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Perianaesthetic challenges in patients undergoing vagus nerve stimulation (VNS) placement

Yeap TB, Ab Mukmin L, Ang SY, Ghani AR

BMJ Case Rep, 2023 Feb 07;16(2).
PMID: 36750294 DOI: 10.1136/bcr-2022-252692

Patients with medically refractory epilepsy (MRE) are indicated for vagus nerve stimulation (VNS) placement. Anaesthesia for VNS placement is extremely challenging and requires several considerations. We present a man in his 20s with MRE who successfully underwent VNS placement. We review the mechanism of action of VNS, anaesthetic challenges and measures to prevent seizures.

Matched MeSH terms: Anesthesiology*
Bispectral Index (BIS) Monitoring and Postoperative Delirium in Elderly Patients Undergoing Surgery: A Systematic Review and Meta-Analysis With Trial Sequential Analysis

Chew WZ, Teoh WY, Sivanesan N, Loh PS, Shariffuddin II, Ti LK, et al.

J Cardiothorac Vasc Anesth, 2022 Dec;36(12):4449-4459.
PMID: 36038444 DOI: 10.1053/j.jvca.2022.07.004

OBJECTIVE: To examine the effect of bispectral index (BIS)-guided anesthesia on the incidence of postoperative delirium (POD) in elderly patients undergoing surgery.
DESIGN: A systematic review, meta-analysis, and trial sequential analysis (TSA).
SETTING: In the operating room, postoperative anesthesia care units (PACU), and ward.
PARTICIPANTS: Elderly patients (>60 years old) undergoing surgery.
INTERVENTIONS: The EMBASE, MEDLINE, and CENTRAL databases were searched systematically from their inception until December 2020 for randomized controlled trials comparing BIS and usual care or blinded BIS.
MEASUREMENTS AND MAIN RESULTS: Ten trials (N = 3,891) were included for quantitative meta-analysis. In comparison to the control group, there was no significant difference in the incidence of POD in elderly patients randomized to BIS-guided anesthesia (odds ratio [OR] 0.71, 95% CI 0.47-1.08, I2 = 76%, p = 0.11, level of evidence = very low, TSA = inconclusive). The authors' review demonstrated that elderly patients with BIS-guided anesthesia were significantly associated with a lower incidence of postoperative cognitive dysfunction (POCD) (OR 0.64, 95% CI 0.46-0.88, p = 0.006), extubation time (mean difference [MD] -3.38 minutes, 95% CI -4.38 to -2.39, p < 0.00001), time to eye opening (MD -2.17 minutes, 95% CI -4.21 to -0.14, p = 0.04), and time to discharge from the PACU (MD -10.77 minutes, 95% CI -11.31 to - 10.23, p < 0.00001).
CONCLUSION: The authors' meta-analysis demonstrated that BIS-guided anesthesia was not associated with a reduced incidence of POD, but it was associated with a reduced incidence of POCD and improved recovery parameters.

Matched MeSH terms: Anesthesiology*
Fulltext Comparison of NeedleTrainer™ and ultrasound tissue simulator in a simulated environment among novice regional anaesthesia practitioners

Mokhtar MN, Suhaini SA, Chan WK, Khalid I, Tan KW, Lim ACC, et al.

BMC Med Educ, 2024 Nov 22;24(1):1350.
PMID: 39578873 DOI: 10.1186/s12909-024-06361-7

BACKGROUND: Utilising ultrasound technology has resulted in higher success and lower complication rates during regional anaesthesia (RA) procedures. Proper training is necessary to accurately identify structures, optimise images, and improve hand-eye coordination. Simulation training using immersive virtual environments and simulation models has enabled this competency training to be conducted safely before performing on patients. We conducted a study to compare the simulator performance and users' feedback on a Blue Phantom Regional Anaesthesia Ultrasound Training Block and NeedleTrainer™.
METHODS: Forty-seven participants were recruited via convenient sampling during a RA workshop for novice practitioners. They were divided into the N or B group and then crossover to experience using both Blue Phantom and NeedleTrainer model. Time-to-reach-target, first-pass success rate, and complication rate were assessed, while the learning and confidence scores were rated using six-item and three-item questionnaires, respectively, via a 5-point Likert scale.
RESULTS: Blue Phantom model has a longer time-to-target as compared to the NeedleTrainer model (16 ± 8 vs 8 ± 3 s, p

Matched MeSH terms: Anesthesiology/education
Fulltext Unity in diversity

Kulenthran, A.

