The ASA Physical Status:

Class I : Healthy patient without organic,

biochemical and psychiatric disease
Class II: A patient with mild systemic
disease, e.g. mild asthma or well controlled
hypertension. No significant impact on daily
activity, unlikely impact on anesthesia and
surgery.
Class III: Significant or severe systemic
disease that limits normal activity, e.g. renal
failure on dialysis or Class 2 Congestive
Heart Failure. Significant impact on daily
activity. Likely impact on anesthesia and
surgery.
Class IV: Severe disease that is a constant
threat to life or requires intensive therapy,
e.g. acute myocardial infection, respiratory
failure requiring mechanical ventilation.
Serious limitation on daily activity. Major
impact on anesthesia and surgery.
Class V: Moribund patient who is likely to
die in the next 24 hours with or without
surgery.
Class VI: Brain dead organ donor.

Liver Function Test with Normal Values

Albumin
3.5-5.5 g/dl
Bilirubin
0.3-1.1 mg/dl
Unconjugated Bilirubin 0.2-0.7
mg/dl
Conjugated Bilirubin 0.1-0.4
mg/dl
AST (SGOT)
10-40 U/ml
ALT (SGPT)
5-35 U/ml
Alkaline Phospatase 10-30 U/ml
Protrombin Time 12-14 sec

Child PUGH Classification

Serum
Bilirubin
Serum
Albumin
PT
Ascites
Encephal
opathy

A
< 2.0

B
2.0-3.0

C
> 3.0

> 3.5

2.8-3.5

< 2.8

1-4
sec
-

4-6 sec

> 6 sec

slight

Minim
al

Moderat
e
Advance
d

Bilirubin (Stoelting)
degradation product of hemoglobin
and mioglobin
unconjugated bilirubin (formed
peripher)

liver (conjugated)

mono & diglucoronides

Unconjugated bilirubin:
bilirubin production
hepatic uptake
conjugation bilirubin
Conjugated hyperbilirubinemia:

canalicular transport bilirubin

acute & chronic hepatocellular
function

The use of opioids during anesthesia can cause

spasm of the sphincter oddi. Thus this response
should influence the selection of drugs,
antagonist spasm by administration of glucagon
/ halothane.
INDEX WAYNE
Gejala
Sesak
napas
Palpitasi

+1
+2

Mudah
lelah
Senang
panas
Senang
dingin
Keringat
berlebih
Gugup

+2

Nafsu
makan
naik
Nafsu
makan
turun
BB naik
BB turun

+3

-5
+5
+3
+2

-3

-3
+1

Tanda

Ada

Pembesaran
tiroid
Bruit pada
tiroid
Exoftalmus

+3

Tidak
Ada
-3

+2

-2

Retraksi
palpebra
Palpebra
terlambat
Hiperkinesis

+2

Telapak
tangan lembab
Nadi <
80x/menit

+1

Nadi >
90x/menit

+3

Fibrilasi atrial

+4

Neurophurology
Cerebral Metabolic Rate
Cerebral Blood Flow
Cerebral Perfusion Pressure

Aliran darah otak

50-54 ml/100 g/mm2

Cerebral perfusion pressure:

Tekanan arteri rata-rata tekanan
vena rata-rata pada sinus sagitalis
atau CPP = MAP
intrakranial rata-rata

a. Autoregulasi
MAP = 50-150 mmHg
b. PaCO2
ET CO2 25-30 mmHg =
PaCO2 29-34 mmHg
c. PaO2

+2

+4
+2
-2

-3

Urology
Ren

simpatis
Spinal cord
Parasimpatis

-2
Ureter
Bladder

Parasimpatis
Prostat Urethra

Pasien dengan hipoalbumin

Dosis dikurangi 20-25% dari BB ideal
jika pasien dengan kekurangan BB
sesuai dengan BB yang dikurangi
Obat dibawa oleh albumin .. obat
aktif. Pada pasien dengan hipoalbumin,
obat aktif akan menembus membran sel.
Obat-obat yang masih bebas kemudian
akan menggantikan obat yang sudah
habis.

T8-L1
T10-L1
vagus
S2-S4
T11-L2
S2-S4
T11-L2
S2-S4

Creatinin Clearance
CCT

= (140-umur) x BB
72 x CR

Normal : 100-120
Decreased renal reserve
Mild renal impairment

60-100
40-60

Moderate renal insufficiency

Renal failure
End stage renal disease

25-40
< 25
< 10

TURP
soluti
on

osm
olal
ity
0

advant
age

Disadvantage

visibil
ity

hemolysis,
hemoglobinemi
a, hyponatremia

Glyci
ne (1,
5%)

200

Transient post
op visual

Sorbit
ol (2,
7%)
Mann
itol
(0,
57%)

165

TURP
syndr
ome
=
glycin
e
Isoos
molar
soluti
on

Destil
ed
water

275

..

