Pemantauan & Manajemen

Hemodinamik
Pada Pasien Covid-19
Dengan Kondisi Kritis

Oleh : Yudi Elyas

Disampaikan Pada :
Webinar Keperawatan PT Madani Tgl. 05 September 2021
Nama : Ns. Yudi Elyas, S.Kep Curiculum Vitae
NIRA : 31730118302
Lama Bekerja : 18 Tahun
Riwayat Jabatan : 1. Ka.Ruang ICU bedah Jantung PJT RSCM
2. Supv. ICCU,ICU bedah jantung, RR PJT RSCM
Jabatan Saat ini : PJ Pelayanan Ruang Intensif RSCM Jakarta
Tlp / Instagram : 081316006831 / @YUDI ELYAS

Pendidikan :
• Ners Keperawatan FIK UI
• Pendidikan ICU Bedah Jantung (CCNP) Institute Jantung Negara (IJN) Malaysia
• Mahasiswa Magister Keperawatan Peminatan Sp.KMB FIK UI

Pelatihan : Trainer : Organisasi :

• Kardiologi Dasar • BLS & ACLS Certified by AHA • PPNI
• Basic Trauma Cardiac Life Support • HIPERCCI DKI (Pengurus)
• Intensive Care Unit (ICU)
(BTCLS) • INKAVIN (Anggota)
• BLS & ACLS AHA 2015
• Pelatihan ICU (RSCM & HIPERCCI) • Provider BTCLS
• TOT BLS & ACLS AHA • Pelatihan Code Blue system di RS
• Asesor Keperawatan • Pelatihan Interpretasi EKG
• TOT Keperawatan
Definisi :
Suatu pengukuran terhadap sistem kardiovaskuler
yang dapat dilakukan dengan cara non invasif atau
invasif untuk memberikan informasi mengenai
keadaan Pembuluh darah, Jumlah darah
dalam tubuh dan Kemampuan jantung untuk
memompakan darah.
(Barbara, 2008)
 JENIS PEMANTAUAN
HEMODINAMIK
Non Invasive
1. Keadaan Umum
2. Tingkat kesadaran
3. Warna kulit / Suhu Invasive Monitoring
tubuh 1. IBP
2. CVP
4. Tanda-tanda vital 3. PAC (Swanganz)
(TD,HR,SatO2,RR)
5. Nadi perifer
6. Capilary refill time
7. Urine output
Adult Intensive Care Unit
 INVASIVE MONITORING
Invasive Invasive +PAC

ABP
PAP
CVP
PCWP
 Covi-19 Mechanism

Sumber : Sumber:
European Society of cardiology. (2020). ESC Guidance for the Diagnosis and Muniyappa, R., & Gubbi, S. (2020, May 1). COVID-19 pandemic, coronaviruses, and diabetes mellitus.
Management of CV Disease during the COVID-19 Pandemic. European Heart American Journal of Physiology - Endocrinology and Metabolism. American Physiological Society.
Journal, 1–115. https://doi.org/10.1152/ajpendo .00124.2020
Tingkat
Keparahan
Pasien Covid-19

Sumber:
Ma C, Gu J, Hou P, et al. Incidence, clinical
characteristics and prognostic factor of patients with
COVID-19: a systematic review and meta-analysis.
medRxiv
WHO
Severity Of
Covid-19

Sumber :
World Health Organization. (2020). Clinical management of
COVID-19: interim guidance, 27 May 2020. World Health
Organization.https://apps.who.int/iris/handle/10665/332196
License: CC BY-NC-SA 3.0 IGO
 Kategori Gejala Kasus Covid-19

