Indonesian Journal of Anesthesiology and Reanimation

Management of Anesthesia in Pediatric Patients with Bronchoscopy Late Onset Foreign Body Aspiration

Rinni Sintani — 2025-07-28

Introduction: Aspiration of foreign bodies in the airways is a severe and fatal condition if it occurs in children, because the risk of life-threatening obstruction is higher. Bronchoscopy is the main choice of procedure for treating foreign body aspiration, either with rigid bronchoscopy or flexible bronchoscopy. Anesthesia techniques are used with comprehensive anesthesia considerations, such as premedication, induction of anesthesia, maintenance of anesthesia, and monitoring.

Objective: To evaluate the management of anesthesia in a pediatric patient with foreign body aspiration in late-onset settings.

Case report: We report a case of anesthesia management in a child who aspirated a foreign body (peanuts) three days before being delivered to the hospital and undergoing a rigid bronchoscopy procedure. The patient experienced respiratory failure, and atelectasis was found in the right lower lobe of the lung upon arrival at the Emergency Unit (ER) due to the late onset of the case, so a secure airway must be performed before rigid bronchoscopy. Post-treatment care is carried out by observation and monitoring in the Intensive Care Unit (ICU) with complications of pneumonia. After three days of ICU treatment, the patient was transferred to the High Care Unit (HCU) in improved condition. The patient was discharged after three days of treatment in the low care Unit.

Conclusion: Rigid bronchoscopy is the best modality for extracting foreign bodies in the pediatric airway. Delayed onset effects from foreign body aspiration in the respiratory tract cause greater complications after bronchoscopy. Pneumonia is the most common complication. Comprehensive anesthesia evaluation and preparation are the keys to the success of this procedure.

Anesthesia and Surgical Considerations in Awake Craniotomy for Eloquent Area Tumor

Mehrdad Masoudifar — 2025-07-28

Introduction: Awake craniotomy is a specialized neurosurgical technique in which the patient remains conscious during surgery, enabling real-time functional mapping of the cerebral cortex. This procedure is primarily employed when a brain tumor or lesion is situated near critical areas responsible for motor, visual, or language functions. Its application minimizes the risk of postoperative neurological deficits, ensuring the preservation of vital brain functions.

Objective: The objective of this case report is to highlight the use of the awake craniotomy technique for a patient with a brain tumor located in the left parietal lobe, emphasizing the surgical and anesthetic considerations necessary for successful outcomes.

Case Report: The patient, diagnosed with a brain tumor in the left parietal lobe, presented unique surgical challenges due to the tumor's proximity to the cortical centers governing movement and speech. To mitigate the risk of neurological impairment, an awake craniotomy was performed. Bilateral scalp nerve blocks were administered for effective pain management, alongside dexmedetomidine to provide conscious sedation. The "awake-wake-wake" protocol was followed, ensuring the patient remained alert throughout critical phases of the surgery. This allowed the surgical team to conduct real-time assessments of motor and language functions, optimizing tumor resection while preserving neurological integrity.

Conclusion: This case underscores the importance of the awake craniotomy technique in neurosurgical interventions involving eloquent brain regions. The use of dexmedetomidine and precise nerve blocks provided effective sedation and analgesia, enabling active patient participation during functional mapping. The procedure highlights the value of interdisciplinary collaboration between neurosurgeons and anesthesiologists to achieve optimal patient outcomes while minimizing neurological risks.

Successful One-Lung Ventilation with Fogarty Balloon for Thoracotomy Lobectomy in A 5-Year-Old Girl

I Putu Kurniyanta — 2025-07-28

Introduction: Pediatric thoracic surgery, particularly lung resection, has special difficulties due to anatomical and physiological differences compared to adults. One-lung ventilation (OLV) is often necessary to optimize surgical exposure while minimizing lung injury. Traditional methods, like double-lumen endotracheal tubes, can be difficult to use in children due to their smaller airways and the risk of trauma. Thus, alternative approaches, such as bronchial blockers like Fogarty occlusion catheters, have gained prominence.

Objective: This case report aims to highlight the use of the Fogarty balloon in a pediatric patient undergoing lobectomy for organized pleural effusion linked to pneumonia.

Case Report: A 5-year-old girl with recurrent pneumonia presented with persistent cough, intermittent fever, and respiratory distress. Physical examination revealed decreased breath sounds and mild cyanosis. Imaging confirmed a large organized pleural effusion, suspected to be empyema. The surgical team chose a right thoracotomy lobectomy to remove the affected lung tissue. Preoperative consultations included pediatric surgery, anesthesiology, and respiratory therapy to ensure comprehensive care. A multi-modal pain management strategy, emphasizing regional anesthesia through epidural blocks, was implemented. For OLV, the anesthetic team selected a Fogarty balloon catheter to minimize airway trauma. After intubating with a single-lumen endotracheal tube, the balloon was inserted into the right main bronchus and inflated to occlude it, allowing ventilation of the left lung.

