souvenir programme & abstract book
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1
Contents
Messages
• Director-GeneralofHealthMalaysia 2
• President,MalaysianSocietyofAnaesthesiologists 3
• President,CollegeofAnaesthesiologists,AMM 4
• OrganisingChairperson 5
• ScientificChairperson,MSAandCoAAnnualScientificCongress 6
• ScientificChairperson,ObstetricAnaesthesiaSatelliteMeeting 7
CitationonMSAHonoraryMember 8–9
MalaysianSocietyofAnaesthesiologists:OfficeBearers2016–2017 10
CollegeofAnaesthesiologists,AMM:OfficeBearers2016–2017 11
OrganisingCommittee 12
ScientificCommittees 13
OpeningCeremonyon26thAugust2016(Friday) 14
GalaDinneron26thAugust2016(Friday) 15
InvitedSpeakers 16
MSA/CoAWorkshops 17–20
ObstetricWorkshops 21
ProgrammeSummary 22
DailyProgramme 23–30
ConferenceInformation 31
FloorPlan&TradeExhibition 32
Acknowledgements 33
Abstracts 34–99
• MSA/CoAPlenariesAndSymposia 34-59
• ObstetricSymposiaAndPanelDiscussions 60-78
• SelectedOralPresentations 79-86
• PosterPresentations 87-99
2
Distinguished delegates, speakers, ladies and gentleman,
I would like to thank the Malaysian Society of Anaesthesiologists, the College of
Anaesthesiologists, the Academy of Medicine of Malaysia, as well as the Special
Interest Group in Obstetric Anaesthesia for allowing me to pen a few words
in this programme book. I take this opportunity to welcome you to the Annual
Scientific Congress of the Malaysian Society of Anaesthesiologists and College
of Anaesthesiologists (ASC of the MSA/CoA) and Obstetric Anaesthesia Meeting,
a satellite event of the 16th World Congress of Anaesthesiologists.
I was informed that many of you will be attending the World Congress of
Anaesthesiologists that will be held in Hong Kong and would like to thank you for
making the time to stop in Kuala Lumpur before proceeding to Hong Kong.
I would also like to congratulate the Organising Committee for coming up with an
appropriate theme for the Congress. The theme is aptly titled ‘Back to Basics’ and
focus on going back to some of the fundamentals of anaesthesiology in ensuring
delivery of safe anaesthesia in an ever evolving world of technology, as well as
keeping up with the current advances in the body of knowledge and technologies
in order to ensure the best possible outcome for our patients.
I sincerely hope that all delegates will find this congress immensely beneficial and
learn from the respected faculty that have been assembled here to impart their
knowledge and experiences. I sincerely hope that we can all learn from each other
on the best practices worldwide.
Finally, I would also like to welcome our fellow delegates to enjoy themselves not
only at the Congress but to explore the many sights and sceneries that Kuala
Lumpur has to offer.
I wish you a fruitful Congress and a memorable stay in Malaysia.
Thank you.
Datuk Dr Noor Hisham Abdullah
Message from the Director-General of Health Malaysia
3
Dear Colleagues and Friends,
Thank you for taking time off from your busy schedule to attend our
Annual Scientific Congress of the Malaysian Society of Anaesthesiologists and
College of Anaesthesiologists (ASC of the MSA/CoA). The Obstetric Anaesthesia
Meeting, a satellite event of the 16th World Congress of Anaesthesiologists is being
held in conjunction with our Annual Scientific Congress and I welcome all our
eminent speakers from all over the world who are here to share with us their
knowledge and experience.
I take this opportunity to congratulate both the Organising Committee and the
Scientific Committees for all their efforts in allowing us to benefit from a truly well
organised Congress.
The theme for the ASC of the MSA/CoA is titled ‘Back to Basics’ and with the
accompanying pre-congress workshops, plenary lectures and symposia, we hope
the Congress will meet the expectations of all our delegates.
We look forward to meeting you and to share a pleasant, interesting and fruitful
Congress.
Dr Raveenthiran Rasiah
Message from the President, Malaysian Society of Anaesthesiologists
4
Dear Colleagues and Friends,
Greetings! It is a great pleasure to bid you a warm welcome to the
Annual Scientific Congress of the Malaysian Society of Anaesthesiologists and
the College of Anaesthesiologists, Academy of Medicine of Malaysia, to be held
in Kuala Lumpur from 25th to 27th August 2016. It is indeed a proud moment for
the Obstetric Special Interest Group of the College as the Obstetric Anaesthesia
Satellite Meeting of the 16th World Congress of Anaesthesiologists is held
simultaneously with the Annual Scientific Congress of the MSA/CoA.
The Congress features a highly interactive, simulating and multidisciplinary
programme including workshops, plenary sessions, symposia, panel discussions,
as well as oral and poster presentations. Under the theme ‘Back to Basics’,
the ASC of the MSA/CoA will address the entire patient pathway and look beyond
the scientific topics alone. The Obstetric sessions not only covers the basics but
addresses the further advancements in techniques and technologies in the care of
the mother.
The Organising and Scientific Committees have worked hard to ensure a dynamic
programme with eminent international and local speakers. The Congress provides
an ideal platform to stimulate ideas and establish collaborations both local and
international, as well as to initiate discussions. Extended networking opportunities
will foster communications between the delegates.
To the international speakers and delegates, please enjoy our camaraderie and
the lovely, vibrant city of Kuala Lumpur or simply KL. KL is a cultural melting pot
that has great food, excellent shopping and warm hospitality.
Have a fruitful and enjoyable meeting!
Thank you!
Dr Sushila Sivasubramaniam
Message from the President, College of Anaesthesiologists, AMM
5
Dear Colleagues and Friends,
Greetings! It gives me great pleasure to extend a warm welcome to the
Annual Scientific Congress of the Malaysian Society of Anaesthesiologists
and the College of Anaesthesiologists (ASC of the MSA/CoA), to be held
from the 25th to the 27th of August 2016, at the Berjaya Times Square Hotel,
Kuala Lumpur. The Obstetric Anaesthesia Satellite Meeting, an international
event preceding the 16th World Congress of Anaesthesiologists in Hong Kong,
will be held in conjunction with our Annual Scientific Congress. It is a great
honour for us to welcome eminent speakers from all over the world before some of
them head to Hong Kong.
The theme for the ASC of the MSA/CoA is titled ‘Back to Basics’ which we hope,
will be able to meet the expectations of delegates in covering a wide range of topics
in the Obstetrics and non-Obstetrics sessions. The Organising Committee and
Scientific Committees have been hard at work to ensure an enjoyable academic
Congress. The Scientific Committees have drawn up a stimulating programme
consisting of pre-congress workshops with hands-on workshops, plenaries and
concurrent symposium sessions.
The Congress will see distinguished and renowned speakers who are experts in
their respective fields, sharing their knowledge and expertise on a wide variety of
topics, representing the latest developments and future trends. This is definitely a
Congress not to be missed!
Please do come and join us for the ever popular Gala Dinner which promises to be
an entertaining affair to ensure that the delegates will have time to catch up with
friends and fellows colleagues in an informal setting.
We look forward to meeting you and to a pleasant, interesting and fruitful
Congress.
Professor Dr Marzida Mansor
Message from the Organising Chairperson
6
Message from the Scientific Chairperson of the MSA and CoA Annual Scientific Congress
Dear Colleagues,
The Annual Scientific Congress 2016 promises to be an exciting meeting full
of new topics and old to revisit our basic fundamental knowledge, as well as
keeping up with progress and advances in anaesthesia. Our team in the
MSA Scientific Committees has prepared an outstanding programme to ensure
all sub-specialty topics, relevant workshops and plenary sessions are delivered by
a panel of international and local speakers who are experts in their field.
This year, we will emphasise on how we manage patient care as perioperative
physicians from adopting new protocols for an enhanced recovery to dealing with
high-risk patients and starting critical care early in the operating theatre. We are
also very fortunate to have the concurrent Obstetric Satellite Meeting of World
Congress for obstetric anaesthetists coming from all over the world. This Congress
is a major event not to be missed, as it is an opportunity for all anaesthetists in this
region to meet, learn and share their experiences while building a strong network
in our professional community.
We look forward to seeing all of you from 25th to 27th August 2016.
Dr Loh Pui San
7
Message from the Scientific Chairperson of the Obstetric Anaesthesia Satellite Meeting
We are very lucky indeed to be able to include in this meeting, some world
renowned obstetric anaesthesia speakers who will be on their way to Hong Kong
to speak in the World Congress of Anaesthesiologists. They have graciously offered
to share their expertise in the form of lectures, panel discussions, and of course,
their skills in the obstetric anaesthesia workshops on topics that reflect issues
present in our everyday obstetric patients. We therefore, put together initially a
programme to be known as the Obstetric Satellite Meeting in Kuala Lumpur under
the auspices of the WCA.
There was, however, a minor concern about the turnout, especially in terms of
participants from the ASEAN region with the understanding that many of them
may not be able to find the funds to attend both the Satellite Meeting, as well as
the WCA. The Scientific Committees have since reconvened and made the decision
to extend the invitation to other non-obstetric attendees and tailor the event
accordingly.
The conference was therefore, merged with the Annual Scientific Meeting to
include the non-obstetric section. Besides speakers who were invited specially
for this portion of the conference, our obstetric anaesthesia colleagues have also
generously extended their stay to cover the non-obstetric anaesthesia section.
We have now a most interesting array of world class speakers (both non-obstetric
anaesthesia and obstetric anaesthesia related) plus of course, our own Malaysian
contingent who have generously given their time and effort to make this meeting
a truly international bonanza.
We welcome you to enjoy the scientific content!
Professor Dr Chan Yoo Kuen
8
It is my honor and pleasure to introduce Dr Chang Ham Long for honorary
membership of the Malaysian Society of Anaesthesiologists.
Born in Pusing, Perak, in 1946, Dr Chang had his primary school education
in the Government English School in Pusing. He did his secondary education
in Ipoh at the Anglo-Chinese School (ACS) and completed Form 6 in 1965.
In 1966, he was given a scholarship to do medicine at the University of Malaya
and graduated with MBBS in 1971.
He worked at the General Hospital, Kuala Lumpur, for four years after
graduation and during that time, in 1973, he passed the Primary Examination
of FFARACS. He moved to the University Hospital in 1974 under the University of
Malaya Assistant Lecturer Training Scheme and passed the Australian Fellowship
of Anaesthesiology (FFARACS) at the end of 1976. At that time, the examinations
were held at the University of Singapore. So he is one of our fully locally trained
anaesthesiologists, long before the Masters programme was started.
Dr Chang decided that an academic career was not his cup of tea, so he joined
Tung Shin Hospital Kuala Lumpur, in 1977, where he worked till he retired in
2013.
Dr Chang was therefore, one of our earliest Malaysian anaesthesiologists in
private practice, and he has been an exemplary medical practitioner,
maintaining high standards of practice and keeping up with the developments
in the field and updating himself with regular attendances at CME sessions over
the years.
Despite being in private practice, Dr Chang has also contributed significantly
to the Malaysian Society of Anaesthesiologists. His involvement started when he
was a trainee lecturer in University Malaya, being the Honorary Secretary of the
then Malayan Anaesthetic Society in 1975. He took a break from Society work
while establishing himself in private practice, but came back again to contribute
to the Society by taking up the position of President of the Malaysian Society
of Anaesthesiologists from 1994 to1996. He was a trustee of the Scientific and
Educational Trust Fund with the late Dato’ Dr Lim Say Wan for many years.
He was conferred the Fellowship of the Academy of Medicine of Malaysia and
served as the first President of the College from 1996 to1998.
MSA Honorary Member – Dr Chang Ham Long
Citation by Dr Mary Cardosa
9
MSA Honorary Member – Dr Chang Ham Long
While it seems that Dr Chang was either working hard in hospital or serving
in our professional Anaesthesiology societies, that is not so. He is married to
Dr Chan Wai May, a General Practitioner (now retired) and has two children,
both boys, who have migrated overseas. He also plays golf regularly and has
been doing so for many years, and was Captain of the Royal Selangor Golf
Club from 1999 to 2001; in fact, his involvement with golf was so regular that
his wife thinks he spent more time in the golf course than working! He has also
been collecting and running classic cars for the past 40 years - over that period
of time, he must have collected so many cars that he must be continuously
renovating his house to make way for his cars!
On a personal note, I have known Dr Chang since 1994 when he was President
of the MSA and I was a young member of the Executive Committee. The thing
that impressed me most about Dr Chang was that he was a very kind and
soft-spoken man, but at the same time, he was firm and efficient and he always
managed to finish the Executive Committee meetings in exactly one hour.
At that time, I naively thought that this was the norm in meetings (that they
would be short and sweet!) and I only found out later that it was due to
Dr Chang’s expert diplomacy and efficiency that this was so.
Dr Chang has now retired and is enjoying the fruits of his labour and relaxing
on the golf course, running his vintage cars, and spending time up keeping his
beautiful garden.
He definitely deserves to be conferred as Honorary Member of the Malaysian
Society of Anaesthesiologists and we hope to see him at our Society conferences
and meetings for many years to come.
10
Malaysian Society of AnaesthesiologistsOffice Bearers 2016 – 2017
Dato’ Dr Subrahmanyam Balan
Dr norliza Mohd nor
Dato’ Dr Jahizah Hassan
Professor Dr Marzida Mansor
Dr gunalan a/l Palari @ Arumugam
Professor Dr Jaafar Md Zain
Dr Mafeitzeral Mamat
Dr Sushila Sivasubramaniam
Dr Raveenthiran Rasiah
Datuk Dr V Kathiresan
Dr Suresh Kumar
Dr Mohamed namazie Ibrahim
President DrRaveenthiranRasiah
Immediate Past President DrSushilaSivasubramaniam
President-Elect Dato’DrJahizahHassan
Chairman DrMohamedNamazieIbrahim
Hon Secretary ProfessorDrMarzidaMansor
Hon Treasurer DatukDrVKathiresan
Committee Members DrGunalana/lPalari@Arumugam
DrMafeitzeralMamat
DrNorlizaMohdNor
Dato’DrSubrahmanyamBalan
DrSureshKumar
Hon Auditors ProfessorDrChanYooKuen
ProfessorDrJaafarMdZain
Professor Dr Chan Yoo Kuen
11
President DrSushilaSivasubramaniam
Vice President AssociateProfessorDrRahaAbRahman
Hon Secretary ProfessorDato’DrWangChewYin
Hon Treasurer DrTanChengCheng
Council Members AssociateProfessorDrInaIsmiartiSharrifuddin
Dato’DrJahizahHassan
DatinDrVSivasakthi
DrMuhammadMaaya
Coopted Council Members DrLimWeeLeong
DrRaveenthiranRasiah
College of Anaesthesiologists, AMMOffice Bearers 2016 – 2017
12
Chairperson ProfessorDrMarzidaMansor
Hon Secretary DrMuhammadMaaya
Hon Treasurer Dato’DrVKathiresan
Publications / Publicity DrGunalana/lPalari@Arumugam
Social Dato’DrJahizahHassan
DrKokMengSum
DrAhmadSuhaimiAmir
DrLeePuiKuan
Trade & Exhibition Dato’DrSubrahmanyamBalan
DrRaveenthiranRasiah
Dato’DrVKathiresan
Audio Visual DrMafeitzeralMamat
Organising Committee
Dato’ Dr Subrahmanyam Balan
Dr Mafeitzeral Mamat
Professor Dr Marzida Mansor
Dr Lee Pui Kuan
Dr Kok Meng Sum
Dr Muhammad Maaya Dr gunalan a/l Palari @ Arumugam
Dr Ahmad Suhaimi Amir
Dr Raveenthiran Rasiah
Datuk Dr V Kathiresan
Dato’ Dr Jahizah Hassan
13
MSA and CoA Annual Scientifi c Congress 2016 DrLohPuiSan(Chairperson)
DrNoorjahanHaneemMdHashim
DrWanRahizaWanMat
DrNgKimSwan
DrKhooEngLea
Obstetric Anaesthesia Satellite Meeting ProfessorDrChanYooKuen(Chairperson)
DrMohdRohishamZainalAbidin
ProfessorDrLeeChoonYee
DrThohirohAbdulRazak
Scientific Committees
Dr Loh Pui San
Dr noorjahan Haneem Md Hashim
Professor Dr Chan Yoo Kuen
Dr Wan Rahiza Wan Mat
Dr ng Kim Swan
Professor Dr Lee Choon Yee
Dr Khoo Eng Lea
Dr Mohd Rohisham Zainal Abidin
Dr Thohiroh Abdul Razak
14
Venue: Manhattan II
0915 – 1030 Opening Ceremony
0915 Arrival of guest of honour
0920 Cultural performance
0925 Doa selamat
0930 Welcome by Prof Dr Marzida Mansor, Organising Chairperson
0935 Speech by Dr Raveenthiran Rasiah, President, Malaysian Society of Anaesthesiologists
0940 Speech by Dr Sushila Sivasubramaniam, President, College of Anaesthesiologists, Academy of Medicine of Malaysia
0945 Speech by Dato’ Dr Hj Azman Abu Bakar, Director, Medical Development Division of the Ministry of Health to be followed by the official opening
1000 Launching of
• RecommendationsofMinimumStandardsforInter-FacilityTransportofthe Critically Ill Patients
• TotalIntravenousAnaesthesiaforPaediatrics
1005 Montage
1015 Citation on Dr Chang Ham Long, Honorary Member by Dr Mary Cardosa
1020 Conferment of Honorary Membership on Dr Chang Ham Long
1025 Opening of the Trade Exhibition
1030 Coffee / Tea
Opening Ceremony26th August 2016 (Friday)
15
Gala Dinner26th August 2016 (Friday)
Venue: Manhattan II
1900–2200 Gala Dinner
Theme: Vintage Glamour
1930 Arrival of guests and delegates
2000 Dinner is served
2015 Entertainment
2030 Welcome remarks by Prof Dr Marzida Mansor, Organising Chairperson
Presentations
• MSAAwardandMSA-AZYIAAwards by Dr Raveenthiran Rasiah, President, Malaysian Society of Anaesthesiologists
• BestPosterAwards by Dr Sushila Sivasubramaniam, President, College of Anaesthesiologists, AMM
Lucky Draw
2100 Entertainment
2130 Lucky Draw
Best Dressed Awards
2200 Dance the night away
16
MSA AND CoA ANNUAL SCIENTIFIC CONGRESS
OBSTETRIC ANAESTHESIA SATELLITE MEETING
AUSTRALIAKanagBaskaAnthonyGuterresPaulStewartEmmaVick
GERMANyFriedrichPuhringer
HONG KONGYongBoonHunKarlYoung
JApANAkihiroSuzukiHiroyukiIkezaki
KOREA KimTae-Yop
NEw ZEALAND TimothyShort
pHILIppINESJosephAbuegPenafranciaCano
SINGApOREChongChinTedChooCheeYongLeeShuYingEugeneLiuHernChoonSeeJeeJianTiLianKah
UNITED ARAB EMIRATESPhilippeMacaire
UNITED KINGDOMGavinKennyStephenLuneyLindaMurdoch
USAGirishPJoshi
MALAySIA
AbdulHalimAbdulGhaforAlzamaniMohammadIdroseAnselmSureshRaoLucyChanChangKianMengTikfuGeeKamalBasharAbuBakarKhairulAzmiAbdulKadirKhooEngLea
LaiHouYeeFeliciaLimLohPuiSanMafeitzeralMamatMohamedHassanMohamedAriffMohdBasriMatNorMuhammadMaayaNgKimSwanNoorjahanHaneemMdHashim
NorAiriniIbrahimOmarSulaimanRahaAbdRahmanShahrilAzlanAriffinRamaniVijayanVinodSuppiahWangChewYinZubaidahJamilOsman
AUSTRALIAStephenGattNolanMcDonnell
CANADAJoseCarvalho
INDIASunandaGuptaSunilTPandya
INDONESIASusiloChandra
JApANKatsuoTerui
pHILIppINESConnieCruz
SINGApOREAlexSia
THAILANDOraluxnaRodanant
USAAshrafHabibCynthiaWong
MALAySIA
ChanYooKuenLeeChoonYeeMohdAzizanGhazali
MohdRohishamZainalAbidinNor’azimMohdYunosNorlizaMohdNor
RafidahAtanRajeswaryKanapathipillaiThohirohAbdulRazak
Invited Speakers
17
Ultrasound Guided Regional Anaesthesia25th August 2016 (Thursday)
venue: auditorium, hospital Putrajaya
CoordinatorsNgKimSwan KhooEngLea(on-site)
FaCilitatorsAminuddinbinAhmad(Hospital Putrajaya)KhooEngLea (Hospital Putrajaya)AhmadAfifibinArshad(Hospital Sultanah Bahiyah)LaiHauYee(UMMC)MafeitzeralbinMamat(KPJ, Rawang)
MohdSanybinShoib(Hospital Ampang)RazimanbinAbdulRazak(Hospital Ampang)HusainibinJawahir(Hospital Selayang)PhilippeMaCaire(Dubai, UAE)NgKimSwan(Hospital Selayang)
0800–0830 Registration
0830–0840 Welcomespeech&introduction
0840–0920 TruncalVscentralneuraxialBlock –Updateonthecurrentpracticeforchest&abdominalsurgery
0920–1000 Truncalblock–PECs,Serratus,Rectusshealth,TAP,QLPB
1000–1030 tea
1030–1300 LECTURES1030–1050 Cervicalplexusblock1050–1110 Centralneuraxial1110–1130 UL1130–1150 LL1150–1300 PNB–USscandemonstration (Quickscandemonstrationbyfacilitator10mineachperson)
– Truncalblock– Cervicalplexus– Centralneuraxial– UL–IS&Supraclavicular
– UL–infraclavicular&Axillary– LL–anterior–Femoral&abductor– LL–posterior–Sciatic
1300–1400 lunCh
1350–1400 Grouping
1400–1630 4stations–8USmachine,8facilitatorsStation1–Truncal–neck/chest/abdomenStation2–CentralneuraxialStation3–UL–supra/infraclavicularStation4–LL–anterior&posterior
1630–1700 Feedback
1700 tea & the end
MSA/CoA WorkShop
18
venue: Manhattan I
CoordinatorWanRahizaWanMat
synopsisThisworkshopaimstoequipparticipantswiththeessentialbasicsofhandlingultrasoundintheperioperativeperiod.Theworkshopbegins inthemorningwithaseriesof introductory lecturestodiscussaboutvariousperioperative indications for theuseofultrasoundandthecorrespondingsonoanatomy. Itwillbe followedbyfocusedhands-onsessionsconductedbyourpanelofexpertstoputtheacquiredinformationintoskilfulpracticeandhopefullycultivatefurtherinterestinthisexpandingfieldofperioperativeandcriticalcare.
