Perioperative Fluid Management in Paediatric Liver Transplantation: A Systematic Review.

Perioperative fluid management remains a challenging aspect of paediatric liver transplantation (LT) because of the risk of postoperative complications and haemodynamic instability. Limited research has specifically investigated the impact of fluid management and transfusion on mortality and morbidity in pediatric LT patients. This systematic review summarizes the evidence regarding perioperative fluid management and its clinical outcomes in paediatric LT patients. All primary studies published in English evaluating perioperative fluid management in paediatric LT patients were eligible. PubMed, EBSCOHost, Embase, Proquest, and Google Scholar databases were searched from inception to December 19, 2023. Risks of bias were assessed using the Joanna-Briggs Institute checklist. The results were synthesized narratively. Five retrospective cohort studies of good-excellent quality were included in this review. Two studies evaluated intraoperative fluid administration, one study compared postoperative fluid balance (FB) with outcomes, and two studies compared massive versus non-massive transfusion. A higher mortality rate was associated with intravenous lactated ringer's (LR) than with normal saline, but not with massive transfusion (MT). Longer hospital stays were correlated with MT, >20% positive FB in the first 72 hours, and greater total intraoperative blood product administration. Higher intraoperative fluid administration was associated with a greater thrombotic risk. Additionally, intraoperative MT and lR infusion were associated with an increased risk of 30-day graft loss and graft dysfunction, respectively. Fluid management may impact the outcomes of paediatric LT recipients. These findings underscore the need for more studies to explore the best fluid management and evaluation strategies for children undergoing LT.

Effectiveness of endotracheal intubation and mask ventilation procedural skills training on second-year student using modified Peyton's Four-Step approach during COVID-19 pandemic.

BACKGROUND: Airway emergency is the reason behind competency in mask ventilation and intubation skills for doctors. Procedural skills are taught through face-to-face training. However, the COVID-19 pandemic has had an impact on the education system, including medical education. The face-to-face training method cannot be carried out and requires a modification to an online method. Therefore, Peyton's Four-Step Approach is modified to adapt this change. OBJECTIVE: Assessing the effectiveness of learning methods between modified Peyton's Four-Step approach and classic Peyton's Four Step approach in learning basic skills of mask ventilation and intubation during the COVID-19 pandemic. METHOD: This was an experimental study with two groups of subjects in the Basic ClinicalSkills module of endotracheal intubation and mask ventilation at the Faculty ofMedicine, Universitas Indonesia during February-June 2022. The first group received training with classic Peyton's Four-Step approach and another group with modified Peyton's Four-Step approach. Both groups were tested and assessed using rubric score and global rating score, and asked to fill a feedback questionnaire. RESULTS: This study was conducted with 133 students in the classic group and 96 students in the modified group. The median rubric score was 21.2 for both groups and the global rating score showed 82%and 78% students passed, for classic and modified group respectively. Therubric score and global rating score, also the pass rate between two learningmethods showed no significant results (P > 0.05). The satisfaction and self-confidence questionnaires got answers 'agree and strongly agree' for all questions. CONCLUSION: The learning method using modified and classic Peyton Four-StepApproach were equally effective for learning basic skill of endotracheal intubation and mask ventilation for students of the Faculty of Medicine,University of Indonesia. Both methods provided equal students' satisfaction and self-confidence.

Emergency separation of conjoined twins in a tertiary hospital in Indonesia: three case reports.

BACKGROUND: Emergency separation of conjoined twins is performed when one twin is already dead or dying and threatens the survival of the other. The particular decision to perform an emergency separation of conjoined twins provides an ethical dilemma that needs special attention. Adding to the complexity of surgical and postsurgical management in emergency separation, ethical and sociocultural aspects further complicate decision-making. CASE PRESENTATION: From 1987 to 2022, 18 conjoined twin separations were performed in our centre. This paper describes three conjoined twin emergency separations. In the first case of thoracoomphalopagus babies at nine days of age, one baby was diagnosed with necrotizing enterocolitis with frequent desaturation and seizures, and the other baby was healthy. Emergency separation was performed on the twelfth day of age; unfortunately, neither baby survived the surgery. In the second case, emergency separation was performed on the 110th day of life due to sepsis in one baby. The nonseptic twin passed away six hours after surgery, while the septic twin died 12 days after surgery due to wound dehiscence and abdominal sepsis. The third case was of an omphalopagus conjoined twin with a parasitic twin. The healthy baby was deemed nonviable but found to be healthy upon birth. Immediate emergency separation was performed at 2 h of age. The living baby survived the surgery but passed away two months later. CONCLUSIONS: When separation is deemed necessary to save one twin, it becomes difficult to apply standard ethical medical reasoning. The decision to separate results in most cases in very high-risk surgeries with poor outcomes during surgery and postsurgery. Compounded by the complexity of the case, sociocultural and religious aspects further add to the dynamics of decision-making. A multidisciplinary team must work together with a health ethics committee and navigate through this ethical conundrum with the patient and family at its decision-making centre to decide on the best plan of care.

