Laporan Kasus Hekal

LAPORAN KASUS
Regional anastesi pada

sectio cesaria
Disusun Oleh :
Chrysza Ayu Agustine (1102014062)
Muhammad Haekal Fadhilah (1102014168)
DAFTAR ISI:
01 Pendahuluan
02 Status anestesi
03 Laporan anestesi
04 Analisis kasus
05 Tinjauan Pustaka
06 kesimpulan
P ENDAHULUAN
Anestesi adalah pemberian obat untuk menghilangkan kesadaran
secara sementara dan biasanya ada kaitannya dengan pembedahan.
Secara garis besar anestesi dibagi menjadi dua kelompok yaitu
anestesi umum dan anestesi regional . Anestesi regional memiliki
berbagai macam teknik penggunaan salah satu teknik yang dapat
diandalkan adalah melalui tulang belakang atau anestesi spinal.
Anestesi spinal adalah pemberian obat antestetik lokal ke dalam ruang
subarakhnoid. Anestesi spinal diindikasikan terutama untuk bedah
ekstremitas inferior, bedah panggul, tindakan sekitar rektum dan
perineum, bedah obstetri dan ginekologi, bedah urologi, bedah
abdomen bawah dan operasi ortopedi ekstremitas inferior.
02 STATUS ANESTESI
IDENTITAS PASIEN
NAMA: Ny. NURHAYATI
Jenis Kelamin : Perempuan 01

Umur : 34 tahun
Alamat : Kp.Walikukun 20/10, Argawana, Puloampel, Serang

02
Agama : Islam
Status : Menikah
03
Pekerjaan : Ibu Rumah Tangga Ruang
Perawatan : Mawar
Tanggal Masuk RS
No RM
: 4 Januari 2020
: 754615
04
RIWAYAT PENYAKIT SEKARANG
AUTOANAMSESIS: Tanggal 4 Januari 2020, pukul 10.30 WIB, di ruang OK RSUD Cilegon
KELUHAN UTAMA: Tekanan darah tinggi
Pasien datang ke Instalasi Gawat Darurat RSUD

Cilegon pada tanggal 4 Januari 2020 rujukan dari
Pasien dirujuk karena pasien hamil 35 minggu RSKM Cilegon.
mengalami tekanan darah tinggi sejak satu hari
SMRS yaitu tekanan sistol mencapai 170 mmHg
pada pemeriksaan urin didapatkan proteinuria +3.

Keluhan mulas dirasakan jarang, keluar lender
campur darah dan keluar air-air banyak dari jalan
lahir disangkal .
Gerakan janin masih dirasakan aktif
Pada autoanamnesis pasien

mengatakan pernah menjalani operasi
.
section Caesar pada kelahiran anak
Oleh dokter OBSGYN pasien didiagnosis G2P1A0 hamil pertamanya
35 minggu dengan preeklampsia berat dan bekas section
caesar sehingga disarankan untuk dilakukan tindakan
operasi section caesar.
.
ANAMNESIS
RIWAYAT PENYAKIT RIWAYAT KEBIASAAN

RIWAYAT PENYAKIT
KELUARGA DAN PENGOBATAN
DAHULU

Pasien mengaku tidak merokok dan
- Riwayat Hipertensi(-) - Riwayat Hipertensi(-)
konsumsi minuman berakohol.
- Riwayat Asma (-) - Riwayat Asma (-)
Pasien tidak memakai gigi palsu,
- Riwayat Alergi Obat(-) - Riwayat Alergi Obat(-)
dan menyangkal adanya gigi goyang
- Riwayat Diabetes Mellitus(-) - Riwayat Diabetes Mellitus(-)
dan gigi bolong.
RIWAYAT TINDAKAN
OPERATIF
Pasien mengaku pernah

operasi Section Caesar tahun
2010 atas indikasi haemorrhoid
Pemeriksaan Fisik
Keadaan Umum : Baik, pucat.
GCS : E4V5M6.
Tekanan Darah : 150/90 mmHg
Nadi : 99x/menit
Suhu : 36,8 oC
Pernafasan : 22x/menit
Status Gizi : BB: 66 kg

TB: 155 kg
IMT : 23.7 (Berat badan berlebih)
Mata : Conjungtiva Anemis (-/-), Sklera Ikterik

(-/-), Pupil Isokor RCL (+/+), RCTL (+/+)
Pemeriksaan Fisik
Thorax : Bentuk normal, massa (-), sikatrik (-), hematom (-) pergerakan napas
kanan kiri simetris, nyeri tekan (-), krepitasi (-), fremitus taktil dan vokal kanan kiri
simetris, sonor pada kedua lapang paru, Vesiculer (+/+), Wheezing (-/-), Rhonki
(-/-)
Jantung: S1S2 tunggal, murmur (-), gallop (-).
Abdomen: Perut cembung lembut, hematom (-), sikatrik (+) pada regio
bawah abdomen horizontal, supel, nyeri tekan (-), hepar lien ginjal
normal, timpani seluruh abdomen, Asites (-), bising usus (+) normal. .
Ekstremitas: Akral hangat, edema kedua tungkai (+) ,

CRT < 2”
STATUS LOKALIS
INSPEKSI Kesan hamil, striae gravidarum (+)
Bising usus (+), DJJ (+)

AUSKULTASI
158 x/menit
Tinggi fundus Uterus (TFU)

32 cm, taksiran berat janin
PALPASASI
(TBJ) 2700 gram , His (-)
LEOPOLD
• Leopold I : Teraba bagian besar, bulat,
lunak
• Leopold II : Teraba tahanan memanjang
di kanan, Teraba bagian kecil di kiri
• Leopold III : Teraba bagian besar, bulat ,
keras
• Leopold IV : Belum masuk PAP, station +2
PEMERIKSAAN PENUNJANG
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TATALAKSANA
INTRAVENA FLUID ASERING

