Made Wiryana
Bagian Pendidikan Kedokteran dan Bagian/SMF Anestesi dan Terapi Intensif Fakultas Kedokteran Universitas Udayana/Rumah Sakit Umum Pusat Sanglah Denpasar Bali
Articles
22
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NUTRISI PADA PENDERITA SAKIT KRITIS

journal of internal medicine Vol. 8, No. 2 Mei 2007
Publisher : journal of internal medicine

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Abstract

Malnutrition is always been being associated with the increase of morbidity and mortality rate due to lack of immunesystem, depending on ventilator, high rate of infection, and delayed healing process, so it will increase the cost and length of stayof the patients. Clinician need to have right information about how to manage nutrition for critical ill patient because it willinfluence the outcome of ICU patient.Objective measurement nutritional status of the patient is difficult because process of illnesses itself will disturb themethod that will be used in the population. Nutritional status is multidimension phenomenon that need several methods formeasurement, including associated factors of nutrition, nutrition intake, and energy expenditure.Nitrogen balance can be used to determine effectiveness of nutritional therapy. Nitrogen balance can be counted by formulathat count nitrogen in 24 hours from patch urine, especially urine urea nitrogen (UUN), minus nitrogen intake from the food.Resting Energy Expenditure (REE) must be determined for nutritional therapy in critical ill patients. Acuracy estimation REE willhelp to reduce complications due to overfeeding, such as infiltration fat to liver and pulmonyary compromise. Several methods areavailable to predict REE such as Calorimetry, and Harris-Benedict equation.The goal in nutritional therapy in critical ill patient is to support metabolic, not to complete their need in that time. Becausein critical ill patient there is no metabolic condition is able to metabolize total amount of calories to fulfill lack of energy expenses.Ideally the route of nutritional therapy is able to supply nutrition with minimal morbidity. Each routes (parenteral andenteral) have advantages and disadvantages, and the choice is depend on patient condition. In critical ill patient care, enteralnutrition is always being the first choice and parenteral nutrition become the next alternative.

VENTILATOR ASSOCIATED PNEUMONIA

journal of internal medicine Vol. 8, No. 3 September 2007
Publisher : journal of internal medicine

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Abstract

Ventilator Associated Pneumonia (VAP) is defined as nosocomial pneumonia that occurred 48 hours afterthe patient had a mechanical ventilation support either from endotracheal tube or tracheostomy tube. VAPussually charactherized by 3 component sign of systemic infection: fever, tachycardia and leukocytosisfollowed by new infiltrate sign or a worsening scheme on the chest x ray and bacteriologic findings of thecausal of lung infection, but acctually we can diagnosed a VAP based on the findings of a number ofcriteria: histopathologic examination of the lung tissue from an open biopsy, a fast cavity formation of alung infiltrate without any sign of tuberculosis or malignancy and a positive pleural fluid culture, in whichthe species that found on the blood culture and airway were the same.The insidens of VAP are high, according to the foreign literature approximately between 9 – 27 % from allIntensive Care Unit population. This condition made VAP as the first causal of a nosocomial infection inthe Intensive Care Unit. The mortality rate of VAP is also high, Chastre and Fagon stated that the crudemortality rate can reach of 76%. Early onset VAP which occurred on the first 4th day after admission in theIntensive Care Unit ussually had a better prognosis because of caused by a still antibiotic sensitivepathogens. The Late onset VAP which occurred after 5 days or more after hospitalization, has worseprognosis because of caused by a multidrug resistance (MDR) pathogens. In order to define the pathogensthat caused VAP, some scientist made a classification of VAP patient based on the degree of disease, riskfactor and the onset, which is the group I with mild-moderate degree, common risk factor and the onset isanytime during hospitalization or a severe degree with an early onset, ussually caused by a gram negativebacteria. The group II, patient with a mild-moderate degree, specific risk factor that happened anytimeduring hospitalization, ussually caused by all bacteria in the group I added with an anaerob bacteria. Thegroup III, patient with a severe degree, early onset with specific risk factor or a late onset, ussually caused by Pseudomonas aeruginosa, Acinetobacter sp and MRSA. Other approach is by classifying the bacteriacausing VAP in a primary endogen, secondary and eksogen type.Prevention of VAP can be done by 2 different ways, first by a non pharmachologic way, routine andstandard things that ussually done in the ICU, but this action still could not enough in lowering the insidensof VAP. Second, by a pharmachologic way, Selective Decontamination of the Digestive Tract (SSD) andOropharyngeal Decontamitation (OD). SSD is proven effective empirically in preventing VAP but the usedof antimicrobial can caused a higher risk on resistention. SDD is not recommended as a routine action inpreventing VAP so that OD with the used of antiseptic is preferred as another alternative.

