1. Pengelolaan Perioperatif Pasien Anak/Bayi Elizeus Hanindito

2. Dimulai sejak persiapan preoperatif

3. Pengelolaan Perioperatif Pengelolaan Preoperatif Pengelolaan Intraoperatif Pengelolaan Postoperatif

4. ANAK LAKI2 USIA 4 TAHUN AKAN DILAKUKAN PEMBEDAHAN HERNIOTOMI TERRENCANA BAGAIMANA PERSIAPAN PEMBEDAHAN ? PENILAIAN PREOPERATIF/PRABEDAH ANAMNESA PEMERIKSAAN FISIK PEMERIKSAAN PENUNJANG (LABORATORIUM)

5. Clear liquids2 jam Breast milk4 jam Infant formula6 jam Light meal6-8 jam Minimum Fasting Periods: Pedoman Puasa MENGAPA PERLU PUASA ?

6. The aim of anesthesia & surgery is safety Safety means accident prevention Accident prevention begin with preoperative evaluation

7. Penilaian Preoperatif Tujuan : deteksi masalah aktual/potensial yang meningkatkan resiko anestesi/pembedahan dan melakukan, Optimalisasi kondisi pasien sehingga meminimalkan penyulit aktual/potensial. Misalnya Gangguan hemodinamik (dehidrasi, shock, aritmia) OSA, asthma, URI Prematuritas Congenital Heart Disease MASALAH PENYAKIT PENYERTA, MASALAH PEMBEDAHAN, MASALAH ANESTESI

8. 8 Patient-related risk Procedure-related risk Anesthetic-related riskProvider-related risk Perioperative risk Michota F, Frost S; Med Clin N Am 2002. Congenital anomaly Prematurity URI, PS - ASA Bleeding Emergency Airway procedure Equipments Environment Surgery team Anesthetic agent Malignant hyperthermia Airway problems

9. Bayi 4 minggu, BB 3.5 kg, muntah setiap minum susu. Tampak lemah, pucat dan kurus, mata cowong Nadi 160 kecil, perfusi dingin, turgor jelek Tensi 60/40, nafas 70 Ngompol terakhir sdh 6 jam Suhu 39, kejang pH 7.25, PaO2 70, PaCO2 25, HCO3 35 Na 115 K 2.1 Cl 89 Bagaimana persiapan preop ?

10. Bayi 1 bulan, abdomen kembung hebat, nafas cepat dangkal. Perfusi dingin, pucat. CRT 5 detik Suhu 38.5 Lethargi Apa permasalahan ? Bgmn persiapan preop ? GANGGUAN VENTILASI/ OKSIGENASI GANGGUAN SIRKULASI GAGAL VENTILASI/ OKSIGENASI GAGAL SIRKULASI

11. PRIORITAS PENANGANAN PREOPERATIF B1 : breath B2 : bleed B3 : brain B4 : bladder B5 : bowel B6 : bone

12. PRIORITAS PENANGANAN PREOPERATIF B1 : breath B2 : bleed B3 : brain B4 : bladder B5 : bowel B6 : bone Gagal beberapa menit saja sudah berakibat kematian

13. Masalah B1 dan B2

14. Konsep Dehidrasi Awal kehilangan cairan berasal dari extracellular fluid (ECF). Bertahap, air bergeser dari intracellular utk mempertahankan ECF. Sakit akut (< 3 hari ): 80% kehilangan cairan berasal dari ECF, 20% dari intracellular fluid (ICF). Sakit memanjang (> 3 hari): 60% kehilangan dari ECF, 40% dari ICF.

15. 5 langkah pengelolaan dehidrasi Seberapa besar derajat dehidrasi? Apakah ada masalah osmolaritas ? Akut atau kronis ? Apakah ada masalah keseimbangan asam-basa? Apakah fungsi ginjal terganggu? Bagaimana status Kalium serum ?

