Tabel 1.

Target Perfusi Jaringan pada Pasien Bedah Berisiko Tinggi

Variable Monitor Reported clinical effects

[references]
Dynamics indices of fluid
responsiveness
TED Decrease LOS or
Corrected flow time complications [22,24,28],
increase LOS [61,62]
Stroke volume TED, Vigileo FloTracystemTM, Decrease LOS or
LiDCOrapidTM complications [23-28]
Pulse pressure variation Multiparametric monitor, Decrease LOS and
LiDCOrapid complications [3C]
Plethysmography Plethysmography None [31]
variability index
Sroke volume variation Vigileo/FloTracsystemTM, Decrease LOS and
LiDCOrapidTM complications [32]
Systolic pressure PiCCOplusTM None [33]
variation
Flow indices
Oxygen delivery PAC, LiDCOplusTM, Decrease mortality [35-38],
Vigileo/FloTracsystemTM decrease complications [35-
38,64,65,68], none [66]
Cardiac index PAC Decrease complications [39],
none [40-43]
Indices of adequacy of
perfussion
Venous oxygen PAC None [52]
saturation
Oxygen extraction ratio Blood gas Decrease complications [53]
TM TM
LiDCO plus , LiDCO system (LiDCO Ltd, London, UK); LiDCOrapid , LiDCO system (LiDCO); LOS, length of stay; PAC,
pulmonary artery catheter; PiCCOplusTM, PiCCO system (Pulsion Medical Systems AG, Munich, Germany); TED,
transesophageal Doppler, Vigileo, Vigileo system (Edwards, Invine, CA, USA).
Gambar 2 Algoritme untuk optimalisasi hemodinamik peroperatif pada pasien yang menjalani
operasi mayor

Major surgeries at risk of significant volume shifts during surgery (bleeding

or other significant intravascular volume losses).

Minimally Invasive Cardiac Output (CO) monitoring – Continuous DO2

Fluid responsiveness testing

Optimalization of dynamic indices of preload

If inadequate CO or blood pressure.

decrease in urine output or signs of
hypoperfusion

Fluid responsiveness testing

Positive Negative

Fluids Inotropes or vasopressors

Gambar 2 Algoritme untuk optimalisasi hemodinamik peroperatif pada pasien-pasien risiko
tinggi yang menjalani operasi mayor

Major surgeries at
Major surgeries at risk
risk of
of significant
significant volume
volume shifts
shifts during surgery (bleeding
during surgery (bleeding or
or
other significant
other significant intravascular volume losses).
intravascular volume losses).

High-risk patient

Age > 60 years

Functional limitation of one or more organ system

Multiple comorbidities

Shoemalkers’s criteria

Minimally Invasive Cardiac Output (CO) monitoring-Continuous DO2

Fluid responsiveness testing

Optimization of dynamic indices of preload

Start dobutamine
maximize DO2
2

If inadequate CO or blood pressure,

decrease in urine output or signs of
hypoperfusion

Fluid responsiveness testing

Intensive Care Unit – 8h of GDT

Target DO2 – tissue perfusion goals

Gambar 1. Contoh strategi optimalisasi hemodinamik

Optimalisasi Hemodinamik Perioperatif

Evaluasi Hantaran Oksigen (Oxygen Delivery)

CO Hb SaO2

Jika di luar batas normal, periksa ada tidaknya gangguan VO2

Disfungsi organ Netto ambilan

spesifik (uptake) oksigen

Jika VO2 terganggu atau suboptimal, usahakan untuk menormalkan DO2

Nilai kembali VO2 (metabolic track)

Jika VO2 masih terganggu, pertimbangkan untuk optimalisasi VO2

Gambar 1. Algoritma pendekatan penderita dengan hipertensi tidak terdiagnosis sebelumnya yang akan
menjalani pembedahan dan anestesi

Hipertensi Bedah
Hipertensi Bedah Berencana Bedah
Berencana Asimptomatik
Dilanjutkan

Bedah
BedahDarurat
Darurat
Simptomatik TDS < 180 mmHg
Teknik
Anestesi
Teknik Anestesi yang Sesuai
Teknik Anestesi TDS > 180 mmHg
yang Sesuai
yang Sesuai atau TN > 80
untuk
untuk mmHg
Kendalikan TD
Kendalikan TD
Optimalisasi
Cari Penyakit End- Tatalaksana
Bedah Organ Medik
Bedah
Dilanjutkan
Dilanjutkan

Gambar 1 suatu pendekatan yang sistematis untuk penatalaksanaan hemodinamik

Hemodynamic
Hemodynamic Management
Management

Control Rate & Rhytm

Optimize Preload

Enhance Contractility

Decrease Increase
Increase
Excessive SVR Inadequate
InadequateSVRSVR
Gambar 2 Farmakoterapi gagal jantung

Combination Inodilator + Vasoconstrictor

Therapy

Milrinone 0.25-0.5 mcg/kg/min

Dobutamine 2-5 mcg/kg/min

Norepinephrine 1-4 mcg/min

AVP 1-4 u/hr

 Contraction

Gambar 5. Interaksi antara platelet dan sel endotel. A. normal endotel : agregasi

Agregating platelets

− ADP 5-HT TXA2

+
Endothelial cell Prostacyclin NO

Smooth muscle
Relaxation Contraction
cell

Agregating platelets

ADP 5-HT TXA2

Dysfunctional
Dysfunctional
endothelium Prostacyclin↓↓
Prostacyclin NO
NO↓↓
endothelium

Smooth
Relaxation
Relaxation
muscle cell

BB
Gambar 11 dan gambar 12 gabung (blm fix)

Major surgeries at risk of significant volume shifts during surgery (bleeding

or other significant intravascular volume losses).

Minimally Invasive Cardiac Output (CO) monitoring – Continuous DO2

Fluid responsiveness testing

Optimalization of dynamic indices of preload

If inadequate CO or blood pressure.

decrease in urine output or signs of
hypoperfusion

Fluid responsiveness testing

Positive Negative

Fluids Inotropes or vasopressors

Frank starling

Pulse variation Filling pressure

domain domain

Stroke
Frank – Starling curve
volume
cardiac Normal
output
SV optimization

Diastolic
dysfunction
Systolic
dysfunction
SV optimization

Compliance curve
End
diastolic
pressure Diastolic
dysfunction

Normal
Systolic dysfunction

Pulse pressure variations

Arterial Normal
pressure
Diastolic
dysfunction

Systolic
dysfunction

End-diastolic volume