GENRAL

ANAESTHESIA
Preseptor : dr. Fauzi Abdillah Susman, Sp.An, MSc

Presentan : Elsa Nur Rahma Diahnissa (2016730030)

KEPANITERAAN KLINIK ILMU ANESTESI

RSUD SEKARWANGI
UNIVERSITAS MUHAMMADIYAH JAKARTA
2021
 Agenda Style
 Name : Mr. AS

 Age : 24 years

 Date of birt : 15 September 1997

 Gender : Male.

 Address : Cijulang

 Date of entry : 14th September 2021

 Operation date : 15th September 2021

ANAMNESIS

Main Complaint

A lump on the neck the right side

since 3 months before in
Current Medical
hospital History
The patient came to the Sekarwangi Hospital with
complaints of a lump on the neck the right side since 3
months before, a lump grew more and more. Sometimes
a lump felt pain. Cough, flu fever is denided.
ANAMNESIS

Past Medical
History

 Hipertension, DM, asthma, and Family History of

cardiovaskular disease (-). Illlness
 TBC (-)
 Hipertension, DM, asthma (-).
 TBC (-)
ANAMNESIS
A history of allergies

History of allergies to food, drink, drugs and weather is denied

Medical history

The patient has never been and is not currently on long-term medication

Psychosocial history

The patient is a security, alcohol consumption(-)

PHYSICAL EXAMINATION

General circumstances

General circumstances : Looks moderately ill.

Awareness : Compos mentis (GCS 15)

Vital sign

 Blood pressure : 100/60 mmHg

 Heart rate : 82x/ minute
 Respiratory rate : 20x/ minute
 Temperature : 36.5o C

Anthropometric status

 Weight : 65 kg
 Height : 169 cm
 IMT : 22,75 kg/m2 (normoweight)
PHYSICAL EXAMINATION

 Head : Normocephal, symmetric, black hair, dan even distribution.

 Eyes : Conjunctiva anemic (-/-), icteric sclera (-/-), light reflex (+/+)

 Nose : Secretions (-/-), blood (-/-), septum deviation (-)

 Ears : Normotia (+), secretions (-/-), blood (-/-)

 Mouth : Moist lip mucosa, cyanosis (-)

 Neck : Enlarged lymph nodes (-/+), enlarged thyroid gland (-)

PHYSICAL EXAMINATION
 Lung
• Inspection : Symmetric, retraction of the thorax wall (-/-)
• Palpation : Vocal fremitus was palpable in both fields.
• Percussion : Sonor in all lung fields.
• Auscultation : Vesicular (+/+), ronkhi (-/-), wheezing (-/-)

 Heart
• Inspection : Ictus cordis is not visible.
• Palpation : Ictus cordis is palpable.
• Percussion : Left border of ICS IV left midclavicularis line.
Right border of ICS IV right parasternalis line.
• Auscultation : Pure regular I and II heart sounds, murmur (-), gallop (-)
PHYSICAL EXAMINATION

 Abdomen
• Inspection : The abdomen look flat, distention (-),
• Auscultation : Bowel sounds (+) normal (8x/minute)
• Palpation : Tenderness (+), no palpable enlargement of the liver and spleen.
• Percussion : Tympanic in all areas of the abdomen.

 Extremities
• Upper : CRT < 2 second, warm perifer body (+/+), oedema (-/-)
• Lower : CRT < 2 second, warm perifer body (+/+), oedema (-/-)
SUPPORTING EXAMINATION
Examination Result Unit Reference value
Haemoglobin 14.4
g/dl 13 - 16
Leukosit 10.200
/mm3 4.0 -11.0
Eritrocyt 5.03
/mm3 4.5 billion- 5.5 billion
Trombosit 348
/mm3 150.000 – 400.000
Count the number of leukocytes
Eosinophil 0
Basophil 0
Rod 0
Segment 75
Lymphosyt 20
Monocyt 5
SUPPORTING EXAMINATION
Examination Result Unit Reference value
Hematokrit 42
% 41 – 53
Cloting time 6 Minutes 3-7
Bleeding time 2
Minutes 1-3
Blood type+rhesus A Rh(+)
Blood creatinine 1,3
mg/dL 0.6 – 1.1
Blood ureum 19
mg/dL 10 – 50
Blood glucose level 81 mg/dL < 180
SGOT 11 U/L 25
SGPT 10 U/L 29
HbsAg Non reactive index Non reactive
HIV Non reactive index Non reactive
 SUPPORTING EXAMINATION
Examination Result Unit Reference value
Chemical clinic
Natrium 140
mmol/L 135 – 155
Kalium 4.4
mmol/L 3.6 – 5.5

