4. SHORT (Cricothyroidotomy)
1. MOANS (Face mask) -Surgery or other airway obstruction : -
- Mask seal/male sex/Mallampati : -/jenggot kumis -/ 2
-Hematoma : -
-Obesity : -
- Obesity/obstruction: -
-Radiation distortion : -
- Age: < 55th -Tumor : -
- No teeth : -
- Stiff/snoring : -
2. RODS (LMA)
- Reduce mouth opening : -
- Obstruction/obesity : -
- Distorted airway : -
- Stiff neck or lung :-
3. LEMON (ETT)
- Look externaly : -
- Evaluate 3-3-2
• Incisor distance : 3 jari
• Hyoidmental distance : 3 jari
• Tyroid to floor of mouth distance : 2 jari
- Mallampati : 2
- Obstruction airway : -
- Neck mobility : mobile
Pemeriksaan Penunjang
Laboratorium
Lab 25 oktober 2022
Hb 14,6
Ht 43
Leukosit 7790
Trombosit 284000
PT 9,9
APTT 25,7
GDS 80
HbsAg non reaktif
Antigen covid negatif
Problem
PROBLEM AKTUAL
1. tumor uterus susp sarkoma uteri pro curetage
2. Anemia ringan
PROBLEM POTENSIAL
3. Hipotensi
Assesment :
ASA II
tumor uterus susp sarkoma uteri pro curettage
Anemia ringan
Plan
Izin Usul
Preoperatif
• Tranfusi PRC 3 kolf
• Pastikan pasien normovolume, IV line lancar (abocath No. 18)
• Siapkan obat emergensi
• Premedikasi inj. Ondancentron 4mg iv, inj. Dexametasone 5mg iv
Anestesi umum
General Anestesi dengan Teknik TIVA
Preventif analgesia
• Inj. Fentanyl 50 mcg
Induksi:
• Inj. Midazolam 3mg
• Inj. Propofol 40mg
VT : 350 ml, RR 12- 18 ( 12 ) x / mnt
MV : 4200
Post OP
• Rawat ruangan
• Awasi KU dan TTV
• Boleh makan minum jika sadar penuh
Analgetik
• inj paracetamol 1gr / 8 jam iv
OK 8
Nama : Ny. TR
Umur : 49 th
Ruang : WIKU
Diagnosa : ca cervix uteri st 2b
Rencana tindakan : pro TAH SO FS
DPJP Bedah : Dr. Adityono, Sp.OG- K Onk
DPJP Anestesi : Dr. Aunun Rofiq, Sp.An
Anamnesis
Riwayat Penyakit Sekarang
pasien datang dengan keluhan nyeri pada perut bawah,
lemas (+), mual (-), muntah (-), perdarahan (-), makan
minum baik, BAB dan BAK dbn.
Riwayat Penyakit Dahulu
Alergi (-), Dm (-) jantung (-) asma(-), merokok (-), HT (-)
Riwayat Operasi Sebelumnya : -
Pemeriksaan Fisik
Vital Sign
- KU baik
- GCS E4V5M6
- TD 100/ 60 mmHg
- N 97 x/m kuat, reguler
- R 20 x/m
- S 37,1
- SpO2 98% udara ruangan posisi supine
- BB 52 kg TB 154 cm
- IMT 22,2
Pemeriksaan General
4. SHORT (Cricothyroidotomy)
1. MOANS (Face mask) -Surgery or other airway obstruction : -
- Mask seal/male sex/Mallampati : -/jenggot kumis -/ 2
-Hematoma : -
-Obesity : -
- Obesity/obstruction: -
-Radiation distortion : -
- Age: < 55th -Tumor : -
- No teeth : -
- Stiff/snoring : -
2. RODS (LMA)
- Reduce mouth opening : -
- Obstruction/obesity : -
- Distorted airway : -
- Stiff neck or lung :-
3. LEMON (ETT)
- Look externaly : -
- Evaluate 3-3-2
• Incisor distance : 3 jari
• Hyoidmental distance : 3 jari
• Tyroid to floor of mouth distance : 2 jari
- Mallampati : 2
- Obstruction airway : -
- Neck mobility : mobile
Pemeriksaan Penunjang
Laboratorium
Lab 25 oktober 2022
Hb 12,5
Ht 37
Leukosit 8340
Trombosit 368000
PT 11,7
APTT 27,6
Alb 4,08
GDS 129
Kalium 3,9
Natrium 147
Klorida 107
Ur 25,06
Cr 0,65
SGOT 42
SGPT 46
HbsAg non reaktif
Antigen covid negatif
RO Thorax PA
EKG
Problem
PROBLEM AKTUAL
1. ca cervix uteri st 2b
PROBLEM POTENSIAL
2. Hipotensi
3. Perdarahan
4. PDPH
5. PONV
Assesment :
ASA II
mioma uteri multiple pro miomektomi sd histerektomi
Plan
Izin Usul
Preoperatif
• Post op icu
• Usaha darah PRC 2 kolf
• Pastikan pasien normovolume, IV line lancar (abocath No. 18)
• Siapkan obat emergensi
• Premedikasi inj. Ondancentron 4mg iv, inj. Dexametasone 5mg iv