16. Dehidrasi Ringan 3-5% Dehidrasi Sedang 7-10% Dehidrasi Berat 10-15% : perlu resusitasi cairan/rehidrasi cepat Derajat Dehidrasi

17. Tipe Dehidrasi Isotonik : Serum Na = 130-150 mEq/L 80% kasus dehidrasi Hipertonik : Serum Na > 150 mEq/L 15% kasus dehidrasi Hipotonik : Serum Na < 130 mEq/L

18. Perkiraan Derajat Dehidrasi RINGANSEDANGBERAT BERAT BADAN TURUN3-5 %6-9 %> 10 % TEKANAN DARAHNORMALORTHOSTATIKSHOCK NADINORMALMENINGKATTAKIKARDI CAPILLARY REFILL2 DETIK2-4 DETIK> 4 DETIK MUKOSABASAHKERING‘PARCHED’ AIR MATAADAKURANGTANPA URINENORMALOLIGURIAANURIA PERILAKUNORMALREWELLETHARGIC

19. Gejala klinis dehidrasi Signs & SymptonsRingan 3-5%Sedang 6-9%Berat > 10% Keadaan umumHaus, rewel, cemas/gelisah MengantukTidak sadar, lemah NadiNormalCepat & kecilCepat, kecil/tak teraba PernafasanNormalCepat & dalamCepat - apnea Ubun2NormalCekungCekung >> Capillary Refill Perfusi perifer < 2 detik HKM 3-4 detik> 4 detik DBP MukosaBasahKeringSangat kering Tekanan darahNormal hipotensi

20. Defisit > 10% - Nadi lemah dan cepat - Tekanan darah turun - Mata cowong & ubun2 cekung - Oliguri – anuria - Mukosa kering - Turgor turun - Perfusi perifer : dingin basah pucat - Capillary refill time memanjang Dehidrasi Berat ~ syok hipovolemik

21. Capillary Refill Time (CRT)

22. Ubun2 & elastistas kulit

23. Turgor kulit

24. Produksi urine

25. Mengantuk-Lethargy

26. Jalur intravena terpasang dalam waktu < 90 detik

27. Terapi cairan pada dehidrasi (shock hypovolemic) I. Resuscitation phase2. Replacement phase3. Stabilization phase

28. Tujuan : mengembalikan fungsi sirkulasi, reperfusi otak, ginjal Moderate :  20 mL/kg iv bolus (10 – 15 menit) Severe :  dosis bisa diulang (sampai 60ml/kg iv bolus) Jenis cairan – selalu cairan isotonik (sesuai komposisi ECF) kristaloid : Normal Saline, Ringer laktat/asetat Phase I – Resuscitation Phase

29. Determinants of Oxygen Delivery (DO2) Fluid resuscitation

30. Oxygen Delivery (DO 2 ) DO 2 =Cardiac Output x 1.34 (Hgb x SaO 2 ) + Pa0 2 x 0.003 O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2 O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2O2 Oxygen Express Ca0 2 Oxygen ContentCardiac output

31. OXYGEN CARRYING CAPACITY SaO2 ~ 97-98% ; Hb 15 g/dL O2 CONTENT =(1.34 x Hb x SaO2) + 0.0031 x PaO2 1gm Hb ~ 1.34 ml oxygen O2 content in 100 ml blood (Hb 15 gm/dL) ~ 20 ml (19.4 ml OxyHb + 0.3 ml dissolve in plasma) DO2 ~ (heart rate x stroke volume) ~ 4-5 liter/menit Dalam 1 menit tersedia oksigen 5000/100 x 20 ml ~ 800 - 1000 ml

32. Cukupi preload  cukupi volume intravaskular

33. Phase II: Replacement Phase Phase III: Stabilization Phase ( Dehidrasi Isotonik/Hipotonik ) Goal: slow replacement deficit of fluids and electrolytes Replacement Phase 1 st 8 hrs Stabilization Phase Next 16 hrs Kebutuhan rumatan (H2O & Na) 1/32/3 Kebutuhan Deficit (H2O & Na) 1/2 24 jam

34. Resusitasi Cairan Dehidrasi Berat/shock hipovolemik RL atau NS : 20 ml/kg iv 10-15 menit (boleh 3x) – mengisi intravaskuler Hitung perkiraan kekurangan cairan : Mis. BB 10 kg, dehidrasi berat (syok)  Defisit cairan 10% x 10 kg (liter) = 1 liter (1000 ml). Shock harus segera diatasi : 20 ml/kg cepat – 200 ml Evaluasi hemodinamik kalau perlu diulangi. Sisa defisit (800 ml) diberikan lebih lambat + kebutuhan rumatan.

