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April, 2005
Dedicated to mykynaocc
KOREKSI
Na, K, Ca, Mg
NATRIUM
Normal : 135 145 mEq / L
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MAGNESIUM ( Mg )
Koreksi :
Hipomagnesemi ringan : Renapar / Aspar 1
tab / 8 jam
Hipomagnesemi berat : Mg SO4 injeksi
Sediaan Mg SO4 20% atau 40 % @ 25 cc
( biasa dipakai 40 % )
Manifestasi hipokalsemia
Susunan saraf
Visual
Pulmoner
Kardiovaskuler
Gastrointestinal
Genitourinaria
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ETIOLOGI :
hipo-albuminemia
sindrom hiperventilasi
gagal ginjal kronik
transfusi darah masif
pemberian bikarbonat berlebihan
hungry bone syndrome.
Pengobatan
hipokalsemia
Bila asimptomatik : kalsium oral dan vit D
( agar kadar Kalsium plasma normal )
Bila simptomatik :
i.v. bolus 10 30 cc Kalsium Glukonas 10% dalam 150 cc Dekstrose 5%
selama 10 menit.
Dosis pertahanan : 0,5 2 mg/kgBB/jam
Klinis HIPERKALSEMIA
Dehidrasi
Ensepalopati metabolik
Keluhan saluran pencernaan
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Pengobatan
HIPERKALSEMIA
* Atasi volume deficit
NaCl 2-4 liter perhari selama 48 jam
** Kalau terjadi overload
gunakan furosemide bukan HCT.
* Selama 3- 5 hari hidrokortison IV 200-300 mg
Akan menurunkan kalsium secara cepat.
** Mencegah resorbsi tulang bifosfonat,
calcitonin.
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OSMOLARITAS
Osm = 2 ( Na + K ) + GDS + Ureum ( mOsm )
18
6
Fluid Deficit ( FD ) : Osm 295 x 0,6 x BB
295
Catatan :
Hitung Osmolaritas ini tidak selalu dapat
menggambarkan FD yang sebenarnya krn
tergantung kadar GDS dan Ureum.
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BGA NORMAL :
pH : 7,35 7,45
BE : +2 s/d -2
PaCO2 : 35 45 mmHg
BICNAT :
Koreksi : 0,5 x BE x 0,3 x BB = ..mEq
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NUTRISI PADA
PASIEN KRITIS
Physiologic benefit
Potential Physiologic
Risk
Protein
catabolism
Ensure adequate
substrate for acute
phase response,
gluconeogenesis,
wound healing,
immune function
Functional tissue
loss,
hypoalbuminemia
Hyperglycemia
Ensure substrate
availabiility
Hypoalbuminemia,
hyperglycemia, osmotic
diuresis, immune
dysfunction
Maintain iv volume
Hyponatremia,
hypervolemia, pulmonary
edema, CHF,
Hypokalemia, Hypo
Mgemia
Cardiac work,
myocardial ischemia,
arrhythmia
Microvasc thrombosis, DVT,
dan CARS
Inflamasi yang
hebat
Katabolisme
protein
Supresi sistim imun
Disfungsi organ
Gagal Organ
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Adaptive response
Anabolic phase
Cytokines reduction
Hormonal response
gradually diminishes
gluconeogenesis
catecolamines
aldosterone and ADH
Salt and water loss
insulin and glucagon
protein anabolism
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Lama perawatan di
ICU & RS
Morbiditas
Mortalitas
Biaya alat dan
obat2an
Biaya perawatan
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2. Tentukan jenis
substrat nutrisi yang
diperlukan
Evaluasi kebutuhan
kualitatif
3. MONITOR
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Substrat nutrisi
Kebutuhan energi,
cairan dan elektrolit
Air cc/kgBB/hari
Jumlah
20-25 (kritis)
30 50
Energi
Kcal/kgBB/hari
20-25 (kritis)
30 50
As.Amino/prot
Gr/kgBB/hari
1,2 1,5
Na meq/kgBB/hari
1 -2
K meq/kgBB/hari
Glukosa : lemak
3:1 - 1;1
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:
:
:
:
:
BB ( kg )
= kg/m2
TB (m) kuadrat
malnutrisi
Underweight
Normoweight
Overweight
> 29
KEBUTUHAN PROTEIN
Anjuran: 0.6-0.8 g/kg/bb/h normal; 0.8-1.0 dirawat; 1.1-1.5
untuk severe burn saja. (Untuk perhitungan gunakan IBW)
mengganti >1.5 g
Diperlukan AA esensial (Val, Le, IsL, Tre, Tri, FA, Mt, His, Lys)
BCAA (v,l,il) /AAA (ty,tr,fa) untuk mencegah false
neurotransmitter ( octopamine + -feniletanolamine)
Kebutuhan Lemak
Diperlukan lemak ( kalori kompak, membran, f.s.vit, palatable )
Komposisi lemak makanan 35% SF, 40%MUFA, 15% PUFA
EFAD perlu dicegah
EFAs : aa linoleat, linolenat, arachidonat prostaglandin, prostaCyclin, thromoboxan, leukotrienes.
Masukan tak lebih dari 30% kalori total
NUTRISI POST OP :
1. GUT FEEDING (post op hari I ) : 10 -15 cc D5% / jam selama 4 jam
. jika residu (-) dinaikkan menjadi 50 cc / 4 jam.