X-ray

Cor and pulmo normal

DIAGNOSIS

 Pre surgical diagnosis : Lympadenopathy colli dextra

 Anesthetic diagnosis : ASA I

 Anesthetic action plan : General Anesthesia

PRE OPERATION

Preoperative preparation :

 Operation and Anesthesia approval letter.

 Fasting 6 hours.

 Premedication: Ondansentron 4 mg.

PRE OPERATION

Anesthetic measures, preparations :

 Setting up the operating table

 Prepare anesthesia machines and equipment

 Prepare STATICS and General Anesthesia Components.

 Prepare the necessary anesthetic drugs

 Prepare resuscitation drugs: Atropine 0.25 mg, Ephedrine 50 mg / mL.

 Prepare the infusion pole and plaster.

ANESTHETIC PREPARATIONS

 The patient was given a pre-medication in the form of Ondansentron 4 mg.

 The patient on supine position.

 Anasthesia drugs : Fentanyl 130 mcg IV, Propofol 65 mg IV and Noveron 39 mg IV

 Giving the intubation via oropharyngeal

INTRAOPERATIVE VITAL SIGNS

Time Blood Pressure Heart rate SpO2

14:15 119/69 mmHg 68 x/minute 99

14:30 95/53 mmHg 69 x/minute 99

14:45 95/53 mmHg 67 x/minute 99

FLUID MONITORING

Maintenance (M) needs → weight : 65 kg.

 10 kg I = 10 kg x 4 cc/kgBB/hour = 40 cc/hour.
 10 kg II = 10 kg x 2 cc/kgBB/hour = 20 cc/hour.
 The rest = 45 kg x 1 cc/kgBB/hour = 45 cc/hour.
 Total = 105 cc/hour.

Evaporation (E) :
 Stressed operative → moderate (4-6 cc/kgBB/hour)  5 x 65 kg = 325 cc.

Devicite (D) Fasting replacement fluid.

 Long fasting x maintenance = 6 hour x 105 cc/hour = 630 cc.

 1st hour : M + E + ½ D  105 + 325 + ½ 630 = 745 cc

POST OPERATIVE STATE

General circumstances Vital Sign

 General circumstances:  BP : 110/69 mmHg

Looks moderately ill.  HR: 68 x/menit
 Awareness :  RR : 20 x/menit
Composmentis  SpO2: 99%

Length of operation : 30 minutes.

POST OPERATIVE STATE

The patient moved to the room,

because the score was 9.
POST SURGICAL THERAPY

Rest in bed.

Observation of General Conditions, Vital Sign, Operation Wound Bleeding.

Patients can eat and drink if they are not nauseous and vomiting.

Ondancetron 4 mg for nausea.

RL 500 cc (20 tpm).

Other therapies according to the doctor in charge.
TINJAUAN PUSTAKA
 Definition

General anesthesia is an altered physiological state characterized by :

• Reversible loss of consciousness
• Analgesia, amnesia
• Some degree of muscle relaxation.

