ANESTESI UMUM UNJANI 2

Anestesi UmumInduksi inhalasi, rumatan anestesi dengan anestetika inhalasi (VIMA= Volatile Induction and Maintenance of Anesthesia)Induksi intravena, rumatan anestesi dengan anestetika intravena (TIVA = Total Intra Venous Anesthesia)Induksi intravena, rumatan anestesi dengan anestetika inhalasi .

Trend baru dalam anestesi umumVIMA (Volatile Induction and Maintenance of Anesthesia)Fast-Track AnesthesiaLow-flow Anesthesia Low-cost AnesthesiaSingle-breath induction (Rapid induction)SAFE (Short Acting Fast Emergence) drugs.Mampu memberikan proeksi pada organ

Kenapa VIMA???Induksi intravena, misalnya: Propofol : induksi cepat dan lancar, tapi dibutukan jalur vena, ada efek samping hipotensi dan apne.Anestesi untuk pediatrik pada umumnya dengan VIMA.Lebih menguntungkan daripada induksi intravena, rumatan dengan anestetika inhalasi.

Induksi intravena tidak nyamanMembutuhkan akses intravena nyeri,takut, sulit.Obat sakit bila disuntikkan Adanya reaksi yang burukhipotensiapnemioklonus, porphyria, anafilaxisEfek sisa : sedasi

Induksi Inhalasi membutuhkan obat yg tepatThe Triad of VIMAAdapted from: Logan Int Proc J 7: 4, 1998Iritasi jalan nafasKelarutanPotensiVIMAVIMA

Proteksi OrganBasic method/Metode mendasar : A,B, CHipotermi Farmakologik : Anestetika intravena Anestetika inhalasi

Gambaran proteksi Otak dari anestetika inhalasiProteksi otak dalam lingkupan efek anti-necrotik and anti-apoptotikMeningkatkan aliran darah otak pada daerah otak yg iskemik.Menurunkan metabolisme otakMenekan kejang Werner C. AOSRA Nov 2003, WCA, April 2004. ESA June 2004.

Gambaran proteksi Otak dari anestetika inhalasiIsofluran, sevofluran, desfluran menekan metabolime otak secara maksimal pada 2 MAC memperbaiki ketidakseimbangan antara kebutuhan dan pasokan oksigen.Menghambat asidosis laktik dan pelapasan neurotransmitter excitatoryMencegah influks patologis Na+, Ca2+ .Menghambat peroksidasi lipid.Mengurangi pembentukan radikal bebas.

Werner C. AOSRA Nov 2003

Narkotik analgetik ideal :Margin of safety lebar.Mula kerja cepatLama kerja singkatMudah mengendalikan efek analgesiknyaAnalgesik kuat Tidak ada pelepasan histamineMetabolitnya tidak aktif

Penggunaan Opiat dalam AnestesiPremedikasiInduksi anestesiNarcotik anestesiBagian dari balans anestesiAdjuvant dalam anestesi regionalNeurolept anestesiPengelolaan nyeri pascabedah

Efek NarkotikBradikardia : efek vagotonik sentral serta depresi nodus SA & AV . Depresi nafas: frekuensi, ritme nafas, respons CO2, Minute Volume, Tidal Volume.Kekakuan ototMual-muntah yg disebabkan stimulasi chemoreceptor triger zone (CTZ), mobilitas saluran cerna, penurunan mobilitas gaster, meningkatkan volume gaster.

Dosis klinis Narkotik

Pelumpuh otot IdealNon depolarisasiMula kerja cepat, lama kerja singkatPemulihan cepat, potensi kuatTidak kumulatif, metabolitnya tidak aktifTidak ada efek kardiovaskulerTidak menimbulkan pelepasan histaminDapat dilawan dengan antikholinesterase

Pelumpuh Otot depolarizing dan Non depolarizingDepolarizingLama kerja singkat: SuccinylcholinNon depolarizingLama kerja panjang : PancuroniumLama kerja sedang: Rocuronium, Vecuronium, AtracuriumLama kerja singkat: Mivacurium

Kondisi yg kemungkinan terjadi hiperkalemia akibat SuccinylcholinLuka bakarTrauma beratInfeksi intra-abdominal beratCedera medulla SpinalisEncephalitisStrokeGuillain-Barre syndromeSevere Parkinsons diseaseTetanusBed rest lamaRuptured cerebral aneurysmPolyneuropathyCedera kepalaSyok Hemorrhagic dengan metabolik asidosisMyopathies ( eg, Duchenness dystrophy )

Mechanism neuromuscular blockadeCompetitive block : non-depol, avoid AcCh access to receptor.Depolarization block : depol, depolarization as AcCh but permanentDeficiency block: influence syntesis and release AcCh: Procaine, toxin botulinus, Ca decrease, Mg increase. Morgan GE, Mikhail MS. Clinical Anesth, 1996

Terminology in muscle relaxantED 50 : dose what can paralyzed 50% muscle strengthED 90 : dose what can paralyzed 90% muscle strength.Onset : interval between start of injection until maximal effect

Table 1. Depolarizing and nondepolarizing muscle relaxant

Depolarizing

Nondepolarizing

Short-acting

Succinylcholine

Decamethonium

Long-acting

Tubocurarine

Metocurine

Doxacurium

Pancuronium

Pipecuronium

Gallamine

Intermediate-acting

Atracurium

Vecuronium

Rocuronium

Short-acting

Mivacurium

Nondepolarizing drugDo not produce muscular fasciculationEffect are decreased by anticholinesterase agent, depolarizing agent, lowered body temperature, epinephrine, acetylcholineEffect are increased by non-depolarizing drugs, volatile anesthetic .

