I Ketut Sinardja
Anesthesiology and Intensive Care Department, Udayana University, Sanglah General Hospital, Denpasar, Bali, Indonesia

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Efficacy of Subcutaneous Morphine Patient Controlled Analgesia Compared to Intravenous Morphine Patient Controlled Analgesia on Cesarean Section Wiryana, Made; Sinardja, I Ketut; Budiarta, I Gede; Senapathi, Tjokorda Gde Agung; Widnyana, I Made Gde; Aribawa, I Gusti Ngurah Mahaalit; Nainggolan, Elisma
Bali Journal of Anesthesiology Vol 1, No 3 (2017)
Publisher : DiscoverSys Inc.

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.15562/bjoa.v1i3.27

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Background: Cesarean section causes moderate to severe pain in the first 48 hours postoperatively, thus requiring an adequate perioperative pain management, not only so that the mother can be quickly discharged but also to perform daily activities after surgery such as breastfeeding and nurse the baby.Objective: To determine the efficacy of subcutaneous morphine patient controlled analgesia (SC-PCA) in lowering VAS (visual analogue score), total morphine consumption and postoperative side effect on cesarean section compared with intravenous morphine patient controlled analgesia (IV- PCA).Methods: This study is an experimental clinical trial using consecutive sampling technique. Sixty-four subjects were allocated into two groups of PCA morphine subcutaneously (SC-PCA) and the group PCA morphine intravenously (IV-PCA), each consisting of 32 subjects using permuted block randomization. Morphine concentration was 5 mg/ml (group SC-PCA) or the concentration of 1mg/ml (group IV-PCA). Both groups were then analyzed for VAS ratings, total morphine consumption, and adverse effects, post operatively at 4th, 8th, and 24th hour. Statistic analysis using repeated ANOVA test and t-test with p <0.05 onsidered significant.Result: Morphine consumption in IV-PCA group showed lower needs than SC-PCA (9.41 mg vs 4,9mg) p <0.001 24 at 24 hours postoperatively. The VAS at resting at 4th hours statistically significantly lower in IV-PCA group (1.06 ± 0.71 vs 0.81 ± 1.40, p=0.029) and at 8th hours (1.03 ± 0.59 vs 0.94 ± 0,9, p=0.048). The moving VAS at 4th hours statistically significant lower in IV-PCA group (2.31 ± 0.47 vs 1.45 ± 2.06, p=0.019) but the static or VAS at moving are not different clinically. Side effects of nausea and vomiting are more common in IV-PCA group. We conclude that SC-PCA provide analgesia more effective and decreases side effects in patients undergo sectio cesarea with spinal anesthesia.
Non-Convulsive Status Epilepticus (NCSE) in ICU Wiryana, Made; Sinardja, I Ketut; Aryabiantara, I Wayan; GdeAgung Senapathi, Tjokorda; Gede Widnyana, I Made; Utara Hartawan, I Gusti Agung Gede; Parami, Pontisomaya; Ryalino, Christopher; Putra Pradhana, Adinda
Bali Journal of Anesthesiology Vol 1, No 1 (2017)
Publisher : DiscoverSys Inc.

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.15562/bjoa.v1i1.5

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Epilepsy is a neurological disorder characterized by recurrent epileptic seizures. Non-convulsive status epilepticus (NCSE) is defined as a persistent change in mental status as opposed to the previous conditions, lasted at least 30 minutes long,  associated with continuous spike wave epileptiform EEG changes. Clinical manifestation of NCSE can present as confusion, personality changes, psychosis, and coma. Indeed NCSE prognosis is dependent on the underlying etiology of persistent EEG changes of. Preferred medication is focus on improving its fundamental pathological changes, such as metabolic disorders, infection, drugs toxicity, and immediate pharmacological treatment. Intravenous benzodiazepine is recommended asthe first drug of choice for NCSE and early recognition of treatment response can help to establish the diagnosis.  This patient has a good outcome which was influenced with short ictal period from the first episode upon arrival on reffered hospital, good initial response and management on emergency department, a conduct and thorough ICU monitoring, as well as the effective treatment response.
Anesthesia on Pediatric Laproscopy Wiryana, Made; Sinardja, I Ketut; Kurniyanta, Putu; GdeAgung Senapathi, Tjokorda; Gede Widnyana, I Made; Utara Hartawan, I Gusti Agung Gede; Parami, Pontisomaya; Darma Junaedi, I Made; Putra Pradhana, Adinda
Bali Journal of Anesthesiology Vol 1, No 1 (2017)
Publisher : DiscoverSys Inc.

