,** Jiranapakul S, M.D.***
* Division of Anesthesiology, Mahachai 2 hospital, Samut Sakhon 74130 and
Makaruk hospital Kanchanaburi 71120
** Division of Obstetrics and Gynecology, Makaruk Hospital, Kanchanaburi 71120
*** Division of Obstetrics and Gynecology, Mahachai 2 Hospital, Samut Sakhon
The prupose of prospective randomized multicenter study was to compare intrathecal pethidine with bupivacaine combined with morphine for elective caesarean section. Forty eight full term, G1P0, no history of abdominal surgery, ASA class 1 parturients scheduled for caesarean delivery were included in the study. All parturients received premedication with oral 0.3 M sodium citrate 30 ml. before lumbar puncture. After IV 750 ml/kg acetate solution, parturients were randomly divided into 2 groups. Parturients were given either 5% heavy pethidine 1 mg/kg, upper limit at 50 mg., or 0.5% heavy bupivacaine 2.4 ml combined with morrphine 0.15 mg intrathecally. Results. Caesarean section was successfully performed in all cases. None of the parturients suffered from any major side effects. Apgar score showed 9, 10, 10 in all newborns. The incidences of hypotension, shivering, epigastric discomfort during modified Crede maneuver (the procedure that applied pressure at the fundus or epigastric area for pushing fetal head birth from lower uterine incision) were higher in the bupivacaine combined with morphine group (p<0.05). Drowsiness, low level of sensory blockade (T5-6) and mildly inadequate motor blockade were higher in pethidine group (p<0.05). Other side effects such as pruritus, nausea, vomiting, parturients' satisfaction score and decision to use the same technique for next operation were not different between the two groups. The mean duration of postoperative analgesia was 7.67 + 2.57and 19.00 + 3.86 hours in pethidine and bupivacaine combined with morphine groups respectively (p<0.01). Neither early nor late respiratory depression, urinary retention, bronchospasm and postdural puncture headache were detected in this study. We concluded that pethidine can be used as the sole agent for caesarean section and was superior to bupivacaine combined with morphine because of antishivering effect, less hypotension, low epigastric discomfort during modified Crede maneuver as well as cheaper and more sedative effect. However, pethidine has short sensory action (mean 52.92 + 6.41 min). and less postoperative analgesia than that of bupivacaine combined with morphinel.
Key words : Intrathecal analgesia, pethidine, bupivacaine, morphine, caesarean section.
Subcutaneous Morphine : The Alternative Route for Postoperative
Analgesia
Angkasuvan W.
Department of Anesthesiology, Hatyai hospital, Songkla
Objective : To evaluate the efficacy of subcutaneous morphine for postoperative
analgesia comparing with intramuscular morphine.
Materials and Methods : The randomized controlled study was conducted in Hatyai
hospital. The 60 conxecutive healthy gynecological patients undergoing the explor
- laparotomy were randomly divided into 2 groups to receive either intramuscular
morphine (group 1) or subcutaneous morphine with an indwelling small intravenous
cannula (group 2) on request four-hourly for postoperative analgesia. They were
interveiwed and evaluated at time of administration and after 1 hour in pain,
sedation and nausea score as well as respiration rate.
Results : There were no signicicantely differenced in pain, sedation and nausea
score as well as respiratory rate between subcutaneous and intramuscular morphine.
Conclusion : Intermittent subcutaneous morphine with and indwelling cannula
would be an alternative to intramuscular morphine for postoperative analgesia.
The advantage of using this route is to improve patient comfort as the number
of skin puncture is decreased.
Key word : Subcutaneous morphien, intramuscular morphine, postoperative analgesia
General Anesthesia with Sevoflurane After the Main Agent
Halothane.
Vongvises P, M.D.,* Chumnanvej S, M.D.*
* Department of Anesthesiology, Pramongkotklao Hospital, Bangkok 10400
Sevoflurane is a very low blood/gas partition coefficient (0.6-0.7) agent
which allows it to provide easy adjustment of anesthesia levels during maintainance,
and rapid offset of anesthesia at the end of the procedure but its cost is more
expensive. Halothane is an agent with blood/gas partition coefficient (2.3)
which allows the slow recovery from anesthesia but its cost is cheaper. The
study was used alternative technique that use sevolurane after halathone.
Whit the approval of the Ethic Committee and the patient inform consent, 24
ASA physical status I-II patients, aged 15-65 years old, scheduled for elective
surgery more than 2 hours, were randomized in order to received either sevoflurane
(n=12) or sevoflurane after halothane (n=12) as the main volatile anesthetic.
At the moment of the peritonium suture, sevoflurane was given in the group who
randomized to received the sevoflurane after halothane. At the moment of the
last skin suture, the inhalation agents were discontinued and neuromuscular
block was reversed. The recovery time from the end of anesthesia to the eyes
opening and anesthetic complications were recorded. The cost of anesthetic agents
were calculated. Results : The result of this study demonstrated that there
was no significant difference in recovery time between two groups. Time to eye
opening in sevoflurane alone is 12.91 + 3.87 minutes and in sevolflurane after
halothane is 10.5 + 3.8 minutes. The cost of anesthesia in sevoflurane alone
(945.76 + 24.15 bahts) is more expensive than is sevoflurane after halothane
(229.16 + 12.24 bahts). Conclusion : Technique which using sevoflurane after
halothane anesthesia is save, no severe complications and suitable for long
duration anesthesia.
Key word : General anesthesia, Recovery time
Does Maternal NPO Time for Elective Cesarean Section
Under General
Anesthesia Affect Maternal and Neonatal Blood Sugar?
Jirasiritham S, M.D.,* Asavawongsatearn A, M.D.,* Adipat J, B.Sc.,*
Benjapongsapun U, B.Sc.*
* Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital,
Bangkok 10400
Background : Hypoglycemia in the newborn is a very serious complication, because it can result in a permanent brain damage. In our practice, every patient scheduled for elective casearean section have an order of nothing per oral (NPO) after midnight. So most of these patients are starving and have the prolonged NPO times before general anesthesia for caesarean section is conducted in the next morning. This study aims to investigate whether there is any correlation between the duration of the maternal NPO time and the level of maternal and neonatal blood sugar, together with any evidence of hypoglycemia in the mother or newborn baby. Methods : The authors studied a population of 70 pregnant women who underwent elective caesarean section under general anesthesia. The duration of the NPO time was recorded. The blood sample from the mother before starting non dextrose solution infusion and cord blood sample from the newborn baby were studied for the level of blood sugar. Results : The duration of the NPO time had an inversely and significantly correlated with the maternal blood sugar (R= -0.279, P = 0.019). No significant correlation between the maternal NPO time and the neonatal blood sugar was observed in this study (R = -0.207, P = 0.086) Conclusions : The authors conclude that the hypoglycemic events should be suspected in every mother who has long NPO time. Though from this study, there is no significant correlation between maternal NPO time and the level of blood sugar in the neonates, it is a devastation complication if only one neonate is born from a starving mother and has hypoglycemic event with neurological deficit.
Key Words : Hypoglycemia, NPO time, elective cesarean section, maternal, neonatal
blood
sugar
Selective Blind Endobronchial Intubation by Recurvature of Endotracheal Tube.
Chinachoti T, M.D., Yathaputanon C, M.D., Pornprasertsuk P, M.D.
*Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol
University Bangkok 10700
We conducted a randomized blind selective endobronchial intubation to evaluate the chance of insertion endotracheal tue into the left or right main bronchus compaired between normal curved bevel to recurvature or redirection of the endotracheal tube. By 800 attempts of endobronchial intubation in two manikins used for practice adult intubation, we demonstrated that the recurvature of a single lumen endotracheal tube increased chance of left endobronchial intubation from 0% to 98%. We concluded that the direction of bevel and curve of an endotracheal tube is the single most important factor to indicate of the left or tight side endobronchial intubation..
The Ability of Nurse Anesthetists in Intubation with the
Laryngeal Tube vs.
Esophageal Tracheal CombitubeTM and Endotracheal Tube in Manikin.
Uppan K, B.Sc. (nursing)*, Chairat L, B.Sc. (nursing)*, Pongjanyakul S, B.N.*,
Chau-in W, M.D.*
*Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, Khon
Kaen, 40002.
Rationa and background : An emergency endotracheal intibation for airway resuscitation can sometimes be difficult and may cause serious complicationsl the laryngeal tube (LT) can be a useful alternative device in this situation. Objective : To assess the ability of nurse anesthetists in LT intubation comparing with conventional endotracheal tube (ETT) and esophageal tracheal Combitube (ETC) intubation on manikin. Methods : Three groups of nurse anesthetists of Department of Anesthesiology, Faculty of Medicine, Khon Kaen University were enrolled into this study. Group I : nurse anesthetists with experience of one year or less. Group II : nurse anesthetists with experience of more than 1 year to 5 years. Group III : nurse anesthetists with experience more than 5 years. We assessed 1) time used for successful intubation and 2) satisfaction and difficulty of intubation assessed by nurse anesthetists using questionnaires. Results : There were no statistically significant difference in mean of intubation time among three groups but the LT intubation required least time (16.90 seconds) when compared with the ETT and ETC (19.04 and 19.05 seconds, respectively). Satisfaction and difficulty of intubation with these tubes were not statistically different. Conclusion : Nurse anesthetists have the ability to use the LT, ETC as effectively as ETT after short period of trainign.
Keyword : Endotracheal tube : Laryngeal tube, esophageal tracheal Combitube
tube. Trainig
nurse anesthetists.
Pain Control After Thoracotomy in Pediatric Patients
Comparing Thoracic Epidural Analgesia with Intercostal Nerve Block : A Pilot
Study
Boonmak P, M.D.,* Boonmak S, M.D.,* Horatanaruang D,
M.D.,* Boonpadhanapong S, M.D.**
* Department of Anesthesiology, Faculty of Medicine,
Khonkaen University, Khonkaen
** Division of Anesthesiology, Vajira Hospital, Bangkok
Objective : To compare the effectiveness of intercostal nerve block and thoracic
epidural analgesia for postoperative pain control after thoracotomy in pediatric
patients Methods : A double blind randomized controlled trial, a pilot study,
was conducted in 12 children (5-12 year old, ASA class 2) who were scheduled
for elective thoracotomy at Srinagarin Hospital. They were randomly divided
into 2 groups, thoracic epidural block (TEB) and intercostal nerve block (ICNB).
Anesthetic management included atropine and fentanyl for premedication, thiopental
and succinyl choline for induction and tracheal intubation as well as atracurium,
N2O, O2 and isoflurane for maintenance.
In TEB group, after intubation of the trachea thoracic epidural catheters were
placed by anesthesiologist at the level of T5-T6 using Touhy needle NO. 18 gauge
with loss of resistance technique. After negative response to test dose, 0.25%
bupivacaine with adrenaline (1:200,000) 0.35 ml/kg was injected via the catheter.
In ICNB group, before closure of the incision intercostal nerve block using
0.25% bupivacaine with adrenaline (1:200,000) 1 ml/kg was performed by surgeon.
Pain score was evaluated at immediate, 1 hr, 2 hr, 6 hr and 24 hr after operation
using CHEOPS scores or face scales. All patients received tramadol 1.5 mg/kg
intravenously every 6 hr for 24 hr
Result : There were no difference in additional analgesic drug usage at 1 hr
and 2 hr after operation as well as in CHEOPS scores or face scales at 1 hr,
2 hr, 6 hr after surgery. Conclusion : TEB and ICNB can be used safely to control
post thoracotomy pain. To compare the effectiveness of these two techniques,
further study with larger sample size may be needed because several factors
can confound the results.
Key word : 1. Pediatric thoracotomy
2. thoracic epidural block
3. intercostal nerve block
Combined Sciatic and Femoral (3-in-1) Nerve Block for
Lower Limb Surgery : 3 Month Experiences with Thai Patients
Raksakietisak M, M.D.,* Chumpathong S, M.D.,* Duangrat
T, M.D.,* Nagasara M, M.D.*
* Department of Anesthesiology, Siriraj Hospital, Mahidol University, Bangkok 10700.
Background : Combined sciatic and femoral (3-in-1) nerve block is an useful
alternative to general anesthesia or neuroaxial block for lower limb surgery.
It provides good post-operative analgesia for 6-24 hours. This technique was
started in our department from August to October 2001. We would like to report
our experiences with 14 Thai patients Method : The blocks were done combined
with several techniques of anesthesia in 14 patients. In the first 2 patients,
the blocks were performed after spinal anesthesia. Two patients received 3-in-1
block while they were awake before induction of general anesthesia. Only 1 patient
had 3-in-1 block when the suxamethonium was wearing off. Nine patients received
general anesthesia with laryngeal mask airway before getting combined sciatic
and femoral (3-in-1) blocks. The different solution had been used to find the
most-suitable one. The blocks were done with modified insulated needle (spinal
needle 22G insulated with plastic venous catheter 20G) connected with nerve
stimulator (1Hz, 0.2-0.8 mA). The operations were ACL reconstruction (10 patients),
dynamic hip screw (2 patients) and minisectomy (2 patients). Results : Thirteen
patients got excellent analgesia which last more than 6 hours (2) and 12 hours
(11). Only one patient had incomplete block and experienced severe pain. There
were few minor complications related to general anesthesia occurred (PONV 21%,
shivering 36%). Only one patient (7%) complained of buttock pain (injection
site). Conclusion : Combined sciatic and femoral (3-in-1) nerve block provided
satisfactory post-operative analgesia with minor complications.
Key word : Anesthetic techniques, regional, femoral, sciatic, anesthetics : local, pain : post-operative ; lower extremities
EMLA Cream and Intraperitoneal Lidocaine Decrease
Intraoperative Pain During Postpartum Tubal Sterilization
Petchpaisit N, M.D.,*Visalyaputra S, M.D.,**Limsakul
A, M.D.,* Santivarangkana T, M.D.,* Parakkamodom S, B.Sc.,* Permpolprasert L,
B.Sc.,* Apidechakul P, B.Sc.,* Latthikaviboon U, B.Ed., ** Sirilertmekasakul
P, B.Sc.**
* Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Bangkok
10700
** Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital,
Bangkok 10700
We conducted a randomized, double-blind, placebo-controlled trial to evaluate
the effectiveness of EMLA cream together with intraperitoneal lidocaine for
pain relief in postpartum tubal ligation. In a factorial designed study, 90
postpartum patients were randomly assigned to have 5 g of EMLA or placebo bream
applied to the skin in 2 groups of 45 patients and to have intraperitoneal instillation
of 20 ml of either 1%, 2% lidocaine or normal saline in 3 groups of 30 patients.
A numerical rating pain score (0-10) was used during skin check, skin infiltration
and uterine tube manipulation. The pain scores were significantly lover in the
EMLA group as compared with the placebo group during the skin forceps check
(p < 0.001) and during the local infiltration (p < 0.05). the pain scores
were also significantly lover during intraabdominal manipulation in the group
using either 1% or 2% intraperitoneal lidocaine as compared with the group using
normal saline (p < 0.001), but no difference was found between the groups
using 1% and 2% lidocaine.
Implication : Five grams of EMLA cream applied to the skin together with 20
ml of 1% lidocaine instilled into the abdominal cavity effectively postpartum
tubal sterilization under local anesthesia.
Awareness in General Anesthesia
Chaiwat O, M.D.,* Vacharaksa K, M.D.,* Prakanrattana
U, M.D.*
* Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol
University,
Bangkok 10700
Objective: to determine the occurrence and associated factors of awareness
in the patients undergoing general anesthesia in the group who has low possibility
of awareness. Method : Eight hundred and two patients, scheduled for elective
general and gynecological surgery under general and endotracheal anesthesia,
age between 16 and 84 years were enrolled in this prospective Cohort study.
Balanced general endotracheal anesthesia were performed in the usual practice.
Standard monitoring and clinical observation for movement, tear, sweat, eye-lid
opening were obtained. They were interviewed at first 12 hours after the surgical
completion. If the patient was suspected to have awareness, then the second
interview was performed at the postoperative day three. Result : We have found
5 cases of awareness and the occurrence was 0.62%. Each patient was analyzed
the factors that may be associated with awareness and the consequence. Positive
clinical observation were only hand movement. The possible causes of awareness
may be inadequate anesthesia. Apart from that, interviewed data in the group
who had no awareness (797 patients), the last subject which they could remember
before they were unconscious were visual and auditory perception was the most
thing that patient could recall when they regained conscious. Conclusion : The
occurrence of awareness was minimal as same as the previous study. They factors
associated with awareness in the most likely cause of awareness.
Effect of IV Atropine (Pre-induction of Anesthesia)
on Prevention of Incidence and Severity of OCR in Children Undergoing Strabismus
Surgery
Srisawasdi S, M.D.,*Dirivannasandha P, M.D.,* Khempila
J, M.D.*
* Department of Anesthesiology Faculty of Medicine, Ramathibodi Hospital, Mahidol
University, Bangkok 10400
Objective : To study the prevention of oculocardiac reflex by atropine. Forty pediatric patients under going eye muscle correction were studied. The patients were double blind randomized divided into 2 groups to receive either atropine 0.01 mg/kg (group A) or NSS (group B) in equal volume prior to induction or as soon as the intravenous line were established. Any changes of heart rate in response to eye muscle traction during operation were recorded as oculocardiac reflex. The result showed no statistical significant difference in demographic data, base line of heart rate, systolic pressure and number of operated eye muscle. No statistical significant difference in the incidence of heart rate change was 80.95 percent in group A, and 92.86% in group B. In the changed group ; the oculocardiac reflex were severe in the control group as compared to the atropine group. We concluded that atropine administration cannot prevent the incidence of oculocardiac reflex but can lessen the severity of the incidence.
Key words : Oculocardiac reflex, atropine.
Nurse's Satisfaction in the patient Controlled Analgesia
Method in Songklanagarind Hospital
Buhachat S, B.Sc.,* Chanvej L, M.D.,* Suwuttikul N,
B.N.,* Choom-upagarn S, B.Sc.*
* Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University,
Songkhla 90110.
Objective : To evaluate nurse's satisfaction and its predictor in the patient controlled analgesia method for postoperative pain management. Material and Method : The questionnaires from 120 nurses working in postoperative care ward of Songklanagarind Hospital were collected. Demographic data, satisfaction and for low, moderate, and high satisfaction were 14.2, 80, 1.6% respectively, Nurse's satisfaction were associated with the convenience of equipment use (p = 0.006), the knowledge in method (p = 0.02) and the idea of workload (p = 0.05). On the contrary, age, ward, number of patient controlled analgesia patient care, year of working and satisfaction in terms of appropriate use were not associated with nurse's satisfaction. Conclusion : most nurses in Songklanagarind Hospital were moderately satisfied in the patient controlled analgesia method, their consideration depended on the convenience of equipment use, the knowledge in method and the nurse's workload.
Key words : Nurse, PCA, postoperative pain management, nurse's satisfaction
Comparison of PCA Alone and PCA with Continuous Infusion
for Post-gynecologic Surgical Pain in Thai Patients
Ittichaikulthol W, M.D.,* Supdommark S, M.D.,* Hahtapornsawan
S, M.D.,* Haemaauppathump A, B.Sc. (Nursing),* Phatanasuthicholakul N, B.Sc.
(Nursing).*
* Anesthesiology Department, Ramathibodi Hospital, Bangkok 10400
Patient controlled analgesia (PCA) has become a widely accepted technique
for managing postoperative pain. Some studies have suggested that the use of
a continuous infusion decreased pain associated with physical activity and improved
quality of sleep. Other studies have questioned the routine use of background
infusion the it might produce an adverse effect of analgesic overdose. Therefore
we studied 72 patients undergoing gynecological procedure (abdominal hysterectomy
with or without bilateral salphingooophorectomy and appendectomy) in Ramathibodi
Hospital. This study was approved by the institutional review board and informed
consent was obtained in every case. All patient received 7.5 mg midazolam per
oral for premedication. Anesthesia was maintained with N2O : O2 : isoflurane,
morphine, atracurium and randomly assigned to 2 groups. Group 1 received PCA
only and group 2 received PCA with morphine infusion. 1 mg/hr for 24 hours postoperatively.
Initially the pain was titrated to a comfort level with intravenous morphine
sulphate. PCA dose of 2 mg and 5 minutes lockout interval was set for both groups.
Pain assessments, total amount of morphine, PCA demand dose and morphine side
effects (respiratory depression, nausea, vomiting sedation) were evaluated at
0, 2, 6 and 24 hours after commencing PCA.
One patient in group 1 was excluded from the study because of severe vomiting.
One patient in group 2 had respiratory depression at 6 hour postoperatively.
There was no statistical significant difference in patient demographics, ASA
physical status, VAS pain score, sedation, nausea and vomiting. Total amount
of morphine used in group 1 was not different from group 2 at 2, 6 and 24 hours
(P>0.05). The demand doses were similar in both groups at 2, 6 hours postoperatively
but group 1 was significantly higher than group 2 at 24 hours (22.5 + 10.89
VS 16.1 + 11.41 ; P < 0.005). We conclude that PCA with continuous infusion
as compared to PCA only is comparable in pain control and patient satisfaction
for post abdominal gynecological procedure with increase risk of respiratory
depression. We recommend PCA only in management of postoperative gynecologic
surgical instead of PCA with continuous infusion
Patient's Knowledge, Attitude and Satisfaction of
Preanesthetic Preparation
Rungreungvanich M, M.D.,* Sirinan C, M.D.,* Benjapongsapun
U, B.Sc.* Ariyapanich P, M.D.,* Songkiatkawin A, M.D.*
* Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol
University Bangkok 10400
Purposes : To develop a questionnaire as the tool for study and to evaluate patient's knowledge, attitude and satisfaction of preanesthetic preparation. Methods : A preoperative questionnaire was developed and used in 217 patients undergone a wide range of surgical procedures in Ramathibodi hospital. The questionnaire contained 24 items : 7 items for the patients' demographic background, previous surgical and anesthetic experience, 10 items for patients' knowledge concerning necessary preanesthetic preparations (i.e., NPO requirements, medications instruction), alternative anesthesia options and the related risks, and 7 items for patients' attitude concerning need for preanesthetic visit and anesthetic information, and visual analog scales for patients' satisfaction. Results : The results support the internal consistency (r = 0.74) and construction validity of the questionnaire. There were forty-five percents of the patients who had previous surgical and anesthetic experience. About anesthesia knowledge, the median score of patients for all ten items was 5. About attitude, eighty-six percents of patients recognized the necessary of preanesthetic visit, and sixty-one percents need for anesthesia information very much. The median score from visual analog scales for patients' satisfaction was 82 and the patients' satisfaction score was correlated with the knowledge score. Conclusion : This study verified the reliability and validity of a questionnaire for measuring patients' anesthesia knowledge. The results of this survey could be used to improve preanesthetic preparation which would result in change of patients' attitude and increase anesthesia knowledge and satisfaction.
Key word : Anesthesia, preanesthetic preparation, patients' knowledge, attitude, satisfaction, questionnaire
The Tracheal Length from Vocal Cord to Carina in 100
Thai Patients. A Preliminary Study Chowvanayotin
S, M.D.,* Suksompong S, M.D.,* Pranootnarabahl T, M.D.,* Limbasuta N, B.N.S.,*
Songpracha P, B.N.S.*
* Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol
University, Bangkok 10700.
Objectives : To measure the length of the trachea from vocal cord to carina in Thai patients and to establish the length with height. Patients and methods : After the consents were obtained from the patients. The patients' height were measured. General anesthesia were given to the patients. After the surgeons completed their rigid bronchoscopic examinations, the tracheal lengths from vocal cord to carina were measured in 100 patients. Results :There were 83 males and 17 females, aged 18-85 years. The average heights were 163.31+6.82 cm in male and 150.67+4.79 cm in female. The average lengths from vocal cord to carina were 12.30+1.76 cm in male and 11.79+1.32 cm in female, Statistical study showed that the tracheal lengths from vocal cord to carina had mild correlation with height. (Pearson correlation 0.303)
Key words : Tracheal length, bronchoscopy
Home - Made Precordial Stethoscope in Siriraj Hospital
for Monitoring the Breath Sound and Heart Sound
Noocharoen P, B.N.*
* Department of Anesthesiology, Faculty of Medicine, Siriraj hospital, Mahidol
University, Bangkok 10700
Precordial stethoscope is one of the basic monitoring equipment during general anesthesia in children. We made precordial stethoscope by using the tip of intravenous infusion set connected to plastic cap. It was used in 54 patients during March to September 1998. All users were satisfied, except in one case which the breath sound was decreased due to thick chest wall. In conclusion, this type of precordial stethoscope can be used to monitor the breath sound and heart sound satisfactorily in pediatric patients.
The Assessment of Opioid Use in Chronic Nonmalignant
Pain
Nakareseisoon P, M.D.,* Dhorranintra C, M.D.,* Sanansilp
V, M.D.*
* Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Bangkok
10700
Objectives : To study the incidence of opioid use in chronic nonmalignant pain, the diagnoses which they were used for, and the outcomes after receiving opioids. Patients & Methods : The retrospective descriptive study was performed in 511 chronic non-malignant pain patients visiting Siriraj Pain Clinic during 1987 to June 1999. We recorded sex, age, occupation, diagnoses, types of opioids used, duration of using opioids, dose received and the outcomes. Results : There were 303 male and 208 female chronic non-malignant pain patients, age 41.9 + 17.4 [15-87] years. Sixty patients (11.7%) 43.9 + 17.7 [16-84] years, received opioids during their pain treatment. The most common diagnosis was traumatic avulsion of brachial plexus (33.3%, 170/511) of which only 5.9% (10/170) received opioids whereas 72.7% (8/11) of chronic pancreatitis cases did. The opioid used mostly was tramadol (56.7%). The duration of using opioids was 59.5+ 180.9 [1-1392] days. From 1987 to 1995 no patients received opioids. The incidence of patients who received opioids increased from 7.5% to 48.1% from 1996 to 1999. Among those who received opioids, only 14 patients (23.3%) got the improvement in their pain and were able to stop receiving opioids, others lost their follow up or stopped opioid use from other reasons. Conclusion : We conclude that the incidence of opioid use in chronic nonmalignant pain was increasing. Most of chronic pancreatitis cases needed opioids. The outcome after using opioids was not promising.
Efficacy of 4% Lidocaine Nebulizer Adjuvant for Flexible
Bronchoscopy
Aroonpruksakul N, M.D.,* Kositsurungkakul S, M.D.,*
Chaikuna C, M.D.,* Sirijaranai R, M.D.*
* Department of Anesthesiology,
** Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University,
Bangkok 10700
Objectives : to determine the efficacy of 4% lidocaine nebulizetr adjuvant for flexible bronchoscopy for cough suppression. Patients and method : After the Siriraj Hospital Ethical Committee approval, a double-blind randomized controlled trial was studied in 60 patients (ASA I-II) scheduled for fiberoptic bronchoscope under topical anesthesia. The patients were randomized to nebulize either 0.9% NSS 4 ml (NSS gr, n = 30) or 4% lidocaine 4 ml (lidocaine, n = 30) via face mask prior to bronchoscopy. The efficacy of adjuvant was assessed by severity of cough, volume of lidocaine that added in the procedure, duration of procedure, satisfaction of patients and bronchoscopists. Descriptive statistic, Student t-test, Chi-square test and Fisher's exact test were used for statistical analysis. Results : There were no difference in the demographic data, duration of procedure, volume of lidocaine that added in the procedure. Visual Analog Scale (VAS) of satisfaction of patients and bronchoscopists. Severity of cough during fiberoptic bronchoscope passed nasal through oropharynx, vocal cords, larynx, tracheal and carina was not significant difference. No sign and symptom of lidocaine toxicity were detected in all patient. Conclusion : 4% lidocaine nebulizer adjuvant for flexible bronchoscopy for cough suppression is not better than topical technique alone.
Key words : Anesthesia, lidocaine, nebulizer, flexible bronchoscopy
Comparison of the Effect of Rocuronium and Pancuronium
for Precurarization Technique : A Randomized Controlled Trial
Phengsrakes N, B.S.c.,* Simajareuk S, M.S.c,* Jariyawisut
S, BN.,* Poomsawat S, B.Sc.,*
Niyompan U, B.Sc,* Thienthong S. M.D.*
* Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, Khon
Kaen 40002
The purpose of this study was to compare the effect of rocuronium and pancuronium
for precurarization technique. One hundred patients were enrolled in the study
and randomly allocated into two groups. Pancuronium 0.014 mg/kg and rocuronium
0.06 mg/kg were injected 3 and 1 minute (s) before succinylcholine 1.5 mg/kg
in group 1 and group 2 respectively. The incidence of fasciculation in rocuronium
group was lower than pancuronium group (54% VS 62%) but no significant difference.
Three patients in pancuronium group reported side effects, two had heaviness
of the eyelids and blurred vision and one had difficulty in breathing but none
in rocuronium group. The incidence of postoperative myalgia was 24% and 16%
in pancuronium group and rocuronium group respectively. The intubating conditions
of the two groups were comparable
It was concluded that the effect of pretreatment or precurarization was not
different with rocuronium or pancuronium, but time used fro precurarization
in rocuronium (1 min). was shorter than pancuronium (3 min). This approach was
a time-saving technique which minimized exposure of the awake patient to the
unpleasant experience of partial neuromuscular blockade from precurarization.
Key words : Muscle relaxant ; pancuronium, rocuronium Technique ; precurarization, pretreatment Side effect ; myalgia
Prevention of Core Hypothemia During Major Infant Surgery.
Kongsayreepong S, M.D.,* Gunnaleka P, B.Sc. Nursing,**
Suraseranivongse S, M.D.,*
Pirayavaraporn S, M.D.,* Chaovanoyotin S, M.D.,* Muntrapaneevat T, B.Sc. Nursing*
Manon J, B.Sc. Nursing.*
* Department of Anesthesioloy
** Department of Surgical Nursing, Faculty of Medicine, Siriraj Hospital, Mahidol
University, Bangkok 10700
Prevention of core hypothermia during major infant surgery is one of the most important part in pediatric anesthesia. A reusable forced air warming was designed to be used during this major surgery with the aim to maximize the efficacy, decrease complications and cost. Two parts as the equipment and clinical study were done to evaluate the efficacy of this blanket about warm air delivery and maintaining body temperature during major infant surgery. Results from the equipment study in the simulated environment showed that this reusable blanket could effectively delivered warm air to the patient with 2-3 oC less temperature than the setting from the warmer unit at the cranium location and another 0.75-1 oC at the foot location (70 cm apart). The underneath patient temperature rose slowly reached plateau at 120 minutes with the temperature ~10 oC less than the setting temperature. Another 1-2 oC of heated air temperature was trapped when a sheet of bed spread was placed on top. A prospective randomized controlled clinical study was done to evaluate the clinical efficacy of this reusable blanker (with a sheet of bed spread on top) compared with a controlled conventional method in maintaining body temperature during surgery. This was done in the 60 healthy infants age > 1 month, body weight less than 10 kgs who were scheduled to have a major intrathoracic or intraabdominal surgery done within 2-3 hours. The results showed that only the conventional method was not effective enough to help maintaining this body temperature with core and skin temperature during surgery and the arrival body temperature in the recovery room or ICU were significantly less than the study group were terminated from this study with the temperature at the time of termination of 35.98 (0.03) oC, 34.87 (0.28) oC, 33.93 (0.23) oC and 0.93 (0.13) oC for core, proximal, distal and the different between proximal and distal skin temperature respectively who were also successfully rescued by using this blanket to the core temperature of 36.46 (0.05) at the end of the surgery. With the cost of 160 bath per use of this reusable blanket compare to 1,000 bath from the disposable commerical blanket, so this blanket may be another measure with a good efficacy and cost effective to help providing heat, maintainting body temperature and correcting hypothermia during major infant surgery.
Key words : Hypothermia, anesthesia, prevention, forced air warming, infant.
Malignant Hyperthermia : A Case Report
Vongvises P, M.D., LL.B.,* Thananowan C, M.D.,* Chiravanich
V, M.D.**
* Phramongkutklao Hospital, Bangkok 10400
** Vibhavadi Hospital, Bangkok
A case of malignant hyperthermia in a 26 year old male patient was reported. The anesthetic agents was halothane and succinyl chloline for intubation. The sign of oxygen desaturation (below 90%) and sinus tachycardia was observed few minutes after intubation. Elevated body temperature to 39 oC and MH was suspected after 30 minutes of anesthesia and later elevated CPK and PoCO2 were confirmed the diagnosis. Inspite of symptomatic treatment. The patient died 8 hours after induction of anesthesia (6 hours postoperatively). Closed monitoring the anesthetic patient including palpation of the pulse should be mandatory for early detection of MH.
Comparison of Propofol and Thiopentone with Lidocaine in Facilitating Laryngeal Mask Insertion
Saengchote W, M.D.,* Sirinan C, M.D.,*
Tiapanit P, M.D.,*
* Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital, Bangkok
10400
Conditions for insertion of laryngeal mask airway (LMA) in 60 unpremedicated,
ASA I, adult patients scheduled for elective surgery were assessed in a randomized,
single-blinded trial. Each patient received fentanyl 1 mg/kg-1 follow by either
2.5 mg/kg propofol (gr.P), or a sequence of 1.5 mg/kg lidocaine and 2 minutes
later 5 kg/mg thiopentone (gr. LT). Gagging coughing, laryngospasm, number of
attempts for successful insertion were graded and haemodynamic data were recorded
after LMA insertion. Conditions for LMA insertion were considered as excellent,
good, poor and unacceptable.
There was no significant difference between two groups regarding to gagging
coughing, laryngospasm, attempts for successful insertion and condition for
insertion.
For haemodynamic data, there was no significant difference between the two groups
but the decrease in systolic blood pressure more than 20% after induction in
propofol group were detected more frequently than in lidocaine-thiopentone group.
(23.3% vs 3.3%)
We conclude that thiopentone preceded by intravenous lidocaine provides condition
for LMA insertion as good as those of propofol. The drugs may be used as an
alternative for propofol.
Antiemetic Effect of Intramuscular Ephedrine in Cesarean
Section under Spinal Anesthesia
Chau-In W, M.D.,* Srimuang T, M.D.,*
Huaoharn H, M.D.*
* Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, Khon
Kaen 40002
Background : Nausea and vomiting during spinal anesthesia for Cesarean section are common. These symptoms are distressing to the patient and disturbing the surgeon. A controlled prospective study is described which re-evaluated the safety and efficacy of intramuscular ephedrine in spinal anesthesia for Cesarean section. Objective : to determine whether intramuscular ephedrine simultaneously with induction of spinal anesthesia for non-emergency cesarean section reduce the incidence of maternal nausea and vomiting. Study design : double-blinded, placebo-controlled trial. Setting : Obstetric unit of Srinagarind hospital, Faculty of Medicine, Khon Kaen University. Subjects : 66 normotensive, ASA class I or II women with term, uncomplicated, singleton pregnancies were include in this study. Methods : The 66 patients (22 in each group) were given either placebo (control group), 15 mg or 30 mg ephedrine intramuscular. The parameters recorded : 1) blood pressure 2) heart rate 3) ephedrine intravenous supplementation 4) neonatal Apgar scores 5) nausea and vomiting symptom. Difference between groups were analyzed by Fisher's Exact test. Significance was determined at p<0.05. Results : The incidence of nausea vomiting in control group was 45.5 which was not significantly different from the incidence of 54.5 and 36.4% in the both treated group. Conclusion : Prophylactic intramuscular ephedrine does not reduce the incidence of maternal nausea and vomiting after spinal anesthesia for non-emergency cesarean section.
Key words : Ephedrine intramuscular, postoperative nausea vomiting (PONV), obstetric anesthesia
Complications of Spinal Anesthesia at Srinagarind Hospital
Palachewa K, B.N.,* Chau-In W, M.D.,*
Naewthong P, B.Sc. (Nursing),* Uppan K, B.Sc. (Nursing),* Kamhom R, B.N.*
* Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, Khon
Kaen 40002
Background : Spinal anesthesia one of the most common technique for general surgery, but complications and risk factors may occur. This problems will lower the quality of life for every patients. Objective : The study was undertaken to determine the incidence of complications and risk factors during spinal anesthesia at Srinagarind hospital. Design : Descriptive study. Setting : Operating room, post anesthetic care unit and surgical ward at Srinagarind hospital, Faculty of Medicine, Khon kaen University. Subjects : Every patients who underwent surgical procedures under spinal anesthesia during March 2000 to October 2000. Measurement : Demographic data, anesthetic records related to postspinal complication were collected by anesthetic nurses. Percentage of complications and risk factors associated with complication were calculated. Association between complications and studied factors were determined using Pearson Chi-square test. Results : There are 420 surgical patients, 283 male (67.4%) and 137 female (32.6%). The patients's mean age and standard deviation were 46.93 (19.10) years. We found that the most common complication was shivering (23.6%) and another were backache (18.3%), hypotension (15.7%) urinary retention (11.7%), nausea vomiting (8.1%) and postdural puncture headache (3.3%), respectively. The shivering was common in female and associated with technique of spinal anesthesia. Factors which were found to be significantly associated with an increased risk to develop complication were female, technique of spinal anesthesia, type of local anesthetic agent, and position of patient during spinal anesthesia. Conclusion : The postspinal complications were common very from mild to severe. There are no severe complication in this study. Some associated with gender, technique, drug, and position.
The Incidence of Transient Neurologic Symptoms (TNS) after Spinal Anesthesia : A Comparison Between 5% Hyperbaric Lidocaine and 0.5% Hyperbaric Bupivacaine
Punjasawadwong Y, M.D.,* Srisawang S,
M.D.,* Prasitdamrong S, M.D.,*
* Department of Anesthesiology, Faculty of Medicine, Chiang Mai University,
Chiang Mai 50200
Introduction : Although 5% hyperbaric lidocaine is to blame for TNS after its spinal anesthesia, it has been widely used for several years in Thailand. Recently, four cases of TNS after spinal anesthesia were reported at Chiang Mai University Hospital but its association with the use of 5% hyperbaric lidocaine was questionable. Objective : To compare the incidences of transient neurologic symptoms after spinal anesthesia with 5% hyperbaric lidocaine versus 0.5% hyperbaric bupivacaine. Study design : Double blinded randomized controlled trial. Method : Two hundred surgical patients scheduled for surgery under spinal anesthesia were randomly allocated to receive either 5% hyperbaric lidocaine or 0.5% hyperbaric bupivacine. On the following postoperative days, they were evaluated by the anesthesilogist who was unaware of the administered solutions for abnormal unaware of the administered solutions for abnormal neurological symptoms. Result : Seventeen patients in the 5% hyperbaric lidocaine group (17.17%) developed TNS while two patients in the 0.5% hyperbaric bupivacaine group (1.98%) developed TNS-like symptoms (p=0.003. Fisher's Exact test). The crude risk (95% CI) of TNS in the 5% lidocaine group is 10.262 (2.28, 46.1) and the adjusted risk (controlling for age, operation time and lithotomy position by the multiple logistic regression analysis) of TNS in this group is 8.82 (1.89, 41.04). Conclusion : The result has indicated that risk of TNS after spinal anesthesia is increased with the use of 5% hyperbaric lidocaine. Despite its risk of TNS, lidocaine is still useful in spinal anesthesia particularly for a short operative procedure. Therefore, the modified concentrations of lidocaine for spinal anesthesia is still required to reduce the risk of TRI and provide adequate analgesia during the operative procedure.
Key works : Anesthesia ; spinal, subarachnoid, complication, neurotoxicity, transient radicular irritation, transient neurologic symptoms
Major Spinal Operation Without General Anesthesia : Cases Report
Chinachoti T, M.D.*, Inphum P, M.D.*, Thanapipatsiri
S, M.D.**, Chavasiri C, M.D.**
* Department of Anesthesiology,
** Department of Orthopedics, Faculty of Medicine, Siriraj Hospital, Bangkok
10700
Major surgical treatments of spinal disorders are almost always performed under general anesthesia. However, severe underlying heart disease may increase the risk of general anesthesia as well as regional anesthesia either epidural or spinal block. Monitoring of spinal cord function is critical in surgical correction of spinal deformities. It requires either sophisticated medical equipment or the cooperation of the conscious patient. We reported two patients who underwent major spinal operations under local anesthesia. The first patient had progressive disabling back and left leg pain due to ruptured disc and degenerative spondylolistesis of L4-L5 which was unresponsive to conservative treatment. She was obese and had severe ischemic heart disease. Disectomy at L4-L5 level and L5 nerve root decompression were performed under local infiltration and intraoperative epidural injection of local anesthetic agent. The second patient had severe kyphotic deformity of the cervical spine as a sequel of ankylosing spondylitis resulting in inability of look straight ahead. Corrective spinal osteotomy at C7-T1 level was accomplished under local anesthesia and controlled sedation. During operation, he was conscious and cooperative therefore his neurological status could be continuously monitored. Successful operations and outcome were achieved in both cases.
Comparison of Droperidol, Dexamethasone and Saline in the Prevention of Postoperative Nausea and Vomiting after Gynecologic Laparoscopic Surgery in Outpatients. A Randomised, Double Blind, Placebo-Controlled Trial.
Vongvatcharanon S, M.D.,* Kittijirawong T, M.D.,* Chanchayanon T, M.D.,* Lim A, M.Sc.**
* Department of Anesthesiology ** Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Had-Yai, Songkhla 90110 Introduction : Laparoscopy is a popular in outpatient gynecology. The most common complication associated with this procedure is postoperative nausea and vomiting (PONV) which sometimes requires patient hospitalization. In this prospective randomised double blinded controlled study, we evaluated prophylactic efficacy in reducing PONV by using droperidol (0.02 mg/kg IV) or dexamethasone (0.15 mg/kg IV) compared with a placebo. Methods : Eighty-four outpatients, age 15-45, ASA Class I-II were divided into three groups at random (28 patients/group). Five minutes after induction and intubation, we gave the studied drug; droperidol, dexamethasone or saline and then maintained anesthesia under balanced technique. Results : The incidence of PONV in the droperidol group was less than the placebo group at 30 min (P=0.033) and less than the dexamethasone group at 60 and 90 min (P=0.035 and 0.048 respectively). The overall incidence of PONV in the droperidol group was less than the dexamethasone and placebo groups (32.1% compared with 46.4% and 53.5% respectively). In patients with a history of PONV or motion sickness, the incidence of PONV in the droperidol group was also less than the dexamethasone and placebo groups. The droperidol gropu had sedation scores higher than the dexamethasone and placebo groups only at 60 min. (P=0.04 and 0.032 respectively). There was no nifference in the incidence of PONV at 120 and 180 min in the postanesthetic care unit (PACU) and 24 hr at home between all three study groups. The number of patients who had to be admitted due to severe nausea and vomiting were three in the placebo group and one patient in the dexamethasone group. Conclusion : Droperidol is more effective in prephylaxis of early PONV than dexamethasone or a placebo with sedation occurring only at 60 min in gynecologic laparoscopic outpatients. Key words : Dexamethasone, droperidol, gynecologic laparoscopy, outpatient, PONV
Leg Wrapping for the Prevention of Hypotension following Spinal Anesthesia in Cesarean Section
Sangkheo C, M.D.,* Vasinanukorn M, M.D.,* Laekatham N, M.D.* * Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Songkla 90110
Introduction : Hypotension following spinal anesthesia for cesarean section remains a common complication despite intravenous preloading fluid and the use of left uterine displacement. Objectives : To investigate whether wrapping of the legs before spinal anesthesia for Cesarean section will reduce the incidence of hypotension without complications from Esmarch bandaging. Methods : 122 parturients, undergoing elective cesarean section under spinal anesthesia with 2.2 ml of 0.5% hyperbaric bupivacaine, were randomly allocated to leg wrapped group (gr. W, n=61) and control (gr. C, n=61). All parturients received intravenous lactated Ringer's solution 2 ml/kg/hr starting at 7.00 AM, 20 ml/kg within 10 minutes prior to spinal injection and 12 ml/kg/hr thereafter until the end of operation. They were placed in the left uterine displacement position after spinal injection. Group W had both legs elevated to 45 degrees and wrapped with Esmarch bandages before spinal injection. Significant hypotension was treated with intravenous ephedrine in 6 mg bolus dose. Results : The leg wrapped and the control groups were comparable with regards to demographic data, baseline hemodynamic data, total intravenous fluid, estimated blood loss, total ephedrine and synthetic oxytocin (Syntocinonâ), operating time and Apgar score at 1, 5 minutes. The incidence of hypotension in group W was 52.4% while in group C was 63.9% which was not statistically different (p=0.198). The parturients in group W were less likely to have hypotension following spinal anesthesia (relative risk = 0.82, 95% confidence intervals =0.60-1.11) than were those in group C. There were no complications from Esmarch bandaging and spinal anesthesia determined for 3 days postoperatively. Conclusion : The study fails to demonstrate a statistically significant difference in the rate of hypotension following spinal anesthesia for cesarean section between parturients receiving leg wrapping and those not receiving. Furthur studies with larger sample size may be needed to examine the efficacy of leg wrapping in preventing hypotension in such condition. Key words : spinal anesthesia, cesarean section hypotension, leg wrapping.
A Double Blind, Randomized Study Comparing Hemodynamic Responses to Endotracheal Intubation During Induction of General Anesthesia Between Inhaled 4% Lidocaine and 0.9% Normal Saline Via Nebulizer
Punkla W, M.D.,* Chinachoti T, M.D.,* Sinjaroenmanee T, M.D.,* Inphum P, M.D.* * Department of Anesthesiology, Siriraj Hospital, Bangkok 10700
Purpose : A double blind, randomized study with two parallel groups, comparing systolic and diastolic pressure changing during intubation between 4% lidocaine and 0.9% normal saline 5 ml nebulized before induction of general anesthesia. Methods : Sixty patients, ASA class 1 or 2, age between 16-60 yrs scheduled for elective surgery under general anesthesia with endotracheal intubation. Patient with history of hypertension, ischemic heart disease or predicted difficult airway management were excluded from the study. Five minutes before induction of general anesthesia, they were breathing through face mask with nebulized with oxygen 10 L/min either with 5 ml of 4% lidocaine or 0.9% normal saline, midazolam 0.04 mg/kg, thiopental 5 mg/kg and succinylcholine 1.5 mg/kg were used for induction and intubation. Results : 4% lidocaine nebulized group failed to reduced hemodynamic changing during intubation period and 1, 2, 3, 5 and 10 minutes after intubation. Discussion : Without opioids premedication, only nebulized with 4% lidocaine 5 ml before intubation during induction of general anesthesia was not enough to blunt hemodynamic response to intubation. Key words : Lidocaine nebulizer, Intubation, Hemodynamic response, Randomized controlled trial
The Comparative Study of the Quality Anesthesia in Cesarean Section from the Hospital Accreditation Project in Chiangrai Regional Hospital
Jitpreecharn N, M.D.,* Cholitkul S, M.D.,* Manoharn P, B.N.* * Department of Anesthesiology, Chiangrai Regional Hospital, Chiangrai 57000
One of the processes of the Hospital Accreditation Project is the Quality activities
which the multidisciplinary teams consider the evidence-based data to improve
their quality services. This study is interested in the quality services provided
for patients who had Cesarean section from July 1997 to January 1998 (before
HA. Implemented) and from July 1998 to January 1999 (Anesthesiology Department
implemented) with the ones from July 1999 to January 2000 (PCT. activities implemented)
The prospective comparative study of the quality anesthesia includes the Cesarean
section rate, regional block rate and the quality of the preparation of the
pregnancy patient by chi-square test at p < .05.
The results will lead to improve the Quality C/S services of the Obstetric Patient
Care Team in which the Anesthetic department play the major role.Key word :
Anesthesia, awareness, hoarseness, hospital accreditation, NPO
time, PDPH., post-op Cesarean section complication, quality improvement, shivering,
sore throat
Malignant Hyperthermia in a Pediatric Patient : A Case Report
Amornyotin S, M.D.,* Piromrat I, M.D.*
* Department of Anesthesiology, Faculty of medicine, Siriraj Hospital, Mahidol
University, Bangkok 10700.
Malignant hyperthermia is a rare inherited syndrome characterized by an acute hypermetabolic state within muscle tissue following induction of general anesthesia. This is a case report of a 3-year-old boy with transepiphyseal plate injury at lateral condyle of the left elbow with posteromedial elbow dislocation. He had undergone open reduction and internal fixation. After rapid sequence induction with thiopental and succinylcholine, masseter muscle was rigid and could not pass the endotracheal tube. Intubation was successfully done by using a non-depolarizing muscle relaxant and maintenance with N2O in O2, halothane and fentanly. During maintenance period the patient was tachycardia, rising of ETCO2 and temperature. Arterial blood gas was showed respiratory and metabolic acidosis. After hyperventilation with 100% O2, cooling the patient and given NaHCO3, the patient was clinically improved. The patient was observed in ICU three days for stabilizing hemodynamic, cooling and correcting acid-base disturbance, and discharged to ward. Ten days after anesthesia, the patient was taken home without the second operation.
Iatrogenic Pneumocephalus Following Attempted
Lumber Epidural Anesthesia
Moungsouy V, M.D.,*
* Anesthesiology Unit, Somdejprabhuddalertla Hospital, Samutsongkram 75000
A case of 49 years old healthy man developed iatrogenic pneumocephalus following attempted lumbar anesthesia by the loss of resistance using air technique for dorsalis pedis free flap and skin graft operation. The epidural space was identified with difficulty. On the fifth attempt, the median approach technique was used to identify the epidural space at L4-5 interspace, the accidental dural puncture was found after 5 ml of air injected. The last attempt was done by paramedian approach at the same level. Following 5 ml of air injected, the patient complained pain in right ear. Another 5 ml of air was injected and severe pain in right ear with severe headache was complained immediately followed by hypertension, emesis and unequal pupil size, Pneumocephalus was diagnosed by plain film of the skull and the operation was cancelled. The headache was resolved within 24 hours and pneumocephalus followed up by plain film of the skull was resolved within 2 weeks. The splitted thickness skin graft was done under intravenous ketamine. The patient was discharged without any neurodificit except unequal size of pupils.
Key word : pneumocephalus, epidural anesthesia
A Case Report : Oxygen and Nitrous Oxide
Pipeline Cross-connection
Raksakietisak M, M.D.,* Pitimanaaree
S, M.D.,* Svastdi-Xuto O, B.N.,* Prakkamodom S, B.N.,* Manon J, B.N.,* Petcharatana
S, B.N.*
* Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Bangkok
10700
A healthy one year old boy with cleft lip and palate was scheduled for reconstructive surgery. Non-invasive blood pressure, pulse oximetry and precordial stethoscope were monitored, then he received inhalation induction with nitrous oxide, oxygen and halothane via face mask and Jackson Ree's breathing system for venous cannulation and infusion. Atropine 0.1 mg and succinylcholine 1.5 mg/kg were given for endotracheal intubation. Nitrous oxide was shut off to provide 100% oxygen ventilation before intubation. In spite of perfect ventilation, oxygen saturation rapidly and continuously dropped. Face mask was removed and breath sound was continuously auscultated to exclude any evidences of regurgitation and aspiration. We could not find oral content and any evidences of aspiration but he suddenly became cyanotic and bradycardia. Halothane was discontinued and atropine 0.3 mg was given intravenously. Fortunately, before he turned to cardiac arrest, the idea the there might be something wrong with anaesthetic machine because he did very well when he was ventilated with 50% N2O : 50% O2 during inhalation induction. Immediately fresh gas flow was turned to 50% N2O : 50% O2 and he quickly returned pink and his oxygen saturation dramatically increased to 100%. Another anaesthetic machine was replaced the first machine and anaesthesia and surgery were uneventfully done. No complications and any neurological sequelae were found postoperatively. After this event the first anaesthetic machine was examined and we found that the male connector of nitrous oxide was connected to the hose of oxygen and vice versa. So when we turned fresh gas flow to 100% oxygen, the patient actually received 100% nitrous oxide. This event cannot be prevented with antihypoxic gas mixture or oxygen failure shut off device, except oxygen analyzer. In some countries, oxygen analyzer is a standard monitor and strongly recommended for safety purpose. Should this monitor be recommended and standard in Thailand.
