Acta Anaesthesiologica Taiwanica

The Quality of Anesthesia in Taiwan

Tak-Yu Lee — 2010-06-01

Survey of 11-year Anesthesia-related Mortality and Analysis of its Associated Factors in Taiwan

2010-06-01

Objective: In developed countries, the societies of anesthesiologists have published reports of anesthesia quality. However, there are still no publications on anesthesia quality in Taiwan, even though the Taiwan Society of Anesthesiologists (TSA) was founded in 1956. This study was designed to evaluate the quality of anesthesia in Taiwan using databases maintained by the TSA and the Bureau of National Health Insurance-Taiwan (BNHI-T). Methods: The TSA published annual reports in 1995–1998 and 2002–2008 (with a 3-year interval), which included a survey on anesthesia-related mortality and morbidity, the manpower and composition of anesthesia teams, and the causes of anesthesia-related complications. Since 2002, the BNHI-T has collaborated with the National Health Research Institute-Taiwan to establish a database of health care service. To understand anesthesia quality in Taiwan, we collected data from the annual TSA surveys and the BNHI-T, and analyzed trends in anesthesia-related mortality, causes of anesthesia complications, and relative manpower composition. Results: The rate of anesthesia-related mortality was 11.9 deaths/100,000 cases. More than 50% of all anesthesia-related complications were preventable. About 1500 anesthetic procedures were performed annually by each anesthesiologist in Taiwan. The ratio of anesthesiologists to nurse anesthetists was 1:3–5. Conclusion: Anesthesia-related mortality was about 10-fold higher in Taiwan than in the United States, Japan and the United Kingdom. Mortality related to quality of anesthesia in Taiwan must be reduced. To achieve this target, we have recommended the following six approaches: (1) decrease the workload of anesthesiologists; (2) increase reimbursement by the BNHI-T for anesthesia; (3) improve the training quality of anesthetist residents; (4) strengthen the quality of board examinations; (5) improve the training quality of nurse anesthetists; and (6) standardize monitoring procedures and equipment. Only once these measures are introduced, in combination with effective quality assurance and subjective improvement systems, can we expect an improvement in the quality of anesthesia in Taiwan.

Evaluation of Risk Factors for Postoperative Prolonged Intubation in Premature Infants After Cryotherapy for Retinopathy of Prematurity

2010-06-01

Objective: Premature infants are more prone to cardiorespiratory complications after surgery than term infants. Risk factors for postoperative apnea include post-conception age, gestational age, postnatal age, birth weight, history of respiratory distress syndrome, bronchopulmonary dysplasia, anemia, necrotizing enterocolitis, use of opioids or nondepolarizing muscle relaxants, aminophylline use, history of apnea, body weight at operation, and pre-existing disease. The aim of this study was to identify the most important factors associated with postoperative extubation and respiratory outcomes among premature infants undergoing cryotherapy for retinopathy of prematurity (ROP). Methods: We retrospectively analyzed the clinical records of 62 premature infants, with mean ± standard deviation gestational age of 26.4 ± 2.3 weeks, birth weight of 914.8 ± 208.5 g, postconception age of 37.0 ± 2.8 weeks, and body weight at the time of operation of 1970.0 ± 446.8 g, who underwent cryotherapy for ROP. Results: Only 17 infants were successfully extubated within 2 hours after operation. The most predictive factor for successful or unsuccessful extubation was body weight at the time of operation. Conclusion: Body weight at the time of operation was the most important factor associated with postoperative ventilatory support among premature infants under-going cryotherapy for ROP.

Epidural Analgesia With Low-concentration Levobupivacaine Combined With Fentanyl Provides Satisfactory Postoperative Analgesia for Colorectal Surgery Patients

Mei-Chi Lin, Jui-Yu Huang, Hsuan-Chih Lao, Pei-Shan Tsai, Chun-Jen Huang — 2010-06-01