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.15562/bjoa.v1i1.1

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Laparoscopic surgery has several advantages compared to a regular surgical procedures. This technique can reduce the stress of surgery, reduce the need for postoperative analgesia, decreased respiratory and wound complications, lowering long hospitalization, including in the intensive therapy, and the patient can go back to eat quickly. The magnitude of changes in vital signs that occur will be influenced by the patients age, cardiovascular function, and anesthetic agents are used. Physiological changes in pediatric laparoscopic surgery were similar to adults. Children have a higher vagal tone and sometimes a stimulus to the peritoneum by insufflation gas or penetration laparoscopic and trocar can lead to bradycardia and asystole. Intra-abdominal pressure is an important determinant for maintaining cardiovascular stability during laparoscopy. Adequate relaxation needed during the duration of the surgery.
Central Venous Pressure Correlates with Inferior Vena Cava Collapsibility Index in Patient Treated in Intensive Care Unit Wiryana, Made; Sinardja, I Ketut; Aryabiantara, I Wayan; GdeAgung Senapathi, Tjokorda; Gede Widnyana, I Made; Mahaalit Aribawa, I Gusti Ngurah; Gede Utara Hartawan, I Gusti Agung; Parami, Pontisomaya; Perangin Angin, Emkel
Bali Journal of Anesthesiology Vol 1, No 1 (2017)
Publisher : DiscoverSys Inc.

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.15562/bjoa.v1i1.2

Abstract

Background: Intravascular volume status is an important parameter in monitoring the patients treated at intensive care unit (ICU), so accuracy and strict monitoring of fluid volume is one factor that influence patient’s health status. Amongst others, two ways to monitor body fluid volume status is central venous pressure (CVP) and collapsibility index of inferior vena cava (IVC) diameter. The purpose of this study is to determine the correlation between CVP with the IVC collapsibility index in patients treated in ICU Sanglah Hospital in Denpasar. Method: Seventy patients treated at Sanglah Hospital ICU with already inserted CVC for appropriate indication, were measured for CVP, then followed by examination the diameter of IVC with ultrasound to measure the maximum and minimum collapsibility index. Spearman’s correlation coefficients was used to assess the correlation between CVP and collapsibility index of the IVC. Results: In 70 patients, we found a very strong negative correlation between CVP and IVC’s collapsibility index (Spearmans rho = -0.854; p <0.001). Conclusion: This study found that there is a very strong negative correlation between CVP and collapsibility index of IVC. This finding indicates that the collapsibility index of the IVC may substitute CVP in determining the status of the intravascular volume.
The effectiveness of Patient Controlled Analgesia (PCA) morphine-ketamine compared to Patient Controlled Analgesia (PCA) morphine to reduce total dose of morphine and Visual Analog Scale (VAS) in postoperative laparotomy surgery Mahaalit Aribawa, I Gusti Ngurah; Agung Senapathi, Tjokorda Gde; Wiryana, Made; Sinardja, I Ketut; Budiarta, I Gede; Gede Widnyana, I Made; Aryabiantara, I Wayan; Parami, Pontisomaya; Nyoman Kurniasari, Pande; Putra Pradhana, Adinda
Bali Journal of Anesthesiology Vol 1, No 2 (2017)
Publisher : DiscoverSys Inc.