2. ENTERAL NUTRISI
3. PARENTERAL
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POTACOL-R @ 500 cc
-5 % maltose dalam RL
-Maltose : 50 gr/L
-Na 130 mEq/L
-K 4 mEq/L
-Kalori : 200 Cal /L
-Osm : 412
-Suplai kalori
-Pengganti ci ekstra seluler
-Perbaiki asid metabolik
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AMINOLEBAN : @ 500cc
- As amino essensial = non essensial
-Tot as amino : 79,9 gr/L
- Karbohidrat ( sorbitol ) : - gr/L
-Tot Kalori : - Elektrolit & vitamin (-)
- Osmolaritas : 768 mOsm/L
- Ensefalopati hepatikum, sepsis, ggg fungsi
hati
COMAFUSIN HEPAR
- Dosis tinggi as amino rantai cabang
- Xylitol
- Vitamin
- Elektrolit
- Precoma & coma hepatikum
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AMIPAREN : @ 500cc
- As amino essensial > non essensial
-Tot as amino : 100 gr/L
- Karbohidrat ( sorbitol ) : -Tot Kalori : - Elektrolit & vitamin (-)
- Osmolaritas : 888 mOsm/L
- Suplai as amino, malnutrisi, pasca bedah
LEMAK
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Manitol @ 500 cc
Manitol 200 g/L
Osm : 1098 mOsm/L
Menurunkan TIK, tingkatkan diuresis
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CAIRAN KOLOID :
FIMAHES 6 % @ 500 ml
HEMOHES 10 % @ 200 ml
Expafusin 6 % @ 500 ml ( HES 40 )
HAES STERIL 6 % @ 500 ml
GELOFUSIN @ 500 ml
Pemberian KOLOID max : 20 cc/kgBB/hr
Ggg koagulasi
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SINDROMA KORONER
AKUT ( SKA )
5
-
SUBSET/MANIFESTASI IHD :
Silent angina ( asimtomatis )
Angina Pektoris Stabil ( APS )
Angina Pektoris tak stabil ( APTS )
Infark miokard NSTEMI ( Non Q )
Infark miokard ST Elevasi ( STEMI /Q
atau
STEMI
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Karakteristik Nyeri :
APS :
nyeri dicetuskan aktifitas ttt
Dalam 30 hr tdk ada perubahan frekuensi,
lama, fc pencetus
Lama nyeri </= 15 menit
APTS :
o Terdapat perubahan pola : frekuensi, durasi,
beratnya nyeri & fc pencetus ( PROGRESIF &
CRESENDO ), perlu obat dg dosis lebih besar
o Rest angina
o Lama > 20 menit
o Angina berat onset baru ( CCS III )
Nyeri > 20 menit : sudah sebabkan infark .
NSTEMI & STEMI , nyeri > 20 menit
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DIAGNOSIS INFARK :
o Ax : karakteristik nyeri dada ( > 20 mnt, tak
berhub dg aktif & tdk hilang dg nitrat )
o Perubahan khas EKG
o Perub enzim > 1 kali
CKMB meningkat ( tjd stlh 4 jam )
Troponin T lebih spesifik
- Ditegakkan jika memenuhi 2 dari 3 kriteria
- Perubahan EKG lebih dulu dp perub enzim
SEHINGGA pengobatan Trombolitik tdk perlu
tunggu enzim. OK trombolitik hrs < 12 jam
( bahkan sebaiknya < 6 jam=golden period )
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PRINSIP TERAPI
APS : Goal : keseimbangan suplai & demand
- Perbaiki suplai : ACEI, Ca antag, Nitrat
- Menurunkan demand : B Bloker, KI :
asma
- Kurangi risiko trombosis : antiplatelet
UA / NSTEMI : Sama dg APS + stabilisasi plaq
( double
platelet =Aspirin/Ticlopidin
+ Clopidogrel )
STEMI : Sama dg diatas
+ REFERFUSI
+Heparin
/ LMWH
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HEPARIN
AMI yg > 12 jam :
-Heparin bolus 5000 U slnjtnya 1000 U jam ( PTTK 50
70 det )
-ASA 160 / 24 jam
-ISDN 10 mg / 8 jam ( sss kan tensi )
-Laxadin syr CI / 24 jam
-Diazepam 5 mg / 24 jam
-Ticlopidin 250/24 jam atau Plavix 1 tab / 24 jam
-Puasa 8 jam diet cair 1300 kkal naikkan bertahap
Dosis heparin 500, 750, 1000, 1250, 1500 sss PTTK
Diberikan selama 4 5 hari
Sljtnya antikoagulan oral utk 3 6 bln ( monitor INR lho
)
Monitor PTTK / 12 jam. EKG / 24 jam
HEPARIN 1 vial = 5 cc = 25 .000 IU
SP Program x Pengenceran
= . ml / jam
Vol obat yg di sedot x 5000
Heparin di encerkan dalam D 5 % menjadi 20 cc atau 50
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PTTK :
< 1,5 dari standar Heparin
dinaikkan 250 U
2x1,5 dari standar tetap
> 2 x 1,5 dari standar Heparin
diturunkan
INFUS
PUMP
INFUS
Or PTTK
: 50 +75
det ( DRIP
ttp ), < 50 (dinaikkan),
I.
x vol infus = . ml /jam
> 75Program
(turunkan)
Vol obat disedot x 5000
II. X kali fc ttsan ( 20 or 15 ) = .
60 menit
Vol infus x fc ttsan ( 20 or 15 ) = tts/ menit
60 menit
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KI MUTLAK :
Perdarahan aktif or br alami perdarahan
CVA < 6 bln
Pembedahan / trauma < 10 hari
Biopsi perkutaneus , 2 mg
Ht berat ( Sistolik > 200 mmHg, Diastolik > 110 mmHg
Baru alami infeksi streptokokus, mis DR
Glomerulonefritis akut atau kronis yg telah dpt po
streptase >
5 hr & < 6 bln
Berbagai kondisi yg ancam jiwa
KI RELATIF
oKehamilan
oRetinopati diabetik proliferasi
oEndocarditis bakterialis
oGg hemostasis ( Trombo < 20.000, > 50.000 dg
perdarahan )
oGg Hepar & Ginjal berat
oDicurigai ada trombus pd bag kiri jantung ( mis MS dg
JIKA
NYERI
DADA
>> :
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Backward failure
Impedance
Cardiac output
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PRINSIP
PENANGANAN
:
UMUM
: Reperfusi
miokard
Perbaiki pertuk gas
Koreksi hipoksia
KHUSUS
: Kontraktil miokard
Pre load , After load
Impedance , Oedem paru
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OBAT
KONTRAKTIL MIOKARD
Lung edem
Dopamin : bila hipotensi (+)
Penghambat PDE :
Amrinon & Milrinon
Klp Digitalis : bila AF (+)
OBAT
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PRE LOAD
Kelompok nitrat
Venodilatasi
Redistribusi (+)
Pre load
Efek arterial sekunder
Diuretika : pre load , elektrolit ,
CO , SRA , impedance
Kombinasi gagal
+ dobutamin
OBAT
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OBAT
KONGESTI PARU
Kelompok nitrat
Dilatasi V sistem + paru
Redistribusi
Kongs paru
Morfin : simpatikolitik
Pomp resp + flebot farmakolo (+)
venous return
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PRINSIP TATALAKSANA
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Obat tambahan
I
II
III
Kaptopril
Kaptopril, nitrat (parentral)
Kaptopril, nitrat (parentral), morfin,
furosemid (parentral), dobutamin,
dopamin (dosis rendah)
Nitrat (parentral), furosemid (parentral),
dobutamin, dopamin (dosis tinggi),
digitalis (?)
