4th plenary
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4th Plenary
By Group 15C
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Members
• Fitri Yani• Aulia Rahmi
• Noprianty Eka Pratiwi• Rian Rizki Ananda• aulina !ani"yah•
No#i $amilah• Putri Pratiwi• %"mi ulya A&ti
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Step 1 - Terminology
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1' %leu" o("tru)tion * hypomotility o& the
+a"trointe"tinal tra)t )au"ed (y "malll or lar+e
(owel o("tru)tion'
,' -aparatomy * a "ur+i)al pro)edure in#ol#in+ a
lar+e in)i"ion throu+h the a(dominal wall to +ain
a))e"" into the a(dominal )a#ity'
.' A/A Phy"i)al /tatu" %%% * Patient" with "e#ere
"y"temi) di"ea"e0 no immediate dan+er o& death'
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1' General ane"the"ia * i" )ommonly produ)ed (y a
)om(ination o& intra#enou" dru+" and inhaled
+a""e"' %t make" you (oth un)on")iou" and una(le
to &eel pain durin+ medi)al pro)edure"'
,' /ta+e %%% "ta+e o& "ur+i)al ane"the"ia2* &rom on"et
o& automati) re"piration to re"piratory paraly"i"'
Plane %% * &rom )e""ation o& eye(all mo#ement" to(e+innin+ o& paraly"i" o& inter)o"tal mu")le"'
Plane %%% * &rom (e+innin+ to )ompletion o&
inter)o"tal mu")le paraly"i"'
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/tep , 3 Pro(lem%denti)ation
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1' hy it i" needed in preparation &or "ur+ery &oremer+en)y a)tion with the dia+no"i" o&
o("tru)ti#e ileu" hi+h layout e) "u"pe)tedmali+nan)y and what preparation" 6,' why i" the a)tion plan laparotomy "ur+ery 6.' what are the impli)ation" o& C7P8 and eat the
la"t &our hour" a+o with the ne9t a)tion 6
4' how i" the interpretation" o& the +eneral "tate o&Na and : to normal 6
5' hy i" planned +eneral ane"the"ia 6 whatindi)ation" 6
;' hy the patient i" prepared &or premedi)ationand indu)tion o& ane"the"ia rea)hed "ta+e %%% onplane ,
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/tep . 3 Pro(lem Analy"i"
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1' to pre#ent )ompli)ation" "u)h a" a"piration o&+a"tri) )ontent"0 e"timate the )ompli)ation" thatwill o))ur a))ount a&ter the operation 0 knowin+the hi"tory o& aller+y to dru+" 0 know "tateor+an" 0 e"pe)ially the #ital or+an" '
,' to e9plore the a(domen (e)au"e it &eared had
peritoniti" due to leaka+e o& inte"tinal )ontent"into peritoneal )a#ity '
.' (e)au"e C7P8 i" a )hroni) )on"tri)tion o& the
airway" and pro+re""i#e ' e9amination i" neededto a""e"" the airway remain" patent &or the"ur+ery or the need &or tool" "u)h a" #entilator(reathin+ a""i"tan)e' And to pre#ent)ompli)ation" "u)h a" a"piration o& +a"tri)
)ontent"
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4' the interpretation" *
unwell
pul"e 1> (eat" < min * ta)hy)ardia,; (reath" < min * ta)hypnea(lood pre""ure o& 1>
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5' %N8%CA%7N/ F7R GENERA-
ANE/!E/%A1' Children who are too youn+ to )ooperate,' -an)in+ a(")e""e"
.' Adult" who are a(normally &ear&ul o& needle
