Palmo Anest

Merry Christmas!

Here to wish everyone a Merry Christmas and a Happy New Year!!!

posted by LT @ 11:50 PM 1 comments

Sick Attitute

Doing quite some locum lately. I'm sick of some patients' attitute.

Those who come in and tell you what drugs they want (but they don't really have a clue what they are taking). "Give me the yellow colour and the green colour one..."

Those who just want a 'quick fix', forget about patient education and following up to this group of patients. (even frequent asthmatic who just want nebuliser and oral drugs and refused to follwow up and to put on inhaller)

Those who comes in and tell you straight that they want exactly the same set of medication the principle doctor had prescribe earlier although this time they comes in with similar but different diagnosis.

Those who wants everything you can offer doesn't matter he/she needs it or not.

Those who wants admission for even a very very small problem because they can claim insurance.

Those who think their insurance company will pay for everything and ask you to give them the best the money can buy in ur clinic/hospital and on top of that, ask for some extra other things for free(like those ahsoh going to market buying vegie but ask for free chilli when they left the stall).

Of coz also those who comes in for MC, for sleeping pills etc etc...

posted by LT @ 11:48 PM 1 comments

American Vs The rest of the world again???

Well, I posted earlier that the new resuscitation guideline by both AHA and ERC is out on 28th Nov 2005.

As usual, there's some difference in both the guidelines. Let's have a look at the algorithm:

For the Adult BLS, the European said:

If he is not breathing normally, send someone for help or, if you are on your own, leave the victim and alert the ambulance service; return and start chest compression...

The reason is for the witnessed suddent collapsed in an adult, most of it is cardiac origin and restore circulation is most important since the body will still have enough oxygen saturation for the first minutes. If it's drowning or trauma victims then we can give rescue breath first.

And the American said:

...if he or she is not breathing, give rescue breaths.

But they (the American)also went on and said:

During the first minutes of VF SCA, rescue breaths are probably not as important as chest compressions113 because the oxygen level in the blood remains high for the first several minutes after cardiac arrest.

The same goes to Child BLS, European said 5 rescue breaths before the compression cycle, American said 2 rescue breaths.

So which guideline are we in Malaysia are following? I'm still waiting for IJN and YJM's CPR coordinator to reply my enquiry by email... Probably like most M'sian institutes, they don't really read/reply emails.

The last CPR manual printed by Institute Jantung Negara (Follows Guideline 2000) was the one used by AHA. So I supposed we are going to follows the American again.

I know it doesn't really makes a difference during in-hospital CPR coz I'll usually jump on the patient first while the staff nurses prepair the ambu bag and ETT for intubation. But it'll be a different story while teaching BLS.

My CPR trainee (and myself together with my team of fascilitators) were quite confused during our CPR course last week. Most of the trainees had had previous CPR training (either pre 2000 or been following guideline 2000) so it takes quite sometime to hammer the idea into their practice.

Any of the readers here involved in the decision making for your local guidelines? Care to share your opinion? Thank you.

posted by LT @ 1:14 AM 1 comments

Sugammadex

In May 2005, Chen, Gasman and I have a short discussion about use of esmeron and suxamethonium in the post I blogged about the new reversal agent of Esmeron (a neuromascular bloking agant): the Org 25969, which is now called Sugammadex.

If this Org 25969 gets to the market, we can all dump Sux away and use Esmeron for all the emergency airway right? Wonder how is the cost like?

At 5/23/2005 3:21 PM, Gasman said...

well, actually Esmeron is not so expensive if you consider all those nightmare of MH like the one you had in your hospital. At least, you have peace of mind...
From my personal experince, Esmeron is not the so called 90sec intubation drug if you don't use volatile agent and 50% to 50% of Oxygen and N2O
How about you?

At 5/23/2005 3:57 PM, LT said...

I usually intubate <60sec after Esmeron too.

My concern is in cases of dificult airway, if it's really really bad one, do u still use Esmeron? I'll go for short acting in that case.

So with this new drug from Organon, we can safely use Esmeron. If really can't intubate & can't ventilate, just reverse it STAT. Simple & easy.

Interested to know the cost of this Org 25969.

At 5/23/2005 8:31 PM, Gasman said...

Pretty interesting, wish to know the drug better...

At 5/26/2005 12:23 PM, Chen said...

I will still use Suxamethonium in suspected difficult airway & in all maternity cases which require GA. Rocuronium still cannot replace Suxamethonium...

Just my 2 cents

At 5/26/2005 6:31 PM, LT said...

Point noted. :)

I still use sux for my LSCS majority of my emergency cases.

However I think with this combo of
Esmeron and Org 25969, we'd b safer in situation where sux is contraindicated. It's a safer alternative.

What is this Sugammadex? According to Organon, the pharmaceutical which produce Sugammadex,

Sugammadex (Org 25969) is a cyclodextrin derivative that has been designed to specifically encapsulate the steroidal NMBA’s Esmeron/Zemuron and Norcuron. Once these steroidal agents have entered the sugammadex molecule, their actions are prevented and almost instant recovery of neuromuscular function occurs.

Sugammadex is the first “selective relaxant binding agent” (SRBA), a new class of agents to reverse neuromuscular block, providing unprecedented control of neuromuscular block. Sugammadex allows the anesthesiologist to maintain deep neuromuscular block throughout the entire surgical procedure, thus providing the optimal surgical conditions until rapid recovery is required.

I was excited to see that one day we can all forget about Suxamethonium and confidently use this combination of Esmeron and Sugammadex even with suspected difficult intubation case. Especially after I seen and involved in management of a case of Malignant Hyperthermia after the use of Suxamethonium.

Seems like I'm not alone in this 'prediction' and looking forward to the 'taking over' of Esmeron from Suxamethonium.

'The Man' in anaesthesiology, Prof. Ronald D Miller also talk about this and think the same in the 14th ASEAN Congress of Anaesthesiologist in Hanoi, Vietnam recently. There is a similar symposium talk he co-chaired in ESA2005, Vienna, in PDA format for viewing.

The recent development of sugammadex (Org 25969), the first of a new
class of selective relaxant binding agents (SRBAs), now offers a new concept of how safe, rapid reversal of neuromuscular block might be achieved.

Sugammadex has the potential to revolutionize neuromuscular recovery by offering fast, effective, and complete reversal of a rocuronium or vecuronium block irrespective of the degree of neuromuscular block.

Sugammadex can allow excellent relaxation to be maintained until the end of surgery, followed by a rapid reversal of block. Sugammadex is effective at both superficial and profound blocks, has no observable muscarinic/vagolytic or other significant side
effects, and may prevent postoperative residual curarization.

I'm sure there are still a lot of Anaesthtist don't agree with me and think that we still needs Suxamethonium. I just hope that they are wrong. :)

Will share with u guys who are interested in this new agent the latest published study which just published in BJA (British Journal of Anaesthesia) this Nov.

Cheers. Happy gassing and safe relaxing.. :)

posted by LT @ 11:31 PM 1 comments