JUMMEC, 2009;12(1):1-2.
MyJurnal

The present issue brings a diverse yet interesting array of research, but they all have a common thread-they answer to a clinical problem raised. The topics span human sexuality, diagnostic challenges, sports medicine, nosocomial infections, screening for neonatal infections, statistical analysis and fine-tuning the art of anaesthesia.(Copied from article).

Matched MeSH terms: Anesthesiology
Fulltext Attitude of patients towards anaesthesia: comparing the use of a single consent for anaesthesia versus the combined surgical and anaesthetic consent

Niew, Y.L., Chee, Magdalene M.X., Juanita, J., Nurul Ezzati, A.K., Mohd Sharol, A.W., Azarinah, I., et al.

Journal of Surgical Academia, 2014;4(2):9-13.
MyJurnal

Anaesthesiology is a specialty which is less well known and the public usually have little knowledge regarding anaesthesia and the roles of Anaesthesiologist. Many hospitals now use a single dedicated consent for anaesthesia. This study was conducted to compare the effectiveness of a single consent for anaesthesia with the combined surgical and anaesthetic consent. A total of 109 patients, scheduled for elective surgery requiring anaesthesia were interviewed with a standardised questionnaire. Patients were divided into two groups, where one group used a single anaesthetic consent while the other used a combined surgical and anaesthetic consent. A single consent for anaesthesia was found to be more effective than the current combined surgical and anaesthetic consent (p

Matched MeSH terms: Anesthesiology
Fulltext Comparison of Carboxyhaemoglobin concentrations between low-flow and minimal-flow anaesthesia with desflurane

Nazarudin, B., Khairulamir, Z., Azarinah, I., Jaafarm, M.Z., Karis, M., Esa, K.

Journal of Surgical Academia, 2015;5(1):19-23.
MyJurnal

This was a prospective randomised study comparing carboxyhaemoglobin concentrations between low-flow anaesthesia (fresh gas flow 1.0 L/min) and minimal-flow anaesthesia (0.5 L/min) using desflurane. Sixty (ASA 1 or 2) adult patients undergoing elective surgery under general anaesthesia were randomly allocated to receive either low-flow (Group 1) or minimal flow anaesthesia (Group 2). Venous blood samples for carboxyhaemoglobin levels were taken at baseline and at 10 mins intervals for 40 mins. Both groups showed significant increase in carboxyhaemoglobin concentrations within the first 10 mins when fresh gas flow of 4.0 L/min was used. Reduction in carboxyhemoglobin levels was seen after 20 mins of minimal or low flow anaesthesia. However, there was no significant difference in the magnitude of reduction of carboxyhemoglobin concentrations between the groups. The fractional inspired of oxygen (FiO2) showed no significant changes in either group. In conclusion, desflurane usage in anaesthesia with either low-flow or minimal-flow was not associated with increased carboxyhaemoglobin concentrations.

Matched MeSH terms: Anesthesiology
Fulltext Patient perception about preoperative information to allay anxiety towards major surgery

Kelly Ee Lu Ting, Maria Sau Sim Ng, Wei Fern Siew

International e-Journal of Science, Medicine & Education, 2013;7(1):29-32.
MyJurnal

Surgeries are seen as stressors that trigger preoperative anxiety. Preparing the patients for surgery through preoperative teaching becomes crucial to allay anxiety level. In a cross sectional descriptive study conducted on eighty patients (age: 18–65 yr) who had undergone open abdominal surgery, 78.8% (n=63) stated that they experienced anxiety prior to surgery. Among these anxious respondents, 47.5% (n=38) experienced high state anxiety. Three of the top information that patients perceived as important to allay anxiety towards major surgery were: details of surgery, details of nursing care to surgery and information on anaesthesia. Nurses working in the surgical wards need to proactively address patients’ psychological concerns towards surgery and provide preoperative information based on patients’ needs to allay anxiety.

