Jurnal Anestesiologi dan Terapi Intensif
Jurnal Anestesiologi dan Terapi Intensif (JATI) (e-ISSN: 3090-3580) is a peer-reviewed, open-access journal published triannually (April, August, and December) by the Department of Anesthesiology and Intensive Care, Faculty of Medicine, Udayana University, in collaboration with the Bali Chapter of Indonesian Society of Anesthesiology and Intensive Therapy (PERDATIN). The journal aims to disseminate high-quality scientific work in the fields of anesthesiology, intensive care medicine, pain management, perioperative medicine, and basic clinical sciences. All submissions are reviewed through a double-blind peer-review process. JATI welcomes original research articles, reviews, selected case reports, and editorials from clinicians, researchers, and scholars in related fields.
Udayana University and Indonesian Society of Anesthesiologists (PERDATIN)
Authors retain copyright and grant the journal the right of first publication with the work simultaneously licensed under a Creative Commons Attribution License (CC BY 4.0) that allows others to share, use, distribute, and reproduce the work in any medium, provided the original author and source are properly credited.
Anesthesia Management in Aneurysm Clipping Surgery with Chilaiditi Sign : a Case Report
Chilaiditi sign is the asymptomatic interposition of the colon between the liver and diaphragm; when accompanied by gastrointestinal symptoms, it is termed Chilaiditi syndrome. Its coexistence with aneurysmal subarachnoid haemorrhage creates competing anaesthetic priorities, including aspiration prevention, lung protection, and control of cerebral haemodynamics. We report a 79-year-old woman who presented with sudden severe headache and transient loss of consciousness. Imaging demonstrated subarachnoid haemorrhage from a ruptured left posterior communicating artery aneurysm, together with incidental colonic interposition beneath an elevated right hemidiaphragm, bilateral pleural effusions, and partial right-lower-lobe collapse. After 10 hours of fasting and pharmacological aspiration-risk mitigation, general anaesthesia was induced with thiopental, remifentanil, and rocuronium using a modified rapid-sequence approach that included preoxygenation, cricoid pressure, gentle mask ventilation, and video laryngoscopy. Pressure-controlled ventilation and close haemodynamic control were maintained throughout aneurysm clipping. No intraoperative rupture, aspiration, haemodynamic instability, or respiratory deterioration occurred. The patient was extubated 36 hours after surgery and discharged on postoperative day 8 with a modified Rankin Scale score of 1. This case highlights the need to individualise induction and ventilation when Chilaiditi sign coexists with urgent intracranial surgery. The uneventful outcome of a single case should not be interpreted as evidence that modified induction is generally safer than classical rapid-sequence induction.
Copyright (c) 2026 Wisnu Wardhana, I Putu Pramana Suarjaya (Author) https://creativecommons.org/licenses/by/4.0
Comparison of Continuous and Intermittent Bolus Enteral Nutrition in Patients with Severe Traumatic Brain Injury: A Randomized Controlled Trial
Introduction: Severe traumatic brain injury (TBI) is associated with impaired gastric motility and dysregulated glucose homeostasis, making optimal enteral nutrition challenging. This study compared continuous and intermittent bolus enteral nutrition in terms of gastric residual volume (GRV), glycemic variability, and gastrointestinal tolerance in patients with severe TBI. Patients and Methods: An assessor-blinded, randomized controlled trial was conducted in 60 adult patients with severe TBI admitted to the intensive care unit. Participants were randomly assigned to continuous (n = 30) or intermittent bolus enteral nutrition (n = 30) during the first 24 hours after ICU admission. GRV was measured every 4 hours using gastric ultrasonography. Glycemic variability was assessed using the coefficient of variation (CV), and diarrhea was recorded as a marker of gastrointestinal tolerance. GRV was analyzed using repeatedmeasures analysis of variance (ANOVA), while glycemic fluctuation and diarrhea incidence were analyzed using Fisher’s exact and chi-square tests. Results: Sixty patients were analyzed, with comparable baseline characteristics between groups. Repeated-measures ANOVA demonstrated a significant overall effect of feeding method on GRV (F(1,58) = 158.235, p < 0.001) and a significant time × group interaction (Greenhouse–Geisser corrected F(3.980,230.814) = 3.437, p = 0.010). During the 24-hour observation period, continuous feeding resulted in a lower overall GRV than intermittent bolus feeding (mean difference 18.9 mL; 95% CI 15.9–21.9). Glycemic fluctuation was similar between groups (p = 0.500), whereas diarrhea occurred less frequently with continuous feeding (20.0% vs 50.0%, p = 0.008). Conclusion: During the first 24 hours of ICU admission, continuous enteral nutrition was associated with lower overall GRV and a lower incidence of diarrhea than intermittent bolus feeding, while glycemic fluctuation was comparable between groups. Further studies are warranted to evaluate long-term clinical outcomes.
Copyright (c) 2026 Agiel Fahlevie Choirunanda, I Wayan Aryabiantara, Ida Bagus Krisna Jaya Sutawan, I Gusti Putu Sukrana Sidemen (Author) https://creativecommons.org/licenses/by/4.0
Faster Induction, Lower Consumption, and Quicker Recovery: A Comparison of Eleveld and Schnider TCI Models for Sedation in Outpatient Colonoscopy
Introduction: Outpatient colonoscopy is commonly performed under sedation, and propofol is frequently selected because of its rapid onset and short recovery profile. Target-controlled infusion (TCI) may improve dosing precision, but the comparative performance of the Eleveld and Schnider models during outpatient colonoscopy remains insufficiently defined. This study compared the Eleveld and Schnider TCI models for propofol sedation in patients undergoing outpatient colonoscopy. Patients and Methods: This randomized, participant- and assessor-blinded, parallel-group controlled trial included 36 adults aged 20-65 years with ASA physical status I-III and BMI <30 kg/m2 who underwent elective outpatient colonoscopy. Participants were allocated to receive propofol using either the Eleveld or Schnider TCI model. The initial effect-site concentration was 2 µg/mL and was titrated by 0.5 µg/mL until a BIS value of 70 was achieved. The primary outcome was induction time, defined as the time from propofol infusion initiation to BIS 70. Secondary outcomes were mean propofol consumption, number of effect-site concentration adjustments, post-procedural agitation assessed using RASS, and recovery time to GCS 15. Results: The Eleveld model was associated with shorter induction time than the Schnider model (4.03 ± 0.81 vs 5.32 ± 0.98 minutes; p <0.001) and lower propofol consumption (92.47 ± 28.29 vs 119.24 ± 31.56 µg/kg/min; p = 0.011). Recovery time was also shorter in the Eleveld group (5.27 ± 1.71 vs 7.88 ± 1.94 minutes; p <0.001). The number of effect-site concentration adjustments and postprocedural agitation did not differ significantly between groups. Conclusion: The Eleveld TCI model was associated with faster induction, lower propofol consumption, and faster recovery than the Schnider model during outpatient colonoscopy, with comparable sedation adjustment requirements and post-procedural agitation. These findings suggest that the Eleveld model may improve sedation efficiency in this setting, although larger studies are needed to confirm its clinical and safety advantages.
