ANESTESI UMUM

DAN REGIONAL
Dedi Herlambang, dr.,SpAn.,MKes.
Anestesi & Reanimasi
RST Latumetten
Ambon

Jembatan Roboh, Kutai, Kertanegara

ANESTESIOLOGI

Pemberian anestesi +
analgesi
Cabang ilmu
kedokteran

Mengawasi menunjang
faal-faal penderita dari stres
operasi
Dan lain-lain

Kematian (337org,
sendai)

Bencan
a

Korban ??

Pengungsia
n
PLTNuklir stop
Bangunan rusak

Operasi ..
?

Anestesi Umum (Balans

anestesi)

Anestesia Regional
1.Spinal Block
2.Epidural Block
3.Peripheral Block

1. Hipnotik
2. Analgesia
3. Relaksan

TRIAS
ANESTESIA

(Anestesi umum / Balans

anestesia)

Concept balanced
anesthesia
Component VIMA
anesthesia

TIVA

Hypnotic

Sevo, Iso, Enf, Hal,

Desfluran

Propofol, Pento,
Ket, Mid

Analgesic

Fentanyl, alf, suf

,Mo, pethidine,
remifentanil

Relaxation

Depol & non depol

Fentanyl, alf,
suf ,Mo,
pethidine,
remifentanil
Depol & non
depol

Indikasi Anestesi Umum

Bayi dan anak-anak.
Dewasa yang ingin di anestesi umum.
Prosedur operasi yang lama & rumit.
Pasien dengan gangguan mental
Pasien dengan riwayat alergi terhadap
obat anestesi lokal
6. Pasien dalam pengobatan
antikoagulan
1.
2.
3.
4.
5.

Teknik Anestesi Umum

Nafas spontan
Controlled ventilation
Face mask
Intubasi
LMA (Laryngeal Mask Airway)
COPA (Cuffed Oro Pharyngeal
Airway)
7. LSA (Laryngeal Seal Airway)
1.
2.
3.
4.
5.
6.

Teknik Anestesi Inhalation

Umum
Open-drop technique
Insufflation
Sistim Ayre T-piece
Sistim dengan katup nonrebreathing
5. Semiclosed
6. Closed
1.
2.
3.
4.

Komponen mesin anestesi

Sumber gas : Oxygen, N2O
Katup regulator pengatur

tekanan
Flow meter
Vaporizer untuk gas anestesi
seperti halothane, enflurane,
isoflurane.
CO2 absorption (soda lime
atau bara lime)

Teknik Induksi
Intravenous
Mask induction / inhalation
Intra muscular
Per rectal

Problem selama induksi anestesi

Problem Utama : airway
Tanda obstruksi partial : snoring, crowing,

gargling, wheezing, retraksi dada, cyanosis

Tanda obstruksi totalis : udara dari
mulut/hidung negatif, retraksi
supraclavicular , retraksi intercostal,
cyanosis

Problem lain ketika

induksi
1.
2.
3.
4.
5.

Depresi nafas
Batuk
Spasme Laring
Hipersekresi mucus dan saliva
Muntah

Penguasaan Jalan Nafas

Tanpa Peralatan : Triple mannuver

Safar
Dengan Peralatan :
OPA (Oro Pharyngeal Airway)
NPA (Naso Pharyngeal Airway)
LMA ( Laryngeal Mask Airway)
ETT (Endo Tracheal Tube)

Indikasi Intubasi
Operasi kepala dan leher
Jalan Nafas sulit
Thoracotomy
Laparotomy
Posisi Lateral
Posisi telungkup/Prone
Ventilasi terkontrol

Teknik laryngoscopy
Posisikan Kepala
Insersi

laryngoscope
blade
Visualisasi
epiglottis
Angkat epiglottis
Lihat laryng dan
jaringan sekitarnya

View Figure

Penyulit Intubasi

Kerugian Endotracheal
Intubasi
Peningkatan resistensi

pernafasan
Trauma pada bibir, gigi,
hidung, tenggorokan, laring,
pita suara.

