Background: Endoscopic retrograde cholangiopancreatography (ERCP) is a lengthy diagnostic/therapeutic procedure performed for various pancreatic-biliary disorders often involving high-risk patients. The aim of our study is to compare the ketamine hydrochloride and fentanyl citrate with propofol for patients undergoing ERCP. Patients and Methods: In this prospective randomized study, 100 consenting patients undergoing ERCP were randomly allocated into two groups of 50 each: Group PK received ketamine 1 mg/kg and Group PF received fentanyl 1 mcg/kg. Sedation (based on the Ramsay Sedation Score), blood pressure (BP), heart rate (HR), peripheral oxygen saturation (SpO₂), recovery time, total propofol consumed, quality of analgesia, endoscopist and patient's satisfaction score, and various complications were recorded. Results: The sedative and analgesic effects did not differ among both the groups. The mean HR in the PK Group was higher than Group PF. The decrease in the mean arterial BP was much more in the PF Group. SpO₂did not differ in both the groups. Total propofol consumption was higher in PF Group than PK. Moreover, the recovery time was longer in the PK Group compared to Group PF. Patients' and endoscopists' satisfaction score showed no significant difference between the two groups. Conclusion: We concluded that ketamine and fentanyl are equally efficacious with propofol for sedation in patients undergoing ERCP. Recovery time was shorter in the propofol-fentanyl regimen compared to the propofol-ketamine regimen.

Background: Postoperative nausea and vomiting (PONV) is a common complication following surgery under spinal anesthesia. The aim of this study was to compare the efficacy and cost-effectiveness of metoclopramide–dexamethasone combination with ondansetron as prophylaxis against PONV in the routine gynecological surgeries amenable to subarachnoid block (SAB). Materials and Methods: Following institutional ethical approval, patients were randomly assigned to receive either ondansetron 4 mg or metoclopramide 10 mg plus dexamethasone 8 mg. All patients had a SAB with 3 ml of 0.5% hyperbaric bupivacaine plus 25 μg of fentanyl. The primary outcome was proportion of patients in both groups with PONV within 24 h from institution of the SAB. Secondary outcome included comparison of severity of PONV between the two study groups, incidence of side effects related to the study drugs (i.e., sedation, headaches, and movement disorder), and cost implication of the study drugs in both groups. Results: One hundred patients were recruited in this study. The overall incidence of PONV for the 24-h period was 10% (n = 5) and 12% (n = 6) for the ondansetron group and the combination group, respectively. Side effects of the study drugs were minimal and comparable in both groups. The cost-effectiveness ratio, evaluated based on the number of women completely free of nausea and vomiting in each group, was higher at ₦ 177.78 for group ondansetron compared to ₦ 113.63 for metoclopramide and dexamethasone combination group. Conclusion: Combined dexamethasone–metoclopramide had comparable clinical effectiveness with lower cost-effectiveness compared to ondansetron for the prevention of PONV in women undergoing myomectomy under SAB.

Background: Shivering has many negative effects on the postanesthesia patient. Shivering is regulated by serotonin. The serotonin antagonists such as ondansetron and granisetron are widely used to prevent nausea and vomiting. Ondansetron is used in regional and general anesthesia, while granisetron is widely used in chemotherapy. This study aimed to determine the effect of low-dose granisetron on the incidence of shivering in postspinal anesthesia. Patients and Methods: The study conducted at Dr. Saiful Anwar General Hospital, Malang, Indonesia. Twenty-three patients divided into two groups: Group C (control) received no premedication and Group G (granisetron) received low-dose granisetron 10 μg/kg. The shivering grade and shivering intensity were recorded every 5 min in the first 1-h postanesthesia. The data were analyzed using t-test, regression test, and effective contribution test. Results: The shivering incidence in Group K was 71.9% and Group G was 9.4% (P = 0.018). The control group experienced shivering Grade I, II, III, and IV. Granisetron group only experienced shivering Grade I and II. Conclusion: The administration of low-dose granisetron before the spinal anesthesia significantly reduced the incidence of shivering in adult patients with no side effects.

