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Penatalaksanaan gagal nafas pada pasien morbid obesitas dengan penyulit ppok, pnemonia dan gagal jantung kanan
The document details the management of respiratory failure in a morbidly obese patient with complications such as COPD, pneumonia, and right heart failure. It describes the clinical history, diagnostic findings, and various treatment protocols employed, including the use of ventilators and medications. The patient's condition was closely monitored in the ICU, highlighting the critical nature of obesity-related respiratory issues.
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Penatalaksanaan gagal nafas pada pasien morbid obesitas dengan penyulit ppok, pnemonia dan gagal jantung kanan
- 1. Penatalaksanaan gagal nafaspada 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
- 2. Pendahuluan • ↑Insidensi ObesityHypoventilation 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.
- 3. Obesity Hypoventilation Syndrome(OHS) CHEST 2016; 149(3):856-868 Gambar 1.Faktor patofisiologis dalam OHS
- 4. Gagal Napas • Terdapat2 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.
- 5. Pemantauan Hemodinamik • Pengamatanyang 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
- 6. 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.
- 7. Pemeriksaan Penunjang Thorax: - Gambaranbronchitis - 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
- 8. Echocardiography: - Fungsi sistoleLV 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
- 9. Penatalaksanaan UGD BP 130/70mmHg, HR HR 98x/min, SpO2 64%, O2 4 Lpm SpO2 79% Nacl 0,9% 12 tpm, furosemide 40 mg/24 jam/ oral, PERAWATAN
- 10. Pasien mengeluh kakibengkak 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
- 11. • KU: keduakaki 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
- 12. 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
- 13. • 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
- 14. 2 3 45 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-
- 15. 2 3 45 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 - Gagal jantung kanan - 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 A: Fentanyl 0,5mg / kgBB S: dexmedetomidine 0,2 mg/ kgBB Midazolam 2 mg/jam/ SP T: - H: elevasi kepala 30⁰ 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
- 16. 2 3 45 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 - Gagal jantung kanan - 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 A: Fentanyl 0,5mg / kgBB S: dexmedetomidine 0,2 mg/ kgBB Midazolam 2 mg/jam/ SP T: - H: elevasi kepala 30⁰ 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
- 17. ICU Hari-3 (09/08/17) A:- -Gagal napas e.c PPOK - Gagal jantung kanan - 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
- 18. ICU Hari-4 (10/8/17) A:- Gagal Napas ec. PPOK - Gagal jantung kanan - 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
- 19. ICU Hari-5 (11/8/17) A:-Gagal Napas ec. PPOK - Gagal jantung kanan - 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
- 20. 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: 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: B1: O2 via ventilator mode PC, RR: 20x/ menit, PEEP 7, Pins 20 FiO2 50%, -->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 (-/-) Laboratorium 11/8/2017 WBC: 15.700 HB: 13,3; cr 1,00 Alb. 3,2 PCT: 0,8 A: Gagal napas ec PPOK + OSA S : - O: B1: O2 via ventilator mode PC, RR: 20x/ menit, PEEP 8, Pins 20 FiO2 50%, -->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: O2 via ventilator mode PC, RR: 20x/ menit, PEEP 8, Pins 20 FiO2 50%, -->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 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 (-) B6: udem (-/-) fraktur (-/-) Laboratorium 14/8/2017 WBC: 14.100HB: 12,2; cr 1,07 Alb. 3,3 PCT: 0,11 K: 2,9 A: Gagal napas ec PPOK + OSA 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 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-5) Norepinefrine 0,2 mcg/KgBB/menit Furosemide 5mg/jam/sp/iv Levofloxacin 750mg/24jam/iv (H-4) Dobutamin 5mcg/kgBB/menit 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-6) Norepinefrine 0,05 mcg/KgBB/menit Furosemide 