The coronavirus disease 2019 (COVID-19) has forced clinicians globally to promptly establish the effective response plans in a very short timeframe. This article seeks to provide a comprehensive and universally applicable “Departmental Readiness Checklist,” readily available for anesthesiologists worldwide in response to any global crisis. We have made considerable efforts to ensure the information provided is supported by current knowledge and recommendations. Preparedness for pandemic readiness requires a concerted multidisciplinary effort and clear leadership to identify the potential issues to allow for appropriate planning and to promote education, teamwork, and clear communication at all phases of the pandemic. Departmental implementation requires both clinical and organizational expertise of the respective specialist groups, and there is a paucity of information for pandemic preparedness on a departmental level at this moment. The information provided are exclusively for staff anesthesiologists, directors of anesthesia departments, and hospital managers to guide and help in decision-making processes in the face of a pandemic and can be applied to mass casualty or natural disaster events.

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Background: Efforts are still conducted to reduce side effects of anesthesia, such as postoperative nausea and vomiting (PONV). This study was performed to compare the effectiveness of prophylactic use of intravenous Ondansetron (4 mg) and Granisetron (2 mg) in the preventive management of postoperative nausea and vomiting in women undergoing elective lower (uterine) segment cesarean section (LSCS). Patients and Methods: A total of 100 patients belonging to the American Society of Anesthesiologists (ASA) Grade I and II posted for elective LSCS were included in the study. 100 patients were further divided into two groups (n = 50), i.e., Group O (ondansetron) and Group G (granisetron). This study was conducted from November 2017 to August 2019 on 100 ASA I and ASA II patients, aged from 18 to 35 years who underwent elective LSCS under the subarachnoid block. Results: Both drugs Ondansetron and Granisetron showed prevention of PONV (Granisetron showed 80% response and Ondansetron showed 44% response). Both drugs have shown promising results for a shorter duration in postoperative care but Ondansetron showed a higher number of PONV incidences than Granisetron in long duration. Conclusion: Granisetron is effective than Ondansetron in preventing nausea and vomiting in the late postoperative period with fewer side effects.

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Background: An anesthesiologist is expected to be able to manage intraoperative crises that can occur at any time. We aimed to determine the effectiveness of mindfulness-based intervention (MBI) technique in reducing stress levels of anesthesiology and intensive therapy residents at the Faculty of Medicine, University of Indonesia. Materials and Methods: This research was an experimental study with paired one group design. The MBI program lasted 4 weeks, consisted of one formal face-to-face training and 4 weeks of informal training (homework). Thirteen study subjects met the inclusion criteria and did not enter the exclusion criteria. One study subject was excluded because the subject did not complete the informal training. Data collection on the Perceived Stress Scale 10-Item (PSS-10) was conducted before and after training. Results: The average age of study subjects was 29.75 years; 75% are women. Four participants were in the 1^st year of education (33%), 3 participants were in the 2^nd year of education (25%), 2 participants were in the 3^rd year of education (16.67%), and 3 participants were in the 4^th year of education (25%). PSS-10 score in the study subjects significantly decreased after applying the MBI technique for 4 weeks (P = 0.001). Conclusion: MBI is effective in reducing stress levels of anesthesiology and intensive therapy residents at the-blinded.

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Background: The addition of adjuvants to local anesthetics in the peribulbar block might be a method to elevate block quality. This study aimed to determine the effectiveness of peribulbar local anesthesia adjuvants using dexmedetomidine 20 mcg and dexamethasone 5 mg. Patients and Methods: This study was a single-blind randomized clinical trial. Patients were divided into three groups who received peribulbar group: Group C (4 ml of levobupivacaine 0.5% and 4 ml of 2% lidocaine added with 1 ml of normal saline), Group D (4 ml of levobupivacaine 0.5% and 4 ml of 2% lidocaine added with 1 ml of dexamethasone 5 mg), and Group M (received 4 ml of levobupivacaine 0.5% and 4 ml of 2% lidocaine added with 1 ml of dexmedetomidine 20 mcg). Sensory and motor block onsets and durations were assessed. Results: There were 42 patients included. The sensory block onset was 70.7 s in Group M and the slowest in Group C (152.1 s). The longest sensory block duration was found in Group D (259.3 min) and the shortest in Group C (143.2 min). Conclusion: Dexamethasone 5 mg adjuvant affected sensory block onset, sensory, and motor block duration but did not affect motor block onset, while dexmedetomidine 20 mcg adjuvant affected sensory and motor block onsets as well as sensory and motor block durations.

