REFERAT

September 2011

ANESTESI PADA OBESITY

Oleh

MULYONO

Klasifikasi obesity (longnecker,

2008)

BMI (kg/m2)
< 18,5

Kelas obesity

Deskripsi
Under
weight

18,5-24,9
25,0-29,9
30,0-34,9
35,0-39,9

Normal
Over weight
Obesity
Morbid

I
II

obesity
>40

Extreme
obesity

III

Tipe dari obesitas ada 2

1. Tipe android ( obesitas sentral)
Pada

tipe ini distribusi lemak dominan di tubuh bagian atas (distribusi trunkal) dan

berhubungan dengan

peningkatan komsumsi oksigen dan

insiden penyakit

kardiovaskuler.
2. Tipe ginekoid ( obesitas perifer)
Pada

tipe ini jaringan adipose dominan lokasi di paha, pantat dan pinggul (lemak

secara metabolik kurang aktif

kardiovaskuler)

sehingga kurang berhubungan erat dengan penyakit

Patofisiologi obesity
Sistem
1.
2.
3.

respirasi :

Work of breathing Pasien obesitas morbid meningkat

merupakan akibat dari compliance dinding dada menurun
Total oksigen komsumsi dan produksi karbondioksida meningkat
pada pasien obese saat istirahat
Hipoxia kronis menyebabkan polycythemia, dimana berkontribusi
dalam peningkatan volume darah. Terjadinya Hipoksemia kronis
dapat menyebabkan hipertensi pulmonal dan korpulmonale.
(Longnecker, 2008)

OBSTRUKTIF SLEEP APNEU

didefinisikan

sebagai berhentinya aliran udara

selama 10 detik, terjadi 5 kali atau lebih setiap jam
saat tidur, walaupun usaha bernafas melawan
penutupan glotis tetap terjadi, dikombinasi dengan
penurunan saturasi oksigen lebih dari 4%.

Obstruksi sleep hypopneu

turunnya

aliran udara >50% dalam waktu>10 detik

terjadi lebih dari 15 kali setiap jam selama tidur.
Biasanya berhubungan dengan snoring dan
desaturasi oksigen> 4% .

Apnea-Hipopnea index = AHI

AHI adalah jumlah total dari apneu dan hipopneu perjam dan digunakan
untuk mengetahui kuantitas dari beratnya OSA. AHI > 30 merupakan
OSA severe, AHI 5-15 osa mild dan AHI 16-30 sebagai OSA moderate.

Indeks total arousal ( Arousal index=AI) adalah jumlah total individu

terbangun per jam. Kesimpulan dari AHI dan total AHI di kenal sebagai
respiratory disturbance index (RDI).

(Longnecker, 2008)

syndrome hipoventilasi obesity

didefinisikan

sebagai kombinasi antara obesitas

(BMI>30 kg/m2) dan hiperkapnia arteri ketika
sadar (Paco2>45 mmhg) dengan tidak adanya
penyebab lain dari hipoventilasi
Sindroma Pickwickian ditandai dengan obesity,
mengantuk berlebihan, hipoksia, hiperkapnia,
gagal ventrikel kanan, dan polisithemia , ini adalah
akhir dari OHS.

Exam: Oropharynx
Patient With the Crowded Oropharynx

Physical Exam
Structural Abnormalities

Guilleminault C et al. Sleep Apnea Syndromes. New York: Alan R. Liss, 1978.

Pathophysiology of Apnea

Pathophysiology of Sleep
Apnea
Sleep Onset
Hyperventilate: correct
hypoxia & hypercapnia

Loss of neuromuscular
compensation

Airway opens

Decreased pharyngeal
muscle activity

Pharyngeal muscle
activity restored

Airway collapses

Arousal from sleep

Apnea
Hypoxia &
Hypercapnia

Increased ventilatory
effort

EFFECT OF POSITION ON LUNG VOLUMES

In obesity, decreased chest wall compliance results in a functional

residual capacity (FRC) that decreases at the expense of expiratory
reserve volume (ERV). (From Vaughan RW. Pulmonary and
cardiovascular derangements in the obese patient. In Brown BR,
editor. Anesthesia and the Obese Patient. Philadelphia, FA Davis
1082:26.)

PICKWICKIAN SYNDROME OR
OHS
8%

of obese patients
Alveolar hypoventilation, somnolence and
morbid obesity
Soft tissue mass of oropharynx
Intermittent obstruction of airway
during sleep
Hypoxemia, hypercarbia
Polycythemia, pulmonary hypertension
and right ventricular failure
Pulmonary embolism and pneumonia

LUNG VOLUME CHANGES IN OBESITY

FRC DECREASES WITH INCREASING

BMI

Normal

Obese
sitting

supine

Sistem kardiovaskuler

1.
2.
3.
4.
5.
6.
7.
8.

