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ANESTHESIA
intravenou
totalaanesthesia
nesthesia
DEFINITION
TIVA means the use of IV agents
exclusively to provide a complete
anesthetic.
s
3 A's of Anesthesia(with or
without muscle relaxation):Amnesia
(anxiolysis, ataraxia), Autonomic
areflexia (CV, resp, GI), Analgesia,
Muscle relaxation
(Gordon, 2003)
intravenou
totalaanesthesia
nesthesia
ADVANTAGES
Combination of drugs, separately
infused, allows titration of each to the
specific dose required to meet the
s
specific needs of the case.
The anesthetic is completely
(vaporizers) needed.
(Gordon, 2003)
intravenou
ADVENTAGES (CONTD)
totalaanesthesia
nesthesia
Discharge time from PACU may be shortened
when propofol used as induction and
maintanance of anesthesia
Decrease morbidity due to malignant
s
hypertermia associated with succinylcholine
and other volatile anesthetics in susceptible
patient
No environmental contamination
Non-cummulative
Potent
s
Resistance to microbial contamination
Non-allergenic
No cardiopulmonary depression
No effect on CBF
No endocrinologic effect
No pain on injection
inexpensive
intravenou
totalaanesthesia
nesthesia
No single agent can provide 3A anesthesia
Need combined drugs with different mechanism
Less toxicity
s
Faster recovery
Reduced cost
intravenou
totalaanesthesia
nesthesia
ROUTE OF TIVA
Simple intravenous bolus
Variable rate continuous infusion
(simple syringe pump, target
s
controlled infusion pump)
intravenou
ADVANTAGES OF CONTINUOUS
totalaanesthesia
nesthesia
INFUSION
Hemodinamic stability
More stable depth of anesthesia
More predictable and rapid recovery
s
Lower total dose of drugs used
intravenou
totalaanesthesia
nesthesia
Amnesia/sedation : propofol,
ketamin, benzodiazepin, barbiturate,
etomidate
s
Analgesia : fentanyl, remifentanyl,
sufentanyl, alfentanyl, morphime
Muscle relaxant : atracurium,
vecuronium
DRUGS COMMONLY USED IN TIVA
intravenou
totalaanesthesia
nesthesia
(TITRATE TO EFFECT)
Propofol
Induction: 2-2.5 mg/kg
Maintenance: 50-200 mcg/kg/min
s
Ketamine
Induction 0.5-2mg/kg
Maintenance 20-90mcg/kg/min
Can combine w/propofol 4:1
e.g.200mgpropfol+50mg ketamine
Dosis 0,1-1 mg/kg iv 2,5-5 mg/kg iv 2-150 mcg/kg 8-100 mcg/kg 0,25-30 mcg/kg 1 mcg/kg iv
intraoperatif iv iv iv 0,5-20
0,5-3 mcg/kg/mnt iv
mcg/kg/mnt iv
Puncak (mnt) 30-60 mnt 5-7 mnt 3-5 mnt 1,5-2 mnt 3-5 mnt 1,5-2 mnt
s
Durasi (jam) 3-4 2-3 0,5-1 0,2-0,3 0,5-1 0,1-0,2
RR D D D D D D
HR D no D D D D
Muscle rigidity + + + ++ ++ +
Waktu D D D D D D
Pengosongan
lambung
Retensi urin + + + + + +
Morgan, 2006
intravenou
CARA PEMBERIAN
totalaanesthesia
nesthesia
1. Intermitten
rentang kedalaman anestesi sangat luas antara
batas atas bawah dari target
konsentrasi obat yang tinggi pada setiap pemberian
bolus diikuti oleh penurunan yang cepat pula,
diakibatkan distribusi dan redistribusi yang cepat
s
menyebabkan fluktuasi kadar obat dalam darah
dan otak, tergantung dosis bolus dan frekuensi
pemberian
bisa menyebabkan ketidakstabilan hemodinamik
dan respiratorik
umumnya dilakukan untuk prosedur operasi yang
durasi pendek
2. Infus kontinyu
intravenou
totalaanesthesia
nesthesia
memungkinkan untuk mempertahankan
konsentrasi obat dalam darah (dan otak)
