BeritaAnestesiologi Nov2021 Vol30

VOLUME 30 • ISSUE 3 • NOVEMBER 2021
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AMA BI
TA N D A L A M
Malaysian Society College of

of Anaesthesiologists Anaesthesiologists, AMM
Message from the President of the MSA
Professor Dr Ina Ismiarti Shariffuddin
Dear Members, as a supplement of the UKM's Medicine and Health

Journal. In this congress, MSA conferred honorary
Over the last two years, fighting the COVID-19 pandemic membership on Professor Dr Haji Karis Misran. We also
has been a challenge. Alhamdulillah, we have stood strong had our first virtual AGM. I would like to congratulate and
together as a fraternity to serve the Malaysian public and welcome the MSA Executive Committee 2021-2022 and
combat the unseen enemy. Through TEAMWORK, we thank the immediate past president, Professor Dr Marzida
have developed endurance and resilience in facing Mansor, for her excellent leadership and all the previous
hardship. The shortcomings, in terms of hospital facilities Executive Committee members for sacrificing their
and equipment, have taught us creativity as we strive to precious time and effort for the Society.
provide the best care for critically ill patients. Despite
stretching our limited resources, we tried to give a fair National Anaesthesia Day Celebration 2021
chance to every patient and had to make difficult choices Every year, on 16th October, we celebrate World
and decisions; many of which weight heavy on the mind. Anaesthesia Day to commemorate the birth of
anaesthesia. The NAD 2021 was launched by the Yg Bhg
Many of us faced a lot of stress and, I believe, suffered Tan Sri Dato' Seri Dr Noor Hisham Abdullah, the
mental and physical breakdowns as a consequence of Director-General of Health. The theme of our celebration
being the last line of frontliners. However, moving forward, this year is "Stronger Together."
much more needs to be done to persevere in this battle
against COVID-19. First and foremost, we need to reopen The celebration was unique, as this was the first time it
our anaesthetic services for elective cases which, was organised by the private anaesthesiologists group
unfortunately, have taken a back seat for the last year. We in collaboration with the MSA and the College of
will be instrumental in overcoming the backlog of Anaesthesiologists. The organising chair was Dr Gunalan
postponed cases. Again, we will need to answer the call to Palari Arumugam. We believe that everyone enjoyed the
arms. So, dear colleagues and friends, take a rest, have a activities conducted by the organising committee to
break, recharge, come back stronger with more passion to encourage all our members to embrace the NAD theme.
providing the best anaesthetic care we can to our patients.
The virtual fun run garnered over 9600 pledges from 1981
I am humbled by the opportunity to serve as President and runners for 51 registered teams representing the various
honoured to lead MSA for the year 2021-2023. We are hospitals. This was truly an amazing response from the
blessed with many dedicated volunteers who care deeply anaesthesia fraternity and the public, pledging their runs to
about our discipline, its standing, and contributions in a their favourite hospitals. Congratulations to the 'Hobin
fast-changing environment. We will do our best to make Jang Hobin' runners, representing Hospital Tuanku Ja’afar
you proud of your association with the Society. Seremban, for the commanding victory. They took home
a trophy and prize money of RM2000. The Quiz also
Since the last Newsletter in July 2021, MSA has organised attracted participation from 173 anaesthesiologists and
activities as listed below: future anaesthesiologists. The first prize winner, Dr Gary
Leong Wei Kean, took home a cash prize of RM250. We
MSA & CoA ASC 2021 received entries from 10 hospitals all over Malaysia for our
This year we had our first virtual annual scientific congress "Anaesthesiologist's got talent" competition on this special
from 6th to 8th August 2021. The congress successfully day. The HKL team won the competition and took home a
attracted 1393 delegates, including foreign delegates from cash prize of RM1000.
South Korea and the Philippines. We had 62 speakers,
consisting of 23 international speakers and 39 local We also conducted an interesting forum, tackling the very
speakers. Nineteen pharmaceutical companies participated pertinent topic of resilience, in which renowned senior and
in the virtual booth exhibition. The abstracts for oral and young anaesthesiologists shared their views and
poster presentations from this congress will be published experiences on maintaining resilience in Anaesthesia. The
continued on page 3
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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
A Day in the Life…in a COVID ICU 17 - 18

continued from page 2
History of Anaesthesiology in Malaysia 19 - 24
celebration ended with the launching of the MSA Yearbook 2020/2021
on the theme 'Evolution and Revolution'. The book looked upon the past The Cold Truth About Hypothermic Therapy 25 - 26
and how it has evolved or revolved to the current practice and future Post-Cardiac Arrest
prospects. It covered specific domains in Anaesthesiology, which
A Novel Way of Positioning for Intubation: 27 - 30
includes Clinical Anaesthesiology, Critical Care, and Pain Medicine. The Bed-Up-Head-Elevated Using Bed Controls
celebration's peak was the soft launch of the Malaysian Journal of
Anaesthesiology (MyJA), the official journal of the MSA and the College My Journey 31 - 32
of Anaesthesiologists. The first edition of this peer-reviewed journal is
MyAnaesthesia 2021: Dawn of a New Era 33 - 34
expected to be published in March 2022. We encourage all members to
send in their case reports or case series, original research articles, and National Anaesthesia Day 2021 35 - 37
brief communication to MyJA. All submission details can be found on
My National Anaesthesia Day 2021: KPJ Pahang 38 - 39
myja.pub starting from next month. Specialist Hospital
K. Inbasegaran Research Grant Teamwork - I love our team 40 - 41

The MSA is pleased to support budding researchers in our fraternity. We National Anaesthesia Day 2021, UMMC
hope to receive many applications for the K. Inbasegaran Research Hosting the First Ever Virtual Pre-Entrance 42 - 43
grant, as the application date is still open until 31st December 2021. A Anaesthesia Workshop
special committee has been set up to evaluate all the applications, and
the results will be announced in the first quarter of 2022. Basic Transesophageal Echocardiography for 44 - 46
Anaesthesiologist
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 secretariat@msa.asm.org.my. 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
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Anestesiologi • Malaysian Society of Anaesthesiologists

• College of Anaesthesiologists, AMM PAGE 3
A COVID Diary of Hospital Sungai Buloh
by Dr Eng Kar Seng
Hospital Sungai Buloh
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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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.
We had to increase our bed capacity gradually up to twice

our COVID patient capacity (60 ICU beds) given the
relentless referrals of category five patients. It was very
tough and taxing as we struggled with an inadequate
number of doctors and nurses. Referrals were coming
from both government and private hospitals in the Klang
Valley. We could never have survived this phase without
the prompt arrival of fresh anaesthesiology Master
graduates from various universities and intensivists from
government and university hospitals. Non-ICU trained
ward and clinic nurses were relocated and sent to ICU for
a daunting task. A buddy system was quickly created to
guide the junior nurses. To achieve good patient
outcomes, a treatment protocol was revised and adhered Prone ventilation remained our best weapon to improve
to (both by doctors and nurses). The number of lung oxygenation. The commitment of the team of
admissions peaked in January 2021, when we had a doctors and nurses was unquestionable as we could
staggering number of 288 patients in that month itself prone 3 to 4 patients in one night. Even the morbidly
(approximately 9 to 10 admissions to ICU per day!). The obese patients were flipped tirelessly like roti canai to save
mortality rate at this surge was around 13-18%. their lives. We usually would not prone a patient more
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than three times. However, there were a few occasions line, central venous line, prone, clerking, family updates
where we prone positioned a patient up to seven times via phone, and reassessment. One could imagine the
due to desperation. A muscle relaxant was given, but we amount of work put into an "unstable" patient. We were
ensured that paralysis infusion was not continued for grateful as medical officers from surgical/ENT/dental/
more than 48 to 72 hours as we had seen significant ophthalmology were deployed to join this war.
myopathy in those given prolonged infusions.
The Emergency Department was crowded by endless
After a year of battling COVID, we finally got our vaccines intubated patients who could not make it for ICU care.
in March 2021. Just as we thought cases were coming Our peripheral on-call team would receive more than 30
down and we could get some breathing space, the now referrals in a day. Peripheral passover board became
notorious delta variant struck us in April. This third wave multiple boards, colour-coded to ensure nothing was
which escalated in May, was what I regarded as the missed. Forty plus-year-olds replaced the 60
COVID apocalypse. It was also our country's darkest days plus-year-olds in ICU. Strangely, that became the new
since the beginning of the pandemic, where daily cases of norm. Triaging patients during this difficult time was
20,000 were recorded. The light at the end of the tunnel extremely challenging as we noticed an upsurge of
had disappeared. A central command for ICU bed younger patients developing severe COVID (20 to
monitoring was established, and all hospitals allocated 40-year-olds).
the maximum number of beds for COVID patients. In May
2021, the maximum number of Klang Valley ICU beds My specialists would always confide in me that deciding
allocated for COVID patients was only 216. Patients who gets and who does not get an ICU bed haunted them
arriving from MAEPS and COVID Assessment Centres long after leaving the hospital for the day. Not long after,
(CACs) to our emergency department were transferred to we lost our youngest patient, a 19-year-old who came in
other hospitals in the Klang Valley and Seremban for ICU with multiorgan failure. Although we vowed to do better,
care via Isopod activation as we could not care for the number of young patients dying just kept growing
everyone. The number of referrals per day to our ICU was despite our best efforts. Some young patients were
approximately 15 patients, and we already had 50 ventilated for weeks on a high ventilator setting without
category five patients in the general wards and any improvement in oxygenation. ICU care aims to allow
emergency department. a dignified death if it cannot be prevented. Guilt and
sadness were soon replaced with frustration, despair and
helplessness.
Physicians stepped up to provide space for patients to be

ventilated inward. By the end of July, we had almost 170
patients either ventilated or on non-invasive ventilation.
Oxygen supply became unstable and alarmed as the
demand was too high. Coming to work was like going to
a warzone with patients gasping silently while some
refused intubation as they knew it would not end up well.
Multiple lives were lost as we were just unable to cope.
Doctors were emotionally wrecked as we had to choose

who LIVES and, what was even more heart-wrenching,
Within a couple of weeks, most ICUs in the Klang Valley who gets a ventilator or a high flow nasal cannula. Some
were filled to the brim. With the same number of staff, of us were awakened by nightmares as we witnessed the
Hospital Sungai Buloh opened up to 85 ICU beds by July. demise of a relatively fit patient. Donations in the form of
One anaesthesiologist was managing 23 patients, while ventilators and HFNC did arrive later, but that did not
one medical officer was managing ten patients. One guarantee good patient outcomes as there were
"stable" admission would also mean setting up arterial inadequate ICU beds.
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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.
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Plexus and peripheral nerve blockade
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UHÁHFWLRQDQGPDNLQJHFKRSOH[HFKRJHQLFULJKWWRWKH • Electrical insulation with a thin layer of PET
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• the distal end 2mm of catheter for nerve stimulation
echoplex+ has following characteristics: • 2cm on the proximal end where the Easy-lock
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SRVVLEOHUHÁX[RIEORRGGXULQJWKHDVSLUDWLRQWHVW inserted and a mark indicating that the catheter is
• electric cord (60cm long) to keep the nerve about to protrude beyond the bevel of the introducer.
stimulator away from the sterile area. Bevel
RULHQWDWLRQLVLGHQWLÀHGE\WKHSRVLWLRQRIHOHFWULF
cord on the hub.
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ECMO in COVID-19 Patients, A Road Less Taken: The IJN Experience
by Dr Nadiah Kamaruzaman
Institut Jantung Negara
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.
Institut Jantung Negara is one of the few hospitals in

Malaysia offering ECMO services nationwide. To date, we
have instituted two ECMO in COVID-19 patients; both
with different demographics but both were in their 20s.
As patient selection was crucial, each case had an
interdisciplinary discussion before a final decision was
made to begin ECMO therapy. The meetings were held
beforehand between the referring teams which consisted
of the referring intensivists, and our esteemed ECMO
team who consisted of cardiothoracic surgeons,
intensivist, anaesthetists, perfusionists, respiratory
Extracorporeal membrane oxygenation (ECMO) is a final physician, cardiologists and trained ECMO nurses. As
alternative in the attempt to rescue these patients. Since resources are scarce, it is very important to ensure that all
the approval of the usage of ECMO in the sickest patients steps are carefully planned and carried out - from patient
contracted with COVID-19 infection by FDA in April 2020, selection, patient preparation, safe transport to our
it has been accepted worldwide as an effective support in hospital, preparation of the ECMO machine, care of the
severe ARDS. ECMO works like a heart, pumping blood patients whilst on ECMO and ECMO termination.
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we kept a higher target activated clotting time (ACT)
between 180 and 200 in this patient. However, we had
some initial bleeding from cannulation sites, hence we
had to revise the target ACT to about 150. After
stabilization, the patient also received steroids,
antibiotics, ventilator recruitment and other supportive
treatments.
Miraculously after about a week on ECMO, we saw great

