ppt. obesity

8/10/2019 Ppt. Obesity

http://slidepdf.com/reader/full/ppt-obesity 1/54

REFERAT

September 2011

ANESTESI PADA OBESITY

Oleh

MULYONO



Klas!"as obesity #l$%&%e'"er(

200)* BMI #"&+m2* Des"rps Kelas obesity

, 1)(- Under

weight

1)(-.2/( Normal

2-(0.2( Over weight

0(0./( Obesity I

-(0.( Morbid

obesity

II

/0 Extreme

obesity

III



Tpe 3ar $bestas a3a 2

14 Tpe a%3r$3 # $bestas se%tral*

Pa3a tpe % 3strb5s lema" 3$m%a% 3 t5b5h ba&a% atas #3strb5s tr5%"al* 3a%

berh5b5%&a% 3e%&a% pe%%&"ata% "$ms5ms $"s&e% 3a% %s3e% pe%6a"t

"ar3$7as"5ler4

2. Tpe &%e"$3 # $bestas per!er*

Pa3a tpe % 8ar%&a% a3p$se 3$m%a% l$"as 3 paha( pa%tat 3a% p%&&5l #lema"

se'ara metab$l" "5ra%& a"t! seh%&&a "5ra%& berh5b5%&a% erat 3e%&a% pe%6a"t

"ar3$7as"5ler*



Pat$!s$l$& $best6Sstem respras 91. Work of breathing Pase% $bestas m$rb3 me%%&"at

mer5pa"a% a"bat 3ar compliance 3%3%& 3a3a me%5r5%

24 T$tal $"s&e% "$ms5ms 3a% pr$35"s "arb$%3$"s3a me%%&"at

pa3a pase% obese saat strahat

4 :p$;a "r$%s me%6ebab"a% p$l6'6thema( 3ma%a ber"$%trb5s

3alam pe%%&"ata% 7$l5me 3arah4 Ter8a3%6a :p$"sema "r$%s

3apat me%6ebab"a% hperte%s p5lm$%al 3a% "$rp5lm$%ale4

#L$%&%e'"er( 200)*



OBSTRUKTIF SLEEP APNEU 33e!%s"a% seba&a berhe%t%6a alra% 53ara

selama 10 3et"( ter8a3 - "al ata5 lebh setap 8am

saat t35r( <ala5p5% 5saha ber%a!as mela<a%

pe%5t5pa% &l$ts tetap ter8a3( 3"$mb%as 3e%&a%

pe%5r5%a% sat5ras $"s&e% lebh 3ar /=4



Obstrksi sleep hypopne t5r5%%6a alra% 53ara -0= 3alam <a"t510 3et"

ter8a3 lebh 3ar 1- "al setap 8am selama t35r4

Basa%6a berh5b5%&a% 3e%&a% s%$r%& 3a%

3esat5ras $"s&e% /= 4



Ap%ea.:p$p%ea %3e; > A:I A:I a3alah 85mlah t$tal 3ar ap%e5 3a% hp$p%e5 per8am 3a% 3&5%a"a%

5%t5" me%&etah5 "5a%ttas 3ar berat%6a OSA4 A:I 0 mer5pa"a%

OSA se7ere( A:I -.1- $sa ml3 3a% A:I 1?.0 seba&a OSA m$3erate4

I%3e"s t$tal ar$5sal # Ar$5sal %3e;>AI* a3alah 85mlah t$tal %3735

terba%&5% per 8am4 Kesmp5la% 3ar A:I 3a% t$tal A:I 3 "e%al seba&a

respiratory distrbance index #RDI*4

#L$%&%e'"er( 200)*



syndrome hipoventilsi o!esity 33e!%s"a% seba&a "$mb%as a%tara $bestas

#BMI0 "&+m2* 3a% hper"ap%a arter "et"a

sa3ar #Pa'$2/- mmh&* 3e%&a% t3a" a3a%6a

pe%6ebab la% 3ar hp$7e%tlas

S%3r$ma P'"<'"a% 3ta%3a 3e%&a% obesity (

me%&a%t5" berlebha%( hp$"sa( hper"ap%a(

&a&al 7e%tr"el "a%a%( 3a% p$lsthema ( % a3alah

a"hr 3ar O:S4



E"m# Orophryn"Patient With the Crowded Oropharynx



Physi$l E"m

Guilleminault C et al. Sleep Apnea Syndromes. New York: Alan R. iss! "#$%.