35. Berikan sisa defisit dalam 24 jam 8 jam pertama : 50% defisit + rumatan 16 jam berikutnya : 50% defisit + rumatan 400 ml/8 jam (NS) + 40 ml/jam (Dextr + elektrolit) 400 ml/16 jam (NS) + 40 ml/jam (Dextr + elektrolit) Observasi hemodinamik

36. Pengelolaan Cairan Perioperatif I.Pengelolaan Cairan Pengganti A.Defisit Cairan Prabedah a.Puasa b. Dehidrasi c. Gangguan keseimbangan elektrolit & asam basa B.Defisit Cairan Intra operasi a. Kehilangan pada ruang ketiga (Third space loss) b. Kehilangan yang sedang berjalan (Ongoing loss) II.Pengelolaan Cairan Rumatan III. Pengelolaan Cairan Pasca operasi a.Cairan Rumatan b.Pengganti Defisit Cairan c.Transfusi

37. Respon hemodinamik pada hipovolemia Tekanan darah arteri Denyut jantung Bayi & anakDewasa Denyut jantung Tekanan darah arteri 40% blood loss/dehidrasi

38. Pengelolaan Intraoperatif Induksi anestesi Rumatan anestesi + pemantauan fungsi vital Pengelolaan cairan dan perdarahan. Pengaturan suhu tubuh.

39. Premedikasi Per oral : Midazolam 0.5 mg/kg bb Ketamine 8 mg/kg bb Intravena : Midazolam 0.025-0.1 mg/kg bb Ketamine 0.25 mg/kg bb Nasal : Midazolam 0.2 mg/kg bb Ketamine 6 mg/kg bb Intramuscular : Ketamine 1 mg/kg bb Kombinasi : Midazolam 0.25 mg/kg bb + Ketamine 3 mg/kg bb

40. Premedikasi oral OBAT DOSIS EFEK PUNCAK Midazolam IV : 0.025 - 0.1 mg/kg

41. Induksi Inhalasi

42. Induksi intravena & Distraksi

44. ‘gujer’ anesthesia

45. Kebutuhan Cairan Perioperatif Kebutuhan Rumatan (Maintenance) Kebutuhan Pengganti (Replacement) : defisit prabedah (preoperative deficit) defisit yang berjalan (ongoing losses)

46. Kebutuhan Cairan Rumatan RUMUS 4 – 2 – 1 Berat badan 1 – 10 kg : 4 ml/kg BB/jam + Berat badan 10 – 20 kg : 2 ml/kg BB/jam + Berat badan > 20 : 1 ml/kg BB/jam

47. Contoh Anak BB 23 kg Hitung kebutuhan rumatan : 10 x 4 = 40 10 x 2 = 20 3 x 1 = 3 Kebutuhan cairan rumatan total 63 cc/jam 63 x 24 cc/hari

48. Cairan pengganti (replacement) Cairan harus bersifat isotonik ~ komposisi plasma (extracellular fluid) Cairan kristaloid/koloid: RL (Ringer laktate) NaCl 0.9% (larutan garam fisilogis) RA (Ringer Asetat) Koloid sintetik/Plasma Transfusi darah

49. Pemantauan Intraoperatif Oksigenasi Ventilasi Hemodinamik

50. Pulse Oximetry Setiap pasien kritis harus dipantau pulse oximeter. Anaesthesia without a pulse oximeter is like flying a plane without a radar, or skydiving without an emergency parachute.

