5. Komplikasi Anestesi

8/18/2019 5. Komplikasi Anestesi

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Gangguan Akibat

AnestesiaMuhammad Gusno Rekozar, dr. SpAn

Fakultas Kedokteran UniversitasBatam

!!"#


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• Anaesthesia is $rom the Greek andmeans %loss o$ sensation%.Anaesthesia allo&s invasive andpain$ul pro'edures to be per$ormed&ith little distress to the patient.


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• (here are three main t)pes o$anaesthesia

• General anaesthesia* the patient issedated, using either intravenousmedi'ations or gaseous substan'es,and o''asionall) mus'les paral)sed,

re+uiring 'ontrol o$ breathing b)

me'hani'al ventilation

• .


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• Regional anaesthesia* this 'an be des'ribedas 'entral &here anaestheti' drugs are

administered dire'tl) in or around the spinal'ord, blo'king the nerves o$ the spinal 'ordeg, epidural or spinal anaesthesia-. (he mainbenet o$ this method is that ventilation is not

needed provided the blo'k is not too high-.Regional anaesthesia 'an also be peripheral /$or e0ample*

• 1le0us blo'ks / eg, bra'hial ple0us.

•

2erve blo'ks / eg, $emoral.• 3ntravenous blo'ks &hilst preventing

venous 4o& out o$ the region / eg, Bier%s blo'k.


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• 5o'al anaesthesia* the anaestheti' is

applied to one site, usuall) topi'all)or sub'utaneousl)


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• 3mportant 'ompli'ations o$ generalanaesthesia

• (he pra'ti'e o$ anaesthesia is$undamental to the pra'ti'e o$ medi'ine.

6o&ever, anaesthesia is not &ithout itsproblems. 3t is di7'ult to determinee0a'tl) the in'iden'e o$ deaths dire'tl)attributable to general anaestheti's, asthe 'ause o$ death is o$ten multi$a'torialand stud) methodolog) varies making'omparisons di7'ult.


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• 8stimates o$ the number o$ deaths &heregeneral anaesthesia &as the dire't 'ause

have been +uoted in the range $rom"*"!,!!! operations to "*"9!! stud) in":; b) the Asso'iation o$ Anaesthetistso$ Great Britain and 3reland-. 2onetheless,

in ":;9 a 'ondential en+uir) intoperioperative deaths revealed that ver)$e& deaths &ere a'tuall) as a dire't resulto$ general anaesthesia / in'iden'e o$ " in";#,!;< rst =ondential 8n+uir) into1erioperative >eaths =81?>--.@"


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• Figures o$ anaestheti'/related morbidit) are moredi7'ult to determine. 8stimates suggest that upto o$ intensive 'are unit admissions at an) onetime are related to anaestheti' problems.@"Although general anaesthesia is not &ithout risk,it should be remembered that it allo&s ne'essar)pro'edures to be per$ormed in a humane &a) /

&ithout &hi'h the patient might other&ise die.Along these lines, i$ a patient is high/risk $or ageneral anaestheti' eg, pre/e0isting'omorbidities- then the) should still be re$erred

$or surger) like an) other patient. (he de'ision tooperate and &hi'h $orm o$ anaesthesia to useshould then be de'isions made b) the surgeonand anaesthetist.


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• 3mportant 'ompli'ations o$ general anaesthesia

• 1ain.• 2ausea and vomiting / up to C! o$ patients.

• >amage to teeth / " in D,#!! 'ases.

• Sore throat and lar)ngeal damage.

• Anaph)la0is to anaestheti' agents / guressu'h as !. have been +uoted.

• =ardiovas'ular 'ollapse.

•

Respirator) depression.• Aspiration pneumonitis / up to D.# $re+uen')

has been reportedE higher in 'hildren.


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• 6)pothermia.

• 6)po0i' brain damage.

•

2erve inur) / !.D in general anaesthesia and !."in regional anaesthesia.

• A&areness during anaesthesia / up to !. o$patientsE higher in obstetri's and 'ardia' patients.

• 8mbolism / air, thrombus, venous or arterial.

• Ba'ka'he.

• 6eada'he.