4' E9tra)tion o& teeth in the early "ta+e o&"uppurati#e in&e)tion
5' ultiple un)ompli)ated e9tra)tion"
;' %n it" anal+e"i) "ta+e &or preparation o&"en"iti#e teeth &or llin+"
=' reatment o& peridental di"ea"e
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;' Be)au"e *• Redu)tion o& an9iety and pain'•
Promotion o& amne"ia'• Redu)tion o& "e)retion"'• Redu)tion o& #olume and p! o& +a"tri)
)ontent" '
• Redu)tion o& po"toperati#e nau"ea and#omitin+'
• Enhan)in+ the hypnoti) eDe)t" o& +eneralanae"the"ia'
• Redu)tion o& #a+al ree9e" to intu(ation'• /pe)i) indi)ation" e+0 pre#ention o&
in&e)ti#e endo)arditi"'
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=' entri)ular (rillation #(2 )au"e" mo"t "udden)ardia) arre"t" /CA"2' Certain type" o& phy"i)al "tre"")an )au"e your heartH" ele)tri)al "y"tem to &ail'
E9ample" in)lude*• %nten"e phy"i)al a)ti#ity' he hormone adrenaline i"
relea"ed durin+ inten"e phy"i)al a)ti#ity' hi"hormone )an tri++er /CA in people who ha#e heartpro(lem"'
• ery low (lood le#el" o& pota""ium or ma+ne"ium' he"e mineral" play an important role in your heartH"ele)tri)al "i+nalin+'
• aIor (lood lo""'• /e#ere la)k o& o9y+en'
ana+ement o& prone )ardia) arre"t may (e impro#ed(y identi)ation o& hi+hri"k patient"0 )are&ul patient
po"itionin+0 u"e o& in#a"i#e monitorin+ and pla)emento& "el&adhe"i#e de(rillator paddle"' /uita(le
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>'o pre#ent re)urrent )ardia) arre"t
@' %ndi)ation in %C? *•. Po"t )ardia) arrre"t•. "toppin+ (reathin+•. )oma•. need #entilator
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Step 4 - Scheme
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an0 =, yo
%leu"7("tru)tion
C7P8/u"pe)tedmali+nan)y
Eat 4 hour" a+o-aparatomy
Generalana"the"ia
A+ent *%0%0
inhalation
premedi)ation
indu)tion
Cardia)arre"t
re"u"itation
Po"t op * %C?
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/tep 5 3 -earnin+ 7(Ie)ti#e
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1' Premedi)ationFurther a)tion i" +i#in+ premedi)ation to do 1,
hour" prior to "ur+ery patient"0 that aim i"*1' Eliminate an9iety
,' Gettin+ "edation
.' Gettin+ anal+e"ia
4' Gettin+ amne"ia
5' Gettin+ eDe)t anti"ialo+oJue
;' %n)rea"in+ the p! o& +a"tri) uid
=' Redu)e the #olume o& +a"tri) uid>' Pre#ent the o))urren)e o& aller+i) rea)tion"'
7ut)ome* "edation o& patient" without depre""iono& re"piration and )ir)ulation
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,' General Ane"the"ia
1' a"k adIu"t the "ize o& the patientH" &a)e2
,' -aryn+o")ope )on"i"tin+ o& holder and (lade'/ele)t the (lade num(er . &or adult patient" withmoderate "ize0 (i++er when wearin+ "ize 40 &or the
)hild to u"e the "ize o& num(er ,' 8o not &or+et to)he)k whether the li+ht i" (ri+ht enou+h li+ht"2
.' Endotra)heal with . "ize"
4' CuD in order to pump the E in order to po"ition
Fi9ed25' Goedel with . "ize" . K +reen0 4 K yellow0 5 K
red2
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;' !oarne"" and Rin+ !oarne"" &ormemk"ir ma"k on the &a)e2
=' /tylet +uide wire airway"2>' $a)k"on Ree" pumpin+ "y"tem i" u"ed
