HEMODINAMIK Hemodynamics (AmE) or hmodynamics (BrE), meaning literally "blood flow, motion and equilibrium under the action

n of external forces", is the study of blood flow or the circulation. It explains the physical laws that govern the flow of blood in the blood vessels. Our understanding of hemodynamics depends on measuring the blood flow at different points in the circulation. A basic approach to understanding hemodynamics is by feeling the pulse. This gives simple information regarding the strength of the circulation via the systolic stroke and the heart rate, both important components of the circulation which may be altered in disease. The blood pressure can be simply measured using a plethysmograph or cuff connected to a pressure sensor (mercury or aneroid manometer). This is the most common clinical measure of circulation and provides a peak systolic pressure and a diastolic pressure, often quoted as a normal 115/75. Sometimes the mean arterial pressure is calculated. MAP ((BPdia 2) + BPsys)/3 mmHg (or torr) BPdia is counted twice since the heart spends two thirds of the heart beat cycle in the diastolic. where: MAP = Mean Arterial Pressure BPdia = Diastolic blood pressure BPsys = Systolic blood pressure. Hemodynamic monitoring is the observation of hemodynamic parameters over time, such as blood pressure and heart rate. Blood pressure can be monitored either invasively through an inserted blood pressure transducer assembly (providing continuous monitoring), or noninvasively by repeatedly measuring the blood pressure with an inflatable blood pressure cuff. GAGAL NAFAS AKUT Adalah ketidakmampuan untuk mengantarkan oksigen ke dalam darah dan mengeliminasi karbondiokasida dari darah. Dapat terjadi akibat hipoventilasi, gangguan difusi gas, dan ventilation-perfusion mismatch Acute or chronic severe malfunction in gas exchange between the lungs and the blood causing hypoxia with or without hypercapnia. Indikator : PO2 < dari 50-60 mmHg, PCO2 > 50 mmHg BGA Gagal nafas (hipoksemia) : pH <7.35, pCO 2 normal/menurun (krn takipneu), HCO3 menurun (asidosis metabolic) Gagal nafas (hipoventilasi): pH <7,35, pCO2 >50mmHg TIPE Hipoventilasi Obstruksi jalan nafas Penyakit paru Penyebab neurologis Cedera dada Gangguan difusi gas Gangguan alveolar Edema paru V-P mismatch CONTOH Spasme laring, aspirasi benda asing, edema jalan nafas Asma, COPD SCI, overdosis obat, stroke Pneumothoraks Pneumonia, COPD Gagal jantung Emboli paru

PERBANDINGAN DOSIS ADRENALIN Dosis syok ringan : 0.3-0.5 mg SC dalam larutan 1:1000 (1 ml=1mg) Dosis pada RJPO : 0.5-1.0 mg IV dalam larutan 1:10.000 (1 mg dalam 10 cc) GOLONGAN ANESTESI LOKAL Anestetik lokal memblok transmisi neuronal secara langsung. Anestetik lokal dibagi menjadi dua golongan:

Golongan ester (-COOC-). Metabolisme oleh enzim pseudo-kolinesterase. Hidrolisa ester sangat cepat dan metabolit diekskresi melalui urine Kokain, benzokain, ametocaine, prokain, piperoain, tetrakain, kloroprokain. o Golongan amida (-NHCO-). Dimetabolisme melalui oksidasi dealkilasi di dalam hati. Metabolit dieksresi lewat urin, sebagian kecil dieksresi dalam bentuk utuh. Lidokain, mepivakain, prilokain, bupivacain, etidokain, dibukain, ropivakain, levobupivacaine. Golongan ester lebih jarang digunakan daripada amida. Ester sering kali digunakan secara topical karena dapat menyebabkan toksik dan reaksi alergi. Lidokain o Onset kerja cepat o Dosis max 3-5mg/kg o Durasi kerja pendek. 60-180 menit o ES: toksisitas kardiak lebih rendah daripada bupivacaine o Metabolisme di hati, dieksresi lewat urine o Sangat popular untuk blok saraf, infiltrasi maupun anestesi regional IV, juga topikalm epidural, intratekal. Antiaritmik kelas 1B dan dapat digunakan untuk terapi takikardi Bupivakain o Onset kerja: blok nervus 40 menit, epidurak 15-20 menit, intratekal 30 detik o Durasi kerja : blok saraf sampai 24 jam, epidural 3-4 jam, intratekal 2-3 jam o ES: cenderung lebih menyebabkan toksisitas kardiak daripada anestesi local lainnya o Dieksresi di urine o Lazim digunakan untuk anestesi spinal. Plain bupivakan dapat membuat naik ke atas atau turun ke bawah sehingga dapat membahayakan fx respirasi. Jika ditambahkan dextrose, menjadi berat dan alirannya dapat diprediksi turun ke tulang belakang, hanya mempengaruhi saraf non esensial.

