3 Obat Sedasi Dan Analgesia-Prof Munar - Lubis PDF
3 Obat Sedasi Dan Analgesia-Prof Munar - Lubis PDF
Palembang 2014
pgd_idai@googlegroups.com
PENDAHULUAN
PEDIATRI GAWAT DARURAT
2
PENDAHULUAN
PEDIATRI GAWAT DARURAT
Perlu
Sedasi
Analgesia
4
ANALGESIA
PEDIATRI GAWAT DARURAT
5
INDIKASI
PEDIATRI GAWAT DARURAT
• Penghilang nyeri
• Ventilasi mekanik
• Kecemasan
• Kebutuhan akan tidur yang cukup
• Amnesia
6
KONTRA INDIKASI
PEDIATRI GAWAT DARURAT
Absolut
Relatif
7
STRATEGI PEMBERIAN
PEDIATRI GAWAT DARURAT
Keadaan umum
Jalan nafas
Kardiovaskular
Evaluasi Prasedasi
Pernafasan
Gastrointestinal
Hepar/ginjal
8
PEMBERIAN
PEDIATRI GAWAT DARURAT
Jalur oral/rektum
Jalur intravena/intramuskuler
9
TUJUAN SEDASI
PEDIATRI GAWAT DARURAT
10
TINGKAT SEDASI
PEDIATRI GAWAT DARURAT
Ringan (anxiolysis)
11
KOMPLIKASI
PEDIATRI GAWAT DARURAT
• Aspirasi
• Hipoventilasi
• Apnea
• Obstruksi jalan nafas
• Depresi kardiopulmonal
12
OBAT-OBAT SEDASI
PEDIATRI GAWAT DARURAT
Golongan benzodiazepine
ü Midazolam
ü Diazepam
ü Lorazepam
Golongan barbiturat
ü Thiopental
Golongan lain
ü Propofol
ü Chloral hydrate
13
MIDAZOLAM
PEDIATRI GAWAT DARURAT
14
MIDAZOLAM
PEDIATRI GAWAT DARURAT
• Kombinasi benzodiazepine/
opioid: risiko apnu dan hipoksia
↑
15
MIDAZOLAM
PEDIATRI GAWAT DARURAT
16
DIAZEPAM
PEDIATRI GAWAT DARURAT
17
DIAZEPAM
PEDIATRI GAWAT DARURAT
18
LORAZEPAM
PEDIATRI GAWAT DARURAT
19
GOLONGAN BARBITURAT
PEDIATRI GAWAT DARURAT
20
THIOPENTAL
PEDIATRI GAWAT DARURAT
• Onset cepat
• Untuk tindakan intubasi pasien TIK↑
21
PROPOFOL
PEDIATRI GAWAT DARURAT
22
CHLORAL HYDARATE
PEDIATRI GAWAT DARURAT
23
KETAMIN
PEDIATRI GAWAT DARURAT
• Takikardia
• Hipertensi
• Efek bronkodilator
• Nightmares
• Kombinasi benzodiazepin
menimbulkan amnesia
24
Drug
Dose
(mg/
kg)
Onset
Indica6on
Comments
(mnts)
Midazolam
OR,
IR:
0.5-‐0.75
2-‐3
Short
procedure
Tolerance
and
withdrawal
syndrome
IN,
SL:
0.2-‐0.5
Prolonged
MV
Lower
dose
in
renal
and
liver
failure
IV:
0.2
Hypotension
in
bolus
dose
INF:
1-‐10
µg/kg/min
Lorazepam
IV:
Loading
dose:
0.02-‐0.06
5-‐20
Prolonged
MV
Limited
clinical
experience
INF:
0.02-‐0.1
mg/kg/h
Withdrawal
syndrome
Propofol
IV:
Loading
dose:
2-‐3
1-‐2
Short
procedure
Propofol
infusion
syndrome
INF:
1-‐4
mg/kg/h
Short
MV
Hypertriglyceridemia
Ketamine
IM:
3-‐5
0.5-‐1
Short
procedures
Releases
endogenous
IV:
Loading
dose:
1-‐3
IntubaXon
in
acute
cathecholamines
INF:
0.7-‐3
mg/kg/h
severe
asthma
Not
recommended
in
ICH
Etomidate
IV:
0.2-‐0.3
Immediate
IntubaXon
with
Suprarenal
failure
hemodynamic
findings
Thiopental
IV:
Loading
dose:
3-‐5
Immediate
IntubaXon
in
ICH
NegaXve
inotrope
INF:
1-‐5
mg/kg/h
VasodilataXon
Dexmedetomidine
IV:
Loading
dose:
1
µg/kg
2-‐5
Short
procedures
Underdocumented
in
children
INF:
0.2-‐0.75
µg/kg/h
Short
MV
Without
respiratory
depression
Clonidine
OR,
IV:
1-‐4
µg/kg/6-‐8
h
5-‐20
Prolonged
MV
Hypertension
in
case
of
sudden
INF:
0.1-‐0.2
µg/kg/h
Withdrawal
withdrawal
syndrome
Without
respiratory
depression
Chloral
hydrate
OR,
IR:
25-‐75
mg/kg
5-‐20
Short
procedures
AgitaXon
and
late
disinhibiXon
Chlorpromacine
OR,
IR:
0.5-‐1.5
every
6-‐8
h
AgitaXon-‐delirium
Extrapiramidal
reacXons
IV:
0.5
mg/kg
25
ANALGESIA
PEDIATRI GAWAT DARURAT
Nyeri ringan:
ü Aspirin
ü Acetaminophen
ü Ibuprofen
ü Kodein
Nyeri sedang/berat:
ü Opioid
ü NSAIDs
26
ANALGESIA
PEDIATRI GAWAT DARURAT
Golongan opioid
27
ACETAMINOPHEN
PEDIATRI GAWAT DARURAT
