Professional Documents
Culture Documents
BeritaAnestesiologi Nov2021 Vol30
BeritaAnestesiologi Nov2021 Vol30
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PAGE 2 Anestesiologi • Malaysian Society of Anaesthesiologists
• College of Anaesthesiologists, AMM
Message from the Editor-in-Chief Editors
Dr Shahridan Mohd Fathil (Editor-in-Chief)
Welcome to the November 2021 issue of the Berita Anestesiologi, the Dr Gunalan Palari
sixth issue of the “makeover” newsletter. The Editorial Board has Dr Anand Kamalanathan
received many contributions from budding authors of our fraternity. We Dr Haslan Ghazali
Dr Shairil Rahayu Ruslan
have also witnessed talents, obvious and hidden, during the recent and
Dr Sivaraj Chandran
previous National Anaesthesia Day celebrations. The creative streak is
alive and well!
As evident by this issue, our graphic editor, Dr Haslan Ghazali, has given Contents
the newsletter a facelift. Apart from the usual article contribution, I would Message from the President of the MSA 2-3
like to encourage members to also contribute anaesthesia photos which
A COVID Diary of Hospital Sungai Buloh 4-7
we can include in the coming issues. Berita Anestesiologi is our platform
to be heard (and seen). ECMO in COVID-19 Patients, A Road Less 9 - 11
Taken: The IJN Experience
Live long and prosper! Transformation of HPKK to a COVID-19 Hospital: 13 - 16
More Than Meets The Eye
Future Activities Planned for 2022 Virtual Basic Critical Care Management Course 47 - 48
1. We will continue the monthly CME webinars in collaboration with the for non-ICU Doctors (VBCCM) 2021
College of Anaesthesiologists. Among the topics that we plan to
Neuroanaesthesia Symposium (NAS) 2021 49
cover in the near future are medico-legal issues in Anaesthesia and
Critical Care, Updates in Daycare Anaesthesia, and Advanced The MY sigRA YouTube Channel 51 - 52
Haemodynamic Management in Anaesthesia and Critical Care.
Ultrasound Guided Vascular Access: Where are 53 - 54
we Right Now?
2. MSA and CoA Annual Scientific Congress 2022 - Shangri-La, Kuala
Lumpur, 4th to 7th August 2022. The Organising Committee is MCAI/FCAI - The Road Not Taken… 55
planning for a hybrid of physical and virtual congress.
The Junior Doctor Conundrum…. 57 - 59
I would like to encourage all members of the Society to send us Fascial Plane Blocks for Cardiothoracic Surgery 61 - 63
suggestions and ideas to consider for our future activities.
Anaesthesiologists Create 65
Please feel free to write to [email protected]. I will be Just for Laughs.. 66
leading a Society that is responsive to direct input from its members. Till
we meet again in another issue, I wish all of you to stay safe and healthy. Message from the President of the 67 - 68
College of Anaesthesiologists, AMM
BERITA
Just a week before Chinese Lunar New Year 2020, I still be West Wing ICU (24), East Wing ICU (18), CCU (7), Burn
vividly remembered Dr Lee See Pheng voicing his concerns Unit (10), and the repurposed areas in General Recovery
about how the next pandemic would hit us soon. I was OT (18), Daycare Recovery OT (14) and Medical HDU (10).
completing my second year intensive care training, totally
ignorant about the magnitude of a pandemic. It seemed It took me a while to learn the process of donning and
like an astonishing feat how the Chinese government doffing. The first few days of managing patients were
could build and complete a hospital in merely ten days immensely stressful due to the fear of the unknown, fear
when Wuhan was plagued by an unknown virus of contracting the disease and worse of all, the fear of
spreading at an alarming pace. spreading the disease to our loved ones. We took longer
than usual to intubate and sort out the patient's
On a fateful Monday, March the 13th, to be exact, I intravenous and intra-arterial lines. Our vision was often
received a call from the head of intensive care to report to impaired by the evaporation of sweat on our visors. After
Hospital Sungai Buloh because of the escalating number attending to a patient, we were often drenched in sweat,
of critically ill COVID patients. I was excited yet anxious more so after resuscitating an unstable patient. This
about the role, not only as a frontliner but also as a junior resulted in shower after shower at any hour of every day.
intensivist about to manage COVID in the epicentre of The physical exhaustion on top of the mental strain
Klang Valley. I only had a couple of days to get updated started to take a toll on each one of us.
on the latest literature on this novel coronavirus. Then, it
was believed that only supportive treatment was Regarding management, we complied with lung
necessary, just like any viral pneumonia-causing Acute protective strategies, prone ventilation and restrictive
Respiratory Distress Syndrome (ARDS). fluid strategy as we have been trained to do. Patients
were treated with a combination of Lopinavir-ritonavir,
March the 23rd, 2020, I hydroxychloroquine, and interferon. None are used in
reported to my final year current practise as the evidence is equivocal at best. We
placement, Hospital Sungai also started them on low dose methylprednisolone for
Buloh. The Intensive Care Units those with 'hot' ARDS. Intubated COVID patients were
were already accommodating more difficult to manage and took much longer to wean.
approximately 20 critically ill Extubating patients while they still had high inflammatory
COVID patients. Non-COVID marker levels was not a wise move, i.e. CRP >70mg/L.
patients had been decanted to
other Klang Valley hospitals. The first surge of patients was mainly from the religious
Existing services such as event cluster, where most came with delayed presentation
elective surgeries had been and severe ARDS and acute kidney injury. Some stayed for
scaled down, and surgical over a month in ICU. Hence dealing with COVID was
teams were being deployed to indeed a monumental task. Thankfully, I have a
other hospitals in preparation to turn Hospital Sungai formidable team comprising intensivists,
Buloh into a COVID hospital entirely. Our Head of anaesthesiologists, medical officers, nurses, medical
Intensive Care Subspecialty Programme came to help assistants and support staff. We also had the unwavering
manage this new disease with the existing team and support of our fraternity, who sent intensivists,
prepared us for the worst. A plan was in place. anaesthesiologists and medical officers on rotation from
both KKM and private institutions to fight the first surge.
The surge capacity intended for this hospital was a 100 The maximum number of patients we had in ICU was
bedded ICU, an almost impossible task, a mind-blowing approximately 35 patients at any given time. We had 131
number, as this hospital had been designed to house only admissions from March to June 2020 with 13 deaths, with
42 ICU patients at the most. The breakdown of this would a low mortality rate of 9.9%.
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PAGE 4 Anestesiologi • Malaysian Society of Anaesthesiologists
• College of Anaesthesiologists, AMM
Every life saved was an achievement, and every life lost The conundrum of steroid use dates back to many
was discussed in a multidisciplinary meeting to see what decades ago for clinicians in various clinical scenarios. We
could have been improved, turning every patient into a practised using higher doses of steroids for patients after
lesson learnt for better or worse. We were a proud and the hyperinflammatory phase, typically at day 10 to 12
contented group of frontliners, or as we called ourselves when their CRP was low, but they remained poorly
'the last defence', honoured by the opportunity to serve oxygenated. Pulsed steroids up to a total dosage of 5
the country while receiving widespread recognition. grams of methylprednisolone were given to patients with
CT evidence of secondary organising pneumonia, or
Little did we know, the battle against COVID was not a worsening CXR infiltrates (not attributed by new bouts of
SPRINT; it was and still is a MARATHON. sepsis/pneumonia). The landmark RECOVERY trial
concluded that intravenous dexamethasone 6mg OD
We had ZERO admissions from July to September 2020 reduces mortality in COVID patients requiring
and gradually resumed our non-COVID duties. Life was oxygenation. The Malaysian Society of Intensive Care
slowly getting back to normal; the light at the end of the produced a guideline for steroid therapy recommending
tunnel was shining brightly. Life was good. intravenous dexamethasone 20mg OD. As we practised
evidence-based steroid therapy, some patients improved
The second wave hit us like a freight train. With sinking while there was still a proportion of patients who
hearts, we watched the crowd turned up in droves to vote required higher doses and prolonged steroids. This was
during the Sabah elections; SOPs were flouted, caution done with the knowledge that steroids suppress the
was thrown out of the window. Our happiness was immune system and could predispose to sepsis and sepsis
short-lived. As we quickly got back to the groove and kills. Hence, I believe that one size does not fit all. I think
decanted non-COVID cases, our team was hit by the the practice of individualized steroid use is the way to go.
departure of our chief intensivist. This was also when we
had a few healthcare workers contracting COVID, likely
from the workplace due to possibly ill-fitting n95s. When
any one of us contracted COVID or were close contacts,
the number of workers being quarantined was large
enough to interfere or even paralyze our workforce.
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PAGE 6 Anestesiologi • Malaysian Society of Anaesthesiologists
• College of Anaesthesiologists, AMM
Then came a TSUNAMI of the pregnant. One or two At the Department of Anaesthesiology and Intensive Care
critically ill pregnant patients is enough to wear one out, Hospital Sungai Buloh, we have managed COVID patients
let alone 25 pregnant patients that we had in the ICUs at solely for the past 19 months. We have lost the memory
any given time. We had approximately 166 admissions of of the smell of Sevoflurane, the feel of the epidural 'give'
COVID maternity cases from June to August. Dealing with and the simple joys an anaesthesiologist feels in an
two lives is never easy in severe COVID. We began proning operation theatre. We fear we are losing touch with
them, which was perceived as a relative contraindication non-COVID management both in the ICU and in the
for patients in the second trimester. As some patients operation theatre.
continued to deteriorate despite multiple prone, what do
you do next? The dilemma to continue or terminate a We are certainly proud of all our accomplishments over
pregnancy during mid-trimester in deteriorating these many months, but we are only human. There will
pneumonia is one that we constantly face. Premature always be a breaking point, and in our case, many. Never
neonates as tiny as 28 weeks would have a fighting would I have envisaged 2020/2021 to be so devastatingly
chance to make it if delivered, all thanks to the ruined by a 0.1-micrometre particle. Our life plans have
exceptional neonatal service. Kudos to the ever-supportive been put to a standstill with the economy ruined and
obstetricians, and we managed to save most of the humans being socially apart. We are a weary bunch of
mothers with eight deaths (mortality rate 4.8%). souls tired of donning, proning and moaning.
Simultaneously, we had a Multi-Resistant Organism Thankfully, the numbers of severe COVID are decreasing
(MRO) infection outbreak with this incredible surge of because of the rampant vaccination programme. Most
patients. Although avoidable, it was not unexpected, as hospitals are seeing a dramatic reduction in cases, but we
we have untrained nurses taking care of patients in a ratio are still operating at more than twice our capacity. None
of 1:2 and overcrowded repurposed ICUs. Swift action can predict when the following Variant of Concern will
was taken, and infection control measures were come, but I believe and hope all of us in the fraternity will
reinforced. However, despite our collective efforts, we come together as ONE to fend off the next wave of
still lost a high percentage of patients to these ruthless, COVID!
unseen enemies.
BERITA
With the emergence of COVID-19, the world has changed out of the body through a very large tube, called a
overnight. Worldwide, we are faced with a both deadly cannula. The oxygenator works like the lungs, taking
and easily transmissible disease. Worse is, we are seeing carbon dioxide out of the blood and adding oxygen to the
how the disease has evolved, where novel variants behave blood. The oxygen-rich blood is pushed through a heater
differently. At the beginning of the pandemic, our to warm the blood to body temperature before it is
number of cases and mortality rates were manageable. pumped back into the body through a return cannula.
Contrarily, the situation has changed. Our health care
system has been hit badly since the beginning of 2021 as There are two types of ECMO for different purposes.
we started having thousands of cases per day with a Venoarterial (VA) ECMO is meant for cardiorespiratory
death toll of more than 200 daily. Despite taking support in patients requiring heart and lung support;
appropriate measures to prevent its transmission and while venovenous (VV) ECMO is purely for respiratory
having more than 50% of the population fully vaccinated; failure. 92% of the total COVID-19 ECMO on the
death from severe COVID-19 infection seems inevitable, Extracorporeal Life Support Organization (ELSO) registry
not only among the older people but also among the were on VV ECMO. How does this VV ECMO work? With
young ones. VV ECMO, deoxygenated blood is drained from the
patient’s venous system (the drainage cannula is located
For critical care physicians, managing Category 4 and 5 in the inferior vena cava), passed through an external
COVID-19 patients with Acute Respiratory Distress membrane gas exchanger (the oxygenator), and returned
Syndrome (ARDS) would require significant effort. to the patient via the right atrium as oxygenated blood
Mechanical ventilation has traditionally been used in through a return cannula. This oxygenated blood mixes
ARDS. In difficult cases, high pressure ventilation is with the patient’s systemic venous return and passes to
required to improve oxygenation. This may lead to the pulmonary circulation which later is distributed to the
ventilator induced lung injury, causing more harm than whole body via the left ventricle and aorta.
good. In combination with the disease progression of
COVID-19 pneumonia, the injury may lead to permanent At the beginning of its use in ARDS caused by COVID-19,
lung damage and futility of treatment. positive results were not many and the survival rates were
low. In fact, a study in China has proven that ECMO
worsened COVID-19 patients when they found that the
amount of Interleukin-6 levels in 5 out of 6 patients were
persistently high while on ECMO and had caused fatal
outcomes. However, early data from the ELSO registry has
shown that ECMO may be an appropriate strategy for
severe ARDS in carefully selected patients with COVID-19
as they found 42% of the total number of patients who
were on ECMO eventually was able to be discharged
home. Their key opinion is to carefully select the patients.
