4th Plenary

By Group 15C

Members

Fitri Yani
Aulia Rahmi
Noprianty Eka Pratiwi
Rian Rizki Ananda
Maulina Hanisyah
Novi Jamilah
Putri Pratiwi
Ismi Mulya Afti

Step 1 - Terminology

1. Ileus obstruction : hypomotility of the

gastrointestinal tract caused by smalll or large
bowel obstruction.
2. Laparatomy : a surgical procedure involving a
large incision through the abdominal wall to gain
access into the abdominal cavity.
3. ASA Physical Status III : Patients with severe
systemic disease, no immediate danger of death.

1. General anesthesia : is commonly produced by a

combination

of intravenous drugs

and

inhaled

gasses. It makes you both unconscious and unable

to feel pain during medical procedures.
2. Stage III (stage of surgical anesthesia): from onset
of automatic respiration to respiratory paralysis.
Plane II : from cessation of eyeball movements to
beginning
Plane

of paralysis of intercostal muscles.

III

from

intercostal muscle

beginning

paralysis.

to

completion

of

Step 2 Problem
Identification

1. Why it is needed in preparation for surgery for

emergency action with the diagnosis of
obstructive ileus high layout ec suspected
malignancy and what preparations ?
2. why is the action plan laparotomy surgery ?
3. what are the implications of COPD and eat the
last four hours ago with the next action ?
4. how is the interpretations of the general state of
Na and K to normal ?
5. Why is planned general anesthesia ? what
indications ?
6. Why the patient is prepared for premedication
and induction of anesthesia reached stage III on
plane 2/3?
7. why could happen cardiac arrest and shall be
promptly resuscitated ?
8. why after surgery hospitalized in ICU with

Step 3 Problem Analysis

1. to prevent complications such as aspiration of

gastric contents, estimate the complications that
will occur account after the operation , knowing
the history of allergy to drugs , know state
organs , especially the vital organs .
2. to explore the abdomen because it feared had
peritonitis due to leakage of intestinal contents
into peritoneal cavity .
3. because COPD is a chronic constriction of the
airways and progressive . examination is needed
to assess the airway remains patent for the
surgery or the need for tools such as ventilator
breathing
assistance.
And
to
prevent
complications such as aspiration of gastric
contents

4. the interpretations :
unwell
pulse 108 beats / min : tachycardia
26 breaths / min : tachypnea
blood pressure of 180/110 mmHg : hypertension
temperature 38.5 OC : fever l
ab :
Hb 11.2 g / dL : anemia
Leukocytes 12,000 / mm3 : leukocytosis , suspected
peritonitis
240,000 platelets / mm 3 : normal
PTT and APTT : normal
random blood sugar of 160 mg / dL : normal (the
same as last GDPP eat 4 hours ago ) Na and K :
normal (no electrolyte disturbance )

5. INDICATIONS FOR GENERAL

ANESTHESIA
1.
2.
3.
4.

Children who are too young to cooperate

Lancing abscesses
Adults who are abnormally fearful of needle
Extraction of teeth in the early stage of
suppurative infection
5. Multiple uncomplicated extractions
6. In its analgesic stage for preparation of
sensitive teeth for fillings
7. Treatment of peridental disease

6. Because :
Reduction of anxiety and pain.
Promotion of amnesia.
Reduction of secretions.
Reduction of volume and pH of gastric
contents .
Reduction of postoperative nausea and
vomiting.
Enhancing the hypnotic effects of general
anaesthesia.
Reduction of vagal reflexes to intubation.
Specific indications - eg, prevention of
infective endocarditis.

7. Ventricular fibrillation (v-fib) causes most sudden

cardiac arrests (SCAs). Certain types of physical stress
can cause your heart's electrical system to fail.
Examples include:
Intense physical activity. The hormone adrenaline is
released during intense physical activity. This
hormone can trigger SCA in people who have heart
problems.
Very low blood levels of potassium or magnesium.
These minerals play an important role in your heart's
electrical signaling.
Major blood loss.
Severe lack of oxygen.
Management of prone cardiac arrest may be improved
by identification of high-risk patients, careful patient
positioning, use of invasive monitoring and placement
of self-adhesive defibrillator paddles. Suitable

8.To prevent recurrent cardiac arrest

9. Indication in ICU :
. Post cardiac arrrest
. stopping breathing
. coma
. need ventilator

Step 4 - Scheme

Post op : ICU

Man, 72 yo

Laparatomy

Cardiac
arrest

General
anasthesia

resusitation

Agent :
IV,IM,
inhalation

Ileus
Obstruction

COPD
Suspected
malignancy
Eat 4 hours ago

premedicati
on

induction

Step 5 Learning Objective

1. Premedication
Further action is giving premedication to do 1-2
hours prior to surgery patients, that aim is:
1. Eliminate anxiety
2. Getting sedation
3. Getting analgesia
4. Getting amnesia
5. Getting effect antisialogoque
6. Increasing the pH of gastric fluid
7. Reduce the volume of gastric fluid
8. Prevent the occurrence of allergic reactions.
Outcome: sedation of patients without depression
of respiration and circulation

