Malaysian Journal of Anaesthesiology

Retained epidural catheter: an update

Kevin Teck Meng Tan — 2023-12-18

The retained catheter fragment is a rare complication when performing epidural techniques. There is a paucity of studies available, with Australian data quoting an incidence of 1 in 60,000. For this article, we reviewed 36 case reports of retained epidural catheters between 1995 and 2020. The case reports found computed tomography scans to be the most reliable modality to investigate a retained epidural catheter. The decision to surgically remove or treat conservatively should be multidisciplinary with most operations involving symptomatic or long fragments. In our review, we found 25 (69.4%) reports of surgical removal, with 21 opting for immediate removal. Conservatively treated retained fragments should be monitored for neurological or infective complications. Patients should receive a follow-up plan and be educated regarding red flag symptoms to facilitate further management. For future reference, a detailed documentation of the incident, parties involved, discussions, and decisions should be made.

Green anaesthesia: a review of sustainable perioperative practices and the potential application in Malaysia

Kwan Tuck Lee — 2023-12-18

Global warming and worsening climate change threaten environmental sustainability and exacerbate disease burdens worldwide. Alarmingly, the health care sector emerged as a substantial contributor to this crisis. The operating theatre significantly contributes to hospital waste and greenhouse gas emissions. Anaesthesiologists are morally compelled to combat this crisis, aligning with our oath as physicians of “first, do no harm,” ensuring patient safety extends beyond the operating room by advocating for sustainable practices that safeguard both health and the environment. Understanding the climate change indicators reveals the alarming impact of human actions on escalating greenhouse gas emissions and their dire repercussions, such as global temperature shifts, severe weather events, and heightened natural disasters.

Greener solutions and adaptive policymaking are essential to address procurement, greenhouse gas emissions, and waste management challenges in health care settings. Anaesthesiologists should collaborate with surgeons and hospital management to navigate patient-specific issues analysing the environmental impact of hospital visits, investigations, and comorbidities. Efforts toward sustainable healthcare practices in the preoperative setting, such as telemedicine adoption, promoting eco-friendly transportation, and optimising patient health before surgery should be encouraged.

Anaesthesiologists should focus on the environmental impact of anaesthesia drugs, medical equipment, and electricity usage on the environment. We should be more responsible and able to justify our practices concerning the ecological implications of inhaled anaesthetic gases, propofol disposal, plastic-based equipment, and energy demands in operating rooms. The emphasis lies on adopting the 6Rs—rethink, refuse, reduce, reuse, recycle, and research—within anaesthesia practices to minimise environmental footprints.

The effect of moderate versus deep neuromuscular blockade on the surgical rating scale in laparoscopic sleeve gastrectomy in a Malaysian tertiary university hospital: a randomised clinical trial

Hajar Rubihah Dzaraly — 2023-12-18

Background: The depth of neuromuscular blockade (NMB) is important to provide optimal space during laparoscopic surgery, especially in the obese population. This study compared the effects of moderate versus deep neuromuscular blockade on the surgical rating scale in laparoscopic sleeve gastrectomy.

Methods: This single-blind, randomised controlled trial involved 24 patients with a body mass index > 30 kg/m2 who underwent laparoscopic sleeve gastrectomy. They were randomised into two groups: moderate NMB with a target train-of four (TOF) of 1-2 (Group M) and deep NMB with a post-tetanic count (PTC) of 1-2 (Group D). The quality of the surgical field was scored by a surgeon using the 5-point Surgical Rating Scale (SRS) from 1 (extremely poor condition) to 5 (optimal condition). The haemodynamic changes, end-tidal CO2, duration of surgery, and intra-abdominal pressure were also recorded. At the end of surgery, patients were given intravenous sugammadex at 2 mg/kg if the TOF count was 12, or 4 mg/kg if the PTC was 1-2. Patients were extubated when the TOF ratio (T4/T1) was greater than 0.9.

Results: The mean SRS was significantly higher in Group D (4.83 ± 0.39) compared with Group M (4.08 ± 0.79), p = 0.004. All patients in Group D had favourable surgical conditions, in which 16.7% of patients achieved SRS of 4 and 83.3% had SRS of 5. In Group M, 8.3% of patients had an unfavourable surgical field.

Conclusion: Deep NMB provided a favourable surgical condition compared with a moderate NMB in the laparoscopic sleeve gastrectomy.

