Anestesi Pediatri

Menghilangkan stress, baik fisik maupun

psikis akibat tindakan tindakan medik
terhadap bayi atau anak dengan aman.
Langkah awal untuk mencapai tujuan
tersebut adalah memahami fisiologis dan
anatomi bayi yang sangat berbeda
dengan orang dewasa.
 1. Airway (Jalan Nafas)
2.Sistem Pernafasan
3. Sistim kardiovaskuler
4. Kebutuhan cairan-elektrolit-
metabolisme
5. Pengaturan suhu tubuh
6. Psikologi
Jalan nafas mudah tersumbat :
1. Kepala relatif besar
2. Leher lebih pendek
3. Lubang hidung (nares) sempit
4. Lidah besar
5. Epiglottis besar, terkulai dan berbentuk U
6. Edema jalan nafas dapat fatal
 Child has smaller nose-------------------------.----,
and mouth.

In child, more space is-------------=----------:::----

taken up by tongue.

Cricoid cartilage is less rigid and --------c::----=--------

less developed.

Airway structures are more easily--------;.;:;;;;;;;;;:;;;;;;;;;::::::::;;:;:;:::;;;;;:=.,......

obstructed.

=::..J.---- proportion to
mouth
Phamyx is smaller
--- -=+------..-+----Tongue

----+-----
is larger in
Epiglottis,islarger
,and flqppier
Lamyx is
more antenor
------ and su,perior
L-r------- Narrowestalaicoid
+---------- Trachea narrow and less rigid

Adulfs Upper 011Ud's

Airway Uppe, f,J Copvngt 2008 EMT-Natl<mal-
Trlllnlng.com
Expansi paru2 terbatas :
1. Rongga dada sempit
2. CTR anak > dewasa
3. Abdomen besar
4. Diafragma tinggi
5. Posisi iga horisontal
6. Otot intercostal belum sempurna
 Dewasa Anak/bayi
 Normal Edema Resistance
Cross-
1 mm (R ex: 1 are )
sectional radius4 a

Infant t 16x !
75/o

Obstructed
Adult f3x
 Nadi bayi 120-180
Nadi anakumur 4 tahun 100
Nadi anak umur 10 tahun 90

Pada anak bradicardi lebih ditakutkan

daripada takikardi.
Pengamatan tensi lebih penting karena
batasan keamanannya sempit sehingga
mudah jatuh ke dalam keadaan shock
 Mudah bradikardi :
* Nyeri
* Rangsangan jalan nafas - Intubasi
- Suction
* Hipoxia , Hiperkarbia.
* Pemberian obat tertentu
Bradikardi ~ cardiac output yang menurun :
* Stroke volume fixed
* Prevensi/terapi Sulfas Atropin.
 Batas keselamatan sempit
* Estimated Blood Volume (perkiraan jumlah darah)
bayi 85 ml/kg = 250 ml
dewasa 65 ml/kg = 3500 ml
* Perdarahan 50 ml sesuai dengan presyok
* Mudah overload.(cairan berlebihan).

Hemoglobin
* 12 19 g%
* HbF 80% mengakibatkan affinitas ikatan terhadap
Oksigen meningkat
* Hematokrit 50%.

Kelainan Kongenital JAntung

* ASD , Potent Ductus Arteriosus, Tetralogi Fallot.
 Rumatan/Kebutuhan sehari-hari.
* Keringat.
* Eksresi
* Uap pernafasan.
* Pertumbuhan.
Cairan Pengganti.

* Perdarahan ( > 10 % EBV ).

* Trauma karena pembedahan ringan sampai besar
(3-10ml/kg/jam).
* Continuing/ongoing loss
Pipa lambung,drainase luka,
- Drainase rongga tubuh.
 4 ml/kg/jam 10 kg bb pertama.
+ 2 ml/kg/jam 10 kg berikutnya.
+ 1 ml/kg/jam untuk berat badan diatas 20 kg.
Contoh:
Bayi 8 kg. kebutuhan cairan rumatan = 8 x 4 =
32 ml/jam.
Bayi 12 kg. kebutuhannya = 10 x 4 = 40 ml/jam
2 x 2 = 4 ml/jam
44 ml/jam
Bayi 25 kg. berapa kebutuhan cairan rumatan ?
TAB'LE 5-6 elllod to Metabollc Rates D
Crl
Predk 1 I ring
ca ess
Averag Hospit Energy RJeq;lllli
e al! rem ents ,Cf'. . I H5 r (Y Expend
I i E) r
it I r
B w 1 St ass
Oto, 1001 .2. , !IJ
'

