Presentasi Kasus Anestesiologi

disusun oleh:

Tommy Suryadi 07120090041Cynthia Chandra 07120090029Cindy Prayogo 07120090073

Irene S 07120090052

Pembimbing: dr. Shirly, SpAn 

LAPORAN KASUSHIDROSEFALUS non communicating

IDENTITAS PASIEN

Nama : Tn. A Umur : 62 tahun Agama : Islam Pendidikan : D3 Suku : Jawa Pekerjaan : Polisi Alamat : Jalan Remaja RT I/1 Kelurahan

Ceger Status : Menikah

ANAMNESA Tanggal masuk RS Said Sukanto

25 Maret 2013

Keluhan utama sakit kepala sejak 1 bulan yang lalu

Keluhan tambahan mual, pandangan mata kabur, gelisah,

Riwayat Penyakit Sekarang

Pasien datang dengan keluhan sakit kepala 1 bulan SMRS. Rasa nyeri ini dideskripsikan seperti berdenyut dan terdapat di seluruh bagian kepala.

Pasien biasanya akan mengonsumsi obat (paracetamol) untuk mengatasi sakit ini, namun 2-3 hari SMRS obat sudah tidak memberi perbaikan lagi.

Rasa nyeri ini diperparah saat pasien bekerja berat, mengedan untuk buang air besar, dan saat batuk. Rasa nyeri ini dirasakan sepanjang hari terutama saat bangun tiduri. Skala nyeri 4-5 saat 1 bulan SMRS dan menjadi 5-6 sekarang.

Rasa sakit kepala ini juga diikuti rasa mual namun tidak sampai muntah.

Pasien juga mengeluhkan pandangan matanya yang menjadi kabur sejak merasakan sakit kepala ini. Pasien menyangkal adanya perbaikan penglihatan dengan menggunakan kacamata baca. Pasien menyangkal adanya rasa silau pada penglihatan.

Keluhan-keluhan yang dialami pasien semakin hari semakin parah hingga pagi hari SMRS pasien menjadi gelisah karena rasa nyeri di kepala sehingga pasien akhirnya dibawa ke RS Said Sukanto.

Riwayat Penyakit DahuluPasien pernah mengalami pendarahan intrakranial 2-

3 bulan yang lalu dan telah dilakukan operasi; riwayat hipertensi disangkal; riwayat DM disangkal; riwayat asma disangkal; riwayat penyakit jantung disangkal

Riwayat Penyakit KeluargaRiwayat hipertensi disangkal; riwayat DM disangkal; riwayat asma disangkal; riwayat penyakit jantung disangkal  Riwayat KebiasaanMerokok - ; Konsumsi Alcohol –  Riwayat AlergiAlergi makanan maupun obat disangkal 

Pemeriksaan Fisik Umum

Keadaan umumtampak sakit sedang, pasien tampak gelisah.

KesadaranCompos Mentis

Tanda vitalSuhu tubuh : 36,4°CTekanan Darah : 120/70 mmHgNadi : 80/mnt Laju Nafas : 16/mnt

Tinggi badan : 167 cmBerat badan : 80 kg

 

Kepala Normocephali Rambut

Kuantitas rambut normal, tekstur normal, tidak rapuh, warna hitam, distribusi rambut normal , tidak ada alopesia sebagian atau total

  Mata

posisi mata dan alis sejajar , Kedua mata tidak cekung , konjungtiva pucat -/-, sclera ikterik -/-, terlihat adanya papil edema +/+

Telinga posisi aurikula normal, bengkak -/-, nyeri tekan

-/-, sekret -/- 

Hidung posisi hidung normal tidak ada sekret tidak ada pendarahan tidak ada nafas cuping hidung

Mulut dan faring bibir tidak sianosis, kering mukosa oral lembab, tidak ada luka gusi tidak ada pendarahan lidah normal uvula dan tonsil tidak membesar langit mulut tidak ada ada sumbing faring tidak hiperemis

  Leher

tidak ada luka tidak ada massa tidak ada pembesaran KGB

DadaInspeksi : bentuk dada normal, bentuk dan

pergerakan nafas simetris tidak ada gerakan yang tertinggal, tidak ada deformitas, ruam (-), benjolan (-), iktus cordis tidak tampak, retraksi (-)

Palpasi : tidak ada massa, tidak ada fraktur, tactile fremituss di kedua lapang paru normal, ekspansi dada normal dan simetris.

