Dr Fredric Michard MD PhD Dr Fredric Michard MD, PhD was trained in Paris, France and at the Mass General HospitalHarvard Medical School in Boston, USA. He is known for his research work on pulse pressure variation (PPV), fluid responsiveness and hemodynamic monitoring (>10,000 citations on Google scholar), the development of intuitive graphic user interfaces, and recent publications on continuous ward monitoring, wearable sensors and digital innovations. He is the founder of MiCo (MichardConsulting.com), a consulting & research firm based in Switzerland.
Cardiac output monitoring why and how? -Dr Fredric Michard In his lecture Dr Michard will discuss successively The burden of postoperative complications The impact of intraoperative hemodynamic optimization on postoperative outcome Which patients may benefit the most of advanced hemodynamic monitoring during surgery How simple hemodynamic variablessuch as Pulse Pressure Variation (PPV) may help to guide fluid therapy How disposable-free pulse contour techniques may help increase the adoption of cardiac output monitoring in low and middle income countries
Dr Zied Ltaief After training as an anaesthesiologist, Dr Ltaief obtained his diploma from the Faculty of Medicine of Tunis in 2011. After a one-year internship at the University Hospital of Grenoble, he moved to Switzerland, specifically to the University Centre of Lausanne, where he obtained his FMH diploma in intensive care medicine and SGUM diploma of echography. Since then, he has been practising as a senior physician. He is involved mainly in the hemodynamic and circulatory groups. He is particularly interested in extracorporeal assistance and heart failure, a field in which he collaborates in teaching, several research projects and publications.
Vasoplegia following CPBP -Dr Zied Ltaief Vasoplegic syndrome (VS) is a common complication following cardiovascular surgery with cardiopulmonary bypass(CPB). Recently, it has been defined as a distributive shock due to a significant drop in vascular resistance after CPB. Risk factors of VS are numerous and include reduced ejection fraction, prolonged aortic cross-clamp and left ventricle assist device surgery. Several factors are involved in the genesis of VS after CPB. First, surgical trauma by an excessive systemic inflammatory response with the release of vasoactive cytokine (IL-6, TNF-alpha). Second, deep sustained baroreflex stimulation induces delayed catecholamine resistance and relative vasopressin deficiency. Third, under cytokine effect: increase of the inducible nitric oxide (NO) synthase expression, which by the higher level of NO decreases vascular resistance and induces low vascular reactivity to vasopressors. After CPB, patients with VS had a higher complication rate with increased mortality ranging from 5 to 40%. Management includes fluid resuscitation and vasopressors. Concerning the pathophysiologic mechanisms, some authors suggest using steroids or hemoadsorption of the cytokine to limit the inflammatory response, NO inhibitors (methylene blue), and the early use of vasopressin. This review aims to detail the different pathophysiological mechanisms and review the therapeutic possibilities according to the available literature, and outlines some thoughts on future research.
Dr Marcus Peck MAAS FRCA 'Focused Intensive Care Ultrasound'. Echo and Professional Standards committees, focused on improving echo training opportunities and quality assurance. He relishes breaking down organisational barriers and dreams of the day when ultrasound is normal practice for every frontline clinician. You can find Marcus on Twitter as @ICUltrasonica (Surrey, UK), chair of the Focused Intensive Care (FUSIC) committee and author of the OUP textbook including the Intensive Care Society Council and British Society of Echocardiography (BSE)’s Level 1 Dr Marcus Peck is a consultant in anaesthesia and intensive care medicine at Frimley Park Hospital He is a passionate ultrasound trainer and teaches widely. Marcus sits on several national committees,
Diastolic dysfunction and anaesthetic challenges -Dr Marcus Peck Diastolic dysfunction causes all the symptoms and signs observed in heart failure, and it can do so without any obvious systolic dysfunction (so-called “heart failure with preserved ejection fraction” or “HFpEF”). Tracheal extubation carries the highest risk, perioperatively, due to elevated heart rate, preload and afterload. So, early recognition is important and it can be simple, as long as one looks for signs of raised left atrial pressure, many of which are evident using point of care ultrasound. I am a general anaesthetist/intensivist and in this talk, I will outline what you need to look out for, when, and why. And, most importantly, I will outline steps you can take to prevent or treat decompensated heart failure in the perioperative setting.
Dr Muralidhar Kanchi MD, MBA, PhD Dr. Muralidhar is a Banglore.. He graduated from the Post Graduate Institute of Medical Education & Research, Chandigrarh, And served in Shree Chitra Tirunal Institute of Medical Sciences, Trivandrum, Nizam’s Institute of Medical Sciences, Hyderabad. B.M. Birla Heart Research Center, Calcutta and at Manipal Heart Foundation at Bangalore. He was also involved in training and teaching at Glenfield General Hospital, Leicester, for couple of years. In 2001 he established departments of anaesthesia and critical care at Narayana Hrudayalaya and is the Senior Consultant –Anaesthesia & Director (Academic) at Narayana Hrudayalaya,, at present. Dr. Muralidhar is actively involved in academic activities and teaching. He has published over 120 original papers in national and international journals. He has traveled extensively both India and abroad to lecture and present his scientific papers. He won the prestigious “Rukmini Pandit Award” (ISA-1993) and ‘the most innovative paper prize” at Germany (EACTA-2002). He is a faculty in anaesthesia for National Board of Examinations, New Delhi; and is presently the Academic programme Director at Narayana Hrudayalaya. In recognition of his contribution to medicine, the Minnesota University, USA, has appointed him as a ‘Professor of International Health’ (1999 onward). He is a fellow of International Society of Cardiovascular Ultrasound (FISCU), Indian College of Anaesthesiologists (ICA), Indian College of Critical Care Medicine, Indian Association of Cardiovascular & Thoracic Anaesthesiologists (IACTA), TEE (IACTA) & Indian College of Cardiology. He is a life member of at least 12 professional societies and is on the editorial board of medical journals. His additional training/qualification includes ECMO (Leicester, UK1994), TOE (Leicester, UK’2006), PGDHHM’2005, and MBA (2011). He was the President of Indian Association of Cardiovascular and Thoracic Anaesthesiology (IACTA) 2007-2008 and currently IACTA-TEE course director from last 12-years. Dr Muralidhar Kanchi was awarded “Distinguished DNB Teacher of Excellence Award” on the Teachers day 2018 by the National Board of Examination. Dr Muralidhar Kanchi was awarded PhD from the Maastricht University, Netherlands, in recognition of his work on renal preservation in cardiac surgery. Currently, he is involved on am ICMR sponsored project as a principal investigator on “Genetic predisposition to acute kidney injury in coronary bypass grafting”. Currently Dr Muralidhar Kanchi is the chief editor of “Journal of Acute Care,” the Dean of “Indian College of Anaesthesiologists” and the Vice Chancellor of India College of Cardiac Anaesthesiologists In addition to his clinical activities and teaching, he is a trained classical vocalist, currently teaches music on Namma Naadi FM 90.4.
IABP – the lifeline - LV supportive devices -Prof Muralidhar Kanchi Cardiac failure is an ever-growing public health concern confronted by both developed and developing nations of the world. The insertion of a mechanical support device must be considered when optimal medical management fails to improve cardiac performance. This is aimed to assist the failing heart and provide adequate organ perfusion. Intra-aortic balloon pump (IABP) is a circulatory assist device that is used to support a failing left ventricle. IABP is designed to augment myocardial perfusion by increasing coronary blood flow during diastolic phase of the cardiac cycle and unloading the left ventricle during systolic phase. The inflation and deflation of the IABP is precisely/ accurately timed and triggered by data derived from ECG or arterial pressure trace. The indications for IABP include the following: cardiogenic shock (acute myocardial infarction, myocarditis, cardiomyopathy), acute LV failure after cardiac surgery, failure to separate from CPB, stabilization of preoperative patient, ventricular septal defect following acute MI, mitral regurgitation following acute MI, procedural support during high-risk coronary angioplasty/PCI, Intractable arrhythmia due to myocardial ischemia and as a bridge to transplantation. Based on results of Shock II trial, the European Society of Cardiology no longer strongly recommends the routine use of IABP in patients with MI associated cardiogenic shock. In a cardiac surgicalsetting, preoperative insertion of IABP is often helpful in unstable angina, left main disease with ongoing ischemia, and ischemia leading to ventricular arrhythmia. For patients with mechanical complications of AMI, such as acute mitral regurgitation or ventricular septal rupture, insertion of IABP may be lifesaving. Likewise, intraoperative IABP is extremely useful when facing difficulty to wean CPB. Until the controversy is resolved regarding the use of IABP in cardiogenic shock, personal experience and decision of the physician, institutional preference/guideline and patient circumstances may form the basis for the IABP use in a clinical setting with acute left ventricular failure.