5mg/jam/sp/iv Levofloxacin 750mg/24jam/iv (H-5) Dobutamin 3mcg/kgBB/menit O2 via ventilator mode AC, RR: 20x/ menit, PEEP 8, 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-7) Norepinefrine 0,05 mcg/KgBB/menit Furosemide 5mg/jam/sp/iv Levofloxacin 750mg/24jam/iv (H-6) Dobutamin 3mcg/kgBB/menit O2 via ventilator mode PC Ringer laktat 2500cc/24jam F: Ensure 6x100kkal/hari A: - S: - T: - H: Head up 30-45 ⁰ U: lansoprazole 60 mg/ 24 jam G: Target GDS 120- 180 mg/ dL Meropenem 2 gr/8 jam/IV (H-8) Furosemide 5mg/jam/sp/iv Levofloxacin 750mg/24jam/iv (H-6) Dobutamin 3mcg/kgBB/menit 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
- 21. 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 5, Pins 10 FiO2 40%, -->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 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 (-) B6: udem (-/-) fraktur (-/-) S : - O: O2 via ventilator mode BILEVEL, RR: 10x/ menit, PEEP 5, Pins 10 FiO2 40%, -->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 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 (-) B6: udem (-/-) fraktur (-/-) S : - O: O2 via ventilator mode BILEVEL, RR: 10x/ menit, PEEP 5, Pins 10 FiO2 40%, -->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 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 (-) B6: udem (-/-) fraktur (-/-) S : - O: O2 via ventilator mode BILEVEL, RR: 10x/ menit, PEEP 5, Pins 10 FiO2 40%, -->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 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 (-) B6: udem (-/-) fraktur (-/-) S : - O: O2 via ventilator mode BILEVEL, RR: 10x/ menit, PEEP 5, Pins 10 FiO2 40%, -->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 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 (-) B6: udem (-/-) fraktur (-/-) O2 via ventilator mode PC Ringer laktat 2500cc/24jam F: Ensure 6x100kkal/hari dari TS Gizi Klinik A: - S: - T: - H: Head up 30-45 ⁰ U: lansoprazole 30 mg/ 12 jam G: Target GDS 120- 180 mg/ dL Meropenem 2 gr/8 jam/IV (H-9) Furosemide 5mg/jam/sp/iv Levofloxacin 750mg/24jam/iv (H-7) Dobutamin 3mcg/kgBB/menit O2 via ventilator mode PC Ringer laktat 2500cc/24jam F: Ensure 6x100kkal/hari dari TS Gizi Klinik A: - S: - T: - H: Head up 30-45 ⁰ U: lansoprazole 30 mg/ 12 jam G: Target GDS 120- 180 mg/ dL Meropenem 2 gr/8 jam/IV (H-9) Furosemide 5mg/jam/sp/iv Amikasin 750mg/24jam/iv (H-1) Dobutamin 3mcg/kgBB/menit O2 via ventilator mode PC Ringer laktat 2500cc/24jam F: Ensure 6x100kkal/hari dari TS Gizi Klinik A: Fentanyl 30mcg/jam/sp + Paracetamol 1gr/6jam/iv S: - T: - H: Head up 30-45 ⁰ U: lansoprazole 30 mg/ 12 jam G: Target GDS 120- 180 mg/ dL Meropenem 2 gr/8 jam/IV (H-10) Furosemide 5mg/jam/sp/iv Amikasin 750mg/24jam/iv (H-2) Dobutamin 3mcg/kgBB/menit Norepinephrine 0,05mcg/kgBB O2 via ventilator mode PC Ringer laktat 2500cc/24jam F: Ensure 6x100kkal/hari dari TS Gizi Klinik A: Fentanyl 30mcg/jam/sp + Paracetamol 1gr/6jam/iv S: - T: - H: Head up 30-45 ⁰ U: lansoprazole 30 mg/ 12 jam G: Target GDS 120- 180 mg/ dL Meropenem 2 gr/8 jam/IV (H-10) Furosemide 5mg/jam/sp/iv Amikasin 750mg/24jam/iv (H-2) Dobutamin 3mcg/kgBB/menit Norepinephrine 0,05mcg/kgBB O2 via ventilator mode PC Ringer laktat 2500cc/24jam F: Ensure 6x100kkal/hari dari TS Gizi Klinik A: Fentanyl 30mcg/jam/sp + Paracetamol 1gr/6jam/iv S: - T: - H: Head up 30-45 ⁰ U: lansoprazole 30 mg/ 12 jam G: Target GDS 120- 180 mg/ dL Meropenem 2 gr/8 jam/IV (H-10) Furosemide 5mg/jam/sp/iv Amikasin 750mg/24jam/iv (H-2) Dobutamin 3mcg/kgBB/menit Norepinephrine 0,05mcg/kgBB BILEVEL, RR: 10x/ menit, PEEP 5, Pins 10 FiO2 40% Norepinefrin 0,05-0,1 mcg/kgbb/mnet Dobutamin 3 - 7,5mcg/kgBB/mnt 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) -
