Malaysian Journal of Anaesthesiology

Optimising Enhanced Recovery After Surgery for breast reduction: a case series incorporating morphine as an adjuvant in intertransverse process block

Mon, 29 Jun 2026 00:00:00 +0000

Breast reduction surgery is associated with significant postoperative pain, commonly managed with intravenous opioids, which can cause adverse effects such as nausea, vomiting, sedation, ileus, and respiratory depression. This case series evaluates postoperative pain outcomes within an Enhanced Recovery After Surgery (ERAS) protocol incorporating morphine as an adjuvant in intertransverse process blocks. This retrospective case series included four patients who underwent bilateral breast reduction surgery at a tertiary hospital and received preoperative bilateral intertransverse process blocks with 0.375% ropivacaine and 2 mg morphine each side, intraoperative multimodal analgesia (ketamine, dexamethasone, magnesium sulphate, paracetamol, fentanyl), and a protocolized postoperative pain management strategy. Pain scores, opioid consumption, complications, and hospital length of stay were analysed. All patients reported low postoperative pain scores (numerical rating scale 0–4). None required additional intravenous patient-controlled analgesia or rescue opioids at any time during hospital stay beyond the scheduled regimen. All patients were discharged within five days postoperatively. No opioid-related side effects were reported. Morphine as an adjuvant to intertransverse process blocks within the framework of a multimodal ERAS analgesia protocol may be associated with improved postoperative pain outcomes following breast reduction surgery.

Acute epiglottitis from diphtheria: the forgotten but fatal disease

Hze Hou Yap, Nor Hidayah Zainool Abidin, Pei Wei Kee — Mon, 29 Jun 2026 00:00:00 +0000

Diphtheria is an infectious disease caused by the gram-positive bacillus Corynebacterium diphtheriae. It is transmitted through direct contact with infectious respiratory secretions or skin lesions and was a significant cause of morbidity and mortality worldwide prior to the introduction of vaccination in the 1930s. We report the case of a 12-year-old boy with no history of vaccination who presented with acute upper airway obstruction secondary to respiratory diphtheria. He required endotracheal intubation and was admitted to the intensive care unit. Despite supportive care, the patient developed cardiogenic shock within 24 hours and ultimately succumbed to the infection. This case underscores the importance of maintaining a high index of suspicion for diphtheria in unimmunized patients presenting with acute airway obstruction, tonsillar exudates, and cervical swelling. It also highlights the critical need for effective interdepartmental communication, early diagnostic testing, and timely access to diphtheria antitoxin to improve outcome of this potentially fatal disease. Effort to promote community awareness on national immunization program is imperative on achieving herd immunity to suppress transmission and reduce morbidity associated with vaccine-preventable disease.

Neuraxial anaesthesia in a patient with Charcot-Marie-Tooth disease for Caesarean delivery: a case report

Lau Chin, Mohd Rohisham Zainal Abidin — Mon, 29 Jun 2026 00:00:00 +0000

Charcot-Marie-Tooth (CMT) disease is a hereditary peripheral neuropathy characterised by slowly progressive, distal-to-proximal muscle weakness. The anaesthetic concerns are the associated respiratory and diaphragmatic muscle weakness, phrenic nerve palsy, and increased sensitivity to anaesthetic agents. Our case report described a patient with underlying CMT disease who had undergone elective Caesarean delivery (CD) under combined spinal-epidural (CSE) anaesthesia. She had underlying bronchial asthma with recent exacerbation secondary to pneumonia at 25 weeks’ gestation. Her lung function test showed a moderately restrictive pattern. We decided to perform CSE using an intrathecal dose of heavy bupivacaine 8.5 mg and fentanyl 15 mcg under pre-procedural ultrasound guidance. The surgery was uneventful, and postoperative analgesia was maintained with an epidural infusion of ropivacaine 0.1% combined with fentanyl 2 mcg/mL running at 5 mL/hour. The patient’s neurological status returned to baseline on postoperative day one. Our case showed the successful use of CSE for elective CD in the patient with CMT disease without worsening neurological symptoms. With a thorough preoperative assessment of neurological status, utilisation of ultrasound guidance and minimum effective local anaesthetic dosage, neuraxial anaesthesia can be safely performed in patients with CMT disease.

Successful combined spinal–epidural anaesthesia for EXIT procedure in foetal goitre associated with maternal Graves’ disease: a case report

Mon, 29 Jun 2026 00:00:00 +0000

The ex-utero intrapartum treatment (EXIT) procedure is a rare, but lifesaving intervention performed during a Caesarean section to enable controlled foetal airway and other intrapartum procedures. Its main goal is to secure the foetal airway while maintaining utero-placental circulation, preventing airway obstruction at birth. The EXIT procedure is preferred in conditions such as congenital high airway obstruction syndrome and airway compression from neck or thoracic masses. This case report details the management of a 22-year-old primigravida with Graves’ disease whose foetus was diagnosed with an anterior neck mass consistent with thyroid goitre. Antenatal ultrasound and magnetic resonance imaging confirmed a lesion anterior to the trachea. After multidisciplinary discussion between the obstetrician, obstetric anaesthesiologist, and paediatric otorhinolaryngology teams, an emergency Caesarean section with an EXIT procedure was performed at 37 weeks and 3 days. Anaesthesia was provided using a combined spinal-epidural technique. Nitroglycerin facilitated uterine relaxation, and phenylephrine maintained maternal hemodynamic stability. Foetal tracheal intubation was successfully performed under direct laryngoscopy while placental circulation was preserved. This case highlights the success of combined spinal-epidural anaesthesia in avoiding a potential high-risk airway complication to the mother and secure the foetal airway while oxygenating the foetus via the placenta.

