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Introduction. Obesity is a condition that increases the challenges in the surgical process. Obesity increases the risk of sleep apnea and affects anaesthetics. This case report aims to discuss the management of anaesthesia in a patient with morbid obesity. Case. Female, 26 years old, with intramural uterine myoma and morbid obesity, will undergo myomectomy per laparotomy with ASA II physical status, performed anaesthesia with general anaesthesia intubation technique using the anaesthetic agent Propofol 1-2.5 mg/kg titration until the patient falls asleep, fentanyl 1-2 mcg/kg, then the patient was intubated in a ramped position with sleep non-apnea. After it was confirmed that the ETT was entered, 30 mg of a muscle relaxant (atracurium) was added. The operation lasts 1 hour 30 minutes, with a bleeding 250 cc, hemodynamically stable.Conclusion. Morbid obesity has extraordinary implications for anaesthetic management. Various considerations for patients with morbid obesity are needed starting from the preoperative, intraoperative, to postoperative periods. Regional anaesthesia is preferred because the physiological function of unhealthy obese patients is impaired due to excess body weight. Selection of anaesthetic agent and calculation of drug dose is crucial to know because there is a change in the volume of distribution. The pharmacokinetics of most general anaesthetics are affected by the adipose tissue mass, produce a prolonged drug effect, and less predictable.

Postoperative Cognitive Dysfunction (POCD) is a neurocognitive disorder characterized by decreased cognitive performance after surgery and anesthesia. POCD is a complication characterized by memory impairment, decreased information processing and reduced attention, accompanied by changes in mood and personality. The incidence of POCD in elderly patients (> 60 years) was approximately 25.8% within seven days after surgery and 10% within three months after surgery. The risk factors and etiology that lead to POCD can be reduced by good patient education, patient care and proper sanitation can prevent the tendency of POCD symptoms in these patients. Examination can be done with the learning test, the word learning test, the tracing test, the manual dexterity test, the ability test to remember a sequence of numbers. Mini Mental Status Examination (MMSE) as a screening test for dementia. MMSE is sometimes used to measure POCD. MMSE can be used in routine clinical practice to identify preoperative subclinical dementia that would put patients at a higher risk of developing POCD. Management in POCD includes two approaches, namely rapid diagnosis and prevention of POCD symptoms. Prevention by knowing the risk factors preoperative, intraoperative and postoperative. In patients with persistent POCD, it has a negative impact on quality of life, subjective memory performance, emotional symptoms, and possible health consequences such as dementia and premature death.

Uterine atonic can result in postpartum hemorrhage, gravid hysterectomy and maternal mortality. Oxytocin is the most commonly used agent for the prevention and treatment of atonic uterine during cesarean section. However, the provision of rapid and increasing the dose may result in hemodynamic instability, cardiovascular collapse, and death. This study aimed to compare the effectiveness of oxytocin bolus 5 IU and oxytocin infusion 20 IU to contractions of the uterus and the hemodynamic response in cesarean section with spinal anesthesia. An experimental study, Randomized Controlled Trial (RCT) was conducted in the operating room Mohammad Hoesin Hospital Palembang from July to August 2016. It was obtained a 44 pregnant at term women who will do a cesarean section that meet the inclusion and exclusion criteria. The frequency and distribution of data are described in tables and comparisons between the two groups were analyzed using SPSS. Of the 44 pregnant women at term, 22 women in the group of oxytocin bolus 5 IU and 22 women in the group of oxytocin infusion 20 IU. By statistical analysis, there was no significant hemodynamic changes after bolus administration of oxytocin 5 IU or oxytocin infusion 20 IU (p> 0.05) and there were no significant hemodynamic differences between oxytocin bolus 5 IU and infusion of 20 IU oxytocin (p> 0.05). In addition, there are significant changes in uterine contractions after bolus administration of oxytocin 5 IU or oxytocin infusion 20 IU (p< 0.05) and there were significant differences in uterine contraction in the 3rd minute (p = 0.006), 6th minute ( p = 0.010) and 9th minute (p = 0.008) between oxytocin bolus 5 IU and infusion of oxytocin 20 IU. It can be concluded that there is no significant hemodynamic changes after administration of oxytocin 5 IU bolus and oxytocin infusion 20 IU and there are differences in uterine contractions significantly in the 3rd minute, 6th minute and 9th minute between oxytocin bolus 5 IU and oxytocin infusion 20 IU.

