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GENERAL ANESTHESIA
Dr. Emilzon Taslim, Sp. An. M.Kes
Medical Faculty University of Andalas
M. Djamil Hospital
ANESTHESIA
GENERAL
•Intravenous
•Inhalation
•Intramuscular
LOCAL
•Topical
•Infiltration
•Block peripheral nerve
•Spinal
•Epidural
•Caudal
•IVRA
COMBINATION
Spinal + propofol
General anesthesia
A reversible state of unconsciousness produced by anesthetic agent, with loss of sensation of pain over the whole body.
Reversible irregular CNS depression. General anesthetic drugs are administered
by inhalation, intravenously, intramuscularly, orally, rectally.
The order of descending depression of the CNS
Cortical and psychic centers Basal ganglia and cerebellum Spinal cord Medullary centers
GENERAL ANESTHESIA
TRIAS ANESTHESIA
Hypnotic
Analgesic
Relaxation
BALANCED ANESTHESIA
Balance anesthesia
Anesthesia
component
Drugs
Hypnotic Pentothal, Propofol, Enflurane,
Isoflurane, Sevoflurane
Analgesic Pethidine, Morphine, Fentanyl,
Sufentanil, Remifentanil
Relaxation Succ choline, Atracurium,
Cisatracurium, Pancuronium
Anesthetic drugs
Volatile anesthetic inhalation :
Halogen hydrocarbon (halothane)
Halogen ether: enflurane, isoflurane,
desflurane, sevoflurane Gas anesthetic inhalation : cyclopropane,
N2O, ethylene. Intravenous : thiopental, propofol, ketamine,
etomidate, diazepam, midazolam
Concept balanced anesthesia
Component anesthesia
VIMA TIVA
Hypnotic Sevo, Iso, Enf, Hal, Desfluran
Propofol, Pento, Ket, Mid
Analgesic Fentanyl, alf, suf ,Mo, pethidine, remifentanil
Fentanyl, alf, suf ,Mo, pethidine, remifentanil
Relaxation Depol & non depol Depol & non depol
Indication general anesthesia
Infant and young children. Adult who prefer general anesthesia. Extensive surgical procedures Patient with mental disease Prolonged surgery Patient with a history of toxic or allergic
reaction to local anesthetic drugs Patient on anticoagulant treatment
General anesthesia
Induction inhalation, maintenance anesthesia with inhalation anesthetic (VIMA)
Induction intravenous , maintenance anesthesia with intravenous anesthetic (TIVA)
Induction intravenous, maintenance anesthesia with inhalation anesthetic
General anesthesia technique
Spontaneous breathing Controlled ventilation
Face mask Intubation LMA (Laryngeal Mask Airway) COPA (Cuffed Oro Pharyngeal Airway) LSA (Laryngeal Seal Airway)
Concentrationof
AnestheticAgent
Inspired Alveolar Arterial Brain Brain Venous Alveolar Inspired Gas Gas Blood Blood Gas Gas
Gambar : Perbedaan tekanan zat anestesi inhalasi pada saat induksi dan pemulihan.
Techniques of general inhalation anesthesia Open-drop technique Insufflation Ayre T-piece system System with non-rebreathing valve Semiclosed Closed
Breathing circuit system
Open system Semi open system Semi closed system Closed system
Flow Rate Definition :
Metabolic-flow : 250
ml/minute
Minimal-flow : 250 - 500
ml/minute
Low-flow : 500 - 1000
ml/minute
Medium-flow : 1-2
liter/minute
High-flow : 2-4
liter/minute
Advantageous Low-flow anesthesia
Less of anesthesia gas consumption Less of pollution Heat loss decrease Cost effective
THE EQUIPMENT
Component anesthesia machine
Gas sources : Oxygen, N2O Reducing valve or pressure regulator Flow meter Vaporizer for halothane, enflurane,
isoflurane, desflurane or sevoflurane. CO2 absorption system (soda lime or bara
lime)
SEE THE MOVIE
L.Heart
R.Heart
FACirculation
V.R.G.BrainHeartSplancKidney
M.G.
V.P.G.
% %
20 55
75 7
5 38
Gases Vapors Diffusion Solubilities COMP. C.O. B.W.