PERANAN TERAPI INSULIN INTENSIF TERHADAP INTERLEUKIN-6 (IL-6) DAN LUARAN KLINIK PADA PENDERITA KRITIS DENGAN HIPERGLIKEMIA

journal of internal medicine Vol. 9, No. 2 Mei 2008
Publisher : journal of internal medicine

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Abstract

Hiperglycemia and insulin resistance are common in critically ill patients, even that have not previously had diabetes.Though it has been reported that pronounced hyperglycemia may lead to complications in such patients and cause of reactiveoxygen species (ROS) production, although data from controlled trial are still lacking. The debatable issue focused on whetherintensive insulin therapy to normalized blood glucose improves prognosis. The debate is mainly about the time to start therapy,and target of blood glucose level. The main purpose of this research is to know the different between intensive insulin therapy andconventional insulin therapy on decreases of cytokine production (IL-6), increase of albumin level and event of systemic inflammatoryrespons syndrome (SIRS). The design of this study is randomized pre and post control group design involving 40 adultpatients that admitted to the ICU Sanglah hospital Denpasar. They were randomly assigned to receive intensive insulin therapy inwhich blood glucose at the level between 80 ? 110 mg/dL or conventionl insulin therapy in which insulin therapy start if the bloodglucose level exceed 215 mg/dL and blood glucose maintained at the level between 180 ? 200 mg/dL. The results of this studyshowed that: (1) Significant decrease of IL-6 level (10.25 vs 2.02; p=0.023); (2) Significant increase of albumin level (0.62 vs0.22); (3) Significant decrease of SIRS (10 % vs 45%, p=0.000) on intensive insulin therapy group compare to the conventionalinsulin therapy group. Conclusions of this study is that the increase insulin dose as well as intensive insulin therapy can maintainblood glucose level at the level normoglycaemia between 80-110 mg/dL faster compare to the conventional insulin therapy. Onthe otherhand, interleukin-6 decreases cause of decreases ROS production and anti inflammatory effect of insulin. Intensiveinsulin therapy can increase albumin level and decrease of SIRS event on hyperglycemia in critically ill ICU patients compare tothe conventional insulin therapy.

MANAJEMEN PERIOPERATIF PADA HIPERTENSI

journal of internal medicine Vol. 9, No. 2 Mei 2008
Publisher : journal of internal medicine

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Abstract

Hypertension is a leading cause of death and the most frequent preoperative abnormality in surgical patients, and becomemajor risk factor for cardiac, cerebral, renal and vascular disease during intraoperative or post-operative periode. Agressivecontrolled hypertension will decrease complications due to the damage of end organs. Consequences by taking anti-hypertensiveagents is the interaction with other medications that being used during surgery. Consideration must be taken especially due to thehalf life and adjustment dose of this medications. The National Committee 7 (JNC 7) on prevention, detection, evaluation andtreatment of high blood pressure 2003, degree of hypertension can be classified into pre-hypertension (120-139/80-89), hypertensionstage 1 (140-159/90-99 mmHg) and hypertension stage 2 (systolic pressure 160 mmHg or diastolic pressure 100 mmHg).According to the etiology, hypertension can be classified into primary hypertension (80-95%) and secondary hypertension (10-15%) due to the causes. Usually hypertension always has association with abnormality of sympathetic activity, increasing thepheripheral vascular resistance (SVR) or increasing both of them. But the most common cause of hypertension is increasing thepheripheral vascular resistance. Management perioperative of hypertension includes evaluation and optimalised patients conditionpreoperative, management patients who under influenced of anesthetic agents and treatment post operative. Patient withhypertension incline to have instability haemodinamic and more sensitive to anesthesia and surgery procedures, so carefull mustbe taken at the beginning of anesthesia and surgery until post operatively, especially to control hemodynamic. The best monitoringfor patient with hypertension is by using suitable anesthetic techniques, anesthetic agents and antihypertensive agents. Postoperative hypertension can be happened due to several factors such as, inadequate antihypertensive agents, respiratory disturbance,pain, fluid overload, or distended of the bladder. Excellent perioperative management of hypertension patients beforesurgery will decrease morbidity and mortality rate