Copyright (c) 2026 Aditya Wangsa, I Gusti Agung Made Wibisana Kurniajaya, Tjahya Aryasa EM, I Made Gede Widnyana (Author) https://creativecommons.org/licenses/by/4.0
Efficacy of Pregabalin Versus Gabapentin as Preemptive Analgesia in Patients Undergoing Modified Radical Mastectomy: a Randomized Controlled Trial
Introduction: Postoperative pain after modified radical mastectomy (MRM) increases morbidity, opioid use, and recovery time. Gabapentinoids may reduce central sensitization when administered before surgical injury. This study compared pregabalin and gabapentin as preemptive analgesics in patients undergoing MRM. Patients and Methods: This double-blind randomized controlled trial was conducted at Ngoerah Hospital, Denpasar. Forty-two patients scheduled for elective MRM were allocated to oral pregabalin 150 mg (n = 21) or oral gabapentin 900 mg (n = 21), administered two hours before surgery. The primary outcome was Visual Analogue Scale (VAS) pain score at 12, 24, and 48 hours postoperatively. Secondary outcomes were time to first rescue analgesia and cumulative opioid consumption during the first 24 postoperative hours. Between-group comparisons used the independent t-test or Mann-Whitney U test, as appropriate. Results: Pregabalin produced lower VAS scores than gabapentin at 12 hours (2.18 +/- 0.65 vs 2.65 +/- 0.74; p = 0.034), 24 hours (2.27 +/- 0.66 vs 2.71 +/- 0.63; p = 0.030), and 48 hours (1.90 +/- 0.65 vs 2.36 +/- 0.71; p = 0.033). Time to first rescue analgesia was longer with pregabalin (232.69 +/- 19.88 vs 219.88 +/- 17.81 minutes; p = 0.034), and 24-hour opioid consumption was lower (240 [145] vs 360 [155] micrograms fentanyl equivalent; p = 0.034). No adverse hemodynamic. Conclusion: Preoperative oral pregabalin 150 mg provided statistically superior analgesia and reduced opioid consumption compared with gabapentin 900 mg after MRM. However, the absolute differences in pain scores and rescueanalgesia time were modest; therefore, safety monitoring and larger studies are warranted
Copyright (c) 2026 Yolanda Jenny Yolanda Jenny, Made Septyana Parama Adi, I Putu Kurniyanta, I Putu Pramana Suarjaya (Author) https://creativecommons.org/licenses/by/4.0
Regional Anesthesia and Ultrasound-Guided Peripheral Nerve Blocks in Current Practice
This editorial underscores the increasing centrality of regional anesthesia in contemporary anesthesiology, as reflected in the current issue. Peripheral nerve blocks and ultrasound-guided techniques are highlighted as key drivers of a broader shift toward precision, safety, and patient-centered perioperative care. Regional anesthesia has evolved beyond its traditional role, contributing to improved postoperative outcomes through optimized analgesia, reduced opioid use, and enhanced recovery. The integration of ultrasound has further strengthened accuracy, reproducibility, and educational value in clinical practice. However, the expansion of these techniques must be supported by adequate training, standardization, and vigilant attention to patient safety. Overall, this issue illustrates an evolving discipline in which innovation must remain aligned with evidence-based practice and clinically meaningful outcomes.
Copyright (c) 2026 Tjokorda Gde Agung Senapathi (Author) https://creativecommons.org/licenses/by/4.0
Phenylephrine Infusion for Preventing Hypotension in Obese Parturients Undergoing Caesarean Delivery: A Systematic Review
Background: Spinal anaesthesia-induced hypotension is common during caesarean delivery, and the optimal phenylephrine dosing strategy for obese parturients remains uncertain. This systematic review evaluated the efficacy and dosing regimens of prophylactic phenylephrine infusion in this population. Methods: PubMed, ScienceDirect, the Cochrane Library, and Scopus were searched for randomised controlled trials published from 2010 through 2025. Eligible studies included parturients with singleton pregnancies at ≥36 weeks of gestation, a body mass index ≥30 kg/m², and no major comorbidities. Phenylephrine infusion was compared with bolus regimens or alternative infusion doses. The primary outcome was maternal hypotension; secondary outcomes included reactive hypertension, maternal adverse effects, and neonatal outcomes. Risk of bias was assessed using Cochrane RoB 2, and findings were synthesised narratively because of clinical and methodological heterogeneity. Results: Three randomised controlled trials involving 334 parturients were included. Phenylephrine infusion was associated with fewer hypotensive episodes than bolus administration, although the certainty of evidence was low. One dose-response trial reported preliminary ED₅₀ and ED₉₀ estimates of 0.42 and 0.68 µg/kg/min, respectively. Higher infusion doses were associated with more reactive hypertension, whereas bradycardia did not differ significantly across groups. Nausea, vomiting, and neonatal outcomes showed no consistent between-group differences. Conclusion: The certainty of evidence was low for most outcomes, precluding firm conclusions about the efficacy and optimal dosing of phenylephrine infusion in obese parturients without major comorbidities. Reactive hypertension increased with higher infusion doses, whereas evidence for bradycardia and neonatal safety remained limited. Larger, standardised trials are needed, particularly in parturients with severe obesity or comorbidities.
Copyright (c) 2026 Dr. Angelo Alexander, Dr. Felix Kurniawan Adithia, Dr. Guwivanda Helga Firjatullah, Dr. Sianty Dewi (Author) https://creativecommons.org/licenses/by/4.0
Bougie-First Versus Stylet-First Technique for Tracheal Intubation in Adults: A Systematic Review and Meta-analysis
Introduction: Bougie-first and stylet-first techniques are widely used to facilitate adult tracheal intubation, but randomized evidence remains inconsistent across emergency, intensive care, and operating room settings. This systematic review and meta-analysis aimed to compare bougie-first versus stylet-first intubation in adults, focusing on first-attempt intubation success and key procedural and airway-related safety outcomes. Material and Methods: We conducted a PRISMA 2020–compliant systematic review registered in PROSPERO (CRD420261298317). PubMed, Scopus, Web of Science, and Cochrane CENTRAL were searched from database inception to 31 January 2026. Records were screened in duplicate, and randomized controlled trials enrolling adults (≥18 years) undergoing oral tracheal intubation comparing a planned bougie-first strategy versus a planned stylet-first strategy were included. Random-effects meta-analyses pooled dichotomous outcomes as odds ratios (ORs) and continuous outcomes as mean differences (MDs). Results: From 1,158 records, eight randomized controlled trials involving 2,578 participants were included. First-attempt intubation success did not differ significantly between bougie-first and stylet-first techniques (OR 0.99, 95% CI 0.37–2.65; p = 0.980), with substantial heterogeneity (I² = 89.05%; p < 0.001). Bougie-first was associated with longer time to successful intubation (MD 21.84 seconds, 95% CI 5.55–38.14; p = 0.010), although heterogeneity was very high (I² = 97.37%; p < 0.001). There were no significant differences in more than one attempt (OR 0.91, 95% CI 0.21–3.91; p = 0.900), esophageal intubation (OR 0.48, 95% CI 0.17–1.40; p = 0.180), pulmonary aspiration (OR 1.47, 95% CI 0.57–3.75; p = 0.420), or postoperative sore throat (OR 1.10, 95% CI 0.48–2.52; p = 0.830). Conclusion: Current randomized evidence did not demonstrate a consistent difference in first-attempt intubation success between bougie-first and styletfirst tracheal intubation in adults. Bougie-first was associated with longer intubation time, but this finding should be interpreted cautiously because of very high heterogeneity and variable timing definitions.
