PENYULIT PASCA BEDAH & PENANGANANNYA

PERNAFASAN

OBSTRUKSI JALAN NAFAS (partial, total)

pangkal lidah jatuh muntahan, aspirasi

ATASI DENGAN :
Head tilt, Chin lift Jaw thrust triple air-way manuver suctioning

HIPOVENTILASI (SISA MUSCLE RELAXANT)

atasi dengan : bebaskan jalan nafas nafas bantu reversal (Prostigmin + Sulfas Atropin)

SIRKULASI

Pantau dengan nadi, perfusi perifer, Hb, Ht, CVP Penyulit yang sering terjadi :
HIPOTENSI SHOCK ARRYTHMIA

ATASI DENGAN :
MONITORING KETAT TERAPI CAIRAN k/p TRANSFUSI ANTI-ARRYTHMIA, ELEKTROLIT (K+) PINDAH PASIEN BILA SUDAH STABIL BAIK

MUNTAH (PONV) RISIKO ASPIRASI

HIPOXIA SELAMA ANESTESIA ANESTESI TERLALU DALAM RANGSANG CTZ (ETHER) TEKANAN LAMBUNG YANG TINGGI NARKOTIK ATASI DENGAN : DHBP 2.5-5. mg/iv Ondansetron 4 mg/iv ( untuk pencegahan berikan sebagai premedikasi) perut kembung NGT

Droperidol
Dose 0.25 0.5-0.75 1.0-1.25 Nausea 0-6 hr 0-24 hr 0-6 hr 0-24 hr 0-6 hr 0-24 hr NNT 5.2 4.8 11 6.1 6.8 95% CI 3.3-12.6 3.0-12 6.9-25 4.5-9.4 5.2-9.7

Prevention of vomiting requires larger doses, NNT 8-10.

Henzi I. Can J Anesth 2000;47(6):537-551.

PONV The Big Little Problem

Nausea and vomiting are among the most distressing aspects of the postoperative experience Incidence ranges between 20-50% Increased morbidity with PONV Prolonged recovery time Leads to hospitalization of ambulatory patients

Increases institutional costs

Disrupts the management of outpatient surgical procedures
Kapur PA. Anesth Analg. 1991;73:243-245. Palazzo MG et al. Can Anaesth Soc 1984.

Watcha MF et al. Anesthesiology 1992; 77(1): 162-184.

Overall Incidence of PONV

Investigator Waters et al. Bellville et al Adriani J et al. Rowley et al. Year 1936 1959 1961 1982 Patients 10,000 748 2,230 1,183 Vomiting (%) 41% 19% 23% 43%

Patel et al. Forrest et al. Karlsson et al. Cohen et al.

1989 1990 1990 1990

9,910 16,000 485 29,220

9% 18-25% 25% 25%

Watcha MF et al. Anesthesiology 1992; 77(1): 162-184.

Medical Consequences of PONV

Patient discomfort (mild to severe) Patient dissatisfaction Increased cost

Personnel, supplies, drugs Unplanned admissions

Increased intraocular and intracranial pressures Increased blood pressure and heart rate Wound dehiscence and bleeding Dehydration and electrolyte imbalance Interruption of oral drugs, nutrition, and fluids Pulmonary aspiration
Palazzo MG et al. Can Anaesth Soc 1984; ASHP Am J Health Syst Pharm 1999; Watcha MF et al. Anesthesiology 1992; 77(1): 162-184.

Receptors

Major Risk Factors for PONV

Patient characteristics
Age Gender Anxiety Weight History of PONV/motion sickness Concomitant disease Non-smoking history
Watcha MF et al. Anesthesiology 1992; 77(1): 162-184. Lerman. Br J Anaesthesia. 1992; 69 (suppl 1): 24S 32S. Bellville et al. Anesthesiology. 1960; 21(2): 186-193.

Major Risk Factors for PONV

Type of surgery

Gynecologic Ophthalmic Ear, nose, and throat Laparoscopic Intraabdominal Breast Testicular Shoulder Dental/oral Lengthy procedure
Watcha MF et al. Anesthesiology 1992; 77(1): 162-184. Lerman. Br J Anaesthesia. 1992; 69 (suppl 1): 24S 32S. Bellville et al. Anesthesiology. 1960; 21(2): 186-193.

Major Risk Factors for PONV

Type of anesthesia
Opioids Nitrous oxide Etomidate Methohexital Barbiturates Neuromuscular blocking drugs Anticholinesterases Potent volatile anesthetic gases
Watcha MF et al. Anesthesiology 1992; 77(1): 162-184. Lerman. Br J Anaesthesia. 1992; 69 (suppl 1): 24S 32S. Bellville et al. Anesthesiology. 1960; 21(2): 186-193.

