General Anesthesia in 1 Year Old Child With Labiognatoschizis Unilateral Complete Sinistra

Supervising Physician: dr. Widodo, Sp.An Complied by: Permadi Wisnu Kuncoro 110.2008.190 Sadiah 110.2008.227

IDENTITY FORM
Name

: Muhamad : 1 y.o : Male ::-

Religion :

Islam

R
Age Gender Occupation Education

Ethnic
Address Date

: Javanese
: Kesambi

of admission :

12 November 2013

Marriage

Status : Single

ANAMNESIS
History

of present illness:

Patient was brought by his parents to the Outpatient Departement of Oral Surgery Gunung Jati Hospital at November 10, 2013 complaint of cleft at his mouth to his nose unilateral in left side. His parents said that the cleft was there since his birth. They want the doctor to perform second operation to repair the cleft.

 History

of past illness:

Cardiovascular disease, asthma, drug allergy, atopic dermatitis are all denied.
History

of previous medication or operation:

First labioplasty was perform when patient age 10 month.

PHYSICAL EXAMINATION
Primary

Survey:

RR: 32x/minute
Circulation:

Airway:

Clear

Cardiac sound regular

Mallampati I
Breathing:

Additional sound (-)

Pulse: 130x/minute, regular content

Spontaneous Vesicular breath sound Additional sound (-)

General State
Awareness Temperature Head

: Fully Alert : 36.8oC

to Toe Examination:

Head : Normocephale

Eyes : No conjunctiva anemic and icteric sclera, light reflex +/+, pupil isokor
Ear : Discharge (-) Mouth : Mallampati I, tonsil T1-T1, cleft to the nose at left side Neck : No trachea deviation or lymphonodes enlargement

Chest :

: Simetrical movement, no retraction, no scars or mass seen P : No mass, simetrical tactil and vocal fremitus P: Sonor, no heart enlargement A: Cor: Cardiac sound normal, regular Pulmo: Vesicular breath sound +/+
Abdomen:

Bowel sound (+), Extremity: Edema (-), cyanotic (-)

OTHER EXAMINATION
Hb Ht : 10.4 gr/dl : 30.0 % BT : 2 30 CT : 4 30 Na : 143.4 mmol/l K : 4.22 mmol/l

WBC : 13.220/uL PLT : 351.000/uL

SGOT : 37 U/I
SGPT : 20 U/I

Cl :105.3 mmol/l

DIAGNOSE

Presurgical diagnose : labiognatoschizis unilateral complete sinistra procedure : labioplasty

Surgical

ANESTHESIA REPORT
ASA:

II

Pre

operative condition:
clear : 130x/minute, regular and

Alert Airway HR

adequate
RR
Fasting

: Spontaneous, 30x/minute
36.5oC : 4 hour before procedure

Temperature :

 Type

of anesthesia Oral Intubation

: General Anesthesia with

Medication
Fluid Induction

: RL 250cc : : 10 g mg

Fentanyl

Propofol :15

Tramus

: 5 mg

Monitoring
08.50 09.05 09.20 09.35 09.50 10.05 10.20 10.35 10.50 11.05 11.20 11.35 11.50 12.00 O2(L/min) N2O Volatile (iso) Infuse (RL) 2,5 2 2 2,5 2 1,5 2,5 2 1,5 2,5 2 1,5 2,5 2 1,5 2,5 2 1,5 2,5 2 1,5 2,5 2 1,5 2,5 2 1,5 2,5 2 1,5 2,5 2 1,5 2,5 2 1,5 2,5 2 1,5 2.5 2 1

HR (x/min)

140

130

130

132

135

130

130

130

130

130

132

30

130

RR(x/min)

18 Induction : 08.50 AM Intubation: 08.55 AM Incision : 09.05 AM

18 Completed surgery: 12.00PM Extubation: 12.20 PM

18

18

18

18

18

18

18

18

18

18

18

State during surgery :

Supine Airway : single lumen ett no. 3 with balloon

Surgical duration

: 2 hours 55 minute

Anesthesia Duration : 3 hours 35 minutes

Recovery room
Post
HR :

anesthesia condition:
130x/minute 36.7oC

Color
Activity Respiration

:2
:2 :2 :1

RR

: 28x/minute score total : 9

:2

Cardiovascular Patient

Temp :

moved to room 7

Aldrette

Awareness

Instruction :
Monitor Fasting

vital sign every 15 minutes

Metamizole

(antrain) 2x80mg

until fully conscious