Penatalaksanaan gagal nafas pada pasien morbid obesitas dengan penyulit ppok, pnemonia dan gagal jantung kanan

Penatalaksanaan gagal nafas pada
pasien morbid obesitas dengan
penyulit ppok, pnemonia dan gagal
jantung kanan
Syamsul Hilal Salam
Program Pendidikan Konsultan Intensive Care
FK UNHAS / RS WAHIDIN SOEDIROHUSODO
Makassar2017

Pendahuluan
• ↑Insidensi Obesity Hypoventilation Syndrome (OHS) pada rawat jalan
dan inap1
• Definisi2
• PaCO2 > 45mmHg pada pasien sadar
• BMI > 30 kg/m2 dengan menyingkirkan semua kelainan hipoventilasi
• Serum bicarbonate >27mmmol/L tanpa adanya penyebab metabolik alkalosis
• Diagnosis dan terapi sering tertunda -> kurangnya pengenalan
sindrom
• ↑Mortalitas lebih sering akibat cardiac event  secondary systemic
inflammation
1. Finucane MM, Stevens GA, Cowan MJ, et al; Global Burden of Metabolic Risk Factors of Chronic Diseases Collaborating Group (Body Mass Index). National, regional, and global
trends in body- mass index since 1980: systematic analysis of health examination surveys and epidemiological studies with 960 country-years and 9.1 million participants. Lancet.
2011;377(9765):557-567.
2. 2. Hart N, Mandal S, Manuel A, et al. Obesity hypoventilation syndrome: Does the current definition need revisiting? Thorax. 2014;69(1):83-84.

Obesity Hypoventilation Syndrome (OHS)
CHEST 2016; 149(3):856-868
Gambar 1.Faktor patofisiologis dalam OHS

Gagal Napas
• Terdapat 2 tipe gagal nafas yaitu :
• tipe 1 hypoxic respiratory failure
• tipe 2 hypercapnic respiratory failure.
• Obesitas dikaitkan dengan berbagai macam penyakit, meliputi :
• Diabetes melitus tipe 2,
• Hipertensi,
• Penyakit jantung koroner,
• Obstructive sleep apnea (OSA),
• Penyakit degeneratif pada sendi (osteoarthritis),
• Kolelithiasis.

Pemantauan Hemodinamik
• Pengamatan yang kontinyu atau intermiten parameter fisiologi / patologi sistem
sirkulasi untuk segera mendeteksi kemungkinan perlunya intervensi terapeutik.
• Diperlukan untuk mengenal secara tepat dan akurat semua variabel
hemodinamik dan memanfaatkan informasi ini agar berkontribusi dalam menilai
organ dan/atau melihat respon terapi

Identitas
• Nama : SN
• Umur : 70 years
• BB/TB : 100 kg/160 cm
• Masuk ke IGD 05/08/ 2017 pk 17.19 dengan keluhan utama kaki
bengkak sejak 2 minggu, riwayat tirah baring dan lemah selama
bengkak, riwayat hipertensi riwayat DM disangkal.

Pemeriksaan Penunjang
Thorax:
- Gambaran bronchitis
- Lymphadenophaty sinistra
- Dilatasi et aterosklerosis aorta
- Elevasi diafragma dextra
• HGB : 13,3
• HCT : 45,3
• RBC : 5,16
• WBC : 15,21
• PLT : 329
• GDS : 158
Laboratorium

Echocardiography:
- Fungsi sistole LV Baik
- Global nomokinetik
- Kalsifikasi RCC, LCC tanpa stenosis
- LVH konsenters
- RVH, RV dilatasi, TAPSE 1,7 cm
- TR moderat
- Moderat probably PH
- ERAP 8 mmHg
EKG: sinus rhythm, HR 98 X/ menit

Penatalaksanaan UGD
BP 130/70 mmHg, HR HR 98x/min, SpO2
64%, O2 4 Lpm
SpO2 79%
Nacl 0,9% 12 tpm, furosemide 40 mg/24 jam/
oral, PERAWATAN

Pasien mengeluh kaki bengkak sejak 2 minggu sebelum
masuk RS. Tampak lemah dan cenderung untuk tidur
Riwayat sakit dengan keluhan yang sama ada ± 1 tahun
yang lalu. Riwayat hipertensi, riwayat DM disangkal, riwayat
penyakit jantung disangkal.
05/08/2017
20.00 PERAWATAN

• KU: kedua kaki bengkak
• Kesadaran : CM, 100kg/158cm
• BP 130/70 mmHg, HR 96x/min, RR 24 x/mnt,
temp 36,7 OC,
• Konjuntiva anemis (-)
• Paru : vesikuler , whezing (-) , ronki basal
bilateral
• Jantung : BJ I-II, murmur (-), gallop (-)
• Abdomen : distensi -
• Extremitas : akral dingin pucat, edema
tungkai +/+
• HGB : 13,3
• WBC : 15,21
• PLT : 329
• GDS : 158
• D DIMER :0,67mg/l (N: 0,5)
• NA : 135
• K : 5
• CL : 93
• PT : 11,2
• APTT : 38,2
Pemeriksaan Fisik Laboratorium

Analisis Gas Darah
5/8/2017
Pkl. 18.07
6/8/2017
Pkl. 06.05
6/8/2017
Pkl. 12.34
PH 7,2 7,19 7,04
pCO2 66,3 75,8 95,6
SO2 67,6 74,9 98,0
PO2 56,3 69,1 188,0
HCO3 29,0 29,7 26,5
ctO2 15,5 17,3 24,3
ctCO2 31,0 32,1 29,4
BE 1,5 1,5 -4,2

