contents xperience” - msa 2017msa.asm.org.my/files/msa2014_spab.pdf · prof boddu worked closely...

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ContentsContents

Messages

• MinisterofHealthMalaysia 2• President,MalaysianSocietyofAnaesthesiologists 3• President,CollegeofAnaesthesiologists,AMM 4• OrganisingChairperson 5

Malaysian society of anaesthesiologists – executive Committee 2013-2014 6

College of anaesthesiologists, aMM – Council 2013-2015 7

Msa / Coa asC/agM 2014 8 – Organising Committee / Scientific Committee

List of Invited speakers 9

Plenary Lecturers – Biodata 10 – 11

Citation on Msa Honorary Member 12 – 13

Programme summary 14

Pre-Congress Workshops 15 – 19

Daily Programme 20 – 25

Conference Information 26

Floor Plan & Trade exhibition 27

acknowledgements 28

abstracts 29 – 90

• Plenaries/Symposia 29–48

• MSAAward/MSA-AZYIAAward 49–55

• PosterPresentations 56–90

PL AT INUM SPONSORPL AT INUM SPONSOR

Malays ian Hea l thcare Sdn Bhd

GOLD SPONSORGOLD SPONSOR

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Message from the Minister of Health MalaysiaMessage from the Minister of Health Malaysia

A vital component of the Government’s far-sighted Vision 2020 is enhancing the capacity,

coverage and quality of the Malaysian healthcare system’s infrastructure. A well-trained,

professional and competent workforce is a key aspect of this high quality infrastructure.

Professionalism is very much associated with the continual upgrading and updating of

knowledge and skills, in keeping with the ethics of excellence that is core to the ethos of

professionalism in healthcare. Thus, the organisation of continuing professional development

activities such as congresses and meetings is one such important part of the nation’s Vision

2020.

I am therefore, delighted to welcome all of you to the 2014 Annual Scientific Congress /

Annual General Meeting of the Malaysian Society of Anaesthesiologists and the College

of Anaesthesiologists of the Academy of Medicine of Malaysia, to be held at Berjaya Times

Square Hotel and Convention Centre, Kuala Lumpur, from 3rd to 6th April 2014.

I would like to urge everyone to seize this golden opportunity to learn from each other, as

well as to exchange your knowledge and skills, in the true spirit of professionalism, with your

colleagues from both far and near, during this important meeting of the top minds in the field

of anaesthesiology.

As this is also Visit Malaysia Year 2014, I would like to invite you to spend some time to

savour the many attractions that Malaysia has to offer, including our beautiful scenery, as

well as our famous gastronomic delights.

Wishing you a fruitful meeting and a memorable stay in Malaysia.

Datuk seri Dr s subramaniam

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Message from the Minister of Health MalaysiaMessage from the Minister of Health MalaysiaMessage from the President,Message from the President,

Malaysian Society of AnaesthesiologistsMalaysian Society of Anaesthesiologists

On behalf of the Malaysian Society of Anaesthesiologists, I am delighted to welcome you

to Kuala Lumpur for the Annual Scientific Congress 2014, held in conjunction with the

51st Annual General Meeting of the Malaysian Society of Anaesthesiologists and the

19th Annual General Meeting of the College of Anaesthesiologists. The theme of the

Congress is “Bridging the Gap: Evidence Meets Experience”.

The primary reason we attend meetings is to further our education. I wish to draw your

attention to the renaming of the Annual Scientific Meeting to a ‘Congress’ in accordance to

the magnitude of the number of participants in recent times compared to its humble

beginnings, and also to acknowledge the numerous sub-specialties that have evolved

in tandem with the advancement in the field of Anaesthesiology. The Annual Scientific

Congress is the most distinguished educational meeting for the Malaysian Society of

Anaesthesiologists and the anaesthesiologists at large.

The Organising and Scientific Committee have worked hard to put forth an attractive and

comprehensive scientific programme, both broad and varied, involving eminent invited

plenary speakers, cutting-edge symposia, and interactive workshops which will arm the

delegates with new visions, knowledge and motivation for their future work, either in practice

or in the academic life.

I thank Dr Raveenthiran Rasiah, Organising Committee Chairperson, and Dr Ina Ismiarti

Shariffuddin, the Scientific Chairperson, and their teams for their combined hard work.

The Congress also gives the delegates an opportunity to network and foster fellowship.

With this in mind, an exciting social programme has been organised with an unforgettable

Gala Night!

Wishing you a fruitful Congress!

Best wishes,

Dr sushila sivasubramaniam

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Message from the President, College of Anaesthesiologists, Message from the President, College of Anaesthesiologists, Academy of Medicine of MalaysiaAcademy of Medicine of Malaysia

On behalf of the College of Anaesthesiologists, I bid you all a warm welcome to the

ASC/AGM 2014 of the MSA and College. This year, the theme is “Bridging the Gap: Evidence

Meets Experience”. I can assure you that this meeting is going to be very academically

stimulating as the scientific committee has put forth plenaries, symposia and workshops

with reputable and prominent speakers, both foreign and local. The Annual General

Meetings of both the MSA and the College are to be attended as these are the platforms to

discuss areas of achievements, issues and possible gaps in the delivery of our services to the

public. The new and revised College guidelines will be distributed to all College members at

the AGM, and I look forward to seeing you there.

The social event, the Gala Night, is a definite “crowd puller” with the theme of “Black

and White” which sounds mystifying… So, please join us for the evening as we watch the

young and budding researchers being recognised and rewarded for their hard work by

walking away with the awards to be given by the MSA and the College. Come also, to join us

in the fun and the various entertainment which have been lined up.

See you there!

Datin Dr V Sivasakthi

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On behalf of the Organising Committee, I take great pleasure in inviting all of you to the

2014 Annual Scientific Congress / Annual General Meeting of the Malaysian Society of

Anaesthesiologists and the College of Anaesthesiologists, Academy of Medicine of Malaysia,

from 3rd to 6th April 2014, at the Berjaya Times Square Hotel and Convention Centre in

Kuala Lumpur.

I wish to highlight the renaming of our event from the Annual Scientific Meeting to the

Annual Scientific Congress. The change in name reflects the growth of this annual event from

a small number of practitioners to almost four figure in recent times. “Congress” is also apt

as it encompasses the varied and additional sub-specialities that have developed over the

years.

In line with this year’s theme “Bridging the Gap: Evidence Meets Experience”, we have lined

up for you, four days of workshops, presentations, practical sessions and problem-based

learning sessions with a distinguished panel of invited speakers. We trust that you will

both discover, as well as update yourselves with new technology and techniques for your

professional development.

The theme for this year’s Gala Dinner is “Black and White”; so do come dressed for the

occasion.

Enjoy the learning, enjoy the fraternising and camaraderie, and enjoy Malaysia!

Dr Raveenthiran Rasiah

Message from the Organising ChairpersonMessage from the Organising ChairpersonMessage from the President, College of Anaesthesiologists, Message from the President, College of Anaesthesiologists, Academy of Medicine of MalaysiaAcademy of Medicine of Malaysia

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MAlAYSIAnSOCIetYOfAnAeStHeSIOlOgIStS

Executive Committee 2013-2014Executive Committee 2013-2014

President President Dr sushila sivasubramaniam

immediate Past Presidentimmediate Past President Datin Dr V sivasakthi

President-electPresident-elect Dr Raveenthiran Rasiah

chairmanchairman Prof Dr Chan Yoo Kuen

hon secretaryhon secretary Prof Dr Marzida Mansor

hon treasurer hon treasurer Datuk Dr V Kathiresan

committee memberscommittee members Dr gunalan Palari

Dr Ina Ismiarti Shariffuddin

Dato’ Dr Jahizah Hassan

Dr Kok Meng sum

Dato’ Dr subrahmanyam Balan

co-oPted committee membersco-oPted committee members Prof Dato’ Dr Wang Chew Yin

assoc Prof Dr Raha abdul Rahman

Dato’ Dr Subrahmanyam Balan

Assoc Prof Dr Raha Abdul Rahman

Prof Dato’ Dr Wang Chew Yin



Dr Kok Meng Sum

Dato’ Dr Jahizah Hassan

Dr Gunalan Palari

Prof Dr Marzida Mansor

Prof Dr Chan Yoo Kuen

Dr Sushila Sivasubramaniam


Datuk Dr V Kathiresan

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PresidentPresident Datin Dr V sivasakthi

Vice PresidentVice President Dr Tan Cheng Cheng

hon secretaryhon secretary assoc Prof Dr Raha abdul Rahman

hon treasurerhon treasurer Prof Dato’ Dr Wang Chew Yin

council memberscouncil members Dr Lim Wee Leong

Dr Mohd Rohisham Zainal abidin

Dr streram sinnasamy

Dr Thohiroh abdul Razak

co-oPted council membersco-oPted council members Prof Dr Lim Thiam aun

Dr sushila sivasubramaniam

COllegeOfAnAeStHeSIOlOgIStS,AMM Council 2013–2015Council 2013–2015

Prof Dato’ Dr Wang Chew Yin

Dr Thohiroh Abdul Razak

Dr Mohd Rohisham Zainal Abidin

Dr Tan Cheng Cheng

Assoc Prof Dr Raha Abdul Rahman

Dr Sushila Sivasubramaniam


Dr Lim Wee Leong

Prof Dr Lim Thiam Aun

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chairPersonchairPerson


hon secretaryhon secretary


hon treasurerhon treasurer


socialsocial

Dr Vineya Rai Hakumat Rai

Publications/PublicityPublications/Publicity

Dr Kok Meng sum

audio Visualaudio Visual

Dr Jeyaganesh s Veerakumaran

MSA/COllegeOfAnAeStHeSIOlOgIStSASC/AgM2014

Organising CommitteeOrganising Committee


Dr Vineya Rai Hakumat Rai


Dr Kok Meng Sum


Dr Jeyaganesh S Veerakumaran

chairPersonchairPerson


committee memberscommittee members

Dr Mafeitzeral Mamat

Dr Mohd Rohisham Zainal abidin

Dr Muhammad Maaya

Dr Vanitha sivanaser

Scientific CommitteeScientific Committee

Dr Mafeitzeral Mamat


Dr Muhammad MaayaDr Mohd Rohisham Zainal Abidin

Dr Vanitha Sivanaser

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Invited SpeakersInvited Speakers

australiaaustralia

Chris acott

Krishna Boddu

Neville gibbs

Nolan McDonnell

belgiumbelgium

Hugo Vereecke

germanygermany

stefan Roehrig

indiaindia

anju grewal

PhiliPPinesPhiliPPines

Florian R Nuevo

singaPoresingaPore

Tan Leng Zoo

usausa

Nicole shilkofski

malaysiamalaysia

adi Osman

ahmad shaltut Othman

amiruddin Nik Mohamed Kamil

ariffin Marzuki Mokhtar

azlina Masdar

azrin Mohd azidin

Dhinesh Bhaskaran

Kavita Bhojwani

Chan Yoo Kuen

Darryl goon

Hamidah Ismail

Hasmizy Muhammad

Lee Choon Yee

Lim Wee Leong

Mafeitzeral Mamat

Marzida Mansor

Mohammad Fadhly Yahya

Mohd Basri Mat Nor

Muhammad Maaya

Nor aizi Md Zain

Nor’azim Mohd Yunos

Raha abdul Rahman

Vinodh suppiah

Ramani Vijayan

Wan Mohd Nazaruddin Wan Hassan

Yong Chow Yen

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Plenary Lecturers - BiodataPlenary Lecturers - Biodata

Krishna Boddu

Prof Krishna Boddu, is currently working as Executive Co-Director, Royal Perth Hospital; Director of Regional Anaesthesia and consultant anaesthetists in the Department of Anaesthesia & Pain Medicine at Royal Perth Hospital, Perth, Australia. He is also Professor of Anaesthesiology at University of Texas Health Sciences at Houston, Texas & University of Western Australia, Perth.

Professor Boddu is very passionate about pain management which is an essential component of anaesthesia practice.

Prof Boddu worked closely with Dr. David L Brown at MD Anderson Cancer Centre and established regional anaesthesia service and enhanced acute pain service which received national and

international recognition. Prof Boddu introduced acute pain service with a goal to improve functionality at University of Texas Health Sciences at Houston. He conducted over 20 hands-on ultrasound guided regional anaesthesia workshops in the USA, Australia, Nepal, Columbia, Sri Lanka, Ethiopia and other countries. Keeping adult learners in mind, he developed unique multiscreen multimedia teaching method which is very well received with great reviews which can be seen by visiting www.nerveblocks.org.

As he believes that nurses play a big role in providing safe and quality pain management, he introduced ‘Path for Pain Championship’ program and trained over 100 nurses to provide Acute Pain Nurse Expertise at Point of Care.

His passion for teaching is evident by the various awards he received including Golden Apple Seed award for Excellence in Teaching at University of Washington, Seattle.

In addition to publishing original articles in the field of regional anaesthesia and acute pain, he is also on the editorial board for various journals in the field of his passion.

Chan Yoo Kuen

Yoo Kuen Chan practices anaesthesia and analgesia in the Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia. Her main mission is to improve care for all from perioperative care to non-surgical admissions into the hospital.

In order to achieve this, she has spent the last 27 years focusing providers on what needs to be done through her teaching, speaking commitments and her publications on the subject. She is in the editorial committee of several journals, has edited four books both in anaesthesia and acute care, published numerous national and international chapters in several anaesthesia books and articles in refereed journals.

She is the current Chairman of the Malaysian Society of Anaesthesiologists and also sits in the Education Committee of the World Federation of Societies of Anaesthesiologists where she is a strong advocate for uplifting the level of education in medical care.

In addition she also pushes very hard to ensure that our vulnerable earth is sustained. She lectures on vermiculture (which is how to rear earthworms to recycle garden and vegetable waste) and has also influenced her son to take up civil and environmental engineering.

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Plenary Lecturers - BiodataPlenary Lecturers - Biodata[cont’d]

Neville Gibbs

Dr Neville Gibbs is a specialist anaesthetist in the Department of Anaesthesia at the Sir Charles Gairdner Hospital in Nedlands, Western Australia, and a Clinical Professor in the School of Medicine and Pharmacology of the University of Western Australia. His clinical and research interests relate mainly to cardiac anaesthesia, perioperative coagulation and patient safety. He was an editor or co-editor of the past three triennial ‘Safety of Anaesthesia in Australia’ national anaesthesia mortality reports. He is currently a member of the Quality and Safety Committee of the Australian and New Zealand College of Anaesthetists, and Chair of the Australian and New Zealand Tripartite Anaesthesia Data Committee. He is also the current Chief Editor of ‘Anaesthesia and Intensive Care’.

Nicole Shilkofski

Dr Nicole Shilkofski is an Associate Professor and the Deputy Dean for Education at Perdana University Graduate School of Medicine in collaboration with Johns Hopkins School of Medicine in Serdang, Malaysia. Before coming to Kuala Lumpur to serve in this role in 2011, she practiced Paediatric Intensive Care in the 40 bed PICU at Johns Hopkins Hospital (Baltimore, Maryland, USA), where she also ran the combined fellowship training program in Paediatric Intensive Care and Paediatric Anesthesiology. She was the Associate Director of the Johns Hopkins Medicine Simulation Center for four years, where she conducted research on outcomes in simulation-based medical education for medical students and postgraduate trainees, particularly within the field of paediatric resuscitation and outcomes in CPR training. She attended medical school at Tulane University in New Orleans, USA and did her residency and fellowship training in paediatrics,

paediatric anesthesiology and paediatric critical care at Johns Hopkins.

Nolan McDonnell

Clinical Associate Professor Nolan McDonnell is a Staff Specialist in the Department of Anaesthesia and Pain Medicine, King Edward Memorial Hospital for Women in Perth, Western Australia. He holds an adjunct title with the School of Women’s and Infants’ Health and the School of Medicine and Pharmacoloy, University of Western Australia. He works extensively in both public and private settings with a focus on obstetric anaesthesia as well as complex gynae-oncology surgery. In addition to being a Fellow of the Australian and New Zealand College of Anaesthetists, he also holds a Master of Clinical Research and is currently working towards a PhD. His main research interests are focused on maternity care and obstetric anaesthesia. He is widely published, particularly in the areas of post caesarean analgesia and the management of unwell obstetric patients and is the lead investigator for the Australian and New Zealand Amniotic Fluid Embolism registry,

run through the Australasian Maternity Outcomes Surveillance System. He is heavily involved in teaching, particularly at a post graduate level and is also an instructor on a number of obstetric emergency courses.

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Amandedicatedtohisfamily.

Amandedicatedtohisprofession.

Amandedicatedtohishospital.

thesesentencescharacterisethecharacterofthisman.

Iconsideritmyprivilegeandpleasuretogivethecitationforsuchaman.

DrAnavangotDamodaranwasborninSungkai,Perak,toDrandMrsKPKrishnankutty.

DrKrishnankuttywaspractisingattheSungkaIestategroupHospital,Perak.

He had his early school education at the Anderson School in Ipoh, Perak, before continuing his

education in India. He graduated in Medicine from the Madras Medical College in 1961. After

graduation, he came back to Malaysia and served as houseman andmedical officer in various

hospitals in Perak before being posted to the Department of Anaesthesia at general Hospital

Kualalumpur,wherehebecameaRegistrarin1965.

In1965,hewasawardedascholarshiptopursuehispost-graduatestudiesinAnaesthesiologyinthe

UnitedKingdom.Hesuccessfullycompletedhispost-graduatecourseandobtainedthefollowing:

1. DiplomainAnaesthesia,inJanuary1968

2. fellowofthefacultyofAnaesthetistsoftheRoyalCollegeofSurgeonsinIreland,in1968

3. fellowofthefacultyofAnaesthetistsoftheRoyalCollegeofSurgeonsofengland,in1969

HealsobecameafellowofthefacultyofAnaesthetistsoftheRoyalAustralasianCollegeofSurgeons,

in1975.

In1992,hewasawardedthefellowshipoftheAustralianandnewZealandCollegeofAnaesthetists.

HewasaConsultantAnaesthetistatgeneralHospitalKualalumpur, in1969.from1970to1978,he

wastheConsultantAnaesthetistatgeneralHospital,AlorStar,Kedah.from1973to1975concurrently,

hewastheMedicalSuperintendentofthegeneralHospital,AlorStar,Kedah,thefirstAnaesthetisttobe

appointedtosuchapost.

HethenjoinedtheAssuntaHospitalinPetalingJaya,asConsultantAnaesthetistin1978,andstayed

theretill1986.In1986,hejoinedPantaiHospital,Kualalumpur,andhasbeentheresincethen.Hewas

alsotheChiefofMedicalStaffatPantaiHospital,Kualalumpur,from2003to2005.

MSA HONORARy MeMBeR

Dato’ Dr A DamodaranDato’ Dr A Damodaran BCKPJKDIMP

Citationbydato’ dr sylVian das

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Inthecourseofhisillustriouscareer,DrDamodaranhaspublishedandpresentedanumberofpapersin

variousjournalsandsymposiaandhasparticipatedinvariousinternationalandregionalconferences.

Amongthehighlightsinhiscareeristhefactthat,heestablishedthefirstintensivecareunitatgeneral

Hospital, Alor Star, Kedah, in 1974, which gained fame for the treatment of snake bites, obstetric

emergenciesandtetanus.HealsoestablishedthefirstPaediatricandneonatalIntensiveCareUnitin

aprivatehospitalnamely,AssuntaHospitalinPetalingJaya,in1982.

DrDamoashe ispopularlyknown,was instrumental indevelopingthe IntensiveCareUnit inPantai

HospitalKualalumpur,inadditiontopromotingtheneonatalICU.

HewastheAnaesthetistforthefirstCardiacsurgerytoperforminPantaiHospital,Kualalumpur.

fortheservicesthathehasrendered,hewasawardedthefollowingawards;

a)BCKfromtheStateofKedah

b)PJKfromtheStateofPerlis

c)DIMPwhichcarriesthetitleDato’fromtheSultanofPahang,in2006

HebecamethePresidentoftheMalaysianSocietyofAnaesthesiologistsin1979,andwastheChairman

oftheSocietyfrom1990to1993.Oneofhisoutstandingcontributionstotheprofessionisthefactthat,

heco-authoredthebook“HistoryofAnaesthesiainMalaysia”togetherwithDrAlexgurubatham,which

waslaunchedinJune2013.

DrDamodaranisaveryhomelypersonandhiswholelifecenteredaroundhishospitalandhishome.

Hehasbeenfortunatetohavehadaverylovingandunderstandingwifeandtwodaughterswhohave

beenverysupportiveofhiminhisworkandbusyschedules.

Heisamanwithakindheartandhasauniquesenseofhumour.

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DatetiMe

4th april 2014FriDaY

5th april 2014SaturDaY

6th april 2014SuNDaY

0730 – 0830 registration Meet-the-professor Session Meet-the-professor Session

0830 – 0915 plenary 1 plenary 3 plenary 4

0915 – 1000 plenary 2 Opening Ceremony plenary 5

1000 – 1030 tea / trade exhibition

1030 – 1200Symposium

1Symposium

2Symposium

5Symposium

6Symposium

11Symposium

12Symposium

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1200 – 1400Lunch satellite symposium

[Janssen]

Friday prayers

Lunch satellite symposium[Merck sharp & dohme]

Lunch

1400 – 1530 Symposium 3

Symposium 4

Concurrent Workshop

1

Symposium 7

Symposium 8

Concurrent Workshop

3


1600 – 1730MSa

aWarD / MSa-aZ Yia

poster rounds

Concurrent Workshop

2

Symposium 9

Symposium 10

Concurrent Workshop

4

1730 – 1900 MSA Annual General Meeting

College of Anaesthesiologists Annual General Meeting

1930 Faculty Dinner(by invitation only)

Gala Night

Pre-Congress WorKsHoPs3rD april 2014, thurSDaY (0830 – 1700 hrs)

1. Obstetric anaesthesia Crisis simulation2. Research for the Novice3. Difficult Paediatric Airway: No More Fears!

4. Ultrasound Life support Workshop5. Deep Block with Neuromuscular Blocking agents

Programme SummaryProgramme Summary

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Programme SummaryProgramme Summary

1. obstetric Anaesthesia Crisis simulation

Venue: bronx 4, berjaya times square hotel & conVention centre, Kuala lumPur

Organised by Special Interest Group (SIG) Obstetric and SIG Simulation, College of Anaesthesiologists and Malaysian Society of Anaesthesiologists

fACUltY:fACUltY:

Mohd Rohisham Zainal abidin (Chairperson)Thohiroh abdul RazakRajeswary Kanapathipillai Rafidah AtanNor’azim Mohd Yunos

Nora azura DintanNoorulhana sukarnakadi HadzaramiMohd azizan ghazaliMohamad Nor Mohd Ithnin

The objective of this workshop is to highlight key issues required to optimise learning within a synthetic environment. In this workshop, participants will be taught how to manage obstetric anaesthesia crisis in the perioperative setting. There will be hands-on training and practice in managing various obstetric emergency scenarios using simulated patients. This session will be conducted by a team of experts in their respective fields, who have had extensive experience in running the simulation programme.

COURSePROgRAMMeCOURSePROgRAMMe

0800–0830 Registration

0830–0845 WelcomeMessage

0845–0900 ObstetricCrisis:AnOverviewMohdRohishamZainalAbidinMohdRohishamZainalAbidin

0900–0945 HumanPerfomanceIssuesanderrorsinAnaesthesiaRajeswaryKanapathipillaiRajeswaryKanapathipillai

0945–1000 Briefing/Ice-breakingSessionRajeswaryKanapathipillaiRajeswaryKanapathipillai

1000–1030 Tea

1030–1130 Hands-onSimulationPart1(group1,2,3)

1145–1245 Hands-onSimulationPart2(group2,1,3)

1245–1400 Lunch

1400–1500 Hands-onSimulationPart3(group3,1,2)1500–1600 DebriefingandQ&A

end of session

Pre-Congress WorkshopPre-Congress Workshop

3RDAPRIl2014,tHURSDAY

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2. research for the Novice: Doing a research project? What You Need to Know

Venue: bronx 3, berjaya times square hotel & conVention centre, Kuala lumPur

Research and publications are an integral part of the medical profession. The practice of medicine, job opportunities and promotions are dominated by the strength of research. Evidence-based practices and publications are the pulse of our current age of medical practice.

