Malaysian Journal of Anaesthesiology

Medicolegal issues affecting anaesthesiologists in Malaysia: an overview

Gunalan Palari Arumugam, Alishya Gunalan, Aishwarya Gunalan — Mon, 30 Jun 2025 00:00:00 +0000

Medicolegal issues have a significant impact on the practice of anaesthesiologists worldwide. Current trends indicates that although anaesthesiologists are less likely to be sued compared to other specialities, the payouts by anaesthesiologists are huge due to the high cost associated with the long-term management of patients with cerebral palsy and hypoxic ischaemic encephalopathy. The impact on anaesthesiologists is acknowledged, with many societies worldwide taking various steps to address them, such as the Second Victim Programme by the Malaysian Society of Anaesthesiologists. This aims to address some of the potential mental health issues affecting anaesthesiologists facing the aftermath of a poor clinical outcome and subsequently having to deal with the process of litigation. Various solutions have been addressed to acknowledge medicolegal issues in Malaysia, such as mediation as a way forward for dispute resolution. However, solutions such as this will take time for widespread adoption, and as such, the impact will not be immediately felt. It is far better for anaesthesiologists to be proactive in having increased awareness of the challenges associated with litigation via comprehensive medicolegal education.

Development and validation of creatinine-based estimates of the glomerular filtration rate equation from chromium EDTA imaging in the multiracial Malaysian population

Mon, 30 Jun 2025 00:00:00 +0000

Introduction: The glomerular filtration rate (GFR) is a reliable parameter for assessing kidney function. It is estimated from equations such as Cockcroft–Gault (CG), Modification of Diet in Renal Disease (MDRD), and Chronic Kidney Disease- Epidemiology Collaboration (CKD-EPI). However, these equations were derived using Western population demographic data and had different performances when applied to other ethnicities and populations.

Objective: We developed a new equation (NE) based on the 51Cr-EDTA-measured GFR, that can be used explicitly in the Malaysian multiracial population.

Methods: A cross-sectional study was conducted using electronic medical records of patients who underwent 51Cr-EDTA imaging between 2013 and 2021. Ethical approval was obtained.

Results: A total of 209 patients were recruited, of which 105 patients were randomised to the development cohort and 104 patients to the validation cohort. The NE was developed using the development cohort data, and its performance was subsequently tested in the validation cohort. The result showed that CKD-EPI had the highest precision and accuracy in estimating GFR. CG had the lowest bias, while the NE performed second best. CKD-EPI had the highest correlation to 51Cr-EDTA imaging-measured GFR, followed by the NE.

Conclusion: CKD-EPI demonstrated the best performance among the estimated GFR equations. However, NE showed comparable performance, exhibiting low bias, high precision, and good accuracy.

Beyond the operating theatre: mindfulness and self-care as antidotes to burnout in anaesthesiology

Chiong Kian Tiong — Mon, 30 Jun 2025 00:00:00 +0000

A breathless journey: airway management in a pregnant patient with non-Hodgkin lymphoma

Nazuha binti Mohd Najid, Ahmad Afifi Mohd Arshad — Mon, 30 Jun 2025 00:00:00 +0000

Airway compromise due to malignancy in pregnancy is rare but presents significant challenges. Physiological changes during pregnancy may further exacerbate airway obstruction from mediastinal masses, complicating management. We report a case requiring early tracheostomy for airway stabilisation and chemotherapy initiation. A 32-year-old at 17 weeks’ gestation presented with non-Hodgkin lymphoma and a large anterior mediastinal mass causing severe airway compression. Multidisciplinary planning prioritised early airway stabilisation to avoid emergent interventions. Awake fibreoptic intubation allowed controlled tracheostomy placement, securing the airway for chemotherapy. Following the third cycle of treatment, the patient showed a good clinical response with significant mass reduction, improved symptoms, and better tolerance of oral intake. Plans were made for elective Caesarean section at 32–34 weeks, with tracheostomy maintained for airway security during delivery. This case underscores the importance of proactive airway management and collaborative planning in pregnancy complicated by mediastinal mass and airway compromise. Early airway stabilisation and multidisciplinary collaboration are critical in managing pregnant patients with compromised airways, thus optimising maternal and foetal outcomes. Future cases with similar risks may benefit from planned airway stabilisation and multidisciplinary collaboration.

