Validation of the Thai version of the obstetric quality of recovery score (obsqor-10-Thai) after elective cesarean delivery

BACKGROUND

The Obstetric Quality of Recovery score (ObsQoR-10) is a questionnaire used to assess recovery after cesarean delivery. However, the original ObsQoR-10 is in English and was mainly validated in the Western population. We therefore evaluated the reliability, validity, and responsiveness of the ObsQoR-10-Thai in patients undergoing elective cesarean delivery.

METHODS

The original ObsQoR-10 was translated into Thai, and psychometric validation was performed to evaluate the quality of post-cesarean recovery. The ObsQoR-10-Thai, activities of daily living checklist, and 100-mm visual analog scale of global health (VAS-GH) questionnaires were administered to the study participants before and 24 and 48-h postpartum. Validity, reliability, responsiveness, and feasibility of the ObsQoR-10-Thai were assessed.

RESULTS

We included 110 patients undergoing elective cesarean delivery. The mean ObsQoR-10-Thai score at baseline and 24 and 48-h postpartum was 83.35 ± 11.15, 56.75 ± 11.6, and 70.96 ± 13.65, respectively. The ObsQoR-10-Thai score differed significantly between the two groups divided based on the VAS-GH (≥ 70 vs. < 70): 75.58 ± 13.81 and 52.56 ± 10.61, respectively (P < 0.001). The convergent validity between the ObsQoR-10-Thai and VAS-GH was good (r = 0.60, P < 0.001). The ObsQoR-10-Thai displayed good internal consistency (Cronbach's alpha = 0.87), split-half reliability (0.92), and test-retest reliability (0.99, 95% CI: 0.98-0.99). The median time to complete the questionnaire was 2 (IQR, 1-6) min.

CONCLUSIONS

Our findings indicate that the ObsQoR-10-Thai is valid and has good reliability, with a high degree of responsiveness in terms of assessment of recovery after elective cesarean delivery.

TRIAL REGISTRATION

This study was registered on the Thai Clinical Trials Registry, identifier TCTR20210204001, registered on 04/02/2021 (Prospectively registration).

Awareness and Perspectives among Asian Anesthesiologists on Postoperative Delirium: A Multinational Survey

Postoperative delirium (POD) is a common perioperative complication. Although POD is preventable in up to 40% of patients, it is frequently overlooked. The objective of the survey is to determine the level of knowledge and clinical practices related to POD among anesthesiologists in different Asian countries. A questionnaire of 22 questions was designed by members of the Asian focus group for the study of POD, and it was sent to anesthesiologists in Singapore, Thailand, and South Korea from 1 April 2019 through 17 September 2019. In total, 531 anesthesiologists (Singapore: 224, Thailand: 124, Korea: 183) responded to the survey. Half the respondents estimated the incidence of POD to be 11–30% and believed that it typically occurs in the first 48 h after surgery. Among eight important postoperative complications, POD was ranked fifth. While 51.4% did not perform any test for POD, only 13.7% monitored the depth of anesthesia in all their patients. However, 83.8% preferred depth of anesthesia monitoring if they underwent surgery themselves. The results suggest that Asian anesthesiologists underestimate the incidence and relevance of POD. Because it increases perioperative mortality and morbidity, there is an urgent need to educate anesthesiologists regarding the recognition, prevention, detection, and management of POD.

Premedication with dexmedetomidine for prevention of hyperdynamic response after electroconvulsive therapy: a cross-over, randomized controlled trial

BACKGROUND

Electroconvulsive therapy (ECT) is an effective therapy for psychiatric disorders, but is associated with acute hyperdynamic responses including transient hypertension and tachycardia. This study aimed to assess the effectiveness of premedication with dexmedetomidine for hemodynamic attenuation after ECT and to evaluate its effects on seizure duration, postictal asystole duration, post ECT agitation and recovery time.

METHODS

Twenty-four psychiatric patients who underwent a total of 72 ECT sessions (three sessions per patient) were randomly allocated to receive either dexmedetomidine 0.5 mcg/kg intravenous, dexmedetomidine 1 mcg/kg intravenous, or saline (control group) 15 min before the first ECT session. The patients subsequently received the other two premedication options for their next two ECT sessions. Blood pressure and heart rate were recorded at 5, 10, and 15 min after drug infusion and at 2.5, 5, 7.5, 10, 15, 20, 25, and 30 min after ECT. Asystole duration, seizure duration, post ECT agitation and recovery times were also recorded.

