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Focus. So I'll introduce our, our paper and our speaker in a moment and before I do that just to introduce myself, um, I'm, I'm one of the UK, um and Gas anesthetic representatives. And um I'll be hosting today along with Doctor Maria Cona, who's our international Anesthetic Representative of Gao and she's an anesthesiologist in Zambia. Uh, so welcome to everyone present today. If you can put your questions in the chat box as we go along, we can then, er, refer back to that when we come to the time at the end after the presentation. Um, the session is going to be recorded today and then uploaded onto medal, er, for catch up viewing afterwards. So, if there's any problems with that, either don't put your video back on at the end, um, or, and let us know if you've got any issues with that and if you could turn your mic and your cameras off for the presentation and then if, if you don't mind turning them back on after the presentation for our discussion time, that would be great because then we could have more of an interactive um, time like everyone's and present in the room. So without further ado, it's my pleasure to introduce Doctor Joel um and Toshi and an an and intensive care doctor working in Dua Caine. He's been on evidence based practice of anesthesiology. His major interest is suggesting new context specific, adaptable, safe and relatively cheap solutions of clinical anesthesia for resource limited settings. Um Our paper today is the efficacy and safety of an adapted opioid free anesthesia and regimen versus conventional general anesthesia in gynecological surgery for low resource settings, a randomized pilot study. So thank you so much for speaking to us today. And without further ado, I'll hand over to you and then we'll open up for a discussion time and following your presentation. Thank you. Thank you. Thank you for your help. Thank you should not forgiving us the floor. Thank you everybody. Uh Good evening everyone. Uh My name is anesthesiologist and intensive care physician from I work with I sleep in like, so which is the so just hospital in Cameroon because he's one of the hospital in Cameroon in terms of his s and the the head of department, the anesthesiology and intensive care. Uh So present great in, in the medium. Uh the that presenting this uh this slides. So we always see much of your, what's what, what? So we don't wasting much of your time. I was talking, it is green. We have the following outline. We begin with the, with this plan shall be short with the objectives, we will describe our materials and methods. We'll present our result, we'll give you discussion and we will briefly give you conclusion. Then that shall be over to introduce our topic. Uh And the study rationale why we conducted this study within its context because it's quite important to say this uh opioids, phentin, a suphan, the integral cornerstone of be anesthesia, general anesthesia or general conventional anesthesia. You will remember our formula for general anesthesia. Uh We're going to need an derivative plus the hypnotic, which can be an intravenous. One plus an inhaled hypnotic plus or minus a neuromuscular blocking agent depending on if we're going to need more relaxation to this patient for, to control v during the operative procedure as well as if we're going to need more relaxation for the procedure for the surgical, the procedure itself. So the use of opioid derivative during the period has not been without side effects. These side effects are quite dangerous and they have been commonly term postoperative adverse effect of opioids. They include respiratory depression, postoperative nausea and vomiting constipation. I use Prusis which are all going to prolong the length of hospital stay, going to cause a poor patient satisfaction as well as they're going to increase the financial cost of huan, which are all uh quite unacceptable to the in the present era where we're trying to rehabilitate patient. First, after surgery, we're trying to enhance or embark on the enhanced recovery after surgery protocol. So it is important to also see opioids. So, using a lot of opioids during the preoperative period is going to cause hyperalgesia. Uh Pain Ron Organization, which is going to lose leads to opioid abuse. And of course, the famous opioid crisis or epidemic due to opioid addiction in the United States in particular way. In 2017, there were almost 500,000 deaths due to opioid addiction and abuse to remedy to the situation of the side effect caused by opioids, uh opioids, opioid use in the pre previous period or some anesthesiologist came to, to, to remedy to this situation by this scribing or invention. And the a technique called ai anesthesia, which is actually void of using opioid within the preop period. And uh it's a kind of multimodal anesthesia drug and uh for cholic anesthesia. When we're talking about cholic anesthesia, we're going to talk about good hypnosis, good analgesia, good sim two, lysis, good anxiolytic uh uh and good my relaxation and some of these drugs that can be used in opiate free anesthesia, which are going to be calling. But the rest of the presentation are going to be alpha two adrenergic agonists, lidocaine, uh ketamine, dexamethasone, a magnesium sulfate just an M issue. But the problem we offer to the is that its si