persiapan pra operasi

8/13/2019 Persiapan Pra Operasi

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PERSIAPAN PRA OPERASI

BAGIAN ANESTESIOLOGI DAN TERAPI INTENSIF

FAKULTAS KEDOKTERAN UNIVERSITAS BRAWIJAYA MALANG

RS. SAIFUL ANWAR

2013


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Team work :

SurgeonInternal medicine/ pediatricAnesthesiologyNurse

Comunication


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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


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PREOPERATIVE

Preop. visite

1.Persiapan

2.Perencanaan

3.Klasifikasi (ASA I-V) Prognosa


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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.


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1. Persiapan

a.HISTORYb.PHYSICAL EXAMINATIONc.LABORATORY/SPECIAL INVESTIGATION:

Rutin: DarahFoto thoraxUrineEKG

Khusus: Faal paruFaal ginjalFaal hatiElektrolitBGA


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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.


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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.


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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.


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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.


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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 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


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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 !!!


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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


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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 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

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- 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

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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


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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 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


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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


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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


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persiapan pra operasi

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