4th plenary

8/20/2019 4th Plenary

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4th Plenary

By Group 15C


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Members

• Fitri Yani• Aulia Rahmi

• Noprianty Eka Pratiwi• Rian Rizki Ananda• aulina !ani"yah•

No#i $amilah• Putri Pratiwi• %"mi ulya A&ti


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Step 1 - Terminology


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1' %leu" o("tru)tion * hypomotility o& the

+a"trointe"tinal tra)t )au"ed (y "malll or lar+e

(owel o("tru)tion'

,' -aparatomy * a "ur+i)al pro)edure in#ol#in+ a

lar+e in)i"ion throu+h the a(dominal wall to +ain

a))e"" into the a(dominal )a#ity'

.' A/A Phy"i)al /tatu" %%% * Patient" with "e#ere

"y"temi) di"ea"e0 no immediate dan+er o& death'


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1' General ane"the"ia * i" )ommonly produ)ed (y a

)om(ination o& intra#enou" dru+" and inhaled

+a""e"' %t make" you (oth un)on")iou" and una(le

to &eel pain durin+ medi)al pro)edure"'

,' /ta+e %%% "ta+e o& "ur+i)al ane"the"ia2* &rom on"et

o& automati) re"piration to re"piratory paraly"i"'

Plane %% * &rom )e""ation o& eye(all mo#ement" to(e+innin+ o& paraly"i" o& inter)o"tal mu")le"'

Plane %%% * &rom (e+innin+ to )ompletion o&

inter)o"tal mu")le paraly"i"'


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/tep , 3 Pro(lem%denti)ation


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1' hy it i" needed in preparation &or "ur+ery &oremer+en)y a)tion with the dia+no"i" o&

o("tru)ti#e ileu" hi+h layout e) "u"pe)tedmali+nan)y and what preparation" 6,' why i" the a)tion plan laparotomy "ur+ery 6.' what are the impli)ation" o& C7P8 and eat the

la"t &our hour" a+o with the ne9t a)tion 6

4' how i" the interpretation" o& the +eneral "tate o&Na and : to normal 6

5' hy i" planned +eneral ane"the"ia 6 whatindi)ation" 6

;' hy the patient i" prepared &or premedi)ationand indu)tion o& ane"the"ia rea)hed "ta+e %%% onplane ,


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/tep . 3 Pro(lem Analy"i"


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1' to pre#ent )ompli)ation" "u)h a" a"piration o&+a"tri) )ontent"0 e"timate the )ompli)ation" thatwill o))ur a))ount a&ter the operation 0 knowin+the hi"tory o& aller+y to dru+" 0 know "tateor+an" 0 e"pe)ially the #ital or+an" '

,' to e9plore the a(domen (e)au"e it &eared had

peritoniti" due to leaka+e o& inte"tinal )ontent"into peritoneal )a#ity '

.' (e)au"e C7P8 i" a )hroni) )on"tri)tion o& the

airway" and pro+re""i#e ' e9amination i" neededto a""e"" the airway remain" patent &or the"ur+ery or the need &or tool" "u)h a" #entilator(reathin+ a""i"tan)e' And to pre#ent)ompli)ation" "u)h a" a"piration o& +a"tri)

)ontent"


10/42

4' the interpretation" *

unwell

pul"e 1> (eat" < min * ta)hy)ardia,; (reath" < min * ta)hypnea(lood pre""ure o& 1>


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5' %N8%CA%7N/ F7R GENERA-

ANE/!E/%A1' Children who are too youn+ to )ooperate,' -an)in+ a(")e""e"

.' Adult" who are a(normally &ear&ul o& needle

4' E9tra)tion o& teeth in the early "ta+e o&"uppurati#e in&e)tion

5' ultiple un)ompli)ated e9tra)tion"

;' %n it" anal+e"i) "ta+e &or preparation o&"en"iti#e teeth &or llin+"

=' reatment o& peridental di"ea"e


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;' Be)au"e *• Redu)tion o& an9iety and pain'•