Inspired Mixture Ventilation Blood Carriage Tissue Uptake
Figure : Schematic diagram of uptake and distribution of inhalation anesthetics. The inspired concentration. F1 or fraction inspired, of anesthetic is under direct control of the anesthetist. F1 is delivered to the alveoli by the minute volume of ventilation (M.V.V.). The alveolar concentration, FA or fraction in alveoli, regulates tension (partial pressure) of anesthetic agent in arterial blood. The four tissue groups or compartments (COMP), the vesel rich group (V.R.G.) tend toward equilibration with anesthetic tension in arterial blood but reach that equilibrium at rates determined by the volume of blood flow to each tissue. The brain is the site of action. C.O. = cardiac output and B.W. = body weight, both expressed in percent. SPLANC = splanchnic circulation.
Pa
Uptake and distribution
Respiration factor Circulation factor Anesthetic gas factor Tissue factor
Respiration factor
Inspiration concentration Ventilation effect
Circulation Factor
Solubility (partition coefficient) Cardiac output The difference of gas partial pressure
alveoli and vein
Partition coefficient of anesthetic
Anesthetic Blood/gas Brain/blood Tissue/blood
Ether
Halothane
Enflurane
Isoflurane
N2O
12.1
2.3
1.8
1.4
0.47
1.1
2.6
2.6
3.7
1.1
0.9
2.5
1.7
4.0
1.2
Anesthetic gas factor
MAC (Minimal Alveolar concentration) MAC 50, MAC 95 MAC Ei 50, MAC Ei 95 MAC BAR 50, MAC BAR 95
MAC inhalation anesthetic
MAC =minimal alveolar concentration, in 1 atmosphere, 50% patient without movement in noxious stimuli
MAC Ei = concentration of volatile agent permitting laryngoscopy and intubation without untoward movement.
MAC BAR = concentration of volatile agent required to block adrenergic response to skin incision
MAC inhalation anesthetic, 40 years old.
Volatile anesthetic MAC
Halothane
Enflurane
Isoflurane
Desflurane
Sevoflurane
N2O
0,72
1.68
1.12
6.0
2.05
105.2
Factors influencing or not influencing MAC
MAC decreased MAC unchanged
MAC increased
Increasing age
CNS depressant:
alcohol,
barbiturate,
lidocaine,
benzodiazepine,
narcotic
Duration of
anesthesia
Gender
Species
Hypertension
Hypocarbia
Alcoholism
chronic
Hyperthermia > 42
Hypercarbia
Anemia
Tissue factor
Tissue rich vessel : brain, heart, endocrine,
kidney. Intermediate : muscle, skin. Fat. Tissue poor vessel : ligament, tendon.
General anesthesia planning
Pre operative visit Premedication Anesthesia technique : General, Regional Intraoperative Postoperative
Anesthesia technique :General anesthesia Airway controlled Induction Maintenance anesthesia Analgesia Muscle relaxation
Intraoperative
Monitoring Patient position Crystalloid and colloid Special technique
Postoperative
Post operative pain treatment Send patient to Ward or ICU
INTRAVENOUS ANESTHETIC
Intravenous anesthetic
Pentothal Propofol Etomidate Midazolam Diazepam
Ideal intravenous anesthetic
Water soluble Non irritation No anta analgesic effect Rapid and smooth Induction Cardiovascular stable in clinically dose
Thiopentone
Blood pressure decrease Heart rate increase or decrease Peripheral vasodilatation Heart contraction depressed Larynx spasm, bronchus spasm Respiratory depression until apnoea Dose 4-6 mg/kg BW
Relative contraindication thiopentone Asthma bronchiale Severe liver disease Severe kidney disease Severe anemia Hypotension Shock
Ketamine Dissociative anesthetic Delirium Hallucination Increase blood pressure : systolic 23% from base
line Increase heart rate Arrhythmias Hypersecretion Dose 1-3 mg/kg I.v or 9-11 mg/kg I.m
Indication and Contraindication Ketamine
Indication : short surgery Contraindication : Hypertension systolic >
160 mmHg Arrhythmias Heart failure Pharynx and larynx surgery without
intubation.
Propofol
New intravenous anesthetic Fast onset, short duration of action Accumulation minimal Fast recovery Rapid metabolism No complication at site of injection Dose 2-2.5 mg/kg BW
Pharmacology Propofol
No histamine release/reaction anaphylactoid (chremophor El change with soya bean oil).
Perivascular injection, tissue necrosis negative.
Injection intra artery : tissue necrosis negative.
