Persiapan Pra Operasi
Transcript of Persiapan Pra Operasi
-
8/13/2019 Persiapan Pra Operasi
1/22
1
PERSIAPAN PRA OPERASI
BAGIAN ANESTESIOLOGI DAN TERAPI INTENSIF
FAKULTAS KEDOKTERAN UNIVERSITAS BRAWIJAYA MALANG
RS. SAIFUL ANWAR
2013
-
8/13/2019 Persiapan Pra Operasi
2/22
2
Team work :
SurgeonInternal medicine/ pediatricAnesthesiologyNurse
Comunication
-
8/13/2019 Persiapan Pra Operasi
3/22
3
PERIOPERATIVE
PSIKOLOGIMEDIK
TIVAINHALASI
REGIONAL
ALDRETE SCORESTEWARD SCORE
BROMAGE SCORE
Pre-ops Durante ops Post-ops
omplikasi
! M O N I T O R I N G 3
-
8/13/2019 Persiapan Pra Operasi
4/22
4
PREOPERATIVE
Preop. visite
1.Persiapan
2.Perencanaan
3.Klasifikasi (ASA I-V) Prognosa
-
8/13/2019 Persiapan Pra Operasi
5/22
5
The overall aims of preoperative assesment shouldinclude:
Confirm that the surgery proposed is realistic when comparing the likelybenefit to the patient with possible risks involved.
Anticipate potential problems and ensure that adequate facilities andappropriately trained staff are available to provide satisfactory peroperative
care.
Ensure that the patient is prepared correctly for the operation, improvingwhere feasible any factors which may increase the risk of an adverse outcome.
Provide appropiate information to the patient and obtain consent for the
planned anaesthetic technique.
Prescribe premedication and/or other specific prophylactic measures ifrequired.
-
8/13/2019 Persiapan Pra Operasi
6/22
6
1. Persiapan
a.HISTORYb.PHYSICAL EXAMINATIONc.LABORATORY/SPECIAL INVESTIGATION:
Rutin: DarahFoto thoraxUrineEKG
Khusus: Faal paruFaal ginjalFaal hatiElektrolitBGA
-
8/13/2019 Persiapan Pra Operasi
7/22
7
HISTORYDirect questions should be asked about the following items of specific relevanceto anaesthesia
PRESENTING CONDITION AND CONCURRENT MEDICAL HISTORYThe indication for surgery determines its urgency and thus influences aspectsof anesthetic management. There are many surgical conditions which havesystemic effects and these must be sought and quantified e.g. bowel cancer maybe associated with malnourishment, anemia and electrolyte imbalance.
The present of coexisting disease must also be identified, together with anassessment of the extent of any associated limitation to normal activity.The most relevant tend to be related to cardiovascular and respiratory diseasebecause their potential effect on perioperative management.
ANAESTHETIC HISTORYDetails ot the administrations and outcome of previous anaesthetic exposureshould be documented, especially if problems were encountered. Previousanaesthetic records should be examined if available, as more serious problemssuch as difficulty with tracheal intubation should have been documented.
-
8/13/2019 Persiapan Pra Operasi
8/22
8
FAMILY HISTORYThere are several hereditary conditions which influenced planned anaestheticmanagement, such as malignant hyperthermia, cholinesterase abnormalitiesand haemoglobinopathies.
DRUG HISTORYA complete history of concurrent medication must be documented carefully.Many drugs interact wih agents or techniques used during anaesthesia.Examples:
- ACE inhibitor (Captopril, Enalapril): hypotensive effect may be potentiatedby aneasthetic agents.- Anticonvulsants: May increase requirements for sedative or anaestheticagents. Sudden withdrawal may produce rebound convulsive activity- MAOIs : React with opioids causing coma or CNS excitement. Severehypertensive response to pressor agents
- Antibiotic aminoglycosides: potentiation of neuromuscular block. Caution withthe use of muscle relaxants.- NSAIDS: interfere with platelet function to varying degrees by inhibition ofplatelet cyclooxygenase.
-
8/13/2019 Persiapan Pra Operasi
9/22
9
HISTORY OF ALLERGYA history of allergy to specific substance must be sought, whether it is a drug,food, and the exact nature of the symptoms and sign should be elicited inorder to distinguish true allergy from some other predictable adverse reaction.
