I Putu Pramana Suarjaya
Bagian Anestesi, Reanimasi dan Terapi Intensif RSUP Sanglah, Fakultas Kedokteran Universitas Udayana

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Manajemen Anestesi Untuk Koreksi Skoliosis pada Pasien Chiari Malformasi Post Dekompresi Foramen Magnum

Jurnal Anestesiologi Indonesia Vol 6, No 1 (2014): Jurnal Anestesiologi Indonesia
Publisher : Perhimpunan Dokter Spesialis Anestesiologi dan terapi Intensif

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ABSTRACTBackground: There are complications in the management of anesthesia for correction of thoracic scoliosis in patients with Chiari malformation post foramen magnum decompression periopoeratif because there are complex issues that accompany it.Case: Anesthesia is used for correction of scoliosis in patients with Chiari Malformation post foramen magnum decompression with limited mobilization of the neck. In the X-ray examination found sublaminer semirigid instrumentation of the neck. MSCT visible on thoracic scoliosis with a curvature center on Thorakal 9 with Cobb s Angle 60º. Examination of cardiovascular, respiratory and neurological within normal limits.Curvature degrees of scoliosis in these patients is still under 70º so it does not compress heart and lungs, but there are complications to perform intubation. This can be overcome by using a fiberoptic instrument in a state of non sleep apnea using 50 mcg fentanyl and propofol 50 mg followed by balance anesthesia using continuous infusion propofol, N2O, O2, vecuronium and fentanyl intermittnent and the hipotension control techniques .Post- anesthesia patients received epidural analgesia with 2 catheters with the end of one catheter is in thoracal 3 and other in thoracal 12. Each wears 0.5 mg morphine and bupivacaine 0.1 %. Patients were evaluated 2 days in ICU with no neurological defects and free of pain, then patient moved to the treatment room.Summary: Management of anesthesia in thoracic scoliosis correction surgery becomes a very important thing because of the complexity of perioperative problems that accompany it. Cardiovascular and respiratory function is most likely impaired that need special attention. Assessment of the degree of severity of skoliosisnya can provide a predictive value to the problems that may occur perioperatively. Patients with impaired mobility of the neck can be complications when performing laryngoscopy-intubation. Post surgery if both cardiovascular and respiratory function are good, considerate extubation may be an option. Postoperative analgesics should be adequate to deal with the pain because the pain can be cause cardiovascular and respiratory instability complicating post-surgery.Keywords : Thoracic scoliosis, chiary malformation, cobb’s angleABSTRAKLatar belakang: Terdapat penyulit pada manajemen anestesi untuk koreksi skoliosis thorakalis pada pasien chiari malformasi post dekompresi foramen magnum karena terdapat permasalahan periopoeratif kompleks yang menyertainya.Kasus: Digunakan tindakan anestesi untuk koreksi skoliosis pada pasien dengan Chiari Malformasi post dekompresi foramen magnum dengan keterbatasan mobilisasi leher. Pada pemeriksaan rontgen didapatkan semirigid sublaminer instrumentasi pada leher. pada MSCT terlihat skoliosis thorakalis dengan pusat kelengkungan pada Thorakal 9 dengan Cobb’s Angle 60º. Pemeriksaan kardiovaskular, respirasi dan neurologis dalam batas normal.Derajat kelengkunan skoliosis pada pasien ini masih dibawah 70º sehingga tidak menekan jantung dan paru, tetapi terdapat penyulit untuk melakukan intubasi, hal ini bisa diatasi dengan memakai alat fiberoptik dalam kondisi sleep non apneu menggunakan fentanyl 50mcg dan propofol 50 mg dilanjutkan dengan balance anestesia menggunakan propofol kontinyu, N2O, O2, vecuronium dan fentanyl intermittnent serta tekhnik hipotensi kendali.Pasca anestesi pasien mendapat analgesi dengan 2 kateter epidural dengan ujung kateter setinggi Thorakal 3 dan ujing kateter lainnya setinggi Thorakal 12. Masing-masing memakai 0,5mg morfin dan bupivacaine 0,1%. Pasien dievaluasi 2 hari di ICU, tidak ada defek neurologis dan bebas nyeri kemudian di pindah ke ruang perawatan.Ringkasan: Manajemen anestesi pada operasi Koreksi skoliosis thorakalis menjadi suatu hal yang sangat penting karena begitu kompleksnya permasalahan perioperatif yang  menyertainya.  Fungsi  kardiovaskular  dan  respirasi  adalah  yang  paling  mungkin terganggu sehingga perlu mendapat perhatian khusus. Penilaian terhadap derajat keparahan dari  skoliosisnya  dapat  memberikan  suatu  nilai  prediksi  terhadap  permasalahan  yang mungkin terjadi perioperatif. Pasien  dengan  gangguan  pada  mobilitas  dari  leher  dapat  menjadi  penyulit  saat melakukan  laringoskopi-intubasi. Post operasi jika fungsi kardiovaskular dan respirasi baik, pertimbangan ekstubasi dapat menjadi pilihan. Analgetik post operasi harus adekuat untuk menangani nyeri karena nyeri dapat dapat menimbulkan instabilitas kardiovaskular dan respirasi yang menjadi penyulit paska operasi.Kata kunci : Skoliosis thorakalis, chiary malformation, cobb’s angle