THE ROLE OF INTENSIVE INSULIN THERAPY ON SUPEROXIDE DISMUTASE (SOD), TUMOR NECROSIS FACTOR-? (TNF-?), AND INTERLEUKIN-6 (IL-6) ON HYPERGLYCEMIA IN CRITICALLY ILL PATIENTS

INDONESIAN JOURNAL OF BIOMEDICAL SCIENCES Vol. 3, No. 1 Januari 2009
Publisher : Udayana University

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Abstract

Hyperglycemia and insulin resistance are common in critically ill patientsin the ICU, although they have not previously had diabetes. It has been reportedthat pronounced hyperglycemia may lead to complications in such patients, andcause the reactive oxygen species (ROS) production, although controlled trial dataare still lacking. The current debatable issue, focusing on whether the intensiveinsulin therapy, aimed at normalizing blood glucose, may improvepatients’prognosis. Then, the debate is mainly about the time to start the therapy,and target of blood glucose level. Therefore, this research is mainly designed andaimed at knowing the difference between intensive insulin therapy andconventional insulin therapy on the increase of superoxide dismutase (SOD),decrease of cytokine production (TNF-? and IL-6), increase of albumin level, andevent of SIRSThis study was carried out in a randomly pre and post-test control groupdesign, involving 40 adult patients being nursed through the ICU Sanglah hospitalDenpasar. They were randomly assigned to receive intensive insulin therapy, inwhich blood glucose was decreased and maintained at the level between 80-110mg/dl, or conventional insulin therapy in which the insulin was infused only if theblood glucose level exceeded 215 mg/dl, decreased and maintained then at thelevel between 180-200 mg/dl.The result of the study showed that there was (1) significant increase ofSOD mean level (370. 70 vs 98.50 U/gHb, p=0.001); (2) no significant decreaseof TNF-? mean level; (3) significant decrease of IL-6 mean level (10.26 vs 2.25;p=0.023); (4) significant increase of albumin mean level ( 0.62 vs 0.22); (5)significant decrease of SIRS (10 % vs 40 %, p=0.000) on intensive insulin therapygroup compared to conventional insulin therapy group. It can be concluded thatintensive insulin therapy could maintain blood glucose level between 80 – 110mg/dl, increase SOD level, decrease IL-6 level, increase albumin level, anddecrease SIRS on hyperglycemia in critically ill ICU patients.

THE ROLE OF INTENSIVE INSULIN THERAPY ON SUPEROXIDE DISMUTASE (SOD), TUMOR NECROSIS FACTOR-? (TNF-?), AND INTERLEUKIN-6 (IL-6) ON HYPERGLYCEMIA IN CRITICALLY ILL PATIENTS

INDONESIAN JOURNAL OF BIOMEDICAL SCIENCES Vol. 4, No. 1 Januari 2010
Publisher : Udayana University

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Abstract

Hyperglycemia and insulin resistance are common in critically ill patientsin the ICU, although they have not previously had diabetes. It has been reportedthat pronounced hyperglycemia may lead to complications in such patients, andcause the reactive oxygen species (ROS) production, although controlled trial dataare still lacking. The current debatable issue, focusing on whether the intensiveinsulin therapy, aimed at normalizing blood glucose, may improvepatients’prognosis. Then, the debate is mainly about the time to start the therapy,and target of blood glucose level. Therefore, this research is mainly designed andaimed at knowing the difference between intensive insulin therapy andconventional insulin therapy on the increase of superoxide dismutase (SOD),decrease of cytokine production (TNF-? and IL-6), increase of albumin level, andevent of SIRSThis study was carried out in a randomly pre and post-test control groupdesign, involving 40 adult patients being nursed through the ICU Sanglah hospitalDenpasar. They were randomly assigned to receive intensive insulin therapy, inwhich blood glucose was decreased and maintained at the level between 80-110mg/dl, or conventional insulin therapy in which the insulin was infused only if theblood glucose level exceeded 215 mg/dl, decreased and maintained then at thelevel between 180-200 mg/dl.The result of the study showed that there was (1) significant increase ofSOD mean level (370. 70 vs 98.50 U/gHb, p=0.001); (2) no significant decreaseof TNF-? mean level; (3) significant decrease of IL-6 mean level (10.26 vs 2.25;p=0.023); (4) significant increase of albumin mean level ( 0.62 vs 0.22); (5)significant decrease of SIRS (10 % vs 40 %, p=0.000) on intensive insulin therapygroup compared to conventional insulin therapy group. It can be concluded thatintensive insulin therapy could maintain blood glucose level between 80 – 110mg/dl, increase SOD level, decrease IL-6 level, increase albumin level, anddecrease SIRS on hyperglycemia in critically ill ICU patients.