pengaturan peningkatan dosis obat
kecepatan infuse disesuaikan kebutuhan
bila obat diberikan melalui infuse dengan
peningkatan dosis dengan interval tertentu,
jumlah yang diberikan akan ditambahkan dengan
s
yang telah ada di dalam tubuh
kadar total obat dalam tubuh meningkat bertahap
sampai kecepatan pemberiannya menyamai
kecepatan eliminasi
bila waktu penambahan obat kurang dari dua kali
kecepatan eliminasi, maka akan terjadi akumulasi
obat
Pemberian dengan kecepatan tetap
intravenou
totalaanesthesia
nesthesia untuk periode yang panjang akan
menyebabkan kenaikan progresif
konsentrasi plasma sampai keadaan
steady state
Pada keadaan steady state ini
s
kecepatan pemberian (rate of
administration) seimbang dengan
kecepatan pembuangan (rate of
elimination)
Waktu untuk mencapai steady state
bervariasi pada setiap obat, dan
tergantung pada waktu paruh
terminal dan volume distribusi
Untuk mencapai keadaan steady state ada
intravenou
totalaanesthesia
nesthesia
beberapa cara (Kay, 1991):
1. Infus kecepatan tetap
konsentrasi obat dalam plasma meningkat secara
eksponensial
mempercepat kecepatan infuse dapat
mempercepat terjadinya stadium anestesi
s
mudah menyebabkan overdosis dan depresi
berbagai system tubuh
Miller, 2005
Efek samping dan kontraindikasi
intravenou
totalaanesthesia
nesthesia Problem signifikan midazolam adalah depresi
respirasi
Diazepam dan lorazepam menimbulkan iritasi
vena dan tromboflebitis
Amnesia post operatif dan sedasi setelah
s
induksi dan maintenance dengan midazolam
dapat memanjang
Efek residual ini dapat diatasi dengan
flumazenil
intravenou
totalaanesthesia
nesthesia
BARBITURAT
Mekanisme :
Fasilitasi GABA
s
Dosis :
Miller, 2005
Efek Samping dan Kontraindikasi
intravenou
totalaanesthesia
nesthesia
Reaksi alergi
Miller, 200
intravenou
totalaanesthesia
nesthesia
Most commonly used hypnotic for tiva
No active metabolites
Rapid onset
s
Antiemetic
Not MH trigger
decrease in ICP
intravenou
totalaanesthesia
nesthesia
DISADVANTAGES
Seizure, opisthotonus, Myoclonus phenomenon
Pain and phlebitis on injection
Alleergic reaction
s
Bacterial growth
Dosis :
s
Miller, 2005
Efek Samping dan Kontraindikasi
intravenou
totalaanesthesia
nesthesia
peningkatan tekanan intrakranial
17
intravenou
totalaanesthesia
nesthesia
DEXMEDETOMIDINE
Highly selective 2 adrenoreceptor agonist
Ssedative and analgesic effect, without
Dosis :
Fentanyl: 1,5 g/kg, dosis lanjutan 0,8 g/kg
s
Sufentanyl: 0,15 g/kg, dosis lanjutan 0,08
g/kg
Alfentanyl: 4 g/kg, dosis lanjutan 2 g/kg
Miller, 2005
Efek Samping dan Kontraindikasi
intravenou
totalaanesthesia
nesthesia
Penurunan tekanan darah biasanya akibat
memperlambat peristaltik
17
intravenou
nesthesia
totalaanesthesia
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intravenou
nesthesia
totalaanesthesia
s
Morgan, 2006
intravenou
nesthesia
totalaanesthesia
s
Morgan, 2006
intravenou
totalaanesthesia
nesthesia
AWARENESS DURING ANESTHESIA
Estimates of awareness during anesthesia in
nonobstetric and noncardiac surgeries are
approximately 0.1-0.2%.
s
Recognized risk factors for awareness include the following:
Light levels of anesthesia, which are common in hypovolemic, trauma, and
obstetric patients.
