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Tugas Akhir
PENGARUH INFILTRASI LOKAL LEVOBUPIVAKAIN PADA
PASIEN DENGAN FRAKTUR COLLUM FEMUR YANG
DILAKUKAN HEMIARTHROPLASTY AUSTIN MOORE
PROSTHESIS DI RS ORTOPEDI PROF. DR. R. SOEHARSO
SURAKARTA
Oleh :
Zen Firhan
Pembimbing :
dr. Ismail Mariyanto, Sp.OT (K)
dr. Mujaddid Idulhaq, Sp.OT (K), M.Kes.
PROGRAM PENDIDIKAN DOKTER SPESIALIS - I
ORTHOPAEDI DAN TRAUMATOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS SEBELAS MARET
RS DR. MOEWARDI / RS ORTOPEDI PROF. DR. R. SOEHARSO
SURAKARTA
2016
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PENGARUH INFILTRASI LOKAL LEVOBUPIVAKAIN PADA
PASIEN DENGAN FRAKTUR COLLUM FEMUR YANG
DILAKUKAN HEMIARTHROPLASTY AUSTIN MOORE
PROSTHESIS DI RS ORTOPEDI PROF. DR. R. SOEHARSO
SURAKARTA
(Tugas Akhir)
Zen Firhan*, Ismail Mariyanto**, Mujaddid Idulhaq***
*Residen Orthopaedi dan Traumatologi, FK Universitas Sebelas Maret
**Staf Pengajar Orthopaedi dan Traumatologi FK. Universitas Sebelas Maret, RSUD Dr. Moewardi, RSO Prof. DR.R
Soeharso, Surakarta
*** Staf Pengajar Orthopaedi dan Traumatologi FK. Universitas Sebelas Maret, RSUD Dr. Moewardi, RSO Prof. DR.R
Soeharso, Surakarta
ABSTRAK
Latar Belakang : Fraktur collum femur merupakan fraktur yang sering terjadi
pada pasien usia lanjut, dan penyebab umum kehilangan fungsional akibat nyeri
yang menetap atau keterbatasan mobilitas. Salah satu pilihan terapi pada fraktur
collum femur adalah Hemiarthroplasty menggunakan implant Austin Moore
Prosthesis, yang masih merupakan pilihan utama karena implant yang cukup
murah dan teknik operasi yang relatif mudah. Tindakan Hemiarthroplasty
bertujuan menghilangkan nyeri dan agar pasien dapat menjalani rehabilitasi
mobilisasi sesegera mungkin. Namun untuk mencapai target tersebut seringkali
terkendala oleh nyeri pasca operasi yang dirasakan oleh pasien, khususnya 24 - 48
jam setelah operasi. Infiltrasi Lokal (Levobupivakain) merupakan salah satu
metode yang digunakan untuk mengurangi nyeri pasca operasi. Telah banyak
dilakukan penelitian yang menjelaskan manfaat metode ini dalam menurunkan
nyeri pasca operasi, dan membantu proses rehabilitasi pasien. Oleh karena itu
Peneliti mencoba mengevaluasi pengaruh Infiltrasi Lokal Levobupivakain pada
pasien dengan fraktur collum femur yang dilakukan Hemiarthroplasty Austin
Moore Prosthesis di RS Ortopedi Prof. Dr. R. Soeharso Surakarta.
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Pasien dan Metode : Penelitian ini dilakukan dengan metode Experimental
Clinical Trial dan Total Consecutive Sampling untuk semua pasien yang datang
ke RS Ortopedi Prof. Dr. R. Soeharso Surakarta dengan fraktur collum femur dan
dilakukan Hemiarthroplasty Austin Moore Prosthesis antara bulan Juli 2016 –
September 2016. Sampel dibagi menjadi 2 kelompok, yaitu kelompok yang diberi
Infiltrasi Lokal Levobupivakain, dan kelompok kontrol yang tidak diberi Infiltrasi
Lokal Levobupivakain. Kemudian dilakukan evaluasi nyeri pasca operasi
menggunakan VAS pada 12 jam, 24 jam, 36 jam, dan 48 jam pasca operasi, serta
kemampuan mobilisasi pasca operasi pasien pada masing-masing kelompok.
