JILID 6 BIL 1 MARCH 2004

JILID 6 BIL 1 MARCH 2004
Newsletter of the Malaysian Society of Anaesthesiologists and the College of Anaesthesiologists,
Academy of Medicine of Malaysia

Table of Contents

• Level of Anaesthetic Care in Malaysia...
• Withdrawal of Life Support In The Critically Ill - An Idea Whose Time Has Come
• Consensus On Withdrawal And Withholding Of Life Support In the Critically Ill
• Key Findings Of The National Audit On Adult Intensive Care Units (NAICU)
• By The Way
• Greeting From Down Under
• Calendar of Events

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Level of Anaesthetic Care in Malaysia...
PROF Y K CHAN
President, Malaysian Society of Anaesthesiologists

As we move towards achieving developed nation status by the year 2020, it is time we take stock of the level of anesthetic care in the country. We have not only to look at the availability of adequate numbers of trained anaesthesia providers, but concern ourselves with the quality of care as well, as is the case in developed countries like the US, UK and Australia.

There is still a definite shortage of anaesthetists in Malaysia. We have only about 360 specialist anesthesiologists in this country of 22 million. This works out to a ratio of 1 anaesthetist to 61,000 population. Australia has a ratio of 1 in 20,000 and Canada 1 in 30,000. Our Ministry of Health is working towards a ratio similar to that in Canada, meaning that the number of anaesthetists required would need to be double that at present. All the 3 main universities are producing specialists and we have a combined output of about 20 - 30 anaesthetists per year. All things remaining stagnant, we can project that in about 16 years time, by 2020, we will have achieved this target. However, life is not so simple, and population increase, retiring anaesthetists and migration, among other things, will ensure that these plans will go awry. So, we take pre-emptive measures to further increase the numbers by encouraging the Ministry to increase the intake of anaesthetic trainees, and also encourage trained specialists working abroad to return home to take their rightful places in the anaesthetic community.

At present, there is a disparity in the quality of care based on geographical considerations. In East Malaysia, there are still areas where anaesthetic services are provided mainly by hospital assistants. The exact numbers are not easy to determine although it is believed to be dwindling as more specialist anaesthetists are sent by the Ministry to fill up vacancies. This shortage pervades in rural districts throughout Malaysia because many specialists, usually posted against their will, are reluctant to remain for long due to envisaged limited financial, professional, family and social prospects.

There is also a disparity in the quality of care between the government and the private sector. The majority of care in the private sector is provided by specialists, whilst in the government sector, a fair amount of care is provided by medical officers undergoing training in anaesthesiology. These trainee anaesthetists are supervised by specialists, although this supervision may occasionally be from a distance, especially when the numbers are short!

Whilst the care in the private sector is laudable, being manned by specialists in the field, there have been recent anxieties expressed of some hospitals condoning the practice of one anaesthetist looking after two patients undergoing surgery simultaneously. Since the anaesthetic community of our country (represented by the Malaysian Society of Anaesthesiologists) has adopted internationally acceptable standards in minimal monitoring of patients under anaesthesia (Recommendations for Standards of Monitoring During Anaesthesia and Recovery, 1997), it is hard to accept this practice, which so clearly violates the basic tenet, being one patient to be looked after by one anesthetist.

As we labour to improve our level of care, we may also have to actively regulate ourselves to ensure that we do not comprise a principle that we have so arduously fought for (in the government sector). We are sincere in our efforts to provide safe and quality care to our patients. We, in keeping with the rest of the anaesthetic communities around the world, take pride in the fact that we are the leaders in the practice of all aspects of safe medicine in Malaysia. While these principles are sometimes impossible to uphold in parts of the country facing a shortage of basic medical care, it is time we adopt a mindset placing safety of our patients first and foremost, and try our utmost to do what we know to be right. In this way, and perhaps with a little peer pressure, we will be able to achieve the highest of standards in anaesthetic practice in the country, which other medical communities can do no better but to emulate.

The practice of anaesthesia is continuously changing. New techniques appear regularly, and are absorbed by the community without much effort. This is made very much easier by members who have traveled abroad to learn these techniques, who return home to generously share their hard earned knowledge. Others have seen fit to invite the experts in the various fields to come to our shores to share their expertise in regular workshops and meetings, so that the wider anaesthetic community can benefit.
In keeping with our collective effort, the level of care in many parts of the country is commendable and is on par with that of the developed world.

Whilst we are going in the correct direction in our endeavours to provide world class care, let us nudge each other to do the correct thing by our patients, so that we can stand tall in the international community, with the knowledge that we are doing our best to provide the best in anaesthetic care in our country.

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Withdrawal of Life Support In The Critically Ill - An Idea Whose Time Has Come
By Dato Dr K Inbasegaran
Chairman
Consensus Committee on Withholding and Withdrawal of Life Support
College of Anaesthesiologists, Academy of Medicine of Malaysia

In this issue of the Berita you will find a full text document of a Consensus statement on withdrawal and withholding of life support in the critically ill adult patient. Sometime
in 2000, the College of Anaesthesiologists in considering various Clinical Practice Guidelines included this topic.