Perkusi : perkusi perbandingan pada kedua lapang paru sonor, perkusi perbatasan paru-hati di ICS 5 atau 6 kanan

Auskultasi: auskultasi paru vesicular di kedua paru, auskultasi jantung normal S1 dan S2, tidak ada suara tambahan jantung (gallop, murmur)

JVP : 5+2 cm, normal

Abdomen Inspeksi : perut cembung, tidak ada luka, tidak ada

bekas operasi, tidak ada massa Palpasi : tidak ada massa, tidak ada nyeri tekan,

tidak ada pembesaran hati dan limpa Perkusi : timpani pada 9 regio Auskultasi : Bising usus normal

Ekstremitas atas dan bawah Keduanya tidak ada bekas luka, tidak ada bekas

operasi, tidak ada tanda inflamasi, tidak ada tophus tes refleks di semua ekstremitas normal tes pergerakan sendi di semua ekstremitas normal CRT <2dtk

  Kulit

Turgor kulit normal Tidak ada sianosis

Pemeriksaan Penunjang

Hematologi Hb : 14,5 g/dl Ht : 42% Leukosit : 7500/ul Trombosit : 266000/ul Masa pendarahan : 2dtk Masa pembekuan : 11menit

Kimia Klinik Ureum 19mg/dl Creatinin 1,1mg/dl GDS 127mg/dl

CT SCAN Kepala terlihat pembesaran ventrikel kiri dan kanan

DIAGNOSISHidrosefalus non communicating

LAPORAN OPERASI

Pre-Operative

Informed Consent Memberi penjelasan kepada keluarga

pasien.

Anamnesis Riwayat operasi sebelumnya (+) Riwayat hipertensi dalam pengobatan

(-). Riwayat alergi obat dan makanan (-). Riwayat asma (-). Riwayat sakit jantung (-). Riwayat diabetes mellitus (-). Riwayat kejang(-)

Persiapan Pasien Puasa 8 jam sebelum operasi. Telah terpasang infus RL pada tangan

kiri 1 jam sebelum operasi. Pasien tidak menggunakan perhiasan

apapun. Pasien tidak menggunakan gigi palsu.

Persiapan Operasi Surat ijin operasi sudah ditandatangani

oleh keluarga pasien. Foto thorax ada. Hasil laboratorium ada. Foto CT-Scan ada. Surat konsultasi anestesi ada (acc

operasi). Surat konsultasi jantung dan hasil EKG

ada (acc operasi). Surat konsultasi penyakit dalam ada (acc

operasi)

Pemeriksaan Fisik

KU : pasien tampak sakit sedang dan gelisah

Kesadaran : CM (GCS 15)Tekanan Darah : 120/70 mmHgNadi : 84x/menit.Pernafasan : 16x/menit.Suhu : 36.5oC

Pemeriksaan 8T Teeth : tidak ada gigi tanggal, tidak ada gigi

palsu Tonsil : T1/T1. Tongue : bentuk dan ukuran lidah normal. Thyroid : tidak ada pembesaran kelenjar

tiroid. Tumor : (-). Torticollis : (-). Trakea : trakea di tengah. Jarak tiromental : 7 cm

AirwayHidung : deviasi septum -, cavum

nasi lapang +/+, sekret -/-, polip -/-Mulut : gigi tanggal -, gigi palsu -.

uvula di tengah, tonsil T1/T1, malampati score I, bentuk dan ukuran lidah normal.

Leher : trakea di tengah, pembesaran tiroid -, tumor -, tortikolis -.Jarak tiromental 7 cm

Breathing I : gerakan dinding dada simetris,

bentuk dada normal, retraksi interkosta -, retraksi suprasternal -

P: gerakan dada simetris, fremitus taktil kanan = kiri.