Tachnique
Induction of GA is usually accomplished by inhalation or intravenous drug administration.
GA is maintained with a total intravenous anesthesia (TIVA) technique, an inhalation technique, or a
combination of the two.
 Pre Operation
• Anamnesis : nutritional and functional status; cardiac, pulmonary, endocrine, kidney, or liver function;
electrolytes or metabolism; and anatomic issues relevant to airway management or regional anesthesia
• Physical Examination
• Airway : Includes Mallampati score, thyromental distance, cervical motion
• Cardiovascular: complete exam with a focus on murmurs or rubs, check for bruits
• Respiratory: complete exam with a focus on wheezes or crackles
• Neurologic: complete exam, note any deficits discovered and compare to old records
• Extremities: complete exam, note any clubbing, deformities, bruising, and gauge level of difficulty for IV
access
• Additional Information
• EKG
• Labs, etc
• ASA (American Society of Anesthesiologists) Status Classification
 Pre Medication

Administering medication 1-2 hours before induction anesthesia , for the purpose:
1. Relieve anxiety and fear
2. Facilitate the induction of an anesthetic
3. Decreasing the secretion of the bronchi and the salivary glands
4. Minimize the quantity of medicine anestetik
5. Alleviates nausea and vomiting after surgical  adult : droperidol 2,5-5 mg or ondancetron 2-4 mg)
6. Created amnesia
7. Reduce the gastric juices  histamine H2 receptor (cimetidine oral 600mg or rhanitidine oral 150 mg) 1-2
hours before operation
8. Reduce their reflex
 A Preparation
Machine anesthesia Endotracheal tube (ETT)

Sungkup Muka Laringeal Mask Airway = LMA

 Induction General Anesthesia

S : Scope  A stethoscope for listening to the sounds pulmonary and heart.Laringoskop select blades or
leaves ) ( blade appropriate with age patients.Must be quite bright light.
T : Tubes  Pipe the trachea.Choose in accordance age. Children less than 5 years without balloons
(cuffed) and more than 5 years with balloons (cuffed)
A : Airway  Pipe mouth-pharing (Guedel,orotracheal airway) and pipe nose-pharing (naso-tracheal
airway). This pipe for hold the tongue when patient is unconscious to keep us the tongue is not clog the
airway .

T : Tape  Plaster to fixation may not pipe out or up

I : Introducer  Mandrin or stillet to guide to the trachea easily put pipe
C : Connector  To connect between the tubing and anesthesia equipment
S : Suction  To vacuum mucus , spittle , etc.
Intavena induction
A drug injected in induction bolus of speed between 30-60 seconds. For induction anestesia, breathing, pulse
and blood pressure patients needs to be done and always given oxygen. Induction this way is done on a
cooperative patient.
Drugs :
• Barbiturates
• Benzodiazepines
• Ketamine
• Etomidate
• Propofol
• Fospropofol
• Dexmedetomidine
 Inhalation induction

• Halotan induction propelling gas needs O2 or mix N2O and O2. Induction began with the flow
of O2 >4L/ minute or mix N2O:O2=3:1 flows >4L/ minute. Begins with halothane vol 0,5 % to
concentration needed.
• Inhalation anesthetics, notably halothane and sevoflurane, are particularly useful in the
induction of pediatric patients in whom it may be difficult to start an intravenous line.
• Induction with enfluran ( etran ) , isofluran ( foran , aeran ) , or desfluran rare .
 Post Operation
PACU recovery and discharge scorings (modified Aldrete score)
 ‫‪THANK‬‬
‫‪YOU‬‬
‫ح َم ُة اهللِ َو َب َر َكاتُ ُه‬
‫السال َ ُم َعلَيْك ُ ْم َو َر ْ‬
‫َو َّ‬ ‫‪32‬‬
FLUID MONITORING
 First hour : Maintenance + (½ x fasting replacement
fluid) + stressed operative.
 1105 + (½ x 684) + 370 = 826 cc.

 Second hour : Maintenance + (¼ x fasting replacement

fluid) + stressed operative.
 114 + (¼ x 684) + 370 = 655 cc.

 Third hour : Maintenance + (¼ x fasting replacement

fluid) + stressed operative.
 114 + (¼ x 684) + 370 = 655 cc.

 The fourth hour : Maintenance + stressed operative.

 114 + 370 = 484 cc.
Inhalation induction