Sabtu, 26 Februari 2011

pengukuran dan monitoring tekanan intra kranial

MEASUREMENT AND MONITORING
PRESSURE INTRA cranial


Sectional HEAD
§ Intra Cranial Pressure
• ICT is the pressure caused by the addition of volume within the cranium

• The contents of the cranium are:

               
86% of brain tissue,

               
CSF of 10%

               
4% of blood

In other words

 
Total blood volume = Volume + Volume + Volume of brain CSF

• Hypothesis Monro kelly:
If there is an addition to the other component parts of the brain will adjust so that the brain volume remains constant.
• If the compensation limit exceeded slight increase in volume will result in an increase in ICT

In other words
Total blood volume = Volume + SCF + Volume Volume Volume + brain tumor

• The normal value of ICT is 1-15 mmHg


§ ICP NORMAL VALUE
Newborn § 0.7 to 1.5 mmHg
Infant § 1.5 to 6 mm Hg
§ Children 3 to 7.5 mmHg
§ Adult 1-15 mm Hg
§ Relationship Between Compliance and ICT
§ meninges (membranes surrounding the brain)

  
A layer of the meninges (connective tissue) that covers the brain and spinal marrow.

   
☺ Piamater

   
☺ arachnoid

   
☺ dural
§
§ Brain blood flow (CBF)
§ The brain receives ± 15% of cardiac output

    
± 800 ml of blood flow to the brain

  
CBF ± 50 cc / 100gr brain / min.

§ The brain blood flow and function to bring 02 glucose for energy.

CBF is governed by:
§ cerebral autoregulation.

      
A. Stress / pressure

      
2. Chemistry (PCO2 and PO2)
§
§ Maintained normal CBF at MAP 50-150 mmHg.
§
§ MAP <50 mmHg → cerebral ischemia, cerebral infarction
§
§ MAP> 150 mmHg

    
→ Damage to the defense of the brain, brain hemorrhage, brain edema
§
§
Pressure autoregulation.
§ pressure autoregulation serves to maintain blood flow to the brain and the CPP in the range of certain MAP
§ The ability of the brain to maintain CBF at MAP between 50-150 mmHg, this process because of the contraction of smooth muscle walls of blood vessels of the brain in response to pressure changes.
§ If MAP <50 mmHg cerebral ischemia occur
§ If MAP> 150 mmHg kontriksi power damage blood vessels and CBF will rise suddenly, there is damage to the blood brain barrier and cerebral edema occurs and bleeding of the brain
§ In certain circumstances this autoregulation is lost in the event of pathological conditions such as head trauma, trepanation, bleeding, chronic hypertension, cerebral ischemia, cerebral infarct, edema surrounding brain tumors
§ In the conditions of loss of autoregulation in case of hypertension will increase CBF and hypotension will occur ischemia.kedua this resulted in an increase in ICT
§
§

§ CBF ↔ PaCO2
§ CBF change at any time in the event of changes in PaCO2
§ CBF doubled in PaCO2 80 mmHg. means when the PaCO2 rises will occur vasodilatation
§ Decreased CBF when PaCO2 20 mmHg half. mean PaCO2 down will occur when vasoconstriction
§
§ CBF ↔ PaO2
§ Changing the state of low PaO2 and little change in the high PaO2.
§ When PaO2 <50 mmHg causes cerebral vasodilation occurs to increase CBF.
§ Circulation css
§ physiology
 
Spinal fluid cerebrovascular (CSS)
§ Factors that influence CBF
§ sympathetic and parasympathetic, sympathetic and parasympathetic vasodilatation resulting in vasoconstriction resulting
§ increased blood viscosity so that CBF decreased
§ The temperature dropped causing cerebral metabolism decreased mean CBF fell
§ Age: the older the blood flow will increasingly fall
§ Causes of increased ICP
§ Edema of the brain
§ Surgery of the brain
§ Hidrocepalus
§ Mass in the brain
§ Bleeding in the brain
§ SIGNS AND SYMPTOMS INCREASING intracranial pressure
§ Dizziness
§ Vomiting
§ Decrease in consciousness
§ Trias chusing

