Conduct of Anesthesia: Koas UPH
Conduct of Anesthesia: Koas UPH
Koas UPH
“You don’t have to know everything. You simply need to know where to find it when necessary” -- Einstein
Pre - Intra - Post
• Pre
• Patient assessment
!!!
• Type and duration of surgery
LP
• Anesthesia planning
HE
• Potential problems
• Intra
FOR
• Execute the plan: induction - maintenance - recovery
• Back up for problems, improvise, plan B – plan C
ASK
• Post
• Pain management
• Monitoring and handling complications
Ko Asisten
• Satu orang per pasien (yg lain membantu)
• Buat planning
• Tipe anesthesia
• Airway management
• Obat induksi dan dosisnya
• Setting ventilator
• Manajemen intraop
• Analgetik, antiemetic dll postop
• Conduct the plan
Di ruang persiapan
• Cek ulang kelengkapan, anamnesis, PF, penunjang
• Monitor
• Bila perlu intervensi
• Bila perlu premedikasi
• Antibiotika profilaksis seharusnya di sini
• Bila perlu consult the surgeon
• Bila perlu change plan
• Bila perlu cancel the procedure
Masuk OT
• STATICS
• Cek IV line – flush bila perlu
• Pasang monitoring
• Cek obat induksi dan efedrin tersedia
• Bila perlu berikan midazolam
• Setting ventilator sebelum intubasi
• Preoksigenasi
Preoxygenation
• Tight mask
• High O2 flow
• Patient’s normal breathing
• 3-5 minutes
• Alternatively:
• 4 deep breaths in 30s (4DB/30)
• 8DB/60
Obat2 induksi
• Fentanyl:
• 2mcg/kgBB
• Onset puncak: 3 menit
• Durasi: 45 menit
• Propofol:
• 1-2 mg/kgBB
• Onset 15-30 detik
• Durasi: 10 menit
Midazolam
• Anti ansietas
• Sedasi
• Amnesia antegrade
• Dosis: 0.1-0.5mg/kg untuk sedasi
Ketamine
• Anesthesia in the war zone, anestesi tunggal untuk hipnotik/sedatif sekaligus analgesia
• Bekerja di reseptor NMDA, berbeda dg IV induction yg lain (GABA)
• Dosis induksi: IV 2mg/kg (IM 5mg/kg)
• Subanesthetic dose (efek analgesia only): 0.3mg/kg
• Onset: 90 detik
• Durasi: 15-20 menit
• Stimulasi sistem simpatik di sentral, BP dan HR , nystagmus, hipersekresi/salivasi, bronkodilator
• Tidak depresi pernafasan dan refleks airway relatif dipertahankan
• Mimpi buruk, halusinasi, delirium on emergence
• Kombinasi dengan midazolam atau propofol: balans efek negatifnya
Pasien tidur setelah propofol
• Tes ventilasi dg bag-mask baru boleh diberikan muscle relaxant
• Bagging hingga pasien relax dan siap untuk intubasi
• Atur APL valve sendiri untuk mendapatkan pengembangan bag sesuai
yg diinginkan
Muscle relaxant
• Atracurium
• 0.5mg/kg
• Onset 2-3 menit
• Durasi 45-60 menit
• Rocuronium
• 0.6mg/kg Onset 2-3 menit
• 1.2mg/kg Onset 1 menit
• Durasi 45-60 menit
Setting Ventilator
• Mode VC
• VT 6-8mL/IBW
• RR: adjust sesuai ETCO2
• I:E ratio 1:2 (dewasa)
• PEEP 5cmH20
• Pmax tak perlu disetting, untuk caution boleh setting 30cmH2O
15o
30o
Bag and Mask Ventilation (BMV)
Full view of glottis Part of the cords Only epiglottis No glottis structure visible
Dealing with high grade Cormack-Lehane !
• BURP maneuver
• McCoy Laryngoscopy blade
• Hockeystick-shaped stylette
• Elastic bougie
• Videoscope
• Intubating through LMA
• Fiberoptic intubation (rigid or flexible)
BURP Maneuver
• Backward – Upward – Rightward
Pressure
• AKA External Laryngeal Manipulation,
Bimanual Laryngoscopy
• The single most practical and effective
airway management technique for
facilitating intubation during direct
laryngoscopy
vre
E NG AN k M ane u
M AD ≠ S ellic
KS A re
TIDA id pressu
co
≠ Cri
McCoy blade
Hockeystick-shaped stylette
Elastic gum bougie
Intubating LMA
Fiberoptics
Supraglottic Airway Devices (SADs)
Laryngeal Mask Airway (LMA)
LMA Unique LMA Supreme
Classic LMA Insertion
1. Turn around (like OPA)
2. Slide-in with index finger (picture)
3. Using laryngoscope blade
Difficult Airway
• Difficulty with facemask ventilation is the inability of an unassisted
anesthesiologist:
• a) to maintain oxygen saturation, measured by pulse oximetry, 92%; or
• b) to prevent or reverse signs of inadequate ventilation during positive-pressure
mask ventilation under general anesthesia
• Difficult laryngoscopy occurs when “it s not possible to visualize any
portion of the vocal cords with conventional laryngoscopy.” This typically
corresponds to a Cormack and Lehane Grade IV laryngoscopy view
• Difficult endotracheal intubation occurs when “proper insertion of the
tracheal tube with conventional laryngoscopy requires more than three
attempts or more than 10 minutes”
Predict Difficult Airway
LEMON
• Look Externally
• Evaluate 3-3-2
• Mallampati Score
• Obstruction
• Neck Mobility
Look Externally
• Facial trauma
• Large incisors
• Beard or moustache
• Large tongue
• Short neck
• Receeding chin
• Etc.