RESULTS

The baseline characteristics were similar between the groups. Systolic blood pressure in both dexmedetomidine groups was significantly lower than that in the control group after ECT (p = 0.002). Diastolic blood pressure and heart rate were significantly lower in the dexmedetomidine 1 mcg/kg group (p = 0.002 and p = 0.013, respectively) compared with the control group. Asystole duration, seizure durations, post ECT agitation and recovery times were similar between the groups.

CONCLUSIONS

Dexmedetomidine 1 mcg/kg administered 15 min before ECT attenuated the hemodynamic response, including suppressing the systolic, diastolic and heart rate increases, during ECT without affecting recovery time. It also did not prolong the post-stimulus asystole duration.

TRIAL REGISTRATION

TCTR20170715003 , registered at Thai Clinical Trials Registry (TCTR), principal investigator: Pattika Subsoontorn, date of registration: 15/07/2017.

Cardiac Arrest and Death in Neurosurgery: An Analysis of Perioperative Anesthetic Adverse Events in Thailand

Background Complexities of pathological causes in cardiac arrest and death in neurosurgery require individualized management. To decrease the incidents, this study was performed to describe characteristics and factors reducing adverse outcomes together with potential corrective strategies of perioperative cardiac arrest and death in neurosurgical patients.

Methods An observational study was performed in 22 hospitals. Peer-reviewed consensus was formed using database from Perioperative Anesthetic Adverse Events in Thailand (PAAd Thai) study. The data contain demography, anesthetic, surgical details, opinions on contributing factors, and factors that minimized incident as well as suggested corrective strategies.

Results From 2,000 incidents, 64 (3%) cardiac arrest events were reported with a 50% chance of return of spontaneous circulation. The most common cardiac rhythm documented was asystole. Essentially, electrocardiography was the most frequent early detector. Surgical-related factors (81.3%), mostly intraoperative bleeding, played a major role in potential causes of arrest. In addition, anesthesia, patient conditions, and system-related factors were found in 65.6%, 57.8%, and 8.3% of the incidents, respectively. Moreover, the severity of the patients (73.3%) was considered to be the most common anesthesia-related risk factor. The prevention of an incident included rule enforcement for patient safety, mandatory knowledge, and also anesthesia personnel's skills development.

Conclusion The optimum fluid assessment and resuscitation, cerebral protection protocols, clinical awareness, and quality assurance together with human resource management are all essential to eliminate the catastrophic cardiac arrest and death in neurosurgery.

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

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

Successful Treatment of Large Occipital Encephalocele Presenting with Bilateral Vocal Cord Paralysis: A Case Report

large subtorcular occipital encephalocele in neonate carries higher risk of associated hindbrain anomalies and secondary process for neurological deterioration which predict the surgical outcomes and long-term prognosis. The dysfunction of the lower cranial nerves often leads to worsening of neurological status from poor respiratory function and repeated aspiration pneumonia. The aims of repairing encephalocele include a good closure of the defect, preservation or restoration of neurological functions and better cosmetic results. The author presented a successful surgical strategy for management of a 4-month-old infant with a large subtorcular occipital encephalocele presented with bilateral vocal cord paralysis and swallowing dysfunction. A step by step approach unlocked the main mechanism(s) of reversible lower cranial dysfunctions in this specific situation, including the increased intracranial pressure and shifting of the axis of lower brain stem.

Transient lesion in the splenium of the corpus callosum in acute uncomplicated falciparum malaria

Patients with acute uncomplicated Plasmodium falciparum malaria have no evident neurologic disorder, vital organ dysfunction, or other severe manifestations of infection. Nonetheless, parasitized erythrocytes cytoadhere to the endothelium throughout their microvasculature, especially within the brain. We aimed to determine if 3 Tesla magnetic resonance imaging studies could detect evidence of cerebral abnormalities in these patients. Within 24 hours of admission, initial magnetic resonance imaging examinations found a lesion with restricted water diffusion in the mid-portion of the splenium of the corpus callosum of 4 (40%) of 10 male patients. The four patients who had a splenial lesion initially had evidence of more severe hemolysis and thrombocytopenia than the six patients who had no apparent abnormality. Repeat studies four weeks later found no residua of the lesions and resolution of the hematologic differences. These observations provide evidence for acute cerebral injury in the absence of severe or cerebral malaria.

Anesthesia-related complications of caesarean delivery in Thailand: 16,697 cases from the Thai Anaesthesia Incidents Study

BACKGROUND

Maternal complications related to anesthesia are low in comparison with the results from obstetric factors in developing countries. The purposes of the present study were to determine the incidence of maternal mortality related to anesthesia, to analyze the causes and to suggest measures to improve anesthetic safety for the parturients.

