4^th International Anesthesia and Pain Medicine Conference November 18-19, 2019 Courtyard by Marriot Bali Seminyak Resort | Bali, Indonesia

Abeer Mostafa Kamel Ali has completed her Doctorate degree from Menoufia University, Egypt. She studied chronic pain management at McGill University, Canada. She is a Consultant Anesthesiologist in Dubai Health Authority, UAE.

For decades opioids were considered the most powerful analgesic agents for balanced anesthesia despite its side effect. Recently, reducing opioid use became influential in the opioid epidemics. Anesthesiologists and surgeons together induce addiction after surgery as evidenced in a Canadian cohort study. Clarke et al. studied more than 40,000 major surgery, patients measured that 50% of opioid-naïve patients leave a hospital with an opioid prescription and 3.1% continue its use after 3 months. This result is supported by Brummett etal., who reported rates of new persistent postoperative opioid use ranging from 5.9% to 6.5%, suggesting that new persistent opioid use after surgery is common. These findings raised the concerns of perioperative opioid use. For enhanced recovery after surgery, it is recommended to reduce the use of postoperative opioids. Among anesthetists, there is a growing movement towards minimizing or avoiding opioids. Opioid-Free Anesthesia (OFA) contributes to a smooth and rapid recovery with less pain. Moreover, OFA avoids tolerance and hyperalgesia development and other side effects.

Anu Aggarwal, nearly lost her life in an accident. PTSD case with retrograde amnesia, dozen fractures, Anu who was a living yogi then, experimented and self-healed, and now shares her miracle healing for wellbeing of the challenged. AHH holistic heaing uses mental hygiene modules, researched extensively to 76% positive results. Anu speaks nationally and internationally in Health Conferences

Pain is an unpleasant sensation in animals that is caused by actual or perceived injury to body tissues and produces physical and emotional reactions. Presumably, pain sensation has evolved to protect our bodies from harm by causing us to perform certain actions and avoid others. Pain might be called a protector, a predictor, or simply a hassle. Pain is typically classified as either acute or chronic. Acute pain is of sudden onset and is usually the result of a clearly defined cause such as an injury. Acute pain resolves with the healing of its underlying cause. Chronic pain persists for weeks or months and is usually associated with an underlying condition, such as arthritis. The severity of chronic pain can be mild, moderate, or severe. Treatment of pain depends on its psychosomatic cause and the overall health of the individual affected. The primary goal of pain treatment is to return the patient to optimal function. Treatments of pain can be classified as either non-medical or medical. Non-medical treatment options for various forms of pain include observation, rest, stretching, exercise, weight reduction, heat or ice applications, and various alternative treatments including acupuncture, chiropractic, massage, manipulation, electrical stimulation, biofeedback, hypnosis, and surgical procedures. Research shows positive re-programming of mind to be deeply effective to reduce and manage pain, and has to be tried with a larger cohort of population.

Dewa Ayu Mas Shintya Dewi is an Anesthesiologist and Associate Lecturer at the Department of Anesthesiology, Pain Management, and Intensive Care, Medical Faculty of Udayana University-Sanglah General Hospital, Denpasar-Bali, Indonesia. She graduated from Medicine Faculty of Udayana University at 2002 then graduated from anesthesiology specialization in the same university at 2010. In 2018, she decided to continue her study in biomuleculer field at Udayana University and untul this time, she still interest in many aspects of biomoleculer especially in relation with pain management. Her researches majority was going around in pain management with biomoleculer aspects. From 2010 until now, she have been working at Sanglah General Hospital and Bali International Medical Centre, Denpasar as an anesthesiologist.

Inflammation, tissue and nerve damage can cause persistent pain signed by increased response of noxious stimulus (hyperalgesia) and pain as a normal response of innoxious stimulus (allodynia). Postoperative pain is a form of pain cause by mechanical tissue damage. The synaptic plasticity of central sensitization is the basic mechanism of postoperative pain and the cause of persistent and establishment of hyperalgesia and allodynia. Central sensitization of the dorsal horn of the spinal cord is modulated by the production of glutamate neurotransmitter by the terminal primary afferent nerve root which activates the postsynapse receptor and or by the effect of the quantity and type of postsynaptic membrane receptor. The AMPA glutamate ionotropic receptor and its interaction with the NMDA receptor is postulated to be involved in the neurophysiology of postoperative incisional pain which may develop to persistent and chronic pain. The regulation interaction of the AMPA and NMDA receptors plays a role in Long Term Potentiation (LTP). Some studies conclude peripheral inflammation cause changes in the subunit AMPA

trafficking through the NMDA receptor that triggers the protein kinase activation at the dorsal horn and this change contributes in the central sensitization in increasing and prolong the persistent inflammation pain. Some

factors are involved in the nociception process in the spinal cord related to the trafficking of AMPA receptor such as subunit composition, phosphorylation regulation and protein interaction.

