BackgroundOver the past 16 years, sepsis management has been guided by large-volume fluid administration to achieve certain hemodynamic optimization as advocated in the Rivers protocol. However, the safety of such practice has been questioned because large-volume fluid administration is associated with fluid overload and carries the worst outcome in patients with sepsis. Researchers in multiple studies have declared that using less fluid leads to increased survival, but they did not describe how to administer fluids in a timely and appropriate manner.Case presentationAn 86-year-old previously healthy Sundanese man was admitted to the intensive care unit at our institution with septic shock, acute kidney injury, and respiratory distress. Standard care was implemented during his initial care in the high-care unit; nevertheless, his condition worsened, and he was transferred to the intensive care unit. We describe the timing of fluid administration and elaborate on the amount of fluids needed using a conservative fluid regimen in a continuum of resuscitated sepsis.ConclusionsBecause fluid depletion in septic shock is caused by capillary leak and pathologic vasoplegia, continuation of fluid administration will drive intravascular fluid into the interstitial space, thereby producing marked tissue edema and disrupting vital oxygenation. Thus, fluids have the power to heal or kill. Therefore, management of patients with sepsis should entail early vasopressors with adequate fluid resuscitation followed by a conservative fluid regimen.

Cedera otak traumatik (COT) masih menjadi masalah kesehatan utama di seluruh dunia. Meskipun terjadi penurunan angka kejadian COT saat pandemi COVID-19 karena mobilisasi yang dibatasi, namun karena keterbatasan akses ke fasilitas kesehatan, penanganan COT menjadi terlambat. Penanganan pasien COT dengan infeksi COVID-19 berbeda karena adanya protokol dan pertimbangan yang harus dilakukan untuk keselamatan tenaga medis dan kelancaran penanganan pasien. Laporan kasus ini mengenai laki-laki berusia 41 tahun datang dengan penurunan kesadaran pasca kecelakaan kendaraan bermotor 24 jam sebelum masuk rumah sakit (RS). Pasien merupakan rujukan dari RS lain dengan cedera kepala berat. Dari hasil Computed Tomography (CT) scan kepala didapatkan epidural hematoma (EDH) akut frontal kiri – frontal kanan parasagital yang menekan lobus frontal kiri – lobus frontal kanan parasagital dengan midline shift sejauh ± 1.35 cm. Hasil pemeriksaan screening menunjukan hasil swab PCR positif. Pasien awalnya akan dirujuk ke RS rujukan COVID-19 namun tidak berhasil mendapatkan rujukan. Perdarahan epidural merupakan kondisi yang mengancam nyawa sehingga tindakan harus segera dilakukan. Pasien menjalani operasi emergensi kraniotomi evakuasi EDH dalam anestesi umum dengan protokol COVID-19. Penanganan anestesi dengan memperhatikan COVID-19 dan implikasinya pada pasien, neuroanestesi, dengan tetap menerapkan protokol COVID-19

Vasospasme cerebral merupakan penyebab morbiditas dan mortalitas utama pada pasien dengan perdarahan subarahonid. Delayed ischemic neurologic deficit yang berhubungan dengan vasospasme serebral menyebabkan kematian pada 50% pasien yang bertahan pada periode awal setelah aneurisma ruptur yang ditangani. Onset vasospasme serebral yang bervariasi, mulai dari 24 jam pasca perdarahan subarahnoid atau subarahcnoid hemorrhage (SAH) sampai dengan 14 hari, patofisiologi vasospasme serebral yang kompleks dan cara diagnosis yang masih kontroversial, turut berkontribusi terhadap morbiditas dan mortalitas yang tinggi pada pasien dengan SAH. Evaluasi ketat selama perawatan di ICU untuk mendeteksi kejadian vasospasme serebral awal sangat penting, setiap gejala neurologis baru yang muncul harus diperiksa dan ditangani secepatnya. Banyak obat-obatan yang diteliti untuk mengatasi vasospasme serebral namun efektifitasnya masih dipertanyakan. Tatalaksana utama yang dulu diketahui adalah dengan melakukan terapi triple H, namun hal ini sudah ditinggalkan. Induced hypertension menjadi satu-satunya bagian dari terapi triple H yang masih digunakan, namun belum banyak dipergunakan secara luas. Oleh karena itu perlu dikaji lebih lanjut bagaimana tatalaksana SAH untuk mencegah luaran yang buruk.

Craniopharyngioma is a benign tumor characterized by cystic and calcification, surrounded by vital structures therefor it is difficult to perform total tumor resection. Combination with Gamma knife radiosurgery (GKRS) is the best treatment option. The complexities of GKRS consisting of several phases lasts for 6-10 hours. Anesthesia is needed for uncooperative patients. This is a case of a 4-year-old girl with cystic craniopharyngioma. The patient had chief complaint of blurry vision, physical examinations revealed bilateral papil atrophy. Result of MRI showed tumor mass compressing inferior hypophyse. Patient underwent the procedure under moderate sedation with Propofol at 75 mcg/kg/min for 6 hours. Intraoperative hemodynamic condition was stable without adverse events. Choice of anesthesia either general anesthesia or sedation, depends on the condition of patient, considerations from anesthesiologist dan neurosurgeon, dan availability of facilities. Unique considerations for GKRS are; a non-operating room anesthesia, long duration, transportation to other units such as radiology and cathlab, head of the patients need to be immobilized to prevent frame displacement, the patient will be alone in the treatment room, and principles of pediatric anesthesia and neuroanesthesia.

Incidence of pineal regio tumor is 0.4-1% of intracranial tumors. Its location which is buried between two cerebral hemispheres, close to brainstem and hypothalamus become a difficult challenge for the neurosurgeon. Surgery with supracerebellar approach in sitting position is the best method to access the lesion. Sitting position also facilitates the optimal visual field with minimal retractions. However, for anesthesiologist, sitting position is challenging since it has its own complexities during positioning the patient and the risk of complications. Venous air embolism is one of the main concern and if not detected early and treated appropriately would leads to cardiovascular collapse instantly. This is a case of a 38-year-old male with chief complaint of severe headache and blurred vision started 4 months before admission. The Magnetic Resonance Imaging showed a pineal region tumor with perifocal edema, without midline deviation. The patient underwent craniotomy tumor removal with sitting position. The procedure lasted for 10 hours and uneventful. The principle of ABCDE neuroanesthesia, sitting position and its implications, and difficult tumor location are some anesthesia considerations for this patient. A thorough preoperative evaluation, good communication and coordination between surgery and anesthesia team are needed for a smooth uneventful procedure performed in sitting position.