Jurnal Komplikasi Anestesi

The Non-Pharmacological Management of Shivering Post-Spinal Anesthesia

agrawijaya rade — 2024-03-01

Shivering is a side effect of hypothermia which includes involuntary movements and contractions of one or more muscle groups that the patient cannot control. Perioperative shivering is a common problem during surgery under spinal anesthesia. Spinal anesthesia can cause shivering in patients because it causes distribution of internal body heat from the core of the body to the environment. Active non-pharmacological treatments for shivering post spinal anesthesia include the use of IV fluid warmed, forced-air warming, and Lower and Upper Body Forced Air Blankets.

Key words: shivering, spinal anesthesia, warming of infusion fluids, forced air warming, and forced air blankets of the lower and upper body.

MANAGEMENT OF DIABETES INSIPIDUS AFTER SUBLABIAL TRANSSPHENOIDAL HYPOPHYSECTOMY SURGERY

Erlangga Prasamya — 2024-04-21

Summary

A 36-year-old female patient was diagnosed with diabetes insipidus after sublabial transsphenoid hypophysectomy (SLTH) surgery. The patient had pituitary adenoma. The patient undergoes 14 days of care in the ICU with titrated intravenous vasopressin dose(0,01-0,3unit/hour) and later subcutaneous dose(6-13unit/8 hours). Subcutaneous vasopressin started on day 3 while intravenous was tapering down; at the early transition from the intravenous vasopressin route to the subcutaneous vasopressin route on day 7, there is a sharp surge of urine production as well at plasma sodium level. The intravenous vasopressin started again, along with the elevated dose of subcutaneous vasopressin. The patient shows a response to therapy after a watchfully titrated dose.

Background

Diabetes insipidus is a combination of signs and symptoms generating a plentiful volume of urine and causing elevated serum osmolality. There are two types of diabetes insipidus: central diabetes insipidus and nephrogenic diabetes insipidus. Central neurogenic diabetes insipidus occurs when the production of the hormone Arginine Vasopressin (AVP) is low. In contrast, nephrogenic diabetes insipidus occurs when the kidneys cannot respond to high levels of the hormone AVP. Postsurgical central insipidus can be categorized into transient, permanent, and triphasic. Transient courses of diabetes insipidus following surgery represent most of the cases. Temporary diabetes insipidus is thought to be caused by temporary dysfunction of AVP-producing neurons as a result of direct surgical trauma or indirect after-surgical edema. The incidence of diabetes insipidus in patients who underwent pituitary surgery is 5%, and 4.6% of these patients will have only transient diabetes insipidus, and only 0.4% became permanent.

Transphenoidal surgery is considered a minimally invasive and effective procedure for pituitary adenomas. Diabetes Insipidus after this surgery is not an uncommon complication, even though the reported rate of postsurgical central diabetes insipidus varies widely from 1 to 67%. Postoperative temporary diabetes insipidus gradually resolves up to 6 months.

Case Presentation

A 36-year-old female patient presented chief complaints of headache and blurred vision, which gradually worsened one year ago. After undergoing several examinations, the patient was diagnosed with pituitary adenoma. The patient underwent a sublabial transsphenoidal hypophysectomy. The duration was three long hours and uneventful.

On Day 0, the patient arrived at the intensive care unit (ICU) intubated, hemodynamically stable, and sedated. The patient is then monitored and weaned; a brain protection strategy and strict fluid balance urine collection and pain management are applied. On day 1, the patient was then extubated. The patient was examined for several parameters, such as electrolytes, kidney function, and blood glucose level. The patient began to significantly increase urine output (>5 milliliters/kilogram body weight/hour). Increased urine production is accompanied by a simultaneous decrease in urine-specific gravity (<1.005) and an increase in serum sodium level up to 151 mmol/liter. The patient was diagnosed with postsurgical diabetes insipidus. The patient started receiving intravenous vasopressin at a dose of 0.3 units/hour and titrated according to urine production until the target urine output was reached after the third day of care. After urine is reached, the dose of vasopressin slowly decreases, and the administration begins to transition to the subcutaneous route. On day 7 of treatment, when the intravenous vasopressin dose had been discontinued and the vasopressin dose at the 8u/h point, there was a significant urine production spike and an increase in the plasma sodium level to 156 mmol/liter. On the eighth day of treatment, the administration of vasopressin was again given intravenously and subcutaneously until a decrease in urine production towards the target was achieved. Finally, on days 11 to 14, vasopressin is administered only subcutaneously until the patient is discharged from the ICU. The patient was successfully discharged to the ward with a tapering-off subtotal dose.