Garima Agrawal have graduated from PGIMS Rohtak in 1999 and completed her Post graduation MD in Anaesthesia and intensive care from Maulana Azad Medical College in 2005. Her areas of expertise are Airway, critical care. Besides having national and international publications I am trained in acupuncture and instructor at Airway management Foundation.

Silver-Russell Syndrome (SRS) presents with intrauterine and post-natal growth failure, relative macrocephaly at birth and later protruding forehead and triangular facies, body asymmetry of varying degree, feeding difficulties and frequent episodes of hypoglycemia. SRS children present for surgeries related to male genital anomalies, orthopedic procedures or in extreme situations for feeding jejunostomies. Anesthetic challenges in such children are found mentioned in literature but have been sparingly reported. Laryngoscopy and intubation becomes difficult due to facial dimorphism because of micrognathia, down turned mouth (small mouth opening) and crowded upper dentition, high arched palate and sometimes subglottic stenosis. We report a case of 1.7-year-old child with typical features of SRS presenting with palpable undescended testes. Orchidopexy via inguinal approach was planned. Difficult airway was anticipated in view of protruding upper dentition, relatively small mouth opening and partial high arched palate. Control of airway was planned with supraglottic airway device. I-gel LMA was found far superior to Proseal LMA in achieving a good seal and airway patency in an asymmetric oropharynx due to a partial high arched palate. Hypoglycemia was prevented by restricting the fasting duration and close monitoring. Ilioinguinal nerve block lowered the anesthetic requirements intraoperatively.

Raksha Kundal has completed MBBS from Government Medical College Jammu, India and completed Post-graduation in Anesthesia from Sher-e-Kashmir Institute of Medical Sciences, Srinagar, India. She has papers published in national and international journals

This surgery involves replacement of non-existent or damaged esophagus with a conduit to restore anatomic and functional continuity between mouth and gastrointestinal tract. Types of esophageal replacement procedure are gastric transposition, gastric tube, colon interposition and jejunal interposition. Indication for esophageal replacement in children are isolated esophageal atresia with long gap, caustic strictures, peptic strictures and anastomotic strictures, tumors, impacted foreign bodies and achalasia. Proper preoperative workout is needed which include assessment of airway ruling out congenital anomalies and optimization of patients. Blood and blood products are to be arranged and beta-blockers to be started in preoperative period. Premedicate and give general anesthesia and insert thoracic epidural catheter. Intraoperative concerns like pain, blood loss massive fluid shift, hemodynamic disturbances, arrhythmia and hypothermia are to be managed. Pain is managed with multimodal analgesia. Intraoperative sinus tachycardia is associated with morbidity of patients for which preoperative betablockers and intraoperative beta-blockers are used. Post-operative elective ventilation is mostly required as there is large organ (stomach) sharing space with other structures in mediastinum resulting compression of lungs and heart also there are chances of airway edema, pleural tears, pneumothorax, pleural effusion and atelectasis. Arrhythmias and hemodynamic disturbances prolonged surgery and hypothermia also require postoperative ventilation in such patients. These patients should be ventilated till heart rate and blood pressure become normal, airway pressures became normal, generates adequate respiratory rate and tidal volume and anemia and hypothermia is corrected.

It has been more than Ten years since Mr. Ahmed Yahya Ayoub have become an official healthcare provider. He finished his bachelor’s degree from Philadelphia University in Jordan 2009. Eventually he proceeds to Study Master’s in Oncology Nursing from Hashemite University in 2013. He has an impressive work experience as a Senior Charge Nurse at King Hussein Cancer Center, Jordan in Medical/Surgical/VIP/ OPD. He is currently working now in Al Dhafra Hospitals (Madinate Zayed Hospital) / SEHA United Arab Emirates as outpatient Staff Nurse for more than three years. Mr. Ahmed Ayoub is a champion of Nursing Research in Al Dhafra Hospitals and follows up around 9 hospitals. He has published 4 papers entitled: Do Not Resuscitate: An argumentative essay, Distributed in Ethics eJournal Vol 6, Issue 81, May 14, 2013. Consent Form Analysis, Distributed in Health Care Law & Policy eJournal Vol 5, Issue 20, April 08, 2013. The Effectiveness of Initial Assessment on Pressure Ulcer Prevention among Adult Jordanian Cancer Patients, Under Review. Assessment of Nurse’s Knowledge about Glasgow Coma Scale at Al Dhafra Hospitals, Abu Dhabi, United Arab Emirates. Journal of Clinical Review & Case ReportsVol3, Issue7, 01Sep 2018.

