SPINAL ANESTHESIA IN SECTIO

CAESARIA

Preceptor : dr. Edwin Haposan Martua Sp.An., M.Kes.AIFO

Presentan : Viedya Adhany Tamala (2016730103)

KEPANITERAN KLINIK STASE ANESTESI

RSUD SEKARWANGI

FKK UNIVERSITAS MUHAMMADIYAH JAKARTA

2021
Patient's Identity
 Name : Ny. C
 Sex : Female

 Age : 29 years

 Religion : Islam
 Occupation : House Wife
 Education : Vocational School
 Adress : Kp. Babakan, Parungkuda,Sukabumi
 Medical Record No : 679***
 Room : Cut Nyak Dien

 Date of Admision : 10th November 2021

 Date of Surgery : 11th November 2021

 ANAMNESIS
Chief Complaint

Water coming out of the birth canal since 3 am

Current Medical History

The patient has came to RSUD Sekarwangi with a referral from the puskesmas and complained of
water coming out of the birth canal since 3 am. The patient also complained of labor since 2 days ago
but it was rare and has been getting worse since 11 o'clock last night.
 ANAMNESIS
Surgery History
Patient said he had a history of SC surgery 1 time, 6 years ago .

Past Medical History

History of hypertension was denied, the history of diabetes mellitus was denied, the history of
cardiovascular disease was denied, the history of respiratory disease was denied, the history of asthma
was denied, the history of drug allergy was denied.

Family History of Illness

Patient denied any family history of illness, a family history of hypertension and diabetes mellitus
was denied
 ANAMNESIS
Medical History
Patient does not take certain drugs

History of Allergies
Patient denies any history of allergies to food, drugs, or to certain weather or temperatures

Psychosocial History

The patient's diet is regular, the patient does not smoke and does not consume alcoholic
beverages.
 PHYSICAL EXAMINATION
General circumstances

General circumstances : Looks moderately ill.

Awareness : Compos mentis

Vital sign

 Blood pressure : 110/70 mmHg

 Heart rate : 88 x/minute
 Respiratory rate : 20 x/minute
 Temperature: 36.5o C
 spO2 : 98%
Anthropometric status

 Weight : 58 kg
 Height : 160 cm
 IMT : 26 kg/m2 ( normoweight)
 PHYSICAL EXAMINATION
 Head : Normocephal, symmetric, black hair, dan even distribution.

 Eyes : Conjunctiva anemic (-/-), icteric sclera (-/-), pupil isokor ( 3mm/ 3mm ), light reflex (+/+)

 Nose : Septum deviation (-), Secretions (-/-), blood (-/-)

 Ears : Normotia (+), secretions (-/-), blood (-/-)

 Mouth : Moist lip mucosa, cyanosis (-)

 Neck : Enlarged lymph nodes (-), enlarged thyroid gland (-)

 PHYSICAL EXAMINATION
 Lung
• Inspection : Symmetric, retraction of the thorax wall (-/-)
• Palpation : Vocal fremitus was palpable in both fields.
• Percussion : Sonor in all lung fields.
• Auscultation : Vesicular (+/+), ronkhi (-/-), wheezing (-/-)

 Heart
• Inspection : Ictus cordis is not visible.
• Palpation : Ictus cordis is palpable.
• Percussion : Left border of ICS IV left midclavicularis line.
Right border of ICS IV right parasternalis line.
• Auscultation : Pure regular I and II heart sounds, murmur (-), gallop (-)
 PHYSICAL EXAMINATION
 Abdomen
• Inspection : Surgery marks (+), linea nigra (+)
• Auscultation : Bowel sounds (+) 10x/menit normal
• Palpation : no palpable enlargement of the liver and spleen.
• Percussion : Tympanic in all areas of the abdomen.
 Extremities
• Upper : CRT < 2 second, warm perifer body (+/+), oedema (-/-)
• Lower : CRT < 2 second, warm perifer body (+/+), oedema (-/-)
• Back : There’s no abnormality
 PHYSICAL EXAMINATION
Obstetrics and Gynecology Status

External Examination
• TFU : 32 cm
• DJJ : 140 x/minute
• HIS : 2x10'25"
• L1: Feels the part is less rounded and soft (Buttocks)
• L2: Feels the hard part extending on the right (Right back)
• L3 : Feels round and hard (Head)
• L4 : Divergent

