Tugas Anestesiologi

1. Mengelola

menghilangkan :

Rasa sakit / nyeri, rasa takut pada persalinan, pembedahan dan tindakan medik lainnya, baik sebelum, selama dan sesudahnya.
2. Mengawasi

dan menunjang fungsi-fungsi vital penderita yang

mengalami stres pembedahan dan pemberian anestesi.

3. Mengelola 4. Mengelola 5. Mengelola 6. Mengelola 7. Mengelola

penderita tidak sadar oleh karena sebab apapun. penderita yang mengidap masalah nyeri masalah resusitasi. terapi pernapasan. berbagai gangguan cairan, elektrolit dan metabolit.
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Sepuluh prinsip amanat (ten commandments)

1. Janganlah bagaimanapun juga mengakibatkan penderita mengalami hipoksia/anoksia. 2. Jalan pernafasan penderita harus dijaga selalu aman dan bebas. 3. Jangan memberikan anestesia kepada penderita tanpa izinnya dan janganlah antara resiko dan hasil tindakan anestesi tidak ada keseimbangan yang menguntungkan. 4. Janganlah menyalahgunakan waktu dari orang lain dengan memperlambat program/rencana pembedahan. 5. Janganlah memberikan anestesi tanpa membuat laporan tertulis (medical record).
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6.

Semua peralatan harus dipersiapkan dengan rapi dan bersih serta lengkap sesuai standard.

7.

Tubuh penderita harus dilindungi terhadap pengaruh-pengaruh yang merugikan selama pembedahan (perioperatif) karena penderita tidak sadar, maka andalah yang bertanggung jawab terhadap keselamatannya.

8.

Janganlah penderita anda diserahkan kepada pihak lain jika belum stabil dan masih membahayakan.

9.

Janganlah memberikan anestesia dengan tehnik-tehnik dan obat-obat yang tidak dikuasai oleh anda.

10. Dalam keadaan bagaimanapun anda adalah seorang spesialis klinik yang mengutamakan kepentingan penderita diatas kepentingan lainnya.
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The purpose of Visite:

Establish rapport with the patient Meet the doctor with the patient Discuss possible causes of anxiety regarding anesthetic and surgical manner Explain how the patient will be cared for during and after anesthesia and about pain relief Establish a doctor-patient relationship that reduces patient anxiety by building trust & respect Assessment of physical status Order special investigations

Table 9-7. Physical Status Classification of the American Society of Anesthesiologists (ASA)
Status
ASA Class 1

Disease State
No organic, physiologic, biochemical or psychiatric disturbance. Mild to moderate systemic disturbance that may not be related to the reason for surgery. Examples: Heart disease that only slightly limits physical activity, essential hypertension, diabetes mellitus, anemia, extremes of age, morbid obesity, chronic bronchitis. Severe systemic disturbance that may or may not be related to the reason for surgery. Examples: Heart disease that limits activity, poorly controlled essential hypertension, diabetes mellitus with vascular complications, chronic pulmonary disease that limits activity, angina pectoris, history of prior myocardial infarction. 5

ASA Class 2

ASA Class 3

Status
ASA Class 4

Disease State
Severe systemic disturbance that is life-threatening with or without surgery. Examples: Congestive heart failure, persistent angina pectoris, advanced pulmonary renal or hepatic dysfunction. Moribund patient who has little chance of survival but is submitted to surgery as a last resort (resuscitative effort). Examples: Uncontrolled hemorrhage as from a ruptured abdominal aneurysm, cerebral trauma, pulmonary embolus.

ASA Class 5

Emergency Any patient in whom an emergency operation is required. Operation (E) Examples: An otherwise healthy 30-year-old female who requires a dilatation and curettage for moderate but persistent hemorrhage (ASA Class 1 E).
(From information in American Society of Anesthesiologists. New classification of physical status Anesthesiology 1963; 24: 111.)

Premedication
Objectives are : Allay anxiety & fear Reduce secretions Analgesia Enhance the hypnotic effect of G.A. agent Reduces post op nausea and vomitting Produce amnesia Reduction in vagal reflex Limit sympathoadrenal responses

Drugs for premedication

Sedativa, tranquilizer Narcotics-analgetics Alkaloid belladona as antisecretion and reduce vagal reflex to the heart from : drugs impuls afferent abdomen, thorax, and eyes Antiemetic

Local Anesthetic Agent

1. Ester Compound
Cocaine Procaine / Novocaine Tetracaine / Pontocaine

Metabolisme: Plasma

Alergi : PABA (+) Metabolisme: Liver

2. Amide Compound
Xylocaine / Lidocaine Prilocaine / Citanest Bupivacaine / Marcaine Etidocaine / Duranest Ropivacaine Levo Bupivacaine

Alergi : (-)