Are you the one who will shy away from research? Does research and related topics daunt you? Are you worried to start because starting is a maze? Here are many reasons why this workshop should interest you...

This workshop prides itself as a stepping stone in building confidence and interest while navigating the researcher in you. The sessions are tailored to cover a broad and wide range of topics that one may find daunting as a novice researcher.

The course will involve interactive lectures followed by a series of questions after each topic. This is to test the candidate’s ability to comprehend what has been taught. It will end with a single best answer test. While the primary aim of the course is to equip the participants with the tools necessary before embarking on a research study, it will be invaluable for those attempting the Part 1 Masters in Anaesthesiology.

Registration

0900–0905 WelcomingSpeech

0905–1000 OverviewofaStudyDesign• ImportanceofKnowingYour

exposureandOutcomeofInterest• Precision/Clarityinthenatureof

exposure

• OutcomeofInterest• CoefficientofVariation

1000–1030 Tea1030–1230 • Hypothesistesting

• PValue• 95%ConfidenceIntervel

• theInterventionalStudy• StudyDesigns• estimatingSampleSizes• MethodstoRandomisePatients

• BasisofAnalysisinanInterventionalStudy

• Intentiontotreat• numberneededtotreat

1230–1330 Lunch1330–1600 theCaseControlStudy

• ItsDesigns• Advantages&Disadvantages• PitfallstoAvoid&Bias

• ImportanceofIdentifyingConfounders• BasisofAnalysis:OddsRatio&95%

ConfidenceIntervels• evaluatingaDiagnostictest/

newClinicaltool• Sensitivity&Specificity

• Positive&negativePredictiveValue• ReceiverOperatorCurves• BlandAltmanPlot

1600–1630 Closing & Tea

After attending this workshop, the participants will be able to:• Applybasicclinicalresearchmethodologyandclinicalappraisalintotheircurrentpractices• Discusstheprocesstostartingaviableandproductiveresearchcareer

fACIlItAtORfACIlItAtOR

Kulenthran arumugam

COORDInAtORSCOORDInAtORS

Vanitha sivanaserZarina abu Kasim


3RDAPRIl2014,tHURSDAY[cont’d]

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3. Difficult Paediatric Airway: no More Fears!

Venue: clinical sKills lab, Faculty oF medicine uitm, sungai buloh, selangor

The Paediatric Difficult Airway Workshop is for trainees and consultants who anaesthetise children and wish to refresh and update skills in managing children with a difficult airway. In this one-day course, we aim to discuss the management of the anticipated and unanticipated paediatric difficult airway.

The format of the day is a combination of short interactive lectures, hands-on small group workshops with different airway adjuncts and management of airway emergencies in simulated airway & crisis scenarios. Participants will work in groups to strategise an optimal approach to securing the airway and manage any complication that might arise. Delegate numbers are limited to 25 places to allow maximum opportunity to interact with the faculty.

fACIlItAtORS:fACIlItAtORS:

Chris acottLucy ChanHamidah IsmailIna Ismiarti Shariffuddin

Izzat IsmailMafeitzeral MamatVinodh suppiahTan Leng Zoo

PROgRAMMePROgRAMMe

0830–0900 Registration

0900–0905 WelcomingSpeech

0905–0935 RecognitionofDifficultAirwayinChildrenlucyChanlucyChan

0935–1000 DifficultAirwayguidelinesinChildrenInaIsmiartiShariffuddinInaIsmiartiShariffuddin

1000–1030 Tea

1030–1100 IntubationinChildrenwithMaxillofacialfracturesChrisAcottChrisAcott1100–1230 DiscussionofCaseScenarios

VinodhSuppiah,tanlengZoo,HamidahIsmailVinodhSuppiah,tanlengZoo,HamidahIsmail1230–1345 Lunch1345–1615 SkillStations(4-5 persons / station, 25 mins each station)

1. fibreopticIntubationUsingaflexiblefiberscope:Oral,nasal,vialMA2. BonfilsIntubationfibrescope/Bambrink3. emergencyCricothyrodotomyandJetVentilation4. Videolaryngoscopy5. SupraglotticAirwayDevices6. SimulationinPaediatricAirway

1615–1635 Q&A

1635–1700 Closing & Tea



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4. ultrasound life Support Workshop

Venue: bronx 8, berjaya times square hotel & conVention centre, Kuala lumPurur

IntRODUCtIOnIntRODUCtIOn

The Ultrasound Life Support workshop deals mainly with protocols and approaches of ultrasound examination in unstable patients. The emphasis is application of ultrasound-assisted clinical examination in the era of perioperative ultrasound.

This compact one-day workshop is structured with lectures, hands-on and interactive sessions. It will provide an overview of relevant head and neck, airway, lung and cardiac sonography in normal and pathological states, as well as hands-on training session on models. A set of focused ultrasound protocols will be discussed, including ACES & RUSH, FEEL and FATE.

The trainers are clinicians trained in perioperative and critical ultrasound, and themselves affiliated to WINFOCUS International.

InStRUCtORSInStRUCtORS

Ahmad Afifi Mohd Arshad (Anaesthesiologist) Coordinator

adi Osman (Emergency Critical Care Physician)

shaik Farid abdull Wahab (Emergency Physician)

saiful safuan Mohd sani (Acute Care Physician)

Lim Teng Cheow (Anaesthesiologist)

PROgRAMMePROgRAMMe

Registration

0830–0840 WelcomingAddressAhmadAfifiMohdArshad/AdiOsmanAhmadAfifiMohdArshad/AdiOsman

0840–0900 PhysicsofUltrasonographyShaikfaridAbdullWahabShaikfaridAbdullWahab

0900–0920 Airway&PrandialScanAhmadAfifiMohdArshadAhmadAfifiMohdArshad

0920–0950 BasiclungScanlimtengCheowlimtengCheow0950–1050 Station1A/B:Airway

Station2A/B:lung1050–1110 Tea

1110–1150 Basicfocusedtransthoracicechocardiography/fAteSaifulSafuanMohdSaniSaifulSafuanMohdSani

1150–1220 UltrasoundforfluidtherapyAdiOsmanAdiOsman

1220–1250 SHOCKProtocols;ACeS/RUSH/feelShaikfaridAbdullWahabShaikfaridAbdullWahab

1250–1410 Lunch1410–1540 PRACtICAlStAtIOnS

Station3A/B:tte–PlAX/SAXStation4A/B:IVC/DVtStation5:PathologicalScan(Allfaculties)

1540–1600 Questions&Discussion

1600–1700 Tea & Closing Remarks





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5. Deep Block with Neuromuscular Blocking agents (Hosted by Hospital Kuala Lumpur, in collaboration with Merck sharp & Dohme) (Hosted by Hospital Kuala Lumpur, in collaboration with Merck sharp & Dohme)

Venue: dePartment oF anaesthesiology and intensiVe care, 3rd Floor cme room, hosPital Kuala lumPur, Kuala lumPur

InVIteDfACUltY:InVIteDfACUltY:Nolan McDonnell

SYnOPSISSYnOPSIS

This workshop, featuring Associate Professor Dr Nolan McDonnell, from King Edward Memorial Hospital for Women, Perth, Western Australia, focuses on the concept of deep neuromuscular blockade to facilitate optimal surgical conditions. This is designed to network the anaesthesiologists with the surgeons, fostering a strong partnership to enhance surgical experience besides serving as a forum to share perpectives and experience. There will also be live demonstrations on the application of this concept in the operating theatre to enable coupling of deep neuromuscular blockade with fast, predictable and complete reversal.

PROgRAMMePROgRAMMe

0830–0840 OpeningRemarksandIntroductionofWorkshopObjectivesbyDatinDrVSivasakthi

0840–0910 HasDeepneuromuscularBlockadeaPlaceinModernAnaesthesia?nolanMcDonnellnolanMcDonnell0910–0940 DeepneuromuscularParalysis–AnOrthopaedicSurgeon’sPerspective

ManmohanSinghSarjitSinghManmohanSinghSarjitSingh0940–1000 Tea

1000–1230 CaseObservation(Orthopaedic)

1230–1330 Lunch

1330–1600 CaseObservation(laparoscopies)

1600–1630 PostoperativeResidualCurarisation:ProblemsandStrategiesnolanMcDonnellnolanMcDonnell1630–1700 BenefitsofDeepneuromuscularParalysisinlaparoscopicSurgeries–

ASurgeon’sPerspectivetikfugeetikfugee1700–1730 groupDiscussionandSummarynolanMcDonnellnolanMcDonnell

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20Daily ProgrammeDaily Programme

4tHAPRIl2014,fRIDAY

0730 – 0830 ReGiStRAt iON

0830 – 0915 PLeNARy 1 PLeNARy 1 Manhattan I IChairperson: Chan Yoo Kuen

evidence-Based Practice in anaesthesia [page 29]

Neville GibbsNeville Gibbs

0915 – 1000 PLeNARy 2 PLeNARy 2 Manhattan I IChairperson: Ramani Vijayan

a Myth or a Reality? Day surgery Craniotomy and Its ChallengesKrishna BodduKrishna Boddu


1030 – 1200 SyMPOSIUM 1 SyMPOSIUM 1 Manhattan I I

Ambulatory AnaesthesiaChairpersons: Norsidah Abdul Manap / Kok Meng Sum

1. The Pain-Free Daycare Patient [page 30]

Kavita Bhojwani Kavita Bhojwani2. TIVa for Daycare anaesthesia [page 31]

Hugo Vereecke Hugo Vereecke3. Quality Recovery in Daycare surgeries [page 32]

Stefan Roehrig Stefan Roehrig

1030 – 1200 SyMPOSIUM 2 SyMPOSIUM 2 Manhattan I

High-Risk AnaesthesiaChairpersons: V Kathiresan / Lucy Chan

1. anaesthesia for the Obese Patient [page 32]

Anju Grewal Anju Grewal2. Perioperative Cardiac Risk Stratification Florian R Nuevo Florian R Nuevo3. The substance-abusing Patient – anaesthesia and analgesia [page 33]

Ramani Vijayan Ramani Vijayan

1200 – 1400 Lunch satellite symposium Manhattan I I [Janssen (pharmaceutical companies of Johnson & Johnson)]

Chairperson: Mary Cardosa

Redefining PainHenry LuHenry Lu

Friday prayers


Regional AnaesthesiaChairpersons: Kavita Bhojwani / Lim Teng Cheow

1. Nerve Injury: Transient or Permanent? The Evidence So Far [page 34]

Amiruddin Nik Mohamed Kamil Amiruddin Nik Mohamed Kamil2. Regional anaesthesia in the anticoagulated [page 34]

Mafeitzeral Mamat Mafeitzeral Mamat3. USRA: Reducing the Steepness of the Curve [page 35]

Krishna Boddu Krishna Boddu

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4tHAPRIl2014,fRIDAY

Daily ProgrammeDaily Programme

4tHAPRIl2014,fRIDAY[cont’d]


Safety and Quality AssuranceChairpersons: Subrahmanyam Balan / Gunalan Palari

1. safety and Quality Indicators in anaesthesia [page 35]

Neville Gibbs Neville Gibbs2. Anaesthesia Safety: Model or Myth? Florian R Nuevo Florian R Nuevo3. Joint Commission International Accreditation: IJN’s Experience [page 36]

Ariffin Marzuki Mokhtar Ariffin Marzuki Mokhtar

1400 – 1530 CONCURReNT WORkSHOP 1 CONCURReNT WORkSHOP 1 Bronx 5 & 6

Effective PresentationChan Yoo Kuen / Lim Wee LeongChan Yoo Kuen / Lim Wee Leong


1600 – 1730 MSA AWARD / MSA-A StRAZeNeCA Y iA Manhattan I I

[page 49-55]

Chairperson: Lim Thiam Aun

1600 – 1730 POSteR ROuNDS [page 56-90] Foyer Bus Iness CentreModerator: Mafeitzeral Mamat


AirwayChris Acott / tan Leng Zoo / Muhammad MaayaChris Acott / tan Leng Zoo / Muhammad Maaya

1730 – 1900 MSA ANNuAL GeNeRAL Meet iNG Manhattan I

1930 FACuLtY D iNNeR (by invitation only)

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5tHAPRIl2014,SAtURDAY

0730 – 0830 MeeT-THe-PROfeSSOR SeSSION MeeT-THe-PROfeSSOR SeSSION Bronx 5

Tips and Tricks of Passing Part I MMed (Anaes)Chan Yoo Kuen / Raha Abdul RahmanChan Yoo Kuen / Raha Abdul RahmanChairperson: Ina Ismiarti Shariffuddin

0830 – 0915 PLeNARy 3 PLeNARy 3 Manhattan I IChairperson: V Sivasakthi

Training and Education in Anaesthesiology: What is the Future? [page 36]

Nicole ShilkofskiNicole Shilkofski

0915 – 1000 OPeNiNG CeReMONY Manhattan I I

0900 ArrivalofDatukSeriDrSSubramaniam,MinisterofHealthMalaysia

0905 WelcomebyDrRaveenthiranRasiah,OrganisingChairperson

0910 SpeechbyDrSushilaSivasubramaniam,President,MalaysianSocietyofAnaesthesiologists

0915 SpeechbyDatinDrVSivasakthi,President,CollegeofAnaesthesiologists,AMM

0920 SpeechbyDatukSeriDrSSubramaniamtobefollowedbyOfficialOpeningoftheCongress

MontageonAnaesthesia

ConfermentofHonoraryMembershiponDato’DrADamodaran



AirwayChairpersons: Muhammad Maaya / Nadia Md Nor

1. Videolaryngoscopy: a Paradigm shift in Daily Routine airway Management [page 37]

Chris Acott Chris Acott2. Cricothyrodotomy Puncture: The Airway Crisis [page 37]

Mohd Basri Mat Nor Mohd Basri Mat Nor3. supraglottic airways in eNT surgeries [page 38]

tan Leng Zoo tan Leng Zoo


Critical CareChairpersons: Vineya Rai Hakumat Rai / Khoo Teik Hooi

1. Criteria for elective ICU admission Following surgery Raha Abdul Rahman Raha Abdul Rahman2. Revisiting acid Base in the Critically Ill Nor’azim Mohd Yunos Nor’azim Mohd Yunos3. Updates on the guidelines for the Management of Pain, agitation & Delirium in Intensive Care [page 38]

Ahmad Shaltut Othman Ahmad Shaltut Othman

1200 – 1400 Lunch satellite symposium [Merck sharp & dohme (Malaysia)] Manhattan I IChairperson: Marzida Mansor

Review strategies in Providing Muscle Relaxation and Managing Deep Neuromuscular BlockadeNolan McDonnellNolan McDonnell

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5tHAPRIl2014,SAtURDAY


5tHAPRIl2014,SAtURDAY[cont’d]


Paediatric AnaesthesiaChairpersons: Thavaranjitham Sandrasegaram / Rajeswary Kanapathipillai

1. Cardiac Output and Haemodynamic Monitoring in the Critically Ill Child [page 39]

Nicole Shilkofski Nicole Shilkofski2. Fluid Management Revisited – Impact of the starch Controversy [page 39]

Hamidah ismail Hamidah ismail3. anaesthesia for Bronchoscopy in Children [page 40]

Vinodh Suppiah Vinodh Suppiah


NeuroanaesthesiaChairpersons: Vanitha Sivanaser / Mohd Fahmi Lukman

1. It’s Just Another Case: Anaesthesia Concerns in Spine Surgery [page 40]

Lim Wee Leong Lim Wee Leong2. awake Craniotomy and Choices of anaesthetics available [page 41]

Wan Mohd Nazaruddin Wan Hassan Wan Mohd Nazaruddin Wan Hassan3. Does it Matter? TIVa vs Inhalational anaesthesia In Neurosurgery Krishna Boddu Krishna Boddu


Ultrasound for Central Neuraxial & Paravertebral RegionAmiruddin Nik Mohamed Kamil / Azrin Mohd Azidin /Amiruddin Nik Mohamed Kamil / Azrin Mohd Azidin / Mafeitzeral Mamat / Lim teng Cheow / Ahmad Afifi Mohd ArshadMafeitzeral Mamat / Lim teng Cheow / Ahmad Afifi Mohd Arshad


1600 – 1730 SyMPOSIUM 9 SyMPOSIUM 9 Bronx 5 & 6

MedicolegalChairpersons: Raveenthiran Rasiah / Gunalan Palari

1. Recent Developments Darryl Goon Darryl Goon2. Consent: The Eternal Dilemma Dhinesh Bhaskaran Dhinesh Bhaskaran


TraumaChairpersons: Ahmad Shaltut Othman / Rafidah Atan

1. Role of echocardiography and Lung Ultrasound in the Critically Ill Patient [page 41]

Adi Osman Adi Osman2. Managing anaesthesia in Trauma Patients [page 42]

Stefan Roehrig Stefan Roehrig3. Updates and extended Use of Ultrasound in Trauma [page 42]

Mohammad Fadhly Yahya Mohammad Fadhly Yahya

1600 – 1730 CONCURReNT WORkSHOP 4 CONCURReNT WORkSHOP 4 Bronx 8

Monitored Anaesthesia CareHugo Vereecke / Muhammad MaayaHugo Vereecke / Muhammad Maaya

1730 – 1900 COLLeGe OF ANAeStHeS iOLOGiStS Bronx 5 & 6 ANNuAL GeNeRAL Meet iNG

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1930 – 2230 GALA N iGHt Manhattan I I

1900 – 1945 arrival of guests and Delegates

1945 – 2015 Introduction by emcee

Dinner is served

2015 – 2030 entertainer – adibah Noor

2030 – 2100 Welcome Remarks by Dr Raveenthiran Rasiah, Organising Chairperson, asC 2014

Presentations • MSA Award and MSA-AZ YIA Awards by Dr sushila sivasubramaniam, President, Msa

• Best Poster Awards by Datin Dr V sivasakthi, President, Coa

Lucky Draw

2100 – 2130 Comedian – Dr Jason Leong

2130 – 2145 entertainer – adibah Noor

games (scavenger Hunt)

2145 – 2215 Lucky Draw

Best Dressed awards

2215 – 2230 Dance the Night away

INVITeD ARTISTeSINVITeD ARTISTeS

Jasonleong(Comedian)

Adibahnoor(entertainer)

LUCky DRAWLUCky DRAWVery attractive prizes!

BeST DReSSeD AWARDBeST DReSSeD AWARD

dresscolourcode:black&white

dresscode:smartcasual

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6tHAPRIl2014,SUnDAY

0730 – 0830 MeeT-THe-PROfeSSOR SeSSION MeeT-THe-PROfeSSOR SeSSION Bronx 5

Tips and Tricks of Passing Part II MMed (Anaes)Lee Choon Yee / Marzida MansorLee Choon Yee / Marzida MansorChairperson: Vanitha Sivanaser

0830 – 0915 PLeNARy 4 PLeNARy 4 Manhattan I IChairperson: Marzida Mansor

anaesthesia and the environment [page 43]

Chan Yoo KuenChan Yoo Kuen

0915 – 1000 PLeNARy 5 PLeNARy 5 Manhattan I IChairperson: Mohd Rohisham Zainal Abidin

Obstetric Resuscitation: What’s New? [page 43]

Nolan McDonnell Nolan McDonnell



Obstetric AnaesthesiaChairpersons: Thohiroh Abdul Razak / Nora Azura Dintan

1. Consent for Labour [page 44]

Anju Grewal Anju Grewal2. Intrathecal Catheter Insertion Following accidental Dural Puncture [page 44]

Lee Choon Yee Lee Choon Yee3. Induction of Anaesthesia for LSCS: Still Thiopentone, Suxamethonium and No Opioids? [page 45]

Azlina Masdar Azlina Masdar


Cardiac AnaesthesiaChairpersons: Jahizah Hassan / Loh Pui San

1. Perioperative Transoesophageal Echocardiography: Advantages and Limitations [page 45]

Neville Gibbs Neville Gibbs2. Haemodynamic Monitoring: Road Towards Non Invasive! [page 46]

Hasmizy Muhammad Hasmizy Muhammad3. Implantable Cardioverter Defibrillator – Key Anaesthesia Issues [page 46]

Yong Chow Yen Yong Chow Yen

1030 – 1200 SyMPOSIUM 13 SyMPOSIUM 13 Bronx 5 & 6

Allied HealthChairpersons: Vanitha Sivanaser / Noorulhana Sukarnakadi Hadzarami

1. Difficult Airway… What To Do? [page 47]

Mafeitzeral Mamat Mafeitzeral Mamat2. Transportation of the Critically Ill Patient (from OT to ICU) [page 47]

Nor Aizi Md Zain Nor Aizi Md Zain3. Drugs in Anaesthesia: Updates [page 48]

Azrin Mohd Azidin Azrin Mohd Azidin

1200 – 1400 Lunch B Ig apple restaurant, Berjaya t IMes square hotel and Convent Ion Centre

CONGReSS VeNueCONGReSS VeNueBerjaya times Square hotel and Convention CentreNo 1 Jalan Imbi, 55100 Kuala Lumpur, Malaysia Tel: (603) 2117 8258

ReGiStRAtiONReGiStRAtiONThe registration hours are:

3th april 2014 (Thursday) 1600 to 1900 hrs

4th april 2014 (Friday) 0730 to 1800 hrs

5th april 2014 (saturday) 0730 to 1800 hrs

6th april 2014 (sunday) 0730 to 1300 hrs

iDeNtitY BADGeSiDeNtitY BADGeSDelegates are kindly requested to wear identity badges during all sessions and functions.

eNtitLeMeNtSeNtitLeMeNtSRegistered delegates will be entitled to the following:

• Admission to the scientific sessions, satellite symposia and trade exhibition

• Conference bag and materials

• Gala Dinner

• Lunches & Coffee/Tea

SPeAKeRS AND PReSeNteRSSPeAKeRS AND PReSeNteRSall speakers and presenters are requested to check into the speaker Ready Room at least two hours prior to their presentation. There will be helpers on duty to assist with your requirements regarding your presentation. The Speaker Ready Room is located at the 7th Avenue at the Congress venue. The operating hours are:

3th april 2014 (Thursday) 1600 to 1900 hrs

4th april 2014 (Friday) 0730 to 1700 hrs

5th april 2014 (saturday) 0730 to 1700 hrs

6th april 2014 (sunday) 0730 to 1100 hrs

all presentations will be deleted from the conference computers after the presentation are over.

PHOtOGRAPHY & ViDeOtAPiNG POLiCieSPHOtOGRAPHY & ViDeOtAPiNG POLiCieSNo photography or videotaping of the presentations is permitted during the scientific sessions.

MOBiLe PHONeMOBiLe PHONeFor the convenience of all delegates, please ensure that your mobile phone is silenced during the conference sessions.

DiSCLAiMeRDiSCLAiMeRWhilst every attempt would be made to ensure that all aspects of the Convention as mentioned in this publication

will take place as scheduled, the Organising Committee reserves the right to make the changes should the need arises.