Professor Mahesh Nirmalan MD, FRCA, PhD, FFICM Professor Mahesh Nirmalan is The Deputy Dean, Faculty of Biology, Medicine and Health (2022-) Vice Dean for Social Responsibility and Public Engagement (2016-) University of Manchester Consultant in Intensive care medicine, Manchester Royal Infirmary (2002-) Visiting Professor of Intensive care medicine, University of Cairo, Egypt (2010-) Visiting professor of Post conflict studies, University of Gulu, Uganda (2019-)
Use of performance art in Patient and Public involvement and engagement in health care: a personal journey - Professor Mahesh Nirmalan The relationship between organisations that deliver health care and/or health care research and the wider public is a two way street. Whereas there is a clear role for the service providers to influence how society views theirservices and perhaps educate the wider public on areas that may be unfamiliar or too technical, there is also an equally important role for members of the society to influence and shape services – clinical or academic research, that are being carried out in their name. In a fast changing world with easy access to factual knowledge, the top down approach based on the age old ‘Doctor knows best’ or ‘Scientists know best’ is being challenged and status- quo is becoming increasingly unsustainable. In this context the Involvement and Engagement of Patients and Public (Or PPIE) in shaping clinical services or shaping research questions is gaining wider recognition amongst service commissioners or agencies that fund academic research (such as the UKRI or the NIHR). This presentation will provide an overview of the Speaker’s own experience in public engagement in two very widely different contexts. In both, broadly unrelated areas, the engagement activities included the use of art and performance as a tool in PPIE. i. The use of digital art in shaping public opinion in areas related to terminal illness, death, dying and palliative care. ii. The use of Street plays in mitigating social determinants of suffering amongst disabled people living in a post conflict area in Northern Uganda One of the outcomes of technical advancements in the sphere of medicine is fact that prolongation of life – at times over very long periods, is feasible. This approach does not always take into account the highly subjective question of ‘Quality of life’ for the survivors and the concept of ‘human suffering’ buried within these issues. The situation becomes even more complex when the financial motives of health care professionals and institutions are brought into the decision making process. In traditional societies such as Sri Lanka, where culture and religion play a very dominant role in how people would interpret these subjective issues, public engagement and widersocial debate is essential in achieving successful outcomes when faced with these situations. The role of arts and other cultural tools can be a powerful adjunct in initiating these debates. The speaker will seek to challenge the audience on how we as clinicians, are engaging the wider public in issues related to end of life issues and are utilizing these alternate methods of engagement.
Monty G Mythen MBBS MD FRCA FFICM FCAI (hon) Monty G Mythen MBBS MD FRCA FFICM FCAI (hon) Emeritus Professor of Anaesthesia and Critical Care Division of Surgery and Interventional Science University College London, UK [email protected] Force, volume or flow - what matters in perfusion? Maintaining an adequate hydration and circulating blood volume and oxygen delivery throughout the continuum of care is essential to protect all organs. Adequate cellular hydration is essential for life and dehydration is potentially harmful to kidney health and is a major cause of patients’ discomfort. Adult patients undergoing major surgery are at particular risk of having critical perturbations of the four of the key components required to deliver sufficient oxygen to all cells. Intravascular blood volume (IBV), Cardiac Output (CO), Blood Pressure (BP) and Oxygen flux (CO x blood oxygen content – determined by hemoglobin concentration and blood oxygen saturation = calculated DO2) must all be maintained to protect all organs. Intravascular blood volume is the most difficult to measure and thus the most difficult to manage. There is no reliable monitor of euvolemia and thus the most reliable surrogate is lack of left ventricular pre-load responsiveness in response to a fluid bolus or straight leg raise (see POQI 5) considering the potential masking effects of endogenous and exogenous vasopressors may have on unstressed volume. Occult hypovolemia (low IBV with no change in BP, CO or DO2) and consequent splanchnic ischemia has been shown to be common during adultsurgery and associated with translocation of gut contents into the blood stream, systemic inflammatory response syndrome and multiple organ dysfunction syndrome (MODS). The kidney, for example, is remarkably resilient to transient ischemia (see transplant literature) but very sensitive to hemodynamic instability combined with systemic inflammations and other humoral cell injury proteins.
Managing intravascular blood volume is challenging during adult major surgery as a high total body water, increased Trans capillary escape rate of fluid (‘leaky capillaries’) causing frank interstitial oedema are common. However, maintain IBV is still essential during all phases of care. Water leaks from the vessels quickly (minutes) but returns slowly (days). Excessive restritction of intravenous fluid and injudicious use of diuretics to treat interstitial oedema may cause intravascular volume depletion and cause more harm than good. A pragmatic approach to maintaining volume, flow and pressure (‘fill, flow, pressure’) using a Goal Directed approach can produce a balanced circulation and improved outcomes following major surgery: 1. Intravascular blood volume (‘fill’) 2. Measure stroke volume or ‘LVEDV’ – give fluid challenges to maximal SV a. How?: Measure SV with continuous arterial waveform analysis device (e.g. arterial line or descending aortic velocimetry). b. Give circa 200 ml fluid bolus c. Aim for Max SV on first cycle 3. Monitor fluid balance 4. Watch for excessive fluid balance (> 2 litres positive) as this is associated with greater harm. It may be unavoidable to greatly increase total body water and thus generate interstitial edema and indeed some edema is inevitable if IBV is to be maintained.Flow a. Measure Cardiac output – target predetermined threshold. i.How? Consider greater use of continuous arterial waveform devices for estimation of cardiac output or descending aortic velocimetry (esophageal doppler). b. Consider pre-load, after load and contractility. 5. Pressure a. Maintain MAP at pre-determined threshold (e.g. MAP 65 mmHg) – consider adjusting threshold for previously hypertensive patients or evidence of inadequate BP (e.g. cerebral NIRS change with MAP). b. Consider IBV, pre-load and contractility before treating with vasopressor. 6. Oxygen flux a. Maintain calculated D02 above pre-determined threshold. References: A multidisciplinary consensus on dehydration: definitions, diagnostic methods and clinical implications. Ann Med. 2019 May-Jun;51(3-4):232-251. Perioperative Quality Initiative (POQI) consensus statement on fundamental concepts in perioperative fluid management: fluid responsiveness and venous capacitance. Perioper Med (Lond). 2020 Apr 21;9:12. Hemodynamic and Intestinal Microcirculatory Changes in a Phenylephrine Corrected Porcine Model of Hemorrhage. Anesth Analg. 2021 Oct 1;133(4):1060-1069. Br J Anaesth. 2014 Nov;113(5):740-7. Pharmacological management of fluid overload. Br J Anaesth. 2014 Nov;113(5):756-63. Perioperative fluid therapy: a statement from the international Fluid Optimization Group. Perioper Med (Lond). 2015 Apr 10;4:3.
