We aimed to determine the correlation between mid-glottic transverse diameter/subglottic diameter and outer diameter of endotracheal tube (ETT) by ultrasonography in children. Ninety-five patients aged 1–8 years who underwent general anesthesia were included. Ultrasonography of glottic/subglottic transverse diameter was performed by two investigators after patients were anesthetized and when the train of four showed ≤ 4. The subglottic diameter was measured at the mid cricoid cartilage. The mid-glottic transverse diameter was measured at the mid-point of true vocal fold triangle whereas the distance between arytenoids was considered as the glottic transverse diameter. Linear regression models and correlation coefficients (r) were used to determine the best formula of glottic/subglottic transverse diameter to predict the outer diameter of ETT. The predicted outer diameter of ETT formula for subglottic diameter, mid-glottic transverse diameter, and glottic transverse diameter were 5.7 + (subglotticmm/3) with an r of 0.45, 5.5 + (midglotticmm/2) with an r of 0.47, and 5.7 + (glotticmm/4) with an r of 0.46, respectively. The correlation between subglottic diameter and mid-glottic transverse diameter was 0.50. Subglottic/mid-glottic/glottic transverse diameter formulae had moderate correlations with the outer diameter of ETT. The glottic/mid-glottic transverse diameter can be used alternatively to predict the ETT size.Trial registration: Thai Clinical Trial Registry: TCTR20191022002 Registered 22/10/2019—Prospectively registered, https://www.thaiclinicaltrials.org/# TCTR20191022002.

Background The effective dose during ultrasound-guided rectus sheath block (URSB) for reducing pain after laparoscopic tubal ligation is reported to be 100 mg of 0.25% bupivacaine. We examined the minimal effective dose of 0.25% bupivacaine for URSB on oral analgesic requirement after ambulatory single-port laparoscopic tubal resection. Methods A prospective, randomized controlled, superiority trial was conducted among patients who had been scheduled for ambulatory laparoscopic tubal resection between September 2015 and January 2019 at a tertiary care hospital in southern Thailand. Anesthesia was induced following protocol. The intervention group was allocated to receive a bilateral URSB using 10 ml of 0.25% bupivacaine on either side after intubation (total 50 mg) while the control group did not receive the sham block. Patients and assessors were blinded to the study intervention. All patients received a multimodal analgesia regimen as follows: fentanyl and ketorolac intraoperatively and fentanyl and oral acetaminophen at the post-anesthetic care unit. Postoperative oral analgesic requirement (acetaminophen and/or ibuprofen) at home was the primary outcome. Postoperative time to first analgesic requirement, oral analgesia (acetaminophen/ibuprofen), and pain score at 6 and 24 h were accessed via telephone interviews. Percentage, effect size (ES), and 95% confidence interval (CI) were presented. Results A total of 66 out of 79 eligible patients were analyzed (32 intervention, 34 control). Intraoperative fentanyl consumption was significantly lower in the intervention group (ES [95% CI]: 0.58 [0.08, 1.07] mcg, p = 0.022). Time to first oral analgesia in the intervention group was significantly longer than that of the control group (ES [95% CI]: 0.66 [0.14, 1.16] h, p = 0.012). The proportion of oral analgesia requirement at 24 h after surgery in the control group was significantly higher than that in the intervention group (97% vs 75%, p = 0.012). Pain scores at 6 and 24 h were similar in both groups although slightly lower in the intervention group (ES [95% CI]: 0.22 [−0.26, 0.71], p = 0.368 and 0.33 [−0.16, 0.81], p = 0.184, respectively). Conclusion A dose of 0.25% bupivacaine 50 mg for URSB reduced the oral analgesic requirement at 24 h and prolonged the time to first analgesic requirement after ambulatory laparoscopic tubal resection. Trial registration Thaiclinicaltrials.orgTCTR20150921002. Registered on 18 September 2015

Intraoperative arterial blood pressure (BP) labil ity refers to deviations beyond the accepted physio logical range or to rapid changes in arterial BP that commonly occur during anaesthesia in noncardiac surgery [1,2]. The presence of BP lability alerts the anaesthetists to potentially deleterious condi tions, such as hypovolaemia, inadequate depth of anaesthesia, and the potential for cardiovascular complications. Intraoperative BP lability has been

Objective: To compare masked uncontrolled hypertension (MUCH) (n=16) and adequately controlled hypertension (ACH) (n=21) patients regarding their haemodynamic response to induction, incision and extubation, and evaluate the risk of perioperative recurrent adverse cardiovascular events in a prospective observational study.  Material and Methods: After home blood pressure (BP) monitoring, patients were classified as MUCH or ACH using objective criteria. Perioperative haemodynamic parameters were monitored. Recurrent adverse event risks were evaluated using total-time and gap-time recurrent-event analysis.  Results: BP responses to induction were qualitatively similar in the two groups, but with an exaggerated response following incision and extubation in the MUCH group. Risks of recurrent hypertensive events were higher in MUCH than in ACH patients during the intraoperative and emergence periods, with hazard ratios [95% confidence intervals] of 2.10 [1.21, 3.64] and 4.73 [1.12, 19.89] from total-time models, and 1.84 [1.20, 2.84] and 5.91 [1.45, 24.11] from gap-time models; the risk of recurrent bradycardia was higher during emergence, 4.08 [1.22, 13.59] from total-time and 4.88 [1.77, 13.45] from gap-time models. In contrast, the risk of recurrent hypotension was significantly lower in the MUCH patients during induction.  Conclusion: Compared to ACH, MUCH patients were at increased risk of recurrent hypertensive events during the intraoperative and emergence periods, and of recurrent bradycardia during emergence.