• Suhu 36,5°C
• RR 24
• 130/70 nadi 98
• Ronki basah
bilateral
• Edema extremitas
• O2 4 lpm,
• Inf NaCl 0,9 12 tpm
IGD 05/08
• RR 24
• 130/70 nadi 96
• SpO2 96 %
• Edema extremitas
• Lemah dan cederung
tertidur
Ruangan
05/08
•Gelisah,keringat
dingin.
•Penurunan kesadaran
•Takhikardi, 120x?m
•Ronki difus bilateral
Gagal NapasICU
06/08

2 3 4 5 6 78 9 10 11 13 14 15 16 17 18 19 20 21 22 23 24 17 12
40
80
120
160
200
BP
40
80
120
160
200
HR
10
20
30
40
50
RR
20 20 0
ICU Hari 0 (6/8/17)
GCS E1M3V1
Pasien masuk ICU dengan indikasi gagal
napas dan syok
AGD:Ph 7,32, 62,3 298, 32,4, 34,3, 6,1,
4, 28, 99
Hb:15,8,HCt: 47 Laktat : 2,4, Na 137, K:
4, Cl 94, GDS 167
A:
- Gagal napas e.c PPOK,Edema paru
- Gagal jantung kanan
- OSA
- Syok
P: Ventilator: NIV
- NACL 0,9 % retriksi cairan
- Ceftazidime 2GR/ 8 jam/ iv
- Amiptriptilin 6mg/kgBB sekali pemberian,
countinue 0,4 mg/ kgBB/ Jam
- Combivent + NACL nebulizer extra
- Furosemide 10mg/ jam/
F: Puasa
A: Fentanyl 0,5mg / kgBB
S: dexmedetomidine 0,2 mg/ kgBB
T: -
H: elevasi kepala 30⁰
U: Omeprazol loading 50 mg/ continue 8
mg/jam/ SP
G: GDS: 120-180 mg/dl
NIV
SaO2 97%
36,7 CNIV intubasi
PCV PS 5 TV 400, PEEP 4, Fio2 100%
BC -3263Analisis Gas Darah 06/08/2017 :
Pkl 12: 34
Ph 7,04
PcO2 95,7
SO2 98,0
PO2 188,0
Analisis Gas Darah 06/08/2017 :
Pkl 13:24
Ph 7,08
PcO2 89,8
SO2 98,3
PO2 197,9
Norepinefrin 0,05-0,1 mcg/kgBB-
Dobutamin 3-7,5mcg/kgbb/min-

2 3 4 5 6 78 9 10 11 13 14 15 16 17 18 19 20 21 22 23 24 17 12
40
80
120
160
200
BP
40
80
120
160
200
HR
10
20
30
40
50
RR
20 20 0
ICU Hari-1 (7-8-2017)
A:
- Gagal napas e.c PPOK, udema paru
- Syok
- OSA
- Pnemonia
P:
- Rl 2000 cc/24 jam
- Meropenem 2GR/ 8 jam/ iv
- Amiptriptilin 6mg/kgBB sekali pemberian,
countinue 0,4 mg/ kgBB/ Jam
- Combivent + NACL nebulizer extra
F: Puasa
Midazolam 2 mg/jam/ SP
T: -
U: Omeprazol loading 50 mg/ continue 8
mg/jam/ SP
G: GDS: 120-180 mg/dl
Norepinefrin 0,05-0,1 mcg/kgBB-
SaO2 98 %S: -
O:
B1: Napas on ventilator, tidal volume
cukup dengan PS minimal, SpO2 97%
dengan FiO2 100%, rh +/+
B2 : Hemodinamik labil dengan support
inotropik dan vasopresor
B3: Kesadaran membaik, kontak (+)
B4 : produksi urine cukup
B5 : abdomen tidak ada kelainan
B6 : Akral dingin, Edema (+)
AGD:Ph 7,56/48,4/111,4/43,7/26,5
fi,(60%)
Dobutamin 3-7,5mcg/kgbb/min-
PCV PS 16 RATE 16 PEEP 6 , FiO2 0.6 TV 700
BC - 3647
Pnemonia sinistra
Bendungan paru, edema paru

2 3 4 5 6 78 9 10 11 13 14 15 16 17 18 19 20 21 22 23 24 17 12
40
80
120
160
200
BP
40
80
120
160
200
HR
10
20
30
40
50
RR
20 20 0
ICU Hari-2 (08-08-2017)
A:
- Gagal napas e.c PPOK, udema paru
- Syok
- OSA
- Pnemonia
P:
- Rl 2000 cc/24 jam
- Meropenem 2GR/ 8 jam/ iv
- Furosemide 5mg/ jam
- Paracetamol 1 gr/8jam
F: gizi Kilinik susu
Midazolam 2 mg/jam/ SP
T: -
U: Lansoprazol loading 50 mg/ continue 8
mg/jam/ SP
G: GDS: 120-180 mg/dl
PS: P:16 PEEP 6 , FiO2 0,6
Norepinefrin 0.05-0,1 mcg/kgBB/mnt
SaO2 99 %
S: -
O:
B1: Napas on ventilator, tidal volume
cukup dengan PS minimal, SpO2 97%
dengan FiO2 100%, rh +/+
B2 : Hemodinamik labil dengan support
inotropik dan vasopresor
B3: Kesadaran membaik, kontak (+)
B4 : produksi urine cukup
B5 : abdomen tidak ada kelainan
B6 : Akral dingin, Edema (+)
Dobutamin 3 - 7,5mcg/kgBB/mnt
BC - 7035
CVP 4
PiCCO Normal
CI 3-5 litres/min/m₂
GEF 25- 35%
GEDI 680- 800ml/m₂
SVRI 1700-2400 dyn
ELWI 3-7mls/kg
PiCCO 08/08/17
CI 4,31
GEF 16
GEDI 1180
SVRI 1992
ELWI 13

