Dear Editor, Emergence from anaesthesia and deep sedation is the transition from unconsciousness to the return of awareness and airway reflexes. The chief patterns of unsafe recovery include sudden unpredictable emergence or delayed return of airway tone and reflex with risk of airway obstruction.1 Agitation includes straining, sitting up, screaming...

Dear Editor, The Academy of Medicine, Singapore (AMS) guideline on the use of sedation by non-anaesthesiologists during gastrointestinal endoscopy in the hospital setting and an accompanying editorial were published in the January 2022 issue of the Annals.1,2 An evidence-based approach was used with reference made to relevant published literature. The...

Dear Editor, I refer to the editorial “Ensuring safe sedation during gastroendoscopy”1 and the original article “Academy of Medicine, Singapore clinical guideline on the use of sedation by non-anaesthesiologists during endoscopy in the hospital setting”2  in your journal in January 2022. The American Society of Gastrointestinal Endoscopy (ASGE) and the European...

Dear Editor, Propofol is a potent intravenous sedative-hypnotic agent. Its popularity for sedation has increased in the last 3 decades because of its smooth, rapid onset of action and fast post-procedural recovery.1 Nonetheless, propofol depresses cardiorespiratory function and could result in life-threatening adverse effects. A workgroup, mainly consisting of gastroenterologists and...

Dear Editor, We read with interest the paper by Ang et al.1 on Singapore guidelines in the use of sedation by non-anaesthesiologists during gastrointestinal endoscopy in the hospital setting. We are especially intrigued by Statement 6, stating that propofol sedation for endoscopy can be safely and effectively administered by trained...

The intermittent manual bolus thermodilution method is the most common means of determining cardiac output in critically ill patients. Although widely used, there are many factors which may affect the accuracy of this technique such as the volume, temperature and timing of the injectate. This article is available only as...

New developments in technology, monitoring and pharmacology over the last decade have improved our understanding of phaeochromocytoma and its management. This review summarises the pathophysiology and clinical features of phaeochromocytoma. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Although deliberate hypotension during surgery may potentially cause organ ischaemia, in particular of the myocardium and cerebrum, it is widely used as an adjuvant technique in oral and maxillofacial surgery aimed at reducing blood loss and improving the surgical field. Deliberate hypotension was reported as the fourth commonest cause...

The incidence of shivering following general anaesthesia varies from 5% to 65%. Postanaesthetic shivering may increase tissue oxygen demand by as much as 500% and accompanied by increases in minute ventilation and cardiac output to maintain aerobic metabolism. This article is available only as a PDF. Please click on “Download...

Significant arterial hypoxaemia is defined as a partial pressure of oxygen (PaO2) that is less than 60 mmHg or a percentage of oxyhaemoglobin (% HbO2) that is less than 90%. The immediate response in acute situations is to rapidly exclude or treat common conditions such as airway obstruction, pneumothorax...

Critical care medicine as a specialty has grown rapidly, both clinically and academically, over the past 25 years. In the USA, certification of competence has been awarded to graduates of the critical care medicine fellowship programmes since 1987. This article is available only as a PDF. Please click on “Download...

The role of ventilatory support in acute lung injury is supportive, whilst the damage to alveolar-capillary membranes resolves and alveolar stability is restored. The optimum mode of support varies with individual patients, but none can reliably prevent progression of acute lung injury and high frequency ventilation (HFV) has been...

The intensive care unit (ICU) is a complex environment in which multidisciplinary expertise has been shown to enhance clinical outcomes. For example, the availability of full-time intensivists has been associated with improved survival. This article is available only as a PDF. Please click on “Download PDF” on top to view...

The Western Pacific region includes a very diverse group of countries varying in their culture, economic development and per capita income, disease prevalence and medical traditions. The Western Pacific Association of Critical Care Medicine (WAPCCM) includes countries from Japan in the north to Australia and New Zealand in the...