MATERIAL AND METHOD

The present study was part of a multi-center study conducted by the Royal College of Anesthesiologists of Thailand aimed at surveillance of anesthesia-related complications in Thailand. The authors conducted a prospective survey of hospital records from all of the cases in and outside the operating room receiving general anesthesia in 18 centers between March 1, 2003 and February 28, 2004. All the forms were checked and verified by three-peer review then included in the analysis, using descriptive statistics.

RESULTS

Sixteen thousand six hundred ninety seven cases were included. The incidence of anesthetic complication in parturients was 35.9: 10,000 (95% CI 27.4, 46.1). Incidence ofthe four most common anesthetic related adverse events in caesarean section were desaturation 13.8 (95% CI 8.7, 20.7), cardiac arrest 10.2 (95% CI 5.9, 16.3), awareness 6.6 (95% CI 3.3, 11.8), and death related anesthesia 4.8 (95% CI 2.17, 9.4). Of these, seven (17.5%) had preeclampsia/eclampsia and 46 (76.7%) presented for emergency caesarean delivery. General anesthesia was used in 41 patients (68.4%) and spinal in eighteen (30%). There were eight maternal deaths including five with general anesthesia, giving a case fatality rate of 0.1% of general anesthetics or 0.3% of caesarean deliveries.

CONCLUSION

The authors found that inexperience, inadequate knowledge, inadequate care, and patient conditions were the major contributory factors. Most of them were preventable and correctable. Additional training and quality assurance can improve and prevent these serious adverse events.

Predictors of intra-operative recall of awareness: Thai Anesthesia Incidents Study (THAI Study): a case-control study

BACKGROUND

The authors determined predictors of intra-operative recall of awareness in the Thai Anesthesia Incidents Study (THAI Study).

OBJECTIVE

To study a multi-centered registry of anesthesia in 20 hospitals across Thailand.

MATERIAL AND METHOD

Structured data collection forms of patients who underwent general anesthesia and experienced intra-operative recall of awareness between March 1, 2003 and February 28, 2004, were reviewed by three independent anesthesiologists. One case of awareness was matched to four controls by age, gender, and level of hospitals. Univariate analysis (p < 0.1) and logistic regression (p < 0.05) identified characteristics associated with intra-operative recall of awareness.

RESULTS

Eighty-one cases were matched with 324 controls in the nested case control study. From univariate analysis, risk factors were cardiac surgery, cesarean delivery, upper abdominal surgery, i.v. anesthetics, depolarizing muscle relaxant, non-depolarizing muscle relaxant, and nitrous oxide (p < 0.1). The predictors from multivariable logistic regression were cesarean delivery p < 0.001, OR 6.48 (95% CI 2.03, 20.71), and cardiac surgery p < 0.001, OR 10.37 (95% CI 3.37, 31.89). Decreased risk was associated with intra-operative use of nitrous oxide p = 0.02, OR 0.42 (95% CI 0.20, 0.88).

CONCLUSION

In the THAI Study, predictors of intra-operative recall of awareness were cesarean delivery and cardiac surgery. Use of nitrous oxide attenuates the risk of awareness.

The Thai Anesthesia Incidents Study (THAI Study) of perioperative convulsion

OBJECTIVES

To identify the incidence of perioperative convulsion within 24 hours, outcome, predisposing risk factors, contributing factors related to anesthesia and corrective strategies.

MATERIAL AND METHOD

The prospective cohort study enrolled all anesthetics from twenty eligible hospitals in Thailand between March 1, 2003, and February 28, 2004. Postoperative convulsion incidents were extracted from the Thai Anesthesia Incidents Study (THAI Study) database in terms of demographic data, details of events, outcome, contributing factors related to anesthesia and corrective strategies.

RESULTS

The incidence of perioperative convulsion was 3.1 per 10,000 from all 172,592 anesthetics. Most patients (73.59%) recovered in 24 hours. The majority of risk factors were related to surgery (67.92%) and patient factors (54.72%) while anesthesia was the minor factor (30.19%). The contributing factors related to anesthesia were medication error (route, type, time) 43.75% and human error (inadequate care, inadequate knowledge, inadequate communication) 43.75%. The important corrective strategies included improved supervision and clinical practice guideline.

CONCLUSION

The incidence of postoperative convulsion was 3.1 per 10000. Anesthesia was the minor contributing factor. The most important risk factors included medication error and human error.