Preanesthetic Anxiety Assessment : HADS
versus APAIS
Sirinan C, M.D.,* Rungreungvanich M,
M.D.,* Vijitpavan A, M.D.,* Morkchareonpong C, M.D.*
*Department of Anesthesiology, Faculty of medicine, Ramathibodi Hospital, Bangkok,
10400
We assessed patients' anxiety and concern regarding anesthesia in preanesthetic
phase by comparing two measurements of anxiety : The hospital anxiety and depression
scale (HADS) and the Amsterdam preoperative anxiety and information scale (APAIS),
and determine their equivalent in assessing anxiety.
One hundred and seventy patients completed questionare which consisted of 7
items of HADS and 6 items of APAIS in Thai language during preanesthetic visit.
We found that the correlation between two scales were high (0.7). Ten percent
of patients could be considered as "anxiety cases" by using HADS cut
off value at 11 compared to twelve percent of patients by using APAIS score
greater than 13. Woman and the middle aged group (26-45 yr.) had significant
higher scores of anxiety than others. Most patients concerned about pain and
possibiltiy of not waking up postoperatively.
The prevalence of "anxiety cases" in our study was low. Both scales,
HADS and APAIS, were equivalent and could provide anesthesiologists with valid,
reliable and easily applicable measurements for assessing preanesthetic anxiety.Key
words : Anxiety, preanesthetic assessment anxiety scale.
Alfentanil for Blunting Hemodynamic Responses
to Tracheal Intubation in Thai Patients
Sirinan C, M.D.,* Ittichaikulthol W,
M.D.,* Nantha-aree M, M.D.,* Arnuntasupakul V, M.D.*
*Department of Anesthesiology, Ramathibodi Hospital, Mahidol University, Bangkok
10400.
A randomized double-blind study was conducted in 60 ASA class 1, 2 patients to determine the effectiveness of alfentanil 20 mg/kg in blunting the hemodynamic responses to tracheal intubation in Thai patients. Patients were premedicated with 7.5 mg. dormicum about 1 hr before induction and were allocated randomly to receive alfentanil 20 mg/kg or normal saline, given intravenously 30 seconds before induction of anesthesia. One minute after administration of thiopental 4.0 mg/kg and succinylcholine 1.5 mg/kg intravenously, tracheal intubation was performed using direct laryngoscopy. In response to intubation, increases in heart rate and systolic blood pressure (SBP) occurred in both groups but these changes were significantly higher in control group than alfentanil group (P=0.00). However, in alfentanil group, there was a transient decrease in SBP to less than 30% baseline value in three of thirty patients (10%) after induction of anesthesia. But SBP was still greater than 80 mmHg and did not require any treatment. In conclusion 20 mg/kg of alfentanil administered 30 seconds before induction is effective for blunting the hemodynamic responses to tracheal intubation. We recommended this as an alternative technique for healthy adult Thai patients.
Key words : Alfentanil, hemodynamic responses, tracheal intubation.
Routine Preoperative Laboratory Tests
for Pediatric Ambulatory Surgery : Should it be Curtailed?
Sirinan C, M.D.,* Rungreungvaich M, M.D.,*
Pongbhesaj P, M.D.,* Tongput A, M.D.*
* Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital, Bangkok
10400
The routine preoperative evaluation of pediatric patients often includes a
history, physical examination, complete blood count, Anti-HIV, CXR and urinary
analysis (UA). It is routinely used in pediatric ambulatory surgery even though
this is low-risked surgery, less blood loss and most of patients are healthy.
So we studied to determine the role of abnormal preoperative laboratory test
in perioperative management.
We retrospectively reviewed the medical record of 461 children. All children
were physical status 1 and 2 who underwent minor surgery procedure between April
1998 to March 2000. The following data were collected : demographic data, number
and result of investigation (e.g. anemia, Anti-HIV), major and minor complication
and surgeons' perpective of laboratory test.
Eighty-eight percent of all patients had laboratory test and the most common
laboratory test were CBC and Anti-HIV (87.2 and 74.8% respectively). Nineteen
percent of patients were anemia, Anti-HIV was negative in all patients. Abnormal
laboratory tests were not related to surgery canceled and perioperative complication.
Some laboratory test did not examine in all patients because of surgeons' different
preference.
We believe that a thorough clinical assessment of the patient is more important
than routine preoperative laboratory screening which should be required only
when justified by real clinical indications and this practice eliminates unnecessary
costs without compromising the safety and the quality of care.
Key word : Pediatric, ambulatory surgery, preoperative labarotory test.
Widespread Application of Topical Steroids to Decrease Sorethroat, Hoarseness
and Cough after Endotracheal Intubation
Chinachoti T, M.D.,* Laohasiri B, M.D.,*
Sukphol J, M.D.*
* Department of Anesthesiology, Siriraj Hospital, Mahidol University, Bangkok
10700
Purpose : A double blind, randomized study with two parallel groups, was done to compare severity of sorethroat, hoarseness of voice and cough after intubation between lubicated endotracheal tube with betamethasone gel or placebo gel. Methods : One hundred patients, ASA class 1 or 2, age between 18-60 years scheduled for elective surgery under general anesthesia with endotracheal intubation. Excluded patients with difficult airway, poorly communicated or position which need to move head and neck after intubation. Endotracheal tubes were lubricated before use. Post-operative sorethroat, hoarseness of voice and degree of cough were evaluated at one or two hours and 24 hours after operation. All study drugs were prepared by code. All investigator team were blind until statistically reports were done. Results : There were no difference incidence and severity of sorethroat after operation between the two groups of study. 0.05% betamethasone gel reduced incidence and severity of hoarseness of voice both immediate and 24 hours after operation and cough at 24 hours after operation. Conclusion : Betamethasone gel could not reduce post intubation sorethroat but could reduce severity of hoarseness of voice and cough compared to placebo gel.
Effect of Narcotics on Pupil Size and
Intraocular During Vitreoretinal Surgery
Koompong P, M.D.,* Chevawattana S, M.D.,*
Singalvanija A, M.D.,** Suraseranivongse S, M.D.,* Charoenvanich N, B.N.,* Poopattanapong
S, B.N.** Santisuk J, B.Sc.**
* Department of Anesthesiology, ** Department of Opthalmology, Siriraj Hospital,
Bangkok 10700
This randomized controlled trial study was performed to evaluate the effect
of narcotics and general anesthesia on pupil size and intraocular pressure (IOP)
during vitreoretinal surgery. We studied in 80 patients, 52 males and 28 females,
ASA I or II aged between 17-65 years, who underwent vitreoretinal surgery. The
affected eye was dilated before surgery. The patients were divided into 4 group
: group A (control group, n=20) received normal saline (NSS) 5 ml IV, gr B (n=20)received
fentanyl 1 mg/kg in NSS 5 ml IV, gr C (n=20) received pethidine 1 mg/kg in NSS
5 ml IV, and gr D (n=20) received nalbuphine (Nubain) 0.1 mg/kg in NSS 5 ml
IV. Narcotics were given 5 minutes after the beginning of general anesthesia.
The diameter of pupil and IOP were measured in non dilated pupil (pupil ND)
and dilated pupil (pupil D) before surgery, after general anesthesia and 5 minutes
after narcotics.
General anesthesia and narcotics did not significantly change the size of pupil
when compared with the preoperative period. Intraocular pressure was significantly
decrease after narcotics but not after general anesthesia, in both dilated and
non dilated and non dilated eyes.
Among the 3 narcotics, in non dilated pupil, pethidine significantly decreased
pupil, fentanyl significantly decreased pupil size more than nalbuphine. Nalbuphine
induced least change in pupil size in both dilated pupil and non dilated pupil
and would be the preferrable narcotic for vitreoretinal surgery.
Key word : pupil size, intraocular pressure, vitreoretinal surgery, intraocular
surgery, narcotics, opioids, general anesthesia.
A Scalenus Medius Approach of Brachial Plexus Anesthesia : A New Technique
Jonfjirasiri Y, M.D.,* Thaosuwan S, M.D.,
D.A.**
* Orthopaedic Department
** Consultant in Anesthesiology, Bangkok Metropolitan Administration General
Hospital, Department of Medical Services, Bangkok Metropolitan
Administration, Bangkok 10100.
One hundred consecutive cases of scalenus medius muscle supraclavicular brachial plexus anesthesia were selected to be injected of 20 ml. of local anesthetic solution at the position of 1.5 to 2 cm above the clavicle at the scalenus medius muscle with upper extremity traction abducted nearly to 90 degrees. This technique was reliable, safe and easy to perform because of the distance of brachial plexus was shorten when the upper extremity rested aside about 5 mm. It was found that anesthesia of the entire extremity in 99 out of the first 100 cases were satisfactory. Complications were minor and transient.
Trachlight (Stylet and Tracheal Lightwand) an Equipment Intubation
Amornyotin S, M.D.*
* Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol
University, Bangkok 10700
Trachlight (stylet and tracheal lightwand) was a device for endotracheal intubation. The technique of transillumination of the soft tissue of the neck has been practiced for more than 30 years. Trachlight has been designed to facilitate both the insertion of tracheal tubes (oral and nasal route) and the accurate positioning of the tube tip within the trachea ; delivering on the promise of transillumination. This technique took advantage of the anterior location of the trachea relative to the esophagus. A well-defined circumscribed glow can readilly be seen in the anterior neck when the endotracheal tube and light enter the glottic opening. If the tip of the tube was placed in the esophagus, the light glow was diffuse and would not be easily seen. In the hands of inexperienced intubators the trachlight proved to be significantly quicker, safer and more successful than the laryngoscope.
Postoperative Analgesia after Intrathecal
Morphine in Hip or Knee Surgery
Chanchayanon T, M.D.,* Thongsuksai P,
M.D.,** Sriwattana A, B.Sc.,* Dilokrattanapichit N, B.Sc.,* Suwuttikul N, B.N.,*
Boonrasri U, B.Sc.,* Buhachat S, B.Sc.,* Lim A, M.Sc.***
* Department of Anesthesiology, ** Department of Pathology, *** Epidemiology
Unit, Faculty of Medicine, Prince of Songkla University, Songkhla 90110
We designed this study to determine the optimal intrathecal dose of morphine in patient undergoing hip or knee surgery. The optimal intathecal dose was defined as the dose that provided effective analgesia with minimal side effects for 24h after surgery. Sixty patients, scheduled for hip or knee surgery, were randomly allocated into 3 double-blinded groups. Group 1 and group 2 received intrathecal morphine 0.3 and 0.5 mg respectively while group 3 received normal saline (NSS) 0.5 ml. All were given a standardized bupivacaine dose intrathecally. Pain scores, IV pethidine injection, and morphine-related side effects (respiratory depression, postoperative nausea and vomiting, pruritus, urinary retention and sedation) were recorded for 24h after surgery. VAS score recorded postoperatively at 6 and 12 h in both morphine groups were significantly less than NSS group. Time to first analgesic requirement was significantly longer in both morphine groups compared to NSS group (group 1=15.1 + 6 .7 h, group 2 = 14.7 + 6.8 h, group 3 = 8.6 + 5.4 h, p value = 0.0001). The number of additional pethidine injection reguired in the first 24 hours was significantly less in the morphine groups (2.22, 2.82 and 4.83 in group 1, 2 and 3 respectively, p value = 0.0001 for group 1 and versus group 3). Incidence of postoperative nausea and vomiting (PONV), pruritus and urinary retention were significantly higher in both morphine groups compared to NSS group. Respiratory depression did not occur in all patients. We conclude that 0.3 mg of intrathecal morphine in the optimal dose for pain relief after hip of knee surgery with acceptable side effects.
Key words : hip or knee surgery, intrathecal morphine, postoperative analgesia, randomized controlled trial
Efficacy of 1% Ropivacaine Eqidurally in Thai Patients
Somboonviboon W, M.D.,* Chinachoti T,
M.D.,* Niruthisard S, M.D.,* Uerpairojkit K, M.D.,* Pechpaisit N, M.D.,* Vorapaluk
P, M.D.,* Palapreewan N, M.D.,* Thongrom C, M.D.,** Wanasaengsakul S, M.D.**
* Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University,
Bangkok 10330
* Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol
University, Bangkok 10700
Background : Ropivacaine is a new amino amide local anesthetic similar in structure to both bupivacaine and mepivacaine. Ropivacaine possesses an anesthetic properties like bupivacaine but the cardiotoxicity is less than bupivacaine. The objective of this study is to evaluate the clinical efficacy and safety of ropivacaine when when employed for epidural anesthesia in Thai patients. Methods : 112 patient, with the physical status I-II underwent for lower abdominal surgery orthopedic procedure were enrolled in the study. The patients received 15-20 ml of 1.0% ropivacaine via continuous epidural block. The datas recorded consisted of the onset and duration of sensory block at T12 T10 T6 and T4 as well as the motor blockade defined by Modified Bromage Scale. The blood pressure, heart rate and sied effects were recorded. The satisfaction by the anesthesiologists and the surgeons were also rated. Results : The mean onset time of sensory block to T12 T10 T6 and T4 were 6.6, 9.6, 18.8 and 19.5 min for the left leg and 7.0, 10.7, 18.3 and 19.9 min for the right respectively. The mean duration of sensory block (at T12) was 259.5 min and 269.0 min for the left and right leg respectively. The mean onset time for motor block evaluated by Modified Bromage Scale 1, 2 and 3 were 11.2, 19.9 and 27.0 min for the left leg as 11.6, 21.0 and 28.1 min for the right leg. The duration for motor block was 274 and 279 min respectively. The incidence of side effects were shivering 62.5% hypotension 49.1%, hypertension 30.4%, nausea 33.9%, vomiting 16.9% anxiety 16.9% and bradycardia 11.6%. The were all resolved with standard treatment such as fluid, vasopressor drugs and antiemetics. The rate of satisfaction from the anesthesiologists was 94.7% while the satisfactory rate from the surgeon was 96.5%. Conclusion : Ropivacaine is a new amide group of local anesthetic. 1% 15-20 ml ropivacaine via epidrual catheter produces rapid and profound sensory block while the motor block is slow in onset and less in intensity.
Risk Factors of Delayed Extubation after
Surgery of Intracranial Aneurysm
Charuluxananan S, M.D.,* Kyokong O, M.D.,*
Kunthonluxame A, M.D.,* Phornsuwannapha S, M.D.**
* Department of Anesthesiology
* Department of Surgery, Faculty of Medicine, Chulalongkorn University,
Bangkok 10330
Background : The incidence of ruptured intracranial aneurysm is progressively
increasing. Delayed extubation in these patients results in significant increasing
in length of intensive care unit and hospital stay, resource utilization and
total hospital cost. This study was carried out to determine the factors contributing
to delayed extubation in patients with ruptured intracranial aneurysm.
Methods : Medical records of 243 intracranial aueurysm patients undergone craniotomy
under general anesthesia between January 1, 1993 to December 31, 1998 were reviewed
retrospectively. Outcome variable was postoperative delayed extubation >
72 hours. University analysis were performed using Chi-square test (Fisher-exact
test when appropriate), p < 0.05 was considered statistically significant.
Multivaariate logistic regression was performed to derive risk factors and logistic
models of the delayed extubation > 72 hours.
Results : There were 99 cases (40.7%) of delayed extubation > 72 hours were
preexisting cardiovascular disease, alteration of consciousness, unidentified
aneurysm, internal coratid artery aneurysm, preoperative intubation or tracheostomy,
transfusion of fresh forzen plasma, reoperation within 1 week, mannitol infusion
and administration of diuretic.
Conclusion : Logistic model was derived for prediction of delayed extubation
after anesthesia and surgery of intracranial aneurysm.
Keywords : Risk factors, predictors, delayed extubation, intracranial aneurysm
A Preliminary Study Comparing Tracheal
Intubation by Anesthetic Nurse Trainees Using Endotracheal Tube and Esophageal
Tracheal Combitube.
Chairat L, B.Sc. (Nursing)*, Chau-In
W, M.D.,* Sumret K, B.N.,* Taesiri W, B.Sc. (Nursing)*
* Department of Anesthesiology, Faculty of Medicine, Khon Kaen
University, Khon Kaen 40002
We compared the time taken by 22 experienced and 21 inexperienced anesthetic
nurse trainees to intubate patients using both the endotracheal tube (ETT) and
esophageal tracheal Combitube (ETC). The nurses were instructed in the use of
both ETT and ETC and were trained on a manikin until they were able to use both
instruments correctly. Intubation time was determined using a stopwatch and
was defined as the time from preparation of instruments to the beginning of
intubation until the lungs were inflated. The time taken to inflate the cuff
(s) was also included.
Comparing the two groups of nurses, the time taken to intubate was statistically
different as was the degree of difficulty for intubation (both at p<0.05).
The experienced group intubated more easily than the inexperienced group, however,
the "within" degree of difficulty between ETT and ETC for the inexperienced
group was statistically different (p=0.038). The degrees of satisfaction vis-?-vis
the two methods between the two groups were not statistically different.
We concluded that training ETC intubation by anesthetic nurses (both trainees
and those in intensive care ) and paramedics would be more successful than the
older ETT method.
Key word : Anesthetic equiment :endotracheal tube, esophageal tracheal Combitube; anesthetic nurse trainees
Humidity During General Anesthesia
Jantorn P, M.D.,* Sirinan C, M.D.,* Krobbuaban
B, M.D.*
* Department of Anesthesiology, Faculty of Medicine, Ramathibodi
Hospital, Mahaidol University, Bangkok 10400.
Rationale : Maintenance of adequate airway humidity is necessary especially
in artificial airway. The humidity of inspired gas from the circle absorber
system may not be adequate for patients under general anesthesia with endotracheal
intubation. Design : Descriptive study and prospective data collection. Methods
: the humidity of inspired gas from the circle absorber system was measured
by a Hygrodynamic electric hygrometer in 70 healthy patients having surgical
procedures under general anesthesia with endotracheal intubation. Results :
Initially the absolute humidity in each patients ranged from 5.9 to 14.3 mgH2O/L.
It reached the maximun level within 10 to 150 minutes ranging from 8.4 to 24.3
mgH2O/L. These maximum values were lower than the American National Standard
Institute (ANSI) recommendation. There was no respiratory complication noted
in our study population. Conclusion : The humidity of the circle absorber system
does not meet the ANSI recommendation and may be inadequate for patient under
general anesthesia with endotracheal intubation. Nevertheless, we did not find
any respiratory complication in our study population within 48 hours.
Key words : Humidity : absolute humidity, relative humidity. Cricle absorber system.
Postoperative Analgesia after Brachial
Plexus Block with Morphine
Tontisirin O, M.D.,* Wongwikrom W, M.D.,*
Sahatsariyanon S, M.D.,* Pantunatviriyakul U, B.Sc., (Nursing)*
* Department of Anesthesiology, Faculty of Medicine, Ramathibodi
Hospital, Mahidol University, Bangkok 10400
Postoperative pain is still troublesome for patients. A prospective randomized
study performed to determine morphine additive effect to local anesthetic for
brachial plexus block should provide longer postoperative analgesia. Fifty Thai
patients, 15-50 years old, were divided into 2 groups, 30 patients in group
I received morphine hydrochloride 100 mg/kg and 1.5% lidocaine (with epinephrine
1: 200,000) 20 ml while 20 patients in group II received 1.5% lidocaine (with
epinephrine 1 : 200,000) 20 ml and normal saline. The duration of postoperative
analgesia was evaluated by using visual analogue scale at 0, 6, 12 and 24 hours
postoperatively.
In morphine group, analgesia extended over 12 hours about 66% while only 15%
is in controlled group. The side effects were nausea/vomiting and sedation.
Nausea/vomiting found in 11 patients (36.67%) was successfully treated with
metoclopramide and sedation was found in 4 patients (13.33%) of morphine group.
We conclude that adding morphine in the brachial plexus block will be a better
postoperative analgesia for upper limb surgery.
Key words : Brachial plexus block, postoperative analgesia, morphine
The Efficacy of Siriraj's Alghorhythm
for Postoperative Pain Management for Total Knee Replacement and Hip Operation,
Compared to Conventional Method.
Chinachoti T, Lurngnateetape A, Chaudakshetrin
P, Mongkonjakkawan P.* Department of Anesthesiology,
Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700.
Objective : To compare the efficiency of postoperative pain control between
the conventional method and scheduled plan correlated to anesthetic technique.
Patients and methods : 124 patients underwent operation for total knee replacement
or hip operation during April to July 1999 at Siriraj Hospital, all were evaluated
by using pain score daily for three days after the operation. A conventional
method of intramuscular opioid prn. Was used in 33 patients and the following
scheduled plan was used in 91 patients. The scheduled plan included patient
controlled intravenous analgesia 30 cases, patient controlled epidural analgesia
16 cased, repeated epidural morphine 32 cases, time scheduled intramuscular
opioid 10 cases and oral analgesia 3 cases.
Results : The pain score in the scheduled group was significantly reduced compared
to the conventional group three days after operation by decreasing from 5.6
+ 3.5, 5.3 + 2.9 and 3.65 + 3.4 to 2.5 + 1.6, 2.5 + 2.6 and 1.0 + 1.9 respectively
( P < 0.05). Pain scores were reduced after total knee replacement (n = 83)
from 7.6 + 2.4, 6.4 + 2.2 and 4.7 + 4 to 2.7 + 2.8, 2.4 + 2.6 and 1.2 + 2.0
respectively (p < 0.05) Scheduled management showed no advatage in postoperative
pain control following dynamic hip screw. Hemiarthroplasty and Gamma nail implantation
of hip.
Conclusion : The postoperative pain management by using scheduled plan correlated
to anesthetic technique for total knee replacement and hip operation showed
rational improvement in pain control. Transfering and distribution of knowledge,
practical guideline and supporting consultants are the keys of success with
patient safety.
Postincisional Wound Infiltration with
0.25% Bupivacaine for Postoperative Pain Relief After Hysterectomy
Nimmaanrat S, M.D.,* Suwanrath C, M.D.,**
Phungrassami T, M.D.***
*Department of Anesthesiology, **Department of Obstetrics and Gynecology, ***Department
of Radiology, Faculty of Medicine, Prince of Songkla University, songkhla 90110
There are many alternatives to control postoperative pain. Using local anesthesia to supplement general anesthesia is one of the current interesting techniques. Our objective was to determine whether postincisional wound infiltration with 0.25% bupivacaine provided postoperative pain control better than without local anesthetic infiltration. A prospective, randomized, double-blind controlled trial was done in 28 ASA class I and II women scheduled to undergo abdominal hysterectomy who were randomized into group I (treatment) or group II (control). Group I (treatment) received 30 ml of 0.25% bupivacaine infiltrated at the wound immediately before closure. Group II (control) received no local anesthetic infiltration. Pain assessment using visual analogue scales, time to first analgesic requirement, and postoperative analgesic consumption. Results revealed significantly less pain (P < 0.05) in the control group at 4 hours postoperatively. There were no significant differences in time to first analgesic request or supplementary analgesics required. We conclude that postincisional wound infiltration with 0.25% bupivacaine had no advantage compared with no wound infiltration in reducing postoperative pain scores or analgesic requirements after abdominal bysterectomy.
Key words : bupivacaine, hysterectomy, postoperative pain, wound infiltration
A Comparison in Electrical Energy during
Modified Electroconvulsive Therapy
Between Thiopentone and Propofol as Induction Agents
Anuntavanitkit S, M.D.,* Pimpsamarn P,
R.N.*
* Section of Anesthesiology, Somdet Chaopraya Hospital, Klongsarn, Bangkok 10600.
This study is to compare the electrical energy when modified electroconvulsive therapy was performed by using induction agents of thiopentone and propofol. Forty patients (ASA physical status I and II) were included and randomly divided into two groups, each group contained twenty patients and were given either thiopentone 3.0 mg/kg or propofol 1.5 mg/kg as induction agents. The duration of seizure in propofol group was significantly shorter than thiopentone group (25.90 + 6.54 and 37.20 + 9.13 sec respectively). The number of patients needed increased electrical energy stimulation was more in propofol than thiopentone groups.
Key words : Electrical energy, modified electroconvulsive therapy
Laryngeal Mask Airway Insertion by Unskilled Performer : Standard Deflated
Versus Fully Inflated Cuff Technic
Rungreungvanich M, M.D.,* Sirinan C,
M.D.,* Thumpenjitt M, M.D.*
*Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital,
Mahidol University, Bangkok 10400.
We compared two technics of the laryngeal mask airway (LMA) insertion by unskilled performer : the standard deflated cuff technic and the fully in flated cuff technic. The study was conducted in forty-eight ASA I-II patients undergoing general anesthesia. We recorded the time to complete LMA insertion the number of attempts before successful placement, the presence of blood after LMA removal and sore throat.
We found that insertion technics made no difference with regard to first attempt success, the time to complete insertion and the occurrence of sore throat. However, the presence of blood after LMA removal was less frequent in the inflated cuff group (p = 0.039).
We conclude that the inflated cuff insertion technic is an acceptable alternative to the standard deflated cuff technic in unskilled performer.
Key words : Technic, equipment, airway, mask, laryngeal
Pneumothorax due to Misconnection of
Semiclosed Circle System : a Case
Report
Moungsouy V, M.D.,* Soontranan P, M.D.**
*Anesthesiology Unit, Somdejprabhuddalertla Hospital, Samutsongkram 75000
**Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol
University, Bangkok 10700.
A case report of misconnection of the semiclosed circle system which was contributed to pneumothorax in 49-years old woman underwent general anesthesia for debridement. After intubation with circoid pressure, the reservoir bag was not filled enough to obtain adequate ventilation. The oxygen flushing could elevate patient's chest wall, but there was no chest wall recoil after flushing discontinued. The elbow joint was disconnected to release airway pressure and was replaced by self-inflating bag which retrieved the ventilation into normal pattern. This incident was contributed to severe hypotension (BP 44/37 mmHg) and bradycardia (40/min) and was treated with ephedrine and atropine intravenously. Investigation later on revealed that the reservior bag and expiratory valve were erroneously connected to the expiratory port of the sodolime canister so the bag could not be filled. The expiratory limb of breathing system was also erroneously connected to the port of reservoir bag without expiratory valve so the exhaled gas could not be released. On the first postoperative day, the breath sound of left lung was slightly decreased without clinical distress or abnormal vital signs and chest X-rays showed minimal pneumothorax of left lung. ST depression on anteroseptal wall was noted in ECG. The patient was treated in ICU for 1 day and was sent back to ward without adverse outcome.
Key word : Anesthesia ; equipment, breathing system, hazard, pneumothorax
Laryngeal Mask Airway in Difficult Airway : A Cases Report
Throngnumchai R, M.D.*
*Department of Anesthesiology, Lerdsin Hospital, Bangkok 10500.
This issue described the use of laryngeal mask airway (LMA) in three adult patients with difficult intubation. LMA were electively inserted in two patients who have severe cervical ankylosing spondylitis with anterior flexion deformity and the last patient was inserted after failed endotracheal intubation and the other patients were controlled ventilation. Ventilation and oxygenation were easily maintained. LMA were inserted without any difficulty and placed in and acceptable position. Laryngospasm was occurred in one patient during emergence period and relieved by positive pressure ventilation with 100% oxygen via LMA and intravenous succinylcholine. When the patients were fully awake, the LMA was removed. No other serious complications in postoperative period. This report showed that LMA was an valuable aid in airway management in three patients with difficult airway.
Key words : Laryngeal mask airway, difficult airway.
Hypercabia with the Use of Jackson-Rees
Breathing Circuit in a Pediatric Patient
: a Case Report
Nimmaanrat S, M.D.*
*Department of Anesthesia, Faculty of Medicine, Prince of Songkla University,
Songkhla 90110
Jackson-Rees breathing circuit is widely used in pediatric patients. It is one kind of semi-opened breathing circuits that need enough fresh gas flow to wash out carbon dioxide (CO2) from the circuit. This is a case report of a 4-year-old boy with recurrent laryngeal papilloma. He had undergone 55 times of direct laryngoscopy and CO2 laser vaporization including this one. Intra-operative period was unremarkable. Muscle relexant was reversed after he began to breath. He was not fully awaked. So the endotracheal tube was remained in place. A Jackson-Rees breathing circuit was continued to use in the recovery room. The patient did not awake and response to stimulation. Arterial blood gas was done and showed hypercarbia (PaCO2 of 169 mmHg). After hyperventilation until PaCO2 toward normal, the patient gained full consciousness and the endotracheal tube was extubated without any adverse event aftermost.
Colour Coding, High Pressure and Low
Pressure Connecting Assemblies for Use
with Medical Gases
Vongvises P, M.D., LL.B.*
*Pramongkutklao Hospital, Bangkok 10400
The colour coding for medical gases was established to prevent the confusion of cylinders. Thai Industrial Standards Institute (TISI) has adopted the colour coding from American, Britrish and International standards for Thailand. The colour coding is almost the same as British standard except for oxygen. The colour coding for oxygen cylinder in Thailand is green with white shoulder. (combination of American and British standard). Despite the mandatory colour coding is established, some medical gas cylinders are different from the standard eg. Nitrogen and carbon dioxide cylinders. Besides the colour coding, the standardization of connecting assemblies for both high pressure and low pressure connections are established by American and British standard organizations also the International Organization for Standardization (ISO) to prevent the wrong connection of medical gases. The cylinder valve outlet (high pressure connection was already assigned by the TISI for standardization in Thailand which is derived from ISO. There are some medical gas manufacturers still use the cylinders with the valve outlet for oxygen (only change colour of the cylinders) filled with nitrogen which has been observed in many hospitals, This is very dangerous, the incidence of connecting these nitrogen cylinders to the oxygen pipeline has been reported and resulting the death of the patients. The filling of carbon dioxide to nitrous oxide cylinder by the factory resulting the dead of many patients were reported several times. Probably the cause of this mistake is very obvious that the carbon dioxide regulator can be fitted to the nitrous oxide cylinder valve outlet. So without observing the colour of cylinders, carbon dioxide can be transfilled from the plant to the nitrous oxide cylinders. The low pressure connecting assembly which is now not assigned by TISI. So both types of DISS, NIST and quick connect are applied. But many mistakes are seen at several hospitals, some carbon dioxide and nitrogen regulators are fitted with DISS outlet for oxygen. In conclusion the anesthesiologists who are in charge should understand the standardization of the medical gas system. They shall not accept medical gases with incorrect, unclear colour coding or wrong valve outlet cylinders the purchase of medical gases should come from a reliable company and finally the equipment used for medical gases should be standard.
Volume 25;Number 4:1999:October-December 1999
Preemptive Intraperitoneal Bupivacaine does not Provide Analgesia after Transabdominal Hysterectomy
Visalyaputra S, M.D.,* Sanansilp V, M.D.,* Parakkamodom S, B.N.,* Vudhikamraksa S, B.N.,* Ngamsanga C, B.N.,* Pitiwan A, B.N.,* Tantipusanont S, M.D.,* Prungsri S, M.D.,* Pinthurak J, B.Sc.,* Phadermwongsa P, B.N.*
* Department of Anesthesiology, ** Department of Obstetric and Gynecology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700
A contraversy exists over the effectiveness and clinical value of preemptive analgesia. To investigate the preemptive effects of intraperitoneal bupivacaine, a randomized double blinded placebe controlled study was done in 62 patients undergoing transabdominal hysterectomy under general anesthesia. Patients in group A (placebo) received 80 ml of intraperitoneal instillation of normal saline with epinephrine 0.2 mg after the abdominal cavity had been opened but before the surgical manipulation of the uterus. Patients in group B (bupivaciane) received 80 ml of 0.125 % bupivacaine with epinephrine 0.2 mg instead of normal saline in the same manner as group A. Pain which was assessed by patients using visual analogue scale at 2, 6, 18, 24 h after surgery and the analgesic requirements were not significant different between the two groups. Metabolic endocrine responses (cortisol levels) were not different either. Plasma bupivacaine levels were investigated. We concluded that intraperitoneal instillation of bupivacaine cannot preempt postoperative pain indicated by cortisol levels, visual analogue scores and postoperative morphine requirement.
Training Anesthetic Nurses to Do Preuse Checkup of Anesthesia Delibery System*
Vudhikamraksa S, B.N.,** Soontranan P, M.D.,** Lertakyamanee J, M.D.,** Somprakit P, M.D.**
* Support by "Chalerm Prakiat Fund", Faculty of Medicine, Siriraj Hospital.
** Department of Anesthesiology, Faculty of medicine, Siriraj Hospital, Bangkok 10700
This descriptive study was done to evaluate the training of anesthetic nurses in Siriraj hospital to check anesthesia delivery system prior to use. Forty-nine anesthetic nurese were trained by attending the lecture, watching video tape and practicing the provided checkup guidelines. The pre-train questionnaires revealed that 79.6 % of them used to attend the "preuse checkup course" by lecture, and 26.5 % by practice. The time since last training was 1-11 years. The anesthetic nurses who know how to check anesthesia machine, breathing system, ventilator, self-inflating bag, vaporizer and scavenging system were 85.7, 81.6, 79.5, 63.2, 51.0 and 38.7 % respectively. After training, all anesthetic nurses could check all equipment according to the provided guidelines. The used to train each nurses was 18.3 + 6.2 minutes (range 9-38). Everyone's attitudes towards this training were satisfaction, agreeing that it increases patient's safety in routine practice. This implies for their routine practice as well as teaching the nurse students. Most of them would like to attend this training regularly (95.9 %), recognized as their duties (83.7 %), accepted that it was appropriate to routine practice (81.7 %) and optimum training time (63.3 %). On the other hand, 18.3 % claimed that it was impractical for daily use due to too much detail. We conclude that training by using guidelines is successful and recommend that these guidelines should be routinely used by all anesthesia personnel.
Key words : Anesthesia : anesthetic nurse, checkup, equipment, guidelines
Is Intramuscular Promethazine a Prophylactic Treatment for Epidural Morphine-induced Pruritus in Cesarean Section
Vichitvejpaisal P, M.D.,* Ae-mornkun R, M.D.,* Mahaphan P, M.D.,* Napachoti T, M.D.,* Suksopee P, R.N.*
* Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700
Objectives. Our objective was to study the clinical effectiveness of promethazine in the prevention of epidural morphine-induced pruritus in cesarean section. Methods. A prospective randomized double-blind placebo-controlled study, 60 ASA I-II patients undergoing Cesarean section under epidural anesthesia with 15-25 ml of 2 % lidocaine with 1 : 200,000 adrenaline. After the delivery of a newborn, each patient received epidural injection of 4 mg of morphine via epidural catheter. Simultaneously, patients were randomly devided into 2 groups to receive intramuscular injection of 1 ml of normal saline in placebo group respectively. In the postoperative period, the pruritus and nausea/vomiting were assessed every 2 hours for 48 hours. Twenty five mg of oral diphenhydramine was also administered as required for the treatment of pruritus during the study. Results. There was no statistically significant differences in the demographic data, the incidence and severity of pruritus. The incidence of pruritus was 76.7 % in placebo group and 60 % in promethazine group. The intensity of pruritus was 3.7 + 2.6 and 2.6 + 2.4 in placebo group and promethazine group respectively. The diphenhydramine requirement for treatment of pruritus showed to increase significantly in placebo group (17.4 + 29.6 mg/patent) as compare to promethazine group (8.3 + 19.2 mg/patient). Additionally the nausea/vomiting in placebo group (30 %) had a higher incidence than that in promethazine group (3.3 %). Conclusion. Intramuscular promethazine could not prevent the epidural morphine-induced pruritus in this study. However it appeared to reduce the diphenhydramine requirement for the treatment of pruritus and incidence of nausea/vomiting in patients undergoing Cesarean section with epidural morphine anesthesia.
Clinical Evaluation of Alfentanil added Topical Analgesia for Esophagogastroseopic Procedure
Pirayavaraporn S, M.D.*, Chevawattana S, M.D.*, Tongdeelers P, M.D.*, Tongdeelers P, M.D.*, Kijlertphairoj S, M.D.*, Chalayonnawin V, B.N.* Udompanthurak S, M.Sc.**
* Department of Anesthesiology, ** Clinical Epidemiology Unit, Faculty of Medicine, Siriraj Hosptial, Mahidol University, Bangkok 10700
Using only topical anesthesia in esophagogastroscopy was found uncomfortable in either patients or surgeous due to unavoidable side effects occurred while passing the instrument. The most common side effects found are nausea, vomiting and cough. Additional intravenous alfentanil, short acting synthetic opioid, prior to esophagoscopic procedure was studied with a view to minimize the afore-mentioned undesirable side effects and thereby acceptable by both of the surgeons and patients.
This double blind clinical evaluation was studied among 80 Thai patients (ASA class I-II) who were undergone elective esophagogastroscopy with or with out esophageal dilatation under topical anesthesia. Half of the patients who received only topical anesthesia were used as control group where as the other fourth patients (50 %) that received additional intravenous alfentanil prior to topical were study group.
The study revealed that more frequent nausea was found in control group (75 %) than in study group (45 %). No significant difference of cough and vomiting in both groups. More stupefaction was found in study (8 patients or 20 %) than in control group (0ne patient or 2.5 %). Patients' and surgeons' satisfaction were also assessed by using scoring as excellent, good, fair and poor respectively. Results of the satisfaction assessment showed no significant difference. The author suggested that intravenous alfentanil 10 microgram/kg might be considered as another alternative method in minimizing side effects. Definite and clearer conclusion could be obtained by increasing number of patients in both study and control group.
Intra-tracheal Lidocaine for Cough Suppression During Extubation
Vorrakitpokatorn P, M.D.*, Chintanapramote B, M.D.*, Raksamani A, B.Sc.*, Raksamani A, B.S.c.*
* Department of Anesthesiology, Faculty of Medicine, Mahidol University, Bangkok 10700
Extubation as well as intubation is associated with cough that give many deteriorated effects to the patient as increase intracranial, intraoccular, intragastric pressure. And for cardiovascular system, cough can produce dysrhythmia, tachycardia, hypertension. Cardiovascular changes before and after extubation and also severity of coughing were observed in 90 urological patients (35 females and 55 males) ASA I-II, age 41.65+13.83 (20-65) years and weight 55.05+8.67 (40-76) kgs, who had to be operated with kidney position. Among these patients, we devided to 3 groups by randomization to give intratracheally 0.9 % NSS or 1 % or 2 % lidocaine 0.1 ml/kg with LITA tracheal tube (for more effective application than ordinary endotracheal tube). We found that severe cough could be significant suppressed with 1 % or 2 % lidocaine but not by 0.9 % NSS (p = 0.00015). Efficiency for cough suppression by 2 % lidocaine is better than 1 % but not significant. And also changing in systolic, diastolic blood pressure, heart rate were less when adding lidocaine and when lidocaine increase from 1 to 2 % it seemed more cardiovascular stability any how not significant. We conclude that 1 and 2 % lidocaine 0.1 ml/kg intratracheally can reduce adverse effect of extubation as severe cough significantly and can also reduce CVS change.
Key words : extubation, lidocaine, intraoccular pressure, intracranial pressure, intragastric pressure,
airway reflex
Efficacy of EMLA and Placebo Cream in Reducing Pain During Extra-corporeal Piezoelectric Shock Wave Lithotripsy
Koompong P, M.D.,* Tritrakarn T, M.D.,* Soontarapa S, M.D.,** Somprakit P, M.D.*
* Department of Anesthesiology, ** Department of Surgery, Faculty of Medicine, Siriraj Hospital, Bangkok 10700
Background : The objectives were to study whether EMLA or placebo cream could reduce pain during extracorporeal piezoelectric shock wave lithotripsy (EPSWL) using the Piezolith 2300 and to determine which of the components of the application i.e. the occlusive dressing, the cream or the local anesthetics reduced pain.
Methods : Two hundred and two ambulatory patients, 125 males and 77 females, ASA I and II subjected to EPSWL were randomly allocated into 5 groups to receive (A) nothing on the skin (control), (B) plastic occlusive dressing, (C) placebo cream and plastic occlusive dressing, (D) EMLA cream and plastic occlusive dressing which were left immersed under water throughout the procedure, (E) EMLA cream and plastic occlusive dressing for 60 min to achieve cutaneous anesthesia and removed before EPSWL.
Results : Patients in the group the had either placebo (group C) or EMLA cream (group D) under occlusive dressing had less pain than patients in the control group while those who had only plastic occlusive dressing or cutaneous anesthesia (EMLA cream dressing removed before EPSWL) had no difference in pain score from the control group.
Discussion : EMLA or placebo cream under an occlusive dressing on the skin at the area of the entry of the shock wave and left immersed in water throughout the procedure behaved as a coupling medium facilitating transmission of the shock wave through skin, reducing energy reflection and absorption and hence reducing skin trauma and pain. This procedure provides a simple, safe and economical method of pain relief for patients subjected to EPSWL without causing any side effect.
Time Required for Artificial CSF to Flow Through Commonly Used Spinal Needles In Thailand in Various Pressures
Duangrat T, M.D.,* Somprakit P, M.D., M.Sc., Diploma Thai Board in Anesthesiology, D.A. (U.K.), F.R.C.A.,** Ratanathaworn S, M.D.,* Sanansil V, M.D., Diploma Thai Board in Anesthesiology*
* Department of Anesthesiology
** Department of Anesthesiology and Clinical Epidemiology Unit, Faculty of Medicine, Sirisaj Hospital, Mahidol University, Bangkok 10700
The standard size of spinal needle is determined by the external diameter, but the important quality, the flow through it, is related to the internal diameter. Twelve needles for each 6 types of 25G spinal needles available in Thailand, namely Pencan (B. Braun), Pencil point (Portex), Whitacre (B-D), Spinocan (B. Braun), Quinke (B-D) and Terumo, were studied using randomized crossover design at 4 different pressure levels. Times required for appearance and drop of artificial CSF were compared among them. We found that the time required for appearance and to drop of CSF were significant different among different levels of pressure and also among different types of spinal needle. The times required for appearance and to drop of CSF may markedly vary especially at the low CSF pressure 9 (from 1.86 to 4.46 seconds and from 50.86 to 162.14 seconds respectively). This means that we should wait for a proper time for different types of spinal needle to judge that the spinal needle is not in a proper position.
Efficiency of Warm Air Blower Via Home-made Blanket Compared with Standard Blanket
Petcharatana S, B.N.,* Manon C, B.N.,* Santawat U, M.D.*
* Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700
Background and objective : Warm air blower is effective in prevention and treatment of postoperative hypothermia. This study aimed to evaluate the efficiency of home-made blanket compared with standard blanket.
Study design : Prospective, randomized, controlled trial.
Method : Sixty adult patients underwent orthopedic and eye surgery were studied in postanesthetic care unit. They were randomly allocated into 2 groups, receiving home-made blanket and standard blanket. Room temperature, temperature of air blower, body temperature, temparature under blanket 3 sites (trunk, arm and leg 0 were recorded at 0, 30, 60, 90, 120 minutes. Patients' satisfication, blanket damage and hazard from blanket were also evaluated.
Result : Both groups were comparable in sex, age, weight, type and duration of surgery, choice of anesthesia, blood loss, blood and fluid replacement. Tenperature increased from T0 min to T120 min were not different in both groups. No hazard occurred from either kind of blanket. Incidence of blanket damage and patients' satisfication were similar in both groups.
Conclusion : Home-made blanket in as effective as standard blanket with lower cost.
Survey of Y2K Problem (Millenium Bug) in Department
of Anesthesiology at King Chulalongkorn Memorial University
Saotongthong J. M.D.,* Somboonviboon W, M.D.,** Charulaxananan , M.D.,** Sookvivat K, Cert. (Nursing)*
* Department of Anesthesiology, King Chulalongkorn Memorial Hosptial , Thai Red Cross Society
** Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, Rama IV Rd., Bangkok 10330
Y2K problem or Millenium bug is an important problem among industrialized and developing countries around the world especially in communication, financial, infrastructure systems and also health care industry. Thai government realized the consequences of the millenium bug which may happen and appointed the national Electronics and Computer Technology Centre (NECTEC) and the National Science and Technology Development Agency (NSTDA) to organize both government and private sectors to survey for solving the Y2K problem.
Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University and King Chula-longkorn Memorial Hospital, Thai Red Cross Society promoted awareness about Y2K problem among colleaguess awareness about Y2K problem among colleagues and surveyed the medical equipment for anesthesia services critical care and pain service. Selection options for testing Year 2000 Compliance included : Roll over to year 2000, power "on" ; roll over to year 2000, power "off", leap year test and test for 9/9/1999. Failure to pass any option was considered "Year 2000 noncompliance" and was further evaluated for impact on patient. Among 67 anesthesia machines, 165 monitoring equipment, 47 syringe or infusion pumps, 61 ventilators and 6 warmers : 26 97.51 % of a total 346 medical equipment) were considered as "Year 2000 noncompliance", only date or time errors without impact on patient. All other 14 patient-controlled analgesia equipments passed the year 2000 compliance.
In conclusion, only 7.51 % of medical equipment, all were monitoring, could not pass Year 2000 compliance test with no impact on patient service.
However contingence planning should be established for safety of patients during the period.
Key word : Y2K, Millenium bug, year 2000, equipment, safety
Selecting Double-Lumen Tube Size by Tracheal Diameter
Techanivate A, M.D.,* Surapong K, M.D.,* Thanachartwet P, M.D.*
* Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330
Sixty patients undergoing thoracic operation were intubated with left double-lumen tube (Malline-krodt left bronchocath endobronchial tube). Size of double-lumen tube was selected by measurement of treacheal diameter on PA chest X-ray film. If tracheal diameter was < 15.5 mm, a double-lumen tube 35 Fr was used. A 37 Fr and 39 Fr double-lumen tube were used in the case with tracheal diameter were 15.5-16.5 and > 16.5 mm respectively. The mean tracheal diameter for men was 16.9 mm and 14.7 mm for women. The data showed statistically significant (p < 0.001) between tracheal diameter and height in both sex. The simple linear regression analysis is applied to determine the predictable relationship. All intubations were successful with standard technique. The position of double-lumen tube was checked by fiberoptic bronchoscopy, 16 cases (26.7 %) required position adjustment (0.5-2 cm up or down). The selected lung was completely collapsed during one lung ventilation. No episode of hypoxemia or high peak airway pressure were noticed. Fiberoptic bronchoscopy immediately after extubation was done and found no serious trauma at vocal cord or bronchus.
We concluded that direct measurement of tracheal diameter from PA chest X-ray can be used to determine the size of double-lumen tube.
Intraarticula Bupivacaine and Bupivacaine Plus Morphine for Postoperative Arthroscopic Knee Surgery Analgesia
Chaiyaphruk S, M.D.,* Hintong gT, M.D.,* Padungkiat S, M.D.,** Kaokulbutskul U, M.D.,* Choomjai S, B.N.*
* Department of Anesthesiology, ** Department of Orthopedics, Faculty of Medicine, Chiangmai University, Chaingmai 50200.
A randomised, double-blind controlled in patients undergoing elective knee arthroscopy to assess the analgesic effect of intraarticular bupivacaine alone and in combination with morphine. Group I (n = 30) received 50 cc of NSS, group II (n = 30) received 50 cc of 0.2 % bupivacaine with adrenaline and group III (n = 30) received a combination of 2 mg of morphine. All drugs were injected intraarticularly. Postoperative pain was assessed by using the visual analogue scale at 0, 2, 4, 8, 12, 16, 20, 24 hr after the intraarticular injection. The need for supplement analgesia was recorded. Results showed that there was no significant difference in the pain scores or analgesic requirements between group II and III. Patients in group II and III had significantly lower pain scores than those in group I. The low pain scores were associated with lower requirements of supplementary analgesics. We conclude that intraarticular bupivacaine alone and in combination with morphine significantly reduces postoperative pain following knee arthroscopy and that there is no advantage of combining bupivacaine with morphine.
Key words : Analgesics : opioid, morphine.
Anesthetics : local bupivacaine.
Pain : postoperative.
Receptors : opioid.
Surgery : arthroscopy.
Volume 25;Number 3:1999:July-September 1999
Cuffed oropharyngeal airway in anesthetized patients at Maharaj Nakorn Chiang Mai Hospital: A preliminary report.
Kaokulbutskul U, M.D.,* Punjasawadwong Y, M.D.,* Phongchlewboon A, M.D.,* Logessathien P, M.D.,* Saringcarinkul C, M.D.,* Sasisoontorn C, B.Sc. (Nursing and Midwisery)*
* Department of Anesthesiology, Faculty of Medicine, Chiangmai University, Chiangmai 50200
The cuffed oropharyngeal airway (COPA) was first described by Greenberg and Toung in 1992 as a potential airway during anesthesia in spontaneous breathing pateints. To determine the ease and the problems of its use in anesthetized Thai patients, the study was conducted in twenty eight patients undergoing minor surgery under general anesthesia with the cuffed oropharyngeal aiway for spontaneous breathing at MaharaJ Nakorn Chiangmai Hospital.
After induction , the first and second attempts in successful insertion of the cuffed oropharyngeal airway were noted in 23 (82.1%) and 4 (14.28%) patients respectively. The conditions for the airway insertion were good to excellent and satisfactory in 20 (71.4%) and 7 (25.0%) patients respectively. Brief airway manipulations during the maintenance of anesthesia, i.e. chin lift, head tilt and jaw thrust were recorded in 8 (28.5%), 3 (10.71%) and 1 (3.5%) patients respectively. The frequencies of airway obstruction, mild stridor and cardiac arrhythmia were observed in 4, 2 and 1 patients respectively. However, these incidents were successfully managed by airway manipulations and deepening anesthesia. The frequencies of postoperative sore throat, jaw-ache, sore tongue and vomiting were recorded in 2,1,1 and 2 patients respectively.
The result from this initial report has supported the use of cuffed oropharyngeal airway as alternative in airway management during anesthesia in spontaneous breathing patients. However, further studies are still required to determine its efficiency inthe other circumstances.
Key words: anesthesia, cuffed oropharyngeal airway
Low-dose Versus Standard-dose Droperidol for Prevention of Postoperative Nausea-vomiting and Sedation Effect
Tribuddharat S, M.D.,* Karun S, M.D.,* Kingsangwan P, B.Sc.*
* Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, Khon
Kaen 40002
Nausea-vomiting is one of the complications which we should be aware of after the operation. Some antiemetic drugs can be given to ameliorate that condition but their side effects make the patients drowsy simultaneously. This study was conducted to reduced nausea-vomiting symptom and to compare the sedative effects in particular. With double-blinded study, forty ASA class I-II patients were evenly divided into 2 groups. The first group received droperidol 50-70 mg/kg IV and diazepam 0.1-0.2 mg/kg IV as premedications. For the second group, the patients were given droperidol 10 mg/kg IV as antiemetic drug at the last 15 minutes before the end of the operation. Blood pressure, heart rate, oxygen saturation were recorded at control, after premedication, after intubation (during operation) and in the recovery room at the period of 0, 15, 30, 60, 90 minutes respectively. The degree of nausea-vomiting and conscious sedation were determined in the recovery room at the same intervals.