Although special areas for postoperative patients existed 50 years ago, the modern specialty of Critical Care began during the polio epidemic of the 1950s. Prolonged hand ventilation, and positive or negative pressure ventilation, enabled maintenance of oxygenation until some patients developed sufficient recovery or compensatory processes to enable separation...

The use of caudal preservative-free morphine for postoperative analgesia in children has gained popularity since it was first described by Jensen. Several studies have reviewed its use for inguinal and genital surgery in children. This article is available only as a PDF. Please click on “Download PDF” on top to...

Injuries form the fifth commonest cause of death locally. They accounted for 27 out of 100 000 deaths in 1993. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

The Singapore General Hospital is a 1700-bedded tertiary hospital with subspecialty intensive care units (ICUs), i.e. Surgical ICU, Cardiothoracic ICU, Neurosurgical ICU, Medical ICU, Burns ICU, Medical ICU, Coronary Care Unit and Neonatal ICU. The SICU receives patients from various surgical disciplines (Table I). This article is available only as...

Does Critical Care Medicine exist and what defines its area of practice? Different countries have embarked on their own journeys of discovery, and have arrived at different paradigms—open versus closed models, specialty-based intensive care units (ICUs) versus general ICUs, internist versus pulmonologist or anaesthetist, and so forth. This article is...

Most obstetric anaesthetists have their favourite epidural concoction for use in labour, This paper surveys the variation in techniques of drug delivery and types of drugs used in labour epidurals. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

In the current era of increasing economic and medicolegal pressures, it is imperative that equipment-related limitations and complications be reduced to a minimum. Epidural catheter breakage can result in the inconvenience of surgical extraction of catheter fragments, while kinking can lead to impairment or failure of drug delivery to...

A 29-year old Thai construction worker, previously well, was admitted to our Orthopaedic Department for sudden onset of lower back pain. Physical examination showed severe tenderness in the lumbar region, limited straight leg raising but no neurological deficit. This article is available only as a PDF. Please click on “Download...

A 15-year-old female patient weighing 40 kg with asymptomatic but severe scoliosis was admitted for correction of a skeletal deformity via a thoracoscopic anterior release approach and posterior instrumentation. Preoperative assessment revealed good effort tolerance. This article is available only as a PDF. Please click on “Download PDF” on top...

In the past, cardiac patients in this institution were ventilated postoperatively for a prolonged period, frequently overnight. Since 1997 some of our cardiac anaesthetists have, whenever possible, adopted the practice of early extubation after cardiac surgery to improve the patient’s level of comfort and to allow an early return...

The discovery of new drugs in anaesthesia previously relied completely on chance. Chemical compounds produced by pharmaceutical companies were screened by a variety of different teams looking for effects of interest to their own area. This article is available only as a PDF. Please click on “Download PDF” on top...

A 44-year-old male, right-handed and ASA 1 bus driver presented for elective mastoidectomy under general anaesthesia. Preoperative venous cannulation with a 20G cannula (Angiocath™) was first attempted on the dorso-lateral aspect of the right wrist at the base of the anatomical snuffbox. This article is available only as a PDF....

Tracheal tube suctioning is frequently performed in critically ill patients. This procedure often results in dissemination of droplets from the patient’s respiratory tract with potential spread of respiratory tract microorganisms from one patient to another. This article is available only as a PDF. Please click on “Download PDF” on top...

Perioperative “wheezing” can be due to upper or lower airway obstruction. The signs and sounds of upper airway obstruction are typically worse during inspiration, whereas those of lower airway obstruction are worse in expiration. This article is available only as a PDF. Please click on “Download PDF” on top to...

A 53-year-old man with a history of hypertension and asymptomatic Wolff-Parkinson-White syndrome was admitted to the hospital for an elective uvulopalatopharyngoplasty, tonsillectomy and bilateral functional endoscopic sinus surgery for mild obstructive sleep apnoea and chronic sinusitis respectively. He weighed 109 kg, all his four upper incisors were missing and...