ICU Hari-3 (09/08/17)
A:-
- Gagal napas e.c PPOK
- OSA
- Pnemonia
P: - Meropenem 3 x 1 gr (E3)
Levofloxacine 750mg
- Furosemide 5 mg/jam
- RL 2000 cc/24 jam
F: gizi klinik
A: Fentanyl 25 mcg/jam
S: Midazolam 2 mg/jam tapering
DEXMEDETOMIDINE 0,2MCG/kgBB
T: -
H: elevasi kepala 30⁰-45⁰
U: Omeprazol 40 mg/24 jam
G: GDS: 120-180 mg/dl
AC RATE 16 6 IPS 20 , PEEP 6, FiO2 0.,5
Norepinefrin 0,05-0,1 mcg/kg/mnt
SaO2 98%
36,5 C
S: Kontak tidak adekuat,
O:)
Paru: ves +/+, rh -/-, wh-/-
Jantung: suara jantung Normal
Abd: distensi (-), luka operasi terawat
GU: terpasang kateter
Lab:
Dobut 3-7,5 mcg/kg/mnt
BC : - 2739
Vital Sign 09/08/17
HR 106
Sistol 137
Diastol 65
PiCCO 09/08/2017
CI 2,63
GEDI 983
SVRI 2519
GEF 17
ELWI 13

ICU Hari-4 (10/8/17)
A: - Gagal Napas ec. PPOK
- OSA
- Pnemonia
-.
P: - RL 2500 cc/24 Jam
- Meropenem 3 x 2 gr (E4)
- Levofloxacin 1 x 750 mg (E3)
- Paracetamol 3x1 gr
- Furosemid 10 mg/jam
- Combivent 3 x 1
- Flexotide 2 x 1
F: gizi
A: Fentanyl 0,5 mcg/kgbb/jam
S: - Midazolam 2 mg/jam,
- Dexmedetomidin 0,2 mcg/kgbb/mnt
T: -
H: Elevasi kepala 30⁰-45⁰
U: Prozopam 60 mg/24 jam
G: GDS: 120-180 mg/dl
PiCCO 10/08/17
CI 4.41
GEF 20
GEDI 1083
SVRI 1209
ELWI 13
AC/PC
SaO2 98 98 98
PS 10, PEEP 6, FiO2 60%
Norepinefrin 0,05-0,1 mcg/kg/mnt
Dobut 3-7,5 mcg/kg/mnt
CVP 5PiCCO Normal
CI 3-5 litres/min/m₂
GEF 25- 35%
GEDI 680- 800ml/m₂
SVRI 1700-2400 dyn
ELWI 3-7mls/kg
AGD Hasil
PH 114
pCO2 111
SO2 50
PO2 60
HCO3 47,3
ctO2 21,4
ctCO2 48,8
BE 25,3

ICU Hari-5 (11/8/17)
A:- Gagal Napas ec. PPOK
- OSA
- Pnemonia
P: - RL 2500 cc/24 Jam
- Meropenem 3 x 2 gr (E5)
- Levofloxacin 1 x 750 mg (E4)
- Paracetamol 3x1 gr
- Furosemid 10 mg/jam
- Combivent 3 x 1
- Flexotide 2 x 1
F: gizi
A: Fentanyl 0,5 mcg/kgbb/jam
S: Dexmedetomidin 0,2
mcg/kgbb/mnt
T: -
H: elevasi kepala 30⁰-45⁰
U: Prozopam 30 mg/24 jam
G: GDS: 120-180 mg/dl
S:
O: Paru: ves +/+, rh -/-, wh-/-
AGD: PH: 7.545, PCO2: 55.1, SO2: 97.1,
PO2: 96.6, HCO3: 48.1, ctO2: 16.1
ctCO2: 25.5, BE: 25.5
WBC: 15.7, HGB: 13.3, HCT: 45, PLT:
328,
Prokalsitonin: 0.82
Vital Sign 11/08/17
HR 87
Sistol 152
Diastol 62
PiCCO 11/08/17
GEDI 1174
GEF 17
CI 3.68
SVRI 2116
ELW 19
AC
SaO2 99 99 99 99 99 9999 9999 99 99 99
PS 10, PEEP 10, FiO2 60%
Norepinefrin 0,05-0,1mcg/kg/mnt
Dobut 3 - 7,5 mcg/kg/mnt
CVP 6
PF ratio 160

