PENYULIT PASCA BEDAH PENYULIT PASCA BEDAH & PENANGANANNYA& PENANGANANNYA
PERNAFASANPERNAFASAN OBSTRUKSI JALAN NAFAS (partial, total)OBSTRUKSI JALAN NAFAS (partial, total)
pangkal lidah jatuhpangkal lidah jatuh muntahan, aspirasimuntahan, aspirasi
ATASI DENGAN :ATASI DENGAN : Head tilt, Chin liftHead tilt, Chin lift Jaw thrustJaw thrust triple air-way manuvertriple air-way manuver suctioningsuctioning
HIPOVENTILASI (SISA MUSCLE HIPOVENTILASI (SISA MUSCLE RELAXANT)RELAXANT)atasi dengan :atasi dengan : bebaskan jalan nafasbebaskan jalan nafas nafas bantunafas bantu reversal (Prostigmin + Sulfas Atropin)reversal (Prostigmin + Sulfas Atropin)
SIRKULASISIRKULASI Pantau dengan nadi, perfusi perifer, Hb, Ht, CVPPantau dengan nadi, perfusi perifer, Hb, Ht, CVP Penyulit yang sering terjadi :Penyulit yang sering terjadi :
HIPOTENSIHIPOTENSI SHOCKSHOCKARRYTHMIAARRYTHMIA
ATASI DENGAN :ATASI DENGAN : MONITORING KETATMONITORING KETAT TERAPI CAIRANTERAPI CAIRAN k/p k/p TRANSFUSI TRANSFUSI ANTI-ARRYTHMIA, ELEKTROLIT (KANTI-ARRYTHMIA, ELEKTROLIT (K++)) PINDAH PASIEN BILA SUDAH STABIL BAIKPINDAH PASIEN BILA SUDAH STABIL BAIK
MUNTAH (PONV)MUNTAH (PONV) RISIKO ASPIRASI RISIKO ASPIRASI
HIPOXIA SELAMA ANESTESIAHIPOXIA SELAMA ANESTESIA ANESTESI TERLALU DALAMANESTESI TERLALU DALAM RANGSANG CTZ (ETHER)RANGSANG CTZ (ETHER) TEKANAN LAMBUNG YANG TINGGITEKANAN LAMBUNG YANG TINGGI NARKOTIKNARKOTIK
ATASI DENGAN :ATASI DENGAN : DHBP 2.5-5. mg/ivDHBP 2.5-5. mg/iv Ondansetron 4 mg/iv ( untuk pencegahan Ondansetron 4 mg/iv ( untuk pencegahan
berikan sebagai premedikasi)berikan sebagai premedikasi) perut kembung perut kembung NGT NGT
DroperidolDroperidolDose Nausea NNT 95% CI
0-6 hr 5.2 3.3-12.6 0.25 0-24 hr - -
0-6 hr 4.8 3.0-12 0.5-0.75 0-24 hr 11 6.9-25
0-6 hr 6.1 4.5-9.4 1.0-1.25 0-24 hr 6.8 5.2-9.7
Prevention of vomiting requires larger doses, NNT 8-10.
Henzi I. Can J Anesth 2000;47(6):537-551.
PONV – The “Big Little PONV – The “Big Little Problem”Problem” Nausea and vomiting are among the most
distressing aspects of the postoperative experience
Incidence ranges between 20-50%
Increased morbidity with PONV
Prolonged recovery time
Leads to hospitalization of ambulatory patients
Increases institutional costs
Disrupts the management of outpatient surgical procedures
Kapur PA. Anesth Analg. 1991;73:243-245.Palazzo MG et al. Can Anaesth Soc 1984.
Watcha MF et al. Anesthesiology 1992; 77(1): 162-184.
Overall Incidence of PONVOverall Incidence of PONVInvestigatorInvestigator YearYear PatientsPatients Vomiting Vomiting
(%)(%)
Waters et al.Waters et al. 19361936 10,00010,000 41%41%
Bellville et alBellville et al 19591959 748748 19%19%
Adriani J et al.Adriani J et al. 19611961 2,2302,230 23%23%
Rowley et al.Rowley et al. 19821982 1,1831,183 43%43%
Patel et al.Patel et al. 19891989 9,9109,910 9%9%
Forrest et al.Forrest et al. 19901990 16,00016,000 18-25%18-25%
Karlsson et al.Karlsson et al. 19901990 485485 25%25%
Cohen et al.Cohen et al. 19901990 29,22029,220 25%25%
Watcha MF et al. Anesthesiology 1992; 77(1): 162-184.
