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CRITICAL CARE

Co-Assistant:
Sasmiza 1161050078

Pembimbing :
dr. Christofel Panggabean, Sp.OG-KFM

Fakultas Kedokteran
Universitas Kristen Indonesia
MASALAH UTAMA

Perdarahan
Intermediate antepartum
Dan HDU
prematur
Sepsis
ICU
Gagal nafas
Postpartum akut
maternal
1%
0% dan 5%
8/1000
Berghella Vincenzo. Maternal-Fetal Evidence Based Guidelines. Third Edition. CRC Press. Philadelphia. 2017. 349-363
Angka Morbiditas

4/1000 14/1000
Kanada
(1991-2001) (2003-2007)

75% severe 129,1/10.000 severe


5,1/1000 morbiditi morbiditi
USA (1991- 114% rawat 29/10.000 rawat inap
2003) inap postpartum pp
(1998-2009) (2009)

Angka kelahiran 4 juta per tahun 50.000 morbiditas selama


kehamilan dan post partum
Berghella Vincenzo. Maternal-Fetal Evidence Based Guidelines. Third Edition. CRC Press. Philadelphia. 2017. 349-363
Definisi Mortalitas Maternal dan Severe Morbiditi Maternal
(or Near-Miss Maternal Mortality)
DEFINISI
Mortalitas Maternal bukan oleh kecelakaan/isidensi
Kehamilan terkait tanpa sebab kematian lain
kematian
Kematian obstetri Komplikasi obstetri (kehamilan, partus, masa
direk nifas)
Kematian obstetri sebelum atau selama kehamilan secara tidak
indirek langsung
Kematian maternal Direk atau indirek obstetri >42 hari dan < 1
terlambat tahun setelah terminasi kehamilan
Severe maternal Hampir meninggal selama kehamilan, partus atau
morbiditas 42 hari terminasi
Severe maternal 4/ > unit sel darah merah dan/atau masuk ICU
morbiditas
Berghella Vincenzo. Maternal-Fetal Evidence Based Guidelines. Third Edition. CRC Press. Philadelphia. 2017. 349-363
DEFINISI
Perawatan khusus pada kasus yang
mengancam nyawa dan membutuhkan
peralatan lengkap

Berghella Vincenzo. Maternal-Fetal Evidence Based Guidelines. Third Edition. CRC Press. Philadelphia. 2017. 349-363
Terapi penuh atau
pasien post operasi

ICU Obstetri High


Dependency Unit perawatan
Unit step-down,
progressive
dan
intermediate

Hemoragik dan Hipertensi


Berghella Vincenzo. Maternal-Fetal Evidence Based Guidelines. Third Edition. CRC Press. Philadelphia. 2017. 349-363
Pertimbangan Transfer Pasien ICU
Risiko tinggi

antepartum

KOMPLIKASI
<36 minggu
(31-32 minggu)
Berghella Vincenzo. Maternal-Fetal Evidence Based Guidelines. Third Edition. CRC Press. Philadelphia. 2017. 349-363
Level ICU dewasa menurut The American College of Critical Care
Medicine (ACCM)

Level I :
RS pusat, komprehensif, perawatan khusus,
teknologi canggih (tabel peralatan &pendukung ICU)

Level II :
Komprehensif, spesialis kurang lengkap

Level III : ruang stabilisasi

Berghella Vincenzo. Maternal-Fetal Evidence Based Guidelines. Third Edition. CRC Press. Philadelphia. 2017. 349-363
Peralatan dan pendukung ICU
Monitor ECG (99%) Beds removeable Capnography
Monitor tekanan Cahaya ruang yang Bronkoskopi fiberoptik
arteri (51%) cukup Monitor tekanan
Monitor tekanan vena Suction intrakranial
central Selimut Monitor EEG
Transcutaneous Timbangan Tekanan + dan ruang
oxygen/Pulse Alat pacu jantung isolasi
oximetry (33%) Alat pemantau suhu Akses informasi segera
Alat bantu nafas Montior tekanan arteri (buku petunujuk RS)
Alat ventilator pulmonalis
Alat resusitasi darurat Monitor cardiac output
Alat hemodinamik Dialisis dan ultrafiltrasi
pasien Dialisis peritoneal
Berghella Vincenzo. Maternal-Fetal Evidence Based Guidelines. Third Edition. CRC Press. Philadelphia. 2017. 349-363
Observer per jam
u/:
o Input/output
o Vital signs
o Neurologi

Komplikasi:
Gagal nafas
e.c infeksi
saluran nafas
(ventilator)

Berghella Vincenzo. Maternal-Fetal Evidence Based Guidelines. Third Edition. CRC Press. Philadelphia. 2017. 349-363
The American College of Obstetricians and Gynecologists,
jointly with the Society for Maternal-Fetal Medicine tentang
Fasilitas Perawatan Maternal

