Jurnal Komplikasi Anestesi

EFFICACY OF PREEMPTIVE ANALGESIC KETAMINE ON POSTOPERATIVE PAIN AT UNIVERSITAS GADJAH MADA ACADEMIC HOSPITAL

David Ferdiansyah — 2024-11-26

Background: Postoperative pain remains a problem in anesthesia services. Preemptive analgesics are known to reduce postoperative pain due to noxious stimuli during the perioperative period. Ketamine can be used as a preemptive analgesic because it has the ability to prevent central sensitization. However, studies on ketamine as a preemptive analgesic have not reached a conclusion. So further research is needed to prove the effectiveness of ketamine as a preemptive analgesic
Objective: This study aims to evaluate the efficacy of preemptive intravenous ketamine 0.5 mg/kgBW in reducing postoperative pain.
Method: This research is an experimental study with double-blind randomized controlled trials. The inclusion criteria for this study are oncology surgery patients, aged 18-65 years, ASA physical status 1 or 2, BMI 18-30, and willing to sign informed consent. Exclusion criteria include patients with contraindications to ketamine, chronic pain, long-term analgesic consumption, hypertension, diabetes mellitus, cerebrovascular disease, and a history of recurrent malignancy. Meanwhile, withdrawal criteria include withdrawing from the study and experiencing ketamine hypersensitivity. The research sample is randomly divided into 2 groups, namely Group A (ketamine preemptive) and Group B (control). Both groups receive the same anesthesia procedure, namely premedication with intravenous midazolam 0.05 mg/kg body weight (BW), fentanyl 2 mcg/kg BW intravenously, rocuronium 0.6 mg/kg BW intravenously (if intubation is performed), then after a confirmed onset, the LMA (laryngeal mask airway) or ETT (endotracheal tube) airway device is inserted. After that, for Group A, preemptive analgesic ketamine 0.5 mg/kg BW intravenously is administered 10 minutes before
surgical incision. The assessment performed is pain scale using the numerical rating scale (NRS) at rest and with movement, total intraoperative rescue fentanyl, total postoperative rescue fentanyl requirement, onset of postoperative rescue fentanyl requirement, and side effects. Observation is conducted for up to 12 hours postoperatively. All variables except side effects are analyzed with independent t-tests, but if the data distribution is not evenly spread, the Mann-Whitney test is conducted. The confidence interval in this study is 95%, with significance set at p < 0.05.
Results: A total of 65 subjects were studied, but 3 subjects dropped out of the study. Therefore, 62 subjects remained, with 31 subjects in each Group A and B. Statistically, Group A had lower NRS pain scores at rest compared to Group B at hours 0, ½, 1, and 2 postoperatively (p<0.05). For NRS on movement, Group A had lower NRS pain scores compared to Group B at hours 0, ½, 1, 2, 6, and 12 postoperatively (p<0.05). Group A had a longer onset of postoperative rescue fentanyl requirement compared to Group B (p<0.05). However, there was no significant difference in total intraoperative rescue fentanyl and total postoperative rescue fentanyl requirement (p>0.05).
Conclusion: Preemptive ketamine analgesic dose of 0.5 mg/kgBW intravenously is effective in reducing postoperative pain better than the control group. This is evidenced by lower NRS pain scores at rest and on movement, as well as a longer onset of postoperative rescue fentanyl requirement compared to the control group.

Quadratus Lumborum Block as Intraoperative Analgesic Treatment in Pediatric with Hirschprung’s disease

Pita Mora Lesmana — 2024-11-26

Overview: A 4-year-old boy diagnosed with Hirschsprung's disease since birth will undergo a planned Duhamel procedure. Internationally, the prevalence of Hirschsprung's disease is approximately 1 in 1,500 to 1 in 7,000 live births and usually requires immediate intervention through surgical procedures. The extended length of pediatric surgeries presents a unique challenge for anesthesiologists aiming to minimize the use of opioids, considering their less desirable effects in this patient population. In this case, we opted for the use of quadratus lumborum block (QLB) as intraoperative analgesia. This refers to a meta-analysis by Wen-li Zhao et al, all suggest that QL block offers more effective postoperative pain relief in children after lower abdominal surgeries.

Management: After the patient was intubated, we performed a quadratus lumborum block using an anterior approach as an intraoperative analgesia technique. The local anesthetic used was 0.375% ropivacaine + 4 mg dexamethasone, volume 10 ml on both sides. Dermatom covered anterior QL block includes T4 to T12-L1, blocks the anterior and the lateral cutaneous branches of the nerves

Result: No additional opioid dose administered during the surgical procedure. Conclusion: The QLB in pediatric patients is quite effective in managing pain during surgery for patients undergoing the Duhamel procedure.