Penatalaksanaan Perioperatif pada Bedah Dekompresi Mikrovaskular: Sajian Kasus Serial

Jurnal Neuroanestesi Indonesia Vol 5, No 1 (2016)
Publisher : Departement of Anesthesiology and Intensive Care Dr. Hasan Sadikin Hospital Bandung

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Dekompresi mikrovaskular (microvascular decompression/MVD) adalah terapi definitif dari spasme hemifasial, yakni suatu gangguan gerakan neuromuskular wajah. Spasme ini ditandai dengan kontraksi involunter berulang pada otat yang diinervasi oleh N. fasialis (N.VII) akibat penekanan oleh arteri, tumor atau kelainan vaskular lainnya. Prevalensinya mencapai 9–11 kasus per 100.000 populasi sehat, dan paling sering terjadi pada usia 40–60 tahun. Meskipun bukaan operasi MVD kecil yaitu di sekitar retroaurikula tetapi teknik anestesi-nya menggunakan prinsip-prinsip pembedahan fossa posterior. Bukaan lapangan operasi yang baik, kewaspadaan terhadap rangsangan ke batang otak maupun nervus kranialis dan kewaspadaan terhadap penurunan perfusi otak merupakan pilar-pilar utama tatalaksana anestesia pada MVD. Disajikan empat kasus spasme hemifasial dengan keadaan khusus. Kasus pertama operasi dilakukan pada pasien geriatri, pasien kedua dengan riwayat hipertensi, pasien ketiga dengan leher pendek dan asma, pasien terakhir dengan diabetes mellitus serta hipertensi. Pemantauan kestabilan hemodinamik, kedalaman anestesia dan relaksasi otot merupakan aspek penting yang menyertai tata laksana anestesi pada kasus ini.Perioperative Management in Microvascular Decompression Surgery: Case Series ReportMicrovascular decompression (MVD) is the definitive surgery for hemifacial spasm. The symptoms is described as a repetitive involuntary muscle contraction which innervated by N.fascialis caused by compression of the nervus by enlarged artery, tumor or vascular malformation. Its happened to 9-11 people from 100.000 population, especially in 4th to 6th decades. Although MVD operation only need small opening in retroauricula area but it still use posterior fossa operation principles. They are sufficient work field, awareness of impulse to brain stem and cranial nerves, and decrease of cerebral perfusion pressure. We present four cases of hemifacial spasm, with variety of considerations. The first case was a geriatric patient, the second was with history of hypertension, the third patient has short neck and also history of hypetension and asthma and the last is with diabetes mellitus and history of hypertension. Hemodynamic monitoring, deepness of anesthesia and adequate muscle relaxation is important parameter of anasthetical management of these cases.

PROFIL PENGGUNAAN ANALGETIKA PADA PASIEN NYERI AKUT PASCA BEDAH DI RSUP SANGLAH BULAN SEPTEMBER TAHUN 2013

E-Jurnal Medika Udayana vol 5 no 2(2016):e-jurnal medika udayana
Publisher : E-Jurnal Medika Udayana