improvements in terms of her oxygenation levels,
improved radiographic appearances, and overall
condition. We were heading towards weaning her off of
ECMO in the second week when she suddenly developed
neurological symptoms. She had unilateral pupillary
First Case: VV ECMO 10th - 24th July 2021 changes with diplopia and drooping of the eyelid and was
Our first patient, a 26-year old lady, who was on day 4 of then referred to the Ophthalmology team. Their
mechanical ventilation due to COVID-19 associated ARDS, impression was the sixth nerve palsy and suggested brain
had been referred to us for ECMO therapy after failing imaging. Since she was dependent on the ECMO machine,
conventional treatment despite being placed in the prone it was unanimously decided that she could not be safely
position twice. She suffered from Grade 3 obesity, with a transferred for a CT scan. Satisfied with her improvement
BMI of 54. We were initially skeptical regarding ECMO in the eye symptoms, on top of improvement of her lungs,
outcome given her obesity. However, from the ELSO the decision to liberate her from ECMO was pursued.
registry, the prevalence of obesity in patients deployed Decannulation was done on 24th July, day 15 of ECMO and
with ECMO for COVID-19 ARDS was about 50%, and most the patient continued to have good oxygenation with
have successfully recovered after ECMO therapy. Hence, minimal settings on the ventilator. Unfortunately the
we hoped that ECMO treatment would increase her following day, her neurological function further declined.
chance of recovery. Apart from refractory respiratory As she was no longer on ECMO, she was sent for an
failure, the patient did not have any evidence of other urgent CT scan of the brain. The scan showed a massive
organ impairment. She was ventilated on a FiO2 of 0.9, intracerebral hemorrhage with an extension to the
with a PF ratio of 91, PEEP 14, compliance 21 ml/cmH20 brainstem. An urgent referral to the neurosurgical team
and 3 quadrants of lung fields had infiltrates on Chest was made. Brainstem test was positive for brainstem
X-ray (CXR). Based on the Murray Score for ECMO, she death. She then succumbed on 29th July 2021. Perhaps,
absolutely was a candidate for ECMO therapy in ARDS. that minor eye symptom was an initial sign of a massive
Being the first COVID-19 patient to be offered ECMO intracerebral bleed.
therapy in our institution, I would say that all our team
members had mixed feelings between the excitement to Second Case: VV ECMO 4th - 17th August 2021
run our new ECMO machine, the Cardiohelp System; and Our second case was referred from another hospital also
the worry of dealing with the sickest form of COVID-19. overwhelmed with COVID-19 patients. This time, it was a
However, we were optimistic of a smooth process. 22-year-old male, who only received his first vaccine dose
before contracting the illness. He presented to the
After being transferred to our centre, we quickly prepped hospital on his fifth day of illness, in Category 5 with
her up for cannulation at the bedside in our intensive care severe ARDS, needing mechanical ventilation soon after
unit. All the involved staff were in full personal protective admission. He had failed conventional treatment
equipment (PPE) during the ECMO deployment. including prone ventilation, hence was referred for ECMO
Cannulation was via the percutaneous femoro‐femoral therapy. Despite the loss of our first patient, we were
approach. Given her morbid obesity, we expected a hopeful that we would succeed this time.
challenging cannulation procedure. Hence, both our
cardiothoracic and vascular surgeons performed Similar to the first case, we used the Cardiohelp System to
percutaneous cannulation via a Seldinger technique establish VV ECMO via peripheral cannulations,
under ultrasound guidance. Cannula placement was femoro-femoral access. The cannulas placement was also
confirmed by transesophageal echocardiography (TEE) - confirmed with the TEE. Despite placing the return
the return cannula in the RA and the tip of the drainage cannula in the RA, and the drainage cannula in the IVC,
cannula within the IVC, just beyond the hepatic vein. To we were faced with recirculation issues. Recirculation
avoid recirculation, both of these cannulas were at least occurs when oxygenated blood from the return cannula is
10cm apart. As soon as the ECMO was instituted, the entrained into the drainage cannula, bypassing the lungs,
ventilation parameters were quickly reduced, to advocate and resulting in arterial hypoxaemia. There are a few
the least-damaging mechanical ventilation with lower possible causes. First, when both cannulas are not
levels of pressure and tidal volume. This allowed the lungs adequately separated from each other; second, when the
to heal whilst on ECMO. The patient was commenced on ECMO circuit flow is too high; and third in case of low
anticoagulation with Heparin intravenous infusion. Given cardiac output or low intravascular volume. How did we
the prothrombotic state of COVID-19 patients, initially, handle this issue? By excluding number two and
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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.
Two days after liberation from ECMO, his oxygenation

turned poor. Now the strategy was to optimize the
ventilator parameters with higher PEEP and perform lung
recruitments. We proceeded with prone ventilation for 16
hours and he remained well for another two days.
Unfortunately, his oxygenation issues returned.
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¸
Patient’s Concern with PONV

Postoperative nausea and vomiting (PONV) is one of
the most unpleasant experiences during the
postoperative period, and has significant
SELECTED SAFETY INFORMATION consequences for patient satisfaction,
INDICATIONS Reversal of neuromuscular blockade
induced by rocuronium or vecuronium. For the patient outcomes and costs of care.1,2
pediatric population: BRIDION® is only
recommended for routine reversal of rocuronium
induced blockade in children and adolescents.
DOSAGE AND ADMINISTRATION BRIDION®
should only be administered by, or under
49% PONV
supervision of an anesthetist. The use of an
appropriate neuromuscular monitoring technique is 27% Pain
recommended to monitor the recovery of
neuromuscular blockade. The recommended dose
to be administered depends on the level of 13% Alertness
neuromuscular blockade to be reversed.
CONTRAINDICATIONS Hypersensitivity to the
active substance or to any of the excipients.
11% Additional costs
WARNINGS AND PRECAUTIONS • Ventilatory 220 GA surgery patients who were asked to rate their
support is mandatory for patients until adequate concerns during immediate postoperative recovery
spontaneous respiration is restored following ranked the relative importance of the 4 factors as above3
reversal of neuromuscular blockade. Ventilatory
support is also required in cases where GA = General Anesthesia
co-administration of drugs which depress Images are for illustrative purposes only.
respiratory function in peri- and postoperative

period. • BRIDION® (doses of 4 mg/kg and 16 mg/kg) In contrast to acetylcholine esterase inhibitors,
resulted in maximum mean prolongations of aPTT
and of PT (INR) prolongations. However, it did not the muscarinic effect of sugammadex is limited.4
show an increase bleeding risk when comparing
BRIDION® versus placebo in patients treated with
anticoagulant. • Based on in-vitro experiments, Why Anti Muscarinic may
additional aPTT and PT prolongation has been
reported in BRIDION® with anticoagulants. • Increase the Incidence of PONV?
Bleeding risk has not been studied systematically at
higher doses than 4 mg/kg, thus, coagulation
parameters should be carefully monitored Cholinesterase inhibitors can cause vomiting and diarrhea by
particularly in patients with known coagulopathies stimulating muscarinic receptors that increase motility and secretions
or those who receive high dose of BRIDION® (16 in the esophagus, stomach, and small and large intestine.5
mg/kg). • It is not recommended to administer doses
lower than the therapeutic doses due to reported
increased incidence of recurrence neuromuscular
blockade after initial reversal. • When rocuronium
1.2 mg/kg is administered within 30 minutes after 2020 Fourth Consensus This set of guidelines
reversal with BRIDION®, the onset of neuromuscular have been officially
blockade may be delayed up to approximately 4
Guidelines for the endorsed by the
minutes and the duration of neuromuscular Latest Management of PONV6 Malaysian Society of
Anesthesiologists
blockade may be shortened up to approximately 15 Update!!
minutes. • The recommended waiting time in
patients with mild or moderate renal impairment for
Strategies to Reduce Baseline Risk
re-use of 0.6 mg/kg rocuronium or 0.1 mg/kg
vecuronium after routine reversal with BRIDION® • Avoidance of GA by the use of regional anesthesia (A1)
should be 24 hours. • A nonsteroidal neuromuscular • Use of propofol for induction and maintenance of anesthesia (A1)
blocking agent should be used for patients requiring • Avoidance of nitrous oxide in surgeries lasting over 1 h (A1)
neuromuscular blockade prior to passing the • Avoidance of volatile anesthetics (A2)
recommended waiting time. • BRIDION® is not
recommended in patients with severe renal
• Minimization of intraoperative (A2) and postoperative opioids (A1)
impairment, including those requiring dialysis. • Adequate hydration (A1)
ADVERSE EVENTS In the subset of Pooled
Placebo-controlled trials where subjects received
anesthesia and/or neuromuscular blocking agents,
Using sugammadex instead of neostigmine for
the following adverse events occurred in 2% of the reversal of neuromuscular blockade (A1)
subjects treated with BRIDION® and at least twice as
often compared to placebo including airway Quality of Clinical Evidence
Category A: Supportive literature. Statistical significance level was set at P < 0.05. (A1)The literature contains multiple randomized
complications of anesthesia, coughing, tachycardia, controlled trials, and aggregated findings are supported by meta-analysis. (A2)The literature contains multiple randomized
bradycardia, movement of a limb or the body, controlled trials, but the number of studies is insufficient to conduct a viable meta-analysis for the purpose of these guidelines.
grimacing or suckling on the endotracheal tube. For PONV = Post-Operative Nausea and Vomiting; NMB = Neuromuscular Blockade; PTCs = Post Tetanic Counts; TOF= Train of Four;
GA = General Anesthesia
additional adverse experience information, see the
Disclaimer : “Sugammadex is not an anti-emetic drug and has no indication for PONV”
product circular.
‘
STUDY DESIGN L H J Eberhart et al.3 This survey evaluates patients' concerns and preferences with respect to
References: 1. Hill RP, et al. Cost-effectiveness of Prophylactic postoperative recovery. Total of 250 consecutive patients (56% females; median age 48 (range16-76) yr) undergoing
Antiemetic Therapy with Ondansetron, Dropeucidol, or Placebo. orthopaedic (48%), gynaecological (28%), urological (10%), or minor general surgical procedures (14%) performed under
Anesthesiology. 2000;92(4) 2. Macario A et al. Which Clinical general anaesthesia were asked to rate nine scenarios during immediate postoperative recovery based on four factors
Anesthesia Outcomes Are Important to Avoid? The Perspective of (alertness, pain, postoperative nausea and vomiting (PONV), and extra costs) each with three levels. 30 were unable to
Patients. Anesth analg. 1999;89(3) 3. Eberhart LHJ, et al. Patient complete the survery, and the remaining 220 patients was analysed. Different methodologies have been used, including
preferences for immediate postoperative recovery. Br. J. Anesth, traditional face to face or paper-based interviews, willingness to pay, or rating of virtual scenarios. The relative impact of
2002:89(5):760-761 4. Kim J.H., et al. Comparison of the Effects of each factor on ranking the scenarios was assessed by using conjoint analysis.
Sugammadex, Neostigmine, and Pyridostigmine on Postoperative
Nausea and Vomiting: A Propensity Matched Study of Five Before administering Bridion®, please read the full prescribing information
Hospitals. J. Clin. Med. 2020, 9, 3477. 5. Nair, V.P., et al. Merck Sharp & Dohme (Malaysia) Sdn. Bhd.
Anticholinesterases and anticholinergic drugs. Contin. Educ. B-22-1 & B-22-2, The Ascent Paradigm, No. 1, Jalan SS 7/26A, Kelana Jaya,
Anaesth. Crit. Care Pain 2004, 4, 164–168. 6. Tong J. Gan, et al. 47301, Petaling Jaya, Selangor Darul Ehsan.
Fourth Consensus Guidelines for the Management of Postoperative Tel: +603 7499 1600 Fax: +603 7499 1700 www.msd-malaysia.com
Nausea and Vomiting. Anesthesia & Analgesia, Volume 131, Number
Copyright © (2021) Merck & Co., Inc., Kenilworth, NJ, USA, and its affiliates. All rights reserved.
2, August 2020, pp. 411-448(38).
MY-XBR-00329 Nov/2021
Transformation of HPKK to a COVID-19 Hospital:
More Than Meets The Eye
by Dr Tan Ru Yi
Hospital Putrajaya
When I volunteered to be in the frontlines once again in

the Klang Valley just after a two-year stint in Sarawak
fighting COVID-19 across the South China Sea, never in a
million years did I imagine that I would be in for a ride of
my life.
I was expecting to be deployed to Hospital Sungai Buloh