Enhancing recovery: translating evidence into practice

Shahridan Mohd Fathil, Vera Qinyi Lim, Fadzwani Basri — Mon, 29 Jun 2026 00:00:00 +0000

Preoperative fasting in Asian children: evidence, context, and the path to region-specific guidance

Mon, 29 Jun 2026 00:00:00 +0000

Preoperative fasting guidelines have evolved substantially over three decades, moving from rigid nil-per-os-after-midnight directives to evidence-based regimens permitting clear fluids within one to two hours of induction. However, most supporting evidence originates from Western high-income settings, raising concerns about its applicability to Asian paediatric populations. This narrative review examines the evidence base for preoperative fasting in Asian children, the contextual factors that shape its practice across the region, and the path toward region-specific guidance. Four integrated lenses are applied: the physiology of gastric emptying and aspiration risk; the evolution of major international fasting guidelines; the persistent problem of prolonged fasting in clinical practice; and the cultural, dietary, and climate considerations that render the Asian context distinctly different from the settings in which current guidelines were conceived. Pulmonary aspiration during elective paediatric anaesthesia is exceedingly rare, fewer than three to four events per 10,000 cases, yet actual clear fluid fasting durations of eight to twelve hours remain common across Asian centres. Three evidence gaps of particular regional significance are identified: uncharacterised gastric emptying profiles of rice-based staple meals in children; nutritional vulnerability of paediatric patients in lower-middle-income Asian settings; and the potential interaction between prolonged fasting and climate-driven heat exposure across South and Southeast Asia. Although current international fasting principles remain physiologically sound, their implementation in Asia requires dedicated research on regional diets, consensus guidelines developed by Asian anaesthesiology societies, and institutional strategies to reduce unnecessary fasting. A multinational survey currently underway aims to support a future Delphi-based regional consensus.

The corner pocket and beyond: a narrative review of the supraclavicular block and its variants

Iskandar Khalid, Shahridan Mohd Fathil, Jatuporn Pakpirom — Mon, 29 Jun 2026 00:00:00 +0000

The supraclavicular brachial plexus block remains a reliable and time-efficient technique for surgical anaesthesia and postoperative analgesia for upper limb procedures. Ultrasound guidance has improved visualisation of the plexus,
subclavian vessels, first rib and pleura, but clinically important risks persist, including pneumothorax, vascular puncture, local anaesthetic systemic toxicity, nerve injury and hemidiaphragmatic paresis. Contemporary practice has moved beyond the traditional cluster injection toward more anatomy-directed strategies. Corner pocket and intertruncal approaches aim to improve coverage of the inferior trunk and the ulnar nerve, while selective trunk and superior trunk blocks allow more tailored sensory profiles for whole-limb or shoulder-focused indications. Continuous supraclavicular catheter techniques, including proximal longitudinal oblique approaches, may expand the role of supraclavicular blockade in shoulder analgesia while reducing, but not abolishing, diaphragmatic involvement compared with interscalene techniques. This narrative review summarises the relevant anatomy, historical evolution, named variants, clinical efficacy, complications, local anaesthetic strategies, adjuvants, and catheter techniques related to the supraclavicular brachial plexus block. It also proposes a practical decision-making framework to guide technique selection based on surgical site, need for ulnar coverage, anticipated duration of analgesia, pulmonary reserve, coagulation status, and patient-specific risk. Meticulous ultrasound technique, appropriate volume selection, as well as readiness to manage complications remain central to safe and effective practice.

Improving preoperative fasting compliance in children undergoing general anaesthesia using written instructions: a quality improvement project at a single institution in Sabah, East Malaysia

Audrey Shuk Lan Chong, Yu Xiang Wong, Jennette Yeen Yii Chin — Mon, 29 Jun 2026 00:00:00 +0000

Background: Prolonged preoperative fasting among children is a global concern with adverse effects. This quality improvement (QI) project aimed to determine the preoperative fasting duration among children undergoing elective surgery under general anaesthesia (GA) at Sabah Women and Children Hospital and improve adherence to recommended fasting timeframe.

Methods: This was a single-centre, before-after QI project using the Plan-Do-Study-Act cycle, conducted from May to August 2023. A total of 180 children (93 control; 87 intervention) were recruited. A baseline audit was conducted, followed by an intervention using a dual-language written instruction leaflet. The study assessed preoperative fasting duration and evaluated the intervention’s effectiveness.

Results: The intervention group demonstrated shorter median fasting durations. Significant reductions were observed for solid food/formula milk (median difference = -1.9 hours, p < 0.001) and clear fluids (median difference = -3.1 hours, p < 0.001). Adherence significantly improved following intervention: for solid food/formula milk, odds of prolonged fasting were reduced by 70% to 75% (relative risk ratio [RRR] range: 0.25 to 0.30, p ≤ 0.002). Similarly, for clear fluids, odds of fasting ≥ 8 hours were reduced by 81% to 90% (RRR range: 0.10 to 0.19, p ≤ 0.005).

Conclusions: The dual-language written instruction leaflet was associated with improved compliance, reducing prolonged preoperative fasting. However, excessive fasting remains an issue. Further strategies, such as multidisciplinary involvement, text message reminders, and offering drinks two hours before surgery, are warranted to optimise compliance. Future research should involve multi-site studies to validate effectiveness and broader applicability.