Predicting End-of-Life in a Hospital Setting.

Background: The ability to predict the prognosis of a disease and anticipate death is valuable for patients and families especially in an acute care setting for chronically ill patient. Multiple scoring systems are used to measure disease progression and predict hospital mortality in patients with life-threatening illnesses, taking into account acute conditions, catastrophic events, and slow decline. Aim: Our primary aim is to assess palliative performance score (PPS), early warning score (EWS) and local rumah sakit Dr Hasan Sadikin (RSHS) score to predict 14 days in-hospital mortality. Methods: This was a single-center prospective cohort study from November 2022 to April 2023. Patients with World Health Organization category of terminal illnesses were scored using PPS, EWS and RSHS score and were followed up for 14 days in hospital. Multivariate analysis were conducted and The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines were used. Results: A multivariable model was calculated using Cox regression. The final model results indicate that EWS (HR: 2.9, 95% CI: 1.1-7.7) and a decrease in consciousness (HR: 3.6, 95% CI: 1.2-10.22) were statistically significant in predicting mortality. Discussions: Most patient in the cohort that died had cancer and were admitted in the previous 6 months. Relying solely on single prediction may not provide enough accuracy, within a 14-day timeframe. Therefore, the results of multivariate analysis were not statistically significant due to Several factors contribute to the complexity of this prediction challenge. As a multifaceted disease with varying stages, treatments, and outcomes, cancer presents a diverse landscape of patient experiences. Conclusion: EWS and decreased consciousness are significant predictors of in-hospital mortality. It is crucial in clinical setting to use multiple indicators to predict death and improve patient care.

Clinical and treatment factors associated with the mortality of COVID-19 patients admitted to a referral hospital in Indonesia.

Background: Indonesia had the second-highest number of COVID-19 cases and deaths in South-East Asia. We aimed to determine the factors associated with this mortality and the effect of the recommended COVID-19 treatment regimen during the first 10 months of the epidemic. Methods: This was a retrospective cohort study using secondary data from medical records. In total, 689 adult COVID-19 inpatients hospitalized between March and December 2020 were enrolled. Clinical characteristics, laboratory parameters, and treatments were analyzed by survival outcome. Kaplan-Meier statistics were used to estimate survival. Findings: Of the 689 patients enrolled, 103 (14.9%) died. Disease severity was highly associated with mortality (hazard ratio [HR]: 7.69, p < 0.001). Other clinical factors associated with mortality were older age and comorbidities. Based on laboratory parameters, higher procalcitonin and C-reactive protein contents and a neutrophil-to-lymphocyte ratio >3.53 were also linked to mortality. Favipiravir was associated with lower mortality, with adjusted HRs of 0.24 (0.11-0.54) and 0.40 (0.17-0.98) among the mild/moderate and severe cases, respectively. Among patients with severe disease, steroids showed some beneficial effects in the early days of hospitalization. Interpretation: Older age and comorbidities were associated with disease severity and, consequently, higher mortality. Higher mortality after the second week of hospitalization may be related to secondary bacterial infection. Favipiravir showed significant benefit for COVID-19 survival, while steroids showed benefit only in the early days of admission among patients with severe disease. Funding: This research did not receive a specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Lunar New Year and Eid al Fitr: the circle of COVID-19.

Lunar New Year and Eid al-Fitr are national holidays, and mass movement of people is seen. Lunar New Year 2020 potentiated the spread of coronavirus disease 2019 (COVID-19), while Eid al-Fitr 2022 was a test for federal management of COVID-19 and the success of the Indonesian vaccination campaign. Analysis of new confirmed cases, hospitalizations and the number of elective surgery cancellations due to positive polymerase chain reaction screening in the pre-operative period provides a snapshot of herd immunity.

The Multidisciplinary Perioperative Management of Conjoined Twin Separation Surgery During the Pandemic.

Background: Conjoined twin management, especially separation surgery, is a complex procedure which requires multidisciplinary work in the perioperative period. This complexity further increased with the COVID-19 pandemic, where social distancing protocols and the general reduction in non-COVID-19-related health-care services added a new dimension to the modern form of teamwork. Methods: This study focused on the process of preparation for conjoined twin separation surgery during the pandemic from March 2020 to May 2022 with pre-pandemic era comparison. We described the decision-making process and the available facilities in terms of equipment, human resources, and the inclusion of information and technology. Results: Among the essential requirements for separation surgery are doctors from various disciplines, pediatric anesthesiologists, nurses from different specialties, radiologists, rehabilitation specialists, nutritionists, pharmacists, psychologists, social workers, public relations, and information and technology staff. The team composition may change depending on the patient's clinical characteristics and social needs. Surgery preparation consists of a prognostication period, preoperative management, surgery, and discharge. Conclusion: Complex surgery such as conjoined twin separation can be managed effectively by a team of multidisciplinary experts. The application of information technology, to manage changes in multidisciplinary work pre- and post-pandemic, can reduce pandemic-related social restrictions while maintaining effectiveness and increasing efficiency.

