Journal of Anesthesiology and Clinical Research

Neuroprotective General Anesthesia for Emergency Cesarean Section in a Patient with Obstructive Hydrocephalus from a Vestibular Schwannoma

Reza Ariestyawan Ramadhan — 2025-07-02

Introduction: The confluence of advanced pregnancy and a large intracranial neoplasm presents a profound clinical challenge. This report details the management of a parturient with a vestibular schwannoma causing obstructive hydrocephalus and critical intracranial hypertension (ICP), a scenario where standard obstetric anesthetic practices are absolutely contraindicated.

Case presentation: A 35-year-old G3P1 parturient at 36 weeks gestation with progressive blindness from a vestibular schwannoma presented for an emergency cesarean section due to fetal compromise. With clear signs of severe ICP, general anesthesia was administered. Anesthesia was induced with propofol and atracurium and maintained with sevoflurane and a remifentanil infusion, a regimen selected for maternal neuroprotection and fetal safety. Invasive arterial and central venous pressure monitoring guided hemodynamic management to ensure cerebral perfusion. A healthy infant was delivered. The family declined postoperative neurosurgery; the patient was managed conservatively with medical therapy and discharged in stable condition, with long-term follow-up confirming favorable maternal and infant outcomes.

Conclusion: This case demonstrates that a meticulously planned general anesthetic, centered on neuroprotective principles and guided by advanced physiological monitoring, can ensure a safe outcome for both mother and child in the face of critical intracranial hypertension. This success underscores the paramount importance of a deep pathophysiological understanding and seamless multidisciplinary collaboration.

Acute Motor Axonal Neuropathy with Respiratory Failure: A Case Report on the Clinical Course Following a Single Session of Therapeutic Plasma Exchange

Wirjapratama Putra — 2025-07-04

Introduction: Guillain-Barré syndrome (GBS) is a severe, immune-mediated peripheral neuropathy. The acute motor axonal neuropathy (AMAN) variant, characterized by a direct antibody attack on motor axons, often leads to rapid, severe paralysis. Standard immunotherapy for severe GBS involves a multi-session course of therapeutic plasma exchange (TPE) or Intravenous Immunoglobulin (IVIg).

Case presentation: We present the case of a 68-year-old male with rapidly progressive GBS, confirmed as the AMAN subtype through clinical, cerebrospinal, and electrophysiological findings. The patient developed flaccid quadriparesis and acute respiratory failure, necessitating emergent intubation and mechanical ventilation in the intensive care unit (ICU). Following a single, large-volume session of TPE, a marked and rapid clinical improvement was observed. The patient was successfully weaned from mechanical ventilation and transferred from the ICU within three days of the intervention.

Conclusion: This case documents a noteworthy temporal association between a single TPE session and rapid clinical recovery in a patient with ventilator-dependent AMAN-GBS. While a causal relationship cannot be definitively established due to the disease's natural history, the observation prompts a deep exploration of the underlying pathophysiology. The discussion theorizes how a single, well-timed intervention might profoundly disrupt the autoimmune cascade by affecting peak antibody titers, complement activation, and cytokine kinetics.

Dexmedetomidine versus Lidocaine for Hemodynamic Stability During Airway Management in Patients with Traumatic Brain Injury: A Randomized Clinical Trial

Shallahudin — 2025-07-23

Introduction: The profound sympathoadrenal stress response to endotracheal intubation in patients with traumatic brain injury (TBI) presents a significant risk for secondary brain injury by inducing perilous hemodynamic instability. Pharmacological attenuation is critical, yet direct comparative evidence between commonly used agents is lacking. This study aimed to rigorously compare the efficacy of dexmedetomidine, a central sympatholytic, versus lidocaine, a peripheral membrane stabilizer, in maintaining hemodynamic stability during airway management in the TBI population.

Methods: In this prospective, randomized, double-blind clinical trial, seventy-one adult patients with TBI (ASA I-III) were allocated to receive either intravenous dexmedetomidine (1 μg/kg over 10 minutes; n=37) or intravenous lidocaine (1.5 mg/kg over 2 minutes, with total infusion time matched to 10 minutes with saline; n=34) prior to a standardized anesthesia induction. The prespecified primary outcome was the change in mean arterial pressure (MAP) from baseline to one minute post-intubation. Secondary outcomes included changes in heart rate (HR) and hemodynamic profiles over 10 minutes.

