Webinar Series #3

Fakultas Farmasi Universitas Airlangga

PELAYANAN FARMASI ICU

UNTUK KASUS COVID-19

GEJALA SEDANG – BERAT

Nugroho Hari Santoso

Instalasi Farmasi, Rumah Sakit Universitas Airlangga

Fokus Bahasan

• Definisi ICU
• Karakteristik ICU
• ICU COVID-19 (Prevalensi – Indikasi ICU)
• Pelayanan Farmasi ICU COVID-19
• APD
• Alkes
• Obat-obatan
• Farmasi Klinik

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suatu bagian dari rumah sakit yang mandiri (instalasi dibawah direktur
pelayanan), dengan staf yang khusus dan perlengkapan yang khusus
yang ditujukan untuk observasi, perawatan dan terapi pasien-pasien
yang menderita penyakit, cedera atau penyulit-penyulit yang
mengancam nyawa atau potensial mengancam nyawa dengan
prognosis dubia
ICU / Instalasi (yang diharapkan masih reversible*)
Rawat Intensif
(IRI)
KMK 1778/MENKES/SK/XII/2010
*Juknis Penyelenggaraan ICU 2011 (HK.02.04/I/1966/11)

Karakteristik ICU
Pasien Sistem Organ Modalitas
- Anak dan Dewasa Memberi bantuan atau - Biaya tinggi
- Penyakit akut mengambil alih fungsi vital - Teknologi tinggi
mengancam nyawa tubuh : - Multidisiplin
- Atau potensial - Sistem pernapasan - Multiprofesi
mengancam nyawa - Kardiosirkulasi
- Prognosis dubia - Susunan saraf pusat
- Ginjal
- dll

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Fasilitas
Pendukung

ICU COVID-19

• ICU Isolasi
• Pertukaran udara dalam tiap
ruangan berbeda tekanan dengan
selisih 15 Pascal (Ante Room)
• pergantian udara per jam ruang
isolasi minimal 12X
• Jarak antar tempat tidur adalah ≥1
meter. Bila memungkinkan 1,8 m
• Ketersediaan alat medis dan APD

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Prevalensi Pasien COVID-19 yang perlu ICU

Global :
Seperempat ( + 25%) pasien yang dirawat di RS
(bervariasi prosentasenya)
5 – 8 % dari total populasi yang terinfeksi
China :
7 – 26 % derajat berat perlu ICU
Itali (preliminary reports)
5 – 12 % Kasus positif COVID-19
16 % dari pasien yang perlu dirawat di RS
USA (Washington) :
ICU admission rate adalah 81%
71% butuh ventilasi mekanik
~ populasi geriatric di suatu tempat
Analisis pada 2449 pasien :
Perlu perawatan di RS : 20 s/d 31%
ICU admission rates : 4,9 – 11,5%
Bhatraju et al, 2020

Uptodate, Juni 2020; Bambang Pujo S,2020)

Karakteristik Pasien ICU COVID-19

Ventilator

Proposed staging of COVID19 (note that potential therapies are indicated, which should only be used in the setting of clinical trials)
(Siddiqi et al, 2020)

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Pelayanan Farmasi ICU

COVID-19

• Obat-obatan
• Farmasi Klinik
• Alat Kesehatan Habis Pakai
• Alat Pelindung Diri

Alat Pelindung Diri

• Kewaspadaan level 3
• Prosedur-prosedur yang menghasilkan
aerosol :
• intubasi trakea
• ventilasi noninvasif
• trakeotomi,
• resusitasi jantung paru,
• ventilasi manual sebelum intubasi,
• bronkoskopi

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Alat Kesehatan Habis Pakai

• Alat oksigenasi (HFNC, masker ketat-reservoir,

ETT, Jackson rees)
• Set ventilator (tubing, filter, close suction)
• Set monitor tekanan darah infasif (arterial
needle, Transducer)
• Akses vena sentral (CVC dan/atau HD)
• Kateter interkosta
• Set trakeostomi

Obat-obatan

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Obat-obatan

Terapi berdasakan manifestasi klinis dan penyakit penyerta

1. Sedasi +/- Pelemas Otot (NMBA)

2. Antikoagulan
3. Nutrisi dan Managemen Glukosa
4. Cairan dan Hemodinamik
Terapi 5. Steroid
6. Analgesik
Suportif ICU
7. Antihipertensi & Diuretik
8. Antibiotik
9. ………..

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 Improving pulmonary compliance and

suppressing ventilatory drive to facilitate the
adaptation of patient to the ventilator
 Deeper sedation may be required to ensure
safety, due to the risk of unplanned extubation
Sedasi +/- and virus transmission

Pelemas otot  deep and/or prolonged sedation is associated

with several complications, e.g. delirium,
(NMBA) withdrawal syndromes, propofol-related infusion
syndrome (PRIS), haemodynamic instability, ICU
acquired muscle weakness, and difficult MV
weaning leading to a sustained utilisation of ICU
resources

(Payen et al,2020)

 Use of prophylactic heparin/low molecular weight

heparin is considered in the regular care of
Intensive Care patients
 Due to the high incidence of thromboembolic
events, some groups suggest the use of
therapeutic doses of heparin/low molecular

Antikoagulan weight heparin unless contraindicated (e.g.,

active bleeding, severe thrombocytopenia,
fibrinogen <0.5 g/L)
 Heparin may have many putative effects in
COVID-19 including reduced microvascular and
large vessel thrombosis, anti-inflammatory effects
and endothelial protection.

