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RACHMAT HIDAYAT
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INDONESIA
Journal of Anesthesiology and Clinical Research
Published by HM Publisher
ISSN : -     EISSN : 27459497     DOI : https://doi.org/10.37275/jacr
Core Subject : Health, Science,
Biochemistry, Genetics & Molecular Biology Health Professions Immunology & microbiology Medicine & Pharmacology Neuroscience
Journal of Anesthesiology and Clinical Research/JACR that focuses on anesthesiology; pain management; intensive care; emergency medicine; disaster management; pharmacology; physiology; clinical practice research; and palliative medicine.
Arjuna Subject : Kedokteran - Anesthesiology and Pain Medicine
Articles 118 Documents
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The Novice Overshoot: A Bispectral Index-Based Analysis of the Anesthesiology Resident Learning Curve for Anesthetic Depth Control in Supervised Practice Rizki Suhadayanti; Isngadi; Buyung Hartiyo Laksono; Ristiawan Muji 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.v6i2.790

Abstract

Introduction: The skillful management of anesthetic depth is a cornerstone of anesthesiology, yet the objective characterization of the resident learning curve remains underexplored. This study aimed to quantitatively map the developmental trajectory of anesthetic depth control among anesthesiology residents in a supervised clinical environment. Methods: We conducted a prospective, cross-sectional, observational study involving 21 anesthesiology residents (from seven sequential semesters of training) and 105 ASA I-II adult patients at a tertiary academic hospital. Under standardized supervision, residents induced general anesthesia. The primary outcome was the Bispectral Index (BIS) value and its categorical distribution (Deep: <40, General: 40-60, Sedation: >60) at 2 minutes post-intubation. Secondary outcomes included propofol induction dose and hemodynamic responses. Data were analyzed using ANOVA, Kruskal-Wallis, and Chi-square tests. Results: Post-intubation mean BIS values showed a non-significant trend towards being lower in junior residents compared to seniors (p=0.088). However, the categorical distribution of BIS values differed significantly across training levels (p=0.015). Junior residents (Semesters I-II) induced a state of deep anesthesia (BIS < 40) in 46.7% of their patients, compared to only 11.1% for senior residents (Semesters V-VII) (p<0.001). This correlated with junior residents using significantly higher weight-adjusted propofol doses (2.4 ± 0.3 mg/kg vs. 1.9 ± 0.2 mg/kg; p<0.001). Conclusion: The anesthesiology resident learning curve is characterized by a distinct pattern of initial over-titration, or a "novice overshoot," leading to a higher incidence of unnecessarily deep anesthesia. While mean BIS values did not differ significantly, the distribution of hypnotic states reveals a critical educational target. BIS monitoring serves as a valuable objective tool for tracking the performance of the resident-supervisor dyad, offering data-driven insights for enhancing competency-based training and patient safety.
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.
Navigating High-Risk Obstetric Anesthesia: Successful Management of Cesarean Section with Graded Epidural Blockade in a Parturient with Atrial Septal Defect and Moderate Pulmonary Hypertension Viky Wicaksana; Septian Adi Permana; Bambang Novianto Putro
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.v6i2.796

Abstract

Introduction: The convergence of a large, uncorrected atrial septal defect (ASD) with secondary pulmonary hypertension (PH) in pregnancy creates a high-risk hemodynamic environment. The physiological stresses of parturition can precipitate cardiovascular collapse. Anesthetic management for cesarean delivery must be meticulously planned to preserve the delicate balance between systemic and pulmonary vascular resistance, with the primary goal of maintaining systemic vascular resistance to prevent exacerbation of the intracardiac shunt. Case presentation: We present the case of a 28-year-old primigravida at 37+2 weeks' gestation with a known large secundum ASD and moderate PH (echocardiographically estimated sPAP of 50.2 mmHg), who required an emergency cesarean section. A comprehensive, multidisciplinary plan was formulated, prioritizing maternal hemodynamic stability. The patient was successfully managed with a carefully titrated, graded lumbar epidural anesthetic using 0.5% levobupivacaine. Advanced invasive monitoring, including arterial and central venous catheters, guided the slow induction of a T6 sensory block. This strategy resulted in hemodynamic parameters being maintained within a clinically acceptable range, obviating the need for vasopressor support. The postoperative course in the cardiovascular ICU was uneventful. Conclusion: This case provides compelling evidence that a graded epidural blockade, executed with vigilance and supported by a robust, team-based safety framework, is a highly effective anesthetic technique for cesarean delivery in parturients with ASD and moderate PH. The ability to exert temporal control over the onset of sympathetic blockade is paramount to preventing abrupt hemodynamic shifts, thereby protecting the vulnerable right ventricle and ensuring maternal safety.
Beyond the Block: Sequential Spinal Anesthesia and Dexmedetomidine-Ketamine TIVA for a Four-Hour Cesarean Section in a 157-kg Parturient Agung Nugroho; Ardana Tri Arianto; Paramita Putri Hapsari
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.v6i2.801