Ekstubasi

Setelah ventilasi adequate

Ketika anestesi dalam atau setelah pasien

sadar penuh
Jalan nafas bersih
Oxygen 100% sebelum dan setelah ekstubasi

Perencanaan Anestesi
umum
Visit pre operative
Premedikasi
Teknik Anestesi: Umum, Regional atau

kombinasi
Intraoperative
Postoperative

Pilihan teknik Anestesi tergantung

pada:
Kondisi pasien
Skill anesthetist
Skill surgeon
Status sosial ekonomis Rumah

Sakit

Teknik selama Anestesi

Umum
Kontrol jalan nafas
Induksi anestesi
Maintenance anestesi
Analgesia
Pelemas otot

Intraoperative
Monitoring pasien (hemodinamik, suhu,

diurasis dll)
Posisi pasien
Crystalloid dan colloid (perdarahan)
Teknik khusus lainnya seperti hipotermi,
hipotensi, dll

Tanda Kedalaman
Anestesi
PRST Score (balanced anesthesia)
Guedel sign (ether anesthesia)
PRST Score (score 2-4: adequate

anesthesia)
P = Systolic arterial pressure
(mmHg)
R = rate (heart rate)
S = sweat/ lacrimation
T = tear

PRST Scoring indexes for Balanced

anesthesia
Index
Systolic arterial
pressure (mmHg)
Heart rate (beats/min)

Sweat

Tears or Lacrimation
(Air mata )

kondisi
Kurang dari awall + 15
Kurang dari awal + 30
Lebih dari awal +30
Kurang dari awal + 15
Kurang dari awal + 30
Lebih dari awal +30
Tidak berkeringat
Licin bila disentuh
Tampak sangat berkeringat
Mata terbuka tanpa airmata
Tampak airmata waktu buka mata
Air mata mengalir dengan mata
tertutup

Score
0
1
2
0
1
2
0
1
2
0
1
2

Postoperative
Post operative pain treatment
Perawatan pasien post anestesi/ operasi di

ICU atau ruang rawat biasa

Regional
Anestesi

Anestesia Regional
Spinal Block
Epidural Block
Caudal Block
Peripheral Block
Ekstremitas atas

Ekstremitas bawah

1.
2.
3.
4.
5.
6.

1.
2.
3.
4.

Interscelenus Block
Supraclavicular Block
Infraclavicular Block
Axilar Block
Cubital Block
Wrist Block

Femoral Block
Sciatic Block
Knee Block
Angkle Block

ANESTESI UMUM :
Impuls masih sampai ke C.N.S.
Cortisol
Cathecolamin
Tachycardi
Gula darah

ANESTESI REGIONAL :
Impuls kurang / tidak sampai ke C.N.S.
Blokade segmen TH5 L1 berarti
splanchnic sympathic system terblok
Cortisol N /
Cathecolamine N /

KEUNTUNGAN :

Sederhana, murah
Non eksplosif
Tidak polusi
Alat sederhana
Perawatan pasca bedah mudah
Sadar resiko aspirasi (-)
Perdarahan
Respon otonom-endokrin

KERUGIAN :
Pasien ingin tidak sadar
Tidak praktis bila perlu beberapa

kali suntikan
Takut operasi belum selesai efek
obat habis
Efek samping serius, sulit diatasi

Obat Lokal Anestesi

1. Ester Compound

Cocaine
Procaine / Novocaine
Tetracaine / Pontocaine

2. Amide Compound

Xylocaine / Lidocaine
Prilocaine / Citanest
Bupivacaine / Marcaine
Etidocaine / Duranest