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Background: Endotracheal tube (ETT) intracuff pressure (P_INTRACUFF) monitoring is not a mandatory part of daily anesthetic practice in many countries. Correct P_INTRACUFF is required to ensure adequate ventilation, to prevent aspiration, and to avoid complications. The aim of this study was to objectively measure the P_INTRACUFF in ETTs among patients from an Australian tertiary hospital to define the range of P_INTRACUFF values seen in a setting without the use of routine objective monitoring. Patients and Methods: A prospective single-center audit of P_INTRACUFF of 268 elective and emergency surgical patients undergoing general anesthesia with an ETT was performed. P_INTRACUFF values were measured with a calibrated cuff manometer following the induction of anesthesia. Patient characteristics were compared between three patient groups of measured P_INTRACUFF values: 20 cmH₂O, 20–30 cmH₂O, and >30 cmH₂O. Results: To estimate the P_INTRACUFF, only the auditory method was used among 66.0% of the patients, the tactile method was used in 18.3%, and the remainder used both or other methods. Following induction of anesthesia, the mean P_INTRACUFF was 31.0 cmH₂O (±standard deviation 16.4). The P_INTRACUFF was <20 cmH₂O for 54 patients (20.1%), and it exceeded 30 cmH₂O for 103 patients (38.4%). Patients with a P_INTRACUFF >30 cmH₂O had a marginally higher body mass index (BMI) compared to patients with a P_INTRACUFF <30 cmH₂O (P = 0.002). Patients with higher BMIs and smaller ETTs had higher cuff pressures. Conclusion: This study demonstrates that replacing subjective estimation methods with mandatory cuff pressure measurement can ensure that normal values are achieved during anesthesia.

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Background: In the dural puncture epidural technique (DPE), a dural hole is intentionally created, but no intrathecal drugs are administered. Our study's main objective was to compare the onset and duration of DPE analgesia with a conventional epidural (CE) when an intermittent epidural bolus dose was used. Materials and Methods: The double-blinded randomized control study was conducted on 60 parturient in active labor. Patients were randomly assigned into two groups using a computer-generated random sequence by closed envelope technique. Group CE received conventional labor epidural with 20 mL 0.1% ropivacaine and 30 μg fentanyl. In group DPE, dural puncture was performed, and 20 mL 0.1% ropivacaine and 30 μg fentanyl were given through an epidural catheter. The onset of analgesia, number of bolus doses required, and pain scores were monitored. Results: The onset of analgesia was faster in Group DPE than CE (4.40 ± 1.32 vs. 6.37 ± 2.04 min, P < 0.001). There was no significant difference in analgesia duration between the two groups (109.00 ± 26.63 vs. 104.17 ± 30.62 min, P = 0.517). The requirement of top-up doses was similar in both groups (2.47 ± 0.50 vs. 2.50 ± 0.50, P = 0.80). At 5 min, mean visual analog scores were less in DPE than CE group, and this difference was statistically significant (2.43 ± 1.25 vs. 3.97 ± 1.84, P = 0.002). Conclusion: Both techniques were effective in producing labor analgesia. However, the use of DPE technique with a 27G spinal needle produced faster onset of analgesia than CE technique when intermittent epidural boluses were used without affecting the maternal and fetal outcome.

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Clinical presentation of COVID-19 infection can be variable in the current pandemic even in patients presenting to the clinic with a mild history of upper respiratory complaints. Various cutaneous manifestations have been noticed in COVID-19 patients with herpes zoster (HZ) being one among them. HZ is an infection that results when varicella zoster virus reactivates from its latent state in the posterior dorsal root ganglion. Here, we aim to expand our knowledge by reporting three cases of associated zoster infection in COVID-19 patients admitted to our intensive care unit in view of respiratory complaints. All the three patients admitted, had revealed lymphocytopenia at the time of HZ diagnosis, and were managed conservatively throughout the course. In all the cases, acyclovir/valacyclovir led to the resolution of lesions in 10 days. No postherpetic sequelae were observed. We here suggest that the clinical presentation of HZ at the time of the current pandemic should be considered as an alarming sign for a latent subclinical SARS CoV-2 infection and thorough follow-up of such patients be adopted.