Discussion

The patient developed polyuria within the initial hours of treatment. Polyuria is a hallmark sign of diabetes insipidus. The clinician should be aware of other polyuria causes, such as postoperative hypervolemia, hyperglycemia, and the use of diuresis drugs. This differential diagnosis must be excluded. In this case, the differential diagnosis was excluded through proper fluid balance calculations, monitoring serum electrolytes and glucose levels, and ensuring the absence of diuretic use. Confirmation of the postoperative central diabetes insipidus is made based on findings of high urine output (5 ml/kg BW/hour), urine specific gravity (<1.005), response to vasopressin, average blood glucose level, and absence of diuretic use.

Diabetes Insipidus is the body's inability condition to concentrate urine due to defective production of the antidiuretic hormone (central diabetes insipidus) or nephrogenic diabetes insipidus (NDI), which corresponds to the insensitivity of the kidney to the antidiuretic effects of vasopressin. Diabetes insipidus (DI) is a syndrome characterized by polyuria (>30ml/kg/24H) of hypotonic urine, equivalent polydipsia, and hypernatremia. The patient shows elevated urine volume (108 cc/kg/24H) and blood sodium levels (144-151mmol/L). The primary therapy was the titrated vasopressin dose, in conjunction with electrolytes and fluid management. Vasopressin titration is based on patient clinical condition, urin output, fluid management, oral intake, and laboratory measures (natrium blood level and urin osmolarity).

Transient Diabetes Insipidus must be closely monitored after neurosurgical operations, especially in regions adjacent to the pituitary DI. Transient Management with good monitoring is the key. The risk of morbidity comes from the risk of untreated dehydration, electrolyte imbalance

Intravenous vasopressin provides a rapid effect with lower doses. At the same time, subcutaneous administration requires caution in critically ill patients because absorption is slow, resulting in a slow effect and the need for higher doses. The conversion of the administration route needs to consider the patient's pharmacology, route, and hemodynamics.

References

Leroy, C., Karrouz, W., Douillard, C., Do Cao, C., Cortet, C., Wémeau, J.-L., Vantyghem, M.-C., 2013. Diabetes insipidus. Ann. Endocrinol. 74, 496–507. https://doi.org/10.1016/j.ando.2013.10.002

Priya, G., Kalra, S., Dasgupta, A., Grewal, E., 2021. Diabetes Insipidus: A Pragmatic Approach to Management. Cureus. https://doi.org/10.7759/cureus.12498

Schreckinger, M., Szerlip, N., Mittal, S., 2013. Diabetes insipidus following resection of pituitary tumors. Clin. Neurol. Neurosurg. 115, 121–126. https://doi.org/10.1016/j.clineuro.2012.08.009

Sharman, A., Low, J., 2008. Vasopressin and its role in critical care. Contin. Educ. Anaesth. Crit. Care Pain 8, 134–137. https://doi.org/10.1093/bjaceaccp/mkn021

Faktor-Faktor yang Berhubungan dengan Mortalitas pada Pasien Pediatrik yang Menjalani Pembiusan di Masa Pandemi Covid-19 di RSUP DR Sardjito

Geza Getar M Getar M — 2024-03-01

Background: Anesthesia has the potential to cause physiological changes that lead to morbidity and mortality. Perioperative mortality alone is higher in children than in adults. During this time, the COVID-19 pandemic has affected anesthesia care around the world. The practice of pediatric surgery shows a significant decrease in the frequency of elective surgeries during the pandemic compared to the last three months before the pandemic. Surgical delays that occur, especially in "time-sensitive" surgeries and urgent illnesses in children, can affect the child's growth, development, and quality of life. There are several risk factors associated with mortality and morbidity in pediatric patients, namely age, ASA III-V physical status, emergency surgery, use of ventilators, oxygen support, inotropic drug support, preoperative sepsis, and patients refusing resuscitation.

Objective: Identifying factors that influence mortality in pediatric patients undergoing anesthesia during the COVID-19 pandemic.