Cancer is a worldwide health problem. In Jordan, cancer is the second leading cause of death. Approximately 2000 people die from cancer every year, 70% of them experiencing varying high levels of pain due to ineffective pain relief. This study aims to identify the attitudinal barriers to effective cancer pain relief in patients and their family caregivers in Jordan. A cross-sectional questionnaire survey was used. A convenience sample of 300 cancer patients and 246 family caregivers were recruited from 4 different Jordanian hospitals

between August 2009 and May 2010. Patients completed the Arabic version of the Barriers Questionnaire II (ABQ-II), the Arabic Brief Pain Inventory (A-BPI) and a demographic questionnaire. Family caregivers completed the ABQ-II and a demographic questionnaire. The A-BPI results identified that over 70% of cancer patients in localized stage and over 90% of the patients with advanced cancer experienced substantial pain. Four major barriers to pain control were highlighted: Fears related to addiction, side-effects, communication concerns and fatalistic beliefs. This study contributes to provide baseline information about the barriers to effective cancer pain control in Jordan.

Over 80% of the population will suffer from lower back pain during their lives; it is the fifth most common reason for all physician visits in the US. Most cases of lower back pain can be linked to a general cause such as muscle strain, injury or overuse or can be attributed to a specific condition of the spine, most commonly: Herniated disc, degenerative disc disease, spondylolisthesis, spinal stenosis and osteoarthritis. A number of less common conditions can cause low back pain as well, such as sacroiliac joint dysfunction, spinal tumors, fibromyalgia and piriformis syndrome. Patients with back pain radiating to the leg(s) report worse symptoms and poorer recovery than those with back pain alone. In primary care, approximately 60% of patients presenting with Low Back Pain (LBP) also report pain in the leg(s). Leg pain associated with LBP is generally considered to be either referred or radicular pain. The latter is commonly labelled sciatica and is often characterized by pain radiating to below the knee, into the foot and toes and may be accompanied by objective findings of nerve root entrapment such as sensory deficits, reflex changes or muscle weakness. The most common reasons for sciatica are a disc bulge/prolapse or stenosis (either of the central canal or the foramen) impinging or irritating a nerve root(s). Referred leg pain from the low back is unrelated to nerve root involvement and is considered as pain referred from any other structure such as muscle, ligament, joint or intervertebral disc. It is generally acknowledged that the differentiation between sciatica and referred leg pain is not always straightforward in clinical practice but ultimately it is a clinical diagnosis. Overall, patients who complain of back and leg pain and/or sciatica suffer more severe pain and disability, take longer to recover and incur most of the indirect costs and lost workdays compared to those with back pain alone. When determining the underlying cause of lower back and lower extremity pain, both the type (a description of how the pain feels) and the area of pain distribution (where the pain is felt) help guide the physician in making a preliminary diagnosis and determining the appropriate treatment plan.

Muhammad Amin Baig is a chairman at International Alternative Medical Council (IAMC) , He continued his profession at Islamabad Pakistan as HoD & Professor of Unani Medicine & TCM, at Ajmal Unani Medical College Rawalpindi. He is a visiting Professor Open International University for Complementary Medicine, Sri-Lanka.

Background: Ancient old technique of Wet cupping commonly known as Hijama has proven its effectiveness in number of medical ailments including sciatic nerve pain. It is a long term study to evaluate the effectiveness of Wet cupping after 2 years and 5 years for patients suffering from sciatic nerve pain.