Medical Consequences of PONVMedical Consequences of PONV Patient discomfort (mild to severe)Patient discomfort (mild to severe) Patient dissatisfactionPatient dissatisfaction Increased costIncreased cost
Personnel, supplies, drugsPersonnel, supplies, drugs Unplanned admissionsUnplanned admissions
Increased intraocular and intracranial pressuresIncreased intraocular and intracranial pressures Increased blood pressure and heart rateIncreased blood pressure and heart rate Wound dehiscence and bleedingWound dehiscence and bleeding Dehydration and electrolyte imbalanceDehydration and electrolyte imbalance Interruption of oral drugs, nutrition, and fluidsInterruption of oral drugs, nutrition, and fluids Pulmonary aspirationPulmonary aspiration
Palazzo MG et al. Can Anaesth Soc 1984; ASHP Am J Health Syst Pharm 1999; Watcha MF et al. Anesthesiology 1992; 77(1): 162-184.
ReceptorsReceptors
Major Risk Factors for Major Risk Factors for PONVPONV
Patient characteristicsPatient characteristics– AgeAge– GenderGender– AnxietyAnxiety– Weight Weight – History of PONV/motion sicknessHistory of PONV/motion sickness– Concomitant diseaseConcomitant disease– Non-smoking historyNon-smoking history
Watcha MF et al. Anesthesiology 1992; 77(1): 162-184.Lerman. Br J Anaesthesia. 1992; 69 (suppl 1): 24S – 32S.Bellville et al. Anesthesiology. 1960; 21(2): 186-193.
Major Risk Factors for Major Risk Factors for PONVPONV
Type of surgeryType of surgery– GynecologicGynecologic– OphthalmicOphthalmic– Ear, nose, and throatEar, nose, and throat– LaparoscopicLaparoscopic– IntraabdominalIntraabdominal– Breast Breast – TesticularTesticular– ShoulderShoulder– Dental/oralDental/oral– Lengthy procedureLengthy procedure
Watcha MF et al. Anesthesiology 1992; 77(1): 162-184.Lerman. Br J Anaesthesia. 1992; 69 (suppl 1): 24S – 32S.Bellville et al. Anesthesiology. 1960; 21(2): 186-193.
Major Risk Factors for Major Risk Factors for PONVPONV Type of anesthesiaType of anesthesia
– OpioidsOpioids– Nitrous oxideNitrous oxide– EtomidateEtomidate– MethohexitalMethohexital– BarbituratesBarbiturates– Neuromuscular blocking drugsNeuromuscular blocking drugs– AnticholinesterasesAnticholinesterases– Potent volatile anesthetic gasesPotent volatile anesthetic gases
Watcha MF et al. Anesthesiology 1992; 77(1): 162-184.Lerman. Br J Anaesthesia. 1992; 69 (suppl 1): 24S – 32S.Bellville et al. Anesthesiology. 1960; 21(2): 186-193.
Major Risk Factors for Major Risk Factors for PONVPONV
Care in the PACUCare in the PACU– PainPain– OpioidsOpioids– MovementMovement– DehydrationDehydration– Orthostatic hypotensionOrthostatic hypotension– SedationSedation– Oral intakeOral intake
Watcha MF et al. Anesthesiology 1992; 77(1): 162-184.Lerman. Br J Anaesthesia. 1992; 69 (suppl 1): 24S – 32S.Bellville et al. Anesthesiology. 1960; 21(2): 186-193.