Results: Baseline patient characteristics, including TBI severity, were well-balanced between groups. Both interventions effectively blunted the pressor response, causing a significant decrease in MAP and HR from baseline (p<0.001 for all). The primary outcome, the change in MAP at one minute post-intubation, was not statistically different between the dexmedetomidine and lidocaine groups (-12.8 ± 6.1 mmHg vs. -11.5 ± 5.9 mmHg, respectively; p=0.412). Similarly, no significant differences in HR or MAP were observed between groups at any time point up to 10 minutes post-intubation. The incidence of rescue therapy for hypotension or bradycardia was low and comparable.

Conclusion: In patients with TBI, both dexmedetomidine and lidocaine are effective and safe for attenuating the hemodynamic stress of intubation. At the doses studied, neither agent demonstrated clinical superiority, providing clinicians with two valid, mechanistically distinct options. The choice can therefore be guided by the specific clinical context, including desired onset, duration of action, and sedative profile.

Early Risk Stratification in a High-Mortality Study of Adult Trauma Patients: A Comparative Validation of RTS, SI, and ISS

Denny Prasetyo — 2025-07-25

Introduction: Accurate, early risk stratification is paramount in managing severe trauma, especially in resource-limited settings. This study aimed to compare the predictive performance of the revised trauma score (RTS), shock index (SI), and injury severity score (ISS) for in-hospital mortality in a group of severely injured adult trauma patients at a tertiary center in Indonesia.

Methods: A retrospective analysis was conducted on a purposively selected study population of 100 adult trauma patients (age 20-60) admitted to the Emergency Department of Dr. Saiful Anwar Regional General Hospital over a three-month period in 2023. This selection method yielded a high-mortality sample (50% mortality) to ensure sufficient statistical power for analyzing fatal outcomes. The predictive performance of RTS, SI, and ISS was evaluated using individual logistic regression models. Discriminatory ability was assessed by calculating the area under the receiver operating characteristic curve (AUC-ROC) for each score. Model calibration was evaluated using the Hosmer-Lemeshow goodness-of-fit test.

Results: All three scoring systems were significant predictors of mortality in individual regression analyses. The injury severity score (ISS) demonstrated the highest discriminatory power for predicting mortality with an AUC of 0.88 (95% CI, 0.81-0.95). The revised trauma score (RTS) also showed good discrimination with an AUC of 0.83 (95% CI, 0.75-0.91). The Shock Index (SI) was a significant predictor but had the most modest discriminatory ability with an AUC of 0.76 (95% CI, 0.67-0.85). All models were well-calibrated.

Conclusion: In this study of severely injured adult trauma patients, the anatomically-based ISS was the most accurate predictor of mortality. The physiological scores, RTS and SI, remain valuable for their utility in rapid, initial patient assessment. The findings support a complementary approach, using the simple physiological scores for immediate triage and the more comprehensive ISS for definitive prognostication.

The Novice Overshoot: A Bispectral Index-Based Analysis of the Anesthesiology Resident Learning Curve for Anesthetic Depth Control in Supervised Practice

Rizki Suhadayanti — 2025-07-28

Introduction: The skillful management of anesthetic depth is a cornerstone of anesthesiology, yet the objective characterization of the resident learning curve remains underexplored. This study aimed to quantitatively map the developmental trajectory of anesthetic depth control among anesthesiology residents in a supervised clinical environment.

Methods: We conducted a prospective, cross-sectional, observational study involving 21 anesthesiology residents (from seven sequential semesters of training) and 105 ASA I-II adult patients at a tertiary academic hospital. Under standardized supervision, residents induced general anesthesia. The primary outcome was the Bispectral Index (BIS) value and its categorical distribution (Deep: <40, General: 40-60, Sedation: >60) at 2 minutes post-intubation. Secondary outcomes included propofol induction dose and hemodynamic responses. Data were analyzed using ANOVA, Kruskal-Wallis, and Chi-square tests.