Derivation of a multi-biomarker model for predicting mortality in hospitalised COVID-19 patients

Nur Izyan Izzati Sathari — 2023-12-18

Introduction: This study aimed to derive and assess the performance of a multi-biomarker model from a combination of basic laboratory biomarkers in predicting mortality of hospitalized COVID-19 patients.

Methods: This was a cross-sectional study conducted in a university-affiliated hospital in Malaysia. Data of confirmed COVID-19 patients who were admitted from January 2020 to August 2021 were retrieved including their admission C-reactive protein (CRP), lactate dehydrogenase (LDH), and neutrophil-lymphocyte ratio (NLR). Patients were classified as non-survivors or survivors according to their hospital mortality status. Multi-variable logistic regression analysis was used to derive the multi-biomarker model.

Results: A total of 188 confirmed COVID-19 patients were analysed, of which 46 (23%) died in the hospital. Their mean age was 52 (SD 17) years, 104 (52%) were males, 114 (57%) had severe COVID-19 pneumonia, with mean APACHE II score of 14 (SD 10). On admission, those who died had higher median levels of CRP 96.0 (IQR 39.8–182.0) vs 23.0 (IQR 0–67.0 mg/L, p < 0.001), of LDH 973.0 (IQR 706.5–1520.0) vs 515.1 (408.8–738.8 IU/L, p < 0.001), and of NLR 10.1 (IQR 5.5–23.6) vs 2.8 (IQR 1.5–5.9, p < 0.001). The multi-biomarker model had a higher area under the curve (0.866, 95% CI 807-0.925) compared to its constituent individual biomarkers. At its optimal cutoff, this model had 78.9% sensitivity and 76.5% specificity for mortality prediction.

Conclusion: A multi-biomarker model of CRP, LDH, and NLR predicted in-hospital mortality with a very good performance in our hospitalised COVID-19 patients.

National postgraduate medical curriculum: enhancing anaesthesiology training in Malaysia

Azrina Md Ralib — 2023-12-18

Successful utilization of blood purification therapy with Oxiris® haemofilter for the management of severe leptospirosis with multiorgan involvement: a case report

Nurul Izzah Binti Azmi — 2023-12-18

Severe leptospirosis is associated with excessive proinflammatory and anti-inflammatory cytokines that lead to multiorgan failure. Oxiris® haemofilter is a blood purification therapy that can be utilized to control these inflammatory responses during early phase of sepsis-associated acute kidney injury (AKI) that requires renal
replacement therapy. We present a case of a 15-year-old male with severe leptospirosis with multiorgan involvement who was admitted to our intensive care unit (ICU). He had septic shock with myocarditis, respiratory failure, AKI with metabolic acidosis, and transaminitis. We started him on continuous veno-venous haemofiltration with the Oxiris haemofilter for metabolic acidosis and cytokine absorption for a total duration of 35 hours. A rapid decrease of vasopressor requirement, lactate, and procalcitonin levels was observed following therapy initiation. He was extubated on day 5 of ICU admission and discharged well to the general ward after 7 days in the ICU. This case highlights the potential benefits of the Oxiris haemofilter as an adjunct in the management of septic shock in severe leptospirosis with multiorgan involvement. Randomized clinical trials are warranted to validate the clinical benefits of this therapy.

Use of dexmedetomidine and low-dose ketamine as conscious sedation for fibreoptic bronchoscopy intubation for temporomandibular joint ankylosis secondary to an unsuspecting childhood trauma: a case report

Jie Cong Yeoh — 2023-12-18

Airway management in the paediatric population is known to be challenging due to its unique anatomical and physiological differences. Maxillofacial injuries further complicate airway management. To date, there is limited evidence to support the technique of airway management and the choice of drugs used in the paediatric population. This case report aims to describe the technique of conscious sedation using dexmedetomidine and ketamine to perform an awake fibreoptic intubation in the case of an 8-year-old boy with limited mouth opening due to a temporo-mandibular joint ankylosis secondary to childhood trauma. The endpoint of this case report showed that this technique proved effective with a good margin of safety in this paediatric patient with an airway concern. Further studies are needed to validate this observation.

Gastric ultrasound for perioperative prandial status

Jie Cong Yeoh — 2023-12-18

Gastric ultrasound is a valuable tool for real-time assessment of gastric content at the bedside, reducing the risk of pulmonary aspiration. A good understanding of the gastric sonoanatomy and techniques for image acquisition will allow the clinician to utilize ultrasound to assess gastric content and volume via qualitative and quantitative
assessment to risk stratify their patient prior to the surgery. We describe the core principles of gastric ultrasound and its practical implications on patient safety during the perioperative period.