ETER Cairan yang tidak berwarna, mudah menguap, mudah terbakar, mudah meledak, mudah teroksidasi menjadi peroksida dan dengan alcohol membentuk asetaldehid. Bau kurang menyenangkan sehingga induksi sulit dilakukan, px sering menahan nafas. Sekresi ludah dan bronkus meningkat. Bisa dicegah dengan premed: Atropin 0.5-1 mg 1 jam sblm induksi Narcosis baik, analgesia sangat kuat, relaksasi otot bergaris sangat baik. Batas keselamatan sangat lebar. Dosis maintenance 2-4%, dosis max 15-20%. Sampai tahapan dalam, px ttp dapat bernafas spontan meskipun reaksi pusat pernafasan thd CO2 menurun. Pada stadium III bidang 2, efek depresi otot jantung tak tampak jelas karena ether merangsang saraf simpatis serta sekresi adrenalin-noradrenalin. Pada stadium dalam, terjadi depresi nafas dan depresi otot jantung. Jangan digunakan pada px rudapaksa kepala, contusion cerebri dan TIK meningkat karena pembuluh darah otak menjadi vasodilatasi. Hindari penggunaan pada px DM karena GDA meningkat 2xlipat sampai bbrp jam post anesthesia.

ISOFLURAN Mekanisme kerja : depresi kortikal global Kecepatan induksi : 2-3 menit. Jarang digunakan sebagai agen induksi karena membuat batuk Konsentrasi induksi : 5% Konsentrasi pemeliharaan : 1-1.5% Kode warna : ungu Nilai MAC : 1.3 pada oksigen inhalasi, 0.6 pada NO Keuntungan : konsentrasi sampai 1 MAC tidak meningkatkan aliran darah coroner dan serebral sehingga popular digunakan untuk bedah jantung dan saraf ES: hipotensi, takikardi, depresi nafas, bau tidak enak Note: digunakan sebagai pemeliharaan karena bau tidak enak dan batuk. Tidak ada efek analgesia SEVOFLURAN Mekanisme kerja : depresi kortikal global. Hidrokarbon terhalogenasi dengan titik didih rendah karena ia menguap pada suhu kamar dan dihirup oleh pasien. Memiliki kelarutan rendah perubahan yg cepat pada kedalaman anestesi Kecepatan induksi : 2-3 menit Konsentrasi induksi : 6-7% Konsentrasi pemeliharaan : 2-3% Kode warna : kuning Nilai MAC : 2.2 pada oksigen inhalasi, 1.2 pada NO

Keuntungan : onset yang lembut dari anesthesia tanpa peningkatan aliran darah otak dibawah MAC 1. Tidak menyebabkan takikardi ES: hipotensi, vasodilatasi, depresi nafas Note: digunakan sebagai induksi karena bau tidak menyengat