IV
IMA
Disf sistol
GJ
LVAD
ARITMIA
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APPROACH :
1. Macam disritmia ( nilai EKG 12 lead )
2. Ada tdknya ggg hemodinamik ancam jiwa
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NSR
A
Flutter
SINUS BRADIKARDI
A Fibrilasi
SVT
SINUS TAKIKARDI
VT
VF
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Asystole
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VES multifokal
VES salvo
VES, R on T
PENANGANAN
ARITMIA
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SVT :
Gel P tersembunyi dlm gel T ok frekuensi
sgt cepat
( 151 250 x / menit )
Terapi : ( versi UPJ )
TANPA GGG HEMODINAMIK
o Manuver valsava ( masagge sin
karotikus ). Hati2 : jk ada bruit : ada
plak,bl dimasagge Ruptur SYOK
o Jika tdk berhasil :
ATP 6 mg bolus cepat tanpa pengenceran
( < 3 dtk )
Tunggu 5 menit : tdk berhasil : ulang 12
mg
CARA LAIN :
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ATRIAL FIBRILASI
Gel P tak teratur, tdpt perbedaan interval &
tinggi gel P
Tjd ok peningkatan iritabilitas semua sel jantung
dlm atrium ( byk t4 yg memulai impuls ) tdk
semua dihantarkan ( depolarisasi atrium tdk
sempurna ), hanya timbul getaran shg gel P
hanya seperti garis gelombang
Dlm menghitung frekuensi, yg dihitung adalah
RESPON VENTRIKEL ( dihitung jumlah QRS
complek dlm lead II panjang )
Frek gel P : 380 600 / mnt
Respon Ventrikel : N ( 60 -100x/mnt ), CPT ( >
100 x /mnt )
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PRINSIP PENGOBATAN AF :
HEMODINAMIK BAIK
1.Kontrol Rate
2.Konversi ke sinus
3.Prevensi stroke / Tromboemboli
HEMODINAMIK TERGANGGU : DC SYOK
KONTROL RATE : ( VERSI UPJ )
1.LANOXIN 0,5 mg / 0,25 mg diencerkan dg D5% 10
cc Injeksi lambat ( 10 mnt ). Jika HR <
100x/mnt STOP ganti oral
@ 1 amp = 0,5 mg. MONITOR EKG lead II
Jika TABLET :
Digoksin Loading Dose : 2 : 1 : 1 tiap 6 jam Sljutnya
maintena (1/2 tb/12 jam)
Keuntungan : Absorbsi 100 %. Hati2 : intoksikasi Digitalis
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VES
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o VES MALIGNA :
- > 5 / menit
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VES :
Bila Frekuensi irama dasar BRADIKARDI, VES dpt
merupakan
upaya jantung me + frekuensi jtg agar sirkulasi
adekuat.
Tdk semua VES memerlukan pengobatan .
Dianggap berbahaya jika :
- VES Maligna
- Kejadian VT
- Hemodinamik tak stabil
TERAPI : ( ICU / UPJ )
JIKA HEMODINAMIK BAIK
LIDOKAIN / XYLOCAIN : memperlambat
repolarisasi
Bolus 1 1,5 mg / kg BB diencerkan . Ulang tiap 3
menit dengan dosis dss awal. Max 3 mg/kgBB
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VT
asal dari 1 tempat di ventrikel ( Frek : 41 250 )
Gel P (-)
QRS lebar & bizzare
VF :
asal dari byk tempat di ventrikel
tdk ada waktu depol/gel P (-) & repol/ QRS (-), PR
int (-), PP
RR int (-)
grs2 gel kacau
TORSADE : VT yg mendekati VF
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PENGELOLAAN VT :
Umum : - rawat ICU
- O2 2 3 ltr/mnt
- Infus line D5%
- diet Lunak
KHUSUS :
Hemodinamik baik : XYLOCAIN : Bolus 1 1,5 mg / kg
BB diencerkan
tunggu 15 mnt
Hemodinamik BURUK :
Pulse (+) : DC shock 50 100 J ( sincronized:
deteksi QRS )
Pulseless : terapi sss VF, DC shock 200 300 J
asincronized 360 J
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BRADIARITMIA
o Sulfas Atrofin 0,4 atau 0,5 mg iv tiap 5 menit, max
2,4 mg
o SA 1 ampul = 1 cc = 0,25 mg
o SA dosis kecil berefek BRADIKARDI, dosis > 2 mg berefek
TAKIKARDI
ATAU :
ALUPENT ( ORCIPRENALINE ) ampul iv bolus , bl
respon (+) teruskan drip : 5 amp + 500 cc D5%
Adrenalin
12 tts / menit
Dosis
0,1
mg/kgBB/mnt
bertahap tiap 10
Sediaan
Alupent
tab : 20 dinaikkan
mg
mnt bl
HR blm naik. Max 0,4 mg / kgBB/mnt. Sasaran HR
100x/mnt
Sediaan: 1amp: 1 cc=1 mg
SP : Program x BB x Pengenceran x 60 mnt
x ampul x 1000
Indikasi :
-AV blok derajad III/ blok total
-Jk respon (+) Adrenalin tapp off selanjutnya ganti Efedrin 50 mg / 8
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Antidotum :
Pengobatan
Pengobatanawal
awal::
Nebulizer
Nebulizer2-agonis
2-agoniskerja
kerjapendek
pendek//20
20menit
menitselama
selama11jam
jam
Oksigen,
Oksigen,targen
targenSa
SaO2
O2>>90%
90%
Serangan
Seranganberat
beratsistemik
sistemiksteroid
steroid
Penilaian
Penilaianulang:
ulang:
APE,
APE,FEV1,
FEV1,SaO2
SaO2
Serangan
Serangansedang:
sedang:
inhalasi
inhalasi2-agonis
2-agonisdan
dan
Antikolinergik
Antikolinergik/ /60
60menit
menit
Pertimbangkan
steroid
Pertimbangkan steroid
Respon
Responbaik:
baik:
Dipulangkan
Dipulangkan
Serangan
Seranganberat
berat::
inhalasi
inhalasi2-agonis
2-agonisdan
dan
Antikolinergik
Antikolinergik/ /60
60menit
menit
Sistemik
2-agonis,
Metilsantin
Sistemik 2-agonis, Metilsantiniv,
iv,Mg
Mgiv
iv
Respon
Responsebagian
sebagian1-2
1-2jam:
jam:
Rawat
Rawatinap
inap
Klinik
Klinikmemburuk
memburukrawat
rawatICU
ICU
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Oksigen
Infus aminofilin
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PATOFISIOLOGI
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Pre load
After load
Kontrak jnt
Frek jantung
Curah jantung
Auto regul
Tekanan darah
Viabilitas
Perfusi jaringan
25 %
6 12 jam
Td diast :
110 100 mmHg
bbrp hari
+ OATDTO
Normotensif
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Acute heart failure ( AHF ) :
sindroma klinik yang ditandai dengan :
penurunan cardiac output
hipoperfusi jaringan
peningkatan tekanan kapiler paru (PCWP) dan
kongesti jaringan.