Perioperative stroke and coma in Thai Anesthesia Incidents Study (THAI Study)

OBJECTIVES

To analyze perioperative stroke and coma using database of Thai Anesthesia Incidents Study (THAI Study) with regard to frequency, contributing factors, preventive and corrective strategies.

MATERIAL AND METHOD

Details of perioperative neurological complications comprising stroke and coma in one year were recorded prospectively by attending anesthesiologists or nurse anesthetists in standardized record forms. All data were analyzed to identify contributing factors and preventive strategies.

RESULTS

Among 172,592 anesthetics, there were 24 cases of coma, and 28 cases of stroke. Most cases of coma that eventually died (12/16 cases, 75%) had ASA physical status (ASA PS) ranging from 2E to 5E. Perioperative stroke was found mainly in patients with ASA PS 3 and most of the incidence (74%) occurred in patients who had no previous history of stroke. These patients already had pre-existing cardiovascular diseases and underwent high risk procedures. There were 54% of perioperative stroke cases that could be due to improper cardiovascular management and 42% due to improper emergency neurological management.

CONCLUSION

The incidence of perioperative stroke and coma in this study was approximately 0.03%. The majority of cases had no prior stroke or coma, which suggested that a problem during perioperative period itself might predispose patients to these complications. Preventive strategies included quality assurance activity, improved communication, and practice guideline.

The Thai Anesthesia Incidents Study (THAI Study) of anesthetic outcomes: I. Description of methods and populations

BACKGROUND AND RATIONALE

Since anesthesia, unlike medical or surgical specialties, does not constitute treatment, The Royal College of Anesthesiologists of Thailand host the Thai Anesthesia Incidents Study (THAI Study) of anesthetic outcomes to determine factors related to anesthesia related adverse events.

MATERIAL AND METHOD

A prospective descriptive study of occurrence screening was conducted in 20 hospitals comprised of 7 university, 4 general and 4 district hospitals across Thailand. Anesthesia personnels were required to fill up patient-related, surgical-related, anesthesia-related variables and adverse outcomes on a strutured data entry form. The data included preanesthetic evaluation intraoperative period and 24 hr postoperative period. Adverse events specific form was recorded when adverse events occurred. All data were keyed in data management unit with double entry technique and descriptive statistics was used in the first phase of this study.

RESULTS

A total of 163403 consecutive cases were recorded in one year. The mean (S.D.) of age, weight and height of patients were 38.6(2.3) yrs, 53.9(17.7) kgs and 153.4(22.7) cm respectively. There were more female (52.9%) than male (47. 1%) patients with ASA PS 1, 2, 3, 4, 5 = 50.8%, 36.3%, 10.7%, 2.0%, 0.2% respectively. Hypertension (11.6%), anemia (7.7%) and diabetes melitus (6.8%) were the three most common abnormalities in preanesthetic history taking. Mallampati score of 111870 patients grade 1, 2, 3, 4 were 54.0%, 39.7%, 5.6%, 0.7% and laryngoscopic grade 1, 2, 3, 4 of 74888 patients were 81.0%, 15.5%, 3.0% and 0.5% respectively.

CONCLUSION

The first phase of THAI study epidemiological project can represent both the anesthesia and surgical profiles in Thailand. The collected data available should be useful for the improvement of the quality of anesthesia, guidelines for clinical practices, medical education and for further research.

An analysis of intraoperative recall of awareness in Thai Anesthesia Incidents Study (THAI Study)

OBJECTIVES

This study aimed to analyze intraoperative awareness using database of Thai Anesthesia Incidents Study (THAI Study) with regard to frequency, contributing factors, preventive and corrective strategies.

MATERIAL AND METHOD

Details of intraoperative recall of awareness were recorded prospectively by attending anesthesiologists or nurse anesthetists in standardized record forms during February 1, 2003 to July 31, 2004. Participating hospitals included 7 university hospitals, 5 tertiary care hospitals, 4 secondary care hospitals, and 4 primary care hospitals. All data were analyzed to identify contributing factors, preventive and corrective strategies.

