MANAJEMEN DISRITMIA KARDIAK

INTRAOPERATIF
 LATAR BELAKANG

• Seorang ahli anestesia dan tim yang melakukan pembiusan di

kamar operasi harus mampu mencegah, mengenali dan
melakukan tindakan resusitasi terhadap komplikasi yang terjadi
saat pembiusan.
• Beberapa kompilkasi anestesi perioperatif dapat terjadi tanpa
diduga, secara mendadak, dengan problem yang mengancam
jiwa, sehingga pengenalan secara dini dan penatalaksanaan
secara cepat dan tepat akan mengurangi terjadinya morbiditas
dan mortalitas pada pasien
 How do we measure heart performance?
Cardiac Output = Blood Volume per Minute!

Cardiac Output = heart rate x stroke volume

Heart rate = of beats per minute; can measure by taking pulse; normally ~ 75 b/min

Stroke Volume = volume of blood ejected by L. Ventricle in one cardiac cycle

Stroke volume = end DIASTOLIC volume – end SYSTOLIC volume

Stroke Volume = 135 mL – 65 mL = 70 mL per beat
Cardiac Output = 75 beat/min x 70 mL/beat = 5250 mL/min
= 5.2 L/min
 How does your body Alter
Cardiac Output?

Cardiac Output = heart rate x stroke volume

 Altering Cardiac Output: Heart Rate

Heart rate is controlled by AUTONOMIC NERVOUS SYSTEM & Hormones!

2) Parasympathetic ANS
decreases HR

3) Sympathetic ANS
increases HR

4) Sympathetic stimulates Adrenal Gland

Epinephrine (hormone)
released to blood
increases HR

Remember: Heart electrical signals are initiated by Pacemaker cells

(Autorhymicity)
Their rate of depolarization is altered by ANS & Hormones
Cardiac Output = heart rate x stroke volume
Mechanisms of Altered Stroke Volume
Stroke Volume is directly related to contraction force
Stroke Volume (EDV – ESV)

What effects the FORCE of Myocardial Contraction?

1. Myocardium Muscle Fiber Length
2. Contractility

Force of Ventricular Contraction

 Mechanisms of Altered Stroke Volume
1) Myocardium Muscle Fiber Length
More STRETCH = longer fibers = greater contraction force = more blood expelled
Frank-Starling Law of the Heart

EDV determines STRETCH

 What determines EDV?

Venous Return: amount of blood entering R. Atrium

Increase Venous Return by:

1) Skeletal Muscle Pump
Return MORE Blood from Muscle Veins

2) Constriction of Veins via Sympathetic ANS

Blood in Veins Back to RA
Compression Tights
mfda
 What determines EDV?

Venous Return: amount of blood entering R. Atrium

Increase Venous Return by:

3) Respiratory Pump
Lower Pressure is created in Inf. Vena Cava & Right Atrium during inspiration
Bulk Flow pushes more blood towards RA
 Cardiac Output = heart rate x stroke volume

1) Venous Return > EDV > Fiber Length > Contractile Force
Mechanisms of Altered Stroke Volume
2) Contractility
Controlled by: 1)Autonomics (Neurotransmitters)
& 2)Endocrine (Hormones)

Norepinephrine (Neuro)
Epinephrine (Hormone)

Acetylcholine (Neuro) Acetylcholine

Mechanism: Altered Calcium Concentrations in Myocardium

Summary: Altering Heart Performance
SISTEM KONDUKSI JANTUNG
 IDENTIFIKASI ARITMIA
1. Apakah rate nya lambat (<60 bpm) atau cepat (>100 bpm)?
Lambat  Suggests sinus bradikardia, sinus arrest, atau blokade konduksi
Cepat  Suggets increased/abnormal automaticity or reentry

2. Apakah ritmenya irregular?

Irregular  Kesan atrial fibrillation, AV block derajad II, multifocal atrial tachycardia, atau atrial flutter dengan
variable AV block

3. Bagaimana kompleks QRS nya, sempit atau lebar?

Sempit  Ritme seharusnya berasal dari AV node atau diatasnya
Lebar  Ritmenya mungkin berasal dari mana saja
4. Apakah ada gelombang P?
Ada gelombang P  Suggests AF, VT , Junctional rhythm

5. Bagaimana keterkaitan gelombang P waves dan

kompleks QRS?
Gelombang P lebih banyak daripada kompleks QRS --> AV block
derajad 2 dan 3
Kompleks QRS lebih sering dibanding gelombang P --> an
accelerated junctional atau ritme ventricular
Aktivasi Code Blue 999
 Bradiaritmia
Any disturbance of the
heart's rhythm resulting
< 60 beats/minute
 BRADIARITMIA
(Symptomps)

General: altered LOC, fatigue, lightheadedness,

dizziness, syncope

Hemodynamic instability: hypotension, poor

end-organ perfusion, respiratory
distress/failure, sudden collapse, ischemic,
acute heart failure.
 Bradiaritmia

Sinus bradycardia
 Case

 Wanita 54 th, akan dilakukan operasi . BP 140/80 mmHg

 EKG

 Tx : - Observasi
 - atropine
 - Dopamin
 - Pace maker
 Case

 Wanita 54 th, akan dilakukan operasi . BP 140/80 mmHg

 EKG

 Tx : - Observasi
 - atropine
 - Dopamin
 - Pace maker
 TAKIARITMIA

Any disturbance of the heart rhythm in

which the heart rate is abnormally
increased >100 beats/ minute
 TAKIARITMIA
(Symptomps)

General: palpitations, lightheadedness,

syncope, fatigue, SOB, chest pain

Hemodynamic instability: respiratory

distress/failure, hypotension, poor end-
organ perfusion, altered LOC, sudden
collapse, ischemia, akute heart failure
 TAKIARITMIA
(Classification)

# Narrow complex : sinus tachycardia,

supraventricular tachycardia, atrial flutter

# Wide complex: ventricular tachycardia,

supraventricular tachycardia with aberrant
intraventricular conduction
 SINDROM KORONER AKUT

• adalah ketidakseimbangan antara pasokan O2

dan kebutuhan miokard yang mengarah ke
iskemia dan infark.

• Diklasifikasikan sebagai UNSTABLE ANGINA, non

- ST elevasi segmen infark miokard ( NSTEMI ) ,
atau STEMI
 Manifestasi Klinis

• Pada pasien sadar, nyeri dada , seperti tertekan, atau menjalar ke

lengan dan rahang. Wanita , penderita diabetes , dan orang tua
mungkin menunjukkan nyeri dada atipikal ( misalnya , nyeri
epigastrium , nyeri , kelelahan , atau dyspnea ) atau tidak ada
gejala sama sekali
• Mual , diaphoresis , palpitasi , sinkop s.d Henti jantung
 Manifestasi Klinis

• Elektrokardiogram: ST segmen elevasi atau depresi kelainan

konduksi ( misalnya , LBBB atau atrioventricular block)
• Puncak Gelombang T menjadi Gelombang T inverted dan
pengembangan gelombang Q
• Aritmia termasuk PVC , VT , atau VF
 Manifestasi Klinis

• Peningkatan troponin I , troponin T , dan CK - MB isoenzim,

Diagnosis MI membutuhkan perubahan EKG atau gejala , karena
kondisi lain mungkin menjadi penyebab
• Peningkatan biomarker jantung,
• Kelainan hemodinamik,
• Hipotensi, Takikardia, Bradikardia
 DAFTAR PUSTAKA
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