Matched MeSH terms: Anesthesiology
Fulltext Pneumocephalus Following Combined Spinal Epidural Anaesthesia for Total Knee Arthroplasty: A Case Report

Chew YW, Suppan VK, Ashutosh SR, Tew MM, Jimmy-Tan JH

Malays Orthop J, 2017 Nov;11(3):42-44.
PMID: 29326765 MyJurnal DOI: 10.5704/MOJ.1711.001

The authors describe a case of pneumocephalus following epidural anaesthesia for total knee arthroplasty. Multiple attempts in locating the epidural space for the anaesthesia and the use of loss of resistance to air (LORA) technique were identified as the source of air entry. Supportive management was given including high flow oxygenation therapy and spontaneous reabsorption of air was noted five days after surgery. The presence of pneumocephalus should be kept in mind if patient develops neurological complications postoperatively following epidural anaesthesia.

Matched MeSH terms: Anesthesiology
Continuing medical education: a needs analysis of anaesthetists

Tucker AP, Miller A, Sweeney D, Jones RW

Anaesth Intensive Care, 2006 Dec;34(6):765-9.
PMID: 17183895

The continuing medical education (CME) needs of anaesthetists within Australia, New Zealand, Hong Kong, Malaysia and Singapore have been largely unknown. The aim of this study was to undertake a comprehensive survey of the attitude to CME, learning preferences, attitudes and abilities relating to self-paced material, literature and information searching, preferred content and preferred approach to CME of anaesthetists within these countries. A survey tool was developed and refined for ease of use by pilot-testing. The survey was mailed to 3,156 anaesthetists throughout Australia, New Zealand, Hong Kong, Malaysia and Singapore. Three options for data return were offered; postal reply, facsimile and a data entry web-page. There were 1,800 responses, which represented a response rate of 57%. The demographics of the respondents were similar to the overall demographics of Fellows of the Australian and New Zealand College of Anaesthetists. A large majority of respondents (92%) stated that their involvement in CME improved patient care. However, almost half the respondents reported that they have difficulty either in participating in current CME activities (31%) or implementing new knowledge into their workplace (14%). Anaesthetists within this region appear to be motivated by the need to make better decisions based on independent standards of practice. While Australia is a world leader in flexible education, it is still emerging as a discipline. Flexible education may be used to facilitate anaesthetists' participation in CME activities and in implementation of new knowledge in their workplace.

Matched MeSH terms: Anesthesiology/education*; Anesthesiology/standards
Obituary. Thomas Babington Boulton

Watts G

Lancet, 2016 Sep 24;388(10051):1274.
PMID: 27673462 DOI: 10.1016/S0140-6736(16)31669-5
Matched MeSH terms: Anesthesiology/history*; Anesthesiology/methods
Fulltext The Performance of Flexible Tip Bougie™ in Intubating Simulated Difficult Airway Model

Mahli N, Md Zain J, Mahdi SNM, Chih Nie Y, Chian Yong L, Shokri AFA, et al.

Front Med (Lausanne), 2021;8:677626.
PMID: 34026801 DOI: 10.3389/fmed.2021.677626

This prospective, randomized, cross-over study compared the performance of the novel Flexible Tip Bougie™ (FTB) with a conventional bougie as an intubation aid in a simulated difficult airway manikin model among anaesthesiology trainees with regards of first pass success rate, time to intubation, number of attempts and ease of use. Sixty-two anesthesiology trainees, novice to the usage of FTB, participated in this study. Following a video demonstration, each participant performed endotracheal intubation on a manikin standardized to a difficult airway view. Each participant performed direct laryngoscopy and intubated the manikin using a conventional bougie and FTB, at least 1 day in between devices, in a randomized order. The first pass success rate was significantly higher with FTB (98.4%) compared to conventional bougie (85.5%), p = 0.008. The median time to intubation was significantly faster when using FTB, median = 32.0 s [Interquartile range (IQR): 23.8-41.3 s] compared to when using conventional bougie, median = 41.5 s (IQR: 31.8-69.5 s), p < 0.001. The FTB required significantly less intubation attempts compared to conventional bougie, p = 0.024. The overall ease of use, scored on a Likert scale from 1 to 5, was significantly higher in the FTB (4.26 ± 0.53) compared to the conventional bougie (3.19 ± 0.83), p < 0.001. This simulated difficult airway manikin study finding suggested that FTB is a useful adjunct for difficult airway intubation. The FTB offered a higher first pass success rate with a faster time to intubation and less required attempts.

