JILID 11 BIL 4 SEPTEMBER 2009

JILID 11 BIL 4 SEPTEMBER 2009
Newsletter of the Malaysian Society of Anaesthesiologists and the College of Anaesthesiologists,
Academy of Medicine of Malaysia

Table of Contents

• Message from the President
• Message from the President, College of Anaesthesiologists
• Report on the 16th ACA and 7th NCIC
• Communication from Dr Steven L Shafer
• WFSA Newsletter October 2009
• CPD event in conjunction with National Anaesthesia Day
  at University of Malaya Medical Centre, Kuala Lumpur
• Infection Control Measures During Pandemic Influenza A (H1N1)
  in Intensive Care Unitsmoh Hospitals
• 2nd End Of Life Care Workshop
• Confederation ASEAN Societies of Aanaethesiologists (CASA)
• Announcements for CPD Klang Valley
  
  
  
  
  Click here to Download Berita Anestesiologi in PDF Format (1.58MB)

Message from the President

Assalamualaikum and warmest greetings to the anaesthetic fraternity!

Ramadhan is here signalling the month of fasting, self control, giving and devotion.It is amazing that many non-muslims are also joining forces in adapting to this dietary change - the day time fasting and the night time food fest! Just visit the Ramadhan Bazaar to witness the 1 Malaysia concept at work.

A picture speaks a thousand words they say, so you can tell it has been a time of ‘change’ for me since the last time I wrote. I can only say it was a remarkable Umrah experience like non other.

National Specialist Register and Name Change of Our Specialty

Our specialty is now officially known as ‘Anaesthesiology and Critical Care’ in the NSR. It was a rather lengthy and arduous process but for the sake of many members (if not most), we hope the grouses and dissatisfaction the incompleteness the name brought will put to rest. The change in name does not alter the fact that anaesthesiologists are accredited to manage ICU patients as stipulated in the NSR criteria. The registration criteria for the ‘Intensive Care’ subspecialty has been deemed tight as most practicing anaesthesiologists will not qualify for it. However, it must also be understood that those registering in a subspecialty such as ‘Intensive Care’ will be expected to perform and hence, judged to that level.

Every specialty is busy enticing their members to register in the NSR as we await the amended 1971 Medical Act to be passed. Please register now as its 5-year validity will start the moment the Act is passed, meaning that there is no advantage whatsoever if you register later. For those registered members with certificates denoting only ‘Anaesthesiology’, please watch for further notices in our website or emailing list as we plan to attend to this issue in due course.

Malaysian Society of Intensive Care (MSIC)

It was just a matter of time that Intensivists (who are not all anaesthesiologists), register separately in their subspecialty. Some countries such as Australia and New Zealand already have their own Faculty with their own Fellowship. It will not be unreasonable for us to head that way in time when we have an adequate number of intensivists. Change, evolution and progress are taking root before our eyes so let us appreciate it. There will be enough work for everyone, but to expect each of us to be highly qualified in all subfields of anaesthesia, will be short of miraculous and a thing of the past. Sure, at the moment, we have to be Jack-of-all-trades to cater for the nation’s and hospital’s needs, but in reality the subfields of anaesthesia have advanced to the extent that it is hard for us to keep up with their individual progress. Other specialties such as surgery and medicine have long been subdivided into various subdisciplines.

As a follow-up to the subspecialization of ‘Intensive Care’, the Malaysian Society of Intensive Care has been formed. I must congratulate the protem committee for working hard and pioneering for the sake of the field. The ‘Intensive Care Section’ (ICS) of the Malaysian Society of Anaesthesiologists will continue to function for its members and complement the activities of the MSIC. After all, anaesthesiologists will continue to be active in intensive care patient management!

16th Asean Congress of Anaesthesiologists & 7th National Conference on Intensive Care

The 16th ACA & 7th NCIC was a tremendously successful congress in Kota Kinabalu, Sabah, with a total of 1654 delegates! We worried about the flu deterrent, the venue support, the weather for the ASEAN Night etc, but it surprised us with only minor hiccups. I must congratulate the Organizing and Scientific Committees, Ms Kong and the Secretariat, Dr Tan Li Kuan and team from KK, the sponsors and trade exhibitors, the speakers, facilitators and everyone involved who deserve all the praises’ from the feedback we received. Two years of planning became painless and worthwhile at the end of it all. A more detailed report is in this Berita issue. At members’ request, the few remaining two volume abstract / lecture journals will be on sale at the MSA secretariat for RM30.

MSA Website and e-mailing list

I hope you will browse our website at www.msa.net.my and notice the changes. We want our members to find it useful and friendly, and in time, of benefit to the public at large as well. It is easy to change the look but it is the contents that we will need help with. I appeal to all members and anaesthesiologists to kindly share with us updates, CME articles, etc. Suggestions and ideas are also most welcome.

You may have noticed that we are contacting you more frequently via our e-mail list of late. This is in-line with our intention for a faster, cheaper and more effective communication within our (big) circle of members. The updating of members database over the last couple of years is only bearing fruit now. If you are not getting our emails, please get in touch with us.

Life Members

MSA life members will be issued certificates and cards (credit card size, with number and photograph) as recognition of your life membership. As such, please ensure that we have your current data and photograph. To our ordinary members, kindly consider the conversion to life membership.

ASEAN Mutual Recognition Arrangement (MRA)

The ASEAN MRA for Medical Practitioners is the hot topic of the season as it will be implemented on 1st January 2010. Our main question is its implications to our country if anaesthesiologists are allowed to practice freely within the ASEAN region. Although the forum organized by AMM and MMA on 16th August 2009 did not foresee a large influx of medical practitioners, it is potentially inviting more qualified anaesthesiologists into Malaysia. This will be a welcome relief with the current shortage of anaesthesiologists in the country. With about 500 practicing anaesthesiologists and the anaesthesiologists : population ratio of 1:56,000, and anaesthesiologist : surgeon ratio of 1:4.5, there is room for more. Nevertheless, there is a maldistribution of anaesthesiologists with more still needed in the public or governmental sectors, particularly in rural areas and in Sabah and Sarawak. If the incoming foreign ASEAN anaesthesiologists are in the private sectors where monetary returns are more lavish, then it defeats the purpose of having more anaesthesiologists in the country to relieve local burden, stop the brain-drain into private centres and reduce maldistribution. At best, one can only hope the saturation in the private sector will prevent further losses from the public sector.

On the brighter side, we can look forward to incoming practitioners with various anaesthetic subspecialties, skilled expertise and varied experience with potential joint CME activities, learning and teaching ventures and even research projects.

Inadequate qualifications of incoming practitioners should not be an issue as individual clearance from the original country as well as approval from the host country, in our case, Malaysian Medical Council which is the Professional Medical Regulatory Authority (PMRA) here. The NSR will serve a very important purpose as a reference for accredited specialist qualification.

Anaesthesia Fees

I believe most anaesthesiologists, in particular those in the private sector, are contentedly abiding by the MMA’s 4th Fee Schedule (and awaiting the 5th Fee Schedule) with the approval of insurance companies. Nevertheless, it is also known that not all practicing anaesthesiologists are lucky enough to have this privilege at all times. Depending on each hospital’s policy and individual or group contract, the anaesthetic charges can vary. Let it be known that MSA supports the MMA Fee Schedule, with our professional anaesthetic fees categorically divided and not tagged as a percentage of the surgeons fees any longer. Our fraternity will have to be united in this stand so as to have a creditable voice and disallow undercutting or overcharging. For those with suggestions and ideas, especially with regards to future trends of anaesthetic fees, our MSA Fee Schedule representatives are Dr R Raveenthiran (Chairperson), Dr K Mohandas, Dr Mary Cardosa and Dr Jamsari Sukro.

Assoc Prof Datin Dr Norsidah Abdul Manap
[email protected]

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Message from the President, College of Anaesthesiologists

Membership of the College

I am taking this opportunity to appeal to all anaesthesiologists to join the College. At the moment, our numbers are still very small and we hope to increase our membership. “What’s in it for me?” you may ask – I would give the (rather clichéd) reply “Ask not what your College can do for you; ask what you can do for your College” – as a member of the College, you have a voice in what the College does. The College of Anaesthesiologists is an important component of the Academy of Medicine Malaysia and numbers-wise, we are much smaller than our counterparts in the College of Surgeons and the College of Physicians. Not that size matters, but having more members helps not just financially but also if we have to lobby for issues of interest to anaesthesiologists at the Academy Council level.

All anaesthesiologists are now eligible to join the College, so please go to the academy of medicine website www.acadmed.org.my, and click on Membership form to download the document, which lists all the requirements. You have to submit a hard copy of the form (signed) together with the necessary documents including your basic and postgraduate medical degrees.

I look forward to receiving a deluge of forms in the coming months!! (I am an optimist…!)

Singapore Malaysia Congress of Medicine

I attended the Singapore Malaysia Congress of Medicine in Singapore from August 6th-8th 2009, representing the College of Anaesthesiologists. In conjunction with this Congress, there was a Joint Council meeting involving the 3 Academies of Medicine – that of Singapore, Malaysia and Hong Kong. The plan is that next year, the Congress of Medicine, which has to date only been a joint activity of the Singapore and Malaysian Academies, will be held in Hong Kong, hosted by the Hong Kong Academy. This is an exciting new development. The congress will be held from 11th-13th November 2010 and the theme is “Benefits and Risks of Recent Medical Advances”

During the joint meeting, members of the 3 councils exchanged information on various issues relating to specialists in our countries, including discussions on the specialist register and continuing professional development (CPD). I also had the pleasure of meeting members of the Singapore College of Anaesthesiologists, including their current president, Dr Khoo Siew Tuan and exchanged views with her and her committee.

Induction of fellows and members of the College

3 fellows and 10 members were inducted at the Opening Ceremony of the 8th MOH-AMM Scientific Meeting, August 17th-18th August 2009, together with many others from the other colleges in the Academy of Medicine. The Academy of Medicine is still very traditional and we all wear gowns and the Scribe (i.e. the secretary) carries a “mace” (which I think signifies power and authority) onto the stage before the Master of the Academy ascends, accompanied by the Presidents of the various Colleges. They keynote address, ”Building a Safety Culture through Accountability” was delivered by the Director General of Health, Tan Sri Dato Seri Dr Ismail Merican and was followed by the 11th Tunku Abdul Rahman lecture entitled “Medical education and Post graduate Training : Quo vadis?” by Prof Dato’ Khalid Abdul Kadir.

Masters of Anaesthesiology program

At the last College council meeting, we decided to get more involved in the Masters program by helping to run the refresher course and mock exams for the MMed primary exams, which are currently being organized by the Department of Anaesthesiology, HKL. Prof Lim Thiam Aun will be in charge of this, and we hope to involve more of our colleagues, both from the public as well as the private sector. We are starting with the primary exam, but may move on to final exam in the future. Anyone who is interested in contributing to this please contact Prof TA Lim or me.

The College has been sending one examiner for the Masters (Final) exams, and the universities have kindly agreed that we can send observers to the exams as we are working on expanding our current pool of examiners.

Special Interest Groups (SIG)

The College has several Special Interest Groups (SIGs) which carry out CPD activities related to their area of interest. At the moment, we appoint convenors for the SIGs, and the convenors get together a group of other anaesthesiologists with the same interest and organize activities every one or two years. Some are very active, some are not so active. I would like to assist in the process by getting members of the College to join at least one SIG – you may join two if you are interested in more than one. That way, we can build up bigger SIG groups and possibly carry out more activities. I have also suggested that the SIGs hold an activity or meeting during the ASM/AGM as this gives another opportunity for people with similar interests to get together to talk about what can be done in there area of interest.

The current SIGs and their convenors are listed below:

Regional Anaesthesia is a new SIG and for now, we have decided that the RA and the Pain SIGs may carry out some activities together.

The Simulation and Airway SIGs held precongress workshops at the 16th ACA/7th NCIC in July this year, and the Paeds SIG held a fluid management workshop in Kota Bharu at the end of July, and launched a handbook on Paediatric Fluid management, which will be distributed to college members.

Please indicate which SIG you would like to join by sending an email to [email protected] and copy to [email protected] stating your name and the SIG, as soon as possible.

Practice Guidelines

The following is a list of practice guidelines which we hope will be drawn up or updated this year:

1. ‘Safety Standard in Anaesthesia’. The Coordinator will be Dr Mohamed Namazie Ibrahim. This will be an update of the ‘Standards of Monitoring’ guideline and will incorporate a section on ‘Infection Control in Anaesthesia’
2. Monitored Anaesthesia Care – Prof Nik Abdullah
3. Pre Anaesthetic Assessment – Prof Jaafar Md Zain

Again, those who are interested in contributing to the above please get in touch with me or with the convenor, or email the college at [email protected]

National Specialist Register (NSR)

Just an update – the change of the name of the Specialty from “Anaesthesiology” to “Anaesthesiology and Critical Care” has been approved by the National Credentialling Committee (NCC) at their last meeting. However, specialists registered under this specialty in the NSR are still called “Anaesthesiologists” whilespecialists registered under Intensive Care are known as “Intensivists”.

There have been a number of new applications for the NSR, many of which came in August in order to beat the “grandfather clause” deadline of August 23rd. The good news, for those who registered, is that the five years validity of your registration will only begin after the NSR becomes law, i.e. after the Medical Act has been amended in parliament (which we hope will happen by the end of this year).

I hope that those who have still not registered with the NSR will do so as soon as possible.

Mary Cardosa
[email protected]

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REPORT ON THE 16TH ACA and 7TH NCIC
By Dr Tan Li Kuan

The 16th Asean Congress of Anesthesiologists and (ACA) and the 7th National Conference on Intensive Care (NCIC) was held in Kota Kinabalu from 2nd to 5th July 2009. The event took place in the beautiful Sutera Harbour Resorts. This is the first time a local meeting (the 7th NCIC) has been held concurrently with an international meeting (the 16th ACA). We had an unprecedented number of participants (1654 delegates and speakers from 32 countries) and the experience was certainly an unforgettable one. The total number of exhibition booths was 98 and the total number of posters presented was 99.

The ASEAN Congress of Anaesthesiologists is a biennial congress organized in turn by each of the members of the Confederation of ASEAN Societies of Anaesthesiologists (CASA) which was formed in the late 1970s to foster better relations among anaesthesiologists in the ASEAN region, to provide a platform for anaesthesiologists in ASEAN to exchange views, information, knowledge and experiences, and to elevate the standard of training and practice in Aanesthesiologiy and Critical Care in ASEAN countries.

The precongress workshops were held on 2nd July 2009 and the participants were kept busy not only with lectures but were also given the opportunity for hands-on practice. The workshops were on Airway Management, Simulation (adults and paediatrics), Ultrasound for regional anesthesia, Ultrasound in ICU as well as Obstetric anesthesia. The workshops were well attended by medical officers as well as specialists not only from Malaysia but from other countries as well.

The Opening Ceremony was on the evening of 2nd July 2009. The event started off with the rhythm of bamboo beats. The procession of the Presidents of CASA member societies was preceded by flag bearers dressed in their beautiful traditional costumes of Sabah. The Quintin Gomez Oration on “Forging Ahead Together” was delivered by Prof Gracie Ong. The opening ceremony was officiated by Dr Angela Enright, President of the World Federation of Societies of Anesthesiologists. The audience was then treated to a very colorful and beautiful cultural dance performance by Sabah Tourism. This was followed by a welcome cocktail reception.

The congress was packed with plenary lectures and concurrent symposia with many excellent talks delivered by several distinguished overseas and local speakers. The topics covered a wide range of subjects both in anesthesia practice as well as in intensive care. There were also concurrent hands-on workshops during the conference, where participants could go to learn specific skills like TIVA and the use of Ultrasound. Kudos to the scientific committee for organizing a comprehensive and educational as well as interesting programme for all.

There were 3 free paper sessions where the best free papers submitted were chosen to compete for three prizes, the MSA-Astra Zeneca Young Investigator award, the MSA-ASEAN award and the NCIC award. All papers presented were of a high standard and impressed the judges.

The faculty night was held in Spice Island, Marina Club in Sutera Harbour resort. The speakers were treated to a fusion of local culinary delights. The atmosphere was relaxed and provided opportunity for the speakers to mingle around and get to know each other. The night was made more lively when Dato’ Dr Balan and his colleagues stepped up spontaneously to entertain the crowd with a Tamil song.

The social highlight of the congress was the ASEAN Night held on the evening of 4th July. The theme for the dinner was Sarong night. The crowd was entertained by performances from representatives from the participating countries. Malaysia was well represented by the Sarawak and Perak team. The Sarawak team made Malaysia proud with their beautiful and colorful cultural dance while Dr Kavita and her team presented a well choreograph modern dance. The crowd has a hilarious time watching the Singaporean belting out the song “Wash your body, wash your hands too (H1N1 song)” The impromptu performance of the traditional war dance (Haka) by the New Zealand duo was equally impressive.

The organizing committee led by co-chairpersons Dr Mary Cardosa and Dato’ Dr Jenagaratnam and Dr Ng Siew Hian (NCIC), as well as the scientific committee, led by Dato’ Dr Wang Chew Yin and Dr Tai Li Ling (NCIC), must be congratulated for organizing an excellent and successful congress. We must also not forget Ms Kong and her team who have been the backbone of the secretariat for the congress since we started organizing it two years ago. Thanks must also be given to the team from Abbott for helping with the registration, as well as the team from Sutera Harbour Resorts who worked round the clock to ensure that the place was set up properly. Last but not least, a special word of thanks goes to the doctors and nurses from Hospital Likas who contributed their time and effort working tirelessly in the secretariat and assisting with the audiovisual service, providing the important but unseen background work that makes a conference successful.

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Communication from Dr Steven L Shafer

The best word to describe the 16th ASEAN Congress of Anaesthesiologists and the 7th National Conference on Intensive Care is “magical”. The program “Forging Ahead Together” brought representatives from around the world together for three days of world class science and warm fellowship. As with many anaesthesia meetings, the Congress was divided into clinical programs and more fundamental scientific presentations. The clinical workshops covered the material that anaesthesiologists everywhere need to learn: state-of-the-art obstetrical anaesthesia, management of complex trauma, paediatric anaesthesia, adult and paediatric critical care, cardiovascular anaesthesia, neuroanesthesia, regional anesthesia with ultrasonography and airway management. I attended many of these lectures and concluded that anaesthesiologists practice to a global standard. “Best practice” taught at the Congress is the same “best practice” we teach at Columbia. We have the same tools, and share the same goals. I was also impressed by the scientific program, and particularly the presentations that considered long-term effects of anaesthetic management decisions. Outcome is increasingly the focus of anaesthesia research, and anaesthetic outcomes were well represented at the Congress. Although the program was outstanding, my lasting memories will be the people I met. The hospitality, the warmth, the graciousness, and the invitation (accepted) to belly dance on stage on the final gala night were beyond compare. I thank the Malaysian Society of Anaesthesiologists for four magical days in Kota Kinabalu.

Steven L Shafer, M.D.
Professor of Anaesthesiology, Columbia University
Editor-in-Chief, Anaesthesia & Analgesia

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WFSA Newsletter October 2009

The WFSA has had a productive year working with the World Health Organization on the Safe Surgery Saves Lives project, led by Atul Gawande which resulted in the Safe Surgery Checklist. Several WFSA member societies have championed the use of the checklist and in a number of countries, such as the UK, the checklist is being introduced to all hospitals. This work has now led on to the WHO Global Pulse Oximetry Project aiming to facilitate the provision of pulse oximeters and training in their use to every operating theatre in the world. Specifications have been produced for a low cost WHO oximeter, and it is hoped that following the tendering process an oximeter will be selected and tested. The WFSA have been particularly involved in producing training materials for the project which will be tested at the All Africa Anaesthesia Meeting in Nairobi in September. This educational work has been led by our President Angela Enright. Special thanks are also due to Isabelle Murat for the French translation of the WHO oximeter manual, Gonzalo Barreiro for the Spanish edition and to Rafael Ortega for his superb instructional video.

A major effort to raise the profile of this lifesaving project is required to ensure that demand for oximeters is realized in parts of the world where anaesthetists work without them. This will result in hospitals and ministries of health “oximeterizing” health systems and thus improving perioperative safety. Major donors will be sought to support the project. Please email [email protected] with any suggestions you may have to ensure the success of this initiative. Without doubt this project is the largest anaesthesia safety initiative ever started, and all WFSA societies will need to put energy into this project to ensure its success.

An account of the oximetry projects in Uganda, Vietnam, India and the Philippines run by a collaboration from the WFSA, AAGBI and GE Healthcare will be published in the journal Anaesthesia along with an accompanying editorial in October 2009. These projects did much to inform WHO of the practical aspects of the global programme.

The WFSA has also assisted the work of WHO through our contact Dr Meena Cherian of the Clinical Procedures Unit. We provided input into the new WHO guideline on the Clinical Use of Oxygen which details indications for oxygen, different ways to administer oxygen and how to monitor patients receiving oxygen.

Countries seeking advice about how to improve anaesthesia services will benefit from a joint WFSA / WHO blueprint describing the essential components of a national anaesthesia service. This will provide guidance in organizing a service, personnel who may provide anaesthesia, training recommendations, equipment required and ways of working to support safe practice. It is anticipated that this guideline will compliment the WHO Emergency and Essential Surgical Care (EESC) program. Improvements in training methods will be coordinated with WHO. The WFSA has some experience with training masterclasses run by Mike Dobson, Shirley Dobson and Lesley Bromley from the UK with their team – “Training the trainers”.

Following participation of WFSA members in a meeting organized by WHO Essential Health Technologies Department on anaesthesia equipment, WFSA and WHO have started work on generic specifications for anaesthesia machines that can operate reliably in resource poor areas of the world. This work is important as many anaesthesia machines in poorer countries remain unrepaired due to shortages of spare parts and maintenance facilities.

Primary Trauma Care (PTC)

PTC is supported by the WFSA and WHO and has run 34 courses during 2007-9 in different regions of the world. The WHO manual Surgical Care at the District Hospital includes the PTC material. The Chairman Douglas Wilkinson, and his international teams, are to be congratulated on this amazing achievement.

Publications Committee

The role of the Publications Committee is to further the work of the WFSA by providing appropriate educational materials for anaesthetists working without up-to-date published materials. The vision is challenging as clinical conditions vary from one country to the next, anaesthesia providers differ in their educational level and communicate in multiple languages. Modern texts which are almost exclusively written for advanced practice may be too expensive and impractical for some settings.

Update in Anaesthesia is the official CME publication of the WFSA. It is designed for anaesthetists working in resource poor settings and is edited by Dr Bruce McCormick. Each English edition is now translated into Russian, Chinese and Spanish. We are working to achieve French and Portuguese language editions. The Spanish edition is published on the internet, English and Russian editions are in paper format and on the internet.

In 2008 two editions have been produced – see www.anaesthesiologists.org The second edition was a 200 page review of Basic Science applicable to anaesthesia. This was a significant undertaking for the editorial team and has received very positive reviews. We were extremely fortunate. Anaesthetists of Great Britain and Ireland (AAGBI) funded half the costs of production to assist the work of the WFSA. In 2009 we intend to produce another special edition – Emergencies in Anaesthesia.

WFSA Anaesthesia Tutorial of the Week was started in 2005 as an on-line weekly tutorial with a number of UK based editors. The tutorials provide material for trainees as well as experienced anaesthetists, and are particularly of interest for those anaesthetists working in isolation without access to CME, both medical and non-medical. The tutorials vary in complexity and are divided into basic science, general anaesthesia, paediatric, obstetric, regional and intensive care. The Tutorials are designed to encourage reflective learning by including questions and self assessments and may be used for self study or teaching in the classroom. Tutorials are issued once a week and are currently hosted on the WFSA website, and are also sent out weekly to hundreds of anaesthetists by email. The archive on the website has around 140 tutorials at present containing a wide variety of material useful for the full range of clinical conditions which has proved popular for trainees in all countries. Since the system is based on the Internet, it is low cost and flexible, although limited where the internet is not available. The website www.frca.co.uk also publishes ATOTW.

Book donation programs continued during 2008-9 to centres in sub-Saharan Africa, Thailand, Fiji, Pacific Islands, Mongolia and Moldova. We have been working collaboratively with the AAGBI, which has a major book distribution program, mainly in sub-Saharan Africa.

In particular, Understanding Paediatric Anaesthesia (R Jacob) has been printed in India in both English (1000)and French (2000) and distributed widely by the WFSA. Special thanks go to Isabelle Murat for organising the French distribution.

During 2009 the American Society of Anesthesiologists is planning to fund and distribute a Spanish translation of this book – a fantastic gesture costing around $15k. In addition, the Association of Paediatric Anaesthetists of Great Britain and Ireland are planning to sponsor 1000 copies of the English version for distribution by the WFSA ($6000).

The AAGBI Overseas Anaesthesia Fund receives donations by members and supports a major book donation program which is hugely appreciated.An Obstetric anaesthesia manual “Anaesthesia for Obstetrics in Developing Countries” is currently being edited by Dr Paul Clyburn in UK and will become available for distribution in 2010. This is a joint venture between the WFSA, AAGBI and the Obstetric Anaesthetists Association. The manual will be published by Oxford University Press.

Dr Iain Wilson
Chairman, WFSA Publications Committee

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CPD event in conjunction with National Anaesthesia Day at University of Malaya Medical Centre, Kuala Lumpur

Programme:

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Infection Control Measures During Pandemic Influenza A (H1N1) In Intensive Care Unitsmoh Hospitals

1. Isolation of patients suspected or infected with Influenza A (H1N1) in ICU
   1. All patients with influenza-like illness (ILI) should be isolated in the following order of preference:
      (i) single rooms
      (ii) cohort in an open area/ cubicle
      As the outbreak evolves, additional knowledge regarding the transmission of Influenza A (H1N1) virus suggests that negative pressure rooms are not needed for the care of these patients. (ILI is defined as fever > 38oC and cough and/or sorethroat in the absence of other diagnosis)
   2. At least 3 feet spacing between patients should be maintained at all times in patients who are cohorted. However, the distance should ideally be six feet apart from patients who are on high frequency oscillatory ventilator, non-invasive ventilator.
   3. The area for cohorting should preferably be at the end of the wards to minimise exposure from regular traffic. The area should be well ventilated with windows opened. The door to the area can remain open.
   4. Use of equipment that re-circulates air (e.g. fans, hot air warming blankets) should be avoided.
   5. Use of equipment that re-circulates air (e.g. fans, hot air warming blankets) should be avoided.
   6. Critically ill adult patients may have prolonged viral shedding and isolation precautions shall be continued for seven days from onset of symptoms or until the resolution of symptoms, whichever is longer.
2. Healthcare workers managing patients with Influenza A (H1N1) infection in ICU
   1. Healthcare workers should monitor their temperature twice daily and not come to work if they develop influenza-like illness. If they develop fever at work, they should cease patient care activities and report themselves to the out-patient department in their local hospital.
   2. Healthcare workers who are at increased risk of complications from Influenza A (H1N1) (e.g. pregnancy, diabetes mellitus, asthma) should be considered for redeployment to nurse non-influenza patients in ICU.
3. Visitors to patients suspected or confirmed Influenza A (H1N1) infection in ICU
   1. Visitors should be restricted to immediate family members. Only two family members may visit at a time.
   2. Family members with influenza-like illness should be prohibited from visiting.
   3. Visitors should be advised to keep a distance of more than three feet from the patient.
   4. Visitors entering isolation room/ cohorted area should wear surgical masks. Masks should be removed on leaving room. They should be supervised to perform hand hygiene before and after visiting.
4. Infection control measures in management of patients with Influenza A (H1N1) infections in ICU
   1. Hand hygiene
      Hand hygiene is the single most important measure to reduce the risk of transmission. Strict adherence to hand hygiene recommendations should be enforced. Alcohol-based handrub is effective if hands are not visibly soiled.
      Hand hygiene should be performed:
      • before and after contact with each patient
      • between different care activities for the same patient
      • after contact with respiratory secretions or contaminated surfaces/ objects
      • after removal of personal protective equipment
      • before any activity that involves hand to face contact
   2. Use of personal protective equipment (PPE)
      1. Healthcare workers need only to wear surgical masks when entering room or cohorted area of patients with suspected or confirmed Influenza A (H1N1) infection. However, gloves and apron should be worn during cleaning procedures.
      2. Surgical mask, plastic apron and gloves should be worn when in close contact (within three feet) with a patient who is suspected or confirmed infected. However, if the patient is on non-invasive ventilation or high frequency oscillatory ventilation, wear a N95 mask if within three feet from the patient.
      3. The following PPE should be worn for all aerosol generating procedures: long sleeved water impermeable gown, N95 mask, eye protection and gloves.
      4. For practical purposes, a nurse who is taking care of a patient who is suspected or confirmed infected should wear a N95 mask at all times. Wear a surgical mask over the N95 mask to minimise the risk of touching the face from repeated removal and donning of N95 mask and contaminating the surface of the N-95 mask. After performing any aerosol generating procedure, discard the surgical mask and perform hand hygiene. Apply a clean surgical mask over the N95 mask.
      5. Before leaving the room/ cohorted area, remove all personal protective equipment and perform hand hygiene.
      6. Eye protection includes face shield, visors or goggles. Reusable eye protection must be cleaned and disinfected after any aerosol generating procedure.

Appropriate PPE for staff who care for patients with influenza A (H1N1) is summarised in table below:

1. Surgical masks (3-ply) are recommended for use at all times in cohorted areas for practical purposes
2. Use eye protection if splashes can be expected during that particular procedure

3. Infection control measures specific to respiratory care
   Standard and droplet precautions should be the minimum level of precautions used when providing care for patients with ILI.
   1. Disposable respiratory equipment should be used wherever possible. Reusable equipment if used, must be disinfected in accordance with local policy and manufacturers guidelines.
   2. All ventilators should be fitted with a viral filter; between the distal end of expiratory tubing and the ventilator
   3. Use disposable ventilatory breathing circuit whenever possible. The ventilatory circuit should not broken unless absolutely necessary. Do not change ventilatory circuits on a routine basis. Ventilators should be put on the stand by mode or turned off if there is a need to break the circuit.
   4. Closed suctioning system should be used. Suctioning using a closed system is not considered as an aerosol generating procedure. Do not disconnect from ventilator or manually ventilate during suctioning. Instead activate the 100% oxygen mode on the ventilator during suctioning.
   5. Water humidification should be discouraged. Use heat moisture exchangers instead.
   6. Avoid the use of nebulisers. For intubated patients use metered dose inhalers if necessary. For non-intubated patients, use spacer devices with metered dose inhalers.
   7. Do not use a T-piece breathing system in weaning from the ventilator.
   8. When using a manual resuscitator bag, connect a viral filter between the endotracheal tube and the manual resuscitator bag.
4. Infection control measures during aerosol generating procedures
   1. Appropriate personal protective equipment while performing potential aerosol generating procedures includes long sleeved water impermeable gown, gloves, eye protection and N95 mask.
   2. The performance or aerosol generating procedures should be minimised while not compromising patient care. To avoid unnecessary exposures, only healthcare workers needed to perform the procedure should be present.
   3. During intubation
      • Only experienced doctors should attempt intubation (spread of infection at the time of intubation appears to be associated with difficult intubation, prolonged manual bagging)
      • Use rapid sequence induction for intubation. Ensure the patient is adequately paralysed before attempting laryngoscopy.
      • A viral filter should be fitted between the face mask and manual resuscitator bag.
      • Minimise manual ventilation. If essential, it should be carried out by two persons: one holds mask tightly against patient’s face while the other squeezes the bag gently.
      • Inflate ETT cuff before ventilating the patient. The ventilator should only be turned on when it is connected to the endotracheal tube.
      • All staff involved in the intubation should remove PPE immediately after intubation and perform hand hygiene.
   4. During non-invasive ventilation (NIV)
      • NIV mask should be applied to the patient’s face and secured before the ventilator is turned on.
      • The ventilator should be turned off before removal of the mask or when lifting the mask away from the face.
      • Water humidification should be avoided.
   5. ddd
5. Handling of the deceased body suspected or confirmed Influenza A (H1N1)
   • Standard precautions should be used when handling deceased individuals regardless of the presumed infectious status; including appropriate use of personal protective equipment (long sleeves gown, glove, N95 mask and eye protection). After PPE is removed, hand hygiene should be performed.
   • Contact with the body in ICU should be limited only to close family members.
   • Direct contact with the body should be discouraged; however, necessary contact may be allowed as long as hands are washed immediately with soap and water.
6. ddd

Prepared by Dr Tai Li Ling
Consultant Anaesthesiologist and Intensivist,
Hospital Kuala Lumpur
11th August 2009

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2nd End Of Life Care Workshop
Dr Noor Airini Ibrahim
Consultant Anaesthesiologist and Intensivist, Universiti Putra Malaysia

To cure sometimes, to relieve often, to comfort always

The End of Life Care (EOL) Workshop which was initiated by the Intensive Care Section of MSA, in collaboration with the Anaesthetic and Intensive Care Section and Ministry Of Health was held for the second time this year in Hospital Serdang on the 5th of August 2009. The first one was held on the 15th of April 2009 at the same venue. Each session was attended by 25 participants, comprising mainly anaesthetists, both from public and private sectors.

The objective of this workshop was firstly, to introduce to our fellow ICU care givers that EOL care is a plannedcare to comfort our critically ill patients when cure is no longer a realistic option. Though the goals of intensive care is to save lives by invasive and intensive therapies, we often forget that in those that we cannot save, providing a dignified and peaceful death is also part of our professional obligation. The workshop was also aimed towards improving knowledge on the ethical and legal aspects of EOL care decisions, improving competency in providing quality EOL care and to address specific communication skills related to EOL care with the overall objective to improve the dying experience for the patient, the family and the health care providers.

It was a one day event, with lectures in the morning on the following topics:

1. Death and Dying In the ICU.
2. Ethics at EOL decisions.
3. Decision-making capacity.
4. Foregoing life sustaining interventions on the basis of medical futility.
5. Conflicts and the Law.
6. Practical Aspects of EOL Care.
7. Communication Skills at End of Life.

What followed in the afternoon was four interactive sessions which many of the participants found very interesting and enlightening. These sessions comprised of 3 role play stations with specific themes complete with “trained actors and actresses”. This was to allow participants to act out and respond to various possible EOL scenarios.

Another session was a case discussion station where discussion of various cases with specific EOL themes was done. This allowed each of the participants to share and learn from each others experience as well discuss certain issues and clear any doubts.

The overall response from the two workshops has been most encouraging and we have received various requests to conduct such courses out of Klang Valley and to open it to non anaesthetists. As it is quite labour intensive and costly to take the whole group of actors and actresses out of Kuala Lumpur (KL), we are looking into ways to increase awareness about End of Life Care among other members of medical fraternity, both in and out of Kuala Lumpur.

The overall response from the two workshops has been most encouraging and we have received various requests to conduct such courses out of Klang Valley and to open it to non anaesthetists. As it is quite labour intensive and costly to take the whole group of actors and actresses out of Kuala Lumpur (KL), we are looking into ways to increase awareness about End of Life Care among other members of medical fraternity, both in and out of Kuala Lumpur.

‘We cannot keep our patients from dying, but we can strive to make the dying experience as comfortable and meaningful as possible for our patients, their families, and ourselves’

Plonk W M, Jr, & Arnold R M (2005)

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Confederation ASEAN Societies of Aanaethesiologists (CASA)
By Ddr Mary CardosSa

The 26th CASA Executive Committee meeting was held on 3rd July 2009 in conjunction with the 16th Asean Congress of Anaesthesiologists (ACA). This committee only meets once in two years, every time the ACA is held, and comprises the presidents and other representatives of each of the CASA member societies. At this meeting, Dr Florian Nuevo from the Philippines and Dr Angela Enright, President of WFSA, were also invited to be present, and Dr Shah Sudhirchandra from Brunei was present as the newly formed Brunei Society of Anaesthesiologists was accepted as the 10th member of CASA at this meeting.

The main business of the meeting is to report on the current (16th) ACA and to discuss plans for the forthcoming (17th) ACA. The committee was informed that the Organizing Committee of the 16th ACA had invited two fellows each from Cambodia, Laos and Myanmar and accorded them complimentary registration, economy airfare and hotel accommodation, but unfortunately only those from Laos were able to attend.

The “tradition” of offering complimentary registration only (without accommodation and airfare) to ASEAN speakers was discussed and it was decided to continue this practice as this was intended to assist the host country by cutting down some of the expenses. The other ASEAN societies were asked to assist the speakers from their own countries with their other expenses; the MSA President gave an example of the MSA, who gives a subsidy to all our members who are speakers (invited or free paper presenters) at any ACA. It was also noted that for the World Congress, the speakers had to pay their own registration fees as well as other costs.

At this meeting, a resolution to hold the Say-Wan Lim Lecture as a regular part of this and all future ACA’s was tabled and unanimously accepted. Therefore, there will now be three named ACA lectures, the Quentin Gomez lecture which is usually at the Opening Ceremony, the George Tay Lecture and the Say-Wan Lim Lecture. The Philippine Society (PSA) reported on their preparations for the 17th ACA during which the 60th Anniversary of the PSA would also be celebrated. The dates proposed for the 17th ACA were 9th to 12th February 2011, but as this would clash with Chinese New Year, the alternative dates of 24th to 27th February 2011 were suggested – the final date will be confirmed later. But please do mark your diary – the 17th ACA will be held in Manila, Philippines, in February 2011.

Another issue discussed was the future of the ASEAN Journal of Anaesthesiology, which had been published two to three times per year since its inception. The main challenge now was the funding of the publication and distribution of the journal as Organon had been taken over by Schering-Plough and could no longer continue to fund the publication after the end of 2009. We will be looking at having an e-journal and other ways of financing the publication.

There was also a proposal to start a CASA Traveling Fellowship, with two categories - junior and senior – with the aim of fostering better relations between the ASEAN Societies of Anaesthesiologists, and to increase awareness among our younger colleagues regarding the practice of anaesthesia in the various ASEAN countries. However, funding had not yet been secured for this, and we hope to be able to achieve this in the not too distant future.

Dr Angela Enright, President of WFSA, commented that she was very impressed with and encouraged by the good cooperation amongst the ASEAN national societies.

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Announcements for CPD Klang Valley

1. Acute and Chronic Pain Management Conference
   'The Multimodal Approach in Pain Management'
   4th-5th December 2009
   University Kebangsaan Malaysia Medical Centre, Kuala Lumpur
2. UMMC External Examiners Talk
   13th November 2009
   University Malaya Medical Centre, Kuala Lumpur, Malaysia