.ever per
Oto 1000 ,_ >3 .
.20 lVkg ardl c ..
150
failure i %, to
>20 0 + 25%
.2i0/kg 1a.j or
20%,
surgery to30%
Bums Up to
evere 100%,
M.od1fierl from Holli day MA: Fluid and nutrition support. d MAJ
rnn Holl sepsis
Barratt
'T Avner ED, editors: Pediatric nephrolfJM 0%, to50%
.
ed 3 .. ii iams and ilkins, l
Baltimore. 9MJ
 Natrium - 2 4 mEq/kg/hari.
Kalium - 1 3 mEq/kg/hari.
Chlorida - 2 3 mEq/kg/hari.
Calcium - 40 80 mEq/kg/hari.
Phosphor - 20 45 mEq/kg/hari.
Magnesium - 6 10 mEq/kg/hari.
 Cadangan glikogen sedikit.
* kebutuhan kalori 30 100 kcal/kg/hari.
Jadwal puasa.
* 10 20 g/kg/hari.
* mulai dengan glukosa 5% -- 20%disesuaikan
dengan jam pembedahan.
Infus mengandung glukosa
 Poikilotermis.
* luas permukaan tubuh > dewasa.
* lemak subkutan minimal.
* kehilangan panas
- Radiasi
- Konveksi
- Evaporasi,
-Konduksi.
 1 2
+

F G E 6-3. Schematic illustration of the four mechanisms

contributing to perioperative hypotherm i : (1) conduction, (2)
ev poration (3) convection, nd (4) radiation. (Modified from Gurtner
C, Paul 0, Bissonnette B: Temperature regulation: physiology and
pharmacology. In Bissonnette B, Dalens 81 editors: Pedi tric
anesthesi
principles and practice, New York, cGraw-
2002, HiJ/.)
 Non-shivering thermogenesis.(sebagai
kompensasi produksi panas bila suhu
turun).Kompensasinya dengan oksidasi brown
fat konsumsi O2 >
- asam lemak bebas> - asidosis metabolik
Suhu sekitar netral.
* selimut,topi,matras hangat.
* cairan infus hangat.
* suhu kamar bedah.
 Psikotrauma - gangguan perilaku.
Usia 2 5 tahun psikis labil.
Nyeri fisik :
* jarum suntik.
* luka pasca bedah.
* penggantian bebat
Rasa tidak nyaman :
* pusing , mual , muntah.
* infus , kateter , drain, pemasangan nasogastric tube,
ventilasi mekanik.
Stress emosional :

* pisah dari orangtua.

* bau2an , suara2 di RS/kamar bedah.
* penglihatan yang mengganggu
 PERSIAPAN PRA-ANESTESI.
PELAKSANAAN ANESTESI.
PERAWATAN PASCA-ANESTESI.
 ANAMNESA/HETEROANAMNESA.
PEMERIKSAAN FISIK & LABORATORIK.

* masalah anestesi.
* masalah pembedahan.
* masalah penyakit utama/penyerta.

TINDAKAN2 PENCEGAHAN PENYULIT.

TEHNIK & OBAT ANESTESI.
A. PERSIAPAN PASIEN
1. ANAMNESA / Kunjungan pra-anestesia

2. PEMERIKSAAN FISIK

3. PEMERIKSAAN PENUNJANG

B. PERSIAPAN ALAT DAN OBAT

 Riwayat kesehatan ibu selama hamil, adanya
pemakaian obat-obatan ataupun alkohol,
merokok, diabetes dan infeksi virus
Pemeriksaan kehamilan sebelum melahirkan : usg
Umur kehamilan saat melahirkan bayi, nilai
APGAR bayi
Adanya infeksi saluran nafas atas saat ini,
trakeobronkitis, asma, riwayat snooring, episode
sianosis
Posisi bayi/anak saat tidur ( terlentang, miring
lateral, telungkup)
 Riwayat perawatan di rumah sakit sebelumnya
Kelainan kongenital, kelainan metabolisme
ataupun adanya suatu sindroma
Riwayat perkembangan dan pertumbuhan pasien
Adanya retardasi mental
Riwayat operasi dan anestesi sebelumnya
Riwayat alergi
Kecenderungan perdarahan bila terjadi luka
Riwayat penggunaan obat-obatan saat ini
 PEMERIKSAAN FISIK
Status fisik secara umum, meliputi kesadaran, tingkat
aktivitas pasien, interaksi sosial, warna kulit, tonus
otot, kelainan kongenital yang ada, ukuran dan lingkar
kepala
Vital sign, tinggi dan berat badan, status nutrisi, status
hidrasi
Kondisi gigi, kelainan craniofacial, ataupun adanya
tonsil yang besar yang dapat menyulitkan penguasaan
jalan nafas
Tanda infeksi saluran nafas atas atau asma. Sekresi di
jalan nafas
Pemeriksaan bunyi jantung ( adanya murmur)
Kemungkinan lokasi untuk pemasangan akses
intravena
 DL rutin tidak perlu dilakukan pada anak yg sehat dengan
operasi minor
Hb 10 g%
Pemeriksaan penunjang sesuai indikasi :
Faal hemostasis susp. Gangguan pembekuan darah dan
operasi dgn perdarahan banyak
Urinalisis jarang diperlukan
Fungsi ginjal : BUN & SC
Fungsi liver
Pada pasien yang diketahui adanya risiko kelainan hati
Menjalani prosedur yang akan mengganggu fungsi hati
Ro thorax
EKG
Serum elektrolit, albumin
Gula darah
USIA LAMA PUASA (JAM)
MAKANAN PADAT MAKANAN CAIR
< 6 BULAN 4 2-3
6-36 BULAN 6 2-3
> 36 BULAN 8 2-3

