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Skill station

Kasus : 1, Bayi baru lahir, SC,BB=2750 gram, AS 6-8 ( gambar )


Potensial Obstruksi jalan nafas
Carikan posisi nyaman
Berhasil TIDAK Berhasil
Pertahankan
Intubasi
Berhasil TIDAK Berhasil

Urgent Operasi
Poerwadi, Pediatric Surgeon
Devision of Pediatric Surgery,
Dr. Soetomo Hospital
Pecah kista  TRAKHEOSTOMY
SURABAYA
Classification
WATERSTON Parameter
A
Pertanyaan 1 :
Birth weight over 2500g and well

Apa diagnosis pasien ini ?


Boutlet obstruction
Birth weight 1800 g to 2500 g and well or over 2500 g with
moderate pneumonia and congenital anomaly
A. Gastric

Chypertrophic pylorus stenosis


Birth weight under1800 g and well or 1800 g to 2500 g
B. Infantil with severe pneumonia and severe congenital anomaly

C. Esophageal Atresia
Spitz
D. Duodenal obstruction
Group I Birth weight over 1500 g with no major cardiac anomaly

Group II Birth weight less than 1500 g or major cardiac anomaly

Group III Birth weight less than 1500 g and major cardiac anomaly
MANAGEMENT

GASTROSTOMY

Gastrostomy : feeding
Gastrostomy : decompr

Gastrostomy : decompr
KASUS : 3
Bayi umur 7 hari, dari RS daerah : perut kembung.
Perut kembung 5 hari lalu, BAB, mekonium hari pertama, hari kedua
diberi makan pisang, mendadak tidak mau minum susu, muntah dan
perut kembung.
Muntah keruh, sedikit, sangat berbau, tidak menyemprot. Riwayat
kehamilan, lahir cukup bulan, ditolong bidan, segera menangis, berat
badan lahir 3200 gram .

Pemeriksaan fisik : Bayi berat badan saat ini 3000 gram, soporo
comateus, cowong, pucat, fontanela cekung, kulit sklerema,
temperatur rektal = 35,6, dyspnoe, RR= 12 X/ menit, dangkal, satu-
satu, ada periodic apnoe. Ronchi / whezing (-),
jantung : murmur (-), HR 60X/ mnt, acral pucat basah, dingin, pulse
oxymetri, saturasi perifer 65%. sudah terpasang infus Dextrose
5%,dengan scalp vein,
Poerwadi, Pediatric Surgeon
, Devision of Pediatric Surgery,
Dr. Soetomo Hospital
SURABAYA
Abdomen kembung hebat, mengkilat, sklerema,kolateral vena banyak,
bising usus tak terdengar, pekak hati hilang, didapatkan cairan bebas.
Terpasang kateter urethra, urine kosong, sejak 1 hari ini..................
Foto polos perut :

Pertanyaan : apa problem pasien


ini ?, tindakan apakah yang
saudara kerjakan saat itu.
Poerwadi, Pediatric Surgeon
Devision of Pediatric Surgery,
Dr. Soetomo Hospital
SURABAYA
Apa yg hrs
dikerjakan,
Dok ?

Poerwadi, Pediatric Surgeon


Devision of Pediatric Surgery,
Dr. Soetomo Hospital
SURABAYA
Pertanyaan 1 :
Apa PROBLEM yg terjadi pada pasien ini ?, bagaimana
langkah yg dikerjakan
A. Penyakit Hirschsprung

B. Peritonotis generalisata

C. Shock

D. Sepsis

E. Adominal Kompartement Syndrome


Adominal Kompartement Syndrome (ACS):
• ACS  distress nafas, shock, gangguan perfusi & oksigenasi
jaringan  MOF.
• Release : secure airway, bantu ventilasi & oksigenasi,
decompression , restore volume cairan, kuras cairan di rongga
ketiga, antibiotika terapi.
Pertanyaan 2 :
Bagaimana langkah selanjutnya ?
A. Ppasang infus.
agging Ventilation
B. Berikan oksigen dengan masker.
C. Respirator. irculation & perfussion
D. Resusitasi.
iseases / iagnostic

nvironment & stablishment

Close
Monitoring
Pertanyaan 2 :
Bagaimana caranya secure airway ?
A. Posisi, chin lift, jaw trust.
B. Dengan oropharyneal tube.
C. Dengan laryngeal mask .
D. Dengan orotracheal intubation.