&or )hildren2
@' $elly
1' pre)ordial
11' Cotton al)ohol
1,' Pla"ter
1.' -ido)aine pump14' Na"o &or the no"e' Not alway" u"ed ''
only in )ertain )ir)um"tan)e"2
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General Ane"the"ia 8ru+"
1' Atropine "ul&ate
,' Pethidin
.' Propo&ol < Re)o&ol
4' /u))inyl Cholin
5' ramu"
;' Ephedrine
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Completene"" o& 7peratin+Room
1' Ane"the"ia ma)hine
,' Ane"the"ia monitor
.' "u)tion
4' hand ta(le
5' pillow
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/tep" o& General Ane"the"ia1' A&ter the patient wa" pla)ed on an operatin+ ta(le'
Atta)h the ten"ion0 "aturation0 pre)ordial' urn on themonitor' urn on the ane"the"ia ma)hine' /et the"peed o& in&u"ion'
,' ait &or in"tru)tion"' A&ter the report to the)on"ultant0 and the operator i" ready' ean"
ane"the"ia may (e per&ormed'.' A"k the patient to pray
4' %nIe)t pre medi)ation"* /A ',5 m+ and .5 m+Pethidin
5' %nIe)t Re)o&ol 1 m+';' ait until the eyela"h ree9 di"appeared'
=' hen eyela"h ree9 wa" lo"t atta)h the ma"k to the)orre)t po"ition' $aw thru"t0 )hin li&t0 pre"" the ma"kwith hi" thum( and &oren+er2
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>' %n)rea"in+ o9y+en to ;1 l
@' redu)e o9y+en to . -' in)rea"e N,7 into .-' openi"ourane < halothane
1'Remain in that po"ition' hile "ometime" do pumpin+when needed' wat)h in&u"ion0 pul"e0 (lood pre""ure0"aturation0 pump or monitor ma)hine' o))a"ionally &eelthe patientH" pul"e
11'hen reJuired the patient to rela90 then +i#e /u))inil
)holine or tramu" dependin+ on the reJuired do"e'1,'Furthermore0 li#e art ane"the"ia' %& (lood pre""ure ri"e"
and &all"0 i& the pul"e ri"e or &all0 i& le"" "pontaneou"(reath0 "low or &a"t' All we )an do i" deepen or redu)eane"the"ia0 plu" )ertain medi)ation"0 uid "et0 adIu"t the
po"ition o& the patient and other"''1.'hen the operation i" almo"t ni"hed0 redu)e the do"e
"lowly until then li#ed o9y+en alone'
14' he operation i" )ompleted ''' (rin+ the patient to the RR'
And wait until the patient i" awake
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.' ana+ementpreoperati#e
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Preoperati#e a""e""ment
• Goal * de)rea"e ri"k o& "ur+ery * – %denti&y unre)o+nized )omor(id di"ea"e
and ri"k &a)tor" &or medi)al
)ompli)ation" o& "ur+ery – 7ptimize preoperati#e medi)al )ondition – ?nder"tand0 re)o+nize0 and treat
potential )ompli)ation"
– ork a" a team with "ur+eon andane"the"iolo+i"t
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Preoperative assessment:
1.Anamnesis : medical history, social history, surgical
history and risk factor (ASA)2.Physical eamination: !ital sign, generalist status,
localist status.
".#asic eamination: air$ay (%&' classification to
predict of difficult intu*ation) , lungs and heartassessment.
+. %a*oratorium: eamination of peripheral *lood,electrolytes , *lood sugar , lotting screen (all patients
and those on anticoagulants), %iver function, &- (all patients +/0s), &chocardiogram (A*normal &-,ischemic heart), hest ray, #lood sugar level.
