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*Pentothal *Propofol *Etomidat Plg sering *Midazolam *Diazepam *Ketamin

Dose 5 + 3 mg -kg 60% or 7 + 55 mg -kg 6 0M Keta!ine indication " contraindication : 56 0ndication 1 'hort surger# 26 ontraindication 1 a6 &#pertension s#stolic 8 5,9 mm&g "6 /rrh#tmia c6 &eart failure d6 Phar#n( & lar#n( surger# :ithout intu"ation PROPO#O$ ;e: intra!enous anesthetic <ast onset) short duration of action /ccumulation minimal <ast reco!er# Rapid meta"olism ;o complication at site of in$ection Dose 2 + 2)= mg -kg.> Phar!acolo%& propo'ol : ;o histamine release - reaction anaph#lactoid ?chremofor E0 change :ith so#e "ean oil@ Peri!ascular in$ection) tissue necrosis ?-@ 0n$ection intraarter# 1 tissue necrosis ?-@ E''ect Propo'ol To CNS : &#pnotic effect 5)A time pentothal /ir:a# depression more than pentothal ;o anti con!ulsant effect Co!parative properties o' I(V( anesthetic Prop Thio6 Ket6 Diaz6 Midaz6 6 /Bueous solution C C C /!aila"le in solution C C C C Pain on in$ection C C %enous throm"us C Co!parative properties o' I(V( anesthetic Thio. Ket. Prop. Diaz. Midaz. Rapidl# acting C C C 'mooth induction CC C C C C Respirator# C C C--

depression % depression Rapid reco!er# 'mooth reco!er# 'uita"le for infusion 0nteraction :ith rela(ant

CC C -





Ideal Intravenous Anesthetic : Larut air Tidak mengiritasi Tidak ada efek anti-analgesi Rapid & smooth induction ardio!ascular sta"il pada dosis klinik THIOPENTONE Tekanan darah menurun Den#ut $antung dapat naik atau turun %asodilatasi perifer &eart contraction depressed 'pasme lar#n() spasme "ronchus Respirator# depression sampai apnoea Dosis * + , mg -kg.. Relative contraindication Thiopentone : /sma "ronkhial 'e!ere li!er disease 'e!ere kidne# disease 'e!ere anemia &#potensi 'hock KETA INE Dissociati!e anesthetic Delirium &allucination 0ncrease .P 1 '#stolic 234 from "ase line 0ncrease &eart Rate /rh#tmia &#persecression

Resu!e : E''ect anesthetic non)volatile to or%an s&ste! Drugs HR MAP Vent. Bdil Thiopentone Diazepam 9- Midazolam Meperidine Morphine <entan#l Ketamin 9 Propofol Resu!e : E''ect anesthetic non)volatile to CNS Drugs CBF CMRO2 CP Thiopentone Diazepam Midazolam Meperidine Morphine <entan#l Ketamin Propofol

Choice o' anesthetic inhalation : ardio-pulmonal effect Product degradation :ith soda lime >hat meta"olitesD

&o: much meta"olism D Ideal Anesthetic Inhalation : Pleasant odor & non + irritation Lo: solu"ilit# ;o organ to(ic 'ide effect cardio!ascular & respiration minimal ;' Effect re!ersi"le :ithout stimulant acti!it# Effecti!e in high E2 concentration .oiling pressure & "oiling point can deli!ered "# !aporizer standard Ne* trend in %eneral anesthesia : %0M/ <ast-track anesthesia Lo: cost anesthesia 'ingle "reath induction ?Rapid induction@ Ph&sicoche!ical Properties :
Edor 0rritating to Respirator# s#st6 'olu"ilit# M/ Meta"olism &al6 C 2)3= 9)F, 5F-294 <) l) .r) T</) . D) <e) DE) TE) D.E Enfl6 C 5)75 5),A 2)*4 0sofl6 C Desfl6 'e!o6 C 9),3 2)9= G =4

0ntra!enous induction) e( 1 propofol 1 rapid & smooth induction) "ut need !ein access first) hipotensi) apnoe Pediatric anesthesia commonl# "# %0M/ More ad!entages than intra!enous induction maintenance inhalation6 Cardiovascular E''ect o' Volatile Inhalation anesthetics :
Varia!le .lood Pressure %ascular resistence ardiac output ardiac contraction %P &eart Rate 'ensitization of the heart to epinephrin Halotane 9 9 9 9 "n#lurane so#lurane

E2 599 46 Advanta%es : Rapid induction & reco!er# ;o sensitized m#ocardium :ith catecolamine ;o irritation respirator# tract Edor pleasant 'trong analgesic /isadvanta%es : >eak anesthetic ;o muscle rela(ation effect ;eed high concentration E2 Possi"ilit# aplasia "one marro:


;ote 1 9 1 no change 1 increase 1 !aria"le Clinicall& Phar!acolo%& o' Inhalational Anesthetic :----, Clinicall& Phar!acolo%& o' Inhalational Anesthetic : CNS ;2E &al Enf 0sofl 'e!o .< 0 P MRE2 'eizure

HA$OTANE / clear) colorness) potent !olatile liguid Meta"olism 5F + 29 4 Advanta%es : Rapid) smooth induction and reco!er# Pleasant ;on-irritating) no secresi .ronchodilator ;on-emetic ;on-flamma"le and non-e(plosi!e /isadvanta%es : M#ocardial depressant /n arh#tmia producing drug 'ensitized the m#ocardial conduction s#stem to the action of cathecolamines / potent uterine rela(ant Possi"le to(ic to li!er 'hi!ering during reco!er# period


<) D/

Interaction *ith Soda $i!e Degradation Ergan /nesthetic product to(icit# &alotane Enflurane 0soflurane Desflurane 'e!oflurane +h& VI A , . D<E E E E ompound / ompound . ;ephroto(ic nephroto(ic

HH66 ;on + 0dentified N.O 5)= time hea!ier than air6 Must "e gi!e :ith E2 59946 >eak anesthetic6 /nalgesic ;2E 294 eBual :ith 5= mg morphine6 DonIt use in closed s#stem6 /t the end operation anesthesia) to pre!ent diffusion h#po(ia

EN#$URANE / clean) colorless) sta"le !olatile liBuid :ith a pleasant ether likeodor / potent inhalation anesthetic ;' e(citation

