k.43 Penyulit Pasca Bedah & Penanganannya

PENYULIT PASCA BEDAH PENYULIT PASCA BEDAH & PENANGANANNYA& PENANGANANNYA

Dr.Hasanul Arifin

PERNAFASANPERNAFASAN OBSTRUKSI JALAN NAFAS (partial, total)OBSTRUKSI JALAN NAFAS (partial, total)

pangkal lidah jatuhpangkal lidah jatuh muntahan, aspirasimuntahan, aspirasi

ATASI DENGAN :ATASI DENGAN : Head tilt, Chin liftHead tilt, Chin lift Jaw thrustJaw thrust triple air-way manuvertriple air-way manuver suctioningsuctioning

HIPOVENTILASI (SISA MUSCLE HIPOVENTILASI (SISA MUSCLE RELAXANT)RELAXANT)atasi dengan :atasi dengan : bebaskan jalan nafasbebaskan jalan nafas nafas bantunafas bantu reversal (Prostigmin + Sulfas Atropin)reversal (Prostigmin + Sulfas Atropin)

SIRKULASISIRKULASI Pantau dengan nadi, perfusi perifer, Hb, Ht, CVPPantau dengan nadi, perfusi perifer, Hb, Ht, CVP Penyulit yang sering terjadi :Penyulit yang sering terjadi :

HIPOTENSIHIPOTENSI SHOCKSHOCKARRYTHMIAARRYTHMIA

ATASI DENGAN :ATASI DENGAN : MONITORING KETATMONITORING KETAT TERAPI CAIRANTERAPI CAIRAN k/p k/p TRANSFUSI TRANSFUSI ANTI-ARRYTHMIA, ELEKTROLIT (KANTI-ARRYTHMIA, ELEKTROLIT (K++)) PINDAH PASIEN BILA SUDAH STABIL BAIKPINDAH PASIEN BILA SUDAH STABIL BAIK

MUNTAH (PONV)MUNTAH (PONV) RISIKO ASPIRASI RISIKO ASPIRASI

HIPOXIA SELAMA ANESTESIAHIPOXIA SELAMA ANESTESIA ANESTESI TERLALU DALAMANESTESI TERLALU DALAM RANGSANG CTZ (ETHER)RANGSANG CTZ (ETHER) TEKANAN LAMBUNG YANG TINGGITEKANAN LAMBUNG YANG TINGGI NARKOTIKNARKOTIK

ATASI DENGAN :ATASI DENGAN : DHBP 2.5-5. mg/ivDHBP 2.5-5. mg/iv Ondansetron 4 mg/iv ( untuk pencegahan Ondansetron 4 mg/iv ( untuk pencegahan

berikan sebagai premedikasi)berikan sebagai premedikasi) perut kembung perut kembung NGT NGT

DroperidolDroperidolDose Nausea NNT 95% CI

0-6 hr 5.2 3.3-12.6 0.25 0-24 hr - -

0-6 hr 4.8 3.0-12 0.5-0.75 0-24 hr 11 6.9-25

0-6 hr 6.1 4.5-9.4 1.0-1.25 0-24 hr 6.8 5.2-9.7

Prevention of vomiting requires larger doses, NNT 8-10.

Henzi I. Can J Anesth 2000;47(6):537-551.

PONV – The “Big Little PONV – The “Big Little Problem”Problem” Nausea and vomiting are among the most

distressing aspects of the postoperative experience

Incidence ranges between 20-50%

Increased morbidity with PONV

Prolonged recovery time

Leads to hospitalization of ambulatory patients

Increases institutional costs

Disrupts the management of outpatient surgical procedures

Kapur PA. Anesth Analg. 1991;73:243-245.Palazzo MG et al. Can Anaesth Soc 1984.

Watcha MF et al. Anesthesiology 1992; 77(1): 162-184.