Matched MeSH terms: Anesthesiology
Fulltext Thirty-Day Morbidity and Mortality after Simultaneous Bilateral Total Knee Arthroplasty

Tai, C.C., Tan, S.H., Misnan, N.A., Nam, H.Y., Choon, S.K.

Malays Orthop J, 2008;2(1):38-43.
MyJurnal

The safety of simultaneous bilateral total knee arthroplasty (TKA) remains controversial. The objective of the current study was to investigate perioperative morbidity and mortality rates within 30 days of simultaneous bilateral TKA. A detailed analysis of medical, surgical and anaesthesia records of 183 consecutive patients who underwent total knee arthroplasty between 2002 and 2006 was performed. The mean age of the patients was 67.6 years old. More than 80% had one or more co-morbidities, but none of them had ASA score greater than class 2. The mean hospital stay was 10 days, and the mean surgical time 156 minutes. Less than half of the patients (42.6%) required blood transfusion. The rate of perimorbidity was 15.3 % and there was no mortality in this series. We believe that simultaneous bilateral total knee arthroplasty is a safe and cost effective option for our patients, provided that patients are selected and informed appropriately.

Matched MeSH terms: Anesthesiology
Fulltext Treatment of Developmental Dysplasia of the Hip: Short and Mid-term Outcome

Malays Orthop J, 2011;5(1):17-20.
MyJurnal

Objective: To review the presentation and outcome of developmental dysplasia of the hip (DDH) cases in the last 6 years. Methodology:We retrospectively reviewed the presentation as well as short and mid-term outcome of 17children (18 hips) with DDH seen and treated from 2004 to 2010. Treatment was either splinting with Pavlik harness,closed or open reduction depending on age at presentation and the individual needs of each patient. Results:Theaverage age at presentation was 31.1 months, and the male to female ratio was 1:4.6. Six patients (35%) presented early(less than 6 months old) while 7 patients (41%) presented between 6 -24 months. In these 2 groups splinting or closed reduction under anaesthesia was initially utilized for treatment depending on age, and open reduction was use dafter failure of closed reduction and for those presented late.Average age at the time of closed reduction was 11 months,and 6 years for those underwent open reduction. The average period of follow up for all patients was 29.4 months. The final outcome was successful in 12 hips (66%) in 11 patients.Ten of these presented at less than 2 years old, in the other 6 hips in which there was failure, 50% presented after 3 years of age. Conclusion:Late presentation of DDH is still common in Malaysia, which necessitates more complex management and more frequent occurrences of unfavourable results.

Matched MeSH terms: Anesthesiology
Fulltext Isobolographic analysis of the hypnotic interaction between propofol and thiopental

Wong, W. H., Lim, T. A., Lim, K. Y.

Malaysian Journal of Medicine and Health Sciences, 2010;6(1):83-89.
MyJurnal

Introduction: Giving two intravenous anaesthetic agents simultaneously generally results in an additive effect. The aim of this study was to investigate the interaction between propofol and thiopental when given to patients who have had sedative premedication. Methods: Fifty patients were admitted into the study. All patients received oral midazolam 3.75 mg and intravenous fentanyl 100 mg before induction of anaesthesia. Twenty patients received an infusion of either propofol or thiopental while 30 patients received an infusion of an admixture of both drugs. Isobolographic analysis was used to determine the interaction between the two drugs. Results: The interaction between propofol and thiopental was
additive. The average dose at loss of the eyelash reflex for propofol and thiopental was 0.71 mg kg-1 and 1.54 mg kg-1 respectively. Premedication decreased the induction dose by 38.2%. Conclusion: Propofol and thiopental interact in an additive fashion when given at induction of anaesthesia.

Matched MeSH terms: Anesthesiology
Fulltext Debulking biopsy of a huge intraoral mass avoiding tracheostomy

Roselinda Abdul Rahman, Irfan Mohamad, Rohaizam Jaafar

Archives of Orofacial Sciences, 2015;10(2):65-68.
MyJurnal

Managing a patient with a huge intraoral mass is always challenging. Manipulation or even a simple biopsy of the mass may lead to hemorrhage and further compromise the airway. An examination under anesthesia is not without risk. The method of securing the airway itself may become an issue if the mass is fully occupying the airway before intubation. Usually a tracheostomy is indicated. We share a gentleman presented with a huge intraoral mass occupying the oropharynx, which initially necessitates tracheostomy. We utilized the ultrasonic scalpel-assisted instrument to biopsy by debulking the tumour, thus avoiding the tracheostomy while waiting for the definitive treatment.