CO2 ABSORBER Function- makes rebreathing possible, thus conserving gases and volatile agents, decreasing OR pollution, and avoiding hazards of carbon dioxide rebreathing. Soda lime- Activator is NaOH or KOH. Silica and kieselguhr TM added as hardeners. Indicators for Sodasorb (such as ethyl violet) are colorless when fresh, and purple when exhausted, because of pH changes in the granules. CO2 absorbent materials consist of a mixture of porous granules made up of base (hydroxide) Two types of absorbents Soda Lime (Sodasorb) Barium hydroxide (Baralyme) Soda Lime consist of 80% calcium hydroxide, 15% water, 4% sodium hydroxide, and 1% potassium hydroxide (an activator). Activator is NaOH or KOH. Silica and kieselguhr added as hardeners 4-8 Mesh size granules-higher the mesh number the smaller the granule Large granules provide small surface area and decrease resistance to flow Indicators are added to absorbent to assess the functional integrity of the absorbent ---ethyl violet are colorless when fresh, and purple when exhausted--PH falls below 10.3 because of alcohol dehydration The color may revert back to white if absorbent remains idle (reactivation). This gives the user a false impression that the absorbent is fully functional. Each canister holds absorbent material of 1000g of granules and has a volume of 1500cc. Each 100g absorbs as much as 15L of CO2 The average production of CO2 by the anesthetized adults is 12 to 18 L/hr. Therefore each canister last 8-10 hours Each canister should be well filled with absorbent material and shaken to provide maximum function and absorption of CO2 Sevoflurane is unstable in soda lime, producing Compound A (lethal at 130-340 ppm, or renal injury at 25-50 ppm in rats; but incidence of toxic [hepatic or renal] or lethal effects in millions of humans are comparable to desflurane). Compound A concentrations of 25-50 ppm are easily achievable in normal clinical practice. Sevoflurane is not recommended at total fresh gas flows less than 1 L/min for more than 2 MAC-Hours (2 L/min fresh gas flow can be used indefinitely). Carbon monoxide has been known to accumulate in absorbers not used with in 24-48 hours because of slow reaction with the volitile agents and absorbents. Deflurane has the highest accumulation of carbon monoxide. It is recommended to flush the system with 100% of O2 for 15 mins before use, turn oxygen off at end of case, change absorbent regularly, change if FGF left on over the weekend or overnight, and use low flows (this will tend to keep granules moist). ANTIDOTUM KERACUNAN MORPHIN Naloxon 0.4-4 mg IV/IM/SC; repeat q2-3min PRN; not to exceed 10 mg (0.01 mg/kg) Consider other causes of respiratory depression if desired response not achieved after 0.8 mg total Endotracheal: 2-2.5 times (0.8-1mg) initial IV dose DOSIS MAKSIMAL LIDOKAIN Pada penggunaan sebagai anestesi local: Lidokain 2mg/kg Lidokain+adrenalin 7mg/kg T-PIECE MAPPLESON Inspiration -The patient inspires fresh gas from the reservoir tube. Expiration - The patient expires into the reservoir tube. Although fresh gas is still flowing into the system at this time, it is wasted as it is contaminated by expired gas. Expiratory pause - Fresh gas washes the expired gas out of the reservoir tube, filling it with fresh gas for the next inspiration. OSA (Obstructive Sleep Apnea) Is a sleep disorder that involves cessation or significant decrease in airflow in the presence of breathing effort. It is [1] characterized by recurrent episodes of upper airway collapse during sleep. These episodes are associated with recurrent oxyhemoglobin desaturations and arousals from sleep. OSA that is associated with excessive daytime sleepiness is commonly called obstructive sleep apnea syndromealso referred to as obstructive sleep apnea-hypopnea syndrome. Gejala : o Gejala nocturnal : Mendengkur Biasanya keras, berulang-ulang dan mengganggu orang lain

Apnea, menginterupsi dengkur dan berakhir dengan mendengus Sensasi terengah-engah dan tersedak yang membangunkan px Nocturia Insomnia, tidur dengan gelisah o Gejala siang : Nonrestorative sleep (tidur tak berkualitas, bangun dengan rasa lelah) Nyeri kepala pagi hari, tenggorokan kering dan nyeri Mengantuk berlebihan di pagi hari Lelah sepanjang hari Penurunan fungsi kognitif, memori, konsentrasi Penurunan kewaspadaan DIsfungsi seksual Diagnosis o Pemeriksaan Fisik: Abnormal (increased) Mallampati score: Identifies risk for difficult tracheal intubation Narrowing of the lateral airway walls: Independent predictor of the presence of obstructive sleep apnea in men but not women Enlarged (ie, "kissing") tonsils (3+ to 4+) Retrognathia or micrognathia Large degree of overjet High-arched hard palate Systemic arterial hypertension: Present in about 50% of obstructive sleep apnea cases Congestive heart failure Pulmonary hypertension Stroke Metabolic syndrome Type 2 diabetes mellitus o Studi tidur/polysomnography o The Epworth Sleepiness Scale is a validated method of assessing the likelihood of falling asleep in a variety of situations. The maximum score is 24.38 The score can be used to clinically subdivide the jective daytime sleepiness (ESS=11.14), Terapi : Conservative therapy and prevention o Restriction of body positions during sleep (avoid supine position) o Sleeping in an upright position for markedly obese patient o Avoiding smoking; smoking cessation o Avoiding alcohol and other sedatives (particularly 4-6 hours before bedtime) o Avoiding sleep deprivation Mechanical measures o Nasal CPAP: Standard treatment option o Bilevel positive airway pressure o Oral appliance therapy Pharmacotherapy Medications are generally not a part of the primary treatment recommendations for OSA. However, central nervous system stimulants such as modafinil and armodafinil have been used adjunctively in the management of this condition. Surgery o Uvulopalatopharyngoplasty o Craniofacial reconstruction with advancement of tongue or maxillomandibular bones o Tracheostomy