115

- Somnolen

110

- Nausea
kejang
coma

Perdarahan
TURP syndrome
Bladder perforation
Hipotermia
Septikemia
DIC

Hyponatremia
Hipoosmolalitas
Fluid overload CHF, Pulmonary
oedem, Hypotension
Hemolysis
Toksisitas
cairan

hyperglycinemia, hyperammonemia,
hyperglycemia,
intravascular
volume expansion

Elektrolit irigasi disperse the

electrocautery current

Massive
diuresis
Pencegahan TURP Syndrome

ECG

Komplikasi TURP

Water excellent visibility because

hypotonicity melisiskan RBC

Hiponatremia signs & Symptoms acute

hiponatremi
Na
(mEq/L)
120

Manifestasi TURP Syndrome (Morgan)

Widening
QRS .
- QRS
melebar
- ST elevasi
VT / VF

Tinggi cairan irigasi ideal < 60 cm

Lama operasi tidak boleh > 1 jam
Na serum diperiksa tiap 30 menit
Perlu
diberikan
furosemid
profilaksis
untuk
mencegah
overload cairan
Pencegahan hipotensi ...
cairan irigasi sampai 37oC

Tatalaksana TURP Syndrome

-

Pastikan oksigenasi dan sirkulasi

adekuat
Komunikasi dengan operator untuk
menghentikan prosedur
Invasive monitor jika terjadi
ketidakstabilan hemodinamik
Cek lab: elektrolit, creatinin,
glukosa, BGA
12 lead EKG

Pemberian diuretik dan retriksi

cairan
Tanggulangi dengan NaCl 3% IV
kecepatan < 100 ml/jam

Seizure : midazolam 2-4 mg

... 3-5 mg

Yang mempengaruhi absorbsi cairan

-

Operasi 45-60 menit, rata-rata 20

ml/menit terabsorbsi
Blood loss average 3-5 ml/menit

HEPATO-RENAL SYNDROME
Hepatorenal syndrome is a functional
renal defect in patients with cirrhosis
that usually follows gastrointestinal
bleeding, aggressive dieresis, sepsis or
major surgery. It is characterized by
progressive oligouria with avid sodium
retention, azotemia, intractable ascites
and very high mortality rate.

Diagnostic
criteria
(Longnecker)

for

HRS

Major criteria
- Acute/chronic liver disease with
advanced hepatic failure and portal
hypertension
- Depressed GFR with a serum
creatinin > 1,5 mg/dl or CCT < 40
ml/mm
- Absence on shock, ongoing
bacterial infection, fluid loss and
treatment
with
nephrotic
medications
- No sustained improvement in renal
function after withdrawal of
diuretics and fluid resuscitation with
1.5 l isotonic saline
- Proteinuria < 500 mg/dl and no
evidence of obstructive nephropathy
Minor criteria
- Oligouria
- Urine sodium < 10 mEq/l
- Urine
osmolality
>
plasma
osmolality
- Urine RBC < 50 ..
- Serum sodium concentration < 130
mEq/l

HRS renal vasoconstriction

GFR
normal renal histology
liver failure

SVR

Systemic & splanchnic vascular resistance


Reduce effective volume renal
hypoperfusion

Cystic Fibrosis
Bronchiectasis
Bronchiolisis

mediator of renal vasoconstrictor

RAA activity, ADH, tune sympathetic

Patients with COPD chronic

bronchritis, erythrocytosis pulmonary
hypertension, CPC (blue bloater
syndrome, pembesaran airway distal s.d.
bronkus terminalis)
Neuraxial Anesthesia (Longnecker)

