Thai Journal of Anesthesiology

Kratom and Anesthesia

Somchai Amornyotin — 2022-10-01

Kratom, known as Mitragyna speciosa (Korth), is a native plant in Thailand and Southeast Asia. It is used as a drug of abuse, opioid alternative, or pain killer. The pharmacokinetics of this plant has been studied only in animals, and there are no such studies in humans. Kratom contains pharmacologically active ingredients, most particularly mitragynine and 7-hydroxy- mitragynine. Kratom leaves contain multiple psychoactive chemicals that stimulate opioid, alpha-2, and serotonergic receptors. It produces complex stimulant and opioid-like analgesic effects. Therefore, it is used to treat pain and to alleviate opioid withdrawal or as an opioid replacement among people with opioid use disorder. Kratom is one of abuse drugs including tobacco and cannabis.1,2 It is illegal in many countries. Conventionally, kratom could be smoked, vaporized, or consumed as a powder. Several patients who consume kratom require medical intervention and care by anesthesiologists. Importantly, kratom users are of direct concerns to periprocedural management. To date, anesthetic personnel need to understand the pharmacodynamics and pharmacokinetics of the use of kratom and its chemical compounds.

General Anesthetic Precaution in Irreversible Electroporation

Pattharaporn Sombood — 2022-10-01

Irreversible Electroporation or Nanoknife is an innovative insertion of needles through the skin for tumor ablation. Consequently, the high electric field creates nanapores in the cell membrane resulting cell death without triggering an inflammatory process, hence bodily immunological response can eradicate it without a trace. Therefore, a Nanoknife is a safe technique in preservation of vital and scaffolding structures within the treatment zone such as gall bladder, pancreas, ureter, blood vessel or nerve fibers. In addition, it reduces susceptibility to heat sink effects which is implicated as a possible contributing cause of the residual tissue and recurrent tumor. However, this procedure can result in full body muscle spasm, severe muscle contraction and cardiac dysrhythmias. As a result, anesthesia personnel have to be aware of the sequence of events. Typically, they provide general anesthesia with endotracheal intubation and muscle relaxation as well as monitor patients’ vital signs particularly an electrocardiography throughout the process. Additionally, a defibrillator must be readily available in case of emergency cardiac arrythmia and arrest.

A Randomized Control Trial of Hyoscine N-Butylbromide versus Lidocaine Pretreatment for Alleviating Pain on Propofol Injection

Peerapong Sangsungnern — 2022-10-01

Propofol is commonly used in anesthesia practice according to its rapid and smooth induction, short duration, and low incidence of postoperative nausea and vomiting. However, discomfort from pain on propofol injection still be a problem.1-4 The incidence of this pain in adults ranged from 28 to 90% and its pain severity was moderate (average numeric rating scale (NRS) was 5.6±2.3).5-7 The mechanism of propofol injection pain was hypothesized that propofol likely irritates the innermost layer of vessels that causes directly stimulating free nerve ending and indirectly releasing of mediators and results in pain on injection.6-8 Several methods were used for alleviating propofol injection pain such as pretreatment of intravenous lidocaine with or without tourniquet, lidocaine mixed with propofol, and pretreatment with opioids, non-steroidal anti-inflammatory drugs, ketamine, or metoclopramide.6-9 Pre-treatment of lidocaine is a common technique to prevent propofol pain because of its local anesthetic effect on the vein and ease to application.7-9 Pretreatment of 30 to 60 mg of intravenous lidocaine with tourniquet was presumed to reduce this pain.9-11 However, appropriate dosages and methods of lidocaine administration were inconclusive and the efficacy of lidocaine administration on propofol injection pain was still varied. From earlier study, 20 mg of Hyoscine N-butylbromide (HBB) significantly alleviated propofol pain on injection when compared to placebo.12 HBB, a quaternary ammonium derivative which an anticholinergic drug, bound to peripheral anti-muscarinic receptors which are located notably in smooth muscle cells of gastrointestinal tract and blood vessels.13,14 It is used for relief abdominal, ureteric colic, labor pain, and prevent spasms of the gastrointestinal tract prior to invasive radiologic and diagnostic procedures, such as endoscopic retrograde cholangiopancreatography (ERCP) and colonoscopy.13-16 Common adverse effects of HBB were tachycardia, dry mouth, and blurred vision.14 This study was intended to compare the efficacy between pretreatment of HBB and lidocaine in adjunction with tourniquet to alleviate propofol pain on injection.