Promotion o& amne"ia'• Redu)tion o& "e)retion"'• Redu)tion o& #olume and p! o& +a"tri)

)ontent" '

• Redu)tion o& po"toperati#e nau"ea and#omitin+'

• Enhan)in+ the hypnoti) eDe)t" o& +eneralanae"the"ia'

• Redu)tion o& #a+al ree9e" to intu(ation'• /pe)i) indi)ation" e+0 pre#ention o&

in&e)ti#e endo)arditi"'


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=' entri)ular (rillation #(2 )au"e" mo"t "udden)ardia) arre"t" /CA"2' Certain type" o& phy"i)al "tre"")an )au"e your heartH" ele)tri)al "y"tem to &ail'

E9ample" in)lude*• %nten"e phy"i)al a)ti#ity' he hormone adrenaline i"

relea"ed durin+ inten"e phy"i)al a)ti#ity' hi"hormone )an tri++er /CA in people who ha#e heartpro(lem"'

• ery low (lood le#el" o& pota""ium or ma+ne"ium' he"e mineral" play an important role in your heartH"ele)tri)al "i+nalin+'

• aIor (lood lo""'• /e#ere la)k o& o9y+en'

ana+ement o& prone )ardia) arre"t may (e impro#ed(y identi)ation o& hi+hri"k patient"0 )are&ul patient

po"itionin+0 u"e o& in#a"i#e monitorin+ and pla)emento& "el&adhe"i#e de(rillator paddle"' /uita(le


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>'o pre#ent re)urrent )ardia) arre"t

@' %ndi)ation in %C? *•. Po"t )ardia) arrre"t•. "toppin+ (reathin+•. )oma•. need #entilator


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Step 4 - Scheme


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an0 =, yo

%leu"7("tru)tion

C7P8/u"pe)tedmali+nan)y

Eat 4 hour" a+o-aparatomy

Generalana"the"ia

A+ent *%0%0

inhalation

premedi)ation

indu)tion

Cardia)arre"t

re"u"itation

Po"t op * %C?


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/tep 5 3 -earnin+ 7(Ie)ti#e


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1' Premedi)ationFurther a)tion i" +i#in+ premedi)ation to do 1,

hour" prior to "ur+ery patient"0 that aim i"*1' Eliminate an9iety

,' Gettin+ "edation

.' Gettin+ anal+e"ia

4' Gettin+ amne"ia

5' Gettin+ eDe)t anti"ialo+oJue

;' %n)rea"in+ the p! o& +a"tri) uid

=' Redu)e the #olume o& +a"tri) uid>' Pre#ent the o))urren)e o& aller+i) rea)tion"'

7ut)ome* "edation o& patient" without depre""iono& re"piration and )ir)ulation


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,' General Ane"the"ia

1' a"k adIu"t the "ize o& the patientH" &a)e2

,' -aryn+o")ope )on"i"tin+ o& holder and (lade'/ele)t the (lade num(er . &or adult patient" withmoderate "ize0 (i++er when wearin+ "ize 40 &or the

)hild to u"e the "ize o& num(er ,' 8o not &or+et to)he)k whether the li+ht i" (ri+ht enou+h li+ht"2

.' Endotra)heal with . "ize"

4' CuD in order to pump the E in order to po"ition

Fi9ed25' Goedel with . "ize" . K +reen0 4 K yellow0 5 K

red2


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;' !oarne"" and Rin+ !oarne"" &ormemk"ir ma"k on the &a)e2

=' /tylet +uide wire airway"2>' $a)k"on Ree" pumpin+ "y"tem i" u"ed

&or )hildren2

@' $elly

1' pre)ordial

11' Cotton al)ohol

1,' Pla"ter

1.' -ido)aine pump14' Na"o &or the no"e' Not alway" u"ed ''

only in )ertain )ir)um"tan)e"2


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General Ane"the"ia 8ru+"