51. Pulse oximetry SpO 2 (%)INTERPRETASI 95 – 100Normal 91 – 94Mild Hypoxemia 86 – 90Moderate Hypoxemia < 85Severe Hypoxemia

52. Capnography

53. Elektrokardiografi 1.Frekwensi (Rate) 2.Irama (Rhythm) 3.Sumbu (Axis). 4.Hipertropi (Hypertrophy). 5.Infark (Infarction).

54. Failsafe monitoring

55. Precordial/esophageal stethoscope Digunakan sebagai monitor anestesi sejak tahun 70an. Deteksi suara jantung & nafas : crisp heart tone, muffled heart sound, murmur. Posisi 2 - 4th intercostal space, left sternal border ( diatas nipple line). Esophageal stethoscope (best position : dengar suara maximal nafas & jantung)

56. Kebutuhan cairan selama pembedahan Minimally invasive surgery : 0-2 ml/kg/jam Strabismus repair Mildly invasive surgery : 2-4 ml/kg/jam Reimplantasi ureter Moderately invasive surgery : 4-8 ml/kg/jam Tutup colostomy Maximally invasive surgery : > 8 ml/kg/jam –Reseksi usus (NEC) C A I R A N I S O T O N I S CAIRANRUMATANACAIRANRUMATANA SISA DEFISIT SISA DEFISIT C A I R A N H I P O T O N IS

57. Isonatremic dehydration By far the most common Equal losses of Na and Water Na = 130-150 No significant change between fluid compartments No need to correct slowly

58. Hypernatremic Dehydration Water loss > sodium loss Na >150mmol/L Water shifts from ICF to ECF Child appears relatively less ill More intravascular volume Less physical signs Alternating between lethargy and hyperirritability

59. Hypernatremic Dehydration Physical findings Dry doughy skin Increased muscle tone Correction Correct Na slowly If lowered to quickly causes massive cerebral edema intractable seizures

60. Hyponatremic Dehydration Sodium loss > Water loss Na <130mmol/L Water shifts from ECF to ICF Child appears relatively more ill Less intravascular volume More clinical signs Cerebral edema Seizure and Coma with Na <120

61. Hyponatremic Dehydration Correction Must again be performed slowly unless actively seizing Rapid correction of chronic hyponatremia thought to contribute to…. Central Pontine Myelinolysis Fluctuating LOC Pseudobulbar palsy Quadraparesis

62. Severe Dehydration Management of severe dehydration requires IV fluids Fluid selection and rate should be dictated by The type of dehydration The serum Na Clinical findings Aggressive IV NS bolus remains the mainstay of early intervention in all subtypes

63. Isonatremic Dehydration Calculate the fluid deficit Deficit (cc’s) = % dehydration x body wt D 5 ½NS is fluid of choice (½ deficit – the bolus) over the first 8hrs Add maintenance and any ongoing losses to above Further ½ the deficit replaced over the next 16hrs Monitor electrolytes and U/O

64. Hypernatremic Dehydration Fluid deficit = (Current Na/Desired Na – 1) x 0.6 x body wt Replace with D 5 0.2%NS Replace over 48hrs Reduce sodium by no more than 10mEq/L/24hrs (½ deficit – the bolus) over the first 24hrs Add maintenance and any ongoing losses to above Further ½ the deficit replaced over the next 24hrs

65. Hyponatremic dehydration Na deficit = (Na desired - Na current ) x 0.6 x Weight (kg) Divide above by Na in mEq/L within the replacement fluid 154 mEq in NS 77 mEq in D 5 ½ NS 513 in 3% saline divide by deficit x 2 to determine rate at 0.5mEq/L/hr

66. Hyponatremic Dehydration If seizing Correct with 3% Saline bolus Target a Na of 120 Further correction beyond this with D 5 ½ NS If not Seizing Correct with D 5 ½ NS Target a Na of 130 Watch for Central Pontine Myelinolysis More likely in chronic hypo-Na with less Sx Correct slowly at rate of 0.5mEq/L/hr

67. 67 Hipotermi Klasifikasi hipothermia berdasarkan suhu tubuh sentral (core temperature) NORMAL : 36.5 to 37.3˚C Cold Stress : 36.0 to 36.4˚C Moderate hypothermia : 32 –35.9˚C Severe hypothermia : < 32˚C