Efficacy of Intravenous 0.25 mg/kg Lidocaine Compared with 0.5 mg/kg Lidocaine for Reducing Fentanyl-Induced Cough: a Randomized Controlled Trial

Wanwipha Malaithong — 2022-10-01

Background: Fentanyl is one of pain medication usually used in anesthetic practice and one common problem after intravenous injection is inducing cough. A 0.5 mg/kg of lidocaine could suppress fentanyl-induced cough, however, the side effect of exceeding doses of lidocaine may cause arrhythmogenic effects and the vasodilatory effects of lidocaine may possibly aggravate cardiovascular depression. Objectives: The study aimed to compare the efficacy of 0.25 mg/kg and 0.5 mg/kg intravenous lidocaine regarding fentanyl-induced cough in general anesthesia. Methods: This study was a randomized double-blinded controlled trial. In all 139 participants, who underwent elective surgery between the ages of 18 to 60 years, were allocated in two groups, to receive lidocaine 0.25 mg/kg and 0.5 mg/kg over two minutes before 1 μg/kg of intravenous fentanyl. Coughing was assessed and classified into 3 grades as mild, moderate, or severe. The risk factors of fentanyl-induced cough and side effects were also noted. Results: Thirteen patients (18.8%) in the 0.25% lidocaine group and eleven patients (15.7%) in the 0.5% lidocaine group experienced fentanyl induced cough. No significant difference was found in the incidence and severity of cough between the two groups (P>0.05). Conclusion: The present findings indicated that pre-operative IV lidocaine 0.25 mg/kg could be considered an alternative dose to suppress fentanyl-induced cough.

Comparing Intraoperative End-Tidal Sevoflurane Concentration in Cirrhosis to Non-cirrhosis Patients Undergoing Open Hepatic Resection

Sahadol Poonyathawon — 2022-10-01

Background: The effect of hepatic cirrhosis on anesthetic requirement is still uncertain. Some studies showed that, end stage hepatic disease or cirrhotic patients might have less inhalational anesthetic requirement than patients with normal hepatic function. In this study, during major hepatic resection, end-tidal sevoflurane concentration was compared between cirrhosis and non-cirrhosis patients. Methods: Our prospective observational study included 30 patients with hepatic tumors undergoing open major hepatic resection. The patients were divided into two groups: cirrhosis group (n=15) and non-cirrhosis group (n=15). Thoracic epidural combined with general anesthesia was performed. End tidal sevoflurane concentration was adjusted with target BIS between 40-55. Morphine and lidocaine were given via epidural catheter for pain control during perioperative periods. The primary outcome of the study is mean end-tidal sevoflurane. Demographic data including age, sex, weight, ASA physical status and other secondary outcomes were obtained from anesthetic records. Results: The mean end-tidal sevoflurane concentration was 1.59±0.23 vol.% in cirrhosis group and 1.67±0.19 vol.% in non-cirrhosis group (P=0.329). Minimal alveolar concentration (MAC) in cirrhosis group and non-cirrhosis group were 0.84±0.10 and 0.87±0.07 (P=0.330), respectively. There is no significant difference in demographic data except for the ASA status (P=0.002) and the duration of operation (P=0.033). Conclusion: Our study shows that there is no difference in end-tidal sevoflurane concentration, minimal alveolar concentration between cirrhosis and non-cirrhosis.

Incidence and Contributing Factors of Anesthesia-Related Critical Events in Neurosurgery in a Tertiary Academic Hospital in a Developing Country: a Retrospective Study