It was found that only the systolic and diastolic blood pressure of the first group (p<0.05). For the other parameters, there were no statistically singificant difference. Moreover, droperidol 10 mg/kg IV is as effective as droperidol 50-70 mg/kg IV in preventing nausea-vomiting in postoperative period. Higher doses of droperidol may sedate some patients, however, there were no statistically significant difference with regard to the length of recovery room stay in this study.Key words : PONV, neuroleptic agent, sedation, droperidol.
Synergism of Atracurium and Vecuronium in Clinical Practice
Wasinwong W, M.D.,* Vasinanukorn M, M.D.*
* Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University,
Songkhla 90110
Introduction: A synergism exists between the combination of non-depolarizing muscle relaxants with different molecular structures i.e. steroidal and benzylisoquinolinium. Smaller amount of each drug can be used, thus lower the side effects which could happen when administered alone in higher dose.
Objectives : To compare the onset, duration and hemodynamic changes including the duration of additional incremental doses of atracurium, vecuronium when given as a single agent or in combination.
Methods : Eighty-nine ASA class I or II patients, aged 18-80 years, scheduled for elective abdominal surgery. They were randomly assigned to one of the three groups. All received same type of anesthetics consisting of 10 mg of diazepam orally as premedication and they were induced with morphine-thiopental. Group A (Atracurium group, n = 30) was given atracurium 0.6 mg/kg, group V (Vecuronium, n = 30) received vecuronium 0.15 mg/kg and group C (Combined, n = 29) received vecuronium 0.05 mg/kg and atracurium 0.2 mg/kg. Anesthesia was maintained with N2O in O2 and additional morphine 1-2 mg. as needed. Neuromuscular blockade response was monitored by adductor pollicis acceleromyography. The speed of onset of neuromuscular blockade was determined when a TOF response = 0. Additional muscle relaxant equals to ? pf the omotoa; dpse was given when TOF response = 2 or T1 recovery twitch height was > 10% which will determine the duration of initial and additional doses. Noninvasive blood pressure, pulse oximetry, capnography, electrocardiography and core temperature were monitored.
Results : There were no statistical differences in demographic data, baseline blood pressure and heart rate of the patients. The onset time was significanthy longer in group C compared with group A and V (group C = 270.48 + 67.43 sec, group A = 213.13 + 61.38 sec, group V = 183.40 + 54.49 sec). The duration of initial bolus dose was comparable between group A and C (36.11 + 9.21) min for group A and 34.78 + 9.56 min for group C) but significantly shorter than group V (43.98 + 12.12 min). The duration of the incremental dose was significantly longer (p < 0.05) in group C and V when compared with group A (group C = 18.51 + 6.21 min, group V = 18.55+4.57 min, group A = 14.46 + 3.38 min).
There were no differences in the changes of heart rate, systolic and diastolic blood pressure after intubation in all 3 groups. The heart rate at 2, 3 and 5 minutes after injection (before intubation) was slower in group C compared with group A while group V had slower heart rate than group A only at 3 minutes after injection.
Conclusion : The combination of atracurium and vecuronium in the equipotent dose ratio of 4:1 for intubation, using 1/3 of intubating dose of each drug, has no benefit over using the full intubating dose of single drug in term of time course and hemodynmic change. A significant longer onset was also noted.
Key words: atracurium, vecuronium, synergism, combination
The Comparative Study of the Quality Anesthesia in the Chiangrai Regional Hospital from the Hospital Accreditation Project.
Jitpreecharn N, M.D.,* Daovijit J, B.N.,* Wandee S, B.N.,* Thuvkhum K, B.N.,* Jongpairojkosit Y, B.N.,* Supamanee S, B.N.,* Chompootawheep D, B.N.*
* Department of Anesthesiology, Chiangrai Regional Hospital Chiangrai 57000
This is a prospective study of the postanesthetic complications and the satisfaction of the patients who did not have any complicated condition before the operation before and after the process for The Hospital Accreditation of the Department from February 1997 to January 1998 and from February 1998 to January 1999.
These results may be used as indicator of the quality of the anesthesia services and may lead to the improvement in the quality of care, further plans and managements.
Key words: Anesthesia, awareness, hospital accreditation, PDPH, post-op complication quality improvement, sorethroat
Tracheal Intubation Time Without Muscle Relaxant : Using Inspired Concentration of 4% and 8% Sevoflurane in Paediatric Patients
Phophichitra C, M.D.,* Saratunti P, M.D.,* Sirinan C, M.D.,* Ittichaikulthol W, M.D.,* Pausawasdi S, M.D.*
* Department of Anesthesiology, Faculty of Medicine, Ramathibodi hospital, Mahidol University, Bangkok 10400
Tracheal intubation can be done in paediatric patients after induction of anesthesia with sevoflurane without muscle relaxant. Forty ASA physical status I-II patients, aged 1-10 yr and weitht 10-25 kg scheduled for surgery under general anesthesia in Ramathibodi hospital were randomly assigned into two groups using 4% sevoflurane (group 1) and 8% sevoflurane (group 2). After gas induction, tracheal intubation was attempted without muscle relaxant. The intubation time (from loss of eyelash reflex to intubation) was predetermined by the up-and-down method (with 30 seconds as a step size) for each patient and started at 4 minutes for the first patient in each group.
Intubation time in 4% sevoflurane group (2.98 + 0.42 minutes) is significantly different from 8% sevoflurane group (1.34 + 0.49 minutes). There were no significant hemodynamic change and desaturation in both groups.
We conclude that tracheal intubation can be performed faster with 8% sevoflurane in N2O/O2 than 4% sevoflurane in N2O/O2 without adverse hemodynamic effect.
Equipment to Spray Fibrin Glue "Rama Spray Connecting Tube"
Popichit C, M.D.*
* Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital, Bangkok 10400
The fibrin glus which is prepared from blood components has benefits in many operations such as neurosurgery, cardiac surgery, hepatic surgery, orthopedic surgery, plastic surgery and dental procedures. It can control local microvascular bleeding and decrease requirement of blood transfusion. The production and utilization of fibrin glue in Thailand are developed by Bangkok International Hemophilia Training Center (IHTC) with supporting from World Federation of Hemophilia and Israel government. However the equipment to spray fibrin glue still has many problems. The inventor develops a simple equipment, Rama Spray Connecting Tube, to solve the problems and support the usage of fibrin glue.
Combined Spinal Epidural Anesthesia Versus Spinal Anesthesia for Cesarean Section; Effect on Maternal Hypotension, a Randomized, Double Blind Controlled Trial
Neti T, M.D.,* Visalyaputra S, M.D.,* Pechpaisit N, M.D.,* Upatinkat K, M.D., Nakkuntod A, M.D.,* Chamadol S, B.Sc.,* Sakulpacharoen N, B.Sc.,*
* Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Bangkok
10700
This study was designed to compare the effect of combined spinal epidural anesthesia (CSEA) and spinal anesthesia on the incidence and severity of hypotension of patients undergone cesarean section. Sixty term parturients, ASA class I-II were randomley divided into two groups. Regional anesthesia was performed in right lateral, horizontal plane position. In Group 1, spinal group, 2.0-2.5 ml. of 0.5% hyperbaric bupivacaine was given intrathecally. In Group 2, CSE group, 1.5-2.0 ml of 0.5% hyperbaric bupivacaine was given intrathecally and epidural lidocaine would be added if analgesic level was lower than T4 at 15 minutes after intrathecal injection or inadequate analgesia occurred during surgery. There were no significant differences in the incidence and severity of maternal hypotension, ephedrine requirement, maximal cephalad level of analgesia and analgesic level at 15 minutes after intrathecal injection between the two groups. CSEA in right lateral, horizontal plane position has no advantages in term of maternal hypotension during cesarean section as compared to spinal anesthesia.
A Randomised, Open-label, Parallel Group Study Comparing the Efficacy and Safety of Kapanol Administered Every 12 Hours to 24 Hours in Patients with Moderate to Severe Cancer Pain
Leelanuntakit S, M.D.*
Pain Clinic, National Cancer Institute, Department of Medical Services, Ministry
of Public Health, Bangkok
A randomised, open-label parallel group study comparing the efficacy and safety of Kapanol capsules administered every 12 hours to every 24 hours to patients with moderate to severe cancer related pain. Thirty advanced or terminal stage cancer patients with life expectancy of more than 8 weeks, aged 18 years old or over who were inpatients at pain clinic service and requiring oral morphine for analgesia were recruited. They were converted to receive Kapanol capsules for the Lead-in Period for 3-14 days with rescue medication not more than 2 dosages per day and maintained at a constant dosage for at least 3 days. Fifteen patients were randomised into group A for Kapanol capsules every 24 hours regimen and the rest into group B for Kapanol capsules every 12 hours regimen as the Treatment period for 7 days. Immediate release morphine solution was availabel as rescue medication for breakthrough or incidental pain. One patient in Group A dropped out before completing the study due to the knowledge of his poor prognosis. Eventhough the disease in these patients were advanced and had metastasized to vital organs, there were only four patients in these two study groups with elevation of liver function tests and all were due to the disease process. The vital signs of both study groups on the day before the Lead-in Peroid and on the day after the Treatment Period were not significantly different. Patients's pain assessments by using visual analogue scale were not significantly different during both regiments. The quality of life and the Karnofsky scales were similar at the time before the Lead-in Period, during the Lead-in Period and in both regimens. No serious adverse effects such as depressed respiration and hypotension were seen during the study phases. "Rescue Immediate Release Morphine Solution" was used in 12 patients, six in each group and all for incidental pain. The efficacy on pain control was evaluated by suing the patients' pain assessment score and this was not different statistically. The patient's assessment about the efficacy on pain control was more than 80% in the good and very good levels for both groups. There were no statistically different patient preferences for previous morphine regimens, Kapanol capsules every 24 hours regimen seemed to be more advantageous. In the investigator's opinion, Kapanol capsules in more convenient for use in tube feeding in cancer patients, as the capsules can be detached and the pellets released into the feeding tube.
Translaryngeal Intubation Technique
Chau-in W, M.D.,* Tribuddharat S, M.D.*
* Department of Anesthesiology, Faculty of medicine, Srinagarind Hospital, Khonkaen University, Khonkaen 40002
In the course of anesthetizing a patient for surgery, we occasionally encounter some patients whom we are unable to intubate. After initial attempt has failed, the anesthesiologist must try the proper alternative techniques. Major challenges facing the anesthesiologist include securing the airway and maintaining adequate ventilation and oxygenation of the lungs. This report demonstrates the successful of transtracheal intubation after failed fiberoptic intubation. The 29 year-old Thai female with fracture of mandible was scheduled for open reduction internal fixation with miniplate under general anesthesia. The patient had limited temporomandibular joint movement due to posttraumatic injury. The attempts for awake fiberoptic intubation were failed, then translaryngeal (retrograde) intubation was performed. Cricothyroid membrane was punctured by intravenous (IV) catheter under local anesthesia. The retrograde guide wire was passed cephaladly through the larynx to the nasopharynx. The nasotracheal tube was passed over the guide wire and was pulled down through the laryngeal inlet into the trachea. The intravenous (IV) catheter was removed. After checking for the proper position of the nasotracheal tube, the balanced anesthesia was started with N2O : O2 = 70 : 30, sedative, narcotics and muscle relaxant. The nasotracheal tube was removed without any serious com;oication except postoperative nausea and vomiting. No serious complication could be related to this technique, however, it is easy and safety. Moreover, this technique is an efficacious method for difficult tracheal intubation.
Massive Blood Transfusion following Accidental Pulmonary Artery Tear
Singthong T, M.D.*
* Department of Anesthesiology, Maharat Nakhon Ratchasima Hospital, Nakhon Ratchasima 30000
A 39-years old man with right lung mass, was planned for pneumonectomy. During operation, serious problem due to massive bleeding from accidental tear of pulmonary artery occurred. It extended into pericardial cavity and cardiac tamponade was a following complication. This complication needed immediate diagnosis and prompt treatment, otherwise the patient could not be saved and turned to his normal life.
Inadvertent Brain Stem Anesthesia Following a Retrobulbar Block : A Case Report Santawat U, M.D., M.Sc.,* Sawadiviphachai P, M.D.*
* Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700
According to the advanced age of the population and the shift to ambulatory surgery, regional anesthesia is the most anesthetic technique of choice used for outpatient cataract surgery. To stress the potentially life-threatening complication after retrobulbar blocks, we reported a case, Thai male 62 years old scheduled for lens extraction of the left eye under retrobular block with 0.5% bupivacaine 1.5 cc plus 2% lidocaine 1.5 cc. Twenty minutes after block, he presental with slurred speech, numbness of his tongue and difficult breathing. After assessment of the patient's consciousness, oxygenation, ventilation and circulation, he received O2 mask with bag 6 1/min, intravenous cannulation with Ringer Lactate Solution, ephedrine 6 mg intravenously and close monitoring. Neurological examination showed paralysis of CN XII, IX, contralateral opthalmoplegia, ptosis and blindness. The diagnosis was inadvertent brain stem anesthesia. The surgery was cancelled. He was fully recovered within hours after block.
Awareness and recognition of this complication is important for all personnel involved. All equipment and prompt treatment should be available whenever a retrobulbar nerve block is done.
Volume 25;Number 2:1999:April-June 1999
The Effect of Clonidine Premedication and Isoflurane Requirement in Laparoscopic Cholecystectomy Patients
Sriswasdi S, M.D.,* Viengteerawat S, M.D.,* Kongtam S, M.D.* Vittayarojwong M, R.N.*
* Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital, Bangkok 10400.
Sixty patients scheduled for elective laparoscopic cholecystectomy under general anesthesia were randomized into 2 groups. Group I received clonidine 5 *g/kg and group II received midazolam 0.15 mg/kg orally as premedicated drug, 90-120 minutes prior to induction. Anesthesia was induced by thiopental 3-4 mg/kg. Vecuronium 0.1 mg/kg was given to facilitate endotracheal intubation. Maintenance of anesthesia was isoflurane with N2O/O2* The blood pressure and heart rate were kept within *20% of baseline level. The concentration of isoflurane used were recorded at 5,10,15,20,25 and 30 minutes after induction. The results showed that the isoflurane requirement and postoperative sedation score in group I (clonidine group) were significant less than group II (midazolam group) (p<0.002 and <0.004 respectively)
We conclude that clonidine reduced the requirement of anesthetic agent by an inhibitory action central nervous system, and locus coeruleus in the brain stem. It also provided better cardiovascular control of blood pressure by decreasing sympathetic outflow and reset baroreceptor reflexes.
Intrathecal Morphine for Postoperative Pain Control in Patients Undergoing Transurethral Resection of the Prostate Gland
Srichintai P, M.D.,* Pukrittayakamee P, M.D.,* Wacharasinthu J, M.D.,* Suratanasanya T, M.D.,*
Krataitong V, B.Sc.*
* Department of Anesthesiology, Faculty of Medicine, Ramathibidi Hospital, Mahidol University Bangkok
10400.
Analgesic effect of low does intrathecal morphine was evaluated in thirty patients underwent transurethral resection of the prostate gland. By prospective randomized double blind control study, each group of ten patients received either placebo (control) or intrathecal morphine 0.1 or 0.5 mg with bupivacaine spinal anesthesia. Visual Analogue Scale and side effects were evaluated at approximately 6, 24, 36 and 48 hr after intrathecal injection. The results showed that patients received intrathecal morphine had significantly lower Visual Analogue Scale comparing to the control group at 6 and 24 hr after intrathecal injection (p<0.05). There was no significant difference in antianalgesic effect (VAS) between patients received 0.1 and 0.15 mg morphine at 6 and 24 hr after intrathecal injection. No significant difference in incidence of pruritus, nausea, vomiting and sedation between the control and treatment groups. None of the patient in all groups developed respiratory depression. The result indicates that 0.1 mg of intrathecal morphine is the optimal does for postoperative pain relief for transurethral prostatectomy.
Prolongation of Bupivacaine Spinal Anesthesia by Oral Clonidine
Ittichaikulthol W, M.D.,* Laowayanont K, M.D.,*
* Department of Anesthesiology, Faculty of Medicine, Ramathibidi Hospital, Mahidol University Bangkok
10400
We studied the effect of oral clonidine on the duration of bupivacaine spinal anesthesia. Forty ASA I-II, aged 15-50 year patients undergoing lower extremities surgery were studied by prospective randomized, double blind, placebo-controlled method. The patients were divided into two groups. All patients received intravenous acetar 8 ml/kg before spinal anesthesia with 2.5 ml of 0.5% heavy bupivacaine. One hour before anesthesia group I (n=20) received placebo ; group II (n=20) received 0.15 mg of oral clonidine.
The times for two segment regression were 78.29 * 3.65 and 104.08 * 2.62 min in group 1 and 2, respectively. The times for four segment regression were 117.75 * 8.81 and 158.25 * 7.66 in group 1 and 2, respectively. All the regression times in group 2 were significantly longer than those in group 1 (p<0.001). The times to maximal level of sensory blockade in group 1 were 15.25 * 2.55 and was not different in group 2, 13.75 * 3.58 min. The number of patients requiring aramine and atropine were similar in both groups.
We conclude the 0.15 mg of oral clonidine prolongs the duration of sensory blockade of spinal anesthesia with 2.5 ml of 0.5% heavy bupivacaine about 30% but does shorten the onset time and has no different effect of the hemodynamic when compare to the control group.
Simple Coaxial Pediatric or Mini-Bain's Circuit : Construction and Clinical Use
Theerapongpakdee S, M.D.,* Chau-In W, M.D.,* Tantanatewin W, B.Sc.,*
* Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002.
The construction of coaxial pediatric or mini-Bain's circuit or coaxial Mapleson F was described using the disposable materials in the operating theatre. This circuit has the advantage of lightness, flexibility and low price. The construction can be easily followed utilizing simple tools. The clinical study in 11 pediatric patients was reported. The mean * SD of age and weight were 6.1 * 1.5 years old and 16.1 * 4.3 kg respectively. The study was done in the mode of controlled respiration using Mark 7 or Mark 8-Bird ventilator, where as the mean SD value of airway pressure and respiratory rate were 18.5 * 2.2 cm H2O and 28 * 5 bpm respectively. The capillary blood gases were studied and the mean * SD values were as follow : pH 7.422 * 0.030, PCO2 34.3 * 4.0 mmHg, and PO2 172.3 * 37.7 mmHg. No complication was noted in this preliminary report.
Keyword : Circuit ; coaxial pediatric, Bain's
Apparatus ; pediatric breathing system.
EAR & Bain Circuit : A Comparison of CO2 Elimination in Controlled Ventilation Mode of General Anesthesia by Capnographic Method.
Ratanasuwan P, M.D.,* Theerapongpakdee S, M.D.,*
* Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002
We have compared the EAR and the Bain circuit on CO2 elimination in 20 general anesthetized patients in controlled ventilation mode by capnographic method at FGF 70 and 100 ml/kg/min. All patients are ASA class 1-2, the ratio of male to female = 3:17. The average * SD value of age, weight, hemoglobin and hematocrit are 41.15 * 11.45 years, 54.18 * 7.16 kg, 12.38 * 1.62 g/dl and 37.15 * 5.18% respectively. There are significant statistical differences between both FICO2 and FECO2 of EAR and Bain circuit at 70 and 100 ml/kg/min respectively with the EAR value lower than the Bain circuit. However all value of CO2 are within normal clinical range.
Keyword : Anesthetic equipment, breathing system, circuit, EAR, Bain.
Second Thoracic Sympathetic Block : A Management of Upper Extremity Pain
Boonsong P, M.D.,* Wisading W, M.D.,* Khunsongkiet P, M.D.,*
* Department of Anesthesilogy, Faculty of Medicine, Chiangmai University, Chiangmai 50200
The pain management of upper extremities is normally used the technique of Stellate ganglion block which has short duration. So repeated Stellate ganglion block may required when prolonged block is needed. To prevent this situation, many schools have introduced the thoracoscopic sympathectomy technique instead of multiple block technique. It is a very good pain relief method but it is more invasive and expensive. The patient has to admitted and the procedure has to prefer under general anesthesia. Our study, found that the percutaneous second thoracic sympathetic ganglion block by using neurolytic agents via fluoroscopy is a good technique, can be done at the out patient clinic, less complications, and in expensive. We performed this technique in 59 patients, 14 cases suffering from vascular pain and 45 cases suffering form neural pain. The pain relief score were noted as good or excellent in 71.19% with mean duration 94.02 * 111.08 days. Vascular pain relief was much more effective than neural pain relief cancer and cancer origin respectively.
Keywords : Second thoracic sympathetic block, upper extremities pain.
Life-Threatening Hazards of Anesthesia Equipment
Soontranon P, M.D.,* Koompong P, M.D.,* Pittimana-aree S, M.D.,* Raksakietisak M, M.D.,*
Svastdi-Xuto O, B.N.*
* Department of Anesthesiology, Siriraj Hospital, Mahidol University, Bangkok 10700.
Life-threatening hazard of anesthesia equipment is defined as any incident occurred from defective equipment or related technique that severely effects patients' vitality if is not properly corrected in time. This prospective study was done by collecting hazards which were reported to The Equipment Committee of Department of Anesthesiology. Five incidents had been reported consecutively during 3-year period which involved 13 patients and resulted in 1 death. These incidents were 1) Intentionally shut off zone valve of O2 pipeline without previous notification which deprived O2 supply of 2 intensive care units. The pressure regulator of O2 reserved manifold was also out of order. There critically-ill patients suffered cyanosis. 2) Three out of 6 N2O cylinders installed to the manifold were incorrectly filled with CO2, resulted in clinical manifestations of severe hypercarbia. At least 5 patients undergone general anesthesia were insulted. 3) The O2 and N2O connectors were cross-connected. Neither post-installation nor preuse check up was done. One patient developed severely cyanosis after induction of general anesthesia. 4) Defective part inside halothane vaporizer caused the output concentration much higher than the dial setting. One patient got marked hypotension during anesthesia. 5) Liquid halothane remained outside the vaporizing chamber of the vaporizers which caused very high concentration of vapor. Three patients undergone general anesthesia developed dysrhythmia and severe hypotension. Comparing to our previous report with minor effects on the patients in 1995, the contributing factors were the same, e.g. lack of knowledge, ignorance and no maintenance. The only difference was detection after insulting the patients. We conclude that close monitoring, early detection and properly decision making can prevent and alleviate outcome severity of the hazard of equipment. We encourage all personnel to practice with good quality of care whenever dealing with anesthesia equipment.
Keywords : Anesthesia, equipment, hazard, safety.
The comparison Between Intrathecal Hyperbaric and Isobaric Bupivacaine in Combined Spinal-epidural Technique for Cesarean Section.
Amornyotin S, M.D.,* Thepchatri C, M.D.,* Visalyputra S, M.D.,* Sakulpachareon N, B.N.*
* Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700.
** Saint's Mary Hospital, Nakhornratchasima 30000.
The combined spinal-epidural (CSE) technique for cesarean section was investigated by comparing between intrathecal hyperbaric and isobaric bupivaciane. Sixty patients, ASA I-II, undergoing for Cesarean section were randomly assigned to receive 0.5% hyperbaric bupivacaine (group II). Both groups received 2% lidocaine with adrenaline 1 : 400,000 via epidural space in the same does. Level and efficacy of blockage, satisfaction of patients, muscle relaxation and side effects were observed. The result showed both hyperbaric and isobaric bupivacaine were good for CSE for cesarean section and there was no statistically significant difference between the two groups.
Recovery from Isoflurane Anesthesia ; A Comparison with Halothane
Samattashai S, M.D.,* Lertakyamanee J, M.D.,** Sakulpacharoen N, B.Sc.** Chevawattana S, M.D.,** Chatpom S, M.D.**
* Department of Anesthesia, Bhummipol Hospital, Bangkok 10210.
**Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700.
This was a randomized double blind clinical trial. The aims of this study were : 1) To compare the recovery time assessed by clinical observation, the Ball Bearing Test (BBT) and the Digit Symbol Substitution Test (DSST) between isoflurane and halothane anesthesia. 2) To compare the side effects of isoflurane anesthesia with halothane anesthesia. Sixty-four female patients were randomly assigned to halothane or isoflurane group. The mean ages of 32.3 * 6.5 and 35.1 * 5.8 years for halothane and isoflurane groups respectively. All of than underwent elective gynecologic diagnostic laparoscopy and anesthesia times were 45.4 * 29.5 and 31.8 * 13.8 minutes for halothane and isoflurane groups respectively. Recovery was assessed by the time to extubation, orientation, response to verbal command, sit up, stand up, walk and success in obtaining the baseline performance of the BBT and DSST. The observer was blinded to the anesthetic technique that the patients received. Recovery tests showed no difference between the two group except the time to stand up and walk. The recovery times assessed by BBT and DSST were 87.2 * 29.8 and 77.8 * 35.6 minutes for halothane and isoflurane group respectively. From questionnaire, both halothane and isoflurane group showed no difference in incidence of side effects and satisfaction of patients. However, isoflurane is more costly compared to halothane.
Combined Cervical Plexus Block and General Anesthesia for Carotid Endarterectomy
Akavipat P, M.D.,*
* Department of Anesthesia, Prasat Neurological Institute, Bangkok 10400.
A case report of an old man who suffered from left retinal arterial embolism. The investigation showed severe left carotid stenosis. The treatment was carotid endarterectomy under combined cervical plexus block and general anesthesia. The result was good without any complication. The blockade technique and brain protection technique were also discussed.
Phrenic Nerve Paralysis Following Brachial Plexus Anesthesia : Case Report
Tratornpisudhikul V, M.D.,*
* Department of Anesthesiology, Sawanpracharak Hospital, Nakornsawan 60000.
Two case reports of upper extremity surgery under brachial plexus anesthesia (parascalene technique) who developed the signs and symptoms of phrenic nerve paralysis which were confirmed by chest radiography. They were treated by symptomatic treatments. The signs and symptoms of phrenic nerve paralysis were relived within one hour. The literatures and articles were review to be a guideline management of this complication.
Keywords : Parascalene block, phrenic nerve paralysis, diaphragmatic paralysis.
Volume 25;Number 1:1999:January-March 1999
Factors Affecting Distress at Induction of Anesthesia in Children
Kongsayreepong S, M.D.,* Suraseranivongse S, M.D.* Gunreka
P, B.Sc. Nursing* Montapaneewat T, Dip. Nursing,* Manon J,
B.Sc. Nursing*
*Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital,
Mahidol University, Bangkok 10700.
This prospective study was designed to determine factors that could affect the distress behavior during induction of anesthesia in children. Two hundred and two ambulatory children, age 1-8 years old, ASA class I-II, without premedication were randomly allocated to a parent pressent and parent absent group. A modified behavioral scoring system using five markers of anxiety score was used to assess the child's behavior before induction and response during inhalation induction. Score 1 and 2 were determined as failure. Children's factors were recorded age, sex, sequence of birth, behavioral before induction, knowing about surgery, previous history of anesthesia and/or surgery. Parents' factors were recorded as education, marrital status, income and anxiety. The behavior of children during induction were analysed by multivariable analysis with Backward Logistic Regression. It was found that factors influencing distress behavior included age under 4 years old (p.0006) parent absence (p.0497), poor preoperative behavior (p.0065) and previous experience of surgery and anesthesia (p < 0.0001). The most important factors were preoperative mood or behavior and previous experience of surgery and anesthesia with odd ratio (95% CI) : 10.99 (2.78 to 43.46) and 4.07 (1.38 to 12.33) respectively. More care or plan such as parental accompanying to the theatre or play room to distract anxiety should be considered when these children come for anesthesia.
Technology Assessment of Anesthesia Delivery System : I. Manpower, Knowledge and Care*
Lertakyamanee J, F.R.C.A., M.P.H.,** Santawat U, F.R.C.A.T., M.Sc., M.B.A.,** Soontranan P, F.R.C.A.T., ** Somprakit P, F.R.C.A., M.Sc.,** Waisayarat N, M.D.*
* Research fund supported from Siriraj China Medical Board.
** Department of Anesthesiology and Clinical Epidemiology Unit,
*** Department of Anesthesiology, Siriraj Hospital, Mahidol
University, Bangkok 10700.
Introduction : The assessment of a technology comprises of its use, personnel who use it and their knowledge, the problems of the use and acquisition. Anesthesia system is a mandatory equipment for anesthesia. We reported part I of the technology assessment of anesthesia system in 342 hospitals around Thailand. Methods : The questionnaire were sent to personnel who were responsible for anesthetic service of the hospitals and asked about manpower, knowledge and care of the equipment. We also organized site visits to 18 hospitals in 5 parts of Thailand during 1996-1997. Results : Nurse anesthetists were the most common personnel and there were lack of anesthesiologists, nurse aids and technicians. The personnel that the hospitals wanted most were anesthesiologists. Only 26.5% of nurse anesthetists felt that they had enough knowledge to work and solve problems should problems occurred during the use of anesthesia system. All nurses wanted to gain more knowledge. The warning of safety in using an anesthesia system were few and far between. These occurred in only 27.7% of all hospitals, Preuse check up of anesthesia machine still waited for guidelines which was being drawn. Conclusion : All parties involved, including high-level administrators and policy planners should pay more interest and cooperate on post-training knowledge distribution, safety warning, guidelines and standards for the whole country. There should also be follow up and evaluation after distribution of guidelines and allocation of budget. Only with these effort would anesthesia system be utilized safely and cost-effectively.
Key words : Anesthesia, manpower, knowledge, technology assessment
Technology Assessment of Anesthesia Delivery System : II.
Problems of Equipment and Acquisition.*
Lertakyamanee J, F.R.C.A., M.P.H.,** Soontranan P, F.R.C.A.T.,*** Somprakit P, F.R.C.A., M.Sc.,** Santawat U, F.R.C.A.T., M.Sc., M.B.A.,**
Wisayarat N, M.D.***
* Research fund supported by Siriraj China Medical Board.
** Department of Anesthesiology and Clinical Epidemiology Unit
*** Department of Anesthesiology, Faculty of Medicine, Siriraj
Hospital, Bangkok 10700.
Introduction : The assessment of a technology comprises of utilization, personnel, encountered problems, efficiency, and acquisition. Anesthesia system is a mandatory equipment for anesthesia. We reported part II of the technology assessment of anesthesia system in 342 hospitals around Thailand. Methods : The questionnaire were sent to personnel who were responsible for anesthetic service and asked about utility, encountered problems and acquisition. We also organized site visits to 18 hospitals in 5 parts of Thailand during 1996-97. Results : We reported the problems of gas sources, safety components, vaporizers, breathing systems, scavenging systems and ventilators. In the acquisition of machines, the users did not have the opportunity to specify what they needed. There were lack of budget and standard of specification. When problems of the equipment occurred, repair was very slow and there was no satisfactory aftersale service. Conclusion : The technology of anesthesia delivery system has not been used properly in Thailand. All parties involved, including high-level administrators and policy planners, academic and professional organizations, should play more roles and cooperate on post-training knowledge distribution, enforcement of safety practice, establishment of national guidelines and standards, follow up and evaluation after distribution of guidelines and allocation of budget. Only with these efforts would anesthesia system be utilized safely, properly and cost-effectively.
Key words : Anesthesia, equipment, safety, technology assessment
Comparison of Ondansetron and Propofol to Prevent
Postoperative Nausea and Vomiting After Minor Gynecologic
Surgery : A Randomized, Double-blind, Controlled Study
Tisavipat S, M.D.* Kusumaphanyo C, M.D.* Takoonsawat P,
M.D.* Poomanee W, M.D.**
* Department of Anesthesiology, Faculty of Medicine,
Srinakarinwirot University, Bangkok 10300
** Department of Anesthesiology, Bangkok Metropolitan Medical
College, Vajira Hospital, Bangkok 10300.
Effect of Oral Clonidine Premedication on Level of Sedation,
Isoflurane Requirement and Hemodynamics in Laparoscopic
Cholecystectomy Patients.
Bunbanchong J, M.D.*
* Department of Anesthesiology, Faculty of Medicine,
Srinakharinwirot University, Vajira Hospital, Samsen, Dusit,
Bangkok 10300.
Objective : To determine the effect of premedication with oral clonidine on level of sedation, isoflurane requirement and hemodynamic responses. Method : Randomized double-blind, placebo-controlled trial. Forty patients (ASA physical status I and II, 16-83 yr old) scheduled for laparoscopic cholecystectomy were allocated randomly to receive either an oral placebo or clonidine 150 micrograms (2-3 micrograms/kg) at 60-120 minutes prior to induction of anesthesia. The patients underwent a standardized induction sequence that include fentanyl 1-2 micrograms/kg, thiopental 5 mg/kg, and succinylcholine 1.5 mg/kg. Ventilation was controlled with 67% nitrous oxide in oxygen and isoflurane to maintain end-tidal carbon dioxide at 32-36 mmHg. Blood pressure and heart rate were measured noninvasively every 3 min intervals. Inspired isoflurane concentration was adjusted every 3 min to a maximum of 2% to maintain hemodynamic variables (systolic, mean, and diastolic blood pressure and heart rate) within 30% of baseline values and nicardipine 0.5 mg was added if hemodynamic variables analyzed more than these. Results : Four patients in clonidine group and one patient in control group had sedation scores 2 (drowsy), they were 68 yr old or older. SBP and MAP responses were significantly blunted in clonidine group during induction, intubation, and first 60 min during CO2 insufflation (p<0.05) but not significantly different in heart rate and DBP. Inspired isoflurane concentration decreased in the group receiving clonidine. Throughout the study, eleven patients (55%) in control group, but only one patient (5%) in clonidine group, were treated with nicardipine 0.5-1 mg for hypertention SBP 183 (11.2) vs 173 and DBP 111.4 (14.4) vs 113 mmHg (p < 0.05). Patients receiving nicardipine 1 mg in control group (3/11) were female, hypertension. There was one patient in each group (5%) developed bradycardia and hypotension led to atropine requirement. No one in clonidine group had severe bradycardia (HR < 45/min). Conclusion : These suggest that a dose of 150 micrograms of clonidine, given orally 60-120 min preoperatively to the patients undergoing laparoscopic cholecystectomy, is effective in decreasing hemodynamic responses during induction, intubation and first 60 min during CO2 insufflation as well as isoflurane and nicardipine requirements, without causing excessive sedation and severe bradycardia.
Key words : Clonidine, cholecystectomy, isoflurane, laparoscopy,
premedication, sedation.
Complications of Spinal Anesthesia at Lerdsin Hospital.
Throngnumchai R, M.D.,* Sanghirun D, R.N.,* Traluzxamee K,
R.N.,* Chuntarakup P, R.N.*
* Department of Anesthesiology, Lerdsin Hospital, Bangkok
Complications and risk factors during spinal anesthesia were studied prospectively in 990 patients under surgery at Lerdsin Hospital from September 1995 to March 1996. The most common complication was hypotension (20.2%). The other complications were backache (15.1%), nausea-vomiting (11.9%), postdural puncture headache or PDPH (7.7%) and shivering (7.3%). The risk factors for hypotension were higher with increasing age of patients (p < 0.05) and paramedian approach (p < 0.05). No risk factor for backache was found. The risk factors for nauseavomiting were higher with hypotension (P < 0.05), female (p < 0.05) and increasing age of patients (p < 0.05). PDPH was related to female patients (p < 0.05) and the risk factor for shivering was younger patients (p < 0.05).
A Comparison of Circle, Bain's and Venturi Circuit in General
Anesthesia at Srinagarind Hospital
Theerapongpakdee S, M.D.,* Krisanaprakornkit W, M.D.,*
Tantanatewin W, B.Sc.,* Rakpong P, B.Sc.*
* Department of Anesthesiology, Faculty of Medicine, Khon Kaen
University, Khon Kaen 40002.
Twenty patients of various diagnosis and ASA class I-II were anaesthetized by general anesthesia with the circle, Bain's and venturi circuit in the same patient at fresh gas flow (FGF) 6, 6 and 2 litres perminute respectively. Standard monitoring with arterial blood gases were done after period of 15-20 minutes stabilization of controlled ventilation following each circuit. The pH, PCO2 and PO2 were within normal clinical range. The statistical difference were found significant on the pH, PCO2 value of circle/venturi and circle/Bain's circuit. It was concluded that venturi circuit at practical flow of 2 litres per minute yielded the pH, PCO2 value as well as the circle and Bain's circuit at 6 and 6 litres per minute respectively.
Key words : Anesthetic breathing system, circuit equipment, venturi circuit,
Bain's circuit, circle circuit.
Malignant Hyperthermia in Siriraj Hospital
Vorakitpokaton P, M.D.,* Kongsayreepong S, M.D.,*
Areewatana S, M.D.,* Suchichantararat P, M.D.**
* Department of Anesthesiology ** Department of Surgery, Siriraj
Hospital, Bangkok 10700.
Thai physicians are less aware of malignant hyperthermia (MH) because it is a rare genetic disease mostly affect in Caucasian. Until now no specific test and no specific drugs for this disease are available in Thailand. Only early detection and rapid supportive treatment can safe the patients. Two suspected MH were found in Siriraj hospital. They both are the girls of aged 2 and 1 1/2 years old who developed hyperrigidity, hypermetabolism, tachyarrhythmia and large increase in muscle enzymes shortly after anesthetic induction with volatile inhalation agents and intubation with succinyl choline. The first child showed severe rigidity and could not pass the endotracheal tube. Intubation successfully done by using a non-depolarizing muscle relaxant. Even without dantrolene which is the only drug for this disease these patients are survived with early detection and rapid supportive management. The reporters want to remind and recall Thai physicians again about this disease because the last report were done by Ramathibodi anesthetists in 1992, that was 7 years ago.
Key words : Malignant hyperthermia, rigidity
Volume 24;Number 4:1998:October-December 1998
Comparison of Laryngeal Mask Insertion with and Without
Insertion Aid by Nurse Anesthetists.
Simajareuk S, M.Sc.,*
Thienthong S, M.D.,* Horatanaruang D, M.D.,* Phengsrakes
N, B.Sc.*
We studied the effect of the S-shape tongue depressor which designed as an insertion aid on the incidence of successful LMA insertion. Twenty nurse anesthetists with no previous experience of the LMA were equally assigned to do LMA insertion in 100 anesthetized patients by using standard technique in group 1 and allowed to use the insertion aid when standard technique was failure in group 2. Each operator attempted a total of five insertions with two minutes for each attempt. The result showed that the success rate in LMA with insertion aid group was higher than LMA without insertion and group 96% and 80% respectively, p<0.05) and there was a chance of 24% to use insertion aid. The incidence of bleeding in the oral cavity was not different and there were no serious complication in both groups. So the S-shape insertion aid modified from tongue depressor was very useful for LMA insertion particulary for inexperienced personel.
Key words : Laryngeal mask airway, insertion aid, nurse anesthetists
A Randomized, Double Blind, Comparative Study to Evaluate the
Efficacy and Safety of Cisatracurium Versus Vecuronium for
Intubation.
Werawatganon T, M.D.,* Bunburaphong P, M.D.,* Techanivate
A,
M.D.,* Cholvisudhi M, M.D.,* Rugchat A, B.N.**
* Department of Anesthesiology, Faculty of Medicine, Chulalongkorn
University, Bangkok 10330.
** Department of Anesthesiology, King Chulalongkorn Memorial
Hospital, Bangkok 10330.
Cisatracurium is one of the ten stereoisomers contained in atracurium besylate. It has potent neuromuscular blocking property, no histamine release and organ independent elimination. This study was a prospective, double-blind, randomized comparison of the recommended intubating dose of cisatracurium (0.15 mg/kg) with vecuronium (0.1 mg/kg) to evaluate the efficacy and safety for endotracheal intubation. Sixty ASA physical status I or II patients, 15-55 yr. or age, 40-65 kg, scheduled for elective intermediate-duration surgical procedure were studied relaxant was given. Arterial blood pressure and heart rate were measured every minute. Onset and duration of relaxant were observed from train of four responses to nerve stimulator. The patient was intubating condition at 2 minutes after relaxant administration.
In cisatracurium group, 63.3% of patients had good or excellent condition for intubation compared with 66.7% in vecuronnium group. Onset of action of cisatracurium and vecuroium were 3.4 + 0.9 and 2.9 + 0.8 min respectively. Duration of cisatracurium was 47.3 + 8.3 min which was longer than 38.2 + 9.7 min from vecuronium (p < 0.05). All of the patients had good recovery from muscle relaxant after reversal with neostigmine. There were 11 patients in cisatracurium group and 16 patients in vecuronium group who had bradycardia during study period. The cause might be induction with midazolam and fentanyl. One patient in cisatracurium group had erythematous rash. No bronchoconstriction of other significant adverse effect from both relaxant was found. So cisatracurium was safe and effective for intubation. Better condition might be achieved with higher dose or longer waiting time before intubation.
The Parameters of Main Bronchial Diameter
Techanivate A, M.D.,* Balamongkhon B, M.D.*
* Department of Anesthesiology, Chulalongkorn University,
Bangkok 10330.
Diameters of the main bronchi are difficult to be measured from most of the plain PA chest X-ray films. For ability to predict the bronchial diameter, 121 patients were reviewed since January 1995 to December 1996 to determine the relationships between them and many parameters. The left main bronchial diameter is 11 + 1.3 mm and related to the tracheal diameter (p < 0.001), tracheal length (p < 0.005) and the diameter of the right bronchus (p < 0.001). The diameter of right bronchus is 12.7 + 1.8 mm and related to the tracheal diameter (p <0.001), tracheal length (p < 0.005) and certainly the left bronchial diameter (p < 0.001). The diameter of main bronchi are different between sexes (p < 0.05) and related to height (p < 0.001). The ratios of bronchial diameter to tracheal diameter are 0.69 + 0.04 and 0.79 + 0.06 of the left and the right sides respectively. (with no significant differences in both sexes).
Besides, we also reviewed problems related to one lung ventilation (OLV) with double lumen tube (DLT) in these patients. During separated lung ventilation, high incidences of leakage, high airway pressure and moderate hypoxemia were occured only in male patients. Causes of these complications may be unpropered size of DLT.
Oxygen Desaturation During Induction of Anesthesia. Prospective
Comparison of Propofol and Thiopental
Vichitrananda C, M.D.,* Suwanno V, B.N.*
* Department of Anesthesiology, Faculty of Medicine, Ramathibodi
Hospital, Mahidol University, Bangkok 10400.
A prospective randomized control trial was done in 60 healthy to observe the incidence of oxygen desaturation (SpO2 < 90%) after intracenous anesthetic induction with propofol and thiopental. The patients were continuously monitored be pulse oximetry before, during and after intravenous injection of 2.5 mg/kg propofol or 5 mg/kg thiopental. 100% oxygen via face mask ventilation was given in patients with SpO2 < 90% and all patients after 3 min until normal oxygen saturation achieved. The arterial oxygen desaturation occured in 73.33% of patients who recieved propofol and none in thiopental group (p < 0.001). The desturation took place within 60.50 + 6.21 sec. After 1 min of 100% oxygen ventilation all patients' oxygenation were normalized.
Key words : Desaturation, propofol, thiopental
A Comparison of 29 Gauge Quincks and 27 Gauge Whitacre
Needles for Spinal Anesthesia in Patients Under 45 Years
Vichitrananda C, M.D.,* Sitthichaikasem W, M.D.,*
Pukrittayakamee P, M.D.,* Sornnil A, B.Sc.,* Suranutkarin P, B.Sc.*
* Anesthesiology Department, Faculty of Medicine, Ramathibodi
Hospital, Mahidol University, Bangkok 10400.
The prospective double blind randomized study was done in 150 patients under 45 years to compare the difficulties in clinical use between 29 G Quincke and 27 G Whitacre needles and postdural puncture complications. All patients received standardized dose of 0.5% hyperbaric bupivacaine and either 29 G Quincks or 27 G Whitacre spinal needle. The duration of needle insertion, failure of the procedure and the incidence of post dural puncture headache (PDPH) were observed. Result : The duration of needle insertion in 29 G Quincke (90 seconds) is longer than 27 G Whitacre needle (35 seconds) (p < 0.05). There was no difference in the failure rate of needle insertion and the incidence of PDPH between two groups.
We concluded that 29 G Quincks was more difficult to use than 27 G Whitacre needle by increasing duration of needle insertion. There was no difference in the post dural puncture complications.
Key words : Spinal anesthesia, Quincke, Whitacre
The Safety and Efficacy of Desflurane During General Anesthesia in
Thai Surgical Patients
Chinachoti T, M.D.,* Ratamanee T, M.D.,*
Chindapornpitak S, M.D.,* Suwannanon P, B.N.,* Silapadat
O, B.N.,* chainjob P, B.N.*
* Department of Anesthesiology, Faculty of Medicine, Siriraj
Hospital, Mahidol University, Bangkok 10700.
We studied the safety and efficacy fo desflurane supplement to narcotic-muscle relaxant based on anesthesia in 104 ASA grade I or II undergoing elective orthopedic operation. Onset, appropriate concentration, adversed effect, recovery profile and problem in controlling anesthetic level were assessed. Hepatic and renal effect were evaluated by blood sample for BUN, creatinine, SGOT, AGPT, billirubin, alkaline phosphatase pre-operation and 24 hours post-operation. correlation coefficients between duration exposed to desflurane and recovery profile were evaluated. Kolmogorov-Smironov Goodness for Fit test, paired and un-paired t-test, Wilcoxon Matched-Pairs Signed-Rank test were used to evaluate pre-operative and postoperative blood chemistry for p valve < 0.05 to be statistic significant.
We included 104 of 63 males and 41 females of age average 34.7 + 9.9 years (range 19-54), body weight 61.5 + 11.01 kg (38.5-96), height 157.8 + 14.12 cm (142-185). Three cases were withdrawn, one due to patient design, one due to vaporizer malfunction and the last desflurane was decided to stop because of severe bradycardia and poor responsed to double doses of atropine. After intubation and control ventilation with total flow 3 litres/min 5-14 minutes average of 7-86 + 3.05 min were used to stabilised adequate anesthetic level by hemodynamic parameter and 10-25 min were used to increase expired concentration to 80% of inspired concentration. Half of our patients were appropriated with 3% desflurane and mean average concentration was 4.17 + 1.6% and easy to control depth of anesthesia. Anesthetic time were varied from 31 to 419 min in average of 123.9 + 68.6 min. Recover profile was determined by time to extubation (6.93 + 2.9 min), spontaneous eye open (6.6 + 3.1 min), follow command (7.4 + 3.1 min), name recall (9.4 + 4.9) min) and birth date recall (9.9 + 5.0min) and all of these parameters were not correlated with anesthetic time Thirty four cases had adversed effect related with desflurane. Most of them were mild and moderate with 11 cases of shivering and 18 cases of bradycardia. Four cases (3.9%) of severs adversed effect with 8 episodes, one was severe bradycardia with hypotension and was withdrawn before the end of study and one with three adversed event include hypertension, shivering and excitement post-operatively. We found high precentage of bradycardia, cighteen cases and should be one of precaution in using desflurane as supplement to contro ventilation. We couldn's demonstrate any liver or kidney function change in the mean of blood chemistry from this study.
In conclusion, desflurane was rapid onset and predictable recovery time, easy to use. Heart rate should be accurately monitor and early treatment with atropine was highly recommend.
Upper Airway Evaluation Correlated to
Laryngoscopic View
Chinachoti T, M.D.,* Muangkasem J, B.Sc. (Nurse and Midwife),*
Parakkamodom S, R.N.,*
Chaikul B, Dp.N.,* Phettongkam A, B.E. (Nursing).,* Chamadol S,
B.Sc. (Nurse and Midwife),*
chaiyaroj A, Dp.N.,* Chalayonnawin W, B.N.,* Tomyem N, B.N.*
* Department of Anesthesiology, Faculty of Medicine, Mahidol
University, Bangkok 10700.
Introduction : Upper airway assessments are safety maneuver to predict difficult intubation and prevent failed intubation. Many assessments were introduced to clinical practice, most of them were valuable useful in obstetic and obesity patients. But what is the best assessment method in ordinary patient without anatomical defects are still in debatable issue. Objective : In this prospective study, we compares four assessments include modified Mallampati's classification, extended angle of neck, mandibular width and thyro-mental distance to laryngoscopic view. Methods : Four hundred and fiftynine patients without anatomical defects, obesity and pregnancy were evaluate upper airway be trained nurse anesthetist and laryngoscopic view were assessed by qualified person who were bline to airway evaluation. Result : Modified Mallampati's classification was the best method that correlated to laryngoscopic view (P value + 0.000). Others were failed to demonstrated statistic correlation significant. At 95% confidence Mallampati class 3, 4 were sensitivity of 54.8 specificity 78.96% with 33.1 positive predictive value and 90.2% negative predictive value. Conclusion : Modified Mallampati's classfication was the best upper airway assessment which correlated well to laryngoscopic view. Patient with class 1 or 2 of modified Maooampati's are predicted to cause less problem in intubation process.
Influencing Accomplishmentof Anesthesiology Residency
Training Factors
Suraseranivongse S, M.D.,* Prakarnrattana U, M.D.,*
Suwannachinda V, M.D.,* Udompunturuk S, M.Sc.,** Hoonnakul
S, M.Sc.**
* Department of Anesthesilogy
* Clinical Epidemiology Unit, Research Promotion Center, Faculty
of Medicine, Siriraj Hospital, Mahidol University, Bangkok10700.
Background and Objective : Certain predictors were traditionally presumed to be reliable measures for selection candidates of anesthesiology training program. The purpose of this study was to determine factors influencing accomplishment of anesthesiology residency training as considerable criterias for selection residency candidates. Method : This case control study used scores of third year In-Training Examination (ITE) as the outcome predicted success of training. The scores were allocated into high score group (< mean) and low score group (< mean). Academic and non-academic factors were retrospectively collected from 103 third year residents in Department of Anesthesiology, Faculty of medicine, Siriraj Hospital, Mahidol University from 1987 through 1997. Sex, age, marrital status were recorded as non-academic variables. Medical school grade point average (GPA), duration since graduation and medical school were recorded as academic variables. All variables were analysed by using bivariate analysis and logistic multivariable analysis. Result : There were significant negative correlations between age (p 0.03, r-0.135), medical school (p 0.001, r-0.181) and scores of third year ITE. Positive correlation was found between (GPA) 9p, .001, r 0.142) and score of third year ITE. conclusion : Younger age, higher GPA and older medical school were associated with accomplishment in residency training.
Anaphylactoid Reaction to Hydroxyethyl Starch : A Clinical
Manifestations
Soontranan P, M.D.,* Kongsayreepong S, M.D.* Sattaratanamai
C, M.D.*
*Department of Anesthesiology, Faculty of Medicine, Siriraj
Hospital, Bangkok 10700.
Single Thai male age 17 years, ASA class 1 and no history of drug allergy, was scheduled for closed Knailing of fracture under subarachnoid block with 0.5% isobaric bupivacaine. The previous subarachnoid block with 0.5% heavy bupivacaine was done 2 days ago without any adverse effect. Ketamine 50 mg was given intravenously to facilitate positioning for subarachnoid block. Five minutes after subarachnoid block with 0.5% bupivacaine, blood pressure dropped to 90/40 mmHg, ephedrine was given IV to restore blood pressure to normal limit. Twenty-five minutes after block 6% hydroxyethyl starch infusion was started. Five minutes later the patient was restless with clinical manifestation fo expiratory wheezing, blood pressure dropped, SpO2 decreased to 90% and skin urticaria. Anaphylactoid reaction to hydroxyethyl starch was diagnosed and the patients was intubated and ventilation was assisted with 100% O2. Intravenous adrenaline, metaraminol, chlorpheniramine, hydrocortisone and aminophyline were administered. The patient responded to treatment well, all signs of anaphylactoid gradually subsided. The operation was completed without other adverse effect, then the patients was sent to ICU for postoperative care and finally discharged to ward.