Prof. Dr. Manu Malbrain MD, PhD 1991. After his primary specialization in internal medicine (1996) he specialized in Intensive Care (1997).He was ICU Director in various hospitals in Belgium. He was medical director at ZNA Stuivenberg and St-Erasmus for about 4 years (2013-2017). Afterwards, he was head of the ICU department and crisis manager at UZ Brussel (UZB), Belgium and professor at the Faculty of Medicine and Pharmacy of the Vrije Universiteit Brussel (VUB), where he successfully realized the transformation of the ICU department (2017-2020). Until March 2022, he was Chief Medical Officer (CMO) of the AZ Jan Palfijn hospital, in Ghent, where he started many innovative projects. Now he made the transition from hospitals to medical data management as CMO of Medaman, an Ehden certified SME, combined with his position as professor of Critical Care Research at the First Department of Anesthesiology and Intensive Therapy of the Medical University of Lublin in Poland. He is co-founder and president of the International Fluid Academy (www.fluidacademy.org). He is also the co-founder, past-president and current treasurer of the Abdominal Compartment Society (WSACS, www.wsacs.org). He studied the effects of elevated intra-abdominal pressure (IAP) and (abdominal) sepsis in ICU patients for the past 30 years and in 2007 he successfully defended his doctoral thesis on the same topic (PhD, KU Leuven). In addition to abdominal pressure, organ-organ crosstalk and hemodynamic monitoring, he is an expert in sepsis and fluid therapy, and he guides hospitals in the roll-out of sepsis and fluid stewardship as a quality project. He is the national coordinator and member of the steering committee of the European Sepsis Care Survey and chair of the Belgian sepsis expert group. Over the years he gave more than 1000 lectures at (inter)nationalscientific meetings. He is author and co-author of more than 330 peer-reviewed articles, reviews, comments, editorials, book chapters and even two complete books on abdominal compartment syndrome (ACS). His cumulative h-index is 54 on scopus and 72 on Google Scholar (with a total of 24856 citations). Besides his work he enjoys even more his family life with his wife Bieke and their 3 sons: Jacco, Milan and Luca. on Research Gate and PubMed https://www.researchgate.net/profile/Manu_Malbrain2 https://www.ncbi.nlm.nih.gov/pubmed/?term=malbrain+m on Social Media Twitter: @manu_malbrain https://twitter.com/manu_malbrain LinkedIn: https://www.linkedin.com/in/manu-malbrain-53574313/ Webpage: www.fluidacademy.org
Fluid Stewardship in ICU - Prof Dr Manu Malbrain Following the speech of Prof Malbrain he expects the delegated to be Understand the 7 Ds of fluid therapy Learn different tools for the diagnosis of hypovolemia Fluid condition and fluid responsiveness monitoring Fluids are drugs - the 4 D's Duration of fluid therapy Fluid therapy dose De-escalation - deresuscitation The 4 questions: when to start IVF, when to stop, when to start fluid removal, when to stop The 4 indications: resuscitation, maintenance, replacement, nutrition The 4 hits The 4 stages and the POSE concept importance of fluid balance, sodium load and sodium balance Principles of fluid management (fluid stewardship)
Professor Marlies Ostermann Professor Marlies Ostermann is Professor of Intensive Care and Nephrology at Guy’s & St Thomas Hospital in London. Her academic and clinical interests relate to acute kidney injury, renal replacement therapy and sepsis in critically ill patients. She is Director of Research of the Intensive Care Society UK and also Chair of the Research Committee of the European Society of Intensive Care Medicine.
Dialysis in ICU: How, when & whom - Prof Marlies Ostermann Acute kidney injury is a common complication during critical illness and renal replacement therapy (RRT) is often needed. Both, continuous and intermittent RRT have advantages and potential adverse effects and should be viewed as complementary therapies. There is general consensus that the initiation of RRT should be considered in AKI patients with medically refractory complications of AKI (‘urgent indications’). ‘Relative indications’ are more common but defined with less precision. In this presentation, I will summarise the latest evidence from recent landmark clinical trials, discuss strategies to anticipate the need for RRT in individual patients and propose an algorithm for decision making. I will emphasize that the decision to consider RRT should be made in conjunction with other forms of organ support therapies and important non-kidney factors, including the patient’s preferences and overall goals of care. In principle, the aim should be to avoid RRT in patients who will not benefit or potentially come to harm, and to deliver high quality RRT in a timely manner to patients with persistent AKI or progressive organ failure impacted by AKI. Based on existing data, I will suggest an individualised approach towards delivery of RRT to critically ill patients with AKI.
Prof. Luciana Mascia Professor Luciana Mascia is the Director of Residency program in anesthesia and critical care; - University of Bologna, Italy. She also serves at Medical school: critical care and anesthesia and at School of "tecnici di neurofisiopatologia": critical care and anesthesia; University of Bologna, Italy Academic qualifications Bachelor in classic science, Liceo O. Flacco : 1986 Bari, Italy Degree in Medicine and Surgery with the honours: University of Bari July 14, 1992 Licence in Medicine and Surgery # 10089; Medical Council Bari , Italy: December 1993 Specialist in Anaesthesia and Intensive Care Medicine : University of Bari, October 14, 199 Clinical training University of Bari, Italy , Internship University of Edinburgh, UK, Resident in Anaesthesia and Intensive Care Medicine. Ospedale Policlinico, Bari, Italy, Attending Physician Ospedale S Giovanni Battista, Turin, Italy, Attending physician University of Turin, Italy, Associate Professor University of Rome, La Sapienza, Italy, Associate Professor University of Bologna, Italy, Associate Professor Awards, Grants & Publications She has won many awards and grants for her research activities More than 3000 publications to her credit.
How to ventilate a lung Donor - Professor Luciana Mascia Lung transplantation represent a lifesaving treatment for end-stage respiratory failure. However, donorshortage remains a concern, despite continuous improvement in donor management. Brain dead donors experience peculiar pathophysiologic changes due to neurogenic pulmonary oedema and inflammatory reaction. A strong line of evidence suggests that: a) Brain injury evolving to brain death is a predisposing factor for ARDS; b) An injurious mechanical ventilation enhancesthe risk of ventilatorinduced lung injury in vulnerable lungs of potential organ donors; c) The application of a protective ventilation significantly increases the number of transplanted lungs without affecting other grafts survival. The implementation of bundles of care is the mainstay of donor management in ICU and protective mechanical ventilation is the cornerstone of this strategy. Indeed available guidelines of organ procurement organizations do not suggest anymore the use of high tidal volume and low level of PEEP, accepting the strong line of evidence that support the application of a protective mechanical ventilation in potential organ donors both to preserve lung function and to minimise multiorgan dysfunction.
Dr M.A. Arshad MBBS FRCA I completed my undergraduate training at Cambridge University where I developed an early interest in pharmacology completing a master’s programme in pharmacology alongside my medical degree. I undertook my training in the UK with dual accreditation in Anaesthesia and Critical Care. I am currently working as a Consultant Intensivist and Liver Transplant Anaesthetist in University Hospitals Birmingham, UK. Our centre has the largest single floor critical care unit in Europe and a large transplantation programme including heart, lung, kidney and liver transplantation. I am particularly interested in the perioperative care of patients undergoing major hepatopancreatobiliary surgery and liver transplantation.
