Cardiac disease in pregnancy remains an important etiology of maternal and fetal morbidity and mortality.1 Mitral stenosis is the most commonly acquired valve lesion encountered in pregnant women and is almost invariably caused by Rheumatic heart disease (RHD).1 Pregnancy and peripartum period represent a physiologic burden that may worsen symptoms in even moderate degrees of cardiac disease.1 Consequently, many women are first diagnosed with the cardiac disease during pregnancy.1 In this case report, we describe the peripartum management of a 38 year old woman with congestive heart failure functional class II, severe mitral stenosis (MS), moderate mitral regurgitation (MR), and moderate tricuspid regurgitation because of RHD. She successfully underwent cesarean section with low-dose spinal anaesthesia using 7 mg hyperbaric bupivacaine intrathecally. This report highlights that low-dose spinal anaesthesia remains a good option in anaesthesia management for cesarean section in gravida with RHD, especially with severe MS.

The adrenal glands are secretory organs that are located above each kidney and produce hormones that play a major role in metabolic processes. Tumours of the adrenal gland can cause metabolic abnormalities associated with hormonal disorders such as Cushing's syndrome, pheochromocytoma, or Conn's syndrome. To be able to provide good anaesthetic management on resection of the adrenal tumour, it requires adequate preoperative evaluation. However, this requires many resources. Management of anaesthesia in an adrenal tumour with an unknown hormonal disorder should consider a variety of hormonal abnormalities that may present in the patient so it can be anticipated effectively.

Esophageal atresia (EA) is a congenital anomaly commonly found with tracheoesophageal fistula (TEF) of neonates in the first week of life. This anomaly can cause several complications including aspiration, reduction in respiration, and complication from other concomitant congenital anomalies, mostly from the heart origin. The treatment for this anomaly is a surgery. Intraoperatively, the patient may develop hypoxia due to lung retraction and hemodynamic instability from bleeding or hypothermia. Anaesthesiologists play an important role in the management of EA during the perioperative period. Careful examination of the preoperative period must be done to discover any other concomitant anomaly and complication. Good anticipation of any complication during surgery and continuous monitoring post surgery can elevate the prognosis of the patient.

A multidrug allergy is a relatively rare immunology abnormality. Generally, it is caused by a congenital genotype and influenced by the environment. After treating the acute symptoms of chronic exacerbation of hypersensitivity type 1, the inflammation can alleviate and the patient will need to be scheduled for evisceration oculi dextra with general anaesthesia. The ophthalmologist was curious about the procedure because evisceration requires an antibiotic to wash the oculi, but there was no antibiotic available for the patient. With respect to general anaesthesia, the patient had no history and therefore we could not predict an allergy to the anesthetic drug. We chose to combine ketamine-midazolamfentanyl to facilitate the anaesthesia. Ketamine significantly reduces the production of inflammatory cytokines without affecting the production of anti-inflammatory cytokines. Fentanyl is an opioid that rarely causes allergy and has strong potential. Finally, midazolam can help the sedation.

Chondrosarcoma 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 the 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. A 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 the foetus to potential teratogens, avoids the potential risk of failed intubation and aspiration, and provides excellent postoperative 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.

Pain has always been a challenging issue in patients with acute and chronic conditions. 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 issues. The important thing to be considered is that this pain process is an intertwined, interconnecting and sustainable process that could not be cut abruptly. Our aim is to remind professionals to accept that the pain pathway is not straight forward but rather a convoluting idea that can evolve and expand. Imagining areas could be defined one day through high technology advances and would lead us into defining the depth of this beautiful and complex pathway

Introduction: Acute kidney injury (AKI) was a frequent complication after open heart surgery, especially in paediatric patients < 2 years old and had been related with increased mortality and adverse renal outcomes. This study aimed to determine the incidence of AKI post open heart surgery in paediatric patients and its relation with duration of cardiopulmonary bypass (CPB) and patient's age in Indonesia's tertiary national hospital. Methods: This was a cohort retrospective study, using medical records and cardiac ICU chart data of 195 paediatric patients who underwent open heart surgery from June 2014 - June 2015 in Integrated Cardiovascular Center Cipto Mangunkusumo hospital. After ethical approval from Research Ethics Committee, data was collected and sorted by inclusion and exclusion criteria. AKI was diagnosed based on RIFLE criteria. Data was analyzed by chi-square and multivariate analysis (SPSS software 22.0 version). Results: Incidence of AKI post open heart surgery in paediatric patients was 36.4%. Duration of CPB > 60 min had a significant correlation with increased incidence of AKI (p 0.043; RR 1.248). Patient's age (≤ 2 years old) also had a significant correlation with increased incidence of AKI (p<0.001; RR 2.431). Multivariate analysis results showed that both the duration of CPB and the patient's age were significant risk factors of AKI (OR 2.951, OR 5.371). Conclusion: Incidence of AKI post open heart surgery in paediatric patients was 36.4%. Duration of CPB duration (> 60 min) and patient's age (< 2 years old) were significant risk factors of AKI.