0800–0830 Registration
0830–0900 Basicultrasoundknobology Anushya Vijayananthan
0900–0930 Cardiacultrasound Hasmizy Muhammad
0930–1000 Lungultrasound Lee Pui Kuan
1000–1015 MorningTea
1015–1045 Abdominalultrasound Nurul Aida Selamat
1045–1115 Ultrasound-guidedvascularaccess Nur Yazmin Yaacob
1115–1315 Demo/Handsonsessions(30minutesperstation)
STATIONS CardiacHasmizy Muhammad
LungLee Pui Kuan
AbdomenNurul Aida Selamat
VascularaccessNur Yazmin Yaacob
1315 Endofworkshop
Perioperative Ultrasound25th August 2016 (Thursday)
MSA/CoA WorkShop
19
Managing Anaesthetic Crises25th August 2016 (Thursday)
MSA/CoA WorkShop
venue: Junior Manhattan
FaCilitatorsNoorjahanHaneemMdHashimCarolynYimChueWaiThiruselviSubramaniamRajeswaryKanapathipillaiRafidahAtan
TARgET AUDIEnCE : Anaesthesiatrainees,specialistsandnurses
TARgET nUMBER : 20-30
PLAn : 4scenariosand1break
0800–0830 Registration Carolyn Yim Chue Wai
0830–0845 Welcomeaddressandfacultyintroduction Noorjahan Haneem Md Hashim
0845–0910 Icebreaking Noorjahan Haneem Md Hashim
0910–0930 Introductiontocrisesmanagement Thiruselvi Subramaniam
0930–1000 Humanperformanceanderrorsinanaesthesiacrisesmanagement Rajeswary Kanapathipillai
1000–1015 Break
1015–1100 Scenario1All facilitators
1100–1145 Scenario2
1145–1230 Scenario3
1230–1315 Scenario4
1315–1330 Debriefandtakehomemessage Rafidah Atan
20
Basic Airway Skills Revisited25th August 2016 (Thursday)
venue: Manhattan I
FaCilitatorsMuhammadMaaya(Malaysia)StephenLuney(UK)FriedrichPuhringer(Germany)KanagBaska(Australia)
This workshop aims to expose the participants to the various devices involved in airway management.Wearehonouredtobeabletogatherinternationalmastersintheirfieldsofexpertisefromaroundtheglobe.
1300–1305 Introductionandoverlayofworkshop Muhammad Maaya
1305–1335 Difficultairwayguidelines:Update Muhammad Maaya
1335–1455 HANDS-ONSESSIONS(20minutesperstation)1. Flexibleintubation&thenervestobeblocked Muhammad Maaya
2. Bonfilsandvideolaryngoscopy Friedrich Puhringer
3. LMA&endobronchialblocker Stephen Luney
4. Baskaairway Kanag Baska
1455–1545 Casescenarios
1545–1600 Q&Afollowedbyclosing
MSA/CoA WorkShop
21
Obstetric Workshops
25th August 2016 (Thursday)
0830–1200
Use Of UltrasOUnd In ObstetrIc anesthesIavenue: bronx V
1330–1800
PerfectIng ePIdUrals and sPInalsvenue: bronx V
FaCilitatorsCynthiaWong(USA)LeeChoonYee(Malaysia)
Smallgroupdiscussion,includingcasescenariosandpracticaltips,on:– Spinal/epiduralinalogicalmanner(includingpreventingcontamination)– Perfectingepidural– Thetechniqueofspinal– Thetestdose– SpinalforemergencyLSCS
26th August 2016 (Friday)
1030–1200
Use Of UltrasOUnd In ObstetrIc anesthesIavenue: Junior Manhattan
1400–1530
sIMUlatIOn wOrkshOP On hIgh rIsk ObstetrIc sItUatIOnsvenue: Junior Manhattan
1600–1730
hIgh rIsk ObstetrIcs venue: Junior Manhattan
22
datetime
25th august 2016 (thursday)
26th august 2016 (friday)
27th august 2016 (saturday)
0730–0830 RegistRation(0715–0815)
RegistRation Brainy Breakfast
plenary 1plenary 20830–0900
MSA/CoA workshops
Obstetricworkshops,Symposium And panel
Discussions
0900–0930plenary 3
Opening ceremony0930–1000
1000–1030 tea / tRade exhibitiontea / tRade exhibition
1030–1100 SyMpOSIAObstetric
workshops,Symposium And panel
Discussions
SyMpOSIA
MIN
I w
OR
KSH
Op
1
1100–11301 2 3 9 10 11 12
1130–1200
1200–1230Lunch
Lunch satellite
symposium(Covidien)
Lunch satellite
symposium(3M)
Lunch satellite
symposium(Baxter)
Lunch satellite symposium
(Merck Sharp & Dohme)
Lunch satellite symposium
(Mundipharma)1230–1300
1300–1330
MSA/CoA workshops
poster presentation (1400 – 1600)
Obstetricworkshops,Symposium And panel
Discussions
Lunch / FRiday PRayeRs Lunch
1330–1430
Obstetricworkshops,Symposium And panel
Discussions
SyMpOSIAM
INI
wO
RK
SH
Op
21430–1500 SyMpOSIA
Ora
l p
rese
nta
tion
13 14 15
1500–1530 4 5
1530–1600tea / tRade exhibition
SyMpOSIA SyMpOSIA
1600–1630
6 7 816 17 18
1630–1700
1700–1730tea / tRade exhibition
1730–1800
1900–2200
(1930–2230)
FACULTy DINNER(by invitation only)
dinner satellite symposium
(Abbvie)(by invitation only)
Gala Dinner
Programme Summary
23
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DiS
CuSS
ion
1
venu
e: A
udito
rium
, Hos
pita
l Put
raja
yaUl
traso
und
Guid
ed R
egio
nal
Anae
sthe
sia
(refe
r pro
gram
me
in p
age
17) ve
nue:
Man
hatta
n I
Perio
pera
tive
Ultra
soun
d (re
fer p
rogr
amm
e in
pag
e 18
)
venu
e: J
unio
r Man
hatta
nM
anag
ing
Anae
sthe
tic C
rises
(re
fer p
rogr
amm
e in
pag
e 19
)
•Simulation
Ultr
asou
nd o
f the
obs
tetr
ic s
pine
Jose
Ca
rva
lho
(Ca
na
da
),T
hoh
iroh
Ab
du
l R
aza
k (
Ma
lays
ia)
(Lim
ited
to 1
2 pa
rtici
pant
s on
ly
on a
firs
t-com
e fir
st-s
erve
d ba
sis)
0830
– 0
900
Mod
ern
tech
niqu
es in
mai
ntai
ning
ne
urax
ial b
lock
in la
bour
[pa
ge 6
1]A
lex S
ia (
Sin
gap
ore)
0900
– 0
930
Wha
t to
do w
ith fe
tal b
rady
card
ia
follo
win
g ne
urax
ial a
nalg
esia
[pag
e 62
]C
ynth
ia W
ong
(USA
)
0930
– 1
000
Man
agem
ent o
f the
sid
e ef
fect
s of
ne
urax
ial o
pioi
ds [
page
63]
Ash
raf
Ha
bib
(U
SA
)
1000
– 1
030
tea
0830
– 1
000
Faile
dairw
ay [
page
64]
Su
na
nd
a G
up
ta (
Ind
ia),
Lee
Ch
oon
Yee
(M
ala
ysia
),O
ralu
xn
a R
oda
na
nt
(Th
ail
an
d)
venu
e: M
anha
ttan
IIo
bSt
etri
C Sy
Mpo
Siu
M 2
« Re
gion
al A
nest
hesi
a »
Chai
rper
son:
Moh
d Ro
hish
am Z
aina
l Abi
din
venu
e: M
anha
ttan
Vo
bSt
etri
C pA
nel
DiS
CuSS
ion
2
1030
– 1
100
CnB
in a
par
turie
nt w
ith a
“p
atho
logi
cal b
ack”
Su
nil
T P
an
dya
(In
dia
)
1100
– 1
130
Low-dos
ese
quen
tialC
SE [
page
64]
Lee
Ch
oon
Yee
(M
ala
ysia
)
1130
– 1
200
Man
agem
ent o
f spi
nal i
nduc
ed
hypo
tens
ion
[pa
ge 6
5]A
shra
f H
ab
ib (
USA
)
1030
– 1
200
Med
ico-lega
l–Preve
ntingthene
xt
cour
t cas
e [
page
66]
Ste
ph
en G
att
(A
ust
rali
a),
Ch
an
Yoo
Ku
en (
Ma
lays
ia),
Cyn
thia
Won
g (U
SA
),C
onn
ie C
ruz
(Ph
ilip
pin
es)
1200
– 1
330
Lunc
h
Dai
ly P
rogra
mm
e –
25
th A
ugust
2016 (
Thurs
day
)
24
Dai
ly P
rogra
mm
e –
25
th A
ugust
2016 (
Thurs
day
) [cont’d]
1330
– 1
800
MSA
/CoA
Wo
rkSh
opS
[C
on
Curr
ent]
venu
e: B
ronx
Vo
bSt
etri
C W
ork
Sho
p«
Perfe
ctin
g Ep
idur
als
And
Spin
als
»
venu
e: M
anha
ttan
IIo
bSt
etri
C Sy
Mpo
Siu
M 3
« M
isha
p In
Obs
tetri
c An
alge
sia/
An
aest
hesi
a »
Chai
rper
son:
Cha
n Yo
o Ku
en
venu
e: M
anha
ttan
Vo
bSt
etri
C pA
nel
DiS
CuSS
ion
3
1300
– 1
600
venu
e: M
anha
ttan
IBa
sic
Airw
ay S
kills
Rev
isite
d
(refe
r pro
gram
me
in p
age
20)
Ste
ph
en L
un
ey (
UK
)Fri
edri
ch P
uh
rin
ger
(Ger
ma
ny)
Ka
na
g B
ask
a (
Au
stra
lia
)
•FO
B•
Suprag
lotic
dev
ices
•Vide
olaryn
gosc
opy
1400
– 1
530
Look
ing
at is
sues
of p
atie
nt
posi
tioni
ng; t
ray
prep
arat
ion;
cl
eani
ng a
gent
s to
use
; tip
s on
pe
rfec
ting
the
spin
al a
nd e
pidu
ral
tech
niqu
es; r
evis
iting
test
dos
es a
nd
cras
h sp
inal
sC
ynth
ia W
ong
(USA
),Lee
Ch
oon
Yee
(M
ala
ysia
)
1330
– 1
400
nea
r mis
ses
in o
bste
tric
ana
esth
esia
–
A cl
inic
al a
udit
of 6
0000
obs
tetr
ic
epid
ural
sSu
nil
T P
an
dya
(In
dia
)
1400
– 1
430
Perm
anen
t par
alys
is p
ost s
pina
l [p
age
67]
Ste
ph
en G
att
(A
ust
rali
a)
1430
– 1
500
The
seco
nd v
ictim
: We
need
hel
p to
o [
page
68]
Moh
d R
ohis
ha
m Z
ain
al
Ab
idin
(M
ala
ysia
)
1500
– 1
530
tea
1330
– 1
500
Post
ope
rativ
e an
alge
sia
[pa
ge 6
9]A
lex S
ia (
Sin
gap
ore)
,Su
silo
Ch
an
dra
(In
don
esia
),K
ats
uo
Ter
ui
(Ja
pa
n)
1400
– 1
600
poSt
er p
reSe
ntA
tio
nve
nue:
Man
hatta
n II
ob
Stet
riC
SyM
poSi
uM
4«
Hem
orrh
age
Prev
entio
n »
Chai
rper
son:
Car
olyn
Yim
venu
e: M
anha
ttan
Vo
bSt
etri
C pA
nel
DiS
CuSS
ion
4
Jud
ges:
Ra
ha
Ab
d R
ah
ma
n (
Ma
lays
ia),
Lu
cy C
ha
n (
Ma
lays
ia),
Moh
am
ed H
ass
an
Moh
am
ed A
riff
(M
ala
ysia
)
1530
– 1
600
Uter
oton
ics
Jose
Ca
rva
lho
(Ca
na
da
)
1600
– 1
630
The
deng
ue p
atie
nt in
obs
tetr
ics
[pag
e 70
]T
hoh
iroh
Ab
du
l R
aza
k (
Ma
lays
ia)
1630
-170
0
Coag
ulat
ion
man
agem
ent i
n ob
stet
ric h
emor
rhag
e [
page
70]
Nol
an
McD
onn
ell
(Au
stra
lia
)
1530
– 1
700
Card
iopu
lmon
ary
resu
scita
tion
in th
e pa
rtur
ient
[pa
ge 7
1]C
onn
ie C
ruz
(Ph
ilip
pin
es),
Moh
d R
ohis
ha
m Z
ain
al
Ab
idin
(M
ala
ysia
),Ste
ph
en G
att
(A
ust
rali
a)
1930
– 2
230
Facu
lty
Din
ner
(by
in
vita
tion
on
ly)
din
ner s
atel
lite
sym
posi
um –
Abb
vie
(by
invi
tati
on o
nly
)
Rem
ifent
anil:
Com
puls
ory
or d
ispe
nsab
le?
Ga
vin
Ken
ny
(UK
)
25
0715
– 0
815
Regi
stra
tion
0815
– 0
915
plen
Ary
1
venu
e: M
anha
ttan
IICh
airp
erso
n: R
aha
Abdu
l Rah
man
Tech
nology
–Frie
ndorfoe
?Ba
ckto
bas
ics–De
alingwith
adv
ance
sinana
esthes
ia [
page
35]
Ga
vin
Ken
ny
(UK
)
0915
– 1
030
Op
enin
g C
erem
ony
(refe
r pro
gram
me
in p
age
14)
venu
e: M
anha
ttan
II
1030
– 1
200
venu
e: M
anha
ttan
IISy
Mpo
Siu
M 1
« N
euro
Ana
esth
esia
»Ch
airp
erso
n: V
anith
a
venu
e: B
ronx
VSy
Mpo
Siu
M 2
« Ca
rdia
c An
aest
hesi
a »
Chai
rper
son:
Zur
aini
Moh
d
venu
e: B
ronx
VI
SyM
poSi
uM
3«
Regi
onal
»Ch
airp
erso
n: Ju
lina
venu
e: J
unio
r Man
hatta
no
bSt
etri
C W
ork
Sho
p«
Use
Of U
ltras
ound
In
Obst
etric
Ane
sthe
sia
»
venu
e: M
anha
ttan
Io
bSt
etri
C Sy
Mpo
Siu
M 5
« Th
e Di
fficu
lt Ca
ses
»Ch
airp
erso
n: N
ora
Azur
a In
tan
venu
e: M
anha
ttan
Vo
bSt
etri
C pA
nel
DiS
CuSS
ion
5
1030
– 1
050
Perio
pera
tive
phar
mac
olog
y in
ne
uroa
naes
thes
ia:
Rem
ifent
anil
to
dexm
edet
omid
ine
Ch
ong
Ch
in T
ed
(Sin
gap
ore)
1030
– 1
050
Anae
sthe
tic
man
agem
ent o
f MIC
S by
pass
[pa
ge 3
6]H
iroy
uk
i Ik
eza
ki
(Ja
pa
n)
1030
– 1
050
Regi
onal
– D
oes
it re
duce
can
cer
recu
rren
ce?
Pen
afr
an
cia
Ca
no
(Ph
ilip
pin
es)
Ultr
asou
nd o
f the
ob
stet
ric s
pine
Jose
Ca
rva
lho
(Ca
na
da
),T
hoh
iroh
Ab
du
l R
aza
k
(Ma
lays
ia)
(Lim
ited
to
1
2 p
art
icip
an
ts o
nly
on
a fi
rst-
com
e fi
rst-
serv
ed b
asi
s)
1030
– 1
100
The
prev
ious
diffi
cult
regi
onal
ana
esth
esia
an
d di
fficu
lt ai
rway
[pag
e 72
]Su
na
nd
a G
up
ta (
Ind
ia)
1100
– 1
130
The
preg
nant
pat
ient
w
ith s
pace
occ
upyi
ng
lesi
on in
the
brai
nC
onn
ie C
ruz
(Ph
ilip
pin
es)
1130
– 1
200
The
card
iac
part
urie
nt
[pag
e 73
]K
ats
uo
Ter
ui
(Ja
pa
n)
1200
– 1
400
Lunc
h
1030
–12
00
The
obes
e pa
rtur
ient
[pag
e 74
]A
shra
f H
ab
ib (
USA
),Su
nil
T P
an
dya
(In
dia
),O
ralu
xn
a R
oda
na
nt
(Th
ail
an
d)
1050
– 1
110
Cere
bral
pro
tect
ion
in p
rolo
nged
ne
uros
urge
ry
Ste
ph
en L
un
ey (
UK
)
1050
– 1
110
Diab
etes
in c
ardi
ac
surg
ery
[pa
ge 3
7]T
i Lia
n K
ah
(S
inga
por
e)
1050
– 1
110
Trai
ning
and
cr
eden
tialin
g fo
r re
gion
al a
naes
thes
iaM
afe
itze
ral
Ma
ma
t (M
ala
ysia
)
1110
– 1
130
Assi
stin
g th
e ne
uroi
nter
vent
iona
l ra
diol
ogis
tK
ha
iru
l A
zmi
Ab
du
l K
ad
ir (
Ma
lays
ia)
1110
– 1
130
Tota
l int
rave
nous
an
aest
hesi
a fo
r car
diac
su
rger
y [
page
38]
Kim
Ta
e-Y
op (
Kor
ea)
1110
– 1
130
guid
elin
es a
nd
advi
sorie
s on
regi
onal
Ph
ilip
pe
Ma
cair
e (U
nit
ed A
rab
Em
ira
tes)
1130
– 1
150
Anae
sthe
sia
for a
wak
e cr
anio
tom
y See
Jee
Jia
n (
Sin
gap
ore)
1130
– 1
150
Fasttrac
k–Ho
wfa
st
can
we
go?
