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p-ISSN 2722-4554 | e-ISSN 2686-021X | Volume 6 | Number 1 | January 2024

Editorial Board
Prof. An Liong Liem, MD. PhD, FIPP
Prof. Dr. H. R Eddy Rahardjo, dr., SpAn-TI., Subsp. TI(K)., Subsp. An. O(K)
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 TABLE OF CONTENTS

p-ISSN 2722-4554 | e-ISSN 2686-021X | Volume 6 | Number 1 | January 2024

ORIGINAL ARTICLE
Developing an Effective Team-Based Emergency Training Program for 1 - 13
Medical Students
Pinter Hartono, Bowo Adiyanto, Rifdhani Fakhrudin Nur, Cornelia
Ancilla, Aulia Zuhria Rahma

Comparison of Intravenous Administration of Remifentanil with Fentanyl for 14 - 22

Increased Blood Sugar Levels in Post Cardiac Surgery Patients
Irvan, Doddy Tavianto, Reza Widianto Sudjud

Investigation of Heart Rate Variability and The Requirement for Vasopressors 23 - 31

Relationship Due to Hypotension in Patients Undergoing Caesarean Section
with Spinal Anesthesia
Kübra Bektaş, Duygu Yücel, Fatih Uğur

CASE REPORT/CASE SERIES

Pulsed Radiofrequency on Sphenopalatine Ganglion as the Interventional Pain 32 - 41
Management in Cluster Headache Secondary to Sphenoid Meningioma
Naomi Rahmasena, Mirza Koeshardiandi, Fajar Tri Mudianto

Perioperative Management of Marfan Syndrome in Pregnancy and Congestive 42 - 49

Heart Failure
Mirza Koeshardiandi, Fajar Tri Mudianto, Muhammad Wildan Afif
Himawan, Ahmed Eliaan Shaker Abuajwa, Bambang Pujo Semedi

Combined Spinal-Epidural Anesthesia with Isobaric Ropivacaine 0.375% for 50 - 57

Inguinal Hernia Surgery in a Heart Failure Patient with Ejection Fraction of
36%
Muhammad Isra Rafidin Rayyan, Salman Sultan Ghiffari, Achmad
Hariyanto, Achmad Wahib Wahju Winarso, Haris Darmawan, Ichlasul
Mahdi Fardhani

REVIEW
AIMS65 Scoring System for Predicting Clinical Outcomes Among 58 - 72
Emergency Department Patients with Upper Gastrointestinal Bleeding
Rifaldy Nabiel, Al Munawir, Jauhar Firdaus

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 INDONESIAN JOURNAL OF ANESTHESIOLOGY AND
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Original Article

DEVELOPING AN EFFECTIVE TEAM-BASED EMERGENCY TRAINING

PROGRAM FOR MEDICAL STUDENTS

Pinter Hartono1 , Bowo Adiyanto1, Rifdhani Fakhrudin Nur1 , Cornelia Ancilla2 , Aulia
Zuhria Rahma2
1
Departement of Anesthesiology and Intensive Therapy, Faculty of Medicine, Public Health, and Nursing, Gadjah Mada University,
Yogyakarta, Indonesia
2
Faculty of Medicine, Public Health, and Nursing, Gadjah Mada University, Yogyakarta, Indonesia
a
Corresponding author: pinterhartono@mail.ugm.ac.id / dr.pinterhartono@gmail.com

ABSTRACT
Introduction: Team-based patient management in critical care demands a knowledgeable, skillful, and responsive doctor
who collaborates well on teams. Medical education is responsible for producing competent graduates who meet the above
requirements. However, the current medical curriculum in Indonesia tends to focus only on individual knowledge and
appraisal. There was no standardized university-based group emergency training and examination with comprehensive
emergency topics beyond cardiac and trauma cases. Objective: This study aimed to develop and evaluate a team-based
emergency training program that enhances medical students' preparedness and teamwork skills in dealing with future
emergencies in the workplace. Materials and Methods: We developed Acute Life Threatening Events Management
(ALTEM), a three-day emergency training program consisting of pre-test, lectures, guided skill practice, group (case-
based) simulation exam, and post-test. Group simulation occurred in a virtual hospital with high-fidelity mannequins,
actual medical equipment (i.e., beds, monitors, drugs, tools, pads), two-way mirror rooms, and simulated patient family to
resemble real hospital situations. The program was then evaluated by a modified Kirkpatrick evaluation model, which
measures individual perception, satisfaction, understanding, and performance related to the program. Results: A total of
114 participants were involved in this study. Most subjects (>80%) had a good experience with the program. ALTEM
training program significantly increased communication and teamwork (p <0.001) and decision-making towards critical
patients (p <0.001) in the univariate analysis. Communication and teamwork remained related considerably in the
multivariate analysis (aOR 7.866; p = 0.005). Conclusion: The ALTEM simulation program obtained a good response
from the subjects and was a prospective program to improve medical students' competence and teamwork skills in
emergencies.

Keywords: ALTEM; Critical Care Training; Education Policy; Emergency Medical Training; Health Emergency
Preparedness; Health System; Medical Education

ABSTRAK
Pendahuluan: Manajemen pasien kritis berbasis tim membutuhkan dokter yang berpengetahuan luas, terampil, dan
responsif serta dapat bekerja baik dalam tim. Pendidikan kedokteran bertanggung jawab dalam menghasilkan lulusan
kompeten yang memenuhi standar tersebut. Akan tetapi, kurikulum pendidikan kedokteran saat ini cenderung hanya
berfokus pada pengetahuan dan penilaian secara individu. Belum ada pelatihan dan ujian kegawatdaruratan terstandar
dari universitas yang berisi topik kegawatdaruratan secara komprehensif, lebih dari kasus jantung dan trauma. Tujuan:
Penelitian ini bertujuan mengembangkan dan mengevaluasi program pelatihan kegawatdaruratan berbasis tim yang
meningkatkan kesiapan dan keterampilan kerjasama tim mahasiswa kedokteran dalam menangani kasus
kegawatdaruratan di tempat kerja yang akan datang. Bahan dan Metode: Kami mengembangkan Acute Life Threatening
Events Management (ALTEM), program pelatihan kegawatdaruratan berdurasi tiga hari yang berisi pre-test, kuliah,
latihan keterampilan terbimbing, ujian simulasi kelompok (berbasis kasus), dan post-test. Simulasi kelompok
dilaksanakan di rumah sakit virtual dengan manekin berteknologi tinggi, peralatan medis (tempat tidur, monitor, obat,
peralatan), ruangan dengan cermin dua arah, dan keluarga pasien simulasi agar menyerupai situasi nyata di rumah sakit.
Program tersebut kemudian dievaluasi dengan modifikasi model evaluasi Kirkpatrick, yang mengukur persepsi,
kepuasan, pemahaman, dan performa subjek terhadap program. Hasil: Sebanyak total 114 subjek berpartisipasi dalam
penelitian ini. Sebagian besar subjek (>80%) memiliki pengalaman yang baik terhadap program. Program ALTEM secara
signifikan meningkatkan keterampilan komunikasi dan kerjasama tim (p<0,001) serta kemampuan pengambilan
keputusan (p<0,001) dalam analisis univariat. Keterampilan komunikasi dan kerjasama tim tetap memiliki hubungan
signifikan dalam analisis multivariat (aOR 7,866; p

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= 0,005). Kesimpulan: ALTEM memperoleh respon yang baik dari subjek dan merupakan program dengan prospek baik
yang dapat menunjuang kompetensi lulusan kedokteran di bidang kegawatdaruratan.

Kata kunci: ALTEM; Pelatihan Manajemen Pasien Kritis; Kebijakan Pendidikan; Pelatihan Kegawatdaruaratan Medis;
Sistem Kesehatan; Pendidikan Kedokteran

Article info: Received: August 24, 2023; Revised: November 14, 2023; Accepted: December 12, 2023; Published: January 29, 2024

INTRODUCTION effort (1–3). There were several training

Critical care is a complex management courses, such as Advanced Cardiac Life
requiring multidisciplinary collaboration, Support (ACLS) and Advanced Trauma Life
various life-saving procedures, and rapid team Support (ATLS). However, in Indonesia,
response. Emergency care should be done those programs were completed by
cautiously and swiftly because any delay or individuals separately after they finished the
incorrect action could compromise patient government medical internship program,
safety. Hard skills (i.e., knowledge, practical which was a year after graduating from the
skills) and soft skills (i.e., leadership, university, making medical faculties unable to
communication, teamwork, and decision- assess the group performance of the medical
making) are essential to good patient care (1– students, including their responsiveness in
3). emergencies.
Patient safety is a crucial indicator of In emergency medical care, the
healthcare quality and is the responsibility of importance of a standardized protocol and
all stakeholders, including medical education. comprehensive training cannot be overstated
Medical education is vital in introducing and (4,5). WHO Global Health Estimates for 2019
cultivating hard and soft skills as early as stated that stroke was the leading cause of
possible. Medical faculties are also mortality, followed closely by ischemic heart
responsible for producing competent doctors disease, tuberculosis, neonatal conditions,
and the capacity to work in teams because diabetes mellitus, cirrhosis of the liver,
teams manage patients in hospitals. However, diarrheal disease, Chronic Obstructive
medical education, including in our Pulmonary Disease (COPD), lower respiratory
university, tends only to appraise knowledge infections, and HIV/AIDS (6). Remarkably,
and individual performance. Furthermore, the existing training programs, such as
medical students are not specifically trained to Advanced Trauma Life Support (ATLS) and
be leaders or collaborators, whereas doctors Advanced Cardiac Life Support (ACLS),
are leaders and collaborators in patient care. inadequately address this spectrum of life-
These phenomena could lead to medical threatening conditions because they focus on
students' unpreparedness in real emergencies cardiac and trauma management, respectively.
(1–3). The need for a comprehensive, all-
Simulation is one of the strategies in encompassing emergency standardized
medical education to increase patient safety. protocol and training becomes evident, aiming
The simulation-based education system is to bridge the gap in addressing critical
proven to be better than the conventional conditions associated with those top leading
education system, especially education for causes of mortality.
critically ill patients due to advanced medical Recognizing the imperative to address the
conditions and requires rapid resuscitative deficiencies in existing emergency training,

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we

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have developed a new initiative, the Acute from Dr. Sardjito

Life Threatening Events Management, at our
institution, Universitas Gadjah Mada. This
pilot training and study have been
meticulously designed to fill the void in
management protocols for critical or life-
threatening conditions associated with the
leading causes of mortality identified in
Indonesia and other diverse medical
emergencies.
This program is a practical response to
our institution's urgent healthcare needs and is
a blueprint for a nationwide solution.
Understanding that these critical conditions
transcend regional boundaries, we aspire to
catalyze a broader impact by envisioning the
integration of this training and study at a
national level. The ultimate goal is to
empower healthcare providers across the
country with the knowledge and skills
necessary to effectively manage acute life-
threatening events associated with the
prevalent causes of mortality. By fostering a
culture of preparedness and responsiveness,
we hope to contribute significantly to
reducing the alarming mortality rates
attributed to these conditions nationwide. The
Acute Life Threatening Events Management
initiative at Universitas Gadjah Mada signifies
a localized effort and a visionary step towards
enhancing emergency medical care across
Indonesia.

MATERIAL AND METHOD

Program Development
Acute Life Threatening Events
Management (ALTEM) is a simulation-based
training program designed by the Department
of Anesthesiology and Intensive Therapy,
Gadjah Mada University / Dr. Sardjito
General Hospital, Indonesia. This 3-day
course (total: 30 hours) was incorporated into
the medical curriculum, and the participants
were trained directly by anesthesiologists
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General Hospital. The program was done pre-test results of the participants.
periodically 4-5 times a year. Each class 2. Refreshment lectures
consisted of 30-50 participants. The anesthesiologists and lecturers of Dr.
A few days before the program, each Sardjito General Hospital / Faculty of
participant was handed a t-shirt and Medicine, Gadjah Mada University, presented
manual book comprising more lectures. Fifteen topics were presented in 3
comprehensive topics, ranging from days. The topics were (7):
cardiorespiratory emergency management a. Emergency Airway-Breathing
to emergency in neurology and internal Management
medicine, such as acute liver failure and b. Management of Patients with Respiratory
seizures. The manual book was written by Distress
the Department of Anesthesiology c. Early Detection and Principle of
and Intensive Therapy of Gadjah Management of Critical Patients
Mada University. ALTEM combines d. Rapid Sequence Intubation and Intubation
theory, practice, and exams, consisting of a Technique in Critical Patients
pre-test, lectures, guided skill practice, e. Oxygen Therapy and Ventilation
group (case-based) simulation, f. Critical Patient Monitoring
and post-test (7). g. Management of Patients with Circulatory
1. Individual pre-test Problems and Vasoactive Drugs Usage
The individual pre-test consisted of 20 h. Management of Patients with Cardiac
multiple-choice choices about emergency Arrest
management. This study did not collect the i. Management of Patients with Arrhythmia

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j. Management of Seizure and Decrease of Each group took turns conducting the
Consciousness group exam. The anesthesiologist rated each
k. Pain and Sedation Management in group's performance. The case information
Critical Patients was given step by step, depending on the
l. Critical Patient Management System in participant's actions. The emergency
the Hospital simulation setting can be in the intensive care
m. Hemorrhagic Shock unit or the ward. Patient management is
n. Blood Gas Analysis in Critical Patients correct if the patient (the mannequin) is
o. Distributive Shock (Sepsis and eventually stated to be alive and is judged
Anaphylactic Shock) incorrect if the patient dies.
Each session lasted 40 minutes, with a The mannequin used in the simulation is
30- minute coffee break to maintain the a high-technology computerized full-body
participants' focus. Five topics were given on mannequin with heart rate, lung sounds, chest
the first day, six topics on the second day, and movement, flexible mouth and neck, and a
the rest on the last day (7). hollow mouth-to-trachea that enabled
3. Guided-skill group practice intubation. The room consisted of a hospital
The event divided participants into six bed, oxygen tube, vital sign monitor, and
small groups. There were three skill stations, emergency trolley consisting of an intubation
and one room comprised two small groups. and bagging set, oxygenation cannula/mask,
Each room has medical equipment and one defibrillator machine, and emergency drugs.
instructor. The instructors are Dr. Sardjito Furthermore, an anesthesiology resident role-
General Hospital anesthesiologists and played the patient's family. The simulation
lecturers at the Faculty of Medicine, Gadjah room was also equipped with a camera from
Mada University. Every group did a role-play numerous points of view so the other groups
to perform team-based critical care could watch and evaluate the group's
management. The group roles were leader, performance in real-time. The instructor
airway and breathing manager, circulator, and performed a debriefing session afterward.
drugs and documentation handler. After Debriefing is done by reviewing each group's
finishing one station, each group will rotate to performance by asking questions, initiating
the next room and perform different cases. discussion, and giving feedback to all groups.
The cases were (7): All participants were also welcome to provide
a. Management of Patients with Respiratory questions, comments, or suggestions to other
Distress groups. Furthermore, there was an
b. Oxygen Therapy and Ventilation announcement of the best group and the best
c. Management of Patients with Circulatory group leader.
Problems and Vasoactive Drugs Usage 5. Individual post-test
d. Management of Patients with Cardiac Similar to the pre-test, the post-test
Arrest and Arrhythmia consisted of 20 multiple-choice questions
e. Management of Seizure and Decreased about emergency management. The questions
Consciousness. were identical to the pre-test, but each
4. Group (case-based) simulation exam and ALTEM period had slightly different
debriefing questions to minimize fraud.

4
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Program Evaluation Statistical analysis

Study design and participants We analyzed the data using SPSS v.26 for
The study utilized a cross-sectional Windows. Before the questionnaire
design. The participants were medical distribution, we examined the questionnaire's
students in their final year at the Faculty of validity and reliability and concluded that the
Medicine, Public Health, and Nursing, Gadjah questionnaire was reliable and valid.
Mada University, Indonesia. The exclusion Afterward, we conducted cross-tabulated
criteria were students with previous frequencies of the variables and univariate
participation in ALTEM, failure to complete tests for association with the chi-square
the training, or incomplete questionnaire statistic. We carried out correlation and
filling. Of the 200 participants, 114 were multivariate ordinal regression tests where
eligible for the study. indicated. The P-value of <0.05 was
Modified Kirkpatrick model considered significant.
The program has been running since Ethical approval
2017, yet its effectiveness has not been The Institutional Review Board (IRB)
objectively measured. The Kirkpatrick model granted approval on 18 May 2022 from the
was a widely recognized mode of evaluation. local IRB at the Faculty of Medicine, Public
This model had a simple approach, only a few Health, and Nursing, Gadjah Mada University
variables, simple evaluation criteria, and was (KE/FK/0589/EC/2022). Written informed
independent of individual or environmental consent was obtained from the research
variables. The original Kirkpatrick consisted participants.
of 4-level measurements (8–11). Our study
used a modified Kirkpatrick model with 3- RESULT AND DISCUSSION
level measurements.
A total of 114 subjects participated in the
Data collection and evaluation
study, with 61.4% of them being women. The
We distributed an online questionnaire in
mean age was 23.92 ± 1.18, and most subjects
Google Forms using a modified Kirkpatrick
did a great job in the post-test (mean score
evaluation model. The questionnaire consisted
93.90 ± 10.32). The first-level questionnaire
of 3 levels: level 1 (reaction), level 2
revealed that most subjects liked and enjoyed
(learning), and level 3 (behavior). Level 1
the training (89.5%), thought the training was
measures individual perception and
relevant (97.4%), considered the training
satisfaction regarding the program. Level 2
applicable (86.3%), had a positive experience
measures individual learning, which involves
(98.2%), was satisfied with the instructor
transferring knowledge and managerial skills.
(84.2%), and was pleased with the skill station
Level 3 assesses performance by assessing the
session (86.9%). However, certain subjects
improvement in the workplace due to previous
were not content with the lecturers (0.9%),
ALTEM training. Subjects rated the extent to
training materials (7.0%), and overall training
which they agreed with the statement on a 5-
design (1.8%) (Table 1).
point Likert scale from 1 (strongly disagree)
On level 2, we conducted a post-test to
to
explore the subject's understanding of the
5 (strongly agree). The answers from the
emergency topics. Participants who thought
questionnaires were then recapitulated and
this program trained protocol implementation
analyzed.
and management algorithm of critically ill

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5

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patients got a higher score (p = 0.002) (Table (p <0.001) in the univariate analysis (Table 3).
2). On level 3, ALTEM training increased Communication and teamwork remained
communication and teamwork skills (p significantly related in the multivariate
<0.001) and decision-making towards critical analysis (OR 7.866; p = 0005) (Table 4).
patients

Table 1. Subject Perception Regarding ALTEM (level 1 Kirkpatrick questionnaire)

Response (n = 114) n (%)
Enjoyment of the training
Neutral 12 (10.5%)
Agree 61 (53.5%)
Strongly agree 41 (36.0%)
The training was relevant to the healthcare provider
Neutral 3 (2.6%)
Agree 32 (28.1%)
Strongly agree 79 (69.3%)
The training was easy to comprehend. #
Disagree 4 (20.2%)
Neutral 23 (20.2%)
Agree 62 (54.4%)
Strongly agree 25 (21.9%)
The lessons were practical and applicable.
Neutral 7 (1.8%)
Agree 39 (34.2%)
Strongly agree 68 (59.6%)
The participant had a good experience with the program
Neutral 2 (1.8%)
Agree 44 (38.6%)
Strongly agree 68 (59.6%)
The participant was satisfied with the lecturer
Strongly disagree 1 (0.9%)
Neutral 26 (22.8%)
Agree 60 (52.6%)
Strongly agree 27 (53.7%)
The participant was satisfied with the instructor
Neutral 18 (15.8%)
Agree 56 (49.1%)
Strongly agree 40 (35.1%)
The participant was satisfied with the training material
Disagree 8 (7.0%)
Neutral 29 (25.4%)
Agree 54 (47.4%)
Strongly agree 23 (20.2%)
The participant was satisfied with the skill station session
Neutral 15 (13.2%)
Agree 59 (51.8%)
Strongly agree 40 (35.1%)
The participant was satisfied with the overall training design
Disagree 2 (1.8%)
Neutral 22 (19.3%)
Agree 62 (54.4%)
Strongly agree 28 (24.6%)
*n = the number of subjects. # = items containing the answers 'disagree' or 'strongly disagree.' There are five scales:
strongly disagree, disagree, neutral, agree, and strongly agree. The scales with zero results (not chosen by the
subjects) are omitted.

The study aimed to evaluate the Gadjah Mada University. Evaluation is

effectiveness of the ALTEM training program needed to know the upsides and downsides of
in increasing the knowledge and skills of the program, which aids in improvement in
medical students of the Faculty of Medicine, the future. The modified Kirkpatrick model

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evaluated the ALTEM program in the form of

a 3-level questionnaire.

Table 2. ALTEM Learning Assessment (level 2 Kirkpatrick questionnaire)

Learning (n = 114) Poor score Fair score Excellent score p-valueª
The program taught about leadership skills. 4
Neutral (n = 4) 0 0 0.882
Agree (n = 47) 0 3 45
Strongly agree (n = 62) 1 3 58
The program taught about communication and
teamwork 1
Disagree (n = 1) 0 0 0.301
Neural (n = 3) 0 1 2
Agree (n = 44) 1 1 42
Strongly agree (n = 66) 0 0 66
The program taught knowledge regarding
emergencies.
Neutral (n = 2) 0 2 0.270
0 32
Agree (n = 33) 1 74
0
Strongly agree (n = 80) 0 6
The program taught about rare emergency cases. 5
Neutral (n = 6) 0 1 0.559
Agree (n = 50) 1 2 47
Strongly agree (n = 58) 0 3 55
The program taught about decision-making. 4
Neutral (n = 5) 0 1 0.145
Agree (n = 43) 1 0 42
Strongly agree (n = 66) 0 5 61
The program taught about confidence in
managing critically ill patients.
Neutral (n = 14) 0 1 13 0.546
Agree (n = 49) 1 1 47
Strongly agree (n = 51) 0 4 47
The program facilitated the competence of the

health workers in the critical areas of the hospital.