Tanpa Gejala Kondisi teringan dan tidak ditemukan gejala

Ringan Infeksi saluran napas tidak berkomplikasi

Pneumonia tetapi tidak membutuhkan

Sedang suplementasi oksigen

Pneumonia disertai RR >30 x/menit, distres napas

Berat berat, SpO2 <93% atau PaO2/FiO2 <300

Gagal napas, acute respiratory distress syndrome

Kritis (ARDS), syok sepsis dan/atau multiple organ failure
Sumber:
Burhan et al (2020). Protokol Tatalaksana Covid-19. Jakarta: PDPI, PERKI, PAPDI, PERDATIN, IDAI
Perjalanan
Virus Covid-19

Sumber:
Susilo A, Rumede CM, Pitoyo CW, et al (2020).
Coronavirus Disease 2019: Tinjauan Literatur
Terkini. Jurnal Penyakit Dalam Indonesia, 7, 1.
Protokol
Terapi Respirasi
Pasien Covid-19

Sumber :
Shang et al (2020) Management of critically ill patients with
COVID-19 in ICU: statement from front-line intensive care
experts in Wuhan, China. Annals of Intensive Care, 10(1), 1–24.
https://doi.org/10.1186/s13613-020-00689-1
 Definisi & Gejala ARDS

Sumber :
Arie Zainul Fatoni1 , Ramacandra Rakhmatullah,2021. Acute Respiratory Distress Syndrome (ARDS) in COVID-19 Pneumonia, Journal of Anaesthesia and
Pain, 2021, Volume: 2, No.1: 11-24
Protokol
Tatalaksana
Covid-19

Sumber:
Burhan et al (2020). Protokol Tatalaksana
Covid-19. Jakarta: PDPI, PERKI, PAPDI,
PERDATIN, IDAI
Terapi Oksigen
Pada Kegagalan Respirasi 1. Basic Respiratory Support
Pasien Covid-19 a) Nasal Cannula
b) NRM
c) HFNC
d) NIV
2. Advance Respiratory Support Invasive
Sumber :
Mechanical Ventilation
World Health Organization. (2020). Clinical management of COVID-19:
interim guidance, 27 May 2020. World Health 3. Extra Corporeal Membrane Oxygenation
Organization. https://apps.who.int/iris/handle/10665/332196. License: CC
BY-NC-SA 3.0 IGO (ECMO)
Respiratory
Therapy Support
in Covid-19

Sumber :
Nicholson, T. W., Talbot, N. P., Talbot, N. P., Nickol, A., Chadwick, A. J., &
Lawton, O. (2020). Respiratory failure and non-invasive respiratory support
during the covid-19 pandemic: An update for re-deployed hospital doctors
and primary care physicians. The BMJ, 369, 1–7.
https://doi.org/10.1136/bmj.m2446
 Conclusion:
Early initiation of oxygen therapy was
associated with lower mortality among
critical patients. This study highlighted the
importance of early oxygen therapy after the
onset of hypoxia symptoms. Our results also
lend support to potentially beneficial effects
of IFNα on critical illness
Sumber :
Long L, Wu L, Chen L, Zhou D, Wu H, Lu D, et al. (2021) Effect of early oxygen therapy and antiviral
treatment on disease progression in patients with COVID-19: A retrospective study of medical charts in
China. PLoS Negl Trop Dis 15(1): e0009051. https://doi.org/10.1371/journal. pntd.0009051
HFNC atau NIV ?
Recommendations :
• Goal of Oxygenation The optimal oxygen saturation (SpO2 ) in adults with COVID-
19 is uncertain. However, a target SpO2 of 92% to 96% seems logical considering
that indirect evidence from experience in patients without COVID-19 suggests that
an SpO2 96% may be harmful.
• For adults with COVID-19 and acute hypoxemic respiratory failure despite
conventional oxygen therapy, the Panel recommends high-flow nasal cannula
(HFNC) oxygen over noninvasive positive pressure ventilation (NIPPV) (BIIa).
• In the absence of an indication for endotracheal intubation, the Panel
recommends a closely monitored trial of NIPPV for adults with COVID-19 and
acute hypoxemic respiratory failure and for whom HFNC is not available (BIIa).

