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Pediatri

Nilai normal tanda vital pada anak


Umur Frekuensi Nafas Frekuensi Nadi Tekanan Sistolik Tekanan Diastolik
[x/menit] [x/menit] [mmHg] [mmHg]
Neonatus 30 – 60 105 – 180 60 – 90 20 – 60
1 – 6 bulan 30 – 50 110 – 180 85 – 92 52 – 54
6 – 12 bulan 24 – 46 110 – 170 93 – 95 53 – 55
1 – 4 tahun 20 – 30 90 – 150 86 – 91 40 – 52
4 – 6 tahun 20 – 25 65 – 130 91 – 94 52 – 56
6 – 12 tahun 16 – 20 60 – 120 94 – 105 59 – 62
> 12 tahun 12 - 16 60 - 100 105 - 111 62 - 66
 IDAI. ERIA. Stabilisasi

Glasgow Coma Scale (GCS)


Eye Verbal Motorik

6 Gerakan spontan, mengikuti


perintah
5 Terorientasi, tersenyum, ikuti Lokalisasi Nyeri (rasa sakit)
objek, interaksi berhubungan
4 Spontan Menangis, interaksi tidak tepat, Menarik karena nyeri
menangis tidak konsisten
3 Respon terhadap bicara / suara Interaksi mengerang Dekortikasi
Rewel, tangis persisten, Fleksi abnormal pada sakit
dapat dibujuk, tidak konsisten
2 Respon terhadap nyeri / rasa Menangis tidak berhubungan, Deserebrasi
sakit Interaksi iritable Ekstensi abnormal pada sakit
Tidak tanggap lingkungan,
gelisah, agitasi
1 Tidak ada respon Tidak ada respon Tidak ada respon

Interpretasi Kualitas Kesadaran


15 CM (Compos Mentis)
13 – 14 Apatis
9 – 12 Somnolen
7–8 Sopor
5–7 Koma Soporus
<5 Koma
 Teasdale G.,Jennett B. Lancet 1974;2:81
 Hahn Ys,dkk. Child Nerv Syst 1988;4:34
Four Score
EYE RESPONSE (E)
Grade the best possible response after at least 3 trials in an attempt to elicit the best level of alertness.
[E4] Eyelids open or opened, tracking or blinking to command; indicates at least 3 voluntary excursions. If eyes are
closed, the examiner should open them and examine tracking of a finger or object. Tracking with the opening of 1
eyelid will suffice in cases of eyelid edema or facial trauma. If tracking is absent horizontally, examine vertical
tracking. Alternatively, 2 blinks on command should be documented. This will recognize a locked-in syndrome
(patient is fully aware).
[E3] Eyelids open but not tracking; indicates the absence of voluntary tracking with open eyes.
E2] Eyelids closed but opens to loud voice; indicates eyelids opening to loud voice.
[E1] Eyelids closed but opens to pain; indicates eyelids open to pain stimulus.
[E0] Evelids remain closed with pain; indicates no eyelids opening to pain.

MOTOR RESPONSE (M)


Grade the best possible response of the arms.
[M4] Thumbs up, fist, or peace sign to command; indicates that the patient demonstrated at least 1 of 3 hand positions
(thumbs-up, fist, or peace sign) with either hand.
[M3] Localizing to pain; indicates that the patient touched the examiner's hand after a painful stimulus compressing the
temporomandibular joint or supraorbital nerve (localization).
[M2] Flexion response to pain; indicates any flexion movement of the upper limbs.
[M1] Extensor posturing; indicates extensor posturing.
[M0] No response to pain or generalized myoclonus status epilepticus; indicates no motor response or myoclonus status
epilepticus.