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.15562/bjoa.v1i2.11

Abstract

Background: Laparotomy may cause moderate to severe after surgery pain, thus adequate pain management is needed. The addition of ketamine in patient controlled analgesia (PCA) morphine after surgery can be the option. This study aims to evaluate the effectiveness of PCA morphine-ketamine compared to PCA morphine in patient postoperative laparotomy surgery to reduce total dose of morphine requirement and pain intensity evaluated with visual analog scale (VAS). Methods: This study was a double-blind RCT in 58 patients of ASA I and II, age 18-64 years, underwent an elective laparotomy at Sanglah General Hospital. Patients were divided into 2 groups. Group A, got addition of ketamine (1mg/ml) in PCA morphine (1mg/ml) and patients in group B received morphine (1mg/ml) by PCA. Prior to surgical incision both group were given a bolus ketamine 0,15mg/ kg and ketorolac 0,5mg/kg. The total dose of morphine and VAS were measured at 6, 12, and 24 hours postoperatively. Result: Total dose of morphine in the first 24 hours postoperatively at morphine-ketamine group (5,1±0,8mg) is lower than morphine only group (6,5±0,9mg) p<0,001. VAS (resting) 6 and 12 hour postoperative in morphine-ketamine group (13,4±4,8 mm) and (10,7±2,6 mm) are lower than morphine (17,9±4,1mm) p≤0,05 and (12,8±5,3mm) p≤0,05. VAS (moving) 6, 12, and 24 hour postoperative morphineketamine group (24,8±5,1mm), (18±5,6mm) and (9±5,6mm) are lower than morphine (28,7±5,2mm) p≤0,05, (23,1±6,0mm) p≤0,05, and (12,8±5,3mm) p≤0,05. Conclusions: Addition of ketamine in PCA morphine for postoperative laparotomy surgery reduces total morphine requirements in 24 hours compared to PCA morphine alone.
Effectiveness of Infusion Warmer Use to Prevent the Occurrence of Hypothermia and Shivering After General Anesthesia Action in General Hospital Center Sanglah Denpasar Wiryana, Made; Sinardja, I Ketut; Budiarta, I Gede; Agung Senapathi, Tjokorda Gde; Widnyana, Made; Aryabiantara, I Wayan; Utara Hartawan, I Gusti Agung Gede; Parami, Pontisomaya; Kusuma Wijaya, Andi; Putra Pradhana, Adinda
Bali Journal of Anesthesiology Vol 1, No 1 (2017)
Publisher : DiscoverSys Inc.

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.15562/bjoa.v1i1.3

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Introduction: Shivering and hypothermia after general anesthesia is a common complication in the recovery room. Heating methods and drugs  widely used, but not yet effective. The purpose of this study was to evaluate the effectiveness of using the infusion warmer in maintaining normal core temperature and prevent shivering. Materials and Methods: The study was a non blindnes randomized control trial study. This study aimed to compare the effectiveness of the use of infusion warmer in preventing the incidence of hypothermia and shivering after general anesthesia. Research conducted at the Sanglah Hospital in October 2016, with sample calculations 58 people who meet the inclusion and exclusion criteria. Both were divided into 2 groups, 29 groups of infusion warmer and 29 people without the infusion warmer Recording the results of assessing multiple parameters vital signs, hemodynamic, aldrette score, body temperature, and shivering from the beginning, after induction, and minutes to 5, 15, 30 , 60 in the recovery room. The data obtained were analyzed with SPSS software with a significance level of p <0.005 expressed significantly, with a relative risk <1 as a preventive. Results: From a comparative picture of events shivering and hypothermia in minutes to 5, 15, 30, 60 in the recovery room seen that the treatment group based on the group lower warmer than in the non warmer. This shows that the use of warmer can prevent the incidence of shivering and hypothermia in patients after general anesthesia. In test statistically significant with p <0.05. Conclusions: The use of infusion warmer can help reduce the incidence of hypothermia and shivering after general anesthesia action.
ANESTHESIA MANAGEMENT OF ESOPHAGEAL ATRESIA REPAIR SURGERY: A CASE REPORT Putra, Kadek Agus Heryana; Kurniyanta, Putu; Wiryana, Made; Sinardja, Ketut; Senapathi, Tjokorda Gde Agung; Widnyana, I Made Gede; Cindryani, Marilaeta; Kurnia, Prajnaariayi Prawira
Bali Journal of Anesthesiology Vol 2, No 2 (2018)
Publisher : DiscoverSys Inc.

