Open Access Indonesian Journal of Medical Reviews

Management of Refractory Mechanical Ventilation Weaning in a Geriatric Neurocritical Patient with ARDS and COPD Using the ISCCM 2023 Guidelines: A Case Report

Sugeng Budi Santoso — 2026-04-06

Mechanical ventilator weaning failure occurs in 20–30% of critically ill patients, with the risk significantly amplified by chronic obstructive pulmonary disease (COPD), acute neurological impairment, and severe hypoxemia. A 72-year-old female with COPD developed acute respiratory distress syndrome (ARDS) secondary to hospital-acquired pneumonia (HAP) following a re-craniotomy for an epidural hematoma. Following an initial extubation failure marked by hypercapnia (PaCO₂ 50.7 mmHg), the patient required reintubation. Her initial PaO₂/FiO₂ ratio of 127 mmHg indicated severe gas exchange impairment. Management utilized the 2023 Indian Society of Critical Care Medicine (ISCCM) guidelines. To facilitate weaning, the sedation strategy was transitioned from an initial thiopental infusion to dexmedetomidine, while continuous electrocardiographic monitoring was employed during the rapid correction of severe hypokalemia. The integration of early percutaneous dilatational tracheostomy (PDT), targeted diuresis, and resolution of ventilator-induced diaphragmatic dysfunction (VIDD) improved her PaO₂/FiO₂ ratio to 295 mmHg. In conclusion, successful ventilator liberation in complex neurocritical cases requires a rigorous, multidisciplinary approach. Integrating the ISCCM ABCDEFGHI bundle ensures the systematic correction of pathophysiological barriers, metabolic derangements, and sedation accumulation, leading to favorable clinical outcomes.

Comparative Evaluation of Target-Controlled Infusion versus Syringe Pump Bolus for Remifentanil Administration on the Incidence of Apnoea and Bradycardia during General Anaesthesia Induction: A Double-Blind Pilot Randomised Controlled Trial

Ardhana Surya Aji — 2026-04-09

Remifentanil is widely utilized during general anaesthesia induction to attenuate adverse haemodynamic responses to tracheal intubation. However, its profound analgesic efficacy is inherently linked to dose-dependent adverse effects, primarily opioid-induced respiratory depression (apnoea) and bradycardia. This pilot study evaluates the safety profile of pharmacokinetically guided target-controlled infusion (TCI) compared to conventional syringe pump (SP) bolus administration. A double-blind, pilot randomised controlled trial was conducted involving 36 ASA I–II patients undergoing elective maxillofacial surgery. Patients received a standardized co-induction of propofol (2.0 mg/kg), followed by remifentanil via SP (1 µg/kg over 60 seconds) or TCI (initial effect-site concentration [Ce] of 6 ng/mL for 5 minutes, reduced to 4 ng/mL). Primary outcomes were the incidence of apnoea (>15 seconds) and bradycardia (<50 bpm). Apnoea occurred in 33.3% of the SP group versus 16.7% in the TCI group (RR 2.00; p=0.222). Mean onset of apnoea was 41.0±11.0 seconds (SP) and 31.0±3.6 seconds (TCI) (p=0.085). Bradycardia was observed in 72.2% of the SP cohort and 50.0% in the TCI cohort (RR 1.44; p=0.153). All bradycardic events were transiently managed with 0.5 mg of atropine. In conclusion, in this pilot cohort, remifentanil delivered via TCI did not achieve statistical superiority over SP bolus administration in reducing the incidence of apnoea or bradycardia. Fully powered clinical trials are required to definitively establish any pharmacokinetic safety advantages.

Delayed Presentation of Lumbosacral Myelomeningocele with Tethered Cord Syndrome: Endogenous Tissue Expansion Enabling Primary Closure Without Flap Reconstruction

Hanifah Hasan — 2026-04-15

Myelomeningocele (MMC) represents the most common open neural tube defect, typically presenting at birth or within the neonatal period. Delayed presentation beyond infancy in resource-limited settings remains exceptionally rare and poses unique surgical challenges, particularly regarding soft-tissue reconstruction and prevention of cerebrospinal fluid (CSF) leakage. This case highlights an unusual 4-year delayed presentation with progressive neurological deterioration including tethered cord syndrome and severe functional impairment requiring comprehensive multidisciplinary intervention. A 4-year-old male from rural Banda Aceh presented with a massive lumbosacral myelomeningocele, significant developmental delay, progressive lower extremity paresis (strength 2/5 bilaterally), and documented tethered spinal cord at L4. The patient demonstrated profound motor and sensory deficits with absent deep tendon reflexes and saddle distribution hypoesthesia. Neurosurgical intervention involved careful meningeal sac dissection, separation of functional from nonfunctional neural tissue, adhesiolysis, filum terminale sectioning, neural placode tubularization, and watertight dural closure. Remarkably, the chronic CSF accumulation had functioned as an endogenous tissue expander, providing sufficient skin laxity to enable primary midline closure without requiring flap reconstruction. Early postoperative assessment demonstrated neurological stabilization with subtle functional improvement and complete wound healing without complications. In conclusion, this case demonstrates the importance of multidisciplinary management in delayed neural tube defect presentation and introduces the concept of endogenous tissue expansion via chronic CSF accumulation as a novel biomechanical phenomenon enabling simplified soft-tissue reconstruction. Primary closure without flap reconstruction successfully prevented CSF leakage while preserving neurological stability in the postoperative period. Recognition of such mechanisms may inform surgical strategy in resource-limited settings where complex reconstructive options remain unavailable. The case highlights that even delayed presentations warrant aggressive surgical intervention when specialized expertise becomes available.