Neutral (n = 3) 0 3 0.539
0 41
Agree (n = 43) 1 1 63
Strongly agree (n = 68) 0 5
The program emphasized the implementation of
management algorithms for critically ill patients. 0
Disagree (n = 1) 0 1 0.002*
Neutral (n = 6) 0 0 6
Agree (n = 38) 1 1 37
Strongly agree (n = 68) 0 4 64
The program was efficient with comparable
efficacy to other similar events
Neutral (n = 9) 0 0 9 0.788
Agree (n = 53) 1 3 49
Strongly agree (n = 53) 0 3 49
The program gave the participants the experience
as expected 0 0 15
Disagree (n = 1) 0 1 0.810
Neutral (n = 6) 1 2 51
Agree (n = 54) 0 3 50
Strongly agree (n = 53)
ªChi-square test; *p <0.05: Significant

Level 1 revealed that ALTEM gained an However, a few participants wanted more from
overall positive response from the subjects. 7
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the lecturers (0.9%), training materials
(7.0%), and comprehensive training design
(1.8%). Based on consumer satisfaction
theory,

8
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satisfaction is an integration of two expectation towards service and the perceived

components. The first component is the service experience. In medical education,
individual emotional experience, which refers factors affecting student satisfaction were the
to interest, pride, and achievement regarding students' emotional experience towards the
the service provided. It is closely related to institution or program, learning experience,
the individual's enthusiasm and mental health educational (knowledge and skill)
condition. The second component, i.e., accomplishment, and expectation fulfillment
expectation confirmation theory, defines (12–15).
satisfaction as the conformity between

Table 3. ALTEM performance (Level 3 Kirkpatrick questionnaire)

Strongly
Perceived performance Disagree Neutral Agree Strongly P-valuea
disagree agree
The program taught about leadership skills. 0
Neutral (n = 2) 0 0 1 1 0.322
Agree (n = 25) 0 0 4 20 2
Disagree (n = 29) 0 0 5 16 8
The program taught about communication and
teamwork 1
Disagree (n = 1) 0 0 0 0 <0.001*
Neutral (n = 1) 0 1 0 0 0
Agree (n = 27) 0 0 5 20 2
Strongly agree (n = 30) 0 1 3 11 15
The program taught about rare emergency cases 2
Neutral (n = 3) 0 0 0 1 0.485
Agree (n = 27) 0 0 2 9 16
Strongly agree (n = 29) 0 0 1 16 11
The program taught about decision-making. 1
Neutral (n = 2) 0 1 0 0 <0.001*
Agree (n = 24) 0 0 1 11 12
Strongly agree (n = 33) 0 0 2 13 18
The program taught about confidence in
managing critically ill patients
Neutral (n = 9) 0 0 0 2 7 0.895
Agree (n = 29) 0 0 2 9 18
Strongly agree (n = 21) 0 0 1 6 14
The program trained competence of the health
workers in the critical areas of the hospital
Neutral (n = 2) 0 0 0 1 1 0.992
Agree (n = 24) 0 0 1 11 12
Strongly agree (n = 33) 0 0 2 14 17
The program emphasized the implementation of
management algorithms for critically ill
patients
0.635
Neutral (n = 4) 0 0 0 3 1
Agree (n = 23) 0 0 1 8 14
Strongly agree (n = 32) 0 0 2 12 18
The program is efficient with comparable
efficacy to other similar programs
Neutral (n = 7) 0 0 0 4 3 0.558
Agree (n = 30) 0 0 5 10 15
Strongly agree (n = 21) 0 0 2 12 7
ªChi-square test; *p <0.05: Significant

9
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Table 4. ALTEM effectiveness

Increased performance aOR p-value 95% CI
ALTEM training and increased communication and teamwork 7.866 0.005* -2.899 s/d -0.514
ALTEM training and increased decision-making skills 0.166 0.684 -1.264 s/d 0.829
*p <0.05: significant; CI = confidence interval; aOR = adjusted odds ratio
We analyzed the data using an ordinal regression test

In this study, 1 of 114 subjects (0.9%) cues. The study by the Faculty of Medicine,
reported dissatisfaction with the lecturers, and National Autonomous University of Mexico
8 of 114 participants (7.0%) reported in 2020 reported another factor affecting the
dissatisfaction with the training material. We student perception regarding the lecturer: the
hypothesized that the reason for the blow was lecturer's knowledge about the materials, the
an incorrect perception regarding the ALTEM treatment towards the students, the
training program. ALTEM training program willingness of the lecturer to share their
aimed to enhance the management skills of personal experience to the student, and the
medical students. The participants were time spent together with the pupils (p = 0.001)
assumed to have a fair understanding of (15–17).
emergency management and have done Linton et al. (2014) found that writing
independent study, so the lectures were brief could enhance students' comprehension of
and only contained knowledge that directly complex concepts (18). Writing about an idea
correlate or is helpful for clinical practice. entails the student conducting systematic
Furthermore, a comprehensive discussion thinking, which helps to connect the dots. The
could be found in the ALTEM module, report could also help the students self-
handed out a few days before the course. The evaluate and increase metacognition because
questionnaire also did not ask about the they could know their ability or inability to
identity of the lecturer(s) with whom the elaborate on a concept. Daou et al. (2020)
subjects feel dissatisfied, so we could not compared students having peer discussions,
conclude whether the dissatisfaction came lectures, and a combination of both. They
from one specific lecturer or overall lecturer found that the combination of peer discussion
performance. Moreover, the proportion of and lectures boosted understanding because
discontent towards the lecturers was the combination enforced the use of a
extremely little (1/114; 0.9%), so it did not simplified approach to elaborate complex
depict the perception of all participants. concepts (19). Therefore, future ALTEM
A few subjects needed help lectures could integrate interactive questions,
understanding the materials (20.2%). writing, peer group discussion, and the
According to Spencer (2003) and Ghasemi et lecturers' experience managing critical
al. (2018), the factors affecting material patients in the emergency units as additional
comprehension were the student and the teaching methods to enhance understanding.
teacher. The student factor includes the degree Level 2 questionnaire revealed that
of motivation, interest in the materials, and participants who thought this program trained
concentration. The teacher has protocol implementation and management
communication skills, especially asking algorithm of critically ill patients got a higher
questions, explaining, active listening, and score (p = 0.002) (Table 2). The result aligns
sensitivity to students' verbal and nonverbal with our program's aim to implement a critical
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patient management algorithm. Hailikari et al. participants

(2008) reported that prior knowledge,
especially procedural knowledge, significantly
determined the student score (p <0.05). As a
result, future ALTEM studies would
incorporate pre-test scores. Moreover,
ALTEM pre-test and post-test quizzes would
be multiple choices, consisting of medical
theory and case-based essays, which could
further measure the student's knowledge and
managerial skills before and after training (20).
We carried out the level 3 questionnaire by
comparing the learning obtained in ALTEM
and the subjects' performance in the
workplace. ALTEM training program was
proven to improve communication and
teamwork in the workplace in univariate
(p <0.001) and multivariate
(OR 7.866; p = 0.005) analysis.
Communication and teamwork are essential
components in the healthcare system,
especially regarding patient safety.
Miscommunication regarding the patient status
and management plan during care transition
(between care areas or health worker shifts)
could endanger patient safety. Moreover,
ineffective communication between health
workers, i.e., clinicians, pharmacists, and
nurses, could cause medication errors. The
fundamentals of good teamwork were that all
members identified the objectives of patient
treatment (including the patient himself),
recognized the roles and responsibilities of
himself and other team members, had effective
communication, measurable process and
outcome, and the leader had good leadership
capability (21–24).
The lecturers explained team-based
emergency management and team roles to the
lecture participants. Later in the skill station
session and simulation exam, the participants
simulated medical management with a prior
discussion with each other. The role
discussion, division, and simulation helped the
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understand each member's management video submission is due on the first day of the
objectives, roles, and responsibilities and course. The instructors then grade the video
practice effective communication. The and give feedback during the skill station the
leader also had the chance to practice 10
leadership skills. All of these contributed to
the increased communication and teamwork
of the subjects after the ALTEM training
program.
The ALTEM training program did not
significantly affect leadership ability (p =
0.322) or confidence in facing critical
patients. Each group only did a one-time
simulation in the simulation exam,
meaning that only one person in each
group could become the leader. The one-
time simulation might contribute to a lack
of perceived leadership skill enhancement
by the subjects. Furthermore, the limitation
of having only one simulation case per
group decreased confidence and
competence, particularly in managing rare
cases, after the training program.
The ideal solution to increase
leadership and decision-making skills is to
give each participant several opportunities
to lead the simulation. The multiple
opportunities can be achieved by providing
more instructors, rooms, and facilities so
that more groups can perform
simultaneously during the simulation
exam.
However, a few alternatives can be
considered due to time and resource
limitations. One week before the course
begins, each participant can be given a
scenario and requested to create a short
video of him (less than 5 minutes) leading
the case in groups (role play). One person
acts as the narrator, one person as the
leader, and 2-3 persons as the team
members doing the leader's instruction. The
video does not need to use real medical
devices or mannequins. The role play urges
participants to deepen their knowledge,
communication, and leadership skills. The
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next day. Participants seen as incompetent 'very important' and 'additional' cases. The
will have more intensive drilling during the necessary cases should be simulated in every
skill station (25). period of the ALTEM course, but the
Action learning (i.e., tutorial sessions) is additional cases can vary. The necessary cases
also a feasible leadership training for short- are taught in the lectures and skill stations,
term courses. The tutorial session consists of and the additional cases are written in the
five to eight persons per group, guided by one manual book.
instructor. The instructor presents the Furthermore, the background of
scenario; then, participants collaboratively simulation cases can be tailored to address
explore solutions using a combination of open specific local medical requirements, allowing
questions, appreciative inquiry, and diverse for the customization of simulation scenarios
perspectives. The objective is to facilitate and based on prevalent or critically important
empower individuals to speak up, train critical cases within a given medical education
thinking, and foster a dynamic and setting. For example, shock is one of the
participatory approach to leadership necessary cases in ALTEM. However, the
development (25). background of the patient suffering from
The program was not an independent shock can be adjusted (e.g., heart attack,
factor in increasing perceived decision- dengue fever, motor vehicle accidents, etc).
making skills in the workplace after ALTEM Therefore, medical students living in dengue-
(p = 0.684). Decision-making should be endemic areas can be given cases of dengue
made as quickly and appropriately as shock syndrome. This adaptability ensures
possible in emergencies. Case-based and that ALTEM remains standardized yet
timed simulation in ALTEM trains subjects flexible to medical students' competency
to make rapid and correct decisions requirements.
based on thepatient's condition and The assessment of learning and
medical knowledge. However, decision- performance was subjective. Therefore, there
making in the workplace does not only rely was a possibility of bias. Moreover, the
on the doctor's medical judgment or absence of essay-based questions in the
fundamental knowledge, but other factors also questionnaires limited our ability to capture
play a role, such as ethical considerations, the underlying reasons behind subjects'
sociocultural aspects, hospital policies, patient responses. The study also did not include the
or family preferences, and cost-effectiveness pre-test data. Nevertheless, it is essential to
analyses. On that account, future simulation highlight that this study comprehensively
cases should also involve the ethical, evaluated the effectiveness of ALTEM from
sociocultural, financial, or policy aspects so various perspectives, employing a validated
that the participants can learn to think beyond questionnaire and evaluation model. This
the medical aspects of treating or making a approach ensures that the feedback gathered is
medical decision, therefore taking a more valuable for assessing and refining the
holistic approach to decision-making (21–24). upcoming ALTEM program.
In the context of reliability, ALTEM has a
manual book and checklists for instructors and CONCLUSION
is now developing simulation videos and a ALTEM training program received good
mobile application to standardize the program. responses from the subjects and demonstrated
However, there are simulation cases rated as
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good effectiveness in enhancing Cook DA. Simulation technology for

communication and teamwork. Several
improvements were needed, but the overall
program was a prospective initiative toward
improving medical students' competence and
collaboration in emergency management. We
anticipate widespread acceptance and
implementation across universities,
envisioning a positive impact on emergency
medical care throughout Indonesia.

Acknowledgment
We thank all Gadjah Mada University
anesthesiology residents for their help and
support in implementing ALTEM.

Conflict of Interest
We declare no conflicts of interest in this
study.

Funding
The study received no funding from external
sources.

Authors’ Contributions
PH, BA, RFN, AZR: study concept and
design, acquisition of the data, critical revision
of the manuscript for important intellectual
content, obtaining funding, administrative,
technical, or material support, study
supervision.
CA: analysis and interpretation of the data,
drafting of the manuscript, critical revision of
the manuscript for important intellectual
content, statistical expertise, administrative,
technical, or material support

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Original Article

COMPARISON OF INTRAVENOUS ADMINISTRATION OF REMIFENTANIL

WITH FENTANYL FOR INCREASED BLOOD SUGAR LEVELS IN POST-
CARDIAC SURGERY PATIENTS

Irvan1a , Doddy Tavianto1 , Reza Widianto Sudjud1

1
Department of Anesthesiology and Intensive Therapy, Faculty of Medicine, Padjadjaran University/Dr. Hasan Sadikin Hospital,
Bandung, Indonesia
a
Corresponding author: email.irvan2@gmail.com

ABSTRACT
Introduction: The incidence of hyperglycemia in patients with heart disease undergoing cardiac surgery reaches 50% in
patients without a history of Diabetes Mellitus. This condition of hyperglycemia can increase morbidity and mortality.
Objective: This study aims to assess the effect of using the agent remifentanil intravenously 0.5-1 µg/kgBW bolus
followed by maintenance at a dose of 0.05-0.1 µg/kgBW/minute intravenously compared to the use of fentanyl 3-10
µg/kgBW followed by a maintenance dose of 0.03-0.1 µg/kgBW/minute for increased blood sugar levels in patients
undergoing cardiac surgery with the Cardiopulmonary Bypass (CPB) procedure. Materials and Methods: This study is
an experimental study with a single-blind randomized controlled design. Patients will be divided into 2 groups consisting
of 12 patients each, namely group R (remifentanil) received remifentanil, and group F (fentanyl) received fentanyl. Blood
sugar levels will be checked before and after surgery. Results: The research has been conducted at Dr. Hasan Sadikin
Hospital Bandung from February 2023 to May 2023. The average increase in blood sugar levels in the remifentanil group
was 74 mg/dl, while in the fentanyl group, it was 90 mg/dl. The p-value given is 0.214. Statistical test results showed that
the value of p> 0.05. Conclusion: This study concludes that there is no significant difference in the increase in blood
sugar levels between the two groups (remifentanil and fentanyl). This can be caused by the use of opioid doses in the
lower range and more complex surgical procedures in our research.

Keywords: Blood Sugar Levels; Cardiopulmonary Bypass; Heart Disease; Remifentanil

ABSTRAK
Pendahuluan: Angka kejadian hiperglikemia pada pasien penyakit jantung yang menjalani operasi jantung mencapai
50% pada pasien tanpa riwayat diabetes melitus. Kondisi hiperglikemia ini dapat meningkatkan angka kesakitan dan
kematian. Tujuan: Penelitian ini bertujuan untuk menilai pengaruh penggunaan agen remifentanil secara intravena bolus
0,5-1 µg/kgBB diikuti dengan dosis rumatan 0,05-0,1 µg/kgBB/menit secara intravena dibandingkan dengan penggunaan
fentanil 3-10 µg/kgBB yang diikuti dengan dosis pemeliharaan 0,03-0,1 µg/kgBB/menit untuk peningkatan kadar gula
darah pada pasien yang menjalani operasi jantung dengan prosedur Pintas Jantung Paru (PJP). Bahan dan Metode:
Penelitian ini merupakan penelitian eksperimental dengan rancangan terkontrol acak buta tunggal. Pasien akan dibagi
menjadi 2 kelompok yang masing-masing terdiri dari 12 pasien, yaitu kelompok R (remifentanil) yang mendapat
remifentanil dan kelompok F (fentanil) yang mendapat fentanil. Kadar gula darah akan diperiksa sebelum dan sesudah
operasi. Hasil: Penelitian ini dilaksanakan di RSUP Dr. Hasan Sadikin Bandung pada bulan Februari 2023 sampai
dengan Mei 2023. Rata-rata kenaikan kadar gula darah pada kelompok remifentanil sebesar 74 mg/dl, sedangkan pada
kelompok fentanil sebesar 90 mg/dl. Nilai p yang diberikan adalah 0,214. Hasil uji statistik menunjukkan nilai p > 0,05.
Kesimpulan: Kesimpulan penelitian ini adalah tidak terdapat perbedaan peningkatan kadar gula darah yang signifikan
antara kedua kelompok (remifentanil dan fentanil). Hal ini dapat disebabkan oleh penggunaan dosis opioid dalam rentang
yang lebih rendah dan prosedur bedah yang lebih kompleks dalam penelitian kami.

Kata kunci: Kadar Gula Darah; Pintas Jantung Paru; Penyakit Jantung; Remifentanil

Article info: Received: October 16, 2023; Revised: December 5, 2023; Accepted: January 20, 2024; Published: January 29, 2024
14
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INTRODUCTION cardiac surgical procedures (10,11).

Cardiopulmonary bypass surgery or Heart Remifentanil is an opioid with a very short
Lung Bypass (CPB) is a procedure that is onset of action and a derivative of piperidine.
often performed in heart surgery. The act of Remifentanil itself has a strong analgesic
CPB can cause an inflammatory response that effect which can reduce sympathetic
increases levels of cytokines and stimulation and maintain pulse rate and blood
catecholamines in plasma, resulting in pressure during surgery. Remifentanil is
hyperglycemia (1). The incidence of metabolized in plasma by nonspecific esterase
hyperglycemia in patients undergoing heart with its metabolite remifentanil acid (12).
surgery without comorbid Diabetes mellitus To the best knowledge of the authors,
reached 56.1% (2). Hyperglycemia is there have been no studies comparing the
associated with an increase in the incidence of usefulness of fentanyl and remifentanil for
major side effects and mortality rate in cardiac surgery with CPB procedures in
patients undergoing heart surgery (3,4). Indonesia. Therefore, this study aimed to
During the CPB procedure, the compare the increased blood sugar levels in
phospholipase A2 enzyme will degrade patients undergoing cardiac surgery with PJP
arachidonic acid which will increase who received fentanyl or remifentanil. We
inflammatory mediators such as leukotrienes, assume that the Patients who receive
prostaglandins, and thromboxane. These remifentanil therapy will experience a lower
mediator substances trigger activation and increase in blood sugar levels compared to
adhesion of neutrophils, vasoconstriction of patients who receive fentanyl therapy. To
blood vessels, platelet aggregation, and tissue investigate this hypothesis, we compared the
damage (5). Increases in inflammatory rate of increase in blood sugar levels in both
mediators and secretion of catecholamine groups of patients undergoing cardiac surgery
hormones will cause Systemic Inflammatory with the CPB procedure.
Response Syndrome (SIRS) which will cause
insulin resistance and cause hyperglycemia MATERIAL AND METHODS
which is complications that often occur after Study Design and Subjects
heart surgery (6,7). The design of this study was an
Opioids are a class of drugs that are often experimental study done in a randomized
used in surgery to control the sympathetic crossover study, approved by the Ethics
response during surgery and are expected to Committee of Dr. Hasan Sadikin Hospital
reduce surgical stress (8). One of the opioid Bandung, Indonesia on 23rd January 2023 with
drugs that is often used in surgery is fentanyl. registered number LB.02.01/X.6.5/27/2023.
Fentanyl is the most widely used opioid Twenty-four patients who underwent cardiac
because it has minimal cardiovascular effects, surgery with the CPB procedure were subjects
does not cause histamine release, has a fast in this study. This research was conducted at
onset of action with a short duration of action, the central surgical installation of Dr. Hasan
and is easy to use (9). Apart from fentanyl, Sadikin Hospital Bandung between February
another class of opioid drugs, remifentanil, has and May 2023.
the same level of effectiveness as other opioids
and maintains better hemodynamic stability in
15
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Study Procedures After the patient has an arterial line

After obtaining approval from the installed, the patient's blood sugar level is
Research Ethics Committee Dr. Hasan Sadikin sampled as basic data (T1). Induction is
Hospital Bandung, patients who meet the carried out with propofol 2-3 mg/kgBW
inclusion criteria (patients aged 18 and over intravenously, after the patient falls asleep
undergoing elective heart surgery using a followed by administration of rocuronium 0.8
heart- lung bypass machine, patients with mg/kgBW intravenously. Additional
physical status based on the American Society medications given by perfusion during CPB
of Anesthesiologists (ASA) in categories I-III) procedures such as insulin will be noted in the
are given informed consent regarding the study. After CPB is finished, protamine is
procedure to be carried out. Drug preparation given at a dose of 1-1.3 the dose of heparin
is carried out in the cardiac surgery central and methylprednisolone
operating theatre pharmacy department. 250 mg IV bolus. After the operation is
Patients were divided into 2 groups, complete, the patient's blood sugar is sampled
namely group R, which received remifentanil as final data (T2).
0.5-1 µg/kgBW/minute intravenously, and Data Collection
group F, which received fentanyl 3-10 The first data collected was blood sugar
µg/kgBW. Drugs are divided into two types, level, which was collected just before the
namely induction drugs and maintenance induction of anesthesia was performed. The
drugs. Remifentanil 2 mg is diluted with 0.9% second data collected was blood sugar level
NaCl 40 ml to the preparation of 50 µg/ml in a checked after the operation had been
50 ml syringe, for the induction dose using a completed.
dose range of 0.5-1 µg/kgBW/minute while Statistical Analysis
the maintenance dose is given at 0.05-0.1
sample size was calculated using 𝛼 = 0.05
This research has a crossover design. The
µg/kgBW/minute in a 50 ml syringe using a
syringe pump. Fentanyl medication for
𝛽 = 0.2 (13). A minimum number of 12
and
induction is given bolus at a dose of 3-10
µg/kgBW. Meanwhile, for maintenance, it is participants was required in each random
given at a dose of 0.03-0.1 µg/kgBW/minute, sequence. Therefore, researchers estimated
and 400 mcg fentanyl is diluted with 40 ml of that a minimum total of 24 participants are
0.9% NaCl to form a preparation of 10 mcg/ml needed for this study. The data was tested
in a 50 ml syringe. statistically using Statistical Product and
Patients who will take part in the Service Solution (SPSS) version 26.0 for
research procedure are required to fast 6 hours Windows. Data are presented as median
before surgery. The patient received fasting (interquartile range) for numeric variables and
replacement fluid with Ringer's lactate given
A value of 𝑃 less than
number (percentage) for categorical variables.
at 10 cc/kgBB for 30 minutes and continued
with maintenance fluid at 2cc/kgBB/hour.
0.05 is considered statistically significant.
Then the anesthesia and surgery procedures
can begin and proceed according to applicable
RESULT AND DISCUSSION
standard operational procedures.
This research was conducted on 24
research subjects who underwent cardiac
surgery with a cardiopulmonary bypass
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procedure at Dr. Hasan Sadikin Hospital

Bandung in the period February 2023 to
May
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2023 which has met the inclusion criteria and F which used fentanyl 3-10 µg /kgBW bolus
is not included in the exclusion criteria. followed by a maintenance dose of 0.03-0.1
Subjects were then divided into 2 groups, µg/kgBW/minute, with each group consisting
namely group R which used remifentanil 0.5-1 of 12 research subjects.
µg/kgBW bolus followed by a maintenance
dose of 0.05-
0.1 µg/kgBW/minute intravenously, and group

