dr. H.

Atik Sutisna, SpA

Vice Dean for Academic affair
Lecturer of Anaesthesiology and
Reanimation,
Faculty of Medicine, Unswagati ,
Cirebon
Vice Director for Medical services and
Nursing
Head of Anaesthesia and Intensive Care
Unit
Putera Bahagia Hospital, Cirebon
1. MANAGEMENT OF ANAESTHESIA
2. MANAGEMENT OF INTENSIVE CARE
3. MANAGEMENT OF EMERGENCY CARE
4. MANAGEMENT OF RESUSCITATION
5. MANAGEMENT OF CARDIOPULMONARY
SUPPORT
6. MANAGEMENT OF UNCONCIOUS PATIENT
7. MANAGEMENT OF TETANIC PATIENT
8. MANAGEMENT OF FLUIDS THERAPY
9. MANAGEMENT OF PARENTERAL NUTRITION
10. MANAGEMENT OF PAIN
GENERAL ANAESTHESIA :
1. INTRA MUSCULER ANAESTHESIA
2. INTRA VENOUS ANAESTHESIA
short acting intravenous anaesthesia
continuous acting intravenous anaesthesi
3. INHALATION ANAESTHESIA :
nasal canule
facemask
endotracheal intubation
REGIONAL ANAESTHESIA :
INFILTRATION ANAESTHESIA
NERVE BLOCKADE ANAESTHESIA
GANGLIONIC BLOCKADE ANAESTHESIA
SPINAL BLOCKADE ANAESTHESIA
EPIDURAL BLOCKADE ANAESTHESIA
CAUDAL BLOCKADE ANAESTHESIA
ANAESTHESIOLOGY AND REANIMATIOn

Dr H Atik Sutisna, SpAn

the TRIAD of anaesthesia :

HIPNOTIC SEDATION :
induction agents
RELAXATION :
muscle relaxant
agents
ANALGESIA :
narcotic analgesia
Some principal rules in modern
anaesthesiology, espescially for
general anaesthesia :
rapid induction and rapid awake
use low flow gas inhalation
operators need is relaxation
patient
use narcotics without hang over
effect
the failure of anaesthesia : patient
AMERICAN SOCIETY OF
ANAESTHESIOLOGISTS

ASA 1 :
perfectly healthy
patient has not physical, physiological,
biochemical or psychiatric diturbance.
 ASA 2 : Mild systemic desease : not
serious enough affect for everyday
activities
mild diabetes, mild asthma
anaemia, obesitas
heavy smoker or alcoholic
children under 5 years old
over than 50 years old
 ASA 3 : significant but
stable systemic desease :
Limiting organic heart desease
Severe diabetes
Severe lung desease
Angina pectoris
Old myocard infarction
 ASA 4 : systemic desease which is
a threat to life :
heart failure, uncontrlled asthma
hepatic/renal failure

ASA 5 : moribund patient unlikely to

survive in 24 hours with or without
operation
 RESUSCITATION : should
correct any problems SAFETY
FIRST for a patient and
anaesthesiologist
oxygen suply
anaesthetic machine : how about oxygen flush
resuscitation kit
endotracheal tubes
medical emergency agents and anaesthetic
agents
Patient preparation :
fasting : espescialy for elective
operation with general anaesthesia :
adult : 6 hours for last intake
children : 4 hours
in emergency case : patient with full
stomach
rapid sequence of induction or regional
anaesthesia
 Pre operative patients visite :
ask for patients medical use
smokers ?
physical,laboratory and radiologic
results etc
intruction for intravenous fluids
premedication :
protect for vagal reflex
protect for hyper salivation /hyper secretion
 Premedication agents : its must
prepare and always use
sulfas atropine

Induction agents :
1. Ketamine hydrochloride : the most
safety anaesthetic in the world
2. Ultra short acting barbiturates :
Recofol etc
 Gas agents : N2O/O2

