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PERSIAPAN ANESTESI PADA

OPERASI EMERGENSI BEDAH


PERUT
KULIAH PAKAR MODUL BENCANA PERUT
Dr. dr. Diana C Lalenoh, M.Kes, SpAnKNA, KAO
Departemen Anestesiologi dan Terapi Intensif
Divisi Neuroanesthesiology and Critical CareDivisi Obstetric Anesthesia
Fakultas Kedokteran UNSRAT/RSU.Prof.RD.Kandou
Manado
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TUJUAN INSTRUKSIONAL
Mengetahui permasalahan preoperatif
pasien operasi bedah perut emergensi.
Mengetahui permsalahan intraoperatif
pasien operasi bedah perut emergensi.
Mengetahui permasalahan pascaoperatif
pasien bedah perut emergensi
Mengetahui penatalaksanaan preoperatif
pasien operasi bedah perut emergensi
Mengetahui penatalaksanaan intraoperatif
pasien operasi bedah perut emergensi
Mengetahui penatalasanaan pascaopepratif
pasien bedah perut emergensi
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PENYAKIT /DIAGNOSA PASIEN YANG


AKAN MENJALANI BEDAH PERUT
EMERGENSI:

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Appendicitis

Peritonitis

Obstruksi

Diverticulitis

Rupture Aneurisma Abdomen

Acute Abdomen in Pregnancy: Solutio placenta, kehamilan


ektopik terganggu, kehamilan disertai torsi kista, hamil
dengan appendicitis akut.

Perforasi Gaster

Invaginasi

dll

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PROBLEM PREOPERATIF PASIEN YANG


AKAN MENJALANI BEDAH PERUT
EMERGENSI
Fluid deficit that may require correction prior to
surgery how long the patient has been without normal
oral fluid intake and whether or not he has been
exposed to extenuating circumstances or other sources
of fluid loss such as vomiting.
The time course and severity may result in
dehydration, increases in plasma osmolality. An
additional consideration is the lack of oral intake after
midnight experienced by most colorectal patients.
Bleeding (blunt & sharp abdominal trauma, ectopic
pregnancy,placenta praevia) etc.
Shock
SIRS; Septic
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T
N
E NS
G R
R
E CE
M
E ON
C

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EMERGENCY PRESENTATIONS
Unstable Vital Signs:
Fever > 102 F
Hypotension Shock?
Decreased urinary output
Incidence of hypertension
Tachycardia >120 bpm X 4 hours
Tachypnea
Hypoxia
A state requiring pharmacologic or mechanical support to maintain a normal
blood pressure or adequate cardiac output
Abdominal pain or colic
Nausea + Emesis
Full of gastric contents Need NGT?
Increased risk for aspiration due to small volume of stomach
Leaks and Sepsis

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Out of range clinical


measurements

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Perfusion Failure
(Shock)
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PRE-OPERATIVE ASSESSMENT
Conventional Assessments of fitness for anesthesia
and surgery cannot be followed
Rapid assessment and intervention to stabilise the
patient

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IN ADMITTING A PATIENT FOR SURGERY THE


FOLLOWING QUESTIONS SHOULD BE
ANSWERED:

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Is the diagnosis firmly established?


Has the disease and the procedure been
adequately explained
Is there a need for further assessments to stage
the disease or to deal with other diseases?
How risky is the operation?
Are corrections of blood volume, nutritional
status or electrolyte imbalances needed?
What are the prophylactic measures needed?
What are the particular preparations required
prior or during the surgery ?
Is a cross match needed?
What is the likely course immediately post-op?
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THE PREOPERATIVE ASSESSMENT


History

CVS ( MI), RS, Smoking, BP, DM, Bleeding diathesis, CVA.


Drugs, Allergies and Alcohol.
Reactions to Anaesthesia.

Examination

CVS, RS, nutritional status, mental status.


Neck, Jaw and presence of dentures.

Investigations

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Routine
Special

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THE DIAGNOSIS
THIS CAN BE ESTABLISHED BY A COMBINATION:
The Patients Document:

The Chronology of OPD notes.