Peningkatan morbiditas dan mortalitas pada pasien obese adalah hasil dari
problem kardiovaskuler seperti hipertensi, penyakit jantung iskemik, gagal
jantung, kardiomiopati, aritmia, dislipidemia, dan meninggal mendadak karena
penyakit jantung.
Jaringan adipose berlebihan :
Volume darah
Cardiac output
aterosklerosis
Disritmia
Sistem RAA
Resistensi insulin
Dislipidemia
Hipofibrinolitik dan hiperkoagulasi

(Longnecker, 2009)

 Gagal

jantung intra operatif dapat terjadi karena

penberian

cairan

intra

vena

yang

cepat

(merupakan indikasi disfungsi diastolik ventrikel

kiri), inotropik negatif dari agent anestesi,
hipertensi pulmonal yang dipresipitasi oleh
hipoksia dan hiperkapnia.(Barash, 2009)

Sistem gastro intestinal dan hepatik

Volume gaster dan keasaman meningkat, gangguan funsi
hepar dan metabolisme obat
Pengosongan lambung menjadi lebih lambat pada pasien
obese, karena peningkatan massa abdomen dan distensi
antrum. Release gastrin, dan penurunan pH dengan
hipersekresi sel parietal.
Peningkatan insiden hiatus hernia dan refluks
gastroesophageal
abnormalitas morfologi dan biokemistri dari hepar
sehubungan dengan obesitas termasuk infiltrasi lemak,
inflamasi, nekrosis fokal dan sirosis.

Sistem metabolik, renal, dan endokrin

Gangguan toleransi glukosa

Hipotiroidism subklinik terjadi sekitar 25% dari semua pasien morbid.

Level TSH sering meninggi.

Obesitas merupakan resiko mayor terhadap end stage renal
disease (ESRD) dan hipertensi essensial.

Obesitas

terkait

glomerulosklerosis

glomerulopati
fokal

sekmental

glomerulopati saja.
(Barash 2009, Longnecker 2008)

di
dan

definisikan
glomerulopati

sebagi
atau

Sindrome metabolik

merupakan hasil dari interaksi antara faktor-faktor genetik, hormonal dan lifestyle

Menurut International Diabetes Federation, seseorang didiagnosis sindrome

metabolik harus mempunyai obesitas sentral (lingkar pinggang > 95 cm untuk lakilaki dan > 80 cm untuk wanita) di tambah dua dari empat faktor di bawah ini :

1.

Peningkatan level trigliserida ( 1.7 mmol/L)

2.

Kadar HDL serum berkurang ( 1.03 mmol/L pada laki-laki dan 1.29 mmol/L pada
wanita)

3.

Peningkatan tekanan darah ( SBP 130 mmhg atau DBP 85 mmhg ) atau sedang
dalam terapi hipertensi.

4.

Kadar glukosa darah puasa 5,6 mmol/L) atau sebelumya didiagnosis DM tipe 2

Menejemen perioperatif
Evaluasi

pre anestesi

Posisi
Airway

menejemen
Preparasi
Monitoring
Induksi, intubasi dan pemeliharaan
Pilihan teknik anestesi
Menejemen pasca operasi

Preanesthetic Evaluation
Includes

Medications
Laboratory Tests
Cardiac Assessment
Respiratory Evaluation
Airway Evaluation
Vascular Access

Preanesthetic Evaluation Patient

Education
menjelaskan keadaan yang mungkin
terjadi selama preparasi pre operatif
(pemasangan cateter infus berulang,
vena central and arterial lines
insertions, awake intubation, pain
management) dan pencegahan
cemas berlebihan

Preparasi
Terdiri

dari:

Equipment
Monitoring
Aspiration prophylaxis
Airway equipment

preparasi Equipment
operating

room tables can accommodate

up to 600 pounds of weight.
Extra

large cuffs can be used on

upper/lower extremity.
warming devices, fluid warms and
warm airflow blankets should be
employed to prevent hypothermia

monitoring

monitoringIntraoperative sesuai kebutuhan

pasien
EKG di atur agar dapat mendeteksi myocardial
ischemia and pathology (leads II and V5).
Placement of an arterial catheter is appropriate
for the monitoring hemodynamic status.
Use of central venous and pulmonary artery
catheters should be consider in patients
undergoing extensive or serious
cardiorespiratory disease.

Prophylaxis aspirasi
preinduction administration of histamine2 and dopamine receptor antagonist coupled
with oral administration of nonparticulate
antacids
Head up position of the patient, with
application of the Sellick maneuver during
rapid-sequence induction
Nasogastric/orogastric suctioning

Airway Equipment

preparation of equipment and personnel

necessary to ventilate and intubate the morbidly
obese patient
STATICS
Laryngeal mask airways (LMAs), fiberoptic and
bronchoscopic devices, emergency tracheotomy
and cricothyrotomy kits must be available in the
event that ventilation by mask or endotracheal
tube is unsuccessful.
A difficult airway flowcart

Maintenance

maintenance consist of:

Intubation
Effects of General Anesthesia on Respiration
Choice of Anesthetic Technique
Volume Replacement
Intraoperative Positioning
Extubation
Regional Anesthesia

Intubation

For airway management to be facilitated, the

obese patient should be positioned with the head
elevated (reverse Trendelenburg position) on the
operating room table.

