COVID-19 in Singapore and Malaysia: Rising to the Challenges of Orthopaedic Practice in an Evolving Pandemic

@#With the increasing number of COVID-19 cases and related deaths worldwide, we decided to share the development of this condition in Singapore and Malaysia. First few cases were diagnosed in the two countries at the end of January 2020, and the numbers have surged to thousands by end of March 2020. We will focus on strategies adopted by the government and also the Orthopaedic community of the two countries up till the beginning of April 2020. We hope that by sharing of relevant information and knowledge on how we are managing the COVID-19 condition, we can help other communities, and health care workers to more effectively overcome this pandemic.

Brugada syndrome and anaesthesia A case report and review

Brugada Syndrome is an inherited form of cardiac disease characterized by arrhythmias and sudden death with a prevalence of 5 per 10.000. Although this condition is estimated to be responsible for 4%-12% of all sudden deaths in the general population, it is not commonly recognized because of limited reports in the literature. The Brugada syndrome is an increasingly recognized disorder and anaesthetists are likely to encounter this syndrome in practice, this review is to find out the implications of Brugada syndrome for anaesthesia and to outline recommendations for per operative anaesthetic management. We present a forty years old female who was successfully resuscitated after a community [ventricular fibrillation] VF arrest. The diagnosis Brugada Syndrome was confirmed with a flecainide provocation test and treated by insertion of an implantable defibrillator [ICD]. Two years later she had another VF arrest which was terminated by the implantable defibrillator [ICD]. In recent years [2000- 2006] less than two dozen cases have been reported, we reviewed published papers written in English language using journals and internet, using the wards anaesthesia and Brugada Syndrome. Drugs that are known triggers [e.g. class-IA and IC anti-arrhythmic drugs] should be avoided. Similarly, conditions that may provoke Brugada ECG like changes [e.g. hyper-and hypokalaemia, hypercalcaemia and hyperthermia] should be avoided. Implantation of ICD is currently the only proven effective therapy. Known patients of Brugada syndrome without an ICD should have external defibrillator paddles attached before commencing anaesthesia. Postoperative monitoring for 36-48 h is highly recommended as cardiac arrhythmias can occur during this time. This is particularly important when continuous infusions of local anaesthetic drug are used for regional blockade. Liaison with a cardiologist for both preoperative preparations and future follow-up improves outcome. The Brugada Syndrome should be excluded in patients with a family history of unexplained sudden death and in those with typical ST segment changes on ECG. Due to limited number of reports, the implications for anaesthesia are limited and it is difficult to draw firm conclusions

Severe sepsis

Infection has become a common cause of morbidity and mortality in intensive care. The syndromes seen have recently been defined by the American College of Chest Physicians to clarify the nomenclature used and potentially to unify research projects. Sepsis is predisposed to by a number of co-existing pathologies and these will influence prognosis, as will any pre-morbid condition. In addition, the infecting agent involved will influence outcome. Sepsis may produce multi-organ dysfunction via alterations in the endothelium with widespread vasodilatation and altered permeability. These changes are mediated via a large array of mediators produced either directly by the infecting agent or indirectly from their action on host cells. Clinical changes include widespread vasodilatation with myocardial dysfunction, adult respiratory distress syndrome, reduced gastrointestinal perfusion with bacterial translocation across the gut wall and impaired renal, liver and endocrine function. The management of patients with sepsis syndrome includes control of the triggering infection both with antibiotics and surgical drainage of infected sites. General supportive therapy is aimed at ensuring adequate oxygen delivery by providing intraventricular filling and augmentation of cardiac output with inotropes and vasoactive drugs. Mechanical ventilation may be required for respiratory support, continuous dialysis for renal failure and nutritional support. The measurement of intraluminal pH, use of pulmonary artery catheters and goal-directed therapy are recent issues that have been discussed. Together with innovative treatments, including the use of specific antibodies to mediators, these provide new approaches to sepsis which are currently being evaluated. In this arena of new therapy the importance of preventing sepsis should be emphasized