CPA Tumor

Perempuan, 45 Tahun
Diagnosa: Petroclival Meningioma
 Anamnesis
Keluhan Utama : Nyeri kepala
Telaah : Hal ini dialami pasien sejak 4 tahun yll. Nyeri
semakin lama semakin memberat. Pasien sebelumnya
sudah pernah berobat ke RS HAM dan di diagnosa dengan
tumor otak. Dalam 6 bulan terakhir pasien mengeluhkan
sudut mulut jatuh ke kiri, penciuman menghilang sebelah
kiri. Pasien juga mengeluhkan mata kiri kabur perlahan-
lahan. Riwayat Kejang (-) Riwayat muntah (-) Riwayat
pingsan (-) Riwayat trauma (-) Riwayat VP Shunt di RS
Ham tgl 5/12/2018. Riwayat demam (-). Riwayat penyakit
terdahulu: Hipertensi (+), tidak rutin minum obat.
 Pemeriksaan Fisik di Ruangan

• B1 : Airway : clear, RR: 20 x/i, SP: Vesikular, ST: -, S/G/C: -/-/-,

MLP 1, JMH > 3 cm, GL bebas. Riw. asma/sesak/batuk :-/-/-

• B2 : Akral : H/M/K, TD : 150/90 mmHg, Pulse Rate: 94 x/i,

reguler, T/V: kuat/cukup, T : 37,2 C

• B3 : Sens : Compos mentis, pupil isokor, ø 3mm/3mm, RC +/+ ,

visus OD: 6/6 OS: 1/∞, Sudut mulut jatuh ke kiri, anosmia (S)

• B4 : UOP(+), volume cukup , warna kuning

• B5 :Abdomen: soepel, peristaltik (+)

• B6 : Oedem pretibial (-), Fx (-)

 Penilaian nyeri (Numeric Rating
Scale)
P : Sewaktu-waktu

Q : Berdenyut

R : Kepala

S : 2-3 (nummeric scale)

T : sejak 6 bulan, hilang timbul

 Penanganan di Ruangan

1) Head Up 300
2) Terpasang IV line venocath 18 G
3) IVFD R-Sol 30 gtt/I
4) Cek Laboratorium lengkap
5) IVFD. Paracetamol 1gr/ 8 jam (IV)
6) Amlodipin 1x 10 mg PO
7) Valsartan 1 x 80 mg PO
8) Foto Radiologi dan Head CT-Scan
9) SIA & informed consent
10) Pasien dipuasakan 6-8 Jam sebelum Operasi
11) Oral dan personal higiene
12) Persiapan CVC
 Laboratorium
 Hb/Ht/L/Tr: 12.6 / 37 / 7520/310.000

 PT/INR/aPTT/TT:
16.5(14.2)/1.15/27.9(33.5)/16.6(18.7)

 KGD: 89(mg/dl) ALB: 4.0 g/dL

 Ur/Cr: 11/ 0,5 (mg/dL)

 Na/K/Cl: 144/ 3,7 / 106 (mEq/L)