Patients undergoing cardiac surgery with cardiopulmonary bypass also
have a higher incidence of postoperative recall (about 1%) because of the
reliance on narcotic-based anesthesia, which minimizes myocardial
depression but produces unreliable amnesia.
The use of muscle relaxants is an independent risk factor for awareness.
Machine malfunction, such as empty vaporizers, intravenous anesthetic
pump malfunction or disconnection, etc.
Occasionally in patients with unrecognized increased anesthetic
requirements, such as the very young, chronic substance-abusing patients,
and hypernatremia.
intravenou
SIGNS AND SYMPTOMS OF LIGHT
totalaanesthesia
nesthesia
ANESTHESIA
Motor signs in response to light anesthesia frequently precede
hemodynamic changes or sympathetic activation. Specific motor
signs include eyelid or eye motion, swallowing, coughing,
grimacing, and movement of the extremities or head. Increased
respiratory effort is due to activity of intercostal and abdominal
s
muscles, which are suppressed at deeper levels of anesthesia.
With the use of neuromuscular blockade, motor signs do not
provide information about anesthetic depth.
Consequently, sympathetic activation represents an additional
method for assessing light anesthesia. Sympathetic effects
associated with light anesthesia include hypertension,
tachycardia, mydriasis, tearing, sweating, and salivation. Such
findings are nonspecific and are modified by anesthetic agents;
thus their presence or absence is an unreliable indicator of
awareness.
intravenou
totalaanesthesia
nesthesia
BISPECTRAL INDEX (BIS)
The purpose of any of these forms of EEG analysis is to
estimate the degree of hypnosis that the patient is
experiencing. Raw data, collected by electrodes placed on
the forehead and temporal area, are processed by the
s
computer module to create a numerical representation of
the degree of sedation. Lower numbers correspond to a
greater depth, while higher numbers are found in awake or
lightly sedated patients.
The incidence of awareness in high-risk cases was reduced
by approximately 82% (0.91-0.17%) when BIS-guided
anesthesia was provided with a BIS goal of 40-60% during
anesthesia. Using BIS during general anesthesia with
concurrent muscle relaxation resulted in a similar
reduction of 77% (0.18-0.04%) in the incidence of
awareness.
intravenou
AUDITORY EVOKED POTENTIALS
totalaanesthesia
nesthesia
(AEP)
AEP use auditory stimuli to evaluate the level of cerebral
activity.
To evaluate the depth of anesthesia, midlatency AEP
(MLAEP) recorded 10-100 min after auditory stimulation.
s
The AEP-A monitor generates an index derived from
analysis of MLAEP waveforms. Once this monitor has
acquired the baseline signal, the signal changes during
anesthesia, the A-line ARX index (scale to 0-100) reflects
the hypnotic state of the individual.
AEP cab be use to control the propofol plasma
consentration sufficient to provoked narcosis status for each
individual patient, avoiding risk of awareness and reducing
side effect.
(ferraro, et all., 2006)
intravenou
TARGET CONTROLLED INFUSION
totalaanesthesia
nesthesia
(TCI)
Consentration in the effect site is a direct
determinant of drug effect rather than plasma
consentration.
TCI : Computerised infusion systems capable of
s
delivering variable infusion regimes based on
mathematical solution to complex
pharmacokinetic models.
Allow the anesthetist to achieve and maintain
desired target drug consentration appropriate to
an individual patient and level of surgery
intravenou
totalaanesthesia
nesthesia
PROPOFOL-REMIFENTANYL
Induction bolus : propofol 1,5 mg/kg, remifentany
1-1,5 mcg/kg 60s before DL
Maintanance infusion :
s
Propofol 150 mcg/kg/min for 15 min
Propofol 125 mcg/kg/min for 2nd 15 min
Propofol 100 mcg/kg/min untul terminated