Local Anestesi Ester Compond

Agent Cocaine

Concent: Clinical use 4-10% Topical

Onset & Duration Slow 30

Max: Single dose 150 Mg 500 Mg EPI 600 Mg + EPI 1012 Mg/Kg

Potency -

Procaine / Novocaine

Infiltration 1% Epidural 2% Plexus block 2% Spinal 10% Infiltration 1% Epidural 2% Plexus block 2%

Slow 30-45

Low

Chloro procaine

Rapid 45-60

600 Mg EPI Intermediate / Low 650 Mg + EPI 10-15 Mg/Kg

Tetracaine / Pontocaine

Topical 0,5-1% Infiltr 0,1-0,2% Epidrl 0,4-0,5% Spinal 1%

Slow 180-300

100 Mg 2 Mg/Kg

High

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Local Anestesi Amide Compond

Agent
Xylocaine / Lidocaine

Concent: Clinical use

Infiltr 0,5-1% Epidural 1-2% N.block 1-1,5% Topical 4% Spinal 5% sda

Onset & Duration

Rapid 60-120

Max: Single dose

300 Mg EPI 500 Mg + EPI 7-8 Mg/Kg

Potency
Intermediate

Prilocaine / Citanest

Slow 60-120 Slow >180>300 Rapid >180 >300

175 Mg EPI 250 Mg + EPI 3-4 Mg/Kg 175 Mg EPI 250 Mg + EPI 3 4 Mg/Kg 300 Mg EPI 400 Mg + EPI 4-5 Mg/Kg

Intermediate

Bupivacaine / Marcaine DOA lama Etidocaine / Duranest Potensial

Infilt 0,25-0,5% N.blok 0,5-0,75% Spinal 0,5% Infiltr 0,5% N.blok 0,5-1% Epidrl 1-1,5%

High

High
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Anesthetic Profile of Local Anesthetic is depend on :

Lipid solubility intrinsic potency
The Higher lipid sol Higher potency Procaine L.S. = 1 Bupivacaine L.S. = 30 Etidocaine L.S. = 140 90 % Axolemma consist of lipid

Protein binding Duration

Higher Protein binding Longer duration Procaine P.B. = 5 Bupivacaine P.B. = 95 10 % axolemma consist of protein

p Ka
P Ka as pH at which its ionized and non ionized are in complete equilibrium L.A. with pKa closer to tissue pH more rapid onset p Ka lidocaine = 7,7 12 Bupivacaine = 8,3

Indication : Spinal An., Epidural An.

Abdominal surgery esp. lower abdomen Hernia Inguinalis Lower extrimities surgery Vesica urinaria and prostatic surgery Obgyn surgery

Indication : Caudal Block Perineal Surgery

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Contraindication: Spinal An., Epiduran An., Caudal Block

Absolute :
- refusal of the patients - local infection - coagulopathy

Relative :
- Sepsis - Neurological disease - Technical problems - Hypovolemia

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Balance anesthesia
Anesthesia Drugs component Hypnotic Pentothal, Propofol, Enflurane, Isoflurane, Sevoflurane Analgesic Pethidine, Morphine, Fentanyl, Sufentanil, Remifentanil Relaxation Succ choline, Atracurium, Cisatracurium, Pancuronium
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Concept balanced anesthesia

Component anesthesia Hypnotic VIMA (Volatile) Sevo, Iso, Enf, Hal, Desfluran TIVA (Total) Propofol, Pento, Ket, Mid

Analgesic
Relaxation

Fentanyl, alf, suf ,Mo, pethidine, remifentanil

Depol & non depol

Fentanyl, alf, suf, Mo, pethidine, remifentanil

Depol & non depol

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Indication general anesthesia

Infant and young children. Adult who prefer general anesthesia. Extensive surgical procedures Patient with mental disease Prolonged surgery Patient with a history of toxic or allergic reaction to local anesthetic drugs Patient on anticoagulant treatment
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Intravenous Anesthetic (General An.)

Pentothal Propofol Etomidate Midazolam Diazepam

Ideal intravenous anesthetic

Water soluble Non irritation No anta analgesic effect Rapid and smooth Induction Cardiovascular stable in clinically dose

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Comparative properties of intravenous anesthetics

Thiopen Ketamin Propof Diazep Midaz Aqueous solution Available in solution Pain on injection Venous thrombosis + + + + + + + + + + 19

Comparative properties of intravenous anesthetics

Thiopen Ketamin Propof Diazep Midaz

Rapidly acting
Smooth induction Respiratory depression

+
++

+
+

+/-

Cardiovascular ++ depression

++

+/-

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Comparative properties of intravenous anesthetics

Thiopen Rapid recovery Smooth recovery Suitable for infusion Interaction with relaxant + Ketamin Propof + + Diazep Midaz -

+/-

+/-

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Resume: Effect anesthetic non volatile to organ system

Drug Thiopentone Diazepam Midazolam Meperidine Morphine Fentanyl Ketamine Propofol HR 0/ 0 MAP * * Vent Bdil 0 0 * * 0 0
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Resume: Effect anesthetic non volatile to CNS

Drug Thiopentone Diazepam Midazolam Meperidine Morphine Fentanyl Ketamine Propofol CBF CMRO2 ICP

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Ideal Anesthetic Inhalation General An.