- 22. 21/08/2017 (15) 22/08/2017(16) 23/08/2017 (17) 24/08/2017 (18) 25/08/2017 (19) S : - O: O2 via ventilator mode BILEVEL, RR: 10x/ menit, PEEP 5, Pins 10 FiO2 40%, -->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 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 (-) B6: udem (-/-) fraktur (-/-) S : - O: O2 via ventilator mode BILEVEL, RR: 10x/ menit, PEEP 5, Pins 10 FiO2 40%, -->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 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 (-) B6: udem (-/-) fraktur (-/-) 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% 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 (-) B6: udem (-/-) fraktur (-/-) Laboratorium 21/8/2017 WBC: 10.700 HB: 9,1; PCT 2,99 Foto Thoraks (20/8/2017) Cardiomegaly disertai bendungan par Dilatatio Aorta 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% 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 (-) B6: udem (-/-) fraktur (-/-) 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% 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 (-) B6: udem (-/-) fraktur (-/-) O2 via ventilator mode PC Ringer laktat 2500cc/24jam F: Ensure 6x100kkal/hari dari TS Gizi Klinik A: Fentanyl 30mcg/jam/sp + Paracetamol 1gr/6jam/iv S: - T: - H: Head up 30-45 ⁰ U: lansoprazole 30 mg/ 12 jam G: Target GDS 120- 180 mg/ dL Meropenem 2 gr/8 jam/IV (H-10) Furosemide 5mg/jam/sp/iv Amikasin 750mg/24jam/iv Dobutamin 3mcg/kgBB/menit Norepinephrine 0,05mcg/kgBB O2 via ventilator mode PC Ringer laktat 2500cc/24jam F: Ensure 6x100kkal/hari dari TS Gizi Klinik A: Fentanyl 30mcg/jam/sp + Paracetamol 1gr/6jam/iv S: - T: - H: Head up 30-45 ⁰ U: lansoprazole 30 mg/ 12 jam G: Target GDS 120- 180 mg/ dL Meropenem 2 gr/8 jam/IV (H-10) Furosemide 5mg/jam/sp/iv Amikasin 750mg/24jam/iv (H-1) Dobutamin 3mcg/kgBB/menit Norepinephrine 0,05mcg/kgBB O2 via ventilator mode PC Ringer laktat 2500cc/24jam F: Ensure 6x100kkal/hari dari TS Gizi Klinik A: Fentanyl 30mcg/jam/sp + Paracetamol 1gr/6jam/iv S: - T: - H: Head up 30-45 ⁰ U: lansoprazole 30 mg/ 12 jam G: Target GDS 120- 180 mg/ dL Meropenem 2 gr/8 jam/IV (H-10) Amikasin 750mg/24jam/iv (H-2) O2 via ventilator mode PC Ringer laktat 2500cc/24jam F: Ensure 6x100kkal/hari dari TS Gizi Klinik A: Fentanyl 30mcg/jam/sp + Paracetamol 1gr/6jam/iv S: - T: - H: Head up 30-45 ⁰ U: lansoprazole 30 mg/ 12 jam G: Target GDS 120- 180 mg/ dL Meropenem 2 gr/8 jam/IV (H-15) Amikasin 750mg/24jam/iv (H-3) O2 via ventilator mode PC Ringer laktat 2500cc/24jam F: Ensure 6x100kkal/hari dari TS Gizi Klinik A: Fentanyl 30mcg/jam/sp + Paracetamol 1gr/6jam/iv S: - T: - H: Head up 30-45 ⁰ U: lansoprazole 30 mg/ 12 jam G: Target GDS 120- 180 mg/ dL Meropenem 2 gr/8 jam/IV (H-15) Amikasin 750mg/24jam/iv (H-4) BILEVEL, RR: 10x/ menit, PEEP 5, Pins 10 FiO2 40% SIMV, RR: 10x/ menit, PEEP 5, PS 10 FiO2 40%, Norepinefrin 0,05-0,1 mcg/kgbb/mnet Dobutamin 3 - 7,5mcg/kgBB/mnt PF Ratio 240 Kultur sputum 23/08 Acinetobacter baumannii Amikasin (S)
- 23. 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 (-) B6: udem (-/-) fraktur (-/-) 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 (-) B6: udem (-/-) fraktur (-/-) 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% 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 (-) B6: udem (-/-) fraktur (-/-) 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% 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 (-) B6: udem (-/-) fraktur (-/-) 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% 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 (-) B6: udem (-/-) fraktur (-/-) O2 via ventilator Ringer laktat 2500cc/24jam F: Ensure 6x100kkal/hari dari TS Gizi Klinik A: Fentanyl 30mcg/jam/sp + Paracetamol 1gr/6jam/iv S: - T: - H: Head up 30-45 ⁰ U: lansoprazole 30 mg/ 12 jam G: Target GDS 120- 180 mg/ dL Meropenem 2 gr/8 jam/IV (H-15) Amikasin 750mg/24jam/iv (H-5) O2 via ventilator Ringer laktat 2500cc/24jam F: Ensure 6x100kkal/hari dari TS Gizi Klinik A: Fentanyl 30mcg/jam/sp + Paracetamol 1gr/6jam/iv S: - T: - H: Head up 30-45 ⁰ U: lansoprazole 30 mg/ 12 jam G: Target GDS 120- 180 mg/ dL Meropenem 2 gr/8 jam/IV (H-15) Amikasin 750mg/24jam/iv (H-6) O2 via ventilator Ringer laktat 2500cc/24jam F: Ensure 6x100kkal/hari dari TS Gizi Klinik A: Fentanyl 30mcg/jam/sp + Paracetamol 1gr/6jam/iv S: - T: - H: Head up 30-45 ⁰ U: lansoprazole 30 mg/ 12 jam G: Target GDS 120- 180 mg/ dL Meropenem 2 gr/8 jam/IV (H-15) Amikasin 750mg/24jam/iv (H-7) O2 via ventilator Ringer laktat 2500cc/24jam F: Ensure 6x100kkal/hari dari TS Gizi Klinik A: Fentanyl 30mcg/jam/SP S: - T: - H: Head up 30-45 ⁰ U: lansoprazole 30 mg/ 12 jam G: Target GDS 120- 180 mg/ dL