A B S T R A C TPain is an unpleasant sensory and emotional experience associated with actual orpotential tissue damage, or described in terms of such damage. APS-POQ-R (RevisedAmerican Pain Society Patient Outcome Questionnaire) is a measuring tool for assessingthe quality of postoperative pain management by exploring patient experiences andoutcomes. This research aims to assess the quality of postoperative pain managementat Mohammad Hoesin Hospital Palembang and to determine the factors that influenceit. The Cross-sectional observational analytic study was conducted toward 51respondents. Data was collected primarily by using questionnares and interview. Datawas analyzed by using chi-square. The study showed that the quality of postoperativepain management at RSUP Mohammad Hoesin General Hospital Palembang has goodquality with a total of 27 patients (52.9%). From statistical analysis there wassignificant relationship between the quality of post-operative pain management withage (p=0,037), gender (p=0,027), ethnicity (p=0,039), education level (p=0,039), andeconomic level (p=0,005). So it can be concluded that was a significant relationshipbetween the quality of post-operative pain management with age, gender, ethnicity,education level, and economic level.

Sindrom Dandy Walker termasuk hidrosefalus yang sangat jarang terjadi dengan insiden 1 kasus dari 65 kasus hidrosefalus berdasarkan penelitian profil hidrosefalus di RSUDZA Banda Aceh. Insiden di Indonesia sebanyak 50–60% kasus dari operasi bedah saraf. Kasus berikut seorang bayi laki-laki lahir prematur, umur 1 bulan, berat badan 3,5 kg, ukuran lingkar kepala 45 cm, muntah dan kejang. CT-Scan terdapat kista, kalium 7 mmol/l ditegakkan diagnosa sindrom Dandy Walker dengan hiperkalemia. Manajemen neuroanestesi dengan cara premedikasi dan pemasangan kateter intravena 24G dengan sevofluran via masker O2 100% setelah jalur vena terpasang, diberikan fentanil 10 mcg sebagai analgetik dan induksi propofol 10 mg. Rocuronium 3,5 mg sebagai fasilitas intubasi. Pemeliharaan anestesi dengan sevofluran dan oksigen. Ventilasi frekuensi nafas 30 x/menit dilakukan manual dan kemudian dengan ventilator TV 30 ml, I:E = 1:1,5, RR 30 kali per menit, FiO2 100%. Monitoring hasil frekuensi nadi 100 – 130 kali per menit, SpO2 100%, suhu afebris, CO2 30 mmHg. Simpulan: sindrom Dandy Walker kasus yang sangat jarang terjadi dan hidrosefalus sering bersamaan dengan hiperkalemia terjadi pada bayi prematur karena gangguan reaborbsi kalium dan terjadi perpindahan kompartemen dari intraseluler ke ekstraseluler sehingga kalium banyak di ekstraseluler, maka diperlukan manajemen neuroanestesi pediatrik yang adekuat. Neuroanesthesia Management in Dandy Walker Syndrome with HyperkalemiaAbstractDandy Walker syndrome including hydrocephalus which is a very rare case with the incidence of 1 case out of 65 cases of hydrocephalus based on a study of hydrocephalus profile at Zainal Abidin Hospital, Banda Aceh. The incidence of Dandy-Walker syndrome in Indonesia are about 50 - 60% cases from all of neurosurgical cases. The following case was a premature baby, 1 month old, weight 3.5 kg, head cicumference 45 cm, vomit and seizure. Cyst was found in the head CT scan and the potassium level of 7 mmol/l. The patient was diagnosed with Dandy-Walker Syndrome with hyperkalemia. Neuroanesthesia management by premedication and infusion using intravenous cathether 24G with sevoflurane and 100% O2 mask After succesful intravenous cathether, given fentanyl 10 mcg as analgesic and propofol 10 mg as induction. Rocuronium 3.5 mg as a facility for intubation. Maintenance of anesthesia with sevoflurane and oxygen. Respiratory rate 30 breaths per minute with ventilation that was done manually and then with TV on ventilator 30 ml, I: E = 1: 1.5, RR 30x/min, FiO2 100%. Monitoring pulse frequency results of 100–130 beats per minute, 100% SpO2, temperature afebrile, CO2 30 mmHg. Conclusions: Dandy-Walker Syndrome was a very rare case and hydrocephalus was often followed with hyperkalemia that occur in premature infants due to potassium reaboration disorder and the displacement of compartment from intracellular to extracellular so that potassium was abundant at extracellular, hence adequate pediatric neuroanesthesia management was needed.

