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   Table of Contents - Current issue
Coverpage
October-December 2022
Volume 6 | Issue 4
Page Nos. 199-255

Online since Monday, October 31, 2022

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EDITORIAL  

Development of stem cells in anesthesiology and intensive therapy p. 199
Zulkifli Zulkifli
DOI:10.4103/bjoa.bjoa_127_22  
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REVIEW ARTICLE Top

Pulmonary complications and 30-day mortality rate in COVID-19 patients undergoing surgery: A systematic review and meta-analysis p. 201
I Made Gede Widnyana, Tjokorda Gde Agung Senapathi, Marilaeta Cindryani, Nova Juwita, Bianca Jeanne
DOI:10.4103/bjoa.bjoa_182_22  
Hundreds of surgeries are postponed every day during the global COVID -19 pandemic. The hospital and clinicians are in dilemma scheduling elective procedures during the pandemic. The current study was designed to evaluate postoperative pulmonary complications and mortality in COVID-19 patients in a systematic review and meta-analysis of globally published peer-reviewed literatures. A systematic literature search was conducted using the selection criteria in five databases. A quality assessment was made with a validated Newcastle-Ottawa Scale. The meta-analysis worked as a generic inverse variance meta-analysis. A total of 308 articles were identified from different databases and 5 articles with a total 1408 participants were selected for evaluation after successive screenings. The meta-analysis revealed a high global rate of postoperative mortality among COVID-19 patients, as high as 23% (95% CI: 15 to 26), and high postoperative pulmonary complications including pneumonia and acute respiratory distress syndrome. The 30-days mortality rate and prevalence of pulmonary complications were high. There was one death for every five COVID-19 patients undergoing surgical procedures, indicating the need for mitigating strategies to decrease perioperative mortality, transmission to healthcare workers, and non-COVID-19 patients. Larger samples and/or multicenter trials are needed to explore the perioperative mortality dan morbidity rate of patients with COVID-19 undergoing surgeries, and in particular, factors with the highest impact on perioperative mortality. There should be a clinical guideline to determine when to operate or not to operate on patients with COVID-19 for elective and emergency surgeries.
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ORIGINAL ARTICLES Top