Perioperative Management for Emergency Surgery in Pediatric Patients with COVID-19: Retrospective Observational Study.

Background: The first wave of COVID-19 in 2020 created massive challenges in providing safe surgery for pediatric patients with COVID-19. Inevitably, emergency surgery and the unknown nature of the disease place a burden on the heavily challenged surgical services for pediatrics in a developing country. Lessons from the pandemic are important for future disaster planning. Aim: To describe the characteristics of pediatric surgical patients with COVID-19 undergoing emergency surgery during the first wave and its perioperative narrative in a developing country. Methods: The study was a multicenter retrospective descriptive study in eight Indonesian government-owned referral and teaching hospitals. The authors reviewed confirmed COVID-19 pediatric patients (≤18 years old) who underwent surgery. Institutional review board clearances were acquired, and data were evaluated in proportion and percentages. The writing of this paper follows the STROBE guidelines. Results: About 7791 pediatric surgical cases were collected, 73 matched the study criteria and 24 confirmed cases were found. Cases were more common in females (58.3%), who were above 12 years old (37.5%) and who were asymptomatic (62.5%). Laparotomy (33.3%), general anesthesia (90.4%) and intubation (80.8%) were common, while use of video laryngoscopy (40%) and rapid sequence intubation (28.8%) were rare. The mean length of stay was 12 ±13.3 days, and in-hospital mortality was 8.3%. Discussions: Lockdown and school closure were successful in protecting children, hence the low incidence of pediatric surgical cases with COVID-19 during the first wave. Many hospitals were unprepared to perform surgery for a droplet or airborne infectious disease, and COVID-19 testing was not available nationally in the early pandemic, hence the use of protective protection equipment  during these early pandemic times are often not efficient. Conclusion: The incidence of COVID-19 in pediatric surgical patients is low. The rapidity and availability of preoperative testing for a new emerging disease are essential in a pandemic.

Prevalence of surgery cancelation and challenges in restarting elective surgery in the pandemic: A cross-sectional study.

Objectives: The COVID-19 pandemic caused primary disruption of health services, especially to elective surgery. As the pandemic goes in waves of high and low infection rates in a country, restarting elective surgery must be dynamic while balancing patients' needs, staff safety and the hospital capacity. We aim to report the prevalence of elective surgery and minimally invasive procedures cancelation due to positive Covid-19 screening and describe steps in restarting elective cases after the third wave of Covid-19 infection. Methods: This study was a descriptive cross-sectional study in Indonesia's tertiary referral and teaching hospital from January to September 2021. Subjects were patients scheduled for elective surgery or minimally invasive procedures from our outpatient clinic. Subjects were screened for SARS-CoV-2 using real-time polymerase chain reaction (rRT-PCR) 24-48 hours before scheduled surgery or intervention. Data was taken from the hospital information system and the central operating theatre online surgical list. Statistical analysis is presented in percentage. Results: There were 5286 subjects identified for the study, and 3088 were included with an available PCR result from the outpatient department. The average elective cancelation rate was 7.4%, and the highest cancelation was on August 2021, with 14.7%. All subjects with positive results were asymptomatic, with more than 90% cycle time rRT-PCR above 30. Conclusion: Elective surgery cancelation can reflect a trend in community infection, and monitoring its values is crucial for saving elective surgery plans during a pandemic.

The Impact of Compression Rates on the Quality of Cardiopulmonary Resuscitation: A Cross Over Randomized Control Study in Manikin.

Background: High-quality cardiopulmonary resuscitation (HQ-CPR) focuses on improving heart and brain blood perfusion. The evaluation of HQ-CPR included depth, frequency, rate of chest compressions, and the occurrence of chest recoil between two chest compressions. Staff performing CPR may not be performing HQ-CPR since it is influenced by individual stamina, physical strength, and lack of target marker. We aimed to study the impact of 100 times per minute rate vs. 120 times per minute CPR rate on the depth and percentage of depth-on-target done by trained staff on a manikin. Methods: This was a cross-over randomized control study. The subjects were anesthesiology and intensive care residents in a tertiary teaching hospital in Indonesia, all certified to perform advanced life support. The subject was asked to perform both CPR of 100 and 120 times per minute after a period of one-day rest. The standardized adult manikin was used, and the depth of CPR was measured using a pad-sensor attached to the manikin, and the results were transferred to recording software. Analysis was done using the chi-square analysis, and p < 0.05 was considered statistically significant. Results: A total of 35 subjects were included. The results showed that the average compression depth at 100 times/minute was more statistically superficial than the 120 times/minute treatment (5.210 ± 0.319 vs. 5.430 ± 0.283, p = 0.007). In contrast, the compression depth-on-target percentage was significantly higher at a speed of 100 times per minute (37.130 ± 10.233 vs. 18.730 ± 7.224, p = 0.0001). Conclusion: One hundred times per minute CPR resulted in a statistically significant lower compression depth, although not clinically significant, with a statistically significant higher percentage of compression depth-on-target than 120 times per minute CPR.