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.15562/bjoa.v2i2.31

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ABSTRACTEsophageal Atresia (EA)is a congenital anomaly commonly found with TracheoesophagealFistula (TEF) of neonates in the first week oflife. This anomaly can cause several complications includingaspiration, reduction in respiration, and other complication from other concomitant congenital anomaly, mostly from heart origin. The treatment for this anomaly is surgery.Intraoperatively, thepatient may develop hypoxia due to lung retraction and hemodynamic instability from bleeding or hypothermia. Anesthesiologists play important role in the management of EA during theperioperative period. Careful examination of the preoperative period must be done to discover any other concomitant anomaly and complication. Good anticipation of any complication during surgery and continuous monitoring post surgery can elevate the prognosis of the patient.
Low Dose Ketamin Wiryana, Made; Sinardja, I Ketut; Budiarta, I Gede; Agung Senapathi, Tjokorda Gde; Widnyana, Made; Aryabiantara, I Wayan; Utara Hartawan, I Gusti Agung Gede; Parami, Pontisomaya; Novita Pradnyani, Ni Putu; Putra Pradhana, Adinda
Bali Journal of Anesthesiology Vol 1, No 1 (2017)
Publisher : DiscoverSys Inc.

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.15562/bjoa.v1i1.4

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Ketamine binds non-competitive against a phencyclidine receptors bound N-methyl-D-aspartate (NMDA), a receptor that is involved in the pathophysiology of acute pain. Ketamine has been used as an intravenous anesthesia, analgesia for acute and chronic pain at a dose of subanaesthetic. Ketamine is a dissociative anesthetic produces a state with a characteristic strong analgesia, amnesia, and catalepsy. Dissociative components resulting from the effect on the limbic system and talamoneokortikal. Low-dose ketamine as known as analgesia dose ketamine or subanestesia dose is 0.2 to 0.75 mg / kg IV. At low doses, ketamine does not increase the effect psikomimetik like dissociation or deep sedation. The combination with midazolam provides satisfactory sedation, amnesia and analgesia without significant cardiovascular depression.
PERIOPERATIVE EFFECTS OF CO-ADMINISTRATION OF TCI PROPOFOL COMBINED WITH CLONIDINE AND KETAMINE Aryabiantara, I Wayan; Sinardja, I Ketut; Sutawan, Ida Bagus Krisna Jaya; Sinardja, Cynthia Dewi; Parami, Pontisomaya; Ryalino, Christopher; Junaedi, Made Darma
Bali Journal of Anesthesiology Vol 2, No 3 (2018)
Publisher : DiscoverSys Inc.

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (371.815 KB) | DOI: 10.15562/bjoa.v2i3.69

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Background: Propofol is often used in Total Intravenous Anesthesia (TIVA). Studies found that adding clonidine and ketamine can increase the potential to achieve an adequate level of anesthesia while reducing inflammation and post-operative pain. The goal of this study is to see if the combination of Target Controlled Infusion (TCI) propofol plus clonidine and ketamine is more effective in reducing the IL-6 level, maintaining intraoperative stability, and reducing postoperative pain and morphine consumption.Methods: Forty patients planned for major oncology surgery were divided into two groups. The treatment group (Group T) received pre-medication with clonidine, induction with TCI propofol, and intraoperative ketamine. The control group (Group C) received normal saline solution.Results: The difference of IL-6 level increase between the two groups was not statistically significant (13.6 vs. 16.6 pg/mL, p>0.05). Mean systolic blood pressure (SBP) and mean arterial pressure (MAP) in group T were higher in 5 and 10 minutes after incision, but lower in minutes 30, 60, and 120 (p <0.05). Heart rate in group T was higher in minutes 5, 10, 15, 30, 60, and 120. Visual analog scale (VAS) in 4, 8, 12, and 24 hours post-surgery were lower in group T compared to group C. And post-operative morphine consumptions in group T were also lower. (3.6 ± 1.5 vs 9.9 ± 3.3, p <0.05).Conclusion: TIVA using TCI propofol combined with preoperative clonidine and intraoperative ketamine is effective in maintaining hemodynamic stability, reducing post-operative and reducing morphine consumption compared to TCI propofol alone.
Penatalaksanaan Anestesi pada Kehamilan dengan Tumor Medula Spinalis Supradnyawati, Ni Made; Suarjaya, I Putu Pramana; Sinardja, I Ketut
Jurnal Neuroanestesi Indonesia Vol 3, No 2 (2014)
Publisher : Departement of Anesthesiology and Intensive Care Dr. Hasan Sadikin Hospital Bandung

