Pneumonia is a common complication after spontaneous intracerebral hemorrhage (sICH) and is associated with increased morbidity and mortality. This study of 290 patients with sICH found that 13.9% developed pneumonia. Factors that significantly increased the risk of pneumonia in both univariate and multivariate analysis included mechanical ventilation, tube feeding, dysphagia, and tracheostomy. Pneumonia was also associated with longer hospital stays and higher mortality rates. Strict adherence to protocols aimed at preventing pneumonia, such as good oral care and minimizing ventilation time, may help reduce the occurrence of pneumonia and its consequences in patients with sICH.
Penggunaan Ca Gluconas pada Transfusi Darah.pptxDokterdiaphragma
Dokumen ini membahas tentang transfusi darah massif dan penggunaan Ca Gluconas untuk mencegah hipokalsemia. Transfusi darah massif didefinisikan sebagai pemberian lebih dari 10 unit darah dalam 24 jam atau lebih dari 4 unit dalam satu jam. Sitrat dalam darah tersitrasi dapat menyebabkan penurunan kalsium terionisasi dan hipokalsemia. Pemberian Ca Gluconas selama transfusi dapat mencegah hal tersebut dan menjaga
Dokumen tersebut memberikan informasi mengenai transfusi darah, termasuk tujuan, komponen darah, indikasi, kontraindikasi, dan reaksi transfusi darah. Secara ringkas, dokumen menjelaskan proses transfusi darah dari donor ke pasien untuk meningkatkan volume darah atau komponen darah tertentu, seperti sel darah merah, trombosit, atau faktor pembekuan.
Dokumen tersebut membahas tentang kegawatdaruran neonatus. Beberapa poin penting yang dibahas adalah pentingnya deteksi dini kondisi berisiko pada neonatus, langkah-langkah dasar resusitasi neonatus seperti evaluasi, keputusan, dan tindakan, serta persiapan peralatan dan tim resusitasi."
Penggunaan Ca Gluconas pada Transfusi Darah.pptxDokterdiaphragma
Dokumen ini membahas tentang transfusi darah massif dan penggunaan Ca Gluconas untuk mencegah hipokalsemia. Transfusi darah massif didefinisikan sebagai pemberian lebih dari 10 unit darah dalam 24 jam atau lebih dari 4 unit dalam satu jam. Sitrat dalam darah tersitrasi dapat menyebabkan penurunan kalsium terionisasi dan hipokalsemia. Pemberian Ca Gluconas selama transfusi dapat mencegah hal tersebut dan menjaga
Dokumen tersebut memberikan informasi mengenai transfusi darah, termasuk tujuan, komponen darah, indikasi, kontraindikasi, dan reaksi transfusi darah. Secara ringkas, dokumen menjelaskan proses transfusi darah dari donor ke pasien untuk meningkatkan volume darah atau komponen darah tertentu, seperti sel darah merah, trombosit, atau faktor pembekuan.
Dokumen tersebut membahas tentang kegawatdaruran neonatus. Beberapa poin penting yang dibahas adalah pentingnya deteksi dini kondisi berisiko pada neonatus, langkah-langkah dasar resusitasi neonatus seperti evaluasi, keputusan, dan tindakan, serta persiapan peralatan dan tim resusitasi."
1. Dokumen tersebut membahas protokol Enhanced Recovery After Cesarean Section (ERAC) untuk meningkatkan pemulihan ibu pasca operasi sesar dan mengurangi komplikasi. Protokol ini meliputi persiapan pra-operasi, intra-operasi, pasca-operasi, dan tindak lanjut setelah pulang.
Dokumen tersebut merangkum proses revisi Kode Etik Kedokteran Indonesia 2012 yang meliputi perubahan struktur dan isi kode etik, penambahan bab penutup, dan penyempurnaan berbagai pasal dan penjelasan untuk menyesuaikan dengan perkembangan ilmu pengetahuan, hukum, dan kebutuhan masyarakat. Revisi ini bertujuan membuat kode etik menjadi pedoman yang lebih jelas dan operasional bagi para dokter di Indonesia.
Terima kasih atas informasinya. Saya mengerti bahwa dokumen tersebut membahas upaya meminimalkan insiden Ventilator-associated Pneumonia (VAP) dengan melakukan dekontaminasi orofaring menggunakan larutan klorheksidin 0,2%.
Lensa mata memiliki struktur cembung ganda dan berfungsi untuk memfokuskan sinar ke retina. Katarak adalah kekeruhan lensa yang disebabkan berbagai faktor dan dapat menyebabkan penurunan penglihatan. Pembedahan katarak dilakukan untuk mengeluarkan lensa keruh dan menggantikannya dengan lensa buatan.
Pemberian nutrisi yang mengandung lemak pada penderita PPOK dapat menurunkan kadar CO2 dalam darah dan mengurangi risiko gagal napas. Nutrisi tinggi lemak lebih baik dibandingkan nutrisi tinggi karbohidrat untuk penderita PPOK.