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PAGE 10 Anestesiologi • Malaysian Society of Anaesthesiologists
• College of Anaesthesiologists, AMM
optimizing number three, we acknowledged the Struggling with high ventilator parameters, we finally
suboptimal position of both cannulas as the cause of this. managed to send him for HRCT of the thorax, to aid us in
In this scenario, the drainage cannula was withdrawn prognosticating his condition. The findings were dreadful,
slightly. We also advanced the return cannula deeper to with bilateral lungs involvement, ground-glass opacities,
achieve more optimum placement so blood flow was signs of organising pneumonia and likely fibrosis, as well
directed towards the tricuspid valve. We have already as a small rim of pneumothorax on both sides. By then,
used the longest return cannula available and placed it at his ventilator settings were rather high to be able to
the maximum allowable level by the manufacturing maintain decent oxygenation. The night he deteriorated, I
instructions. By repositioning the cannulas, recirculation was the anaesthetist-on-call. Initially, he was having high
of the ECMO circuit was significantly reduced. airway pressures between 45-51cmH20; it must have
been the pneumothorax that had gotten worse.
In the first week of ECMO, we managed to only see a Consequently, chest drains were inserted in an attempt to
slight improvement in terms of oxygenation, CXR images expand the remaining lung parenchyma, yet, the lung
and inflammatory markers. However, we were faced with compliance remained poor. We placed him in the prone
bleeding complications secondary to the anticoagulation. position, hoping to improve the distribution of perfusion
He not only developed bleeding from the cannulation and ventilation; but it only lasted for an hour as he
sites, but also the oral cavities and invasive line puncture became more unstable. The oxygenation continued to
sites. We had to reduce the target ACT, and thus revise the worsen. I witnessed him deteriorating in front of my eyes
heparin dose to lessen this problem. He also developed after all measures taken failed. Cardiopulmonary
right lower limb swelling which was probably caused by resuscitation (CPR) was commenced after he went into
an obstruction to the local venous drainage of that limb. asystole, and we managed to get return of spontaneous
A bedside ultrasound excluded deep vein thrombosis. circulation after two cycles of CPR. However, things
However, we were concerned and tried our very best to continued to deteriorate and we discussed with the family
wean him off of ECMO. With the help of the visiting regarding consent for a Do-Not-Resuscitate order. He lost
Infectious Disease physician, we managed his antibiotics the battle that night. Again, we lost another young
as well as steroids therapy appropriately. Despite that, he patient to COVID-19.
developed a superimposed infection with the
multi-resistant organism Acinetobacter Baumannii. Again, When will this pandemic end? When can we return to
the antibiotic course was changed, but this time ‘normal’ life? What is the ‘normal’ life? Some say, this is
specifically targeting this organism. Now, we could only our new norm. ECMO has thus far been proven to be
pray that recovery belonged to him. Despite these beneficial in COVID-19 patients. It takes a committed
challenges, the goal was to wean him off ECMO at the team to manage the patients on ECMO. All the steps are
earliest opportunity. The question was, was he ready to be extremely important; from the decision on who should be
liberated? on ECMO, to the management, till the liberation from
ECMO. Instituting ECMO should be for everyone’s benefit;
A simple test to assess his readiness was to turn off the from the patient, the institution and the nation, despite
fresh gas flow (sweep gas) on the oxygenator. This meant the many challenges we face, not to mention limited
that all the gas exchange would have to be done by his resources. Yes, this is not an easy battle to fight entirely.
native lungs. The first day doing that, he could sustain To all the frontliners out there, you are the unsung heroes
with good parameters for five hours before getting of this nation. Those ill patients require our great care. We
exhausted. Before attempting the test again, we added have made it this far. Giving up is not in our vocabulary,
nitrous oxide to improve the existing ventilation-perfusion my comrades! The light will eventually shine at the end of
mismatch. The second time, he did better with more than the tunnel, and we shall all dance our way out of the
eight hours without sweep gas running on ECMO. darkness.
Satisfactory lung complianced, which was estimated from
good tidal volume and normal airway pressure on the
ventilator was observed. Everything seemed alright. The
team was ready to decannulate the ECMO circuit from the
patient. After liberation from ECMO, given dissatisfying
and persistent left lung changes on the CXR,
bronchoscopy was performed in the patient. To our
surprise, not much secretions were present. Generally, it
was only hyperemic bronchial mucosa with patches of
what looked like petechiae on the mucosa.
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PAGE 14 Anestesiologi • Malaysian Society of Anaesthesiologists
• College of Anaesthesiologists, AMM
have to come to that. Referrals to other teams were drugs for us. The physiotherapists were also excellent in
mostly to Hospital Canselor Tuanku Muhriz (HCTM) of their work as they came daily and even on weekends to
which logistics were a major challenge. help rehabilitate our patients. The ICU medical assistants
always ensured the PAPRs and other equipment were
By 8th July, nearing the height of the COVID-19 pandemic, thoroughly cleaned, checked and available when we
the Greater Klang Valley Special Task Force (GKVSTF) was needed them. These were just some examples of the many
set up and given the mandate by our Prime Minister commendable and outstanding work the team in HPKK
through the Health Minister to bolster the health care did for us.
system which was already at the brink of collapse. It was
spearheaded by the Deputy Health Director-General, Dr Majority of the staff (nurses and medical assistants)
Chong Chee Keong and included personnel from the deployed were young and inexperienced in the Covid
Armed Forces. Its purpose was to make swift decisions at battlefield, many of them were fresh out of college or
ground level to alleviate stress on the Klang Valley from the PKD. Compounding to that, the bulk of deployed
hospitals. This included the procurement of equipment Medical Officers were also just out of housemanship and
and mobilization of resources such as manpower, oxygen were still wet behind their ears. They were thrown into
supply, and intensive care (ICU) beds. With the help of this the deep end by having to work in the ICU, it was either
task force, the emergency team from KKM came into the sink or swim for them. However, what they lacked in
picture, they opened more beds in the lobby and experience and skill, they made up for in enthusiasm and
Emergency Department of HPKK which functioned like a teachability. We were amazed at how they showed
mini MAEPs to either assist in decongesting overcrowded tremendous resilience, courage, strength, and eagerness
Emergency Departments all over the Klang Valley that had to learn. Despite some being unable to handle the stress
many stranded COVID-19 patients needing urgent and long working hours in suffocating PPEs and
treatment especially from Hospital Tengku Ampuan subsequently had to be transferred to less
Rahimah, Klang or to take in step down patients from our labour-intensive work in the wards, most of them
critical care beds upstairs. Some of the patients brought managed to overcome the steep learning curves and high
over from the Emergency Departments who had intensity work required of them in a short period of time.
deteriorated were subsequently brought upstairs to our In the initial stages of HPKK operations, we had the help
critical care beds for escalation of treatment. Indirectly, of a small handful of postgraduate students to lead and
we were helping to reduce the burden of ICU referrals to guide the junior MOs but they eventually went back to
these other hospitals. their respective hospitals. The high staff turnover was also
a frustrating problem. Staff that we painstakingly trained
Besides managing COVID ICU patients, our team also over a period of a few weeks to a month were being
organised weekly CME and teaching sessions for the pulled back to their respective hospitals and replaced with
medical officers and housemen. Bedside hands-on new inexperienced staff and we had to start from square
teaching was also conducted frequently. We even had one.
weekly radio-clinical conferences and MDT discussions
with consultants from HCTM, IPR and HKL on a regular As in any war, there were casualties but there were also
basis. It was a great challenge daily to keep the ICU many lives that we were able to snatch from the clutches
running and staying afloat as we always had recurring of death. We had the privilege to care for parents of our
issues of manpower, equipment, medications, and staff who were stricken with COVID too. By the grace of
consumables shortage. However, working with a smaller God, many were successfully discharged and went home.
and younger team meant it was easier and faster to Throughout, we were able to see many being reunited
execute plans because there was less interference from with their loved ones. It was a thankless job, but this was
politics and without little napoleons running the show. the greatest satisfaction and everlasting reward that we
All of us were on the same page from the beginning. as healthcare workers could ever ask for.
We worked hand-in-hand with the pharmacists,
physiotherapists, dieticians, lab pathologists, radiologists, Despite what seemed to be a despairing situation, we
mortuary staff and others. Everyone’s input and were blessed to receive some help along the way. Dr
contribution were greatly appreciated. In fact, we were Foong Kit Weng (Intensivist from Hospital Raja Permaisuri
very touched that the pharmacists went the extra mile by Bainun, Ipoh) came to HPKK about three weeks after its
driving up to hospitals in other states to procure or barter opening. Albeit he was around for a short period of 10
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PAGE 16 Anestesiologi • Malaysian Society of Anaesthesiologists
• College of Anaesthesiologists, AMM
A Day in the Life…in a COVID ICU
by Dr Ivy Sim Chui Geok
Universiti Teknologi MARA
A doctor hurries into the hospital from the wide expanse in fluid-repellant material with only pairs of eyes peering
of the Hospital Sungai Buloh staff carpark, feeling out from behind plastic face shields. We look like the
triumphant at finding parking close enough to the lifts to PPE-teletubbies and it is amazing how we can even tell
ensure minimal walking required and thinks hopefully… each other apart.
please do not let there be an intubation today.
The doctors cross the threshold with a welcoming gush of
After reaching the hallowed 3 floor where the ICUs are
rd
air from the negative pressure anteroom with their
housed and were recently proliferating, doctors squint at phones safely in their clutches holding important
the wall with a sea of yellow cards until they find the information on jobs for the day.
correct one with their name on it and punch-in with an
old-style clock-in device, thanking the powers that be We approach our first
that they made it before the stroke of 08:00. patient, one who is
playing a game of
At the infamous ‘Oncall Complex’, the daily bustle begins tug-of-war with the
with the jostling for scrubs and after hunting high and ventilator. A minor
low, and sometimes sneakily pilfering from the nurses’ adjustment later, he
pile…we rejoice in an attire which is neither the correct breathes comfortably
size, a flattering colour (bright orange), or of matching and settles into the
tops and bottoms. cross legged stance
that everybody knows
We patiently wait for everyone to assemble for handover, is the soft clinical sign
some stragglers smiling sheepishly as they slide into a indicating ‘ready to be
chair conspicuously. Listening to the drone of the extubated’.
patient’s age, co-mobidities, day of illness, some proceed
to fall sleep till jolted awake by…”man…look at that chest The next patient is one who is intubated and in the prone
X-ray” as if it were the scene of a gruesome car crash or position. A doctor tries to imagine if it would be
feel a chill down the spine when someone comfortable in that position and ponder if he could sleep
announces…”blood cultures are growing gram negative in this position for 16 hours. We make sure that every
rods”. Then, as the doze continues through body part is not overstretched, padded and out-of-harm
admission-transfer out, intubation-extubation and the way and at the same time mentally calculate the number
manoeuvre prone-supine, we are vaguely reminded of our of staff that will be required to turn the patient to the
favourite roti canai being tossed back and forth and start upright position, before moving on.
to wonder…”when can we get to breakfast!”
