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Penanganan Ventilasi Pascaoperasi pada Penderita Tumor Intradural Ekstradural Medula Spinalis Servikal 1-3: Sebuah Laporan Kasus Syahril, Chandra Patrya Putra; Tri C, Rizky Rahmad; Anindita, Eliezer Iswara; Harahap, M Sofyan
Jurnal Neuroanestesi Indonesia Vol 12, No 3 (2023)
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Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.24244/jni.v12i3.572

Pendahuluan: Reseksi bedah tumor sumsum tulang belakang dapat menimbulkan tantangan yang signifikan dalam manajemen jalan napas. Sebagian besar pasien yang menjalani reseksi tumor sumsum tulang belakang dikelola melalui intubasi endotrakeal, nafas kendali selama operasi, dan bantuan ventilasi pascabedah. Kasus: Perempuan 43 tahun datang dengan mengeluh nyeri leher belakang dirasakan menjalar sampai dengan kedua telapak kanan terutama sisi kiri, kemudian pasien mengeluh kelemahan semua anggota gerak yang dirasakan sepanjang hari dan membuatnya kesulitan untuk beraktivitas sehari-hari. Rasa kesemutan dirasakan dari kedua ujung jari kaki hingga ke leher depan. Pasien menjalani operasi kraniotomi far lateral approach sisi kiri dan eksisi tumor, operasi berlangsung selama 7 jam 30 menit dengan hemodinamik yang stabil selama anestesi dan pembedahan. Pascaoperasi dilakukan bantuan pernapasan dengan ventilator di ICU dan dilakukan pengecekan laboratorium darah rutin, blood gas arterial (BGA) dan elektrolit. Setelah hari ke dua pipa endotrkeal dapat dilepas dan pasien kembali ke ruangan biasa. Pasien pulang pada hari kelima dan kontrol rawat jalan. Diskusi: Manajemen anestesi pada kasus tumor medula spinalis servikal, membutuhkan perhatian khusus, terutama bantuan ventilasi pasca operasi. Dengan pemantauan yang baik dan penyesuaian ventilasi sesuai kebutuhan, pasien dapat segera disapih dari ventilator. Kesimpulan: Penatalaksanaan anestesi pada pasien yang menjalani operasi tumor sumsum tulang belakang bersifat kompleks. Diperlukan pemahaman lengkap tentang jenis tumor, lokasi, dan efek massa dalam manajemen ventilasi pada pasien paska operasi tumor medulla spinalis.Postoperative Ventilation Management in Patients with Cervical Spinal Cord Intradural and Extradural Tumors 1-3 : a Case ReportAbstractIntroduction : Surgical resection of spinal cord tumors can pose significant challenges in airway management. Most patients undergoing spinal cord tumor resection are managed via endotracheal intubation, controlled ventilation during surgery and post operative ventilation support. Case: A 43 year old woman came in complaining of back neck pain that spread to both right palms, especially the left side, then the patient complained of weakness in all limbs felt throughout the day and making it difficult for her to carry out daily activities. A tingling sensation is felt from the tips of the toes to the front of the neck. The patient underwent a left-sided far lateral approach craniotomy and tumor excision, the operation lasted 7 hours 30 minutes with stable hemodynamics during anesthesia and surgery. Post-operatively, ventilation was supported with a ventilator in the ICU and laboratory checks were carried out including routine blood, arterial blood gas (BGA) and electrolytes. After the second day the endotrcheal tube can be removed and the patient returns to the normal room. The patient went home on the fifth day and was outpatient control. Discussion: Anesthetic management in cases of cervical spinal cord tumors requires special attention, especially postoperative ventilation assistance. With good monitoring and ventilation adjustments as needed, patients can be quickly weaned from the ventilator. Conclusion: Anesthetic management in patients undergoing surgery for spinal cord tumors is complex. A complete understanding of tumor type, location, and mass effect is needed in ventilation management in post-operative spinal cord tumor patients.