Comparison of Efficacy of Premedication between Dexmedetomidine and Midazolam Intranasal for the Prevention of Emergence Delirium in Children Undergoing Ophthalmic Surgery.

OBJECTIVE: Emergence delirium (ED) is a condition that can occur when a child recovers from anaesthesia uncomfortably. ED can potentially injure children and indirectly discomforts parents. Various interventions were carried out to reduce ED, but there is no specific standard that has been established to prevent ED. Dexmedetomidine and midazolam are said to be effective in reducing ED. This study aims to determine the effectiveness of intranasal dexmedetomidine premedication compared to intranasal midazolam to prevent ED in children undergoing eye surgery. METHODS: This study was a double-blinded randomised clinical trial. Paediatric patients aged 1-12 years with physical status ASA 1 and 2 who underwent eye surgery under general anaesthesia using sevoflurane inhalation were included in the study. There were 64 children obtained by consecutive sampling who underwent eye surgery in our institution between February and May 2019. The subjects were then randomised into the dexmedetomidine group and the midazolam group. Effectiveness was assessed from ED events, recovery time and post-premedication desaturation events. Data analysis was performed using Chi-square test and Mann-Whitney test. RESULTS: ED incidence in the dexmedetomidine group was 11.18% compared to 28.12% in the midazolam group (P » .109). The recovery time was found to be at a median of 6 minutes for both groups, and no desaturation was found in either group. CONCLUSION: There is statistically no significant difference between the effectiveness of intranasal dexmedetomidine and midazolam premedication 30 minutes before induction to prevent ED occurrence in children undergoing eye surgery.

Efficacy of 0.5 mg/kg of propofol at the end of anesthesia to reduce the incidence of emergence agitation in children undergoing general anesthesia with sevoflurane.

BACKGROUND AND AIMS: Emergence agitation (EA) is a common transient behavioral disturbance after inhalational anesthesia and may cause harm to the patient. This study evaluated the efficacy of 0.5 mg/kg of propofol administered at the end of anesthesia to reduce the incidence of EA in children undergoing general inhalational anesthesia. MATERIAL AND METHODS: This double-blind randomized clinical trial was done in children aged 1-5 years undergoing general anesthesia with sevoflurane. One hundred and eight subjects were included using consecutive sampling method and randomized into two equal groups. Propofol in the dose of 0.5 mg/kg was administered at the end of anesthesia to children in the propofol group, while those in the control group did not receive any intervention at the end of anesthesia. Incidence of EA, transfer time, postoperative hypotension, desaturation, and nausea-vomiting were observed. Aono and Pediatric Anesthesia Emergence Delirium scale were used to assess EA. RESULTS: Incidence of EA was 25.9% in the propofol group compared to 51.9% in the control group (RR = 0.500; 95% CI 0.298-0.840; P = 0.006). Mean transfer time in propofol group was longer (9.5 ± 3.9 min) than control group (7.8 ± 3.6 min) (mean difference 1.71 min; 95% CI 0.28-3.14; P = 0.020). Hypotension was found in one patient (1.9%) in propofol group, while in control group there was none. Nausea-vomiting was found in five patients (9.3%) in propofol group and eight patients (14.8%) in control. There was no desaturation in both the groups. CONCLUSION: Administration of 0.5 mg/kg of propofol at the end of anesthesia effectively reduces the incidence of EA in children undergoing general inhalational anesthesia with sevoflurane.

State of emergency medicine in Indonesia.

OBJECTIVES: As an emerging country with the fourth largest population in the world, Indonesia's purchasing power has strengthened, leading to socioeconomic changes that affect its healthcare system. Additionally, there is a surge of healthcare utilisation after the implementation of a new national insurance scheme, particularly within emergency departments. Similar to other low- to middle-income countries, Indonesia has not prioritised the progress of emergency medicine despite existing evidence that suggests that the early intervention of many acute conditions lowers the rates of morbidity and mortality. This article will review the past and current state of emergency medicine in Indonesia. METHODS: The information gathered through PubMed, Ovid, and private and government institution databases, using the search term 'Indonesia', 'Emergency Medicine', 'Emergency Medical Services', and 'Disaster Medicine'. Additionally, we interviewed physicians who are involved in the development of emergency medicine in Indonesia. RESULTS: Indonesia's emergency medicine can be broken down into three sections: pre-hospital, hospital and the development of emergency medicine as a specialty. At the pre-hospital setting, disaster medicine and emergency medical service have not been established well enough to meet the demands of the population. For hospitals, there are two types of emergency departments - academic versus non-academic. Currently, there is no accredited emergency medicine residency programme despite the recognition of the specialty. CONCLUSION: The development of emergency medicine in Indonesia is in its infancy and will require rapid improvement to meet its country's demand. Academic, private and government sectors need to collaborate to promote and invest in emergency medicine.