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Conference InformationConference Information

27

Floor Plan & Trade ExhibitionFloor Plan & Trade Exhibition

MANHATTANI

Gents Ladies

MANHATTANVI

MANHATTANVII

JUNIOR MANHATTAN

MANHATTANVIII

BRONXI

BRONXII

BRONXIII

BRONXIV

BRONXV

BRONXVI 7th

Avenue

MANHATTANII

BusinessCentre

Stage

46

51

52

54

39

38

37

36

35

34 33

3 6

4

2

1 5

7 10

8 9

11 14

12 13

15 18

16 17

19 22

20 21

23 26

24 25

55

56

32 31 30 29 28 27Hospitality Suite

(Jebsen & JessenTechnology

(M) Sdn Bhd)

Hospitality Suite

(Schiller (Malaysia)Sdn Bhd)

Hospitality Suite

(Abbvie)

Hospitality Suite

(Insan Bakti)

(Secretariatand

SpeakerReadyRoom)

Lecture Hall Lecture Hall

E-Posters

Registration

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Conference InformationConference Information

BootH StaND

CoMPAny

1 aTN Medic sdn Bhd

2 Janssen

3 & 6 Baxter Healthcare (M) sdn Bhd

4 & 5 Pfizer Malaysia Sdn Bhd

7, 8, 9 & 10 Malaysian Healthcare sdn Bhd

11 & 14 KL Med supplies (M) sdn Bhd

12 & 13 Norse Crown Co (M) sdn Bhd

15 & 18 Primed Medical sdn Bhd

16 UMMI surgical sdn Bhd

17 Medi-Life (M) sdn Bhd

19 & 22 Drager Medical sea Pte Ltd

20 Dispo-Med Marketing (M) sdn Bhd

21 Pahang Pharmacy sdn Bhd

23 3M Malaysia sdn Bhd

24 Heal Integrated solutions sdn Bhd

25 BTL Industries Malaysia sdn Bhd

26 Laerdal Malaysia sdn Bhd

BootH StaND

CoMPAny

27 ge Healthcare sdn Bhd

28 IDs Medical systems (M) sdn Bhd

29 Transmedic Healthcare sdn Bhd

30 & 31 Fresenius Kabi Malaysia sdn Bhd

32 & 33 B Braun Medical supplies sdn Bhd

34 Merck sharp & Dohme (M) sdn Bhd

35 star Medik sdn Bhd

36 Biolight Healthcare Malaysia

37 Roche (Malaysia) sdn Bhd

38 & 39 Philips Healthcare

46 shriro (Malaysia) sdn Bhd

51 Indizium sdn Bhd

52 schmidt BioMedTech sdn Bhd

54 Infinity Medical Sdn Bhd

55 Medental (M) sdn Bhd

56 Mundipharma Pharmaceuticals sdn Bhd

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28

AcknowledgementsAcknowledgements

The Organising Committee of the Annual Scientific Congress 2014 wishes to thank the following for their support and contribution:

PLATINUM SPONSOR PLATINUM SPONSOR

Malaysian Healthcare sdn Bhd

GOLD SPONSORGOLD SPONSOR

Baxter Healthcare (M) sdn Bhd

SPONSORSSPONSORS

Janssen

Merck sharp & Dohme (M) sdn Bhd

abbvie sdn Bhd

B Braun Medical supplies sdn Bhd

Drager Medical sea Pte Ltd

Fresenius Kabi Malaysia sdn Bhd

Insan Bakti sdn Bhd

Jebsen & Jessen Technology (M) sdn Bhd

KL Med supplies (M) sdn Bhd

Norse Crown Co (M) sdn Bhd

Philips Healthcare

Pfizer Malaysia Sdn Bhd

Primed Medical sdn Bhd

schiller (Malaysia) sdn Bhd

3M Malaysia sdn Bhd

aTN Medic sdn Bhd

Biolight Healthcare Malaysia

BTL Industries Malaysia sdn Bhd

Dispo-Med Marketing (M) sdn Bhd

ge Healthcare sdn Bhd

Heal Integrated solutions sdn Bhd

IDs Medical systems (M) sdn Bhd

Indizium sdn Bhd

Infinity Medical Sdn Bhd

Laerdal Malaysia sdn Bhd

Medi-Life (M) sdn Bhd

Medental (M) sdn Bhd

Mundipharma Pharmaceuticals sdn Bhd

Pahang Pharmacy sdn Bhd

Roche (Malaysia) sdn Bhd

schmidt BioMedTech sdn Bhd

shriro (Malaysia) sdn Bhd

star Medik sdn Bhd

Transmedic Healthcare sdn Bhd

UMMI surgical sdn Bhd

Research Books asia Pte Ltd

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EvidEncE-BasEd PracticE in anaEsthEsiaNeville Gibbs

Department of anaesthesia, sir Charles gairdner Hospital, Nedlands, Western australia

Evidence-based practice is the ‘integration of best research evidence with clinical expertise and patient values’1. Unfortunately, the ‘best research evidence’ may be low level, indeterminate, or even contentious. For example, systematic reviews have found that there is no high level evidence that anaesthesia provided by physicians is safer than that provided by nurses2, or that pulse oximetry improves outcomes3, or that adrenaline is effective in the emergency treatment of anaphylaxis4. Yet we feel strongly that anaesthesia should be physician-based or supervised, that pulse oximetry is mandatory, and that adrenaline is a first line drug for the emergency treatment of anaphylaxis. These examples are not exceptions: very few anaesthetic practices are supported by consistent ‘high level’ evidence. In fact, when we read that a practice is ‘evidence-based’, this may not necessarily indicate level 1 or 2 evidence. In many cases, it is expert opinion in the form of a consensus statement or a guideline based mostly on level 3 or 4 evidence. This should not de-value these statements and guidelines: They most likely represent the ‘best evidence’ available. What is clear is that there is now no place for ‘rules of thumb’, ‘we have always done it this way’ or other forms of dogma in current medical practice. Nevertheless, the limitations of current evidence should be appreciated, and basing a practice on a sound rationale should not be criticized in the setting of insufficient or conflicting experimental data. An important aspect of evidence-based practice is to ‘critically appraise’ evidence: this is very different to ‘uncritically praising’ it.

1. Sackett DL, Straus SE, Richardson WS, Rosenberg W, Haynes RB. Evidence-Based Medicine: How to practice and teach EBM, 2nd edition. Churchill Livingstone, Edinburgh, 2000, p.1).

2. Smith AF, Kane M, Milne R. Comparative effectiveness and safety of physician and nurse anaesthetists: a narrative systematic review. Br J Anaesth 2004; 93: 540-545.3. Pedersen T, Hovhannisyan K, Møller AM. Perioperative monitoring with pulse oximetry does not appear to affect the outcomes of anaesthesia. Published Online: December

8, 2010. (http://summaries.cochrane.org/CD002013/perioperative-monitoring-with-pulse-oximetry-does-not-appear-to-affect-the-outcomes-of-anaesthesia - accessed February 2014)

4. Sheikh A, Shehata YA, Brown SGA, Simons FER. Adrenaline for the emergency treatment of anaphylaxis. Published Online: April 18, 2012 (http://summaries.cochrane.org/CD006312/adrenaline-for-the-emergency-treatment-of-anaphylaxis – accessed February 2014)

PLeNARy 1

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30

thE Pain-FrEE daycarE PatiEntKavita Bhojwani

Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia

Pain is the most common problem in the postoperative period in the daycare patient.

It leads to prolonged stay and is also a common reason for unanticipated admission. Pain is also a major cause of nausea and vomiting which again further delays discharge. It leads to patient dissatisfaction and sleep disturbance, limits early return to normal function and work. Hence, it is necessary for good effective perioperative analgesia .

Analgesia for day surgery should start with identifying the at risk groups of patients and to educate and inform them about the analgesic regimes planned. This should include preventive analgesia which not only incorporates pain management prior to its onset but even intra and post operative intervention to relieve it. It is important that pain management in the postoperative period is started early in order to achieve maximum benefits. Hence, multimodal analgesia should be commenced with paracetamol, NSAIDs/COX 2 inhibitors, local anaesthetics and opioids and continued intra and post operatively

Postoperatively, a number of non pharmacological methods can be used as well, like elevating the operated site and use of cold compresses among other techniques.

On discharge, there should be clear written instructions given and a follow up call the next day.

Postoperative pain management in the ambulatory setting is always a challenge and it is good to develop guidelines, planned multimodal approach, which are procedure specific to achieve the pain free patient.

References1. Showan A Day Care Anaesthesia Anesthesia & Analgesia July 2001 vol 93-issue 1 p2472. Rawal N Analgesia for day-case surgery BJA 2001; 87(1) : 73-873. White P.F The role of non opioid anlgesic techniques in the management of pain after ambulatory surgery Review article Anesth Analg 2002 Gupta A Analgesia techniques for Day Cases Chapter 9 iDay surgery-Development and Practice Chandrakantan A , Glass P.S.A Multimodal therapies for postoperative nausea and vomiting, and pain BJA 107(51) 2011 Guidelines Day case and short stay surgery:2 Association of Anaesthetists of Great Britain and Ireland and British Association of Day Surgery (2011)

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tiva FOr daycarE anEsthEsiaHugo Vereecke

University Medical Center groningen, Department of anesthesia (eB32), groningen, Netherlands

Dr Vereecke has specialized in anesthetic pharmacology and is actively involved in research that allows titration of hypnotics and opiates in a more predictable, evidence based way.

As the topic of this conference is related to the translation between scientific progress and clinical practice, Dr Vereecke will review how current state-of –the-art TIVA techniques could be optimally applied as to serve the goals of a day case surgery unit at best. As we now have availability of hypnotic and analgesic drugs with short onset times and fast decay of effect, TIVA has never been better suited for day case surgery.

Rational drug dosing -according to evidence based concepts- demands the availability of technology as the complex interplay between pharmacokinetics and –dynamics should be translated in user friendly devices, pumps and advisory tools.

The major criticism on TCI technology (and subsequently on interaction model technology) is that it is derived from historical observations in populations that might be different from the individual patient. It is however a law of nature that most individuals will behave according to a population average. The probability that an individual is an outlier in response is (by definition) smaller compared to the probability of being in the middle of the Gaussian curve. There is evidence that TCI application improves the recovery profile of medium long acting opioids in such a way that they evoke comparable predictable recovery results compared to a TCI titrated recovery after remifentanil administration. Therefore, one could wonder whether TCI has any advantage for remifentanil. It does so, because TCI also prevents excessively high plasma concentrations by controlling infusion rate and estimating the optimal initial dose more accurately compared to manual dosing. In order to control unnecessary peak effects of remifentanil during sudden dose adjustments, TCI remains the most rational approach for short acting opioids also.

The goal of improved quality must however be balanced against the availability and cost of new technology. Technology always comes with a price tag. At the other hand, application of evidence based technology is a logic evolution towards improved safety and predictability of TIVA titration. It incorporates more and more knowhow on covariates that can be controlled in clinical practice. As such, the number of drug dose adjustments throughout a case can be diminished, the number of outliers in recovery time can be decreased and steady-state conditions can be maintained more easily. These advantages will be cost saving eventually as more predictable anesthesia effect will allow day case surgery in a wider population of sometimes fragile patients such as elderly, it provides more predictable discharge conditions and has a low side-effect incidence compared to inhaled anesthetic techniques. These characteristics will make TIVA the preferred approach for day case surgery.


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Quality rEcOvEry in daycarE surgEriEsStefan Roehrig

Dept. of anaesthesiologie & Intensive Care Medicine, Marienhospital Muensterland, germany

Quality of health care is defined as care that is safe, timely, effective, efficient, equitable and patient-centered. It is a daily challenge for the anaesthetist to ensure the best possible result in relation to patients safety, the quality of care and the cost-effectiveness. Healthcare systems are finding themselves catering for increasingly older and fatter patients with higher co-morbidities. Furthermore outpatient anaesthesia has increased considerably in the last years. On the other hand medical advantages are e.g. less appearence of delir and nosocomial infections. Based on a patient- centred risk management the anesthetist has to evaluate the egiligibility of the patient for ambulatory anaesthesia. As a part of the assessment carried out by the anaesthetist, which includes a thorough examination of the patient`s medical records and risk stratification, a dicision is made on which treatment and anaesthetic concept is appropriate. The goal is to ensure the patient makes it through the perioperative phase with the best possible results. Anaesthetics that provide faster early recovery of spontaneous ventilation, protective airway reflexes and a high level of consciousness nearly independent of the duration of use, body weight or organ insufficiency should be beneficial for patients safety and implicate the potential to increase the quality of care in ambulatory anesthesia. The prevention of hypothermia, perioperative nausea and vomiting and postoperative residual curarization, combined with a good perioperative pain therapy plays a further central role. The different pharmacokinetic and phamarcodynamic effects of common used anaesthetics with respect to patients characteristics, safety and quality of recovery in considering of recent scientific data will be discussed. A modern concept of anaesthesia based on desflurane that is feasible for nearly all kind of patients in the ambulatory setting will be presented. In combination with tissue-protective surgical techniques such a concept might facilitate a rapid recovery of the patient.

anaEsthEsia FOr thE OBEsE PatiEntAnju Grewal

Department of anaesthesiology, Dayanand Medical College & Hospital, Ludhiana, Punjab, India

Obesity is rampantly invading developing nations consequent to sweeping globalization. Degree of Obesity has been classified on the basis of Body Mass (Quetelet’s) Index (BMI) as Obesity class I (BMI ≥30 Kg/m2), Obesity class II (BMI ≥35 Kg/m2) and Morbid obesity (Class III: BMI≥40 Kg/m2). This classification helps quantify systemic risks, however body circumference indices correlate strongly with mortality. The pathophysiological effects of obesity are wide ranging, adversely affecting all organ systems, with cardiovascular and respiratory systems bearing the maximal brunt. Obstructive sleep apnea, Obese Hypoventilation syndrome, Metabolic syndrome and other systemic comorbidities predispose obese individuals to chronic hypoxemia, pulmonary hypertension, cardiac failure, hypertension, coronary artery disease, dysrhythmias, sudden cardiac death, DM type 2, stroke, hypercoagulability, osteoarthritis and host of problems, all of which pose greater challenges to the anesthesiologists.

Preoperative evaluation should include an assessment of cardiopulmonary issues, securing airway, aspiration risks, and issues arising due to co-morbidities. An honest discussion with the patient goes a long way in building a rapport and ensuring cooperation during perioperative care. Perioperative investigations include urine analysis, Full Blood count, Urea, Electrolytes, Blood glucose, ECG, Chest radiography, Pulmonary Function Tests, Arterial Blood Gases, Echocardiography & specialists opinions for optimization of medical therapies.

The focus of anesthetic management is ensuring safer outcomes and avoidance of postoperative pulmonary and other systemic complications. General anesthesia with airway control maybe preferred for majority of bariatric & non-bariatric surgical procedures, however regional anesthesia and analgesia can be judiciously used with ultrasound guidance whenever feasible. Adequate preparation, careful preoxygenation, special positioning, apt monitoring, awake or facilitated endotracheal intubation using fibreoptic or videolaryngoscopes, drug dosing based on pharmacokinetic variations, adapted intraoperative ventilation, optimal fluid management, multimodal postoperative analgesic techniques and deep venous thromboprophylaxis are some of the key issues for successful anesthetic management.


SympoSium 2HIGH-RISK ANAESTHESIA

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thE suBstancE-aBusing PatiEnt – anaEsthEsia and analgEsia Ramani Vijayan

University Malaya Medical Centre, Kuala Lumpur, Malaysia

In the last two decades, the abuse of illicit substances has risen dramatically, particularly in those below forty years. This is threatening the social fabric of society both in terms loss of family relationships and loss of productivity and is a major health concern to any country.

Although Anaesthesiologists are not the primary care physicians of these patients, we do encounter them in emergency rooms or in trauma situations, obstetrics or when they present for elective surgery.

Understanding the complexity of substance abuse is a challenge since interplay of biological, genetic, psychological, social, cultural, environmental and spiritual factors are involved. As Anaesthesiologists we need to be aware that adverse effects of substance abuse will impact on anaesthetic care. The adverse effects range from pulmonary and cardiovascular effects to changes in the central nervous system. It is important to be aware of a history of substance abuse prior to administering anaesthesia or analgesia as it allows us to predict adverse drug interaction, predict tolerance to some agents and recognize drug withdrawal signs and symptoms.

Injected drugs and high-risk sexual behaviours are key risk factors for the transmission of blood borne diseases such as HIV/AIDS, hepatitis C and there should be high level of suspicion about deep-seated infections when dealing with these patients. Patients using illicit substances are also frequently under-medicated for pain since they may require more frequent doses of analgesics to achieve expected effects due to cross tolerance to opioid analgesics.

The list of substances that can be abused is long. Hence this review will concentrate mainly on problems associated with alcohol, marijuana, opioids and ‘hallucinogenic’ or party drugs that represent the major problems in Malaysia.

Management should be multi-disciplinary and should include addiction specialist colleagues. The principles of management include the provision of adequate anaesthesia and analgesia in a non-judgemental holistic manner, allaying anxiety and preventing withdrawal symptoms.

SympoSium 2HIGH-RISK ANAESTHESIA

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nErvE inJury: transiEnt Or PErManEnt? thE EvidEncE sO FarAmiruddin Nik Mohamed Kamil

Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

The incidence of transient neurological deficits might be as high as 8–10% in the immediate days following the block. Incidence of severe neurological complication occurred in 0.2% to 0.4% of population.The pathogenesis of peripheral nerve injury includes direct local anesthetic toxicity, edema, intrafascicular injection and ischemia.

Intraneural InjectionNeedle tip injury may lead to posttraumatic inflammation and considerable structural changes within the nerves in porcine study. In animal study nerve expansion seen on ultrasound during intraneural injection of relevant volumes of LA results in histologic but not necessarily functional nerve injury. In cadaver study findings suggest that intraneural needle insertion more commonly result in interfascicular rather than intrafascicular placement. How intraneural is intraneural? The Epineurium -Moderately dense connective tissue merging with adipose tissue surrounding peripheral nerve. The Perineurium - Concentric layers of flattened cell separated by layers of collagen.The Endoneurium - Hold the nerve fibers, support the capillary vessels. In another study animals that received intrafascicular LA injections showed increased severity of fascicular injury. Extrafascicular – loose and compliant. Intrafascicular, tight and noncompliant space.Probability of nerve injury.

Direct Local Anaesthetic ToxicityLocal anaesthetics are neurotoxic. When placed on nerve fibres, high concentrations of lidocaine have caused irreversible conduction loss. In fetal mouse brain study, disappearance of neuron was caused by apoptosis.

Neural IschaemiaEpinephrine 1:400000 prolonged the action of 1% lidocaine in a block. Epinephrine decreases neural blood flow and facilitates the penetration of local LA into the nerve. It may be beneficial but may also potentiate the neurotoxicity of LA.

rEgiOnal anaEsthEsia in thE anticOagulatEdMafeitzeral Mamat

Department of anaesthesiology & Critical Care, Faculty of Medicine, UiTM Hospital, sungai Buloh, selangor, Malaysia

Patients with anticoagulants on board can be a relative or absolute contraindication for anaesthetists to perform regional anaesthesia. Studies suggest that the use of peripheral nerve blocks, especially continuous peripheral nerve catheters, provides better analgesia compared to opioids, greater patient satisfaction, decreased pruritus, decreased nausea vomiting, improved sleep, and decreased length of hospitalization.

Recommendations by the most recent ASRA guidelines suggest that the same guidelines on neuraxial injections apply to deep plexus or peripheral nerve blocks. Some clinicians may find this to be too restrictive and apply the same guidelines only to deep plexus and noncompressible blocks (e.g., lumbar plexus block, deep cervical plexus blocks) or to blocks near vascular areas, such as celiac plexus blocks or superior hypogastric plexus blocks. If peripheral nerve blocks are performed in the presence of anticoagulants, the anesthesiologist must discuss the risks and benefits in a multidisciplinary fashion; the patient and the surgeon. Following up the patient very closely after the block is vital to ensure the risks are being look after.

We would be looking into the evidence and worldwide practice in tackling this issue. Hopefully this will guide us to make the best decision for our patients.

SympoSium 3REGIONAL ANAESTHESIA


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usra: rEducing thE stEEPnEss OF thE curvE Krishna Boddu

Royal Perth Hospital, anesthesiology University of Texas Health sciences at Houston, University of Western australia, australia

It is believed that Ultrasound Guided Regional Anaesthesia is a steep learning curve and this lecture covers various aspects of USGRA and various factors that affects steepness of its learning curve.

saFEty and Quality indicatOrs in anaEsthEsiaNeville Gibbs

Department of anaesthesia, sir Charles gairdner Hospital, Nedlands, Western australia

Safety in relation to healthcare can be defined as ‘the avoidance or reduction to acceptable limits of actual or potential harm from health care management or the environment in which it is delivered ’1. Quality can be defined as the ‘extent to which a service or product produces a desired outcome’1. Safety is a subset of quality, as hazard or harm would not be consistent with a desired outcome. Safety indicators include mortality and morbidity rates, the frequency of near misses (e.g. in clinical incident reports), and performance in relation to some specialty specific clinical indicators. Anaesthetic mortality is now so rare in developed countries2 that it would be a poor indicator of safety or quality, but this may not be the case in less developed countries. Anaesthetic morbidity rates are difficult to measure because the causes are typically multi-factorial, and denominators may not be known. At present, the Victorian Consultative Council on Anaesthetic Mortality and Morbidity has one of the largest databases of anaesthetic morbidity (www.health.vic.gov.au/vccamm/). Another approach is to audit specific complications: for example, the Australasian Regional Anaesthesia Collaboration monitors regional anaesthesia complications3. Incident reporting is another method to estimate morbidity rates. The Australian and New Zealand Tripartite Anaesthesia Data Committee has developed an on-line incident reporting system (webAIRS) for reporting incidents (www.anztadc.net/).

The quality of anaesthesia can be assessed from a quality assurance or from a patient perspective4. Quality assurance assesses whether the facilities, staffing, and processes are fit for service, and involves accreditation (compliance with recognized standards), credentially (including scope of practice), reporting of clinical incidents and clinical indicators (e.g. documentation of pre-anaesthetic visits, incidence of postoperative hypothermia, number of unplanned admissions to an intensive care unit), and periodic audits of both processes and outcomes. From the patient’s perspective, quality relates mostly to the recovery phase from anaesthesia, given that general anaesthesia itself is nearly 100% effective, and mortality and serious morbidity are rare. Factors influencing quality of recovery relate mostly to pain control and absence of nausea and vomiting4,5,6. Others factors include achieving a feeling of well-being, feeling supported by doctors and nurses, and being able to understand instructions4,5. Patient satisfaction alone is likely to be a poor indicator of quality due to variations in patient expectations6. A recent study of the quality of anaesthesia from the patient’s perspective highlighted the importance of communication with, and confidence in, the anaesthetist7.

1. Australian Institute for Health and Welfare (www.aihw.gov.au/sqhc-definitions/ - accessed February 2014)2. Gibbs NM. National anaesthesia mortality reporting in Australia 1985-2008. Anaesth Intensive Care 2013; 41: 294-301.3. Barrington, MJ, Watts SA, Gledhill SR, et al. Preliminary results of the Australasian Regional Anaesthesia Collaboration: a prospective audit of more than 7000 peripheral

nerve and plexus blocks for neurologic and other complications. Reg Anesth Pain Med 2009; 34: 534-541.4. Benn J, Arnold G, Wei I, Riley C, Aleva F. Using quality indicators in anaesthesia: feeding back data to improve care. Br J Anaesth 2012; 109: 80-91.5. Myles PS, Hunt JO, Nightingale CE, et al. Development and psychometric testing of a quality of recovery score after general anaesthesia and surgery in adults.

Anesth Analg 1999; 88: 83-90.6. Royse CF, Chung F, Newman S, Stygall J, Wilkinson D. Predictors of patient satisfaction with anaesthesia and surgery care: a cohort study using the postoperative quality

of recovery scale. Eur J Anaesthesiol 2012; 29: 106-110.7. Hocking J, Weightman WM, Smith C, Gibbs NM, Sherrard K. Measuring the quality of anaesthesia from a patient’s perspective: development, validation, and implementation

of a short questionnaire. Br J Anaesth 2013; 111: 979-989.


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JOint cOMMissiOn intErnatiOnal accrEditatiOn: iJn’s ExPEriEncEAriffin M Mokhtar

Institut Jantung Negara, Kuala Lumpur, Malaysia

The Joint Commission International Accreditation is a patient centered health care organization accreditation exercise managed by the Joint Commission International (JCI), a division of Joint Commission Resources, Inc.

The presentation shall cover the JCI accreditation from IJNs experience starting from the preliminary work to the survey preparation, going through the initial survey, the period between the surveys, going through the triennial survey, following which a focus/follow-up survey and the strategic improvement program. The presentation will cover specific portions on clinical care and management of information chapters in the Joint Commission International standards 5th Edition that is effective from the 1st of April 2014.

In the later part of the presentation, there will be section on moving forward beyond the Joint Commission International (JCI) accreditations and architecting quality and safety into clinical practice and making it a commodity with Information Systems as an enabling tool.

training and EducatiOn in anEsthEsiOlOgy: What is thE FuturE?Nicole Shilkofski

Perdana University graduate school of Medicine, Departments of Pediatrics and anesthesiology/Critical Care, Johns Hopkins University school of Medicine

This discussion will focus on recent pedagogical strategies in education of future generations of anaesthesiologists, with an emphasis on simulation based medical education (SBME) strategies. This overview will include examples of innovative teaching and learning programs designed to promote learning and retention strategies for critical knowledge, skills and attitudes within anaesthesiology. It will also review strategies to teach communication and non-technical skills crucial to patient safety and effective care delivery within the field of anaesthetics.