11/08/2017 (5) 12/08/2017 (6) 13/08/2017 (7) 14/08/2017 (8) 15/08/2017 (9)
S : -
O:
B1: O2 via ventilator mode PC, RR: 20x/ menit, PEEP
7, Pins 20 FiO2 60%, -->TV 400 cc RR: 20x/mnt, rh -/-
wh -/- SpO2 98%
B2 : BP 110/65 mmHg, MAP: 76 mmHg, HR 90
x/menit, reguler, kuat angkat, akral hangat, CRT <
2detik
B3 : GCS tersedasi, Pupil isokor (2.5mm/2.5mm), RC
(+/+), SB 36.5 BPS: 3
B4 : Urine Per Kateter Produksi 150 cc/jam, warna
kuning jernih
B5 : perut datar ikut gerak nafas Peristaltik (+) Normal;
Distended (-), defekasi belum , NGT Residu (-)
B6: udem (-/-) fraktur (-/-)
A: Gagal napas ec PPOK + OSA
S : -
O:
wh -/- SpO2 98%
2detik
(+/+), SB 36.5 BPS: 3
kuning jernih
S : -
O:
wh -/- SpO2 98%
2detik
(+/+), SB 36.5 BPS: 3
kuning jernih
Laboratorium 11/8/2017
WBC: 15.700 HB: 13,3; cr 1,00 Alb. 3,2 PCT: 0,8
S : -
O:
wh -/- SpO2 98%
2detik
(+/+), SB 36.5 BPS: 3
kuning jernih
S : -
O:
O2 via ventilator mode PC, RR: 20x/ menit, PEEP 8,
Pins 20 FiO2 50%, -->TV 400 cc RR: 20x/mnt, rh -/- wh -
/- SpO2 98%
2detik
B3 : GCS 10x (E4M6Vx), Pupil isokor (2.5mm/2.5mm),
RC (+/+), SB 36.5
kuning
B5 : perut datar ikut gerak nafas Peristaltik (+) kesan
Normal; Distended (-), NGT Residu (-)
WBC: 14.100HB: 12,2; cr 1,07 Alb. 3,3 PCT: 0,11 K: 2,9
O2 via ventilator mode AC, RR: 20x/ menit, PEEP 7,
Pins 35.FiO2 60%
Ringer laktat 2000cc/24jam
F: Ensure 6x100kkal/hari
A: Fentanyl 0,5 mcg/KgBB/Jam/SP + Paracetamol
1gram/8jam/iv
S: Midazolam 2 mg/jam/SP + Dexmedetomidine 0,2
mcg/KgBB/Jam/SP
T: -
H: Head up 15 - 30 ⁰
U: lansoprazole 6 mg/ jam /SP
G: Target GDS 120- 180 mg/ dL
Meropenem 2 gr/8 jam/IV (H-4)
Norepinefrine 0,2 mcg/KgBB/menit
Furosemide 5mg/jam/sp/iv
Levofloxacin 750mg/24jam/iv (H-3)
Dobutamin 5mcg/kgBB/menit
Pins 35.FiO2 60%
1gram/8jam/iv
mcg/KgBB/Jam/SP
T: -
H: Head up 15 - 30 ⁰
Pins 35.FiO2 60%
1gram/8jam/iv
mcg/KgBB/Jam/SP
T: -
H: Head up 15 - 30 ⁰
Pins 35.FiO2 60%
1gram/8jam/iv
mcg/KgBB/Jam/SP
T: -
H: Head up 15 - 30 ⁰
O2 via ventilator mode PC
A: -
S: -
T: -
H: Head up 30-45 ⁰
U: lansoprazole 60 mg/ 24 jam
PC RR 20 PEEP 7 PInsp 20 FiO2 60% PC RR 20 PEEP 7 PInsp 20 FiO2 50%
Norepinefrin 0.05-0,1 mcg/kgBB/mnt 0,05 mcg/kgbb/mnet
Dobutamin 3 - 7,5mcg/kgBB/mnt 3 mcg/kgbb/mnt
Parameter 11/08
WBC (x103
mm3)
N (5,0–10,0)
39,7
PCT (ng/mL)
N (< 0,05)
25,9
LACTAT
(mg/dL)
N (0 -20)
76,3
Parameter 14/08
WBC (x103
mm3)
N (5,0–10,0)
45,4
PCT (ng/mL)
N (< 0,05)
0,11
PiCCO normal 11/08/2017 12/08/2017 13/08/2017 14/08/2017 15/08/2017
CI (l/min/m2) 3,0-50 3,47 3,49 3,41 4,40 3,86
GEDI (ml/m2) 680-800 1117 10,85 1062 1183 801
SVRI (dysn*s*cm*m) 1700-2400 1673 1773 1915 1592 1270
GEF (%) 25-35 17 18 17 18 21
ELWI (ml/kg) 3,7-7,0 14 18 14 5 9
7.53
49.8
96,3
85,4
42,8
19,3
44,3
20
PF Ratio 240
Cardiomegali
Edema paru

16/08/2017 (10) 17/08/2017 (11) 18/08/2017 (12) 19/08/2017 (13) 20/08/2017 (14)
S : -
O:
O2 via ventilator mode BILEVEL, RR: 10x/ menit, PEEP
wh -/- SpO2 98%
2detik
RC (+/+), SB 36.5
kuning
S : -
O:
wh -/- SpO2 98%
2detik
RC (+/+), SB 36.5
kuning
S : -
O:
wh -/- SpO2 98%
2detik
RC (+/+), SB 36.5
kuning
S : -
O:
wh -/- SpO2 98%
2detik
RC (+/+), SB 36.5
kuning
S : -
O:
wh -/- SpO2 98%
2detik
RC (+/+), SB 36.5
kuning
F: Ensure 6x100kkal/hari dari TS Gizi Klinik
A: -
S: -
T: -
H: Head up 30-45 ⁰
A: -
S: -
T: -
H: Head up 30-45 ⁰
Amikasin 750mg/24jam/iv (H-1)
A: Fentanyl 30mcg/jam/sp + Paracetamol 1gr/6jam/iv
S: -
T: -
H: Head up 30-45 ⁰
Norepinephrine 0,05mcg/kgBB
S: -
T: -
H: Head up 30-45 ⁰
S: -
T: -
H: Head up 30-45 ⁰
BILEVEL, RR: 10x/ menit, PEEP 5, Pins 10 FiO2 40%
Norepinefrin 0,05-0,1 mcg/kgbb/mnet
Parameter 18/08
WBC (x103 mm3)
N (5,0–10,0)
37,2
PCT (ng/mL)
N (< 0,05)
25,59
LACTAT (mg/dL)
N (0 -20)
-