When I first formed a committee to discuss this, it very quickly became apparent that it had to be a consensus statement rather than a clinical practice guideline as it had no evidence base to speak of. However it was important to have some sort of policy when managing patients who have no hope of recovery in intensive care units. The scope was further narrowed to adult patients as paediatric cases had a different set of principles to consider and it was far more complex. The original team that drew up the consensus statement came from the various disciplines in Hospital Kuala Lumpur including surgery, medicine, intensive care, neurology and neurosurgery and of course anaesthesia. The document was then circulated to a much wider group within the country to get feedback and opinions and also presented at the last combined scientific meeting of the MSA, College and CCMS. It has been now been handed to the College of Anaesthesiologists for adoption as one of the Practice Guidelines.

Why withdrawal and withholding of life support? Intensive care is now one of the fastest growing specialities and there is a constant and strong demand for beds. Inspite of many new beds being made available in our public hospitals, there does not seem be enough of them. Many of us are also aware that in so many instances patients who have no reasonable chance of recovery or to have some sort of meaningful quality of life are being kept alive by life support technology that is now available. Decision making as to who should be given ICU care and who should not be considered is always a very difficult and contentious issue in medicine. The cost of intensive care is astronomical, and rising all the time due to new technologies and this cost will eventually come from hospital and health budgets. It may deprive many more deserving health programmes as seen in some countries like the U.S. It involves many ethical issues and often involves multiple caregivers who may have differing thoughts on this. Anaesthesiologists and intensivists (many of whom are drawn from anaesthesology) are not the primary team of caregivers but look after patients on their behalf. Our thoughts and feelings on this issue, which are drawn from experiences in working in the ICU or from meetings of like minded people, may not readily find acceptance amongst the majority of primary care givers. Thus the need for a consensus statement, that involves a broad section of disciplines that admit patients into intensive care.

If we follow the trends in many developed countries (Malaysia will be soon one of them) the majority of patients in the ICU die because of a clinical decision to withdraw, withhold or limit therapy. It represents a dramatic shift in thinking from trying to save lives at all costs to saving only those who have a chance of recovery.

Preparing this consensus is the easy part. The most difficult part will be to implement these guidelines across all intensive care departments in all types of hospitals. It will require, as often said, a combination of political or maybe clinical will and a shift in thinking amongst doctors. I am quite confident that this will happen just as in other countries as this consensus is one whose time has come.

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Consensus On Withdrawal And Withholding Of Life Support In the Critically Ill
DRAFT DOCUMENT

INTRODUCTION

One of the major advances in medicine occurred soon after the last World War when life supporting technologies were developed and continued throughout the 20th century. Intensive care units were developed which with life support technology could save many ill patients as well as allow major procedures in ill patients to be carried out. Before the mid sixties the goal of medicine was to use whatever it takes to preserve life. However it became apparent to most caregivers in the intensive care setting that significant numbers of patients would eventually die because of the underlying disease and all that these new technologies were doing was to prolong the process of dying. In the nineties the concept of a dignified death and the medicalisation of death became more acceptable. The medical community again particularly in the West learnt to accept that caregivers have to actively help patients to come to terms with terminal illnesses and minimise aggressive intervention such as CPR and ventilation in many of these cases.


GOALS OF MEDICINE AND INTENSIVE CARE

The primary goal of medical treatment is to benefit the patient by restoring or maintaining the patient's health as far as possible, maximising benefit and minimising harm. If treatment fails, or ceases to give a net benefit to the patient (or if the patient has competently refused the treatment) that goal cannot be realised and the justification for providing the treatment is removed. Unless some other justification can be demonstrated, treatment that does not provide net benefit to the patient may, ethically and legally, be withheld or withdrawn and the goal of medicine should shift to the palliation of symptoms.

The goal of intensive care is to treat reversible life threatening conditions so that patients can recover and continue to enjoy a reasonably good quality of life. In many of the developed societies and broad consensus has emerged during the past 30 years that it is appropriate to withhold or withdraw life support therapy in many clinical situations. The consensus did not come about easily. There had been much debates and controversies within the medical community. It had also raised numerous societal, ethical, religious, legal and economic issues in the last two decades. Today up to 90% of deaths in critical care units in the West are as result of the caregivers to limit or withhold therapy. In many of the consensus guidelines there is no moral difference between the decision to withhold or to withdraw life support.

In Malaysia the medical profession is still a little behind in accepting many of the concepts that lead to the limitation or withdrawal of intervention in certain categories of patients. However with the rapid growth of both public and private health care there is also an increase in the demand for intensive care which is becoming very expensive to provide. Although economic factors are not a criteria for limiting therapy it is also justifiable for the medical community to have a consensus as to the kind of patients who will truly benefit and those who will not benefit from intensive care therapy.