Copyright (c) 2026 Oktavio Jalu K.J, I.P. Fajar Narakusuma, G.B.S.P.N. Oka, Regina F. Napitupulu, Jeseline F. Liem, Tirza F. Amaris, Elmer S. Cruz (Author) https://creativecommons.org/licenses/by/4.0
Pre-induction Stroke Volume Variation as a Predictor of Early Post-induction Hypotension in Non-Cardiac Surgery: A Cross-sectional Observational Study
Introduction: General anesthesia induction-related hypotension is common and is associated with postoperative organ injury. Dynamic indices derived from echocardiography may help identify patients at risk, although stroke volume variation (SVV) is conventionally more robust under controlled mechanical ventilation than during spontaneous breathing. We investigated whether pre-induction transthoracic echocardiography-derived SVV was associated with arterial pressure 10 min after induction in adult elective non-cardiac surgical patients. Patients and Methods: This single-centre cross-sectional observational study enrolled consecutive adult patients undergoing elective non-cardiac surgery with general anesthesia at a tertiary hospital (August–September 2022). Pre-induction SVV was measured in the supine position using the left ventricular outflow tract method during standardized spontaneous breathing. Anesthesia was induced with propofol 1.5 mg kg−1, fentanyl 2 µg kg−1, and atracurium 0.5 mg kg−1. Non-invasive arterial pressure was recorded for 10 min after induction. The prespecified primary outcomes were systolic blood pressure (SBP) and mean arterial pressure (MAP) at 10 min. Spearman’s rank correlation was used. Results: Sixty-four patients were analysed (mean age 48.4 yr; 57.8% male; 62.5% ASA physical status II). Mean pre-induction SVV was 13.4% (SD 4.3). Mean systolic blood pressure (SBP) decreased from 116.1 (7.9) mmHg pre-induction to 93.3 (6.3) mmHg at 10 min; mean arterial pressure (MAP) from 93.4 (12.3) to 76.8 (6.1) mmHg. Higher pre-induction SVV correlated with lower SBP at 10 min (Spearman r = −0.494; 95% CI −0.660 to −0.282; P < 0.001) and lower MAP at 10 min (r = −0.676; 95% CI −0.790 to −0.516; P < 0.001). Conclusion: Pre-induction transthoracic echocardiography-derived SVV was associated with lower arterial pressure 10 min after induction. Because the study was observational and measurements were obtained during spontaneous breathing, the findings should be interpreted as hypothesis-generating and warrant confirmation in prospective studies.
Copyright (c) 2026 Marthen Luther King Elmas, Putu Agus Surya Panji, I Ketut Wibawa Nada (Author) https://creativecommons.org/licenses/by/4.0
Diaphragm Thickening Fraction vs Rapid Shallow Breathing Index in Predicting Weaning Success: A Prospective Diagnostic Study
Introduction: Weaning from mechanical ventilation is a critical step in intensive care, and inaccurate assessment may increase the risk of complications. The rapid shallow breathing index (RSBI) is widely used to evaluate weaning readiness but does not directly assess diaphragmatic function. Diaphragm thickening fraction (DTF), measured by bedside ultrasound, has been proposed as an additional predictor of weaning success. This study aimed to compare the diagnostic performance of DTF and RSBI in mechanically ventilated ICU patients. Patients and Methods: This prospective diagnostic accuracy study was conducted in a tertiary hospital in Denpasar, Indonesia, from September to December 2022, in accordance with STARD 2015 guidelines. Adult patients aged 18–65 years who received invasive mechanical ventilation for >24 hours and were considered ready for weaning were included. RSBI and right-sided DTF were measured at the fifth minute of a spontaneous breathing trial. Weaning success was defined as extubation without reintubation, noninvasive ventilation, or death within 48 hours. Results: Fifty-six patients were included, of whom 73.2% achieved successful weaning. DTF demonstrated high sensitivity (95.4%) and moderate specificity (75.0%), with a positive predictive value of 93.3% and a negative predictive value of 81.8%. RSBI showed sensitivity of 97.5% and specificity of 80.0%, with higher discriminative performance (AUC 0.88 vs 0.79). Confidence intervals and statistical comparisons between AUCs were not performed. Conclusion: Both RSBI and DTF were associated with weaning success. RSBI demonstrated superior overall diagnostic performance and remains the primary assessment tool. DTF may provide additional physiological information on diaphragmatic function and serve as a complementary parameter during weaning assessment.
Copyright (c) 2026 Deif Tunggal, I Gusti Ngurah Mahaalit Aribawa, Dewa Ayu Mas Shintya Dewi (Author) https://creativecommons.org/licenses/by/4.0
Epidural Anesthesia for Cesarean Section in a Parturient with Chiari I Malformation: a Case Report
Chiari I malformation is a congenital neurological condition characterized by caudal herniation of the cerebellar tonsils, which may alter cerebrospinal fluid dynamics and complicate anesthetic management during pregnancy. The optimal anesthetic approach for parturients with this condition remains controversial, particularly regarding the safety of neuraxial anesthesia. We report the case of a 28-year-old woman with a known Chiari I malformation who presented at term gestation and underwent an urgent cesarean section after the onset of regular uterine contractions. Preoperative neurological evaluation and imaging demonstrated stable cerebellar tonsillar herniation without syringomyelia or signs of increased intracranial pressure. Following multidisciplinary consultation, epidural anesthesia was selected to minimize abrupt cerebrospinal fluid pressure changes and maintain hemodynamic stability. Epidural anesthesia was performed using 15 mL of 0.5% plain bupivacaine, achieving a T6 sensory block level. A healthy neonate was delivered with APGAR scores of 8 and 9 at 1 and 5 minutes, respectively. The procedure was performed uneventfully, with stable intraoperative parameters and no neurological complications. Postoperative recovery was smooth, and no neurological deterioration was observed during follow-up. This case highlights that carefully planned and titrated epidural anesthesia may be a feasible anesthetic option for cesarean section in selected parturients with Chiari I malformation following thorough multidisciplinary assessment.
Copyright (c) 2026 I Wayan Ade Punarbawa, Nyoman Bendhesa Wirananggala (Author) https://creativecommons.org/licenses/by/4.0
Scalp Nerve Block for External Ventricular Drain in a Geriatric Patient with Anticipated Difficult Airway: A Case Report
Emergency neurosurgical procedures in geriatric patients with an anticipated difficult airway pose major anesthetic challenges due to limited physiological reserve and the risk of hemodynamic instability during general anesthesia. We report the use of a scalp nerve block (SNB) as the primary anesthetic technique for urgent external ventricular drain (EVD) placement in a female patient in her mid-70s with intracerebral hemorrhage and obstructive hydrocephalus. She presented with decreased consciousness and a LEMON score of 6, indicating a high likelihood of difficult airway, and was classified as American Society of Anesthesiologists (ASA) physical status IIIE. Given the elevated intracranial pressure and anticipated difficulty in airway management, SNB with lidocaine and dexmedetomidine as an adjuvant was performed under standard monitoring. The procedure was completed uneventfully, with stable hemodynamics and adequate analgesia, without the need for airway manipulation or conversion to general anesthesia. This case highlights that SNB may be a feasible alternative anesthetic approach for selected high-risk geriatric patients undergoing EVD placement, particularly when airway intervention may be hazardous or when advanced airway and critical care resources are limited. Further reports and larger studies are required to determine safety and generalizability.