Sindrom Crouzon adalah sindrom dominan autosom yang ditandai dengan trias yaitu deformitas tengkorak, anomali wajah, dan eksoftalmus. Sindrom Crouzon memiliki prevalensi 1: 60.000 kelahiran. Sindrom ini disebabkan sinostosis dini sutura koronal dan sagital yang mengakibatkan dismorfisme wajah. Pada anestesi pasien dengan sindrom Crouzon, harus dilakukan langkah-langkah untuk antisipasi dan persiapan penanganan jalan napas yang sulit. Pada kasus ini, seorang bayi 5 bulan dengan sindrom Crouzon datang dengan keluhan kepala membesar sejak 2 bulan sebelum masuk rumah sakit. Dari CT-scan didapatkan hidrosefalus, dan dilakukan tindakan VP-shunt. Telah diantisipasi adanya kesulitan intubasi, maka dilakukan persiapan alat-alat termasuk bougie anak. Bougie tersebut kemudian ternyata sangat berguna saat dilakukan intubasi ulang karena ketidaksesuaian ukuran tube endotrakeal. Operasi VP-shunt berjalan dengan baik, pasca operasi dan anestesi pasien sadar baik, respirasi dan hemodinamik stabil dan kemudian pindah ke ruang rawat biasa. Dalam penanganan pasien ini, antisipasi, peralatan difficult airway yang lengkap, rencana alternatif, serta pendekatan multidisiplin sangat diperlukan. Anaesthetic Management for VP-Shunt in Baby Crouzon syndrome with Hydrocephalus Crouzon syndrome is an autosomal dominant syndrome characterized by triad of skull deformity, facial anomalies, and exophthalmos. Crouzon syndrome has a prevalence of 1: 60,000 births. This syndrome is characterized by early synostosis of coronal and sagittal sutures which leads to facial dysmorphism. In Crouzon syndrome, steps must be taken to anticipate and prepare for difficult airway handling.In this case, a 5-month-old baby with Crouzon syndrome presents with an enlarged head complaint 2 months before being hospitalized. CT scan showed hydrocephalus was, and VP-shunt action was planned. It is anticipated that there will be difficulty in intubation, so preparations for tools including child bougie were made. Bougie then turned out to be very useful because it had to be re-intubated because of the incompatibility of the size of the endotracheal tube. VP-shunt surgery works well, surgery and anesthesia were uneventful, then patient moved to the ward. Anticipation, complete difficult airway equipment and alternative plans, as well as a multidisciplinary approach are needed in handling these patients.