Scope of guideline

This consensus is directed to adult patients who are critically ill and are being treated by various means in critical care or intensive care units. The consensus is not directed
at children, patients who are receiving treatment in conventional wards, patients undergoing palliative therapy in homes or nursing homes. There are also a category of patients who will be receiving life support in conventional wards due to lack of intensive care beds at the moment and this guideline can also be applied to them as well.

Definition

Life support treatment or life prolonging treatment refers to all treatment which has the potential to postpone the patients death and includes cardiopulmonary resuscitation, artificial ventilation, specialised treatments for particular conditions such as chemotherapy or dialysis, vasoactive drugs, antibiotics when given for a potentially life-threatening infection and artificial nutrition and hydration.

Artificial nutrition and hydration refers specifically to those techniques for providing nutrition or hydration which are used to by pass a pathology in the swallowing process. It includes the use of nasogastric tubes, percutaneous endoscopic gastrostomy (PEG feeding) and total parenteral nutrition.


PRINICPLES OF WITHDRAWAL OR WITHHOLDING LIFE SUPPORT

Withholding or withdrawal of life support is the process by which various medical interventions are either withdrawn or withheld with the expectation that the patient will die of the underlying disease. Palliative care is the prevention or treatment of pain, dyspnea and other kinds of suffering and providing basic care for patient comfort. Both these closely related processes must be supported by ethical principles in medicine.

The principles of withholding or withdrawal of life-support should be based on the six basic principles of medical ethics. These are:

1. Preservation of life which is frequently tempered by the second principle.
   
   

2. Relief of suffering - This covers distressing symptoms such as pain, distress caused by anxiety etc.
   
   

3. First do no harm- Non maleficence
   
   

4. Respect the autonomy of patients - Patients have the right to inform choices in treatment and have the right to refuse or accept a given mode of treatment.
   
   

5. Concept of a just allocation of medical resources - This is a concept that it must be good for the majority in society. Allocation of scarce and expensive resources for potentially non-salvageable patients limits the amount that can be utilised on potential survivors. Allocating scarce and expensive resources like intensive care for potentially non-salvageable patients limits the amount that can be spent on potential survivors. Increasing medical costs also make some form of rationing inevitable. Intensive care is extremely expensive and economic considerations form part of the consideration in ethical discussion regarding intensive care management.
   
   

6. To be truthful to the patients and family or surrogates as to the prognosis of their loved ones.

CATEGORIES OF PATIENTS TO BE CONSIDERED FOR WITHDRAWAL OR WITHHOLDING OF LIFE SUPPORT

1. A patient with imminent death
   A patient facing imminent death has an acute illness whose reversal or cure would be unprecedented and will certainly lead to death during the present hospitalisation within hours or days, without a period of intervening improvement. This is a patient who is clearly not responding to therapy, and is reasonably unlikely to survive with continued therapy. Futility will be determined by prolonged multiple organ system failure. Further intensive care management with four or more organ systems failure for over 3 days is futile as shown
   
   

2. A patient with terminal condition
   A patient with a terminal condition has a progressive, unrelenting terminal disease incompatible with survival longer than 3 - 6 months. Life support treatment should be provided to treat superimposed, reversible condition only with clear and achievable goals in mind. Cardiopulmonary resuscitation should not be instituted in a patient with terminal, irreversible illness whose death is expected and in whom resuscitation represents a violation of the right to die with dignity.
   
   

3. A patient with severe and irreversible condition impairing cognition and consciousness but death may not occur for many months
   This category includes patients with persistent vegetative state or severe dementia. In many of these cases who are nursed in wards, the decision is often not to initiate CPR or other rescustitative measures in the event of a downturn in the patients condition. Although these patients are not recipients of intensive care the treatment decision by caregivers should include one not to initiate resuscitation i.e. Do not resuscitate or DNR orders.
   
   

4. A competent patient who has stated his/her wish not to initiate or who has stated his/her wish to have life support withdrawn
   This will include patients who when competent have given clear wishes before the present episode of illness or those who have given do not rescustitate orders (DNR). The principle of patient autonomy requires that physicians respect the decision to forego life-sustaining treatment of a patient who possesses decision-making capacity. The medical team however has to be very certain that this is indeed the case and in the case of doubt should disregard previous wishes.
   
   

5. A patient who is brain dead
   Brain death as death is now recognised as death in many countries including Malaysia and it is perfectly legitimate and legal to withdraw all forms of life support from such patients once a diagnosis is made. Life support is only continued in the event where consent for organ procurement is needed.

OTHER DECISION MAKING AIDS IN WITHDRAWAL OR WITHHOLDING

Scoring systems
Recently various scoring systems have gained increasing importance as decision making aids. Among the multitude of predictors available the best known is perhaps the APACHE (Acute Physiological and Chronic Health Evaluation) which is now available in version III. There are also others such as SAPS (Severe acute Physiological Score), TISS (to indicate the number of interventions), Trauma scores and many more. Regardless of the accuracy of these predictors of outcome these can only aid in decision making. They should not replace conscientious medical decision making taking other factors into account.