Clinical
Clinicalsigns:
signs:Shock,
Shock,hypoperfusion,
hypoperfusion,
Congestive
heart
failure,
acute
Congestive heart failure, acutepulmonary
pulmonaryedema
edema
Most
likely
problem
?
Most likely problem ?
Acute
Acutepulmonary
pulmonary
edema
edema
11ststAcute
Acutepulmonary
pulmonaryedema
edema
Furosemide
iv
0.5
1.0
Furosemide iv 0.5 1.0mg/kg
mg/kg
Morphine
iv
2
4
mg
Morphine iv 2 4 mg
Nitroglycerin
NitroglycerinSL
SL
Oxygen/intubation
Oxygen/intubationasasneeded
needed
Systolic
SystolicBP
BP nd
BP
defines
BP defines22nd
Line
Lineofofaction
action
(see
below)
(see below)
Volume
Volumeproblem
problem
Administer
Administer: :
Fluids
Fluids
Blood
Bloodtransfusions
transfusions
Cause-specific
Cause-specificinterventions
interventions
Consider
vasopressors
Consider vasopressors
Systolic
SystolicBP
BP
<<7070mmHg
mmHg
Signs/symptoms
Signs/symptoms
ofofshock
shock
Systolic
SystolicBP
BP
7070toto100
100mmHg
mmHg
Signs/symptoms
Signs/symptoms
ofofshock
shock
Pump
Pumpproblem
problem
Rate
Rateproblem
problem
Bradicardia
Bradicardia Tachycardia
Tachycardia
Blood
Blood
See
algorithm
See
algorithm
Pressure
Pressure?? See algorithm See algorithm
Systolic
SystolicBP
BP
7070toto100
100mmHg
mmHg
No
sign/symptoms
No sign/symptoms
ofofshock
shock
Systolic
SystolicBP
BP
>>100
mmHg
100 mmHg
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Systolic
SystolicBP
BP nd
BP
defines
BP defines22nd
Line
Lineofofaction
action
(see
below)
(see below)
Systolic
SystolicBP
BP
<<7070mmHg
mmHg
Signs/symptoms
Signs/symptoms
ofofshock
shock
Norepinephrine
Norepinephrine iviv
0.5
0.53030mcg/min
mcg/min
Systolic
SystolicBP
BP
7070toto100
100mmHg
mmHg
Signs/symptoms
Signs/symptoms
ofofshock
shock
Dopamine
Dopamine iviv
551515mcg/kg/min
mcg/kg/min
Systolic
SystolicBP
BP
7070toto100
100mmHg
mmHg
No
sign/symptoms
No sign/symptoms
ofofshock
shock
Dobutamine
Dobutamine iviv
222020mcg/kg/min
mcg/kg/min
22ndnd- -Acute
Acutepulmonary
pulmonaryedema
edema
Nitroglycerin
/
nitroprusside
if
Nitroglycerin / nitroprusside ifBP
BP>>100mmHg
100mmHg
Dopamine
if
BP
70
100
mmHg,
signs/symptoms
Dopamine if BP 70 100 mmHg, signs/symptomsofofshock
shock
Dobutamine
if
BP
>
100
mmHg,
no
signs/symptoms
of
Dobutamine if BP > 100 mmHg, no signs/symptoms ofshock
shock
Further
Furtherdiagnostic
diagnostic/ /therapeutic
therapeuticconsideration
consideration
Pulmonary
artery
catheter
Pulmonary artery catheter
Intra-aortic
Intra-aorticballoon
balloonpump
pump
Angiography
for
AMI
Angiography for AMI/ /ischemia
ischemia
Additional
diagnostic
studies
Additional diagnostic studies
Systolic
SystolicBP
BP
>>100
mmHg
100 mmHg
Nitroglycerin
Nitroglyceriniviv
10102020mcg/min
mcg/min
Consider
Consider
Nitroprusside
Nitroprussideiviv
0.1-5
0.1-5mcg/kg/min
mcg/kg/min
Dedicated to mykynaocc
1. Gagal jantung kongestif akut dengan tanda dan gejala AHF yang
ringan dan tidak memenuhi kriteria cardiogenic shock, pulmonary
oedema atau hypertensive crisis.
2. Hypertensive AHF : tanda dan gejala gagal jantung disertai
tekanan darah yang tinggi dan radiologis thorax menunjukkan
edema paru akut.
3. Edema Pulmo (verified by chest X-ray) disertai severe respiratory
distress, dengan ronki basah diseluruh paru dan orthopnoe,
dengan saturasi O2 biasanya < 90 % pada suhu ruangan sebelum
terapi.
4. Syok Kardiogenik : keadaan dimana terjadi hipoperfusi jaringan
yang diakibatkan oleh gagal jantung.
Tidak ada definisi yang jelas mengenai parameter hemodinamik
namun biasanya ditandai dengan : penurunan TD (systolic BP
<90mmHg atau MAP Turun >30mmHg) & atau Oliguria
(<0.5ml/kg/h), with a pulse rate >60b.p.m. dengan atau tanpa
kongesti organ.