Dexmedetomidine Administration does not Affect Electrocorticography Reading during Epilepsy Focal Removal Surgery Nauli, Anggarian Oloan; Harahap, M Sofyan
Jurnal Neuroanestesi Indonesia Vol 13, No 2 (2024)
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Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.24244/jni.v13i2.591

Epilepsy prevalent across all ages and genders, making it one of the most widespread neurologic disorder. Worldwide, 20-40% of epilepsy patients are refractory or resistant to oral anti-epileptic drugs, requiring surgery to treat their seizures. The use of electrocorticography (ECoG) can help determine the focus of epilepsy and requires anaesthetic drugs that do not affect the electroencephalography (EEG) readings during surgery. The aim of this case was to study the effect of using dexmedetomidine (DEX) as additional to maintenance anesthesia in epileptic craniotomy surgery with ECoG. A 28-year-old man came to the hospital with complaints of recurrent seizures, generalized tonic-clonic type seizures that lasted 2-3 minutes, was unconscious during the seizure, fell asleep afterwards, and recurred 2-3 times a day. The patient had suffered from epilepsy since 4 years ago. Physical and supporting examinations were within normal limits. Head MSCT examination with contrast suspected oligodendroglioma. The patient was administered dexmetomidine while underwent epilepsy craniotomy surgery with ECoG to remove the tumor which was suspected to be the epileptic focus. The choice of anesthetic agent in epilepsy craniotomy, especially when involving ECoG modalities, requires special consideration to improve intraoperative quality and postoperative outcomes. Propofol is the most widely used induction agent. However, these agents have anticonvulsant effects and activate non-specific spike waves in large areas of the brain. This has the potential to interfere with spike wave monitoring with ECoG. The use of dexmedetomidine has been shown to produce a stable hemodynamic effect and does not affect the ECoG readings. The use of DEX as an adjuvant in anesthesia maintenance does not inhibit spike waves during surgery, so ECoG can be used effectively for anesthesia in craniotomy operations with ECoG

Manajemen Anestesi pada Pasien dengan Tumor Regio Pineal yang Menjalani Kraniotomi Pengangkatan Tumor dengan Posisi Duduk Widiastuti, Monika; Bisri, Dewi Yulianti; Harahap, M Sofyan; Gaus, Syafruddin
Jurnal Neuroanestesi Indonesia Vol 10, No 3 (2021)
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Tumor regio pineal memiliki insiden 0.4-1% dari tumor intracranial. Lokasinya yang dalam, di antara kedua hemisfer otak, berdekatan dengan batang otak dan hipotalamus menjadi tantangan bagi bedah saraf. Operasi dengan supracerebellar approach dalam posisi duduk adalah pilihan terbaik untuk mencapai lokasi. Posisi duduk juga memfasilitasi lapang operasi yang optimal dengan retraksi cerebellum minimal. Posisi duduk membawa tantangan tersendiri untuk dokter anestesi, dengan segala kompleksitas saat memposisikan pasien dan risiko komplikasinya. Venous air embolism adalah pertimbangan utama yang jika tidak terdeteksi dan ditangani dapat menyebabkan kolaps kardiovaskular dalam waktu singkat. Pasien laki-laki berusia 38 tahun datang dengan keluhan nyeri kepala berat dan penglihatan kabur sejak 4 bulan sebelum masuk rumah sakit. Hasil Magnetic Resonance Imaging menunjukkan adanya massa di regio pineal dengan edema perifokal, tanpa deviasi struktur midline. Pasien dilakukan kraniotomi pengangkatan tumor dalam posisi duduk. Operasi berjalan selama 10 jam dengan hemodinamika stabil dan tidak terjadi komplikasi, dalam anestesi umum dengan kombinasi intravena dan inhalasi. Prinsip ABCDE neuroanestesi, posisi duduk dan implikasinya, dan lokasi operasi yang sulit adalah pertimbangan-pertimbangan anestesi yang harus diperhatikan pada pasien ini. Evaluasi preoperasi yang baik, komunikasi dan koordinasi yang baik antara tim bedah dan anestesi sangat diperlukan untuk kelancaran dalam kraniotomi dalam posisi duduk.Anesthetic Management of Patient with Pineal Region Tumor Underwent Craniotomy Tumor Removal in Sitting PositionAbstractIncidence of pineal regio tumor is 0.4-1% of intracranial tumors. Its location which is buried between two cerebral hemispheres, close to brainstem and hypothalamus become a difficult challenge for the neurosurgeon. Surgery with supracerebellar approach in sitting position is the best method to access the lesion. Sitting position also facilitates the optimal visual field with minimal retractions. However, for anesthesiologist, sitting position is challenging since it has its own complexities during positioning the patient and the risk of complications. Venous air embolism is one of the main concern and if not detected early and treated appropriately would leads to cardiovascular collapse instantly. This is a case of a 38-year-old male with chief complaint of severe headache and blurred vision started 4 months before admission. The Magnetic Resonance Imaging showed a pineal region tumor with perifocal edema, without midline deviation. The patient underwent craniotomy tumor removal with sitting position. The procedure lasted for 10 hours and uneventful. The principle of ABCDE neuroanesthesia, sitting position and its implications, and difficult tumor location are some anesthesia considerations for this patient. A thorough preoperative evaluation, good communication and coordination between surgery and anesthesia team are needed for a smooth uneventful procedure performed in sitting position.