Evaluate 3-3-2
• The 3-3-2 rule
Incisor distance <3 fingerbreadths
Hyoid/mental distance <3 fingerbreadths
Thyroid-to-hyoid disance <2 fingerbreadths)
Thyromental distance (TMD) < 3 fingerbreadths
Mallampati Score
• Sitting patient
• Mouth wide open
• Tongue extended
• Without phonation
Neck Mobility
• Limited neck mobility
• Contraindicated (cervical spine trauma)
• Due to disease
• Ankylosing spondilytis
• Rheumatoid arthritis
• Scleroderma
• Tumor on neck
• Degenerative
• Limited by device
• Hard neck collar
• Halo
• Post cervical spine fusion
Dealing with limited neck mobility
• MILS (Manual Inline Stabilization) (picture)
• Videoscope
• Flexible fibreoptic intubation
Berapa vol% Sevoflurane?
• Tidak ada patokan
• Sesuaikan dengan hemodinamik dan kedalaman anesthesia pasien
• Ingat balans anesthesia – top up Fentanyl, muscle relaxant
Berapa target TD?
MAP 70-110
Uncontrolled hypertension Aim higher
Berapa vol% Sevoflurane?
• Tidak ada patokan
• Sesuaikan dengan hemodinamik dan kedalaman anesthesia pasien
• Ingat balans anesthesia – top up Fentanyl, muscle relaxant
Berapa liter O2, berapa liter Air? Berapa
FiO2?
• O2 1L + Air 1L (total 2 L)
O2 100% x 1 = 100
Air 21% x 1 = 21 121 : 2 = 60.5%
• O2 1L + N2O 2L (total 3 L)
O2 100% x 1 = 100 100 : 3 = 33.3%
N2O 0% x 2 = 0
Kapan top up Fentanyl?
• Mulai insisi
• Jenis operasi/jaringan yg distimulasi
• Perubahan hemodinamik (takikardia, hipertensi) karena durasi habis
• Pertimbangkan top up bila pindah insisi baru di area lain
Kapan top up Muscle relaxant?
• Pasien bergerak
• Pasien kurang relax untuk operasi tsb (atas permintaan surgeon)
• Pasien ada usaha bernafas -> curare cleft
• Dosis top-up kira2 sepertiga dosis induksi
Pasien sudah ada usaha bernafas, tapi pembedahan
sudah hampir selesai.. Beberapa pilihan
• Increase Minute Volume (MV) dg menaikkan either TV or RR, or both bring
ETCO2 to lower side
• Increase depth of anesthesia (with propofol or increase Sevo) if hemodynamic
allows it
• Tak ada salahnya top up atracurium, dengan konsekuensi perlu menunggu
recovery lebih lama dan dosis reversal lebih besar
• Pindah ke mode SIMV atau PS bila tersedia di ventilator
• Sekalian pindah ventilator ke nafas spontan dan beri reversal, monitor closely till
patient can generate adequate spontaneous ventilation
Emergence
• Matikan gas dan beri O2 100%, naikkan O2 flow 5L atau lebih
• Pasang bite-block (kebiasaan yg baik)
• Bangun dari inhalasi akan melewati stage 2
• Bila ventilasi belum adekuat tapi pasien struggle boleh ekstra Propofol
• Beri reversal (Neostigmine + Atropine) sesuai evaluasi
(specific reversal named Sugammadex available for Rocuronium)
Extubation
• Monitor tidal volume > 5cc/kgBB ideal
• ETCO2 dapat dipertahankan dalam batas normal dg RR < 30
• Pernafasan Torakoabdominal
• Suction secukupnya selagi masih deep dan jangan diganggu hingga
pernafasan adekuat, baru suction lagi sekaligus ekstubasi
• Walau pernafasan adekuat belum tentu pasien sudah bisa
mempertahankan airway tunggu pasien bangun/reflex airway cukup
• Pertimbangkan posisi “head up” untuk obese patients or patients with
distended abdomen
Analgetik
• Pre-emptive analgesia
• Multimodal analgesia
Risiko PONV
• Wanita, muda, cemas, riwayat motion sickness, bukan perokok
• Inhalasi (terutama N2O) tinggi, opioid dosis besar
• Operasi yg melibatkan organ2 keseimbangan dan gastrointestinal