Jse of ephinephrine 1sa!e than halotan Advanta%es : Pleasant Rapid induction and reco!er# ;on-irritating .ronchodilator Kood muscle rela(ation ;on emetic ;on flamma"le ompati"le :ith HH /isadvanta%es : M#ocardial depressant 'hi!ering on emergence '< production increase '< e(citation in high dose and h#pocor"ia ISO#$URANE / sta"le !olatile liBuid /n isomer enflurane Advanta%es : Rapid induction of anesthesia and s:ift reco!er# ;on-irritating / 0nhalatin anesthetic choice for ner!e surgical patient Kidne#) li!er HH6 /isadvanta%es : Less than halotane and anflurane HH6 ;on H66 .lood pressure HHH6 SEVO#$URANE 0nhalation anesthetic :ith lo: solu"ilit# ?9),3@) lo: M/ ?2)9=@) pleasant odor) no air:a# irritation) H66 HH66 Rapid induction :ith techniBue single "reath induction) induction time 23 second HH66

Drugs of choice for neuroanesthesia 1 > / 2999 Montreal) anada Drugs of choice HHH 0n sectio caesaria eBual :ith isoflurane and spinal anesthesia Reduce sphlancnic HHH6

.radikardia 1 central !agotonic effect and '/ & /% node depression Respirator# depression 1 RR) rh#tm) respon E2 H6 Muscle stiffness ;ausea) !omitting) cause "# stimulation HH) K0T mo"ilit#) decrease gastric mo"ilit# increase gastric !olume6 Appro'i(ate$ duration 3-= h 2-3 h *= min + 2 h G 39 min G ,9 min

Clinical doses o' narcotics Drug Morphine Meperidine <entan#l 'ufentan#l /lfentan#l V$dose 9)9=-9)3 Onset =-59 =-59 2 G5 G5



Narcotic Anal%esic : >ide margin of safet# <ast onset of action 'hort duration of action Easier analgesia controlled 'trong analgesic ;o histamine release ;on-acti!e meta"olic

39-A9 mg-kg

%er# useful in general anesthesia6 Lar#ngoscop# and intu"ation more easier and a!oid in$ur#6 Muscle rela(ation !er# useful during surger# and controlled !entilation6 Ideal uscle Rela2ant : ;on-depolarization Rapid onset) short duration of action Rapid reco!er#) high potenc# ;on cumulati!e) meta"olite non acti!e ;o cardio!ascular effect ;o histamine release ounterage :ith anticholinesterase echanis! o' neuro!uscular 3loc4ade : ompetiti!e "lock 1 non depolarization) a!oid /c h access to reseptor Depolarization "lock 1 depolarization) depolarization on as /c h "ut permanent Defficienc# "lock 1 influence s#nthesis and release /c h) prokain) to(in "otulinus) a decrease) Mg increase Ter!inolo%& in !usce rela2ant

Opiate in anesthesia : 56 premedikasi 26 induksi anesthesia 36 narcotic anesthesia *6 part of "alance anesthesia =6 ad$u!ant and regional anesthesia ,6 neurolept anesthesia F6 post operation pain reliefe drugs Morphine Pethidine <entan#l 'ufentan#l /lfentan#l Protein$!inding CC CCC CCC CCCC CCCC %ipid$solu!ilit& C CC CCCC CCCC CCC

;ote 1 C 1 !er# lo: CC 1 lo: CCC 1 high CCCC 1 !er# high Narcotic e''ect :

ED =9 1 dose :hat can pral#zed =94 muscle strength ED 79 1 dose :hat can paral#zed 794 muscle strength Enset 1 inter!al "et:een start of in$ection until ma( effect6 /epolari5ation and non)depolari5ation e''ect o' !uscle rela2ant Depolarization )on*depolarization Long acting 1 'hort acting 1 - tu"ocurarin - 'uccinilcholine - metocurine - Decametonium - do(acurium - pancuronium ?plg srng@ 0ntermediate acting 1 - atracurium - !ecoronium - rocuronium 'hort acting 1 - mi!acorium Non 6 depolari5ation dru%s : Do not produce muscular fasciculation Efek are decreased "# anticholinesterase) HHHH66) epinephrine) acet#lcholine Effect are increased "# non-depolarizing drugs and !olatile anesthetic /epolari5ation dru%s : Produce muscular fasciculation Effect are increased "# anticholinesterase Effect decrease :ith non-depolarizing Dose succinilcholine 1 5 mg-kg.> Conditional causin% succepti3ilit& to Succinilcoline 6 induced h&per4ale!ia : .urn in$ur# Massi!e trauma 'e!ere cord in$ur# Encephalitis 'troke Kuillan .arre s#ndome

'e!ere Parkinson disease Tetanus Prolonged total "od# imo"ilization Rupture Polineuritis losed heart in$ur# ;ear dro:ning &aemorhagic shock or meta"olic asidosis M#opath# ?e6g6 DunchennerIs athroph#@

'ign of partial o"struction 1 snoring) cro:ing) gargling) :heezing) chest retraction) c#anosis 'ign of total o"struction 1 air flo: from nose-mouth negati!e) supracla!icular retraction) intercostal retraction) c#anosis6 Other Pro3le! /urin% Induction Respirator# depression ough-"atuk Lar#n( spasm Moucous and sali!a !omiting
n#usion$ rate$#or$ stead&$ state$ !lo1/ade -(g./g.h0 E)2= 9)932 9)9FA

Drugs "D$+, -(g./g 0 9)25 9)9,F 9)9*3 Re1o((ende d$intu!ating$ dose -(g./g0 9)3 + 9), 9)99= + 9)99A 9)9A + 9)5

/tracurium Pancuronium !ecuronium

Air*a& Controlled :ithout eBuipment 1 trilple manou!er 'afar :ith eBuipment 1 - EP/ ?orophar#ngeal air:a#@ - ;P/ ?nasophar#ngeal air:a#@ - LM/ ?Lar#ngeal Mask air:a#@ - ETT ?Endotracheal tu"e@ Tindakan memasang ETT 1 L intu!asi$M Indi4asi Intu3asi : .edah kepala dan leher Difficult air:a# Thoracotom# Laparotom# Lateral position Prone position ontrolled !entilation Techni8ue $a&n%oscop& &ead position 0nsertion lar#ngoscop# "lade %isualization epiglotis Lift epiglotis %ie: lar#n( and surrounding structure Advanta%es Endotracheal Intu3ation Ensures and patient air:a# ;ormal anatomic dead space ?F= ml@ is decreased to 2= ml %entilation can "e assisted or controlled Possi"ilit# of aspiration diminished drasticall#