Agent

Concent:
Clinical use

Onset &
Duration

Max:Single
dose

Potency

Cocaine

4-10% Topikal

Slow 30

150 Mg

Procaine

Infiltrasi 1%
Epidural 2%
Plexus blok 2%
Spinal 10%

Slow
30-45

500 Mg EPI
600 Mg + EPI
1012 Mg/Kg

Low

Chloro
procaine

Infiltrasi 1%
Epideral 2%
Plexus block 2%

Rapid
45-60

600 Mg EPI Interme

diate
650 Mg + EPI
10-15 Mg/Kg

Tetracaine

Topikal 0,5-1%
Infiltr 0,1-0,2%
Epidrl 0,4-0,5%
Spinal 1%

Slow
180-300

100 Mg
2 Mg/Kg

High

Agent

Concent: Clinical
use

Onset &
Duration

Max:Single
dose

Potency

Xylocaine

Infiltr 0,5-1%
Epidural 1-2%
N.block 1-1,5%
Topical 4%
Spinal 5%

Rapid
60-120

300 Mg EPI Interme

diate
500 Mg + EPI
7-8 Mg/Kg

Prilocaine

sda

Slow
60-120

175 Mg EPI Interme

diate
250 Mg + EPI
3-4 Mg/Kg

Bupivacaine

Infilt 0,25-0,5%
N.blok 0,5-0,75%
Spinal 0,5%

Slow
>180>300

175 Mg EPI
250 Mg + EPI
3 4 Mg/Kg

High

Etidocaine

Infiltrasi 0,5%
N.blok 0,5-1%
Epidrl 1-1,5%

Rapid
>180 >300

300 Mg EPI
400 Mg + EPI
4-5 Mg/Kg

High

Metabolism

Allergy

Sterilis :
(Heat)

ESTER.C

Hydrolisa
(Ps.Choline)
Plasma

(+)
PABA

(-)

AMIDE.C

Degradasi
Liver

(-)

(+)

General
Anesthesia
All sensation loss
Unconscious

Lokal/Regional
Anesthesia
Partial sensation loss
Conscious

Gambaran anestesi pada obat anestesi

lokal ditentukan oleh :
Lipid solubility potensi intrinsik
Makin larut, makin poten
Procaine L.S. = 1
Bupivacaine L.S. = 30
Etidocaine L.S. = 140
90 % Axollemma = lipid

Protein binding
Protein binding lama kerja
Procaine P.B. = 5
Bupivacaine P.B. = 95
Protein membran = 10%

 p Ka
P Ka = pH dimana bentuk ion dan non ion
seimbang
Untuk mula kerja bila pKa mendekati pH
jaringan onset of action lebih cepat
p Ka lidocaine = 7,7
Bupivacaine = 8,3
Non nervous tissue difussibility : dengan

mula kerja

 Intrinsic vasodilator activity

Potensi dan lama kerja
Derajat absorbsi vaskuler, tergantung blood
flow bila vasodilatasi obat cepat habis
Semua obat anestesi lokal vasodilatasi
kecuali cocaine.
Lidocaine > Mepivacaine

Maka ada 3 golongan obat anestesi lokal

1. Potensi rendah & lama kerja pendek

Procaine
chloroprocaine

2. Potensi sedang & lama kerja sedang

Lidocaine
Mepivacaine
Prilocaine

3. Potensi kuat & lama kerja panjang

Bupivacaine
Tetracaine
Etidocaine

Spinal Anestesi
L.A Subarachnoid space
Blokade anterior
Blokade posterior

Serabut saraf dari kecil besar

Otonom
Sakit
Temperatur
motorik

Blokade otonom 2 3 segmen lebih tinggi dari

level analgesi kulit

Blokade motoris 2 3 segmen lebih rendah

dari level analgesi kulit

Indikasi

Operasi
Operasi
Operasi
Operasi
Operasi

abdomen terutama bawah

Hernia Inguinalis
ekstrimitas bawah
kandung kencing dan prostat
kebidanan

Keuntungan

Penderita tetap sadar

Relaxasi cukup baik
Komplikasi paru post op hampir (-)
Perdarahan selama op berkurang

Kerugian

Hypotensi
Tensi turun sekali
Durante & post op muntah / mual-mual
Sakit kepala post op
Kadang ada gangguan nafas

Penatalaksanaan
Cairan 0,5 1 L
Post suntikan :
Test analgesi anestesi
Monitor nafas
Susah nafas O2 masker
Paralise intercostal & diafragma bantuan

nafas
Tensi < 100 mmHg hypotensi

< 100 mmHg cairan 2 3 fles

O2 mask
Ephedrine : 10 15 Mg I.V. / 25-50 Mg I.M.
(Vasopressor)

Pasien resiko tinggi, coroner / cerebral

ischaemi Ephedrine drip dini

Terapi
Tidur terlentang 24 jam
Banyak minum / infus
Gurita
Analgetik
Epidural Blood Patch