Table1. Comparison of the Characteristics of Research Subjects

Group
Variable Remifentanil Fentanyl p-value
N=12 N=12
Age (year)
Mean±SD 42 ± 12 41 ± 16 0.909a
Sex, n (%)
Male 7 (58.3) 8 (66.7) 1.000c
Female 5 (41.7) 4 (33.3)
2
BMI (kg/m )
Mean±SD 21.9 ± 4.8 22.2 ± 4.7 0.854a
ASA, n (%)
1 0 0 -
2 0 0
3 12 (100) 12 (100)
Total operation time (minute)
Mean±SD 255 ± 58 240 ± 52 0.510a
Duration of operation-start of CPB (minute)
Mean±SD 66 ± 19 68 ± 17 0.758a
Duration of completion of CPB - completion of surgery
(minute)
Mean±SD 97 ± 34 89 ± 25 0.522a
Duration of CPB
Mean±SD 93 ± 21 83 ± 25 0.339a
Aortic cross-clamp duration
Mean±SD 60 ± 20 61 ± 22 0.871a
Amount of bleeding
Median 800 800 0.519b
Range (min-max) 500 – 3000 500 – 1600
Operation type, n (%)
CABG 2 (16.7) 2 (16.7) 0.430d
MVR 5 (41.7) 4 (33.3)
ASD Closure 1 (8.3) 3 (25.0)
VSD Closure 1 (8.3) 0 (0.0)
MVR+TVr 1 (8.3) 2 (16.7)
CABG+MVR 0 (0.0) 1 (8.3)
MVR+ASD Closure 1 (8.3) 0 (0.0)
MVR+TVr+ASD Closure 1 (8.3) 0 (0.0)
Notes: Analysis uses unpaired t-test, Mann Whitney, Fisher Exact, Chi Square *meaning p<0,05
a b c d

1
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Table 2. Comparison of Blood Sugar Levels of the Two Groups

Group p-value
Variable Remifentanil Fentanyl (Remifentanil vs
N=12 N=12 Fentanyl)
Preoperative blood sugar levels (mg/dl)
Mean±SD 91 ± 16 95 ± 14 0.482
Postoperative blood sugar levels (mg/dl)
Mean±SD 164 ± 27 185 ± 39 0.137
P value (pre vs post) <0,001* <0,001*
Notes: Analysis uses unpaired t-test, (pre and post) uses paired t-test*meaning p<0,05
\

Characteristics of research subjects In the Table 3, it is found that the average

include age, gender, BMI, ASA, total duration increase in blood sugar levels in the
of surgery, duration of surgery until the start remifentanil group was 74 mg/dl, and in the
of PJP, duration of completion of PJP until fentanyl group, it was 90 mg/dl. The statistical
completion of surgery, length of PJP, length of test results obtained a value of p=0.214
aortic cross-clamping, amount of bleeding and (p0.05), which means that there was no
type of operation can be seen in Table 1 and significant difference in the increase in blood
comparison blood sugar levels for both groups sugar levels in Group Remifentanil and Group
can be seen in Table 2. The results of Fentanyl.
statistical tests for all the research groups There were no significant differences in
above showed that the P value for all variables the characteristics of the research subjects
was greater than 0.05 (p value>0.05), which between Group Remifentanil and Group
means it is not significant or not statistically Fentanyl., this shows that all samples from
significant. Thus, it can be explained that there each group were in relatively the same range
is no statistically significant difference so that the two groups were homogeneous and
between all variables in patient characteristics worthy of comparison for further statistical
in Group Remifentanil and Group Fentanyl. analysis.
There are no differences or the same in the two Based on Table 1, it is known that the
research groups so it can be concluded that the average age of research subjects in group R
two groups are homogeneous and can be was 42 ± 12 years, and in group F was 41 ± 16
compared statistically. years. The statistical test results obtained a
value of p=0.909 (p0.05), which means that
Table 3. Comparison of the Increase in Blood there were no significant differences in the
Sugar Levels of the Two Groups
characteristics of the research subjects based
Group
on age between group R and group F. At older
ages, the ability to regulate blood sugar will
decrease due to a
Variable Remifentanil Fentanyl P-value decrease in insulin sensitivity. This is based on
N=12 N=12 research by Shou which explains that the
Increase in blood elderly population experiences a decrease in
sugar levels
the
function of the glucose transporter 4 (GLUT 4)
Mean±SD 74 ± 24 90 ± 38 0.214
Notes: P value (Remifentanil vs Fentanyl) using unpaired t- enzyme and a decrease in insulin sensitivity.
test.*)Statistically significant (p-value < 0,05) In this study, the average age of research
1
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subjects in both groups was not included in

the elderly

1
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Therefore, the results

category so the increase in perioperative blood
sugar levels can be compared (14).
The average body mass index (BMI) in
group R was found to be 21.9 ± 4.8 kg/m2 and
in group F the average BMI was 22.2 ± 4.7
kg/m2. The statistical test results obtained a
value of p=0.854 (p0.05), which means that
there were no significant differences in the
characteristics of the research subjects based
on BMI between group R and group F.
Patients with a higher BMI tended to
experience an increase in blood sugar levels
during intraoperative. This is with research
conducted by Nakadate that there is a negative
correlation between BMI and insulin
sensitivity (15).
In terms of total operating time, it is
known that the average in group R was 255 ±
58 minutes and in group F 240 ± 52 minutes.
The duration of the operation-start of CPB in
group R was 66 ± 19 minutes and in group F
68 ± 17 minutes. Duration of completion of
CPB - completion of surgery in group R was
97 ± 34 minutes and in group F 89 ± 25
minutes. The average CPB duration in group R
was 93 ± 21 minutes and in group F 83 ± 25
minutes. The average duration of aortic cross-
clamping in group R was 60 ± 20 minutes and
in group F 61
± 22 minutes. The average amount of bleeding
in group R was 500 - 3000 ml and in group F
500 - 1600 ml. The CPB procedure is a
procedure that is often used in cardiac surgery
today. However, the CPB procedure has
several disadvantages that can result in
complications after surgery. This
extracorporeal circulation can stimulate an
inflammatory response caused by exposure of
the patient's blood to the circuit of the CPB
machine. Aortic cross-clamp time (ACCT) and
cardiopulmonary bypass time are associated
with increased morbidity and mortality after
cardiac surgery, which is related to myocardial
injury, ischemia, and inflammatory response.
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and valve replacement. This is different from

of post-operative cardiac surgery can be the surgical procedures carried out by Lee
influenced by the length of cardiac surgery where the type of surgery in all research
and the CPB procedure. This is based on samples was valve replacement surgery (17).
research conducted by Madhavan that a Meanwhile, in this study the surgical
longer CPB procedure can increase the risk procedures carried out were more diverse with
of postoperative complications (16). several surgical procedures covering two
The surgical procedures carried out in groups of surgical procedures.
this study were divided into three large The results of this study also showed that
groups, namely valve replacement surgery, after surgery, the average increase in blood
Coronary Artery Bypass Graft, and septal sugar levels in group R was 164 mg/dl, and in
closure. Valve replacement surgery was the group F was 185 mg/dl. The statistical test
most common surgical procedure results obtained a value of p=0.137 (p0.05)
performed in both groups, namely 5 cases indicating that there was no significant
(41.7%) in group R and 4 cases (33.3%) in difference in blood sugar levels after surgery
group F, CABG surgery in both groups between group R and group F.
amounted to 2 cases (16.7%), surgery Blood sugar levels in group R and group F
closure of the septum hole in group R seen from each group before surgery and after
amounted to 2 cases (16.7%) and in group surgery showed a significant difference
F there were 3 cases (25%), the remaining (p<0.001), this shows that there was a
cases studied included two valve significant influence on the treatment given to
replacement operations, CABG with valve group R and group F. Previous research
replacement, closure of the septum hole

19

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conducted by Umpierrez in the GLUCO- Meanwhile, in Lee's research, the surgical

CABG study also explained that the incidence procedure involved only valve replacement.
of hyperglycemia is something that often This also influences research outcomes where
occurs in patients undergoing cardiac surgery various surgical procedures will trigger wider
with an incidence of more than 50% in tissue damage and cause a higher sympathetic
patients without a history of diabetes mellitus response.
(18). This can be caused by tissue damage that Some limitations of this research are that
occurs during cardiac surgery using the CPB the study did not look at postoperative
procedure. outcomes such as length of treatment in the
Research conducted by Lee shows that intensive care room, complications after
remifentanil is more effective in reducing surgery, mortality rate, and the number of
cytokines in cardiac surgery accompanied by samples in this study was 24 with each group
PJP procedures. This is indicated by an of 12 patients, so this will affect the statistical
increase in IL-6 and IL-8 levels which is lower calculations on this research.
than in the group of patients who used the drug
fentan- yl. Lee divided 2 groups of patients CONCLUSION
who received the opioid remifentanil with an
There was no significant difference in the
induction dose of 0.5-1.0 μg/kg and a
increase in blood sugar levels after surgery in
maintenance dose of 0.05-0.1 μg/kg/min with
the group receiving the opioid remifentanil
a group of patients who received the opioid
and the opioid fentanyl. This could be because
fentanyl with an induction dose of 3-10 μg/kg
the number of samples in this study was 12
and a maintenance dose 0.03-0.1 μg/kg/min
patients in each group. It is hoped that future
(17). In research conducted at Dr. Hasan
research can involve a larger sample size so
Sadikin General Hospital, the induction dose
that it can represent the population. Apart from
in group R was 1.0 μg/kg and the maintenance
that, the use of doses with different ranges will
dose was in the lower range, namely 0.05
certainly affect different research outcomes in
μg/kg/min and the induction dose was in the
each group. Various types of surgery also
lower range, namely 3 μg/kg and the average
influence the outcome of the operation where
maintenance dose is 0.05 μg/kg/min where the
this study involved valve replacement surgery,
use of this dose takes into account the patient's
CABG, septal closure, and a combination of
hemodynamic condition. Apart from that, the
surgical procedures.
depth of anesthesia in this study was also not
assessed, which allowed inadequate sedation
Acknowledgement
and opioid medication to be given so that the
The authors thank Doddy Tavianto and Reza
stress response due to surgical trauma
Widianto Sudjud for editing and revising the
continued and there was an increase in
grammar and language in the manuscript
postoperative blood sugar levels.
Another difference in patient
Conflict of Interest
characteristics is the type of surgical procedure
The authors declare that they have no conflict
performed, where this study involved valve
of interest regarding the publication of this
replacement surgery, CABG, septal closure,
article.
and a combination of surgical procedures.

20
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Funding hyperglycemic stress response and oxygen

The authors declared that this study has
received no financial support.

Authors’ Contributions
IT, DT, RW planned the study and contributed
to data collection and analysis. All authors
have reviewed and approved the final
manuscript.

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Original Article

INVESTIGATION OF HEART RATE VARIABILITY AND THE

REQUIREMENT FOR VASOPRESSORS RELATIONSHIP DUE TO
HYPOTENSION IN PATIENTS UNDERGOING CAESAREAN SECTION
WITH SPINAL ANESTHESIA

Kübra Bektaş1a , Duygu Yücel2 , Fatih Uğur3

1
Sakarya Karasu State Hospital, Sakarya, Turkey
2
Erciyes University, Department of Medical Biology, Kayseri, Turkey
3
Erciyes University School of Medicine, Anesthesiology and Reanimation Department, Kayseri, Turkey
a
Corresponding author: quixote93@gmail.com

ABSTRACT
Introduction: The most common effect of spinal anesthesia applied in cesarean section operations is hypotension. It is
very important to prevent hypotension due to fetal bradycardia, acidosis, and maternal effects. Objective: This research
was conducted to predict and prevent maternal hypotension in pregnant women undergoing elective cesarean section with
spinal anesthesia by measuring heart rate variability parameters about hypotension. Materials and Methods: The study
included pregnant women aged 18-45 with ASA 2 classification who underwent elective cesarean section with spinal
anesthesia. Using the 'CorSense Heart Rate Variability Finger Sensor by Elite HRV' device and its smartphone
application, 102 volunteer pregnant patients were monitored for 5 minutes in the recovery unit, and their data were
recorded. After the administration of spinal anesthesia, patients who exhibited a decrease in systolic blood pressure of
20% or more from their baseline values received intravenous ephedrine in 10 mg bolus doses at each instance of low
blood pressure measurements. Patients who received a total of 20 mg or more ephedrine doses or more as needed were
designated as 'Group 1,' while patients who received less than 20 mg or no ephedrine were classified as 'Group 2.'
Results: This study was completed with a total of 102 pregnant patients With 46 patients in Group 1 and 56 patients in
Group 2, the relevant parameters that showed a statistically significant difference between patient groups were subjected
to ROC analysis for predicting hypotension. It was determined that patients with high HF POWER and TOTAL POWER
values had a greater need for vasopressors due to hypotension following spinal anesthesia (p<0.05). Conclusion: In the
research, these values are believed to have the potential to predict hypotension in patients undergoing cesarean sections
with spinal anesthesia.

Keywords: Heart Rate Variability; Hypotension; Childbirth Complications; Pregnant; Spinal Anesthesia

ABSTRAK
Pendahuluan: Efek paling umum dari anestesi spinal yang diterapkan pada operasi sesar adalah hipotensi. Sangat
penting untuk mencegah hipotensi karena bradikardia janin, asidosis, dan efek maternal. Tujuan: Penelitian ini dilakukan
untuk memprediksi dan mencegah hipotensi maternal pada wanita hamil yang menjalani operasi sesar elektif dengan
anestesi spinal dengan mengukur parameter variabilitas detak jantung terkait hipotensi. Bahan dan Metode: Penelitian
ini melibatkan wanita hamil berusia 18-45 tahun dengan klasifikasi ASA 2 yang menjalani operasi sesar elektif dengan
anestesi spinal. Menggunakan perangkat 'CorSense Heart Rate Variability Finger Sensor by Elite HRV' dan aplikasi
smartphone nya, 102 pasien hamil sukarelawan dipantau selama 5 menit di unit pemulihan, dan data mereka dicatat.
Setelah pemberian anestesi spinal, pasien yang menunjukkan penurunan tekanan darah sistolik sebesar 20% atau lebih
dari nilai awal mereka menerima ephedrine intravena dalam dosis bolus 10 mg pada setiap pengukuran tekanan darah
rendah. Pasien yang menerima total dosis ephedrine sebanyak 20 mg atau lebih atau lebih sesuai kebutuhan dianggap
sebagai 'Kelompok 1,' sedangkan pasien yang menerima kurang dari 20 mg atau tidak ada ephedrine diklasifikasikan
sebagai 'Kelompok 2.' Hasil: Penelitian ini diselesaikan dengan total 102 pasien hamil. Dengan 46 pasien di Kelompok 1
dan 56 pasien di Kelompok 2,
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parameter yang relevan yang menunjukkan perbedaan yang signifikan secara statistik antara kelompok pasien dikenai
analisis ROC untuk memprediksi hipotensi. Ditemukan bahwa pasien dengan nilai HF POWER dan TOTAL POWER
yang tinggi memiliki kebutuhan yang lebih besar untuk vasopresor akibat hipotensi setelah anestesi spinal (p<0,05).
Kesimpulan: Dalam penelitian ini, hasil-hasil tersebut diyakini memiliki potensi untuk memprediksi hipotensi pada
pasien yang menjalani operasi sesar dengan anestesi spinal.

Kata Kunci: Variabilitas Denyut Jantung; Hipotensi; Komplikasi Persalinan; Hamil; Anestesi Spinal

Article info: Received: December 4, 2023; Revised: January 4, 2024; Accepted: January 24, 2024; Published: January 29, 2024

INTRODUCTION demonstrates the interaction between cardiac

Spinal anesthesia is frequently preferred and cerebral systems and is used to obtain
in cesarean section procedures due to its ease detailed information about the autonomic
of application, rapid onset of action, and nervous system's control of the heart.
advantages such as reduced intraoperative The likelihood of developing hypotension
blood loss compared to general anesthesia. due to spinal anesthesia is higher in patients
Hypotension, one of the complications of with pre-existing autonomic dysfunction.
spinal anesthesia, occurs in one-third of Some studies have suggested that hypotension
pregnant women. Intraoperative hypotension, observed in cesarean sections under spinal
associated with serious complications in the anesthesia in pregnant women can be
mother such as perioperative acute kidney predicted using parameters related to HRV,
injury and myocardial ischemia, has been but there are also conflicting results from other
noted to have adverse neurological effects on studies (5).
the fetus in the first hours after birth and can This research aims to predict significant
lead to fetal acidemia (1). Therefore, hypotension that may occur after the
predicting and preventing significant administration of spinal anesthesia in pregnant
hypotension with unwanted effects on the women undergoing elective cesarean section
pregnant woman and the fetus is of paramount by measuring heart rate variability using a
importance for morbidity and mortality. non- invasive device that is clinically
In the literature, numerous studies aim to convenient. This approach seeks to identify
predict and intervene early in intraoperative patients at risk of hypotension in advance,
hypotension following cesarean section under allowing for early intervention to reduce the
duration and severity of hypotension.
spinal anesthesia. However, these studies have
often been insufficient in predicting MATERIALS AND METHODS
hypotension or have used methods that lack Ethical Approval and Study Design
clinical convenience (2–4). This study was initiated after obtaining
ethical approval from the Erciyes University
Heart Rate Variability Measurements Non-Invasive Clinical Research Ethics
Even at a regular rhythm, there is a few Committee (2022/698). The study is a non-
milliseconds difference between each interventional descriptive observational study
heartbeat, known as 'heart rate variability' with a post-hoc analysis investigating the
(HRV). HRV is an important parameter that relationship between heart rate variability and
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the need for vasopressors due to hypotension obtained from 24-hour electrocardiographic
in patients undergoing cesarean section records and calculations from 5-minute
between October 2022 and March 2023 in the measurements (6). All data were recorded in
operating theater unit of Kayseri Erciyes the phone application without grouping for
University Hospital. each patient.
Patients taken to the operating table
Study Participants underwent standard monitoring, including
The study included pregnant women aged ECG, non-invasive blood pressure, and
18-45 with ASA 2 classification, who were saturation. All measurements were performed
scheduled for elective cesarean section. with patients in the supine position. Fluid
Patients with hypertension or any other heart loading was performed with approximately
disease during pregnancy, those using 1000 ml of crystalloid solution before the
medications that could affect heart rate, those procedure and continued with crystalloid
undergoing other intraoperative anesthetic infusion during the operation. Patients without
techniques, those with contraindications for the need for intraoperative sedation were
spinal anesthesia, those who experienced included in the study.
significant blood loss before or during the
operation, and those for whom the use of Spinal Anesthesia Procedure
ephedrine was contraindicated were excluded Baseline systolic blood pressure values
from the study. measured before the operation were recorded
as 'pre-procedural values' for each patient.
Data Collection and Analysis Spinal anesthesia was provided with a dose of
For the study, the 'CorSense Heart Rate 0.5% hyperbaric bupivacaine calculated
Variability Finger Sensor by Elite HRV' according to the patient's height, using the
device, which provides heart rate variability formula (0.06 x patient's height in cm =
measurements through digital pulse wave bupivacaine dose in mg), administered through
analysis from the fingertip, was ordered from a Quincke 25-gauge spinal needle at the L3-4
abroad and obtained for use. Subsequently, the intervertebral space with the patient in a sitting
device's existing smartphone application was position, head down (7). A pin-prick test was
installed on the research phone. 102 volunteer applied to measure the sensory block level and
pregnant patients who had no exclusion patients who did not reach the T6 level within
criteria and underwent cesarean section under 20 minutes or developed a block at levels
spinal anesthesia in the operating room of higher than T4 were excluded from the study.
Erciyes University between October 2022 and Patients' blood pressure and pulse were noted
March 2023 were included in the sample after at specified stages: before spinal anesthesia
obtaining their consent. All the patients were (pre- procedure), immediately after spinal
monitored with the device in the recovery unit anesthesia (0 minutes), 1 minute after spinal
at rest. Heart rate variability and parameters anesthesia (1
were calculated using the data obtained from minute), 3 minutes, 5 minutes, 15 minutes, and
5- minute measurements, based on studies 30 minutes after spinal anesthesia.
indicating correlations between measurements

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Definition of Hypotension RESULTS AND DISCUSSION

In this study, a decrease of 20% or more Descriptive Statistical Analysis Results
in the baseline systolic blood pressure values Between Patient Groups
measured before the procedure, as measured In this study, 102 patients were included,
before the operation, was considered with 46 (45.1%) in Group 1 and 56 (54.9%) in
hypotension, following routine practice in the Group 2. The ages of Group 1 patients ranged
operating room, and ephedrine was from 19 to 44 years, with a mean age of
administered in intravenous bolus doses of 10 28.24±5.47 years, while Group 2 patients' ages
mg for patients with low blood pressure ranged from 18 to 45 years, with a mean age
measurements. High-dose ephedrine was of 31.32±6.50 years. Based on the
defined as the intravenous administration of 20 measurements conducted with the device
mg or more of ephedrine during the operation. before the operation, Mann-Whitney U Test
Patients receiving a total of 20 mg or more of results revealed statistically significant
ephedrine during the operation were included differences between Group 1 and Group 2
in 'Group 1', while patients receiving less than patients in HRV and time- related
20 mg or no ephedrine were classified as measurements, including the root mean square
'Group 2'. of successive differences between normal
heartbeats (RMSSD), the standard deviation of
Data Analysis the R-R intervals of normal sinus beats
The data obtained were evaluated using (SDNN), the natural logarithm (LN) and the
the IBM SPSS 25.0 statistical package percentage of adjacent the number of pairs of
program. Descriptive statistics were presented successive NN (R-R) intervals that differ from
as unit count (n), percentage (%), mean ± each other by more than 50 ms (pNN50%).
standard deviation (mean±sd), median (M), Regarding frequency domain measurements,
minimum (min), and maximum (max) values. statistically significant differences were
Data distribution was assessed using Q-Q observed between the groups in TOTAL
plots, Shapiro-Wilk tests, and histogram POWER, Low Frequency (LF) / High
graphics. Parametric data were analyzed using Frequency (HF), LF POWER, and HF
Student's t-test for normally distributed data, POWER values. Furthermore, there was a
while non- parametric data were analyzed statistically significant difference in the ages
using the Mann- Whitney U test. Group of patient groups (p<0.05) (Table 1).
differences were analyzed using Student's t- The average baseline systolic blood
test for parametric data, the Mann-Whitney U pressure values measured before the operation,
test for non- parametric data, and ROC the average systolic blood pressure values
analysis. The study was conducted with a 95% measured during the intraoperative periods,
confidence interval and a 5% margin of error, and the average total ephedrine dosage
and a p-value of less than 0.05 was considered administered throughout the operation
statistically significant. following spinal anesthesia were calculated for
the patients. Out of the 102 patients
participating in the study, 46 patients received
ephedrine doses of 20 mg or higher, while 56

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patients received ephedrine doses lower than Hypotension ROC analysis with TOTAL
20 mg or no ephedrine at all. Based on the POWER
measurements conducted in both groups, In the ROC analysis conducted to assess
statistically significant differences were the predictive power of TOTAL POWER for
observed in the averages of systolic blood post-spinal anesthesia hypotension in pregnant
pressure values and the total ephedrine doses women, the AUC (95%) value was calculated
administered to patients during the as 0.905 (0.848-0.963). The cut-off value was
measurements performed at 1st, 3rd, and 5th determined as 984.07, with a sensitivity of
minutes after spinal anesthesia (p<0.05) (Table 83% and specificity of 17% (p 0.0001) (Table
2). 3) (Figure 1).