Method: 250 patients were randomly selected having no previous physical injury, between ages 18-80 years. Wet cupping sessions were done on every alternate day, 3 sessions were done in which removal of subcutaneous blood with the help of glass suction cups was done after making superficial incisions. One cup was generally applied between shoulders at T1 and C7 vertebrae area and two cups were applied on L3-L4 or L4-L5 and L5- S1 vertebrae. After these sessions the decrease in sciatic pain and improvement in quality of life of patient was assessed by Visual Analogue Score, Numeric Pain Rating Scale and WHOQOL scale at before treatment, after treatment, 1 year after treatment, 2 years after treatment and 5 years after treatment (data were analyzed by paired t test and ANOVA).

Result: Out of 250 patients, about 225 (90%) of patients have shown marked decrease in sciatic nerve pain. After 1 year of treatment, 175 (70%) of patients were satisfied and does not need any further treatment of sciatic pain, after 2 years of treatment more than 125 (50%) patients showed marked decrease in pain as compared to before treatment. 5 years after treatment 92 (37%) of patients were enjoying good quality of life as shown by their WHOQOL scale.

Conclusion: Long term benefits of Wet cupping in patients suffering from sciatic nerve pain was observed, it is concluded that overall quality of life of patient is improved and pain score is significantly decreased after 2

years and 5 years of Hijama treatment.

It has been more than Ten years since Mr. Ahmed Yahya Ayoub have become an official healthcare provider. He finished his bachelor’s degree from Philadelphia University in Jordan 2009. Eventually he proceeds to Study Master’s in Oncology Nursing from Hashemite University in 2013. He has an impressive work experience as a Senior Charge Nurse at King Hussein Cancer Center, Jordan in Medical/Surgical/VIP/ OPD. He is currently working now in Al Dhafra Hospitals (Madinate Zayed Hospital) / SEHA United Arab Emirates as outpatient Staff Nurse for more than three years. Mr. Ahmed Ayoub is a champion of Nursing Research in Al Dhafra Hospitals and follows up around 9 hospitals. He has published 4 papers entitled: Do Not Resuscitate: An Argumentative Essay, Distributed in Ethics eJournal Vol 6, Issue 81, May 14, 2013. Consent Form Analysis, Distributed in Health Care Law & Policy eJournal Vol 5, Issue 20, April 08, 2013. The Effectiveness of Initial Assessment on Pressure Ulcer Prevention among Adult Jordanian Cancer Patients, Under Review. Assessment of Nurse’s Knowledge about Glasgow Coma Scale at Al Dhafra Hospitals, Abu Dhabi, United Arab Emirates. Journal of Clinical Review & Case ReportsVol3, Issue7, 01 Sep 2018.

Background: The most important assessment in the neurological examination is to assess the level of consciousness (LOC), which is considered as the first step in neurological examination. Detecting the changes in level of consciousness depends on the accuracy of nursing assessment. The nurses should be knowledgeable, confident, and quick in performing this task. Purpose: This study is to assess UAE nurses' knowledge about GCS working in Al Dhafer Hospitals, Abu Dhabi, United Arab Emirates. Methodology: This study was carried out in the Dhafra hospitals, Abu Dhabi, United Arab Emirates in April

2018. It is a cross-sectional, descriptive study. Eighty-five nurses met the inclusion criteria, the survey was sent to 165 nurses (Respondent rate 51%). Data collection was carried out using a survey monkey instru¬ment called

“Glasgow Coma Scale”. Data coding, entry and analysis has been conducted using SPSS 20 software. The difference has been tested at 95% level of significance, and the difference that has P-value < 0.05 was considered significant. Results: The study revealed that the knowledge percentages mean of correct answers about GCS is 56.1 % {SD: ±11.7; 95% CI: [26.67-100]}. On the other hand, it revealed also that the percentages of nurses who have a good

knowledge about GCS was 50.6% and staff whom have poor knowledge were 49.4 %. Moreover, the results revealed significant relation between gender and GCS training with level of GCS knowledge. Conclusion and recommendations: The present study showed that the nurses in Al-Dhafra hospitals reflect inadequate knowledge. This finding raises concerns about the importance of knowledge and skill in assessing GCS. Continuing education and practice on the use of the GCS tool are important. A Brochure and booklet should be designated and distributed to all nurses who working in critical care units and dealing with an unconscious patient. Specific and advanced courses about GCS should be conducted in Al-Dhafra hospitals.