its efficacy and safety had been controversial due to mixed results from recent systematic review and me analysis. We're just going to show you about four, systematic review and meta analysis which were done uh recently between 6022. Both of them comparing opioid for anesthesia to opioid base anesthesia, both in general surgery. Here we have two randomized control trial, one by J Franken and the other one by, by Larson and the other to control trial. Uh, one specifically done in bariatric surgery and the other one done in thoracic surgery. Uh We have this and we have that and just as a sys of all these 44 randomized control trial. Uh what did they find? It actually saw that the efficacy of free anesthesia is undoubtable in good postoperative pain, reducing postoperative nausea and vomiting, reducing morphine consumption, postoperatively. But its safety has been most doubted in terms of its hemodynamic profile within the intraoperative period. Uh Some studies have shown that opioid free anesthesia is going to cause more hemodynamic instability, bradycardia hypotension, which are not quite good for the patient. And some of the side effects have mostly been used or mostly been related to the use of to do, which is quite, quite one of the reasons opioid free, free medication. And so, uh because of this, the conclusion of many of these my control trial or systematic review, sorry has been that World Power address the problem of the safety of opio free anesthesia. Uh and more precisely perhaps with the profile of DEX me or without using Dex me. And so this study came to actually answer this question. One study carried out by, by Helen Beon in French was a multicenter study on non cardiac surgery. And they compared Dex base opio anesthesia to remi phentin opioid base Estess. And they found that opio anesthesia using DEX, which is going to cause more also hypoxia, delayed ex after surgery, but especially severe brady cardia, which wanted the stop of the OPI free free anesthesia protocol. And the study was quite catastrophic because of this randomized control trial, which actually in until 214 patients showed that oid free anesthesia was quite harmful for patient. So what is the context in Africa and in Cameroon, uh where I'm, I'm working, uh, the problem with free anesthesia is that Dex Meth, which is one of the reference drug like we said, is not available in Africa because it's not marketed mainly because it is quite always relatively expensive. Uh The other problem is that gynecology, surgery is one of the most frequent surgery in our, in our in Africa and Cameroon. But well, and this surgery is particularly prone to press nausea and vomiting and intense surgical pain within 1st 48 hours. So we ask ourselves, is opiate free anesthesia do with all this or reducing postop pain, reducing postop no. And is it going to have an impact on, uh, on gynecologic surgery if we use it? And if we actually use it in the protocol is void of, they asked me to go in. So we propose this study actually control trial. It was safe and effective protocol for opioid freesia not contain in uh gynecological surgery in resource limited set to to carry our, our study was also about to determine the feasibility of our opiate free anesthesia protocol. Determine its feasibility. That means its success rate. How many of our opio freesia are we going to carry out without convincing to general anesthesia or without in adding uh more of opioid derivatives intraoperatively. Uh Equally, we wanted to find a sub specific objective. I wanted to compare the frequency of intraoperative complication and intraoperative Hagen consumption with between an Ofra group as well as uh an an opioid base anesthesia group. Then lastly, we wanted to compare the the postop pain intensity and the rate of post supress complication, the postoperative nausea and vomiting, uh Prusis urinary retention as well as patient satisfaction and financial cost of our opiate free anesthesia protocol as compared to our opioid base anesthesia protocol. So, so achieve this object, we, we describe the fully material and the methods. Firstly, this was a randomized controlled trial. Uh It was carried out in the hospital which was in room which in the period we included all as one and two adult female under green elective mastectomy, abdominal myomectomy, abdominal, uh overran debulking surgery as well as abdominal hysterectomy for benign pathology as non cancer surgery. We excluded all patient with past stroke allergy to any of the drug used for of a or opioid based anesthesia, any patient with planned adjuvant regional anesthesia and those are gen surgical complication not to advance to our to our results. We use the flu sample size uh formula. So according to this formula, we need a minimum of 34 participants, 17 in each groups, we want to insist that uh we, we actually match patient for age and in one oios group as well as an opiate based anesthesia group, we could match them on type of surgery, the type of we match them on the as a reading. So, in the preoperative period, what did we do? We obtained all the E A uh approval we needed, we obtain patient consent, E A clearance. We consulted patient where we randomized them using a simple randomization uh procedure in a ratio of 1 to 1 into an 05 group. And an opioid based uh anesthesia group data was collected to finally grade