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   Table of Contents - Current issue
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July-September 2022
Volume 6 | Issue 3
Page Nos. 127-197

Online since Wednesday, July 27, 2022

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REVIEW ARTICLES  

Comparison of oxycodone with morphine as adjuvant epidural analgesia and its side effects: A systematic review p. 127
Tjokorda Gde Agung Senapathi, Dewa Ngakan Gde Dwija Sanjaya, Adinda Putra Pradhana, Christopher Ryalino, Ida Bagus Krisna Jaya Sutawan
DOI:10.4103/bjoa.bjoa_83_22  
Despite morphine’s ability to deliver effective analgesia, its use as an epidural adjuvant is limited by adverse effects such as nausea, vomiting, and pruritus, which are typically intractable with conventional antihistamines. Another negative effect that we are particularly concerned about is respiratory depression. This systematic review aimed to summarize the evidence based on randomized controlled trials (RCTs) comparing epidural analgesic adjuvants between oxycodone and morphine. We searched the Cochrane Library, PubMed, and EMBASE databases from 1990 until 2021 to find RCTs published in English language, which have investigated pain score and side effects such nausea and vomiting. Three RCTs were included in the final analysis. All of them employed similar argument that epidural analgesic with oxycodone has good analgesic effects at higher dose than morphine. Oxycodone provides analgesic properties equivalent to morphine, but with less nausea and vomiting. We found that epidural analgesic with oxycodone has comparable analgesic effect to morphine, as well as lower side effects on nausea and vomiting at twice morphine doses. Future study is needed to compare epidural oxycodone with morphine in terms of analgesia and adverse effects.
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The use of blood versus crystalloid cardioplegia in adult open heart surgery: A systematic review p. 133
Bambang Novianto Putro, Purwoko Purwoko, Raden Theodorus Supraptomo, Eka Satrio Putra, Ageng Sunjoyo
DOI:10.4103/bjoa.bjoa_62_22  
Myocardial ischemia can occur due to hypotension, shock, coronary heart disease, and aortic cross-clamping during open-heart surgery using a cardiopulmonary bypass machine. Cardioplegia is classified into the blood or crystalloid base as a cardioprotective method. This systematic review and meta-analysis aimed to describe the effectiveness of blood and crystalloids cardioplegic solutions in adult open-heart surgery by focusing on their effects on cardiac enzymes. This study investigated the effect of blood and crystalloid cardioplegia on troponin (cTn) and creatinine kinase myocardial bound (CKMB). The literature search was carried out on several Cochrane, PubMed, PMC, and Google Scholar databases from January 2014 to August 2020 using the medical subject heading keywords and Boolean operator. We obtained 346 articles and identified nine prospective randomized studies from five countries that met the eligibility criteria. The majority discussed the comparison of blood cardioplegia and crystalloids in coronary revascularization cardiac surgery (CABG). The cTn values (weighted mean difference [WMD] –2.67, confidence interval [CI] –4.18 to 1.17, P = 0.0005) and CKMB values (WMD –2.67, CI –4.18 to 1.17, P = 0.0005) 24 h operatively showed that the level of the cardiac enzymes increased in the crystalloids cardioplegia group more than the blood cardioplegia group. Overall, the articles used have a low risk of bias despite their high level of homogenicity. The current literature on cardioplegia in adults does not provide adequate advanced-phase trials. Both types of cardioplegia provide reasonable protection for the myocardium. However, several studies reveal that crystalloid cardioplegia increases cardiac enzymes more significantly than blood cardioplegia.