Volume 24;Number 3:1998:July-September 1998
The Effect of Thiopentone 2 mg/kg and Succinylcholine 0.5 mg/kg in Modified ECT
Viengteerawat S, M.D.,* Yuktanon S, B.N.,* Sirivanasandha P, M.D.*
* Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital, Bangkok
10400.
The key of anesthetic management for ECT is to carry out the patient from suffering during ECT treatment, but less interfere to siezure threashold to obtain the therapeutic range of siezure'stime (25-60 seconds).
This procedure needs and experienced person, but practically is being assigned to anyone available. Because, in general ECT considered as a short, simple procedure should need a simple anesthetic management.
This study aims to set the specific protocol of anesthetic management, easy to follow, but obtains an effective psychiatric treatment along with patient's safety and comfort.
The most familiar drugs, thiopentone and succinylcholine were selected as an IV sedation of choice. Subinduction dose of thiopentone (2 mg/kg) followed by subintubation dose of succinyl choline (0.5 mg/kg) along with 100% oxygen by mask were desired for this study in 90 ECT treatment. Monitoring were carried out with NIBP, ECG, pulse oximeter. Siezure's activity and time were observed.
We found that, these selected drugs and doses yeil satisfactory therapeutic range of siezure's time around 70%. Poor responese by siezure's time less than 25 seconds which may lead to ineffective ECT treatment occurred up to 30%. SpO2 maintained more than 90% in most of the patients.
Side effect on cardiovascular by increasing BP and HR more than acceptable range (> 20% from base line) was around 30%. Beta blockade or IV calcium chanal blocker treatment instead of increasing dose of thiopentone is suggested. No other undesirable effects such as awareness, headache, nausea, vomiting etc were found in this study.
Conclusion : Thiopentone 2 mg/kg followed by succinylcholine 0.5 mg/kg along with O2 supplement is recommended as a save and suitable IV sedation for ECT.
Comparison of 3 Doses Bupivacaine in Continous Thoracic Epidural Infusion for Postoperative Pain Relief Following Thoracotomy and Upper Abdominal Surgery
Uerpairojkit K, M.D.,* Charuluxananan S, M.D.,* Rukchart A, M.D.,*
Singhapreecha S, M.D.,*
* Department of Anesthesiology, Chulalongkorn University, Bangkok 10330.
Introduction : Continous thoracic epirdural infusion of local anesthetics can provide postoperative analgesia following thoracotomy and upper abdominal surgery. Bupivacaine in commonly used for its selective sensory blockade.
Objective : In this prospective study, we compared the efficacy and safety of continuous thoracic epidural infusion with bupivacaine in 3 doses.
Methods : Sixty patients undergoing thoracic or upper abdominal surgery were equally randomised into 3 groups ; 3.75 mg/hr of bupivacaine in group 3.1, 7.5 mg/hr in group 2 and 15 mg/hr in group 3. The infusion rate was 6 ml/hr for 48 hours postoperatively. The efficacy was evaluated by total milligrams of supplementary morphine via intravenous PCA.
Results : At the 24th hour postoperatively, the total dosages of morphine were 35.85, 29.65 and 22.32 mg in group 1, 2 and 3 respectively. The total morphine of group 3 was signigicantly less than group 1 but was not significantly different from group 2. The higher average age in group 2 seemed to lessen the local anesthetic requirement and no statistical ddifference was detected between group 2 and 3. But after 24 hours postoperatively, there was no statistical difference for the total dose of morphine as 20.25, 17.80 and 15.68 mg in group 1, 2 and 3 respectively. There was no statistical difference for severity of pain at rest and during exercise among the 3 groups when they were evaluated by numeric rating scale 0-10. Hypotension was found for 1 case in group 2,which responded to colloid replacement and 1 case in group 3, which required multiple doses of vasopressor and crystalloid.
Conclusion : For the first 24 hours postoperatively, infusion of bupivacaine 15 mg/hr via thoracic epidural catheter seemed to be the most effective dose for pain relief in the patients undergoing thoracic or upper abdominal surgery. Lower dose would be considered in elderly patients. However, after 24 hours the efficacy of higher dose (15 mg/hr) was not better than 3.75 mg/hr. Circulatory monitoring was required throughout the period of bupivacaine administration.
Using Halothane Vaporizer for Isoflurane
Kanjanakonthong P, M.D.,* Ketanond C, M.D.,* Vongvises P, M.D.,*
*Department of Anesthesiology, Pramongkutklao Hospital and Collage of
Medicine, Bangkok 10400.
Isflurane is an expensive inhalation anesthetic compares to the commonly used halothane. The costly specific vaporizer is also required, this causes financial problem especially in the developing countries. The aim of this study was to evaluate the safety of using isofurane with the halothane vaporizer. Isoflurane was filled in 5 halothane vaporizers using several dial setting and gas flow rate at 2 and 3 I/min. The isoflurane output concentrations were measured and compared to those from another 5 inoflurane vaporizers. Isoflurane in the haolthane vaporizers was then used to anesthetize 50 patients with the fixed dial setting at 1%. The inspired isoflurane concentrations were measured every 5 minuters and compared to those using isoflurane vaporizers in another 50 patients. The isoflurane output concentrations measured from the halothane vaporizers were not significantly different from those measured from the isoflurane vaporizers. The inspired and expired isoflurane concentrations measured at the tracheal tube every 5 minutes for 2 hours from the patients using halothane vaporizer group were similar to the isoflurane vaporizer group especially at gas flow rate of 3 I/min. Isoflurane could be safely used with the halothane vaporizers which are readily available, hence purchasing a new isoflurane vaporizer may not be necessary.
Combined Epidural Morphine and General Anesthesia in Lumbar
Laminectomy : Evaluation of Postoperative Pain Relief.
Wisadsing W, M.D.,* Wongpunkamol S, M.D.,* Praditwarakun N, M.D.*
* Department of Anesthesiology Faculty of Medicine, Chiang Mai University,
Chiang Mai 50200.
This study was designed to determine postoperative analgesia and safety of a balancedd anesthetic technique : combined epidural morphine and general anesthesia for lumbar laminectomy. Twenty-two patients were randomly selected into two groups. Group I (n=11) recieved conventional general anesthesia with intravenous morphine (0.1 mg/kg) as intraoperative analgesia. Group II (n=11) recieved combined epidural morphine (0.5% bupivacaine with adrenaline 1 : 200,000 and morphine 3 mg) and general anesthesia. The result of study showed that group II had longer postoperative analgesia with significant reduction of first postoperative day analgesic requirement. There were no significant difference of postoperative complications, sedation, motor function, nausea, vomiting and respiratory ddepression between two groups except pruritus. We suggest combined epidrual morphine and general anesthesia is an alternative anesthetic technique for lumbar laminectomy.
Key words : Epidural morphine, Laminectomy, Postoperative pain.
The Laryngeal Mask Airway in Pediatric Anesthesia : Two Methods of Insertion
Chatmongkolchart S, M.D.,* Chanchayanon T, M.D.*
* Department of Anesthesiology, Faculty of Medicine, Prince of Songkla
University, Songkal 90110.
In a randomized study of eighty children (aged 6 mo-15 yr, ASA I-II) undergoing standard general anesthesia for elective surgery, we comparedd the percentage of successful placement on the first attempt between deflated technique (D-gr., n = 38) and rotational technique (R-gr., n = 42), the time to complete insertion, circulatory responses, PETCO2, and the occurrence of the complications.
We found that no significant difference in success rate (81.1 VS 88.1%), the time of insertion (13.27 + 09.94 VS 9.92 + 4.46 s) and PETCO2, (54.44 + 7.22 VS 54.18 + 80. mmHg) between D and R-gr. respectively. There were no significant difference in circulatory response between two groups except systolic blood pressure in R-gr which is statistically increased (5.32 + 1.58 mmHg) through 5 minutes. The complications we found (coughing, vomiting, laryngospasm, etc) most occured after removal of LMA.
We conclude that rotating the laryngeal mask during placement is as effective as the standard technique.
Key words : Anesthesia : pediatric, Carbondioxide : end-tidal, Equipment : laryngeal mask,
Measurement Techniques : capnometer, Technique : rotational
Digital Ischemia After Radial Artery Cannulation
Singthong T, M.D.,* Laumanuworrarat P, M.D.,*
* Department of Anesthesiology, Maharaj Nakhonrajsima Hospital, Nakhonrajsima,
30000.
Volume 24;Number 2:1998:April-June 1998
Taylor's Technique with Isobaric Bupivacaine in Anorectal Surgery
Pokaprakarn C, M.D.*, Polburi C, M.D.*, Vongvises P, M.D., LL.B.*
* Department of Anesthesiology, Pramongkutklao Hospital and College of Medicine, Bangkok 10400 Saddle block with hyperbaric technique to block only the lumbosacral area is the preferred spinal anesthetic technique for anal operation. But in Jackknife position which is commonly used by many surgeons, the hypobaric technique may be preferrable. In Thailand only isobaric bupivacaine is available, so the isobaric bupivacaine is used for this study. Eighty patients under going anal operations were divided into 2 groups. In group 1, the lumbosacral or Taylor's approach with the patients in prone position was used. In group 2, lateral position with conventional midline approach was used. After local anesthetic injection, the patients were then turned to Jackknife position. The anesthetic used was 1 ml (5 mg) of 0.5% isobaric bupivacaine in both groups. The level of anesthesia was observed 5-10 minutes later by pinprick sensation, vital signs were monitered every 5 minutes as usual. In group 1, the anesthetic level was obtained from L3 to S1 compared with T12 to S1 in group 2. Hypootension was observed in 2 patients in each group. The anesthetic results were considered to be satisfactory. Spinal anesthesia with lumbosacral apporach using 5 mg of 0.5% isobaric bupivacaine is suitable for surgery of the anus in Jeckknife position. However for anesthesiologists who are not familiar with the Taylor's approach, the conventional midline approach can be used instead.
Can Transdermal Scopolamine Prevent Postoperative Nausea and Vomiting after Spinal Surgery under General Anesthesia ?
Akavipat P, M.D.,* Chulaka S, R.N.,* Kaewsingha P, B,Sc. (Nursing)
* Department of Anesthesiology, Prasat Neurological Institute, Bangkok 10400
In a double blind, prospective, randomized study, we have compared the efficacy of transdermal scopolamine in the prevention of nausea and vomiting after spinal surgery under general anesthesia. In both placebo (n = 30) and scopolamine groups (n = 30), had low incidence and no statistical significant difference in postoperative nausea and vomiting at 0, 0.5, 2, 12 hours after the end of anesthesia. However, in the scopolamine group, there were more side effects (p < 0.005). We conclude that transdermal scopolamine has no clinical benefit in the prevention of postoperative nausea and vomiting in the patients undergoing spinal surgery.
The Effect of Epidural Tramadol on Shivering Following Epidural Block in Parturients
Hintong T, M.D.,* Paiboonworachat S, M.D.* Suntrapiwat R, M.D.,* Phuchareon L, S.R.N.,* Jaisawang W, S.R.N.*
* Department of Anesthesiology, Faculty of Medicine, Chiangmai University, Chiangmai 50200
This randomized double blind study was performed to evaluate the effect of epidural tramadol on shivering. We studied in 120 parturients, ASA I or II, who underwent epidural blocks for elective cesarean section. The patients were divided randomly into 2 groups : group I (control group, n = 60) received 20-25 ml of 2% lidocaine with adrenaline 1 : 200,000 whereas group II (tramadol group, n = 60) received the same solution with 50 mg tramadol. The patients were asked when they had shivering and the observer recorded its duration and severity. The incidence of shivering in group I and group II was not statistical difference (group I : 33/60, 55%, group II : 23/60, 38.3% ; p = 0.1). However the duration and severity of shivering in group II was less than in group I (duration = 4.68 min and 13.33 min in group II and group I respectively ; p < 0.01 and the number of patients who had severe shivering = 3/60 and 13/60 in group II and group I respectively ; p < 0.05). We conclude that epidural tramadol cannot prevent shivering caused by an epidural anesthesia but can reduce its duration and severity.
Key words : Anesthesia : epidural, tramadol, shivering
The Construction of Interface for Scavenging System
Srinarong S, R.N.*
* Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Bangkok
10700
This paper described the construction of an interface for a scavenging system by using PVC pipe, water tap regulator and reservoir bag. This is a part of active scavenging system, connecting between exhaust gas outlet and a negative pressure hose. The equipment is simple, using the local made parts which are not expensive. The advantages and disadvantages of the scavenging system were mentioned. The use in 100 patients with no complication was also reported.
Acute Postoperative Pain Management in Pediatric Patients
Khamrat P, M.D.,* Janngam J, M.D.,* Suraseranivongse S, M.D.,* Sanansilp V, M.D.,* Maneenoy S, M.Sc.**
* Department of Anesthesiology, ** Computer Center, Siriraj Hospital, Faculty
of Medicine, Mahidol University Bangkok 10700
This prospective study surveyed the status of postoperative pain and pain management in children as well as personnel's attitude from 1 November 1996 to 28 February 1997. Seventy-nine children (aged 2 days to 13 years) undergoing all kinds of surgery except cardiothoracic and neurosurgery were enrolled in this study. Pain score was assessed in 4 year-old children and younger using Objective Pain Scale and in over 4 year-old children using Visual Analogue Scale, Verbal Numerical Scale and Verbal Rating Scale. The assessment was performed preoperatively and at 0-6, > 6-24, > 24-48 and > 48-72 hours postoperation. All pain scores were high within 24 hours after operation and declined to the preoperative level during 48-72 hours. We interviewed 40 doctors and 53 nurses about the attitude of postoperative pain management. Sixty-nine percent of personnel aimed to irradicate all pain on the safety basis. The most popular prescription (85%) was "prn (given as requested)". The current pain management was satisfied in 98% of patients (or parents) whereas 65% of personnel indicated that their service was still unsatisfied. We conclude that the practice of postoperative pain management in the first 24 hours needs further improvement. Proper guideline or algorithm for postoperative pain management in children should be established.
Inspection of Non-interchangeable Connectors and Gas Pipeline Outlets in the Operating Suites
Soontranan P, F.R.C.A.T.,* Noocharoen P, B.N.,* Silapadech A, B.N.*
* Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol
University, Bangkok 10700
This descriptive cross-sectional study inspected the non-interchangeable (quick coupler) connectors and outlets of O2, N2O and medical air pipelines currently in use in the operating suites (operating and induction rooms) of Siriraj Hospital during December 1997 to March 1998. There were 80 rooms (61 operating rooms and 19 induction rooms) with 429 gas outlets. Seventeen defects (3.9%) were identified, 7 of them were gas leakage from the O2, N2O and medical air connectors (1, 4 and 2 respectively), the other 10 incidents were failure to connect the connectors into their outlets properly (O2 and N2O = 9 and 1 respectively and none for air). There was no statistical significant difference among these gases (p = 0.11). There was no relationship between leakage and connection failure because they did not occur in the same connectors. The postulated contributing factors were lack of proper maintenance, low-quality material and overuse. The defective connectors were classified into 2 types : wall and ceiling outlets. The former had more defects that the latter (13 VS 4 connectors or 6.9 VS 1.6% respectively) which was statistically significant (p = 0.012). This led to another postulation that the wall-type connectors'alignment were horizontal which might cause levereffect to the outlets by the hose's weight with the wall outlets as fulcrum. Our result could be used as basic data for the policy planer to develop and promote the maintenance program of medical gas piping systems in Thailand because it is essential to the safety of all patients and personnel.
Key words : Anesthesia, connectors, pollution, safety, test
Volume 24;Number 1:1998January-March 1998
Comparison of laryngeal mask airway insertion and endotracheal intubation by nurse anesthetist trainees
Tienthong S.,M.D.,Horatanarung D.,M.D.,Simajaruk S.,M.Sc.,Krisanaprakonkit
W.,M.D. Department of Anesthesiology, Faculty
of Medicine, Khon Kaen University, Khon Kaen 40002
We compared the success rate of laryngeal mask airway(LMA) insertion and endotracheal intubation (ETT) by ten inexperienced nurse anesthetist trainees. Two hundred patients scheduled for elective surgery under general anesthesia were randomized to receive LMA (n=100) or ETT (n=100). There were two minutes allowed for each attempt. The result showed that the success rate was not statistically different (88% in LMA group VS 84% in ETT group) but the mean time used in LMA group was less than in ETT group (39+18 VS 47+20 sec respectively,p<0.05). The difficulty of insertion (using VAS) was lower in LMA group (40+25 VS 48+27,p<0.05). There was no correlation between the success rate and ASA physical status,sex,the order of insertion,VAS and airwa grading by direct laryngoscopy. Two complications were found in LMA group (1 aspiration and 1 bleeding in the oral cavity) and four complications in ETT group (1 lost teeth,1 bleeding and 2 lip lacerations) We concluded that nurse anesthetist trainees were able to insert LMA successfully as endotracheal intubation but the mean time used was less and the procedure easier. Therefore training the nurse anesthetists to use LMA is reasonable.
Prevention of N2O-induced increase in endotracheal tube cuff pressure by inflating the cuff with mixture of N2O and O2
Sinkuakool C.,M.D.,Thamtharanon P.M.D.,Muknumporn T.,B.Sc.,Kingsungwal P.,B.N.,Sinkuakool Y.,B.Sc.*
Department of Anesthesiology, *Research Division, Faculty of Medicine, Srinagarind Hospital, Khon Kaen University, Khon Kaen 40002
Nitrous oxide can diffuse into the endotracheal tube cuff and then overexpand it and increase the intracuff pressure. This can cause tracheal ischemia and injury or even obstruction in intubated patients under general anesthesia with mixture of N2O and O2. We then evaluated the change of the intracuff pressure in such patients by inflating the cuff with the same concentration of gases,believing that it could prevent intracuff overpressure. Forty female patients, ASA I-II, undergoing general anesthesia with 67% N2O in O2 and,were randomly allocated into two groups. In group A(control, n=20),the cuffs were inflated with room air while in group B(n=20),they were inflated with the same mixture of inhaled gases. In both groups,the initial cuff pressure was 15 mmHg and it was measured every 5 minutes until extubation. We found that the mean intracuff pressures differed significantly between groups from the first 5 minutes of measurement thereof(p<0.05). In group A,the mean intracuff pressure increased rapidly within 21.74 minutes to over 25 mmHg,the level exceeding normal mucosal capillary perfusion of the trachea. While in group B, the mean intracuff pressure stayed fairly constant and none over 25 mmHg. Three in this group were found to have a cuff leakage and thus excluded from the study. In conclusion, inflation of endotracheal tube cuff with mixture of nitrous oxide and oxygen of which the same concentration they inhaled during general anesthesia could prevent the cuff overpressure.
Incidence of neurological complications after subarachnoid anesthesia in Chulalongkorn Hospital Mahutchawaroj N.,M.D.,Somboonviboon W.,M.D.,Werawatganon T.,M.D.,Tawitsri T.,M.D.,Prapaitrakool S.,M.D.
Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330
Subarachnoid anesthesia is one of the most common regional techniques used in Chulalongkorn Hospital. Since neurological complications have been reported more frequently than before, especially minor complications like transient and persistent symptoms of leg pain or numbness. Therefore we decided to look for the incidence of neurological and other complications as well after our standard technique of subarachnoid anesthesia. Sixteen hundred and thirty patients were followed after subarachnoid anesthesia was done with 25 G Quincke everyday for 3 days and asked to answer the questionaire within one week for any delayed complications. Chi-square and multiple logistic regression analysis were used with statistical significance at p<0.05. Almost ninety percent of patients had no complication at all, 2.3% had minor neurological complications like leg pain and numbness on the first few postoperative days, 0.8% had postdural puncture headache, 9% had backache and 0.4% difficult urination. There were no serious neurological sequelae. Eighty-four percent of patients who had minor neurological complications recovered within 1-3 days and 81% were satisfied and would choose this technique again in the future. All patients with postdural puncture headache recovered within 1-2 days after symptomatic treatment. Twenty-five point four percent answered the questionaire- 85.5% would choose the technique again while 72.9% had no delayed complication. Most thought that backache was due to subarachnoid anesthesia. In conclusion,understanding the potential hazards of subarachnoid anesthesia should make safe the technique. The possibility of minor neurological complications should not be underestimated,they should be looked for and if major one detected,early intervention would help full recovery.
Anesthesia for open heart surgery : the first 10 cases in Maharaj Nakhonratchasima Hospital
Lermanuworarat P.,M.D.,Ambua P.,M.D.,Chadprom S.,M.D.,Singthong T.,M.D.
Department of Anesthesiology, Maharaj Nakonratchasima Hospital, Nakonratchasima 30000
We report the anesthesia for the first ten cases of open heart surgery in Maharaj Nakonratchasima Hospital. They were 3 males and 7 females with the ages 12-48 years old,body weight 40-55 kg and functional classes I-III. Thress cases were atrial septal defects,6 mitral stenoses and 1 combined mitral stenosis and aortic regurgitation. Most of them were on digitalis and diuretics. Echocardiography was done in all patients preoperatively. The operations were performed under cardiopulmonary bypass for intracardiac correction. Two patients had complications of postoperative congestive heart failure and one had digital ischemia after percutaneous radial arterial cannulation. There was no mortality from anesthesia or surgery.
Comparative study of postoperative analgesia between epidural morphine and systemic narcotics in TAH
Tontisirin O.,M.D.,Ponpiboonlap P.,M.D.,Chankam R.,B.Sc.
Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University
A comparative study of postoperative analgesia between systemic narcotics and combined epidural general anesthesia in TAH(Total abdominal hysterectomy) was done in Ramathibodi Hospital. Eighty Thai patients were divided into two groups;group I received general anesthesia and systemic narcotics while group II received combined epidural and general anesthesia with epidural morphine for postoperative pain. Pain scores were recorded and divided into 2 groups : 0-3 (low pain score) and > 4 (high pain score). Pain scores,side effects,patients’ activity and satisfaction assessment were recorded within 48 hours. In the first 24 hours,6 patients in group I and 28 in group II had low pain score while 34 in I and 12 in II had high pain score. On the second day, 16 in I and 27 in II had low score but 13 in I and 24 in II had high score respectively. The side effects: nausea,vomiting,patients’ satisfaction and activity, were not significantly different. There was no respiratory depression but itching was found more in the epidural morphine group. The epidural morphine thus had better postoperative pain relief than systemic narcotics in TAH.
Efficacy of EMLA cream in reducing pain during lithrotripsy
Koompong P.,M.D.,Chayachinda D.,B.N.,Amatayakul M.,B.N.,Tritrakarn T.,M.D.
Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700
Efficacy of EMLA cream in reducing pain during lithotripsy was studied in 67 patients aged 19-80 years subjected to the treatment by Extracorporeal Piezoelectric Lithotriptor(EPL),Wolf Piezolith 2,300. The patients were randomized into 4 groups: the first group(control) received nothing,the other three groups received tegaderm plastic covering,EMLA cream and placebo cream under tegaderm plastic covering on the flank at the point of entry of the EPL shock wave. All partients received 4,000 shots of the shock wave. Pain scores during lithotripsy treatment were evaluated by verbal analogue scale. There was no statistical difference of pain scores between any of the studied groups. Further study with a larger number of patients is recommended.
Predictive Index of Weaning Outcome in Postoperative Cardiac Patients.
Krataijan J, M.D.,* Techakittiroj N, M.D.,* Prakanrattana U, M.D.*
* Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700.
To assess whether standard weaning parameters are helpful in postoperative cardiac patients, a prospective study was done in 100 patients underwent coronary artery bypass graft surgery (CABG), valvular surgery or congenital defects repair under cardiopulmonary bypass technique. Maximal inspiratory pressure (PImax), minute ventilation (VE), respiratory frequency (RR), tidal volume (VT) and rapid shallow breathing index (RVR = RR/VT) were obtained immediately and 10, 20, 30 minutes after disconnection from mechanical ventilators. There were no significant differences in VE and PImax between success and failure groups, but significant differences were found in RR, VT and RVR. Using RVR > 105 as a cut off point for weaning failure, sensitivity and specificity were 0.90 and 0.25 respectively. We concluded that RVR may help predicting weaning outcome in this group of patients.
The Effect of Nicardipine on the Circulatory Response to Laryngoscopy and Intubation in Hypertensive Patients.
Chintanapramote B, M.D.,* Vorrakitpokatorn P, M.D.*
* Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Bangkok 10700
This study was undertaken to examine the effect of nicardipine on circulatory response to laryngoscopy and tracheal intubation in hypertensive patients (n = 30). Laryngoscopy and tracheal intubation were performed after induction of anaesthesia with thiopentone followed by administration of intravenous saline or nicardipine 10 *g.kg-1 or 20 *g.kg-1 and suxamethonium. Blood pressure and heart rate were recorded and rate-pressure product was calculated. Nicardipine 10 *g.kg-1 and 20 *g.kg-1 prevented the increase in mean arterial pressure after intubation in hypertensive patients (p < 0.05 compared with normal saline). The changes in heart rate after intubation were significantly in hypertensive patients by normal saline but the heart rate changed significantly after intubation and 1 minute by nicardipine 20 *g.kg-1 was given. Heart rate did not change significantly when nicardipine 10 *g.kg-1 was given. Rate pressure product increased significantly (p < 0.05) after intubation in hypertensive patients after giving normal saline and rate pressure product decreased significantly by nicardipine 10 ro 20 *g.kg-1 were given in hypertensive patients. We conclude that nicardipine is effective in preventing the circulatory responses to laryngoscopy and tracheal intubation in hypertensive patients.
The Use of Photograph as Visual Aid in Positioning Obstetric Patients for Epidural Block
Chayachinda D, B.N.,* Soontranan P, M.D.,* Thaworanun J, M.D.,* Udompunturak
S, M. Sc.,** Chaiyaroj O, B.N.*
* Department of Anesthesiology** Clinical Epidemiology Unit, Faculty of Medicine, Siriraj Hospital, Bangkok 10700
This randomized controlled trial was done in sixty obstetric patients scheduled for cesarean section under regional anesthesia. They were divided by random number into two groups. Group 1, control group, were conventionally positioned by verbal command. Group 2, visual-aided group, were positioned by verbal command plus showing photograph of standard position for epidural block. The nurse anesthetist, who did not know about method of positioning, was called into operating room and adjusted the patient's position the best she could, then evaluated the previous position as : very good, good and unsatisfied. The anesthesiologist, who also did not know about method of positioning, palpated the patient's interspinous space before and after adjustment by nurse anesthetist and commented about improvement of the width of space as : wider, not change and narrower. The results showed significantly better positioning by using photograph (very good = 73.4%, good = 22.3% and unsatisfied = 3.3%) compared to control group (very good = 3.3%, good = 46.7% and unsatisfied = 50%), p < 0.0001. Adjustment of position which increased interspinous width in the visual-aided group (30%) was significantly less than control group (56.7%) with no change more common in study group (60%) than control group (36.6). These meant that visual-aided positioning needed adjustment significantly less than the conventional method. The time used to identify epidural space by loss of resistance technique and number of needle insertion in visual-aided group were less than in control group, but there was no statistical difference. Successful epidural block in visual-aided group (96.7%) was higher than in control group (90%) but there was no statistical difference. We concluded that photograph of standard position for epidural block can be used as a visual aid to improve positioning in obstetric patients scheduled for cesarean section.
Index to previous edition of Thai Journal of Anesthesia was also included in this volume.
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The incidence,perioperative factors and clinical signs of immediate postoperative hypoxemia in recovery roomChatrkaw P.,M.D.,Mahutchawaroj N.,M.D.,Werawatganon T.,M.D.,Somboonviboon W.,M.D.,Amnauyphol S.,R.N.*
Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330
*Department of Anesthesiology, Chulalongkorn Memorial Hospital, Thai Redcross Society, Bnagkok 10330
After anesthesia, one of the most common hazardous problems is hypoxemia. The aims of this cross-sectional observation study were to investigate the incidence of immediate postoperative hypoxemia (SpO2 < 94% or PaO2 < 70 mmHg), to evaluate the influence of perioperative factors and to determine the usefulness of clinical signs. In recovery room,209 healthy adult patients,undergoing elective surgery under general anesthesia, were continuously monitored the oxygen saturation during spontaneous room air breathing. In addition, observers recorded the perioperative factors and clinical signs such as Aldrete's score, breathing characteristics, surface color, etc. The Student t-test, chi-square and Mann-Whitney U test were used to determine statistical significance (p<0.05). The result showed at least one hypoxemic episode in 38.3%. This group had older age, more body mass index, higher ASA physical status and lower preoperative, first postoperative SpO2 and Aldrete's score than the non-hypoxemic group. Both groups also had difference in anesthetic technique, depth of breathing and surface color. However, the level of consciousness, rate and pattern of breathing were not statistically different. Among fifty-nine patients who responded to tactile or verbal stimuli, breathed normally with surface color pink to red and gained Aldrete's score 9-10, 13 patients yet had episode of hypoxemia (22%). In conclusion, immediate postoperative patients had unexpectedly high incidence of hypoxemia. The hypoxemic patients had some factors different from those of non-hypoxemic. Hypoxemia might be found in any case even though he was arousable, had good color and normal breathing.
Propofol for sedation and anesthesia for colonoscopy
W. Waikakul, S. Pausawasdi, P. Thongcharoen.
Department of Anesthesiology, Ramathibodi Hospital, Mahidol University, Bangkok,
Thailand.
Aim of Investigation To find out the dose and outcome of using Propofol as a sedative and anesthesisa in patients who underwent colonoscopy.
Methods The study was an open, prospective one in ASA 1-3 patients as day-case surgery. No premedication was given. Propofol 1-2 mg/kg was given as an induction dose followed by continuous infusion or bolus doses as maintenance. Biographic data, patients'response and complications were recorede and their relationships to the doses were analysed.
Results There were 40 patients, 18 males and 22 females. Age 16-74 (53.08+13.83) yrs. Average indution dose was 1.63 mg/kg. Average maintenance dose was 0.082+0.048 mg/kg/min for anesthetic time of 36.18+18.35 min. Average recovery time was 5.43+6.02 min white discharge time was 48.6+21.86 min. ASA2 patients responded to verbal command later than ASA1 patients although needed less drug. Scopolamine, antispasmodec used by the surgeons, delayed emergence and discharge time significantly. Hypotension (BP less than 20% of control) was found in 75% of the patients. There was no serious complication.
Conclusion Propofol was found to be save and good for colonoscopy which needed a unique anesthetic care that is sedation together with anesthesia.
Propofol for inproving recovery from halothane anesthesia
T. Werawatganon, P. Bunburaphong, P. Chatrkaes.
Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
Propofol had been claimed to have rapid awakening and antiemetic effect, when
it was infused during total intravenous anesthesia. Nausea, vomiting, confusion,
and delayed recovery time were not uncommon after inhaloationanesthesia. The
objective of this study was to improve these problems by adding a small dose
(1 mg/kg) of propofol before the end of conventional anesthesia. 120 elective
gynecological patients were included and randomized into 4 groups. The study
was divided into 2 phases. Phase I was a comparison between halothane versus
halothane plus propofol Phase II was a controlled trial between propofol infusion
halothane plus propofol. After the operation, nausea, vomiting, sedation score,
orientation, visual analog pain score, awareness and complication such as restlessness
were observed for 6 hours
In phase I, halothane plus propofol group had better orientation than halothane group
Transtracheal Injection of Lidocaine for Fiberoptic Nasotracheal Intubation for difficult airway
Anchalee Techanivate, M.D.*,Ruenreong Leelanukrom,M.D.*,Wanna
Somboonviboon,M.D*.
Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University,
Bangkok 10330, Thailand.
The objective of the study was to evaluate the success rate of fiberoptic nasotracheal intubation, using transtracheal injection and nasal spray of local anesthetics plus intravenous sedation. Thirty patients ASA I-II, undergoing elective surgery who suspected diffecult intubation were allocated in this study. The success rate was 86.67% infirst attempt and 100% in second attempt. The mean duration of fiberoptic nasotracheal intubation was 2.83+0.21 minutes. There were no serious complications such as hypoxemia, arrhythmia or postoperative airway edama. We can conclude that this technique is useful and safe for fiberoptic intubation in patient who suspected difficult intubation.
Cardlopulmonary Bypass And thyroid Function : In Valvular
Replacement Patients
Virankabutra T,MD.,Pukrittiyakamee P, MD., Kuntakudusadi B, MD. et al.
Department of Medicine, Faculty of Medicine, Ramathibodl Hospital, Mahidol University, Bangkok 10400.
The purpose of this prospective study was to define the effect of cardiopulmonary bypass on thyroid function in 25 patients undergoing valvular replacement surgery. Serum samples were obtained before anesthesia, half and hour after bypass and at 1 and 24 hours postoperatively. Thyroid-stimulating hormone (TSH), thyr oxine (T4), trio do thyronine (T3), free (4 and reverse (3 levels were measured by chemiluminescent assay. Values of TSH, T4, T3, free T4 were significantly decreased upto 24 hours after bypass (p<0.001) while reverse T3 level increased approximately two folps postoperatively (P<0.001). These results indicate that cardiopulmonary bypass triggered changes in thyroid function. These changes simulated low T3 syndrome and are progressively exacerbated during postoperative period.
Comparison of the Placoment of Left Sided Double-Lumen Endobronchial Tube with the Univentr Tube for One-Lung Ventllation
Ketchada Uerpairojkit, MD.,Karunpan Surapong, MD.,
Department of Anesthesiology, Chulalongkorn University.
The objective of the study is to compare the left sided duoble-lumen endobronchial tube and the UniventR tube with movable bronchial blocker for one-lung ventilation (OLV) during the anesthesia for noncardiac thoracic surgical procedures. The following were studied : 1) ease of vocal cord passing 2) percentage of correct side of bronchial blockade by blind technique3) ease of insertion of flexible-fiberoptic bronchoscopes and suction4) peak airway pressure during OLV and 5) surgical exposure. 60 patients were equally divided into two groups. The patients in group I were intubatied with left
sided double-lumen tubes (DLT) and in group II with UniventR tubes. The double-lumen tubes were blindly placed and the position was assessed by auscultation or flexible-fiberoptic bronchoscopy. The UniventR tubes were placed by blind rotation method and the bronchial blockers were cheched and repositioned by the flexible-fiberop-ticbroncho scepy. Ease of vocal cord passing, fiberoptic bronchoscope insertion and suction were assessed by anesthesiologists and surgical exposure was evaluated by surgeons. Peak airway pressure and complication during OLV were recorded. No statistical differences were found in the ease of vocal cord passing by the different tubes. The perentage of correct-sided bronchial blockade were 90% in DLT group, 89.47% and 66.67% in UniventR group with right and left sided blockade respectively. 7.41% of the correct-sided bronchial blockade of DLT was detected as malposition. After repositioning of the patients, 8.00% in DLT group and more than 19.05% in UniventR group were ditected as malposilion. The insertion of flexible-fiberoptic bronchoscopes and suction was easily performed via UniventR tybe (p-0.000). Peak airway pressure in UniventR group was lower than in DLT group (UniventR 27.82+7.79 cm H2O vs DLT 33.19+7.64 cm H2OO, P<0.019). Surgical exposure in DLT group is better than in UniventR (p<0.019).
In conclusion, UniventR tube allows more ease of insertion of fiberoptic bronchoscopes and suction and lower peak airway pressure during OLV due to bigger internal diameter, but left sided double -lumen tube provides more reliable lung isolation. Each technic offers particular advantages over the other, so selection of the technique will depend on each surgical indication and an individual patient.
Reduction of pain during propofol injection: a comparison between thiopentone pretreatment and lidocaine-propofol mixture.
Thongsukh V.,M.D., Viengteerawat S.,M.D., Saengkaew T.,M.D.
Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400
We performed the study to compare propofol injection pain between pretreatment with thiopentine prior to induction of anesthesia with propofol and lidocaine-propofol mixture. The 120 unpremedicated patients ASA class 1 or 2 were allocated to 4 groups. Group 1 was injected with NSS 2 ml before propofol injection. Group 2 was pretreated with 2.5% thiopentone 2 ml 2 min before propofol injection. Group 3 was injected with 2.5% thiopentone 2 ml immediately before propofol injection. Group 4 was injected with lidocaine-propofol mixture(propofol 180 mg and lidocaine 20 mg). These patients were assessed with verbal rating sclae for injection pain during administration of propofol. The number of patients showing pain in each group were 93,70,40 and 30% respectively. We concluded that group 3,thiopentone just before propofol,could reduce injection pain significantly. However,when compared with group 4,lidocaine plus propofol, it did not differ. Pretreatment with thiopentone is another choice in reducing propofol injection pain other than adding lidocaine to the drug.
Anesthesia in preganancy with cyanotic heart disease
Tontisirin O.,M.D.
Department of Anesthesiology, Ramathibodi Hospital, Bangkok 10400
Anesthetic management of pregnant patients with cyanotic heart disease is very challenging because of the severities of clinical conditions, complications and high maternal mortality rate. Effective team work should be organized for proper maternal care during antepartum, intrapartum and postpartum periods. If the mother faces the life-threatening situation, termination of pregnancy may be necessary. The antepartum care should aim to stabilize and optimize maternal conditions and close monitor fetal conditions. Vaginal delivery by low forceps extraction under epidural analgesia is a preferable procedure. For cesarean section, continuous epidural anesthesia is the anesthetic technique of choice due to less catecholamine release and better pain relief. If general anesthesia is used, high-dose narcotic technique is preferable to inhalation. Adequate analgesia should be provided postoperatively together with close monitoring of vital signs in case of heart failure.
Volume 23;Number 2:1997 April-September
HIV Screening in Trauma Patients (December 1994-March 1995)
Tonmukayakul P, M.D.,* Santawat U, M.D.,*Bunsaeng N, B.N.,* Lertakayamanee J, M.D.,* Somprakit P, M.D.*
*Department of Anesthesiology, Siriraj Hospital, Faculty of Medicine, Mahidol University, Bangkok 10700.
HIV (human immunodeficiency virus) infected patients are increasingly seen in emergency rooms and traauma centers because the number of infected patients is large and growing. This study’s objectives are to survey the seroprevalence in the trauma patients who were treated in resuscitation room and operating rooms of a general hospital, epidemiologic data and HIV risk factors and whether the result of the investigation were known before anesthesia and operation. Screening test for HIV was the enzymelinked immunosorbent assay method (Elisa). Results showed HIV seropositivity of the studied trauma patients to be 2.7 percent (11/408). HIV antibody was found in patients of age 18-33, male : female =10 : 1,7 patients were employees, 1 patient had the history of transfusion, 2 patients had tattoo. The report of HIV screening was late in both elective and emergency surgery. The results were known before operation in only 10.3 percent of elective cases and 0.4 percent of emergency case. Anesthesia personnel must strictly practice the universal precaution when looking after trauma patients.
Intravenous Morphine in the PACU for Postoperative Pain Relief*
Sanansilp V, M.D.,** Mahuntasanapong W, M.D.,** phoncharoensomboon P, M.D.**
*This study received a research grant support from Faculty of Medicine, siriraj Hospital,
**Department of Anesthesiology, sirirag Hospital, Mahidol University, Bangkok 10700.
This prospective randomized control trial aimed to study whether the administration of intravenous morphine in the Post-anesthesia Care Unit (PACU) can reduce postoperative analgesic requirement at ward compare with conventional method and to find the optimum dose of morphine for administration in the PACU.
Eighty patients undergoing gynecological operation were studied for 24 hours after operation. Forty patients, the control group, received morphine intramuscularly on demand every 6 hours as a conventional method, no pain medication received in the PACU. In the PACU, morphine was administered intravenously in titration manner to 40 patients, the intravenous morphine group, starting with 0.04 mg/kg, then 0.02 mg/kg every 10 minutes until they felt comfortable or the morphine dosage reached 0.1 mg/kg. The patients were evaluated at a 10 minutes interval after each injection for sedative score, pain score, pain relief score and vital signs. At ward, morphine was given intramuscularly to the patients as required.
We found that the duration from the end of the operation to the first morphine intramuscular injection at ward in the intravenous morphine group was statistically significant longer than the control group. The amount of morphine needed by the patients in the PACU directly related to their first pain scores after recovering from anesthesia. The amount of morphine and the number of morphine injections during 24 hours post-operation for the intravenous morphine group was significantly less than the control group. No patient had respiratory depression.
We concluded that the administration of intravenous morphine in the PACU could make the patients more comfortable for a longer period of time and decrease frequency and amount of analgesic requirement, and the dosage of morphine given in the PACU was related to their first pain score after recovering from anesthesia.
Key words : Intravenous morphine, PACU, postoperative pain relief.
The Efficacy of Ginger Root on Postoperative Nausea and Vomiting after Outpatient Gynaecologic Laparoscopy a Randomized Double Blind Placebo Controlled Comparison with Droperidol
Visalyaputra S, M.D.,* Petchapisit N, M.D.,* Choavaratana R, M.D.,** Sauwakont R,*** Roongvejwudwithaya Y, *** Sawadimongkol O,*** Somcharoen K, R.N.,* Piyapat S, R.N.*
*Department of Anesthesiology, **Department of OB-GYN, Siriraj Hospital, Bangkok 10700, *** Department of Pharmacology, Mahidol University, Bangkok 10400.
To determine the antiemetic effect of ginger root as compared to droperidol, 120 patients ASA I and II, scheduled to have gynaecologic laparoscopy were randomly devided into 4 groups to receive placebo capsules and normal saline injection (control gr), placebo capsules and droperidol 1.25 mg (droperidol gr), 2 grams of ginger capsules and normal saline injection (ginger gr), and 2 grams of ginger capsules plus droperidol 1.25 mg (ginger plus droperidol gr). Each patient received 2 capsules (either 1 gm of ginger or placebo) orally 1 hour prior to induction of anesthesia. Thiopental 5 mg.kg was given for induction and intubation was done by using succinyl choline 1.5 mg/kg and maintenanced with N2O : O2 and halothane. Another 2 capsules (1 gm ginger or placebo) were given 3 hours after the first 2 capsules and waited for half an hour to get action before discharge home. The incidences of nausea were 32% ,20%,22% and 33% in the control, droperidol, ginger and ginger plus droperidol groups respectively, and the incidences of vomiting were 35%,15%,25% and 25% in each group respectively without significant differences. There was no significant difference in the side effects. Between the 4 groups. We concluded that ginger 2 gm, droperidol 1.25 mg or both can not decrease the incidence of nausea and vomiting in patients having gynaecologic laparoscopy.
Comparison of Using Laryngeal Mask Airway and Standard Face mask by Nurse Anesthetist Trainees
Thienthong S, M.D.,*Krisanaprakonkit W, M.D.,*Simacharuk S, M.Sc.*
*Department of Anesthesiology, Faculty of Medicine, Khonkhaen University, Khonkhaen
Management of general anesthesia by standard face mask (FM) and laryngeal mask airway (LMA) was studied in 34 nurse anesthetist trainees with at least 6 months of clinical experience but no previous experience using the LMA. General anesthesia was induced with sodium thiopentone and maintained with nitrous oxide, oxygen and halothane in both groups. Succinylcholine 1 mg/kg was given for insertion of the LMA. Success rate of LMA insertion, airway problems during maintenance of anesthesia, the ease of their management and complications during and postoperative period were recorded.
The result showed that most of the trainees successed their anesthesia mangement. Airway problems were not statistically different (29.41% in FM group and 11.76% in LMA group for partial airway obstruction and 17.65% in FM group and 8.2% in LMA group for SpO2 less than 95%) but trauma in the oral cavity occured only in the LMA group (8.82%). Other intra and postoperative complications were comparable.
Duration of anesthesia was logger in the LMA group (92.50?62.49 vs 52.50?28.48 minutes). With the LMA, the mandible was lesser supported (5.89 vs 85.29%) and the operators’ hands were lesser fatigue. Most of the trainees felt that airway management by LMA was easier than by FM. Success rate of LMA insertion was 76.47% and mean duration of insertion was 51.31?21.09 minutes. This study suggests that the LMA might be a useful aid in airway management and nurse anesthetists should be trained to use it as alternative technique for general anesthesia.
Key words : Laryngeal mask airway, face mask, murse anesthetists
Comparison Sevoflurane with Halothane in Ambulatory Pediatric Anesthesia
Leelanukrom R, M.D., *Somboonviboon W, M.D.,* Charoenphol P, M.D.*
*Department of Anesthesiology, Faculyt of Medicine, Chulalongkorn University, Bangkok 10330
Sevoflurane is a new inhalational anesthetic suitable for pediatric anesthesia because of rapid and smooth induction and less airway irritation effect. Induction and recovery characteristics of sevoflurane was compared with halothane in ambulatory pediatric surgery. Anesthesia was induced with either sevoflurane or halothane in nitrous oxide and oxygen via face mask in incremental doses to maximum inspired concentration of 6 and 3% respectively. The patients were maintained under face mask with spontaneously breathing during the operation. Regional nerve block or local infiltration was performed when appropriatd. Induction time of sevoflurane was statistically significant more rapid than of halothane (58.96?27.3 and 163?91.9 sec).
Cardiovascular effect : heart rate was more stable in sevoflurane. Incidences of airway reflex responses of sevoflurane were less than halothane but without statistically significance. Early recovery evidenced by the times to eye opening and fully conscious after sevoflurane was more rapid than after halothane (but without statistically significance), although time to discharge from hospital was similar in both groups. There fore sevoflurane is a preferrable inhalational anesthetic in pediatric anesthesia, especially for induction of anesthesia.
Comparative Study the Effect of Sevoflurane, Isoflurane and Halothane in Induction and Maintenance of Anesthesia
Chinchoti T, M.D.,*Jurachart D, M.D.*
*Department of Anesthesiology, Faculty of Medicine, Mahidol University, Bangkok 10700
Ninety ASA physical status I or II patients aged 15-55 years, scheduled for elective surgery within 90 minutes, received one of three volatile anesthetics : sevoflurane, isoflurane or halothane. Anesthesia was induced with pentothal followed by 0.5 minimum alveolar concentration (MAC) of the anesthetic in 70% nitrous oxide wi30% oxygen by mask. The inspired concentration of anesthetic was increased by 0.5 MAC every 4-5 breaths till no response to pain stimuli. Induction time, maintenance concentration, recovery time and anesthetic complications were recorded.The results of this study demonstrated that sevoflurane could induce anesthesia as rapid as halothane and both took less time than isoflurane significantly. Airway irritation and tachycardia were found more in sioflurane group. Short recovery period was found in sevoflurane group significantly compared to other two groups.
Local Lidocanine, Propofol and Ketamine for Anesthesia in Cystoscopy Panthawangked
J, M.D.,* Santati-anan J, M.D.,* Lertakyamanee J, M.D., **Somprakit P, M.D.,**Soontrapa S, M.D.,*** Tantiwong A, M.D., ***Udompunturak S, M.Sc.****
*Department of Anesthesiology, **Department of Anesthesiology and Siriraj Clinical Epidemiology Unit,
***Department of Surgery, ****Siriraj Clinical Epidemiology Unit, Faculty of Medicine, Siriraj Hospital, Bangkok 10700. This research is supported by faculty of Medicine, Siriraj Hospital Fund.
This study was undertaken to evaluate and compare the effectiveness and side effects among propofol, keamine and local anesthesia in the patients undergoing cystoscopy. We had two steps in the study. Step I : forty-eight males in group I received 10 ml of 2% lidocaine jelly to lubricate and anesthetize the urethra and were cystoscopied by staff urologists (n=24) or residents (n=24). Step II : another forty-eight males, after lubrication with 2% lidocaine jelly, were randomly allocated to receive propofol 2 mg/kg IV in group II (n=24) or ketamine 0.5 mg/kg plus midazolam 0.04 mk/kg IV in group III (n=24). We recorded the pain score and satisfaction score by using verbal rating scale and visual analogue scale. The average pain score of group I (48?2.2) was significantly higher than group II (0.2?0.6) and group III (0.2?0.5). The satisfaction score of group I (6.7?2.1) was significantly lower than group II (9.2?1.1 and group III (8.8?1.6). Group II and III were not significantly different. If they were to have cystoscopy again, all patients in group II and 90% in group III would choose the same drugs. Only 57% of patients in the local anesthesia (staff subgroup) and 22% in the local anesthesia (resident subgroup) would like to have local anesthesia for the next time. When comparing the recovery from anesthesia, the time to discharge in propofol group (48.0?15.4 min) was significantly shorter than in ketamine group (92.9?47.9 min) and they also had fewer side effects (nausea, vomiting, vertigo and headache). We concluded that intravenous anesthetic techniques resulted in better quality of care than local anesthesia alone.
The Final Inspection of New Gas Delivery System in Queen Sirikit Hospital
Leiu. Com. Limprayoon J, M.D.,* Capt. Hatajich P, M.D.,* Capt. Chaimuangraj P,M.D.*
*Devision of Anesthesiology, royal Thai Navy Hospital, Royal Thai Navy Medical Department, Bangkok 10600.
Most healthcare facilities use piping system to deliver medical gasses (oxygen, nitrous oxide, air, nitrogen) and vacuum to operating rooms, wards, ICU and other area where they are needed. When medical gas system is installed, modified or repaired, it is essential that such a system is thoroughly tested before being put into use. Errors during installation can lead to many incidents of hazard such as crossed medical gas and vacuum pipelines which resulted in patient death.
Queen Sirikit Hospital, a new one in Cholburi province, had 1,000 beds and 30 operating rooms. It was opened the first phase on November 15th, 1996 with 300 beds in use. After completing installation of medical gas system, the mechanical contractors tested the entire system and corrected the errors. In October 1996, the Royal Thai Navy Medical Department sent the anesthesiology team, other medical staffs and technicians to carry out the final (commissioning) tests to make sure the piping system complies with regulations. Twenty eight defects in leakage were found in operating rooms and patient wards. Most of them resulted from the O-ring in the wall outlets not completely sealed. The eighe gas pressure-alarm equipment were malfunction. We found the particulate matters from the gas outlets in the fifteen operating rooms and one patient ward. In the central plant, one of two vacuum pumps was detected nonfunction due to failure of the control switch. No cross-connection was detected. The total flow test and gas purity check cannot be performed efficiently because of the lack of testing equipment.
We suggest that it is necessary to conduct the final inspection of the new piping system by medical staff of the hospital before using for patient safety. Do you think it is time to formulate our own stringent standard for the installation and testing such new system, which should be required to certify by and engineering firm?
Meningitis Follwing Epidural Anesthesia for Cesarean Section
Sujirattanawimol K, M.D.,*Techakittiroj N, M.D.,* Ae-mornkun R, M.D.*
*Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700.
Meningitis after epidural anesthesia is a rare event. We report a case of parturient who received epidural aneshtesia for cesarean section with the indication of prolonged rupture of the membranes and cephalopelvic disproportion. Epidural block was succeeded after two insertions under aseptic technique. The operation was uneventful. The epidural catheter was removed at the end of the operation. On the third postoperative day, the patient developed severe headache, fever and nuchal rigiedity. Lumbar puncture was performed and turdid cerebrospinal fluid (CSF) was found. Although the CSF culture was negative, microscopic and chemical examination of CSF correlated with bacterial meningitis. The symptoms also disappeared after antibiotics therapy. Recovery was complete. A possible cause of contamination was hematogenous spread because the membranes had ruptured for more than 24 hours before delivery and that might caused transient bacteremia. Since epidural vein was punctured by the catheter during the block, the chance of infection might be increased.