RESULTS

Among 126078 general anesthetized cases, there were 99 cases of intraoperative recall of awareness. Awareness was found in female patients more than male patients (63% versus 37%). The majority of patients had ASA PS 1 and 2. Cardiac, obstetric, and lower abdominal surgery were involved in anesthesia awareness more than other type of surgery. Patients experiencing awareness reported sound (62%), pain (51%), feeling operated without pain (33%), and paralysis (25%). There was slight impact of anesthesia awareness in Thai patients (only 13% had temporary emotional stress and 13% had mild anxiety) despite small percentage of proper management by reassurance and psychiatric consultation (15%). The contributing factors included inadequate knowledge (67%), inadequate medication dosage (44%), and inadequate care from inexperience (11%). Awareness incidents were documented to be preventable in 36% of patients and partially preventable in 38% of patients. The corrective strategies included guideline practice (30%), additional training (28%), quality assurance activity (19%), and improved supervision (16%).

CONCLUSION

The incidence of intraoperative recall of awareness in this study was 0.08%. Patients reported sound, pain, feeling operated without pain, and paralysis. Corrective strategies included guideline practice, additional training, quality assurance activity, and improved supervision.

Trihydroxyethylrutosides in the treatment of hemorrhoids of pregnancy: a double-blind placebo-controlled trial

The safety and efficacy of Trihydroxyethylrutosides (HR) in the treatment of 53 patients with 1st-2nd degree hemorrhoids of pregnancy (16th-34th week) was investigated in a double-blind randomised, placebo controlled trial. The dosage of Trihydroxyethylrutosides was 1 tablet of 300 milligrams twice daily for the first 2 weeks. If the treatment was successful, the treatment was stopped. If the clinical signs or symptoms still persisted, the treatment was continued for another two weeks using the same dosage and re-evaluated at the end of the fourth week after initial treatment. The parameters for efficacy were symptoms (pain, bleeding, exudation and pruritus) and the objective signs on proctoscopy (bleeding, inflammation and dilatation of the hemorrhoidal venous plexus). The study revealed improvement of symptoms in the study group which was better than in the control group after 2 weeks of treatment but the clinical signs were not different. After a further 2 weeks of treatment, the result showed improvement of both clinical signs and symptoms in this study. Only one mild transient side effect was reported in the HR group and there were no drug-related problems in the pregnancies, delivery or the babies.

Effect of intraoperative fluid on blood glucose level in neurosurgery

There is a considerable controversy regarding glucose administration during intracranial surgery. However, recent animal and human studies suggest that hyperglycemia exacerbates ischemic brain damage and intraoperative hypoglycemia may not be a concern if the surgical procedure is less than 4 hours. We, therefore, studied the blood glucose in neurosurgery with craniotomy in 90 Thai patients, divided into 3 groups. 30 patients in each group received balanced salt solution (0.9% NSS), 5 per cent glucose rate 60-80 ml/h and 5 per cent glucose rate more than 120 ml/h. Blood for the determination of glucose concentration was obtained after induction and every 2 hours later until the end of the surgery. There was one male patient in group I who received balanced salt solution (0.9% NSS) had blood glucose concentration lowered to 57 mg% at 4 hours after induction. The patients in group II who received 5 per cent glucose solution at maintenance rate did not have hyperglycemia (161.20 +/- 38.30 mg%). In group III; patients given 5 per cent glucose infusion at the rate of more than 120 ml/h had hyperglycemia (236.75 +/- 63.57 mg%) at 6 hours. In conclusion, we suggest that in Thai patients undergoing neurosurgical procedures; blood glucose levels should be checked intraoperatively if glucose is withheld from the intraoperative fluid regimen. Otherwise 80 ml/h of 5 per cent dextrose intravenous infusion should be given to the patients to prevent hypoglycemia.

Efficacy of prophylactic ondansetron in Thai patients undergoing gastrointestinal tract surgery

Postoperative nausea and vomiting (PONV) although frequently is considered a minor postoperative complication, it may be greatly trouble some especially in ambulatory surgical patients. This study was performed to compare the efficacy and safety of a single intravenous bolus dose of ondansetron 4 mg with the placebo in the prevention of PONV and to assess the safety and tolerability in Thai patients. By using the randomized, double-blind, placebo controlled study design, we enrolled 82 Thai male and female patients, ASA physical status I or II, between the ages of 12 and 75 year undergoing gastrointestinal tract surgery with general anesthesia in the study. A single intravenous bolus dose of ondansetron 4 mg or a single dose of placebo was administered immediately prior to the induction of the anesthesia. The patients were followed for 24 hours to assess PONV and adverse events. We found that intravenous ondansetron 4 mg seemed to be effective and safe in the prevention of PONV especially in female patients (P = 0.037) based on clinical observation. However there was no statistical significance between groups. None of the patients in both groups had any adverse events. In addition, there was no significant difference between preoperative and postoperative abnormalities of liver enzymes. Also we had found no difference in patient satisfaction between two groups.