5. High output failure biasanya pada keadaan : high heart rate
(caused by arrhythmias, thyrotoxicosis, anaemia, Paget's disease,
iatrogenic or by other mechanisms),dengan perifer hangat,
Dedicated to mykynaocc
Medical treatment
Dedicated to mykynaocc
1. Morphine , jika ingin diambil efek sedasi
2. Vasodilators in the treatment of AHF (first line terapy)
3.Calcium antagonists TIDAK DIREKOMENDASIKAN
4. ACE-inhibitors TIDAK DIINDIKASIKAN untuk stabilisasi
awal.
5. Diuretik
6. Inotropik
Glyceryl
trinitrate, 5mononitrate
Isosorbide
dinitrate
Nitroprusside
Nesiritide
Indication
Dosing
Main side
effects
Other
Hypotension,
headache
Tolerance on
continuous
use
Hypotension,
headache
Tolerance on
continuous
use
0.35g/kg/min
Hypotension,
isocyanate
toxicity
Drug is light
sensitive
Bolus 2 g/kg +
infusion 0.015
0.03 g/kg/min
Hypotension
Start 20 g/min,
increase to 200 g/min
Dedicated to mykynaocc
NITRAT
SYRINGE PUMP
Mulai dosis 10
mikro
dinaikkan 10
mikro tiap 10
menit
Dedicated to mykynaocca
DOSIS
( mikrog
r)
SYR
PUMP
DOSIS
SYR PUMP
10
0,6
150
9,0
20
1,2
160
9,6
30
1,8
170
10,2
40
2,4
180
10,8
50
3,0
190
11,4
60
3,6
200
12
70
4,2
210
12,6
80
4,8
220
13,2
90
5,4
230
13,8
100
6,0
240
14,4
110
6,6
250
15
120
7,2
260
15,6
130
7,8
270
16,2
140
8,4
280
16,8
290
17,4
Dedicated to mykynaocc
Dobutamin/Dobutrex/Dobujec
Sediaan:
Dobutrex : 1 vial
: 20 cc=250 mg
Dobujec: 1 ampul : 5 cc= 250 mg
Dosis: 5-10 mikrogram/kg BB/mnt
Syring pump:
(Dosis x BB x pengenceran x 60): 250.000=
ml/jam
Drip infus:
(dosis x BB x 60 x vol infus):250.000= A ml/jam
(A
x tetes (15/20)):60=. tts/mnt
Norpinephrin/Levoped/Vascon
Dedicated to mykynaocc
Dedicated to mykynaocc
KOMPLIKASI AKUT DM
HIPERGLIKEMI
HIPOGLIKEMI
Edema cerebri
Kerusakan SSP
KETOASIDOSIS
LAKTOASIDOSIS
Kontraktilitas miokard
Cardiac output
Tensi
Perfusi ke organ2
Respons vaskuler thd katekolamin
Syok hipovolemi
HIPEROSMOLER
Syok hipovolemi
Trombo-emboli
KETOASIDOSIS
HIPEROSMOLER
LAKTOASIDOSIS
TERAPI
Insulin ( prioritas pembahasan )
Lain-lain :
Cairan
Elektrolit
Nutrisi
Antibiotika
LABORATORIUM
KAD
HONK
> 250
> 600
pH
< 7.3
> 7.3
< 15
> 20
Keton urine
3+
1+
Keton serum
Bervariasi
330
130 140
145 155
56
45
18 - 25
20 - 40
BUN (mg/dl)
50% i.v
Dedicated to mykynaocc
Continous
infusion
Banyak diminati
dalam praktek
efek terapi cepat
komplikasi minimal
Hipoglikemi
Hipokalemi
0.1 u/kgBB/jam me insulin plasma memenuhi
(100 200 u/mL)
kapasitas maksimal
reseptor insulin
am
r
og
Glukosa (< 50-100 mg/dl) dosis (2x)
r
ip
r
IA da
S
N sis
Dosis s/d 100 u/jam + kortikosteroid
A
L do
(menekan resist. Insulin)
mencegah hipoglikemi
menekan ketoasidosis
Dedicated to mykynaocc
DEHIDRASI
REHIDRASI
Koreksi
Sliding Scale
@ 4 jam
s.c
> 300 mg/dl
20 u
Short acting
3x / hari
30 menit sebelum
porsi makan utama
Intermediate acting
malam hari
15 20 unit
Dedicated to mykynaocc
KRISIS TIROID
Trias kecurigaan
krisis:
stroke )
KRISIS TIROID
Dedicated to mykynaocc
Indeks utk status fungsi tiroid :
Indeks Wayne
Gejala
Skor Y / N
Sesak bila bekerja
+1
Berdebar-debar
+2
Kelelahan
+2
Lebih suka udara panas
Lebih suka udara dingin
+5
Keringat berlebihan
+3
Keguguran
+2
Tanda
Skor Y / N
Kelenjar tiroid teraba
Bising kelenjr tiroid
Exopthalmus
-5
Kelopak mata ketinggalan
Gerakan hiperkinetik
Tangan panas
Tremor halus jari
Tangan basah
Nafsu makan bertambah
+3
Fibrilasi atrium
Nafsu makan berkurang
-3
Nadi teratur :
BB naik
-3
< 80 x / mnt
BB turun
+3
80-90 x / mnt
> 90 x / mnt
Nilai < 10 : eutyroid, Nilai 10 19 : meragukan, Nilai > 20 : HIPERTIROID
+3 / -3
+2 / -2
+2
+1
+4 / -2
+2 / -2
+1
+1 / -1
+4
0
+3
-3
0
Dedicated to mykynaocc
2.
3.
4.
5.
6.
bergerak keatas.
Darlympe : Retraksi kelopak mata atas ( membelalak )
Stelwag : Mata jarang berkedip
Moebius : Kelemahan akomodasi
Von Graefe
: Kelopak mata terlambat turun dibanding
bola mata
Rusenbach
: Tremor kelopak mata sewaktu mata
tertutup.
Pembertons Sign :
Bila kedua tangan diangkat keatas, struma akan menekan vasa
shg
terbentuk bendungan darah didaerah muka & otak, shg
penderita
pusing pusing sampai sinkop.