patient. Uh using the AA classification, we choose our intra patient monitoring devices which was basically oxygen, peripheral saturation, noninvasive BP, ecg temp temperature, few and uh intraoperatively, uh we corrected vital signs in the operating room. We compensated any fasting, uh any food, fasting, we administer antibiotic, prophylaxis stress, we proxy patient. And now year now we describe now our opioid free anesthesia protocol, which was basically lidocaine at 1.5 mg per kilogram. IV, magnesium sulfate at 30 mg per kilogram without without excess exceed 2.5 g in 24 hours. It was diluted in 100 MS of cline and administered as the as A as an Iviv infusion to patient. We give ketamine at 0.5 mg per kilogram. IV dexamethasone was given at 0.1 mg per kilogram IV propofol at 1.5 mg per kilogram. IV Roni was given at 0.6 mg per kilogram. IV. This was what was used to induce anesthesia in the opiate free anesthesia group. And then we proceed to intro intubation, followed by maintenance, uh anesthesia with patient. We we put under vol volume control intubation using iso one a 0.5 to 2% minimum major concentration volume. Uh Then we we calibrate it an electric pump syringe mixture, uh 10 mils to 15 mils per hour containing magnesium sulf with ST lidocaine, ketamine and cloNIDine are the following doses you can see on the screen. We want to see this uh protocol was quite adapted. Our of our protocol was adapted from a fresh protocol. Uh We, we describe earlier during our introduction for our opiate based anesthesia protocol. Uh This was just what we used for the induction for propofol and we intubated patient, we place them on wooden control still on isoflurane. Then we reinjected phentin propofol as need be the patient was placed on an electro pump, syringe mixture of the placebo normal cline stay at the same speed. We now proceed to, to really describe what we our study, uh what we uh monitoring parameter. Intraoperatively, we monitor the respiratory rate, the oxygen saturation, the tidal volume. Of course, the inspiratory expiratory uh ratio, the peep and the carbon dioxide expiratory uh uh concentration temperature was monitor. So in we equal it resuscitated any hypertension bradycardia and high BP. That was what we aim for. And post pre organization was given 30 minutes prior to the end of surgery trauma though, and it will come systematically in both groups with the o free anesthesia and the o bees anesthesia. So what was finally our, our uh our end or our end points which we need to study. The primary endpoint was the failure of opiate free anesthesia with the success rate of opiate anesthesia, which was going, which we define the failure as the need to convert to opiate base anesthesia by either injection or giving Amiri phentin, which was the main derivative we use in the opioid free anesthesia group. The occurrence of any opper complication, hypertension, high BP, in particular, as well as the amount of uh isoflurane consume in both room. The secondary endpoint was measured within the 1st 48 hours of surgery and this has to do with the pain in pain intensity, which was measured on the numerical regions. Pill, the need of post morphine or the occurrence of hypoxia postive a use, uh postop nausea and vomiting, the time taken for the patient to face to his first work with the occurrence of pur we eval postoperative satisfaction orthopedic transaction based on the cor rehabilitation uh for c uh questionnaire and the financial cost, the mean financial cost of all the anesthetic drug used in the opioid free anesthesia as well as the opioid based anesthesia protocol was compared uh to, to know what was really a state our results. So also we approached 40 women undergoing elective gynecology surgery of these, that six women were included, that was 18 in the anesthesia group and is seen in the opioid based anesthesia group. Uh Both group were quite comparable uh given that way match on many variables. So they were quite comparable at baseline. Uh In terms of age, the mean age was quite similar. The pro was quite similar. The mean uh the mean of the mean arterial pressure pre uh the mean of the of their post of the your oxygen saturation as well as the the type of surgery. We notice that very different uh that significantly different between both groups, apart from the mean body mass index where we noticed that the o bee anesthesia group was highly uh overweight or slightly obese it. And the difference was slightly was was that uh uh different, then we go to assess our prime point immediately, we had 100% success rate for the opio anesthesia group. So in our operating in our 18 page uh participant or the green ate for anesthesia, there was no need to actually use Fenty or any op derivative intraoperatively work. I work fairly well. And uh there was no re uh that was that different between group. Uh but we could, we could actually see that in the anesthesia group, there was no occurrence of hypertension, bradycardia, high BP. But we noticed some few uh occurrence of hypertension and tachycardia in the anesthesia group. But different was that nonsignificant then coming through the the intraoperative complications. Uh We decided to, we aim to monitor the hemodynamic stability of our opioid free anesthesia protocol compared to uh opioid base anesthesia protocol. And we can, we decided to if I read