Abstract

Introduction: Cesarean delivery in super-obese parturients (BMI ≥ 50 kg/m²) presents a complex combination of anesthetic challenges, amplified by comorbidities like preeclampsia. The strong imperative to avoid airway instrumentation makes regional anesthesia the preferred technique. However, the finite duration of a single-shot spinal block poses a significant risk in unexpectedly prolonged procedures, requiring a pre-planned strategy for anesthetic extension. Case presentation: A 38-year-old G2P1 parturient with a BMI of 63.7 kg/m² presented for an emergency cesarean section for fetal hypoxia and preeclampsia. After a rapid multidisciplinary consultation, a deliberate decision was made to proceed with spinal anesthesia to mitigate profound airway risks. The surgery became unexpectedly complex, lasting four hours. As the spinal block regressed, a planned transition to an opioid-sparing total intravenous anesthesia (TIVA) with dexmedetomidine and ketamine was initiated. This technique preserved spontaneous respiration and provided excellent hemodynamic stability, even during a 2000 mL hemorrhage. Conclusion: This case highlights the value of anesthetic adaptability in high-risk obstetrics. A sequential spinal-TIVA technique offers a safe and effective alternative to a high-risk conversion to general anesthesia, emphasizing the importance of having a pre-planned contingency for insufficient neuraxial blockade in super-obese parturients. This approach underscores the necessity of multidisciplinary communication and patient-centered care in navigating complex obstetric emergencies.
Hemodynamic-Focused Anesthetic Strategy for Duodenal Atresia with Annular Pancreas in a Low-Birth-Weight Neonate: A Case Report and Pathophysiological Review Wardhana, Anggia Rarasati; Ardana Tri Arianto; Heri Dwi Purnomo
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.v6i2.802

Abstract

Introduction: The anesthetic management of low-birth-weight (LBW) neonates with complex congenital anomalies like duodenal atresia presents a profound physiological challenge. These patients exhibit immature organ systems, precarious fluid balance, and heightened sensitivity to anesthetic agents. This case report describes a successful hemodynamically-focused anesthetic strategy in a particularly high-risk neonate with the combined pathology of duodenal atresia and a constricting annular pancreas. Case presentation: A 4-day-old, 1800-gram male infant, born at 37 weeks with intrauterine growth restriction, presented with prenatally diagnosed duodenal atresia. Preoperative stabilization focused on correcting a severe hypochloremic, hypokalemic metabolic alkalosis. A hemodynamically stable anesthetic induction was achieved using intravenous fentanyl (2.8 mcg/kg) and ketamine (2.8 mg/kg), avoiding myocardial depressant volatile agents. Anesthesia was maintained with 60% oxygen in air and intermittent opioid boluses. Intraoperative management was centered on meticulous, goal-directed fluid therapy, rigorous maintenance of normothermia, and lung-protective ventilation. The surgery, a duodenojejunostomy, was completed successfully with remarkable hemodynamic stability. The infant was transferred to the NICU for planned postoperative ventilation and was extubated on the second postoperative day. Postoperative analgesia was achieved with a continuous sub-anesthetic ketamine infusion, later transitioned to intermittent metamizole. Conclusion: The successful outcome in this fragile neonate underscores the value of a tailored anesthetic approach grounded in neonatal pathophysiology. A strategy utilizing hemodynamically stable induction agents, proactive correction of metabolic derangements, goal-directed fluid therapy, and a planned, staged recovery can effectively mitigate the significant perioperative risks associated with major abdominal surgery in LBW infants with complex congenital anomalies.
Opioid-Sparing Anesthesia: The Dual Efficacy of Ketamine on Postoperative Pain and Systemic Inflammation Following Spinal Surgery Elanda Rahmat Arifyanto; Ardana Tri Arianto; Heri Dwi Purnomo
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.v6i2.804

