PERSIAPAN PRA OPERASI

BAGIAN ANESTESIOLOGI DAN TERAPI INTENSIF FAKULTAS KEDOKTERAN UNIVERSITAS BRAWIJAYA MALANG RS. SAIFUL ANWAR 2013
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Team work :
Surgeon Internal medicine/ pediatric Anesthesiology Nurse

Comunication
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PERIOPERATIVE
Pre-ops Durante ops Post-ops

PSIKOLOGI MEDIK

TIVA INHALASI REGIONAL

ALDRETE SCORE STEWARD SCORE BROMAGE SCORE

Komplikasi

! MONITORING

PREOPERATIVE

Preop. visite
1.Persiapan
2.Perencanaan 3.Klasifikasi (ASA I-V) Prognosa
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The overall aims of preoperative assesment should include:

Confirm that the surgery proposed is realistic when comparing the likely benefit to the patient with possible risks involved. Anticipate potential problems and ensure that adequate facilities and appropriately trained staff are available to provide satisfactory peroperative care.

Ensure that the patient is prepared correctly for the operation, improving where 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 if required.

1. Persiapan
a.HISTORY b.PHYSICAL EXAMINATION c.LABORATORY/SPECIAL INVESTIGATION: Rutin: Darah Khusus: Faal paru Foto thorax Faal ginjal Urine Faal hati EKG Elektrolit BGA

HISTORY

Direct questions should be asked about the following items of specific relevance to anaesthesia PRESENTING CONDITION AND CONCURRENT MEDICAL HISTORY The indication for surgery determines its urgency and thus influences aspects of anesthetic management. There are many surgical conditions which have systemic effects and these must be sought and quantified e.g. bowel cancer may be associated with malnourishment, anemia and electrolyte imbalance. The present of coexisting disease must also be identified, together with an assessment of the extent of any associated limitation to normal activity. The most relevant tend to be related to cardiovascular and respiratory disease because their potential effect on perioperative management. ANAESTHETIC HISTORY Details ot the administrations and outcome of previous anaesthetic exposure should be documented, especially if problems were encountered. Previous anaesthetic records should be examined if available, as more serious problems such as difficulty with tracheal intubation should have been documented.

FAMILY HISTORY There are several hereditary conditions which influenced planned anaesthetic management, such as malignant hyperthermia, cholinesterase abnormalities and haemoglobinopathies.
DRUG HISTORY A 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 potentiated by aneasthetic agents. - Anticonvulsants: May increase requirements for sedative or anaesthetic agents. Sudden withdrawal may produce rebound convulsive activity - MAOIs : React with opioids causing coma or CNS excitement. Severe hypertensive response to pressor agents - Antibiotic aminoglycosides: potentiation of neuromuscular block. Caution with the use of muscle relaxants. - NSAIDS: interfere with platelet function to varying degrees by inhibition of platelet cyclooxygenase.

HISTORY OF ALLERGY A 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 in order to distinguish true allergy from some other predictable adverse reaction.
SMOKING Long term deleterious effects of smoking include vascular disease of the peripheral, coronary and cerebral circulation, carcinoma of the lung and chronic bronchitis. 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 sympathetic nervous system,producing tachycardia and hypertension, increasing coronary vascular resistance. Cigarette smoke contains carbon monoxide, which converts Hb to carboxyhaemoglobin. In heavy smokers, this may result in a reduction in available oxygen by as much 25%. Finally, the effect of smoking on the respiratory tract lead to a sixfold increase in postoperative respiratory morbidity.

PHYSICAL EXAMINATION

A full physical examination should be performed on every patient admitted for surgery and the findings documented in the medical notes. In addition, the anaesthetist must predict any potential difficulty in maintaining the patients airway 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 significant dyspnoea. BGA is required in all patient with dsypnoea at rest. - Coagulation studies: history of bleeding disorders, patient receiving anticoagulant therapy, patiens with liver disease.
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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

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3. Menentukan Prognosa
ASA CLASSIFICATION OF PHYSICAL STATUS AND THE ASSOCIATED MORTALITY RATES (for elective and emergency cases)
ASA RATING Class I Class II Class III Class IV Description of patient A normally healthy individual A patient with mild systemic disease Mortality rate (%) 0.1 0.2

A patient with severe systemic disease that is 1.8 not incapacitating A patient with incapacitating systemic disease that is a constant threat to life 7.8

Class V
Class E

A moribund patient who is not expected to survive 24 hour with or without operation
Added as a suffix for emergency operation

9.4

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Berhubungan dg informed consent ASA I II 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 !!!