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The use of blood and crystalloid cardioplegia in adult open-heart surgery on postsurgical outcomes: A systematic review of atrial fibrillation incidence, myocardial infarction, inotropic use, length of stay in ICU, and postoperative mortality p. 145
Bambang Novianto Putro, Jefferson K Hidayat, Ratna Farida Soenarto
DOI:10.4103/bjoa.bjoa_148_22  
Background: Myocardial ischemia can occur due to hypotension, shock, coronary heart disease, and aortic cross-clamping during open-heart surgery using a cardiopulmonary bypass machine. As the cardioprotective method, cardioplegia is classified into blood or crystalloid base. This systematic review is aimed to describe the effectiveness of blood and crystalloid cardioplegic solutions in adult open-heart surgery procedures by focusing on their effects on cardiac enzymes. Materials and Methods: This study investigated the effect of blood and crystalloid cardioplegia on troponin (cTn) and creatinine kinase myocardial bound. The literature search was carried out on several Cochrane, PubMed, PMC, and Google Scholar databases from January 2014 to August 2020 using the MeSH keywords and Boolean operator. Results: We obtained 346 articles and identified six prospective randomized studies from four countries. The majority discussed the comparison of blood cardioplegia and crystalloids in coronary revascularization cardiac surgery (coronary artery bypass grafting). Overall, the articles used have a low risk of bias despite their high level of homogenicity. Conclusions: The current literatures on cardioplegia in adults do not provide adequate advanced-phase trials. Both types of cardioplegia provide a reasonable protection for myocardium. However, several studies reveal that crystalloid cardioplegia increases cardiac enzymes more significantly than blood cardioplegia. This research has been registered with PROSPERO with the number CRD42022312548.
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ORIGINAL ARTICLES Top

Efficacy of preoperative oral glucose on blood glucose response and neutrophil–lymphocyte ratio in patient undergoing brain tumor resection: Randomized controlled trial study p. 152
Tjokorda Gde Agung Senapathi, Farrell Tanoto, I Made Gede Widnyana, I Putu Pramana Suarjaya, I Gusti Agung Gede Agung Utara Hartawan, Christopher Ryalino
DOI:10.4103/bjoa.bjoa_89_22  
Background: Hyperglycemia and inflammatory conditions due to surgical stress response in conventional brain tumor resection can increase the morbidity and mortality of neurosurgery patients. Enhanced recovery after surgery (ERAS) protocol has been widely used in various types of surgery, but data on the neurosurgery are still limited. The aim of this study was to analyze the role of preoperative oral glucose administration in attenuating surgical stress response in patients undergoing brain tumor resection. Materials and Methods: Thirty-four elective craniotomy brain tumor resection patients underwent a double-blind, randomized controlled trial. Patients were divided into two groups: one group that received oral carbohydrate (CHO; maltodextrin 12.5% 50 g in 400 ml water) 2 h preoperatively and a control group that only received water. Blood glucose level and neutrophil–lymphocyte ratio (NLR) were obtained preoperatively, before induction, and 6 h and 24 h postoperatively. Results: Blood glucose was better in the CHO group at 6 h (117.18 ± 16.25 mg/dl vs. 154.88 ± 28.22 mg/dl, P < .001) and 24 h (118.05 ± 13.89 mg/dl vs. 153.76 ± 34.81 mg/dl, P < .001) postoperatively compared to that in the control group. NLR in the CHO group showed a lower value compared to that in the control group at 6 h (8.21 ± 6.20 vs. 15.47 ± 6.76, P < .001) and 24 h (9.43 ± 7.35 vs. 20.04 ± 10.99, P < .001) postoperatively. Conclusion: Preoperative oral glucose administration can help reduce the stress response in brain tumor resection by maintaining blood glucose level and attenuating the increase of NLR postoperatively better than in routine preoperative fasting.
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Haloperidol vs. dexamethasone in lowering postoperative nausea and vomiting and pain in adult after laparoscopy: A randomized, double-blind study p. 157
Aldy Heriwardito, Sidharta Kusuma Manggala, Suryo Indah Widhyanti, Lara Aristya
DOI:10.4103/bjoa.bjoa_101_22  
Background: The incidence of PONV (Postoperative Nausea and Vomiting) and pain are still one of the most common symptoms of post-surgery and prophylaxis to reduce the event is needed. Therefore, we wanted to know the effectiveness of 1 mg intravenous haloperidol compared to 5 mg intravenous dexamethasone to prevent the occurrence of nausea and vomiting and to control pain in adult patients after laparoscopic surgery. Materials and Methods: Eighty subjects (n = 40 for each group) scheduled for laparoscopic-assisted surgery were enrolled in a randomized double-blind clinical trial. One milligram intravenous haloperidol was given one hour before the end of surgery, while 5 mg intravenous dexamethasone was given right after induction. The occurrence of PONV and VAS pain score were recorded. Results: This study showed a significant difference in the incidence of nausea between haloperidol and dexamethasone at 2–6 hours (5% vs 25%, P = 0.012), 6–12 hours (10% vs 24%, P = 0.012), and 12–24 hours (12.5% vs 60%, P < 0.001) after laparoscopic surgery. The incidence of vomiting after laparoscopic surgery between two groups was not significantly different (P > 0,05). However, haloperidol group resulted in lower VAS pain score at every postoperative period with statistically significant result. Conclusion: The administration of 1 mg intravenous haloperidol is significantly better than 5 mg intravenous dexamethasone to prevent the occurrence of nausea and to lower the pain, but not significantly different to prevent the incidence of postoperative vomiting in adult patients after laparoscopic surgery.