Overall Incidence of PONVOverall Incidence of PONVInvestigatorInvestigator YearYear PatientsPatients Vomiting Vomiting

(%)(%)

Waters et al.Waters et al. 19361936 10,00010,000 41%41%

Bellville et alBellville et al 19591959 748748 19%19%

Adriani J et al.Adriani J et al. 19611961 2,2302,230 23%23%

Rowley et al.Rowley et al. 19821982 1,1831,183 43%43%

Patel et al.Patel et al. 19891989 9,9109,910 9%9%

Forrest et al.Forrest et al. 19901990 16,00016,000 18-25%18-25%

Karlsson et al.Karlsson et al. 19901990 485485 25%25%

Cohen et al.Cohen et al. 19901990 29,22029,220 25%25%

Watcha MF et al. Anesthesiology 1992; 77(1): 162-184.

Medical Consequences of PONVMedical Consequences of PONV Patient discomfort (mild to severe)Patient discomfort (mild to severe) Patient dissatisfactionPatient dissatisfaction Increased costIncreased cost

Personnel, supplies, drugsPersonnel, supplies, drugs Unplanned admissionsUnplanned admissions

Increased intraocular and intracranial pressuresIncreased intraocular and intracranial pressures Increased blood pressure and heart rateIncreased blood pressure and heart rate Wound dehiscence and bleedingWound dehiscence and bleeding Dehydration and electrolyte imbalanceDehydration and electrolyte imbalance Interruption of oral drugs, nutrition, and fluidsInterruption of oral drugs, nutrition, and fluids Pulmonary aspirationPulmonary aspiration

Palazzo MG et al. Can Anaesth Soc 1984; ASHP Am J Health Syst Pharm 1999; Watcha MF et al. Anesthesiology 1992; 77(1): 162-184.

ReceptorsReceptors

Major Risk Factors for Major Risk Factors for PONVPONV

Patient characteristicsPatient characteristics– AgeAge– GenderGender– AnxietyAnxiety– Weight Weight – History of PONV/motion sicknessHistory of PONV/motion sickness– Concomitant diseaseConcomitant disease– Non-smoking historyNon-smoking history

Watcha MF et al. Anesthesiology 1992; 77(1): 162-184.Lerman. Br J Anaesthesia. 1992; 69 (suppl 1): 24S – 32S.Bellville et al. Anesthesiology. 1960; 21(2): 186-193.


Type of surgeryType of surgery– GynecologicGynecologic– OphthalmicOphthalmic– Ear, nose, and throatEar, nose, and throat– LaparoscopicLaparoscopic– IntraabdominalIntraabdominal– Breast Breast – TesticularTesticular– ShoulderShoulder– Dental/oralDental/oral– Lengthy procedureLengthy procedure


Major Risk Factors for Major Risk Factors for PONVPONV Type of anesthesiaType of anesthesia

– OpioidsOpioids– Nitrous oxideNitrous oxide– EtomidateEtomidate– MethohexitalMethohexital– BarbituratesBarbiturates– Neuromuscular blocking drugsNeuromuscular blocking drugs– AnticholinesterasesAnticholinesterases– Potent volatile anesthetic gasesPotent volatile anesthetic gases



Care in the PACUCare in the PACU– PainPain– OpioidsOpioids– MovementMovement– DehydrationDehydration– Orthostatic hypotensionOrthostatic hypotension– SedationSedation– Oral intakeOral intake


Risk FactorsRisk FactorsAnesthetic RelatedAnesthetic Related

Risk FactorsRisk Factors OR*OR* CICI

Volatile anesthetics Volatile anesthetics

isofluraneisoflurane 3.413.41 2.18; 5.372.18; 5.37

sevofluranesevoflurane 2.782.78 1.79; 4.311.79; 4.31

enfluraneenflurane 3.113.11 1.98; 4.881.98; 4.88

Apfel et al. BJA 2002;88:659-668* Compared to propofol

Volatile Anesthetics

Antiemetic AgentsAntiemetic Agents

• 5-HT3 Receptor Antagonists– Dolasetron– Granisetron– Ondansetron

• NK-1 Inhibitors– Aprepitant

• Corticosteroids– Dexamethasone– Methylprednisolone

• Substituted Benzamides– Metoclopramide

• Cannabinoids– Dronabinol– Nabilone– NK-1 Inhibitors

• Benzodiazepines– Lorazepam– Alprazolam

• Butyrophenones– Droperidol– Haloperidol– Domperidone

• Phenothiazines– Prochlorperazine– Chlorpromazine– Thiethylperazine Maleate– Promethazine Hydrochloride