  
(Hypertension, bradicardia, impaired breathing pattern)
§ herniation of the brain
§ Management of ICT increases
§ Intubation
§ Control of ventilation by maintaining a PO 2 <35 mmHg
§ Volume resusitation
§ Normal blood pressure
§ normal CPP
§ Normalised ICP
§ Provide sedation
§ bolus of mannitol
§ Prophylactic anti seizure: Penitoin
§ Monitoring
§ Monitor the ICP
§ Monitor CVP
§ Monitor the CPP
§ Monitor Pulse oximetry
§
§ ICP MONITORING
§ icp monitoring objective is to determine directly the value of Seara intra cranial pressure (ICP) that can be calculated CPPnya value, because the CPP is essential for cerebral blood flow indicator.
§ Monitorning ICP can be through sub aracnoid, epidural, or intraventricular brain intraparenkim
§ masnig Each location has its advantages and disadvantages.
§ Advantages and disadvantages
§ Ventrikulostomy
§ Installation of ventricular catheter into the lateral ventricle.
§ Indications:
1.COB with GCS <7 or less with unstable hemodynamics with CT scans could not be examined
2.COB with normal CT scan with age> 40 years there are signs of SBP <90 mmHg with abnormal posture changes
3.COB difusse injury with damage
4.Secondary cerebral injury
5.Untuk monitor the effects of therapy to lower intracranial pressure sepoerti: Hyperventilation, diuresis, in patients with high ICT
§
§
§ Contra Indications:
§ Thrombocytopenia (<50,000)
§ the freezing extends
§ There is an open wound near the site of insertion
§ imunosupressi

§ Installation Destination
§ To drain excess CSS
§ For external mendrainage
§ Monitor the intra cranial pressure.
§ Old installation
5-10 days, should be replaced every 5 days
Criteria for the release of ICP monitor
ICP-normal with no other therapy after 24 hours
-Increase in GCS> 9
§ Insertion Locations ICP
§ Point Kocher

    
Intersection:

    
Mid pupillary line perpendicular to the

    
3-4 cm lateral sagittal suture and 1 cm in the anterior sutura coronaria
§ ventriculostomy
§ How pegukuran ICP
§ Using the transducer and monitor
§ Passive
§
§ ventricle Drainage and ICP Monitoring
§
§ HOW TO MEASUREMENT ICP
1.Atur position of the patient as comfortable as possible.
2.Petugas wash hands
3.Pasang manometer on the IV pole
4.Ukur by using a water fitting to the zero point on the manometer (ventricles) are the temples of patients / acusticus external meatus
5.Titik equate to zero in patients with a zero point in using a water manometer fitting
6.Buka three way from the ventricle into the manometer while in view undulasinya.
7.Tunggu until the flow stops
8.Setelah stop the flow of reading on the manometer.
9.Kemudian three way back to its original position towards the reservoir
10.Petugas wash their hands and blame the results of measurements
11.Alat device cleared
§
§
§
§ Conversion of Measurement ICP / CVP
§ 1 mmHg = 13.6 mmH20 = 1.36 CmH2O
§ 1 cm H2O = 0.74 mmHg
§ How to calculate the conversion from cmH2O mmHg

          
5 CmH2O = 5 CmH2O

                          
1.36

           
= 3.7 mmHg
Another way:

  
CmH20 5CmH2O = 5 X 0.74 mm Hg = 3.7 mmHg
RISKS AND COMPLICATIONS OF INSTALLATION § ICP
§ Intracerebral Hemorrhage with ivh
§ ICT> 20 mmHg
§ Installation of> 5 days
§ irrigation system at the catheter is not smooth or clogged
§ Infection
§ Complications ventriculostomy
§
§ Care Objectives:
§ Preventing the ICT ↑ caused by body position, changing the physical state and the disease process
§ Treatment:
§ Neurological Examination
§ GCS, pupils, light reflexes, vital sign observation.
§ Setting the position of Head Up heads 150-300 and straight neck position
§ Maintain periodic aseptic measures in wound care
§ Maintain a closed system.

§
Care
§ Peimmeriksaan kepatenan airway
§ Maintain a supine patient position monitor function accurately sewhingga
§ Do not manipulate the drainage system
§ Avoid excessive stimulation in patients
§ Maintenance drainage continuously
- Note the periodic undulations of the following pulse.
-Place the container in accordance with the principles of sterile normal.hankan ICT
-Maintain the principle of sterile



§

Inhaled anesthetics

Inhaled anesthetics

FACTORS AFFECTING D GAS uptake ANAESTHESIAThe solubility of anesthetic gases in the blood.Alveolar blood flow.Partial pressure difference between alveolar air and venous blood.FACTORS DETERMINING THE CONCENTRATION D GAS INSPIRASI/F1Fresh Gas Flow speed.Volume breathing circuit.Absorption circuit anesthesia.
MINIMUM Alveolar ConcentrationMAC: The concentration of inhaled anesthetics which

                
prevent 50% of patient movement

                
to the standard stimuli

                
(Surgical incision).





