Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries.

BACKGROUND: As global initiatives increase patient access to surgical treatments, there remains a need to understand the adverse effects of surgery and define appropriate levels of perioperative care. METHODS: We designed a prospective international 7-day cohort study of outcomes following elective adult inpatient surgery in 27 countries. The primary outcome was in-hospital complications. Secondary outcomes were death following a complication (failure to rescue) and death in hospital. Process measures were admission to critical care immediately after surgery or to treat a complication and duration of hospital stay. A single definition of critical care was used for all countries. RESULTS: A total of 474 hospitals in 19 high-, 7 middle- and 1 low-income country were included in the primary analysis. Data included 44 814 patients with a median hospital stay of 4 (range 2-7) days. A total of 7508 patients (16.8%) developed one or more postoperative complication and 207 died (0.5%). The overall mortality among patients who developed complications was 2.8%. Mortality following complications ranged from 2.4% for pulmonary embolism to 43.9% for cardiac arrest. A total of 4360 (9.7%) patients were admitted to a critical care unit as routine immediately after surgery, of whom 2198 (50.4%) developed a complication, with 105 (2.4%) deaths. A total of 1233 patients (16.4%) were admitted to a critical care unit to treat complications, with 119 (9.7%) deaths. Despite lower baseline risk, outcomes were similar in low- and middle-income compared with high-income countries. CONCLUSIONS: Poor patient outcomes are common after inpatient surgery. Global initiatives to increase access to surgical treatments should also address the need for safe perioperative care. STUDY REGISTRATION: ISRCTN5181700

Analysis of anesthesia chief resident competencies in anesthesia crisis management simulation

Marilaeta Cindryani, I Made Gede Widnyana, I Gusti Ngurah Mahaalit Aribawa, Tjokorda GA Senapathi Anesthesiology and Intensive Care Department, Udayana University, Denpasar, Bali, Indonesia Background: Anesthesia crisis management (ACM) simulation would expose anesthesiology residents and trainees to dynamic emergencies that need quick yet effective responses to gain their core strength and capabilities as anesthesiologists. Our department had already employed ACM simulation into modules and practiced in examinations. The aim is to enhance professional working ethics and human responsibility in residents, which would be accomplished in semi-realistic simulation. This would be a useful tool for lecturers to evaluate current teaching methods and measure protégés in daily emergencies, which should be done better in continuous pattern.Methods: We analyzed the ACM simulation scores from resident examination using Strata SE programs. The examination consisted of four topics in which points counted for each topic ranged from 0 to 15 and then would be counted into percentage for passing grade. The required minimum passing grade for each topic was 75%, in which the average score for one topic was 11.25.Discussion: Overall average score for all subjects was 12.07, which already achieved the 75% passing grade with a cutoff point of 11.25. Postsurgical bleeding and cannot intubate–cannot oxygenate topics were the two bottom topics that could not achieve the 75% passing grade. Preoperative evaluation and decision making were two lowest non-technical skill scores in the examination.Conclusion: Weakest core competencies were found in preoperative evaluation and decision making even though all subjects had already passed the minimum requirements of 75% passing grade. Postsurgical bleeding and cannot intubate–cannot oxygenate were also topics with lowest scores in core competencies. These findings would suggest for innovation and reevaluation of current teaching. Keywords: anesthesia, resident competencies, crisis management simulatio

Combined ultrasound-guided Pecs II block and general anesthesia are effective for reducing pain from modified radical mastectomy