Copyright (c) 2026 Komang Ady Widayana, Andika Metrisiawan (Author) https://creativecommons.org/licenses/by/4.0
Integrasi Pendekatan Multimodal dalam Praktik Anestesiologi dan Terapi Intensif
Praktik anestesiologi dan terapi intensif mengalami pergeseran paradigma dari penggunaan terapi tunggal menuju strategi multimodal yang terstruktur dan saling melengkapi. Bukti ilmiah menunjukkan bahwa multimodal analgesia pada pembedahan mayor meningkatkan kontrol nyeri, menurunkan konsumsi opioid, serta mempercepat pemulihan pascaoperasi. Temuan ini menegaskan bahwa pendekatan multimodal merupakan elemen utama dalam manajemen perioperatif modern yang berfokus pada luaran klinis yang lebih baik. Pendekatan ini sejalan dengan konsep personalized anesthesia, di mana pilihan obat, teknik anestesi, dan strategi analgesia disesuaikan dengan karakteristik, komorbiditas, serta risiko individual pasien. Pada populasi berisiko tinggi, personalisasi multimodal menjadi faktor kritis dalam menjaga stabilitas perioperatif. Pemahaman baru mengenai respons stres perioperatif semakin menguatkan urgensi pendekatan multimodal. Peningkatan sitokin proinflamasi dan biomarker stres telah dikaitkan dengan komplikasi neurologis pascaoperasi, sehingga mengatur respons biologis berlebihan menjadi bagian penting dari keberhasilan terapi. Agen farmakologis seperti dexmedetomidine, dengan efek sedasi, analgesia, dan stabilitas hemodinamik, memberikan nilai tambah melalui penurunan kebutuhan opioid dan anestetik volatil, serta peningkatan kualitas pemulihan. Teknik anestesi regional berbasis ultrasonografi juga berperan sentral dalam multimodal perioperatif karena meningkatkan presisi tindakan, mengurangi risiko komplikasi, dan memberikan analgesia superior. Meskipun terdapat kekhawatiran mengenai kompleksitas protokol dan ketersediaan sumber daya, bukti menunjukkan bahwa strategi multimodal dan personalisasi terapi memberikan hasil klinis yang lebih baik serta efisiensi sistem yang lebih tinggi. Dengan komitmen terhadap praktik berbasis bukti dan pelayanan yang berpusat pada pasien, integrasi multimodal akan menjadi fondasi penting bagi peningkatan mutu dan keselamatan dalam anestesiologi dan terapi intensif.
Copyright (c) 2025 Aryawangsa Anak Agung Ngurah (Author) https://creativecommons.org/licenses/by/4.0
Supportive Care for Severe Tetanus in the Intensive Care Unit: A Narrative Review
Tetanus is an acute infectious disease caused by Clostridium tetani and remains associated with high mortality, particularly in severe cases requiring intensive care unit (ICU) admission. The neurotoxin tetanospasmin induces persistent muscle spasms, autonomic dysfunction, and respiratory failure, rendering ICU management complex and resource-intensive. This narrative review aims to synthesize current evidence on multimodal supportive care strategies that improve clinical outcomes in patients with severe tetanus managed in the ICU. This literature review identifies several interrelated components as central to successful management, including early airway control and mechanical ventilation, optimized sedation and spasm control using benzodiazepines, magnesium sulfate, and selected adjuvant agents, targeted nutritional and metabolic support through early enteral feeding, prevention of ICU-related complications, and early rehabilitation to mitigate ICU-acquired weakness. Collectively, evidence indicates that a comprehensive, evidence-based supportive care approach improves hemodynamic stability, reduces complication rates, and facilitates functional recovery in patients with severe tetanus.
Copyright (c) 2026 Michael Jaya, I Putu Fajar Narakusuma, Cynthia Dewi Sinardja (Author) https://creativecommons.org/licenses/by/4.0
Supraclavicular Block for ORIF of Distal Humerus Fracture in End-Stage Renal Disease: A Case Report
Supraclavicular block (SCB) is a well-established regional anesthesia technique for upper limb surgery; however, its application in patients with end-stage renal disease (ESRD) receiving antiplatelet therapy presents distinct clinical challenges. This case is noteworthy because of the coexistence of ESRD, ongoing clopidogrel therapy, anemia, and potential respiratory compromise, all of which complicate anesthetic decision-making. We report a 44-year-old female with ESRD on regular hemodialysis who sustained a comminuted intra-articular distal humerus fracture and underwent open reduction and internal fixation under ultrasound-guided SCB. The block was performed using 15 mL of 0.75% ropivacaine with dexamethasone as an adjuvant, following careful consideration of bleeding risk, local anesthetic dosing, and pneumothorax prevention. The procedure provided effective intraoperative anesthesia and prolonged postoperative analgesia without neurological, respiratory, or bleeding complications. Postoperative pain scores remained low, opioid consumption was minimal, and motor function recovered uneventfully. This case highlights that ultrasound-guided SCB can be safely and effectively performed in carefully selected ESRD patients receiving antiplatelet therapy when meticulous technique, dose justification, and risk mitigation strategies are applied. The key learning point is the importance of individualized anesthetic planning rather than a generalized preference for regional over general anesthesia.
Copyright (c) 2026 Dessy Kusumadewi, Taufiq Siswagama (Author) https://creativecommons.org/licenses/by/4.0
Wound Infiltration for Enhanced Recovery After Cesarean Surgery in Rural Hospital: A Case Series
Cesarean section is a major surgical procedure frequently associated with significant postoperative pain, which may delay mobilization and prolong hospital stay, particularly in rural hospitals with limited healthcare resources. Wound infiltration with local anesthetic represents a simple and practical analgesic component within the multimodal pain management strategy of the Enhanced Recovery After Cesarean Surgery (ERACS) pathway. This case series describes ten parturients scheduled for elective cesarean section with American Society of Anesthesiologists (ASA) physical status II and body mass index (BMI) < 30 kg/m2. All patients received regional anesthesia using subarachnoid block without intrathecal adjuvants. Local wound infiltration was performed before skin closure using 0.2% isobaric bupivacaine with adrenaline (1:200,000) along the incision margins. Postoperative outcomes included pain intensity was assessed by the Visual Analog Scale (VAS) at 2, 4, and 6 hours, as well as postoperative nausea and vomiting, early ambulation, early initiation of breastfeeding and length of hospital stay. Across all cases, low early postoperative pain scores were observed, with VAS score ≤ 2 during the first 4 hours and decreasing to 1 at 6 hours postoperatively. Eight patients achieved early ambulation and successfully initiated breastfeeding within 24 hours. Two patients experienced postoperative nausea and vomiting, which delayed mobilization and prolonged hospital stay beyond 24 hours. No wound complications or signs of local anesthetic systemic toxicity were observed. In this rural hospital setting, wound infiltration with bupivacaine and adrenaline was associated with favorable early postoperative outcomes and appears to be feasible, low-resource adjunct within ERACS protocols to support early recovery after cesarean delivery.