Norepinefrin 0,1 mcg/KgBB/mnt Dobutamin 7,5 mcg/KgBB/mnt Bisolvon 1 vial/8 jam/ nebulizer Amikasin 750mg/24jam/iv (H-8) Flexotide 1 vial/12 jam/nebulizer Zink 20 mg/8 jam/NGT Combivent 1 vial/8 jam/nebulizer O2 via ventilator Ringer laktat 2500cc/24jam F: Ensure 6x100kkal/hari dari TS Gizi Klinik A: Fentanyl 30mcg/jam/SP S: - T: - H: Head up 30-45 ⁰ U: lansoprazole 30 mg/ 12 jam G: Target GDS 120- 180 mg/ dL Norepinefrin 0,1 mcg/KgBB/mnt Dobutamin 7,5 mcg/KgBB/mnt Bisolvon 1 vial/8 jam/ nebulizer Amikasin 750mg/24jam/iv (H-9) Flexotide 1 vial/12 jam/nebulizer Zink 20 mg/8 jam/NGT Combivent 1 vial/8 jam/nebulizer CPAP PEEP 5 FiO2 40% TRACHEOSTOMI -> BILEVEL, RR: 10x/ menit, PEEP 5, Pins 10 FiO2 40% Norepinefrin 0,05-0,1 mcg/kgbb/mnet Dobutamin 3 - 7,5mcg/kgBB/mnt 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)
- 24. 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% 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 (-) B6: udem (-/-) fraktur (-/-) 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% 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 (-) B6: udem (-/-) fraktur (-/-) Laboratorium 30/8/2017 WBC: 13.800, Hb : 8.4, Alb 2.8, PCT 3,9 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% 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 (-) B6: udem (-/-) fraktur (-/-) 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% 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 (-) B6: udem (-/-) fraktur (-/-) S : - O: B1: O2 via Trakeostomi on Ventilator mode SIMV--> 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 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 (-) B6: udem (-/-) fraktur (-/-) O2 via ventilator Ringer laktat 2500cc/24jam F: Ensure 6x100kkal/hari dari TS Gizi Klinik A: Fentanyl 30mcg/jam/SP S: - T: - H: Head up 30-45 ⁰ U: lansoprazole 30 mg/ 12 jam G: Target GDS 120- 180 mg/ dL Norepinefrin 0,1 mcg/KgBB/mnt Dobutamin 7,5 mcg/KgBB/mnt Bisolvon 1 vial/8 jam/ nebulizer Amikasin 750mg/24jam/iv (H-4) Flexotide 1 vial/12 jam/nebulizer Zink 20 mg/8 jam/NGT Combivent 1 vial/8 jam/nebulizer O2 via ventilator Ringer laktat 2500cc/24jam F: Ensure 6x100kkal/hari dari TS Gizi Klinik A: Fentanyl 30mcg/jam/SP S: - T: - H: Head up 30-45 ⁰ U: lansoprazole 30 mg/ 12 jam G: Target GDS 120- 180 mg/ dL Bisolvon 1 vial/8 jam/ nebulizer Cefepime 2gr/8 jam/intravena Flexotide 1 vial/12 jam/nebulizer Zink 20 mg/8 jam/NGT Combivent 1 vial/8 jam/nebulizer Cernevit 1 vial/24 jam/drips intravena O2 via ventilator Ringer laktat 2500cc/24jam F: Ensure 6x100kkal/hari dari TS Gizi Klinik A: Fentanyl 30mcg/jam/SP S: - T: - H: Head up 30-45 ⁰ U: lansoprazole 30 mg/ 12 jam G: Target GDS 120- 180 mg/ dL Bisolvon 1 vial/8 jam/ nebulizer Cefepime 2gr/8 jam/intravena Flexotide 1 vial/12 jam/nebulizer Zink 20 mg/8 jam/NGT Combivent 1 vial/8 jam/nebulizer Cernevit 1 vial/24 jam/drips intravena O2 via ventilator Ringer laktat 2500cc/24jam F: Ensure 6x100kkal/hari dari TS Gizi Klinik A: Fentanyl 30mcg/jam/SP S: - T: - H: Head up 30-45 ⁰ U: Lansoprazole 30 mg/ 12 jam G: Target GDS 120- 180 mg/ dL Bisolvon 1 vial/8 jam/ nebulizer Cefepime 2gr/8 jam/iv (H-3) Flexotide 1 vial/12 jam/nebulizer Zink 20 mg/8 jam/NGT Combivent 1 vial/8 jam/nebulizer 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 F: Ensure 6x100kkal/hari dari TS Gizi Klinik A: Fentanyl 30mcg/jam/SP S: - T: - H: Head up 30-45 ⁰ U: Lansoprazole 30 mg/ 12 jam G: Target GDS 120- 180 mg/ dL Amikasin 1 gr/24jam/iv (H.16) Cefepime 2gr/8 jam/iv (H-3) Flexotide 1 vial/12 jam/nebulizer Zink 20 mg/8 jam/NGT Combivent 1 vial/8 jam/nebulizer Cernevit 1 vial/24 jam/drips iv Albumin 3x1 sachet Bisolvon 1 vial/8 jam/ nebulizer SIMV RR: 20x/ menit, PEEP 5, Pins 10 FiO2 40% Norepinefrin 0,05-0,1 mcg/kgbb/mnet Dobutamin 3 - 7,5mcg/kgBB/mnt PF Ratio 240
