Tugas Akhir PENGARUH INFILTRASI LOKAL LEVOBUPIVAKAIN …

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Tugas Akhir

PENGARUH INFILTRASI LOKAL LEVOBUPIVAKAIN PADA

PASIEN DENGAN FRAKTUR COLLUM FEMUR YANG

DILAKUKAN HEMIARTHROPLASTY AUSTIN MOORE

PROSTHESIS DI RS ORTOPEDI PROF. DR. R. SOEHARSO

SURAKARTA

Oleh :

Zen Firhan

Pembimbing :

dr. Ismail Mariyanto, Sp.OT (K)

dr. Mujaddid Idulhaq, Sp.OT (K), M.Kes.

PROGRAM PENDIDIKAN DOKTER SPESIALIS - I

ORTHOPAEDI DAN TRAUMATOLOGI

FAKULTAS KEDOKTERAN UNIVERSITAS SEBELAS MARET

RS DR. MOEWARDI / RS ORTOPEDI PROF. DR. R. SOEHARSO

SURAKARTA

2016




PENGARUH INFILTRASI LOKAL LEVOBUPIVAKAIN PADA

PASIEN DENGAN FRAKTUR COLLUM FEMUR YANG

DILAKUKAN HEMIARTHROPLASTY AUSTIN MOORE

PROSTHESIS DI RS ORTOPEDI PROF. DR. R. SOEHARSO

SURAKARTA

(Tugas Akhir)

Zen Firhan*, Ismail Mariyanto**, Mujaddid Idulhaq***

*Residen Orthopaedi dan Traumatologi, FK Universitas Sebelas Maret

**Staf Pengajar Orthopaedi dan Traumatologi FK. Universitas Sebelas Maret, RSUD Dr. Moewardi, RSO Prof. DR.R

Soeharso, Surakarta

*** Staf Pengajar Orthopaedi dan Traumatologi FK. Universitas Sebelas Maret, RSUD Dr. Moewardi, RSO Prof. DR.R

Soeharso, Surakarta

ABSTRAK

Latar Belakang : Fraktur collum femur merupakan fraktur yang sering terjadi

pada pasien usia lanjut, dan penyebab umum kehilangan fungsional akibat nyeri

yang menetap atau keterbatasan mobilitas. Salah satu pilihan terapi pada fraktur

collum femur adalah Hemiarthroplasty menggunakan implant Austin Moore

Prosthesis, yang masih merupakan pilihan utama karena implant yang cukup

murah dan teknik operasi yang relatif mudah. Tindakan Hemiarthroplasty

bertujuan menghilangkan nyeri dan agar pasien dapat menjalani rehabilitasi

mobilisasi sesegera mungkin. Namun untuk mencapai target tersebut seringkali

terkendala oleh nyeri pasca operasi yang dirasakan oleh pasien, khususnya 24 - 48

jam setelah operasi. Infiltrasi Lokal (Levobupivakain) merupakan salah satu

metode yang digunakan untuk mengurangi nyeri pasca operasi. Telah banyak

dilakukan penelitian yang menjelaskan manfaat metode ini dalam menurunkan

nyeri pasca operasi, dan membantu proses rehabilitasi pasien. Oleh karena itu

Peneliti mencoba mengevaluasi pengaruh Infiltrasi Lokal Levobupivakain pada

pasien dengan fraktur collum femur yang dilakukan Hemiarthroplasty Austin

Moore Prosthesis di RS Ortopedi Prof. Dr. R. Soeharso Surakarta.


Pasien dan Metode : Penelitian ini dilakukan dengan metode Experimental

Clinical Trial dan Total Consecutive Sampling untuk semua pasien yang datang

ke RS Ortopedi Prof. Dr. R. Soeharso Surakarta dengan fraktur collum femur dan

dilakukan Hemiarthroplasty Austin Moore Prosthesis antara bulan Juli 2016 –

September 2016. Sampel dibagi menjadi 2 kelompok, yaitu kelompok yang diberi

Infiltrasi Lokal Levobupivakain, dan kelompok kontrol yang tidak diberi Infiltrasi

Lokal Levobupivakain. Kemudian dilakukan evaluasi nyeri pasca operasi

menggunakan VAS pada 12 jam, 24 jam, 36 jam, dan 48 jam pasca operasi, serta

kemampuan mobilisasi pasca operasi pasien pada masing-masing kelompok.