this used by comparing the me arterial BP. And we can see that there was quite good hemodynamic stability in the opioid free anesthesia group. Uh before induction, uh at induction of anesthesia takes a minute prior to after incision, one, a after incision. And at the end of surgery, uh the the upper free an the upper free anesthesia group, uh the upper free anesthesia group actually had really good hemodynamic stability, as you can see on the blue curve. And this was quite sally significant at one. after incision, it was really quite low and more hemodynamic stable in the o for anesthesia group. Still comparing the amount of consumption of Haine. In this case, we use for the ISO this is quite we now in Cameroon in a resource limited set. And it's also quite uh relatively cheap compared to Seran, which is at times really scarce and also very expensive. So comparing the amount of uh m Alvear concentration amount volume of, of isoflurane, we we use uh if we look again our, our blue arrow, we should present our anesthesia group. We see that uh it was quite, starting from 0.5 volume of, of isofl use. It was quite low, all true uh surgery, it was quite all low or through surgery. And this was quite that was that significantly different compared to the upper be anesthesia group. Then now we go to the secondary endpoint which was mainly the pain intensity as well as post complication or we measure up post pain intensity by uh on the numerical ratings rating scale. And we can, we can see, we can see that the post pain intensity from the first to the to the to the 20 ft, uh post rely was quite slightly significantly less in the oper free anesthesia group compared to the ate base anesthesia group. So the patient really had lesser pain at the 1st 2nd c 12 and 24. Uh postoperatively in the opiate free anesthesia group at the between 48 hours. Uh after surgery, it was still low, but the difference was not very significantly different. Then the next secondary endpoint, we sought to measure was the occurrence of re respiratory depression, which we define as hypoxemia and oxygen saturation, peripheral oxygen saturation less than equal to 95% at room. And we saw that at the effect second and sit uh sit up also, the oxygen saturation was, was really quite uh higher in the opiate free anesthesia group compared to the ate uh opiate base ania group. And the difference was that is significantly different. The this last rule actually gives a summary of all the all the uh secondary endpoint that were measured. We consider the total cost of drug use for anesthesia in the operate free anesthesia group was about 61 lbs compared to about 90 lbs used in the operate base anesthesia group. And this was significantly lesser for opio anesthesia. So it was quite economical for the opioid free anesthesia group. There, there was less postive nausea and vomiting in the op anesthesia group. There was less, there was Noris patient. We we were more saci postop recently in the opioid free anesthesia group and there was less paraly it all this was significantly different. So we'll go straight to just give you a brief discussion because we've taken so much time already talking uh by, we just want to discuss uh the pharmacodynamic property of the opioid free uh anesthesia drugs. Uh One talk about de do not use here uh which has uh all of them talk about Dez lidocaine, ketamine, magnesium, sulfate and DEXAmet dexa methasone. All of them are analgesic, that is for sure. But what is particularly uh uh good to, to, to, to emphasize here is that DEX has good sedative properties as well as good simple two properties. CloNIDine also has good sedative properties, some hypnotic properties as well as uh some angiolytic and sympatholytic properties. Lidocaine is an analgesia, of course, it has anti properties, anti-inflammatory properties and has some activities against N MD A receptors. Lido ketamine uh has good hypnotic and sedative properties. It has strong uh activities against NMG receptors. So it's been quite important in hyperalgesia, reducing the occurrence of chronic pain after surgery and reducing the need for for patient. You're getting into kind of of overuse or abuse and end up in uh what we call the opioid crisis. Ate pandemic Dexone is me uh DEXAsone. Sorry, it's an anti-inflammatory drug. Of course, with strong anti-inflammatory properties. Obviously, it has also antiemetic properties. It has some sedative and uh and anxiolytic properties. So we actually understand that combine all these drug chrome Clonazine, lidocaine, ketamine, dex, uh dex me metasone as well as magnesium. So we're going to have not only analgesic properties, we're going to have hypnosis, we're going to have anti properties. We're going to have anti-inflammatory properties of this drug. We're going to reduce anxiety. We're going to achieve hemodynamic stability through sympatholytic and we're going to reduce chronic pain as well as acute pain. So this is actually the goal of re anesthesia. We got, we got uh uh just has to give some of the strengths and limitation of this study. We'll start by giving the limitation of for relatively small samples size of 36 which was actually due to the prevailing COVID-19 pandemic. During that we conducted, this study makes it a little bit difficult to cautiously generalize the our results. Secondly, uh we cannot also cautiously