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Coronary artery bypass graft (CABG) is performed on patients with blocked coronary arteries by creating a shortcut to resolve and improve blood flow to the heart muscle. The CABG procedure can be performed using a cardiopulmonary bypass (CPB) or an off-pump artery bypass graft technique. One complication in heart surgery is acute kidney injury (AKI) incidence. The risk factors in the incidence of AKI include CPB, complications from surgery (e.g., bleeding and blood transfusions), type of surgery, preoperative high-osmolarity state, preoperative serum creatinine level, age >60 years, the presence of comorbid conditions (e.g., hypertension, diabetes, and dyslipidemia), impaired left ventricular function, hemodynamic disturbances, hypoperfusion, use of vasopressor drugs/inotropes, and preoperative hypoalbuminemia. We report an observation to six of our recent patients underwent CABG aged 36–69 years old. Five patients with coronary arterial diseases (CAD) underwent CABG, and one patient with CAD and mitral regurgitation underwent CABG surgery and mitral valve replacement. All patients had a preoperative albumin level of >3.5 g/dL. Two patients developed AKI <24 h postsurgery and three followed by the next day. Serum creatinine monitoring was carried out daily for 7 days, where two patients showed improvement in serum creatinine, and other two had their creatinine returned to normal. This case series found that AKI incidence after CABG was relatively high despite an excellent clinical outcome. Further research is needed with a larger number of cases to find the risk factors for AKI for perioperative prevention.

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Placenta accreta in cesarean section presents problem for an anesthesiologist. It may cause massive bleeding which is usually managed with massive transfusion. In this case series, we report cases of placenta accreta patients undergoing cesarean section managed with massive transfusion. A retrospective case series review of patients diagnosed with placenta accreta undergoing cesarean section with massive bleeding and massive transfusion was conducted between April 2018 and March 2019 in Dr. Moewardi General Hospital using the medical record data. A total of five patients with placenta accreta underwent cesarean section, and massive bleeding as well as massive transfusion was identified. Hysterectomy was performed at the time of cesarean section in all cases. All patients underwent general anesthesia, had central venous catheter, and required massive transfusion. Patients were transferred to the intensive care unit postoperatively. There were no transfusion reactions and maternal death.

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Mortality rate in COVID-19 is mainly contributed to respiratory failure caused by intractable acute respiratory distress syndrome (ARDS). However, the direct cause could be caused by diffusion failure or probably pulmonary embolism. Increased central venous pressure (CVP) will ensue in higher pulmonary vascular resistance and in turn would increase pulmonary arterial pressure. Coagulopathy is a common feature of severe acute respiratory syndrome coronavirus 2 infection, and an increase in D-dimer is the most common finding. These factors lead to thrombosis and finally embolism. We observed 14 intensive care unit-admitted COVID-19 patients suffered from CARDS from March to May 2020. We measured their CVP and D-dimer values and pulmonary embolism severity index (PESI) scores to search for possible associations. Only CVP and PESI scores were statistically significant between those three parameters (P < 0.005). Lack of regular D-dimer samples and measurements due to limited resources could be one of potential causes, which contributes to the insignificant value. Further investigations with larger samples should be advised.

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Background: A scoring system to predict patient's prognosis may aid clinicians in deciding patient's treatment continuation. This study aimed to investigate the reliability of Acute Physiology and Chronic Health Evaluation (APACHE) II score in predicting mortality in critically ill COVID-19 patients in intensive care unit (ICU). Patients and Methods: This retrospective observational study included the data from medical records of critically ill patients from April to November 2020. The collected data were patient's identity, age, gender, comorbid, Glasgow coma scale (GCS) score, temperature, mean arterial pressure, heart rate, hematocrit, leukocyte, natrium, kalium, serum creatinine, blood pH, PaO₂ level, and history of organ insufficiency or immunocompromised within 24 h after ICU admission. Patient's outcome (survival and nonsurvival) was recorded. Results: A total of 120 patients were included in the study. APACHE II score was significantly higher in nonsurvival compared to survival group (19.12 vs. 12.33; P < 0.001). The area under curve value was 0.955 (P < 0.001) which indicated APACHE II score as a good predictive value for mortality. The cutoff value of the APACHE II score for mortality prediction in this study was 15, with sensitivity, specificity, positive prediction value, negative prediction value, and accuracy of 94%, 79.4%, 80.6%, 94.3%, and 86.7%, respectively. GCS score, heart rate, age, and serum kalium level were related to mortality. Conclusion: The APACHE II score is reliable in predicting mortality in critically ill COVID-19 patients in ICU.

