Dranor's Substack: Anaesthesia & Critical Care

Sometimes, during routine discussions about difficult cases, you can see the weight a person is carrying long before they say anything. A pause that stays too long. A voice that hesitates. Eyes that struggle to stay composed while recounting events that happened weeks or even months ago.

On paper, the case may already be closed. But for the person who lived through it, the moment is often still very present. And it made me think about a question we probably ask too little in our profession.

Are you okay?

When someone is going through a setback, we often sense it before they say anything. They are usually subtle.

A longer pause than usual. A colleague stares into space as if their thoughts have travelled far beyond the room. Someone who normally talks a lot becoming unusually quiet. A face that looks more tired than usual. Less attention to appearance. An unshaven beard or no makeup today. Small cues. But they tell a story.

Life places many burdens on our shoulder. People often say that looking too much into the past brings regret and despair, while looking too far into the future creates anxiety and restlessness.

Sometimes it helps to pause our thoughts for a moment. To feel numb. Not to escape the problem, but to allow the mind to breathe. Problems rarely disappear when ignored. In fact, they often grow heavier when left unspoken. or unattented.

Recognising a problem early is always better than walking around it in silence. When the truth eventually arrives, the fall can be much harder.

That is when a simple human gesture matters… a brief conversation, a hand on the shoulder, a moment of genuine concern for a friend, a colleague, or a family member.

Are you okay?

Sometimes we need someone outside our own minds to offer a clearer perspective. When we are trapped inside the turbulence of life’s problems, it can feel suffocating.

After an OT or ICU crisis.
After losing a patient despite prolonged resuscitation.
After a long and exhausting on-call.
After seeing a colleague being questioned by authorities.
After an unsuccessful application.
After making difficult decisions that carry heavy consequences.
Or after the quiet grief of losing someone we love. Swamp in grievance…

Over the years working in anaesthesia and critical care, our patients, at times, when life can change suddenly and unpredictably.

A patient can deteriorate suddenly. One moment stable, the next moment falling rapidly into shock. And sometimes, despite everything we do, we lose them.

The hardest moments are when we feel that somehow, we might have contributed to the chain of events.

Looking back at certain moments in my own career, I realise that memories do not disappear completely. Imagine a person coming to you for help… and leaving the world under your watch. The weight of that experience is difficult to describe. An ASA I/II patient collapsing during induction is one of the most painful situations an anaesthesiologist and the entire team can face. Because behind that patient is a family. Children who lose their father. A wife who becomes a widow. A mother who loses her son. The grief of the family that is overwhelming. And the echo of that grief does not stop at the hospital doors. Even when we know we have done our best, a quiet voice begins to whisper in the mind.

Could I have done better? The questions begin to circle.

Even when we understand that crises can happen to anyone, the mind still walks down the road of WHAT IF…

Should we have done a CT scan earlier?
Would detecting a lesion earlier have changed the approach to induction?
Should the case have been prioritised differently for surgery?
Would a deeper history have changed the ASA classification?
Would involving a more experienced colleague earlier have altered the outcome?

The questions return again and again.

Sometimes, without even realising it, tears fall quietly, having to feel the heartache.

Many of us have experienced a patient dying perioperatively.

Many of us have cried silently behind the GA machine. Inside the on-call room. In the surau.

Some went home after a post-call shift and were unable to close their eyes, failing to fall asleep. The mind replays the events repeatedly, searching for a perfect reconstruction of what might have been done differently.

The thoughts keep circling.

What if…

And then we return to the reality of our healthcare system. Our MOs/Specialist work twenty-four-hour calls, often with almost no meaningful rest. Basic needs such as eating, going to the toilet, or even praying are squeezed between responsibilities. Mothers with small babies who need to express breast milk struggle to find time.

The day begins with handover from the post-call team. Soon after, OT bookings arrive from house officers who are still learning the system, requiring time to gather missing clinical details. The workload grows rapidly. At the same time, they must discuss cases, induce anaesthesia, manage ongoing operations, resuscitate unstable patients, monitor recovery patients, and coordinate with multiple teams.

Our patients range from newborns on the first day of life to the very elderly.

Each case carries medical complexity, social circumstances, human and system expectations.

And within this environment, we ask doctors to maintain unwavering concentration for twenty-four continuous hours. Managing routine cases in the operating theatre already demands intense cognitive focus and emotional energy.

But when a crisis occurs and when a life is lost, the emotional toll becomes something else entirely. These moments leave marks. The kind that remain within a person.

And yet this is us. Still standing. Still working.

Still returning to the OT and ICU the next day. Because patients will continue to need us.

My hope is that those who work in crisis management; doctors, nurses, paramedics, everyone involved in patient care cold find healthier ways to process these burdens.

And that we build cultures where people are not left alone with these invisible scars.

Because sometimes the strongest people in the room are also the ones who most need someone to ask them, even just once,

Are you okay?

Protecting our colleagues from the Second Victim phenomenon is a systemic necessity. We need formal debriefing protocols and ‘safe spaces’ where we can process grief without the fear of judgment or litigation. If we want to keep our healers whole, we must treat their invisible scars with the same urgency as any clinical emergency. No one should have to carry the weight of a ‘What if’ alone.

Perhaps what we need in medicine is not only stronger individuals, but kinder systems where colleagues look out for one another.