1' Atropine "ul&ate

,' Pethidin

.' Propo&ol < Re)o&ol

4' /u))inyl Cholin

5' ramu"

;' Ephedrine


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Completene"" o& 7peratin+Room

1' Ane"the"ia ma)hine

,' Ane"the"ia monitor

.' "u)tion

4' hand ta(le

5' pillow


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/tep" o& General Ane"the"ia1' A&ter the patient wa" pla)ed on an operatin+ ta(le'

Atta)h the ten"ion0 "aturation0 pre)ordial' urn on themonitor' urn on the ane"the"ia ma)hine' /et the"peed o& in&u"ion'

,' ait &or in"tru)tion"' A&ter the report to the)on"ultant0 and the operator i" ready' ean"

ane"the"ia may (e per&ormed'.' A"k the patient to pray

4' %nIe)t pre medi)ation"* /A ',5 m+ and .5 m+Pethidin

5' %nIe)t Re)o&ol 1 m+';' ait until the eyela"h ree9 di"appeared'

=' hen eyela"h ree9 wa" lo"t atta)h the ma"k to the)orre)t po"ition' $aw thru"t0 )hin li&t0 pre"" the ma"kwith hi" thum( and &oren+er2


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>' %n)rea"in+ o9y+en to ;1 l

@' redu)e o9y+en to . -' in)rea"e N,7 into .-' openi"ourane < halothane

1'Remain in that po"ition' hile "ometime" do pumpin+when needed' wat)h in&u"ion0 pul"e0 (lood pre""ure0"aturation0 pump or monitor ma)hine' o))a"ionally &eelthe patientH" pul"e

11'hen reJuired the patient to rela90 then +i#e /u))inil

)holine or tramu" dependin+ on the reJuired do"e'1,'Furthermore0 li#e art ane"the"ia' %& (lood pre""ure ri"e"

and &all"0 i& the pul"e ri"e or &all0 i& le"" "pontaneou"(reath0 "low or &a"t' All we )an do i" deepen or redu)eane"the"ia0 plu" )ertain medi)ation"0 uid "et0 adIu"t the

po"ition o& the patient and other"''1.'hen the operation i" almo"t ni"hed0 redu)e the do"e

"lowly until then li#ed o9y+en alone'

14' he operation i" )ompleted ''' (rin+ the patient to the RR'

And wait until the patient i" awake


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.' ana+ementpreoperati#e


26/42

Preoperati#e a""e""ment

• Goal * de)rea"e ri"k o& "ur+ery * – %denti&y unre)o+nized )omor(id di"ea"e

and ri"k &a)tor" &or medi)al

)ompli)ation" o& "ur+ery – 7ptimize preoperati#e medi)al )ondition – ?nder"tand0 re)o+nize0 and treat

potential )ompli)ation"

– ork a" a team with "ur+eon andane"the"iolo+i"t


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Preoperative assessment:

1.Anamnesis : medical history, social history, surgical

history and risk factor (ASA)2.Physical eamination: !ital sign, generalist status,

localist status.

".#asic eamination: air$ay (%&' classification to

predict of difficult intu*ation) , lungs and heartassessment.

+. %a*oratorium: eamination of peripheral *lood,electrolytes , *lood sugar , lotting screen (all patients

and those on anticoagulants), %iver function, &- (all patients +/0s), &chocardiogram (A*normal &-,ischemic heart), hest ray, #lood sugar level.