Copyright (c) 2026 dr. Roy Sando, dr. Jimmy Wongkar Sp.An-Ti (Author) https://creativecommons.org/licenses/by/4.0
Rotational Thromboelastometry-guided Transfusion in Major Obstetric Hemorrhage: A Case Series
Major obstetric hemorrhage remains a critical cause of maternal morbidity and mortality, requiring rapid yet precise transfusion management to prevent coagulopathy and adverse outcomes. We report a case series of seven obstetric patients with major perioperative hemorrhage managed using rotational thromboelastometry (ROTEM) guided transfusion at a tertiary referral center. The patients, predominantly with placenta accreta spectrum disorders, placenta previa, uterine atony, and one case of idiopathic thrombocytopenic purpura, experienced a wide range of estimated blood loss from 200 to 4500 mL. ROTEM assessment using EXTEM and FIBTEM parameters was performed during active bleeding to identify specific coagulation abnormalities and guide transfusion decisions. All patients received packed red cell transfusion, while fibrinogen replacement, fresh frozen plasma, platelet concentrates, and tranexamic acid were administered selectively based on viscoelastic findings rather than estimated blood loss alone. Four patients received tranexamic acid due to evidence of impaired clot stability, whereas others with preserved clot firmness were managed without empiric plasma or antifibrinolytic therapy despite significant hemorrhage. One patient with minimal bleeding required platelet transfusion after ROTEM detected qualitative platelet dysfunction. All patients achieved hemodynamic stabilization without major transfusion-related complications or need for reoperation. This case series highlights the clinical value of ROTEM in enabling goal-directed, individualized transfusion strategies in obstetric hemorrhage, emphasizing that viscoelastic-guided management may optimize hemostasis while limiting unnecessary blood product exposure.
Copyright (c) 2026 David, Tjahya Aryasa EM, Marilaeta Cindryani Ra Ratumasa (Author) https://creativecommons.org/licenses/by/4.0
Ultrasound-Guided PENG Block for Analgesia in Early Pregnancy with Femoral Head Fracture and Hip Dislocation: A Case Report
Femoral head fracture accompanied by hip dislocation during pregnancy is an uncommon clinical event that presents significant challenges in maternal analgesia and fetal safety. Traumatic hip dislocations account for a small proportion of joint dislocations, while their occurrence during pregnancy is rarely reported, particularly when associated with femoral head fractures. Management becomes more complex because timely reduction and defenitive orthopedic fixation must be achieved while ensuring adequate analgesia and minimizing systemic drug exposure. We describe the case of a 32-year-old woman in early pregnancy (11 weeks of gestation) who presented with a posterior dislocation of the left hip accompanied by a Pipkin type I femoral head fracture following a traffic accident. To provide effective analgesia and reduce fetal risk, a pericapsular nerve group (PENG) block was selected as part of the anesthetic strategy. This regional technique enabled optimal positioning for reduction, minimized the requirement for systemic opioids, and supported early mobilization. Maternal hemodynamics and fetal parameters remained stable throughout the perioperative period. This case highlights the potential role of the PENG block as a focused regional analgesic technique in pregnant trauma patients, particularly during early gestation, where minimizing systemic drug exposure is a critical priority.
Copyright (c) 2026 Made Agus Cahya Nugraha Koriawan, I Gusti Agung Gede Utara Hartawan (Author) https://creativecommons.org/licenses/by/4.0
Dexmedetomidine as Adjuvant in Scalp Nerve Block for Craniotomy: A Double-Blind Randomized Clinical Trial
Introduction: Scalp nerve block (SNB) is an effective adjunct for attenuating hemodynamic responses and reducing postoperative pain in craniotomy. Dexmedetomidine (DEX), with its analgesic and anti-inflammatory properties, may enhance the quality of SNB. This study evaluated the effects of adding DEX to SNB on hemodynamic stability, postoperative pain, inflammatory response, and analgesic duration in craniotomy patients. Methods: A double-blind, parallel-group randomized clinical trial was conducted on 36 adult patients undergoing elective craniotomy (July–September 2025) at a tertiary hospital Denpasar. Participants received SNB using 0.375% ropivacaine (20 mL) with or without DEX 1 µg/kg under standardized general anesthesia. Outcomes included mean arterial pressure (MAP), Visual Analog Scale (VAS) scores at 12 and 24 hours, neutrophil-to-lymphocyte ratio (ΔNLR), and time to first rescue analgesic (TTFAR). Statistical analyses used mixed ANOVA and Mann–Whitney U tests. Ethical approval number was 2159/UN14.2.2.VII.14/LT/2025. Results: MAP was significantly lower in the DEX group at 10 minutes (Δ = 4.89 mmHg; 95% CI 1.62–8.16), 20 minutes (Δ = 4.83; 95% CI 1.57–8.10), 30 minutes (Δ = 3.67; 95% CI 0.40–6.94), and upon PACU arrival (Δ = 3.72; 95% CI 0.45–6.99) (all p < 0.05). Median VAS scores were significantly lower with DEX at 12 hours (1.50 vs 3.00; p < 0.001) and 24 hours (1.00 vs 2.00; p < 0.001). ΔNLR was reduced in the DEX group (−0.56 vs 3.08; p = 0.004). TTFAR was markedly prolonged (554 vs 257 minutes; p < 0.001). No adverse events were reported. Conclusion: Dexmedetomidine added to scalp nerve block enhances hemodynamic stability, reduces postoperative pain for up to 24 hours, suppresses early systemic inflammation, and prolongs analgesic duration in craniotomy without observed complications. DEX–SNB represents a beneficial component of multimodal analgesia in neuroanesthesia and may support enhanced recovery pathways
Copyright (c) 2025 Putu Eka Nantha Kusuma, I Putu Pramana Suarjaya, Pontisomaya Parami, IGAG Utara Hartawan, I Gusti Ngurah Mahaalit Aribawa, I Putu Kurniyanta, Ida Bagus Krisna Jaya Sutawan, Putu Herdita Sudiantara, I Made Gede Widnyana, Tjokorda Gde Agung Senapathi (Author) https://creativecommons.org/licenses/by/4.0
Anesthetic Approach to Placenta Previa with Associated Bladder Rupture: A Case Report
This case report outlines the anesthetic management of total placenta previa with high-risk features of placenta accreta spectrum (PAS) complicated by bladder rupture, representing a rare but clinically significant form of invasive placentation. A 29-year-old G2P1001 at 35+3 weeks’ gestation presented with recurrent antepartum bleeding and ultrasonographic features consistent with PAS, including grade III lacunae, bridging vessels, severe myometrial thinning, and a Placenta Accreta Indeks (PAI) score of 6. Spinal anesthesia was initiated for delivery, followed by a controlled conversion to general anesthesia to facilitate hysterectomy, two-layer bladder repair, ureteral reconstruction, and Double-J stent placement. Hemodynamic stability was maintaned using tranexamic acid, colloid co-loading, invasive arterial monitoring, and norepinephrine titration. An estimated blood loss of 2,300 mL was managed with targeted transfusion, resulting in favourable maternal recovery and neonatal outcomes (Apgar 7 and 9). This case underscores the importance of early PAS recognition, structured anesthetic planning, and coordinated multidisciplinary care, supporting the benefit of a staged neuraxial-to-general anesthesia strategy in complex PAS with urologic involvement.