Nitrous OXIDE/N2ORespiratory system:

         
- Cause tachypnea.

         
- Reduce the tidal volume.

         
- Hypoxic drive.Cardiovascular system:

         
- Stimulate the sympathetic nervous system.

         
- Increased resistance vasculer.

           
blood vessels of the lungs.Nitrous OxideSSP:

         
- Increase cerebral blood flow

            
And cerebral blood volume.

         
- Causes an increase in intra

            
cranial pressure is light.

         
- Increase CMRO ₂Renal:

         
- Reduce RBF.

         
- Decrease in GFR.


                                                                                          
HalothaneRespiratory system:

        
- Reduce the tidal volume.

        
- Increased respiratory rate.

        
- Increased PaCO2.

        
- A potent bronchodilator.Cardiovascular system:

        
- Depressed myocardial contractility.

        
- Reduce the frequency of the heart.

        
- Reduce coronary blood flow.

HalothaneCardiovascular system

        
- Decrease in arterial blood pressure

           
is dose dependent, occurring

           
direct effect on depression

           
myokardium.

        
- At a concentration of 2 MAC, crossed the

           
causes decreased cardiac output

           
And blood pressure by 50%.Halothane

Central nervous system:

       - Pemb vasodilator. Cerebral blood.

       - Increase CBF.

       
- Degrade CMR.

 
Renal:

       
- Reduce RBF and GFR.Hepatic:

       
- Reduce the hepatic blood flow.
EnfluraneRespiratory system:

        
- Increase the frequency of breath.

        
- Reduce the minute ventilation.

        
- Increased PaCO2.Cardiovascular system:

        
- Depressed myocardial contractility.

        
- Lower the SVR.

        
- Increase the frequency of heart.EnfluraneCentral Nervous System:

        
- Increase CBF and ICP.

        
- Degrade CMR.

        
- Increase seizure activity.Renal:

        
- Reduce RBF and GFR.Hepatic:

        
- Reduce the hepatic blood flow.IsofluraneThe respiratory system;

        
- Reduce the minute ventilation.

        
- Rarely cause tachypnea.Cardiovascular system:

        
- Lower the SVR.

        
- Dilatation of coronary arteries.

        
- Lowering blood pressure.

      
Isoflurane* Central nervous system:

       
- At concentrations> 1 MAC, increased

         
katkan CBF and ICP.

       
- Decrease CMR O2.

 
* Renal:

       
- Reduce RBF and GFR.

 
* Hepatic:

       
- Reduce the hepatic blood flow.

       
- Maintain hepatic perfusion.
SevofluraneCentral Nervous System:

       
- A slight increase CBF and ICP.

       
- Decrease CMR O2.Renal:

       
- Slightly lower RBF.Hepatic:

       
- Improve artery blood flow.

       
- Decrease portal vein blood flow.SevofluraneRespiratory system:

       
- Depression of respiration.

       
- Increase the frequency of breath.Cardiovascular system:

       
- Depressed myocardial contractility.

       
- Prolong the QT interval.

       - A smaller decrease SVR

          of isoflurane and halothan.