Level I dan II : Unit perawatan step-down,


progressive dan intermediate

Level III :fasilitas ICU dan penyedia


layanan critical care

Level IV :fasilitas dan tim ibu-janin,


dan keadaan kompleks
Berghella Vincenzo. Maternal-Fetal Evidence Based Guidelines. Third Edition. CRC Press. Philadelphia. 2017. 349-363
Level Critical Care dari the Intensive Care Society (ICS)
United Kingdom

Level 0 : perawatan bangsal


Level 1 : pasien berisiko buruk
Level II : kegagalan 1 organ
Level III : kegagalan > 1 organ dan
membutuhkan ventilasi

Berghella Vincenzo. Maternal-Fetal Evidence Based Guidelines. Third Edition. CRC Press. Philadelphia. 2017. 349-363
Tingkat Perawatan Critical Care
Menurut Kelompok Maternal
Tingkat Perawatan Contoh Maternal

Level 0 : perawatan Risiko rendah


bangsal
Level 1 : monitor/ Risiko hemoragik, infus oksitosin,
intervensi/ dibawah antihipertensi oral pada mild
level ICU preeklampsia/restriksi cairan
Level 2: Bantuan BRS, BCVS, ACVS, neurological support
satu organ
Level 3: bantuan ARS, bantuan 2/lebih sistem organ
respirasi atau disertai
> 2/ > sistem organ
Berghella Vincenzo. Maternal-Fetal Evidence Based Guidelines. Third Edition. CRC Press. Philadelphia. 2017. 349-363
Parameter Objektif Kriteria Penerimaan ICU
Vital Signs:
HR : <40x/>150x/m PF:
MAP : <60mmHG Obstruksi jalan nafas
BP : >120 mm Luka bakar >10%
diastolik Tamponade jantung
RR : >35/m Coma
Kejang, sianosis
Pupil berbeda ukuran

Berghella Vincenzo. Maternal-Fetal Evidence Based Guidelines. Third Edition. CRC Press. Philadelphia. 2017. 349-363
Parameter Objektif Kriteria Penerimaan ICU
Hasil Lab:
Sodium s: <110/>170 mEq/L ECG:
Radiologi:
Pottassium s: <2.0/>7.0 Komplek aritmia,
Perdarahan
mEq/L CHF/ hemodinamik
serebroaskular,
PaO2 : <50 mmHg tidak stabil
kontusio, atau SAH
pH : <7.1/>7,7 Ventricel
Viscus ruptur/
Kalsium s: >15 mg/dL takikardia/
varises esofagus
Glukosa s: >800 mg/dL ventrikel fibrilasi
d/ hemodinamik
Level toxic obat secara Complete heart tidak stabil
hemodinamik atau block
Diseksi aorta
neurologis
aneurisma
Berghella Vincenzo. Maternal-Fetal Evidence Based Guidelines. Third Edition. CRC Press. Philadelphia. 2017. 349-363
Keterampilan petugas kesehatan dalam critical
care:

Berghella Vincenzo. Maternal-Fetal Evidence Based Guidelines. Third Edition. CRC Press. Philadelphia. 2017. 349-363
SEPUTAR SEPSIS OBSTETRI

Syok Septik mortalitas 35-54%

Berghella Vincenzo. Maternal-Fetal Evidence Based Guidelines. Third Edition. CRC Press. Philadelphia. 2017. 349-363
Seputar Sepsis Obstetri

Penyebab
1. Infeksi uteri
1. Infeksi genitalia20%
2. Korioamnionitis
2. ISK 34%
dan
endomiometritis 3. Infeksi saluran nafas 9%
3. Aborsi septik 4. Tidak diketahui 30%
4. Luka infeksi
5. invasif

Berghella Vincenzo. Maternal-Fetal Evidence Based Guidelines. Third Edition. CRC Press. Philadelphia. 2017. 349-363
Sepsis
Gold standars

Quick Sequential Organ Failure


Assessment (qSOFA) score
1. BP sistolik 100 mmHg
2. RR 22 x/ m
3. Penurunan kesadaran

Berghella Vincenzo. Maternal-Fetal Evidence Based Guidelines. Third Edition. CRC Press. Philadelphia. 2017. 349-363
Formulir Diagnostik Kriteria Sepsis
Infeksi, dokumentasi atau suspek dan disertai:
Variabel General:
Demam (>38,3C)
Hipotermia ( <36C)
HR > 90/m atau >2 SD angka normal
Takipnea
Penurunan kesadaran
Edema signifikan/ gangguan keseimbangan
cairan (>20 mL/kgBB/24 jam)
Hiperglikemia (>140 mg/dL)
Berghella Vincenzo. Maternal-Fetal Evidence Based Guidelines. Third Edition. CRC Press. Philadelphia. 2017. 349-363
Variabel Inflamasi :
1. Leukositosis (WBC>12.000/uL)
2. Leukopenia (WBC<4.000/uL)
3. WBC normal dengan neutrofil > 10%
4. Protein plasma C-reaktif > 2 SD
5. Prokalsitonin plasma . 2SD

