Current state of reflective learning in anaesthesiology residents: a call for 'reflection-on-action' training in Singapore.

INTRODUCTION: Reflective learning is the cognitive process whereby information from new experiences is integrated into existing knowledge structures and mental models. In our complex healthcare system, reflective learning (specifically 'reflection on action') is important for postgraduate learners. We observed that our anaesthesiology residents were not building on their competence through deliberate experiential and reflective practice. This qualitative study explored the current state and challenges of reflective learning in anaesthesia training in Singapore. METHODS: This study was conducted at KK Women's and Children's Hospital, Singapore, from 1 January 2018 to 31 October 2018. A semi-structured interview format was used in focus groups. Information collection continued until data saturation was reached. The interviews were coded and analysed, and themes were identified. Seven focus group interviews involving 19 participants were conducted. RESULTS: Reflective learning was found to be poor. It was of concern that the stimuli for reflection and reflective learning emerged from medical errors, critical incidents and poor patient outcomes. Challenges identified were: (a) lack of an experiential learning framework; (b) need for reflective training; (c) quality of experiential triggers; (d) clinical pressures; and (e) poor learner articulation and feedback. We described some strategies to frame, teach and stimulate reflective learning. CONCLUSION: This study described the state and challenges of reflective learning in anaesthesia training. We advocate the implementation of reflective training strategies in postgraduate training programmes in Singapore. Research is warranted to integrate patient feedback and outcomes into reflective practice.

Low-dose S+ ketamine in target-controlled intravenous anaesthesia with remifentanil and propofol for open gynaecological surgery: A randomised controlled trial.

BACKGROUND AND AIMS: Using remifentanil-propofol target-controlled infusion (TCI) in open gynaecological surgeries could be associated with opioid-induced hyperalgesia postoperatively. This study's aim was to investigate the effect of low-dose S-ketamine compared with control on cumulative morphine consumption 24 h postoperatively in women undergoing open abdominal hysterectomy with remifentanil-propofol TCI technique. METHODS: Ninety female patients above 21 years old who underwent elective open abdominal hysterectomy under general anaesthesia with remifentanil-propofol TCI were recruited. They were randomised to receive either normal saline as control (n = 44) or 0.25 mg/kg intravenous boluses of S-ketamine before skin incision and after complete removal of uterus (n = 45). The primary outcome measure was cumulative morphine consumption measured over 24 h postoperatively. The secondary outcome measures were incidences of opioid-related and psychotomimetic side effects, pain and level of sedation scores. RESULTS: The cumulative 24-h morphine consumption postoperatively (P = 0.0547) did not differ between both the groups. S-ketamine group had slower emergence from general anaesthesia (P = 0.0308) and lower pain scores (P = 0.0359) 15 min postoperatively. Sedation level, common opioid-related side effects (nausea, vomiting, pruritus), respiratory depression and psychotomimetic side effects were similar between both the study groups. CONCLUSION: Low-dose S-ketamine did not reduce the total cumulative morphine consumption in patients undergoing major open gynaecological surgeries with remifentanil-propofol TCI.

Incidence and association factors for the development of chronic post-hysterectomy pain at 4- and 6-month follow-up: a prospective cohort study.

Chronic pain has major adverse effects on health-related quality of life and contributes to significant socioeconomic burden. Hysterectomy is a very common gynecological surgery, resulting in chronic post-hysterectomy pain (CPHP), an important pain syndrome. We conducted a prospective cohort study in 216 Asian women who underwent abdominal or laparoscopic hysterectomy for benign conditions. Demographic, psychological, and perioperative data were recorded. Postoperative 4- and 6-month phone surveys were conducted to assess the presence of CPHP and functional impairment. The incidence rates of CPHP at 4 and 6 months were 32% (56/175) and 15.7% (25/159), respectively. Women with CPHP at 4 and 6 months had pain that interfered with their activities of daily living. Independent association factors for CPHP at 4 months were higher mechanical temporal summation score, higher intraoperative morphine consumption, higher pain score in the recovery room, higher pain score during coughing and itching at 24 hours postoperatively, and preoperative pain in the lower abdominal region. Independent association factors for CPHP at 6 months were preoperative pain during sexual intercourse, higher mechanical temporal summation score, and higher morphine consumption during postoperative 24 and 48 hours. In a majority of cases, CPHP resolved with time, but may have significant impact on activities of daily living.