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Abstract

Anestesi pada pembedahan nonobstetri dalam kehamilan merupakan tantangan khusus bagi ahli anestesi. Sekitar 0,75%–2% pembedahan nonobstetri dilakukan selama masa kehamilan. Setiap tahunnya di AS diperkirakan sekitar 75.000 wanita hamil menjalani anestesi dan pembedahan. Penatalaksanaan anestesi optimal memerlukan pemahaman mengenai perubahan fisiologi maternal, pertimbangan terhadap fetus akibat pembedahan dan anestesi, dan upaya mempertahankan perfusi uteroplasenta dan oksigenasi maternal-fetus. Tujuan yang ingin dicapai adalah anestesi yang aman kepada ibu dan memelihara kesejahteraan janin. Kami melaporkan kasus wanita berusia 29 tahun dengan G4P1A2–1 25‒26 minggu janin tunggal hidup yang mengalami kelemahan motorik akut pada kedua tungkai bawah, gangguan sensibilitas semua kualitas setinggi Th6, serta inkontinensia urine dan alvi. Hasil pemeriksaan penunjang magnetic resonance imaging thorakolumbal menunjukkan suatu massa di daerah epidural setinggi C7–Th1 sisi kanan dan hambatan aliran likuor serebrospinal. Pasien dilakukan anestesi umum dengan intubasi endotrakeal. Induksi menggunakan propofol dan fentanyl, diikuti dengan penekanan krikoid. Fasilitas intubasi menggunakan vecuronium. Pemeliharaan menggunakan isofluran, oksigen, compressed air, bolus fentanyl dan vecuronium intravena intermitten. Posisi operasi adalah posisi prone. Intraoperatif ditemukan tumor ekstradura setinggi level C7–Th1, dilakukan laminektomi total dan stabilisasi dengan pemasangan pedicle screw. Pascabedah pasien menunjukkan perbaikan status neurologis dan kehamilan dapat dipertahankan sampai aterm. Anesthesia Management for Spinal Cord Tumor in PregnancyAnesthesia management for non-obstetric surgery in pregnancy was considered a specific challenge for anesthesiologist. About 0,75–2% of non-obstetric surgery is performed during pregnancy. Annually in the US, about 75.000 pregnant women are exposed to anesthesia and surgery. Optimal anesthetic management requires comprehensive understanding on maternal physiologic changes, fetal consideration due to effect of surgery and anesthesia, and maintaining uteroplacental perfusion and maternal-fetal oxygenation. The endpoint is to provide safe anesthesia for both the mother and fetal well being. We reported a case of a 29-year old pregnant woman G4P1021 single fetus with 25–26 weeks of gestation, acute weakness of lower limbs, and sensibility impairment on all qualities at Th 6 level, as well as urine and alvi incontinence. Thoraco lumbal MRI examination showed epidural mass at C 7–Th 1 level of the right side vertebrae, and cerebrospinal fluid flow obstruction. The patient underwent general anesthesia with endotracheal intubation. Induction with propofol and fentanyl, followed by cricoid pressure. Intubation was facilitated with vecuronium. Maintenance with isoflurane, oxygen, compressed air, intermittent IV bolus of fentanyl and vecuronium. Surgery was performed on prone position. Extradural tumor at C7–Th1 vertebrae level was found intraoperatively and total laminectomy and stabilization with pedicle-screw were performed. Patient showed improvement in neurological status after the surgery, and the pregnancy was survived until aterm period.