Tinjauan Literatur: Alkalosis Respiratorik pada COVID-19: Sleeping with the “Silent Devil”

Dewasa ini krisis pertumbuhan penyakit coronavirus disease (COVID-19) telah menekan sistem kesehatan secara global bahkan lebih dari sebelumnya, menyebabkan kebutuhan peningkatan kapasitas unit perawatan intensif dalam menangani jumlah pasien kritis yang meningkat secara tajam. Gagal napas pada COVID-19 diperburuk oleh keadaan hipoksemia dan dapat memburuk menjadi acute respiratory distress syndrome (ARDS) yang segera membutuhkan terapi suplementasi oksigen. Menilai kebutuhan memulai terapi oksigen dapat dilakukan salah satunya dengan analisis gas darah untuk mengevaluasi gangguan asam basa terutama pada perjalanan awal COVID-19 simtomatis berat. Silent hypoxemia sebagai gejala COVID-19 yang mematikan merupakan sebuah tantangan dalam kegawatdaruratan COVID-19. Hipoksemia berat akibat hiperventilasi tanpa gangguan pernapasan akan menunjukkan gambaran hasil analisis gas darah berupa alkalosis respiratorik sebagai upaya kompensasi penurunan kadar PaCO2 untuk meningkatkan saturasi. Pergeseran kurva disosiasi ke kiri menyebabkan peningkatan afinitas Hb-O2 untuk memfasilitasi kebutuhan oksigen. Maka dari itu, tenaga kesehatan harus memperhatikan bukan hanya keadaan umum pasien melainkan juga laju pernapasan dan melihat tanda hiperventilasi untuk mengetahui gangguan asam basa melalui analisis gas darah agar dapat mencegah komplikasi alkalosis respiratorik. Literature Review: Respiratory Alkalosis in COVID-19: Sleeping with the Silent DemonToday the growing crisis of coronavirus disease (COVID-19) has urged the health system globally even more than ever before, leading to the need to increase the capacity of intensive care units in dealing with the sharply increasing number of critically ill patients. Respiratory failure in COVID-19, exacerbated by hypoxemia, can worsen into acute respiratory distress syndrome (ARDS), requiring immediate oxygen supplementation therapy. The need to start oxygen therapy can be assessed by examining blood gas analysis to evaluate the presence of acid-base disorders, especially in the early progress of severe symptoms of COVID-19. Silent hypoxemia, a deadly symptom of COVID-19, is a challenge in the emergency of COVID-19. Severe hypoxemia due to hyperventilation in the absence of respiratory disorders will show a picture of the results of blood gas analysis in the form of respiratory alkalosis to compensate for decreased PaCO2 levels to increase saturation. The left shift of the dissociation curve leads to an increase in Hb-O2 affinity to facilitate oxygen needs. Hence, healthcare workers should pay attention to the patient's general condition and breathing rate. Besides, looking for the signs of hyperventilation to find the presence of acid-base disorders through analysis of blood gases to prevent respiratory alkalosis complications.Dewasa ini krisis pertumbuhan penyakit coronavirus disease (COVID-19) telah menekan sistem kesehatan secara global bahkan lebih dari sebelumnya, menyebabkan kebutuhan peningkatan kapasitas unit perawatan intensif dalam menangani jumlah pasien kritis yang meningkat secara tajam. Gagal napas pada COVID-19 diperburuk oleh keadaan hipoksemia, dapat memburuk menjadi acute respiratory distress syndrome (ARDS) yang segera membutuhkan terapi suplementasi oksigen. Menilai kebutuhan memulai terapi oksigen dapat dilakukan salah satunya dengan pemeriksaan analisis gas darah untuk mengevaluasi adanya gangguan asam basa terutama pada perjalanan awal COVID-19 simtomatis berat. Silent hypoxemia sebagai gejala COVID-19 yang mematikan merupakan sebuah tantangan dalam kegawatdaruratan COVID-19. Hipoksemia berat akibat hiperventilasi tanpa adanya gangguan pernapasan akan menunjukkan gambaran hasil analisis gas darah berupa alkalosis respiratorik sebagai usaha kompensasi menurunnya kadar PaCO2 untuk meningkatkan saturasi. Pergeseran kurva disosiasi ke kiri menyebabkan peningkatan afinitas Hb-O2 untuk memfasilitasi kebutuhan oksigen. Maka dari itu, tenaga kesehatan harus memperhatikan bukan hanya dari keadaan umum pasien melainkan juga laju pernapasan dan melihat tanda hiperventilasi untuk mengetahui adanya gangguan asam basa melalui analisis gas darah agar dapat mencegah terjadinya komplikasi alkalosis respiratorik