Hasil : Sebanyak 64 pasien telah dianalisa dan diteliti, terdapat 9 pasien pria dan

55 pasien wanita. Usia rata-rata adalah 70,95 tahun. Terdapat perbedaan secara

signifikan (p = 0,00) pada kelompok yang diberikan Infiltrasi Lokal

Levobupivakain untuk nilai nyeri pasca operasi (VAS 12 jam = 4,7188, 24 jam =

4,000, 36 jam = 3,3125, 48 jam = 2,3438), dibandingkan dengan kelompok

kontrol (VAS 12 jam = 5,5312, 24 jam = 5,0938, 36 jam = 4,6250, 48 jam =

3,5625), dimana nilai VAS yang lebih rendah didapatkan pada kelompok yang

diberikan infiltrasi lokal. Juga terdapat perbedaan secara signifikan (p = 0,00)

pada kemampuan mobilisasi pasien pasca operasi kelompok yang diberikan

Infiltrasi Lokal Levobupivakain (5,6562) dibandingkan kelompok kontrol

(2,4688), dimana mobilisasi yang lebih tinggi didapatkan pada kelompok yang

diberikan infiltrasi lokal.

Kesimpulan : Pada penelitian ini dapat disimpulkan bahwa Infiltrasi Lokal

Levobupivakain berpengaruh dalam menurunkan nyeri pasca operasi dan

meningkatkan kemampuan mobilisasi pasien dengan fraktur collum femur yang

dilakukan Hemiarthroplasty Austin Moore Prosthesis di RS Ortopedi Prof. Dr. R.

Soeharso Surakarta.

Kata Kunci : Fraktur Collum Femur, Hemiarthroplasty, Austin Moore

Prosthesis, Infiltrasi Lokal, Levobupivakain


THE EFFECT OF LEVOBUPIVACAINE LOCAL

INFILTRATION ON PATIENTS WITH FEMORAL NECK

FRACTURE TREATED WITH HEMIARTHROPLASTY

AUSTIN MOORE PROSTHESIS AT PROF. DR. R. SOEHARSO

ORTHOPAEDIC HOSPITAL SURAKARTA

(Final Paper)

Zen Firhan*, Ismail Mariyanto**, Mujaddid Idulhaq***

* Orthopaedic and Traumatology Resident, Faculty of Medicine Sebelas Maret University

** Teaching Staff Orthopaedic and Traumatology Residency, Faculty of Medicine Sebelas Maret University, Dr.

Moewardi General Hospital, Prof. Dr. R Soeharso Orthopaedic Hospital, Surakarta

*** Teaching Staff Orthopaedic and Traumatology Residency, Faculty of Medicine Sebelas Maret University, Dr.

Moewardi General Hospital, Prof. Dr. R Soeharso Orthopaedic Hospital, Surakarta

ABSTRACT

Background : Femoral neck fracture are fractures that commonly occur in

elderly patients, and a common cause of functional loss as a result of persistent

pain or limited mobility. A treatment option in femoral neck fracture is

Hemiarthroplasty using Austin Moore Prosthesis, which is still the main choice of

treatment that are reasonably low cost and relatively easy surgical technique.

Hemiarthroplasty aimed at the relief of pain so that patients can undergo

mobilization as soon as possible. However, these targets is often constrained by

postoperative pain experienced by the patient, especially 24 - 48 hours after

surgery. Local infiltration (Levobupivacaine) is one method used to reduce

postoperative pain. A lot of research has been done which explain the benefits of

this method in reducing postoperative pain, and assisting mobilization of patients.

Therefore, we tried to evaluate the effect of Levobupivacaine local infiltration in

patients with femoral neck fracture treated with Hemiarthroplasty Austin Moore

Prosthesis at Prof. Dr. R. Soeharso Orthopaedic Hospital, Surakarta.

Patients and Methods : This research was conducted using Experimental

Clinical Trial and Total Consecutive Sampling for all patients who came to Prof.


Dr. R. Soeharso Surakarta Orthopaedic Hospital with femoral neck fracture and

treated with Hemiarthroplasty Austin Moore Prosthesis between July 2016 until

September 2016. The samples were divided into 2 groups, that is a group given

Levobupivacaine Local Infiltration, and a control group who were not given the

Levobupivacaine Local Infiltration. Then we evaluate postoperative pain using the

VAS with interval 12 hours, 24 hours, 36 hours, and 48 hours post-surgery, as

well as the patient’s ability to mobilize postoperatively in each group.