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A/A Cla""i)ation
Cla"" 1 * !ealthy patient with no di"ea"e out"ide o& the"ur+i)al pro)e""
Cla"" ,* ildtomod' "y"temi) di"ea"e )au"ed (y the"ur+i)al )ondition or (y other patholo+i) pro)e""e"
Cla"" .* /e#ere di"ea"e pro)e"" whi)h limit" a)ti#ity(ut i" not in)apa)itatin+
Cla"" 4* /e#ere in)apa)itatin+ di"ea"e pro)e"" that i" a)on"tant threat to li&e
Cla"" 5* 8yin+ patient not e9pe)ted to "ur#i#e ,4hour" with or without an operation
E* /uL9 to indi)ate an emer+en)y "ur+ery &or any )la""
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-E7N airway a""e""mentmethod
• - K -ook e9ternally &a)ial trauma0 lar+ein)i"or"0 (eard or mou"ta)he0 lar+e ton+ue2
• E K E#aluate the .., rule in)i"or di"tan)e.
n+er (readth"0 hyoidmental di"tan)e.n+er (readth"0 thyroidtomouth di"tan)e,n+er (readth"2
• K allampati allampati ")ore M .2
• 7 K 7("tru)tion pre"en)e o& any )onditionlike epi+lottiti"0 periton"illar a(")e""0 trauma2'
• N K Ne)k mo(ility limited ne)k mo(ility2
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allampati ")ore
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Postduralpuncture headache (PP3) is a complication of puncture of the
dura mater (one of the mem*ranes that surround the *rain and spinal
cord). 4t is a common sideeffect of spinal anesthesia and lum*ar puncture
and may occasionally accidentally occur in epidural anesthesia.
%eakage of cere*rospinal fluid through the dura mater puncture causes
reduced fluid levels in the *rain and spinal cord, and may lead to the
development of PP3 hours or days later. nset occurs $ithin t$o days
in 55 percent and $ithin three days in ninety percent of PP3 cases. 4t
occurs so rarely immediately after puncture that other possi*le causesshould *e investigated $hen it does.
4' Compli)ation po"t "ur+ery
Po"t 8ural Pun)ture !eada)he
P8P!2
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• he heada)he i" "e#ere and de")ri(ed a" "earin+and "preadin+ like hot metal0 in#ol#in+ the (a)kand &ront o& the head0 and "preadin+ to the ne)kand "houlder"0 "ometime" in#ol#in+ ne)k"tiDne""' %t i" e9a)er(ated (y mo#ement0 and
"ittin+ or "tandin+0 and relie#ed to "ome de+ree(y lyin+ down'
• Nau"ea0 #omitin+0 pain in arm" and le+"0 hearin+lo""0 tinnitu"0 #erti+o0 dizzine"" and parae"the"iao& the ")alp are )ommon
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/ymptom"
!eada)he i" the predominant0 (ut not u(iJuitou" pre"entin+)omplaint'
he heada)he i" de")ri(ed a" "e#ere0O"earin+ and "preadin+like hot
metalH'he )ommon di"tri(ution i" o#er the &rontal ando))ipital area"radiatin+ to the ne)k and "houlder"'
he temporal0 #erte9 and nu)hal area" are reported le"")ommonly a"
the "ite o& di")om&ort0 althou+h ne)k "tiDne"" may (e pre"ent' he paini" e9a)er(ated (y head mo#ement0 and adoption o& the
upri+ht po"ture0and relie#ed (y lyin+ down'An in)rea"e in "e#erity o& the heada)he on "tandin+ i" the sine
qua non o& o"tdural un)ture heada)he'
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7ther "ymptom" a""o)iated with dural pun)ture heada)hein)lude
• nau"ea• #omitin+• hearin+ lo""• tinnitu"
• #erti+o• dizzine""• parae"the"ia o& the ")alp• upper and lower lim( pain'
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i"ual di"tur(an)e" "u)h a" diplopia or )orti)al (lindne"" ha#e(een
reported' Cranial ner#e pal"ie" are not un)ommon' wo )a"e"o&
thora)i) (a)k pain without heada)he ha#e (een de")ri(ed'