Voletile agents : isoflurane

sevorane

Muscle relaxant agents :

depolarizing muscle relaxant
non depolarizing mucle relaxant
 Narcotic analgesia agents :
Petidine : 1 mg/kg bodyweight
Morphine : 0,1-0,3 mg/kg bodyweight
Fentanyl : 0,05-0,1 mg/kg bodyweight
1. Ketamine hydrochloride
can be used for all average age
can be used under certain
circumtances, such as failed intubation
intramuscular : 8-13 mg /kgBW
intravenous : 1-3 mg/KgBW
infusion : 1-3 mg/kgBW/hour
to decreased a excesive effect, used
midazolam ,espescially before ketamine
 Advantages :
sleeping beauty
after awakeness : still satisfaction
until the analgetic effect was gone
good analgesic
it allows spontaneous ventilation
without hang over effect
not pulmonary depression, but some
times should be depression of
respiratory centre(medulla oblongata)
Disadvantages :
the chance of awareness
tachycardia
Increased blood flow : heart, brain,
renal etc
Increase inotropic effect of the heart
Increase muscle tone
Increase epiglotis/nasopharynx reflex
Increase orotracheal secretions
dreams and hallucinations
2. Ultra short acting barbiturates :
Profopol derivates
2-3 mg/KgBW

Advantages :
rapid induction and rapid awake
without hang over effect
without dreams and halllucination
good for cerebral vascularitation
Disadvantages :
irritable agent : aches, hot effect, necrosis
to the muscle ( do not use intramuscular inj)
use only intravenous injection
Respiratory depression : central and perifer
decrease blood flow
decrease inotropic effect of the heart
without Analgetic effect

do not use to children under 5 year,

must be careful monitoring if use to 5-
12 year old
Nitrous oxide (N2O/O2)
first used : a dentist
it is the only one inorganic gas used in
clinical anaesthesia
for identification : stored in steel
cylinders colored blue ( O2 : white)
Colorless, tasteless, sweet odor
1 times heavier than air, espescilly
than O2 ( need about 5 minutes
oxygenitation after N2O release as
anasthesia, to prevent diffusion anoxia
 weak anaesthetic but enough analgetic for
short term operation
Little effect to the heart rate, blood flow,
myocardial contractility, respiration, blood
pressure, metabolisme and emesis
rapid induction, nonirritating
nonflammable, nonexplosive but supports the
combustion other flamable gases
very safe anaesthetic agent if O2 supplied in
sufficient concentration (minimally 30 % of O2)
Non muscular relaxation
1. Chloroform :
clear, sweet-smelling, non irritating
rapid induction and recovery
good muscle relaxation
noninflammable,nonexplosive
myocardial depressant
hepatotoxic
2. Diethyl ether
colorless, very smell
depth anaesthesia
stimulated respiration,bronchodilator
not depressed circulation
Good muscle relaxant
prolonged induction and recovery
irritating, hyper secretion, emetic
flammable and explosive
3. Isoflurane and Sevoflurane ( newest)
good patient acceptance,pleasant
rapid induction and recovery
nonirritating, no secretion
bronchodilator
nonflammable, nonexplosive
depressed cardiovascular system, but not
the cardiac rhythm
non emetic,nonflammable,noneexplosive
in depth of anaesthesia : decline the
blood pressure, elevated pulse rate
good cerebral vascularisation ( sevorane
is best for cerebral operation : stroke,
cerebral haemorhage /trauma capitis)
shivering
liver intoxication
not used in renal failure
expensive
1. Depolarizing MR ( succinylcholine)

similarly to acetylcholine, but more

stronger affect by receptor
fasciculation follow by flaccidity
effect are increase by antichlinesterase
agents, lowered body temperature
Twitching
depressed hepatic function
 not depressed cerebral function, the
patient still awake
best fascilation for endotracheal
intubation
onset of action : 30-60 seconds
Duration of action : 1-3 minutes
NO ANTIDOTUM
dose : 1 mg/Kg BW, intravenous
2. Nondepolarizing MR ( competitive Inhibitor )