Suxamethonium apnoea in a pregnant patient undergoing emergency lower segment Caesarean section under general anaesthesia

Billy Wei Loong Voon, Kevin Teck Meng Tan, Nur Zulaikha Zainol, Norliza Mohd Nor — Mon, 30 Jun 2025 00:00:00 +0000

We report a well-described but rare occurrence of suxamethonium apnoea, also known as Phase II block. A 16-year-old Burmese primigravida at 38 weeks and 4 days’ gestation was scheduled for an emergency lower segment Caesarean section due to poor progress in labour. Her antenatal course had been uneventful, and she had no significant medical history, allergies, or history of prior surgery. General anaesthesia was chosen due to her age and clinical circumstances. Rapid sequence induction was performed using intravenous propofol and suxamethonium. Muscle relaxation was subsequently maintained with atracurium. At the end of an uneventful surgery, reversal with neostigmine and atropine was administered upon observing spontaneous breathing effort. However, 30 minutes later, the patient still exhibited poor respiratory effort with persistent hypercapnia and poor motor strength. The patient was subsequently sedated with propofol and transferred to the Intensive Care Unit for ventilatory support and neuromuscular monitoring. She was extubated and transferred to the general ward the following morning.

Resection of tracheal tumour under cardiopulmonary bypass: a case report

Ahmad Fariz Elias, Huey Nee Ng, Farah Nadia Razali, Mohd Fitry Zainal Abidin — Mon, 30 Jun 2025 00:00:00 +0000

Primary tracheal tumours can cause critical airway obstruction, challenging standard anaesthetic management. We report the case of a 66-year-old male with a large subglottic tracheal tumour causing severe airway compromise. Due to a high intubation risk, endoscopic transoral laser resection was performed using femoro-femoral cardiopulmonary bypass (CPB) for oxygenation, uniquely deferring endotracheal intubation until after tumour removal. Despite a brief intraoperative desaturation episode and postoperative bleeding requiring intervention, the benign oncocytoma was successfully resected, and the patient recovered well. This case demonstrates femoro-femoral CPB as a safe and effective alternative for airway management during resection of severely obstructing tracheal tumours.

Navigating complexity: futureproofing anaesthesia for patient safety

Ina Ismiarti Shariffuddin — Mon, 30 Jun 2025 00:00:00 +0000

Ultrasound-guided central neuraxial blocks: breaking barriers to greater adoption

Iskandar Khalid, Shahridan Mohd Fathil, Manoj Kumar Karmakar — Mon, 30 Jun 2025 00:00:00 +0000

Central neuraxial blocks (CNB) remain a cornerstone of modern anaesthesia, yet traditional landmark-based techniques carry inherent limitations in accuracy and safety. Ultrasound-guided CNB has emerged as a transformative technique, offering improved first-pass success, shorter procedure times, fewer needle passes, and decreased incidence of complications such as inadvertent dural puncture and paraesthesia. Despite compelling evidence supporting these advantages, global adoption of ultrasound-guided CNB remains limited. Surveys across North America, Europe, and Asia consistently reveal underutilisation, suggesting significant barriers to implementation. This editorial explores the multifactorial impediments to wider ultrasound-guided CNB adoption, including logistical issues such as cost and equipment access, workflow disruptions in high-volume settings, the complexity of spinal sonoanatomy, and a steep learning curve requiring structured training. Cultural resistance to change and inadequate institutional support further hinder progress. Drawing from change management models, we propose strategies to overcome individual and systemic inertia. The proliferation of portable ultrasound devices and training dissemination by younger, ultrasound-proficient practitioners are expected to drive change. Ultimately, formal certification pathways and sustained advocacy will be essential to achieving mainstream adoption of ultrasound-guided CNB.