Dr. Murali Krishna MD Dr. Murali Krishna is the senior consultant in cardiac anesthesia and critical care at MGM Health care, Chennai. Academic qualifications MD from PGIMER Chandigarh Senior residency AIIMS new Delhi DM from SCTIMST Trivandrum Work experience – 17 years Credentials Part of the team that has done maximum number of thoracic organ (heart / lung) transplants in India (> 550) Assessed > 500 and handled > 1000 donors Instituted ECMO and transferred patients from acrossthe country and abroad Delivered > 50 lecture in different national platforms as faculty on transplant, donor, echo, ECMO, LVAD, & cardiac intensive care
Role of intensivist in organ donor management -Dr Krishna Murali Number of transplants is limited by the availability of usable donor organs. The utilization rates of various organs are, liver & kidney 70%, heart 35% and lungs 25%. Guided intensive care can increase the usable donor organ pool. The main goals in the donor management are stabilization and ensuring utilization of maximum number of organs. Brain death leads to autonomic instability and pituitary hormones deficiency, these patients need hormone resuscitation with steroid, thyroid, vasopressin, and insulin. Hypovolemia, ventricular dysfunction, sepsis, bleeding can cause hemodynamic instability, Identifying the cause is important in treatment. Intensivist should know the criteria for acceptance or declining of various organs, this will help in titrating or optimizing the care so that maximum organs are utilized. Stress cardiomyopathy can lead to severe ventricular dysfunction; this leads to non-utilization of heart, pulmonary edema, and hemodynamic instability. Echo should be repeated at regular intervals to diagnose; management is with hormone resuscitation, afterload reduction, inotropes and decreasing vasoconstrictors. Infection, aspiration, and fluid overload are the common causes for non-utilization of lungs, they should be actively prevented. Ventilation goals are lung protective ventilation, minimal required FiO2 and adequate PEEP.P/F ratio should be maintained above 350 for lungs to be usable. Diabetes insipidus due to brain death causes free water loss and hypernatremia. Hypernatremia causes intracellular dehydration, organs harvested from donors with hypernatremia can have inferioroutcomes. Vasopressin and hydration are the main stay of management of hypernatremia. Apart from clinical management of donorintensivistmust play a role of fulcrum in handling and coordinating the clinical decisions of different organ harvesting teams. To conclude a guided intensive care can increase the usable donor organ pool apart from that the intensivist has a significant role in identifying the possible brain-dead organ donors, initial stabilization, and coordinating between the different clinical teams. Number of transplants is limited by the availability of usable donor organs. The utilization rates of various organs are, liver & kidney 70%, heart 35% and lungs 25%. Guided intensive care can increase the usable donor organ pool.
Free Paper & Poster Competition
L.M.V Attygalle Prize Competition The prize is open to medical practitioners holding a non-consultant appointment in anaesthesiain Sri Lanka. This is a free paper competition and is held every year as a part of annual academic congress of the College of Anaesthesiologists & Intensivists of Sri Lanka. The prize will be awarded at the inauguration ceremony of annual academic congress of the subsequent year. Abstracts would be called for in late May or June, each year. Dr. L M V Attygalle was among the pioneering anaesthetists in Sri Lanka who contributed to the anaesthetic literature in the country. Among his papers are a description of an adaptation of the Ayre’s T piece for use in neuroanaesthesia for patients with diabetes mellitus and anaesthesia for ophthalmic surgery. He obtained the Diploma in Anaesthesia (London) and the fellowship of the Faculty of Anaesthetists of the Royal College of Surgeons(England) in 1955. He wasthe first Sri Lankan to obtain thisfellowship. On his return to Sri Lanka, he was appointed a Consultant Anaesthetist to the Colombo group of hospitals. With the establishment of the Neurosurgical Unit at the National hospital of Sri Lanka in 1956, Dr. Attygalle was appointed as anaesthetist to the Neurosurgical Unit. Subsequently he worked as a Consultant Anaesthetist in Holland. In 1983, Dr. Attygalle made a donation to the College of Anaesthesiologists of Sri Lanka to establish a prize in his name to be awarded at the Annual Scientific Sessions of the College to the bestpaper presented by a practising non-consultant grade anaesthetist in Sri Lanka. He also donated a trophy to be awarded along with the cash prize. Dr. L M V Attygalle prize competition has been a feature of every Scientific Session of the Collegesince the inception of the academic sessions in 1984.
Abstract 1 USE OF ULTRASOUND DURING CENTRAL VENOUS CATHETERIZATION IN SRI LANKAN ICUS P S Amarasekara 1, B P Kudavidanage 2, 1 Leeds Teaching Hospital, 2 National Hospital of Sri Lanka Keywords: Ultrasound, Central venous catheterisation Abstract Introduction: Use of ultrasound in critically ill is advantageous as it is a rapid bedside method and provides reliable information in the care of critically ill. However the use of ultrasound in ICU for diagnostic and therapeutic purposes in Sri Lanka is not available. Objectives: To evaluated the frequency of use of Ultrasound among practitioners for insertion of central venous catheters, and to explore their perception and barriers to use of ultrasound in their practice. Material and methods: A cross sectional, descriptive study using an internet based survey was performed among anaesthetists and intensivists who looked after critically ill patients in Sri Lanka hospitals. Results: Out of 200 consultants’ responses were received from 97 individuals (48.5%). Of this study sample, 50% (n=49) were anaesthesiologists with special training in intensive care. Ninety-six (99%) respondents reported use of ultrasound during central venous catheterization. Seventy-seven consultants had formal training in use of ultrasound while 19 did not receive any formal training. Among those who had formal training, majority (n=41) gained training by attending local Ultra sound workshops. Lack of organized training(n=42), lack of time(n=14) and lack of equipment (n=27) were identified as the main barriers for training in use of ultrasound in central venous catheterization. Conclusions: Use of ultrasound for insertion of central venous catheters among anaesthetic and intensive care consultants managing acutely ill patients is satisfactory. Conducting training programmes and improving ultrasound facilities is essential to overcome the barriers to ultrasound use among the practitioners.
Dr Rathnasabapathy Sashidharan Prize The prize is open to all medical practitioners holding an appointment in anaesthesiology. The competition is held every year as a part of annual academic congress of the College of Anaesthesiologists & Intensivists of Sri Lanka with the prize being awarded at the inauguration ceremony of annual academic congress of the following year. Abstracts would be called for in late May or June, each year. This prize is awarded in memory of DR. RATHNASABAPATHY SASHIDARAN MD (Sri Lanka),FFARCS (Ire), FRCA (UK) Dr. Rathnasabapathy Sashidaran was a Consultant Anaesthetist with a special interest in Obstetrics and Regional Anaesthesia. He was appointed Consultant Anaesthetist to Barts and the London NHS Trust in 1996. He graduated fromthe Faculty ofMedicine,University of Colombo Sri Lanka in 1983. Followinghispreliminary training inanaesthetics in Sri Lanka hemigrated to the United Kingdom and completed his training as a registrar in anaesthesiology at Whittington Hospital, London and subsequently at Royal London Hospital, Whitechapel. He was a dedicated teacher and trainer and was a mentor to many post graduate trainees both local and overseas. He held the posts of College Tutor and Deputy Regional Advisor for Barts and London School of anaesthesia and was a primary examiner for the Royal College of Anaesthetists, United Kingdom. He was appointed as Bernard Johnson Advisor in postgraduate anaesthetic studies for overseas trainees to the Royal College of Anaesthetists in October 2008. He was one of the most sought out resource personnel at the annual academic sessions of the College of Anaesthesiologists of Sri Lanka and at the biannual SARCA conference held in South Asia. He conducted many pre and post congress workshops of varied themes during these sessions. He was awarded the Dr. B.S Perera oration in 2008 and delivered on the topic “Misunderstandings, Miscommunications or Malpractice?” For being a devoted and true friend to his family, friends and colleagues and to the yeomen service that he rendered to the country, his trainees whom he mentored inaugurated the Rathnasabapathy Sashidaran prize for the best free paper and best poster presentation, which is open to all medical officers holding an appointment in anaesthesiology both local and overseas and is presented at the Annual Scientific Sessions of the College of Anaesthesiologists & Intensivists of Sri Lanka
Free paper competition Dr Rathnasabapathy Sashidharan Prize
Abstract 1 EFFECT OF HIGH PROTEIN NORMO-CALORIC NUTRITION ON SKELETAL MUSCLE WASTING IN CRITICALLY ILL MECHANICAL VENTILATED PATIENTS: A RANDOMIZED DOUBLE-BLIND STUDY Authors: Bikash Ranjan Ray1#, Vetriselvan 2 , Puneet Khanna1and Rahul Kumar Anand1 1 Affiliation: Additional Professor, All India Institute of Medical Sciences, New Delhi 2 Affiliation: Senior Resident, All India Institute of Medical Sciences, New Delhi # For correspondence; <[email protected]> Background: Muscle wasting is a common finding among patients in intensive care units (ICU)and is associated with poor outcomes. During ICU stay, delivering appropriate nutritional support minimize the muscle loss which can be reliably track using ultrasound. Objective: We sought to measure the impact of high-dose protein based nutrition on musclemass, muscle echogenicity and fascial characteristics in critically ill patients. Methods: We conducted a randomized prospective, double-blind trial in 30 critically ill patients, anticipated to be mechanically ventilated for >48 hours. Patients received 1.5gm/kg/day of protein in the high protein group (HPF) compared to 1gm/kg/day of proteinin standard feed group (SF). Muscle thickness, cross-sectional area, echogenicity and pennation angle was measured on days 1, 3, 5, and 7 after admission to critical care. Right lower limb Vastus lateralis, medial head of gastrocnemius were investigated. Results: We found progressive loss of muscle mass from day1 to 7 in both the groups. However in the gastrocnemius and vastus lateralis muscles, muscle thickness, and cross- sectional area were significantly high in the HPF over 7 days. Change in echogenicity, pennation angle were not significant between the groups. Conclusion: In critically ill, mechanically ventilated patients, high protein normo-caloric nutrition decreases the muscle wasting in lower limb weight-bearing muscles, during first seven days of ICU stay. However, the changesin qualitative muscle parameters (echogenicityand pennation angle) were not significant.