Materi Ventilasi Mekanik (Mechanical Ventilation) disampaikan oleh Eri Yanuar Akhmad Budi Sunaryo, S.Kep., Ns., M.N.Sc.(I.C) pada seminar yang diselanggarakan oleh Berca Niaga Medika
TPM digunakan untuk mengobati gangguan sistem konduksi jantung sementara. TPM bekerja dengan memberikan impuls listrik ke jantung untuk menjaga irama kontraksi yang normal. Ada beberapa jalur pemasangan elektrode TPM, dan komponen utamanya adalah generator, kabel, dan elektrode. Pemasangan TPM harus dilakukan dengan hati-hati untuk mencegah komplikasi seperti infeksi atau pergeseran elektrode.
Pasien laki-laki berusia 24 tahun dirujuk ke rumah sakit dengan keluhan sesak napas dan nyeri dada setelah mengalami kecelakaan sepeda motor. Pemeriksaan fisik menunjukkan tanda-tanda hematothoraks di paru-paru kanan. Diagnosis hematothoraks kanan ditunjang dengan hasil rontgen dada dan pemeriksaan darah. Pasien ditatalaksana dengan pemasangan selang thoracostomy, antibiotik, dan oksigen.
Klasifikasi stadium klinis HIV/AIDS menurut WHO terdiri dari 4 stadium. Stadium 1 adalah asimtomatik, stadium 2 ringan, stadium 3 sedang, dan stadium 4 berat. Pada anak, stadium klinis meliputi limfadenopati, hepatosplenomegali, dan berbagai infeksi seperti kandidiasis. HIV adalah virus yang menyerang sel kekebalan dan menyebabkan AIDS akibat defisiensi sistem kekebalan.
Partograf adalah lembar observasi yang digunakan untuk mencatat kemajuan persalinan, kondisi ibu dan janin, serta tindakan medis yang diberikan untuk memantau dan membuat keputusan klinik selama persalinan. Partograf digunakan oleh tenaga kesehatan untuk memantau persalinan normal maupun komplikasi, dan berisi informasi tentang kontraksi rahim, dilatasi serviks, dan kondisi ibu dan janin.
Dokumen tersebut membahas tentang edema paru, yaitu penumpukan cairan di alveoli paru yang menyebabkan kesulitan bernapas. Edema paru dibedakan menjadi kardiogenik, yang disebabkan gagal jantung, dan non-kardiogenik, yang berkaitan dengan infeksi, cedera, atau kondisi medis lainnya. Gejala utama edema paru adalah sesak napas."
Dokumen tersebut membahas tentang asuhan keperawatan gagal napas akut, yang meliputi manajemen airway, pola napas tidak efektif, dan gangguan pertukaran gas. Langkah-langkah pentingnya adalah memastikan jalan napas bebas, memberikan bantuan ventilasi yang memadai, serta menjaga keseimbangan gas darah.
The document discusses the AU-HRM Joint Residency Program presentation on healthcare-associated infections (HAP and VAP). It provides definitions, outlines the content to be covered including epidemiology, risk factors, microbiology, clinical manifestations, diagnostic evaluation, management, and prevention of HAP and VAP. Prevention is emphasized as the first priority, with rapid identification and treatment if infection occurs. Diagnosis involves clinical evaluation, imaging, and respiratory tract sampling for microscopy and culture. Empiric antibiotic therapy targets likely pathogens based on risk factors. Ongoing culture-directed therapy and measures like oral care, positioning, and ventilator circuit maintenance can help prevent future cases.
Hospital acquired pneumonia remains an important cause of mortality. It includes healthcare associated pneumonia and ventilator associated pneumonia. The document discusses the definition, epidemiology, etiology, pathogenesis, diagnosis and treatment of hospital acquired pneumonia. Effective preventive strategies and prompt initiation of appropriate antibiotic therapy based on local microbiology patterns are important for management.
1. Dokumen tersebut membahas protokol Enhanced Recovery After Cesarean Section (ERAC) untuk meningkatkan pemulihan ibu pasca operasi sesar dan mengurangi komplikasi. Protokol ini meliputi persiapan pra-operasi, intra-operasi, pasca-operasi, dan tindak lanjut setelah pulang.
Dokumen tersebut merangkum proses revisi Kode Etik Kedokteran Indonesia 2012 yang meliputi perubahan struktur dan isi kode etik, penambahan bab penutup, dan penyempurnaan berbagai pasal dan penjelasan untuk menyesuaikan dengan perkembangan ilmu pengetahuan, hukum, dan kebutuhan masyarakat. Revisi ini bertujuan membuat kode etik menjadi pedoman yang lebih jelas dan operasional bagi para dokter di Indonesia.
Terima kasih atas informasinya. Saya mengerti bahwa dokumen tersebut membahas upaya meminimalkan insiden Ventilator-associated Pneumonia (VAP) dengan melakukan dekontaminasi orofaring menggunakan larutan klorheksidin 0,2%.
Lensa mata memiliki struktur cembung ganda dan berfungsi untuk memfokuskan sinar ke retina. Katarak adalah kekeruhan lensa yang disebabkan berbagai faktor dan dapat menyebabkan penurunan penglihatan. Pembedahan katarak dilakukan untuk mengeluarkan lensa keruh dan menggantikannya dengan lensa buatan.