SympoSium 4SAFETY AND QUALITY ASSURANCE

plenary 3

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vidEOlaryngOscOPy: a ParadigM shiFt in daily rOutinE airWay ManagEMEnt

C J AcottRoyal adelaide Hospital, adelaide, australia

Dr Acott is a Senior specialist Anaesthetist at the Royal Adelaide Hospital, Adelaide, South Australia. Past medical and anaesthesia experience has been gained in several countries – Papua New Guinea, England, South Africa, Bermuda, Fiji and several Australian states. He was responsible for the creation of Intensive Care and Medical Retrieval services in Central Queensland, Australia, in the 1980s. He was one of the two ‘founding fathers” of the Airway Special Interest Group of the Australian and New Zealand College of Anaesthetists.

Anaesthesia and Medical interests include the Difficult Airway, Head and Neck Surgery, the History of Anaesthesia and Medicine, Marine Animal Envenomation, Diving Medicine and Medicine in the 3rd World. He conducts courses in airway management, diving medicine and a paramedic course for commercial divers. He has lectured internationally in diving medicine, marine envenomation and difficult airway management and has authored or co-authored book chapters and journal articles on these topics .

Dr Acott is involved with AusAid projects in Fiji and Papua New Guinea and is a member of the Overseas Aid Committee of the ANZ College of Anaesthetists.

cricOthyrOtOMy PuncturE – thE airWay crisisMohd Basri Mat Nor

Kulliyyah of Medicine, International Islamic University Malaysia, Kuantan, Pahang, Malaysia

Cricothyrotomy is the establishment of a surgical opening in the airway through the cricothyroid membrane for oxygenation and ventilation. It is rarely performed but potentially life-saving procedure of last resort in patient with failed airway. Therefore, all clinicians responsible for airway management must retain familiarity with the necessary equipment and relevant anatomy. It is vital that clinicians review the anatomy and practice with the equipment needed several times a year. With ongoing adoption of advanced video laryngoscopy and increasingly effective non-invasive airway rescue techniques, the rate of cricothyrotomy will continue to decline. However, cricothyrotomy will likely remain the cornerstone of failed airway management for the future.

The primary indication is when a failed airway has occurred and the patient cannot be adequately ventilated or oxygenated with a bag and mask or the patient is adequately oxygenated but there is no another available device that is believed likely to successfully secure the airway. The term failed airway is generally applied to any circumstances when the primary selected airway management technique is unsuccessful and alternative techniques are not able to maintain oxygenation. The clinician must take effective action immediately to avoid oxygen desaturation with resultant cerebral hypoxia. Failed airway can arise during a rapid sequence intubation, during management of a difficult airway or during management of a crash airway. A deliberate approach must be used to ensure that oxygenation is preserved, and that the airway is ultimately secured. A second indication is a method of primary airway management as a rescue technique in conditions associated with a difficult airway e.g. massive haemorrhage, obstructing lesions or in patients with severe facial trauma. There is no absolute contraindications to emergency cricothyrotomy in adults. For children younger than 10 years, needle cricothyrotomy is the surgical airway technique of choice.Once a cricothyrotomy is contemplated, the clinician must address a few fundamental considerations: Will a cricothyrotomy effectively bypass the airway obstruction?Which cricothyrotomy technique is to be used?

Will the patient’s anterior neck anatomy make the procedure particularly difficult or time consuming?

SympoSium 5AIRWAY

SympoSium 5AIRWAY

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38

suPraglOttic airWays in Ent surgEriEs Tan Leng Zoo

Department of anaesthesiology, alexandra Hospital, singapore

Supraglottic airways (SGAs) were put into clinical practice with the introduction of the laryngeal mask airway by Archie Brain in the 1980s.

SGAs have numerous advantages over endotracheal tubes and face masks and some of these make them suitable for use in ENT surgeries.

1. Smoother emergence with less cardiovascular response, straining and patient movement to diminish postoperative bleeding and displacement of newly positioned prosthesis or grafts

2. Insertion and tolerance of the SGA without need for neuromuscular blocking agents hence allowing for intraoperative facial nerve monitoring or surveillance of recurrent laryngeal nerve through fibreoptic observation of vocal cord movement

3. Reduced likelihood of trauma to the glottis permitting maintenance of normal vocal cord function and decreased incidence of postoperative dysphonia thus ideal for voice surgery

4. Less stimulating to the trachea with reduced bronchospasm, coughing and desaturation therefore useful in patients with chronic upper respiratory tract infections undergoing tonsillectomy

5. As a conduit for surgical access to the glottis and upper trachea while providing an uninterrupted means of ventilation

The safety and efficacy of SGAs in ENT surgeries have been extensively described in the scientific literature so its use for selected patients can be considered as the standard of care.

uPdatEs On thE guidElinEs FOr thE ManagEMEnt OF Pain, agitatiOn & dEliriuM in intEnsivE carE

Ahmad Shaltut OthmanDepartment of anaesthesiology & Intensive Care, Hospital sultanah Bahiyah, alor setar, Kedah, Malaysia

Most critically ill patients will likely experience pain during their ICU stay. However, many critically ill patients may be unable to self-report their pain (either verbally or with other signs) because of an altered level of consciousness, the use of mechanical ventilation, or high doses of sedative agents. Therefore, clinicians must be able to reliably detect pain, using assessment methods adapted to a patient’s diminished com¬munication capabilities. Detection, quantification, and management of pain in critically ill adults are major priorities.

Agitation and anxiety occur frequently in critically ill patients and are associated with adverse clinical outcomes. Sedatives are commonly administered to ICU patients to treat agitation and its negative consequences. Prompt identification and treatment of possible underlying causes of agitation, such as pain, delirium, hypoxemia, hypoglycemia, hypotension, or withdrawal from alcohol and other drugs, are important. The use of sedation scales, sedation protocols designed to minimize sedative use, and the use of non-benzodiazepine medications are associated with improved ICU patient outcomes, including a shortened duration of mechanical ventilation, ICU and hospital LOS, and decreased incidences of delirium and long-term cognitive dysfunction.

Delirium, as a manifestation of acute brain dysfunction, is an important inde-pendent predictor of negative clinical outcomes in ICU patients, including increased mortality, hospital LOS, cost of care, and long-term cognitive impairment consistent with a dementia-like state. Patients with delirium may be agitated (hyperactive delirium), calm or lethargic (hypoactive delirium), or may fluctuate between the two subtypes.

More patient-centred, integrated and interdisciplinary approach to managing pain, agitation and delirium. Treatment, including prevention, must be undertaken without delay, and the ICU physician should follow logical, strict and systematic rules when applying therapy.

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SympoSium 6CRITICAL CARE

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cardiac OutPut and hEMOdynaMic MOnitOring in thE critically ill childNicole Shilkofski

Perdana University graduate school of Medicine, Departments of Pediatrics and anesthesiology/Critical Care, Johns Hopkins University school of Medicine

Hemodynamic monitoring is the cornerstone of perioperative anaesthetic monitoring of the paediatric patient. This type of monitoring can provide information relating to cardiac output, volume status and tissue perfusion. This overview will provide a discussion of the devices currently available for monitoring of the paediatric patient, ranging from non-invasive measures to more invasive strategies for monitoring, including discussion of PiCCO catheter devices, Near-infrared spectroscopy (NIRS) cerebral oximetry, bedside echocardiography, end tidal CO2 monitoring and central venous pressure monitoring. The aim of the discussion is to assist paediatric anesthesiologists in selection of the most appropriate device and technology for a given situation, particularly to assess targets and outcomes in goal-directed therapy for various forms of shock and hemodynamic compromise in a critical care and/or perioperative setting.

Fluid ManagEMEnt rEvisitEd – iMPact OF thE starch cOntrOvErsyHamidah Ismail

Hospital serdang, selangor, Malaysia

Fluid management of the paediatric surgical patient present challenges to the anaesthesia team. We rely on formulas and concepts once thought to be certain but these are presently being examined and challenged.

One of the key overall questions faced in fluid responsiveness is whether to use crystalloids or colloids. In general terms there are two groups of fluid, crystalloid group (saline, lactates ringer’s solution) and colloids family (albumin, gelatin and hydroxyl ethyl starch [HES]). It has been controversial for decades and hopefully the impact of the new trials can bring new clarity in longstanding debates in the field of fluid therapy.

Both Scandinavian Starch for Severe Sepsis/Septic Shock (6S) Trial and CHEST (Crystalloid versus Hydroxy-ethyl Starch Trial) has made a strong recommendation of poor safety profile of starch group in clinically ill patients, even though CRYSTMAS (Crystalloids Morbidity Associated With Severe Sepsis) trial did not show the same result.

Recent issues of fraud in research has made some meta-analysis that was being done before 2011, been reanalyze again. Zarychanski 2013 has removed Joachim Boldt starch studies on 7 trials involving 590 patients, and make a new conclusion on safety profile of starch-base colloids: HES associated with higher mortality, more renal failure and more RRT.

Even if we agreed to accept the trial result that showed poor safety profile of starch-base colloids in critically ill population, some people would say we need to allow its use for certain patient subgroup in which we have not established harm.

SyMPOSIUM 7PAEDIATRIC ANAESTHESIA


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40

anaEsthEsia FOr BrOnchOscOPy in childrEnVinodh Suppiah

sabah Women and Childrens Hospital, Kota Kinabalu, sabah, Malaysia

Anaesthesia for bronchoscopy in children is often rightly viewed by many anaesthetists as challenging, dangerous and frightening. This is perhaps especially true for those of us who have only occasional paediatric practise.

The purpose of this lecture is to demystify the topic, explain the terminology, surgical requirements and equipment, and key anaesthetic considerations.

At the end of the talk it is hoped the audience will have a set of key take home messages they can amalgamate into their practise to make anaesthesia for paediatric bronchoscopy safe and even enjoyable!

it’s Just anOthEr casE: anaEsthEsia cOncErns in sPinE surgEryLim Wee Leong

sungai Buloh Hospital, selangor, Malaysia

Lecture OutlineReview current issues and safety concerns in anesthesia for spine surgery.

Tips for ensuring safe conduct and avoiding complications in spine surgery.

Proper management in anaesthesia for spinal surgery requires a good understanding the various types of spine diseases and their pathophysiology requiring surgery. The spine surgeon’s operative needs and patient’s co-morbid risk factors also need to be taken into account when giving anaesthesia fro spine surgery. With regards to surgery, all fractures with canal compromise in the presence of neurological deficit should be treated as emergencies. Indications for urgent surgery include i) progression of neurological deficit, ii) bone fragments in spinal canal in incomplete SCI, iii) open or penetrating trauma, iv) non-reducible unstable fractures.

There are very few convincing data showing any advantage of one anaesthetic agent or technique over another. Hence, our goals for anaesthesia in spinal surgery in elective and emergency spine surgery should focus on the following:

Prevent worsening of spinal cord injury during airway management and positioning

Provide optimum conditions for electro-physiologic monitoring of the spinal cord when needed

Managing of intra-operative blood loss

Ensure good haemodynamic control for spinal cord perfusion

Correcting metabolic and electrolyte derangement

Hence, it is important that there should not only be good co-operation between surgeon and the anaesthetist for any spinal procedure but that the risks are explained to the patient and documented clearly before undertaking the assignment.

References• EarlyAcuteManagementinAdultswithSpinalCordInjury:AClinicalPracticeGuidelineforHealth-CareProviders.PublishedbytheConsortiumforSpinalCordMedicine

2008• PhilippaVealaandJoanneLamb.Review.Anaesthesiaandacutespinalcordinjury.BJA2002,volume1number5.• JSpinalCordMed2008;31(4):403-79Earlyacutemanagementinadultswithspinalcordinjury:aclinicalpracticeguidelineforhealth-careprofessionals.• RJohnHulbert.StrategiesofMedicalInterventionintheManagementofAcuteSpinalCordInjury.SPINEvolume312006516-521.• FaisalT.Sayer,ErikKronvall,Olag,Nilsson.Methyprednisolonetreatmentinacutespinalcordinjury:themythchallengedthroughastructuredanalysisofpublished

literature. The Spine Journal 6 (2006) 335-343.


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aWakE craniOtOMy and chOicEs OF anaEsthEtics availaBlE W Mohd Nazaruddin W Hassan

Department of anaesthesiology & Intensive Care, school of Medical sciences, Health Campus, Universiti sains Malaysia, Kubang Kerian, Kelantan, Malaysia

Awake craniotomy is a brain surgery in awake patients, which is indicated for certain intracranial pathologies. It is useful for procedures that require electrocorticographic mapping or precise electrophysiological recordings, resection of lesions located close to or into eloquent area of the brain, or minor intracranial procedures that aim to avoid general anaesthesia for faster recovery and earlier discharge. The main challenge of anaesthetic management relies on the ability to titrate the level of sedation and analgesia to the sequence of the surgical event, while maintaining haemodynamic stability and adequate ventilation. In general, there are two main anaesthetic techniques for awake craniotomy; asleep-awake-asleep (AAA) or monitored anaesthesia care (MAC) with or without loco-regional block (local infiltration or scalp block). AAA technique usually requires laryngeal mask airway (LMA) to control ventilation during general anaesthesia. MAC technique requires combination of a few drugs such as dexmedetomidine, propofol, remifentanil, fentanyl or midazolam. The availability of target-controlled infusion (TCI) mode of administration for propofol and remifentanil facilitates the titration of the sedation. Scalp block is also very useful for analgesia and it can reduce the consumption of opioids. Sites of infiltration for scalp block are supraorbital nerve, supratrochlear nerve, auriculotemporal nerve, zygomaticotemporal nerve, greater occipital nerve and lesser occipital nerve (pneumonic: S2AZO2). The choice of anaesthetic agents, as well as the anaesthetic technique is very important for the success of awake craniotomy.

rOlE OF EchOcardiOgraPhy and lung ultrasOund in thE critically ill PatiEnt

Adi OsmanHospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia

Recent recommendations and evidences had proven the usage and effectiveness of critical ultrasound in acutely ill patient1, 2. Bedside echo and lung ultrasound is fast, reliable and reproducible method for diagnosis, therapeutic and monitoring successful therapeutic strategy in critically ill patient.

The use of echocardiography in shock patients allows us to measure various hemodynamic variables in an accurate and a non-invasive manner. By using echocardiography not only as a diagnostic technique but also as a tool for continuous hemodynamic monitoring. We can evaluate various aspects of shock states, such as cardiac output and fluid responsiveness, myocardial contractility, intracavitary pressures, heart-lung interaction and biventricular interdependence.

Echocardiography also allow us to get an information on real time for making vital decisions in a noninvasive or semiinvasive form, such as fluid therapy continuity, early vasoactive or inotropic treatment, realization of a ultrasound guided pericardiocentesis in a cardiac tamponade.

WINFOCUS through the International Liaison Committee on Lung Ultrasound has released and published on the Intensive Care Medicine Journal entitled the “International evidence-based recommendations for point-of-care lung ultrasound”3. This document reflects the statements and discussions by experts who published the vast majority of papers on clinical use of lung ultrasound in the last 20 years. This recommendations were produced to guide implementation, development, and standardization of lung ultrasound in all relevant setting in managing critically ill patient3.

References1. Vieillard-Baron A, et al. Echocardiography in the intensive care unit: from evolution to revolution? Intensive Care Medicine. 2008; 34:243–249.2. Adi Osman, Tan WC et al: A feasibility study on bedside upper airway ultrasonography compared to waveform capnography for verifying endotracheal tube location after

intubation. Crit Ultrasound Journal. 2013 Jul 4; 5(1): 7. 3. Volpicelli G, Elbarbary M, Blaivas M, Lichtenstein DA, et. al: International evidence-based recommendations for point-of-care lung ultrasound. International Consensus

Conference on Lung Ultrasound (ICC-LUS). Journal Intensive Care Med. 2012 Apr; 38(4): 577-91.2012

SympoSium 8NEUROANAESTHESIA

SympoSium 10TRAUMA

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Managing anaEsthEsia in trauMa PatiEntsStefan Roehrig

Department of anaesthesiologie & Intensive Care Medicine, Marienhospital Muensterland, Marienstrasse, emsdetten, germany

Death from traumatic injury is the leading cause of death in adults younger than 45 years of age. For adults older than 45 years of age, trauma is the third leading cause of death, the primary causes being cardiovascular events and malignancies. The management of a severely injured person is an interdisciplinary task (e.g. anaesthetist, surgeon,radiologist). The basic vital functions directly linked to survival have to be secured. The treatment of “A” airway “B” breathing and “C”circulation are core competences of the anaesthetist and are First Aid measures found in established standards on trauma care and therefore have a particular value in terms of weighting in both the prehospital and the early hospital management. Regarding to “A” the endotracheal intubation and ventilation, and hence definitive securing of the airways, with the aim of the best possible oxygenation and ventilation of the patient, is a central therapeutic measure in emergency medicine (“Treat first what kills first”).The lecture will present recommendations and instructions for the anaesthetist in management of trauma patients deduced from the current evidence based “S3 – Guideline on Treatment of Patients with Severe and Multiple Injuries” from the German Trauma Society. These guideline is a systematically developed decision aid e.g. for anaesthetists on the appropriate method applicable in trauma patients and can be summarized into a kind of checklist. Based on the ABCD-algorithm (ATLS) a focus will be on airway management and ventilation, diagnosis of pneumothorax with lung ultrasound, prevention, diagnosis and treatment of trauma-induced coagulopathy and goal-directed volume resuscitation. An appropriate anaesthesia concept that differentiates between trauma patients with and with-out traumatic brain injury will be presented. A patient fitted anaesthesia concept can provide the surgeons with the best possible conditions to treat severe trauma successfully in the OR and can lead to better outcome in trauma patients.

uPdatEs and ExtEndEd usE OF ultrasOund in trauMaMohammad Fadhly bin Yahya

Department of emergency and Trauma, Hospital Melaka, Melaka, Malaysia

The use of routine bedside ultrasound for trauma patients was started since 1970’s in Germany and Japan. In the United States emergency physicians started using this tool in the 1980’s and it has now become the initial imaging test of choice for trauma care in the US. It is already integrated as part of the Advanced Trauma Life Support (ATLS) protocol developed by the American College of Surgeons.

Initially the purpose of bedside ultrasound in trauma is to rapidly identify free fluid (usually blood) in the peritoneal and pericardial space, namely FAST (Focused Assessment with Sonography in Trauma). Recently, research studies have shown that bedside ultrasound is equivalent to, or better than, chest radiography for identifying a hemothorax or pneumothorax in trauma patients, later known as Extended FAST, EFAST.

At present, the usage of ultrasound is not only confined to finding of free fluid in traumatic patients. It is also invaluable in the assessment of traumatic airway, traumatic eye, fluid requirement, bony fracture/musculoskeletal injuries and others. It is not only used for diagnostic purposes, but as well as therapeutic (pericardiocentesis) and as a tool for the emergency procedures.

The draft regarding International Consensus for Trauma Ultrasound will be presented, in addition to several updates regarding the use of ultrasound in trauma patient, including Contrast Enhanced Ultrasound (CEUS).

SympoSium 10TRAUMA

SympoSium 10TRAUMA

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anaEsthEsia and thE EnvirOnMEntY K Chan

Department of anaesthesiology and Intensive Care, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia

We are experiencing extreme changes in the environment at a pace never seen before in our existence. Some of these changes include extreme temperatures recorded on either end of the scale, wind speeds far beyond human comprehension and for Malaysians an unusually prolonged drought.

These experiences may seemingly be unrelated to our activities as anaesthesiologists. Closer examination of these changes makes us realize that some of the anaesthetic agents we use in our everyday provision of care may be in the thick of this global concern. Nitrous oxide, an agent that most of us use with a lot of pride is not only a green house gas but causes ozone depletion in the atmosphere. A fair number of the volatile agents we use impact the environment far worse than the carbon load the world is trying to get a handle on.

The volatile agents have different impact, desflurane being the worst and sevoflurane being many folds less. These agents stay in the stratosphere for years and continue their impact for the duration. The intravenous agents have the least negative impact on the environment – mainly that associated with their manufacture and this is miniscule compared to the volatile agents.

A relook at our choice of agents is definitely very much the responsibility of all caring anaesthesiologists. Re-examining our technique and awakening this social conscience to inflict less harm, in each and every provider whether anaesthesiologists or otherwise, should be the next life transforming mission in our career. We have to do this before it is too late. The disease pattern is slowly but definitely changing to reflect this impact – we are beginning to see disease pattern changes in line with ozone depletion and massive global disasters from these extreme climate changes secondary to the increasing accumulation of greenhouse gases.

OBstEtric rEsuscitatiOn: What’s nEW?Nolan McDonnell

Department of anaesthesia and Pain Medicine, King edward Memorial Hospital for Women, subiaco, Western australia, australia

Cardiac arrest in pregnancy is fortunately a rare event, estimated to occur in approximately 1:20-30 000 deliveries. However, it may occur in any obstetric setting, even traditionally low risk birthing environments. In addition, the management of the collapsed obstetric patient differ in a number of key areas, if these differences are not appreciated then despite other exemplary care the outcomes may be poor. In this regard, the education of all obstetric care providers into the management of collapse and resuscitation in pregnancy is a key step in the prevention of maternal morbidity and mortality.

The key differences in the resuscitation of the obstetric patient are the requirement for measures to prevent aorto-caval compression and the performance of a perimortem caesarean delivery if there has been no response to standard treatment after 4 minutes. In addition, there are a number of causes of collapse which are either unique or more likely to occur in pregnancy, for example amniotic fluid embolism, haemorrhage and pulmonary embolism.

The performance of a perimortem caesarean was initially popularised by Katz et al in 1986 and a “four minute rule” from the onset of maternal arrest to initiation of caesarean delivery was advocated. This time frame presents a significant challenge and even in well trained teams it can be very difficult to meet this benchmark. Transfer to an operating theatre is not usually possible and hence plans need to be in place to be able to perform the caesarean at the scene of the arrest. Only a minimum amount of equipment is required for this and in our institution this equipment forms part of a perimortem caesarean pack which is located on resuscitation trolleys in key areas of the hospital. As the fetus is likely to be severely compromised at birth, staff trained in neonatal resuscitation should form part of the response team.

The potential benefits of a perimortem caesarean include the relief of aorto-caval compression, improved chest mechanics and a decreased maternal oxygen demand as well as the improved chance of fetal survival. A perimortem caesarean is not usually recommended below 24 weeks gestation, although it may occasionally be indicated in situations where significant aorto-caval compression exists.

It is highly recommended that institutions practice mock scenarios in regards to collapse in pregnancy to help refine local protocols, especially in regards to perimortem caesarean deliveries. A number of multidisciplinary courses are now available to assist with training obstetric care providers.

PLeNARy 4

PLeNARy 5

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cOnsEnt FOr laBOur Anju Grewal

Department of anaesthesiology, Dayanand Medical College & Hospital, Ludhiana, Punjab, India

Consent for labour maybe required for a variety of interventions, especially prior to central neuraxial analgesic pain relief techniques. The challenge lies in obtaining a truly informed consent particularly from parturient’s who are in active labour. Informed consent is a process involving the principles of Beneficence, Respect for autonomy, Non- maleficence & Justice. The underlying ethical obligation of the anaesthesiologist being “Primum Non Nocere”

It is pertinent that certain preconditions or threshold elements be fulfilled for the process of informed consent to be valid. These include decision making capacity or competency, freedom or voluntariness in decision making, with the aid of adequate material information including risks and alternatives, which have been comprehended fully by the distressed parturient. Current guidelines focus on a shift from paternalistic reasonable physician standard to a reasonable patient standard conferring greater patient autonomy in shared decision making with disclosures of material risks in a non-coercive manner.