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instek VP SHUNT


Handling instrumen
Instek  pemasangan VP SHUNT
Ø  pengertian
     Suatu cara melakukan pengelolaan instrumen  
     selama operasi pemasangan VP SHUNT
Ø  Indikasi
§   Pasien dengan Hidrocephalus
1.        Persiapan alat
v  Set dasar
Handvat mess no 3,4
Handvat mess panjang
Pincet anatomis
Pincet  chirurgis
Arteri klem van pean
Arteri klem khocker
Nald voeder
Gunting
Doek klem
Desinfeksi klem
v  Set tambahan
Raspatorium
Desektor
Gelpy/ sprider
Bor set
Mess no11
Mandrin ventrikel katheter
Klem sepatu
Spaner VP SHUNT
2. Persiapan bahan
Larutan desinfektan
Kassa steril
Watches
Bon wax
Surgicel
Spuitt 10 cc
Ventrikel katheter
ST
Steril drape
Sufratul
Hypafic
Mess no 24, 10,11
Sterile  drapes
Larutan adrenalin 1: 200.000
3.  Persiapan benang
Side 2,0 :  untuk fiksasi v katheter
Side no 1 : u fiksasi spaner sbgpengantar VP SHUNT
Benang absorbable 2,0 : u jahit soft tissue
Benang non absorbable no 3,0 : u jahit kulit
4. linen steril
Doek kecil 4-5
Doek besar lubang 1
Gaun operasi
handuk
5.  Persiapan pasien
Posisi supine kepala diganjal dg bantal bulat(donat)
Posisi sedikit head up (15-30)
Pasang body strapping
Prosedur operasi
Tim operasi melakukan scrubbing, gowning and gloving
Desinfeksi area operasi
Drapping area operasi
Pasang sterile drapes (opsite)
Pasang couter bipolar, selang suction + canule suction
Injeksi dg adrenalin 1: 200000 pada lokasi incisi
Lanjutan…
Berikan mess 1 u incisi kulit- sub cutis
Berikan mess 2 u incisi fat – galea – otot- periosteum
Rawat perdarahan dengan couter bipolar, irigasi dg larutan NS saat c bipolar difungsikan, sambil dilakukan suction
Berikan raspatorium u menyisihkan periosteum
Tutup luka incisi kepala sementara dg kassa basah
Lanjutan…
Berikan mess 1 u incisi kulit abd bag atas
Perdalam incisi s/d fasia (sampai kelihatan fasia)
Berikan  spaner VP shunt u memasang Ventrkel VP shunt,dari kepala-leher-abdomen        keluar pada daerah incisi di abdomen.
Ujung mandrin VP shunt diikat dg side no 1
Tarik mandrin VP shunt ke atas ( bag incisi kepala )
Lanjutan…..
Berikan ventrikel VP shunt kmd diikat dg side no 1 yg sudah dimasukkan dalam soft tissue ( dibawah fat diatas fasia)
Side no 1 ditarik ke bag bawah ( incisi pd abdomen)       ventrikel VP shunt sudah masuk dan terhubung dari kepala ke abdomen
Pasang konector VP shunt kmd di spool dg NS     sampai lancar tidak ada hambatan
Berikan bor set u bor hole  kmd    rawat perdarahan
Berikan desector dan klem pean bengkok u ambil sisa tulang
Berikan couter bipolar u ces dura
Berikan speed mess u incisi dura

Lanjutan….
Berikan ventrikel katheter + mandrin dimasukkanke dalam intra cerebral sampai keluar cairan (hidrocephalus)
Sambung ventrikel katheter dg ventrikel VP shunt
Sambungan difiksasi
Tarik ventr VP shunt ke arah distal (abdomen)
Pastikan aliran cairan pada ventrkel lancar
Berikan pincet anatomis 2 buah + gunting metzenbaum u incisi peritoneum ± 1 cm
Masukkan ventrikel VP shunt kedalam peritoneum.
Lanjutan…
Tutup luka incisi
Berikan jahitan benang absorbable u jahit fasia, fat pada kepala dan abdomen
Berikan jahitan benang non absorbable u jahit kulit
Bersihkan luka dg kassa basah kmd keringkan
Beri sufratul – kassa – hipafic
Inventaris alat
Op selesai
Terima kasih

