anestesi umum unjani 2 (2)
DESCRIPTION
Anestesi UmumTRANSCRIPT
-
ANESTESI UMUM UNJANI 2
-
Anestesi UmumInduksi inhalasi, rumatan anestesi dengan anestetika inhalasi (VIMA= Volatile Induction and Maintenance of Anesthesia)Induksi intravena, rumatan anestesi dengan anestetika intravena (TIVA = Total Intra Venous Anesthesia)Induksi intravena, rumatan anestesi dengan anestetika inhalasi .
-
Trend baru dalam anestesi umumVIMA (Volatile Induction and Maintenance of Anesthesia)Fast-Track AnesthesiaLow-flow Anesthesia Low-cost AnesthesiaSingle-breath induction (Rapid induction)SAFE (Short Acting Fast Emergence) drugs.Mampu memberikan proeksi pada organ
-
Kenapa VIMA???Induksi intravena, misalnya: Propofol : induksi cepat dan lancar, tapi dibutukan jalur vena, ada efek samping hipotensi dan apne.Anestesi untuk pediatrik pada umumnya dengan VIMA.Lebih menguntungkan daripada induksi intravena, rumatan dengan anestetika inhalasi.
-
Induksi intravena tidak nyamanMembutuhkan akses intravena nyeri,takut, sulit.Obat sakit bila disuntikkan Adanya reaksi yang burukhipotensiapnemioklonus, porphyria, anafilaxisEfek sisa : sedasi
-
Induksi Inhalasi membutuhkan obat yg tepatThe Triad of VIMAAdapted from: Logan Int Proc J 7: 4, 1998Iritasi jalan nafasKelarutanPotensiVIMAVIMA
-
Proteksi OrganBasic method/Metode mendasar : A,B, CHipotermi Farmakologik : Anestetika intravena Anestetika inhalasi
-
Gambaran proteksi Otak dari anestetika inhalasiProteksi otak dalam lingkupan efek anti-necrotik and anti-apoptotikMeningkatkan aliran darah otak pada daerah otak yg iskemik.Menurunkan metabolisme otakMenekan kejang Werner C. AOSRA Nov 2003, WCA, April 2004. ESA June 2004.
-
Gambaran proteksi Otak dari anestetika inhalasiIsofluran, sevofluran, desfluran menekan metabolime otak secara maksimal pada 2 MAC memperbaiki ketidakseimbangan antara kebutuhan dan pasokan oksigen.Menghambat asidosis laktik dan pelapasan neurotransmitter excitatoryMencegah influks patologis Na+, Ca2+ .Menghambat peroksidasi lipid.Mengurangi pembentukan radikal bebas.
Werner C. AOSRA Nov 2003
-
Narkotik analgetik ideal :Margin of safety lebar.Mula kerja cepatLama kerja singkatMudah mengendalikan efek analgesiknyaAnalgesik kuat Tidak ada pelepasan histamineMetabolitnya tidak aktif
-
Penggunaan Opiat dalam AnestesiPremedikasiInduksi anestesiNarcotik anestesiBagian dari balans anestesiAdjuvant dalam anestesi regionalNeurolept anestesiPengelolaan nyeri pascabedah
-
Efek NarkotikBradikardia : efek vagotonik sentral serta depresi nodus SA & AV . Depresi nafas: frekuensi, ritme nafas, respons CO2, Minute Volume, Tidal Volume.Kekakuan ototMual-muntah yg disebabkan stimulasi chemoreceptor triger zone (CTZ), mobilitas saluran cerna, penurunan mobilitas gaster, meningkatkan volume gaster.
-
Dosis klinis Narkotik
-
Pelumpuh otot IdealNon depolarisasiMula kerja cepat, lama kerja singkatPemulihan cepat, potensi kuatTidak kumulatif, metabolitnya tidak aktifTidak ada efek kardiovaskulerTidak menimbulkan pelepasan histaminDapat dilawan dengan antikholinesterase
-
Pelumpuh Otot depolarizing dan Non depolarizingDepolarizingLama kerja singkat: SuccinylcholinNon depolarizingLama kerja panjang : PancuroniumLama kerja sedang: Rocuronium, Vecuronium, AtracuriumLama kerja singkat: Mivacurium
-
Kondisi yg kemungkinan terjadi hiperkalemia akibat SuccinylcholinLuka bakarTrauma beratInfeksi intra-abdominal beratCedera medulla SpinalisEncephalitisStrokeGuillain-Barre syndromeSevere Parkinsons diseaseTetanusBed rest lamaRuptured cerebral aneurysmPolyneuropathyCedera kepalaSyok Hemorrhagic dengan metabolik asidosisMyopathies ( eg, Duchenness dystrophy )
-
Mechanism neuromuscular blockadeCompetitive block : non-depol, avoid AcCh access to receptor.Depolarization block : depol, depolarization as AcCh but permanentDeficiency block: influence syntesis and release AcCh: Procaine, toxin botulinus, Ca decrease, Mg increase. Morgan GE, Mikhail MS. Clinical Anesth, 1996
-
Terminology in muscle relaxantED 50 : dose what can paralyzed 50% muscle strengthED 90 : dose what can paralyzed 90% muscle strength.Onset : interval between start of injection until maximal effect
-
Table 1. Depolarizing and nondepolarizing muscle relaxant
Depolarizing
Nondepolarizing
Short-acting
Succinylcholine
Decamethonium
Long-acting
Tubocurarine
Metocurine
Doxacurium
Pancuronium
Pipecuronium
Gallamine
Intermediate-acting
Atracurium
Vecuronium
Rocuronium
Short-acting
Mivacurium
-
Nondepolarizing drugDo not produce muscular fasciculationEffect are decreased by anticholinesterase agent, depolarizing agent, lowered body temperature, epinephrine, acetylcholineEffect are increased by non-depolarizing drugs, volatile anesthetic .