- 25. 05/09/2017 (30) 06/09/2017(31) 07/09/2017 (32) 08/09/2017 (33) 09/09/2017 (34) S : - O: B1: O2 via Trakeostomi on Ventilator mode SIMV--> 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 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 (-) B6: udem (-/-) fraktur (-/-) S : - O: B1: O2 via Trakeostomi on Ventilator mode SIMV--> 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 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 (-) B6: udem (-/-) fraktur (-/-) S : - O: B1: O2 via Trakeostomi on Ventilator mode SIMV--> 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 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 (-) B6: udem (-/-) fraktur (-/-) S : - O: B1: O2 via Trakeostomi on Ventilator mode SIMV--> 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 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 (-) B6: udem (-/-) fraktur (-/-) 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: B1: O2 via Trakeostomi on Ventilator mode SIMV--> 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 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 (-) B6: udem (-/-) fraktur (-/-) O2 via ventilator modeSIMV TV 500 cc RR: 10x/ menit, PEEP 5, PS 10 FiO2 40%, IVFD Ringer laktat 500cc/24jam F: Ensure 6x100kkal/hari dari TS Gizi Klinik A: Fentanyl 30mcg/jam/SP S: - T: - H: Head up 30-45 ⁰ U: Lansoprazole 30 mg/ 12 jam G: Target GDS 120- 180 mg/ dL Amikasin 1 gr/24jam/iv (H-17) Cefepime 2gr/8 jam/iv (H-3) Flexotide 1 vial/12 jam/nebulizer Zink 20 mg/8 jam/NGT Combivent 1 vial/8 jam/nebulizer Cernevit 1 vial/24 jam/drips iv Albumin 25%/24jam/iv Bisolvon 1 vial/8 jam/ nebulizer Fluimucil 300mg/8jam/iv O2 via ventilator modeSIMV TV 500 cc RR: 10x/ menit, PEEP 5, PS 10 FiO2 40%, IVFD Ringer laktat 500cc/24jam F: Ensure 6x100kkal/hari dari TS Gizi Klinik A: Fentanyl 30mcg/jam/SP S: - T: - H: Head up 30-45 ⁰ U: Lansoprazole 30 mg/ 12 jam G: Target GDS 120- 180 mg/ dL Cefepime 2gr/8 jam/iv (H-4) Flexotide 1 vial/12 jam/nebulizer Zink 20 mg/8 jam/NGT Combivent 1 vial/8 jam/nebulizer Cernevit 1 vial/24 jam/drips iv Albumin 25%/24jam/iv Bisolvon 1 vial/8 jam/ nebulizer Fluimucil 300mg/8jam/iv O2 via ventilator mode SIMV TV 500 cc RR: 10x/ menit, PEEP 5, PS 10 FiO2 40%, IVFD Ringer laktat 500cc/24jam F: Ensure 6x100kkal/hari dari TS Gizi Klinik A: Fentanyl 30mcg/jam/SP S: - T: - H: Head up 30-45 ⁰ U: Lansoprazole 30 mg/ 12 jam G: Target GDS 120- 180 mg/ dL Cefepime 2gr/8 jam/iv (H-6) Flexotide 1 vial/12 jam/nebulizer Zink 20 mg/8 jam/NGT Combivent 1 vial/8 jam/nebulizer Cernevit 1 vial/24 jam/drips iv Albumin 25%/24jam/iv Bisolvon 1 vial/8 jam/ nebulizer Fluimucil 300mg/8jam/iv O2 via ventilator mode SIMV TV 500 cc RR: 10x/ menit, PEEP 5, PS 10 FiO2 40%, IVFD Ringer laktat 500cc/24jam F: Ensure 6x100kkal/hari dari TS Gizi Klinik A: Fentanyl 30mcg/jam/SP S: - T: - H: Head up 30-45 ⁰ U: Lansoprazole 30 mg/ 12 jam G: Target GDS 120- 180 mg/ dL Tygacil 50mg/12jam Cefepime 2gr/8 jam/iv (H-7) Flexotide 1 vial/12 jam/nebulizer Zink 20 mg/8 jam/NGT Combivent 1 vial/8 jam/nebulizer Cernevit 1 vial/24 jam/drips iv Bisolvon 1 vial/8 jam/ nebulizer Fluimucil 300mg/8jam/iv O2 via ventilator mode SIMV TV 500 cc RR: 10x/ menit, PEEP 5, PS 10 FiO2 40%, IVFD Ringer laktat 500cc/24jam F: Ensure 6x100kkal/hari dari TS Gizi Klinik A: Fentanyl 30mcg/jam/SP S: - T: - H: Head up 30-45 ⁰ U: Lansoprazole 30 mg/ 12 jam G: Target GDS 120- 180 mg/ dL Cefepime 2gr/8 jam/iv (H-8) Flexotide 1 vial/12 jam/nebulizer Zink 20 mg/8 jam/NGT Combivent 1 vial/8 jam/nebulizer Cernevit 1 vial/24 jam/drips iv Bisolvon 1 vial/8 jam/ nebulizer Fluimucil 300mg/8jam/iv SIMV RR: 10x/ menit, PEEP 5, Pins 10 FiO2 40% Norepinefrin 0,05-0,1 mcg/kgbb/mnet Dobutamin 3 - 7,5mcg/kgBB/mnt Kultur darah 05/09 Burkholderia cepacia Meropenem (S) Tygecicline (S) Cefepime (S) Amikasin (R)
- 26. 10/09/2017 (35) 11/09/2017(36) 12/09/2017 (37) 13/09/2017 (38) 14/09/2017 (39) S : - O: B1: O2 via Trakeostomi on Ventilator mode SIMV--> TV 400 cc, RR: 8x/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 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 (-) B6: udem (-/-) fraktur (-/-) 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% B2 : BP 125/60 mmHg, MAP: 81 mmHg, HR 100x/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 90 cc/jam, warna kuning B5 : perut datar ikut gerak nafas Peristaltik (+) kesan Normal; Distended (-), NGT Residu (-) B6: udem (-/-) fraktur (-/-) Laboratorium (8/9/2017) Hb 8,4 gr/dl, PLT 249.000/mm3, WBC 20.400/mm3, K 3,3 mmol/L 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% B2 : BP 125/60 mmHg, MAP: 81 mmHg, HR 100x/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 90 cc/jam, warna kuning B5 : perut datar ikut gerak nafas Peristaltik (+) kesan Normal; Distended (-), NGT Residu (-) B6: udem (-/-) fraktur (-/-) Foto Thoraks (11-9-2017) Efusi pleura (S), skoliosis thoracalis sisnistroconvex 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% B2 : BP 125/60 mmHg, MAP: 81 mmHg, HR 100x/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 90 cc/jam, warna kuning B5 : perut datar ikut gerak nafas Peristaltik (+) kesan Normal; Distended (-), NGT Residu (-) B6: udem (-/-) fraktur (-/-) 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% B2 : BP 125/60 mmHg, MAP: 81 mmHg, HR 100x/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 90 cc/jam, warna kuning B5 : perut datar ikut gerak nafas Peristaltik (+) kesan Normal; Distended (-), NGT Residu (-) B6: udem (-/-) fraktur (-/-) O2 via ventilator mode SIMV TV 500 cc RR: 8x/ menit, PEEP 5, PS 10 FiO2 40%, IVFD Ringer laktat 500cc/24jam F: Ensure 6x100kkal/hari dari TS Gizi Klinik A: Fentanyl 30mcg/jam/SP S: - T: - H: Head up 30-45 ⁰ U: Lansoprazole 30 mg/ 12 jam G: Target GDS 120- 180 mg/ dL Cefepime 2gr/8 jam/iv (H-8) Flexotide 1 vial/12 jam/nebulizer Zink 20 mg/8 jam/NGT Combivent 1 vial/8 jam/nebulizer Cernevit 1 vial/24 jam/drips iv Bisolvon 1 vial/8 jam/ nebulizer Fluimucil 300mg/8jam/iv O2 via Trakeostomi on Ventilator mode SIMV TV 450 cc RR 8x/mnt PS 13 PEEP 8 FiO2 60% IVFD Ringer laktat 500cc/24jam F: Ensure 6x100kkal/hari dari TS Gizi Klinik A: Fentanyl 30mcg/jam/SP S: - T: - H: Head up 30-45 ⁰ U: Lansoprazole 30 mg/ 12 jam / iv G: Target GDS 120- 180 mg/ dL Cefepime 2gr/8 jam/iv (H-10) Flexotide 1 vial/12 jam/nebulizer Zink 20 mg/8 jam/NGT Combivent 1 vial/8 jam/nebulizer Cernevit 1 vial/24 jam/drips iv Bisolvon 1 vial/8 jam/ nebulizer Fluimucil 300mg/8jam/iv O2 via Trakeostomi on Ventilator mode SIMV TV 450 cc RR 8x/mnt PS 13 PEEP 8 FiO2 60% IVFD Ringer laktat 500cc/24jam F: Ensure 6x100kkal/hari dari TS Gizi Klinik A: Fentanyl 30mcg/jam/SP S: - T: - H: Head up 30-45 ⁰ U: Lansoprazole 30 mg/ 12 jam / iv G: Target GDS 120- 180 mg/ dL Cefepime 2gr/8 jam/iv (H-11) Flexotide 1 vial/12 jam/nebulizer Zink 20 mg/8 jam/NGT Combivent 1 vial/8 jam/nebulizer Cernevit 1 vial/24 jam/drips iv Bisolvon 1 vial/8 jam/ nebulizer Fluimucil 300mg/8jam/iv O2 via Trakeostomi on Ventilator mode SIMV TV 450 cc RR 8x/mnt PS 13 PEEP 8 FiO2 60% IVFD Ringer laktat 500cc/24jam 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 U: Lansoprazole 30 mg/ 12 jam / iv G: Target GDS 120- 180 mg/ dL Tygacyl 50mg/12j/iv (H-5) Claritromicyn 500 mg/24jam/NGT Flexotide 1 vial/12 jam/nebulizer Zink 20 mg/8 jam/NGT Combivent 1 vial/8 jam/nebulizer Bisolvon 1 vial/8 jam/ nebulizer Fluimucil 300mg/8jam/iv O2 via Trakeostomi on Ventilator mode SIMV TV 450 cc RR 8x/mnt PS 13 PEEP 8 FiO2 60% IVFD Ringer laktat 500cc/24jam 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 U: Lansoprazole 30 mg/ 12 jam / iv G: Target GDS 120- 180 mg/ dL Tygacyl 50mg/12j/iv (H-6) Claritromicyn 500 mg/24jam/NGT (H-1) Flexotide 1 vial/12 jam/nebulizer Zink 20 mg/8 jam/NGT Combivent 1 vial/8 jam/nebulizer Bisolvon 1 vial/8 jam/ nebulizer Fluimucil 300mg/8jam/iv SIMV RR: 8x/ menit, PEEP 5, Pins 10 FiO2 40% Norepinefrin 0,05-0,1 mcg/kgbb/mnet PF Ratio 247
- 27. Parameter 18/09/2017 WBC (x103mm3) 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: 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% B2 : BP 125/60 mmHg, MAP: 81 mmHg, HR 100x/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 90 cc/jam, warna kuning B5 : perut datar ikut gerak nafas Peristaltik (+) kesan Normal; Distended (-), NGT Residu (-) B6: udem (-/-) fraktur (-/-) 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% B2 : BP 125/60 mmHg, MAP: 81 mmHg, HR 100x/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 90 cc/jam, warna kuning B5 : perut datar ikut gerak nafas Peristaltik (+) kesan Normal; Distended (-), NGT Residu (-) B6: udem (-/-) fraktur (-/-) S : - O: B1: RR: 26x/mnt, Rh -/- Wh -/- SpO2 98% B2 : BP 125/60 mmHg, MAP: 81 mmHg, HR 100x/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 