Case Report

IDENTITAS

An. Bagas Amar Danik

9 th

01474274

BB : 25 kg

Tb : 123 cm
RPS
keluhan (-) batuk (-) pilek (-) demam (-) bak (+) normal kuning jernih, ba
b (+)

A : disangkal

M : disangkal
P: biru2(-) tersedak(-) asma (-), jantung (-), sesak (-), riw operasi (+) orcid
opexi bulan september 2019 dg GA,
L: 6 jam sblm tindakan
E: sesak (-), mual (-), muntah (-)
 PEMERIKSAAN FISIK

Airway buka mulut 3 jari, mallampati 2, gerak leher bebas, gigi ompong (+), gigi palsu
(-)

B1: RR 18x/menit, Sp O2 99% posisi supine udara ruang, SDV (+/+), ST (-/-)
B2: TD 123/78 , HR 86, kuat angkat, akral hangat, bunyi jantung I-II reguler, bising (
-), kulit tampak normal, CRT < 2

B3: anak aktif, GCS E4V5M6, pupil isokor (2mm/2mm) defisit neurologis (-)
B4: tidak terpasang DC
B5: Abd supel, BU (+), NT (-)
B6: motorik superior (5/5), inferior (5/5), edema sup (-/-) inf (-/-), S: 36.6°C
 PEMERIKSAAN FISIK

(V) = vertebral abnormalities (-)

(A) = anal atresia (-)
(C) = cardiac (heart) defects (-)
(T) = trachealanomalies including TE (-)
(E) = esophageal atresia (-)
(R) = renal (kidney) and radial (thumb side of hand) abn (-)
(L) = other limb abnormalities (-)
 HASIL LAB

Tgl 7.11.2019 Tgl 7.11.2019

Hb 14,3 PT 12.7
Ht 39 APTT 32.8
Al 9,2 INR 0.99
At 267 Na+ 133
Ae 5.27 K+ 3.6
Cr 0.3 Cl- 1004
Ur 19 HBsAg Non
Reaktif
DIAGNOSA ANESTESIOLOGI

Anak 9 tahun dengan Undecensus

Testiculorum bilateral Post Orchido
peksi Dextra Pro Orchidopeksi Sinis
tra Dengan Status Fisik ASA II
 Problem

• Pediatric
 Potensial Problem

 Perdarahan
 High Spinal
 Total Spinal
 Nyeri post op
Pre Operasi Durante Operasi

 Ku : Sedang  Anestesi : 08.00-09.15

 GCS : E4V5M6  Operasi : 08.00-09.00
 T : 123/78 mmHg
 N : 86x/mnt, reguler
 Posisi : Supine
 RR : 18x/mnt
 Sp02 : 99% Udara Ruang
Obat Masuk
 S : 36.6 oC

 VAS :2 Ondancentron 2.5 mg

Agen RA SAB Maintenance

Levobupivacain 10 mg
O2 3 lpm
 Balance Cairan
Durante Operasi

 EBV =25X 75 = 1875 cc

 ABL = (39-24)X3/100X1875 = 843.75 cc
 Maintenance (4x10) + (2x10) + (5x1) = 65 cc
 Stress Operasi (2x25) = 50 c
 Kebutuhan per jam = 115 c
c
 Balance Cairan
Durante Operasi
Input Output Balance

Jam Kris Kol Drh Drh Urin SO+M

08.00 110 - - 20 - 115 -25
-
09.00
140
120
100
80 Sistole
60 Diastole
40 HR
20
0
15.00 15.30 16.00 16.30
POST OP

Kesadaran: GCS E4V5M6

Tensi : 112/78mmHg
Nadi : 97 x/menit
RR : 18 x /mnt
SaO2 : 98% NC 3 lpm
VAS :2
ANALGETIK POST OP
Metamizol 500 mg/8jam
Fentanyl 0.5 mcg/kgbb/jam
TERIMAKASIH