Discussion: The Fogarty balloon effectively provided lung isolation while preserving airway integrity, facilitating optimal surgical exposure and stable oxygenation. Continuous monitoring of oxygenation during OLV was crucial for patient safety.

Conclusion: The use of a Fogarty balloon for bronchial blockade and epidural anesthesia was successful in this pediatric lobectomy case. These techniques enhanced surgical safety, efficacy, and postoperative recovery, suggesting that there must be ongoing research to establish standardized protocols for pediatric thoracic procedures.

Health Impacts and Medical Interventions on Physical Violence Among Adolescents: A Review And Strategies in Indonesia

Nur Flora Nita TB Sinaga — 2025-07-28

Introduction: Violence against adolescents is a global public health issue with significant impacts on physical and psychological health. Data shows that many children around the world experience physical, sexual, or emotional violence, with a high prevalence in Indonesia. Based on data from the 2013 Child Violence Survey, violence against adolescents in Indonesia remains very high, with significant impacts on their physical and psychological health, as well as their academic performance.

Objective: This study aims to identify the causes of violence, including family dynamics, social media, and mental health, as well as its impacts, such as health disorders and decreased academic performance.

Review: Various factors causing physical violence among adolescents in Indonesia include family influence, social media, and peers. The impact is very detrimental, both in the short and long term, both in terms of physical and mental health. The findings indicate the need for early intervention and additional education in schools to effectively address adolescent violence. The synergy between various disciplines at the Faculty of Medicine is key to creating evidence-based prevention strategies. To mitigate the negative impact, additional education in schools and early interventions involving various disciplines are greatly needed. The synergy between educational programs, government policies, and social support is key to preventing violence. With the strengthening of legal protection, as well as increased attention from parents and the social environment, it is hoped that a safer environment for teenagers can be created.

Summary: Overall, this review emphasizes the importance of holistic interventions involving families, schools, and communities to address violence among adolescents and improve their quality of life. There is a need for preventive efforts that involve education in schools, family interventions, and stricter government policies. The success of preventing and addressing physical violence among adolescents heavily relies on the collaboration of all parties involved.

Mortality Determinants in Severe Traumatic Brain Injury with Pneumonia: A Retrospective Study

Tedy Apriawan — 2025-07-28

Introduction: Traumatic brain injury (TBI) is defined as an acute brain injury caused by mechanical forces to the head, excluding those related to drugs, alcohol, medications, or other conditions, such as systemic injuries, psychological trauma, or coexisting medical issues. TBI is a global public health issue responsible for significant disability and mortality, with an estimated global incidence of 69 to over 100 million new cases annually. This burden may be higher due to underreporting, particularly in low- and middle-income countries (LMICs). Several methods have been established to classify TBI, one of them is based on its severity with the Glasgow Coma Score (GCS). Pneumonia is a frequent complication in traumatic brain injury (TBI) patients, especially those on prolonged mechanical ventilation. Pneumonia could be classified based on the source of infection into ventilator-associated pneumonia (VAP), hospital-associated pneumonia (HAP), and community-acquired pneumonia (CAP).

Objective: To evaluate the mortality and risk factors of severe traumatic brain injury (sTBI) with pneumonia.

Methods: This study is a cross-sectional study with observational analytical investigations. The sample of this study is sTBI patients who were treated in Dr. Soetomo General Academic Hospital in 2023. Descriptive statistics were used to summarize the patients' characteristics. Chi-square tests and logistic regression were used to find relationship between factors that increase the risk of death and the development of pneumonia.

Results: In 2023, we documented 832 TBI cases, of these, 479 cases (57.6%) were mild TBI, 273 cases (32.8%) were moderate brain injuries, while severe brain injuries (sTBI) with 80 cases (9.6%). Our study shows that 50% of patients with sTBI have pneumonia, and VAP itself is one of the contributing factors to mortality in this population (p<0.001).

Conclusion: Of all types of pneumonia in this study, there is a statistical correlation between mortality and VAP in sTBI patients.

Comparing Hemodynamic Responses to Intubation in Hypertensive Patients: Clearvue® Video Laryngoscope Versus Macintosh Direct Laryngoscope

Ram Kishan Vyas — 2025-07-28

Introduction: The ClearVue^® video-laryngoscope (CVL) is believed to alleviate the stress response associated with intubation by providing superior laryngeal views, minimizing oropharyngo-laryngeal stimulation, and potentially reducing the pressor response.