when fate decided otherwise. To my surprise, the
deployment letter stated that I was supposed to report to This new hospital had the capacity of 243 beds including
HPKK UKM (Hospital Pakar Kanak-Kanak Universiti existing 28 gazetted critical care/ICU beds with the
Kebangsaan Malaysia) instead. potential to expand further to a total of 46 critical care
beds. It was equipped with a state-of-the art electronic
hospital management system. The plans came to fruition
when the process of conversion into a full COVID-19
hospital started on 1st June 2021. When I reported for
duty to HPKK in early June, I was mentally prepared to hit
the ground running and fire on all cylinders, but to my
surprise it was a new hospital that was not operational
yet even more so able to manage critically ill COVID-19
patients. It hit me right there and then that it was a
Before this, I never even knew this hospital existed. When do-or-die mission and the burden of responsibility
my consultant informed me that I would be the acting weighed heavily on our shoulders.
consultant running the COVID ICU in that place as my
other colleagues would be mainly to be gazetted or junior Being the pioneering batch of KKM specialists in this
specialists, I brushed it aside thinking that she must be place, we had the gargantuan and difficult task of not
joking, little did I know it was going to be true. only managing the COVID ICU but also to set it up and get
it running within an extremely short time. Despite much
Since 22nd May 2021, to prevent the healthcare system adversity and being thrust into the limelight due to visits
from collapsing under the brunt of the pandemic, the by the Prime Minister, Director-General of Health and
Health Director-General Tan Sri Dato’ Seri Dr Noor Hisham other KKM VIPs, our galvanised efforts came to realization
Abdullah announced that HPKK was to be temporarily when HPKK finally opened its doors on 17th June to
converted into a COVID-19 hospital under the Emergency COVID-19 patients. As the saying goes, Rome was not
Ordinance (Essential Power) 2021 at the behest of our built in one day, in this case the COVID ICU and wards were
then Prime Minister YB Tan Sri Muhyiddin Yassin. Through literally set up in a short period of 16 days. I believe that
this Ordinance, the Health Ministry had the power to most anaesthesiologists/intensivists would attest that the
temporarily take over HPKK UKM and other resources Masters training programme did not prepare us for this.
including human resource for the purpose of managing We had to learn fast on the job. Most of the planning had
the surge of the COVID-19 pandemic. It was one of the to be done from the ground up.
first few non-MOH facilities around the country
repurposed under the Emergency Ordinance to Unlike most established hospitals in the Klang Valley
accommodate intensive care COVID-19 cases. which ran like a well-oiled machine, we were faced with
numerous daunting issues which included lack of trained
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and senior staff, problems of converting a partially COVID-19 management to the newly deployed staff.
equipped Paediatric ICU into an adult ICU i.e., ICU beds Besides that, the NGO also donated some essential
were smaller in size, mattresses were thinner, no HD consumables and equipment such as HFNC to us.
facility, no appropriate medications, no consumables
especially adult sized ones like ventilator circuits, HMEs, HPKK was unique in the sense that it would function like
adult BP cuff, no adult blood specimen bottles, IV a field hospital but with the trappings of a luxurious shell
cannulas, the list went on and on. We had to (meaning the hospital was equipped with modern
painstakingly vet through a long list of at least 800 items infrastructure but were lacking in major clinical
including essential equipment to request and procure. In disciplines). Furthermore, it was not an empty canvas that
other words, even trivial things that we took for granted we could do anything with. We had to manoeuvre our
in KKM hospitals were severely lacking. way and tread carefully through bureaucracy and red tape
because we were in a way serving two masters at the
We practically had meetings after meetings daily with same time (KKM/JKWPKL and HPKK/KPT).
staff, vendors, and everyone else involved, sometimes way
past office hours into the night to discuss and plan on I must admit that my hair had just become a shade greyer,
various aspects e.g., budget planning and getting because of juggling between administrative issues and
quotations, ICU and Ward set up, equipment and clinical management of patients, working without breaks
medication procurement, etc. Even the minutest details or leave, sometimes even going to work on weekends
had to be planned and thought through e.g. floor plans, when not on call; not to mention the countless
fire exit and evacuation plans, cordoning and zoning of emergency meetings (sometimes until night) with the
areas, rostering, manpower distribution, staffing ratios HPKK admin team or various other parties regardless of
etc. In the beginning, we had to beg and borrow the time and day. With the COVID-19 cases rising to
equipment, consumables, and medication from other unprecedented levels, we were pressured to open our
hospitals around the Klang Valley just to kickstart as doors as soon as possible. Time was our enemy, we
supplies had not arrived due to various reasons. In planned, prepared, and trained as much as we could.
desperation, we even had to transport HD machines and Despite various shortcomings, we simply took the leap of
portable RO machines from HKL in a “van jenazah” and faith and, finally, on 17th June 2021, HPKK opened its
medications using our personal vehicles. Fortunately, Dr doors to its first COVID-19 patients. It was a bumpy ride
Melor Mansor (Ex-National Head of Service for from the start, some problems we were able to anticipate
Anaesthesia and Critical Care Services) and Dr Zalina but some took us completely off guard. We learned,
Abdul Razak (current National Head of Service) were very adapted, innovated, and put out fires as we went along.
supportive of our efforts and helped us throughout as When the going got tough, the tough got going. As
much as they could in many aspects. forewarned by Dr Melor, once we opened the floodgates,
there was no turning back. True enough, many things did
not go according to plan; the ICU bed occupancy
increased drastically with each passing day. Before we
knew it, the numbers bloated up to 31 beds, we were at
the point of reaching our limits in terms of workload,
supplies and manpower when reinforcements finally
trickled in. At the start, the primary source of our referrals
was from MAEPs via the Central Bed Management Unit. In
the later half, we received referrals from all hospitals in
the Klang Valley. Our daily admissions only consisted of
During the initial operational stage, we also had Category 4b (high risk of further deterioration) and
daily passover meetings with Dr Melor Mansor via Category 5 patients. From the get-go, clinical teams in
teleconferencing to discuss cases and got his advice on HPKK comprised the ICU team and general medical team.
urgent issues until we were able to stand on our own feet. We did not have the luxury of support from other clinical
Mercy Malaysia was in the picture from the start. In or surgical disciplines. Any surgical related issues
collaboration with them, we managed to organise requiring surgery had to be outsourced elsewhere and we
orientation and training programmes on the basics of had to cross our fingers many times that it would not
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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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days, we managed to pick his brain and draw from his In other words, the war is not over, and we are in it for the
wealth of experience and expertise to make many long haul.
improvements in terms of managing and streamlining the
ICU. We were also mesmerized by his unassuming With this, I would like to extend and express my gratitude
demeanour and willingness to teach. His lessons were to everyone working in HPKK for making this endeavour a
always so enlightening and insightful. We were also glad success. You are all champions in my eyes. A big thank you
to have Dr Azizol Mohamad (Head of Department of especially to the HPKK staff led by Professor Dr Syed
Anaesthesia Department, Hospital Kuala Krai, Kelantan) Zulkifli (HPKK Hospital Director) and Deputy Directors:
who came to give us a helping hand for a whole month. Professor Dr Tang Swee Fong, Professor Dr Hamzaini
He was a humble and generous senior, who walked the Abdul Hamid, Associate Professor Dr Abdul Halim Abd
talk; he did daily rounds in the ICU with us and did on-call Rashid for affording us your trust, warm hospitality, and
without complaining or pulling rank. There were also two cooperation throughout this crisis. Kudos to everyone
senior consultant anaesthetists from the private sector who worked in the COVID ICU from doctors and nurses to
who came to assist on a pro bono basis, Dr Seah Keh Seng ancillary staff for without which it would not have been
and Dr Jude Morgan who sacrificed their time and money possible to achieve these. Special mention goes to the
to ensure our welfare and safety were well taken care of. core team of specialists whom we started this place
They used their network of contacts to help get us together: Dr Zahrin bin Ma'Zam, Dr Siew Gee Ho, Dr Faiz
donations for better PPEs, N95 masks, electronics, etc. bin Rusli and Dr Billy Voon Wei Loong. It is not possible to
They donned up like the rest of us and entered the COVID list out each and everyone else in this article, but you
ICU many a time to help manage difficult patients. We know who you are.
were also grateful to Dr Syarifah Noor Nazihah binti Sayed
Masri (one of the lecturers from HCTM) who took time out
of her busy schedule to volunteer in the ICU especially at
time when we were short staffed.
Although there were many hiccups along our journey, we

were fortunate to receive continuous support of everyone
involved including from HPKK, JKWPKL, KKM, HCTM,
GKVSTF, Mercy Malaysia, and numerous other parties
Personally, I have learnt a lot from this once in a lifetime
from the private sector and NGOs. Because of their
experience especially the soft skills such as having greater
concerted effort we managed to enter the fray just in time
patience and humility, better interpersonal skills, putting
fighting along bigger hospitals resisting the COVID-19
one’s ego down and willing to relinquish roles and
onslaught. At the height of operations, bed occupancy
delegating responsibility besides not attempting to
was at 177 beds, this included 31 mechanically ventilated
micromanage everything.
patients, 56 patients on HFNC in the gazetted and
repurposed ICU and approximately 75 patients in the At the time of writing, HPKK is in the soft-landing phase,
wards. Plans were already in place to expand our capacity gradually winding up as a COVID hospital and being
to 46 ICU beds in anticipation of a further surge in cases, transformed into a paediatric specialist hospital as it was
but as we were gearing up to do so, the COVID-19 originally built for. Most of the KKM staff have already
situation in the Klang Valley had begun to improve due to been redeployed elsewhere or returned to their respective
aggressive vaccination efforts, hence we were ordered to hospitals. On one hand, it was sad to see people whom
stand down. Eventually, a total of 842 Category 4b and we have gone through thick and thin say their goodbyes,
Category 5 COVID patients have walked through its but on the other hand it is a promising sign that we may
doors. Now that we are seeing some light at the end of get back to our normal lives soon. I believe that with the
the tunnel, we are grateful to be given the opportunity to experience, knowledge and expertise gained, camaraderie
make a positive impact in the fight against the COVID-19 and bonds forged throughout our stint in HPKK, we will
pandemic in the Greater Klang Valley. I believe it was no emerge stronger and better wherever life leads us next.
meagre feat given the circumstances that we were in. Keep up the good work! Do take care and stay safe!
Nevertheless, we do not want to rest on our laurels just
yet as we need to be constantly vigilant of the enemy who “Every Experience is orchestrated to teach you something
is lurking in the shadows bidding its time to strike again. you need to know to move forward.” Brian Tracy
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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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with the art line…it took 2 hours to get!”. A couple of contact precautions or will be eaten alive by angry nurses
minutes later the patient is finally face down and or Intensivists, whoever is closer”.
everyone watches the oxygen saturation climb from 86 to
95 to 98 to 100% and there is a collective smile…now As if on que, the lab calls and after a suitable pause for
that was totally worth it. effect, announces, ”it’s MRO”. The unfortunate patient is
swiftly plucked out of the masses and deposited into his
Meanwhile, a patient sitting in a bedside chair watches cubbyholes to prevent the contagion from spreading. The
his own saturation monitor while contemplating life lab calls again…”it’s CRE”. This time the threat level rises
outside the ICU. The doctors note the low grade from catastrophic to apocalyptic. It is time for the big
temperature and increasing numbers marching across the guns, the big antibiotic guns that is. We lock everything
serial investigation chart and wonder the age old down and do some contact tracing within the ICU to reign
question…”is it sepsis?” in any possible CRE-hitchhikers on the loose. Nobody gets
in and nobody gets out.
Further along the ICU, a huddle of doctors scrutinise a
chest X-ray and wonder where on earth did the Some patients are not doing well, some are cruising along
nasogastric tube that they saw just a minute ago snake its and some are ready to go to the wards but the round
way to? A few more minutes of contemplating whether a ends finally with a master plan set for the day.
new pair of glasses were in order and a few contrast
changes later…it magically appears. There it is…! Bladders full, stomachs empty and minds churning…the
group scrambles out of the ICU. As we head for the
Somebody bellows…”Transfer OUUUT!”. The patient showers, someone spots a pile of actual towels lying
heaves a sigh of relief, nurses and doctors rejoice and the innocently unattended. Everyone pounces on these and
ward staff arrive with a bed like busboys a few moments congratulate himself/herself on an excellent find.
later to ferry the patient to the ward. The patient waves Emerging suitably cleansed and ready for handover, we
goodbye. The ICU staff wave back thinking…please do walk towards the sun and think…thank goodness for
not come back. ‘PM’.
A young doctor walks up to another patient who is

intubated and enthusiastically asks, “what’s your name
sir?”. The patient unable to respond turns to the nurse
and shrugs. The nurse pats the patient’s hand, nods
understandingly and turns to tell the doctor…”Sorry, he
can’t chat at the moment…”.
A bit of a morning lull sets in during rounds until the

Intensivist is suddenly spotted hovering over a patient and
naturally, a crowd gathers and rounds truly get going.
Steroids and antibiotics get tossed around and the parade
follows all around the ICU.
We examine, adjust ventilators, look at investigation

charts, gaze at X-rays and medication charts. Rinse and GLOSSARY
repeat the process multiplied by the number of patients
until we finally reach a group of patients that we have Art line Arterial line
been leaving for last or have been intentionally ‘avoiding’.
MRO Multi-drug resistant organisms
These patients are sequestered into isolation rooms or
CRE Carbapenem resistant enterococci
strategically grouped together. The infected within the
infected of the COVID ICU, we have reached the ‘MRO PM The afternoon shift
crowd’. An invisible line is drawn all around them with a
sign that says metaphorically, “Keep out and obey all
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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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began to make its appearance on the inner side of the described not so much as a feeling of pain as a sense of
upper lip several years ago; it had attained the size of a the sound of that, and it was, at all events, not so
common walnut, was free from pain, but inconvenient disagreeable as the slight pain which on recovery he felt
from its bulk and situation, and as latterly it had been in the wound. A tingling sensation was experienced in all
growing quickly, the patient was desirous to have it the extremities when the influence of the Ether began to
removed. When informed of the effects which have been subside, and which spread through them to the body
usually observed from ether administration as above, he before the sense of feeling and power of motion was
said, “that was the sort of medicine for him” and perfectly restored. He felt a little drowsy afterwards, laid
requested that it might be used. Everything being down and had two hours’ sleep from which he arose
prepared and the patient seated for the operation, a feeling in every respect comfortable and on the same day
common bladder fitted with an ivory tube, as he followed his usual avocations.
recommended by Mr Herapath, was the apparatus used.
Into this was poured half an ounce of good sulphuric PIONEER GENERATION OF MALAYSIAN
ether, the bladder was then blown up and well agitated ANAESTHESIOLOGISTS 1959-1970
so as to saturate the air in it with the vapour, after which In the 1950s, Anaesthesia services were available in Kuala
the patient was desired to receive the pipe into his mouth, Lumpur, Penang, Ipoh, Johor Bahru and Malacca
to embrace it with his lips and breathe freely through it. Government Hospitals. The first qualified British
His nostrils were held perfectly closed. After a very few anaesthetist was Dr E G Hudson who worked in Kuala
inhalations, and certainly in a space not exceeding a Lumpur from 1947-1951. One of his early anaesthetic
minute and a half, the patient slightly groaned, his lips let trainees was Dr Fred Pais who settled in Singapore. Dr J
go their hold and the pipe fell from his mouth. He George Lomaz was a Polish doctor who emigrated to
appeared in a deep sleep and there was total suspension Malaya and served in Kuching as a general medical officer
of motion. The operation was now commenced and until 1952 when, at the encouragement of Dr Pais, he
completed in about four minutes, during which he went to Liverpool to study anaesthetics under Professor
continued to groan but never uttered a word or moved a Cecil T. Gray. Dr Micaleff was another anaesthetist from
muscle, and his breath was remarked to be extremely Malta. In 1953 Dr L P Scott was appointed specialist
cold. “At the termination of the operation he was still anaesthetist on contract first in Kuala Lumpur and then in
insensible and as he continued in this condition two Penang. Dr A L Gardiner was an anaesthetist in Taiping
minutes afterwards with a pulse of 40, extremities cold, and later at Lady Templar Hospital, Cheras, Kuala Lumpur.
general pallor, lips, and conjunctivae especially pale, some
wine was administered and water sprinkled over the face, In Penang Hospital, Dr (Professor) John Francis Nunn was
and these repeated several times before he began to a general duty medical officer. Nunn had arrived from
recover his powers of sensations and motions. Altogether, England in December 1949 with the experience of 20
the effects continued fully ten minutes. anaesthetics he had administered as a medical student.
He was placed in charge of anaesthetics for surgery,
The patient described his feelings while under the carried out in the main operating theatre, and obstetric
influence of ether as follows: anaesthesia, the latter performed in the maternity wing
across the Residency Road. He had then no qualifications
The first draught of the vapour produced a sensation of in anaesthesia but a real interest and was the first to use
coldness which spread upwards to the different parts of cyclopropane and muscle relaxants in Penang. A 1:1
the body; the hands and feet became numb and destitute mixture of oxygen and cyclopropane was used for
of feeling, then there were giddiness and a feeling of efficient induction of anaesthesia. The apparatus for
confusion in the head, noise in the ears, and lastly a total delivering this mixture became well known to Malaysian
loss of power and feeling in every part, but still a pleasant anaesthetists as Nunn's Bag although it was correctly a
sensation of most perfect ease and quiet, altogether modification of Dr J.G. Bourne's Bag, consisting of a
different from that kind of stupor occasioned from an two-litre bag attached to a one litre pre-filling bag. Open
overdose of spiritous liquors. He could draw no chloroform and ether, using a Schimmelbusch mask
comparison between its effects and those produced by with oxygen supplementation via nasal catheter, were
smoking chandoo (opium) never having himself on the principal methods of anaesthesia. Intravenous
occasion tried the latter. He was not conscious of having thiopentone was used for rapid induction of anaesthesia
groaned, but he knew when the operation was and spinal heavy nupercaine was also available. By 1950
commenced and when it was completed, during it he was the introduction to Penang of the anaesthetic machine,
sensible of a scratching in the part, which however, he known as Boyle's apparatus, of laryngoscopes, curare and
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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.
In England Cecil Grey introduced thiopentone,