Sumber :
NIH. (2020). Coronavirus Disease 2019 (COVID-19) Treatment Guidelines. Disponible en:
https://covid19treatmentguidelines.nih.gov/. Nih, 2019, 130.
 Studi Literatur
• (Kusubae et al., 2020), 81% pasien yang menggunakan HFNC toleransi
baik, tanpa sedasi dan tidak ada komplikasi yang parah
• (Kusubae et al., 2020) Penelitian perbandingan Efektifitas HFNC dan NIV
sebagai penenganan pertama pada pasien kritis Covid 19 memiliki efektifitas
yang tidak jauh berbeda.
• (Teng et al., 2020), membandingkan HFNC dengan terapi Oksigen
Konvensional (COT): penggunaan HFNC pada pasien berat dengan Covid
19 dapat meningkatkan Oksigenasi, HR dan RR lebih stabil, mengurangi
indeks infeksi serta mengurangi lama rawat di ICU.
• (Li et al., 2020), HFNC memiliki Bioaerosol yang lebih rendah,
meningkatkan oksigenasi dan mencegah laju intubasi pada pasien dengan
Covid 19.
• Shang et al (2020), Dari 320 pasien yang mengalami ARDS berat laju
intubasi pada HFNC lebih rendah dibandingkan NIV. Akan tetapi tidak cukup
bukti HFNC lebih baik dibandingkan NIV
 ROX Index
• RoX Index adalah Rasio SPO2 / FiO2 terhadap laju pernapasan.
• Indeks ROX berguna untuk memprediksi berhasil tidaknya HFNC pada pasien
hipoksemia akut.
• Roca et al melaporkan bahwa titik potong indeks ROX > 4,88 setelah 12 jam terapi
HFNC mungkin menunjukkan kemungkinan keberhasilan yang lebih tinggi.
• Indeks ROX >2.85, 3.47, 3.85 masing-masing pada 2,6,12 jam diidentifikasi untuk
memprediksi keberhasilan HFNC.
• Indeks ROX dapat digunakan untuk memprediksi penyapihan dari HFNC. FiO2 <= 0,4
dan ROX >= 9,2 merupakan prediksi keberhasilan penyapihan dari HFNC pada
pasien dengan hipoksemia akut.

Sumber :
The ARDS Definition Task Force. Acute Respiratory Distress Syndrome: The Berlin
Definition. JAMA. 2012;307(23):2526–2533. doi:10.1001/jama.2012.5669
Indikasi &
Kontra-indikasi
Penggunaan
HFNC

Sumber :
Xu, J. Q., Su, L. X., Yan, P., Hu, X. S., Wen, R. X., Xiao, K., Gu, H. J., Xia, J. G., Sun, B., Zhou, Q. T., Dong, Y. C., Liu, J. L., Pan, P. H., Luo, H., Li, Q.,
Song, L. Q., Xu, S. C., Li, Y. M., Wang, D. X., … Xie, L. X. (2020). Expert consensus on clinical standardized application of high-flow nasal cannula
oxygen therapy in adults. Chinese Medical Journal, 133(11), 1322–1324. https://doi.org/10.1097/CM9.0000000000000769
 Monitoring Patient
During HNFC

• HNFC memberikan oksigen

dengan PEEP yang telah
dilembabkan dan dihangatkan.
• HNFC dapat menurunkan
kebutuhan intubasi dan
memperbaiki kondisi klinis pasien
• Lakukan monitoring ROX Index
• Jika hypoxemia berlanjut dan
peningkatan kerja napas
(WOB) lakukan intubasi
• Oleh karena resiko peningkatan
aerosol, tempatkan pasien pada
ruangan negative pressure

Sumber:
Anesi, 2020; http://www.emdocs.net
 Pemberian HFNC
 Batasi Flow agar tidak melebihi 30 liter/menit.
 1 jam pertama pemberian HFNC, lakukan evaluasi :
o Jika indeks ROX >4.88, menandakan
perbaikan dan ventilasi aman pada jam ke-2,
6, dan 12, maka pasien tidak membutuhkan
ventilasi invasif.
o Jika indeks ROX <3.85, menandakan risiko
tinggi untuk kebutuhan intubasi.

