I Ketut Sinardja
Anesthesiology and Intensive Care Department, Udayana University, Sanglah General Hospital, Denpasar, Bali, Indonesia

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Journal : Jurnal Neuroanestesi Indonesia

Manajemen Anestesi pada Pasien dengan Cedera Medula Spinalis Segmen Cervicalis Kurniawan Komala, Tomas Ari; Suarjaya, I Putu Pramana; Sinardja, I Ketut
Jurnal Neuroanestesi Indonesia Vol 3, No 2 (2014)
Publisher : Departement of Anesthesiology and Intensive Care Dr. Hasan Sadikin Hospital Bandung

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Abstract

Manajemen medula spinalis, terutama bagian cervical selama operasi dan resusitasi pasien dengan cedera spinal, memiliki banyak pertimbangan penting untuk ahli anestesi, antara lain dengan memperhitungkan hal-hal yang berpotensi menyebabkan cedera berat irreversibel selama dilakukan intubasi trakeal. Pasien laki-laki usia 57 tahun, datang ke Rumah Sakit Sanglah Denpasar dalam kondisi sadar mengeluh nyeri pada leher dan tidak bisa menggerakkan ke empat anggota geraknya segera setelah kecelakaan. Pengelolaan anestesi untuk membantu tindakan operasi ini dilakukan dengan anestesi umum inhalasi dengan pemasangan pipa nasotrakheal non kinking, nafas kendali. Untuk premedikasi diberikan midazolam intravena, induksi dengan propofol dan fentanyl intravena, dan fasilitasi intubasi dengan menggunakan vekuronium intravena. Intubasi dikerjakan dengan bantuan glidescope untuk meminimalisasi ekstensi kepala. Pemeliharaan anestesi dengan menggunakan N2O, O2, sevofluran dan vekuronium intermitten. Monitoring tanda vital tekanan darah, laju nadi, EKG, SaO2, dan ET CO2. Operasi dikerjakan dengan posisi telungkup, pendekatan dari posterior. Selama operasi hemodinamik pasien relatif stabil. Hari I pascaoperasi dimulai program diet enteral, hari II pascaoperasi penderita dipindahkan ke ruangan biasa. Penilaian nyeri dengan Numeric Rating Scale (NRS) dengan hasil 1–2. Fungsi motorik pasien meningkat 1 point dibandingkan pre op, hari IX pascaoperasi penderita diprogram rawat jalan oleh sejawat Bedah Saraf. Cedera pada medulla spinalis segmen cervical memerlukan penanganan yang cermat. Penanganan jalan nafas definitif dengan melakukan intubasi trakheal harus sangat berhati–hati, dan harus dijaga agar tidak terjadi cedera lebih jauh akibat tindakan laryngoscopy.  Anesthetic Management for Patient with Cervicalis Spinal Cord InjuryManagement for spinal cord injury, especially the cervical part during surgery and also resuscitation of patients with spinal injuries, has many important considerations for anesthesiologists,which is also have potential to cause severe irreversible injury during tracheal intubation. Patient male, 57 years old, came to Sanglah Hospital with chief complain neck pain and could not move all extremities immediately after an accident. Anesthesia performed by general anesthesia inhalation with insertion nasotracheal tube. For premedication was given IV midazolam. Induction with IV propofol and fentanyl, and vecuronium used as muscle relaxant. Intubation performed with glidescope guidance to minimize the extension of the head. Maintenance of anesthesia with N2O, O2, sevoflurane and intermittent IV vecuronium. Monitoring during anesthesia and surgery such as blood pressure, pulse rate, ECG, SaO2, and ET CO2. The surgery was done with prone position and posterior approach. During surgery the patient’s hemodynamic relative stable. Day I post operation, patient start to have enteral diet, and the next day patient was transferred to regular ward. Pain assesment was done with Numeric Rating Scale (NRS) with score 1–2. Motor function of the patients increased 1 point compared to preoperation. Day IX post operation, patient was discharged from the hospital. Cervical spinal cord injury requires careful handling. Definitive airway by endotracheal intubation should be done with extreme careful, and shall not cause further injury due to laryngoscopy.
Pemberian Salin Hipertonik 3% Selama Kraniotomi pada Pasien dengan Cedera Otak Traumatik Memberikan Relaksasi Otak yang Lebih Baik Dibandingkan dengan Manitol 20% Damayanthi, Made Ayu; Sinardja, I Ketut
Jurnal Neuroanestesi Indonesia Vol 2, No 3 (2013)
Publisher : Departement of Anesthesiology and Intensive Care Dr. Hasan Sadikin Hospital Bandung