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ANALGESICS USING PROFILE TO THE PATIENTS WITH POST-SURGERY ACUTE PAIN IN SANGLAH GENERAL HOSPITAL, SEPTEMBER 2013Surgery is a common action taken to overcome the problem of patients who got tissue-damagewhich caused the pain. Acute pain of patients which is happened after the surgery generally accompanied by emotional and autonomic response that inflicted physiological response and finally would disturb the patient’s recovery process. The pain management usually uses multimodality analgesics such as opioid group, NSAID (Non Steroid Anti-Inflammatory Drugs), and adjuvant. Many patients still complaining because of the pain management therapy has not run well yet. This complained caused by the less knowledge or understanding of the medical practitioner about analgesics regiments, which made they are still afraid of the side effect that may affect patients.  This research is aim to acknowledge the pain overcoming profile and analgesics therapy method in Sanglah General Hospital to the post-surgery patients during September 2013 and characteristic of the post-surgery patients. The design of this research is non-experimental cross-sectional which gathering data retrospectively using the secondary data of APS (Acute Pain Service) that belongs to Anesthetic, Re-animation, and Intensive Care Department of Sanglah General Hospital during September 2013, which amount 396 samples.Result and conclusion of this research is from 396 after surgery patients during September 2013 in Sanglah General Hospital receive multimodality analgesics regiments with 5 therapy method and monitoring by VAS (Visual Analogue Scale). Characteristics of patients with male sex amounts to 206 (52.0%) with the status ASA (American Society of Anesthesiology) dominated ASA 1 shows a patient undergoing surgery in good condition without significant systemic disorders. There are 13 types of surgeries which the largest number is 72 cases (18.2%).  There are 154 persons of the sample (38.9%) receive the therapy method using syringe pump which become the most frequently method used to overcome the acute pain happened post-surgery. The pain measurement 24–48 hours reduced in amount 2.7 point which is calculated using VAS (Visual Analogue Scale).

LOW FLOW ANESTHESIA WILL GAIN ERAS (ENHANCED RECOVERY AFTER SURGERY)

Bali Journal of Anesthesiology Vol 1, No 3 (2017)
Publisher : DiscoverSys Inc.

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ABSTRACT As we know, the volatile agent needs fresh gas flow to be carried out to the patient. It is very common in anesthesia practice, we use the fresh gas flow more than 2 liters per minute. In recent practice, the more flow we gave, the more volatile agent blew out to the patient. The present of APL (adjustable pressure limit) also leaks out of the circuit, we spend more gases, volatile agent, hence gave more pollutant to the operating theater. The consequences of those are an increase of anesthesia expenses and change the way of health care being delivered.ERAS (Enhanced Recovery After Surgery) is popular with its quick recovery after surgery, include quick emergence post anesthesia, that will reduce the time in the operating theater, recovery room, and as results, reduce the cost of anesthesia and surgery. 

EXTENDED GLASGOW OUTCOME SCALE AND CORRELATION WITH BISPECTRAL INDEX

Bali Journal of Anesthesiology Vol 1, No 3 (2017)
Publisher : DiscoverSys Inc.

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Traumatic brain injury (TBI) is a major public health issue, which results in significant mortality and long-term disability. The profound impact of TBI is not only felt by the individuals who suffer the injury but also their caregivers and society as a whole. Clinicians and researchers require reliable and valid measures of long-term outcome not only to truly quantify the burden of TBI and the scale of functional impairment in survivors but also to allow early appropriate allocation of rehabilitation supports. In addition, clinical trials which aim to improve outcomes in this devastating condition require high-quality measures to accurately assess the impact of the interventions being studied. In this article, we review the properties of an ideal measure of outcome in the TBI population. Then, we will describe the measurement tools include: the Glasgow Outcome Scale (GOS) and extended Glasgow Outcome Scale (GOSe) in correlation with bispectral index (BIS).

Konsep Dasar Target Controlled Infusion (TCI) Propofol dan Penggunaannya pada Neuroanestesi

Jurnal Neuroanestesi Indonesia Vol 6, No 1 (2017)
Publisher : Departement of Anesthesiology and Intensive Care Dr. Hasan Sadikin Hospital Bandung