Matched MeSH terms: Anesthesiology
Fulltext Dexamethasone and postoperative capillary glucose levels in type 2 diabetes mellitus

Elliza, R., Nadia, M.N., Azlina, M., Yeoh, C.N., Maryam, B., Hanita, O.

Journal of Surgical Academia, 2018;8(2):11-16.
MyJurnal

Perioperative intravenous (IV) dexamethasone is administered prophylactically for post operative nausea and vomiting. However, its glucocorticoid property which raises blood glucose is of concern, especially among diabetic patients. The surgical stress response also contributes to increased perioperative blood glucose. Prior studies showed higher glucose levels with dexamethasone 8 mg compared to 4 mg, hence we studied the effect of the lower dose amongst diabetic patients. This prospective, single blinded, randomised study recruited forty-six type 2 diabetes mellitus patients planned for surgery under general anaesthesia. They received IV dexamethasone 4 mg or saline (placebo) after induction of anaesthesia. Capillary blood glucose levels were recorded preoperatively, and subsequently at recovery (T0), and at 6, 12, 18 and 24 (T6, T12, T18, T24) hours post-operatively. Median glucose levels were higher at 9.0 [10.5-7.7] mmol/l in the dexamethasone group, versus 7.4 [9.2-5.9] mmol/l in the placebo group at T0, p = 0.022. Similarly at T6, the dexamethasone group recorded higher glucose levels of 11.2 [15.0-9.3] mmol/l, versus 7.7 [9.0-6.2] mmol/l in the placebo group, p = 0.001. This corresponded to a significant difference between the groups, in the change of glucose levels from baseline values, p = 0.042. Subsequent readings at T12, T18, and T24 were comparable between the groups. In conclusion, IV dexamethasone 4 mg in type 2 diabetic patients, resulted in higher glucose levels immediately postoperative and 6 hours later. The change in blood glucose from baseline levels was significant between the groups at 6 hours postoperatively. Glucose levels however remained within acceptable range of approved guidelines in both groups at all recorded intervals.

Matched MeSH terms: Anesthesiology
Coca leaf and cocaine addiction--some historical notes

Blejer-Prieto H

Can Med Assoc J, 1965 Sep 25;93(13):700-4.
PMID: 5318484

Coca-leaf habituation has affected millions of Andean natives for over 400 years. In the last half-century it has also involved millions more Malayans. Coca leaf, from which cocaine and extracts for some commercial carbonated soft drinks are obtained, remains relatively unknown by the medical and allied professions elsewhere. A review of the original medical, historical and other pertinent literature of the last 350 years illustrates the origins of the use of coca leaf, its spread, the isolation of cocaine and its first uses, as well as some of the euphoric and other effects of both substances.

Matched MeSH terms: Anesthesiology/history*
Fulltext Post-intubation airway related adverse effects: a aomparison between intra-cuff dexamethasone and intra-cuff alkalinized lignocaine

Kep, Kee W., Nadia, M.N., Melvin, K., Muhammad, M., Raha, R., Nurlia, Y.

Journal of Surgical Academia, 2013;3(2):26-31.
MyJurnal

Post-intubation airway related adverse effects such as coughing on the endotracheal tube (ETT), restlessness, hoarseness and sore throat are common and undesirable outcomes of anaesthesia using endotracheal intubation. This prospective randomized single blind study was carried out to compare the effectiveness of intra-cuff dexamethasone and alkalinized lignocaine in reducing the incidence of post-intubation airway related adverse effects. Eighty four patients aged 18 – 60 years, of ASA status I or II, were randomly allocated into three groups: air, dexamethasone and alkalinized lignocaine. Their ETT cuffs were inflated according to the group they were allocated to. The incidence of coughing on the ETT, restlessness, hoarseness and sore throat was assessed, postoperatively. The results showed a significant difference in the incidence of cough, restlessness, hoarseness and sore throat in the dexamethasone group compared to the air group. All the patients had minimal or no sore throat at all documented times. Both intra-cuff dexamethasone and alkalinized lignocaine significantly reduced the incidence of hoarseness. However, alkalinized lignocaine additionally lowered the incidence of restlessness, significantly.