Major Risk Factors for PONV

Care in the PACU

Pain Opioids Movement Dehydration Orthostatic hypotension Sedation Oral intake
Watcha MF et al. Anesthesiology 1992; 77(1): 162-184. Lerman. Br J Anaesthesia. 1992; 69 (suppl 1): 24S 32S. Bellville et al. Anesthesiology. 1960; 21(2): 186-193.

Risk Factors
Volatile Anesthetics
Risk Factors Volatile anesthetics isoflurane sevoflurane enflurane
* Compared to propofol

Anesthetic Related

OR* 3.41 2.78 3.11

CI 2.18; 5.37 1.79; 4.31 1.98; 4.88

Apfel et al. BJA 2002;88:659-668

Antiemetic Agents
5-HT3 Receptor Antagonists Dolasetron Granisetron Ondansetron NK-1 Inhibitors Aprepitant Corticosteroids Dexamethasone Methylprednisolone Substituted Benzamides Metoclopramide Cannabinoids Dronabinol Nabilone NK-1 Inhibitors Benzodiazepines Lorazepam Alprazolam Butyrophenones Droperidol Haloperidol Domperidone Phenothiazines Prochlorperazine Chlorpromazine Thiethylperazine Maleate Promethazine Hydrochloride Antihistamines

ASHP Guidelines. Am J Health-Syst Pharm 1999;56:729

Receptor Site Affinity of Antiemetic Agents

Pharmacologic group/drug Phenothiazines Fluphenazine Chlorpromazine Prochlarperazine Butyrophenones Droperidol Haloperidol Domperidone Antihistamines Diphenhydramine Promethazine Anticholinergic: scopolamine Benzamides Metoclopramide 5-HT3 Receptor Antagonists Ondanensetron Granisetron Tricyclinic Antidepressants Amitriptyline Nartriptyline Dopamine (D2) ++++ ++++ ++++ ++++ ++++ ++++ + ++ + +++ Muscarinic Cholinergic + ++ Histaminic ++ ++++ Serotonin (5-HT3) +

+ +

+ -

++ ++ ++++ -

++++ ++++ + + -

++ ++++ ++++

+++ +++

+++ ++

++++ +++

Number of positive signs (+) indicates degree of activity; negative sign (-) indicates no activity. Adapted from Watcha and White. Anesthesiology. 1992;77(1):162-184

5-HT3 Receptor Selectivity

Serotonergic receptors of the 5-HT3 subtype seem to have a crucial role in the systems mediating emesis Ondansetron has a greater affinity for this receptor than any other Avoids the acute dystonic reactions associated with dopamine blockade

Prevention of PONV:
Metoclopramide

II-A

Henzi I, Walder B, and Tramer, MR. Metoclopramide in the prevention of postoperative nausea and vomiting: a quantitative systematic review of randomized, placebo-controlled studies. BJA 1999;83:761-771

In summary, metoclopramide, although used as an antiemetic for almost 40 years in the prevention of PONV, has no clinically relevant antiemetic effect . . . it is very likely that the doses used in daily clinical practice are too low.

Metoclopramide
Metoclopramide in the prevention ofpostoperative nausea and vomiting: a quantitative systematic review of randomized, placebo-controlled studies.

Conclusion:

No benefit from metoclopramide as a prophylactic antiemetic

Tramer MR Br J Anaesth. 1999 Nov;83(5):761-71

Dimenhydrinate

Dimenhydrinate for prophylaxis of postoperative nausea and vomiting: a meta-analysis of randomized controlled trials.
Kranke P, Morin AM, Roewer N, Eberhart LH. Acta Anaesthesiol Scand 2002 Mar;46(3):238-44

Yes . but at 1 2 mg/kg

sleepy

Dimenhydrinate
Antiemetic

efficacy of prophylactic dimenhydrinate (Dramamine) vs ondansetron (Zofran): a randomized, prospective trial inpatients undergoing laparoscopic cholecystectomy.
Kothari Surg

SN, Boyd WC, Bottcher ML, Lambert PJ. Endosc 2000 Oct;14(10):926-9

Ondansetron

4 mg Dimenhydrinate 50 mg

45 40 35 30 25 20 15 10 5 0 PONV

Dimenhydrinate Ondansetron

Droperidol
Dose 0.25 0.5-0.75 1.0-1.25 Nausea 0-6 hr 0-24 hr 0-6 hr 0-24 hr 0-6 hr 0-24 hr NNT 5.2 4.8 11 6.1 6.8 95% CI 3.3-12.6 3.0-12 6.9-25 4.5-9.4 5.2-9.7

Prevention of vomiting requires larger doses, NNT 8-10.