Volume
23;Number 1:1997 January-March
Comparison of EMLA Cream and Penile Nerve Block for Surgical Analgesia for Circumcision in Children
Raksamani A,M.D.,* Rushatamukayanand W,M.D.,* Tritrakarn
T,M.D.* *Department of Anesthesiology, Faculty
of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700.
A prospective study was done in 27 boys
(age 3-14, mean 8,6 years) subject to circumcision for religious
purpose at a mobile medical unit. Fourteen boys were assigned
to receive EMLA cream 1-3 ml pushed through the opening of the
prepuce and 3-7 ml covered the foreskin under an occlusive dressing
and 13 boys received 3-7 ml of 2% lidocaine for dorsal nerve
of penis blockade and / or a subcutaneous ring block of penis.
Successful anesthesia was found in 4 out of 14 (28.6%) in EMLA
group and 11 in 13 (84.6%) in the block group. Additional local
infiltration or penile nerve block had to be given in 10 out of
14 (71.4%) in EMLA group and 2 of 13 (15.4%) in the block group.
Penile nerve block was found to be superior to EMLA cream in
producing surgical analgesia for circumcision in these children.
Phimosis and adhesion of the foreskin to the glans penis interfering
the spreading of the cream to the inner surface of the prepuce
resulting in sparing of some area of the inner surface may be
a major contributing factor to the high failure rate of the EMLA
cream.
Potential Hazards of Compressed Gas Cylinders : a Survey in Siriraj Hospita
Soontranan P, M.D.,* Iamaroon A, M.D.,* Halilamien P, M.D.,* Lertakyamanee J, F.R.C.A.**
Somprakit P, F.R.C.A.,**
*Department of Anesthesiology, **Department of Anesthesiology
and Clinical Epidemiology Unit, Faculty of Medicine, Siriraj Hospital,
Bangkok 10700
Descriptive cross-sectional study was done to investigate all compressed gas cylinders in clinical use at Siriraj hospital. We checked the gas concentration, service pressure, gas symbol, general appearance, cylinder marking, plastic wrapper, cylinder cap, tag and placement. There were 799 cylinders of O2, N2O, AIR, CO2 and N2=445 (55.6%),216 (27.0%),124 (15.5%),9 (1.3%) and 5 (0.6%) cylinders respectively . They were of 3 sizes of E, G and H = 289 (36.2%) , 37 (4.6%) and 473 (59.2%) cylinders respectively. The concentration of O2 and N2O were all correct. The numbers of gas cylinders was not less than 21%, the concentration of CO2 and N2 were not investigated due to the lack of gas analyser . The numbers of gas cylinders with optimal, over and under service pressure were 19 (2.4%), 142 (17.8%) and 638 (79.8%) respectively. The maximal pressure of O2, N2O AIR and CO2 in cylinders were 3,000. 792, 2,400 and 1,000 psig respectively. The colour of O2, N2O, AIR, CO2, and N2 cylinders were wrong in 334, 186, 124, 6 and 5 cylinders which were 75.1. 86.1, 100.0,66.7 and 100.0% of the individual gas respectively. The symbols of gas were nit standard in 590 (73.8%) cylinders. No cylinder had complete markings on its shoulder. Visual inspection showed that 593 (74.2%) cylinders were not in good general appearance because of rust and scratch on the cylinder surface. The number of defect cylinder valves were 35 (4.4%) . The number of cylinders without plastic wrappers, cylinder caps and tags were 789 (98.7%) ,796 (99.6%) and 798 (99.9%) respectively. There were 714 cylinders (89.4%) that were left freestanding or unsupported on the floor.
The contributing factors of these potential
hazards are ignorance of safety precaution and lack of knowledge.
We propose that the education on standards of compressed gasses
and cylinders should be established, and that safe practice should
be established, and that safe practice should be encouraged in
all hospitals and manufacturers.
Key words : Anesthesia : cylinder, hazard, safety
Accuracy for Detection of Endotracheal Tube Position by Home-made Esophageal Detector Device in Full-stomach Patients.
Limpisathian K,M.D.,* Thaworanun J,M.D.,* Vorrakitpokathorn P,M.D.,* Prakkamodom S,B.N.*
*Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Bangkok 10700
To ascertain that home-made EDD can detect position of endotracheal tube in full stomach patients as accurate as in empty stomach patients (which was studied befor.
By prospective double blind trial, we studied 76 full-stomach patients who
had to be emergency operated. Among these patients who had to be emergency operated.
Among these patients, there were 63 female and 13 male, aging between 14-60
years. Mean arterial pressure, HR, SpO2 before and after detection
and time consuming for detection were recorded. The results showed that sensitivity
and specificity for detection are 100% . There were no significant changes in
mean BP, HR,SpO2, p<0.1 (MBP changed from 108.8+-11.3 mmHg, Hr103.213.6
to 103.34.2 bpm and Spo2 from 98.5 +- 12 to98.1+-1.4%) and time consumed
for detection were 15.8+-7.1 seconds which was in acceptable range.
In conclusion, our study succeed to demonstrate that home-made EDD has an advantage and very accurate for detection position of endotracheal tube even in full stomach patients.
Quality of Reused Endotracheal Tube
Srirojanakul W,M.D.,* Chaikul B,B.N.,* Wattanakul R, B.N.,* Piyapat S,B.N.,* Chaiyaroj O, B.N.,*
Phettongkam A,B.M.,* Mantraporn N,B.N.,* Maneenoy S,M.sc.*
*Department of Anesthesiology, ** Siriraj Computer Center,
Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700
This study aimed to compare the quality of the cuff and the complication of the four-times reused endotracheal tubes. Six hundred and ninty-nine female patients undergoing general anesthesia for gynecological surgery were randomly allocated into 4 groups according to the types of endotracheal tube: Curity, Portex, Rusch and Sherwood. After intubation, all cuffs were inflated with air by using just-seal technique. Inflated cuff volume, intraculf pressure at 5,10,15,20,30,45, and 60 min, deflated cuff volume and duration of intubation were recorded. All patients were interviewed postoperatively after 20-24 hours by observer who did not know which kind of tube had been used. The result show that the average intracuff pressure and inflated cuff volume of Portex tube was significant hegher than the others. The initial intracuff pressure and inflated cuff volume of Curity and Sherwood tubes were significantly decreased when reusing more than one time but no significantly decreased when reusing more than one time but no significant changes were found in Portex and Rusch tubes. None of the intracuff pressure was below 18.4 mmHg. The deflated cuff volume were significantly higher than inflated cuff volume in all kinds of tubes except Portex. The incidence of post operative sore throat and dryness feeling was not significant difference among each Kind of tubes. In conclusion, the cuff of three time reused endotracheal tube in this study were still safe in order to prevent aspiration. No significant post -operative sore throat and hoarseness of voice was found in any group.
Preuse Check Up of Anesthesia Equipment : Study of Resident Practice
Soontranan P, F.R.C.A.T.,* Nimmanrach S, M.D.,* Singthong T,M.D..,* Somprakit P, F,R,C.A.,
F.R.C.A.T,** Lertakyamanee J, F.R.C.A., F.R.C.A.T.**
*Department of Anesthesiology, **Department of Anesthesiology
and Clinical Epidemiology Unit, Faculty of Medicine, Siriraj Hospital,
Bangkok 10700
A descriptive cross-sectional study was
done to investigate the practice of "equipment preuse check
up" designed by the authors. Twenty nine anesthesia residents
were individually assigned to demonstrate their daily check up
practice, and the results were categorized into 3 groups : correctly
done, incorrectly done and not done. Seven out of the total 27
items were done by more than 50% of the residents (ranking from
100 to 51.7%) which were ;-ve pressure leak test (vaporizer
off), +ve pressure leak test of breathing system, power supply
of ventilator, O2 supply failure alarm, cylinder cross
connection, -ve pressure leak test of breathing system, power
supply of ventilator, CO2 absorber. Among these 7
items, only 2 items were correctly done by 100% of residents,
1 item by 90.9% and the other 4 were correctly done b 16.6-52.6%.
there were 6 items which fewer than 10% of residents did (3 items of scavenging system,
check self-inflating bag, calibrate the O2 analyser
and monitor). Two items were done by none (0%), which were ;
verification of O2 from O2 flushing device
and check ventilator expiratory valve. The contributing factors
of failure to check equipment are lack of knowledge, negligence,
no guideline available in OR, check up regulation is not reinforced,
unfamiliar with checking equipment, no skill and the recommended
guidelines are not practical. We suggest that improvement of
teaching and regulation enforcement are needed together with further
evaluation should be done.
Key words : Anesthesia : equipment, preuse check
up, safety
The Effect of Nicardipine on the Circulatory Response to Laryngoscopy and Intubation Akavipat P, M.D.*
*Department of Anesthesia, Prasat Neurological Institute,
Bangkok 10400
This objective was to study the effect
of nicardipine in varied doses on the circulatory response to
laryngoscopy and intubation. Sixty patients of ASA 1-2 were randomized
into 3 groups. The baseline blood pressure(BP) and heart rate
(HR) were recorded, induction with thiopental 5 mg/Kg, vecuronium
0.1 mg/Kg 0.5% halothane in 100% oxygen and recorded BP,HR at
1,2 minute after, then administered intravenous saline 5 ml,
micardipine 20 ug/Kg, nicardipine 30 ug/Kg in group 1,2,3 respectively.
After 1 minute, recorded HR again. Applied laryngoscope, intubated,
recorded BP,HR immediately and next every 1 minute for 4 times.
The result showed that BP after laryngoscopy and intubation
in group 1,2 were increased significantly when compared with
baseline and turned to normal in 3 minute. In group 3, the
BP was not changed significantly but it was decreased in 3 minute
but not less than 12% . The HR in all groups were increased
significantly and group 2,3 were increased more than group 1.
In conclusion, nicardipine 30 ug/kg
administered 1 minute before is effective in controlling
BP after laryngoscopy and intubation until 3 minute but not effective
in controlling HR.
Key words : pharmacology : nicardipine
Cardiovascular response : intubation, hypertension
Evaluation of High Volume, Low pressure Endotracheal Tube Cuff for Appropriated Intracuff
Pressure by Nurse Anesthetists in General anesthesia
Sinkuakool C,M.D.,* Muknumporn T, B.Sc. (Nursing)*
*Department of Anesthesiology, Faculty of Medicine,
srinagarind Hospital, Khon Kaen University, Khon kacn. 40002
Sixty male patients, ASA I-II underwent
elective surgery, were randomly intubated by twenty nurse anesthetists
(9 experienced<-3 years and 11experienced>3 years) from
three different products of high volume, low pressure endotracheal
tube cuff, size 8.0 mm internal diameter (20 {portex@
blue line, 20 Curity @and 20 Mallinckrodt@).
After successful intubation, the cuff was inflated with minimum
occluding volume until was inflated with minimum occluding volume
unit no-leak was detected (just-seal technique). Then intracuff
pressure was measured. It was found that only 18.33% was appropriated
intracuff pressure (normal range 20-25 mmHg) in all 3 groups.
(25% Portex,@ 10% Curity@ and 20% Mallinckrodt@)
while inappropiated intracuff pressure was 81.67% (overpressure
11.67% and underpressure 70%). It has no statistical differences
between intracuff pressure measured and experience of nurse anesthetists
of product of endotracheal tubes. In conclusion, endotracheal
tube cuff inflated by subjective assessment was unreliable and
danger to the intubated patients if underpressure (risk of aspiration
and tidal volume leakage) or overpressure (risk of tracheal mucosal
damage, cartilagenous necrosis and tracheal stenosis subsequence
if prolonged intubation). Therefore using the objective
systems for intracuff pressure measurement may be useful and more
reliable. It can prevent or reduce complications if use as routine
practice in intubated patients boths in and out of operating
theater.
Key words : High volume-low pressure endotracheal
tube cuff, intracuff pressure, just-seal technique
Volume 22;Number 4:1996 October-December
Increasing Dose of Mivacurium Chloride at 0.2 , 0.25 and 0.3 mg/kg and Tracheal
Intubation
Condition at 60 Seconds during Induction of Anesthesia with
Thiopental
Chinachoti T, M.D.,* Pramanpol S, M.A., ** Chumpathong S,
M.D.*
*Department of Anesthesia, Faculty of Medicine, Siriraj Hospital,
Mahidol
University, Bangkok 10700
** ASEAM Institute for Health Development, Mahidol University,
Salaya,
Barigkok 10700, Thailand
Three doses of mivactirium chloride of 0.2, 0.25 and 0.3 mg/kg were studied
in sixty patients during induction of anesthesia with thiopental. Slow injection of
mivacurium within 30 seconds was performed before induction of anesthesia.
Tracheal intubation conditions and depressed twitch tension were recorded at 60
seconds after induction of anesthesia with 4-5 mg/kg of thiopental. Tracheal
intubation conditions was statistically improved in group ofmivacurium chloride
0.3 mglkg.
Depressed twitch tension at 60 seconds and time to maximal response among
the three groups were slightly different without statistically significant. Duration
of 0.3 mg/kg mivacuriiim chloride was longer than the other two groups
statistically significant. We concluded that increasing dose of mivacurium
chloride from 0.2 to 0.3 mg/kg could improved clinical tracheal intubation
condition at 60 seconds.
Clinical Pharmacology of Mivacurium Chloride in Thai Patients
for Non-emergency Operations
Chinachoti T, M.D.,* Chumpathong S, M.D.,* Tunithong P, M.D.,
* Wangthaweesilp K, M.D.*
* Department of Anesthesiology, Faculty of Medicine, Siriraj
Hospital, Mahidol University, Bangkok 10700
Mivacurium chloride (BW B1090 U), a bisbenzylisoquinolium diester compound, is a new short-acting non-depolarizing neuromuscular blocking agent. Camparative clinical pharmacology of onset, duration, type of administration and side effect were study in 40 Thai patients. Continuous records of machanomyogram of adductor pollicis to ulnar nerve stimulation were used to determine degree of neuromuscular blocking effect. Single twitch depression and train-of-four were used to represent onset, potency and duration of drugs. Depression of twitch height at 25, 50, 75% were faster in dose of 0.25 mg/kg to 0.2 mglkg mivacurium chloride but both bolus dose reached to time of 90% depression of twitch height and maximal onset time with no statistically significant.
Clinical tracheal intubation conditions were good to excellent in 95% of patients at 2.5-3.5 minutes. Both intermittent bolus and infusion techniques could be used easily to maintain relaxation during operation without any problems of reversal. Bradycardia and skin rash were found 20 and 5% respectively in study group. Slower injection and atropine premedication were strongly recommended.
Propofol-Fentanyl VS. Thiopental-Isonurane for Neurosurgical
Anesthesia in Thai Patients:
Comparison of Hemodynamics, Recovery and Cost Effectiveness
Ittichaikulthol W, M.D.,* Pausawasdi S, M.D.,* Srijintai P, M.D.,
* Sarnvivad P, M.D.*
* Department of Anesthesiology, Ramathibodi hospital, Bangkok
10400
Sixty Thai patients, ASA class I-II, Glasgow coma score of 15 undergoing elective intracranial surgery were randomly assigned to 2 groups. In group I, 30 patients were induced with thiopental 3.5 mg/kg, intubation with succinylcholine 1.2 mg/kg and then maintained witli 60% N20 in 02 isoflurane and vecuronium as a muscle relaxant. In group II, 30 patients received fentanyl 50 mg, propofol 1.0-2.5 mg/kg for induction and vecuronium 0.08 mg/kg for intubation then maintained with 60% N20 in 02 , continuous infusion of propofol 2-12 mg/kg/hr and vecuronium infusion as a muscle relaxant. Controlled ventilation in both., groups was set to maintain PET CO2 in the range of 28-35 mmHg. Three patients (1 in group I and 2 in group II) were excluded from the study due to surgical problem. There was no statistical difference in age, sex, ASA status, weight and dura(ion of anesthesia. Group II were more stable in systolic BP, diastolic BP and pulse rate than group 1 during induction and emergence from anesthesia. Glasgow coma scores in the recovery period were higher in group II than in group I at 5 and 15 minutes but not at 30 minutes.Mean recovery times (eye opening) was 14.03 ? 4.85 minutes in group 1 which is significantly different from 10 ? 5.17 minutes in group II. The cost of anesthesia in group II was 2 times of group I. In conclusion, although neurosurgical anesthesia for 'l'hai patients with fentanyl-propofol technique produces more stable blood pressure, rapid recovery from anesthesia and a higher Glasgow coma score, but the cost of anesthesia is doubled. Furthermore, this technique is more difficult and needs more experience.
Simplified Caudal Anesthesia for Anal Surgery
Ketanond C, M.D.,* Vongvises P, M.D.*
*Pramongkutklao Hospital, Bangkok 10400
Regional anesthesia is the technique of choice far anal surgery especially when the patient is in the Jack-Knife position. Caudal anesthesia is not popular because of the higher incidence of failure rate, toxic reaction and risk of infection, compared to epidural and spinal anesthesia. This study was to simplify the caudal anestliesia technique, its results and complications. This technique had been performed in 72 patients undergoing surgery of the anus. The effectiveness of the technique and complications were determined. In this procedure, 15 ml of 1.5% lidocaine with epinephrine 1/200,000 was injected as a local anesthetic. The effectiveness of anesthesia was classified as sastisfactory in 93%. Convulsion in one case was noted, due to intravascular injection. The simplified caudal anesthesia technique resulted In lesser risk of bleeding and intravascular injection than conventional technique, puncture of the dura was not possible. This technique may be the anesthetic technique of choice for surge of the anus but requires more practice and experience of the anesthesiologists.
Comparisions of Induction and Emergence Time between
Sevoflurane
and Halothane in Pediatric Anesthesia
Nisoong C, M.D.,* Churnchongkolkul W, M.D.,* Lapisatepun W.
M.D.,* Punjasawadwong Y, M.D.,* Nipitsukarn T, M.D.,* Arasaki Y, M.D.**
* Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200
** Departrnent of Anestliesia, Naba Prefectural Hospital, Okinawa,
Japan
The low blood/gas partition coefficient of sevoflurane (0.63) suggests that it should have rapid uptake and elimination. The authors compared the rapidity of induction and recovery after sevoflurane anesthesia with those after halothane anesthesia. Twenty unpremedicated pediatric cases undergoing either herniotomy or circumcision were randomly allocated to receive either sevoflurane (group I, N = 10) or halothane (group II, N = 10) anesthesia. Anesthesia was induced by administration of 67% N20 in 0 2 with the total flow of 6 litres per minute, in conjunction with either sevoflurane or halothane in a concentration up to 2.5 MAC. Times from the start of induction to the absence of eyelash reflex, and when the eyeballs were at central position were 61.0 (54.5, 67.0) and 140 sec (103.6, 154.0) in group I compared with 91.0 (64.0, 105.0) and 228.5 sec (166.0, 346.0) in group II respectively (p = 0.043 and 0.001).
Each agent was administered between 1.0-2.5 MAC during maintenance and was discontinued at the end of the operation. Times from discontinuation of the agent to movement of extremities, rejection of the oroPharyngeal airway and awakening (eye opening/crying) were 136.5 (32.5, 335.0), 195.0 (82.5, 354.5) and 306.5 sec (187.5, 477.5) in group 1 compared with 265.5 (200.0, 565.5), 411 (281.5, 613.5) and 515.0 sec (378.0,599.9) in group II respectively (p = 0.015, 0.004 and 0.017). The results suggest that sevoflurane may have one rapid induction and recovery than halothane.
Note Data shown in are in median and interquartile range.
Key words : Inhaled anesthetics : sevoflurane, halothane : pediatric anesthesia
The Comparison of Intrathecal Morphine Dosages for Post-operative Analgesia in Cesarean Section Patients
Ratanachai P, M.D.,* Ungkasuwan W, M.D.,* Umpa K, Cert. Nursing & Midwifery,* Bunyakiat P, B. Se. Nursing*
*Department of Anesthesiology, Hatyai hospital, Songkhla 90110
A prospective randomized study was performed to determine optimal dosage of morphine in combination with bupivacaine spinal anesthesia among cesarean section patients at Hatyai hospital during February to July 1995. One hundred and fifty cases were divided into 3 groups. Fifty one cases (group 1) were administered with 0.5% hyperbaric bupivacaine 2.4 ml (control group), 49 (group 2) and 50 cases (group 3) were administered with the same dosage of hyperbaric bupivacalne combined with 0.2 and 0.4 mg of morphine respectively. Verbal and visual analogue scale for pain score had been interviewed at 0, 1, 2, 3, 6, 9, 12, 18, 24 postoperative hours.
The result showed that group 2 and 3 had better postoperative pain relief than in group 1. Group 3 showed more potent and longer pain relief than group 2 (p
0.05). However, the side effects were more frequent in the higher morchine group but not serious and symptomatically treatable.
Key words: Intranthecal morphine, spinal morphine, postoperative analgesia, postcesarean section
First Successful Report of Anesthetic Management for
Implantation of
Automatic Implantable
Cardioverter Defibrillator in Thailand
Chinachoti T, M.D,* Chamadol S, B.N., * Parakkamodom S, B.N.,* Kwoasaard A, B.N.*
* Department of Anestheiology , Faculty of Medicine , Mahidol
University, Bangkok 10700
** Nursing Department, Siriraj Hospital, Bangkok 10700
We reported first nine successful anesthetic management for implantation of automatic implantable cardioverter defibrillator (AICD) in 'l'hailand. All of them were suspected cases of sudden cardiac arrest from malignant arrhythmia. Anesthetic technique included endotracheal intubation, controled ventilation and continuous infusion of propofol and tentanyl. During induced arrhythmia for programming tite AICD,most of them developed severe hypotension but terminated when arrhythmia were treat by cardioverter.
Communicating and understanding among team members were, the keys of success far- first step of new technology transfer. All of our patients were fully awake, hemodynamic stable, spontaneous respiration and left with calm without pain.
Volume 22;Number 3:1996 July-September 1996
A Comparison of Propofol and Thiopentone as Anesthetic Agents for Electroconvulsive Therapy
Anuntavanitkit S, M.D.,* llmpsamarn P, GN.,* Arunplord R, GN.*
* Section of Anesthesiology, Somdej Chaophya hospital, Klongsarn, Bangkok 10600.
Propofol 1.61 ? 0.34 mglkg or thiopentone 3.78 ? 0.82 mg/kg was used as anesthetic agent for eletroconvulsive therapy in 80 patients to compare the effects on duration of seizure, hemodynamic changes, and recovery. There was no significant difference in duration of seizure by observation between both of them. Propofol successfully attenuated the increase in blood pressure and heart rate after the convulsion. The recovery and early ability to walk were more rapid in the patients with propofol than thiopentone. Pain on injection and unpurposeftil movement were found in the patients with propofol but not with thiopentone.
Comparison of Halothane and Isoflurane for Laryngeal Mask Insertion in Pediatric Patients
Rungrengvanich m,m.d., *Sriswasdi S, M.D., *Soranastaporn C,M.D.*
* Department of Anesthesiology, Ramathibodi hospital, Bangkok 10400.
The laryngeal mask airway (LN1[A) is particularly useful when endotracheal intubation is either undesirable or impossible. It has been used increasingly in pediatric anesthesia. However, airway stimulation during insertion, maintenance, and removal of the A may cause coughing and laryngospasm. Since Increased airway irritability had been reported during lsoflurane anesthesia, we doubted whether isoflurane was clinically suitable for general anesthesia using the LMA. We compared the induction and recovery time,time for successful insertion of the I,MA, and the LNIArelated complication during isoflurane anesthesia in unpremedicated children under 6 years of age to those during halothane anesthesia. There was no significant difference in the induction time, time for successful insertion of the LNIA, recovery time, or LMA-related complications between isotlurane and halothane onesthesia. In conclusion, isoflurane should he as suitable as halothane for general anesthesia via the I,MA in pediattle patients.
Snergistic Effect Between Muscle Relaxants for Rapid Intubation
Chumpatbong S, M.D.,* Toomtong P, M.D.,* Tbahpenthai Y, M.D.,* Chinacboti T, M.D.*
* Department of Anesthesiology, Faculty of Medicine, Sixiraj Hospital, Mahidol 1Jniversity,
Bangkok 10700
We studied the synergistic effect in priming techniques of mivacurium or atracurium and pancuronium 0.5 mg.Sixty-one patients of ASA 1.2 were randomised into 4 groups. Mivacurium 0.025 mg/kg, pancuronium 0.5 mg, atracurium 0.06 mg/kg and pancuronium 0.5 mg were used for priming in each group respectively, 3 minutes after priming dose all patients received intubating doses of 0.25 mg/kg mivacurium in group 1 and 11 and of 0.6 mg/kg atracuiium in group 111 and IV. Intubation were performed at 60 sec after cover dose. Twitch height at 1 min, time to complete neuromuscular blockade, time to presence of 2 net TOF and intubating conditions were recorded in all patients. Twitch height at 1 min and time to complete blockade were not different statistically. Time to presence of 2 nd TOF were significantly prolonged
Continuous Infusion with Propofol and Fentanyl for Sedation during Radiofrequency Intracardiac Catheter Ablation
Chinachoti T,M.D.,*Muntraporn N,B.N.,*Chalayonnawin V,B.N.,*Suwanapiam P,B.N.*
* Department of Anesthesiology, Faculty of Medicine , Mahidol University , Bangkok 10700.
Developing of total intravenous sedation technique for prolonged, unexpected operation time were performed in 80 patients undergoing radiofrequency catheter ablation in Siriraj Hospital. The technique included oral midazolam 15 mg, intramuscular injection of 2.5 - 5 mg dehydroperidol, slow and tritrate sedation with 25 - 50 mg meperidine and 1 - 2 mg midazolam intravenously. When sedative effect was confirm we induced anesthesia with 1 - l.5 mg/kg of propofol. Oral or nasal airway was inserted, positioning patient to extend neck, 0 2 by mask with bag 10 L/min was given.
Then control sedation with propofol 1 - 3 mg/kg/hr with fentanyl 0.5 . (g/kg/hr. In 82 procedures, we successed with very good outcome for 73 (89%) with 5 mild complications and 4 of severe complications of hypoventilation during and post operation. We suggest that even this technique seem to be practically well with the operation but still not safe enough to handle by untrained personal especially in prolonged operation time, patient with congenital heart disease, ischemic heart disease and unstable hemodynamic status.
Intubation Condition of Mivacurium 0.2 mg/kg at 60 Seconds Compared Effect of Propofol
to Thiopental for Induction Agent
Wangtaweesup K,M.D.,* Chinachoti T,M.D.*
* Department of Anesthesiology,Faculty of Medicine, Siriraj Hospital,Mahidol University, Bangkok 10700.
In two groups of 25 females induced anesthesia with 2-3 mg/kg propofol or 4-5 mg/kg thiopental, tracheal intubation conditions with 0.2 mg/kg mivacuritim (2.5 ED 95) at 60 seconds were assessed. Intubation conditions were found to he clinically acceptable (good or excellent) in 84 % of patients in propofol group and 52 % of patients in thiopental group. Two patients ineach group, intubation were impossible at 60 seconds and three were succeeded excellently at 90 c ds.
The last one was in thiopental group, good and successful intubation was done at 180 second with more thio ntal and mivacurium. We conclude that induction with propofol allows smooth intubation wit O@ hig/kg mivacurium at 60 seconds than thiopental,
Ambulatory Dental Anesthesia
Raksamani A, M.D.,* Santawat U, M.D.,* Rushatamukayanunt W, M.D.,* Lertakyamanee J, M.D.,*Somprakit P, M.D.,* Pechpaisit N, M.D.,* Vatanasunthon S, D.D.S.** Srimaserm T, 1C, B.N.**
Department of anesthesiology, ** Dentistry Devision, Faculty of Medicine, Siriraj Hospital, Bangkok 10700.
We report anesthesia of 163 dental patients, 92.6% of which were ambulatory cases and compared these patients with the previous group. We found that patients in this study were older and had more systemic diseases, e.g. hypertension and ischemic heart disease. Impact and embedded teeth, common in young adults, were the indications for surgery in 41 percent of the patients, therefore 2/3 of all patients were in ASA class 1. Routine complete blood count and urine examination yielded lower prevalence findings than CXR and EKG which were ordered only when anesthesiologists required.
The technique of anesthesia was intravenous induction (with propofol), intubation (succinyl choline), controlled ventilation (atracurium), N 2O, O2 , isoflurane and local infiltration. Blood pressure, hemoglobin 0 2 saturation and EKG were monitored. The most common postoperative side effect was pain. The incidence of nausea and vomiting was reduced, may be due to propofol.
Pediatric Outpatient Anesthesia in Ramathibodi Hospital
Janton P,M.D.,* Soranastaporn C, M.D.,* Rungreungvanich M, M.D.,* Vichitranonda C, M.D.,* Srisawasdi S, M.D.*
*Department of Anestliesiology, Remathibodi hospital, Mahidol University, Bangkok 10400.
The interdepartmental project between Department of Anesthesiology and Department of Surgery, Ramathibodi Hospital has provided Pediatric Outpatient Anesthesia Sevice since October 1993. The objectives are to collect the baseline data and evaluate the anesthetic care in order to extend the service in other fields. The prospective data collection of 457 pediatric patients was done and analyzed. Most of the operations performed were inguinogenital.
Anesthetic techniques were GA-mask, GA-endotracheal tube and IV-ketamine. Postoperative pain was managed by using opioid analgesics or regional anesthesia. Minor anesthetic complications were found in 21 patients (4.6%), 7 of them (1.5%) were admitted from both anesthetic and surgical indications. The outcome was well accepted by the parents, surgeons, anesthetists and nursing staffs. In conclusion, our pediatric outpatient anesthetic care was achieved with satisfactory results.
Caudal Block in Pediatric Neck Surgery
Somboonviboon W,M.D.,* Charuworn P, M.D.,* Charuworn P, M.D.,* Charoenraj P, M.D.*
* Department of Anesthesiology, Faculty of Medicine, Chulaongkorn University, Bangkok 10330.
Caudal anesthesia is a simple technique to perform in children with minimal acceptable incedence of side effects. The purpose of this stydy was to evaluate the effectiveness and safety of caudal morphine combined with bupivacaine for postoperative pain therapy in children undergoing neck surgery. Thirty two children ages 2 to 14 years,, ASA physical status 1 tin. dergoing elective neck su cry in the pediatric surgery unit, Chulalongkorn Hospital were enrolled for the study. Caudal block was performed after general anesthesia by using 0.125% bupivacaine 0.5 ml/kg combined with morphine 0.05 mg/kg.
Illustrated BAS,supplemental analgesic drugs and side effects of caudal block were recorded for 24 hr. The results showed that 71.87% of the patients were pain free for 24 hours. 'l'heie were 3 patients who needed oral acetaminophen at each period of first 6, 12 and 24 hr respectively. The side effects were minimal. So the authors believe that caudal block might be one of the safe method for postoperative pain control in these children.
Anesthetic Management in Patient Following Orthtopic Heart Transplantation for Non - cardiac operation
Chinachoti T, M.D.,* Ratanathavon S, M.D.*
* Department of Anesthesiology, Faculty of Medicine, Siriraj hospital, Mabidol University, Bangkok10700.
We reported anesthetic techniques in two patients following orthotopic heart transplantation for hip hemiarthroplasty and laparoscopic cholecystectomy. 'I'he first patient was younger and physical healthier than the second and tolerated well with combined epidural and general anestliesia. 'rite second case came with progressive weakness and systemic involved both from hypertensiveischemicheart diseascand sideeffect of inirnuni)suppressive therapy. Endotracheal and control ventilation was used with fentany], isoflurane and propofol infusion. Only short period of hypotension after intubation was detected and effectively treat with aramine. At the end of operation, he was fully awake and stayed one day in intensive care unit.
He was discharged ten days after operation but came back two days later with severe generalized weakness. Treatment of acute infection and low cardiac output were done in coronary care unit without success and he died on the twenty-first postoperative day. Autopsy demonstrated of generalized occlusion of coronary vessels more than 90% and chronic rejection without acute infarction. We concluded that anesthetic plan and management had to be tailor to each individual patient. Extensive history taking, progressed and outcome of symptom and sign included all cardiac investigation were valued in management of successful anesthesia.
Increased Airway Pressure due to Mesconnection of Scavenging
System
Soontranan P, M.D.,* Somprakit P, F.R.CA.,** Lertakyamance J, F.R.C.A.**
* Department of Anesthesiology,** Department of Anesthesiology and Clinical Epidemiology Unit, faculty of Medicine, Sitiraj hospital, Bangkok 10700
A 51-year-old male with abdominal blunt injury and multiple fractures of right leg from car accident was anesthetized by balanced technique. Five minutes after intubation, his blood pressure was dropped to 68/.35 mmHg and the airway pressure was increased to + 9 cmH20 at the end of each expiration phase. The ventilator was disconnected and the patient was manually ventilated. After a brief cheek up, the cause was identified ; the excess gas outlet of breathing system was loosely misconnected to the pressure, relief valve (outlet) of the ventilator. After the cause was corrected, the airway pressure and blood pressure were returned to normal range.
Key words : Anesthesia equi pment . scavenging syvtem, safety.
Volume
22;Number 2:1996 April-June
Incidence of Postdural Puncture Headache in Obstetric Patiens : Comparison of the 25 G Quincke VS the 25 G Whitacre Needles
Bunburaphong P, M.D., *Werawatganon T, M.D.,*Sriprajittichai P, M.D.,*
Leepuengtham T, M.D.*
*Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University,
Bangkok 10330.
Postdural puncture headache (PDPH) is an important Complication of spinal
anesthesia that leads to prolonged hospitalization and increased cost. The incidence of
PDPH appears to be related to the types of needle used. We studied 301 obstetric patients,
ASA I-II, who underwent spinal anesthesia for Caesarean section in Chulalongkorn
Hospital. They were randomised into two groups. The patients in group I were blocked
using the 25G Whitacre and those in group II using the 25G Quincke spinal needle. We
evaluated the adequacy of analgesia for Caessarean section, ease of needle insertion and
followed the incidence of PDPH up to four days postoperatively. Student t - test and Chi
square were used to compare between groups, p
results indicated that the indicences of PDPH in Whitacre and Quincke groups were 1.29 (2
of 155 patients) and 1.37% (2 of 146 patients) respectively. The difference between groups
was not statistically significant. Number of patients with adequate analgesia for Caesarean
section were nearly the same (98.06 VS 97.95%). The Whitacre spinal needle is mordifficult to insert for the beginner. In conclusion, the 25 G Whitacre spinal needle does
not reduce the incidence of PDPH in obstetric patients comparing to the 25 G Quincke
spinal needle.
This study is supported by Ratchadapiseksompot Fund, Faculty of Medicine,
Chulalongkorn University.
Dose of Intrathecal Morphine for Postoperative Pain Relief in Caesarean Se
Charuluxananan S, M.D.,* Kyokong O, M.D.,* Pongpakdee K, M.D.
*Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University,
Bangkok 10330
The effectiveness of low dose intrathecal morphine for postoperative analgesia were
evaluated in ninety patients who were anticipating caesarean section under bupivacaine
spinal anesthesia. In a double blinded fashion, each group of thirty patients received either 0.1, 0.15 or 0.2 mg of morphine intrathecally with bupivacaine 12 mg. Visual analogue scale and side effects were noted at 1, 2, 3, 6, 12, 24, 36, and 48 hrs after intrathecal
injection. The result showed that the mean postoperative analgesia time (visual analogue
scale
1.19, and 46.87 + 0.84 hrs respectively which were significantly longer than mean
postoperative analgesia time, 29.07 + 2.10 hrs, in patients receiving 0.1 mg of morphine.
There was no significant difference in postoperative itching, nausea and/or vomiting
between groups. No respiratory depression detected. The neonatal condition was excellent
in all groups. We therefore suggest that 0.15 mg of intrathecal morphine is the optimum
dose for postoperative pain relief in caesarean section.
Key words : Intrathecal morphine, spinal morphine postoperative analgesia,
caesarean section
Anesthetic Considerations for HIV Infected Patients at
Chulalongkorn Hospital (November 1, 1993 -
October 31, 1994)
Charuluxananan S, M.D.,* Makarasara N, M.D.,* Ruttananurug S, M.D.*
*Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University,
Bangkok 10330.
Prospective, descriptive study was performed at Chulalongkorn Hospital during 1
year period. The study revealed total 200 cases of HIV seropositive patients undergoing
anesthesia and surgery. Among these, 54 cases (27%) were emergency. Fifteen cases
(7.5%) were symptomatic and 185 cases (92.5%) were asymptomatic. Heterosexual
transmission was the most common route of HIV transmission of 142 cases (71%), other
were 4 cases (2%) of IVDU, 2 cases (1%) of vertical transmission, 2 cases (1%)
homosexual, and 50 cases (25%) of unidentified risk. Mean age was 32.58 + 12.15 years
in male and 25.06 + 5.86 years in female. There were 127 cases (63.5%) from department
of obstetric and gynecology. 37 cases (18.5%) of general surgery, 10 cases (5%) of plastic
surgery, 10 cases (5%) of urosurgery, 8 cases (4%) of orthopaedic surgery, 4 cases (2%) of
neurosurgery, 2 cases (1%) of cardiothoracic surgery, 1 case (0.5%) of ENT and 1 case
(0.5%) of opthalmology. One hundred and ninety-eight cases (99%) were detected to be
HIV seropositive preoperatively and 2 cases (1%) were detected postoperatively. Abnormal
HiV related symptoms were 1 case (0.5%) of pneumonia, 3 cases (1.5%) of diarrhea, 4
cases (2%) of lymph node enlargement, 3 cases (1.5%) of cachexia, 2 cases (1%) of
Herpes simplex and 2 cases (1%) of oral candidiasis. Anemia (hematocrit
most common laboratory abnormality : 15 cases (7.5%). One hundred and ninety one
cases (95.5%) were ASA physical status I, 5 cases (2.5%) were status II, and 4 cases (2%)
were status III. Regional anesthesia was performed in 154 cases (77%) including 150 cases
(75%) of spinal anesthesia, 1 case (0.5%) of epidural anesthesia, 3 cases (1.5%) of brachial
plexus anesthesia. Only 1 case recieved general anesthesia after failure of brachial plexus
anesthesia. General anesthesia was performed in 46 cases (23%), 45 cases (22.5%) were
intubated and 1 case (0.5%) was performed undermask. No serious anesthetic complication
occured. We concluded that at Chulalongkorn Hospital, characteristic of HIV seropositive
patient showed fourth wave of epidemic. Anesthesiologist prefered regional anesthesia to
general anesthesia. Further characteristic and natural history of HIV seropositive patients
should be followed to provide appropriate anesthetic technique in more serious
condition.
Anesthesia for Modified Electroconvulsive Therapy at Chulalongkorn Hospital (1995)
Markarasara N, M.D.,* Charuluxananan S, M.D.*, Charoenraj P, M.D.*
*Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University,
Bangkok 10330
A descriptive retrospective study of 52 psychiatric patients who were treated by
electroconvulsive therapy at Chulalongkorn Hospital in 1995 (January-December).
Diagnosis were : 29 cases (55.77%) of schizophrenia, 16 cases (30.77%) of depression, 5
cases (9.62%) of bipolar, the other 2 were acute psychosis and borderline personality.
Thiopentone 3.40 + 0.71 mg/kg and succinyl choline 0.68 + 0.22 mg/kg were given with
100% oxygen via face mask through Mapleson type C circuit. Of 442 stimulations, there
were 3 (0.68%) strong (+++), 41 (9.28%) moderate (++), 325 (73.53%) mild (+) clinical
convulsions and 73 cases (16.51%) of no clinical convulsion. EEG monitoring was more
sensitive than clinical convulsion. There were only 26 stimulations of no EEG convulsion.
Most common complications were hypertensive response and tachycardia (calculated mean
blood pressure and heart rate rose more than 30% of preinduction level). There was one
case of difficult in maintaining airway which needed intubation. There were 9 oral
bleedings, two of which had dental injury. We concluded that the technique of intravenous
thiopentone and succinylcholine can be used effectively for modified electroconvulsive
therapy without serious complications. Further study should be followed to reduce adverse
effects and improve outcome.
Key words : Anesthesia, Anesthetic technique, Electroconvulsive therapy,
Psychiatric patients
Abstract : Propofol and Thiopental Anesthesia for Electroconvulsive Therapy
Werawatganon T, FRCAT,* Uerpairojkit K, FRCAT,* Yunsit R, M.D.*
*Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University,
Bangkok 10330
This study is to compare propofol with thiopental for electroconvulsive therapy in
psychotic patients in the aspects of convulsive threshold, recovery to discharge, and side
effects.
There were 32 comparisons in 25 patients. Each patient received anesthesia with
either propofol or thiopental for the first electroconvulsive therapy. Then he would receive
another anesthetic agent for the next time. The average dose of propofol was 1.29 + 0.33
mg/kg and thiopental was 3.34 + 0.65 mg/kg.
We found that the time of convulsion from clinical observation after propofol
anesthesia was significantly shorter than after thiopental anesthesia (p
Nevertheless, the time of convulsion from electroencephalogram evaluation was not
statistically different. The patients waked up to sit up and were ready to go home earlier
after propofol.
We concluded that propofol might be another choice for electroconvulsive therapy.
It had benefit of rapid recovery in the expense of shorten clinical convulsion time.
Key words : Propofol, Thiopental, Anesthesia, Electroconvulsive therapy
Pain During Injection of Propofol : the Effect of Pretreatment with Lidocaine
Srichintai P, M.D.,* Pukrittayakamee P, M.D.,* Puangklang M, B.Sc.*
*Department of Anesthesiology, Ramathibodi Hospital, Bangkok 10400.
The controlled double blind prospective study was performed to determine the effect
of prior administration of lidocaine on the pain produced by injection of propofol. There
were one hundred and twenty-two patients, ASA class I or II undergoing general anesthesia
with endotracheal intubation, classified into three groups. The patients in group I were
given intravenous saline 2 ml (N = 39), in group II and III were given lidocaine 10 and 20
mg (N = 40, 43) respectively prior to injection of propofol. The data was analysed by
using chi square test. The result showed that pain score and recall to pain were not
statistically significant in all groups (p > 0.05). There was no side effect observed after
pretreatment with lidocaine.
Pre-emptive Analgesia with Intravenous Fentanyl in Gynecological Operations
Ularangura W, M.D.,* Waikakul W, M.D.,* Ittichaikulthol W, M.D.,*
Vichitrananda C. M.D.,* Pausawasdi S, M.D.*
*Department of Anesthesiology, Ramathibodi Hospital, Mahidol University,
Bangkok 10400.
Pre-emptive analgesia by 2 mg/kg fentanyl administered intravenously before skin
incision in gynecological operations were evaluated. Fourty-eight patients, ASA class 1 or
2, were randomly allocated into 2 groups. Group 1, studied group, recieved intravenous
fentanyl during induction of anesthesia and 0.9% NSS in equal volume 1 minute after skin
incision. Group 2, control group, recieved 0.9% NSS during induction of anesthesia and
fentanyl 1 minute after skin incision. We found that postoperative morphine requirement
by patient - controlled analgesia (PCA) in both groups during 24 hours were not different
(mean 7.46 + 6.1 mg vs 8.09 + 6.9 mg in the studied vs controlled group, p = 0.7).
Postoperative paion assessed by visual analogue scale (VAS) and verbal rating score (VER)
at rest and during movement were also indifferent. This study showed that fentanyl 2
mg/kg administered before skin incision could not pre-emptive postoperative pain in
gynecological operations.
A Survey of Anesthesia Scavenging System in Siriraj Hospital
Soontranan P, M.D.,* Lertakyamanee J, F.R.C.A.,** Somprakit P, F.R.C.A.**
*Department of Anesthesiology **Department of Anesthesiology and Clinical
Epidemiology Unit, Faculty of Medicine, Siriraj Hospital, Bangkok 10700
Anesthetic pollution is one of the problems in operating theaters. Over 90% of
pollution can be reduced by using scavenging system. Such systems increases complexity,
and thus the hazards of administering anesthesia. A case of pneumothorax prompted an
investigation of active scavenging systems currently used at Siriraj Hospital by using
preanesthesia check protocol. Thirty-eight closed reservoir active scavenging safety
interface (Ohmeda) systems were included.
Ten systems (26.3%) had been assembled incorrectly. All systems passed negative
pressure relief valve test. Seventeen systems (44.7%) failed to pass positive pressure relief
valve test because high pressure (over 10 cmH2O) was developed during O2 flush, but
direct measurement of pressure at the scavenging interface revealed that these defects were
caused by the problem of APL valves, not by positive pressure relief valves of the systems.
We suggest that routing preanesthetic check together with regular maintenance of
equipment should be emphasized and all personnel should be encouraged to learn more
about safety precaution.
Key words : Anesthesia equipment : scavenging system, safety.
Abstract : Laryngeal Mask Airway in Pediatric Tracheal Stenosis
Tantivitayatan K, M.D.,* Aimarreerat O, M.D.*
*Department of Anesthesiology, Rajavithi Hospital, Bangkok 10400
We presented a case to document another use of the laryngeal mask airway (LMA)
in pediatric difficult airway management. The patient was a 9-year-old boy who underwent
ocular surgery for total retinal detachment of left eye. The first anesthesia was uneventful
but in the second time, which was 4 months later, endotracheal intubation was attempted
but failed due to tracheal stenosis, diagnosed by emergency bronchoscopy, and resulting in
tracheostomy. Tracheal reconstruction was considered after which he was put on
mechanical ventilator for postoperative respiratory failure. He came again for silicone
removal under general anesthesia with LMA. Intraoperatively, we came across some
difficulty in ventilation, hypercarbia and towards the end of anesthesia, laryngospasm
occurred. Details, pitfalls and case reference were disussed. We thought that the
management of difficult airway like this was possible with the aids of LMA, especially in a
small child whose airway could be easily compromised.
Volume 22;Number 1:1996 January-March
Reduction of Postoperative Residual Relaxation : Using
a Peripheral Nerve Stimulator or a Newer Relaxant ?
Somprakit P,M.D.*, Lertakyamanee J,M.D.*, Svastdi-xuto
O,B.N.**, Kraiprasit K, B.N.**.
*Department of Anesthesia and Clinical Epidemiology Unit, Siriraj Hospital,
Faculty of Medicine, Mahidol University, Bangkok 10700
**Department of Anesthesia, Siriraj Hospital, Faculty of Medicine, Mahidol University,
Bangkok 10700
Objective : To compare the effectiveness of using a peripheral nerve stimulator (PNS) to guide muscle relaxant administration and using a newer relaxant in reducing postoperative residual muscle relaxation.
Design : A randomized, double blind, balanced factorial design.
Settings : Tertiary care hospital setting.
Patients : The study included 180 patients, healthy or with only mild systemic disease, who had elective gynecological operations.
Interventions : Patients were divided into 4 groups. Group I received long action muscle relaxant (pancuronium) at a fixed time interval of 60 minutes, group II received pancuronium guided by PNS, group III received intermediate acting relaxant (vecuronium) at a fixed time interval of 30 ,minutes and group IV received vecuronium guided by PNS.
Main Outcome Measures : The main outcome was the prevalence of residual relaxation measured by an accelograph at 30 minutes after operation. The value of T4/TI<70% was used as the cutoff point for diagnosis of residual relaxation.
Results : The % T4/T1 ratios in each group were 54.3?26.0%,61.3?24.2%,76.4?20.3% and 88.2?23.1% respectively and were different statistically (p<0.001). There were 26,24,12 and 8 cases of residual relaxation resulting in prevalence rates of 57.8%,53.3%,26.7% and 17.8% respectively, which were statistically different (p =0.00007). The difference was explained by the difference in type of relaxant, but not by whether PNS was used or the interaction between these 2 factors.
Conclusion : This study showed that changing the type of relaxant could help reducing the prevalence of postoperative residual relaxation while using the PNS could not.
Key words : Residual relaxation, monitoring : train-of-four, muscle relaxants.
Hazards of Anesthesia Equipment : Fifty Consecutive Incidents
Soontranan P, M.D.*, Lertakyamanee J, M.D.,** Somprakit P, M.D.**
*Department of Anesthesiology, ** Department of Anesthesiology and Clinical Epidemiology Unit, Siriraj Hospital, Bangkok 10700
Anesthesia practice in Thailand has different problems from developed countries because there is no standard guideline and suitable personnel to take care of equipment. The objective of this study was to identify hazards of anesthesia equipment and factors contributing to their occurrence by collecting 50 consecutive abnormal equipment and techniques which might endanger to an individual or lead to disaster.
The equipment involved were liquid oxygen (4%), piping system (18%), cylinders (46%), wall outlet connectors (4%), breathing systems (10%) vaporizers (6%), scavenging systems (4%) self-inflating bag (2%), gas supply failure alarm (2%) and miscellaneous (4%). There were more incidents found behind the wall (68%) than in the operating suites (32%) but no harm to the patient occurred. Factors contributing to these incidents were lack of knowledge, ignorance of safety precaution, lack of check up and regular maintenance and false techniques.
These incidents reflected the fact that most anesthesiologists who worked in operating rooms were unaware of the important task of equipment engineers and this responsibility were left to unreliable personnel. This result clearly showed the different situations between anesthesia in
developing countries and well organized institutes. In order to avoid hazards and medico-legal problems, we strongly propose that guideline development and improvement of training and supervision are urgently needed.
Key words : Anesthesia equipment : potential hazards, safety.
The Accuracy of Modified Esophageal Detector Device
Jiranantarat V, M.D.*, Sujiratanawimol K,M.D.*, Tonsuchai N,M.D.*, Vorrakitpokathorn P, M.D.*
*Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Bangkok 10700
Esophageal intubation is one of the most fearful fatal complication of anesthesia. We reported the accuracy of modified esophageal detector device (EDD). This device consists of a 50 ml plastic syringe, a 3 cm long elastic tube with internal diameter of 3.2 mm, a no.3 slip joint connector and a cylindrical (3 cm long) plastic tube. One hundred patients of ASA class I-II undergoing general anesthesia were studied from June to December 1993. Their ages ranged between 5-75 years (mean 41.38?15.01). Two endotracheal tubes were intubated into the trachea and esophagus of each patient by one anesthesiologist. Another anesthesiologist blindly checked the position of both endotracheal tubes with EDD. The time required to detect the position of both tubes was 5-28 seconds (mean 6.67?4.59). Blood pressure recorded before and two minutes after the test were 126?15.01/78?12.09 and 129?11.23/49.23.7 mmHg respectively and were not significantly different. The sensitivity and specificity of the test were 100%. In conclusion, the EDD is proved to be highly accurate in detection of the tube’s position in either trachea or esophagus. It will be very useful in the situation of difficult intubation. Finally the device is very simple, easy to carry and apply as well as cost-effective.
Prophylaxis of shivering for Caesarean Section after Epidural
Anesthesia
Toomtong P,M.D.*, Tanwattanakul S, M.D.*, Ratthirom A, M.D.*, Lurngnateetape A,M.D.*
*Department of Anesthesiology, Siriraj Hospital, Bangkok 10700
We have compared the efficacy of pethidine and tramadol hydrochloride for prevention of shivering in the patients undergoing caesarean section under epidural anesthesia. The study was performed in a randomized and double-blind manner. One hundred and fifty patients, ASA physical status 1 or 2, were randomly allocated to one of the three gourps (each group =50) to receive normal saline (group 1, control group), pethidine 25 mg (group 2 ) or tramadol hydrochloride 50 mg (group 3) intravenously after delivery. The patients were observed for shivering and other complications throughout the operation and twenty four hours postoperation. The results showed that there were no statistical differences in patient characteristic data, indication for caesarean section, intraoperative fluid administration, blood loss, operative time and anesthetic time in the three groups. Pethidine was comparable with tramadol in prevention of shivering during operation significantly. However, the patients who received pethidine had significantly higher incidence of nausea and vomiting than those who received tramadol.