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Latar Belakang dan Tujuan: Manitol telah dipakai secara luas sebagai pilihan osmoterapi untuk menurunkan masa otak baik itu akibat cedera otak maupun tumor. Beberapa penelitian menyebutkan bahwa salin hipertonik sama efektifnya bahkan lebih baik dalam menurunkan tekanan intrakranial maupun menurunkan masa otak intraoperatif. Penelitian ini bertujuan untuk menilai kondisi relaksasi otak setelah pemberian salin hipertonik 3% dibandingkan dengan manitol 20% selama kraniotomi pada pasien dengan cedera otak traumatik. Subyek dan Metode: Empat puluh dua pasien dengan cedera otak traumatik yang memenuhi kriteria eligibilitas diikutsertakan dalam penelitian uji klinik prospektif ini. Keempatpuluhdua pasien dibagi menjadi dua kelompok, kelompok A menerima 5 mL/kgBB salin hipertonik 3% dan kelompok B menerima 5 mL/kgBB mannitol 20% yang diberikan saat insisi kulit kepala selama 15 menit. Pada saat pembukaan duramater, dokter bedah saraf menilai relaksasi otak berdasarkan skala empat poin, selanjutnya data relaksasi otak dibagi menjadi data dikotom (favorable dan unfavorable). Analisis statistik dilakukan uji chi-kuadrat dan nilai p<0,05 dianggap signifikan. Hasil: Kondisi otak favorable didapatkan pada 19 pasien (90,5%) pada kelompok A dan 13 pasien (61,9%) pada kelompok B. Analisis statistik menyebutkan kondisi relaksasi otak setelah pemberian salin hipertonik 3% bermakna lebih baik dibandingkan dengan manitol 20% (uji chi-kuadrat), nilai p<0,05). Simpulan: Pemberian salin hipertonik 3% selama kraniotomi pada pasien dengan cedera otak traumatik memberikan relaksasi otak yang lebih baik dibandingkan manitol 20%  Hypertonic Saline 3% Provide a Better Brain Relaxation During Craniotomy in Patients with Traumatic Brain Injury Compared to Mannitol 20% Background and Objective: Mannitol has been widely used as an osmotherapy agent to reduce brain mass caused either by brain injury or tumor. Many studies argued that hypertonic saline is as effective or even better in reducing intracranial pressure and intraoperative brain mass. The purpose of this study was to evaluate brain relaxation after administration of hypertonic saline 3% compared to mannitol 20% during craniotomy in patients with traumatic brain injury.Material and Methods: Forty two patients who met the eligibility criteria were enrolled into this prospective clinical trial. Patients were randomized into two groups, group A received 5 mL/kg of hypertonic saline 3% and group B received 5 mL/kg of mannitol 20% at scalp incision, infused in 15 minutes. After opening duramater, neurosurgeon assessed brain relaxation on four-point scale. Data were dichotomized into two points (favorable and unfavorable) and analyzed by chi-square test, p-value less than 0.05 was considered significant. Results: Favorable brain were observed in 19 patients (90.5%) in group A and 13 patients (61,9%) in group B. Statistical analysis showed that brain relaxation after administration of hypertonic saline 3% was significantly better compared to mannitol 20% (chi-square test, p-value less than 0.05). Conclusion: The present study demonstrated that administration of hypertonic saline 3% provides better brain relaxation during craniotomy in patients with traumatic brain injury compared to mannitol 20%.
Penatalaksanaan Anestesi pada Kehamilan dengan Tumor Medula Spinalis Supradnyawati, Ni Made; Suarjaya, I Putu Pramana; Sinardja, I Ketut
Jurnal Neuroanestesi Indonesia Vol 3, No 2 (2014)
Publisher : Departement of Anesthesiology and Intensive Care Dr. Hasan Sadikin Hospital Bandung