The Chronology of correspondence or consultations.
Report of lab., radiological & histopathological
investigations.

The Patient:

Complete history and physical examinations


Note any changes in symptoms or signs.

The family or relatives

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Complete any missing links.


Ask for any voluntary information.

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RISK ASSESSMENT
IMPORTANCE & AIMS:

Patient selection:
Finding the balance between benefit vs risk

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Provides a guide to the degree of support


required in post-op period.

Provides a data base for risk adjusted


outcomes.

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RISK ASSESSMENT

RISK FACTORS I

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Age
Cardiovascular
Respiratory diseases
Smoking
GI: malnutrition, Jaundice & Adhesions
Renal dysfunction
Haematological disorders
Obesity
Diabetes
Surgeon and Operative severity
Emergency
Drugs
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RISK FACTORS II
Age

BMI> 30

Distinction must be
made between
physiological state and
chronological age.

Increased risk in:

Are less mobile,


intercurrent disease,
less physiological
reserve.

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More likely to have


wound infection.
In 65 CVA 1%, In 80 CVA
3%

DVT,
Wound infections &
Dehiscence
Respiratory complications &
sleep apnoea.
Intercurrent diseases.
Operative difficulty

Relative risk of mortality


3-5

Advise controlled wt
reduction

Arrange ICU post-op

IVF & Narcotic analgesia.

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Caution with regards to:

Obesity

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RISK FACTORS III


CARDIOVASCULAR DISEASES
Predictors: CPCEN
Major:

Unstable coronary
syndrome.

Decompensated CCF.

Significant Arrhythmias

Severe valvular disease


Intermediate:

Mild angina

PMH MI

Compensated CCF

DM
Minor
Age, abnormal ECG..etc

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Action:

Evaluation:
Clinical, Specialist opinion, ECG,
Stress ECG, CXR, Echo
..others

IF Major:
Cancel unless life threatening
Consider CABG prior to elective
surgery.

If intermediate:
Objective performance.

Hypertension:
Indicates CAD
More likely to develop
hypotension during surgery.
Control prior to surgery.

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RISK FACTORS IV
RESPIRATORY DISEASES
Estimate function:

Clinical and Specialist opinion.


ABG
CXR
Spirometry: FEV1/FVC, PEFR

Chest infection:

Postpone for 2 weeks


Antibiotics & Physio.

Leis with specialist


Reschedule surgery.

Plan to transfer to ICU for


mechanical ventilation
pending:
Lung function, type & duration
of surgery.

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10 cigr.=6 fold increase in postop respiratory complications.

Respiratory and CVS effects

Carbon monoxide has higher


affinity for O2 than Hb.

Nicotine increases heart rate


and BP.

Hypersecretion of thick mucus

Immunosuppressive

Stop 3 months= improve


pulmonary functions

Stop 1-2 days= Decreases CO


levels.

COAD

Smoking

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RISK FACTORS V
GASTRO INTESTINAL DISEASES
Malnutrition

Jaundice poses a risk for:

Loss o15-20% of body wt is


associated with severe
impairment of physiological
function

Sepsis

Clotting disorders

Renal failure

No evidence of benefit of
preop feeding.

Liver failure

Fluid and electrolyte


abnormalities

Drug metabolism

Adhesions:

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Higher risk of bowel injury


and subsequent fistula
formation

Management:

Vit k & FFP

Adequate hydration and


diuretics & oral Lactulose

Antibiotics

Nutrition.

Longer duration of surgery

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RISK FACTORS V
DIABETES
Interest to the surgeon:

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Patients are more sensitive


to protein depletion, U&E&
glucose imbalance.
Surgical stress can
precipitate DKA.
DKA is a cause of acute
abdomen
Decreased phagocytosis,
neutrophil activation and
antibody production
Small vessel disease
Peripheral vascular disease
Peripheral neuropathy
Autonomic neuropathy
Recognition of
hypo/Hyperglycaemic attacks

NSC

Minor LA

4 hourly close
Type II
observations
GA
Omit dose in mane.
Management:
Either lowOpinion
dose infusion
Specialist
required
or fixed dose insulin
GIK
G: 500 ml 10% dextrose
I : Insulin sliding scale
K : Potassium 10 mmol
Continue till first light
meal

Type I GA

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RISK FACTORS V
RENAL & HAEMATOLOGICAL DISORDERS
Renal:

Identify the cause:


Pre-renal, eg: cardiac,
hypovolaemia
Renal, eg: acute tubular
necrosis( drug induces)
Post renal, eg: obstructive
uropathy.
Identify pt for renal
dialysis.

