Backgrounds. The incidence of molar pregnancies has increased during the COVID-19 pandemic. Molar pregnancy can cause hyperthyroidism and if not treated immediately can worsen the patient's condition. Molar pregnancy with hyperthyroidism infected with SARS-CoV-2 pose a challenge for anesthesiologists in perioperative management to prevent complications of thyroid crisis and worsening of COVID-19. Case presentation. A 38-year-old woman was referred to our hospital with a gestational age of 11-12 weeks with vaginal bleeding. Since 2 weeks before being admitted to the hospital the patient complained of fever and the last 3 days had a cough and runny nose. She had no history of contact with COVID-19 patient. On physical examination, her blood pressure was 160/90 mmHg, heart rate was 114 beats per minute, respiratory rate was 18 times per minute, SpO2 was 97% on room air, and body temperature was 37.4oC. Laboratory tests revealed hemoglobin levels of 9.2 g/dl, hCG levels > 1,000,000 mIU/ml, and thyroid function tests showed hyperthyroidism. Obstetric ultrasound examination revealed a molar pregnancy. A Burch-Wartofsky score was 20. The results of the real-time transcription polymerase chain reaction (RT-PCR) test were positive for SARS-CoV-2. Preoperatively she was treated with 100 mg of propylthiouracil (PTU) orally every 8 hours and 20 mg of propranolol orally once a day. We performed the curettage suction on the next day under spinal anesthesia using 10 mg of 0.5% hyperbaric bupivacaine. Surgery lasted 90 minutes and performed uneventfully. Evaluation up to 30 days after curettage we found no complications of thyroid crisis and worsening of COVID-19. Conclusion. In patients infected with SARS-CoV-2, innate immune dysregulation due to hyperthyroidism can worsen the clinical course of COVID-19, and conversely, SARS-CoV-2 infection can cause thyroid hormone disorders. Spinal anesthesia is safe to perform in molar pregnancy patients with hyperthyroidism accompanied by COVID-19.

Latar Belakang: Corona Virus Disease 2019 (COVID-19) adalah penyakit pandemi yang menjadi masalah global yang melanda seluruh dunia. Manifestasi klinis dan tingkat keparahan penyakit COVID-19 sangat bervariasi. Pada pasien COVID-19 derajat kritis yang memerlukan perawatan di intensive care unit (ICU) telah ditemukan adanya proses badai sitokin yang meningkatkan mortalitas dan morbiditas. Interleukin-6 (IL-6) berperan dalam terjadinya badai sitokin.Kasus: Berikut kami laporkan serial kasus 5 pasien COVID-19 terkonfirmasi positif derajat sedang-kritis yang diberikan tocilizumab (TCZ) sebagai suatu IL-6 inhibitor yang memiliki potensi terapi menurunkan mortalitas dan morbiditas pasien COVID-19 derajat berat-kritis.Pembahasan: Dari 5 pasien yang diberikan TCZ, didapatkan hasil 3 pasien bisa pulang dan 2 pasien meninggal. Terdapat potensi pemberian IL-6 inhibitor karena dari patofisiologi penyakit COVID-19 yang berkaitan dengan IL-6 dan badai sitokin. IL-6 inhibitor dapat menurunkan mortalitas dan morbiditas dengan mencegah terjadinya badai sitokin. Hal ini diukur menggunakan evaluasi onset penyakit, kadar biomarker inflamasi dan gangguan koagulasi yang sering diteliti pada pasien COVID-19 seperti c-reactive protein (CRP), lactate dehydrogenase (LDH), D-Dimer dan ferritin.Kesimpulan: Pemberian TCZ memiliki potensi efek terapeutik jika diberikan pada onset penyakit <10 hari. Perlu dilakukan penelitian lebih lanjut untuk menilai efek terapeutik dan timing pemberian yang tepat.