• Antihistamines

ASHP Guidelines. Am J Health-Syst Pharm 1999;56:729

Pharmacologic group/drug Dopamine (D2) Muscarinic Cholinergic Histaminic Serotonin (5-HT3)

PhenothiazinesFluphenazine ++++ + ++ -Chlorpromazine ++++ ++ ++++ +Prochlarperazine ++++

ButyrophenonesDroperidol ++++ - + +Haloperidol ++++ - + -Domperidone ++++

AntihistaminesDiphenhydramine + ++ ++++ -Promethazine ++ ++ ++++ -

Anticholinergic: scopolamine + ++++ + -Benzamides

Metoclopramide +++ - + ++

5-HT3 Receptor AntagonistsOndanensetron - - - ++++Granisetron - - - ++++

Tricyclinic AntidepressantsAmitriptyline +++ +++ ++++ -Nartriptyline +++ ++ +++ -

Number of positive signs (+) indicates degree of activity; negative sign (-) indicates no activity.

Adapted from Watcha and White. Anesthesiology. 1992;77(1):162-184

Receptor Site Affinity of Antiemetic AgentsReceptor Site Affinity of Antiemetic Agents

5-HT5-HT33 Receptor Selectivity Receptor Selectivity

Serotonergic receptors of the 5-HTSerotonergic receptors of the 5-HT33 subtype seem to have a crucial subtype seem to have a crucial role in the systems mediating role in the systems mediating emesisemesis

Ondansetron has a greater affinity Ondansetron has a greater affinity for this receptor than any otherfor this receptor than any other

Avoids the acute dystonic Avoids the acute dystonic reactions associated with reactions associated with dopamine blockade dopamine blockade

Prevention of PONV:Prevention of PONV:MetoclopramideMetoclopramide

““In summary, metoclopramide, although used as In summary, metoclopramide, although used as an antiemetic for almost 40 years in the an antiemetic for almost 40 years in the prevention of PONV, has no clinically relevant prevention of PONV, has no clinically relevant antiemetic effect . . . it is very likely that the antiemetic effect . . . it is very likely that the doses used in daily clinical practice are too low.”doses used in daily clinical practice are too low.”

Henzi I, Walder B, and Tramer, MR. Metoclopramide in the prevention of postoperative nausea and vomiting: a quantitative systematic review of randomized, placebo-controlled studies. BJA 1999;83:761-771

II-A

MetoclopramideMetoclopramide

Metoclopramide in the prevention Metoclopramide in the prevention ofpostoperative nausea and ofpostoperative nausea and vomiting: a quantitative systematic vomiting: a quantitative systematic review of randomized, placebo-review of randomized, placebo-controlled studies.controlled studies.

Conclusion:Conclusion: No benefit from metoclopramide as a No benefit from metoclopramide as a

prophylactic antiemeticprophylactic antiemetic

Tramer MR Br J Anaesth. 1999 Nov;83(5):761-71Tramer MR Br J Anaesth. 1999 Nov;83(5):761-71

DimenhydrinateDimenhydrinate

Dimenhydrinate for prophylaxis of Dimenhydrinate for prophylaxis of postoperative nausea and vomiting: a meta-postoperative nausea and vomiting: a meta-analysis of randomized controlled trials.analysis of randomized controlled trials.

Kranke P, Morin AM, Roewer N, Eberhart LH. Kranke P, Morin AM, Roewer N, Eberhart LH. Acta Anaesthesiol Scand 2002 Mar;46(3):238-44 Acta Anaesthesiol Scand 2002 Mar;46(3):238-44

Yes …. but at 1 – 2 mg/kgYes …. but at 1 – 2 mg/kg

sleepysleepy

DimenhydrinateDimenhydrinate

Antiemetic efficacy of Antiemetic efficacy of prophylactic dimenhydrinate prophylactic dimenhydrinate (Dramamine) vs ondansetron (Dramamine) vs ondansetron (Zofran): a randomized, (Zofran): a randomized, prospective trial inpatients prospective trial inpatients undergoing laparoscopic undergoing laparoscopic cholecystectomy.cholecystectomy.