Quality of Life
Patients in intensive care who are unlikely to regain some form of meaningful life as we know it pose a particularly challenging problem. These include patients who are in vegetative states secondary to severe hypoxia. Most intensivists have resisted managing such patients in the ICU as there is no meaning these individuals. There are consensus by the American Thoracic Society in 1991 that there is no use in treating them in intensive care settings in the hope of just prolonging biological life. At the same time it will be an easier decision not to admit these patients to an intensive care unit rather than taking them out of one. In the US many of these have finally been decided by the courts but in the local context we do not want to involve the legal profession in this at our state of development. (see above in categories of patients to be considered for withdrawal)


STEPS IN DECISION MAKING TO WITHDRAW OR WITHHOLD LIFE SUPPORT

1. Medical consensus - It is essential that the primary physician and the intensive care team have agreed on a consensus before any decision is taken. In certain cases more than one primary team may be involved and it is essential to have the consensus of all the caregivers. In the event of absence of medical consensus, active treatment is continued. A further time period of active treatment is set and subsequent review of management plan. The primary physician in our context refers to the specialist or consultant under whose department the patient is admitted.
   
   

2. Nursing consensus - Nurses play a key role in intensive care and are in continuous contact with patients and relatives. They sense of sympathy for the patient is often stronger and it is essential that they also are in support of the decision to withhold or withdraw therapy.
   
   

3. Communication - In the unfortunately rare event that the patient is fully rational, awake and competent the communication should be with the patient. More often in the intensive care setting the discussion is with the relatives. A clear and honest medical opinion should always be given the family. To avoid any seeming conflict of opinion, it is best that a single resource person deal with the family, while the others can be present. The physician orchestrating discussion with either the family or patient must be someone who is involved in the active care of the patient. This key person must be someone who has been frequently communicating with the family and has a rapport with them. This task should be done by a senior medical staff and should never be left to the most junior doctor in the unit.
   
   

4. The family should be given time to come to terms with the impending loss of the their loved ones. They should be allowed to ventilate their feelings and be as often as possible with the patient.
   
   

5. Time limited goals should be established by the clinical team and this must be based on clinical judgement and best medical evidence. Families will usually agree to discontinuation of life support systems after a reasonable trial of therapy has demonstrated failure. In the event of disagreement between the physician and the patient or family, the assistance of an individual consultant and a patient representative is often helpful to reach resolution amongst all parties. An institutional committee such as an ethics committee may be involved if disagreements are not resolvable.
   
   

6. In dealing with the family they should not be rushed as the mental shift from hope and cure to accepting the inevitable will not occur quickly. All explanations should be kept as simple as possible (in a manner easily understood by lay persons). Facilities for discussion such as a private counselling room must be made available and the designated staff should help them with any clarifications if needed. If cadaveric organ donation is being planned these discussions should also be approached with great degree of sensitivity.
   
   

7. The decision and processes taken must not be conflict with the laws of the country. Although active termination of life i.e euthanasia or assisted suicide may be acceptable legally in some countries it is unlawful here.

MANAGEMENT PLAN FOR WITHDRAWAL OF LIFE SUPPORT

While the medical team puts its plan for withdrawal into operation the exact mechanics of this need not be told to the family or patient. It is however important to emphasise that the patient will be comfortable and will not be in distress or pain etc during the process. There should be great sensitivity to cultural norms and dignity to the dying patient. There should be five main objectives for ensuring a good end of life care;

1. Receiving adequate pain relief and relief of any other distressing symptom such as dyspnea

2. Avoidance of prolongation of dying

3. Active sense of control over events

4. Strengthen relationship among loved ones

5. Relief of burden amongst caregivers and the loved one

THE PLAN FOR WITHDRAWAL WILL GENERALLY HAVE THE FOLLOWING COMPONENTS

1. All basic support such as pain control, hydration and nutrition, patent airway and freedom from breathlessness must be ensured to keep the patient comfortable.
   
   

2. All life support must be continued until the patient and his family had enough time together.
   
   

3. Removal of life sustaining therapy are removed in an escalating fashion after ensuring the patient is both pain free and free from any form of discomfort.
   
   

4. Support therapies such as inotropes and other medications are withdrawn first. Usually in a patient with multi organ failure this alone may sometimes result in death.
   
   

5. Relief of pain and discomfort - At this stage, most ICU patients are already receiving some form of sedation and analgesia. These drugs are continued, often at higher doses.

Opioids are the most useful drugs for relieving pain in terminally or critically ill patients. Morphine is the most common opioid and there is no maximum dose when used in these situations. In patients who have not previously received opioids, it should be titrated and rapidly increased until symptoms of pain and dyspnoea are relieved. Benzodiapines should be used to treat anxiety until during the dying process.