• 3dios)n'rati' rea'tions related to spe'i' agents / eg,malignant h)perp)re0ia &ith su0amethonium,

su''in)l'holine/related apnoea.• 3atrogeni' / eg, pneumothora0 related to 'entral line

insertion.

• >eath.


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• Some spe'i' 'ompli'ations o$ generalanaesthesia

•

Anaph)la0is

• Anaph)la0is 'an o''ur to an) anaestheti'

agent and in all t)pes o$ anaesthesia.@" (he

severit) o$ the rea'tion ma) var) but $eaturesma) in'lude rash, urti'aria, bron'hospasm,h)potension, angio/oedema, and vomiting. 3tneeds to be 'are$ull) looked $or in the pre/

operative assessment and previous generalanaestheti' 'harts ma) help.

• .


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• 1atients &ho are suspe'ted o$ anallergi' rea'tion should be re$erred $or$urther investigation to tr) to determinethe e0a't 'ause.@ 3$ ne'essar), thisma) involve provo'ation testing or skin

pri'k testing and patients should bere$erred to lo'al immunologists.Anaph)la0is needs to be promptl)re'ognised and managed and patients

should be advised to &ear a medi'alemergen') identi'ation bra'elet orsimilar on'e the) re'over


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• Aspiration pneumonitis

• A redu'ed level o$ 'ons'iousness 'an lead to an

unprote'ted air&a). 3$ the patient vomits the) 'anaspirate the vomitus 'ontents into their lungs. (his'an set up lung in4ammation &ith in$e'tion. (he risko$ aspiration pneumonitis and aspiration pneumoniais redu'ed b) $asting $or several hours prior to the

pro'edure and 'ri'oid 'artilage pressure duringindu'tion o$ anaesthesia.@" 6o&ever, the eviden'e$or the use o$ 'ri'oid pressure is not 'learl)do'umented and $urther investigation is re+uired.@C


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• ?ther methods o$ redu'ing aspirationpneumonitis asso'iated &ith anaesthesia arethe use o$ meto'lopramide to enhan'e gastri'empt)ing and ranitidine or proton pumpinhibitors to in'rease the p6 o$ gastri''ontents. (he eviden'e $or the benet o$ thesemethods appears promising.@D

•

Aspiration pneumonitis ma) also o''ur inspinal anaesthesia i$ the level o$ spinal blo'k istoo high, leading to paral)sis or impairment o$the vo'al 'ords and respirator) impairment.


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• 1eripheral nerve damage

• (his 'an o''ur &ith all the t)pes o$anaesthesia and results $rom nerve 'ompression.

(he most 'ommon 'ause is e0aggeratedpositioning $or prolonged periods o$ time. Both

the anaesthetist and the surgeons should bea&are o$ this potential 'ompli'ation and patientsshould be moved on a regular basis i$ possible.

(he severit) varies and re'over) ma) be

prolonged. (he most 'ommon nerves ae'tedare the ulnar nerve and the 'ommon peronealnerve. More rarel), the bra'hial ple0us ma) beae'ted.@"


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• 3nur) to nerves 'an be avoided b) prevention o$e0treme postures $or length) periods during surger). 3$

nerve damage o''urs then patients should be $ollo&edup and $urther investigations su'h as ele'trom)ograph)

ma) be re+uired.@#

• >amage to teeth

• 3t is no& 'ommon pra'ti'e to 'he'k the teeth in the

anaesthetist%s pre/operative assessment. >amage toteeth is a'tuall) the most 'ommon 'ause o$ 'laims madeagainst anaesthetists. (he tooth most 'ommonl) ae'ted

is the upper le$t in'isor.@


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• 8mbolism

• 8mbolism is rare during an anaestheti' but

is potentiall) $atal. Air embolism o''ursmore 'ommonl) during neurosurgi'alpro'edures or pelvi' operations.1roph)la0is o$ thromboembolism is

'ommon and begins pre/operativel) &iththromboemboli' deterrents (8>S- and lo&mole'ular &eight heparin 5MH6-.@9


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• 3mportant 'ompli'ations o$ regional anaesthesia

• =entral regional anaesthesia &as rst used at the

end o$ the ";th 'entur). 3t provided a method o$blo'king aerent and eerent nerves b) ine'tinganaestheti' agents in either the epidural spa'earound the spinal 'ord epidural anaesthesia- ordire'tl) in the 'erebrospinal 4uid surrounding the

spinal 'ord ie in the subara'hnoid spa'e 'alledspinal anaesthesia-. All nerves are blo'ked in'ludingmotor nerves, sensor) nerves and nerves o$ theautonomi' s)stem.


