Introduction: This prospective cross sectional study assessed surgical antibiotic prophylaxis (SAP) practice,
the incidence of surgical site infection (SSI) and its associated risks in Universiti Kebangsaan Malaysia Medical
Centre. Methods: Patients for elective colorectal, hepatobiliary, upper gastrointestinal, breast and
endocrine surgery, who received SAP were included and followed up until day-30 postoperatively. Types of
antibiotic, preoperative–dose timing, intraoperative re-dosing and its duration were recorded. The incidence
of SSI was calculated and its associated risks expressed in odds ratio. Results: Out of 166 patients recruited,
121 (72.89%) patients received SAP preoperatively, and 91 (75.21%) of them were prescribed the appropriate
antibiotic as per our institutional guideline. Three patients who continued to receive therapeutic antibiotic
postoperatively were excluded from statistical analysis. Eleven (9.10%) patients received SAP beyond the
preoperative–dose timing of 60 minutes (p=0.001), which was an independent risk factor for SSI (adjusted OR
4.527, 95% CI; 1.058-19.367, p=0.042). The risk of SSI also remained in patients who continued to receive
SAP beyond 24 hours (OR 4.667, 95% CI; 1.527-14.259, p=0.007). The overall rate of SSI was 17.18%.
Conclusion: We found that the choice of antibiotic prescribed for SAP was in accordance to institutional
guideline and the relatively high SSI incidence was similar to a recent local report. Although the number of
patients receiving preoperative dose-timing of > 60 minutes was low, it was nonetheless an independent risk
factor for SSI. The postoperative continuation of SAP for more than 24 hours showed no benefit in reducing
SSI.
This prospective crossover study compared the incidence of posterior vessel wall puncture between two approaches during ultrasound-guided simulated central venous cannulation by anaesthesiology trainees. Each phantom model, simulating a central vein and artery, was cannulated by 37 anaesthesiology trainees under ultrasound-guidance using the in-plane approach (IPA) and out-of-plane approach (OPA). Total procedural time and the time taken from starting image scanning until commencing puncture, was recorded. The number of attempts required to achieve successful venous cannulation was noted. Finally, the models were examined for posterior venous wall and arterial puncture. Total procedural time was shorter with the OPA (26.5 vs 50.3 seconds, p=0.001). The time taken from starting image scanning until commencing puncture was shorter for the OPA (2.2 vs 12.3 seconds, p
This prospective cross sectional studyassessed surgical antibiotic prophylaxis (SAP) practice, the incidence of surgical site infection (SSI) and its associated risks in Universiti Kebangsaan Malaysia Medical Centre. Methods: Patients for elective colorectal, hepatobiliary, upper gastrointestinal, breast and endocrine surgery, who received SAP were includedand followed up until day-30 postoperatively. Types of antibiotic, preoperative–dose timing, intraoperative re-dosing and its duration were recorded. The incidence of SSI was calculated and its associated risks expressed in odds ratio.Results: Out of 166 patients recruited, 121 (72.89%) patients received SAP preoperatively, and 91 (75.21%) of them were prescribed the appropriate antibiotic as per our institutional guideline. Three patients who continued to receive therapeutic antibiotic postoperatively were excluded from statistical analysis. Eleven (9.10%) patients received SAP beyond the preoperative–dose timing of 60 minutes (p=0.001), which was an independent risk factor for SSI (adjusted OR 4.527, 95% CI; 1.058-19.367, p=0.042). The risk of SSI also remained in patients who continued to receive SAP beyond 24 hours (OR 4.667, 95% CI; 1.527-14.259, p=0.007). The overall rate of SSI was 17.18%. Conclusion:We found that the choice of antibiotic prescribed for SAP was in accordance to institutional guideline and the relatively high SSI incidence was similar to a recent local report. Although the number of patients receiving preoperative dose-timing of > 60 minutes was low, it was nonetheless an independent risk factor for SSI. The postoperative continuation of SAP for more than 24 hours showed no benefit in reducing SSI.
