Anestesi Pada Pasien Dengan

Penyakit Sistem Kardiovaskular

Departemen Anestesiologi dan Terapi Intensif

Fakultas Kedokteran
Universitas Sumatera Utara
Medan
2012

Clinical Predictors of Increased Perioperative

Cardiovascular Risk
(myocardial infarction, heart failure, death)

Major
Unstable coronary syndromes
- Acute of recent MI with evidence of important ischemic
by clinical symptoms or noninvasive study
- Unstable of severe angina (Canadian class III and IV)
Decompensated heart failure
Significant arrythmias
- High-grade atrioventricular block
- Symptomatic ventricular arrythmias is the presence of
underlying heart disease
- Supraventricular arrythmias with uncontrolled ventricular rate
Severe valvular disease

Clinical Predictors of Increased Perioperative

Cardiovascular Risk
(myocardial infarction, heart failure, death)

Intermediate

Mild angina pectoris (Canadian class I or II)

Previous MI by history of pathological Q waves
Compensated or prior heart failure
Diabetes mellitus (particularly insulin dependent)
Renal insufficiency

Clinical Predictors of Increased

Perioperative Cardiovascular Risk

(myocardial infarction, heart failure, death)

Minor
Advanced age
Abnormal ECG (left ventricular hypertrophy, left
bundle branch block, ST-T
abnormalities)
Rhythm other than sinus (eg, atrial fibrillation)
Low Functional capacity (eg, inability to climb one
flight of stairs with a bag of
groceries)
History of stroke
Uncontrolled systemic hypertension

Shortcut to noninvasive testing

in preoperative patients
if any two factors are present
1.

2.
3.

Intermediate clinical predictors are present

(Canadian class I or II angina, prior MI based
on history of pathological Q waves,
compensated or prior heart failure, or
diabetes)
Poor functional capacity (less than 4 METs)
High surgical risk procedure (emergency major
operations, aortic repair or peripheral vascular
surgery, prolonged surgical procedures with
large fluid shifts of blood loss)

Cardiac risk stratifaction for

noncardiac surgical procedures
High (reported cardiac risk often greater than 5%)
- Emergent major operations, particularly in the elderly
- Peripheral vascular surgery
- Anticipated prolonged surgical procedures associated
with large fluid shift and/or blood loss
Intermediate (reported cardiac risk generally les than 5%)
- Carotid endarterectomy
- Head and neck surgery
- Prostate surgery
Low (reported cardiac risk generally less than 1%)
- Endoscopic procedures
- Superficial procedure
- Cataract surgery
- Breast surgery

25 50% kematian setelah pembedahan non

jantung disebabkan komplikasi kardiovaskuler.
Perioperatif Infark Miokard (IM), Edema
Pulmonal, Gagal Jantung Kongestif (GJK),
Aritmia dan Tromboemboli adalah yang paling
sering tampak pada pasien dengan dengan
penyakit kardiovaskuler sebelumnya.

Insiden kardiogenik pulmonari edema post

operative sekitar 2% pada pasien-pasien
dengan usia diatas 40 tahun, 6% pada pasienpasien dengan riwayat gagal jantung dan 16%
pada pasien dengan poorly compensated heart
failure.

PRE OPERATIVE
MANAGEMENT
-

Riwayat penyakit, pemeriksaan fisik dan EKG harus

difokuskan untuk mengidentifikasi potensi terjadinya
kardiovaskuler yang serius (CAD, CHF, Aritmia)

Bila ditemukan penyakit kardiovaskuler maka perlu ditentukan

resiko kardiak adalah evaluasi dasar yang meliputi keadaan
umum, usia, kelas fungsional, fakta resiko kardiak,
kormodibitas penyakit lain (diabetes mellitus, gangguan
fungsi ginjal, penyakit vaskular perifer dan penyakit paru
kronik) dan jenis operasi

Bila perlu dapat dilakukan pemeriksaan transthoracic

echocardiography (TTE) yang dapat membantu evaluasi
resiko perioperative komplikasi kardiak yang berat

Oxygen delivery = Cardiac output x Arterial oxygen content

Stroke volume x Heart rate Hemoglobin x Arterial

oxygen
saturation

Preload

Afterload

Contractility

INTRAOPERATIVE
MANAGEMENT
Intraoperative Predictors for PCM
(Perioperative Cardiac Morbidity)

