Pertanyaan Lapsus Adzkia

1. Mengapa pada pasien, dilakukan prosedur kolostomy terlebih dahulu dan harus
menunggu untuk dilakukan duhamel? Apa saja indikasinya?.
Prosedur kolostomi dilakukan pada pasien kemungkinan untuk tujuan dekompresi dan
memungkinkan untuk menambah berat badan sebelum dilakukannya duhamel.
Prosedur operasi dapat dilakukan sekaligus atau bertahap, tergantung derajat
keparahan dari penyakit. Pasien Hirschsprung disease segmen pendek tanpa komplikasi
dapat langsung menjalani pull-through operation. Namun, jika ditemukan enterokolitis
atau kolon yang sangat terdilatasi maka langkah awal adalah melakukan kolostomi
dekompresif dahulu. Biasanya, jarak antara kolostomi dan reseksi definitif adalah 6 bulan.
Indikasi dilakukannya kolostomi yaitu apabila terdepat dilatasi colon proksimal yang
parah, enterokolitis parah, perforasi, malnutrisi, dan ketidakmampuan untuk secara akurat
menentukan zona transisi antara usus sehat dan usus aganglionik.

2. Setelah operasi, kapan pasien tersebut bisa dibolehkan untuk makan minum?
Pasca operasi, pasien akan dapat cairan infus dan antibiotik; namun, tidak ada yang
dapat diberikan secara oral sampai keluarnya flatus atau feses yang menandakan
kembalinya fungsi usus. Jika bayi baru lahir menjalani colostomy, juga sama, harus
nunggu pengeluaran flatus atau feses dari stoma sebelum pemberian makanan oral.
Pemberian makanan rata-rata dimulai pada hari kedua sesudah operasi dan pemberian
nutisi enteral secara penuh dimulai pada pertengahan hari ke empat pada pasien yang
sering muntah pada pemberian makanan. Intolerasi protein dapat terjadi selama periode
ini dan memerlukan perubahan formula. ASI tidak dikurangi atau dihentikan.

3. Intervensi apa yang bisa dilakukan keluarga dirumah apabila mengetahui bahwa
anaknya menderita hirscsprung disease?
Yang bisa dilakukan keluarga saat dirumah atau ketika menunggu prosedur operasi
dilakukan adalah dengan cara melakukan perawatan untuk memastikan bahwa usus besar
telah didekompresi secara adekuat dan tanda atau gejala enterokolitis tidak berkembang.
Ajari keluarga teknik dekompresi dan irigasi rektal karena terapi ini membantu mengurangi
dilatasi kolon dalam persiapan pembedahan. irigasi rektal dilakukan untuk dekompresi usus,
mengatasi obstruksi usus, dan agar pasien dapat diberikan terapi nutrisi enteral. Irigasi rektal
dilakukan menggunakan cairan salin normal, sebanyak 1–3 kali/hari. Pasien yang tidak
berespon baik terhadap irigasi rektal, biasanya ternyata memiliki segmen aganglionik yang
lebih panjang.
Irigasi usus melalui rektum atau washout merupakan suatu prosedur menggunakan
sebuah pipa yang dimasukkan melalui anus dan sejumlah cairan dimasukkan melalui pipa
tersebut dengan tujuan untuk membersikan usus. NaCl 0,9% sering digunakan pada pasien–
pasien penderita penyakit Hirschsprung sebagai cairan washout. Ada berbagai jenis cairan
washout yang digunakan, beberapa diantaranya berupa cairan siap pakai yang dapat dibeli di
apotek atau toko obat, cairan lainnya dapat dibuat di rumah yaitu larutan garam. Larutan
garam ini dianggap sama dengan NaCl 0,9%.

……………………………….

4. Mengapa bisa terjadi komplikasi enterocolitis?

5. Mengapa procedure Duhamel yang dipilih dari pada prosedur operatif lainnya?
 Untuk menghindari diseksi pelvis pada prosedur Swenson
• Manipulasi rektum dilakukan secara anterior, mempertahankan pleksus
saraf otonom dari system genitourinaria
• Menggunakan stapling otomatis
• Usus yang berganglion ditarik sampai 1 cm di atas linea Dentata

Advantages of the Duhamel operation include technical ease and a

theoretically lower risk of stricture because the anastomosis is so wide.
Reported long-term results of the Duhamel procedure have been similar to
those with the other two operations.