Pemberian nutrisi yang mengandung lemak pada penderita PPOK dapat menurunkan kadar CO2 dalam darah dan mengurangi risiko gagal napas. Nutrisi tinggi lemak lebih baik dibandingkan nutrisi tinggi karbohidrat untuk penderita PPOK.
Materi Ventilasi Mekanik (Mechanical Ventilation) disampaikan oleh Eri Yanuar Akhmad Budi Sunaryo, S.Kep., Ns., M.N.Sc.(I.C) pada seminar yang diselanggarakan oleh Berca Niaga Medika
TPM digunakan untuk mengobati gangguan sistem konduksi jantung sementara. TPM bekerja dengan memberikan impuls listrik ke jantung untuk menjaga irama kontraksi yang normal. Ada beberapa jalur pemasangan elektrode TPM, dan komponen utamanya adalah generator, kabel, dan elektrode. Pemasangan TPM harus dilakukan dengan hati-hati untuk mencegah komplikasi seperti infeksi atau pergeseran elektrode.
Pasien laki-laki berusia 24 tahun dirujuk ke rumah sakit dengan keluhan sesak napas dan nyeri dada setelah mengalami kecelakaan sepeda motor. Pemeriksaan fisik menunjukkan tanda-tanda hematothoraks di paru-paru kanan. Diagnosis hematothoraks kanan ditunjang dengan hasil rontgen dada dan pemeriksaan darah. Pasien ditatalaksana dengan pemasangan selang thoracostomy, antibiotik, dan oksigen.
Klasifikasi stadium klinis HIV/AIDS menurut WHO terdiri dari 4 stadium. Stadium 1 adalah asimtomatik, stadium 2 ringan, stadium 3 sedang, dan stadium 4 berat. Pada anak, stadium klinis meliputi limfadenopati, hepatosplenomegali, dan berbagai infeksi seperti kandidiasis. HIV adalah virus yang menyerang sel kekebalan dan menyebabkan AIDS akibat defisiensi sistem kekebalan.
Partograf adalah lembar observasi yang digunakan untuk mencatat kemajuan persalinan, kondisi ibu dan janin, serta tindakan medis yang diberikan untuk memantau dan membuat keputusan klinik selama persalinan. Partograf digunakan oleh tenaga kesehatan untuk memantau persalinan normal maupun komplikasi, dan berisi informasi tentang kontraksi rahim, dilatasi serviks, dan kondisi ibu dan janin.
Dokumen tersebut membahas tentang edema paru, yaitu penumpukan cairan di alveoli paru yang menyebabkan kesulitan bernapas. Edema paru dibedakan menjadi kardiogenik, yang disebabkan gagal jantung, dan non-kardiogenik, yang berkaitan dengan infeksi, cedera, atau kondisi medis lainnya. Gejala utama edema paru adalah sesak napas."
Dokumen tersebut membahas tentang asuhan keperawatan gagal napas akut, yang meliputi manajemen airway, pola napas tidak efektif, dan gangguan pertukaran gas. Langkah-langkah pentingnya adalah memastikan jalan napas bebas, memberikan bantuan ventilasi yang memadai, serta menjaga keseimbangan gas darah.
The document discusses the AU-HRM Joint Residency Program presentation on healthcare-associated infections (HAP and VAP). It provides definitions, outlines the content to be covered including epidemiology, risk factors, microbiology, clinical manifestations, diagnostic evaluation, management, and prevention of HAP and VAP. Prevention is emphasized as the first priority, with rapid identification and treatment if infection occurs. Diagnosis involves clinical evaluation, imaging, and respiratory tract sampling for microscopy and culture. Empiric antibiotic therapy targets likely pathogens based on risk factors. Ongoing culture-directed therapy and measures like oral care, positioning, and ventilator circuit maintenance can help prevent future cases.
Hospital acquired pneumonia remains an important cause of mortality. It includes healthcare associated pneumonia and ventilator associated pneumonia. The document discusses the definition, epidemiology, etiology, pathogenesis, diagnosis and treatment of hospital acquired pneumonia. Effective preventive strategies and prompt initiation of appropriate antibiotic therapy based on local microbiology patterns are important for management.
This document discusses nosocomial infections, also known as hospital-acquired infections. It provides definitions and discusses the highest incidence locations. It then presents a case scenario of a patient developing nosocomial pneumonia after surgery. Risk factors, pathogenesis, diagnosis, treatment and specific types of infections like ventilator-associated pneumonia and central line-associated bloodstream infections are explained. Management involves prompt empiric antibiotics guided by cultures and symptoms while avoiding unnecessary antibiotic use.
Dr. Ionescu Sinziana discusses fever in the postoperative period. She defines fever and classifies it by degree of temperature elevation. The causes of postoperative fever can be infectious or non-infectious. Fever timing is important, with fever under 48 hours usually not infectious and fever over 5 days more likely to indicate infection. Clinical effects of fever include increased oxygen needs, confusion, and low blood pressure.