Table 1. Statistical Analysis Results Between Patient Groups

Group 1 Group 2
Variable (n=46) (n=56)
z u p-value*
Mean±SD Min. Max. Mean±SD Min. Max.

Age 28.24±5.47 19.00 44.00 31.32±6.50 18.00 45.00 -2.432 927 0.015

HRV 56.87±4.71 46,00 67.00 47.75±7.39 27.00 60.00 -6.311 351 0.000

RMSSD 42.24±13.30 19.87 78.34 24.50±10.29 5.84 50.32 -6.318 348.5 0.000

SDNN 56.30±16.10 31.45 126.73 39.33±13.22 16.48 87.04 -5.542 464 0.000

LN 3.70±0.30 2.99 4.36 3.10±0.48 1.8 3.9 -6.383 339 0.000

pNN50% 16.28±12.95 3.00 48.00 4.66±4.58 0.00 17.00 -6.009 397 0.000

MEANRR 674.80±100.16 472.49 932.00 644.11±94.60 454.43 863.52 -1.244 1103 0.213
TOTAL 1813.82±991.03 448.19 4809.79 628.87±384.51 126.44 1744.61 -7.122 229 0,000
POWER

LF/HF 1.53±0.96 0.18 3.88 3.55±3.82 0.37 22.48 -4.422 630.5 0.000

LF POWER 971.30±599.41 266.85 3240.53 434.12±267.61 90.74 1071.72 -5.568 460 0.000

HF POWER 842.52±677.79 181.34 4081.77 194.68±168.77 17.98 890.36 -7.445 181 0.000

LF PEAK 0.09±0.03 0.04 0.15 0.09±0.09 0.04 0.70 -1.323 1091.5 0.186

HF PEAK 0.24±0.08 0.15 0.45 0.25±0.10 0.15 0.48 -0.475 1217.5 0.635
*Mann-Whitney U Test SD: Standard deviation

Hypotension ROC analysis with HF women, the AUC (95%) value was calculated
POWER as 0.925 (0.876-0.975). The cut-off value was
In the ROC analysis conducted to assess determined as 327.05, with a sensitivity of
the predictive power of HF POWER for post- 85% and specificity of 15% (p 0.0001) (Table
spinal anesthesia hypotension in pregnant 3) (Figure 2).
27
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As a result of the significance analyses and specificity. The intergroup values were
conducted, the relevant parameters were found to be significant in the analysis of the
subjected to ROC analysis. The ROC analysis average TOTAL POWER and HF POWER
of TOTAL POWER and HF POWER values values of Group 1 and Group 2 patients, and
revealed that they could be decisive high sensitivity was observed in the ROC
parameters in predicting hypotension in terms analysis.
of sensitivity

Table 2. Average of SBP (Systolic Blood Pressure) Values and Total Amount of Ephedrine Administered
Between Patient Groups
Group 1 (N=46) Group 2 (N=56) p-value

124,54 ± 11,43 0.202

Average of Baseline SBP 127,66 ± 12,8
0.022
Average SBP at 0-Minute Post-Spinal 114,41 ± 16,04 122,91 ± 20,09
<0,01
Average SBP at 1 Minute Post-Spinal 94,33 ± 15,01 118,33 ± 15,25
<0,01
Average SBP at 3 Minutes Post-Spinal 89,74 ± 15,26 115,49 ± 16,30
<0,01
Average SBP at 5 Minutes Post-Spinal 99,13 ± 16,69 116,91 ± 19,2
0.060
Average SBP at 15 Minutes Post-Spinal 112,3 ± 11,59 116,58 ± 12,04
0.803
Average SBP at 30 Minutes Post-Spinal 115,83 ± 11,08 115,11 ± 11,37
Average Total Amount of Ephedrine <0,01
Administered 23,04 ± 4,65 2,36 ± 4,29
Notes: Mean±Standard deviation. Systolic blood pressure values were calculated in mmHg and the amount of
ephedrine administered was calculated in mg. SBP: systolic blood pressure

Table 3. Hypotension ROC analysis with TOTAL POWER and HF POWER

AUC (%95) cut-off p-value Sensitivity (%) Specificity (%)

TOTAL POWER 0,905(0,848-0,963) 984,07 0,00 0,83 0,17

HF POWER 0,925(0,876-0,975) 327,05 0,00 0,85 0,15

Notes: AUC – Area under the curve

In cesarean-section surgeries, the desired intraoperative hypotension (8). In an article

outcome of anesthesia is maternal comfort and related to the predictability of intraoperative
safety, along with fetal well-being and the hypotension, it was noted that artificial
maintenance of vital fetal functions without intelligence programs could accurately predict
depression (1). In a study utilizing the hypotension, but they did not improve clinical
'Hypotension Prediction Index' (HPI) for outcomes. It was suggested that with the
preventing intraoperative hypotension, the development of 'Augmented Intelligence'
guidance of the index did not meet the programs, the cause of hypotension, including
expectations of significantly reducing surgical manipulations, could be determined.

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These programs could guide clinicians agents, or inotropic drugs, aiming to prevent
regarding the choice of interventions, such as hypotension (9).
intravenous fluid replacement, vasoactive

Figure 1. ROC analysis of TOTAL POWER in Figure 2. ROC analysis of HF POWER in

predicting hypotension predicting hypotension
One effective method for preventing studies in 2005 and 2006 that patients with
hypotension following spinal anesthesia in higher sympathetic tone were particularly
obstetrics is the administration of ephedrine. sensitive to hypotension following spinal
Some studies on spinal anesthesia for cesarean anesthesia, and an LF/HF ratio greater than 2.5
delivery have defined a systolic blood pressure was indicative of severe hypotension in
drop of 20% or more from baseline as pregnant women (9,10). In Bishop et al.'s
'hypotension' (3). Yeh, Chang, and Tsai (2020) study from 2017, the LF/HF ratio was
characterized a 20% drop in systolic blood identified as an optimal threshold with a value
pressure measured as baseline as a of 2.0 for predicting obstetric spinal
'hypotension criterion' and administering hypotension, indicating that heart rate
ephedrine at 20 mg or more as 'high-dose variability analysis techniques have significant
ephedrine' (10). Kang et al. found that the use potential for predicting and managing
of ephedrine was essential for preventing hypotension (5). However, in this study, the
maternal hypotension and had a minimal LF/HF value showed negative significance but
impact on umbilical artery pH. They also did not demonstrate the desired sensitivity in
suggested the use of 20 mg prophylactic the ROC analysis.
ephedrine infusion for the prevention of Thomas et al. stated in 2019 that
maternal hypotension (11). In this study, the parameters such as SDNN, LF POWER, HF
usage of ephedrine was considered a predictor POWER, and LF/HF ratio were essential in
of significant hypotension and was used as a predicting the health of the autonomic nervous
criterion for grouping patients. system (12). In a study conducted by Frandsen
Some studies have suggested that heart et al. in 2022, they found that low TOTAL
rate variability measurements are related to POWER and HF values measured on the day
hypotension following spinal anesthesia in of surgery were indicative of
cesarean surgeries. Hanss et al. found in their
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intraoperative
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hypotension under general anesthesia (13). larger patient cohort and artificial intelligence
Eller in 2007 stated that TOTAL POWER and
HF values were associated with
atherosclerosis (14). Vinayagam et al. reported
in their studies in 2019 that variables like
SDNN and RMSSD were independently
associated with hypotension and could be
useful in predicting hypotension following
spinal anesthesia (15). In Shehata et al.'s
research from 2019, HRV was not predictive
for hypotension in preeclamptic pregnant
women (16).
This study is limited to patients
undergoing cesarean section in the operating
room unit of Erciyes University Hospital
between October 2022 and March 2023and it
is acknowledged that patients may vary in
terms of mental stress and anxiety. Despite
warning patients to "remain calm" during heart
rate variability measurements before entering
the operating room, it is unlikely that all
patients will be equally unaffected by these
factors.

CONCLUSION
This study suggests that elevated TOTAL
POWER and HF POWER values, measured
by the 'CorSense Heart Rate Variability Finger
Sensor by Elite HRV,' indicate a higher
likelihood of requiring vasoactive agents for
hypotension after spinal anesthesia during
cesarean surgery. Despite being an indirect
measure of autonomic activity, this device
offers a practical means of predicting
hypotension in routine cesarean operations.
Implementing interventions like preoperative
fluid replacement and positioning adjustments
for high HF POWER and TOTAL POWER
values could mitigate intraoperative
hypotension severity. Future research with a
3
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integration aims to enhance predictive

accuracy for vasoactive agent requirements
during elective cesarean surgeries.
Acknowledgment
None.

Conflict of Interest
None of the authors in the study have any
conflict of interest.

Funding
This research did not receive any specific
grant from funding agencies in the public,
commercial, or not-for-profit sectors.

Authors’ Contributions
All authors have contributed to all
processes in this research.

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Case Report

PULSED RADIOFREQUENCY ON SPHENOPALATINE GANGLION AS THE

INTERVENTIONAL PAIN MANAGEMENT IN CLUSTER HEADACHE
SECONDARY TO SPHENOID MENINGIOMA

Naomi Rahmasena1 , Mirza Koeshardiandi2a , Fajar Tri Mudianto2

1
Faculty Medicine of Universitas Airlangga, Surabaya, Indonesia
2
Departement of Anesthesiology and Reanimation, dr. Soedono General Hospital, Madiun, Indonesia
a
Corresponding author: Mirzakoes@gmail.com

ABSTRACT
Introduction: Cluster headache is one of the neurovascular headaches characterized by severe recurrent unilateral pain
distributed around the orbit and accompanied by autonomic symptoms such as lacrimation, conjunctival injection nasal
congestion or rhinorrhea, edema of the eyelid, sweating, and miosis. The attack usually lasts for 15 to 180 minutes. The
possible mechanism of cluster headache is through the trigeminal-autonomic reflex. Management of the cluster headache is
divided into pharmacological therapy including abortive and prophylaxis, as well as interventional pain management like
deep brain stimulation, occipital nerve stimulation, and radiofrequency of the sphenopalatine ganglion. Objective: This
report aims to demonstrate the effectivity of pulsed radiofrequency sphenopalatine ganglion on cluster headaches secondary
to meningioma. Case Report: A 47-year-old female consulted the pain clinic with a chief complaint of profound facial pain
for a year. The patient also reported autonomic symptoms such as rhinorrhea and lacrimation. The patient was diagnosed with
meningioma and already treated with conventional therapy such as gabapentine, carbamazepine, omeprazole, and
mecobalamin. Due to the location of meningioma which causes the tumor inoperable. The patient complained of constant and
worsening pain, therefore pulsed radiofrequency on sphenopalatine ganglion was chosen to treat the patient. The patient
reported relief of pain ever since. Discussion: Among the consequences and benefits, pulsed radiofrequency is the choice of
interventional pain management. Possibly the pain from the compression of the greater palatine nerve, intervention on the
sphenopalatine will cause relief of the pain. Pulsed radiofrequency on sphenopalatine ganglion was reported successful in
alleviating the pain of the patient. Conclusion: Pulsed radiofrequency of the sphenopalatine ganglion successfully alleviates
the pain of the cluster headache due to meningioma. However, further study with a bigger population is recommended to see
the efficacy of interventional pain management objectively.

Keywords: Intervention Pain Management; Pulsed Radiofrequency; Secondary Cluster Headache; Sphenoid Meningioma;
Sphenopalatine Ganglion

ABSTRAK
Pendahuluan: Nyeri kepala cluster merupakan nyeri kepala neurovaskuler yang ditandai dengan nyeri unilateral berat
rekuren yang berada di daerah orbita dan adanya gejala otonom seperti lakrimasi, injeksi konjungtiva, kongesti nasi atau
rhinorrhea, edema pada kelopak mata, berkeringat dan miosis. Serangan umumnya berdurasi 15 menit sampai dengan 2 jam.
Mekanisme yang mendasari kemungkinan disebabkan refleks trigeminal otonom. Manajemen nyeri kepala kluster dibagi
menjadi terapi farmakologis yaitu abortif dan profilaksis serta terapi intervensi nyeri seperti deep brain stimulation, occipital
nerve stimulation dan radiofrekuensi pada ganglion spenopalatin. Tujuan: Studi ini bertujuan untuk demonstrasi efektivitas
pulsed radiofrequency ganglion spenopalatin pada nyeri kepala kluster akibat meningioma. Laporan Kasus: Perempuan 47
tahun dikonsultasikan pada klinik nyeri dengan keluhan utama nyeri kepala hebat selama 1 tahun. Pasien menyebutkan
adanya gejala otonom seperti rinorea dan lakrimasi. Pasien terdiagnosis meningioma dan mendapat terapi konvensiopnal
seperti gabapentin, carbamazepine, omeprazole, dan mecobalamin akibat lokasi meningioma yang menjadi kasus yang tidak
dapat dilakukan pembedahan. Adanya nyeri yang konstan dan memburuk, radiofrekuensi berdenyut pada ganglion
spenopalatin menjadi pilihan untuk terapi pasien. Pasien melaporkan nyeri berkurang setelah dilakukan intervensi. Diskusi:
Menimbang keuntungan dan kerugian manajemen intervensi nyeri lainnya, PRF merupakan pilihan manajemen
intervensional nyeri. Radiofrekuensi berdenyut dilaporkan berhasil mengurangi nyeri pada pasien. Kesimpulan: Pulsed
radiofrequency pada ganglion spenopalatin

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berhasil mengurangi nyeri kepala kluster akibat meningioma. Namun dibutuhkan dilakukan studi lebih lanjut untuk melihat
efektivitar terapi secara objektif.

Kata kunci: Manajemen Nyeri Intervensi; Radiofrekuensi Berdenyut; Nyeri Kepala Kluster Sekunder; Meningioma Sphenoid;
Ganglion Spenopalatin

Article info: Received: April 14, 2023; Revised: December 8, 2023; Accepted: December 11, 2023; Published: January 29, 2024

INTRODUCTION trigeminovascular pathway. Through the

Cluster headache is one of the sphenopalatine ganglion, the reflex is also
neurovascular headaches which usually activated through the parasympathetic outflow
triggered by vasodilators such as alcohol or from the superior salivatory nucleus, and the
nitroglycerin (1). The characteristic of cluster cranial nerve which causes vasodilatation and
headache is severe recurrent unilateral pain parasympathetic activation (3). Other than the
usually distributed around the orbit. The primary cause, cluster headaches are also caused
symptoms are usually accompanied by by other etiologies such as nasopharyngeal
autonomic cranial symptoms such as carcinoma, sphenoidal meningioma, carotid
lacrimation, conjunctival injection, nasal artery dissection, vertebral artery dissection,
congestion or rhinorrhea, edema of the eyelid, pituitary adenoma, or aneurysm (KOU) (4).
sweating, and miosis. The duration of the attack Management of cluster headaches varied
is from 15 minutes to 180 minutes (2). In from conservative to interventional
August 2007, a meta-analysis found during 1- management. Conservative therapy from
year prevalence, the number of cluster abortive therapy such as the use of oxygen,
headaches ranged from 3 to 150/100,000 cases. ergotamine, or sumatriptan injection. The use of
The sex ratio on cluster headaches differs verapamil is still widely applied for prophylactic
according to the type of cluster headaches and therapy. When the conservative therapy is
the age of the onset. During the age of onset ineffective, and the pain recurrent the clinician
under 50 years old, both episodic and chronic should start to consider interventional
cluster headaches happened to males more likely management like radiofrequency of the ganglion
than females. Meanwhile, on the age of onset of pterygopalatine (PPG), Occipital nerve
50 years old, the distribution differed, episodic stimulation (ONS), or deep brain stimulation
cluster headaches were more likely to happen to (DBS) (5).
males, while chronic cluster headaches were In this study, we reported the case of
more likely to happen to females (3). secondary cluster headache due to sphenoid
Cluster headache possibly caused by meningioma. Due to the tumor being inoperable,
activation of trigeminal-autonomic reflex. The we need to gather the physicians to alleviate the
trigeminal-autonomic reflex is a connection in pain. This report aims to demonstrate the
the brainstem that connects between the effectivity of pulsed radiofrequency
trigeminal nerve and facial cranial nerve sphenopalatine ganglion on cluster headaches
parasympathetic outflow. The reflex is usually secondary to meningioma.
triggered by the stimulation of the

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CASE REPORT
A 47-year-old female was consulted at the
pain clinic for interventional pain management.
The patient came with a chief complaint of
profound facial pain. The pain has already been
felt since one year ago but has worsened in the
last two months. The pain was located in the
right ocular area and radiated through the back
of the head. Recently, the pain also radiated
through the back of the neck. The quality of the
pain was constant, and sharp stabbing. The pain
was triggered while the patient prayed, looked
up, woke up, and closed her eyes. The pain is
constant during the day, but when triggered the
pain worsens for 15 to 30 minutes.

Figure 2. Coronal and Axial View MRI of the

Patient

The patient first comes to the

ophthalmologist due to the ocular pain, there are
no visual disturbances, double vision, tunnel
vision or floaters. The patient was cleared
because of no apparent disturbances in her
vision. The patient was prescribed hyaluronic
acid eyedrops. The pain did not subside, then
the patient went to the neurologist and
was diagnosed with migraine due
to unilateral headache. The patient
was given ibuprofen but
still the pain has not subsided.
The patient was taken to MRI and found a
meningioma on the right super-sellar which
Figure 1. Coronal and Sagittal View MRI of the pressed the dextrous optic chiasm with the size
Patient 1.9 x 2.5 x 2.7cm. The patient has a history of
three-month birth control injections for fourteen
years. Before the patient was referred to the
neurosurgeon, the neurologist was prescribing
gabapentin, phenobarbital, and dexamethasone.
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The patient was referred to the neurosurgeon done with a cotton tip applicator, therefore
and prescribed mecobalamine, gabapentin, needed to measure the estimated depth of the
carbamazepine, and omeprazole. Due to the cotton tip applicator by measuring the opening
location of the meningioma, the management of the nares to the mandibular notch below the
taken was conventional and nothing invasive. zygoma. The applicator was soaked with
The neurosurgeon then referred to the pain lidocaine 1% and then inserted into the nares
clinic for interventional pain management. parallel to the zygoma, angled laterally until it
When asked the Numeric Rating Scale lays on the nasopharyngeal mucosa posterior to
(NRS) from 0 to 10, with 0 being pain-free and the middle nasal turbinate. Then the second
10 being the worst facial pain in her life, the applicator was applied slightly posteriorly and
patient answered the scale was 7-9. The pain cranially to the initial applicator. The patient
disturbed her daily activities such as bathing, well responded to the diagnostic block by
eating, and her quality of sleep. During the confirming the current NRS was 1-2, which has
attack, the patient also experienced autonomic proven sensitive to future intervention.
symptoms such as rhinorrhea, and lacrimation
(epiphora). The patient had no history of
hypertension, diabetes, or allergy.
The vital signs of the patient were compos
mentis with a total Glasgow coma score (GCS)
of fifteen. Blood pressure was 120/80 mmHg,
with 79 beats per minute, regular. The
temperature was 36 degrees Celsius, and the
respiratory rate was 16 times per minute.
The patient was given sphenopalatine
ganglion block for the pain intervention. The
empiric therapy given included bedrest, slight
head up thirty degrees, ringer acetate (RA)
solution 1500cc/24hours, fentanyl drip
100mcg/kolf of RA solution, tramadol
administered per oral twice daily, amitriptyline
per oral twice administered twice daily,
ondansetron 40mg injection administered twice
daily intravenous, and topazole 40mg injection
administered twice daily intravenous.
The patient also did a diagnostic procedure Figure 3. Fluoroscopy Imaging of the
to confirm the sensitivity of the sphenopalatine Intervention
ganglion block beforehand. The patient was The intervention began with positioning the
prepared in a supine position with an extending patient supine on the operation table. The area
cervical spine. The transnasal approach will be of the intervention which is the zygoma area
disinfected with betadine and alcohol and later
3
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covered with sterile draping. The intervention still able to tolerate the pain and the pain does not
was guided by fluoroscopy and positioned both interfere with her daily activities.
AP and lateral projection. The local anesthetized
by lidocaine 1% infiltrated around the injection DISCUSSION
area until wheal was formed. The needle is
Meningioma can cause several alterations in
inserted by inferior to the zygomatic arch and
the physiology of the brain such as increased
directed medially in coaxial view until the
intracranial pressure, compression of pain-
zygomatic arch is passed. Then needle slightly
sensitive structures (dura, blood vessels,
redirected the cephalad into the pterygopalatine
periosteum), secondary to difficulty with vision,
fossa. The depth of the needle was later
extreme hypertension (part of cushing triad),
confirmed by the AP projection of the
and also psychogenic due to stress from loss of
fluoroscopy.
functional capacity (5). A study conducted by
The stimulation began with sensory
Hadidchi, et al (6), states 40% of meningioma
stimulation at 0.15Hz 2.5mV then followed by
showed the symptom of meningioma-associated
motoric stimulation at 5mV. The pulsed
headache, with tension-type headache as the
radiofrequency was used with 10 Ampere with 2
most likely type shown. The characteristic of the
mV with four cycles of four minutes at 42
headache is mostly dull, with NRS 4-6, without
degrees Celsius. The bleeding caused by this
trigger, and bilateral. These findings are in
procedure was minimal.
contrast with the patient due to the characteristic
Following the procedure, the patient only
of the pain sharp, with NRS 7-9, trigger-
felt pain in the injection area, which is still and
involved and unilateral.
locally anesthetized using lidocaine 1%. Patients
According to the International
did not experience epistaxis, transient anesthesia
Classification Headache Society (7), cluster
or hypoesthesia, lacrimation of the eye, or local
headache is described as severe unilateral pain
or retroorbital hematoma.
usually located orbital, supraorbital, and
The patient was prescribed paracetamol
temporal and lasts between 15 and 180 minutes.
three times a day for the anti-inflammation,
The autonomic symptoms such as ipsilateral
amitriptyline twice a day as the prophylactic
conjunctival injection, lacrimation, nasal
therapy, and tramadol twice a day as needed for
congestion, rhinorrhea, forehead, and facial
the painkiller.
sweating, miosis, ptosis, and/or eyelid edema
The day after the procedure, said the patient
and or agitation usually accompany the cluster
the pain was abruptly lessened. The NRS was
headache. This type of headache matches our
between 1-2 on the dextrous area. The patient
finding in this report, in which the patient
felt comfortable with the daily activities. And
complained of sharp pain in the right orbital
the pain is still constant with NRS 1-2 until day
area with lacrimation and rhinorrhea. The
5 after the procedure. Patients were followed
patient also felt symptoms for approximately 9
after 10 months post interventional pain
months. This complaint matches the ICHS
management, and the NRS still constant in 1-2.
criteria for chronic cluster headaches (7).
The patient is

3
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Prevalence of the cluster headaches is about mostly in high grade. With the activation of
0.1% worldwide, which mostly happens to mast cells, it will release multi-potent
males. Due to the rare incidence of cluster molecules, one of them is histamines (11).
headaches, the incidence of cluster headache- Histamine works as a vasoactive substance,
secondary to meningioma becomes rarer. which will cause vasodilatation. The patient
Secondary cluster headaches are usually caused already felt the pain for almost 10 months
by nasopharyngeal carcinoma, sphenoidal without remission, which according to the IHS
meningioma, carotid artery dissection, vertebral diagnosed with chronic cluster headache. Due to
artery dissection, pituitary adenoma, or the location of the meningioma, the
aneurysm (4). With the MRI confirmation, the neurosurgeon decides the tumor is inoperable,
patient has meningioma located on suprasellar which according to the studies before shows
dextra. Possibly the patient had a secondary complete relief of pain after tumor resection
cluster headache due to the meningioma. (12,13). Treated with conventional therapy like
The position of the meningioma itself carbamazepine, mecobalamine, and gabapentine
possibly induces the cluster headache. With the for 10 10-month periods the patient admitted
MRI, the position of the meningioma on this there was no significant difference in pain
patient posteriorly to the orbital fissure which levels. The patient also complained two weeks
presses the greater palatine nerves. The greater recently, that the pain had worsened Therefore,
palatine nerve is one of the sensory fibers of the this suggests the therapies are ineffective for this
sphenopalatine ganglion which supplies the patient and need to consider possible
sensation of the palate, and mucus membrane interventional pain management.
and also the sympathetic vidian nerve passing The patient was done diagnostic block
through the SPG which is distributed later to the transnasal with lidocaine 1% and proven to
nose, palate, and lacrimal gland, this possibly relieve the pain with confirming from VAS 7-9
explained the symptoms of rhinorrhea and to VAS 1-2. Relief of the pain confirms the
lacrimation of the patient (8). This theory patient might be sensitive to the sphenopalatine
aligned with a systematic review in 2020, which ganglion block. The intervention was done with
showed secondary cluster headaches associated pulsed radiofrequency at 42 Celsius and four
with 37.7% vascular pathologies and 32.5% due cycles of 120 seconds. The patient later
to tumor pathologies including brain mass-like confirmed the relief of the pain until the tenth
lesions (9). month after the intervention follow-up. These
The cluster headache pathophysiology findings aligned with studies before (14,15).
includes the trigeminal system, parasympathetic Sphenopalatine ganglion is hypothesized to
system, and hypothalamus mediated. The play a role in the pathophysiology of trigeminal
trigeminal system plays a role where there is a autonomic cephalgia (TAC) which includes
trigeminal nococervical complex that modulates cluster headache. The sphenopalatine ganglion
and transmits potentially painful stimuli from parasympathetic effect mechanism is through
the face and head to the brain (8). Study (10) the afferent signals from cranial vessels and
showed evidence of mast cells in all grade dura mater get relayed through the trigeminal
meningioma, ganglion and then end in the trigeminal cervical

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complex.