Diantara predictor intraoperative klasik, pembedahan

emergensi, pembedahan vaskular besar dan operasi lebih
dari 3 jam pada pembedahan abdominal atas atau torak
Diantara prediktor dinamik, hipotensi dan takhikardi
memprediksi PCM
Sedanngkan hipertensi masih merupakan prediktor yang
kontroversial
Myocardial iskemia diduga sebagai prediktor
LV end-diastolic pressure adalah pengukur yang sensitif
pada iskemia
Mangano DT. Perioperative cardiac morbidity. Anesthesiology 1990;72:153-184

INTRAOPERATIVE MANAGEMENT
Monitor the Patient
-

EKG: simultaneous leads V5 and II, multiple-lead ST-segment

analysis if available
Blood pressure: noninvasive automatic Doppler
sphygmomanometric technique
Pulse oximeter for arterial oxygenation
Temperature: esophageal
Swan-Ganz catheter: PCWP, pulmonary artery diastolic pressure
(PADP), hemodynamic study only for patients with ventricular
dysfunction
Central venous pressure (CVP) line: if the patient has good LV
function
Foley catheter: urine output
Oxygen analyzer for inspired gas mixture
End-tidal CO2 analyzer

Hemodynamic
Monitoring

Hemo = Blood (Darah)

Dynamic = Flow (Aliran)
Parameter Utama:
Invasive Blood Pressure (IBP) tekanan darah yang
diukur
Cardiac Output jumlah darah yang dipompa per
menit
Contractility kecepatan dan kekuatan kontraksi
Vascular Resistance hambatan aliran darah
Fluid Level jumlah cairan dalam tubuh/pembuluh
darah

OVERVIEW OF FACTORS AFFECTING TISSUE PERFUSSION

MYOCARDIAL CONTRACTILITY
PRE-LOAD

AFTER-LOAD

STROKE VOLUME

HEART RATE

CARDIAC OUTPUT

PERIPHERAL RESISTANCE
VOLUME

BLOOD PRESSURE

TISSUE PERFUSSION

DIAMETER
VISCOSITAS

PRINSIP UMUM

Sensor harus mendeteksi signal secara

akurat
Monitoring tidak pernah sebagai
terapeutik
Evaluasi resiko keuntungan
menggunakan monitor
Monitoring adalah suatu tim proses

Artery Line

Pengukuran langsung tekanan darah

Teknik lebih akurat
Informasi hemodinamik kontinyu
Pengambilan multipel sampel arteri

Pada Kondisi apa perlu

pengukuran invasive
arterial pressure ?

Akut hipertensi atau perdarahan

Cirulatory or cardiac arrest
Hipertensi krisis
Sepsis
Neurologik injuri
Komplikasi post operasi
Pasien dengan vasoactive drugs
Pasien membutuhkan pemeriksaan analisa
gas darah yang sering

Haemodynamic Monitoring

NON INVASIVE

INVASIVE

Non Invasive

Palpation
Doppler Probe
Auscultation
Oscillometry
Arterial tonometry

100

115
110

20 cm

Aneroid gauge

Brachial artery
Radial artery
Doppler probe
Doppler

Air chamber
Pressure

Element of
pressure sensor

Sensor
Artery Wall

Invasive

Arterial Catheter
Central Venous Catheter
for pressure monitoring, volume
replacement, or central drug infusion

Pulmonary Artery (Swan-Ganz)

Catheter

Pemakaian
Hemodynamic Monitoring

Banyak dibutuhkan di Critical Care dan

Surgery
Fungsi:
Memantau kondisi jantung pasien
Menentukan perawatan yang akan diambil

Dilakukan oleh dokter Anesthesi

Menggunakan Swan-Ganz
Parameter yang dibaca: PAW & TD CO

Tujuan Monitoring
Hemodinamik Invasif
Memberi informasi kuantitatif

Homeostasis fisiologis ada atau tidak

Mendapatkan peringatan dini
perubahan status pasien
Intervensi terapeutik adekuat/ tidak
dan benar/ keliru

INTRAOPERATIVE MANAGEMENT

Penggunaan Pulmonary Artery

Catheter (PAC)

Diperkirakan terjadi peningkatan fluid shifts

CHF akibat komplikasi MI
Pada CAD yang signifikan yang menjalani prosedur
yang berhubungan dengan stress hemodinamik
yang signifikan ; dan pada sistolik dan diastolik LV
disfunction, cardiomiopaty dan valvular disease
yang menjalani operasi dengan resiko tinggi