Kombinasi Dexmedetomidine Sevoflurane 0,5 MAC pada Bedah Mikro Reseksi Malformasi Arteri-Vena Tjahyanto, Adhy; Samdani, Ibnu Siena; Harahap, M Sofyan
Jurnal Neuroanestesi Indonesia Vol 10, No 2 (2021)
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Malformasi arterivena (MAV) merupakan kasus yang jarang terjadi, terutama pada usia muda (40 tahun). Usaha untuk menjaga kestabilan hemodinamik dan pencegahan perdarahan masif selama reseksi bedah mikro MAV adalah hal yang harus dikuasai oleh seorang ahli anestesi. Total Intra Venous Anesthesia dengan propofol masih populer untuk mengendalikan tekanan intrakranial karena mudah dititrasi dan agen kerja cepat (baik onset maupun durasi). Penilaian status neurologis umum segera setelah anestesi dihentikan juga termasuk komponen penting dalam pembedahan mikro reseksi MAV otak. Pada kasus ini, dilaporkan seorang wanita berusia 20 tahun yang mengalami penurunan kesadaran dan hemiparesis sinistra mendadak. Hasil angiografi otak menunjukan adanya MAV di lobus frontal dekstra. Tindakan reseksi MAV dilakukan dengan pembedahan mikro. Setelah 5-menit-preoksigenasi dilakukan, induksi anestesi menggunakan propofol, fentanil, rocuronium, dan sevoflurane. Sepuluh detik proses intubasi tidaklah menimbulkan gejolak hemodinamik. Pembedahan berlangsung lancar dengan kombinasi dexmedetomidine-sevoflurane 0,5MAC. Hemodinamik pasien pasca-anestesi stabil dan tanpa lesi neurologis baru.A Combination of Dexmedetomidine Sevoflurane 0.5MAC in Microsurgical Resection of Arteriovenous Malformation: a Case ReportAbstractArterio-venous malformation (AVM) is a rare case, particularly among young patients (40 years old). Maintaining haemodynamic stability and anticipating massive haemorrhage during micro surgery resection of AVM are fundamental for an anaesthetist. Total Intra Venous Anesthesia using propofol is still popular to control intracranial pressure as it is easily titrated and fast acting agent (both in onset and duration). Moreover, general neuruologic evaluation soon after anesthesia terminated is an integral important component of microsurgery of brain MAV. In this case report: a 20-year-old woman suddenly lost her consciousness and left-sided motors strength. Brain angiographic revealed an AVM in right frontal lobe. Microsurgery of brain AVM resection was performed. After 5-minute-preoxygenation, anaesthetic induction was performed by using propofol, fentanyl, rocuronium, and sevoflurane. The surgery went successfully using a combination of dexmedetomidine-sevoflurane 0.5MAC. Post-anaesthesia hemodynamic of this patient was in stable and without new neurologic deficit afterward.