Specific Considerations for Enteral Nutrition in Extended Period Prone Positioned Non-ARDS ICU atient

Ika Cahyo Purnomo — 2024-11-26

Background: Early enteral nutrition (EN) is recommended in critical care to reduce the complications. However, hesitancy exists when administering EN in a prone position. We report a case of non-ARDS patient with extended periods of prone position receiving EN.

Case: A 18 years, quadriplegic, male, underwent cervical internal fixation and gluteal flap. Postoperatively, he was to be prone positioned for 10 days. Analgesics was tramadol and NSAID. NGT placement and patency was confirmed. The bed was tilted 30º upright and EN intermittently administered every 4 h, followed by GRV check in 2 h. Intake was gradually increased in each feeding. Patient was discharged after 48 h. Further management was also in the prone position.

Discussions: Feeding tolerance reduction and tube displacement is associated with EN in prone patients. Pre-feeding tube patency and position check is imperative. Feeding tolerance, GRV, and vomiting should be monitored. No recommendation for ultrasound monitoring. Upright tilting was to aid nutrition passage by gravity. Prokinetics and pump feeding were not performed in this patient. Tolerance was excellent, no complications in nutritional management were found.

Conclusions: EN during a prone position is challenging, yet the findings support that EN is feasible and can be well tolerated.

FAST-TRACK EXTUBATION IN CARDIAC SURGERY : A CASE SERIES

Paramita Putri Hapsari — 2024-11-26

Fast-track extubation (FTE) has been shown to reduce the incidence of prolonged mechanical ventilation, resulting in shorter hospitalization, lower morbidity, mortality, and hospital costs. We present a case series of fast-track extubation involving two females aged 31 and 33 with Atrial Septal Defect (ASD) and a 33-year-old male with Ventricular Septal Defect (VSD) scheduled for defect closure. These patients were in good clinical condition with normal biventricular function and a low probability of pulmonary hypertension. The anesthesia and surgery procedures proceeded smoothly, with cardiopulmonary bypass time < 90 minutes, aortic cross-clamp time < 60 minutes, no residual shunt, acceptable lactate and blood gas analysis, stable hemodynamic with low doses of vasoactive agents, and adequate analgesia. Following the successful execution of the fast-track extubation protocol in the operating theatre, the patients were transferred to the intensive care unit (ICU) where they received postoperative management. The total ICU length of stay was < 24 hours, demonstrating the safety and efficacy of FTE for simple cardiac procedures and favourable outcomes. This approach is aimed at accelerating patient recovery, reducing complications, and enhancing overall surgical outcomes.

Severe Respiratory Distress after C Section Due to Hypertension-Related Pulmonary Edema : A Case Report

Achmad Ma’ruf Fauzi — 2024-11-26

Introduce Pulmonary edema is a very rare complication of pregnancy. It is more commonly seen as a complication of preeclampsia. The physiopathology of this relationship is not well understood. This is a life-threatening condition that requires immediate treatment and termination of pregnancy.

Case Presentation We present the case of a women 24 year old who developed preeclampsia, complicated by pulmonary edema (pe) with heart failure after elective c section under spinal anesthesia in her first pregnancy. In the Intensive Care Unit (ICU) the patient received fist using Non-invasive ventilation (niv), after six hour using niv the oxygen saturation go down, and move using ventilator intubation, using ARDS NET hight peep.

Discussion Acute respiratory distress syndrome (ARDS) is a life threatening condition characterized by poor oxygenation and noncompliant or “stiff” lungs. This disorder is associated with capillary endothelial injury and diffuse alveolar damage. Many mechanisms have been proposed to explain the pathogenesis of pulmonary oedema in pre-eclampsia including hypervolaemia, left ventricular failure and pulmonary capillary leakage.

Conclusion Pulmonary edema is an emergency that can occur in pregnancy with preeclasmsia which has a high mortality if not treated immediately. Early screening and adequate therapy can improve patient outcomes.