CPAP (Continous Positive Airway Pressure) is the use of continuous positive pressure to maintain a continuous level of positive airway pressure in a spontaneously breathing patient. It is functionally similar to positive end-expiratory pressure (PEEP), except that PEEP is an applied pressure against exhalation and CPAP is a pressure applied by a constant flow. As a treatment or therapy, CPAP uses mild air pressure to keep an airway open. CPAP typically is used for people who have breathing problems, such as sleep apnea. CPAP also may be used to treat preterm infants whose lungs have not yet fully developed. For example, physicians may use CPAP in infants with respiratory distress syndrome. It is associated with a decrease in the incidence of bronchopulmonary dysplasia. In some preterm infants whose lungs haven't fully developed, CPAP improves survival and decreases the need for steroid treatment for their lungs. Continuous positive airway pressure has been shown to increase arterial oxygen content. 2, 3, 4 The mechanisms by which this is achieved are complex and probably due to a combination of the factors outlined below. 1. Increases functional residual capacity. 19

2. 3. 4. 5. 6. 7. 8.

Reduces right to left shunting by reducing the ventilation:perfusion mismatch. 20 Decreases airway resistance by increasing pharyngeal cross-sectional area. 19 Reduces obstructive apnoeas. 21 Stabilises the respiratory rate. 22 Reduces the severity of central apnoea. 23 Protective effect on surfactant. Decreases alveolar oedema.

SHOCK Definisi : Syok adalah suatu sindrom klinis akibat kegagalan akut fungsi sirkulasi yang menyebabkan ketidakcukupan perfusi jaringan dan oksigenasi jaringan, dengan akibat gangguan mekanisme homeostasis. Macam syok: Syok hipovolemik, direct loss of effective circulating blood volume leading to: A rapid, weak, thready pulse due to decreased blood flow combined with tachycardia Cool, clammy skin due to vasoconstriction and stimulation of vasoconstriction Rapid and shallow breathing due to sympathetic nervous system stimulation and acidosis Hypothermia due to decreased perfusion and evaporation of sweat Thirst and dry mouth, due to fluid depletion Cold and mottled skin (Livedo reticularis), especially extremities, due to insufficient perfusion of the skin The severity of hemorrhagic shock can be graded on a 1-4 scale on the physical signs. This approximates to the effective loss of blood volume. Syok kardiogenik, caused by the failure of the heart to pump effectively. This can be due to damage to the heart muscle, most often from a large myocardial infarction. Other causes of cardiogenic shock include dysrhythmias, cardiomyopathy/myocarditis, congestive heart failure (CHF), contusio cordis, or cardiac valve problems. Gejala : Distended jugular veins due to increased jugular venous pressure Weak or absent pulse Arrhythmia, often tachycardic Pulsus paradoxus in case of tamponade Syok obstruktif, due to obstruction of blood flow outside of the heart. Several conditions can result in this form of shock. Cardiac tamponade in which fluid in the pericardium prevents inflow of blood into the heart (venous return). Constrictive pericarditis, in which the pericardium shrinks and hardens, is similar in presentation. Tension pneumothorax Through increased intrathoracic pressure, bloodflow to the heart is prevented (venous return). Pulmonary embolism is the result of a thromboembolic incident in the blood vessels of the lungs and hinders the return of blood to the heart. Aortic stenosis hinders circulation by obstructing the ventricular outflow tract Syok distributif, due to impaired utilization of oxygen and thus production of energy by the cell. It includes : septic shock anaphylactic shock, used by a severe anaphylactic reaction to an allergen, antigen, drug or foreign protein causing the release of histamine which causes widespread vasodilation, leading to hypotension and increased capillary permeability endocrine, such as hypothyroidism, thyrotoxicosis, acute adrenal insufficiency, and relative adrenal insufficiency [11] neurogenic shock such as high spinal injury. The classic symptoms include a slow heartrate due to [11] loss of cardiac sympathetic tone and warm skin due to dilation of the peripheral blood vessels. (This term can be confused with spinal shock which is a recoverable loss of function of the spinal cord after injury and does not refer to the haemodynamic instability per se CUSHING RESPONSE Cushing reflex/Cushing effect/Cushing phenomenon/Cushing response/Cushing's Law) is a physiological nervous system response to increased intracranial pressure (ICP) that results in Cushing's triad of hypertension, bradycardia, irregular respirations (caused by impaired brainstem function) Dr. Harvey Cushing recognized that the bodys initial response to rising intracranial pressure is a rise in systolic blood pressure widened pulse pressures, bradycardia and irregular breathing. As intracranial pressure continues to increase heart rate will increase, breathing will became shallow, periods of apnea will occur, and blood pressure will begin to fall. Eventually an agonal rhythm will develop as herniation begins, followed soon by cessation of brain stem activity, respiratory arrest and cardiac arrest. DOSIS ENERGI KARDIOVERSI PADA AF DAN SVT AF : 200 J monofasik atau 12-200 J bifasik, naik bertahap SVT lain dan atrial flutter : 50-100 J mono/bifasik

