Indonesian Journal of Anesthesiology and Reanimation

The Differentiating of Sepsis-Associated and Sepsis-Induced Acute Kidney Injury in Intensive Care Unit Patients

Nusi Hotabilardus — 2025-01-30

Introduction: Acute kidney injury (AKI) is a severe and common complication in Intensive Care Unit (ICU) patients, commonly resulting from sepsis. It is associated with elevated mortality, chronic renal failure, and other long-term consequences. Sepsis-associated AKI (SA-AKI) and Sepsis-induced AKI (SI-AKI), a specific sub-phenotype, differ in their underlying pathophysiology. Objective: To examine the distinctions between SA-AKI and SI-AKI, focusing on their pathophysiology, biomarkers for detection, and associated prognoses in critically ill patients. This literature review examines the findings of randomized control trials (RCTs) or meta-analysis studies that learn about biochemical mediators and biomarkers for SA-AKI and SI-AKI, including NGAL, Kim-1, and others, as well as the prognostic impact of these conditions. The literature was gathered from Google Scholar and PubMed using the keywords Sepsis-Associated Acute Kidney Injury, Sepsis-Induced Acute Kidney Injury, Intensive Care Unit, and Sepsis and published within the last ten years (2018–2023). Articles unavailable in the full text were excluded. Review: SA-AKI and SI-AKI are distinct entities within the broader spectrum of sepsis and AKI. SI-AKI involves sepsis-induced direct kidney damage, which differentiates it from other forms of SA-AKI. Various biomarkers such as NGAL, Kim-1, and others are crucial for early detection and differentiation between these conditions. Patients with SA-AKI and SI-AKI usually have a bad outlook. They are more likely to die, be disabled for a long time, and need longer stays in the ICU and hospital than patients with sepsis or AKI alone. Figuring out the underlying pathophysiology and using the right biomarkers can help with early diagnosis and could lead to better outcomes for patients through targeted therapies. Summary: SA-AKI and SI-AKI represent critical complications in ICU patients with sepsis, leading to high mortality and long-term adverse outcomes. Differentiating between these conditions using biomarkers is essential for early detection and management. These patients have a worse prognosis than those with sepsis or AKI alone. This shows how important it is to keep researching and finding better ways to treat these serious complications in critically ill patients.

Cerebral Oxygenation Monitoring During Coronary Artery Bypass Grafting and Its Correlation with Hematocrit, Mean arterial pressure, and Partial pressure of Oxygen in Arterial Blood

Jai Sharma — 2025-01-30

Introduction: Optimal cerebral oxygenation is vital during coronary artery bypass grafting (CABG) to prevent neurological complications like cognitive decline and stroke. Non-invasive monitoring methods include near-infrared spectroscopy (NIRS), electroencephalography (EEG), and transcranial doppler (TCD). It offers real-time rSO2 assessment, detecting critical thresholds and reducing risks during cardiopulmonary bypass (CPB). Objective: This observational study aims to investigates cerebral oxygenation changes during CABG and correlations with hematocrit, mean arterial pressure (MAP), blood oxygen levels, CPB flows, and temperature. Methods: Seventy-two elective CABG patients underwent CPB with parameters including rSO2, hematocrit, MAP, PaO2, temperature, and pump flows assessed at specific time points: T1: Baseline pre-anesthesia; T2: Post-anesthesia induction (FiO2 100%); T3: Post-anesthesia induction (FiO2 50%); T4: CPB initiation; T5: CPB at 35°C; T6: CPB at 32°C; T7: CPB rewarming (36°C); T8: Post-CPB weaning (FiO2 100%); T9: Post-CPB weaning (FiO2 50%). Results: The mean baseline values for rSO2 were 72.14 for the right side and 71.90 for the left side. Upon initiating CPB at 35°C, a significant maximum reduction in rSO2 of 10.5% was observed, which remained below baseline during the hypothermia phase. The rSO2 values began to increase during the rewarming phase, nearly reaching baseline levels after CPB. A post hoc analysis indicated that changes in rSO2 were correlated with variations in hematocrit (correlation coefficient = 0.518), MAP (correlation coefficient = 0.399), and PaO2 (correlation coefficient = 0.001). Conclusion: This study explored the fluctuations in rSO2 during CABG with CPB and examined its correlations with hematocrit, MAP, PaO2, CPB flows, and temperature. The findings highlight significant correlations among these variables, providing insights into factors influencing cerebral oxygenation during cardiac surgery.