DrAnor Hidayah

SGLT2 Inhibitors in Diabetes and Heart Failure - Perioperative Risk

DrAnor Hidayah — Mon, 02 Mar 2026 16:01:29 GMT

1. Basic Pharmacology

What are SGLT2 inhibitors?

Examples:

Empagliflozin (Jardiance)
Dapagliflozin (Forxiga, Dapiga)
Canagliflozin (Invokana)
Ertugliflozin

Mechanism of action

Block SGLT2 transporter in proximal renal tubule
↓ Glucose reabsorption → ↑ glucosuria
Mild osmotic diuresis + natriuresis
↓ plasma glucose (insulin-independent)
↓ intraglomerular pressure
↓ preload & afterload (HF benefit)

Metabolic effects relevant to perioperative care

↑ glucagon-to-insulin ratio
↑ lipolysis
↑ ketogenesis
Mild chronic volume contraction

2. Evidence-Based Indications

A) SGLT2 inhibitors in T2DM patients:

With HF → reduce HF hospitalization & CV death
With CKD → reduce renal progression
With Atherosclerotic Cardiovascular Disease (ASCVD) → reduce CV events

Cardiovascular protection

DECLARE, EMPA-REG, CANVAS trials:

↓ HF hospitalization
↓ CV death (especially empagliflozin)

Renal protection

Slows CKD progression
Reduces albuminuria
Lowers risk of dialysis in CKD

B) Heart Failure (Independent of Diabetes)

HFrEF (LVEF ≤40%)

Guidelines:

Class I recommendation (ACC/AHA & ESC)
One of the 4 pillars:
- ARNI/ACEi/ARB
- Beta-blocker
- MRA
- SGLT2 inhibitor

Benefits:

↓ CV death
↓ HF hospitalization
Benefit seen within weeks
Works with or without diabetes

HFmrEF & HFpEF

Recent ESC 2023 update:

Class I recommendation across EF spectrum
↓ HF hospitalization consistently

Dosing in HF

Empagliflozin 10 mg daily
Dapagliflozin 10 mg daily
No titration needed.

3. Perioperative Withholding Guidelines

US ACC/AHA / FDA

Stop 3 days before elective surgery
4 days for ertugliflozin in some recommendations

EU ESC

Earlier guidance allowed 1–2 days
Newer practice shifting toward 3 days

Why Withhold?

Because of risk of euglycemic diabetic ketoacidosis (euDKA)

Perioperative triggers:

Fasting
Surgical stress
Reduced insulin
Volume depletion
Infection

Even though half-life ≈ 12 hours —> metabolic ketone-promoting effect lasts 48–72 hours

4. Euglycemic DKA (euDKA)

Definition

High anion gap metabolic acidosis
Elevated ketones
Glucose normal or mildly elevated

Mechanism of “euglycemic”?

Ongoing glucosuria prevents marked hyperglycemia
Insulin levels low → ketone production unchecked

Time Window of Risk - Risk window lasts ~72 hours

Time from last dose — Risk

0–24h — High

24–48h — Significant

48–72h — Present

>72h — Much lower

Rare reports up to day 4–5 post-op.

5. High-Risk Patients for euDKA

Type 1 diabetes (off-label use)
Low insulin reserve
HbA1c >9–10%
Prolonged fasting
Bariatric surgery
Major surgery
Sepsis
CKD
Low-carb diet
Dehydration
Emergency surgery (drug not withheld)

6. When Is It Safe to Restart?

Restart only when ALL are met:

✔ Hemodynamically stable
✔ Eating normally
✔ No nausea/vomiting
✔ No metabolic acidosis
✔ Normal ketones
✔ Renal function stable

Usually:

Post-op day 2–3 (minor surgery)
Later, if major surgery or complications

Never restart during:

Ongoing fasting
Active infection
Hypotension
ICU instability

7. Cardiac Perspective on Holding 3 Days (Important reassurance):

HF benefit is chronic (disease-modifying)
3-day interruption does NOT cause rebound HF
Mortality benefit develops over months
Short hold does not remove long-term benefit

Thus: Temporary perioperative discontinuation is safer than risking euDKA.

8. Endocrine Perspective

Short interruption:

Usually safe in type 2 DM
Maintain basal insulin
Monitor glucose
Avoid insulin dose reduction

Main concern: → Prevent ketogenesis, not hyperglycemia.

9. Perioperative Algorithm

Elective surgery

Stop 3 days before
Monitor glucose
Continue basal insulin
Check ketones if acidosis is suspected

Emergency surgery

Assume risk
Check ABG + serum ketones early
Low threshold for DKA protocol

Summary

SGLT2 inhibitors are foundational cardio-renal-metabolic therapy, but perioperative metabolic stress creates a temporary window of vulnerability to euglycemic DKA.

In most stable patients, holding SGLT2 inhibitors for 3 days does NOT significantly compromise the primary therapeutic goal (glycemic, cardiac, or renal).

The perioperative risk of DKA outweighs the short-term interruption risk.

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Human Factors in Anaesthesia & Critical Care Crisis

DrAnor Hidayah — Tue, 17 Feb 2026 10:09:12 GMT

When I return home after a particularly hectic on-call shift, especially one involving a crisis in the operating theatre, I often reflect on what I could have done better and how I might improve my team’s performance.

