Bali Journal of Anesthesiology (BJOA)
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Effectiveness of Partial and Adjustment Neostigmine Dose as a Neuromuscular Reversal for Single Dose Rocuronium
Get PDFBackground: Routine reversal (neostigmine) and the use of quantitative monitoring of neuromuscular blockade (Train of Four Ratio (TOFR)) are recommended to prevent the occurrence of residual paralysis. This study attempted to determine the effectiveness between neostigmine partial dose 0.02 mg/kgbw and adjusted dose based on TOFR value in recovering neuromuscular blockade of single dose rocuronium 0.6 mg/kgbw.Methods: This randomized clinical trial was performed in the operating room of Integrated Surgical Care Unit of Cipto Mangunkusumo General Hospital and Kirana Clinic. Sixty-one patients who underwent elective surgery in general anesthesia were randomized in to 2 groups: administration of neostigmine in partial dose 0.02 mg/kgbw (group A) and adjusted dose based on TOFR value (group B). Quantitative monitoring evaluation of neuromuscular blockade was performed four times: after adequate spontaneous breathing, 5, 10, and 15 minutes after reversal.Result: The mean of TOFR values in group A and group B respectively: after spontaneous breathing 42% and 50% (p=0.436); 5 minutes after reversal 80.2% and 89.2% (p=0.083); 10 minutes after reversal 92.2% and 94% (p=0.399); 15 minutes after reversal 94.3% and 94.9% (p=0.526). After the 5 minutes of reversal, group B (80.6%) reaches TOFR value ≥ 90% many more than group A (63.3%) (p=0.132).Conclusion: Neostigmine partial dose 0.02 mg/kgbw was as effective as administering neostigmine in adjustment dose based on TOFR values to achieve complete recovery from the neuromuscular block effect of single-dose rocuronium 0.6 mg/kgbw. This study also show the complete recovery of neuromuscular block when TOFR value ≥ 90%
ANAESTHESIA CHALLENGES DURING MANAGEMENT OF EMERGENCY CESAREAN SECTION IN A POST-PNEUMONECTOMY PRIMIGRAVIDA WITH PLACENTA PREVIA
Get PDFPulmonary disease is a known risk factor for perioperative respiratory complications. So anesthesiologists are expected to experience these postpneumonectomy patients coming for elective or emergency surgeries. But there is little data to anesthesia management for cesarean delivery of postpneumonectomy parturient. On reviewing the literature, there is only one reported case of the trial of vaginal delivery followed by cesarean section done under epidural anesthesia, a 41 years-old parturient having preoperative respiratory failure and pneumonia in the antenatal period which was managed on continuous positive airway pressure (CPAP) simultaneously. Our case presented a 24 years-old primigravida of 34 weeks gestation with placenta previa and complaints of two days per vaginal bleeding was posted for the emergency cesarean section. She had past history of left lung lobectomy 10 years back, video bronchoscopy 3 years back and history of admission for treatment of an episode of pneumonia at 32 weeks of present gestation. Emergency cesarean section was managed successfully under spinal anesthesia. This case report highlights that spinal anesthesia may remain a good option in anesthesia management for cesarean section in a primigravida with postpneumonectomy
Supraspinal Modulation : Something to be Remembered
Get PDFPain had always been a challenging issue in patients with acute and chronic condition. Pain results from activation of sensory receptors specialized to detect actual or impending tissue damage. However, a direct correlation between activation and nociceptors and the sensory experience of pain is not always apparent. Emotional state, the degree of anxiety, attention and distraction, past experiences, memories, and many other factors can either enhance or diminish the pain experience.Many active agents are used to block and alleviate pain sensation in acute and chronic settings. When an inadequate treatment for acute pain and neuralgia occurred, it would induce complex processes involving both central and peripheral sensitization contributing to persistent post-surgical pain and worsening neuralgia that would lead to chronic pain issue.The important thing to be considered is that this pain process is an intertwined and interconnecting and sustainable process that could not be cut abruptly. Our aim is to remind us to accept that pain pathway is merely not one straight way but still a convoluting idea which could still revolve and expand. Imagining areas could be defined surely one day through high technology advances and would lead us into defining the depth of this beautiful yet complex pathway
THE SIGNIFICANCE OF MODIFIED PIRO SCORING WITH NLR BIOMARKER ON ENHANCING MORTALITY PREDICTION OF PATIENTS WITH VENTILATORS‑ASSOCIATED PNEUMONIA IN INTENSIVE CARE UNIT