PERBANDINGAN EFEK OKSITOSIN BOLUS 3 IU, 5 IU, DAN 10 IU TERHADAP KONTRAKSI UTERUS DAN RESPON KARDIOVASKULAR PADA SEKSIO SESAREA DENGAN ANESTESI BLOK SUBARAKNOID

Medicina volume 44 nomor 3. september 2013
Publisher : Medicina

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Abstract

Oksitosin merupakan obat yang rutin diberikan setelah kelahiran bayi pada seksio sesarea untukmemulai dan mempertahankan kontraksi uterus adekuat tetapi efek samping kardiovaskulardiketahui muncul setelah pemberian intravena seperti takikardi, hipotensi dan disritmia. Hal iniakibat efek relaksasi otot polos vaskular yang menyebabkan penurunan resistensi vaskular sistemik,hipotensi, dan takikardia. Besarnya efek ini tergantung dosis dan cara pemberiannya. Tujuan penelitianini adalah membandingkan kontraksi uterus, tekanan arteri rerata (TAR), dan laju nadi setelahoksitosin bolus 3, 5, dan 10 IU pada seksio sesarea dengan anestesi blok subaraknoid. Penelitian iniadalah uji klinik acak terkontrol tersamar ganda. Enam puluh enam pasien yang memenuhi kriteriapenelitian dibagi 3 yaitu kelompok 3IU, 5IU, dan 10IU. Oksitosin bolus diberikan setelah kelahiranbayi dalam 30 detik dan dilanjutkan kontinyu 0,04 IU/menit. Kontraksi uterus dinilai oleh operatordan perubahan TAR serta laju nadi dicatat pada lembar penelitian. Tidak ditemukan perbedaanprevalensi kontraksi uterus adekuat antar kelompok penelitian. Penurunan rerata TAR danpeningkatan rerata laju nadi kelompok 3IU secara bermakna lebih kecil dibandingkan kelompok 5dan 10IU, dan kelompok 5IU secara bermakna lebih kecil dibandingkan kelompok 10IU. Simpulanpenelitian ini bahwa oksitosin bolus 3 IU menghasilkan keadekuatan kontraksi uterus yang sama,penurunan TAR dan peningkatan laju nadi lebih kecil dibandingkan oksitosin bolus 5 dan 10 IU padaseksio sesarea dengan anestesi blok subaraknoid.

Efektivitas Magnesium Sulfat 30 mg/kgBB Intravena Dibanding dengan Fentanil 2 mcg/kgBB Intravena dalam Menekan Respons Kardiovaskular pada Tindakan Laringoskopi dan Intubasi

Jurnal Anestesi Perioperatif Vol 3, No 2 (2015)
Publisher : Faculty of Medicine, Universitas Padjadjaran