Depolarizing drugsProduce muscular fasciculation .Effect are increased by anticholinesterase agent, Acetylcholine, hypothermiaEffect decrease with non-depolarizing relaxant drugs, anesthetic inhalationDose Succ choline : 1 mg/kg BW

Burn injuryMassive traumaSevere intra-abdominal infectionSpinal cord injuryEncephalitisStrokeGuillain-Barre syndromeSevere Parkinsons diseaseTetanusProlonged total body immobilizationRuptured cerebral aneurysmPolyneuropathyClosed head injuryNear drowningHemorrhagic shock with metabolic acidosisMyopathies ( eg, Duchenness dystrophy )Table 9 - 5. Conditions causing susceptibility to succiniylcholine-induced hyperkalemia.

Resume farmakologi pelumpuh otot nondepolarizing

Sheet1

RelaxantMetabolismPrimaryOnsetDurationHistamineVagalRelativeRelative

ExcretionReleaseBlockadePotency1Cost2

TubocurarineInsignificantRenal++++++++01Low

MetocurineInsignificantRenal+++++++02Moderate

Atracurium+++Insignificant+++++01High

Mivacurium+++Insignificant++++02.5Moderate

DoxacuriumInsignificantRenal++++0012High

Pancuronium+Renal+++++0++5Low

Pipecuronium+Renal+++++006High

Vecuronium+Biliary++++005High

RocuroniumInsignificantBiliary+++++0+1High

1For example, pancuronium and vecuronium are five times more potent than tubocurarine or atracurium

2Based on average wholesale price per 10 mL; does not necessarily reflect duration and potency

Onset : + = slow; ++ = moderately rapid; +++ = rapid

Duration : + = short; ++ = intermediate; +++ = long

Histamine release : 0 = no effect; + = slight effect; ++ = moderate effect; +++ marked effect

Vagal blockade : 0 = no effect; + = slight effect; ++ = moderate effect

Sheet2

Sheet3

Choice of anesthesia technique depend on:Patient conditionSkill anesthetistSkill surgeonHospital socio economy

Problem during induction of anesthesiaMain problem : airwaySign of partial obstruction : snoring, crowing, gargling, wheezing, chest retraction, cyanosisSign of total obstruction : air flow from nose/mouth negative, supraclavicular retraction, intercostal retraction, cyanosis

Other problem during inductionRespiratory depressionCoughLarynx spasmMucus and salivavomiting

Airway controlledWithout equipment : Triple mannuver SafarWith equipment: OPA (Oro Pharyngeal Airway) NPA (Naso Pharyngeal Airway) LMA ( Laryngeal Mask Airway) ETT (Endo Tracheal Tube)

Indication IntubationHead and neck surgeryDifficult airwayThoracotomyLaparotomyLateral positionProne positionControlled ventilation

Technique laryngoscopy Head positionInsertion laryngoscope bladeVisualization epiglottisLift epiglottisView larynx and surrounding structure

Advantages Endotracheal intubationEnsures a patent airwayNormal anatomic dead space (75 ml) is decreased to 25 ml.Ventilation can be assisted or controlledPossibility of aspiration diminished drasticallySuctioning of the lung is facilitated

Disadvantages endotracheal intubation

Increases resistance to respirationTrauma to the lips, teeth, nose, throat, larynx.

Complication IntubationTeeth ruptureMouth bleedingEndobronchial intubationOesophageal intubationSore throatHypertensionArrhythmias

Teknik InduksiMask induction / inhalasi : induksi melalui sungkup muka.IntravenaIntramuscularPer rectal

WHY VIMA???intravenous induction, ex: Propofol : rapid and smooth induction, but need vein access first, hypotension, apnoe.Pediatric anesthesia commonly by VIMA.More advantages than intravenous induction, maintenance inhalation.

Mask Induction dengan SevofluranGradual InductionSingle Breath InductionTriple Breath Induction (Multiple Breath Induction)

Teknik cepat dengan Single Breath Induction, tanpa kejadian batuk, nahan nafas, spasme laring.

Induksi BertahapMetode klasik untuk induksi inhalasi.Tujuannya untuk menurunkan iritasi saluran nafas dan bau yg menyengat tidak diperlukan untuk Sevofluran.Anestetika volatil dikombinasikan dg N2O atau oksigen 100%.