Indu4si adl !e!persiap4an pasien dari sadar sa!pai !en7adi tida4 sadar( aintenance adl pe!eliharaan 4eadaan tida4 sadar terse3ut sa!pai selesai operasi( Choice o' Anesthesia Techni8ue /epend on : PatientIs condition 'kill anesthetist 'kill surgeon &ospital socioeconomi Pro3le! /urin% Induction o' Anesthesia : Main pro"lem1 air:a#

'uctioning of the lung is facilitated /isadvanta%es endotracheal intu3ation 0ncrease resistance to respiration Trauma to the lips) teeth) nose) throat) lar#n( Co!plication intu3ation Teeth rupture Mouth "leeding Endo"ronchial intu"ation Eesophageal intu"ation 'ore throat &ipertention /rrh#tmias Induction Techni8ue Mask induction - inhalation 0ntra!enous 0ntramuscular Per rectal as4 Induction +ith Sevo'lurane Kradual induction 'ingle "reath induction Triple "reath induction ?multiple "reath induction@ <ast techniBue :ith single "reath induction :ithout cough) "reath holding) spasm lar#n( 0radual Induction lassic method for mask inductiom To decrease respirator# tract irritation To decrease respirator# tract irritation and non pungent Edor no need for se!oflurane om"ined :ith ;2E or E2 5994 oncentration se!oflurane increase 9)= + 5)= !ol4 e!er# 23 "reath until anesthesia adeBuate ommonl# reach in ,9-79 seconds :ith se!oflurane F 4 Sin%le 9reath Induction Priming circuit :ith ;2E ,94 C se!oflurane A4 39 seconds

/sk patient inspiration ma(imal ?!ital capacit#@) keep 29 seconds) then normal "reathing /fter e#elash refleks negati!e se!oflurane turn to 2 4 Triple 9reath Induction / !ariation from single "reath induction /sk patient 3 times deep "reath Ho* to aintain Anesthesia Maintenance anesthesia depend on deep of anesthesia to reach adeBuate anesthesia ommonl# :ith se!oflurane 5 + 5)= !ol4 depend on t#pe of surger#) spontaneous "reathing or controlled To reduce !ol4 ?M/ @ add ;2E or fentan#l Si%n o' /eep Anesthesia PR'T score ?"alanced anesthesia@ Kuedel sign ?ether anesthesia@ PR'T score ?score 2-* 1 adeBuate anesthesia@ P N '#stolic arterial pressure R N Rate ' N ':eat - lacrimation T N Tear PRST Scorin% Inde2es 'or 9alanced Anesthesia nde' Condition 21ore '#stole Less than control C 5= 9 /rteriol Less than control C 39 5 Pressure More than control C 39 2 ?mm&g@ Less than control C 5= 9 &eart Rate Less than control C 39 5 ?"eats-minute@ More than control C 39 2 9 ':eat 5 2 9 Tears or 5 lacrimation 2 E2tu3ation /fter adeBuate !entilation 0n deep anesthesia or after patient a:ake

lear air:a# E2 5994 after and "efore e(tu"ation

#actor *hich In'luence Total Anesthetic Inhalation 56 onstanta 26 <resh gas flo: 36 !olume 4 ?M/ @ *6 Length of 'urger# Total$Anestheti1$ nhalation$3 1onstanta$'$$#resh$gas$#lo4$-(l0$'$5ol$6$'$ti(e$-(inute0 I' len%th o' sur%er& . hours total sevo'lurance induction( Fresh$gas$#lo4$-(l0$'$7.789$'$5ol$6$'$ti(e$-(inute0 <irst 39 minute ,999 ( 5-5A3 ( A4 ( 9)= N 5)3 3 minute for intu"ation ,999 ( 5-5A3 ( 24 ( 3 N5)7 3 minute start of lo: flo: 3999 ( 5-5A3 ( 34 ( 3 N5)* 'econd 3 minute 5999 ( 5-5A3 ( 54 ( 3 N9)3 Eperation 2 hours 5999 ( 5-5A3 ( 54 ( 529 N,)= Total$se5o#luran1e$77:;$(l TIVA Continue Propofol ,-59 mg-Kg-h C !ecuronium 9)5 mg-kg-h C fentan#l 2 ug-Kg o Pentotal 5-3 mg-Kg-h C !ecuronium 9)5mg-Kg-h C fentan#l 2 ug-Kg o Ketamine 2 mg-Kg-h C !ecuronium 9)5 mg-Kg-h C diazepam 9)2= mg-Kg o Midazolam =9 ug-Kg-h C Ketamine 2 mg-Kg-h C atracurium 9)2= mg-Kg-h o POST ) OPERATIVE See lecture o' RR and ICU :; <UNI .::=

$OCA$ ANESTHESIA Anesthesia 0eneral Intravenous Intramuscular block Inhalation $ocal Topikal

conscious aspiration risk ?@ "lood loss autonomic and endocrine respons


24 ; "lock 55)=4 Tropical *4 'pinal =4 sda

EP0 F-A mg-Kg


nerve block spinal epidural intrvenous co!3ination

/isadvanta%es Patient prefer unconscious ;ot practical if se!eral in$ction are needed <ear that the effect of drug !anished the surger# not finished 'ide effect so se!ere death

'lo: ,9I529I


0nfiltration 9)2=-9)=4 ; "lock 9)=9)F=4 'pinal 9)=4 0nfiltrtion 9)=4 ; "lock 9)=54 Epidural 55)=4

'lo: > 5A9I >399I Rapid > 5A9I >399I


0eneral anesthesia *0mpuls still leach to ;' - cortisol - cathecolamin - takikardia - "lood sugar Re%ional anesthesia *0mpuls less - not reach to ;' * segmental "lokade T=-L5 .lock s#mpathic s#stem - cortisol ;-less6 - katekolamine ;-less6

$OCA$ ANESTHETIC A0ENT 1. Ester compound ocain Procain - no!ocain Tetracain - pantocain 2. /mide compound - O#locain - lidocaine - Prilocain - citanest - .upi!akain - marcaine - Etidocain - duranest - Ropi!acain - Lero"upi!acain
/gent ocain Procain oncent clinical use *-594 topical 0nfiltration 54 Epidural 24 Ple(us "lock 24 'pinal 594 0nfltration 54 Epidural 24 Ple(us "lock 24 Topical 9)=54 0nfiltration 9)5-9)24 Epidural 9)*-9)=4 'pinal 54 0nfiltration 9)=-54 Epidural 5Enset & duration 'lo: 39I 'lo: 39I+ *=I Ma(imal single dose 5=9 mg =99 mg EP0 ,99 mg + EP0 59-52 mg-Kg ,99 mg EP0 ,=9 mg + EP0 59-5= mg-Kg 599 mg 2 mg-Kg Potenc# lo:

5F= mg EP0 2=9 mg+ EP0 3-*mg-Kg 52= mg EP0 2=9 mg+ EP0 3-* mg-Kg 399 mg EP0 *99 mg+ EP0 *- mg-Kg





Meta"olism &idrol#zed in plasma ? ps6 holine@ Degradation in the li!er

/llerg# ?+@ P/./ ?@

Anesthetic pro'ile o' local anesthetic is depend on : Lipid solu"ilit# intrinsic potenc# The higher lipid sol higher potenc# Procaine) L6'6 N 5 .upi!acaine) L6'6 N 39 Etidocaine) L6'6 N 5*9 79 4 a(olemma consist of lipid Protein "inding &igher protein "inding longer duration Procaine) P6.6 N = .upi!acaine) P6.6 N 7= 59 4 a(olemma consist of protein pKa pKa as p& at :hich its ionized and non-ionized L6/6 :ith pKa closer to tissue p& more rapid onset pKa lidocaine N F)F .upi!acaine N A)3 0ntrinsic !asodilator act!it#

<eneral$anesthesia - all tension loss - unconscious %o1al$.$regional$anestheasia - partial sensation - conscious Advanta%es 'imple) cheep non + e(plosi!e no pollution post of care relati!e eas#


Rapid *=I,9I



'lo: 5A9I399I



Rapid ,9I529I

399 mg EP0 =99 mg +


0nfluence potenc# and duration of action Degree of !ascular a"sorption is reltre to "lood flo: through the area /ll local anesthetic !asodilatation e(cept cocain 9ase upon poten& and duration o' action 56 lo: potenc# and short duration of action - procaine - clhloroprocaine 26 intermediete potenc# and duration of action - lidocain - mepi!acain - prilocain 36 high potenc# and long duration of action - "upi!acain - tetracain - etidocain To2icit& o' local anesthetic >:?. 6 @?=AB '#stmic to(icit# ;' - e(citation - depression %' - h#potention - % collaps Local iritation ;eural damage chloroprocaine Miscellanous /llerg# ester compound Meta"olism hemoglo"inemia prilocain /ddiction cocaine $(A a%ent are relativel& 'ree o' side e''ect? i' : 56 in appropiate dosage to(ic e(cessi!e dose 26 in appropiate anatomical location to(ic reaction follo:ing 1 - accidental i6!6 in$ection - su"arachnoid in$ection of large dose S&ste!ic to2icit& Local anesthetic are relati!el# free of side effect if 1 1. in appropriate dosage to(ic e(cessi!e dose6 2. in appropriate anatomical locatiaon ti(ic reaction6 <ollo:ing 1 /ccidental 0% in$ection6 su"arachnoidal in$ection of large dosage6 - ;' is more suscepti"le than %'6

- /d!erse effect in!ol!ing %' then to "e more serious and more to manage6 CNS to2icit& ;' is more suscepti"le to the s#stemic actions of L/ than %' Tinnitus Light headed ness on!usion ircumoral num"ness Dro:siness unconscious T:itching and tremormuscle of face and distal e(tremitas con!ulsion Respirator# arrest .upi!acane 1 etidocaine 1 lidocaine N *1215 on!ulsi!e Threshoid in in!ersel# related to the Pa E2 le!el - Pa E2 con!ulsi!e threshoid - p& con!ulsien threshoid CVS to2icit& ardial ;egatife inotropik action More potent more depress contractiling more difficult to resuscitate6 %entricular 1 "iphasic action Lo:er dose !asocontriction 0ncrease dose !asodilatation ;o correlation "et:een L/ potenc# and !ascular smooth muscle effect6 &#potension initeall# as a result of decrease in '% E Later on !asodilation % collaps Neurolo%ical 9loc4ade Peripheral 1 Topikal 0nfiltration <ield "lock ;er!e "lock 0% regional anesthesia 'entral 1 'pinal epidural

SPINA$ ANESTHESIA L/ su"arachnoid space 56 /nterior horn "lockade 26 Posterior horn "lockade 'mall ner!e fi"er large fi"er 56 /utonom 26 sensorius ?pain@ 36 Temperatur *6 Motorik =6 Proprio ceptik /utonomic "lockade 2-3 segmentales a"o!e analgesic le!el 6 Motorik "lockade 2-3 segmentales under analgesic le!el6 Indication 56/"dominal surger# esp lo:er a"domen 26&ernia inguinalis 36lo:er e(trimitiessurger# *6%esica urinaria and Prostatic surger# =6o"g#n surger# Contra Indication 1. /"solut 1 Refusal of the patientIs Local 0nfection oagulopath# 2. Relati!e 1 'epsis ;eurological disease Technical pro"lems &#po!olemia Advanta%es onscious Rela(ation ?C@ Pulmonar# post op complication GG .lood loss /isadvanta%es &#potension Durante and post op nausea and !omiting Post op headache Distur" Respiration high le!el Jrinar# retention

Techni8ue 56 Lateral - 'itting position 26 /pproach midline - lateral a. le!el of in$ection 1 iliaca crest L-R L* - = b. needle is ad!anced until durameter is pierced '< flo: "ack c6 The higher the dose the greater the height of "lock d. Lo:er a"dominal surger# TA - 59 5)A 2 cc e. &igher a"dominal surger# T* - = 2 - 2)= cc

Duramater 0s "egine from foramen magnum and end at ' 2 le!el Posterior to the duramater lies lig6latum Duramater 9)= cm at L2 ontent of epidural space 1 - fat - !ascular !essel - l#mph !essel - areolar tissue - spinal ner!e roots Detection of epidural space using Tuoh# needle less of resistance hanging drop dose 1 5 + 5)= ml - segment in$ection login :ith 3 ml of test dose consist of lidocaine 24 C adrenaline 5 1 2996999

TechniBue 1 Disad!antages 1 -

prone position cornu sacralis hiatus sacralis penetrating HHHH6 &igher le!el of analgesia difficult to reach s#stemic reaction could "e ?C@

.rachial Ple(us .lock 'upracla!icular /(illaris

a6 fluid 1 9)= - 5 l b. Post in$ection 1 Test analgesic Respirator# monitor E2 "# mask assist !entilation c6 &#potension fluids ephedrine = - 59 mg 0% d. &igh risk patients earl# ephedrine drips

Co!plication :
- penetrate duramater 1 - Post spinal headache - Total spinale - s#stemic reaction