37

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These signals then activate the superior neuromodulation. The neuromodulation process
salivatory nucleus then show sympathetic alters the excitability of c-fibers, which are
activity which correlates with the symptoms commonly involved in neuropathic pain
shown in patients such as rhinorrhea, and syndromes (19,20). PRF is also shown evident
lacrimation (16). in some immune activity-pain pathways. The
Intervention pain management on study showed PRF pain management resulted in
sphenopalatine ganglion such as neural block, decreased microglial activity, which is one of
continuous radiofrequency, pulsed the neuropathic pain pathways. PRF also
radiofrequency, and electrical stimulation was modulates inflammatory cytokines such as IL-
proven significant to relieve the patient pain on 6, IL-17, IFN-gamma, IFR8, and TNF-alpha,
cluster headache (2,16–18). The SPG nerve which mediate neuropathic pain
block provides a positive result, and the side (20). The other mechanisms
effect is typically local, which is a bitter taste include adjustment of the inner structure axons,
and numbness of the throat. However, one study gene expression, and inhibition of extracellular
showed the need for repetitive intervention to signal-regulated kinase (19). Studies have
reach long-term pain relief. The evidence of shown the increase of c-fos immunoreactive
nerve block pain management is mostly case neurons in the superficial lamine
reports and case series, but there are few of the dorsal horn three hours after
randomized controlled studies. Continuous application, meanwhile on conventional
radiofrequency or some called radiofrequency radiofrequency the enhancement starts on day
ablation, tends to have a longer-lasting effect seven after the intervention. This enhancing c-
than SPG nerve block. The side effects of CRF fos immunoreactive will form prepodinorphin
are more complex than the nerve block. which acts as endogenous analgesia. c-fos
Temporary paresthesia in the upper gums and neuron also acts as an inhibitory interneuron
cheeks which last for 3-6 weeks, and permanent that reduces nociception (21,22). Enhancement
hypoesthesia over the cheek and the palate, of c-fos is also inversely correlated with the
which disappeared within 3 months (18). CRF excitability of C fibers which attenuates the
mechanism to alleviate the pain is via ablating neuropathic pain (19). This intervention in pain
the nociceptive nerve fibers, exposing the nerve management is also supported by the other
to high temperatures (70- 90 Celsius degree) study (15,23), which shows the long-term
continuously. This mechanism is probably the efficacy of the SPG PRF. Small prospective
reason why there are such profound studies of 6 patients with chronic short-lasting
uncomfortable side effects due to the damage to unilateral neuralgiform headache
the nerve itself (19). The neurostimulation of with conjunctival injection and tearing
SPG proved efficient for treating cluster accompanied by cranial autonomy symptoms
headaches (18), but the utilities and showed that SPG PRF is considered a safe and
infrastructure are unavailable. effective treatment. Three patient patients
Our rationale for choosing PRF laid on the experienced worsening head pain for two to four
main mechanism of the pulsed radiofrequency is weeks after the procedure. However, the authors
explained this is a common and high percentage
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due to the small population of the study (24).

38

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There are currently no reports on interventional longer period of follow-up to conclude a more
pain management for cluster headaches objective result.
secondary to meningioma with SPG PRF due to
the rarity of the cases. Acknowledgment
The study conducted by Ho and Elahi, 2014 None.
(25) showed successful interventional pain
management of cluster headaches secondary to Conflict of Interest
sphenoid meningioma through SPG-CRF. The The authors declare no conflict of interest
patient also reported NRS after the intervention
pain management is 2-3, and able to wean off all Funding Disclosure
of the narcotics drugs. Although the result of This study did not receive funding from any
SPG PRF may vary possibly due to different organization.
parameters such as frequency, pulse width,
temperature, time, cannula, and active tip size; Authors’ Contributors
varies tissue types like sympathetic ganglia, All authors have contributed to all processes in
peripheral nerves, and DRG; and varies of this research.
species such as humans versus rodents (20). The
incomplete pain relief in this case was
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.

4
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Case Report

PERIOPERATIVE MANAGEMENT OF MARFAN SYNDROME IN

PREGNANCY AND CONGESTIVE HEART FAILURE

Mirza Koeshardiandi1a , Fajar Tri Mudianto1 , Muhammad Wildan Afif Himawan1 ,

,
Ahmed Eliaan Shaker Abuajwa1 Bambang Pujo Semedi2
1
Department of Anaesthesiology and Reanimation, dr. Soedono General Hospital, Madiun, Indonesia
2
Department of Anesthesiology and Reanimation, Faculty of Medicine, Universitas Airlangga/dr. Soetomo General Academic Hospital,
Surabaya. Indonesia
a
Corresponding author: mirzakoes@gmail.com

ABSTRACT
Introduction: A mutation in fibrillin-1 (FBN1) leads to the autosomal dominant condition known as Marfan Syndrome
(MFS). The condition of pregnancy with MFS may increase morbidity and mortality during pregnancy and delivery. Due
to a greater frequency of maternal problems and fetal involvement, pregnancy with Marfan syndrome (MFS) provides
challenges to healthcare professionals and patients and requires special treatment. Objective: This study aimed to
analyze the perioperative management of Marfan syndrome in pregnancy and congestive heart failure (CHF). Case
report: A 27- year-old primigravida with 38-39 weeks gestation presented with a referral letter with a diagnosis of
G1P0A0 with scoliosis and peripartum cardiomyopathy. The patient complained of shortness of breath accompanied by
cold sweat since the second trimester of gestation. Physical examination revealed the presence of arachnodactyly and
spine deformity. The patient underwent an emergency cesarean section with general anesthesia. Breathing problem
appeared the next day after cesarean section, the patient was intubated in the ICU. Chest X-ray depicted bilateral
pulmonary edema. A mechanical ventilator was set up and fluid restriction had been done. The patient was extubated
after showing breathing improvement in the second week in the ICU. Discussion: The diagnosis of MFS in this patient
was defined based on the revised Ghent Nosology. MFS with spine deformity causes breathing problems because of the
altered geometry of the thoracic cavity. MFS in pregnancy may worsen the breathing problem due to autotransfusion that
leads to pulmonary edema. A mechanical ventilator with a specific setting accompanied by fluid restriction is
recommended to reduce the fluid overload in the lungs. Conclusion: Mechanical ventilators with specific settings and
fluid restriction are effective perioperative management to reduce pulmonary edema on MFS in pregnancy and
congestive heart failure.

Keywords: Cardiovascular disease; Marfan Syndrome; Perioperative management; Pregnancy; Preventable death.

ABSTRAK
Pendahuluan: Mutasi pada fibrillin-1 (FBN1) menyebabkan kondisi dominan autosom yang dikenal sebagai Sindrom
Marfan (MFS). Kehamilan dengan MFS dapat meningkatkan morbiditas dan mortalitas terkait kehamilan dan persalinan.
Tujuan: Laporan kasus ini akan menganalisa manajemen perioperatif Marfan Syndrome dengan gravida dan gagal
jantung kongestif. Laporan kasus: Seorang wanita 27 tahun dengan hamil 38-39 minggu dengan diagnosis G1P0A0 dan
skoliosis dan gagal jantung. Pasien mengeluh sesak disertai keringat dingin sejak trimester 2. Pemeriksaan fisik
ditemukan araknodaktili dan deformitas tulang belakang. Kemudian dilakukan section caesarea segera dengan anestesi
total. Sehari pasca operasi, pasien mengeluh sesak dan diputuskan untuk dilakukan intubasi di ICU. Rontgen thorax
menunjukkan edema paru bilateral. Dilakukan pengaturan ventilator yang tepat dan restriksi cairan. Pasien di ekstubasi
pada minggu kedua di ICU setelah menunjukkan perbaikan pernafasan. Diskusi: Penegakan diagnosis MFS pada pasien
ini berdasarkan Nosologi Ghent yang telah direvisi. MFS yang disertai dengan kelainan tulang belakang dapat
menimbulkan masalah pernafasan akibat berubahnya bentuk dan lapang rongga dada. MFS pada kehamilan juga
memperparah masalah penafasan akibat autotransfusi yang dapat menyebabkan edema paru. Pengaturan ventilator yang
disesuaikan dengan derajat keparahan ARDS serta restriksi cairan yang tepat dapat mengurangi penumpukan cairan pada
paru. Kesimpulan: Pengaturan ventilator yang spesifik dan restriksi cairan yang tepat merupakan manajemen
perioperative yang efektif untuk mengatasi edema paru pada MFS dengan gravida dan gagal jantung kongestif.

Keywords: Penyakit Kardiovaskular; Sindroma marfan; Manajemen perioperatif; Kehamilan; Kematian yang dapat
dicegah.
Article info: Received: April 28, 2023; Revised: December 8, 2023; Accepted: December 11, 2023; Published: January 29, 2024

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INTRODUCTION Patients who are diagnosed with cardiac

A mutation in fibrillin-1 (FBN1) leads to disease should be referred to a higher center
the autosomal dominant condition known as with adequate monitoring facilities and
Marfan Syndrome (MFS). This syndrome has professionals for peripartum and perinatal
various manifestations including aortic care. The condition of pregnancy with MFS
aneurysm that can be followed by ectopia may increase morbidity and mortality during
lentis, aortic dissection, and other systemic pregnancy and delivery. The anesthesiologist
abnormalities. Cardiovascular abnormalities has to understand the history of the patient and
findings, such as progressive aneurysm of the possible side effects of the surgical procedure,
aortic root are considered the highest mortality this aims to assess the risks and suitable
risk for Marfan Syndrome (MFS). The anesthesia treatment for the patient.” (6).
progressive aneurysm of the aortic root could Because of a greater prevalence of maternal
lead to aortic dissection and rupture if the problems and fetal involvement in pregnancy
corrective surgery was not performed (1). The with Marfan syndrome (MFS), healthcare
diagnosis of MFS depends on specific clinical professionals and patients face unique
criteria (updated Ghent nosology), although obstacles (4). Therefore, in this case report, the
this can be complicated because aspects of the authors will conduct an analysis of the
disease change based on the patient's age, while perioperative management of Marfan
others are seen regularly in the general syndrome in pregnancy and congestive heart
failure (CHF).
population, with significant phenotypic
diversity. Certain manifestations of MFS also CASE REPORT
overlap with other connective tissue diseases A 27-year-old primigravida with 38-39
(2). weeks gestation presented to the emergency
Although MFS is an uncommon condition obstetrics and gynecology department of Dr.
(1:5.000), the prevalence is estimated to be Soedono General Hospital with a referral letter
substantially higher among athletes, from Dolopo General Hospital. The patient was
particularly in sports where height and longer referred with G1P0A0 with scoliosis and
limbs provide them a significant advantage. peripartum cardiomyopathy. The patient
Voley ball is one of the examples, which is complained of persistent uterine contraction for
classified as a moderate dynamic and a low the past two days. The patient was referred
static sport (3). However, this does not rule out from the previous hospital due to pulmonary
the possibility that it will occur in pregnant edema and a high risk of cardiovascular
women. Goland described AoD in 29 of 39 disease. The patient complained of shortness of
cases of pregnancy-related difficulties, breath accompanied by cold sweat since the
including the ascending aorta (19 cases), second trimester of gestation. Shortness of
descending aorta (8 cases), or both (2 cases). breath gets worse with activity and doesn't get
Eight of these women had not been diagnosed better with lying down. Previously, the patient
with MFS before the emergence of aortic had been receiving treatment since she was 11
issues. (5). years old due to her complaint of shortness of
“These patients need anesthesia treatment breath. It was suspected by the doctor at that
either for heart surgery or other operations. time that the patient had a heart condition and
scoliosis, so
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she had to take regular medication forever.

However, the patient did not take medication
regularly. The patient has no history of
allergies and surgery.
The patient appeared short of breath and
was first seen with a thin and tall stature with a
sunken chest. Physical examination revealed
the presence of arachnodactyly and spine
deformity. The patient’s consciousness is
compos mentis, blood pressure was 128/94 Figure 1. The Electrocardiography Showed Sinus
Rhythm and Left Ventricle Hypertrophy
mmHg, and the pulse was increasing to 118
beats per minute. The patient had a
temperature of 37,5ºC, oxygen saturation of Treatment
98% (in 3 liters per minute of the nasal The patient was diagnosed with G1P0A0,
cannula), and was tachypneic with a 38/39 weeks inpartu latent phase with
respiratory rate of 34 breaths per minute. The scoliosis dan peripartum cardiomyopathy. The
obstetric examination resulted in a fundal patient had planned an emergency cesarean
height of 26 cm and a fetal heart rate of 124 section with general anesthesia. There was no
beats per minute. Cervical exam revealed ± 1 problem during the surgery and the patient was
cm dilated, 25% effaced, and -1 station. Chest moved to the maternity ward in stable
X-ray showed normal lungs and heart condition. Post SC treatment was Ringer
radiographic appearance and severe Lactate infusion of 20 drops per minute,
thoracolumbar scoliosis with right convexity. Ketorolac injection of 30 mg/8 hours, and
Complete blood count test showed Ondancetron injection of 4 mg/8 hours.
Hemoglobin 11.2 g/dL, platelets 371x103/µL,
Hematocrite 43.1%, total leucocytes count Result and Follow-Up
10.53x103/µL, erythrocytes count 5.69 The next day after the C-Section
juta/cm, MCV 75.7 fL, MCH 22.5 pg, MCHC procedure, the patient complained of shortness
29.7 g/dl. of breath and then was given 3 liters/minute
The coagulation test showed PT 8.7 second oxygenation with a nasal cannula. The
(Control 11.9) and APTT 26.5 The liver complaint was getting worse that night, and
function test showed albumin 2.94 g/dl (N 3.5- the anesthesiologist decided to undergo
5), SGOT 20 U/L (N 8-31), SGPT 18 U/L (N intubation for indications of persistent
6-31). The kidney function test showed blood shortness of breath due to suspicion of
urea 6 mg/dl (N 10-20), and creatinine 0.56 pulmonary edema. The patient was then
mg/dl (N 0.6-1.1). A random blood glucose referred to the Intensive Care Unit (ICU) to
test showed 112 mg/dl (N 136-145). The have a ventilator which was set to BIPAP FiO2
electrolytes blood test showed natrium 132 70%, PEEP 5 cmH2O, PIns 8
mmol/L (N 136-145), calium 4.90 mmol/L (N cmH2O, PSupp 8 cmH2O. Mean Arterial
3.5-5.1), and calcium ION 1.03 mmol/L (N Pressure (MAP) was maintained above 65
1.12-1.32). The immunological test showed mmHg and a fluid deficit of 2000-4000 cc per
anti-HIV non-reactive and HbsAg Negative. day. Echocardiography and chest X-ray were
planned for the next day. Intravenous drugs
were prescribed by the anesthesiologist;
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Aminofluid infusion 500cc/ 24 hour, nutritional

milk on nasogastric tube 6x100cc, Cefotaxime
injection 1gr/8hr, Pantoprazole injection
40mg/12hr, Paracetamol 500mg/8hr (if
needed), Dobutamin on syringe pump 4mcg/hr,
Vasoconstrictor on syringe pump 50nn/hr,
Furosemide injection 10mg/hr. Cripsa
2,5mg/24hr and Caralan 5mg/12hr were given
as oral medications.

Figure 3. Chest X-ray Depicting Bilateral

Pulmonary Edema

Figure 2. Echocardiography

Echocardiography revealed the systolic

function of the Left Ventricle (LV) was
normal with an Ejection Fraction (EF) of 56% Figure 4. Radiological evaluation Chest X-rays on
the sixth day in the ICU
and the diastolic function of the LV was
impaired relaxation. The function of the Right
After the evaluation, ventilator weaning
Ventricle (RV) was normal. The result of
was demonstrated gradually and MAP was
blood gas examination showed that pH 7.33,
maintained above 60 mmHg. On day 14 in
PCO2 70 mmHg, PO2 149 mmHg,
ICU, the patient’s condition showed
Bicarbonate (HCO3)
improvement, and shortness of breath was
37.6 mmol/L, Excess Base (EB) 9.5 mmol/L,
completely diminished so that the patient
Oxygen Saturation (SO2) 99.0%, and
could be extubated and moved to the High
temperature 36,0 ºC
Care Unit (HCU) for monitoring, then moved
On the sixth day of follow-up in the ICU,
to the maternity ward for 5 days before
the shortness of breath was diminished and the
discharge.
condition showed improvement in breathing.
Another anteroposterior chest X-ray was
DISCUSSION
planned for further evaluation and the result
New diagnostic guidelines for patients
showed normal lungs and heart radiographic
with or without a family history of Marfan
appearance and severe thoracolumbar scoliosis
syndrome have been provided in the 2010
with right convexity.
revised Ghent nosology. In the absence of an
established family history of Marfan’s
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syndrome, the diagnosis might be made using according to Ghent Nasology diagnostic
one of the following methods: criteria with a total systemic score of 10 (8).
1. Regardless of the presence or absence of The patient has severe thoracolumbar
systemic features, the diagnosis of Marfan scoliosis. This is one of the musculoskeletal
syndrome can be made in the presence of manifestations caused by the abnormalities of
aortic root dilatation or dissection and the connective tissues as a result of the
ectopia lentis, unless there are indications mutation of FBN1. The musculoskeletal
for Sphrintzen-Goldberg syndrome (SGS), manifestations in MFS include spinal
Loeys-Dietz syndrome (LDS), or vascular deformities, chest wall deformities, and low
Ehlers-Danlos syndrome (vEDS). back pain. This patient suffered from breathing
2. The presence of aortic root dilatation or difficulty because of her severe scoliosis.
dissection and FBN1 mutation) is sufficient Scoliosis affects the geometry of the chest and
to establish the diagnosis even when reduces the three- dimensional range of
ectopia lentis is absent. motion of the thoracic cage and spine during
3. The presence of aortic root dilatation or breathing. This may result in reduced lung
dissection with no ectopia lentis and FBN1 capacities, limited diaphragmatic excursion,
status is either unknown or negative, the and inefficiency of the chest wall muscles (9).
diagnosis of Marfan syndrome is confirmed Mechanical ventilation may help to
by the presence of other systemic findings overcome the breathing problem. Another
(≥7 points, according to the new scoring breathing problem in this patient came from
system). However, signs suggestive of bilateral pulmonary edema that was caused by
SGS, LDS, or vEDS should be ruled out autotransfusion in pregnancy. Approximately
and suitable alternative genetic tests ±20-30% of blood volume enters the
(TGFBR 1/2, collagen biochemistry, circulation as the result of uterine contractions
COL3A1, and other relevant genetic tests (10). There is an increase in cardiac output of
when indicated) should be performed. 60 to 80% and also an increase in peripheral
4. Before diagnosing Marfan syndrome in the resistance in the lungs (10). The presence of
presence of ectopia lentis without aortic MFS prompted the occurrence of pulmonary
root dilatation or dissection, an FBN1 edema. The connective tissues in the lungs
mutation previously associated with aortic become looser and the movement of fluid from
disease must be identified. If the FBN1 intravascular to interstitial becomes faster
mutation is not linked to cardiovascular rather than the condition without MFS (9).
illness, the patient should be labeled as A mechanical ventilator was used in this
having "ectopia lentis syndrome" (7). case to reduce the pulmonary edema and to
In this case, the physical examination of overcome the breathing problem. The severity
this patient revealed a sunken chest/pectus of acute respiratory distress syndrome (ARDS)
deformity, arachnodactyly, and spinal caused by pulmonary edema needs to be
deformity as severe thoracolumbar scoliosis. considered before setting up the ventilator.
Ectopia lentis as one of the clinical signs of According to the severity, ARDS is classified
MFS appeared in this patient accompanied by into three based on the following criteria (11):
high myopia. The diagnosis of MFS can be 1. Mild: 200 mm Hg < Pao2/Fio2 ratio ≤ 300
established by the following clinical signs mm Hg with positive end-expiratory

46
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pressure (PEEP) or continuous positive third of the filtered sodium will be reabsorbed.
airway pressure ≥ 5 cm H2O. This
2. Moderate: 100 mm Hg < Pao2/Fio2 ratio
≤ 200 mm Hg with PEEP ≥ 5 cm H2O.
3. Severe: Pao2/Fio2 ratio ≤ 100 mm Hg
with PEEP ≥ 5 cm H2O
In this case, the patient was classified into
moderate ARDS, and the following
recommendations for mechanical ventilator-
specific settings are:
1. ARDS should be started at lower tidal
volumes (6 mL per kg) instead of at
traditional volumes (10 to 15 mL per kg),
2. Higher positive end-expiratory pressure
values (12 cm H2O) should be considered
for initial mechanical ventilation in patients
with ARDS,
3. Prone positioning for 12 to 16 hours per
day,
4. Prophylaxis for venous thromboembolism
should be given to all patients,
5. Enteral feeding should be initiated if a
patient is anticipated to be on a ventilator
for 72 hours,
6. Spontaneous breathing trials guided by a
ventilator liberation (weaning) protocol
should be initiated once a patient with
ARDS begins to improve. (11)
Fluid therapy, in addition to the ventilator
setting, must be explored in this patient. The
goal is to maintain tissue perfusion, integrity,
and function while restoring intravascular
volume to maximize hemodynamic
parameters. (12). It is matched with
Malbrain’s statement that also recommend the
ROSE concept of fluid balance therapy, which
shows the relationship between positive fluid
balance and overload fluid in critically ill
patients (13).
The administration of loop diuretic drugs
in this case may reduce fluid overload. The
mechanism of action of the drug is by
inhibiting the co-transporter Na+/2Cl-/K+ in
the thick ascending loop of Henle where one-
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process can decrease sodium and chloride
reabsorption and increase diuresis (14). Loop 47
diuretic drugs may increase the synthesis
of prostaglandins which cause kidney and
venous dilation. This effect will indirectly
reduce pulmonary wedge pressure. Loop
diuretic drugs may also decrease
electrolytes such as potassium, magnesium,
calcium, and chloride. Furosemide can be
given 20-40 mg twice a day with a maximum
dose of 600 mg per day (14). Patients with
heart failure should avoid excessive fluid
intake, according to European Society of
Cardiology (ESC) guidelines. For severe
heart failure, a fluid restriction of 1.5–2
liters per day is advised. Fluid restriction
has been shown to have a favorable effect.
Fluid restrictions of 1000 cc per day with
explicit instructions or 2000 cc per day
without specific instructions can improve
quality of life. Fluid restriction is not
always recommended for all patients with
heart failure, but this therapy can be
considered for patients with poor quality of
life, low adherence to medication,
and decompensated heart failure
with or without hyponatremia. Fluid
restriction can be adjusted
based on body weight at 30 ml/kg/day (15).