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Semakin banyaknya dokter anestesi yang cendrung memilih total intravenous anesthesia (TIVA) terutama untuk operasi bedah saraf, merangsang munculnya sebuah penemuan baru yang dapat menghitung dan memperkirakan kadar obat anestesi di dalam plasma dan target organ yang selanjutnya dikenal dengan Target-controlled Infusion (TCI). Jika obat yang digunakan adalah propofol maka dikenal dengan TCI propofol. Ada dua model yang saat ini tersedia secara komersial untuk TCI propofol yaitu model Marsh dan model Schnider. Untuk dapat dengan baik menggunakan kedua model tersebut diperlukan pengetahuan yang mendalam mengenai konsep farmakokinetik tiga kompartemen dan farmakodinamik yang menjadi dasar dalam penghitungan dosis propofol pada kedua model tersebut. Jika menggunakan model Marsh maka disarankan untuk menggunakan target plasma, sedangkan  pada model Schneider sebaiknya digunakan target effect. TCI propofol yang digunakan dengan baik dapat memberikan keadaan anestesi yang hemodinamiknya relatif stabil pada saat induksi dan pemeliharaan, penurunan angka penekanan respirasi, dan peningkatan waktu pemulihan. Basic Consept on Targeted-controlled Infusion (TCI) Propofol and its use in NeuroanesthesiaThere is increasing number of anesthesiologist who prefer to use total intravenous anesthesia especially neurosurgery, stimulate new invention that can calculate and predict drug concentration in plasma and target organ, that have known as Target-Controlled Infusion (TCI). If propofol is used, it is known as TCI propofol. There are two kind of TCI propofol modes that provided commercially, that are Marsh mode and Schnider mode. Understanding the different between those two modes needs knowleadge about pharmacokinetic of the three compartement models and pharmacodynamic which is the base of the calculation of the propofol dose. If Marsh mode is used, than it is suggested to use it in plasma target, however if the Schnider mode is used, than it is suggested to use it in target effect. TCI propofol, which is used in good manner can provide an anesthesia with relatifly stable haemodinamic on induction and maintenance, decrease respiratory depression and increase recovery time.

Penatalaksanaan Anestesi pada Pasien Cedera Kepala Berat akibat Hematoma Epidural Akut disertai Kehamilan

Jurnal Neuroanestesi Indonesia Vol 6, No 3 (2017)
Publisher : Departement of Anesthesiology and Intensive Care Dr. Hasan Sadikin Hospital Bandung

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Penanganan cedera kepala berat selalu bertujuan untuk mempertahankan tekanan perfusi otak (TPO) dan mencegah peningkatan tekanan intrakranial yang dapat menyebabkan cedera otak sekunder. Pada pasien dengan kehamilan, janin juga harus dipantau. Hiperventilasi harus dihindari karena berefek buruk terhadap perfusi otak dan aliran darah plasenta. Seorang wanita, 25 tahun, 60 kg, 160 cm datang ke rumah sakit akibat trauma kepala karena kecelakaan lalu lintas yang dialami kurang dari 1 jam sebelum masuk rumah sakit dengan GCS E4M6V4. Pasien dalam keadaan hamil G1P0A0 dengan usia kehamilan 28–30 minggu. Di unit gawat darurat terjadi penurunan kesadaran mendadak hingga GCS E1M5V1 sehingga dilakukan intubasi endotrakhea disusul dengan pemeriksaan CT Scan dengan hasil hematoma epidural dekstra dan hematoma subarachnoid disertai midline shift. Pasien kemudian menjalani operasi evakuasi hematoma epidural dengan anestesi umum kemudian di rawat di unit perawatan intensif dengan pipa endotrakhea masih dipertahankan. Denyut jantung janin (DJJ) masih terdengar dan dilakukan observasi ketat DJJ selama perawatan di ICU. Namun setelah beberapa hari di ICU, janin dinyatakan meninggal. Ringkasan: Pasien cedera kepala berat dengan hematoma epidural dan subarachnoid disertai kehamilan telah menjalani operasi anestesi umum dengan tetap memperhatikan pemeliharaan tekanan perfusi otak (TPO) dan mempertahankan kondisi janin dalam batas normal. Meskipun pada akhirnya janin tidak bisa diselamatkan akibat lamanya perawatan ibu dengan ventilator.Anesthesia Management for Patients in Pregnancy with Severe Head Injury Due to Acute Epidural Hematoma Management of severe head injury cases, in any given situation, is targeted to maintain cerebral perfusion pressure (CPP), and preventing increase of intracranial pressure that possibly cause secondary brain injury. In a case of pregnancy, besides considering the maternal status, fetus condition is equally important to observe. Hyperventilation should be avoided due to its possible detrimental effect to both the brain perfusion and placental blood flow. A 25 year old female, 60 kg, 160 cm, was taken to the hospital due to head trauma caused by a traffic accident, roughly about an hour prior to hospitalization. GCS was E4M6V4. The patient was in her 28 – 30 week of pregnancy (G1P0A0). Sudden decrease in consciousness occurred and GCS lowered to E1M5V1. Endotracheal intubation was then prompted. Epidural haematoma subarachnoid haematoma with midline shift revealed in CT scan. The patient underwent epidural hematoma evacuation with general anesthesia then transferred to Intensive Care Unit (ICU) with ETT maintained. Fetal heart rate remains heard, followed with close monitoring of the fetal heart rate during treatment in the ICU. After 3 days in ICU, fetus died. Summary: A pregnant patient with severe head injury of epidural and subarachnoid bleeding, has undergone an operation with general anesthesia. The fetus was unfortunately cannot be saved due to the patient long ventilator treatment.

