A survey of anaesthetic training logbook management among postgraduate students.

BACKGROUND: A logbook system is essential to ensure standardized competency in medical education. This survey will provide the first overview of our current logbook and can serve as an initial proposal for improvement to a more relevant and valuable tool to assess our postgraduate training programme. METHODS: This survey was conducted among all Universiti Kebangsaan Malaysia (UKM) anaesthetic trainees. The data for this survey was collected by using Google Forms. A link to the form was distributed to all UKM anaesthetic trainees. The survey questionnaire consisted of five sections, demographic data, strengths and weaknesses of logbook content, evaluation of logbook usage experience, perception of the feedback received regarding the logbook performance, and potential improvements that can be made. RESULTS: 107 anaesthetic trainees participated in this study. All of the sections in the logbook were deemed relevant by more than 60% of the trainees except for the on-call section which was seen as relevant only by 37.4% of them. 53.3% agreed that the logbook is useful for learning during the course. However, only 43.9% of them perceived that the logbook was easy and convenient to use. Only 59 respondents received feedback regarding their logbook performance. The analysis of open-ended answers highlights the necessity of transitioning to a fully digitalized logbook system for easy accessibility. It also reveals the need to re-evaluate specific logbook contents and incorporate additional teaching and learning tools to enhance the overall training process. Moreover, the findings emphasize the importance of effectively implementing feedback mechanisms within the logbook system to optimize student learning. CONCLUSION: Serving as a foundational step towards developing a more efficient and structured educational tool, this research provides valuable insights for future advancements in medical education, particularly in anaesthesiology.

A Veiled Lymphatic Malformation: Stridor in a Child.

Lymphatic malformation (LM) is a congenital lymphatic dysplasia associated with the p110α subunit of PI3K (PIK3CA) mutation. A two-year-old boy presented with a history of noisy breathing from the age of two months, which was progressively worsening. Inspiratory stridor was audible with subcostal recession. Flexible nasopharyngolaryngoscopy (FNPLS) revealed an enlarged right arytenoid. Other supraglottic structures were normal, and bilateral vocal cords were mobile. Direct laryngoscopy showed that the right arytenoid was enlarged with a smooth surface. On the subsequent visit, there was a painless soft lateral neck swelling, 4 cm x 4 cm in size, with normal skin. MRI confirmed LM with the predominantly macro-cystic component, involving primarily the right neck and upper mediastinum, causing airway compression. Sirolimus therapy was initiated, and at one month of follow-up after the treatment, his stridor had improved. The incidence of stridor secondary to head and neck tumors such as teratomas, hemangiomas, and LM accounts for less than 3%. The typical manifestation of LM often involves a painless, soft, and compressible mass that progressively increases in size. Features of macrocystic LM on MRI are multilocular and hyperintense cystic mass on T2-weighted imaging. The treatment methods for LM include surgical and non-surgical options. Despite being an off-label application, the response rate of sirolimus therapy in children with LM is reported to be 91%, and the first clinical response was observed in less than three weeks. Stridor is frequently encountered in children but rarely due to head and neck tumors. However, as in our case, a large LM may cause recurrent airway obstruction, and the neck swelling may appear later. Atypical airway findings, especially endoscopic examination, in a child with stridor should be complemented with imaging to examine the possibility of extra-laryngeal mass or external compression.

Effects of MDR1 and OPRM1 genetic polymorphisms on the pharmacodynamics of propofol-remifentanil TIVA in pediatrics.

Aims: To investigate the roles of MDR1 (1236C>T, 2677G>T/A, and 3435C>T) and OPRM1 (118A>G) gene polymorphisms on the anesthetic and adverse effects of propofol-remifentanil total intravenous anesthesia in pediatric surgery. Materials & methods: The genotypes were identified through Sanger sequencing. The clinical data including hemodynamics on anesthesia, postanesthesia pain and sedation score and the occurrence of adverse effects were recorded and compared against the genetic data. Results: A total of 72 pediatric patients undergoing surgery were recruited. A weak to no association was found between the genetic polymorphisms of MDR1 and OPRM1 and the anesthetic and adverse effects of propofol-remifentanil. Conclusion: Genetic polymorphisms in OPRM1, but not in MDR1, gene polymorphism, demonstrated plausible association with the effects of propofol-remifentanil.

Performance of Point-of-Care Ultrasonography in Confirming Feeding Tube Placement in Mechanically Ventilated Patients.

