Background: Pain management after craniotomy is very important, 60-84% patient experience moderate to severe pain. Postoperative pain especially transmitted by C fiber neurons involved neuropeptide Substance P (SP). Postoperative opioid analgesia gives some adverse effect, such as allergy, gastrointestinal effect, nausea. vomiting, hypotension, sedation, repiratory depression and urinary retention. Paracetamol has opioid sparing effect that may reduce the need of opioid analgesia, and also inhibits SP mediated hyperalgesia. Objective: To study the effect of perioperative intravenous paracetamol on SP level in post craniotomy patientMethods: Forty subject aged 18 -45 years underwent elective craniotomy intracerebral tumour resection who have ASA physical status I-II, divided into 2 groups. P group received 1000 mg intravenous paracetamol every 6 hours during 24 hours postoperative, K group received placebo. Postoperative analgesia using morphine syringe pump 0,01 mg/Kg/hour titration to VAS. SP serum levels were examined with Cusabio substance Elisa kit ELx 800 before and 12 hours after surgery. Visual Analog Scale noted in 1, 6, 12, and 24 hours postoperative. Total amount of morphine given, nausea and vomiting was noted.Results: Preoperative SP level in P group was 16,89± 31,395 pg/ml and 36,58 ± 46,960 pg/ml postoperatively. Preoperative SP Level in K group was 9,58 ± 10,656 pg/ ml and 26,09 ± 22,506 pg/ml postoperatively. SP level elevation in P group and K group were 19,69± 28,625 pg/ml and 16,51 ± 14,972 pg/ml. Postoperative SP level and the elevation were not significantly different between two groups (p=0,793 and p=0,540), VAS and total amount of morphine given was significantly different (p<0,05). Conclusion:Perioperative intravenous paracetamol reduced morphine consumption and gave better VAS in post craniotomy patient, but did not affected postoperative SP level.

Latar belakang: Epilepsi refrakter merupakan epilepsi yang tidak membaik dengan pemberian obat anti epilepsi yang adekuat. Epilepsi refrakter terjadi pada 30-40% pasien dengan epilepsi. Bedah epilepsi merupakan salah satu tatalaksana dalam epilepsi refrakter, dan penggunaan elektrokortikografi dapat membantu menentukan daerah yang dioperasi. Penggunaan obat-obatan anestesi memiliki pengaruh terhadap gelombang electrocorticography (ECoG), sehingga diperlukan pendekatan anestesi khusus. Pada laporan kasus ini akan dibahas manajemen perioperatif anestesi untuk operasi lesionektomi dengan bantuan ECoG pada pasien epilepsi refrakter.Kasus: Seorang laki-laki 24 tahun dengan epilepsi refrakter, post kraniotomi pemasangan EEG intrakranial, post kraniotomi evakuasi extra dural haemorraghe (EDH), bronchitis dalam pengobatan direncanakan untuk dilakukan tindakan lesionektomi dengan elektrokortikografi. Pasien memiliki riwayat epilepsi dengan pengobatan rutin berupa asam valproat, namun kejang masih terus terjadi. Kejang berupa kelojotan pada kedua lengan terutama sisi kiri. Kejang berdurasi 10 menit dengan frekuensi kejang 2-10 kali per hari. Sebelum kejang pasien seringkali merasakan adanya kesemutan pada kedua lengan, dan setelah kejang pasien merasa mengantuk. Durante operasi pasien diberikan dosis maintainace dari propofol dan rocuronium. Saat perekaman ECoG, infus propofol dihentikan, sementara rocuronium tetap diberikan. Setelah perekaman ECoG, dilakukan reseksi dan dosis maintainance propofol kembali diberikan sampai operasi selesai.Pembahasan: Bedah reseksi atau lesionektomi merupakan bedah pengangkatan daerah epileptogenik tanpa menyebabkan defisit neurologi permanen. Penggunaan subdural ECoG intraoperatif atau ekstraoperatif dapat membantu untuk menentukan zona epileptogenik akurat. Apabila ECoG dilakukan, anestesi umum perlu disesuaikan agar gelombang ECoG dapat dipertahankan.Kesimpulan: Agen anestesi dosis rendah seperti fentanil, alfentanil, remifentanil, sufentanil dan propofol dapat digunakan untuk operasi epilepsi tanpa mempengaruhi ECoG.

Background: Monitoring of hemoglobin saturation during management of airway is important for patients. Desaturation below 70% can lead patient to dysrhythmic, hemodynamic decompensation, brain damage due to hypoxia and death. The challenge for emergency doctor is to perform agile and swift endotracheal intubation to patients without getting hypoxia or aspiration. Preoxygenation with 100% oxygen before induction of anesthesia is an extensive maneuver that can increase the body's oxygen storage, adjourning the onset of desaturation during apnea period after induction of anesthesia and musclerelaxants. Objective: The purpose of preoxygenation is to replace nitrogen in FRC with oxygen; which is called the denitrogenation. This has an impact on the body's oxygen storage and increases tolerance for substantial apnea. Effective preoxygenation produces safe limits for emergency intubation and prolongation of apnea duration without getting desaturation. Method: Preoxygenation in the operating room uses a circuit attached to theanesthesia machine, which will provide high FiO2. Then, the success of preoxygenation can be evaluated by estimating denitrogenation level using gas analyzer to determine the concentration of exhaled oxygen fraction (FeO2). For the operation of patients with high risk aspiration, anesthesia develops induction with quick sequences by giving sedative and paralytic without ventilation simultaneously while waiting the paralytic effects which can help to reduce aspiration risk. The supine position is not ideal for achieving optimal preoxygenation because it becomes more difficult to breathe and the posterior lungs become susceptible to collapse. On the contrary, Trendelenburg position will increase preoxygenation and may be beneficial in immobilized patients due to possible spinal cord injury. Conclusion: In apnea condition, the factor that have the greatest effect in hypoxia are FRC, alveoli's oxygen concentration, and metabolic rate. The hemoglobin concentration and the circulation shunting level are less important factors. Anesthesiologists can avoid Preoxygenation in General Anesthesia