Internal Examination
Vulva Vagina no abnormalities, thick portio, Ø 3-4 cm head presentation
 SUPPORTING EXAMINATION
PEMERIKSAAN HASIL NILAI RUJUKAN
HEMATOLOGI    
Hemoglobin 12.9 g/dL 12 – 14
Jumlah Leukosit 9.400 /uL 4.000 – 11.000
Trombosit 337.000 /uL 150.000 – 400.000
Hematokrit 38 % 41 – 53
Waktu Pembekuan 5 3-7
Waktu Pendarahan 2 1-3
GOL. DARAH + RHESUS A
GDS 82 mg/dL <180
Ureum 14mg/dL 10-50
IMUNOLOGI SEROLOGI    
HbsAg Skrining: Non Reactive Nonreactive
Anti HIV Skrining: Non Reactive Nonreactive
ANTI SARS-COV-2 Negative Negative
Sifilis Negative Negative
DIAGNOSIS
 Pre surgical diagnosis : G1P0A0 Gravida 39 weeks Kala I Fase Laten

with CPD + PROM 6 hours

 Operation action plan : Sectio Caesaria

 Anesthetic diagnosis : ASA II

 Anesthetic action plan: Regional anesthesia with spinal technique

PRE OPERATION
Preoperative preparation :
o Operation and Anesthesia approval letter

o Fasting 6 hours

o Premedication: Ondancetron 4 mg
PRE OPERATION
Anesthetic measures, preparations :
 Setting up the operating table

 Prepare anesthesia machines and equipment

 Prepare STATICS and General Anesthesia Components

 Prepare the necessary anesthetic drugs

 Prepare resuscitation drugs: Atropine 0.25 mg, Ephedrine 50

mg/Ml

 Prepare the infusion pole and plaster

 PRE OPERATION
 The patient was given a pre-medication in the form of Ondancetron 4 mg.

 The patient is then seated, then bows his head.

 The injection is carried out at L3 - L4, using a spinal needle size of 25G. Stab + 2 cm
slightly towards the cephalic, After the resistance disappears, the mandrin of the spinal
needle is pulled out and it comes out of the liquid, put in a syringe filled with medicine and
insert the drug slowly alternating with a little aspiration.
 INTRAOPERATIVE
VITAL SIGNS
TD HR SpO2
Waktu Cairan Obat IV
(mmHg) x/menit (%)

10.55 106/78 93 98 RL 500 -

Oxytocin
20 IU
11.10 110/57 78 99 -
Ergometrin
0,2 mg

11.25 100/45 90 100 - -

11.40 105/56 89 100 - -

FLUID MONITORING
 Maintenance needs → weight : 58 kg.
 10 kg I = 10 kg x 4 cc/kgBB/hour = 40 cc/hour.
 10 kg II = 10 kg x 2 cc/kgBB/hour = 20 cc/hour.
 The rest = 38 kg x 1 cc/kgBB/hour = 38 cc/hour.
Total = 98 cc/hour

 Stressed operative → moderate (4-6cc/kgBB/hour).

5 x 58 kg = 290 cc

 Fasting replacement fluid.

Long fasting x maintenance = 6 hour x 98 cc/hour = 588 cc
FLUID MONITORING
Fluid requirements
First hour : Maintenance + (½ x fasting replacement fluid) + stressed operative.
98 + (½ x 588) + 290 = 682 cc.
 POST OPERATIVE STATE

General circumstances Vital Sign

 General circumstances :  TD : 116/68 mmHg
Looks moderately ill  HR : 70 x/menit
 Awareness :  RR : 20 x/menit
Compos mentis
 SpO2 : 99%

Length of operation :
45 minutes
POST OPERATIVE STATE

The patient moved to the room,

because the score was < 2.
 POST SURGICAL THERAPY

Rest in bed head up 30

Observation of General Conditions, Vital Sign, Operation Wound Bleeding every 15
minutes for 2 hours

Patients can eat and drink gradually if they are not nauseous and vomiting

Ondancetron 4 mg for nausea

Maintanance fluid RL 1500 cc / 24 hours

Other therapies according to the doctor in charge
LITERATURE
REVIEW
 Regional Anesthesia