Aspiration pneumonia occurs when gastric contents are aspirated into the lungs, causing infection. It can range from mild to life-threatening. Historically, anaerobic bacteria were most common causes, but recently aerobic bacteria like streptococcus pneumoniae and hospital-acquired gram-negative rods have emerged as primary pathogens. Risk factors include impaired swallowing or consciousness. Diagnosis is based on clinical presentation and chest imaging. Treatment involves antibiotics selected according to likely causative organisms and infection severity and source. Preventive measures focus on managing risk factors in high-risk patients.
Sepsis and antibiotic guidance in neurology wardsDivya Shilpa
1) A one-time survey in a neurology ward and ICU found that 15 out of 69 patients (21.73%) had sepsis. Common organisms found included Klebsiella, Enterobacter, Pseudomonas, Acinetobacter, and E. coli.
2) Guidelines for treating ventriculostomy-associated infections recommend intravenous and intraventricular antibiotics such as vancomycin. Combined treatment may improve outcomes over intravenous antibiotics alone.
3) Post-stroke infections are common, with reported rates around 30%. Pneumonia is the most frequent type of infection and is associated with increased mortality. Preventive antibiotics may reduce infection rates but not affect mortality.
This document discusses hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP). It covers the definitions, risk factors, pathogenesis, microbiology, prevention, clinical features, diagnosis through imaging and respiratory sampling, and treatment considerations for HAP and VAP. Key points include that HAP develops 48 hours after admission, VAP develops 48 hours after intubation, and the most common causes are gram-negative bacteria and Staphylococcus aureus. Invasive respiratory sampling methods like bronchoscopic BAL are preferred for diagnosis but carry more risk than noninvasive methods.
PATTERN OF HOSPITAL-ACQUIRED PNEUMONIA IN INTENSIVE CARE UNIT OF SUEZ CANAL U...Khaled Mohamed
Hospital-acquired pneumonia occurs more than 48 h after hospital admission and was not present at the time of admission, while ventilator-associated pneumonia occurs
after 48–72 h of endotracheal intubation or within 48 h of extubation. HAP is the second most common nosocomial infection and accounts for approximately 25% of all infections in the Intensive
Care Unit worldwide.
Epidemiology treatment and_outcomes_of_sa_nosocomial_pneumonia_chest_2005-1Christian Wilhelm
This study examined outcomes of nosocomial bacteremic Staphylococcus aureus pneumonia (NBSAP) in 60 patients over 5 years. It found that NBSAP commonly developed late in a patient's hospital stay among critically ill patients on mechanical ventilation. NBSAP was associated with high mortality and infection-related mortality rates of 55.5% and 40%, respectively. While delayed appropriate antibiotic therapy did not predict worse outcomes compared to early therapy, the study was limited by small sample size. The findings suggest a need for new antibiotics with better activity against NBSAP.
This document discusses non-resolving pneumonia, defined as persisting symptoms or deterioration after at least 72 hours of antimicrobial treatment. Infectious causes are responsible for 40% of non-resolving cases, with common organisms including S. pneumoniae, Legionella, P. aeruginosa, and S. aureus. Non-infectious causes like cancer, connective tissue diseases, and drug reactions must also be considered. Evaluation involves history, physical exam, labs, imaging like chest X-ray and CT, and bronchoscopy with samples for microbiology. Treatment requires correcting any host abnormalities, adjusting antimicrobial therapy to expand coverage of possible resistant organisms, and draining any abscesses.
Antibiotic Strategy in Lower Respiratory Tract Infections (part 2)Gamal Agmy
This document provides guidelines for evaluating and treating patients with hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) based on the latest evidence and expert consensus. It discusses recommendations for using clinical scoring systems to decide whether to initiate antibiotics, recommendations for empiric and pathogen-directed antibiotic therapy, evaluating treatment failure, the role of inhaled antibiotics, duration of treatment, and other important management considerations. The overall aim is to guide clinicians in providing appropriate antibiotic treatment while minimizing unnecessary use of antibiotics.
Ventilator-associated pneumonia (VAP) is a common hospital-acquired infection that prolongs mechanical ventilation and ICU stays. It has a high mortality rate of 20-50%. Risk factors include prolonged mechanical ventilation, supine positioning, and use of sedatives. Diagnosis is difficult due to non-specific signs. New tools like LUPPIS aim to aid early diagnosis. Prevention strategies recommended by guidelines include early mobility, oral care, subglottic secretion drainage, and selective decontamination in some settings.
This document discusses community-acquired pneumonia (CAP). It defines CAP and outlines its epidemiology, noting risk factors like increasing age and winter season. Diagnosis involves clinical evaluation, chest imaging, and ruling out other causes if imaging is abnormal but symptoms aren't. Severity is assessed using scores like CURB-65 to determine appropriate treatment setting. Most ambulatory patients receive 5 days of antibiotics while hospitalized patients get broader empiric coverage. Adjunctive steroids may benefit severe cases. Proper follow up and prevention through vaccination and smoking cessation are also discussed.
Ventilator-associated pneumonia (VAP) is pneumonia that develops 48-72 hours or more after endotracheal intubation. It is characterized by new infiltrates on chest imaging and signs of infection. Early onset VAP within 4 days is usually caused by antibiotic-sensitive bacteria, while late onset VAP after 4 days often involves multidrug-resistant organisms. Preventing VAP involves care bundles focusing on endotracheal tube maintenance and secretion removal, along with prudent antibiotic usage and limiting intubation time.