Get PDFVentilator-associated pneumonia (VAP) is a pulmonary infection that occurs as a mechanical ventilator-related disease which accounts for almost 80% of hospital-acquired pneumonia with of high mortality rate, lengthens the hospital-stay rate and increases health costs. To provide a description of the likelihood of the patient's life expectancy, mortality, and prognosis of patients in ICU, a scoring system should be utilized in order to assess the severity of the disease and estimate mortality during hospital treatment. The PIRO scoring system is a comprehensive concept that provides good validity and derivation in predicting mortality risk in a wide range severity of the disease so that it is very useful in the selection or categorization of patients, especially those admitted to the ICU with VAP. A conjunction or integration with a simple biomarker such as Neutrophil-to-lymphocyte ratio (NLR) provides a better performance of the tool in regards to the predictive value in VAP mortality risk estimation. Since the NLR has a strong predictive value, is simple, low-cost, and easily available compared to other biomarkers, therefore it is practical and useful for prognostic indications for VAP with conjunction with the PIRO score where medical facilities are lacking
Anaesthesia Management of Patient at 16 Weeks Pregnancy with Primary Malignant Bone Tumour Underwent Hemipelvectomy Surgery
Get PDFChondrosarcoma is a type of sarcoma that affects the bones and joints. It is a rare cancer that accounts for about 20% of bone tumours and is diagnosed in approximately 600 patients each year in the United States. Chondrosarcoma typically affects adults between the age of 20 and 60 years old. The disease usually starts in the bones of the arms, legs or pelvis, but it can be found in any part of the body that contains cartilage. Sometimes chondrosarcoma grows on an otherwise healthy bone or it grows on a benign bone tumour (an enchondroma or osteochondroma). Non-obstetric surgery during pregnancy is not uncommon and can have excellent outcomes with proper planning. Between 0.75% and 2% of pregnant women require non-obstetric surgery. Surgery can be required during any stage of pregnancy depending on the urgency of the indication. When caring for pregnant women undergoing non-obstetric surgery, safe anaesthesia must be provided for both the mother and the child. Thorough understanding of the physiological and pharmacological adaptations to pregnancy is required to ensure maternal safety. Fetal safety requires avoidance of potentially dangerous drugs at critical times during fetal development, assurance of continuation of adequate uteroplacental perfusion, and avoidance and/or treatment of preterm labour and delivery.Pregnant patients beyond 18–20 weeks of gestation should be positioned with a 15° left lateral tilt, to reduce aortocaval compression and supine hypotension syndrome. Regional anaesthesia with combined spinal epidural is an option for this case. Regional anaesthesia does reduce the exposure of foetus to potential teratogens, avoids the potential risk of failed intubation and aspiration, and provides excellent post-operative analgesia. The major concern with neuraxial anaesthesia is maternal hypotension, which may reduce placental perfusion. During anaesthesia and surgery, foetal well-being is best ensured by careful maintenance of stable maternal haemodynamic parameters and oxygenation. Close monitoring of foetal responses for signs of distress is strongly advocated
DIFFICULT MASK VENTILATION RESCUED BY A PEDIATRIC FACEMASK
Get PDFAnesthetic challenges arises in securing airway due to difficult mask ventilation because of obstructed nasal passage and unanticipated intraoral extension by a tumour mass leading to difficult intubation also. This sometime lead to the dreaded path of “Cannot Intubate & Cannot Ventilate”. We are describing a successfully managed case of ossifying fibroma arising from the maxilla causing difficulty in ventilation with the help of pediatric circular facemask and airway
PERIOPERATIVE EFFECTS OF CO-ADMINISTRATION OF TCI PROPOFOL COMBINED WITH CLONIDINE AND KETAMINE
Get PDFBackground: Propofol is often used in Total Intravenous Anesthesia (TIVA). Studies found that adding clonidine and ketamine can increase the potential to achieve an adequate level of anesthesia while reducing inflammation and post-operative pain. The goal of this study is to see if the combination of Target Controlled Infusion (TCI) propofol plus clonidine and ketamine is more effective in reducing the IL-6 level, maintaining intraoperative stability, and reducing postoperative pain and morphine consumption.Methods: Forty patients planned for major oncology surgery were divided into two groups. The treatment group (Group T) received pre-medication with clonidine, induction with TCI propofol, and intraoperative ketamine. The control group (Group C) received normal saline solution.Results: The difference of IL-6 level increase between the two groups was not statistically significant (13.6 vs. 16.6 pg/mL, p>0.05). Mean systolic blood pressure (SBP) and mean arterial pressure (MAP) in group T were higher in 5 and 10 minutes after incision, but lower in minutes 30, 60, and 120 (p <0.05). Heart rate in group T was higher in minutes 5, 10, 15, 30, 60, and 120. Visual analog scale (VAS) in 4, 8, 12, and 24 hours post-surgery were lower in group T compared to group C. And post-operative morphine consumptions in group T were also lower. (3.6 ± 1.5 vs 9.9 ± 3.3, p <0.05).Conclusion: TIVA using TCI propofol combined with preoperative clonidine and intraoperative ketamine is effective in maintaining hemodynamic stability, reducing post-operative and reducing morphine consumption compared to TCI propofol alone