Results: Post-intubation mean BIS values showed a non-significant trend towards being lower in junior residents compared to seniors (p=0.088). However, the categorical distribution of BIS values differed significantly across training levels (p=0.015). Junior residents (Semesters I-II) induced a state of deep anesthesia (BIS < 40) in 46.7% of their patients, compared to only 11.1% for senior residents (Semesters V-VII) (p<0.001). This correlated with junior residents using significantly higher weight-adjusted propofol doses (2.4 ± 0.3 mg/kg vs. 1.9 ± 0.2 mg/kg; p<0.001).

Conclusion: The anesthesiology resident learning curve is characterized by a distinct pattern of initial over-titration, or a "novice overshoot," leading to a higher incidence of unnecessarily deep anesthesia. While mean BIS values did not differ significantly, the distribution of hypnotic states reveals a critical educational target. BIS monitoring serves as a valuable objective tool for tracking the performance of the resident-supervisor dyad, offering data-driven insights for enhancing competency-based training and patient safety.

Early versus Late Percutaneous Tracheostomy in Critically Ill Stroke Patients: A Competing Risk Analysis of Ventilator Liberation and Complications

Wiyogo — 2025-08-08

Introduction: The optimal timing of percutaneous dilatational tracheostomy (PDT) in critically ill stroke patients remains controversial. The procedure may facilitate ventilator weaning and neurological assessment, but carries inherent risks. This study aimed to determine the impact of early versus late PDT on clinical outcomes in this specific and vulnerable population.

Methods: This retrospective cohort study was conducted at a single tertiary care center. We included all mechanically ventilated adult stroke patients who underwent PDT between January 2024 and December 2024. Patients were categorized into an Early PDT group (≤7 days of intubation) and a Late PDT group (>7 days). The primary outcome was time to ventilator liberation, with in-hospital death as a competing risk. This was analyzed using a Fine-Gray subdistribution hazard model. Secondary outcomes included ICU and hospital mortality, length of stay (LOS), and ventilator-associated pneumonia (VAP), analyzed with multivariable regression.

Results: Seventy patients were included (34 Early PDT, 36 Late PDT). After adjusting for age, admission GCS, NIHSS, and stroke type, early PDT remained significantly associated with a higher probability of ventilator liberation (adjusted subdistribution Hazard Ratio [sHR]: 2.48; 95% CI: 1.41–4.36; p=0.002). Early PDT was also independently associated with lower odds of developing VAP (adjusted Odds Ratio [aOR]: 0.31; 95% CI: 0.10–0.94; p=0.038). There were no significant differences in ICU mortality (aOR: 0.82; 95% CI: 0.28–2.41; p=0.721) or hospital mortality (aOR: 0.70; 95% CI: 0.25–1.96; p=0.495).

Conclusion: In critically ill stroke patients, an early tracheostomy strategy is independently associated with a significantly shorter time to ventilator liberation and lower odds of VAP, after accounting for competing risks and baseline confounders. While not associated with a survival benefit, early PDT should be considered a key strategy to optimize respiratory management and reduce pulmonary complications in this population.

Navigating High-Risk Obstetric Anesthesia: Successful Management of Cesarean Section with Graded Epidural Blockade in a Parturient with Atrial Septal Defect and Moderate Pulmonary Hypertension

Viky Wicaksana — 2025-08-27

Introduction: The convergence of a large, uncorrected atrial septal defect (ASD) with secondary pulmonary hypertension (PH) in pregnancy creates a high-risk hemodynamic environment. The physiological stresses of parturition can precipitate cardiovascular collapse. Anesthetic management for cesarean delivery must be meticulously planned to preserve the delicate balance between systemic and pulmonary vascular resistance, with the primary goal of maintaining systemic vascular resistance to prevent exacerbation of the intracardiac shunt.