CONCLUSION
Marfan Syndrome is an inherited
disorder that affects connective tissue. The
condition of pregnancy with MFS may
increase morbidity and mortality during
pregnancy and delivery. During pregnancy,
many changes occur in the cardiovascular
system, one of which is autotransfusion. This
condition may cause an increase in cardiac
output which leads to pulmonary edema and
respiratory failure. A mechanical ventilator
with specific settings and fluid restriction
can be used to reduce the clinical symptoms.

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Acknowledgment Decompensasio Cordis Fc II , Hipertensi

None. Pulmonal dan Scoliosis Thorakalis :
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Case Report

COMBINED SPINAL-EPIDURAL ANESTHESIA WITH ISOBARIC

ROPIVACAINE 0.375% FOR INGUINAL HERNIA SURGERY IN A HEART
FAILURE PATIENT WITH EJECTION FRACTION OF 36%

Muhammad Isra Rafidin Rayyan1 , Salman Sultan Ghiffari1, Achmad Hariyanto2a ,

Achmad Wahib Wahju Winarso2, Haris Darmawan2, Ichlasul Mahdi Fardhani1
1
Faculty of Medicine, University of Jember/ dr. Soebandi General Hospital, Jember, Indonesia
2
Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Jember/ dr. Soebandi General Hospital, Jember,
Indonesia
a
Corresponding author: anestesi.mad@gmail.com

ABSTRACT
Introduction: Heart failure is a condition caused by myocardial abnormalities that interfere with the fulfillment of the
body's metabolism. It is one of the primary causes of high perioperative morbidity and mortality rates, and its
management presents a challenge to anesthesiologists. Objective: To demonstrate combined spinal-epidural anesthesia
with isobaric ropivacaine 0.375% for inguinal hernia repair surgery in a heart failure patient with an ejection fraction of
36%. Case Report: A 53-year-old man presented with a complaint of a lump on his left groin accompanied by pain with
a visual analog scale (VAS) pain score of 3/10 three days before admission. The patient was also known to often
complain of shortness of breath and chest palpitations when lying down at night and during strenuous activity. Based on
the examination, the patient was then diagnosed with reducible left lateral inguinal hernia and heart failure with LVEF
36%. Subsequently, the patient was scheduled for elective herniotomy-hernioraphy surgery under low-dose combined
spinal- epidural anesthesia. Spinal anesthesia was performed with isobaric ropivacaine 0.375% and fentanyl 25 μg in a
total volume of 3.5 ml at the L3-L4 intervertebral space. Epidural anesthesia was performed with isobaric ropivacaine
0.375% and fentanyl 25 μg in a total volume of 8 ml at the L2-L3 intervertebral space. After 10 minutes, the sensory
block reached the T6 level, but the motor block was only partial (Bromage 1). A continuous infusion of isobaric
ropivacaine 0.1875% 1 ml/hour was administered through the epidural catheter to control postoperative pain. During
surgery and hospitalization, the patient's hemodynamic condition remained stable. Conclusion: Combined spinal-
epidural anesthesia with isobaric ropivacaine 0.375% can provide adequate anesthesia with relatively stable
hemodynamics, thus making it safe for inguinal hernia repair surgery in heart failure patients with reduced ejection
fraction.

Keywords: Combined Spinal-Epidural Anesthesia; Isobaric Ropivacaine 0.375%; Inguinal Hernia; Heart Failure; Case
Report; Anesthesia Management

ABSTRAK
Pendahuluan: Gagal jantung adalah penyakit yang disebabkan oleh abnormalitas miokardium yang mengganggu
pemenuhan metabolisme tubuh. Kondisi ini menjadi salah satu penyebab utama tingginya angka morbiditas dan
mortalitas perioperatif sehingga penatalaksanaannya menghadirkan tantangan bagi ahli anestesi. Tujuan: Untuk
memaparkan penggunaan kombinasi anestesi spinal-epidural dengan ropivacaine isobarik 0.375% untuk operasi
perbaikan hernia inguinalis pada pasien gagal jantung dengan fraksi ejeksi 36%. Laporan Kasus: Seorang pasien laki-
laki berusia 53 tahun datang dengan keluhan terdapat benjolan pada lipatan paha sebelah kiri disertai nyeri dengan skor
nyeri visual analog scale (VAS) 3/10 sejak tiga hari sebelum masuk rumah sakit. Pasien juga diketahui sering
mengeluhkan sesak napas disertai dada yang berdebar-debar saat berbaring di malam hari dan saat beraktivitas berat.
Berdasarkan pemeriksaan, pasien kemudian didiagnosis dengan hernia inguinalis lateralis kiri yang dapat direduksi dan
gagal jantung dengan LVEF 36%. Selanjutnya, pasien dijadwalkan untuk menjalani operasi herniotomi-herniorafi elektif
dengan kombinasi anestesi spinal- epidural dosis rendah. Anestesi spinal dilakukan dengan ropivacaine isobarik 0.375%
dan fentanil 25 μg dalam volume total 3.5 ml pada intervertebral space L3-L4. Anestesi epidural dilakukan dengan
ropivacaine isobarik 0.375% dan fentanil 25 μg dalam volume total 8 ml pada intervertebrale space L2-L3. Setelah 10
menit, blok sensorik tercapai hingga T6, tetapi blok motorik hanya parsial (Bromage 1). Infus kontinu ropivacaine
isobarik 0.1875% 1 ml/jam diberikan melalui kateter epidural untuk mengontrol nyeri pascaoperasi. Selama operasi dan
perawatan di rumah sakit kondisi hemodinamik pasien tetap stabil. Kesimpulan: Kombinasi anestesi spinal-epidural
dengan ropivacaine isobarik 0.375% dapat menghasilkan

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anestesi yang adekuat dengan hemodinamik yang relatif stabil sehingga aman untuk operasi perbaikan hernia inguinalis
dari pasien gagal jantung dengan fraksi ejeksi berkurang.

Kata Kunci: Kombinasi Anestesi Spinal-Epidural; Ropivacaine Isobarik 0.375%; Hernia Inguinalis; Gagal Jantung;
Laporan Kasus; Manajemen Anestesi

Article info: Received: November 22, 2023; Revised: December 21, 2023; Accepted: January 22, 2024; Published: January 29,2024

INTRODUCTION become an increasingly common approach to

Heart failure reflects a complicated providing anesthesia in patients with complex
disorder of the heart caused by functional or medical conditions, such as heart failure. It
structural damage of the myocardium. This can provide precise sensory and motor blocks
disorder reduces the capacity to fill the in the area to be operated on while allowing
ventricles or expel blood into the systemic for better management of hemodynamic
circulation, leading to an inability to fulfill the changes that may occur during surgery (4,5).
body's metabolic demands. In general, heart However, the use of combined spinal-
failure can be classified based on the level of epidural anesthesia in the context of inguinal
left ventricular ejection fraction (LVEF), hernia surgery in patients with heart failure
including heart failure with reduced ejection and reduced ejection fraction has yet to be
fraction (HFrEF), ejection fraction <40%; widely described in the literature. Therefore,
heart failure with mildly reduced ejection this case report aims to present the use of
fraction (HFmrEF), ejection fraction 41-49%; combined spinal-epidural anesthesia with
and heart failure with preserved ejection isobaric ropivacaine 0.375% for inguinal
fraction (HFpEF), ejection fraction ≥50%. The hernia repair surgery in a heart failure patient
incidence of heart failure reaches 64 million with an ejection fraction of 36%.
cases worldwide, and many of these cases
require non-cardiac surgery, including has
inguinal hernia repair. On the other hand,
heart failure itself is one of the risks of
increased perioperative morbidity and
mortality (1–3).
Whenever heart failure patients require
surgical procedures, the decision to perform
surgery is often a challenge for
anesthesiologists. Reports suggest the
likelihood of death during elective surgery in
individuals with heart failure rises by up to
14%. This is because anesthesia and the
surgical procedure itself can potentially
worsen the heart failure condition. Therefore,
anesthesiologists should be able to determine
the appropriate type of anesthetic technique
and perioperative management to minimize
the risk of cardiac complications during
surgery. Combined spinal-epidural anesthesia
5
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CASE REPORT
A 53-year-old male farmer presented to
the emergency department with a one-year
history of a lump on the left groin that had
been in and out. Three days before
admission, the patient began complaints of
pain, especially when the lump came out. In
addition, the patient also often complained
of shortness of breath when lying down at
night and during strenuous activity
accompanied by chest palpitations. The
patient denied any complaints of nausea,
vomiting, difficulty defecating, or farting.
The patient's previous medical history
included a heart attack five years ago and
uncontrolled hypertension. The patient
denied having diabetes mellitus but was a
heavy smoker and had quit since the heart
attack. The patient was previously treated
by a cardiologist

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with atorvastatin 20 mg, sacubitril-valsartan and there is pain when pressed with a visual
50 mg, bisoprolol 2.5 mg, spironolactone 25 analog scale (VAS) pain score of 3/10.
mg, and furosemide 40 mg, each once daily. Preoperative laboratory and blood gas
On preoperative physical examination, analysis results are presented in Table 1 and
the patient appeared moderately ill; weight 65 Table 2. Anterior-posterior (AP) chest X-ray
kg; height 160 cm; Glasgow Coma Scale demonstrated cardiomegaly with a
(GCS) E4V5M6; patent airway; maximal cardiothoracic ratio (CTR) of 67% (Figure 1).
mouth opening; Mallampati II; free neck A 12-lead electrocardiographic (ECG)
motion; no short neck or mandibular indicates sinus rhythm, heart rate of 75
protrusion; vital signs: blood pressure 149/75 beats/min, left axis deviation (LAD), and left
mmHg, pulse rate ventricular hypertrophy (LVH). Furthermore,
69 beats/min, body temperature 36.7 °C, an echocardiographic investigation showed
respiratory rate 16 breaths/min, and SpO2 mild aortic regurgitation, left ventricular
97% in room air. Respiratory and dilatation (LVIDd 7.18 cm), decreased left
cardiovascular examinations were normal, ventricular systolic function (LVEF 36% with
with no wheezing, rhonchi, murmurs, or S3 Teich), impaired left ventricular diastolic
gallop. Abdominal examination showed a flat function (DT 246 ms, E/A 0.6, E/E' 15.7,
abdominal wall with no ascites. Auscultation PCWP 21 mmHg), and normal right
showed normal peristalsis of 12 times/min. ventricular function (TAPSE 2.1 cm).
The percussion examination sounded Segmental LV analysis showed mid-anterior
tympanic throughout the abdominal field. basal kinetics, normokinetics of other
Palpation revealed no mass or muscular segments, and eccentric LVH.
defense, and the borders of the spleen and
liver could not be identified. The lump that
came out on the left groin can be repositioned,
Table 1. Preoperative Laboratory Test Results
Parameters Value Parameters Value
Hb 13.3 g/dl ALT 23 U/L
NLR 4.96 Albumin 4 g/dl
WBC 8.1 x 103/uL Random blood glucose 104 mg/dl
HCT 38.8% Na 140.3 mmol/L
Platelets 427 x 103/uL K 3.7 mmol/L
PT 11.4 secs Cl 107.6 mmol/L
APTT 30.1 secs Serum creatinine 1 mg/dl
AST 14 U/L BUN 12 mg/dl

Table 2. Preoperative Blood Gas Analysis Results

Parameters Value Parameters Value
Temperature 36 °C TCO2 31 mmol/L
FiO2 0.21 HCO3 30 mmol/L
Ca 1.14 mmol/L Hb 12.5 g/dl
pH 7.52 SO2 96%
pO2 72 mmHg AaDO2 32 mmHg
pCO2 35.8 mmHg Na 143 mmol/L
BE 7.1 K 3.5 mmol/L

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Based on the examination, the patient was catheter with epinephrine 1:100.000 1 ml plus
diagnosed with a reducible left lateral inguinal lidocaine 2% 2 ml. Then, isobaric ropivacaine
hernia and planned for elective herniotomy- 0.375% plus fentanyl 25 μg in a total volume
hernioraphy surgery with low-dose combined of 3.5 ml was injected into the subarachnoid
spinal-epidural anesthesia. On pre-anesthesia space. Epidural anesthesia was administered
evaluation, the patient was labeled with with isobaric ropivacaine 0.375% plus
American Society of Anesthesiologists (ASA) fentanyl 25 μg in a total volume of 8 ml.
Physical Status III, Revised Cardiac Risk Sensory block was achieved up to the level of
Index for Pre-Operative Risk (RRCI) 3 with T6 segment at the 10th minute as checked by
an estimated risk of a major adverse cardiac pinprick test. However, the motor block was
event in 30 days of 15%, New York Heart not entirely achieved as the patient could still
Association (NYHA) Class II, and estimated move his knee slightly during intraoperative
metabolic equivalents of task (MET) score ≥ (Bromage 1).
4.
The surgical procedure lasted 75 minutes
and went smoothly, with a relatively stable
hemodynamic status without the support of
vasopressor or inotropic agents (Figure 2).
During surgery, 500 ml of 6% hydroxyethyl
starch (HES) was infused, and the patient was
given 5 liters/minute of oxygen using a simple
mask. The patient was then transferred to the
intensive care unit (ICU) shortly after the
surgical procedure. Estimated blood loss and
urine output were 30 ml and 100 ml,
respectively. To control postoperative pain, a
Figure 1. Preoperative Chest X-Rays
continuous infusion of isobaric ropivacaine
The surgery was performed one week 0.1875% 1 ml/hour was given through an
after the hospital admission. Before the epidural catheter plus an intravenous injection
surgery, the patient was fasted for 6 hours, of metamizole sodium 1 gram three times a
and the medication given by the cardiologist day. The patient's hemodynamic condition
was continued during the perioperative remained stable during the ICU stay, with no
period. ECG, heart rate, SpO2, and blood adverse events or complications related to
pressure were closely monitored in the anesthesia and surgical procedures. After two
operating room. The patient was positioned days of hospitalization in the ICU, the
sitting, and the hanging-drop technique was epidural catheter was removed, and oxygen
used to identify the epidural space at the L2- administration was changed to 4 liters/minute
L3 intervertebral space with a median via nasal cannula. Finally, the patient was
approach. Then, the epidural catheter was transferred to a regular inpatient room and
inserted to a depth of 12 cm. Spinal anesthesia discharged the following day.
was carried out at the L3- L4 intervertebral
space through a paramedian approach using a
27G Quincke needle. Next, a test dose was
performed through the epidural
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DISCUSSION illness and death in individuals having non-

Inguinal hernia repair is one of the most cardiac surgery. More precisely, the
common surgical procedures performed by percentage of patients who die within 30 days
surgeons globally, with over 20 million following surgery is notably greater among
patients operated on each year. Current individuals with heart failure (9.3%)
guidelines recommend that hernia repair be compared to those with atrial fibrillation
tailored according to expertise, resources, and (6.4%) and coronary heart disease (2.9%).
factors related to the patient's condition, Furthermore, the mortality rate of patients
including comorbidities such as heart disease with heart failure was also markedly higher
(6). Comorbid heart disease is a medical in patients with LVEF
condition that significantly contributes to <40% compared to those with normal LVEF
(7).

Figure 2. Intraoperative Hemodynamic Status

Effective pain management is a crucial resection, and securing the airway.
aspect of caring for surgical patients.
Additionally, it is important to note that pain
is a contributing factor to the occurrence of
postoperative myocardial ischemia. This is
because the associated tachycardia can
shorten the diastolic phase and diminish the
supply of blood flow to the myocardium (7).
There is no consensus on which anesthetic
technique should be used in inguinal hernia
surgery. The most widely used anesthetic
technique for inguinal hernia surgery is
general anesthesia (almost 80%), as it can
facilitate laparoscopy by relaxing the
abdominal muscles, allowing additional
procedures, such as laparotomy or bowel
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However, general anesthesia tends to be

contraindicated in patients with cardiac
disease, as induction of anesthesia and
intubation are often associated with
hemodynamic instability. Regardless of how
tight blood pressure control is in the
preoperative period, not a few hypertensive
patients experience hypotension in response
to anesthetic induction agents, followed by
hypertension due to increased catecholamine
secretion in response to intubation or
surgical procedures (5,8,9).
Over the past few years, the use of
spinal anesthesia has recently become a
popular anesthetic technique for lower
abdominal and inguinal hernia surgery.
However, the use of this technique is often
associated with the
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incidence of hypotension and bradycardia. group treated with ropivacaine plus fentanyl
These conditions are mainly caused by arterial exhibited superior hemodynamic stability and
and venous vasodilation due to excessive a lower incidence of pruritus compared to the
sympathetic block accompanied by activation group given ropivacaine with sufentanil (13).
of cardioinhibitory receptors that disrupt Meanwhile, another study by Wang and
sympathovagal balance and increase Xu compared the use of combined spinal-
parasympathetic tone. Therefore, to overcome epidural anesthesia with ropivacaine 0.1% 2-3
this, modification of anesthetic techniques, ml and epidural anesthesia with ropivacaine
adjustment of the dose and type of drugs used, 0.5% 3 ml for labor analgesia (each group also
and preloading colloidal fluids before starting received a continuous infusion of ropivacaine
anesthesia can be done (10,11). In this case, 1% 10 ml plus sufentanil 0.3-0.4 μg/ml in 100
we performed a combined spinal-epidural ml normal saline at a rate of 5 ml/hour via an
anesthesia technique with isobaric ropivacaine epidural catheter), showed that the combined
0.375%. Sensory block was achieved up to the spinal-epidural anesthesia group had
T6 level, but motor block was only partially significantly lower VAS pain scores during
achieved. This implies that a low dose of labor than the epidural anesthesia group. In
ropivacaine is sufficient to produce the addition, the incidence of side effects, such as
anesthetic block required for hernia surgery. nausea, vomiting, and pruritus, was also
In addition, our patient was preloaded with significantly lower in the combined spinal-
500 ml of 6% HES. Furthermore, the patient epidural anesthesia group (14).
was also asked to continue treatment from a Currently, combined spinal-epidural
cardiologist during the perioperative period as anesthesia has been widely used for lower
recommended by the 2014 American Heart abdominal surgery. With low-dose combined
Association guidelines (7). spinal-epidural anesthesia, anesthesia can be
Ropivacaine is a long-acting local done by administering small amounts of local
anesthetic. It has the same pharmacokinetic anesthetic drugs into the subarachnoid space,
and pharmacodynamic features as bupivacaine followed by continuous infusion into the
by reversibly inhibiting sodium ion entry into epidural space. Spinal anesthesia can provide
nerve fibers, but with lower cardiovascular rapid sensory and motor block onset and
toxicity. It is also less lipophilic than other sufficient muscle relaxation. Meanwhile, an
local anesthetics, such as bupivacaine, and has epidural catheter insertion allows titration and
a lower ability to reach large myelinated extension of anesthesia and analgesia,
motor fibers. As a result, it tends to act on especially for postoperative pain control. This
nociceptive fibers A, B, and C rather than technique facilitates the adjustment of the
motor fibers, resulting in minimal motor block block to the appropriate level, resulting in
(12). Based on a clinical trial by Mohtadi et better hemodynamic stability and a decreased
al., which compared the use of spinal occurrence of hypotension. As a result, this
anesthesia with ropivacaine 0.5% 3.5 ml plus decreased the requirement for vasopressors
fentanyl 25 μg and ropivacaine 0.5% 3.5 ml and inotropic drugs (15). Therefore, the use of
plus sufentanil low- dose combined spinal-epidural
2.5 μg, it was indicated that there was no anesthesia may be an option for a safe and
significant difference in the duration of effective anesthetic modality in patients with
analgesia and motor block. Nevertheless, the heart failure who are

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typically contraindicated with other anesthetic Soebandi General Hospital, Jember, for their
modalities. support in writing this case report.
The goals of anesthetic management in
patients with cardiac disease consist of Conflict of Interest
preventing tachycardia, maintaining The authors declare that there is no conflict of
normovolemia, preventing increased afterload, interest.
and avoiding drug-induced myocardial
depression. Neuraxial anesthesia can be used Funding Disclosure
as the primary anesthetic or in combination There are no funding sources or sponsorship
with general anesthesia for patients with in this case report's writing.
cardiac disease. Several factors, including the
presence of other medical conditions, the type Authors’ Contribution
of surgery, and the patient's preference, play a Muhammad Isra Rafidin Rayyan, Salman
crucial role in assessing the advantages and Sultan Ghiffari, Achmad Hariyanto –
disadvantages of neuraxial anesthesia (16). conceptualization, data collection, data
Since this is a case report, the main limitation analysis and interpretation, and manuscript
of this study is that we only included one preparation; Achmad Wahib Wahju
patient, making our findings difficult to Winarso, Haris Darmawan, Ichlasul Mahdi
generalize to a broader population. In Fardhani – supervision, critical review, and
addition, the absence of a comparator also final approval of the manuscript.
makes it impossible to compare outcomes
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Systematic Review

AIMS65 SCORING SYSTEM FOR PREDICTING CLINICAL OUTCOMES

AMONG EMERGENCY DEPARTMENT PATIENTS WITH UPPER
GASTROINTESTINAL BLEEDING
,
Rifaldy Nabiel Erisadana1a Al-Munawir2 , Jauhar Firdaus3
1
Faculty of Medicine University of Jember, Jember, Indonesia
2
Department of Pathological Anatomy, Faculty of Medicine University of Jember, Jember, Indonesia
3
Department of Physiology, Faculty of Medicine University of Jember, Jember, Indonesia
a
Corresponding author: rifaldydana@gmail.com

ABSTRACT
Introduction: Several scoring systems were developed for early risk stratification in Upper Gastrointestinal Bleeding
(UGIB) patients. AIMS65 score is a scoring system that only consists of five parameters, it might be used in daily clinical
practice because of rapid and easy to calculate within 12 hours of admission. Objective: To evaluate the AIMS65 scoring
system as a predictor of mortality, rebleeding events, need for endoscopic therapy, blood transfusion, and ICU admission
for all causes of UGIB. Methods: We conducted a systematic review on PubMed, ScienceDirect, ProQuest, and
Cochrane Library databases from the 2012 to 2022 publication period. We included either prospective or retrospective
cohort studies that reported UGIB with all kinds of aetiologies who presented in the emergency department (ED),
reported discriminative performance for each outcome, and reported the optimal cut-off of AIMS65. The primary
measurement of discriminative performance for clinical outcomes includes mortality, rebleeding incidents, need for
endoscopic therapy, blood transfusion, and ICU admission. Results: We identified 351 published studies, of which 20
were included in this study. Most of the studies reported discriminative performance for predicting mortality, which
amounts to about 18 out of 20 studies. Rebleeding prediction was reported in 11 studies, need for endoscopic therapy in 5
studies, blood transfusion in 7 studies, and ICU admission in 2 studies. Most of the studies reported fair to excellent
discriminative performance for predicting mortality, but in contrast for predicting rebleeding, the need for endoscopic
therapy, blood transfusion, and ICU admission. Cut-off values≥ 2 are frequently reported to distinguish between high-risk
and low-risk patients in mortality. Conclusion: AIMS65 can be applied to patients with UGIB in ED for predicting
mortality, but not applicable for predicting rebleeding events, the need for endoscopic therapy, blood transfusion, and
ICU admission. It enhances early decision-making and triage for UGIB patients.

