Duodenum yang dilakukan Duodenoduodenostomy Tim Pediatrik Anesthesia
Anamnesa Identitas pasien : Nama Umur
: By. M : 1,5 bulan
Keluhan utama : muntah muntah sejak umur 4 hari
Umur 4 hari muntah kuning dirawat RSUD, dirawat 5 hari, kemudian di rujuk ke (Lahir spontan cukup bulan 38 mgg, ditolong bidan langsung menangis BBL 3900g) Dirawat oleh TS IKA dan direncanakan untuk operasi sambung-sambung usus duabelas jari.
Pemeriksaan Fisik
Ku : Aktif, menangis kuat
BB : 2700 g
Nadi Respirasi SpO2 Suhu Jalan napas Kepala Thoraks
Abdomen distensi Extrimitas
Post Conceptional Age: 45minggu
: 138-142 x/menit : 38-40 x/min, : 98% : 36,4 C : sulit dinilai : ubun ubun tidak cekung, ikterik (-) : bentuk & gerak simetris pulmo: rhonki -/-, wheezing -/-, suara napas vesikular cor : normal, murmur (-) : BU (+) ,teraba lembut, tidak tegang, tidak ada : akral hangat
Terapi di Ruang Rawat
Pediatri Nutrisi Parenteral D 10/D 40/NaCl 3%/KCl 7,46/Lipid 20%/Aminosteril 9cc/jam Akses vena melalui PICC di vena basilica kiri NGT (+): 12cc/4jam hijau Diuresis : popok 5cc/jam Ampicyclin 4 x125 mg Gentamycin 1x10 mg Paracetamol prn
Laboratorium Hb (21/8 )
Ht
Leuko
Tr
Ur
Cr
Alb
Prot total
9,8
27
9.700
79.000
43
0,33
3,1
5,2
PT
INR
aPTT
Na
10,9
0,98
28,8
137
5,6
Pemeriksaan Penunjang Rontgen Thoraks : kesan Pneumonia (-), kardiomegali (-)
Pasien dengan Status Fisik ASA III
Rencana tindakan Anestesi umum
Rencana Anestesi Preoperatif Informed consent tentang tindakan anestesi umum, puasa preoperatif dan manajemen nyeri pasca operasi dan ruang rawat pasca operasi. IVFD RL 12cc/jam Persiapan darah
Pre Induksi Dipasang monitor EKG, SpO2 dan Temp Radiant warmer, PRC tersedia dan blood warmer Akses vena untuk tranfusi Check GDS
Induksi Dilakukan suction dari NGT hingga bersih. Diberikan preoksigenasi, kemudian diberikan propofol 7,5 mg, setelah pasien tertidur, diberikan rocuronium 3,5mg dilakukan intubasi dengan ETT non spiral no.3 Kemudian dihubungkan kembali ke sirkuit anesthesia (Jackson Rees,gas flow 3lpm) Maintenance dengan sevoflurane 2-3 vol%. O2:N2O=50:50%. Sebelum insisi diberikan fentanyl 5 mcg Dilakukan penggantian darah yang hilang dengan darah Mencegah hipotermia .
Post operatif Analgetik post op dengan paracetamol 4x10 dan fentanyl Ruang rawat
Anesthetic management of duodenal atresia case Incidence: 1 in 2500-5000 live births In 25-40% of cases, the anomaly is encountered with trisomy 21 Down syndrome Treatment: duodenoduodenostomy in the newborn period.
Differential diagnosis of neonatal
upper GI obstruction Esophageal atresia Malrotation with midgut volvulus Pyloric stenosis Duodenal atresia and stenosis Annular pancreas
Presentation Onset of vomiting within hours of birth. Vomitus is most often bilious, it may be nonbilious because 15% of defects occur proximal to the ampulla of Vater. Duodenal stenosis baby might present later with above complaints Scaphoid abdomen with epigastric fullness.
Medical management before
definitive surgery Dehydration, weight loss, and electrolyte imbalance soon follow unless fluid and electrolyte losses are adequately replaced. If intravenous (IV) hydration is not begun, a hypokalemic/ hypochloremic metabolic alkalosis with paradoxical aciduria develops, as with other high GI obstruction. An orogastric (OG) tube in an infant with suspected duodenal obstruction typically yields a significant amount of bile-stained fluid
Pre-op preparation Adequate intravenous (IV) hydration, Total parenteral nutrition, Gastric decompression are essential until the neonate has been stabilized for surgical repair. Special attention to cardiac and pulmonary function before undertaking duodenal repair
Intra-op management Standard monitoring Thorough suctioning of the NG tube. Pre-oxygenation adequately. RSI Maintenance with proper analgesia and anesthesia (inhalational / I.V)
Intra-op suctioning of the NG tube
might be needed Also manipulation of NG tube might be needed during the repair, take proper care for ETT.
Post -op Proper analgesia i.v fluid management Oral fluid allowed only after passing flatus and or drainage from the OG is less than 1 mL/kg/h and is clear. Feeding can then be advanced slowly by mouth.