The COST EFFECTIVENESS ANALYSIS OF

Krisna Hario Adiyatma — 2024-11-26

Background : One of the frequent post-operative complications is pain, which is experienced by more than 80% of patients and 75% of them experience post-operative pain of moderate to severe intensity. Major abdominal surgery is a surgical procedure with moderate to severe postoperative pain intensity. Analgesic approach strategies that are often used are intravenous opioids and epidural analgesia. Epidural analgesia is considered the analgesic therapy of choice for post-major abdominal surgery, but at a higher cost when compared with intravenous opioids. The differences in route of administration, efficacy and side effect profiles make it important to assess the cost effectiveness between the two approaches as part of hospital quality control and cost management.Objective : To determine the cost effectiveness of epidural analgesia compared with intravenous opioids as analgetic after major abdominal surgery.Method : This study used a descriptive analytical design with decision tree analysis to assess clinical outcomes and estimated costs for two alternative therapies. Research samples were taken retrospectively from September – December 2022 at RSUP Dr. Sardjito Yogyakarta, using simple random sampling. The Incremental Cost Effectiveness Ratio (ICER) value was assessed and Probabilistic Sensitivity Analysis (PSA) was carried out with Monte Carlo simulation using Microsoft Excel®.Results : Epidural analgesia as anti-pain after major abdominal surgery has an Incremental Cost Effectiveness Ratio (ICER) value of IDR 20,857,416/pain free days. Probabilistic Sensitivity Analysis (PSA) produces data distribution with dominance in quadrant 3 of the CEA Plane. Conclusion : The epidural analgesia strategy for pain relief after major abdominal surgery is a cheaper strategy but with slightly lower effectiveness than intravenous opioids at RSUP Dr. Sardjito. Epidural analgesia has an ICER value of IDR 20,857,416/pain free days, has the opportunity to be an alternative choice for post-major abdominal analgetic management that is cost effective.

THE INFLUENCE OF PERIANESTESIA SEVERE CRITICAL EVENT ON THE MORTALITY OF PEDIATRIC PATIENTS UNDERGOING ANESTHESIA AT DR. SARDJITO HOSPITAL

Annika Napitu — 2024-11-26

Background: severe critical events or unwanted and preventable incidents associated with anesthesia in pediatrics have a higher incidence rate compared with adults. It could be due to the immature anatomy, physiology, pharmacology, emotional, and social aspects of pediatric patients. In addition to the higher incidence, the mortality rate of severe critical events in pediatric patients is also higher than in adults. In general, severe critical events in pediatric patients include difficult airway, cardiovascular events, and medical negligence. Based on the time of occurrence, those events can happen pre-anesthesia, during anesthesia, or post-anesthesia with different incidence numbers.

Purpose: To assess the impact of critical events during peri-anesthesia on the mortality rate of pediatric patients. Such events include bronchospasm, laryngospasm, pulmonary aspiration, stridor, croup, desaturation, hypotension, arrhythmia, hemorrhage, cardiac arrest, anaphylaxis, neuro injury, delayed emergence, and medication errors.

Method: This is a prospective cohort study. All pediatric patients who underwent anesthesia for surgical and non-surgical procedures at RSUP Dr. Sardjito hospital are consecutively included in this study. The inclusion criteria for this study are pediatric patients less than 18 years of age who underwent anesthesia procedures at RSUP Dr. Sardjito hospital. The exclusion criteria are patients who have no complete medical records. The severe critical events included in this study are bronchospasm, laryngospasm, pulmonary aspiration, stridor, croup, desaturation, hypotension, arrhythmia, hemorrhage, cardiac arrest, anaphylaxis, neuro injury, delayed emergence, and medication errors. To statistically assess the relationship between severe critical events and mortality outcomes, bivariate analysis using chi-square was used. Multivariate analysis was then conducted using logistic regression on the variables that had a p-value of less than 0.25 on the bivariate analysis. A p-value of less than 0.05 indicates statistical significance.

Result: From the 425 research participants, 70 severe critical events happened in 39 patients, in which 14 cases resulted in mortality were recorded. The multivariate analysis showed that severe critical events of cardiac arrest (p=0,004; OR= 52,259; 95%CI= 3,505 – 779,081) and laryngospasm (p=<0,001; OR= 46,394; 95%CI= 6,001 – 358,640) significantly associated with patient mortality. Patient's demographic of ASA status (p=0,016; OR= 6,056; 95%CI= 1,403-26,139) and prematurity history (p=0,011; OR= 7,730; 95%CI= 1,607-37,193) are shown to be significantly associated with patient mortality.

Conclusion: There is a statistically significant relationship between severe critical events of cardiac arrest and laryngospasm with the mortality of pediatric patients who undergo anesthesia in RSUP Dr. Sardjito hospital.