Managing surgical patients with a COVID-19 infection in the operating room: An experience from Indonesia.

BACKGROUND: The Coronavirus and the COVID-19 pandemic in 2020 have significantly impacted hospital care, including surgery practice. Hospitals must balance patient care, staff safety, resource availability, and medical ethics. Differences in community infection trends, national policies, availability of resources and technology, plus local circumstances may make uniform management impossible globally. This paper described the practical workflow of emergency COVID-19 surgery in a tertiary referral national hospital in Indonesia. METHOD: This study focused on the process of preparation for COVID-19 surgery from March 2020-March 2021. We also described the available facilities in terms of equipment and human resources. RESULTS: Steps of COVID-19 surgery preparations were described, such as the setup of general and infectious triage in the emergency department, development of preoperative screening protocol for COVID-19, designation of a specialized COVID-19 operating room and surgical staff, changes in preoperative surgery and anesthesia workflow, development of checklists and postoperative monitoring on staff health. CONCLUSIONS: Changes in the workflow are essential during the pandemic for safe surgery. These changes require a multidisciplinary approach, communication, and a continued willingness to adapt. We recommend local adaptation of our general workflow for emergency surgery during an epidemic or pandemic.

Management of Anaesthesia for a High-Risk Aerosol-Generating Procedure in a Paediatric Patient with COVID-19.

INTRODUCTION: Paediatric patients represent a small portion of the COVID-19 disease population. Nevertheless, the possibility of a paediatric patient requiring surgery, especially high-risk aerosol-generating surgery on the airway, while having the SARS-CoV-2 infection may potentially result in problems during the perioperative period due to concerns regarding patient, family, and staff safety. When unplanned and unrehearsed, this scenario may cause delays and efficiency issues. Our aim is to report on an 8-year-old patient with a foreign object lodged in the oesophagus with COVID-19 that required emergency surgery. Case Report. An 8-year-old female patient came to the emergency room with a history of difficulty in swallowing for 12 hours before admission, having accidentally swallowed a metal coin while playing. She did not have any recent history of disease, but her parents had noticed that, for the previous 4 days, she had had a mild fever and dry cough. Her parents and other relatives in the house had no similar complaints, and they assured us they had not been in contact with any suspected or confirmed COVID-19 patients. Our goal was to create a safe paediatric anaesthesia environment with safe working conditions for the surgical team. In this case report, we will describe our approach to patient transport, parental presence, preventions of aerosol risk, personal protection, the anaesthesia induction technique, and postoperative management. CONCLUSION: Safe paediatric anaesthesia, especially in a high-risk aerosol-generating procedure, during the COVID-19 era requires consideration and preparation of both the patient and healthcare provider. Multidisciplinary team work with an emphasis on a systematic and planned approach is required to improve efficiency.

Delayed definitive treatment of life-threatening neurosurgery patient with suspected coronavirus disease 2019 infection in the midst of pandemic: Report of two cases.

BACKGROUND: Coronavirus disease 2019 (COVID-19) pandemic has affected global health system; in the context of the COVID-19 pandemic, both surgeon and anesthesiologist often dealt with emergency situation, optimal timing of surgery and safety protocol in hospital setting must be implemented with many facets for both patients and health-care providers. CASE DESCRIPTION: We reported two cases. Case#1 - A 16-year-old male was referred to our hospital, due to a decreased of consciousness following a motor vehicle accident. Head CT scan revealed an epidural hemorrhage on the left temporoparietal. The patient was suspected for having COVID-19 from the reactivity of his serum against SARS-CoV-2 antigen. Procedures for the confirmation of COVID-19 and surgical preparation caused 12 h delayed from the admission. Nevertheless, the patient was deteriorated clinically before he was transported to the operating room and died after 6 cycles of cardiopulmonary resuscitation. Case#2 - A 25-year-old male was referred to RSHS, due to a decreased of consciousness, diagnosed as bilateral proximal shunt exposed with suspected COVID-19; delay occurred due to unavailability of negative pressure intensive unit for postoperative care. This caused 5760 h (4 days) delayed for bilateral shunt removal and temporary extraventricular drainage. CONCLUSION: Optimal timing of surgery, a good safety, and health protocol during pandemic in emergency setting are an obligation to protect health providers and patients. A decision-making plan must be organized precisely to maintain alertness, achieve the highest possible standard of care, and outcome in emergency surgical cases. Lack of monitoring must be abated to avoid fatality for patient, especially in emergency surgery setting.