Epidural Analgesia

Di daerah lumbal, thoracal, caudal

Indikasi dan kontraindikasi = spinal

anestesi
Keuntungan spinal dibandingkan epidural :
Obat anestesi lokal lebih sedikit
Onset lebih singkat
Level anestesi lebih pasti
Teknik lebih mudah

Keuntungan epidural dibandingkan

spinal :

Bisa segmental
Tidak terjadi headache post op
Hypotensi lambat terjadi
Efek motoris lebih kurang
Dapat 12 hari dengan kateter

post op pain

Kerugian epidural dibandingkan

spinal :

Teknik lebih sulit

Jumlah obat anestesi lokal lebih

besar
Reaksi sistemis
Total spinal anestesi
Obat 510x lebih banyak untuk
level analgesi yang sama

Keuntungan epidural dibandingkan

anestesi umum :
Sedikit pengaruh pada respirasi
Diperoleh analgesi, relaksasi otot

dan usus
Dapat diberikan pada pasien
dengan kontra indikasi muscle
relaxant

Anatomi
Duramater berakhir di S 2
Diameter 0,5 cm, paling besar di

L2
Jarak rata-rata dari kulit 4-5 cm
Ruang epidural berisi jaringan ikat,
lemak, vena, arteri, pembuluh lymfe
dan saraf
Vena distensi pada : batuk, hamil,
mengedan
Foramen intervertebralis lebih
permeabel pada usia muda

Metode menentukan ruang

epidural
Metode Loss of Resistance
Metode Hanging Drop
Bila pakai udara jangan lebih dari 3

ml

Komplikasi
Tertusuk duramater
Post spinal headache
Total spinal anestesi

Reaksi sistemis : akibat obat

anestesi lokal dan epinephrin

Caudal Analgesi
Indikasi : operasi perineal
Kontra indikasi : = epidural
Cara :
1. Cari cornu sacralis kanan-kiri
2. Diantaranya adalah membran

sacro coccygeal hiatus sacralis

Kerugian :
Sulit mencapai level analgesi

yang tinggi
Bisa terjadi relaksasi sistemik
Kegagalan 5-10%
Komplikasi : = epidural

Terimakasih

Hipnotik
Intravena
1.Propofol
2.Pentotal
3.Ketamin
4.Etomidat
5.Midazolam

Inhalasi (Gas)
1.N2O
2.Halotan
3.Enfluran /
Etran
4.Isofluran
5.Sevofluran
6.Desfluran

Anestesi Intravena Ideal

Larut dalam Air
Tidak irritatif
Tidak berefek negatif dengan

analgetik
Induksi cepat dan nyaman
Cardiovascular tak terganggu dalam
dosis klinis

Propofol
intravenous anestesi terbaru
Onset cepat (one arm brain

circulation), sort duration

Accumulation minimal
Fast recovery
Rapid metabolism
No complication at site of injection
Dose 2-2.5 mg/kg BW

Pharmacology Propofol
Tidak histamine release/reaksi

anaphylactoid (chremophor El change

with soya bean oil).
Perivascular injection, nekrosis
jaringan negative.
Injection intra artery : nekrosis
jaringan negative.

Efek Propofol terhadap

CNS
Efek Hypnotic 1,8X pentothal
Airway depression > pentothal
Efek Anti emetic
No anti convulsant effect

Pentotal (Thiopentone)
Blood pressure menurun
Heart rate meningkat atau menurun
Peripheral vasodilatasi
Heart contraction depressed
Larynx spasm, bronchus spasm
Respiratory depresi hingga apnoea
Dose 4-6 mg/kg BW

Relative contraindication
thiopentone
Asthma bronchiale
Severe liver disease
Severe kidney disease
Severe anemia
Hypotension
Shock

Ketamine
Dissociative anesthetic
Delirium
Hallucination
Increase blood pressure : systolic

23% from base line

Increase heart rate
Arrhythmias
Hypersecretion
Dose 1-3 mg/kg I.v or 9-11 mg/kg I.m

Indikasi & Kontra Indikasi Ketamine

Indication : short surgery
Contraindication : Hypertension

systolic > 160 mmHg

Arrhythmias
Heart failure
Pharynx and larynx surgery
without intubation.