Asi dapat diberikan s/d 4 jam preoperative

ALAT :
1. Masker + jackson
reese
2. Oropharyngeal tube
3. Endotracheal tube
4. Laryngoscope + blade
5. Plester fiksasi
6. LMA
7. Bantal intubasi + bantal
donat
8. Mesin anestesi +
sumber oksigen
9. Suction catheter
10. EKG electrode +
monitor
11. Stetoskop prekordial
12. Saturasi O2
13. Tampon + Mcgill
14. Nasogastric tube
15. Salep mata + plester
16. Temperatur
17. Matras penghangat
18. Penghangat infus
 Obstruksi jalan nafas & expansi paru <.
* bantal punggung.
* dead space mekanik <.
* sistim anestesi inhalasi ringan,tanpa katup.
Kardiovaskuler & hemodinamika.
* siap Sulfas Atropin.
* pediatric infus set + burette.
* observasi perdarahan teliti.
* pembedahan pagi.
Pencegahan hipo/hipertermi.
Pencegahan trauma psikis.
* pendekatan psikologis.
* pendekatan farmakologis.
 Pembedahan jalan nafas & posisi telungkup.
* intubasi trachea.
Perdarahan.
* siap darah.
* infus lancar.
* perkiraan perdarahan cermat kassa ditimbang.
Pembedahan darurat.
* rehidrasi/transfusi.
* terapi oksigen.
* pengosongan lambung.
 PREMEDIKASI.
INDUKSI.
RUMATAN ANESTESI.
 SEDASI
ANALGESIA
PENGERING JALAN NAFAS
VAGOLITIK
ANTIEMETIK
AMNESIA
 SEDATIVA/AMNESIK.
* Benzodiazepines diazepam , midazolam.
* Antiemetika dehydrobenzperidol (DHBP).
* Antihistamin promethazine (Phenergan).
ANALGETIKA.
* Narkotik morphine , pethidine,fentanyl
VAGOLITIK/PENGERING.
* Sulfas atropine.
* Scopolamine.
Pasien relatif kooperatif :
Diazepam oral 0.2-0.3 mg/kgbb
Ketamin oral 4-6 mg/kgbb
Fentanyl lolypop 5-15 gkgbb pasien dgn nyeri
(trauma) atau prosedur operasi kelainan jantung
Pasien tidak koopertif :
Midazolam im 0.1-0.15 mg/kgbb
Ketamin im dosis rendah 2-3 mg/kgbb
Premed antikolinergik im tidak dianjurkan iv saat induksi
Bila resiko refluks astroesofageal : metokloperamide 0.1
mg/kg + simetidin 7.5 mg/kg atau ranitidin 2 mg/kgbb iv)
Obat-obat preoperative lain tetap diminum : obat asma,
epilepsi, hipertensi, dll
 < 1 TAHUN.
* inhalasi overface.
*parenteral.

> 1 TAHUN.
* inhalasi overface + orangtua
* parenteral intramuskuler , intravena.
* perrectal.
 Induksi inhalasi : halotan, sevoflurane
Yang lain tidak bisa karena berbau,
menimbulkan batuk, menahan napas dan
laringospasme (desflurane atau isofurane)
Induksi intravena : ketamin, penthotal,
propofol
Induksi intramuskular : pasien yang sangat
tidak kooperatif dan mengamuk / gelisah
ketamin
Induksi perrektal : ketamine, pentotal,
midazolam
 PER-INHALASI.
* ether.
* halothane. + O2
* enflurane.
* isoflurane.
PAR-ENTERAL.
* ketamine yang mengakibatkan dissociative
anesthesia.
 Ringan sesuai dengan resistensi pernafasan / <
Dead space mekanik minimal.
Contoh :
* Schimmelbusch mask. * Jackson Rees
apparatus.
* Ayres T-piece. * Pediatric Circle System.