Check K levels

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Accurate fluid balance


Look for signs of fluid
overload.
Do not misinterpret poly
ureamic phase

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Anaemia

Correction 1 week pre-op


Correction day preop is undesirable
Haemodilution

Thrombocytopaenia
In splenomealy, Platelets must be
transfused immediately preop and on
ligating the arterial supply.

Sickle cell disease

Crisis caused by : dehydration,


infection, hypoxia, hypothermia.
Jaundice & anaemia
Splenic infarctions: sepsis
Prevention: Warm, well hydrated, well
analogised
Consider exchange transfusion in SS

Correction of coagulopaties

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RISK FACTORS
OPERATIVE SEVERITY
Minor:

Procedures under LA, Uncomplicated hernia

Moderate:

Appendicectomy, Cholecystectomy
TURP

Major:

Laparotomy, Bowel resection

Major+:

AP resection, hepatioco-pancreatic surgery


Emergency surgery.

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RISK FACTORS
ASA ( AMERICAN SOCIETY OF
ANAESTHESIOLOGIST)
Physical Status

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Class

Normal healthy individual

Mild-moderate systemic disease eg: DM,


BP

Severe systemic disease, NOT


incapacitating eg: CCF with limited
exercise tolerance

Incapacitating disease, constant threat to


life. with or with out surgery eg:
Uncontrolled angina

Moribund pt not expected to live, surgery


is the last resort.

Patient requiring emergency surgery.

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ANESTHETIC MANAGEMENT
Preoperative Assessment
Laboratory Investigations
Monitoring
Induction
Maintenance
Recovery / Shifting to ICU

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PRIMARY SURVEY

A
B
C
D
E

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ASSESS

DIAGNO
SE

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TREAT

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Airway
Breathing
Circulation
Disability (Neurology)

Assess

Diagno
se

Treat

If not assessed, diagnosed and treated immediately you


may not have a live patient on the operating table
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AIRWAY ASSESSMENT
Assessment of patency and anatomy
Difficult Laryngoscopy with risk of failed intubation

Beware of
C- Spine Injury
Full Stomach

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DIFFICULT AIRWAY - LEMON

L
E
M
O
N

ook

Surgery

valuate
allampatti

Hematoma
Obesity
Radiation

bstruction

Tumor

eck Mobility

Low Threshold for Surgical Airway


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Assess neck for access ( SHORT)

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TREAT
Simple airway maneuversSimple airway adjuncts-

Jaw Thrust, chin lift

oral, nasal airways

Endotracheal Intubation

Gum elastic bougie

Surgical Access - Cricothyroidotomy

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BREATHING WITH
VENTILATORY SUPPORT
Respiratory rate Bradypnoea, tachypnoea
Breath sounds- 5 life threatening conditions
Oxygen saturation very useful if signals are picked up

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ANTICIPATED PROBLEMS
NEEDING INTERVENTION
1.

Tension pneumothorax

2.

Massive Hemothorax

3.

Open Pneumothorax

4.

Flail Chest

5.

Cardiac Tamponade

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Treatment Intercostal drain insertion


Sealing of the wound
Intubation & ventilation

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CIRCULATION
Assessment of circulatory state
Pulse Rate, Volume, character,
Cold extremities
Level of Consciousness
Blood Pressure Potentially late sign

Shock Index

Heart Rate

<0.7

Systolic Pressure
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Higher the ratio poorer
the prognosis
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DIAGNOSE-5 PLACES TO LOOK FOR


External
Long bones
Chest x ray chest
Abdomen - FAST
Pelvis and Retro peritoneum

Shock in a multiply injured patient is


hemorrhagic
shock unless proved otherwise
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TREAT- MANAGEMENT OF SHOCK


Stop Bleeding
Surgical intervention /
interventional Radiology
2 large bore canulae peripheral send for group, cross
matching - lab
2 litres of warm crystalloids ???
Exsanguinating hemorrhage o -ve packed cells

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PREOPERATIVE HYPOVOLEMIA
(NON TRAUMATIC/ NON
BLEEDING CASES)
Based on those alterations, some authors
suggest that low levels of crystalloid
replacement (<500 mL) may improve
subjective sensations such as thirst,
whereas large volumes of replacement (2
L) improve postoperative symptoms such
as dizziness and nausea.