Anaesthesia Management of Patient at 16 Weeks Pregnancy with Primary Malignant Bone Tumour Underwent Hemipelvectomy Surgery

Bali Journal of Anesthesiology Vol 2, No 2 (2018)
Publisher : DiscoverSys Inc.

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Chondrosarcoma is a type of sarcoma that affects the bones and joints. It is a rare cancer that accounts for about 20% of bone tumours and is diagnosed in approximately 600 patients each year in the United States. Chondrosarcoma typically affects adults between the age of 20 and 60 years old. The disease usually starts in the bones of the arms, legs or pelvis, but it can be found in any part of the body that contains cartilage. Sometimes chondrosarcoma grows on an otherwise healthy bone or it grows on a benign bone tumour (an enchondroma or osteochondroma). Non-obstetric surgery during pregnancy is not uncommon and can have excellent outcomes with proper planning. Between 0.75% and 2% of pregnant women require non-obstetric surgery. Surgery can be required during any stage of pregnancy depending on the urgency of the indication. When caring for pregnant women undergoing non-obstetric surgery, safe anaesthesia must be provided for both the mother and the child. Thorough understanding of the physiological and pharmacological adaptations to pregnancy is required to ensure maternal safety. Fetal safety requires avoidance of potentially dangerous drugs at critical times during fetal development, assurance of continuation of adequate uteroplacental perfusion, and avoidance and/or treatment of preterm labour and delivery.Pregnant patients beyond 18–20 weeks of gestation should be positioned with a 15° left lateral tilt, to reduce aortocaval compression and supine hypotension syndrome. Regional anaesthesia with combined spinal epidural is an option for this case. Regional anaesthesia does reduce the exposure of foetus to potential teratogens, avoids the potential risk of failed intubation and aspiration, and provides excellent post-operative analgesia. The major concern with neuraxial anaesthesia is maternal hypotension, which may reduce placental perfusion.  During anaesthesia and surgery, foetal well-being is best ensured by careful maintenance of stable maternal haemodynamic parameters and oxygenation. Close monitoring of foetal responses for signs of distress is strongly advocated.

CASE REPORT ANESTHETIC MANAGEMENT OF ADRENAL TUMOR RESECTION

Bali Journal of Anesthesiology Vol 2, No 2 (2018)
Publisher : DiscoverSys Inc.

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ABSTRACTThe adrenal glands are secretory organs that are located above each kidney and produce hormones that play a major role in the metabolic processes. Tumors of the adrenal gland can cause metabolic abnormalities associated with hormonal disorders such as Cushings syndrome, pheochromocytoma, or Conns syndrome. To be able to give a good anesthetic management on resection of the adrenal tumor, it requires adequate preoperative evaluation. However, this will take large resources. Management of anesthesia in adrenal tumor with an unknown hormonal disorder should consider a variety of hormonal abnormalities that may present in the patient so it can be anticipated effectively.Keywords: incidentaloma, adrenalectomy, hormonal disorder, perioperative

Supraspinal Modulation : Something to be Remembered

Bali Journal of Anesthesiology Vol 2, No 2 (2018)
Publisher : DiscoverSys Inc.

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Pain had always been a challenging issue in patients with acute and chronic condition.  Pain results from activation of sensory receptors specialized to detect actual or impending tissue damage. However, a direct correlation between activation and nociceptors and the sensory experience of pain is not always apparent. Emotional state, the degree of anxiety, attention and distraction, past experiences, memories, and many other factors can either enhance or diminish the pain experience.Many active agents are used to block and alleviate pain sensation in acute and chronic settings. When an inadequate treatment for acute pain and neuralgia occurred, it would induce complex processes involving both central and peripheral sensitization contributing to persistent post-surgical pain and worsening neuralgia that would lead to chronic pain issue.The important thing to be considered is that this pain process is an intertwined and interconnecting and sustainable process that could not be cut abruptly. Our aim is to remind us to accept that pain pathway is merely not one straight way but still a convoluting idea which could still revolve and expand. Imagining areas could be defined surely one day through high technology advances and would lead us into defining the depth of this beautiful yet complex pathway.