2. General Anesthesia
1. Mask (adjust the size of the patient's face)
2. Laryngoscope (consisting of holder and blade.
Select the blade number 3 for adult patients with
moderate size, bigger when wearing size 4, for the
child to use the size of number 2. Do not forget to
check whether the light is bright enough lights)
3. Endotracheal with 3 sizes
4. Cuff (in order to pump the ETT in order to position
Fixed)
5. Goedel with 3 sizes (3 = green, 4 = yellow, 5 =
red)

6. Hoarness and Ring Hoarness (for

memfiksir mask on the face)
7. Stylet (guide wire airways)
8. Jackson Rees (pumping system is used
for children)
9. Jelly
10. precordial
11. Cotton alcohol
12. Plaster
13. Lidocaine pump
14. Naso (for the nose. Not always used ..
only in certain circumstances)

General Anesthesia Drugs

1.
2.
3.
4.
5.
6.

Atropine sulfate
Pethidin
Propofol / Recofol
Succinyl Cholin
Tramus
Ephedrine

Completeness of Operating
Room
1.
2.
3.
4.
5.

Anesthesia machine
Anesthesia monitor
suction
hand table
pillow

Steps of General Anesthesia

1. After the patient was placed on an operating table.
Attach the tension, saturation, precordial. Turn on the
monitor. Turn on the anesthesia machine. Set the
speed of infusion.
2. Wait for instructions. After the report to the
consultant, and the operator is ready. Means
anesthesia may be performed.
3. Ask the patient to pray
4. Inject pre medications: SA 0.25 mg and 30-50 mg
Pethidin
5. Inject Recofol 100 mg.
6. Wait until the eyelash reflex disappeared.
7. When eyelash reflex was lost attach the mask to the
correct position. (Jaw thrust, chin lift, press the mask
with his thumb and forefinger)

8. Increasing oxygen to 6-10 l

9. reduce oxygen to 3 L. increase N2O into 3L. open
isoflurane / halothane
10.Remain in that position. While sometimes do pumping
when needed. watch infusion, pulse, blood pressure,
saturation, pump or monitor machine. occasionally feel
the patient's pulse
11.When required the patient to relax, then give Succinil
choline or tramus depending on the required dose.
12.Furthermore, live art anesthesia. If blood pressure rises
and falls, if the pulse rise or fall, if less spontaneous
breath, slow or fast. All we can do is deepen or reduce
anesthesia, plus certain medications, fluid set, adjust the
position of the patient and others..
13.When the operation is almost finished, reduce the dose
slowly until then lived oxygen alone.
14.The operation is completed ... bring the patient to the RR.
And wait until the patient is awake

3. Management
preoperative

Preoperative assessment
Goal : decrease risk of surgery :
Identify unrecognized co-morbid disease
and risk factors for medical
complications of surgery
Optimize preoperative medical condition
Understand, recognize, and treat
potential complications
Work as a team with surgeon and
anesthesiologist

Preoperative assessment:
1.Anamnesis : medical history, social history, surgical
history and risk factor (ASA)
2.Physical examination: Vital sign, generalist status,
localist status.
3.Basic examination: airway (LEMON classification to
predict of difficult intubation) , lungs and heart
assessment.
4. Laboratorium: examination of peripheral blood,
electrolytes , blood sugar , Clotting screen (all patients
and those on anticoagulants), Liver function, ECG (all
patients > 40Ys), Echocardiogram (Abnormal ECG,
ischemic heart), Chest x-ray, Blood sugar level.

ASA Classification
Class 1 : Healthy patient with no disease outside of the
surgical process
Class 2: Mild-to-mod. systemic disease caused by the
surgical condition or by other pathologic processes
Class 3: Severe disease process which limits activity
but is not incapacitating
Class 4: Severe incapacitating disease process that is a
constant threat to life
Class 5: Dying patient not expected to survive 24
hours with or without an operation
E: Suffix to indicate an emergency surgery for any class

LEMON airway assessment

method
L = Look externally (facial trauma, large
incisors, beard or moustache, large tongue)
E = Evaluate the 3-3-2 rule (incisor distance-3
finger breadths, hyoid-mental distance-3
finger breadths, thyroid-to-mouth distance-2
finger breadths)
M = Mallampati (Mallampati score > 3)
O = Obstruction (presence of any condition
like epiglottitis, peritonsillar abscess, trauma).
N = Neck mobility (limited neck mobility)

Mallampati score

4. Complication post surgery

Post Dural Puncture Headache
(PDPH)
Post-dural-puncture headache (PDPH) is a complication of puncture of the
dura mater (one of the membranes that surround the brain and spinal
cord). It is a common side-effect of spinal anesthesia and lumbar puncture
and may occasionally accidentally occur in epidural anesthesia.
Leakage of cerebrospinal fluid through the dura mater puncture causes
reduced fluid levels in the brain and spinal cord, and may lead to the
development of PDPH hours or days later. Onset occurs within two days
in 66 percent and within three days in ninety percent of PDPH cases. It
occurs so rarely immediately after puncture that other possible causes
should be investigated when it does.