d-tubocurarine, controlled hyperventilation and nitrous
oxide with oxygen, known as the Liverpool technique and
made the Royal Liverpool Hospital the most advanced
British centre for anaesthesia training in the 1950s. In
September 1956, Dr Bhupalan, his wife Madam
Rasammah and their two young children, together with
Dr George Tay from Singapore and Dr Fred Pais, sailed on
SS Canton to Liverpool. Dr Bhupalan, Dr Tay and Dr Pais
were British colonial Government scholars sent to study
for the FFARCS. Dr Bhupalan was the first Malaysian to 1963, 5th October. Birth of the Malaysian Anaesthetic Society, 6
Jalan Garland (Dato’ Seri Dr Shaari Road), 31350 Ipoh, Perak.
win the Nuffield prize (gold medal) for the highest Home of Dr M C Poopathy
examination score in the Primary FFARCS in 1957 and the
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Anaesthesiologists to co-organise the Annual Scientific
Congress of MSA-CoA, AMM, co-publishes a triannual
newsletter, the Berita Anestesiologi, and oversees the
parallel pathway training in Anaesthesiology with the
Ministry of Health Malaysia.
THE FIRST UNIVERSITY DEPARTMENT OF

ANAESTHESIOLOGY
The Department of Anaesthesiology in the University of
Malaya was the first in the country to be established to
further the science and practice of anaesthetics. After the
training of the first Malaysian anaesthetists in the United
Kingdom in the 1950s and 1960s, the creation of an
1993, 1st - 3rd February. WFSA requested Malaysia and the academic department was the most significant step in the
Malaysian Society of Anaesthesiologists sponsored Dr Karis
development of the specialty in Malaysia. It secured
Misiran and Dr Patrick Tan to give lectures at the Refresher
Course in Anaesthesiology, Ho Chi Minh City, Vietnam recognition for the specialty among medical and lay
persons and provided a foundation for the training of
FOUNDING OF THE MALAYSIAN SOCIETY OF doctors and, in time to come, anaesthesiologists. In
ANAESTHESIOLOGISTS 1963 clinical specialties directed by the staff of the faculty,
Despite working in frenetic circumstances, without the emphasis was placed for sufficient staff to be provided so
comradeship fostered in an anaesthetic department and that adequate time was available for doctors to have
with little opportunity to build an identifiable profile in enough contact time with patients to maintain high
the public’s mind, early Malaysian anaesthetists were standards of diagnosis and patient care, time for teaching
drawn towards fellowship and establishment of the and research work. In its founding year in 1965, the
specialty. Urged on by Sir Robert MacIntosh and Cecil department of anaesthesiology had one senior lecturer,
Gray who both visited Malaya in 1961, and by Quintin one lecturer and one medical officer.
Gomez from Philippines, Secretary General of the World
Federation of Societies of Anaesthesiologists, Dr The safe provision of anaesthesia throughout the period
Bhupalan, Dr Antony Manavalan, Dr Gopal Krishnan and of a patient’s unconsciousness until recovery became the
Mr Rajadurai travelled from Kuala Lumpur and Dr Law benchmark of the first Department’s provision of quality
Gim Teik from Penang, and Dr T.V. Nesaratnam to meet at health care. No longer were patients herded on trolleys in
Dr M.C. Poopathy’s house at 6 Jalan Dato’ Seri Saari the corridor outside an operating theatre after surgery,
(formerly Jalan Garland), Ipoh, Perak on 5th October 1963 without vigilant attention to a patient’s pulse, breathing,
to found the Malaysian Anaesthetic Society (later oxygenation, haemorrhage, shock, or pain symptoms. No
Malaysian Society of Anaesthesiologists), registered on longer were anaesthetists pressured to place a patient
29th January 1964. under anaesthesia without pre-anaesthesia review,
physiologic and pharmacologic optimization. Anaesthesia
FOUNDING OF THE COLLEGE OF rooms and post-anaesthesia recovery areas, trained
ANAESTHESIOLOGISTS, ACADEMY OF MEDICINE anaesthesia nurse assistants and recovery area nurses
OF MALAYSIA 1999 became the norm in the design and workflow of
The College of Anaesthesiologists is one of the 10 Malaysian operating theatres from the start of the
colleges under the Academy of Medicine of Malaysia University Hospital Kuala Lumpur.
which was registered on 22nd December 1966. Dr S
Jenagaratnam was instrumental as the chairman of the The first department of anaesthesiology was headed by
committee that oversaw the formation of the Chapter of Dr A Ganendran who was working at the Singapore
Anaesthesiologists which was later accorded College General Hospital and who was invited to join the
status in December 1999, with Dr Patrick Tan Seow Koon University as a senior lecturer by the Dean Professor T J
who was elected to be the first President. Danaraj. Dr Ganendran had been a graduate of Bristol
University and was the second Malaysian to earn the
As the academic arm of anaesthesiologists in Malaysia, Nuffield prize in the Primary FFARCS examination. He
the college’s primary objective to advance the art and went on to be the first Malaysian to complete his M.D.
science of anaesthesia and its related disciplines. The thesis from his alma mater (1974) on the effects of
college works closely with the Malaysian Society of Cholinesterase. His strong academic stature, a high regard
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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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Dr Noor Airini Ibrahim (Head), Dr Lim Thiam Aun, Dr who laid the foundations in five public universities and
Imran Osman, Dr Felicia Su-Min Hu and Afnizar Akbar as several teaching and Ministry of Health (MOH) hospitals,
lecturers. Dr Aizad Azahar was the first Master of along with trainers in British, Australia-New Zealand and
Anaesthesiology (UPM) graduate in 2017. In 2020, the Irish Anaesthesia Colleges. Their combined efforts in
Unit was renamed as Department of Anaesthesiology. anaesthesia education, training and research have raised
a strong profile in Malaysia of anaesthesia, perioperative
International Islamic University Malaysia in Kuantan is the medicine, pain medicine and intensive care governance
latest university to provide the Master of Anaesthesiology for public safety and comfort.
program in 2014 with lecturers Dr Ariff Osman, Dr Mohd
Basri Mat Nor, Dr Azrina Md Talib dan Dr Abdul Hadi The need for many more specialists in anaesthesiology,
Mohamad. The first specialist to graduate from the perioperative medicine, pain medicine and intensive care
program in 2019 was Dr Shahir Asraf Mohamad. continues to grow. A supply shortfall has generated
particular awareness of the essential roles of
The College of Anaesthesiologists of Ireland signed a anaesthesiologists through media and social media since
memorandum of understanding with the College of the beginning of the COVID-19 Pandemic. Crudely, 1,205
Anaesthesiologists, Academy of Medicine of Malaysia on anaesthesiologists represent 1 per 27,000 population and
27th April 2016 for a Parallel Pathway Anaesthesiology 1 intensivist per 1.6 million population. During the
Training comprising the Final Fellowship of the College of COVID-19 pandemic anaesthesiologists have provided
Anaesthesiologists of Ireland (FCAI) examination, unfaltering service and leadership to the healthcare
followed by 36 months of competency training in system in managing, caring, providing comfort,
accredited Ministry of Health Hospitals, culminating in the compassion and dignity to COVID-19 and other patients.
Certificate of Completion of Training (CCT) in The Society and the College of Anaesthesiologists have
Anaesthesiology and Critical Care. The first specialist, Dr been extremely supportive of members’ experiences and
Indra Sadasivam, completed the FCAI CCT in this provided leadership framing position statements on the
programme in 2019. allocation of resources during the pandemic. To maintain
continuing professional development the Society’s and
ANAESTHESIOLOGY IN MALAYSIA AND THE FUTURE College’s Special Interest Groups have co-hosted a large
The National Specialist Register was created through number of well-attended anaesthesia, pain and intensive
legislation by Amendment to the Medical Act (2012) to care webinars.
credential each specialist under a specialty or
subspecialty. In June 2021, the number of registered Anaesthesia, Perioperative Medicine, Pain and Intensive
specialists in Anaesthesiology and Critical Care is 1,205 Care will continue their individual growth trajectories on
and the number of registered specialists in Intensive Care the assurance that foundations laid 50 years ago by a very
is 50. The time taken to achieve this since the first small number of steadfast industrious anaesthesiologists
Malaysian anaesthesiology graduate (1959) is a little have multiplied their own numbers to provide great
more than 60 years. Annually, an average of 85 specialists harvests of safety, sensibility, security and enhanced
have completed Master of Anaesthesiology and CCT. recovery for surgically susceptible patients, with the aim
that such care be accessible by the entire population as
This achievement is hard won by total dedication - early as possible in the future.
delivered by pioneering academics and anaesthesiologists
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
3. Smith. Anaesthesia for surgery on a fibrocartilaginous 7. Usha N. Correspondence

tumour of the face. Penang Free Gazette. 1847. 3 July
8. Basri M. Correspondence
BERITA
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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a longer time for a patient to wake up hence the longer now but pyrexia has been well known to cause significant
duration of ventilation, more complications and ICU detrimental effects on neurology and hence poor
mortality. The trial also did not answer if early cooling outcomes of the patient. As the review is still ongoing to
could improve survival and outcome because the mean see any chance for hypothermic treatment turning the
temperature of 33-34°C is only achieved at 3 hours after tide around in long term, a rational approach should be
the arrest, which could bypass the ‘golden hour’ rule for practised in treating post-cardiac arrest patients for now.
any benefit to be seen. As hypothermia leads to With the evidence available from TTM2 we can
haemodynamic compromise in the treatment group, confidently cool down patients to lower temperature
whether this has an impact on overall mortality need to without worrying it will bring more harm such as sepsis
be explored. That is because haemodynamic stability also and issues with coagulation. We might not have to cool
means the patient will be likely to require a longer ICU the patient aggressively until 33°C in post-arrest care but
stay, use of vasopressors and kidney injury. All of these we should still be vigilant with the patient’s temperature
could contribute to higher mortality among the treatment (bladder, nasopharynx or oesophageal probe monitoring)
group5 and clouding the actual benefits of hypothermia in and more importantly, still aggressively treating a patient
patients. with fever (37.8°C or higher) in post-arrest because any
intervention that can reduce the harm to the patient is the
So, where do we go from here? Should we just give up on first winning step until the next discovery is made. I hope
the cooling treatment in arrest patients? The answer is that future trials could fill in the blank for us.
NOT YET. Cooling patients might not have clear benefits
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
BERITA
A Novel Way of Positioning for Intubation:
Bed-Up-Head-Elevated Using Bed Controls
by Dr Samuel Ern Hung Tsan
University of Malaysia, Sarawak
INTRODUCTION BENEFITS OF BUHE POSITION

Intubation is a skill that anaesthesiologists must have as
part of their arsenal in managing patients undergoing Improved laryngeal exposure
surgery or critically ill patients. It is a skill gained through One of the main advantages of the BUHE position is
years of training and experience, finally culminating in improved laryngeal exposure, facilitating intubation. In
anaesthesiologists being considered as masters of airway their pioneering RCT, Lee et al investigated the 25°
management. As every anaesthesiologist will know, the back-up position for intubation in 40 surgical patients
positioning of a patient prior to intubation is one of the undergoing general anaesthesia. The authors found that
most important aspects of successful intubation. the 25° back-up position provided a more superior
laryngeal view, by increasing the percentage of glottic
Most anaesthesiologists in Malaysia are familiar with and, opening (POGO) (Figure 2) score from mean 42.2% in the
in fact, regularly practice the sniffing position for supine group to 66.8% in the back-up group.1
intubation, using pillows or head rings. For obese
patients, the ramping position is commonly used, utilizing
pillows, blankets, or specialized positioning devices. Lee
et al in 2007 introduced a novel ramping position, by
studying the effects of back elevation of 25° using bed
controls compared with the supine position.1 This new
positioning, also termed bed-up-head-elevated (BUHE)
Figure 2: Percentage of glottic opening (POGO). A 100% POGO
position for intubation, has gained more and more score refers to visualization of the entire glottic opening from
popularity in recent years. Despite that, few the anterior commissure of the vocal cords to the interarytenoid
notch. A POGO score of 0% refers to no visualization of
anaesthesiologists in Malaysia have heard of the BUHE laryngeal structures
position.
The finding by Lee et al has been confirmed by a recent
The BUHE position is a variation of the ramping position, RCT investigating the BUHE position, carried out by Tsan
using bed controls alone to elevate the head of the bed and colleagues, which compared the BUHE position with
(by breaking the bed at the level of the patient’s hip to video laryngoscopy (VL).2 In this study, 138 surgical
prevent patient from sliding off) until alignment of the patients undergoing general anaesthesia had a baseline
patient’s sternal angle and external auditory meatus is Macintosh blade laryngoscopy in the SSP position,
achieved (Figure 1).2 To achieve this endpoint, the bed followed by randomization to one of two groups
elevation could range from 15° to 45°. This article will preceding intubation, namely Group BUHE (direct
discuss the benefits and potential complications of the laryngoscopy in BUHE position) or Group GLSC (VL using
BUHE position, and its applications in the operating Glidescope). The authors found that mean POGO scores
theatre (OT) and the intensive care unit (ICU). between both groups differed by -6.3% (98% CI, -13.2%
to 0.6%), indicating non-inferiority of BUHE laryngoscopy
to VL within the prespecified margin of 15% difference.
For patients undergoing intubation in the BUHE position,
there was a clinically significant mean improvement in the
POGO scores compared with the baseline SSP position
[mean improvement 25.8%, p < 0.0001]. Importantly, a
subgroup of patients with Cormack-Lehane (CL) grade III
classification in the SSP demonstrated a mean 49.17%
improvement in POGO scores, converting potentially
Figure 1: Bed-up-head-elevated position. The head of bed is
elevated until the endpoint of horizontal alignment between
difficult intubations into straightforward intubations.
the sternal angle and external auditory meatus is achieved
BERITA