Hasil : Sebanyak 64 pasien telah dianalisa dan diteliti, terdapat 9 pasien pria dan
55 pasien wanita. Usia rata-rata adalah 70,95 tahun. Terdapat perbedaan secara
signifikan (p = 0,00) pada kelompok yang diberikan Infiltrasi Lokal
Levobupivakain untuk nilai nyeri pasca operasi (VAS 12 jam = 4,7188, 24 jam =
4,000, 36 jam = 3,3125, 48 jam = 2,3438), dibandingkan dengan kelompok
kontrol (VAS 12 jam = 5,5312, 24 jam = 5,0938, 36 jam = 4,6250, 48 jam =
3,5625), dimana nilai VAS yang lebih rendah didapatkan pada kelompok yang
diberikan infiltrasi lokal. Juga terdapat perbedaan secara signifikan (p = 0,00)
pada kemampuan mobilisasi pasien pasca operasi kelompok yang diberikan
Infiltrasi Lokal Levobupivakain (5,6562) dibandingkan kelompok kontrol
(2,4688), dimana mobilisasi yang lebih tinggi didapatkan pada kelompok yang
diberikan infiltrasi lokal.
Kesimpulan : Pada penelitian ini dapat disimpulkan bahwa Infiltrasi Lokal
Levobupivakain berpengaruh dalam menurunkan nyeri pasca operasi dan
meningkatkan kemampuan mobilisasi pasien dengan fraktur collum femur yang
dilakukan Hemiarthroplasty Austin Moore Prosthesis di RS Ortopedi Prof. Dr. R.
Soeharso Surakarta.
Kata Kunci : Fraktur Collum Femur, Hemiarthroplasty, Austin Moore
Prosthesis, Infiltrasi Lokal, Levobupivakain
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THE EFFECT OF LEVOBUPIVACAINE LOCAL
INFILTRATION ON PATIENTS WITH FEMORAL NECK
FRACTURE TREATED WITH HEMIARTHROPLASTY
AUSTIN MOORE PROSTHESIS AT PROF. DR. R. SOEHARSO
ORTHOPAEDIC HOSPITAL SURAKARTA
(Final Paper)
Zen Firhan*, Ismail Mariyanto**, Mujaddid Idulhaq***
* Orthopaedic and Traumatology Resident, Faculty of Medicine Sebelas Maret University
** Teaching Staff Orthopaedic and Traumatology Residency, Faculty of Medicine Sebelas Maret University, Dr.
Moewardi General Hospital, Prof. Dr. R Soeharso Orthopaedic Hospital, Surakarta
*** Teaching Staff Orthopaedic and Traumatology Residency, Faculty of Medicine Sebelas Maret University, Dr.
Moewardi General Hospital, Prof. Dr. R Soeharso Orthopaedic Hospital, Surakarta
ABSTRACT
Background : Femoral neck fracture are fractures that commonly occur in
elderly patients, and a common cause of functional loss as a result of persistent
pain or limited mobility. A treatment option in femoral neck fracture is
Hemiarthroplasty using Austin Moore Prosthesis, which is still the main choice of
treatment that are reasonably low cost and relatively easy surgical technique.
Hemiarthroplasty aimed at the relief of pain so that patients can undergo
mobilization as soon as possible. However, these targets is often constrained by
postoperative pain experienced by the patient, especially 24 - 48 hours after
surgery. Local infiltration (Levobupivacaine) is one method used to reduce
postoperative pain. A lot of research has been done which explain the benefits of
this method in reducing postoperative pain, and assisting mobilization of patients.
Therefore, we tried to evaluate the effect of Levobupivacaine local infiltration in
patients with femoral neck fracture treated with Hemiarthroplasty Austin Moore
Prosthesis at Prof. Dr. R. Soeharso Orthopaedic Hospital, Surakarta.
Patients and Methods : This research was conducted using Experimental
Clinical Trial and Total Consecutive Sampling for all patients who came to Prof.
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Dr. R. Soeharso Surakarta Orthopaedic Hospital with femoral neck fracture and
treated with Hemiarthroplasty Austin Moore Prosthesis between July 2016 until
September 2016. The samples were divided into 2 groups, that is a group given
Levobupivacaine Local Infiltration, and a control group who were not given the
Levobupivacaine Local Infiltration. Then we evaluate postoperative pain using the
VAS with interval 12 hours, 24 hours, 36 hours, and 48 hours post-surgery, as
well as the patient’s ability to mobilize postoperatively in each group.
Results : A total of 64 patients have been analyzed and studied, there are 9 male
patients and 55 female patients. The average age is 70,95 years. There is a
significant difference (p = 0.00) in the group given the Levobupivacaine Local
Infiltration for postoperative pain score (VAS 12 hours = 4.7188, 24 hours =
4,000, 36 hours = 3.3125, 48 hours = 2.3438 ), compared with the control group
(VAS 12 hours = 5.5312, 24 hours = 5,0938, 36 hours = 4.625, 48 hours =
3.5625), where the lower VAS score belong to group given local infiltration.