Management Of Community Acquired PneumoniaAshraf ElAdawy
This document provides information on community-acquired pneumonia (CAP), including its definition, classification, pathogens, pathophysiology, diagnosis, and methods for assessing severity. CAP is defined as an alveolar infection developing outside of a hospital within 48 hours of admission. The most common causative pathogens are Streptococcus pneumoniae, Haemophilus influenzae, and atypical bacteria. Severity must be assessed to determine the appropriate site of care, and several prognostic scoring systems are discussed including the Pneumonia Severity Index (PSI), CURB-65, and CRB-65, which stratify patients into risk groups to guide management decisions.
This document provides an overview of community acquired pneumonia. It discusses the epidemiology, risk factors, clinical presentation, causes, diagnostic tests, imaging, treatment strategies, and prevention. Community acquired pneumonia is a leading cause of morbidity and mortality worldwide. It most commonly presents with fever, cough, and difficulty breathing. Diagnosis involves chest imaging and lab tests. Treatment involves antibiotics, with duration and setting of care determined by severity scores. Prevention includes vaccines and controlling risk factors.
This document discusses ventilator-associated pneumonia (VAP). Some key points:
- VAP affects 5-10% of ventilated patients and increases ICU and hospital length of stay. Mortality ranges from 0-50% depending on patient factors.
- Common causative pathogens are gram-negative organisms like Pseudomonas, E. coli, and Acinetobacter. Early-onset VAP is associated with community-like pathogens while late-onset involves more nosocomial pathogens.
- Risk factors for developing multi-drug resistant pathogens should take precedence over early vs. late onset distinction in treatment.
- Diagnosis is based on clinical, radiological and microbiological criteria. The Clinical
This document provides guidelines for the diagnosis and management of community-acquired pneumonia (CAP). It defines CAP and discusses its epidemiology and common causes. Streptococcus pneumoniae is often the leading cause worldwide, though causes can vary regionally in India. Chest radiography is important for diagnosis but has limitations. Computed tomography is not routinely needed. The role of microbiological testing of blood and sputum in hospitalized patients is outlined.
Ventilator-acquired pneumonia (VAP) is a type of hospital-acquired pneumonia that occurs in critically ill patients on mechanical ventilation. It is caused by pathogenic bacteria spreading from the oropharynx to the lungs. Risk factors include prolonged ventilation, comorbidities, and supine positioning. Diagnosis involves assessing symptoms, chest imaging, and microbiological testing of respiratory samples. Treatment involves timely administration of broad-spectrum antibiotics, with later de-escalation based on culture results. Prevention focuses on minimizing ventilation time, proper positioning, oral care, and ventilator bundles.
This document discusses ventilator associated pneumonia (VAP), including its definition, causes, risk factors, prevention, and treatment. Some key points:
- VAP is pneumonia that develops in intubated patients and accounts for most ICU infections. It occurs in 10-20% of mechanically ventilated patients and has a high mortality rate.
- Risk factors include underlying illnesses, suppression of immune system, and prolonged ventilation. Common causes are oropharyngeal/GI bacteria and viruses that enter the lungs through the endotracheal tube or around the cuff.
- Prevention strategies include following bundles like elevating the head, oral care with chlorhexidine, and stopping unnecessary devices; as well
Choosing the right antiseizure medication for epilepsy Ersifa Fatimah
The document discusses choosing the right antiseizure medication for epilepsy. It covers several key points:
1) Antiseizure medications (ASMs) are the first-line treatment for epilepsy, and many patients can achieve seizure freedom with the appropriate drug. However, the number of ASM options has increased and not all work for every seizure type or patient.
2) Choosing the right ASM involves considering factors like seizure type, patient characteristics, tolerability, and potential for drug interactions to select the most suitable option. The goal is to tailor treatment to the individual.
3) Successful treatment requires not only selecting the right ASM but also properly managing dosage, monitoring for side effects and
"..The proposed definition, therefore, is not intended to be prescriptive but represents a working framework. Clinicians and researchers should exercise their judgment in interpreting the principles described in this report when applying the definition to diverse settings.."
-- Kwan P, et al, 2017
Klasifikasi tipe kejang terbaru tahun 2017 oleh ILAE didasarkan pada "onset" kejangnya. Focal atau General. Kenapa kita harus tahu tipe kejang yang diderita ini focal atau general? Bagaimana kita tahu suatu kejang ini focal atau general? Apakah hanya berdasarkan "onset"-nya saja? Seberapa spesifik kah "focal" yang diperlukan untuk menentukan keputusan klinis kita? Apakah "focal" itu cukup sebatas mengetahui hemisfer kanan/kiri, atau sampai menentukan lobus yang terkait, atau gyrus, atau area yang lebih spesifik? Apa gold standar diagnosis topis sumber kejang? Apakah semiologi masih relevan dengan begitu berkembangnya teknologi imaging, EEG, genetika?