Keywords: AIMS65; Upper Gastrointestinal Bleeding (UGIB); Health Emergency Preparedness; Systematic Review.

ABSTRAK
Pendahuluan: Beberapa sistem skoring dikembangkan untuk stratifikasi risiko dini pada Pasien Perdarahan
Gastrointestinal Bagian Atas (PSCBA). Skor AIMS65 adalah sistem skoring yang hanya terdiri dari lima parameter,
dapat digunakan dalam praktik klinis sehari-hari karena cepat dan mudah dihitung dalam waktu 12 jam setelah admisi.
Tujuan: Untuk mengevaluasi sistem penilaian AIMS65 sebagai prediktor mortalitas, kejadian perdarahan ulang,
kebutuhan terapi endoskopi, transfusi darah, dan admisi ke ICU untuk semua penyebab PSCBA. Metode: Kami
melakukan tinjauan sistematis melalui basis data PubMed, ScienceDirect, ProQuest, dan Cochrane Library dari periode
publikasi 2012 hingga 2022. Kami memasukkan studi kohort prospektif atau retrospektif yang melaporkan UGIB dengan
semua jenis etiologi yang dilaporkan di unit gawat darurat (UGD), melaporkan kemampuan diskriminatif untuk setiap
hasil, dan melaporkan batas optimal AIMS65. Pengukuran utama kinerja diskriminatif untuk hasil klinis mencakup angka
mortalitas, kejadian perdarahan ulang, kebutuhan terapi endoskopi, transfusi darah, dan admisi ke ICU. Hasil: Kami
mengidentifikasi 351 penelitian yang dipublikasikan, 20 di antaranya diinklusi dalam penelitian ini. Sebagian besar
penelitian melaporkan kinerja diskriminatif dalam memprediksi kematian, yaitu pada 18 dari 20 penelitian. Prediksi
perdarahan ulang dilaporkan dalam 11 penelitian, kebutuhan terapi endoskopi dalam 5 penelitian, transfusi darah dalam 7
penelitian, dan admisi ke ICU dalam 2 penelitian. Sebagian besar penelitian melaporkan kinerja diskriminatif yang cukup
baik hingga sangat baik dalam memprediksi angka kematian, namun berbeda dalam memprediksi perdarahan ulang,
kebutuhan terapi endoskopi, transfusi darah, dan admisi ke ICU. Nilai batas ≥ 2 sering dilaporkan untuk membedakan
antara pasien berisiko tinggi dan pasien berisiko rendah dalam hal kematian. Kesimpulan: AIMS65 dapat diterapkan
pada pasien PSCBA di IGD untuk memprediksi mortalitas, namun tidak dapat diterapkan untuk memprediksi kejadian
perdarahan ulang, kebutuhan terapi

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endoskopi, transfusi darah, dan admisi ke ICU. Ini dapat meningkatkan pengambilan keputusan dini dan triase untuk pasien
dengan PSCBA.

Kata Kunci: AIMS65; Pasien Pendarahan Gastrointestinal Bagian Atas (PSCBA); Kesiapsiagaan Darurat Kesehatan;
Tinjauan Sistematis.

Article info: Received: September 16, 2023; Revised: January 16, 2024; Accepted: January 18, 2024; Published: January 29, 2024

INTRODUCTION (GBS), Rockall Score, and AIMS65 (4,6). The

Upper gastrointestinal bleeding (UGIB) is Rockall Score requires an endoscopic
a medical emergency case located between the component so it cannot be used for pre-
oral cavity to the proximal treitz ligament. endoscopic triage. The GBS and AIMS65
UGIB is clinically presented by haematemesis, scoring systems are possible to overcome these
coffee-ground emesis, and melena. Despite the problems because the prognostic parameters
improvement of overall mortality and do not require endoscopic examination, but the
morbidity rates in developing countries GBS system has limitations compared to
because of advanced diagnosis and treatment, AIMS65 when used in clinical practice
the mortality rate of UGIB around the world in because it weighted each parameter so the
the past decade unchanged and varied between outcome was often over-evaluated when
3– 14% (1). Patients with UGIB can present in calculated (7).
either stable condition or requiring rapid AIMS65 score is a more recent scoring
management, such as resuscitation, blood system compared to the two others which only
transfusion, ICU admission, and endoscopic consists of 5 parameters, such as albumin
therapy depending on the clinical assessment levels, INR, changes in mental status, blood
of the patient. Endoscopy has an important pressure, and age > 65 years old. It might be
role in the diagnostic and therapeutic of UGIB used in daily clinical practice because of rapid
(2). Because of limited competent operators and easy to calculate within 12 hours of
and equipment in all health facilities, most admission (7,8). As such, this systematic
patients with UGIB do not receive rapid review aims to identify the AIMS65 scoring
endoscopic intervention. Endoscopic system for its ability to predict the prognosis
procedures also have risks such as perforation including mortality rebleeding events, the need
and discomfort to patients so several for therapy including endoscopic therapy,
considerations are needed to decide whether blood transfusion, and ICU admission for all
the patient needs an endoscopy or not (3). causes of upper gastrointestinal bleeding based
on predictive accuracy.
The existing scoring system is considered
helpful for physicians in the emergency MATERIAL AND METHOD
department (ED) to enhance decision-making. Search Strategy
A scoring system is able to guide earlier The literature search was conducted on
treatment or care for patients above the cut-off four databases, including PubMed,
which is considered as a high risk, thus leading ScienceDirect, ProQuest, and Cochrane
to improvements in mortality and morbidity Library with a publication period ranging
rates (4,5). Several scoring systems were from 2012 to 2022 using keywords related to
developed for early risk stratification in UGIB "AIMS65" and "Upper Gastrointestinal
patients, such as the Glasgow Blatchford Score Bleeding". Only studies written in English
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and
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full-text access articles were considered in extracted all performances of the score in
this systematic review. terms of discrimination ability or AUC. The
AUC thresholds to judge predictive ability
Eligibility Criteria have been described by other researchers:
This study was conducted using excellent (AUC ≥0.90); good (AUC ≥0.80
Preferred Reporting Items for Systematic and
Reviews and Meta-Analysis (PRISMA). We <0.90); fair (AUC ≥0.70 and <0.80); and
only included articles that match our poor (AUC <0.70) (9). Calibration,
eligibility criteria based on PICOS: (i) sensitivity, specificity, positive predictive
Population: all-cause UGIB patients admitted value, and negative predictive value were
to the emergency department; (ii) also reported if available. The extracted data
Intervention: AIMS65 score; from each study will be conducted for
(iii) Comparison: not applicable; (iv) narrative synthesis. All included studies will
Outcomes: mortality, rebleeding, endoscopic be assessed by two independent reviewers.
therapy, blood transfusion, and ICU The risk of bias and concern for applicability
admission (v) Study design: a prospective or were assessed using a Prediction-model Risk
retrospective cohort. The analyzed variables of Bias Assessment Tool (PROBAST).
were the discriminative performance of PROBAST was developed to assess the
AIMS65 for each outcome, and the optimal quality of primary studies on multivariable
cut-off should be reported to distinguish models in a systematic review. This tool
between low and high-risk patients. We evaluated the risk of bias using four domains
excluded the AIMS65 score which validated (participants, predictor, outcome, and
variceal or non-variceal bleeding only. analysis) and concern for applicability using
Furthermore, we exclude studies that three domains (participants, predictor,
measure discrimination ability for composite outcome) then finally judged by criteria of
clinical outcomes. Two reviewers ‘low’, ‘high’, and ‘unclear’.
independently screened the titles and abstract
based on inclusion and exclusion criteria, the RESULTS AND DISCUSSION
discrepancies are solved by consensus and
Search Result
involve a third reviewer when needed.
We identified 351 published studies in the
PICOS framework for inclusion studies can
initial literature search. From a total of 72
be seen in Table 1.
articles selected for full-text review, we only
Table 1. PICOS framework
included 20 studies that reported optimal cut-
Population All-cause UGIB patients admitted
to the emergency department off and discrimination ability of AIMS65
Intervention AIMS65 score scores for predicting mortality, rebleeding,
Comparison Not applicable
Outcome Mortality, rebleeding, endoscopic endoscopic therapy, blood transfusion, and
therapy, blood transfusion, ICU ICU admission to conduct this systematic
admission
Study design Cohort review. PRISMA flowchart for the selection
studies process can be seen in Figure 1.
Data Extraction and Quality Assessment
The following data were extracted from Study and Sample Characteristics
each study: publication date, study design, Total of 20 studies, 10 prospective cohort
sample size, and optimal cut-off, and we also (6,10–18), 9 retrospective cohort (7,19–26),
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and 1 both prospective and retrospective

cohort
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(27). The population ranged between 129 to reported the calibration measurement for the
4019. The studies recruited from several clinical outcome of AIMS65 scores. Eighteen
countries with a median age between 52 to 71 of the studies evaluate the accuracy of
years old. All of the studies recruited only predicting mortality. Detailed characteristics
assessed ED patients and reported the of included studies can be seen in Table 2.
discrimination ability of AUC. No study

Figure 1. PRISMA flowchart

Table 2. Characteristics of Included Studies

First Median
author, Sample Male Age (IQR) Optimal
Design Eligibility Criteria Outcome
year size (%) Mean Age Cut-off
± SD
Hyett et Retrospective, UGIB based on ICD-9 278 150 63 (IQR 50– (≥2) Inpatient mortality
al. 2013 single-center codes (54%) 77)
Thandass Retrospective, UGIB patients who 251 193 52 (IQR 15– (≥2) Blood transfusion,
ery et al. single-center underwent endoscopic (76.8 84) endoscopic therapy,
2015 evaluation within 12 %) ICU admission,
hours; above 14 years of rebleeding,
age mortality
Abougerg Prospective, Patients with UGIB either 298 197 64 (IQR 52– ≥4 In-hospital
i et al. multicenter at the time of presentation (66%) 75) mortality, 30-day
2016 to the hospital or if mortality,
developed UGIB as an in-hospital
inpatient rebleeding, 30-day
rebleeding

61
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First Median
Sample Male Age (IQR)
author, Design Eligibility Criteria size Optimal
year (%) Mean Age Cut-off Outcome
± SD
Martı´nez Prospective, UGIB patients who 309 214 64.6 ± 16.7 (≥1) In-patient mortality,
-Cara et single center underwent endoscopy; all (69.3
al. 2016 patients received %) (≥2) Endoscopic therapy,
pantoprazole 80 mg iv as blood transfusion,
an initial bolus followed 6-month mortality
by a continuous infusion
of 120 mg for the first 24
hours
Robertso Retrospective, UGIB based on ICD-10 424 279 71 (IQR 15– (≥2) In-hospital
n et al., single-center codes (66%) 93) rebleeding,
2016 (≥3) ICU admission,
blood transfusion,
in-hospital mortality
Zhong et Prospective, Acute UGIB. Recurrent 320 198 63 (IQR 42– (≥2) In-hospital
al. 2016 single center episode of UGIB; (61.9 79) mortality, in-patient
admission to the hospital %) rebleeding
and developed AUGIB
for unrelated disease
excluded
Lau et al. Prospective, UGIB patients who are 129 79 65.1 ± 21 (≥1) In-patient mortality,
2016 single center not admitted to the (61.2 blood transfusion
hospital ward were %)
excluded.
Zhao et Retrospective, UGIB patients above 65 293 170 72.4 ± 6.3 (≥2) In-patient mortality,
al. 2017 single-center years of age; endoscopic (58%) rebleeding
evaluation within 24
hours
Kalkan et Retrospective, Patient with the presence 335 202 72.9 ± 9 (≥2.5) 30-day mortality,
al. 2017 single-center of overt endoscopic (60%) rebleeding
stigmata of UGIB; above
60 years of age
Stanley et Propsektif, Patient with evidence of 3012 1750 65 (IQR 24– (≥2) 30-day mortality,
al. 2017 International UGIB defined by (58%) 90) Endoscopic therapy
multicenter haematemesis, coffee- (≥1)
ground vomiting,
melaena. A patient who
developed UGIB while an
inpatient for another
reader were excluded
Tang et Retrospective, UGIB patients above 14 395 274 65 (IQR 50– (≥2.5) 30-day mortality
al. 2018 single-center years of age. Patients who (69/4 77）
had been followed up for %)
less than 30 days and
were diagnosed other than
UGIB were excluded
Gu et al. Retrospective, UGIB patients who did 799 612 57.46 ± (≥2) In-hospital mortality
2018 single-center not receive endoscopy (77.22 18.04
examination as they had %)
severe clinical symptoms
and needed emergent
clinical treatment
Shafaghi Retrospective, UGIB patients above 18 563 345 60.53 ± (≥2) In-patient mortality,
et al. 2019 single-center years of age. Patients who (61.3 18.62 30-day mortality,
didn’t undergo endoscopy %) endoscopic
were excluded intervention, blood
transfusion
Redondo- Prospective, UGIB patients were 547 367 64.1 ± 16.4 (≥2) 30-day mortality
Cerezo et
single center followed for 6 months (67.1
al. 2020 (≥1) 7-day rebleeding,
after their discharge %) endoscopic therapy

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First Median
author, Sample Male Age (IQR) Optimal
Design Eligibility Criteria Outcome
year size (%) Mean Age Cut-off
± SD
Saffouri Prospective, UGIB patients who 3012 1746 65 (IQR 24– (≥1) Blood transfusion
et al. 2020 international developed upper GI (58%) 90)
multicenter bleeding as inpatients
were
Liu et al. Prospective, UGIB patients non- 1072 779 61.41 ± (≥0.5) 90-day mortality,
2020 multicenter trauma; above 18 years (72.67 1577 90-day rebleeding
%)
Lu et al. Retrospective, UGIB patients who are 284 197 64 (IQR 50– (≥2) In-hospital mortality
2020 single-center hospitalized within 48 (69.4 73)
hours of endoscopy; non- %)
AUGIB cause death
Sachan et Prospective, UGIB patients above 18 268 222 48.49 ± (≥2) 8-week mortality,
al. 2021 single center years of age (82.8 13.23 rebleeding, blood
%) transfusion
Chang et Prospective, UGIB patients above 18 337 247 61.1 ± 16.5 (≥3) In-hospital mortality
al. 2021 single center years of age. Patients who (73.3
had a history of UGIB in %)
the previous 3 months or
had undergone endoscopy
at another institution
before admission were
excluded
Laursen Prospective Patients with acute UGIB 4019 2703 65 (IQR 30) (≥2) 30-day rebleeding
et al. 2021 and are defined as presenting (67.25
Retrospective, with haematemesis, %)
multicenter coffee-ground vomiting,
or melaena.

Quality Assessment reported good discriminative performance,

All of the studies reported low and only 3 studies reported poor
concerns of applicability due to included discriminative performance. A total of 11 had
studies having similar result in the review data on sensitivity and specificity, ranging
question. The analysis is the most common from 38% to 100% and 24% to 95.76%,
biased domain because the most studiesdo not respectively. PPV and NPV were available in
report the calibration measurement of the 4 studies, ranging from 5.8% to 12% and 91%
AIMS65 score to predict clinical outcomes, to 100%, respectively. Included studies were
therefore the judgment for all included studies reported with various optimal cut-offs
is identified as high risk of bias. Quality ranging from ≥
assessment using PROBAST can be seen in 0.5 to ≥ 4 with a frequently reported was ≥ 2.
Table 3. Mortality was reported on various follow-ups
such as inpatient, in-hospital, 30-day, 8-week,
Outcomes: Mortality prediction 90-day, and 6-month. The predictive ability of
From 20 studies that reported the AIMS65 to predict mortality can be seen in
discriminative performance of AIMS65 scores Table 4.
for predicting mortality, it was acceptable in
general because the AUC showed ≥ 0.7 in Outcomes: Rebleeding prediction
most studies with a range from 0.65 to 0.955. A total of 11 studies evaluated discriminative
4 studies reported excellent discriminative performance for rebleeding incidence. The
performance, 5 studies reported good AUC for rebleeding events prognosis ranged
discriminative performance, 10 studies
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from 0.491 to 0.86.

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Table 3. Quality assessment by PROBAST There is only one study that reported fair and
Author Risk of Applica Overall good discrimination performance with optimal
Bias bility
Risk cut-offs≥ 2 and ≥ 2.5, respectively.The
1 2 3 4 5 6 7 of Applica
bility remaining studies reported poor discriminative
bias
(19) + ? ? - + + + - + performance with optimal cut-off ranging from
Thandassery + ? ? - + + + - + ≥ 0.5 to ≥ 3. Sensitivity and specificity were
et al., 2015
Abougergi + + + - + + + - +
available in 6 studies, and they ranged from
et al., 2016 57%-78.9% and 35.52% - 89.4%,
Martı´nez- + + + - + + + - +
Cara et al., respectively. PPV and NPV were available
2016 only in 1 study with the value of 14.25% and
Robertson et + + ? - + + + - +
al, 2016 92.29%. Follow- up time for rebleeding varies
Zhong et al., + + + - + + + - + in all studies, such as inpatient, in-hospital,
2016
7-day, 30-day,
and 90-day. The predictive ability of AIMS65
Lau et al., + + - - + + + - +
2016 to predict rebleeding can be seen in Table 5.
Zhao et al., - ? - - + + + - -
2017 postoperative pain between the experimental
Kalkan - + - - + + + - - and placebo groups.
dkk., 2017
Stanley et + - + - + + + - +
al., 2017 Outcomes: Need for endoscopic therapy
Tang et al., + + + - + + + - + prediction
2018
Gu et al., + - + - + + + - + Five studies consistently found the poor
2018 discriminative performance of AIMS65 scores
Shafaghi et + - ? - + + + - +
al., 2019 for predicting the need for endoscopy therapy
Redondo-
Cerezo et
+ + ? - + + + - + with the AUC ranging from 0.48 to 0.63. Three
al., 2020 studies reported optimal cut-off was ≥ 1 and
Saffouri et + - ? - + + + - + two studies reported optimal cut-off was ≥ 2.
al., 2020
Rao et al., - - + - + + + - + Of 5 studies, only 2 studies included sensitivity
2020 and specificity, those 2 studies also reported
Liu et al., + + + - + + + - +
2020 PPV and NPV. The predictive ability of
Lu et al.,
2020
+ ? ? - + + + - + AIMS65 to predict the need for endoscopic
Sachan et therapy can be seen in Table 6.
al., 2021 + + + - + + + - +
Chang et al.,
2021 + + ? - + + + - + Outcomes: Need for blood transfusion
Laursen et Seven studies reported blood transfusion
+ ? + - + + + - +
al., 2021
*PROBAST = Prediction model Risk Of Bias Assessment Tool, prediction with the AUC ranged from 0.57 to
ROB; risk of bias
*1, risk of bias for participants; 2, risk of bias for predictor; 3, risk of
0.72. Only 2 optimal cut-offs were reported
bias for outcome; 4, risk of bias for analysis; 5, concern applicability for blood transfusion specifically ≥ 1 and ≥ 2.
for participants; 6, concern applicability for predictor; 7, concern
applicability for outcome Two studies reported fair discrimination
*(+) indicates low ROB/low concern regarding applicability; (−) performance with different optimal cut-offs of
indicates high ROB/high concern regarding applicability; and (?)
indicates unclear ROB/unclear concern regarding applicability. ≥ 1 and ≥ 2 respectively. Five remaining
studies reported poor discrimination for
rebleeding events. The predictive ability of
AIMS65 to predict blood transfusion can be
6
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seen in Table 7.