97 $uni 299=


near the operating room and other intensi!e care fasilities open :ard ?to facilitate o"ser!ation of all patient simultanousl#@ :ell lighted ?da#light@ pulse o(#metri E K .P monitor >arming-cooling "lanket Emergenc# trolle# Eutlet 1 E(#gen) electrical) suction Minor set 0nfussion - s#ringe pump

Spinal advanta%es 1
less time to perform eB6 techniBue easier less doses more rapid onset "etter Bualit# sensor# and motor "lock

f6 Diazepam - Midazolam g6 &#pnotic h6 ;2E - E2 i6 Light Keneral anesthesi Post spinal headache o Due to leakage of '< smaller the needle less P'& o K6; 2= 3)=4 P 2F 54 P 27 G 54 Therap& a6 Laid flat 2* hrs "6 /nalgesic agent c6 /uto log epidural "lood patch6 EPI/URA$ ANESTHESIA - thoracal) lum"ar) caudal - 0ndication - contraindication N spinal anesthetic6 Anato!&

Epidural advanta%es :
segment "lock ;o P' &#potension is not a"rupt Less motoric "lock en "e used for post operation pain catheter Epidural disadvanta%es more difficult larger dose s#stemic reaction increase

E8uip!ent :

9e'ore *orld +ar II

Post operation death after anesthesia and surger# is high6 This period is characterized "# relati!el# high incidecne of potentiall# life threatening6 Respirator# and circulator# complication6

Caudal 3loc4 :
0ndication 1 perineural surger#

A'ter +orld +ar II

'uccess of RR 'taffing 1 factor in e!aluation of modern 0 J - P/ J

ontraindication 1 epidural

;urse 1 -trained in care of emerging patient ?/ L'@ 5 nurse for 2 "eds ?patients@ Medical direction of anesthesiologist coordinate to surgeon and an# consultant

Shiverin%? cause D 56

opioid !agal tone increase

residual effect of cholinesterase inhi"itor

E!er%ence 'ro! Anesthesia

.ecause post operation is a time of great ph#siologic stress E(1 - air:a# o"struction shi!ering !omite) etc

un:arm 0% fluids e(posure of large :aind / &#pertermia Meta"olic acidosis) etc

Co!plication in PACU
air:a# o"struction - unconscious patient tounge falling "ack against the posterior6 - phar#n( 1 lar#n( spasm) glottic edema) etc

/ela&ed E!er%ence
>hen the patient fail to regain consciousness ,9 + 79 minute follo:ing general anesthesia ?K/@ The causes residual anesthetic sedati!e prolong effect of opiate h#potermia meta"olic distur"ance Perioperati!e stroke ?rare@

26 &#po!entilation - define as Pa E2 8 *= mm&g) p& G F)2= - causes residual effect of anesthesia agent ?o!erdose@ - inadeBuate re!ersal - se!ere pain - tight a"dominal dressing - E2 production is high 36 &#po(aemia Define as PaE2 G F9 mm&g auses 1 - h#po!entilation - E(#gen consumption - <R - Lung edema *6 &#potension Define as a 29 + 39 4 reduction of .P auses 1 - h#po!olemia - !entricular disfunction - impaired cardiac filling &#pertension Define as .P 8 29 + 394 of "ase line6 auses 1 - s#mpathetic acti!ation - pain - h#percapnia /rrh#tmia h#percardia electrolite distur"ance

Para(eters Value Colors$=$ - pink 2 - pale 5 - c#anotic 9 Respiration$=$ - .reath deepl# and cough 2 - 'hallo: "ut adeBuate 5 Cir1ulation$= - .P :ithin 294 of normal 2 - 29 + =9 4 5 - =94 from normal 9 Cons1iousness$= - a:ake - allert 2 - arousa"le 5 - no respon 9 A1ti5it&$= - mo!e all e(trimitas 2 - mo!e 2 e(trimitas 5 dinilai sela!a . 7a!? D ; : %ood(

Intensive Care Unit >ICUB

multi diciplinar# as intensi!e care :ith potencial# life threathening illlness supporting therapies1 - neurologic cardio!ascular-hemod#namic pulmonrar#-respirator# electrolite-meta"olism nutritional

Post opertaion C Post anesthesia ana%e!ent

.P Pulse - &R RR E(#gen suplementation ?'pE2@ Temperature 'ensor# and motor le!er ?regional anesthesia@ Pain Control parenteral regional anesthesia ner!e "lock A%itation C Resthessness cause D ?h#po(emia) acidosis) etc@ Nausea and vo!itin% auses D &#potension "# regional anesthesia onitorin% : !ital sign 1

Neurolo%ic Suporrt
.< is constant auto regulation at range of .P ?M/P =9 -5=9 mm&g@ 0n$ur# losses of a"ilit# .< related to PP ? PPNM/P-0 P@ .< ere"ral .lood for:ard6 PP ere"ral Percusion Pressure6 0 P 0ntra ranial Pressure6 -



Acute CNS in7ur&

ischemia ?focal or generelize@ structural distortionof "rain scoring-K ' ;' support is focused on 1 Eptimizing s#stemic and cere"ral

to "e prefent !asospasm steroid ?D@ 26

Cardiovascular C he!od&na!ic support

ma$or determinants of cardiac output heart rate and contractilit# "lood !essels !olume intra!ascular preload after load o(#gen delie!er# E N &R ( '! 'troke %oume is determined "# 1 pre load after load contractilit#

.< ;ormalizing 0 P - immediate concern air:a#-!entilation-o(#genation hemod#namic issues1 h#potention ?loss of automat#c control@ h#pertention ?h#peradrenergic state@ cardiac d#sfunction seizure control ?meta"olic-infection@ neorologic e(amination 1 is there a surgical lessionD K ' La"orator# T-scan

E P >P '%R h#po!olemic shock a. E b. P >P c. '%R distri"uti!eshock a. E ;- b. P >P ; - c. '%R o"structi!e shock a. E b. P >P c. '%R



ana%e!ent O' Shoc4

E increasing E Therap# arr#thmias To manage - pre load - after load - fluid 0mpro!e contractilit# optimize o(#gen delie!er# &" PaE2 ?<iE2 and lung function@ %asopressor and inotropic agent Dopamine) etc /nti"iotic Decrease o(#gen demand


preload echocardiograph# P >P

Supportive care:
general treatment o(#genation correct anemia hemod#namic sta"ilit# esta"lish normo!olemia contol h#perthermia control seizures contol pain a!oid agatation-shi!ering correct meta"olic a"normalities control 0 P '< ?!olume reduction@ &#per!ent#lation Esmotic agent .ar"iturate &ead position

after load N '%R-'#stemic %ascular Resistance N M/% + % ( A9 contractilit# N echo N E< o(#gen deli!er# ?DE2@ DE2 N aE2 ( E ( 59 N ?&. ( 5)3* ( 'aE2@ C ?PaE2 ( 9)935@ ( E ( 59