Effect Propofol to CNS
Hypnotic effect 1,8 time pentothal Airway depression > pentothal Anti emetic effect No anti convulsant effect
Comparative properties of intravenous anesthetics
Thiopen Ketamin Propof Diazep Midaz
Aqueous solution
Available in solution
Pain on injection
Venous thrombosis
+
-
-
-
+
+
-
-
-
+
+
-
-
+
+
+
+
+
-
-
Comparative properties of intravenous anesthetics
Thiopen Ketamin Propof Diazep Midaz
Rapidly acting
Smooth induction
Respiratory depression
Cardiovascular depression
+
++
+
++
-
+
-
-
+
+
+
++
-
+
-
+/-
-
+
+/-
+/-
Comparative properties of intravenous anesthetics
Thiopen Ketamin Propof Diazep Midaz
Rapid recovery
Smooth recovery
Suitable for infusion
Interaction with relaxant
-
+
-
-
-
-
+/-
-
+
+
+/-
-
-
-
-
-
-
-
-
-
Resume: Effect anesthetic non volatile to organ system
Drug HR MAP Vent B’dil
Thiopentone
Diazepam
Midazolam
Meperidine
Morphine
Fentanyl
Ketamine
Propofol
0/ 0
*
*
0
0
*
*
0 0
Resume: Effect anesthetic non volatile to CNS
Drug CBF CMRO2 ICP
Thiopentone
Diazepam
Midazolam
Meperidine
Morphine
Fentanyl
Ketamine
Propofol
INHALATION ANESTHETIC
Choice of anesthetic inhalation
Cardio pulmonal effect Product degradation with soda lime What metabolites ? How much metabolism?
Ideal anesthetic inhalation Pleasant odor and non irritation Low solubility No organ toxic Side effect cardiovascular and respiration minimal CNS effect reversible without stimulant activity Effective in high O2 concentration Boiling pressure and boiling point can delivered by
vaporizer standard
New Trend in General Anesthesia VIMA Fast-Track Anesthesia Low-flow Anesthesia Low-cost Anesthesia Single-breath induction (Rapid induction)
Physicochemical properties
Halothane Enfl Isofl Desfl Sevo
Odor + - - - +
Irritating to
Resp system - + + + -
Solubility 2,35 1,91 1,4 0,42 0,63
MAC 0,76 1,68 1915 6,0 2,05
Metabolism 17-20% 2,4% <0,2% 0,02% <5%
Metabolites F, Cl, F, F, F, F, Br, TFA CDA TFA TFA HFIP
BCDFE,CDE, CTE,DBE
Interaction with SodalimeInteraction with SodalimeAnesthetic degradation
Product organ Toxicity
clinical Relevancy
Halothane BCDFE Nephrotoxic Non identified to data
Enflurane CO - -
Isoflurane CO - -
Desflurane CO - -
Sevoflurane Compound A
Compound B
Nephrotoxic Non identified to date
WHY VIMA???
intravenous induction, ex: Propofol : rapid and smooth induction, but need vein access first, hypotension, apnoe.
Pediatric anesthesia commonly by VIMA. More advantages than intravenous
induction, maintenance inhalation.
Cardiovascular effect of Volatile inhalational anesthetics
Variable Halothane Enflurane Isoflurane
Blood pressure
Vascular resistance
Cardiac output
Cardiac contraction
CVP
Heart rate
Sensitization of the heart to epinephrine
0
0
0
0
0
0?
0 = No change (<10%)
= increase
= Variable change
= 10-20% decrease
= 20-40% decrease
Clinical pharmacology of Inhalational anesthetics : Respiratory
N2O Halo Enflur Isoflu Sevoflu
Tidal volume
Resp rate
PaCO2 resting
Clinical pharmacology of Inhalational anesthetics : CNS
N2O Halo Enflur Isoflu Sevoflu
CBF
ICP
CMRO2
Seizure
Clinical pharmacology of Inhalational anesthetics
N2O Halo Enflur Isoflu Sevoflu
HBF
Nondep blockade
Metabolism
0.004
15-20
2.5
0.2
2-3
N2O
1.5 time heavier than air Must be give with O2 100% Weak anesthetic Analgesic N2O 20% equal with 15 mg
morphine Don’t use in closed system At the end of anesthesia, to prevent
diffusion hypoxia O2 100%
Advantages N2O
Rapid induction and recovery No sensitized myocardium with
catecholamine No irritation respiratory tract Odor pleasant Strong analgesic
Disadvantages N2O
Weak anesthetic No muscle relaxation effect Need high concentration oxygen Possibility aplasia bone marrow
Halothane
A clear, colorless, potent volatile liquid. Metabolism 17-20%
Advantages Halothane
Rapid, smooth induction and recovery. Pleasant Non irritating, no secretion Bronchodilator Nonemetic Non flammable and non explosive
Disadvantages Halothane
Myocardial depressant An arrhythmia producing drug Sensitizes the myocardial conduction
system to the action of catecholamines A potent uterine relaxant Possible toxic to the liver Shivering during recovery period.