BRAINSTEM REFLEXES (B)


Grade the best possible response. Examine pupillary and corneal reflexes. Preferably, corneal reflexes are tested by instilling
2-3 drops of sterile saline on the cornea from a distance of 4-6 inches (this minimizes corneal trauma from repeated
examinations). Cotton swabs can also be used. The cough reflex to tracheal suctioning is tested only when both of these
reflexes are absent.
[B4] Pupil and corneal reflexes present; indicates pupil and cornea reflexes are present.
[B3] One pupil wide and fixed; indicates one wide and fixed.
[B2] Pupil or corneal reflexes absent; indicates either pupil or cornea reflexes are absent.
[B1] Pupil and corneal reflexes absent; indicates both pupil and cornea reflexes are absent.
[B0] Absent pupil, corneal, and cough reflex; indicates pupil, cornea and cough reflex (using tracheal suctioning) are absent.

RESPIRATION (R)
Determine spontaneous breathing pattern
[R4] Not intubated, regular breathing pattern; in a nonintubated patient and grade simply as regular R4.
[R3] Not intubated, Cheyne-Stokes breathing pattern; Cheyne-Stokes R3 breathing.
[R2] Not intubated, irregular breathing pattern; irregular R2.

In mechanically ventilated patients


[R1] Breathes above ventilator rate; assess the pressure waveform of spontaneous respiratory pattern or the patient
triggering of the ventilator R1. The ventilator monitor displaying respiratory patterns is used to identify the patient
generated breaths on the ventilator. No adjustments are made to the ventilator while the patient is graded, but grading is
done preferably with PaC02 within normal limits.
[R0] Breathes at ventilator rate or apnea;A standard apnea (oxygen-diffusion) test may be needed when patient breathes
at ventilator rate RO.
Analisa Gas Darah
Asidosis 7,350  pH  7,450 Alkalosis
Respiratorik 45  pCO2  35 Respiratorik
85 PaO2 100
Metabolik 22  HCO3-  26 Metabolik
19 T.CO2 25
Metabolik -2  BE  +2 Metabolik
95 Sat. O2 100

Anion Gap (8-16 mEq/L)


Normal: 9-16 mEq/L
= Na+ - (Cl- + HCO3-) Anion Gap Meningkat pada peningkatan zat asam (Laktat, Keton,
Uremic, Alkohol)

APGAR Score
0 1 2
Appearance Pucat Badan merah, ekstremitas Seluruh tubuh kemerahan
(warna kulit) biru
Pulse rate - < 100 x/i > 100 x/i

Grimace - Sedikit gerakan, Batuk/ bersin aktif


(reaksi rangsang) perubahan mimik
Activity - Ekstremitas sedikit fleksi Gerakan aktif,
(tonus otot) ekstremitas fleksi
Respirasi - Lemah/ tidak teratur Baik / menangis kuat
(Usaha nafas)

Body Surface Area (BSA)


Berat badan [m2]
1 - 5 kg (0,05 x bb) + 0,05
6 - 10 kg (0,04 x bb) + 0,1
11 - 20 kg (0,03 x bb) + 0,2
21 - 40 kg (0,02 x bb) + 0,4

Dehidrasi (Kriteria WHO)


KU* Baik Gelisah Tidak sadar Tanpa dehidrasi (<5% bb)
Oralit: 1thn: 50-100 cc /x BAB
Air mata (+) (-) (-) >1thn: 100-200 cc /x BAB
Dehidrasi Ringan Sedang (5-10% bb)
Mata N cekung Sangat cekung 75cc/kgbb dalam 3-4 jam
Dehidrasi Berat (>10% bb)
Mulut N kering Sangat <1 tahun:  30 cc/kgbb (habis dalam 1 jam)

Haus* Minum Haus Tidak mau  70 cc/kgbb (habis dalam 5 jam)


mnum lambat >1 tahun:  30 cc/kgbb (habis dalam 0,5 jam)
Turgor* Baik lambat Sangat  70 cc/kgbb (habis dalam 2,5 jam)

* Tanda kunci
Derajat dehidrasi : min. 2 tanda + 1 tanda kunci (dibaca dr kanan ke kiri).
Down Score
0 1 2