Comparative properties of
intravenous anesthetics

Aqueous
solution
Available in
solution
Pain on
injection
Venous
thrombosis

Thiopen Ketamin Propof

Diazep Midaz

Comparative properties of
intravenous anesthetics

Rapidly
acting
Smooth
induction
Respiratory
depression
Cardiovascul
ar depression

Thiopen Ketamin Propof

Diazep Midaz

++

+/-

++

++

+/-

+/-

Comparative properties of
intravenous anesthetics

Rapid
recovery
Smooth
recovery
Suitable for
infusion
Interaction
with relaxant

Thiopen Ketamin Propof

Diazep Midaz

+/-

+/-

Resume: Effect anesthetic non

volatile to organ system
Drug

HR

MAP

Vent

Bdil

Thiopentone
Diazepam
Midazolam
Meperidine
Morphine
Fentanyl
Ketamine
Propofol

0/

*
*

0
0
*
*
0
m
0

Resume: Effect anesthetic non

volatile to CNS
Drug

CBF

CMRO2

ICP

Thiopentone
Diazepam
Midazolam
Meperidine
Morphine
Fentanyl
Ketamine
Propofol

INHALATION
ANESTHETIC

Pilihan Anestesi Inhalasi

Efeknya thd Kardio pulmonal
Product degradation with soda

lime
What metabolites ?
How much metabolism?

Ideal anestesi inhalasi

Bau yg enak & tidak iritasi
Low solubility
No organ toxic
Efek samping kardiovascular and

respirasi minimal
Efek CNS reversible tanpa gejala sisa
Effective in high O2 concentration
Boiling pressure and boiling point can
delivered by vaporizer standard

New Trend in General

Anesthesia
VIMA
Fast-Track Anesthesia
Low-flow Anesthesia
Low-cost Anesthesia
Single-breath induction (Rapid

induction)

Physicochemical properties
Halothane
Odor
+
Irritating to
Resp system Solubility
2,35
MAC
0,76
Metabolism 17-20%
Metabolites F, Cl,
Br, TFA
BCDFE,
CDE, CTE,
DBE

Enfl
+
1,91
1,68
2,4%
F,
CDA

Isofl
+
1,4
1915
<0,2%
F,
TFA

Desfl
+
0,42
6,0
0,02%
F,
TFA

Sevo
+
0,63
2,05
<5%
F,
HFIP

Interaction with Sodalime

Anesthetic
Halothane

degradation
Product
BCDFE

organ Toxicity clinical

Relevancy
Nephrotoxic Non identified
to data
-

Enflurane

CO

Isoflurane

CO

Desflurane

CO

Sevoflurane

Compound A
Compound B

Nephrotoxic

Non identified
to date

WHY VIMA???
Induksi intravenous , ex: Propofol :

rapid and smooth induction, tetapi

membutuhkan akses vena terlebih
dahulu, hypotension, apnoe.
Pediatric anesthesia commonly by
VIMA.
More advantages than intravenous
induction, maintenance inhalation.

Cardiovascular effect of Volatile

inhalational anesthetics
Variable

Halothane

Enflurane

Isoflurane

Blood pressure
Vascular resistance
Cardiac output
Cardiac contraction
CVP
Heart rate
Sensitization of the heart
to epinephrine

0
0
0

0?

0 = No change (<10%)
= increase

= Variable
change

= 10-20%
decrease

= 20-40%
decrease

Clinical pharmacology of Inhalational

anesthetics : Respiratory
N2O

Tidal

volume
Resp rate
PaCO2
resting

Halo

Enflur

Isoflu

Sevoflu

m
m

Clinical pharmacology of
Inhalational anesthetics : CNS

CBF
ICP
CMRO2
Seizure

N2O

Halo

Enflur

Isoflu

Sevoflu

Clinical pharmacology of
Inhalational anesthetics

HBF
Nondep
blockade
Metabolism

N2O

Halo

Enflur Isoflu

Sevoflu

0.2

2-3

m m

0.004 15-20
2.5

N2O
1.5 X lebih berat dari udara
Harus diberikan bersamaan dgn O2

100%
Anestesia lemah
Tidak dipergunakan pada closed
system
Akhir anesthesia, utk mencegah
hipoksia difusi O2 100%