Objective: This study aims to assess and compare how effective and safe intubation is when using a CVL versus a Macintosh direct laryngoscope (MDL) in patients with high blood pressure who are having surgery.

Methods: This prospective, randomized, interventional study was conducted on 140 hypertensive patients on antihypertensive medication undergoing elective surgery under general anesthesia (GA), who were allocated into two groups, CVL group (n = 70) and MDL group (n = 70). Hemodynamic parameters, including mean arterial pressure (MAP), mean heart rate (HR), systolic blood pressure (SBP), and diastolic blood pressure (DBP), were monitored at baseline, induction, and at various intervals post-intubation (1, 2, 3, 4, 5, and 10 minutes). Other metrics, such as intubation time, intubation attempts, ease of intubation, and associated complications, were documented.

Results: Significant differences in heart rate were observed between the groups, right at intubation and at 1, 2, and 3 minutes post-intubation (p-values: 0.011; 0.028; 0.002; 0.003). SBP showed significant differences at intubation and during the first four minutes post-intubation (p-values < 0.001 except for the fourth minute, p = 0.001). DBP and MBP also showed significant differences at various intervals post-intubation (p-values < 0.001 to 0.025 and < 0.001 to 0.020, respectively). No significant difference in airway complications was noted.

Conclusion: The CVL offers advantages over MDL in patients with controlled hypertension, specifically in reducing hemodynamic changes during intubation without increasing airway complications. At the same time, MDL offered less intubation time overall than CVL.

Prophylactic Effectiveness of Phenylephrine 100 mcg and Ephedrine 10 mg on the Incidence of Spinal Anesthesia Induced Hypotension in Patients Undergoing Cesarean Section

Cassandra Etania — 2025-07-28

Introduction: Birth by cesarean section (C-section) has increased significantly, with a high risk of maternal hypotension due to spinal anesthesia.

Objective: This study aims to compare the prophylactic effectiveness of phenylephrine 100 mcg and ephedrine 10 mg in preventing spinal anaesthesia induced hypotension in C-section patients. With a focus on safety and reducing the incidence of fetal acidosis, the results of the study are expected to provide clinical insights that can improve the safety and quality of care for pregnant women undergoing this procedure.

Methods: This study compared the effectiveness of phenylephrine 100 mcg and ephedrine 10 mg in preventing hypotension due to spinal anesthesia in cesarean section patients in four hospitals in Medan, Indonesia. Using a double-blind design, 40 patients aged 18-40 years were randomly selected, and blood pressure and heart rate were measured before and after anesthesia. Data were analyzed using SPSS, and ethical aspects were taken care of through informed consent.

Results: This study found that phenylephrine 100 mcg was more effective than ephedrine 10 mg in preventing spinal anaesthesia induced hypotension in cesarean section, with more stable blood pressure and mean arterial pressure (MAP) at the 5th, 10th, and 15th minutes (p-value < 0.05). Although ephedrine remained above 100 mmHg for systolic blood pressure (SBP), the incidence of nausea and vomiting was slightly higher in the ephedrine group. Results support phenylephrine as the primary choice for hypotensive management.

Conclusion: Phenylephrine 100 mcg is more effective than ephedrine 10 mg in preventing hypotension due to spinal anesthesia, without increasing heart rate. Despite causing nausea, ephedrine has a higher incidence of vomiting. Ephedrine is recommended if phenylephrine is not available, with further studies needed for lower doses of phenylephrine.

Comparison of Intercostal Nerve Block Versus Patient-Controlled Intravenous Analgesia for Post Thoracotomy Pain

Reema Meena — 2025-07-28

Introduction: Acute pain after thoracic surgery is frequent, intense and can raise morbidity. Effective postoperative pain control is essential to support early mobilization, optimal respiratory function, and recovery. Different pain relief methods, such as systemic opioids, patient-controlled analgesia, and intercostal nerve blocks, have been studied to reduce problems and enhance recovery for patients who have had thoracic surgery.

Objectives: This research aims to compare the difference in analgesic effect of intercostal nerve block (ICNB) versus patient-controlled intravenous analgesia (PCIA) for post-thoracotomy analgesia in cardiac surgery.

Methods: This prospective, single-blind, randomized comparative study involved 128 patients aged 30-60 years undergoing cardiac surgery through a thoracotomy under general anesthesia. Patients were randomly assigned to two groups. Group A received ICNB with 2.5 mg/kg of 0.5% ropivacaine and 0.5 mcg/kg fentanyl at the end of surgery; rescue analgesia with fentanyl 1mcg/kg was given if VAS score exceeded 4 within 24 hours post-intubation. Group B received PCIA with IV fentanyl (25 mcg/ml) at a basal rate of 1 ml/hour, with 1 ml bolus doses available every 15 minutes post-extubation for 24 hours. Pain was assessed using the Visual Analogue Scale (VAS), and total fentanyl consumption and sedation score were recorded. Significance level was kept at 95%.