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FLUID RESUSCITATION
Early
responders

Transient
responders

Non
responders

Definitive
surgery

Damage control
surgery

Life Saving
Surgery

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NEUROLOGICAL
Quick GCS
Secondary Neurological damage
Hypoxia

Hypotension
Hypercapnia

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Permissive Hypotension probably is not to be


advocated for head injured patients
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RADIOLOGY
X rays
Chest
Pelvis
C Spine lateral view
FAST
CT ????

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Do Not Shift Hemodynamically unstable


patient to Radiology Room

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LAB
Hb/ Hct
Screening
Sugar
Lactate
Group/ cross match
Coagulation
PT INR
APTT

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SHIFTING OF PATIENTS
FROM RESUSCITATION SUITE
Primum Non nocere Dont think
Only down the corridor
Airway
Ventilation
Fluids and drugs
Monitoring
Check Battery of ventilators, Oxygen
cylinders, Syringe pumps
Only half way through PS Beware of
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injuries
1undiagnosed
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6
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POSITIONING
Beware lines- tubes- bags
All are inserted as they are important so keep them
accessible
Take care of fractured limbs
Every shifting in a hypovolemic patient can cause further fall in
blood pressure

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MONITORING
Basic Monitors
Pulse Oximetry, ECG, Temperature, NIBP
Invasive Arterial blood pressureDont waste time in getting an arterial line can be placed after surgeons have started hemorrhage control
CVP PCWP ??

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DASAR DASAR
ANESTESIA I
Dr. dr. H. J. Lalenoh, SpAnKMN, KAO

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GENERAL ANESTESIA
(GA)/ANESTESIA UMUM
Definisi : Suatu keadaan dimana terjadi
kehilangan kesadaran secara reversible
yang disebabkan oleh obat anestesia,
disertai oleh hilangnya sensasi nyeri
diseluruh tubuh.
Trias G.A. :
1. Hilangnya Keasadaran (Sedatif
Tidur)
2. Analgesia
3. 6/Penekanan
Refleks (Supresi Refleks)
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JENIS-JENIS TEKNIK GA
1. Pemberian melulu obat-obatan
parenteral :
Pentothal
Ketamin
Propofol, dll
2.
Pemberian melulu obat-obat inhalasi :
a. Volatile :
Halotan
Isofluran
Sevofluran, dll
b. Gas : N2O
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3. Pemberian obat-obat parenteral &


inhalasi :
a. Parenteral :
Pentothal
Ketamin
Propofol, dll
b. Inhalasi (Volatile) :
Halotan
Isofluran
Sevofluran, dll
c. Inhalasi (Gas) : N2O
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TEKNIK GENERAL ANESTESIA :


Persiapan Pra-Anestesia

Induksi Anestesia

Stadium Anestesia Yang Diinginkan

Maintenance Anestesia

Mengakhiri Tindakan Anestesia

Fase Pemulihan Ruang Pulih (R.R.)