Abstract 2 DELAYED ONSET OF MALIGNANT HYPERPYREXIA IN A PATIENT WITH PRIOR UNEVENTFUL VOLATILE ANAESTHESIA EXPOSURE (CASE REPORT) Harshani H.G.H.D #, (1) Ratnayake R. M. A.S. K. (2) , Jayasinghe A (3) , Abeysundara A (2) , Wijekoon P (4) , Kumbukgolla K.G.V (1) , De Silva K.H.Y.T (1) 1. Registrar in Anesthesia , Teaching Hospital, Peradeniya 2. Lecturer in Anesthesia and Intensive care, Department of Anaesthesiology and Critical Care, University of Peradeniya 3. Senior lecturer in Anaesthesia and Critical Care, Department of Anaesthesiology and Critical Care, University of Peradeniya 4. Professor in OMF surgery, Faculty of Dental Sciences, University of Peradeniya. Introduction Malignant hyperthermia (MH) is a rare (incidence1:10000 to 1:250000) (1) life threatening hypermetabolic response of skeletal muscles due to abnormal response of Ryanodine receptors in response to volatile anaesthetics and Suxamethonium, resulted in severe muscle rigidity, hyperthermia and hypercapnoea. Case History A nine-year-old boy presented for alveolar bone grafting. Previously he had two uncomplicated surgeries under general anaesthesia for repair of cleft lip and palate in two stages, where volatile agents had been used. Propofol, fentanyl, morphine atracurium were given at induction and Isoflurane was used in maintaining anaesthesia. The intraoperative period was uneventful (one and a half hours). At the end of the surgery, patient developed a temperature of 102F with rising EtCO2 (90mmHg) and muscle rigidity. A tentative diagnosis of MH was made. IV Paracetamol was commenced with active cooling. Dantrolene was started in 90 min. The patient was electively ventilated in the ICU. There was rapid improvement of muscle rigidity, temperature and ETCO2 within 4 hours. Lactate remained high for the next 24 hours. CPK peaked in the second day. (2) Liver enzymes, INR and myoglobinuria were elevated and remained high for two days. He was discharged on day 4 without any residual effects. Family counselling was done and waiting for genetic studies. Discussion and conclusion. MH should be suspected not only during the intraoperative period, but during the recovery as well. Patents can develop MH even if the patient had previous safe exposure to volatiles anaesthetic agents. Early administration of dantrolene is vital for a better outcome. (3)
Abstract 3 A MOVE TOWARDS SUSTAINABLE AND COST-EFFECTIVE OPERATING THEATRE K Jayathilake 1# , S Madugalle 1 , K Wijeratne 1 , L Kariyawasam 2 , V Kerner 2 1 Registrar in Anaesthesiology , Teaching Hospital Anuradhapura. 2 Consultant Anaesthetist, Teaching Hospital Anuradhapura. # For correspondence ; <[email protected]> Abstract - Health care system is the fifth largest carbon emitter on the planet. Anaesthetic nitrous oxide(N2O) is responsible for 1% to 3% of global N2O emission while halogenated compounds are responsible for 0.1% of global warming. This emphasizes the responsibility of anaesthetist to minimize this environmental impact. Random thirty patients undergoing general anaesthetic were studied excluding paediatric patients and minor procedures. Circle system was used in 100% of encounters. Mean total Fresh Gas Flow(FGF) rate used was 3.96 l/min while average oxygen flow rate was 2.08 l/min. Nitrous oxide was used in 43% of occasions at mean flow rate of 2 l/min. Mean medical air flow rate was 2.04 l/min. Isoflurane usage was 100% for maintenance of anaesthesia and mean dial setting was 1.17. There was no scavenging system in any theatre. Carbon dioxide equivalence(CO2e) of inhalational agents was calculated with calculator introduced by AAGBI. When using medical air, CO2e was 10.99 KgCO2e/hr while it was 78.78 KgCO2e/hr with N2O. This study revealed that the use of N2O at current practice emits 8 times higher CO2e compared to medical air. One hour ofsurgery using N2O is equivalent to car ride from Colombo to Jaffna. Thisstudy emphasizes the importance of low flow anaesthesia and minimize use of N2O. Even though low flow anesthesia is cost effective, it is limited in our setting due to lack of awareness and limited availability of gas analysis. But this study is eye opener to Sri Lankan anaesthetists to change their practice. Keywords : sustainable anaesthesia, global warming, air pollution, Sri Lanka
Abstract 4 A STUDY OF RISK FACTORS PREDICTIVE OF POOR PERIOPERATIVE OUTCOMES FOLLOWING HEMIARTHROPLASTY FOR FRACTURE NECK OF FEMUR P T R Makuloluwa1#, L K D C R Karunathilaka2 , R P J Ramukkana3 1,2 Faculty of Medicine, Kotelawala Defence University, Ratmalana, 3 University Hospital, Kotelawala Defence University For correspondence; [email protected] Globally increased life expectancy is associated with an increased incidence of hip fractures. Generally, surgery ensures faster recovery with full mobility. However, premorbid status and perioperative factors are likely to impact adversely on perioperative outcomes. Recognition ofrisk factors associated with poor perioperative outcomes provides a guide to optimizing and planning perioperative care. The aim was to study the risk factors predictive of poor perioperative outcomes following hemiarthroplasty for fracture neck of the femur. The data relevant to the studied risk factors (age, gender, co-morbidities, pre-fall mobility, ASA status, Nottingham Hip Fracture Scores (NHFS), time from injury to surgery, and the mode of anaesthesia) and the perioperative outcomes (intra-operative & post-operative complications, time for re-mobilization & re-enablement, time from surgery to discharge, morbidity and mortality) were collected retrospectively from the bed-head notes of patients (n=145) admitted to University Hospital, KDU from January 2020 to June 2022. Data were analysed using descriptive statistics andmultivariate logistic regression. In contrast to previousstudies, the mode of anaesthesia was shown a statistically significant predictor of intraoperative complications (p=0.008). The majority had surgery under spinal anaesthesia sedation (n=125; 86.2%). Intraoperative complications (n=20; 13.75%) were 5.2 times higher following general anaesthesia others (OR: 5.267 with a 95% CI 1.555 to 17.837). We conclude that in comparison to other risk factors studied, the mode of anaesthesia is a ‘modifiable’ risk factor that can be carefully chosen and administered to improve perioperative outcomes. Further studies, preferably multicenterwith larger sample sizes are recommended to generalize the results. Keywords: Fracture neck of femur, hemiarthroplasty, preoperative risk predictors, perioperative outcomes