Sh
ah
ril
Azl
an
Ari
ffin
(M
ala
ysia
)
1130
– 1
150
Allie
d He
alth
Sci
ence
: n
euro
logi
cal
dysf
unct
ion
afte
r pe
riphe
ral n
erve
bl
ocks
– S
trat
egie
s an
d m
anag
emen
t La
i H
ou Y
ee (
Ma
lays
ia)
1150
– 1
200
Q &
a11
50 –
120
0 Q
& a
1150
– 1
200
Q &
a
Dai
ly P
rogra
mm
e –
26
th A
ugust
2016 (
Fri
day
)
26
1200
– 1
300
venu
e: M
anha
ttan
IILu
nch
sate
llite
sym
posi
um –
Cov
idie
nAi
rway
vis
ualiz
atio
n te
chno
logy
– th
e er
a of
vid
eo
lary
ngos
cope
Ak
ihir
o Su
zuk
i (J
ap
an
)
venu
e: B
ronx
VII
Lunc
h sa
telli
te s
ympo
sium
– 3
M
Peri-
operativehy
pothermia:Isitalway
sin
adve
rten
t (PB
L) L
ee S
hu
Yin
g (S
inga
por
e)
venu
e: M
anha
ttan
ILu
nch
sate
llite
sym
posi
um –
Ba
xter
Ch
airp
erso
n: L
oh P
ui S
an
Post-ope
rativ
eco
gnitive
dys
func
tion:Serious
m
atte
rs G
iris
h P
Jos
hi
(USA
)
1300
– 1
430
Lunc
h /
Frid
ay P
raye
rs
1400
– 1
540
venu
e: M
anha
ttan
IISy
Mpo
Siu
M 4
« Pa
edia
trics
»Ch
airp
erso
n:
Sush
ila S
ivas
ubra
man
iam
venu
e: B
ronx
VSy
Mpo
Siu
M 5
« Am
bula
tory
Sur
gery
»Ch
airp
erso
n:
Subr
ahm
anya
m B
alan
venu
e: B
ronx
VI
orA
l pr
eSen
tAti
on
Chai
rper
sons
: No
orja
han
Hane
em M
d Ha
shim
/ W
an R
ahiz
a W
an M
at
venu
e: J
unio
r Man
hatta
no
bSt
etri
C W
ork
Sho
pve
nue:
Man
hatta
n I
ob
Stet
riC
SyM
poSi
uM
6«
Spin
als,
Spi
nals
, Sp
inal
s »
Chai
rper
son:
Tho
hiro
h Ab
dul R
azak
venu
e: M
anha
ttan
Vo
bSt
etri
C pA
nel
DiS
CuSS
ion
6
1430
– 1
450
How
we
caus
e an
d tr
eat t
rach
eal
sten
osis
in c
hild
ren
Lin
da
Mu
rdoc
h (
UK
)
1430
– 1
450
Post
oper
ativ
e na
usea
an
d vo
miti
ng [
page
40]
Ash
raf
Ha
bib
(U
SA
)
Jud
ges:
Lim
Wee
Leo
ng
(Ma
lays
ia),
Cyn
thia
Won
g (U
SA
),C
hon
g C
hin
Ted
(S
inga
por
e)
1400
– 1
530
Sim
ulat
ion
wor
ksho
p on
hig
h ris
k ob
stet
ric
situ
atio
ns
Ra
fid
ah
Ata
n
(Ma
lays
ia),
Ra
jesw
ary
K
an
ap
ath
ipil
lai
(Ma
lays
ia),
Nor
’azi
m M
ohd
Yu
nos
(M
ala
ysia
),M
ohd
Azi
zan
Gh
aza
li
(Ma
lays
ia)
(Lim
ited
to
20
pa
rtic
ipa
nts
pe
r se
ssio
n o
nly
on
a fi
rst-
com
e fi
rst-
serv
ed b
asi
s)
1400
– 1
430
PDPH
: Hea
dach
e fo
r an
aest
hetis
t too
Nor
liza
Moh
d N
or
(Ma
lays
ia)
1430
– 1
500
Low
dos
e sp
inal
Su
silo
Ch
an
dra
(I
nd
ones
ia)
1500
– 1
530
Is s
pina
l or e
pidu
ral
easi
er in
the
obes
e pa
rtur
ient
?O
ralu
xn
a R
oda
na
nt
(Th
ail
an
d)
1400
– 1
530
Regi
onal
Ana
esth
esia
an
d th
e us
e of
an
tithr
ombo
tic a
gent
s
[pag
e 75
-76]
Ch
an
Yoo
Ku
en
(Ma
lays
ia),
Ste
ph
en G
att
(A
ust
rali
a),
Nol
an
McD
onn
ell
(Au
stra
lia
)
1450
– 1
510
Anae
sthe
sia
for
thor
acos
copi
c su
rger
y in
chi
ldre
n [
page
39]
Fel
icia
Lim
(M
ala
ysia
)
1450
– 1
510
Puta
stoptopos
t-an
aest
hesi
a de
laye
d re
cove
ryP
au
l Ste
wa
rt
(Au
stra
lia
)
1510
– 1
530
Wei
ghin
g th
e sc
ales
for
child
hood
obe
sity
Vin
od S
up
pia
h
(Ma
lays
ia)
1510
– 1
530
Allie
d He
alth
Sci
ence
: Th
e ne
w P
lan
A in
da
ycar
e Fri
edri
ch P
uh
rin
ger
(Ger
ma
ny)
1530
– 1
540
Q &
a15
30 –
154
0 Q
& a
Dai
ly P
rogra
mm
e –
26
th A
ugust
2016 (
Fri
day
) [cont’d]
27
Dai
ly P
rogra
mm
e –
26
th A
ugust
2016 (
Fri
day
) [cont’d]
1540
– 1
710
venu
e: M
anha
ttan
IISy
Mpo
Siu
M 6
« Tr
aum
a »
Chai
rper
son:
Jahi
zah
Hass
an
venu
e: B
ronx
VSy
Mpo
Siu
M 7
« Ai
rway
»
Chai
rper
son:
Ra
veen
thira
n Ra
siah
venu
e: B
ronx
VI
SyM
poSi
uM
8«
Spec
ial C
once
rns
»Ch
airp
erso
n: N
g Ki
m S
wan
venu
e: J
unio
r Man
hatta
no
bSt
etri
C W
ork
Sho
pve
nue:
Man
hatta
n I
ob
Stet
riC
SyM
poSi
uM
7«
Airw
ay O
f The
Pa
rturie
nt »
Chai
rper
son:
Nor
liza
Moh
d No
r
venu
e: M
anha
ttan
Vo
bSt
etri
C pA
nel
DiS
CuSS
ion
7
1540
– 1
600
Usef
ul b
lock
s in
the
EDM
afe
itze
ral
Ma
ma
t (M
ala
ysia
)
1540
– 1
600
Airw
ay m
anag
emen
t ov
er th
e la
st 5
yea
rs
[pag
e 41
]E
uge
ne
Liu
Her
n C
hoo
n
(Sin
gap
ore)
1540
– 1
600
Futilesu
rgeryan
dou
r an
aest
hetic
aim
s in
ca
ncer
See
Jee
Jia
n (
Sin
gap
ore)
1600
– 1
730
High
risk
obs
tetr
ics
Ra
jesw
ary
K
an
ap
ath
ipil
lai
(Ma
lays
ia),
Ra
fid
ah
A
tan
(M
ala
ysia
), a
nd
te
am
1600
– 1
630
gast
ric a
sses
smen
t by
POC
ultr
asou
nd to
as
sess
risk
of
aspi
ratio
nJo
se C
arv
alh
o (C
an
ad
a)
1630
– 1
700
Lary
ngea
l mas
k ai
rway
in
obs
tetr
ics
– Is
it
safe
?Su
nil
T P
an
dya
(In
dia
)
1700
– 1
730
Airw
ay o
f the
obe
se
part
urie
nt [
page
77]
Ash
raf
Ha
bib
(U
SA
)
1600
– 1
730
The
last
24
hour
s in
ut
ero
[pa
ge 7
8]C
ha
n Y
oo K
uen
(M
ala
ysia
),A
lex S
ia (
Sin
gap
ore)
,N
ola
n M
cDon
nel
l (A
ust
rali
a)
1600
– 1
620
Bew
are
– Th
e ne
ck
with
a fr
actu
reP
ena
fra
nci
a C
an
o (P
hil
ipp
ines
)
1600
– 1
620
Faile
dfle
xiblefib
reop
tic
intu
batio
n: R
epor
ts,
reas
ons,
rem
edie
s [p
age
42]
Lu
cy C
ha
n (
Ma
lays
ia)
1600
– 1
620
Allie
d He
alth
Sci
ence
: An
aest
hetic
role
for
intr
acta
ble
canc
er p
ain
Ch
oo C
hee
Yon
g (S
inga
por
e)
1620
– 1
640
From
che
micalto
bo
mbs
: Rea
l life
ac
tions
!A
lza
ma
ni
Moh
am
ma
d
Idro
se (
Ma
lays
ia)
1620
– 1
640
Tips
for a
n un
hurr
ied
stop
-startapn
oiec
w
indo
wSte
ph
en L
un
ey (
UK
)
1620
– 1
640
Wha
t's n
ew in
an
aest
hesi
a fo
r MRI
[pag
e 44
]Loh
Pu
i Sa
n (
Ma
lays
ia)
1640
– 1
700
Allie
d He
alth
Sci
ence
: Tr
ansp
ortin
g th
e cr
itica
lly il
l to
OTJo
sep
h A
bu
eg
(Ph
ilip
pin
es)
1640
– 1
700
Allie
d He
alth
Sci
ence
: As
sist
ing
the
diffi
cult
airw
ay [
page
43]
Mu
ha
mm
ad
Ma
aya
(M
ala
ysia
)
1640
– 1
700
Slee
p m
edic
ine
in o
ur
daily
pra
ctic
eW
an
g C
hew
Yin
(M
ala
ysia
)
1700
– 1
710
Q &
a17
00 –
171
0Q
& a
1700
– 1
710
Q &
a
1710
– 1
730
tea
/ tr
ade
exhi
bitio
n
1900
– 2
200
Gal
a D
inn
er (r
efer
pro
gram
me
in p
age
15)
venu
e: M
anha
ttan
IIT
hem
e: V
inta
ge G
lam
ou
r
28
0730
– 0
800
brA
iny
bre
Akf
ASt
Cha
irper
son:
Cha
n Yo
o Ku
en
venu
e: B
ron
x VI
Eat,
live
and
trai
n w
ell
Nol
an
McD
onn
ell
(Au
stra
lia
)
0800
– 0
900
plen
Ary
2 C
hairp
erso
n: R
avee
nthi
ran
Rasia
h ve
nue:
Man
hatta
n II
Wor
king
tow
ards
enh
ance
d re
cove
ry a
fter s
urge
ry (E
RAS)
[pa
ge 3
5] G
iris
h P
Jos
hi
(USA
)
0900
– 1
000
plen
Ary
3 C
hairp
erso
n: M
arzi
da M
anso
r ve
nue:
Man
hatta
n II
Enha
nced
per
iope
rativ
e ca
re o
f hig
h ris
k su
rgic
al p
atie
nts
(EPO
CH):
Wha
t's o
ur k
ey ro
le?
Tim
oth
y Sh
ort
(New
Zea
lan
d)
1000
– 1
030
tea
/ tr
ade
exhi
bitio
n
1030
– 1
200
venu
e: M
anha
ttan
ISy
Mpo
Siu
M 9
« Pe
riope
rativ
e M
edic
ine
1 »
Chai
rper
son:
Nor
liza
Moh
d No
r
venu
e: M
anha
ttan
IISy
Mpo
Siu
M 1
0«
Pain
Man
agem
ent »
Chai
rper
son:
Lim
Ern
Min
g
venu
e: B
ronx
VSy
Mpo
Siu
M 1
1«
Tran
spla
nt »
Chai
rper
son:
Aza
rinah
Izah
am
venu
e: B
ronx
VI
SyM
poSi
uM
12
« Sa
fety
And
Qua
lity
»Ch
airp
erso
n:
Moh
amed
Nam
azie
Ibra
him
venu
e: J
unio
r Man
hatta
nM
ini W
ork
Sho
p 1
« M
onito
ring
Stra
tegi
es F
or
A Sa
fe A
naes
thes
ia »
1030
– 1
050
ERAS
pro
toco
l for
abd
omin
al
surg
erie
sG
iris
h P
Jos
hi
(USA
)
1030
– 1
050
Tack
lingpo
st-surgica
lpain:
Is p
reve
ntio
n be
tter t
han
cure
? W
hose
resp
onsi
bilit
y is
it?
Ch
oo C
hee
Yon
g (S
inga
por
e)
1030
– 1
050
Upda
tes
on o
rgan
don
atio
n in
Mal
aysi
a [
page
48]
Om
ar
Su
laim
an
(M
ala
ysia
)
1030
– 1
050
Safe
ty in
the
oper
atin
g th
eatr
eP
au
l Ste
wa
rt (
Au
stra
lia
)
Faci
litat
ors:
Jose
ph A
bueg
, S
Y Ar
lene
, Ric
hmon
d Ch
ang
1030
– 1
200
Inva
sive
mon
itorin
g, d
epth
of
anae
sthe
sia
mon
itorin
g, n
MT
1050
– 1
110
Thro
mbo
prop
hyla
xis:
Re
duci
ng ri
sks
and
impr
ovin
g qu
ality
Moh
d B
asr
i M
at
Nor
(M
ala
ysia
)
1050
– 1
110
Post
oper
ativ
e pa
in
man
agem
ent:
Curr
ent
tech
niqu
es in
the
new
era
[pag
e 46
]K
hoo
En
g Lea
(M
ala
ysia
)
1050
– 1
110
The
liver
tran
spla
nt te
am
[pag
e 49
]Y
ong
Boo
n H
un
(H
ong
Kon
g)
1050
– 1
110
Team
wor
k an
d ac
coun
tabi
lity
[pag
e 52
]E
uge
ne
Liu
Her
n C
hoo
n
(Sin
gap
ore)
1110
– 1
130
Stra
tegi
es to
opt
imiz
e pe
riope
rativ
eflu
ids
Ka
rl Y
oun
g (H
ong
Kon
g)
1110
– 1
130
Chal
leng
es in
acu
te
post
oper
ativ
e pa
in
man
agem
ent f
ollo
win
g kn
ee
arth
ropl
asty
– A
n up
date
[pag
e 47
]Su
na
nd
a G
up
ta (
Ind
ia)
1110
– 1
130
Intr
abdo
min
al tr
ansp
lant
–
Live
r tra
nspl
anta
tion
[pa
ge 5
0]A
nth
ony
Gu
terr
es (
Au
stra
lia
)
1110
– 1
130
Thees
sentialsoftim
e-ou
t [p
age
53]
Nol
an
McD
onn
ell
(Au
stra
lia
)
1130
– 1
150
Allie
d He
alth
Sci
ence
: As
sess
ing
our p
atie
nts’
risk
s pre-op
eratively
[pa
ge 4
5]A
nse
lm S
ure
sh R
ao
(Ma
lays
ia)
1130
– 1
150
Allie
d He
alth
Sci
ence
: M
anag
ing
pain
with
out d
rugs
Zu
ba
ida
h J
am
il O
sma
n
(Ma
lays
ia)
1130
– 1
150
Allie
d He
alth
Sci
ence
: Live
rtrans
plan
tsatfl
inde
rs,
an a
naes
thet
ic n
urse
’s pe
rspe
ctiv
e [
page
51]
Em
ma
Vic
k (
Au
stra
lia
)
1130
– 1
150
Cons
ent:
Don’
t tak
e it
for
gran
ted!
Noo
rja
ha
n H
an
eem
Md
H
ash
im (
Ma
lays
ia)
1150
– 1
200
Q &
a11
50 –
120
0Q
& a
1150
– 1
200
Q &
a11
50 –
120
0Q
& a
Dai
ly P
rogra
mm
e –
27
th A
ugust
2016 (
Sat
urd
ay)
29
Dai
ly P
rogra
mm
e –
27
th A
ugust
2016 (
Sat
urd
ay) [cont’d]
1200
– 1
300
venu
e: M
anha
ttan
ILu
nch
sate
llite
sym
posi
um –
Mer
ck S
ha
rp &
Doh
me
nM
BA re
vers
al: P
ast,
pres
ent a
nd fu
ture
P
au
l Ste
wa
rt (
Au
stra
lia
)
venu
e: M
anha
ttan
IILu
nch
sate
llite
sym
posi
um –
Mu
nd
iph
arm
aOx
ycod
one:
cur
rent
per
spec
tives
and
clin
ical
use
s in
pos
tope
rativ
e pa
inC
hoo
Ch
ee Y
ong
(Sin
gap
ore)
1300
– 1
400
Lunc
h
1400
– 1
530
venu
e: M
anha
ttan
ISy
Mpo
Siu
M 1
3«
Perio
pera
tive
Med
icin
e 2
»Ch
airp
erso
n: K
ok M
eng
Sum
venu
e: M
anha
ttan
IISy
Mpo
Siu
M 1
4«
Criti
cal C
are
»Ch
airp
erso
n: L
ee P
ui K
uan
venu
e: B
ronx
VSy
Mpo
Siu
M 1
5«
Spec
ial I
ssue
s »
Chai
rper
son:
V K
athi
resa
n
venu
e: J
unio
r Man
hatta
nM
ini W
ork
Sho
p 2
« Ve
ntila
tion
Stra
tegi
es: W
hat’s
Be
st F
or P
eri-O
pera
tive
Care
? »
Coor
dina
tor a
nd ch
airp
erso
n:
Wan
Rah
iza
Wan
Mat
1400
– 1
420
Stra
tegi
es in
pat
ient
s w
ith a
cute
liv
er fa
ilure
[pag
e 54
]Y
ong
Boo
n H
un
(H
ong
Kon
g)
1400
– 1
420
Pre-op
erativestab
ilisa
tion:W
hen
is it
saf
e to
brin
g a
sept
ic p
atie
nt
to O
T?N
or A
irin
i Ib
rah
im (
Ma
lays
ia)
1400
– 1
420
Smar
t ste
p in
the
right
dire
ctio
nLin
da
Mu
rdoc
h (
UK
)
1400
– 1
420
Vent
ilatio
n m
odes
: Any
mod
e su
perio
r tha
n th
e ot
her?
Ph
ilip
pe
Ma
cair
e (U
nit
ed A
rab
Em
ira
tes)
1420
– 1
440
Deal
ing
with
rena
l fai
lure
Ab
du
l H
ali
m A
bd
ul
Gh
afo
r (M
ala
ysia
)
1420
– 1
440
Star
ting
criti
cal c
are
early
in
thea
tre
Ka
ma
l B
ash
ar
Ab
u B
ak
ar
(Ma
lays
ia)
1420
– 1
440
Mal
igna
nt h
yper
ther
mia
– A
n up
date
[pag
e 56
]C
ynth
ia W
ong
(USA
)
1420
– 1
440
Perio
perativ
eus
eofnon
-inva
sive
ve
ntila
tion
Ra
ha
Ab
d R
ah
ma
n (
Ma
lays
ia)
1440
– 1
500
Upda
tes
on c
ardi
ac fa
ilure
in
patie
ntsun
dergoing
non
-cardiac
su
rger
ySh
ari
l A
zla
n A
riffi
n (
Ma
lays
ia)
1440
– 1
500
Met
abol
ic a
cido
sis:
Its
impo
rtanc
eK
arl
You
ng
(Hon
g K
ong)
1440
– 1
500
Man
agin
g an
adv
erse
eve
ntR
afi
da
h A
tan
(M
ala
ysia
)
1440
– 1
500
Perio
pera
tive
wea
ning
ven
tilat
ion
stra
tegi
esM
ohd
Ba
sri
Ma
t N
or (
Ma
lays
ia)
1500
– 1
520
Safe
ana
esth
esia
for p
atie
nts
with
a ‘b
ad lu
ng’ [
page
55]
Kim
Ta
e-Y
op (
Kor
ea)
1500
– 1
520
Allie
d He
alth
Sci
ence
: Ad
aptin
g po
int o
f car
e in
the
oper
atin
g th
eatr
eA
kih
iro
Su
zuk
i (J
ap
an
)
1500
– 1
520
Med
ical
neg
ligen
ce
Moh
am
ed H
ass
an
Moh
am
ed A
riff
(M
ala
ysia
)
1520
– 1
530
Q &
a15
20 –
153
0Q
& a
1520
– 1
530
Q &
a
1530
– 1
550
tea
/ tr
ade
exhi
bitio
n
30
Dai
ly P
rogra
mm
e –
27
th A
ugust
2016 (
Sat
urd
ay) [cont’d]
1550
– 1
700
venu
e: M
anha
ttan
ISy
Mpo
Siu
M 1
6«
The
Obes
e Pa
tient
»Ch
airp
erso
n: L
oh P
ui S
an
venu
e: M
anha
ttan
IISy
Mpo
Siu
M 1
7«
The
Elde
rly P
atie
nt »
Chai
rper
son:
Maf
eitz
eral
Mam
at
venu
e: B
ronx
VSy
Mpo
Siu
M 1
8«
Trai
ning
»Ch
airp
erso
n: C
arol
yn Y
im
1550
– 1
610
Upda
tes
in b
aria
tric
sur
gery
Tik
fu G
ee (
Ma
lays
ia)
1550
– 1
610
Chro
nic
med
icat
ions
: Wha
t to
stop
an
d w
hen?
[pa
ge 5
7]O
ma
r Su
laim
an
(M
ala
ysia
)
1550
– 1
610
Mas
terin
g ba
sic
scie
nces
: Cou
ld
we
do b
ette
r?N
or’a
zim
Moh
d Y
un
os (
Ma
lays
ia)
1610
– 1
630
Pred
ictin
g dr
ug b
ehav
iour
in th
e ob
ese
Tim
oth
y Sh
ort
(New
Zea
lan
d)
1610
– 1
630
Post-opco
gnitive
dys
func
tionin
elde
rly p
ost s
urgi
cal p
atie
nts
[pag
e 58
]Su
na
nd
a G
up
ta (
Ind
ia)
1610
– 1
630
nav
igat
ing
thro
ugh
ethi
cs fo
r yo
ur s
tudy
Ch
an
g K
ian
Men
g (M
ala
ysia
)
1630
–16
50
Find
ingthesp
ace:N
euroax
ialb
lock
sin
the
obes
eP
hil
ipp
e M
aca
ire
(Un
ited
Ara
b
Em
ira
tes)
1630
–16
50
Pain
in o
lder
pat
ient
s: A
m
ultid
imen
sion
al a
ppro
ach
Ng
Kim
Sw
an
(M
ala
ysia
)
1630
–16
50
Embr
ace
a cr
itica
l min
d [p
age
59]
Ra
ma
ni
Vij
aya
n (
Ma
lays
ia)
1650
– 1
700
Q &
a16
50 –
170
0Q
& a
1650
– 1
700
Q &
a
31
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34
MSA/CoAPLENARIES AND SYMPOSIA
35
TECHNOLOGy - FRIEND OR FOE? BACK TO BASICS – DEALING wITH ADVANCES IN ANAESTHESIA
Gavin Kenny
university of glasgow, uK
There is increasing complexity within anaesthesia caused by the greater number of alarms, the increased amount and complexity of patient monitoring, and more complex anaesthetic machines. In addition, the available drugs and equipment have changed markedly over the past decades.
As anaesthetic and monitoring systems become more highly automated and removed from our direct control, the user can become further disconnected from understanding the processes and problems associated with clinical care, especially during the developmentofacriticalsituation.Thishasbecomeincreasinglyevident in theairline industrywherepossibleover-relianceonautomation has led to the reduced ability of some pilots to deal with complex and critical situations. We may already be seeing similar signs within the practice of anaesthesia and we must ensure that teaching provides our juniors with the ability to rely on the basics of good clinical practice.
There are two rules which apply to any proposed new development. It must either undertake a task which would be impossible without the technology or else it must perform the task better than with present technologies and with a better outcome. If the development follows neither of these two rules, then it is likely that it will not succeed.
Development and implementation of new technology must be controlled and directed by anaesthetists. It must be used with as much skill as we practice the art of anaesthesia. Examples will be given of systems which demonstrate real improvement in clinical care.
wORKING TOwARDS ENHANCED RECOVERy AFTER SURGERy (ERAS)Girish P Joshi
Professor of anesthesiology and Pain Management at the university of texas southwestern Medical school in dallas, texas
In recent years, there has been an emphasis on enhanced recovery after surgery to allow for shorter hospital length of stay. It is now realizedthatintraoperativeanesthesiatechniqueinfluencesnotonlyimmediatepostoperativeoutcome(e.g.delayedemergence),but also increase postoperative morbidity (e.g. postoperative pulmonary complications). The aim of this presentation is to discuss the current evidence for an optimal general anesthetic technique that would allow rapid recovery after surgery in adults.
Plenary 1
Plenary 2
36
ANESTHETIC MANAGEMENT OF MICS BypASSHiroyuki Ikezaki
department of anesthesiology and critical care, Kawaguchi cardiovascular and Respiratory hospital (Kawaguchi city, saitama) Japan
Over the past two decades, cardiac surgery for cardiac ischemic patients has been greatly advanced, especially in off pump CABg (OPCAB)andanesthesiaforOPCABwelladaptedtothisprogress.Recently,theminimallyinvasivecardiacsurgeryCABG(MICS-CABg) via a small left thoracotomy, has emerged as safe and effective alternatives. However, the best practical method of anesthesia for theMICS-CABGpatient hasnot been fully established. In this presentation, Iwill reviewsome topicsof current anestheticmethodsforconventionalOPCABandMICS-CABG,andalsointroducemytipsandopinionforpracticalmanagements.
SyMPOSIUM 2
« Cardiac Anaesthesia »
37
DIABETES IN CARDIAC SURGERyTi Lian Kah
department of anaesthesia, yong Loo Lin school of Medicine, national university of singapore, singapore national university health system, singapore
Diabetes is unfortunately a very common disease in both Malaysia and Singapore. Almost 50% of patients presenting for cardiac surgery at the two national heart centres in Singapore are diabetic. Patients with diabetes have higher rates of perioperative morbidityandmortalityandareducedlong-termsurvivalratethanthosewithoutdiabetes;withanoddsratioof1.15fordeathwithin30 days, increased risk of stroke, renal failure, and deep sternal wound infection. Although much of these risks may be explained by co-morbiddiseasesandcomplicationsofdiabetes,glycemiccontrolinpatientswithdiabetesdecreasesperioperativemorbidityandimprovesbothshortandlong-termsurvival.