Sumber:
Burhan, E., Susanto, A. D., Nasution, S. A., et al (2020). Protokol Tatalaksana Covid-19. Jakarta: PDPI, PERKI, PAPDI,
PERDATIN, IDAI
Faktor Kegagalan HFNC
- Penggunaan perangkat HFNC
yang tidak tepat.
- Tidak melakukan pemantauan
AGD
- Keputusan penggunaan HFNC
tidak memenuhi kriteria : RoX
Index

Sumber :
Kim et al., (2020) Factors associated with failure of high-flow nasal cannula. Respiratory Care, 65(9), 1276–1284.
https://doi.org/10.4187/respcare.07403
Prone Position In Covid-19 Patient
Prone Position
• Posisi pronasi telah banyak diteliti pada pasien
dengan ARDS.

• Penelitian oleh Fan et al (rasio P/F ≤200 mmHg)

merekomendasikan perawatan pasien ARDS berat
dengan posisi pronasi minimal 12 jam sehari.

• Posisi pronasi bermanfaat untuk meningkatkan

ventilasi paru melalui mekanisme peningkatan
perfusi paru dan volume akhir ekspirasi paru, serta
pemerataan distribusi tidal volume pada semua
bagian paru

• Posisi pronasi dapat meningkatkan rasio PaO2/FiO2 Sumber :

https://www.uptodate.com/contents/image/print?imageKey=P
ULM%2F108807&topicKey=PULM%2F1630&source=see_link
 Prone Position
Step 1 – Staffing Step 2 – Positioning

Sumber :
Bamford, P., Denmade, C., Newmarch, C., Shirley, P., Singer, B., Webb, S., &
Whitmore, D. (2019). Guidance For : Prone Positioning in Adult Critical Care.
Intensive Care Society, 1–39.
 Prone Position
Step 3 – Patient wrapping

Sumber :
Bamford, P., Denmade, C., Newmarch, C., Shirley, P., Singer, B.,
Webb, S., & Whitmore, D. (2019). Guidance For : Prone
Positioning in Adult Critical Care. Intensive Care Society, 1–39.
 Prone Position
Step 4 – Horizontal Move Step 5 – Lateral turn Step 6 – Proning completion

Sumber :
Bamford, P., Denmade, C., Newmarch, C., Shirley, P., Singer, B., Webb, S., & Whitmore, D. (2019).
Guidance For : Prone Positioning in Adult Critical Care. Intensive Care Society, 1–39.
 Prone Position
Step 7 – Positioning
• Ensure the patient is in the centre of the bed and
remove the slide sheet, ensuring counter traction
on the patient to prevent them slipping off the bed
• Absorbent pad placed under patients head to
catch secretions
• Carefully position the arms in the ‘swimmers
position’. This involves raising one arm on the same
side to which the head is facing whilst placing the
other arm by the patients side. The shoulder
should be abducted to 80° and the elbow flexed
90° on the raised arm
• The position of both the head and arms should be
alternated every two to four hours
• The patient should be nursed at 30° in the reverse
trendelenburg position
Sumber :
Bamford, P., Denmade, C., Newmarch, C., Shirley, P., Singer, B., Webb, S., & Whitmore, D.
(2019). Guidance For : Prone Positioning in Adult Critical Care. Intensive Care Society, 1–39.
Haemodinamik
Management
 BLOOD PRESSURE

X SVR

Penurunan Penurunan Penurunan

Kondisi  Shock Kondisi  Shock Kondisi  Shock
Hypovolemik Kardiogenik Distributif
 Haemodinamik Management