68. Case #4 9 month old Male Previously healthy Weight 10kg 5 day hx of severe diarrhea with intermittent vomiting Mother says stool like liquid Has been aggressively rehydrating him with water at home Today is much more lethargic and difficult to rouse By ambulance to the ED

69. Case #4 Exam Vitals = HR 172, RR 41, BP 65/40, Temp 37.2, Child is minimally responsive to pain He is Tachycardic and Tachypneic Cap refill time is >3 seconds As you are examining him he begins to have a seizure What do you want to do now? Investigations? Cap gas comes back and the patients sodium is 115

70. Back to our case Exam Vitals = HR 172, RR 41, BP 65/40, Temp 37.2, Child is minimally responsive to pain He is Tachycardic and Tachypneic Cap refill time is 5 seconds Fontanelle and eyes are sunken As you are examining him he begins to have a seizure What do you want to do now? Investigations? Cap gas comes back and the patients sodium is 115!!!

71. Case cont Initial bolus 20cc/kg of NS Seizing Correct Na to 120 with 3% saline bolus (120 – 115) x 0.6 x 10kg = 30mEq 30mEq ÷ 513mEq/L = 58cc bolus Further correction after above Correct Na to 130 with D 5 ½ NS (130-120) x 0.6 x 10kg = 60mEq 60mEq ÷ 77mEq/L = 780cc 780 ÷ (10 x 2) = 39cc/hr to correct at 0.5mEq/L/hr

72. Penggantian Perdarahan Kristaloid : 2-3 kali perkiraan perdarahan Koloid : 1 kali perkiraan perdarahan Darah : 1 kali perkiraan perdarahan

73. Cegah hipotermi Meningkatkan perdarahan dan koagulopati perioperatif. Meningkatkan waktu pulih sadar. Menggigil  konsumsi oksigen meningkat ‘cardiac event’ (aritmia, iskemia miokard) Potensi infeksi luka operasi Depresi fungsi kognitif

74. Mengapa terjadi hipotermi intraoperatif ? Hilangnya respon tubuh terhadap penurunan suhu. Eksposur pada lingkungan Pengaruh dari gas anestesi, cairan infus Aktivitas metabolisme tubuh turun

75. Thermoregulatory system

76. Hypothalamic Thermoregulation

79. hours

80. Heat loss mode Radiation : 40% Convection : 30% Conduction : 5% Evaporation : 8-15% Respiration : 8-10%

81. Hypothermia Impaired thermoregulation Lack of fat insulation Larger surface to volume ratio Fewer brown fat cells Thin skin  increased heat loss apnea, bradycardia, metabolic acidosis, hypoglycemia

82. Surgical site infection & hypothermia Normothermia is more effective than antibiotics! Melling et al

83. Matras penghangat Penghangat infus

84. desinfeksi keringkan precordial stethoscope

85. Pipa nasogastrik Probe suhu oesofagus Fiksasi pipa e.t. Ukuran pipa e.t.

86. Akses terbatas Lapangan operasi >>

87. Post Anaesthesia Care Unit (PACU) Respiratory Cardiovascular Hypo/hyperthermia Pain & Agitation PONV Croup & Sore-throat Shivering

88. Perioperative transfusion trigger Infant <4 bulan : Hb < 12 g% 24 jam pertama postpartum. Hct 35%, CPAP, apnea+bradycardia Hct > 35% + ventilator Hct > 45% + Cyanotic Heart Disease Acute blood losses > 10% EBV Infants >4 bulan : Perdarahan akut > 15% Postoperative anemia Hb < 10 g% Preoperative Hb < 12 g% + severe cardiopulmonary disease Anemia kronis Hb < 7 g%