Results : A total of 64 patients have been analyzed and studied, there are 9 male

patients and 55 female patients. The average age is 70,95 years. There is a

significant difference (p = 0.00) in the group given the Levobupivacaine Local

Infiltration for postoperative pain score (VAS 12 hours = 4.7188, 24 hours =

4,000, 36 hours = 3.3125, 48 hours = 2.3438 ), compared with the control group

(VAS 12 hours = 5.5312, 24 hours = 5,0938, 36 hours = 4.625, 48 hours =

3.5625), where the lower VAS score belong to group given local infiltration.

There is also a significant difference (p = 0.00) for patient’s ability to mobilize

postoperatively in the group given the Levobupivacaine Local Infiltration

(5,6562) than the control group (2,4688), where the higher mobilization belong to

group given local infiltration.

Conclusion : In this study it can be concluded that Levobupivacaine Local

Infiltration has the benefit in reducing postoperative pain and improving

mobilization of patients with femoral neck fracture treated with Hemiarthroplasty

Austin Moore Prosthesis at Prof. Dr. R. Soeharso Orthopaedic Hospital,

Surakarta.

Keywords : Femoral Neck Fracture, Hemiarthroplasty, Austin Moore

Prosthesis, Local Infiltration, Levobupivacaine


DAFTAR ISI

HALAMAN JUDUL .................................................................................... i

KATA PENGANTAR .................................................................................. ii

HALAMAN PENGESAHAN ...................................................................... iii

ABSTRAK .................................................................................................... iv

DAFTAR ISI ................................................................................................. viii

DAFTAR GAMBAR .................................................................................... xii

DAFTAR TABEL ......................................................................................... xiii