Jobell D Matias Mercado is currently an Anesthesiology Resident in De La Salle Medical and Health Sciences Institute, Philippines. One of her interest is to train further in the fields of cardiothoracic anesthesia, critical care medicine and neuroanesthesia. She is also enthusiastic to create researches that will contribute significantly to the advancement of the anesthetic field and care for the patients

Background & Objective: Spinal anesthesia using hyperbaric bupivacaine has become the preferred technique in cesarean section because it provides rapid anesthesia and analgesia. In many years, the conventional dose of bupivacaine is associated with hypotension that increases maternal and neonatal morbidity and mortality. Fentanyl is known to have a selective effect on the spinal cord which it enhances the action of bupivacaine on the efferent pathways but without an effect on the sympathetic pathways. The main objective of this study is to determine if low dose bupivacaine plus fentanyl is associated with less maternal hypotension compared to conventional dose bupivacaine from induction to delivery of the fetus in cesarean section. Methods: A total of 50 pregnant patients between the age of 18 and 45 years of American Society of

Anesthesiologists (ASA) physical status II for cesarean section are included. Study group-A received a total volume of 2-3 ml with a combination of 15 mcg fentanyl and less than or equal to 10 mg of 0.5% hyperbaric bupivacaine, whereas group-B also received 2-3 ml of 0.5% hyperbaric bupivacaine more than 10 mg only. The baseline demographics (age, weight, height, body mass index), baseline and intraoperative Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP), Maternal Heart Rate (MHR), Oxygen Saturation (O2

Sat) and Respiratory Rate (RR), duration of the procedure, number of hypotensive episodes and number of vasopressor used from induction to the delivery of the fetus and the APGAR score were all obtained and analyzed in this study. Results: Results after 1 minute of anesthesia administrations showed bupivacaine only group had significantly lower SBP (81.56±7.16 vs. 94.64±11.01, p-value<0.001) and DBP (51.8±9.33 vs. 63.76±9.1, p-value=01)

compared to bupivacaine plus fentanyl group. The bupivacaine only group presented with more episodes of hypotension (1, range 0-3 vs. 0, range 0-1, p value<0.001), thus with more vasopressor use as well (20 vs. 3,p-value<0.001). No notable difference in the APGAR score between the two anesthetic groups and none of the newborns delivered had an APGAR score lower than 7 at either 1 or 5 minutes of life. Conclusion: Spinal anesthesia for cesarean section using less than or equal to 10 mg bupivacaine plus fentanyl 15 mcg is effective in providing rapid anesthesia and analgesia with significantly less hypotension

and vasopressor requirements.

M S Suchi is an experienced International Pre School Principal/Manager who picked up laughter exercises from many coaches around the world. She then designed ‘Laughter Therapy' which is being used in many places such as hospitals and senior activity centres. She provides individual and group therapy in educational and home settings. She currently engages in building social awareness about holistic approach for recovery, be it depression, anxiety caused by physical or emotional pain, death in the family and the harm the unhappiness brings to people, families and communities. Her aim is to encourage people to seek help early and get on the path to recovery. Her works has been featured in local press, TV and radio and has been an invited speaker at various community clubs and educational institutions. She has also been awarded by MINDS and various community clubs in recognition of her social work.

Statement of the Problem: There is a lack of awareness about what happy hormones are, how to use positive words to feel energetic and what can be done to get happy hormones. People tend to feel unhappy for multiple reasons and neuropathic pain adds on stress levels of not only the patient but the caregivers as well. Being in pain, leads to feeling depressed and anxious in some cases. Methodology & Theoretical Orientation: Review of books and research shows that getting a dosage of happy hormones will not only ease slight pain of the patient but feeling happy will also have a positive impact on the recovery of the patient. Adopting laughter therapy and getting hormones which makes one feel good will help many to recover from neuropathic pain/long term sadness caused by having grief, anger or resentment, depression and anxiety.

 

Findings: One needs to work on his/her energies using laughter therapy which is a positive approach for not having depression and anxiety caused by neuropathic pain. The therapy can be used as a holistic way to recovery.

 

Conclusion & Significance: The laughter therapy which includes ways to get the dosage of happy hormones promotes overcoming depression and anxiety caused by neuropathic pain is a fun way to manage pain. Repeated sessions to be conducted to remind patients that life while having pain or during the recovery should go beyond just seeking medical and counselling help and also include rebuilding spiritual, physical, emotional, relational and mental health. The model has been put together for testing in many settings including hospitals, elderly homes and senior citizen centres. This study is just an effort to demystify the help available for depression and anxiety caused by pain. It is an attempt to motivate and encourage people to seek help and take a simple approach to remember and work on all aspects of their recovery.