Risk FactorsRisk FactorsAnesthetic RelatedAnesthetic Related
Risk FactorsRisk Factors OR*OR* CICI
Volatile anesthetics Volatile anesthetics
isofluraneisoflurane 3.413.41 2.18; 5.372.18; 5.37
sevofluranesevoflurane 2.782.78 1.79; 4.311.79; 4.31
enfluraneenflurane 3.113.11 1.98; 4.881.98; 4.88
Apfel et al. BJA 2002;88:659-668* Compared to propofol
Volatile Anesthetics
Antiemetic AgentsAntiemetic Agents
• 5-HT3 Receptor Antagonists– Dolasetron– Granisetron– Ondansetron
• NK-1 Inhibitors– Aprepitant
• Corticosteroids– Dexamethasone– Methylprednisolone
• Substituted Benzamides– Metoclopramide
• Cannabinoids– Dronabinol– Nabilone– NK-1 Inhibitors
• Benzodiazepines– Lorazepam– Alprazolam
• Butyrophenones– Droperidol– Haloperidol– Domperidone
• Phenothiazines– Prochlorperazine– Chlorpromazine– Thiethylperazine Maleate– Promethazine Hydrochloride
• Antihistamines
ASHP Guidelines. Am J Health-Syst Pharm 1999;56:729
Pharmacologic group/drug Dopamine (D2) Muscarinic Cholinergic Histaminic Serotonin (5-HT3)
PhenothiazinesFluphenazine ++++ + ++ -Chlorpromazine ++++ ++ ++++ +Prochlarperazine ++++
ButyrophenonesDroperidol ++++ - + +Haloperidol ++++ - + -Domperidone ++++
AntihistaminesDiphenhydramine + ++ ++++ -Promethazine ++ ++ ++++ -
Anticholinergic: scopolamine + ++++ + -Benzamides
Metoclopramide +++ - + ++
5-HT3 Receptor AntagonistsOndanensetron - - - ++++Granisetron - - - ++++
Tricyclinic AntidepressantsAmitriptyline +++ +++ ++++ -Nartriptyline +++ ++ +++ -
Number of positive signs (+) indicates degree of activity; negative sign (-) indicates no activity.
Adapted from Watcha and White. Anesthesiology. 1992;77(1):162-184
Receptor Site Affinity of Antiemetic AgentsReceptor Site Affinity of Antiemetic Agents
5-HT5-HT33 Receptor Selectivity Receptor Selectivity
Serotonergic receptors of the 5-HTSerotonergic receptors of the 5-HT33 subtype seem to have a crucial subtype seem to have a crucial role in the systems mediating role in the systems mediating emesisemesis
Ondansetron has a greater affinity Ondansetron has a greater affinity for this receptor than any otherfor this receptor than any other
Avoids the acute dystonic Avoids the acute dystonic reactions associated with reactions associated with dopamine blockade dopamine blockade
Prevention of PONV:Prevention of PONV:MetoclopramideMetoclopramide
““In summary, metoclopramide, although used as In summary, metoclopramide, although used as an antiemetic for almost 40 years in the an antiemetic for almost 40 years in the prevention of PONV, has no clinically relevant prevention of PONV, has no clinically relevant antiemetic effect . . . it is very likely that the antiemetic effect . . . it is very likely that the doses used in daily clinical practice are too low.”doses used in daily clinical practice are too low.”
Henzi I, Walder B, and Tramer, MR. Metoclopramide in the prevention of postoperative nausea and vomiting: a quantitative systematic review of randomized, placebo-controlled studies. BJA 1999;83:761-771
II-A
MetoclopramideMetoclopramide
Metoclopramide in the prevention Metoclopramide in the prevention ofpostoperative nausea and ofpostoperative nausea and vomiting: a quantitative systematic vomiting: a quantitative systematic review of randomized, placebo-review of randomized, placebo-controlled studies.controlled studies.
Conclusion:Conclusion: No benefit from metoclopramide as a No benefit from metoclopramide as a
prophylactic antiemeticprophylactic antiemetic
Tramer MR Br J Anaesth. 1999 Nov;83(5):761-71Tramer MR Br J Anaesth. 1999 Nov;83(5):761-71
DimenhydrinateDimenhydrinate
Dimenhydrinate for prophylaxis of Dimenhydrinate for prophylaxis of postoperative nausea and vomiting: a meta-postoperative nausea and vomiting: a meta-analysis of randomized controlled trials.analysis of randomized controlled trials.
Kranke P, Morin AM, Roewer N, Eberhart LH. Kranke P, Morin AM, Roewer N, Eberhart LH. Acta Anaesthesiol Scand 2002 Mar;46(3):238-44 Acta Anaesthesiol Scand 2002 Mar;46(3):238-44
Yes …. but at 1 – 2 mg/kgYes …. but at 1 – 2 mg/kg
sleepysleepy
DimenhydrinateDimenhydrinate
Antiemetic efficacy of Antiemetic efficacy of prophylactic dimenhydrinate prophylactic dimenhydrinate (Dramamine) vs ondansetron (Dramamine) vs ondansetron (Zofran): a randomized, (Zofran): a randomized, prospective trial inpatients prospective trial inpatients undergoing laparoscopic undergoing laparoscopic cholecystectomy.cholecystectomy.