Case presentation: We present the case of a 28-year-old primigravida at 37+2 weeks' gestation with a known large secundum ASD and moderate PH (echocardiographically estimated sPAP of 50.2 mmHg), who required an emergency cesarean section. A comprehensive, multidisciplinary plan was formulated, prioritizing maternal hemodynamic stability. The patient was successfully managed with a carefully titrated, graded lumbar epidural anesthetic using 0.5% levobupivacaine. Advanced invasive monitoring, including arterial and central venous catheters, guided the slow induction of a T6 sensory block. This strategy resulted in hemodynamic parameters being maintained within a clinically acceptable range, obviating the need for vasopressor support. The postoperative course in the cardiovascular ICU was uneventful.

Conclusion: This case provides compelling evidence that a graded epidural blockade, executed with vigilance and supported by a robust, team-based safety framework, is a highly effective anesthetic technique for cesarean delivery in parturients with ASD and moderate PH. The ability to exert temporal control over the onset of sympathetic blockade is paramount to preventing abrupt hemodynamic shifts, thereby protecting the vulnerable right ventricle and ensuring maternal safety.

Beyond the Block: Sequential Spinal Anesthesia and Dexmedetomidine-Ketamine TIVA for a Four-Hour Cesarean Section in a 157-kg Parturient

Agung Nugroho — 2025-09-19

Introduction: Cesarean delivery in super-obese parturients (BMI ≥ 50 kg/m²) presents a complex combination of anesthetic challenges, amplified by comorbidities like preeclampsia. The strong imperative to avoid airway instrumentation makes regional anesthesia the preferred technique. However, the finite duration of a single-shot spinal block poses a significant risk in unexpectedly prolonged procedures, requiring a pre-planned strategy for anesthetic extension.

Case presentation: A 38-year-old G2P1 parturient with a BMI of 63.7 kg/m² presented for an emergency cesarean section for fetal hypoxia and preeclampsia. After a rapid multidisciplinary consultation, a deliberate decision was made to proceed with spinal anesthesia to mitigate profound airway risks. The surgery became unexpectedly complex, lasting four hours. As the spinal block regressed, a planned transition to an opioid-sparing total intravenous anesthesia (TIVA) with dexmedetomidine and ketamine was initiated. This technique preserved spontaneous respiration and provided excellent hemodynamic stability, even during a 2000 mL hemorrhage.

Conclusion: This case highlights the value of anesthetic adaptability in high-risk obstetrics. A sequential spinal-TIVA technique offers a safe and effective alternative to a high-risk conversion to general anesthesia, emphasizing the importance of having a pre-planned contingency for insufficient neuraxial blockade in super-obese parturients. This approach underscores the necessity of multidisciplinary communication and patient-centered care in navigating complex obstetric emergencies.

Hemodynamic-Focused Anesthetic Strategy for Duodenal Atresia with Annular Pancreas in a Low-Birth-Weight Neonate: A Case Report and Pathophysiological Review

Anggia Rarasati Wardhana — 2025-09-22

Introduction: The anesthetic management of low-birth-weight (LBW) neonates with complex congenital anomalies like duodenal atresia presents a profound physiological challenge. These patients exhibit immature organ systems, precarious fluid balance, and heightened sensitivity to anesthetic agents. This case report describes a successful hemodynamically-focused anesthetic strategy in a particularly high-risk neonate with the combined pathology of duodenal atresia and a constricting annular pancreas.

Case presentation: A 4-day-old, 1800-gram male infant, born at 37 weeks with intrauterine growth restriction, presented with prenatally diagnosed duodenal atresia. Preoperative stabilization focused on correcting a severe hypochloremic, hypokalemic metabolic alkalosis. A hemodynamically stable anesthetic induction was achieved using intravenous fentanyl (2.8 mcg/kg) and ketamine (2.8 mg/kg), avoiding myocardial depressant volatile agents. Anesthesia was maintained with 60% oxygen in air and intermittent opioid boluses. Intraoperative management was centered on meticulous, goal-directed fluid therapy, rigorous maintenance of normothermia, and lung-protective ventilation. The surgery, a duodenojejunostomy, was completed successfully with remarkable hemodynamic stability. The infant was transferred to the NICU for planned postoperative ventilation and was extubated on the second postoperative day. Postoperative analgesia was achieved with a continuous sub-anesthetic ketamine infusion, later transitioned to intermittent metamizole.