Structural Abnormalities



Pthophysiolo%y o& Apne



Pthophysiolo%y o& SleepApne

oss o& neuromus'ular

'ompensation

()e'reased pharyn*eal

mus'le a'ti+ity

Sleep Onset

,yper+entilate: 'orre't

hypoxia - hyper'apnia

Airway opens

Airway 'ollapses

Pharyn*eal mus'le

a'ti+ity restored

Apnea Arousal &rom sleep

,ypoxia -

,yper'apnia

n'reased +entilatory

e&&ort



PICKWICKIAN SYNDROME OR

OHS

8% of obese patients

Alveolar hypoventilation, somnolence and

morbid obesity

↑ Soft tissue mass of oropharynx→Intermittent obstruction of airway

during sleep

Hypoxemia, hypercarbiaPolycythemia, pulmonary hypertension

and right ventricular failure

Pulmonary embolism and pneumonia



+- V/+01 23#-14 I- /"14I56



FR2 $12R1#414 I53 I-2R1#4I-

"0I



sitting supine

Normal Obese



Sstem "ar3$7as"5ler

Pe%%&"ata% m$rb3tas 3a% m$rtaltas pa3a pase% obese a3alah hasl 3ar pr$blem "ar3$7as"5ler sepert hperte%s( pe%6a"t 8a%t5%& s"em"( &a&al

8a%t5%&( "ar3$m$pat( artma( 3slp3ema( 3a% me%%&&al me%3a3a" "are%a

pe%6a"t 8a%t5%&4

@ar%&a% a3p$se berlebha% 9

14 $l5me 3arah24 Car3a' $5tp5t

4 ater$s"ler$ss

/4 Dsrtma

-4 Sstem RAA

?4 Resste%s %s5l%

4 Dslp3ema

)4 :p$!br%$lt" 3a% hper"$a&5las

#L$%&%e'"er( 200*



a&al 8a%t5%& %tra $perat! 3apat ter8a3 "are%a pe%bera% 'ara% %tra 7e%a 6a%& 'epat

#mer5pa"a% %3"as 3s!5%&s 3ast$l" 7e%tr"el

"r*( %$tr$p" %e&at! 3ar a&e%t a%estes(

hperte%s p5lm$%al 6a%& 3presptas $leh

hp$"sa 3a% hper"ap%a4#Barash( 200*



Sstem &astr$ %test%al 3a% hepat"

$l5me &aster 3a% "easama% me%%&"at( &a%&&5a% !5%s

hepar 3a% metab$lsme $bat

Pe%&$s$%&a% lamb5%& me%8a3 lebh lambat pa3a pase%

$bese( "are%a pe%%&"ata% massa ab3$me% 3a% 3ste%sa%tr5m4 Release &astr%( 3a% pe%5r5%a% p: 3e%&a%

hperse"res sel paretal4

Pe%%&"ata% %s3e% hat5s her%a 3a% re!l5"s

&astr$es$pha&eal

ab%$rmaltas m$r!$l$& 3a% b$"emstr 3ar hepar

seh5b5%&a% 3e%&a% $bestas termas5" %!ltras lema"(

%!lamas( %e"r$ss !$"al 3a% sr$ss4



Sstem metab$l"( re%al( 3a% e%3$"r% a%&&5a% t$lera%s &l5"$sa

:p$tr$3sm s5b"l%" ter8a3 se"tar 2-= 3ar sem5a pase% m$rb34

Le7el TS: ser%& me%%&&4

Obestas mer5pa"a% res"$ ma6$r terha3ap end stage renaldisease #ESRD* 3a% hperte%s esse%sal4

Obestas ter"at &l$mer5l$pat 3 3e!%s"a% seba&

&l$mer5l$s"ler$ss !$"al se"me%tal 3a% &l$mer5l$pat ata5

&l$mer5l$pat sa8a4

#Barash 200( L$%&%e'"er 200)*



S%3r$me metab$l"

mer5pa"a% hasl 3ar %tera"s a%tara !a"t$r.!a"t$r &e%et"( h$rm$%al 3a% l!est6le Me%5r5t !nternational "iabetes #ederation( sese$ra%& 33a&%$ss s%3r$me

metab$l" har5s memp5%6a $bestas se%tral #l%&"ar p%&&a%& - 'm 5%t5" la".