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Relationship between age, sex, and anthropometric factors with the distance of L4-L5 interspace from Tuffier’s line: Observational study with ultrasonography guidance p. 162
Aida Rosita Tantri, Darto Satoto, Stesy Natassa
DOI:10.4103/bjoa.bjoa_122_22  
Background: The anatomical marker used in spinal anesthesia is L4-L5 interspace. The L4-L5 interspace is thought to be right on the Tuffier’s line, which connects the two highest points on the iliac crest. The location of L4-L5 interspace from the Tuffier’s line varies greatly because of the influence of several factors such as differences in race, sex, age, and anthropometric factors. This study aimed to examine the relationship between age, sex, and anthropometry factors with the distance of L4-L5 interspace from the Tuffier’s line using ultrasound guidance at Cipto Mangunkusumo National General Hospital. Materials and Methods: This was an observational analytic study with a cross-sectional design in 93 subjects at Cipto Mangunkusumo National General Hospital recruited for the study. Statistical analysis was performed to find the relationship between age, sex, and anthropometry factors with the distance of L4-L5 interspace from the Tuffier’s line and to continue with multivariate analysis to obtain the prediction formula of the distance between L4-L5 interspace and the Tuffier’s line. Results: This study found that the distance of L4-L5 interspace to the Tuffier’s line is −2.59 ± 1.58 cm. Correlation analysis showed a significant relationship between height and sex to the distance of L4-L5 interspace and the Tuffier’s line. The distance prediction formula obtained in this study is 4.921 + [0.536 × (1 for male or 2 for female)] + (−0.052 × height in cm). Conclusion: There was a significant relationship between height and sex to the distance of L4-L5 interspace from the Tuffier’s line.
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Autoregulation disturbance events correlate with history of loss of consciousness in mild traumatic brain injury patients p. 167
Ida Bagus Krisna Jaya Sutawan, Tatang Bisri, I Putu Pramana Suarjaya, I Made Prema Putra, Christopher Ryalino
DOI:10.4103/bjoa.bjoa_13_22  
Introduction: Cerebral autoregulation disturbance may compromise cerebral blood flow, thereby increasing the risk of hypoperfusion, which increases the risk of loss of consciousness (LOC). Transient hyperemic response test (THRT) using transcranial Doppler (TCD) can be used to assess cerebral autoregulation disturbance. The goal of this study was to assess the relationship between impaired cerebral autoregulation assessed using TCD and a history of LOC in patients with a mild head injury. Patients and Methods: This study was a comparative analytic study with unpaired data and cross-sectional design that involved 73 people divided into two groups. Group A (36 subjects) consists of mild brain injury patients with a history of LOC, and Group B (37 subjects) consists of mild brain injury patients without a history of LOC. THRT was assessed using TCD by identifying the absence (negative result) in flow velocity increase upon applying pressure on ipsilateral carotid artery. We employed the chi-square and logistic regression tests to assess any correlation between variables. A value of P < 0.05 was considered significant. Results: Approximately 93% of subjects who experienced LOC also showed negative THRT results. We found a statistically significant relationship (P < 0.001) between the history of LOC and THRT. In the logistic regression test, we found that age, gender, and hematocrit were not statistically related to negative THRT results. Conclusion: There is a statistically significant relationship between cerebral autoregulation disturbance and decreased consciousness event in mild head injury patients.