Kothari SN, Boyd WC, Bottcher ML, Lambert Kothari SN, Boyd WC, Bottcher ML, Lambert PJ.PJ.Surg Endosc 2000 Oct;14(10):926-9Surg Endosc 2000 Oct;14(10):926-9

Ondansetron 4 mgOndansetron 4 mgDimenhydrinate 50 mg Dimenhydrinate 50 mg

0

5

10

15

20

25

30

35

40

45

PONV

Dimenhydrinate

Ondansetron

DroperidolDroperidolDose Nausea NNT 95% CI

0-6 hr 5.2 3.3-12.6 0.25 0-24 hr - -

0-6 hr 4.8 3.0-12 0.5-0.75 0-24 hr 11 6.9-25

0-6 hr 6.1 4.5-9.4 1.0-1.25 0-24 hr 6.8 5.2-9.7

Prevention of vomiting requires larger doses, NNT 8-10.

Henzi I. Can J Anesth 2000;47(6):537-551.

5-HT5-HT33 Receptor Antagonists Receptor Antagonists 5-HT5-HT33 Receptor Antagonists Receptor Antagonists

– AnzemetAnzemet®® (dolasetron mesylate) (dolasetron mesylate)– Zofran (ondansetron)Zofran (ondansetron)– Kytril (granisetron)Kytril (granisetron)

Block 5-HTBlock 5-HT33 receptors in the CNS and periphery (i.e., in receptors in the CNS and periphery (i.e., in the GI mucosa), preventing the binding of serotonin (5-the GI mucosa), preventing the binding of serotonin (5-HT) to the 5-HTHT) to the 5-HT33 receptors receptors

Activity is based on receptor binding, not kinetic Activity is based on receptor binding, not kinetic parameters; therefore, once 5-HTparameters; therefore, once 5-HT33 receptors are receptors are saturated, higher doses do not increase effectsaturated, higher doses do not increase effect– Duration of action is independent of ½ lifeDuration of action is independent of ½ life

Gralla et al. J Clin Oncol 1999;17:2971ASHP Guidelines. Am J Health-Syst Pharm 1999;56:729

Ondansetron Ondansetron ProphylaxisProphylaxisDose Event NNT 95% CI

0-6 hr 9.0 5.3-30 1 mg 0-24 hr 21 9.1- ?

0-6 hr 5.6 4.4-7.5 4 mg 0-24 hr 6.4 5.3-7.9

0-6 hr 6.4 4.7-10 8 mg 0-24 hr 5.0 4.0-6.7

Tramer MR. Anesthesiology 1997;87(6):1277-89.

OndansetronOndansetron Prophylactic ondansetron for post-operative Prophylactic ondansetron for post-operative

emesis: meta-analysis of its effectiveness in emesis: meta-analysis of its effectiveness in patients with and without a previous history of patients with and without a previous history of

motion sicknessmotion sickness Eur J Anaesthesiol 1999 Aug;16(8):556-64 Eur J Anaesthesiol 1999 Aug;16(8):556-64

– Twelve trials involving 2122 patients Twelve trials involving 2122 patients – The dose of The dose of 4 mg4 mg ondansetron was ondansetron was

71.5%71.5% more effective in patients with more effective in patients with a positive Hx of motion sickness a positive Hx of motion sickness

DexamethasoneDexamethasoneDose Vomiting NNT 95% CI

0-6 hr 3.6 2.3-8.0 8-10 mg

0-24 hr 4.3 2.6-12.0

Henzi I. Anesth Analg 2000;90:186-94

•Synergism with 5 HT3 antagonistsLopez-Olaondo L. BJA 1996;76(6):835-40

Fujii Y. Can J Anesth 1995;42(5):387-90

•Side effect freeBluming AZ. J Clin Oncol 1986;4:21-3

IGAR.NEJM 2000;342(21):1554-9

DexamethasoneDexamethasone The effect of dose of dexamethasone for antiemesis The effect of dose of dexamethasone for antiemesis

after major gynecological surgeryafter major gynecological surgery Anesth Analg 1999 Nov;89(5):1316-8Anesth Analg 1999 Nov;89(5):1316-8

– 30 pts per group30 pts per group– Dex 0 to 10 mg per pt Dex 0 to 10 mg per pt

PONV

0

20

40

60

80

Placebo D1.25 D2.5 D5 D10

OxygenOxygenOndansetron is no more Ondansetron is no more

effective than effective than supplemental supplemental

intraoperative oxygen intraoperative oxygen for prevention of for prevention of

postoperative nausea postoperative nausea and vomiting.and vomiting.

