Monitoring

intraoperati
ve
By: Suparto

 Tujuan utama: Keselamatan pasien

Pemantauan adalah
Menginterpretasikan data yang ada
untuk membantu mengenali kelainan
atau kondisi sistem yang tidak
diharapkan, yang sedang atau akan
terjadi (D. John Doyle, MD. Cleveland Clinic Foundation)

1. Anestesiologis harus
hadir dan menjaga
keselamatan pasien
sepanjang prosedur
anestesia

2. Semua peralatan
harus diperiksa
sebelum digunakan

3. Alat pantau harus

terpasang sejak
sebelum induksi
hingga pulih dari
anestesia

4. Selama prosedur, semua parameter

harus dievaluasi ulang

5. Data yang diperoleh dari alat pantau harus

terekam dalam rekaman medis anestesia

6.

Standar ini berlaku untuk semua

tindakan anestesia (MAC, Sedasi,
Anestesia regional, Anestesia
umum)

Standard Monitoring
ASA standard: Oxygenation, ventilation,
circulation, and temperature
Standard for General Anesthesia:
ASA standard (Pulse Oximetry, Capnography,
minute ventilation, ECG, BP, temp if necessary
Standard for MAC and Regional Anesthesia:
Pulse Oximetry, RR, ECG, BP, temp if
necessary
Additional: Arterial line, CVP, NMBA monitor
Preparation before induction: Anesthesia
Mechine, ECG Monitor

Clinical Signs and Symptoms of Perfusion

Abnormalities
CNS: mental status changes, neurologic
deficits
CVS: Chest pain, Shortness of breath, ECG
abnormalities, wall motion abnormalities on
echo
Renal: UO, BUN, creatinine
Gastrointestinal: Abdominal pain, bowel
sounds, bleeding
Peripheral: cool limbs, poor capillary refill,
diminished pulses.

Cardiovascular system
O2 delivery
CO = SV x HR
ECG
Determine HR
Detect and diagnose
dysrhytmia
Myocardial ischemia
Electrolyte imbalance
(hipo/hyperkalemia)

 Manual Blood Pressure

BP = CO x SVR
Measures systolic dan
diastolic BP by
auscultation of korotkoff
sound, palpation
Cuff width should cover
2/3 of upper arm or
thigh
Palpation:
A. radial (80mmHg)
A. femoral (60mmHg)
A. Carotid (50mmHg)

Mean Arterial
Pressure
MAP = sis + 2 Dias/ 3
Normal: 60-70mmHg

 Mean Arterial Pressure (MAP):

Reflects changes in the relationship
between cardiac output (CO) and
systemic vascular resistance (SVR) and
reflects the arterial pressure in the
vessels perfusing the organs.
A low MAP indicates decreased blood flow
through the organs.
A high MAP indicates an increased cardiac
workload.

 Cardiac Output (CO): The volume

of blood pumped by the heart in one
minute.
Increased cardiac output may indicate a
high circulating volume.
Decreased cardiac output indicates a
decrease in circulating volume or a
decrease in the strength of ventricular
contraction.

 Systemic Vascular Resistance

(SVR): The measurement of resistance
or impediment of the systemic vascular
bed to blood flow.
An increased SVR can be caused by
vasoconstrictors, hypovolemia, or late
septic shock.
A decreased SVR can be caused by early
septic shock, vasodilators, morphine,
nitrates, or hypercarbia.

 Stroke Volume (SV): The amount of

blood pumped by the heart per cardiac
cycle. It is measured in ml/beat.
A decreased SV may indicate impaired
cardiac contractility or valve dysfunction
and may result in heart failure.
An increased SV may be caused by an
increase in circulating volume or an
increase in inotropy.

Joint National
th

 Arterial BP indication
Tight BP control
Unstable patient
Arterial blood
sampling

Central Venous
Catheter
CVP (Central Venous
Pressure)
At the vena cava or
Right atrium

Measurement of right
filling pressure to
assess intravascular
volume and right
heart function
Drug administration
IV access
Accsess for insertion
PAC

 Normal CVP is 2 to
12 mmHg
Complication:

Dysrhythmias
Arterial puncture
Pneumothorax
Hemothorax
Infection, air
embolism

 Contraindication CVC insertion:

1.Tumor at RA
2.Tricuspid vegetation
3.Post carotid endarterectomy ipsilateral
4.Coagulopathy

Pulmonary Artery Catheter

 Pulmonary Artery Pressure (PA

Pressure): Blood pressure in the
pulmonary artery. Increased
pulmonary artery pressure may
indicate: a left-to-right cardiac shunt,
pulmonary artery hypertension,
COPD or emphysema, pulmonary
embolus, pulmonary edema, left
ventricular failure.

 Mengetahui fungsi jantung kiri

Mengetahui adanya hipertensi
pulmonal
Mengukur cardiac ouput, systemic
vascular resistance (SVR), pulmonary
vascular resistance (PVR), pulmonary
capillary wedge pressure (PCWP)

 Pulmonary Capillary Wedge

Pressure (PCWP or PAWP): PCWP
pressures are used to approximate
LVEDP (left ventricular end diastolic
pressure).
High PCWP may indicate left ventricle
failure, mitral valve pathology, cardiac
insufficiency, cardiac compression post
hemorrhage.

Respiratory System
Pulse Oxymetri
Normal: 96%-99%
88% acceptable for
patient with lung
disease

High pulse ox
indicates:
O2 available in the lung,
taken up in the blood,
delivered to distal
tissues.

Low pulse ox
Problem along the above
pathway or due to error

 Capnography
Ventilation
Assessment
Confirmation
endotracheal
intubation
Normal: PetCO2 is
2-5mmHg lower
than arterial PCO2,
so typical range 3040 mmHg under
General anesthesia

 Estimasi volume darah:

Dewasa laki-laki: 75cc /kg, perempuan 65
cc/kg

Maximal allowable blood loss:

20% dari estimasi volume darah

Estimasi darah yang hilang

Darah yang tertampung di botol
penampung
Kain kasa, kain penutup

 Replacing blood loss:

Crystalloid, colloid
Hb 7-8 g/dL (Ht 21-24%)
Elderly Hb 10 g/dL

1 unit of red blood cells : Hb 1 g/dL

and Ht 2-3% in adults
10 ml/Kg transfusion of red blood cells
Hb concentration by 3 g/dL and Ht by
10%

 Suhu tubuh
normal 365-375 C
Suhu nasofaringeal mendekati suhu inti
Peningkatan menandakan meningkatnya
metabolisme sel
Suhu produksi CO2

Produksi Urine
Dewasa: 0.5-1cc/Kg/jam
Pediatrik: 1-2cc/Kg/jam

 Pemantauan sistem
saraf
Bispectral Index, utk
mengetahui kedalaman
anesthesia dari
mendeteksi dan
rekaman gelombang
elektroensefalogram
(EEG)
Tingkat anestesi nilainya
40-60 (100 artinya sadar
penuh)

 Train of Four
Mengukur tingkat
blokade oleh
pelumpuh otot
memberikan 4
stimulus
berturutan
dengan
frekwensi 2 Hz
selama 2 detik

Dan lain-lain

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