Further evidence on the superiority of the BUHE position Effective preoxygenation
over SSP for optimizing laryngeal exposure has also been Aside from facilitating a better glottic view during
suggested by a recent systematic review and tracheal intubation, the BUHE position also has the added
meta-analysis.3 This study compared the ramping position advantage of improving the effectiveness of
and the SSP [ramping position defined as the back preoxygenation during intubation. There is strong
elevated position in which the sternal notch and external evidence that the BUHE position improved the tolerance
auditory meatus were horizontally aligned, irrespective of of apnoea in surgical OT patients, by prolonging the safe
the methods used (specialized pillows, blankets, apnoea period (SAP), defined as the time taken for
head-of-bed elevation, etc)]. There was no difference oxygen saturation to drop to a low level during apnoea.
found between groups with regards to odds for CL 1/2 or Boyce et al in 2003 were the first to investigate the
CL 3/4 views. However, further subgroup analysis based impact of positioning on apnoea tolerance.5 They
on type of population [surgical vs intensive care unit (ICU) randomized 26 obese surgical patients to one of three
patients] revealed that in surgical OT patients, patients in groups, namely 30° reverse Trendelenburg, 30° back-up,
ramping position had a significantly higher odds of CL 1/2 or horizontal-supine positions. They demonstrated that
views, and a lower odds of CL 3/4 views. the SAP was significantly prolonged in the ramped
positions compared to the supine position (p < 0.001).
In the only RCT to date investigating the BUHE ramping Subsequently, other RCTs have also showed similar
position for intubation in ICU patients, Semler et al findings in obese and non-obese OT population, with all
compared the ramped position (head of bed elevated to demonstrating statistically and clinically significantly
25º) and the SSP for emergency intubation.4 The authors prolonged SAP in the ramped position compared to the
discovered that there was a higher incidence of CL 3/4 supine position.6-8
views in the ramped group (25.4%) compared to the SSP
group (11.5%) (p = 0.01). Of note, a majority of the On the other hand, available data on the effectiveness of
intubators reported having more experience intubating in preoxygenation in BUHE position for ICU patients remain
the SSP compared to the ramped position. Until further limited. The only RCT to date which have focused on
evidence becomes available, this study provides the most critically ill ICU patients was carried out by Semler et al.4
current evidence with regards to the effect of BUHE The authors reported no difference in the lowest arterial
position on laryngeal exposure in ICU patients. oxygen saturation peri-intubation (defined as time from
induction to 2 minutes after successful endotracheal
The explanation for improved glottic exposure in the intubation) between groups. Additionally, there was no
BUHE position may be that this position confers a difference in incidence of hypoxaemia SpO2 < 90% or
biomechanical advantage during intubation. When SpO2 < 80% between groups. These findings, however,
compared to the SSP position, the BUHE position allowed have been criticized and should be interpreted with
the operator to change the direction of force (relative to caution as patients in both groups may not be
the horizontal plane) required to lift the laryngoscope comparable.9 There were significantly more difficult
handle, from about 45° in the SSP to about 20° in the airways in the ramped group (CL 3/4 views) compared to
BUHE position.1 This subsequently led to a change of force the sniffing group, and hence time required for
and torque, by increasing horizontal force and reducing intubation in these patients were longer.
vertical force against gravity. In other words, with the
same force, the operator is able to push the laryngoscope The reason for improved effectiveness of preoxygenation
blade further forward rather than upward to obtain the in the BUHE position can be understood from a
most optimal laryngeal exposure. Another potential physiological perspective. Studies have shown that the
explanation for the improvement in laryngeal exposure is ramped BUHE position is associated with increase in
the movement of the laryngeal structures in the BUHE functional residual capacity (FRC).10 In the raised torso
position. When the torso is elevated, laryngeal structures position, the pressure exerted by abdominal contents on
are pulled more caudally directly through the effects of the diaphragm is reduced, allowing the diaphragm to
gravity, or indirectly through the pulling down of the descend further. Additionally, the weight of the chest wall
whole upper thorax which is connected to laryngeal tissues compressing the lungs is also reduced. All this lead
structures. This could affect the laryngeal axis, bringing it to an increased FRC, which serves as a storage for oxygen
nearer to alignment with the line of sight, and hence molecules. The additional oxygen reserve subsequently
improving laryngeal view.1 allows a longer period of apnoea without adverse
complications.
BERITA
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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SSP was based on a few descriptive articles from 1852 to evidence the BUHE position is associated with lesser
1944, and yet it has become the gold standard for peri-intubation complications. However, there is a risk of
positioning.15 Newer evidence in the 21st century has worsened glottic exposure based on available evidence.
challenged the superiority of the SSP for intubation, There is also conflicting data to suggest either a higher or
finding that it may not be as beneficial as once lower rate of successful intubation. Until more research is
thought.16 With the amount of scientific data supporting available, the decision to place critically ill patients in the
the BUHE position, it is sensible to replace the SSP with SSP or the BUHE position should be on a case-by-case
the BUHE position as the ideal starting intubation basis, depending on the clinical judgment of the clinician.
position. In patients who may be vulnerable to
hypotension or the effects of hypotension, the BUHE CONCLUSION
position may still be used with adequate precautions The BUHE position is a novel and easy way to position
taken such as optimizing volume status and usage of patients for intubation, with multiple benefits and no
vasopressor agents. proven disadvantage. Anaesthesiologists should consider
the BUHE position as a starting position for endotracheal
On the other hand, the application of BUHE position as a intubation in the OT for the majority of patients. More
starting intubating position in critically ill patients is not research is needed to determine the suitability of BUHE
so straightforward. Arguments for it state that there is positioning for intubations in the emergency setting.
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
BERITA
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.
Nobody would have predicted that the COVID-19

pandemic would drop like a bomb and loom over all
aspects of life affecting everything. This made the
application processes so much tougher as local and
international bodies started working from home while all
healthcare workers and government bodies around the As I received the letter of offer from the UHS, it was time
world scurried to focus on one thing only, tackling the for me to complete all the necessary documents for my
COVID-19 pandemic. Our subspecialty and Masters Tier 2 Visa application, GMC registration as well as getting
training in Malaysia were also put on hold. Despite all the permission from the Ministry of Health Malaysia. With
this, I was adamant on keeping tabs with the NHS Jobs determination and persistence that I had, all were done
website and I had my eye set on UHS as it was the only and dusted, and I started my journey in November 2020,
accredited centre in the UK that offers European three months earlier than expected. Thankfully, I was able
Association of Cardiothoracic Anaesthesia (EACTA) to travel to the UK without any hitches as a month later,
Fellowship which I was very keen on doing. UHS, however, the country went into lockdown. Oh blimey! Luckily for
was not part of the Medical Training Initiative by the Royal me too, my husband was able to follow and helped me
College of Anaesthetists which meant that I had to get settle down in Southampton. We just got married a few
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months earlier and I was happy that he was able to spend system was used across all critical care units, whereas
some time with me in the UK. other wards had different software in use.
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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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.
Dr Chong Jun Leong from University of Malaya and Dr

Low Joe An from Universiti Kebangsaan Malaysia won the
MSA Award and the MSA Young Investigator Award
respectively. Associate Professor Dr Azrina Md Ralib from
International Islamic University Malaya, Dr Lee Jia Hang
from Universiti Kebangsaan Malaysia and Dr Kuan Tong
Yin from International Islamic University Malaya, won the
first, second and third prizes for the E-Poster
Presentations. Dr Rusnani Mustapha Kamar from
Universiti Teknologi MARA won the Best Case
Report/Series prize. A big congratulation to all winners.
For the Opening Ceremony on 7th August 2021, we had
the Director-General of Health, Tan Sri Dato’ Seri Dr Noor
Hisham Abdullah, who delivered the keynote address and
officially declared the Congress open. He acknowledged
the immense contribution of the Anaesthesiology and
Critical Care fraternity in helping the country combat the
COVID-19 pandemic. It was an amazing virtual opening
ceremony which received much attention from major
news media, including The Star, Malay Mail, New Straits
Times, Malaysiakini and various other Facebook postings.
There were headlines with outpourings of support and
encouragement echoing his speech for the
Anaesthesiology and Critical Care fraternity in our daily
challenge and struggle to provide care for COVID-19
patients and leading the way in the pandemic
management for the sickest of the sick. It was at the
height of uncertainties of which direction the pandemic
was going in the country that we held this conference,
and the caring words spoken directly by Tan Sri Dato’ Seri
Dr Noor Hisham to us gave us much respite in the
troubled world.
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Delegates stayed with us till the very end of the last day of the talks that were pre-recorded to the registered
when we held the Datuk Dr Radha Khrishnan Best Master delegates via email. Thankfully by the later part of the
Student Award Ceremony. Due to the absence of ASC morning, much of the technical difficulties were resolved
2020, best students from 2019, 2020 and 2021 received and we were back to near normal. Although there were
the awards at the same time. They were Dr Mohammad shortcomings especially from the IT aspects, we hope that
Hafizshah bin Sybil Shah from University of Malaya for a major part of the Congress remained beneficial to the
November 2019 examination, Dr Samuel Tsan Ern Hung delegates.
from University of Malaya for the November 2020
examination and Dr Kuan Tong Yin from International We do miss some of the camaraderie and networking
Islamic University Malaya for the April 2021 examimation. opportunities that physical congresses present. However,
A round of applause for the recipients. what is evident over the last two years is that life is never
going to be the same again. Learning to adapt to a 'new
For the virtual exhibition, we had a total of 19 normality' and embracing opportunities that were not
pharmaceutical and biomedical industry partners. The present before will have long lasting effects on the format
booths provided interactive virtual connections between future (actually current) conferences, seminars and
the industry representatives and delegates. workshops will be held. We hope in August 2022,
MyAnaesthesia can allow us some degree of a
Last, but not the least, with delegates all holding on to face-to-face or hybrid congress. We look forward to meet
their online communications on the congress platform, up with all of you at the Shangri-La Hotel, Kuala Lumpur,
we conducted a Wheel of Fortune lucky draw to reward both physically and virtually. Indeed, we have arrived at a
those who stayed on till the very end. It was indeed very new era.
fun and exciting to end the congress on this note, with
hilarious call-outs and re-draws conducted by our very
animated Master of Ceremony, Dr Mohd Azizan Ghazali.
At the very end, the MSA President for the coming year,
Professor Dr Ina Ismiarti Shariffuddin, concluded the
congress with a short farewell and appreciation speech.
MyAnaesthesia 2021 was a challenge, and an opportunity

for us to learn as it was the first time we organised a
virtual conference of this scale. The first day started with
a small hiccup when the main server crashed, and we had
to kick in the backup server which took a while to reboot.
Luckily, we had a backup plan of sending the video links
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National Anaesthesia Day 2021
by Associate Professor Dr Loh Pui San
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.
Similar to the virtual NAD in 2020, a forum was organised.

