The determination of cerebral perfusion pressure (CPP) is regarded as vital in monitoring patients with severe traumatic brain injury. Besides indicating the status of cerebral blood flow (CBF), it also reveals the status of intracranial pressure (ICP). The abnormal or suboptimal level of CPP is commonly correlated with high values of ICP and therefore with poor patient outcomes. Eighty-two patients were divided into three groups of patients receiving treatment based on CPP and CBF, ICP alone, and conservative methods during two different observation periods. The characteristics of these three groups were compared based on age, sex, time between injury and hospital arrival, Glasgow Coma Scale score, pupillary reaction to light, surgical intervention, and computerized tomography scanning findings according to the Marshall classification system. Only time between injury and arrival (p = 0.001) was statistically significant. There was a statistically significant difference in the proportions of good outcomes between the multimodality group compared with the group of patients that underwent a single intracranial-based monitoring method and the group that received no monitoring (p = 0.003) based on a disability rating scale after a follow up of 12 months. Death was the focus of outcome in this study in which the multimodality approach to monitoring had superior results.

Over the years, the number of pediatric patients undergoing surgeries are increasing steadily. The types of surgery vary between elective to emergency with involvement of multidisciplinary teams. The development of day care surgery unit is expanding where the patients will only come to the hospital on the day of surgery and discharge home after such as satisfactory parameters achieved, minimal to no pain, minimal to no bleeding from surgical site and able to tolerate fluids. Hospitalization and surgery could contribute to significant psychological disturbance to the children. These issues are not being addressed as children have difficulty in conveying their problems and fear. They do however express it through negative behavioral changes.

The ideal intraoperative intravenous fluid in paediatric anaesthesia and surgery is still debatable. This is essential to overcome physiological changes to maintain safety and wellbeing of the patient. A new isotonic "balanced solution" (Sterofundin ® ISO) has been introduced to replace existing intraoperative fluid of choice (Ringer's Lactate). The study aimed to observe any changes in electrolytes and acid base after infusion of each study solutions and to evaluate any post infusion electrolytes and acid base differences between both study solutions. The double blinded randomized control trial involved 141 paediatric patients who were subjected to minor surgical procedure of less than 3 hours were randomized into Ringer's Lactate or Sterofundin ® ISO group. The electrolytes and acid base parameters were assessed at pre-infusion and post-infusion time. There were significant difference in glucose, potassium (K +) and chloride (Cl-) level between pre-infusion and post-infusion values with those given Ringer's Lactate. There were also significant different in pH, base excess, glucose, Calcium (Ca 2+), Chloride (Cl) and lactate level between pre-infusion and post-infusion values with Sterofundin ® ISO. When comparing the mean difference (pre-infusion and post-infusion) between Ringer's Lactate and Sterofundin ® ISO, calcium (Ca 2+) is the only electrtolyte which found to be significant (P=0.015) with the values of (Means±SD 0.005±0.07) mmol/L and (Means±SD 0.02±0.06) mmol/L respectively. Both study solutions showed variable effects of electrolytes and acid base parameters and no fluid was found to be superior in paediatric surgical patients underwent minor surgery of less than three hours.

Anaesthesia for early emergency separation of premature conjoined twins is extremely rare as surgery generally done electively between 2 to 4 months of age. However, urgent separation may be needed due to life-threatening complications. We report a case of successful early separation of premature omphalopagus twins at 36 weeks of gestational age with a combined weight of 2.7 kg. To the best of our knowledge, this was the lowest weight yet reported of successful surgical separation in Malaysia. Early separation was indicated as extrauterine twin-to-twin transfusion with unbalanced blood shunting through the porto-systemic anastomoses within the shared liver parenchyma potentially risked impending life-threatening organ failures. Anaesthesia for the separation of premature conjoined twins in the emergency setting requires extensive multidisciplinary discussion and planning. Factors predicting difficult anaesthesia in this case were the twins’ size and age as well as duration of anaesthesia. Two separate anaesthetic teams were required with all team members well versed in the operative workflow. Simultaneous airway management, prevention of hypothermia, and vigilant haemodynamic monitoring are key to successful anaesthesia in premature conjoined twin separation.