High-stakes crises in the OT and critical care demand coordinated effort on team members and multiple factors. Outcomes are shaped by the interaction of physiological factors, anatomical complexity, and human factors operating simultaneously under pressure.

Teaching crisis management in Anaesthesia and Critical Care is now focusing on knowing that Every crisis evolves differently, and there is rarely a single “correct” way to manage it.

An anaesthesiologist may manage the same issue differently depending on:

the magnitude of the problem
the number and experience of staff
equipment
environment
patient factors
the type of Surgery

Today, let us discuss several terms related to Human Factors:

Task fixation
Cognitive overload
Tunnel vision
Loss of situational awareness
Flattened hierarchy

𝐓𝐚𝐬𝐤 𝐅𝐢𝐱𝐚𝐭𝐢𝐨𝐧

Task fixation is a cognitive phenomenon in which a clinician becomes intensely focused on a single aspect of a crisis while ignoring surrounding information that suggests the approach is failing.

This may present as technical fixation or diagnostic fixation

An initial signal may anchor the diagnostic pathway toward one hypothesis. After that, the clinician may remain within that hypothesis tree longer than appropriate, optimising depth within one branch instead of stepping back to reclassify the problem.

This is interesting… In high-stakes crises, task fixation often affects:

Skilled operators
Technically confident clinicians
Individuals with strong ownership over a task

This suggests that high performers are also vulnerable. Increased competence may strengthen the belief that “I can fix this.”

It is therefore commonly seen in:

Experienced airway operators
Senior anaesthetists during a crisis

The more invested one is in solving the problem, the harder it is to let go.

Task fixation may manifest as:

Repeating the same intervention
Delayed expansion of differential diagnosis
Failure to step back and reassess

𝐂𝐨𝐠𝐧𝐢𝐭𝐢𝐯𝐞 𝐎𝐯𝐞𝐫𝐥𝐨𝐚𝐝

Cognitive overload occurs when the brain is required to process excessive information simultaneously. As mental load increases, decision-making narrows.

Fixation may temporarily help by focusing attention on one plan, technique, or diagnosis. However, it may also delay escalation.

The longer task fixation persists, the harder it becomes to recognise that the situation has changed.

𝐓𝐮𝐧𝐧𝐞𝐥 𝐕𝐢𝐬𝐢𝐨𝐧

Tunnel vision can occur in the context of task fixation and may result in loss of situational awareness.

It leads to failure to re-evaluate the patient’s overall status and may convert a manageable complication into a fatal outcome.

Consequences include:

Delayed action
Inappropriate responses
Failure to recognise emerging hazards

𝐒𝐢𝐭𝐮𝐚𝐭𝐢𝐨𝐧𝐚𝐥 𝐀𝐰𝐚𝐫𝐞𝐧𝐞𝐬𝐬

Situational awareness is the dynamic, distributed process by which individuals and teams interpret available cues within an operational context to guide ongoing action.

It involves understanding what is happening with the patient at a given moment, based on the information available, and adjusting actions accordingly.

In a crisis, loss of situational awareness happens when attention narrows to a specific task or assumption, and leaving other important information is not incorporated into the team’s overall understanding of the situation.

𝐅𝐥𝐚𝐭𝐭𝐞𝐧𝐞𝐝 𝐇𝐢𝐞𝐫𝐚𝐫𝐜𝐡𝐲

Flattened hierarchy refers to a team structure in which members, regardless of seniority, are able to voice concerns and contribute observations during a crisis.

It facilitates communication and may help interrupt task fixation or cognitive narrowing. Effective crisis management requires structured leadership while maintaining openness to input from all team members.

Let’s learn about PACE approach to adress particular concern during crisis management. When concerns are raised in a structured way, like using the PACE approach, conversations become clearer and more respectful even when there’s a big hierarchy gap.

It helps teams speak up without tension, and that alone can make the OT safer and everyday team member interaction smoother.

Example: In limited OT time/staffing, etc. Example of an approach on the operating team. Escalating from Probe --> Alert --> Challenge --> and address Emergency

I 𝐏𝐫𝐨𝐛𝐞 - Curious, neutral, information-seeking

How are things progressing from your side?

Are you encountering any technical difficulty?

I 𝐀𝐥𝐞𝐫𝐭 - Highlight a concern (fact-based, non-judgmental)

We’re approaching 12 noon, and the list is scheduled to finish shortly.

Just to update, we’re nearing the allocated theatre time

𝐂𝐡𝐚𝐥𝐥𝐞𝐧𝐠𝐞 - Express concern clearly but professionally

I’m concerned about the extended operative time and its impact on recovery and staffing.

Given the duration, would it help to have senior input to facilitate completion?

𝐄𝐦𝐞𝐫𝐠𝐞𝐧𝐜𝐲 - Clear boundary / safety declaration

We need to decide now whether to continue or close due to staffing limitations.

To be continued…

Strategies to mitigate Task fixation in Crisis e.g airway crisis, collapse patient on table while undergoing surgical procedure.

The Art of Communication Among Health Professionals in the Hospital Setting

DrAnor Hidayah — Sat, 31 Jan 2026 13:19:13 GMT

Managing critical care patients in a hospital setting is inherently demanding, and this burden intensifies during on-call hours. During these periods, the responsibility for multidisciplinary referrals, perioperative assessments, acute pain management, emergency responses, and patient handovers is concentrated in a limited number of clinicians. Care is rarely delivered by a single individual; rather, it depends on highly integrated, coordinated efforts among clinical teams that are often physically separated and operating under different pressures.

