A review of 111 anaesthetic patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

<p><b>INTRODUCTION</b>Cytoreductive surgery (CRS) along with hyperthermic intraperitoneal chemotherapy (HIPEC) is the treatment of choice for selected patients with peritoneal carcinomatosis, a previously lethal condition with dismal survival rates.</p><p><b>METHODS</b>We reviewed CRS and HIPEC procedures performed at our centre from January 1997 to December 2012, focusing on perioperative events and anaesthetic implications.</p><p><b>RESULTS</b>In total, 111 patients underwent 113 procedures. Mean age of the patients was 51.7 (range 14-74) years and 84.1% were women. Mean duration of surgery was 9 hours 10 minutes ± 2 hours 56 minutes. Most tumours were ovarian or colorectal in origin, and the mean peritoneal cancer index (PCI) score was 14.3 ± 8.9. Mean estimated blood loss was 1,481 ± 1,064 mL. Mean total intravenous fluids and blood products administered was 8,498 ± 3,941 mL. Postoperatively, 79.5% of the patients needed intensive care, as 75.2% of the 113 procedures required interval extubation. Patients with lower PCI scores were more likely to be extubated immediately after surgery (p < 0.05). 80.0% of patients had coagulopathy postoperatively, and this was associated with longer HIPEC duration (p < 0.05). Median lengths of intensive care unit and hospital stays were two days and 14 days, respectively. Longer duration of surgery significantly correlated with longer hospitalisation. Prolonged hospitalisation was due to nosocomial pneumonia, pleural effusions, respiratory failure, sepsis, surgical complications (such as anastomotic or wound dehiscence), and intra-abdominal infections.</p><p><b>CONCLUSION</b>The CRS and HIPEC technique is a major surgery with significant morbidity, as highlighted by the perioperative concerns observed in our study.</p>

Efficacy of intubation performed by trainees on patients in the lateral position

<p><b>INTRODUCTION</b>Anaesthetists may be called upon to emergently secure the airway of a laterally positioned patient. Intubating a patient's trachea in the lateral position may be difficult due to unfamiliarity. This exploratory study aimed to investigate the success rate of lateral intubation performed by novices in a controlled setting.</p><p><b>METHODS</b>In this observational study, all patients who presented for elective surgery requiring the lateral position with planned lateral intubation at Singapore General Hospital were included. The trainee assigned to each patient had no prior indication of the proposed lateral intubation until the start of the case. Verbal instructions were given before the start of and during the procedure. The consultant anaesthetist in attendance could intervene at any point to prevent patient harm or if the trainee requested assistance. Time to intubation, adjuncts used and complications encountered were recorded.</p><p><b>RESULTS</b>A total of 44 consecutive patients were included in this study. The trainees completed 42 of the 44 lateral intubations, with 41 being successfully performed on the first attempt. All patients were intubated successfully in a lateral position within two attempts. The mean duration of intubation was 57.3 ± 36.4 seconds. There was no difference between left and right lateral intubation. Other than one episode of transient desaturation on pulse oximetry, there were no complications.</p><p><b>CONCLUSION</b>Lateral intubation by trainees had a high success rate when supervised by an experienced operator. Intubation of patients in unconventional positions using routine airway equipment should be included in airway training for trainees.</p>

A review of perioperative anaphylaxis at a Singapore tertiary hospital

<p><b>INTRODUCTION</b>Perioperative anaphylaxis is an anaesthetic emergency, but its incidence is not well described in the local literature. This retrospective study aims to look at a group of patients who had perioperative anaphylaxis in our institution.</p><p><b>METHODS</b>We conducted a retrospective review of electronic databases and clinical case sheets, and identified 34 patients who had possible perioperative anaphylaxis during anaesthesia in our institution between 1 January 2007 and 30 April 2012.</p><p><b>RESULTS</b>After reviewing clinical and biochemical data, we found that 16 out of 151,876 patients who underwent surgery had confirmed perioperative anaphylaxis, an incidence of 1:10,000. Neuromuscular blockers were identified as the most common causative agent for perioperative anaphylaxis. The offending agent could not be identified in seven patients.</p><p><b>CONCLUSION</b>To the best of our knowledge, this is the first study in Southeast Asia on the incidence of perioperative anaphylaxis. Having a preoperative history of allergy did not seem to predispose patients to the subsequent development of perioperative anaphylaxis.</p>