Dedicated to mykynaocc
PRINSIP PENGOBATAN :
1. Koreksi Hipertiroidisme
2. Normalkan mekanisme homeostasis yg terganggu ( ci,elekt )
3. Obati faktor pencetus
Secara rinci :
o
Umum : Cairan rehidrasi dan koreksi elektrolit, kalori, vitamin,
oksigenasi.
o
Koreksi hipertiroidisme dg cepat :
- Blok sintesis ho tiroid : PTU dosis besar ( loading dose 600 1000 mg ) diikuti
200 mg tiap 4 jam dg dosis total sehari 1000 1500 mg. Cara pemberian :
DI GERUS
- Blok keluarnya simpanan ho tiroid : LUGOL ( 10 tts tiap 6-8 jam ) atau SSKI
( Kalium Yodida pekat ) 5 tts tiap 6 jam. Jk ada NaI : injeksi 1 gr/8-12 jam
- Hambat konversi T4 mjd T3 diperifer : Propanolol 20 40 mg/6 jam
o
Hidrokortison dosis stres ( 100 mg/8 jam atau Dexametason 2 mg/6jam). Alasan
: tjd def steroid relatif
o
Antipiretik : Acetaminofen. NO ASPIRIN ok akan berkompetisi dg ho tiroksin utk
berikatan dg TBG shg meningkatkan kadar T4 ( tiroksin ) bebas
o
Jk ada AF : digoksin
o
Obati fc pencetus
Dg pengobatan adekuat : 12 24 jam akan alami perbaikan ( suhu,frek nadi turun,
kesadaran membaik ). Membaik dlm waktu 5 7 hari.
Dedicated to mykynaocc
Koma miksedema
( as severe form of prolonged hypothyroidism )
Dedicated to mykynaocc
Komplikasinya :
Koma
Hipotensi
Hipoventilasi
Gagal jantung
Kelainan elektrolit
Hipotermi
Bradikardia
Hiponatremia
Hipoglikemia
PENCETUS :
Infeksi sistemik berat
Paska pembedahan
Efek samping obat narkotika
Akibat obat hipnotika
Dedicated to mykynaocc
Penanganan
koma miksedema
Dosis permulaan : LTiroksin 300 500
ug intra vena
Dosis pertahanan :50 - 100 ug L T4 @
hari
Karena konversi T4 ke T3 gagal pada
keadaan berat ini, berikan L T3 : 12,5
ug intra vena setiap 6 jam
Atasi dehidrasi dan kelainan elektrolit
Atasi infeksi dan pemberat
Dedicated to mykynaocc
OBAT- OBAT
EMERGENSI ICU
EPINEPHRINE
Dedicated to mykynaocc
Meningkatkan :
Resistensi vaskuler sistemik
TD diastolik & sistolik
Electrical activity in the myocardium
Coronary and cerebral blood flow
Strength of myocardial contraction
Myocardial oxygen requirements
Automaticity
INDIKASI :
Cardiac arrest from : VF or Pulseless VT
unresponsive to initial
countershocks, asystole, PEA
Symptomatic bradycardia
DOSIS & CARA PEMBERIAN :
o 1 mg IV, repeated every 3-5 minutes
o During cardiac arrest and symptomatic bradycardia
profound hypotension :
continuous infusion, 30 mg Epinephrine HCl added to 250
mL of normal saline
ATROPINE
Dedicated to mykynaocc
A parasympatholytic drug
Enhances both sinus node automaticity and AV conduction via
its vagolytic action
INDIKASI :
Initial therapy for symptomatic bradycardia
In 1st degree AV block, Mobitz type I AV block and bradyasystoloc cardiac arrest :
excessive vagal stimulation.
DOSIS & CARA PEMBERIAN :
Without cardiac arrest : 0.5 1 mg,IV. Repeated at 5 minutes
interval.
Brady-asystolic cardiac arrest : 1 mg IV. Repeated every 3 5
minutes.
HATI
- HATI :
Induce tachycardia
Administered with caution in the setting of myocardial
infarction
Excessive doses can cause : anti-cholinergic syndrome of
delirium, tachycardia,
come, flushed, hot skin and blurred vision
LIDOCAINE
Dedicated to mykynaocc
INDIKASI :
Ventricular ectopy, wide complex tachycardias, ventricular
tachycardia and VF.
Pulseless VT and VF that is refractory to electrical therapy and
epinephrine.
Patient with significant risk factors for malignant ventricular
arrhythmia.
Routine
DOSIS
& CARA
PEMBERIAN
:
prophylactic
Lidocaine
therapy in patient with AMI can
noInitial
longerdose
be : 1,0 1,5 mg / kg I.V. bolus
recommended.
Via ETT : 2 2,5 x IV dose
Second bolus : 0,5 0,75 mg / kg after 10`
Additional bolus : 0,5 0,75 mg/kg every 5 ` -10` (if arrhythmia
persists), until total
dose: 3 mg/kg.
Continuous iv infusion: 2-4 mg/min (spontaneous circulation).
HATI - HATI :
Neurological change
Myocardial & circulatory depression
ADENOSINE
Dedicated to mykynaocc
INDIKASI :
Terminating SVT that involve a re-entry pathways including
the AV node
DOSIS & CARA PEMBERIAN :
Initial dose : 6 mg rapid bolus over 1-3 followed quickly by
20 ml saline flush
Repeat dose : 12 mg, if no response within 1 2 minutes
Patients taking theophylline are less sensitive
HATI HATI :
Flushing, dyspnea, chest pain ( usually resolve within 1 2
minutes )
Transient bradycardia and ventricular ectopy
Produce few hemodynamic effects
VERAPAMIL
Dedicated to mykynaocc
INDIKASI :
Terminates SVT by direct effects on the AV node
Slows ventricular response to atrial flutter and fibrillation
DOSIS & CARA PEMBERIAN :
Initial dose : 2,5 5 mg bolus over 1-2 minutes,slowly
Repeat dose : 5 10 mg in 15-30 minutes after first dose
5 mg bolus, every 15 minutes, until response or total dose 30 mg
HATI HATI :
Atrial flutter / fibrillation with WPW syndrome
VT , may induce hypotension or VF
Hypotension , A-V block
AMIODARONE
Dedicated to mykynaocc
INDIKASI :
Ventricular rate control of rapid atrial arrhythmia in
patients with severely impaired LV function, and in
patients with accessory pathway conduction.