This year, the discussion by the panel was led by two
eminent fellow colleagues, Dr Gunalan A/L Palari from
Subang Jaya Medical Centre and Datin Dr Vanitha
Sivanaser from Hospital Kuala Lumpur. The six-member
panelists were invited from various subspecialties,
seniority and positions to represent the anaesthesiology
At precisely 9.00am on a lovely Saturday morning (16th profession and how each of them pursued different
October 2021), the event, packed with many activities, directions in the battle against COVID-19. First in line was
started with Lagu Negaraku followed by an introduction the National Head of Anaesthetic Services in Malaysia, Dr
by the lively and spontaneous Master of Ceremony, Dr Zalina Abdul Razak, who described the strategic actions
Mohd Azizan Ghazali, from Hospital Kuala Lumpur. The of the Ministry of Health when several hospitals were
event was blessed with the Doa Recital by Dr Mafeitzeral converted fully to manage only COVID-19 cases, for
Mamat from Gleneagles Hospital Medini Johor. In the example Hospital Ampang and Hospital Sungai Buloh.
opening speech, as the Chair of the Organising These were subsequently followed by newly established
Committee, Dr Gunalan A/L Palari expressed how this COVID-19 centres such as UKM Specialist Children’s
year’s theme “Teamwork: Stronger Together” was Hospital (HPKK). She praised all the medical officers who
reflected on the blueprint created in the midst of a worked tirelessly throughout these two years as the
pandemic where both the public and private sectors backbone and pillar of our healthcare service. Most
worked hand-in-hand to overcome the surging waves of importantly, she noted the importance of a large
COVID-19 cases recently. An example of this exemplary workforce and the need to achieve the trajectory ratio of
teamwork was the assistance extended by the private 5 anaesthesiologists to 100,000 population by 2030.
institutions to help decant many patients from public
hospitals at the peak of the pandemic when admission The next invited panelist was Professor Dato’ Dr Patrick
beds were scarce. In many ways, he reminded us that the Tan from University Malaya Medical Centre (UMMC),
NAD was a meaningful celebration as a strong team. Kuala Lumpur who has vast experience in intensive care
and needed little introduction being the mentor for many
anaesthesiologists amongst us. He related our current
pandemic situation to the handling of the Nipah Virus
epidemic in the past and emphasized that trust in
teamwork builds resilience. In this age of digital
technology, social media has become an easy source of
information that can be rapidly disseminated regardless
of the authenticity of content. Dr Hana Hazrani from
Hospital Kuala Lumpur became our medical advocate by
dedicating her time to field questions, allay fears and
misunderstandings from the public through her social
influence during the pandemic. In the panel discussion, Dr
Hana Hadzrani outlined the importance of honesty and
mental preparedness to face challenges in the future.
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Representing the Ministry of Defence, Lt. Col. Dr
Mohamed Azlan Ariffin from Hospital Angkatan Tentera
Tuanku Mizan described the set-up of field Intensive Care
Units (ICU) across the country. Previously, Ministries
worked in silos and thus Dr Azlan suggested to form
strong collaborations among the Ministries of Health,
Education and Defence that should be transparent with
one goal and one direction. Just like in a war, the battle
against COVID-19 requires unified commands and online competition for Anaesthesia Got Talent showcased
coordination to win. As a training medical officer in the a total of ten submitted videos. Dr Mohd Azizan then
Anaesthesiology Department of UMMC, Dr Tan Boey Warn announced the top five short videos in no particular order
was also delegated heavy COVID-19 duties like many of - Hospital Sultanah Maliha Langkawi, Hospital Serdang,
his peers and, therefore, he could attest to the issues Hospital Tuanku Ja’afar Seremban, Hospital Port Dickson
while performing the line of duty and juggling the safety and Hospital Kuala Lumpur. Three distinguished judges -
of their families. He realized it was always best to be Dr Mohd Rohisham Zainal Abidin, the Deputy National
prepared for the unprepared. Last but not least, Dr Eng Head of Service; Datuk Dr Asmil Farid Zabir from Prince
Kar Seng, the lead Intensivist from Hospital Sungai Buloh Court Medical Centre and Professor Dr Karis Misiran from
was interviewed at the forum. Dr Eng was given free rein Universiti Technologi Malaysia selected Hospital Kuala
to navigate his ICU team in leading the fully COVID-19 Lumpur as the winner,
hospital at a time when cases were overwhelming in Hospital Sultanan Maliha
Selangor. “Everyone should be interdependent on each Langkawi as the first
other,” he said and should have individual coping runner-up and Hospital
mechanisms by practising balanced lifestyles, enjoying Serdang as the second
food or achieving satisfaction from witnessing patient’s runner-up.
recovery.
From the videos of multi-talented anaesthesiologists, we
Following the forum, the Presidents of the MSA and the moved on to test their white and grey matter for
CoA delivered their speeches. Professor Dr Ina Ismiarti knowledge and speed. A total of 158 MSA members
Shariffudin, President of the MSA, delivered an impressive signed up for the online quiz with 20 questions prepared
message that anaesthesiologists play unforgettable roles by Professor Dr Rafidah Atan from University of Malaya
in many of our lives. Professor Dr Ina acknowledged the based on the history of anaesthesia, clinical and current
donations given to equip many COVID-19 hospitals. She anaesthetic related knowledge. The top five winners
also emphasized the classical Malay proverb “bersatu kita (brilliant anesthesiologists under cover) were as listed
teguh, bercerai kita roboh,” that symbolized the exact below.
sentiments of “Teamwork: Stronger Together” as
the NAD theme this year. An equally eloquent
speaker, Professor Dr Marzida Mansor, President
of the CoA, spoke on the collective
public-private hospital response that helped
tremendously in this pandemic and how
teamwork skills should encompass leadership,
communication, mutual monitoring and
feedback. Although the MSA and the CoA were
established 31 years apart, both will continue to
work together in unison. It was also timely to
reactivate the Wellness SIG as well as to bring
forth the National Resilience Workshop and Joy
at Work Campaign.
After all the formalities, it was time to have

some fun. A lot of exciting announcements and
activities were lined up for NAD. First of all, the
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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!
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My National Anaesthesia Day 2021:
KPJ Pahang Specialist Hospital
by Dr Haslan Ghazali
KPJ Pahang Specialist Centre
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'.
As we were still amidst the COVID pandemic, most events

were conducted virtually through social media platforms
or meeting applications. Unlike last year’s celebration
with exhibitions and games, a virtual event will be
without much physical interaction. So, we quickly put on
our thinking caps and started work on our event. As it was
done on a smaller scale and virtual, the organizing
committee consisted mainly of the marketing department
personnel of the hospital. They were experienced in
conducting virtual events.
Sarah Seri Masran. After the speeches, guests were shown

a short video montage of the Anaesthesia and
This year, the World Sight Day and National Anaesthesia Ophthalmology Departments of KPJ Pahang. At about
Day of KPJ Pahang Specialist Hospital was held in the 10.00am we had a 'Meet the expert' forum conducted by
marketing department where we recorded the event in Dr Siti Sarah and I. We talked about our role in patient
front of a big green screen. There were several activities care especially on the teamwork spirit in the operating
lined up. We had publicized the event via Facebook and theatre. We also touched about the celebration and what
through Whatsapp groups of KPJ staff. It was held via the it meant to us. We also entertained a lot of questions
'KPJ Pahang Anaesthesia Day' Facebook page and Google pertaining to our clinical expertise. This lasted for about
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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
Click on link below or QR code

to watch the recorded event on FB
https://www.facebook.com/Anaesthesia-Day-KPJ-Pahang-214283817247815
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Teamwork - I love our team
National Anaesthesia Day 2021, UMMC
by Dr Ng Jia Hui & Dr Zamirah Basher
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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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.
Despite being an online event and we could not celebrate

To spice up the event, we had a TikTok competition with as a team physically, it was still a fun and exciting day. Last
the theme of ‘teamwork’ open to all the UMMC staff. We but not least, utmost gratitude to all the frontliners for
were pleased to receive many entries and the panel of their sacrifice during this tough time. Let us hope that we
judges had a hard time deciding on the winners as the can celebrate this special day face-to-face in the future
entries were all equally fascinating. The winners were when the pandemic is over.
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Hosting the First Ever Virtual Pre-Entrance
Anaesthesia Workshop
by Dr Nor Fadhilah Shahril & Professor Dr Ina Ismiarti Shariffuddin
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.
Held over Zoom platform over two weekends on the

14th - 15th and 21st - 22nd August 2021, the workshop
provided an overview on basic physiology and
pharmacology - two major key subjects examined in the
Part 1 examinations of Masters in Anaesthesiology. The
workshop also prepared participants with the exam
standards and the opportunity to directly engage with the
National Conjoint Examination Board examiners to
understand the programme better. In total, this workshop
attracted over 280 candidates from all over Malaysia,
including Sabah and Sarawak.
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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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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Basic Transesophageal Echocardiography for Anaesthesiologist
by Dr Hasmizy Muhammad
Pusat Jantung Sarawak
Introduction Safety of TEE

Transesophageal Echocardiography (TEE) is used by Although TEE is generally safe, the complications can
Cardiothoracic Anaesthesiologists in this country for occur either by the probe itself or during the probe
perioperative monitoring of cardiac performance, assist placement procedure. Thermal pressure injuries,
with surgical decision-making, evaluation of surgical compression of the structures proximal to the esophagus,
repairs and assessment of patient’s hemodynamic at and soft tissue damage in hypopharynx, esophagus, and
cardiothoracic intensive care unit. Recently, TEE use has stomach are some of the probe-related complications.
been expanded to other anaesthesia sub-specialties. It is Circulatory complications such as hypertension,
used for the detection of venous air embolism and patent hypotension and arrhythmias, and pulmonary difficulties
foramen ovale in neurosurgery, evaluation of pericardial i.e. laryngospasm, bronchospasm, hypoxia are examples
effusion and compression of the cardiac chambers in of procedure-related complications.
liver transplantation, and diagnosis of cardiovascular
pathology that may cause intraoperative hemodynamic, TEE Probe System
pulmonary, or neurologic compromise. TEE is also used to At the tip of TEE probe, there is a phased array
supplement Transthoracic Echocardiography (TTE) in the piezoelectric crystal, which function both as the
intensive care unit for diagnosis and management when transmitter and receiver of ultrasonic waves. The standard
the latter is unable to obtain the necessary images. probe connector is plugged and locked into the machine
slot. The handle contains two control wheels and array
Indication for Basic TEE Application rotation multiplane buttons. The probe position and
TEE offers a wide range of applications in clinical practice. orientation can be changed by manoeuvring the probe
However, for basic TEE, the main indication is monitoring using the two control wheels. The large wheel flexes the
of the cardiac and adjacent structures such as ventricular tip of the probe anteriorly (anteflexion) and posteriorly
size and function, valvular anatomy and function, volume (retroflexion). The small wheel allows for lateral flexion or
status, pericardial and pleural abnormalities, and great side-to-side movement of the tip. The array rotation
vessels that may cause hemodynamic or ventilatory buttons turn the multiplane angle from 0 to 180° as
instability. piezoelectric elements can be electronically rotated either
clockwise or counter clockwise. Since TEE requires less
depth penetration, it uses higher frequency transducers
between 5 to 7 MHz.
Figure 1: Transesophageal Echocardiography Probe
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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.
Figure 2: Lateral chest x-ray show positions of the heart, TEE

probe, esophagus and aorta. Arrows indicate the positions of
the TEE probe at upper esophageal (UE), mid esophageal (ME),
transgastric (TG) and deep transgastric (DTG)
Figure 3: Terminology used to describe the manipulations of the

TEE Probe Manipulation probe and transducer during image acquisition
The position and orientation of the TEE probe can be
altered by several types of manipulation (Figure 3): Basic TEE Views
Basic TEE examination emphasizes on the 11 most
a) “Advancing” is pushing the tip of the probe distally important views, which can provide the necessary
toward the stomach while “withdrawing” is pulling information for diagnosing the aetiology of patient’s
the tip in the opposite direction proximally. hemodynamic instability.
b) “Turning to the right;” is rotating the anterior aspect

of the probe clockwise toward the patient’s right while
“turning to the left” is rotating the probe counter
clockwise.
c) Axial rotation of the multiplane angle from 0° toward

180° is called “rotating forward,” and rotating in the
opposite direction toward 0° is called “rotating back”.
i. At 0 degrees the transducer beam is transverse
ii. At 90 degrees the transducer beam is longitudinal
iii. At 180 degrees the transducer beam is transverse
(mirror image of 0 degrees) Figure 4: Transesophageal views at mid esophageal level. Start
(clockwise) with the four-chamber view (angle: 0-10°),
two-chamber view (angle: 80-100°), long axis (LAX) view (angle:
d) Flexing the tip of the probe anteriorly with the large 110-130°), ascending aortic long axis view (angle: 100°) and
control wheel is called “anteflexing” and flexing it ascending aortic short axis (SAX) view (angle: 10-30°)
posteriorly is called “retroflexing”.
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c) Assessment of volume status and monitoring fluid
therapy response by obtained LV end-diastolic
diameter and LV end-diastolic area in the TG
midpapillary SAX view.
d) Assessment of valvular regurgitation and stenosis at

Aortic valve (AV), Mitral valve (MV), Tricuspid valve
(TV), and Pulmonary valve (PV). Colour flow Doppler
with visual inspection of regurgitant jet area within the
receiving chamber and vena contracta width able to
differentiate mild, moderate and severe degrees of
regurgitation while visualizing leaflet motion and
Figure 5: Transesophageal views at mid esophageal level. Start using continuous-wave Doppler (CW) through the
(clockwise) with the right ventricle inflow-outflow view (angle:
valve able to provide severity of valvular stenosis.
50-70°), aortic short axis view (angle: 25-45°), bicaval view
(angle: 100-110°), descending aortic short axis view (angle: 0°)
and descending aortic long axis view (angle: 90°) e) Assessment of Pulmonary Embolism (PE) although TEE
has low sensitivity for direct visualization of a
thrombus in the pulmonary artery. TEE findings
consistent with acute PE are RV dilation and RV
hypokinesia.
f) Assessment of Venous Air Embolism (VAE). Basic TEE

provides real-time data and a visual quantification of
VAE and detection of right-to-left shunts.
g) Assessment of Pericardial Effusion and Thoracic

Trauma as basic TEE offers a rapid, accurate diagnosis
Figure 6: Transgastric short axis view at midpapillary level
(angle: 0°) of pericardial effusions, traumatic aortic injuries, and
cardiac contusions although visualization of the distal
Information gathers from Basic TEE ascending aorta and aortic arch are limited.
The basic information obtained from TEE:
h) Assessment of patent foramen ovale and secundum
a) Assessment of global LV function by visual estimation atrial septal defect (ASD) by using colour flow Doppler
of systolic function, and assessment of regional LV imaging in the ME bicaval view as the defect in the
function by evaluation of 17-segment wall motion interatrial septum.
from the ME four chamber, ME two-chamber, ME LAX
and TG midpapillary SAX views. Conclusion
Basic TEE has distinct advantages over conventional TTE in
b) Assessment of RV function by visual estimation of RV certain clinical circumstances and can be used as
systolic function. non-invasive hemodynamic monitoring tools either in the
operation theatre or intensive care unit.
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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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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Dr Siew Gee Ho (HPKK & Hospital Miri), Dr Shahridan Bin Overall, at the end of the day, we garnered mostly positive
Mohd Fathil (MERCY), Dr Lee Yew Ching (Hospital feedback from the participants as this course helped them
Serdang), Dr Hetty Ayuni binti Sulaiman (Hospital Umum to understand better and improve their knowledge in
Sarawak), Dr Yang Wai Wai (HPKK) and moderators Dr management of critically ill patients. Many had also
Choo Mei Ann (Hospital Sungai Buloh) and Dr Leong Ai requested for recording of the event and MY-sigRA had
Leng (Hospital Selayang). again graciously allowed them to be uploaded online on
their YouTube channel. These can be accessed at
Throughout the course, the chemistry among the https://www.youtube.com/c/MYsigRA under ‘Critical Care
organising committee was fantastic and was noticeable Management Course for Non-ICU Doctors’ playlists.
especially during the live Questions & Answers segment of
each lecture. Each of us from behind the scenes was We were glad that VBCCM played a role during this
helping to answer all the burning questions from pandemic especially in helping our junior doctors and
participants both via live and in the chat section at Zoom non-ICU trained clinicians to manage the critically ill
and YouTube. We were also glad that there were some patients with COVID-19 during the surge crisis. This
good Samaritans who had volunteered to answer our course was subsequently made into a compulsory
participants' questions via the chatbox when we were introductory course during orientation week for the
busy sorting out issues behind the scenes. Although there House Officers who came to HPKK for their COVID
were technical hiccups in the beginning, these were all rotation. Looking back, I am touched as this might be one
sorted out promptly to prevent delay to each section. of the times when clinicians from various disciplines get
together to show their support during this pandemic
crisis.
#kitamestimenang
Ps.: The author would like to express his gratitude to