Conclusion: The successful outcome in this fragile neonate underscores the value of a tailored anesthetic approach grounded in neonatal pathophysiology. A strategy utilizing hemodynamically stable induction agents, proactive correction of metabolic derangements, goal-directed fluid therapy, and a planned, staged recovery can effectively mitigate the significant perioperative risks associated with major abdominal surgery in LBW infants with complex congenital anomalies.

Opioid-Sparing Anesthesia: The Dual Efficacy of Ketamine on Postoperative Pain and Systemic Inflammation Following Spinal Surgery

Elanda Rahmat Arifyanto — 2025-10-01

Introduction: Postoperative pain and inflammation after major spinal surgery, such as laminectomy, pose significant challenges to patient recovery and contribute to opioid consumption. Ketamine, an N-methyl-D-aspartate (NMDA) receptor antagonist, is proposed to have both analgesic and anti-inflammatory properties, positioning it as a key component of an opioid-sparing strategy. This study aimed to evaluate the clinical efficacy of a specific intraoperative ketamine infusion regimen compared to a continuous micro-dose morphine regimen on early postoperative pain and systemic inflammation.

Methods: This prospective, double-blind, randomized controlled trial included 24 adult patients (ASA I-II) undergoing thoracolumbar laminectomy. Patients were randomly assigned to receive either a continuous intraoperative infusion of ketamine at 10 mcg/kg/minute (n=12) or morphine at 10 mcg/kg/hour (n=12). The primary outcomes were postoperative pain intensity, measured by the Visual Analog Scale (VAS) at 6 and 12 hours, and the systemic inflammatory response, assessed via high-sensitivity C-reactive protein (hs-CRP) levels measured preoperatively and 6 hours postoperatively.

Results: The study groups were comparable regarding baseline demographic and surgical characteristics (p>0.05). At 6 hours postoperatively, the ketamine group reported significantly lower VAS pain scores than the morphine group (mean score of 2.33 ± 0.78 versus 3.83 ± 1.03, respectively; p=0.001). This difference was not maintained at 12 hours (p=0.646). Critically, the surgically-induced increase in hs-CRP was significantly attenuated in the ketamine group, which showed a mean increase of only 1.43 ± 1.04 mg/L from baseline, compared to a much larger increase of 2.88 ± 1.06 mg/L in the morphine group (p=0.003).

Conclusion: An intraoperative ketamine regimen of 10 mcg/kg/minute is more effective at reducing pain in the immediate 6-hour postoperative period and mitigating the systemic inflammatory response than a continuous micro-dose morphine regimen. These findings underscore ketamine's potent dual-mechanism action, targeting both nociceptive and inflammatory pathways, and strongly support its use in multimodal, opioid-sparing protocols for spinal surgery.

Inappropriate Empirical Antibiotic Therapy and Mortality in Critical Illness: A Retrospective Cohort Study with Propensity Score Analysis in an Indonesian ICU

Riska Yulinta Viandini — 2025-10-02

Introduction: Inappropriate empirical antibiotic therapy (IEAT) is a critical driver of mortality in sepsis, particularly in regions with high antimicrobial resistance (AMR) like Southeast Asia. This study aimed to quantify the association between IEAT and 28-day mortality in a critically ill Indonesian patient cohort, employing advanced statistical methods to control for confounding.

Methods: We conducted a retrospective cohort study of 280 adult patients who received empirical antibiotics and had positive cultures upon admission to a tertiary ICU in Indonesia (January 2022–December 2023). The primary exposure was the appropriateness of the initial antibiotic regimen (IEAT vs. AEAT) based on in-vitro susceptibility. We used multivariate logistic regression and a 1:1 propensity score-matched (PSM) analysis to adjust for baseline differences in patient severity, including APACHE II score and the presence of septic shock.