Abstract 5 INTRODUCTION OF DIFFICULT AIRWAY BAG TO DEVELOPING WORLD AS AN ALTERNATIVE TO DIFFICULT AIRWAY TROLLEY Wijeratne K 1#, Jayathilake K 1 , Madugalle S 1 , Kariyawasam K A D L P 2 , Kerner V2 1 Registrar in Anaesthesiology, 2 Consultant Anaesthetist, 1,2-Department of Anaesthesia and Intensive Care, Teaching Hospital - Anuradhapura Abstract - The difficult airway is a significant challenge to the anaesthetist. Difficult Airway Society (DAS) recommend use ofstandard Difficult Airway Trolley (DAT) since itsignificantly reduces the stress of the anaesthetist1 . We conducted an audit on adequacy and availability of difficult airway equipment at all operation theatres and Intensive Care Units in Teaching Hospital Anuradhapura. We further analysed the feasibility of the introduction of DAT to our setting. Results of this audit showed significant deficiency in availability of difficult airway equipment in the audited areas compared to the DAS recommendation. Further, there were 0% availability of organised trolley in these areas. Even though DAT is a practical solution to theatres, our feasibility analysis revealed that it is not a practical option for places outside the theatres since it expand in large area. We managed to improvise a Difficult Airway Bag (DAB) which can be used for multiple areas in the hospital which will provide best care from limited resources. The main feature of the bag is that it follows the same structure as the plan A,B,C and D according to DAS recommendation. Presence of FONA pack and the SCOOP pack complete the recommendation similar to the DAT. This significantly reduces the stress of the anaesthetists attending the difficult airway scenario. DAB is a practical solution in resource limited setting where hospitals expand over large area. This auditsuggeststhe importance of modification of the DAT recommendation according to the Sri Lankan setting to share the limited resources within the hospital. Key words : Airway management, Emergencies, Developing country
Abstract 6 AUDIT ON INITIAL MANAGEMENT OF SEPSIS AND SEPTIC SHOCK OF PATIENTS WHO ARE ADMITTED TO INTENSIVE CARE UNITS AT NATIONAL HOSPITAL OF SRI LANKA KAMSP Kandearachchi 1# , R. Amarasena2 1 Acting Consultant Anaesthetist, Base Hospital Kantale 2 Department of Anesthesia, National Hospital of Sri Lanka # [email protected] Introduction Key aspects in management of sepsis include early diagnosis, early start of antibiotics and fluid resuscitation. Objectives To assess whether initial management of sepsis and septic shock within the first 24hours of presentation is carried out according to International Guidelines for Management of Sepsis and Septic Shock in the wards and intensive care units in National Hospital of Sri Lanka Method Data was extracted from medical records of patients who got admitted to the intensive care units for the management of sepsis and septic shock between 1 st of April to 31st of May 2022. Audit standards were formulated according Surviving sepsis campaign International Guidelines for Management of Sepsis and Septic Shock 2018 and 2021 Thirty-five patients in surgical and medical intensive care units with septic shock met audit criteria. Results Screening tool which was used in 64.7% of the cases was qSOFA. To diagnose sepsis, lactate levels measured in 82.9% of the cases. To guide resuscitation, Capillary refill time was used in 57.1% and lactate in 85.7% of the cases. Standard fluid regime used in 48.6% of the cases. Balanced crystalloid used in 20% of the cases. Antibiotics were started within 1 hour in 14.3% of the cases. ICU admission within 6 hours in 34.3% of the cases Conclusion Adherence to audit standards when managing patients in septic shock was below the average. Use of diagnostic tools, monitoring resuscitation and initial management requires further improvement. Regular educational programs, institutional protocols and provision of adequate resources will help safe management of patient with sepsis and septic shock. Key words – septic shock, septic, capillary refill time
Poster competition Dr Rathnasabapathy Sashidharan Prize
Abstract 1 A RETROSPECTIVE REVIEW OF PERIOPERATIVE OUTCOMES FOLLOWING ANAESTHESIA RELATED CRITICAL INCIDENCES Suhitharan T 1# , Kong A 1 1 Department of Anaesthesiology, Singapore General Hospital # For correspondence: [email protected] Abstract: Despite the advancement in anaesthesia practices, adverse events still continue. Anaesthesia-related morbidity represents a major burden for patients and the reported incidence varies widely across the world. After obtaining ethical board approval, we reviewed the anaesthesia related critical incidences reported between 2014 to 2019. Data on patient demographics, type of surgery, critical incidence, contributing factors and the immediate outcomes were collected and analysed. We reviewed 743 anaesthesia related critical events from 138384 surgical procedures. Data on patient demographics, type of surgeries, nature of critical event and the immediate outcomes were extracted from critical event reports and documented in excel spread sheet. Pivot tables were used for categorisation of critical events and the outcomes. 83% of the procedures were elective and the rest were emergency procedures. The incidence of reported anaesthesia related adverse events is 5.3 / 1000 anaesthetics. 17.9% of the critical events did not have any adverse outcomes. The most common outcome was physical injury, reported 15.1 per 10000 anaesthetics. Surgical procedure was cancelled or modified due to the critical event in 5.7 per 10000 anaesthetics. Incidence of peri operative cardiac arrest and death were 3.64 and 0.94 per 10000 anaesthetics performed in our cohort, respectively. The incidence of perioperative mortality and morbidity reported in our study is lower than previously published data. (1) The main limitation of our study that needs to be considered is the possibility of underreporting. We recommend each institute to take serious efforts to identify the modifiable risk factors for the adverse events and continue to improve the anaesthesia outcomes. Keywords: Anaesthesia, Critical events, Immediate outcomes, Morbidity, Mortality
Abstract 2 ACUTE KIDNEY INJURY FOLLOWING CORONARY ANGIOGRAPHY AT CARDIOLOGY ICU NHSL T K Wickramasuriya1# , N Ranawaka2 1 International Clinical Fellow Anaesthetics, King’s College Hospital, London, UK 2Consultant Intensivist, Cardiology Unit of National Hospital of Sri Lanka # For correspondence; [email protected] Abstract Coronary angiography (CA) & percutaneous coronary interventions (PCI) utilise iodinated radiocontrast media to give visual imaging of vessels & cardiac chambers. Regardless of current advancements in relevant imaging techniques & usage of contrast media, iodinated contrast still constitute a risk for contrast-induced acute kidney injury (CI-AKI). According to studies, patients that develop CI-AKI have shown to possess a greater risk for death & also have shown prone to longer hospitalisation durations & immediate or late, cardiovascular complications. Objectives of thisstudy were to assess incidence of CI-AKI in patients admitted to cardiac ICU NHSL following CA and/or PCI, discover other risk factors for development of CI-AKI and to assess incidence & outcome of patients who require renal replacement therapy(RRT) 58 patients admitted to Cardiology ICU NHSL following CA+/-PCI over a period of two weeks were included into the study. This was a retrospective observational study. CI-AKI was defined according to serum creatinine component of the KDIGO criteria. The incidence of CI-AKI was 22.4% & identified risk factors were hypertension, dyslipidemia & cardiac arrest. The average length of ICU stay was 5.8days for those who developed CI-AKI whereas 2.4days for others. 30.76% patients who developed CI-AKI required invasive ventilation & 69.23% had vasopressor support. 38.46% patients with AKI died during ICU stay whereasit was 2.22% for others. Of 15.38% patients who required RRT, the mortality rate was 100%. CI-AKI leads to increased morbidity & mortality. It can be minimised by identification & aggressive management of common risk factors. Keywords: Contrast Induced Acute Kidney Injury (CI-AKI), Risk factors, Coronary angiography (CA) & percutaneous coronary interventions (PCI)