P: sonor pada kedua lapang paru.A: vesikuler +/+, ronkhi -/-, wheezing

-/-

CirculationAkral hangatCRT < 2 detikPulsasi a. Radialis teraba teratur,

kuat, penuh.A. Dorsalis pedis teraba teratur, kuat,

penuh.Sianosis

_ _

_ _

Sistem neurologis : tidak ada kelainan. Sistem gastrointestinal : tidak ada kelainan. Sistem kardiovaskular : tidak ada kelainan. Sistem respirasi : tidak ada kelainan. Sistem hematologi : tidak ada kelainan. Sistem hepatobilier : tidak ada

kelainan, hepar dan lien tidak teraba. Sistem genitourinarius : tidak ada kelainan Klasifikasi ASA II

Hasil laboratorium

Hematologi : Hb : 14,5 g/dL.HT : 42%Leukosit : 7500/µL Trombosit : 266.000/µLMasa perdarahan : 2 detik.Masa pembekuan : 11 menit

Kimia klinik Ureum : 19 mg/dL Kreatinin : 1,1 mg/dL Gula darah sewaktu : 127 mg/dL

Intra-operative

Langkah-langkah Siapkan stetoskop, peralatan anestesi

umum, obat – obatan yang dibutuhkan, monitor TTV, saturasi O2, oksigen, lampu untuk operasi, infus telah terpasang, aliran lancar.

Pukul 15.05 WIB, pasien dibaringkan pada posisi supine kemudian dipasangkan lead EKG, pulse oximeter dan lakukan TTV awal.

Pukul 15.10 pasien kemudian diberikan obat premedikasi anestesi yaitu fentanyl 250mcg.

Pukul 15.15 WIB pasien diberikan obat induksi intravena yaitu propofol 200 mg dan dilakukan preoksigenasi pemberian O2 100% 5Lpm selama ± 1 menit.

Sembari diberikan obat pelumpuh otot yaitu rocuronium 6 mg yang berfungsi untuk relaksasi otot dan memudahkan pemasangan intubasi.

Pukul 15.17 WIB, dilakukan prosedur intubasi. Perlengkapan intubasi yang digunakan adalah ETT no. 8 (dengan cuff) dengan laringoskop blade lengkung no. 3.

Setelah ETT terpasang segera dilakukan pemeriksaan auskultasi dengan stetoskop untuk memastikan apakah ETT masuk ke dalam paru-paru atau ke lambung. Setelah memastikan ETT masuk ke paru-paru, kemudian periksa apakah ETT masuk tepat ke bagian trakea dan tidak menembus terlalu dalam menuju bronkus.

Kemudian pasien diberikan maintenance dengan isovofluran 1,5%, N2O 2Lpm dan O2

2Lpm. Pukul 15.20 WIB operasi dimulai. Operasi

dimulai dengan TTV pasien sebagai berikut: Tekanan darah (TD) = 130/80 mmHg Nadi (N) = 70 x/ menit Laju pernafasan (P) = 12 x/menit

Pukul 15.30 WIB, pasien diberikan IV Ceftriaxone 2gr, TTV pasien sebagai berikut: TD = 110/70 mmHg N = 60 x/menit P = 11x/menit

Pukul 15.45 WIB, TTV pasien sebagai berikut: TD = 115/80 mmHg N = 70 x/menit P = 13 x/menit

Pukul16.00 WIB, TTV pasien sebagai berikut: TD = 90/65mmHg N = 78 x/menit P = 12 x/menit

Pukul 16.10 WIB, pasien diberikan Ketorolac 30 mg dan Tramadol 100 mg

Pukul16.15 WIB, TTV pasien sebagai berikut: TD = 110/75mmHg N = 60 x/menit P = 14 x/menit

Operasi selesai pada pukul 16.20 WIB dengan TTV pasien sebagai berikut:TD = 120/70mmHgN = 70 x/menitP = 14 x/menit

Pukul 16.40 WIB, anestesi selesai

Post-operative

Observasi TTV di ruang pemulihan setiap 15 menit selama 2 jam hingga aldrete score ≥ 9 Bila mual diberikan ondansentron 4 mg IV

Bila kesakitan diberikan tramadol 100 mg IV

Makan-minum bila tidak mual/muntah, Bising usus + normal

Cairan infus RL 0.9% 20 tpm.Bila ada tanda alergi berikan

dexamethasone 5 mg IV.Bed rest 24 jam

TINJAUAN PUSTAKA

HIDROSEFALUS The excessive accumulation of CSF results in an

abnormal widening of spaces in the brain called ventricles. This widening creates potentially harmful pressure on the tissues of the brain.

