Aulyan Syah, Bau Indah
Departement of Anesthesiology and Intensive Care Dr. Hasan Sadikin Hospital Bandung

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Penatalaksanaan Anestesi pada Pasien Cedera Kepala Berat akibat Hematoma Epidural Akut disertai Kehamilan Aulyan Syah, Bau Indah; Suarjaya, I Putu Pramana; Rahardjo, Sri; Saleh, Siti Chasnak
Jurnal Neuroanestesi Indonesia Vol 6, No 3 (2017)
Publisher : Departement of Anesthesiology and Intensive Care Dr. Hasan Sadikin Hospital Bandung

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.24244/jni.v6i3.54

Abstract

Penanganan cedera kepala berat selalu bertujuan untuk mempertahankan tekanan perfusi otak (TPO) dan mencegah peningkatan tekanan intrakranial yang dapat menyebabkan cedera otak sekunder. Pada pasien dengan kehamilan, janin juga harus dipantau. Hiperventilasi harus dihindari karena berefek buruk terhadap perfusi otak dan aliran darah plasenta. Seorang wanita, 25 tahun, 60 kg, 160 cm datang ke rumah sakit akibat trauma kepala karena kecelakaan lalu lintas yang dialami kurang dari 1 jam sebelum masuk rumah sakit dengan GCS E4M6V4. Pasien dalam keadaan hamil G1P0A0 dengan usia kehamilan 28–30 minggu. Di unit gawat darurat terjadi penurunan kesadaran mendadak hingga GCS E1M5V1 sehingga dilakukan intubasi endotrakhea disusul dengan pemeriksaan CT Scan dengan hasil hematoma epidural dekstra dan hematoma subarachnoid disertai midline shift. Pasien kemudian menjalani operasi evakuasi hematoma epidural dengan anestesi umum kemudian di rawat di unit perawatan intensif dengan pipa endotrakhea masih dipertahankan. Denyut jantung janin (DJJ) masih terdengar dan dilakukan observasi ketat DJJ selama perawatan di ICU. Namun setelah beberapa hari di ICU, janin dinyatakan meninggal. Ringkasan: Pasien cedera kepala berat dengan hematoma epidural dan subarachnoid disertai kehamilan telah menjalani operasi anestesi umum dengan tetap memperhatikan pemeliharaan tekanan perfusi otak (TPO) dan mempertahankan kondisi janin dalam batas normal. Meskipun pada akhirnya janin tidak bisa diselamatkan akibat lamanya perawatan ibu dengan ventilator.Anesthesia Management for Patients in Pregnancy with Severe Head Injury Due to Acute Epidural Hematoma Management of severe head injury cases, in any given situation, is targeted to maintain cerebral perfusion pressure (CPP), and preventing increase of intracranial pressure that possibly cause secondary brain injury. In a case of pregnancy, besides considering the maternal status, fetus condition is equally important to observe. Hyperventilation should be avoided due to its possible detrimental effect to both the brain perfusion and placental blood flow. A 25 year old female, 60 kg, 160 cm, was taken to the hospital due to head trauma caused by a traffic accident, roughly about an hour prior to hospitalization. GCS was E4M6V4. The patient was in her 28 – 30 week of pregnancy (G1P0A0). Sudden decrease in consciousness occurred and GCS lowered to E1M5V1. Endotracheal intubation was then prompted. Epidural haematoma subarachnoid haematoma with midline shift revealed in CT scan. The patient underwent epidural hematoma evacuation with general anesthesia then transferred to Intensive Care Unit (ICU) with ETT maintained. Fetal heart rate remains heard, followed with close monitoring of the fetal heart rate during treatment in the ICU. After 3 days in ICU, fetus died. Summary: A pregnant patient with severe head injury of epidural and subarachnoid bleeding, has undergone an operation with general anesthesia. The fetus was unfortunately cannot be saved due to the patient long ventilator treatment.
Tatalaksana Anestesi pada Microvascular Decompression (MVD) Aulyan Syah, Bau Indah; Saleh, Siti Chasnak; Rahardjo, Sri
Jurnal Neuroanestesi Indonesia Vol 4, No 1 (2015)
Publisher : Departement of Anesthesiology and Intensive Care Dr. Hasan Sadikin Hospital Bandung