Parturient’s capacity to give consent in active labor, presence of anticipatory directives or external pressures, level of disclosure especially information on risks, timing of imparting information and urgency of the proposed procedure are factors which comprise the dilemmas faced by an anaesthesiologist during the informed consent process in labour. Various studies have established that the capacity for decision making i.e. the ability to comprehend information is not affected by pain score, anxiety, opioid premedication or level of education. Comprehensive information including benefits and risks (both transient or permanent risks) of all available alternatives merit disclosure at all times. An ideal time for exchange of information would be early antenatal period wherein this information can be imparted in a structured format in the form of antenatal classes, information brochures etc.

A truly informed consent obtained voluntarily provides anaesthesiologists with an opportunity to dissolve barriers, thereby enhancing safety for the laboring mother.

intrathEcal cathEtEr insErtiOn FOllOWing accidEntal dural PuncturEC Y Lee

Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia

The reported incidence of accidental dural puncture (ADP), a complication of central neuraxial blockade, varies between 0 and 6.6% in the obstetric population. Postdural puncture headache (PDPH) develops in approximately half of the cases of ADP. As such, a prophylactic or proactive action to prevent PDPH is justified. One of the interventions following ADP is intrathecal (IT) insertion of the catheter at the time of dural puncture. This practice has gained popularity and was recommended by 59% of UK obstetric units in 2003, compared to only 1% in 1993. Data on the effectiveness of IT catheters in preventing PDPH and reducing the need for epidural blood patch (EBP) are mixed. A meta-analysis by Apfel (2010) revealed no significant difference in the incidence of PDPH for short- and long-term IT catheters.1 In a recent meta-analysis by Heesen (2013), the incidence of PDPH was similar but the need for EBP was significantly reduced.2

There are further advantages in inserting an IT catheter. Besides avoidance of a second ADP, it enables rapid establishment of effective analgesia or anaesthesia. However, problems include unfamiliarity, risk of accidental administration of an epidural dose, and confusion regarding the dose for maintenance of analgesia or anaesthesia.

In practice, the next course of action following ADP is influenced by the experience or preference of the anaesthetist and surrounding circumstances. Explanation should be given to the parturient and subsequent management outlined. All involved in the management of the parturient should be aware of the use of IT catheter. This should be clearly labelled and the incidence documented. Subsequent doses should be carefully administered and the parturient monitored for high sensory block. Post delivery management includes regular follow-up and treatment of PDPH if this occurs.

References1. Apfel CC. Br J Anaesth 2010.2. Heesen M. Int J Obstet Anaesth 2013.

SympoSium 11OBSTETRIC ANAESTHESIA


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inductiOn OF anaEsthEsia FOr lscs: still thiOPEntOnE, suxaMEthOniuM and nO OPiOids?

Azlina Masdar Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia

For over 50 years, routine use of ‘thio, sux, endotracheal tube’ has long association with general anaesthesia (GA) for obstetric patients. Not until late 1980’s when Thiopentone usage as induction agent for parturients was challenged by Propofol, and it has been a subject of debate over the last decade. The introduction of Rocuronium-Sugammadex combo has also been successful in stealing the interest of obstetric anaesthetists. Opiod and nitrous oxide usage are also among the subjects of current debate. This lecture will bring us into looking at current practice of caesarean section under GA around the globe, and its suitability in Malaysian context

PEriOPErativE transOEsOPhagEal EchOcardiOgraPhy: advantagEs and liMitatiOns

Neville GibbsDepartment of anaesthesia, sir Charles gairdner Hospital, Nedlands, Western australia

Transoesophageal echocardiography (TOE) has many advantages over other methods of haemodynamic assessment and cardiac monitoring in the perioperative period. TOE can be used to assess and quantify left ventricular and right ventricular function, cardiac valvular lesions, intracardiac volumes, pressures and flows, pericardial and aortic pathologies, and congenital cardiac anomalies, all in real time, both before and after surgical interventions. It can also be used to assist and confirm the correct placement of intracardiac catheters required for some surgical procedures. Other monitors could fulfil some, but not all of these roles, and possibly without the same degree of accuracy. For these reasons, TOE is now recommended for most open cardiac and thoracic aortic procedures, some coronary artery bypass procedures, and some non-cardiac procedures ‘where patients have known or suspected cardiovascular pathology which may impact outcomes’1. It may be considered mandatory for some catheter-based intracardiac procedures. There is a much wider range of indications in critically ill patients who would otherwise benefit from transthoracic echocardiography (TTE), but in whom TTE is not possible.

Other advantages of TOE include the minimal costs of disposables required for each examination (unlike many other monitoring modalities), and the relative safety of its use in experienced hands. Most of the costs per individual patient are related to cleaning and sterilisation. Serious morbidity is extremely rare. These advantages apply even more to TTE.

The limitations of TOE relate mainly to the initial purchase costs, which are considerable, and the fundamental requirement for appropriate training. Training is required for its safe use, image acquisition, image interpretation, pressure and flow measurements, and recognition and quantification of pathology. This cannot be achieved without extensive hands-on supervised experience and detailed knowledge of the theoretical principles on which TOE is based. Many societies and colleges have published recommendations for the minimum training and experience required for the use of TOE, including specific requirements for accreditation in its use. Another practical limitation is the discomfort involved for awake patients, although this rarely applies intraoperatively. TOE is also contraindicated in patients with known oesophageal pathology. The major limitation, however, is potential misuse leading to injury, or to incorrect interpretation of the information obtained, which could lead to inappropriate haemodynamic management or incorrect surgical decisions. These serious potential limitations highlight the importance of appropriate training, ongoing education, and audit and quality assurance.

1. Hahn RT, Abraham T, Adams MS. Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. Anesth Analg 2014; 118: 21-68.


SympoSium 12CARDIAC ANAESTHESIA

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hEMOdynaMic MOnitOring: rOad tOWards nOn invasivE!Hasmizy Bin Muhammad

Hospital Raja Perempuan Zainab II, Kota Bharu, Kelantan, Malaysia

Hemodynamic monitoring is aimed at maintaining adequate oxygen delivery to the tissues while cardiac output is the principal determinant of tissue oxygen delivery. Methods to calculate the cardiac output in almost non-invasive include the pulse wave analysis, Doppler, Echocardiography, Gas breathing, Bioimpedance and Bioreactance.

Pulse wave analysis methods can be divided in two groups, ‘autocalibrated’: FloTrac/Vigileo, LidCO rapid, Nexfin and esCCO and externally calibrated: PiCCOplus , EV1000 and LidCO plus.

FloTrac derives the SV from the pulse pressure of the arterial waveform, after correcting for the compliance and the resistance of the arterial system. LidCO rapid system based on the same algorithm as LidCO plus but relies on nomograms for the calculation of the CO. In Nexfin, finger arterial pressure is reconstructed into brachial arterial pressure waveform using a transfer function for determining continuous CO. esCCO derives the CO using the Pulse Wave Transit Time (PWTT), which is obtained from pulse oximetry and the ECG signals.

PiCCO plus uses the transpulmonary thermodilution for calibration and pulse pressure analysis to provide continuous real-time assessment of the CO. EV1000/VolumeView displays the global end-diastolic volume, extravascular lung water and global ejection fraction. LiDCO plus uses a lithium-based dye-dilution technique to calibrate its pulse contour analysis to determine stroke volume and CO.

Transesophageal, transthoracic echocardiography and Esophageal Doppler measured blood velocity and calculate cross sectional area to determine stroke volume. Bioreactance measured the phase shifts from alternating currents that applied across the chest. It is almost linearly to blood flow in the aorta. NICO uses Fick’s principle applied to carbon dioxide (CO2) for CO measurement. Masimo has Perfusion Index and Pleth variability index for peripheral blood flow and fluid responsiveness assessment.

In conclusion, less to non-invasive hemodynamic monitors can give reliable measurements of CO and dynamic variables.

iMPlantaBlE cardiOvErtEr dEFiBrillatOr: kEy anaEsthEsia issuEsYong Chow Yen

Unit Cardiothoracic dan Perfusi, Jabatan Bius dan Rawatan Rapi, Hospital Pulau Pinang, Pulau Pinang, Penang, Malaysia

Learning ObjectivesAt the end of the session, the participants should be able to

1. Briefly describe the functions cardiac implantable electronic devices (CIEDs) including implantable cardioverter defibrillator (ICD)

2. Explain the effects of electromagnetic interference (EMI) on CIED functions

3. Explain the caution against routine use of a magnet on an ICD

4. Outline the perioperative management of patients with CIEDs, including

• afocusedpreoperativeevaluationandpreparation

• managementofEMI

• appropriatemonitoring

• treatmentofpacemakerfailure

• post-operativere-interrogationandrestorationofCIEDfunction



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diFFicult airWay… What tO dOMafeitzeral Mamat

Department of anaesthesiology & Critical Care, Faculty of Medicine, UiTM Hospital, sungai Buloh, selangor, Malaysia

The knowledge of managing difficult airway is of second nature to the anaesthetists. However having this knowledge alone can be detrimental if it is not shared and organized well amongst the operation theatre members ie the surgeon, nurses and technicians.

Crisis management requires effective leadership, active team members, optimizing resources and holistic understanding of the situation. Most often communication breakdown and unmatched expectations between the anaesthetists and his/her staff would be the main factor when looked upon retrospectively after a crisis.

Regular multidisciplinary team simulation training is essential in the department to ensure the core understanding of everybody’s role. It covers the preparation, ongoing crisis algorithm and understanding the function of each equipment prepared. Airway crisis might not be of everyday tragedy, but when it happens all team members should automatically fit into their roles while organizing the chaos.

transPOrtatiOn OF thE critically ill PatiEnt (FrOM Ot tO icu)Nor Aizi Bt Md Zain

selayang Hospital, selayang, selangor, Malaysia

This presentation aims to highlight the importance of good preparation for transportation of the critically ill patients (especially from OT to ICU).

The critically ill patients have much reduced physiological reserves. Hence, they are often unstable, requiring supports such as ventilatory and vasoactive substances.

Taking into considerations of all possible adverse events during this intra-hospital transfer, careful plannings must be diligently made in order to transfer these patients safely.

All staff must be well versed with the protocols and procedures involved during this transport.

Thank You.

SympoSium 13ALLIED HEALTH


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drugs in anaEsthEsia: uPdatEsAzrin Mohd Azidin

Jabatan anaesthesia & Rawatan Rapi, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

IntroductionSince the advent of modern anaesthesia, advances in research and technology have contributed to the development of new anaesthetics with better pharmacological profile. In our pursuit of ideal anaesthetics through the years, discoveries of various compounds have been made, but many were subsequently replaced by another. Features of an ideal drug is in conception at best and as a result we are faced with a multitude of drugs each with claims of superiority over the other. This presentation will highlight recently available anaesthetics locally and will include a pharmacological review of a few drugs from the various groups of anaesthetics.

Pharmacological Review of recently available drugs In Malaysia:• Non-depolarizingneuromuscularblockingagentCis-atracurium

• NeuromuscularblockerreversalSugammadex

• Opioids:Remifentanil

FutureThere is an expanding body of evidence in the field of Regional Anaesthesia in the area of tumour recurrence and chronic pain. With the interest in prolongation of perioperative analgesia, more extensive trials have begun on the use of the extended release Local anaesthetics: Exparel (Liposomal Bupivacaine). Preliminary studies have also shown promise in the use of Toxins as Local anaesthetics.

ConclusionUnderstanding the pharmacological effects of these anaesthetics will improve safety and can optimize ways in which the drugs can be used during patient care.


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The effects Of Intraoperative IV Paracetamol On Post Supratentorial Craniotomy Pain 50Mohd Fahmi Lukman1, Asmarawati Mohammad Yatim2, Mohamed Saufi Awang3, Chan Kin Hup3, Azura Sharena Yahaya4

1Department of anesthesiology and Critical Care, Kulliyyah of Medicine, International Islamic University Malaysia, Malaysia 2Department of anesthesiology and Intensive Care, Hospital Tengku ampuan afzan, Kuantan, Pahang, Malaysia 3Neurosurgery Unit, Department of surgery, Kulliyyah of Medicine, International Islamic University Malaysia, Malaysia 4Department of Radiology, Kulliyyah of Medicine, International Islamic University Malaysia, Malaysia

High PeeP Setting Versus Vital Capacity Manoeuvre During General Anaesthesia: 51 A Comparison On The effect Of Respiratory functionsSabri Dewa1, Raha Abdul Rahman2, Wan Rahiza Wan Mat2, Nurlia Yahya2, Adnan Dan2, Norsidah Abdul Manap2

1Hospital Kuala Lumpur, Kuala Lumpur, Malaysia 2Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia

Don’t Worry, Block Deeply! A Randomized Controlled Trial Comparing 52 Deep-Block Reversal By Sugammadex And Moderate-Block Reversal By NeostigmineMaria Lee H S1, Rahmat A H1, Azmiza M1, Tey W Y1, Ngoh C E1, Nuzul M1, Balan S1, Ooi Q X2, Amar-Singh H S S2, Sondi Sararaks3

1Hospital sultanah aminah, Johor, Malaysia 2Hospital Ipoh, Perak, Malaysia 3Institute for Health systems Research, Ministry of Health Malaysia

Comparing The efficacy Of Granisetron And ketamine for The Prevention Of 53 Shivering In Patients Undergoing Spinal AnaesthesiaS H Teoh1, E Kamaruzaman1, C A Ang2, K Zainuddin1, M Maaya1, C Y Lee1 1University Kebangsaan Malaysia Medical Centre (UKMMC), Kuala Lumpur, Malaysia 2Hospital Pulau Pinang, Penang, Malaysia

Target-Controlled Infusion Remifentanil Versus Bolus Dosed fentanyl In Coronary 54 Artery Bypass Graft Surgery : Comparing Postoperative Analgesic RequirementKhairulamri Abdul Wahab1, Azarinah Izaham1, Yong Chow Yen2, Wan Rahiza Wan Mat1, Nurlia Yahya1, Nadia Md Nor1

1Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia 2Hospital Pulau Pinang, Pulau Pinang, Malaysia

The efficacy of Spinal Anaesthesia for Sequential Bilateral Total knee Arthroplasty. 55 A Retrospective Cohort Comparison Of Intrathecal Isobaric Levobupivacaine And Hyperbaric BupivacaineC K Chen1, Francis C S Lau1, W G Lee1, V E Phui2

1Kuching specialist Hospital, sarawak, Malaysia 2sarawak general Hospital, sarawak, Malaysia

MSAAWARD/MSA-AStRAZeneCAYOUngInVeStIgAtORAWARD

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thE EFFEcts OF intraOPErativE iv ParacEtaMOl On POst suPratEntOrial craniOtOMy Pain

Mohd Fahmi Lukman1, Asmarawati Mohammad Yatim2, Mohamed Saufi Awang3, Chan Kin Hup3, Azura Sharena Yahaya4

1Department of anesthesiology and Critical Care, Kulliyyah of Medicine, International Islamic University Malaysia, Malaysia 2Department of anesthesiology and Intensive Care, Hospital Tengku ampuan afzan, Kuantan, Pahang, Malaysia

3Neurosurgery Unit, Department of surgery, Kulliyyah of Medicine, International Islamic University Malaysia, Malaysia 4Department of Radiology, Kulliyyah of Medicine, International Islamic University Malaysia, Malaysia

Background and ObjectivesPain management in craniotomy patients is challenging, not only limited to pain intensity but these patients require frequent neurological examinations and therefore not suitable for postoperative opioids therapy. In contrast to opioids, IV Paracetamol does not produce sedation and respiratory depression. The aim of this study was to determine whether IV Paracetamol administered before skin incision and during skin closure reduced pain score and morphine consumption within 24 hours after surgery.

Methods50 patients presenting for supratentorial craniotomy with standardized general anesthesia TCI propofol-remifentanil were included in the study. 25 patients received IV Paracetamol 1 gram 30 minutes before skin incision and during skin closure. All patients received IV Fentanyl 1.0 mcg/kg 20 minutes before end of surgery and followed by patient-controlled Morphine. Postoperatively, all patients were admitted into ICU and pain was assessed in the fully awake patient after extubation (hour 0) and at hour 1,2,4,6,12 and 24 using visual analog score. Morphine consumption and opioids related side effects were recorded within 24 hours after surgery.

Results32 patients who were extubated immediately after the surgery included in analyses, 18 patients were remained intubated more than 24 hours for postoperative stabilization. 14 patients (44%) received intraoperative IV Paracetamol. Pain scores at multiple time points were significantly lower in patients who received IV Paracetamol (P<0.05). There were significant differences between the two groups in morphine consumption (P<0.005) and opioids related side effects (P<0.05).

ConclusionsIV Paracetamol as one of the multimodal analgesia improved pain control, reduced opioid requirement and side effects in post supratentorial craniotomy patients.

mSa award / mSa-aZ yia

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high PEEP sEtting vErsus vital caPacity ManOEuvrE during gEnEral anaEsthEsia: a cOMParisOn On thE EFFEct OF rEsPiratOry FunctiOns

Sabri Dewa1, Raha Abdul Rahman2, Wan Rahiza Wan Mat2, Nurlia Yahya2, Adnan Dan2, Norsidah Abdul Manap2


BackgroundVentilation strategies promoting intraoperative lung recruitment may improve respiratory function parameters following general anaesthesia.

ObjectiveThis prospective, randomised, single blind study compared the effect on respiratory function parameters when different ventilation strategies were applied during general anaesthesia.

MethodsForty six ASA I or II patients who underwent orthopaedic or minor surgical procedures under general anaesthesia were randomised into Group PEEP (n=23), where positive end expiratory pressure (PEEP) of 8 cm H2O was given intraoperatively and Group VCM (n=23), where PEEP of 5 cm H2O was given intraoperatively with vital capavity manoeuvre (VCM) in which the lungs were ventilated up to 40 cm H2O peak inspiratory pressure for 15 minutes, applied 30 minutes prior to extubation. Measurement of forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), FEV1/FVC ratio, peak expiratory flow rate (PEFR) were recorded during preoperative assessment (baseline), 1 hour and 24 hours post- extubation. Arterial blood gases were also recorded at these times, plus at 30 minutes post-intubation.

ResultsIn both groups, significant depression of all the respiratory function parameters occurred at 1 hour post-extubation as compared to baseline (p<0.05) but it was not significantly different between the groups (p>0.05). At 24 hours, the respiratory function parameters of both groups were similar to their baselines and were comparable between the two groups (p>0.05).

ConclusionWe concluded that applying intraoperative ventilation strategies of PEEP 8 cm H2O or PEEP 5 cm H2O with VCM had similar effects on respiratory function parameters postoperatively.


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dOn’t WOrry, BlOck dEEPly! a randOMizEd cOntrOllEd trial cOMParing dEEP-BlOck rEvErsal By sugaMMadEx and MOdEratE-BlOck rEvErsal By

nEOstigMinEMaria Lee H S1, Rahmat A H1, Azmiza M1, Tey W Y1, Ngoh C E1, Nuzul M1, Balan S1, Ooi Q X2,

Amar-Singh H S S2, Sondi Sararaks3

1Hospital sultanah aminah, Johor, Malaysia 2Hospital Ipoh, Perak, Malaysia

3Institute for Health systems Research, Ministry of Health Malaysia

AimsThis trial aimed to evaluate the rapidity and reliability of muscle power recovery at the end of surgery as well as intra-operative quality of paralysis comparing two intra-operative neuromuscular blockade techniques: deep blockade with rocuronium infusion followed by sugammadex reversal (CI-sugammadex technique) versus moderate neuromuscular blockade using intermittent boluses of rocuronium followed by neostigmine reversal (IB-neostigmine technique).

MethodsFifty patients who underwent midline laparatomy were randomized into 2 treatment arms: CI-sugammadex arm were kept deeply paralyzed (post-tetanic count of 1-2) intraoperatively while IB-neostigmine arm maintained at moderate paralysis (train-of-four-count of 1-2). At the end of surgery, subjects were reversed at 2 different depths of paralysis with sugammadex and neostigmine respectively. Timing for extubation was decided by blinded anaesthetist. Quality of paralysis was rated by surgeons using visual analogue scale (VAS) of 0mm-100mm. Patients were monitored for speed of recovery to train-of-four-ratio (TOFR) of 0.9 and occurrence of residual blockade in recovery

ResultsCompared to IB-neostigmine, CI-sugammadex arm had 3.8 times shorter recovery time to TOFR=0.9 with a geometric mean (95%CI) of 4.9 (3.4-7.1) vs.18.6 (12.4-27.7) min (p<0.001], lower risk of premature extubation where tracheal extubation occur before TOFR=0.9 (0.27 vs. 0.78; relative risk= 0.35, 95%CI 0.17- 0.71) and lower incidence of residual blockade in recovery bay (31.8% vs. 91.3%, p<0.001). No significant difference in mean time to extubation (95%CI) [14.3 (12.1-16.4) vs. 15.7 (12.6-18.7) min, p=0.439] and mean VAS (86.1mm vs. 80.7mm, 95%CI of the difference -1.07, 11.87) were observed in CI-sugammadex and IB-neostigmine arm respectively.

ConclusionsContinuous infusion deep-block with sugammadex reversal technique improved quality of intra-operative paralysis with rapid and reliable recovery. Risk of premature extubation and residual blockade was markedly lower. This should be the technique of choice for patient safety and surgeon satisfaction.


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cOMParing thE EFFicacy OF granisEtrOn and kEtaMinE FOr thE PrEvEntiOn OF shivEring in PatiEnts undErgOing sPinal anaEsthEsia

S H Teoh1, E Kamaruzaman1, C A Ang2, K Zainuddin1, M Maaya1, C Y Lee1 1University Kebangsaan Malaysia Medical Centre (UKMMC), Kuala Lumpur, Malaysia

2Hospital Pulau Pinang, Penang, Malaysia

ObjectiveThis prospective, randomized, double-blind placebo-controlled trial was conducted to evaluate the efficacy of granisetron and ketamine for the prevention of shivering during spinal anaesthesia.

MethodsA total of 90 patients with ASA classification I and II, aged between 20 and 60 years old scheduled for elective orthopaedic lower limb surgery under spinal anaesthesia were recruited. Patients were randomly allocated to receive either intravenous (IV) ketamine 0.25 mg/kg, granisetron 40 mcg/kg or normal saline as control before an intrathecal injection of 12 mg 0.5% hyperbaric bupivacaine. The incidence and severity of shivering then were recorded during surgery.

ResultsThe incidence of shivering associated with spinal anaesthesia in our study was 43.3% in the control group which was significantly higher when compared to ketamine (10.0%) and granisetron group (10.0%), p < 0.05. However, there was no significant difference between the ketamine and granisetron group.

ConclusionIV ketamine 0.25 mg/kg had a similar efficacy when compared to IV granisetron 40 mcg/kg in preventing shivering during spinal anaesthesia for elective orthopaedic lower limb surgery.


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targEt-cOntrOllEd inFusiOn rEMiFEntanil vErsus BOlus dOsEd FEntanyl in cOrOnary artEry ByPass graFt surgEry : cOMParing POstOPErativE

analgEsic rEQuirEMEntKhairulamri Abdul Wahab1, Azarinah Izaham1, Yong Chow Yen2, Wan Rahiza Wan Mat1,

Nurlia Yahya1, Nadia Md Nor1

1Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia 2Hospital Pulau Pinang, Pulau Pinang, Malaysia

BackgroundHigh dose fentanyl for anaesthetic induction in coronary artery bypass graft (CABG) surgery effectively obtunds sympathetic responses whilst maintaining stable haemodynamics. However, doses ranging 20-30 µg/kg risks delayed patient awakening, extubation and may result in postoperative respiratory depression. Remifentanil, an ultra-short acting opioid may be a favourable alternative to fentanyl.

ObjectiveCompare postoperative morphine consumption, pain score and time to patient extubation after remifentanil target-controlled infusion (TCI) versus bolus dosed fentanyl, post CABG surgery.

MethodsSixty patients were randomly assigned to receive anaesthetic induction and intraoperative analgesia with either TCI remifentanil (Group R) or bolus dosed fentanyl (Group F). Both groups received morphine intraoperatively, and patient controlled morphine analgesia with oral paracetamol postoperatively.

ResultsMorphine requirement and pain score (using the visual analogue scale (VAS)) were documented at 4, 8, 12, 24, 36 and 48 hours postoperatively. Cumulative morphine was comparable at 48 hours (p=0.09) and not significantly different at prior intervals of assessment. At the fourth hour postoperatively, median VAS score was significantly higher in Group R, at rest and with movement (p=0.04. 0.02 respectively); however, morphine requirement was comparable (p=0.10). Pain scores were comparable between groups at subsequent intervals. The time taken from skin closure to extubation was significantly shorter in Group R compared to Group F (p = 0.04).