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Comparison of dexmedetomidine, lidocaine, magnesium sulfate, and remifentanil in cough suppression during endotracheal extubation: A double-blind, randomized clinical trial p. 171
Ehsan Jafarzadeh, Hesameddin Modir, Esmail Moshiri, Farzad Zamani Barsari, Amir Almasi-Hashiani
DOI:10.4103/bjoa.bjoa_47_22  
Background: This study was undertaken to compare the effects of several drugs on attenuation of stimulatory responses and cough suppression at the end of endotracheal extubation under general anesthesia. Patients and Methods: This trial was conducted on 120 patients who were candidates for general anesthesia in Arak, Iran. The patients were randomly assigned into four groups. All groups received the study drugs 10 min prior to the end of surgery in the following manner: group 1, 0.5 μg/kg intravenous (IV) dexmedetomidine; group 2, 1.5 mg/kg IV lidocaine; group 3, 1 μg/kg IV remifentanil; and group 4, 30 mg/kg IV magnesium sulfate 50%. Laryngospasm, the presence of cough, mean arterial pressure, heart rate (HR), arterial oxygen saturation, and sedation were assessed and recorded. Results: No significant difference was observed in the number of coughs (P = .740) among the study groups. Although the dexmedetomidine group showed more sedation, the lowest increase in HR (P = .001) was observed in lidocaine and dexmedetomidine groups, respectively. The lowest and highest HR was observed in lidocaine and magnesium sulfate groups, respectively. The patients did not have laryngospasm during the assessment. In addition, dexmedetomidine had the highest Ramsay score (P = .019). Conclusion: There was no difference in the amount of laryngospasm and cough in the groups, and due to the lack of no serious complication requiring treatment, the study drugs can be recommended to be used for attenuating and suppressing stimulatory responses during endotracheal extubation.
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Accuracy Comparison between Four Methods of Endotracheal Tube Diameter Estimation for Pediatric Patients: An Observational, Cross-sectional Study p. 177
Sendhi Raka Putra, Tjokorda Gde Agung Senapathi, I Gusti Agung Gede Utara Hartawan, Christopher Ryalino, Adinda Putra Pradhana
DOI:10.4103/bjoa.bjoa_69_22  
Background: Successful intubation with the correct endotracheal tube (ETT) size is more difficult to achieve in pediatric patients. Several estimation methods exist, including ultrasonography and several conventional methods, but it is unclear which would be the most accurate method. Thus, this study aimed to compare the accuracy between several ETT diameter estimation methods. Materials and Methods: This was an observational study with a cross-sectional design. The sample includes pediatric patients (0–6 years) at a tertiary hospital recruited from January 2022 to March 2022. Primary data evaluated included age, gender, height, weight, actual ETT size used in the procedure, and the estimation of ETT size obtained by four different methods: ultrasonography, little finger diameter, little fingernail width, and age-based formula. Primary analysis was linear regression test between estimated diameter and the actual ETT diameter used in the procedure, controlling for potential confounders. The accuracy of each ETT size estimation method was seen from the values of the B and R2 coefficients from the linear regression test results. Results: Ultrasonography was found as the most accurate method, with B and R2 coefficients of 0.963 and 0.991, respectively. Among conventional methods, the diameter of the little finger was the most accurate (B = 0.918, R2 = 0.772). The age-based formula method was found to be the least accurate (B = 0.797, R2 = 0.735). Conclusion: Linear regression tests confirmed that the ultrasonography was the estimation method with the highest accuracy. For healthcare facilities with limited resources, the estimation method with little finger diameter should be considered.