Enflurane
A clear, colorless, stable volatile liquid with a pleasant ether-like odor.
A potent inhalation anesthetic CNS excitation Use of epinephrine : saver than halothane.
Advantages Enflurane
Pleasant Rapid induction and recovery Non-irritating : no secretion Bronchodilator Good muscle relaxation Nonemetic Non flammable and non explosive Compatible with epinephrine
Disadvantages Enflurane
Myocardial depressant Shivering on emergence CSF production increase CNS excitation, in high dose and
hypocarbia.
Isoflurane
A stabe, volatile liquid A isomer enflurane Inhalation anesthetic choice for
neurosurgical patient, kidney, liver.
Advantages Isoflurane
Rapid induction of anesthesia and swift recovery
Nonirritating : no secretion Blood pressure remain stable Indicated in poor-risk patient
Disadvantages Isoflurane
Less than halothane and enflurane
SevofluraneSevoflurane
Inhalation anesthetic with low solubility (0,63), low MAC (2,05), pleasant odor, no airway irritation, rapid uptake and elimination , cardio vascular stable.
Rapid induction, with technique single breath induction, induction time 23 seconds.
Sevoflurane
Drugs of choice for Neuro anesthesia : WCA 2000 Montreal, Canada.
Drugs of choice for Pediatric Anesthesia : ESA Barcelona, 1998. ASPA, Singapore, 2000., ESA Sweden 2001.
In Sectio Caesarea equal with Isoflurane and spinal anesthesia
Reduce sphlannic blood flow, hepatic blood flow lesser than other anesthetic inhalation.
NARCOTIC ANALGESIC
Narcotic analgesic ideal :
Wide margin of safety Fast onset of action Short duration of action Easier analgesia controlled Strong analgesic no histamine release Non active metabolite
Opiate in Anesthesia
1. Premedication2. Induction Anesthesia3. Narcotic anesthesia4. A part of balanced anesthesia5. Adjuvant in regional anesthesia6. Neurolept anesthesia7. Post operative pain relief
Drugs Protein binding Lipid solubility
Morphine ++ +Pethidine +++ ++Fentanyl +++ ++++Sufentanil ++++ ++++Alfentanil ++++ +++
Note : + = very low; ++ = low; +++ = high ++++ = very high
Morgan GE. Clinical Anesthesiology, 1996.
Narcotic effect :
Bradycardia : central vagotonic effect & SA & AV node depression
Respiratory depression : respiratory rate, rhythm, Response CO2, Minute Volume, Tidal Volume
Muscle stiffness Nausea vomiting cause by
stimulation CTZ, GIT mobility, decrease gastric mobility, increased gastric volume
Clinical Doses of Narcotics
Drug i.v dose Onset (min)
Approximate duration
Morphine
Meperidine
Fentanyl
Sufentanil
Alfentanil
0.05-0.3 mg/kg
0.5-1 mg/kg
1-5 ug/kg
10-40 ug/kg
30-80 ug/kg
5-10
5-10
2
<1
<1
3-5 h
2-3 h
45 min – 2 h
< 30 min
< 60 min
MUSCLE RELAXANT
Muscle relaxant
Very useful in general anesthesia. laryngoscopy and intubation more easier
and avoid injury Muscle relaxation very useful during
surgery and controlled ventilation
Ideal muscle relaxant
Non depolarization Rapid onset, short duration of action Rapid recovery, high potency non cumulative, metabolite non active No cardiovascular effect No histamine release Counteract with anticholinesterase
Mechanism neuromuscular blockade Competitive block : non-depol, avoid AcCh
access to receptor. Depolarization block : depol, depolarization
as AcCh but permanent Deficiency block: influence syntesis and
release AcCh: Procaine, toxin botulinus, Ca decrease, Mg increase.
