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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 Care-
Divisi 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:

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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N S
E R
N C
C O
N T
G E
E R
E M

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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 Perfusion Failure
measurements (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:
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
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
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
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
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 Obesity
Distinction must be BMI> 30
made between Increased risk in:
physiological state and DVT,
chronological age. Wound infections &
Are less mobile, Dehiscence
intercurrent disease, Respiratory complications &
less physiological sleep apnoea.
reserve. Intercurrent diseases.
Operative difficulty
Caution with regards to:
IVF & Narcotic analgesia. Relative risk of mortality
3-5
More likely to have
wound infection. Advise controlled wt
reduction
In 65 CVA 1%, In 80 CVA
3% Arrange ICU post-op

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RISK FACTORS III
CARDIOVASCULAR DISEASES
Predictors: CPCEN Action:
Major: Evaluation:
Unstable coronary Clinical, Specialist opinion, ECG,
syndrome. Stress ECG, CXR, Echo
Decompensated CCF. ..others
Significant Arrhythmias IF Major:
Cancel unless life threatening
Severe valvular disease Consider CABG prior to elective
Intermediate: surgery.
Mild angina If intermediate:
Objective performance.
PMH MI
Hypertension:
Compensated CCF Indicates CAD
DM More likely to develop
hypotension during surgery.
Minor Control prior to surgery.
Age, abnormal ECG..etc

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RISK FACTORS IV
RESPIRATORY DISEASES
Estimate function: Smoking
Clinical and Specialist opinion. 10 cigr.=6 fold increase in post-
ABG
op respiratory complications.
CXR
Spirometry: FEV1/FVC, PEFR
Respiratory and CVS effects
Chest infection:
Carbon monoxide has higher
affinity for O2 than Hb.
Postpone for 2 weeks
Antibiotics & Physio. Nicotine increases heart rate
and BP.
COAD
Leis with specialist Hypersecretion of thick mucus
Reschedule surgery. Immunosuppressive
Plan to transfer to ICU for Stop 3 months= improve
mechanical ventilation pulmonary functions
pending: Stop 1-2 days= Decreases CO
Lung function, type & duration levels.
of surgery.

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RISK FACTORS V
GASTRO INTESTINAL DISEASES
Malnutrition Jaundice poses a risk for:
Loss o15-20% of body wt is Sepsis
associated with severe Clotting disorders
impairment of physiological
function
Renal failure
No evidence of benefit of
Liver failure
preop feeding. Fluid and electrolyte
abnormalities
Drug metabolism
Adhesions:
Management:
Higher risk of bowel injury
and subsequent fistula
Vit k & FFP
formation Adequate hydration and
diuretics & oral Lactulose
Longer duration of surgery
Antibiotics
Nutrition.

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RISK FACTORS V
DIABETES
Interest to the surgeon: Management:
Patients are more sensitive Specialist Opinion required
to protein depletion, U&E&
glucose imbalance.
Surgical stress can NSC Minor LA
precipitate DKA.
DKA is a cause of acute 4 hourly close Type II
abdomen observations GA
Decreased phagocytosis, Omit dose in mane.
neutrophil activation and Either low dose infusion
antibody production or fixed dose insulin
Small vessel disease GIK Type I GA
Peripheral vascular disease G: 500 ml 10% dextrose
Peripheral neuropathy I : Insulin sliding scale
K : Potassium 10 mmol
Autonomic neuropathy
Continue till first light
Recognition of meal
hypo/Hyperglycaemic attacks

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RISK FACTORS V
RENAL & HAEMATOLOGICAL DISORDERS
Renal: Anaemia
Correction 1 week pre-op
Identify the cause: Correction day preop is undesirable
Pre-renal, eg: cardiac, Haemodilution
hypovolaemia
Renal, eg: acute tubular
necrosis( drug induces) Thrombocytopaenia
Post renal, eg: obstructive In splenomealy, Platelets must be
uropathy. transfused immediately preop and on
ligating the arterial supply.

Identify pt for renal


dialysis.
Sickle cell disease
Crisis caused by : dehydration,
infection, hypoxia, hypothermia.
Check K levels Jaundice & anaemia
Splenic infarctions: sepsis
Prevention: Warm, well hydrated, well
Accurate fluid balance analogised
Consider exchange transfusion in SS
Look for signs of fluid
overload.
Do not misinterpret poly Correction of coagulopaties
ureamic phase
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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 Class


Normal healthy individual 1
Mild-moderate systemic disease eg: DM, 2
BP
Severe systemic disease, NOT 3
incapacitating eg: CCF with limited
exercise tolerance
Incapacitating disease, constant threat to 4
life. with or with out surgery eg:
Uncontrolled angina
Moribund pt not expected to live, surgery 5
is the last resort.
Patient requiring emergency surgery. E
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ANESTHETIC MANAGEMENT
Preoperative Assessment
Laboratory Investigations
Monitoring
Induction
Maintenance
Recovery / Shifting to ICU

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A
PRIMARY SURVEY
B
C
D
E

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Airway
Breathing
Circulation
Disability (Neurology)

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 ook
Surgery
E valuate
Hematoma
M allampatti Obesity
Radiation
O bstruction
Tumor
N eck Mobility

Low Threshold for Surgical Airway


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Assess neck for access ( SHORT)
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TREAT
Simple airway maneuvers- Jaw Thrust, chin lift
Simple airway adjuncts- 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

Treatment Intercostal drain insertion


Sealing of the wound
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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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6 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
17
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 Transient Non


responders responders responders

Definitive Damage control Life Saving


surgery surgery Surgery

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NEUROLOGICAL

Quick GCS
Secondary Neurological damage
Hypoxia

Hypotension
Hypercapnia

Permissive Hypotension probably is not to be


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RADIOLOGY

X rays
Chest
Pelvis
C Spine lateral view
FAST
CT ????

Do Not Shift Hemodynamically unstable


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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
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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 pressure-

Dont 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. 16Penekanan
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7 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 pre-


operatif) :
Pemeriksaan ulang tensi, nadi, resp, temp, dll
Cek ulang ada gigi palsu, gigi goyah
Cek Ulang hal-hal yang merupakan kontra-
indikasi anestesi (lihat kuliah persiapan pra-
anestesi)
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
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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 :
* Ether
* Halotan + N2O/O2
* Enfluran + N2O/O2
* Isofluran + N2O/O2
* Sevofluran , dll
5. Mengakhiri tindakan anestesia Obat anestesia
dihentikan pemberiannya
6. Fase Pemulihan Di ruang pulih (Recovery Room)

Monitoring penderita Refleks -refleks (+) / sadar

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Penderita
7 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
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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
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7 - Hyperthermia:
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Terutama beresiko pada pasien dengan febris sebelum B E N C A N A Poperasi
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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. /1 Observasi akibat yang ditimbulkan
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PROBLEM PASCAOPERATIF BEDAH PERUT
EMERGENSI YANG HARUS DIPERHATIKAN:
- 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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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
7 D. Dasar-Dasar Anesthesia IIb-III. FK UNSRAT, 2010.
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