After office hours, while most colleagues return home to rest, the on-call clinician continues navigating an unrelenting stream of patient-related demands. It is therefore unsurprising that many doctors experience “pre-on-call blues.” On-call days are frequently characterised by skipped meals, inadequate hydration, delayed prayers, and the inability to attend to even basic personal needs. Beyond physical fatigue, the mental load is substantial. Each referral carries not only immediate clinical responsibility but often the expectation of ongoing involvement should the patient deteriorate.

The emotional and cognitive strain accumulates rapidly. Continuous referrals, competing priorities, and the responsibility of co-managing critically ill patients can erode patience, judgement, and resilience. When coping mechanisms are overwhelmed, even well-intentioned clinicians may struggle to maintain composure. Yet professionalism and mutual respect remain essential, because effective communication ultimately serves a single purpose: patient safety.

Importantly, referral does not signify the end of responsibility. Patients rarely stabilise simply because another team has been informed. More often, physiological decline continues while awaiting further intervention. This underscores the need for vigilance, continuity, and clear handover until responsibility is formally and safely transferred.

Communication in hospitals is multidirectional. Doctors receive referrals and must also initiate them. They communicate upward to specialists and consultants, laterally to peers, and downward to house officers. Interactions extend beyond doctors to nursing staff in wards, operating theatres, and intensive care units. In high-risk environments such as surgery and critical care, where time-sensitive decisions are routine, communication is not ancillary—it is fundamental.

Despite this, communication failures remain a major contributor to delays, errors, and inefficiencies in patient management. Many problems arise not from lack of knowledge, but from failure to convey relevant information, unclear expectations, hierarchical barriers, and disruptive behaviours. When communication breaks down, processes that should take minutes may extend into hours or days, wasting resources and compromising patient outcomes.

While much of the literature focuses on doctor–patient or doctor–nurse communication, far less attention is paid to doctor-to-doctor communication, particularly during referrals. Yet this interaction is often the most critical determinant of timely and appropriate care.

Common Communication Barriers in Hospital Practice

Fatigue and exhaustion
On-call work frequently follows days of inadequate rest, prolonged travel, or prior overnight duties. Physical exhaustion impairs cognition, judgement, and emotional regulation. Failure to adequately prepare for on-call duties increases the risk of miscommunication and clinical errors, particularly in settings with high caseloads and limited support.
Incomplete clinical information (“blank areas”)
Effective referral begins with knowing the patient. Missing or inaccurate information may lead to incorrect prioritisation, misdiagnosis, or delayed intervention. A structured referral should include patient demographics, comorbidities, admission diagnosis, current problem, clinical status, relevant investigations, interventions already undertaken, and preparations made. Referrals should be prioritised based on clinical urgency, not on a first-come basis.
Cognitive block during emergencies
Inexperienced clinicians may experience thought paralysis during emergencies, making it difficult to articulate the problem clearly. Simulation training and structured emergency courses such as ACLS, ATLS, Airway simulation help clinicians maintain diagnostic clarity and communicate effectively under pressure. A call for help must convey actionable information; vague or fragmented messages serve neither the recipient nor the patient.
Overconfidence and lack of insight
Medicine is hierarchical by necessity, but misplaced confidence can be harmful. Junior doctors may overestimate their competence and delay the escalation of clinical problems and the making of acceptable joint decisions. Expertise develops over years, not months. Early discussion with seniors/specialists prevents diagnostic errors, inappropriate management, and avoidable complications.
Orders without explanation
Clinical decisions often originate with senior clinicians but are carried out by junior staff. Without adequate explanation, juniors may be unable to justify referrals or respond to questions from other teams. Statements such as “my superior asked me to refer” reflect a communication failure, not a lack of effort. Teaching the rationale behind decisions, the ‘thought process’ is essential for safe delegation and professional development.

Uncooperative or disruptive colleagues
Personal stressors and burnout may affect workplace behaviour. While empathy is important, patient care cannot be compromised by dysfunctional teamwork. Clear delegation, defined roles, and timely escalation to seniors or supervisors are necessary when cooperation breaks down.
Time pressure and competing demands
Time constraints are universal in healthcare. Effective triage, prioritisation, and task management are critical skills that must be actively cultivated rather than assumed.
Failure to listen
Listening to respond is not the same as listening to understand. Interruptions and premature conclusions create unnecessary conflict and error. In medicine, assumptions are dangerous; clarity and confirmation are essential.
Inconsistency and dishonesty
Repeated errors, inaccurate information, or deliberate misrepresentation during referrals erode trust and jeopardise patient safety. Questioning unclear or unsafe instructions is a professional responsibility, not insubordination.
Hierarchy-dependent behaviour
Power differentials may foster dismissive or intimidating conduct, particularly toward junior staff. Such behaviour discourages escalation and delays care. Respect should never be contingent on job title; psychological safety is integral to patient safety.

Reaction Matters: Professional Responses to Poor Behaviour

When confronted with rudeness or intimidation, clinicians may react with anger, withdrawal, sarcasm, or silence. While understandable, these responses rarely improve outcomes. More importantly, repeated exposure to verbal abuse may cause junior staff to hesitate before seeking help, placing patients at risk.