Manajemen Low Flow Anesthesia pada Pasien Kraniosinostosis dengan Hipertelorisme yang menjalani Four Box Wall Osteotomy, dan Eksisi Redundant Skin Fronto Nasal Cahyadi, Arief; Bisri, Dewi Yulianti; Harahap, M Sofyan; Gaus, Syaruddin
Jurnal Neuroanestesi Indonesia Vol 10, No 3 (2021)
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Kraniosinostosis merupakan kasus yang didagnosis di tahun pertama kehidupan dan dapat membutuhkan pembedahan pada usia muda. Kraniosinostosis merupakan salah satu bagian dari sindrom hipertelorisme dengan angka kejadian sebesar 20%. Anak laki laki 13 tahun dengan hipertelorisme yang sudah menjalani rangkaian operasi koreksi hipertelorisme sebelumnya. Pasien direncanakan operasi koreksi lanjutan berupa four box wall osteotomy yang merupakan koreksi bagian frontal berupa pelepasan kraniosinostosis di sutura koronal. Risiko perdarahan masif karena anak sudah besar serta operasi panjang menjadi penyulit. Tatalaksana jalan napas memerlukan modifikasi karena deformitas yang ada, penggunaan low flow anestesi untuk membantu menjaga suhu dan mengurangi penggunaan gas anestesi, manajemen cairan intraoperatif berupa kombinasi kebutuhan pemeliharaan dan penggantian perdarahan yang terjadi, serta tatalaksana nyeri pasca operasi pada anak menjadi pertimbangan lain. Penyulit covid-19 terjadi pada pasien sehingga membuat ekstubasi tertunda. Perdarahan masif memerlukan protokol transfusi masif untuk mendukung ketersediaan darah dalam waktu singkat. Produk darah PRC, FFP dan TC harus tersedia karena faktor koagulasi juga perlu diperhatikan. Manajemen anestesi pada hipertelorisme dengan tindakan four box wall osteotomy memerlukan kerja sama baik antara anestesi, bedah saraf, bedah plastik serta ICU anak untuk menurunkan risiko perioperatif termasuk kekhususan covid-19 di era pandemi.Low Flow Anesthesia Management Craniosynostosis Patient with Hypertelorism underwent Four Box Wall Osteotomy and Fronto Nasal Redundant Skin ExcisionAbstractCraniosynostosis is a case that diagnosed in the first year of life and can need surgical in young age. Craniosynostosis is a part of hypertelorism with incidence rate around 20%. Boy, 13 years old with hypertelorism had undergone multiple surgery for correction of hypertelorism before. Patient was planned to advance surgical correction of four box wall osteotomy which consist frontal part correction and part of it is release craniosynostosis in coronal suture. Risk of massive bleeding because patient already in teen age and length of surgery can be prolonged. Difficult airway management due to fascial deformity, use of low flow anesthesia to preserve temperature and reduce inhalation anesthesia usage, intraoperative fluid management in consideration maintenance and replacement blood loss and post operative pain management has become another consideration. Covid-19 as part of problems post operatively being known before extubation made the process is delayed. Massive bleeding needs massive transfusion protocol to speed up blood availability. Blood product such as PRC, FFP and TC should be available because coagulation factor is part of consideration. Anesthesia management in hypertelorism with four box wall osteotomy need good communication between anesthesiologist, neurosurgeon, plastic surgeon and pediatric intensivist to reduce perioperative risk including covid-19 in pandemic era.Key words: Low flow anesthesia management, craniosynostosis, hypertelorism, four box wall osteotomy

Peranan Hiperventilasi terhadap Penurunan Tekanan Intrakranial dalam Kasus Bedah Saraf Wibowo, Irwan; Harahap, M Sofyan
Jurnal Neuroanestesi Indonesia Vol 9, No 1 (2020)
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AbstrakHiperventilasi telah ditemukan sebagai salah satu cara untuk menurunkan aliran darah otak (cerebral blood flow) (CBF) sejak tahun 1920-an. Pada saat itu telah dilaporkan bahwa penggunaan hiperventilasi dapat mengurangi peningkatan tekanan intrakranial (intracranial pressure/ICP) dengan vasokonstriksi serebral sehingga mampu menurunkan volume darah di daerah serebral. Secara teoritis, manfaat hiperventilasi mungkin lebih khusus diharapkan pada pasien di mana peningkatan ICP terjadi terutama karena peningkatan volume darah otak akibat mekanisme vasodilatasi. Efek vasokonstriksi tersebut akan menghilang setelah pH pada ruang perivaskular kembali normal setelah 24 jam. Yang menjadi perhatian utama dalam metode ini adalah tindakan tersebut mampu menginduksi terjadinya iskemia serebral baik secara regional maupun global. Risiko kerusakan iskemik tersebut bergantung pada sejauh mana dan seberapa lama otak mengalami aliran darah yang rendah. Masih terdapat data yang kontroversial antara yang mendukung ataupun menentang penggunaan terapi hiperventilasi, namun menurut penelitian yang telah