Morgan GE, Mikhail MS. Clinical Anesth, 1996
Terminology in muscle relaxant ED 50 : dose what can paralyzed 50%
muscle strength ED 90 : dose what can paralyzed 90%
muscle strength. Onset : interval between start of
injection until maximal effect
Depolarizing Nondepolarizing
Short-acting Succinylcholine Decamethonium
Long-acting Tubocurarine Metocurine Doxacurium Pancuronium Pipecuronium GallamineIntermediate-acting Atracurium Vecuronium RocuroniumShort-acting Mivacurium
Table 9 - 1. Depolarizing and nondepolarizing muscle relaxants.
Nondepolarizing drug
Do not produce muscular fasciculation Effect are decreased by anticholinesterase
agent, depolarizing agent, lowered body temperature, epinephrine, acetylcholine
Effect are increased by non-depolarizing drugs, volatile anesthetic .
Depolarizing drugs Produce muscular fasciculation . Effect are increased by anticholinesterase
agent, Acetylcholine, hypothermia Effect decrease with non-depolarizing
relaxant drugs, anesthetic inhalation Dose Succ choline : 1 mg/kg BW
• Burn injury• Massive trauma• Severe intra-abdominal infection• Spinal cord injury• Encephalitis• Stroke• Guillain-Barre syndrome• Severe Parkinson’s disease• Tetanus• Prolonged total body immobilization• Ruptured cerebral aneurysm• Polyneuropathy• Closed head injury• Near drowning• Hemorrhagic shock with metabolic acidosis• Myopathies ( eg, Duchennes’s dystrophy )
Table 9 - 5. Conditions causing susceptibility to succiniylcholine-induced hyperkalemia.
Relaxant Metabolism Primary Onset Duration Histamine Vagal Relative RelativeExcretion Release Blockade Potency1 Cost2
Tubocurarine Insignificant Renal ++ +++ +++ 0 1 Low
Metocurine Insignificant Renal ++ +++ ++ 0 2 Moderate
Atracurium +++ Insignificant ++ ++ + 0 1 High
Mivacurium +++ Insignificant ++ + + 0 2.5 Moderate
Doxacurium Insignificant Renal + +++ 0 0 12 High
Pancuronium + Renal ++ +++ 0 ++ 5 Low
Pipecuronium + Renal ++ +++ 0 0 6 High
Vecuronium + Biliary ++ ++ 0 0 5 High
Rocuronium Insignificant Biliary +++ ++ 0 + 1 High
1For example, pancuronium and vecuronium are five times more potent than tubocurarine or atracurium2Based on average wholesale price per 10 mL; does not necessarily reflect duration and potencyOnset : + = slow; ++ = moderately rapid; +++ = rapidDuration : + = short; ++ = intermediate; +++ = longHistamine release : 0 = no effect; + = slight effect; ++ = moderate effect; +++ marked effect Vagal blockade : 0 = no effect; + = slight effect; ++ = moderate effect
Table 9 - 6. A summary of the pharmacology of nondepolarizing muscle relaxant
Relaxation
Drug ED95 (mg/kg)
Recommended intubating dose (mg/kg)
Infusion rate for steady state blockade (mg/kg/h)
Atracurium
Pancuronium
Vecuronium
0.21
0.067
0.043
0.3-0.6
0.005-0.008
0.08-0.1
0.25
0.032
0.078
INDUCTION AND MAINTENANCE OF ANESTHESIA
Choice of anesthesia technique depend on:
Patient condition Skill anesthetist Skill surgeon Hospital socioeconomi
Problem during induction of anesthesia
Main problem : airway Sign of partial obstruction : snoring,
crowing, gargling, wheezing, chest retraction, cyanosis
Sign of total obstruction : air flow from nose/mouth negative, supraclavicular retraction, intercostal retraction, cyanosis
Other problem during induction
Respiratory depression Cough Larynx spasm Mucus and saliva vomiting
Airway controlled
Without equipment : Triple mannuver Safar With equipment:
OPA (Oro Pharyngeal Airway)
NPA (Naso Pharyngeal Airway)
LMA ( Laryngeal Mask Airway)
ETT (Endo Tracheal Tube)
Indication Intubation
Head and neck surgery Difficult airway Thoracotomy Laparotomy Lateral position Prone position Controlled ventilation
Technique laryngoscopy
Head position Insertion laryngoscope blade Visualization epiglottis Lift epiglottis View larynx and surrounding structure
Advantages Endotracheal intubation Ensures a patent airway Normal anatomic dead space (75 ml) is
decreased to 25 ml. Ventilation can be assisted or controlled Possibility of aspiration diminished
drastically Suctioning of the lung is facilitated
Disadvantages endotracheal intubation
Increases resistance to respiration Trauma to the lips, teeth, nose, throat,
larynx.
