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AKSES AKSES VASKULARVASKULAR
Komisi Resusitasi Pediatrik
UKK PGD IDAI
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Akses Vaskuler :• Kanulasi Vena
• Kanulasi Arterial
• Akses Intraoseus
• Venaseksi
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Kanulasi Vena
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Akses Vena Perifer pd Anak• Vv dorsalis metacarpae
• V cephalica
• V basilica
• V cubiti mediana
• Vv dorsalis pedis
• V saphena magna
• V jugularis externa
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V. sefalika
V. basilika
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V. safena magna
VV. dorsalis pedis
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V. jugularis eksterna
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Akses vena perifer pd bayi
• V frontalis
• V temporalis
• V occipitalis
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Akses vena sentral• V. femoralis (pada saat resusitasi)
• V. jugularis interna
• V. jugularis externa
• V. subclavia
• V. umbilicalis (pada bayi baru lahir)
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Alat-alat akses vena sentral
• Kateter intra vena melalui jarum
(through the needle catheter)
• Kateter intravena dengan kawat pemandu
(modifikasi teknik Seldinger)
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AB
CD
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Indikasi :Indikasi : 1. Pemberian cairan/darah segera pd hipovolemia
2. Nutrisi Parenteral
3. Pengukuran tekanan vena central ( CVP )
4. Pemasangan kateter Swans Ganz/pacu jantung
5. Pemberian cairan/obat2an yg tdk bisa diberikan
melalui pembuluh darah perifer
Kontraindikasi : 1. Diathesis hemorrhagis
2. Kelainan anatomi infraklavikular
Kanulasi Vena Subclavia
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Persiapan :Persiapan :• Periksa deformitas infraklavikular• Periksa faal hemostasis• Jelaskan prosedur + komplikasi, minta persetujuan
tertulis
Peralatan :Peralatan :• Kateter jugular - subklavia, semprit 3 - 5 ml, benang
sutera, pemegang jarum dan gunting.• Kasa steril, larutan antiseptik, masker, tutup rambut,
gaun steril,sarung tangan, duk steril dan klip duk.• Alat anaestesi : semprit 3 ml, lidokain1 %. Cairan
infus, infus set dan standar penyangga infus.• Pembalut : Kasa steril, desinfektan, perban , plester.
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V. subklavia
Klavikula
Kosta I
M. sternokleidomastoideus
Sternum
V. subklavia
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Tekhnik :Tekhnik :1. Posisi penderita TrendelenburgTrendelenburg, pasang penyangga di
bawah bahu, kepala menghadap kontralateral.
2. Tentukan lokasi pungsi ( dibawah bag. tengah klavikula ) 3. Pasang masker, tutup rambut, sarung tangan dan gaun
steril. Siapkan kulit didaerah suprasternal - infraklavikula kanan dengan anti septik, tutup duk steril, Anaestesi kulit
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Kanulasi V. jugularisIndikasi :• Pemberian cairan/ darah segera• Pemakaian intravena bila tidak dapat dilakukan di
tempat lain• Pemantauan CV• Pemasangan alat pacu jantung temporer atau
kateter Swans Ganz• Pemberian cairan/ obat2an yang tidak dapat
diberikan melalui vena perifer• Nutrisi parenteralKontraindikasi :• Diatesis hemorrhagik• Kelainan anatomis daerah kanulasi
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Persiapan 1. Periksa faal hemostasis2. Periksa deformitas didaerah kanulasi3. Jelaskan prosedur kanulasi, komplikasi yang
bisa terjadi, minta persetujuan tertulis
Peralatan• Peralatan utama : Jarum pelacak, semprit 5 ml,
kateter jugular, benang sutera, pemegang jarum, gunting
• Alat antiseptik : kasa steril, sarung tangan, masker, gaun steril,duk steril, penjepit duk.
• Alat anaestesi : semprit 3 ml, lidokain 1%• Cairan infus, infus set dan standar infus Perban,
kasa steril, salep desinfektan dan plester
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V. jugularis eksterna
M. sterno-kleido-mastoideus
V. jugularis eksterna300
V. jugularis interna
V. jugularis interna
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V. jugularis eksterna
M . sterno-kleido-mastoideus
V. jugularis eksterna300
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TekhnikPendekatan yg sering dipakai : medial & posteriormedial & posterior
Pendekatan medial :1.Penderita dalam posisi Trendelenburg, kepala
menoleh kekiri, bahu diganjal gulungan kain2.Penderita diminta mengangkat kepala, tentukan
kaput sternal dan klavikular m. sternokleidomastoideus, tentukan segitiga antara kedua kaput tsb ( 2 - 3 cm diatas klavikula ). Palpasi arteria karotis di medial dari titik ini.
3.Siapkan kulit,pakai sarung tangan,masker,gaun steril. Desinfeksi kulit dan tutup duk steril.