89. Bayi wanita 1 tahun dibawa ke IRD dengan dugaan intususepsi (invaginasi). Bayi tampak lemah nadi kecil susah diraba pada nadi brachialis. Berat badan 10 kg Pernafasan 40 permenit Urine saat dikateter 25 ml, selanjutnya tidak ada produksi urine lagi. Hb 16. Analisa gas darah : pH 7.10 PaCO 2 25 PaO 2 76 BE – 15 Bagaimana pengelolaan penderita ini ? A – B – C : Airway bebaskan ; Breathing support ; Circulation support

90. PASCA BEDAH HEMOGLOBIN 8 G% APAKAH BAYI INI PERLU TRANSFUSI ?

91. Hb 7-15 Jika faal kardiopulmoner normal | Hb 7 -15 gm/dl Hct 20-40% Kapasitas transport O2 sama Sunder-Plasman (1968)

92. Intraoperative Transfusion Trigger Maximum Allowable Blood Loss Normal Acceptable EBV (%) (%) (ml/kg) Premature 40 – 45 35 90 – 100 Newborn 45 – 65 30 – 35 80 – 90 3Months 30 – 42 25 1Year 34 – 42 20 – 25 70 – 80 6 Years 35 – 43 20 – 25 70

93. CONTOH : Anak 10 kg, Hct 42%. Berapa ‘maximal allowable blood loss’ jika diharapkan Hct terrendah 25% ? EBV = 70 ml/kg = 700 ml MABL = = 285 ml Ganti perdarahan : 2-3 x kristaloid atau 1 x koloid/albumin 5% Jika perdarahan > MABL atau Hct < target : beri PRC. Jika resiko perdrhan postop besar  naikkan Hct target. 700 x (42 – 25) 42

95. Calculator MABL 9/20/201795

97. Pain Management Pain therapy Pain documentation Pain assessment 97

98. Communication & Number Concept (> 3 yrs) (O’Rourke, 2004) Pediatric Pain Assessment

99. Pain management Pain therapy Pain documentation Pain assessment 99 MASALAH UNTUK KELOMPOK ‘NON- VERBAL’ Pain Definition Is not for baby! (G.Noia et al, 2008)

100. Special Situations Cognitively impaired Cerebral palsy with normal cognitive level Hearing or vision impaired Non-English speaking Intubated / paralyzed patients

101. ‘Non-verbal Age’ Pain Assessment ‘Behavioural parameters’ ‘Physiological parameters’ Cohen LL, 2008 Pain Assessment Tool/Scale

102. Developmental Aspects of Pain Newborn/Infant : CRIES, NIPS, PIPP Toddler : FLACC, Oucher, Faces Pain Scale Preschooler : FLACC, Oucher, Faces Pain Scale, Body Outline School age : Oucher, Faces Pain Scale, Poker Chip Tool, Visual Analogue Scale Adolescent : Oucher, Faces Pain Scale, Poker Chip Tool, Visual Analogue Scale, Adolescent Pediatric Pain Tool

103. Skala Face Legs Activity Cry Consolability (FLACC) Merkel,1997 103 KategoriNilai 012 FaceEkspresi biasa Senyum Menyeringai Merengut Dahi mengerut Merengut Otot rahang kontr. Dagu gemetar LegsSantai Normal Gerak terus Tegang Menyepak Kaki ditekuk ActivityTenang,posisi normal Gerak santai Menggeliat Bergerak terus Tegang Posisi kaku Gerakan kejang CryTidak menangis (sadar atau tidur) Merengek Menangis tdk terus Menangis terus Teriak, terisak2 Selalu mengeluh ConsolabilitySenang /santaiTenang dengan bicara, sentuhan,pelukan Tidak bisa dihibur No pain : 0 ; Mild pain : 1-3 ; Moderate pain : 4-6 ; Severe pain : 7-10

104. Analgesic drugs By the ladder By the clock By the appropriate route By the child Multimodal Persistent & increasing pain (Cancer) START LOW POTENCY ANALGETICS Decreasing pain (Trauma, surgery) START POTENT ANALGETICS, OPIOIDS Self report pain assessment Behaviour pain assessment