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AnesthCalc™ is associated with superior accuracy and faster accomplishment in simulation-based anesthesia drugs dosage calculation p. 182
Mayang Indah Lestari, Zulkifli, Rizal Zainal, Muhammad Imam Mulia
DOI:10.4103/bjoa.bjoa_157_21  
Background: Medication error is one of the barriers to achieving sustainable patient safety. We aim to determine the efficacy and reliability of a smartphone dosage calculator application (AnesthCalc™) when compared with the manual calculation of various anesthetic drugs to prevent medication error. Materials and Methods: This is a pre-test–post-test intervention study. There are 52 participants who included residents in anesthesiology, which is divided into two groups. Each group performed two simulation cases in which they had to calculate drugs dosage in anesthesia settings. One set of cases was performed with the app and the other set was performed manually. The order of drugs and simulation patients was randomized. The accuracy and the deviation of administered drug doses were recorded. Accuracy of dosage was categorized as either accurate (80–100% of target dose) or inaccurate (less than 80%), whereas the deviation of dosage was categorized as either deviant (<50% or >200% of target dose) or safe (between the range). Results: There is a significant increase in the accuracy of calculation between the manual group and that using the app group (from 46% to 92%, a mean increase of 18.29%, P < 0.005). There is a significant decrease in the duration of calculation between without using the app group and with using the app group (from 32.92 to 18.79 s, a mean decrease of 30.55 s, P = 0.001). Conclusion: AnesthCalc™ is a valid and reliable instrument as it increases users’ accuracy and shortens calculating time. AnesthCalc™ may be the potential to reduce calculation errors and may increase patients’ safety.
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CASE REPORTS Top

Severe hyponatremia and cerebral edema after laparoscopic salpingectomy, hysteroscopy myomectomy, and adenomyosis resection: A case report p. 187
Alfan Mahdi Nugroho, Andy Omega, Christian Danneto
DOI:10.4103/bjoa.bjoa_29_22  
The usage of hypotonic irrigation solution during hysteroscopy and laparoscopy can cause systemic fluid absorption and complications such as hyponatremia, fluid overload, and cerebral edema. Moreover, Trendelenburg position on gynecologic laparoscopy with a long duration can increase intracranial pressure and decrease cerebral perfusion pressure. A woman, 39 years old, suffered from severe hyponatremia and cerebral edema after hysteroscopy myomectomy, laparoscopic salpingectomy, adenomyosis resection, and adhesiolysis procedure. Water for injection was used as an irrigation solution during the procedure, totaling 20 L. The position of the procedure was supine, Trendelenburg, with a procedure duration of 4 h 50 min. A spontaneous respiratory trigger was not found for about 1 h during extubation. We found anisochoric pupil 5/4 mm without direct and indirect light reflex on physical examination. From the laboratory result, the sodium level was 118. Brain CT scan with contrast showed cerebral edema. Sodium correction was given using NaCl 3%, 500 mL/24 h IV drip. Sodium was corrected slowly and cautiously to prevent cerebral pontine myelinolysis. In the ICU, the sodium level was increased to a normal level. But, the light reflex was still absent, and the pupil was anisochoric. Brain MRI showed diffuse cerebral edema.
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Amniotic fluid embolism with cardiac arrest and coagulopathy during Cesarean section: A case report p. 191
Lan Fern Michele Lim, Xiu Ling Jacqueline Sim, Ban Leong Sng
DOI:10.4103/bjoa.bjoa_96_22  
Amniotic fluid embolism (AFE) is a rare but potentially fatal condition of pregnancy. It is a diagnosis of exclusion and its management largely supportive. We present a case of a 36-year-old patient who was admitted at 32 weeks gestational age with an acute abdomen. She underwent an emergency Cesarean section for fetal distress secondary to possible placental abruption. This was complicated by post-delivery cardiac arrest and respiratory failure from suspected AFE, disseminated intravascular coagulation and severe postpartum hemorrhage. She was managed with vasopressors, point-of-care coagulation testing, massive transfusion, anti-fibrinolytics, fibrinogen concentrate and eventual hysterectomy. Post-operatively, she was treated for acute respiratory distress syndrome in the intensive care unit. She and her neonate survived with good outcome. We discuss the practical constraints faced in the diagnosis and management of AFE, due to a lack of specific diagnostic tests and the need for prompt high-quality resuscitation, simultaneous management of coagulopathy and massive hemorrhage, timely activation of senior personnel and the involvement of a multi-disciplinary team in a crisis situation.
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LETTER TO THE EDITOR Top

Successful management of Roemheld syndrome: A diagnosis of exclusion p. 196
Sarin P John, Vijay Adabala, Mridul Dhar
DOI:10.4103/bjoa.bjoa_128_22  
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