Kothari SN, Boyd WC, Bottcher ML, Lambert Kothari SN, Boyd WC, Bottcher ML, Lambert PJ.PJ.Surg Endosc 2000 Oct;14(10):926-9Surg Endosc 2000 Oct;14(10):926-9
Ondansetron 4 mgOndansetron 4 mgDimenhydrinate 50 mg Dimenhydrinate 50 mg
0
5
10
15
20
25
30
35
40
45
PONV
Dimenhydrinate
Ondansetron
DroperidolDroperidolDose Nausea NNT 95% CI
0-6 hr 5.2 3.3-12.6 0.25 0-24 hr - -
0-6 hr 4.8 3.0-12 0.5-0.75 0-24 hr 11 6.9-25
0-6 hr 6.1 4.5-9.4 1.0-1.25 0-24 hr 6.8 5.2-9.7
Prevention of vomiting requires larger doses, NNT 8-10.
Henzi I. Can J Anesth 2000;47(6):537-551.
5-HT5-HT33 Receptor Antagonists Receptor Antagonists 5-HT5-HT33 Receptor Antagonists Receptor Antagonists
– AnzemetAnzemet®® (dolasetron mesylate) (dolasetron mesylate)– Zofran (ondansetron)Zofran (ondansetron)– Kytril (granisetron)Kytril (granisetron)
Block 5-HTBlock 5-HT33 receptors in the CNS and periphery (i.e., in receptors in the CNS and periphery (i.e., in the GI mucosa), preventing the binding of serotonin (5-the GI mucosa), preventing the binding of serotonin (5-HT) to the 5-HTHT) to the 5-HT33 receptors receptors
Activity is based on receptor binding, not kinetic Activity is based on receptor binding, not kinetic parameters; therefore, once 5-HTparameters; therefore, once 5-HT33 receptors are receptors are saturated, higher doses do not increase effectsaturated, higher doses do not increase effect– Duration of action is independent of ½ lifeDuration of action is independent of ½ life
Gralla et al. J Clin Oncol 1999;17:2971ASHP Guidelines. Am J Health-Syst Pharm 1999;56:729
Ondansetron Ondansetron ProphylaxisProphylaxisDose Event NNT 95% CI
0-6 hr 9.0 5.3-30 1 mg 0-24 hr 21 9.1- ?
0-6 hr 5.6 4.4-7.5 4 mg 0-24 hr 6.4 5.3-7.9
0-6 hr 6.4 4.7-10 8 mg 0-24 hr 5.0 4.0-6.7
Tramer MR. Anesthesiology 1997;87(6):1277-89.
OndansetronOndansetron Prophylactic ondansetron for post-operative Prophylactic ondansetron for post-operative
emesis: meta-analysis of its effectiveness in emesis: meta-analysis of its effectiveness in patients with and without a previous history of patients with and without a previous history of
motion sicknessmotion sickness Eur J Anaesthesiol 1999 Aug;16(8):556-64 Eur J Anaesthesiol 1999 Aug;16(8):556-64
– Twelve trials involving 2122 patients Twelve trials involving 2122 patients – The dose of The dose of 4 mg4 mg ondansetron was ondansetron was
71.5%71.5% more effective in patients with more effective in patients with a positive Hx of motion sickness a positive Hx of motion sickness
DexamethasoneDexamethasoneDose Vomiting NNT 95% CI
0-6 hr 3.6 2.3-8.0 8-10 mg
0-24 hr 4.3 2.6-12.0
Henzi I. Anesth Analg 2000;90:186-94
•Synergism with 5 HT3 antagonistsLopez-Olaondo L. BJA 1996;76(6):835-40
Fujii Y. Can J Anesth 1995;42(5):387-90
•Side effect freeBluming AZ. J Clin Oncol 1986;4:21-3
IGAR.NEJM 2000;342(21):1554-9
DexamethasoneDexamethasone The effect of dose of dexamethasone for antiemesis The effect of dose of dexamethasone for antiemesis
after major gynecological surgeryafter major gynecological surgery Anesth Analg 1999 Nov;89(5):1316-8Anesth Analg 1999 Nov;89(5):1316-8
– 30 pts per group30 pts per group– Dex 0 to 10 mg per pt Dex 0 to 10 mg per pt
PONV
0
20
40
60
80
Placebo D1.25 D2.5 D5 D10
OxygenOxygenOndansetron is no more Ondansetron is no more
effective than effective than supplemental supplemental
intraoperative oxygen intraoperative oxygen for prevention of for prevention of
postoperative nausea postoperative nausea and vomiting.and vomiting.