Professor Dr Tang Swee Fong (Deputy Director of HPKK) to
allow us to organise this course, Dr Melor bin Mohd
Mansor for gracing the event, Dr Teo Shu Ching
(PEKA-HUS) for the support, Dr Azrin Mohd Azidin,
Convenor of Malaysian SigRA for permission to use their
YouTube channel, Dr Muhammad Amir Ayub, who
manages MY-sigRA YouTube channel, Mr Yazeed (IT
department of HPKK) for the webinar technical support,
and Ms Lia (HPKK Corporate Communications Services)
for the certificate preparations.
Picture 2: Post event group photo of the organising committee
Picture 1: Our initial flyer prior to last minute changes
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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.
It was a challenging experience for the organising

The programme was well-crafted with topics related to committee and the delegates, as we head into an era of
the current trends in perioperative neuroscience which virtual meetings due to the COVID pandemic. With the
consisted of four plenary lectures, five mini symposia and excellent feedback gained through the NAS 2021, we
two lunch symposia. The invited overseas speakers were strive to make the upcoming Virtual Neurocritical Care
Associate Professor Dr John Patrick F Bebawy (USA), Conference on 1st to 3rd July 2022 a success.
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The MY sigRA YouTube Channel
by Dr Muhammad Amir Ayub
Hospital Kuala Lumpur
There was a problem of obsolete technology when RA

Asia 2017 symposium was recorded and published on a
DVD format. This had made many people unable to view
this on the DVD format. That was when Dr Azrin Mohd
Azidin and Dr Amiruddin approached me in June 2020
regarding this issue. I have always had my own personal
YouTube channel https://www.youtube.com/c/anakayub,
which was never successful despite it being more than a
decade old. That channel has all of the videos I had ever
produced in my life, of which the majority is not
anaesthesia-related content. When initially approached
for help, I ripped out the contents, edited, transcoded and
republished those videos as separate cuts on my personal The channel. Take note that procedural videos are most popular
YouTube channel. But then issues came about: myriad
audio issues, recorded stuff that the public did not need Video making, even for a short video clip, is hard and long
to see, censorship issues, and many others. work. Some may argue that getting the audio right is
more important than the video. The shortest work time is
I then self-educated myself the knowledge and skills probably 1.5 times the duration of the final, equalling the
related to those problems and many others related to time to listen and edit the audio without doing any video
video production to improve on what was initially just a edits. Work with poorly recorded audio (you don’t want
change in the publishing format. This was admittedly an to hear it), and the work time may triple the clips’
extension of my self-education when I started my duration. Getting a good room to record in with the right
personal YouTube channel. audio setup is an essential aspect of recording our
lectures and narrations.
It was soon suggested that we have the content
published on a dedicated channel, but still managed Add in video edits, and if we are working on original
by me. A logo was already worked on by Dr Herna. procedural videos, scripting, debating (direction and
That was how the MY sigRA (Malaysia Special Interest medical facts), shooting, narrating, special effects. You
Group in Regional Anaesthesia) YouTube channel will get the picture that it is not easy for a one-man
https://www.youtube.com/c/MYsigRA started: as a editing machine (there is usually help in shooting and
channel to put our very own local regional anaesthesia getting other recorded video clips). Let us not forget that
educational content. we are producing medical educational material of which
it has to be correct. Starting out, production of that
The type of content has evolved into more complex work anterior QL video probably took around 30-man hours;
since from recorded slide presentations, online lectures & subsequent productions took much less time as my skills
symposiums to procedural videos. What was supposed to improved and a proper workflow was formulated (you
be exclusively regional anaesthesia content has also been need to treat the production exactly like producing a
deviated from slightly; with ICU-related content published movie).
in the wake of non-ICU doctors being deployed to work in
the ICU when COVID-19 ravaged across the country. Our What about equipment and workflow? Most of the
first material came via YouTube livestreaming (with the shooting for our original procedural videos were shot just
channel being the streaming host for the organisers), on iPhones (they are pretty good), sometimes with
reaching a couple of thousand viewers at one point. accessory lenses. Footage from ultrasound machines were
obtained either via the machines’ built-in video recording
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or via streaming to my laptop with a HDMI capture device
(subsequently recorded via a streaming app, in our case
OBS). Even though our most popular video, the anterior
quadratus lumborum block video, had its narration
recorded via “just an Android smartphone” (see the
importance of the right recording environment), most of
our videos have their narrations recorded with either a
shotgun (Takstar SGC-598) or a clip-on lavalier (Boya
BY-M1) microphone (check out the review of my
microphones: https://youtube.com/watch?v=6SJS-7XJUk0).
It is then edited on my MacBook Pro with Final Cut Pro,
A more complex project, which includes finished motion
working either on the laptop itself or on an external drive. graphics work
I listen to the audio on my Klipsch X20i earphones to base
my edits. Both original footage and the final production
videos are archived on external storage. That 2017 ASRA
original footage came from 2 DVD’s, which amounts to
around 9 GB. The current archived footage for MY sigRA
altogether right now is around 120 GB, and the amount
of archived space to store the footage for Dr Melor’s
farewell video was 175 GB. That archive does not include
storing the final output files, nor projects lost due to
glitches in my backup and archive solution/workflow. The
former would have been even bigger (especially when
editing vs archiving) if not for the relatively powerful
computer I have been using to edit from (generally My most complex project, though not MY sigRA:
https://youtu.be/LwFBjDdWywk and that was not the whole
negating the need for a scratch disk). After making the timeline
videos public, I would then also promote it on my
personal website/blog (https://www.anakayub.com) and subscriber numbers, this situation may change. Even
various social media posts. though I love doing these IT work, not having any
monetary rewards (at least for now) does make it difficult.
Though it is fun work if you are into it, it is not all With a very busy life, time to work on new videos is a
sunshine. If you are asking, the channel has not made any premium. Burnout among YouTubers (aka content
money. I do hope that with good viewership and creators) is an established fact, but those same people are
also not doctors, who do not deal with the treatment of
patients during COVID times. Hopefully it becomes a
sustainable endeavour.
That is all I have to share for now. I hope to share more

about my workflow. I have shared my audio workflow on
my personal channel here: https://youtu.be/_Pfr0tCMIdc.
The current project is on how to perform central venous
cannulation for junior doctors but, as usual, there are
snags. If you are willing to volunteer your internal jugular
A relatively simple project of a recorded lecture without vein or common femoral vein, you know who to keep in
simultaneous screen recording
touch. Till next time, please do not forget to subscribe
and share!
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Ultrasound Guided Vascular Access: Where are we Right Now?
by Dr Hasmizy Muhammad
Pusat Jantung Sarawak
Introduction American College of Critical Care Medicine, Association of

Knowledge of surface anatomy is an important Anaesthetists of Great Britain and Ireland and the
prerequisite for vascular cannulation of peripheral and European Federation of Societies for Ultrasound in
central veins, and arteries. However, failure and Medicine and Biology have published recommendations
complications can occur even in expert hands. Landmark and guidelines for ultrasound guided vascular access.
techniques for vascular cannulation are associated with a
60% to 95% success rate. This is evidenced by the number
of complications of central venous cannulation either by
our own fraternity or other disciplines.
Complications of Central Venous Cannulation

The number of insertion of central venous catheters
(CVCs) of the Internal Jugular, Subclavian, and Femoral
veins in the United States is reported to be more than 5
million annually, with complication rates ranging from
5% to 19%. The immediate complications of CVC include
arterial puncture, haematoma, pneumothorax,
haemothorax, chylothorax, brachial plexus injury, air
embolism, puncture of the aorta and catheter
malposition.
The Clinical Audit Unit, Medical Development Division and

the Perioperative Mortality Review (POMR) Committee of
the Ministry of Health Malaysia in its POMR eBulletin 2020
reported a case of malposition of a right internal jugular
CVC into the posterior of the Superior Vena Cava in an The author using real time ultrasound guidance for
a right internal jugular cannulation
elderly lady with underlying end stage renal failure, after
multiple attempts at cannulating the right internal jugular
vein with a haemodialysis catheter. Ultrasound Guided Vascular Access Practice in
Malaysia
Rationale of Using Ultrasound for Vascular In Malaysia, there are no guidelines or recommendations
Cannulation from medical societies/bodies on the usage of ultrasound
Ultrasound guidance for vascular access has been widely for vascular access in clinical practice. Ultrasound has
used for the past four decades. It has been shown to been used for difficult vascular access e.g. in obese
improve success rates, reduce the number of insertion patients or after failed multiple cannulation attempts, or
attempts, and reduce complications. Ultrasound imaging in cases of potential bleeding e.g. coagulopathic patients.
can differentiate between the vein or artery, identify The usage of ultrasound guidance for CVC placement is
vascular thrombosis, guard against through-and-through influenced by the competency of the operator and the
puncture and prevents passage of the needle into availability of the ultrasound machine. Recently, the use
surrounding structures. of ultrasound guidance for vascular access in the intensive
care unit, operation theatre and wards has increased.
The National Institute of Clinical Excellence, American There is no structured training for ultrasound guided
Society of Echocardiography, Society of Cardiovascular vascular access in our postgraduate Anaesthesiology
Anesthesiologists, American Society of Anesthesiologists, programme. The trainees gain the necessary knowledge
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and skills from either workshops or during on-the-job Ultrasound Guided Vascular Access. The guideline
training in their hospitals. should state the minimum criteria for the safe
performance of Ultrasound Guided Vascular Access.
Steps to Enhance Ultrasound Guided Vascular
Access Programme in Our Fraternity
a) Special Interest Group in Ultrasound (SIG)
The College of Anaesthesiologists, Academy of
Medicine of Malaysia has taken initiatives to improve
and enhance the usage of ultrasound in anaesthesia
and intensive care services in the country by setting up
the Special Interest Group in Ultrasound in 2020. The
main focus of the Ultrasound SIG is to propagate the
use of ultrasound in our fraternity.
b) Systematic Education Program

A standardized training incorporating knowledge on
ultrasound and vascular anatomy, followed by a
Ultrasound guided vascular access simulation on a training
combination of simulation-based practice and manikin
supervised cannulation on patients is essential to
promote a safe central venous cannulation practice Conclusion
throughout the country. Such programme can be The routine use of ultrasound for vascular access is still
organised by the Special Interest Group in Ultrasound, lacking. While the availability of the ultrasound machine
College of Anaesthesiologists and the Malaysian especially in the district hospitals is the main obstacle, the
Society of Anaesthesiologists. competency of the operators also needs to be addressed.
Continuous education on ultrasound guided vascular
c) Practice Guideline for Ultrasound Guided Vascular access either during workshops or on-the-job training will
Access improve patient safety in the future.
Practice guideline is intended to provide our fraternity
with a standard protocol for the performance of
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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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
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The Junior Doctor Conundrum….
by Dr Kevin Ng Wei Shan
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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static since the early 2000s. This is in line with the As part of the Section Concerning House Officers, Medical
Government’s plans to keep the size of the civil service in Officers and Specialists (SCHOMOS) Executive Committee,
check, started by our 4th Prime Minister and his we had raised our concerns that the contract issue is a
government. This was again reiterated by the 7th Prime stop-gap measure. We felt that although it would reduce
Minister, in his opening week of office. In 2020, the JPA the waiting time a little, it would not offer a long-term
has launched a quest to resize civil services, and the career pathway to the doctors. As such we pushed for a
process is ongoing. Those amongst us who have asked for more comprehensive review of the career pathway for the
additional staffing would understand the ordeal and the junior doctors, looking at medium and long-term
tribulations necessary to even obtain one extra Medical solutions. We presented to all levels asking first for a
Officer for the department. yearly increase in positions to match the population
growth and needs (we estimated 2000 positions per year)
Rightsizing of the civil services. While this is something I and an extended contract. We also suggested the
agree with in principle, I believe that education and reduction or merging of medical schools, but this was not
medical services should be excluded from this. And here is a popular solution.
why. The population of Malaysia grows at a rate of about
1 to 1.2 million per year. We are an aging population and The process has been long and arduous. With every
a society that is hyperfocused on food. The incidence of change in government, we had to lobby the new
non-communicable diseases increases yearly, increasing administration again to review this. The solution is not
the burden and demands on the already stretched simple, as funds are limited and the issue was not a
healthcare services. How is it possible to reduce or priority at that point in time as there was a perception
maintain the same number of staff to provide the services that there were 4 years to solve the issue at hand. In May
needed? How are the medical services to expand without 2021, in a meeting with the JPA top administration, the
the necessary support of human resources? We can only issue was discussed and KKM indicated that a decision
look around and we can see the hidden secret of unused was soon to be made. Thus, in July 2021, the decision was
infrastructure, that lies empty due to the lack of sufficient released by the 8th Prime Minister, Tan Sri Muhyuddin
staff to man and operate them. What we need is better Yassin, that there would be an extended contract for the
planning with regards to human resource management to junior doctors, as well as opportunities to further their
match population needs, not just match administrative studies with government scholarships to those who
needs. But I digress, let us come back to the issue at hand, qualify. This is not the ideal solution, but it is the only one
the plight of the junior doctors. possible at this point to quickly resolve the conundrum
faced by the junior doctors who were at the end of their
To deal with the lack of permanent positions, and the contracts.
slow process to increase these very positions, the Ministry
and Administration decided to reintroduce the contract The extended contracts will allow for some of the
system for housemen. To the seniors here, those who remaining contract doctors to specialize and continue
were HOs before 1980 would remember that housemen their medical education. They have been given an extra 2
were contract officers then, before the introduction of years of service, and 4 years to specialize after that, which
permanent positions to encourage doctors to join the is barely enough to qualify for and complete many of the
government service in the early 1980s. So, in December Master’s programmes in our country. There are plans to
2016, the contract system was reintroduced. This entailed offer permanent positions with only an EPF option, but
a 2 + 1-year contract for Housemanship training followed again this would involve a major policy issue, and as such
by 2 years’ contract for the completion of compulsory will not happen overnight. The offer on the table is still a
service. In theory, those who excelled in these 4 years contract offer, and one that many junior doctors feel is
would be offered permanent positions as it opened up not sufficient reason to stay, a sentiment I can understand
and it was hoped that more than 60% of the intakes and commiserate with. The delay in this announcement
would be absorbed. has also caused Malaysia to lose a large number of young
talents to other countries around the globe, and perhaps
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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.
5) Increasing the perks for those serving in the rural and

less popular hospitals. Tying the permanent positions
to the district hospitals
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Fascial Plane Blocks for Cardiothoracic Surgery
by Dr Mohd Fahmi Zakariah & Dr Rusnaini Mustapha Kamar
Introduction anaesthesia technique for thoracic wall.10 There are two