There is a flurry of activity at another end of the ICU where
Run through the daily checklist - personal items stored a proning is imminent. The patient has every pressure
away, mobile phones wrapped up tightly, tummies full point imaginable covered in pressure dressings by a group
and bladders empty, one by one we head to the respective of nurses, with a few more for good measure. When the
ICUs, passing by others slowly munching on breakfast in patient is deemed suitably ‘padded’, a nurse hurries along
the corridors and grinning toothily back (a rare sighting of and ‘lassoes’ one of the doctors from the ward round
a smile without a face mask). herd to co-ordinate the manoeuvre. As the team
assembles around the patient, someone realises… “oops,
Lets go to the ICU! the patient is at least 150kg”. Nurses are, in general, lean
and mean, and this particular patient will require a few
At the threshold, we carefully put on an N95 mask and more bodies to shift. A few more doctors and nurses
then don the rest of the ‘costume’ of full PPE. Indeed the arrive. Another voice says, “oh wait don’t forget to lift the
end result is a sight to behold, covered from head to toe urine bag” and yet another “for goodness sake be careful
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PAGE 18 Anestesiologi • Malaysian Society of Anaesthesiologists
• College of Anaesthesiologists, AMM
History of Anaesthesiology in Malaysia
17th World Congress of Anaesthesiologists - Global Anaesthesia Village, 2021
by Dato’ Dr Yong Chow Yen1 & Professor Dato’ Dr Patrick S K Tan2
1
Hospital Pulau Pinang
2
University Malaya Medical Centre
TWO ANAESTHETICS. MALACCA AND PENANG, The present case being perhaps the first serious operation
1847 performed in the Straits in connection with the inhalation
Today, real-time demonstrations of anaesthesia can be of ether. The man, a Malays, a lascar on board the Topay
witnessed or viewed anywhere within the radius of Sri Melaka, had his right hand blown away from a gun on
information technology, just like our participation in WCA the morning of the 28th instant. The bones of the forearm
2021 from the comfort of our home countries. In the era being also extensively fractured, and the parts otherwise
of COVID-19 pandemic, information technology is injured, circumstances which call for an amputation
emerging as the most powerful educational tool available below the elbow. He was at first put under the influence
to ensure continuing progress and learning in of ether by inhaling the vapour from a simple Mudges
anaesthesiology and critical care medicine. inhaler attached to the hospital (containing small pieces
of sponge saturated with the ether), common care only
However, 175 years ago, at the time of the first being taken by compressing the nostrils during the act of
demonstration of ether anaesthesia by William T G inspiration and making the mouthpiece pass through a
Morton for surgery by John Collins Warren in the piece of sponge to secure its full inhalation into the lungs.
Massachusetts General Hospital on 16th October 1846, the This was effected in about four minutes when his eyes
news and medical scientific reports of this event reached being closed, his head sank upon his chest in an apparent
London only one or two months later and Malaysia five state of insensibility; the operation was now immediately
months later. Dr Francis Boott, an American physician and commenced by the flap operation. The man at the
botanist who practised medicine in London, wrote to moment of transfixation by the knife merely exclaimed
Lancet in 1846 to inform his colleagues about ether “what are you doing to me?” when he relapsed into his
anaesthesia when he heard it from his friend John comatose state and though he moaned twice remained in
Bigelow, thus ensuring the medical scientific community this state of insensibility and unconsciousness during the
throughout Britain, Europe and the countries linked to operation, and after the steps of tying the arteries,
the British colonial administration received the news. securing the flaps by sutures and removal to bed. And in
this quiet somnolent state I left him, breathing naturally
British newspapers of January 1847, carrying news of the with a quiet natural pulse of 80. When seen three hours
first anaesthetics in England on 19th and 21st December afterwards and questioned relative to the operation, he
1846, were transported on the P&O steamship Hindostan, stated that he was aware of my intention to remove his
which departed Suez 15th February 1847 and reached arm, but of the operation itself, pain or of any of the
Galle Sri Lanka. These papers were transferred to the circumstances connected with it, he was perfectly
steamship Braganza which left Galle 4th March and unconscious. The haemorrhage, it may be remarked, was
reached Penang 12th March 1847. The Penang Gazette unusually trifling. The man is going on very favourably.”
and Straits Chronicle reported the London anaesthetics on
20th March 1847. This led to the first anaesthetic in Two months later, the Penang Gazette reported another
Malaysia by Dr Ratton in Melaka, previously known as anaesthetic and surgical success on 3rd July 1847:
Malacca, on 28th April 1847 which was reported in the
Singapore Free Press on 30th April 1847. The account of The inhalation of the vapour of sulphuric ether combined
the first anaesthetic in Malaysia is transcribed below, from with atmospheric air was tried on Tuesday last by Mr
microfilm archives in the National Library Singapore. Smith, surgeon, in the presence of several other persons,
upon a patient from whom he removed a
“I have the pleasure to forward you the following brief fibro-cartilaginous tumour and proved completely
particulars of an operation I performed at this Station on successful in rendering the patient insensible to the pain
the 28th instant, the patient being previously placed under of the operation. The partly operated upon is a
the influence of sulphuric ether and thereby rendered respectable Chinese merchant of this place, about 30
perfectly insensible to pain or the steps of the operation. years of age, and of a spare habit of body. The tumour
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PAGE 20 Anestesiologi • Malaysian Society of Anaesthesiologists
• College of Anaesthesiologists, AMM
tracheal tubes were a great assistance to Sam Campbell pioneer Malaysian to pass the final FFARCS examination in
the surgeon. The following year closed circuit anaesthesia 1958. On his return, Dr Bhupalan served for a year in the
was added to the growing armamentarium. Malacca Hospital, taking over from Dr George Lomas,
before becoming the senior consultant anaesthetist in the
Dr Franklin Rajendram Bhupalan was born in Kuala Kuala Lumpur Hospital from 1959 until 1962. The Kuala
Lumpur on 18th October 1923, schooled at the Victoria Lumpur Hospital was a very busy hospital, performing
Institution and studied medicine at the King Edward VII 11,000 surgical operations a year in operating theatres
College of Medicine, graduating MBBS from the which, at that time, functioned without anaesthesia
University of Malaya in 1951. As a student he had rooms, recovery rooms and sufficient numbers of
completed a one-month anaesthesia clerkship, had anaesthetists. Dr Bhupalan was elected the first president
administered anaesthesia for short dental procedures of the Malaysian Anaesthetic Society (now the Malaysian
which had fostered his enthusiasm for anaesthesia Society of Anaesthesiologists) in 1964. Dr Bhupalan also
practice. After his house officer year in Penang, he was a served as an organising committee member of the Fourth
medical officer assigned to give anaesthetics in the Asian Australasian Congress of Anaesthesiologists in 1974
operating theatre for the general surgeon Mr Sam and was the President of the Second ASEAN Congress of
Campbell. Duties in the Penang Hospital kept Dr Bhupalan Anaesthesiologists in 1981.
busy and work was plentiful and challenging, frequently
necessitating anaesthetic innovation to handle As the first Malaysian anaesthetist, Dr Bhupalan firmly
hyperthyroid crises and mandibular osteomyelitis planted the roots of the specialty’s fraternity. To his
presenting with trismus. patients who had significant apprehensions about
anaesthesia and surgery, his soothing voice and gentle
Dr Nunn taught anaesthetics to "various medical officers hands were a priceless gift enabling each patient’s
assigned to me, of whom (Frank) Bhupalan was the best”. anxieties to be allayed, at the same time supporting the
Nunn taught Bhupalan to administer oxygen and surgeon with the anaesthetic skills and camaraderie that
cyclopropane with Nunn’s modification of the Bourne’s were crucial to meet the task that lay ahead. Uncle Bhupy
bag. Using the first textbooks by Minnitt and Gillies, and died on 26th May 2011, missed dearly by all who knew
J Alfred Lee and the British Journals which had just arrived him and were touched by his warmth, kindness and
in Malaya in 1952, Nunn and Bhupalan developed their supremely gentleman attributes.
expertise to use ether, chloroform, thiopentone,
papaveretum, hyoscine, suxamethonium, nitrous oxide, Another senior anaesthetist with experience in Penang in
ethyl chloride, rectal paraldehyde, bromethal, the early days was Dr Law Gim Teik. As a medical officer in
hexamethonium and spinal nupercaine to perform 1956, Law's first love was medicine. "I was more or less
abdominal, thoracic, maxillofacial, orthopaedic, and coerced to do anaesthesia" was his description of being
paediatric surgery and obstetrics. Predominant malignant brought into contact with the specialty. Dr Law served as
conditions requiring surgery were carcinoma of the cheek the senior anaesthetist in Kuala Lumpur Hospital from
caused by betel nut chewing, lymphoepithelioma of the 1963 until 1983.
pharynx and cancer of the oesophagus. It is to their great
credit that the standards of anaesthesia in Malaya were
the equal of standards achieved in England.
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PAGE 22 Anestesiologi • Malaysian Society of Anaesthesiologists
• College of Anaesthesiologists, AMM
for British training coupled with a philosophical nature ANAESTHESIOLOGY EDUCATION IN MALAYSIAN
and good technique, earned respect from surgeons and UNIVERSITIES AND MINISTRY OF HEALTH
he was appointed the country’s first professorial chair in MALAYSIA
Anaesthesiology from 1975 to 1979 before he emigrated Five public Universities and the Ministry of Health have
to Brisbane, Australia. been the prime source of growth in the numbers of
trained anaesthesiologists over 70 years.
In 1965, Professor Danaraj and Dr Ganendran appointed
Dr Alexius Ernald Delilkan and Dr Alex Isaac Gurubatham In the 1970s there were three public Universities with
as the first ASTS Academic Staff Training Scheme Lecturer medical faculties. Universiti Kebangsaan Malaysia
and Assistant Lecturer, respectively. In 1966, Dr M K Chin established the second academic department of
from Singapore and Dr Lim Say Wan from Kuala Lumpur anaesthesiology in 1972 with Professor Dato’ Haji Abdul
were the ASTS appointees. After passing the Primary Hamid bin Abdul Rahman as its founding Head. Dr C H Lee
examination in London, Dr Delilkan and Dr Gurubatham and Dr Ahmad bin Ismail were Ministry of Health
became registrars in St Thomas's Hospital London, Anaesthesiology Consultants who were appointed as
working with Drs Churchill-Davidson, Wylie, Nosworthy full-time lecturers. Dr Law Gim Teik, Dr Lim Say Wan, Dr
and J.G. Bourne, a visiting anaesthetist from Salisbury. On Jenagaratnam, Dr K Vigneswaran and Dr A Damodaran
passing the FFARCS, Dr Delilkan returned immediately to were visiting lecturers. Dr Rusli bin Arshad, Dr Tan Kok Hin,
the University Hospital. On 4th July 1967, Dr Ganendran Dr Peter Tan and Dr Indran Muthiah obtained their FFARCS
and Dr Delilkan administered the first anaesthetic at the and FFARCSI after training in UKM. In 1987, lecturer Dr
University Hospital Kuala Lumpur for a 30 year old male Karis Misiran obtained FFARACS and was appointed Head
patient undergoing electroconvulsive therapy. Dr Delilkan of Department. Dr Karis, Professor Delilkan, and Drs
was the second appointment to the chair of Mackay, Kester Brown and John Paul from Australia, were
anaesthesiology in 1979 and served as head of the examiners in the first Master of Anaesthesiology UKM
department from 1979 to 2000. examination in 1987. Dr Norsidah Abdul Manap, Dr
Adnan bin Dan, Dr Goh Chin Woo, Dr Chen Tuck Pew, Dr
In 1975 the department consisted of two Associate Felicia Lim, Dr Wan Mohd Akbar bin Wan Moss and Dr
Professors Dr Ganendran, Dr Delilkan and four lecturers, Arbayah binti Rais were the first among distinguished
Dr Peter Kam Chin Aik, Dr Robert Liew Pak Chin, Dr Gracie graduates in the Master of Anaesthesiology (UKM).
Ong Siok Yan and Dr Tan Poh Hwa. This was a youthful
and talented team which sounded the clarion for University of Malaya commenced its Master of
anaesthesiology research and learning in the country. In Anaesthesiology programme in 1987. Lecturers were
the faculty report of 1975, "The Department of Professor Delilkan, Associate Professor Gracie Ong Siok
Anaesthesiology has been engaged in various projects to Yan, Associate Professor Ramani Vijayan, Dr Lucy Chan, Dr
investigate the usefulness of new drugs introduced in Wang Chew Yin, Dr Chan Yoo Kuen, and Associate
anaesthesia, with particular reference to the cost of these Professor Patrick Tan Seow Koon. In 1991, Dr Aminah Ali,
drugs. Modification of established anaesthetic techniques Dr Mary Cardosa, Dr Hussain H Ahmad, Dr Lilian Oh, and
in ophthalmology and in electroconvulsive therapy, using Dr Tan Cheng Cheng were the first among illustrious
scientific methods of evaluation had been of interest to graduates from Master of Anaesthesiology (Malaya). In
several of the staff. Research into poisoning by addition, Dr Loh Seck Poh, Dr Tan It and Dr Yong Boon Hun
anticholinesterases has been in progress for the last three were trainee lecturers who completed the FANZCA.
years and the results had been published as a thesis for a
doctorate in medicine. Research in progress included Universiti Sains Malaysia in Kubang Kerian began its
studying oxygen transport and its availability to tissues Master of Anaesthesiology programme in 1995 with
by stored blood as well as by blood in patients exposed lecturers Dr Kamaruddin Jaalam, Dr Nik Abdullah, Dr
by artificial ventilation to prolonged and varying Sanjay Sharma, Dr Zulkarnain and Dr Wan Aasim. In 1999,
concentrations of inspired oxygen. The stress response of Dr Usha Nair, Dr Shamsul, Dr Saedah Ali and Dr Ruwaida
patients and prolonged artificial ventilation also being Isa were the first Master of Anaesthesiology (USM)
studied to evaluate its possible metabolic consequences. graduates.