Phaeochromocytomas are catecholamine-secreting tumours of the chromaffin cells of the body derived from neural crest tissue. They may secrete both adrenaline and noradrenaline in varying proportions. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Both intubation and extubation are processes associated with blood pressure and heart rate flux. While many studies have been carried out on the changes associated with intubation, the frequency and magnitude of the changes associated with extubation are less well documented. This article is available only as a PDF. Please...

Bladder tumours frequently arise from the posterolateral wall of the bladder1 over the course of the obturator nerve. It is during transurethral resection of these tumours that direct electrical stimulation of the obturator nerve occurs. This article is available only as a PDF. Please click on “Download PDF” on top...

Pneumomediastinum is a well-recognised clinical entity. It may present either intraoperatively or postoperatively from a number of possible causes. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Total intravenous anaesthesia (TIVA) implies achieving the 3 components of anaesthesia (hypnosis, analgesia and muscle relaxation) by the administration of anaesthetics via the intravenous (IV) route without the use of inhalation agents. The main advantages of TIVA are avoidance of both volatile agent and nitrous oxide exposure and reduction...

Patients with ischaemic heart disease have a high incidence of perioperative ischaemia resulting in an increased risk of cardiac events in the post-surgical period.1 Goldman et al2 formulated the “cardiac risk index”, implicating previous myocardial infarction (MI), heart failure and unstable angina as major determinants of postoperative cardiac events. This...

Difficult intubation remains a key problem1 and the value of a flexible introducer (gum elastic or wire) as a first approach is well recognised in the UK and USA. It is the simplest method, effective for all grade 2 laryngoscopies, where at least the arytenoids are visible and most...

Breast cancer is the commonest malignancy in Singapore women, with an age-standardised rate of 46.1 per 100,000 per year and an annual increase in incidence of 3.68%. It comprises 22.8% of all local female cancers, with an annual mortality of 13.7 per 100,000 per year. This article is available only...

Unremitting pain remained a primary therapeutic challenge in cancer patients. Both opioids and non-opioids are often the main stay of therapy for many. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Many areas of medical research require the application of statistical techniques. Although most clinicians are taught some statistics as part of their basic medical training, the important role of statistics in medical research has led to many pharmaceutical companies, hospitals and medical research institutions employing full time statisticians to...

Occupational asthma is the most common occupational respiratory disease in the United Kingdom and also in Singapore. Recent estimates of the proportion of adult asthmatics where the cause could be occupational range from 4% to 9%. This article is available only as a PDF. Please click on “Download PDF” on...

Intravenous regional anaesthesia (IVRA) has a reported success rate of between 94% and 98% for upper limb surgery. Limitations to its use include the quality of intraoperative anaesthesia, tourniquet pain and lack of adequate postoperative analgesia. This article is available only as a PDF. Please click on “Download PDF” on...

The traditional statistical approach used in most areas of medical research involves what is commonly known as frequentist statistics. Bayesian methods provide an increasingly popular alternative to frequentist approaches. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Helicobacter pylori is one of the commonest infections in human, affecting 30% to 50% of people worldwide. It is associated with the development of peptic ulcer, chronic gastritis and gastric cancer and may play a role in a small subset of patients with non-ulcer dyspepsia. This article is available only...

Intravascular catheters are indispensable for patient care. Despite advances in catheter technology and patient care, catheter infection remains a significant clinical problem. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

This handbook serves an important function for Intensive Care Units in Singapore. It is a collective effort of 35 specialists in 5 different institutions in Singapore. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Although the detrimental effects of raised intra-abdominal pressure have been known for over 100 years, it is only in the last two decades that the clinical importance of these changes are being recognised.1-7 This coincides with the increasing availability of intensive care, which allows many more patients to survive...

The function of haemoglobin (Hb) is to transport oxygen to the tissues. Approximately 97% of oxygen is transported via Hb, while 3% is transported dissolved in the plasma. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Intensive care has undergone rapid technological advancement in recent years enabling complex treatment of patients of advanced age and/or with advanced chronic diseases underlying their acute medical problems. New interventions have been introduced with success determined by their ability to save lives. This article is available only as a PDF....