Background: The low-flow technique could reduce the direct and indirect total cost as well as lower the pollution and glasshouse effects. This study aimed to compare the effectiveness of two inhalation anesthetic agents using low-flow techniques on the hemodynamic changes and cost needed. Subjects and Methods: This is an experimental study with posttest-only control group design and a cost minimization analysis on sixty patients, who had underwent surgery and met the inclusion and exclusion criteria. Patients were grouped into high-flow isoflurane (HIS), low-flow isoflurane (LIS), and low-flow sevoflurane (LSV) groups. The amount of anesthetic agent used was measured before and after the surgery. The cost needed was the main outcome of this research. Results: There was no significant difference in the hemodynamic changes between these three groups (P > 0.05). There was a significant cost difference between the three groups (P = 0.003). There was no significant cost difference between LIS and LSV groups (P = 0.353). There was a significant difference between the cost of high flow and low flow, but there was no significant difference between the cost of low-flow anesthetic agents. Conclusion: HIS resulted in a more expensive compared to the LIS and LSV. However, there was no significant cost difference between the use of low-flow techniques.

Background: Sepsis directly affects the immune system, leads tissue damage, and forms system organ dysfunction. The immunological biomarker of sepsis has a possibility to become an immunotherapy target of sepsis. This study was conducted to determine the effect of ketamine on the number of immature granulocyte and C-reactive protein (CRP) concentration in rat models of sepsis. Materials and Methods: This study used thirty white mice (Rattus norvegicus) divided into six treatment groups. The negative control group received nothing, and the positive control (sepsis) group was fecal-induced peritonitis (FIP) by fecal administration (i. p). The treatment groups (A, B, C, and D) treat with ketamine 5 mg/kg body weight (i. p.) right after FIP, 3 h after FIP, 5 h after FIP, and intermittent every 2 h. The peripheral mononuclear blood cell was isolated 6 h after FIP. The immature granulocytes counted using a hematology analyzer while CRP concentration analyzed using kit enzyme-linked immunosorbent assay. Data were analyzed statistically using the one-way ANOVA test using SPSS version 20 software (P < 0.05). Results: Sepsis induction with FIP increases the number of immature granulocytes in animal models from 0.48% to 9.12% (P < 0.05) but did not affect CRP concentration (P > 0.05). The ketamine administration significantly decreases the immature granulocytes in Groups C (1.04%) and D (1.58%). Ketamine administration did not have a significant effect on CRP concentration. Conclusion: The ketamine administration at 5 h after FIP and intermittently every 2 h can be an alternative to be sepsis immunotherapy with immature granulocyte as the potential target.

Malignant hyperthermia (MH) is a rare genetic disorder. Susceptible one could suffer fatal condition if the patient is exposed to triggers. MH can be seen in many general anesthesia procedures using volatile anesthetics. In susceptible patients who will be undergoing surgery, the most important is to prevent intraoperative MH despite overcoming the crisis. This case will discuss an elective spine surgery performed in a patient with a family history of MH.

In anesthetized patient, aspiration occurs because of insufficient airway protective reflex and subsequent aspiration of gastric contents. It is rare but potentially fatal, depending on its severity. Symptoms may vary from hypoxia to respiratory failure and acute respiratory distress syndrome, even collapsed lung and death. A 30-year-old woman who had a hysterectomy with intra-abdominal packing was scheduled for pack removal. She vomited during induction and ended up with aspiration pneumonitis (Mendelson's syndrome). She was admitted to the intensive care unit after surgery and was extubated on the 4^th day. She was then moved to the ward 6 days after the surgery. Awareness and skills to minimize the risk of aspiration anesthetic practice are developing well, but it still causes more than 50% of deaths related to the airway during anesthesia. Recognizing risks and its management is essential to prevent morbidity and mortality.

Postoperative pain, when poorly controlled, will cause chronic pain and prolong the healing process. The use of an epidural catheter is a safe and effective method for pain relief in the intraoperative and postoperative period. Opioid as an adjuvant can increase the potency and duration of epidural analgesia. Morphine has been used as an adjuvant in epidural analgesia, but with known side effects such as nausea, vomiting, and pruritus. Oxycodone is one of the opioids which can be given through epidural route as an adjuvant with fewer side effects than morphine. In this case series, we describe six patients with American Society of Anesthesiologists physical status I–II who underwent laparotomy gynecological surgery. All patients were managed by combined general and epidural anesthesia. The regimen for epidural anesthesia is bupivacaine with oxycodone as adjuvant. In this study, we described the hemodynamic profile, quality of analgesia, side effects, and anti-inflammatory effect of oxycodone as an adjuvant in epidural analgesia.