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Abstract

Laringoskopi dan intubasi merupakan tindakan rutin yang berisiko menyebabkan respons kardiovaskular berupa peningkatan tekanan darah dan laju denyut jantung terutama pada pasien risiko tinggi seperti kelainan jantung. Penelitian ini bertujuan mengetahui efektivitas MgSO4 30 mg/kgBB intravena dibanding dengan fentanil 2 mcg/kgBB  intravena dalam menekan respons kardiovaskular pada  tindakan laringoskopi dan intubasi sehingga dapat menjadi obat altenatif. Penelitian ini dilakukan secara uji klinis  acak terkontrol tersamar ganda terhadap 42 pasien dengan status fisik American Society of Anesthesiologist (ASA) I–II yang dilakukan operasi dengan anestesi umum intubasi trakea di RSUP Sanglah Denpasar Bali pada Agustus–September 2014. Subjek dibagi menjadi dua kelompok, MgSO4 30 mg/kgBB (n=21) dan fentanil 2 mcg/kgBB (n=21) secara acak. Perubahan tekanan darah dan laju denyut jantung yang terjadi sebelum dan setelah tindakan dicatat sebagai data penelitian. Data penelitian dianalisis dengan uji repeated ANOVA, dengan p<0,05 dianggap bermakna. Analisis statistik menunjukkan bahwa tidak terdapat perbedaan bermakna antara kedua kelompok perlakuan. Simpulan, pemberian MgSO4 30 mg/kgBB sama efektif dengan fentanil 2 mcg/kgBB dalam menekan respons kardiovaskular pada tindakan laringoskopi dan intubasi.Kata kunci: Fentanil, intubasi, laringoskopi, magnesium sulfat, respons kardiovaskularComparison of Intravena Magnesium Sulfate 30 mg/kgBW and Intravena Fentanil 2 mcg/kgBW  Effectiveness for Attenuating Cardiovascular Response in Laryngoscopy and Tracheal IntubationLaryngoscopy and intubation are routine actions which cause the risk of cardiovascular responses, including increased blood pressure and heart rate, especially in high-risk patients such as patients with heart disorders. The aim of this study was to determine the effectiveness of intravenous MgSO4 30 mg/kgBW compared to that of intravenous fentanyl 2 mcg/kgBW in reducing cardiovascular responses to laryngoscopy and intubation to assess its possibility as an alternative drug. This study was a clinical trial with randomized double-blind controlled to 42 patients with physical status of the American Society of Anesthesiologists (ASA) I–II who underwent tracheal intubation under general anesthesia in Sanglah Denpasar Hospital Bali in the period of  August–September 2014. Subjects were divided into two groups, MgSO4 30 mg/kgBW (n=21) and fentanyl 2 mcg/kgBW (n=21) groups. Changes in blood pressure and heart rate that occured before and after the action were recorded as research data. Data were analyzed with repeated ANOVA test, with p<0.05 considered significant. Statistical analysis showed that there was no significant difference between the two treatment groups. it is concluded that the administration of MgSO4 30 mg/kgBW is as effective as fentanyl 2 mcg/kgBW in reducing cardiovascular responses to laryngoscopy and intubation.Key words: Cardiovascular response, fentanyl, intubation, laryngoscopy, magnesium sulfate DOI: 10.15851/jap.v3n2.574

Correlation Between Protein Intake and Nitrogen Balance of Surgical Patients in Anesthesiology and Intensive Care Installation, Sanglah General Hospital, Denpasar, Bali, Indonesia

BALI MEDICAL JOURNAL Vol 5, No 2 (2016)
Publisher : BALI MEDICAL JOURNAL

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Abstract

Background: A cell injury from surgical stress in a trauma or a non-trauma case will induce a hyper metabolic response in which the protein degradation increases, the somatic protein synthesis decreases and the amino acid catabolism increases. Thus, the pyper metabolic response contributes to nitrogen loss in urine. This response, without an adequate nutrition, will lead an iatrogenic malnutrition and deterioration. A balance nitrogen formula through urinary urea nitrogen is one of many nutrition evaluation methods. This method aids in evaluating the daily nutrition status and it can be the baseline data for daily intake. Objective: To find a correlation between the protein intake and the nitrogen balance of the surgical patients in anesthesiology and intensive care installation, Sanglah General Hospital, Denpasar, Bali. Methods: Fifty-one surgical patients with trauma and non-trauma cases were observed for their protein intake for 2-3 days continuously. Moreover, they were evaluated for their nitrogen balance based on the urinary urea nitrogen per 24 hours for 2-3 days. For statistical analysis, we utilized Shapiro-Francia, Shapiro-Wilk, Spearman Frank correlation, two-sample t test, and multivariate regression analysis in Strata SE 12.1. Results: The correlation between the protein intake and the nitrogen balance on the first day was ra=0.50 (p<0.05), on the second day ra=0.70 (p<0,05), and on the third day ra=0.740 (p<0,05) Conclusions: There is a correlation between the protein intake and the nitrogen balance of surgical patients in Anesthesiology and Intensive Care Installation Sanglah General Hospital Denpasar.