6. Antibiotiik apa yang dapat diberikan post op?

Pemberian antibiotik juga direkomendasikan sebelum operasi definitif. Pemberian
antibiotik, misalnya metronidazole, terbukti menurunkan infeksi luka postoperative
sebanyak 75%. Pemberian antibiotik dapat dilanjutkan hingga 24–48 jam setelah operasi

Tujuan farmakoterapi adalah memberantas infeksi, mengurangi morbiditas, dan

mencegah komplikasi. Segera setelah kolostomi pengalihan dibuat atau prosedur pull-
through definitif dilakukan, pasien sering tetap menggunakan antibiotik intravena
spektrum luas (misalnya, ampisilin, gentamisin, dan metronidazol) sampai fungsi usus
telah kembali dan tujuan makan tercapai.
Setelah prosedur pull-through definitif dilakukan dan fungsi usus normal diperoleh, tidak
diperlukan pengobatan tambahan. Terapi antimikroba empiris harus komprehensif dan
mencakup semua kemungkinan patogen dalam konteks pengaturan klinis ini. Pemilihan
antibiotik harus dipandu oleh sensitivitas kultur darah bila memungkinkan.
Ampisilin (Marcillin, Omnipen, Principen)
Aktivitas bakterisida terhadap organisme yang rentan. Alternatif untuk amoksisilin ketika
tidak dapat minum obat secara oral.

Gentamisin (Garamisin, Jenamisin)

Antibiotik aminoglikosida untuk cakupan gram negatif. Digunakan dalam kombinasi
dengan agen melawan organisme gram positif dan yang mencakup anaerob. Bukan DOC.
Pertimbangkan apakah penisilin atau obat lain yang kurang toksik merupakan
kontraindikasi, bila terindikasi secara klinis, dan pada infeksi campuran yang disebabkan
oleh stafilokokus yang rentan dan organisme gram negatif.
Regimen dosis banyak; sesuaikan dosis berdasarkan CrCl dan perubahan volume
distribusi. Dapat diberikan IV/IM.

Metronidazol (Flagyl)
Antibiotik berbasis cincin Imidazole aktif melawan berbagai bakteri anaerob dan
protozoa. Digunakan dalam kombinasi dengan agen antimikroba lainnya (kecuali untuk
enterokolitis Clostridium difficile).

7. Indikasi dilepas kateter pada pasien? Mengapa tidak langsung dilepas padahal tidak
terdapat masalah pada urin?

Lepaskan kateter urin segera setelah berkemih normal diharapkan setelah

operasi dasar panggul. Indikasi untuk mempertahankan kateter urin pada tempatnya
adalah anestesi epidural pasca operasi. Pantau kecukupan keluaran urin pasca operasi,
karena retensi urin setelah pelepasan kateter dapat terjadi setelah anestesi atau dengan
pembengkakan jaringan pasca operasi di dasar panggul.

…………………………...
Rectal irrigation before the surgery and in the management of HAEC is highly
recommended. It might have a couple of crucial advantages, including colon size
decompression and preventing the most devastating complication, enterocolitis. Surgical
planning is profoundly affected by the presence of comorbidities, while short-segment
HD without any comorbidities can be subjected to a single-stage pull-through procedure.
contrast, in the presence of HAEC or a remarkably dilated colon, a staged reconstruction,
starting with a temporary decompressive colostomy, should be preferred.
The recommended timing for a definite pull-through procedure varies from four to six
months following colostomy placement.
The preferred management of each patient affected with HAEC is based on the
corresponding clinical grade. In grade I or possible HAEC, outpatient management with
oral metronidazole accompanied by fluid and electrolytes might be considered. The more
severe cases, including definite and severe HAEC, should be admitted to the hospital and
treated with intravenous fluid resuscitation and broad-spectrum antibiotics. Rectal
irrigation to remove the retained stool and decrease the bacterial load might be considered
in those with abdominal distention, irrespective of the HAEC grade. Surgical intervention
with a proximal colostomy might be considered in those children with severe HAEC who
fail to respond to primary medical management with bowel rest, intravenous fluid
resuscitation, rectal irrigations, and broad-spectrum antibiotics
………….