Technological advances over the last 30 years have had an enormous impact on the way in which medicine is delivered today. This is particularly so in the specialty of intensive care where intensivists possess the necessary knowledge and tools to prolong life in many situations where patients would previously...

In the domain of medical education of both the general public and healthcare professionals, the next decade will present both challenges and opportunities centred on training issues and technologies. Since the introduction of external cardiopulmonary resuscitation in 1960 through to the establishment of International Guidelines for Cardiopulmonary Resuscitation and...

Gram-negative bacteria induced septic shock, a condition with high mortality, is frequently seen in critical care medicine. The wall of gram-negative bacteria consists of endotoxin, which is chemically composed of lipopolysaccharide, and is extremely biologically active. This article is available only as a PDF. Please click on “Download PDF” on...

The monitoring of circulating blood volume (CBV) is important in the care and management of critically ill patients. Progressive blood volume depletion, if unmonitored and uncorrected, can result in tissue ischaemia, acidosis and systemic inflammatory response syndrome. This article is available only as a PDF. Please click on “Download PDF”...

Epidural abscess complicating epidural catheterisation was first reported in 1974. Two recent studies indicated a local infection incidence of epidural catheters of 4.3% to 12% and about 0.7% are reported to have central nervous system infection e.g. epidural abscess or meningitis. This article is available only as a PDF. Please...

Type 2 diabetes mellitus is now recognised as a metabolic syndrome and although the treatment paradigm has shifted from one that focuses solely on glycaemic control to one addressing global cardiovascular risk factors in a particular individual, glycaemic control remains one of the key challenges that the physician faces...

Stroke is the fourth leading cause of death and a leading cause of morbidity in Singapore. The number of hospital admissions for cerebrovascular disorders has been rising dramatically over the last few years, exceeding 10,400 in 2001. This article is available only as a PDF. Please click on “Download PDF”...

Laryngospasm occurring at extubation is not an uncommon complication seen with use of endotracheal tubes and laryngeal mask airway. We report a case of laryngospasm on extubation of a Benjamin jet tube resulting in pulmonary haemorrhage. This article is available only as a PDF. Please click on “Download PDF” on...

There have been multiple reports of accidental subdural blocks published in the last 20 years. Majority of these have been the result of an epidural gone astray, and the lowest reported volume of local anaesthetic used was 3.5 mL. This article is available only as a PDF. Please click on...

Epidural analgesia has been shown to provide excellent pain relief following thoracotomy, abdominal and other surgery. Studies have shown improvement in specific variables with epidural analgesia; and effective postoperative pain relief is a prerequisite to attain improved postoperative outcome. This article is available only as a PDF. Please click on...

In an article published in this journal, Chia discusses the difference between measuring association and agreement. In this paper, we extend the discussion to the difference, in terms of the concepts as well as the practical usage, between analysing agreement and prediction. This article is available only as a PDF....

Age-related macular degeneration (AMD) is the leading cause of irreversible blindness in the developed western world, accounting for approximately 50% of all cases of registered blindness. The prevalence of AMD seems to be increasing at a rate not commensurate with the increasing age of the population, although this observation...

Cervical cancer is one of the most common female cancers worldwide. It is ranked second only to breast cancer and in many underdeveloped countries, it is the most common female cancer. This article is available only as a PDF. Please click on “Download PDF” on top to view the full...

Deep vein thrombosis (DVT), and its acute complication–pulmonary embolism (PE), is one of the most important preventable causes of death in hospital patients. It also contributes to significant morbidity in terms of post-phleblitic syndrome and chronic venous ulcers. This article is available only as a PDF. Please click on “Download...

Only until a few years ago, the only surgical alternative for patients with severe emphysema was lung transplantation. However, with transplantation, there are problems of rejection, infection, immunosuppression and declining donor pools. This article is available only as a PDF. Please click on “Download PDF” on top to view the...