-
Depolarizing drugsProduce muscular fasciculation .Effect are increased by anticholinesterase agent, Acetylcholine, hypothermiaEffect decrease with non-depolarizing relaxant drugs, anesthetic inhalationDose Succ choline : 1 mg/kg BW
-
Burn injuryMassive traumaSevere intra-abdominal infectionSpinal cord injuryEncephalitisStrokeGuillain-Barre syndromeSevere Parkinsons diseaseTetanusProlonged total body immobilizationRuptured cerebral aneurysmPolyneuropathyClosed head injuryNear drowningHemorrhagic shock with metabolic acidosisMyopathies ( eg, Duchenness dystrophy )Table 9 - 5. Conditions causing susceptibility to succiniylcholine-induced hyperkalemia.
-
Resume farmakologi pelumpuh otot nondepolarizing
Sheet1
RelaxantMetabolismPrimaryOnsetDurationHistamineVagalRelativeRelative
ExcretionReleaseBlockadePotency1Cost2
TubocurarineInsignificantRenal++++++++01Low
MetocurineInsignificantRenal+++++++02Moderate
Atracurium+++Insignificant+++++01High
Mivacurium+++Insignificant++++02.5Moderate
DoxacuriumInsignificantRenal++++0012High
Pancuronium+Renal+++++0++5Low
Pipecuronium+Renal+++++006High
Vecuronium+Biliary++++005High
RocuroniumInsignificantBiliary+++++0+1High
1For example, pancuronium and vecuronium are five times more potent than tubocurarine or atracurium
2Based on average wholesale price per 10 mL; does not necessarily reflect duration and potency
Onset : + = slow; ++ = moderately rapid; +++ = rapid
Duration : + = short; ++ = intermediate; +++ = long
Histamine release : 0 = no effect; + = slight effect; ++ = moderate effect; +++ marked effect
Vagal blockade : 0 = no effect; + = slight effect; ++ = moderate effect
Sheet2
Sheet3
-
Choice of anesthesia technique depend on:Patient conditionSkill anesthetistSkill surgeonHospital socio economy
-
Problem during induction of anesthesiaMain problem : airwaySign of partial obstruction : snoring, crowing, gargling, wheezing, chest retraction, cyanosisSign of total obstruction : air flow from nose/mouth negative, supraclavicular retraction, intercostal retraction, cyanosis
-
Other problem during inductionRespiratory depressionCoughLarynx spasmMucus and salivavomiting
-
Airway controlledWithout equipment : Triple mannuver SafarWith equipment: OPA (Oro Pharyngeal Airway) NPA (Naso Pharyngeal Airway) LMA ( Laryngeal Mask Airway) ETT (Endo Tracheal Tube)
-
Indication IntubationHead and neck surgeryDifficult airwayThoracotomyLaparotomyLateral positionProne positionControlled ventilation
-
Technique laryngoscopy Head positionInsertion laryngoscope bladeVisualization epiglottisLift epiglottisView larynx and surrounding structure
-
Advantages Endotracheal intubationEnsures a patent airwayNormal anatomic dead space (75 ml) is decreased to 25 ml.Ventilation can be assisted or controlledPossibility of aspiration diminished drasticallySuctioning of the lung is facilitated
-
Disadvantages endotracheal intubation
Increases resistance to respirationTrauma to the lips, teeth, nose, throat, larynx.
-
Complication IntubationTeeth ruptureMouth bleedingEndobronchial intubationOesophageal intubationSore throatHypertensionArrhythmias
-
Teknik InduksiMask induction / inhalasi : induksi melalui sungkup muka.IntravenaIntramuscularPer rectal
-
WHY VIMA???intravenous induction, ex: Propofol : rapid and smooth induction, but need vein access first, hypotension, apnoe.Pediatric anesthesia commonly by VIMA.More advantages than intravenous induction, maintenance inhalation.
-
Mask Induction dengan SevofluranGradual InductionSingle Breath InductionTriple Breath Induction (Multiple Breath Induction)
Teknik cepat dengan Single Breath Induction, tanpa kejadian batuk, nahan nafas, spasme laring.
-
Induksi BertahapMetode klasik untuk induksi inhalasi.Tujuannya untuk menurunkan iritasi saluran nafas dan bau yg menyengat tidak diperlukan untuk Sevofluran.Anestetika volatil dikombinasikan dg N2O atau oksigen 100%.