Frekwensi nafas < 60 x/i 60-80 x/i > 80 x/i <4: Distres nafas ringan
 O2 nasal kanul
Retraksi (-) Ringan Berat
Sianosis (-) Hilang dengan Menetap 4-7: Distres nafas sedang
O2 dengan O2  CPAP
Air entry Udara masuk Kurang baik Tidak masuk
bilateral baik > 7: Distres nafas berat / Ancaman gagal
Merintih (-) Terdengar Terdengar nafas
Dengan tanpa stetoskop  Intubasi
stetoskop  AGDA

Endotracheal Tube (ETT)


Ukuran/ Diameter
Cuff (Umur [tahun]/4) + 3
Non Cuff (Umur [tahun]/4) + 4

Kedalaman (Umur [tahun]/2) + 12

Gizi Buruk
Kondisi Syok Letargis Dehidrasi

I (+) (+) (+) O2; RLD; D10% bolus 5 cc/kgbb; Resomal 5 cc/kgbb per
NGT.
II (-) (+) (+) Bolus D10% 5 cc/kgbb, D10% 50 cc/NGT; 2 jam pertama
berikan resomal /30 menit, dosis 5 cc/kgbb/x.
III (-) (-) (+) D10% 50 cc per oral atau NGT; 2 jam pertama berikan
resomal/30 menit, dosis 5 cc/kgbb/x.
IV (-) (+) (-) Bolus D10% 5 cc/kgbb, D10% 50 cc per NGT; 2 jam
pertama berikan F75/30 menit, ¼ dosis utk dosis 2 jam
dengan BB (NGT).
V (-) (-) (-) D10% 50cc oral.

Glomerulus Filtration Rate (GFR)


K x Tinggi badan [cm] Nilai Normal
GFR =
Kreatinin plasma Umur Nilai Min Max
Lahir 20,8 ± 1,9 18,9 22,7
0-1 tahun 0,45 1 mgg 46,6 ± 5,2 41,4 51,8
1-13 tahun 0,55 3 – 5 mgg 60,1 ± 4,6 55,5 64,7
K
13-21 tahun ♂ 0,70 6 – 9 mgg 67,5 ± 6,5 61,0 74,0
♀ 0,57 3 bln 73,8 ± 7,2 66,6 81,0
6 – 12 bln 93,7 ± 14,0 79,7 107,7
1 – 2 thn 99,1 ± 18,7 80,4 117.8
2 – 5 thn 126,5 ± 24,0 102,5 150,5
5 – 15 thn 116,7 ± 20,2 96,5 136,9
Glucose Infusion Rate (GIR)
% Dextrose x tetesan x Dextrose concentration
GFR =
0,167
kgbb D 5% (cc) D 40% (cc)
Target normal: 4-6 mg/ kgbb/ menit D 10% 430 70
D 12,5% 400 100
D 15% 360 140
D 20% 285 215
D 25% 215 285

Glukosa darah pada anak


Kadar glukosa darah (mg/dL)

Hipoglikemia berat
Neonatus < 30
1 bulan – 16 tahun < 40
Normal
Neonatus 30 – 60
0 – 1 tahun 50 – 80
1 – 16 tahun 70 – 100
Hiperglikemia
Puasa (batas atas ) WHO : 110
Random > 150
 Klein GW et al. Hyperglycemia in the pediatric intensive care unit. Curr Opin Clin Nutr Metab Care 2007;10:187-92.

Hematology Index

ANC
Neutrofil batang + Neutrofil segmen → < 500: Kontraindikasi Kemoterapi
= x L
100

MCH
Hb gr/100ml x 10 → Mean corpuscular Hb = KHR
=
Jumlah Eritrosit (.juta/mm3) → N = 27 – 31 pikogr/sel darah merah
→ Mikrositer, makrositer
MCHC
Hb gr/100ml x 10 → N = 30 – 36 gr/ 100 ml darah
=
Ht vol% → Hipokrom, hiperkrom

MCV
Ht vol % x 10 → N = 81 – 90 mikr/m3
=
Jumlah Eritrosit (.juta/mm3) → Makrositer, mikrositer