Kriteria Hemodialisa

- Oligouria < 5 cc/kg/hari

Bupivacai
n

Dos
e
5

- Anuria
7.5

- BUN > 100 mg/dl

- Creatinin > 10 mg

10

- K > 6,5 mEq/L

15

- Asidosis metabolik berat

Chronic Obstructive Pulmonary Disease

Anamnesis: merokok, batuk kronis,
sesak, produksi sputum, breath sounds
, prolonged expiration
Bronkitis kronis: sekresi berlebih mucus
bronchial, batuk produktif 3 bulan /
lebih
Emphysema: pembesaran permanent
ruang udara distal s/d terminal
Obstructive P.D
Asthma
Emphysema
Bronkitis kronik

disorders
involving
the
pleura, chest wall
diaphragm
Ex.
Pulmonary
oedem, ARF

Restrictive P.D
Acute and chronic
intrinsic
pulmonary

Bloc
k
T5
(T4T7)
T8
(T4T11)
T8
(T6T10)
T5
(T4T7)

Duratio
n
123

Discharg
e
181

144

202

194

260

343

471

Analgesic .. Neuraxial Anesthesia

-

Fentanyl: 10-25 mg
Clanidine: 15-45 mg
Epinefrin: 0,1-0,6 mg
Neostigmin: 6,25-50 mcg

Upper abdomen

T4

Intestinal, gynecologic, urology

T6

Vaginal delivery

T10

Thigh surgery + Lower leg amputation L1

Foot and Ankle

L2

Perineal

S2-S5

Thyroid Storm
-

Hyperperexia
Takikardia
Altered consciousness
delirium)
Hypotension

Obat-obat yang diberikan hati-hati

pada .:

Pancronium
Indirect acting adrenergic agonist

(agitation,

. V/Q ratio has a low O2 tension and high

CO2 tension.
Ejection Fraction
EF
=
EDV ESV
EDV
Normal= 0,67 8 (Morgan)
EDV = End Diastolic Volume
ESV= End Sistolic Volume
Epidural continuous vs intermittent
Intermittent lebih bagus karena dengan
intermittent tekanan lebih kuat sehingga
bisa mencapai level blok nya
Reverse Alarm Reactions
- Pasien terkontrol dengan obat

Ventilation / Perfution Relationships

Ventilasi: jumlah gas yang ditiup dalam
1 menit
VA
= RR x (VTVo)
VT : Volume tidal
Vo : Dead space (150 ml/2ml/kg)
Distribution of pulmonary perfusion
Lower (..) portion of the
lung receive greater blood flow
than upper arcus

- Infeksi gula (dibutuhkan .. )

- Dosis = untuk infeksi
Operasi
(infeksi
dibersihkan,
katekolamin , produksi glukosa ,
.. hipoglikemia)
- Apakah perlu di blok sampai adrenal?
Tidak perlu, karena jika terblok, tidak
bias mengeluarkan katekolamin drop
nya
SIRS (Systemic Inflammatory Response
Syndrome)

Ventilation / Perfutions ratio

Sekumpulan gejala akibat .
Alveolar ventilation (VA) = 4 lpm
- Demam < 36 / > 38
Pulmonary capillary perfusion (Q) = 5 lpm
- Takikardia > 90x/menit
V/Q = 0,8.

Normal= 0,3-3,0.

The importance of V/Q ratio relates to

the efficacy with which lungs units
venous blood flow and eliminate CO2.
Pulmonary venous blood flow from arcus with

- Takipneu > 20x/menit atau PaCO2 <

32 mmHg
- Leukosit < 4 ribu / >12 ribu
SIRS (+) jika 2 dari 4 positif

 Cauda Equina Syndrome

Associated with the use of continuous
spinal catheters and 5% lidocain
CES blood and bladder perforation,
multiple nerve injury, paresis of the legs
Maldistribution of hyperbaric solutions
of lidocain neurotoxicity the nerve
roots of cauda equine
Prevention CES: aspiration ..
before + local anesthetic injection
Hernia Inguinalis
Hernia congenital
Akuisita
Protusi / penonjolan dari isi suatu
rongga melebihi / melalui defek / bag.
lemah dari dinding rongga

- Kanalis Inguinalis

Kraniolateral:
annulus
inguinalis
Medial bawah: tuberkulum
pubikum,
dibatasi
annulus
inguinalis
Atap: atap m. obliquus interna
Dasar: lig. Inguinale

- Hernia Inguinale Indirekta (HIL)

keluar dari rongga peritoneum melalui
annulus inguinalis internus lateral dari
mll kanalis inguinalis

PEMERIKSAAN FISIK PARU

1. Inspeksi
- Irama dan frekuensi napas:
normal, takipneu
- Dinilai pergerakan dinding
dada simetris/tidak
- 9,9 / 7,7
2. Palpasi
- Untuk menilai kelainan pada
dinding dada
- Gunakan dua tangan untuk
menilai gerakan dinding dada
- Periksa taktil fremitus dinilai
dengan .. / 99 / 77
- Jar. Paru .. dinding
dada
3. Perkusi
- Mencari
batas
dan
menentukan kualitas jar.
Paru
- Direk:
ketuk
langsung.
Indirek: ketukan di tangan
yang lain.
- Suara: sonor normal
Merendah
Redup: cairan/efusi
pleura
Tympani
- Batas paru hati
4. Auskultasi
- Inspirasi > ekspirasi
- SD: Vesiculer I > E
Vesiculer lemah
paru

- Hernia Inguinalis Directa

Vesiculer ..

