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Background Emergency separation of conjoined twins is performed when one twin is already dead or dying and threatens the survival of the other. The particular decision to perform an emergency separation of conjoined twins provides an ethical dilemma that needs special attention. Adding to the complexity of surgical and postsurgical management in emergency separation, ethical and sociocultural aspects further complicate decision-making. Case presentation From 1987 to 2022, 18 conjoined twin separations were performed in our centre. This paper describes three conjoined twin emergency separations. In the first case of thoracoomphalopagus babies at nine days of age, one baby was diagnosed with necrotizing enterocolitis with frequent desaturation and seizures, and the other baby was healthy. Emergency separation was performed on the twelfth day of age; unfortunately, neither baby survived the surgery. In the second case, emergency separation was performed on the 110th day of life due to sepsis in one baby. The nonseptic twin passed away six hours after surgery, while the septic twin died 12 days after surgery due to wound dehiscence and abdominal sepsis. The third case was of an omphalopagus conjoined twin with a parasitic twin. The healthy baby was deemed nonviable but found to be healthy upon birth. Immediate emergency separation was performed at 2 h of age. The living baby survived the surgery but passed away two months later. Conclusions When separation is deemed necessary to save one twin, it becomes difficult to apply standard ethical medical reasoning. The decision to separate results in most cases in very high-risk surgeries with poor outcomes during surgery and postsurgery. Compounded by the complexity of the case, sociocultural and religious aspects further add to the dynamics of decision-making. A multidisciplinary team must work together with a health ethics committee and navigate through this ethical conundrum with the patient and family at its decision-making centre to decide on the best plan of care.

Introduction As one of the top ranks in the pain-producing procedure, spinal surgery requires adequate perioperative pain management to improve outcomes. Likewise, perioperative pain management in cirrhotic hepatic patients with thrombocytopenia is quite challenging. Modified TLIP block can be an option for perioperative pain management in the lumbar decompression surgery for a cirrhotic hepatic patient with thrombocytopenia. Case Presentation A man, 67 years old, who suffered from cirrhosis hepatic with thrombocytopenia underwent endoscopic spinal decompression with laminotomy and flavectomy of L4-L5. After induction of general anesthesia with midazolam 1,5 mg, fentanyl 150 mcg, propofol 100 mg, and rocuronium 1mg/kg, patient was intubated. The lungs were ventilated with a pressure control mode with tidal volume 8 ml/kg BW, respiratory rate 12/min, and PEEP 5 cmH2O with FiO2 50%. and 1% sevoflurane. Modified TLIP block was performed at L3 level. Twenty ml of bupivacaine 0,5% was administered between the longissimus and iliocostalis muscles on both sides. Results Intraoperative, modified TLIP block provide adequate analgesia with stable hemodynamics. The visual Analog Scale (VAS) of pain was 1-2 in 24h postoperative. No additional opioid was required within 24 hours postoperatively. There were no neurological complications or bleeding due to modified TLIP block found in this patient. Conclusion Modified TLIP block can be an effective and safe analgesic technique for hepatic cirrhosis patients with thrombocytopenia. However, further research is needed to determine the safety limits of modified TLIP block in patients with coagulation disorder or anticoagulant use.

BACKGROUND Coagulopathy is a serious COVID-19 complication that requires rapid diagnosis and anticoagulation. This study aimed to determine the role of coagulation examination using thromboelastography (TEG) on the decision-making time of anticoagulant therapy in COVID-19 patients and its clinical outcomes. METHODS A prospective observational study was conducted in Cipto Mangunkusumo Hospital, Indonesia, from October 2020 to March 2021. We consecutively recruited moderate and severe COVID-19 patients in the high and intensive care units. Turnaround time, time to anticoagulant therapy decision, and clinical outcomes (length of stay and 30-day mortality) were compared between those who had a TEG examination in addition to the standard coagulation profile examination (thrombocyte count, PT, APTT, D-dimer, and fibrinogen) and those who had only a standard coagulation profile laboratory examination. RESULTS Among 100 moderate to severe COVID-19 patients recruited, 50 patients had a TEG examination. The turnaround time of TEG was 45 (15–102) min versus 82 (19–164) min in the standard examination (p<0.001). The time to decision was significantly faster in the TEG group than the standard group (75 [42–133] min versus 184 [92–353] min, p<0.001). The turnaround time was positively correlated with time to decision (r = 0.760, p<0.001). However, TEG did not improve clinical outcomes such as length of stay (10.5 [3–20] versus 9 [2–39] days) and 30-day mortality (66% versus 64%). CONCLUSIONS The TEG method significantly enables quicker decision-making time for moderate to severe coagulation disorder in COVID-19 patients.