Bronchopulmonary dysplasia (BPD) and chronic lung disease of infancy (CLD) are two chronic pulmonary conditions which are the result of incomplete resolution or abnormal repair of lung injury in the neonatal period. Although BPD and CLD are closely related, they have differing diagnostic criteria and the spectrum of severity...

Fractures, the most serious complication of osteoporosis, are increasing and constitute an evolving public health problem in terms of disability, mortality and cost. A paradigm shift in the management of osteoporosis has resulted from the development of techniques which can diagnose osteoporosis before fractures occur, and effective medications which...

The perioperative management of surgery for laparoscopic resection of phaeochromocytoma presents a significant challenge. Many different anaesthetic techniques and drugs have been used to control the haemodynamic fluctuations during phaeochromocytoma resection. This article is available only as a PDF. Please click on “Download PDF” on top to view the full...

Despite the highest standards of training, practice and equipment, morbidity and mortality due to anaesthesia still occur. These risks are difficult to quantify, and medicolegal considerations may limit any comprehensive study of anaesthetic mishaps. This article is available only as a PDF. Please click on “Download PDF” on top to...

In the 1970s, several studies appeared to suggest that users of oral contraceptives (OCs) were at increased risk of cardiovascular events. More recently following newer studies on lower dose OCs and re-analysis of the old studies, it was concluded that the risk of cardiovascular accidents was attributable primarily to...

Fibroids are the most common, solid benign pelvic tumours occurring in about 30% of women beyond the age of 30. They are asymptomatic in most women. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Infertility is defined as the inability to conceive after 1 to 2 years of unprotected intercourse. In general, an estimated 84% of all women would conceive after a year of intercourse. This article is available only as a PDF. Please click on “Download PDF” on top to view the full...

The understanding of hormone replacement therapy (HRT) for postmenopausal women has undergone dramatic change since the publication of the results of the Women’s Health Initiative (WHI) study in July 2002. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

Without prenatal diagnosis, 1 in 50 babies are born with serious physical or mental handicap, and as many as 1 in 30 with some form of congenital malformation. These may be due to structural or chromosomal abnormalities, or single gene disorders. This article is available only as a PDF. Please...

Cervical cancer affects >400,000 women a year worldwide, and represents a significant health issue for women. In the United States (US) however, screening programmes have reduced the incidence to 8.3 cases per 100,000 women with only 14,000 cases and 5000 deaths annually. This article is available only as a PDF....

A chromosome abnormality contributes significantly to fetal loss during pregnancy, and perinatal morbidity and mortality. The contribution of chromosomal abnormalities to fetal loss decreases as pregnancy progresses; an estimated 50% of first-trimester spontaneous abortions are due to chromosomal abnormalities. This article is available only as a PDF. Please click on...

Caesarean sections performed without medical indication, better known as maternal request caesarean sections, have generated intense debate in recent times. While uncommon in the past, a recent national audit in the United Kingdom (UK)1 revealed that 7% of all elective caesarean sections were performed for precisely this reason. This article...

Biopsy may be performed at surgery (open biopsy) or percutaneously (closed biopsy). Percutaneous bone biopsies are usually performed under imaging guidance using a variety of modalities, such as fluoroscopy1 and computed tomography (CT), and less commonly, ultrasonography (US) and magnetic resonance (MR) imaging. This article is available only as a...

In females with cancer, cervical carcinoma is second to breast cancer in both incidence and mortality worldwide. About 465,000 new cases are diagnosed each year in both developing and industrialised nations, with a higher incidence in women of low socioeconomic status. This article is available only as a PDF. Please...

Preterm birth, delivery prior to 37 weeks of gestational age, accounts for a major and disproportionate amount of infant and neonatal morbidity and mortality. Despite advances in medical technology, the prevalence of preterm birth in Singapore has increased, secondary to an increase in multiple gestations and obstetric interventions. This article...

Colorectal carcinoma is the second commonest cancer in both males and females in Singapore, accounting for about 15% of all cancer cases. The liver is the most common site of distant metastases from colorectal cancer. This article is available only as a PDF. Please click on “Download PDF” on top...