• Inhibition of pain impulses from one part of the body while on sensory
nerve impulses, so that pain impulses from one part of the body are
temporarily blocked (reversible).
• Motor function can be affected partially or completely. But the patient
remains conscious.
 CLASSIFICATION OF REGIONAL
ANESTHESIA
Regional Anethesia

Spinal Epidural Caudal

anesthesia anesthesia anesthesia
ANATOMI
SPINAL ANESTHESIA (SUBARACHNOID)
Cutis
Spinal anesthesia is obtained by injecting a
local anesthetic into the subarachnoid space. Subcutis

Supraspinosum ligament

Interspinosum ligament

Flavum ligament

Epidural chamber

Duramater

Subarachnoid chamber
Clinical Considerations
Indications

Lower limb surgical

Inguinal surgical
Rectum-perineum surgical
Obstetric gyecology surgical

Urology surgical
Lower abdominal surgical
 Contraindications
Absolut Relative

Lack of consent Sepsis

There is infection at the injection site Uncooperative patient

Suffering from coagulopathy Preexisting neurological deficits

Severe hypovolemia Cardiology disease

Increased intracranial pressure Severe spinal deformity

Controversial

• Prior back surgery at the site of injection

• Complicated surgery
• Prolonged operation
• Major blood loss
SPINAL ANESTHESIA (SUBARACHNOID)

Preparation

• Informed consent, physical examination, laboratory examinations.

Equipment

• Monitor (TD, HR, RR, SpO2), Oxymeter, EKG, Resucitation equipment,

Spinal needles and spinal drugs.
Position

Patients sit with their elbows resting on their thighs or a bedside table, or they can hug a
pillow.

The anatomic midline is often easier to identify when the patient is sitting than when the
patient is in the lateral decubitus position
SPINAL ANESTHESIA (SUBARACHNOID)
Technique

• Put the patient in a lateral decubitus position or sit down and

make the patient bend maximally so that the spinous process is
easily palpable
• Determine the puncture site for example L2-L3, L3-L4 or L4-L5
• Sterilize the puncture site with betadine and alcohol
• Give a local anesthetic to the puncture site eg lidocaine
• The mode of puncture is median or paramedian
• Recommended to use an introducer guide
• Insert needle into subarachnoid space
• Remove the mandrin, the LCS will drip out
• The local analgesic solution is injected into the subarachnoid
space.
 local anesthetic Specific gravity characteristics Dose

CSF has a specific gravity of 1.003 to 1.008 at 37°C.

Factors affecting the dermatomal spread of spinal
anesthesia

Most important factors : Other factors :

• Baricity of aneshetic solution • Curvature of the spine
• Position of the patient • Needle direction
• Drug dosase • Needle size
• Site of injection • Intraabdominal pressure
 Comparison of the Esther and Amide groups
CLASSIFICATION POTENTION ONSET OF ACTION DURATION OF ACTION TOXICITY
Ester
Procaine 1 (low) fast 45-60 low
Chlorocaine 3-4 (high) Very fast 30-45 Very low
Tetracaine 8-16 (high) slow 60-180 moderate
Amida
Lidocaine 1-2 (moderate) fast 60-120 moderate
Etidocaine 4-8 (high) slow 240-480 moderate
Prilocaine 1-8 (low) slow 60-120 moderate
Mepivacaine 1-5 (moderate) moderate 90-180 high
Bupivacaine 4-8 (high) slow 240-480 low
Ropivacaine 4 (high) slow 240-480 low
Levobupivacaine 4 (high) slow 240-480  
 Complication

Severe hypotension
Brachicardia Hypoventilation

Naussea and vomitting Vascular trauma Nerve trauma

High spinal
 EPIDURAL ANESTHESIA

• Nerve blockade by placing drugs in the epidural space.

• This space is between the ligamentum flavum and
• dura mater.
• The average depth of this space is 5mm and is posterior to the
maximum depth in the lumbar region.
• The onset of action of epidural anesthesia is slower
• than that of spinal anesthesia, whereas the quality of
• the sensory-motor blockade is also weaker.
 CAUDAL ANESTHESIA

• Indication : perineal surgical

• Method : find the right-left sacral
horn,
• which is located between the sacro
• coccygeal membrane and the hiatus
sacralis
Thankyou