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All Journal Jurnal Anestesiologi Indonesia Jurnal Anestesi Perioperatif Majalah Kesehatan FKUB Jurnal Respirologi Indonesia Journal of Anaesthesia and Pain Open Access Indonesian Journal of Medical Reviews Journal of Anesthesiology and Clinical Research Majalah Anestesia & Critical Care (MACC)
Arie Zainul Fatoni
Universitas Brawijaya- RSUD Dr. Saiful Anwar, Malang
Biochemistry, Genetics & Molecular Biology Education Health Professions Immunology & microbiology Medicine & Pharmacology Neuroscience Public Health

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Successful Management of Myasthenia Gravis Crisis with Septic Shock and Arrhythmia using Plasmapheresis: A Case Report Viandini, Riska Yulinta; Arie Zainul Fatoni
Journal of Anesthesiology and Clinical Research Vol. 5 No. 3 (2024): Journal of Anesthesiology and Clinical Research
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/jacr.v5i3.638

Abstract

Introduction: Myasthenia gravis (MG) is an autoimmune disorder that causes muscle weakness. In severe cases, it can lead to myasthenic crisis, a life-threatening condition characterized by respiratory failure. Sepsis, a systemic inflammatory response to infection, can further complicate MG and increase the risk of mortality. This case report describes the successful management of a patient with MG crisis complicated by septic shock and arrhythmia using plasmapheresis. Case presentation: A 52-year-old male with a history of MG presented with progressive dyspnea, decreased consciousness, and oxygen desaturation. He was diagnosed with MG crisis, septic shock, and arrhythmia. The patient was treated with plasmapheresis, antibiotics, and supportive care. Following plasmapheresis, the patient showed significant improvement in muscle strength, respiratory function, and hemodynamic stability. The arrhythmia resolved, and the patient was eventually weaned off mechanical ventilation. Conclusion: This case report highlights the potential benefits of plasmapheresis in managing MG crisis complicated by septic shock and arrhythmia. Plasmapheresis may be considered as a therapeutic option in such cases to improve patient outcomes.
Successful Application of Non-Invasive Ventilation in Acute Respiratory Failure Complicating Thyroid Storm-Induced Pulmonary Edema: A Case Report Muhammad Priangga Akbar; Arie Zainul Fatoni
Journal of Anesthesiology and Clinical Research Vol. 6 No. 1 (2025): Journal of Anesthesiology and Clinical Research
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/jacr.v6i1.752

Abstract

Introduction: Thyroid storm is a rare, life-threatening exacerbation of thyrotoxicosis characterized by severe multisystem organ dysfunction, including cardiovascular collapse and respiratory failure. Acute pulmonary edema is a recognized but challenging complication, often stemming from high-output cardiac failure or tachyarrhythmia-induced cardiomyopathy. Non-invasive ventilation (NIV) offers a crucial therapeutic modality for acute respiratory failure by improving oxygenation, reducing the work of breathing, and providing beneficial hemodynamic effects, potentially obviating the need for endotracheal intubation. Case presentation: We present the case of a 23-year-old female who developed acute hypoxemic respiratory failure secondary to acute pulmonary edema precipitated by a thyroid storm, occurring post-operatively after a ureterorenoscopy. She presented with severe dyspnea, tachycardia (atrial fibrillation with rapid ventricular response), tachypnea, and significant hypoxemia (PaO₂/FiO₂ ratio of 106.4). Diagnosis of thyroid storm was confirmed by elevated free thyroxine (FT4), suppressed thyroid-stimulating hormone (TSH), and a Burch-Wartofsky Point Scale (BWPS) score of 80. The patient was managed with NIV, alongside standard medical therapy for thyroid storm, including antithyroid drugs, beta-blockers, iodine solution, and corticosteroids. Conclusion: NIV was successfully utilized as primary respiratory support, leading to rapid clinical and radiological improvement, resolution of respiratory failure, and avoidance of invasive mechanical ventilation. The PaO₂/FiO₂ ratio improved to 260 within four days. This case highlights the efficacy and safety of early NIV initiation in patients with acute respiratory failure due to pulmonary edema in the complex setting of thyroid storm.
Early Risk Stratification in a High-Mortality Study of Adult Trauma Patients: A Comparative Validation of RTS, SI, and ISS Denny Prasetyo; Arie Zainul Fatoni; Ristiawan Muji Laksono; Buyung Hartiyo Laksono
Journal of Anesthesiology and Clinical Research Vol. 6 No. 2 (2025): Journal of Anesthesiology and Clinical Research
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/jacr.v6i2.788