Unprofessional behaviour must be addressed through appropriate reporting channels. Conversely, genuine errors or unsafe practices should be managed through constructive feedback and formal processes rather than emotional confrontation. Accountability protects both patients and professionals.

Conclusion

Effective communication among health professionals is not only a ‘soft skill’. It is a core clinical competency that needs to be addressed from time to time. Fatigue, hierarchy, workload, and culture all influence how information is exchanged. Addressing communication failures requires more than individual effort; it demands systemic awareness, deliberate training, and a culture that prioritises respect, clarity, and patient safety.

Ultimately, how we speak to one another during heavy clinical work determines how well we care for those entrusted to us.

drpakarbius.com

Perbezaan antara ‘ditidurkan’ dan ‘diberikan sedasi’.

DrAnor Hidayah — Wed, 21 Jan 2026 10:35:47 GMT

Pemberian ubat sedasi adalah untuk menyebabkan ketidaksedaran yang boleh dibangunkan semula (reversible).

Ini lakukan dengan pemberian ubat sedatif dan ubat tahan sakit untuk memastikan pesakit tidak berasa sakit dan tidak ingat apa yang berlaku serta berada dalam keadaan selesa ketika sebarnag prosedure dilakukan ke atas pesakit. Ubat-ubat sedasi tidak bertahan lama didalam badan kerana kadar metabolasi yang tinggi.

Pesakit boleh dibangunkan dalam masa yang singkat selepas ubat sedasi diberhentikan untuk berkomunikasi dengan doktor dan nurse.

Pemberian ubat sedasi adalah diperlukan ketika proses memasukkan tiub ke dalam mulut.

Antara sebab keperluan memasukkan tiub ke dalam mulut untuk bantuan pernafasan adalah:

Ketika pembedahan yang memerlukan pembiusan penuh (General Anaesthesia).
Jika pesakit mengalami ‘distres’ masalah pernafasan dan memerlukan bantuan alat pernafasan sehingga paru-paru sembuh.
Pesakit berada dalam keadaan yang tidak stabil seperti terlalu asidosis memerlukan resusitasi air atau darah yang banyak. Untuk antisipasi keadaan menjadi lebih teruk.
Pesakit tidak sedarkan diri disebabkan masalah otak atau jantung berhenti.

Untuk menjaga saluran pernafasan daripada tersumbat dan tidak dapat mengalirkan udara ‘ventilasi’ dari mulut ke paru-paru.

Sedasi ringan pula diberikan membolehkan pesakit berkomunikasi semasa mendapat ubat sedasi.

Antara prosedur lain yang memerlukan sedasi ringan adalah seperti:

OGDS, colonoscopy, ERCP, pencucian luka yang besar seperti luka terbakar.

Sesetengah pesakit yang memerlukan bantuan pernafasan yang tidak invasif seperti CPAP dan HFNC jugak akan diberikan ubat sedasi untuk memberikan keselesaan kepada pesakit. Memandangkan keadaan pesakit yang memerlukan rawatan permhatian rapi, pesakit perlu dipasangkan tiub kencing, tiub makanan, salur pemerhatian tekanan darah yang invasif yang mungkin menyebabkan kesakitan jika tidak diberikan ubat sedasi dan tahan sakit.

Mengapa pesakit tidak bangun semula selepas pemberian ubat sedasi diberhentikan?

Ada byk sebab pesakit tidak dapat sedar selepas ubat sedasi diberhentikan. Antaranya adalah:

Pesakit berada dalam keadaan yang sangat teruk (irreversbile shock with multi organ failure)

Kegagalan fungsi buah pinggang membuang bahan kumuh dan acid akan menyebabkan bahan kumuh yang tinggi seperti urea.
Kegagalan hati untuk berfungsi meneutralkan toksin di dalam badan seperti ammonia.
Kegagalan badan mengawal garam penting seperti calcium, potassium, natrium, phosphate

Pesakit seperti ini mempunyai kadar kematian yang sangat tinggi.

Pesakit mendapat masalah otak (yang mengawal tahap kesedaran seseorang)

stroke otak
pendarahan di dalam otak
otak bengkak

Hormone thyroid yang terlalu rendah boleh menyebabkan myodema koma.

Manakala ditidurkan bermaksud pesakit dapat tidur secara natural. Beberapa keadaan dapat membantu pesakit tidur seperti keadaan yang tenang, mendengar musik yang mendayu juga memudahkan seseorang pesakit untuk tidur. Sesetengah ubat juga dapat membantu untuk tidur seperti melatonin, dan anxiolysis seperti benzodiazepine.

Tidur juga mempunyai fasa otak yang berbeza dengan sedasi. Tidur mempunyai 2 jenis fasa iaitu Non-REM sleep dan REM sleep. Kedua-dua fasa ini mengambil masa dalam 90 min untuk lengkap satu pusingan. Seseorang yang mendapat tidur yang mencukupi akan berasa tenang dan lebih bertenaga selepas bangun dari tidur.

Walaupun setelah pesakit diberikan ubat sedasi, pesakit juga akan tidak sedarkan diri (unconciousness) akan tetapi fasa sedasi adalah berbeza dengan fasa ketika tidur. Fasa sedasi boleh dibahagikan kepada beberapa tahap mengikut pengkelasan tertentu.