Objective: Epidural patient-controlled analgesia (EPCA) with a mixture of low-concentration levobupivacaine (0.0625% or 0.1%) plus fentanyl, with basal infusion, has been extensively used for postoperative analgesia in our allied institutions. To elucidate whether these two EPCA regimens provide satisfactory analgesia, we compared the analgesia efficacy and incidence of drug-related side effects for both EPCA regimens with those of the most widely used postoperative analgesia regimen, intra-venous PCA (IVPCA) with morphine. Methods: Data collection was performed through retrospective chart review. A total of 335 patients who underwent colorectal surgery were included. Patients received IVPCA (n = 200), EPCA with 0.0625% levobupivacaine/fentanyl (n = 45), or EPCA with 0.1% levobupivacaine/fentanyl (n = 90). The analgesia efficacy and side effects were compared. Results: Pain scores with 0.0625% and 0.1% EPCA were significantly lower than those with IVPCA. Most patients were satisfied with their postoperative analgesia, and the satisfaction scores of these three groups were comparable. No patients developed respiratory depression or over-sedation. The incidence of nausea and vomiting was significantly higher with 0.1% EPCA (16.7% and 7.8%, respectively) compared with IVPCA (6.1% and 3.5%, respectively) and 0.0625% EPCA (9.3% and 2.3%, respectively). Moreover, the incidence of sensory and motor blockade was significantly higher with 0.1% EPCA (13.5% and 5.6%, respectively) than with 0.0625% EPCA (4.7% and 0%, respectively). Conclusion: Epidural analgesia with low-concentration levobupivacaine plus fentanyl provides satisfactory postoperative analgesia with few side effects for patients after colorectal surgery.

Evaluation of the Relationships Between Intravenous Patient-controlled Analgesia Settings and Morphine Requirements Among Patients After Lumbar Spine Surgery

2010-06-01

Background: To evaluate the association between daily morphine requirement and the intravenous patient-controlled analgesia (IVPCA) setting in patients undergoing spinal surgery. Methods: We conducted a retrospective analysis of 179 patients of American Society of Anesthesiologists physical status class I-III who underwent elective posterior lumbar spinal surgery and consented to IVPCA for postoperative pain control. The regi-mental solution contained morphine 1 mg/mL. The IVPCA program was set to deliver a priming dose of 1.5–4 mL, a basal infusion rate of 0–1.2 mL/hr, and a 0.5–1.5 mL bolus on demand with a 5-minute lockout interval. Demographic data, surgical procedures, analgesia program setting variables, 4-hour cumulative morphine dose and 11-point numeric rating scale for pain on postoperative days 1 and 2 were collected for comparison. Results: The IVPCA requirement decreased gradually over time (p < 0.001). The number of vertebrae involved significantly influenced the daily morphine requirements (p = 0.01). None of the IVPCA settings, including continuous infusion, affected daily morphine requirements. On average, the analgesic requirement on postoperative day 2 was 18% less than that on postoperative day 1. Conclusion: The number of vertebrae involved was significantly associated with the daily IVPCA requirement. The IVPCA settings, including priming dose, basal infusion rate and bolus dose, did not affect the daily morphine requirements.

Effects of Auricular Acupressure on Pain Reduction in Patient-controlled Analgesia After Lumbar Spine Surgery

Mei-Ling Yeh, Mei-Yung Tsou, Bih-Yun Lee, Hsing-Hsia Chen, Yu-Chu Chung — 2010-06-01

Objective: This study aimed to examine the adjuvant effects of auricular acupres-sure in augmenting intravenous patient-controlled analgesia with morphine and droperidol for postoperative lumbar surgery patients in terms of postoperative pain relief satisfaction, and the incidence of postoperative nausea and vomiting (PONV). Methods: In this single-blind experimental study, 94 subjects were randomly assigned to the experimental group in which patients received auricular acupressure to six auricular acupoints or a control group without acupressure. Data were collected using the American Pain Society Patient Outcome Questionnaire. Descriptive analyses, t tests, χ2 tests, Mann-Whitney tests, and the generalized estimating equation model were used. Results: The experimental group had lower average pain scores than the control group, but no between-group difference was found. Analgesic dose and satisfaction were similar in both groups. The incidence of PONV was low and similar in both groups. Conclusion: Although this study did not demonstrate adjuvant effects of auricular acupressure on postoperative pain, analgesic dose, analgesic satisfaction and PONV, most subjects were satisfied with the pain management even though they were subjected to moderate pain because of insufficient analgesia. Further studies should reconfirm the effects of auricular acupressure on analgesia provided by intravenous patient-controlled analgesia in postoperative patients, and its influence on the frequency and duration of analgesia administration.