A PRELIMINARY STUDY ON THE PECTORALIS BLOCK II AS A PART OF MULTIMODAL ANALGESIA FOR INTRA AND POSTOPERATIVE PAIN MANAGEMENT IN MODIFIED RADICAL MASTECTOMY
Get PDFBackground: Inadequate acute postoperative pain management is the main risk factor for chronic pain after breast surgery. Pectoralis blocks I and II (pecs block I and II) are novels peripheral nerves block techniques introduced since 2011 by Blanco et al.Methods: Ten patients diagnosed with breast cancer planned for modified radical mastectomy (MRM), from preoperative evaluation patients with a physical status of American Society of Anesthesiologist (ASA) I and II. Anesthesia management under general anesthesia with an endotracheal tube and we performed PECS block II after general anesthesia. We recorded the systolic blood pressure, mean arterial pressure (MAP), and heart rate intraoperatively, and the pain scale at 4th, 6th, 12th, and 24th hours postoperatively.Results: The pain scale at 4th and 6th hours postoperatively were 0.3±0.5 and 0.6±0.5 respectively. The pain scale at resting starts to increase at the 12th and 24th hours (1.2±0.4 and 1.1±0.6). The mean total use of morphine recorded on PCA was 3.3 ± 0.9 (mg). No pecs block II complications were recorded in this study.Conclusion: Pecs block II is a relatively easy, safe, and effective for MRM surgeries. Further larger and double-blinded studies are needed to know its effectiveness compared to other techniques available
Case Series : Efficacy of Local Infiltration Analgesia with Lidocaine – Epinephrine 0.5% as Post Cesarean Section Pain Management in Kalabahi Public Hospital
No full textBackground: Caesarean section is one of the most commonly performed surgical operations in the world today. Caesarean section commonly induces moderate to severe pain for about 48 hours. It requires optimal perioperative pain management. Postoperative pain management is an important issue in clinic. Proper and efficient pain management is necessary during hospitalization for preventing the related complication which could affect mother and neonate health status. Recently, multimodal pain management has been tested as postoperative pain management. One of the alternatives that can be used is local infiltration analgesia (LIA) method. Local infiltration analgesia technique can provide an adequate effect of analgesia and reduced parenteral opioid consumption without any adverse effects.Case Presentations: Cases in this study collected from Kalabahi Public Hospital, East Nusa Tenggara, Indonesia. 42 patients who met the inclusion criteria underwent caesarean section was injected with Lidocaine-Epinephrine 0.5% in abdominal muscle and subcutaneous layer as postoperative pain management. After that, the patients were observed to evaluate pain score with Visual Analog Scale (VAS), opioid consumption as the pain rescue, the level of satisfaction, and to evaluate post caesarean wound.Conclusion : This study showed that lidocaine-epinephrine 0.5% injection reduced postoperative pain, so allowed early mobilization and reduced the nurse’s work, increased the patient’s satisfaction, and there were no report of wound complication. This study also showed the pain score of the first 24 hours was 2.095238 with standard deviation 0.878178, and just 4 patients who asked for rescue analgesic
POSITIONING OF FRACTURE FEMUR PATIENTS FOR SPINAL ANAESTHESIA: FEMORAL NERVE BLOCK OR INTRAVENOUS FENTANYL?
No full textBackground: Fracture of the femur is a common, but extremely painful bone injury. Anaesthesiologists face the common problem of improper positioning of the patient while giving sitting spinal due to their extreme pain.Methods: After Institutional Ethical Committee (IEC) clearance, 60 of American Society of Anaesthesiologists (ASA) I/II patients age 18 to 80 years with fracture femur were recruited. Patients in Femoral Nerve Block (FNB) group received ultrasound-guided FNB was given with 15 mL of 1% lignocaine after visualizing the femoral nerve. Patients in the fentanyl group received injection fentanyl 1μg/kg IV. The target was to reduce the Visual Analog Scale (VAS) score less than 4. If despite the intervention, VAS was more than 4, a repeat fentanyl dose (0.5μg/kg) was given.Results: Mean VAS during positioning was 1.57 in FNB versus 2.93 in the fentanyl group (p<0.001). An additional dose of fentanyl required was less in FNB group and was more in fentanyl group (p<0.001). Performer rated quality of patient position was more in FNB group (mean±SD) 2.73 + 0.450 while1.47 + .507 in fentanyl group. This difference was statistically more significant (p<0.001). Patients satisfaction was more in the FNB group than fentanyl group (p<0.001) which was highly significant.Conclusion: Ultrasound-guided FNB provides better analgesia, patient satisfaction, less time for anesthesia and satisfactory positioning than IV fentanyl for a central neuraxial block in patients undergoing surgeries for femur fractures