Indonesian Journal of Anesthesiology and Reanimation

AIMS65 Scoring System for Predicting Clinical Outcomes Among Emergency Department Patients with Upper Gastrointestinal Bleeding

Rifaldy Nabiel — 2024-01-29

Introduction: Several scoring systems were developed for early risk stratification in Upper Gastrointestinal Bleeding (UGIB) patients. AIMS65 score is a scoring system that only consists of five parameters, it might be used in daily clinical practice because of rapid and easy to calculate within 12 hours of admission. Objective: To evaluate the AIMS65 scoring system as a predictor of mortality, rebleeding events, need for endoscopic therapy, blood transfusion, and ICU admission for all causes of UGIB. Methods: We conducted a systematic review on PubMed, ScienceDirect, ProQuest, and Cochrane Library databases from the 2012 to 2022 publication period. We included either prospective or retrospective cohort studies that reported UGIB with all kinds of aetiologies who presented in the emergency department (ED), reported discriminative performance for each outcome, and reported the optimal cut-off of AIMS65. The primary measurement of discriminative performance for clinical outcomes includes mortality, rebleeding incidents, need for endoscopic therapy, blood transfusion, and ICU admission. Results: We identified 351 published studies, of which 20 were included in this study. Most of the studies reported discriminative performance for predicting mortality, which amounts to about 18 out of 20 studies. Rebleeding prediction was reported in 11 studies, need for endoscopic therapy in 5 studies, blood transfusion in 7 studies, and ICU admission in 2 studies. Most of the studies reported fair to excellent discriminative performance for predicting mortality, but in contrast for predicting rebleeding, the need for endoscopic therapy, blood transfusion, and ICU admission. Cut-off values≥ 2 are frequently reported to distinguish between high-risk and low-risk patients in mortality. Conclusion: AIMS65 can be applied to patients with UGIB in ED for predicting mortality, but not applicable for predicting rebleeding events, the need for endoscopic therapy, blood transfusion, and ICU admission. It enhances early decision-making and triage for UGIB patients.

Pulsed Radiofrequency on Sphenopalatine Ganglion as the Interventional Pain Management in Cluster Headache Secondary to Sphenoid Meningioma

Naomi Rahmasena — 2024-01-29

Introduction: Cluster headache is one of the neurovascular headaches characterized by severe recurrent unilateral pain distributed around the orbit and accompanied by autonomic symptoms such as lacrimation, conjunctival injection nasal congestion or rhinorrhea, edema of the eyelid, sweating, and miosis. The attack usually lasts for 15 to 180 minutes. The possible mechanism of cluster headache is through the trigeminal-autonomic reflex. Management of the cluster headache is divided into pharmacological therapy including abortive and prophylaxis, as well as interventional pain management like deep brain stimulation, occipital nerve stimulation, and radiofrequency of the sphenopalatine ganglion. Objective: This report aims to demonstrate the effectivity of pulsed radiofrequency sphenopalatine ganglion on cluster headaches secondary to meningioma. Case Report: A 47-year-old female consulted the pain clinic with a chief complaint of profound facial pain for a year. The patient also reported autonomic symptoms such as rhinorrhea and lacrimation. The patient was diagnosed with meningioma and already treated with conventional therapy such as gabapentine, carbamazepine, omeprazole, and mecobalamin. Due to the location of meningioma which causes the tumor inoperable. The patient complained of constant and worsening pain, therefore pulsed radiofrequency on sphenopalatine ganglion was chosen to treat the patient. The patient reported relief of pain ever since. Discussion: Among the consequences and benefits, pulsed radiofrequency is the choice of interventional pain management. Possibly the pain from the compression of the greater palatine nerve, intervention on the sphenopalatine will cause relief of the pain. Pulsed radiofrequency on sphenopalatine ganglion was reported successful in alleviating the pain of the patient. Conclusion: Pulsed radiofrequency of the sphenopalatine ganglion successfully alleviates the pain of the cluster headache due to meningioma. However, further study with a bigger population is recommended to see the efficacy of interventional pain management objectively.