TheACCF/AHA1 and STS2 both published guidelines on glucose control management during cardiac surgery, derived primarily from research on patients undergoing CABg. The guidelines confirmed that blood glucose levels of >11.1 mmol/l in the perioperative period resulted in greater morbidity and mortality. The evidence also showed that maintaining blood glucose level <10 mmol/l was beneficial, but tighter control to <7.8 mmol/l did not appear to confer further benefit.
Data from our local patients in Singapore, however, suggest that tighter glycemic control to <8 mmol/l results in less infection, acute kidney injury and atrial fibrillation3-5. We postulate that this may be due to a reduction in variability of glucose levels afforded by tighter control.
references1. Circulation 2011;124:e652– e735
2. Ann Thorac Surg 2009;87:663–9
3. JThoracCardiovascSurg2015;149(1):323-8
4. Medicine 2015;94(44):e1953
5. Abstract, SCA 2016
SyMPOSIUM 2
« Cardiac Anaesthesia »
38
TOTAL INTRAVENOUS ANAESTHESIA FOR CARDIAC SURGERyTae-Yop Kim
department of anesthesiology, Konkuk university school of Medicine, seoul, Republic of Korea, Konkuk university Medical center, seoul, Republic of Korea
Volatile and intravenous anaesthetics can be used as a part of various cardiac anaesthesia regimens for cardiac surgery. However, itisstillunclearwhichagentsaresuperiortoothersintermsofprovidingcardio-protectiveeffectinclinicalsetting.Furthermore,the condition for exerting protective effects upon using certain agents varied widely with respect to the mode of administration, the technique of cardiac surgery, the type of cardioplegia solutions, and the use of cardiopulmonary bypass.
VolatileanaestheticagentshavebeenpreferredforcardiacsurgeryduetotheirischemicpreconditioningeffectviaATP-dependentK+ channels.
Propofol, due to its free radical scavengingeffectandcardio-protectivemechanisms,hasbeenusedasamajorcomponentoftotalintravenousanaesthesia(TIVA).Opioidsalsoinducedcardiacprotectiveeffectreducingischemia-reperfusioninjury,similartoischemic preconditioning, via δ-andκ-opioidreceptorstimulation,inmanypreviousexperimentalanimals.However,therequirementneededtoactivateopioidreceptorstotriggercardio-protectiveeffectisrelativelyhigh;thismaybethereasonforthelackofclinicalstudiesspeculatingopioid-inducedcardio-protection.
Remifentanil, an ultrashort-acting opioid, may be promising because it is rapidly metabolized by nonspecific blood and tissueesterases;evenafter itsprolongedadministration, itdoesnotprolongrecovery.Analgesia-basedTIVAregimenemployinghigh-dose remifentanil may be another option for enjoying myocardial protective effect, stable hemodynamics and rapid recovery in cardiac surgery. It provides excellent hemodynamic control in attenuating adrenergic response to surgery and does not directly affect myocardial contractility and intrinsic cardiac automaticity.
reference1. ActaAnaesthesiolScand.2010;54:510-8.2. CardiovascDrugsTher.1998;12:365-73.3. JCardiothoracVascAnesth.2010;24:790-6.4. CurrPharmDes.2014;20:5696-5705.5. BrJAnaesth.2010:105:122-30.
SyMPOSIUM 2
« Cardiac Anaesthesia »
39
ANAESTHESIA FOR THORACOSCOpIC SURGERy IN CHILDRENFelicia S K Lim
universiti Kebangsaan Malaysia Medical centre, Kuala Lumpur, Malaysia
With the advancement in technology and refinement in techniques and the development of fine instruments for small infants and children, the use of video assisted thoracoscopic surgery (VATS) in paediatric patients is increasing. VATS offers many advantages suchasminimalinvasiveness,smallincision,reductioninpost-operativepain,andfasterpostoperativerecovery.However,VATSininfants and younger children still remains a challenge largely due to their small size and lower capacity.
VATS involves performance of intrathoracic procedures through several small thoracostomy openings without a thoracotomy. Requirements include adequate ventilation and oxygenation, a ‘quiet’ surgical field with adequate exposure and avoidance of contamination of normal lung. Visualization of intrathoracic structures requires a partially or totally collapsed ipsilateral lung and canbeperformedbyone-lungventilation(OLV)ortwo-lungventilationincombinationwithCO2insufflation.
Anaesthetic management for VATS should take into consideration the patient’s underlying status as well as the physiological derangementscausedbyCO2insufflationandtheeffectsoflateraldecubitusposition.Thiscanhavesignificantadverseeffectsonthe cardiopulmonary physiology which can aggravate the pathophysiological changes already present due to the existing disease process.
A thorough preoperative evaluation, thorough understanding of the underlying pathology, severity of pulmonary disease, ability of patient to tolerate lateral decubitus position and positive pressure ventilation. A knowledge of the various methods of lung isolation, the physiology of one lung ventilation is also very important. An individualized meticulous planning, and continuous vigilance to detect any untoward event at the earliest, with good communication between the anaesthetic and surgical teams contributes to a safe and successful surgery.
SyMPOSIUM 4
« Paediatrics »
40
pOSTOpERATIVE NAUSEA AND VOMITINGAshraf S Habib
duke university, durham, nc, usa
Postoperative nausea and vomiting (POnV) are frequent and unpleasant side effects following surgery. The overall incidence of POnV has decreased from 60 % when ether and cyclopropane were used, to approximately 30 % nowadays. However in certain high-riskpatientsthisincidenceisstillashighas70%.PONVcanincreasemedicalcostsbydelayingrecoveryroomdischargeorleadingtounplannedadmissionsfollowingoutpatientsurgery.Post-dischargenauseaandvomiting(PDNV)canalsoleadtoadelayinresumptionofdailyactivities.Fromthepatients’perspective,nauseaandvomitingareamongthemostunpleasantexperiencesassociatedwith surgery.Numerouspatient, anesthesia, and surgical risk factorshavebeen identified.Well-establishedpatientrelated risk factors include femalegender,non-smokingstatus,andhistoryofPONVormotionsickness. Increasingdurationofsurgery, and use of volatile agents, nitrous oxide, and opioids are well established surgery and anesthesia related risk factors. Some types of surgery are also associated with a higher risk for POnV. The etiology of POnV is multifactorial, with at least 5 major receptor systems involved in the pathogenesis of POnV: the dopaminergic D2 receptors, the cholinergic muscarinic receptors, the histaminergic H1 receptors, the serotonergic (5HT3) receptors, and the neurokinin 1 (nK1) receptors. Antagonists at those receptors constitute the mainstay of POnV management. Use of a combination of antiemetics acting at different receptor subtypes is associated with improved POnV prophylaxis compared to monotherapy. The multimodal approach refers to using combination antiemetic therapy in addition to strategies to reduce the baseline risk of POnV. The ideal prophylactic strategy (risk adapted strategy vs. universal combination therapy) is debated.
objectives1. Review prevalence and risk factors for POnV
2. Discuss various interventions for POnV prophylaxis.
3. Review strategies for the treatment of established POnV.
4. Review recent advances and guidelines for the management of POnV
SyMPOSIUM 5
« Ambulatory Surgery »
41
AIRwAy MANAGEMENT OVER THE LAST 5 yEARSEugene Liu
national university hospital, singapore
Patterns of airway usage now show that supraglottic airway devices, in particular laryngeal mask airways, are used in the majority of general anaesthetics. LMAs feature in all algorithms for cannot ventilate cannot intubate situations but caution is needed. Although the ease and success of LMA insertion may not be affected by the factors that make tracheal intubation and mask ventilation difficult, some factors such as short thyromental distance and limited neck movement also affect LMA insertion. Video laryngoscopes are increasingly used in difficult airway management and could become routinely used for normal airways in the future.
SyMPOSIUM 7
« Airway »
42
FAILED FLExIBLE FIBEROpTIC INTUBATION: REpORTS, REASONS, REMEDIESLucy Chan
department of anesthesiology & intensive care, university Malaya Medical centre Kuala Lumpur, Malaysia
Strategies for difficult airway management have guided the practice of anaesthetists with the development of consensus algorithms thatareregularlyupdatedaswellasthetechnologicalimprovementsinairwaydevices.Theuseofthereusableflexiblefiberopticbronchoscope(FFB)toaiddifficultintubationremainsacorner-stoneintheteachingcurriculumofanaesthetictrainees.However,thereisaquotedincidenceoffailedintubationwithFFBof1.8%to10%.Reasonsforfailureincludeinabilitytoviewtheglottisorto advance the insertion cord through the glottis due to severely distorted and altered airway structures or the mere presence of bloodandsecretions.Expertisewithvideo-laryngoscopesoracombinationoftechniques(suchasavideo-laryngoscopetogetherwithassisted-flexibleopticalscope)hasbailedoutmanyfailedintubationswithFFB.Insomecases,asurgicalairwayisrequiredorsurgery is cancelled.
SyMPOSIUM 7
« Airway »
43
allIed health scIence: ASSISTING THE DIFFICULT AIRwAy
Muhammad Maaya
universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
The difficult airway can be a very traumatising experience for all health professionals. The incidence has not changed much despite the development of new airway devices. The key points to successfully manage this situation are preparation and a good team work. The presentation will highlight what is expected of an anaesthetic assistant during such an episode, including the basic usual airway management, the anticipated difficult airway and the dreaded unanticipated. Different gadgets and conduct of management will also be presented.
SyMPOSIUM 7
« Airway »
44
wHAT’S NEw IN ANAESTHESIA FOR MRILoh Pui San
university Malaya, Kuala Lumpur, Malaysia
introductionMagnetic resonance (MR) imaging has become more powerful as an invaluable tool in diagnosis and intervention. As anesthetists, we are increasingly involved in this area of remote anesthetic service. Since 2002, available guidelines have been developed by the Association of Anesthetists of great Britain and Ireland (AAgBI) with recent updates in 2010 that would prove useful to all attending anaesthetists.1 The additional knowledge in recommendations for working in the MRI suite will ensure patient and personnel safety on top of improved quality of care during each procedure.
Outline of the presentation:
1. Safety terminology – MR safe or unsafe
– new MR conditional equipment
– Medical implants
2. MRsystems – Highermagnetic-fieldstrengthsandmoreopendesigns
– Interventionalandintra-operativeMR
– Out-of-hoursavailability
3. Training and safety of personnel
4. Safety of contrasts.
references1.GraingerD,KingS,McBrienM,etal.Safetyinmagneticresonanceunits:anupdate.Anaesthesia2010;65:766-70.
SyMPOSIUM 8
« Special Concerns »
45
allIed health scIence: ASSESSING OUR pATIENT’S RISKS pREOpERATIVELy
Anselm Suresh Rao
gleneagles hospital, Kuala Lumpur, Malaysia
The aim of the preoperative assessment is to identify interventions that can lead to improved outcomes in patients with comorbidities.
Pulmonary predictors of postoperative pulmonary complications (PPC) are smoking, chronic obstructive airway disease (COAD), asthma, interstitial lungdiseaseandupper respiratory tract infection.Non-pulmonarypredictorsofPPCareage,generalhealth(ASA) status, obstructive sleep apnoea, pulmonary hypertension, heart failure, chronic kidney disease, nutritional status, dependent functional status and the degree of neurologic impairment.
Pre-operative strategies to reducePPCare smoking cessation, optimizing airflow limitation in patientswithCOPDand asthma,treating lower respiratory tract infections when present and lung expansion techniques.
Intra-operative strategies include considering intraoperative analgesia with epidural or regional technique when indicated,consideringlaparoscopicversusopensurgeryandensuringadequatefluidmanagementwithgoal-directedtherapy.
Post-operative strategies to reducePPC include selective nasogastric tube decompression after abdominal surgery, nutritionalsupport, lung expansion maneuvers and epidural analgesia.
Preoperative cardiovascular testing is recommended only for patients with increased risk and poor exercise capacity. Coronary revascularizationbeforenon-cardiacsurgeryisonlyforpatientsinwhomitiswarranted,independentofnon-cardiacsurgery.Therisk of reinfarction remains high for at least 2 months after an acute myocardial infarction (AMI) thus the need to delay elective surgeryfor2monthsafteranAMI.Forthepreventionofstentthrombosisafterpercutaneouscoronaryintervention(PCI)withstentinsertion,baremetalstentsneeds30daysofdualantiplatelettherapy(DAPT)whiledrug-elutingstentneedsDAPTfor12months.Thus elective surgery should be delayed during this period.
The key to improving perioperative patient outcomes is a comprehensive process with preoperative risk stratification and interventions performed preoperatively, intraoperatively, and postoperatively.
SyMPOSIUM 9
« Perioperative Medicine 1 »
46
pOSTOpERATIVE pAIN MANAGEMENT: CURRENT TECHNIqUES IN THE NEw ERAKhoo Eng Lea
national cancer institute, Putrajaya, Malaysia
Over the years, postoperative pain management has undergone a major paradigm shift from emphasis on a sickness model of care to a wellness model of care. Since the introduction of the Enhanced Recovery After Surgery (ERAS) pathway and the PROSPECT (procedure specific postoperative pain management) group about a decade ago, it is now well recognized that perioperative, including postoperative pain management, embraces a multidisciplinary team strategy that focuses on early restoration of function, and reduction of complications and duration of hospital stay. Besides that, prevention of chronic postsurgical pain is another important goal of effective postoperative pain management.
Pivotal to this is the concept of preventive analgesia, which traditionally hinges on using multimodal preventative pharmacological analgesictechniquessuchasepiduralanalgesia,andotheropioid-sparingagentslikeNMDAantagonist,gabapentinoids,NSAIDsandlocalanaestheticwoundinfiltration.Itisinterestingtonotethatthereareincreasingutilizationandevidenceofultrasound-guidedperipheral nerves block and truncal blocks (TPVB,PECS, QLB, TAP) for postoperative pain management. These will play an important role in the new era, especially with the increased availability of ultrasound machines and the rise in number of anaesthetists who are trainedinultrasound-guidedregionalanaesthesia.
Nevertheless, there must be also emphasis on non-pharmacological techniques. This is where we should fully utilize themultidisciplinary armamentarium in pain management; which include patient education, physiotherapy, psychological therapy & behavioural therapy.
SyMPOSIUM 10
« Pain Management »
47
CHALLENGES IN ACUTE pOSTOpERATIVE pAIN MANAGEMENT FOLLOwING KNEE ARTHROpLASTy… AN UpDATE
Sunanda Gupta
geetanjali Medical college, udaipur, india
Multimodal approach to pain control involves administration of combination and often multiple analgesics or modalities at various time points during the course of surgery that includes preoperative period. Pain control after knee arthroplasty (TKA) can be achieved withacombinationofdrugsusedduringthepreoperative(NSAIDS,COX-2inhibitors,anticonvulsants),intra-operative(opioids,localanesthetics),andthepostoperativeperiods(opioids,NSAIDS,COX-2inhibitors,α2-Agonists,NMDAantagonists,anticonvulsants,and centrally acting analgesics as acetaminophen).
PreemptivetreatmentwiththeNSAIDssuchasKetorolacandIbuprofen,COX-2selectiveinhibitors,andanti-neuropathicdrugsasgabapentin and Pregabalin are shown to have the advantage of decreasing postoperative pain scores, opioid requirements, and postoperative nausea after surgery.
Regionalanalgesiaduringtheperioperativeperiodinvolvestheusesofspinalanalgesia,combinedspinal-epiduralanalgesia,orperipheralnerveblockadeforpaincontrolduringandaftersurgery.Femoralnerveblockinvariablyresultsinquadricepsmuscleweakness.So inaneffort topreservequadricepsmusclepower,alternativeanalgesic techniquesconsistingofperi-and intra-articular infiltration of a large volume of local anesthetics in the knee (LIA), and Adductor canal block (ACB) has been included in the analgesic armamentarium with fast functional recovery and good pain control. Thus choosing an effective and safe analgesic techniqueinfluencesthepostoperativeoutcomesinthisgroupofpatients.
SyMPOSIUM 10
« Pain Management »
48
UpDATES ON ORGAN DONATION IN MALAySIAOmar Sulaiman
hospital sultanah aminah, Johor bahru, Johor, Malaysia
Organ donation programme was started in Malaysia in late 80s and started with kidney donation and successfully transplanted. Subsequently the programme of organ and tissue donation move on with great support from government and ngOs. With the start of 0.5 to 0.7 donor pmp , last year we had greatly successful donation rate with 1 donor pmp that was 70 deceased donors , which wasthehighestrateforthepast20years.Afewprogrammesthatwereinitiatedeg.JOMIKRARforMOHstaffsclinicalandnon-clinical,10-focused-MOHHospitaland“GIFT”cardfordoctorsandparamedicsworkingincriticalcareunit.Hencesupportfromtheprivate sectors in terms of promoting organ donation and detection of potential brain death and finally became actual donors were tremendously excellent. Organ and tissue donation: A gift of Life.
SyMPOSIUM 11
« Transplant »
49
THE LIVER TRANSpLANT TEAMYong Boon Hun
hong Kong sanatorium and hospital, hong Kong
Experienceofsettingupalivertransplantationteamandprogramindifferentcountriesisreviewed.Theteamisnormallyspear-headed by a transplant surgeon or hepatobiliary surgeon with transplant training. More than one surgeon is needed to start a program. A team of transplant anaesthetists is essential and should be involved early in planning and program strategy. Other core members include intensivists, hepatologists, microvascular surgeons (if live donor liver transplantation is planned), a transplant coordinator, theatre nursing team and perfusionists with experience or training in transplantation. Clinical psychologists are needed for pre-operative assessment and preparation, especially for live-donor programs. Interventional radiologists and pathologistsexperienced with transplant patients are other team members who can help ensure a successful program.
Livertransplantationisaresource-intensivetreatmentandstronginitialandcontinuingsupportintermsofstaffingandfinancialresources need to be committed by institution heads for a program to succeed. All team members must understand the scarcity oforgangrafts,andproperselectionof recipients, tomaximizeandoptimize theuseof resources.Pre-operativeassessment iscomprehensiveandrequiresamulti-disciplinaryteam.Likewisepost-operativeacutecareandlong-termfollow-uparekeyissueswhichhave tobeconsidered in initial resourceplanning.Other issues tobeconsideredarewhether tobeginwithdead-donoror live-donor programs, legislation on brain death and organ donation. Innovations like split liver, donor exchange and dominotransplantation and donation after cardiac death, have major implications for manpower and rostering issues. A successful program requiresexpertise,commitment,persistenceandteam-work.
SyMPOSIUM 11
« Transplant »
50
INTRA-ABDOMINAL TRANSpLANT – LIVER TRANSpLANTATIONAnthony Guterres
Flinders Medical centre, adelaide, south australia
Livertransplantationhasevolvedfromahighmortality,highbloodlossoperationinthe1960stoaprocedurewithahigh5-yearsurvivalrateandwiththepotentialtobeablood-product-freeoperation.Thisimprovementhasbeendrivenbothbysurgicaltechniqueandanaesthetic management and monitoring. Liver transplantation can however still pose itself as one of the most challenging cases for the anaesthetist, especially in the presence of fulminant liver failure. This presentation will review the current practice and developments in liver transplantation, as well as ongoing current challenges in liver transplantation.
SyMPOSIUM 11
« Transplant »
51
allIed health scIence: LIVER TRANSpLANTS AT FLINDERS, AN ANAESTHETIC NURSE’S pERSpECTIVE
Emma Vick
Flinders Medical centre, adelaide, south australia
TheLiverTransplantUnitatFlindersMedicalCentrewasestablishedin1992,andsincethattime,hasperformedover330transplants.Havingbeenpartoftheteamfor6years,Ihaveseenfirst-handthecommitmenttopatientcareandincredibleattentiontodetailthatunderpins the unit’s efficacy.
Whilst the transplant process itself lies at the cutting edge of operative medicine, ultimately it is the people behind the process that are thesinglemostsignificant factor influencingqualitypatientoutcomes.Asmallgroupofspecialistanaestheticnurses in theFlinders’LiverUnitplayacriticalroleintheperioperativemanagementofpatientsandintraoperativeperformanceoftheanaestheticspecialists involved.
Theinvolvementofmultipleanaestheticspecialists,foreducationandskilldevelopment,placesFlindersattheforefrontoftransplantpractices globally and demands the support of highly skilled and efficient anaesthetic nurses. This talk will focus on the preparatory phaseofthelivertransplantprocessatFlindersandthepivotalroleplayedbyanaestheticnursesinensuringthatpatientsarebestplaced to successfully receive donor organs. Equipment set up and provision, patient support and procedural observance will also beexploredinmynurse’s-eyeviewoftheFlindersLiverTransplantstory.
SyMPOSIUM 11
« Transplant »
52
TEAMwORK AND ACCOUNTABILITyEugene Liu
national university hospital, singapore
The existence of teamwork should not be left to chance; the growth of teamwork should be consciously driven by specialty andhospital leadership. Inter-professional trainingcanhelp teamwork in patient safety.Such training shouldbeginearlywhilefuturehealthcareprofessionalarestillstudents.Bringingmulti-disciplinaryteamstogetherforsharedgoalsinsafetyandqualityimprovement projects helps build the teamwork. Team spirit and the sense of responsibility to the team are critical when handling crises. Setting of department targets for quality and safety and alignment of group rewards to these targets can improve teamwork and accountability.
SyMPOSIUM 12
« Safety And Quality »
53
SyMPOSIUM 12
« Safety And Quality »
THE ESSENTIALS OF TIME OUTNJ McDonnell
King edward Memorial hospital, Perth, Western australia the university of Western australia, Perth, Western australia
st John of god hospital, subiaco, Western australia
In 2007 the World Alliance for Patient Safety took up the WHO Second global Patient Safety Challenge: Safe Surgery Saves Lives. The challenge focused on improving the safety of surgical care across both the developing and developed world. Whilst surgery is often life saving and no doubt improves the lives of the majority of patients, a large number of patients worldwide suffer from preventable harm secondary to surgery.