Method: This study is a retrospective cohort observational study. This study included all pediatric patients who underwent anesthesia at Dr. Sardjito General Hospital between April 1, 2020 - March 31, 2021. Variables suspected of having a relationship with mortality will be tested bivariately in this study, and if p<0.25 is considered significant, they will be included in the multivariate analysis. They will be excluded from the multivariate analysis if p<0.05 is considered significant.

Result: Factors that influence the incidence of mortality in pediatric patients undergoing anesthesia at Dr. Sardjito General Hospital are ASA III-V physical status with a value of p = 0.004 (OR 3.47), and the use of mechanical ventilation postoperative with a value of p=<0.001 (OR 9.46), both factors that have a significant effect with a p<0.05.

Conclusion: ASA III-V physical status and the use of mechanical ventilation postoperative are factors that significantly influence the mortality of pediatric patients undergoing anesthesia at Dr. Sardjito General Hospital.

FAKTOR RISIKO YANG MEMPENGARUHI TERJADINYA KOMPLIKASI KARDIOVASKULAR PASCA PEMBIUSAN/SEDASI PROSEDURAL PADA PASIEN PEDIATRI

hendra hermawan hendra — 2024-03-01

Background: The morphology and physiology of neonates and children differ from those of adults. The most common complications encountered involve respiratory issues followed by cardiovascular problems. The predominant cardiovascular complications in the field of pediatric anesthesia are hemodynamic instability followed by cardiac arrest. Perioperative cardiovascular complications are closely related to a history of prematurity under the age of 1 year, ASA physical status ≥3, concomitant cardiovascular or metabolic diseases, emergency surgeries, and surgical procedures. To date, few risk factors related to the cardiovascular system have been identified in pediatric anesthesia.

Objective: To identify risk factors influencing the occurrence of post-anesthesia/sedation cardiovascular complications in pediatric patients at Dr. Sardjito Hospital, Yogyakarta.

Method: The research design employed in this study was a prospective cohort observation of pediatric patients undergoing anesthesia or procedural sedation at Dr. Sardjito Hospital. Research subject data included demographic characteristics, ASA status, history of concomitant diseases, type of surgery, urgency level, and post-anesthesia complication occurrences. Data normality was tested using the Kolmogorov-Smirnov test, bivariate analysis was conducted using the Fisher test, variables with p-value <0.25 underwent multivariate analysis using logistic regression for categorical data. The results were processed using SPSS version 23.00.

Results: A total of 181 subjects were predominantly male patients aged >5 years. Factors influencing post-anesthetic cardiovascular complications included ASA physical status ≥3 (p=0.033) OR 8.96 (95% CI 2.07 – 38.89), emergency procedures (p=0.043) OR 12.63 (95% CI 1.08 – 147.15), age >5 years (p=0.033) OR 5.67 (95% CI 1.15 – 28.1), female gender (p=0.001) OR 7.85 (95% CI 2.23 – 27.71), and type of surgical procedure (p=0.017) OR 16.64 (95% CI 1.63 – 169.05).

Conclusion: Age >5 years, female gender, ASA physical status ≥3, emergency procedures, and surgical procedures are risk factors associated with the occurrence of post-anesthetic/sedation cardiovascular complications in pediatric patients.

THE RELATIONSHIP OF PLASMA BUN-ALBUMIN RATIO TO MORTALITY AND LENGTH OF STAY IN COVID-19 PATIENTS AT DR. SARDJITO GENERAL HOSPITAL

Githa Rizki Primastuti — 2024-03-01

Background: The increasing incidence of the COVID-19 pandemic has caused quite high mortality rates and length of stay in developing countries. Early detection is needed to reduce mortality rates. Early detection methods are reported, such as RT-PCR, immunoassay, and CT-scan, but they are expensive. Elevated BUN with decreased albumin is a laboratory condition produced by highly inflammatory states, such as COVID-19. The relationship between the plasma BUN-Albumin ratio in pneumonia sufferers has been proven to predict mortality and length of stay more strongly than the single parameter BUN or albumin. If proven to be relevant, these markers are advantageous because they are widely accessible, simple, and economical.

Objective: To determine the relationship between plasma BUN-Albumin ratio on mortality and length of stay for COVID-19 patients at Dr. Sardjito.