BACKGROUND: A feeding tube (FT) is routinely placed in critically ill patients, and its correct placement is confirmed with a chest X-ray (CXR), which is considered the gold standard. This study evaluated the diagnostic accuracy of ultrasonography (USG) in verifying FT placement compared to a CXR in an intensive care unit (ICU). METHOD: This was a prospective single-blind study conducted on patients admitted to the ICU of a tertiary hospital in Malaysia. The FT placements were verified through a fogging test and USG at the neck and subxiphoid points. The results of confirmation of FT placement through USG were compared with those obtained using CXRs. RESULTS: A total of 80 patients were included in this study. The FT positions were accurately confirmed by overall USG assessments in 71 patients. The percentage of FT placements correctly identified by neck USG was 97.5%, while the percentage of those identified by epigastric USG was 75%. The corresponding patients' CXRs confirmed correct FT placement in 76 patients. The overall USG assessment had a sensitivity of 92.11% and specificity of 75%, a positive predictive value of 98.59%, and a negative predictive value of 33.33%. The USG findings also showed a significant association between FT size and BMI. FTs with a size of 14Fr were better visualized (p = 0.008), and negative USG findings had a significantly higher BMI (p < 0.001). CONCLUSION: USG is a simple, safe, and reliable bedside assessment that offers relatively high sensitivity in confirming correct FT placement in critically ill patients.

Ultrasound-Determined Residual Gastric Volume after Clear-Fluid Ingestion in the Paediatric Population: Still a Debatable Issue.

Background: Current fasting guidelines are often exceeded in clinical practice, resulting in stressful events during anaesthesia in children. This prospective study compares residual gastric volume after 1 versus 2 h of clear fluid ingestion in fasted children. METHODS: A total of 106 patients were enrolled in the study. Ultrasonography (USG) of gastric antrum (GA) was performed in the supine and right lateral decubitus (RLD) positions. All children fasted from solid food for 6 h. Blackcurrant flavoured drink (3 mL/kg) was given following the measurement of baseline (T0) USG of GA, with follow-ups after 1 (T1) and 2 (T2) hours post-ingestion. Residual gastric volume (RGV) was calculated from the cross-sectional area of GA using a standard formula. Parental satisfaction with their children's behaviour concerning fasting time was recorded. Results: RGV was significantly higher at T1 compared to T2 (p < 0.001). No significant difference was seen between T0 and T2 (p = 0.30). Parental satisfaction was similar at T1 and T2 (p = 0.158). Conclusions: The RGV in paediatric patients after 1 h of clear fluid ingestion was significantly higher than after 2 h of ingestion. There was no difference observed in parental satisfaction concerning the two intervals of fluid fasting. RLD and supine positions can be used reliably to measure the RGV in children.

Acute Kidney Injury following Rhabdomyolysis in Critically Ill Patients.

INTRODUCTION: Rhabdomyolysis, which resulted from the rapid breakdown of damaged skeletal muscle, potentially leads to acute kidney injury. AIM: To determine the incidence and associated risk of kidney injury following rhabdomyolysis in critically ill patients. METHODS: All critically ill patients admitted from January 2016 to December 2017 were screened. A creatinine kinase level of > 5 times the upper limit of normal (> 1000 U/L) was defined as rhabdomyolysis, and kidney injury was determined based on the Kidney Disease Improving Global Outcome (KDIGO) score. In addition, trauma, prolonged surgery, sepsis, antipsychotic drugs, hyperthermia were included as risk factors for kidney injury. RESULTS: Out of 1620 admissions, 149 (9.2%) were identified as having rhabdomyolysis and 54 (36.2%) developed kidney injury. Acute kidney injury, by and large, was related to rhabdomyolysis followed a prolonged surgery (18.7%), sepsis (50.0%) or trauma (31.5%). The reduction in the creatinine kinase levels following hydration treatment was statistically significant in the non- kidney injury group (Z= -3.948, p<0.05) compared to the kidney injury group (Z= -0.623, p=0.534). Significantly, odds of developing acute kidney injury were 1.040 (p<0.001) for mean BW >50kg, 1.372(p<0.001) for SOFA Score >2, 5.333 (p<0.001) for sepsis and the multivariate regression analysis showed that SOFA scores >2 (p<0.001), BW >50kg (p=0.016) and sepsis (p<0.05) were independent risk factors. The overall mortality due to rhabdomyolysis was 15.4% (23/149), with significantly higher incidences of mortality in the kidney injury group (35.2%) vs the non- kidney injury (3.5%) [ p<0.001]. CONCLUSIONS: One-third of rhabdomyolysis patients developed acute kidney injury with a significantly high mortality rate. Sepsis was a prominent cause of acute kidney injury. Both sepsis and a SOFA score >2 were significant independent risk factors.