Antara pengkelasan sedasi adalah

Richmon sedation scale
Sedation scale
Geudal’s klasifikasi untuk pembiusan penuh

Adakah pemberian ubat sedasi boleh membawa maut?

Setiap prosedur sudah tentu mempunyai risiko tersendiri. Sama seperti risiko kemalangan di jalan raya, risiko tercekik ketika makan. Setiap perkara juga mempunyai risiko.

Terdapat pesakit yang sensitif terhadap ubat sedasi namun risiko mendapat alahan kepada ubat-ubatan sedasi adalah kecil. Pemberian ubat sedasi adalah mengikut dos yang telah ditetapkan berdasarkan kajian yang banyak dan berkualiti tinggi (evidence-based medicine).

Namun, jika pesakit mengalami masalah organ yang teruk seperti jantung yang lemah dan ritma jantung yang tidak menentu, pesakit boleh menjadi semakin teruk dan membawa maut.

Juga jika pesakit mengalami kegagalan paru-paru yang teruk menyebabkan oksigen tidak sampai ke otak.

Pesakit yang mengalami perdarahan yang teruk juga mempunyai risiko yang sama.

Otak, jantung, paru-paru, hati dan buah pinggang adalah 5 organ penting manusia. Kegagalan fungsi salah satu organ boleh menyebabkan organ lain turut mendapat kesan yang negatif. Keseimbangan fungsi organ badan adalah amat penting untuk meneruskan kehidupan yang sihat dan efektif. Maka apabila seseorang jatuh sakit, kita hendaklah mendapatkan rawatan yang betul dengan segera untuk mengelakkan keadaan menjadi lebih teruk.

Oleh itu, jagalah kesihatan, kurangkan makanan dan minuman manis. Banyakkan berjalan dan bersenam. Jauhi perkara yang mendatangkan tekanan minda dan jiwa serta jauhi apa jua ketagihan. Tenangkan diri dengan perkara-perkara yang baik.

buang STIGMA ditidurkan

Rawatanbius untuk pesakitTidakStabil

RawatanBius untuk pembedahan

Dilemma menjalani Pembedahan & pembiusan

DrAnor Hidayah — Sun, 11 Jan 2026 05:33:51 GMT

Sejak beberapa hari lalu, ramai rakyat Malaysia dikejutkan dengan berita bahawa seorang bekas Perdana Menteri yang disayangi telah dimasukkan ke hospital akibat terjatuh, dan keputusan dibuat untuk memilih rawatan konservatif.

Apabila pesakit mengalamai masalah yang boleh dirawat Dengan pembedahan, doktor akan menilai samaada kebaikan manfaat daripada pembedahan adakah lebih baik dari tidak melakukan pembedahan (conservative treatment).

Situasi seperti ini sering menimbulkan persoalan. Apakah yang sebenarnya mempengaruhi keputusan seorang pesakit, ahli keluarga, pakar bedah, atau pakar bius untuk menentukan sama ada pembedahan perlu diteruskan atau tidak?

Bagi kebanyakan orang, persoalan yang sering timbul ialah: mengapa tidak dibedah, jika pembedahan itu diperlukan?

Soalan ini biasanya muncul apabila penyakit atau kecederaan menjejaskan keupayaan seseorang untuk menguruskan kehidupan seharian seperti bangun dari katil, berjalan, makan, mengurus diri sendiri, atau melakukan perkara yang mereka gemari. Ada juga yang berharap pembedahan dapat mengurangkan kesakitan atau meringankan beban penjagaan oleh ahli keluarga.

Pembedahan sering dibincangkan sebagai jalan untuk memulihkan kehidupan seharian pesakit, mengurangkan kesakitan yang mungkin berpanjangan, atau mencegah kemerosotan fungsi tubuh badan. Namun pada tahap ini, keputusan tidak pernah tertumpu kepada pembedahan semata-mata. Ianya memerlukan pertimbangan yang teliti antara manfaat dan risiko komplikasi yang mungkin berlaku ketika pembiusan pembedahan dan selapas itu.

Hakikatnya, pembedahan dan bius boleh memberi bebanan tambahan kepada fisiologi tubuh badan. Risiko banyak bergantung kepada keupayaan tubuh pesakit untuk menanggung tekanan pembedahan serta pulih daripada perubahan hemodinamik dan metabolik yang kompleks selepasnya.

Apabila seseorang menjalani pembedahan, matlamat utama biasanya adalah untuk memperbaiki masalah utama yang menyebabkan penyakit atau kecederaan. Namun bagi individu yang mempunyai tubuh yang lebih rapuh atau kebolehupayaan fisiologi yang terhad, pembedahan boleh menjadi sesuatu yang amat mencabar.

Kadangkala, usaha untuk membetulkan satu masalah boleh mendedahkan masalah lain seperti fungsi jantung yang lemah, keupayaan buah pinggang yang terjejas, atau rizab fisiologi yang sudah pun terbatas.

Keadaan-keadaan ini boleh mengubah imbangan tubuh daripada pemulihan kepada kemerosotan, apabila organ-organ tubuh tidak lagi mempunyai daya tahan yang mencukupi.