Respirator& Support SHOCK

Charateri5ed 9V organ "lood flo: that is an adeBuate to meet tissue demands #our Cate%ories O' Shoc41 1 56 cardiogenic shock Ene of most common this order leading to 5 cm admission is /R<? acute respirator# failure@ 6 /R< :hen the plmonar# s#stem is no longer a"le to meet the meta"olic6 Demand of the "od# To t&pes o' respirator& 'ailure >R#B(

- t#pe 51 h#po(emic R< ?PaE2 =9 To RR@ - t#pe 21 h#percapmic R< ?Pa E2 =9 Torr@ - :ith h#po(emic - :ithout h#po(emic Causes o' R#CRespirator& #ailure t#pe 5 ? usuall# the result of missmatch of a!eolar !entilation and pulmonar# perfussion@ E(1 - acute long in$ur# - acute pulmonar# edema T#pe 2 ?characterized "# aleolar h#po!entilation @ E(1 - air flo: o"struction - ;' - ;euromuscular distur"ances

Total "od# fluid 0 < 39 + *94 e(tracelluler fluid E < transelluler fluid 5 + 34

Anesthesiolo%i ca"ang - disiplin ilmu kedokteran ruang lingkup 56 i6 ii6 iii6 i!6 v. !i6 26 36 i6 ii6 iii. i!6 !6 2F Mei 299= Pendidikan pera:at mahasis:a kedokteran dokter spessialis dokter spesialis lain dokter spesialis anestesi super spesialis a:am penelitian dan pengem"angan pela#anan anesthesiologi anesthesia dan analgesia resusitasi intensi!e care unit intensi!e care medicine therapi anhalasi penanggulangan n#eri

0ntra!ascular =4 .>

fluid intestitiil fluid 5=4 .>


ani'estation o' AR# is AR/S

onset 52 + F2 hours after trigers respirator# distress ? gasping) c#anotic)etc@ lung edema ?non cardiogenic@ PaE2 G =9 mm&g P>P 8 5A mm&g PaE2 - <iE2 G299 mm&g o(#egn suplement 1 - nasal canula - face mask 0PP% 1 - non in!asi!e Pharmacologic

anesthesia hilangn#a kesadaran

sensasi rasa panas + dingin pera"aan


narkose anesthesi C analgesi anestesiologi a"ang ilmu kedokteran - pem"erian anesthesi C analgesi - mengatasi N menun$ang faal faal penderita dari stres operasi - dll Trias : &ipnotik /nalgesic Muscle Rela(ant

Electrolite /istur3ances
/s the most common distur"ances are in K) ;a) a Pottasium ?; 3)= + =)= mEB-l@ &#pocalemia ?KC G 3)=mEB-l@ auses1 - renal and e(tra renal losses HHHHHHHHHHH66DDDD



Prinsip 9loc4ade anesthesia " anal%esia Lokasi "lock 1 5)2)3 1 regional "lock * 1 general anesthesia

Se7arah :
22=9 'M .a"ilonia) &#osc#amus ;iger gigi 5=99 'M Tro#a Epium &erodotus anna"is indica ?Mari$uana@ /"ad 53 1 Theodorico) Dr6 .orgogni 'laap spons spons tidur ;icholas pra erositus 1 gonoticon opium hina &ashish ? 6 indica@ Qunani .eladona alkaloid /ss#ria mencekik tidak sadar sirkumsisi /"ad 5F + 5A morphine) scopolamin /"ad 57 alkohol >illiam Thomas Kreen Morton Drg demonstrasi ether di Massachusetits ruang Lether domeM general hospital .oston J'/ Dr6 ra:ford >6 long 5A*2 tidak diumumkan Keorgia Penderita $ames M6 !era"le ether operasi tumor di leher Drg &orace :ells ;2E zat gelak dilakukan untuk olton demonstrasi di &ar!ard med 'chool C Prof6 Rohn olling gagal hadi harles R6 Rackson ?ahli kimia@ C Morton Demonstrasi ahli "edah 1 Morton R6 Rackson >aren &enr# R6 .igelo:

26 36 *6 =6 ,6 F6

medik lainn#a "aik se"elum) selama) maupun sesudahn#a Menga:asi dan menun$ang fungsi-fungsi !ital pasien #ang mengalami stress pem"edahan dan pem"erian anestesi Mengelola pasien tidak sadar oleh karena se"a" apapun Mengelola penderita #ang mengidap masalah n#eri Mengelola masalah resusitasi Mengelola therapi pernafasan mengelola "er"agai gangguan cairan) elektrolit dan meta"olit

menger$akan tindakan #ang memerlukan kemampuan tekhnik kemampuan 36 memakai "er"agai alat anestesi 4. memakai "er"agai alat monitor memantau Resi4o 4arena : 56 "erhu"ungan dengan status fisik penderita 26 pem"edahan 1 rasa sakit) gangguan nafas) trom"osis) em"oli) dll 36 pemakaian o"at-o"atan *6 pemakaian alat 2.

Ris4 O' Anesthesia

9idan% il!u &an% dipela7ari 56 fisika 26 /natomi 36 <aal *6 <armakologi =6 Klinik Jmum ,6 Klinin Khusus F6 Keterampilan 'kill ?motorik@ Kognitif ?otak@ HHHH

Resi4o Tinda4an Praktek anestesi "ukan pengo"atan Mem"eri fasilitas - Tidak sakit - Relaksasi - Tidur tidak sadar RESIKO TIN !K!N Catat 1 pintu ger"ang kematian nafas "erhenti detak $antung "erhenti tidak sadar Resi4o Pra4te4 Anestesi eliputi : 56 pem"erian o"at #ang sangat poten ?kuat@