generalize our results or resources limited set because this study was carried out in the tertiary modern char hospital, tertiary level of care, hospital level of care in where there was availability or reach availability of an ECG machine, electric pump range and cloNIDine intraoperatively. It's good to say these devices as well as drug cni actually scales in primary and secondary level of chaos in Cameroon. And we just this can be this the same picture in all resource limited country or settings out of Cameroon. So the randomization technique we use was a single blind uh which is not very conventional if we want to compare to double blind randomization, which so uh we think the as some select by us, which are present in our result. Then secondly, uh population study population was relatively young, healthy Nonobese, uh ST study population age uh 40 with the mean body uh mass index of uh 26 most of them were as R one and two. So we believe that we did not really test all the benefits of opiate free anesthesia, uh particularly obese patient, uh patient with respiratory handicap or insufficiency like morbid obese, patient, patient with chronic obstructive pulmonary diseases, patient having chronic pains, also, uh weight of preanesthesia has really been shown to have a lot of merits. But uh our relatively young and obese population is quite justified because this was the kind of plot study. It was the first time we conducted a anesthesia in the Cameroon. Uh and we really wanted to be sure that we really put enough security on the patient side, on the anesthesia side, in order not to have any kind of preop morbidity or mortality, which may not be good for the patient. The main strength of our study was the fact is that we propose a simple, practical, safe, effective and economic uh anesthesia which can be implemented in resource controlled environment like subs Saharan Africa where patients are really quite poor. Uh We uh we cannot overemphasize again on the the necessity of safe anesthesia in a setting where uh a lot of morbidity, a lot of an not only anesthesia but also to the surgery and to the to pre period. So in conclusion, we're going to see that uh anesthesia is growing technique, growing anesthesia technique is a multimodal anesthesia technique. Uh Our protocol of opioid free anesthesia we propose without sin which as a reference anesthetic drug that which is actually case in uh in Africa in Cameroon because of it basically high cost as well as uh the fact that it's not marketed uh uh opioid free anesthesia protocol not containing sine uh as associate in lidocaine magnesium sulfate, ketamine, dexamethasone rate with few oppressive complication including uh mild intraoperative hemodynamic exchanges. As shown that mean arterial BP that was quite relatively stable in the cul anesthesia group. Compared to the O Basia group, there was also decrease, a tremendous decrease in significance. That's a slightly significant decrease in postoperative complication. When we, we're talking about the reduction in postoperative nausea and vomiting reduction in uh post re respiratory depression crisis. Uh I use and of course, uh patient had laser pain and he had really low uh postoperative consumption. So this come to the end of our presentation, we're going to thank you for your kind attention. This is all about it. Thank you. Oh, thank you so much, Doctor Tosh for that great presentation. Uh and quiet uh timing for the kind of study that you did. Uh considering all the cha the challenges that we've had uh in our in the low middle income countries when it comes to uh access to some of these drugs. So when I was going through the paper, I thought, oh, ok. Wow. These drugs actually do have and if it actually a study was done as such as because we could actually work with some of those drugs uh to be able to carry out some of the the surgeries for our patients. So uh we are just going to open for questions now and I can see we got some questions in the chart as well from um a number of our clients, people who have joined in. And uh I've got a question from Phylis right now. Thank you so much Phyllis for having joined us. So, um the question is that, can you kindly comment on the rationale for the use of IV traMADol intraoperatively for both groups as you know, traMADol also being uh an opioid. Yeah, I don't know what to be your comment on that. Doctor Josh, the use of traMADol. Uh No, I should, I should look uh actually traMADol uh fill, fill this for your join. Thank you so much. Uh Actually traMADol or traMADol is uh is not really an derivative. TraMADol is a, is a second class analgesic. Uh We have uh we have, we have, we, if we look at the w classification of analgesic, we have uh stage grade one or stage one analgesic, we have pro more, we have uh no an we have, we have Nepa uh we have stage two analgesic where we have uh codeine, we have traMADol. Uh We have uh that's basically it. Then we have stage three analgesic where we have opioids. It's going to be morphine derivative. TraMADol is not really an op derivative, but nevertheless, traMADol was used post-operatively, not intraoperatively. It was used 30 minute prior to the end of surgery and it was continue post-operatively every eight early given as an IV intravenous bodies died intravenous bodies. So it was just as a normal, well, you know, normal