Diskusi kasus

Pasien HD di ICU/HCU

PRIMA FEBRIYANTO
 Identitas Pasien

 Nama : Ny. A
 Usia : 62 tahun
 Alamat : Tangerang
 Pembiayaan : Pribadi
 Anamnesis

 Pasien datang ke IGD RSSAC tanggal 20/11/2017

dengan penurunan kesadaran bertahap sejak 3 hari
SMRS
 Pasien rutin HD 2x/ minggu sejak 1 tahun yang lalu
di RS luar, HD terakhir 3 hari yang lalu dan pasien
mulai bicara meracau pasca HD
 Sejak 2 hari SMRS timbul lenting di tungkai kiri
 Sejak 1 hari SMRS pasien mulai cenderung tidur,
terkadang gelisah dan mengamuk
 Riwayat Penyakit Dahulu

 Stroke iskemik tahun 2016

 Diabetes Melitus sejak ± 20 tahun yang lalu
 Pemeriksaan Fisik

 Keadaan Umum = sakit berat

 GCS 9(E=2,M=5,V=2)
 Tanda- Tanda Vital
TD = 170/100 mmhg
Frek Napas = 20 x/ menit
Nadi = 94x/ menit
Suhu = 36,9°C
 Kepala = normochepali, Mata = sclera ikterik(-/-),konj. Pucat(+),
terpasang NGT (kecoklatan)
 Leher = jvp 5-2cmhg,KGB tidak membesar
 Paru = bunyi napas vesikuler, Ronkhi (- /-),wheezing (-/-)
 Jantung = BJ I-II regular,gallop (-),murmur (-)
 Abdomen = soepel, lemas dan datar,BU normal,Hepar dan Lien tdk
teraba, pain(-/-)
 Ekstremitas = akral hangat, terdapat akses AV Vistula di lengan kiri,
oedema pretibial(+/+), vesikel berkelompok pada tungkai
kiri
 Status Gizi

 BB : 55 kg
 TB : 160 cm
 IMT : 22.6 kg/m2
 Hasil Laboratorium
 Hb: 7.4 g/dl
 Ht: 21.5 %
 Leukosit: 6390/ul
 Trombosit: 218.000/ul
 SGOT: 49 U/L
 SGPT: 54 U/L
 Protein total: 7 g/dl
 Albumin: 3.69 g/dl
 Globulin: 3.31 g/dl
 Creatinin darah: 8.20 mg/dl
 Ureum darah: 102 mg/dl
 eGFR: 4.8 ml/min/1.73m2
 Serum iron (Fe): 48 ug/dl
 TIBC: 137 ug/dl
 Saturasi Transferin: 35%
 Ferritin: 1273 ng/dl
 Gula darah puasa: 263mg/dl
 Na+: 135 mEq/L
 K+: 3.91 mEq/L
 Cl-: 90 mEq/L
 Ca+: 9.2 mg/dl
 Fosfat inorganik: 2 mg/dl
 Pemeriksaan penunjang

 Ro thorax
Cardiomegali, tampak infiltrat di paracardial
dan perihiler kanan
 Brain CT Scan non contrast
Infarct multipel di ventrikel lateral kanan dan
kiri, cornu anterior dan ganglia basalis, atrofi
cerebri
 Daftar Masalah

 Penurunan kesadaran e.c. Encephalitis viral susp.

VZV
 CKD stage V on HD
 Herpes zoster L2-L3 tungkai kiri
 Stroke infark lama

 Pasien HD di ICU-HCU
 Obat- obatan

 Bicnat 3x1 tab po  Zovirax 1x750mg iv

 Vit. B12 2x50mg po  Ceftriaxone 1x2gr iv
 Vit. B6 2x10mg po  Azitromycin 1x500mg po
 Asam folat 2x5mg po  Omeprazole 2x40mg
 Inpepsa 3x15ml po  Lantus 1x20 unit sk
 Domperidone syrup  Novorapid 3x5 unit sk
2x600mg  Diberikan diet cair DM 1700 Kcal via
NGT
 Clonidin 3x0.15mg po
 Perdipine 1mg/jam
 Amlodipine 1x10mg po
 Riwayat Hemodialisis

• Mulai HD: Februari 2016

• Saat ini 2x seminggu.
• Berat badan kering : tidak diketahui
• Akses vaskuler:
– Fistula AV (CIMINO), lokasi lengan kiri

• Resep HD saat ini:

– Lama HD 4 jam
– UF goal 2500 ml
– Qb 200 ml/menit, Qd 500 ml/menit
– Heparin minimal ( kontinyu 2000 IU)
 Hasil Pemantauan HD
PRE-HD 1 2 3 4 5
WAKTU
15.20 15.35 16.30 17.30 18.30 19.30
BB (kg)
Tidak
ditimbang
Kesadaran
Sopor Sopor Sopor Sopor Sopor Sopor
TD (mmHg) 171/73 170/70 179/82 195/73 185/75 188/65
Suhu (oC)
36,5 36,5 36,5 36,5 36,5 36,5
Nafas (x/min)
24 24 24 20 20 20
Nadi (x/min)
98 98 100 95 96 98
QB
200 220 220 220
Tekanan vena
120 120 120 120
TMP
90 90 90 90
Vol yang ditarik
670 1300 1610 2500
Keluhan Kontak tidak Kontak tidak Kontak tidak Kontak tidak Kontak tidak
adekuat adekuat adekuat adekuat adekuat
Asesmen intervensi Identifikasi Mulai Observasi Observasi Observasi Terminasi
HD/Observasi
 Pembahasan