Less serious risk1 - nausea and !omiting - "ruissing and superficial trm"ophle"itis at the intra !enous acces site - dental in$ur# - corneal a"ration - headache More serious risk1 - perifheral neuropath# ? ulna neuropath# most common@ - cardiac d#srh#mias - m#ocardial infection - atelektasis - pneumonia - renal or hepatic insuficienc# - stroke - allergic drug reaction - Malignant h#pertherm#a - .lood reaction Mortalit# 'tates /'/ lass 5 /sa lass 2 Disease atate ;o organic ph#sicologic) "iochemical or ps#ciatric distur"ance Mid to moderate s#stem distur"ance that ma# not "e related to the reason for surger#6 E(1 &eart disease is onl# slightl# )limit ph#sial act#!it#) essential &T) DM) anemia)) e(trems of age) mor"id o"sesif) chronic "ronchitis6 'e!ere s#stemic

Ether "erhasil 25 ;o!em"er 5A*, 1 Eli!er >endell &olmes istilah anestesi Kongres /merika sulit menentukan siapa pemenang hadiah penemu anesthesi terse"ut6 /khirn#a Long meninggal mendadak >ells "unuh diri Morton C - apople(ia Morton Rackson gila

TU0AS ANESTESIO$O0I 1. Mengelola menghilangkan 1 rasa sakit - n#eri ) rasa takut pada persalinan) pem"edahan) dan tindakan

/'/ lass 3

/'/ lass *

/'/ lass =

distur"ance that ma#or ma# not "e related to the reason for surger# E(1 heart disease that limits acti!it# ) poorl# controlled) essential &T) Dm :ith !ascular complication) chronic pulmonar# disease that limit acti!it#) ;K0; petoris) histor# of prior m#ocardial infarction 'e!ere s#stemic distur"ance that is life threatening :ith or :ithout surger#6 EO1 congestif heart failure ? &<@) persisstence angina pecroris) ad!ance pulmonar# renal or hepatic6 Mori"und patient :ho has little chance of sur!i!al "ut is su"mitted to surger# as a last resort ? resusitati!e effort@6 E(1 uncontrolled hemorages as from a rupture a"dominal aneurism) cere"ral trauma) pulmonar# em"olus /n# patienat in :hom an emergenc# operation is reBuired E(1 an other :ise health# 39 #ears old female :ho reBuires a dilataition and curretage for moderate "ut persistent hemorrhage ?/'/ lass 5) E@

Perioperative Events That Should 3e /iscussed +ith The Patient Pre operativel& Preoperati!e insomnia and medication a!aila"e for its treatment Time) route of administration and e(pected effect from the preoperati!e medication Time of anticipated transport to operating room for surger# /nticipated duration of surger# /:akening after surger# in the reco!er# room Likel# presence of sheaters on a:akening ? tracheal) gastric)"ladder) !enous) arter#al@ Time of a(pected rreturn to hospital room after surger# Magnitude of posst operati!e discomfort and method a!aila"le for its treatment 0nsidence post operati!e nausea and !omiting ConsideratiosThat /eter!ine The Techni8ue o' Anesthesia o e(sisting disease that ma# or ma# not "e related to the reason for surger# 'ite of surger# .od# position of patient during surger# Electi!e or emergenc# surger# Likel#hood of the presence of increased amount of gastric contents /ge of patient Preference of patient Keneral 56 26 36 *6 =6 ,6 F6 A6 76 596 556 526 536 5*6 onsideration preanesthetic preparation of #he patient choice of anesthesia preanesthesia medication medicolegal acpects of anesthesia cleaning and sterilization of the anesthesia eBuipment monitoring during anesthesia and post anesthesia period electrocardiograph# cardiac arrest and cardiopulmonar# resuscitation the anesthesia machine general anesthesia intra!enous anesthesia muscle rela(ant lar#ngoscop# and endotracheal intu"ation local and regional anesthesia

5=6 spinal anesthesia 5,6 lum"ar ) epidural) and caudal anesthesia 5F6 regional ner!e "lock anesthesia 5A6 !asopresor and adrenergic "locking agents 576 h#pertensi!e techniBues and induced h#pothemia 296 intra!enous fluid therap# 256 "lood transfussion 226 li!er and anesthesia 236 the rec!er# room and intensi!e care unit 2*6 "lood gasses1 acid + "ase "alance and o(#gen transfer 2=6 respirator# therap# 2,6 chest ph#siotherap# 2F6 respiration and respirator# care 2A6 dia"etes and anesthesia 276 pollution) fires) e(plossionand electrical hazzardes 396 complication during anesthesia and the reco!er# periode Special Anesthesia Pro3le!s In sur%ical Specialities 56 anesthesia in thoracic surger# 26 anesthesia in cardiac surger# 36 anesthesia in neurosurger# *6 anesthesia in surger# for endocrine this order =6 anesthesia and analgesia in o"stetric g#necologic ,6 pediatric anesthesia F6 anesthesia for orthopedic procedures A6 dental anesthesia 76 anesthesia in oftalmolog# 596 anesthesia in otolar#ngolog# 556 anesthesia in urologic surger# 526 anesthesia for out patient surger# 536 anesthesia for emergenc# surger# 5*6 in!asi!e hemod#namic monitoring Sepuluh Prinsip A!anat >Ten Co!!ende!entsB 56 $anganlah "agaimanapun $uga mengaki"atkanpenderita mengalami hipoksia atau anoksia 26 $alan pernafasan penderita harus di$aga selalu aman dan "e"as 36 $angan mem"erikan anestesia kepada pasien tanpa izinn#a dan $anganlah antara resiko dan hasil tindakan anestesi tidak ada keseim"angan #ang menguntungkan *6 $angnlah men#alahgunakan :aktu dari orang lain dengan memperlam"at prorram atau rencana pem"edahan =6 $anganlah mem"erikan anesthesi tanpa mem"uat laporan tertulis ? medical record@

Emergenc# operation ?E@

.; !ei .::= ANESTHESIO$O0E


semua peralatan harus dupersiapkan dengan rapi dan "ersih serta lengkap sesuai standar F6 tu"uh pasien harus dilindungi terhadap pengaruh2 #ang merugikan selama pem"edahan ? perioperatif@ karena penderita tidak sadar) maka andalah #ang "ertanggung $a:a" terhadap keselamatann#a A6 $angnlah pasien and diserahkan kepada pihak lain $ika "elum sta"il dan masih mem"aha#akan 76 $angan mem"erikan anestesia dengan tehnik2 dan o"at2an #ang tidak dikuasai oleh anda 596 dalam keadaan "agaimanapun anda adalah seorang spesialis klinik #ang mengutamakan kepentingan penderita diatas kepentingan lainn#a6

Possi"le chancre dissa"ling A=4 se(s 1 :oman higher than man t#pe of "od# "uild asthenic 8 normal or o!er:eight ?p#knic@