Efficacy and Safety of Psilocybin-Assisted Therapy for Depression: A Meta-Analysis of Randomised Controlled Trials

Siti Nashria Rusdhy — 2026-04-21

Psilocybin-assisted therapy shows promise for depression, though current evidence relies on Phase 2 trials with notable methodological limitations. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) evaluating psilocybin-assisted therapy for major or treatment-resistant depression up to February 2024. We evaluated depressive symptom severity using random-effects meta-analysis, moderator analyses, Cochrane Risk of Bias 2, and GRADE methodology. Nine RCTs (N=514) were included. Psilocybin therapy demonstrated a large pooled effect size for symptom reduction (SMD = 1.270, 95% CI: 0.865–1.676, p<0.001). However, substantial heterogeneity was observed (I² = 79.1%). Comparator type significantly moderated outcomes, with waitlist controls showing substantially larger effects than active/placebo controls. Overall GRADE certainty of evidence was rated LOW due to risk of bias, heterogeneity, short-term outcomes, and publication bias concerns. In conclusion, while psilocybin-assisted therapy yields a large pooled effect estimate for depression, current findings are preliminary. Results are heavily qualified by methodological constraints, including waitlist-inflated efficacy, compromised blinding from subjective psychedelic effects, and the confounding influence of integrated psychological support. Confirmation through robust Phase 3 trials is required before supporting routine clinical implementation.

Semaglutide and the Risk of Non-Arteritic Anterior Ischaemic Optic Neuropathy: A Systematic Review and Meta-Analysis

Jovita Jutamulia — 2026-04-23

Semaglutide, a glucagon-like peptide-1 receptor agonist (GLP-1 RA), has emerged as an effective treatment for type 2 diabetes mellitus and obesity management. However, recent pharmacovigilance and observational studies have raised concerns regarding a potential association between semaglutide use and non-arteritic anterior ischaemic optic neuropathy (NAION), a serious form of optic neuropathy causing sudden vision loss. We conducted a systematic review and meta-analysis of observational studies examining the association between semaglutide exposure and NAION risk. We searched PubMed, Embase, and Google Scholar without date restrictions, with the final search completed on 31 March 2026. Study selection was based on predefined inclusion criteria, and quality was assessed using the Newcastle-Ottawa Scale (NOS). A random-effects model was used to estimate pooled hazard ratios (HR) with 95% confidence intervals (CI). Heterogeneity was quantified using the I² statistic. Publication bias was examined using funnel plots and Egger’s regression test. Six observational studies comprising 699,141 participants were included in the meta-analysis. Overall, semaglutide was associated with a significantly increased risk of NAION (pooled HR 1.802; 95% CI 1.221–2.658; p = 0.003). Substantial heterogeneity was observed (I² = 72.8%, Q = 18.37, p = 0.003). Subgroup analyses revealed that the positive association was driven by four prospective cohort studies reporting elevated NAION risk (HR = 2.402; 95% CI 1.662–3.468), whereas two retrospective studies reported null associations (HR = 0.98; 95% CI 0.60–1.60). Sensitivity analyses demonstrated robustness of the primary finding. In conclusion, this meta-analysis provides evidence of a potential increased risk of NAION associated with semaglutide use in observational studies, particularly among individuals with type 2 diabetes and obesity. Clinical awareness of this signal is warranted, and further prospective investigation is recommended.

Ultrasound-Guided Combined Femoral and Popliteal-Sciatic Nerve Block for Foot Debridement in a Patient with Peripheral Arterial Disease, Heart Failure with Reduced Ejection Fraction, and Pulmonary Oedema: A High-Risk Case Report

Heri Dwi Purnomo — 2026-04-30

Peripheral arterial disease (PAD) in its advanced stage leads to critical limb ischaemia requiring operative debridement, and coexisting heart failure with reduced ejection fraction (HFrEF) and pulmonary oedema make general and neuraxial anaesthesia hazardous. We describe a 59-year-old man with three-vessel coronary artery disease previously treated by multiple percutaneous coronary interventions, HFrEF (ejection fraction 36%), hypertension, diabetes mellitus and bilateral PAD who presented with acute decompensated heart failure, pulmonary oedema and bilateral pleural effusion together with an extensive left foot ulcer requiring urgent debridement and necrotomy. An ultrasound-guided combined femoral and popliteal-sciatic nerve block was performed using 20 mL of 1.5% lidocaine and 20 mL of 0.25% bupivacaine. The patient remained conscious and haemodynamically stable with systolic blood pressure 90–110 mmHg, heart rate ~85 beats/min and SpO₂ 100%. The 60-minute procedure was uneventful with no local anaesthetic toxicity, new neurological deficit or respiratory compromise, and the patient was transferred to the high-care unit. Ultrasound-guided peripheral nerve blockade represents a cardiopulmonary-sparing anaesthetic strategy that can deliver adequate operating conditions for lower-extremity surgery in patients with PAD and severe cardiac and respiratory comorbidity. Keywords: Peripheral nerve block, Peripheral arterial disease, Heart failure with reduced ejection fraction, regional anesthesia, ultrasound guidance.