As part of the push to improve surgical safety, the WHO developed the Safe Surgical Checklist. This, in conjunction with the book by US surgeon and author Atul guwande (“The Checklist Manifesto: How to get things right”), led to the formal adoption and roll out of the Safe Surgical Checklist across a large number of institutions worldwide. In many countries the checklist became a mandated part of surgical care, however just because a checklist may be mandated by authorities does not necessarily mean it will be utilised as it should be, unless there is significant buy in from all staff who work in the operating theatre environment.
The Safe Surgical Checklist has three main components which are potentially modifiable to suit individual institutions (or specialty) requirements. These steps are the “sign in” process, the “time out” and then the “sign out” of the patient from the operating theatre. The anaesthetist has an important role at all three steps, not only does the checklist potentially benefit patients by ensuring aspects ofcaresuchasantibioticandthrombo-prophylaxisplanshavebeenconfirmed,onemajorbenefitofthechecklististheimprovementofteamworkandcommunicationamongstmembersoftheoperatingtheatreteam-breakingdowntraditionalhierarchicalmodelsand giving staff more confidence to speak up when a patient safety related situation may be arising.
54
STRATEGIES IN pATIENTS wITH LIVER FAILUREYong Boon Hun
hong Kong sanatorium and hospital, hong Kong
Thispresentationwill focusonacuteliverfailure(ALF),sometimestermed“fulminanthepaticfailure”.DefinitionofALFincludesevidenceofcoagulopathyandencephalopathyinapatientwithoutpre-existingcirrhosis,wheretheillnessisof<26weeks’duration.Acuteonchronicliverfailure(ACLF)isanewclinicalentitydistinctfromdecompensatedcirrhosis,characterizedbyaprecipitatingevent,multi-organ failure, SIRSand a highmortality rate. InALF prognosis depends on speed of onset of encephalopathy andaetiology. If <7 days the likely cause is viral infection or paracetamol toxicity and recovery without liver transplantation is more likely. Onset of >8 days is associated with idiosyncratic drug reactions or autoimmune hepatitis, with spontaneous recovery less likely.AetiologyofALFvarieswithgeographicallocation.Initialmanagementincludesorgansupport,cerebralprotection,N-acetylcysteine in known or suspected paracetamol poisoning, and identifying patients who benefit from liver transplantation. Initial imaging with ultrasound can exclude acute portal or hepatic vein thrombosis, malignant infiltration and cirrhosis. Antibiotic prophylaxis may behelpful.Overtbleedingisnotcommon.Freshfrozenplasmashouldonlybegivenforactivebleedingorforinvasiveprocedures.Cerebral oedema is the main cause of death and at risk patients should receive early liver transplantation if available.
SyMPOSIUM 13
« Perioperative Medicine 2 »
55
SAFE ANAESTHESIA FOR pATIENTS wITH A ‘BAD LUNG’Kim Tae-Yop
Konkuk university school of Medicine, seoul, Republic of Korea, Konkuk university Medical center, seoul, Republic of Korea
Lung-protectivestrategyemploying low tidalvolume (4-6ml/kg), sufficientplateaupressures, lung recruitmentandpositiveendexpiratorypressure(PEEP),andlowerFiO2canreduceatelectasisoravoidaggravationoflunginjuryinpatientswithpreoperative“badlung”.Sincerepetitivetidalrecruitmentandalveolarover-distensioncauseseriouslunginjury,ventilatorstrategyemployinghighertidal volumes (>10 ml/kg) without PEEP and high plateau pressures (>30 cmH2O) should be avoided during anaesthesia, especially inhigh-riskpatients.An‘openlungphilosophy’withcontinuouspositiveairwaypressuremayhelpmaintaininglungaerationand,thereby, decreasing hypoxemia and risk of postoperative pulmonary complication. As respiratory acidosis, impaired gas exchange, and systemic congestion may develop acute kidney injury (AKI) in pulmonary dysfunction, the lung is highly susceptible to injuries byAKI. Ventilatory strategies, producing lung-injury,may generate pulmonary and systemic release of inflammatorymediators,responsibleto“biotrauma”ofkidney.Mechanicalventilationcanincreasenotonlythoracicpressuresbutintra-abdominalpressure,causingrenalvenouscongestionandedemaespecially inseverechronicobstructive lungdisease.This lung-kidney interactioncompromisesrenalperfusion,whichresultsinAKIwithdiuretic-resistantfluidoverload.Associatedrightventriculardysfunctionandcongestioncancontributetoalterationsinrenalperfusion,leadingtodiuretic-resistantfluidoverload.ExcessfluidadministrationcannotpreventnewAKI,butitincreasestheneedofrenalreplacementtherapy:fluidoverloadaggravatingpulmonarydysfunctionshouldbeavoided,particularlyinpatientswithpre-existingbadlungs.
references• TusmanG,etal.Atelectasisandperioperativepulmonarycomplicationsinhigh-riskpatients.CurrOpinAnaesthesiol.2012;25:1-10.• KellumJA,etal.Theeffectsofalternativeresuscitationstrategiesonacutekidneyinjuryinpatientswithsepticshock.AmJRespirCritCareMed2016;193:281-7• Husain-SyedF,etal.Lung-kidneyCrosstalkintheCriticallyIllPatient.AmJRespirCritCareMed.2016.[Epubaheadofprint]
SyMPOSIUM 13
« Perioperative Medicine 2 »
56
MALIGNANT HypERTHERMIA – AN UpDATECynthia A Wong
university of iowa Roy J and Lucille a carver college of Medicine, iowa city, ia, usa
objectivesAt the completion of this lecture participants should be able to:
1. Describe and define malignant hyperthermia (MH), including the classic presentation and the newly recognized “awake” MH;
2. Review the intracellular mechanisms associated with an acute MH event;
3. Explain the treatment of an acute intraoperative MH event;
4. Describe testing for MH susceptibility
abstractMalignant hyperthermia (MH) susceptibility is a pharmacogenetic disorder of skeletal muscle.1 The hypermetabolic syndrome is classically triggered in susceptible individuals by exposure to volatile anesthetic agents and/or succinylcholine. Classic signs of acute MHincludehypercarbia(raiseinend-tidalCO
2), rigidity, hyperthermia, hyperkalemia and acidosis (often resulting in dysrhythmias),
andultimately,rhabdomyolysisandmulti-organfailure.Thedefinitivetreatmentisadministrationofdantrolene.Othertreatmentissupportive. Untreated, a significant proportion of patients will die. Although MH has classically been described in association with anesthesia, it has more recently been described in awake patients with a stress trigger.2
An MH crisis is caused by an uncontrolled increase in intramyocellular calcium concentration, triggering muscle cell contracture and hypermetabolism. Dantrolene controls the release of calcium from the sarcoplasmic reticulum. Many individuals with MH susceptibility have mutations in the ryanodine receptor gene (rYr1), leading to dysfunction of the ryanodine protein which controls calcium release into the cytoplasm.
ThegoldstandardtestforMHsusceptibilityisthecaffeine-halothanecontracturetest,aninvasivetestrequiringamusclebiopsy.Mutations in rYr1 and CACnA1S have been associated with MH, but 30% to 50% of individuals with phenotypic MH do not have mutations in these genes. Thus, researchers continue to search for other genes associated with MH and to determine which rYr1 and CACnA1S mutations are causal.
references1. Rosenberg H, et al. Orphanet J Rare Dis 2015;10:93.2. groom L, et al. Anesthesiology 2011;115:938.3. Stowell KM. Anesth Analg 2014;118:397.
SyMPOSIUM 15
« Special Issues »
57
CHRONIC MEDICATIONS: wHAT TO STOp AND wHEN?Omar Sulaiman
hospital sultanah aminah, Johor bahru, Johor, Malaysia
Optimizing drug therapy is an essential part of caring for an older person. The process of prescribing a medication is complex and includes: deciding that a drug is indicated, choosing the best drug, determining a dose and schedule appropriate for the patient’s physiologic status, monitoring for effectiveness and toxicity, educating the patient about expected side effects, and indications for seeking consultation.
Avoidable adverse drug events (ADEs) are the serious consequences of inappropriate drug prescribing. The possibility of an ADE should always be borne in mind when evaluating an older adult individual.
Mostofthemarewithmultiplemedicationsforvariousdiseasesviaprescription,over-the-counterandherbalpreparations.Thearetermed“polypharmacy”withdrug-druginteractionthatleadtoADEs.Thereareseveraltoolseg.Beers,STOPPandSTARTcriteriasto assess the drug interactions and to minimise and optimise polypharmacy.
As conclusion, a stepwise approach to prescribing for older patients that should include periodic review of current drug therapy and considering nonpharmacologic alternative strategies. Prevention is better than cure.
SyMPOSIUM 17
« The Elderly Patient »
58
pOST-Op COGNITIVE DySFUNCTION IN ELDERLy pOST SURGICAL pATIENTSSunanda Gupta
geetanjali Medical college, udaipur, india
POCD has been defined in a consensus statement as “a spectrum of postoperative central nervous system (CnS) dysfunction both acute and persistent… including brain death, stroke, subtle neurologic signs and neuropsychological impairment. It refers to problems in thinking and memory after surgery, and occurs more in patients age > 60, is associated with early exit from the workforce, decreased quality of life, and premature mortality and typically lasts for weeks to months. POCD should be distinguished from delirium or dementia.
Some of the risk factors include more extensive surgery under gA, following secondary surgery or prolonged surgery, presence of Intraoperative complications, alcohol abuse, poor educational status etc.
Theoldbrainissaidtobemorevulnerablethanayoungonetosurgery-inducedneuroinflammationbecauseitsinnateimmunecells,principallymicroglia,developanexaggeratedinflammatoryresponsetoaperipheralsurgicalprocedure.Howeveramyriadothercauses have been implicated in its pathogenesis.
A variety of scoring methods for the detection of POCD have been used across studies, investigators generally agree that scoring methods should consider 1) baseline performance, 2) practice effects, and 3) change on more than one neuropsychological test.
Recent studies have concluded that there was no relationship between anesthetic techniques and the magnitude or pattern of POCD. Preoperative Counseling and strategies to improve physical and cognitive resilience in the elderly may help prevent POCD and improve overall recovery after surgery. Thus, Preoperative environmental enrichment (PEE) consisting of both physical and cognitive activitywouldattenuatetheneuroinflammationandpreventpostoperativecognitiveimpairment.
SyMPOSIUM 17
« The Elderly Patient »
59
EMBRACE A CRITICAL MINDRamani Vijayan
department of anaesthesiology, university Malaya Medical centre, Kuala Lumpur, Malaysia
Critical thinking means making reasoned judgments that are logical and well thought out. It is a way of thinking in which you don’t simply accept all arguments and conclusions you are exposed to but rather have an attitude involving questioning them before acceptingthem.Beingcritical-mindedmeansthatyouarenotonlyopentonewideasbutyoualsohavetothinkifyourideaislogicalor not. It is therefore an important attribute is any endeavour, but particularly so in the scientific field involving research.
Critical thinking can be divided into the following three core skills:
1. Curiosity is the desire to learn more information and seek evidence as well as being open to new ideas.
2. Scepticism involves having a healthy questioning attitude about new information that you are exposed to and not blindly believing everything everyone tells you.
3. Finally,humility is the ability to admit that your opinions and ideas are wrong when faced with new convincing evidence that states otherwise.
Critical thinking is not intuitive and needs to be taught starting from high school and continued into universities. It is a matter of changingthemind-set.Unleashingacriticalmindwillhelpstudentsnotonlyenhancetheirachievementsbutthriveandsurviveinthe real world.
“To raise new questions, new possibilities, to regard old problems from a new angle, requires creative imagination and marks real advance in science.” – Albert Einstein
SyMPOSIUM 18
« Training »
60
OBSTETRICSYMPOSIA AND PANEL DISCUSSIONS
61
MODERN TECHNIqUES IN MAINTAINING NEURAxIAL BLOCK IN LABOURAlex TH Sia
KK Women’s and children’s hospital, duke nus Medical school, singapore
The recent advances in the practice of evidence-basedmedicine and the evolution of technology, particularly in drug deliverysystems, have conferred changes in the provision of neuraxial block for labour pain management.
These enhancements have improved the efficacy, safety and efficiency of intrapartum neuraxial analgesia. Epidural analgesia has commonly been considered as the method of choice for labour pain relief because of its ability to provide unparalleled analgesia and superior maternal satisfaction; modern neuraxial block could confer bespoke analgesia for parturients’ at various stages of labour with a comparably favourable profile of side effect.
The talk aims to provide an update on some of the advances made in neuraxial blokc in labour in the last few years. The impact of combined spinal-epidural technique will be outlined; the role of low-dose concentration epidural solutions, in relation withobstetricoutcomeswillalsobediscussed.Patient-controlledepiduralanalgesia(PCEA)andmorerecently,programmedintermittentor automated mandatory boluses in the maintenance of epidural labour analgesia will be described. A discourse on the newer interactive techniques of drug delivery in labour analgesia, such as computer-integrated patient controlled epidural analgesia(CIPCEA) and variable frequency automated mandatory bolus (VAMB) will be provided. The role of these techniques and their future clinical research perspectives will be explored.
ObStetrIC SyMPOSIUM 1
« Regional Analgesia »
62
wHAT TO DO wITH FETAL BRADyCARDIA FOLLOwING NEURAxIAL ANALGESIACynthia A Wong
university of iowa Roy J and Lucille a carver college of Medicine, iowa city, ia, usa
objectivesAt the completion of this lecture participants should be able to:
1. Describe the mechanisms contributing to fetal bradycardia following neuraxial anesthesia;
2. Formulateatreatmentplanforinuterofetalresuscitation.
abstractnonreassuring fetal heart rate patterns, including bradycardia, within 60 minutes of the initiation of neuraxial labor analgesia reportedly occurs with an incidence of 2% to 30%. Although maternal hypotension leading to decreased uteroplacental perfusion is an obvious mechanism of fetal hypoxemia causing bradycardia, many of these episodes occur in the setting of normotension. In a sentinel report, Clarke et al. described fetal bradycardia in 9 of 30 women who received intrathecal fentanyl.1 The bradycardia was associated with uterine tachysystole. They proposed that acute onset of pain relief results in an acute decrease in circulating epinephrine. Epinephrine, through its β-adrenergicagonistaction,isatocolytic.Acutelossoftocolysiscausesuterinetachysystole.Because the uterus is perfused during diastole, tachysystole results in decreased uteroplacental perfusion, fetal hypoxemia, and ultimately,fetalbradycardia.Thebradycardiaisusuallyself-limiting(<10min)andstudieshavenotfoundanincreaseincesareandelivery rate.
Thedataareinconsistentastowhethertheincidenceoffetalbradycardiaisworsenedbytheuseofcombinedspinal-epidural(CSE)compared with an epidural analgesia, use of intrathecal opioids compared with other neuraxial drugs, and higher opioid doses.
In utero fetal resuscitation traditionally consists of discontinuing exogenous oxytocin infusion, maternal repositioning, oxygen administration,IVfluids,tocolysisandamnioinfusion.Datearelimited,butthereislittleevidencethatamnioinfusionorIVfluidsarebeneficial. Tocolysis may result in faster uterine relaxation. Maternal oxygenation administration has not been shown to be beneficial and may be harmful.
references1. Clark VT. Anesthesiology 1994;81:1083. 2) Bullens LM. Obstet gynecol Surv 2015;70:524. 3) Hamel MS. Am J Obstet gynecol 2014; 211:124.
ObStetrIC SyMPOSIUM 1
« Regional Analgesia »
63
MANAGEMENT OF THE SIDE EFFECTS OF NEURAxIAL OpIOIDSAshraf S Habib, MBBCh, MSc, MHSc, FRCA
duke university, durham, nc, usa
neuraxial opioids currently represent the gold standard for providing effective analgesia following cesarean delivery. Morphine is the least lipophilic agent, so it has a long duration of action and is used as standard of care in many countries for post cesarean analgesia. However its use can be associated with side effects including pruritus, postoperative nausea and vomiting (POnV), urinary retention and respiratory depression. Using the least effective dose of neuraxial morphine is recommended to reduce the incidence and severity of side effects. Pruritus occurs very commonly after neuraxial morphine administration, and is described as moderate to severe in intensity in up to 50 % of women. The mechanism of neuraxial morphine induced pruritus is not clear. Parturients appear to be particularly susceptible to morphine induced pruritus. A number of strategies have ben investigated fro the prophylaxis and treatment of neuraxial morphine induced pruritus, with opioid antagonists being the most commonly used drugs for this purpose. POnV also occur commonly following neuraxial morphine administration. The etiology of POnV is multifactorial. Administration of prophylacticantiemeticsreducestheincidenceofPONV,withcombinationtherapybeingmoreeffectivethanmonotherapy.Forthetreatment of POnV in patients who received antiemetic prophylaxis, a drug acting at a different receptor should be used. Respiratory depression following neuraxial morphine administration is very rare in the obstetric patient population. Data on urinary retention is very limited, but suggest that the risk may be increased following neuraxial opioids. Rarely hypothermia has also been reported following neuraxial morphine administration.
objectives1. Discuss the incidence of side effects related to neuraxial opioid administration in women undergoing cesarean delivery.
2. Highlight risk factors, as well as strategies that can be used for the prophylaxis and treatment of those side effects.
3. Review guidelines for monitoring parturients who have received neuraxial morphine.
ObStetrIC SyMPOSIUM 1
« Regional Analgesia »
64
pANEL DISCUSSION ON FAILED AIRwAySunanda Gupta1, Oraluxna Rodanant2, Lee Choon Yee3
1geetanjali Medical college, udaipur, india 2chulalongkorn university, thailand
3universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
It iswell recognized that the incidenceofdifficultand failed intubation ishigher in theobstetriccompared to thenon-obstetricpopulation. As such, airway assessment and management is an integral part of anaesthetic management of the obstetric patient.
It is equally important to be able to satisfactorily manage a failed obstetric airway, which is usually in an emergency and highly stressful environment. Topics in this panel discussion include case scenarios, scope of the problem, older and latest guidelines on obstetric airway management, as well as some controversial issues in the management of the failed obstetric airway.
LOw-DOSE SEqUENTIAL CSELee Choon Yee
universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
SpinalanaesthesiaistheregionalanaesthetictechniqueofchoiceforCaesareandeliveryinhealthyparturients.However,spinal-inducedhypotensionremainsacommonproblemdespitevariousprophylacticand/ortherapeuticmeasures.Whileashort-livedandmilddegreeofhypotensionmaybetoleratedbymostASAI-IIparturients,therisksassociatedwithrapidorprofoundreductionsinsympathetic tone, systemic vascular resistance and blood pressure can be deleterious in those with significant cardiac pathology.
Inthelow-dosesequentialcombinedspinal-epidural(CSE)technique,adeliberatelysmallintrathecaldoseisadministeredtoprovidean initially low block; while the block height can be increased to the desired level by incremental doses of local anaesthetic ± opioid viatheepiduralcatheter.Beingatwo-stagetechnique,itproducesamulti-compartmentalandsynergisticblockassociatedwithminimal haemodynamic changes. This technique is further enhanced by epidural volume extension (EVE), which entails injection of saline or local anaesthetic into the epidural space soon after intrathecal injection, with the intention of extending the block height achieved by the small intrathecal dose.
Inaddition tohaemaodynamicstabilityachievedby low-dosesequentialCSE,EVEmayreducetheriskof intravascularepiduralcatheter placement if saline is injected through the Tuohy needle before catheter insertion. Potential drawbacks include a slower onset, less intense and shorter duration of block. The optimal intrathecal dose, epidural solution and volume for supplementation shouldbedeterminedtomaximizeitsbenefitsandminimizeunwantedside-effects.However,thesevaryamonginstitutionsastheymaybeinfluencedbylocalsurgicalandanaestheticfactors.Usingthesetechniques,manycasereportshavedocumentedsuccessfulanaesthetic management of high-risk obstetric and non-obstetric patients, such as pulmonary hypertension, cardiomyopathy,cyanotic heart disease, cardiac failure, and severe stenotic valvular lesions.
references1. Hamlyn EL, et al. IJOA, 20052. McNaughtAF,StockGM.IJOA,2007
ObStetrIC
Panel DISCUSSIOn 1
ObStetrIC SyMPOSIUM 2
« Regional Anesthesia »
65
MANAGEMENT OF SpINAL INDUCED HypOTENSIONAshraf S Habib
duke university, durham, nc, usa
Hypotension occurs commonly following spinal anesthesia for cesarean delivery and has adverse maternal and fetal effects. Administrationoffluids,eitherasapreloadorcoload,reducesbutdoesnoteliminatetheoccurrenceofhypotension.Vasopressorsare therefore needed in a significant proportion of patients. While historically ephedrine was considered the vasopressor of choice in obstetric patients, many now use phenylephrine as the first line agent as it is associated with a more favorable neonatal acid base balance, and a lower incidence of maternal intraoperative nausea and vomiting. The use of a combination of phenylephrine and ephedrine does not confer any advantages compared to phenylephrine alone. The optimum dosing and method of phenylephrine administration is not clear. Use of a prophylactic phenylephrine infusion is associated with a lower incidence and magnitude of hypotension compared to treatment of established hypotension with phenylephrine boluses. This method of administration is however associatedwithanincreasedriskofreactivehypertension,bradycardiaandareductioninmaternalcardiacoutput.Fixedrateandvariable rate phenylephrine infusions, as well as prophylactic phenylephrine boluses have been studied. Closed loop techniques may offer better blood pressure control compared with manual administration of vasopressors.
objectives1. Review the effectiveness of crystalloids and colloids for the reduction of spinal induced hypotension.
2. Review the impact of administration of different vasopressors on maternal and neonatal outcomes.
3. Understand the advantages and disadvantages of various methods of phenylephrine administration.
4. Review the optimum strategy for hemodynamic control during cesarean delivery.
ObStetrIC SyMPOSIUM 2
« Regional Anesthesia »
66
MEDICO-LEGAL – pREVENTING THE NExT COURT CASEYoo Kuen Chan1, Connie Cruz2, Stephen Gatt3, Cynthia A Wong4
1university of Malaya, Faculty of Medicine, Kuala Lumpur, Malaysia 2section of obstetric anesthesia, dept. of anesthesiology- uP college of Medicine Philippine general hospital
3university of new south Wales, Kensington, sydney, australia 4university of iowa Roy J. and Lucille a. carver college of Medicine, iowa city, ia, usa
objectivesAt the completion of this lecture participants should be able to:
1. Discuss methods of rescuing inadequate or failed neuraxial anesthesia for cesarean delivery;
2. Understand the levels of obstetric emergency, the importance of communication with the obstetric and nursing team, and describe anesthetic considerations for the emergency cesarean delivery;
3. Describe the pathogens and mechanisms of infection following neuraxial procedures and techniques/methods to prevent infection;
4. Monitor major neuraxial block recovery following Caesarean section appropriately and have a plan of action when recovery is slow or arrested.