Low incidence of vitamin D levels deficiency in anesthesiology residents: A cross-sectional, retrospective study p. 210
Aida Rosita Tantri, Ratna Farida Soenarto, Riyadh Firdaus, Sandy Theresia, Vircha Anakotta
DOI:10.4103/bjoa.bjoa_172_22  
Background: Vitamin D deficiency is now a major global health problem. The prevalence of vitamin D deficiency in Indonesia is 60–90% in various studies. Age, race, sunscreen use, medication, and malabsorption diseases are all factors that affect vitamin D levels. Recent studies also show the relation between COVID-19 and vitamin D deficiency in severity and disease mortality. Vitamin D deficiency causes skeletal and extra-skeletal consequences. With limited studies on vitamin D levels of anesthesiology residents in Indonesia, we aim to determine the average vitamin D level and the affecting factors in this population. Materials and Methods: Sixty-nine anesthesiology residents working in a tertiary care hospital were enrolled in this study. The participants were asked to complete the questionnaire, and blood samples were drawn to measure serum 25(OH)D. The factors that influence vitamin D levels were recorded for analysis. Statistical analysis was performed using SPSS version 20. Results: The mean vitamin D level in anesthesiology residents was 39.99 ng/mL. There were no significant relationships between vitamin D levels among anesthesiology residents with vitamin D consumption, high-calcium foods, frequency of exercise, history of COVID-19 infection, comorbidities, and duration of exposure to sunlight. Conclusion: Prevalence of vitamin D deficiency/insufficiency was low among anesthesiology residents. Vitamin D levels were optimal in professionals who are taking vitamin D supplements.
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Higher dose of dexmedetomidine infusion provides better oxygenation and lung mechanics in obese patients undergoing laparoscopic cancer surgeries: A randomized clinical trial p. 215
Mohamed Elsayed Hassan, Mohamed Alfattah Wadod
DOI:10.4103/bjoa.bjoa_173_22  
Background: As a result of the growing international prevalence of overweightness, following then, the proportion of obese people undergoing major surgery increased. Both obesity and laparoscopic cancer surgeries had physiological effect on the respiratory system. Various studies have shown that Dexmedetomidine improves both lung compliance and oxygenation. The goal of the work to compare the effect of two various doses of dexmedetomidine infusion intraoperative on the oxygenation and lung mechanics in obese underwent laparoscopic cancer surgeries. Materials and Methods: This randomized double-blinded, trial was performed on 70 cases who underwent laparoscopic pelviabdominal cancer surgery. Cases were categorized into 2 equal groups. Group A: was given 1 μg/kg body weight dexmedetomidine then 0.5 μg/kg/hour, and group B: received 0.5 μg/kg body weight then 0.3 μg/kg/hour. Dexmedetomidine was administered as a bolus following intubation, then infusion till the end of surgery. Arterial blood gases and lung mechanics were measured at baseline, 30, 60, 90,120 min, and end of surgery. Results: PaO2/FiO2 ratio at 90min, 120min, and the end of surgery and delta PaO2/FiO2 were significantly increased in group A than in group B (P = 0.045, 0.048, and 0.047, respectively). Dynamic compliance at 120 min and at end of surgery were significantly increased in group A in comparison to group B (P = 0.047 and 0.04, respectively). Conclusions: Dexmedetomidine at a higher dose provides better oxygenation, dynamic compliance, lower dead space in obese laparoscopic cancer patients.
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Correlation of syndecan-1 level and fluid overload in children with sepsis: A cross-sectional study p. 221
Nyoman Budi Hartawan, Ni Putu Indah Kusumadewi Riandra
DOI:10.4103/bjoa.bjoa_198_22  
Background: Fluid resuscitation is one of the basic principles for managing sepsis, but excessive fluid causes the shedding of the endothelial glycocalyx (syndecan-1) and can cause capillary leakage and tissue edema. This study aimed to determine the correlation between the syndecan-1 level and fluid overload in children with sepsis. Materials and Methods: This was an analytic, cross-sectional study conducted in a pediatric intensive care unit. A total of 49 children aged 0–18 participated in this study. Factors investigated were age, gender, nutritional status, the site of infection, organ dysfunction, the severity of sepsis, outcome, blood culture, procalcitonin level, and Pediatric Logistic Organ Dysfunction-2 score. The syndecan-1 level was measured by examining the subject’s blood serum. Statistical analysis was done using the Spearman correlation test. Results: Forty-nine sepsis children aged 0–18 were enrolled, with a median age of 12 months. The respiration system was the most common site of infection, and dysfunction of the respiration system was the most common found in the subjects. The median of fluid overload was 8.3%, and the median of procalcitonin and syndecan levels was 17 ng/mL (interquartile range [IQR] = 1.97–64.03 ng/mL) and 372 ng/mL (IQR = 223.5–1389 ng/mL), respectively. The Spearman’s correlation test found a moderate correlation between syndecan-1 and fluid overload (r = 0.469, P = 0.001). Conclusion: The plasma concentrations of syndecan-1, a marker of endothelial glycocalyx shedding, were moderately correlated with the fluid overload in patients with sepsis, indicating the link between the fluid overload and the shedding of the glycocalyx.
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Comparison of intraperitoneal dexamethasone, dexmedetomidine, and dexamethasone–dexmedetomidine combination on postoperative nausea, vomiting, and analgesics requirement after gynecological laparoscopy: A randomized clinical trial p. 225
Vinit Kumar Srivastava, Pooja Shree, Sanjay Agrawal, Ambikesh Pandey, Kavita Babbar, Kumari Manju
DOI:10.4103/bjoa.bjoa_202_22  
Background: Female patients who undergo gynecological laparoscopic surgery are more likely to suffer from postoperative nausea and vomiting (PONV). The study aimed to probe and investigate the effectiveness of intraperitoneal administration of dexamethasone, dexmedetomidine, and combination in reducing the incidence of PONV and postoperative analgesic requirements in laparoscopic hysterectomies. Materials and Methods: One hundred ninety-two female patients undergoing laparoscopic hysterectomies were randomly assigned to four groups. Anesthesia was identical in each group. Patients in the group D1 received dexamethasone 8 mg, group D2 received dexmedetomidine 1 μg/kg, group D3 received dexamethasone 8 mg + dexmedetomidine 1 μg/kg combination, and group D4 received 20 mL normal saline intraperitoneally at the end of the surgery, before trocar removal. The primary outcome was the incidence of PONV experienced by the patients within 24-h postoperative period. Results: In the first 24 h postoperatively, the incidence of PONV was significantly reduced in D1, D2, and D3 groups compared with D4 (P = 0.001); however, there were no significant differences among the three groups. The requirement for rescue antiemetic and rescue analgesic was similar among the groups but significantly decreased compared with the control group (group D4) (P = 0.002 and P = 0.0003, respectively). Conclusion: Intraperitoneal administration of dexamethasone, dexmedetomidine, and a combination of dexamethasone–dexmedetomidine in laparoscopic hysterectomies significantly reduces both PONV and postoperative analgesics requirements compared with the control group.
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Multidrug-resistant organism infections correlate with increased mortality in COVID-19 patients: A retrospective, observational cohort study p. 231
I Wayan Sumardika, Frederick Cokro, I Wayan Suranadi, Komang Januartha Putra Pinatih
DOI:10.4103/bjoa.bjoa_181_22  
Background: The uncontrolled use of antibiotics is a big problem that will lead to antibiotic resistance. One of the recommendations for Corona Virus Disease 2019 (COVID-19) therapy is antibiotics. This study aimed to present the incidence of multidrug-resistant organism (MDRO) infections in COVID-19 patients and the risk of mortality in COVID-19 patients in the Indonesian population. Materials and Methods: A retrospective cohort study was conducted at a tertiary medical center in Indonesia. A total of 120 subjects were included in this study and divided equally into group M (COVID-19 patients with MDRO infections) and group N (without MDRO). The culture was conducted between the 17th and 10th days of treatment. A 2 × 2 table and chi-square test calculated the relative risk (RR) of MDRO causing mortality in COVID-19 patients. Results: The median age was 52 and 51 years old in groups M and N, respectively (P = 0.599). Based on the documented data related to microbiological culture to detect the types of microorganisms, carbapenem-resistant Acinetobacter baumannii was found to be the most MDRO isolated (30%), followed by extended-spectrum beta-lactamase (26.6%). Bivariate analysis showed that MDRO infection strongly correlates with the incidence of death with a RR of 4.167 (P < 0.001). Conclusion: MDRO infection is significantly correlated with mortality in COVID-19 patients. MDRO infections pose a four-fold chance of mortality compared to those without MDRO infections.
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CASE REPORTS Top