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Abstract

Microvascular decompression (MVD) nervus kranialis merupakan salah satu terapi untuk trigeminal neuralgia, spasme hemifacialis, dan neuralgia glosspharyngeal. Seorang wanita 52 tahun masuk ke rumah sakit dengan keluhan utama kedutan pada wajah sebelah kiri selama 17 tahun dan telah berobat ke beberapa dokter, termasuk suntikan botoks, namun hasilnya tidak memuaskan. Pemeriksaan MRI otak menunjukkan persilangan arteri cerebellaris anterior inferior (AICA) kiri dengan N. VII di daerah entry zone. Hal ini dapat menyebabkan TIC fasialis kiri. Pasien ini didiagnosis dengan spasme hemifasialis sinistra dan akan menjalani prosedur MVD. Pasien dianestesi dengan teknik anestesi umum intubasi endotrakea dengan menerapkan prinsip-prinsip neuroanestesia. Pada pasien ini tidak ditemukan tanda-tanda peningkatan tekanan intrakranial, namun dalam memfasilitasi pembedahan untuk dekompressi saraf yang tertekan, sangat penting untuk menurunkan volume otak. Karena itu, diterapkan beberapa metode, seperti hiperventilasi volunter, pemberian mannitol 20% 150mL dengan mempertahankan batas autoregulasi. Kombinasi anestesi inhalasi (sevofluran 0,6-1,5%) dan intravena (propofol kontinyu 60–100mg/jam), relaksasi dengan vecuronium kontinyu 2,5–4,5mg/jam. Cairan rumatan dipilih ringer fundin 400ml dan NaCl 0,9% 500ml melalui 2 jalur intravena. Operasi berjalan selama 2 jam, pendarahan sebanyak 150mL, urin 1000mL dilakukan ekstubasi segera setelah operasi selesai. Pasca anestesi, pernapasan dan hemodinamik stabil dan adekuat. Pemeriksaan neurologis di ruang pemulihan didapatkan kedutan menghilang Anesthesia Management for Microvascular Decompression (MVD)Microvascular decompression (MVD) cranial nerves as a therapy for trigeminal neuralgia, hemifacial spasm, and glosso pharyngeal neuralgia. A 52 years old female, came to the hospital due to the twitching on the left side of her face. She had been experiencing the twitching for over 17 years, had been treated by several doctors, including Botox injection, but with no satisfying outcome. MRI examination showed intercrossing of the left anterior inferior cerebellar artery (AICA) with the seventh cranial nerve in the area of entry zone. The condition caused the left facial TIC. She was diagnosed with left hemifacial spasm and planned for a MVD procedure. The patient was anesthetized with endotracheal intubation under general anesthesia using neuroanesthesia principles. There was no sign of increased intracranial pressure. Nevertheless, it is importance to facilitate the nerve decompression procedure by reducing the brain volume that can be perform with several methods, such as voluntary hyperventilation, administering mannitol 20% 150 mL while maintaining the autoregulation level. Combination of inhalation (sevofluran 0,6-1,5%) and intravenous anesthesia (propofol continuously 60–100mg/hour) was chosen, relaxation was obtained with continuous vecuronium 2,5-4,5mg/hr. Maintenance of intravenous fluids were Ringer fundin 400ml and NaCl 0,9% 500ml delivered via two intravenous routes. The operation was last for 2 hours, the amount of bleeding was 150 mL, and the urine was 1000 mL. The patient was extubated immediately after the operation. Breathing and hemodynamic post anesthesia were both stable and adequate. Neurological examination in the recovery room revealed no more twitching observed.
Penatalaksanaan Anestesi untuk Operasi Tumor Fossa Posterior disertai Hidrosefalus Aulyan Syah, Bau Indah; Rahardjo, Sri; Saleh, Siti Chasnak
Jurnal Neuroanestesi Indonesia Vol 4, No 3 (2015)
Publisher : Departement of Anesthesiology and Intensive Care Dr. Hasan Sadikin Hospital Bandung