Menonjol melalui hasselbach (lig.

Inguinale inferior, vasa epigastrika
inferior lateral) m. rectus dari medial:
dasar fascia

Bronchial ekspirasi >

jelas
-

ST: ronchi kering

Ronchi basah: bunyi di

inspirasi

RBK di bronchioli

RB

THALASSEMIA (Barosh)
-

Autosomal
resesif
anemia,
insufficient production of one of the
globin , , , . Paling sering
thalassemia.
Temuan klinik: anemia, hemolisis,
hyperplasia sumsum tulang
Anemia mikrositer hipokrom
thalassemia

Inadequate production of globin

(normal globin)
Eritrosit gagal untuk dan
didestruksi di limpa dan RES
- Splenomegali
- Hepatomegali
- Cholelithiasis
- Ikterus
Anemia .. eritropoietin
hyperplasia sumsum tulang
bisa menyebabkan abnormalitas
pertumbuhan, . dismorfisme.
. develops in pleura sinus,
epidural space and pleural cavities.
Spontaneous
bleeding
from
.

Thalassemia Major
Homozygous thalassemia
Severe + thalassemia
Heterozygous thalassemia
Severe + thalassemia
Thalassemia Intermedia
Homozygous hemoglobin

Thalassemia
minor
mild
reductions in and globin
production
Protokol transfusi:
Paliatif
transfusion,
hyper
transfusion,
super
transfusion
paliatif, daerah yang .
Hypertransfusion menjaga Hb 910 mg/dl
Supertransfusion Hb > 12 g/dl
- Management of anesthesia
Tergantung berat / tidaknya anemia
.. eritropoiesis can produce
.. and narrowing of m. nasal
.
Epidural contraindication relative
pada presence of .. bone
marrow in .

Epidural
Absolute:

Patient refusal
Uncorrected hipovolemia
Increased ICP
Infection of site
Allergic to amide/eter LA
Relative: Coagulopathy
Platelet count < 100.000
Uncooperative patient
Severe
Sepsis
Hypertension
Controversial: Inadequate training
.
.

.
Diabetes Mellitus
Diagnosis elevated fasting plasma
glucose (> 140 mg/dl) and blood
glucose (> 126 mg/dl)
Komplikasi akut: DKA

ETT perfect aspiration

Hipoglikemia
Komplikasi kronis: Hipertensi
CAD (Coronary Artery
Disease)
Myocardial infarction
Congestive
Heart
Failure
Diastolic dysfunction
Peripheral and cerebral
vascular disease
Peripheral
and
autonomic
Renal failure
Seizure disorders (EPILEPSY)
- Caused: .
- abnormalities: hyperglycemia,
hyponatremia, hyperthermia, drug
totality
- Klasifikasi berdasarkan: kehilangan
kesadaran dan fokus kejang
- Treatment: anti-epileptikum
Partial Seizures: carbamazepine,
phenytoin, valproat (barbiturates,
.seizures)

Antiepilepsi
propofol + thiopental
BGA

Long acting antiepileptic

(.)
Management of Anesthesia
Kuncinya: pemilihan obat yang tidak
mengganggu elektris otak
. ketamin, enflurane,
isoflurane,
sevoflurane

epileptikum spike in EEG

Propofol
Relaxant: atracurium .

N2O produce seizure activity

Halogen eter

Menurut Cottrel
Epilepsi: 1. Partial: simple partial
Complex partial
Convulsive
2. Generalized

Phenitoin:
hipotensi,
cardiac
arithmia,
gingival
hyperplasia,
anemia aplastic
Valproat: hepatic failure
Carbamazepine can cause dysplasia,
leukopenia, hyponatremia
Status epileptikus: keadaan kejang 2x
atau lebih, dimana antara 2 kejang itu
tidak ada fase sadar
Treatment: A, B, C
Hipoglikemia D50 60 cc

anesthetics: