Instituting Pandemic Plans in a Singapore Anaesthesia Unit: The Challenges and Learning Points

The World Health Organization declared COVID-19 as a pandemic on 11 March 2020. Its rapid spread has put a strain on healthcare systems globally. Singapore ranked the highest in terms of reported cases outside of China in the first few weeks of this outbreak. The management of a patient with COVID-19 in the Operating Theatre (OT) presents a unique set of challenges to the Anaesthetist. Delivery of timely and quality care must be upheld while reducing the risk of transmission to healthcare staff and other patients. This article describes our Anaesthesia Unit’s experiences and challenges in instituting our pandemic plans. The authors hope that the sharing of our experience and practical approach would be useful to other Anaesthesia Units worldwide.

Multidisciplinary basic and clinical research of acute kidney injury with COVID-19:Pathophysiology,mechanisms,incidence,management and kidney transplantation

Acute kidney injury(AKI)linked to coronavirus disease 2019(COVID-19)has been identified in the course of the disease.AKI can be mild or severe and that is dependent on the presence of comorbidities and the severity of COVID-19.Among patients who had been hospitalized with COVID-19,some were admitted to intensive care unit.The etiology of AKI associated with COVID-19 is multifactorial.Prevention of severe AKI is the prime task in patients with COVID-19 that necessitates a battery of measurements and precautions in management.Patients with AKI who have needed dialysis are in an increased risk to develop chronic kidney disease(CKD)or a progression of their existing CKD.Kidney transplantation patients with COVID-19 are in need of special management to adjust the doses of immunosuppression drugs and corticosteroids to guard against graft rejection but not to suppress the immune system to place the patient at risk of developing a COVID-19 infection.Immunosuppression drugs and corticosteroids for patients who have had a kidney transplant has to be adjusted based on laboratory results and is individualized aiming at the protection of the transplanted from rejection.

A Comparison of Local Infiltration Analgesia and PECS II Block for Analgesia in Mastectomy with Axillary Dissection—A Randomised Equivalence Study

Objective: Various analgesic techniques can be used for a mastectomy with axillary dissection with varying degrees of efficacy. In our institution, local anaesthesia infiltration (LIA) is commonly performed by surgeons. In this study, we hypothesise that the relatively novel PECS II block is equivalent to the analgesic profile of LIA. Methodology: In this single center, prospective, randomised control trial, 40 patients undergoing unilateral mastectomy with axillary dissection were randomly assigned to receive either 30 ml 0.5% ropivacaine before skin via LIA by a specialist breast surgeon during surgery or 30 ml 0.5% ropivacaine via PECS II block, before skin incision. Fentanyl was used as rescue analgesia intraoperatively, and all patients received morphine via patient-controlled analgesia (PCA) device postoperatively. The primary outcome was the difference in total morphine consumption in 24 hours between the 2 groups after surgery with equivalency set at ±1 mg. Secondary outcomes included time to rescue analgesia after block administration, post-operative pain score over 24 hours, adverse effects encountered, total intraoperative opioid usage, effect on operative time, block performance time as well as block and surgery related complications. Results: Unadjusted mean PCA morphine consumption over 24 hours post-operatively comparing local infiltration analgesia (LIA) to that of PECS II at 95% confidence interval was -1.22 mg (95% CI: -3.77, 1.33). Total IV Fentanyl use comparing LIA to PECS II was 2.53 ± 0.98 mcg/kg and 1.96 ± 0.57 mcg, P = 0.035. There were no other significant differences in the secondary outcome. Conclusion: We conclude there is a lack of equivalence between that of LIA and PECS II block, with the PECS II block providing superior analgesia.

Comparison of the Analgesic Effects of Ultrasound Guided Supra-Inguinal Fascia Iliaca Block with Femoral Nerve Block for Surgical Fixation of Hip Fractures

Introduction: Regional anaesthesia techniques have been used for perioperative analgesia for hip fractures. The supra-inguinal approach to fascia iliaca block (FIB) can potentially provide superior analgesia compared to femoral nerve block (FNB) by blocking the obturator and lateral femoral cutaneous nerves. We aimed to evaluate the analgesic effect of single shot FIB and FNB for surgical fixation of hip fractures. Methods: After obtaining ethics approval and written, informed consent, 30 patients undergoing surgical fixation of hip fractures were recruited and randomized into 2 groups. Patients received either a single shot FIB or FNB with 0.5% Ropivacaine 30 mls, and a subarachnoid block. Pain scores were assessed pre-operatively, post-block, in recovery and at 24 hours post-operatively. Time to first analgesic, oxynorm consumption, opioid related side effects and block related complications were assessed at 24 hours. Results: There were no statistically significant difference in post-block pain scores, median (IQR) of 0 (0 - 0) versus 0 (0 - 0) at rest and 3 (2 - 6) versus 5 (2 - 6) on positioning for spinal;and 24 hour pain scores were 0 (0 - 0) versus 0 (0 - 0) at rest and 4 (2 - 5) versus 5 (2 - 6) on movement for FIB and FNB groups respectively. 5 patients from each group required post-operative opioids, post-operative opioids requirement were similar. Conclusions: Though ultrasound guided supra-inguinal FIB was more consistent in blocking the lateral femoral cutaneous nerve then a femoral nerve block, this did not translate to any difference in terms of pain scores, opioid consumption and side effects.

Bilateral Sphenopalatine Ganglion Block for the Treatment of Post Dural Puncture Headache: A Case Report

Background: Post dural puncture headache (PDPH) is a known and potentially debilitating complication of neuraxial anesthesia that can impede patient recovery. The conventional treatment includes hydration and symptomatic treatment like simple analgesics. Those who have unremitting symptoms following conservative measures are offered an epidural blood patch (EBP). However, EBP, an invasive procedure, is associated with complications in itself. Case: We report a 40-year-old man who experienced PDPH after spinal anesthesia. His symptoms recurred after conservative management was instituted. He was then offered a trans-nasal sphenopalatine ganglion (SPG) block. He had excellent pain relief and did not require an EBP. Conclusion: SPG blocks can be considered early in the treatment of PDPH together with general supportive measures. However, if pain relief is not achieved, an epidural blood patch should still be considered.

Erector Spinae Plane Block for Open and Laparoscopic Liver Surgery: Two Case Reports

Epidural analgesia has long been regarded as the gold standard in abdominal surgery. However, concerns regarding risks associated with central neuraxial blockade, catheter placement and the presence of coagulopathy in patients undergoing liver resection have limited its use. Bilateral erector spinae plane blocks and catheter placement may mimic the effects of epidural analgesia by blocking both somatic and visceral pain while concomitantly avoiding central neuraxial blockade and catheter placement. We describe our experience in using the erector spinae plane block and catheter placement as part of a multimodal analgesia approach in a patient undergoing laparoscopic and another patient undergoing open liver resection. Our findings concur with previous reports which suggest that erector spinae plane blocks may be more efficacious as somatic rather than visceral analgesia. However, we conclude that further studies on factors affecting its efficacy should be conducted in view of the present lack of researched evidence.

Erector Spinae Plane Block for Mastectomy and Breast Flap Reconstructive Surgery: A Three Case Series

Uncontrolled pain after breast surgery can have early to chronic repercussions. The repertoire of pre-emptive opioid-sparing analgesic options includes regional blocks such as paravertebral blocks to myofascial blocks and more recently the Erector Spinae (ESP) block. Case 1 demonstrates the ESP block as an easy and conveniently performed post-operative rescue block for a patient who still experienced uncontrolled pain despite a combination of myofascial blocks and systemic analgesics. Case 2 and 3 demonstrate the advantage of providing an extensive coverage of surgical field in breast reconstruction surgery covering variable donor sites. It was due to the extent of coverage, that allowed the placement of ESP block catheter distantly without interrupting the surgical site. Post operative prolongation of pain relief was also successful by titrating analgesia via intermittent boluses. In our case series, the ESP block consistently and safely provided satisfactory pain relief for breast reconstruction surgery. It can be a viable option for peri-operative analgesia compared to other more invasive or less extensive alternatives.