DISCONTINUATION OF MECHANICAL VENTILATION

Withdrawal of mechanical ventilation is probably viewed as more problematic than withdrawal of other interventions. Discontinuing mechanical ventilation does not differ morally from forgoing dialysis or cardiopulmonary resuscitation. There are two strategies for the withdrawal of mechanical ventilation

1. Terminal weaning i.e. gradually reducing the ventilator rate, positive end-expiratory pressure, oxygen levels or tidal volume while leaving the endotracheal tube in place
   
   

2. Extubation after appropriate suctioning

There is no significant difference in patient comfort between the two methods. However, the endotracheal tube should generally be left in place while ventilatory support is reduced for the patients with difficulty in clearing their secretions or protecting their airways. Regardless of the method, frequent assessment of the patients comfort during and after withdrawal of the ventilator is most important. Intravenous opioids and benzodiazepines should be used liberally to relief dyspnoea and other discomfort.

The alarms on the monitors should be disabled. The family should be allowed to be with the patient if they choose to. The physician should be present to ensure the patients and familys comfort during withdrawal of mechanical ventilation.

CONCLUSIONS

Today the medical technology available has made it possible for many patients in intensive care to be successfully treated and given an acceptable quality of life. At the same time the intensive care teams and other caregivers have recognised that in many cases one should be aware of the limitations or futility of trying to achieve a cure and turn towards allowing the patient a dignified and peaceful death. This paradigm change in thinking amongst doctors has taken many years and is here to stay. Although these are difficult decisions, discussion amongst doctors and other caregivers on this issue should constantly be encouraged to allow acceptance of a consensus on limitation or withdrawal of life support therapy.

References

1. American Medical Association Guidelines on Withholding or Withdrawing Life sustaining treatment. June 1994.
   
   

2. BMJ Guideline on End of Life; BMJ Publishing Group 14 October 2000.
   
   

3. Recommendations for end of life care in the Intensive care unit; The Ethics Committee of the Society of Critical Care Medicine; Critical Care Medicine 2000 Vol 2; 9; No 12 Pg 2332-2349.
   
   

4. Increasing incidence of withholding and withdrawal of life support from the critically ill. Am J of Respir. Crit Care Med; Vol 155. No 1. Jan 1977; 15-20
   
   

5. Ethical issues in Anaesthesia - Edited by Micheal Vickers, Wendy Scott; published by Butterworth Heinemann 1994.
   
   

6. John Edward Ruarn; Thomas Alfred Raffin; Standard University Medical Center Committee on Ethics; Initiating and withdrawing Life support - Principles and Practice in Adult Medicine; NEJM; 7 Jan 1988; Vol 318; Pgs 25-30.
   
   

7. John Luce; Making Decisions about the Forgoing of life sustaining therapy; Am J. Resp Crit. Care Med; 1997; Vol 156 pp 1715-1718.
   
   

8. Statement on the Limitations of Life Sustaining Therapy in the Intensive Care Unit; Intensive Care Committee of the Hong Kong College of Anaesthesiologists;
   
   

9. January 2002.

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Key Findings Of The National Audit On Adult Intensive Care Units (NAICU)
By Dr Ng Siew Hian
National Committee for NAICU, Ministry of Health Malaysia

Established in July 2002, the National Audit on Adult Intensive Care Units (NAICU) is an on-going audit of the intensive care service in Ministry of Health hospitals under the purview of the Medical Development Division. It is coordinated by a National Committee and currently, it involves the general ICUs of fourteen major state hospitals. The audit is supported by the Malaysian Society of Anaesthesiologists through a yearly grant of RM10,000 in year 2002 and 2003.

The following are excerpts taken from the audits First Report under the sections Summary and Recommendations. The findings were based on a survey of intensive care facilities conducted in August 2003 and a review of 6739 admissions from 1.7.2002 to 30.6.2003. Copies of the First Report are available at the anaesthetic departments and hospital libraries of Ministry of Health state hospitals.


SUMMARY

The key findings of the audit are summarised below. Unless specified the findings refer to the fourteen ICUs in the state hospitals.

1. Resource survey

1. As of August 2003, the total number of intensive care beds in Malaysia was 509 and only 54% of these beds were in the government hospitals.

2. The ICU bed to population ratio for the country is 2 : 100,000 population.

3. ICU beds made up only 1% of all hospital beds.

4. The bed occupancy rates for the past 5 years were above 80%.

5. Almost 5,000 patients i.e one out of every two deserving patients were denied admission to ICUs last year.

6. The nurse-to-patient ratio was 1 : 1.1 during the morning and afternoon shifts and 1 : 1.5 during the night shift. 36.5% of nurses working in ICU had undergone post-basic training in intensive care nursing.

2. Clinical practice

1. The mean age for all patients admitted to ICU was 40.7 ± 21.8 years. For the adult population (equal or more than 18 years old), the mean age was 46.6 ± 18.2 years.