Copyright (c) 2025 Made Bagus Cahya Maha Putra, IGAG Utara Hartawan, DA Mas Shintya Dewi (Author) https://creativecommons.org/licenses/by/4.0
Dexmedetomidine pada Blok Torakolumbar Interfasial Plane Modifikasi: Tinjauan Naratif
Nyeri pascaoperasi merupakan tantangan klinis utama pada pasien yang menjalani bedah tulang belakang lumbal. Pendekatan analgesia multimodal semakin berkembang, dan blok interfasial torakolumbal (Thoracolumbar Interfascial Plane/TLIP) menjadi salah satu teknik yang efektif dalam mengurangi nyeri dengan risiko minimal terhadap fungsi motorik. Modifikasi teknik TLIP, terutama dengan penambahan adjuvan seperti dexmedetomidine, menawarkan potensi peningkatan durasi dan kualitas analgesia. Tinjauan naratif ini bertujuan merangkum bukti terkini mengenai efektivitas, mekanisme, dan keamanan penggunaan dexmedetomidine sebagai adjuvan pada TLIP modifikasi untuk bedah lumbal. Pencarian literatur dilakukan melalui basis data PubMed, Scopus, dan Google Scholar dengan menggunakan kata kunci “modified TLIP block”, “dexmedetomidine”, “lumbar spine surgery”, dan “postoperative analgesia” untuk artikel berbahasa Inggris atau Indonesia yang diterbitkan antara tahun 2013 hingga 2024. Hasil sintesis menunjukkan bahwa penambahan dexmedetomidine (0,5–1 µg/kg) pada anestesi lokal dapat memperpanjang durasi analgesia hingga 6–8 jam, menurunkan skor nyeri pascaoperasi, serta mengurangi konsumsi opioid tanpa menimbulkan efek samping berat, seperti bradikardia atau hipotensi yang signifikan. Efek analgesik ini terkait dengan aktivasi reseptor α₂-adrenergik di perifer dan spinal yang menghambat transmisi nyeri. Tinjauan ini membahas secara komprehensif dasar fisiologi dan farmakologi kombinasi TLIP–dexmedetomidine, perbandingan dengan blok interfasial lain, bukti klinis terkini, serta arah penelitian yang diperlukan untuk penerapan optimal dalam praktik anestesiologi modern.
Copyright (c) 2025 I Putu Eka Ariyasa, I Made Gede Widnyana, I Made Agus Kresna Sucandra (Author) https://creativecommons.org/licenses/by/4.0
Renal Resistive Index in Early Detection of AKI after Neurosurgery: A Case Series
Postoperative acute kidney injury (AKI) is a frequent yet underrecognized complication in neurosurgical patients, often contributing to increased morbidity and mortality. Brain injury can trigger systemic effects, including sympathetic overactivation, inflammatory responses, and hemodynamic instability, all of which predispose patients to renal dysfunction. The Renal Resistive Index (RRI), obtained by Doppler ultrasonography, reflects intrarenal vascular resistance and has emerged as a promising early marker of AKI. This case series describes three patients undergoing decompressive craniectomy for intracranial hemorrhage who had normal preoperative renal function and subsequently developed stage 1 AKI according to Kidney Disease; Improving Global Outcome (KDIGO) guideline within 24 hours postoperatively. In each case, an elevated RRI (>0.7) measured during the early postoperative period preceded the rise in serum creatinine and the reduction in urine output. The consistent pattern across these patients highlights the potential utility of RRI as a noninvasive, bedside predictor of postoperative AKI in neurosurgical populations. The findings support the clinical relevance of integrating RRI into perioperative monitoring, particularly in high-risk patients where early detection of renal dysfunction may guide timely interventions to optimize hemodynamic stability and prevent further injury. Further prospective studies with larger cohorts are warranted to validate these observations and establish standardized thresholds for practice.
Copyright (c) 2025 Aldy Sethiono, Pontisomaya Parami, I Made Wirga Wirgunatha (Author) https://creativecommons.org/licenses/by/4.0
Effectiveness of Dexmedetomidine Compared to Midazolam for Sedation in Mechanically Ventilated Patients: A Narrative Review
Delirium is a common and clinically significant neuropsychiatric complication in mechanically ventilated adult ICU patients, contributing to prolonged hospitalization, increased morbidity, and long-term cognitive impairment. The choice of sedative agent plays a pivotal role in preventing delirium, with dexmedetomidine and midazolam representing the most commonly used drugs with contrasting mechanisms. This narrative review evaluates the clinical efficacy, safety profile, neurocognitive outcomes, and cost-effectiveness of dexmedetomidine compared with midazolam in mechanically ventilated ICU patients. Literature was searched through PubMed, Scopus, ScienceDirect, Cochrane Library, and Google Scholar for studies published between 2020 and 2025 using the keywords dexmedetomidine, midazolam, sedation, mechanical ventilation, delirium, and intensive care units. Seventeen peer-reviewed publications were included and analyzed narratively. Dexmedetomidine consistently reduced the incidence and duration of delirium (RR 0.55–0.65; 95% CI 0.4–0.8), shortened mechanical ventilation by 0.7–1.5 days, and facilitated earlier extubation compared to midazolam. Its α₂-adrenergic agonism at the locus coeruleus produces a sleep-like, cooperative sedation, with mild, dose-dependent bradycardia as the most frequent adverse effect. Despite higher acquisition cost, economic analyses reported average savings of US$ 450–700 (≈ IDR 7–10 million) per patient through reduced ICU stay and delirium-related complications. Overall, dexmedetomidine demonstrates superior efficacy and safety compared with midazolam for ICU sedation, providing both clinical and economic advantages. Integration into light-sedation and delirium-prevention bundles may improve ICU outcomes, particularly in resource-limited settings.
Copyright (c) 2025 Guntur Mu Ammar Haithami, Putu Agus Surya Panji, Ida Bagus Krisna Jaya Sutawan, Christopher Ryalino (Author) https://creativecommons.org/licenses/by/4.0
Peran Gabapentinoid dalam Strategi Analgesia Preemptif pada Mastektomi Radikal Termodifikasi: Tinjauan Naratif
Nyeri pascaoperasi tetap menjadi tantangan utama pada pasien kanker payudara yang menjalani prosedur Modified Radical Mastectomy (MRM), dengan prevalensi nyeri sedang hingga berat mencapai hampir 70%. Salah satu pendekatan yang menjanjikan adalah penggunaan analgesia preemptif dengan agen gabapentinoid, seperti pregabalin dan gabapentin, yang bekerja menghambat sensitisasi sentral serta menurunkan konsumsi opioid. Tinjauan naratif ini bertujuan mengevaluasi efektivitas kedua agen tersebut dalam mengurangi nyeri pasca-MRM, memperpanjang durasi bebas nyeri, dan menekan kebutuhan analgesik tambahan. Penelusuran literatur dilakukan melalui basis data PubMed, Scopus, ScienceDirect, dan Google Scholar dengan kata kunci “pregabalin”, “gabapentin”, “preemptive analgesia”, “modified radical mastectomy”, dan “postoperative pain”, mencakup publikasi berbahasa Inggris dan Indonesia periode 2013–2024. Hasil sintesis menunjukkan bahwa pregabalin dan gabapentin secara konsisten menurunkan skor nyeri Visual Analog Scale (VAS), memperpanjang waktu hingga permintaan analgesik pertama, dan mengurangi total konsumsi opioid pascaoperasi. Pregabalin dosis 150 mg menunjukkan efektivitas yang setara atau lebih baik dibandingkan gabapentin 900 mg, dengan onset kerja lebih cepat dan profil efek samping yang lebih ringan. Secara keseluruhan, gabapentinoid terbukti efektif dan aman sebagai bagian dari strategi analgesia multimodal pasca MRM, dengan pregabalin menunjukkan keunggulan farmakokinetik dan tolerabilitas yang lebih baik. Penelitian berskala besar dengan populasi homogen masih diperlukan untuk memperkuat rekomendasi klinis berbasis bukti.