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• 8pidural anaesthesia takes slightl) longerthan spinal anaesthesia to take ee't and

provides predominantl) analgesi' properties.Hith both, the need $or mus'le paral)sis andventilation is not usuall) re+uired but there isa risk that a high blo'k &ill impair respiration,

meaning that ventilation &ill be ne'essar).Results $rom a revie& o$ ""D studies and a=o'hrane s)stemati' revie& have sho&n thatregional anaesthesia is asso'iated &ith

redu'ed mortalit) and redu'tion in serious'ompli'ations in 'omparison &ith general

anaesthesia.@;@:


20/34

• 1ain / # o$ patients still e0perien'e pain despitespinal anaesthesia.

• 1ost/dural heada'he $rom 'erebrospinal 4uid=SF- leak.

• 6)potension and brad)'ardia through blo'kadeo$ the s)mpatheti' nervous s)stem.

• 5imb damage $rom sensor) and motor blo'k.

• 8pidural or intrathe'al bleed.

• Respirator) $ailure i$ blo'k is %too high%.

• >ire't nerve damage.

• 6)pothermia.


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• >amage to the spinal 'ord / ma) be transientor permanent.

• Spinal in$e'tion.

•

Asepti' meningitis.• 6aematoma o$ the spinal 'ord / enhan'ed

b) use o$ 5MH6 pre/operativel).

• Anaph)la0is.

• Urinar) retention.

• Spinal 'ord in$ar'tion.

• Anaestheti' into0i'ation.@"!


22/34

• Some spe'i' 'ompli'ations o$ regionalanaesthesia

• 1ost/dural pun'ture heada'he

• 1ost/dural pun'ture heada'he is ver)

'ommon a$ter spinal anaesthesia andespe'iall) in )oung adults and obstetri's. (heheada'he results $rom =SF leak $rom thepun'ture site. 3t is enhan'ed b) use o$ larger/gauge needles and redu'ed b) pen'il/tippedneedles. 1resenting s)mptoms ma) in'ludeheada'he, photophobia, vomiting anddizziness.@""


23/34

• 1ost/dural pun'ture heada'he is usuall) treated &ithanalgesia, bed rest and ade+uate h)dration. (heeviden'e does not suggest that bed rest prevents or'hanges the out'ome.@" @"C ?''asionall) epidural

blood pat'h is used &here "# ml o$ the patient%s bloodare ine'ted at the site o$ the meningeal tear.@""=aeine is also used and a'ts as a stimulant o$ the=2S and has sho&n benet.@"D ?ther medi'ations&ith benet in'lude gabapentin, theoph)lline and

h)dro'ortisone.@"D Sub'utaneous sumatriptan,adreno'orti'otrophi' hormone A=(6- and epiduralsaline have not sho&n 'onsistent benets.@"@"D


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• (otal spinal blo'k

• (otal spinal blo'k 'an o''ur &ith theine'tion o$ large amounts o$ anaestheti'agents into the spinal 'ord. 3t is dete'ted b)a high sensor) level and rapid mus'leparal)sis. (he blo'k moves up the spinal'ord so that respirator) embarrassment ma)o''ur, as 'an un'ons'iousness. 3n thesesituations the patient needs promptassessment and ma) need to be intubatedand ventilated until the spinal blo'k &earso.