Bispectral Index Versus Minimum Alveolar Concentration Guided Anesthesia for Assessment of Intraoperative Awareness in Patients Undegoing Laparascopic Abdominal Surgery

Shreya Garg — 2025-01-30

Introduction: Intraoperative awareness with explicit recall (AWR) occurs when an individual retains memory of intraoperative events after completion of anesthesia. It is an unpleasant feeling feared by both the patients and the anesthetists. Objective: This research aims to compare Bispectral Index (BIS) versus Minimum Alveolar Concentration (MAC) guided anesthesia for assessment of intra-operative awareness in patients undergoing laparoscopic abdominal surgery. Methods: This research is a prospective comparison involving 100 patients divided into two groups of 50 patients each. Group M (MAC): Desflurane concentration was maintained at a MAC value of 1. The BIS monitor was not to be applied to this group of patients at the time of induction, but in Group B (BIS), the BIS electrode was applied on the forehead immediately before induction. Hemodynamic parameters including heart rate and mean arterial blood pressure were recorded. After the surgery, the patients were interviewed using the Modified Brice Awareness Questionnaire and Michigan Awareness Classification score for assessment of intra-operative awareness or consciousness at two intervals: in the post-anesthesia care unit and 48 hours after surgery. Results: Demographic data were comparable between groups M and B. No significant differences in the hemodynamic parameters, which include heart rate and mean arterial blood pressure (MAP) between the M group and the B group (p value>0.05). The patient’s awareness was compared based on a modified Brice awareness questionnaire. The distribution of awareness was comparable between groups M and B (0% vs. 4% respectively) (p value=0.495). The distribution of Michigan awareness classification scores was comparable between groups M and B. Class 0 (no awareness) was 98% vs. 96% respectively, and Class 1(isolated auditory perception) of 2% vs. 4% respectively with (p value=1). Conclusion: This research found that BIS-guided anesthesia works just as well as MAC-guided anesthesia at keeping patients from waking up and keeping an eye on changes in their blood pressure while they are under general anesthesia for laparoscopic abdominal surgery.

A Comparison of Postoperative Analgesic Effect of Intravenous Tramadol versus Transdermal Buprenorphine Patch in Patients Undergoing Aortofemoral Graft Surgery

Reema Meena — 2025-01-30

Introduction: The popularity of the transdermal buprenorphine patch (TDB) is currently increasing for chronic pain management because of its ease of use, non-invasive nature, sustained drug delivery, and avoidance of side effects associated with oral or parenteral routes. However, its role in postoperative pain management for aortofemoral bypass surgery is poorly established. The study was designed to compare the postoperative analgesic effect of intravenous tramadol versus transdermal buprenorphine patch in patients undergoing aortofemoral graft surgery. Objective: To compare the efficacy between a buprenorphine patch versus intravenous tramadol for postoperative analgesia in patients undergoing aortofemoral bypass surgeries. Methods: This is a hospital-based, prospective, randomized, and interventional study. This study was conducted in the cardiac surgery Operation Theatre (OT). A total of 60 patients of either sex belonging to ASA 2 or 3 in the age group of 30-60 years and BMI ≤ 40 kg/m2 scheduled for aortofemoral bypass surgery were enrolled in this study. These 60 patients were divided into two groups; the intravenous tramadol and the transdermal buprenorphine patch group using a randomization table. Results: The two groups were comparable in terms of demographical data, duration of surgery, and time for extubation. The analysis of variance showed that the VAS score was higher in the buprenorphine group as compared to the tramadol group for the first 3 hours post operatively but after that, the VAS score was significantly less in the buprenorphine group at various study intervals. A greater number of patients complained of pain for the first 3 hours postoperatively, but after that the patients had better pain relief for the rest of the study period. Conclusion: Transdermal buprenorphine applied preoperatively is a safe and effective option for postoperative pain management as it offers superior pain control and reduces the need for rescue analgesia, thereby decreasing potential side effects as compared to intravenous tramadol.

Surface Anatomy-Based Clavipectoral Fascia Plane Block for Clavicle Surgery

Heri Dwi Purnomo — 2025-01-30

Introduction: Clavicular fractures are often observed cases. In the majority of clavicle fractures, both in adults and children, the fracture is located in the midshaft. Generally, General Anesthesia techniques are usd in such instances, as regional anesthesia through peripheral nerve block often presents its own challenges. The clavipectoral fascial plane block was first introduced in 2017. Apart from its ease of implementation, the Surface Anatomy-Based Clavipectoral Plane Block can avoid the risks associated with other regional anesthesia techniques such as Plexus Brachialis Block or Interscalene Block. Objective: This report aims to provide an overview of the procedures for carrying out surface anatomy-based clavipectoral fascia plane block for clavicle surgery. Case Report: A 33-year-old man with the primary complaint of pain in the right shoulder following a fall while playing football. The patient was diagnosed with closed re-fracture of the clavicle (D) Allman Group I. Clavicle surgery was conducted with the Surface Anatomy-Based Clavipectoral Fascia Plane Block technique. In this patient, local anesthetic agents were administered as Levobupivacaine 0.375% in a volume of 20 cc. The operation lasts approximately 1.5 hours. The Patient’s hemodynamic condition was stable during the surgery. The patient had no complaints and post-operative pain was effectively managed. Conclusion: The surface Anatomy-based Clavipectoral fascia plane block can be considered for clavicular surgery, especially in Allman Group type 1. Besides being easy to implement, this technique also poses fewer risks compared to other regional anesthesia techniques.