dilakukan, tindakan ini mampu menurunkan ICP jika dilakukan dalam jangka pendek. Pemantauan multimodalitas terhadap pasien tetap diperlukan untuk memantau keberhasilan dalam tindakan ini.Hyperventilation Management for Decrease Intracranial Pressure in Neurosurgery CasesAbstractHyperventilation has been found as a way to reduce cerebral blood flow (CBF) since 1920s. At that time it was reported that the use of hyperventilation can reduce the increase in intracranial pressure (ICP) by causing cerebral vasoconstriction and decreasing cerebral blood volume. Theoretically, the benefits of hyperventilation may be more specifically expected in patients which has increasing ICP because of an increasing in blood volume and vasodilation mechanism. The vasoconstriction effect disappears after the pH in the perivascular space returns to normal after 24 hours. The main concern in treating patients with increased ICP using hyperventilation is to induce cerebral ischemia both regionally and globally. As with a stroke, the risk of ischemic damage depends on the extent and how long the brain experiences low blood flow. Controversial data still exists between those that support or oppose the use of hyperventilation therapy, but if hypocapnia monitoring is done to control the increase in ICP in the short term, hyperventilation therapy remains beneficial. Multimodality monitoring is needed so that hyperventilation therapy can be used safely in certain patients who may need this therapy.

Penggunaan Calcium Channel Blocker pada Tatalaksana Anestesi Clipping Aneurisma Otak Rindiati, Fanda Ayyu; Sasongko, Himawan; Harahap, M Sofyan
Jurnal Neuroanestesi Indonesia Vol 8, No 3 (2019)
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Perdarahan subarachnoid dapat diartikan sebagai proses pecahnya pembuluh darah di ruang yang berada dibawah arakhnoid (subarachnoid). Prevalensi terjadinya perdarahan subaraknoid dapat mencapai hingga 33.000 orang per tahun di Amerika Serikat. Penyebab paling sering perdarahan subarachnoid adalah ruptur aneurisma salah satu arteri di dasar otak dan adanya malformasi arteriovena (MAV). Pada umumnya aneurisma terjadi pada sekitar 5% dari populasi orang dewasa, terutama pada wanita. Penanganan pada aneurisma pembuluh darah otak salah satunya dengan clipping aneurisma. Tindakan tersebut beresiko terjadi vasospasme serebral. Nimodipine adalah suatu calcium chanel blocker yang penting dalam pengelolaan operasi aneurisma karena mempunyai efek vasodilatasi pembuluh darah serebral dan termasuk dalam bagian dari manajemen vasospasme serebral. Pada laporan ini, dilaporkan dua kasus tindaan clipping aneurisma. Pasien pertama adalah wanita usia 69 tahun, berat badan 60 kg dengan diagnosa SAH hari ke 18 yang mengalami defisit neurologi berupa hemiparese dextra dan afasia motorik. Pasien kedua adalah wanita usia 57 tahun berat badan 60 kg dengan diagnosa SAH hari ke 20 dan mengalami defisit neurologi hemiparese kanan dan afasia sensorik. Pada kedua pasien dilakukan tindakan pembedahan kraniotomi clipping aneurisma. Kedua pasien memiliki hasil akhir yang baik. Akan tetapi, ada perbedaan lama perawatan antara pasien yang menjalani terapi awal nimodipine dan yang tidak menerima terapi tersebut.Administration of Calcium Channel Blocker in Anaesthesia Management of Cerebral Aneurysm ClippingAbstractSubarachnoid hemorrhage can be interpreted as the process of rupture of blood vessels in the space under the arachnoid (subarachnoid). The prevalence of subarachnoid hemorrhage can reach up to 33,000 people per year in the United States. The most common causes of subarachnoid bleeding are ruptured aneurysm in one of the arteries at the base of the brain and the presence of arteriovenous malformations (MAV). In general, aneurysms occur in about 5% of the adult population, especially in women.Therapy in cerebral vascular aneurysms, one of which is clipping aneurysms. These actions are at risk of cerebral vasospasm. Nimodipine is a calcium channel blocker which is important in the management of aneurysm surgery because it has a vasodilating effect on cerebral vessels and is included in the management of cerebral vasospasm. In this report, two cases of clipping aneurysm are reported. The first patient was a woman aged 69 years, body weight 60 kg with a diagnosis of SAH day 18 who had a neurological deficit in the form of hemiparese dextra and motor aphasia. The second patient was a 57-year-old woman weighing 60 kg with a diagnosis of SAH day 20 and had a neurological deficit in the form of right hemiparese and sensory aphasia. In both patients, clipping aneurysm was performed by craniotomy surgery. Both patients had good results. However, there is a difference in the length of stay between patients who underwent initial nimodipine therapy and who did not receive it.