Perlengkapan lain.
* laryngoskop. * jalan nafas orofaring.
* penghisap. * pipa endotrakheal.
* obat2 darurat.
1. MONITORING DURANTE OP
a. Airway tetap bebas ( ETT terfiksasi dengan baik)
b. RR, amplitudo, suara nafas, saturasi O2, ETCO2
c. Perfusi, Nadi, tekanan darah, EKG, stetoskop
prekordial
d. Produksi urine 0,5 cc/kg/jam dan keseimbangan
cairan
e. NGT
f. Suhu (axilla , rectal , oesophagus).
g. Gula darah
hipoglikemia diterapi dengan 1-3 ml/kg glucose
20% i.v dalam 5 menit
 RR HR TD TD
sistolik diastolik
Neonatus 40 140 65 40
12 bln 30 120 95 65
3 th 25 100 100 70
12 th 20 80 110 60
 Bradikardia :
Bila karena hipoksia diterapi dengan cara ventilasi
& oksigenasi adekuat akan mengembalikan
denyut jantung
Bila karena Reflek vagal : contoh pada operasi
mata, usus diterapi dengan cara meminta operator
berhenti sementara dan pemberian Sulfas Atropin
0,5 mg (2 ampul) secara intravena
Bila karena peningkatan Tekanan Intra Kranial
maka dilakukan hiperventilasi, diuretik, operator
diminta untuk berhenti sementara
 Endotracheal Tube terlepas, kinking maka dilakukan
fiksasi yang baik ,dan pemasangan tampon
Perdarahan
Dehidrasi harus dilakukan reasses dehidrasi yang
baik dan rehidrasi sehingga harus diperhatikan cairan
maintenance + evaporasi
Nyeri diberikananalgetika
Bila Hipotermi maka pasien dihangatkan dengan
bantal penghangat, penghangat infus
Bila Hipertermi maka dilakukan kompres dingin, buka
pembungkus extremitas, suhu ruangan didinginkan
 REGIONAL

KOMBINASI REGIONAL dan GENERAL

 RA only :
Reduces the risk of post operative
apnoea in pre mature children.
Over night monitoring must be there
In older age group RA can not be done
alone.
 Keuntungan Regional anestesi:

Safe, reliable technique in infants at risk of

apnoea, bradycardia and desaturation after GA

Good alternative for day care surgeries

Minimal risk of postoperative respiratory

depression

Limited stress response to surgery

Cost effective
 KOMBINASI RA + GA :
Usually RA for anaesthesia and also for post
operative pain relief
Single caudal
Continuous epidural / caudal
Peripheral nerve blocks
Field blocks
Local infiltration.
 Contra-indications:
Parent refusal
Sensory nervous system diseases
Serious sepsis
Bleeding disorders
Vertebral malformations

Previous surgery on spines

Allergy
 Acceptable environment for performing
regional blocks:
Minimal mandatory monitoring
Anaesthetic and emergency drugs
Resuscitation equipments
Trained anaesthesiologist
Trained staff
iv line in situ
 Most common regional block in children
Simple to perform
Easily adaptable to ambulatory anesthesia
practice
Greatly decreases risk of reflex laryngospasm
 Sacral hiatus easy to identify
Palpable large bony processes on each side of
hiatus called cornua
Hiatus covered by sacrococcygeal membrane
Dural sac may extend to S3 or S4 in infants
(short distance between hiatus and dural sac)
 I

Figure 3. The sacral hiatus is relatively more cephalad in infants. (From McClain B:
Pediatric Caudal Anesthesia, Medical College of Georgia, Augusta, 1990; with permission.)
 Lateral decubitus position
Palpate coccyx
Move finger gently from side to side and
proceed in cephalad direction
First double bony protuberance encountered
are sacral cornua which define the sacral
hiatus
KIDDIE CAUDAL

B
.
 Major complications rare
Intravascular injection with systemic toxicity
Dural puncture causing high spinal blockade
Infection (especially after interosseous
puncture/penetration)
CAUDAL ANESTESI
Caudal block procedure. A, Insertion of the needle at right angles to
the skin in relation to the coccyx (1) and the sacrococcygeal
membrane (2). B, Cephalad redirection of the needle after piercing
the sacrococcygeal membrane.
 Anatomy and physiology:
The spinal cord and dural sac of infants younger
than 1 year of age end at a lower level
Volume of CSF
a. 10 mL/kg in neonates
b. 4 mL/kg in infants weighing less than 15 kg
c. 3 mL/kg in children
d. 1.5 to 2.0 mL/kg in adolescents and adults

