Curriculum Vitae dr. Yose Muliawan Pangestu,Sp.

A
DATA PRIBADI
◉Nama : dr. Yose Muliawan Pangestu , SpA
◉Tempat/Tanggal Lahir : Sumbawa Besar, 8 Desember 1981
◉Jenis Kelamin : Laki-laki
◉Agama : Katholik
◉Alamat : Jl. Wijaya Kusuma Blok A9/8
Banjarwijaya, Tangerang
RIWAYAT PENDIDIKAN
2010-2014 : Program PendidikanDokterSpesialis–1, Program Studi Ilmu
Kesehatan Anak, UniversitasSam Ratulangi
2001-2007 : Fakultas Kedokteran Universitas Udayana Denpasar Bali
1997-2000 : SMU St. Ursula II , BSD Tangerang
1994-1997 : SMP St. Maria 1 Tangerang
1988-1994 : SD St. Aloysius 1 Tangerang

RIWAYAT PEKERJAAN
2014- Skrg : Dokter Spesialis Anak RS Mayapada Tangerang, RS Hermina
Bitung
2014-2015 : Dokter Spesialis Anak RSIA Bun Kosambi
2010-2014 : Dokter PPDS Ilmu Kesehatan Anak RS.Prof.R.D
KandouManado
2009 : Dokter IGD RS.Kesdam Jaya Daan Mogot Tangerang
2008 : Dokter PTT Pusat, Tual , Maluku Tenggara
ORGANISASI
2014 - sekarang : Anggota IDAI Banten
2009 - sekarang : Anggota PERINASIA
2010- 2014 : Anggota IDAI Muda cabang Sulawesi Utara

PUBLIKASI
◉Profile of fasting blood glucose in obese children with insulin resistance. International J Ped
Endocr. 2013(Suppl 1):P100
◉Hubungan Kadar 25-Hydroksivitamin D dan High Molecular Weight Adiponectin pada Remaja
Obes. Sari Pediatri. 2015;17(1):64-70
◉Lumbar Mass as The Presentation Form of A Tuberculosis Spondylitis. PIT IKA Solo. 2013
◉Perbandingan Kadar Gula Darah Puasa pada Anak Obes dengan Resistensi Insulin dan Tanpa
Resistensi Insulin. Sari Pediatri. 2013;15,77-81
◉Profil Kasus Tetanus Anak Di RS Prof. Dr. R.D. Kandou Manado. Sari Pediatri 2012;14(3):173-
8
◉Investasikan Masa Depan Anak dengan Imunisasi. 2009. Tangerang Tribun
PELATIHAN YANG PERNAH DIIKUTI
◉Pelatihan Basic Mechanical Ventilation in Newborn Infant and Clinical Practice : RDS Babies, MAS, PPHN. Indonesian Pediatric Critical Care Foundation. Bintaro. Februari
18-19, 2016
◉Pelatihan Tatalaksana Praktis Imbalans Cairan, Asam Basa, dan Elektrolit. PKB IDAI Jaya XIV. 5-6 Feb 2016
◉Pelatihan Basic Mechanical Ventilation in Critically Ill Children, Indonesian Pediatric Critical Care Foundation- UKK Emergensi dan Rawat Intensif Anak Ikatan Dokter
Anak Indonesia, Bintaro, 5-6 Maret 2016
◉Pelatihan Vaksinologi untuk Dokter Spesialis Anak, IDAI, Jakarta, 4-5 Juni 2016
◉Pelatihan Resusitasi Neonatus : Early CPAP. PKB IDAI Jaya, Jakarta 3-4 Mei 2015
◉Participant of UpToDate Internet point of care activity period June 24 2015 to May 10 2016, Wolters Kluwer Health.
◉Pelatihan Practical Management of ARI (Acute Respiratory Infection), YAPNAS –IDAI Jaya, Jakarta, 29-30 Mei 2016
◉Pelatihan “ Antibiotik pada Anak”, UKK Infeksi dan Pediatri Tropis IDAI dan Bagian IKA FK Universitas Sam Ratulangi, Manado, 7-8 Februari 2014
◉Pelatihan “ Deteksi Dini Gangguan Kognitif dan Bahasa” , UKK Tumbuh Kembang IDAI dan Bagian IKA FK Universitas Sam Ratulangi, Manado, 30 November 2013
◉Round Table Discussion” The Basic Principle of Dietary Aspect in Allergy Prevention in Infants and Children”, IDAI Sulawesi Utara, Manado, 6 April 2013
◉Pelatihan “ Medical Writing” , Bagian IKA FK Universitas Sam Ratulangi, Manado, 14-15 April 2012
◉Pelatihan “Towards better management of Hemophilia” , World Federation of Hemophilia dan IDAI cabang Sulawesi Utara, Manado, 6-8 September 2011
◉Updates in Pediatric Allergic and Immunologic Disease (UPAID), BagianAlergi&ImunologiDepartemenIlmuKesehatanAnak FKUI-RSCM, Jakarta, 4-5 Juni 2009
◉2’nd ASEAN Pediatric Ear Nose Throat Meeting, Jakarta, 5-7 Maret 2009
◉Pelatihan Manajemen Bayi Lahir Rendah dengan Metode Kangguru, PERINASIA, Jakarta, 22-23 Februari 2009
◉PelatihanResusitasiNeonatus, RSAB Harapan Kita, Jakarta, 7-8 Februari 2009
◉Pelatihan Tata Laksan Infeksi Dengue, Departemen Ilmu Kesehatan Anak FKUI/RSCM, Jakarta, 29- 30 Januari 2008
◉Workshop Hematology Pediatric, IDAI , Hotel Tiara Medan, 16 Januari 2008
Terapi Cairan DSS
pada Anak