Abstract 3 PLATELET TRANSFUSION AFTER LIVER TRANSPLANT: A DOUBLE-EDGED SWORD CATASTROPHIC INTRACEREBRAL HAEMORRHAGE AFTER LIVER TRANSPLANT: A CASE REPORT Widisinghe N1#,8, Gunetilleke B2,7 , , Dissanayake PRJP3,7 ,Dassanayaka U4,7, Thilakaratne S5,7, Mudalige A 6,7 ,Siriwardana RC5,7 1MBBS, MD Anaesthesiology, 2MBBS, MD Anaesthesiology, FRCA, 3MBBS, Diploma and MD in transfusion medicine, 4MBBS, MD, MRCP, 5MBBS, MD Surgery, MRCS, 6MBBS, MD Anaesthesiology, FRCA, FFCIM, EDIC,7 Colombo North Center For Liver Disease Postgraduate instituteof Medicine, University of Colombo. #[email protected] An adult with chronic end stage liver disease (ESLD) developed an extensive intracerebral haemorrhage (ICH) following cadaveric liver transplant (LT). Perioperative bleeding and thrombosis are a constant threat in LT. Rotational Thromboelastometry (ROTEM) guided correction of impaired haemostasis minimizes use of blood products and positively impacts outcome in LT. Rebalanced coagulation (RC) in ESLD, the role of platelets in ischemia reperfusion injury (IRI), thrombosis, graft failure (GF) and poor outcome following LT is documented. Coagulopathy caused by liver dysfunction (LD) and acute kidney injury (AKI) impaired platelet function (PF) is poorly assessed by ROTEM. An adult male with decompensated ESLD due to autoimmune hepatitis underwent cadaveric LT. Transfusion of platelets triggered by a count of 6 x 103 microliter on D3 was followed by a steep rise in transaminases. Consciousness progressively declined without focal neurology. Cerebral atrophy without haemorrhage was noted on MRI. Heparin-free CRRT was initiated due to rising serum creatinine and hyperkalemia. HD with low dose heparin was initiated as renal functions was deteriorated. Pre HD ROTEM revealed A5 EXTEM > 25mm, CTINT/CTHEP <1.25 without thrombolysis. During HD the patient suffered a respiratory arrest. CT brain showed extensive ICH. RC, the role of transfused platelets in thrombosis, IRI, GF and poor outcome should be balanced with perioperative bleeding risk1 . ROTEM guided protocol-based optimization of haemostasis minimizes blood product use without an increase in bleeding events in LT1 .LD and AKI adversely affect PF. Tests of PF should supplement ROTEM as its ability to assess PF is limited. Key words: Rotational thromboelastometry, liver transplant, Intracranial hemorrhage
Abstract 4 HOMOZYGOUS SICKLE CELL PATIENT WITH ACUTE CHEST SYNDROME FOR CATEGORY 1 CAESAREAN SECTION UNDER EPIDURAL ANAESTHESIA- A CHALLENGING RARE CASE Kannangara D K R <#>1,5 , Liyanage H 2,4 , Jayasinghe S 3,4 1MBBS,MD Anaesthesiology 2MBBS, MD Anaesthesiology , FRCA 3MBBS, MD Anaesthesiology ,FCARCSI 4De Zoysa Maternity Hospital, Colombo 5Post Graduate Institue of Medicine ,University of Colombo For correspondence;<[email protected]> Introduction Sickle cell disease can lead to life threatening complications such as acute chest syndrome in pregnancy which increases both maternal and fetal mortality and morbidity. Management of these can be really challenging. Case history A 21 year old primi mother with homozygous sickle cell disease who had a planned pregnancy presented at 39 weeks of period of gestation with fever, tachypnea and desaturation associated with chest radiographic changes which was suggestive of acute chest syndrome. Her hemoglobin S was 44%.Patient was offered an exchange transfusion. Noninvasive ventilation was started along with IV antibiotics. Early epidural was cited with the onset of uterine contractions and allowed vaginal delivery with intensive care monitoring. Due to fetal distress she underwent operative delivery. Anaesthesia was provided with epidural while continuing non invasive ventilation. Post partum period was uncomplicated and patient made full recovery along with a healthy neonate. Discussion Acute chest syndrome is the commonest cause of mortality in sickle cell disease.1 Mainstay of management consist of exchange transfusion, meticulous fluid management, antibiotics and pain relief. Epidural analgesia is safe and effective in providing labour analgesia and management and prevention of sickle cell crisis.2,3,4 Conclusion Prompt recognition of life threatening rare complications in sickle cell disease, timely interventions and management with multidisciplinary involvement would improve both patient and fetal outcomes. Key words: Sickle cell disease, Acute chest syndrome, Epidural anaesthesia Patient consent was obtained with regard to collection of relevant information without disclosure to any other party.
Abstract 5 ANAESTHETIC MANAGEMENT OF HIP FRACTURES UNDERGONE HEMIARTHROPLASTY: CURRENT PRACTICE AND ADHERENCE TO UPDATED GUIDELINES OF AAGBI (2020) P T R Makuloluwa1#, L K D C R Karunathilaka2 , M I D Perera3 1,2 Faculty of Medicine, Kotelawala Defence University, Ratmalana, 3 University Hospital, Kotelawala Defence University # For correspondence; [email protected] Globally, hip fractures represent a common orthopaedic problem among the aging population with a substantial socio-financial burden. The majority are managed surgically, as fixation offers faster recovery. However, wide variations in perioperative anaesthetic practice exist. The Association of Anaesthetists of Great Britain and Ireland (AAGBI) published updated guidelines (2020) for greater standardization of anaesthetic practice in line with international consensus guidance to improve perioperative outcomes. In the absence of a local guideline, adherence to AAGBI guidelines (2020) during hemiarthroplasty was studied. Retrospectively studied the notes of patients (n=145) admitted to University Hospital, KDU from January 2020 to June 2022. Descriptively analyzed the data; mean age 77 (SD 9.63), females (78.6%); ASA 2 (64.8%), and 3 (31%). Consultant anaesthetist-led multidisciplinary care was available for prehabilitation and postoperative care of high-risk patients. Only 19.3% (28) had surgery within 36 hours of injury; delays were due to late admission and the nonavailability of OT time. In the absence of an institutional guide, perioperative blood transfusions were given if Hb was 9g/dl. Though no orthogeriatricians were available, remobilized in 24 hrs (70.3%); re-enabled in 2-5 days (93.1%), and discharged within a week of surgery (72.4%). None had peripheral nerve blocks for perioperative analgesia. Best practice-based institutional care pathways for perioperative anesthetic management were unavailable. Patient information leaflets, data from institutional audits, and regional review networks were unavailable. Current practice falls short of the AAGBI guide (2020). Suggest developing and implementing institutional care pathways for standardization of anaesthetic care. Further, conduct audits and research for quality improvement. Keywords: Hip fractures, hemiarthroplasty, AAGBI Guidelines (2020) Conflict of interest Authors have no conflict of interest to declare. Acknowledgment We wish to acknowledge Ms. NP Edirisinghe for assisting with data analysis and Ms. MKH Peiris for assisting with data collection.