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CONTOH TEKNK GENERAL ANESTESIA :

1. Persiapan praanestesia (di ruang preoperatif) :


Pemeriksaan ulang tensi, nadi, resp, temp, dll
Cek ulang ada gigi palsu, gigi goyah
Cek Ulang hal-hal yang merupakan kontraindikasi anestesi (lihat kuliah persiapan praanestesi)
Pemasangan infus harus ada vena terbuka
Premedikasi obat apa yang akan diberikan
i.m. (1/2 1 jam pra anestesia), atau
i.v. (5 pra anestesia)
Transport pend dari ruang pra-operatif ke ruang
bedah
Menyiapkan obat-obat anestesia yang akan
dipakai dan obat-obat yang diperlukan pada
keadaan
darurat /
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2 obat-obat untuk resusitasi jantung paru
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2. Induksi anestesia: Bisa dengan


obat parenteral atau obat inhalasi
atau kedua-duanya
a. Parenteral :
@ Tiopenton
@ Ketamin
@ Propofol
@ Midazolam , dll
b. Inhalasi :
# Halotan
# Ether
# Halotan + N2O/O2
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# Enfluran + N2O/O2

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3. Stadium anestesia yang diinginkan Stadium III


Plane 2 atau 3
4. Maintenace anestesia Dosis obat dikurangi
untuk
mempertahankan penderita pada stadium
anestesia yg
diinginkan, dengan obat-obat seperti :
* Halotan + O2 /N2O/Air
* Enfluran + O2 / N2O / Air
* Isofluran + O2 / N2O / Air
* Sevofluran , Desflurane dll
5. Mengakhiri tindakan anestesia Obat anestesia
dihentikan pemberiannya
6. Fase Pemulihan Di ruang pulih (Recovery
Room)
Monitoring penderita Refleks -refleks (+) / sadar

Penderita bisa kembali ke ruangan.


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PROBLEM INTRAOPERATIF PASIEN YANG


AKAN MENJALANI BEDAH PERUT
EMERGENSI:
I. Problem respirasi :
1) Depresi pernapasan Penyebabnya o/k:
- Tekananan intraabdominal
- Penekanan terhadap diafragma
- Penyakit dasar yang menyebabkan kejadian bencana perut
- Premedikasi narkotik >>
2) Obstruksi Jalan Napas Penyebabnya :
Lidah jatuh menutup farings
Pipa Endotrakeal tertekuk / tersumbat
Laringospasme
Bronkospasme
Lendir, gigi palsu, perdarahan, dll
3) Pernapasan tidak adekwat Penyebabnya airway (jalan napas)
tidak bebas, ataupun stadium anestesia agak dalam CO2, O2
(Hiperkarbia, Hipoksemia/Hipoksia) :
Denyut jantung
Tensi
Takipnu
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II. Problem kardiovaskuler :


1) Hipotensi Penyebabnya :
Perdarahan (luka operasi)
Penyakit yang mendasari kejadian bencana perut
Obat premedikasi atau induksi atau maintenance anestesia
2) Hipertensi Penyebabnya:
Kesakitan, CO2 , O2
Riwayat hipertensi sebelumnya (yg tidak terdeteksi atau sudah ada
sebelumnya)
3) Takikardi Penyebabnya :
Refleks fisiologis pada hipotensi
Penyakit dasar yang menyebabkan bencana perut
Dehidrasi, hipovolemia
SIRS, Sepsis
Kesakitan
CO2 , O2
Kelainan irama/kelainan jantung yang mendasari sebelumnya
Obat premedikasi (vagolitik), Obat anestesia
4) Bradikardi Penyebabnya :
Vagal refleks
Kelainan irama/kelainan jantung yang mendasari sebelum ya
Rangsang parasimpatis o/ pembedahan
6 Obat anestesia
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5) Gangguan irama jantung Penyebabnya:


Gangguan irama jantung sebelumnya
Penyakit yang mendasari kejadian bencana perut
CO2
Kesakitan
Obat anestesia
6) Syok (Hipotensi, Takikardi, Nadi Kecil, Akral Dingin)
Penyebabnya:
Peradarahan (luka operasi)
Reaksi anafilaktik (obat anestesia)
7) Henti jantung (cardiac arrest) Penyebabnya (point 1 - 6
yang dibiarkan / tidak
diatasi) Resusitasi jantung paru.
III. Muntah & Regurgitasi :
Bersihkan jalan napas (miringkan pend & rendahkan kepala
pend)
Pasang nasogastric tube
Intubasi endotrakeal
IV. Malignant
- Hyperthermia:
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6
B E N C A N A Poperasi
ERUT
2
Terutama
beresiko pada pasien dengan febris sebelum
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HAL YANG HARUS