CORRELATION STUDY OF SERUM VITAMIN D LEVELS WITH IN-HOSPITAL MORTALITY IN SEPTIC SHOCK PATIENTS

Novierta Prima Kusumandaru — 2024-11-26

Latar Belakang: Sepsis adalah keadaan darurat medis yang melibatkan respons imunologis sistem tubuh terhadap infeksi, yang dapat menyebabkan disfungsi organ dan kematian. Syok sepsis, sebagai bentuk parah dari sepsis, memiliki tingkat mortalitas yang tinggi. Vitamin D diketahui memiliki peran penting dalam modulasi imun dan inflamasi, yang dapat mempengaruhi hasil klinis pada pasien sepsis.

Tujuan: Penelitian ini bertujuan untuk mengevaluasi korelasi antara kadar serum vitamin D dengan mortalitas pada pasien syok sepsis di RSUP Dr. Sardjito.

Metode: Penelitian ini merupakan studi kohort prospektif yang melibatkan 22 pasien syok sepsis. Kadar vitamin D serum diukur saat pasien masuk ICU, dan mortalitas dicatat selama 28 hari. Skor SAPS-3 digunakan untuk menilai keparahan penyakit. Analisis statistik dilakukan untuk menentukan hubungan antara kadar vitamin D, skor SAPS-3, dan mortalitas.

Hasil: Dari 22 pasien, 15 pasien (68,18%) memiliki kadar vitamin D normal-insufisiensi, sementara 7 pasien (31,82%) mengalami defisiensi ringan-berat. Mortalitas tercatat sebesar 27,27% (6 pasien). Analisis menunjukkan bahwa pasien dengan defisiensi vitamin D memiliki odds ratio (OR) sebesar 8,6667 untuk mortalitas dibandingkan dengan pasien dengan kadar vitamin D normal-insufisiensi (p= 0.026; 95% CI: 1,0495 hingga 71,5719). Selain itu, terdapat korelasi negatif yang signifikan antara kadar vitamin D dan skor SAPS-3 (p= 0.0001; OR=7,1111; 95% CI: 1,0888 hingga 46,4425).

Kesimpulan: Penelitian ini menunjukkan bahwa defisiensi vitamin D berkorelasi dengan peningkatan risiko mortalitas pada pasien syok sepsis.

THE RELATIONSHIP OF LACTATE-ALBUMIN RATIO TO MORTALITY AND LENGTH OF STAY IN SEPSIS PATIENTS AT ICU DR. SARDJITO GENERAL HOSPITAL

Desti Pasmawati — 2024-11-26

Background : Sepsis is one of the causes of morbidity and mortality patients hospitalized in the intensive care unit (ICU) which requires early detection and management to predict outcomes. An increase in lactate together with decrease in albumin is encountered in severe inflammatory states. Lactate-albumin ratio has a predictive value of mortality in patient with sepsis that is similar to APACHE II and SOFA scores. These biomarkers can be done quickly, affordable, and available in many hospitals in Indonesia.

Objective : To determine the relationship between the lactate-albumin ratio and mortality and length of stay patient with sepsis in ICU of Dr. Sardjito Hospital.

Method : Research design using a retrospective cohort observational study method by collecting data from the medical records of sepsis patients treated at ICU of Dr. Sardjito Hospital. Data on lactate and albumin in plasma levels at admission and mortality events were collected to calculate the optimal cutoff using the ROC curve. The relationship between lactate-albumin ratio levels and mortality was analyzed using the chi-square test method followed by logistic regression in multivariate analysis.

Results : The total study subjects were 136 patients, wuth a median age of 55 years. The cut-off value for the Lactate-Albumin ratio in predicting mortality was found to be 0,878, with a sensitivity of 73.0 % and a specificity of 57.1% (AUC = 0,687; 95% CI 0,56-0,81; p=0,007). The cut-off value for the Lactate-Albumin ratio in predicting ICU length of stay was found to be 0,878, sensitivity 71,2% and specificity 63,6% (AUC = 0,684; 95% CI 0,53-0,84; p=0,043). Multivariate analysis showed that an increase in the Lactate-Albumin ratio was an independent and significant factor as a predictor of mortality (OR=3,43; 95% CI 1,29-9,16; p=0,013) and ICU length of stay (OR=4,33; 95% CI 1,19-15,68; p=0,036). Age, sex, hypertension, diabetes mellitus, cancer, obesity, and cerebrovascular disease were not independently associated with mortality dan ICU length of stay.

Conclusion : An increase in the Lactate-Albumin ratio is independently and significantly associated with an increased risk of mortality and length of stay in sepsis patients.