Phenol for pain Relief
Panich A, M.D.,* Waikakul W, M.D.*
*Department of Anesthesiology, Faculty , Faculty of Medicine, Ramathibodi Hospital, Bangkok 10400
Study in the patients who had chronic and severe pain in Pain Clinic, Songklanagarind Hospital during 1989-1993. Those patients got strong analgesics, narcotics, radiation, surgery and chemotherapy for cancer and chronic pain. There were 46 cases altogehter, 21 were cancer patients and 25 cases were not. We use phenol as a neurolytic agent for injection at the site of the nerves or nerve plexuses. The methods for approach the nerves follow the text book ; Regional Block by Moore.
We have done lumbar sympathetic ganglion block =19 cases, stellate ganglion block = 12 cases, caeliac plexus block = 4 cases and peripheral nerve block =8 cases. The 1-5 ml of phenol was used, depend on the site for injection.
The results of treatment were excellent = 16 cases (34.8%), good =23 cases (50%), slightly better = 5 cases (10.8%) and unchange =3 cases (6.8%). No severe complication occured. The patients were free from pain for 2-3 months or had mild pain and could take only oral analgesic drugs for supplement.
Postoperative Nausea Vomiting (PONV) : Influence of Bowel Manipulation During Intraabdominal Surgery
Sirivanasandha P, M.D.* Puangklang M,B. Sc.**
*Staff** Nurse Anesthetist, Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospitol, Bangkok 10400
High incidence of postoperative nausea and vomiting (PONV) in intraabdominal surgery were recognized. The mechanism of PONV was thought to be from 5 hydroxytryptamine 3 (5 HT3) released by enterochromaffin cells of gastrointestinal mucosa, triggers vagus nerve ending and sends impulse to stimulate vomiting center in medulla. According to this hypothesis, incidence and intensity of PONV should vary to the degree of bowel manipulation during surgery. Thus 5 HT3 receptor antagonist should be specific management for PONV in intraabdominal surgery. This drug is rather expensive for Thai patients, cost and benefit should be taken into serious consideration.
The effect of different degree of bowel manipulation during surgery on incidence and intensity of PONV were studied at random in 130 patients going for intraabdominal surgery under general anesthesia which was rather unique as a routine anesthetic technic in Ramathibodi Hospital. The degrees of bowel manipulation were allocated into 3 grades (minimum, moderate and maximum) and also intensity of PONV (mild, moderate and severe).
The other risk factors which probably increase incidence of PONV : age, sex, premedication, narcotic supplement, duration of surgery, and types of surgery (general surgery, laparoscopic, GYN) were in consideration. Those patients subsequently experienced PONV were managed by psychological approach and rescued by metoclopramide.
The incidence of PONV in this study was 29.29%, much lower than the studies in western countries (50-70%). The different degree of bowel manipulation did not change incidence and intensity of PONV significantly by chi-square test. The tendency to develop PONV was high (significant) in female patients. Routine management of PONV by psychological approach, and rescued using metoclopramide was successful for all effected cases.
In conclusion, this study does not confirm hypothesis of "bowel manipulation during intraabdominal surgery may release 5 HT3 to stimulate vomiting center via vagus nerve." Thus specific treatment of PONV in intraabdominal sugery by 5 HT3 receptor antagonist is probably not necessary.
Efficacy of Sublingual Buprenorphine (TemgesicR) on Abdominal
Cancer Pain
Khunsongkiet P, M.D.*, santikulanont U, M.D.*, Thongprasert S, M.D.**
*Department of Anesthesiology ** Department of Internal Medicine, Faculty of Medicine, Chiangmai University, Chiangmai 50200
From January 1994 to January 1995, all cancer patients with abdominal pain were entered into the study. Prior to treatment, all patients were evaluated by the Brief Pain Interventory Questionaire. These patients were treated with sublingual buprenorphine. The dosage of buprenorphine was 0.2 mg every six-hours, then the dosages were titrated up to the level of pain free (patients had satisfactorily pain relief). Pain score, general activity, walking activity, ability to sleep, mood, enjoyment and relation to other persons were observed.
There was statistically significant difference of pain scores, general activity, walking activity, ability to sleep, mood and enjoyment, between the day before and after the treatment (p=<0.05). The relation to other persons was not different. The side effects of buprenorphine were mainly constipation, nausea and vomiting. Itching and sleepy were seen in some patients. Sublingual buprenorphine is an effective analgesic for abdominal cancer pain. This drug is most useful in cancer patients who could not able to swallow due to either bowel obstruction or severe nausea and vomiting from other causes.
The Evaluation of Upper Airway Assessment Correlated with Laryngoscopic View
Somboonwong W,M.D.*, Boonbunjong J,M.D.*, Akavipat P,M.D.*, Nutakul T,M.D.**
*Department of Anesthesiology, Faculty of Medicine,
Mahidol University, Bangkok 10700.
Three hundred and sixteen patients scheduled for elective surgery under general anesthesia with endotracheal intubation were evaluated were evaluated correlation between upper airway anatomy and laryngoscopic view. Upper airway evaluation included anatomical defects, modified Mallampati classification, extension degree of neck, thyromental distance and mandibular width. From this study, we found that anatomical defects (loose of teeth, protrusion of incisors, etc.) and obesity were strong indicator of poor laryngoscopic view and difficulty in intubation process especially when combined with grade III and IV of modified Mallampati classification (P=0.0058). From this study we could not demonstrate the correlation among evaluation process of upper airway in patient without anatomical defects. Further investigations were indicated.
A Comparison of Epidural Buprenorphine and Morphine for the Management of post-Cesarean Section Pain and the Side Effects.
Pothikasem V,M.D.,* Puernngooluerm P,M.D.**
*Department of Anesthesiology, ** Department of Obstetrics
& Gynecology, Rajvithi Hospital, Bangkok 10400.
Epidural buprenorphine and epidural morphine
were investigated as a postoperative analgesia in a randomized
study of cesarean patients given epidural analgesia with 2% lidocaine
with adrenaline. After testing dose, patients were given either
0.3 mg buprenorphing (B group, n=30) or 5 mg morphine M group,
(n=30) with 2% lidocaine with adrenaline 17 cc. In postoperative
period, the postoperative pain felt by the patients and side effects
were recorded.
Analgesia after 0.3 mg buprenorphine was
not significant difference from those of 5 mg morphine in eight
hours after surgery (P>0.05)., After the tenth to twenty-fourth
hour, M group had less pain than B group (p<0.05). However
the side effects of M group e.g. pruritus, nausea and vomiting
were more marked that B group (p<0.05).
We conclude that the epidural administration of 0.3 mg buprenorphine
may be recommended for postoperative analgesia following cesarean section with
less side effects
Comparison of 25 Gauge Whitacre and Quincke Point Spinal Needles in Cesarean Section
Hintong T,M.D.*, Mankong N,M.D.*, Soopachokechiwatana S,M.D.*, Panjasawadwong Y,M.D.*
*Department of Anesthesiology, Faculty of Medicine, Chiangmai
Universit, Chiangmai 50200.
This prospective study was designed to
compare the ease of use and incidence of postdural puncture headache
(PDPH) using 25 gauge Whitacre and Quincke type spinal needles
in 200 parturients undergoing elective cesarean section. The
used needle was assigned in a random manner : group I, 25 G Whitacre
(n=100); assessed daily following the operation by an investigator
blinded to the needle used. An inability to insert the Quincke
needle occurred in 2 patients in group II. Therefore, 100 patients
in group I and 98 patients in group II completed the study. Easy
use of the needle which was defined by 1 or 2 needle insertion,
"pop" sensation on dural puncture and rapid appearance
of cerebrospinal fluid with easy aspiration was found by larger
number of the anesthetists who used the whitacre needles (p=0.11)
and not related to their experience. Only one patient (1.0%)
in the Whitacre group developed PDPH compared with 9 patients
(9.2%) in the Quincke group did (p<0.01). We conclude that
the 25 G Whitacre needle for spinal anesthesia in cesarean section
is easy to use and associated with a low incidence of PDPH.
Key words : Anesthetic techniques : Spinal, Cesarean section,;
Complications : Headache;
Equipment : Whitacre needle,Quincke needle.
Comparison of Efficacy between Lidocaine Spraying VS Nebulization in Topical Anesthesia for Fiberoptic Endoscopy of Upper Gastrointestinal Tract
Mahattanaviroj O,M.D.*, Valairucha S,M.D.*, Thakulsawadi P,M.D.*, Santawat U,M.D.*, Vanadornvaravisan R,B.N.*
*Department of Anesthesiology, Faculty of Medicine,
Siriraj Hospital, Mahidol University, Bangkok 10700.
We designed a randomized study to compare
the efficacy of topical anesthesia for fiberoptic esophagogastroscopy
between lidocaine spraying and nebulization. After the Siriraj
Hospital Ethical Committee approval, 40 patients (ASA I-II) undergoing
elective fiberoptic esophagogastroscopy were allocated into 2
groups, gr I: lidocaine spraying (n=20) and gr II : lidocaine
nebulization (n=20). Lidocaine was equally administered 3 mg/kg
in both groups. The patients were well informed regarding to
the anesthetic procedure. The efficacy of topical anesthesia
was evaluated by patients, surgeons and the same nurse anesthetist
who were blind to the anesthetic techniques. The results showed
no difference in the demographic data and duration of the endoscopic
procedure between the two groups. During the anesthetic procedures,
the patients' selfassessment of their discomfort, nausea-vomiting,
bitterness and mouth dryness were similar in both groups except
for coughing. In gr II, the grading of coughing was found to
be significantly less tan in gr I (p=0.08). During the endoscopy,
the grading of patients' cooperation, discomfort, nausea-vomiting,
coughing as well as surgeon's satisfaction were not significantly
different in both groups. The endoscopic procedure could be continued
without any supplemental drugs to the patients. Neither lidocaine
toxicity nor other complications were detected in this study.
We concluded that the nebulization technique as compared to the
spraying technique could be used in fiberoptic esphagogastroscopy.
However the nebulization technique showed to have lesser grading
of coughing during lidocaine administration.
Postoperative Sore Throat and Hoarseness : a Comparison between Endotracheal Intubation and Laryngeal Mask Insertion
Rungreungvanich M,M.D.*, Thongsukh V,M.D.*, Tonglim N,R.N.*. Adipat J,R.N.*
*Department of Anesthesiology, Ramathibodi Hospital,
Mahidol University, Bangkok 10400.
The incidence of postoperative sore throat
and hoarseness was evaluated prospectively in 200 patients undergoing
general anesthesia for surgical procedures. Patients were randomly
assigned to have either red rubber endotracheal tube (group A)
or laryngeal mask (group B) in place during the operation and
were evaluated for the occurrence of postoperative sore throat
and hoarseness 24 and 48 hours after surgery.
The incidence of postoperative sore throat
and hoarseness 24 hours after surgery was significantly higher
in group A than in group B (20%,11% versus 9%,1% respectively)
(p<0.05). In the case of 48 hours after surgery the incidence
of postoperative sore throat was significantly higher in group
A than in group B (11% versus 2%) (p<0.05) while the incidence
of hoarseness was higher, but not statistically significant, in
group A than in group B (4% versus 1%).
The data from this study indicated that the intraoperative use of laryngeal mask, compared with the use of red rubber endotracheal tube, lowered the incidence of postoperative sore throat and hoarseness.
Does Chin Lift Facilitate the Laryngeal Mask Airway Insertion in Neutral Position?
Wongpunkamol S,M.D.*, Boonsong P,M.D.*, Punjasawadwong Y,M.D.*, Loamuangthong C,M.D.*
*Department of anesthesiology, Faculty of Medicine,
Chiangmai University, Chiangmai 50200.
The standard recommended insertion technique
for the laryngeal mask airway (LMA) involves
flexion of the neck and extension of the bead. It is not known whether insertion in neutral position is generally feasible with a view to its use in case of cervical spine instability. The ease of insertion of
the LMA with the patient's head in neutral position
alone (group A'30 patients) was compared in 60 healthy patients.
The condition for LMA insertion was noted and successful insertion
was assessed by the functioning of the airway. All complications
and problems related to either technique were also recorded.
In terms of the functioning of the airway,
the successful insertion rate in neutral position alone was 60%
(18/30) compared to the other group with chin lift 93% (28/30)
(p=0.006,Yates corrected chi-square's test).
We concluded that facilitation technique,
chin lift, may have a role in the insertion of the LMA in the
airway management in patients with known or suspected cervical
spine instability.
Key words : Equipment ; Iaryngeal mask airway
Anesthetics ; propofol, fentanyl
Combined Spinal-Epidural Anesthesia in Orthopedics
Boomsong P,M.D.*, Seethanawiboonchai P,M.D.*, Suntikulanoon U,M.D.** Khunsongkiet P,M.D.*
*Deparment of anesthesiology, Faculty of medicine, Chiangmai University, Chiangmai 50200
** Resident, Department of Anesthesiology, Faculty of
Medicine, Chiangmai University, Chiangmai 50200
The authors used the combined spinal-epidural
technique (CSE) in 20 patients undergoing orthopedic surgery.
Four ml of 0.5% heavy bupivacaine and 3 mg of morphine were injected
into subarachnoid and epidural space respectively. Satisfactory
surgical conditions were obtained in every patients with median
height of block at T4 (range T3-T7) and median duration of block
of 225 minutes (range 185-270 minutes) whereas in 15 patients
median duration of postoperative analgesia
was 19.14 hours (range 9.46-21.17 hours) and others
have postoperative analgesia more than 24 hours. Hypotension
occured in 8 patients (40%), however responded well to fluids
and ephedrine. Other side effects included nausea (10%), vomiting
(5%) and pruritus (15%). No respiratory center depression was
noted up to 24 hours postoperatively. The results from this preliminary
study suggested that this technique could be used in orthopedic
patients with good surgical conditions and long postoperative
pain relief
Key word Technique : combined spinal-epidural block, epidural morphine.
Pain : postoperative
Postpartum Hemorrhage with Pulmonary Edema
Surapong K,M.D.*, Pungpoonsub W,M.D.*
*Department of Anesthesiology, Faculty of Medicine,
Chulalongkorn University, Bangkok 10330.
A patient in premature labour was treated
with an oral salbutamol for 68 hours before delivery by cesarean
section. Postpartum hemorrhage had occured. Prostaglandin E2
was given to stop uterine bleeding. Severe vasoconstriction and
pulmonary edema was found postoperatively. We discuss the pharmacological
implications of these drugs and the possibilities of these complications.
A Comparision of Prevention of Hypothermia in Pediatric Patients between Wrapping with Webril Together with Warmer Blanket and Plastic
Suwandalud N,M.D.* Yimrattanabowon P,M.D.* Maneesawangwong S,M.D.* Nuttakul T,M.D.*
*Department of anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700.
Prevention of hypothermia in pediatric
patients undergoing general anesthesia is very important. We
studied the effectiveness of two intraoperative warming devices
in 32 pediatric patients. Age range from one day to 2 years,
ASA physical status 1 or2, underwent major surgical procedure
more than one hour. The patients were randomly allocated to receive
warming blanket with webril wrapped their arms, legs and bodies
in group 1 and wrapped with plastic in group 2. We found that
within ninety minutes, even though there were no patient developed
hypothermia, patients in group 1 showed significant higher temperature
than group 2. But their costs were significantly different.
In group 1 the costs was 35 bahts/case and group 2 was 13 bahts/case.
We concluded that using plastic wrap in pediatric patients could
prevent intraoperative hypothermia in less effectiveness than
conventional method but could be used according to operative situation.
Comparison of Induction, Emergence and Recovery Characteristics of Sevoflurane-N2O :O2 with Propofol-N2O:O2
Nisoong C,M.D.* Paiboonworachatti S, M.D.* Nipitsukarn 'T, M.D.* Panjasawadwong Y, M.D.*
Petcharuk A,M.D.* Weerawong k,G.N.* Sivirojana P,G.M.*
Arasaki Y,M.D.**
*Department of
Anesthesiology, Faculty of Medicine, Chiangmai University, Chiangmai 50200,
Thailand.
**Naha Hospital, Okinawa, Japan.
The objective of this study was to compare
the induction, emergence and recovery times between sevoflurane-N2O"O2
and propofol-N2O"O2 in twenty ambulatory
patients undergoing litholapaxy at Chiangmai University Hospital.
These patients were randomly allocated to receive either propofol
for induction (group1) or inhalation induction with sevoflurane
and nitrous oxide in oxygen (group2). The anaesthesia in group
1 was maintained with propofol infusion and N2O:O2
and group 2 with sevoflurane and N2O:O2.
The median (Q1,Q3)
induction times (loss of verbal command) in group 1 and group2
were 66 (44,66) sec and 105 (98,140) sec respectively. By the
Mann Whitney U test, this difference was statistically significant
(p<0.03). The decreases in both systolic (^BPs) and diastolic
(^BPd) arterial blood pressures were significantly greater after
propfol induction (^BPs= -23mmHg,^BPd =-21 mmHg) when compared
to sevoflurane induction (^BPs =-7.5 mmHg,^BPD =-3.5 mmHg
Patients in group 1 spent longer time in
emergence (325 sec for eye opening and 390 sec for responding
to command) than patients in group 2 (208 sec for eye opening
and 285 sec for responding to command). However, the two groups
did not differ with regard to the time for their recovery room
stay.
It can be concluded from our finding that
induction with propofol P40 in faster
than with sevoflurane. Despite its faster induction,
intravenous propofol can cause more profound decrease in blood
pressure in some patients. Although its induction is shower when
compared to propofol, the emergence from sevoflurane is faster.
Neither of the two techniques appears to affect the time for
recovery room stay.
Simple Morphine Intravenous Infusion for Postoperative Analgesia in Cesarean Section
Werawatganon T,M.D.*, Poomanee W,M.D.*, Puengtomwatanakul S,M.D.*, Luangtunjai P,M.D.*
*Department of Anesthesiology, Faculty of Medicine,
Chulalongkorn University, Bangkok 10300.
This study is to compare morphine infusion
by simple technique with conventional intramuscular injection
on demand technique for pain relief after Cesarean section.
The dose, pain, and safety are concerned.
In the fist group of patients, we gave
morphine 0.1 mg/kg intravenous bolus injection and added morphine
10 mg to every 1000 ml fluid running intravenously at the rate
of normal daily fluid requirement. Then intramuscular morphine
was given if the patients requested for supplemental dose. The
second group of patients received intramuscular morphine 0.2 mg/kg
on demand every 4-6 hours as a conventional method.
The pain score and total morphine were not statistical different between both groups. However the first group (morphine Infusion group) requested less morphine than the conventional group in both dose and frequency. No patient had any danger from respiratory depression. So we suggest that this simple morphine infusion technique be introduced to decrease painful request for analgesics and burden on nursing care.
A Comparative Study of 0.15% Bupivacaine with Adrenaline Plus Fentanyl and 0.25% Bupivacaine with Adrenaline for Painless Labour
Pukrittayakamee P,M.D.* Tontisirin O,M.D.* Choompia S,M.D.*
*Department of Anesthesiology, Faculty of Medicine,
Ramathibodi Hospital, Mahidol University,
Bangkok 10400.
The randomized, double blind study was performed in 63 full term pregnant women whom were decided into two groups. Group I received 0.15% bupivacaine with adrenaline and fentanyI 5 g/ml. Group received 0.25% bupivacaine with adrenaline. The results demonstrated no statistical significance in age, weight, height, cervical dilatation and number of nulliparous patients (p =0.55-1.0). In first stage of labour, the proportion of patients having pain score zero determined at 30 minutes after first dose was significantly higher in group I (p =0.04) and the proportion of patients having no motor block (Bromage score =0) in group I was also significantly higher (p = 0.04). But
in the second stage of labour, the proportion of
patients having pain score as well as
Bromage score zero (no pain and no block) were no statistically difference in both groups (p =0.62 and 0.13). Besides, there were no statistic significances in modes of
delivery, neonatal apgar score and side effects between
two groups (p =0.51 and 0.68).
Key words : Bupivacaine, fentanyl, painless labour
Combined Epidural and General Anesthesia in Renal and Urinary Tract Surgery
Pukrittayakamee P,M.D.*, Srichinthai P,M.D.*, Wacharasind J,M.D.*, Chumnarnkitkosol P,M.D.*, Boonyakariyakorn S,M.D.*
*Department of Anesthesiology, Ramathibodi Hospital,
Bangkok 10400.
The randomized comparison study was performed in 60 patients whom were devided into two groups. Group I received combined general and epidural anesthesia. Group II received only general anesthesia. The results showed no significant difference in age, weight, height, sex and duration of anesthesia (p =0.1-0.87). The observed systolic blood pressure and pulse rate during maintenance of general anesthesia were decreased in group I and increased in group II while the diastolic blood pressure in both groups were decreased when compared to the control values. The amount of isoflurane (ml) and atracurium (mg/kg/min) used in group I were significantly less than
group II (p<0.001 and p =0.003) with no incidence of awareness. In conclusion, combined general and epidural anesthesia decreased cardiovascular response of surgery, amount of inhalation anesthetics as well as muscle relaxant requirement. This technique would lead to the reduction in anesthetic cost and could provide epidural opioid for excellent postoperative analgesia.
Management of Cancer Pain at the pain Clinic Ramathibodi Hospital
Vichitranonda C,M.D.*, Waikakul W,M.D.* Pausawasdi S,M.D.*
*Department of Anesthesiology, Faculty of Medicine,
Ramathibodi Hospital, Mahidol University, Bangkok 10400.
Cancer is ranked the second cause of death
in Thai patients. More than seventy percent of advancedstage
cancer associates with severe pain but pain relief scems to be
inadequate and unsatisfied to the patients, their families and
the physicians themselves.
A descriptive study was done to analyse
cancer patients referred to pain clinic, Ramathibodi Hospital
during 1993. The objectives are to collect the baseline data,
to evaluate the treatments and the results. This data will be
useful for improvement of pain management service in the future.
Fifty-two cancer patients, cousulted mostly from department of surgery, aged average 50 years, sixty-five percent had severe continuous pain (VAS = 8.9+-0.9) before treatments. Forty-six percent had depression and thirty-nine percent had acute anxiety-pain greatly affected socioeconomic status of the patient and forty-six percent loss job. We found that the causes of unsatisfied pain relief were incomplete pain assessment, improper usage of analgesics and adjuvant drugs (agent, dose, frequency). More than
twenty percent received analgesics at "prn dose".
After complete pain assessment, treatments at pain clinic followed the 3-step analgesic ladder program of WHO. Seventy-five percent of patients were treated
effectively by analgesics and twenty-five percent were treated by nerve blocks and other modalities. Most of the patients satisfied with the result of treatments and had improved quality of life. Average VAS after treatment was 1.4 0.6.
Leakage in Anesthesia Machines
Soontranan P, M.D.*, Somprakit P,M.D.**, Lertakyamanee J,M.D.**
*Department of Anesthesiology, **Department of Anesthesiology
and Clinical Epidemiology Unit, Faculty of Medicine, Mahidol University, Bangkok
10700.
Anesthesia machine is the essential equipment
which needs regular maintenance and meticulous routine pre-use
check up. The undetected leakage of the machine is not only harmful
to the patients, but the also causes intraoperative awareness
and pollution. This study investigated leakage in 49 anesthesia
machines used in 1991 at Siriraj Hospital. The machines' age
were approximately 10-20 years except one was used in the first
year. The soap bubble test was done to identify the number and
position of leak points in all approachable parts. The pressures
which created leak were also observed by aneroid pressure gauge
attached at the common gas outlet. The results revealed that
32 machines were leak (prevalence rate 65.30%). The total leak
points were 57; there were 1,2 and 3 leak points in 15 (30.6%),
12 (22.4%)
and 4 (8.1%) machines respectively with other one machine (2.0%) had maximum
6 leak points. Most of leak points (59.65%) were at the vaporizer's connections
on the back bar, the others were at the joint near distal end of back bar (28.07%),
upper part of flow meters (5.26%),pressure regulating valves (5.26%) and machine's
piping system (1.76%). Fifty two leak points (91.22%) were detected within pressure
range of 80 mmHg, while the other 5 (8.78%) were leak in unmeasurable high pressure
(4 in the high pressure section and 1 in distal end of back bar with high back
pressure flow through defected check valve and O2 flush valve). We
conclude that soap bubble test is effective to identify position and number
of leak points. The high prevalence rate was due to lack of regular maintenance
in old age machines, pre-use check up errors, frequent vaporizer removal for
cleaning thymol, many connections on back bar, improper check of leakage in
low pressure section of anesthesia machines with check valve near the common
gas outtet. We suggest that annual maintenance together with meticulous care
in routine check up are essential and, for the service purpose, higher pressure
test is needed to identify total leak points.
Key words : Equipment : anesthesia machine, leak test
Safety
Blood Glucose During Open-heart Surgery
Borvornvanichyakul S.M.D.*, Sungkahapong V,M.D.*,
Rojanapithayakorn P.M.D.*, Kusolwiwatana O,M.D.*,
*Department of Anesthesiology, Central Hospital, Nonthaburi
11000.
To review the blood glucose level during
open heart surgery in the patients who received dextrose-free
priming solution and dextrose-free intravenous fluid.
Intermittent sampling of blood glucose
concentration was performed in 37 non-diabetic adult patients
undergoing open-heart surgery in Central Chest Hospital. The
result showed that in spite of receiving dextrose-free fluid,
none of them was hypoglycemia. Blood glucose level is minimum
at preinduction period (78.359.37 mg%) and then was higher during
cardiopulmonary bypass, but no significant change. Blood glucose
level at 60 minutes after cardiopulmonary bypass was significant
higher than preinduction period (120.9621.52 mg%) and maximum
at immediate in ICU (144.7830.55 mg%)
It is concluded that dextrose-free priming solution and dextrose-free intravenous fluid are safe in nondiabetic patients undergoing open-heart surgery. However we may give small amount of dextrose intravenous fluid to these patients at induction period and discontinue before cardiopulmonary bypass.
The Laryngeal Mask Airway in Pediatric Anesthesia
Somboonvibul W,M.D.*, Lelanukrom R,M.D.*, Sriprachittichai P,M.D.*
*Department of Anesthesiology, Faculty of Medicine,
Chulalongkorn University, Bangkok 10330.
The laryngeal mask airway (LMA) is an airway device which is less invasive
than the endotracheal tube and more convenient than the face mask. It is well
recognized to use both in pediatric and adult patients. Therefore the purpose
of this study was to evaluate the ease of insertion of LMA and also the complications
occurred. Ninety five children, aged between 9 months to 15 years with the physical
status of I-II were enrolled in this study. Standard general anesthesia with
nitrous oxide, oxygen and halothane or thiopental or propofol were used as an
anesthetic agents. The records were age, sex, weight, anesthetic time, time
at removal of LMA, attempts of insertion LMA, vital signs included blood pressure,
pulse rate, oxygen saturation as control, during insertion, 1 and 5 minutes
after insertion and the complications during insertion, during operation and
after removal of LMA. We found that the success rate for
the first attempt was 71.58%, the second attempt was 23.16. There were no statistically
change of vital signs from the control through out the operation. The complications
were breath holding, laryngospasm, cough, trauma, secretion and salivation.
There were no serious complications at all. The LMA may be considered to be
useful device and will have a role in helping anesthesiologists managing the
airway.
N2O/O2/ Isoflurane Low-flow anesthesia
Leelanukrom R,M.D.*, Somboonviboon W,M.D.*,Ketsittibu L,M.D.*, Meerasen P,M.D.*,
*Department of Anesthesiology, Faculty of Medicine, Chulalongkorn
University, Bangkok 10330.
Low-flow anesthesia has many advantages
such as reduction in atmospheric pollution, improvement of humidification,
reduction of heat loss and economy. Forty ASA physical status
I-II patients were randomized into two groups: low-flow group
and high-
flow group. In the low-flow group, anesthesia was conducted with nitrous oxide II/min, oxygen 700ml/min and isoflurane compared with the high-flow group, nitrous oxide41/min, oxygen 21/min and isoflurane. No statistical differences in FiO2, ETCO2, arterial blood gases and vital signs between the groups. FiN2O in the low-flow group was statistical significant lower than FiN2O in the high-flow group. When end-tidal isoflurane concentration was maintained at 0.7%, the hourly consumption of isoflurane in the low-flow group and the high, flow group was 8.11.16 ml/hr and 18.133.42 ml/hr, respectively. There was greater discrepancy between dial setting and inspired concentration of isoflurane in the low-flow group. The authors believe the low-flow technique is the safe and economical way of delivering anesthesia.
The Effectiveness of Single Administration of Piroxicam Intramuscularly for the Prophylactic Purpose of Postoperative Pain in Trans-urethral-resection of prostate Gland
Charuworn P,M.D.*, Tophi-Boon S,M.D.*, Poonyathawon S,M.D.*, Cholitkul S,M.D.*
*Department of Anesthesiology, Faculty of Medicine,
Chulalongkorn University, Bangkok 10300.
Piroxicam, a non-steroidal anti-inflammatory
drug, was administered intramuscularly in a single dose to 82
patients. They were divided into three groups : 22 patients in
the control group, 39 patients received 20 mg of piroxicam, and
21 patients received 40 mg of piroxicam. There were no statistical
significant differences in age and body weight (p = 0.3378 and
0.8656). The pain relief by piroxicam was evaluated by visual
analogue scale pain score and analyzed by chi square and analysis
of variance. The results were significantly different between
group II (20 mg piroxicam) and the control group (p<0.05).
Concerning the need of another pain killing medicine in
the three groups, 17 patients in group I (control) needed pain relief medicine (pethidine, morphine or paracetamol). In group II (20 mg piroxicam), 19 patients received pain relief medicine and in group III (40 mg piroxicam) only one patient received pain relief medicine.
Follow up Study of Knowledge, Attitude and Practice Related to AIDS Among Thai Anesthetic Personnel (Nurse Anesthetists and Anesthesiologists) 1994.
Makarasara N,M.D.*, Charuluxananan S,M.D.*, Poomanee W,M.D.*
*Department of Anesthesiology, Faculty of Medicine,
Chulalongkorn University, Bangkok 10330.
At the annual scientific congress of the
Royal College of Anesthesiologists of Thailand, 1994. questionnaires
about AIDS were distributed to registered participants. In the
questionnaires of true and false type there are 24 questions on
the knowledge about AIDS, 12 on attitudes and opinions, 12 on
current practice in their hospitals and one general question.
Among 481 questionnaires collected, 88 were answered by anesthesiologists
(18.30%),362 by nurse anesthetists (75.26%) and 31 (6.44%) of
unspecified status. The knowledge questions asked about epidemiology,
modes of transmission, risk factors, and clinical knowledge.
It was found that over 50% of the respondents gave wrong answers
to at least 11 out of 24 questions. About attitude and opinion,
61.47% thought that there should be special hospital for HIV positive
AIDS risks, 43.78% felt bad when they were assigned to take care
an HIV positive patient, 73.39% thought that there should be law
prohibit an HIV positive woman to bear a child. In practice,
majority of anesthesia personnel usually protected themselves
when contact the patients' blood or secreta. However, 27.10%
of them thought that their wounds had contacted patients' blood
recently (within 3 months). 82.66% chose regional anesthesia whenever
possible. One last interesting answer was that 9.68% of respondents
had someone closely related such as relatives, colleagues, of
friends had HIV positive.
It is recommended that there should be
guidelines for service of HIV positive patients and anesthesia
personnel should be informed about current of AIDS in the country.
This would result in change of attitude and practice for better
and safe service, both for the patients and the personnel.
Key words: Knowledge, Attitude, Practice, AIDS, Thai nurse anesthetists and anesthesiologists.
Intravenous Nitroglycerin for Manual Removal of Placenta
Vichitranonda C,M.D.* Virankabutra T, M.D.*, Thaveechaiyagarn J,M.D.* Sukpirom P.*
*Department of Anesthesiology, Faculty of Medicine,
Ramathibodi Hospital, Mahidol University, Bangkok 10400.
Retained placenta occurs in about 1% of
all vaginal deliveries. Usually, uterine relaxation is accomplished
with the potent inhalation agent that exposes the parturient to
the risk of regurgitation and aspiration. There are reports using
intravenous nitroglycerin (NTG) successfully aid manual removal
of placenta. Our objectives are to evaluate the effectiveness
for uterine relaxation by NTG and the adequacy of analgesia provided
by intravenous fentanyI and 66% nitrous oxide (N2O)
spontaneous ventilation via face mask. The complications were
also observed.
Prospective study was done in 25 parturient
with retained placenta. Inclusion criteria were ASA class I-II,
systolic pressure>-100 mmHg and pulse rate <-100/min .
Successful extraction of placenta was achieved in all cases.
Fifteen patients (60%) were achieved in 90 seconds, 8 patients
(32%) required second dose and 2 patients (8%) required third
dose for the entire procedure. Recovery of uterine muscle tone
occurred in 1-2 minutes after NTG injection in all patients.
There were no clinically significant changes in blood pressure
and heart rate. All patients remained conscious during the procedure.
Adequate analgesia was achieved in 22 patients (88%)
discomfort in 2 patients (8%) and one patient (4%)
with pain that required intravenous ketamine 25 mg for supplement
analgesia. Tracheal intubation was not required in any patients.
Side effects such as prolong uterine relaxation and headache
were not observed.
In conclusion, intravenous NTG is an effective smooth muscle relaxant with short half-life and brief duration of action. NTG can be used effectively for manual removal of placenta with supplement analgesia. It is another attractive technique for uterine relaxation that avoids the use of potent inhalation agent.
Clinical Evaluation of alfentanil-Propofol Anaesthesia for Dilatation and Curettage
Soontranan P,M.D.*, Lertakyamanee J,M.D.*, Santawat U,M.D.*, Udompunturak S, M.Sc.**
*department of anesthesiology, ** Clinical Epidemiology
Unit, Faculty of Medicine, Siriraj Hospital, Bangkok 10700.
This clinical evaluation was done with 22 Thai females
(ASA class I-II) for elective dilatation and curettage (D&C) by using alfentanil
10 g/kg as premedication, propofol up to 2 mg/kg as induction agent and N2O:O2:
halothane. We found that all the patients were anaesthetized successfully with
no awareness. The perioperative complications were pain during propofol injection
(13.6%) ,increased muscle tone (4.5%), mild airway obstruction (4.5%), postoperative
chill (4.5%), bradycardia (9.9%), hypotension (22.7), hypoventilation (4.5%)
and apnea (4.5%). After alfentanil injection, there was no significant change
in average blood pressure (syst, mean, dias BP), pulse
rate and haemoglobin oxygen saturation. After propofol induction, the mean syst BP and mean BP dropped to the lowest value of 100.013.1 and 74.312.8 mmHg at the 4th minute (significant, P<0.05), the average dias BP dropped to the lowest value of 55.013.1 at the 5th minute (significant, p<0.05). The mean heart rate dropped to the lowest value of 64.67.3 per minute at the 10th minute (significant, P<0.05). the Spo2 did not change significantly from the control and the lowest mean Spo2 was 95.16.9 after propofol induction. All of these values returned to control after discontinuing halothane and N2O. The mean duration of anaesthesia was 12.3 8.6 minutes, time response to open eye and to answer date of birth and/or address correctly were 3.01.8 and 4.32.4 minutes respectively. The evaluation of anaesthetist for the GA were good (91.0%) and satisfactory (9.0%), none was unsatisfactory. We concluded that this technique for D&C was satisfactory, simple and practical with rapid recovery. Perioperative complications (hypotension, bradycardia, hypoxia, hypoventilation and apnea) which occurred in this study, although in a short episode, need meticulous monitoring and rapid intervention to carry on the safe anaesthesia.
Effect of Maternal Inspired oxygen concentration during Caesarian Section under General anesthesia on the Fetal Oxygenation and APGAR Score
Thawilvejjakul V,M.D.*, Ongart K,M.D.*, Nutakul T,M.D.*
*Department of Anesthesiology, Faculty of Medicine,
Siriraj Hospital, Mahidol University, Bangkok 10700.
Sixty-one cases of caesarian section at
term were studied under general anesthesia, endotracheal intubation
and balanced technique. All were anesthetized with 50% N2)
in O2 and 0.5% halothane Just before hysterotomy,
the first group was
maintained with 50% N2O in O2 and 0.5% halothane but the second group was increased O2 concentration to 100% and 0.5% halothane until birth. There were no statistical difference of umbilical arterial, venous PO2 and APGAR score between two groups. The study showed that the increasing maternal inspired oxygen concentration from FiO2 0.5 to FiO2 1.0 before hysterotomy and birth has no effect on fetal PO2 and APGAR score. Thus, this technique is not necessary in general anesthesia for caesarian section.
Accuracy of anesthetic gas flowmeter.
Adipat J,RN., Denduong S,RN., Janthorn P,M.D., Jirasiritham s,M.D.
*Department of Anesthesiology, Faculty of Medicine,
Ramathibodi Hospital, Mahidol University, Bangkok 10400.
The accuracy of anesthetic gas flowmeter was studied in 24 years in Ramathibodi hospital. The gas flowmeter was measured by using wet test meter (wet gas meter). It was found that the percentage of deviation from the preset flow rate of oxygen and nitrous oxide was quite high. The oxygen gas flow meter always showed positive and constant range of deviation, no matter how much present flow rate we used. There was significant difference when we measured the flow rate of nitrous oxide. We found that the higher the preset flow rates were, the lower the range of deviation. The durability of anesthetic machine had no statistically significant with the percentage of deviation.
Comparison of the Effectiveness between Ketamine Hydrochloride and Chloral Hydrate for Oral Premedication in Pediatric Patients.
Vichitranonda C,M.D.* Navakulsirinatta P,M.D.**
* Anesthesiology Department, Ramathibodi Hospital.
**Senior Resident, Anesthesiology Department, Faculty of Medicine, Ramathibodi Hospital, Mahidol
University, Bangkok 10400.
Chloral hydrate is widely used as a convenient,
orally administered premedication in children. Its use in clinical
practice associates with some problems of excessive sedation and
agitation. There are reports using ketamine hydrochloride for
oral premedication and claimed to be effective. This study compared
the efficacy between the two drugs for oral premedication in pediatric
patients.
The double-blind randomized control study
was done in 120 patients aged 6 months-7 years, ASA status I-II,
scheduled for elective surgery. The patients were randomly allocated
into 2 groups. Group I (N =60) were given chloral hydrate (50
mg/kg) and group II (N =60) were given ketamine
(6mg/kg). The effectiveness was assessed by the
evaluation scales consisting of sedation, emotional state, secretion
scales and acceptability to face mask. We also took note of the
side effects and complications of both drugs.
The success rate in ketamine group was
significantly higher than the chloral hydrate group for sedation
scale (p<0.05). There were no significant different between
2 groups for emotional state, secretion scales and acceptability
to face mask (p>0.05).
In conclusion, ketamine hydrochloride can
be used for oral premedication in pediatric patients more effectively
than chloral hydrate for sedation.
Key words : Anesthesia : pediatric
Premedication : chloral hydrate, ketamine.
Effectiveness of Added Epidural Fentanyl or Pethidine for Orthopedic Surgery.
Sangchoti W,M.D.*, Wiangthirawat S,M.D.*
*Department of Anesthesiology, Faculty of Medicine,
Ramathibodi Hospital, Bangkok 10400.
The effectiveness of fentanyI and pethidine
added to 2% Xylocaine with adrenaline I : 200,000 used in epidural
anesthesia for orthopedic surgery were compared. Twenty-four
patients scheduled for lower extremity surgery were randomized
into two groups. Both received local anesthetics via epidural
catheter until the maximum spread reached T8. The added epidural
narcotic dosage in 1 g/kg for fentanyI and 1 mg/kg for pethidine.
Sensory block were evaluated by pinprick and motor block with
Bromage's scale. The study showed that both groups were comparable
in rapid onset of analgesia, intensified sensory and motor blockade
of epidural anesthesia with stable hemodynamic parameters and
helpful in tourniquet pain prevention. The differences were longer
duration of analgesia but more minor complications (nausea, drowsiness)
with epidural pethidine. Added epidural fentanyl or pethidine
proved more advantageous than plain epidural
anesthesia by providing better operating conditions. The patients were reasonably comfortable and required little sedatives.
Patient-Controlled analgesia : a Comparison with q.i.d. and p.r.n..l.m. Injection for Postoperative
Pain Relief, and their Cost-Effectiveness Analysis in Thai Patients.
Sanansilp V,M.D.*, Boonvisudhi K,M.D.*, Srimuangthon S,M.D.*, Phauksungnoen N,M.D.*,
*Department of Anesthesiology, ** Clinical Epidemiology
Unit, Faculty of medicine, Siriraj Hospital, Mahidol University,
Bangkok 10700,Thailand.
We have undertaken a randomized controlled trial to
assess the efficacy and cost-effectiveness of postoperative analgesia techniques.
After major orthopedic surgery under a standard general
anesthesia,63 patients were randomly allocated into three groups, 21 patients
in each group, to receive (1) L.V. patient controlled analgesia (PCA), (2) intramuscular
morphine p.r.n. Pain was scored by using verbal rating scale (0-10). Pain scores
were recorded at preoperation, immediately postoperation,4, 12, 24, 36 and 48
hours postoperation. Maximum, minimum, average pain scores and satisfaction
scores at 24 and 48 hours after operation were also recorded. The average pain
scores at 48 hours postoperation of group 1 was 2.51.9,group 2 was 4.12.1, and
group 3 was 4.5+-2.2; which were significantly different. The undesirable effects
of all three techniques such as nausea, vomiting, pain at pain at the injection
site, bladder dysfunction, sedative effect and respiratory depression were observed.
Only group 2 showed significantly more pain at the injection site. There was
significant difference in the pattern of morphine consumption, group 2>1>3.
The patients' assessment to each technique was obtained. The satisfaction scores
showed no statistical difference. However, there was a difference in preference
for postoperative analgesia technique if the patient would have the operation
again. All patients in group 1 (100%) preferred to use PCA again, while 25%
of patients in group 2 and 3 would rather not use the same technique they had
3 would rather not use the same technique they had received. If we prefer PCA
to conventional method by using a commercial set, in order to reduce one more
score of pain, we
need to pay 118.37 bath more. But if we use a modified
PCA set, in order to reduce one more score of pain, we need to
pay 72.12 baht more. If we prefer intramuscular morphine q.i.d.
to conventional I.M. p.r.n. method, we need to pay 270.15 baht
more, in order to reduce one more score of pain. All patients
in PCA group could use the device with success regardless of their
education level. We concluded that PCA is easy and safe to use
and is a costeffective technique.
Key words : PCA,I.M. injection q.i.d., conventional p.r.n., postoperative pain relief, efficacy, cost-effectiveness analysis, Thai patients.
Sedative Effect of Intranasal Midazolam Compared with Oral Midazolam for Premedieation
Sarakul W,M.D.* Denduong S,RN.,** Ittichaikulthol W,M.D.***
*Third-year resident ** Nurse anesthetist *** Consultant
Anesthesiology Department, Faculty of Medicine, Ramathibodi
Hopital Mahidol University, Bangkok 10400.
A study was carried out to determine the sedative effect of administration intranasal midazolam compared with oral midazolam as a premedication. Sixty Thai patients aged between 15-75 years old, ASA class I-II were randomly allocted into 2 groups. Group I received 7.5 mg midazolam orally while group II received intranasal midazolam 5 mg in 1 ml/ampule. Both groups were observed for the sedative effect in 5,10,15, and 20 minutes. The data was analysed by using chi-square test. We found that intranasal midazolam is significantly better and faster sedative than the oral midazolam group in 5,15, and 20 minutes (p<0.05). There were no nervousness, upper airway obstruction or respiratory depression in both groups. In conclusion, using 5 mg midazoiam intranasally is a good route for premedication in adult Thai patients.
Oxygenation, Ventilation and Hemodynamic Changes during Diagnostic Pelvic Laproscopy in Siriraj Hospital.
Pitimana-aree S,M.D.,* Mahattanaviroj O,M.D.*, sujirattanawimol K,M.D.*
*Department of Anesthesiology, Faculty of Medicine,
Siriraj Hospital, Mahidol University, Bangkok 10700,Thailand.
Thirty-five female patients undergoing
diagnostic pelvic laparoscopy in Siriraj hospital for gynaecologic
reasons were investigated. Laparoscopy was done under local anaesthetic
technique and supplemented with systemic sedation and analgesia.
Hemodynamic (MAP, PR, ECG), oxygenation and ventilation (spO2,
EtCO2, ABG) values at baseline control, post sedation,
post CO2 insufflation, post CO2 exsufflation
and postoperative periods were compared. Hemodynamic changes
were not significantly different. Oxygen saturation (SpO2)
and O2 tension decreased significantly at post sedation
period. Six patients had O2 saturation less than 95
percent and three less than 92 percent. An increase in end tidal
CO2 (EtCO2) was observed at post
sedation and postoperative periods. Three patients
had end tidal CO2 higher than 50 mm Hg. Although diagnostic
pelvic laparoscopy is classified as a minor procedure, oxygenation
and ventilation changes could be anticipated due to the effect
of posture and insufflation of abdomen with CO2. Local
anaesthetic technique with conscious sedation has an advantage
over general anaesthesia because of the low cost and simplicity
of the method. Nevertheless for safe practice, simple O2
supplement, hemodynamic and respiratory monitoring are recommended
to avoid a decrease in oxygenation and a prompt response to any
abnormalities.
Key words : Pelvic laparoscopy, O2 saturation, End tidal CO2
Epidural and Intramuscular Morphine for Postoperative Analgesia for upper gunitourinary tract snymy
Pukrittayakamee P, Srijinthai P, Wacharaasind J, Voranitath N.
Department of Anesthesiology, Ramathibodi Hospital,
Mahidol University, Bangkok 10400, Thailand.
The study was to compare postoperative
pain relief between epidural and intramuscular morphine in 60
patients having kidney and upper ureter operation. These patients
were randomly devided into two groups, group I received 5 mg epidural
morphine one hour before the operation was finished and group
II received 0.15 mg/kg of intramuscular morphine at the end of
operation. These patients were then followed up at ward three
times within 48 hours postoperatively to assess pain visual analog
score (PVAS) and the side effects. The results showed no significant
difference in age, weight, height and sex (p =0.10-0.68). Pain
score (meanSD) determined by visual analog scale (PVAS) in group
I was significantly lower than group II (p<-0.001) since the
proportion of patients in group I having pain score less than
5 was significantly higher (p<-0.001). This study found no
respiratory depression. The incidence of nausea, vomiting and
puritus were significantly higher in group I (p<0.111). Proportion
of patients who could sleep well in the evening after the operation
and on the second day of the operation were significantly higher
in group I (p<0.001 and p<0.05). But this proportion was
not significantly difference on the first day of the operation
(p =0.11). Patients in group I were more satisfied
with epidural morphine for postoperative analgesia (p<0.001)
whereas the incidence of anxiety was not signiticantly difference
between two groups (p =0.14-0.3).
Key word : Epidural morphine, Postoperative analgesia.
Sore Throat and Hoarseness after General Anesthesia with 2% Hydrocortisone in Glycerin.
Rungreungvanich M, Srichintai P, Tontisirin O, Suwanno V, Yuktanan S.
Department of Anesthesiology, Ramathibodi Hospital,
Bangkok 10400.
Double-blind prospective study of the incidence
of sore throat and hoarseness after general endotracheal anesthesia
was done in 204 patients in ASA physical status class I and II.
The oroendotracheal tube intubation was performed by student
nurse anaesthetists obtaining more than three months experience.
The polyvinyl chloride endotracheal tube was lubricated either
by 2% hydrocortisone in glycerin or KY jelly.
The result indicated that , 24 hours after intubation, the incidence of sore throat and hoarseness were 17.6% and 5.9% in the group of 2% hydrocotisone in glycerin compared to 14.7% and 8.8% in KY jelly were 3.9% and 0.9% while 1.9% of the patients in 2% hydrocortisone in glycerin had only sore throat, not any symptom of hoarseness.
The result of the study shows that there
is no statistically significant difference (p>0.005) in using
both lubricants for oroendotracheal intubation.
Key words : Intubation, tracheal : complication
The Effects of Three Methods of Injection of Atropine
Neostigmine Mixture on Cardiovascular System. Bunburaphong P,M.D.*, Poomanee W,M.D.*, Nokhoon P,M.D.*
*Department of Anesthesiology, Faculty of Medicine,
Chulalongkorn University, Bangkok 10330.
One hundred and twenty patients, ASA status
I-II were anesthetized with thiopental, succinylcholine, midazolam,
morphine, pancuronium and nitrous oxide-oxygen. At the end of
anesthesia, each patient received the same dose of atropine 1.2
mg. And neostigmine 2.5 mg. Mixture to reverse pancuronium. They
were randomized into three groups. Group I received the mixture
in single bolus dose. Group II received it in three divided doses
at one minute intervals. Group III received the mixture plus
2 ml. Of water in five divided doses at the same intervals. Statistically
significant tachycardia developed in group I and II. Statisically
significant drop in blood pressure but less than 20% from the
control developed in group III. One case in group I developed
SY depression suggestive of myocardial ischemia during the episode
of tachycardia. Injection of atropine-neostignime mixture for
the reversal of neuromuscular blockade in bolus dose is quite
harmful to the tachycar-dia-risk patient and injection of atropine-neostigmine
mixture in five divided doses may be more suitable.
Volume 20;Number 3:1994
Interaction between pancuronium and Atracurium (I)
Suraseranivongse S, MD.*, Anekpong N,MD.,* Vacharapinyo
I, MD.,
Yuckpan P, MD.,* Maneenoy S, Msc.
*Department of Anesthesiology **Computer Center Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.
This is a randomized clinical study aimed to compare the time course of action among 3 groups : pancuronium given as a second drug after pancuronium, atracurium as a second drug after pancuronium, atracurium as a second drug after pancuronium and atracurium as a second drug after atracurium. Seventy-four patients were operated under general anesthesia, balanced technique and intubated with succinylcholine. Peripheral nerve stimulator was used to monitor the "train of four (TOF)" throughout the study. After 100% TOF recovery from succinylcholine, group I received pancuronium 0.08 mg/kg intravenously followed by pancuronium 0.02 mg/kg intravenously when 2 twitches of TOF appeared. Group II received pancuronium 0.08 mg/kg intravenously followed by atracurium 0.125 mg/kg (one-fourth of the equivalent initial dose) intravenously. Group III received atracurium 0.5 mg/kg intravenously followed by atraurium 0.125 mg/kg intravenouly. The time course of action was the time recorded when the second drug was injected until 2 twitches of TOF reappeared.
There was no significant difference in age, sex, body weight, ASA physical status, type of operation and duration of operation among the three groups. The time course of action (T) in group I,II and III were 42.61(10.29 min, 51.18(17.27 min and 27.90(7.87 min respectively and were significantly longer in group I,II than group III where as no signiticant difference between group I and II. It is concluded that the time course of action of atracurium given after pancuronium was longer than that of atracurium following atracurium but not different form that of pancuronium following pancuronium. The prolonged duration of atraurium administered after pancuronium may be due to the dominant role of the first drug influencing the duration of action of the subsequent drug and the synergistic effect of atracurium to pancuronium.