SMOKINGLong term deleterious effects of smoking include vascular disease of theperipheral, coronary and cerebral circulation, carcinoma of the lung and chronicbronchitis. Advising all patient to cease cigarette smoking for at lest 12 hour
prior to surgery.The CV effect of smoking are caused by the action of nicotine on sympatheticnervous system,producing tachycardia and hypertension, increasing coronaryvascular resistance. Cigarette smoke contains carbon monoxide, which convertsHb to carboxyhaemoglobin. In heavy smokers, this may result in a reduction inavailable oxygen by as much 25%.
Finally, the effect of smoking on the respiratory tract lead to a sixfold increasein postoperative respiratory morbidity.
-
8/13/2019 Persiapan Pra Operasi
10/22
10
PHYSICAL EXAMINATIONA full physical examination should be performed on every patient admitted forsurgery and the findings documented in the medical notes. In addition, theanaesthetist must predict any potential difficulty in maintaining the patientsairway during GA.
SPECIAL INVESTIGATIONS- Urinalysis- Full blod count: Hb concentration tends to be of greatest interest to
anaesthetist.- Blood chemistry: Ureum, creatinin, electrolytes, blood glucose concentration, -- LFT: any history of liver disease, alcoholism, previous hepatitis.- Chest X ray: Should be reserved for an older populations (>60 years of age)and patients with clear indication.-ECG: Change in rhythm or occurance of myocardial ischaemia or infarction.
- Pulmonary fuction tests : Peak expiratory flow rate, Forced vital capacity,Forced Expiratory Volume should be measured in all patients with significantdyspnoea. BGA is required in all patient with dsypnoea at rest.- Coagulation studies: history of bleeding disorders, patient receivinganticoagulant therapy, patiens with liver disease.
-
8/13/2019 Persiapan Pra Operasi
11/22
11
2. PERENCANAAN
Teknik anestesi: - GA (Intubasi, LMA, TIVA, Face mask/cup)
- Regional (Spinal/ Epidural/ Blok)
Pemilihan obat/agen anestesi, misal:
- Panas Atropin
- Kesadaran Midazolam
- Gangguan faal hati Halotan
- Premedikasi
-
8/13/2019 Persiapan Pra Operasi
12/22
12
3. Menentukan PrognosaASA CLASSIFICATION OF PHYSICAL STATUS AND THE
ASSOCIATED MORTALITY RATES(for elective and emergency cases)
ASA RATING Description of patient Mortality rate (%)
Class I A normally healthy individual 0.1
Class II A patient with mild systemic disease 0.2
Class III A patient with severe systemic disease that isnot incapacitating
1.8
Class IV A patient with incapacitating systemicdisease that is a constant threat to life
7.8
Class V A moribund patient who is not expected tosurvive 24 hour with or without operation
9.4
Class E Added as a suffix for emergency operation
-
8/13/2019 Persiapan Pra Operasi
13/22
13
Berhubungan dg informed consentASA III tidak merupakan jaminan 100%
bebas dari masalah, demikian juga sebaliknya.
Unexpected events: kesulitan intubasi, airway problems(laringospasme,
bronkospasme), KV problems(disritmia jantung, hiper/hipotensi), efek obat
anest (sistemic toxicty anest. regional, alergi, anafilaktik), dll tuduhan
malpraktek !!!
-
8/13/2019 Persiapan Pra Operasi
14/22
14
Persiapan sebelum operasi
Puasa aspirasi mortalitas : penjelasan dan pengawasanPengukuran tinggi badan, berat badan teknik anestesi regional, dosis obat
Pemasangan iv catheter (venocath, abocath) :
- Sesuai dengan umur: Untuk pasien dewasa nomor 18 G, minimal nomor 20 G
- Jenis operasi: minor/mayor surgery,kemungkinan perdarahan masif durante op
- Tranfusi set atau Infus set (BB < 30 kg mikro drip)
- Sebaiknya dilakukan sejak mulai puasa dehidrasi hipotensi saat induksi
- Bayi dan anak < 2 th D5 / N
Lepas gigi palsu, perhiasan, kosmetik (make up), baju pasien pakaian khusus
Pengosongan VU/ kateter/ lavement sesuai kebutuhan
Label (identitas, jenis operasi)
Ijin operasi (informed consentoperasi dan anestesi), penjelasan manfaat &resiko op dan anest. perawat, dokter.
Premedikasi
Pemeriksaan fisik ulang di OK
-
8/13/2019 Persiapan Pra Operasi
15/22
Persiapan pra op baik safety & success.
Persiapan pra op jelek resiko, morbiditas
BENCANA !!!