Abstract

Introduction: Accurate, early risk stratification is paramount in managing severe trauma, especially in resource-limited settings. This study aimed to compare the predictive performance of the revised trauma score (RTS), shock index (SI), and injury severity score (ISS) for in-hospital mortality in a group of severely injured adult trauma patients at a tertiary center in Indonesia. Methods: A retrospective analysis was conducted on a purposively selected study population of 100 adult trauma patients (age 20-60) admitted to the Emergency Department of Dr. Saiful Anwar Regional General Hospital over a three-month period in 2023. This selection method yielded a high-mortality sample (50% mortality) to ensure sufficient statistical power for analyzing fatal outcomes. The predictive performance of RTS, SI, and ISS was evaluated using individual logistic regression models. Discriminatory ability was assessed by calculating the area under the receiver operating characteristic curve (AUC-ROC) for each score. Model calibration was evaluated using the Hosmer-Lemeshow goodness-of-fit test. Results: All three scoring systems were significant predictors of mortality in individual regression analyses. The injury severity score (ISS) demonstrated the highest discriminatory power for predicting mortality with an AUC of 0.88 (95% CI, 0.81-0.95). The revised trauma score (RTS) also showed good discrimination with an AUC of 0.83 (95% CI, 0.75-0.91). The Shock Index (SI) was a significant predictor but had the most modest discriminatory ability with an AUC of 0.76 (95% CI, 0.67-0.85). All models were well-calibrated. Conclusion: In this study of severely injured adult trauma patients, the anatomically-based ISS was the most accurate predictor of mortality. The physiological scores, RTS and SI, remain valuable for their utility in rapid, initial patient assessment. The findings support a complementary approach, using the simple physiological scores for immediate triage and the more comprehensive ISS for definitive prognostication.
Early versus Late Percutaneous Tracheostomy in Critically Ill Stroke Patients: A Competing Risk Analysis of Ventilator Liberation and Complications Wiyogo; Aswoco Andyk Asmoro; Arie Zainul Fatoni; Buyung Hartiyo Laksono
Journal of Anesthesiology and Clinical Research Vol. 6 No. 2 (2025): Journal of Anesthesiology and Clinical Research
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/jacr.v6i2.791

