Malaysian Journal of Anaesthesiology

Optimal nutritional therapy in critically ill patients: a narrative review

Mohd Basri Mat Nor — 2024-06-25

Inadequate nutrition delivery remains a pervasive issue in critically ill patients, with significant challenges in accurately measuring nutritional requirements and personalising nutrition. Current medical nutrition therapy is constrained by difficulty in objectively measuring nutritional requirements and patient responses. Both enteral and parenteral nutrition are effective, but achieving and assessing nutritional targets pose substantial challenges. The adoption of computerised nutrition monitoring is on the rise, with future strategies potentially incorporating advanced muscle monitoring tools such as ultrasound and bioelectrical impedance analysis (BIA). Early enteral nutrition has been shown to reduce complications and shorten ICU stays; however, it should be delayed in specific conditions such as gastrointestinal bleeding. When EN is not feasible, PN serves as a safe alternative. Indirect calorimetry offers a method to measure energy expenditure and guide nutritional interventions, though larger trials are necessary to validate its benefits in personalised nutrition strategies. Significant muscle mass loss is prevalent in ICU patients, necessitating optimal amino acid delivery. Protein intake should be tailored to lean mass rather than total body weight, and bedside techniques like BIA and muscle ultrasound can aid in personalising protein delivery. While high protein intake may help mitigate muscle loss, its effect on clinical outcomes remains debated. Further trials are essential to enhance personalised ICU nutrition and improve patient outcomes throughout their ICU and post-ICU care journey.

Comparative study on efficacy of ultrasound-guided supraclavicular versus costoclavicular brachial plexus block in patients for arteriovenous fistula surgery

Rhendra Hardy Mohamad Zaini — 2024-06-25

Background: Patients with end-stage renal failure (ESRF) who require arteriovenous fistula (AVF) creation often have multiple comorbidities, making the brachial plexus block a suitable choice for anaesthesia. The objective of this study is to compare the efficacy of ultrasound-guided supraclavicular and costoclavicular brachial plexus blocks for AVF creation.

Methods: A total of 70 patients scheduled for the creation of AVF in the distal upper extremity were randomly assigned to 2 groups: supraclavicular block (SCB), Group A: n = 35, and costoclavicular block (CCB), Group B: n = 35. Both groups received 20 ml of 0.5% ropivacaine and 10 ml of 1% lidocaine. The measured parameters included the speed of onset of motor and sensory blockade, the quality of blockade, procedural-related pain score, patient satisfaction, and regional perfusion.

Results: The costoclavicular block demonstrated a significantly faster onset to achieve complete paralysis (p = 0.01) in all sensory and motor nerves compared to the supraclavicular block. Additionally, there was a significant difference in regional perfusion, with higher perfusion observed in the supraclavicular block (p = 0.013). However, there were no significant differences in the quality of block (p = 0.573), and procedural-related pain score (p = 0.117) between the 2 groups.

Conclusion: The costoclavicular block offers a faster onset of sensory and motor blockade compared to the supraclavicular block. However, they are comparable in terms of the quality of the block and procedural-related pain. This new technique can be considered as an alternative for providing anaesthesia in patients with ESRF
undergoing AVF creation.

Development of a nomogram for predicting perioperative blood transfusions in major hepatobiliary and colorectal surgeries: a retrospective study

Mohamad Zahir Anverdeen — 2024-06-25

Background: Major hepatobiliary and colorectal surgeries are associated with a risk of blood transfusions. However, risk assessment tools for predicting blood transfusions have not been studied extensively among patients undergoing these types of surgeries. We evaluated the risk factors for perioperative blood transfusions in patients who underwent major hepatobiliary and colorectal surgeries and subsequently created a nomogram.

Methods: Medical records of patients who underwent elective major hepatobiliary and colorectal surgeries in a single university hospital in Malaysia from 2015 to 2020 were retrospectively reviewed. A nomogram to predict transfusions risk was developed, and its discriminatory ability was tested using the area under the receiver operating characteristic (ROC) curve.

Results: Data from 293 patients (61.1% male) with an average age of 59.7 years (± SD 14.51) were analysed. The prevalence of anaemia was 61.1%. A total of 127 patients (43.3%) received at least 1 unit of packed red cells transfusions. On multivariable analysis, gender (odds ratio [OR 1.646), preoperative haemoglobin of 8.0 g/dl or less (OR 0.777), Charlson Comorbidity Index score (OR 1.14) and procedure type (versus colonic surgery, major hepatectomy, OR 6.094; other pancreatomy, OR 1.487; Whipple’s procedure, OR 9.667; and anterior resection, OR 3.569) were associated with a significantly higher risk of transfusions. All 4 of these factors were included in the nomogram. The nomogram’s discrimination and calibration results showed an AUROC curve of 0.754.