Eagle KA, Berger PB, Calkins H, Anesth Analg 2002;94:1052-1064

Alat yang selama ini

dipakai

Pulmonary Artery
Catheter:
Swan Ganz / Right
Heart Catheter
Sudah sejak >25
tahun
Parameter:
PA Pressure
PA Wedging (PAOP)
CO/CI

Lumen pada SwanLumen:

Ganz
1. Distal:
mengukur pressure
2. Proximal: Injeksi cairan
3. Middle: pemberian obat

Lubang
Distal

Lubang
Proximal
Lokasi
Thermist
or

Suntikan
untuk
membuka

Balon

Kabel Thermistor

Cara pemasangan

Masuk dari vena leher

(Jugular) atau
selangkangan (femoral)
Dorong Catheter di
jantung kanan
Keluar dari RV ke
pembuluh utama
sebelum paru-paru
(Pulmonary Artery)
Injeksi cairan (dingin),
thermistor mengukur
perubahan suhu darah
terhadap waktu
(Thermodilution)

Pemasangan Swan-Ganz
ke Monitor

Tampilan di Monitor
MONITORED:

CALCULATE
D:

CO

6.9

HR

70

MAP

86

CVP

10

PAM

18

PAW

12

WEIGH
T

75.0

HEIGHT

168.0

BSA

1.85

CI

3.7

SV

98.6

SVR

88.0

SVRI

1626

PVR

69

PVRI

128

LVSWI

53.7

RVSWI

5.8

Tetapi tidak semua monitor bisa menghitung seperti ini!

Keunggulan Swan
Ganz

Sudah populer
Bisa mengukur Pressure PA
Wedging (PAW/PAOP)
Pemberian obat langsung ke
jantung (melalui Middle Lumen ke
jantung kanan)
Paling Akurat

Kelemahan Swan Ganz

Pemasangan sulit,
tergantung skill
Data yang di baca
tidak continuous
(hanya pada saat
injeksi cairan)

Posisi di dalam jantung

(RA & RV)
Parameter: CO/CI, PA
pressure, PAW pressure

Tidak semua orang

bisa memasang
Terlambat memberikan
perawatan tepat
karena kurang data
dan tidak update
Jika terlalu lama bisa
menyebabkan aritmia
Kebutuhan sekarang
lebih banyak
parameter

LOW PRELOAD
Hypoperfusion

RAP

or CVP < 6 mmHg

PAW or LA pressure < 8 mmHg in patient without
cardiac dysfunction, or < 18 mmHg in patient with
cardiac dysfunction

Administration of fluid in attempt to increased

circulating volume IV fluid challenges of 100 to
250 ml crystalloid solution should be administrered
over 10 minute until evidence of improved perfusion
occurs.

HIGH
PRELOAD

Left-side filling pressure pulmonary venous pressure

becomes higher than colloid osmotic pressure surrounding the
vasculature causes fluid to be driven from the vasculature
and into surrounding interstitial or interalveolar spaces

dyspnea
PAW > 20 -22 mmHg
hypoperfusion
PAW > 30 mmHg

Cardiogenic pulmonary edema

Oxygen uptake hypoxemia with increased oxygen delivery

High ventricular end diastolic pressure (measured by PAWP)
decreased coronary collateral blood flow

Therapy Diuretics and Ventilator

Nitropruside
Phentolamine
Digitalis

Output symptoms

normal

Low cardiac

Cardiac output (L/min/m2)

Nitropruside and
dopamine

Diuretics nitrates
Heart failure

Left ventricular end diastolic pressure (mmHg)

Pulmonary
congestion

Ventricular function curves depicting effects of various agents used for treating heart failure.
Diuretics and nitrates lower filling pressure along the same curve and have little action on
forward cardiac output. Positive inotropic agents and arterial vasodilators shift the
ventricular function curve upward and to the left, increasing cardiac output for any left
ventricular end-diastolic pressure. The combination of an arterial vasodilator and a positive
inotropic agents (e.g, nitropruside and dopamine or amrinone) can augment cardiac output
and lower filling pressure to a greater extent.

AFTERLOA
D
Left ventricle SVR
vasoconstriction
Right ventricle
PVR
vasodilatation

Myocardial Vein oxygen

consumption (MVo2)

Stoke volume

Wall tension
Relation ship between stroke volume and wall tension (i.e., afterload) for the
intact left ventricle. At constant preload, increase in wall tension result in a
decline in stroke volume. Increased preload or increased contractility shifts the
curve upward and to right, resulting in a greater stroke volume for any given
afterload.

