Monitoring Hemodynamic

Suparto
Anesthesia Department FK UKRIDA
Preoperatif:
Anamnesis
Riwayat Keluarga
Riwayat operasi sebelumnya
Riwayat perokok, alkohol?
Alergi?
Mengkonsumsi obat-obat rutin?
Pemeriksaan Fisik
Pemeriksaan lab: DR, PT, aPTT, elektrolit
Pemeriksaan radiologis, EKG
Edukasi tentang prosedur
Inform Consent, ASA atau physical status
Instruksi: Premedikasi, puasa




Pemeriksaan Fisik


A.S.A (American Society of Anesthesiology)
Class I Tidak ada kelainan organ fisiologi, biologi dan
psikiatri
Class II Mild to Moderate systemic disturbance
Class III Moderate to severe systemic disturbance
Class IV Life threatening
Class V Moribund, pasien yang tidak diharapkan
hidup dalam 24 jam, Tidak perlu dioperasi
Operasi Emergency (E)

Intraoperative
Anestesi umum/ Anestesi Regional
Monitoring hemodinamik
Perioperative fluid requirement:
Hitung preoperative Defisit cairan:
(kebutuhan cairan/jam x jam puasa)
Koreksi defisit cairan
Jam I: 50% defisit + maintenance
Jam II: 25% defisit + maintenance
Jam III: 25% defisit + maintenance


Third-space losses
Operasi besar (Eks laparatomi bowel surgery, Hip
replacement, cardio thorasic surgery, vascular surgery): 6-
10 ml/kg/jam
Operasi sedang (Ekstremities surgery, appendectomy,
TURP, breast surgery, obgyn surgery) : 4-6 ml/kg/jam
Operasi kecil (cataract surgery) : 2-4 ml/kg/jam
Estimasi volume darah:
Adult 70 cc/kg
Maximal allowable blood loss:
15-20% dari estimasi volume darah

Estimasi darah yang hilang
Darah yang tertampung di botol penampung
Kain kasa, kain penutup
Replacing blood loss:
Crystalloid, colloid
Hb 7-8 g/dL (Ht 21-24%)
Elderly Hb 10 g/dL
1 unit of red blood cells : Hb 1 g/dL and Ht 2-3% in
adults
10 ml/Kg transfusion of red blood cells Hb
concentration by 3 g/dL and Ht by 10%
Post Operative
Cairan maintenance
Pain control : NSAID, Opioid

Tujuan utama: Keselamatan pasien
Pemantauan adalah
Menginterpretasikan data yang ada untuk
membantu mengenali kelainan atau kondisi sistem
yang tidak diharapkan, yang sedang atau akan
terjadi (D. John Doyle, MD. Cleveland Clinic Foundation)

Standar Perilaku untuk Pemantauan Anestesia
1. Anestesiologis harus
hadir dan menjaga
keselamatan pasien
sepanjang prosedur
anestesia
2. Semua peralatan harus
diperiksa sebelum
digunakan

3. Alat pantau harus
terpasang sejak
sebelum induksi hingga
pulih dari anestesia
4. Selama prosedur, semua parameter harus
dievaluasi ulang
5. Data yang diperoleh dari alat pantau harus terekam
dalam rekaman medis anestesia



6. Standar ini berlaku untuk semua tindakan
anestesia (MAC, Sedasi, Anestesia regional,
Anestesia umum)

Standard Monitoring
ASA standard: Oxygenation, ventilation, circulation,
and temperature
Standard for General Anesthesia:
ASA standard (Pulse Oximetry, Capnography, minute
ventilation, ECG, BP, temp if necessary
Standard for MAC and Regional Anesthesia:
Pulse Oximetry, RR, ECG, BP, temp if necessary
Additional: Arterial line, CVP, NMBA monitor
Preparation before induction: Anesthesia Mechine,
ECG Monitor


Clinical Signs and Symptoms of Perfusion Abnormalities
CNS: mental status changes, neurologic deficits
CVS: Chest pain, Shortness of breath, ECG
abnormalities, wall motion abnormalities on echo
Renal: UO, BUN, creatinine
Gastrointestinal: Abdominal pain, bowel sounds,
bleeding
Peripheral: cool limbs, poor capillary refill,
diminished pulses.
Cardiovascular system
O2 delivery
CO = SV x HR
ECG
Determine HR
Detect and diagnose
dysrhytmia
Myocardial ischemia
Electrolyte imbalance
(hipo/hyperkalemia)
Manual Blood Pressure
BP = CO x SVR
Measures systolic dan
diastolic BP by
auscultation of korotkoff
sound, palpation
Cuff width should cover
2/3 of upper arm or
thigh
Palpation:
A. radial (80mmHg)
A. femoral (60mmHg)
A. Carotid (50mmHg)



Mean Arterial Pressure
MAP = sis + 2 Dias/ 3
Normal: 60-70mmHg
Mean Arterial Pressure (MAP): Reflects
changes in the relationship between cardiac
output (CO) and systemic vascular resistance
(SVR) and reflects the arterial pressure in the
vessels perfusing the organs.
A low MAP indicates decreased blood flow
through the organs.
A high MAP indicates an increased cardiac
workload.