Interaction between pancuronium and Atracurium (II)
Srirojanakul W, M.D.,* somcharoen K, B.sc.,* Maneenoy S,
M.sc.,**
*Department of Anesthesiology ** Computer Center
Faculty of medicine, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.
In teraction between different non-depolarizing muscle relaants is still controversy.
A randomized clinical trial to compare the effect of the time course of the
interaction of atracurium and pancuronium was performed. Seventy-seven patients
were operated under general anesthesia, balanced technique and intubated with
succinylcholine 1.5 mg/kg. Constant current peripheral nerve stimulator was
used to monitor the "Train of four (TOF)" throughout the study. After
4 twitches recovery of TOF from succinylcholine, fiftyfour patients recieved
atracurium 0.5 mg/kg as an inital dose and then 0.02 mg/kg of pancuronium was
given in twenty-three patient as group I (A/P) and 0.125 mg/kg of atracurium
was given in twenty-nine patients as group II (A/A) when 2 twithches of TOF
appeared. The time course of action (T) which was the time from injecting the
second dose of muscle relaxants to the appearance of 2 nd twitch of TOF were
recorded.
There were no singificant difference in age, sex, body weight, ASA physical
status, duration and type of operation between the three groups, the time course
of action (T) of the sceond muscle relaxxants in group I (A/P) was 31.08(8.37
min, group II (A/A) was 27.90(7.87 min, and group III (P/P) was 42.61(10.27
min. Time course of action of action of the group I was not different from group
II while that of group III was significant longer than group I. It revealed
that after an initial dose of atracurium, topping up with pancuronium (A/P)
does not significant prolong the neuromuscular blockade than topping up with
atracurium (A/A). The top-up dose of pancuronium following atracurium (A/P)
has a significant shouter duration than that following pancuronium (P/P).
Preoccupation of the receptor sites by the initial dose of musche relaxant has
influenced on shortening or prolonging of the duration of the top up dose.
Cardiovascular and Respiratory Changes in Laparoscopic
Cholecystectomy
Anaprayode T. MD*, Pungpoonsub W. MD*, Somboonviboon W.
MD*,
Kyokong O. MD*, Charuluananan S. MD*, Muangmingsuk V. MD*.
Department of Anesthesiology, Faculty of Mecicine, Chulalongkorn University,
Bangkok 10330, Thailand.
Laparoscopic cholecystectomy has emerged rapidly nowadays as an alternative
to traditional open cholecystectomy because of its rapid recovery and shorter
hospital stay. The operative technique involving the intraperitoneal insufflation
of carbon dioxide may cause the deleterious cardiovascular and pulmonary effects.
We study the cardiovascular and respiratory changes associated with laparoscopic
cholecystectomy by measuring blood pressure, heart rate, oxygen saturation,
end-tidal CO2 concentration, arterial blood gases and body temperature before
carbon dioxide insufflation, at 5,15,25 minutes after carbon dioxide insufflation
and 10 minutes after carbon dioxide removal in 62 patients. This study revealed
significant increase in bioxod pressure, heart rate, PaCO2 and end-tidal CO2
concentration after carbon dioxxide insufflation. In addition, the oxygen saturation
also decreased significantly and affhythmias occurred in 17.6% of patients during
the procedure. These changes were probably caused by hypercarbia due to absorption
of carbon dioxide from the peritoneal cavity and inadequate minute ventilation
in some cases. We also found that the body temperature significantly decreased
although the peritoneal cavity was not exposed as in open cholecystectomy. We
therefore recommend that appropriate hemodynamic and respiratory monitorings
should be used rourtinely in order to prevent deleterious complications especially
in old age and rather sick patients.
Key words : Laparoscopic cholecystectomy, cardiovascular
changes, respiratory changes.
General Anesthesia in Pigs : Report 175 Cases
Rungreungvanich M. M.D.*, Sriswasdi S. M.D.*, Tontisirin
O. M.D.*, Virangkabutra T. M.D.*,
Chaysang A.R.N.*, Suwanno V. R.N* Denduong S. R.N*, Yuktanon S.R.N*, Pausawasdi
S. M.D.*Department of Anesthesiology, Ramathibodi Hospital, Mahidol University.
During our experimental period from 1987 to 1994, one hundred and seventy-five
pigs had been anesthetized. They were divided into four groups according to
the nature of operations and the four different anesthetic techniques. The operations
included liver transplantaion, laparoscopic cholecystectomy, bowel resection
and anastomosis with staplor. This four anesthetic techniques were analysed
in term of simplicity, safety and effectivenees for operations in pigs. Its
application may be useful for anesthesiologists who take responsilbility of
veterinary anesthesia in other researches or studies.
Anesthesia in Pig
Rungreungvanich M, M.D.*, Sriswasdi S, M.D.*, Pausawasdi S, M.D.*
*Department of Anesthesiology, Ramathibodi Hospital, Mahidol University.
Occasionally, surgeons must learn how to use new instruments and put into practice with animate training models prior to actual application of the new instruments in the clinical setting.
Anesthesiologists have to participate in this process of learning, being responsible for the veterinary anesthesia.
In this article, we will discuss various anesthetic methods in pigs used during our six-years' experimental period from 1987 to 1994. We have come to the conclusion that the total intravenous anesthesia with intubations has proved to be simple and safe anesthetic method for surgery in pigs.
Blood Glucose Concentration in Pediatric Outpatient Anesthesia
Kijmahatrakul W,M.D.,* Somboonviboon W,M.D.**,
*Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University.
Blood glucosse concentration were measured in 85 pediatric patients aged between 1 month to 13 years who were scheduled for elective outpatient surgery at Chulalongkorn Hospital. The duration of starvation was 4 to 17 hrs. All children were premedicated with chloral hydrate and atropine rectally. General anesthesia under mask with nitrous oxide, oxygen and halothane were used in all cases without intravenous infusion. Preoperative blood glucose levels were 62 to 148 mg% (mean 88.28 mg%) compared to the postoperative levels of 64 to 184 mg% (mean 115.85 mg%). It is concluded that the preoperative starvation did not result in significant hypoglycemia but increasing in blood glucose concentration during surgery were found in these children
Key word : Starvation, hypoglycemia
Perioperative Blood Glucose in Pediatric Outpatients
Sirivanasandha P,M.D.*, Pukrittayakamee P,M.D.*, Srisawasdi S,M.D.*
Department of Anesthesiology, Ramathibodi Hospital, Bangkok 10700, Thailand
Glucose free solution for pediatric patients during surgery is still controversial. Many investigators found no hypoglycemia while the others still found some in their series.
This study was conducted in 93 pediatric patients scheduled for outpatient surgery under genral anesthesia to determine blood glucose level in perioperative period. The result of this study may lead to suggestion for proper fluid administration in children during surgery
The patients were divided into 2 groups, group A (n = 39) and group B (n =54), without and
with 5% D 1/3 NSS administration at maintenance rate respectively. The results showed no
significant difference in age, body weight, duration of fasting, duration of surgery and anesthesia.
P>0.05 (p =0.11-0.92)
Mean blood glucose in both groups were within normal limit. Intraoperative blood glucose
were significantly different between group A and group B (111.3(30.6 VS 131.4(32.8 mg%) p
=0.003). Preoperative (94.23(26.31 VS 95.94(3.98 mg%) and post operative blood glucose
(98.42(30.34 VS 94.71(38.82 mg%) were comparable.
The result showed that 9 patient (9.67%) had hypoglycemia (BG
was the number of children failing to response to the stress of surgery, their blood glucose was lower
than the control (preoperative value). This incidence during intraoperative and postoperative period
was found in group A 30.77%, 56.41% and group B9.43%,61.22%.
The result of this study suggested that stress response in children by increasing blood glucose
is not a simple pattern as someone expected. Both non dextrose fluid and dextrose fluid
administration may result in blood glueose temporarily below control in some children. The
administration of dextrose fluid at maintenance rate may lead to high blood glucose intraoperatively
but not upto the dangerous level.
In conclusion, the administration of dextrose fluid at maintenance rate is suggested to prevent
decreasing blood glucose encountered in certain children until oral intake is resumed.
Key words : Blood glucose level, Pediatric, outpatient surgery.
The Comparative Study of Venturi and Circle Circuit
Vichayanheewin M,M.D.*, Theerapongpakdee S,M.D.*, Krisanaprakornkit
w,M.D.*
*Department of Anestheiology, Faculty of Medicine, Khon Kaen University, Khon
Kaen 40002, Thailand.0
This is the comparative study of the use of circle circuit and venture breathing system in 20 patients of physical status I and II. The mean age, body weight and hemoglobin concentration are 41.65(11.5 yrs 57.28(8.01 kgs and 10.78( 1.81 gm% respectively. In circlecircuit, we used fresh gas flow 6 lpm (N2O : O2 =4 :2), tidal volume 10 ml/kg, respiratory rate 12 bpm. The mean pH, PCO2 and PO2 values are 7.40(0.053,33.41(4.06 mmHg and 181.72 (35.70 mmHg respectively. In venturi
breathing system, fresh gas flow 3 lpm (N2O : O2 =2 : 1), tidal volume and respiratory rate were used in the same manner. The mean pH, PCO2 and PO2 values when on venturi breathing system are 7.386(0.051,35.24(3.70 mmHg respectively. There are no significant difference
Key words : Equipment : Breathing system ; circle, venturi.
Postanesthetic Complications in Chulalongkorn Hospital
Tuchinda ,M.D.*, Somboonviboon W,M.D.*, Topiboon S,M.D.*,
Cholitkul S,M.D.*, Sriprajittichai
P,M.D.*, Urusophon P,M.D.*, Daruthep N. Diploma of Nursing and Certificate in
Midwifery*.
*Department of Anesthesiology, Faculty of Medicine, Chulalongkorn Hospital,
Bangkok 10330, Thailand.
The postanesthetic complications at Chulalongkorn Hospital were studied prospectively
in 8747 patients who required general and regional anesthesia from August 1992
to July 1993. The total incidence of complications was 12.71% and only 1.23%
was major complications. The common minor complications were nausea and vomiting
505%, sore throat 4.2% and backache 1.13%. Major complications occurred in patients
with advanced age, major surgery and higher physical status. The mortality rate
was 0.35% and only 0.02% was related to anesthesia. Patients' satisfaction was
91.8% while 0.86% was rated as unsatisfactory. Intramuscular narcotics was the
most common route for postoperative pain control. This prospective study identifies
the incidence, the risk factors and the complications from anesthesia. This
information may be used to predict, prevent and improve our quality of anesthetic
management for the patients.
Key word : Anesthetic morbidity and mortality
Anesthetic complications
Anesthetic mishaps
Parameters in Weaning from Mechanical ventilator
Vorakitpokatorn P,M.D.*, Suraseranivongse S,M.D.*
Department of Anesthesiology, Faculty of Medicine, siriraj Hospital, Mahidol
University, Bangkok 10700,Thailand.
To assess the standard weaning parameters in Thai patients, this prospective
study was performed in 100 postoperative patients underwent lower abdominal
surgery who needed ventilatory support more than 24 hours. After obtaining fulfil
criteria for weaning, the data of tidal volume (VT), vital capacity (VC), minute
volume (MV), respiratory rate (RR), maximal inspiratory pressure (pI Max) and
rapid shallow breathing index (RR/VT) were collected prior to disconnect the
patients from mechanical ventilators. We found that only 85 patients were weaning
success but other 15 patients were not. Comparing these weaning success group
(Gr.I) and the weaning failure group (Gr II ), there were no significant difference
in weight, sex, VT ,VC, MV and PI Mex but there were significant difference
in age (Gr I = 53.90(15.46,Gr II 61.33 (12.57yr), respiratory rate (Gr I =20.54(4.34,
Gr II 24.00(5.69/min), and rapid shallow breathing index (Gr I =60.5(26.03,
Gr II = 77.59(31.01). the sensitivity of these parameters except vital capacity
were more than 0.9 but the specificity of these parameters except vital capacity
were less than 0.3 . We concluded that no single parameter could be used to
predict successful weaning. Nevertheless, age, RR and RR/VT would help in prediction
weaning outcome in our patients.
A Comparative Study of the Two Anesthetic Techniques for Laryngeal Mask Airway Insertion
Wongpunkamol S.M.D.,* Boonsong P.M.D.,* Paiboon worachatti S.M.D.,*
Punjasawadwong Y.M.D.* M.Med. Sc (Newcastle)
*Department of Anesthesiology, Faculty of Medicine, Chiangmai University Chiangmai 50200. Thailand
The purpose of this study was to compare two anesthetic technique (propofol VS. thiopental plus succinylcholine) for the insertion of laryngeal mask airway (LMA). Sixty patients, scheduled for elective surgical procedure, were randomly allocated to receive either propofol 2 mg. Kg- 1 (group A, 30 patients) or thiopental 5 mg.kg.- 1 plus succinylcholine 1.5 mg. Kg- 1 (group B,30 patients). The condition and the time for LMA insertion were noted and graded. All complications and problems related to either technique were also recorded.
The median insertion times were 8 and 5.5 seconds in group A and group B respectively. By the Mann Whitney U test, this difference was statistically significant (p =0.0009). Sixty three percents of patients in group A experienced undesirable responses during LMA insertion while no patient in group B experienced these responses.
It can be concluded from our study that thiopental and succinylcholine can be sucessfully used to facilitate the insertion of LMA. Although propofol can be used as a sole agent for LMA. Insertion, the undesirable responses occured in some patients.
Key word : Anesthetic : Propofol, Thiopental, Succinylcholine
Equipment : Laryngeal mask airway
Spinal anaesthesia for Caesarean section : a comparison
of two spinal needles (25 Gauge Quincke vs 24 Gauge Sprotte)
Hintong T,M.D.* Soopachokchaiwatana S,M.D.* Punjasawadwong Y,M.D.*
*Department of Anaesthesia, maharajnakornchiangmai Hospital, Chiangmai University,
Chiangmai 50200.
The ease of spinal puncture, the incidence of postspinal headache and back pain were studied in 80 term pregnant patients undergoing elective caesarean section. These eligible patients were randomly allocated to have spinal anaesthesia with either a 25 G Quincke needle (n = 40) or a 24 G Sprotte needle (n = 40). Feel of firm needle, obvious "pop" sensation during dural puncture, free DCF aspiration and easy local anesthetic (LA) injection were noted in 40%,22.5%,35% and 5% of patients in the Quincke group and 80%, 75%, 100% and 92.5% in the Sprotte group (p
Key words : Anaesthetic techniques : Spinal, caesarean section;
Complications : Headache;
Equipment : Sprotte needle.
Body Image in Spinal Anesthesia
Chaedamphai E,MD*, Satproedproedprai A,MD*, Tophiboon S,MD*, Cholitkul S,MD*.
Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University,
Bangkok 10330,Thailand.
Body image concerning the position oflower limbs after spinal anesthesia given for lower abdominal, perineal and lower limb surgery was studied in Chulalongkorn Hospital during January to December 1993.
One hundred and one patients, ASA physical statur 1 or 2, were randomized into two groups according to the designed position of lower limbs. Being placed in supine position immediately after the administration of the local anesthetic, one of the lower limbs was placed into the designed position and the other was kept straight on the table which served as their control. Observations were made after sensory level of anesthesia was obtained above the sixth thoracic dermatome. Ninetyone patients experienced phantom sensation which was correlated with the designed leg positions prior to the completion of anesthesia, nine patients experienced bizzared sensation and one was not able to describe any position at all. The disappearance of the phantom sensation was related to the recovery of motor activity and pin prick sensation of the body.
Intrathecal Morphine and Lignocaine for Cesarean Section.
Leelanukrom R., Charuluxananan S., MuangmingsooKV., Agprudyakul S., Attasat, S.
Department of Anesthesia, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand.
The intrathecal administration of 60 mg. Hyper baric lignocaine plus 0.1 mg. Morphine as an anesthetic technic for providing surgical anesthesia and postoperative analgesia was evaluated in sixty ASA I parturients undergoing cesarean section. Maximum cephalic spread of analgesia was T3.68(0.52 (man (sd.) dermatome. General anesthesia was required in one patient whose
maximum analgesic dermatome was T 10' she received no additional narcotics intraoperatively with long lasting postoperative analesia. Hypotension was the most common intraoperative problems (48.33%). Satisfactory postoperative analgesia, lastling for 24 hours, was obtained in 76.67% of the patients. Although these provided good surgical wound analgesia, three patients complained of uterine contraction pain. These were effectively treated with parenteral administration of low dose morphine. Whether this result is due to insufficient dose of morphine is a topic for further investigation. No serious sied effect was observed.
W. Lapisatepun*, C. Nisoong*,
W. Churnchongkolkul*, Y. Punjasawadwong*,
T. Nipitsukarn*, A. Phongchiewboon*, Y. Arasaki*
*Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand, +Naha Prefectural Hospital, Okinawa, Japan.
Volatile anesthetics have long been known to interfere with the action of neuromuscular blocking agents. This study was to determine the effect of 1% sevoflurane on the duration of an intubation dose (0.1% mg/kg-1) of vecuronium during N2O-fentanyl anesthesia. Thirty ASA class I-II female patients were randomly allocated to receive either droperidol (group 1) or 1% sevoflurane (group 2). Neuromuscular function was monitored by means of the Accelograph TM. The duration of vecuronium was 44.86(8.57 minutes in group 1 and 39.58(3.95 minutes in group 2. Group 2 tended to have a shorter duration than group 1 (p =0.03). The finding does not agree with previous studies which reported the potentiating effect of sevofluranes on the action of neuromuscular blocking agents. This contradictory result may be due to the initial stimulatory effect of low concentration (1%) sevoflurane on the muscle cells.
The Effects of Preincisional skin Infiltration with pH
Adjusted Bupivacaine vs Epidural pH Adjusted Bupivacaine plus Morphine for Postoperative
Pain Relief in Transabdominal Hysterectomy.
Shusee Visolyaputra M.D.,* somchart Maneenoy BSc.**
*Department of Anesthesiology, ** Computer Center, Faculty of Medicine, siriraj
Hospital, Mahidol University, Bangkok 10700, Thailand.
Since recent studies showed that, by blocking nociceptive impulses, local infiltration with bupivacaine can give better and longer postoperative pain relief. So, the objective of this study was to see whether preincisional local skin infiltration with pH adjusted bupivacaine can effectively relief postoperative pain in transabdominal hysterectomy as compare to epidural pH adjusted bupivacaine plus morphine and the control group. Sixty patients were randomly devided into 3 groups to receive : general anesthesia without local infiltration (control) ; general anesthesia with
0.5% bupivacaine with epinephrine 20 ml plus 1 ml of 8.4% sodium bicarbonate for preincisional skin infiltration ; epidural 0.5% pH adjusted bupivacaine plus morphine 5 mg in 15 ml before general anesthesia. The visual analog scale (0-100 mm) was evaluated every 3 hours for constant pain (rest) and movement pain (coughing) within 48 hours postoperation. The pain scores in epidural group were significantly less than the local group and the control group during rest and coughing but not between the local group and the control group except during rest at 6 to 9 hours postoperation. The morphine supplement and the onset time to require the first dose for pain relief were also significantly less and longer in the epidural group but not different between local and the control groups. The conclusion is that preincisional local infiltration with bupivacaine can not effectively prevent postoperative pain in transabdominal hysterectomy as compare to epidural bupivacaine plus morphine.
Effectiveness of Piroxicam for Post-operative Pain Treatment.
Plernsri Charuworn, M.D.,* Oraluxna Rodanant, M.D.,*
Nipon Wuthithepbuncha, M.D.,* Yuttana Punghansaporn, M.D.*
*Department of Anesthesiology, Chulalongkorn Hospital, Medical school, Chulalongkorn University, Bangkok 10300, Thailand.
Piroxicam, anon steroidal anti-inflammatory drug administered in a single daily dose, found a satisfactory pain relief effect in various kinds of pain problems such as rheumatoid arthritis, musculoskeletal disorder, and recently the post orthopedics surgical pain. Base on long half-life of piroxicam, the patients (33 ; male 17, female 16) were scheduled to receive 40 mg. Of piroxicam2 hours before surgery. The results demonstrated that piroxicam provided a 30.3% pain-free and 45.5% mild pain and 8% have severe pain which need narcotics (Pethidine) to be administered.
Propofol Infusion for Sedation During Epidural Anesthesia
W. Saengchote, MD*
*Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol
University, Bangkok 10400, Thailand.
This study investigated the use of propofol given as a continuous infusion for sedation to supplement epidural anesthesia for various kinds of operations in 35 adult patients (ASA I or II). Premedication was only oral benzodiazepine. The desired level of sedation, defined as absence of the eyelash reflex, was achieved with acceptable cardiovascular alterations. The average duration of infusion was 52.9 minutes (SD 19.48) and the recovery was within 10 minutes and quite impressive with eyes open in 2.9 minutes (SD 0.49). The mean rate of infusion was 2.995 mg/kg/hr. (SD 0.325). Pain on injection occurred in9 patients, it was mild in 4. Only 2 patients remembered the pain postoperatively. No respiratory obstruction, nausea or vomiting occurred. Thirty-two patients described the period of sleep as pleasant. All surgeons, anesthetists and patients satisfied with this technique.
A Comparative Study between Hyperbaric and Isobaric Bupivacaine for Spinal Anaesthesia. Sireeluck Klanarong*, Mali Rungrangvanich*
Aree Jessadayanmetha*
*Department of Anesthesiology, Buddhachinaraj Hospital
Sixty patients of ASA physical status I or II, undergoing lower abdominal and lower extremity surgery were randomly allocated into 2 groups (group 1,2). Spinal anaesthesia were preformed in lateral decubitus position with 3 ml of hyperbaric or isobaric bupivacaine in group 1 and group 2 respectively. Level of anaesthesia and hemodynamic effect were compared. Patients with hyperbaric significantly higher anaesthetic level than those with isobaric group ; T 6-7 compared to T 9-10. Hypotension was noted at 16.7 and 3.3 percents of cases in group 1 and 2 respectively. No other complications was found in this study.
Anesthetic Management for Harlequin Fetus.
Kamthorn Tantanawigrai M.D.*
*Instructor of Anesthesia, Children's Hospital, Department of Medical Service,
Bangkok 10400
This is a case report of a 6 weeks-old-girl, weighed 2,700 gm. Underwent amputation of the fingers of both hands. Her diagnosis of Harlequin fetus was made because she had her body covered by a hard, keratotic cast which cracked after some hours, resulting in deep and irregularly branched fissures (Fig. 1). This was happened directly after birth. The thick plates of stratum corneum covering the body surface impaired normal food intake and breathing. Owing to the armorlike keratoses, the baby was immobile and the limbs were fixed in flexion. The affected baby was unable to move or suck effectively, but she could swallow. The face could have a frog-like appearance. The eyes were often covered with coagulated blood and turned out (severe ectopion), a flattened nose and a wide-open mouth were further facial characteristics. She was born maturely and tremendously additional skin problems. She required the treatment with etretinate directly from birth. Etretinate was very effective and slowly cleared the skin, reversal of the ectopion and improved development of the nose and ears. Careful attention should be given to fluid balance, caloric intake, tem perature control, skin protection with moisture, oxygen therapy and treatment of infection. The medical cares and treatments were quite satisfactory.
The anesthetic management for the amputation of her fingers included atropine 0.1 mg intravenously as premedication, smooth induction following intravenous administration of succinylcholine 4 mg. Maintenance in oxygen, and 1% halothane along assisted ventilation. The outcome of anesthesia was excellent.
Key words : Anesthesia, Harlequin fetus
Intraoperative temperature maintenance and pulmonary secretion in infants and childreu by use of heat and moisture exchanger.
Somchart Maneenoy B.Sc.**
*Department of Anesthesiology, ** Computer Center, Faculty of Medicine, Siriraj
Hospital, Mahidol University Bangkok 10700, Thailand.
We determined the effects of heating and humidifying inspired anesthetic gases on body temperature and pulmonary secretion of 43 pediatric patients. Their weight were ranged from 2.5 to 22 kgs, ASA physical status 1 or 2, underwent major surgical procedures. The patients were anesthetized with halothane and 70% N2O ventilated via Jackson Rees' modification of an Ayre's T-piece. The patients were randomly assigned to receive passive airway humidification using the Thermovent 600@ heat and moisture exchanger (HME) placed between the Ayre's Y-piece and the endotracheal tube (n = 21). Central body temperature increased 0.280c during passive humidification whereas temperature decreased 0.580c without airway heating and humidification. Distal tracheal temperature was significantly higher in the group given passive humidification than in the control group. Mean maximal airway pressure difference across HME was 2.5 cm H2O. Pulmonary secretion was less voluminous in patients receiving heat and moisture exchangers but the tenacity was not significantly different between the two groups. We concluded that heat and moisture exchangers can prevent the decrease in intraoperative body temperature and reduce the volume of pulmonary secretion during surgery. HME should be used only in controlled respiration.
Key words : Temperature : body, intraoperative
Secretion : pulmonary
Equipment : heat and moisture exchanger
Anesthesia : pediatric
Total Intravenous Anesthesia in Anorectal surgery
Siriwan Jirasirtham*
Sopon Jirasirtham**
*Department of Anesthesiology, Rpmathibodi Hospital
**Department of surgery, Ramathibodi Hospital
This is a study of a special intravenous anestheia for anorectal surgery. The study composed of 52 cases of the patients. The anesthetie agents used were 3 mg/kg min of thiopental sodium, together with 1-2 mg/kg of fentanyl for the induction of anesthesia and propofol infusion with the rate of 0.18 mg/kg/min for the maintenance. The result was that all the operations were performed smoothly. The patients recovered faster than the conventional general anesthesia. There was no side effect of nausea, vomiting detected after the operation. With this technique, the complication from intubation and regional block could be avoided. Finally, the cost of total intravenous anesthesia used in these operations was cheaper when compared with any other technique
Couscious Sedation in Gynecological Laparoscopy
K. Uerpairojkit, W. Somboonviboon, P. Urusopone, D. Kongratanawan
*Department of Anesthesiology, Chulalongkorn Medical School, Bangkok 10300,
Thailand.
Gynecological laparoscopy is a common outpatient procedure. The anesthetic technique should be safe and, ensure rapid recovery with as few after-effects an possible. Thirty ASA physical status I-II patients undergoing gynecological laparoscopy for diagnosis and tubal sterilization were enrolled in this study to quantify the effects of CO2 insufflation and the trende lenberg position on respiratory and cardiovascular changes in patients who received sedation with pethidine 75 mg, diazepam 10 mg IV and local infiltration. Blood pressure, heart rate, respiratory rate and oxygen saturation were recorded at control, 3,6 minutes after sedation, 3, 6, 9 minutes after pneumoperitoneum and arterial blood gas at 3 minutes after sedation and 7 minutes after pneumoperitoneum. Mild hypoxemia occurred after sedation and slightly improved after pneumoperitoneum which corresponded to increasing of the respiratory rate. Mild hypercarbia and respiratory acidosis occurred especially during pneumoperitoneum but were clinically insignificant. No clinically significant changes of blood pressure and heart rate through the study period.
From this study, we recommend that conscious sedation with oxygen supplement would be a safe mothod for short diagnostic laparoscopy.
Conscious Sedation in Gynecological Laparoscopy with and without oxygen Supplement
K. Uerpairojkit, W. Somboonviboon, P. Urusopone, D. Kongratanawan
*Department of Anesthesiology, Chulalongkorn Midical School, Bangkok 10300,
Thailand.
Gynecological laparoscopy is a common outpatient procedure. The anesthetic technique should be safe and ensure rapid recovery with as few respiratory or cardiovascular complications as possible. Conscious sedation combined with local infiltration for diagnostic laparoscopy causes hypoxemia from respiratory depression and upper airway obstruction especially in the trendelenberg position.
Forty ASA physical status I-II patients undergoing elective laparoscopy were allocated randomly to two groups. All patients received pethidine 75 mg and diazepam 10 mg IV and local infiltration. The patients were randomized into 2 groups : group I 20 patients without oxygen supplement and group II 20 patients with oxygen supplement (O2 mask 6 L/min). Blood pressure, heart rate, respiratory rate and oxygen saturation were recorded at control, 3,6 minutes after sedation, 3,6,9 minutes after pneumoperitoneum. Arterial blood gas was obtained at 3 minutes after sedation and 7 minutes after pneumoperitoneum Significant mild hypoxemia occurred in group I but no evid ence of hypoxemia occurred in group II. No statistically significant changes of PaCo2, pH, BP, HR and RR between the two groups. Conscious sedation with oxygen supplement is considered to be the simple safe and effective procedure for short gynecological laparoscopy for diagnosis and tubal sterilization.
Preload Fluid for Spinal Anesthesia in Caesarean section
A. Satproedprai M.D.* D. Kongratanawan M.D.* J. Saothontthong M.D.* p. Urusopone M.D.*
T. Werawatganon, W. Somboonoiboon
*Department of Anaesthesiology, Chulalongkorn Medical School, Bangkok 10300,
Thailand
The effect of preload fluid on cardio vascular system to prevent hypotension in caesarean section was studied in Chulalongkorn hospital during August 92-June 93. One hundred and twenty parturients of ASA class 1, 1E using standard technic of spinal anesthesia were included in the study and randomly allocated into 3 groups of 40 cases each according to preload fluid as group 1 received 10 ml/kg of normal saline solution, group 2 received 5 ml/kg of Haemaccel@ and group 3 received 5 ml/kg of 10% HAES Steril@ We found that hypotension occurred more frequent in group 1 compared to group 2 or 3 without any statistical difference in other side effects such as neonatal outcomes. We may conclude that colloid might be more effective in prevention of spinal hypotension.
Preoperative Elecrocardiography in Ramathibode Hospital
Chomchaba Soranastaporn MD*, Kaewjai Aporntanakul MD8,
*Department of Anesthesiology, Ramathibodi Hospital, Faculty of Medicine, Mahidol
University.
To evaluate the usefulness of the preoperative electrocardiogram, we retrospectively studied 1,067 patients scheduled for surgery under general or regional anesthesia from January until June 1990. We found 325 electrocardiograms suggested abnormality, only 3 of them were Q-wave abnormality and 29 of them were supraventriclar tachycardia (SVT) or ventricular ectopic beats. Only age and systemic disease predicted the yield of the admission electrocardiograms. To reduce costs related to unnecessary tests, routine use of ECG is warranted only in selected subsets of patients, including those at risk of occult heart disease, particularly older patient.
Caudal Morphine Combined with Bupivacaine fpr Postoperative Analgesia in Pediatric Patients
P. Charuworn, W. Soomboonviboon, S. Charuluxananan, S. Poonyathawon
*Department of Anesthesiology, Faculty of Medicine, Chulalongkoun University
**Resident, Department of Anesthesiology, Faculty of Medicine, Chulalongkorn
University
Caudal morphine for postoperative pain relief in children has been advocated for several years. The purpose of this study is to evaluate the duration of analgesia and the side effects of caudal morphine combined with bupivacaine in children undergoing surgery in Chulalongkorn hospital.
One hundred and thirty six children, age between 2 months and 15 years undergoing surgery classified by site of operations as following : extremities 5 cases (3.7%), perineum 60 cases (44.1%), lower abdomen 31 cases (22.8%), upper abdomen 21 cases (15.4%) and thorax 19 cases (14%) had been studied. After inhalation induction with nitrous oxide and halothane, caudal anesthesia was performed using 0.5 millilitres per kilogram body weight of 0.125% bupivacaine combined with morphine sulfate 0.03 milligram per kilogram body weight. Duration of analgesia and side effects were recorded during the first 24 hours postoperatively. The duration of analgesia : more than 24 hours, 18-24 hours, 12-18 hours. 6-12 hours and 4-6 hours were in 90 cases (66.18%), 9 cases (6,62%), 11 cases (8.09%), 16 cases (11.76%) and 10 cases (7.35%) respectively. No serious complication was detected, there were 10 cases of pruritus (7.35%), 7 cases of nausea vomiting (5.14%), 4 cases of urinary retention (2.94%), 3 cases of drowsy (2.20%) and only 1 case of abdominal distension (0.37%).
This study suggests that caudal morphine combined with bupivacaine is suitable for postoperative pain relief with manageable minor side effects.
Different Flows of Blow-by Oxygen Supplement for Infants
and Children in the Recovery Room
S. Suraseranivongse, S. Maneenoy, S. Foongdej
*Department of Anesthesia, **Computer center ***Department of Nursing, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700. Thailand
This randomized cross-over trial compared the efficacy of a blow-by oxygen supplement with different flows in infants and children recovering from anesthesia. Using an Ohmeda 3700 Biox pulse oximeter, 24 infants and children (ASA class I, mean age 3.9 yrs, range 10 mos.-7 yrs, underwent lower abdominal or peripheral surgery, were continuously monitored for 30 minutes in the recovery room. Patients received oxygen blow-by supplement in randomized sequence of different flows (3,4 and 5 lpm) to prevent bias of hypoventilating effects of residual anesthetics and of the awakening. Each flow was given
for 10 minutes and SpO2 was recorded before changing the flow. The results showed that all patients tolerated blow-by oxygen very well. The SpO2 measurements after 10 minutes of different flows were all significantly higher than the SpO2 measurements obtained on room air upon arrival to the recovery room. The SpO2 measurements afO2 3 Ipm. The least SpO2 obtained from O23,4, and 5 Ipm were 95,96,and 97 respectively
It is concluded that blow-by oxygen supplement with the flow 5 Ipm can be used effectively and safely to prevent postoperative hypoxemia in the infants and children.
Key words : Pediatric anesthesia, postoperative Hypoxemia,
blow-by, delivery system, oximetry, oxygen therapy
Low Dose Stellate Ganglion Block : 1st Thoracic Vertebral
Level, Anterior Approach
M. Phopichit, P. Kunusongkiet, S. Paiboonvorachati, S. Chaiyaphruk
N. *Department of Anesthesiology, Faculty of Medicine, Chiangmai University.
Chiangmai 50002, Thailand
The sympathetic supply to the head, neck and arm can be interrupted at the stellate ganglion. Several possible approaches to the stellate ganglion had been described. The anterior approach at the level of the sixth cervical transverse process with 10-20 ml of local anesthetics is commonly used. Repeated blocks with local anesthetics or injection of neurolytic agent can provide prolonged sympathetic block. Stellate ganglion blocks via anterior approach at the first thoracic vertebral level were done in 9 cases of cancer pain under fluoroscopy. 1.5-2 ml. Of 2% lidocaine mixed with Telebrix was jnjected as a test dose, followed by 1.5-2 ml of 7% phenol in water was injected if there were signs of suceessfulblock. The immediate results of block were fair to good and there was no complication. We purpose that our technique may avoid complications due to spread of large volume of the neurolytic solution to the adjacent structures.
KKU Jet Ventilator VS Conventional Anesthetic Ventilator
in Bain's Breathing System
S. Theerapongpakdee, C. Sinkuakul, D. Arayasatjapong,
W. Chau-in
*Department of Anesthesiology, Srinagarind Hospital, Faculty of Medicine, Khon
Kaen University, Khun Kaen 40002, Thailand.
We compared the performance of KKU jet ventilator and conventional anesthetic
ventilator as used in the Bain's breathing system at Srinagarind hospital. Twenty
patients of ASA I-II class were anesthetized under gener al anesthesia with
controlled ventilation by using fresh gas flow of 100 ml/kg/min and minute ventilation
of 10 ml/kg x 10 bpm. After stabilization for twenty minutes, arterial blood
gases were investigated for conventional ventilation and jet ventilation respectively.
No statistical differences on pH,PaO2,PaCO2 and bicarbonate values were found
between both types of ventilation. We con cluded that KKU jet ventilator could
be used as effectively as conventional anesthetic ventilator.
Key words : Ventilator, KKU jet circuit Bain's breathing system.
Spinal Anesthesia with 0.5% Plain Bupivacaine for Lower-extremity
and Perineal Surgery
S. Niruthisard, W. Somboonviboon, P,Sriprachittichai,
O. Vaewsorn
* Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University,
Bangkok 10330
Anesthetic level from spinal anesthesia with plain bupivacaine has been reported
to be difficult to predict, Nevertheless it is acceptable to use for lower-extremity
and perineal surgery. In this study of 40 male patients undergoing lower-extremity
and perineal surgery, 3 ml. Of 0.5% plain bupivacaine mixing with the patient's
CSF 2 ml. Was administered intrathecally in lateral horizontal position. The
onset of maximum sensory blockade was 15.43(1.75 min. and the motor block was
15.50(6.09 min (mean(SD). The maximum level of sensory bolckade was T6.74(2.57.
The duration from maximum sensory blockade til regression to L1 was 188.33(37.16
min. and the total duration of action was 280.58(63.34 min. Age, weight and
height of the patients die not have correlation with the maximal level of sensory
blockade (P>0.05). The complications found were hyporension (10%) , bradycardia
(5%) and shivering (2.5%). To conclude from this study, we found that 3 ml.
Of 0.5% plain bupivacaine could be used safely for lower-extremity and perineal
surgery with only a few complication.
Isobaric vs. Hyperbaric Bupivacaine in spinal anesthesia
I. Sukcharoen, P. Thepsitthar, R. Benjakul, A. Sorahoung,
K. Jirasan
*Department of Anestheaia and operating room, Bhumiphol Adulyadej Hospital,
Directorate of medical services Royal Thai Air Force
We evaluated the effects of baricity on the spread of analgesia and the hemodynamics
in bupivacaine spinal anesthesia. Fourty patients undergoing lower extremity,
inguinal, pelvic or transurethral surgery were randomly given either isobaic
(group 1) or hyperbaric (Group 2) bupivacaine for spinal anesthesia. The injection
was done through a 25G Quinke-tip spinal needle at L3-4 interlaminar space in
the sitting position. After injection of the local anesthetic, the patient was
immediately placed in the supine and horizontal position. The following paramters
were recorded at 0,1,2,3,4,5,10,15,20,30, and 60 min : pricklevel of analgesia,
degree of motor blockade, mean arterial pressure (MAP), and heart rate (HR).
The duration of sensory block, measured by two-segment regression of sensory
blockade, was also recorded. There were no significant difference between two
groups in the maximun sensory analgesic level, time to block at highest dermatome,
time to have maximum motor blockade, and hemodynamic changes. The time to two-segment
regression of sensory blockade was significantly prolonged in Group 1.
Key words : Anesthesia, spinal; local anesthetics, bupivacaine.
Anesthesia for Coronary Artery Bypass Graft Surgery :
O.Kusolwiwatana, P. Hongtiumtong, N. Kijdamrongchai, S.
Bovornvanichkul, W. Somboonviboon
*Department of Anesthesiology, Central Chest Hospital, Karai, Nonburi 11000,
Thailand.
**Department of Anesthesiology, Chulalongkorn Hospital, Chulalongkorn University,
Bangkok, Thailand.
Descriptive study of anesthesia for coronary artery bypass graft surgery in
Central Chest Hospital was reported from 1983-1992. There were 500 cases (409
males and 91 females) with the age, of 12-85 years, body weight of 32-91 kilograms
and functional class of III-IV. Most of the cases were treated with B-blocker,
calcium channel blocker and coronary vasodilator. Coronary angiographs were
performed in all of the patients before the operation. The coronary artery bypass
graft (CABG) surgerys were done under cardiopulmonary bypass technique using
saphenous vein and internal mammary artery grafts (IMAG). Techniques of anesthesia,
monitoring and complication from anesthesia and surgery were reported in this
discriptive study.
A Comparative study between oral and rectal administration
of midazolam for premedication in Thai Children
Somboon Thienthong M.D.*, Deena Arayasatjapong M.D.*
*Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, Khon
Kaen 40002.
The effectiveness of midazolam premedication was investigated comparing oral
to rectal
administration. Sixty children (1-5 years) were randomly assigned to receive
midazolam 0.4 mg/kg body weight orally (group I) and rectally (group II). All
children were classified as ASA I. Within the two group the children were not
different with respect to their general data, age, weight, anxiety score
and duration of premedication. Parameters of efficacy were the degree of sedation
before and at
10,20 and 30 minutes after midazolam as well as the acceptance of the mask at
induction of
anesthesia. Good sedation were established in most of the patients in both groups
within 10 minutes post premedication. Acceptance of the mask was comparable
in both groups and was tolerated well to very well by 66.67-76.67 percent of
the children. No undesirable side effect was observed. In conclusion, midazolam
is a suitable drug for oral as well as rectal premedication in pediatric
anesthesia.
Key Words : Midazolam, Premedication.
Oxygen Saturation Following Sedation During Regional
Anesthesia
S.Suksompong, U. Prakanrattana, S. Maneenoi.
*Anesthesiology department, Siriraj Hospital, Faculty of Medicine, Mahidol University,
Bangkok 10700, Thailand.
**Siriraj cmoputer center, Siriraj Hospital, Faculty of Medicine, Mahidol University,
Bangkok 10700. Thailand.
The effect of sedation with meperidine on arterial oxygen saturation during
regional anesthesia
was studied. The study comprised of 78 patients underwent urological surgery
at Siriraj Hospital. They were randomly allocated into 2 groups. Group 1 breathed
room air while group2 received supplementary oxygen 3 litres/minutes via cannula.
The baseline of mean arterial oxygen saturation of the two groups were 96.98?1.64%
and 96.47?1.39% respectively without any significant difference. The mean arterial
oxygen saturation after intravenous meperidine were 94.6? 2.76% and 97.34?1.61%
respectively which was statistically significant difference. There was a significant
reduction in arterial oxygen saturation in 5% of the patients who did not receive
supplementary oxygen. The minimal oxygen saturation in group 2 was 94. It is
concluded that patients undergoing regional anesthesia should receive additional
oxygen routinely unless a pulse oximeter is available for monitoring.
Recovery Room Stay in outpatients After General Anesthesia
VS. Caudal Block : A Comparative Study
S. Wongpunkamol MD, Y, Punjasawadwong MD, S. Choomjai
BSc.*
T. *Department of Anesthesiology Faculty of Medicine, Chiang Mai University,
Chiang Mai, Thailand.
The goal of outpatient anesthesia is to keep the same comparable quality as
inpatient
anaesthesia while providing a swift and safe discharge condition for the patients.
This study was aimed to compare the recovery room stay time between general
anesthesia and regional anesthesia- caudal block in 38 outpatients, ASA class
I-II, aged 24-65 years who were scheduled for litholapaxy. The eligible patients
were randomly allocated to receive either general anesthesia (group A, 19 patients)
or caudal block (group B, 19 patients). The recovery room discharge criteria
used in this study were modified from. Phoenix Surgicenter Patient Criteria.
All complications and problems related to either technique were also recorded.
The median recovery room stay times were 95 and 145 minutes in the general anesthesia
group and caudal group respectively. By the Mann Whithney U test, this difference
was statistically significant (p=0.002). No serious complications were found
in both groups.
In conclusion, dispite no evidence of serious complications following either
technique, the
recovery room stay time tended to be longer in the caudal block group than that
in the general
anesthesia group. This might cause a delay in discharge of the patients from
the hospital. The
finding can probably be socially important, particularly for those who live
in a remote area where the public transportation is limited.
Key words : Outpatients : General anesthesia : Caudal block
The Incidence of Nausea & Vomiting After Narcotic
Administration in Thai Patients
P. Sirivanasandha,T. Virankabutra, J. Bautongsri.
*Department of Anesthesia, Ramathibodi Hospital.
**Third year Resident
The incidence of emesis (nausea, retching and vomiting) after narcotic administration
was
highly recognized since the earliest days of surgical procedures carried out
under general
anesthesia. Many authors have published in the last 40 years of the incidence
of post operative
emesis from 40-82 percent. Most of the papers were reported from westhern countries.
We wonder this figure is true for Thai patients. 325 Thai patients were studied
at random to
assess the incidence of emesis after narcotic administration on daily operative
schedule at
Ramathibodi Hospital during the 1st February to 31st March 1992. The choice
of anesthesia narcotic administration and dosage were freely selected by anesthesiologists
and nurse anesthetists incharge. The data recorded for analysis include sex,
age, premedication, anesthetic of choice and dosage, type of operations as well
as severity of the symptoms and signs of emesis in recovery room until 24 hours
post-operatively.
The incidence of emesis in this study is only 12.9%, much lower than previous
reported from
other countries. Sex and age group play a role over incidence of emesis, significantly
higher in
female and age over 30 years. Conventional narcotics used in Thailand, mohrpine,
pethidine,
fentanyl and nalbuphine fail to demonstrate significant advantage on each other
in term of causing emesis. Types of operation may relate to incidence of emesis
too, but were not analysed in this study.The different result of this study
from the others may due to lower dose of narcotic required. This reflected a
higher pain threshold in Thai people such as rather patience, less anxiety automatically
reduces the incidence of emesis.
In conclusion, the incidence of emesis after narcotic administration is low
and less severe in
Thai people. Conventional narcotics nowadays create the same incidence of emesis.
Selected use of more expensive drug is not necessary and routine use of antiemetic
for prevention of emesis is questionable.
Influence of glucose on postdural puncture headache
K.Tantivitayatan, V. Tharathornpisutikul.
*Anesthesiology Section, Sawanpracharak Hospital, Nakornsawan 60000
To evaluate whether glucose had any influence on the incidence of postdural
puncture
headache (PDPH), this study was carried on 141 patients at Sawanpracharak Hospital.
They were randomly allocated into 2 groups : the glucose-mixed group included
64 cases receiving hyperbaric spinal 0.5% bupivacaine and the other 77 received
glucose-free isobaric solutions. Both groups were similar in characteristics.
During the 2-day interviews, PDPH took place more frequently in the former than
in the latter group (21.90,23.40 VS 14.30,9.10%), especially on the second postoperative
day (P only mild symptoms. It was concluded that besides estalished high-risk
factors to PDPH, type of local anesthetics employed probably played some role
in PDPH.
Home-Made Esophageal Detector Device. A method to detect
esophageal intubation.
P. Soontranan, P. Somprakit.*
*Department of Anesthesiology, Faculty of Medicine siriraj Hospital, Mahidol
University, Bangkok 10700.
The esophageal detector device, made of negativepressure created rubber balloon,
is a
reliable apparatus to distinguish esophageal from tracheal intubation. By squeezing
the rubber
ballon when attached to the endotracheal tube, if the tube is correctly in the
trachea it can aspirate gas from the patient’s lungs (the ballon is fully
reinflated). If the endotracheal tube is in the nonrigid esophagus, negative
pressure created by the rubber ballon will cause the esophageal wall to occlude
the tube’s lumen (the balloon still be deflated). This is the sign of esophageal
intubation which needs to be corrected immediately. This device can be easily
made by using common parts available in every hospital. It is a rapid, inexpensive,
reliable and easy to use method to detect esophageal intubation are questionable
eg asthma, obesity.
Geriatric Anesthesia
V. Itichaikhunton, J. Punaray.
*Department of Anesthesiology, Ramathibodi Hospital, Mahidol University, Bangkok
10400, Thailand.
With recent economical and medical progress in Thailand, There has been a big
change in the
health structure. People are living longer and enjoying better medical service.
Because of this, there has been a big increase in the number of elderly patients
in all Thai hospital. So, in administering anesthesia to the elderly, thereareseveral
specific precautions. The anesthesiologists must understand the effects of aging
in the organ and the consequences of age-related disease. The optimal anesthetic
management of elderly patients requires adequate diagnosis and treatment of
concurrent diseases, meticulous attention on the details of preparation and
positioning and the use of monitoring techniques permitting adjustments in dosage
appropriate to the altered requirment for anesthetic and adjuvant drugs. However,
elderly patients are at greater risk of perioperative morbidity and mortality
than the young ones. Increased rate and severity of complications may also reflect
decreased autonomic homeostasis and a reduced capacity to tolerate or compensate
for imposed pathology or surgical stress.
Cross-sectional descriptive study of knowledges, attitudes and practices related to AIDS of Thai anesthetic personnels (nurse anesthetist and anesthesiologist). 571 questionaires answered by 61 doctors. (10.60%) and 514 nurse anesthetists (89.40%) were collected in the after noon of February 17,1991 at Bhumibholadulyadej Hospital during the first scientific congress held by the college of anesthesiologists of Thailand. Only 15 out of 22 numbers (68.18%) of questionnaires about knowledges were answered correctly by more than half of them. The uncorrected answers about knowledges were related to epidemiologic statistics of high risk groups among normal population and among health care workers, risk of infection after contact and laws about AIDS. About attitudes on AIDS, data revealed that AIDS caused major psychological concern. More than one third of them had thought of changing their job if possible. Data about practices revealed that universal precaution should strictly be the standard of preventive measure during their routine work. About one-fourth of them thought that they contacted or contaminated with blood or body fluid from HIV positive patient during three months before answering the questionaires. In conclusion, It is likely to develop continuing educational program to promote knowledges of AIDS precaution and preventive behaviour and focus on attitiudinal change of health care workers.
Key words : Knowledges, Attitudes, AIDS, Thai nurse anesthetist and anesthesiologist.
Risks of blood and body fluid contamination during general
endotracheal anesthesia in Chulalongkorn Hospital.
Somrat Charuluxananan, M.D., Vorasri Muangmingsuk, M.D., Nicharee Makarasra, M.D., Oraluck vaewsorn, M.D., Pornlert Chatkaew, M.D.
*Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, Thailand.
Adesired outcome of an AIDS-preventive educational strategy for health care workers is changed to or maintenance of safe pracheal anesthesia were reported by observation of blood and/or body fluid contamination during intravenous catheterization, endotracheal intubation, endotracheal suction and endotracheal extubation etc.
Intravenous catheterization. Two hundred and sixty-one intravenous procedures were done while wearing gloves 191 (73.18%) and without waring gloves (bared) 70 (26.81%). The results observed were clean 190 procedures (72.79%) and blood-contaminated 71 procedures (27.20%). Ratio of blood contamination while wearing gloves and without wearing gloves were 29 : 72 (41.42%) and 42 : 191 (21.98%) respectively. Ratio of blood contamination during assisting and/or supervision intravenous procedures was 30 : 201 (14.92%).Endotracheal intubation. Three hundred endotracheal intubation were performed whil wearing gloves 146 (48.66%) and without wering gloves 154 (51.33%). The results were contaminated with saliva 137 procedures (45.66%) and blood contaminated 10 procedures (3.33%). Ratio of saliva contamination during assisting and/or supervision of intubation was 40 : 403 (9.92%).
Endotracheal suction. Two hundred and eighty-five endotracheal suction were performed while wearing gloves 241 procedures (84.56%) and without wearing gloves (bared) 44 procedures (15.43%). The observed result were contaminated with secretion 221 procedures (77.54%) and contaminated with visible blood 33 procedures (11.57%). Ratio of secretion contamination during assisting and/or supervision of endotracheal suction was 108 : 264 (40.90%).
Endotracheal extubation. Two hundred and sity-seven endotracheal extubation were performed while wearing gloves 234 procedures (87.64%) and without wearing gloves (bared) 33 procedures (12.35%). The results were secretion contamination 167 procedures (62.54%) and visible blood contamination 33 procedures (12.35%). Ratio of secretion contamination during assisting and/or supervision of endotracheal extubation was 113 :261 (43.29%)
The result of the study indicate that knowledge of transmission routes does not predict safe practice and universal precaution should be promoted.
Key words : Risk, blood and body fluid contamiation, anesthesia.