Mentzer index
MCV → > 16%: defisiensi Fe
= x 100%
RBC

RDW index
MCV → jika > 220: ADB
= x RDW
RBC → jika < 220: thalasemia min.(92%)
Hill Formula
[ pCO2 = (1,54 - HCO3) + 8,36 ± 1,1 ]
pCO2 Lab < N  Asidosis Metabolik + Alkalosis Respiratorik
pCO2 Lab  N  Asidosis metabolik murni
pCO2 Lab > N  Asidosis metabolik + Asidosis respiratorik

Dalam rentang  Dapat dikoreksi dengan Bicnat


< rentang bawah  Proses cerebral (masuk PICU tanpa koreksi)
> rentang atas  Proses respiratorik (cukup O2 saja)

Holiday Segar
BB [kg] Kebutuhan Cairan

< 10 kg 100 cc/kgbb


11 - 20 1000 cc + 50 (bb - 10)
>20 1500 cc + 20 (bb - 20)

INFUS
Cairan Ca++ K+ Na+ Osm Cl- HCO3-
mEq/L mEq/L mEq/L mOsm/L mEq/L mEq/L
Aminofusin L600 - 30 40 - 14 - Mg: 10 mEq/L
Asering 2,7 4 130 273,4 108,7 - Asetat-: 28 mEq/L
D5% - - - 252 - - Glu: 50 g/L
D5% NaCl 0,225% 38,5 354 38,5 200 Kkal/L
D5% NaCl 0,45% 77 406 77 Glu: 50 g/L
D5% NaCl 0,9% 154 560 154 190 Kkal/L
D40% - - - 2.018 - - Dextrose: 400 mg/L
Darrow 1/2
Gelofusin 154 274 120 Gelatin 40 g/L
HES 6% 154 308 154 Starch 60 g/L
KAEn 3A
KAEn 3B
Lipofundin - - - 380 - - 1908 Kkal/L
NaCl 0,9% - - 154 308 154 -
Ringer Fundin
Ringer Laktat 2,7 4 130,3 274 109,4 27,7
Ringer Sol 4,5 4 147,2 311 155,7

Insensible Water Lose (IWL)


Neonatus 50 cc/kgbb/hari
1-12 bulan 40 cc/kgbb/hari
1-5 tahun 30 cc/kgbb/hari
> 5 tahun 20 cc/kgbb/hari

Kebutuhan Total Cairan (KTC)


Enteral
cc / hari kkal
= x
100 BBS

Parenteral
cc / hari kkal
= x
100 BBS
Potensi Tinggi Genetik (PTG)

TB Ayah + TB Ibu + 13
♂ = ± 8,5
2

TB Ayah + TB Ibu - 13
♂ = ± 8,5
2

Ramsay scale (Sedation)


1 Pasien sadar, cemas, dan gelisah atau tidur gelisah atau keduanya
2 Pasien sadar, kooperatif, terorientasi, dan tenang
3 Pasien sadar, berespons hanya terhadap perintah verbal
4 Pasien mengantuk, respons cepat terhadap ketukan ringan glabela atau rangsang suara keras
5 Pasien mengantuk, respons lambat terhadap ketukan ringan glabela atau rangsang suara keras
6 Pasien mengantuk, tidak berespons terhadap ketukan ringan glabela atau rangsang suara keras

Recommended Dietary Allowances (RDA)/ AKG


Umur (tahun) kkal /kgbb
0– 1 100 – 120
1– 3 100
4– 6 90
7– 9 80
10 – 12 ♂ lk: 60 – 70
♀ pr: 50 – 60
12 – 18 ♂ lk: 50 – 60
♀ pr: 40 – 50
Kebutuhan Kalori [kkal]

= RDA HA (kkal/kg)menurut umur X BB ideal (kg)