Sebenernya "filosofi" merupakan topik yang "ketinggian" buat si cip yang masih berada dalam stage mengasah "teknik" interpretasi. Dalam perjalanannya, sang guru sudah menanamkan filosofi ke dalam benak si cip, bahkan sejak hari pertama. "Bad EEG is worse than no EEG at all". Dan beliau tidak bosan-bosannya mengulang.
Mungkin, hikmah yang terpenting dari mempelajari "filosofi" interpretasi EEG sejak awal adalah membuat kita menyadari limitasi diri kita dan instrumen yang kita gunakan, menjadi pengingat agar tidak berhenti belajar, dan kemudian dengan cara yang terbaik mendayagunakan seluruh knowledge, skill & technique yang kita punya..
Stroke iskemik memiliki risiko kematian, disabilitas, dan serangan ulang yang berbeda-beda menurut subtipe yang didasarkan pada mekanisme penyebab stroke. Identifikasi penyebab stroke merupakan elemen penting dalam praktik klinis sehari-hari untuk memandu keputusan terapi, menentukan prognosis, dan mencegah kekambuhan stroke setiap pasien.
Kejadian stroke hemodinamik diperkirakan sekitar 10% dari seluruh infark otak. Pasien dengan stroke hemodinamik umumnya memiliki gejala ringan dibandingkan dengan subtipe stroke infark lainnya. Stroke hemodinamik jarang bersifat fatal sehingga kurang diperhitungkan. Padahal, pasien stroke hemodinamik sering disertai stenosis berat arteri mayor. Stroke hemodinamik berkaitan dengan peningkatan risiko perburukan neurologis, kekambuhan stroke, dan risiko kardiovaskular lainnya. Namun, stroke hemodinamik dapat dideteksi dengan gejala klinis tertentu & pemeriksaan radiologis. Pengenalan tentang adanya hipoperfusi sebagai faktor penyebab stroke iskemik akan membawa konsekuensi penting dalam perawatan dan manajemen pasien stroke..
Keunikan anatomi small vessel of the brain dan neurovascular unit, kontroversi peran stganasi vena dalam patofisiologi, klasifikasi small vessel disease, variasi kriteria diagnostik, pitfall dalam neuroimaging, pilihan antiplatelet untuk prevensi sekundar, dampaknya bagi outcome pasien, hubungannya dengan gangguan fungsi kognitif.
Hmm, apa lagi nih yang baru?
Blood-Pressure Management in Patients with Acute Cerebral Hemorrhage
Kontroversi hasil studi ATACH-2 dan dampaknya dalam manajemen hipertensi pada stroke perdarahan intraserebral akut.
Effect of Blood Pressure Lowering in Early Ischemic Stroke, Time to Change Pr...Ersifa Fatimah
Seorang rekan residen neuro sampai mengirim (via e-mail) sebuah jurnal yang baru ditelaahnya di larut malam. Kepada si cip, dia menyatakan bagaimana jurnal ini membuat pikirannya bergejolak, “Seperti dipaksa untuk menerima sebuah pemikiran baru yang melawan apa yang telah kita yakini bersama dalam proses belajar kita selama 5 tahun terakhir ini!”
Artikel itu berjudul Effect of Blood Pressure Lowering in Early Ischemic Stroke: Meta-Analysis oleh Lee et al., dan dipublikasi dalam jurnal Stroke Juli 2015.
Ischemic Stroke Subclassification, An Asian ViewpointErsifa Fatimah
Pada awalnya, sistem klasifikasi stroke diderivasi dari temuan autopsi yang dikaitkan dengan klinis pasien. Seiring dengan berkembangnya modalitas imaging & investigasi vaskular, klasifikasi stroke yang pada awalnya menitikberatkan pada sindroma klinis beralih menjadi suatu proses decision-making berdasarkan data klinis-radiologis-laboratoris.
Menariknya lagi, proporsi subtipe stroke ini pun berubah, sesuai sistem & kriteria yang digunakan...
Hmmm, bagaimana dengan klasifikasi dan proporsi tipe stroke di Asia?
Dokumen tersebut membahas konsep kesehatan yang holistik dan pendekatan ekologi kesehatan untuk mencapai kondisi sehat secara menyeluruh. Pendekatan ini melihat kesehatan tidak hanya sebagai absensi penyakit tetapi kondisi seimbang secara fisik, mental dan sosial yang bergantung pada lingkungan hidup yang bersih dan lestari. Lingkungan hidup yang rusak dan tercemar dapat menyebabkan berbagai gangguan kesehatan
Teruntuk Perempuan Indonesia,
Waspada risikonya dan cegah STROKE sejak dini.
*from NEUROLOGISTS, with LOVE.
Hari Stroke Dunia, 29 Oktober 2015 : Saya Perempuan.
Kapan aneurysma yang belum ruptur memerlukan intervensi?
"In the decision-making process, the PHASES score may be considered for predicting a patient’s risk of aneurysm rupture."
Terapi Endovaskuler, Standar Baru Manajemen Stroke Iskemik Akut? Ersifa Fatimah
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1. Predictors and Outcomes
of Pneumonia in Patients
With Spontaneous
Intracerebral Hemorrhage
Alsumrain M, et al
J Intensive Care Med
February 14, 2012
Journal Reading
Ersifa Fatimah, dr.
