Background & objective: Patients with COVID-19 have Acute Respiratory Distress Syndrome (ARDS) which progresses to lung edema and disorders of the liver, kidneys and heart associated with cytokine storms, which are the body's immune response to SARS-CoV-2. SARS-CoV-2 patients showed clinical neutrophilia, increased D-Dimer and increased IL-6. In addition, increased lactate dehydrogenase and increased aminotransferase are often found. This study aimed to analyze the clinical relevance of increased IL-6 and lactate in the first 24 hours of ICU-admission of COVID-19 patients in predicting mortality rate. Methodology: This study was a retrospective cohort design. The study was conducted in the Intensive Care Unit (ICU) of Dr. Moewardi Surakarta Hospital. The study was conducted by tracing the medical records of COVID-19 patients treated in the ICU of Dr. Moewardi Surakarta Hospital during the period of March 1, 2020 to March 31, 2021 that met the admission criteria. The patient's mortality assessment is seen as the patient's condition for a maximum of 30 days after discharge from the hospital. Results: Variables that meet the regression model are the lactate levels (OR = 3,143; P = 0.064) as well as the IL-6 levels (OR = 25.41; p<0.001). AUC score of 86.9% with significance of < 0.001. IL-6 levels and lactate levels in the study can be used as predictors of mortality rates with 95.7% sensitivity and 60% specificity. Lactate levels in COVID-19 cases in severe cases can be related to lung damage and tissue damage. Lactate levels have also been recognized as a marker of poor prognosis in patients with COVID-19. IL-6 as a predictor of mortality risk has been recognized and the administration of IL-6 inhibitors in COVID-19 patients may lower the risk of mortality. Conclusion: Raised IL-6 and lactate levels in this study can be a predictor of the mortality rate of COVID-19 patients within 24 hours of ICU-admission. Citation: Nugroho A, Hapsari PP, Santoso SB, Permana SA, Sitompul H. Clinical relevance of IL-6 and lactate within 24 hours of ICU-admission of COVID 19 patient in predicting mortality rate. Anaesth. pain intensive care 2022;26(5):689−694. DOI: 10.35975/apic.v26i5.2032

Placenta accreta in cesarean section presents problem for an anesthesiologist. It may cause massive bleeding which is usually managed with massive transfusion. In this case series, we report cases of placenta accreta patients undergoing cesarean section managed with massive transfusion. A retrospective case series review of patients diagnosed with placenta accreta undergoing cesarean section with massive bleeding and massive transfusion was conducted between April 2018 and March 2019 in Dr. Moewardi General Hospital using the medical record data. A total of five patients with placenta accreta underwent cesarean section, and massive bleeding as well as massive transfusion was identified. Hysterectomy was performed at the time of cesarean section in all cases. All patients underwent general anesthesia, had central venous catheter, and required massive transfusion. Patients were transferred to the intensive care unit postoperatively. There were no transfusion reactions and maternal death.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has created severe medical and economic consequences worldwide since 2019. Tocilizumab is one of the therapies considered capable of improving the condition of patients with COVID-19. However, there is not much information about the best time to give tocilizumab. METHODS: This was an analytical study with a retrospective cohort design, using the data of 125 patients infected by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) with signs of acute respiratory distress syndrome in Dr. Moewardi Hospital, Surakarta, from March to August 2020. We analyzed various available clinical data to see which factors into clinical improvement with tocilizumab therapy. RESULTS: Most patients showed clinical improvement after administration of tocilizumab. During the follow-up period, 21 patients died despite tocilizumab therapy. Significant risk factors associated with the need for intubation were heart rate, neutrophil, lymphocyte, pH, PaCO2, and PO2. The most influential variable on the need for intubation without being associated with other risk factors was PaO2 (p = 0.003, Confidence Intervals 95%). CONCLUSIONS: Tocilizumab has a role in treating patients infected by SARS-CoV-2, preventing the need for intubation when given to patients in good saturation condition with oxygen supplementation without positive pressure (PaO2 >65mmHg; SpO2 >93%).

A 59 yrs old male with severe ARDS due to COVID-19 infection was in life threatening ‘cytokine storm’. He had also co-morbids including diabetes mellitus and hypertension. He had come from Grobogan, a red area for COVID-19. Clinical finding indicted systemic inflammatory response syndrome (SIRS) with dyspnea, tachycardia, and high fever. Laboratory tests showed raised leukocyte count, CRP, SGOT/SGPT, blood sugar, PCT, low PaO2/FiO2 ratio. RT PCR showed he was infected by COVID-19. Sputum culture showed Klebsiella infection and CXR showed bilateral pneumonia. Patient was treated with standard therapy and a combination of tocilizumab for cytokine-storm and helmet CPAP for severe ARDS. Helmet CPAP has become the first modality for COVID-19 ARDS in some countries but not in Indonesia. We chose helmet CPAP because of the cost efficient, comfortable, and easy operation compared to other modality. We chose tocilizumab because it uses a single dose. Although it is expensive, only one dose is enough and it is effective in blocking the cytokine storm. We found that helmet CPAP and tocilizumab combination in COVID-19 lead severe ARDS could be promising to prevent intubation for patients. Key words: Helmet CPAP; ARDS; COVID-19; Tocilizumab; Cytokine storm Citation: Permana SA, Sugiarto A, Thamrin MH, Arifin, Harsini. A promising therapy of tocilizumab and helmet CPAP to prevent intubation for COVID-19 induced severe ARDS: a case report. Anaesth. pain intensive care 2020;24(6):659-663; DOI: 10.35975/apic.v24i6.1409 Received - 17 September 2020, Reviewed – 01 October 2020, Accepted – 6 November 2020

BACKGROUND: Recently, sepsis has become a serious problem worldwide. There are many studies trying to find the etiologies of morbidity and mortality of sepsis. One of them is the damage of endothelial glycocalyx layer, which can lead to an increase in plasminogen activator inhibitor-1 (PAI-1) level and a decrease in platelets. This damage can be prevented by administering albumin; unfortunately, it is costly. Therefore, an alternative albumin is required. Channa striata extract albumin has been found to be relatively effective in increasing serum albumin levels. However, studies on its effectiveness are still limited. Hence, we analyzed this channa striata extract albumin in stabilizing PAI-1 and platelet levels of septic patients. AIM: This study analyzed channa striata extract albumin in stabilizing PAI-1 and platelet levels of septic patients. METHODS: We conducted a randomized control experimental study in patients with sepsis hospitalized at Dr Moewardi Hospital, Surakarta, Indonesia. The samples were taken by consecutive sampling technique. These patients were allocated into two groups, the albumin extract of channa striata, and human albumin 20% (the control) groups. We examined the PAI-1 and platelet levels on the 1st and 3rd days. We used Mann–Whitney test for statistical analysis with p < 0.05 was considered significant. RESULTS: There were 21 subjects in each group of channa striata (study) and human albumin (control). The increase of PAI-1 level in the study group (0.36 ng/ml) was lower than that of in control group (0.72 ng/ml). More subjects in study group experienced decreased PAI-1 level (n = 5) than those in control group (n = 3), the decrease more profound in control group (p = 0.004) than study group (p = 0.054). The decrease of platelet level was also greater in study group (22 × 103/mcl) than that of in control group (1 × 103.md) despite insignificant difference (p = 0.364 and p = 0.468). CONCLUSION: The administration of channa striata extract effective in stabilizing PAI-1 level in sepsis patient and also had potential benefit as human albumin in stabilizing platelet levels of septic patients.