Research work in Anaesthesia, Critical Care or Pain Medicine Shirani and Thilak Hapuarachchi Prize
Abstract 1 PREOPERATIVE FASTING IN ELDERLY PATIENTS AWAITING ELECTIVE SURGERY IN SELECTED SURGICAL UNITS AT A TERTIARY CARE HOSPITAL IN SRI LANKA: A PRELIMINARY REVIEW Lakmali R.S.P.M.1# Buddhika T.M.2 Vihara Dassanayake3 Affiliations: 1Fourth year medical student, Faculty of Medicine, University of Colombo 2Fourth year medical student, Faculty of Medicine, University of Colombo 3Senior Lecturer in Anaesthesiology & Consultant Anaesthetist, Department of Anaesthesiology & Critical Care, Faculty of Medicine, University of Colombo3 Introduction American Society of Anaesthesiologists recommend preoperative fasting, for six hours for solids and two hours for clear fluids. Fasting reduces the risk of aspiration under anaesthesia. However, prolonged fasting impacts negatively on outcomes. Thisis detrimental in elderly patients, as they have limited physiological reserves to overcome consequences of prolonged fasting. Objective We aimed to identify the duration of fasting and causes of prolonged fasting in elderly patients awaiting elective surgery. Method This was a cross-sectional study conducted over three-weeks. Patients above 65-years, undergoing elective surgery in selected surgical units at the National Hospital of Sri Lanka were recruited. Interviewer based google form questionnaire was used to collect data in the theatre waiting area, prior to surgery. Descriptive statistics were used for data analysis. Results All elderly patients from randomly selected surgical units were recruited during three-weeks, the time allocated to complete our elective appointment in anaesthesia. Majority were females(73.6%), 50.9% were between 65-74 years and 49.1% had a maximum education level up to G.C.E.O/L. Majority (66.0%) were from orthopedic wards. Mean fasting time for solids was 12.36 hours (range 6 to 18.50 hours) and liquids 3.27 hours (1.25 to 11.00 hours). Among respondents, 54.7% had fasted for more than 12 hours for solids and 47.2% between 2 to 4 hours for liquids. Nursing officers provided instructionsto 69.8%. Doctors provided instructionsto 20.8%. From the respondents, 59.5% who were given instructions by nurses have fasted >12 hours for solids and 2.1-4 hours for liquid/s and 72.7% who received instructions from doctors have fasted between 6.1-12 hours for solids and 54.6% for 2 hours or less for liquid/s. Incorrect instructions (45.3%), untimeliness in waking up (28.3%) andunavailability of food at mid night (7.5%) despite receiving correct information, resulted in prolongedfasting. Conclusion Elderly patients fast much longer than recommended. Majority received fasting instructions from nurses. Despite correct instructions, there were multiple barriers which contributed to prolonged fasting. Keywords: elderly, fasting, surgery
Abstract 2 KNOWLEDGE, ATTITUDE, PRACTICE AND IMPLEMENTATION OF WORLD HEALTH ORGANISATION SURGICAL SAFETY CHECKLIST AMONG THE HEALTH CARE PROFESSIONALS IN TEACHING HOSPITAL RATNAPURA, SRILANKA. Shathir A 1# . Kasun L. Dissanayke1 , Isuru S. Tissadeniya1 , Chamika K 1 , Sulochana M.Piyasekara1 , 1 Faculty of Medicine, Sabaragamuwa University of Sri Lanka, Batuhena, Hidellana, Ratnapura. [email protected] This study was aimed to assess the status of implementation of the WHO surgical safety check list (SSC) as well as, the knowledge, attitude and behaviour of the medical community regarding the SSC at Teaching Hospital Ratnapura (THR), Sri Lanka. A descriptive cross sectional study was carried out among the health care professionals of THR in general surgical wards, gynaecology and obstetrics wards and the operation theatres with the use of questionnaires(n=103) to assess the attitude and knowledge while 223 bed head tickets(BHT) records related to the surgeries done from August 2021 to September 2022 were collected and analyzed to assess the implementation status. The results showed that all nurses and 95.91% of doctors have heard about SSC. Majority (94.2%, n=97) of participants were aware that the SSC was developed to be implemented globally. In general, 78% (n=81) of healthcare workers use WHO SSC in all kinds of surgeries. Less than half (44.7%) of healthcare professionals had experienced a complication that may have been avoided if the WHO SSC had been properly implemented. The majority (99% , n=102) believe that the check-list should be used in every surgical procedure. The working category of THR had a significant association with their attitude on performing SSC. Lack of time (55.4%, n=36), training and knowledge (31.7%, n=), and overwork were identified as the key challenges to SSC implementation, highlighting the need for thorough training and proper introduction to the procedure. Even though BHTs audit has shown zero adoption during the study period, participants had a fairly good knowledge and attitudes regarding the proper implementation of SSC. Key words – WHO, surgicalsafety checklist, patient safety
PRIZE WINNERS – 2022 PRIZE COMPETITIONS OF 38THANNUAL ACADEMIC CONGRESS - 2022 Rathnasabapathy Sashidaran Prize for the best poster -Not awarded Photography Competition- Not awarded Rathnasabapathy Sashidaran Prize for the best free paper Dr Inthuja Megalanathan Shirani & Thilak Hapuarachchi prize for the research work in Anaesthesia, Critical Care or Pain Medicine by a Medical Student Dr Heerthikan Kanagalingam LMV Attygalle prize competition is awarded to - Dr Minura Hapugoda
PRIZES AWARDED FOR POST GRADUATE EXAMINATIONS IN ANAESTHESIOLOGY 2022 PRIZE WINNER Laddie Fernando Gold Medal for the best results MD Anaesthesiology Part II Examination – March 2022 Dr Dona Kalpani Ruwanari Kannangara B S Perera Prize for the best candidate MD Anaesthesiology Part 1A Examination -June 2022 Dr Ran Hotige Shanika Nilmini Ranasinghe Warusavitharana Prize for the highest marks in Physics and Clinical Measurements MD Anaesthesiology Part IB Examination July /August 2022 Dr Gayathri Chathurika Kariyawasam Paranawithana G M Attygalle Memorial award for the highest marks CCA Examination – June 2022 Dr Loku Appulage Kanchana Eranda Technomedics prize for best examination results MD Anaesthesiology Part II examination August/September 2022 Dr Dona Kalpani Ruwanari Kannangara Laddie Fernando Gold Medal for the best results MD Anaesthesiology Part II Examination October 2022 Not Awarded Ponnambalam Prize for the best results MD Anaesthesiology Part 1B Examination January / March 2022 Ponnambalam Prize for the best results MD Anaesthesiology Selection Examination August / September 2022 Warusavitharana Prize for the highest marks inPhysics and Clinical Measurements MD Anaesthesiology Part IB Examination January/March 2022
Acknowledgement On behalf of the president and the council of the College of Anaesthesiologists and Intensivists of Sri Lanka (COAISL), I would like to express my gratitude to Dr Helgi Johannsson, Vice president, Royal College of Anaesthetists for representing the Royal College of Anaesthestits (RCOA), at our Annual Academic Congress. We are thankful for his good wishes and for acceptance of our invitation to deliver the first plenary speech of the congress. We extend our sincere appreciation to the RCOA for their unflagging support extended throughout the years in promoting and enhancing academic activities of the COAISL, as well for Co-badging the event with the approval of CPD points for revalidation. We express our gratitude to Dr Klaus Goerlinger, who has been a long term friend of the COAISL for accepting our invitation to grace the congress as our guest of honour amidst your busy schedule, and traveling all the way to Sri Lanka to share your expertise and wisdom. Professor Wayne Morriss, who have been sharing his expertise with us for so many years we are thankful for you for joining our congress 2023 as the President, World Federation of Societies of Anaesthesiologists (WFSA). We gratefully acknowledge the support extended by both local and foreign faculty who presented at main congress on anaesthesia, critical care, pain medicine and resuscitation science. We extend our sincere gratitude to Asia tours and events for technical support and staff of the BMICH for offering the ground support provided. We extend our sincere appreciation to our industrial sponsors of this event for their generosity and contribution given to make this event a great success. We are also grateful to each and every one whose names may not have been mentioned for their support extended. Last but not least we would like to thank the participants for their enthusiasm and we hope that your gained knowledge will help us for a better patient outcome in Sri Lanka. Dr Anushka Seneviratna General Secretary College of Anaesthesiologists and Intensivists of Sri Lanka
Sponsors for the 39th Annual Academic Congress -2023 COLLEGE OF ANAESTHESIOLOGISTS AND INTENSIVISTS OF SRI LANKA Diamond Sponsors A J Medichem B Braun Technomedics Medica Phramaceuticals Pvt Ltd Gold Sponsor Slim Pharmaceuticals Pvt Ltd Fresenius Kabi Yaden Laboratories Pvt Ltd Medex holdings Romsons Sukhee Pharma Pvt Ltd and NiiX Holdings NextGen health care Meditechnology Hayleys Lifesciences Sunshine Healthcare Lanka Silver Sponsor Mervynsons Pvt Ltd Kalbe Internationa Pvt Ltd Other Sponsor A Baur and Co Pvt Ltd Lanka Hospitals Sethmedi International Pvt Ltd