500CC 20 TPM
dilakukan operasi sectio cesaria dengan

INFORM CONSENT regional anestesi dengan klasifikasi ASA
TINDAKAN .
mengenai tindakan, resiko serta dampak

dari tindakan operasi caesar pada pasien/ KONSUL ANESTESI
keluarga pasien .
INFORM CONSENT
PEMBIUSAN
KESIMPULAN
Berdasarkan anamnesis dan pemeriksaan fisik,

maka:

Diagnosis pre operatif : G2P1A0 hamil 35
minggu dengan preeklampsia
berat dan bekas sectio cesaria satu kali

Status
STATUS operatif
OPERATIF : ASA 2

: Sectio cesaria
JENIS OPERASI

JenisANESTESI
JENIS Anestesi : Regional Anestesi
(Sub Arachnoid Block)
03 LAPORAN ANESTESI
Infographic Style
Preoperatif TTV Premedikasi Tindakan
Anestesi
• Informed
Consent (+)
Sebelum
• Puasa (+) dilakukan Dilakukan
kurang lebih
6 jam
tindakan tindakan
• IV line Tekanan darah : 155/102 mmHg anestesi anestesi RA
Pernafasan : 22 x/menit
terpasang
dengan infus
Nadi : 103 x/menit diberikan teknik spinal
Suhu : 36,8˚C
Asering 500 Ondancetron 4 dengan obat
cc, mengalir mg secara Levobupivacain
lancar
• Keadaan bolus
umum intravena.
tampak sakit
sedang
• Kesadaran
Compos Mentis
Pemantauan
Kardiovaskular Respirasi Cairan

Pemantauan Inspeksi pernapasan Monitoring input
terhadap tekanan spontan kepada cairan infus.
darah dan frekuensi pasien dan saturasi
nadi setiap 5 menit. oksigen
1. Diagnosis Pra Bedah
G2P1A0 hamil 35 minggu dengan preeklampsia berat dan
bekas sectio cesaria satu kali
2. Diagnosis Pasca Bedah
-
3. Penatalaksanaan Preoperasi
1. Infus Asering 500cc
2. Ondansetron 4 mg
Penatalaksanaan Anestesi
a. Jenis pembedahan : Sectio cesaria
b. Jenis Anestesi : Regional Anestesi
c. Teknik Anestesi :Sub Arachnoid Block, L3-4, LCS+,
spinocain no 27G
d. Mulai Anestesi : pukul 11.27 WIB
e. Mulai Operasi : pukul 11.32 WIB
f. Premedikasi : Ondansetron 4 mg IV

g. Medikasi : Levobupivacain 20 mg
h. Medikasi tambahan : Tramadol 100 mg, oxytocin 20 IU,
methylergometrine maleate 0,2 mg, misoprostol 3 tab, kaltrofen
supp 100 mg
i. Respirasi : Pernapasan spontan
Laporan
j. Cairan durante operasi : Asering 1000cc
k. Pemantauan TD dan HR: Terlampir
l. Selesai operasi : Pukul 12.17 WIB Anestesi
a. Pasien masuk ke dalam ruang pemulihan
(Recovery Room) kemudian dibawa kembali
ke ruang rawat inap.
b. Observasi tanda-tanda vital dalam batas
normal :
Keadaan umum : tampak sakit sedang
Kesadaran : compos mentis
TD : 145/89 mmHg
Nadi : 91x/menit
Saturasi oksigen : 100% Post
Penilaian pemulihan kesadaran : skor Bromage
Operatif
Analisa Kasus
1
Premedikasi Ondansentron
Mencegah mual dan muntah yang
dapat menyebabkan aspirasi. 3
Pemberian Tramadol dan
Pronalges
2 Tramadol yang merupakan opioid

sebagai analgetik yang tidak
mempengaruhi kesadaran pasien
Induksi dengan Levobupivacaine
20 mg dan pronalges (ketoprofen 100mg)
yang merupakan analgetik
Levobupivacaine adalah obat
golongan NSAID diberikan secara
anastetik local yang mempunyai
suppositoria utnuk mengurangi
awitan lambat tetapi memiliki masa
rasa nyeri pasca operasi.
kerja panjang sampai dengan 8
jam
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LAPORAN KASUS

Regional anastesi pada

NAMA: Ny. NURHAYATI

Jenis Kelamin : Perempuan 01

Alamat : Kp.Walikukun 20/10, Argawana, Puloampel, Serang

Pasien datang ke Instalasi Gawat Darurat RSUD

pada pemeriksaan urin didapatkan proteinuria +3.

Gerakan janin masih dirasakan aktif

Pada autoanamnesis pasien

RIWAYAT PENYAKIT RIWAYAT KEBIASAAN

Pasien mengaku pernah

Status Gizi : BB: 66 kg

Mata : Conjungtiva Anemis (-/-), Sklera Ikterik

Jantung: S1S2 tunggal, murmur (-), gallop (-).

Ekstremitas: Akral hangat, edema kedua tungkai (+) ,

Bising usus (+), DJJ (+)

Tinggi fundus Uterus (TFU)

INTRAVENA FLUID ASERING

dilakukan operasi sectio cesaria dengan

mengenai tindakan, resiko serta dampak

Berdasarkan anamnesis dan pemeriksaan fisik,

Kardiovaskular Respirasi Cairan

b. Observasi tanda-tanda vital dalam batas

2 Tramadol yang merupakan opioid

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