Tjokorda Gde Agung Senapathi, I Made Gede Widnyana, I Gusti Ngurah Mahaalit Aribawa, A A Gde Putra Semara Jaya, I Made Darma JunaediDepartment of Anesthesiology and Intensive Care, Sanglah Hospital, Faculty of Medicine, Udayana University, Denpasar, Bali, IndonesiaPurpose: Combined regional and general anesthesia are often used for the management of breast cancer surgery. Thoracic spinal block, thoracic epidural block, thoracic paravertebral block, and multiple intercostal nerve blocks are the regional anesthesia techniques which have been used in breast surgery, but some anesthesiologists are not comfortable because of the complication and side effects. In 2012, Blanco et al introduced pectoralis nerve (Pecs) II block or modified Pecs block as a novel approach to breast surgery. This study aims to determine the effectiveness of combined ultrasound-guided Pecs II block and general anesthesia for reducing intra- and postoperative pain from modified radical mastectomy.Patients and methods: Fifty patients undergoing modified radical mastectomy with general anesthesia were divided into two groups randomly (n=25), to either Pecs (P) group or control (C) group. Ultrasound-guided Pecs II block was done with 0.25% bupivacaine (P group) or 0.9% NaCl (C group). Patient-controlled analgesia was used to control postoperative pain. Intraoperative opioid consumption, postoperative visual analog scale (VAS) score, and postoperative opioid consumption were measured.Results: Intraoperative opioid consumption was significantly lower in P group (P≤0.05). VAS score at 3, 6, 12, and 24 hrs postoperative were significantly lower in P group (P≤0.05). Twenty-four hours postoperative opioid consumption was significantly lower in P group (P≤0.05). There are no complications following Pecs block in both groups, including pneumothorax, vascular puncture, and hematoma.Conclusion: Combined ultrasound-guided Pecs II block and general anesthesia are effective in reducing pain both intra- and postoperatively in patients undergoing modified radical mastectomy. Ultrasound-guided Pecs II block is a relatively safe peripheral nerve block.Keywords: Pecs block, interfascial injection, regional anesthesia, ultrasound-guided, pain, modified radical mastectomy, breast surger

Extended Glasgow Outcome Scale correlates with bispectral index in traumatic brain injury patients who underwent craniotomy

Tjokorda Gde Bagus Mahadewa,1 Tjokorda Gde Agung Senapathi,2 Made Wiryana,2 I Gusti Ngurah Mahaalit Aribawa,2 Ketut Yudi Arparitna,2 Christopher Ryalino2 1Department of Neurosurgery, Sanglah General Hospital, Denpasar, Indonesia; 2Department of Anesthesiology, Intensive Care, and Pain Management, Sanglah General Hospital, Denpasar, Indonesia Background: Assessing consciousness in traumatic brain injury is important because it also determines the treatment option, which will influence patients’ outcome. A tool used to objectively assess consciousness level is the bispectral index (BIS) monitor, which was originally designed to monitor the depth of anesthesia. Glasgow Outcome Scale-Extended (GOS-E) provides a measuring tool to assess traumatic brain injury (TBI) outcome. The goal of this study was to assess the correlation between GOS-E scores with BIS values in patients with TBI who underwent craniotomy. Patients and methods: A total of 68 patients admitted to the emergency department with decreased consciousness due to TBI who underwent craniotomy were included in the study. BIS value was measured upon admission, then GOS-E score was determined 6 months after the incident took place. Spearman’s correlation coefficient was used to assess the correlation between GOS-E score and BIS value. Results: In 68 patients, the GOS-E score was found to have a strong correlation (r =0.921, p<0.01) with BIS values. From this study, the formula to estimate GOS-E score based on BIS value upon admission stands as: GOS-E =0.19 (BIS) – 8.31. Conclusion: This study found that there is a strong correlation between GOS-E score and BIS value. These findings suggest that BIS scores upon admission may be used to predict the outcomes in patients with TBI. However, the wide distribution of BIS values for each GOS-E score may limit the use of BIS scores in accurately predicting GOS-E scores. Keywords: decreased consciousness, head injury, outcome, predictio

Effectiveness of intramuscular neostigmine to accelerate bladder emptying after spinal anesthesia

Tjokorda Gde Agung Senapathi, Made Wiryana, I Made Subagiartha, I Putu Pramana Suarjaya, I Made Gede Widnyana, Ida Bagus Krisna Jaya Sutawan, A A Gde Putra Semara Jaya, Andri Thewidya Department of Anesthesiology and Intensive Care, Sanglah Hospital, Faculty of Medicine, Udayana University, Denpasar, Bali, Indonesia Purpose: Postoperative urinary retention (POUR) is one of the most common complications following spinal anesthesia. Spinal anesthesia may influence urinary bladder function due to interruption of the micturition reflex. Urinary catheterization is the standard treatment of POUR. Urinary catheter insertion is an invasive procedure, which is associated with catheter-related infections, urethral trauma, and patient discomfort. The purpose of this study was to determine the effectiveness of intramuscular (IM) neostigmine to accelerate bladder emptying after spinal anesthesia. Patients and methods: A total of 36 patients undergoing lower abdominal (except for pelvic, urologic, anorectal, and hernia surgery) and lower extremity surgery under spinal anesthesia were divided into two groups randomly (n=18), to either neostigmine (N) group or control (C) group. Neostigmine 0.5 mg (N group) or NaCl 0.9% (C group) was administered intramuscularly when Bromage score 0 and sensory level sacral two have been achieved. The time to first voiding after IM injection and the time to first voiding after spinal anesthesia were measured. Results: The time to first voiding after IM injection was significantly faster (P≤0.05) in the N group than that in the C group, with median time as 40 minutes (20–70 minutes) and 75 minutes (55–135 minutes), respectively. Time to first voiding after spinal anesthesia was also significantly faster (P≤0.05) in the N group than that in the C group (mean of 280.8±66.6 minutes and 364.2±77.3 minutes, respectively). Conclusion: IM neostigmine effectively accelerates bladder emptying after spinal anesthesia. Keywords: neostigmine, postoperative urinary retention, bladder emptying, spinal anesthesia, anticholinesterase, neuraxial anesthesi