• Preoksigenasi. • Cricoid pressure


• Atropin 10- 20 µg/kg • Suxamethonium 2-3 mg/kg
• Thiopenton 3-5 mg/kg atau nondepol muscle relaxant
atau ketamin 1 mg/kg IV (atracurium 0.5mg/kg)
Rapid sequence induction: Inhalational induction:
(technique of choice) (hati-hati bahaya aspirasi !)
• Preoksigenasi. • Preoksigenasi
• Atropin 10- 20 µg/kg • Atropin 10-20 µg/kg
• Thiopenton 3-5 mg/kg • Intubasi dilakukan setelah:
atau ketamin 1 mg/kg IV o Halothan dalam ( stadium 3
plane 2 ): bradikardi !
• Cricoid pressure
o Sevoflurane dalam : mahal
• Suxamethonium 2-3 mg/kg o Halothan-ether dalam:
relative lebih aman tapi lama,
atau nondepol muscle relaxant
obat sudah tidak ada
(atracurium 0.5mg/kg) o Halothan/sevoflurane ringan
+ musscle relaxan non-
• Intubasi trachea
depolarizing

Apapun pilihannya : posisi head down & siapkan


penghisap, Pencegahan hipotermi perlu!!!
Pertanyaan 3 :
Hal-hal yang harus diperhatikan pada bantuan nafas
adalah?
A. Hindari baro trauma
B. Ingat TV bayi
C. Frekuensi tinggi
D. Semua tersebut benar.
D
E
C
O
M
pression !
COMPLIANCE <<<
and PERFUSSION
Pertanyaan 3:
Tentukan derajat dehidrasi pasien ini ?

A. Normal

B. Dehidrasi ringan (3-5 %)

C. Dehidrasi sedang (6 – 8 %)

D. Dehidrasi berat ( 10% atau lebih )


Severe dehydration : Skin turgor : ↓ ↓
 Body weight loss : >10%  Mucous membranes : Very dry
 Estimation fluid defisit : 100-110 ml/kg  Eyes : Deeply sunken
 Respiration : Deep & rapid  Peripheral perfusion : pale, cool,
 Pulse /HR : ↑↑, feeble wet
 Blood pressure : Reduced  Urine : oliguria
 Mental status : apatis to coma
1. DEHIDRASI
Penilaian derajat dehidrasi
Clinical findings Mild Moderate Severe

% body weight loss 4-5% 6-9% >10%


Estimation fluid defisit 40-50ml/kg 60-90 ml/kg 100-110 ml/kg

Respiration Normal Deep Deep & rapid


Pulse Normal ↑, Weak ↑↑, feeble
Blood pressure Normal Normal of low Reduced
Skin turgor Normal ↓ ↓↓
Mucous membranes Moist Dry Very dry
eyes normal sunken Deeply sunken
Peripheral perfusion Normal Poor Poor, cool, extremitas
Urine Reduced Oliguria Marked oliguria
Mental status Normal normal to listless Normal to coma

Source: Nelson W
PENATALAKSANAAN DEHIDRASI
a. Estimasi Cairan Defisit
b. Rehidrasi
Kasus : Bayi 3 kg, dehidrasi berat dengan estimasi 10%

Dehidrasi 10%, 3 kg
ECD : 100 ml x 3 = 300 ml

Cairan pertama resusitasi : 10-20ml/kg = 60 cc (20-30’)

- Urine prod
Penilaian kembali status klinis
-Respiration
- Circulation
membaik Tidak membaik - Mental status

Ulangan : 20 ml/kg (60cc) dlm 20-30’

 8 jam pertama : 50% sisa cairan defisit Resassess


(240 cc) =120cc + fluid maintenance
16 jam kedua : 50% rest fluid deficit Choice of the fluid :
(120cc) + fluid maintenance Rehydration : Isotonic crystalloid
Maintenance : Hypotonic crystalloid
CONGENITAL DIAPHRAGMATIG
Bayi, 2 bln, BB=3100
HERNIA
gram
PROBLEM : Sesak
Breathing nafas
Emergencies
Distress nafas
Hypoplasia paru
Hipertensi pulmonal Intubasi  Respirator
Monitoring ABG
 OPERASI ?
( BILA GAS DARAH
MEMBAIK )
NOTE :
 Key to consider that CDH is a
a surgical emergency
 The post birth transition of vascular and pulmonary
function is prolonged in CDH.
 In theory, provides additional time for
this transition to occur resulting in a

 Infants should be

 May be managed on a conventional ventilator or a


Management
 Key to success is currently
thought to be gentle
ventilation with permissive
hypercapnea to reduce
barotrauma.
 Pulseoximetry should be
monitored.
 Metabolic acid base
disturbances should be
corrected with fluid
management or bicarbonate
administration.
 Nitrid Oxyde
 Surfactan
 ECMO in severe cases - but
often NOT necessary
Anak
HEMATEMESIS ANAK :
1) Varises Esofagus.
2) Divertikel /ulkus
3) Corpus alienum
Varisces Esofagus
Anak:
Hypertensi
Portal
( non cirrhotik )
Anak