la" 3a% )0 'm 5%t5" <a%ta* 3 tambah 35a 3ar empat !a"t$r 3 ba<ah % 9

14 Pe%%&"ata% le7el tr&lser3a # 14 mm$l+L*

24 Ka3ar :DL ser5m ber"5ra%& # 140 mm$l+L pa3a la".la" 3a% 142 mm$l+L pa3a˂ ˂

<a%ta*

4 Pe%%&"ata% te"a%a% 3arah # SBP 10 mmh& ata5 DBP )- mmh& * ata5 se3a%&

3alam terap hperte%s4

/4 Ka3ar &l5"$sa 3arah p5asa -(? mm$l+L* ata5 sebel5m6a 33a&%$ss DM tpe 2



Me%e8eme% per$perat!E7al5as pre a%estes

P$ss

Ar<a6 me%e8eme%

Preparas

M$%t$r%&

I%35"s( %t5bas 3a% pemelharaa%

Plha% te"%" a%estes

Me%e8eme% pas'a $peras



!reanesthetic 1valuation!reanesthetic 1valuation

IncludesIncludes

– MedicationsMedications

– Laboratory TestsLaboratory Tests

– Cardiac AssessmentCardiac Assessment

– Respiratory EvaluationRespiratory Evaluation

– Airway EvaluationAirway Evaluation

– Vascular AccessVascular Access



!reanesthetic 1valuation !atient!reanesthetic 1valuation !atient

1ducation1ducation

menjelaskan keadaan yan munkinmenjelaskan keadaan yan munkin

terjadi selama preparasi pre operati! terjadi selama preparasi pre operati! ""pemasanan cateter in!us berulanpemasanan cateter in!us berulan##

venavena central and arterial linescentral and arterial linesinsertions# awake intubation# paininsertions# awake intubation# pain

manaement$manaement$ dan pencea%andan pencea%an

cemas berlebi%ancemas berlebi%an



preparasipreparasi 17uipment17uipment

operatin room tables can accommodateoperatin room tables can accommodateup to )** pounds o! wei%t+up to )** pounds o! wei%t+

E(tra lare cu!!s can be used onE(tra lare cu!!s can be used onupper,lower e(tremity+upper,lower e(tremity+

warmin devices# !luid warms andwarmin devices# !luid warms and

warm air!low blankets s%ould bewarm air!low blankets s%ould beemployed to prevent %ypot%ermiaemployed to prevent %ypot%ermia



monitoringmonitoring

monitorinmonitorinIntraoperativeIntraoperative sesuai kebutu%ansesuai kebutu%anpasienpasien

E-. di atur aar dapat mendeteksiE-. di atur aar dapat mendeteksi myocardialmyocardialisc%emia and pat%oloy "leads II and V/$+isc%emia and pat%oloy "leads II and V/$+

0lacement o! an arterial cat%eter is appropriate0lacement o! an arterial cat%eter is appropriate!or t%e monitorin %emodynamic status!or t%e monitorin %emodynamic status++

1se o! central venous and pulmonary artery1se o! central venous and pulmonary arterycat%eters s%ould be consider in patientscat%eters s%ould be consider in patients

underoin e(tensive or seriousunderoin e(tensive or seriouscardiorespiratory disease+cardiorespiratory disease+



#irway 17uipment #irway 17uipment

preparation o! e'uipment and personnelpreparation o! e'uipment and personnelnecessary to ventilate and intubate t%e morbidlynecessary to ventilate and intubate t%e morbidlyobese patientobese patient

5TATIC55TATIC5

Laryneal mask airways "LMAs$# !iberoptic andLaryneal mask airways "LMAs$# !iberoptic andbronc%oscopic devices# emerency trac%eotomybronc%oscopic devices# emerency trac%eotomyand cricot%yrotomy kits must be available in t%eand cricot%yrotomy kits must be available in t%eevent t%at ventilation by mask or endotrac%ealevent t%at ventilation by mask or endotrac%ealtube is unsuccess!ul+tube is unsuccess!ul+

A di!!icult airwayA di!!icult airway !low!lowcartcart



0aintenance0aintenance

maintenance consist o!&maintenance consist o!&

– IntubationIntubation

– E!!ects o! .eneral Anest%esia on RespirationE!!ects o! .eneral Anest%esia on Respiration

– C%oice o! Anest%etic Tec%ni'ueC%oice o! Anest%etic Tec%ni'ue– Volume ReplacementVolume Replacement