LOW
AFTERLOAD
Pressure = Flow x Resistance
SVR severe hypotension
inadequate coronary artery perfusion
Vasopressor vasoconstriction secondary to
stimulation of
alpha receptors in
vascular smooth muscle

Phenylephrine,
metaraminol,
norepinephrine,
1-stimulating properties
ephedrine,
dopamine (> 10 to 20 g/kg/min)

HIGH
AFTERLOAD
CO Symphatetic stimulation cause arterial
BP vasoconstriction to maintain blood pressure
Stroke volume
MV02
Arteriovasodilators smooth muscle relaxant
activate 2 adrenergic
receptor in the smooth muscle of the arterioles
(hydralazine, nitroprusside, nitroglycerine)
Calcium channel blockers
Alpha blockers
Angiotensin converting enzyme (ACE) inhibitors
Counterpulsation

CONTRACTILIT
Y
Decreased

contractility associated with reduced

ejection can occur with :
- Hypovolemia
- Myocardial ischemia
- Infraction
- Certain pharmacologic and anesthetic agents
Increases in inotropism may be necessary to
maintain adequate stroke volume and oxygen
delivery
In patient with ischemic heart disease increase
in MVo2 that accompanies increased contractility

DECREASED
CONTRACTILITY

Studies by Shoemaker et.al. have shown that

maintenance of a stroke work index of the left ventricle
> 55 g-m/beat is associated with improved survival in
the shock patients.

Improvement in myocardial contractility can be

obtained with the use of :
- Inotropic agents catecholamins
(dopamine, dobutamine, isoproterenol, epinephrine)
increased adenosine 3 :5-cyclic phosphate (cyclic
AMP)
- Phosphodiesterase inhibitors (amrinone and
milrinone)
inhibits the breakdown of cyclic AMP into its inactive
form

INCREASED
CONTRACTILITY
Increase in oxygen demand
Beta

blockers inhibits
stimulation of 1 adrenergic
receptors in the myocardium
(cardioselective) and 2 adrenergic
receptors in the smooth muscle in
the arterioles of the lung
(nonselective)

HEART
RATE
CO = Stroke volume (SV) x Heart rate (HR)
HR > 120 bpm may associated with
decreased in SV and CO because of decreased
diastolic filling time of the left ventricle
HR with shortened diastolic duration also
decrease left ventricle coronary perfuasion
time and increased MVo2 causing imbalance
between myocardial oxygen supply and
demand

HEART
RATE
Beta

blocker reduce chronotropism

and calcium channel blockers to
decrease conduction
Bradycardia with the heart rate of <
50 bpm CO and tissue perfusion

Therapy

Atropine
Pace maker

HEMOGLOBIN

Abnormal reduction of hemoglobin can

improve a significans threat to tissue
oxygenation has much as aproximatelly
98 % of the oxygen is carried by the
hemoglobin molecules.
Abnormally high hemoglobin
concentration can increase cardiac out
put secondary to increased viscosity

Arterial Oxygen
Saturation

SaO2 can be maintaine at norma

level
( >97 % ) with :
Increased
PEEP
CPAP
ACMO

Vasopressors

Too Low

(Afterload)
SVR/PVR

Too Low

(Preload)
PAW/LA/RA

Vasopressors
Positive inotropics
Ventricular
ossist devices

Too Low

Pacemaker
Atropine

Too Low

(Contractility)
LVWSI/RVWSI
Heart rate

FiO2
Too Low Arterial oxygen
PEEP/CPAP
saturation
Hyperbaric oxygenation
ECMO
Blood product
Hb solution

Too Low

Hemoglobin

Calcium antagonists
Arterial vasodilatos
Too High
IABP
Alpha blockers
ACE inhibitors
Too High
Diuretics
Venous vasodilators
Too High

Beta blockers
IABP
Calcium antagonist

Too High
Beta blockers
Calcium antagonist
Too High

Too High

Hemodynamic effects of commonly used cardiovascular

drugs
Drugs
INOTROPIC
AGENTS
Digoxin
Dopamine

Dobutamine
Isoproterenol
Norepinephri
ne
Epinephrine
Methoxamine
Amrinone/
milrinone