-
Induksi dg 1 tarikan nafas (Single-Breath Induction)Priming sirkuit dg N2O 60% + Sevo 8% selama 30 detik.Minta pasien mengeluarkan nafas maksimal, lalu tempelkan face mask nya.Minta pasien narik nafas maksimal, pertahankan 20 detik, lalu nafas normal.Setelah refleks bulu mata negatif, Sevo turunkan jadi 2%.
-
Triple Breath InductionSuatu variasi dari Single Breath InductionMinta pasien narik nafas dalam 3 kali.Perbedaan dg Single Breath, pasien tidak diminta menahan nafas.Umumnya pasien sudah tidur dalam 2-3 nafas.
-
How to maintain anesthesia ?Maintenance anesthesia depend on deep of anesthesia to reach adequate anesthesia.Commonly with inhalation anesthetic 0.5-1 MAC depend on type of surgery, spontaneous breathing or controlled.To reduce vol% (MAC) : add N2O or Fentanyl.
-
Tanda kedalaman anestesiPRST Score (untuk balans anestesi)Guedel sign (untuk ether anesthesia)PRST Score (score 2-4: adequate anesthesia) P = Pressure = tekanan sistolik (mmHg) R = rate (heart rate) = denut jantung S = sweat/ lacrimation = keringat T = tear=air mata
-
Skor PRST untuk Balans anestesiSkor 2-4 : anestesi adekuat
-
EkstubasiSetelah ventilasi adekuatPada anestesi dalam atau setelah pasien bangunJalan nafas harus bebasBerikan oksigen 100% sebelum dan setelah ekstubasi.
-
Tatang Bisri, 2009
-
N2O1.5 time heavier than airMust be give with O2 100%Weak anestheticAnalgesic N2O 20% equal with 15 mg morphineDont use in closed systemAt the end of anesthesia, to prevent diffusion hypoxia O2 100%
-
Advantages N2ORapid induction and recoveryNo sensitized myocardium with catecholamineNo irritation respiratory tractOdor pleasantStrong analgesic
-
Disadvantages N2OWeak anestheticNo muscle relaxation effectNeed high concentration oxygenPossibility aplasia bone marrow
-
HalothaneA clear, colorless, potent volatile liquid.Metabolism 17-20% Advantages HalothaneRapid, smooth induction and recovery.PleasantNon irritating, no secretionBronchodilatorNonemeticNon flammable and non explosive
-
Disadvantages HalothaneMyocardial depressantAn arrhythmia producing drugSensitizes the myocardial conduction system to the action of catecholaminesA potent uterine relaxantPossible toxic to the liverShivering during recovery period.
-
EnfluraneA clear, colorless, stable volatile liquid with a pleasant ether-like odor.A potent inhalation anesthetic CNS excitationUse of epinephrine : saver than halothane.
-
Advantages EnfluranePleasantRapid induction and recoveryNon-irritating : no secretionBronchodilatorGood muscle relaxationNonemeticNon flammable and non explosiveCompatible with epinephrine
-
Disadvantages EnfluraneMyocardial depressantShivering on emergenceCSF production increaseCNS excitation, in high dose and hypocarbia.
-
IsofluraneA stabe, volatile liquidA isomer enfluraneInhalation anesthetic choice for neurosurgical patient, kidney, liver.
-
Advantages IsofluraneRapid induction of anesthesia and swift recoveryNonirritating : no secretionBlood pressure remain stableIndicated in poor-risk patient
Disadvantages IsofluraneLess than halothane and enflurane
-
SevofluraneInhalation anesthetic with low solubility (0,63), low MAC (2,05), pleasant odor, no airway irritation, rapid uptake and elimination , cardio vascular stable.Rapid induction, with technique single breath induction, induction time 23 seconds.
-
SevofluraneDrugs of choice for Neuro anesthesia : WCA 2000 Montreal, Canada.Drugs of choice for Pediatric Anesthesia : ESA Barcelona, 1998. ASPA, Singapore, 2000., ESA Sweden 2001.In Sectio Caesarea equal with Isoflurane and spinal anesthesiaReduce sphlannic blood flow, hepatic blood flow lesser than other anesthetic inhalation.
-
ThiopentoneBlood pressure decreaseHeart rate increase or decreasePeripheral vasodilatationHeart contraction depressedLarynx spasm, bronchus spasmRespiratory depression until apnoeaDose 4-6 mg/kg BW
-
Relative contraindication thiopentoneAsthma bronchialeSevere liver diseaseSevere kidney diseaseSevere anemiaHypotensionShock
-
KetamineDissociative anestheticDeliriumHallucinationIncrease blood pressure : systolic 23% from base lineIncrease heart rateArrhythmiasHypersecretionDose 1-3 mg/kg I.v or 9-11 mg/kg I.m
-
Indication and Contraindication KetamineIndication : short surgeryContraindication : Hypertension systolic > 160 mmHgArrhythmiasHeart failurePharynx and larynx surgery without intubation.
-
PropofolNew intravenous anestheticFast onset, short duration of actionAccumulation minimalFast recoveryRapid metabolismNo complication at site of injection Dose 2-2.5 mg/kg BW
**