Hasil yang dibimbangkan bukan sekadar hidup atau mati semata-mata. Ia merangkumi:

kadar kematian dalam tempoh 30 hari, 60 hingga 90 hari.
komplikasi besar seperti jangkitan seperti radang paru-paru, jangkitan luka pembedahan, atau kegagalan implan.
komplikasi khusus organ seperti kecederaan buah pinggang akut, masalah jantung, atau strok (angin ahmar)
kesan lanjutan seperti keperluan sokongan mesin pernafasan yang berpanjangan, kemasukan ke ICU, atau gangguan fungsi kognitif/ akal dalam jangka panjang

Semua ini bukan sahaja menentukan kelangsungan hidup, tetapi turut mempengaruhi kualiti pemulihan, tahap kebergantungan terhadap penjaga, dan perjalanan hidup seseorang selepas pembedahan.

Oleh yang demikian, perlulah ditimbangtara keperluan pesakit kerana setiap pesakit mempunyai keutamaan dan matlamat yang berbeza. Bagi sesetengah orang, keinginan untuk menghabiskan lebih banyak masa di rumah bersama keluarga terutamanya menjelang waktu penting seperti Bulan Puasa, Ramadan, dan Hari Raya atau hari-hari penting yang lain mungkin lebih bermakna berbanding risiko yg dimaksudkan seperti:

keberadaan di hospital yang lama
penurunan fungsi kognitif/akal/ pemikiran
kemasukan ke unit rawatan rapi akibat komplikasi pembedahan dan bius

Maka, bagaimana kita menentukan sama ada sesuatu pembedahan itu berisiko tinggi atau sangat tinggi?

Di sinilah penilaian dan pengelasan risiko pra-pembedahan, proses pengurangan risiko, serta perbincangan mengenai hala tuju rawatan menjadi sangat penting sebelum keputusan untuk meneruskan pembedahan dibuat.

Pelbagai model ramalan risiko telah dibangunkan untuk menganggarkan kemungkinan komplikasi ini. Penilaian risiko biasanya dibuat dengan menggabungkan:

faktor kesihatan pesakit (status ASA, tahap kerapuhan, penyakit sedia ada)
tahap fungsi pesakit (kelas NYHA, skor METs)
faktor berkaitan pembedahan (kecemasan atau elektif, jenis dan tahap risiko pembedahan)

Prosedur kemudiannya sering diklasifikasikan sebagai:

risiko rendah (<1%)
risiko sederhana (1–5%)
risiko tinggi (>5%)

bagi kebarangkalian serius seperti kematian atau serangan jantung.

Namun, menjadi pesakit yg berisiko tinggi tidak bermakna pembedahan mustahil atau tiada harapan untuk sembuh seperti sediakala.

Ramai pesakit berisiko tinggi tetap memilih untuk menjalani pembedahan besar dan kompleks, dan bersyukur kerana ada yang berjaya melaluinya dengan baik.

Apabila pesakit berisiko tinggi bersetuju untuk meneruskan pembedahan, maka, langkah seterusnya ialah perbincangan yang terbuka dan jujur bersama pesakit dan ahli keluarga terdekat.

Ini termasuk berbincang tentang hasil yang boleh diterima, keperluan atau kemungkinan kemasukan ke ICU, serta keperluan sokongan hayat seperti ubat sokongan jantung, mesin pernafasan, atau dialysis unutk mencuci darah, kadangkala seawal hari pertama selepas pembedahan.

Selepas risiko dan manfaat dijelaskan dengan baik, dan harapan jangka pendek serta jangka panjang dibincangkan dengan penuh teliti, akan tiba satu saat di mana perubatan perlu berundur dengan lembut. Segala perancangan telah dibuat, setiap tangan bersedia, dan segala usaha dalam kemampuan manusia telah dilakukan.

Selebihnya, kita redha dan berserah utk setiap apa yang di luar kawalan kita kepada Tuhan. Kita bersandar kepada doa keluarga dan sahabat dan mamalan yang baik. Biarla doa yang berbisik, air mata yang mengalir dalam keheningan malam, dan hati yang memohon dengan penuh harapan agar diberi rahmat dan ketenangan.

Semoga Yang Maha Esa membimbing setiap tangan, menenangkan setiap keputusan, dan melindungi pesakit yang dikasihi dalam setiap hela nafas, setiap detik, dan setiap langkah yang tidak pasti. Semoga diberikan kekuatan kepada mereka yang menunggu dengan penuh kesabaran, harapan yg menjulang, dan usaha pembedahan yang dipenuhi dengan penyembuhan dan keberkatan.

InsyaAllah.

𝐌𝐨𝐧𝐢𝐭𝐨𝐫𝐞𝐝 𝐀𝐧𝐚𝐞𝐬𝐭𝐡𝐞𝐬𝐢𝐚 𝐂𝐚𝐫𝐞 (𝐌𝐀𝐂)

DrAnor Hidayah — Sun, 21 Dec 2025 08:49:12 GMT

While doing 𝐌𝐨𝐧𝐢𝐭𝐨𝐫𝐞𝐝 𝐀𝐧𝐚𝐞𝐬𝐭𝐡𝐞𝐬𝐢𝐚 𝐂𝐚𝐫𝐞 (𝐌𝐀𝐂) for some URO surgery cases today, I asked about how we classify our sedation during MAC? This is my favourite question to test the depth of understanding for anaesthesia & critical care practice.

