teknik anestesi umum

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

+

-

-

-

+

+

-

-

-

+

+

-

-

+

+

+

+

+

-

-



Rapidly acting

Smooth induction

Respiratory depression

Cardiovascular depression

+

++

+

++

-

+

-

-

+

+

+

++

-

+

-

+/-

-

+

+/-

+/-



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


CBF

ICP

CMRO2

Seizure

Clinical pharmacology of Inhalational anesthetics


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


More 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

teknik anestesi umum

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