Hypercalcaemia is a relatively common clinical problem with the widespread use of routine biochemical screening. Population studies have suggested a prevalence of 3% in women and <1% in men above the age of 60 years. This article is available only as a PDF. Please click on “Download PDF” on top...

Marijuana has been used for thousands of years for both medical and recreational purposes. Because the pharmacological actions of marijuana are complex and include a unique blend of effects of alcohol, opioids, tranquilisers and hallucinogens, the clinical picture could be very unpredictable and the diagnosis is often difficult. This article...

Tuberculosis poses a very real problem to healthcare workers (HCWs). In Singapore, the prevalence of tuberculosis in the general population remains high at 44 per 100,000 in the year 2001. This article is available only as a PDF. Please click on “Download PDF” on top to view the full article.

The rates of myopia, including high myopia , have been reported to be rising to epidemic proportions in Asia and solutions to this huge public health problem are urgently needed. Many researchers agree that myopia is not determined solely by genes and that environment may play a huge role. This...

Percutaneous indwelling central venous catheters are commonly used for a variety of medical and surgical indications. There are various complications associated with the insertion of central venous lines despite the advances made in the design, material of the catheter and the technique of insertion. This article is available only as...

The realisation that students have different cognitive and learning styles has had major implications on medical curriculum design efforts. If the student’s learning style is mismatched with the teaching style or the teaching environment, the student may spend considerable effort to adapt, and this may negatively impact the student’s...

We thank Dr Nicholas Chua et al for their interest in our review article. We agree and appreciate the experience and comments by the authors regarding the usage of externalised intrathecal catheter for analgesia in cancer pain. This article is available only as a PDF. Please click on “Download PDF”...

We thank the authors for a comprehensive review on the role of interventional pain therapies used in cancer pain as well as a informative local audit using the intrathecal catheter (PORT-A-CATH® IT) implantable system (Deltec Inc, USA). This article is available only as a PDF. Please click on “Download PDF”...

Dear Editor, We presented recommendations for neuromuscular monitoring during anaesthesia, which were approved by the Council of the College of Anaesthesiologists, Singapore in September 2019 and the Council of the Academy of Medicine, Singapore in May 2021. Neuromuscular blocking drugs (NMBDs) are used to facilitate tracheal intubation and mechanical ventilation;...

Studies show that the incidence of chronic pain is approximately 18% in Australia and developed countries in Europe. In Asia, data from Hong Kong and Singapore indicate that chronic pain is experienced by about 10% of adults, with chronic pain being more common in women and older adults. In...

Chronic pain is a prevalent disease that is often diffi cult to manage. According to a World Health Organisation survey, the worldwide prevalence of chronic pain is in the range of 20% to 30%. Chronic pain disease has an impact not only on the individuals’ general health and psychological health,...

A significant proportion of patients with underlying obstructive sleepapnoea (OSA) remain undiagnosed when they present for surgery. Epidemiologic data have placed the prevalence in the general adult Western populations with a diagnosis of OSA at up to 5%,3 with a higher incidence in certain subpopulations such as males and obese...

Core temperature is the temperature of blood and internal organs; influenced by biorhythm, metabolism, activity and hormones. It is regulated within a narrow range, but this is impaired during general and/or neuraxial anaesthesia. Inadvertent peri-operative hypothermia is defined as a core temperature of <36C, the prevalence of which can...

Emergency airway management is a keystone of emergency medicine practice and critical skill in residency training. An accredited emergency attending is expected to handle difficult airways that may present unexpectedly with expertise. Flexible bronchoscopic intubation (FBI) technique is considered an important option in the management of predicted difficult airways....

Cataract surgery is performed mainly as day-case surgery, with the majority performed under regional anaesthesia. Retrobulbar block, combined with facial nerve block, provides good operating conditions, with the facial nerve block preventing blepharospasm and providing lid akinesia. This article is available only as a PDF. Please click on “Download PDF”...