preventially bound to cholinergic receptors,

competition with acethylcholine
no muscular contraction/fasciculation,
no twitching effect
not to decreassed hepatic and renal function
not so good for fascilatation of endotracheal
intubation as like as depolarizing MR
 onset of action 1-3 minutes
duration of action 10-15 minutes
antidotum/reversed by
anticholineesterase drugs ( such as
neostigmine), but must be used
atropine sulphate, before or together
with neostigmine)
dose : 0,4-08 mg/kgBW, intravenous
 Narcotic agents are potent analgesics
which are effective for the relief of severe
pain.
without pain".
respiratory depression, nausea, and
drowsiness.
produces tolerance, psychic, and physical
dependence addiction.
If the drug is discontinued
withdrawal symptoms
 1)Morphine and codeine - natural
alkaloids of opium.
2) Synthetic derivatives of morphine
such as heroin.
3) Synthetic agents which resemble the
morphine structure.( ec phetidine Hcl )
4) Narcotic antagonists which are used
as antidotes for overdoses of narcotic
analgesics.
 The main pharmacological action
cerebrum and medulla of the
central nervous system.
Another effect is on the smooth
muscle and glandular secretions of
the respiratory and gastro-intestinal
tract.
 MORPHINE
standard analgesic narcotic drug
dpresses the central nervous
system, including respiration and
cough reflex centers, constipation
broncho constrictor
miosis
Dose : 0,1 0,3 mg/kgBW, intra
venous
 FENTANYL
powerful narcotic analgetic
respiratory depression
euphoria, sometimes hypotention
rigidityu of muscle : thorax,
abdomen, extrimitaies
miosis
 PHETIDINE
morphine derivate (sinthetic)
dose : 1mg/kgBW
1/10 strongly to morphine
miosis

NARCOTIC ANTAGONISTS

Naloxone ( Narcan ) : 0,2-

0,4 mg/kgBW
 Morphine and codeine are contained in
opium from the poppy (Papaver
Somniterum) plant found in Turkey,
Mexico, Southeast Asia, China, and India.
This plant is 3-4 feet tall with 5-8 egg
shaped capsules on top.
Ten days after the poppy blooms in June,
incisions are made in the capsules
permitting a milky fluid to ooze out.
The following day the gummy mass (now
brown) is carefully scraped off and
pressed into cakes of raw opium to dry.
Heroin:
Heroin is synthesized from morphine by a
relatively simple esterification reaction of
two alcohol (phenol) groups with acetic
anhydride (equivalent to acetic acid).
Heroin is much more potent than
morphine but without the respiratory
depression effect. A possible reason may
be that heroin passes the blood-brain
barrier much more rapidly than morphine.
Once in the brain, the heroin is hydrolyzed
to morphine which is responsible for its
activity.
 Meperidine ( Phetidine )
it is most common subsitute for
morphine.
analgesic, local anesthetic, antihistamine.

Methadone:
more active and more toxic than
morphine.
is used as a narcotic substitute in
addiction treatment because it prevents morphine
1. SPINAL BLOCKADE ( subarachnoid or
intrathecal blockade )
by injecting the local anaesthetic
(hyperbaric) into the spinal subarachnoid
space ( show by cerebrospinal fluid at
the canule of spinal needle )
The patient is conscious
danger situation : the local anaesthetic
through into the brain, carriying by
cerebrospinal fluid depressed
the brain function
 Mechanisme of action : symphatic
nerve system blockade
vasodilatation of the area under the blocked
was take it
.
the blood through the vesels to fill it with
a large of volume decrease of blood
volume in the heart decrease of cardiac
output

HYPOTENTION
 to protect hypotention effect :
1. vasopressor drugs :
ephedrine hcl
dopamine/dobutamine
2. Intravenous fluids therapy :
cristaloid
coloids
do not use
dextrose infusion
 EPIDURAL AND CAUDAL BLOCKADE
to inject the drug to the epidural/
caudal space show by negative
pressure at the shiring injection.
should be single blockade/one
shoot
or continuous blockade by
using epidural catheter for long time
operation need
REGIONAL ANAESTHETICS :

Infiltration /nerve/ganglionic blockade

** Procaine/Lidocaine/xylocaine 1-2 %
** Bupivacaine/Marcaine : 0,5 %
Spinal blockade :
Lidocaine/xylocaine/marcaine : 5 %
Epidural/caudal blckade :
Lidocaine/xylocaine / Marcaine :
0,5 %