Abstract

Introduction: The optimal timing of percutaneous dilatational tracheostomy (PDT) in critically ill stroke patients remains controversial. The procedure may facilitate ventilator weaning and neurological assessment, but carries inherent risks. This study aimed to determine the impact of early versus late PDT on clinical outcomes in this specific and vulnerable population. Methods: This retrospective cohort study was conducted at a single tertiary care center. We included all mechanically ventilated adult stroke patients who underwent PDT between January 2024 and December 2024. Patients were categorized into an Early PDT group (≤7 days of intubation) and a Late PDT group (>7 days). The primary outcome was time to ventilator liberation, with in-hospital death as a competing risk. This was analyzed using a Fine-Gray subdistribution hazard model. Secondary outcomes included ICU and hospital mortality, length of stay (LOS), and ventilator-associated pneumonia (VAP), analyzed with multivariable regression. Results: Seventy patients were included (34 Early PDT, 36 Late PDT). After adjusting for age, admission GCS, NIHSS, and stroke type, early PDT remained significantly associated with a higher probability of ventilator liberation (adjusted subdistribution Hazard Ratio [sHR]: 2.48; 95% CI: 1.41–4.36; p=0.002). Early PDT was also independently associated with lower odds of developing VAP (adjusted Odds Ratio [aOR]: 0.31; 95% CI: 0.10–0.94; p=0.038). There were no significant differences in ICU mortality (aOR: 0.82; 95% CI: 0.28–2.41; p=0.721) or hospital mortality (aOR: 0.70; 95% CI: 0.25–1.96; p=0.495). Conclusion: In critically ill stroke patients, an early tracheostomy strategy is independently associated with a significantly shorter time to ventilator liberation and lower odds of VAP, after accounting for competing risks and baseline confounders. While not associated with a survival benefit, early PDT should be considered a key strategy to optimize respiratory management and reduce pulmonary complications in this population.
Inappropriate Empirical Antibiotic Therapy and Mortality in Critical Illness: A Retrospective Cohort Study with Propensity Score Analysis in an Indonesian ICU Riska Yulinta Viandini; Wiwi Jaya; Arie Zainul Fatoni
Journal of Anesthesiology and Clinical Research Vol. 6 No. 2 (2025): Journal of Anesthesiology and Clinical Research
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/jacr.v6i2.807

Abstract

Introduction: Inappropriate empirical antibiotic therapy (IEAT) is a critical driver of mortality in sepsis, particularly in regions with high antimicrobial resistance (AMR) like Southeast Asia. This study aimed to quantify the association between IEAT and 28-day mortality in a critically ill Indonesian patient cohort, employing advanced statistical methods to control for confounding. Methods: We conducted a retrospective cohort study of 280 adult patients who received empirical antibiotics and had positive cultures upon admission to a tertiary ICU in Indonesia (January 2022–December 2023). The primary exposure was the appropriateness of the initial antibiotic regimen (IEAT vs. AEAT) based on in-vitro susceptibility. We used multivariate logistic regression and a 1:1 propensity score-matched (PSM) analysis to adjust for baseline differences in patient severity, including APACHE II score and the presence of septic shock. Results: In the full cohort, 108 patients (38.6%) received IEAT. The 28-day mortality was profoundly higher in the IEAT group than the AEAT group (77.8% vs. 8.1%; p < 0.001). After multivariate adjustment, IEAT remained a powerful predictor of mortality (Adjusted Odds Ratio [aOR]: 38.72; 95% CI: 18.91–79.30; p < 0.001). In the PSM cohort of 200 patients with balanced baseline characteristics, the association remained strong and significant (OR: 25.15, 95% CI: 11.54–54.81; p < 0.001). Local prescribing patterns revealed that levofloxacin monotherapy, the most common regimen, had an inappropriateness rate of 76.4%. Conclusion: Inappropriate empirical antibiotic therapy is strongly associated with a substantially increased risk of death in critically ill Indonesian patients. This association persists after rigorous adjustment for confounding. These findings highlight the urgent need for robust antimicrobial stewardship programs, guided by dynamic local surveillance, to combat the lethal impact of AMR.
Comparative Efficacy of Low-Dose Ketamine versus Midazolam Co-induction on Hemodynamic Stability and Early Neurocognitive Recovery in Geriatric Anesthesia: A Randomized Double-Blind Pilot Trial Aditya Guna Wicaksono Panatagama; Aswoco Andyk Asmoro; Arie Zainul Fatoni; Rudy Vitraludyono
Journal of Anesthesiology and Clinical Research Vol. 7 No. 1 (2026): Journal of Anesthesiology and Clinical Research
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/jacr.v7i1.849

