Background: Most surgeries are carried out with ease using neuromuscular blocking agents. This study was aimed to compare the intubating dose of cisatracurium and rocuronium regarding the onset of action, clinical duration, recovery index, intubating conditions, efficacy, and safety in elective surgery. Method: 60 adult patients of American Society Anesthesiology (ASA) grade I & II, underwent elective laparoscopic surgery were randomized to receive either cisatracurium 0.1 mg/kg (Group C) or rocuronium 0.6 mg/kg (Group R). Neuromuscular monitoring was done using STIMPOD Xavant NMS450. Relaxogram interpretation was carried out for the onset of action, clinical duration, and recovery index. Results: Cisatracurium had significant longer onset (233.33±62.31 vs. 86.66±28.62 seconds, p <0.001) and significant longer clinical duration (40±3.56 vs. 27.46±2.14 minutes, p <0.001) than rocuronium. Recovery index was significantly longer in the cisatracurium group (12.23±1.54 vs. 8.30±1.80 minutes, p <0.001). Clinically acceptable intubating conditions were achieved in 180 seconds (C group) compared to 60 seconds in the R group. No untoward or adverse response and complications were distinguished in either group. Conclusion: Cisatracurium 0.1 mg/kg exhibited a slower onset of action than rocuronium 0.6 mg/kg and provided excellent intubating conditions in the majority of patients after 180 seconds. The clinical duration and recovery index were significantly longer in cisatracurium compared to rocuronium. Both are potent and safe agents with excellent cardiovascular stability.

Background: Over half of soft tissue tumor surgeries require intraoperative packed red cell (PRC) transfusion. Several factors that can be identified in the preoperative period have been associated with surgical bleeding and transfusion in soft tissue tumor surgery. This study aimed to determine factors associated with surgical blood loss and intraoperative PRC transfusion. Methods: A retrospective cohort was analyzed on 84 records of orthopedic soft tissue tumor surgery during 2014-2018. Data were analyzed by linear regression and multivariate analysis. Results: Most commonly found malignant tumor in this study was rhabdomyosarcoma (20 . 2 % ). Preop hemoglobin of 11.5 g/dL (p=0.013) and tumor size of =5 cm (p<0.001) are the two significant predictors for intraoperative transfusion. Conclusion: tumor size and preoperative Hb value were predictors of the probability of requiring intraoperative PRC transfusion.

Introduction: Carotid artery puncture during central venous catheter (CVC) insertion could lead to serious complication if there were an overlapping of internal jugular vein (IJV) and carotid artery (CA). IJV and CA overlap ratio and distance were determined by contralateral head rotation angle. The optimal angle of contralateral head rotation during CVC insertion can decrease the risk of CA puncture complication. This study was aimed to investigate the optimal angle of contralateral head rotation on IJV to CA distance and overlap ratio at the cricoid level by ultrasound guidance. Methods: This was a cross-sectional study of 34 patients undergoing elective surgery with CVC insertion. IJV to CA distance and overlap ratio at the cricoid level on each subject in the supine position was measured by using two-dimensional ultrasound (Sonosite® M-Turbo, 6-13 MHz probe) at 0°, 30°, 45°, 60° contralateral head rotation of insertion site. Collected data were analyzed using SPSS 21.0. Results: There were significant differences on IJV to CA distance and overlap ratio at different contralateral rotation angles (0°, 30°, 45°, 60°, p<0.001). Overlapping of IJV and CA started to occur at contralateral head rotation 30° (11.72%) and increased in line with the increasing of contralateral head rotation angle (21.21% at 45°). Conclusion: There were significant effects of contralateral head rotation to distance and overlapping IJV to CA at the cricoid level. Optimal contralateral head rotation angle for CVC was less than 30° to prevent IJV and CA overlapping.

Background: Emergence delirium (ED) also known as emergence agitation, is a postoperative condition characterized by aberrant cognitive and psychomotor behaviors such as agitation, irritable, uncompromising, uncooperative, inconsolably crying following general anesthesia. A high noise level in the operating room can be reduced with an earplug application. This study aimed to see the effectiveness of earplug utilization in reducing the incidence of emergence delirium without extending the time of extubation compared to control patients. Methods: This is a double-blind, randomized clinical trial towards 1-5 years old patients underwent inhalational general anesthesia in Dr. Cipto Mangunkusumo hospital in 2018. They were assigned to either the Earplug (E) group with an application of an earplug at the end of the surgery or Control (C) group, without the use of an earplug. The incidence of ED was measured using the Pediatric Anesthesia Emergence Delirium (PAED) scale. Data were analyzed using multivariate logistic regression and analysis of covariance tests. Results: Incidence of ED in earplug group was 16.7% while in control group was 32.1% (OR = 0.402, CI95%=0.152-1.062, p=0.066). The mean time-to-extubation in E vs. C groups were 5.76±3.23 vs. 6.54±3.67 minutes, respectively. Conclusion: The application of an earplug at the end of anesthesia was not statistically effective to reduce the incidence of ED in 1-5 years old patients underwent inhalational general anesthesia.