Yose Muliawan Pangestu

6
50 juta kasus/ thn

500.000 DHF
90%
Rawat inap/
Anak
Thn

7
30 thn terakhir, ↑ global

Case-fatality rates (0,5-

1%)
CFR DSS 7- 26%
8
Source: Comprehensive
guideline for prevention
and control of dengue
and dengue
haemorrhagic fever.
Revised and expanded
edition. Regional office
for South-East Asia, New 3-5%
Delhi, India 2011.

9
90% 10%
 Mengapa Syok pada
DBD perlu mendapat
perhatian khusus?
Harus segera diatasi (<60 mnt),
krn dapat meninggal dlm 10-24
jam

Prolonged syok(>90mnt)
menyebabkan hipoksia berat,
memicu DIC pendarahan berat,
gagal multifungsi organ
WARNING SIGN
Abdominal Pain or tendernes Clinical fluid accumulation

Persistent vomiting Mucosal bleed

Laboratory : Increase in HCT, concurent rapid ↙ trombocyte 10
Lethargy, restlessness Liver enlargement >2cm
Sindrom Syok Dengue (DSS)
Beberapa Beberapa Kolaps kardiovaskular
jam menit

• Takikardia • Asidosis
• Hipotensi
• Diastolik Syok metabolik
Syok berkepanjanga Profound
meningkat dekom berat
terkom tanpa n shock
pensasi • Multi organ
pensasi peningkatan • Hipoksia
failure
sistolik

Gangguan
Perdarahan masif (akibat DIC)
koagulasi
Trombositipenia
Tanpa pengobatan tepat dan segera, kematian terjadi dengan cepat
(“tsunami storm”)
11
 Tanda Syok pada DBD
• Keadaan umum mendadak memburuk, gelisah atau letargi
• Nyeri perut : tanda awal syok (anak besar)
• Akral dingin, nadi cepat dan lemah
• Penyempitan Tekanan nadi (Sistolik-diastolik ≤20 mmHg
atau Hipotensi)
• Capilary refill memanjang > 2 dtk
• Oliguria (diuresis< 0,5 ml/kgbb/jam)
• Hematokrit tetap meningkat walaupun sedang mendapat
12
cairan IV
 Terapi Cairan pada DSS
• GOAL : Mengganti volume plasma yg hilang
Two pronged :
– Early recognition and reversal of shock
– Avoiding Fluid overload
• Arah : Mengganti volume sirkulasi minimal, adekuat menunjang
perfusi organ vital shg mencegah pendarahan & multiorgan
failure
• Serial monitoring & koreksi coexisting
hipoglikemia,hipocalsemia, elektrolit
Ranjit S et al,abnormalities 13 Medicine 2011;12
Pediatric Critical Care
Differences between DSS & Septic Shock

Dengue shock are vasoconstricted, narrow pulse pressure

vs vasodilated states in septic shock

Children septic shock require rapid, large volume fluid resuscitation

(Major differences both in the rates and volumes of fluid
resuscitation for dengue shock)
Suchitra Ranjit, WCPIC Geneva 2007 14
 Differences between DSS & Septic Shock
Wills et al have used much lower fluid resuscitation rates in 500
patients with DSS
--> successful in reversing shock
--> minimizing complications of FO, including the need for assisted
ventilation
mortality rates in the range 0.2%
slow fluid-filling at rates of 25 mL/kg over the first 2 hrs.