Henzi I. Can J Anesth 2000;47(6):537-551.

5-HT3 Receptor Antagonists

5-HT3 Receptor Antagonists

Anzemet (dolasetron mesylate) Zofran (ondansetron) Kytril (granisetron)

Block 5-HT3 receptors in the CNS and periphery (i.e., in the GI mucosa), preventing the binding of serotonin (5HT) to the 5-HT3 receptors Activity is based on receptor binding, not kinetic parameters; therefore, once 5-HT3 receptors are saturated, higher doses do not increase effect
Duration of action is independent of life
Gralla et al. J Clin Oncol 1999;17:2971 ASHP Guidelines. Am J Health-Syst Pharm 1999;56:729

Ondansetron Prophylaxis
Dose 1 mg 4 mg 8 mg Event 0-6 hr 0-24 hr 0-6 hr 0-24 hr 0-6 hr 0-24 hr NNT 9.0 21 5.6 6.4 6.4 5.0 95% CI 5.3-30 9.1- ? 4.4-7.5 5.3-7.9 4.7-10 4.0-6.7

Tramer MR. Anesthesiology 1997;87(6):1277-89.

Ondansetron

Prophylactic ondansetron for post-operative emesis: meta-analysis of its effectiveness in patients with and
without a previous history of motion sickness

Eur J Anaesthesiol 1999 Aug;16(8):556-64

Twelve trials involving 2122 patients The dose of 4 mg ondansetron was 71.5% more effective in patients with a positive Hx of motion sickness

Dexamethasone
Dose 8-10 mg Vomiting 0-6 hr 0-24 hr NNT 3.6 4.3 95% CI 2.3-8.0 2.6-12.0

Henzi I. Anesth Analg 2000;90:186-94

Synergism with 5 HT3 antagonists

Lopez-Olaondo L. BJA 1996;76(6):835-40 Fujii Y. Can J Anesth 1995;42(5):387-90

Side effect free

Bluming AZ. J Clin Oncol 1986;4:21-3 IGAR.NEJM 2000;342(21):1554-9

Dexamethasone

The effect of dose of dexamethasone for antiemesis after major gynecological surgery

Anesth Analg 1999 Nov;89(5):1316-8

30 pts per group Dex 0 to 10 mg per pt

80 60 40 20 0 Placebo D1.25

PONV

D2.5

D5

D10

Oxygen
Ondansetron is no more effective than supplemental intraoperative oxygen for prevention of postoperative nausea and vomiting.
Goll V, Akca O, Greif R, Freitag H, Arkilic CF, Scheck T, Zoeggeler A, Kurz A, Krieger G, Lenhardt R, Sessler DI. Anesth Analg. 2001 Aug;93(2):518-9.

60 40 20 0

PONV

30% 30% 80% + Ond

Avoid Hypoxia and Hypotension

Prevention of PONV:
Combination Therapy
Which Combination?
5-HT3 + drop Event Early Nausea Vomiting Late Nausea
N Rate

5-HT3 + dex
N Rate P-value OR

138 318

17% 1%

260 419

11% 1%

0.12 1.00

1.6 1.0

358 443

27% 9%

623 813

21%* 9%

0.02 1.00

1.4 0.9

Vomiting

Ashraf et al. Anesthesiology 2001; 95:A-41

Evidence Rating for Antiemetics

Strength of Evidence Prevention
Ondansetron 4 mg
Ondansetron 1 mg Dolasetron 12.5 mg Granisetron 1 mg Droperidol Dexamethasone Dimenhydrinate Metoclopramide

Treatment Consequences* Prevention

5.5 6.5
4.0 5.0 3.1 4.2 4.3 5.0 4.3 7.1 4.8 8.0 ?

Treatment
I-A
I-A I-A I-A V-B V-B

Treatment
3.2 3.9
3.8 4.8 3.6 4.2 3.1 3.8 ? ? ? *NNT

I-A
I-A I-A I-A II-A II-A -

PROLONGED UNCONSCIOUSNESS

KERJA OBAT YANG MEMANJANG

DOSIS OBAT YANG BERLEBIH METABOLISME YANG MENURUN EKSKRESI OBAT YANG LAMBAT

GANGGUAN METABOLISME DI OTAK

HIPERCAPNEA SHOCK YANG LAMA HIPOGLIKEMIA NARKOTIK HIPONATREMIA

STROKE
DURANTE OP.

TEKANAN

DARAH ATASI DENGAN :

MONITORING KETAT ATASI GANGGUAN SPESIFIK k/p RAWAT ICU