4.Anaestesi kulit di apeks
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5. Masukkan jarum dengan bantuan semprit 5 ml 30 derajat terhadap kulit arah ke punting susu ipsilateral terus ke kaudal sampai keluar darah. Bila tdk keluar darah geser arah jarum agak ke lateral 5 - 10 dearajat.
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Perawatan pasca tindakan :1. Pemeriksaan auskultasi toraks
2. Pemeriksaan foto toraks
3. Perawatan dan penggantian perban tiap hari
Komplikasi • Non spesifik :
- Infeksi - Thrombophlebitis - Emboli - Hidrotoraks
• Spesifik : - Pneumotoraks - Pungsi arteria karotis- Trauma duktus torasikus - Trauma thd saraf- Pungsi trachea - Nyeri tekan leher- Kegagalan kanulasi atau malposisi kateter
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Ligamentuminguinale
N. femoralis
A. femoralis
V. femoralis
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450
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Kanulasi Arterial
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Kanulasi ArterialIndikasi :
– Pengukuran tekanan darah– Pengambilan sampel darah arteri
Kontraindikasi :– Sirkulasi kontralateral tidak adekwat – Infeksi ditempat kanulasi– Deformitas daerah kanulasi
Pilihan tempat kanulasi :1. Arteria Radialis
2. Arteria Dorsalis Pedis
3. Arteria Femoralis
4. Arteria Brachialis
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Alat-alat akses vena perifer
• Winged needle 19-21-23-25
• Kateter intravena 16-18-20-22-24
(over the needle catheter)
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Persiapan :1. Penjelasan prosedur dan kemungkinan komplikasi2. Persetujuan tertulis3. Evaluasi kollateral (tes Allen)
Peralatan :• Katater teflon, gunting, benang, pemegang jarum• Tranducer tek arteri, kabel osiloskop kalibrasi, saluran
tekanan, jalur triway• Pembilas : kateter harus dibilas minimal tiap 30 menit
dengan larutan PZ + heparin ( 1 - 5 U/ml )• Larutan antiseptik, kasa steril, sarung tangan dan gaun
steril, penutup rambut, duk dan penjepit• Semprit 3 ml, lidokain 1%• Perban, salep antiseptik, plester
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A. radialis
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Akses Intraoseus
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Akses intraoseus
• Pada resusitasi bayi dan anak balita (< 6 tahun)
• Pilihan kedua setelah vena perifer
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A
B
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Venaseksi
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Indikasi : • Perlu akses ke sistem vena tapi kanulasi tidak berhasil
Kontraindikasi :• Flebitis atau luka ditempat insisi
Persiapan : • Penjelasan prosedur termsk komplikasi • Persetujuan tertulis
Perlengkapan :• Kasa steril, skalpel, klem muskuito, klem bengkok,
retraktor,benang sutra,forsep bergigi halus, pengangkat vena, gunting, jarum + handel, torniket
• Kateter CVP/Swans Ganz, Jarum (abocath)• Semprit + jarum suntik dan Lidokain 1 %
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Lokasi Venaseksi : • V. saphena magna dan V. basilika
Tehnik :1.Posisi kaki terlentang, abduksi, diimmobilisasi
Tentukan letak vena (anterior malleolus tibialis)2.Desinfeksi lapangan operasi dan tutup duk steril
Pakai sarung tangan dan gaun steril, masker kemudian lakukan anaestesi kedalam kulit tempat insisi
3. Insisi kulit melintang 1 - 2 cm diatas vena, masukkan klem bengkok untuk mencari vena sampai ke perios, angkat ke permukaan.
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4. Isolasi vena dari jaringan sekitar, kemudian ikat vena bagian distal. Ujung bagian proksimal tidak diikat hanya dipasang benang lepas. Klip kedua ujung benang dengan klem lurus.
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5. Venotomi • Pegang vena dengan klem bergigi halus, angkat,
potong dengan skalpel
6. Insersi Jarum/ kateter• Pegang potongan proksimal venotomi, masukkan
jarum, lepas pegangan vena dan dorong jarum sejauh mungkin
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7. Pasang semprit dan coba isap untuk mengetahui masuknya dan patensi lumen. Hubungkan dengan cairan infus (Hati-hati emboli udara)
8. Fiksasi kateterIkat bagian proksimal venotomi agar kateter tidak lepas
9. Tutup luka operasi Sebelum menutup luka operasi,lakukan irigasi dengan PZ. Beri obat desinfeksi dan tutup dengan kasa steril.
Komplikasi :1. Kerusakan jaringan sekitar2. Infeksi3. Thrombophlebitis4. Kesalahan kanulasi arteri
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Pelatihan Resusitasi PediatrikAngkatan XV
Banjarmasin, 5 – 6 Oktober 2002
UKK Pediatrik Gawat Darurat IDAI