Analysis of cricoid pressure application: anaesthetic trainee doctors vs. nursing anaesthetic assistants.

BACKGROUND AND OBJECTIVE: To evaluate the ability of anaesthetic trainee doctors compared to nursing anaesthetic assistants in identifying the cricoid cartilage, applying the appropriate cricoid pressure and producing an adequate laryngeal inlet view. METHODS: Eighty-five participants, 42 anaesthetic trainee doctors and 43 nursing anaesthetic assistants, were asked to complete a set of questionnaires which included the correct amount of force to be applied to the cricoid cartilage. They were then asked to identify the cricoid cartilage and apply the cricoid pressure on an upper airway manikin placed on a weighing scale, and the pressure was recorded. Subsequently they applied cricoid pressure on actual anaesthetized patients following rapid sequence induction. Details regarding the cricoid pressure application and the Cormack-Lehane classification of the laryngeal view were recorded. RESULTS: The anaesthetic trainee doctors were significantly better than the nursing anaesthetic assistants in identifying the cricoid cartilage (95.2% vs. 55.8%, p=0.001). However, both groups were equally poor in the knowledge about the amount of cricoid pressure force required (11.9% vs. 9.3% respectively) and in the correct application of cricoid pressure (16.7% vs. 20.9% respectively). The three-finger technique was performed by 85.7% of the anaesthetic trainee doctors and 65.1% of the nursing anaesthetic assistants (p=0.03). There were no significant differences in the Cormack-Lehane view between both groups. CONCLUSION: The anaesthetic trainee doctors were better than the nursing anaesthetic assistants in cricoid cartilage identification but both groups were equally poor in their knowledge and application of cricoid pressure.

[Analysis of cricoid pressure application: anaesthetic trainee doctors vs. nursing anaesthetic assistants]. / Análise da aplicação de pressão cricoide: residentes em anestesiologia vs. enfermeiros assistentes de anestesia.

BACKGROUND AND OBJECTIVE: To evaluate the ability of anaesthetic trainee doctors compared to nursing anaesthetic assistants in identifying the cricoid cartilage, applying the appropriate cricoid pressure and producing an adequate laryngeal inlet view. METHODS: Eighty-five participants, 42 anaesthetic trainee doctors and 43 nursing anaesthetic assistants, were asked to complete a set of questionnaires which included the correct amount of force to be applied to the cricoid cartilage. They were then asked to identify the cricoid cartilage and apply the cricoid pressure on an upper airway manikin placed on a weighing scale, and the pressure was recorded. Subsequently they applied cricoid pressure on actual anaesthetized patients following rapid sequence induction. Details regarding the cricoid pressure application and the Cormack-Lehane classification of the laryngeal view were recorded. RESULTS: The anaesthetic trainee doctors were significantly better than the nursing anaesthetic assistants in identifying the cricoid cartilage (95.2% vs. 55.8%, p=0.001). However, both groups were equally poor in the knowledge about the amount of cricoid pressure force required (11.9% vs. 9.3% respectively) and in the correct application of cricoid pressure (16.7% vs. 20.9% respectively). The three-finger technique was performed by 85.7% of the anaesthetic trainee doctors and 65.1% of the nursing anaesthetic assistants (p=0.03). There were no significant differences in the Cormack-Lehane view between both groups. CONCLUSION: The anaesthetic trainee doctors were better than the nursing anaesthetic assistants in cricoid cartilage identification but both groups were equally poor in their knowledge and application of cricoid pressure.

Comparing the effectiveness of ropivacaine 0.5% versus ropivacaine 0.2% for transabdominis plane block in providing postoperative analgesia after appendectomy.

OBJECTIVE: The basis for the transversus abdominis plane (TAP) block involves infiltration of a local anesthetic into the neurofascial plane between the internal oblique and the transversus abdominis muscles, causing a regional block that spreads between the L1 and T10 dermatomes. Thus, the TAP block is said to be suitable for lower abdominal surgery. This study was designed to compare the analgesic efficacy of two different concentrations of ropivacaine for TAP block in patients undergoing appendectomy. METHODS: Fifty-six patients with American Society of Anesthesiologists physical status I or II, aged 18 years and above, undergoing appendectomy were recruited in this prospective, randomized, double-blind study. They were divided into two groups: Group A patients who received 0.5 mL/kg of ropivacaine 0.5% and Group B patients who received 0.5 mL/kg of ropivacaine 0.2% via TAP block under ultrasound guidance. Postoperative pain was assessed using the visual analog scale upon arrival at the recovery room in the operating theatre, just prior to being discharged to the ward, and at 6 hours, 12 hours, 18 hours, and 24 hours postoperatively to compare the effectiveness of analgesia. RESULTS: Intraoperatively, patients in Group B required a significantly greater amount of additional intravenous fentanyl than those in Group A. There were no significant statistical differences in pain scores at rest and on movement at all assessment times as well as in the dose of 24-hour intravenous morphine consumption given via patient-controlled analgesia postoperatively between the two groups. CONCLUSION: The effectiveness of two different concentrations of ropivacaine (0.5% versus 0.2%) given via TAP block was comparable in providing postoperative analgesia for patients undergoing appendectomy.

