ANESTESI UMUM UNJANI 2

Anestesi Umum
Induksi 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 umum

VIMA (Volatile Induction and Maintenance of Anesthesia) Fast-Track Anesthesia Low-flow Anesthesia Low-cost Anesthesia Single-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 nyaman

Membutuhkan akses intravena
nyeri,takut, sulit.

Obat sakit bila disuntikkan Adanya reaksi yang buruk

hipotensi apne mioklonus, porphyria, anafilaxis

Efek sisa : sedasi

Induksi Inhalasi membutuhkan obat yg tepat

VIMA
Iritasi jalan nafas

Potensi

VIMA

Kelarutan

The Triad of VIMA

Adapted from: Logan Int Proc J 7: 4, 1998

Proteksi Organ
Basic method/Metode mendasar : A,B, C Hipotermi Farmakologik : Anestetika intravena Anestetika inhalasi

Gambaran proteksi Otak dari anestetika inhalasi

Proteksi otak dalam lingkupan efek anti-necrotik and anti-apoptotik Meningkatkan aliran darah otak pada daerah otak yg iskemik. Menurunkan metabolisme otak Menekan kejang
Werner C. AOSRA Nov 2003, WCA, April 2004. ESA June 2004.

Gambaran proteksi Otak dari anestetika inhalasi

Isofluran, sevofluran, desfluran menekan metabolime otak secara maksimal pada 2 MAC memperbaiki ketidakseimbangan antara kebutuhan dan pasokan oksigen. Menghambat asidosis laktik dan pelapasan neurotransmitter excitatory Mencegah 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 cepat Lama kerja singkat Mudah mengendalikan efek analgesiknya Analgesik kuat Tidak ada pelepasan histamine Metabolitnya tidak aktif

Penggunaan Opiat dalam Anestesi

Premedikasi Induksi anestesi Narcotik anestesi Bagian dari balans anestesi Adjuvant dalam anestesi regional Neurolept anestesi Pengelolaan nyeri pascabedah

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

Dosis klinis Narkotik

Obat Dosis intravena Mula kerja (menit) 0.05-0.3 mg/kg 5-10 0.5-1 mg/kg 5-10 1-5 ug/kg 2 10-40 ug/kg <1 30-80 ug/kg <1 Perkiraan lama kerja 3-5 h 2-3 h 45 min 2 h < 30 min < 60 min

Morfin Petidin Fentanyl Sufentanil Alfentanil

Pelumpuh otot Ideal

Non depolarisasi Mula kerja cepat, lama kerja singkat Pemulihan cepat, potensi kuat Tidak kumulatif, metabolitnya tidak aktif Tidak ada efek kardiovaskuler Tidak menimbulkan pelepasan histamin Dapat dilawan dengan antikholinesterase

Pelumpuh Otot depolarizing dan Non depolarizing

Depolarizing Lama kerja singkat: Succinylcholin Non depolarizing Lama kerja panjang : Pancuronium Lama kerja sedang: Rocuronium, Vecuronium, Atracurium Lama kerja singkat: Mivacurium

Kondisi yg kemungkinan terjadi hiperkalemia akibat Succinylcholin

Luka bakar Trauma berat Infeksi intra-abdominal berat Cedera medulla Spinalis Encephalitis Stroke Guillain-Barre syndrome Severe Parkinsons disease Tetanus Bed rest lama Ruptured cerebral aneurysm Polyneuropathy Cedera kepala Syok Hemorrhagic dengan metabolik asidosis Myopathies ( eg, Duchenness dystrophy )

Mechanism neuromuscular blockade

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

Terminology in muscle relaxant

ED 50 : dose what can paralyzed 50% muscle strength ED 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 Short-acting Succinylcholine Decamethonium

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

Nondepolarizing drug
Do not produce muscular fasciculation Effect are decreased by anticholinesterase agent, depolarizing agent, lowered body temperature, epinephrine, acetylcholine Effect are increased by non-depolarizing drugs, volatile anesthetic .

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

Table 9 - 5. Conditions causing susceptibility to succiniylcholine-induced hyperkalemia.

Burn injury Massive trauma Severe intra-abdominal infection Spinal cord injury Encephalitis Stroke Guillain-Barre syndrome Severe Parkinsons disease Tetanus Prolonged total body immobilization Ruptured cerebral aneurysm Polyneuropathy Closed head injury Near drowning Hemorrhagic shock with metabolic acidosis Myopathies ( eg, Duchenness dystrophy )

Resume farmakologi pelumpuh otot nondepolarizing

Relaxant Tubocurarine Metocurine Atracurium Mivacurium Doxacurium Pancuronium Pipecuronium Vecuronium Rocuronium
1 2

Metabolism Insignificant Insignificant +++ +++ Insignificant + + + Insignificant

Primary Excretion Renal Renal Insignificant Insignificant Renal Renal Renal Biliary Biliary

Onset ++ ++ ++ ++ + ++ ++ ++ +++

Duration +++ +++ ++ + +++ +++ +++ ++ ++

Histamine Release +++ ++ + + 0 0 0 0 0

Vagal Blockade 0 0 0 0 0 ++ 0 0 +

Relative Potency1 1 2 1 2.5 12 5 6 5 1

Relative Cost2 Low Moderate High Moderate High Low High High High

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

Choice of anesthesia technique depend on:

Patient condition Skill anesthetist Skill surgeon Hospital socio economy

Problem during induction of anesthesia

Main problem : airway Sign of partial obstruction : snoring, crowing, gargling, wheezing, chest retraction, cyanosis Sign of total obstruction : air flow from nose/mouth negative, supraclavicular retraction, intercostal retraction, cyanosis

Other problem during induction

Respiratory depression Cough Larynx spasm Mucus and saliva vomiting

Airway controlled
Without equipment : Triple mannuver Safar With equipment: OPA (Oro Pharyngeal Airway) NPA (Naso Pharyngeal Airway) LMA ( Laryngeal Mask Airway) ETT (Endo Tracheal Tube)

Indication Intubation
Head and neck surgery Difficult airway Thoracotomy Laparotomy Lateral position Prone position Controlled ventilation

Technique laryngoscopy
Head position Insertion laryngoscope blade Visualization epiglottis Lift epiglottis View larynx and surrounding structure

Advantages Endotracheal intubation

Ensures a patent airway Normal anatomic dead space (75 ml) is decreased to 25 ml. Ventilation can be assisted or controlled Possibility of aspiration diminished drastically Suctioning of the lung is facilitated

Disadvantages endotracheal intubation Increases resistance to respiration Trauma to the lips, teeth, nose, throat, larynx.

Complication Intubation
Teeth rupture Mouth bleeding Endobronchial intubation Oesophageal intubation Sore throat Hypertension Arrhythmias

Teknik Induksi
Mask induction / inhalasi : induksi melalui sungkup muka. Intravena Intramuscular Per 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 Sevofluran

Gradual Induction Single Breath Induction Triple Breath Induction (Multiple Breath Induction) Teknik cepat dengan Single Breath Induction, tanpa kejadian batuk, nahan nafas, spasme laring.

Induksi Bertahap
Metode 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 Induction

Suatu variasi dari Single Breath Induction Minta 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 anestesi

PRST 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 anestesi

Indeks Sistolik Kondisi Kurang dari awal + 15 Kurang dari awal + 30 Lebih dari awal +30 Skor 0 1 2 0 1 2 0 1 2

Denyut jantung Kurang dari awal + 15 Kurang dari awal + 30 Lebih dari awal +30 Keringat Tidak ada Kulit teraba berkeringat Terlihat berkeringat

Air mata

Tidak ada air mata bila kelopak mata dibuka 0 Air mata terlihat bila kelopak mata dibuka 1 Air mata keluar walau kelopak mata tertutup 2

Skor 2-4 : anestesi adekuat

Ekstubasi
Setelah ventilasi adekuat Pada anestesi dalam atau setelah pasien bangun Jalan nafas harus bebas Berikan oksigen 100% sebelum dan setelah ekstubasi.

Tatang Bisri, 2009

N2O
1.5 time heavier than air Must be give with O2 100% Weak anesthetic Analgesic N2O 20% equal with 15 mg morphine Dont use in closed system At the end of anesthesia, to prevent diffusion hypoxia O2 100%

Advantages N2O
Rapid induction and recovery No sensitized myocardium with catecholamine No irritation respiratory tract Odor pleasant Strong analgesic

Disadvantages N2O
Weak anesthetic No muscle relaxation effect Need high concentration oxygen Possibility aplasia bone marrow

Halothane
A clear, colorless, potent volatile liquid. Metabolism 17-20% Advantages Halothane Rapid, smooth induction and recovery. Pleasant Non irritating, no secretion Bronchodilator Nonemetic Non flammable and non explosive

Disadvantages Halothane
Myocardial depressant An arrhythmia producing drug Sensitizes the myocardial conduction system to the action of catecholamines A potent uterine relaxant Possible toxic to the liver Shivering during recovery period.

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

Advantages Enflurane
Pleasant Rapid induction and recovery Non-irritating : no secretion Bronchodilator Good muscle relaxation Nonemetic Non flammable and non explosive Compatible with epinephrine

Disadvantages Enflurane
Myocardial depressant Shivering on emergence CSF production increase CNS excitation, in high dose and hypocarbia.

Isoflurane
A stabe, volatile liquid A isomer enflurane Inhalation anesthetic choice for neurosurgical patient, kidney, liver.

Advantages Isoflurane
Rapid induction of anesthesia and swift recovery Nonirritating : no secretion Blood pressure remain stable Indicated in poor-risk patient

Disadvantages Isoflurane
Less than halothane and enflurane

Sevoflurane
Inhalation

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.

Sevoflurane
Drugs 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 anesthesia Reduce sphlannic blood flow, hepatic blood flow lesser than other anesthetic inhalation.

Thiopentone
Blood pressure decrease Heart rate increase or decrease Peripheral vasodilatation Heart contraction depressed Larynx spasm, bronchus spasm Respiratory depression until apnoea Dose 4-6 mg/kg BW

Relative contraindication thiopentone

Asthma bronchiale Severe liver disease Severe kidney disease Severe anemia Hypotension Shock

Ketamine
Dissociative anesthetic Delirium Hallucination Increase blood pressure : systolic 23% from base line Increase heart rate Arrhythmias Hypersecretion Dose 1-3 mg/kg I.v or 9-11 mg/kg I.m

Indication and Contraindication Ketamine

Indication : short surgery Contraindication : Hypertension systolic > 160 mmHg Arrhythmias Heart failure Pharynx and larynx surgery without intubation.

Propofol
New intravenous anesthetic Fast onset, short duration of action Accumulation minimal Fast recovery Rapid metabolism No complication at site of injection Dose 2-2.5 mg/kg BW