Cerebral venous sinus thrombosis (CVST) adalah suatu sindrom seperti stroke, angka kejadiannya sangat jarang, sehingga dapat menjadi dilema bagi dokter di instalasi gawat darurat dalam menegakkan diagnosis. Seorang lelaki 25 tahun, 50 kg, tinggi badan 165 cm, mengeluh lemah anggota badan sebelah kanan sejak 12 jam sebelum masuk rumah sakit. Keluhan disertai dengan sukar berbicara. Satu hari sebelum masuk rumah sakit, pasien mabuk-mabukan dan mengalami muntah-muntah ± 3–5 x/hari. Riwayat kejang, konsumsi obat-obatan dan trauma sebelumnya disangkal. Tidak ada riwayat demam, hipertensi, diabetes mellitus dan penyakit penyerta lainnya. Dilakukan dekompresi evakuasi perdarahan sebagai tindakan penyelamatan jiwa setelah pasien terehidrasi, operasi dilakukan dalam anestesi umum. Lama operasi selama 2 jam dan lama pasien teranestesi 2 jam 15 menit. Pasien dirawat di ICU selama 2 hari, lalu dipindahkan ke ruang HCU. Pada hari ke-5 pascabedah mulai diberikan enoxaparin sodium 50 mg subcutan selama 6 hari. Lalu pasien dipindahkan ke ruang rawat inap dan pulang ke rumah pada hari ke-15 perawatan. Target pencapaian utama pada pasien CVST adalah untuk rekanalisasi penyumbatan, menjaga venous return, mengurangi risiko hipertensi vena, infark serebral dan emboli paru. Algoritma tatalaksana pasien CVST terkadang harus disesuaikan dengan kondisi klinis pasien saat tiba di rumah sakit. Pemberian low-weightmoleculer heparin (LWMH) tetap diberikan selama tidak terjadi peningkatan tekanan darah yang bermakna Cerebral Venous Sinus Thrombosis Management with Alkoholic and Intracerebral Hemorrhage Cerebral venous sinus thrombosis (CVST) is a syndrome similar a stroke, the incidence is very rare, so it can be a dilemma for doctors at emergency departments to make the diagnosis. A 25 year old male weighing 50 kg and height 165 cm. Patients complained of right limb wekness since 12 hours before admission. Complaints are accompanied by difficulty speaking. One day before entering the hospital, the patient got drunk and experienced vomiting ± 3–5 times a day. History of seizures, previous consumption of drugs and trauma was denied. No history of fever, hypertension, diabetes mellitus and other comorbidities. Decompression by hematoma evacuation was performed as a life-saving action after the patient was hydrated, surgery was performed under general anesthesia. Operation duration was 2 hours and anesthesia duration was 2 hours 15 minutes. The patient was admitted to the ICU for 2 days, then transferred to the HCU room. On the 5th day post-surgery patient got 50 mg subcutaneous enoxaparin for 6 days. Then the patient was transferred to the ward and returned home on the 15th day of treatment. The main achievement targets in CVST patients were for clotting recanalization, maintaining venous return, reducing the risk of venous hypertension, cerebral infarction and pulmonary embolism. The CVST patient management algorithm sometimes has to be adjusted to the patient's clinical condition upon arrival at the hospital. Provision of LWMH is still given as long as the blood pressure does not increase significantly.

Respons stres adalah perubahan hormon dan metabolik yang terjadi setelah trauma seperti pembedahan, salah satunya terjadi peningkatan kadar kortisol. Dexmedetomidine dapat menurunkan respons stres dengan menghambat sintesis kortisol. Tujuan penelitian ini adalah mengetahui efek dexmedetomidine terhadap kadar kortisol pada pasien yang menjalani operasi ginekologi dalam anestesi umum yang dilakukan di RSUP dr. Mohammad Hoesin Palembang dari Januari–Maret 2018. Jumlah sampel 30 orang yang dibagi menjadi 2 kelompok, kelompok dexmedetomidine dan kelompok plasebo. Kelompok dexmedetomidine mendapatkan dosis dexmedetomidine awal 1 µg/kgBB selama 10 menit dilanjutkan 0,5 µg/kgBB/jam, 20 menit sebelum induksi. Pada kelompok plasebo menggunakan NaCl 0,9%. Induksi menggunakan propofol, fentanil 2 µg/kgBB, dan atrakurium 0,5 µg/kgBB serta pemeliharaan menggunakan sevofluran 3% dalam O2 dan N2O 50%:50%. Kemudian 1 jam pascaekstubasi diambil sampel darah kembali untuk pemeriksaan kadar kortisol. Hasil penelitian pada kedua kelompok