Cardiac arrest with pulseless VT or VF ( after
defibrillation and epinephrine )
hemodinamically stable VT
polymorphic VT
Wide-complex tachycardia of uncertain origin
AMIODARONE
DOSIS & CARA PEMBERIAN :
Initially, 150 mg. I V. over 10 minutes,Repeated 150 mg, as
necessary, for recurrent or
resistant arrhythmia
Followed by 1 mg / min infusion (6 hrs). Then, 0,5 mg / min
Max. daily dose : 2 grams
In cardiac arrest due to pulseless VT or VF :
o Initially , 300 mg, rapid infusion, diluted in 20-30 ml saline or
D5W.
o Repeated, 150 mg for recurrent or refractory VT/VF.
o 1 mg / min ( 6 hrs ), then 0,5 mg/min. Max. daily dose: 2 grams
HATI HATI :
- Hypotension
- Bradicardia
- Heart block
Dedicated to mykynaocc
VASOPRESSIN
Dedicated to mykynaocc
INDIKASI :
Shock-refractory VF ( II b)
DOSIS & CARA PEMBERIAN :
40 U, I.V. single dose, 1 time only
Sod. Bicarbonate
Dedicated to mykynaocc
Buffer agent
CO2 generated, during CPR when the transport of CO2 to and
from the lung is
decreased
INDIKASI :
Tissue acidosis resulting acidemia during cardiac arrest and
CPR, it depends on the duration of cardiac arrest and the level
of blood flow during CPR
DOPAMINE
Dedicated to mykynaocc
DOPAMINE
Dedicated to mykynaocc
DOBUTAMINE
Dedicated to mykynaocc
MORPHIN SULPHATE
Dedicated to mykynaocc
Reduce anxiety
Reduce pain and ischemia
Increase venous capacitance
Decrease systemic vascular resistance
Lead to reduced oxygen demands, less ischemia and
infarct extension
INDIKASI :
o Pain and anxiety associated with AMI
o Acute cardiogenic pulmonary edema
DOSIS & CARA PEMBERIAN :
o 1-3 mg, at frequent intervals as often as every 5 min.
o GOAL : eliminate pain
HATI HATI :
Respiratory depressant
Excessive narcosis can be reverse by : Naloxone ( 0.4
0.8 mg )
NITROGLYCERIN
Dedicated to mykynaocc
ASPIRIN
Dedicated to mykynaocc
Anti-platelet aggregation
Block the formation of thromboxane A2
Reduce overall mortality from acute MI
Reduce nonfatal reinfarction
Reduce nonfatal stroke
KAPAN DIBERIKAN :
As soon as possible !
Standard therapy for all patients with new pain
suggestive of acute M I
Give within minutes of arrival
DOSIS & CARA PEMBERIAN :
160 320 mg tablet, as soon as possible
Emergency or pre-hospital
Dedicated to mykynaocc
RKP / CPR
Dedicated to mykynaocc
CPR
|
pijat jantung 100 x pm
nafas 12 x pm atau
sinkronisasi 15:2
(satu atau dua penolong)
|
pasang monitor ECG
siap DC-shock
|
VF/VT
|
DC shock
|
Asystole / PEA
|
Dedicated to mykynaocc
DEFIBRILATION
DC shock
Un - Synchronized
Synchronized
VF / VT Pulseless
Asystole-withness
AF - SVT
kardioversi
Dedicated to mykynaocc
Dedicated to mykynaocc
PEA
CPR 3 menit
Intubasi, iv line,
adrenalin 1 mg / 3-5 menit
1-1-1 / 1-3-5 mg
|
|
Asystole / PEA
|
ROSC
( Recovery of
Spontaneous Circulation )
CPR 3 mnt
|
|
bradycardia normal
Dedicated to mykynaocc
Cardiac arrest =
carotis (-)
Asystole
= ECG flat,
tak ada gelombang
UNshockable
CPR + adrenalin
(+atropin?)
ROSC < 10%
( Recovery of
Spontaneous
Circulation )
Dedicated to mykynaocc
Dedicated to mykynaocc
PEA =
EMD
P-ulseless
E-lectrical
A-ctivity
E-lectro
M-echanical
D-issociation
VT / Ventricular Tachycardia
|
|
carotis (+)
Lidocain
1 mg/kg iv
cepat
carotis (-)
DC shock
200 Joules
Dedicated to mykynaocca
Dedicated to mykynaocc
VF / VT
Bentuk gelombang
khas
pulseless
VT = Ventricular Tachycardia
VF = Ventricular Fibrillation
DC shock
1. Switch ON
Oles paddles dengan
jelly ECG tipis rata
Dedicated to mykynaocca
Dedicated to mykynaocc
DC
shock
sternum
apex
siap charge
lagi bila
irama masih
shockable
Dedicated to mykynaocc
DC shock
200 Joules
ROSC
|
|
masih VF/VT ROSC ROSC carotis (+)
|
|
200/300 Joules
pertahankan
ROSC
|
oksigenasi
pertahankan
tensi
CPR 1masih
menit, intubasi,
VF/VT iv line, adrenalin 1 mg
intravena, intra-trachea, intra-osseus
RESUME
CPR 1
DC shock 200
- menit,
200/300 - 360
intubasi,
Joules
iv line, adrenalin 1 mgROSC
|
masih VF/VT
|
ROSC
Dedicated to mykynaocc
Dedicated to mykynaocc
DRUGS
adrenalin 1-1-1 / 3-5 menit
atropin 1-1-1 / 3-5 menit
Na-bik hanya 1 mEq/kg dan
paling
akhir
Dedicated to mykynaocc
4H
4T
MA
Hipoksia
Hipovolemia
Hiperkalemia
Hipotermia
Tamponade jantung
Tension
pneumothorax
Thromboemboli
paru
Toxic overdose
B-block, Ca-block
Digitalis, Tricyclic
AD
Dedicated to mykynaocc
GAGAL NAFAS
Dedicated to mykynaocc
GAGAL NAPAS
Dedicated to mykynaocc
Klasifikasi Gagal Napas
I. Gagal Napas Tipe I
(Kegagalan oksigenasi, Hipoksia arterial)
tergantung dari tekanan parsial 02 :
1. Tek. Parsial O2 dalam udara respirasi
2. venttilasi per menit
3. Kuantitas darah yang melewati kapiler paru
4. Saturasi O2
5. Difusi membran alveoler
6. Ventilasi-perfusi
PaO2 < 60 mmHg
Penyebab gagal napas tipe I :
ARDS
Asma
Udema Paru
COPD
Fibrosis intersisial
Pneumonia
Pneumothoraks
Emboli Paru
Hipertensi Pulmonal
Dedicated to mykynaocc
II. Gagal Napas Tipe II
Kegagalan Ventilasi = Hiperkapnia arteri
Peningkatan tekanan parsial CO2 dalam darah arteri (Pa CO2 > 46 mmHg)
Penyebab gagal napas tipe II :
Infark / perdarahan batang otak
Miastenia gravis
SGB
Multiple sklerosis
Flail Chest
Amiotropik lateralis sklerosis
Gagal Napas Tipe III
Kombinasi kegagalan oksigenasi dan kegagalan ventilasi (= kombinasi
hipoksemia dan
hiperkarbia, PaO2 menurun dan PaCO2 menigkat).