21/08/2017 (15) 22/08/2017 (16) 23/08/2017 (17) 24/08/2017 (18) 25/08/2017 (19)
S : -
O:
wh -/- SpO2 98%
2detik
RC (+/+), SB 36.5
kuning
S : -
O:
wh -/- SpO2 98%
2detik
RC (+/+), SB 36.5
kuning
S : -
O:
O2 via ventilator mode SIMV, RR: 10x/ menit, PEEP 5,
PS 10 FiO2 40%, -->TV 400 cc RR: 20x/mnt, rh -/- wh -
/- SpO2 98%
2detik
RC (+/+), SB 36.5
kuning
WBC: 10.700 HB: 9,1; PCT 2,99
Foto Thoraks (20/8/2017)
Cardiomegaly disertai bendungan par
Dilatatio Aorta
S : -
O:
/- SpO2 98%
2detik
RC (+/+), SB 36.5
kuning
S : -
O:
/- SpO2 98%
2detik
RC (+/+), SB 36.5
kuning
S: -
T: -
H: Head up 30-45 ⁰
Amikasin 750mg/24jam/iv
S: -
T: -
H: Head up 30-45 ⁰
S: -
T: -
H: Head up 30-45 ⁰
S: -
T: -
H: Head up 30-45 ⁰
S: -
T: -
H: Head up 30-45 ⁰
BILEVEL, RR: 10x/ menit, PEEP 5, Pins 10 FiO2 40% SIMV, RR: 10x/ menit, PEEP 5, PS 10 FiO2 40%,
PF Ratio 240
Kultur sputum 23/08
Acinetobacter baumannii
Amikasin (S)

26/08/2017 (20) 27/08/2017 (21) 28/08/2017 (22) 29/08/2017 (23) 30/08/2017 (24)
S : -
O:
O2 via ventilator mode CPAP PEEP 5
B2 : BP 110/65 mmHg, MAP: 76 mmHg, HR
90 x/menit, reguler, kuat angkat, akral
hangat, CRT < 2detik
B3 : GCS 10x (E4M6Vx), Pupil isokor
(2.5mm/2.5mm), RC (+/+), SB 36.5
B4 : Urine Per Kateter Produksi 80 cc/jam,
warna kuning
B5 : perut datar ikut gerak nafas Peristaltik
(+) kesan Normal; Distended (-), NGT
Residu (-)
S : -
O:
O2 via ventilator mode CPAP PEEP 5
(2.5mm/2.5mm), RC (+/+), SB 36.5
warna kuning
Residu (-)
S : -
O:
O2 via Trakeostomi on Ventilator, RR: 10x/
menit, PEEP 5, Pins 10 FiO2 40%, -->TV 400
cc RR: 20x/mnt, rh -/- wh -/- SpO2 98%
(2.5mm/2.5mm), RC (+/+), SB 36.5
warna kuning
Residu (-)
S : -
O:
(2.5mm/2.5mm), RC (+/+), SB 36.5
warna kuning
Residu (-)
S : -
O:
(2.5mm/2.5mm), RC (+/+), SB 36.5
warna kuning
Residu (-)
O2 via ventilator
A: Fentanyl 30mcg/jam/sp + Paracetamol
1gr/6jam/iv
S: -
T: -
H: Head up 30-45 ⁰
O2 via ventilator
1gr/6jam/iv
S: -
T: -
H: Head up 30-45 ⁰
O2 via ventilator
1gr/6jam/iv
S: -
T: -
H: Head up 30-45 ⁰
O2 via ventilator
A: Fentanyl 30mcg/jam/SP
S: -
T: -
H: Head up 30-45 ⁰
Norepinefrin 0,1 mcg/KgBB/mnt
Dobutamin 7,5 mcg/KgBB/mnt
Bisolvon 1 vial/8 jam/ nebulizer
Flexotide 1 vial/12 jam/nebulizer
Zink 20 mg/8 jam/NGT
Combivent 1 vial/8 jam/nebulizer
O2 via ventilator
S: -
T: -
H: Head up 30-45 ⁰
CPAP PEEP 5 FiO2 40% TRACHEOSTOMI -> BILEVEL, RR: 10x/ menit, PEEP 5, Pins 10 FiO2 40%
PF Ratio 240PF Ratio 185
7,57
40,5
95,6
74,2
37,7
19,2
38,9
15,5
Kultur darah 28/08
Burkholderia cepacia
Meropenem (S)
Amikasin (R)