ConclusionMorphine requirement at all observed time intervals were comparable between TCI remifentanil and bolus dosed fentanyl groups. Pain scores were comparable except for the fourth hour, where it was significantly higher in the remifentanil group. Patients in the remifentanil group were also extubated significantly earlier.


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thE EFFicacy OF sPinal anaEsthEsia FOr sEQuEntial BilatEral tOtal knEE arthrOPlasty. a rEtrOsPEctivE cOhOrt cOMParisOn OF intrathEcal

isOBaric lEvOBuPivacainE and hyPErBaric BuPivacainEC K Chen1, Francis C S Lau1, W G Lee1, V E Phui2

1Kuching specialist Hospital, sarawak, Malaysia 2sarawak general Hospital, sarawak, Malaysia

IntroductionLow dose subarachnoid bupivacaine or levobupivacaine has been shown to be efficacious and safe in lower limb and lower abdominal surgeries. There is no study yet comparing higher dosage of intrathecal bupivacaine with intrathecal levobupivacaine for longer duration surgery. Given the possibility of clinical application of higher dosage of intrathecal local anesthetic for surgery of longer duration, we evaluated the efficacy and safety of higher dosage of intrathecal levobupivacaine and hyperbaric bupivacaine for patients undergoing sequential bilateral TKA in this retrospective cohort study.

MethodsA total of 156 medical records of patients underwent sequential bilateral TKA under spinal anaesthesia in the year 2012 and 2013 were reviewed. Data on dermographic, episode of vasopressor usage and intraoperative analgesia supplement, and postoperative morbidity were collected and compared between 2 groups of spinal anaesthesia. Group A: isobaric levobupivacaine (n=100) and group B: hyperbaric bupivacaine with fentanyl 25mcg (n=56).

ResultsMean dose of 28.7mg (range 25-30mg) isobaric levobupivacaine was used in group A and mean dose of 18.6mg (range 17.5-20mg) hyperbaric bupivacaine with fentanyl 25mcg was used in group B. There was no significant difference in both surgical and anaesthesia duration for both groups. Group B have significant more episodes of vasopressor usage (p<0.05) and intraoperative analgesia supplement (p<0.05) compared with group A. Postoperative bleeding was significantly higher in group B compared with group A (p<0.001). There was no significant different in incidence of postoperative nausea and vomiting between the two groups (p=0.166).

ConclusionThis study suggests that higher dosage of intrathecal levobupivacaine could be a safe and efficacious choice of anaesthesia for surgery of longer duration. The favourable hemodynamic profile with high dosage intrathecal levobupivacaine warrants further study.


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01 Comparing Remifentanil And fentanyl On Haemodynamic Response To 60 Tracheal Intubation Duringrapid Sequence Inductionof Anaesthesia

G E Xavier, C Y LeeUniversiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia

02 Combined Spinal-epidural Analgesia In Labour: Its effects On Delivery 61 Outcome

Suneet Kaur Sra Charanjit Singh1, Nurlia Yahya1, Karis Misiran2, Azlina Masdar1, Nadia Md Nor1, C Y Lee1 1Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia 2Universiti Teknologi MaRa, Jalan Hospital, Malaysia

03 A Clinical Audit On endotracheal Tube Cuff Pressure In The Intensive Care Unit 62 Of Hospital Pulau Pinang

L W Luah, Jahizah, T W Wong, H C WeeHospital Pulau Pinang, Pulau Pinang, Malaysia

04 Assessment Of Speed And ease Of Insertion Of Supreme™ Laryngeal Mask 63 And i-gel™ By final year Medical Students: A Manikin Study

E L Khoo, Noorjahan H M HashimUniversity of Malaya, Kuala Lumpur, Malaysia

05 Comparison Between Total Intravenous Anaesthesia And Inhalational 64 Anaesthesia: Changes In Respiratory function And Oxygen Saturation After Lumbar Surgery

Fakhirudin Mohd Razali, Norsidah Abdul Manap, Azarinah Izaham, Nadia Md Nor, Wan Rahiza Wan Mat, Nurlia YahyaUniversiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia

06 effect of Preoperative Dexamethasone On Postoperative Sore Throat 65 After endotracheal Intubation

Norbaniza Mohd Nordin1, Nik Azizah Nik Junoh1, Esa Kamaruzaman2, Khairulamir Zainuddin2, Karis Misiran3

1Hospital Kuala Lumpur, Kuala Lumpur, Malaysia 2Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Kuala Lumpur, Malaysia 3Faculty of Medicine, Universiti Teknologi MaRa (UITM), sg Buloh, Malaysia

07 Postoperative Pain Management In Children: A Retrospective Review 66 Of Acute Pain Services from January 2013 To December 2013 In University Malaya Medical Centre

Nadzrah S Y, I I ShariffuddinUniversity of Malaya, Kuala Lumpur, Malaysia

08 Comparison Of ease Of Intubation Between Glidescope® And C-Mac® 67 for Novices

Badariah Yatim1, Azlina Masdar2, Aliza Mohamed Yusof2, Shereen Tang Suet Ping2, Nurlia Yahya2, Muhammad Maaya2

1Hospital sultan Ismail, Johor Bahru, Johor, Malaysia 2Univesiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia

POSteRPReSentAtIOnS

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POSteRPReSentAtIOnS[COnt’D]

09 Normal Saline Versus Balanced-Salt Solution (Sterofundin® ISO) As 68 Intra-Operative fluid Therapy In Neurosurgery: The effects On Acid-Base Balance, electrolyte Status And Serum Osmolarity

Hafizah Mohamed, Chian Yong Liu, Joanna Su Min OoiUnivesiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia

10 A Comparison Of The Airtraq® And Macintosh Laryngoscope: Use 69 In easy And Simulated Difficult Airways By House Officers

Mohd Nazir Md Salleh1, Nor Mohammad Md Din1, Aliza Mohamad Yusof2, Esa Kamaruzaman2, Khairulamir Zainuddin2

1Hospital Kuala Lumpur, Kuala Lumpur, Malaysia 2Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Kuala Lumpur, Malaysia

11 Anaesthetic Management for Surgical Correction By ‘CHULA Technique’ 70 Of frontoethmoidal encephalomeningocele In Children: A Review Of 9 Cases

Z Habibullah1, R Leelanukrom2

1Department of anaesthesiology, Paediatric Institute, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia 2Department of anaesthesiology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand

12 Peripheral Nerve Blocks In Hospital Raja Permaisuri Bainun (HRPB): 71 A Review 2012 – 2013

Azlina M¹, Kavita B¹, Alvin S¹ , Sarimah A¹, Farah M N¹, Norlaili Y¹, Mohd Zamri M A²¹Hospital Raja Permaisuri Bainun (HRPB), Ipoh, Perak, Malaysia ²Perak state Health Department, Ipoh, Perak, Malaysia

13 Comparing Haemodynamic And Uterotonic effects Of Oxytocin 3 IU 72 With 5 IU Bolus During Caesarean Section Under Spinal Anaesthesia

Z Z Zainal1, T Abd Razak1, C Y Lee2


14 Comparing The effectiveness Of Ropivacaine 0.5% Versus Ropivacaine 0.2% 73 for Transabdominis Plane Block In Providing Postoperative Analgesia After Appendicectomy

Reymi Marseela Abdul Jalil1, Nurlia Yahya1, Omar Sulaiman2, Wan Rahiza Wan Mat1, Rufinah Teo1, Azarinah Izaham1, Raha Abdul Rahman1 1Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia 2Hospital sultanah aminah, Johor Bahru, Johor, Malaysia

15 Case Report: Severe Metabolic Acidosis And Spontaneous Pneumothorax 74 With Severe Bronchopleural fistula During emergency Caesarian Section

Nur Hafiizhoh Abd-Hamid, Murniati MustafaDepartment of anaesthesiology and Intensive Care, Hospital enche’ Besar Hajjah Khalsom, Kluang, Johor, Malaysia

16 Pneumocephalus After Combined Spinal epidural Using Loss-Of-Resistance 75 To Air Technique : A Case Report

Wan Salwanis W I, Yamminidevi L, Kavita BHospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia

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17 A Rare Case Of Pulmonary Arteriovenous Malformation (PAVM) In 76 A Pregnant Lady Underwent elective Lower Segment Caesarian Section

YY Phang , Norzalina Esa, Norsaliza Isarawak general Hospital, sarawak, Malaysia

18 Anaesthesia Management Of Awake Craniotomy: Universiti kebangsaan 77 Malaysia Medical Centre (UkMMC) experience With ‘Asleep-Awake-Asleep’ (AAA) Technique

Esa Kamaruzaman, Ramesh Kumar, Muhammad Zurrusydi Zainuddin, Khairulamir Zainuddin, Adnan DanUniversiti Kebangsaan Malaysia Medical Centre (UKMMC), Kuala Lumpur, Malaysia

19 Patients’ Understanding On The Status And Role Of Anaesthesiologists 78 As Healthcare Providers

Maryam Budiman, Esa Kamaruzaman, Azlina Masdar, Khairulamir Zainuddin, Jaafar Md Zain, Adnan DanUniversiti Kebangsaan Malaysia Medical Centre (UKMMC), Kuala Lumpur, Malaysia

20 A Clear Vocal Cord But A Blind Oral Cavity 79Rahimah AR, Ismaliza I, MS Kok, Azrin MA, V SivasakthiHospital Kuala Lumpur, Kuala Lumpur, Malaysia

21 Audit On Practice Of Peripheral Nerve Block 80N M K Amiruddin, M A AzrinDepartment of anaesthesiology, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

22 An Unfortunate Case Of Arachnoiditis following A Central Neuraxial Block 81Cindy T J, M S Kok, Sivasakthi V, R S ChanHospital Kuala Lumpur, Kuala Lumpur, Malaysia

23 Preemptive Analgesia With Oral Gabapentin In Reducing 82 Postoperative Pain After Gynaecological Surgery

Ban Chung Poh1, Chian Yong Liu1, Shanti Rudra Deva2, Joanna Su Min Ooi1 1Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Kuala Lumpur, Malaysia 2Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

24 Comparison Of Clinical Performance Between I-gel™ And 83 Ambu® Aura 40™ Laryngeal Mask Airway

Lee San Tay1, Joanna Su Min Ooi1, Cheng Cheng Tan2, Chian Yong Liu1

1Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Kuala Lumpur, Malaysia 2Hospital sultanah aminah, Johor Bahru, Johor, Malaysia

25 Non-Technical Skills Of Anaesthetic Specialists In Operation Theatre, 84 A Survey In Department Of Anaesthesiology, Tengku Ampuan Rahimah Hospital, klang

Muralitharan Perumal , Sebastian Sundaraj , F A Isa Tengku ampuan Rahimah Hospital, Klang, selangor, Malaysia

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26 Critical Decision Making In Anaesthetic Practices; A Case Report 85Mat Ramlee Md Tahir1, Sakthi A Nathan2, Puzizer M S2, Lily Ng2

1Department of Cardiothoracic anaesthesia and Perfusion, Hospital Queen elizabeth II, Kota Kinabalu, sabah, Malaysia 2Department of anaesthesia and Intensive Care, Hospital Queen elizabeth II, Kota Kinabalu, sabah, Malaysia

27 knowledge, Attitude And Practice Of Paediatric Critical Care Nurses 86 Towards Pain: A Survey In Hospital Raja Permaisuri Bainun, Ipoh

D Krisnan1, E L Chew2, K Ramalingam2, P H Loo3 1Department of anaesthesiology & Intensive Care, Pain Management Clinic, Hospital Raja Permaisuri Bainun, Ipoh , Perak, Malaysia 2Department of Paediatrics, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia 3Department of anaesthesiology & Intensive Care, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia

28 Multimodal Approach To Pain Management In ‘Bertolotti’s Syndrome’ 87Ahmad Afifi M A1, Cardosa M S1, S H Sulaiman2, Ng K S1, Seet S N1, Khoo E L1

1Department of anaesthesia and Intensive Care, Hospital selayang, selayang, selangor, Malaysia 2Department of Orthopaedics, Faculty of Medicine, Universiti Teknologi MaRa, shah alam, selangor, Malaysia

29 Optimizing Preventive Analgesia Strategy With Postoperative 88 Peripheral Nerve Blocks

Ahmad Afifi M A, Cardosa M S, Ng K SDepartment of anaesthesia and Intensive Care, Hospital selayang, selayang, selangor, Malaysia

30 Acute Airway In A Case of Central Venous Occlusion Post Catheter 89 Placements, A Case Report

S S Yap, S K Cheah, L W Luah, C H Lim, Jahizah HassanDepartment of anaesthesia & Intensive Care, Hospital Pulau Pinang, Penang, Malaysia

31 The Management Of Increased Intracranial Pressure And Refractory 90 Bradycardia In A Child

Ramanesh K Mageswaran, Vanitha SivanesarHospital Kuala Lumpur, Kuala Lumpur, Malaysia

32 Report Of A Case Of Tourniquet- Induced Rhabdomyolysis After 90 Arthroscopic knee Surgery

Woon Lai Lim1, Tashna2, Rohayu Othman3

2Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

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cOMParing rEMiFEntanil and FEntanyl On haEMOdynaMic rEsPOnsE tO trachEal intuBatiOn duringraPid sEQuEncE inductiOnOF anaEsthEsia

G E Xavier, C Y LeeUniversiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia

Background & ObjectiveRapid sequence induction (RSI) of anaesthesia is often associated with tachycardia and hypertension. Remifentanil, having a rapid onset and offset of action, may be useful to obtund such responses. This prospective, randomized, double-blinded study was undertaken to compare haemodynamic response to tracheal intubation with remifentanil and fentanyl during RSI.

MethodsForty two ASA I-II patients aged 18-60 years scheduled for emergency surgery under general anaesthesia with tracheal intubation were recruited and randomized into Group A (remifentanil 0.75 µg/kg), Group B (remifentanil 1 µg/kg) and Group C (fentanyl 2 µg/kg). Following test drug administration, RSI with cricoid pressure was performed using propofol 2 µg/kg and suxamethonium 1.5 µg/kg. Endotracheal intubation was carried out 1 min later. Haemodynamic parameters were recorded at baseline (T0), immediately after RSI (T1), before laryngoscopy (T2) and post-intubation at 1-min intervals for 5 min (T3-T7).

ResultsAll groups revealed significant changes in mean MAP and HR from baseline. Haemodynamic profile of both remifentanil groups was comparable throughout the study. While mean MAP was significantly lowered in Group A and Group B, Group C showed fluctuations both above (T5, T6) and below (T4, T7) baseline. Mean HR remained below baseline values throughout the study period in Group A and Group B. Group C showed a significantly greater mean HR at induction (T1), before laryngoscopy (T2) and 1 min following intubation (T3). The incidences of hypotension and bradycardia were comparable in all three groups.

ConclusionBoth remifentanil 0.75 µg/kg and 1 µg/kg were superior compared to fentanyl 2 µg/kg in obtunding haemodynamic responses during RSI in patients scheduled for emergency surgery. No significant differences were observed between the two doses of remifentanil.

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cOMBinEd sPinal-EPidural analgEsia in laBOur: its EFFEcts On dElivEry OutcOME

Suneet Kaur Sra Charanjit Singh1, Nurlia Yahya1, Karis Misiran2, Azlina Masdar1, Nadia Md Nor1, C Y Lee1

1Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia 2Universiti Teknologi MaRa, Jalan Hospital, Malaysia

BackgroundCombined spinal-epidural (CSE) has become an increasingly popular alternative to traditional labour epidural due to its rapid onset and reliable analgesia.

ObjectiveThis was a prospective, convenient sampling study to determine the effects of CSE analgesia on labour outcome.

MethodsOne hundred and ten healthy primigravida parturients with a singleton pregnancy of ≥ 37 weeks gestation, in the active phase of labour were studied. They were enrolled to the CSE (n = 55) or Non-CSE (n = 55) group based on whether they consented to CSE analgesia. Non-CSE parturients were offered other methods of labour analgesia. The duration of first and second stage of labour, rate of instrumental vaginal delivery/emergency caesarean section and Apgar scores were compared.

ResultsThe mean duration of first and second stage of labour was not significantly different between both groups. Instrumental delivery rates between the groups was not significantly different (CSE group, 11% versus Non-CSE group, 16%). The slightly higher incidence of caesarean section in the CSE group (16% versus 15% in the Non-CSE group) was not statistically significant. Neonatal outcome in terms of Apgar score of less than 7 at 1 and 5 minutes, was similar in both groups.

ConclusionThere were no significant differences in the duration of labour, rate of instrumental vaginal delivery/emergency caesarean section and neonatal outcome in parturients who received compared to those who did not receive CSE for labour analgesia.

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62

a clinical audit On EndOtrachEal tuBE cuFF PrEssurE in thE intEnsivE carE unit OF hOsPital Pulau Pinang

L W Luah, Jahizah, T W Wong, H C WeeHospital Pulau Pinang, Pulau Pinang, Malaysia

This purpose of this audit is to establish the percentage of endotracheal tube cuffs which are properly inflated within the range of 25-30 cm H20.

This is a randomized audit performed by multiple operators at the Intensive Care Unit ( ICU) of Hospital Pulau Pinang. All patients who were admitted to the ICU with an endotracheal tube or cuffed tracheostomy tube were included. Data was collected for a total of 3 months (July 2013 – September 2013) or until a total of 300 samples have been collected. The timing of the data collection was block randomized into :

i) 8am – morning shift

ii) 2pm – afternoon shift

iii) 8pm – night shift

The cuff pressures were measured using VBM Cuff Pressure Gauge (REF 54-07-000) and was compared against the nursing charts. Demographic data such as age and gender were also recorded.

A total of 331 subjects were audited, of which 30 were excluded for various reasons. The mean age group was 47.34. There were 211 males and 107 females. ETT’s comprised 68.4% of the group and tracheostomies 31.6%. 77.6% of the nurses had more than 1 patient to nurse during their shift. Only 19.8% of the measured cuff pressure was within range compared to what was recorded 64.4%. This yields a compliance rate of only 19.8%. Based on Pearson chi square analysis, There is statistical significant difference between the shift of the nurses (X2= 17.381, df=2, p=0.001). PM Shift is 3.95 time (95% CI 1.78-8.75) more non-compliance in cuff pressure measurement compared to the AM shift. ON shift is 2.63 time (95% 1.46-4.76) non-compliance in cuff pressure measurement compared to the AM shift. Interestingly, regardless of the number of the patients taken care by a nurse, there no statistically significant difference between the ratio of the patients and nurses. (X2=0.845, df=1, p=0.358).

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assEssMEnt OF sPEEd and EasE OF insErtiOn OF suPrEME™ laryngEal Mask and i-gEl™ By Final yEar MEdical studEnts: a Manikin study

E L Khoo, Noorjahan H M HashimUniversity of Malaya, Kuala Lumpur, Malaysia

Background and ObjectivesAlthough placement of an advanced airway is vital during cardiopulmonary resuscitation, the 2010 European Resuscitation Council (ERC) and 2010 American Heart Association (AHA) guidelines stressed that it should be done with the least interruption to chest compressions. The use of supraglottic airway devices (SADs) is endorsed by both guidelines as the technique for insertion is simpler than endotracheal intubation especially for inexperienced healthcare providers. The objective of this study was to assess the speed and ease of insertion of two disposable SADs; Supreme™ Laryngeal Mask (LMA-S) and i-gel™ into a manikin by final year medical students.

MethodologyThis was a prospective, randomized crossover study involving 26 final year medical students. Insertion time, number of attempts, ease of insertion and presence of leak of both SADs were compared in an airway trainer. The students were then asked which device they preferred and why. Results were analyzed using Student’s t-test, Fisher’s exact test and chi-square analysis.

ResultsThe i-gel was faster to place with mean insertion time of 13.3 ± 1.4s (95% CI) compared to LMA-S 16.6 ± 1.3s (95% CI) (p<0.01). Nevertheless, the LMA-S was graded as easier to place (p<0.01) and the incidence of leak was lower (p<0.01). The success rate of insertion was similar. 73.1% chose the LMA-S as their preferred SAD with the main reason being the ease of insertion.

ConclusionBoth the LMA-S and i-gel were easily and rapidly inserted in this manikin study. Although the i-gel was faster to place, the LMA-S may be more superior due to the participants’ preference, ease of insertion and better seal.

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cOMParisOn BEtWEEn tOtal intravEnOus anaEsthEsia and inhalatiOnal anaEsthEsia: changEs in rEsPiratOry FunctiOn and

OxygEn saturatiOn aFtEr luMBar surgEryFakhirudin Mohd Razali, Norsidah Abdul Manap, Azarinah Izaham, Nadia Md Nor,

Wan Rahiza Wan Mat, Nurlia YahyaUniversiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia

BackgroundMost surgical procedures require general anaesthesia which can result in impaired respiratory function that may be aggravated by the surgical site and positioning of the patient intraoperatively. It is still uncertain if the newer, shorter acting anaesthetic drugs used in total intravenous anaesthesia (TIVA) as compared to inhalational anaesthesia (IA) affects respiratory parameters to the same extent.

ObjectiveThis prospective, randomised, single blind study compared the postoperative changes in basic respiratory functions in patients who had general anaesthesia with either TIVA or IA for lumbar surgery in the prone position.

MethodsFifty four ASA I or II patients undergoing lumbar spine surgery were recruited and randomised into two groups, TIVA group (n=27) and IA group (n=27). The forced expiratory volume in 1 sec (FEV1), forced vital capacity (FVC), FEV1/FVC ratio, peak expiratory flow rate (PEFR) and oxygen saturation (SpO2) were determined at baseline, and at 1, 6 and 24 hours post general anaesthesia.

ResultsIn the IA group, significant depression of both FEV1 and FVC were measured within 6 hours post general anaesthesia. In the TIVA group, only FEV1 was significantly reduced at 1 hour. The PEFR was significantly reduced in both groups at all intervals. The reduction of FEV1/FVC ratio in the IA group and the SpO2 in both groups were noted but this was not significant clinically. With the exception of the SpO2 reduction at the first hour post general anaesthesia, there were no significant differences in FEV1, FVC, FEV1/FVC ratio and PEFR between both groups.

ConclusionsThe general anaesthetic techniques TIVA and IA were both comparable in their reduction of the patients’ postoperative basic respiratory functions following lumbar surgery in the prone position.

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EFFEct OF PrEOPErativE dExaMEthasOnE On POstOPErativE sOrE thrOat aFtEr EndOtrachEal intuBatiOn

Norbaniza Mohd Nordin1, Nik Azizah Nik Junoh1, Esa Kamaruzaman2, Khairulamir Zainuddin2, Karis Misiran3


3Faculty of Medicine, Universiti Teknologi MaRa (UITM), sg Buloh, Malaysia

Objectives

This prospective, randomized, double-blind placebo controlled trial was conducted to determine the efficacy of preoperative intravenous dexamethasone and its dose-dependant effects in reducing the incidence of postoperative sore throat (POST), cough and hoarseness of voice after endotracheal intubation.

Methods

A total of one hundred and fifty patients aged between 18 to 60 years old, ASA status I or II who had been scheduled for elective surgery estimated to last between 1 to 5 hours, under general anaesthesia with endotracheal intubation were randomly allocated into three groups. Group 1 patients (n=50) as control group received normal saline, Group 2 patients (n=50) were given dexamethasone 4 mg and Group 3 patients (n=50) were given dexamethasone 8 mg after tracheal intubation. After induction of anaesthesia, the trachea was intubated with appropriate size disposable low pressure endotracheal tube (Portex® profile). Assessment for the presence and severity of sore throat, cough and hoarseness of voice were done at 1, 12 and 24 hours postoperatively.

Results

The results showed that the incidence of POST and cough were significantly less in the dexamethasone groups compared to the placebo group (p<0.05) and none of the patients developed hoarseness of voice. The mean VAS score for sore throat was significantly lower in dexamethasone 8 mg compared with 4 mg and placebo.