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• 6)potension

• Up to hal$ o$ patients re'eiving spinalanaesthesia &ill develop transienth)potension as s)mpatheti' nerves are

blo'ked. (his usuall) responds toprompt 4uid repla'ement, usuall)starting &ith 'r)stalloids $ollo&ed b)

'olloids. ?''asionall) h)potension 'anbe severe and ma) re+uirevasopressors along &ith 4uids.@"!@"#


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• =are must be taken in patients &ith a 'ardia'histor), as the) ma) develop m)o'ardial

is'haemia &ith minor drops in blood pressure.@"


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• 2eurologi'al de'its

• =auda e+uina s)ndrome ma) o''ur and 'an betransient or permanent. (his is a 'ommon reason$or patients to re$use spinal anaesthesia. (herema) also be traumati' inur) to the spinal 'ord.

@"!@";• Adhesive ara'hnoiditis is a longer/term se+uela

o$ spinal anaesthesia, o''urring &eeks and evenmonths later.@"; 3t is 'hara'terised b)proli$eration o$ the meninges and vaso'onstri'tiono$ spinal 'ord blood vessels. (his results ingradual sensor) and motor de'its $romis'haemia and in$ar'tion o$ the spinal 'ord.@":


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• 3mportant 'ompli'ations o$ lo'alanaesthesia

• 1ain.

•

Bleeding and haematoma$ormation.

• 2erve inur) due to dire't inur).

•

3n$e'tion.• 3s'haemi' ne'rosis.


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• All $orms o$ anaestheti's are invasive toa patient and there$ore 'onsent should

be obtained as $or other pro'edures.3deall) patients should be given a lea4etregarding anaesthesia and then'ounselled regarding the intendedbenets and the risks o$ anaesthesia. 3na general pra'ti'e setting it &ill be theresponsibilit) o$ the 'lini'ian &ho

administers the lo'al anaesthesia toensure good, non/'oer'ive 'onsent isobtained.


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• Further reading I re$eren'es

• Aitkenhead ARE 3nuries asso'iated &ith anaesthesia. A

global perspe'tive.E Br J Anaesth. !!# JulE:#"-*:#/"!:.8pub !!# Ma) !.

• Kroigaard M, Garve) 56, Menne (, et alE Allergi' rea'tionsin anaesthesia* are suspe'ted 'auses 'onrmed onsubse+uent testingE Br J Anaesth. !!# ?'tE:#D-*D


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• 6omann J, Hestendor =, Reinert SE 8valuation o$ dental inur)$ollo&ing endotra'heal intubation using the 1eriotest te'hni+ue.E >ent (raumatol. !!# ?'tE"#-*RE Updates in perioperative 'oagulation*ph)siolog) and management o$ thromboembolism and haemorrhage.EBr J Anaesth. !!D AugE:C-*9#/;9. 8pub !!D Jun #.

• Rodgers A, Halker 2, S'hug S, et alE Redu'tion o$ postoperativemortalit) and morbidit) &ith epidural or spinal anaesthesia* results $romovervie& o$ randomised trials.E BMJ. !!! >e' "atabase S)st Rev. !"D Jan#E"*=>!"!"!;. doi* "!."!!"D


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• Ku'zko&ski KME 1ost/dural pun'ture heada'he in theobstetri' patient* an old problem. 2e& solutions.E MinervaAnestesiol. !!D >e'E9!"-*;C/C!.

• (urnbull >K, Shepherd >BE 1ost/dural pun'ture heada'he*pathogenesis, prevention and treatment.E Br J Anaesth. !!C2ovE:"#-*9";/:.

• Arevalo/Rodriguez 3, =iapponi A, Munoz 5, et alE 1ostureand 4uids $or preventing post/dural pun'ture heada'he.=o'hrane >atabase S)st Rev. !"C Jul "E9*=>!!:"::. doi*"!."!!"Database S)st Rev. !"" Aug "!E;-*=>!!9;;9. doi*"!."!!"D


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• =ompli'ations o$ Regional AnaesthesiaE Anaesthesia UK, !!#

• Jin F, =hung FE Minimizing perioperative adverse events inthe elderl).E Br J Anaesth. !!" ?'tE;9D-*

• 6anss R, Bein B, Heseloh 6, et alE 6eart rate variabilit)predi'ts severe h)potension a$ter spinal anesthesia.EAnesthesiolog). !!< MarE"!DC-*#C9/D#.

• 6)derall) 6E =ompli'ations o$ spinal anesthesia.E Mt Sinai JMed. !! Jan/MarEe'E


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