Tatakelola Ventilasi Mekanik pada Pengangkatan Tumor Metastasis Ekstradura Torakal dengan Teknik Anestesi Satu Paru dan Posisi Lateral Dekubitus Putri, Dini Handayani; Bisri, Dewi Yulianti; Fuadi, Iwan; Harahap, M Sofyan
Jurnal Neuroanestesi Indonesia Vol 9, No 1 (2020)
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Spinal adalah lokasi yang paling umum untuk metastasis tulang. Metastasis spine dapat menyebabkan nyeri, ketidakstabilan tulang belakang dan cedera neurologis lainnya. Pada operasi tumor spinal metastasis pendekatan pembedahan menjadi hal penting baik bagi ahli bedah saraf maupun neuroanestesi. Pada kasus ini laki-laki 60 tahun dengan tumor ekstradura metastasis torakal akan menjalani operasi pengangkatan tumor dan stabilisasi dengan pendekatan posterolateralextracavity untuk mendapat akses yang optimal ke bagian ventral spinal bagian torakal atas. Pasien di induksi dengan fentanil 200 mcg dan propofol 100 mg, fasilitasi intubasi dengan rocuronium 50 mg dan pemasangan double lumen tube kiri, posisi lateral dekubitus. Ketika dilakukan ventilasi satu paru pasien mengalami kejadian desaturasi oksigen sampai 93%, dilakukan penyesuaian mode ventilator sebagai penanganannya. Pascaoperasi pasien tidak diekstubasi dan menjalani perawatan diruangan intensif selama dua hari dan dipulangkan pada hari ke 13. Tatakelola kasus ini difokuskan pada penilaian preoperatif, pengaruh posisi lateral dekubitus dan teknik anestesi satu paru terhadap fungsi respirasi dan kardiovaskular. Risiko hipoksemia akibat ketidaksesuaian ventilasi / perfusi yang menyebabkan gangguan oksigenisasi dan perfusi terhadap otak dan medulla spinalis, sehingga diperlukan tatakelola ventilasi mekanik, monitoring intraoperasi yang berhubungan dengan kaidah-kaidah neuroproteksi terhadap otak dan medulla spinalis.Management of Mechanical Ventilation in the Removal of Thoracal Extradura Metastatic Tumors with One Lung Anesthesia Technique in Decubitus Lateral PositionAbstractThe spine is the most common location for bone metastases. Spine metastases can cause pain, spinal instability and other neurological injuries. In spinal metastatic tumor surgery a surgical approach is important for both neurosurgeons and neuroanesthesiologists. In this case, a 60-year-old man with a thoracic metastatic extradura tumor would undergo tumor removal and stabilization with the posterolateralextracavity approach to obtain optimal access to the ventral spinal ventral region. Patients were induced with 200 mcg fentanyl and propofol 100 mg, facilitation of intubation with 50 mg rocuronium and installation of the left double lumen tube, lateral decubitus position. When one lung is ventilated, the patient experiences an oxygen desaturation event of up to 93%, adjusting the ventilator mode as a treatment. Postoperatively the patient was not extubated and underwent intensive care for two days and was discharged on day 13. The case management focused on preoperative assessment, the influence of lateral decubitus position and one-pulmonary anesthetic technique on respiration and cardiovascular function. The risk of hypoxemia due to ventilation / perfusion mismatches that cause oxygenisation and perfusion disorders of the brain and spinal cord, so that management of mechanical ventilation, intraoperative monitoring associated with neuroprotection rules of the brain and spinal cord.

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