Conclusion: The nomogram effectively predicted the need for blood transfusions in major colorectal and hepatobiliary surgeries in our patients.

Our choices in the face of genocide: resistance or collaboration

Shahridan Mohd Fathil — 2024-06-25

Erector spinae plane block with ropivacaine 0.2% in children: a single-centre case series in a tertiary paediatric centre in Malaysia

Jie Cong Yeoh — 2024-06-25

Erector spinae plane block (ESPB) was first described in 2016 by Forero et al. as a modified interfascial plane block used for patients with chronic neuropathic thoracic pain. It was applied in the paediatric population for postoperative pain management as early as 2017. Most evidence on the efficacy of ESPB as postoperative analgesia in the literature is mainly found in case reports, but very few trials had been conducted. This case series describes 4 paediatric patients who received ESPB as part of multimodal analgesia while undergoing different types of surgery,i.e., 1 Kasai procedure, 1 closure of stoma, and 2 thoracotomies. All 4 patients had general anaesthesia for the surgery. No complications were observed in relation to the regional anaesthetic technique. Pain control was achieved with a pain score of 0–2 for 3 patients and 2–4 for 1 patient (thoracotomy) on Day 1 postoperatively, while all of them a had pain score of 0–2 on postoperative Day 2. We found ESPB with ropivacaine 0.2% to be a safe and effective analgesia as part of multimodal management of postoperative surgical pain. Further studies are needed to validate this observation.

Propofol-induced postoperative unconsciousness in hepatocellular carcinoma

Mohammad Faiz Taqiyuddin Mohd Nor — 2024-06-25

Although propofol is a commonly used medication for inducing general anaesthesia, it is not without side effects. In this case report, we present a patient with hepatocellular carcinoma who experienced postoperative unconsciousness following general anaesthesia induction using propofol. While this is a rare occurrence, it underscores the importance of remaining vigilant and understanding propofol’s pharmacokinetic properties. The drug can be redistributed from fat tissues into the systemic circulation, resulting in delayed recovery and potential adverse effects. We also discuss the possible impact of disease interactions, particularly hepatic impairment with possible CYP450 deficiency, on propofol metabolism. We stress the necessity of closely monitoring patients during anaesthesia induction and maintenance.

Misoprostol-induced seizures following self-abortion: a rare, but repeated occurrence

Darshelaan Purushotmanan — 2024-06-25

Misoprostol is a synthetic prostaglandin E1 (PGE) analogue used for medical termination of pregnancy, managing miscarriage, inducing labour, cervical ripening, and treating postpartum haemorrhage. Generally, it is safe and well-tolerated, with dose-dependent adverse effects such as nausea, vomiting, diarrhoea, abdominal pain, fever, and headache that usually resolve within a few days. However, seizures are a rare complication, occurring primarily in patients with a history of epilepsy or a predisposition to seizures and is associated with high doses and rapid administration. This case report highlights the repercussions of a misoprostol overdose used for pregnancy termination, leading to seizures induced by hyperthermia. The first patient required temporary invasive ventilation and resuscitation but recovered, whereas the second patient receiving a lower dose, exhibited milder symptoms. Both patients received psychosocial counselling prior to discharge.

Bradycardic peri-arrest after electrical cardioversion for atrial fibrillation: a case report

Jinxuan Cai — 2024-06-25

Electrical cardioversion can precipitate prolonged bradycardia and cardiac arrest when the sinoatrial node is dysfunctional, and the escape rhythms from the atrioventricular node and ventricles fail to take over. We report the case of an elderly male who rapidly progressed into bradycardic peri-arrest after electrical cardioversion for persistent atrial fibrillation. Despite the immediate initiation of intravenous atropine and transcutaneous pacing, 2 minutes of cardiopulmonary resuscitation with further boluses of atropine and adrenaline were required before the return of spontaneous circulation. The patient was transferred to the intensive care unit, and a permanent pacemaker was implanted before discharge. Advanced age, long duration of atrial fibrillation, previous aortic valve replacement, use of anti-arrhythmic drugs, and intravenous propofol bolus were all contributing factors to this event. We summarise the relevant clinical features, risk factors, and management considerations, in the hope of promoting awareness of this rare complication of a common procedure.