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Persiapan sebelum operasi

Puasa aspirasi mortalitas : penjelasan dan pengawasan Pengukuran 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 consent operasi dan anestesi), penjelasan manfaat & resiko op dan anest. perawat, dokter. Premedikasi Pemeriksaan fisik ulang di OK
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Persiapan pra op baik safety & success.

Persiapan pra op jelek resiko, morbiditas

BENCANA !!!

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CONTOH KASUS :
- Tidak bisa mengatasi laringospasme saat induksi GA pada op. elektif (sirkumsisi, herniotomi dll) pasien pediatrik (bayi/ anak) karena tidak/belum terpasang infus line hipoksia sangat cepat KEMATIAN - Keterlambatan resusitasi cairan pada perdarahan durante operasi mayor (nefro/pielolitotomi, mastektomi, craniotomi dll) akibat terpasang iv cath kecil (no: 20) syok KECACATAN/ KEMATIAN

- Muntah (partikel padat) saat induksi/ pengakhiran anestesi akibat puasa yg

kurang aspirasi KEMATIAN penjelasan & 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 caesarean cito MUAL MUNTAH, GELISAH, SYOK, FETAL DISTRESS,

HENTI JANTUNG morbiditas, mortalitas
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- Gigi palsu yang lepas saat laringoskopi intubasi aspirasi/ tertelan

MORBIDITAS, kemungkinan TUNTUTAN HUKUM - Pasien tetap memakai kosmetik (bedak, lipstik) mengaburkan SIANOSIS pada keadaan hipoksia saat induksi/ pasca op

- Pasien tetap memakai perhiasan terlepas saat memindah/ transport pasien

- Tidak/ belum adanya persetujuan op /informed consent pada pasien yg direncanakan bedah sehari (minor surgery, pagi datang, pasca op sore pulang) kompilkasi outcome jelek TUNTUTAN HUKUM

Bad things tend to happen when you least expected, at the worse possible moment

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OPERASI ADALAH TINDAKAN YG BERMANFAAT, TAPI JUGA

MENGANDUNG RESIKO MEDIS !!!

TIDAK ADA TINDAKAN OPERASI YANG TIDAK BERESIKO!!!

MANFAAT HARUS SEBANDING/LEBIH BESAR DARI RESIKO MEDIS

Bagi dokter keselamatan pasien adalah hukum tertinggi baginya (yang utama) : Aegroti Salus Lex Suprema

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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 nasib sial Penyakit yg menyertai Tidak diketahui Sensitivitas thd obat Hipotensi/ perdarahan Gagal hati Halotan 107 46 39 32 24 % 14 6 5 4 3 Terutama akibat kesalahan Kesalahan teknik Kegagalan perawatan pasca bedah Dosis obat berlebihan Penilaian pra bedah tidak adekuat Kesalahan obat 326 71 34 22 9 % 43 9 5 3 1

Hiperpireksia
Embolisme

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2
2

Kegagalan dokter ahli anestesi

Bekuan dalamop by pass

Total

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281 37 469 62
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The Medical Defense Union : 37 % karena nasib sial

1% kegagalan dokter ahli anestesiologi

Kesimpulan

KEMUNGKINAN CEDERA MAUPUN KEMATIAN MERUPAKAN SUATU RESIKO YANG HARUS SELALU DIHADAPI DAN MUNGKIN AKAN SELALU DAPAT TERJADI DALAM SETIAP TINDAKAN PEMBIUSAN

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DOKTER Anestesi
Interna/ Pediatrik Operator (Bedah, Obsgyn, Mata, THT)

PERAWAT IGD/ Poliklinik Kamar Operasi

Ruangan/ Bangsal

KOMUNIKASI DAN KERJASAMA YANG BAIK

PERIOPERATIF (PRA, DURANTE, PASCA OPERASI

KEAMANAN, KUALITAS DAN KEBERHASILAN TINDAKAN OPERASI

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