90 cc/jam, warna kuning B5 : perut datar ikut gerak nafas Peristaltik (+) kesan Normal; Distended (-), NGT Residu (-) B6: udem (-/-) fraktur (-/-) S : - O: B1: RR: 26x/mnt, Rh -/- Wh -/- SpO2 98% B2 : BP 125/60 mmHg, MAP: 81 mmHg, HR 100x/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 90 cc/jam, warna kuning B5 : perut datar ikut gerak nafas Peristaltik (+) kesan Normal; Distended (-), NGT Residu (-) B6: udem (-/-) fraktur (-/-) S : - O: B1: RR: 26x/mnt, Rh -/- Wh -/- SpO2 98% B2 : BP 125/60 mmHg, MAP: 81 mmHg, HR 100x/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 90 cc/jam, warna kuning B5 : perut datar ikut gerak nafas Peristaltik (+) kesan Normal; Distended (-), NGT Residu (-) B6: udem (-/-) fraktur (-/-) Laboratorium (18/9/2017) 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 O2 via Trakeostomi on Ventilator mode SIMV TV 450 cc RR 8x/mnt PS 13 PEEP 8 FiO2 60% IVFD Ringer laktat 500cc/24jam 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 U: Lansoprazole 30 mg/ 12 jam / iv G: Target GDS 120- 180 mg/ dL Tygacyl 100mg/12j/iv (H-7) Claritromicyn 500 mg/24jam/NGT (H-2) Flexotide 1 vial/12 jam/nebulizer Zink 20 mg/8 jam/NGT Combivent 1 vial/8 jam/nebulizer Bisolvon 1 vial/8 jam/ nebulizer Diamox 1 tab/8jam/NGT Norepinefrin 0.05 mcg / KgBB/ min O2 via Trakeostomi on Ventilator mode SIMV TV 450 cc RR 8x/mnt PS 13 PEEP 8 FiO2 60% IVFD Ringer laktat 500cc/24jam 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 U: Lansoprazole 30 mg/ 12 jam / iv G: Target GDS 120- 180 mg/ dL Tygacyl 100mg/12j/iv (H-7) Claritromicyn 500 mg/24jam/NGT (H-3) Flexotide 1 vial/12 jam/nebulizer Zink 20 mg/8 jam/NGT Combivent 1 vial/8 jam/nebulizer Bisolvon 1 vial/8 jam/ nebulizer Diamox 1 tab/8jam/NGT Norepinefrin 0.05 mcg / KgBB/ min O2 via NRM 8 LPM IVFD Ringer laktat 500cc/24jam 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 U: Lansoprazole 30 mg/ 12 jam / iv G: Target GDS 120- 180 mg/ dL Tygacyl 100mg/12j/iv (H-9) Claritromicyn 500 mg/24jam/NGT (H-4) Flexotide 1 vial/12 jam/nebulizer Zink 20 mg/8 jam/NGT Combivent 1 vial/8 jam/nebulizer Bisolvon 1 vial/8 jam/ nebulizer Diamox 1 tab/8jam/NGT Norepinefrin 0.05 mcg / KgBB/ min O2 via HFNC IVFD Ringer laktat 500cc/24jam 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 U: Lansoprazole 30 mg/ 12 jam / iv G: Target GDS 120- 180 mg/ dL Tygacyl 100mg/12j/iv (H-9) Claritromicyn 500 mg/24jam/NGT (H-5) Flexotide 1 vial/12 jam/nebulizer Zink 20 mg/8 jam/NGT Combivent 1 vial/8 jam/nebulizer Bisolvon 1 vial/8 jam/ nebulizer Diamox 1 tab/8jam/NGT O2 via HFNC IVFD Ringer laktat 500cc/24jam 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 U: Lansoprazole 30 mg/ 12 jam / iv G: Target GDS 120- 180 mg/ dL Tygacyl 100mg/12j/iv (H-9) Claritromicyn 500 mg/24jam/NGT (H-6) Flexotide 1 vial/12 jam/nebulizer Zink 20 mg/8 jam/NGT Combivent 1 vial/8 jam/nebulizer Bisolvon 1 vial/8 jam/ nebulizer Diamox 1 tab/8jam/NGT 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
- 28. 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% B2 : BP 125/60 mmHg, MAP: 81 mmHg, HR 100x/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 90 cc/jam, warna kuning B5 : perut datar ikut gerak nafas Peristaltik (+) kesan Normal; Distended (-), NGT Residu (-) B6: udem (-/-) fraktur (-/-) S : - O: B1: RR: 26x/mnt, Rh -/- Wh -/- SpO2 98% B2 : BP 125/60 mmHg, MAP: 81 mmHg, HR 100x/menit, reguler, kuat angkat, akral hangat, CRT < 2detik B3 : GCS 15 (E4M6V5), Pupil isokor (2.5mm/2.5mm), RC (+/+), SB 36.5 B4 : Urine Per Kateter Produksi 90 cc/jam, warna kuning B5 : perut datar ikut gerak nafas Peristaltik (+) kesan Normal; Distended (-), NGT Residu (-) B6: udem (-/-) fraktur (-/-) S : - O: B1: RR: 26x/mnt, Rh -/- Wh -/- SpO2 98% B2 : BP 125/60 mmHg, MAP: 81 mmHg, HR 100x/menit, reguler, kuat angkat, akral hangat, CRT < 2detik B3 : GCS 15 (E4M6V5), Pupil isokor (2.5mm/2.5mm), RC (+/+), SB 36.5 B4 : Urine Per Kateter Produksi 90 cc/jam, warna kuning B5 : perut datar ikut gerak nafas Peristaltik (+) kesan Normal; Distended (-), NGT Residu (-) B6: udem (-/-) fraktur (-/-) S: - O: B1: RR: 26x/mnt, Rh -/- Wh -/- SpO2 98% B2 : BP 125/60 mmHg, MAP: 81 mmHg, HR 100x/menit, reguler, kuat