HR

Afterloa
d

Contractili
ty

Preloa
d

Coments

or
or

- or

or

Ventricular rate in AF
Effect on SVR is dose
dependent; renal
blood flow

or

Can cause dysrythmias

Can cause dysrythmias
Can cause dysrythmias

- or

or

- or

Hemodynamic effects of commonly used cardiovascular

drugs
Drugs
ANALGESIC
AGENTS
Morphine
DIURETICS
(furosemide,
ethacrynic acid,
bumetanide)
ANTIDYSRHYTHMI
C AGENTS
Lidocaine
Procainamide
Quinidine
Atropine

HR

Afterloa
d

Contractili
ty

Preload

- or

Coments

May cardiac
output if diuresis
excessive

INTRAOPERATIVE MANAGEMENT

Regional VS General Anestesia pada Pasien

dengan Penyakit Jantung

Pasien dengan penyakit jantung telah dibandingkan efek-efek

regional vs general anestesi pada insidensi infarc perioperative,
disritmia dan CHF. Pada kebanyakan penelitian telah
menunjukkan tidak ada perbedaan pada infarction rate selama
general dan regional (spinal, epidural, nerve block, lokal
anestesia)
Regional anestesi dapat menguntungkan pada pasien-pasien
dengan sebelumnya MI yang menjalani transurethral
prostatectomy; reinfarction rate pada anestesi spinal kurang
dari 1% vs 2-8% pada anestesi general
Pemilihan anestesia yang paling baik adalah sesuai dengan
kebijakan tim perawatan anestesia, yang mana akan
mempertimbangkan kebutuhan ventilasi posoperative; efek
kardiovaskular, depresi miokardial; blokade simpatis

- Bode RH Jr, Lewis KP, Zarich SW, et al. comparison of general and regional anesthesia. Anesthesiology
1996;84:3-13
- Mangano DT. Perioperative cardiac morbidity. Anesthesiology 1990;72:153-184
- Norris EJ, Beattie C, Perler BA, et al. Anesthesiology 2001;95:1054-1067

INTRAOPERATIVE MANAGEMENT

INDUKSI ANESTESI

Induksi yang baik adalah penting untuk

mencegah hipotensi, hipertensi dan
takhikardi, yang mana dapat menyebabkan
iskemi miokardial
Semua obat-obat anesthesi dapat digunakan
pada pasien penyakit jantung, kecuali
ketamin karena dapat menyebabkan
hipertensi dan takhikardi

Martin DE, Rosenberg H, Aukburg SJ, et al. Lowe-dose fentanyl blunts circulatory responses to tracheal
intubation. Anest Analg 1982;61:680

INTRAOPERATIVE MANAGEMENT

Penggunaan Obat Anestesia

Pada akhir pembedahan, diharapkan dapat dilakukan

ekstubasi. Digunakan N2O dan kombinasi Isoflurane
dosis rendah dan Fentanil untuk mempertahankan
anestesia

Narkotik dosis tinggi sebaiknya dicegah bila ventilasi

postoperative tidak direncanakan

Pemakaian intermediate-acting neuromoscular

blocking agent seperti vecuronium, atracurium dan
rocuronium dapat digunakan secara aman karena
tidak menyebabkan perubahan kardiovaskular

-Fleming N.Con: the chice of muscle relaxants is not important in cardiac surgery. J Cardiothorac Vas Anesth :
1995;9:772-774
Hudson RJ, Thomson IR. Pro: the choice of muscle relaxants is important in cardiac surgery. J Cardiothorac Vas

HYPOTENSION
Remember : BP = CO x SVR
BP = (SV x HR) x SVR
1. Low SVR :
sympathetic blockade
vasodilators
spinal shock
anaphylaxis
blood transfusion
septic shock
2. Low HR ( see bradycardia )
3. Low Stroke Volume
4. Medicine :
SVR lowering : nipride
preload lowering : NTG
contractility lowering : beta blockers
5. Surgeons disturbing baroreceptors
carotid artery surgery

HYPERTENSION
1. Pain / Light anesthesia
2. Hypermetabolic state (fever / sepsis,
thyroid storm, MH crisis)
3. Catecholamine (hypoxia, hypercarbia,
acidosis, awareness during surgery)
4. Medicine (eg, epinephrine injection )
5. Endocrine (pheochromacytoma, MH,
thyroid crisis)
6. Renal (parenchymal, renovascular)
7. Cushings reflex
8. Coarctation
9. Full bladder

TACHYCARDIA
1. Light anesthesia / pain
2. Hypovolemic Shock
3. Hypermetabolic State :
shivering
fever
MH
thyroid
alcohol withdrawal
4. Catecholamine :
hypoxia, hypercarbia
acidosis
pheochromacytoma
5. Sepsis
6. Medicine :
atropin, gallamine
pancuronium, ketamin
7. Arrhytmia :
Atrial : SVT, Atrial fibrillation ,
Atrial flutter, pre-excitation
Ventricular : VT (remember epi + halothane )

BRADYCARDIA
1.
2.
3.
4.