instek SDD/ICP

•    Handling instrumen
•    Operasi pemasangan SDD / ICP 
1.    Persiapan alat
    Set dasar
•    Handvat mess no 3,4
•    Handvat mess panjang
•    Pincet anatomis
•    Pincet  chirurgis
•    Arteri klem van pean
•    Arteri klem khocker
•    Nald voeder
•    Gunting
•    Doek klem
•    Desinfeksi klem
    Set tambahan
•    Raspatorium
•    Desektor
•    Gelpy/ sprider
•    Bor set
•    Mess no11
•    Mandrin ventrikel katheter
•    Klem sepatu
•    2. Persiapan bahan
•    Larutan desinfektan
•    Kassa steril
•    Watches
•    Bon wax
•    Surgicel
•    Spuitt 10 cc
•    Ventrikel katheter
•    Adrenalin 1: 2000000 dan lidocain
•    Sufratul
•    Hypafic
•    Mess no 24, 10,11
•    Sterile  drapes
•    Larutan adrenalin 1: 200.000
•    3.  Persiapan benang
•    Side 2,0 :  untuk fiksasi v katheter
•    Benang absorbable 2,0 : u jahit soft tissue
•    Benang non absorbable no 3,0 : u jahit kulit
•    4. linen steril
•    Doek kecil 4-5
•    Doek besar lubang 1
•    Gaun operasi
•    handuk
•    5.  Persiapan pasien
•    Posisi supine kepala diganjal dg bantal bulat(donat)
•    Posisi sedikit head up (15-30)
•    Pasang body strapping
•    Prosedur operasi
•    Tim operasi melakukan scrubbing, gowning and gloving
•    Desinfeksi area operasi
•    Drapping area operasi
•    Pasang sterile drapes (opsite)
•    Pasang couter bipolar, selang suction + canule suction
•    Injeksi dg adrenalin 1: 200000 pada lokasi incisi
•    Berikan mess 1 u incisi kulit- sub cutis
•    Berikan mess 2 u incisi fat – galea – otot- periosteum
•    Rawat perdarahan dengan couter bipolar, irigasi dg larutan NS saat c bipolar difungsikan, sambil dilakukan suction
•    Berikan sprider u membuka area operasi
•    Berikan bor set u buka cranium sampai kelihatan duramater
•    Berikan desector dan pean bengkok kecil u menganbil tulang yang masih menempel
•    Rawat perdarahan dg bipolar Sebelum dura diincisi
•    Berikan mess no 11 u incisi dura, rawat perdarahan
•    Berikan ventrikel kateter + mandrin ( u pemasangan ICP), setelah berhasil berikan klem sepatu.
•    Berikan ventr katheter + 2 pincet anatomis dimasukkan di bawah dura ( u pemasangan SDD), kmd lakukan spooling dg NS
•    Berikan mess dan klem pean u keluarkan ventr katheter
•    Berikan jahitan side 2,0 u fiksasi drain (ventr kath)
•    Cuci luka dg NS
•    Berikan jahitan benang absorbable 2,0 u jahit sofft tissue
•    Berikan jahitan dg benang non absorbable no 3,0 u jahit kulit
•    Bersihkan luka op. keringkan
•    Tutup dg sufratul, kassa steril, fixasi
•    Operasi sselesai
•    Inventaris alat