Induksi dg 1 tarikan nafas (Single-Breath Induction)Priming sirkuit dg N2O 60% + Sevo 8% selama 30 detik.Minta pasien mengeluarkan nafas maksimal, lalu tempelkan face mask nya.Minta pasien narik nafas maksimal, pertahankan 20 detik, lalu nafas normal.Setelah refleks bulu mata negatif, Sevo turunkan jadi 2%.

Triple Breath InductionSuatu variasi dari Single Breath InductionMinta pasien narik nafas dalam 3 kali.Perbedaan dg Single Breath, pasien tidak diminta menahan nafas.Umumnya pasien sudah tidur dalam 2-3 nafas.

How to maintain anesthesia ?Maintenance anesthesia depend on deep of anesthesia to reach adequate anesthesia.Commonly with inhalation anesthetic 0.5-1 MAC depend on type of surgery, spontaneous breathing or controlled.To reduce vol% (MAC) : add N2O or Fentanyl.

Tanda kedalaman anestesiPRST Score (untuk balans anestesi)Guedel sign (untuk ether anesthesia)PRST Score (score 2-4: adequate anesthesia) P = Pressure = tekanan sistolik (mmHg) R = rate (heart rate) = denut jantung S = sweat/ lacrimation = keringat T = tear=air mata

Skor PRST untuk Balans anestesiSkor 2-4 : anestesi adekuat

EkstubasiSetelah ventilasi adekuatPada anestesi dalam atau setelah pasien bangunJalan nafas harus bebasBerikan oksigen 100% sebelum dan setelah ekstubasi.

Tatang Bisri, 2009

N2O1.5 time heavier than airMust be give with O2 100%Weak anestheticAnalgesic N2O 20% equal with 15 mg morphineDont use in closed systemAt the end of anesthesia, to prevent diffusion hypoxia O2 100%

Advantages N2ORapid induction and recoveryNo sensitized myocardium with catecholamineNo irritation respiratory tractOdor pleasantStrong analgesic

Disadvantages N2OWeak anestheticNo muscle relaxation effectNeed high concentration oxygenPossibility aplasia bone marrow

HalothaneA clear, colorless, potent volatile liquid.Metabolism 17-20% Advantages HalothaneRapid, smooth induction and recovery.PleasantNon irritating, no secretionBronchodilatorNonemeticNon flammable and non explosive

Disadvantages HalothaneMyocardial depressantAn arrhythmia producing drugSensitizes the myocardial conduction system to the action of catecholaminesA potent uterine relaxantPossible toxic to the liverShivering during recovery period.

EnfluraneA clear, colorless, stable volatile liquid with a pleasant ether-like odor.A potent inhalation anesthetic CNS excitationUse of epinephrine : saver than halothane.

Advantages EnfluranePleasantRapid induction and recoveryNon-irritating : no secretionBronchodilatorGood muscle relaxationNonemeticNon flammable and non explosiveCompatible with epinephrine

Disadvantages EnfluraneMyocardial depressantShivering on emergenceCSF production increaseCNS excitation, in high dose and hypocarbia.

IsofluraneA stabe, volatile liquidA isomer enfluraneInhalation anesthetic choice for neurosurgical patient, kidney, liver.

Advantages IsofluraneRapid induction of anesthesia and swift recoveryNonirritating : no secretionBlood pressure remain stableIndicated in poor-risk patient

Disadvantages IsofluraneLess than halothane and enflurane

SevofluraneInhalation anesthetic with low solubility (0,63), low MAC (2,05), pleasant odor, no airway irritation, rapid uptake and elimination , cardio vascular stable.Rapid induction, with technique single breath induction, induction time 23 seconds.

SevofluraneDrugs of choice for Neuro anesthesia : WCA 2000 Montreal, Canada.Drugs of choice for Pediatric Anesthesia : ESA Barcelona, 1998. ASPA, Singapore, 2000., ESA Sweden 2001.In Sectio Caesarea equal with Isoflurane and spinal anesthesiaReduce sphlannic blood flow, hepatic blood flow lesser than other anesthetic inhalation.

ThiopentoneBlood pressure decreaseHeart rate increase or decreasePeripheral vasodilatationHeart contraction depressedLarynx spasm, bronchus spasmRespiratory depression until apnoeaDose 4-6 mg/kg BW

Relative contraindication thiopentoneAsthma bronchialeSevere liver diseaseSevere kidney diseaseSevere anemiaHypotensionShock

KetamineDissociative anestheticDeliriumHallucinationIncrease blood pressure : systolic 23% from base lineIncrease heart rateArrhythmiasHypersecretionDose 1-3 mg/kg I.v or 9-11 mg/kg I.m

Indication and Contraindication KetamineIndication : short surgeryContraindication : Hypertension systolic > 160 mmHgArrhythmiasHeart failurePharynx and larynx surgery without intubation.

PropofolNew intravenous anestheticFast onset, short duration of actionAccumulation minimalFast recoveryRapid metabolismNo complication at site of injection Dose 2-2.5 mg/kg BW

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