50% CSF volume is located within the spinal

subarachnoid space versus 25% in adults
Lower CSF hydrostatic pressure
Children older than 5yr behave like adults after
spinal anaesthesia, whereas younger patients
remain hemodynamically stable, without
 Indications:
Inguinal hernia repair in former preterm infants
<60 weeks of postconceptual age
Elective lower abdominal or lower extremity
surgery
Cardiac surgery or cardiac catheterization
(controversial)
 Spinal anaesthesia: Technically similar to
adults. Not very commonly done procedure,
must have IV access, 1.5 inch 25 G beveled
needle.
Dose: 0.3-0.6 mg/kg of 0.5 % Bupivacaine
heavy. Higher the age, lower the dose and
vice versa
 Improved surgical outcomes:
Decreased stress response
Fewer episodes of hypoxia
Decreased cardiac morbidity
Decreased pulmonary infections
Decreased thromboembolic events
Decreased blood loss
Faster return of GI function
 Drugs Used:
Ropivacaine/Bupivacaine
2 - Chloroprocaine
Morphine
Clonidine
 Complications:
Intrathecal injection
High block
Postdural puncture headache
Intravascular injection/Local anesthetic toxicity
Sympathectomy
Hypotension
Bradycardia
 Complications:
Opioid induced respiratory depression
Damage to neural structures
Infection
Epidural Hematoma paraplegia
< 1 in 150,000
Usually associated with anticoagulation
Epidural anesthesia

2 1

Epidural block procedures: sacral intervertebral approach (1), lumbar

approach (i.e., midline route) (2), and thoracic approach (i.e., midline
route) (3).
PERIPHERAL BLOCKS
 Penile block (Dalens sub pubic block):
 Provides analgesia after superficial surgery of
penis
Circumcision
Meatotomy
Blocks both dorsal nerves at base of penis
Anesthesia to distal two-thirds of penis
 Usually performed by surgeon
Avoid epinephrine
May lead to ischemia of tissue
Complications:
Intravascular injection
Hematoma formation
 Simple subcutaneous ring block at the root of
the penis is sufficient but duration is only for
2-4 hrs.
UPPER LIMB BLOCKS
 Brachial plexus block:
It can be sole anaesthetic or as an adjuvant to
GA or for post OP analgesia or for
sympathetic blocks. It should not be used for
trivial reasons. Age is not a contra-indication
for this block. Must be associated with GA.
PNS or USG can be used to locate the nerves.
 Inter scalene block:
 Supra clavicular block:
 Axillary block:
Axillary approaches

)
-: 1
2

Axillary approaches to the brachial plexus: classic approach (A) and

transcoracobrachialis approach (B), indicating the pectoralis major muscle (1),
axillary artery (2), and coracobrachialis muscle (3).
LOWER LIMB BLOCKS
 Femoral nerve block:
 LATERAL CUTANEOUS NERVE OF THIGH
(LCNT) BLOCK:
 Sciatic nerve block (L4 S2):

Fig 4. Posterior approach to the sciatic nerve. Injection point (X) at midpoint of a line
between the lschlal tuberoslty and fibular head. The apex of the popllteal fossa and the
edge of biceps femorls are also marked.
 Simple Block
Good pain relief for hernia repair,
hydrocelectomy and orchiopexy
Can be done at beginning of case for both
intraop and postop analgesia
May be done intraop under direct
visualization
 .,#,l-Area
'
Infiltrated
Anterior Superior--,. with Local
Iliac Spine Anesthetic

Figure 1. llioinguinal and iliohypogastric nerve blocks are performed by infiltrating tlu
abdominal wall muscle medial to the anterior superior iliac spine. (From Hannallah R, Epsteir
B: The pediatric patient. In Wetchler BV (ed): Anesthesia Ambulatory Surgery. ed 2
for Philadelphia, JB Lippincott, 1991; with permission.)
 Pemantauan sistim pernafasan & kardiovaskuler.
Temperatur > 35 derajat Celsius.
Posisi miring/semiprone.
Nyeri pasca-bedah.
Bisa memakai fentanyl, ketorolak, acetaminopen
rektal, pethidin
Antisipasi penyulit pasca-bedah.
* edema larynx.
* laringspasme
* aspirasi.
* perdarahan.
Kebutuhan cairan , elektrolit , kalori.
TERI MA
KASIH