terjadi peningkatan kadar kortisol saat 1 jam pascaekstubasi dibanding dengan awal (9,638±7,082 µg/dL menjadi 14,503±7,082 µg/dL pada kelompok dexmedetomidine dan 10,276±3,166 µg/dL menjadi 19,99±6,273 µg/dL pada kelompok placebo). Namun, kadar kortisol signifikan lebih tinggi pada kelompok plasebo. Simpulan, pada kedua kelompok terjadi peningkatan kadar kortisol dibanding dengan nilai awal, tetapi kadar lebih rendah pada kelompok dexmedetomidine. Effectiveness of Dexmedetomidine on Cortisol Level in Patients Undergoing Gynecologic Surgery under General Anesthesia Stress response is a term used to define the metabolic and hormonal changes following an injury or trauma, including as surgery. One of the responses is an increase in cortisol release. Dexmedetomidine may attenuate stress response by inhibiting cortisol synthesis. The aim of this study was to determine the effects of dexmedetomidine on cortisol level, compared to placebo, in patients undergoing major gynecological surgery under general anesthesia. A double-blind randomized clinical trial was performed at Mohammad Hoesin General Hospital from January to March 2018. There were thirty samples that were divided into two groups, dexmedetomidine group and placebo group. The dexmedetomidine group received an initial dexmedetomidine loading dose of 1 µg kg -1 over 10 min, followed by 0.5 µg kg-1h-1 20 minutes before induction. In the placebo group, 0.9% sodium chloride was administered. Anesthesia was induced with propofol, 2 µg/kgBW fentanyl, and 0.5 mg/kgBW atracurium and was maintained with 3% sevoflurane in O2 and N2O 50%:50%. After standard monitoring was established, blood samples were collected for cortisol plasma testing at baseline and 1 hour post-extubation. Hemodynamic data were recorded intraoperatively and postoperatively. Results in both groups presented a significant increase in cortisol level relative to the baseline at 1 hour post-extubation (9.638±7.082 µg/dL to 14.503±7.082 µg/dL in dexmedetomidine group and 10.276±3.166 µg/dL to 19.99±6.273 µg/dL in placebo group [P value

Otak adalah organ vital tubuh yang rentan untuk rusak. Mempunyai kebutuhan oksigen yang tinggi, sangat tergantung terhadap glukosa, mempunyai kecepatan metabolisme yang tinggi, tetapi mempunyai daya adaptasi yang rendah terhadap cedera serta sangat sulit beregenerasi. Cedara pada sel otak (neuron) adalah suatu kondisi yang serius yang dapat menyebabkan disfungsi dan kematian sel otak. Kebutuhan otak yang tinggi akan oksigen dan glikogen secara konstan adalah untuk memproduksi energi tubuh berupa adenosine-5’-triposphate (ATP) yang berguna untuk mempertahankan kehidupannya. Injuri sel dapat mengganggu metabolisme tersebut, mengurangi produksi ATP, menurunkan cadangan ATP dan menyebabkan proses glikolisis dan penggunaan laktat tubuh sebagai sumber energi metabolisme. Kondisi patologis ini memicu untuk terjadinya kerusakan sampai kematian sel melalui jalur nekrosis maupun apoptosis. Oleh karena itu otak dilindungi oleh membran sel dan sistem pembuluh darah otak yang bersifat spesifik, yang disebut sawar darah otak. Membrane Neuronal Cell and Blood Brain Barriere as Structure Brain Protection The brain is the body's vital organs are susceptible to damage. Have a high oxygen demand, is highly dependent on glucose, has a high metabolic rate, but have low adaptability of the injury and it is very difficult to egeneration. Injury on brain cells (neurons) is a serious condition because of risk for dysfunction and cells death. The brain needs for oxygen and glycogen constanly to produce the body's energy in the form of adenosine-5'-triposphate (ATP) which is useful for maintaining life. Injury can interfere with the metabolism of these cells, reducing the production of ATP, reducing ATP reserves and cause glycolysis process in the body and the use of lactate as an energy source metabolisme. This pathological condition for the occurrence of damage cell and trigger to cell death through necrosis or apoptosis process. Therefore, the protective structure cell membran and cerebral vascular system such as special, the vascular structure is blood brain barrier.