Comparison of double intravenous vasopressor automated system using nexfin versus manual vasopressor bolus administration for maintenance of haemodynamic stability during spinal anaesthesia for caesarean delivery: A randomised double-blind controlled trial.

BACKGROUND: Hypotension is a common side effect of spinal anaesthesia during caesarean delivery and is associated with maternal and foetal adverse effects. We developed an updated double intravenous vasopressor automated (DIVA) system that administers phenylephrine or ephedrine based on continuous noninvasive haemodynamic monitoring using the Nexfin device. OBJECTIVE: The aim of our present study is to compare the performance and reliability of the DIVA system against Manual Vasopressor Bolus administration. DESIGN: A randomised, double-blind controlled trial. SETTING: Single-centre, KK Women's and Children's Hospital, Singapore. PATIENTS: Two hundred and thirty-six healthy women undergoing elective caesarean delivery under spinal anaesthesia. MAIN OUTCOME MEASURES: The primary outcome was the incidence of maternal hypotension. The secondary outcome measures were reactive hypertension, total vasopressor requirement and maternal and neonatal outcomes. RESULTS: The DIVA group had a significantly lower incidence of maternal hypotension, with 39.3% (46 of 117) patients having any SBP reading less than 80% of baseline compared with 57.5% (65 of 113) in the manual vasopressor bolus group (P = 0.008). The DIVA group also had fewer hypotensive episodes than the manual vasopressor bolus group (4.67 versus 7.77%; P < 0.0001). There was no difference in the incidence of reactive hypertension or the total vasopressor requirement. The DIVA group had less wobble in system performance. Maternal and neonatal outcomes were similar. CONCLUSION: The DIVA system achieved better control of maternal blood pressure after spinal anaesthesia than manual vasopressor bolus administration. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT02277730.

A preliminary assessment of the LMA protector™ in non-paralysed patients.

BACKGROUND: The LMA Protector™ is the latest CE marked single use supraglottic airway device. This airway device provides access and functional separation of the respiratory and digestive tracts. There are two ports (male, female ports) to provide suction in the laryngeal region and insertion of the gastric tube. The aim of our study is to assess the ease of use, airway quality, device positioning, airway leak and complications associated with initial clinical experience in LMA Protector™ usage. METHODS: This is an initial investigation of LMA Protector™ airway device. We conducted a preliminary assessment in the anaesthetised women who underwent minor gynaecological procedures with spontaneous ventilation in order to evaluate the performance of the airway device. RESULTS: Insertion was successful on first and second attempts in 23 (88.5%) and 3 (11.5%) respectively. Median [IQR (range)] insertion time was 19 [17-21(14-58)] seconds. Airway leak pressure was 25.5 [23-29(21-30] cmH2O. On fibreoptic examination via the device, vocal cords were visible in all 26 patients. There were no alternative airway use or airway manipulations required during maintenance of anaesthesia. Six patients had sore throat 24 h after procedures and there was no dysphagia or hoarseness. CONCLUSION: This pilot study of the LMA protector shows that the device is easily inserted with fast insertion time, providing a reliable and adequate airway seal. TRIAL REGISTRATION: Clinicaltrials.gov Registration NCT02531256 . Retrospectively registered on August 21, 2015.

Comparison of epidural oxycodone and epidural morphine for post-caesarean section analgesia: A randomised controlled trial.