Effective perioperative pain management plays a crucial variants of SAP block; superficial and deep in which the LA
role affecting the outcomes of patients undergoing is deposited within the plane superficial or deep to
cardiothoracic surgery. Perioperative cardiothoracic serratus anterior muscle respectively at the level of 4th - 5th
surgery pain may arise from multifactorial causes, rib mid-axillary line. This results in analgesia to
including pain from skin incision, sternotomy, sternal or anterolateral and posterolateral chest wall via blockade of
rib retraction, internal mammary artery harvesting, and the intercostal nerves, long thoracic nerve, and
chest drains.1 Inadequate pain management in cardiac thoracodorsal nerve.
surgery results in increased morbidities, prolonged
Indications
recovery and hospital stay, and increased risk of chronic
SAP block has been reportedly used in breast surgery,
postoperative pain.2,3 Chronic pain post sternotomy and
video assisted thoracoscopic surgery (VATS),
thoracotomy has been observed in about 20% and 25 -
thoracotomy, minimally invasive cardiac surgery (MICS),
60% of patients, respectively.2,3
and in acute pain management of ribs fracture.
Until recently, parenteral opioids have been the main
How to perform
analgesics used for cardiac surgery. However, opioids have
SAP block is performed in supine position with the
well known adverse effects such as respiratory
ipsilateral arm abduction. Following the usual preparation
depression, ileus, nausea, vomiting, pruritus, and opioid
for regional anaesthesia block (intravenous access,
induced hyperalgesia.4 Enhanced recovery after surgery
standard monitoring, aseptic preparation), the high
(ERAS) program for cardiac surgery advocates
frequency linear ultrasound probe is placed transversely
opioid-sparing pain management strategy which
at the mid-axillary line of fifth rib (nipple level). In this
incorporates multimodal analgesia with regional blocks.5
position, identify a superficial and thick muscle, the
Regional anaesthesia techniques have been shown to
latissimus dorsi, overlying the deeper serratus anterior
provide acute postoperative pain relief as well as
muscle (Figure 1). The thoracodorsal artery can be
protecting against opioid induced hyperalgesia and
identified in the plane between latissimus dorsi and
chronic post-surgical pain.6
serratus anterior by using colour doppler. Following the
Thoracic epidural analgesia (TEA) and paravertebral block identification of the landmark, a 22G 4-inch echogenic
(PVB) are traditionally the “gold standard” regional needle is inserted in-plane from anteromedial to
anaesthesia techniques for cardiac surgery. However, they posterolateral direction into the fascial plane between
are technically demanding, and are associated with rare latissimus dorsi and serratus anterior (superficial SAP) or
but serious complications such as epidural haematoma between serratus anterior and the rib (deep SAP). Long
secondary to post-heparinization, haemodynamic acting LA (Levobupivacaine 0.25% or ropivacaine 0.375%)
instability, and pneumothorax.7,8 0.4ml/kg is then injected into the fascial plane.
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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neuropathic pain.12 It is an interfascial plane block
wherein LA is injected to a plane between transverse
processes of thoracic spine and erector spinae muscles.
Since its introduction, ESP block has been rapidly gaining
popularity and used as perioperative analgesia in a
multitude of cases including thoracic, abdominal, and
spine surgery. Recently, bilateral ESP block has been
described as an effective alternative to TEA and PVB as a
regional anaesthesia technique for cardiac surgery.9
The exact mechanism of action of ESP block remains a

much-debated topic. Collective evidence suggests that
ESP block may work through several mechanisms such as
LA spread towards dorsal ramus, ventral ramus,
paravertebral space, and epidural space.13
Figure 1: Patient positioning and ultrasound probe placement

Indications
for SAP block ESP block has been described in breast surgery,
thoracotomy, VATS, MICS, and in cardiac surgery
involving sternotomy (bilateral ESP).
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.
The 21G 4-inch echogenic block needle is inserted in

cranio-caudad or caudo-cranial orientation until the
needle tip touches the transverse process. The correct
plane is confirmed when there is linear fluid spread lifting
the erector spinae muscle after a small hydrodissection of
1-2 ml. After confirmation a bolus of 20-30 ml of LA is
injected. Continuous ESP block could be performed using
a continuous RA kit.
Figure 3: Surgically inserted continuous SAP block catheter
reduced 24-hour opioid consumption, prolonged time to

analgesic request, and reduced PONV and pruritus.
Erector Spinae Plane (ESP) Block

Erector spinae plane (ESP) block was introduced in 2016
by Forero et al. as an analgesia technique for thoracic Figure 4: Patient positioning when performing ESP block
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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 dedicated to showcase the creative works of
Anaesthesiologists in Malaysia. This page is specially
made for the budding artists, the avid photographers and the
creative talents amongst our fellow anaesthesiologists. This
page provides a platform to share and showcase their
masterpieces... Dr Loy Yuong Siang . Columbia-Asia Puchong
Dr Haslan Ghazali . KPJ Pahang Specialist Hospital
Dr Mahmud Zuhdi Abdullah . Kuantan Medical Centre
Dr Mahmud Zuhdi Abdullah

Kuantan Medical Centre
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by Dr Ivy Sim Chui Geok
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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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Message from the President of the
College of Anaesthesiologists, AMM
Professor Dr Marzida Mansor
This will be my first message I would like to especially thank the NAD Organising
as the President of the College Committee, Dr Gunalan Palari, and his team, who had
of Anaesthesiologists. The last been highly creative and had worked very hard, to ensure
two years as the President the success of this event. My special thanks also to the
of the Malaysian Society of Virtual Run, Virtual Quiz and Anaesthesia Got Talent
Anaesthesiologists, in the midst of a coordinating teams, headed by Dr Kevin Ng, Professor Dr
pandemic, has taught me things that Rafidah Atan and Dr Mohd Azizan Ghazali. Huge thanks
I could not even imagine. We had, also to the secretariat, frontliners and public out there who
for the first time, conducted our webinars, National had participated and supported all these activities. Judging
Anaesthesia Day celebration and Annual Scientific from the overwhelming responses, we had lots of fun while
Congress virtually. The pandemic has also kept us on our celebrating the skills and attributes of those whom we work
toes by ensuring that we continue to provide the alongside with and rely on.
recommendations and resources to fight it. We are thankful
that we are now slowly moving into the recovery phase and Anaesthesiologists all over the world are well known
the country has started opening up its economy. Huge for our teamwork skills which include leadership,
thanks to all the frontline workers for their selfless communication, mutual monitoring, giving and receiving
sacrifices. At the same time, we shall continue to be feedback, etc. Incidentally, the theme of our NAD this year
prepared for any eventuality. is Teamwork: Stronger Together. The fraternity of
anaesthesia in this country is represented by two bodies,
On 4th to 6th August 2021, we have successfully organised namely the Malaysian Society of Anaesthesiologists and
the MyAnaesthesia 2021 also known as MSA/CoA Annual the College of Anaesthesiologists, Academy of Medicine of
Scientific Congress. The Congress was officiated by YBhg Malaysia. The MSA was established on 29th January 1964
Tan Sri Dato’ Seri Dr Noor Hisham Abdullah, and the CoA, AMM on 16th December 1995, 31 years apart.
Director-General of Health. The entirely virtual congress was Ever since the CoA’s inception, both bodies have been
very well received and attracted about 1200 participants. The working hand-in-hand, forging ahead together and this
theme was “Dawn of a New Era” to depict the new way of year, we are embarking on another milestone with the
living that we have to adapt to due to the pandemic. In line launching of our very own official journal “Malaysian
with the theme, we had expounded on numerous topics Journal of Anaesthesiology”. My best wishes to the MSA
related to the pandemic. I would like to thank the organising and the CoA for this new endeavour. An exemplary show of
committee and the scientific committee that were led by Dato teamwork: Team Anaesthesia.
Dr Jahizah Hassan, Associate Professor Dr Azarinah Izaham
and Dr Hasmizy Muhammad for their sterling work. As our members are our strength, I would also like to take
this opportunity to encourage anaesthesiologists to join the
The virtual 17th World Congress of Anaesthesiologists was CoA. We have about 1100 anaesthesiologists registered in
held on 1st to 5th September 2021. We participated in the the National Specialist Register but only 207 are members
WFSA Global Village at the Congress and had established of the CoA. Out of this, 48 are Fellows of the CoA, AMM.
networking with the UK Royal College of Anaesthetists So, do not waste any more time, visit the AMM website and
(RCoA). We hope to collaborate with RCoA in expanding fill up the membership form today if you are committed to
and enhancing Perioperative Medicine in Malaysia. upholding the highest ethical standards and professional
competence of our fraternity and wanting to improve the
On 16th October 2021, we celebrated World Anaesthesia safety and quality of our work.
Day, also known in some countries as National
Anaesthesia Day (NAD) or Ether Day. The NAD celebration A follow-up to the last year’s NAD celebration that focussed
this year was organised by both the MSA and the CoA in on the relationship between the well-being of the
collaboration with the private anaesthesiologists. This was anaesthesiologists and patient safety, this year, the CoA
the first time that the private anaesthesiologists were fully will also be resurrecting its Well-Being SIG that has laid
involved in the Anaesthesia Day celebration at a national dormant for a couple of years. We could foresee the
level and we could not thank them enough for their very parallel pandemic that will be affecting the mental
generous contributions this year. This reminded me of the well-being of health workers including anaesthesiologists.
Public-Private collective response in combating COVID-19
in Malaysia: Stronger together indeed. continued on page 67
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VOLUME 30 • ISSUE 3 • NOVEMBER 2021

Malaysian Society College of

Dear Members, as a supplement of the UKM's Medicine and Health

A Day in the Life…in a COVID ICU 17 - 18

K. Inbasegaran Research Grant Teamwork - I love our team 40 - 41

Anestesiologi • Malaysian Society of Anaesthesiologists

We had to increase our bed capacity gradually up to twice

Anestesiologi • Malaysian Society of Anaesthesiologists

Physicians stepped up to provide space for patients to be

Doctors were emotionally wrecked as we had to choose

Anestesiologi • Malaysian Society of Anaesthesiologists

VYSET® in regional anaesthesia

For more information and the set

Mediwide Sdn Bhd / No. 1-1, Jalan Wangsa Delima 10,

Institut Jantung Negara is one of the few hospitals in

Anestesiologi • Malaysian Society of Anaesthesiologists

Miraculously after about a week on ECMO, we saw great

Two days after liberation from ECMO, his oxygenation

Anestesiologi • Malaysian Society of Anaesthesiologists

Patient’s Concern with PONV

respiratory function in peri- and postoperative

When I volunteered to be in the frontlines once again in

I was expecting to be deployed to Hospital Sungai Buloh

Anestesiologi • Malaysian Society of Anaesthesiologists

Anestesiologi • Malaysian Society of Anaesthesiologists

Although there were many hiccups along our journey, we

Anestesiologi • Malaysian Society of Anaesthesiologists

A young doctor walks up to another patient who is

A bit of a morning lull sets in during rounds until the

We examine, adjust ventilators, look at investigation

Anestesiologi • Malaysian Society of Anaesthesiologists

In England Cecil Grey introduced thiopentone,

Anestesiologi • Malaysian Society of Anaesthesiologists

THE FIRST UNIVERSITY DEPARTMENT OF

Anestesiologi • Malaysian Society of Anaesthesiologists

3. Smith. Anaesthesia for surgery on a fibrocartilaginous 7. Usha N. Correspondence

Anestesiologi • Malaysian Society of Anaesthesiologists

INTRODUCTION BENEFITS OF BUHE POSITION

Anestesiologi • Malaysian Society of Anaesthesiologists

Anestesiologi • Malaysian Society of Anaesthesiologists

Nobody would have predicted that the COVID-19

Anestesiologi • Malaysian Society of Anaesthesiologists

Dr Chong Jun Leong from University of Malaya and Dr

Anestesiologi • Malaysian Society of Anaesthesiologists

MyAnaesthesia 2021 was a challenge, and an opportunity

Similar to the virtual NAD in 2020, a forum was organised.

Anestesiologi • Malaysian Society of Anaesthesiologists

After all the formalities, it was time to have

Anestesiologi • Malaysian Society of Anaesthesiologists

As we were still amidst the COVID pandemic, most events

Sarah Seri Masran. After the speeches, guests were shown

Click on link below or QR code

Anestesiologi • Malaysian Society of Anaesthesiologists

Despite being an online event and we could not celebrate

Anestesiologi • Malaysian Society of Anaesthesiologists

Held over Zoom platform over two weekends on the

Anestesiologi • Malaysian Society of Anaesthesiologists

Introduction Safety of TEE

Figure 1: Transesophageal Echocardiography Probe