Methods: The research design used a retrospective cohort observational study method of patients with confirmed COVID-19 at RSUP Dr. Sardjito. Data on BUN and plasma albumin levels at admission were collected to calculate the optimal cut-off using the ROC curve. The relationship between BUN-Albumin ratio levels and mortality was analyzed using the chi-square test method followed by logistic regression in multivariate analysis. Analysis of length of stay using cox-regression survival analysis and is declared significant if it produces p < 0.05.

Results: The total research subjects were 1650 patients, with a median age of 56 years. The cut-off value for the BUN-Albumin ratio in predicting mortality was found to be 5.634, with a sensitivity of 65.0% and a specificity of 63.7%. (AUC = 0.689; 95% CI 0.663-0.715; p=0.001). Multivariate analysis showed that an increase in the BUN-Albumin ratio was an independent and significant factor as a predictor of mortality (OR 2.378; 95% CI 1.809 - 3.127) and patient length of stay (HR 0.655; 95% CI 0.574 - 0.748; p<0.001). Age, gender, use of positive pressure oxygenation, hypertension, obesity, COPD, and asthma were not independently associated with mortality.

Conclusion: An increase in the BUN-Albumin ratio is independently and significantly associated with an increased risk of mortality and length of stay in COVID-19 patients.

A Case report Myasthenia Gravis

Sudjati Adhinugroho — 2024-03-01

Myasthenic crisis, defined as respiratory failure requiring mechanical ventilation, occurs in 15 to 20% of patients with myasthenia gravis (MG). Infection (usually pneumonia or viral upper respiratory infection) is the most common precipitant (40%), followed by no obvious cause (30%) and aspiration (10%). As a general rule, 25% of patients are successfully extubated after 1 week, 50% after 2 weeks, and 75% after 1 month. Risk factors for intubation beyond 2 weeks, the point at which tracheostomy is usually performed, include age greater than 50 years, preintubation serum bicarbonate 30 mg/dL or greater, and vital capacity within 6 days of intubation less than 25 mL/kg.

Intensive care management of the myasthenic patient should focus on timely intubation, prevention of aspiration with tube feedings, and avoidance of complications, such as atelectasis, that can prolong the duration of crisis. Plasmapheresis leads to short-term improvement of weakness in 75% of patients, and should be performed in all patients unless otherwise contraindicated. Residual weakness leads to functional dependence in 50% of patients at the time of discharge, and one-third will experience two or more episodes of crisis

LUARAN KLINIS MATERNAL PADA PASIEN OBSTETRI DENGAN COVID – 19 YANG MENJALANI SEKSIO SESAREA DI RSUP DR. SARDJITO

Bambang Hadiwinoto — 2024-03-01

Background : COVID-19 is a global pandemic with pregnant women is one of the affected populations. Physiological changes in pregnant women, coupled with the pathological conditions of COVID-19, impact maternal outcomes, including the amount of intrapartum hemorrhage, the requirement for mechanical ventilation, and mortality in patients undergoing cesarean section.

Objective : To analyze the impact of OCVID – 19 on the maternal outcomes of obstetric patients undergoing cesarean section at Dr. Sardjito General Hospital.

Methods : This research employ a retrospective descriptive study. Secondary data were obtained from medical records of COVID – 19 obstetric patient who underwent a cesarean section at Dr. Sardjito General Hospital from January to December 2021. The data were analyze using descriptive data analysis with SPSS software version 26.

Results : The study resulting in a total sample size of 89 patients. The median age of the study subjects was 32 years, with a mean body mass index (BMI) of 28.3 kg/m^2. There was 7% incidence of hemorrhage exceeding 1000 cc , mortality rate was 25,8 %, and 20,2% from the population sample need mechanical ventilation pregnant women undergoing cesarean sections with COVID-19 at Dr. Sardjito General Hospital.

Conclusion : There was no significant increase in the incidence of hemorrhage exceeding 1000 cc (7% vs. 18.4%), However there was a noticeable rise in mortality rates (25.8% vs. 0.34%, 1.3%) and an increased need for mechanical ventilation (20.2% vs. 0.071%, 0.01%) when compared to descriptive studies conducted on pregnant women undergoing cesarean sections without COVID-19.