105. Pharmacologic Intervention of Pain Paracetamol & Nonsteroidal anti-inflammatory drugs. Intermittent/continuous narcotic. Patient-controlled analgesia. Regional anesthetic techniques : Central neuraxial nerve block : spinal, epidural block Peripheral nerve block : upper limb, lower limb American Academy of Pediatric,Canadian Paediatric Society,Committee on Drugs,Committee on Fetus and Newborn and Section on Anesthesiology Prevention and Management of Pain and Stress in the Neonate Pediatrics 2009

106. TONSILLECTOMY ORCHIDOPEXY HERNIOTOMY PPPM SCORE POSTOP DAY CUTOFF PPPM SCORE Pediatric Anesthesia 22 (2012)

107. Caudal epidural analgesia Most popular central block Easiest & safest approach Excellent analgesia-painfree awakening Applicable to children of all ages

108. 4 APPROACHES TO BRACHIAL PLEXUS BLOCK

109. Brachial plexus block (Axillary approach)

110. Brachial plexus block (supraclavicular approach)

111. Post Thoracotomy

112. Local anesthetic systemic toxicity (LAST) Christie LE, Continuing Education in Anaesthesia, Critical Care & Pain 2014

113. Thanks for your attention

114. Non- Verbal Age Pain Definition Is not for baby! (G.Noia et al, 2008)

115. PHARMACOTHERAPY Non Opioid Analgesics  NSAIDs  Acetaminophen Opioid Analgesics  Morphine : drug of choice  Fentanyl  Codeine Nerve blocks  Central neuraxial, peripheral nerve block

116. Wong-Baker Faces Pain Scale

118. Terima Kasih

119. Safe Anesthesia for Children ASPA - WFSA Skill aspects : Airway Vascular Simple regional anesthesia CPR : Neonatal Pediatric

120. Standards for Basic Anesthetic Monitoring Oxygenation Ventilation Circulation Body temperature American Society of Anesthesiologists, 2011

121. Pediatric Patient Premature (gestational age < 37 wks, BW < 2500 g) Neonates – born - < 27 days Infant – 28 days - 12 mo Toddlers – 1 yrs - 3 yrs Preschool – 4 yrs - 6 yrs School age – 7 yrs - 12 yrs Adolescent – 13 yrs - <16(19) yrs Anatomy, Physiology, Pathology, Psychology Considerations

122. Paediatric trained nurses Paediatric trained surgeons Paediatric trained anaesthetists Requirements for paediatric surgical care (Provider-Related)

123. Physiologic Anemia

124. Pain Management Persistent & increasing pain (Cancer) START LOW POTENCY ANALGETICS Decreasing pain (Trauma) START POTENT ANALGETICS, OPIOIDS

125. Co-analgesia Paracetamol IV :  32-36 weeks – 7.5 mg/kg/8 hourly, maximum dose 25/kg/day  Aterm – 10 mg/kg/4-6 hourly, maximum dose 30 mg/kg/day

126. Pendekatan Farmakologis ‘Around the clock dosing’ ‘PRN dosing’ hanya untuk nyeri yang intermittent (termasuk ‘breakthrough pain’ dan nyeri karena aktivitas) Pemberian intramuskuler tidak dianjurkan Multimodal analgetik : NSAID + acetaminophen : utk nyeri ringan-sedang Non-opioid + opioid : utk nyeri sedang-berat

127. Hilangnya elastisitas kulit karena dehidrasi.

128. Risk Factors Out of controlled Age (ie.,prematurity) Physical state (ASA) Emergency surgery Extensive surgery Under controlled Preop optimation Technique/drugs Monitoring Standard Procedure/QA Education/training Physician (experience)

129. ASA Classification Class 1 A normally healthy patient Class 2 A patient with mild systemic disease Class 3 A patient with moderate-severe systemic disease (not life threatening) Class 4 A patient with an incapacitating systemic disease that is a constant threat of life Class 5 A moribund patient who is not expected to survive for 24 hour with or without operation (Class 6 – a declared brain-dead patient whose organ are being removed for donor purposes) Anesthesiology 1963; 24: 111. Pediatric Anesthesia 2007 17: 216–222.