The ventricular system is made up of four ventricles connected by narrow passages.. Normally, CSF flows through the ventricles, exits into cisterns (closed spaces that serve as reservoirs) at the base of the brain, bathes the surfaces of the brain and spinal cord, and then reabsorbs into the bloodstream.

HIDROSEFALUS The balance between production and absorption of CSF

is critically important. Because CSF is made continuously, medical conditions that block its normal flow or absorption will result in an over-accumulation of CSF. The resulting pressure of the fluid against brain tissue is what causes hydrocephalus.

Hydrocephalus may be congenital or acquired. Congenital hydrocephalus is present at birth and may be caused by either events or influences that occur during fetal development, or genetic abnormalities. Acquired hydrocephalus develops at the time of birth or at some point afterward. This type of hydrocephalus can affect individuals of all ages and may be caused by injury or disease.

HIDROSEFALUS Acquired causes in adults:

Benign or malignant tumors Subarachnoid hemorrhage Head injury Idiopathic Infections : bacterial meningitis, cerebral

abscess Medication : infliximab

HIDROSEFALUS Hydrocephalus presents in one of two forms:

Non-communicating hydrocephalus is caused by a blockage in the ventricular pathway through which the CSF flows.

Communicating hydrocephalus is caused by the poor absorption of CSF when the pathways are not obstructed.

The most common ways for diagnosing hydrocephalus are the CT (computerized tomographic) scans and MRI (magnetic resonance imaging). They can accurately measure the size of the fluid spaces, or ventricles, within the skull.

The most common way is the surgical diversion of the excess fluid by placing a synthetic tube (shunt) into the ventricle.

Vp shunt

SHUNT A shunt is a tube that diverts the excess fluid from the

expanded brain cavity (ventricle) to another part of the body. This procedure re-directs the fluid to another body cavity such as the abdomen. In most cases, the fluid is diverted to the peritoneal cavity in the abdomen or one of the chambers of the heart.

A shunt is usually composed of three parts: a silicone catheter that enters the enlarged ventricle; a one-way valve that only allows flow away from the ventricle; and tubing which enters the cavity that is to receive the fluid. Each valve is designed to operate at a set pressure, so that a high-pressure valve will allow less fluid to flow through it than a low-pressure valve. A variety of valve designs are available and efforts are constantly underway to improve them. The entire shunt system is placed underneath the skin.

SHUNT

Although, shunting systems represent a major medical breakthrough, patients are still left vulnerable to complications, most notably obstruction or infection of the shunt. However, most people diagnosed with hydrocephalus live full and active lives.

SHUNT Despite their success rate, shunts have potential

problems. The most common complications are: Bacterial infection

Infected shunts are treated with antibiotics and the removal and replacement of the system. Infections are typically accompanied by fever, redness and swelling along the tubing under the skin. Drainage of infected liquid (pus) from one of the incisions used to insert the shunt may also occur.

Obstruction. When a shunt is obstructed it no longer is able to drain fluid

from the ventricles. This results in elevated intracranial pressure, causing headache, vomiting, lethargy, and sometimes double or blurred vision. Frequently such elevated pressure can be relieved temporarily by draining the shunt’s valve or reservoir with a needle. However, an operation to replace part or all of the shunt is generally required.

VP SHUNT

ANESTESI

PROPOFOL Propofol is 2,6-diisopropylphenol, a simple derivative of

phenol is an oil at room temperature and is essentially insoluble

in water onset: 40seconds duration: 3-5 minutes adverse effect : pain on injection, hypersensitivity

reactions clinical use:

induction of anesthesia 1-2,5 mg/kgBW maintenance sedation target controlled infusion

FENTANYL This potent synthetic opioid is extremely fat

soluble, which accounts forits rapid onset and relatively short duration

is used to treat breakthrough pain (sudden episodes of pain that occur despite round the clock treatment with pain medication) in cancer patients at least 18 years of age (or at least 16 years of age if taking Actiq brand lozenges) who are taking regularly scheduled doses of another narcotic (opiate) pain medication, and who are tolerant (used to the effects of the medication) to narcotic pain medications

dosis: 2-150 mcg/kg BW Onset: 2 menit Durasi: 45 menit

ROCURONIUM BROMIDE Neuromuscular blocking (paralyzing) agent indication: Skeletal muscle paralysis— onset: With doses of 0.6 – 1.2mg rocuronium per kg of

body weight administered over 5 seconds, effective intubating conditions are achieved within 60 to 70 seconds

duration: 30 minutes Rocuronium is indicated as an adjunct to general

anesthesia to facilitate rapid-sequence or routine tracheal intubation and to induce skeletal muscle relaxation during surgery or mechanical ventilation