BACKGROUND AND AIMS: Epidural morphine after caesarean section may cause moderate to severe pruritus in women. Epidural oxycodone has been shown in non-obstetric trials to reduce pruritus when compared to morphine. We hypothesised that epidural oxycodone may reduce pruritus after caesarean section. METHODS: A randomised controlled trial was conducted in pregnant women at term who underwent caesarean section with combined spinal-epidural technique initiated with intrathecal fentanyl 15 µg. Women received either epidural morphine 3 mg or epidural oxycodone 3 mg via the epidural catheter after delivery. The primary outcome was the incidence of pruritus at 24 h after caesarean section. The secondary outcomes were the pruritus scores, treatment for post-operative nausea and vomiting (PONV), pain scores and maternal satisfaction. RESULTS: One hundred women were randomised (group oxycodone O = 50, morphine M = 50). There was no difference between Group O and M in the incidence of pruritus (n [%] 28 [56%] vs. 31 [62%], P = 0.68) and the worst pruritus scores (mean [standard deviation] 2.6 (2.8) vs. 3.3 [3.1], P = 0.23), respectively. Both groups had similar pain scores at rest (2.7 [2.3] vs. 2.0 [2.7], P = 0.16) and sitting up (5.0 [2.3] vs. 4.6 [2.4], P = 0.38) at 24 h. Pruritus scores were lower at 4-8, 8-12 and 12-24 h with oxycodone, but pain scores were higher. Both groups had a similar need for treatment of PONV and maternal satisfaction with analgesia. CONCLUSION: There was no difference in the incidence of pruritus at 24 h between epidural oxycodone and morphine. However, pruritus scores were lower with oxycodone between 4 and 24 h after surgery with higher pain scores in the same period.

A non-synonymous single nucleotide polymorphism in an OPRM1 splice variant is associated with fentanyl-induced emesis in women undergoing minor gynaecological surgery.

BACKGROUND: Fentanyl-induced emesis (FIE) is a distressing adverse effect in the postoperative setting. The genetic basis of FIE remains largely unknown, therefore, we examined whether it was associated with specific genetic variants of OPRM1, the gene encoding the main receptor target of fentanyl. METHODS: In this prospective case-control study, 193 women undergoing gynaecological surgery under a standardized anaesthetic with a low emetogenic risk were enrolled. Inclusion and exclusion criteria were designed to select extreme phenotypes as well as to ensure that most major confounders for FIE were either excluded or present in all patients. To control for unforeseen intra- and postoperative confounders for FIE, only 161 patients were further analysed, out of which 10 were categorized as having FIE, defined by the presence of at least one of three symptoms: nausea, vomiting or retching that was likely to be fentanyl-related. To identify SNPs relevant to FIE in our population, DNA from 40 controls and 10 cases was sequenced at the following OPRM1 regions: 3 kbp of the promoter, main and alternative exons as well as 2 kbp of the 3' downstream region. The genotype of the significant SNP was further determined in the remaining 111 controls. RESULTS: The incidence of FIE was 6.2%. Initial sequencing of 10 cases and 40 controls identified 25 SNPs. Only rs540825, a non-synonymous SNP in the splice variant, MOR1X, showed a significant association with FIE post-Bonferroni correction. This SNP was further examined in the remaining 111 controls which confirmed its significant association with FIE (p = 0.019 post-Bonferroni, OR: 5.6, 95% CI: 1.42-21.91). CONCLUSIONS: This is the first report of an association between the occurrence of FIE in Chinese women undergoing gynaecological surgery and an OPRM1 splice variant SNP, rs540825.

Combined spinal epidural causes higher level of block than equivalent single-shot spinal anesthesia in elective cesarean patients.

Combined spinal epidural (CSE) is an established technique for lower segment cesarean delivery. In this study we tested the hypothesis that the spinal block from a CSE technique results in a more extensive spread of local anesthetic in the subarachnoid space than the single-shot spinal (SSS) technique. We recruited 30 ASA physical status I parturients admitted for elective lower segment cesarean delivery into our randomized, controlled, double-blind study. All patients intrathecally received 2 mL of 0.5% hyperbaric bupivacaine. The patients were randomized into one of the two groups using sealed opaque envelopes. Group S (n = 15) received a SSS technique. Group CS (n = 15) received a CSE technique using loss of resistance to 2 mL of air, but the epidural catheter was not inserted after the intrathecal drug administration. The maximal sensory block achieved in group CS was statistically higher than that in Group S (median C6 interquartile range, C5 to C8 versus median T3, T2 to T4, P < 0.001). Time taken to reach maximal sensory block was significantly longer in group CS. There were no differences in the time taken for the block to recede to T10, hemodynamic profile, or side effects. In conclusion, the CSE technique without placing an epidural catheter or administering epidural medication resulted in a significantly higher level of sensory block when compared with the SSS technique when the same dose of local anesthetic was given intrathecally.