Keuntungan N2O
Induction and recovery yg cepat
No sensitized myocardium with

catecholamine
Tidak mengiritasi saluran
pernafasn
Bau yg enak
Memiliki efek analgetik

Kekurangan N2O
Anestesia lemah
Tidak ada efek relaksan
Membutuhkan konsentrasi O2 yg tinggi
Possibility aplasia bone marrow

Halothane
A clear, colorless, potent volatile

liquid.
Metabolism 17-20%

Keuntungan Halothane
Rapid, smooth induction and recovery.
Pleasant
Non irritating, no secretion
Bronchodilator
Nonemetic
Non flammable and non explosive

Kekurangan Halothane
Myocardial depressant
An arrhythmia producing drug
Sensitizes the myocardial conduction

system to the action of

catecholamines
A potent uterine relaxant
Possible toxic to the liver
Shivering during recovery period.

Enflurane (Etran)
A clear, colorless, stable volatile liquid with a

pleasant ether-like odor.

A potent inhalation anesthetic
CNS excitation
Use of epinephrine : saver than halothane.

Keuntungan Enflurane
Pleasant
Rapid induction and recovery
Non-irritating : no secretion
Bronchodilator
Good muscle relaxation
Nonemetic
Non flammable and non explosive
Compatible with epinephrine

Kekurangan Enflurane
Myocardial depressant
Shivering on emergence
CSF production increase
CNS excitation, in high dose and hypocarbia.

Isoflurane
A stabe, volatile liquid
A isomer enflurane
Inhalation anesthetic choice for neurosurgical

patient, kidney, liver.

Keuntungan Isoflurane
Rapid induction of anesthesia and swift

recovery
Nonirritating : no secretion
Blood pressure remain stable
Indicated in poor-risk patient

Kekurangan Isoflurane
Less than halothane and enflurane

Sevoflurane
Inhalation

anesthetic with low

solubility (0,63), low MAC (2,05),
pleasant odor, no airway irritation,
rapid uptake and elimination ,
cardio vascular stable.
Rapid induction, with technique
single breath induction, induction
time 23 seconds.

Sevoflurane
Drugs of choice for Neuro anesthesia : WCA

2000 Montreal, Canada.

Drugs of choice for Pediatric Anesthesia : ESA
Barcelona, 1998. ASPA, Singapore, 2000., ESA
Sweden 2001.
In Sectio Caesarea equal with Isoflurane and
spinal anesthesia
Reduce sphlannic blood flow, hepatic blood
flow lesser than other anesthetic inhalation.

ANALGESIA
NARKOTIK

Analgesia
1. Morphine
2. Pethidine
3. Fentanyl
4. Sufentanil
5. Remifentanil

ideal analgesia narcotik :

Batas keamanan lebar

Onset of action cepat
Durasi pendek
Mudah mengontrol analgesia
Analgesic kuat
no histamine release
Non active metabolite

Opiate in Anesthesia
1. Premedication
2. Induction Anesthesia
3. Narcotic anesthesia
4. A part of balanced
anesthesia
5. Adjuvant in regional
anesthesia

Drugs
Protein binding
solubility
Morphine
Pethidine
Fentanyl
+
Sufentanil
+
Alfentanil

Lipid

++
+++
+++
++++
++++

Note : + = very low;

++ = low;

+
++
+++
+++
+++
+++ = high

Narcotic effect :
Bradycardia : central vagotonic
effect & depresi SA- AV node
Respiratory depression :
respiratory rate, rhythm, Response
CO2, Minute Volume, Tidal Volume
Muscle stiffness
Nausea vomiting cause by
stimulation CTZ, GIT mobility,
decrease gastric mobility, increased
gastric volume

Clinical Doses of
Narcotics
Drug

i.v dose

Onset
(min)

