CASE DISCUSSION UNEXPLAINED LIGHT ANESTHESIA DISKUSI KASUS : ANESTESI YG TIDAK DIJELASKAN DENGAN JELAS.

An extremely obese but otherwise healthy 5 year old girl presents for inguinal hernia repair. After uneventful intubation of general anesthesia and tracheal intubation, the patient is placed on a ventilator set to deliver a tidal volume of 7 ml/kg at a rate of breaths/min. Despite delivery of 2% halothane in 50% nitrous oxide, tachycardia (a45 beats/min) and mild hypertension (144/94 mmHg) are noted. To increase anesthetic depth, fentanyl (3ug/kg) is administered. Heart rate and blood pressure continue to rise and are accompanied by frequent premature ventricular contractions. Seorang gadis berusia 5 tahun yang sangat gemuk namun tidak sehat hadiah untuk hernia inguinalis perbaikan. Setelah lancar intubasi anestesi umum dan trakea intubasi, pasien ditempatkan pada ventilator set untuk memberikan volume tidal 7 ml/kg pada tingkat napas/min. Meskipun pengiriman 2% halothane di 50% nitrous oksida, takikardia (a45 denyut per menit) dan ringan hipertensi (144/94 mmHg) dicatat. Untuk meningkatkan kedalaman anestesi, duragesic (3ug/kg) diberikan. Denyut jantung dan tekanan darah terus meningkat dan disertai dengan sering kontraksi ventrikel prematur.

What should be considered in the differential diagnosis of this patients cardiovascular changes ? Apa yang harus dipertimbangkan dalam diferensial diagnosis pasien ini perubahan kardiovaskularnya ? The combination of tachycardia and hypertension during general anesthesia should always alert the anesthesiologist to the possibility of hypercapnia or hypoxia, both of which produce signs of increased sympathetic activity. These life threatening conditions should be quickly and immediately ruled out by end tidal CO2 monitoring. Pulse oximetry, or arterial blood gas analysis. Kombinasi dari takikardia dan hipertensi selama anestesi umum harus selalu waspada para anestesi untuk kemungkinan hypercapnia atau hipoksia, kedua yang menghasilkan simpatik tanda-tanda dari peningkatan aktivitas. Ini kondisi yang mengancam kehidupan harus cepat dan segera memerintah keluar oleh ujung tideal pemantau co2. Nadi oximetry, atau darah arteri gas analisi A common cause of intraoperative tachycardia and hypertension is an adequate level of anesthesia. Normally, this confirmed by movement. If the patient is paralyzed, however, there are few reliable indicators of light anesthesia. The lack of a response to a dose an opioid should alert the anesthesiologist to the possibility of other, perhaps more serious, causes. Malignant hyperthermia is rare but must be considered in cases of unexplained tachycardia, especially if accompanied by premature contractions (see Case Discussion in Chapter 44). Certain drugs used in anesthesia (eg, pancuronium, ketamine, ephedrine) stimulate the sympathetic nervous system and can produce or exacerbate tachycardia and hypertension. Diabetic patients who become hypoglycemic from administration of insulin or long-acting oral hypoglycemic agents can have similar cardiovascular changes. Other endocrine abnormalities (eg, pheochromocytoma, thyroid storm, carcinoid) should also be considered.

Could any of these problems be related to an equipment malfunction ? Briefly shifting the anesthetic gas being delivered to the patient is an easy if not aesthetic method of confirming the presence of a volatile agent. Nitrous oxide is more difficult to detect without sophisticated equipment, but an oxygen analyzer should provide a clue. A misconnection of the ventilation could result in hypoxia or hypercapnia. In addition, a malfunctioning unidirectional valve will increase circuit dead space and allow rebreathing of expired CO2. Soda lime exhaustion could also lead to rebreathing in the presence of a low fresh gas flow. Rebreathing of CO2 can be detected during the inspiratory phase on a capnograph (see chapter 6). If breathing appears to be due to an equipment malfunction, the patient should be disconnected from the anesthesia machine and ventilated with a resuscitation bag until repairs are possible. How are unidirectional valves checked before anesthesia machine is used ? The incidence of incompetent unidirectional valves has been found to approach 15%. There is a quick procedure for fasting the function of these valves : 1. First, disconnect the breathing tubes from anesthesia machine, close the APL valve, and turn off all gas flow. 2. To check inspiratory valve function, connect one of a section of breathing tube to the inhalation outlet and occlude the exhalation outlet. If a breathing bag that is connected to its usual site fills when air is blown into the breathing tube, the inspiratory valve is incompetent. (figure 3-`12A) 3. To check expiratory valve function , connect one end of a section of breathing tube to the usual breathing bag site and cover the inhalation outlet. If a breathing bag connected to the exhalation outlet fills when air is blown into the breathing tube, the expiratory valves is in competent (figure 3-12B).