 The headache is severe and described as "searing

and spreading like hot metal," involving the back
and front of the head, and spreading to the neck
and shoulders, sometimes involving neck
stiffness. It is exacerbated by movement, and
sitting or standing, and relieved to some degree
by lying down.
Nausea, vomiting, pain in arms and legs, hearing
loss, tinnitus, vertigo, dizziness and paraesthesia
of the scalp are common

Symptoms
Headache is the predominant, but not ubiquitous presenting
complaint.
The headache is described as severe,`searing and spreading
like hot
metal'.The common distribution is over the frontal and
occipital areas
radiating to the neck and shoulders.
The temporal, vertex and nuchal areas are reported less
commonly as
the site of discomfort, although neck stiffness may be present.
The pain
is exacerbated by head movement, and adoption of the
upright posture,
and relieved by lying down.
An increase in severity of the headache on standing is the sine
qua non
of post-dural puncture headache.

Other symptoms associated with dural puncture headache

include
nausea
vomiting
hearing loss
tinnitus
vertigo
dizziness
paraesthesia of the scalp
upper and lower limb pain.

Visual disturbances such as diplopia or cortical blindness have

been
reported. Cranial nerve palsies are not uncommon. Two cases
of
thoracic back pain without headache have been described.
Neurological symptoms may precede the onset of grand mal
seizures.
Intracranial subdural haematomas, cerebral herniation and
death, have
been described as a consequence of dural puncture.
Unless a headache with postural features is present, the
diagnosis of
post-dural puncture headache should be questioned, as other
serious
intracranial causes for headache must be excluded.

Diagnosis
The history of accidental or deliberate dural puncture and symptoms of
a postural headache, neck ache and the presence of neurological signs,
usually guide the diagnosis.
Where there is doubt regarding the diagnosis of post-dural puncture
headache, additional tests may confirm the clinical findings. A
diagnostic lumbar puncture may demonstrate a low CSF opening
pressure or a `dry tap', a slightly raised CSF protein, and a rise in CSF
lymphocyte count.
An MRI may demonstrate: diffuse dural enhancement, with evidence of
a sagging brain; descent of the brain, optic chiasm, and brain stem;
obliteration of the basilar cisterns; and enlargement of the pituitary
gland.
CT myelography, retrograde radio nuclide myelography, cisternography,
or thin section MRI --> can be use to locate the spinal source of the
CSF leak.

Treatment
Overview
The literature regarding the treatment of post-dural
puncture headache often involves small numbers of
patients, or uses inappropriate statistical analysis.
Studies
observing the effects of treatments in post-dural
puncture
headache oftenfail to recognize that, with no
treatment,
over 85% of postdural puncture headaches will
resolve
within 6 weeks.

Technique
The presence of fever, infection on the back, coagulopathy, or
patient
refusal are contraindications to the performance of an epidural
blood
patch. As a precautionary measure, a sample of the subject's
blood
should be sent to microbiology for culture. With the patient in
the lateral
position, the epidural space is located with a Tuohy needle at
the level
of the supposed dural puncture or an intervertertebral space
lower.
The operator should be prepared for the presence of CSF
within the
epidural space.
Up to 30 ml of blood is then taken from the patient's arm and

Contraindications
Contraindications include those that normally apply to
epidurals, but
include a raised white cell count, pyrexia and technical
difficulties.
Limited experience with HIV-positive patients suggest that it is
acceptable providing no other bacterial or viral illnesses are
active.
Epidural blood patch following diagnostic lumbar puncture in
the
oncology patient raises the potential for seeding the neuroaxis
with
neoplastic cells.
One case has been reported of a successful patch without
complications, and one case where the risks of central
nervous system
(CNS) seeding of leukaemia were considered to outweigh the
benefits
of an epidural blood patch.

5. Intensive Care
Medicine
Concerned with themanagement of
life-threatening conditions requiring organ
supportandinvasive monitoring.
Patients requiring intensive care may
require support for cumulative effects
ofmultiple organ failure. They may also be
admitted for intensive/invasive monitoring,
such as the crucial hours after major
surgery when deemed too unstable to
transfer to a less intensively monitored unit.

The nine key IC systems are

cardiovascular system,central nervous
system,endocrine
system,gastrointestinal
tract(and
nutritional condition), haematology,
microbiology (including sepsis status),
peripheries
(and
skin),renal(and
metabolic), andrespiratory system.
Intensive care is usually only
offered to those whose condition is
potentially reversible and who have a
good
chance
of
surviving
with
intensive care support.

Thank you