Revision of loop colostomy under regional anaesthesia and sedation

Patients presenting for emergency abdominal procedures often have medical issues that cause both general anaesthesia and central neuraxial blockade to pose significant risks. Regional anaesthetic techniques are often used adjunctively for abdominal procedures under general anaesthesia, but there is limited published data on procedures done under peripheral nerve or plexus blocks. We herein report the case of a patient with recent pulmonary embolism and supraventricular tachycardia who required colostomy refashioning. Ultrasonography-guided regional anaesthesia was administered using a combination of ilioinguinal-iliohypogastric, rectus sheath and transversus abdominis plane blocks. This was supplemented with propofol and dexmedetomidine sedation as well as intermittent fentanyl and ketamine boluses to cover for visceral stimulation. We discuss the anatomical rationale for the choice of blocks and compare the anaesthetic conduct with similar cases that were previously reported.

Infant lumbar and thoracic epidurals for abdominal surgeries: cases in a paediatric tertiary institution

<p><b>INTRODUCTION</b>There is strong evidence that epidural analgesia provides good postoperative pain relief in adults, but its use in infants is less established. In this retrospective study, we present our experience with managing infant epidural analgesia for abdominal surgeries in a tertiary paediatric institution.</p><p><b>METHODS</b>The records of 54 infants who had received a thoracic or lumbar epidural as perioperative analgesia for abdominal surgeries were included. The mean age of the infants was 6.1 (standard deviation [SD] 3.8) months and their mean weight was 6.8 kg (SD 1.8). Most (63%) had an ASA (American Society of Anesthesiologists) status of 2 and all underwent elective gastrointestinal, urogenital, hepatobiliary or retroperitoneal surgeries. 20 catheters (37.0%) were inserted in the thoracic region and 33 (61.1%) in the lumbar region.</p><p><b>RESULTS</b>A total of 52 (96.3%) catheters provided adequate intraoperative analgesia and 36 (66.7%) provided effective analgesia for the postoperative period. Active management of epidural analgesia, such as through epidural top-ups and infusion rate adjustment, was necessary to optimise analgesia in 22 (44%) of the 50 patients postoperatively. Reasons for premature catheter removal were mainly technical issues such as catheter disconnection, leakage and blockage.</p><p><b>CONCLUSION</b>Our data suggests that in experienced hands, specialised settings and active management, the success rate of epidural analgesia in infants undergoing major abdominal surgeries is high and without major incident.</p>

Incidence of phantom limb phenomena after lower limb amputations in a Singapore tertiary hospital

<p><b>INTRODUCTION</b>Phantom limb sensations (PLS), phantom limb pain (PLP) and stump pain (SP) are well-recognised postamputation phenomena. However, there is a dearth of related epidemiological data in Asian populations. This study was conducted to fill the information gap.</p><p><b>METHODS</b>Telephone interviews were conducted with patients who underwent lower limb amputations at a tertiary hospital in Singapore. Information was obtained on phantom limb characteristics, perioperative pain and functional assessment.</p><p><b>RESULTS</b>A total of 159 patients underwent amputations over a 31-month period. At the time of the interview, 47 patients had died and 66 were contactable, of whom 49 patients were interviewed. Of these, 31 (63%) patients experienced PLS. 22 patients had postoperative pain, with 9 having both PLP and SP, 3 having PLP alone and 10 having SP alone. Among the 12 patients with PLP, at least 6 (50%) experienced constant or daily pain and 7 (58%) scored their pain as moderate-to-severe. Among those with PLP and/or SP (n = 22), 5 were distressed by the pain, 11 were on analgesics and 3 received medical follow-up. 7 (32%) patients reported functional limitations secondary to PLP or SP. Altogether, 28 (57%) patients were wheelchair or bed bound.</p><p><b>CONCLUSION</b>The incidence of PLP was 25% in our cohort. Although this is lower than that reported in other studies, it remains significant, as some patients suffered moderate-to-severe pain. The difference in incidence may be due to differences in the ethnic composition and/or indications for amputation in our group. Follow-up and care could improve the outcomes in these patients.</p>