Objective: We examined the association between midterm examinations and anaesthetists’ non-technical skills (ANTS) knowledge using multiple choice questions (MCQs) for anaesthesia training. Materials and Methods: A prospective cross-sectional study was implemented based on two cohort studies conducted in November 2017 and November 2019 at the university hospital in southern Thailand. Each cohort consisted of MCQs, short answer questions (SAQs), objective structured clinical examinations (OSCEs), and MCQs after ANTS simulation workshops during the midterm examinations. The main exposure variable was the midterm examination (MCQs/ SAQs/ OSCEs) whereas the ANTS MCQs were the outcome. The potential predictors were the residents’ role, sex, PGY (1-3), and competency. Associations between midterm examinations and ANTS MCQ scores were analysed using Pearson’s correlation coefficients (r) and multivariate linear regression analysis, and presented as beta coefficient (β) and 95% confidence limit (CL). Results: Forty-eight anaesthesia residents were recruited for the study. After adjusting for PGY, knowledge score, and attitude evaluated by the staff, OSCE was found to be significantly associated with the pretest ANTS scores (β [95% CL]= 1.02 (0.06, 1.98)) and MCQ scores were significantly associated with the posttest ANTS scores (β [95% CL]= 0.14 (0.04, 0.24)). SAQ scores had negative associations with the pretest (β [95% CL]=-0.11 (-0.21, -0.01)) and posttest (β [95% CL]=-0.16 (-0.27, -0.05)) ANTS scores. It was found that there was a significant relationship between midterm examinations and posttest ANTS scores (r=0.52). Conclusion: Technical skills using OSCE and midterm MCQ examination scores were associated with non-technical skill knowledge in anaesthesia training.

Objective: The authors assessed whether anesthesia residents who acted as a scenario creators would have better knowledge retention than their juniors 90 days after participating in a simulation-based anesthetists’ non-technical skills (ANTS) workshop. Materials and Methods: A prospective observational study via simulation ANTS workshop was conducted at a university hospital in southern Thailand in November 2017. Seven third-year post-graduate (PGY-3) residents volunteered as scenario creators, while the remaining anesthesia residents were randomly selected to participate in or observe three case scenarios, which were cardiac arrest, hypotension, and difficult ventilation. Resident’s knowledge was assessed before, immediately after, and 90 days after the workshop using a 20-item multiple-choice questionnaire. Predictors of change in knowledge scores were analyzed using multivariate linear regression analysis and presented as beta coefficient (β) and 95% confidence limits (CL). Results: Twenty-four anesthesia residents were recruited in the present study and included eight PGY-1, seven PGY-2, and nine PGY-3. The roles consisted of seven scenario creators, seven participants, and 10 observers. The overall immediate post-test and 90-day post-test scores increased significantly compared to the pre-test scores with a mean of 15.5 and 13.2 versus 11.7 (p<0.001 and p=0.007, respectively). The predictors of change in 90-day scores were PGY-3 versus PGY-1 (β 95% CL 4.0 [0.5 to 7.6], p=0.039), and role of participants and observers versus scenario creator (β 95% CL 5.5 [2.2 to 8.8] and 6.7 [2.8 to 10.6], p=0.004, respectively). Conclusion: Anesthesia residents who were participants or observers could improve their knowledge 90 days after a simulation-based ANTS workshop without necessarily being a scenario creator. Keywords: Anesthetists’ non-technical skill; Knowledge retention; Scenario creator; Simulation workshop

Background: Emergence agitation is one of the unpleasant symptoms after general anesthesia, especially in pediatric patients. This study was designed to evaluate the correlation between emergence time and emergence agitation. The predictors associated with emergence agitation and behavioral changes in children was also determined as specific outcomes.Methods: This prospective cohort study was conducted in children undergoing anesthesia between 3 to 12 years. The preoperative unit nurse evaluated the child's baseline behaviors preoperatively. From pre to post anesthesia period, nurse anesthetist recorded anesthetic management data and clinical emergence time. Meanwhile, the investigator team recorded the Processed-EEG emergence time. At the Post-Anesthetic Care Unit (PACU), the well trained PACU nurse evaluated clinical emergence time and emergence symptoms. For the behavioral symptoms, the investigator team evaluated any changes by telephone interview at postoperative days 1, 3, and 7. Statistical significance was set at p <0.05. Results: Ninety-one pediatric patients were enrolled in the study. Preoperative baseline behaviors were not related to emergence agitation or behavioral changes. There were correlations between clinical emergence time and the incidences of emergence agitation and postoperative separation anxiety. There was no relationship found between processed-EEG emergence time and the incidence of emergence agitation. Multivariate logistic regression analysis showed the significant predictors (ASA physical status, clinical emergence time, and pain) to predict Emergence agitation. (AUC=0.92, sensitivity = 0.89, specificity 0.81). Separation anxiety was significantly higher at postoperative days 1,3 and 7 in the children with emergence agitation (p-values = 0.020, 0.020, and 0.017, respectively).Conclusion: Clinical emergence time significantly related to emergence agitation and postoperative separation anxiety.Trial registration: ClinicalTrials.gov Identifier: NCT03358069. Registered 18 January 2017 - Retrospectively registered, https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S0007IOW&selectaction=Edit&uid=U0001FGB&ts=2&cx=-7ofx36