Matched MeSH terms: Anesthesiology
Fulltext Routine intraoperative forced-air warmer usage in prevention of perioperative hypothermia: to use or not to use in daycare breast lumpectomy?

Nadia, H.I., Raha, A.R.

Journal of Surgical Academia, 2015;5(1):34-43.
MyJurnal

Intraoperative active warming in daycare surgery may be least popular compared to major elective surgeries due to the lesser risk of perioperative hypothermia. This prospective, single blind, randomized, controlled trial in daycare breast lumpectomy was done to evaluate the routine use of intraoperative forced-air warmer in the presence of other warming modalities in prevention of perioperative hypothermia. Fifty patients were randomized into two groups; Group 1 received forced-air warmer and Group 2 received a standard cotton thermal blanket. Both groups received circulating-water mattress. Intraoperatively, all patients received pre-warmed intravenous fluid with an in-line warmer. Ear and ambient temperature was recorded using infrared ear thermometer and digital thermo-hygrometer respectively. Measurement was done before induction, every 15 minutes intraoperatively, upon arrival in recovery room and 30 mins later, postoperatively. All patients were normothermic prior to induction of anaesthesia. During the initial half an hour post-induction, both groups mean core temperature decreased at approximately 0 ̊.C5 . Both showed no statistical difference in mean core temperature (0.04 ̊C) within the initial half an hour. The next half an hour, both groups had approximately 0 ̊.C2 decrement but this time, Group 2 had a slightly higher mean core temperature than Group 1 which maintained until the end of surgery. Overall, within the initial one hour post- induction of GA, there was a drop of 0.7 ̊C and 0.6°C in Group 1 and Group 2 respectively, however the difference in final mean core temperature between the two groups was 0.05°C and it was not statistically significant (p value < 0.05). None of the patients experienced intraoperative hypothermia (< 36 ̊C) and all remained in the normothermic range with no shivering or sense of feeling cold, postoperatively. The results of the present study found no significant difference in the changes of final core temperature with or without the usage of intraoperative forced-air warmer in the presence of other warming measures in daycare breast lumpectomy.

Matched MeSH terms: Anesthesiology
Comparison between the use of LMA™ and SLIPA™ in patients undergoing minor surgeries

Wan Rahiza, W.M., Nurlia, Y., Abd Rahman, I., Esa, K., Nadia, M.N., Raha, A. R.

Journal of Surgical Academia, 2012;2(1):8-13.
MyJurnal

Supraglottic airway devices have been used as safe alternatives to endotracheal intubation in appropriate types of surgery. This was a prospective, randomised, single blind study comparing the use of LMA™ and SLIPA™ in terms of ease of insertion, haemodynamic changes and occurrence of adverse effects (e.g. blood stains on the device upon removal and sore throat). A total of 62 ASA I or II patients, aged between 18 to 70 years were recruited for this study. Patients were randomised into two groups; LMA™ and SLIPA™ group. Following induction of anaesthesia, an appropriate sized LMA™ or SLIPA™ was inserted after ensuring adequate depth of anaesthesia. Anaesthesia was maintained with oxygen, nitrous oxide and sevoflurane. The ease of insertion was graded and haemodynamic changes were recorded at 2 minute intervals up to 10 minutes after insertion of the airway devices. The presence of blood stains upon airway device removal at the end of surgery and incidence of sore throat was also recorded. No difficult insertion was experienced in either of these devices. Insertion was either easy [LMA™ 87.1% versus SLIPA™ 80.6% (p = 0.49)] or moderate [LMA™ 12.9% versus SLIPA™ 19.4% (p = 0.16)]. Throughout the study period, the haemodynamic changes that occurred in both groups were not statistically different. Traces of blood were noted on the surface of the device in 9.7% of patients in the SLIPA™ group versus 6.5% of patients in the LMA™ group. The incidence of sore throat was recorded in 12.9% versus 19.4% of patients in the SLIPA™ and the LMA™ groups respectively. These findings were not statistically significant. In conclusion, this study showed no significant differences between the use of LMA™ and SLIPA™ in terms of ease of insertion, haemodynamic changes and adverse effects in patients undergoing minor surgical procedures.

Matched MeSH terms: Anesthesiology

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