Results: In the full cohort, 108 patients (38.6%) received IEAT. The 28-day mortality was profoundly higher in the IEAT group than the AEAT group (77.8% vs. 8.1%; p < 0.001). After multivariate adjustment, IEAT remained a powerful predictor of mortality (Adjusted Odds Ratio [aOR]: 38.72; 95% CI: 18.91–79.30; p < 0.001). In the PSM cohort of 200 patients with balanced baseline characteristics, the association remained strong and significant (OR: 25.15, 95% CI: 11.54–54.81; p < 0.001). Local prescribing patterns revealed that levofloxacin monotherapy, the most common regimen, had an inappropriateness rate of 76.4%.

Conclusion: Inappropriate empirical antibiotic therapy is strongly associated with a substantially increased risk of death in critically ill Indonesian patients. This association persists after rigorous adjustment for confounding. These findings highlight the urgent need for robust antimicrobial stewardship programs, guided by dynamic local surveillance, to combat the lethal impact of AMR.

Determinants of Postoperative ICU Admission in the Elderly: A Prospective Multicenter Study of Elective Surgeries in Indonesia

Alief Ilman Zaelany — 2025-10-09

Introduction: The increasing global geriatric population presents significant challenges for surgical care, particularly regarding the allocation of Intensive Care Unit (ICU) resources. This study aimed to identify determinants of postoperative ICU admission among elderly patients in Indonesia, a setting with a rapidly aging demographic.

Methods: We conducted a prospective, multicenter cohort study across 15 Indonesian hospitals from February to April 2021. Patients aged ≥60 years undergoing elective surgery were enrolled via consecutive sampling. Data on patient demographics, American Society of Anesthesiologists (ASA) physical status, Charlson Comorbidity Index (CCI), and type of anesthesia (general vs. regional) were collected. The primary outcome was postoperative ICU admission. Multivariate logistic regression was used to identify independent predictors.

Results: Of 893 patients enrolled, 18.8% required postoperative ICU admission. The final multivariate model revealed that a higher ASA physical status was the strongest predictor of ICU admission (Odds Ratio [OR] 4.13; 95% CI 2.88-5.92; p < 0.001). The administration of general anesthesia was also independently associated with a significantly increased likelihood of ICU admission compared to regional anesthesia (OR 2.77; 95% CI 1.83-4.19; p < 0.001). While the CCI was a significant factor in unadjusted analyses, its effect was attenuated after inclusion of the ASA score.

Conclusion: ASA physical status and the choice of general anesthesia are powerful, independent determinants of postoperative ICU admission in the Indonesian geriatric surgical population. These findings highlight the critical role of preoperative physiological assessment and suggest that the choice of anesthetic technique has significant implications for postoperative resource needs.

A Neuroprotective Anesthetic Strategy: Ultrasound-Guided Dual Plexus Blockade for Clavicle Fixation Following Decompressive Craniectomy

Muhammad Husni Thamrin — 2025-10-21

Introduction: Anesthetic management for non-neurosurgical procedures in patients with recent severe traumatic brain injury (TBI) presents a formidable challenge. General anesthesia carries inherent risks of hemodynamic instability and increased intracranial pressure (ICP), which can precipitate devastating secondary brain injury. Regional anesthesia offers a neuroprotective alternative, though its application in this specific high-risk population is not extensively documented.

Case presentation: A 24-year-old male, ASA status III-E, required open reduction and internal fixation of a clavicle fracture six days after an emergency decompressive craniectomy for an acute epidural hematoma. To mitigate neurological risk, a definitive anesthetic plan consisting of an ultrasound-guided dual plexus blockade was implemented. This involved a combination of an interscalene brachial plexus block (15 mL of 0.375% levobupivacaine) and a superficial cervical plexus block (10 mL of 0.375% levobupivacaine), supplemented with light, non-opioid sedation using dexmedetomidine. The 150-minute surgery was completed with exceptional hemodynamic stability, no requirement for airway manipulation, and no anesthetic or surgical complications. The patient remained comfortable and neurologically intact throughout.

Conclusion: This case demonstrates that an ultrasound-guided dual plexus blockade is a safe, effective, and neurologically protective primary anesthetic technique for clavicle surgery in the post-craniotomy patient. By providing dense surgical anesthesia while preserving stable cerebral perfusion pressure, this approach represents a superior alternative to general anesthesia in this fragile patient population. We advocate for its consideration in similar clinical scenarios.