5. Evaluatecomplaintsofpostpartumnerveinjuryandformulateadifferentialdiagnosisandwork-up.
abstractThe panel of experts from around the world will discuss four scenarios that anesthesiologists encounter in the care of the obstetric patient that may lead to lawsuits. Through interaction with the audience, the panel will explore prevention and management options, andfollow-throughthatdecreasesthelikelihoodofmedicolegalaction.
The four cases include:
1. Rescue from failed neuraxial anesthesia for cesarean delivery: methods to decrease the risk of failed neuraxial anesthesia and techniques to rescue failed anesthesia.
2. Emergency cesarean delivery—the anesthesiologist’s role: definitions of levels of obstetric emergency, communication with the obstetricandnursingteams,identifyingat-riskpatients/fetuses,andanestheticchoices.
3. Neuraxial infection—meningitis and spinal-epidural abscess: Pathogens responsible for neuraxial infection, techniques fordecreasingtheriskofinfection(proceduralattire[masks,gowns,gloves],skinprepsolutions[chlorhexidine,povidoneiodine,alcohol]).
4. neurologic injury after childbirth—role of neuraxial anesthesia: intrinsic obstetric palsies, direct neurologic trauma secondary to neuraxialanestheticprocedure,work-upofcomplaintofneurologicinjury.
ObStetrIC
Panel DISCUSSIOn 2
67
pERMANENT pARALySIS FOLLOwING MAJOR NEURAxIAL BLOCKADE – A SIGNIFICANT THREAT?
Stephen Gatt1, Andre van Zundert2
1university of new south Wales, Kensington, nsW, and Royal hospital for Women & Prince of Wales & sydney children’s hospitals, Randwick, sydney, nsW 2university of Queensland, brisbane, Qld, and Royal brisbane and Women’s hospital, herston, Qld, australia.
Permanent Paralysis as a result of a Regional Anaesthesia (RA) technique is an exceedingly rare event. nevertheless, because of the catastrophic nature of this serious adverse event, the natural history of patterns of use of these techniques across many nations has been shaped by this one complication. Regional popularity of epidurals (EDB), spinals (SAB) and combined (CSE) has waxed and waned, over time, often in tune with some major local inadvertent mishap.
Inability to use major neuraxial blockade, for whatever reason (eg. sepsis, bleeding diathesis, spinal deformity) for anaesthesia and analgesia for the parturient of itself poses a significant threat to life and limb. Avoidance of RA for CS and operative delivery on the basis that a major complication could occur commits a woman to a far more dangerous course of obstetric, anaesthesia and intensive care management and of trauma from that delivery.
Thesameappliestonon-acutemanagementoflabourwithoutRA.FailuretoaccessRAforpainreliefinlabourbecauseofnon-availability or contraindication condemns a woman to potentially higher maternal and foetal mortality and morbidity rates several orders of magnitude worse than those imposed by major neuraxial block complications.
Epiduralsareusedin80%ofdeliveriesinFrance,66%intheUS,28%intheUKand42%inAustraliaandashighas90+%insomecountries. The great relative safety of SABs, EDBs and CSEs has enabled the development of a milieu for much less painful labour and much more secure and efficient labour and delivery service.
Last year (2015), our hospital, the Royal Hospital for Women (RHW), celebrated 50 years since the establishment of a 24/7 epidural service (and 150 years of a delivery service, 100 years of antenatal care and 25 years of Obstetric Intensive Care). RHW epidural rates for the last 40 years have been ~40%.
The rarity of permanent paralysis from neuraxis regional techniques has to be seen against a backdrop of 131.4 million births per year worldwide. Assuming an EDB overall rate of only 10%, this is equivalent to 260 million safe epidurals over the last 20 years which have generated untold benefit.
nevertheless, the constant search for a safer method of application, of better drugs, equipment, treatment protocols and environment, of education in technique, of superior skill acquisition and of risk reduction by better monitoring and surveillance will render SAB, EDB and CSE even rosier options for future labours and future births.
ObStetrIC SyMPOSIUM 3
« Mishap In Obstetric Analgesia/Anaesthesia »
68
THE SECOND VICTIM; wE NEED HELp TOOMohd Rohisham Zainal Abidin
hospital tengku ampuan Rahimah, Klang, Malaysia
Throughout the world, approximately 830 women die every day. In Malaysia, at least 2 women die every day during pregnancy and childbirth.Followingamaternaldeath,therewillbeenquiresafterenquiriesstartingfromthedepartment,thedistrictandatstatelevel. The case will also then be scrutinised at national level. If the death was due to major substandard care, then there will be a possibility that a special “external enquiry” that those involved will have to endure. It will be even more complicated when it involves litigation by the family members.
While it is important to investigate a maternal death in the manner that we have today, we tend to totally forget that the event may also have a significant effect to the healthcare personnel involved. Anger, guilt, shame, fear, loneliness, frustration are some of the symptoms. These may be also accompanied with physical disturbances such as fatigue, insomnia, inability to concentrate, tachycardia and hypertension. Some may quickly recover from it but a few may take months or years to heal. These healthcare personnel are known as the “second victim”.
Healthcare personnel are human too. We too need support and care following such a catastrophic event. There is a need to create awareness of this phenomenon. When such events occur, institutions must have a mechanism to support them.
ObStetrIC SyMPOSIUM 3
« Mishap In Obstetric Analgesia/Anaesthesia »
69
pOST-OpERATIVE ANALGESIAAlex Sia1, Susilo Chandra2, Katsuo Terui3
1KK Women’s and children’s hospital, duke nus Medical school, singapore 2department of anesthesiology and intensive care unit cipto Mangunkusumo hospital, Medical Faculty university of indonesia
3saitama Medical center, saitama Medical university, Kawagoe, Japan
Postoperativeanalgesiaaftercesareandelivery(CD)warrantsuniquechallengestofacilitatemother-infantbondingandbreastfeeding.Mothers want to recover and ambulate sooner to take care of their babies. Intravenous or intrathecal opioid related POnV will hinder such interactions. Epidural infusion offers excellent analgesia, but depending on the location of epidural catheterization, motor blockade may interfere ambulation. Sympathetic blockade may cause dizziness upon ambulation. Breast milk transfer and neonatal effects of analgesic agents is another issue in postcesarean analgesia. We will discuss anesthetic and postcesarean analgesia plan in the following 3 scenarios.
1. Elective repeat cesarean section with history of severe POnV in previous CD
Considerations include use of intrathecal opioid, antiemetic regimen, inclusion of antiemetic in epidural drug regimen, combined use of nSAID/acetaminophen, TAP block.
2. general anesthesia for stat CD due to fetal bradycardia
DrugchoiceforIV-PCAanditsneonataleffect,multimodalanalgesia,TAPblockanditscomplications.
3. Morbidlyobeseparturientforsemi-electiveCDdurtofailuretoprogress
Considerations include risk of sleep apnea and use of neuraxial hydrophilic opioid, delayed respiratory depression, DVT prophylaxis and management of epidural catheter.
ObStetrIC
Panel DISCUSSIOn 3
70
THE DENGUE pATIENT IN OBSTETRICSA R Thohiroh
hospital Kuala Lumpur, Kuala Lumpur, Malaysia
Dengue is the fastest emerging arboviral infection that encompasses a broad spectrum of systemic manifestations ranging from self-limitingfebrileillnesstofeaturesofseveredengue(SD),denguehemorrhagicfever(DHF)anddengueshocksyndrome(DSS)thatmayleadtorapiddeteriorationandeventuallydeath.WHOestimates50-100millioncasesofdengueinfectionyearly,ofwhich500,000arecasesofDHFand22,000mortalitiesfromcomplicationsofthedisease.Pregnantpatientisalsoatriskofbeinginfected,ie0.8-1.0%orhigheriftheyareimmunenaïve.DengueistransmittedbyAedesaegyptiandAedesalbopictuswiththeir4dengueserotypes,DEN-1,2,3and4.Eachepisodeof infection inducesa life-longprotective immunity to thehomologousserotype.Butconfers only partial and transient protection against subsequent infection by the other serotypes.Secondary infection causes a major risk factor forDHFandDSSdue to antibody-dependent enhancement.Capillary leakage is thought to bedue to viremia,antibody complex and intense immune activation. Pregnant patients show similar clinical presentations with the general population but with some important differences. Plasma leakage can be masked by higher heart rates, lower BP with wide pulse pressure, anemia,thrombocytopaenia,haemodilutionandacidosis.Graviduterushidesaccumulationoffluid.Managementincludesjudiciousfluidinfusionandclosemonitoring.Plateletandbloodtransfusionisonlyforbleedingcases.Majorityofpatientsshouldbeallowedto progress to spontaneous vaginal delivery. However delivery should be delayed until acute infection resolves. Caesarean section is only for maternal or fetal indication. general anaesthesia is safer compared to spinal. Pregnant patient should be managed by a multidisciplinary teams. So far prevention activities still unable to control the global spread. We are waiting for a good news from Tetravalent Vaccine Phase III trial in children.
COAGULATION MANAGEMENT IN OBSTETRIC HAEMORRHAGEN J McDonnell
King edward Memorial hospital, Perth, Western australia the university of Western australia, Perth, Western australia
st John of god hospital, subiaco, Western australia
Obstetric haemorrhage continues to be a leading worldwide cause of maternal mortality. Whilst the incidence of maternal deaths secondary to post partum haemorrhage has decreased in many developing countries, in most of the developed world there has been an increase in the incidence of post partum haemorrhage (of which the majority appear to be secondary to uterine atony). Of significant concern is that each maternal death represents just the extreme end on the scale of maternal morbidity secondary toobstetrichaemorrhage.Foreachdeaththatoccursthereareliterallythousandsofwomenthatexperiencesignificantmorbiditysecondarytotheirhaemorrhage.Thismorbiditymayincludeoutcomessuchasaprolongedstayinhospital,peri-partumhysterectomy,fetal loss and the complications associated with blood and blood product transfusion.
Obstetric bleeding has a number of unique issues, one of which includes the unpredictable tendency to develop sometimes rapid disordersofcoagulation.Pregnancyitselfisahypercoagulablestate-whilstthisofferssomepotentialprotectionintimesofsignificanthaemorrhage, it also means that when coagulation deficits become apparent on clinical or laboratory testing, a potentially far greater amount of blood and/or coagulation factors has been lost or consumed.
Thistalkwillbrieflycoverthemajorcoagulationchangespresentinpregnantpatients,thecoagulationchangescommonlyseeninmajor obstetric bleeding and then examine strategies to plan for, diagnose and manage the major coagulation insults that can occur with obstetric haemorrhage. The key role of fibrinogen monitoring and replacement as well as the role of standard and point of care coagulation testing will be highlighted.
ObStetrIC SyMPOSIUM 4
« Hemorrhage Prevention »
ObStetrIC SyMPOSIUM 4
« Hemorrhage Prevention »
71
CARDIOpULMONARy RESUSCITATION IN THE pARTURIENTConnie Cruz1, Mohd Rohisham Zainal Abidin2, Stephen Gatt3
1Philippines, 2Malaysia, 3australia
Case scenario31 y.o lady g3P2. Antenatally uneventful. no significant pass medical or surgical history. no known drug allergy. Presented to labour ward with show and contraction pain. VE revealed OS 3 cm and membrane bulging. ARM performed by attending obstetrician. A few minutes later the patient complained of SOB. Pulse oximetry showed 88% and rapidly declining. The patient then became unconscious. BP unrecordable, ECg showed PEA.
Questions1. CPR modification in the parturient – the ABCD2. Left Uterine Displacement – how to perform3. PMCD – when, where, who should perform, – consent and medico legal issues, – survival rate of mother and baby4. You as the registrar arrived at the scene, 10 minutes after cardiac arrest and found that PMCD still not performed. Should it still
be carried out?5. When should you decide to abandone CPR?6. What is the latest update from the 2015 AHA guidelines on resuscitation in the pregnant patient?
ObStetrIC
Panel DISCUSSIOn 4
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THE pREVIOUS DIFFICULT REGIONAL ANAESTHESIA AND DIFFICULT AIRwAySunanda Gupta
geetanjali Medical college, udaipur, india
The anesthetic management of the obstetric patient with a difficult airway, whether anticipated or unanticipated, can be a challenge for any anesthesiologist. If she also has a difficult back due to morbid obesity or previous spinal interventions, with a history of a failed regional anaesthetic technique, the risk of morbidity and mortality can further increase. These patients should be thoroughly evaluated in the antenatal period for risks involving the major organ systems, with special emphasis on examination of the airway and the spines. A plan of airway management should be formulated regardless of primary anaesthetic technique chosen.
All morbidly obese parturients undergoing caesarean section should be placed in a ramped position with left uterine displacement. Regional anaesthesia, whenever possible, is the best choice. An Ultrasound guided placement of Regional anaesthesia with the help of an experienced anaesthesiologist will increase the chances of success in patients with challenging lumbar spine anatomy. A difficult airway cart should always be kept as a standby.
If general anaesthesia is required, the airway should be secured awake by using fibreoptic bronchoscopy ideally performed by an experienced endoscopist. The nasal mucosa is friable during pregnancy and nasal intubation may be problematic because of bleeding hence oral route should be preferred. Thus the key to successful management is a close loop communication between obstetrician and an experienced anesthesiologist with a careful anesthetic planning to ensure safe maternal and fetal outcome in these parturients with a difficult airway and anticipated difficult regional anaesthesia. Some cases, with author’s personal experience in managing such cases will be discussed.
ObStetrIC SyMPOSIUM 5
« The Difficult Cases »
73
THE CARDIAC pARTURIENTKatsuo Terui
saitama Medical center, saitama Medical university, Kawagoe, Japan
Cardiac disease is now the number one cause of maternal mortality in some countries. With the advance of pediatric cardiology and cardiac surgery, more and more women with congenital heart disease are now reaching childbearing age. In taking care of these parturients with congenital cardiac disease, I would like to point out 3 important points as below.
1. Understand the patient
Understanding the pathophysiology and optimal balance of systemic and pulmonary circulation is most important to optimize hemodynamics and oxygenation, especially in complex congenital heart disease. Review previous operation records to identify the type and location of BT shunt, so that blood pressure monitoring site is appropriate. The regurgitation to the subpulmonic ventricle is one of the risk factors to cardiac event during pregnancy and parturition by CARPREg score.
2. Plan labor epidural analgesia accordingly
Labor epidural analgesia (LEA) is beneficial in most of the cardiac diseases to stabilize hemodynamics and to reduce burden to thevasculatureduringparturition.EvenaorticstenosisorHOCMpatientsmaybenefitfromLEAwhencombinedwithcarefulfluidmanagement and judicious use of epidural local anesthetic. LEA will prevent sympathetic nervous system activation dur to pain during labor, and reduce, but not eliminate, the periodic BP and CVP increase with each uterine contraction. Bearing down for delivery of the infant may be avoided in certain patients with pulmonary hypertension or severe mitral stenosis. Postpartum blood lossislargestinwomenafterFontanoperation,thusmaintainingbloodvolumeisimportant.
3. Plan emergency cesarean delivery
Some women inevitably require stat cesarean delivery during labor for obstetric indications, or during pregnancy due to cardiac condition. Anesthetic plan for such emergencies must be made in advance by consulting anesthesiologists during pregnancy.
Expertise in both cardiac and obstetric anesthesia will make anesthesiologist most useful profession for cardiac parturients.
ObStetrIC SyMPOSIUM 5
« The Difficult Cases »
74
ObStetrIC
Panel DISCUSSIOn 5
THE OBESE pARTURIENTAshraf S Habib1, Sunil T Pandya2, Oraluxna Rodanant3
1duke university, durham, nc, usa 2century hospital, hyderabad, india
3chulalongkorn university, bangkok thailand
Obesity is a worldwide epidemic. It is associated with numerous comorbidities and increased maternal, fetal and neonatal complications. The anesthetic management of these patients is challenging and requires multidisciplinary collaboration and referral for an antenatal anesthesia consultation for adequate planning. The incidence of difficult intubation is increased in obese parturients. neuraxial analgesia represents the best modality for providing labor analgesia in the obese parturient, to avoid the risk for needing general anesthesia in a patient with a potentially difficult airway. However, it can be technically challenging. The risk of both elective and emergent cesarean delivery is increased in the obese parturient. An existing labor epidural catheter can be topped upforcesareandelivery.Inpatientswhodonothaveawell-functioninglaborepidural,acombinedspinalepiduraltechniquemightbepreferredoverasingle-shotspinaltechniquesinceitistechnicallyeasierandallowsforextendingthedurationoftheblockasrequired. A continuous spinal technique can also be considered. Intraoperatively, patients should be placed in a ramped position, with close monitoring of ventilation and hemodynamic status. Post operatively adequate analgesia is crucial to allow for early mobilization, neonatal bonding, and pain control. This can be achieved using a multimodal regimen incorporating neuraxial morphine (withappropriateobservations)withschedulednonsteroidalanti-inflammatorydrugsandacetaminophen.Thromboprophylaxisisessential in this patient population due to the increased risk of thromboembolic complications. These patients should be monitored carefully in the postoperative period, since there is increased risk of postoperative complications in the morbidly obese.
objectives1. Identify prevalence and definitions of obesity.
2. Discussco-morbiditiesandpregnancyrelatedcomplicationsassociatedwithobesity.
3. Review anesthetic management for labor analgesia and cesarean delivery in the obese parturient.
75
REGIONAL ANAESTHESIA AND THE USE OF ANTITHROMBOTIC AGENTS Yoo Kuen Chan1, Nolan Mcdonnell2, Stephen Gatt3
1university of Malaya, Faculty of Medicine, Kuala Lumpur, Malaysia 2department of anaesthesia and Pain Medicine King edward Memorial hospital for Women, Western australia
3university of new south Wales, Kensington, sydney, nsW, australia
objectivesAt the completion of this interactive session participants should be able to:
1. Assess the cost: benefit ratio of the continued use of antithrombotic agents and their discontinuation to provide a window for the anesthesia and surgery;
2. Understand which antithrombotic agents can be monitored using simple haematological investigations, what the effective life of each agent is and which agents can be reversed;
3. Interpret what the current guidelines mean;
4. Assesstherelativeriskofproceedingwithregionalanaesthesiainapatientwithableedingdiathesisorreceivinganti-thromboticsor fibrinolytics;
5. Interpret preoperative and intraoperative data with respect to bleeding tendencies – innate or induced;
6. Evaluatepost-operativemonitoringand‘bestcare’toprovideabasisforgoodoutcomeinthisgroupofvulnerablepatients.
abstractRegional anesthesia is the predominant form of anesthesia for Caesarean Section (CS) and of analgesia for labour and delivery. In parturients who are, knowingly or unknowingly, on antithrombotic agents or have a bleeding tendency, management of their major neuraxial regional anesthesia can be fraught with danger.
The number of parturients on antithrombotics (used for a variety of reasons, eg. mechanical heart valves, venous thromboembolism, previous pulmonary embolism) continues to rise.
One solution lies in making a cost:benefit assessment of the choice of RA versus other alternatives, eg. in labour, a switch to remifentanil PCA; at CS the switch to gA.
Sometimes,adecisiontostopananti-thromboticcarriesameasurableriskwiththedurationofthewindowofdrugcessationbeinga major potential morbidity adverse outcome factor. It becomes important to weigh the consequences of discontinuation of the antithrombotic agents, and for how long to do so, to create a safe window for the RA. The stakes are high because one has to balance therelativeriskofamajorthrombo-embolicevent(eg.thromboticstroke)againstthepossibilityofsignificantspinalhaemorrhageproducing serious neurological injury (eg. paraplegia).
The experts would like the participants to look at how to rationally use the existing guidelines for the planning process and to inform andguidethechoicetowardsanoptimalanesthesiatechnique.Considerationforsafetyliesnotonlyinhavingasafeintra-operativeplanbutalsoanactiveprogrammeofmonitoringanddecisionmakinginthepost-deliveryperiod.Vigilantmonitoringforevidenceofa developing spinal bleeding can lead to early salvage haematoma evacuation with good outcome.
The introductionofnovelanti-thrombotics (eg.oral ‘xabans’eg. rivaroxaban (Xarelto®) and fibrinolytics (eg. tissue plasminogen
ObStetrIC
Panel DISCUSSIOn 6
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ObStetrIC
Panel DISCUSSIOn 6
activator, rt-PA, use in the Obstetric ICU), and, sometimes, corresponding reversal agents (eg. idarucizumab for dabigatran;prothrombin complex concentrate (Octaplex®) for warfarin), is currently dramatically changing the landscape for both provision of regional anesthesia for parturients and for best choice of agent for use in pregnancy (eg. low molecular weight heparins) and during labour and operative delivery.
Fourcasescenarioshavebeenselected:
1. A known difficult airway (previous – twice – grade 4 C+L laryngeal view) woman on antithrombotic agents presenting for elective CS;
2. UnanticipatedprolongedrecoveryfollowingroutineCSEforCSinaP1G2ontraditionalChineseblood-thinningmedicine;and
3. Coronaryartery(CA)diseaseparturientwithrecentdrug-elutingCAstentondualclopidogrel-aspirin(Co-Plavix®) antithrombotic agents;
4. A patient on Dabigatran (Pradaxa®) coming for elective CS reversed with idarucizumab.
77
AIRwAy OF THE OBESE pARTURIENTAshraf S Habib
duke university, durham, nc, usa
The risk of difficult intubation is higher in obstetric patients compared to the general surgical population. This risk is further increased in the obese parturient. Historically, intubation problems and aspiration of gastric contents were major causes of anesthesia related maternal mortality. Airway problems at emergence are also associated with maternal mortality, with obesity being a major risk for those problems. neuraxial techniques are therefore strongly encouraged in the obese parturient to reduce the likelihood of needing general anesthesia in a parturient with a potentially difficult airway. Maternal mortality associated with general anesthesia has however significantly decreased in recent years due to better monitoring and published standards for anesthetic care including difficult airway algorithms.
objectives1. Review data on anesthesia related maternal mortality.