post analgesic treatment and it was given both in the opiate free anesthesia group as well as the opiate based anesthesia group in order to be to have a kind of homogeneous population and to reduce uh any kind of bias when you have results. Thank you. Uh I don't know if that is, I don't know if you've gotten that. So it used postop uh operative. Yeah. OK. Uh So then the only other question is uh when do we prepare to use OPPA? There was a question from um OK. That was the question we prefer to do. Mhm Yeah. OK. Thank you. Thank you. Thank you very much. Thank you. And uh for your uh actually, uh Nepa could have be used with, you know, you also one g every six IV every it a given intravenously. Then we have uh we have Diclofenac, that's an anti-inflammatory drug uh that was given se 7.5 mg uh every 12 R at the uh intramuscularly or intravenously depending on the form we had. We, we had uh we had already three analgesics which were quite strong. Uh We could have used it for problem, we decided not to use it and we could have used it. It has its perfect place. But uh we do not also want to over anal our patient to a point that because already given anesthesia is is good post post analgesia. Given, I think again, uh this three analgesic process, more traMADol uh diclofenac is good uh in the in the the opioid group in itself is an, is a strong, strong up. It's an, it's an and it's a good analgesic and also the patient traMADol and Diclofenac, we would have used Nera with uh we thought as the food analgesic would have been too much. So nevertheless, you can use Nephro in your setting. It is not contraindicated, particularly if you're trying to uh anticipate um hyperalgesia because one good quality of the problem is that it is antihyper ges as a good activity against N MD receptors. So it's going to reduce the phenomenon of hyperalgesia. Uh it's going to reduce or inhibit pain ization and patient are going to require less period in future as well as as well as in the postoperative uh postoperative uh fix. Thank you. Uh Also, I think of a it's not all the centers that might have in our settings. I think doctor po know. So I think that is also, I think the drugs that were also used postoperatively for analgesia uh were also drugs that are quite ly available. I would say when I was looking at that they are quite available. Yeah, so I think it comes to it might be a little bit difficult for sets that do not have uh those drugs. Yeah. Uh So then uh the other question was um in terms of the contraindications for N SAS. So now the question, the question is now in the case where we have patients who uh w where the use of uh NSA is contraindicated. Uh I think that the question is what can we do in that case because you are using dexamethasone in that in I in these patients also. And then later on, we have to use diclofenac postoperatively. Yeah. So now we have those patients where we are saying, OK, we are not going to use uh NSS if I get the question correctly. Yeah, that's a, that's a very good, thank you. Thank. Thank. Thank you, Maria. That's a very, I wanted to go to the slides on uh the pharmacodynamic process of, of this drug. Uh It's, it's a very good question. Uh Maybe let me just go first to the slide on the pharmacodynamic if you be alone. Yeah. Uh uh I want to say and dexamethasone and, and that can be switched zone treat it, it doesn't change, it's not going to change much on your re anesthesia to go. Uh You can avoid it. It's not going to change anything much because uh if you have the other drug being constant, if you have ketamine, you have uh lidocaine sulfate and uh you have, you have uh uh what else? We plus or minus 20 we're going to change what we actually want with the with dexamethasone is, is an, is, is analgesic uh analgesic properties. Uh which I would say they, they will be negligible if we have the blood drugs you have, we have try ketamine magnesium. So then what we one more with dexamethasone is this anti em properties. So, no DEXAmet is you used to. So uh you just actually prevent, not only prevent but also treat also nausea and vomiting at times. Uh uh So, but it, it's good to see that it is not only DEXAmet zone has this. Mhm Hello. Yes, we can get you, we can get you now b you if you use, you can get part of the exam as well. Um uh Like is when you actually want to have antiemetic properties, you want to post nausea and vomiting. One of the side effect effect of, of opioids. Ph ph phentermine. Yeah. Uh yeah. So that, that was a good point on the uh on the point of uh having to use uh dexamethasone to for as an anti. So because um we are saying that one of the, of course, the complications of uh our opioid based anti as well as an see uh his analgetic properties. But le also as, as uh for the anti-inflammatories we see lido. So is properties. So you're not using because it is no an an drug we have the patient. I think we seem to be losing it at times. Yeah, I think we lost all again. Yeah, we've lost him again, I think. Um, ok. Um, what are the other questions that we haven't touched on just yet? We've got just curious about the general duration of the procedures. Do you ever need to redose and repeat your infusion syringe? Oh, cool. You want to talk with Jane? Do we want to tackle that question for you? Maybe tell Joel again. Um So from Jean, Joel, it says just curious about