31/08/2017 (25) 01/09/2017 (26) 02/09/2017 (27) 03/09/2017 (28) 04/09/2017 (29)
S : -
O:
O2 via Trakeostomi on Ventilator mode SIMV, RR:
10x/ menit, PEEP 5, Pins 10 FiO2 40%, -->TV 400 cc RR:
20x/mnt, rh -/- wh -/- SpO2 98%
2detik
RC (+/+), SB 36.5
kuning
S : -
O:
B1: O2 via Trakeostomi on Ventilator mode SIMV, RR:
10x/ menit, PEEP 5, PS 10 FiO2 40%, -->TV 400 cc RR:
20x/mnt, rh -/- wh -/- SpO2 98%
2detik
RC (+/+), SB 36.5
kuning
WBC: 13.800, Hb : 8.4, Alb 2.8, PCT 3,9
S:-
O:
20x/mnt, rh -/- wh -/- SpO2 98%
2detik
RC (+/+), SB 36.5
kuning
S : -
O:
20x/mnt, rh -/- wh -/- SpO2 98%
2detik
RC (+/+), SB 36.5
kuning
S : -
O:
B1: O2 via Trakeostomi on Ventilator mode SIMV-->
TV 400 cc, RR: 20x/mnt, rh -/- wh -/- SpO2 98%
2detik
RC (+/+), SB 36.5
kuning
O2 via ventilator
S: -
T: -
H: Head up 30-45 ⁰
O2 via ventilator
S: -
T: -
H: Head up 30-45 ⁰
Cefepime 2gr/8 jam/intravena
Cernevit 1 vial/24 jam/drips intravena
O2 via ventilator
S: -
T: -
H: Head up 30-45 ⁰
Cefepime 2gr/8 jam/intravena
Cernevit 1 vial/24 jam/drips intravena
O2 via ventilator
S: -
T: -
H: Head up 30-45 ⁰
U: Lansoprazole 30 mg/ 12 jam
Cefepime 2gr/8 jam/iv (H-3)
Cernevit 1 vial/24 jam/drips iv
Albumin 3x1 sachet
O2 via ventilator modeSIMV TV 500 cc RR: 10x/ menit,
PEEP 5, PS 10 FiO2 40%,
IVFD Ringer laktat 1000cc/24jam
S: -
T: -
H: Head up 30-45 ⁰
Amikasin 1 gr/24jam/iv (H.16)
Albumin 3x1 sachet
SIMV RR: 20x/ menit, PEEP 5, Pins 10 FiO2 40%
PF Ratio 240

05/09/2017 (30) 06/09/2017 (31) 07/09/2017 (32) 08/09/2017 (33) 09/09/2017 (34)
S : -
O:
2detik
RC (+/+), SB 36.5
kuning
S : -
O:
2detik
RC (+/+), SB 36.5
kuning
S : -
O:
2detik
RC (+/+), SB 36.5
kuning
S : -
O:
2detik
RC (+/+), SB 36.5
kuning
Laboratorium (4/9/2017)
WBC: 27.600/mm3,Hb : 7.3gr/dl,PLT 226.000,Alb 3.2
gr/dl,PCT 3,47
K 2,5 mmol/L, Cl 85 mmol/ml
S : -
O:
2detik
RC (+/+), SB 36.5
kuning
PEEP 5, PS 10 FiO2 40%,
S: -
T: -
H: Head up 30-45 ⁰
Amikasin 1 gr/24jam/iv (H-17)
Albumin 25%/24jam/iv
Fluimucil 300mg/8jam/iv
PEEP 5, PS 10 FiO2 40%,
S: -
T: -
H: Head up 30-45 ⁰
O2 via ventilator mode SIMV TV 500 cc RR: 10x/ menit,
PEEP 5, PS 10 FiO2 40%,
S: -
T: -
H: Head up 30-45 ⁰
PEEP 5, PS 10 FiO2 40%,
S: -
T: -
H: Head up 30-45 ⁰
Tygacil 50mg/12jam
PEEP 5, PS 10 FiO2 40%,
S: -
T: -
H: Head up 30-45 ⁰
Kultur darah 05/09
Burkholderia cepacia
Meropenem (S)
Tygecicline (S)
Cefepime (S)
Amikasin (R)

10/09/2017 (35) 11/09/2017 (36) 12/09/2017 (37) 13/09/2017 (38) 14/09/2017 (39)
S : -
O:
2detik
RC (+/+), SB 36.5
kuning
S : -
O:
B1: O2 via Trakeostomi on Ventilator mode SIMV TV
450 cc RR 8x/mnt PS 13 PEEP 8 FiO2 60% --> TV 340 cc,
RR: 26x/mnt, Rh -/- Wh -/- SpO2 98%
100x/menit, reguler, kuat angkat, akral hangat, CRT <
2detik
RC (+/+), SB 36.5
kuning
Hb 8,4 gr/dl, PLT 249.000/mm3, WBC 20.400/mm3, K
3,3 mmol/L
S : -
O:
RR: 26x/mnt, Rh -/- Wh -/- SpO2 98%
2detik
RC (+/+), SB 36.5
kuning
Foto Thoraks (11-9-2017)
Efusi pleura (S), skoliosis thoracalis sisnistroconvex
S : -
O:
RR: 26x/mnt, Rh -/- Wh -/- SpO2 98%
2detik
RC (+/+), SB 36.5
kuning
S : -
O:
RR: 26x/mnt, Rh -/- Wh -/- SpO2 98%
2detik
RC (+/+), SB 36.5
kuning
PEEP 5, PS 10 FiO2 40%,
S: -
T: -
H: Head up 30-45 ⁰
O2 via Trakeostomi on Ventilator mode SIMV TV 450
cc RR 8x/mnt PS 13 PEEP 8 FiO2 60%
S: -
T: -
H: Head up 30-45 ⁰
U: Lansoprazole 30 mg/ 12 jam / iv
S: -
T: -
H: Head up 30-45 ⁰
F: Peptisol 3x250 kkal + bubur saring 3x200 cc + Jus
buah 1x100 cc/hari dari TS Gizi Klinik
A: -
S: -
T: -
H: Head up 30-45 ⁰
Tygacyl 50mg/12j/iv (H-5)
Claritromicyn 500 mg/24jam/NGT
A: -
S: -
T: -
H: Head up 30-45 ⁰
Claritromicyn 500 mg/24jam/NGT (H-1)
PF Ratio 247

