Penatalaksanaan Anestesi Untuk Kliping Ruptur Aneurisma Serebral

Abstract

Aneurisma cerebral merupakan suatu kelainan vaskuler intraserebral, dengan angka kejadian sekitar 5% dari jumlah populasi pada usia 45-60 tahun. Perdarahan subarachnoid (Subarachnoid Hemorrhage /SAH) merupakan gejala serius dari aneurisma yang ruptur dengan angka kejadian berkisar antara 10-15 kasus per 100.000 populasi. Aneurisma yang pecah ulang atau iskemia merupakan masalah utama pada pengelolaan perioperatif pasien dengan aneurisma serebral. Seorang wanita berusia 73 tahun, berat badan 80 kg dengan aneurisma sakuler dari arteri vertebralis kanan bagian proksimal dari arteri sereberal posterior inferior (Posterior Inferior Cereberal Artery /PICA) dengan gambaran SAH, GCS 7, tekanan darah 200/160 mmHg, nadi 100 x/ menit, respirasi 18 x/permenit dengan Kriteria Hunt and Hess III-IV. Dilakukan intubasi dan penanganan tekanan darah di Unit Gawat Darurat dan pasien dirawat di ICU. Di ICU pasien diventilasi, dengan sedasi propofol 1 mg/kgBB/jam, diberikan perdipine 0,5 mg/kg BB/menit, dan pasien dapat diekstubasi hari ke-10 setelah perawatan di ICU. Operasi dilakukan pada perawatan hari ke 17, dengan keadaan prabedah GCS 13, tekanan darah 160/80 mmHg, nadi 90 x/menit, respirasi 14 x/menit SpO2 100% dengan binasal canul, dan direncanakan dilakukan kliping aneurisma. Dipasang alat pantau tekanan darah non-invasif, EKG, SpO2, dan urine kateter. Pasien tanpa premedikasi, induksi dengan propofol, fentanyl, lidokain, dan fasilitas intubasi dengan rocuronium 0,9 mg/kg BB. Rumatan anestesi dengan Sevofluran - Oksigen 40% - propofol kontinyu 1-3 mg/kg/jam - vecuronium 0,1 mg/kgBB/jam. Pemasangan arteri line setelah induksi anestesi. Untuk pengaturan tekanan darah sebelum dan saat kliping temporari dan permanen dengan nitrogliserin titrasi. Pascabedah pasien dipindahkan ke ICU, tidak diekstubasi, dan dilakukan ventilasi mekanis selama 24 jam, dan dirawat selama 12 hari, dengan mendapatkan terapi hipertensi dengan menaikkan tekanan darah maksimal 20% dari nilai dasar. Pasien di pindahkan ke ruangan GCS 15, Tekanan darah 140/90 mmHg, Nadi 80x/menit, respirasi 12x/menit SpO2 100%. Komplikasi pada post operasi aneurisma adalah hidrocephalus, rebleeding, kejang dan vasospasme. Adanya penurunan kesadaran pascabedah terutama disebabkan karena menurunnya aliran darah otak akibat vasospasme. Pencegahan dan penanganan kemungkinan terjadinya komplikasi ini dapat memperbaiki luaran pasien. Penatalaksaanaan preoperasi, intraoperatif dan postoperatif yang benar dapat memperbaiki luaran pasien.

Anesthesia Management For Clipping Cerebral Aneurysm Rupture

Cerebral aneurysm is considered an intra cerebrovascular structural dysfunction, with the incidence rate around 5% of total 45-60 years of age population. Subarachnoid Hemorrhage (SAH) is considered a serious symptom of ruptured aneurysm and the incidence rate is around 10-15 cases per 100.000 human population. Re-ruptured or ischemia are the main problems in perioperative management of patient with cerebral aneurysm. A 73-year-80 kg BW female with saculler aneurysm on the right vertebral artery proximal to Posterior Inferior Cereberal Artery (PICA) and the appearance of subarachnoid haemorrhage (SAH), GCS 7, blood pressure 200/160 mmHg, heart rate 100 beats/minute, respiration rate 18 beats/minute with the Hunt and Hess Criteria III-IV was admitted to the hospital. Performed intubation and hypertension management at the emergency ward and the patient was treated at the ICU. At the ICU, the patient was on ventilator, sedated using propofol 1 mg/kgBW/hr, perdipine 0,5 mg/kgBW/minute, and the patient was extubated on the day-10 after ICU treatment. The surgery was performed on the day-17, and the presurgery descriptions were GCS 13, blood pressure 160/80 mmHg, heart rate 90 beats/minute, respiration rate 14 beats/minute, SpO2 100% with oxygenation using binasal canule, and the patient was scheduled for aneurysm clipping. A non-invasive monitor was installed for blood pressure, ECG, SpO2 and urine foley catheter was also installed. The patient was without premedication, inducted using propofol, fentanyl, lidocain, and facilitate intubation with rocuronium 0,9 mg/kgBW. Anesthetic maintenance using Sevoflurane - oxygen 40% - propofol continuously 1-3 mg/kgBW/hr - vecuronium 0,1 mg/kgBW/hr. Installation of arterial line was performed right after anesthetic induction. Nitrogliserin titration was used to manage blood pressure before and during temporary and permanent clipping. After surgery, the patient was transferred to ICU, unextubated, and was on mechanical ventilator for 24 hr, being treated for 12 days, and received hypertension therapy by increasing the blood pressure 20% maximum from the baseline. The patient was then transferred to the inpatient ward at GCS 15, blood pressure 140/90 mmHg, heart rate 80 beats/minute, respiration rate 12 beats/minute, and SpO2 100%. Complications that may occur at the post aneurysm surgery were hidrocephalus, re-bleeding, seizure and vasospasm. The awareness decline post surgery may due to the decreasing of intra cerebral blood circulation due to vasospasm. Anticipation and management the possibility of those complications may determine the patient’s outcome. The correct management of pre-surgery, intrasurgery and post surgery will improve the patient outcome as well.