Pleasant odor and non irritation Low solubility No organ toxic Side effect cardiovascular and respiration minimal CNS effect reversible without stimulant activity Effective in high O2 concentration Boiling pressure and boiling point can delivered by vaporizer standard

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Physicochemical properties Inhalation An.

Halothane Odor + Irritating to Resp system Solubility 2,35 MAC 0,76 Metabolism 17-20% Metabolites F, Cl, Br, TFA BCDFE, CDE, CTE, DBE Enfl + 1,91 1,68 2,4% F, CDA Isofl + 1,4 1915 <0,2% F, TFA Desfl + 0,42 6,0 0,02% F, TFA Sevo + 0,63 2,05 <5% F, HFIP

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Interaction with Sodalime

(Inhalation An.)
Anesthetic Halothane degradation Product BCDFE organ Toxicity Nephrotoxic clinical Relevancy Non identified to data

Enflurane
Isoflurane Desflurane Sevoflurane

CO
CO CO Compound A Compound B

Nephrotoxic

Non identified to date

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Cardiovascular effect of Volatile inhalational anesthetics

Variable Blood pressure Vascular resistance Cardiac output Cardiac contraction CVP Heart rate Sensitization of the heart to epinephrine 0 = No change (<10%) = increase Halothane 0 0 = Variable change Enflurane = 10-20% decrease Isoflurane 0 0 0 0? = 20-40% decrease
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Clinical pharmacology of Inhalational anesthetics : Respiratory

N2O Halo Enflur Isoflu Sevoflu

Tidal volume Resp rate PaCO2 resting

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Clinical pharmacology of Inhalational anesthetics : CNS

N2O Halo Enflur Isoflu Sevoflu

CBF ICP CMRO2 Seizure

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Clinical pharmacology of Inhalational anesthetics

N2O Halo Enflur Isoflu Sevoflu

HBF Nondep blockade Metabolism

0.004

15-20

2-3

2.5 0.2

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Narcotic analgesic ideal :

Wide margin of safety Fast onset of action Short duration of action Easier analgesia controlled Strong analgesic no histamine release Non active metabolite
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Ideal Muscle Relaxant

Non depolarization Rapid onset, short duration of action Rapid recovery, high potency non cumulative, metabolite non active No cardiovascular effect No histamine release Counteract with anticholinesterase

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Table 9 - 1. Depolarizing and nondepolarizing muscle relaxants.

Depolarizing Short-acting Succinylcholine Decamethonium

Nondepolarizing Long-acting Tubocurarine Metocurine Doxacurium Pancuronium Pipecuronium Gallamine Intermediate-acting Atracurium Vecuronium Rocuronium Short-acting Mivacurium
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Sign of deep anesthesia

PRST Score (balanced anesthesia) Guedel sign (ether anesthesia) PRST Score (score 2-4: adequate anesthesia) P = Systolic arterial pressure (mmHg) R = rate (heart rate) S = sweat/ lacrimation T = tear

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PRST Scoring indexes for Balanced anesthesia

Index
Systolic arterial Pressure (mmHg) Heart Rate (beats/min)

Condition
Less than control + 15 Less than control + 30 More than control +30 Less than control + 15 Less than control + 30 More than control +30 Nil Skin moist to touch Visible beads of sweat No excess tears when eyelids open Excess teas visible when eyelids open Tears overflow from closed eyelid

Score
0 1 2 0 1 2 0 1 2 0 1 2
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Sweat

Tears or Lacrimation

SHOCK * Characterized BV - Organ Blood Flow that Is Inadequateto meet Tissue Demands * Four Categories Of Shock 1. Cardiogenic Shock - Co - PCWP - SVR 2. Hypovolemic Shock - CO - PCWP - SVR 3. Distributive Shock - CO N/ - PCWP N / - SVR 4. Obstructive Shock - CO - PCWP 36 -SVR

MANAGEMENT OF SHOCK - Increasing C.O - Therapy Arrhythmias - To Manage - Pre Load - After Load - Fluid - Improve Contractility

- Optimize Oxygen Delivery - Hemoglobin - P a O2 (FiO2 & Lung Function) - Vaso Pressor & Inotropic Agent - Dopamine. etc - Antibiotic - Decrease Oxygen Demand

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