Parameter 18/09/2017
WBC (x103 mm3)
N (5,0–10,0)
23,5
PCT (ng/mL)
N (< 0,05)
1,16
LACTAT (mg/dL)
N (0 -20)
-
15/09/2017 (40) 16/09/2017 (41) 17/09/2017 (42) 18/09/2017 (43) 19/09/2017 (44)
S : -
O:
RR: 26x/mnt, Rh -/- Wh -/- SpO2 98%
2detik
RC (+/+), SB 36.5
kuning
S : -
O:
RR: 26x/mnt, Rh -/- Wh -/- SpO2 98%
2detik
RC (+/+), SB 36.5
kuning
S : -
O:
B1: RR: 26x/mnt, Rh -/- Wh -/- SpO2 98%
2detik
RC (+/+), SB 36.5
kuning
S : -
O:
B1: RR: 26x/mnt, Rh -/- Wh -/- SpO2 98%
2detik
RC (+/+), SB 36.5
kuning
S : -
O:
B1: RR: 26x/mnt, Rh -/- Wh -/- SpO2 98%
2detik
RC (+/+), SB 36.5
kuning
Hb 8,4 gr/dl, PLT 353.000/mm3, WBC 23.900/mm3, K
3,6mmol/L Cl 95, Alb 3.6, PCT 1.16
Foto Thoraks (17-9-2017)
Efusi pleura (S),Bronchopneumoni bilateral,
Cardiomegaly disertai dilatatio aortae
A: -
S: -
T: -
H: Head up 30-45 ⁰
Diamox 1 tab/8jam/NGT
Norepinefrin 0.05 mcg / KgBB/ min
A: -
S: -
T: -
H: Head up 30-45 ⁰
O2 via NRM 8 LPM
A: -
S: -
T: -
H: Head up 30-45 ⁰
O2 via HFNC
A: -
S: -
T: -
H: Head up 30-45 ⁰
O2 via HFNC
A: -
S: -
T: -
H: Head up 30-45 ⁰
SIMV RR: 10x/ menit, PEEP 5, Pins 10 FiO2 40% HFNC
Norepinefrin 0,05 mcg/kgbb/mnet
Parameter 18/09/2017
WBC (x103 mm3)
N (5,0–10,0)
23,5
PCT (ng/mL)
N (< 0,05)
1,16
LACTAT (mg/dL)
N (0 -20)
-
PF Ratio 239

20/09/2017 (45) 22/09/2017 (47) 23/09/2017 (48) 24/09/2017 (49) 25/09/2017 (50)
S : -
O:
B1: RR: 26x/mnt, Rh -/- Wh -/- SpO2 98%
2detik
RC (+/+), SB 36.5
kuning
S : -
O:
B1: RR: 26x/mnt, Rh -/- Wh -/- SpO2 98%
2detik
B3 : GCS 15 (E4M6V5), Pupil isokor (2.5mm/2.5mm),
RC (+/+), SB 36.5
kuning
S : -
O:
B1: RR: 26x/mnt, Rh -/- Wh -/- SpO2 98%
2detik
RC (+/+), SB 36.5
kuning
S: -
O:
B1: RR: 26x/mnt, Rh -/- Wh -/- SpO2 98%
2detik
RC (+/+), SB 36.5
kuning
S : -
O:
B1: RR: 26x/mnt, Rh -/- Wh -/- SpO2 98%
2detik
RC (+/+), SB 36.5
kuning
O2 via HFNC
A: -
S: -
T: -
H: Head up 30-45 ⁰
O2 via Nasal kanula 2lpm
A: -
S: -
T: -
H: Head up 30-45 ⁰
A: -
S: -
T: -
H: Head up 30-45 ⁰
A: -
S: -
T: -
H: Head up 30-45 ⁰
A: -
S: -
T: -
H: Head up 30-45 ⁰
Pindah ke Ruangan
HFNC NC

Pemantauan PiCCO
PiCCO normal 08/08/17 09/08/2017 10/08/2017 11/08/2017 12/08/2017 13/08/2017
CI (l/min/m2) 3,0-50 4,31 2,63 4,41 3,47 3,49 3,41
GEDI (ml/m2) 680-800 1189 983 1083 1117 10,85 1062
SVRI
(dysn*s*cm*m)
1700-2400 1592 2519 1209 1673 1773 1915
GEF (%) 25-35 16 17 20 17 18 17
ELWI (ml/kg) 3,7-7,0 13 13 13 14 18 14
PiCCO normal 14/08/2017 15/08/2017 25/08/2017 27/08/2017 02/09/2017 04/09/2017
CI (l/min/m2) 3,0-50 4,40 3,86 6,28 5,58 4,25 4,94
GEDI (ml/m2) 680-800 1183 801 838 945 980 915
SVRI
(dysn*s*cm*m)
1700-2400 1592 1270 1408 1446 1161
GEF (%) 25-35 18 21 18 21 18 20
ELWI (ml/kg) 3,7-7,0 5 9 12 10 11 13

Pembahasan
• Pasien dengan Geriatri
• BMI = 100/1.60² = 39 {Morbid Obesity}
• Tgl 5-8 pk 21.08 sadar PCO2 66 {Obesity Hypoventilation Syndrome}
• Ttttttiitititikkgk.
- kgkgmvmvmv,,R
- Tricuspid anularVH, RV dilatasi, TAPSE 1,7 cm
- TR moderatt
- Moderat probably PH
- ERAP 8 mmHg
R. Cardio ..ardium tab. & furosemide 40 mg /24jam oral
Tgl 6-8 pk 07.15 konsul SpJP ke Anestesi , penanganan airway
NIV  INTUBASI
VENTILASI MEKANIK 
TRACHEOSTOMI 
DEKANULASI 
HFNC