Abstract

Introduction: Geriatric patients undergoing general anesthesia are susceptible to hemodynamic instability and delayed neurocognitive recovery. The choice of co-induction agent significantly influences these outcomes. This study compares the effects of low-dose Ketamine versus Midazolam co-induction on intraoperative hemodynamic stability and immediate post-operative cognitive trajectory. Methods: A prospective, double-blind, randomized controlled pilot trial was conducted on 32 geriatric patients aged 65 years or older classified as American Society of Anesthesiologists (ASA) physical status II or III undergoing elective surgery. Patients were randomized to receive either intravenous Ketamine (0.3 mg/kg, n=16) or Midazolam (0.075 mg/kg, n=16) prior to Propofol induction. The primary outcome was the magnitude of early cognitive change measured by the Mini-Mental State Examination (MMSE) at 1-hour post-operation relative to baseline. Secondary outcomes included intraoperative mean arterial pressure (MAP), incidence of hypotension, total Propofol consumption, and time to extubation. Data were analyzed using Analysis of Covariance (ANCOVA) and independent t-tests; effect sizes were calculated using Cohen’s d. Results: Baseline characteristics were comparable between groups. The Ketamine group exhibited significantly superior early cognitive preservation with a mean decline of -0.50 ± 0.63 compared to the Midazolam group, which showed a decline of -1.25 ± 0.93 (p = 0.012; Cohen’s d = 0.93). Hemodynamically, the Ketamine group maintained significantly higher Mean Arterial Pressure post-induction (p = 0.003) with a lower risk of hypotension (Relative Risk 0.29, 95% Confidence Interval 0.07–1.18). Additionally, the Ketamine group required significantly less induction of Propofol (p < 0.001) and achieved faster extubation times (p < 0.001). Conclusion: Co-induction with sub-anesthetic Ketamine provides superior hemodynamic stability and facilitates faster early neurocognitive recovery compared to Midazolam in geriatric patients. These findings suggest Ketamine is a preferable adjuvant for optimizing emergence profiles and maintaining perfusion pressure in the aging population.
Hemodynamic Attenuation During Tracheal Intubation: A Randomized Comparative Analysis of Video vs. Direct Laryngoscopy in Adult Elective Surgery Imam Safi'i; Arie Zainul Fatoni; Taufiq Agus Siswagama; Ahmad Feza Fadhlurrahman
Journal of Anesthesiology and Clinical Research Vol. 7 No. 1 (2026): Journal of Anesthesiology and Clinical Research
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/jacr.v7i1.850

Abstract

Introduction: Laryngoscopy and tracheal intubation inevitably trigger a sympathoadrenal response, manifesting as tachycardia and hypertension. While video laryngoscopy (VL) offers improved glottic visualization compared to direct laryngoscopy (DL), its efficacy in specifically attenuating this hemodynamic stress remains a subject of debate. This study investigates whether VL provides superior hemodynamic stability during the critical post-intubation period by analyzing the rate pressure product (RPP) and temporal hemodynamic interactions. Methods: In this prospective, single-blind, randomized controlled trial, 40 adult patients (ASA I-II) undergoing elective surgery were allocated to either Group VL (GlideScope, n=20) or Group DL (Macintosh, n=20). Anesthesia was strictly standardized with Fentanyl 2 mcg/kg, Propofol 2 mg/kg, and Atracurium 0.5 mg/kg. Hemodynamic parameters, including systolic blood pressure (SBP), mean arterial pressure (MAP), and heart rate (HR), were recorded at baseline (T0) and at 1 (T1), 2 (T2), and 5 (T5) minutes post-intubation. The primary analysis utilized a general linear model (Repeated Measures ANOVA) to assess Time-Group interactions, corrected for sphericity. Results: Demographics were homogeneous between groups. A significant Time-Group interaction was observed for MAP (p less than 0.001), indicating a blunted pressor response curve in the VL group. Heart Rate at 1-minute post-intubation was significantly lower in Group VL (75.45 plus or minus 11.23 bpm) compared to Group DL (90.15 plus or minus 15.22 bpm; p equals 0.001). Analysis of the rate pressure product revealed that Group DL approached ischemic thresholds, whereas Group VL maintained significantly lower myocardial workload at minutes 1 and 2 (p less than 0.01). Conclusion: Video laryngoscopy significantly attenuates the reflex tachycardia and arterial pressure surge associated with tracheal intubation compared to direct laryngoscopy. VL is recommended to minimize cardiovascular stress in susceptible surgical populations.
Evaluation of Morphine-Sparing Efficacy with Low-Dose Ketamine in Pediatric Postoperative Pain: A Pilot Randomized Controlled Trial Naim Ismail Imunu; Isngadi; Rudy Vitraludyono; Arie Zainul Fatoni
Open Access Indonesian Journal of Medical Reviews Vol. 6 No. 1 (2026): Open Access Indonesian Journal of Medical Reviews
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/oaijmr.v6i1.835