Approximate
duration

Morphine
Meperidine
Fentanyl
Sufentanil
Alfentanil

0.05-0.3 mg/kg
0.5-1 mg/kg
1-5 ug/kg
10-40 ug/kg
30-80 ug/kg

5-10
5-10
2
<1
<1

3-5 h
2-3 h
45 min 2 h
< 30 min
< 60 min

MUSCLE RELAXANT

Relaksan
Depolarisasi

1.Sucsinilcholin
2.Decamitonium

Non Depolarisasi
1.Atracurium
2.Cisatracuium
3.Vecuronium
4.Rocuronium
5.Mivacurioum
6.Pancuronium

Pelemas Otot
Sangat berguna dalam anestesi

umum.
laryngoscopy dan intubasi lebih
mudah serta mengurangi cedera
Kelemasan otot sangat berguna
selama operasi dan kontrol
ventilasi

Pelemas Otot Ideal

Non depolarisasi
Onset cepat, short duration of action
Pemulihan cepat
Tak terakumulasi, tanpa metabolite

aktif
Tanpa efek cardiovascular
Bukan histamine release
Dapat dilawan dengan
anticholinesterase

Mekanisme
block neuromuskular
Block kompetitif : non-depol,halangi ikatan

AcCh dengan receptor.

Block Depolarisasi : depol, depolarisasi seperti
AcCh tapi permanent
Block Defisiensi : pengaruhi sintesa dan
pelepasan AcCh, Procaine, toxin botulinus, Ca
decrease, Mg increase.
Morgan GE, Mikhail MS. Clinical
Anesth, 1996

Obat
Depolarisasi

Hasilkan fascikulasi otot .

Efek kerja meningkat dengan obat
anticholinesterase, Acetylcholine,
hypothermia
Efek kerja menurun dengan obat non-depol
relaxant, anestesi inhalasi
Dosis Succ choline : 1 mg/kg

Obat Nondepolarisasi
Tak akan hasilkan fascikulasi otot
Efek kerja berkurang oleh anticholinesterase,

obat depolarisasi, suhu tubuh rendah,

epinephrine, acetylcholine
Efek kerja meningkat oleh obat non-depol,
volatile anestesi .

Table 9 - 5. Conditions causing susceptibility

to
succiniylcholine-induced
hyperkalemia.

Burn injury
Massive trauma
Severe intra-abdominal infection
Spinal cord injury
Encephalitis
Stroke
Guillain-Barre syndrome
Severe Parkinsons disease
Tetanus
Prolonged total body immobilization
Ruptured cerebral aneurysm
Polyneuropathy
Closed head injury
Near drowning
Hemorrhagic shock with metabolic acidosis
Myopathies ( eg, Duchenness dystrophy )

Table . A summary of the pharmacology of

nondepolarizing
muscle relaxant
Relaxant

Metabolism

Primary
Excretion

Onset

Duration

Histamine
Release

Vagal
Blockade

Relative
Potency1

Relative
Cost2

Tubocurarine

Insignificant

Renal

++

+++

+++

Low

Metocurine

Insignificant

Renal

++

+++

++

Moderate

Atracurium

+++

Insignificant

++

++

High

Mivacurium

+++

Insignificant

++

2.5

Moderate

Doxacurium

Insignificant

Renal

+++

12

High

Pancuronium

Renal

++

+++

++

Low

Pipecuronium

Renal

++

+++

High

Vecuronium

Biliary

++

++

High

Rocuronium

Insignificant

Biliary

+++

++

High

For example, pancuronium and vecuronium are five times more potent than tubocurarine or atracurium
2
Based on average wholesale price per 10 mL; does not necessarily reflect duration and potency
Onset
: + = slow;
++ = moderately rapid; +++ = rapid
Duration : + = short; ++ = intermediate;
+++ = long
Histamine release : 0 = no effect; + = slight effect; ++ = moderate effect; +++ marked effect
Vagal blockade : 0 = no effect; + = slight effect;
++ = moderate effect

Relaxation
Drug

ED95
(mg/kg)

Atracurium 0.21
Pancuronium 0.067
Vecuronium 0.043

Recommended Infusion rate

intubating dose for steady state
(mg/kg)
blockade
(mg/kg/h)
0.3-0.6
0.005-0.008
0.08-0.1

0.25
0.032
0.078

Mallampati/SamsoonYoung
classification