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.
The tranversus abdominis plane (TAP) block for postoperative analgesia after caesarean section may confer potential benefits comparable to that of intrathecal opioids. We compared postoperative analgesia, and the incidence of nausea, vomiting, pruritus and sedation between the TAP block and intrathecal morphine (ITM) in patients undergoing Caesarean section. This was a prospective, randomised clinical study. Fifty American Society of Anaesthesiologists physical status I or II patients, planned for elective caesarean section under spinal anaesthesia, were randomly allocated to the TAP group (patients receiving spinal anaesthesia with bilateral TAP block without ITM) or ITM group (patients receiving spinal anaesthesia with ITM without a TAP block). Assessment for pain, postoperative nausea and vomiting, pruritus and sedation was done upon arrival and discharge from recovery, and at 6, 12 and 24 hours, postoperatively in the post natal ward. Results were analysed using analysis of variance (ANOVA). There was no pain at rest in either groups. Both groups experienced pain on movement at the 12th (p = 0.6) and 24th hour (p = 0.4). None of the patients in the TAP group experienced nausea, vomiting, pruritus or sedation. However, these incidences were found to be significantly higher in the ITM group. Ultrasound guided TAP block provided comparable postoperative analgesia to ITM without the side effects of the latter.
This prospective, randomised study compared the effectiveness of patient controlled epidural analgesia (PCEA) versus continuous epidural infusion (CEI) in providing pain relief post gynaecological surgery. Sixty six ASA I or II patients planned for gynaecological surgery via Pfannensteil incision under combined spinal epidural anaesthesia were recruited. They were randomised into two groups: Group A patients received PCEA while Group B patients received CEI. In the recovery area, both groups received an epidural combination of levobupivacaine 0.1% and fentanyl 2 μg/ml. Group A patients were allowed demand bolus doses of 5 ml with a 20 minute lockout interval, while Group B patients had their epidural infusion initiated at 6 ml/hour with increments as required to a maximum of 12 ml/hour. Pain score and degree of motor blockade was assessed hourly in the first four hours and subsequently at four hourly intervals. Side effects were recorded at four-hourly interval. The total amount of analgesia, number of anaesthetic interventions and patient satisfaction was assessed 24 hours, postoperatively. There was no significant difference in pain score, total amount of analgesia, number of anaesthetic interventions and patient satisfaction. The degree of motor blockade and side effects were comparable between the groups. In conclusion, PCEA was comparable to CEI for pain relief after gynaecological surgery.
This study aimed to compare dexmedetomidine and propofol, in terms of haemodynamic parameters, respiratory rates and offset times, when used for sedation in patients undergoing elective orthopaedic and surgical procedures under regional anaesthesia. This was a prospective, randomised, single-blind study where 88 patients were recruited. Patients were randomised into two groups to receive either dexmedetomidine or propofol infusion. Central neuraxial blockade (spinal, epidural or combined spinal epidural) was performed. After ensuring an adequate block and stable haemodynamic parameters, dexmedetomidine was infused 15 minutes later at 0.4 μg/kg/hr, and propofol, at a target concentration of 2.5 μg/ml. Both drugs were titrated to achieve a bispectral index score of 70 before surgery commenced. Sedation level was monitored using the bispectral index score and assessed by the Observer Assessment of Alertness Scale score. Drug infusion was adjusted to maintain bispectral index scores ranging between 70-80 during surgery. Both groups showed reductions in mean arterial pressure and heart rate from baseline readings throughout the infusion time. However there was no significant reduction in the first 15 minutes from baseline (p > 0.05). Haemodynamic parameters and respiratory rate between both groups were not significantly different (p > 0.05). No patient demonstrated significant respiratory depression or SpO2 ≤ 95%. Offset times were also not significantly different between both groups (p = 0.594). There were no significant differences in haemodynamic parameters, respiratory rates and offset times between dexmedetomidine and propofol used for sedation in patients undergoing elective orthopaedic and surgical procedures under regional anaesthesia.
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.
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.