2. Understand factors leading to increased risk of difficult intubation in the obese parturient.
3. Review changes in anesthetic management that contributed to reduced maternal mortality related to airway problems.
4. Review current guidelines for the management of difficult and failed intubation in obstetric patients.
ObStetrIC SyMPOSIUM 7
« Airway Of The Parturient »
78
THE LAST 24 HOURS IN UTERO Yoo Kuen Chan1, Alex Sia2, Nolan McDonnell3
1university of Malaya, Faculty of Medicine, Kuala Lumpur, Malaysia 2KK Women and children’s hospital national university of singapore, singapore
3university of Western australia, Perth, australia
objectivesAt the completion of this lecture participants should be able to:
1. Describethestrategiesthatwilloptimizebloodflowandoxygendeliverytothefetus.
2. Describe the potential effects of regional and general anaesthesia on the fetus and strategies to minimize potential adverse effects.
3. Recognise that the first day of life is a vulnerable period and discuss how we can cooperate with our neonatology colleagues in improving outcomes in for this period.
4. Understand the principles of neonatal resuscitation.
abstractThe panel of experts from around the world will discuss scenarios that anesthesiologists encounter in the care of the obstetric patient so that all newborn babies have the best possible chance of having a good outcome. Every year approximately 1 million babiesdieonthefirstdayoftheirlives-alargenumberofthesedeathsarepotentiallypreventable.MostmaynotbesecondarytoAnaesthesia Care; however anesthesiologists have specific skills in airway and vascular access as well as resuscitation of unwell patients that make them well placed to assist in the care of critically ill newborns.
The cases include:
1. Youareintheelectivecaesareantheatreandatermbabyhasjustdeliveredunderspinalanaesthesia.Thebabyappears“flat”andtheneonatalresidentappearstobestrugglingwiththeresuscitation.Theyaskforyourhelp-whatwillyoudo?
2. You have just inserted an epidural into a term mother. On reattaching the CTg there appears to be a significant fetal bradycardia. How will you manage this situation?
3. A “crash” caesarean is coming into your theatre in the next 2 minutes. All you know is that there is a prolonged fetal bradycardia in a pregnant woman at term with no epidural in situ. Is there a role for a “rapid sequence spinal” in this setting? What are the risks and benefits for both the mother and the baby with regional versus general anaesthesia.
4. Therewasarequesttoreviewa30-weekpregnantpatientdiagnosedwithseverepre-eclampsia.Sherequiresdeliveryinthenext 24 hours. What strategies may improve the fetal outcome? Does the administration of maternal magnesium have a role?
5. You are the administrator in an obstetric hospital. What strategies can you put in place to ensure that the newborns would not be in the 1 million doomed babies.
ObStetrIC
Panel DISCUSSIOn 7
79
SELECTEDORAL PRESENTATIONS
80
01 Refeeding Syndrome In A Malaysian Intensive Care Unit: An Assessment 81 Of Incidence, Risk Factors And Outcome
Azrina Md Ralib, Mohd Basri Mat Nor
department of anaesthesiology and intensive care, Kulliyyah of Medicine, international islamic university Malaysia, Kuantan, Pahang, Malaysia
02 Serial Measurement Of plasma Neutrophil Gelatinase Associated Lipocalin 82 In Mortality prediction In Critically Ill patients with Systemic Inflammatory Disease And Sepsis
Azrina Md Ralib, Mohd Basri Mat Nor
department of anaesthesiology and intensive care, Kulliyyah of Medicine, international islamic university Malaysia, Kuantan, Pahang, Malaysia
03 Low Volume Interscalene Block: Is It Safe, with Fewer Complications? 83C Y Lean, J S Ling, N Sabarudin, P Y Thang, N I Rahmat, A Huzaifah
hospital sarikei, sarikei, sarawak, Malaysia
04 A Retrospective Audit Of More Than 1800 peripheral Nerve Blocks For 84 Neurological Complications In The Largest Tertiary Center In Malaysia
Z Y Beh1, L J Tan1, A M Azidin1, A N M Kamil1, S Velayuthapillai1, M Shahnaz Hasan2, K U Ling3, S Fathil4
1hospital Kuala Lumpur, Kuala Lumpur, Malaysia 2university of Malaya, Kuala Lumpur, Malaysia 3Ramsay sime darby ara damansara Medical centre, selangor, Malaysia 4ng teng Fong general hospital, Jurong east, singapore
05 Complications After Neuraxial Block: A Five-year Experience In The Largest 85 Tertiary Center In Malaysia
Z Y Beh1, L J Tan1, H X Chang1, Y W Lim1, A R Thohiroh1, S Velayuthapillai1, M N Norliza2, M Shahnaz Hasan3, S Fathil4
1hospital Kuala Lumpur, Kuala Lumpur, Malaysia 2hospital selayang, selangor, Malaysia 3university of Malaya, Kuala Lumpur, Malaysia 4ng teng Fong general hospital, Jurong east, singapore
06 A Study On Evaluating The Cough Evoked Response On Emergence In 86 patients Undergoing General Anaesthesia
M M Miskan1, P S Loh2 1hospital umum sarawak, Kuching, sarawak, Malaysia 2university of Malaya, Kuala Lumpur, Malaysia
Oral Presentations
81
01
REFEEDING SyNDROME IN A MALAySIAN INTENSIVE CARE UNIT: AN ASSESSMENT OF INCIDENCE, RISK FACTORS AND OUTCOME
Azrina Md Ralib, Mohd Basri Mat Nor
department of anaesthesiology and intensive care, Kulliyyah of Medicine, international islamic university Malaysia, Kuantan, Pahang, Malaysia
objectiveRefeeding hypophosphataemia (RH) is characterised by acute electrolyte derangement following the start of nutrition. Complications associated with this syndrome include heart failure, respiratory failure, paraesthesia, seizure and death. We aim to assess its incidence, risk factors, and outcome in our local intensive care unit (ICU).
MethodsThis is a preliminary analysis prospective observational study at the ICU of Hospital Tengku Ampuan Afzan Kuantan. The study wasregisteredundertheNationalMedicalResearchRegister(NMRR-14-803-19813)andhasreceivedethicalapproval.Inclusioncriteria includes adult admission longer than 48 hours who were started on enteral feeding in the ICU. Chronic renal failure patients and those receiving dialysis were excluded. RH was considered if plasma phosphate was less than 0.65 mmol/l within 7 days of ICU admission.
resultsAtotalof108patientswererecruitedintothestudy.Ofthis,51(47.2%)hadRH.PatientswithRHhadhigherSOFAscorecomparedto those without RH (7.1±3.0 vs 5.7±3.4, p=0.02). There were no differences in the APACHE II score (16±6 vs 15±6, p=0.30), and in the nUTRIC score (2.9±1.7 versus 2.7±1.7, p=0.63) between patients with and without RH. Patients with RH had lower albumin concentration compared to those without RH (23 vs 25, p=0.04). There were lower trend of magnesium, calcium and potassium concentration, however these were not statistically significant. All four patients with hypomagnesaemia (less than 0.5 mmol/l) had RH (p=0.04). There were no differences in mortality, length of hospital or ICU stay and duration of mechanical ventilation.
ConclusionRefeeding hypophosphataemia is common, occuring in almost half of ICU admission. Patients with RH had higher organ failure score, andloweralbuminlevel.TherewerenodifferencesintheNUTRICscoreandinshort-termoutcomes.FurtherstudiescouldevaluatetheassociationbetweenRHandlong-termoutcome
82
SERIAL MEASUREMENT OF pLASMA NEUTROpHIL GELATINASE ASSOCIATED LIpOCALIN IN MORTALITy pREDICTION IN CRITICALLy ILL pATIENTS wITH
SySTEMIC INFLAMMATORy DISEASE AND SEpSISAzrina Md Ralib, Mohd Basri Mat Nor
department of anaesthesiology and intensive care, Kulliyyah of Medicine, international islamic university Malaysia, Kuantan, Pahang, Malaysia
objectivePlasma neutrophil gelatinase Associated Lipocalin (ngAL) is the most promising acute kidney injury biomarker to date. ngAL expressionisalsoincreasedbyinflammationandinfection.NGAL’sabilitytopredicthardoutcomesuchasmortalityinthisgroupofpatients is of interest. Sepsis is the leading cause of ICU admission in Malaysia, and contributes to a high mortality rate. Previous studiesshowedconflictingresultsontheNGAL’sabilitytopredictofmortality.Wehypothesisedthatserialmeasurementofbiomarkermay offer extra advantage compared to a single measurement. We aim to assess the ability of serial measurement of ngAL in predictionofmortalityincriticallyillpatientswithsystemicinflammatorydiseases.
MethodsThis is a secondary analysis of a prospective observational study of Hospital Tengku Ampuan Afzan, Kuantan. The study was registeredundertheNationalMedicalResearchRegister(NMR-11-1102-9248)andhasreceivedethicalapproval.Patientswhomfulfill theSystemicInflammatoryResponseSyndrome(SIRS)criteriawererecruited in thestudy.DeltaNGALat24and48hours(DNGAL-24andDNGAL-48)weredefinedas24and48hNGALminusDay-1NGAL.
resultsAtotalof151patientswiththreedaysofNGALmeasurementwereanalysed.Ofthis,53(35.1%)died.Non-survivorswereolder(51vs45,p=0.03)andhadhigherSOFA(9±7vs7±4,p=0.02)andSAPSII(47±15vs40±15,p=0.01)scorescomparedtosurvivors.NGALconcentrationsover threedayswerehigher in non-survivorscompared to survivors (RepeatedMeasuresANOVA,p=0.02).Day1-NGALandDNGAL-24werenotindependentlypredictiveofmortality.However,DNGAL-48waspredictiveafteradjustedforageandseverity of illness (OR 9.1 (1.97 to 41.7, p=0.005).
ConclusionsngAL dynamics over 48 hours independently predicted mortality in critically ill patients with SIRS. This could assist clinicians in risk stratificationofthisgroupofhigh-riskpatients.
02
83
LOw VOLUME INTERSCALENE BLOCK: IS IT SAFE, wITH FEwER COMpLICATIONS? C Y Lean, J S Ling, N Sabarudin, P Y Thang, N I Rahmat, A Huzaifah
hospital sarikei, sarikei, sarawak, Malaysia
The objective of this study is to assess the safety profile of using low volume local anaesthetics (10ml of 0.5% levobupivacaine) for interscalene block under ultrasound guidance; at the same time to achieve adequate surgical anaesthesia.
Patientsaged12 to70yearsold,withAmericanSocietyofAnaesthesiologistPhysicalStatus (ASA) I-IIwere recruited into thestudy.Thepatientwasrequiredtoperformpeakexpiratoryflowrate,andtheirpupils’sizewerecheckedbeforetheinterscaleneblock. Interscalene block was performed with Stimuplex A 22 gauge 2 inch needle, under ultrasound guidance using 10ml of 0.5% levobupivacaine.Theproceduredurationwastimed;andpatientwasagainrequiredtoperformpeakexpiratoryflowrate(PEFR)and pupils’ size were rechecked after the block was established, and post operatively. Hemodynamic status was closely monitored throughout. Pain score was assessed and any immediate and delayed complication was documented.
The mean age of patient is 36.2years old, with the average weight, height and body mass index were 62.87kg, 1.658m, 22.8718 respectively..Themeandurationofanalgesiawas533minutes.Hemodynamicstatusremainedstableintra-operatively.ThemeanbaselinePEFRwas337.33litre/minute,upon theestablishmentofblockandat therecoverybaypostoperativelywere329.67litre/minuteand314.67litre/minute.ThepercentageofPEFRreductionpost-anaesthesiawas-15.4%(p<0.001).Allsubjectsdocumented0painscoredespiteundergoingsurgeryusingsolelyregionalanaesthesia.Noadditionalanalgesicsweregivenintra-operatively.Only 20% of the subjects showed possible ipsilateral phrenic nerve block (p<0.001). However, there are no adverse respiratory events in the recovery bay.
Interscalene block using low volume local anaesthetics under ultrasound guidance is considered safe in upper limb surgeries and it provides adequate surgical anaesthesia. All these outcomes favour the clinical application of low volume interscalene block in district settings. .
03
84
A RETROSpECTIVE AUDIT OF MORE THAN 1800 pERIpHERAL NERVE BLOCKS FOR NEUROLOGICAL COMpLICATIONS IN THE LARGEST TERTIARy CENTER IN MALAySIA
Z Y Beh1, L J Tan1, A M Azidin1, A N M Kamil1, S Velayuthapillai1, M Shahnaz Hasan2, K U Ling3, S Fathil4
1hospital Kuala Lumpur, Kuala Lumpur, Malaysia 2university of Malaya, Kuala Lumpur, Malaysia
3Ramsay sime darby ara damansara Medical centre, selangor, Malaysia 4ng teng Fong general hospital, Jurong east, singapore
Background and objectiveOur institution had seen a surge in number of patients had postoperative neurological symptoms (POnS) after peripheral nerve blocks (PnBs). The hype was many pinpoint as block related nerve injury. Hence we carried out a retrospective audit on all patients received PnBs over the last two years.
MethodologyThis was an institutional review with waiver of informed consent. Ethical approval was not required. The audit period were from 1st January2014until31stDecember2015andcomprisedoftwoparts:First,descriptionoftotalnumberofpatientsreceivedPNBs,totalnumber of blocks performed and number of patients who developed POnS. Second, review the cohort of patients required follow up for POnS after PnBs in the anaesthetic clinic. The independent expert panel would evaluate their summarized information. Overall findings were presented in quantitative analysis in combination with literature interpretation, case review (clinical vignettes) and expert opinion.
resultsA total of 1435 patients received PnBs and 1,856 blocks were performed on them (highest number in Malaysia).
36 patients developed POnS, giving incidence of 19 per 1000 blocks. 28 of them had persistent numbness beyond the expected duration of block (78%). The rest had combined motor weakness and numbness. Most of them recovered few days after operation and discharged without the need for clinic follow up.
17 patients required follow up. 7 of them had electrodiagnostic study. Detailed analysis with expert feedback, majority were surgical related nerve injury, 4 patients had significant patient related factor. none had block related nerve injury. Most had full recovery and many defaulted subsequent follow up.
ConclusionPOnS was common with most had sensory paraesthesia which resolved within few weeks postoperatively. Most were likely due to non anaesthesia related cause than nerve block related nerve injury. There is definite need to have guideline to manage patients with POnS.
04
85
COMpLICATIONS AFTER NEURAxIAL BLOCK: A FIVE-yEAR ExpERIENCE IN THE LARGEST TERTIARy CENTER IN MALAySIA
Z Y Beh1, L J Tan1, H X Chang1, Y W Lim1, A R Thohiroh1, S Velayuthapillai1, M N Norliza2, M Shahnaz Hasan3, S Fathil4
1hospital Kuala Lumpur, Kuala Lumpur, Malaysia 2hospital selayang, selangor, Malaysia
3university of Malaya, Kuala Lumpur, Malaysia 4ng teng Fong general hospital, Jurong east, singapore
Background and objectiveAlthoughcomplicationsaftercentralneuraxialblocks (CNBs)areextremely rare,butwhen theyoccur, theyoften result in life-altering injuries. We attempt to identify the incidences of neuraxial complications in the largest institute in Malaysia.
MethodologyThis was an institutional review with waiver of informed consent. Ethical approval was not required. The audit period were from 1stJanuary2011until 31stDecember2015andcomprisedof twoparts:First,anassessmentof thenumberofCNBsperformedthroughout five year period (for denominator information) and an audit of the major complications of these procedures performed during same period (for numerator information). Second, review the cohort of obstetric patients who had accidental dural puncture (ADP) and postdural puncture headache (PDPH) following CnBs. The independent expert panel would ascertain causation, severity and outcome of each cases with complication. Overall findings were presented in quantitative analysis in combination with literature interpretation, case review (clinical vignettes) and expert opinion.
resultsAtotalof37481patientsreceivedcentralneuraxialblocksduringfive-yearperiod.79.5%ofthemspinal,12.3%epidural,3.2%CSEand5% combined gA with epidural or caudal.
75 patients developed postoperative complications after neuraxial blocks. Two unlikely related to neuraxial blocks. 10 had major complications – 1 case of epidural hematoma (giving incidence of 2.7 per 100,000 neuraxial blocks), 9 cases of cardiovascular collapse (whether direct or indirect to CnBs – e.g. high spinal, confounding sepsis; with 1 death on table). The most common minor complications were ADP with PDPH, followed by transient neurological symptoms (TnS), retained epidural catheter and backache. Identifiable risk factors: female, obstetric and extreme body mass index (BMI) patients.
1 case had filed complaint to the hospital authority.
ConclusionThis was the first baseline database for Malaysian population on neuraxial complications. Major limitation was poor data entry and it’s a retrospective analysis. There’s a great need for proper documentation and data collection system (prospective, digitalized information).
05
86
A STUDy ON EVALUATING THE COUGH EVOKED RESpONSE ON EMERGENCE IN pATIENTS UNDERGOING GENERAL ANAESTHESIA
M M Miskan1, P S Loh2 1hospital umum sarawak, Kuching, sarawak, Malaysia
2university of Malaya, Kuala Lumpur, Malaysia
objectivesCoughing during emergence from general anaesthesia may cause unfavorable side effects namely; sore throat, nausea, surgical site bleeding and increase in intracranial and intraocular pressure. To compare the incidence and severity of cough on emergence in patients undergoing general anesthesia receiving either neostigmine or sugammadex in a bolus or staggered dose for their reversal. Risk factors for severe cough on emergence are determined as the secondary objective.
MethodsThiswasarandomizedcontroltrialperformedintheoperationtheatreofUniversityMalayaMedicalCentre.120ASA1-3patients,18-80 years old, undergoing general anaesthesia and planned for extubation were included and randomized to three groups of reversal:
A – sugammadex 1mg/kg on emergence and another 1mg/kg immediately post extubation
B – sugammadex 2mg/kg on emergence
C – neostigmine 2.5mg/glycopyrrolate 200mcg as control
Perioperative and demographic data, incidence and severity of cough on emergence, sedation score, vital signs and reversal time were recorded and analyzed. Patients were followed up until discharge to ward. Postoperative cough, sore throat, agitation, vital signs and postoperative nausea and vomiting were monitored in recovery.
resultsStaggered dose of sugammadex compared to bolus dose showed less incidence of severe cough with good safety profile. Sugammadex 2mg/kg as a single bolus showed a significantly higher incidence of severe cough on emergence compared to the other2groups(OR:11,95%CI:3.8-31.7,P<0.001).Otherriskfactorsforcoughincludemale,andsmokers.Nosignificantdifferencewas seen in vital signs or adverse events on emergence.
ConclusionStaggered dose of sugammadex is safe and can avoid the hazards of severe cough on emergence.
06
87
POSTER PRESENTATIONS
88
01 Comparison Of The Venner A.p. Advance And C-Mac Video Laryngoscopes 90 In patients Undergoing Tracheal Intubation with Cervical Spine Immobilization
J L Khaw, I I Shariffuddin, N H Hashim
university of Malaya, Kuala Lumpur, Malaysia
02 Cranioplasty: It Is More Than Just A Cosmetic Repair 91B Voon1, P N Ng2, P Tan1
1hospital umum sarawak, Kuching, sarawak, Malaysia 2hospital Kuala Lumpur, Kuala Lumpur, Malaysia
03 Intraoperative I.V. paracetamol Reduces pain Scores, Morphine Consumption 92 And Opioid-Related Side Effects After Supratentorial Craniotomy
Mohd Fahmi Lukman1, Asmarawati Mohammad Yatim2, Mohamed Saufi Awang3, Chan Kin Hup3, Azura Sharena Yahaya4
1unit of anaesthesiology and critical care, Faculty of Medicine and defence health, national defence university of Malaysia, Kuala Lumpur, Malaysia 2department of anaesthesiology and intensive care, htaa, Kuantan, Pahang, Malaysia 3neurosurgery unit, department of surgery, Kulliyyah of Medicine, iiuM, Malaysia 4unit of Radiology, Faculty of Medicine and defence health, national defence university of Malaysia, Kuala Lumpur, Malaysia
04 24 Hour Observation Of patients After Intrathecal Morphine For Lower 93 Segment Caesarean Section – Is It Overrated?
Kong Shu Ning1, Tee Shi Ting1, Muhammad Faiz Bin Ismail1, Joanne Sue James1, Hamitra Gandhi1, Thiruselvi Subramaniam1, Jenny Tong May Geok2
1international Medical university clinical school, seremban, negeri sembilan, Malaysia 2hospital tuanku Jaafar seremban, seremban, negeri sembilan, Malaysia
05 Assessment Of The Depth Of Endotracheal Tube In pediatric Using 94 Fluoroscopy Technique: A pilot Study
Hasmizy M1, W Lynn Xuan2, Siti Baiduri B1, Hanafi S1, Norzalina E1
1department of cardiothoracic anaesthesiology and Perfusion, sarawak heart centre, Kota samarahan, sarawak, Malaysia 2department of anesthesiology and intensive care, sarawak general hospital, Kuching, sarawak, Malaysia
06 A Crossover Study Comparing In-plane and Out-of-plane Techniques For 95 Simulated Ultrasound-Guided Central Venous Cannulation On phantom Models By Trainees in Anaesthesiology
Yap Ka Boi1, Lee Yan Wei1, Kamal-Bashar Abu Bakar2, Liu Chian Yong2, Joanna Ooi Su Min2, Muhammad Maaya2
1hospital Kuala Lumpur, Kuala Lumpur, Malaysia 2universiti Kebangsaan Malaysia Medical centre, Kuala Lumpur, Malaysia
Poster Presentations
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Poster Presentations
07 postoperative Recovery profiles After Ambulatory Anaesthesia Using 96 Spectral Entropy
Md Nor Nadia, Zainuddin Muhammad Zurrusydi, Anaesth&CritCare, Wan Mat Wan Rahiza, Masdar Azlina, Raha Abdul Rahman
department of anaesthesiology and intensive care, Faculty of Medicine, universiti Kebangsaan Malaysia Medical centre, Kuala Lumpur, Malaysia
08 A Comparison Of Depth Of Muscle Relaxation To Improve performance 97 Of Thermal Ablation For Liver Tumours
S Masohood N, Loh P S
university of Malaya, Kuala Lumpur, Malaysia
09 Epidural Analgesia For Labour: Comparison between pre-puncture Ultrasound 98 Localisation Versus palpation Technique
Nahemah Hasanaly1, Thohiroh Abdul Razak1, Muhammad Maaya2, Joanna Ooi Su Min2, Liu Chian Yong2
1hospital Kuala Lumpur, Kuala Lumpur, Malaysia 2universiti Kebangsaan Malaysia Medical centre, Kuala Lumpur, Malaysia
10 The Spreading Of Labor Analgesia Concerned By A Marketing Theory In 99 Japanese private Hospital
Shingo Irikoma, Yoshie Toba, Sotaro Kokubo
department of anesthesiology, seirei hamamatsu general hospital, hamamatsu, Japan
90
COMpARISON OF THE VENNER A.p. ADVANCE AND C-MAC VIDEO LARyNGOSCOpES IN pATIENTS UNDERGOING TRACHEAL INTUBATION wITH CERVICAL SpINE IMMOBILIZATION
J L Khaw, I I Shariffuddin, N H Hashim1
university of Malaya, Kuala Lumpur, Malaysia
BackgroundWith the increasing availability of video laryngoscopes and improved glottic views, video laryngoscopes were incorporated in the difficult airway algorithms by the American Society of Anesthesiologists in 2013 and Difficult Airway Society in 2015. numerous video laryngoscopes are available to facilitate tracheal intubation in difficult airways. We compare the intubating characteristics of the VennerA.P.AdvanceandC-MACvideolaryngoscopesinpatientsundergoingtrachealintubationwithdifficultairwaybysimulatingcervical spine immobilization.