Complication Intubation
Teeth rupture Mouth bleeding Endobronchial intubation Oesophageal intubation Sore throat Hypertension Arrhythmias
Induction technique
Mask induction / inhalation Intravenous Intra muscular Per rectal
Mask Induction with SevofluraneMask Induction with Sevoflurane
Gradual InductionSingle Breath InductionTriple Breath Induction (Multiple Breath
Induction)
Fast technique with Single Breath Induction,
without cough, breath holding, spasm
larynx.
Gradual InductionGradual Induction
Classic method for Mask Induction.To decrease respiratory tract irritation and non
pungent odor no need for Sevoflurane.Combined with N2O or Oxygen 100%.Concentration Sevo increase 0.5-1,5 vol% every
2-3 breath until anesthesia adequate.Commonly reach in 60-90 seconds with Sevo
7%.
Single-Breath InductionSingle-Breath Induction
Priming circuit with N2O 60% + Sevo 8% 30 seconds.
Ask patient for maximal expiration (until residual volume) face mask .
Ask patient inspiration maximal (vital capacity), keep 20 seconds, then normal breathing.
After eyelash reflex negative, Sevo turn to 2%.
Triple Breath InductionTriple Breath Induction
A variation from Single Breath InductionAsk patient 3 times deep breath.Difference with Single Breath, no breath
holding.Commonly patient sleep, in 2-3 breathing.
How to maintain anesthesia ?
Maintenance anesthesia depend on deep of anesthesia to reach adequate anesthesia.
Commonly with SEVO 1-1,5 vol% depend on type of surgery, spontaneous breathing or controlled.
To reduce vol% (MAC) : add N2O or Fentanyl.
Sign of deep anesthesia
PRST Score (balanced anesthesia) Guedel sign (ether anesthesia) PRST Score (score 2-4: adequate anesthesia) P = Systolic arterial pressure (mmHg) R = rate (heart rate) S = sweat/ lacrimation T = tear
PRST Scoring indexes for Balanced anesthesia
Index Condition Score
Systolic arterial pressure (mmHg)
Heart rate (beats/min)
Sweat
Tears or Lacrimation
Less than control + 15
Less than control + 30
More than control +30
Less than control + 15
Less than control + 30
More than control +30
Nil
Skin moist to touch
Visible beads of sweat
No excess tears when eyelids open
Excess teas visible when eyelids open
Tears overflow from closed eyelid
0
1
2
0
1
2
0
1
2
0
1
2
Extubation
After adequate ventilation In deep anesthesia or after patient awake Clear airway Oxygen 100% after and before extubation
Factor which influence total anesthetic inhalation :
1. Constanta2. Fresh gas flow3. Volume % (MAC)4. Length of surgery
Total anesthetic inhalation = constanta x fresh gas flow (ml)
x vol % x time (minute)
If length of surgery 2 h, total Sevoflurane :
Inductionfirst 30 secondFresh gas x 1/183 x Vol % x timeflow (ml) (minute) 6000 x 1/183 x 8% x 0,5 = 1,33 minute for intubation : 6000 x 1/183 x 2% x 3 = 1,93 minute start for low-flow : 3000 x 1/183 x 3% x 3 = 1,4second 3 minute: 1000 x 1/183 x 1% x 3 = 0,5Operation 2 hours : 1000 x 1/183 x 1% x 120 = 6,5
Total Sevoflurane 11,6 mlTotal Sevoflurane 11,6 ml
TIVA CONTINU
Propofol 6-10 mg/kg/h + Vecuronium 0.1 mg/kg/h + Fentanyl 2 ug/kg
Pentotal 1-3 mg/kg/h + Vecuronium 0.1 mg/kg/h + Fentanyl 2 ug/kg
Ketamine 2 mg/kg/h + Vecuronium 0.1 mg/kg/h + Diazepame 0.25 mg/kg
Midazolam 50 ug/kg/h + Ketamine 2 mg/kg/h + Atracurium 0,25 mg/kg/h
POSTOPERATIVE
See: Lecture of RR and ICU
Thank you for your kind attention
Tatang Bisri
Bandung, 2001