Cost Minimization Analysis of Hypnotic Drug: Target Controlled Inhalation Anesthesia (TCIA) Sevoflurane and Target Controlled Infusion (TCI) Propofol

BALI MEDICAL JOURNAL Vol 5, No 3 (2016)
Publisher : BALI MEDICAL JOURNAL

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Background: Cost minimization analysis is a pharmaco-economic study used to compare two or more health interventions that have been shown to have the same effect, similar or equivalent. With limited health insurance budget from the Indonesian National Social Security System implementation in 2015, the quality control and the drug cost are two important things that need to be focused. The application of pharmaco-economic study results in the selection and use of drugs more effectively and efficiently. Objective: To determine cost minimization analysis of hypnotic drug between a target controlled inhalation anesthesia (TCIA) sevoflurane and a target controlled infusion (TCI) propofol in patients underwent a major oncologic surgery in Sanglah General Hospital. Methods: Sixty ASA physical status I-II patients underwent major oncologic surgery were divided into two groups. Group A was using TCIA sevoflurane and group B using TCI propofol. Bispectral index monitor (BIS index) was used to evaluate the depth of anesthesia. The statistical tests used are the Shapiro-Wilk test, Lavene test, Mann- Whitney U test and unpaired t-test (? = 0.05). The data analysis used the Statistical Package for Social Sciences (SPSS) for Windows. Results: In this study, the rate of drug used per unit time in group A was 0.12 ml sevoflurane per minute (± 0.03) and the group B was 7.25 mg propofol per minute (±0.98). Total cost of hypnotic drug in group A was IDR598.43 (IQR 112.47) per minute, in group B was IDR703.27 (IQR 156.73) per minute (p>0.05). Conclusions: There was no statistically significant difference from the analysis of the drug cost minimization hypnotic drug in a major oncologic surgery using TCIA sevoflurane and TCI propofol.

Co-Authors - Yehezkiel, - Adinda Putra Pradhana, Adinda Andi Kusuma Wijaya, Andi Christopher Ryalino, Christopher Elisma Nainggolan, Elisma Emkel Perangin Angin, Emkel Gede Semarawima, Gede Hari Bagianto I Gede Budiarta, I Gede I Gusti Agung Gede Utara Hartawan, I Gusti Agung I Gusti Agung Gede Utara Hartawan, I Gusti Agung Gede I Gusti Agung Gede Utara Hartawan, I Gusti Agung Gede Utara I Gusti Ngurah Mahaalit Aribawa, I Gusti Ngurah I Gusti Ngurah Mahaalit Aribawa, I Gusti Ngurah Mahaalit I Gusti Putu Sukrana Sidemen, I Gusti Putu Sukrana I Ketut Sinardja I Made Darma Junaedi, I Made I Made Gde Widnyana, I Made Gde I Made Gede Widnyana I Made Gede Widnyana I Made Subagiartha I Nyoman Hariyasa Sanjaya I Wayan Aryabiantara, I Wayan IB Krisna Jaya Sutawan, IB Krisna Jaya Ida Bagus Gde Sujana, Ida Bagus Gde IGNA Putra Arimbawa, IGNA Putra Kadek Agus Heryana Putra, Kadek Agus Heryana Ketut Semara Jaya, Ketut Semara Ketut Suastika Kurnia, Prajnaariayi Prawira Made Adi Kusuma Made Agus Kresna Sucandra, Made Agus Kresna Made Bakta Made Widnyana, Made Marilaeta Cindryani, Marilaeta Ni Putu Novita Pradnyani, Ni Putu Ni Putu Wardani, Ni Putu Okta, Ida Bagus Pande Nyoman Kurniasari, Pande Pontisomaya Parami, Pontisomaya Putu Agus Surya Panji, Putu Agus Putu Agus Surya Panji, Putu Agus Surya Putu Kurniyanta Putu Pramana Suarjaya Sinardja, Ketut Sonni Soetjipto, Sonni stefanus taofik, stefanus tjokorda agung senapathi, tjokorda agung Tjokorda Gde Agung Senapathi, Tjokorda Gde Tjokorda Gde Agung Senapathi, Tjokorda Gde Agung Tjokorda GdeAgung Senapathi, Tjokorda