Berghella Vincenzo. Maternal-Fetal Evidence Based Guidelines. Third Edition. CRC Press. Philadelphia. 2017. 349-363
Berghella Vincenzo. Maternal-Fetal Evidence Based Guidelines. Third Edition. CRC Press. Philadelphia. 2017. 349-363
Berghella Vincenzo. Maternal-Fetal Evidence Based Guidelines. Third Edition. CRC Press. Philadelphia. 2017. 349-363
* Modifikasi pada kehamilan

Berghella Vincenzo. Maternal-Fetal Evidence Based Guidelines. Third Edition. CRC Press. Philadelphia. 2017. 349-363
Klasifikasi dan Kriteria Terbaru Sepsis
(Sepsis-3)

Berghella Vincenzo. Maternal-Fetal Evidence Based Guidelines. Third Edition. CRC Press. Philadelphia. 2017. 349-363
Tatalaksana Sepsis (2012)
Antimikroba spektrum luas 1 jam
(7-10 jam)

Antibiotik <45 menit


(2% of >40.000 )

Control sumber (<12 jam ) atau


a. Maternal morbiditi (3%)
b. Infant mortaliti (33%)
c. Infant morbiditi (75%)
Berghella Vincenzo. Maternal-Fetal Evidence Based Guidelines. Third Edition. CRC Press. Philadelphia. 2017. 349-363
Core Bundles for Management of Sepsis
(SSC)
Laktat level

Kultur darah antibiotik 3

J
Antibiotik spektrum luas A
M

Kristaloid 30 mL/kgBB jika


Hipotensi atau laktat 4 mmol/L

Berghella Vincenzo. Maternal-Fetal Evidence Based Guidelines. Third Edition. CRC Press. Philadelphia. 2017. 349-363
Core Bundles for Management of Sepsis
(SSC)
resusitasi cairan vasopresor

Pertahankan MAP> 65 mmHg, cairan tercukupi, 6


laktat > 4mmol/L
J
A
Nilai kembali status voliume dan perfusi jaringan
M

Periksa ulang laktat yang


Berghella Vincenzo. Maternal-Fetal Evidence Based Guidelines. Third Edition. CRC Press. Philadelphia. 2017. 349-363
Terapi Tambahan untuk Hemodinamik

1. Pemberian cairan kristaloid


2. Cairan awal 30 mL/kg pada hipoperfusi jaringan
3. Vasopressor (norepinephrine) MAP 65 mmHg
4. Pemberian dobutamin pada disfungsi miokard/hipoperfusi lanjut
5. Kortikosteroid jika terapi sebelumnya gagal

Berghella Vincenzo. Maternal-Fetal Evidence Based Guidelines. Third Edition. CRC Press. Philadelphia. 2017. 349-363
Sindrom Distress Pernafasan Akut
3/10.000 postpartum

= edema paru tipe nonkardiogenik

Sindrom dari inflamasi dan


permeabilitas kapiler paru
Berghella Vincenzo. Maternal-Fetal Evidence Based Guidelines. Third Edition. CRC Press. Philadelphia. 2017. 349-363
Definisi ARDS (menurut Berlin)
Waktu 1 minggu sindrom respirasi
Foto Bilateral opaque
Thoraks
Sumber Tatalaksana objektif
edema
Oksigenasi
- Ringan - 200<mmHg<PaO2/FIO2 300 mmHg
- Sedang d/ PEEP/CPAP 5 cm H2O
- Berat - 100mmHg<PaO2/FIO2 200 mmHg
d/ PEEP 5 cm H2O
- PaO2/FIO2 100 mmHg
d/ PEEP 5cm H2O
Berghella Vincenzo. Maternal-Fetal Evidence Based Guidelines. Third Edition. CRC Press. Philadelphia. 2017. 349-363
Pantau ARDS !!!
SpO2 > 95% atau PaO2 > 60 mmHG
(ibu hamil)

airway pressure release


ventilation (ARPV)
PEEP (28-33 cm H2O) dan
(8-10 cm H2O)
pO2 31-42 mmHg
(fetal umbilicus)

Death 24-44% 2x ibu hamil


Berghella Vincenzo. Maternal-Fetal Evidence Based Guidelines. Third Edition. CRC Press. Philadelphia. 2017. 349-363
TERIMAKASIH

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