Keywords : COVID-19 , clinical outcome, cesarean section

USG Guiding Spinal Anesthesia Pada Sectio Caesarea

Dya Saputra — 2024-03-01

The practice of using central neuraxial block (CNB) techniques is now increasingly being done. In principle, this technique is highly dependent on the palpation of anatomical markings in bones, along with feedback from tactile sensations when inserting needles. Although anatomic landmarks are useful, they are often difficult to find or feel in patients pregnancy with obesity, changes in the patient's anatomical structure, edema in the back, and underlying spinal abnormalities or after spinal surgery. Recent years have seen increasing interest in the use of ultrasound for interventions in regional anesthesia. Ultrasound is non-invasive, safe, easy to use, can be done quickly, does not involve exposure to radiation, provides real-time images, is free of side effects, and may also be beneficial in pregnancy with obesity and abnormal spinal anatomy

Profil Keamanan Ventilator Venindo Kode R-03 dengan Penilaian Oxygen Index (OI), Rasio PaO2/FiO2 dan Oxygen Saturation Index (OSI) Pada Pasien Paska Operasi di ICU RSUP Dr. Sardjito Yogyakarta

Aisyah Ratna Yuniarti — 2024-03-01

Background: Respiratory failure is a condition resulting from inadequate gas exchange in the respiratory system which is characterized by failure to transport O2 into the blood (hypoxemic type respiratory failure) or removal of carbon dioxide (CO2) from the blood (hypercapnic type respiratory failure). A ventilator is a device used to assist and replace the respiratory system in critical patients who experience respiratory failure. Mechanical ventilation can induce lung injury. The use of Oxygen Index (OI), PaO2/FiO2 ratio, Oxygen Saturation Index (OSI) can describe aspects of the severity of lung injury.

Objective: To determine the OI value, PaO2/FiO2 ratio, and OSI as markers for assessing the safety of the Venindo R-03 Ventilator in post-operative patients treated in the ICU of RSUP Dr. Sardjito.

Method: This research uses a quasi-experimental research design. The number of samples taken were post-operative patients treated in the ICU. A sample size of 38 patients was obtained and data processing could then be carried out.

Results: This research shows that the use of the Venindo ventilator code R-03 and the Hamilton ventilator code T1 does not affect oxygenation status from the basic condition before using the ventilator as evidenced by the average OI value with both types of ventilator not being significantly different compared to the basic condition before using the ventilator (OI pre vs OI post 1 p = 0.527, OI pre vs OI post 2 p = 0.566, PF pre vs PF post 1 p = 0.199, PF pre vs PF post 2 p = 0.274, OSI pre vs OSI post 1 p = 0.600, OSI pre vs OSI post 2 p = 0.402). The average PaO2/FiO2 ratio after using the Venindo ventilator code R-03 when compared with after using the Hamilton ventilator had a statistically significant difference (PF post 1 vs PF post 2 p = 0.039) but clinically there was no difference.

Conclusion In this study, it was found that there were no significant differences in OI values, PaO2/FiO2 ratio and OSI before and after using the Venindo R-03 ventilator and the HamiltonT-1 ventilator. Meanwhile, the average PaO2/FiO2 ratio after using the Venindo ventilator code R-03 when compared with after using the Hamilton ventilator has a statistically significant difference but clinically no significant difference was found. This research also proves a strong correlation between OI and the PaO2/FiO2 ratio so that OI can have the potential to be a parameter in assessing lung injury.

Keywords: Ventilator, Oxygen Index, PaO2/FiO2 ratio, oxygen saturation index

Blok Pleksus Servikalis Superfisialis pada Insisi Abses Submandibula

Timor Krisna Bayu — 2024-03-01

This case study explores the use of bilateral superficial cervical plexus block as a regional anesthesia method in a 44-year-old male patient with a submandibular abscess. The patient, who has comorbidities of type 2 diabetes mellitus, renal insufficiency, and grade 1 obesity, underwent a 60-minute abscess drainage incision operation. This technique was chosen based on patient factors and the medical team's preference, avoiding the risks associated with general anesthesia. Lidocaine 2% at 6cc per side was used, demonstrating the effectiveness of the cervical plexus block in this procedure and others such as lymph node dissection and laceration repair. The study confirms that regional anesthesia guided by ultrasound is a quick, resource-efficient, and safe option, with the potential to avoid improper analgesic dosing. For longer procedures, local anesthetics like ropivacaine or bupivacaine can be utilized. The main conclusion is that the superficial cervical plexus block is an effective and safe alternative for anesthesia in certain neck procedures.