– Intraoperative 0ositioninIntraoperative 0ositionin

– E(tubationE(tubation

– Reional Anest%esiaReional Anest%esia



IntubationIntubation

7or airway manaement to be !acilitated# t%e7or airway manaement to be !acilitated# t%eobese patient s%ould be positioned wit% t%e %eadobese patient s%ould be positioned wit% t%e %eadelevated "reverse Trendelenbur position$ on t%eelevated "reverse Trendelenbur position$ on t%eoperatin room table+operatin room table+




preo(yenated wit% 8**9 mask o(yenpreo(yenated wit% 8**9 mask o(yen!or at least : to / minutes+!or at least : to / minutes+

T%e patients %ead# neck and s%ould beT%e patients %ead# neck and s%ould becare!ully moved into ;sni!!in position<care!ully moved into ;sni!!in position<



$ifficult to

"ag90as:

Ventilate

#ssistant holds

bac: breasts,

applies cricoid

pressure

/RAC,0A

N/12A/ON in the

S1PN0 POS/ON

Rapid SpO3

)esaturation

4hort

laryngo;scope

handle

!oor view

with direct

laryngoscopy



S1PN0 POS/ON

Reduced lung volumes

Increased V9<

mismatch

n'reased intra4

a5dominal pressure



/R0N)00N21RG POS/ON

8 Improved surgical exposure1ngorged nec: veins (central line placement)

;$ecreased pulmonary compliance and lung volumes

;$ecreased Intra;abdominal volume (I#V)

;(!otential) advancement of 155 into bronchus



S/AN)NG AN) S//NG




5ome practitioners advocate t%e use o! an5ome practitioners advocate t%e use o! an ;awake look< to visuali=e t%e di!!iculty o! ;awake look< to visuali=e t%e di!!iculty o!t%e airway+t%e airway+

Care!ul administration o! sedative drusCare!ul administration o! sedative drusand application o! topical anest%esia to t%eand application o! topical anest%esia to t%eorop%aryneal structuresorop%aryneal structures

6asal o(yen is used as a supplement6asal o(yen is used as a supplement

durin awake larynoscopy+durin awake larynoscopy+




>ika>ika epilottic and laryneal anatomyepilottic and laryneal anatomymuda% di li%atmuda% di li%at# intuba# intubasi denan sedasisi denan sedasidapat di lakukandapat di lakukan## jika tidak jika tidak# intuba# intubasisidenandenan LMA or awake !iberoptic intubationLMA or awake !iberoptic intubation

dapat di unakandapat di unakan++ 7iksasi7iksasi endotrac%eal tubeendotrac%eal tube denan amandenan aman++ re'uires one person to support t%e mask andre'uires one person to support t%e mask and

airway w%ile anot%er person ba ventilates t%eairway w%ile anot%er person ba ventilates t%e

patient+patient+ In t%e case o! inability to ventilate,intubate# t%eIn t%e case o! inability to ventilate,intubate# t%e

American 5ociety o! Anest%esioloist di!!icultAmerican 5ociety o! Anest%esioloist di!!icultairway alorit%m s%ould be !ollowed+airway alorit%m s%ould be !ollowed+



mene=emen ventilasimene=emen ventilasi

.eneral anest%esia depresses respiration +.eneral anest%esia depresses respiration + T%e type o! surery# positionin and underlyinT%e type o! surery# positionin and underlyin

diseasedisease .eneral anest%esia causes a /*9 reduction in 7RC in.eneral anest%esia causes a /*9 reduction in 7RC in

t%e obese anest%esia# as compared wit% a 3*9t%e obese anest%esia# as compared wit% a 3*9reduction in anest%eti=ed non obese patientsreduction in anest%eti=ed non obese patients 7RC can be increased by ventilatin wit% lare7RC can be increased by ventilatin wit% lare

tidal volumes "8/ to 3* ml,k$tidal volumes "8/ to 3* ml,k$ 0EE00EE0 dilakukan untuk memperbaikidilakukan untuk memperbaiki 7RC and7RC and

0a?30a?3 Current ventilation recommendations includeCurrent ventilation recommendations include

usin tidal volumes o! 8* to 83 ml,k to avoidusin tidal volumes o! 8* to 83 ml,k to avoidbarotrauma+barotrauma+



2hoice of #nesthetic 5echni7ue2hoice of #nesthetic 5echni7ue

?bjective !or maintenance o! anest%esia in?bjective !or maintenance o! anest%esia in

t%e obese include&t%e obese include&

– 5trict maintenance o!5trict maintenance o! airwayairway

– Ade'uate skeletalAde'uate skeletal muscle rela(ationmuscle rela(ation– ?ptimum?ptimum o(yenationo(yenation