High Flow Nasal Cannula (HFNC)

Pembahasan
• Penyebab Gagal Napas Akut( pasien ini adalah masalah ventilasi dimana terganggunya sistem
mekanik respirasi : yaitu gangguan sistem pengembangan paru-paru akibat obesitas
OHS 
1. obesity and the development of chronic
daytime alveolar hypoventilation
2. treatment options including positive pressure
therapy, weightloss, and pharmacological
management
3. awake hypercapnia (PaCO2>45 mm Hg)
4. Positive Pressure Therapy, Tracheostomy,
Bariatric Surgery
Vital capacity, expiratory reserve
volume,compliance
Reduced

Morbid Obesity
Impaired respiratory Increased
mechanic work of breathing
Sleep
disordered breathing
Respiratory
muscle
endurance
Leptin Respiratory Drive
Severe Sleep
Hypoxemia
Sleep
Hypercapnia
HCVR
Bicarbonate
compensation
Normal
ventilation
Low
ventilation
Eucapnia Hypercapnia
-
-
--
-+
++
+ -
- -

5-agustus 7-agustus
CPIS
VENTILATOR
ANTIBIOTIK

RHF + EDEMA PARU
• RHF :
• Ro thorax Kardiomegali dilatasi jantung kanan
• Echo: TAPSE 1,7cm, eRAP 8 mmhg , TR moderat, probably PH
• (Tricuspid anular plane systolik excursion, estimated Right Atrial pressure)
GEDI 1180
GEF 16
CI 4,31
SVRI 1592
ELWI 13 CVP 4

KESIMPULAN
• Telah dilakuan penatalaksanaan pasien Gagal nafas dengan penyebab OHS,
PPOK, RHF, dan Edema Paru akut
• Meliputi
• Ventilator mekanik
• Tracheostomy
• Terapi antibiotik
• Obat inotropik dan vasopresor
• Bronkodilator
• Diuretik
• High Flow Nasal Canul
• Pemantauan hemodinamik dengan alat PICCO sangat membantu dalam tatalaksana RHF
dan edema paru akut.

Tabel 2. Indeks Massa Tubuh (IMT/BMI)

Analisa Gas Darah
22/08 26/08 28/08 29/08 30/08 31/08 1/09 2/09 4/09 5/09
06/09 07/09 13/09 14/09 15/09 16/09
26/08-01/09 SIMV PEEP 8 PS 13 FiO260% 02–16/09 SIMV 10 PEEP 5
PS10 FiO2 40%
17-18/09 CPAP PEEP 5 FIO2 40%
26/08
Tracheostomi
27/08 Repair kanul
-> NKK tube
04/09 Repair kanul ->
Tracheostomi tube
18/09 Tutup stoma -> HFNC 21/09 Nasal Kanul 25/09 Pindah Perawatan

Obesity Hypoventilation Syndrome (OHS)
Tabel 1. Karakteristik dan Prevalensi OHS Pada Pasien Dengan Gangguan Tidur

21 18 17 16 14 11 7 24 Laktat/procalcitonin
37,2/25,59 - / -/ 39,7/25,
9/cpr
76,3
Wbc
39,3
laktat
Pc 0,53

21-9 18-9 14 12 8 4 30-8
Wbc 30,9
Pc 1.10
Wbc 23,5
Pc 1.16
1,05 1,52 1,29 3,47 3,59
Leptin is a circulating protein produced mainly by adipose
tissue (adipokine) that interacts with hypothalamic
receptors to inhibit eating
potential mechanisms of OHS
Serum CRP sensitivitas 5 mg/L -90mg/L
PCT sensitivitas 0,05 ng/ml – 200ng/ml

• Thermodilution Parameters
• 1.CO – Cardiac Output: 4 - 8litres/min
• 2.CI – Cardiac Index : 3- 5litres/min/m₂
• Preload
• 3.GEDI – Global end diastolic index: 680- 800ml/m₂
• 4.ITBVI – Intra thoracic blood volume index: 850-1000ml/m₂
• Pulmonary oedema
• 5. ELWI –Extravascular lung water index: 3-7mls/kg
• 6. PVPI - Pulmonary vascular permeability index: 1.0- 3.0
• Contractility
• 7.CFI - Cardiac function index: 4.5- 6.5%
• 8. GEF - Global ejection fraction: 25- 35%

• Pulse contour Parameters
Flow
• 1.PCC -Pulse contour cardiac output
• 2.ABP - Arterial blood pressure
• 3.HR - Heart rate
• 4.SV - Stroke volume: 50-110mls
Volume responsiveness
• 5.SVV - Stroke volume variation: <10%
• 6.PPV - Pulse pressure variation
Afterload
• 7.SVRI - Systemic vascular resistance index: 1700-2400 dyn*s*cm-5*m2
Contractility
• 8.Index of left ventricular contractility

PiCCO
Indikasi :
1. Syok
2. Edema pulmo
3. Pembedahan dengan
risiko tinggi
4. Hipertensi emergensi
5. Peningkatan tekanan
intracranial

PiCCO tidak hanya memberikan informasi tentang curah jantung (CO) tapi bisa
memberi pengukuran untuk menilai preload, kontraktilitas, afterload, dan air paru
ekstravaskular (ELWI)

Penatalaksanaan gagal nafas pada pasien morbid obesitas dengan penyulit ppok, pnemonia dan gagal jantung kanan

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