Results: The demographic data were comparable between the two groups. The VAS score was significantly lower in the ICNB group than in the PCIA group (p value < 0.05). The total dose of fentanyl required in 24 hours after extubation was significantly higher in the PCIA group than in the ICNB group. The mean Ramsay sedation score was higher in the PCIA group compared to the ICNB group. Patients in ICNB group showed a lower incidence of side effects.

Conclusion: Our study suggests that the ICNB is more effective than PCIA for post-thoracotomy analgesia and also requires a lesser total dose of opioid.

Albumin Levels in Nontraumatic Acute Abdomen Patients Undergoing Emergency Laparotomy: A Retrospective Study in the Intensive Observation Ward of Dr. Soetomo General Academic Hospital

Fitri mazia — 2025-07-28

Introduction: Acute abdomen is a critical medical emergency characterized by the abrupt onset of severe abdominal pain, often requiring emergency laparotomy. Emergency laparotomy, due to limited preoperative preparation, generally has a higher morbidity and mortality rate than elective surgery. Optimizing perioperative care, particularly by monitoring albumin levels, may improve outcomes, as albumin plays a crucial role in maintaining fluid balance, wound healing, and controlling inflammatory responses. Postoperative emergency patients at Dr. Soetomo General Academic Hospital are closely monitored in a specific ward known as the Intensive Observation Ward (Ruang Observasi Intensif/ROI).

Objective: To evaluate albumin levels in nontraumatic acute abdomen patients treated in ROI following emergency laparotomy.

Methods: This study used a retrospective descriptive study design and was conducted from January to June 2022. Patients under 18 with malignancy, trauma, gynecological or obstetrical cases, and incomplete medical records were excluded.

Results: The male and female number of 90 patients was equal, most patients were aged 41-50, and had a normal BMI. Generalized peritonitis was the most common indication, followed by acute appendicitis and bowel obstruction. Appendectomy and exploratory laparotomy were the primary procedures, mostly done in under 3 hours. Most patients had no prior laparotomy history. Most patients had normal albumin levels preoperatively, but these shifted to mild hypoalbuminemia postoperatively. Of 13 deaths, 12 involved preoperative hypoalbuminemia. The predominant PS-ASA scores were 2 and 3. Electrolyte imbalance, especially hypokalemia, was the prevalent preoperative complication. Frequent comorbidities included kidney disorders and hypertension. The average ROI stay was 2.1±1.59 days, with most patients staying for 1 to 3 days. Operation-related complications included intra-abdominal infections and bleeding, while medical complications involved electrolyte imbalances, sepsis, and metabolic acidosis.

Conclusion: Nontraumatic acute abdomen patients with low preoperative albumin levels tend to have higher rates of postoperative complications and mortality.

Preoperative Gastric Volume Assessment in Full-Term Pregnant and Non-Pregnant Females: A Prospective Observational Study

Nikila Devarayasamudram Gopal — 2025-07-28

Introduction: Perioperative pulmonary aspiration (PA) of gastric contents is a serious anesthetic complication that can lead to significant morbidity and mortality. Obstetric patients, due to substantial anatomical and physiological changes, face a significantly higher risk of PA compared to non-pregnant individuals undergoing planned gynecological or other procedures.

Objective: The objective of this study is to compare gastric contents and volume through point-of-care gastric ultrasound (PoCUS) in full-term pregnant women and non-pregnant females scheduled for elective surgeries.

Methods: This single-center, prospective, observational study included 140 patients who underwent surgery between March 2022 and July 2023. Quantitative and qualitative measurements of the stomach were performed using PoCUS.

Results: The study included 140 patients with a mean age of 25±2.5 years (pregnant, range: 22-31 years) and 29±6 years (non-pregnant, range: 21-30 years), respectively. Patients in the pregnant group are classified as ASA II (70 (100%)), while those in the non-pregnant group (ASA I: 22 (31%); ASA II: 48 (69%)) are mixed. In Perlas, a 3-point grading system was used to classify the antrum based on the presence or absence of clear fluid in the supine position. The majority of the pregnant patients’ antrum levels were reported to contain clear fluid (37 (53%)), while in non-pregnant patients, they were empty (45 (64%)). The average gastric antrum cross-sectional area (302.63±4.87 cm²) and gastric volume (1.85±0.5 mL) were found to be high in pregnant females.

Conclusion: PoCUS was proven to be a simple, non-invasive method that can evaluate and offer a more precise bedside measurement of gastric volume, both qualitatively and quantitatively, in patients at risk for PA.