Tehnik Proteksi Otak pada Pembedahan Non Neurosurgery (Radical Neck Dissection) dengan Premorbid Space Occupying Lesion (SOL) dan Infark Serebri

Abstract

Insidensi kasus tumor dengan metastase otak berkisar antara 100.000 sampai 170.000 pertahun. Metastase otak bersifat multiple dengan 80% terletak pada hemis ferserebri. Pendesakan akibat lesi tersebut mengakibatkan gangguan neurologis dan peningkatan tekanan intrakranial (TIK). Seorang laki-laki, 62 tahun dengan tumor sub mandibula direncanakan radical neck dissection. Pada pasien didapatkan proses metastase pada serebri dan cerebropontine angle disertai infark serebri daerah pons dan otak tengah. Defisit neurologis berupa kelemahan ekstremitas kanan dan disartria. Preoperatif diberikan kortikosteroid untuk menurunkan edema perifokal. Tatalaksana anestesi dengan prinsip tehnik proteksi otak, dilakukan induksi kombinasi dengan midazolam, fentanyl, lidokain, propofol dan rocuronium. Kontrol ventilasi target paCO2 30–35 mmHg. Pemeliharaan anestesi dengan kombinasi sevofluran dan propofol. Pembedahan berjalan 7 jam, temperature selama pembedahan 35–36 °C dan MAP dijaga >70 mmHg. Dilakukan ekstubasi, setelah menilai status neurologis dan hemodinamik, difasilitasi dengan lidokain. Pascabedah tidak didapatkan perburukan defisit neurologis. Pasien dirawat di ICU selama 2 hari kemudian ke ruangan dengan perbaikan status neurologis. Tehnik proteksi otak bertujuan mencegah cedera sekunder dari SOL dan iskemia. Tindakan anestesi dan pembedahan dapat menambah perburukan cedera sekunder. Penatalaksanaan anestesi yang baik dengan prinsip proteksi otak akan menghasilkan outcome pembedahan sesuai yang diharapkan.

Brain Protection Technique in Non Neurosurgical Procedure (Radical Neck Dissection) on a Patient with Space Occupying Lession (SOL) and Cerebral Infarction

The incidence of tumors with brain metastases ranged from 100,000 to 170,000 per year. Brain metastases are multiple with 80% of lesion located on the cerebral hemispheres. These lesions could cause neurological disorders and increase intracranial pressure (ICP). A 62 years old male, diagnosed with sub mandibular tumour was scheduled for radical neck dissection. From preoperative evaluation he hadcerebral metastasis at the cerebrum and cerebro-pontine angle with cerebral infarction at pons and middle brain regions. Neurological deficits were weakness of the right limband dysarthria. The patient received corticosteroids pre-operatively to reduce perifocal edema. Anesthesia management was given using brain protection principles. Induction was done by using midazolam, fentanyl, lidocaine, propofol and rocuronium. Ventilation was controlled with a target PaCO2 of 30–35 mmHg. Sevoflurane and propofol was given as anesthesia maintenance. Surgery was done for 7 hrs, temperature was 35–36 °C during surgery and MAP was maintained >70 mmHg. Extubation was done after assessing the neurologic and hemodynamic status,facilitated with lidocaine. There was no worsening of neurologic deficits post surgery. Patients was managed in the ICU for 2 days and transferred to ward with increased neurological state. The technique of brain protection aims to prevent further process of secondary injury from SOL and ischemia. Anesthesia and surgery itself could increase the progression of secondary injury. Anesthesia management usingbrain protection principles will provide better outcomes as expected.