Kehamilan mempunyai dampak terhadap perubahan anatomi, fisiologi, farmakologi dan psikis pada sang ibu sehingga seksio sesarea pada ibu hamil merupakan tantangan tersendiri untuk spesialis anestesiologi, karena pertimbangannya terhadap keselamatan ibu dan anak. Apabila kehamilan disertai dengan penyulit yang lain, maka kondisi ini akan semakin kompleks. Kasus ini mengemukakan ibu hamil penderita HIV/AIDS dengan penyulit Space Occupying Lession (SOL), pertimbangan seksio sesarea dilakukan sebagai terminasi kehamilan untuk mengurangi paparan Maternal to Child Transmission (MTCT) terhadap anak yang dilahirkan. Pertimbangan pemilihan tehnik anestesinya berdasarkan fisiologi kehamilan, patofisiologi HIV/AIDS, efek samping obat Anti Viral (ARV), interaksi obat ARV dengan obat anestesi, komplikasi HIV/AIDS pada otak berupa SOL yang berhubungan dengan peningkatan TIK, dampak infeksius penyakot ini kepada lingkungannya serta antisipasi terhadap medis/paramedic yang ikut menangani tindakan terminasi. Pada penderita ini kami lakukan tehnik anestesi edpidural dengan bupivacaine 0,5 % sebagai bfasilitas anestesi selama seksio sesarea. Pascaoperasi dilanjutkan nyeri melalui kateter epiduralnya. Anesthesia Management of Sectio Caesaria HIV/AIDS Patient with Space Occupying Lession (SOL) Sectio caesarea on prenatal vidual have challenge in anaesthesia because influence safety mothers and children. Pregnancy to changes anatomy, physiology, pharmacology and psychology on the mother moreover that’s can accompanied by another complications, and make change this increasingly complex. In this case was pregnant mothers HIV/AIDS sufferes with a complication space occupying lesion (SOL). Sectio caesaria done to termination of pregnancy to reduce exposure transmission against children born gord loan-to- maternal child transmission (MCTC), Consideration of anestesinya technique based on pregnancy, physiology, pahtopfisiologi HIV/AIDS, adverse side effects anti retro viral (ARV) and interaction with medicine. Anaethetic complication SOL in HIV/AIDS in the brain associated with increased intracranial pressure. The impact of infectious disease that contaminate the environment and anticipations for medical paramedics / anaesthetic to prevent its. We did the patient with ep[idural anaethetic technique and used bupivacaine 0.5 % as facilitate anesthesia during section caesaria. Postoperaive continued pain releave through her catheter epidural.

Shaken Baby Syndrom adalah suatu kondisi perdarahan intraserebral atau intraokuler tanpa atau dengan hanya minimal trauma pada kepala, leher atau wajah. Kasus ini sering disebut kasus kekerasan anak- orang tua. Jumlah kejadian ini cukup banyak terjadi di US, sekitar 50.000 kasus pertahun, sepertiganya meninggal dunia dan setengah dari kasus yang bertahan hidup mengalami defisit neurologis yang berat. Umumnya prognosa penderita buruk. Di Indonesia sendiri data mengenai hal ini belum ada. Tapi mempunyai kecenderungan untuk meningkat.Gejala yang sering didapat adalah hematom subdural, perdarahan retina dan edema otak. Sering diikuti juga dengan multipel fraktur, trauma cervical dan jaringan leher lainnya. Peneliti lain melaporkan banyaknya kasus Diffuse Axonal Injury (DAI) pada kasus ini. Penanganan neuroanestesinya secara umum sama dengan neuroanestesi cedera otak traumatika pada pediatrik, karena terjadi peningkatan ICP sehingga mempengaruhi CBF, CMRO 2 dan autoregulasi otak. Obat, tehnik anestesi yang digunakan dan perhitungan cairan selama operasi diusahakan tidak memperburuk keadaan . Pasca operasi penderita dirawat dan diobservasi di PICU. Anesthesia Management For Shaken Baby Syndrome Shaken Baby Syndrome is a condition of intracerebral hemorrhage or intraocular without or with only minimal trauma to the head, neck or face. This case is often referred to cases of child-parent violence. This cases in the U.S, approximately 50,000 cases per year. From all event, one third died and half of the cases that survive with severe neurological deficit. Generally, prognosis of patients is poor. In Indonesia data on this subject does not exist. But it has a tendency to increase. Symptoms of a subdural hematoma is often obtained, retinal hemorrhages and brain edema.This case often followed by multiple fractures, cervical and other neck trauma tissues. Diffuse axonal injury researchers often reported for this case. Generally neuroanestesi technique for pediatric equal with pediatric trauma neuroanesthesia. Anesthesi challenges for this case was ICP, because increased ICP could influence for CBF, CMRO2 and cerebral autoregulation. Avoid anesthesi drugs , technique and the calculation of fluid during surgery to damaged this condition. Postoperative patients were treated and observed in the PICU.