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Abstract

Operasi tumor fossa posterior mempunyai permasalahan spesifik antara lain penekanan jalur aliran cairan serebrospinal sehingga terjadi hidrosefalus yang akan meningkatkan tekanan intrakranial. Seorang wanita 25 tahun, berat badan 52 kg masuk ke rumah sakit dengan keluhan utama kepala pusing yang dialami sejak 5 jam sebelum masuk rumah sakit disertai mual, muntah, telinga rasa berdengung, dan nyeri ulu hati. Hasil pemeriksaan MSCT kepala axial tanpa kontras ditemukan hidrosefalus non-communicating, tumor serebellum hemisfer kanan, curiga astrositoma, diagnosis banding medulloblastoma. Pada pemeriksaan MSCT kepala potongan aksial, coronal dan sagittal dengan kontras ditemukan massa tumor daerah fossa posterior, sangat mungkin suatu pilokistik serebelar astrositoma disertai hidrosefalus ringan, didiagnosis hidrosefalus tipe obstruksi dan tumor serebellum serta ditemukan tanda-tanda peningkatan tekanan intrakranial dengan hidrosefalus, sehingga dilakukan pemasangan VP-shunt sebelum eksisi tumor. Teknik anestesi dilakukan dengan metode untuk mempertahankan perfusi otak sambil memelihara otak tetap rileks demi memfasilitasi pembedahan seperti hiperventilasi, pemberian mannitol 20% dan mempertahankan MAP yang adekuat. Operasi VP-shunt dalam posisi supine dan operasi fossa posterior dalam posisi prone berlangsung selama 4,5 jam. Dilakukan penundaan ekstubasi postoperatif. Ekstubasi dilakukan keesokan harinya di unit perawatan intensif. Pasien tersedasi dan terventilasi selama 14 jam. Tidak ditemukan adanya emboli udara vena. Pasca ekstubasi, pernapasan adekuat, hemodinamik stabil, dan tidak ada gangguan neurologis yang signifikan. Management of Anesthesia for Fossa Posterior Tumor with Hydrocephalus Surgery Fossa posterior tumor removal procedure may have spesific problem including obstruction of cerebral spinal fluid pathway, development of hydrocephalus and an increased intracranial pressure. A 25 year old woman, 52 kgs, admitted to the hospital with major complaint of dizziness occurred approximatelly 5 hours prior to hospital admission. The patient also suffered from nausea, vomiting, buzzing hearings, and heartburn sensation. The non-contrast MSCT revealed a non-communicating hydrocephalus, tumor of the right cerebellar hemisphere, suspected as astrocytoma with differential diagnosis of medullablastoma. From axial, coronal and sagittal view of MSCT with contrast, a tumor mass was found in the posterior fossa, and most likely to be considered as a polycystic cerebellar astrocytoma with mild hydrocephalus. She was diagnosed with obstructive type of hydrocephalus and cerebellar tumor with increased intracranial pressure signs due to hydrocephalus, and planned for VP shunt prior to the tumor removal. To maintain brain perfusion as well as to ensure brain relaxation, anesthesia management was done with several methods such as hyperventilation, administration of mannitol 20%, while maintaining adequacy of MAP. The VP shunting was conducted in supine position, whilst the posterior fossa excision in conducted in prone position. Both procedures were done in 4.5 hours. Postoperative extubation was postponed until the following day at the intensive care unit. The patient was sedated and ventilated for 14 hours. No sign of venous air embolisms. Post extubation on the next day, the patient’s breathing and hemodynamic statuses were both stabile and adequate, with no significant neurological defect.
Terapi Hipotermia pada Stroke Hemoragik Aulyan Syah, Bau Indah; Fuadi, I; Rahardjo, Sri
Jurnal Neuroanestesi Indonesia Vol 4, No 1 (2015)
Publisher : Departement of Anesthesiology and Intensive Care Dr. Hasan Sadikin Hospital Bandung