I always like to emphasise the fact that there is no clear cut between classification sedation MILD, MODERATE, DEEP sedation and while giving anaesthetic agents, the patient can dive deep into general anaesthesia (GA).

With no clear-cut, distinctive factors for the differences.

That’s why it is called a 𝐜𝐨𝐧𝐭𝐢𝐧𝐮𝐮𝐦 𝐨𝐟 𝐬𝐞𝐝𝐚𝐭𝐢𝐨𝐧.

Therefore, it is very important to assess patient responsiveness from time to time and at the same time always be ready to support the patient whenever the patient goes into deep sedation and at any moment may enter a state of GA. As anaesthesiologists/

Anaesthesia providers, we must be qualified to recognise DEEP sedation, manage its consequences, and adjust the level of sedation to a “moderate”/concious sedation or MILD level.

We also must be prepared to manage all levels of sedations and respond to the pathophysiology - the airway and hypotension, bradycardia (hemodynamic changes) to ensure patient safety.

𝐌𝐢𝐥𝐝 𝐬𝐞𝐝𝐚𝐭𝐢𝐨𝐧 gives anxiolysis, which can be achieved with a single dose of anxiolytic or sedative. Usually, a normal verbal response, some even become talkative. ( anaesthetist wouldn’t like this) Time to give more Midazolam. --> cognitive and physical coordination may be impaired.

𝐌𝐨𝐝𝐞𝐫𝐚𝐭𝐞 𝐬𝐞𝐝𝐚𝐭𝐢𝐨𝐧, also known as conscious sedation, in which the patient will respond to purposeful verbal stimulation with some tactile stimulation. Airway and CVS function are usually preserved,

while for 𝐃𝐄𝐄𝐏 𝐬𝐞𝐝𝐚𝐭𝐢𝐨𝐧, the patient will need to be given repeated verbal stimulation + repeated or painful stimulation.

Anaesthesia provider may need to support the patient’s airway and breathing and manage hypotension. It is not always possible to predict how an individual patient will respond.

Monitoring of these 4 important parameters is essential to classify it as mild, moderate and DEEP sedation, as in the stable.

𝐂𝐨𝐦𝐦𝐨𝐧 𝐩𝐫𝐨𝐜𝐞𝐝𝐮𝐫𝐞 𝐝𝐨𝐧𝐞 𝐮𝐧𝐝𝐞𝐫 𝐌𝐀𝐂

OGDS
ERCP
Oocyte retrieval
Spine Discectomy
AFOI
Awake intubation
Flexible bronchoscopy
Awake craniectomy
MRI
Post RA for delirious/ demented patient
URO case – Botox injection of detrusor muscle, ureter and urethral dilatation

*that’s why MAC is paid as GA cases in private setting

*be extra careful whengiving MAC in private small centre. make sure all equipment/medications for general anaesthesia are functional and ready.

*dont forget to assess for difficult airway even plan for giving concious sedation.

𝐅𝐈𝐍𝐀𝐍𝐂𝐈𝐀𝐋 𝐋𝐈𝐓𝐄𝐑𝐀𝐂𝐘 𝐅𝐎𝐑 𝐘𝐎𝐔𝐍𝐆 𝐃𝐎𝐂𝐓𝐎𝐑𝐒

DrAnor Hidayah — Sun, 21 Dec 2025 08:35:32 GMT

𝐃𝐢𝐬𝐜𝐥𝐚𝐢𝐦𝐞𝐫:

I’m not a financial advisor.

I’m simply a senior doctor who learned everything the hard way and I’m writing this because no one warned us in medical school, HO years, or even as MOs. Even during specialist year, we just keep working and working...

So if this helps even one junior avoid a long-term trap, then it’s worth writing.

Doctors are among the most targeted professionals in Malaysia:

property agents
insurance agents
MLM
“doctor packages”
personal loan sellers
property gurus
business consultants
GP clinic contractors
investment clubs
schemes disguised as “professional community”

𝐖𝐡𝐲?

Because we have income, but our financial literacy starts at zero.

1. Income grows fast yet, financial maturity doesn’t

From HO to MO to specialist, the pay jumps quickly.

But:

No one teaches us cash flow.

No one teaches loans + credit.

No one teaches about hidden interest, 𝐃𝐒𝐑, property, equity, invesment basics, compulsory contributions, or business structure and debt management and even taxes.

So, the money grows, but the financial literacy doesn’t.

And that gap is where most doctors may fall into a debt trap.

2. Learn about Credit cards. It can become dangerous when used without understanding.

Take care our patient's CVL

DrAnor Hidayah — Thu, 27 Nov 2025 15:44:10 GMT

In OR while teaching my new budding Anaesthesia Drs and team... Observing CVL insertion procedure to prevent CRBSI.

This is where CRBSI prevention begins:

CRBSI is far more expensive than

* the extra green towel to properly cover the patient & proper sterile draping of non-sterile areas,

* The Tegaderm to cover the probe (sterile probe cover is the Best)

* the normal saline to flush blood from the catheter, and

* The alcohol swab to “scrub the hub” each time before using the CVL.

- Courses of antibiotics..

- Days of hospital admission

- Septic shock requiring ICU admission

- Caregiver missing work

No cutting corners

Let’s always observe precautions sharing responsibility to prevent infection to our patients.

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