THE SIGNIFICANCE OF MODIFIED PIRO SCORING WITH NLR BIOMARKER ON ENHANCING MORTALITY PREDICTION OF PATIENTS WITH VENTILATORS‑ASSOCIATED PNEUMONIA IN INTENSIVE CARE UNIT

Ventilator-associated pneumonia (VAP) is a pulmonary infection that occurs as a mechanical ventilator-related disease which accounts for almost 80% of hospital-acquired pneumonia with of high mortality rate, lengthens the hospital-stay rate and increases health costs. To provide a description of the likelihood of the patient's life expectancy, mortality, and prognosis of patients in ICU, a scoring system should be utilized in order to assess the severity of the disease and estimate mortality during hospital treatment. The PIRO scoring system is a comprehensive concept that provides good validity and derivation in predicting mortality risk in a wide range severity of the disease so that it is very useful in the selection or categorization of patients, especially those admitted to the ICU with VAP. A conjunction or integration with a simple biomarker such as Neutrophil-to-lymphocyte ratio (NLR) provides a better performance of the tool in regards to the predictive value in VAP mortality risk estimation. Since the NLR has a strong predictive value, is simple, low-cost, and easily available compared to other biomarkers, therefore it is practical and useful for prognostic indications for VAP with conjunction with the PIRO score where medical facilities are lacking

SPONTANEOUS RUPTURE OF ARTERIOVENOUS MALFORMATION: ICU BASED BRAIN RESUSCITATION

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

Management of Critically Ill Patients with Severe Diabetic Ketoacidosis and Acute Renal Failure: A Case Report

Background: Diabetic ketoacidosis (DKA) is one of the hyperglycemic crises related to diabetes. The main problem in DKA is ketogenesis, a metabolic process that increases the production and decreases the utilization of ketones. DKA is characterized by a biochemical triad such as hyperglycemia, ketonemia, and high anion gap metabolic acidosis. Management of DKA needs to be carried out appropriately and immediately because it may lead to diabetic coma and death. Case presentation: A 38-year-old woman had decreased consciousness due to metabolic encephalopathy as a complication of severe DKA. The metabolic derangement shows an overlapping high anion gap metabolic acidosis and non-anion gap metabolic acidosis. This case is complicated by acute renal failure. The patient also had been in a hypovolemic state, causing pre-renal acute kidney injury. We treat the patient using a balanced solution to correct hypovolemia. Sonography of the vena cava and blood lactate levels are used to guide fluid resuscitation. We intubate and control the patient's breathing to reduce the metabolic demand. We titrate the insulin infusion until the ketogenesis process is abolished. Antibiotics are given based on sputum culture. Conclusion: Acute renal failure (ARF) is a rare but potentially fatal complication of diabetic ketoacidosis (DKA). Early recognition and aggressive treatment of ARF during DKA may improve the prognosis of these patients

COMBINE MIDAZOLAM-FENTANYL-KETAMIN FOR EVISERATION SURGERY IN PATIENT WITH MULTIDRUG ALERGY IN ACUTE ON CHRONIC EXCACERBATION OF HIPERSENSITIVITY REACTION

ABSTRACTMultidrug Alergy is a relatively rare imunology abnormality. Generally, it caused by congenital genotype and influence with environment. After treated the acute on chronic exacerbation of hypersensivity tipe 1, and the inflamation can alleviate, the patient schedule of eviseration oculi dextra with general anesthesia. And the opthamologist curious about the proceddure because eviseration need antibiotic to wash the oculi, but there are no antibiotic saved for the patient. For general anesthesia, the patient has no history so we can’t predicted about the anesthetic drug’s allergy. We choose combine ketamine-midazolamadn fentanyl to facilitate the anesthesia. Ketamine significantly reduces the production of inflammatory cytokines without affecting the production of anti-inflammatory cytokines. Fentanyl is the opioid which is the most rarely caused allergy and have strong potential. Midazolam can help the sedatio

Manajemen Anestesi Reseksi Tumor Cerebello-pontine Angle Vestibular Schwannoma dengan Posisi Lateral