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Abstract

Terapi antipiretik merupakan salah satu terapi yang dianjurkan untuk pasien stroke karena peningkatan suhu tubuh dianggap berhubungan dengan luaran neurologis yang buruk. Namun demikian, belum ada rekomendasi yang paling tepat untuk kontrol demam baik secara farmakologi maupun mekanik akibat kurangnya temuan klinik.Saat ini, hipotermi terapeutik dianggap satu-satunya metode neuroprotektif yang sukses dalam meningkatkan luaran pasien stroke iskemik. Istilah neuroprotektif disini mengacu pada memelihara atau melindungi cedera saraf yang reversibel agar tidak rusak atau mengalami kematian sel. Metode hipotermi dianggap berpengaruh terhadap sejumlah jalur patofisiologi stroke. Pada penelitian in vitro, hipotermi mencegah edema serebral dan kerusakan sawar darah otak. Selain itu, mencegah aktivasi mikroglia, produksi radikal bebas, dan pelepasan neurotransmitter eksitotoksik serta asam laktat dan piruvat. Selain itu, cerebral metabolic rate (CMR), apoptosis dan respon inflamasi lokal juga berkurang. Hipotermi otak secara lokal dilaporkan menurunkan ekspresi gen interleukin-1b dan pembentukan edema vasogenik pada model perdarahan intraserebrial binatang. Hipotermi terapeutik dianggap lebih efektif bila dimulai lebih awal setelah onset gejala. Durasi hipotermia yang lebih lama juga memiliki efek neuroprotektif persisten dalam jangka waktu lama. Namun demikian, terapi hipotermia memiliki beberapa komplikasi terhadap jantung, paru-paru, immunologi, hematologi, dan metabolik. Komplikasi yang paling sering dilaporkan adalah pneumonia, bradikardi, aritmia, dan trombositopenia. Evaluasi efektivitas hipotermia sulit dievaluasi pada pasien yang tersedasi karena pemeriksaan neurologis harian seringkali membingungkan. Hypothermia Therapy in Hemorrhagic StrokeAntipyretic is among one of the suggested therapies for stroke patients. The reason is because increase in body temperature is considered related to bad neurological outcomes. However, there is no best recommendation available for controlling the temperature, neither pharmacologically nor mechanically due to less clinical practices findings available. Currently, therapeutic hypothermia is considered as the one and only successful neuroprotective in enhancing the ischemic strokes patients’ outcomes. The term neuroprotective refers to protecting or conserving various types of reversible neurological injuries from damage or further cell impairment. In vitro studies showed hypothermia prevent cerebral edema and blood brain barrier damage, as well as successfully proven effective in preventing microglia activation, free radical production, and release of exotoxic neurotransmitters, lactic acid and piruvate. In addition, cerebral metabolite rate (CMR), apoptosis, and local inflammatory response are also decreased. Local brain hypothermia is reported could lowering the 1b-interleukin gen expression and establishment of vasogenic edema among animal models with intracerebral hemorrhage. Therapeutic hypothermia is considered highly effective when initiated early in subsequent to the symptom onset. Longer duration of cooling is related to a more persistent neuroprotective effect in long periode. Despite its effectiveness, therapeutic hypothermia could generate several complications affecting the heart, lung, immunology, hepatology and metabolic states. The most common complications are pneumonia, bradicardia, arrhythmia, and thrombocytopenia. Evaluation to the effectiveness of hypothermia is difficult to measure in sedated patients due to difficulty in defining the patient’s neurological states on day to day bases
Manajemen Cairan dan Elektrolit pada Pasien Cedera Kepala Aulyan Syah, Bau Indah; Gaus, Syafruddin; Rahardjo, Sri
Jurnal Neuroanestesi Indonesia Vol 5, No 3 (2016)
Publisher : Departement of Anesthesiology and Intensive Care Dr. Hasan Sadikin Hospital Bandung