There is also a significant difference (p = 0.00) for patient’s ability to mobilize
postoperatively in the group given the Levobupivacaine Local Infiltration
(5,6562) than the control group (2,4688), where the higher mobilization belong to
group given local infiltration.
Conclusion : In this study it can be concluded that Levobupivacaine Local
Infiltration has the benefit in reducing postoperative pain and improving
mobilization of patients with femoral neck fracture treated with Hemiarthroplasty
Austin Moore Prosthesis at Prof. Dr. R. Soeharso Orthopaedic Hospital,
Surakarta.
Keywords : Femoral Neck Fracture, Hemiarthroplasty, Austin Moore
Prosthesis, Local Infiltration, Levobupivacaine
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DAFTAR ISI
HALAMAN JUDUL .................................................................................... i
KATA PENGANTAR .................................................................................. ii
HALAMAN PENGESAHAN ...................................................................... iii
ABSTRAK .................................................................................................... iv
DAFTAR ISI ................................................................................................. viii
DAFTAR GAMBAR .................................................................................... xii
DAFTAR TABEL ......................................................................................... xiii
DAFTAR SINGKATAN .............................................................................. xv
BAB I. PENDAHULUAN ............................................................................ 1
1.1. Latar Belakang Masalah ................................................................... 1
1.2. Perumusan Masalah .......................................................................... 3
1.3. Tujuan Penelitian .............................................................................. 4
1.3.1. Tujuan Umum ....................................................................... 4
1.3.2. Tujuan Khusus ...................................................................... 4
1.4. Manfaat Penelitian ............................................................................ 4
1.4.1. Manfaat Teoritik ................................................................... 4
1.4.2. Manfaat Praktis ..................................................................... 5
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BAB II. TINJAUAN PUSTAKA ................................................................. 6
2.1. Fraktur Collum Femur ........................................................................... 6
2.1.1. Anatomi Sendi Panggul .......................................................... 6
2.1.2. Mekanisme Fraktur ................................................................. 9
2.1.3. Gejala Klinis ........................................................................... 10
2.1.4. Pemeriksaan Penunjang .......................................................... 10
2.1.5. Klasifikasi ............................................................................... 11
2.1.6. Penatalaksanaan ...................................................................... 13
2.2. Hemiarthroplasty Austin Moore Prosthesis ........................................... 16
2.2.1. Teknik Operasi ....................................................................... 16
2.2.2. Rehabilitasi ............................................................................. 19
2.3. Nyeri ...................................................................................................... 20
2.3.1. Patofisiologi Nyeri .................................................................. 21
2.3.2. Nyeri Pasca Operasi ................................................................ 24
2.3.3. Penilaian Nyeri ........................................................................ 25
2.4. Anestesi Infiltrasi Lokal ......................................................................... 28
2.4.1. Mekanisme Kerja Anestetikum Lokal .................................... 29
2.4.2. Jenis-jenis Obat Anestesi Infiltrasi Lokal ............................... 31
2.4.3. Faktor-Faktor Yang Mempengaruhi Mula dan Masa Kerja ... 32
2.4.4. Levobupivakain ....................................................................... 37
2.4.4.1. Struktur Kimia ......................................................... 37
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2.4.4.2. Farmakodinamik ...................................................... 38
2.4.4.3. Farmakokinetik ........................................................ 39
2.4.4.4. Aplikasi Klinik ........................................................ 40
2.4.5. Anestesi Infiltrasi Lokal dan Manajemen Nyeri Pasca Operasi 40
2.6. Kerangka Konsep Teori ......................................................................... 43
2.7. Hipotesis ................................................................................................ 43
BAB III. METODE PENELITIAN .............................................................. 44
3.1. Jenis Penelitian ...................................................................................... 44
3.2. Lokasi Penelitian .................................................................................... 44
3.3. Objek Penelitian ..................................................................................... 44
3.4. Besar Sampel ......................................................................................... 45
3.5. Pengambilan Sampel .............................................................................. 45
3.5.1. Kriteria Inklusi ........................................................................ 45