MethodsWe recruited 120 patients into a randomized control trial from June 2015 to December 2015 at the University Malaya Medical Centre, KualaLumpur.AtrainedanestheticmedicalofficerperformedthelaryngoscopybyusingeitherAPAorC-MACvideolaryngoscopes.The primary endpoint was time to successful intubation. Other endpoints were the numbers of intubation attempts, the best glottic view, manoeuvres to aid intubation and the complications associated with tracheal intubation. Analysis includes comparison of resultsbetweentheAPAandC-MAC.
resultsWefoundshorterintubationtimeswiththeC-MAC[mediantime21.12s,inter-quartilerange(IQR)17.13,27.37,p<0.001]comparedwiththeAPA[mediantime28.46s,IQR23.25,38.12,p<0.001];95%CI[56.94-57.05].AllthepatientsweresuccessfullyintubatedwiththeC-MAC,whereas3(5%)patientsfailedwiththeAPA,pvalue0.172.ThetwovideolaryngoscopeshadcomparableCormackandLehane(CL)grades:88.1%achievedaCLgradeIviewwiththeC-MAC,versus80.7%withtheAPA,pvalue0.269.
ConclusionsIntubationwassignificantlyfasterwiththeC-MACvideolaryngoscopethanwiththeAPAvideolaryngoscopesinpatientsundergoingtracheal intubation with cervical spine immobilization. However, APA video laryngoscope, with its feature of portability makes it handyandmoreconvenienttobringalongforuseinpre-hospitalsettings,ambulances,emergencydepartmentandintensivecareunits.
01
91
CRANIOpLASTy: IT IS MORE THAN JUST A COSMETIC REpAIRB Voon1, P N Ng2, P Tan1
1hospital umum sarawak, Kuching, sarawak, Malaysia 2hospital Kuala Lumpur, Kuala Lumpur, Malaysia
BackgroundCranioplasty after decompressive craniectomy (DC) does not only restore cosmesis and protective function of the skull, it also facilitates rehabilitation of those patients with syndrome of the trephined. However, cranioplasty is associated with a relatively high overallcomplicationrate(15-36.5%)andtherateofpost-cranioplastyseizuresisquotedas14%.
Case reportA21-year-oldmanunderwentanelectivealloplastic(titanium)cranioplastyfollowingDCperformedtwoyearsagofortraumaticleftfrontoparietal subdural haemorrhage. His glasgow Coma Scale (gCS) score was full. He had mild right hemiparesis but independent inactivitiesofdailyliving.Theawakeningafteranaesthesiawasdelayedfollowingthe2.5-houroperationandcomplicatedwithtonic-clonic seizures which was aborted with propofol and midazolam. Computed tomographic scan of the brain was done on operating table showed an expanded brain with open cisterns, a mild extradural collection without significant mass effect. The collection of subgaleal drain was 800 ml in the 12 hours postoperative period. He had multiple fitting episodes which were eventually controlled with dual antiepileptic drugs. Unfortunately, his gCS remained poor necessitated tracheostomy and prolonged rehabilitation.
discussion and learning pointsCranioplasty is associated with changes in cerebrospinal fluid hydrodynamics, cerebral blood flow and cerebral metabolism.Fatalmassivecerebraloedemahasbeenreportedsporadicallyfollowinganotherwiseuneventfulprocedure.Anegativepressuredifference from the elimination of atmospheric pressure that had been chronically applied on the injured sinking brain in combination with the negative pressure created by a subgaleal vacuum drain may cause shifting of the depressed brain to the reconstructed cranialvaultandinitiateafatalvasomotorreaction.Wepostulatethatpost-cranioplastyseizuresillustratedherewasattributedtointracranial hypotension explainable by the same mechanisms. Both surgeon and anaesthesiologist should be vigilant and aware of this clinical syndrome. Avoiding the application of suction via the subgaleal drain until the patient is fully awake in recovery bay could potentially minimize this uncommon complication.
02
92
INTRAOpERATIVE I.V. pARACETAMOL REDUCES pAIN SCORES, MORpHINE CONSUMpTION AND OpIOID-RELATED SIDE EFFECTS AFTER SUpRATENTORIAL CRANIOTOMy
Mohd Fahmi Lukman1, Asmarawati Mohammad Yatim2, Mohamed Saufi Awang3, Chan Kin Hup3, Azura Sharena Yahaya4
1unit of anaesthesiology and critical care, Faculty of Medicine and defence health, national defence university of Malaysia, Kuala Lumpur, Malaysia 2department of anaesthesiology and intensive care, htaa, Kuantan, Pahang, Malaysia
3neurosurgery unit, department of surgery, Kulliyyah of Medicine, iiuM, Malaysia 4unit of Radiology, Faculty of Medicine and defence health, national defence university of Malaysia, Kuala Lumpur, Malaysia
Background and objectivesPain management in craniotomy patients is delicate as these patients are required to be pain free postoperatively but awake for neurological assessment. In contrast to opioids, intravenous Paracetamol (i.v PCM) does not produce sedation and respiratory depression.Wehypothesizedthat intraoperative i.v.PCMmight influencepostoperativepainscores,morphineconsumptionandopioid-relatedsideeffects.
Methods50 adult patients undergoing elective supratentorial craniotomy were enrolled into the study. Patients were randomized into two groups: i.v. PCM group (n=25), and Control group (n=25). All patients had general anaesthesia with TCI Propofol – Remifentanil. PCMGroup received i.v.PCM1gram30minutesbeforeskin incisionandduringskinclosure.Allpatients received IVFentanyl 1.0mcg/kg20minutesbeforeendofsurgeryandfollowedbypatient-controlledMorphine.Postoperatively,allpatientswereadmittedinto ICU and pain was assessed in the fully awake 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.
results18 patients were excluded as they remained intubated 24 hours after surgery, 32 patients who were extubated immediately included in the analysis. 14 patients (44%) received intraoperative i.v. PCM, and postoperatively their pain scores at multiple time points were significantly lower (χ2 (6, n=32) = 167.0, P < 0.001) and they had lesser morphine consumption (Z = -3.001, P = 0.03) as well. They had lower POnV scores (χ2 (6, n=32) = 33.7, P < 0.001) and less sedated (χ2 (6, n=32) = 158.3, P < 0.001). Their heart rate were significantly lower (P<0.001) but higher systolic blood pressures (P=0.005).
ConclusionsIntraoperative use of i.v. PCM is a useful method of decreasing immediate postoperative pain scores, morphine consumption and opioid-relatedsideeffectsaftersupratentorialcraniotomy.
03
93
24 HOUR OBSERVATION OF pATIENTS AFTER INTRATHECAL MORpHINE FOR LOwER SEGMENT CAESAREAN SECTION – IS IT OVERRATED?
Kong Shu Ning1, Tee Shi Ting1, Muhammad Faiz Bin Ismail1, Joanne Sue James1, Hamitra Gandhi1, Thiruselvi Subramaniam1, Jenny Tong May Geok2
1international Medical university clinical school, seremban, negeri sembilan, Malaysia 2hospital tuanku Jaafar seremban, seremban, negeri sembilan, Malaysia
BackgroundIntrathecalmorphine improvesthemanagementofpost-surgicalpain.However,sideeffectsofmorphinecanbedangerousanddistressingtopatients.24-hourmonitoringbyacutepainservice(APS)teamisconductedforearlydetectionandinterventionoflife-threateningsideeffectslikerespiratorydepression.Withincreaseduseofintrathecalmorphineforlowersegmentcaesareansections (LSCS) and increased patient: staff ratio, attention to patients on other forms of pain management can get delayed.
objectivesThisstudyaimstoidentifythesideeffectsofintrathecalmorphineat0-6hours,6-12hoursor12-24hoursafteradministrationforLSCS and to determine the incidence of respiratory depression. We also aim to compare side effects and pain score among different races.
MethodAcross-sectionalstudywasconductedon323patients(18to45yearsold)whoreceivedintrathecalmorphineforLSCSinHospitalTuankuJaafar,Seremban.Aninterviewer-centeredquestionnairewasprovidedanddemographicinformationwasobtained.Thepresence and nature of side effects were noted. The data was analysed using SPSS statistical software.
results80% (n=259) patients experienced the side effects of intrathecal morphine. Pruritus is the most common side effect (88%; n=227). Side effects commonly occurred during the first 6 hours, 94% (n=244). There were no patients with respiratory depression in this study. We also found that there is statistically significant more occurrence of side effect among the Malay (p= 0.004).
ConclusionWefoundthatmostsideeffectscausedbyintrathecalmorphineoccurredwithin12hoursofplacement.Weconcludethat12-hourmonitoring by APS team is adequate before discharging from the APS care and regular monitoring can be continued in the ward by theparentteam.Furtherstudywithabiggersamplesizemaybeneededespeciallytolookattheracialpredominanceofsideeffectsthat was noted in our study.
04
94
ASSESSMENT OF THE DEpTH OF ENDOTRACHEAL TUBE IN pEDIATRIC USING FLUOROSCOpy TECHNIqUE: A pILOT STUDy
Hasmizy M1, W Lynn Xuan2, Siti Baiduri B1, Hanafi S1, Norzalina E1
1department of cardiothoracic anaesthesiology and Perfusion, sarawak heart centre, Kota samarahan, sarawak, Malaysia 2department of anesthesiology and intensive care, sarawak general hospital, Kuching, sarawak, Malaysia
BackgroundIn children, precise depth of tracheal tube insertion is important to avoid inadvertent tracheal extubation or endobronchial intubation. We practiced endotracheal tube length in centimeter at the patient lip based on formula, age/2 +12 for children more than 1 year old and endotracheal tube internal diameter x 3 for children less than 1 year old.
objectiveThe aim of this study was to determine the accuracy of standard practice for estimating oral tracheal tube length in children by using fluoroscopy.
MethodsWe performed orotracheal intubation in pediatric patients undergoing cardiac catheterization. ETT length was calculated based on age formula (ET1). However, the final ETT length placement will depends on equal auscultation of bilateral breath sounds (ET2). FluoroscopywasusedtomeasurethedistancebetweenthecarinaandthedistaltipoftheETT(D).ActualdistancecalculatedETT(DA)betweenthecarinaandthedistaltipoftheETTwasD–(ET1-ET2).
resultsFourty-twochildrenagedbetween0.11and10years(median4.7yr)werestudied.InET2,noendobronchialintubation,3patients(7.1%) had ETT < 0.5 cm from the carina and 36 patients (85.7%) had ETT > 1 cm from the carina. In DA, 5 patients (11.9%) will have endobronchial intubation while 7 patients (16.7%) will have ETT < 0.5cm from the carina and 22 patients (52.3%) will have ETT above 1 cm from the carina.
ConclusionThis study showed that by using ETT length age-formula alone without clinical assessment will results in high incidence ofendobronchial intubation and low placement of the ETT.
05
95
A CROSSOVER STUDy COMpARING IN-pLANE AND OUT-OF-pLANE TECHNIqUES FOR SIMULATED ULTRASOUND-GUIDED CENTRAL VENOUS CANNULATION ON pHANTOM MODELS
By TRAINEES IN ANAESTHESIOLOGyYap Ka Boi1, Lee Yan Wei1, Kamal-Bashar Abu Bakar2, Liu Chian Yong2, Joanna Ooi Su Min2,
Muhammad Maaya2
1hospital Kuala Lumpur, Kuala Lumpur, Malaysia 2universiti Kebangsaan Malaysia Medical centre, Kuala Lumpur, Malaysia
BackgroundIn-planeandout-of-plane,thetwocommonapproachestoultrasound-guidedvenouscannulation,canresultinposteriorvenouswall puncture especially in novices.
objectivesThiscrossoverstudycomparedtheincidenceofposteriorvesselwallpuncturebetweenthesetwoapproachesduringultrasound-guided simulated central venous cannulation by anaesthesiology trainees.
MethodsEach phantommodel, simulating a central vein and artery, was cannulated by 37 anaesthesiology trainees under ultrasound-guidanceusingthein-planeapproach(IPA)andout-of-planeapproach(OPA).Totalproceduraltime,whichincludedthetimetakenfrom starting image scanning until commencing puncture, was recorded. The number of attempts required to achieve successful venouscannulationwasnoted.Finally,themodelswereexaminedforposteriorvenouswallandarterialpuncture.
resultsTotal procedural time was shorter with the OPA (26.5 vs 50.3 sec, p = 0.001). The time taken from starting image scanning until commencing puncture was quicker for the OPA (2.2 vs 12.3 sec, p < 0.0001). The IPA resulted in significantly more attempts for cannulation. Twenty and eleven participants were successful within the first pass using the OPA and IPA, respectively (p = 0.034). There was no statistical difference in the incidence of posterior vessel wall puncture between these two techniques. The OPA had significantly less arterial puncture compared to the IPA (2 vs 9, p = 0.022).
ConclusionTherewasacomparable incidenceofposterior vesselwall puncturebetween the in-planeandout-of-plane techniquesduringultrasound-guidedsimulatedcentralvenouscannulationbyanaesthesiologytrainees.
06
96
pOSTOpERATIVE RECOVERy pROFILES AFTER AMBULATORy ANAESTHESIA USING SpECTRAL ENTROpy
Md Nor Nadia, Zainuddin Muhammad Zurrusydi, Anaesth&CritCare, Wan Mat Wan Rahiza, Masdar Azlina, Raha Abdul Rahman
department of anaesthesiology and intensive care, Faculty of Medicine, universiti Kebangsaan Malaysia Medical centre, Kuala Lumpur, Malaysia
BackgroundAnaesthesia for ambulatory surgery affects postoperative patient recovery impacting on safe discharge home.
objectiveTo compare postoperative recovery profiles between patients with spectral entropy and patients without spectral entropy monitoring, aftersevofluraneanaesthesia,inthedaycaresetting.
MethodsThisprospective, randomised,double-blindcontrolled studycomparedpostoperativepatient recoveryprofilesafter sevofluraneanaesthesia,with andwithout spectral entropymonitoring. FortyASA I-II patients agedbetween 18 to 65 years, scheduled forambulatory surgery were recruited. They were randomised into group A (without spectral entropy monitoring) and group B (withspectralentropymonitoring). InGroupA,sevofluranewastitratedtopreventawarenesswhilemaintaininghaemodynamicparameterswithin20%ofbaselinevalues.IngroupB,sevofluranewastitratedtomaintainstateentropy(SE)andresponseentropy(RE)valueswithintherangeof40-60.
resultsPatient demographic, duration of anaesthesia and surgery, and accumulative intraoperative propofol and fentanyl were comparable betweenthegroups.Meanend-tidalconcentrationofsevofluraneandtotalamountofsevofluraneusedwassignificantly lowerin group B. This corresponded with significantly higher SE and RE values with spectral entropy monitoring, p<0.05. Postoperative patient recovery profiles were also significantly better in group B, p<0.05. Significantly more patients in group B achieved a minimal modified Aldrete score of 10 on arrival in the phase I recovery area, and at three hours scored higher mean quality of recovery score, p<0.05.
ConclusionSpectral entropy monitoring improved postoperative recovery profiles after ambulatory surgery using sevoflurane withoutcompromising on patient safety or imposing additional side effects to the patient.
07
97
08
A COMpARISON OF DEpTH OF MUSCLE RELAxATION TO IMpROVE pERFORMANCE OF THERMAL ABLATION FOR LIVER TUMOURS
S Masohood N, Loh P S
university of Malaya, Kuala Lumpur, Malaysia
Percutaneous thermal ablation of hepatic tumours is one of the main treatment modality for small primary hepatocellular carcinoma (HCC) and liver metastases. Movement by patients during these ablation procedures may reduce the accuracy of targeting the tumour and increase the risk of complications. Large hepatic motion during breathing would also cause technical difficulties for the interventional radiologist to perform the procedure safely.
Recent studies have shown that deep neuromuscular blockade improves surgical conditions in laparoscopic surgery by improving visibility in the surgical field and reducing involuntary movements. This study hopes to prove that deep neuromuscular block will improve the performance of microwave ablation by radiologist. The main objective of this study is to compare the different depths of neuromuscular block between deep neuromuscular blockade (DMB) and moderate neuromuscular blockade (MMB) groups during microwave ablation (MWA) for primary or secondary hepatic tumours to look at the ease of performing the MWA by the interventional radiologist.
This was a single-centre, prospective, double-blinded, randomized controlled trial involving 50 patients undergoing computedtomography (CT) guided microwave ablation (MWA) of primary and secondary liver tumours in Department of Biomedical Imaging, University Malaya Medical Centre from January 2015 to november 2015. This study is registered with national Medical Research Register(NMRRID15-51-24027)andtheUniversityMalayaMedicalCentreEthicsCommittee(MECIDNo.20151-930)approvedthestudy protocol.
The mean performance score by radiologist in the DMB group was higher (mean 4.5, SD ±0.59) compared to the MMB group (mean 3.6, SD±0.85) (p < 0.01). There is a mean difference in the performance score of 0.9 between the two groups. This study proved that deep neuromuscular blockade improves performance of microwave ablation of hepatic malignancy. However, it did not reduce the complications of MWA nor did it shorten procedure duration.
98
EpIDURAL ANALGESIA FOR LABOUR: COMpARISON BETwEEN pRE-pUNCTURE ULTRASOUND LOCALISATION VERSUS pALpATION TECHNIqUE
Nahemah Hasanaly1, Thohiroh Abdul Razak1, Muhammad Maaya2, Joanna Ooi Su Min2, Liu Chian Yong2
1hospital Kuala Lumpur, Kuala Lumpur, Malaysia 2universiti Kebangsaan Malaysia Medical centre, Kuala Lumpur, Malaysia
introductionEpidural analgesia is the preferred method of pain relieve during labour. Performing an epidural block in a parturient in labour is always challenging especially in locating the intervertebral space, hence routine use of ultrasound has been recommended.
objectivesThis prospective, randomised study compared the number of attempts, time taken and the desired intervertebral space for epidural catheterinsertionbyusingpre-punctureultrasoundlocalisationorpalpationtechnique.
MethodologySixtysixASAI/IIparturientsinearlyphaseoflabourwererandomisedintotwogroups:GroupU(pre-punctureultrasound,n=33)orgroup P (palpation technique, n=33) for localisation of the intervertebral space for Tuohy needle insertion in labour epidural.
resultsPatients from group U had a significant higher first successful attempt than group P (60.6% vs 33.3%, p = 0.042). The median number ofattemptswas lesser inGroupUcompared toGroupP [1 (1-2)vs2 (1-3),p=0.011].Allparturients fromGroupUhadcorrectintervertebral space for insertion of Tuohy needle compared to group P (100% vs 84.8%, p = 0.027). However, the mean time taken for localisation of the intervertebral space was significantly longer in group U (341.8 ± 65.4 sec vs 15.8 ± 7.2 sec, p < 0.001). There were no complications recorded.
ConclusionPre-puncture ultrasound localisation of intervertebral space for Tuohy needle insertion in labour epidural wasmore accurate,achieving a higher success rate with fewer attempts compared to the palpation method.
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99
THE SpREADING OF LABOR ANALGESIA CONCERNED By A MARKETING THEORy IN JApANESE pRIVATE HOSpITAL
Shingo Irikoma, Yoshie Toba, Sotaro Kokubo
department of anesthesiology, seirei hamamatsu general hospital, hamamatsu, Japan
objectivesLabor analgesia is gradually spreading among Japanese pregnant women in recent years. Because an intensification of delivery is difficult in Japan, obstetric anesthesiologists cannot work in only labor ward. Though the need for labor analgesia is increasing, there are not many institutes can provide labor analgesia in Japan. So we have trained obstetricians to be able to insert the epidural catheterization and manage the labor analgesia. Midwives also support the labor analgesia management. Cases of labor analgesia have increased in our hospital in recent 3 years. We retrospectively researched our new labor analgesia system from the point of view of marketing theory.
MethodsThis study was approved by the Institutional Review Board in our hospital. We investigated new our labor analgesia project and system from the point of view of marketing theory July in 2013 to June in 2016. We tried to explain the factor of our successful project to use the 5C analysis and the marketing mix (4P).
resultsThere are the 5C analysis and the marketing mix (4P) in the marketing theory. The 5C are company, consumer, customer competitor and community. The marketing 4P are product, price, place and promotion. The key factors of our successful labor analgesia project and novel were management resource about general hospital (company in 5C) and low frequency of breakthrough pain because of quick responses by obstetricians and midwives (product in 4P). Monthly average number of cases with labor analgesia was 8, 15, 23, 30 cases in 2013, 2014, 2015, 2016, respectively.
ConclusionsWe unwittingly used the marketing theory and increased number of cases with labor analgesia in our private hospital in Japan.
10
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