 Management of ESKD patients in ICU

 Volume status control
 Administer isotonic fluids to maintain a normal serum sodium
concentration and tonicity
 Perform a daily assessment of weight, fluid intake and output
 Monitor central venous pressure, central venous oxygen saturation
 Perform hemodynamic invasive monitoring
 Electrolyte control
 Consider insulin and salbutamol to treat hyperkalemia and initiate A-
RRT promptly
 Avoid hypokalemia during RRT because of risk of cardiac
arrhythmias
 Hypotonic hyponatremia, hyperphosphatemia and hypocalcemia are
frequent
 Hypercalcaemia may be a consequence of excessive calcium
supplementation or related to the underlying cause of renal failure
 Dialysis access and vein preservation
 Consider absolute and relative indication to PD catheters use
 Avoid arteriovenous fistulas and grafts for CRRT, but consider it
for IHD or hybrid therapies in ICU, if necessary
 Avoid the placing of identification bands or restraints over the
fistula
 An internal jugular line for short-term or tunneled access is
recommended
 Minimize venipuncture, limit placement of peripherally inserted
central catheter and avoid the use of subclavian venous site
 Hemostasis
 Bleeding diatheses are frequent because of platelets dysfunction
and extracorporeal therapies
 Low-molecular-weight heparin to maintain patency of the
extracorporeal dialysis circuit is of similar efficacy and safety to
unfractionated heparin
 Sodium citrate may be used for ‘regional anticoagulation’ where
systemic anticoagulation is undesirable
 Administration of vasopressin analogues and/or conjugated
estrogens may complicate the management
 Imaging
 There is no need to perform HD immediately after radiocontrast
administration
 Drug use and adjustment
 Consider reduced GFR, the altered protein binding, the variable
volume of distribution and the RRT mode when you prescribe a drug
 The required dose of propofol should be titrated to effect and it is
better to avoid continuous infusion of Midazolam
 Morphine and Fentanyl accumulate in renal failure and it should be
used with caution. Remifentanil has no toxic effect
 The continuous infusion of Furosemide has greater effect, but the
increasing of diuretic dosage may cause diuretic resistance. The
concurrent use of a thiazide diuretic may improve loop diuretic
responsiveness
 Avoid undertreatment, adverse effects but also consider
pharmacokinetic/pharmacodynamic and extracorporeal clearance
prescribing an antibiotic
 Pilihan Modalitas RRT
Intermittent Hybrid Continuous

IHD SLEDD CVVH

Intermittent Sustained (or slow) Continuous veno-venous
haemodialysis low efficiency daily haemofiltration
dialysis

IUF SLEDD-F CVVHD

Isolated Continuous veno-venous
Ultrafiltration Sustained (or slow) haemodialysis
low efficiency daily
dialysis with
filtration CVVHDF
Continuous veno-venous
haemodiafiltration

SCUF
Slow continuous
ultrafiltration
 Intermittent hemodialysis (IHD)

• Oldest and most common technique

• Primarily diffusive treatment: blood and dialysate are

circulated in countercurrent manner
– Also some fluid removal by ultrafiltration due to
pressure driving through circuit

• Best for removal of small molecules

• Typically performed 4 hours 3x/wk or daily

 Intermittent Therapies - PRO

(Relatively) Inexpensive

Flexible timing allows for mobility/transport

Rapid correction of fluid overload

Rapid removal of dialyzable drugs

Rapid correction of acidosis & electrolyte abnormality

Minimises anticoagulant exposure

 Intermittent Therapies - CON

Hypotension 30-60%

Cerebral oedema Limited therapy duration

Renal injury & ischaemia

Gut/coronary ischaemia
 Continuous Renal Replacement Therapy

Defined as
– “Any extracorporeal blood purification therapy
intended to substitute for impaired renal function
over an extended period of time and applied for
or aimed at being applied for 24 hours /day.”
Bellomo R., Ronco C., Mehta R, Nomenclature for Continuous Renal
Replacement Therapies, AJKD, Vol 28, No. 5, Suppl 3, November 1996
 Continuous Therapies - PRO

Haemodynamic stability => ??? better renal recovery

Stable and predictable volume control

Stable and predictable control of chemistry

Stable intracranial pressure

Disease modification by cytokine removal (CVVH)?

 Continuous Therapies - CON

Anticoagulation requirements

Higher potential for filter clotting

Increased bleeding risk

Expense – fluids etc.
High heparin exposure

Immobility & Transport issues

 SLED(D) & SLED(D)-F : Hybrid therapy

 Conventional dialysis equipment

 Online dialysis fluid preparation
 Excellent small molecule detoxification
 Cardiovascular stability as good as CRRT
 Reduced anticoagulation requirement
 11 hrs SLED comparable to 23 hrs CVVH
 Decreased costs compared to CRRT
 Phosphate supplementation required
Fliser, T & Kielstein JT. Nature Clin Practice Neph 2006; 2: 32-39
Berbece, AN & Richardson, RMA. Kidney International 2006; 70: 963-968