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All Journal Jurnal Locus Penelitian dan Pengabdian Eduvest - Journal of Universal Studies
Anas Alatas
Universitas Indonesia
Aerospace Engineering Automotive Engineering Computer Science & IT Decision Sciences, Operations Research & Management Electrical & Electronics Engineering Health Professions Mathematics Neuroscience Social Sciences

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Total Intravenous Anesthesia for Coronary Artery Bypass Grafting: A Case Report of Successful Hemodynamic Management and Early Recovery Sriwahyuniati Purwaningsih; Anas Alatas; Yudi Hadinata
Eduvest - Journal of Universal Studies Vol. 6 No. 7 (2026): Eduvest - Journal of Universal Studies
Publisher : Green Publisher Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59188/eduvest.v6i7.53332

Abstract

Coronary artery bypass grafting (CABG) is a complex cardiac surgical procedure that requires precise anesthetic management to maintain hemodynamic stability and support optimal postoperative recovery. Total intravenous anesthesia (TIVA) has emerged as an alternative anesthetic technique in cardiac surgery due to its advantages in anesthetic titration, hemodynamic control, and facilitation of fast-track recovery protocols. This case report aimed to describe the application of TIVA in a high-risk CABG patient and evaluate its effectiveness in achieving intraoperative stability and early postoperative recovery. A case report was conducted involving a 66-year-old male patient with three-vessel coronary artery disease who underwent CABG at the National Cardiovascular Center Harapan Kita, Jakarta. Clinical data were collected from preoperative assessments, intraoperative anesthesia records, hemodynamic monitoring parameters, and postoperative intensive care management in accordance with the CARE guidelines. The patient received TIVA using propofol, sufentanil, and rocuronium, supported by multimodal monitoring, including the Bispectral Index (BIS), Near-Infrared Spectroscopy (NIRS), arterial line monitoring, and central venous catheter monitoring. The results demonstrated stable intraoperative hemodynamic conditions with appropriate vasoactive support using dobutamine and nitroglycerin. The patient successfully underwent early extubation eight hours after surgery, with acceptable postoperative laboratory parameters and no significant anesthetic complications. In conclusion, TIVA combined with comprehensive hemodynamic monitoring and fast-track protocols provided effective anesthetic management for CABG, supporting cardiovascular stability and early recovery. Further studies involving larger patient populations are required to confirm its broader clinical benefits.
Establishing a TAVR Program in a Non-ECMO Center: Anesthetic Considerations and Safety Workflow Defitra Nanda Sasmita; Anas Alatas
Jurnal Locus Penelitian dan Pengabdian Vol. 5 No. 7 (2026): JURNAL LOCUS: Penelitian dan Pengabdian
Publisher : Riviera Publishing

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.58344/locus.v5i7.6130

Abstract

Optimal anesthetic management during the initiation of a transcatheter aortic valve replacement (TAVR) program in centers without extracorporeal membrane oxygenation (ECMO) capability remains underexplored. This case report describes anesthetic considerations and contingency planning for establishing a new TAVR program in a cardiac catheterization laboratory. A 66-year-old male patient with severe aortic stenosis (valve area: 0.74 cm²; mean gradient: 43.89 mmHg; ejection fraction: 47%), coronary artery disease, congestive heart failure (NYHA class II), and chronic kidney disease stage III underwent transfemoral TAVR under general anesthesia as the inaugural procedure of the program. The procedure was performed in a cardiac catheterization laboratory without on-site ECMO support, with cardiac surgery standby and cardiopulmonary bypass equipment prepared in an adjacent operating room. Hemodynamic management during rapid ventricular pacing (180 beats/min for 10 seconds during balloon valvuloplasty and 120 beats/min during valve deployment) included preemptive phenylephrine boluses (total dose: 2 mg) and cautious crystalloid administration (500 mL). A 27 mm VitaFlow valve was successfully deployed. Post-deployment transesophageal echocardiography demonstrated mild paravalvular leak without intravalvular regurgitation or valve dislodgement. The patient was discharged on postoperative day 3 without complications. General anesthesia supported by structured hemodynamic management protocols and clearly defined cardiac surgery contingency planning enabled safe TAVR implementation during program initiation in a non-ECMO center. This case provides a practical framework for institutions establishing similar programs without immediate ECMO capability.
How Much Protamine is Enough? Current Evidence and Controversies: A Narrative Review Brillyan T. Jehosua; Anas Alatas
Jurnal Locus Penelitian dan Pengabdian Vol. 5 No. 9 (2026): JURNAL LOCUS: Penelitian dan Pengabdian
Publisher : Riviera Publishing

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.58344/locus.v5i9.6120

Abstract

Protamine sulfate remains the standard agent for reversing unfractionated heparin following cardiopulmonary bypass (CPB). Conventional reversal is typically based on a fixed protamine-to-heparin ratio of 1 mg per 100 IU of heparin. However, increasing evidence indicates that this empirical approach may not accurately reflect residual circulating heparin levels at the end of CPB and may result in either inadequate reversal or protamine overdose. Excess protamine administration has been associated with platelet dysfunction, impaired thrombin generation, coagulopathy, and increased postoperative bleeding. This narrative review summarizes current evidence on individualized protamine dosing and discusses major controversies and future directions in precision anticoagulation reversal. A literature search was conducted in PubMed/MEDLINE, Embase, and the Cochrane Library for English-language studies published between 2021 and 2026, with earlier landmark studies included when relevant. Priority was given to randomized controlled trials, pharmacokinetic–pharmacodynamic studies, systematic reviews, and meta-analyses.Current evidence consistently demonstrates that individualized protamine dosing reduces total protamine exposure compared with conventional fixed-ratio protocols while maintaining effective heparin neutralization. Heparin concentration-guided strategies and low-dose protamine protocols have achieved comparable reversal outcomes without increasing postoperative bleeding or transfusion requirements. Pharmacokinetic–pharmacodynamic modeling suggests that a protamine-to-heparin ratio of approximately 0.625:1 may be adequate for most patients, substantially lower than traditional recommendations. Meta-analytic evidence further indicates improved coagulation-related outcomes and fewer bleeding complications with concentration-guided management, although definitive benefits regarding mortality, re-exploration for bleeding, and thrombotic events remain uncertain. Individualized protamine dosing represents a promising approach to optimizing anticoagulation reversal after CPB. Nevertheless, further large, multicenter randomized trials evaluating patient-centered outcomes are required before individualized dosing strategies can be recommended as the universal standard of care.
Co-Authors Brillyan T. Jehosua Defitra Nanda Sasmita Sriwahyuniati Purwaningsih Yudi Hadinata