The value of prolonged artificial ventilation in neonatal
tetanus has been investigated and established as a means Universiti Putra Malaysia Anaesthesiology Unit (1999)
of reduction of mortality in that disease." commenced the Master of Anaesthesiology in 2013 with
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REFERENCES
1. Watson G. The first anaesthetics in the Straits Settlements. 4. History of Anaesthesia in Malaysia. Gurubatham A I,
Chapter 7 in: Atkinson R S, Boulton T B. The History of Damodaran A. Malaysian Society of Anaesthesiologists,
Anaesthesia. 1989. Royal Society of Medicine. ISBN College of Anaesthesiologists, Academy of Medicine
0850702632; 9781850702764. Page 143 Malaysia. 2013
2. Ratton A J. The first serious operation performed in the 5. Annual Report 2020-2021. College of Anaesthesiologists. 8
Straits in connection with the inhalation of ether. Singapore August 2021
Free Press. 1847. 30 April. National Library, Singapore
(microfilm archive) 6. Lim TA. Correspondence
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PAGE 24 Anestesiologi • Malaysian Society of Anaesthesiologists
• College of Anaesthesiologists, AMM
The Cold Truth About Hypothermic Therapy Post-Cardiac Arrest
by Dr Cheah Kean Seng
Tallaght University Hospital, Dublin
Long ago, we have been taught that patients who have 1.04; 95% confidence interval [CI], 0.94 to 1.14; P=0.37).
sustained an out-of-hospital cardiac arrest should be Even among the survivors (1747 patients) in whom the
placed under hypothermic therapy in the hospital for a functional outcome was assessed, 488 of 881 (55%) in
better outcome. This eventually became the backbone of the hypothermia group had a moderately severe disability
post-cardiac arrest care for years in practice. In fact, every or worse (modified Rankin scale score ≥4), as compared
hospital has its own protocol on post-cardiac arrest care with 479 of 866 (55%) in the normothermia group
and hypothermia post-arrest has been widely practised (relative risk with hypothermia, 1.00; 95% CI, 0.92 to
worldwide despite the lack of convincing evidence. 1.09). They did not seem to have better neurological
function than the control group. Patients in the
There were some hypothermic trials done 20 years ago hypothermic group were more likely to develop
but these ended with inconclusive results due to being arrhythmias resulting in haemodynamic compromise
unblinded studies and only small sample sizes involved.1,2 (24% vs. 17%, P<0.001). The incidence of other
The first TTM trial carried out in 2013 (comparing the complications such as the risk of sepsis, skin breakage,
outcome between hypothermia 33°C and normothermia pneumonia or clotting abnormalities did not increase
36°C therapy in patient post-cardiac arrest) showed that with hypothermia.
patients who were given cooling did not perform any
better than the control group in general, be it overall TTM2 is a better study as it involved a larger sample size
mortality or neurological status after survival.3 The first (nearly double the first study), and instead of actively
TTM trial started off with much enthusiasm and curiosity subjecting all patients to normothermia (36°C) like TTM1,
about whether will this consolidate and justify the only patients with a temperature higher than 37.8°C will
principle that cooling is actually beneficial to post-cardiac receive the cooling intervention (surface or intravascular
arrest patients. Unfortunately, it did not show any cooling). It is also a trial with a better strength of the
benefits statistically. study as the sample number was close to the sample size
needed (1900) to achieve 90% power of the study and a
Thus, TTM2 trial was conducted to look into whether p-value of 0.05. The patients also share similar
cooling provides any benefits statistically. This is a characteristics before randomisation to reduce bias. So,
multinational, multicentre randomised trial.4 After initial this is a promising start to a good trial. In order to answer
screening, a total of 1850 comatose post-arrest patients the question left over from the first TTM trial, patients are
presumed from cardiac causes was randomised to receive also being followed up for a longer period of time than
either hypothermic (33°C) or targeted normothermic the first (6 months and 24 months vs 3 months) to
(37.5°C) treatment in the hospital. Patients are also being determine if, by cooling, patients have any long-term
followed up to assess if any change in long term outcome benefit or harm. Although more than half (55%) of the
on (6 months and 24 months). Overall mortality was patients were excluded from randomisation after the
decided as the primary outcome, whereas the secondary screening process, mainly due to delayed presentation
outcome on the impact of hypothermia on the after the successful return of circulation, only a small
neurological function of survivors was assessed by number was due to unknown reasons.
Modified Rankin scale and EuroQo1 visual analogue scale
(EQVAS) assessment tools. Recent results released after 6 There is little doubt that other factors that were missing
months of follow-up shows there was no difference in could be the confounders in this trial. For example, the
all-cause mortality between the two groups. At 6 months, trial did not give us information regarding the duration of
465 of 925 patients (50%) in the hypothermia group had hypothermic patients on a ventilator in comparison with
died, as compared with 446 of 925 (48%) in the the one from the control group, because subjecting a
normothermia group (relative risk with hypothermia, patient to a body temperature of 33°C means it will take
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REFERENCES
1. Bernard SA, Gray TW, Buist MD et al.. N Engl J Med. 2002 4. Dankiewicz J, Cronberg T, Lilja G et al. Am Heart J. 2019
Feb 21;346(8):557-63. doi: 10.1056/NEJMoa003289. PMID: Nov;217:23-31. doi: 10.1016/j.ahj.2019.06.012. Epub 2019
11856794 Jun 26. PMID: 31473324
2. Holzer M, et al. “. New Engl J Med. 2002. 346(8):549-556 5. Na SJ, Chung CR, Cho YH et al.. Rev Esp Cardiol (Engl Ed).
2019 Jan;72(1):40-47. English, Spanish. doi: 10.1016/j.rec.
3. Nielsen N, Wetterslev J, Cronberg T et al.. N Engl J Med. 2018.01.003. Epub 2018 Feb 17. PMID: 29463462
2013 Dec 5;369(23):2197-206. doi: 10.1056/NEJMoa
1310519. Epub 2013 Nov 17. PMID: 24237006
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PAGE 26 Anestesiologi • Malaysian Society of Anaesthesiologists
• College of Anaesthesiologists, AMM
A Novel Way of Positioning for Intubation:
Bed-Up-Head-Elevated Using Bed Controls
by Dr Samuel Ern Hung Tsan
University of Malaysia, Sarawak
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PAGE 28 Anestesiologi • Malaysian Society of Anaesthesiologists
• College of Anaesthesiologists, AMM
Success of intubation Khandelwal et al conducted a retrospective cohort study
The BUHE position has been found to be associated with investigating complications associated with the BUHE
a higher rate of successful intubation. A well-designed position and SSP. The authors found that the BUHE
RCT conducted by Lee et al investigated the rate of position was associated with a lower risk of complications
successful intubation between the ramped and sniffing (any of difficult intubation, oesophageal intubation,
positions in surgical patients with expected difficult hypoxaemia, or pulmonary aspiration) (Adjusted OR 0.47,
intubation.11 In their study, the authors found that the 95% CI 0.26 - 0.83, p = 0.01).14
ramped position was significantly associated with a
higher rate of successful intubation (Ramped 63% vs Other benefits
Sniffing 42%, p < 0.05). Additionally, more patients in the Additional benefits of placing patients in the BUHE
ramped group were successfully intubated within the first position for intubation include the ease with which
two attempts compared to the sniffing group. patients’ positions can be adjusted. In the majority of OTs
in Malaysia, the OT table is equipped with electronic
Meanwhile in the critically ill population, the evidence of controls, allowing staff to manipulate the table position
BUHE position on intubation success at first attempt with the press of a button. This allows much easier
remains controversial. In a prospective observational positioning compared to physically lifting patients to
cohort study, Turner et al analysed 231 emergency place pillows or blankets below their torsos and heads.
intubations performed in the supine (head elevation 0 - Moreover, risks of cervical trauma or intravenous lines
10°), inclined (11 - 44°) and upright (≥ 45°) positions. disconnection is greatly minimized. In the event the
They found a higher first pass success rate in the upright patient has to be placed supine for any reason
group (85.6%) and inclined group (77.9%) compared to post-intubation, this can be easily done with bed controls,
the supine group (65.8%) (p = 0.024). Interestingly, the without the need to lift an anaesthetised patient up to
authors also demonstrated increased odds of first pass remove the pillows and blankets.
success for every 5° increase in angle of bed elevation
(Adjusted OR 1.11, 95% CI 1.01 - 1.22, p = 0.043).12 On POTENTIAL COMPLICATIONS
the other hand, Semler et al in their study on ICU patients From a physiological standpoint, there is a theoretical
found a lower rate of success at first intubation attempt complication associated with the BUHE position. Due to
in the ramping position (76.2%) compared to the sniffing venous pooling in the lower extremities and subsequent
position (85.4%) (p = 0.02).4 reduced venous return to the heart, cardiac output and
cerebral perfusion can be compromised during induction
Time required for intubation of anaesthesia. The potentially detrimental impact of a
Several studies have shown that the BUHE position does transient reduction in cardiac output, in the setting of
not prolong the time to intubation, but may in fact sympathetic stimulation from laryngoscopy and
shorten it. Tsan et al investigated the BUHE position and intubation, has yet to be proven from scientific data. To
showed that the time to intubation in BUHE direct date, no studies investigating BUHE position have
laryngoscopy patients (mean 36.23 seconds) was shorter reported any adverse events such as hypotension during
than the time to intubation for patients undergoing VL intubation in the ramping position. However, until more
(mean 44.33 seconds).2 In addition, a prospective cohort evidence is available, it is important to keep in mind the
study demonstrated that the 25° back-up position was possible dangers of hypotension and cerebral
associated with a shorter median time to intubation hypoperfusion when intubating patients in the BUHE
(median 24 seconds) when compared to the SSP (median position. In physiologically vulnerable patients, it is
28 seconds) (p = 0.031).13 Although the differences in important to immediately place the patient back supine
time required may not be clinically significant, it is an after induction of anaesthesia and treat hypotension
added benefit when performing intubations in this accordingly with vasopressor agents.
position, especially in patients undergoing rapid sequence
intubation or those with poor pulmonary reserves. APPLICATIONS IN OT AND ICU
In the OT population, endotracheal intubation in the
Complications during intubation BUHE position is associated with many advantages and
In patients requiring intubation in the ward and ICU, lack of proven disadvantages. Because of this, it is an ideal
there is data to suggest the BUHE position is associated time to reconsider whether the SSP should still be the
with a lower risk of peri-intubation complications. starting position for intubation. The development of the
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REFERENCES
1. Lee BJ, Kang JM, Kim DO. Laryngeal exposure during 9. Rahiman SN, Keane M. Ramped position: what the “neck”!
laryngoscopy is better in the 25 back-up position than in the Chest. 2018;153:567-8
supine position. British Journal of Anaesthesia.
2007;99:581-6 10. Couture EJ, Provencher S, Somma J, Lellouche F, Marceau S,
Bussières JS. Effect of position and positive pressure
2. Tsan SEH, Lim SM, Abidin MFZ, Ganesh S, Wang CY. ventilation on functional residual capacity in morbidly obese
Comparison of Macintosh laryngoscopy in patients: a randomized trial. Canadian Journal of
bed-up-head-elevated position with GlideScope Anesthesia. 2018;65:522-8
laryngoscopy: a randomized, controlled, noninferiority trial.