Lin, L et al. 2020, Tang, N et al 2020, Thachil, J. 2020

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• Hyperglycemia is common in critically ill patients, both with and without

diabetes (predictor of adverse outcomes, including mortality). Target
blood glucose range is 140-180 mg/dL (lower limit 110 mg/dl)

• Intravenous insulin, using a validated protocol to minimize hypoglycemia,

is the preferred approach in critical care settings

• Energy: COVID-19 need more energy than normal (84-126 kJ/kg/day)

• Protein: to reduce the catabolism due to the inflammatory mediators, it is
indicated to increase protein supply as top priority. It is recommended
Nutrisi dan 1.3 g/kg/day increasing the supply of branched chain amino acids to

Managemen 50%, to prevent muscle loss, enhance the strength of respiratory muscles
(gastroparesis  hydrolyzed whey protein)

Glukosa • carbohydrate administration should be limited in the critically COVID-19

patient with respiratory failure (2 g/kg/day not exceed 150 g/day), The
oxidation of a mole of carbohydrates leads to the production of equal
CO2

• Give priority to the use of medium and long chain fatty acids and
increase the proportion of ω-3 fatty acids and ω-9 fatty acids. Essential
fatty acids play a major role in immune responses by altering the
composition of cell membranes and modulating cell signaling.
American Association of Clinical Endocrinologists
(Romano et al, 2020)

• Avoid positive fluid balance/ hypervolaemia

• Excessive negative fluid balance (e.g. diuretics) could
contribute to AKI
• Fluid resuscitation may be required in the early phase,
especially prior to intubation and initiation of positive
pressure ventilation (to avoid hypotension from impaired
venous return)

Cairan dan • For the acute resuscitation of adults with COVID-19 and
shock, we recommend using crystalloids over colloids
Hemodinamik (strong recommendation, moderate quality evidence)
• noradrenaline as the first-line vasoactive agent. If
noradrenaline is not available, use either argipressin
(vasopressin) or adrenaline as the first-line vasoactive
agent if a target mean arterial pressure (MAP) of 60-65
mmHg cannot be achieved by maximal doses of first-line
monotherapy with a vasoactive agent, add a second
vasoactive agent

(Alhazzani et al, 2020)

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 Septic shock: The effect of corticosteroids in COVID-19

patients with sepsis or septic shock may be different than
the effects seen in those with ARDS. The Surviving Sepsis
Campaign and NIH suggest the use of low-dose
corticosteroid therapy (e.g., hydrocortisone 200 mg daily
as an IV infusion or intermittent doses) over no
corticosteroid therapy in adults with COVID-19 and
refractory shock.

Steroid  IDSA suggests the use of corticosteroids over no

corticosteroid therapy in hospitalized patients with severe
COVID-19 (i.e., defined as patients with SpO2 ≤94% on
room air and those who require sup-plemental oxygen,
mechanical ventilation, or ECMO).
 Cytokine storm: There is no well-established or evidence-
based treatment for cytokine storm in patients with COVID-
19. higher dosages of corticosteroids ??

(Ashp, 2020)

Farmasi Klinik

• Kompatibilitas obat iv
• Interaksi obat
• Penyesuaian dosis pasien
gangguan renal
• Monitoring efek terapi dan efek
samping

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Farmasi Klinik
Terapi Monitoring
Sedasi +/- Pelemas Otot Analisa gas darah, GCS
(reversal)
Antikoagulan Tanda perdarahan, D-Dimer, fibrinogen, INR
(penyiapan heparin pump) antidot protamin??
Nutrisi dan Managemen Glukosa Glukosa darah, Retensi NGT, profil lipid, elektrolit, albumin
(penyiapan insulin pump)
Cairan dan Hemodinamik Balance cairan, TD, MAP
Steroid Tekanan darah, Glukosa darah, elektrolit (Na↑, K↓), C-rp,
ferritin
Fungsi ginjal (BUN, Sc)
Fungsi hepar (SGOT/PT, Bilirubin)
Hematologi (Hb, WBC, HCT)
Kultur kuman dan sensitifitas Ab, PCT

Pustaka
1. Alhazzani et al, 2020. Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19). Crit
Care Med. 2020 Apr 21 : 10.1097
2. ASHP COVID-19 Resource Center, updated July 2020
3. Coronavirus disease 2019 (COVID-19): Epidemiology, virology, and prevention (uptodate,Juni 2020)
4. https://www.aace.com/disease-state-resources/diabetes/depth-information/management-hyperglycemia-critical-care-setting
5. Juknis Penyelenggaraan ICU 2011 (HK.02.04/I/1966/11)
6. KMK 1778/MENKES/SK/XII/2010
7. Lin, L et al. 2020. Hypothesis for potential pathogenesis of SARS-CoV-2 infection-a review of immune changes in patients with viral pneumonia. Emerg
Microbes Infect. 2020 Dec;9(1):727-732
8. Payen et al, 2020. Sedation for critically ill patients with COVID-19: Which specificities? One size does not fit all. Anaesth Crit Care Pain Med. 2020 Jun;
39(3): 341–343.
9. Romano et al, 2020. Short Report – Medical nutrition therapy for critically ill patients with COVID-19. Eur Rev Med Pharmacol Sci. 2020;24: 4035-4039.
10. Siddiqi HK, Mehra MR. COVID-19 illness in native and immunosuppressed states: A clinical-therapeutic staging proposal. J Heart Lung Transplant.
2020;39(5):405-407.
11. Tang, N et al 2020. Anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy. J
Thromb Haemost. 2020 May;18(5):1094-1099
12. Thachil J. The versatile heparin in COVID-19 [published online ahead of print, 2020 Apr 2]. J Thromb Haemost. 2020;10.1111/jth.14821.
doi:10.1111/jth.14821

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Terima Kasih

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