Copyright (c) 2025 Yolanda Jenny Pratana, IGA Made Wibisana Kurniajaya, Nyoman Bendhesa Wirananggala (Author) https://creativecommons.org/licenses/by/4.0
Transformasi ICU Modern: Teknologi, Humanisasi, dan Perawatan Individual dalam Era Perawatan Kritis
Transformasi ICU modern ditandai oleh kemajuan teknologi, pendekatan humanistik, dan perawatan individual yang terintegrasi. Penerapan ICU Liberation Bundle (ABCDEF) terbukti mengurangi durasi rawat, delirium, dan meningkatkan survival jangka panjang. Inovasi seperti kecerdasan buatan, tele-ICU, serta pemantauan hemodinamik lanjutan memperkuat deteksi dini dan intervensi tepat waktu. Strategi manajemen cairan berbasis responsivitas dinamis dan ventilasi protektif semakin diutamakan. Penggunaan ECMO dan imunoterapi untuk sepsis menunjukkan perkembangan signifikan. Meski demikian, tantangan seperti burnout tenaga kesehatan dan rehabilitasi pasca-ICU masih perlu diatasi. Kolaborasi dan inovasi terus menjadi kunci dalam membentuk ICU masa depan yang lebih adaptif dan berpusat pada pasien.
Copyright (c) 2025 I Made Prema Putra (Author) https://creativecommons.org/licenses/by/4.0
Albumin Use and Its Association with Nutritional Status in the Intensive Care Unit : A Narrative Review
Introduction: Albumin is the major protein in blood plasma that plays a pivotal role in the regulation of oncotic pressure and nutritional status, particularly in critically ill patients. Hypoalbuminemia is frequently observed in ICU patients and is associated with increased morbidity and mortality. This narrative review aims to assess the role and efficacy of albumin supplementation, administered both orally and intravenously, in supporting the nutritional status and prognosis of critically ill patients. Methods: A literature search was conducted across the PubMed, Google Scholar, ScienceDirect, and ProQuest databases utilizing the keywords: "albumin", "critical illness", "nutrition", and "ICU". Articles included were those published within the last 10 years, available in English and Indonesian, and comprised review articles, clinical trials, and clinical practice guidelines. The selection process was performed through the screening of titles, abstracts, and subsequent full-text reviews. A total of 23 articles were included in this review. Results: The literature indicates that albumin supplementation contributes to hemodynamic stability, a reduction in nosocomial infections, and improved prognosis in patients with conditions such as sepsis, ARDS, hepatic and renal dysfunction, and in post-operative states. Supplementation with snakehead fish (Channa striata) extract has also been reported to increase albumin levels. Accurate nutritional assessment, using tools like the Nutrition Focused Physical Exam (NFPE), Subjective Global Assessment (SGA), and biomarkers such as Total Lymphocyte Count (TLC) and Neutrophil to Lymphocyte Ratio (NLR) are essential for determining the nutritional status of critically ill patients. Specific recommendations from the ESPEN consensus and various hepatology and nephrology associations exist concerning the application of albumin in specific clinical conditions. Conclusion: Albumin supplementation holds significant potential in supporting the nutritional status and improving the clinical outcomes of critically ill patients. Further studies are required to determine optimal protocols and the cost-effectiveness of albumin therapy in the critically ill patient population.
Copyright (c) 2025 Putu Eka Nantha Kusuma, Jeremy Jonathan, Putu Agus Surya Panji (Author) https://creativecommons.org/licenses/by/4.0
External Oblique Intercostal Plane Block (EOIPB) sebagai Tambahan Analgesia Multimodal Pasca Laparoskopi Kolesistektomi: Tinjauan Naratif
Pendahuluan: Nyeri pascaoperasi, terutama setelah kolesistektomi laparoskopi, adalah masalah signifikan yang meningkatkan morbiditas dan memperpanjang masa rawat inap. Penanganan nyeri sering kali melibatkan opioid sistemik yang memiliki efek samping merugikan. Oleh karena itu, pendekatan analgesia alternatif yang minim opioid sangat dibutuhkan. Tinjauan naratif ini bertujuan mengevaluasi efektivitas External Oblique Intercostal Plane Block (EOIPB) sebagai tambahan analgesia multimodal pasca kolesistektomi laparoskopi, berfokus pada kualitas analgesia, pemulihan pasien, dan respons inflamasi sistemik. Metode: Tinjauan naratif ini didasarkan pada penelusuran literatur terstruktur dari PubMed, Scopus, ScienceDirect, Cochrane Library, dan Google Scholar. Pencarian menggunakan kombinasi kata kunci seperti "external oblique intercostal plane block", "laparoscopic cholecystectomy", "postoperative pain", "quality of recovery", "neutrophil to lymphocyte ratio", dan "platelet to lymphocyte ratio". Publikasi dibatasi pada tahun 2019–2024, berbahasa Inggris atau Indonesia. Kriteria inklusi meliputi studi primer peer-reviewed (RCT, kohort, observasional) yang mengevaluasi EOIPB atau blok interfasial sebanding, serta melaporkan skor nyeri pascaoperasi, konsumsi opioid, skor quality of recovery (QoR-15), dan/atau nilai neutrophil to lymphocyte ratio (NLR) / platelet to lymphocyte ratio (PLR). Hasil: EOIPB secara konsisten memperpanjang durasi analgesia, menurunkan intensitas nyeri dengan skor visual analog scale (VAS), dan mengurangi konsumsi opioid pascaoperasi secara signifikan. Studi juga menunjukkan profil keamanan EOIPB yang baik dengan insiden efek samping minimal. Bupivakain, agen anestesi lokal yang umum digunakan, tidak hanya memblok transmisi nyeri tetapi juga menunjukkan sifat anti-inflamasi. Meskipun demikian, terdapat heterogenitas dalam teknik dan jenis anestesi yang digunakan antar studi. Kesimpulan: EOIPB adalah teknik blok interfasial yang efektif dan aman untuk manajemen nyeri pasca kolesistektomi laparoskopi, memberikan analgesia yang lebih baik dan mengurangi kebutuhan opioid. Namun, masih diperlukan penelitian lanjutan berskala besar, terstandarisasi, dan multicenter untuk memperkuat bukti ilmiah dan mengevaluasi dampak jangka panjangnya.