Abstract

Introduction: Postoperative pain and inflammation after major spinal surgery, such as laminectomy, pose significant challenges to patient recovery and contribute to opioid consumption. Ketamine, an N-methyl-D-aspartate (NMDA) receptor antagonist, is proposed to have both analgesic and anti-inflammatory properties, positioning it as a key component of an opioid-sparing strategy. This study aimed to evaluate the clinical efficacy of a specific intraoperative ketamine infusion regimen compared to a continuous micro-dose morphine regimen on early postoperative pain and systemic inflammation. Methods: This prospective, double-blind, randomized controlled trial included 24 adult patients (ASA I-II) undergoing thoracolumbar laminectomy. Patients were randomly assigned to receive either a continuous intraoperative infusion of ketamine at 10 mcg/kg/minute (n=12) or morphine at 10 mcg/kg/hour (n=12). The primary outcomes were postoperative pain intensity, measured by the Visual Analog Scale (VAS) at 6 and 12 hours, and the systemic inflammatory response, assessed via high-sensitivity C-reactive protein (hs-CRP) levels measured preoperatively and 6 hours postoperatively. Results: The study groups were comparable regarding baseline demographic and surgical characteristics (p>0.05). At 6 hours postoperatively, the ketamine group reported significantly lower VAS pain scores than the morphine group (mean score of 2.33 ± 0.78 versus 3.83 ± 1.03, respectively; p=0.001). This difference was not maintained at 12 hours (p=0.646). Critically, the surgically-induced increase in hs-CRP was significantly attenuated in the ketamine group, which showed a mean increase of only 1.43 ± 1.04 mg/L from baseline, compared to a much larger increase of 2.88 ± 1.06 mg/L in the morphine group (p=0.003). Conclusion: An intraoperative ketamine regimen of 10 mcg/kg/minute is more effective at reducing pain in the immediate 6-hour postoperative period and mitigating the systemic inflammatory response than a continuous micro-dose morphine regimen. These findings underscore ketamine's potent dual-mechanism action, targeting both nociceptive and inflammatory pathways, and strongly support its use in multimodal, opioid-sparing protocols for spinal surgery.
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.
Determinants of Postoperative ICU Admission in the Elderly: A Prospective Multicenter Study of Elective Surgeries in Indonesia Alief Ilman Zaelany; Isngadi Isngadi; Taufiq Agus Siswagama; 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.v6i2.809

Abstract

Introduction: The increasing global geriatric population presents significant challenges for surgical care, particularly regarding the allocation of Intensive Care Unit (ICU) resources. This study aimed to identify determinants of postoperative ICU admission among elderly patients in Indonesia, a setting with a rapidly aging demographic. Methods: We conducted a prospective, multicenter cohort study across 15 Indonesian hospitals from February to April 2021. Patients aged ≥60 years undergoing elective surgery were enrolled via consecutive sampling. Data on patient demographics, American Society of Anesthesiologists (ASA) physical status, Charlson Comorbidity Index (CCI), and type of anesthesia (general vs. regional) were collected. The primary outcome was postoperative ICU admission. Multivariate logistic regression was used to identify independent predictors. Results: Of 893 patients enrolled, 18.8% required postoperative ICU admission. The final multivariate model revealed that a higher ASA physical status was the strongest predictor of ICU admission (Odds Ratio [OR] 4.13; 95% CI 2.88-5.92; p < 0.001). The administration of general anesthesia was also independently associated with a significantly increased likelihood of ICU admission compared to regional anesthesia (OR 2.77; 95% CI 1.83-4.19; p < 0.001). While the CCI was a significant factor in unadjusted analyses, its effect was attenuated after inclusion of the ASA score. Conclusion: ASA physical status and the choice of general anesthesia are powerful, independent determinants of postoperative ICU admission in the Indonesian geriatric surgical population. These findings highlight the critical role of preoperative physiological assessment and suggest that the choice of anesthetic technique has significant implications for postoperative resource needs.

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