instek trepanasi

Handling instrumen
Neuro surgery
Heru Cahyono, SST.
INSTANSI : OK IRD RSSA MALANG
ALAMAT : PARANGARGO WAGIR MALANG
D3 KEP ANGK 98
D4 KMB PERIOPERATIF 2009 ANGK KE 4
Anatomi kepala
Struktur eksternal
      Tengkorak  : 8 tulang utama yang membungkus dan       melindungi otak.
   Kranium/ tulang tengkorak : frontalis, parietalis D/S, temporalisD/S, sfenoidalis, etmoidalis, interior tengkorak.
      SCALP ( kulit kepala ) :  kulit, jaringan lunak, galea, otot,dan periosteum.
Struktur internal
Bagian utama otak
Serebrum  tdd:
o    2 hemisfer: D/S
o    4 lobus : frontalis, parietalis, temporalis,dan oksipitalis.
Batang otak :
o    Midbrain, pons, dan medula oblongata
Serebelum:
o    Tdd 2 lobus berada langsung dibawah serebelum.
Daerah tambahan
Talamus
Hipotalamus
Ganglia basalis
Selaput otak ( meningen)
    Duramater
    Arahcnoid
    piamater
Handling instrumen
Neuro surgery / bedah saraf
Handling instrumen
operasi trepanasi
     pengertian
     Suatu cara melakukan pengelolaan instrumen selama  
     operasi trepanasi.
    Indikasi
    Pasien dengan kelainan intrakranial : EDH, SDH, ICH luas, TUMOR OTAK.
1. Persiapan alat
Basic instrumen
desinfeksi klem 
duk klem
handvat mesz no 4
handvat mesz no 3
handvat mesz panjang
pinset chirrurgie
pinset anatomis
klem van pean bengkok mosquito
klem van kocher
nald voeder
wound haak tajam
langen beck
gunting metzenbaum
gunting kasar/prepare
gunting benang lurus
Persiapan alat
   Set tambahan
cauter bipolar/monopolar
raspatorium
desektor 
dendy klem 
boor set
knable tang/bone rongeours B/S/K 
metal scalp haemostasis clips
separator dura
pinset dura chirrurgies
galea / spring haak
brain spatula/maliable, caliber
dura haak
dura sonde
elevator
Gigli saw
Gunting dura
2. Persiapan bahan
Larutan desinfektan
Kassa steril
Watches
Bon wax
Surgicel
Spongostan/lyostip
Spuitt 10 cc
Ventrikel katheter
Adrenalin 1: 200.000 (gr/mL)
Sufratul
Hypafic
Mess no 24, 10,11
Sterile  drapes
Redon drain
NS
Selang suction
3.  Persiapan benang
Side 2,0 :  untuk fiksasi v katheter
Benang absorbable 2,0 : u jahit soft tissue
Benang non absorbable no 3,0 : u jahit kulit
Benang non absorbable atraumatic no 3,0 :u hit steach
Side 3,0 u fiksasi drain
4. Linen steril
Doek kecil 5
Doek besar lubang 1, buntu 1
Gaun operasi 5
Handuk 4
5. Persiapan pasien
Posisi supine bawah kepala diganjal dg bantal bulat(donat)
Posisi sedikit head up (15-30)
Pasang body strapping
Ganjal punggung dg bantal kecil bl posisi kepala miring
Prosedur
Pada saat pasien di induksi perawat instrumen melakukan perasat sebagai berikut :
Cuci tangan (Hand washing) lalu di keringkan dengan waslap steril
Mengenakan gaun bedah(gawning) dan handschoen steril (gloving)
Menutup meja mayo dengan sarung meja mayo lalu di lapisi dengan perlak steril kemudian duk steril
Menata instrument di meja mayo.
Mengenakan gaun bedah dan handschoen steril kepada operator atau assisten.
Prosedur
Berikan desinfeksi klem +larutan desinfektan kepada operator/ asisten  untuk desinfeksi lapangan operasi.
Melakukan drapping yaitu menutup lapangan operasi letakkan u pad dilapisi dg doek kecil 2 lapis, doek yg paling atas ditutupkan pada kepala bag atas, fiksasi dg doek klem, kmd psg doek kcl bag bwh kpl, kmd psg doek besar lubang, pasang sterile drape (opsite).
Berikan spuit 10 cc yang telah berisi campuran adrenalin 1/200.000 dan lidocaine kepada operator /assisten.
Siapkan alat-alat penunjang seperti kabel diatermi dan slang penghisap di tambah kanula yang di Bantu dengan perawat sirkulasi, Dekatkan meja mayo di lapangan operasi
Dekatkan meja mayo di lapangan operasi
Berikan informasi kepada operator bahwa instrument siap
Lanjutan….
Berikan mesz 1 dan pinset chirrurgies kepada operator untuk incisi kulit , sub cutis.
Berikan couter/ monopolar untuk rawat perdarahan 
Berikan mesz 2 kepada operator untuk incise pada fasia dan otot, dan berikan dandy klem untuk mengontrol perdarahan
Berikan mesz 2, pinset chirrurgie kepada operator dan wound haak tajam kepada assisten
Berikan raspatorium / cauter monopolar untuk membebaskan periosteum dan kasa basah untuk membungkus SCALP
Berikan spring haak atau doek kecil untuk mempertahankan scalp terbuka
Berikan boor kepada operator dan langen beck, spull (spuit 10 cc berisi NS) kepada assisten
lanjutan
Berikan adson/desector kepada operator dan masquito bengkok untuk mengambil tulang pada daerah yang diboor
Berikan pengantar dura/pelindung  gigli, masukkan gigli dan pasang handle gigli,spull NS, kemudian siap dilakukan pemotongan cranium
Berikan knabel tang untuk meratakan tulang ( bila perlu )
Berikan benang non absorbable 3.0 untuk menggantung dura ( heat sticth )
Berikan separator dura untuk membersihkan tolsel/hematom pada epidural ( bila perdarahan epidural )
Berikan speed mess ( mess no 11 ) untuk membuka dura( bila ada kelainan intracerebral).
Berikan gunting dura u perlebar dura
Evakuasi cloth B perdarahan sub dural hematom
Bila  ICH/Tumor otak, maka berikan bipolar u evakuasi cloth/ tumor pada lokasi hematom/tumor
Rawat perdarahan dg bipolar + wathes
Berikan surgicel s/ ukuran u homeostasis perdarahan.
lanjutan
Rawat perdarahan dengan menggunakan cauter bipolar dan tutup dengan waches basah dengan NS
Berikan benang absorable  3/0, nald voeder  dan pinset dura kepada operator untuk menjahit dura.
Berikan benang absorbable  2-0 , nald voeder dan pinset chirrurgies kepada operator untuk menjahit fasia / fat .
Berikan benang non absorbable 3/0 untuk kulit.
Membersihkan luka operasi dengan kasa basah lalu kasa kering
Kemudian Berikan desinfektan dan tutup dengan kassa steril.
Tutup luka operasi dengan hipafix
Lepaskan semua duk dari pasien, lepaskan gaun operasi.
Inventarisasi alat
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