Background: Non-invasive ventilation (NIV) has become an essential tool in the treatment of both acute and chronic respiratory failure in children. This study aimed to determine the efficacy of NIV usage in pediatric patients who were admitted to the Pediatric Intensive Care Unit (PICU) with respiratory failure. Patients and Methods: This study is a retrospective, cross-sectional review. The data were collected from the medical record of PICU patients at our hospital from 2017 to 2018. Successful NIV was defined as patients who survived without intubation. Failure was defined as worsened patients and needed intubation for the rescue. Results: The total subjects of this study was 78 patients. The most common indication for NIV was ARDS (78.1%), and CPAP was the most common frequently used (78.68%). The data shows that the NIV was commonly used after extubation (52.56%) than for the first-time rescue (47.44%). The success rate of NIV after extubation were 65.85% and 34.15% failed and shifted to mechanical ventilation. The duration of NIV usage was less than three days (73.77%). Conclusion: NIV is a useful tool for the treatment of respiratory failure in pediatrics. The use of post-extubation NIV may be a valuable tool to prevent reintubation.

Background: Ropivacaine and levobupivacaine possess the property of sensory-motor dissociation. Hence these drugs allow a faster recovery of motor function and hence, these are potentially useful agents for walking spinal anaesthesia in daycare surgeries. Patients and Methods: This is a prospective, double-blind, randomized study involving 120 adult ASA 1 and 2 patients who were randomly allocated into two groups. Group R (n = 60) received 7.5 mg 0.75% ropivacaine + 25 μg fentanyl + 1.5 ml sterile water. Group L (n = 60) received 5 mg 0.5% levobupivacaine + 25 μg fentanyl + 1.5 ml sterile water. Each solution was made to a total volume of 3 ml, administered intrathecally. Sensory and motor block characteristics, hemodynamic changes and postoperative recovery profile characteristics were noted. Paired/unpaired t-test and chi-square test were used wherever applicable for statistical analysis using SPSS version 15.0. Results: Sensory block onset time and time to reach the maximal cephalic spread were comparable in both the groups, whereas time to the two-segment regression and time to first analgesic requirement were significantly shorter in group RF. Out of 60 patients in each group, 59 patients in group RF and 57 patients in group LF were MBS grade 5. Time to home discharge was also significantly shorter in group RF. Conclusion: We concluded that both local anaesthetics could be used in the walking spinal technique; however, ropivacaine is preferred because of its favourable block characteristics and early ambulation time.

Background: Cervical myofascial pain or neck pain is in the fourth most disease that causes disability after back pain, depression, and other musculoskeletal diseases. Cervical myofascial pain is characterized by pain originating from a trigger point located in the skeletal muscle, commonly referred as myofascial trigger points (MTrPs). Methods: An observational study with a cross-sectional design, conducted on 3 to 9 of December 2018 with research subjects were medical students at Udayana University who undergoing 5^th and 6^th year in clinical clerkship at Sanglah General Hospital Denpasar. The data was taken using Google Form which was filled in online by the subject and then analyzed using SPSS version 21. Results: From 307 respondents, 62.2% stated experiencing neck pain (196 respondents) with the majority of women 65.4%, the duration of neck pain occurred for <24 hours with the most frequent frequency at least once per month (46.1%), and appeared most often at night (39.8%) and occurs after night shift in 106 subjects (55.5%). The pain was said getting worse by activity in 102 subjects (52.4%) and getting better when resting in 185 subjects (96.9%). Most of the subjects did not use pain relievers to treat neck pain experienced (84.3%). In subjects who use painkillers, Paracetamol is the most often drug of choice to relieve pain (11%). For non-pharmacological treatment, 53.4% of respondents chose to rest or sleep. Conclusion: Most of the respondents who were clerkship reported experiencing neck pain at least once a month and often felt after a night shift. Respondents who reported neck pain were mostly women.

In the pregnancy process, there is a significant physiological change in the mother. Physiological changes, pre-pregnancy conditions, or those that arise during the pregnancy process will affect the delivery outcome. Also, it turns out that the presence of this preexisting condition will affect the outcome process, especially the anaesthetic technique used, the chosen anaesthetic technique is determined based on the age of the pregnancy, surgical procedures to be performed, surgery site, and overall patient condition. Whatever technique is selected, it must use the right method based on clinical decisions and accordingly to the existing guidelines. This condition is a challenge for an anesthesiologist.

Pheochromocytomas (PCC) is rare neuroendocrine tumors which present as the malignant and familial features. These catecholaminesecreting tumors have classic triad symptoms of headache, sweating, and palpitation primarily due to the release of catecholamines and their metabolites in the body with hypertensive crisis become its predominant clinical symptoms. The excessive release of catecholamines may produce a life-threatening hemodynamic surge during the intraoperative period. Therefore preoperative preparation and intraoperative monitoring become an essential point. Nevertheless, postoperative care is also a critical issue to curtail its morbidity and mortality rates further.