VT monomorfik : 100 J mono/bifasik

DOSIS AMIODARON UNTUK VF 300mg IV/IO push (if no conversion) 150 mg IV/IO push (after conversion) Infusion #1 360 mg IV over 6 hours (1mg/min) Infusion #2 540 mg IV over 18 hours (0.5mg/min) KATEKOLAMIN Katekolamin adalah senyawa yang mempunyai struktur katekol (suatu struktur aromatik dengan dua gugus hidroksil) terhubung dengan suatu amina Katekolamin penting pada manusia adalah adrenalin/epinefrin, noradrenalin/norepinefrin (NE), dan dopamin. Diproduksi oleh chromaffin cells pada medula adrenal dan postganglionic fibers dari sistem saraf simpatik. Dopamine diproduksi di neuronal cell bodies pada batang otak, yaitu substantia nigra dan ventral tegmental area. Melanin-pigmented cell bodies pada locus ceruleus memproduksi norepinephrine.

INDIKASI PENGHENTIAN RJPO ROSC (Return Of Spontaneous Circulation) Ada rescuer (penolong) yang lebih terlatih Penolong kelelahan Diputuskan sudah tidak bisa ditolong lagi (lebam mayat, pupil dilatasi penuh, kulit dingin) SKORING ANESTESI AMBULATORI A. Aldrete Score (dewasa) Penilaian : Nilai Warna Merah muda, 2 Pucat, 1 Sianosis, 0 Pernapasan Dapat bernapas dalam dan batuk, 2 Dangkal namun pertukaran udara adekuat, 1 Apnoea atau obstruksi, 0 Sirkulasi Tekanan darah menyimpang <20% dari normal, 2 Tekanan darah menyimpang 20-50 % dari normal, 1 Tekanan darah menyimpang >50% dari normal, 0 Kesadaran Sadar, siaga dan orientasi, 2 Bangun namun cepat kembali tertidur, 1 Tidak berespons, 0 Aktivitas Seluruh ekstremitas dapat digerakkan, 2 Dua ekstremitas dapat digerakkan,1 Tidak bergerak, 0 Jika jumlahnya > 8, penderita dapat dipindahkan ke ruangan B. Steward Score (anak-anak) Pergerakan Gerak bertujuan 2 Gerak tak bertujuan 1 Tidak bergerak 0 Pernafasan Batuk, menangis 2

 Pertahankan jalan nafas 1 Perlu bantuan 0 Kesadaran Menangis 2 Bereaksi terhadap rangsangan 1 Tidak bereaksi 0 Jika jumlah > 5, penderita dapat dipindahkan ke ruangan. C. Bromage Score (spinal anestesi) Kriteria Nilai Gerakan penuh dari tungkai, 0 Tak mampu ekstensi tungkai, 1 Tak mampu fleksi lutut, 2 Tak mampu fleksi pergelangan kaki, 3 Jika Bromage Score 2 dapat pindah ke ruangan EBV ROSC SVT MALIGNANT TAKIKARDI