DAFTAR SINGKATAN .............................................................................. xv

BAB I. PENDAHULUAN ............................................................................ 1

1.1. Latar Belakang Masalah ................................................................... 1

1.2. Perumusan Masalah .......................................................................... 3

1.3. Tujuan Penelitian .............................................................................. 4

1.3.1. Tujuan Umum ....................................................................... 4

1.3.2. Tujuan Khusus ...................................................................... 4

1.4. Manfaat Penelitian ............................................................................ 4

1.4.1. Manfaat Teoritik ................................................................... 4

1.4.2. Manfaat Praktis ..................................................................... 5


BAB II. TINJAUAN PUSTAKA ................................................................. 6

2.1. Fraktur Collum Femur ........................................................................... 6

2.1.1. Anatomi Sendi Panggul .......................................................... 6

2.1.2. Mekanisme Fraktur ................................................................. 9

2.1.3. Gejala Klinis ........................................................................... 10

2.1.4. Pemeriksaan Penunjang .......................................................... 10

2.1.5. Klasifikasi ............................................................................... 11

2.1.6. Penatalaksanaan ...................................................................... 13

2.2. Hemiarthroplasty Austin Moore Prosthesis ........................................... 16

2.2.1. Teknik Operasi ....................................................................... 16

2.2.2. Rehabilitasi ............................................................................. 19

2.3. Nyeri ...................................................................................................... 20

2.3.1. Patofisiologi Nyeri .................................................................. 21

2.3.2. Nyeri Pasca Operasi ................................................................ 24

2.3.3. Penilaian Nyeri ........................................................................ 25

2.4. Anestesi Infiltrasi Lokal ......................................................................... 28

2.4.1. Mekanisme Kerja Anestetikum Lokal .................................... 29

2.4.2. Jenis-jenis Obat Anestesi Infiltrasi Lokal ............................... 31

2.4.3. Faktor-Faktor Yang Mempengaruhi Mula dan Masa Kerja ... 32

2.4.4. Levobupivakain ....................................................................... 37

2.4.4.1. Struktur Kimia ......................................................... 37


2.4.4.2. Farmakodinamik ...................................................... 38

2.4.4.3. Farmakokinetik ........................................................ 39

2.4.4.4. Aplikasi Klinik ........................................................ 40

2.4.5. Anestesi Infiltrasi Lokal dan Manajemen Nyeri Pasca Operasi 40

2.6. Kerangka Konsep Teori ......................................................................... 43

2.7. Hipotesis ................................................................................................ 43

BAB III. METODE PENELITIAN .............................................................. 44

3.1. Jenis Penelitian ...................................................................................... 44

3.2. Lokasi Penelitian .................................................................................... 44

3.3. Objek Penelitian ..................................................................................... 44

3.4. Besar Sampel ......................................................................................... 45

3.5. Pengambilan Sampel .............................................................................. 45

3.5.1. Kriteria Inklusi ........................................................................ 45

3.5.2. Kriteria Eksklusi ..................................................................... 46

3.6. Identifikasi Variabel ............................................................................... 47

3.6.1. Variabel Bebas ........................................................................ 47

3.6.2. Variabel Terikat ...................................................................... 47

3.6.3. Variabel Perancu ..................................................................... 47

3.7. Definisi Operasional Variabel ................................................................ 47

3.8. Alat dan Bahan Penelitian ...................................................................... 48

3.9. Instrumen Pengumpulan Data ................................................................ 49


3.10. Langkah-langkah Penelitian ................................................................. 49

3.11. Rancangan Penelitian ........................................................................... 51

3.12. Analisis Data ........................................................................................ 51

BAB IV. HASIL DAN PEMBAHASAN ..................................................... 52

4.1. Hasil Penelitian ...................................................................................... 52

4.1.1. Karakteristik Data Pasien ....................................................... 52

4.1.2. Nilai VAS dan Kemampuan Mobilisasi ................................. 56

4.2. Pembahasan ........................................................................................... 60

BAB V. KESIMPULAN DAN SARAN ..................................................... 63

5.1. Kesimpulan ............................................................................................ 63

5.2. Saran ...................................................................................................... 64

DAFTAR PUSTAKA .................................................................................. 65

LAMPIRAN ................................................................................................ 69


DAFTAR GAMBAR

Gambar 1. Struktur anatomi Femur proksimal ............................................. 7

Gambar 2. Struktur vaskularisasi pada collum femur ................................... 9

Gambar 3. Klasifikasi fraktur collum femur berdasarkan lokasi anatomis .. 13

Gambar 4. Klasifikasi fraktur collum femur menurut Pauwel ..................... 13

Gambar 5. Klasifikasi fraktur collum femur menurut Garden ..................... 14

Gambar 6. Implant Austin Moore Prosthesis ............................................... 18

Gambar 7. Incisi posterior approach (Moore), dan incisi dalam .................. 19

Gambar 8. Tahapan operasi Hemiarthroplasty Austin Moore Prosthesis ..... 21

Gambar 9. Proses neurofisiologis nyeri ...................................................... 25

Gambar 10. Wong-Baker Faces Pain Rating Scale ...................................... 27

Gambar 11. Verbal Rating Scale .................................................................. 28

Gambar 12. Numerical Rating Scale ............................................................ 28

Gambar 13. Visual Analogue Scale .............................................................. 29

Gambar 14. Mekanisme kerja anestesi pada membran sel ........................... 31

Gambar 15. Struktur kimia Levobupivakain ................................................ 38


DAFTAR TABEL

Tabel 1. Nilai pKa anestetikum lokal ........................................................... 37

Tabel 2. Terapi penanganan nyeri yang direkomendasikan WHO .............. 43

Tabel 3. Distribusi pasien berdasarkan jenis kelamin .................................. 52

Tabel 4. Statistik usia rata-rata per kelompok .............................................. 52

Tabel 5. Statistik Independent T-test untuk usia .......................................... 53

Tabel 6. Statistik berat badan rata-rata per kelompok .................................. 53

Tabel 7. Statistik Independent T-test untuk berat badan .............................. 53

Tabel 8. Statistik tinggi badan rata-rata per kelompok ................................ 54

Tabel 9. Statistik Independent T-test untuk tinggi badan ............................. 54

Tabel 10. Statistik Body Mass Index rata-rata per kelompok ....................... 55

Tabel 11. Statistik Independent T-test untuk Body Mass Index .................... 55

Tabel 12. Statistik VAS 12 jam pasca operasi rata-rata per kelompok ........ 56

Tabel 13. Statistik Independent T-test untuk nilai VAS 12 jam pasca operasi 56








Tabel 20. Statistik kemampuan mobilisasi pasca operasi rata-rata per kelompok 60

Tabel 21. Statistik Independent T-test untuk kemampuan mobilisasi .......... 60


DAFTAR SINGKATAN

CT Scan : Computed Tomography Scan

HA : Hemiarthroplasty

LIA : Local Infiltration Anesthesia

MRI : Magnetic Resonance Imaging

NADW : The National Arthritis Data Workgroup

NSAID : Non Steroid Anti Inflammation Drug

USG : Ultrasonography

VAS : Visible Analog Scale

WHO : World Health Organization

Tugas Akhir PENGARUH INFILTRASI LOKAL LEVOBUPIVAKAIN …

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