Ultrasound-guided bilateral superficial cervical plexus block is more effective than landmark technique for reducing pain from thyroidectomy

Tjokorda Gde Agung Senapathi, I Made Gede Widnyana, I Gusti Ngurah Mahaalit Aribawa, Made Wiryana, I Ketut Sinardja, I Ketut Wibawa Nada, AA Gde Putra Semara Jaya, I Gede Koko Swadharma Putra Department of Anesthesiology and Intensive Care, Sanglah Hospital, Faculty of Medicine, Udayana University, Denpasar, Bali, Indonesia Purpose: Thyroidectomy causes postoperative pain and patient discomfort. Bilateral superficial cervical plexus block is a regional anesthesia technique that can provide analgesia during and after surgery. This study aims to compare the effectiveness of ultrasound (US)-guided versus landmark (LM) technique for bilateral superficial cervical plexus block in thyroidectomy. Patients and methods: Thirty-six patients undergoing thyroidectomy were divided into two groups randomly (n=18); either US-guided (US group) or LM technique (LM group) for bilateral superficial cervical plexus block. Patient-controlled analgesia was used to control postoperative pain. Intraoperative opioid rescue, postoperative visual analog scale (VAS) score and opioid consumption were measured. Results: The number of patients who required intraoperative opioid rescue was significantly lower in the US group (p≤0.05). There was no significant difference in postoperative VAS score at 3 hours (p>0.05), but postoperative VAS score at 6 and 24 hours was significantly lower in the US group (p≤0.05). Twenty-four hour postoperative opioid consumption was significantly lower in the US group (p≤0.05). Conclusion: Ultrasound-guided bilateral superficial cervical plexus block is more effective in reducing pain both intra- and postoperatively compared with landmark technique in patients undergoing thyroidectomy. Keywords: peripheral nerve block, superficial cervical plexus block, ultrasound-guided, pain, thyroidectom

Effectiveness of low-dose intravenous ketamine to attenuate stress response in patients undergoing emergency cesarean section with spinal anesthesia

Tjokorda Gde Agung Senapathi, I Made Gede Widnyana, Made Wiryana, I Gusti Ngurah Mahaalit Aribawa, I Wayan Aryabiantara, I Gusti Agung Gede Utara Hartawan, I Ketut Sinardja, I Putu Pramana Suarjaya, I Ketut Wibawa Nada, AA Gde Putra Semara Jaya Department of Anesthesiology and Intensive Care, Faculty of Medicine, Udayana University, Sanglah Hospital, Bali, Indonesia Purpose: Cesarean section is a surgical procedure. Surgical procedures will induce stress responses, which may have negative impact on postoperative recovery. Ketamine plays a role in the homeostatic regulation of inflammatory response in order to attenuate stress response. We tried to determine the effectiveness of low-dose intravenous ketamine to attenuate stress response in patients undergoing emergency cesarean section with spinal anesthesia.Patients and methods: Thirty-six pregnant women undergoing emergency cesarean section with spinal anesthesia were randomly divided into two groups (n=18). Ketamine 0.3 mg/kg (KET group) or NaCl 0.9% (NS group) was administered intravenously before the administration of spinal anesthesia. C-reactive protein (CRP) and neutrophil levels were measured preoperatively and postoperatively.Results: Elevation of CRP stress response was lower in the KET group and significantly different (P≤0.05) from that in the NS group. Neutrophil level was elevated in both the groups and hence not significantly different from each other (P>0.05). Postoperative visual analog scale pain score was not significantly different between the two groups (P>0.05), but there was a statistically significant (P≤0.05) positive and weak correlation between visual analog scale and CRP level postoperatively.Conclusion: Low-dose intravenous ketamine effectively attenuates the CRP stress response in patients undergoing emergency cesarean section with spinal anesthesia. Keywords: ketamine, stress response, pain, spinal anesthesia, cesarean sectio

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