Tumor Cerebello-pontine angle (CPA) adalah tumor yang paling sering terjadi di daerah fossa posterior, dan berkisar 5-10 % dari seluruh kasus tumor intrakranial. Sebagian besar tumor CPA adalah tumor jinak, 85% diantaranya merupakan vestibular schwannoma (neuroma akustik). Terapi pilihan untuk tumor CPA vestibular schwannoma dengan gejala adalah tindakan pembedahan. Kraniotomi dengan posisi lateral penuh pada reseksi vestibular schwannoma yang berlangsung lama memberikan tantangan karena potensi terjadinya ketidaksesuaian ventilasi-perfusi dan atelektasis paru sisi bawah. Seorang pasien perempuan, usia 25 tahun, dengan gangguan pendengaran, gangguan keseimbangan, kelemahan separuh badan kiri, mengalami kesulitan menelan dan pada pemeriksaan magnetic resonance imaging (MRI) didapatkan lesi padat di cerebelo-pontine angle dengan ukuran 5,6 x 5 x 4.5 cm yang meluas hingga internal auditory canal dan didiagnosa sebagai tumor cerebro-pontine angle vestibular schwannoma sinistra. Pasien menjalani pembedahan dengan anestesi umum intubasi endotrakeal, posisi lateral kanan penuh, yang berlangsung selama 6 jam 40 menit. Target dari pengelolaan anestesi pada tindakan pembedahan tumor vestibular schwannoma adalah memfasilitasi lapangan pembedahan yang ideal dan melakukan proteksi serebral untuk mencegah cedera sekunder dengan mempertahankan tekanan perfusi serebral, menghindari instabilitas hemodinamik, memungkinkan dilakukannya pemantauan neurologi intraoperatif, deteksi dini dan pengelolaan segera bila terjadi komplikasi pembedahan.   Anesthesia Management of Cerebello-pontine Angle Tumor Vestibular Schwannoma Resection in Lateral Position Abstract Cerebellopontine angle (CPA) tumors are the most common neoplasms in the posterior fossa, accounting for 5-10% of intracranial tumors. Most CPA tumors are benign, with over 85% being vestibular schwannoma (acoustic neuromas). The preferred treatment for symptomatic vestibular schwannoma has been surgical excision. Craniotomy for vestibular schwannoma resections in lateral position gave better surgical field exposure, but also posed increased risk of ventilation-perfusion mismatch and atelectasis of the dependent lung in lengthy surgery. A 25 years old woman, with loss of hearing function, disturbed sense of balance, left hemiplegia, difficulties to swallow, on magnetic resonance imaging (MRI) examination had solid lesion in the cerebello-pontine angle size 5,6 cm x 5 cm x 4.5 cm which is diagnosed as Cerebello-pontine angle vestibular schwannoma sinistra. Patient underwent surgical resection in right lateral position under general anesthesia and the surgical resection performed in 6 hour 40 minutes. The goals of anesthetic management in vestibular schwannoma tumor resection are to facilitate ideal surgical condition and provide brain protection by maintaining cerebral perfusion pressure, avoid hemodynamic instability, enable intraoperative neuro-monitoring and ensure the early detection and prompt management of potential complications

Programmed intermittent epidural bolus improves efficacy of patient controlled epidural analgesia in postoperative pain management

Background: Postoperative acute pain will have negative impacts if not handled properly so it must be treated effectively. Patient Controlled Epidural Analgesia (PCEA) allows the patient to have an active role in determining the need of analgesia personally. Programmed Intermittent Epidural Bolus (PIEB) is a new method which proven better than Continuous Epidural Infusion. Ropivacaine has similar characteristic to Bupivacaine but with minimal cardiotoxic effect. Fentanyl as an adjuvant can accelerate the onset of action of local anesthetics in epidural analgesia. The purpose of this study was to compare the efficacy of PCEA+PIEB with PCEA as a modality of postoperative analgesia. Methods: Total 54 patients undergoing major surgery of the abdomen and lower extremities were divided into 2 groups randomly: PIEB+PCEA and PCEA. Then we did an evaluation of VAS, PCA demand, and total consumption of solution Ropivacaine 0.1% + Fentanyl 2 mcg/mL at 4 hours, 8 hours, and 24 hours postoperative Results: VAS at resting and at moving in both groups were found clinically comparable, although statistically, VAS at moving at 4 hours and 24 hours postoperative were lower in PCEA+PIEB group (p < 0.01). PCA attempted and PCA given were lower in PCEA+PIEB group (p = 0.05). Total consumption of solution until 8 hours postoperative was comparable in both groups but at 24 hours postoperative it was much greater in PCEA+PIEB group (p < 0.01). Conclusions: PCEA+PIEB have greater efficacy than PCEA. VAS (at resting and at moving), PCA attempted, and PCA given were lower in PCEA+PIEB group. Total consumption of solution Ropivacaine-Fentanyl until 8 hours postoperative was comparable, but at 24 hours postoperative it was much greater in PCEA+PIEB group. In orthopedic surgery, VAS at resting was obtained below 30 mm in PCEA+PIEB group but VAS at moving was obtained in the category of moderate pain in both groups