Pharmacodynamic Mismatch in Adductor Canal Blockade: Dexamethasone Phosphate (Rapid-Salt) Outperforms Methylprednisolone Acetate (Depot-Suspension) for Early Mobilization

Beny Firmansyah — 2025-11-14

Introduction: The motor-sparing adductor canal block (ACB) is central to enhanced recovery after surgery (ERAS) protocols for knee surgery. Corticosteroid adjuvants are used to prolong analgesia, but a direct comparison of perineural Dexamethasone and Methylprednisolone is lacking. This study aimed to observe real-world associations between these adjuvants, postoperative pain, and functional recovery.

Methods: This analytical, prospective, observational cohort study was conducted at a tertiary hospital from November 2024 to April 2025. Fifty-three patients undergoing knee surgery under subarachnoid anesthesia were enrolled. Following surgery, patients received an ultrasound-guided ACB with 20 mL of Ropivacaine 0.5% combined with either Dexamethasone 10 mg (n=24) or Methylprednisolone 60 mg (n=29), based on the attending anesthesiologist's preference. The primary functional outcome was time to mobilization. Secondary outcomes included Numerical Rating Scale (NRS) pain scores at 12, 24, and 48 hours.

Results: A significant association was observed for the primary functional outcome: 87.5% of the Dexamethasone cohort mobilized within 24 hours, versus 62.1% of the Methylprednisolone cohort (p = 0.037). This functional advantage was congruent with a superior early analgesic profile; the Dexamethasone group reported significantly lower mean NRS scores at 12 hours (2.71 ± 0.81 vs. 3.86 ± 1.13; p < 0.001) and 24 hours (2.17 ± 0.56 vs. 3.24 ± 0.69; p < 0.001). A significant baseline difference in age distribution (p = 0.009) was identified as a key variable.

Conclusion: This study provides the first clinical comparison of a rapid-acting salt (Dexamethasone Phosphate) versus a depot-suspension (Methylprednisolone Acetate) as perineural adjuvants in ACB. The observed superior functional and analgesic profile of Dexamethasone aligns with its pharmacokinetic properties, suggesting a pharmacodynamic mismatch between slow-release formulations and the pathophysiology of acute 24-hour postoperative pain.

Successful Use of Low-Dose Combined Spinal-Epidural Anesthesia for Cesarean Section in a Parturient with Eisenmenger Syndrome: A Case Report

Sahala Trident Sitorus — 2025-11-17

Introduction: Eisenmenger syndrome (ES) in pregnancy is a catastrophic condition associated with maternal mortality rates of 30-50%. The profound physiological changes of pregnancy, particularly the decrease in systemic vascular resistance (SVR), exacerbate right-to-left (R-L) shunting, leading to severe hypoxemia and right ventricular failure. Anesthetic management is perilous, as both general and neuraxial anesthesia can precipitate hemodynamic collapse.

Case presentation: We present the case of a 25-year-old G2P101Ab000 parturient at 32-34 weeks of gestation with ES secondary to a large secundum atrial septal defect and severe pulmonary hypertension. She presented for an urgent Cesarean section due to labor. A meticulous anesthetic plan was executed, centered on a low-dose Combined Spinal-Epidural (CSE) technique. This involved an intrathecal injection of 7.5 mg hyperbaric bupivacaine with 50 mcg fentanyl, followed by incremental epidural titration of 0.2% ropivacaine. Hemodynamic stability was proactively managed with inline infusions of phenylephrine and milrinone. The procedure was successful, maintaining stable maternal hemodynamics, SVR, and oxygen saturation. A healthy infant was delivered with APGAR scores of 7 and 8. The patient had an uncomplicated postoperative recovery.

Conclusion: This case demonstrates that a carefully titrated, low-dose CSE technique, combined with invasive monitoring and proactive pharmacological support, can be a safe and effective strategy for Cesarean section in ES patients. This approach successfully navigates the hemodynamic dilemma by providing excellent analgesia while preventing a clinically significant drop in SVR.