Conclusion

Preoperative administration of dexamethasone was statistically significant to reduce incidence of POST. In addition, we demonstrated that IV dexamethasone 8 mg was more effective than dexamethasone 4 mg and placebo to reduce the severity of POST and cough after endotracheal intubation.

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POstOPErativE Pain ManagEMEnt in childrEn: a rEtrOsPEctivE rEviEW OF acutE Pain sErvicEs FrOM January 2013 tO dEcEMBEr 2013

in univErsity Malaya MEdical cEntrENadzrah S Y, I I Shariffuddin

University of Malaya, Kuala Lumpur, Malaysia

Good control of postoperative pain has been shown to hasten recovery. However, postoperative pain management in paediatric patients can be challenging. Effective postoperative paediatric pain management can be achieved by multidisciplinary approach via acute pain services (APS), consisting of trained nurses in pain assessment, anaesthetists and surgeons. Hence, the main objective of this study is to audit the current management of postoperative APS in children in University Malaya Medical Centre (UMMC).

MethodThis is a retrospective review of data obtained from APS summary form and paediatric anaesthesia critical incident rEPrt run by anaesthesia department on children who underwent surgery from January 2013 to December 2013 in UMMC. 1417 patients between the ages of day 1 up to 13 years who underwent surgery during this period were analysed.

Result1417 children underwent operations in UMMC during this period, however the APS team followed up only 41 patients. Out of 41 patients, 65% of underwent general surgical procedures, 27.5% underwent orthopaedic procedures and 7.5% underwent other surgeries such as gynaecology and ENT surgery. Nineteen patients received PCA morphine and 22 patients received epidural analgesia. Mean pain VAS in patients on epidural analgesia is better than PCA morphine (0.95(1.29) vs 2.50(1.04) P value <0.001). Only two patients experienced mild side effects, mainly vomiting. The most common subsequent analgesia provided to patient after discontinuation of PCA or epidural is paracetamol. Overall, global satisfaction of the analgesia and acute pain service provided in UMMC was rated to be good to excellent by patients and their parents.

ConclusionThe number of patients followed up by APS team is small. Epidural is shown to be more effective for pain management of these children. In future, more patient should be encouraged to have epidural for postoperative pain relief when it is appropriate.

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cOMParisOn OF EasE OF intuBatiOn BEtWEEn glidEscOPE® and c-Mac® FOr nOvicEs

Badariah Yatim1, Azlina Masdar2, Aliza Mohamed Yusof2, Shereen Tang Suet Ping2, Nurlia Yahya2, Muhammad Maaya2

1Hospital sultan Ismail, Johor Bahru, Johor, Malaysia 2Univesiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia

BackgroundVideolaryngoscopes, like Glidescope® and C-Mac®, have emerged as an important role in the management of unanticipated difficult or failed laryngoscopy intubation. The ease of directing and inserting the endotracheal tube through the vocal cord is regarded as highly important when intubating with such devices.

ObjectiveThis prospective, randomised, single blinded clinical trial compared the ease of intubation between Glidescope® and C-MAC® videolaryngoscpe for novices.

MethodsA total of 56 American Society of Anesthesiologists (ASA) physical status I and II patients scheduled for elective surgery under general anaesthesia without any features suggesting difficult intubation were randomly allocated to either the Glidescope® Group (n = 28) or C-MAC® Group (n = 28). Following induction of anaesthesia with intravenous fentanyl, propofol and either rocuronium or atracurium, intubation was carried out by junior anaesthesiology trainees using either of the two videolaryngoscopes. The following were recorded: the success of intubation at first attempt, the time taken for successful intubation at first attempt and the number of optimisation manoeuvres.

ResultsMore novices in the Glidescope® Group (14.3%) required more than one intubation attempt and more number of optimisation manoeuvres compared to those in the C-MAC® Group. The time taken for successful intubation at first attempt was also statistically significantly longer in the Glidescope® Group compared to the C-MAC® Group (51.0 vs 37.0 seconds).

ConclusionThis study showed that the C-MAC® videolaryngoscope significantly provided ease of intubation for novices compared to Glidescope® videolaryngoscope in patients without any features suggesting difficult intubation.

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nOrMal salinE vErsus BalancEd-salt sOlutiOn (stErOFundin® isO) as intra-OPErativE Fluid thEraPy in nEurOsurgEry: thE EFFEcts On

acid-BasE BalancE, ElEctrOlytE status and sEruM OsMOlarityHafizah Mohamed, Chian Yong Liu, Joanna Su Min Ooi

Univesiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia

IntroductionOsmotic gradients are the primary determinants of the movement of water across the blood brain barrier. Therefore, the type of intravenous solutions used during surgery in neurosurgical patients is important. 0.9% normal saline (NS) has physiological osmolarity but excessive chloride that cause hyperchloraemic metabolic acidosis. Sterofundin®ISO contains electrolytes that mimic human plasma and is deemed to have a better electrolyte and acid-base homeostasis.

MethodsThis prospective, randomised controlled study was carried out to compare the changes in acid-base balance, serum electrolyte and serum osmolarity with the use of NS or Sterofundin as intra-operative maintenance and replacement fluid during elective craniotomies. Thirty ASA I or II patients were recruited and randomly allocated into these two groups. Biochemical indices for acid-base balance and serum electrolyte were reviewed at hourly intervals during surgeries.

ResultsIn the NS group, there were significant lower pH, base excess and bicarbonate values over time when compared to its baseline values (p<0.01) which were not seen in the Sterofundin Group. Patients from NS Group also had significantly higher sodium and chloride level when compared to its baseline value. These differences of pH, base excess, bicarbonate, serum sodium and chloride levels were significant when compared between NS Group and Sterofundin Group. Serum osmolarity of patients from NS Group increased significantly at the end of surgery compared to its baseline value (296.9 ± 5.2 vs 286.5 ± 5.7 mOsm/L, p<0.001) while in the Sterofundin Group, there was a small significant decrease in the values (284.6 ± 4.7 versus 288.5 ± 6.1 mOsm/L, p=0.003). The difference in osmolarity was significant between NS group and Sterofundin Group.

ConclusionThe use of balanced solution Sterofundin®ISO as intra-operative maintenance and replacement fluid in neurosurgical patients provided significantly better control of acid-base balance, sodium and chloride levels when compared to NS.

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a cOMParisOn OF thE airtraQ® and MacintOsh laryngOscOPE: usE in Easy and siMulatEd diFFicult airWays By hOusE OFFicErs

Mohd Nazir Md Salleh1, Nor Mohammad Md Din1, Aliza Mohamad Yusof2, Esa Kamaruzaman2, Khairulamir Zainuddin2


ObjectivesThe Airtraq® laryngoscope is a unique intubation device that may have benefits over conventional Macintosh laryngoscope for use by house officer that are seldom required to execute tracheal intubation. A study was designed to evaluate the intubation performance of house officers in simulated easy and difficult airway scenarios using Macintosh laryngoscope and Airtraq® on a manikin.

MethodsTen house officers with little intubation experience were recruited in this study. After a brief instruction and demonstration, the house officers will take turn to perform intubation using the Macintosh and Airtraq® in two simulated scenarios on the manikin.

ResultsIn easy and difficult scenarios, there was no difference between the time for successful intubation in the Airtraq® and Macintosh laryngoscope (p = 0.052). Similar results were observed for optimization manoeuvres required and ease of use scores between the two devices. However, Airtraq® reduced number of intubation attempts in difficult scenario compared to Macintosh laryngoscope (p = 0.02).

ConclusionWe concluded that the performance of the Airtraq® was comparable to Macintosh laryngoscope when used by house officers in simulated easy and difficult airway scenarios in manikins.

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anaEsthEtic ManagEMEnt FOr surgical cOrrEctiOn By ‘chula tEchniQuE’ OF FrOntOEthMOidal EncEPhalOMEningOcElE

in childrEn: a rEviEW OF 9 casEsZ Habibullah1, R Leelanukrom2

1Department of anaesthesiology, Paediatric Institute, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia 2Department of anaesthesiology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand

IntroductionFrontoethmoidal encephalomeningocele (FEEM) is a congenital neural tube defect characterized by herniation of brain and meninges through an anterior skull defect located at the junction between the ethmoidal and frontal bones. In King Chulalongkorn Memorial Hospital, most FEEM patients were operated by one-stage extracranial repair or ‘CHULA technique’ developed by local craniofacial surgeons. The advantage of this technique is abandonment of formal frontal craniotomy and performing a small ‘T’ shape osteotomy at the nasofrontal and medial orbital walls and osteotomy around the bone defect with less blood loss and less retraction on the brain. The objective of this study was to review anaesthetic management for surgical correction of this condition.

MethodsA retrospective chart review of FEEM children who were treated by “CHULA technique” surgical correction in King Chulalongkorn Memorial Hospital during November 2012 - July 2013. The collected data were categorized into preoperative and intraoperative data.

ResultsA total of 9 charts were reviewed. Preoperative data: The mean age of the patients was 3.8 years. The nasoethmoidal type was the most common. 6 patients (66%) had associated abnormalities ie; CNS or ophthalmologic. Intraoperative data: The mean duration of the anaesthesia and surgery were 6.42 h and 5.38 h, respectively. The estimated mean red cell mass loss was 14.02 ml/kg. No difficult intubation case. No major anaesthetic complication was found.

ConclusionsWe reported our experience in anaesthesia management for surgical repair by “CHULA technique” of FEEM in 9 children. Careful preoperative preparation, meticulous intraoperative management and continuing care in PICU were the attributes of successful outcome.

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PEriPhEral nErvE BlOcks in hOsPital raJa PErMaisuri Bainun (hrPB): a rEviEW 2012 – 2013

Azlina M¹, Kavita B¹, Alvin S¹ , Sarimah A¹, Farah M N¹, Norlaili Y¹, Mohd Zamri M A²¹Hospital Raja Permaisuri Bainun (HRPB), Ipoh, Perak, Malaysia

²Perak state Health Department, Ipoh, Perak, Malaysia

BackgroundOver the past years, there has been growing enthusiasm towards the use of ultrasound to facilitate peripheral regional anaesthesia. In Malaysia, since 2012, several Ministry of Health (MOH) hospitals had started using ultrasound guided peripheral nerve blocks.This paper will describe the performance of peripheral nerve blocks in Hospital Raja Permaisuri Bainun (HRPB) from the years 2012 to 2013.

Objectives1. To describe demographic profiles of patients who underwent the peripheral nerve blocks

2. The techniques used for peripheral nerve blocks in HRPB.

MethodsThis is a cross sectional study of patients who underwent peripheral nerve blocks in HRPB from April 2012 to December 2013. The data was collected from the MOH regional anaesthesia data collection form.

ResultsA total of 139 cases of peripheral nerve blocks were performed in HRPB from April 2012 to December 2013. 66% of cases were males, 34% of cases were females. The average age, weight and height of the patients were 47 years old, 49 kg and 120 cm respectively. 50% cases were ASA II, 43% of ASA I and 7% of ASA III. Out of 139 patients, 65% blocks were done using only ultrasound, 23% were performed with both ultrasound and nerve stimulator while 15% blocks used nerve stimulator alone. 71% blocks involved upper limb sites while 29% blocks involved lower limb sites.

Conclusions

From the year 2012 to 2013, a total of 139 nerve blocks were performed in HRPB. Out of which, the majority of were ultrasound guided and were mainly for the upper limb.However with more training, we will be able to increase the number of ultrasound guided peripheral nerve blocks.

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cOMParing haEMOdynaMic and utErOtOnic EFFEcts OF OxytOcin 3 iu With 5 iu BOlus during caEsarEan sEctiOn undEr sPinal anaEsthEsia

Z Z Zainal1, T Abd Razak1, C Y Lee2


Background & ObjectiveOxytocin has been shown to reduce incidence and severity of post-partum haemorrhage (PPH) during Caerarean section (CS), but causes hypotension and tachycardia. This prospective, double-blind, randomized study aimed to compare haemodynamic and uterotonic effects between IV bolus of oxytocin 3 IU and 5 IU.

MethodsA hundred and four (104) term parturients with low risk of PPH and scheduled for CS under spinal anaesthesia were recruited. After delivery of baby and umbilical cord clamping, oxytocin was administered according to group allocation (Group 1: oxytocin 3 IU, Group 2: oxytocin 5 IU), followed by infusion of oxytocin 40 IU/500 ml Hartmann’s solution at 120 ml/h. Parameters recorded were heart rate (HR), mean arterial pressure (MAP), uterine tone as assessed by the obstetrician, additional uterotonic drugs, total IV fluids, vasopressors, estimated blood loss and adverse effects.

ResultsIncreases in mean HR were significantly larger in Group 2 within first 3 min after oxytocin bolus (p = 0.002, p = 0.004 and p = 0.37 respectively). Significant MAP reductions from pre-oxytocin levels occurred in both groups within first 4 min (p = 0.05, p = 0.04, p = 0.03, p = 0.02 respectively). Mean MAP was significantly lower in Group 2 at all time intervals except at 3 min. Wider haemodynamic fluctuations were observed in Group 2. There were no significant differences in uterine tone, use of additional uterotonic drugs, estimated blood loss and adverse effects.

ConclusionIn parturients at low risk of PPH, oxytocin 3 IU produced less haemodynamic changes compared to oxytocin 5 IU without affecting uterine tone.

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cOMParing thE EFFEctivEnEss OF rOPivacainE 0.5% vErsus rOPivacainE 0.2% FOr transaBdOMinis PlanE BlOck in

PrOviding POstOPErativE analgEsia aFtEr aPPEndicEctOMy Reymi Marseela Abdul Jalil1, Nurlia Yahya1, Omar Sulaiman2, Wan Rahiza Wan Mat1, Rufinah Teo1,

Azarinah Izaham1, Raha Abdul Rahman1 1Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia

2Hospital sultanah aminah, Johor Bahru, Johor, Malaysia

BackgroundThe basis for the transversus abdominis plane (TAP) block involves infiltration of local anaesthetic into the neuro-fascial plane between the internal oblique and the transversus abdominis muscles, causing a regional block that spreads between the L1 and T10 dermatomes. Thus the TAP block is said to be suitable for lower abdominal surgery.

ObjectiveThis study was designed to compare the analgesic efficacy of two different concentrations of ropivacaine for TAP block in patients undergoing appendicectomy.

MethodsFifty six ASA I or II patients, aged 18 years and above undergoing appendicectomy were recruited into this prospective, randomised, double blind study. They were divided into Group A patients who received 0.5 ml/kg ropivacaine 0.5% versus Group B patients who received 0.5 ml/kg of ropivacaine 0.2% via TAP block under ultrasound guidance. Postoperative pain was assessed using the visual analog scale (VAS) upon arrival in the recovery room in the operating theatre, just before discharged to the ward and at 6, 12, 18 and 24 hours postoperatively to compare the effectiveness of analgesia.

ResultsIntraoperatively, patients in Group B required a significantly greater amount of additional intravenous fentanyl than patients in Group A. There were no significant statistical differences in pain scores at rest and on movement at all assessment times as well as the 24 hour intravenous morphine consumption given via patient controlled analgesia (PCA) postoperatively between the two groups.

ConclusionThe effectiveness of two different concentrations of ropivacaine 0.5% versus 0.2% given via TAP block was comparable in providing postoperative analgesia for patients undergoing appendicectomy.

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casE rEPOrt: sEvErE MEtaBOlic acidOsis and sPOntanEOus PnEuMOthOrax With sEvErE BrOnchOPlEural Fistula

during EMErgEncy caEsarian sEctiOnNur Hafiizhoh Abd-Hamid, Murniati Mustafa

Department of anaesthesiology and Intensive Care, Hospital enche’ Besar Hajjah Khalsom, Kluang, Johor, Malaysia

IntroductionMaternal mortality ratio in Malaysia has declined tremendously aiming to achive MDG5 of 11 deaths per 100 000 live births by 2015. We described a tragic maternal mortality in our center which was classified as a fortuitous death.

Case DescriptionA 29 years old primigravida was admitted in labour which progressed well with oxytocin augmentation. She later went for emergency caeserian section for prolonged second stage. Stratified as ASA 1E, it was done under subarachnoid block with established block at level T6-T8. Five minutes into surgery, she became agitated, complained of chest pain and headache. She was hypertensive and tachycardic, mimicking severe pre-eclampsia, hence IV Hydralazine and Magnesium Sulphate were given. A healthy 3.95 kg baby girl was delivered soon after. The patient had another wave of severe chest pain, headache, became more restless, with persistent hypertension and tachycardia but no desaturation. She was intubated uneventfully. Blood gases showed severe metabolic acidosis, and needed boluses of IV Sodium Bicarbonate. Estimated blood loss was 1300 ml. Uterus was not well contracted. Uterine massage was instituted; IM carboprost was given and Bakri balloon was inserted per vagina. The severe acidosis persisted despite blood transfusion and other supportive measures. She became hypotensive, developed PEA and CPR was done successfully. IV vasopressor and inotropes were started. Subcutaneous emphysema was noted over the neck but left chest needle throracocentesis was negative. Abdomen became grossly distended and relaparotomy revealed massive gush of air with uterine atony, proceeded with B-Lynch suture. Noted air leak at right retroperitoneal area with ?right pneumothorax. Right chest tube was inserted with continuous bubbling seen suggestive of bronchopleural fistula. She was transfered to ICU but remained unstable with high inotropes support, worsening metabolic acidosis, subcutaneous emphysema and pneumoperitonium. She was pale and mottled, and succumbed despite heroic efforts. Autopsy was firmly refused by the family members.

ConclusionAmniotic fluid embolism and spontaneous pneumothorax are rare obstetric conditions which require prompt recognition and aggressive interventions which can be a major obstacle in a district hospital. Post mortem would help to find causes of death.

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PnEuMOcEPhalus aFtEr cOMBinEd sPinal EPidural using lOss-OF-rEsistancE tO air tEchniQuE : a casE rEPOrt

Wan Salwanis W I, Yamminidevi L, Kavita BHospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia

BackgroumdLoss-of-resistance to air (LORA) technique for identifying the epidural space carries risk of developing pneumocephalus especially if there is accidental dural puncture. We discussed a case in which pneumocephalus was detected radiographically involving both subdural and subarachnoid spaces with no evidence of unintentional dural puncture.

ReportAn 82 year old lady, scheduled for elective left Total Knee Replacement developed severe headache and sudden increase in blood pressure associated with pneumocephalus immediately after combined spinal epidural (CSE) with LORA technique to locate the epidural space. Operation was postponed due to high blood pressure of 230/70 with other signs of increased intracranial pressure. Urgent computed tomography of the brain showed presence of air in both subdural and subarachnoid spaces intracranially. Patient was treated conservatively with analgesics and 100% oxygen. Symptoms gradually subsided over 3 days and repeated computed tomography of the brain showed reduction in amount of air collection. Operation then proceeded under general anaesthesia and was uneventful.

ConclusionPneumocephalus can happen when LORA technique is used to identify the epidural space even though without evidence of accidental dural puncture. Possibility includes air bubbles entering the subarachnoid space from subdural space through a tear in arachnoid membrane either caused by increased tension of air in subdural space or created by the 27G spinocan needle which used in the procedure. Perhaps we should consider to stop using LORA technique and use only normal saline.

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a rarE casE OF PulMOnary artEriOvEnOus MalFOrMatiOn (PavM) in a PrEgnant lady undErWEnt ElEctivE lOWEr sEgMEnt caEsarian sEctiOn

YY Phang , Norzalina Esa, Norsaliza Isarawak general Hospital, sarawak, Malaysia

IntroductionPulmonary arteriovenous malformation (PAVM) is rare and can be asymptomatic. Pregnancy and its physiological demands unmask and can exacerbate PAVM with attendant risks, additionally a tendency for misdiagnosis with pulmonary embolism and congenital cyanotic heart disease.

Case descriptionA 27-year-old primigravida first presented for antenatal check up at 33 weeks gestation with mild shortness of breath. She was asymptomatic prior to this, has finger clubbing since young, but peripheral cyanosis during pregnancy. Her presentation mimicked congenital cyanotic heart disease. Echocardiography (ECHO) showed good ejection fraction without regional wall motion and intracardiac structure abnormality, intracardiac shunt or pulmonary artery hypertension. Admission at 36.5 weeks gestation for further investigation to assist in her delivery mode revealed peripheral saturation of 89%, type one respiratory failure with PaO2 of 55mmHg and A-a gradient of 54mmHg. Electrocardiography, chest X ray, routine blood investigation and cardiac enzymes were all normal. Fetal ultrasound showed healthy singleton. Cardiology and respiratory consultation were advised but no active intervention was needed as she was fairly comfortable. Surgical delivery was suggested. Further investigations were needed for future management. Few diagnoses including primary pulmonary hypertension, chronic pulmonary embolism disease and extra cardiac shunt were postulated. Intramuscular dexamethasone was given in anticipation of premature delivery. Thromboprophylaxis with subcutaneous clexane 40 mg started. A positive Bubble ECHO test performed was highly suggestive of intrapulmonary shunt, with possible PAVM. An elective LSCS was successfully performed at 37 weeks gestation under Combined spinal epidural technique with invasive arterial blood pressure monitoring. Precautions were taken against air embolism. Her course in hospital was uneventful. Further diagnostic and therapeutic measures were arranged after delivery to avoid possible life threatening complication of PAVM in this patient.

ConclusionA multidisciplinary approach is pertinent in deciding appropriate management in pregnancy, which has to be weighed against potential maternal and fetal risks.

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anaEsthEsia ManagEMEnt OF aWakE craniOtOMy: univErsiti kEBangsaan Malaysia MEdical cEntrE (ukMMc)

ExPEriEncE With ‘aslEEP-aWakE-aslEEP’ (aaa) tEchniQuEEsa Kamaruzaman, Ramesh Kumar, Muhammad Zurrusydi Zainuddin, Khairulamir Zainuddin,

Adnan DanUniversiti Kebangsaan Malaysia Medical Centre (UKMMC), Kuala Lumpur, Malaysia

Awake craniotomy is becoming more popular as a neurosurgical technique that allows for increased tumour resection and decreased postoperative neurologic morbidity especially involving eloquent areas. This technique however presents many challenges to both the neurosurgeon and the anaesthesiologist.

In 2013, four patients in UKMMC underwent awake craniotomy using AAA technique with scalp block. The patients were thoroughly reviewed and counselled preoperatively regarding the procedures and the expected discomfort that they might experience during the surgery. They received total intravenous anaesthesia (TIVA) which consists of propofol, remifentanil and dexmedetomidine with Supreme® Laryngeal Mask Airway (LMA) to protect the airway. Standard anaesthetic monitoring with additional intra-arterial line measurement were used in all patients. Bispectral Index (BIS®) monitoring was also applied.

After induction of anaesthesia, all patients received scalp block before placement of Mayfield® clamp. Cortical stimulator with SSEP and MEP were used as additional intraoperative neuromonitoring. Infiltration of local anaesthesia at the incision site was also given. Once the dura was opened, the infusion of anaesthetics was reduced and the patient was slowly awakened and the LMA removed. Direct communication and assessment were carried out during the awake period. Once the surgeon has removed the tumour, the patient was induced back to anaesthesia.

Three patients were successfully operated using this technique but one patient was uncooperative during the speech monitoring and had to be reverted back to general anaesthesia. Two patients developed minor intraoperative seizure captured via MEP without significant motor movements and were aborted with cold saline irrigation to the affected brain. All patients were observed in the post-anaesthesia care unit. One patient developed hemiparesis immediately after surgery which required recraniotomy due to clot formation.

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PatiEnts’ undErstanding On thE status and rOlE OF anaEsthEsiOlOgists as hEalthcarE PrOvidErs

Maryam Budiman, Esa Kamaruzaman, Azlina Masdar, Khairulamir Zainuddin, Jaafar Md Zain, Adnan Dan

Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Kuala Lumpur, Malaysia

ObjectivesThe primary objective of this study was to evaluate patients’ understanding on the qualification, training and role of anaesthesiologists. The secondary objective was to study the patients’ attitude towards anaesthesia and anaesthesiologists.

MethodsThis was a questionnaires-based cross-sectional study done on 384 adult patients with normal mental status undergoing surgery at the UKMMC between 1st August and 31st October 2013. The questionnaires which were prepared in Malay and English languages have three sections. Section 1 evaluates patients’ knowledge on qualification, training and role of anaesthesiologists. A score of one was given for each correct answer. Section 2 evaluates patients’ attitude towards anaesthesia and anaesthesiologists while section 3 were about demographic data of patients including their past anaesthetic experience.