– Avoidance o! t%eAvoidance o! t%e residual e!!ectsresidual e!!ects o! muscleo! muscle

rela(antsrela(ants

– appropriate intraoperative and postoperativeappropriate intraoperative and postoperativetidal volumetidal volume

– E!!ectiveE!!ective postoperative analesiapostoperative analesia



2hoice of #nesthetic 5echni7ue2hoice of #nesthetic 5echni7ue

@ependin on t%e patients condition@ependin on t%e patients condition epidural anest%etic wit% ;li%t< eneral anest%esiaepidural anest%etic wit% ;li%t< eneral anest%esia

is !re'uently c%osen+is !re'uently c%osen+ A li%t eneral anest%etic can !acilitateA li%t eneral anest%etic can !acilitate

manaement o! t%emanaement o! t%e airway# ventilation# and t%eairway# ventilation# and t%epatients level o! consciousnesspatients level o! consciousness# w%ere as t%e# w%ere as t%eepidural provides surical analesia andepidural provides surical analesia andanest%esia+anest%esia+

Epidural cat%eter can be used !or postoperativeEpidural cat%eter can be used !or postoperativeanalesic administration and will en%ance earlieranalesic administration and will en%ance earlierreturn o!return o! deep breat%in and cou%indeep breat%in and cou%inmaneuvers+maneuvers+



Volume ReplacementVolume Replacement

T%eT%e normal adultnormal adult percentae o! totalpercentae o! total

body water isbody water is )*9 to )/9)*9 to )/9T%ere!ore calculation o! estimatedT%ere!ore calculation o! estimatedblood volume s%ould beblood volume s%ould be B/ to //B/ to //ml,kml,k o! actual body wei%t rat%ero! actual body wei%t rat%er

t%ant%an *ml,k*ml,k apportioned inapportioned in nonnonobese adults+obese adults+Accurate volume replacementAccurate volume replacement



Volume ReplacementVolume Replacement

Dlood loss replacement o! :&8 ratioDlood loss replacement o! :&8 ratio": ml o! crystalloid to 8 ml o! blood": ml o! crystalloid to 8 ml o! bloodlossloss$ is applicable in severely obese$ is applicable in severely obese

patients+patients+Dlood products a!ter care!ulDlood products a!ter care!ul

identi!icationidenti!ication



1xtubation1xtubation

Criteria !or e(tubation consist o!&Criteria !or e(tubation consist o!&– Awake state# tidal volume andAwake state# tidal volume and

respiratory rate at preoperative levelsrespiratory rate at preoperative levels

– Ability to sustainAbility to sustain %ead li!t or le li!t !or%ead li!t or le li!t !orat least / secondsat least / seconds

– ConstantConstant %and rip%and rip

– E!!ective cou%E!!ective cou%

– Ade'uateAde'uate vital capacityvital capacity o! at leasto! at least8/ml,k8/ml,k



1xtubation1xtubation

0atients must be placed wit% t%e0atients must be placed wit% t%e

%ead up%ead up or in aor in a sittin positionsittin position++



!ostoperative 2are!ostoperative 2are

0ostoperative Care includes&0ostoperative Care includes&

0ain Manaement0ain Manaement

0ostoperative Complication0ostoperative Complication



!ain 0anagement!ain 0anagement

0ili%an analesik &0ili%an analesik & oral analesics#oral analesics#nonsteroidal antiin!lammatory aents#nonsteroidal antiin!lammatory aents#narcotics# patient2controlled analesia#narcotics# patient2controlled analesia#local in!iltration o! surical site andlocal in!iltration o! surical site and

epidural anest%esiaepidural anest%esia 4ati2%ati &4ati2%ati &?bese patients are more?bese patients are more

sensitive to t%e respiratory depressantsensitive to t%e respiratory depressante!!ects o! opioide!!ects o! opioid analesics t%ere!oreanalesics t%ere!ore

caution and close monitorincaution and close monitorin

5upplemental o(yen and pulse o(imetry5upplemental o(yen and pulse o(imetrymonitorin are mandated+monitorin are mandated+



!ostoperative 2omplications!ostoperative 2omplications

Early ambulation and maintenance o!Early ambulation and maintenance o!

vascular volumevascular volume !urt%er reduces t%e!urt%er reduces t%e

likeli%ood t%atlikeli%ood t%at clotsclots will develop+will develop+

Found in!ections and pulmonaryFound in!ections and pulmonary

embolism are /*9 %i%erembolism are /*9 %i%er in obesein obese

patients t%an non obese patients+patients t%an non obese patients+



terma"ash

ppt. obesity

Documents