the general duration of the procedures. Do you ever need to redose or repeat your infusion syringe? I can't hear you. I think you're muted still. Yeah, it's, you're muted still. I think Joel, have you come off mute, Joel? We can't hear you. Yeah, fab. Thank you. Did you? Um So the question from Jean was, what was the question? The question from Jean was, do you need to redo of the procedure? Do you redo you? Oh, thank you. Thank you. Thank you. Thank you. Uh No, I've, I've read a quick question. This one is uh do you ever need, we do repeat your in syringe. Uh Never, never, never, never, never. Oh Did talk about this. We just use with a six ML syringe, six M syringe and we, we mix this list of a mixture of for of Analia Pro uh Yes. Uh and Cine. So, so cloNIDine, we mix this we brought it to six. And if you remember, we said we give 10, 15, ah, 10 of means per r most of our gynecology surgery in back to gynecology surgery be my, uh, abdominal myomectomy, abdominal hysterectomy, uh, ovarian, as well as, uh, mastectomy. Most the, the surge that most did not need more than three did not go above. So we should be at 15 minutes. 00, that's at least that at least five hours is syringe for at least 0.5 duration procedure. So in the syringe, there was just a syringe before the procedure got finished and you will do so. But rather in the, in the open an if you remember, we say we, we injected intravenous, the uh uh maintenance goes doses of entine as well as, as needed as need a right? Uh Sorry, that's great. Thank you, Joel. Um I think the other question we've got from lean. Did you ever have wake up delay coming from Lona Cho? Yeah. Have we lost Joel Maria? Can you hear him? Uh No, unfortunately, I can't get him actually. I think I can't, I can't hear him either. Um So I think we had a few more questions. I had a few but I think if we can't get him back, we'll maybe wait for a minute and see whether we can get him back. Um But just in the meantime, thank you so much to everyone for attending. Um in terms of feedback, you'll be sent an email and if you can fill in um the, the feedback form, then you'll get a certificate emailed through to me from me. Um And if anyone has any ideas of papers or speakers for our upcoming and journal club, please let us know um in terms of upcoming events. So the next journal club from office on the 12th of September and that one will be with a surgical focus um our annual conference. So I'll just share screen, see if I can get the poster wrap is coming up. So our annual conference is coming up on the 23rd of it's hybrid and in person is in Oxford, but there's also virtual options available and it, it be uh for all those from N IC attending virtually. Um The theme is health equity. Um So it'd be great to see as many there as possible. It should be really exciting, exciting day like ours last year. Let's see if I can show you the poster. I don't know whether the technology is being on our side tonight. It might not be coming up. Oh, it is. If not, then we'll uh have a little of our events on our, our social media. So that's the conference and the abstract um have now open so you can submit abstracts um to present. Um And finally, our Innovation Girls course is ongoing and all of these events access through the medal platform. Um And the on demand content. It also on there so you can catch up to date um and keep an eye on our social media and I we were hoping that Joel might return. I don't know whether has he left or not? Was there any other comments from anybody else in terms of discussion? Hi, Jack. Hi Fe. Um Let me try and contact him and see and then we'll see what happens. He might just be back, I think. Um, and then he can answer all the questions fab Thank you, Jim and Maria. I was, I was just gonna ask in terms of in Zambia, do you tend to use any opioid free anesthetic regimes there for any particular types of surgery or patient? Uh, not if we can't help it. Yeah, not if we can't help it. Yeah. Um, yeah. Well, in terms of a crisis, of course, uh, when we are trying to still get in some stock, we had to use, uh, and the combination of dexamethasone, but not because we wanted to, only because we are still waiting for the, to come by and when they came by, of course, we use them. So that's why I said this is an interesting paper. I'm looking at things a little bit differently now. So, yeah, and in terms of we'll see how it goes in terms of the availability of that, that job that you did in the free, um, and regimen. Are they that are available on year. Yes. So uh is already available. Yeah. So both for the induction, the only one which we might struggle a little bit with was the Rocuronium. We are not yet. Um having that already, especially in our uh uh public hospitals. I think our private hospitals have, have that but our government hospital is not yet. It's already available. So that's otherwise everything else is there. Yeah. Yeah. Any luck with uh with, with Joel Jan or no, I've texted him. He hasn't replied. So I don't know what's happening at the moment. However, I think, um have we got a few more questions um from the suggestion box then we can divert it to um Maria and see if she can share some of her great in. Um Did we talk about MP P? No, we haven't talked about PPI yet. That was the only one we haven't mentioned. Cool. Um Maria, do you guys do nsaids? Uh