Perioperative Management of Marfan Syndrome in Pregnancy and Congestive Heart Failure

Mirza Koeshardiandi — 2024-01-29

Introduction: A mutation in fibrillin-1 (FBN1) leads to the autosomal dominant condition known as Marfan Syndrome (MFS). The condition of pregnancy with MFS may increase morbidity and mortality during pregnancy and delivery. Due to a greater frequency of maternal problems and fetal involvement, pregnancy with Marfan syndrome (MFS) provides challenges to healthcare professionals and patients and requires special treatment. Objective: This study aimed to analyze the perioperative management of Marfan syndrome in pregnancy and congestive heart failure (CHF). Case report: A 27-year-old primigravida with 38-39 weeks gestation presented with a referral letter with a diagnosis of G1P0A0 with scoliosis and peripartum cardiomyopathy. The patient complained of shortness of breath accompanied by cold sweat since the second trimester of gestation. Physical examination revealed the presence of arachnodactyly and spine deformity. The patient underwent an emergency cesarean section with general anesthesia. Breathing problem appeared the next day after cesarean section, the patient was intubated in the ICU. Chest X-ray depicted bilateral pulmonary edema. A mechanical ventilator was set up and fluid restriction had been done. The patient was extubated after showing breathing improvement in the second week in the ICU. Discussion: The diagnosis of MFS in this patient was defined based on the revised Ghent Nosology. MFS with spine deformity causes breathing problems because of the altered geometry of the thoracic cavity. MFS in pregnancy may worsen the breathing problem due to autotransfusion that leads to pulmonary edema. A mechanical ventilator with a specific setting accompanied by fluid restriction is recommended to reduce the fluid overload in the lungs. Conclusion: Mechanical ventilators with specific settings and fluid restriction are effective perioperative management to reduce pulmonary edema on MFS in pregnancy and congestive heart failure.

Combined Spinal-Epidural Anesthesia with Isobaric Ropivacaine 0.375% for Inguinal Hernia Surgery in a Heart Failure Patient with Ejection Fraction of 36%

Muhammad Isra Rafidin Rayyan — 2024-01-29

Introduction: Heart failure is a condition caused by myocardial abnormalities that interfere with the fulfillment of the body's metabolism. It is one of the primary causes of high perioperative morbidity and mortality rates, and its management presents a challenge to anesthesiologists. Objective: To demonstrate combined spinal-epidural anesthesia with isobaric ropivacaine 0.375% for inguinal hernia repair surgery in a heart failure patient with an ejection fraction of 36%. Case Report: A 53-year-old man presented with a complaint of a lump on his left groin accompanied by pain with a visual analog scale (VAS) pain score of 3/10 three days before admission. The patient was also known to often complain of shortness of breath and chest palpitations when lying down at night and during strenuous activity. Based on the examination, the patient was then diagnosed with reducible left lateral inguinal hernia and heart failure with LVEF 36%. Subsequently, the patient was scheduled for elective herniotomy-hernioraphy surgery under low-dose combined spinal-epidural anesthesia. Spinal anesthesia was performed with isobaric ropivacaine 0.375% and fentanyl 25 μg in a total volume of 3.5 ml at the L3-L4 intervertebral space. Epidural anesthesia was performed with isobaric ropivacaine 0.375% and fentanyl 25 μg in a total volume of 8 ml at the L2-L3 intervertebral space. After 10 minutes, the sensory block reached the T6 level, but the motor block was only partial (Bromage 1). A continuous infusion of isobaric ropivacaine 0.1875% 1 ml/hour was administered through the epidural catheter to control postoperative pain. During surgery and hospitalization, the patient's hemodynamic condition remained stable. Conclusion: Combined spinal-epidural anesthesia with isobaric ropivacaine 0.375% can provide adequate anesthesia with relatively stable hemodynamics, thus making it safe for inguinal hernia repair surgery in heart failure patients with reduced ejection fraction.

Developing an Effective Team-Based Emergency Training Program for Medical Students