6
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Table 4. Predictive Ability of AIMS65 to Predict

Mortality
Sensitivity/ PPV/
Study Optimal Specificity NPV
Follow-up AUC and Category
Cut-off
(%) (%)
Hyett et al. ≥2 Inpatient mortality 0.93 (95% CI, 0.89–0.96) (Excellent) 83/48 NS
Thandassery et al. ≥2 NS 0.74 (95% CI, 0.63–0.85) (Fair) NS NS
Abougergi et al. ≥4 In-hospital mortality 0.85 (95% CI, 0.81–0.89) (Good) NS NS
30-day mortality 0.74 (95% CI, 0.70–0.79) (Fair)
≥4 NS NS
Martı´nez-Cara et ≥1 Inpatient mortality 0.76 (95% CI, 0.68–0.83) (Fair) 100/24 12/100
al. 6-month mortality 0.74 (95% CI, 0.66–0.82) (Fair) 31/91
≥2 38/89
Robertson et al. ≥3 Inpatient mortality 0.80 (95% CI, 0.69–0.91) (Good) 72/77 NS
Zhong et al. ≥2 In-hospital mortality 0.786, 95% CI, 0.670-0.903) (Fair) NS NS
Lau et al. ≥1 Inpatient mortality 0.83 (95% CI, 0.67–0.99) (Good) 100/48 5.8/100
Zhao et al. ≥2 Inpatient mortality 0.833 (95% CI, 0.785–0.874) (Good) 96/54 NS
Kalkan et al. ≥2.5 30-day mortality 0.88 (Good) 79.6/89.2 NS
Stanley et al. ≥2 30-day mortality 0.78 (95% CI, 0.75–0.81) (Fair) 65.8/76.2 18/96.6
Tang et al. ≥2.5 30-day mortality 0.907 (95% CI, 0.874–0.934) 70.73/95.76 NS
(Excellent)
Stokbro et al. ≥1 30-day mortality 0.74 (Fair) NS NS
Gu et al. ≥2 In-hospital mortality 0.91 (95% CI, 0.84–0.98) (Excellent) NS NS
Shafaghi et al. ≥2 Inpatient mortality 0.675 (95%CI 0.545–0.806) (Poor) 57.1/79.5 NS
Redondo-Cerezo ≥2 30-day mortality 0.75 (95% CI, 0.69–0.81) (Fair) NS NS
et al.
Liu et al. ≥0.5 90-day mortality 0.672 (95% CI, 0.624–0.721) (Poor) 87.18/36.44 14.39/
95.87
Lu et al. ≥2 In-hospital mortality 0.955 (95%CI, 0.923–0.976) NS NS
(Excellent)
Sachan et al. ≥2 8-week mortality 0.725 (95%CI, 0.656–0.794) (Fair) 80.3/53.9 NS
Chang et al. ≥3 In-hospital mortality 0.747 (95% CI, 0.630–0.863) (Fair) NS NS
Laursen et al. ≥2 30-day mortality 0.65 (95% CI, 0.62–0.69) (Poor) NS NS
*AUC, area under the curve; PPV, positive predictive value; NPV; negative predictive value, NS; not stated.
*AUC thresholds : excellent (AUC ≥0.90), good (AUC ≥0.80 and <0.90), fair (AUC ≥0.70 and <0.80), and poor (AUC <0.70)

Table 5. Predictive Ability of AIMS65 to Predict

Rebleeding Sensitivity/ PPV/
Study Optimal Specificity NPV
Follow-up AUC and Category
Cut-off
(%) (%)
Hyett et al. ≥2 Inpatient rebleeding 0.63 (95% CI, 0.57–0.69) (Poor) 57/73 NS
Thandassery et al. ≥2 NS 0.53 (95% CI, 0.40–0.66) (Poor) NS NS
Abougergi et al. ≥3 In-hospital rebleeding 0.69 (95% CI, 0.63–0.74) (Poor) NS NS
≥3 30-day rebleeding 0.63 (95% CI, 0.57–0.69) (Poor)
NS NS
Robertson et al. ≥2 In-hospital rebleeding 0.61 (95% CI, 0.51–0.70) (Poor) 76/44 NS
Zhong et al. ≥2 Inpatient rebleeding 0.735 (95% CI, 0.667-0.802) (Fair) NS NS
Zhao et al. ≥2 NS 0.646 (95% CI, 0.588–0.700) (Poor) 74/52 NS
Kalkan et al. ≥2.5 NS 0.86 (Good) 75.5/89.4 NS
Shafaghi et al. ≥2 30-day rebleeding 0.491 (95% CI 0.369–0.614) (Poor) NS NS
Redondo-Cerezo et ≥1 7 day-rebleeding 0.64 (95% CI, 0.59–0.68) (Poor) NS NS
al.
Liu et al. ≥0.5 90-day rebleeding 0.585 (95% CI, 0.537–0.634) (Poor) 78.29/35.52 14.25/9
2.29
Sachan et al. ≥2 NS 0.626 (95% CI, 0.546–0.707) (Poor) 78.9/48.3 NS
*AUC, area under the curve; PPV, positive predictive value; NPV; negative predictive value, NS; not stated.
*AUC thresholds : excellent (AUC ≥0.90), good (AUC ≥0.80 and <0.90), fair (AUC ≥0.70 and <0.80), and poor (AUC <0.70)

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Outcomes: Need for ICU admission al using the same optimal cut-off reported
Discriminative performance for ICU good discrimination for inpatient mortality for
admission was only presented in 2 studies, elderly UGIB patients above 65 years in
Thandassery et al reported an AUC for ICU which they had at least one comorbid, and
admission to be 0.61, and Robertson et al (x) also reported in non-survival patients they had
reported an AUC of 0.74 for ICU admission. significantly lower hemoglobin levels (21).
All of the studies reported optimal cut-off was Lau et al. and Martı´nez-Cara et al. reported
≥ 2. Only Robertson et al reported sensitivity good and fair discriminative performance for
and specificity of about 88% and 47%. The inpatient mortality using cutoff ≥ 1 (11,13).
predictive ability of AIMS65 to predict ICU Martı´nez-Cara et al. also reported fair
admission can be seen in Table 8. discriminative performance for 6-month
mortality using cut-off ≥ 2. Extending time to
Discussion follow-up was considered because patients
We conducted a systematic review to with UGIB could challenge the precarious
assess the predictive accuracy of AIMS65 as clinical balance of frail patients, such as
pre-endoscopic risk scoring in emergency patients with cirrhotic and cardiovascular
department’s UGIB patients for mortality, diseases with the result that cause delayed
rebleeding, need for endoscopic therapy, death (11). Robertson et al. using cut-off ≥ 3
blood transfusion, and ICU admission. showed good discriminative performance in
AIMS65 is a scoring system developed by predicting inpatient mortality (20). Zhong et
Saltzman et al. on al. and Gu et al. reported good and excellent
29.222 patients to predict inpatient mortality discriminative performance using cut-off ≥ 2
in UGIB patients (8). A total of 20 studies in predicting in-hospital mortality in the
included in this systematic review reported a Chinese population (12,24). Chang et al.
various follow-up time to predict mortality reported fair discriminative performance using
indicating that AIMS65 had an acceptable cut-off ≥ 3 in predicting in-hospital mortality
discriminative performance in most studies. and specified that AIMS65 showed significant
Hyett et al. reported excellent discriminative predictive accuracy in variceal bleeding than
performance for inpatient mortality using non-variceal bleeding (18). Abougergi et al.
optimal cut-off ≥ 2. This is not surprising reported discriminative performance ≥ 0.7
even though the accuracy showed better using optimal cut-off ≥ 4 not only for in-
performance than the derived study because hospital mortality but also for 30-day
AIMS65 was established for that (19). Zhao et mortality (10).

Table 6. Predictive Ability of AIMS65 to Predict the Need for Endoscopic Therapy
Optimal Sensitivity/
Study AUC and Category Specificity PPV/NPV(%)
Cut-off
(%)
Thandassery et al. ≥2 0.48 (95% CI, 0.39–0.56) (Poor) NS NS
Martı´nez-Cara et al. ≥1 0.62 (95% CI, 0.56–0.68) (Poor) 87/28 45/76
Stanley et al. ≥1 0.63 (95% CI, 0.60–0.65) (Poor) 79.7/38.7 25.9/87.6
Shafaghi et al. ≥2 0.562 (95% CI, 0.487–0.637) (Poor) NS NS
Redondo-Cerezo et al. ≥1 0.59 (95% CI, 0.54–0.64) (Poor) NS NS
*AUC, area under the curve; PPV, positive predictive value; NPV; negative predictive value, NS; not stated.
*AUC thresholds : excellent (AUC ≥0.90), good (AUC ≥0.80 and <0.90), fair (AUC ≥0.70 and <0.80), and poor (AUC <0.70)

6
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Table 7. Predictive Ability of AIMS65 to Predict Blood Transfusion

Optimal Sensitivity/
Study AUC and Category Specificity PPV/NPV(%)
Cut-off
(%)
Thandassery et al. ≥2 0.60 (95% CI, 0.51–0.67) (Poor) NS NS
Martı´nez-Cara et al. ≥1 0.71 (95% CI, 0.65–0.77) (Fair) 88/37 69/64
Robertson et al. ≥2 0.72 (95% CI, 0.67–0.77) (Fair) 71/63 NS
Lau et al. ≥1 0.57 (95% CI, 0.43–0.68) (Poor) 60.9/48.1 20.3/8.5
Shafaghi et al. ≥2 0.674 (95% CI 0.628–0.721) (Poor) NS NS
Saffouri et al. ≥1 0.692 (95% CI, 0.663–0.720) (Poor) NS NS
Sachan et al. ≥2 0.643 (95% CI, 0.574–0.711) (Poor) 68.1/55.4 NS
*AUC, area under the curve; PPV, positive predictive value; NPV; negative predictive value, NS; not stated.
*AUC thresholds : excellent (AUC ≥0.90), good (AUC ≥0.80 and <0.90), fair (AUC ≥0.70 and <0.80), and poor (AUC <0.70)

Table 8. Predictive Ability of AIMS65 to Predict ICU Admission

Optimal Sensitivity/
Study AUC and Category Specificity PPV/NPV(%)
Cut-off
(%)
Thandassery et al ≥2 0.61 (95% CI, 0.52–0.70) (Poor) NS NS
Robertson et al. ≥2 0.74 (95% CI, 0.68–0.80) (Fair) 88/47 NS
*AUC, area under the curve; PPV, positive predictive value; NPV; negative predictive value, NS; not stated.
*AUC thresholds : excellent (AUC ≥0.90), good (AUC ≥0.80 and <0.90), fair (AUC ≥0.70 and <0.80), and poor (AUC <0.70)

Stanley et al. (n = 3012) is the only study ≥ 2. This study reported the most common
that collected data from six countries. The etiology for UGIB was variceal bleeding,
study reported fair discriminative performance replacing peptic ulcer disease in most studies
for 30-day mortality using cut-off ≥ 2 and that reported the etiology of all-cause UGIB.
stated that AIMS65 scores had a lack of Thandassery et al. using optimal cut-off≥ 2
measurement for albumin that led to an reported the mortality incidence of AIMS65 in
underestimation of the accuracy of AIMS65 scores 0, 1, 2, 3, and 4 are about 3%, 7.8%,
scores to identify low-risk patients. Redondo- 20%, 36%, and 40%, respectively (7,17).
Cerezo et al. using a similar cut-off reported Despite most included studies reporting
fair discriminative and stated that low albumin fair to excellent discriminative performance
levels might be a surrogate marker of severe for mortality, three studies reported poor
comorbidities that lead to adverse outcomes discriminative performance. Shafaghi et al.
(6,14). Kalkan et al. and Tang et al. used a using a cut-off value ≥ 2 for inpatient
cut- off ≥ 2.5 in predicting 30-day mortality. mortality stated although albumin is an
Kalkan et al. reported good discriminative independent risk factor that is included in the
performance in which the population included variable, the albumin threshold is not the best
in those studies only ≥ 60 years old, It also to get one point in AIMS65 scores. This study
stated that increased risk of mortality was reported that 41.14% of patients in the non-
associated with serum albumin, hemoglobin survival group had albumin ranging between 3
level, multiple medications, and creatinine to 3.5 so changing the Albumin threshold to 3
level, age, and comorbidity in which multiple to 3.5 in AIMS65 increased its discriminative
medications and elevated creatinine level was performance to predicting mortality from 0.67
an independent risk factor for mortality (22). to 0.72 (25). Liu et al using cut-off ≥ 0.5 for
Sachan et al. reported fair discriminative 90- day mortality stated that AIMS65 had a
performance in 8-week mortality using cut-off lower discriminative performance compared
with
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ABC scores (0.672 vs 0.722) but had a endoscopy. It was caused by 16 patients with
sensitivity higher than ABC score (87.18% vs AIMS65 scores of 0 still needing endoscopic
76.07%) (16). The largest international therapy. Thandassery et al. reported no
multicenter cohort by Laursen et al. in 2021 significant difference between low-risk (< 2)
(n=4019) collected data from Israel, Spanyol, and high-risk (≥ 2) patients in need of
and Italy showed poor discriminative endoscopic therapy (26.1% vs 21.8%). This
performance in predicting 30-day mortality in study also reported about 37 patients with a
the Italian population in a setting with the score of 0 and 15 patients with a score of 1
largest population in this study. This condition still required endoscopic therapy. Most
affects the overall discriminative performance studies are concerned about biases because
of AIMS65 scores in this study. The lower the need for endoscopic therapy is carried
predictive accuracy of AIMS65 in the Italian out due to early endoscopic examination by a
cohort may be explained by a high proportion physician (7,11). Blood transfusions
of cirrhotic in high-risk patients about 21% showed fair discriminative only in
(27). two studies. Martı´nez- Cara et al. using
Accuracy of scores for predicting optimal cut-off ≥ 1 stated about 30%
rebleeding events showed fair and good of non-survival patients had
discriminative performance by Zhong et al. cardiovascular disease, which may affect the
and Kalkan et al. Kalkan et al. stated that need for blood transfusion. Lau et al using
AIMS65 using a cut-off score ≥ 2.5 predicted optimal cut-off ≥ 1 showed poor
rebleeding with 75.5% sensitivity and 89.4% discrimination performance. It may be
specificity (12,22). However, the remaining explained because hemoglobin level is not
studies reported poor discriminative included as a variable component that led to
performance for rebleeding events. Studies an inability to predict the need for blood
using cut-off value transfusion. Blood transfusion requirements,
≥ 2 with sensitivity and specificity reported as an endpoint for UGIB, have an essential
are Hyett et al. about 57% and 73%, role in resuscitation rather than intervention.
Robertson et al about 76% and 44%, Zhao et It may raise questions as to whether the
al. about 74% and 52%, and Sachan et al. need for blood transfusion should be included
about 78.9% and 48.3%. It showed as an endpoint (11,13). ICU admission was
inconsistent sensitivity and specificity that led only reported in 2 studies with different
to hesitation for its predictive ability in terms discriminative performances.
of discriminative performance (17,19–21). Robertson et al. showed fair discriminative
Thandassery et al. using a similar cut-off performance (AUC 0.74) and reported that
reported that rebleeding events are not linear patients managed in the general ward who
with increases in scores. Scores 0, 1, 2, 3, and required ICU admission are about 56 (13.2%)
4 are reported around 6.1%, 10.9%, 15%, 4%, patients. Thandassery et al. showed poor
and 20%, respectively. The need for discriminative performance (AUC 0.61). It is
endoscopic therapy showed poor also stated although significant difference in
discriminative performance in all included the number of low-risk and high-risk patients
studies. Martı´nez-Cara et al stated that in ICU admission (16.8% vs 38.2%, p=0.001),
AIMS65 is an optimal scoring for low-risk the study reported 11 (8.3%) patients with a
patients, especially if the goal is to avoid score of 0 and 22 (34.3%) patients with a

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score 1 underwent admission to ICU. ICU admission

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has an important role in the management of objective assessment and applicable to

UGIB patients in critical condition or requires enhance decision-making than individual
close monitoring to improve their quality of clinical judgment only as an early risk
life, while low-risk patients on AIMS65 stratification assessment (2,4,7).
scores do not avoid the chances admitted to All studies included in this study were
ICU (7,20). conducted in the Emergency Departments, so
A good scoring system shows a good fit it fits in line with the main objective of this
between the probabilities calculated using the review. We also determined, especially for
scoring system and the outcomes observed. clinical outcomes that it might be favorable to
Discriminative performance is an essential consider it as decision-support rather than
indicator of predictive accuracy to overcome a composite outcomes. To our knowledge, this
lack of accuracy using sensitivity or review is among the few that systematically
specificity only. A cut-off for each scoring synthesize on specific topic of AIMS65 score
system is also important to distinguish low- in patients with UGIB. Additionally, all
risk and high-risk in predicting clinical included studies were very recent and
outcomes (28). Unfortunately, cut-off values publicized from 2012 to 2022.
were reported almost differently for each However, this study has some limitations.
included study. The reason for the First, the clinical outcomes of the need for
inconsistent cut-off value from the studies intervention are limited to the need for
included is difficult to explain. However, this endoscopic therapy, blood transfusion, and
condition might be due to some differences in ICU admission. Surgery and radiology may be
those studies such as participant’s ethnicity, considered as clinical outcomes for this study.
UGIB etiology, use of medical treatment Second, lack of studies that reported long-
before endoscopy, time of endoscopy, and term mortality or rebleeding events. There is
adherence to the guidelines regarding only one study that reported mortality for 6
endoscopic therapy (23,24). months. Another limitation is all included
This systematic review shows a lack of studies do not report calibration performance
evidence for discriminative performance in analysis. Knowing that the included studies
ranging from fair to excellent in predicting were designed as a validation study, recent
rebleeding events, the need for endoscopic impact analysis studies are needed to evaluate
treatment, blood transfusion, and ICU the usefulness of the score in a clinical setting
admission. AIMS65 only showed sufficient in terms of patient satisfaction or
evidence of fair to excellent discriminative resource/time allocation.
performance in predicting mortality. It is
clinically important because knowing which CONCLUSION
patients are at a true high risk of mortality can
In conclusion, AIMS65 is a simple, non-
help to guide limited resources such as
dependent-to-endoscopic examination, and
emergency endoscopy or ICU beds. AIMS65
easily calculated, so it is practical for UGIB
included variables that are easily remembered,
cases in the emergency department. AIMS65
obtained, and less subjective. Furthermore, the
showed fair to excellent evidence in
variables are non-weighted and easy to
predicting mortality, but the evidence for
calculate within 12 hours as part of the initial
predicting rebleeding events, the need for
evaluation in ED. This is very potent to ensure
endoscopic
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therapy, blood transfusion, and ICU 5. Lanas A, Dumonceau JM, Hunt RH,
admission, says otherwise. However, AIMS65 Fujishiro M, Scheiman JM, Gralnek IM,
still has a critically important role in early et al. Non-variceal upper gastrointestinal
decision- making and triage for UGIB bleeding. Nat Rev Dis Prim [Internet].
patients. 2018;4:1–21. Available from:
http://dx.doi.org/10.1038/nrdp.2018.20
[PubMed]
Acknowledgment 6. Stanley AJ, Laine L, Dalton HR, Ngu JH,
The authors are grateful to the Faculty of Schultz M, Abazi R, et al. Comparison of
Medicine, University of Jember for supporting risk scoring systems for patients presenting
this study. with upper gastrointestinal bleeding:
International multicentre prospective
Conflict of Interest study. BMJ. 2017;356:1–8. [PubMed]
7. Thandassery RB, Sharma M, John AK,
The authors declared that there is no conflict
Al- Ejji KM, Wani H, Sultan K, et al.
of interest in this study. Clinical application of AIMS65 scores to
predict outcomes in patients with upper
Funding gastrointestinal hemorrhage. Clin Endosc.
This study did not receive any funding. 2015;48(5):380–4. [PubMed]
8. Saltzman JR, Tabak YP, Hyett BH, Sun
Authors’ Contributor X, Travis AC, Johannes RS. A simple
risk score accurately predicts
All authors have contributed to several
in-hospital mortality, length of stay, and
processes in this study. cost in acute upper GI bleeding.
Gastrointest Endosc [Internet].
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to identify parts of the illustrations, identify Up to six authors, list all the authors.
and explain each one clearly in the legend.
Explain the internal scale and identify the  Yi Q, Li K, Jian Z, Xiao Y. Risk
method of staining in photomicrographs.
factors for acute kidney injury after
Units of Measurement cardiovascular surgery: Evidence from
2,157 cases and 49,777 controls - A
For measurements use S.I. (System meta-analysis. Cardio Renal Med.
International) units. Measurements should be 2016; 6: 237–50
More than six authors, list the first six 1. Copyright holder is the author(s).
authors, followed by et al.
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 Amini S, Najafi MN, Karrari SP, redistribute) and adapt (remix, transform, and
Mashhadi ME, Mirzaei S, Tashnizi build) upon the works under license without
MA, et al. Risk factors and outcome of restrictions.
acute kidney injury after isolated cabg
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Brazilian J Cardiovasc Surg. 2019; publishing rights without restrictions.
34(1): 70–5.
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2. A book
original.
McKnight CL, Burns B. Pneumothorax. In:
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StatPearls. StatPearls Publishing; 2021.
violations against the requirement mentioned
above.
3. Homepage/Web site

Ikatan Dokter Anak Indonesia. Rekomendasi IJAR Copyright Ownership

Ikatan Dokter Anak Indonesia: Asuhan
The copyright holder is the author(s).
Nutrisi Pediatrik (Pediatric Nutrition Care).
Paediatric. 2011; 3(2): 5–6. Legal Formal Aspect
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TABLE OF CONTENTS
p-ISSN 2722-4554 | e-ISSN 2686-021X | Volume 6 | Number 1 | January 2024

ORIGINAL ARTICLE
Developing an Effective Team-Based Emergency Training Program for Medical Students 1 - 13
Pinter Hartono, Bowo Adiyanto, Rifdhani Fakhrudin Nur, Cornelia Ancilla, Aulia
Zuhria Rahma

Comparison of Intravenous Administration of Remifentanil with Fentanyl for Increased Blood 14 - 22

Sugar Levels in Post Cardiac Surgery Patients
Irvan, Doddy Tavianto, Reza Widianto Sudjud

Investigation of Heart Rate Variability and The Requirement for Vasopressors Relationship 23 - 31
Due to Hypotension in Patients Undergoing Caesarean Section with Spinal Anesthesia
Kübra Bektaş, Duygu Yücel, Fatih Uğur

CASE REPORT/CASE SERIES

Pulsed Radiofrequency on Sphenopalatine Ganglion as the Interventional Pain Management in 32 - 41
Cluster Headache Secondary to Sphenoid Meningioma
Naomi Rahmasena, Mirza Koeshardiandi, Fajar Tri Mudianto

Perioperative Management of Marfan Syndrome in Pregnancy and Congestive Heart Failure 42 - 49

Mirza Koeshardiandi, Fajar Tri Mudianto, Muhammad Wildan Afif Himawan, Ahmed
Eliaan Shaker Abuajwa, Bambang Pujo Semedi

Combined Spinal-Epidural Anesthesia with Isobaric Ropivacaine 0.375% for Inguinal Hernia 50 - 57
Surgery in a Heart Failure Patient with Ejection Fraction of 36%
Muhammad Isra Rafidin Rayyan, Salman Sultan Ghiffari, Achmad Hariyanto,
Achmad Wahib Wahju Winarso, Haris Darmawan, Ichlasul Mahdi Fardhani

REVIEW
AIMS65 Scoring System for Predicting Clinical Outcomes Among Emergency Department 58 - 72
Patients with Upper Gastrointestinal Bleeding
Rifaldy Nabiel, Al Munawir, Jauhar Firdaus