Anesthesia & Analgesia. 2020;131:210-9 11. Lee J-H, Jung H-C, Shim J-H, Lee C. Comparison of the rate of
successful endotracheal intubation between the" sniffing"
3. Tsan SEH, Ng KT, Lau J, Viknaswaran NL, Wang CY. A and" ramped" positions in patients with an expected difficult
comparison of ramping position and sniffing position intubation: a prospective randomized study. Korean Journal
during endotracheal intubation: a systematic review and of Anesthesiology. 2015;68:116
meta-analysis. Revista Brasileira de Anestesiologia.
2021;70:667-77 12. Turner JS, Ellender TJ, Okonkwo ER, Stepsis TM, Stevens AC,
Sembroski EG, Eddy CS, Perkins AJ, Cooper DD. Feasibility of
4. Semler MW, Janz DR, Russell DW, Casey JD, Lentz RJ, Zouk upright patient positioning and intubation success rates at
AN, Santanilla JI, Khan YA, Joffe AM, Stigler WS. A two academic emergency departments. American Journal of
multicenter, randomized trial of ramped position vs sniffing Emergency Medicine. 2017;35:986-92
position during endotracheal intubation of critically ill
adults. Chest. 2017;152:712-22 13. Reddy RM, Adke M, Patil P, Kosheleva I, Ridley S. Comparison
of glottic views and intubation times in the supine and 25
5. Boyce JR, Ness T, Castroman P, Gleysteen JJ. A preliminary degree back-up positions. BMC Anesthesiology 2016;16:113
study of the optimal anesthesia positioning for the morbidly
obese patient. Obesity Surgery. 2003;13:4-9 14. Khandelwal N, Khorsand S, Mitchell SH, Joffe AM.
Head-elevated patient positioning decreases complications
6. Altermatt FR, Munoz HR, Delfino AE, Cortinez LI. of emergent tracheal intubation in the ward and intensive
Pre-oxygenation in the obese patient: effects of position on care unit. Anesthesia & Analgesia. 2016;122:1101-7
tolerance to apnoea. British Journal of Anaesthesia.
2005;95:706-9 15. Greenland KB, Eley V, Edwards MJ, Allen P, Irwin MG. The
origins of the sniffing position and the three axes alignment
7. Dixon BJ, Dixon JB, Carden JR, Burn AJ, Schachter LM, theory for direct laryngoscopy. Anaesthesia and Intensive
Playfair JM, Laurie CP, O’brien PE. Preoxygenation is more Care. 2008;36:23-7
effective in the 25° head-up position than in the supine
position in severely obese patients: a randomized controlled 16. Adnet F, Borron SW, Lapostolle F, Lapandry C. The three axis
study. Anesthesiology. 2005;102:1110-5 alignment theory and the “sniffing position”: perpetuation
of an anatomic myth? Anesthesiology. 1999;91:1964
8. Lane S, Saunders D, Schofield A, Padmanabhan R, Hildreth
A, Laws D. A prospective, randomised controlled trial
comparing the efficacy of pre‐oxygenation in the 20°
head‐up vs supine position. Anaesthesia. 2005;60:1064-7
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PAGE 30 Anestesiologi • Malaysian Society of Anaesthesiologists
• College of Anaesthesiologists, AMM
My Journey
by Dr Mazlilah Abdul Malek
Hospital Serdang
Looking back at almost a year ago, my journey as a Senior the Tier 2 Visa and GMC registration all by myself. Out of
Fellow in Cardiac Anaesthesia and Intensive Care in three interviews, I successfully received offers from two of
University Hospital Southampton (UHS) NHS Foundation them; the post for Fellow in Paediatric Cardiothoracic
Trust in the United Kingdom was one with many Anaethesia in Newcastle Upon Tyne and to my delight, the
challenges. My overseas attachment was due in February post for Clinical Fellow in Cardiac Anaesthesia and Cardiac
2021 thus I started my applications as early as December Intensive Care in UHS and it was not difficult for me to
2019 by emailing many cardiac anaesthesia consultants in select between the two. Apart from the EACTA fellowship,
both the UK and Australia. But with the pandemic proving UHS also offers a multifaceted cardiothoracic anaesthesia
to be more than just a hindrance, getting applications experience with a wide mix of cardiac and thoracic cases
through during this time proved to be tougher with many from adult, adult congenital, paediatrics, interventional
delayed replies. They were all enthusiastic to have me as cardiac catheter labs, extracorporeal membrane
their Clinical Fellow and offered guidance for my oxygenation and cardiac intensive care training, basically
applications but, due to several reasons, I ultimately covering everything under the sun except for heart
decided to go to the UK. There were countless tasks that transplants. With Southampton located in the south of
had to be completed, most arduous would be the England, it brings together the warmer weather and a
documentation and administrative work needed to get closer proximity to London compared to Newcastle which
the applications accepted for consideration. Part of it was became the icing on the cake.
having my medical qualifications verified by the Electronic
Portfolio of International Credentials, a service of the
Educational Commission for Foreign Medical Graduates
which is an international independent body that verifies
foreign medical qualifications, a prerequisite to have me
licensed for practice in the UK
by the General Medical Council
(GMC). Another requirement
to be fulfilled for the GMC was
that I had to provide evidence
of English proficiency by
obtaining at least the
minimum requirement in
either International English
Language Testing System or
Occupational English Test
exams.
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I arrived in the gloomy and wet autumn weather but was Some of the clinical protocols and practices did differ.
cheerfully greeted by Dr Kirstin Wilkinson and Dr Some drugs and medication prescribed were ones that I
Jonathan Huber, the lead consultants for the fellowship was not familiar with, have never used or perhaps were
programme. Much to my disappointment, I was then told just not available in Malaysia. It took me a few months to
that the EACTA Fellowship course recently changed its get used to the systems, processes, surgeons’ preferences,
programme to a mandatory two years (one year of basic staff and how things are done in UHS. I have always
training and another year of advanced training) in an juggled my special interests in anaesthesia between
accredited training centre along with the completion of paediatric, cardiac and intensive care. The settings in UHS
transoesophageal echocardiography (TOE) certification gave me the perfect combination to do all three but with
with the European Association of Cardiovascular Imaging more time spent in paediatric cardiac theatres after
(EACVI). As I was only staying for a year of overseas professing extra love for anaesthesizing the little bubbas.
training, this had meant that I was unable to partake as It is a field I find challenging yet gratifying.
an EACTA Fellow.
I was fortunate to have had the opportunity to work with
The UHS serves as a District General Hospital as well as all 14 dedicated consultants who have been extremely
regional/supra-regional specialist hospital comprising helpful and supportive in my learning. They often allowed
Southampton General Hospital (SGH), Princess Anne me to lead with their guidance and this greatly helped
Hospital and both Netley Castle and Countess boost my confidence knowing that I have their trust in
Mountbatten House for terminal and respite care. Under running the operation theatres and CICU. I was also given
the Wessex Cardiothoracic Unit, I was part of the Cardiac the opportunity to sharpen my skills and hone my
Anaesthesia Unit which houses 14 consultants, 5 knowledge even further in cardiac anaesthesia and
associate specialists, 4 anaesthetic trainees and between perioperative TOE by attending weekly teachings and this
9 to 12 fellows at one time from different nationalities encouraged me to pursue the EACVI TOE certification.
who see a myriad of cases daily along with high turnover One of the advantages working in UHS was the ability to
of patients in 3 adult cardiac theatres, 1 paediatric cardiac share my experiences and learn from others who had
theatre, 1 thoracic theatre, cardiac hybrid theatre, cardiac worked in the clinical settings elsewhere. Many of my
catheter labs, a 16-bedded Cardiac Intensive Care Unit senior fellow colleagues were from countries like India,
(CICU) and 10-bedded Cardiac High Dependency Unit. I Egypt, Jordan, Mexico, Romania and Ireland to name a
usually work in SGH but also the Princess Anne Hospital few. This made it into a wholesome learning experience
on occasions when I needed to anaesthetize those cute where all of us were able to compare notes and learn
neonates in their neonatal intensive care unit. I could just from each other. It was an eye-opener working with
eat them up (not literally, of course). people from different backgrounds in good camaraderie
as equal colleagues; there were not any discrimination,
The early part of 2021 and everyone happily worked together as a team. Even
was tough. Cardiac the consultants were more like colleagues and friends
theatres and CICU were rather than bosses. Not only have I received invaluable
forced to run at reduced experience working in UHS, but I also gained lasting
capacity to make room friendships. This experience has been greatly rewarding in
for the influx of COVID both my personal and professional growth as a doctor, a
cases that came through team member, a cardiac anaesthetist and, most
the doors. Rota had to be importantly, as a person.
attuned which led me to
briefly be part of the As I am nearing the end of my stint here in the UK, it is
Non-COVID ICU (NOVID) bittersweet to be leaving soon for home. I strongly
and proning team. recommend UHS as an ideal training place for cardiac
Fortunately, the COVID anaesthesia for future trainees from Malaysia. I hope that
situation in Southampton improved and the I have carried the Malaysian flag well in the UK and I will
cardiothoracic services were again fully operational by the be bringing home many good memories along with
end of February 2021. There were many challenges in the clinical knowledge, skills and experience that would make
beginning, and I had to adjust being in a new hospital me a better cardiac anaesthetist. Thank you, Wessex
with different work culture and processes. The hospital Cardiothoracic and Cardiothoracic Anaesthesia Unit, UHS,
information system was different but luckily the same the experience working there was nothing less than
amazing.
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PAGE 32 Anestesiologi • Malaysian Society of Anaesthesiologists
• College of Anaesthesiologists, AMM
MyAnaesthesia 2021: Dawn of a New Era
by Dr Gunalan A/L Palari1 & Dato’ Dr Yong Chow Yen2
1
Subang Jaya Medical Centre
2
Hospital Pulau Pinang
The Malaysian Society of Anaesthesiologists and the During the Opening Ceremony, Professor Dr Hj Karis
College of Anaesthesiologists, Academy of Medicine of Masiran was conferred the MSA Honorary Membership
Malaysia had its first ever virtual Annual Scientific in recognition of his enormous contribution to the
Congress from 6th to 8th August 2021. With the theme field of Anaesthesiology and Critical Care in Malaysia, in
‘’MyAnaesthesia 2021: Dawn of a New Era”, the particular the establishment of the Master of
Organising Committee led by Chairperson, Professor Dr Anaesthesiology Specialty Training Programme.
Marzida Mansor, worked hard to bring to fruition a
congress that marks the beginning of an era when we Apart from the scientific congress, we also had the
embrace a new way to reach out to our members and Annual General Meetings of both the Malaysian Society
scientific fraternity. of Anaesthesiologists as well as the College of
Anaesthesiologists. The AGMs held on 6th August and 7th
With 1393 delegates, this congress received the highest August respectively were well attended and had active
ever number of registered delegates in its history. The participation from members. Elections were held and a
Scientific Committee led jointly by Dato Dr Jahizah Hassan new team each for both the College and the Society was
and Associate Professor Dr Azarinah Izaham ensured that selected.
the content, delivered by 23 foreign speakers and 39 local
speakers, was current and relevant to the interest of the The poster and free paper presentations were well
delegates. represented by young investigators from all over the
country. The esteemed panel of judges was very
impressed by the high standard of the scientific content
of the papers.
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PAGE 34 Anestesiologi • Malaysian Society of Anaesthesiologists
• College of Anaesthesiologists, AMM
National Anaesthesia Day 2021
by Associate Professor Dr Loh Pui San
University Malaya Medical Centre
Anaesthesia Day is an annual event that falls on 16th In his officiating speech, Yang Berbahagia Tan Sri Dato’
October every year. Despite facing numerous adversities Seri Dr Noor Hisham Abdullah, Director-General of Health,
for the last two years, both the Malaysian Society of thanked frontliners for their services and continued the
Anaesthesiologists (MSA) and the College of emphasis on teamwork and to stay stronger together.
Anaesthesiologists (CoA) continued to co-organise the “Alone we can do little, together we can do so much” were
National Anaesthesia Day (NAD) on a virtual platform to his wise words that echoed in our hearts when he praised
stream live and celebrate with the whole fraternity of the camaraderie developed among multidisciplinary
anaesthesiologists in Malaysia. clinicians throughout the country in the fight against
COVID-19 in the last few months. His speech was then
followed by a beautiful montage developed by the
creative director of the Organising Committee, Dr Haslan
Ghazali from KPJ Hospital Kuantan, which resonated the
poignant unity among anaesthesiologists in overcoming
the pandemic disaster that all of us had to face.