Intubation
preoxygenated with 100% mask oxygen
for at least 3 to 5 minutes.
The patients head, neck and should be
carefully moved into sniffing position

Difficult to
Bag/Mask
Ventilate
Assistant holds
back breasts,
applies cricoid
pressure

TRACHEAL
INTUBATION in the
SUPINE POSITION

Poor view
with direct
laryngoscopy

Short
laryngoscope
handle

Rapid SpO2
Desaturation

SUPINE POSITION
Reduced lung volumes
Increased V/Q
mismatch
Increased intraabdominal pressure

TRENDELENBURG POSITION

Improved surgical exposure

Engorged neck veins (central line placement)
-Decreased pulmonary compliance and lung volumes
-Decreased Intra-abdominal volume (IAV)
-(Potential) advancement of ETT into bronchus

STANDING AND SITTING

Intubation
Some practitioners advocate the use of an
awake look to visualize the difficulty of
the airway.
Careful administration of sedative drugs
and application of topical anesthesia to the
oropharyngeal structures
Nasal oxygen is used as a supplement
during awake laryngoscopy.

Intubation
Jika epiglottic and laryngeal anatomy
mudah di lihat, intubasi dengan sedasi
dapat di lakukan, jika tidak, intubasi
dengan LMA or awake fiberoptic intubation
dapat di gunakan.
Fiksasi endotracheal tube dengan aman.

requires one person to support the mask and

airway while another person bag ventilates the
patient.
In the case of inability to ventilate/intubate, the
American Society of Anesthesiologist difficult
airway algorigthm should be followed.

menejemen ventilasi

General anesthesia depresses respiration .

The type of surgery, positioning and underlying
disease
General anesthesia causes a 50% reduction in FRC in
the obese anesthesia, as compared with a 20%
reduction in anesthetized non obese patients

FRC can be increased by ventilating with large

tidal volumes (15 to 20 ml/kg)
PEEP dilakukan untuk memperbaiki FRC and
PaO2
Current ventilation recommendations include
using tidal volumes of 10 to 12 ml/kg to avoid
barotrauma.

Choice of Anesthetic Technique

Objective for maintenance of anesthesia in

the obese include:

Strict maintenance of airway

Adequate skeletal muscle relaxation
Optimum oxygenation
Avoidance of the residual effects of muscle
relaxants
appropriate intraoperative and postoperative
tidal volume
Effective postoperative analgesia

Choice of Anesthetic Technique

Depending on the patients condition

epidural anesthetic with light general anesthesia
is frequently chosen.
A light general anesthetic can facilitate
management of the airway, ventilation, and the
patients level of consciousness, where as the
epidural provides surgical analgesia and
anesthesia.
Epidural catheter can be used for postoperative
analgesic administration and will enhance earlier
return of deep breathing and coughing
maneuvers.

Volume Replacement
The

normal adult percentage of total

body water is 60% to 65%
Therefore calculation of estimated
blood volume should be 45 to 55
ml/kg of actual body weight rather
than 70ml/kg apportioned in non
obese adults.
Accurate volume replacement

Volume Replacement
Blood

loss replacement of 3:1 ratio

(3 ml of crystalloid to 1 ml of blood
loss) is applicable in severely obese
patients.
Blood products after careful
identification

Extubation
Criteria

for extubation consist of:

Awake state, tidal volume and

respiratory rate at preoperative levels
Ability to sustain head lift or leg lift for
at least 5 seconds
Constant hand grip
Effective cough
Adequate vital capacity of at least
15ml/kg

Extubation
Patients

must be placed with the

head up or in a sitting position.

Postoperative Care
Postoperative

Care includes:
Pain Management
Postoperative Complication

Pain Management
Pilihan analgesik : oral analgesics,
nonsteroidal antiinflammatory agents,
narcotics, patient-controlled analgesia,
local infiltration of surgical site and
epidural anesthesia
Hati-hati :Obese patients are more
sensitive to the respiratory depressant
effects of opioid analgesics; therefore
caution and close monitoring
Supplemental oxygen and pulse oximetry
monitoring are mandated.

Postoperative Complications

The risk of thromboembolism, wound infections,

and atelectasis is amplified in patients with
increased BMI.
Thromboembolism is facilitated by immobility
(Venous stasis, increased blood viscosity
(polycythemia, hypovolemia) increased
abdominal pressure, and abnormalities in serum
procoagulants and anticoagulants.

Postoperative Complications
Early

ambulation and maintenance of

vascular volume further reduces the
likelihood that clots will develop.
Wound infections and pulmonary
embolism are 50% higher in obese
patients than non obese patients.

terimakasih