2. The average length of ICU stay was 4.9 ± 7.4 days.

3. The average length of hospital stay was 19.8 ± 21.7 days.

4. About two-thirds (65.7%) of admission to ICUs were from surgical-based disciplines.

5. There were an almost equal number of admissions of non-operative (47.1%) and operative patients (52.9%). 36.2% of ICU admissions were emergency operative cases.

6. About one third of patients admitted were without organ failure while another one third had single organ failure with respiratory failure being the commonest followed by cardiovascular failure.

7. The commonest main diagnosis leading to admission was sepsis, followed by trauma-related injuries.

8. For operative cases, the most common surgery performed were laparotomies, craniotomies followed by orthopaedic operations.

9. The average SAPS II score was 36.1 ± 18.1, which carried a predicted risk of hospital death of 35.9%.

10. 82.9% of patients required invasive mechanical ventilation with an average duration of 5.2 ± 8.3 days.

3. Clinical indicators

1. The incidence of ventilator-associated pneumonia was 26.9 per 1000 ventilator days or 23.2%.

2. The incidence of unplanned extubation among the patients who were mechanically ventilated was 3.5% or 0.7 per intubated day.

3. The incidence of pneumothorax associated with central venous catheter insertion in ICU was 1.1%.

4. Outcome

1. The in-ICU mortality rate was 22.1% while in-hospital mortality rate was 31.1%.

2. The observed mortality for patients with SAPS II prediction was less (31.6%) than predicted (36.3%), giving a standardised mortality ratio (SMR) of 0.85.

3. In-hospital mortality for patients without organ failure was 8.6%. The mortality rates for single, two, three, four and five organs failure were 29.0%, 59.8%, 75.5%, 86.1% and 90.5% respectively.

RECOMMENDATIONS

The following recommendations aim to overcome the shortage of beds and to improve the performance of ICUs.

1. Increase the number of ICU beds by expanding existing facilities or establishing new ICUs
   
   This can be achieved through the mid-term review of the 8th Malaysian Plan and Dasar Baru over the next five years. Special funding from the government may be required for this purpose. A total of 100 beds need to be urgently created to meet current demands.
   
   

2. Ensure efficient bed management

1. Written admission and discharge guidelines
   For effective use of expensive intensive care resources, only patients who are going to benefit from intensive care management are admitted. When resources are scarce, it is necessary to incorporate triage guidelines to admit patients who will benefit the most.
   
   There is a need to have clearly written guidelines in every unit to ensure consistency in care.
   
   

2. Conduct regular in-unit audit
   Regular in-unit audit should be conducted to identify the percentage of ICU beds that are occupied by patients:
   
   Who are too ill and are not expected to recover from their illness as these patients should not be admitted to the ICUs.
   
   Who are too well to benefit from intensive care as these patients can be cared for in the ward or high dependency areas.
   
   Whom intensive care admission are required following inadequate surgical or anaesthetic management

3. Optimise utilisation of resources and staff

1. Integrated ICU and HDU
   There are some high risk patients who require high dependency care, not necessarily intensive care. Many intensive care patients need to be cared for in a high dependency area before being discharged to the wards. Having high dependency beds which are integrated into the intensive care unit area is more cost-efficient for staffing and equipment as beds are interchangeable within the same unit or in adjacent areas and patients level of care can be upgraded or downgraded wherever appropriate. It improves continuity of care for patients and reduces the anxieties among patients and relatives associated with moving from one environment to another.
   
   

2. Networking of ICUs within a geographical region
   ICUs within a geographical region can form a network where deserving patients who cannot be admitted to an ICU will be transferred to another ICU where a bed is available. Hospitals in the Klang Valley and its vicinity i.e. Hospital Kuala Lumpur, Hospital Selayang, Hospital Tengku Ampuan Rahimah, Klang, Hospital Kajang, Hospital Putrajaya and Hospital Seremban have been identified to form a network for this purpose.

4. Minimise the length of stay through efficient treatment

1. Closed system ICU
   The closed system of organisation practised in some ICUs should be extended to all ICUs in the country. In the closed system, the ICU clinicians take responsibility for clinical management of the patient. This helps to ensure that there is consistency and continuity of care and has been shown to improve performance compared to the open system concept. More clinicians should be trained in intensive care medicine so that all ICUs can practice the closed system of organisation.
   
   

2. Clear management plan for every patient
   The intensive care environment is a complex network involving different people and effective communication is most important to achieve the best outcome for patients with the shortest length of stay. For each patient there should be a clear management care plan which is regularly reviewed and updated.
   
   

3. Continuity of nursing care
   To improve continuity and quality of nursing care, the same nurse should be assigned to take care of the same patient as long as she is on-duty and the patient is in ICU.
   
   

4. Improve nosocomial infection control measures
   Since nosocomial infections prolong patients length of stay in the unit, it is imperative to ensure that infection control measures are strictly adhered to in the unit.
   