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PAGE 36 Anestesiologi • Malaysian Society of Anaesthesiologists
• College of Anaesthesiologists, AMM
Next, we had the announcement of the most awaited University of Malaya respectively. “Evolution and
results for the Virtual Run that was organised by Dr Kevin Revolution” was selected as the theme for the MSA Year
Ng from University of Malaya. For two weeks from 1st to Book this year to emphasize how anaesthesiology as a
15th October 2021, hospital staff and members of the medical field has progressed with times. Interesting
public pledged their runs to registered hospitals. articles such as Artificial Intelligence (A.I.) versus humans,
Attractive cash prizes were awarded to the leading burnt-out and the human factors will surely appeal to all
hospitals - Hobin Jang Hobin Hospital Tuanku Ja'afar MSA readers. In the near future, we will look forward to
Seremban (Winner), The A Team University Malaya having local articles published in our own anaesthetic
Medical Centre (1st Runner-Up) and Starlight Army journal. Professor Dr Ina presented the front cover of the
Hospital Angkatan Tentera Tuanku Mizan (2nd Runner-Up). Malaysian Journal of Anaesthesiology and encouraged
Congratulations and well done to all participating everyone to browse through myja.pub for the latest
hospitals and the top 100 runners! updates.
The last event was the launch of the MSA Year Book Alas, the virtual celebration came to an end and Dr Mohd
2020/2021 and the upcoming anaesthesia journal by Azizan wrapped up all the interesting activities. Heartiest
Associate Professor Dr Azrina bt Md Ralip from congratulations to all the winners and participants and
International Islamic University Malaysia and our MSA big thank you to the Organising Committee led by Dr
President, Professor Dr Ina Ismiarti Sharifuddin from Gunalan for another year of successful NAD celebration!
BERITA
It all started when Dr Siti Sarah Seri Masran, our only meet. We started our event at 9.00am sharp with myself
resident ophthalmologist, asked me about the plan for as the Master of Ceremony. We had Dr Mohd Ashri
this year’s Anaesthesia Day celebration. She was really Ahmad one of my anaesthesia colleagues, to recite the
intrigued with our National Anaesthesia Day celebration doa'. This was followed by the opening speeches by the
we had in KPJ Pahang last year. World Sight Day falls on Medical Director, Dato' Dr Khaled Mat Hassan; the Chief
14th October every year, two days ahead of our Executive Officer, Tuan Haji Yasser Arafat; Head of
Anaesthesia Day. She asked me about the possibility of a Department of Anaesthesia, Dr Lukman Mohd Mokhtar
joint celebration and I agreed. Thus, began our and also Head of Department of Ophthalmology, Dr Siti
collaboration for this year’s event. The theme for the
National Anaesthesia Day this year is 'Teamwork: Stronger
Together' and the theme for the World Sight Day is 'Love
Your Eyes'.
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PAGE 38 Anestesiologi • Malaysian Society of Anaesthesiologists
• College of Anaesthesiologists, AMM
an hour. We wished we had more time to answer tokens were given away as prizes. The last event which
questions from the viewers. This was followed by an everyone was looking forward to was the lucky draw. We
online virtual quiz competition which was organized by had sold T-shirts commemorating the event and the
the marketing team using the Kahoot! application. buyers were entitled to the lucky draw. There were 30
Questions were provided by Dr Siti Sarah and I. It was lots prizes in total including two bicycles and a smart phone.
of fun and the staff enjoyed themselves. Kudos to the Everyone had fun and despite it being virtual, I think it
marketing team. was an interesting experience organizing it. Next year I
hope it will be a much grander event when life will be
At the end of our half day event, we announced the back to normal and we can have our usual gatherings.
winners for the TikTok competition. Money and small Let’s hope for the best.
SCAN ME
BERITA
National Anaesthesia Day falls on 16th October annually. entire celebration virtually. Yet, we are glad to say that it
This day is a remembrance of the first successful was indeed an amusing and successful event.
demonstration of anaesthesia back in the 18th century and
it is one of the most remarkable times in the medical We selected ‘Teamwork - I love our team’ as the theme of
world, indicating patients will be able to experience celebration this year, as it is a reminder to us that unity is
painless surgical procedures since then. It is a memorable stronger than solitude. There was a total of 75
day celebrated by anaesthetists globally. participants in the online event. It started with a
welcoming speech from our beloved head of
department, Associate Professor Dr Loh Pui San.
She expressed deepest gratitude to all the
healthcare workers from our department as well
as the deployed staff, all of whom held pivotal
roles in the intensive care of the sickest
COVID-19 patients, as we tirelessly pulled
through the busiest of the days and countless
sleepless nights. As a chain is no stronger than
its weakest link, teamwork is the utmost
important factor leading to the success of our
services.
For the past few years, the Department of Fighting the COVID-19 pandemic was not a bed of roses
Anaesthesiology in University Malaya Medical Centre and our ICU was one of the most heavily hit units. Our
(UMMC) has held various interesting events to intensive care team was resilient in handling the huge
commemorate this auspicious day. Unfortunately, due to surge of Category 5 COVID-19 patients to the unit.
the COVID-19 pandemic this year, we chose to hold the
Head of Department, Associate Professor Dr Loh Pui San presenting certificates to doctors from left to right: Dr Athirah binti Aminudin
(Department of Ophthalmology), Dr Wan Aizat bin Wan Zakaria (Wellness Team Leader, Department of Anaesthesiology) and
Dr Mohd Fitry bin Zainal Abidin (OSHE Team Leader, Department of Anaesthesiology)
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PAGE 40 Anestesiologi • Malaysian Society of Anaesthesiologists
• College of Anaesthesiologists, AMM
We could not be more grateful for the lending hand from announced during the event
all the doctors and nurses of other departments when we and they won cash prizes.
needed it most. This further shows the importance of
team-play as portrayed by the theme this year. As a token The virtual National
of appreciation, we took the opportunity to present the Anaesthesia Day 2021
deployed staff with certificates and souvenirs. In addition celebration ended with the
to that, we had special thanks to the wellness team, led launching of the Department
by Dr Wan Aizat, in ensuring the mental and physical of Anaesthesiology alumni
health of our departmental staff are well taken care of group. Packed lunch and
during the fight with the pandemic. We also thank our dessert were also provided to
department OSHE team, which is led by Dr Fitry, who all the staff at the end of the
tirelessly traced members of staff who were in close event.
contact with COVID-19 positive patients in order to
reduce spread of disease among staff to the minimum.
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The pandemic has impacted all aspects of our lives, Nor'azim Mohd Yunos, and Dr Jeyaganesh A/L
including the way we work, learn, and communicate. The Veerakumaran, who introduced basic physiology during
entrance examination is an integral part of selecting the the first weekend. The Physiology topics presented were
best candidates for the medical specialist postgraduate cardiovascular, respiratory, central nervous system as well
programmes. It is currently run by the MedEx (Medical as renal physiology. A well-executed series of physiology
Specialist Pre-entrance Examination) in collaboration with lectures certainly enlightened the participants. The
the National Anaesthesiology Specialty Committee. It is Pharmacology subject speakers were Associate Professor
made available to candidates all over Malaysia through a Dr Noorjahan Haneem Md Hashim, Professor Dr Ina
unified online registration portal and multiple Ismiarti Shariffuddin, Professor Dr Marzida Mansor,
examination centres. However, as the pandemic Associate Professor Dr Loh Pui San, and Dr Kevin Ng Wei
continues, there are concerns that many medical officers Shan. The topics covered were intravenous induction
are struggling to better prepare themselves for the exams agents, inhalational agents, analgesics, muscle relaxants,
to balance their role as frontliners and to acquire formal and local anaesthestics. The series of lectures indeed was
accreditation to enter the postgraduate programme, an eye-opener to the participants. The participants
especially for the aspiring medical officers who are due to submitted their questions and interact with the speakers
sit for the entrance exams in the year 2022. via a chat box, albeit an online webinar. In addition, we
had a real-time single best answer polling in the lectures
To address this challenge, University of Malaya has to better engage the participants which received good
recently taken the initiative to host the first virtual feedback.
pre-entrance anaesthesia exam workshop in Malaysia.
Professor Dr Ina Ismiarti Shariffuddin led the organising At the end of the workshop, online feedback was sought
committee with Associate Professor Dr Loh Pui San, from the participants, and the majority rated the
Associate Professor Dr Noorjahan Haneem Md Hashim, Dr workshop as very helpful in preparing for the entrance
Nor Fadhilah Shahril, Dr Farah Nadia Razali, Dr examination (Figure 1). They highly rated the speakers to
Muhammad Syamel Aizad Mohd Amin, Dr Iwadh Abd be well organised and prepared (Figure 2) and the
Rashid, and Dr Ng Jia Hui as committee members. We sessions to be well planned (Figure 3). After the workshop
were proud to have our own technical and IT support
delivered by Dr Syamel and Dr Iwadh.
The esteemed Physiology subject speakers were Professor Figure 1: How helpful do you think this workshop is for your
Dr Chan Yoo Kuen, Professor Dr Rafidah Atan, Professor Dr preparation of entrance examination?
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PAGE 42 Anestesiologi • Malaysian Society of Anaesthesiologists
• College of Anaesthesiologists, AMM
Figure 2: The speakers were organised and well prepared for Figure 3: The course contents were organised and
each topic. well planned.
concluded, session recordings were made available to Instagram to reach out and advertise our workshop to the
participants for the next three months on University of potential participants in a short period. On the other
Malaya Anaesthesiology Department website. To improve hand, the Telegram app provided a centralised messaging
the quality of our education, we created a platform for system to better facilitate the participants and respond to
the participants to assess their level of performance by queries or technical difficulties during the workshop.
answering the pre-test and post-test questions for both
Physiology and Pharmacology topics. We are happy to Overall, the organising team feels honoured and grateful
note that the score for the post-test improved after the to help our fellow medical officers further their education
course. journey. The team also gained a lot of knowledge in
managing the event while fulfilling our roles as frontliners
We faced some challenges as the organising committee in the operating theatres, general ICU, and COVID ICUs,
was also heavily involved as frontliners in treating patients and some while being under home quarantine.
with COVID-19. It was around the peak of the pandemic
when our hospital was running three COVID ICUs. With a We would like to thank the speakers who made the
dedicated team, we managed to execute this task after webinar more insightful and finally, the participants who
getting approval from the Anaesthesiology National made our effort worth taking. We hope to organise
Conjoint Board in just about four weeks. similar sessions in the future and wish our future
anaesthesiology candidates the best of luck and see you
Among the lessons learned was the availability of on the field soon!
different social media platforms such as Facebook and
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PAGE 44 Anestesiologi • Malaysian Society of Anaesthesiologists
• College of Anaesthesiologists, AMM
TEE Probe Position e) Flexing the tip of the probe to the patient’s right with
There are four TEE probe placement position in TEE the small control wheel is called “flexing to the right,”
examination which are at the upper esophageal (UE), the and flexing it to the patient’s left is called “flexing to
mid esophageal (ME), the transgastric (TG) and the deep the left”.
transgastric (DTG) levels. The distance of the probe tip
from lips is approximately 20-25cm for UE, 30-40cm for
ME, 40-45cm for TG and 45-50cm for DTG. In basic TEE
examination, the TEE probe is usually positioned at UE
and ME levels.
BERITA
REFERENCES
1. Koshy T, Kumar B, Sinha P K. Transesophageal 3. Reeves ST, Finley AC, Skubas NJ et.al. Basic Perioperative
Echocardiography and Anaesthesiologist. Indian Journal of Transesophageal Echocardiography Examination: A
Anaesthesia (2007);51(4):324-333 Consensus Statement of the American Society of
Echocardiography and the Society of Cardiovascular
2. Flachskampf FA, Decoodt P, Fraser AG, Daniel WG, Roelandt Anesthesiologists. J Am Soc Echocardiogr (2013);26:443-56
JRTC. Recommendations for Performing Transoesophageal
Echocardiography. Eur J Echocardiography (2001) 2, 8-21. 4. Shillcutt SK, Bick JS. A Comparison of Basic Transthoracic
doi:10.1053/euje.2000.0066, available online at and Transesophageal Echocardiography Views in the
http://www.idealibrary.com Perioperative Setting. International Anesthesia Research
Society (2013);116:6. www.anesthesia-analgesia.org
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PAGE 46 Anestesiologi • Malaysian Society of Anaesthesiologists
• College of Anaesthesiologists, AMM
Virtual Basic Critical Care Management Course for
non-ICU Doctors (VBCCM) 2021
by Dr Chan Weng Ken
Hospital Umum Sarawak
Virtual Basic Critical Care Management Course for transitioned to online learning. The initial plan to use
non-ICU doctors (VBCCM) was held successfully on the a pro account in Zoom had to be escalated due to the
31st July 2021, as a full day webinar on YouTube, jointly account limitation (limited to 100 participants, lack of
organised by Hospital Pakar Kanak-Kanak, Universiti webinar function and unable to stream to social
Kebangsaan Malaysia (HPKK), MERCY Malaysia (MERCY) media) in view of the increasing number of
and Persatuan Kakitangan Anestesiologi Hospital Umum participants. Subsequently, transition was made to use
Sarawak (PEKA-HUS). VBCCM has successfully garnered an education account in Zoom. However it was not
more than 2000 participants live on both the Zoom enough as the number of registered participants was
Meeting platform and on MY-sigRA’s YouTube channel. over its limit of 300 participants too. Fortunately,
the Malaysian Special Interest Group in Regional
VBCCM was initiated in late July 2021 when the COVID-19 Anaesthesia (MY-sigRA) has agreed to offer their
pandemic situation worsened in Malaysia, especially in YouTube channel for live streaming purposes. Hence,
the Greater Klang Valley. From the official statistics shown we were able to reach out to over 2000 participants
in https://covidnow.moh.gov.my, there were about (at one point, it was about 2500 online viewers).