Cardiac Output (CO): The volume of blood
pumped by the heart in one minute.
Increased cardiac output may indicate a high
circulating volume.
Decreased cardiac output indicates a decrease in
circulating volume or a decrease in the strength of
ventricular contraction.

Systemic Vascular Resistance (SVR): The
measurement of resistance or impediment of
the systemic vascular bed to blood flow.
An increased SVR can be caused by
vasoconstrictors, hypovolemia, or late septic
shock.
A decreased SVR can be caused by early septic
shock, vasodilators, morphine, nitrates, or
hypercarbia.

Stroke Volume (SV): The amount of blood
pumped by the heart per cardiac cycle. It is
measured in ml/beat.
A decreased SV may indicate impaired cardiac
contractility or valve dysfunction and may result in
heart failure.
An increased SV may be caused by an increase in
circulating volume or an increase in inotropy.

Joint National Commitee 7
th
,
2004


Arterial BP indication
Tight BP control
Unstable patient
Arterial blood sampling


Central Venous Catheter
CVP (Central Venous
Pressure)
At the vena cava or
Right atrium
Measurement of right
filling pressure to assess
intravascular volume
and right heart function
Drug administration
IV access
Accsess for insertion
PAC (using introducer)
Normal CVP is 2 to 12
mmHg
Complication:
Dysrhythmias
Arterial puncture
Pneumothorax
Hemothorax
Infection, air embolism
Contraindication CVC insertion:
1. Tumor at RA
2. Tricuspid vegetation
3. Post carotid endarterectomy ipsilateral
4. Coagulopathy
Causes of increased pressure:
Right sided heart failure
Volume overload
Tricuspid valve insufficiency or stenosis
Pulmonary hypertension
Cardiac tamponade
Causes of decreased pressure
Reduced circulating blood volume
Pulmonary Artery Catheter

Pulmonary Artery Pressure (PA Pressure):
Blood pressure in the pulmonary artery.
Increased pulmonary artery pressure may
indicate:
a left-to-right cardiac shunt,
pulmonary artery hypertension,
COPD or emphysema,
pulmonary embolus, pulmonary edema
left ventricular failure.

Mengetahui fungsi jantung kiri
Mengetahui adanya hipertensi pulmonal
Mengukur cardiac ouput, systemic vascular
resistance (SVR), pulmonary vascular
resistance (PVR), pulmonary capillary wedge
pressure (PCWP, PAOP)
Normal PAP systolic15-30 mmHg and diastolic
5-12 mmHg. PAOP 5-12 mmHg


Pulmonary Capillary Wedge Pressure (PCWP or
PAWP): PCWP pressures are used to approximate
LVEDP (left ventricular end diastolic pressure).
Reflecting left arterial pressure and left
ventricular preload
High PCWP may indicate left ventricle failure, increase
in end diastolic volume, decrease compliance, mitral
valve pathology, cardiac insufficiency, cardiac
compression post hemorrhage.
Low PCWP can be due to decrease end diastolic
volume, increase in compliance

Respiratory System
Pulse Oxymetri
Normal: 96%-99%
88% acceptable for
patient with lung disease
High pulse ox indicates:
O2 available in the lung,
taken up in the blood,
delivered to distal
tissues.
Low pulse ox
Problem along the above
pathway or due to error
Capnography
Ventilation Assessment
Confirmation
endotracheal intubation
Normal: PetCO2 is
2-5mmHg lower than
arterial PCO2, so typical
range 30-40 mmHg
under General
anesthesia

Suhu tubuh
normal 365-375 C
Suhu nasofaringeal mendekati suhu inti
Peningkatan menandakan meningkatnya
metabolisme sel
Suhu produksi CO2
Produksi Urine
Dewasa: 0.5-1cc/Kg/jam
Pediatrik: 1-2cc/Kg/jam



Pemantauan sistem saraf
Bispectral Index, utk
mengetahui kedalaman
anesthesia dari
mendeteksi dan rekaman
gelombang
elektroensefalogram
(EEG)
Tingkat anestesi nilainya
40-60 (100 artinya sadar
penuh)


Train of Four
Mengukur tingkat
blokade oleh
pelumpuh otot
memberikan 4
stimulus berturutan
dengan frekwensi 2
Hz selama 2 detik