Ekanong Sutthipongkiat — 2022-10-01

Background and aim: Neurosurgery is regarded as high-risk surgery due to comorbidities of patients, urgency and complexities of procedures. Mostly, reported complications were surgical-related complications. Very few studies reported anesthesia-related complications. This study aims to determine the incidence and contributing factors of anesthesia-related complications in neurosurgical unit. Methods: Total 12,418 patients of this retrospective study had neurosurgical procedures during 7 years (2014-2020). Every incident report would be extensively reviewed by 3 investigators to classify the contributing factors of complications together with severities and outcomes. The immediate (first 24 hours) and delayed (7 days) outcomes were recorded. The outcomes were classified as complete recovery, prolonged ventilation, prolonged hospital stay, vegetative state and death. The descriptive analysis was used for the outcome. Results: There were 214 incidents of 184 patients per 12,418 anesthetics or 1.7%. Top five complications were lip trauma (53 events, 28.8%), difficult intubation (36 events, 19.6%), reintubation (23 events, 12.5%), dental injury (18 events, 9.8%), esophageal intubation (15 events, 8.2%). Top three contributing factors were inexperience (38.4%), inappropriate decision (17.8%) and patient factor (15.5%). Major complications such as death, cardiac arrest, stroke and convulsion were found in 23 cases, mostly related to patient factor, surgical factor and inappropriate decision. Nearly half (n=91, 44%) had complete recovery during immediate postoperative period. Conclusion: Airway complications were the most anesthesia-related complications in neuroanesthesia and the most contributing factor was inexperienced trainee. Attention should be focused on improving in-training in airway management and developing protocols to minimize human and system errors.

Successful Discharge Rate of One-Day Laparoscopic Cholecystectomy Surgery by Modified Post-Anesthetic Discharge Scoring System in Siriraj Hospital

Tithiganya Duangrat — 2022-10-01

Background: Ambulatory laparoscopic cholecystectomy (LC) could be done safely. One day surgery (ODS) is a new program supported by Thai government. It is to discharge the patient within the same day of surgery or within 24 hours from incision time. A modified post-anesthesia discharge scoring system (PADSS) is recommended. Objective: To determine the successfully discharge rate (PADSS = 9,10) within 24 hours from incision time in normal practice LC without specific ODS protocol and to compare the anesthetic and surgical factors between the patients with PADSS = 9,10 and the patients with PADSS score < 9. Methods: The prospective cohort, non-allocation study in elective LC from 18 years in Siriraj hospital in February-March 2020. Demographic, preoperative intraoperative and postoperative data were reviewed from the hospital chart. PADSS evaluation were done at 24 hours after incision. The number of patients with PADSS = 9,10 reported by percentage and 95% CI. Comparing factors between two groups using a t-test. Results: Patients with PADSS = 9,10 were found 44 from 55 cases (80.0%) (95%CI 67-89.6%): 100.0%, 87.0% and 65.2% of ASA I, II and III, respectively. Patient’s age (59.6±13.8 years vs 71.7±16.0 years, P=0.016), operative time (84.4±34.6 min vs 112.3±35.2 min, P=0.021) and anesthetic duration (152.3±36.6 min vs 121.5±36.8 min, P=0.016) in the PADSS score 9,10 group were significantly lower than in the PADSS score < 9 group. Conclusions: In normal practice of elective LC in Siriraj Hospital, we could discharge patients within 24 hours after incision by using modified PADSS (score = 9,10) in 80.0% of cases. The major problem of delayed discharge time was ambulation. Important factors are ASA physical status, age, operative time, and anesthetic time.

Outcomes of Difficult Intubation in Emergency Condition Outside the Operating Room

Thadakorn Tantisarasart — 2022-10-01

Background: The Songklanagarind airway management outside the operating room practice guidelines were first developed and implemented in 2018. This study aimed to determine the success rate of emergency call for endotracheal intubation outside the operating room and other outcomes. Methods: This retrospective cohort study was conducted from January 2018 until December 2020. We determined intubation performances and outcomes of endotracheal intubation outside the operating room in patients with anticipated difficult intubation, by either anesthesiologist staff or residents. The outcomes were compared from the three years of study period. Results: During the three-year period, there were 171 airway consultations: divided into 26, 54, and 91 intubations in 2018, 2019, and 2020. The overall success of intubation was 98.8%. The rate of successful intubation in the emergency unit was significantly lower (87.5%) compared to the rate of successful intubation in the intensive care units (100.0%) and general wards (100.0%) (P=0.008). Residents claimed 76.9% of intubation success. The median waiting time was five minutes. The intubation success and the waiting time were not different among years. Conclusion: There was not significantly different between the success rate of intubation within each year. Compared to other settings, intubation performed in the emergency unit carried the greater chance of failure.