Low pressure leakage in anesthetic machine : Positive
or negative pressure test, which one is better?
P. Somprakit F.R.C. Anaes., P. Soontranan M.D.
*Department of Anesthesiology, siriraj Hospital, Mahidol University, Bangkok 10700.
Low pressure leakage testing in anesthetic machines, positive and negative tests were prospectively compared in anesthetic machines currently use in Siriraj Hospital. Thirty-six machines were included in the study because of their simple low pressure sections that allowed soap bubble test to be used as a gold standard. Six and four machines were excluded for the positive and negative pressure tests respectively because three were problems causing continuous flow through anesthetic machines which made the tests invalid. The prevalence rate of leakage in this study was 86.1 per cent (31 machines). The sensitivity and specificity for positive pressure test were 92 percent and 100 percent respectively. While both sensitivity and specificity for negative pressure test were 100 per cent. It was interesting that seven macnines tested leak by negative pressure test, had a problem with their flushing devices causing unintentional continous flow. So if all these machines were not coincidentally leak, these tests would be false positive. This would reduce in specificity of this negative pressure test down to only 41.7 per cent. Positive pressure test could be used to detect the problem of unintentional continuous flow by noticing the rising of pressure test could be used to detect the problem of unintentional continuous flow by noticing the rising of pressure without turning on the flow needle valve. As both tests could be done easily and if the problem of unintentional continuous flow were excluded, they would have high sensitivity and specificity. So we recommend that both tests should be done serially, positive pressure test followed by negative pressure test.
Key words : Equipment : anesthetic machines, maintenance, safety.
Level of Consciousness and Oxygen Desaturation During
Early Recovery from General Anesthesia
Y. Punjasawadwong MD., A. Phongchiewboon MD., FICS. T. Nipitsukarn MD.,FICS. S. Vorasit M.Sc. P. Puttawong B.Sc. S. Jaitoom B.Sc.
*Department of Anesthesiology, the Faculty of Medicine, Chiang Mai University, Chiang Mai 50002, Thailand.
To determine the occurrence and risk factors of oxygen desaturation (SpO2< or=90%) during early recovery from general anesthesia, a study was prospectively conducted in a sample of 181 subjects randomly drawn from 480 adult surgical patients, ASA class I-II. All anesthetic managementw were judged by their attending anesthesiologists. Oxygen saturation was continuously measured by the same pulse oximeter (Biox@3700, revision M) during their transfer from the operating theatre and admission to the post anesthetic care unit. Level of consciousness was graded as spontaneous eye opening, responsive only to verbal command, only to physical stimuli and unresponsive by one investigator unaware of values of oxygen desaturation was analyzed by using the Chisquare test and again adjusted for effects of other variables (i.e.age, sex,body mass index., ASA physical status, and periods of 100 per cent O2 given before the transfer) by using multiple logistic regression analysis. A p-value of less than 0.05 was cpmsodered statostoca;;u sogmofocamt/ Thirteen patients were excluded in this analysis due to invalid values of the pulse oximetry reading. Oxygen desaturation (SpO2< or=90) occurred in 68 patients and was strongly associated (p<0.001) with level of consciousness. Furthermore, with the multiple logistic regression analysis, the risk of oxygen desaturation was increased with either increasing age (odds ratio = 1.029, 95% CI =1.00,1.06), or increasing body mass index (odds ratio = 1.97,95% CI =1.2,1.33).
Level of consciousness is one factor which can be modified by an anesthetic practice. Any practice which can provide patients with better level of consciousness during their recovery can probably reduce the risk of early postoperative hypoxmia. However, to achieve this ultimate need without some potential hazards of such practice (awareness and pain), a well planned and fine adjusted anesthetic technique must be sought.
A comparative study of rapid tracheal intubation with
succinylcholine, priming and timing techniques with vecuronium
S. Pitimana-aree, MD
*Department of Anesthesiology, Siriraj Hosp. Bangkok 10700 Thailand.
Rapid sequence tracheal intubation using three techniques with succinylocholine, priming and timing principles with vecuronium were compared. Sixty patients were randomly assigned to one of three groups : timing with vecuronium (0.15 mg kg-1). Intubations were performed at 60 sec. post induction. Hemodynamic changes (MAP, PR, ECG) were similar in all three groups. Oxygen saturation values at 4 min post priming and at the time to experience clinical weakness in timing group were 99.6 and 99.1 per cent respectively. Intubation score of the timing was not significantly different from the succinylcholine group but was significantly better than the priming group (P = 0.008). Use of the timing technique for rapid sequence tracheal intubation is a reliable alternation in cases when succinylcholine is contraindicated.
Key words : Rapid sequence intubation, succinylcholine, vecuronium, timing principle, priming rpinciple.
GA or RA for Hip and Femur surgery*
Lertakyamanee, J. M.D.*S. Pitimana-aree, M.D.* P. Vacharotayanagul, M.D.**T.Tri-Trakarn, M.D.*S. Udompanrak***
*Department of Anesthesia, **Department of Orthopedics, ***Computer Center, Siriraj Hospital, Bangkok 10700 Thailand.
Seventy-nine patients who received general anesthesia (GA) or regional anesthesia (RA) for hip and femur surgery were studied of blood loss, duration of admission and mortality. Blood loss was evaluated by measuring volume and swab weighing intraoperatively ; whereas the duration of admission and mortality were recorded retrospectively. Since the types of surgery had influence on blood loss, the patients were divided into 4 groups : hemiarthroplasty, total arthroplasty, plating and nailing. Blood loss was significantly lower in RA than GA in hemiarthroplasty, and total arthroplasty but not significantly so in plating and nailing ; although old age and associated diseases were more common in RA groups. Number of units of blood transfusion were not significantly different.
Primary Hyperaldosteronism and Anaesthesia, a Report
of 26 Cases 1979-1992
K. Bhavakula M.D.*, K. Sindhvananda M.D.**, A. Vichayanrat M.D.***, K. Charoenlarp M.D., A.Saneewong Na Ayudthaya B.N.*, P. Suwananonda B.N.*
*Department of Anaesthesia, **Department of Surgery, ***Endocrinology Dividion, Department of Medicine, Tropical Medicine, Department of Medicine, Siriraj Hospital, Bahidol University, Bangkok 10700.
Twenty six patients with primary aldosteronism admitted in Siriraj hospital between July 1979 and July 1992 were retrospectively analysed the clinical features, method of diagnosis, localization, anaesthesia and the results of treatment. The results showed that either total unilateral adrenalectomy or excision of adenoma was the safe and effective treatment for aldosterone producing adenoma (APA).
Anesthesia for Carotid Body Tumor Resection : A Case
Report and Review of the Literature
T. Neti M.D., K. Bhavakula M.D., P. Yuckpan M.D., W. Juengsaguanpornsuk M.D.
*Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700.
Carotid body tumors are uncommon tumours which present diffeculties to the surgeons and the anesthesiologists. The larger the tumor size, the higher the risk of cerebrovascular, neurological and bleeding complications. A case of large carotid body tumor which intraoperative massive bleeding, cranial nerve injury, but no postoperative cerebrovascular complication is presented. The literature was briefly reviewed and the adjunctive techniques to enhance regional cerebral perfusion during anesthesia were discussed.
Anesthesia for Laparoscopic Cholecystectomy in Pigs
S. Pausawasdi M.D*, T. Virangkabutra M.D.*, J. Wacharasindhu M.D.*,
S. Srisawasdi M.D.*, K. Phongthana M.D.*, L Srivijit M.D.**
*Department of Anesthesiology, Ramathibodi Hospital, Mahidol University.
**Department of Anesthesiolgy, Phumipol Hospital
Occasionally, anesthesiologists may take responsibility of veterinary anesthesia in some researches or studies. There are many anesthetic methods which depend on the nature of the operation; its magnitude, site and duration. Our group tries to choose the simple and safe anesthetic method for laparosecopic cholecystecotmy in pigs.
Totally 29 pigs were studied, 7 pigs were anesthetized simultaneously, age between 3-4 months, weight 20-25 kg. Ketamine 100 mg. midazolam 5 mg, atropine sulfate 0.6 mg. Were injected intramuscularly for induction. After the pig felt asleep, we started intravenous fluid at the ear, adding nembutal 50 mg intravenously before intubation, using endotracheal tube No. 5.0-6.0. During operation ketamine infusion and nembutal 25-50 mg were giver intravenously for proper anesthetic level.
Anesthetic time was about 64 minutes. Average anesthetic doses, nembutal was 132 mg/hr, ketamine was 144 mg/hr. The pigs were extubated within 30 minutes after operation. All are well and still alive till now.
A Postoperative Analysis of the patient’s attitude
of Anaesthesia in Siriraj Hospital
Pitimanaree S. MD, Santawat U.MD, Neti T. MD, Luangnateetape A. MD, Tengapiruk Y. Md,
Catithammanit T.MD.
Department of Anaesthesiology, Siriraj Hospital, Bangkok 10700
A postoperative questionaire was used in 185 patients undergone a wide range of surgical procedures to assess their personal attitudes and experiences of anaesthesia in Siriraj teaching hospital during a two-week peroid. Eventhough nearly 90 percent satisfied their anaesthetic
received. Up to 85 percent neither expected nor had any idea about their anaesthesia before having an operation. 22 and 14 percent expected their anaesthesia to be without complicaitons and with minor complications respectively. Nevertheless almost half of the patients who had previous anaesthesia thought that their anaesthesia at this time were better than the previous ones.
Only 43 percent recognised that the anaesthetist was a doctor compared to 90 percent knew that the surgeon was. Prior to operation 46 required preanaesthetic visit but 33 percent seemed not to recognise the advantage of preanaesthetic visit and 20 percent deny to have the visit. Nevertheless at the postoperative period there was 20 percent increasing in percentages of the patients requiring preanaesthetic visit and 93 per cent appreciated its benefit. 55 percent were aware that preanaesthetic visit would alleviate the anaesthetic fear and apprehension. It was surprising that 58 percent of the patients had premedication by anaesthetist but only 23 percent recognised or knew that they had preanesthetic visit. This will reflect the anaesthetist patient relationship and the reason of widespread underestimation of the anaesthetists’ status.
Key words : Anaesthesia, anaesthetist, patient’s attitude
Residual Curarization in the Recovery Room : The Occurrence
and Risk Factors
W. Lapisatepun,* Y. Punjasawadwong,* A. Pongchiewboon,* S. Paiboonworachatti,* M.Piriyakunthorn.*
*Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai 50002, Thailand.
The train-of-four (TOF) stimulation of the ulnar nerve was assessed to determine residual curarization in 100 adult patients of immediate arrival in the recovery room, after general balanced anesthesia. A peripheral nerve stimulator was not used in any patient intraoperatively. When the criterion of a TOF ration of 70 percent was used to indicate adequate neuromuscular recovery, there were 34 percent of the patients having residual curarization. With respect to pancuronium, which was given in a majority of the studied patients (n=77), 42 percent of the patients given this relaxant were found inadequately recovered. In this group, after exclusion of 8with renal dysfunction (n=69), the incidence of residual curarization was higher in the subgroup of 2 increments or greater as well as the incrementaal dose of greater than 1 mg (p<0.05). The results also showed that in the non-increment subgroup, a logarithmic relationship was found between dose (mg/kg/hr) and the TOF ratio (r=-0.566, P<.01) as well as between the time from the first injection of pancuronium to the injection of neostigmine and the TOF ratio (r=0.515, P<.05). In conclusion, residual curarization in the recovery room is commonly encountered following the use of long-acting non-depolarizing muscle relaxants, particularly when a nerve stimulator has not been used intraoperatively. In case of pancuronium, residual curarization is associated with the number and dose of increments. And, when a single bolus dose of pancuronium is administered without increment, the TOF ratio after reversal is associated with the dose (mg/kg/hr) and the time from injection of the relaxant to the injection of neostigmine.
Key words : residual curarization, train-of-four, pancuronium
A comparative study between EAR and coaxial circle breathing
system
S. Theerapongpakdee, M.D.*, U. Sermdamrongsak, M.D.*
Department of Anesthesiology, Faculty of Medicine, Srinagarind Hospital, Khon Kaen University, Khon Kaen 40002, Thailand.
Arterial blood gases were compared in 20 patients of ASA class I-II between coaxial circle breathing system and enclosed afferent reservoir (EAR) breathing system under 100 ml/kg/min FGF’s. The results indicated that at FGF of 100 ml/kg/min, there were no significant statistically differences on pH,PaCO2. From this study we concluded that EAR breathing system was as efficient as coaxial circle breathing system at FGF 100 ml/kg/min, but less efficient at FGF 70 ml/kg/min. However, EAR circuit can be used safely at FGF 70 ml/kg/min because the results of the study are within normal clinical range.
Key words : Equipment, Breathing system,
EAR, Coaxial circle breathing system
A Successful Cesarean Section Following Hellp Syndrome
: A Case Report
Phongthara Vichitvejpaisal M.D.* Shusee Visolyaputra M.D.* Bencharatana Yok-ubol M.D.* Suwanee Lertwinyu M.D.*
*Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.
A 28 year-old patient with a pregnancy of 33 week gestation developed HELLP Syndrome and required urgent delivery by Cesarean section. Before operation, a central venous catheter and urinary catheter were in serted, automated blood pressure, EKG and pulse oximeter were recorded, and platelets were administered to correct severe thrombocytopenia. Blood pressure was controlled with intravenous administration of hydralazine. A general anaesthesia with rapid sequence induction and cricoid pressure was performed. The patient had no complications nor sequelae on her discharge. The liver function returned toward normal within 1 week after the surgical procedure. The low birthweight baby was cared in neonatal intensive care unit for 2 months.
Key words : Anesthesia : Obstetric.
Complicaitons : HELLP Syndrome, Pre-eclampsia, Toxemia of Pregnancy.
Difficult tracheal intubation
V. Ittichaikul M.D.,*, C. Phannarai M.D.*
*Department of Anesthesiology, Ramathibodi Hospital, Faculty of Medicine, Bangkok
10400, Thailand.
Difficult or failed tracheal intubation is an important cause of anesthetic-related morbidity and mortality. There are many causes of difficult intubation. Assessment of the patients may lead to preoperative recognition of a difficlt airway. A careful history taking and physical examination will identify most patients who will be difficult to intubate. When the difficult intubation is anticipated, the problem is far simpler than when it is unexpected. Altered positioning of the patient may be of help in recognition and management. Unfortunately an unexpectedly difficult situation may still be met or the technique selected may be unsuccessful. So, to prevent such catastrophes, all necessary monitors and equipment should be available, needed to deal with a failed intubation. Adequate assistance, correct use of cricoid pressure and confirmation of tracheal intubation are fundamental to safe practice. Finally, this paper also shows the management protocol for suspected, unsuspected and failed intubation of the parturient protocol.
Insulinoma and Anesthesia : Report of 14 Cases in 1981-1991
Bhavakul K, Sindhvanandha K.
*Department of Anesthesia, **Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700
Insulinoma is an insulin secreting of the pancreatic islets of Langherhans. It produces hypoglycenia and this episode increases in frequency and may progress from mild affective disorders, confusion, generalized seizure and irreversible central nervous system damage with death. Ninety percent of tumors are benign adenoma.
The classic triad of Whipple is valid in diagnosis of the tumor. Localization of the tumor may be accomplished by celiac angiography. Resection of insulinoma is best performed in cooperation with the surgeon and clinical pathologist (enucleation or 75% distal pancreatectomy). Rebound
hyperglycemia will be seen after removal of the tumors.
This paper presents our experience in 14 cases at Siriraj Hospital between 1981 and 1991, 11 patients had benign insulinomas, 2 were malignant and one had hypertrophy of the islets of Langerhans, nesidioblastoma. Removal of tumors were enucleation in 10 cases and 75 percent
distal pancreatectomy in 4 cases.
Intraoperative Blood Sugar Monitoring for Insulinoma
Resection.
K Bhavakula, K Sindhvananda, J Lertakyananee, S Santawat,
S Udompanruk.
*Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Bangkok
10700, Thailand.
Fourteen insulinoma patients who were operated at Siriraj Hospital were retrospectively studied. The aims were to study the changes in blood sugar during anesthesia, to determine the correlation between blood sugar and intravenous (IV) glucose given to the patients and also to evaluate the benefit of using "rebound hyperglycemia", increased blood sugar level withing 30 minutes after resection, in confirming total removal of insulinoma. The patients were divided into 2 group 1 received constant IV glucose rate while group 2 received variable rate. Blood sugar was determine at 60,30 minutes before resection and 10,20,30,90 minutes after resection. The result showed that blood sugar rose significantly at 30 minutes (group 1) and 90 minutes (group 2) after resection and there was no correlation between blood sugar level and IV glucose given at any time. The increase in blood sugar was therefore caused by the resection of tumor. However, one patient had residual insulinoma but her blood sugar also rose. Therefore, blood sugar level within 30 minutes after resection was required but not helpful in determining complete resection of tumor.
Arterial Carbon Dioxide Tension During Laparoscopic
Cholecystectomy.
Sirilak Suksompong M.D..,* Kalapangha Bhavakul M.D.,* Vorapa Suwanchinda M.D.*
*Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700.
The effects of carbon dioxied (CO2) induced pneumoperitoneum during laparoscopic cholocystectomy on the cardiovascular and respiratory system were studied in 40 ASA 1 and 2 patients. General anesthesia with controlled respiration was achieved using either nitrous oxide or air in oxygen and muscle relaxant. Respiratory volumes were calculated according to the patient’s body weight. The patients were devided into 2 groups according to end-tidal carbon dioxide tension. Group 1 consisted of the patients who had end-tidal CO2 tension not more than 30 mmHg after 1 hour of CO2 insufflation. The patients who had end-tidal CO2 tension higher than 30 mmHg were classified as group 2. Both groups showed significant increase in PaCO2 and a fall in pH after intraperitoneal insufflation with carbon dioxide. And the changes were also statistically significant different between groups. There was an increase in blood pressure in group 2 with mean PaCO2
after CO2 insufflation of 43.81?5.02 mmHg, while there was no change in the other group with mean PaCO2 of 34.85?5.44 mmHg. Associated with more hypercarbia, group 2 patients suffered from significant higher incidence of subcutaneous emphysema and cardiac arrhythmias.
Key words : Laparoscopy, arterial carbon dioxide tension.
Pain Relief During Positioning for Sobarachnoid Block
in Lower Limb Fractures : A Comparison Between Ketamine and Etomidate.
P.Soontranan, P. Somprakit.
*Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.
Fourty patients (ASA class I-II) scheduled for elective operations on lower limb fractures were randomized into 2 groups. Either Ketamine (1 mg/kg body weight) or etomidate (0.2 mg/kg body weight) was administered intravenously to these patients. After loss of consciousness, the patients were positioned for subarachnoid block with close and careful monitoring of the airway patency, vital signs, consciousness, pain response and other side effects or complications. Arterial blood pressure, pulse rate and haemoglobin oxygen saturation had been recorded every 1 minute for 15 minutes. Subarachnoid block was performed successfully in every case with isobaric 0.5% bupivacaine. No patient recalled having pain during the positioning when interviewed postoperatively. Three-step scores were used to evaluate the ease of positioning and there was no difference between the 2 groups. All, except one patient in each group, could be properly positioned. In etomidate group, mean arterial pressure (MAP) had been stable for 9 minutes then significantly dropped at the 10th minute (p<0.01), 12th,13th,15th minutes (p<0.05). Pulse rate in this group was stable throughout the study.
In ketamine group, MAP started to increase from the 2nd minute after intravenous injection with maximum increase at the 4th minute (from 99.55?10.30 to115.05?21.45 mmHg, p<0.01) and remained significantly greater than etomidate group at the 2nd,11th,13th, minutes (p<0.05) and 3rd,4th,8th,10th,12thminutes (p<0.01). Pulse rate was also increased significantly in ketamine group at the 3rd,4th,5th,6th,7th,9th,10th,13th minutes (p<0.01), and 11th,15th minutes (p<0.05) with the maximal in crease at the 4th minute (from 90.00?16.05 to 100.85?15.83 beats/min, p<0.01). There was no significant difference in oxygen saturation between these 2 groups, In etomidate group, 5 patients had pain during intravenous injection,8 patients developed tremor of hands and arms with one exceptionally marked myoclonic tremor. Two patients needed oxygen supplement by mask because hemoglobin oxygen saturation fell below 90%. In ketamine group, there were 3 patients who needed oxygen supplement, 3 patents dreamed but had no nightmare. In conclusion, both drugs could be used to relieve pain due to positioning for subarachnoid block satisfactorily.
Influence of Age on Sodium Thiopentone Sleep Dose in
Thai Patients
Wichai Ittichaikulthol, Suvit Sangalangharn, Chantima Pannarai, Somsri Pausawasdi
*Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital Mahidol Universtiy.
Fifty elderly patients (p>60 years old) and 50 younger patients (16 to 57 tears old) were studied to evaluate the effect of aging on the sleep dose of sodium thiopentone for induction of anesthesia in Thai patients. We excluded records from the patients who have abnormal LFT,BUN/Cr, ECG, heart failure, neurological disease, alcohol abuse and malnutrition status. No premediaction was given to all patients. Anesthesia was induced by the intravenous administration of 50 mg. Sodium thiopentone every 15 seconds until the patients lost of eyelash reflex. The average induction dose of sodium thiopentone in the elderly patients was 2.87?0.85 mg/kg, Significantly less than the 4.02?0.72 mg/kg in the young groups. A found in elderly Thai patients when compared with the younger Thai patients.
Key words : Sodium thiopentone, geriatric anesthesia
The Neuromusulcar Blocking Action of Vecuronium in Anesthetized
patients
Worawut Lapisatepun, M.D., Yodying Punjasawadwong, M.D., Aram Pongchiewboon M.D.
Department of Anesthesiology, Faculty of Medicine, Chiangmai University, Chiangmai 50002, Thailand
This study was carried out on 30 adult surgical patients ASA classification 1 and 2) under general anesthesia. Anesthesia was induced with 0.015 mg/kg of fentanyl and 5 mg/kg of thiopentone. After calibration of the evoked compound electromyogram analyser (RelaxographTM), vecuronium 0.12 mg/kg was given, and then the patients were ventilated with N2O and O2 and intubated at 5 minutes later. Anesthesia was maintained under con trolled ventilation with N2O,O2 and 0.5 per cent halothane. The study showed that the onset time to 95 percent block and clinical duration of the initial bolus dose were 189.63?67.36 seconds and 46.70?7.88 minutes respectively. In long cases, 0.02 mg/kg incremental doses of vecuronium were given. The clinical duration of first, second and third increment were about 25 minutes and not significantly different. Cumulative ratio of the third increment were about25 minutes and not significantly different. Cumulative ratio of the third increment was 0.97 which indicated no cumulative effect. In 7 cases, 25-75 percent recovery time could be studied with a result of 12.13?5.75 minutes, indicating rapid recovery. Blood pressure and heart rate were also studied. After 3 minutes of vecuronium administration, the systolic and diastolic blood pressure decreased significantly, but there was no significant change in heart rate. However, there was no significant change in both systolic and diastolic blood pressure when compared with thiopentone. We conclude that 0.12 mg/kg of vecuronium can be used to provide muscle relaxation during anesthesia with N2O,O2, fentanyl and halothane for a surgery shorter than 1 hour without further increment. Although this dose is adequate for intubation, the result from this study indicates that its onset of action is still much slower than that of suxamethonium. In longer cases, further increments could be given without cumulative effect. The change of blood pressure in this study might be the result of the combination effects of thiopentone, fentanyl and vecuronium rather than that of the muscle relaxant alone.
Key words : Neuromuscular blocking agent, vecuronium.
Vecuronium in Patients with Renal Dysfunction
Yodying punjasawadwong M.D., Worawut Lapisatepun M.D., Aram Pongchiewboon M.D.
*Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai 50002, Thailand.
The speed of onset, clinical duration of action and 10-25 percent recovery time after injection of the initial bolus dose (0.12 mg/kg) of vecuronium were determined by measuring electromyographic responses to the TOF ulnar nerve stimulation in 22 adult surgical patients with chronic renal failure during anaesthesia with thiopentone, 60-70 percent N2O in O2,0.5 percent halothane and supplemented fentanyl. The mean time of the speed of onset to 95 percent suppression of T1, the duration of action to 25 percent recovery and 10-25percent recovery time were 240?84.85 seconds, 57.13?16.00 minutes and 11.23?3.24 minutes respectively.
The mean time of clinical duration and 10-25 percent recovery time were longer than the results obtained from the parallel study in 30 patients with normal renal function. The biochemical changes in renal failure such as accumulating toxic substances, metabolic acidosis and electrolyte imbalances (hypocalcaemia, hypermagnesaemia) may alter the responses of muscle to the muscle relaxant. We also observed that the mean time of clinical duration of action and 10-25 percent recovery time in 4 patients who had been dialyzed before surgery were not grossly different from the results in patients with normal renal function, but the sample size was too small to make conclusion.
Anaesthesiologists should realize that, although vecuronium does not appear to be eliminated by kidney to any great extent, some factors such as biochemical changes may affect the pharmacodynamic responses to vecuronium in renal failure. Close monitoring of neuromuscular function during the use of the muscle relaxant in such patients is required so as to provide adequate surgical relaxation and avoid overdosage.
Key words : neuromuscular blocking agent, renal dysfunction, vecuronium
Spinal Anesthesia with the Mixture of 0.5% Plain Bupivacaine
and 5% Hyperbaric Lidocaine.
Pojanasupawan S, M.D.*, Vasinanukorn M,M.D.*
*Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Haadyai, Songkla 90110, Thailand.
Both 0.5% plain bupivacaine and 5% hyperbaric lidocaine, when solely used, have some limitation in spinal anesthetic practice. Plain bupivacaine has long duration but unpredictable level of anesthesia while hyperbaric lidocaine has more predictable level of anesthesia but with short duration. The effect of 2 milliliters of 0.5% plain bupivacaine mixed with 1 milliliter 5% hyper-bariclidocaine was studied in 42 orthopedic patients undergoing spinal anesthesia. The time to the onset of maximum segmental spread of anesthesia was 17.7?7.80 minutes. The maximum segmental spread of anesthesia was at the level of T 6.34?2.41. The duration of anesthesia from the time of injection to the level of Ls was 183.4?26.46 minutes. All of the patients had complete motor blockade. There were minimal changes in heart rate and blood pressure. Eight patients (19%) needed ephedrine for the treatment of hypotension.
Key words : Anesthetic techniques, regional; spinal.
Anesthetic, local ; bupivacaine, lidocaine.
Optimal Induction Dose of Propofol (Diprivan) in Normal
Thai Patients.
S Kongserepong M.D.,* S Pitimana-aree M.D.,* R Deluckanatin M.D.**
*Department of Anesthesiology, Siriraj Hospital, Bangkok 10700, Thailand, **Department of Anaesthesiology, Srinagarind Hospital, Khon-Kaen 40002, Thailand.
One hundred and fifty-four female Thai patients (ASA class I,II), underwent gynaecological operation were randomly allocated to receive the various doses of propofol (1.5,2,2.5 mg/kg) as an induction agent without or with (fentanyl 1.5 mg/kg, morphine 0.15 mg/kg) premedication. In order to study the optimal induction dose of propofol, the onset time, the effect on hemodynamic status, intubaion score and untoward effects were recorded and statistically analysed. Considering of pharmacological and untoward effects of propofol, the optimal induction dose of propofol in unpremedicated patient was 2.5 mg/kg and in premedicated patient was 2 mg/kg. Fentanyl is prefereable to morphine as premedicant in this study.
Key words : Propofol, induction.
Retrograde Tracheal intubation
Vimolluck Sanansilp M.D.,* Preecha soontranan M.D.*
*Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital , Mahidol
University, Bangkok 10700, Thailand
In the course of anesthetizing a patient for surgery, we occasionally encounter some patients whom we are unable to intubate. After initial attempt has failed, the clinician must try the proper alternative techniques. This report demonstrates the successful of retrograde tracheal intubation after failed awake nasal intubations. The 32 year-old Thai male with ankylosing spondylitis was scheduled for corrective osteotomy of spine under general anesthesia. The patient has fixed curve cervical spines and limited temporomandibular joint movement. The attempts for awake nasal intubations were failed, then retrograde tracheal intubation was performed. Cricothyroid membrane was punctured by Touhy needle under local anesthesia. The epidural catheter was threaded cephaladly through the larynx to the oropharynx and was picked out of the mouth by Magill forceps. The orotracheal tube was tied by the catheter at Murphy eye and was pulled down through the laryngeal inlet into the tracheal tube, the balanced anesthesia was started with thiopental, N2O,O2, halothane and muscle relaxant. The orotracheal tube was retained over night and was removed without any serious complication except sore throate.
Sublingual Nifedipine on Cardiovascular Response of
Tracheal Intubation in Severe Pregnancy in duced Hypertensive Patients
S. Suraseranivongse M.D.*, T. Kolatat M.D.**, S. visolyaputra M.D.*, S. Kritalak M.D.***, N. Mantraporn**
*Department of Anesthesiology, **Pediatrics, ***Forensic Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700, thailand.
To assess the effect of sublingual nifedipine in minimizing hemodynamic response during tracheal intubatijon in severe pregnancy induced hypertensive (PIH) patients compared to sodium nitroprusside, the placental transfer of nifedipine and its adverse effects in newborns, fourteen patients with severe PIH, undergoing general anesthesia for cesarean section were studied. By randomization, group A, 6 patients received sodium nitroprusside 10 mg in isotonic glucose 100 ml intravenous infusion, group B, 8 patients received sublingual nifedipine 10 mg to reduce BP to 140/90 mmHg before induction. The average increase in systolic BP during intubation was 35.00 mmHg in group A and 38.38 mmHg in group B. The onset time from durg administration until BP decreased to 140/90 mmHg was 10.50 minutes in group A and 14.13 minutes in group B, all were not statistical different. Nifedipine level inumbilical cord blood was more than 90 percent of maternal blood, nevertheless nifedipine level followed up in new borns 1 hour and 2 hours afterbirth declined rapidly. The apgar score 1 and 5 minutes were not different in both groups. 5 Babies from nifedipine group were recorded BP 1 hour after birth, 3 babies were recorded BP until 12 hours afterbirth. No baby had systolic BP less than 40 mmHg. All babies from nifedipine group were discharged healthy from the hospital. In
conclusion, nifedipine could be used effectively as sodium nitroprusside to attenuate the potential dangerous reflex cardiovascular response associated with tracheal intubation in severe PIH without any adverse effect in newborns. The placental transfer of nifedipine was nearly complete but the level in newborn declined rapidly.
Key words : Nifedipine, tracheal intubation, severe PIH
New Pain-Reducing Technique for Extracorporeal Piezoelectric
Lithotripsy (EPL)
Thara Tritrakarn M.D., jariya Lertakyamanee M.D., Anupan Tantiwong M.D., Adul Raksmanee M.D., sunee Jittapapai R.N.
*Department of anesthesiology, siriraj Hospital, Bangkok 10700, Thailand.
Although treatments with extracorporeal piezoelectric lithotriptor are usually done without anesthesia, our survey showed that 37% of them still resulted in severe to very severe pain.
A randomized, double blind, cross over study was carried ot to evaluate the efficacy of 10 gms of 2.5% EMLA (Eutectic mixture of local anesthetic =50% lidocaine+50% prilocaine) cream VS placebo cream in 12 patients. The cream were applied on the flank at the area of entry of the ultrasound shock wave and were covered with occlusive dressing until the end of the procedure. Pain was evaluated by the patients using modified analogue scale (0-100 scores). both EMLA and placebo cream significantly (p<0.001) reduced pain scores from 82.1+14 to 43.2+23 and 45.5+14, repectively.
When ultrasound wave passes through media of different conduction, there will be absorption of energy or impact at the interface between the media, resulting in cracking of the surface of the stone and pain at the skin. Application of cream which have similar conduction to skin and soft tissue fat facilitates transmission of sound with less energy absorption and less pain. The interface between water and skin is shifted to be water and thin plastic covering film. This is our hypothesis to explain the reduction of pain in the study.Key words : Lithotripsy, extracorporeal; Anesthesia, topical.
Evaluation of Pain During Extracorporeal Piezoelectric
Lithotripsy (EPL) with Piezolith 2300.
Thara Tritrakarn M.D.,* Jariya Lerktakyamanee M.D.,* Anupan Tuntiwong M.D.,** Adul Raksamanee M.D.,* Sunee Jittaprapai R.N.**
*Department of Anesthesiology, **Department of Surgery, Faculty of Medicine, siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.
Though treatment with extracorporeal piezoelectric lithotriptor (EPL) is considered painless and can be done without general or regional anesthesia, many patients complained of pain during the treatment. A prospective study using visual analogue scale was done to evaluate the magnitude of pain in 43 patients treated with Piezolith 2300 EPL. Only 2 of them (5%) had no pain (pain score 0-10). Twelve and 17 of them
(28 and 40%) had mild (score 11-40) and moderate pain (score 41-70). Twelve patients (28%) had severe pain (score 71-100) with abdominal colic, nausea and fever. The last group of patients deserve some supplemental pain-reducing therapy.
Transdermal Scopolamine VS. Droperidol in the Prevention
of Posvention of Postoperative Nausea Vomiting.
Shusee Visolyaputra M.D.,*
*Department of Anesthesiology, siriraj Hospital, Bangkok 10700, Thailand.
To evaluate the efficacy of transdermal scopolamine compared to i.v. droperidol in the prevention of postoperative nausea vomiting. Sixty patients underwent major gynaecologic surgery were studied and randomly divided into 3 groups to receive : adhesive patch of trans-dermal scopolamine 1.5 mg behind the ear in the evening before surgery (TS group); identical placebo patch (control group); i.v. droperidol 2.5 mg after induction of anesthesia (DHBP group). All patients were received morphine 0.15 mg/kg and atropine 0.4 mg as remedication. Anesthesia was induced with thiopenthal and maintained with nitrous oxide and oxygen, halothane and pancuronium. Prostigmine and atropine were administered for reversal. There were no significant differences in age, weight, height, operative time and narcotic used among 3 groups.
In the recovery room, no differences in nausea or vomiting were observed among the groups. During the following 24 hours, though no difference in nausea among the groups, actual vomiting was reported more by the placebo patients (10) than by those on DHBP group (2) or those on TS group (6), which is significant only in DHBP group (P<0.01). side effects such as visual disturbance, dry month, dizziness or others were not differences among the groups. In conclusion, transdermal scopolamine is not effective as droperidol in preventng postoperative nausea vomiting in the patients undergoing major gynaecologic surgery.
Etomidate VS Propofol as Total Intravenous Anesthesia
in Short Gynecological Procedure.
Jaru Petsuwan M.D.,* Suwanna Teerasakdakul B.N.*
*Department of anesthesiology, Saraburi Hospital, Saraburi, Thailand.
Froty gynecologic patients underwent minor procedure were randomly divided into 2 groups. Group 1 received etomidate and group 2 received propofol as total intravenous anesthesia. All patients were premedicated with intravenous fentanyl 1 ug/kg 1 minute before induction. The cardiovascular and respiratory response, the side effects and recovery time were compared between cach groups. Pain on injection and involuntary muscular movement were found more common in etomidate group while propofol produced more hypotension and rapid recovery. No apnea was found following induction in any group. It was concluded that etomidate had an advantage over propofol in their minimal effect to cardiovascual system, but the discharge time from the operating room was the same in both groups.
Spinal Block for Cesarean Section at Chulalongkorn Hospital.
T Werawatganon, U, Sorahong, P Wunwimolsuk, U Sutprerdprai, P Sriplakit.
*Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand.
This was a prospective descriptive study of spinal block in 100 healthy pregnant women scheduled for elective cesarean section at Chulalongkorn Hospital. Techniques and results of spinal block were recorded. Analgesia was rapid and impressive. Operation could start in all cases while only 4% of these needed some sedatives added before delivery. Ninety-seven percent of the cases accepted to undergo cesarean section under spinal block again for the next time. complication was discovered in 68 cases without grave aftermath. The most common complication was hypotension (43%) probably due to insufficiency of preventive measures.
Key word : spinal anesthesia, cesarean.
Prehydration in Spinal Block for Cesarean Section.
T Werawatganon, O Wallsorn, P Chutrgale, T Manthananon.
*Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand.
Optimal intravenous fluid to prevent hypotension form spinal block was studied in one hundred healthy \pregnany women. Both elective and emergency cases were included. They were allocated randomly into three group and given intravenous fluid 5, 10. 20 ml/kg respectively before spinal block. Incidence of hypotension in each group was 58%, 57%, 87% orderly with overall incidence of 64 cases from 100 cases. So prehydration alone was not essential preventive measure for hypotension from spinal block in cesarean section cases.
Key word : Prehydration, spinal, anesthesia, hypotension, cesarean.
Subcutaneous Emphysema During Laparoscopic Cholecystectomy
Strilak Suksompong M.D.,* Kalapangha Bhavakul M.D.,* Navin Phauksungnoen M.D.*
*department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.
Laparoscopy with carbon dioxide or nitrous oxide insufflation is a common procedure with several potential major complications, for example, subcutaneous emphysema, pneumomediastinum and pneumothorax. The authors report two patients in whom subcutaneous emphysema developed without pneumomediastinum and pneumothorax. As a result of careful control and conservative treatment, this event disappeared within a short time.
Key words : Laparoscopy, subcutaneous emphysema.
Subarachnoid Phenol : A method of
Cancer Pain Management.
P. Khunsongkiet, M. Piriyakunthorn, S. Paiboonvorachatti.
*Department of Anesthesiology, Faculty of Medicine, Chiangmai University, Chiangmai 50002, Thailand.
Subarachnoid neurolytic block with phenol is a method of pain management in cancer patients. Twenty-three cancer patients suffered from severe pain were divided into 2 groups according to pain areas; trunk and perineum. The intervertebral space was selected according to painful site and the patients were positioned to make the selected intervertebral space be lowest dependent point. Ten percents phenol solution dissolved in glycerin was injected by titration technique into subarachnoid space at the selected intervertebral space. Volume of phenol used for trunk area ranged from 0.2-0.5 ml. (average 0.304+0.086 ml) and for perineal area ranged from 0.2-0.4 ml (average 0.275+0.066 ml). Results of the blockade were evaluated by patients rating the visual analogue scale. Pain relief ranged from 50-100% (average 81.74+18.74%). The average time of pain relief was 1.57+1.36 months. There were untoward effects such as headache and dysuria in 5 patients (21.74%). Subarachnoid phenol is an effective method for pain management in patients whom suffered from malignance but should be performed in terminal cases only.
Key word : Cancer pain, phenol in glycerin, subarachnoid phenol.
The Comparative Study of Neuromuscular blocking action
between Vecuronium and Atracutium in Thai Patients.
C Prasertchuang M.D.,* R Bundit M.D.,* W Chua-in M.D.,* S Prapaitrakul Bsc.,*L Kosum Bsc.,* W Tantanatewin Bsc.*
*Department of Anesthesiology, Faculty of Medicine, Khon-Kaen University, Khon-Kaen 4002, Thailand.
The onset, intubating condition, duration of spontaneous recovery and erythematous rash of intravenous vecuronium 0.1 mg/kg and atracurium 0.6 mg/kg, were investigated in 80 anesthetized patients.Vecuronium had a significantly more rapid onset time and shorter duration of action than atracurium. Both drugs provided equally and generally good intubating conditions at 100% depression of T1 in Train-of-four. There were higher percentages of spontancous recovery from neuromuscular blockage in vecuronium group than atracurium group.Local erythematous rash was detected in 10% of the patients received atracurium.
Thoracic Sympathetic Block : Managgement of Upper Extremities
Pain.
M.Piriyakunthorn, P. Khunsongkiet, S. Paiboonvorachati.
*Department of Anesthesioloy, Faculty of Medicine, Chainmai University, Chaimai 50002, Thailand.
The thoracic sympathetic block was performed in 16 patients who had pain on the upper extremities from either cancer or noncancer pain. All patients recieved stellate ganlion blocks on the painful side, if they got effective pain relief, thoracic sympathetic block would be done on the followin day. The sympathetic block was done at level either T2 or T2 and T3 under fluoroscopy with 95% alcohol 1.5-2 ml. Prior to injection, 1-2% lidocaine 1.5-2 ml. Was given for testing. Effectiveness of the blocks were evaluated by visual analogue scale which showed the decreasing of pain ranging from 0-100% (average was 68.13+26.03%). The duration of pain relief ranged from 1-8 months (average 2.50+2.33 months). The results have been reviewed and confirmed that thoracic sympathetic block is one of the alternative methods for controlling of pain in the upper extremities which are solely or partially mediated by sympathetic nervous system.
Key words : Thoracic sympathetic block, stellate ganglion block, neurolytics,
intravenous regional guane-thidine, upper extremities pain
Mesenteric-Hypogastic Plexus Block : A New Technique
for Tenesmus Pain.
S. Paiboonvorachati, P. Khunsongkiet, M. Piriyakunthorn.
*Department of Anesthesiology, Faculty of Medicine, Chiangmai University, Chiangmai 50002, Thailand.
Pelvic pathology may cause severe tenesmus pain syndromes that are refractory to systemic analesics. While epidural, subarachnoid and sacral nerve blocks may alleviate such pain, they are often associated with loss of sphincter tone and/or paresis of the lower extremities. In order to avoid these problems, mesenteric-hypogastric plexus block had been done in 9 patients. All of them had severe tenesmus pain from pelvic neoplasm or secondary to radiotherapy. The block was performed by injection of 5-8 ml of 95% alcohol after a test dose of 5-8 ml of 1-2% lidocaine at the level of L4 under fluoroscopy. The result world be evaluated within 24-48 hrs by the patient rating the visual analogue scale. The result showed decreasin of pain score raning from 20-to 90 percent (averae 60.00+20.55%). The duration of pain relief raned from 1-2 months (average 1.33+0.47 months). There was no complication obsered in this study. We proposed that mesenteric-hypoastric plexus block is a viable option for treating tenesmus pain secondary to pelvic malignancy.
Key word : Cancer pain, hypogastric plexus, rectum, tenesmus, uterus.
Halothane for Surgical Removal of Pheochromocytoma
Plernchit Sirivannasandha, M.D.
*Department of Anesthesiology, Ramathibodi Hospital, Bangkok 10400, thailand.
The anesthetic manaement of patients operated for pheochromocytoma was studied, using halothane as a principle anesthetic, desining to support the use of halothane for this condition. It is because halothane is the only inhalation anesthetic most familiar to anesthesiologists and nurse anesthetists in Thailand.
Patients were 24 in series, scheduled for operation from January 1979 to February 1990. Fourteen were females and 10 males. All patients had typical symptoms and signs with VMA positive. Phenoxybenzamine was used as a pharmacoloic preparation combined with inderal@ (Prazpsom) as omdocated/ Dorected arteroa; pressire. EKG, CVP, urine output are essential monitoring. Well reconized intraoperative complications, hypertension, arrhythmia and hypotension after tumors removal occured but are easily managed. Arterial pressure was controlled by varyin the inspired concentration of halothane. Sodium nitroprusside (SNP) was given in addition in only 10 cases with minimal dosage and short period of time. Arrhythmia appeared in10 cases which is not serious, easily converted with 1-2 doses of xylocaine or propanolol. Hypotension after tumor removal is also easily corrected mostly by fluid replacement.
In conclusion, the successful use of halothane in 24 patients is confirmed the safety of halothane for pheochromocytoma, its sympathoadrenal depressin properties is very useful to modulate the charcteristic hypertension during operation. Arrhythmogenic effect is not really a contraindication.
Infact, alert anesthesiologist, well understanding pathophysiology of the disease, effective monitoringg and prompt management to the complication are more meaning than anesthetic drugs.
Caudal Morphine Combine with Bupivacaine for Postoperative
Analggesia in Pediatric Patients.
Plernsri Charuworn, M.D.
*Department of Anesthesiology, Chulalongkorn Hospital, Medical School Chulalongkorn University, Bangkok 10330, Thailand.
The use of morphine small dose (0.03 mg/kg B.W.) in combination with Bupivacaine 0.25%, 0.5 ml/kg B.W. for caudal block in the pediatric patients underoing the lower abdominal surgeries were performed in 28 patients with satisfactory result. The detail will be describred.
Cost-effectiveness analysis of intravenous
cannulae
Matinee Sujarittam M.D.*, Jariya Lertakyamanee M.D.*, Vimonrat Kritsanaprakarnkit M.D.*,
Chulalak Komoltri M.Sc.*
*Department of Anaesthesia, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
We studied a clinical trial by randomizing 4 intravenous needles to be used in 186 patients. Medical students who were blinded to the study were taught by the investigators to insert the needles. The steel needle group was given up due to high rate of intraoperative problem. Three cannula-type groups were therefore reported : Vasculon@ (58 patients), Jelco@ (57 patients) and Venflon@ (49 patients). The success rate, the ease of insertion, the number of attempts and number of cannulae used before insertion was successful were not significantly different among the three groups. The ease of insertion was not statistically associated with previous experience of intravenous cannula insertion or type of cannulae, but was associated with the visualization of veins. One hundred and six patients were followed up by another investigator in the third day after cannula insertion to record the time and reasons of cannula insertion to record the time and reasons of cannula removal. Those reasons and their frequencies had no statistically-significant difference. Phlebitis was diagnosed in 4 patients and there was no difference among the 3 groups.
From this study we concluded that the effectiveness of the 3 cannulae were equal (with cannula indwelling time of 1.59?1.88 days) and the ease of insertion were equal (for new learner); and therefore, the decision to buy the cheapest one will be most cost-effective.
A comparison of three doses of Vecuronium for intubation
K. Uerpairojkit, M.D.*, S. Borvornwanichyakul, M.D.*, W. Somboonviboon, M.D.*,P. Kongsakulvatanasuk, M.D.*
*Department of Anesthesiology, Faculty of Medicine, Chulongkorn University, Bangkok 10330, Thailand.
The authors compared the onset time, duration and tracheal intubating conditions using three doses of vecuronium. Sixty patients were randomly assigned to one of the three groups : vecuronium 0.07 mg/kg, 0.10 mg/kg and 0.15 mg/kg were used for intubation 75 seconds after intravenous administration. The onset time were 312.6?115.4,284.6?96.3 and 183.4?55.8 seconds in group 1,2 and 3, the duration were 20.2?5.1,27.7?8.5 and 42.0?7.6 minutes respectively. The differences in the onset time and the duration among the groups were statistically significant. Conditions for intubation were determined as satisfactory and fair in all 3 groups but there was no statistically significant difference among the groups.
Key words : Vecuronium, endotracheal intubation.
Effect of Various Intravenous Fluid on Serum Electrolytes
during Transurethral Prostatectomy.
C. Phannarai M.D. *, K. Pongdhana M.D.*
D. *Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400.
The serum electrolytes changes and transurethral prostatectomy syndrome were studied in 182 patients receiving either 5% dextrose in water, 5% dextrose in saline during transurethral prostatectomy. Distilled water was used as irrigating fluid. The serum Na, K, CI, and HCO3 concentrations were decreased significantly at the immediate postoperative period in the patients who received 5% dextrose in water and 5% dextrose in half strength saline. When lactated ringer’s solution was given, all except K level decreased. Only the K and HCO3 concentrations were decreased in the patients who received 5% dextrose in saline. The decreased in serum electrolytes was still evident 24 hours after the operation in most cases. But the decrease was within normal limit in both periods, and the patients were symptom-free. It was concluded that the high content of Na and CI in the 5% dextrose in normal saline could protect the dilutional effect of the same electrolytes.
Key words : Intravenous fluid ; serum electrolytes ; transurethral prostatectomy.
Prevention of Post-Spinal Anesthetic Shivering in TUR-P
by Nalbuphine Hydrochloride
Soranastaporn C, M.D.*, Jirasiritham S, M.D.*, Pausawasdi S, M.D.**
*Department of Anesthesiology, Ramathibode Hospital ** Professor, Head of Department
The effectiveness of intravenous nalbuphine hydrochloride for prevention of post-spinal anesthetic shivering was studied in seventy-five patients scheduled for elective TUR-P. The patients were divided in three groups by random. Group A were not given any premedication drug. Group B were given 0.1 mg/kg. nalbupnine HCI intravenously and group C were given intravenous midazolam or diazepam 5-10 mg. Both nalbuphine HCI and benzodiazepines significantly reduced the incidence of post-spinal shivering. There were no untoward effect produced by each drug.
Key words : Spinal anesthesia, shivering, nalbuphine HCI, benzodiazepines.
A Comparison of Ketamine and Propofol for Reliving
Pain due to Positioning Before Epidural Block in Patients with Lower Limb Fractures
Soontranan P, M.D.,* Somprakit P, M.D., DA. (U.K.), F.C. Anaes.*
*Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.
This study was designed for anaesthetists who would like to perform epidural block for the elective operations on lower limb franctures. Changing these patients from supine to lateral decubitus position prior to epidural block would cause severe pain, especially in fracture of femurs. Fifty patients (ASA class I-II) were randomized into 2 groups. Etiher ketamine (1 mg/kg body weight)or propofol (2 mg/kg body weight) was administered intravenously to these patients and the positioning was performed with close and careful monitoring of the airway patency, vital signs, consciousness, pain response and other complications. Epidural block was done successfully in every cases with 2% lignocaine or 0.5% bupivacaine. No patients recalled having pain during the positioning when interviewed postoperatively. Three-step scores were given to evaluate the ease of positioning. In ketamine group, the proper positioning for epidural block was significantly less easy than in propofol group (p<0.01). This was due to increased muscle tone in a few cases in ketamine group. Mean arterial pressure incrased significantly in ketamine group throughout the 15 minute period of the study and the maximal increase was at 5 minute perild (from 88.6?12.5 mmHg to 102.6?11.5 mmHg, P = 0.000). In propofol group, mean arterial pressure decreased significantly for the whole period of study and decreased significantly for the whole period of study and decreased maximally at 5 minute period (from 87.8?9.0 mmHg to 72.8?12.0 mmHg, P = 0.001). Heart rate in the period of study also increased significantly in ketamine group but there was no significant change in propofol group. The differeces in heart rate between these two groups were significant at 5,10 and 15 minute period of study. The incidence of dream-ing in ketamine group was significantly higher than in propofol group (8 in 25 cases compared to nil respectively). But there was no nightmare in this study. Neither awareness nor serious complications was observed in any cases. In conclusion, both drugs could be used to relieve pain due to positioning for epidural block satisfactorily. The difference in cardiovascular effects may influence the choice of drugs in some patients.
Key words : Ketamine Propofol pain relief anesthesia, epidural
Antiemetic effect of Droperiodol (Dehydrobenzperidol)
in postoperative lapaposcopy
C. Prasertchuang M.D.*, W. Chau-in M.D.*, R. Bundit M.D.*, B. Boonkratok B.Sc.**
*Department of Anesthesiology, **Nursing staff, Obstetric and Gynecological ward, Srinagarind Hospital, Faculty of medicine, khon-Kaen University, Khon-Kaen 4002, Thailand.
A double blind study, comprising of 80 gynecological patients-ASA class I who underwent laparoscopy, was carried out. The prophylactic use of intravenous droperidol 50 mg/kg B.W. before induction of general anesthesia produced a significant reduction of postoperative nausea and vomiting in the first 6 hours or until the onset of first oral intake. Increased postoperative nausea and vomiting was observed in the patients whom neostignime was not given for the antagonism of muscle relaxant. Droperidol 50mg/kg could be safely used as prophylaxis for postoperative antiemesis in the gynecological laparoscopy.
To be continue !