28
NSAIDs
PEDIATRI GAWAT DARURAT
29
KETOROLAC
PEDIATRI GAWAT DARURAT
30
MORPHINE PEDIATRI GAWAT DARURAT
31
PETHIDINE
(MEPERIDINE) PEDIATRI GAWAT DARURAT
• Lebih efektif
• Onset lebih cepat dibanding morphine
• Tremor, disorientasi dan kejang
32
FENTANYL PEDIATRI GAWAT DARURAT
• Opioid sintetis
• Larut dalam lemak
• Onset kerja cepat
• Durasi singkat
• Efek toleransi
33
FENTANYL PEDIATRI GAWAT DARURAT
• Efek toleransi
• Akumulasi pada jaringan
lemak
• Depresi pernafasan
• Tanpa pelepasan histamin
• Stabilitas hemodinamik
34
REMIFENTANYL PEDIATRI GAWAT DARURAT
• Derivat fentanyl
• Efek sedasi
• Tanpa risiko akumulasi
• Toleransi
• Hipotensi
• Mahal
35
KETAMINE PEDIATRI GAWAT DARURAT
36
METAMIZOLE PEDIATRI GAWAT DARURAT
37
TRAMADOL PEDIATRI GAWAT DARURAT
• Kerja sentral
• Ketergantungan
• Hindari pada pasien
kejang, trauma kepala,
ketergantungan opioid
38
Drug
Dose
(mg/
kg)
Onset
(minutes)
Indica6on
Comments
Morphine
IV:
0.1-‐0.2
mg/kg/4-‐6h
20
SedaXon
and
analgesia
in
MV
Lower
dose
in
renal
or
liver
INF:
10-‐40
µg/kg/h
Acute
or
chronic
pain
failure
Pulmonary
edema
Releases
histamine
Nausea
and
vomiXng
Fentanyl
IV:
1-‐3
µg/kg
1-‐2
Short
painful
procedures
Prolonged
clearance
INF:
1-‐10
µg/kg/h
Same
as
morphine
Beger
hemodynamic
tolerance
Thoracic
rigidity
aher
quick
administraXon
Remifentanil
IV:
1
µg/kg
1
SedaXon
and
analgesia
in
MV
immediate
clearance
INF:
analgesic:
0.5-‐6
µg/kg/h
Immediate
postoperaXve
period
Beger
hemodynamic
SedaXon:
6-‐12
µg/kg/h
tolerance
Thoracic
rigidity
aher
quick
administraXon
Alfentanil
IV:
15-‐25
µg/kg
in
60
min
1-‐2
Short
painful
procedures
High-‐priced
INF:
0.4-‐2
µg/kg/min
Not
to
be
used
in
liver
failure
Methadone
IV:
0.1-‐0.2
mg/kg/h
45
Treatment
of
withdrawal
syndrome
Nausea
and
vomiXng
Chronic
pain
Tramadol
IV:
1-‐2
mg/kg/4-‐6
h
10
Acute
pain
Good
hemodynamic
INF:
0.2-‐0.4
mg//kg/h
tolerance
SEBELUM
SETELAH SELAMA
40
PEMANTAUAN PEDIATRI GAWAT DARURAT
S suction
O oxygen
A airway
P pharmacy
M monitors
E equipment
41
Clinical
Situa6on
Indica6ons
Procedural
Suggested
Seda6on
Strategist
Requirements
Noninvasive
procedures
Computed
tomography
MoXon
control
ComforXng
alone
Echocardiography
Chloral
hydrate
PO
(in
paXents
<
3
yr
of
age)
Electroencephalography
Pentobarbital
IV
or
IM
MagneXc
resonance
imaging
Methohexital
PR
Ultrasonography
Midazolam
IV
Procedures
associated
with
Dental
procedures
SedaXon
ComforXng
and
topical
or
local
analgesia
low
level
of
pain
and
high
Flexible
fiberopXc
laryngoscopy
Anxiolysis
Midazolam
PO,
IN,
PR,
or
IV
anxiety
Foreign-‐body
removal,
simple
MoXon
control
Nitrous
oxide
Intravenous
cannulaXon
LaceraXon
repair,
simple
Lumbar
puncture
Ocular
irrigaXon
Phlebotomy
Slit-‐lamp
examinaXon
Procedures
associated
with
Abscess
incision
and
drainage
SedaXon
Midazolam
and
fentanyl
IV
high
level
of
pain,
high
Arthrocentesis
Anxiolysis
ketamine
IM
or
IV
anxiety,
or
both
Bone
marrow
aspiraXon
Analgesia
Burn
debridement
Amnesia
Cardiac
catheterizaXon
MoXon
control
Cardioversion
Central
catheter
placement
Endoscopy
Foreign-‐body
removal,
complicated
Fracture
or
dislocaXon
reducXon
Hernia
reducXon
IntervenXonal-‐radiology
procedures
LaceraXon
repair,
complex
Paracentesis
Paraphimosis
reducXon
Sexual-‐assault
examinaXon
Thoracentesis
42
Thoracostomy-‐tube
placement
KESIMPULAN
PEDIATRI GAWAT DARURAT
43
PEDIATRI GAWAT DARURAT
TERIMA KASIH
44