Analysis of cricoid pressure application: anaesthetic trainee doctors vs. nursing anaesthetic assistants / Análise da aplicação de pressão cricoide: residentes em anestesiologia vs. enfermeiros assistentes de anestesia

ABSTRACT BACKGROUND AND OBJECTIVE: To evaluate the ability of anaesthetic trainee doctors compared to nursing anaesthetic assistants in identifying the cricoid cartilage, applying the appropriate cricoid pressure and producing an adequate laryngeal inlet view. METHODS: Eighty-five participants, 42 anaesthetic trainee doctors and 43 nursing anaesthetic assistants, were asked to complete a set of questionnaires which included the correct amount of force to be applied to the cricoid cartilage. They were then asked to identify the cricoid cartilage and apply the cricoid pressure on an upper airway manikin placed on a weighing scale, and the pressure was recorded. Subsequently they applied cricoid pressure on actual anaesthetized patients following rapid sequence induction. Details regarding the cricoid pressure application and the Cormack-Lehane classification of the laryngeal view were recorded. RESULTS: The anaesthetic trainee doctors were significantly better than the nursing anaesthetic assistants in identifying the cricoid cartilage (95.2% vs. 55.8%, p = 0.001). However, both groups were equally poor in the knowledge about the amount of cricoid pressure force required (11.9% vs. 9.3% respectively) and in the correct application of cricoid pressure (16.7% vs. 20.9% respectively). The three-finger technique was performed by 85.7% of the anaesthetic trainee doctors and 65.1% of the nursing anaesthetic assistants (p = 0.03). There were no significant differences in the Cormack-Lehane view between both groups. CONCLUSION: The anaesthetic trainee doctors were better than the nursing anaesthetic assistants in cricoid cartilage identification but both groups were equally poor in their knowledge and application of cricoid pressure.

RESUMO JUSTIFICATIVA E OBJETIVO: Avaliar a capacidade de residentes em anestesiologia em comparação com enfermeiros assistentes de enfermagem para identificar a cartilagem cricoide, aplicar a pressão cricoide adequada e produzir uma vista adequada da entrada da laringe. MÉTODOS: Foram convidados 85 participantes, 42 residentes em anestesiologia e 43 enfermeiros assistentes de enfermagem a responder questionários sobre a quantidade correta de força a ser aplicada na cartilagem cricoide. Os participantes deviam identificar a cartilagem cricoide e aplicar a pressão cricoide em modelos de vias aéreas superiores colocados sobre uma balança de pesagem e a pressão era registada. Posteriormente, aplicaram pressão cricoide em pacientes anestesiados reais após a indução de sequência rápida. Os detalhes sobre a aplicação de pressão cricoide e a classificação de Cormack-Lehane da visibilidade da laringe foram registrados. RESULTADOS: Os residentes em anestesiologia foram significativamente melhores do que os enfermeiros assistentes de enfermagem na identificação da cartilagem cricoide (95,2% vs. 55,8%, p = 0,001). No entanto, o conhecimento de ambos os grupos era precário sobre a quantidade de força necessária para aplicar a pressão cricoide (11,9% vs. 9,3%, respectivamente) e a correta aplicação da pressão cricoide (16,7% vs. 20,9%, respectivamente). A técnica de três dedos foi aplicada por 85,7% dos residentes em anestesiologia e 65,1% dos enfermeiros assistentes de enfermagem (p = 0,03). Não houve diferença significativa entre os dois grupos em relação à classificação de Cormack-Lehane para a visão. CONCLUSÃO: Os residentes em anestesiologia foram melhores do que os enfermeiros assistentes de enfermagem para identificar a cartilagem cricoide, mas ambos os grupos apresentaram um conhecimento igualmente precário sobre a aplicação de pressão cricoide.