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A/A Cla""i)ation

Cla"" 1 * !ealthy patient with no di"ea"e out"ide o& the"ur+i)al pro)e""

Cla"" ,* ildtomod' "y"temi) di"ea"e )au"ed (y the"ur+i)al )ondition or (y other patholo+i) pro)e""e"

Cla"" .* /e#ere di"ea"e pro)e"" whi)h limit" a)ti#ity(ut i" not in)apa)itatin+

Cla"" 4* /e#ere in)apa)itatin+ di"ea"e pro)e"" that i" a)on"tant threat to li&e

Cla"" 5* 8yin+ patient not e9pe)ted to "ur#i#e ,4hour" with or without an operation

E* /uL9 to indi)ate an emer+en)y "ur+ery &or any )la""


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-E7N airway a""e""mentmethod

• - K -ook e9ternally &a)ial trauma0 lar+ein)i"or"0 (eard or mou"ta)he0 lar+e ton+ue2

• E K E#aluate the .., rule in)i"or di"tan)e.

n+er (readth"0 hyoidmental di"tan)e.n+er (readth"0 thyroidtomouth di"tan)e,n+er (readth"2

• K allampati allampati ")ore M .2

• 7 K 7("tru)tion pre"en)e o& any )onditionlike epi+lottiti"0 periton"illar a(")e""0 trauma2'

• N K Ne)k mo(ility limited ne)k mo(ility2


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allampati ")ore


31/42

Postduralpuncture headache (PP3) is a complication of puncture of the

dura mater (one of the mem*ranes that surround the *rain and spinal

cord). 4t is a common sideeffect of spinal anesthesia and lum*ar puncture

and may occasionally accidentally occur in epidural anesthesia.

%eakage of cere*rospinal fluid through the dura mater puncture causes

reduced fluid levels in the *rain and spinal cord, and may lead to the

development of PP3 hours or days later. nset occurs $ithin t$o days

in 55 percent and $ithin three days in ninety percent of PP3 cases. 4t

occurs so rarely immediately after puncture that other possi*le causesshould *e investigated $hen it does.

4' Compli)ation po"t "ur+ery

Po"t 8ural Pun)ture !eada)he

P8P!2


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• he heada)he i" "e#ere and de")ri(ed a" "earin+and "preadin+ like hot metal0 in#ol#in+ the (a)kand &ront o& the head0 and "preadin+ to the ne)kand "houlder"0 "ometime" in#ol#in+ ne)k"tiDne""' %t i" e9a)er(ated (y mo#ement0 and

"ittin+ or "tandin+0 and relie#ed to "ome de+ree(y lyin+ down'

• Nau"ea0 #omitin+0 pain in arm" and le+"0 hearin+lo""0 tinnitu"0 #erti+o0 dizzine"" and parae"the"iao& the ")alp are )ommon


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/ymptom"

!eada)he i" the predominant0 (ut not u(iJuitou" pre"entin+)omplaint'

he heada)he i" de")ri(ed a" "e#ere0O"earin+ and "preadin+like hot

metalH'he )ommon di"tri(ution i" o#er the &rontal ando))ipital area"radiatin+ to the ne)k and "houlder"'

he temporal0 #erte9 and nu)hal area" are reported le"")ommonly a"

the "ite o& di")om&ort0 althou+h ne)k "tiDne"" may (e pre"ent' he paini" e9a)er(ated (y head mo#ement0 and adoption o& the

upri+ht po"ture0and relie#ed (y lyin+ down'An in)rea"e in "e#erity o& the heada)he on "tandin+ i" the sine

qua non o& o"tdural un)ture heada)he'


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7ther "ymptom" a""o)iated with dural pun)ture heada)hein)lude

• nau"ea• #omitin+• hearin+ lo""• tinnitu"

• #erti+o• dizzine""• parae"the"ia o& the ")alp• upper and lower lim( pain'


35/42

i"ual di"tur(an)e" "u)h a" diplopia or )orti)al (lindne"" ha#e(een

reported' Cranial ner#e pal"ie" are not un)ommon' wo )a"e"o&

thora)i) (a)k pain without heada)he ha#e (een de")ri(ed'

Neurolo+i)al "ymptom" may pre)ede the on"et o& +rand mal"eizure"'%ntra)ranial "u(dural haematoma"0 )ere(ral herniation and

death0 ha#e(een de")ri(ed a" a )on"eJuen)e o& dural pun)ture'?nle"" a heada)he with po"tural &eature" i" pre"ent0 the

dia+no"i" o&po"tdural pun)ture heada)he "hould (e Jue"tioned0 a" other"eriou"

intra)ranial )au"e" &or heada)he mu"t (e e9)luded'