Goll V, Akca O, Greif R, Freitag H, Goll V, Akca O, Greif R, Freitag H, Arkilic CF, Scheck T, Zoeggeler A, Kurz Arkilic CF, Scheck T, Zoeggeler A, Kurz
A, Krieger G, Lenhardt R, Sessler DI.A, Krieger G, Lenhardt R, Sessler DI.
Anesth Analg. 2001 Aug;93(2):518-9Anesth Analg. 2001 Aug;93(2):518-9. .
PONV
0
20
40
60
30% 30%+
Ond
80%
Avoid Hypoxia and Hypotension
Prevention of PONV:Prevention of PONV:Combination TherapyCombination TherapyWhich Combination?
EventEvent
5-HT3 + drop5-HT3 + drop 5-HT3 + dex5-HT3 + dex
NN RateRate NN RateRate P-valueP-value OROR
EarlyEarly
NauseaNausea 138138 17%17% 260260 11%11% 0.120.12 1.61.6
VomitingVomiting 318318 1%1% 419419 1%1% 1.001.00 1.01.0
Late Late
NauseaNausea 358358 27%27% 623623 21%*21%* 0.020.02 1.41.4
VomitingVomiting 443443 9%9% 813813 9%9% 1.001.00 0.90.9Ashraf et al. Anesthesiology 2001; 95:A-41
Evidence Rating for Evidence Rating for AntiemeticsAntiemetics
Strength of EvidenceStrength of Evidence Treatment Consequences*Treatment Consequences*
PreventionPrevention TreatmentTreatment PreventionPrevention TreatmentTreatment
Ondansetron 4 mgOndansetron 4 mg I-AI-A I-AI-A 5.5 – 6.55.5 – 6.5 3.2 – 3.93.2 – 3.9
Ondansetron 1 mgOndansetron 1 mg -- I-AI-A -- 3.8 – 4.83.8 – 4.8
Dolasetron 12.5 mgDolasetron 12.5 mg I-AI-A I-AI-A 4.0 – 5.04.0 – 5.0 3.6 – 4.23.6 – 4.2
Granisetron 1 mgGranisetron 1 mg I-AI-A I-AI-A 3.1 – 4.23.1 – 4.2 3.1 – 3.83.1 – 3.8
DroperidolDroperidol I-AI-A -- 4.3 – 5.04.3 – 5.0 ??
DexamethasoneDexamethasone II-AII-A -- 4.3 – 7.14.3 – 7.1 --
DimenhydrinateDimenhydrinate II-AII-A V-BV-B 4.8 – 8.04.8 – 8.0 ??
MetoclopramideMetoclopramide -- V-BV-B ?? ??
*NNT
PROLONGED PROLONGED UNCONSCIOUSNESSUNCONSCIOUSNESS
KERJA OBAT YANG MEMANJANGKERJA OBAT YANG MEMANJANG DOSIS OBAT YANG BERLEBIHDOSIS OBAT YANG BERLEBIH METABOLISME YANG MENURUNMETABOLISME YANG MENURUN EKSKRESI OBAT YANG LAMBATEKSKRESI OBAT YANG LAMBAT
GANGGUAN METABOLISME DI OTAKGANGGUAN METABOLISME DI OTAK HIPERCAPNEAHIPERCAPNEA SHOCK YANG LAMASHOCK YANG LAMA HIPOGLIKEMIAHIPOGLIKEMIA NARKOTIKNARKOTIK HIPONATREMIAHIPONATREMIA
STROKESTROKE TEKANAN DARAH DURANTE OP.TEKANAN DARAH DURANTE OP. ATASI DENGAN :ATASI DENGAN :
MONITORING KETATMONITORING KETAT ATASI GANGGUAN SPESIFIKATASI GANGGUAN SPESIFIK k/p RAWAT ICUk/p RAWAT ICU
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