Meskipun pendidikan bedah standar menganjurkan itu

Pendekatan lain termasuk primer yang tertunda

operasi definitif tanpa colostomy ketika
neonatus memiliki evakuasi harian yang memadai dengan penggunaan
supositoria, dilatasi rektum dan enema dan
tetap bernutrisi dengan baik.[2] Kami, dalam penelitian kami, memiliki
mencoba melewati kolostomi awal dengan efektif
pencucian rektal.
.
………………………………………
How much 0.9% Sodium Chloride do I use?

It will depend on the infant’s weight and condition. It should be warm sterile 0.9%
Sodium Chloride, and instilled in stages. Each instillation should rarely exceed
10ml/kg body weight and the total volume used can be between 50-500mls per
kilogram of body weight. The volume should be confirmed by the treating Paediatric
Surgeon (e.g. if the baby weighs 3kgs, a maximum of 1500mls of the solution may be
required, but only 20-30mls of fluid should be instilled each time).

While in the hospital, the 0.9% Sodium Chloride solution is stored in a warming
cabinet at a temperature of 37-38 degrees. At home parents are advised to stand the
bottles of 0.9% Sodium Chloride in a basin of hot water. The temperature of the fluid
should be “hand hot”.

Equipment.
Warm sterile 0.9% Sodium Chloride.
Lubricating gel – alcohol free
Disposable bowl and jug.
Rectal tube (Jacques catheter – size 10-16FR).
50ml bladder-tip syringe.
Apron and gloves.
Incontinence pads.
Towels
Nappy and wipes.
Disposable bag.
Procedure

Prepare equipment and ensure a warm environment.

Wash hands and put on gloves and apron.
Assess and record the abdominal findings. Seek advice from clinicians if it appears
firm, tense or tender.
Wrap the baby in a towel or blanket leaving the buttocks exposed.
Lay the baby in a comfortable position (lying the baby on his/her left side will aid the
flow of the solution into the rectum, but can be performed in any position as long as
the baby is comfortable.)
Apply lubricating gel to the tip of the catheter and gently insert the catheter into the
rectum, initially 10 cms.
Fill the syringe to 20-30mls and gently instil the 0.9% Sodium Chloride and then
aspirate the fluid back, if the tubing collapses and the fluid does not aspirate back
remove the syringe and allow the fluid to drain out from the catheter onto the pad. As
the fluid aspirated becomes clearer the catheter should be advanced in small
increments, continuing to instil and aspirate fluid till catheter fully inserted or
resistance is felt.
Withdraw the catheter in small increments and repeat the above procedure.
Observe and record the colour, consistency and smell of the effluent.
The total volume instilled should be recorded.
Assess and record the abdomen (as above)
At the end of the procedure, wash and dry buttocks and apply barrier cream.
Dispose of the soiled fluid. Discard all used supplies as per hospital policy.
An initial total volume of 50mls/kg is recommended and gradually increased over the
first few days until effective decompression is achieved (the total volume of 0.9%
Sodium Chloride should not exceed 500mls/kg). If maximal volumes are consistently
required, medical staff should be consulted regarding the need to assess for serum
biochemical instability (U&Es). If the abdomen is not adequately decompressed or
the returning fluid remains dirty, twice or even three times daily washouts maybe
required initially.

Signs of Entercolitis

Offensive smelling stools.

Unusual colour of stools.
Looser consistency, explosive stools.
Blood in stools.
Pyrexia
Lethargy, poor feeding, vomiting, pallor.
Obtain stool sample and alert clinical team.
Problem solving for rectal washout in HD

Most of the problems with the process of the washout involve stools that are too thick
and block the tube or prevent the tube from passing into the rectum.

If the tube becomes blocked remove it and flush the catheter with the solution till
catheter is cleared and then recommence procedure.
Difficulty advancing rectal tube – Initially try smaller size of catheter. Try
repositioning baby and gently move the tube around to re-position the tip of the tube.
Also could be caused by tube kinking within the bowel, remove tube and re-insert.
If there is difficulty in passing the tube initially; this can be eased by introducing the
catheter and advancing the tube whilst flushing with 0.9% Sodium Chloride.
Never force the tube in.
Occasional specks of blood may be seen in the tubing, due to the irritation of the tube
with the intestinal tract.
Fresh bleeding down the catheter- stop the rectal washout and alert the clinical team.
Solution does not drain out fully- check tube is not blocked, reposition baby. Observe
nappies as the baby may pass fluid/stool later.
Inform clinical team if problem persists.
…………………………
How much 0.9% Sodium Chloride do I use?