Unexpected Upper Airway Obstruction Due to Disseminated Human Papilloma Virus Infection Involving the Pharynx in a Parturient

Yuet Tong Ng, Wai Meng Lau, Tuan Jen Fang, Jing Ru Hsieh, Peter Chi Ho Chung — 2010-06-01

Human papilloma virus has been implicated as the cause of juvenile-onset recurrent respiratory papillomatosis in first-born children. Thus, cesarean section is strongly recommended by obstetricians to avoid direct contact with papilloma in an infected birth canal. We report a parturient with silent hypopharyngeal papilloma, which was associated with severe clinical problems at the induction of general anesthesia. The anesthesiologist considered general anesthesia for this case because of disseminated skin warts and secondary pus across the patient's body. Although the patient's breathing was smooth before starting general anesthesia, it was difficult to maintain positive pressure ventilation despite administration of a muscle relaxant. High air-way resistance without chest wall motion was noted, despite the insertion of an oral airway. Therefore, direct laryngoscopy was immediately performed and an obstructing mass was found. This mass acted as a check valve during positive ventilation. Our report should remind clinicians that human papilloma virus infection, although benign, can be disastrous in certain circumstances, as in our case where it resulted in airway obstruction and distal spread during cesarean section. Its presence necessitated preoperative laryngoscopic evaluation and aggressive treatment.

Solutions to Some of the Existing Problems With Breathing Equipment Type

Goneppanavar Umesh, Kaur Jasvinder, Shetty Nanda — 2010-06-01

Despite the stringent guidelines laid down by the American Society of Anesthesiologists for equipment checks, there are occasional reports of problems related to the equipment used to administer anesthesia. In this article, we discuss two important, albeit rare, problems associated with breathing equipment that have been reported in the literature. The rarity of these problems in itself may hinder early diagnosis because anesthesiologists do not usually consider these problems to be the cause of an ongoing patient morbidity. The first problem discussed here is the presence of a foreign body within the breathing system used to administer anesthesia. The second problem discussed is a kink in the breathing circuits that can precipitate life-threatening problems if it is not detected early enough.

Unexpected Pulmonary Aspiration During Endoscopy Under Intravenous Anesthesia

2010-06-01

Intravenous anesthesia is commonly used during endoscopy. This approach greatly improves patient satisfaction with pain control. The risks of anesthesia are usually focused on the cardiopulmonary effects of anesthetics. The risk of pulmonary aspiration is often overlooked, unless there are other risk factors that may increase the incidence of pulmonary aspiration. Here, we report a patient with unexpected aspiration pneumonia after gastroscopy under intravenous anesthesia. We suggest that pulmonary aspiration should be taken into consideration as a risk associated with anesthesia for gastroscopy.

Takayasu Aortoarteritis With Dilated Cardiomyopathy: Anesthetic Management of Labor Analgesia

Renu Sinha, Vimi Rewari — 2010-06-01

Takayasu aortoarteritis in a pregnant patient is often associated with severe life-threatening complications. The coexistence of associated dilated cardiomyopathy can further complicate the pregnancy, particularly during parturition and at the time of delivery. We describe the management of labor analgesia in a symptomatic parturient suffering from advanced Takayasu aortoarteritis with dilated cardiomyopathy and a recent episode of congestive cardiac failure. The patient was man-aged with graded epidural analgesia instituted early in labor. Intermittent boluses of 0.0625% bupivacaine with 2 μg/mL fentanyl were administered epidurally, which provided adequate analgesia without impaired hemodynamic status.

Hypothermia as a Cause of Coagulopathy During Hepatectomy

Albert Wai-Cheung Lau, Chia-Chen Chen, Rick Sai-Chuen Wu, Kin-Shing Poon — 2010-06-01

We report a 27-year-old hemostatically competent female scheduled for partial hepatectomy. During the operation, she experienced an accidental inferior vena cava tear and suffered acute blood loss. After fluid resuscitation and blood transfusion, she developed hypothermia, with a temperature of 33.8°C, and severe coagulopathy with activated clotting time exceeding 1500 seconds measured using the Hemochron Response system (ITC, Edison, NJ, USA). Despite sufficient blood transfusion and correction of her electrolyte imbalance, the poor hemostasis persisted. After per-forming peritoneal lavage with warm saline, her condition dramatically improved and her hypothermia and severe coagulopathy were reversed.

Development of Pneumomediastinum Following Blunt Dissection of Esophagus in Mediastinum for Transhiatal Esophagectomy

Jyotsna Punj, Deepak Narang, Ravindra Pandey, Vanlal Darlong — 2010-06-01