angkat, akral hangat, CRT < 2detik B3 : GCS 15 (E4M6V5), Pupil isokor (2.5mm/2.5mm), RC (+/+), SB 36.5 B4 : Urine Per Kateter Produksi 90 cc/jam, warna kuning B5 : perut datar ikut gerak nafas Peristaltik (+) kesan Normal; Distended (-), NGT Residu (-) B6: udem (-/-) fraktur (-/-) S : - O: B1: RR: 26x/mnt, Rh -/- Wh -/- SpO2 98% B2 : BP 125/60 mmHg, MAP: 81 mmHg, HR 100x/menit, reguler, kuat angkat, akral hangat, CRT < 2detik B3 : GCS 15 (E4M6V5), Pupil isokor (2.5mm/2.5mm), RC (+/+), SB 36.5 B4 : Urine Per Kateter Produksi 90 cc/jam, warna kuning B5 : perut datar ikut gerak nafas Peristaltik (+) kesan Normal; Distended (-), NGT Residu (-) B6: udem (-/-) fraktur (-/-) O2 via HFNC IVFD Ringer laktat 500cc/24jam 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 U: Lansoprazole 30 mg/ 12 jam / iv G: Target GDS 120- 180 mg/ dL Tygacyl 100mg/12j/iv (H-10) Claritromicyn 500 mg/24jam/NGT (H-7) Flexotide 1 vial/12 jam/nebulizer Zink 20 mg/8 jam/NGT Combivent 1 vial/8 jam/nebulizer Bisolvon 1 vial/8 jam/ nebulizer Diamox 1 tab/8jam/NGT O2 via Nasal kanula 2lpm IVFD Ringer laktat 500cc/24jam 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 U: Lansoprazole 30 mg/ 12 jam / iv G: Target GDS 120- 180 mg/ dL Tygacyl 100mg/12j/iv (H-12) Claritromicyn 500 mg/24jam/NGT (H-8) Flexotide 1 vial/12 jam/nebulizer Zink 20 mg/8 jam/NGT Combivent 1 vial/8 jam/nebulizer Bisolvon 1 vial/8 jam/ nebulizer Diamox 1 tab/8jam/NGT O2 via Nasal kanula 2lpm IVFD Ringer laktat 500cc/24jam 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 U: Lansoprazole 30 mg/ 12 jam / iv G: Target GDS 120- 180 mg/ dL Tygacyl 100mg/12j/iv (H-12) Claritromicyn 500 mg/24jam/NGT (H-9) Flexotide 1 vial/12 jam/nebulizer Zink 20 mg/8 jam/NGT Combivent 1 vial/8 jam/nebulizer Bisolvon 1 vial/8 jam/ nebulizer Diamox 1 tab/8jam/NGT O2 via Nasal kanula 2lpm IVFD Ringer laktat 500cc/24jam 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 U: Lansoprazole 30 mg/ 12 jam / iv G: Target GDS 120- 180 mg/ dL Tygacyl 100mg/12j/iv (H-12) Claritromicyn 500 mg/24jam/NGT (H-10) Flexotide 1 vial/12 jam/nebulizer Zink 20 mg/8 jam/NGT Combivent 1 vial/8 jam/nebulizer Bisolvon 1 vial/8 jam/ nebulizer Diamox 1 tab/8jam/NGT O2 via Nasal kanula 2lpm IVFD Ringer laktat 500cc/24jam 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 U: Lansoprazole 30 mg/ 12 jam / iv G: Target GDS 120- 180 mg/ dL Tygacyl 100mg/12j/iv (H-12) Claritromicyn 500 mg/24jam/NGT (H-11) Flexotide 1 vial/12 jam/nebulizer Zink 20 mg/8 jam/NGT Combivent 1 vial/8 jam/nebulizer Bisolvon 1 vial/8 jam/ nebulizer Diamox 1 tab/8jam/NGT Pindah ke Ruangan HFNC NC
- 29. Pemantauan PiCCO PiCCO normal08/08/17 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
- 30. Pembahasan • Pasien denganGeriatri • 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
- 31. High Flow NasalCannula (HFNC)
- 32. Pembahasan • Penyebab GagalNapas 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
- 33. Morbid Obesity Impaired respiratoryIncreased 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 - - -- -+ ++ + - - -
- 34.
- 35. RHF + EDEMAPARU • 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
- 36.
- 37. KESIMPULAN • Telah dilakuanpenatalaksanaan 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.
- 38.
- 39. Tabel 2. IndeksMassa Tubuh (IMT/BMI)
- 40. Analisa Gas Darah 22/0826/08 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
- 42. Obesity Hypoventilation Syndrome(OHS) Tabel 1. Karakteristik dan Prevalensi OHS Pada Pasien Dengan Gangguan Tidur
- 53. 21 18 1716 14 11 7 24 Laktat/procalcitonin 37,2/25,59 - / -/ 39,7/25, 9/cpr 76,3 Wbc 39,3 laktat Pc 0,53
- 54. 21-9 18-9 1412 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
- 57. • 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%
- 58. • Pulse contourParameters 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
- 59. PiCCO Indikasi : 1. Syok 2.Edema pulmo 3. Pembedahan dengan risiko tinggi 4. Hipertensi emergensi 5. Peningkatan tekanan intracranial
- 60. PiCCO tidak hanyamemberikan informasi tentang curah jantung (CO) tapi bisa memberi pengukuran untuk menilai preload, kontraktilitas, afterload, dan air paru ekstravaskular (ELWI)