10
-
8/13/2019 Persiapan Pra Operasi
16/22
CONTOH KASUS :
- Tidak bisa mengatasi laringospasme saat induksi GA pada op. elektif
(sirkumsisi, herniotomi dll) pasien pediatrik (bayi/ anak) karena tidak/belum
terpasang infus linehipoksia sangat cepat KEMATIAN
- Keterlambatan resusitasi cairan pada perdarahan durante operasi mayor
(nefro/pielolitotomi, mastektomi, craniotomidll) akibat terpasang iv cathkecil
(no: 20) syok KECACATAN/ KEMATIAN
- Muntah (partikel padat) saat induksi/ pengakhiran anestesi akibat puasa yg
kurang aspirasi KEMATIANpenjelasan & pengawasan pra op !!
- Hipotensi hebat saat spinal anestesi akibat dehidrasi/ hipovolemi/ preload
cairan yg kurang akibat terpasang iv cath kecil (no: 20) misalnya pada pasien
sectio caesareancito MUAL MUNTAH, GELISAH, SYOK, FETAL DISTRESS,
HENTI JANTUNGmorbiditas, mortalitas
11
-
8/13/2019 Persiapan Pra Operasi
17/22
- Gigi palsu yang lepas saat laringoskopi intubasi aspirasi/ tertelan
MORBIDITAS, kemungkinan TUNTUTAN HUKUM
- Pasien tetap memakai kosmetik (bedak, lipstik)
mengaburkan SIANOSISpada keadaan hipoksia saat induksi/ pasca op
- Pasien tetap memakai perhiasan terlepas saat memindah/ transport pasien
- Tidak/ belum adanya persetujuan op /informed consentpada pasien yg
direncanakan bedah sehari (minor surgery, pagi datang, pasca op sorepulang) kompilkasi outcomejelek TUNTUTAN HUKUM
Bad things tend to happen when you least
expected, at the worse possible moment
12
-
8/13/2019 Persiapan Pra Operasi
18/22
18
OPERASI ADALAH TINDAKAN YG BERMANFAAT, TAPI JUGA
MENGANDUNG RESIKO MEDIS !!!
TIDAK ADA TINDAKAN OPERASI YANG TIDAKBERESIKO!!!
MANFAAT HARUS SEBANDING/LEBIH BESAR DARI
RESIKO MEDIS
Bagi dokter keselamatan pasien adalah
hukum tertinggi baginya (yang utama) :Aegroti Salus Lex Suprema
-
8/13/2019 Persiapan Pra Operasi
19/22
19
The Medical Defense Union of the United Kingdom and Ireland :2000 Dokter Spesialis Anestesiologi : Pembiusan 1970-1982 :750 kasus kecelakaan mayor kematian dan kerusakan otak
PENYEBAB KEMATIAN DAN KERUSAKAN OTAK
Terutama akibat nasibsial
% Terutama akibatkesalahan
%
Penyakit yg menyertai 107 14 Kesalahan teknik 326 43
Tidak diketahui 46 6 Kegagalan perawatan pascabedah
71 9
Sensitivitas thd obat 39 5 Dosis obat berlebihan 34 5
Hipotensi/ perdarahan 32 4 Penilaian pra bedah tidakadekuat
22 3
Gagal hati Halotan 24 3 Kesalahan obat 9 1
Hiperpireksia 18 2 Kegagalan dokter ahlianestesi
7 1
Embolisme 14 2
Bekuan dalamop by pass 1
Total 281 37 469 62
-
8/13/2019 Persiapan Pra Operasi
20/22
20
The Medical Defense Union: 37 % karena nasib sial
1% kegagalan dokter ahli anestesiologi
KEMUNGKINAN CEDERA MAUPUN KEMATIAN MERUPAKANSUATU RESIKO YANG HARUS SELALU DIHADAPI DAN MUNGKIN
AKAN SELALU DAPAT TERJADI DALAM SETIAP TINDAKANPEMBIUSAN
Kesimpulan
-
8/13/2019 Persiapan Pra Operasi
21/22
21
DOKTERAnestesi
Interna/ PediatrikOperator (Bedah, Obsgyn, Mata, THT)
PERAWAT
IGD/ PoliklinikKamar Operasi
Ruangan/ Bangsal
PERIOPERATIF
(PRA, DURANTE, PASCA OPERASI
KOMUNIKASI DAN KERJASAMA YANG BAIK
KEAMANAN, KUALITAS DAN KEBERHASILAN
TINDAKAN OPERASI
-
8/13/2019 Persiapan Pra Operasi
22/22