Rocuronium is a nondepolarizing neuromuscular blocking agent with a rapid to intermediate onset of action, depending on dose, and with an intermediate duration of action. Rocuronium produces neuromuscular blockade by competing with acetylcholine for cholinergic receptors at the motor end plate

ROCURONIUM BROMIDE Rocuronium causes increases in heart rate of over 30% of

baseline in some patients. While the etiology of the tachycardia is believed to be multifactorial, vagal blockade may contribute to tachycardia. Rocuronium is more likely than vecuronium but less likely than pancuronium to cause tachycardia.

Rocuronium may cause histamine release. In a study of histamine release, 1 of 88 (1.1%) patients receiving rocuronium had clinically significant concentrations of histamine. In premarketing clinical trials, rocuronium administration was accompanied by clinical signs of histamine release (e.g., flushing, rash, or bronchospasm) in 9 of 1137 (0.8%) patients. No clinical evidence of histamine release was observed in the 45 patients enrolled in one study designed to provoke histamine release by the rapid injection of rocuronium

KETOROLAC Ketorolac is in a group of drugs called nonsteroidal anti-inflammatory drugs

(NSAIDs). Ketorolac works by reducing hormones that cause inflammation and pain in the body.

Dosage : 15 - 30mg IV Onset : 30 menit Durasi : 4-6 jam Ketorolac is used short-term (5 days or less) to treat moderate to severe pain. Ketorolac may also be used for other purposes not listed in this medication

guide. This medicine can increase your risk of life-threatening heart or circulation

problems, including heart attack or stroke. This risk will increase the longer you use ketorolac. Do not use this medicine just before or after having heart bypass

surgery (also called coronary artery bypass graft, or CABG). Do not use this medication if you are allergic to ketorolac, aspirin, or other

NSAIDs, or if you have: severe kidney disease; a bleeding or blood clotting disorder; a closed head injury or bleeding in your brain; a stomach ulcer or a history of stomach or intestinal bleeding; or if you are breast-feeding a baby.

TRAMADOL Tramadol is a narcotic-like pain reliever. Tramadol is used to treat moderate to severe pain. Tramadol

extended-release is used to treat moderate to severe chronic pain when treatment is needed around the clock.

Dosage : 50-100mg IV ; maximum dosage 400mg/day You should not take this medication if you are allergic to

tramadol, if you have ever been addicted to drugs or alcohol, or if you have ever attempted suicide. Do not take tramadol while you are intoxicated (drunk) or taking any of the following: alcohol or street drugs, narcotic pain medicine, sedatives or tranquilizers, or medicine for depression, anxiety, or mental illness.

Seizures (convulsions) have occurred in some people taking this medicine. Tramadol may be more likely to cause a seizure if you have a history of seizures or head injury, a metabolic disorder, or if you are taking certain medicines such as antidepressants, muscle relaxers, narcotic, or medicine for nausea and vomiting.

CEFTIZOXIME Third generation cephalosporin Pharmacokinetics

Ceftizoxime is given parenterally. It is not metabolised in the body and is excreted through the kidneys. Plasma half life is 1.5-2 hours.

Indications Ceftizoxime is a third generation cephalosporin that is used in the treatment

of meningitis, intra-abdominal infections, respiratory infections, skin and soft tissue infections, bone and joint infections, obstetric and gynaecological infectins. It is active against aerobic gram negative bacteria and some gram gram positive bacteria. Not very active against bacteroides,pseudomonas and staph.aureus

Routes of Administration and Dosage For bacterial infections: For injection dosage form in Adults : 0.5 -1 gms I.M

or I.V every eight to twelve hours. Contra Indications

Ceftizoxime is contraindicated in renal disease, pregnancy, lactation, infants less than one month of age, and hypersensitivity .

Precautions Precautions are to be taken in renal failure, hypersensitivity to penicillins,

and pseudomembranous colitis. Interactions

Probenicid reduces the renal clearance of Ceftizoxime. Chlorampenicol reduces the drug's activity.