   

5. Recognise when continued intensive care is futile
   Although intensive care is often successful at saving and prolonging life, it can also prolong the process of dying in some. Withholding or withdrawal of treatment guidelines are needed to:

• place limits on treatment for those patients for whom there is little or no hope for survival

• cover the conditions in which treatment should be withdrawn or withheld

5. Prevent preventable admissions to ICU
   
   Improving care outside ICU can reduce demand by preventing some patients from deteriorating into a need for intensive care.

1. Training of ward staff
   Ward nurses and junior doctors need to be trained to recognise the signs of deterioration in patients and to seek early specialist or consultant advice.
   
   

2. Medical Emergency Team (MET) or Patient-at-risk
   Team The team is led by the ICU doctor and when alerted by the ward staff attends to the patients in the ward when their physiological parameters fall outside certain ranges. These patients are managed aggressively in the ward to prevent them from deteriorating into a need for intensive care.

6. Extend NAICU to all ICUs
   
   NAICU should be extended to all ICUs in the country including the private hospitals to provide a more comprehensive picture of the intensive care service in the country.

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By The Way
Editor

When anaesthetists scan say no to surgery

In response to a query from one of our readers regarding the accuracy of the statement made in the above article published in the last issue of Berita Anestesiologi which stated &Here (in Malaysia) we tend to be a little conservative and in public hospitals we have arbitralily set the age of consent as 16 years&

Dato Dr Inbasegaran clarifies that actually there is no legal age for consent for surgery in Malaysia. On consulting some members of the legal profession, it would appear that in this country, any person of sound and mature mind can give consent, with no specification with regards to age. With the lack of legal guidelines, many hospitals have resorted to using their own age of consent, the majority opting for the upper limit ie. 18 yr, although he has seen some as young as 16 yr. Legally this cannot be challenged as a person of 16 may be of sufficient maturity to make a decision of this kind. To date Dr Inba has no knowledge of this being challenged in case law in this country.


Maintenance of Professional Standards (MOPS)

More news. There was no dissent from members after circulation of the document in the last issue of Berita so the Exco has decided to take the plunge and implement the MOPS programme in our MSA. We are looking into providing a web based format, where information can be entered directly online into a personal MOPS diary and the data processed for you to monitor your own points. Participation is voluntary and we hope to have it up and running soon. Keep an eye out for the official launch of the MOPS programme later this year. More to come &. watch this space.


History of Anaesthesia

For your information&.. Things are progressing smoothly and at the current rate, we have been told to expect the first draft by years end. Keep up the good work Dato Inba, Dr Joseph and Prof Tan!

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Greeting From Down Under
By Dr Thong Chwee Ling

Dr Thong C L is a lecturer in the Department of Anaesthesia, Faculty of Medicine, University Malaya, who is currently in Australia. She was offered a post as registrar in the St George Hospital, Sydney for a one year rotation beginning this January. Follow her experiences and exploits in Australia throughout this year for some refreshing insights on life as a young registrar overseas. Feedback, queries or just contact is welcome at chwee69@hotmail.com.

13 February 2004
Gday, mates! Greetings from Sydney, Australia. I cannot believe it has been exactly a month since I landed at the Sydney airport, and have worked the last four weeks at St George Hospital in Kogarah, a suburb to the south of the city.

I had jumped at the offer of a post as a registrar in this hospital and took a years leave from University Malaya Medical Centre. I have not regretted that decision at all; so far it has been an interesting experience, both personally and professionally.

I had been prepared for some amount of culture shock, but did not expect it to be severe as I had visited Sydney ten years ago as a tourist. However, I had not expected so many Asians and Middle Easterners in the city and its outskirts. In the land of plenty, with its warm and friendly people, it was a little disconcerting to see homeless people living on the streets of Sydney. I was also a little concerned by the number of female smokers I met. The most disturbing observation was the number of obese people on the streets - I found myself unconsciously examining their airways from a distance! (I am happy to report that generally, Caucasians are easy to intubate. Despite their larger frames, their Malampatti and Cormack-Lehane scores are low)

My mission during my first week in Sydney was to find a place to stay.

I found a unit a 5 minutes walk from St George Hospital. It was a blessing in disguise, as the citys rail service plunged into chaos a week ago due to train drivers launching a
work-to-rule campaign, resulting in many regular train services being cancelled or delayed. I found, to my delight, that landlords pay the water bills. Most units are unfurnished, except for kitchens, which usually come complete with cabinets, stoves and dishwashers. (IMHO, a useless contraption which consumes water and electricity) One should always check for fly screens on doors and windows, otherwise one might end up performing the Aussie wave endlessly. [definition of Aussie wave - the movement of hands in front and around ones face or head in a futile effort to ward off flies and other insects]

