Arteriovenous malformations (AVM) is a relatively rare intracranial abnormality. Generally, it caused by congenital abnormalities that recognized after the bleeding started. Spontaneous intracranial bleeding after AVM rupture is an emergency condition and require immediate treatment to reduce mortality rate. After stabilization of intracranial bleeding due to AVM rupture, secondary injury may occur hours or even days after the inciting traumatic event. The injury may result from impairment or local declines in cerebral blood flow (CBF) after brain injury. The decrease in CBF is the result of local edema, hemorrhage, or increased intracranial pressure (ICP). An adequate brain resuscitation is needed to decrease brain edema and intracranial pressure by achieving several targets and avoid things that can interfere with CBF. A recovery phase should be given to the patient with rupture of AVM before going to definitive therapy.

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As we know, the volatile agent needs fresh gas flow to be carried out to the patient. It is very common in anesthesia practice, we use the fresh gas flow more than 2 liters per minute. In recent practice, the more flow we gave, the more volatile agent blew out to the patient. The present of APL (adjustable pressure limit) also leaks out of the circuit, we spend more gases, volatile agent, hence gave more pollutant to the operating theater. The consequences of those are an increase of anesthesia expenses and change the way of health care being delivered. ERAS (Enhanced Recovery After Surgery) is popular with its quick recovery after surgery, include quick emergence post anesthesia, that will reduce the time in the operating theater, recovery room, and as results, reduce the cost of anesthesia and surgery.

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Venous Air Embolism (VAE) is one of the most serious complications in neuroanesthesia case. The highest number of VAE incident is during neurosurgery procedure with sitting position, even tough VAE may occur during craniotomy of supratentorial tumor in the supine position. VAE occurs due to the pressure differential between open vein in the surgical field and right atrium. A 46 years old woman underwent craniotomy for supratentorial meningioma in the supine position. Intraoperative, the patient was experiencing a decrease in end-tidal CO₂ pressure about 6 mmHg in 5 minutes. Therefore, management of acute VAE was proceed to the patient, such as informed the surgeon immediately, discontinued N₂O and increased flow of O₂, modified the anesthesia technique, asked the surgeon to irrigate the surgical field with fluids, gave compression on jugular vein, aspirated the right atrial catheter, prepared drugs to support the hemodynamic, and changed the patient's position if possible.

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Hydatidiform mole or molar pregnancy is a benign Gestational Trophoblastic Disease (GTD) that originates from the placenta. Treatment consists of vacuum evacuation but rarely hysterectomy may be required. One common complication of molar pregnancy is hyperthyroid. Anesthetic management is often complicated by the associated systemic complications. These complications cannot be prevented, but with a better understanding of the disease, some measurements to avoid maternal mortality can be performed.

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Background: Pericardial effusion is an abnormal fluid accumulation in the pericardial space that potentially compromises cardiovascular function, thus it needs a prompt treatment. Pericardial effusion evacuation in paediatrics can be done by subxyphoid pericardiotomy, which requires patient's cooperation. General anaesthesia for paediatrics with pericardial effusion has been reported unfavourable. This case series reports safe anaesthesia procedures done for pericardiocentesis through both sedation and general anaesthesia. Case Presentations: Cases were taken from Cipto Mangunkusumo Hospital, Jakarta, Indonesia. 6 patients underwent sedation and 3 patients underwent general anaesthesia. Both groups used ketamine, midazolam and fentanyl. Sevoflurane was used as inhalation agent for maintenance. Blood pressure, heart rate, and SpO₂ were recorded before and after pericardiocentesis. In both groups, there were no significant different between systolic and diastolic blood pressure, heart rate, and SpO₂ before and after the procedure (p=0.05). Immobilization through sedation or general anaesthesia is required to perform an optimal pericardiotomy. Anaesthetic agents were chosen based on their minimal effects toward myocardial depression. Fluids balance before and after the procedure was crucial to prevent hemodynamic instability during effusion evacuation. Conclusion: Both sedation and general anaesthesia were safe for pericardiocentesis, with concern toward anaesthetic agents that were minimally depressive to myocardium, combined with opioid analgesics and other sedative agents, with balanced anaesthesia principle. Optimal intravenous fluid therapy with echocardiography monitoring is crucial. Sedation is more advantageous for patients requiring pericardiocentesis without preoperative preparation for general anaesthesia.

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Background: Cesarean section causes moderate to severe pain in the first 48 hours postoperatively, thus requiring an adequate perioperative pain management, as of the mother can be quickly discharged and immediately can perform daily activities after surgery such as breastfeeding and nurse the baby. Objective: To determine the efficacy of subcutaneous morphine patient controlled analgesia (SC-PCA) in lowering VAS (visual analogue score), total morphine consumption and postoperative side effect of cesarean section compared with intravenous morphine patient controlled analgesia (IV- PCA). Methods: This study is an experimental clinical trial using consecutive sampling technique. Sixty-four subjects were allocated into two groups of PCA morphine subcutaneously (SC-PCA) and the group PCA morphine intravenously (IV-PCA), each consisting of 32 subjects using permuted block randomization. Morphine concentration was 5 mg/ml (group SC-PCA) or the concentration of 1mg/ml (group IV-PCA). Both groups were then analyzed for VAS ratings, total morphine consumption, and adverse effects, postoperatively at 4th, 8th, and 24th hour. Statistic analysis using repeated ANOVA test and t-test with p <0.05 considered significant. Result: Morphine consumption in IV-PCA group showed lower than SC-PCA (9.41 mg vs 4,9mg) p <0.001 24 at 24 hours postoperatively. The resting VAS at 4th hours significantly lower in IV-PCA group (1.06 ± 0.71 vs 0.81 ± 1.40, p=0.029) and at 8th hours (1.03 ± 0.59 vs 0.94 ± 0,9, p=0.048). The moving VAS at 4th hours significant lower in IV-PCA group (2.31 ± 0.47 vs 1.45 ± 2.06, p=0.019) but the resting or moving VAS are not different clinically. Side effects of nausea and vomiting are more common in IV-PCA group. We conclude that SC-PCA provides analgesia more effective and decreases side effects in patients undergo cesarean section with spinal anesthesia.

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Traumatic brain injury (TBI) is a major public health issue, which results in significant mortality and long-term disability. The profound impact of TBI is not only felt by the individuals who suffer the injury but also their caregivers and society as a whole. Clinicians and researchers require reliable and valid measures of long-term outcome not only to truly quantify the burden of TBI and the scale of functional impairment in survivors but also to allow early appropriate allocation of rehabilitation supports. In addition, clinical trials which aim to improve outcomes in this devastating condition require high-quality measures to accurately assess the impact of the interventions being studied. In this article, we review the properties of an ideal measure of outcome in the TBI population. Then, we will describe the measurement tools include: the Glasgow Outcome Scale (GOS) and extended Glasgow Outcome Scale (GOSe) in correlation with bispectral index (BIS).

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We report a case involving a 46 year old male with schizophrenia who presented with fever, inability to speak, sialorrhoea, limb stiffness, profuse sweating, tremors and rigidity of bilateral upper and lower limbsfollowing an increase in dosage of his antipsychotics. A provisional diagnosis of neuroleptic malignant syndrome (NMS) was made based on the Levensen criteria. His antipsychotics were promptly discontinued and he was transferred to ICU for critical care support. We utilised lorazepam and prescribed bromocriptine and his NMS symptoms improved. However, in view of residual catatonic symptoms, decision was made to commence ECT. A combination of rocuronium sugammadex was used successfully in all his ECT procedures and found to be an excellent alternative to succinycholine in this patient.

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