CT Scan
Teknik Head up 30o
Inj Midazolam 3 mg IV
Anestesi Inj. Fentanyl 150 ug IV
Inj. Lidocain 50 mg IV
PreOksigenasi 8 l/i
Inj. Propofol 100 mg – Sleep non apnoe
Inj. Rocuronium 50 mg – Sleep apnoe
Intubasi ETT no 7,0 cuff (+)
SP ka = ki  Fiksasi
Inhalasi Anestesi Sevoflurane 0.8 - 1 %,
O2 : Air = 2 L/I : 2 L/i
Rocuronium 10 mg/20 menit (maintenance )
Syrnge pump Fentanyl 300 mcg dalam 50 ml
NaCl 0.9%  10 ml jam  Pantau
Hemodinamik
Syrnge pump Propofol  10 mg/ jam
Durante operasi
 Durante Operasi
• Lama 0perasi : 6 jam
• TD : 100 – 132 / 58 – 84 mmHg
• HR : 52 – 90 x/menit
• SpO2 : 99 – 100 %
• Perdarahan : + 650 ml
• Penguapan + maintenance : 200 ml/jam
• UOP = 2000 ml
• Cairan :
– Pre Op :RSOL 1000 ml
– Durante op :RSOL 2000 ml
– PRC : 2 x 125 ml
– Manitol : 125 ml
 Post Operasi
• B1 : Airway : Clear terintubasi MV, Mode: CMV, Tv: 400ml, RR: 14
x/menit, I:E= 1:2, FiO2: 40%, PEEP: 4
• B2 : Akral : H/M/K, TD 103/68 mmHg, HR 98 x/i,reguler,
T/V kuat/cukup
• B3 : Sens : dalam pengaruh obat, pupil bulat isokor, Ø : 3 mm/3
mm, RC +/+. Kejang (-)
• B4 : UOP (+), vol. 250 ml/3jam, warna kuning jernih
• B5 : Abdomen soepel, peristaltik (+) lemah. NGT (+)
• B6 : Edema (-).
 Terapi Post operasi

• Bed rest , Head up 30 o

• MV, Mode: CMV, Tv: 400ml, RR: 14 x/menit, I:E= 1:2, FiO2: 40%,
PEEP: 4
• Inj. Ceftriaxon 2 gr/12 jam IV
• Syrnge Pump Fentanyl 300 mcg/ 50 cc NaCl 0.9%  4 cc jam
• Inj. Omeperazole 40 mg/12 jam/IV
• Diet SV 1500 Kkal
• Monitoring hemodinamik

Rencana post operasi :

• Cek Darah Rutin, AGDA, Elektrolit, KGD ad random, RFT
Anesthetic Consideration
in
CPA Tumor Removal
 Lateral Position
• This is suitable for approaches to lesions not in the
midline, particularly the cerebellopontine angle.
• A pad should be placed under the body in the
axilla to minimize weight on the lower arm and
shoulder  brachial plexus injury
Lateral Position
Intraoperative anesthetic
considerations
• Hemodynamic instability occurs if the brainstem is
manipulated.
• Bradycardia can occur when the peri ventricular
grey matter and the reticular formation are
stimulated.
• Most arrhythmias occur during surgery near the
pons, and the roots of nerves V, IX and X.
• Severe hypertension can result from stimulation of
the trigeminal nerve
 Post operative special
considerations after
Posterior Fossa Surgery
 Ventilation/airway
abnormalities
• Because of disease- or surgery-induced dysfunction of
cranial sensory or motor nerves, patients may have
difficulty swallowing, vocalizing, or protecting the
airway.
• In addition, damage to or edema of the respiratory
centers from intraoperative manipulation can result in
hypoventilation or erratic respiratory patterns.

• Therefore, longer-term ventilation and airway

protection might be required in some patients.
• Severe tongue and facial edema can occur owing
to position-induced venous or lymphatic
obstruction.
• The endotracheal tube should be left in place until
the edema resolves.
• Pulmonary edema may result from large VAE.
• Although pulmonary edema is usually responsive to
conservative measures such as supplemental
oxygen (O2) and diuretics, continued
postoperative ventilation may be appropriate until
evaluation is completed.
 Cardiovascular Complications
• Hypertension is common after posterior fossa
surgery and may contribute to edema formation
and intracranial hemorrhage. Hence, one should
be prepared to control postoperative hypertension.
Neurologic complications
• Atered levels of consciousness, varying degrees of
paresis, and specific cranial nerve deficits (e.g.,
visual disturbances, facial nerve paresis, impaired
swallowing or phonation).

Treatment is supportive, but evaluation of delayed emergence

should proceed lest a treatable non anesthetic cause go
unrecognized.
If cerebral paradoxical air embolism is suspected,
hyperbaric oxygen therapy may be warranted.

Extreme neck flexion can cause mid cervical quadriplegia.

Peripheral nerve damage can result from faulty

positioning. The brachial plexus, ulnar nerve and common
peroneal nerve are most vulnerable.
Thank you