It will depend on the infant’s weight and condition. It should be warm sterile 0.9%
Sodium Chloride, and instilled in stages. Each instillation should rarely exceed
10ml/kg body weight and the total volume used can be between 50-500mls per
kilogram of body weight. The volume should be confirmed by the treating Paediatric
Surgeon (e.g. if the baby weighs 3kgs, a maximum of 1500mls of the solution may be
required, but only 20-30mls of fluid should be instilled each time).

While in the hospital, the 0.9% Sodium Chloride solution is stored in a warming
cabinet at a temperature of 37-38 degrees. At home parents are advised to stand the
bottles of 0.9% Sodium Chloride in a basin of hot water. The temperature of the fluid
should be “hand hot”.

Equipment.

Warm sterile 0.9% Sodium Chloride.

Lubricating gel – alcohol free
Disposable bowl and jug.
Rectal tube (Jacques catheter – size 10-16FR).
50ml bladder-tip syringe.
Apron and gloves.
Incontinence pads.
Towels
Nappy and wipes.
Disposable bag.
Procedure

Prepare equipment and ensure a warm environment.

Wash hands and put on gloves and apron.
Assess and record the abdominal findings. Seek advice from clinicians if it appears
firm, tense or tender.
Wrap the baby in a towel or blanket leaving the buttocks exposed.
Lay the baby in a comfortable position (lying the baby on his/her left side will aid the
flow of the solution into the rectum, but can be performed in any position as long as
the baby is comfortable.)
Apply lubricating gel to the tip of the catheter and gently insert the catheter into the
rectum, initially 10 cms.
Fill the syringe to 20-30mls and gently instil the 0.9% Sodium Chloride and then
aspirate the fluid back, if the tubing collapses and the fluid does not aspirate back
remove the syringe and allow the fluid to drain out from the catheter onto the pad. As
the fluid aspirated becomes clearer the catheter should be advanced in small
increments, continuing to instil and aspirate fluid till catheter fully inserted or
resistance is felt.
Withdraw the catheter in small increments and repeat the above procedure.
Observe and record the colour, consistency and smell of the effluent.
The total volume instilled should be recorded.
Assess and record the abdomen (as above)
At the end of the procedure, wash and dry buttocks and apply barrier cream.
Dispose of the soiled fluid. Discard all used supplies as per hospital policy.
An initial total volume of 50mls/kg is recommended and gradually increased over the
first few days until effective decompression is achieved (the total volume of 0.9%
Sodium Chloride should not exceed 500mls/kg). If maximal volumes are consistently
required, medical staff should be consulted regarding the need to assess for serum
biochemical instability (U&Es). If the abdomen is not adequately decompressed or
the returning fluid remains dirty, twice or even three times daily washouts maybe
required initially.

Signs of Entercolitis

Offensive smelling stools.

Unusual colour of stools.
Looser consistency, explosive stools.
Blood in stools.
Pyrexia
Lethargy, poor feeding, vomiting, pallor.
Obtain stool sample and alert clinical team.
Problem solving for rectal washout in HD

Most of the problems with the process of the washout involve stools that are too thick
and block the tube or prevent the tube from passing into the rectum.

If the tube becomes blocked remove it and flush the catheter with the solution till
catheter is cleared and then recommence procedure.
Difficulty advancing rectal tube – Initially try smaller size of catheter. Try
repositioning baby and gently move the tube around to re-position the tip of the tube.
Also could be caused by tube kinking within the bowel, remove tube and re-insert.
If there is difficulty in passing the tube initially; this can be eased by introducing the
catheter and advancing the tube whilst flushing with 0.9% Sodium Chloride.
Never force the tube in.
Occasional specks of blood may be seen in the tubing, due to the irritation of the tube
with the intestinal tract.
Fresh bleeding down the catheter- stop the rectal washout and alert the clinical team.
Solution does not drain out fully- check tube is not blocked, reposition baby. Observe
nappies as the baby may pass fluid/stool later.
Inform clinical team if problem persists.