Schofield Formula
0-3thn ♂ 0,167(BB) + 15,17(TB) - 617,6 Gagal jantung : 1,15 – 1,25
♀ 16,252(BB) + 10,232(TB) - 413,5 Gagal tumbuh : 1,5 - 2
3-10thn ♂ 19,59(BB) + 1,303(TB) + 414,9 Luka bakar : 1,5 – 2,5
♀ 16,969(BB) + 1,618(TB) + 371,2 Operasi : 1,05 – 1,5
10-18thn ♂ 16,25(BB) + 1,372(TB) + 515,5 Sepsis : 1,2 – 1,6
♀ 8,365(BB) + 4,65(TB) + 200 Starvation : 0,7 – 0,85
Trauma : 1,1 – 1,8
Trauma kepala : 1,3

Status Nutrisi
Obesitas
< 5 tahun > 5 tahun < 2tahun > 2 tahun
WHO (BB/TB) CDC (BB/TB) WHO CDC (IMT)

Obesitas > (+3SD) > 120% IMT CDC > P95


Overweight (+2SD) - (+3SD) 110% – 120% IMT CDC P85-95
Normoweight (-2SD) – (+2SD) 90% – 110%
Gizi Kurang (-3SD) – (-2SD) 70% – 90%
Gizi Buruk < (-3SD) < 70%
TB Skoring
Parameter 0 1 2 3

Kontak TB Tidak jelas - Laporan keluarga, BTA (+)


BTA (-)
/ BTA tidak jelas
/ tidak tahu
Uji tuberkulin (Mantoux) Negatif - - Positif (≥10 mm
atau ≥5 mm pada
imunokompromais)
Berat badan - BB/TB<90% Klinis gizi buruk -
/ keadaan gizi atau BB/U<80% atau BB/TB<70%
atau BB/U<60%
Demam yang tidak diketahui - ≥2 minggu - -
penyebabnya
Batuk kronik - ≥3 minggu - -
Pembesaran kelenjar limfe - ≥1 cm, - -
kolli, aksila, inguinal lebih dari 1 KGB,
tidak nyeri
Pembengkakan tulang/sendi - Ada - -
panggul, lutut, falang pembengkakan
Foto toraks Normal/ kelainan Gambaran sugestif - -
tidak jelas (mendukung) TB

Transfusi
Kebutuhan
Albumin [mg] (3,0 – Alb lab) x bb x 0,8
Cryoprecipitate [cc] 10 cc/ kgbb
FFP [cc] 10-15 cc/ kgbb
PRC [cc] 4 x bb x ∆ Hb
Trombosit [Unit] 1 Unit /10 kgbb
Whole Blood [cc] 6 x bb x ∆ Hb

Kemampuan
Hb < 5 3 cc/ kgbb/ x transfusi
Hb 5 – 7 5 cc/ kgbb/ x transfusi
Hb 7 – 10 7 cc/ kgbb/ x transfusi

Kemampuan (Max)
Hb < 3 3 cc/ kgbb/ x transfusi
Hb < 5 5 cc/ kgbb/ x transfusi
Hb 5 – 10 10 cc/ kgbb/ x transfusi
Utility
Umur ETT Laryngoscope NGT Foley
[mm] (Miller) (Fr) (Fr)
Premie Or < 3 kg 2.,5-3.0 0 5-8 5
Term Newborn 1 – 7 days 3.0 1 5-8.5 5
1 – 3 wks 3.0 1 8.5 5
1 month 3.0-3.5 1 8 5-8
6 mos 3.5-4.0 1 8 5-8
12 mos 4.0-4.5 1-2 10-12 8-10
2 yrs 4.5-5.0 1-2 10-14 8-10
3 yrs 4.5-5.0 1-2 10-14 10
4 yrs 5.0-5.5 2 10-14 10
5 yrs 5.0-5.5 2 10-14 10
6 yrs 5.5 2 12-14 10
8 yrs 6.0 cuff 2-3 12-14 10
10 yrs 6.0-6.5 cuff 2-3 14-16 10-12
12 yrs 6.5-7.0 cuff 2-3 14-16 10-12
14 yrs > 7.0-7.5 cuff 3 16+ 14
 Stabilization of the Critically Ill Children
 Children’s Hospital Colorado