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Abstract

Manajemen pasien cedera kepala harus selalu difokuskan pada penatalaksanaan cedera primer dan cedera sekunder. Pemeliharaan perfusi serebral dan pencegahan hipertensi intrakranial yang mencakup pemeliharaan osmolalitas merupakan bagian penting dalam tatalaksana cairan dan elektrolit pasien cedera kepala, terutama bila diduga sawar darah otak tidak intak. Pemberian dan jenis cairan harus mempertimbangkan ketidakmampuan otak pasien dalam mengatasi perubahan volume dan osmolalitas seluler dan peningkatan konsumsi oksigen serebral. Target tekanan perfusi serebral antara 50–70 mmHg. Pemilihan jenis cairan pada cedera kepala masih kontroversi, karena baik koloid maupun kristaloid dianggap memiliki efek samping yang sama beratnya terhadap otak yang cedera. Dari penelitian SAFE (Saline and Albumin Fluid Evaluation) ditemukan luaran mortalitas-28 hari yang lebih tinggi pada pasien yang menerima koloid (albumin 4%) dibanding yang menerima kristaloid (salin isotonik). Sifat hipotonis albuminlah (osmolalitas 260 mOsml/kg) yang membahayakan pasien cedera kepala, bukan karena sifat koloidnya. Rekomendasi terkini menganjurkan penggunaan larutan isotonik seperti NaCl 0,9%. Penanganan hipertensi intrakranial pada cedera kepala juga sering melibatkan terapi hiperosmolar, dan yang paling dominan adalah mannitol yang dianjurkan hanya untuk jangka pendek dan pada sawar darah otak yang intak, serta dalam cakupan osmolaritas darah 300–310 mOsm/l. Selain mannitol, salin hipertonik dapat menjadi alternatif, namun harus dihindari bila kadar natrium serum lebih dari 160 mmol/L.Fluid and Electrolyte Management in Head Injury PatientTreatment for head trauma patients should always be focused on the management of the primary and secondary trauma. Maintaining cerebral perfusion and preventing intracranial hypertension, which include maintaining cerebral osmolality, is part of the crucial fluid and electrolyte management for patients with head injury, particularly when the blood brain barrier is assumed to be no longer intact. Fluid administration and the type of the fluids given should carefully account the patient brain capability to adjust to volume change and cellular osmolality, and to an increase in cerebral oxygen consumtion. Target of cerebral perfusion pressure in the range of 50-70 mmHg. The preference fluid for patients with head injury remains controversial, because either colloid or crystalloid fluids are both believed to be equally detrimental in side effects. However, SAFE (Saline and Albumin Fluid Evaluation) research revealed 28 days mortality outcome higher among patients receiving colloid (4% albumin) compared to those receiving crystalloid (Isotonic saline). It was the hypotonisity of the albumin (osmolality 260 mOsml/kg) that was harmful in nature for the patients brain, instead of its colloid characteristics. Recent updates recommend using isotonic solution such NaCl 0.9%. Intracranial hypertension management in head injury cases is frequently combined with hyperosmolar therapy, which dominantly using mannitol which is recommended limited to certain circumstances: short period of administration, intact condition of blood brain barrier, and with osmolarity coverage in range of 300-310 mOsml/L. As alternative, hypertonic saline can also be used, hence should be avoided when sodium serum concentration is higher than 160 mmol/L.