Pembimbing: dr. Hendro Susilo, SpS(K)
Pengamat: dr. Yudha Haryono, SpS
2. Introduction
ICH, common form of stroke 1/5 of all cases
Respiratory tract infection in ICU 30-60% of all infection
Pneumonia have the highest mortality rate among all
medical complications after stroke
To predict which patients will benefit from early & more
aggressive treatment
There is little data on the incidence of pneumonia in patients
with ICH / neuro-ICU
2
4. Methods
290 consecutive patients with sICH admitted within 24 hours of stroke onset, at New
Jersey Neuroscience Institute - J F Kennedy Hospital, from January 2006 to July 2009
Data
Demographic data GCS & mRS Pneumonia & exposure
Additional data
Site & type pneumonia, LoS, PPI, H2B, ACE-I, smoking, alcohol
Statistical analysis
4
5. Definitions
Pneumonia
• Dx: 2007 consensus guidelines from the Infectious Diseases Society of
America & the American Thoracic Society
• Include: a constellation of suggestive clinical features, a
demonstrable infiltrate by chest radiograph or other imaging
technique, with / without supporting microbiological data.
Ventilator-associated pneumonia (VAP)
• Exposure to MV at any point during hospital course
• Px developed pneumonia after 48 hours on the ventilator
• Uses VAP bundle according to the Joint Commission on
Accreditation of Healthcare Organizations for the prevention of
pneumonia in mechanically ventilated patients.
Dysphagia
• diagnosed after a standardized speech and swallow evaluation
completed by a team of speech therapist.
Tube feeding
• Started within 48 hours of hospitalization.
5
6. Results & Discussion
• 290 patients (-10?)
• 159 (56.5%) male
• mean age of 66.6 years (SD +/- 16.2).
• 13.93% patients developed pneumonia.
6
7. Cont.
• Patients who developed pneumonia had a lower GCS (mean = 9.1) &
higher mRS (mean = 4) on admission. Those without pneumonia, the mean
of GCS = 12.6 & mRS = 2.77
Substantial risk of pneumonia is associated with
(each of these parameters, cut offs):
mRS 2.5 (=< 2 vs =>3) ORa 5.18 (2.10 – 12.8)
GCS 13.5 (=<13 vs =>14) ORa 6.27 (2.84 – 13.9)
7
8. PPI , H2-blockers and Pneumonia
Normal gastric juice with a pH below 4 most
pathogens are killed
• Suppression of gastric acid no defense from bacteria
multiplying colonization of pathogens, particularly gram-
positive bacteria, from the upper GIT
• Aspiration is important mechanism in the development of
nosocomial pneumonia.
Degree of bacterial overgrowth depends on
the degree of reduction in gastric acid
secretion
• Bacterial overgrowth is considerably higher in patients
treated with PPI compared with H2-receptor antagonist.
8
9. ACE inhibitors & Pneumonia
Our study Other studies
The use of ACE-I predisposes those ACE-I beneficial for elderly patients
with sICH to develop pneumonia with intracerebral hemorrhage or
stroke, who are at risk of
pneumonia.
Protective effects of ACE-I
• Attributed to an increase in substance P & bradykinin.
ACE-I has different effects on racial populations:
• Most of the studies involving ACE-I involve only Asian population.
• Studies involving a general white population show no reduced
hospitalization for community acquired pneumonia for patients using
ACE-I.
9
10. • 93(33.2%)patients required mechanical ventilation at one point of
their disease course VAP 76%.
• The most common site of pneumonia: the right lower lobe (41%).
• The most common isolated organisms: Pseudomonas aeruginosa &
Klebsiella pneumoniae, from 12 patients (30.7%) with pneumonia
Univariate analysis: Variables & OR (95% CI)
Mechanical ventilation 9.42 (4.24 - 20.9)
Tube feeding 22.3 (8.91 – 55.8)
Dysphagia 13.1 (4.66 – 36.7)
Tracheostomy 26.8 (8.02 – 89.3)
10
11. Multivariate analysis • Relatively small
differences in ORa
after adjusting for
potential
confounders
• Most interaction
terms were not
significant
• Exception:
o H2-blockers for MV
o GCS & mRS for all but
dysphagia & MV [only
GCS yielded a
significant interaction].
All potential
confounders left the 4
primary exposures
statistically significant
after adjustment.
11
12. • Primary route of
bacterial entry into
the trachea:
• aspiration of
oropharyngeal
pathogens
• leakage of
bacteria around
the endotracheal
tube cuff.
• Frequent need of
MV in px with sICH
at a higher risk of
pneumonia than
any other group of
patients. (in this
study, 76.9% of
patients who
developed
The minimum ORa was 3.72 (95% CI: 1.68 - 8.26) pneumonia were on
when adjusted for GCS MV)
12
13. • The bronchial
colonization of
bacteria in upper
airways during
tracheostomy
reservoir for the
lower airways
colonization
increases risk of
pneumonia.