Peningkatan perbedaan PAO2 PaO2
Penyebab :
1.
ARDS
2.
Asma
3.
COPD
-
Dedicated to mykynaocc
VENTILATOR
Dedicated to mykynaocc
Ventilator ~ ventilasi
Ventilasi = keluar masuknya udara dari atmosfer ke alveolus
Ventilator = menghantarkan (delivery) udara
udara/gas
/gas TEKANAN
POSITIF ke dalam paru
Ventilasi semenit = TV x RR (frekuensi
(frekuensi nafas)
nafas )
TV
= 5-7 cc/kgBB
cc/ kgBB
RR = 10 12 kali/menit
kali/ menit
Dedicated to mykynaocc
INDIKASI VENTILASI
Mekanik (RR)
> 35x/m
TV (cc/kg)
<5
Oksigenasi (PaO2mmHg)
P(A-aDO2) mmHg
> 350
Ventilasi (PaCO2mmHg)
> 60
NORMAL RANGE
10-20x/m
5-7
75-100 (air)
25-65(FiO2 1.0)
35-45
Dedicated to mykynaocc
Dedicated to mykynaocc
TUJUAN FISIOLOGIS
MEMPERBAIKI VENTILASI ALVEOLAR
MEMPERBAIKI OKSIGENASI ALVEOLAR
(FiO2, FRC,V'A)
MEMBERIKAN PUMP SUPPORT ( ME
WOB)
Consensus conference on mechanical ventilation, Int Care Med 1994,
20:64-79
Dedicated to mykynaocc
Indications for
Mechanical Ventilation
Oxygenation abnormalities
Refractory hypoxemia
Need for positive endexpiratory pressure (PEEP)
Excessive work of
breathing
Dedicated to mykynaocc
Time-cycled breath
Pressure control breath
Constant pressure for preset time
Flow-cycled breath
Dedicated to mykynaocc
Modes of Mechanical
Ventilation
SPONTANEUS
SPONTANEUS VENTILATION
VENTILATION
Dedicated to mykynaocc
Continuous
Continuous Positive
Positive Airway
Airway Pressure
Pressure
(CPAP)
(CPAP)
No
No machine
machine breaths
breaths delivered
delivered
Allows
Allows spontaneous
spontaneous breathing
breathing at
at elevated
elevated baseline
baseline pressure
pressure
Patient
Patient controls
controls rate
rate and
and tidal
tidal volume
volume
Assist-Control
Ventilation
Dedicated to mykynaocc
Pressure-Support
Pressure-Support
Ventilation
Ventilation
Pressure assist during spontaneous inspiration with flow-cycled
breath
Pressure assist continues until inspiratory effort decreases
Delivered tidal volume dependent on inspiratory effort and
resistance/compliance of
lung/thorax
Dedicated to mykynaocc
Pressure-Support Ventilation
Potential
Potential advantages
advantages
Patient
Patient comfort
comfort
Decreased
Decreased work
work of
of breathing
May
May enhance
enhance patient-ventilator
patient-ventilator synchrony
synchrony
Used
Used with SIMV to support spontaneous breaths
Pressure-Support Ventilation
Potential
Potential disadvantages
disadvantages
Variable
Variable tidal
tidal volume
volume if
if pulmonary
pulmonary resistance/compliance
resistance/compliance changes
changes
rapidly
rapidly
If
If sole
sole mode
mode of
of ventilation,
ventilation, apnea
apnea alarm
alarm mode
mode may
may be
be only
only backup
backup
Gas
Gas leak
leak from
from circuit
circuit may
may interfere
interfere with
with cycling
cycling
Dedicated to mykynaocc
Volume
Volume or
or time-cycled
time-cycled breaths
breaths at
at a
a preset
preset rate
rate
Additional
Additional spontaneous
spontaneous breaths
breaths at
at tidal
tidal volume
volume and
and
rate
rate determined
determined by
by patient
patient
Used
Used with
with pressure
pressure support
support
Potential
Potential advantages
advantages
More
More comfortable
comfortable for
for some
some patients
patients
Less
Less hemodynamic
hemodynamic effects
effects
Potential
Potential disadvantages
disadvantages
Increased
Increased work
work of
of breathing
breathing
Spontaneous
Spontaneous breathing
breathing I:E
I:E =
= 1:2
1:2
Inspiratory
Inspiratory time
time determinants
determinants with
with volume
volume breaths
breaths
Tidal
Tidal volume
volume
Gas
Gas flow
flow rate
rate
Respiratory
Respiratory rate
rate
Inspiratory
Inspiratory pause
pause
Expiratory
Expiratory time
time passively
passively determined
determined
I:E Ratio during Mechanical Ventilation
Expiratory
Expiratory time
time too
too short
short for
for exhalation
exhalation
Breath
Breath stacking
stacking
Auto-PEEP
Auto-PEEP
Reduce
Reduce auto-PEEP
auto-PEEP by
by shortening
shortening inspiratory
inspiratory time
time
Decrease
Decrease respiratory
respiratory rate
rate
Decrease
Decrease tidal
tidal volume
volume
Increase
Increase gas
gas flow
flow rate
rate
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Permissive
Hypercapnia
Acceptance
Acceptance of
of an
an elevated
elevated PaCO
PaCO22, e.g., lower tidal volume
to
to reduce
reduce peak
peak airway
airway pressure
pressure
Contraindicated
Contraindicated with
with increased
increased intracranial
intracranial pressure
pressure
Consider
Consider in
in severe
severe asthma
asthma and
and ARDS
ARDS
Critical
Critical care consultation advised
Auto-PEEP
Can
Can be
be measured
measured on
on some
some ventilators
ventilators
Increases
Increases peak,
peak, plateau, and mean airway pressures
Potential
Potential harmful
harmful physiologic
physiologic effects
effects
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