ResultsMost respondents (95.6%) knew that anaesthesiologists are medical doctors. However their knowledge on training, qualification and roles of anaesthesiologists was limited. Only 27.1% knew the minimum duration needed to train an anaesthesiologist locally while 25.5% and 12.2% were aware of the anaesthesiologists role in managing intensive care units and labour pain respectively. Forty-nine percent and 99.5% of respondents were aware of the anaesthesiologists role in chronic pain and postoperative pain management. The majority of respondents (73.7%) knew that anaesthesiologists were responsible for monitoring the patients during surgery but only 42.2% were aware that anaesthesiologists were actively treating medical problems intraoperatively. Most respondents would like to be seen by anaesthesiologists before the operation (95.1%) and be informed of all possible anaesthetic complications (97.7%).

ConclusionThe knowledge of surgical patients in UKMMC on the status of anaesthesiologists and their role in health care is still poor. However their attitude towards anaesthesia and anaesthesiologist are generally very good.

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a clEar vOcal cOrd But a Blind Oral cavityRahimah AR, Ismaliza I, MS Kok, Azrin MA, V Sivasakthi

Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

IntroductionGlideScope®, a common adjunct to difficult intubation, is not without complications. We report an unexpected case of anterior tonsillar pillar perforation following GlideScope® intubation. This is the first reported case in an adult with severe obstructive sleep apnoea (OSA).

ReportA 55-year-old ASAII overweight gentleman with severe OSA and anticipated difficult airway, presented with right ureteric calculi for elective right retrograde intrarenal ureteroscopic surgery and ureteroscopic lithotripsy. Direct laryngoscopy showed Cormack Lehane Three. He was intubated with a normal Portex endotracheal tube (ETT) reinforced with a Rigid Stylet with tip in place, using GlideScope® Video Laryngoscopy with minimal difficulty. Injury was only suspected upon removal of the GlideScope® blade, and noticing a pool of blood in the pharynx. Preliminary examination showed the ETT piercing through soft tissues before passing into the vocal cords. Immediate otorhinolaryngology referral and endoscopic assessment showed right anterior pillar and right tonsillar mucosal perforation through a length of 2cm, which warranted repair. The upper airway was crowded and narrowed with abundance of redundant soft tissues. A challenging but successful exchange of ETT was performed under direct endoscopic vision by placing the fibreoptic scope side by side the existing ETT, followed by fibreoptic guided insertion of a new one.

DiscussionSimilar injuries in non-OSA patients had been described since 2007. We postulated that patients with OSA are predisposed to these injuries due to excessive soft tissues in the upper airway. The combination of blind advancement of ETT prior to visualisation on the monitor, with abundance of accessory soft tissues could have contributed to this tragedy. Advancement of ETT under direct vision, the use of blunt tip ETT coupled with extra precaution in patients with OSA may reduce the risk of injury. Securing a fibreoptic guide prior to exchange of ETT under direct vision represents an alternative way of reintubation.

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audit On PracticE OF PEriPhEral nErvE BlOckN M K Amiruddin, M A Azrin

Department of anaesthesiology, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

BackgroundRegional block provides superior pain relief, compared to opioid-based analgesic techniques alone. The aim of performing regional techniques is to achieve optimum postoperative pain management, to be able to undergo physiotherapy comfortably, reduced length of stay and for faster resumption of daily activities.

ObjectivesThis audit was done to review the practice of peripheral nerve block in Hospital Kuala Lumpur on the types of blocks given, local anaesthetics used and its dynamics, and review of complications and sequelae.

MethodologyThis is a prospective audit of the practice of peripheral nerve blocks in Hospital Kuala Lumpur from January to December 2013. A data collection form for nerve blocks was designed and used as a tool to obtain the perioperative information. Observed data includes demography, types of blocks. Types and concentration of local anaesthetics used, block characteristics and requirement for rescue analgesia and perioperative complications. All data were tabulated using Epi-Info software.

Results343 blocks were done on 298 patients with 154,149 and 40 upper, lower limb and other blocks respectively. 0.375% ropivacaine were used in 32.5% of all blocks with 41.7% blocks lasting for 6-12 hours. No major complications arose during block performance. However, 26 patients developed neurological complaints in the ward which resolved at discharge or at 1 month.

ConclusionThe complication rate for post nerve block neurological sequelae in Hospital Kuala Lumpur was 4.66% postoperatively, with no permanent neurological deficit at 1 month follow up. The low numbers of complications were helped by the growing use and training of ultrasound-guided peripheral nerve blocks in our daily practice.

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an unFOrtunatE casE OF arachnOiditis FOllOWing a cEntral nEuraxial BlOck

Cindy T J, M S Kok, Sivasakthi V, R S ChanHospital Kuala Lumpur, Kuala Lumpur, Malaysia

BackgroundArachnoiditis is a rare and unfortunate complication of central neuraxial blocks. The data surrounding its incidence is obscure, the causative factors variable, the clinical manifestations complex coupled with the scary possibility of a permanent sequelae. We report a case of arachnoiditis following a combined spinal epidural anaesthesia for an elective arthroscopic knee surgery.

Case ReportA young ASA I gentleman presented for a diagnostic arthroscopy and meniscus repair of the right knee. A combined spinal epidural was performed uneventfully under aseptic technique with povidone as the antiseptic. All intrathecal and epidural drugs administered were preservative-free. He developed cauda equina syndrome postoperatively with urinary, bowel and erectile dysfunction. Haematoma and infection were excluded. A delayed diagnosis of arachnoiditis was made on MRI one week postoperatively and he was treated with high dose steroid therapy and non-steroidal anti-inflammatory drugs. Ten months down the line, he is now back to his usual sporting activities with minimal residual symptoms.

DiscussionThe causative factors of arachnoiditis are manifold; among the aetiologies postulated in our patient include chemical irritation from unintentional intrathecal injection of antiseptic, possible maldistibution and neurotoxic effects of large doses of local anaesthetics and additives administered. A high index of suspicion and early radiological confirmation are essential in clinching the diagnosis allowing immediate intervention. Institution of early high dose steroids and non-steroidal anti-inflammatory drugs aid in reducing inflammation and preventing progression to proliferative phase leading further to possible permanent neurological sequelae. It is imperative that early diagnosis and treatment is made to allow for a more favourable outcome.

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PrEEMPtivE analgEsia With Oral gaBaPEntin in rEducing POstOPErativE Pain aFtEr gynaEcOlOgical surgEry

Ban Chung Poh1, Chian Yong Liu1, Shanti Rudra Deva2, Joanna Su Min Ooi1 1Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Kuala Lumpur, Malaysia


IntroductionPrevention and treatment of postoperative pain is an important element of anaesthesia management to improve patient satisfaction, reduce risk of postoperative complications and reduce the incidence of chronic pain. Gabapentin is a second generation anti-convulsant introduced for the treatment of refractory partial seizures. It has been shown to be effective in treating a variety of chronic pain conditions. There is growing evidence that it is useful in the treatment of postoperative analgesia.

MethodsThis was a prospective, randomized, double-blind, placebo controlled study conducted in Hospital Kuala Lumpur to assess the efficacy of preemptive analgesia with a single dose of oral gabapentin 600 mg in reducing postoperative pain after elective open total abdominal hysterectomy with or without bilateral salpingo-oophrectomy (TAH±BSO). Forty consented adult patients aged 18-70 years old were randomly assigned to two equal groups. Group G patients received oral gabapentin 600 mg two hours before surgery and Group P patients received placebo. All patients underwent a standardised anaesthesia protocol and were given intravenous morphine via patient-controlled analgesia (PCA) machine as postoperative pain relief for 24 hours. Pain assessment at rest and on movement by Visual Analog Scale (VAS) was performed at 1, 6, 12 and 24 hours postoperatively.

ResultsThere was no significant difference in the VAS at rest and on movement at every time interval tested. Time to first morphine rescue (Group G 11.6 ± 2.6 min vs Group P 12.3 ± 3.4 min, p = 0.759) and post operative total morphine consumption (Group G 28.6 ± 8.2 mg vs 28.7 ± 9.0 mg, p = 0.956) were comparable in both groups.

ConclusionA single dose of oral gabapentin 600 mg was not effective when used as preemptive analgesia in reducing postoperative pain after TAH±BSO.

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cOMParisOn OF clinical PErFOrMancE BEtWEEn i-gEl™ and aMBu® aura 40™ laryngEal Mask airWay

Lee San Tay1, Joanna Su Min Ooi1, Cheng Cheng Tan2, Chian Yong Liu1

1Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Kuala Lumpur, Malaysia 2Hospital sultanah aminah, Johor Bahru, Johor, Malaysia

IntroductionLaryngeal mask airway (LMA) has modernised anaesthesia and avoided the need of tracheal intubation. However, the inflatable cuff of LMAs had been associated with the issues of potential tissue distortion, venous compression and nerve injury in the oropharynx. I-Gel™ (I-gel) was a new anatomically designed, disposable cuffless LMA marketed to avert the complications and pitfalls of inflatable masks.

MethodsThis was a prospective randomised study conducted to compare the clinical performance of I-gel with Ambu® Aura40™ (Ambu) LMA. A total of 210 ASA I or II patients, scheduled for minor surgery under general anaesthesia were randomly allocated to either device, with 105 patients in each group. Induction of anaesthesia was standardised and appropriate size of the randomised LMA was inserted on these patients. Insertion time and number of attempts were recorded. Airway leak pressure was determined clinically by determining audible leakage sound at a gas flow of 3 L/min with expiratory valve of the circle system set to 30 cmH2O. The incidence of airway morbidities such as visible dental, tongue or lip trauma, blood stain on the device, sore throat and hoarseness of voice were assessed post-operatively.

ResultsBoth I-gel and Ambu had comparable and high overall and first attempt success rate (93.3% vs 95.2%, p=0.79). Mean insertion time of I-gel was significantly shorter than Ambu (21.1 ± 5.8 sec vs 22.8 ± 5.9 sec, p=0.04). Both devices had comparable mean airway leak pressures (I-gel 25.7 ± 3.8 cmH2O vs Ambu 25.6 ± 3.6 cmH2O, p=0.83). The airway complications occurrence rates were low and comparable in both groups.

ConclusionBoth devices were comparable with regards to successful overall and first attempt insertion, airway leak pressure and post-insertion airway morbidities. I-gel had significant shorter mean insertion time compared to Ambu.

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nOn-tEchnical skills OF anaEsthEtic sPEcialists in OPEratiOn thEatrE, a survEy in dEPartMEnt OF anaEsthEsiOlOgy,

tEngku aMPuan rahiMah hOsPital, klangMuralitharan Perumal , Sebastian Sundaraj , F A Isa

Tengku ampuan Rahimah Hospital, Klang, selangor, Malaysia

Non-technical skills (NTS) play an equal role with technical skills in an organization. In operation theatre (OT), anaesthetic specialists frequently face difficult situations that requires NTS, a subject void in postgraduate training. A survey was conducted to assess level of NTS among anaesthetic specialists in Department of Anaesthesiology, Tengku Ampuan Rahimah Hospital, Klang. A survey form of six themes with 27 statements, was formulated and translated to Bahasa Malaysia. 10 anaesthetic specialists were assessed. 17 anaesthetic nurses responded. Outcome measure was ratio (%) of specialists complying to the themes and statements. Of the six themes, about 90% of specialists are *structured,responsible and focused in approaching tasks as well as *clear and informative. and *patient centered. About 70% of them are *fluent in practical work without losing overview or *calm and clear in critical situations, able to change to strong leading style. Only 50% of the specialists are considered *humble. “Generally specialists are present in operation theater during critical situations” (95.3%) and “performs responsibly” (95.9%). 95.9% of these specialists “can give clear insructions to the nurses in complicated cases”, with 54.7% of them “do not make GA nurses feel very stressed”. 94.1% of specialists “calms and relaxes the patient before induction” and “has the patients best interests at heart “(91.1%). They “move about in OT in a purposeful manner” (86.5%) and “have smooth and efficient workflow” (87.6%). Majority (73.5%) are “humble and open to good ideas from team members “ but few “admits own fault” (30%) or “expresses in futile” (22.4%) although 60% of them “asked for help when failing to perform procedures”. In conclusion, most of the anaesthetic specialists do have and have applied high levels of non-technical skills in OT.

*Survey theme; “Survey statements”

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critical dEcisiOn Making in anaEsthEtic PracticEs; a casE rEPOrtMat Ramlee Md Tahir1, Sakthi A Nathan2, Puzizer M S2, Lily Ng2

1Department of Cardiothoracic anaesthesia and Perfusion, Hospital Queen elizabeth II, Kota Kinabalu, sabah, Malaysia 2Department of anaesthesia and Intensive Care, Hospital Queen elizabeth II, Kota Kinabalu, sabah, Malaysia

IntroductionDecision making is one of the most challenging tasks faced by many practising anaesthesiologists. We present a case highlighting the importance of making the right decision in a timely manner.

Case ReportA 55 year old man with background history of right below knee amputation for diabetic foot and dialysis dependent end stage renal failure presented with inferior non-ST elevation myocardial infarct. He was successfully thrombolysed with streptokinase. His angiogram showed severe distal left main stem obstruction with 99% blockade and 70% to 80% blockade at the left anterior descending and circumflex coronary artery. His echocardiogram showed severe left and right ventricular dysfunction with ejection fraction of only 25% and global hypokinesia. Intra-aortic balloon pump (IABP) was inserted and dobutamine infusion was started to support the heart whilst awaiting coronary bypass surgery. Unfortunately, he developed acute necrotizing fasciitis of his remaining left foot which grew Klebsiella sp.

At that moment, we had to make a critical decision; whether to proceed with cardiac surgery knowing that the sepsis may worsen with cardiopulmonary bypass or to proceed with below knee amputation whilst risking his vulnerable heart.

Ultimately we decided to proceed with below knee amputation when the sepsis progressively worsened. The procedure was performed under sciatic and femoral nerve block which was well tolerated by his heart.

Several days later, he underwent coronary artery bypass surgery. He survived the surgery and was extubated after overnight ventilation. He was transferred relatively well to the ward after one week in cardiothoracic intensive care unit.

ConclusionsRegional anaesthesia has proven its virtue in this challenging case by allowing us to eradicate the source of sepsis whilst the heart was supported with IABP and inotropic agent.

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knOWlEdgE, attitudE and PracticE OF PaEdiatric critical carE nursEs tOWards Pain: a survEy in hOsPital raJa PErMaisuri Bainun, iPOh

D Krisnan1, E L Chew2, K Ramalingam2, P H Loo3 1Department of anaesthesiology & Intensive Care, Pain Management Clinic, Hospital Raja Permaisuri Bainun,

Ipoh , Perak, Malaysia 2Department of Paediatrics, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia

3Department of anaesthesiology & Intensive Care, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia

ObjectivesTo document knowledge and perceptions of pain assessment and management practices among paediatric critical care nurses of Hospital Raja Permaisuri Bainun, Ipoh.

MethodsA self-administered questionnaire was provided to 125 paediatric critical care nurses of Hospital Raja Permaisuri Bainun, Ipoh.

ResultsOf the 77 nursing personnel working in the two critical care units, 64 (90.1%) responded to the questionnaire, 44 received formal training in paediatric nursing. Less than half the respondents felt that infants perceive less pain than adults. Training in pediatric nursing was a significant contributing factor in the domain of knowledge (P=0.03). Restraint and distraction were the common modalities employed to facilitate painful procedures. Pharmacological approaches like eutectic mixture of local anaesthetic and the judicious use of sedatives were adopted routinely. Observing a child’s face and posture in accordance to the FLACC (Faces, Legs, Attitude, Cry and Consolability) pain assessment tools were widely used parameters to assess pain (83%).

ConclusionsA substantial proportion of paediatric critical care nurses did not routinely use pain assessment tools for patients unable to communicate and but were unaware of published pain management guidelines.

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MultiMOdal aPPrOach tO Pain ManagEMEnt in ‘BErtOlOtti’s syndrOME’Ahmad Afifi M A1, Cardosa M S1, S H Sulaiman2, Ng K S1, Seet S N1, Khoo E L1

1Department of anaesthesia and Intensive Care, Hospital selayang, selayang, selangor, Malaysia 2Department of Orthopaedics, Faculty of Medicine, Universiti Teknologi MaRa, shah alam, selangor, Malaysia

IntroductionIn 1917, Bertolotti first described a mechanical low back pain associated with assimilation of the 5th lumbar vertebra with the sacrum. Since then, various researchers have refined the anatomical classifications and established terms such as lumbar transitional vertebra or lumbar sacralization which leads to dysfunctional joint and surrounding structures. Pain may arise from the anomalous joint, contralateral facets, periarticular structures or early disc degeneration.

ObjectiveWe present a case of a young lady with chronic pain from the right 5th lumbar anomalous transverse process with lumbosacral diarthrodial articulation who was managed using a multimodal approach.

Case ReportA 23-year-old medical student with Bertolotti’s Syndrome who had low back pain since 2012, was refered to the pain team in January 2014 for possible pain interventions. She had progressively worsening pain on the right lower back, associated with pain and burning sensation around the ipsilateral gluteal region. The pain was aggravated by prolonged sitting and lying supine.

She had no signs of neuropathic pain or neurological deficits. She was also seen by clinical psychologist and pain physiotherapist. She was prescribed specific exercise, relaxation technique and oral non-steroidal analgesics two weeks prior to pain intervention.

An ultrasound and fluroscopic guided intervention was subsequently performed. Two steroid injections were done at medial periarticular structure and lateral intraarticular injection. One week after injection, she had improved functional tolerance and reduced pain at rest. However pain can still be elicited at extreme range of motion.

ConclusionPain in Bertolotti’s Syndrome may arise from the pseudojoint or periarticular structures. Multimodal approach to pain management is necessary to improve functional outcome and prevent secondary pain.

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OPtiMizing PrEvEntivE analgEsia stratEgy With POstOPErativE PEriPhEral nErvE BlOcks

Ahmad Afifi M A, Cardosa M S, Ng K SDepartment of anaesthesia and Intensive Care, Hospital selayang, selayang, selangor, Malaysia

IntroductionPeripheral Nerve Blocks (PNB) is recognized as one of the integral technique for postoperative pain management. The contemporary concept to augment pain control has evolved from preemptive to preventive analgesia, hence an intervention deemed useful to relieve pain can be performed at any point in time perioperatively.

ObjectiveWe aimed to analyze indications and outcomes of PNB performed in recovery area for postoperative analgesia.

MethodologyRecords of all patients having PNBs in recovery room for acute postoperative pain in 2013 at Selayang Hospital were analyzed retrospectively. Indications of the blocks, types of surgery, pain scores (PS) at postoperative day (POD) 1 and 2, other forms of analgesia and side effects or complications were recorded. Simple descriptive analysis was performed.

Result288 peripheral nerve blocks were performed in 2013. 34 PNBs were done in the recovery area. 19 (56%) of cases had catheter insertion for continuous peripheral nerve blocks. The most common block was Fascia Iliaca Block (32%), followed by Femoral Nerve Catheter (20%), Adductor Canal Catheter (20%), Adductor Canal Block (9%), Supraclavicular Catheter (6%), Interscalene Catheter (6%), Femoral Block (3%) and Infraclavicular Catheter (3%).

Pain control was good with mean resting PS of 1.3 and 0.9, and mean dynamic PS of 3.3 and 2.5 at POD1 and POD2 respectively. Median duration of postoperative Acute Pain Service follow up was 2 days. No complications were observed from the interventions. Advantage and disadvantage of postoperative blocks will be discussed.

ConclusionPostoperative PNBs result in good analgesia, thus enhancing preventive analgesia strategy. Further study should be done to determine indications for specific postoperative PNBs.

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acutE airWay in a casE OF cEntral vEnOus OcclusiOn POst cathEtEr PlacEMEnts, a casE rEPOrt

S S Yap, S K Cheah, L W Luah, C H Lim, Jahizah HassanDepartment of anaesthesia & Intensive Care, Hospital Pulau Pinang, Penang, Malaysia

BackgroundCentral venous occlusions present as true emergency when airway is obstructed. This warrants airways to be secured and for urgent angioplasty or stent placements.

ReportA 70 year-old man admitted with 6 months history of progressively worsening dyspnea and facial edema. He has past history of end stage renal failure, diabetes, hypertension and recurrent central venous occlusion symptoms. He had multiple central venous cannulations for hemodialysis with repeated arterio-venous fistula failures. On examination, he was alert with signs of respiratory embarrassment; marked tachypnea with respiratory rate 30bpm on face mask oxygen, sitting in upright position, talking only in phrases, hoarseness, no obvious stridor and had facial, neck and arm swelling. Chest x-ray showed collapsed right lung. Urgent contrasted computed tomography scan of neck/thorax reviewed distal laryngo-pharynx narrowing with surrounding edema, right brachiocephalic and distal left internal jugular vein occlusion. In view of impending respiratory distress and difficult airway, decision made to immediately secure airway in emergency operating theater. Awake fiberoptic intubation attempts were hampered due to ongoing bleeding from hyperaemic mucosa and patient continued desaturating. Classic LMA was inserted to temporarily ventilate the patient. Subsequently, successful intubation achieved by glidescope assistance. Close monitoring continued in intensive care unit, awaiting further interventions by vascular team.

Conclusion Although incidence for central vein or superior vena cava obstruction due to catheter placements is less than 10%, however it carries high risk of morbidity and mortality as patients can present as acute airway obstruction. If present late, a case of ‘can’t intubate, can’t ventilate’ becomes inevitable. As invasive procedures requiring central venous cannulations become commonplace and clinical covert thrombosis is not uncommon, this iatrogenic complication will occur more often. Even ultrasound guidance does not avoid catheter-related obstruction. Early recognition of airway emergency and early ENT referral for emergency tracheostomy warranted.

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thE ManagEMEnt OF incrEasEd intracranial PrEssurE and rEFractOry Bradycardia in a child

Ramanesh K Mageswaran, Vanitha SivanesarHospital Kuala Lumpur, Kuala Lumpur, Malaysia

BackgroundA 9 year old child presented at the Emergency Department with seizures and loss of consciousness. Clinical examination and radiological features revealed the presence of raised intracranial pressure(ICP). An operative procedure was planned. We intend to highlight the challenge in managing the refractory bradycardia intraoperatively. While conventional treatment measures failed, the application of the transcutaneous external pacemaker was sought as well as the use of isoprenaline infusion.

The report will detail the probable causes and management of persistent bradycardia in a child with signs of raised ICP. It includes the various methods employed in the treatment of bradycardia intraoperatively. This report additionally reports the first use of isoprenaline in treatment of refractory bradycardia in a case of raised ICP.

ConclusionThis case highlights the unusual presentation of refractory bradycardia secondary to increased in intracranial pressure as well as the usage of Isoprenaline infusion in the management of refractory bradycardia.

rEPOrt OF a casE OF tOurniQuEt- inducEd rhaBdOMyOlysis aFtEr arthrOscOPic knEE surgEry

Woon Lai Lim1, Tashna2, Rohayu Othman3


We report a case of a young healthy patient who underwent arthroscopic knee surgery and developed postoperative myoglobinuria and rhabdomyolysis with elevated serum creatine kinase (CK) and hyperkalemia.

Pneumatic tourniquets are widely used in arthroscopic knee surgery to provide a bloodless field and to facilitate dissection. However, it is very important to recognise their potential complications, which are commonly pressure- related, and can also be caused by excessive tourniquet time like what happen to our patient.

Our patient is a healthy 24 years old gentleman who underwent an operation for 8 hours and 30 minutes with tourniquet time of 3 hours and 10 minutes leading to a life threatening complication postoperatively. Early recognition of rhabdomyolysis and aggressive fluid resuscitation with forced alkaline diuresis and correction of metabolic derangement improves patient morbidities.

As a conclusion, the clinicians must be aware of such risk and understand the

pathophysiological changes by which these occur. A strict adherence to tourniquet guidelines and prompt diagnosis helps in minimising tourniquet related morbidity.

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contents xperience” - msa 2017msa.asm.org.my/files/msa2014_spab.pdf · prof boddu worked closely...

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