• Subsequent need
for tracheostomy
who required
prolonged use of
MV with
tracheostomy, incre
ased risk of
mRS reduced OR to 16.2 (95% CI: 4.98 - 52.8) ventilator-
for tracheostomy associated
tracheobronchitis ~
precursor for VAP.
13
14. The mechanisms
responsible:
• desensitization of the
pharyngo-glottal
adduction reflex,
• loss of anatomical
integrity of the
esophageal
sphincters,
• migration of gastric
bacteria upward
along the tube
causing colonization
of the pharynx.
• Both GCS and mRS reduced ORa
• GCS to14.7(95% CI: 6.16-35.0)
• mRS to15.7(95% CI: 6.63-37.0).
14
15. • Dysphagia is seen in
40 - 70% of patients
who had an acute
stroke 40 - 50%
aspirate increases
the likelihood of
developing
pneumonia by 7-fold.
mRS reduced OR to 7.46 (95% CI: 3.34 -
10.6)
15
16. Effect of pneumonia on morbidity:
• Increase in mRS between admission and discharge:
o by 1.07(4-5.07) in patients with pneumonia
o by 0.33 (2.77-3.1) in patients without pneumonia
o P = .003
• The hospital length of stay:
o The pneumonia group (mean = 19.56 days)
o The no-pneumonia group (mean = 9.14 days),
o P <.0001.
• Mortality rate:
o 10 (25.6%) patients died in pneumonia group
o 30 (12%)patients died in no pneumonia group
o P = .041
16
17. Limitations
• Retrospective protocol:
o Some limitations, primarily due to existing documentation
• Not include:
o length of time on mechanical ventilation
o the use of hypothermia
o the size and location of ICH.
• The sample size
o adequate in establishing significant associations between
the exposures and outcomes,
o not large enough to avoid fairly broad CIs.
17
18. Conclusion
Increased risk of the development of
pneumonia in patients with sICH:
• Mechanical ventilation, tube feeding, dysphagia, and
tracheostomy
• Independently associated with pneumonia, even when
potentially confounding variables are considered: GCS &
mRS on admission and the use of PPI / H2 blockers, ACE-I.
Pneumonia in patients with sICH
• Increased morbidity, hospital length of stay, and mortality
Need for increased vigilance & scrupulous
adherence to intensive care protocols
• designed to reduce the occurrence of pneumonia in
patients with sICH.
18
19. Education of health care personnel
Active surveillance of VAP
Minimizing the duration of ventilation
Adherence to hand hygiene guidelines
Maintaining patients in a semi-recumbent position
Good oral care
The use of strategies to decrease the contamination of equipments
used for care in patients on mechancal ventilation.
19
22. Research Question
1 2
P Patients with sICH Patients with sICH
I MV, tracheostomy, Pneumonia
tube feeding, dysphagia
C - -
O Increase risk of Increase in
development of morbidity, mortality, length
pneumonia of stay
Prognosis
Study design: Retrospective
22
25. Case-Control
Odds diseased
Factor = Exposed to factor
early 37 = (37/18)
infant
formula
50
Odds diseased
13 Unexposed to factor
Disease = = (13/32)
Early onset
of
asthma 18
50 Odds Ratio (OR)
32 =
(37/18)
Present Time
(13/32)
= 5,1
Starting
point
Past Time
25
26. Cohort Study
100
300
200
1000
50
Factor = Disease =
early Early onset
infant
formula
of
asthma
700
650
Present Time Past Time
Starting
Relative Risk =
point
Incidence diseased Incidence diseased
Exposed to factor Unexposed to factor (100/300) = 4,7
= (100/300) = (50/700) (50/700)
26
27. Validity
Recruitment -- “Were the subjects representative?”
Patients should ideally be enrolled at a sICH at 24-h onset
uniformly early time in the disease
Patients should also be representative Demographic data
of the underlying population.
Patients from tertiary referral centres Single-center, type?
may have more advanced disease
and poorer prognoses than patients
from primary care.
Adjustment — “If subgroups with different prognoses are identified, did
adjustment for important prognostic factors take place?”
Adjust for known prognostic factors in Multivariate analysis
the analysis so that the result indicate
the additional prognostic information.
28. Maintenance --“Was the comparable status of the study groups maintained
through equal management? Adequate follow-up?””
Prognosis is always conditional on Equal?
treatment, initial and subsequent Protocol to treat pneumonia
treatment should be clearly spelt out, Limitation in ICH therapy
Follow-up should be long enough to All px: Discharge or death
detect the outcome of interest Reasons for loss to follow-up?
Measurement: “Were the subjects and assessors kept „blind‟ to which treatment
was being received and/or were the measures objective ?”
Ideal if both the outcome assessors and Outcome: dx pneumonia criteria,
the subjects are blinded to the nature mortality, mRS, LoS
of the study groups.
If the outcome is objective (eg death)
then blinding is less critical.
If the outcome is subjective (eg
symptoms or function) then blinding of
the outcome assessor is critical.
28
29. Importance
• OR, ORa clinical significance (+)
• Statistical significance available p-value
30. Applicability
• Study population similar to our own
• Results will lead to therapy selection
• Results useful for counseling patient or family