3.5.2. Kriteria Eksklusi ..................................................................... 46
3.6. Identifikasi Variabel ............................................................................... 47
3.6.1. Variabel Bebas ........................................................................ 47
3.6.2. Variabel Terikat ...................................................................... 47
3.6.3. Variabel Perancu ..................................................................... 47
3.7. Definisi Operasional Variabel ................................................................ 47
3.8. Alat dan Bahan Penelitian ...................................................................... 48
3.9. Instrumen Pengumpulan Data ................................................................ 49
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3.10. Langkah-langkah Penelitian ................................................................. 49
3.11. Rancangan Penelitian ........................................................................... 51
3.12. Analisis Data ........................................................................................ 51
BAB IV. HASIL DAN PEMBAHASAN ..................................................... 52
4.1. Hasil Penelitian ...................................................................................... 52
4.1.1. Karakteristik Data Pasien ....................................................... 52
4.1.2. Nilai VAS dan Kemampuan Mobilisasi ................................. 56
4.2. Pembahasan ........................................................................................... 60
BAB V. KESIMPULAN DAN SARAN ..................................................... 63
5.1. Kesimpulan ............................................................................................ 63
5.2. Saran ...................................................................................................... 64
DAFTAR PUSTAKA .................................................................................. 65
LAMPIRAN ................................................................................................ 69
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DAFTAR GAMBAR
Gambar 1. Struktur anatomi Femur proksimal ............................................. 7
Gambar 2. Struktur vaskularisasi pada collum femur ................................... 9
Gambar 3. Klasifikasi fraktur collum femur berdasarkan lokasi anatomis .. 13
Gambar 4. Klasifikasi fraktur collum femur menurut Pauwel ..................... 13
Gambar 5. Klasifikasi fraktur collum femur menurut Garden ..................... 14
Gambar 6. Implant Austin Moore Prosthesis ............................................... 18
Gambar 7. Incisi posterior approach (Moore), dan incisi dalam .................. 19
Gambar 8. Tahapan operasi Hemiarthroplasty Austin Moore Prosthesis ..... 21
Gambar 9. Proses neurofisiologis nyeri ...................................................... 25
Gambar 10. Wong-Baker Faces Pain Rating Scale ...................................... 27
Gambar 11. Verbal Rating Scale .................................................................. 28
Gambar 12. Numerical Rating Scale ............................................................ 28
Gambar 13. Visual Analogue Scale .............................................................. 29
Gambar 14. Mekanisme kerja anestesi pada membran sel ........................... 31
Gambar 15. Struktur kimia Levobupivakain ................................................ 38
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DAFTAR TABEL
Tabel 1. Nilai pKa anestetikum lokal ........................................................... 37
Tabel 2. Terapi penanganan nyeri yang direkomendasikan WHO .............. 43
Tabel 3. Distribusi pasien berdasarkan jenis kelamin .................................. 52
Tabel 4. Statistik usia rata-rata per kelompok .............................................. 52
Tabel 5. Statistik Independent T-test untuk usia .......................................... 53
Tabel 6. Statistik berat badan rata-rata per kelompok .................................. 53
Tabel 7. Statistik Independent T-test untuk berat badan .............................. 53
Tabel 8. Statistik tinggi badan rata-rata per kelompok ................................ 54
Tabel 9. Statistik Independent T-test untuk tinggi badan ............................. 54
Tabel 10. Statistik Body Mass Index rata-rata per kelompok ....................... 55
Tabel 11. Statistik Independent T-test untuk Body Mass Index .................... 55
Tabel 12. Statistik VAS 12 jam pasca operasi rata-rata per kelompok ........ 56
Tabel 13. Statistik Independent T-test untuk nilai VAS 12 jam pasca operasi 56
Tabel 14. Statistik VAS 24 jam pasca operasi rata-rata per kelompok ........ 57
Tabel 15. Statistik Independent T-test untuk nilai VAS 24 jam pasca operasi 57
Tabel 16. Statistik VAS 36 jam pasca operasi rata-rata per kelompok ........ 58
Tabel 17. Statistik Independent T-test untuk nilai VAS 36 jam pasca operasi 58
Tabel 18. Statistik VAS 48 jam pasca operasi rata-rata per kelompok ........ 59
Tabel 19. Statistik Independent T-test untuk nilai VAS 48 jam pasca operasi 59
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Tabel 20. Statistik kemampuan mobilisasi pasca operasi rata-rata per kelompok 60
Tabel 21. Statistik Independent T-test untuk kemampuan mobilisasi .......... 60
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DAFTAR SINGKATAN
CT Scan : Computed Tomography Scan
HA : Hemiarthroplasty
LIA : Local Infiltration Anesthesia
MRI : Magnetic Resonance Imaging
NADW : The National Arthritis Data Workgroup
NSAID : Non Steroid Anti Inflammation Drug
USG : Ultrasonography
VAS : Visible Analog Scale
WHO : World Health Organization