130. Perioperative transfusion trigger Infants of <4 months of age require red blood cells transfusion if : Hb < 12 g% in the first 24 h of life Hct 35%) ; CPAP ; apnea+bradycardia Hct > 35% on ventilator Hct > 45% in presence of Cyanotic Heart Disease Acute blood losses > 10% EBV Infants of >4 months of age require red blood cells transfusion if: Acute blood losses > 15% Postoperative anemia (Hb < 10 g%) Preoperative Hb < 12 g% in severe cardiopulmonary disease Severe chronic anemia with Hb < 7 g%

131. Intraoperative monitoring (according to blood loss)

132. Multimodal approach pain therapy NON- PHARMACOLOGIC APPROACH

133. Systemic opioids for severe pain in neonates and infants DRUGROUTEDOSAGE GUIDE MORPHINEINTRAVENOUS NCA : NEONATE Bolus Lockout Infusion NCA : INFANT Bolus Lockout Infusion 5-30 µg/kg/h 10 μg/kg 20 minutes 0-5 µg/kg/h 10-20 μg/kg 20 minutes 5-20 µg/kg/h FENTANYLINTRAVENOUS1-10 μg/kg/h CARDIORESPIRATORY MONITORING MANDATORY

134. Estimated Values for Vd – t 1/2 – CL of Morphine Vd (L/kg) t1/2 (h) CL (ml/min/kg) Preterm2.8 + 2.69.0 + 3.42.2 + 0.7 Term2.8 + 2.66.5 + 2.88.1 + 3.2 Infants & children 2.8 + 2.62.0 + 1.823.6 + 8.5 Kart T, Lona L. Recommended Use of Morphine in Neonates,Infants and Children Based on Literature Review : Part 1 – Pharmacokinetics. Pediatric Anesthesia 1997.

135. PCA INFUSION BOLUS + INFUSION BOLUS Intravenous opioid Pain

136. Codeine Codeine adalah prodrug  metabolisme oleh enzim  variasi genetik aktivitas enzim. Efektivitas bervariasi tergantung aktivitas enzim. Efek samping terutama OSA & obesitas. UK : Paracetamol + NSAID, Codeine prn (breakthrough pain). NA : Paracetamol + Codeine

137. Tramadol Opioid sintetis, lebih efektif daripada Codeine. Aktivitas metabolit aktif desmethyltramadol (MI) masih belum jelas. Dosis 1-2 mg/kg BB Rekomendasi usia > 12 tahun Efek samping mual muntah (dose related)

138. Co-analgesics (adjuvant) Sedative ; hypnotics Corticosteroids Antidepressants Anti-emetics Antihistamines

139. Penilaian Ulang Derajat Nyeri Akut Pascabedah Minimal setiap 2 jam dalam 24 jam pertama Selanjutnya setiap 4 jam Sesaat sebelum terapi atau intervensi nyeri 30-60 menit setelah terapi atau intervensi nyeri Penilaian lebih sering jika nyeri sulit dikontrol Penilaian setiap 8 jam jika nilai konsisten dibawah ‘cut-off point’

140. Informasi Untuk Orangtua-Pasien Peran orangtua dan pasien dalam pengelolaan nyeri Perencanaan pengelolaan nyeri & perkiraan derajat nyeri Pendekatan farmakologis dan nonfarmakologis, disertai instruksi tertulis Efek samping obat analgetika & bagaimana mengatasi, mencari pertolongan

141. Analgesi Pre-emptif Caudal epidural block Ilio-inguinal – ilio-hypogastric block Penile block Brachial plexus block

142. Brachial plexus block (supraclavicular approach) 12 years old boy, BW 35 kg - neglected supracondylus humeri fracture (2 hours) Continuous SCBPB : USG + nerve stimulator – lidocaine 1.5% + epinephrine 1 : 200.000, 17 ml Tuohy 20G  catheter inserted  tunneling Postoperative pain : Ropivacaine 0.2% bolus 5 ml  3-5 ml/hour Catheter removal after 48 hours