Next came the problem of having to furnish the unit. There are many bargain stores in
Australia, and as long as one is not fussy, one can furnish a whole unit with second or third hand goods relatively cheaply. One just needs to stop multiplying all prices by a factor of three. One can easily find used cutlery and crockery sets as well as used irons, kettles, pots and pans. It was with a sense of national pride that I bought a bed and a Sony television, both made in Malaysia. I was delighted when the TV was finally delivered to my unit, but my joy ended rather quickly when I discovered that TV sets are delivered without antenna cables! I spent the first night in my unit staring at the blank screen && fortunately my boss loaned me a cable the very next day and I was soon enjoying the uncensored shows on the idiot box. I even enjoy watching the TV ads - a great source of education of the Aussie way of life. One can buy a new car for
under AUD20,000 including air. Huh, air? In the tyres? It took me three weeks to figure out they were talking about air conditioning.

Food? Not a problem. It is cheaper to cook than to eat out. It is ridiculously easy to find Asian sauces and spices, should one get tired of Australian food. My kitchen has been stocked with oyster sauce, soy sauce, instant noodles and other spices. One can easily find kailan, choysum, and whatever green leafy vegetables one fancies. But beware! Most kitchens come equipped with electric stoves with flat cooking surfaces - forget about getting a wok; a flat-bottomed pan would serve you better. Dont even think of making yourself a plate of char kway teow using the electric stove. One also needs to check with the neighbours too - some may find the smell of your heavenly rendang offensive.

The biggest changes in my life? Having to walk and to rely on public transport. I had been so reliant on my wheels back home; I now walk everywhere come rain or shine (and winter, 5 months from now). Having to apply sun block and lip balm before leaving
home, and moisturizers at night, no thanks to the weather.

What about the workplace?

I reported to the operating theatre on the first day and it was quite a change to see my new colleagues trooping in, casually dressed in jeans, T-shirts, spaghetti straps. A female consultant walked into the room in her scrubs - which consisted of a blue knee-length dress, complete with a pair of red tights. In contrast, some of the male consultants would attend the weekly hospital CME meetings in suits and neckties.

The biggest surprise? One could actually walk into the OT without having to change ones shoes. Shoe covers are optional, used only to protect the shoes. I wore my pair of Hush Puppies at work for the first couple of days, feeling decidedly strange, before I purchased a more suitable pair from a bargain store.

A colleague of mine from Singapore faithfully brings a pair of sneakers to work daily.

The biggest problems at work? Firstly, cannulation of blood vessels. Aussies are very concerned about safety in the workplace, and in their eagerness to minimize the danger of needlestick injuries, a variety of needle-safe gadgets are used. I was thoroughly embarrassed on my first day at work as I poked a young man with huge veins three times in vain before seeking help from a colleague. Wait till you see the stuff we use for arterial lines. Secondly, having to get used to the Aussie accent. I go I beg your pardon? more often. Premed rounds and running the preadmission clinic can be a nightmare. Patients will give you a list of drugs in their trade names, and I would have to ask them to spell it out before thumbing the MIMS to realize they are on enalapril, statins or some other common stuff. Not uncommon to find patients on antidepressants and painkillers. Surgeons are just as bad. A shot of cefothin Huh? Was that cefoten or cephalothin? The neurosurgeon requested for man-in-toll; luckily I am sufficiently experienced to expect that she wanted mannitol. Phone calls are worse - I cannot read lips nor cue on body language to understand what the caller is trying to tell me.

The biggest change? The mode, median and mean ages of my patients have shown a significant shift to the right. Almost all geriatric patients live independently or with a partner. (Always use the politically correct term partner and not spouse) These patients come for CABG, clipping of aneurysms, repair of AAA, besides the usual surgeries for joint replacements, fractures and malignancies. Many general surgical and
gynaecological procedures are performed laparoscopically. Just had a 72-year young lady coming in for laparoscopic pelvic floor repair today. Unfortunately the surgeon perforated her bladder, which he then repaired laparoscopically as well. Be prepared for a bigger drop in blood pressure after induction as surgical stimulation will be slow in coming. Positioning, cleaning and draping may feel as if it takes forever, especially if you had gained most of your anaesthetic experience in busy places like HKL or HSAJB. If you are anaesthetizing an open procedure, do turn off the volatiles a little earlier - most skins are closed with staples.

Patients are generally better informed, and most of them can rattle off their medical history and allergies. Central neural blocks are unpopular, except in the labouring patient. Anaesthetizing a patient for LSCS may turn out to be a nerve-wracking experience for the uninitiated. The partner of the patient (and sometimes, another companion as well) is allowed into the OT and gets a seat at the spot where you normally expect your assistant to stand at induction. God help you if the patient runs into trouble and needs conversion to GA in a hurry.

Need to perform a procedure? I find the motion sensors used to turn on the taps really cool. But dont forget to check the water temperature first, otherwise one may end up with scalds.

LMAs are disgustingly easy to position. The stem could be sticking out halfway and yet the patient will still have a decent airway. Do that with one of the

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