HYPOXEMIA !!
Athletic heart
Deep anesthesia
Vagal Causes :
occulocardiac
maxillary traction
peritoneal traction
cervical dilatation
laryngoscopy
5. Cushings reflex
6. Medicine :
neostigmine, edrophonium,
pyridostigmine
beta blocker
7. Arrhytmias

OBAT INTRAVENA :
BARBITURAT
BP

ok :

* METHOHEXITONE
* THIOPENTONE
* CAPACITANCE VENODILATATION
PRELOAD
* SVR

* MYOCARDIAL CONTRACTILITY

BENZODIAZEPIN :
* DIAZEPAM
* MIDAZOLAM
BP

PENGARUHNYA TIDAK KENTARA

CARDIAC INDEX
SVR

PERUBAHAN
MINIMAL

K E TAM I N :
HEART RATE
CONTRACTILITY
SVR

BP
O2 Consumption
Risk MCI

CONTRA INDICATION :

Hypertension ( + )
Hyperthyroid
History of MCI
Intra Cranial Pressure

OPIAT
MORPHINE

HIPOTENSI ( + ) , ok :
- VASOMOTOR TONE
- CAPACITANCE VESSEL
- HISTAMIN RELEASE

PETIDINE

HEART RATE
- ANTICHOLENERGIC ACTION
(PARASYMPHATOLITIC,
ATROPIN LIKE ACTION)
BLOOD PRESSURE
- CONTRACTILITY
- SVR

INHALASI
N2O

circulation effect minimal

SVR, PVR

HALOTHANE

contractility

ENFLURANE

cardiac output
SVR

HALOTHANE provocator :
catecholamine induced dysrhytmias
HALOTHANE + ADRENALINE EMERGENCY

BP

ETHER
ISOFLURANE

SYMPHATIC STIMULATION

CYCLOPROPAN

BP

N @

RESPON KARDIOVASKULAR
TERHADAP PEMBEDAHAN DAN
ANESTESI

TEKNIK PREANESTETIK & MONITORING

LARINGOSKOPI & INTUBASI

PERUBAHAN FUNGSI VENTILASI

POSISI TUBUH

PERDARAHAN

STIMULASI DARI PEMBEDAHAN

KEDALAMAN ANESTESI

INTRAOPERATIVE MANAGEMENT
Depressi Segment ST
- Menunjukkan iskemia miokard disebabkan
peningkatan myocardial oksigen demand atau
penurunan oksigen supply. Peningkatan oksigen
supply
koreksi hipotensi, hipoksemia dan anemi
berat. Penurunan oksigen demand
koreksi
hipertensi dan takhikardi dengan memperdalam
level anestesia atau gunakan vasodilator, beta
blockers dan kalsium channel blockers.
- Bila tidak ada perubahan haemodinamik
nitrogliserin drip, intravenous nicardipine dapat
digunakan untuk mengurangi spasme koroner

- Ishibashi Y, Shimada T, Yoshitomi H, et al. Clin Exp Pharmacol Physiol 1999;26:404-410

Mangano DT. Perioperative cardiac morbidity. Anesthesiology 1990;71:153-184

INTRAOPERATIVE MANAGEMENT
Ekstubasi
-

Ketika pasien bangun, nafas adekuat dan

efek blokade neuromuscular telah hilang

Untuk mencegah takhikardi yang

berhubungan dengan ekstubasi dan
emergensi, dapat diberikan dosis preventif
seperti 1 mg/kg lidokain atau esmolol atau
0,1 mg/kg labetalol, diltiazem, atau
verapamil 2 menit sebelum ekstubasi

- Helfman SM, Gold MI, Delissen EA, et al. Anesth Analg 1991;72:482-486
Mikawa K, Nishina K, Maekawa N, et al. Anesth Analg 1996;82:1205-1210