Do you do ppi for nsaids? Oh NSA is I think you want me. I, sorry, sorry. Uh I was saying not as routinely as we would like to, to do it just uh the availability of the, the tps. Um but when it's available, we do get to use it not just consistently though because it's uh quite erratic in terms of supply. So when it's available, we get to have protection for some of these patients. Yeah, cool, quick question. Um Do you ever do G A sections, there's a complication and this uh there is a complication that OK. Um Just so because in England, um obviously talking about H IC context, we tend to get pre so that will be a PPI and A uh I can't remember what is sorry, it's been a long day neighbor. Um But yeah, um and we tend to give pre for everyone for section not only G A but also for um spinal so lungs, they were like 12 and that the case maybe refer to what um Fiona have we got any more questions? I mean, I had a few questions particularly. So um really um as much, do you have any, do you have much experience Jane in your Institute of Opioid Free Anesthetics? I know we've had a couple consultants like it down here, but not totally opiate free. Um But more like opiate light is what people tend to do. So if I can get away with most things with a block of the spinal, then we go ahead and do it. Um And then we'll just try and be opiate free, the other thing that we normally do um So that I can do a good block. So we do a fair amount of ultrasound guided region around here, big um fractures, rib fractures, that kind of thing. Um So it's not in the Jerry's in population that we tend to go. Um Absolutely gun ho about opaque free, but the others. Um, it, it's up to what's happened and whatever is happening around. Um, it's more in the day and age of TIVA. I do notice I don't give any long acting, um, opiates in our institutes but I won't say opiate. Well, I, I call rem is still opioid so there'll be, there'll be some reme on board and then see what happens. POSTOP and that's pretty much what we normally do. Love you guys. We got back. I think Jo back. Is he when I just saw him pop up again? But maybe he's not. Yeah. Hello. Hello. Hi. The network was a little bit messy. Sorry. That's ok. Don't worry too. Um, I think the last question we had was, um, talked about the PPI one. I mean, I was just interested in knowing since you've done this study. Have you adopted it as your practice in, in this, um, a subpopulation of patients. Have you, have you noticed any ongoing changes? Ok. OK. I know. Did you hear the question Joel? Did that come through or not? I'm sorry. Uh uh Thank you. I'm sorry. Uh Fiona, the, the network is very bad. I, I'm not really had to put some cloud. Is it possible for you to type it down? Yeah, of course. No, no, I did not get your question very well. The network was, was, was a little bit a mess. It's possible for you to type your question down. It will be for me. Yeah, I was in a question from Maria. Hi. I, I'm waiting questions from, from, so which show home now? I've just had mine in the chat. Not yet. Where is it? Mm. Ok. Cool. Cool. Since doing this study, have you adopted this in your practice in this group? And have you noticed any ongoing change? Yeah. Thank you for your question. Uh, Fiona, actually, we, we adopted this, uh, this, I need to, I have to really uh admit that this study was, was done as my end of the end of this ation for my specialization as an anesthesiologist in uh it was done when the, I mean, it will because cities in Cameroon is, which is the cap, the cap the political capital of and one is like uh is like the economic capital elsewhere is there is much more risk than the more presidency and it takes many things. So this study was done, written anesthesiologist and to, to while I'm practicing today. And uh I bet you we do it almost for all uh procedure. We do it enc surgery and the legs who moved to, to ur I need uh you move to thoracic surgery. Uh No, just see is working like the actually um um and you need to right now on the benefit of this uh protocol or particularly the now did surgery with this. There are a few studies on you on the. So with where there are a few studies on it. So we see for the, the the OK, good. Is working well using practice and. Ok. Ok. Right. Fab Joel. Thank you so much. Um And thank you so much for taking the time to and present to us this evening. It was going to be my, my next question actually was what studies you're planning on doing. So, um but thank you so much for joining us and um and thank you everyone for bringing us online. And uh yes, hopefully we'll see you for our next journal club or at the conference coming up in, in the autumn. It'd be great to see you there. Alright, everyone take care we use use, we use for in our day. So the practice she anesthesia um it is walk. Uh I could be well. Oh, yes, fair. Shall we close the stage? I think we're done now, aren't we? Hello? Yeah, I just wanted to double check on. Yeah, just are you able to see that, Fiona? No, I think we just press the red hangout button and then we finish. Ok. But well done. That was good. It's really difficult with the internet sometimes. Um sometimes it is best if we just let them them talk and then we do the presentation but we can discuss it later. Yeah, but thank you very much, Doctor Ducky. Thank you very much, Doctor. Bye bye. I'm just going to go