Succes'ull Approach >9us4ir4B treat all patient as human "eing "e friendl#) e(plain #our !isit and #our plan "e patient and s#mphatetic listen to his concern) ans:er all Buestion in understanding and :arm manner alla# patientIs fears Histor& and ph&sical e2a!ination Personal and famil# histor# hereditar# condition associated :ith anesthesia 1 porph#ria) malignant) h#perthermia) hemophilia6 Pre!ious operation and anesthetic /llergies Medication drug interaction &a"its 1 alcohol and smoking Diseases of %' and respirator# s#stems /lcoholism 'moking HHHHHHH HHHHHHH decrease cere"ral "lood flo: and increase risk of stroke increase gastric !olume and acidit# increase HHHHHHHH illiar# function reduce distur"ing tracheo"ronchial clearence 0ncrease production HHHHHHHH66 HHHHHHHHH6 HHHHHHHH66 impairment of li!er funtion heart cardiac HHHHHHH66 HHHHHHH HHHHH66

Ph&sical E2a!ination Keneral condition 1 name) age) :eight) .P) pulse rate and temperature6 ardiopulmonar# e(amination including 1 c#anosis in fingers tips !ena $ugularis engorgement E"esit# ?> - & 2 8 39@ air:a# pro"lems mechanical !entilation is impaired tendenc# to h#po!entilation e6c6 fi( thora( and ele!ated diaghragma easil# de!eloped h#po(ia e6c6 <R is reduced HHHHHHHHH6 HHHHHHHHHH6 HHHHH - Difficult estimate sirculatpr# !olume "# !ena $ugular pressure andHHHHHHHHHHH HHHHHH66 HH66 DM 3 + * ( more 0ncrase gastric !olume) accidit#) and pressure /ir:a#1 ;eck1 short) sunkers checks) distance from mentum to h#oid ? = cm@ Mouth1 mouth opening) "ose or damage teeth) protruding upper incissors %erte"ral column1 /natomical deformiting ma#render some "lock in practical Si!ple 3ed side cardiopul!onar& 'unction HHHHH HHHHH G 29 scd se!erel# copromised

F: !ei .::= PREOPERATIVE PREPARATION Preoperative Visit 0nadeBuate preoperati!e preparation ma# "e a ma#or contri"utor# factor to the peri operti!e mor"idit# and mortalit#6 0t is essential that aneshetist !isits e!er# patient "efore surger# The purpose o' it : esta"lished report :ith the patient - meet the doctor :ith the patient - discuss possi"le causes of an(iet# regarding anesthetic and surgical manner - e(plain ho: the patient :ill "e cared for during and after anesthesia and a"out pain relief - esta"lish a doctor patient relationship that reduces patient an(iet# "# "uilding trust and respect /ssessment of ph#sical status Erder spacial in!estigation #ears related to Anesthesia >She''erB &e ma# tell secrets The operation :ill start too soon &e ma# :ake up during surger# &e ma#not :ake up after surger# <ears of suffocation) mutilation) !omiting and chancre Insidence o' an2iet& t#pe of surger# KJT A94

- match test1 the a"ilit# to "lo: out a standart match held , inci from the open mouth negati!e makes "reathing cap lo: - tilt test lla"orator# testing HHHHHHHHH 9lood$= - &") leuko all female male 8 =9 ma#or surger#) clinicall# indicated - ureum creatinin patient 8 =9) renal and hepatic disease) dia"etes) a"normal nutrition state HHH6 - "lood sugarDM !ascular disease corticosteroid drugs - urinalisis e!er# patient) !er# in e(pensi!e and ma# occasional# re!eal an undiagnosed dia"etic or JT0 $Chest$'*ra&s1 - histor# of pulmonar# and cardiac disease - T. incidens - 'moking $"C< patient 8*9 h#pertention) histor# of cardiac disease HHHHHH HHHHHH6 lass 21 a patient :ith mild or moderate s#stemic disease lass 31 a patient :ith se!ere s#stemic disease that is not in capacitating limits the patient acti!it# HHHH6 HHHH6 Iin'or!ed concent - a patient acti!e kno:ledgea"le authorh#zation to allo: a specific procedur to "e pro!ided "# an anesthesiologist - concent must "e informed to ensure that the patient has sufficient information a"out the prosedurs) their risks and "enefit - o"taining informed concent honors a patientIs right to self deternation :hether general anesthesia)regional anesthesia or i! sedation #ASTIN0 to pre!ent aspiration of gastric content PPE after midnight has "een Buestioned no:ada#s hazard fasting 68 52 hrs

h#dration is compromised fasting for 5 da# ma# deplete li!er gl#cogen and greater risk hepato(icit# fasting 5 da# increases <</ Lo:er the threst hold to epinefrin induced arr#thm#a) recomendarion1;PE * hrs gastric empt#ing is dela#ed "# an(iet#) pain) trauma) and pregnanc#

0n sirculating !olume is enough) &" A),4 is not necessar# to get transfusion shock 1 anesthesia depression of !ital organs shock is :orsening6 %olume replacement until "lood pressure FA9 mm&g) good peripheral condition) diuresis enough6 Temperature 1 3A antipiretica) fine local infection especiall# respirator# tract6 RESPIRATORE IN#ECTION influenza) far#ngitis) "ronchitis electi!e operation is dela#ed air:a#s instruments 1 trauma of infection mucosa respirator# o"struction) spasm) h#persecretion post operati!e respirator# complication infection spread

-a stud# an premediacated patient oral intake 5=9 ml :ater 2 + 3 hhrs preoperati!el# RK% lo:) p& more alkcaline ?F24@ 5=9 ml :ater C ranitidine 5=9 mg onl# 24 had RK% 8 2= ml p& G 2)= -to a!oid h#poglicemia and thrus "# and in order pediatric patient come and cooperati!e - milk 59 ml -Kg * hrs "efore surger# - de(trosa = = 59 ml-Kg 2 hrs "efore surger# PRE E/ICATION E"$ecti!e care1 alla# an(iet# and fear reduce secretion analgesia enchance the h#pnotic effect of general anesthetic agent reduces poat op nusea and !omiting produce amnesia reduction in !agal refle( HHHHH66 HHHHH6 alcaloid "eladona as antisecretion and reduce !agal refle() HHHHH6 Drugs iMpuls aferen a"doment thora( and e#es anti emetic HHHHH6 OPERATION CANCE$$E/ /;EM0/1 &" ) 59 gr4 0n research &." )59gr4 0ts not increase mor"iditas - mortalitas