Pinter Hartono — 2024-01-29

Introduction: Team-based patient management in critical care demands a knowledgeable, skillful, and responsive doctor who collaborates well on teams. Medical education is responsible for producing competent graduates who meet the above requirements. However, the current medical curriculum in Indonesia tends to focus only on individual knowledge and appraisal. There was no standardized university-based group emergency training and examination with comprehensive emergency topics beyond cardiac and trauma cases. Objective: This study aimed to develop and evaluate a team-based emergency training program that enhances medical students' preparedness and teamwork skills in dealing with future emergencies in the workplace. Materials and Methods: We developed Acute Life Threatening Events Management (ALTEM), a three-day emergency training program consisting of pre-test, lectures, guided skill practice, group (case-based) simulation exam, and post-test. Group simulation occurred in a virtual hospital with high-fidelity mannequins, actual medical equipment (i.e., beds, monitors, drugs, tools, pads), two-way mirror rooms, and simulated patient family to resemble real hospital situations. The program was then evaluated by a modified Kirkpatrick evaluation model, which measures individual perception, satisfaction, understanding, and performance related to the program. Results: A total of 114 participants were involved in this study. Most subjects (>80%) had a good experience with the program. ALTEM training program significantly increased communication and teamwork (p <0.001) and decision-making towards critical patients (p <0.001) in the univariate analysis. Communication and teamwork remained related considerably in the multivariate analysis (aOR 7.866; p = 0.005). Conclusion: The ALTEM simulation program obtained a good response from the subjects and was a prospective program to improve medical students' competence and teamwork skills in emergencies.

Comparison of Intravenous Administration of Remifentanil with Fentanyl for Increased Blood Sugar Levels in Post Cardiac Surgery Patients

Irvan — 2024-01-29

Introduction: The incidence of hyperglycemia in patients with heart disease undergoing cardiac surgery reaches 50% in patients without a history of Diabetes Mellitus. This condition of hyperglycemia can increase morbidity and mortality. Objective: This study aims to assess the effect of using the agent remifentanil intravenously 0.5-1 µg/kgBW bolus followed by maintenance at a dose of 0.05-0.1 µg/kgBW/minute intravenously compared to the use of fentanyl 3-10 µg/kgBW followed by a maintenance dose of 0.03-0.1 µg/kgBW/minute for increased blood sugar levels in patients undergoing cardiac surgery with the Cardiopulmonary Bypass (CPB) procedure. Materials and Methods: This study is an experimental study with a single-blind randomized controlled design. Patients will be divided into 2 groups consisting of 12 patients each, namely group R (remifentanil) received remifentanil, and group F (fentanyl) received fentanyl. Blood sugar levels will be checked before and after surgery. Results: The research has been conducted at Dr. Hasan Sadikin Hospital Bandung from February 2023 to May 2023. The average increase in blood sugar levels in the remifentanil group was 74 mg/dl, while in the fentanyl group, it was 90 mg/dl. The p-value given is 0.214. Statistical test results showed that the value of p> 0.05. Conclusion: This study concludes that there is no significant difference in the increase in blood sugar levels between the two groups (remifentanil and fentanyl). This can be caused by the use of opioid doses in the lower range and more complex surgical procedures in our research.

Investigation of Heart Rate Variability and The Requirement for Vasopressors Relationship Due to Hypotension in Patients Undergoing Caesarean Section with Spinal Anesthesia

Kübra Bektaş — 2024-01-29

Introduction: The most common effect of spinal anesthesia applied in cesarean section operations is hypotension. It is very important to prevent hypotension due to fetal bradycardia, acidosis, and maternal effects. Objective: This research was conducted to predict and prevent maternal hypotension in pregnant women undergoing elective cesarean section with spinal anesthesia by measuring heart rate variability parameters about hypotension. Materials and Methods: The study included pregnant women aged 18-45 with ASA 2 classification who underwent elective cesarean section with spinal anesthesia. Using the 'CorSense Heart Rate Variability Finger Sensor by Elite HRV' device and its smartphone application, 102 volunteer pregnant patients were monitored for 5 minutes in the recovery unit, and their data were recorded. After the administration of spinal anesthesia, patients who exhibited a decrease in systolic blood pressure of 20% or more from their baseline values received intravenous ephedrine in 10 mg bolus doses at each instance of low blood pressure measurements. Patients who received a total of 20 mg or more ephedrine doses or more as needed were designated as 'Group 1,' while patients who received less than 20 mg or no ephedrine were classified as 'Group 2.' Results: This study was completed with a total of 102 pregnant patients With 46 patients in Group 1 and 56 patients in Group 2, the relevant parameters that showed a statistically significant difference between patient groups were subjected to ROC analysis for predicting hypotension. It was determined that patients with high HF POWER and TOTAL POWER values had a greater need for vasopressors due to hypotension following spinal anesthesia (p<0.05). Conclusion: In the research, these values are believed to have the potential to predict hypotension in patients undergoing cesarean sections with spinal anesthesia.