MONITORING
When values are LOW When values are HIGH
PARAMETERS
Volume Expander : Diuretics  CRRT / HD
CVP/PAWP
Coloid Venodilator
Critalloid PreLoad

Arteriovasodilators :
Volume Ca Channel Blokers
Vasopressors : SVR/PVR
Alpha Inhibiitors
Alpa Stimulator Afterload Vascular Relaxants
Ace Inhibitors
Positif Inotropik:
Beta 1 stimulator Negatif Inotropik :
Phospodiaters inhibitor Contractility Beta Blokers
Cardiac Glikosiders Ca Channel Blockers

Positif Cronotropic : Negatif Cronotropic :

Beta 1 stimulator Heart rate Beta Blokers
Atropine Ca Channel Blokers
 Continuous Renal Replacement Therapy ( CRRT)

 Dialisis yang dilakukan secara terus menerus selama 24 jam dengan

menggunakan alat extra corporal
 Digunakan pada pasien dengan hemodinamik yang tidak stabil
 Haemodinamik Management

MONITORING
When values are LOW When values are HIGH
PARAMETERS
Volume Expander :
CVP/PAWP Diuretics
Coloid
PreLoad Venodilator
Critalloid

Arteriovasodilators :
Volume Ca Channel Blokers
Vasopressors : SVR/PVR
Alpha Inhibiitors
Alpa Stimulator Afterload Vascular Relaxants
Ace Inhibitors
Positif Inotropik:
Beta 1 stimulator Negatif Inotropik :
Phospodiaters inhibitor Contractility Beta Blokers
Cardiac Glikosiders Ca Channel Blockers

Positif Cronotropic : Negatif Cronotropic :

Beta 1 stimulator Heart rate Beta Blokers
Atropine Ca Channel Blokers
 CO MO2 Coronary Renal Arrhythmia

Norepinephrine

Epinephrine DD DD

Dopamine DD DD

Dobutamine DD

IABP
Lollgen et. Al. Care of the critically ill. Vol 6. No 2. P62-66
Intra-Aortic Balloon
Counter pulsation
Therapy
 • Intraaortic Balloon Counterpulsation (IABC)
Counterpulsation has become a standard component of
treatment in patients with cardiogenic shock or severe
acute left heart failure that :
• Does not respond rapidly to fluid administration, vasodilatation, and inotropic support;
• Is complicated by significant MR or rupture of the interventricular septum, to obtain
haemodynamic stabilization for definitive diagnostic studies or treatment; or
• Is accompanied by severe myocardial ischemia, in preparation for coronary
angiography and revascularization.
• Class of recommendation I, Level of evidence B
Sumber :
European Heart Journal doi: 10.1093/ eurheartj. /ehi044
Pemasangan Mesin ECMO
Pada Pasien Covid-19
BLS & ACLS
In Covid-19.. ???

Edelson, D. P., Sasson,Topjian, A. A. (2020). Interim Guidance for Basic and Advanced Life
Support in Adults, Children, and Neonates with Suspected or Confirmed COVID-19: From
the Emergency Cardiovascular Care Committee and Get with the Guidelines-Resuscitation
Adult and Pediatric Task Forces of the American Heart Association. Circulation, E933–E943.
https://doi.org/10.1161/CIRCULATIONAHA.120.047463
 High Risk for COVID-19 Transmission
A systematic review of healthcare-associated transmission of beta-coronavirus during the
SARS epidemic showed that tracheal intubation, non-invasive positive pressure ventilation,
tracheostomy, and manual ventilation prior to intubation were all associated with a
significantly increased risk of transmission to healthcare workers

• Tracheal intubation
• Positive pressure ventilation with bilevel positive airway pressure (BiPAP)
• Continuous positive airway pressure (CPAP)
• High-flow nasal cannula (HFNC)
• Bronchoscopy
• Nebulizer treatments

Sumber : Sullivan et al. Critical Care (2020) 24:292 https://doi.org/10.1186/s13054-020-03018-x