A Diagnostic Challenge in the Differential Diagnosis of Recurrent Seizures During Pregnancy: Epilepsy Versus Eclampsia

Andri Subiantoro — 2025-01-30

Introduction: Seizures during pregnancy are associated with adverse outcomes for mothers and infants. Seizures during pregnancy can be associated with multiple factors. To establish effective treatment and management of seizures, it is important to identify all of the factors that may contribute to seizures during pregnancy. Objective: This study aimed to evaluate and identify the cause of seizures in pregnancy to facilitate appropriate treatment. Case Report: We present a case of a 32-week pregnant woman who experienced eclampsia and recurrent seizures during the peripartum period. The patient had a history of inadequately managed epilepsy. Seizure management required multiple medications, including magnesium sulfate, benzodiazepine, and phenytoin. The patient underwent an emergency caesarean utilizing the Rapid Sequence Intubation (RSI) procedure and general anesthesia to rescue the baby. Nicardipine, furosemide, isosorbide dinitrate, captopril, spironolactone, and hydrochlorothiazide were used to manage blood pressure. The patient needs to be continuously observed, and the therapy should be adjusted according to the patient’s condition. Discussion: The patient had a history of epilepsy and had experienced two bouts of generalized seizures with characteristics of eclampsia before being arrived at the emergency room. Determining how to control the seizures in this spesific individual was a challenge. The primary therapy of patients with active seizures should include maintaining the airway, respiration, and circulation. The therapeutic objectives are immediate delivery of a viable fetus and maintenance of maternal health. Perioperative management aims to control blood pressure and seizures, maintain hemodynamics, manage anesthesia for terminating a pregnancy, and support critical care management for any potentially fatal complications from this condition. Conclusion: Seizures in pregnancy are attributable not just to eclampsia but can also cause by another or concurrently together with other causes. Early diagnosis and appropriate treatment are required to achieve the best outcome for this patient.

Acute Lung Oedema in Severe Pre-eclampsia: Advanced Management and Anesthetic Interventions

Nusi Andreas Hotabilardus — 2025-01-30

Introduction: Acute Lung Oedema (ALO) during pregnancy is an uncommon but potentially life-threatening condition, particularly when associated with severe pre-eclampsia. This critical obstetric emergency requires prompt recognition and comprehensive management to prevent adverse maternal and fetal outcomes. Objective: This report aims to highlights the management of a complex case of ALO in a pregnant patient with severe pre-eclampsia, underscoring the essential role of multidisciplinary collaboration, evidence-based protocols, and individualized care in achieving favorable outcomes. Case Report: A 30-year-old woman at 29–30 weeks gestation presented with significantly reduced consciousness and severe shortness of breath. Clinical examination revealed hypertension, tachycardia, and profound hypoxemia, with radiological evidence of pulmonary oedema. The diagnosis included severe-feature pre-eclampsia complicated by acute respiratory distress syndrome (ARDS) secondary to ALO. Endotracheal intubation was used to protect the mother's airway, mechanical ventilation was used to help her get enough oxygen, and her blood pressure and heart rate were stabilized right away. Fluid therapy was carefully monitored to avoid exacerbating pulmonary oedema. Obstetric management prioritized delaying delivery until maternal stabilization was achieved. A surgical intervention under general anesthesia resulted in the delivery of a moderately distressed neonate. Postoperative care in the intensive care unit included continued mechanical ventilation, sedation, and meticulous fluid management. Gradual stabilization allowed for successful weaning off ventilatory support, extubation, and transfer to a general hospital ward. Discussion: Management strategies were guided by the ABCDE principle, targeting reductions in left ventricular preload and afterload, adequate oxygenation, and infection prevention. The case emphasizes the value of early diagnosis, prompt intervention, and interdisciplinary collaboration involving obstetricians, intensivists, and anesthetists. Conclusion: This case illustrates the importance of early recognition, swift intervention, and tailored care in managing ALO associated with severe pre-eclampsia. Comprehensive, team-based approaches are critical for optimizing maternal and neonatal outcomes in such high-risk scenarios.