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Postoperative breast pain may lead to poorer outcome if left untreated. Common analgesia modalities for postoperative breast pain include opioids and regional anesthesia. However, both of these modalities can cause significant side effects or complications. Serratus anterior plane (SAP) block is a new procedure that is relatively easier to perform and safer, compared with other modalities. Previous studies have reported its usefulness in reducing the need for both intraoperative and postoperative opioids. We report two patients who underwent SAP block combined with general anesthesia in modified radical mastectomy (MRM). Patient 2 was given rescue analgesia during the intraoperative period. The administration of postoperative opioids did not exceed 24 h in both patients. Pain assessment using Numeric Rating Scale showed minimal postoperative pain. No side effects were found during 24-h monitoring period. SAP block can be used as one of the modalities in managing the pain of MRM surgery.

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Congenital diaphragmatic hernia (CDH) is a condition in which a developmental defect in the diaphragm leads to protrusion of abdominal contents into the thoracic cavity. Its definitive management is by surgical repair. Postoperative analgesia is crucial following the surgery as inadequate analgesia is a major contributing factor for postoperative pulmonary complications in these patients. Systemic analgesics with or without regional techniques such as epidural analgesia have been the mainstay of postoperative pain management following surgical correction of the defect. We report the case of a child with right-sided Morgagni hernia who underwent surgical repair under general anesthesia. For postoperative analgesia, right erector spinae plane block (ESPB) along with right celiac plexus block (CPB) was performed under ultrasound guidance with excellent results. We observed that ESPB combined with CPB provides excellent analgesia following repair of CDH.

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Placenta accreta is one of the emergency conditions and has resulted in increased mortality and morbidity of pregnant women due to the massive obstetric hemorrhage. Placenta accreta can lead to secondary complications including coagulopathy, multisystem organ failure, acute respiratory distress syndrome, need for repeat surgery, and death. Assessment by anesthesia should be carried out as early as possible before surgery to reduce or even eliminate morbidity and mortality. In this report, we present the case of a patient with total placenta previa and high-risk morbidly adherent placenta score with a transverse lie fetal position. The various anesthetic treatments and transfusion strategies are discussed with a multidisciplinary approach to delivery.

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The global pandemic of coronavirus disease 2019 (COVID-19) has inevitably affected pediatric surgical services. Clinical manifestations of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection in pediatrics are generally asymptomatic to mild, so they are often not detected during initial screening. In adult population, the postoperative mortality of patients infected with SARS-CoV-2 is 23.8%. The possibility of SARS-CoV-2 transmission to health workers during surgery, the increasing postoperative mortality, and the risk of postoperative complications pose challenges for anesthetists in treating pediatric patients with COVID-19 undergoing emergency surgery. Here, we describe the management of anesthesia and postoperative evaluation of a pediatric patient with asymptomatic COVID-19 who underwent emergency laparotomy due to grade 3 traumatic pancreatic injury under general anesthesia. We found no worsening of clinical symptoms or complications related to COVID-19 on 30 days after surgery. The increase in inflammatory markers was not related to COVID-19 but was an inflammatory response to traumatic injury and surgery.

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Background: Ketamine can provide sedation and analgesia in specific doses. Whereas most other anesthetic agents exert a suppressive effect on the cardiovascular system and can lower blood pressure, ketamine can have the opposite effect. Although it provides many benefits, the use of ketamine is still limited in patients who are at the risk of increased intracranial pressure, such as head injury and stroke. The present study aims to compare the mean flow velocity-medial cerebral artery's (MFV-MCA) in patients receiving propofol with patients receiving a low-dose combination of propofol and ketamine. Materials and Methods: This was an experimental study with a double-blind, randomized controlled trial design. A total of 58 ASA I-II patients who underwent surgery with general anesthesia technique were collected by the consecutive sampling technique. The sample was divided into two groups: Group A received a low dose of ketamine after the patient was induced with propofol and Group B received NaCl 0.9% after the patient was induced with propofol. We used transcranial Doppler to measure the MFV-MCA before, 5 min after, and 10 min after the administration of ketamine. Results: We found no statistical difference between the groups in terms of MFV-MCA values before ketamine administration (P = 0.908), 5 min after ketamine administration (P = 0.890), and 10 min after ketamine administration (P = 0.981). Conclusion: The administration of low-dose ketamin at 0.3 mg/kg after induction did not increase the MFV-MCA in patients who underwent general anesthesia using propofol.

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