Successful recovery of a critically ill pregnant covid-19 patient treated with extracorporeal membrane oxygenation (ECMO) in Sanglah General Hospital, Bali, Indonesia: A case report p. 235
I Made Susila Utama, Cokorda Agung Wahyu Purnamasidhi, Putu Agus Surya Panji, Made Bagus Dwi Aryana, Komang Adhi Parama Harta
DOI:10.4103/bjoa.bjoa_164_22  
Extracorporeal membrane oxygenation (ECMO) has been shown to be effective as a form of a life-sustaining modality in previous outbreaks such as Middle East respiratory syndromes covariant and H1N1. A 28-year-old woman was referred from a military hospital after experiencing prolonged dyspnea and a loss of consciousness. At the time of admission, the patient was pregnant with a gestational age of 24–25 weeks and has a history of hypertension and a caesarian section. Respiratory failure forced a caesarean section, which was followed by an intensive care unit admission. Five days after admission, the patient was placed on ECMO with a heparin drip. The patient suffered coinfections identified in the patient’s sputum, blood, and urine samples. Significant clinical improvement observed after the second ECMO weaning and was followed by successful discharge. The successful treatment of a critically ill COVID-19 pregnant patient with ECMO as a life-sustaining critical-care modality is uncommon. However, potential coinfections must be considered, and physicians must prepare for waves of clinical worsening and improvement.
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A successful treatment of rhesus positive transfusion in traumatic brain injury patient with rhesus negative: A case report p. 239
Maulydia Maulydia, Dewi Rosita Hendriana
DOI:10.4103/bjoa.bjoa_153_22  
Management of Traumatic Brain Injury (TBI) aims to prevent secondary brain injury from factors such as hypoxia, hypotension, and anemia. Transfusion is one of the treatments for anemia in patient with TBI. However, unexpected side effects might occur as a result of transfusion, especially transfusion using different rhesus (Rh). Herein, we reported a 33-years-old male Rh(-) patient who suffered from TBI and anemia, receiving a different Rh transfusion due to stock unavailability and emergency condition. A Focused Abdominal Scan for Trauma (FAST) examination did not discover any fluid in the abdominal cavity. Head CT-scan found intracerebral hemorrhage (ICH) in the right frontotemporal. Legs x-ray found inter trochanter fracture on the right femur. Open reduction and internal fixation (ORIF) plating surgery was conducted to manage the intertrochanter fracture. This patient received 4 bags of blood product type B with Rh(+). After undergoing intensive observation and several more surgeries, the patient survived. In an emergency, patient with Rh(-) who requires blood transfusion but is faced with stock unavailability should considered using Rh(+) blood transfusion to prevent worsening of their condition. Blood product transfusions with different rhesus must be given with the utmost caution and close monitoring to avoid triggering a transfusion reactions.
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An anesthetic management of patient with hemophilia A undergoing recurrent perianal abscesses: A case report p. 243
Oktom Nurumbetova, Özer Tuç, Nedim Çekmen
DOI:10.4103/bjoa.bjoa_187_22  
Hemophilia A is an x-linked recessive disorder characterized by an absent or reduced factor VIII (FVIII). It is a genetic deficiency that causes increased bleeding. It can be challenging for anesthesiologists to discover it in the perioperative management. This case report represents the successful management of a 25-year-old male patient having severe hemophilia A. We managed a 25-year-old man, 89 kg, 180 cm, with a recurring history of perianal abscesses. Previously at 13 years old, he experienced prolonged and excessive bleeding after a minor cut and injury. Following clinical and laboratory investigation, he was diagnosed with severe hemophilia A. Ever since, he used to take antihemophilic factor (AHF) VIII transfusion therapy and revealed severe disease with a positive inhibitor. No other coexisting disease was revealed during history-taking. We managed this case with general anesthesia because of the fact that he was hemophilic. We administered 2000 International Unit (IU) of recombinant Factor VIII (rFVIII) preoperatively as per the hematologist’s recommendation. We continued with 2000 IU of AHF FVIII transfusion after the surgery, but unfortunately, he redeveloped the abscess again. Another careful anesthesia and surgery were then conducted with a satisfactory result. The multidisciplinary team approach was provided to a positive outcome in these patients. Perioperative transfusion of AHF FVIII is essential for patients with hemophilia.
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Central venous pressure as end-point fluid removal in drowning patients: A case report p. 247
Eka Yudha Lantang, Yohanes George, Adhrie Sugiarto, Arifah Diana
DOI:10.4103/bjoa.bjoa_210_22  
Central venous pressure (CVP) is used as a guidance to control hemodynamics and to achieve the efficacy of hemodynamic balance. The drowning patient experienced a laryngeal spasm, which caused water passively enter the respiratory tract and accumulated in the lungs. Excess fluid in the lungs leads to pulmonary hypertension, venous congestion, and increased CVP. The use of diuretics guided by CVP values is the best way to achieve hemodynamic balance. Two drowning patients in different water had an increased CVP up to 12 mmHg in the sea, with serum creatinine (sCr) of 0.5 mg/dL and cumulative fluid balance (CFB) of −250 cc, and others in the lake CVP up to 14 mmHg with sCr of 0.7 mg/dL and CFB of −320 cc. Both were given furosemide at a dose of 5 mg from the first day of treatment until day 5 when both patients’ CVP returned to normal values, CVP of 5 mmHg, sCr of 0.6 mg/dL, and CFB of −1105 cc, and the others with CVP of 1 mmHg, sCr of 0.6, and CFB of −1170, then furosemide was discontinued. The use of furosemide with CVP guidance shows effective results in reducing fluids and venous congestion and is safe for the kidney, which is marked by normal values of sCr and CFB.
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Pulmonary hypertension crisis management in adult atrial septal defect surgical closure: A case report p. 251
Prieta Adriane, Rudyanto Sedono, Ni Luh Kusuma Dewi
DOI:10.4103/bjoa.bjoa_97_22  
Atrial Septal Defect (ASD) is the most common congenital disorder found in adulthood, accounting for 35% of Adult Congenital Heart Disease (ACHD). In ASD, there is a defect in the septum/wall between right and left atria, resulting in left-to-right shunt which lead to an increase of the right heart volume and pulmonary circulation. If left untreated, increased pulmonary resistance develop to pulmonary hypertension (PH) which results in a progressive decrease in right ventricular function, causing right heart failure and death. Although ASD surgical closure is not a complicated procedure, patients with complication of PH and right heart failure have a high mortality rate if not managed properly. Increase in mortality was mainly due to perioperative pulmonary hypertensive crisis (PH crisis), condition of an acute increase in mean pulmonary arterial pressure (mPAP) exceeding mean systemic arterial pressure (MAP). In this case report, we will discuss the management of postoperative adult patients with ASD closure complicated by intraoperative pulmonary hypertensive crisis who are treated in the intensive care unit (ICU).
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LETTER TO THE EDITOR Top

The “brick” anesthesiologist: Another stone on the wall p. 254
Bambang Tutuko, Marilaeta Cindryani
DOI:10.4103/bjoa.bjoa_110_22  
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