Neurolo+i)al "ymptom" may pre)ede the on"et o& +rand mal"eizure"'%ntra)ranial "u(dural haematoma"0 )ere(ral herniation and
death0 ha#e(een de")ri(ed a" a )on"eJuen)e o& dural pun)ture'?nle"" a heada)he with po"tural &eature" i" pre"ent0 the
dia+no"i" o&po"tdural pun)ture heada)he "hould (e Jue"tioned0 a" other"eriou"
intra)ranial )au"e" &or heada)he mu"t (e e9)luded'
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8ia+no"i" he hi"tory o& a))idental or deli(erate dural pun)ture and "ymptom" o&
a po"tural heada)he0 ne)k a)he and the pre"en)e o& neurolo+i)al "i+n"0u"ually +uide the dia+no"i"'here there i" dou(t re+ardin+ the dia+no"i" o& po"tdural pun)tureheada)he0 additional te"t" may )onrm the )lini)al ndin+"' Adia+no"ti) lum(ar pun)ture may demon"trate a low C/F openin+pre""ure or a Odry tapH0 a "li+htly rai"ed C/F protein0 and a ri"e in C/F
lympho)yte )ount'An R% may demon"trate* diDu"e dural enhan)ement0 with e#iden)e o&a "a++in+ (rain de")ent o& the (rain0 opti) )hia"m0 and (rain "temo(literation o& the (a"ilar )i"tern" and enlar+ement o& the pituitary+land'C myelo+raphy0 retro+rade radio nu)lide myelo+raphy0 )i"terno+raphy0or thin "e)tion R% M )an (e u"e to lo)ate the "pinal "our)e o& the
C/F leak'
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reatment
7#er#iew
he literature re+ardin+ the treatment o& po"tduralpun)ture heada)he o&ten in#ol#e" "mall num(er" o&
patient"0 or u"e" inappropriate "tati"ti)al analy"i"'/tudie"o("er#in+ the eDe)t" o& treatment" in po"tdural
pun)tureheada)he o&ten&ail to re)o+nize that0 with no
treatment0o#er >5Q o& po"tdural pun)ture heada)he" will
re"ol#ewithin ; week"'
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e)hniJue
he pre"en)e o& &e#er0 in&e)tion on the (a)k0 )oa+ulopathy0 orpatient
re&u"al are )ontraindi)ation" to the per&orman)e o& an epidural(lood
pat)h' A" a pre)autionary mea"ure0 a "ample o& the "u(Ie)tH"(lood"hould (e "ent to mi)ro(iolo+y &or )ulture' ith the patient in
the lateralpo"ition0 the epidural "pa)e i" lo)ated with a uohy needle at
the le#el
o& the "uppo"ed dural pun)ture or an inter#erterte(ral "pa)elower'
he operator "hould (e prepared &or the pre"en)e o& C/Fwithin the
epidural "pa)e'
?p to . ml o& (lood i" then taken &rom the patientH" arm and
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Contraindi)ation"
Contraindi)ation" in)lude tho"e that normally apply toepidural"0 (ut
in)lude a rai"ed white )ell )ount0 pyre9ia and te)hni)aldiL)ultie"'
-imited e9perien)e with !%po"iti#e patient" "u++e"t that it i"
a))epta(le pro#idin+ no other (a)terial or #iral illne""e" area)ti#e'Epidural (lood pat)h &ollowin+ dia+no"ti) lum(ar pun)ture in
theon)olo+y patient rai"e" the potential &or "eedin+ the neuroa9i"
with
neopla"ti) )ell"'7ne )a"e ha" (een reported o& a "u))e""&ul pat)h without)ompli)ation"0 and one )a"e where the ri"k" o& )entral
ner#ou" "y"temCN/2 "eedin+ o& leukaemia were )on"idered to outwei+h the
(enet"
o& an epidural (lood pat)h'
i C
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5. Intensive CareMedicine
Con)erned with the mana+ement o&liðreatenin+ )ondition" reJuirin+ or+an"upport and in#a"i#e monitorin+'
Patient" reJuirin+ inten"i#e )are mayreJuire "upport &or )umulati#e eDe)t"o& multiple or+an &ailure' hey may al"o (eadmitted &or inten"i#e
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hank you
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