Typhoid fever, caused by Salmonella enterica, serovar Typhi, is restricted to humans as its host and evades the human immune system with ease. This quality has been one of the many reasons why it is commonly found as an endemic bacterium in emerging economies. Also, due to a remarkably low yield from blood cultures (median of 1 CFU/mL of blood), Salmonella septicemia is uncommon. New evidence gathered together with clinical investigations have provided insight into the mechanisms that underlie the pathogenesis of typhoid, host restriction as well as antibiotic and vaccine susceptibility. However, very little has been done to curb the persistence of disease and emergence of resistant strains. We discuss a case of Salmonella Septic Shock in the Intensive Care Unit (ICU) that takes us through various aspects in diagnosis, the treatment potential and the problems surrounding prevention.

Airway management in maxillofacial and head and neck cancer patients has remained a challenge even after significant development towards difficult airway management. When such patients have multiple difficult intubation predictors, management becomes more thought-provoking. Mucosal preparation and sedation play a vital role in producing co-operative patient and successful procedure but is not always feasible. On the other hand, intravenous sedation lacks titratability and reversibility. We describe awake fiberoptic intubation in three adult patients having multiple difficult intubation predictors whose airway preparation was not feasible due to obscured surface anatomy and nil mouth opening. The cases were done under titrated conscious sevoflurane sedation of MACage 0.4-0.6 using nasopharyngeal airway and closed circuit. This report highlights that Sevoflurane based conscious sedation is a feasible alternative for awake fiberoptic intubation in patients whose airway anesthesia and blocks are not possible.

Head injuries are a common case throughout the world, based on data from the Centers for Disease Control, emergency cases, hospitalization cases, and also deaths due to head injuries have increased in the decade 2001-2010. Cerebral autoregulation (CA) is a mechanism for cerebral blood flow (CBF) regulation if there is a change from cerebral perfusion pressure (CPP). The mechanism of brain autoregulation is negative feedback that holds back the increase in mean arterial pressure (MAP) by reducing the diameter of blood vessels so that CBF returns to normal, whereas if MAP falls, brain autoregulation tends to widen blood vessel diameter so that CBF is normal. Transcranial doppler examination can be one of the modalities of investigation that is very useful in patients with head injuries. Transcranial doppler in patients with a head injury can be used to measure mean flow velocity of cerebral artery media and transient hyperemic response test, both of which can assess the prognosis of a course of head injury.

The traumatic and ankylosing cervical spine being rare in pregnancy can cause serious problems continuing a pregnancy. To minimise the risk of spinal cord injury, airway management providers must understand the anatomic and functional relationship between the airway, cervical column, and spinal cord. Extensive neurological involvement, which is rapidly progressive due to compression, should be considered for immediate decompression. To provide safe and efficient, practitioners must identify high-risk patients, be comfortable with available methods of airway adjuncts, and know-how airway manoeuvres, neck stabilisation, and positioning affect the cervical spine. For many anesthesiologists, awake fiberoptic bronchoscope intubation is the preferred method of intubation when treating patients with symptoms or signs of cervical spinal cord compression. The advantage of this method is to minimise the movement of the cervical spine, which can contribute to neurological disorders. We present a case of a patient in the 19th weeks with diagnosis C5 compression fracture and paracervical abscess C5 et causa suspect TB spondylosis, complaints with paralysis in all four limbs. Surgical intervention was deemed necessary and was performed in the prone position. The early operative treatment and appropriate anaesthetic procedure resulted in better clinical outcome with the improvement of neurological recovery.

Carotid body tumour (CBT) is a rare tumour of chemoreceptor cells, which arises at the bifurcation of the carotid artery. These cells sense the partial pressure of oxygen and carbon dioxide from the blood. Hence, the carotid body plays an important role in the control of ventilation during hypoxia, hypercapnia and acidosis. The tumour arising from these cells is benign and tends to turn out malignant. This tumour is found in persons who live at high altitudes. Removal of tumour poses several anaesthetic challenges and perioperative morbidity or mortality. We report successful anaesthetic management of CBT excision.

The search for safer anesthetic solutions has always been one of the primary needs in anesthesiology practice. Levobupivacaine, the pure S (-) enantiomer of bupivacaine, emerged as a safer alternative for intrathecal anesthesia than its racemic parent (bupivacaine). Levobupivacaine shows a lower risk of the central nervous system and cardiovascular toxicity. However, in many countries, levobupivacaine is only available in isobaric solution, where the isobaric solution for intrathecal anesthesia is still often be questioned its effectiveness because of the fear that the block spreading is unpredictable. In this case series, we describe sensory and motor block characteristics, hemodynamics profile and adverse effects of isobaric levobupivacaine in intrathecal anesthesia for six patients with American Society of Anesthesiology physical status II-III whose undergo transurethral endoscopic surgery.