Latar Belakang: Corona Virus Disease-19 (COVID-19) merupakan penyakit pandemi yang dapat menyebabkan komplikasi tromboemboli sebagai akibat terjadinya koagulopati dengan insidensi sekitar 16.5-21%.  Salah satu patofisiologi koagulopati pada pasien COVID-19 disebabkan oleh proses inflamasi. Peningkatan faktor inflamasi, faktor koagulasi, dan skoring klinis digunakan sebagai prediksi terjadinya komplikasi tromboemboli. Pemberian antikoagulan memiliki peran untuk mencegah terjadinya komplikasi tersebut.Kasus: Pasien laki-laki, 43 tahun, positif COVID-19 dengan skor PADUA = 4, peningkatan D-dimer dan mendapatkan terapi profilaksis antikoagulan. Dalam perawatan hari ke-14, sesak napas memberat, takikardi dan hipoksemia dialami pasien. Didapatkan gambaran Humpton’s hump pada foto toraks dan gambaran elektrokardiography (EKG) pola S1Q3T3 dan corrected QT interval (QTc) 552 mms. Penatalaksanaan pasien dengan ventilasi mekanik dan terapi unfractionated heparin (UFH) dosis terapeutik. Saat pasien bebas dari sedasi, ditemukan kelemahan tubuh bagian kiri.Diskusi: Gejala klinis emboli paru umumnya berupa dispnea/takipnea, takikardi, sianosis, hemoptisis, hipoksemia dengan onset akut. Berdasarkan keparahannya, dibagi menjadi masif, sub-masif, risiko rendah. Gambaran Humpton’s hump pada foto toraks dapat menjadi dugaan terjadi emboli paru. Pemeriksaan computed tomography pulmonary angiogram (CTPA) merupakan standar diagnosisnya, namun EKG dapat digunakan sebagai modalitas kecurigaan emboli dengan gambaran takikardi/takiaritmia, pola S1Q3T3 dan pemanjangan interval QTc. Pemberian antikoagulan sebagai tromboprofilaksis tetap tidak dapat mencegah terjadinya komplikasi tromboemboli seperti terjadinya stroke iskemik, tetapi emboli paru merupakan komplikasi tromboemboli yang paling sering terjadi.Kesimpulan: Evaluasi klinis, EKG secara rutin dan kadar D-dimer dapat menjadi pertimbangan dalam pemberian tromboprofilaksis dan dapat menjadi strategi penapisan awal risiko komplikasi tromboemboli. Pada pasien COVID-19 derajat kritis perlu dipertimbangkan pemberian antikoagulan yang lebih agresif dan menggunakan dosis terapeutik.

Introduction: The management of conjoined twins requires multidisciplinary teamwork. The complex problems in conjoined twin separation surgery are challenging for anesthesiologists without experience in the management of conjoined twins. Objective: To describe anesthetic management and utilization of teleanesthesia in conjoined twin separation surgery. Case Report: Sixty days-old pygopagus type conjoined twins, with a total body weight of 7030 grams. Both babies looked healthy, moved actively, found no respiratory function disorders, were hemodynamically stable and had no congenital abnormalities. The sacral region's computerized tomography scan (CT-scan) reveals conjoined twins with skin unification and subcutaneous in the perianal region and no internal-vertebral-spinal fusion. Two anesthesia teams performed the management of anesthesia. After confirming there was no cross-circulation with the atropine test, we alternately induced anesthesia by inhalation technique while maintaining spontaneous breathing. Anesthesia was maintained with sevoflurane 2.0-3.0 vol%, in a mixture of oxygen and air with a flow of 4 L/min using Jackson Reese. Circulating volume, hemodynamic stability, and normothermia were maintained intraoperatively. The separation surgery lasted 20 minutes, and the total surgical time for each baby was two hours. Awake extubation was performed immediately after the surgery was complete. Both babies underwent postoperative care at the PICU and were discharged on day 11. During the pre-operative for surgery, the local team conducted telemedicine consultations with the pediatric anesthesia team at Dr. Soetomo hospital and performed intra-anesthesia telementoring. Conclusion: Careful preparation and pre-operative evaluation, proper intra-anesthesia maintenance and monitoring, as well as good communication and teamwork, are keys to successful anesthesia management in conjoined twin separation surgery. Consultation and assistance from an experienced team during surgery using teleanesthesia are significantly beneficial to the anesthesiologist without experience in conjoined twin separation surgery.

Background. Elective surgery during the COVID-19 pandemic must continue to prevent a backlog of surgical cases. Several institutions are implementing a COVID-19-free surgical pathway to minimize the risk of SARS-CoV-2 transmission. This study aimed to assess the safety of patients undergoing surgery against hospital-acquired SARS-CoV-2 infections by implementing a COVID-19-free pathway. Methods. This study is cross-sectional of 572 patients who underwent elective surgery with a COVID-19-free pathway. All patients underwent two days of quarantine in the hospital for RT-PCR testing. A negative COVID-19 test result is valid within 48 hours before surgery, and all surgeries were performed in a non-COVID-19 operating room. Age, gender, ASA classification, type of anesthesia, surgery criteria, length of stay, and ICU admission were the baseline characteristics of the patients in this study. The outcome in this study was hospital-acquired SARS-CoV-2 infections after the patient underwent surgery based on COVID-19 symptoms during hospitalization and 14 days after discharge. Results. This study involved 303 males (53%) and 269 females (47%) with a mean age of 40.16 years ± 11.35 years (12 days–84 years). According to the ASA classification, 44 patients (7.7%) ASA I, 450 (78.7%) ASA II, 77 (13.4%) ASA III and 1 (0.2%) ASA 4. Major or complex surgery criteria accounted for 48% (277) of all surgeries. One hundred and fifty-seven patients (27,4%) underwent postoperative hospitalization for 0-3 days, 190 (33.3%) 4-7 days, and 225 (39.3%) had a length of stay ≥ 8 days. None of the patients showed postoperative COVID-19 symptoms. Three patients died postoperatively, but their deaths were not COVID-19 related. Fourteen days after discharge, eight patients (3%) had fever and cough but did not perform the RT-PCR test. These eight patients experienced clinical improvement and recovery. Conclusion. Implementing a COVID-19-free pathway provides safety for patients from hospital-acquired SARS-CoV-2 infections.