 Tindakan-
Tindakan Risiko
Menyebabkan
Aeorosol

Sumber : Sullivan et al. Critical Care (2020) 24:292 https://doi.org/10.1186/s13054-020-03018-x

CPR In Covid-19 Patient
With Mask
In Prone Position… How To Do CPR..??
 CPR in Prone Position

• 2010 AHA Guidelines (2015 AHA Not

Reviewed)
When the patient cannot be placed in the
supine position, it may be reasonable for
rescuers to provide CPR with the patient in
the prone position, particularly in
hospitalized patients with an advanced
airway in place
(Class IIb, LOE C-LD / Lemah,data terbatas).
 CPR in Prone Position
CPR
• 2 hands Together
• Put Hands on T 7 from scapula
• While performing a prone CPR, it is important to ensure high-
quality CPR

Defibrilator
• Defibrillator should be applied using maximum energy
discharge and should be shocked at the end of expiration
with the lowest positive end expiratory pressure to minimize
the chest impedance.
• One of which is the one electrode technique placed to the left
lower sternal border and the other posteriorly below the
scapula.
• Successful electrical defibrillation has been reported in
patients having spinal surgery in the prone position
 Prinsip Tatalaksana Jalan Nafas
Pasien Covid-19

Cook, T. M., El-Boghdadly, K., McGuire, B., McNarry, A. F., Patel, A., & Higgs, A. (2020). Consensus guidelines for managing
the airway in patients with COVID-19: Guidelines from the Difficult Airway Society, the Association of Anaesthetists
the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists.
Anaesthesia, 75(6), 785–799. https://doi.org/10.1111/anae.15054
 Daftar Pustaka
1. Ashish R. Panchal. Circulation. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care, Volume: 142, Issue: 16_suppl_2, Pages: S366-S468, DOI: (10.1161/CIR.0000000000000916
2. Bansal, M. (2020). Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel
coronavirus COVID- 19 . The COVID-19 resource centre is hosted on Elsevier Connect , the company ’ s public news and information. 14(3), 247–250
3. Bellomo R GD, Uchino S, Buckmaster J, Hart GK, Opdam H, et al. A prospective before-and-after trial of a medical emergency team. MJA. 2003;179:283-7.
4. Chen J, Ou L, Hillman K, Flabouris A, Bellomo R, Hollis SJ Assareh H. Cardiopulmoary arrest and mortality trends and their association with rapid response
system expansion. MJA 2014; 201: 167-170
5. Circulation. 2020;141:e933–e943. DOI:10.1161/CIRCULATIONAHA.120.04746
6. https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/algorithms
7. Edelson, D. P., Sasson,Topjian, A. A. (2020). Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates with Suspected or
Confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get with the Guidelines-Resuscitation Adult and Pediatric Task Forces of
the American Heart Association. Circulation, E933–E943. https://doi.org/10.1161/CIRCULATIONAHA.120.04746
8. European Society of cardiology. (2020). ESC Guidance for the Diagnosis and Management of CV Disease during the COVID-19 Pandemic. European Heart
Journal, 1–115.
9. Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 5-Circulation. 2015;132 (suppl 2):S414–S435
10. http://ecgguidelines.heart.org/wp-content/upload/2015-AHA-Guidelines-Highlights-Indonesia.pdf
11. https://www.physiciansweekly.com/cpr-in-covid-19-patients-has-a-low-survival-rate/
12. M. SenthilVelou, E. Ahila (2020). Happy hypoxemia: What has been forgotten.IAIM, 2020; 7(8): 75-79.,
13. Tobin, M. J., Laghi, F., & Jubran, A. (2020). Why COVID-19 silent hypoxemia is baffling to physicians. American Journal of Respiratory and Critical Care
Medicine, 202(3), 356–360. https://doi.org/10.1164/rccm.202006-2157CP
TERIMAKASIH...
Email : yudielyas@gmail.com
HP : 081316006831
IG : @YUDI ELYAS