Copyright (c) 2025 David Rendra Mahardika, Made Agus Kresna Sucandra, Tjokorda Gde Agung Senapathi (Author) https://creativecommons.org/licenses/by/4.0
Managemen Anestesi pada Congenital Diapragmatic Hernia dengan Ventrikel Septal Defek dan Atrium Septal Defek pada Pasien Pediatrik : Laporan Kasus
Congenital diaphragmatic hernia (CDH) merupakan kelainan kongenital pada diafragma yang terjadi pada pediatri. Insiden terjadinya hernia tipe Borchdalek lebih sering terjadi pada sisi kiri dari pada sisi kanan. Penyulit lain pada CDH adalah hipoplasia paru, hipertensi paru dan kelainan pada jantung. Pada kasus ini kami mendiskusikan bayi 12 hari dengan kelainan CDH sisi kanan dengan kelainan jantung berupa ventrikel septal defek (VSD) dan atrium septal defek (ASD) yang dilakukan operasi laparotomi hernia. Manajemen anestesi pada pasien ini menggunakan inhalasi sevoflurane, fentanil, volume tidal rendah, obat inotropik dengan kondisi hemodinamik yang stabil selama pembedahan. Kami melaporkan management anestesi dengan sevoflurane yang dikombinasi dengan volume tidal rendah dan inotropik dobutamine pada operasi congenital diaphragmatic herdia dengan VSD dan ASD membantu dalam keberhasilan intraoperatif. Setelah operasi, pasien dilakukan perawatan di NICU untuk perawatan secara ketat.
Copyright (c) 2025 Mauritius Septa Kristiawan, Adinda Putra Pradhana, I Putu Kurniyanta, Ketut Wibawa Nada, Novandi Kurniawan, Tjokorda Gde Agung Senapathi (Author) https://creativecommons.org/licenses/by/4.0
Awake Intubation in Patient with Superoanterior Mediastinal Mass and Superior Vena Cava Syndrome (SVCS): A Case Report
Superior vena cava syndrome (SVCS) with airway compression is challenging in anesthesia management. We report the case of a 69-year-old man with a superoanterior mediastinal mass and grade 3 SVCS who underwent Video-Assisted Thoracoscopic Surgery (VATS) with awake intubation using a double lumen tube (DLT) and videolaryngoscope. Awake intubation was chosen as the safest anesthesia technique where patients still breathe spontaneously without experiencing the effects of deep sedation. The combination of 4% lidocaine nebulization, oropharyngeal lidocaine spray, and dexmedetomidine infusion (0.5 μg/kg bolus over 10 minutes followed by 0.3-0.6 μg/kg/hour during surgery) in this patient, successfully maintained spontaneous ventilation without hemodynamic complications. The use of nebulized lidocaine, lidocaine spray, and dexmedetomidine as intubation facilities showed excellent effectiveness by maintaining the patient's spontaneous breathing, increasing the pain threshold, suppressing the nausea-vomiting reflex, and providing comfort in the form of mild sedation during awake intubation. This approach emphasizes the importance of topical anesthesia and selective sedation in high-risk patients with airway difficulties.
Copyright (c) 2025 Ery Oktadiputra, I Putu Fajar Narakusuma, Tjokorda Gde Agung Senapathi (Author) https://creativecommons.org/licenses/by/4.0
Hubungan MAP dan CVP terhadap PEEP dan Perubahan Stroke Volume pada Pasien Ventilasi Mekanik Invasif: Studi Observasional Analitik
Pendahuluan: Penggunaan parameter statis seperti mean arterial pressure (MAP) dan central venous pressure (CVP) sering kali tidak cukup akurat untuk memprediksi fluid responsiveness, sehingga diperlukan parameter dinamis yang lebih praktis dan dapat diandalkan. Penelitian ini bertujuan untuk mengevaluasi korelasi antara perubahan MAP dan CVP akibat perubahan positive end expiratory pressure (PEEP) dengan perubahan stroke volume (SV) sebagai prediktor kecukupan cairan pada pasien ICU dengan ventilasi mekanik. Pasien dan Metode: Penelitian ini merupakan studi observasional analitik. Subjek penelitian adalah pasien berusia 18–65 tahun yang menjalani ventilasi mekanik. Setelah mendapatkan persetujuan etik dan informed consent, dilakukan pengukuran MAP dan CVP pada PEEP 5 dan 15 cmH₂O. Selanjutnya, SV diukur menggunakan ekokardiografi transtorakal dan setelah manuver passive leg raising (PLR). Fluid responsiveness didefinisikan sebagai peningkatan SV ≥10% setelah PLR. Analisis korelasi dilakukan untuk menilai hubungan antara perubahan MAP dan CVP akibat PEEP dengan perubahan SV akibat PLR, serta analisis kurva ROC untuk menentukan nilai ambang diagnostik. Hasil: Sebanyak 28 pasien memenuhi kriteria inklusi dan dianalisis dalam penelitian ini. Hasil analisis menunjukkan bahwa tidak ditemukan korelasi yang signifikan antara perubahan MAP akibat PEEP dengan perubahan SV akibat PLR (r = -0,233; p = 0,232). Sebaliknya, ditemukan korelasi kuat antara perubahan CVP akibat PEEP dengan perubahan SV akibat PLR (r = 0,751; p < 0,001). Analisis kurva ROC memperlihatkan area under curve (AUC) sebesar 0,872 untuk perubahan CVP, dengan nilai ambang optimal 3,25 cmH₂O yang memberikan sensitivitas 71,4% dan spesifisitas 78,6% dalam memprediksi fluid responsiveness. Kesimpulan: Perubahan CVP akibat peningkatan PEEP memiliki korelasi kuat dengan fluid responsiveness dan dapat digunakan sebagai parameter dinamis untuk menilai kecukupan cairan pada pasien ICU dengan ventilasi mekanik.
Copyright (c) 2025 Win Muliadi, Cynthia Dewi Sinardja, I Made Subargiartha (Author) https://creativecommons.org/licenses/by/4.0
Fibrinolytic and Anticoagulant Therapy in COVID-19 Associated Pulmonary Embolism: A Case Report
Pulmonary thromboembolism is a complication that can occur in coronavirus disease-2019 (COVID-19). Efforts to prevent and therapy for thromboembolism have been a challenge to this date. The side effects of fibrinolytic, anticoagulant, and platelet anti-aggregation therapies, such as hemorrhage, are some of the causes of morbidity and mortality that must be addressed immediately. In this case, the patient received prophylaxis with the anticoagulant enoxaparin and platelet anti-aggregation agents with aspirin and clopidogrel. The COVID-19 patient presented a complication of pulmonary thromboembolism that was established using a computed tomography pulmonary angiography (CTPA) performed on his third day of care (day 14 of onset treatment) due to the patient’s clinical aggravation of pulmonary manifestation. After fibrinolytic therapy had been given, the patient’s clinical condition improved. However, on the 7th day after the provision of recombinant tissue plasminogen activator (r-TPA), the patient experienced a side effect of hemorrhage, and management was undertaken to address these issues by transfusions of blood components, such as cryoprecipitates, thrombocyte concentrate, fresh frozen plasma, and packed red cell. Thromboembolism occurring in COVID-19 patients is based on the Virchow triad concept, comprising endothelial injury, static blood flow, and hypercoagulation. The principle of prevention and management of thromboembolism refers to this concept. Currently, further studies are required to treat thromboembolism and the side effects of fibrinolytic and anticoagulant therapies on COVID-19 patients.
Copyright (c) 2025 Putu Eka Nantha Kusuma, I Made Prema Putra, I Gusti Ngurah Mahaalit Aribawa (Author) https://creativecommons.org/licenses/by/4.0