Goll V, Akca O, Greif R, Freitag H, Goll V, Akca O, Greif R, Freitag H, Arkilic CF, Scheck T, Zoeggeler A, Kurz Arkilic CF, Scheck T, Zoeggeler A, Kurz

A, Krieger G, Lenhardt R, Sessler DI.A, Krieger G, Lenhardt R, Sessler DI.

Anesth Analg. 2001 Aug;93(2):518-9Anesth Analg. 2001 Aug;93(2):518-9. .

PONV

0

20

40

60

30% 30%+

Ond

80%

Avoid Hypoxia and Hypotension

Prevention of PONV:Prevention of PONV:Combination TherapyCombination TherapyWhich Combination?

EventEvent

5-HT3 + drop5-HT3 + drop 5-HT3 + dex5-HT3 + dex

NN RateRate NN RateRate P-valueP-value OROR

EarlyEarly

NauseaNausea 138138 17%17% 260260 11%11% 0.120.12 1.61.6

VomitingVomiting 318318 1%1% 419419 1%1% 1.001.00 1.01.0

Late Late

NauseaNausea 358358 27%27% 623623 21%*21%* 0.020.02 1.41.4

VomitingVomiting 443443 9%9% 813813 9%9% 1.001.00 0.90.9Ashraf et al. Anesthesiology 2001; 95:A-41

Evidence Rating for Evidence Rating for AntiemeticsAntiemetics

Strength of EvidenceStrength of Evidence Treatment Consequences*Treatment Consequences*

PreventionPrevention TreatmentTreatment PreventionPrevention TreatmentTreatment

Ondansetron 4 mgOndansetron 4 mg I-AI-A I-AI-A 5.5 – 6.55.5 – 6.5 3.2 – 3.93.2 – 3.9

Ondansetron 1 mgOndansetron 1 mg -- I-AI-A -- 3.8 – 4.83.8 – 4.8

Dolasetron 12.5 mgDolasetron 12.5 mg I-AI-A I-AI-A 4.0 – 5.04.0 – 5.0 3.6 – 4.23.6 – 4.2

Granisetron 1 mgGranisetron 1 mg I-AI-A I-AI-A 3.1 – 4.23.1 – 4.2 3.1 – 3.83.1 – 3.8

DroperidolDroperidol I-AI-A -- 4.3 – 5.04.3 – 5.0 ??

DexamethasoneDexamethasone II-AII-A -- 4.3 – 7.14.3 – 7.1 --

DimenhydrinateDimenhydrinate II-AII-A V-BV-B 4.8 – 8.04.8 – 8.0 ??

MetoclopramideMetoclopramide -- V-BV-B ?? ??

*NNT

PROLONGED PROLONGED UNCONSCIOUSNESSUNCONSCIOUSNESS

KERJA OBAT YANG MEMANJANGKERJA OBAT YANG MEMANJANG DOSIS OBAT YANG BERLEBIHDOSIS OBAT YANG BERLEBIH METABOLISME YANG MENURUNMETABOLISME YANG MENURUN EKSKRESI OBAT YANG LAMBATEKSKRESI OBAT YANG LAMBAT

GANGGUAN METABOLISME DI OTAKGANGGUAN METABOLISME DI OTAK HIPERCAPNEAHIPERCAPNEA SHOCK YANG LAMASHOCK YANG LAMA HIPOGLIKEMIAHIPOGLIKEMIA NARKOTIKNARKOTIK HIPONATREMIAHIPONATREMIA

STROKESTROKE TEKANAN DARAH DURANTE OP.TEKANAN DARAH DURANTE OP. ATASI DENGAN :ATASI DENGAN :

MONITORING KETATMONITORING KETAT ATASI GANGGUAN SPESIFIKATASI GANGGUAN SPESIFIK k/p RAWAT ICUk/p RAWAT ICU

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k.43 Penyulit Pasca Bedah & Penanganannya