900-odd ventilated patients and over 1500 patients being
managed in intensive care units (ICUs) by the end of July. 3. Notification - As the transition to stream live at
There was also news that patients were stranded in YouTube was made at the eleventh hour, we had to
emergency departments due to the congestion in wards. notify our participants promptly. Since there was no
As such, many patients who required intensive care were official website or official social media channel, we
being managed in repurposed ICUs. There were also had to rely on email notifications and word of mouth
clinicians from other departments who were mobilised to via Whatsapp messages. Although there were some
help to cope with the surge of patients with COVID-19 congestion on the Zoom platform on the morning
categories 4 and 5. of event, eventually most of the participants were
successfully diverted to the YouTube channel.
HPKK was a new training hospital used by the Ministry of
Health, Malaysia (MOH) through powers under Section 3 4. Time constraint - The time from decision made to the
and 4 of the Emergency Ordinance to help to meet the event date was only a week. Our invited speakers had
increasing demand of patients requiring critical care. only a few days to prepare their presentations. Despite
However, many staff were mobilised from other hospitals that we managed to have positive feedback for the
and many of them had very limited experience in lectures and many requested for the recorded version
managing critically ill patients. of the lectures. These lectures were subsequently
uploaded in MY-sigRA’s YouTube channel for future
To address all the clinical shortcomings and with aims to viewing. As we do not have adequate time to request
improve patient care, the idea of VBCCM was mooted by CPD points from the MMA, HPKK Corporate
a group of young anaesthesiologists to provide a quick Communications Services has agreed to issue
and comprehensive training for non-ICU doctors in HPKK certificate of participation to all the online delegates.
and to other hospitals in Malaysia as well.
On the day of the event, we were privileged to have Dr
However, there were a few challenges that needed to be Melor bin Mohd Mansor, our then National Head of
addressed: Anaesthesia and Intensive Care Services and Head of
Department of Anaesthesiology and Intensive Care,
1. Speakers - Many clinicians in MOH hospitals were Hospital Kuala Lumpur to grace the opening ceremony.
heavily engaged in managing the surge crisis; hence, Our participants started to show up as early as 8.45am
the decision to invite speakers from less affected MOH (15 mins earlier) to secure limited places in the Zoom
hospitals and voluntary bodies (MERCY Malaysia). platform. Our speakers on that day were Dr Mafeitzeral
Bin Mamat (MERCY), Dr Tham Sook Mun (Hospital Queen
2. Platform (Zoom & YouTube) - Since the start of Elizabeth I), Dr Vincent Teo Shih Loong (Hospital
pandemic, many educational activities have Segamat), Dr Vimal Varma (Hospital Sultanah Aminah),
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#kitamestimenang
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PAGE 48 Anestesiologi • Malaysian Society of Anaesthesiologists
• College of Anaesthesiologists, AMM
Neuroanaesthesia Symposium (NAS) 2021
by Dr Elisha Culas & Dr Peter Tan
Hospital Umum Sarawak
The first virtual edition of Neuroanaesthesia Symposium Professor Dr Deepak Sharma (USA), Dr Judith Dinsmore
(NAS) was held on 3rd and 4th July 2021 which was (UK) and Professor Dr Matthew Chan TV (Hong Kong,
jointly organised by the Special Interest Group (SIG) China) whereas the local faculties were mainly the
in Neuroanaesthesia, College of Anaesthesiologists, neuroanaesthesiologists and neuroanaesthesia fellows
Academy of Medicine of Malaysia; Malaysian Society of from the SIG.
Anaesthesiologists (MSA) and Persatuan Kakitangan
Anestesiologi Hospital Umum Sarawak (PEKA-HUS). This A virtual exhibition was also set up to allow the
virtual event received an overwhelming response of 422 participants to keep abreast of the latest products and
registered participants nationwide. services in the field of anaesthesiology. Seven companies
from the biomedical industry participated in this
exhibition.
NEUROANAESTHESIA
SYMPOSIUM The organising committee held an online survey at the
end of the symposium to assess the delegates satisfaction
in terms of the secretariat work, virtual platform, time
VIRTUAL management, lectures and their general overall
experience. We are proud to report the survey concluded
that the NAS 2021 had met the expectations of the
3-4 JULY 2021 delegates in all categories mentioned above.
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PAGE 52 Anestesiologi • Malaysian Society of Anaesthesiologists
• College of Anaesthesiologists, AMM
Ultrasound Guided Vascular Access: Where are we Right Now?
by Dr Hasmizy Muhammad
Pusat Jantung Sarawak
BERITA
REFERENCES
1. P. Blanco P. Ultrasound-guided vascular cannulation in 4. Atkinson P, Boyle A, Robinson S, Campbell-Hewson G.
critical care patients: A practical review. Med Intensiva. Should ultrasound guidance be used for central venous
2016;40(9):560-571 catheterisation in the emergency department? Emerg Med J
2005;22:158-164
2. Miller AH, Roth BA, MD, Mills TJ, Woody JR. Ultrasound
Guidance versus the Landmark Technique for the Placement 5. Leibowitz A, Oren-Grinberg A. Ultrasound Guidance for
of Central Venous Catheters in the Emergency Department. Central Venous Access: Current Evidence and Clinical
Acad Emerg Med. 2002;9:8 Recommendations. Journal of Intensive Care Medicine.
2019:1-19
3. Practical guide for safe central venous catheterization and
management 2017. Safety Committee of Japanese Society
of Anesthesiologists. Journal of Anesthesia.
2020;34:167-186
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PAGE 54 Anestesiologi • Malaysian Society of Anaesthesiologists
• College of Anaesthesiologists, AMM
MCAI/FCAI - The Road Not Taken…
by Dr Noreen Louis
Institut Jantung Negara
The memorandum of understanding (MoU) between the and the very few whom you will hold close to heart. To
College of Anaesthesiologists, Academy of Medicine of this, all I can say is, great teachers do not just come
Malaysia and the College of Anaesthesiologists of Ireland armed with knowledge from great books. They are mere
was officially signed on 27th April 2016. That was the mortals who mastered the supreme art of teaching with
starting point where the parallel pathway for eager passion and inclusion. So much changed for me when I
learners of Anaesthesia and Intensive Care was paved. decided to hold on, and it will continue, even faster than
Even so, all that glitters is not gold and the epitome of before.
uncertainty, discreditation and exam stigma was all too
overbearing. There were many who rushed headfirst into Make hay while the sun shines. If you find yourself
the exams and then gradually withdrew as there was a thinking and waiting to follow the norm you are already
lack of response, scarcity of experience and infrequent too late to start moving. My advice to those seeking to
availability of ‘role models’. dabble whether with the parallel pathway or the local
board exams is to create space for this new change in
From my perspective it was like dipping your toes into your life. The rules are clearly defined now after many
water to test and see if you are ready to go in, as the discussions and endless meetings fuelled by constant
water may be too warm or too cold at first but that is not rumours while we sat around at one point in a daze.
a reason to shy away from it. The positives may far Finish the exams within the stipulated time frame (always
outweigh the negatives, as it did for me. This course is not easier said than done), complete three years of training in
for the faint hearted. It relies upon one’s efforts at signing a certified centre and then find yourself on the route to
up for local and overseas courses as well as finding study gazettement. In these centres you will find yourself down
partners who may hail from different hospitals, some of the gruelling six-monthly assessments that you must
whom were perfect strangers prior to that. This is done balance between life, family, career and a log book. All of
while also holding on to the grit of pushing through this do not translate to be an easy feat and those who are
despite the many factors that could delineate a person in the process of it have gone through great lengths.
from his/her path at any one time. Finding superior Those hellbent on going abroad will find that the exams
colleagues at work who would genuinely support you was are readily approved by the General Medical Council,
another task of its own but truly you would come to United Kingdom. Now this is where it can get tricky
realise that great men are also generous and they are the because most people are not good at change. They want
very few who would inspire you that true teachers are to keep holding on to the familiar and comfortable, while
both wise and enlightened. others are already exploring the unfamiliar and growing
professionally and personally.
As the Greek philosopher, Heraclitus, said ‘change is the
only constant’. When I decided to leave behind the I have so many people to give credit to for getting
comfort of familiarity of the local anaesthesia board through the exams; people who motivated me and
exams, I created space for my personal development. encouraged me; those who believed in me. Surprisingly,
Everything that was once normal suddenly changed. I had those who did not (believe in me) fuelled me even more.
to reinvent myself which came with a lot of insecurity Their insight and perspective pushed me forward. Life
dashed with a feeling of failure but above all I had to does not have its own navigational system that directs
promote perseverance. The exams comprised plenty of someone to their desired destination. One must make
additional new inputs ranging from anatomy to core decisions and rely upon his/her choices made to get
physics and technicalities. Methods of answering and him/her to the preferred destination. It is amazing how
marking may differ but it is the same ball game. These we all have our own resiliency and ability to recover from,
exams do not require you to uproot and move to a new and all I can say is when you finally grab the bull by its
centre or join at a specific date. There is no set mould to horn, anything is possible.
fit yourself into. In fact, nothing pertaining to it is specific.
It boils down to you picking up every ounce of your effort ”I took the one less travelled by, and that has made all the
and studying until the date of payment is due and then difference”.
you start your lonely journey down the exam hall. There is
no post-mortem and neither are there people you can Thank you.
share your complexities with. You learn to rely on yourself
BERITA
GENERAL
Anaesthesia
REGIONAL
Anaesthesia
MUSCLE
Relaxant
For more information, please refer to full prescribing information For healthcare professionals only
In mid-2021, amidst the height of the worse pandemic junior doctors walked out for about 60 mins. The
the country has seen, a group of young doctors got demonstration showed the frustration of the junior
together and formed a group known as Hartal Doktor doctors, and it indicated a will to unite for a common
Kontrak, threatening to strike and walk out of their goal, which in my opinion is promising.
respective positions in protest of their uncertain futures.
The day selected was 26th July 2021, and despite the So why have we gotten to this stage? And where do we
dramatic name of Hartal, a peaceful protest was instead go from here? First, we have to take a little history lesson
carried out on that day where about 500 out of 20000+ in the development of medical graduates in Malaysia.
Year 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Local Uni 945 993 1104 1449 1726 1864 1964 2180 2588 2370 2195 2106 3077 3498
Overseas 104 66 186 877 1332 1388 1600 1563 2403 1490 1945 2254 1826 1426
Uni
Total 1049 1059 1290 2326 3058 3252 3564 3743 4991 3860 4140 4360 4903 4924
Figure 1: Chart and table showing the total number of Houseman Intake by the Ministry of Health and place of graduation from
2005 to 2018 (Medical Planning Division, KKM)
In the 1990s, as Malaysia emerged as one of the fastest One would think that a large number of graduates would
growing economies in the world, there was an urgent be a boon for the healthcare system, which has been
need to increase the supply of medical staff for the crying out for help since Merdeka. Everywhere we look,
growing population. As such there was a mushrooming we see a shortage of doctors within the departments, and
of medical schools and colleges offering allied health we would always face the eternal crisis of not enough
courses, pharmacy, dentistry and medicine. We then saw coverage for Medical Officers during peak periods like
a mass production of graduates, leading to the perceived holidays and exams. So, what has happened?
oversupply that we see today. From the chart above we
can see an increase in medical graduates from 2008 The apparent shortage of doctors in service, and the
onwards, peaking in 2013, and plateauing to just under perceived glut of medical graduates boils down to one
5000 medical graduates a year. In 2010, to control the simple matter, the lack of positions to hire these
rising number of graduates, the Government instituted a graduates and to keep them in service. As such, despite
Moratorium on the expansion of new medical schools, having an abundance of graduates, the number of
and this was renewed in 2015 and again in 2020. employment opportunities (i.e. Perjawatan) has been
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PAGE 58 Anestesiologi • Malaysian Society of Anaesthesiologists
• College of Anaesthesiologists, AMM
one day we will once again “tumpang gembira” as we 6) Setting up a more sustainable healthcare financing
always do with their success in the international arena. plan. Our system cannot go on where patients are
paying RM1 for treatment. It is imperative that we
So where do we go from here? And what are the other have a system that would allow for the protection of
issues we face? the B40, yet ensure that those who can afford it will
contribute their fair share.