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8ia+no"i" he hi"tory o& a))idental or deli(erate dural pun)ture and "ymptom" o&

a po"tural heada)he0 ne)k a)he and the pre"en)e o& neurolo+i)al "i+n"0u"ually +uide the dia+no"i"'here there i" dou(t re+ardin+ the dia+no"i" o& po"tdural pun)tureheada)he0 additional te"t" may )onrm the )lini)al ndin+"' Adia+no"ti) lum(ar pun)ture may demon"trate a low C/F openin+pre""ure or a Odry tapH0 a "li+htly rai"ed C/F protein0 and a ri"e in C/F

lympho)yte )ount'An R% may demon"trate* diDu"e dural enhan)ement0 with e#iden)e o&a "a++in+ (rain de")ent o& the (rain0 opti) )hia"m0 and (rain "temo(literation o& the (a"ilar )i"tern" and enlar+ement o& the pituitary+land'C myelo+raphy0 retro+rade radio nu)lide myelo+raphy0 )i"terno+raphy0or thin "e)tion R% M )an (e u"e to lo)ate the "pinal "our)e o& the

C/F leak'


37/42

reatment

7#er#iew

he literature re+ardin+ the treatment o& po"tduralpun)ture heada)he o&ten in#ol#e" "mall num(er" o&

patient"0 or u"e" inappropriate "tati"ti)al analy"i"'/tudie"o("er#in+ the eDe)t" o& treatment" in po"tdural

pun)tureheada)he o&ten&ail to re)o+nize that0 with no

treatment0o#er >5Q o& po"tdural pun)ture heada)he" will

re"ol#ewithin ; week"'


38/42

e)hniJue

he pre"en)e o& &e#er0 in&e)tion on the (a)k0 )oa+ulopathy0 orpatient

re&u"al are )ontraindi)ation" to the per&orman)e o& an epidural(lood

pat)h' A" a pre)autionary mea"ure0 a "ample o& the "u(Ie)tH"(lood"hould (e "ent to mi)ro(iolo+y &or )ulture' ith the patient in

the lateralpo"ition0 the epidural "pa)e i" lo)ated with a uohy needle at

the le#el

o& the "uppo"ed dural pun)ture or an inter#erterte(ral "pa)elower'

he operator "hould (e prepared &or the pre"en)e o& C/Fwithin the

epidural "pa)e'

?p to . ml o& (lood i" then taken &rom the patientH" arm and


39/42

Contraindi)ation"

Contraindi)ation" in)lude tho"e that normally apply toepidural"0 (ut

in)lude a rai"ed white )ell )ount0 pyre9ia and te)hni)aldiL)ultie"'

-imited e9perien)e with !%po"iti#e patient" "u++e"t that it i"

a))epta(le pro#idin+ no other (a)terial or #iral illne""e" area)ti#e'Epidural (lood pat)h &ollowin+ dia+no"ti) lum(ar pun)ture in

theon)olo+y patient rai"e" the potential &or "eedin+ the neuroa9i"

with

neopla"ti) )ell"'7ne )a"e ha" (een reported o& a "u))e""&ul pat)h without)ompli)ation"0 and one )a"e where the ri"k" o& )entral

ner#ou" "y"temCN/2 "eedin+ o& leukaemia were )on"idered to outwei+h the

(enet"

o& an epidural (lood pat)h'

i C


40/42

5. Intensive CareMedicine

Con)erned with the mana+ement o&li&ethreatenin+ )ondition" reJuirin+ or+an"upport and in#a"i#e monitorin+'

Patient" reJuirin+ inten"i#e )are mayreJuire "upport &or )umulati#e eDe)t"o& multiple or+an &ailure' hey may al"o (eadmitted &or inten"i#e


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hank you

4th plenary

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