DIPERHATIKAN
1. Apakah kebutuhan O2 cukup Lihat
pada warna darah dari luka operasi,
warna kuku, dll.
2. Jumlah perdarahan Apakah cukup
dengan cairan infus atau perlu
transfusi.
3. Apakah derajat relaksasi otot cukup,
mis. pada operasi abdominal
Anestesia perlu didalamkan atau
pemberian obat pelumpuh otot.
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4.
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PROBLEM PASCAOPERATIF BEDAH


PERUT EMERGENSI YANG HARUS
DIPERHATIKAN:

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Support ventilasi post operasi Perlu Ventilator? Rawat ICU

Apakah tetap terintubasi? Berapa lama?

Apakah perlu support kardiovaskular? Kalau perlu


vassopressordengan infus pump atau syringe pump titrasi

Bagaimana Intake dan maintenance cairan

Bagaimana Intake nutrisibila perlu parenteral nutrisipasang CVP

Bagaimana Balance Cairan?

Bagaimana seluruh sistem tubuh? Breathing, Blood, Brain, Bowl,


Bladder, Bone (6B)

Koreksi: electrolyte imbalance, fluid deficit, hypoalbumine,


hypoproteinemia, malnutrition, hypo/hyperthermia, arrhytmias,
hypo/hyperglycemia , dan kelainan lain

Pemberian Antibiotik dan obat lain

Mobilisasi/fisioterapi

Rawat bersama sejawat lain/disiplin ilmu terkait

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POSTOPERATIVE NUTRITION
Purely restrictive procedures
Gastric Banding, Sleeve Gastrectomy, Vertical Banded Gastroplasty
Daily multivitamin
Monitor protein intake
1 gm protein/kg ideal body weight/day
Primarily Restrictive with some malabsorption
Gastric Bypass
Calcium, Iron and B-complex vitamins supplemented at higher
than daily recommended levels
Prioritize protein intake

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APPARATUS ANESTESIA LAIN YANG


SERING DIPAKAI
Berikut ini adalah gambar contoh alat-alat
anestesia :
1. Endotracheal tube (= pipa endotrakeal) :
Ada dua tipe : # Oro-trakeal
# Naso-trakeal

2. Oropharyngeal tube (= gudel) :

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3. Laryngoscope :

4. Ambu - bag (= Air - Viva) :


Ambu bag

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Laryngeal Mask Airway (LMA)

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Face Mask Corrugated - Anesthesia


apparatus - Bag

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Face Mask
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Anaesthesia Machine
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Anaesthesia Machine
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REFFERENCES
Bamboat ZM, Bordeianou L Periooerative Fluid Management. Sweeney
WB (Ed). Perioerative Management and Anesthesia. Clinics in Colon
and Rectal Surgery. Journal List Clin Colon Rectal Surg v22(1); Feb
2009.
Bhat R. Anesthesia for Emergency Surgery in Hemodynamically Unstable
Patient. Ganga Hospital Coimbatore.
Kadowaki M. Perioperative Care of The Bariatric Patient. Wellmont
Surgical Semas Heysprint Tenessee.
AlAmoudi AB. Preoperative Assessment.
Leonard A, Thompson J. Anesthesia for Ruptured Abdominal Aortic
Aneurysm. Continuing Education in Anaesthesia, Crit Care & Pain;
8(1):2008: 11-6. Downloaded from
http://ceaccp.oxfordjournals.org/by guest on April 21, 2014.
Chhetri RK, Shrestha ML. A Comparative Study of Preoperative with
Operative Diagnosis in Acute Abdomen. Kathmandu University Medical
Journal; 3(2): 2005: 107-10.
Kilpatrick cc, Monga M. Approach to The Acute Abdomen in Pregnancy.
Obstet Gynecol Clin N Am; Elsevier Saunders: 2007: 389-93.
Lalenoh HJ. Dasar-Dasar Anesthesia I. Kuliah Anestesiologi. FK UNSRAT,
2010.
Lalenoh D. Dasar-Dasar Anesthesia IIb-III. FK UNSRAT, 2010.

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