I would highlight these four as the most pertinent of
issues we face The Malaysian healthcare system is amongst the best in
the world. But it is the best because of its affordability, as
1) Continuous overproduction of medical graduates well as accessibility. However, there are issues that are
2) Aging healthcare infrastructure slowly coming to boil, and we need the political will, as
3) Disproportionate distribution of human resources, well as the combined cooperation of all levels of
urban favoured over rural governance, to ensure that we will continue to be
4) A non-existent healthcare financing plan amongst the best. Should the focus on healthcare waver,
more so as the pandemic winds down, we may not be
To discuss this would take more than the scope of this able to cope when the next pandemic comes our way. So
write-up, but in short, here are some suggestions we have let us all take heed, and keep the issue of a fairer and
put forth to the government clearer pathway for the junior doctors in the forefront of
everyone’s minds, as these very doctors will be our
1) Merging of medical schools to reduce the number of specialists in the future.
graduates and improve the teacher-to-student ratios.
This suggestion was extremely unpopular when we I was once told by a senior administrator, that the issue of
presented it to the powers-that-be healthcare human resources in Malaysia is not new, and
has been an issue documented in books from the 1930s.
2) Medical licensing exams, to ensure the quality of My answer is this, so let the issue come to rest now. We
doctors serving the Rakyat have the trained members to meet the demands of the
country, but not the ability to put them in jobs where they
3) Increasing the healthcare budget to match our needs, are needed most. We can solve the issue, should we want
to ensure that the infrastructure of healthcare is to. Healthcare must be a priority, as seen in the battle
upgraded and maintained against COVID-19. So let us unite to call upon the
Government and Administration to ensure that the
4) Improving the benefits of those who remain in contract issues of our junior healthcare workers are
government service, rewarding the doctors who stay attended to, and resolved quickly to ensure a fair and
to serve, rather than across the board sustainable career pathway for them all.
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Fascial plane blocks are defined as regional anaesthesia Continuous SAP block could also be performed using a
techniques in which the space ("plane") between two continuous catheter. In Hospital UiTM, we collaborated
discrete fascial layers is the target of needle insertion and with the cardiothoracic surgeons to introduce surgically
injection. The deposition of local anaesthetics (LA) within inserted continuous SAP catheter insertion for open
the fascial plane is expected to block the sensory nerves thoracotomy and MICS (Figure 2). The SAP catheter is
responsible for nociception along the surgical incision. In inserted by the surgeons within the deep serratus anterior
recent times, fascial plane blocks have been gaining plane prior to wound closure. We also perform surgically
popularity in cardiac and thoracic surgery due to their inserted continuous fascial plane catheter techniques in
simplicity and perceived low risk of complication. There other open surgeries such as open cholecystectomy
are a number of fascial plane blocks that have been (subcostal TAP catheter) and laparotomy (rectus sheath
described for the chest wall.9 However, this article will catheter).
focus on two techniques that are most used for
Evidences
cardiothoracic surgery - serratus anterior plane (SAP) and
In a systemic review and meta-analysis of SAP block
erector spinae plane (ESP) block.
conducted by Chong et al, there were 6 RCTs involved in
Serratus Anterior Plane (SAP) Block thoracic surgery and 13 in breast surgery.11 The
Serratus anterior plane (SAP) block was introduced by meta-analysis found that SAP block reduced early
Blanco et al. in 2013 as a less invasive regional postoperative pain score compared to non-block care,
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How to perform
ESP block can be performed in sitting, lateral, or prone
position. Following the usual preparation for regional
anaesthesia block (intravenous access, standard
monitoring, aseptic preparation), the high frequency
linear ultrasound probe is placed in the paramedian
sagittal orientation 2-3cm lateral to midline. Transverse
process of the thoracic spine is identified as squared-off
acoustic shadows (Figure 4). If the transducer is too
lateral, the ribs will be visualized instead; these are
recognizable as rounded acoustic shadows with an
intervening hyperechoic pleural line. Upon visualisation of
the transverse process, the trapezius muscle, rhomboid
major muscle (if performing at T5 level or higher), and
erector spinae muscle should be identified above the
Figure 2: Ultrasound view of the SAP block. LDM = latissimus transverse process. ESP block is usually performed at T5
dorsi muscle, SAM = serratus anterior muscle
level for thoracic surgery or T4 level for sternotomy.
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PAGE 62 Anestesiologi • Malaysian Society of Anaesthesiologists
• College of Anaesthesiologists, AMM
Evidence of ESP block in cardiac surgery is still limited.
Currently there are 2 RCTs reported in the literature. RCT
conducted by Nagaraja et al. compared bilateral
continuous ESP block to thoracic epidural in 50 patients
undergoing CABG. The study concluded that ESP block
provides comparable analgesia, shorter duration of
mechanical ventilation, and ICU stay compared to
thoracic epidural.15 Another RCT conducted by Krishna et
al compared ESP block to non-block care in 106 patients
undergoing cardiac surgery with cardiopulmonary
bypass. They concluded that single shot ESP block
provides lower postoperative pain score, reduced opioid
requirement and shorter extubation time and ICU stay as
compared to non-block care.16
Figure 5: The ultrasound image of Erector spinae plane block
Summary
Evidences Fascial plane blocks are rapidly gaining popularity in the
A recent meta-analysis of ESP block by Huang et al.14 ERAS era for cardiothoracic surgery and should be in the
analysed 7 RCTs for thoracic surgery and 7 RCTs for anaesthesiologists’ armamentarium. In our opinion, ESP
breast surgery. They reported that ESP block reduced block is currently a high value block in cardiothoracic
postoperative pain score, 24-hour opioid consumption, surgery, followed by SAP block. We have also introduced
and postoperative nausea and vomiting as compared surgically inserted continuous SAP block catheter
to non-block care. The meta-analysis also showed technique along with other surgically inserted continuous
comparable outcome between ESP block and thoracic fascial plane catheter that are easy to perform. However
paravertebral block. further research is needed to investigate the safety and
efficacy of such applications.
REFERENCES
1. Mueller XM, Tinguely F, Tevaearai HT, Revelly JP, Chioléro R, 10. Blanco R, Parras T, McDonnell JG, Prats-Galino A. Serratus
Von Segesser LK. Pain location, distribution, and intensity plane block: a novel ultrasound-guided thoracic wall nerve
after cardiac surgery. Chest. 2000;118(2):391-6 block. Anaesthesia [Internet]. 2013 Nov 1;68(11):1107-13
2. Kleiman AM, Sanders DT, Nemergut EC, Huffmyer JL. 11. M C, N B, K K, C L. The serratus plane block for postoperative
Chronic Poststernotomy Pain Incidence, Risk Factors, analgesia in breast and thoracic surgery: a systematic review
Treatment, Prevention, and the Anesthesiologist’s Role. Reg and meta-analysis. Reg Anesth Pain Med. 2019 Dec
Anesth Pain Med 2017;42:00-00 1;44(12):1066-74
3. Gottschalk A, Cohen SP, Yang S, Ochroch EA. Preventing and 12. Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The Erector
treating pain after thoracic surgery. Anesthesiology. Spinae Plane Block: A Novel Analgesic Technique in Thoracic
2006;104:594-600 Neuropathic Pain. Reg Anesth Pain Med [Internet]. 2016 Sep
1;41(5):621-7. Available from: https://rapm.bmj.com/
4. Fletcher D, Martinez V. Opioid-induced hyperalgesia in content/41/5/621
patients after surgery: A systematic review and a
meta-analysis. Br J Anaesth. 2014;112(6):991-1004 13. Leyva FM, Mendiola WE, Bonilla AJ, Cubillos J, Moreno DA,
Chin KJ. Continuous Erector Spinae Plane (ESP) Block for
5. Coleman SR, Chen M, Patel S, Yan H, Kaye AD, Zebrower M, Postoperative Analgesia after Minimally Invasive Mitral Valve
et al. Enhanced Recovery Pathways for Cardiac Surgery. Curr Surgery. J Cardiothorac Vasc Anesth [Internet]. 2018 Oct
Pain Headache Reports 2019 234 [Internet]. 2019 Mar 14;2 1;32(5):2271-4
6. Rivat C, Bollag L, Richebé P. Mechanisms of regional 14. Huang W, Wang W, Xie W, Chen Z, Liu Y. Erector spinae plane
anaesthesia protection against hyperalgesia and pain block for postoperative analgesia in breast and thoracic
chronicization. Curr Opin Anaesthesiol [Internet]. surgery: A systematic review and meta-analysis. J Clin
2013;26(5):621-5 Anesth. 2020 Nov 1;66:109900
7. Freise H, Van Aken HK. Risks and benefits of thoracic 15. Nagaraja P, Ragavendran S, Singh NG, Asai O, Bhavya G,
epidural anaesthesia. Br J Anaesth. 2011 Dec Manjunath N, et al. Comparison of Continuous Thoracic
1;107(6):859-68 Epidural Analgesia with Bilateral Erector Spinae Plane Block
8. Batra, Krishnan K, Agarwal A. Paravertebral block. J for Perioperative Pain Management in Cardiac Surgery. Ann
Anaesthesiol Clin Pharmacol [Internet]. 2011 Jan [cited Card Anaesth 2018;21(3):32
2021 Jul 21];27(1):5 16. SN K, S C, D B, B K, S H, T S, et al. Bilateral Erector Spinae
9. Kelava M, Alfirevic A, Bustamante S, Hargrave J, Marciniak Plane Block for Acute Post-Surgical Pain in Adult Cardiac
D. Regional Anesthesia in Cardiac Surgery: An Overview of Surgical Patients: A Randomized Controlled Trial. J
Fascial Plane Chest Wall Blocks. Anesth Analg [Internet]. Cardiothorac Vasc Anesth [Internet]. 2019 Feb
2020;127-35 1;33(2):368-75
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PAGE 66 Anestesiologi • Malaysian Society of Anaesthesiologists
• College of Anaesthesiologists, AMM
continued from back page
The main objectives of the SIG will be to increase (FCAI). The CoA is planning to employ a staff to solely
awareness on the importance of good well-being in focus on coordinating this programme, in order to provide a
healthcare providers, that will have a direct effect on the more efficient and professional service to the candidates
quality of patient care. It is also to promote wellness who are registered for the programme with our CoA. In
amongst anaesthesiologists, focusing on the five key addition, the CoA has recently accredited University
elements of well-being which include Physical, Science Malaysia (USM) as a training hospital for FCAI
Mental/Emotional, Spiritual, Intellectual and Social and, candidates, in our effort in making sure that candidates are
finally, to provide support to ensure continuous effort in trained in hospitals that have been accredited by the MQA.
improving the general well-being of anaesthesiologists in We also participated in the writing up of the National
Malaysia, which begins at the work place, both in the Curriculum for Anaesthesiology to ensure the
operating theatres and the intensive care units. harmonization between the National and Parallel
Programme curriculum.
The activities in the pipeline include organising a national
resilience workshop and the “Joy at Work” campaign and Our CoA will also be reviewing our recommendations for
competition to promote happiness at workplace and reward patient safety and minimal standards of monitoring during
the happiest workplace. Joy at work will result in the anaesthesia and recovery that was last updated in 2013.
formation of a “Good Team”. It is not enough to just work as
a team but also has to be a good team, to improve patient The monthly webinars in collaboration with the MSA will
outcomes, increased staff satisfaction and reduced resume with a webinar on Hemodynamic Monitoring on the
incidence of burnout. 13th November 2021.
Apart from the above activities, the CoA will continue to I would like to end this message by wishing everyone to
oversee the training of the parallel programme, the stay happy and healthy.
fellowship of College of Anaesthesiologists of Ireland
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PAGE 68 Anestesiologi • Malaysian Society of Anaesthesiologists
• College of Anaesthesiologists, AMM