Abstract

Postoperative pain management in the pediatric population requires a delicate balance between effective analgesia and the minimization of opioid-related adverse events, particularly respiratory depression. While multimodal analgesia is the standard of care, the optimal dose-reduction potential of opioids when combined with N-methyl-D-aspartate (NMDA) antagonists remains undefined. We conducted a prospective, single-center, pilot randomized controlled trial using a double-blind observer protocol. Twenty pediatric patients aged 2 months to 7 years undergoing elective surgery were randomized into four groups. The control group (Group M) received standard continuous morphine at 0.33 µg/kg/min. Three intervention groups received fixed low-dose ketamine at 0.33 µg/kg/min combined with tapered morphine doses: Group KM-1 at 0.23 µg/kg/min, Group KM-2 at 0.16 µg/kg/min, and Group KM-3 at 0.06 µg/kg/min. The primary outcome was analgesic efficacy assessed by FLACC scores at 24 hours. Secondary outcomes included hemodynamic stability and rescue analgesia requirements. Baseline characteristics were comparable across groups. At 24 hours, the median FLACC scores were comparable between the high-dose control (Median 2.0; Interquartile Range 1.5–2.0) and the lowest morphine group (Group KM-3: Median 2.0; Interquartile Range 1.5–2.0; p = 0.438). Group KM-3 achieved an 81% reduction in morphine consumption with a 0% rescue analgesia rate, identical to the control group. In conclusion, preliminary data from this pilot study suggest that low-dose ketamine may permit a substantial reduction in morphine dosage of up to 81% without compromising analgesic efficacy. These findings warrant confirmation in larger, fully powered multicenter trials.
Co-Authors Aditya Guna Wicaksono Panatagama Ahmad Feza Fadhlurrahman Ahmad Feza Fadhlurrahman Alwi Shahab Anugrah Onie Ardianto Ardianto Ariady, Randika Rea Aswoco Andyk Asmoro Aswoco Andyk Asmoro Aulia Martyana Achsar Buyung Hartiyo Laksono Christian Ambrosius Soeiono Della Fitricana denny prasetyo Devi Ariani Dewi Arum Sawitri Dewi Arum Sawitri Harri Kurnia Chandra Imam Safi'i Isngadi Isngadi Isngadi Karmini Yupono Kinanti Narulita Dewi Laksono, Buyung Hartiyo Maya sari Muhammad Priangga Akbar Naim Ismail Imunu Nasywa Florean Dzakiyyah Ramacandra Rakhmatullah Ratna Maila Dewi Razi Ageng Pratama Resa Putra Adipurna Riska Yulinta Viandini Ristiawan Muji Laksono Ristiawan Muji Laksono Ruddi Hartono Rudy Vitraludyono Rudy Vitraludyono Slamet Hadi Santoso Taufiq Agus Siswagama Taufiq Agus Siswagama Trianna Mailawati Ulil Abshor Viandini, Riska Yulinta Vilda Prasastri Yuwono Wiwi Jaya Wiwi Jaya Wiyogo Yana Agung Satriasa Yoan Levia Magdi Yuliato Kusnadi