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Anestesi pada pembedahan nonobstetri dalam kehamilan merupakan tantangan khusus bagi ahli anestesi. Sekitar 0,75%–2% pembedahan nonobstetri dilakukan selama masa kehamilan. Setiap tahunnya di AS diperkirakan sekitar 75.000 wanita hamil menjalani anestesi dan pembedahan. Penatalaksanaan anestesi optimal memerlukan pemahaman mengenai perubahan fisiologi maternal, pertimbangan terhadap fetus akibat pembedahan dan anestesi, dan upaya mempertahankan perfusi uteroplasenta dan oksigenasi maternal-fetus. Tujuan yang ingin dicapai adalah anestesi yang aman kepada ibu dan memelihara kesejahteraan janin. Kami melaporkan kasus wanita berusia 29 tahun dengan G4P1A2–1 25‒26 minggu janin tunggal hidup yang mengalami kelemahan motorik akut pada kedua tungkai bawah, gangguan sensibilitas semua kualitas setinggi Th6, serta inkontinensia urine dan alvi. Hasil pemeriksaan penunjang magnetic resonance imaging thorakolumbal menunjukkan suatu massa di daerah epidural setinggi C7–Th1 sisi kanan dan hambatan aliran likuor serebrospinal. Pasien dilakukan anestesi umum dengan intubasi endotrakeal. Induksi menggunakan propofol dan fentanyl, diikuti dengan penekanan krikoid. Fasilitas intubasi menggunakan vecuronium. Pemeliharaan menggunakan isofluran, oksigen, compressed air, bolus fentanyl dan vecuronium intravena intermitten. Posisi operasi adalah posisi prone. Intraoperatif ditemukan tumor ekstradura setinggi level C7–Th1, dilakukan laminektomi total dan stabilisasi dengan pemasangan pedicle screw. Pascabedah pasien menunjukkan perbaikan status neurologis dan kehamilan dapat dipertahankan sampai aterm. Anesthesia Management for Spinal Cord Tumor in PregnancyAnesthesia management for non-obstetric surgery in pregnancy was considered a specific challenge for anesthesiologist. About 0,75–2% of non-obstetric surgery is performed during pregnancy. Annually in the US, about 75.000 pregnant women are exposed to anesthesia and surgery. Optimal anesthetic management requires comprehensive understanding on maternal physiologic changes, fetal consideration due to effect of surgery and anesthesia, and maintaining uteroplacental perfusion and maternal-fetal oxygenation. The endpoint is to provide safe anesthesia for both the mother and fetal well being. We reported a case of a 29-year old pregnant woman G4P1021 single fetus with 25–26 weeks of gestation, acute weakness of lower limbs, and sensibility impairment on all qualities at Th 6 level, as well as urine and alvi incontinence. Thoraco lumbal MRI examination showed epidural mass at C 7–Th 1 level of the right side vertebrae, and cerebrospinal fluid flow obstruction. The patient underwent general anesthesia with endotracheal intubation. Induction with propofol and fentanyl, followed by cricoid pressure. Intubation was facilitated with vecuronium. Maintenance with isoflurane, oxygen, compressed air, intermittent IV bolus of fentanyl and vecuronium. Surgery was performed on prone position. Extradural tumor at C7–Th1 vertebrae level was found intraoperatively and total laminectomy and stabilization with pedicle-screw were performed. Patient showed improvement in neurological status after the surgery, and the pregnancy was survived until aterm period.