Wills et al, N Eng J Med 2005; 29:787– 15

94
 Fluid therapy in dengue shock has two parts

1. Initial, rapid fluid boluses 2. Followed by titrated fluid volumes

to reverse shock to match ongoing losses

The end points/targets of fluid administration :

1. Normalization systolic BP (if low), obtaining a pulse pressure of > 30 mm Hg,
2. a urine output of 0.5–1 mL/kg/hr with stable vital signs
3. a gradual decrease in the elevated baseline Hct level
Ranjit S et al, Pediatric Critical Care Medicine 2011;12 16
1. Initial, rapid fluid boluses 2. Followed by titrated fluid volumes
to reverse shock to match ongoing losses

Monitoring Urin Output/ 1 jam

Output of 0.5–1.0 mL/kg/hr with stable vital signs → shock reversal and ensures a
minimal acceptable circulating volume

Output of >1.5–2 mL/kg/hr may be the earliest indicator of overhydration/FO with the
potential risk of respiratory insufficiency
Ranjit S et al, Pediatric Critical Care Medicine 2011;12 17
 1. Initial, rapid fluid boluses 2. Followed by titrated fluid volumes
to reverse shock to match ongoing losses

Monitoring HCt / 4 jam

Status Sirkulasi

High or ↗ Hct + unstable hemodynamics --> ↗ volumes crystalloids

Low / “normal” Hct + shock may be an indicator occult hemorrhage --> urgent blood transfusion

High Hct + Stable patient --> monitor the patient closely without increasing fluid rates.

Ranjit S et al, Pediatric Critical Care Medicine 2011;12 18

 Sindrom Syok Dengue Terkompensasi
• Berikan oksigen 2-4L/menit
• Cek kadar hematokrit
•Kristaloid RL/RA 10-20ml/kg.BB bolus dalam 30-60 menit

Ya Tidak
Syok teratasi
IVFD 10ml/kg.BB, 1-2 Periksa Ht, AGD, gula darah,
jam kalsium, perdarahan (ABCS)
Koreksi asidosis, hipoglikemia, hipokalsemia
Tanda vital stabil
Turunkan IVFD bertahap Ht naik
7, 5, 3 , dan 1,5 Ht turun
ml/kg.BB/jam
Bolus ke-2 dg kristaloid
atau Perdaraha
Stop IVFD n
Koloid 10-20ml/kg.BB Tidak jelas
maksimal 48 jam
dalam 10-20 menit
setelah syok
Koloid 10-20ml/kg.BB
teratasi Transfusi darah
dalam 10-20menit, jika syok
UKK IPT 2014, WHO 2011 menetap dianjurkan 19
 Fluid Overload
● excessive and/or too rapid intravenous fluids
● large volumes of fluid in patients with unrecognized severe
bleeding
● inappropriate transfusion of fresh-frozen plasma, platelet
concentrates and cryoprecipitate
● continuation of intravenous fluids after plasma leakage has
resolved (24-48 h from defervescence)
● co-morbid conditions :congenital or ischemic heart disease ,
renal diseases
20
 Minimizing Fluid Overload
● Kecepatan bolus resusitasi tgntung shock :
○ Compensated shock : resuscitation NS/RL 10 mL/kg dlm 1 jam
○ Decompensated shock : resuscitation 1–2 boluses 20 mL/kg
NS/RL/synthetic colloid dlm 15–20 mnt. Repeat second bolus of 10
mL/kg colloid if shock persists and Hct level is still high.
● Titrasi cairan --> Status sirkulasi stabil, serial Hct perlahan normal,
diuresis 0,5-1ml/kg/jam
○ diuresis 1.5–2 mL/kg/jam --> reduction in fluid infusion rates 21
Pediatr Crit Care Med,
 Minimizing Fluid Overload
● Gunakan kristaloid isotonik (RL, RA) → pd fase kritis
● Gunakan BB Ideal (kalkulasi kebutuhan cairan) → pd Obes
● Pendarahan signifikan → transfusi WB atau PRC segera
● Minimalkan/hindari transfusi Trombosit / FFP (kecuali
pendarahan tidak terkontrol walaupun 2–3 aliquots WB / PRC)

● Koloids dpt meringankan derajat kelebihan cairan -->pada

DSS berat Pediatr Crit Care Med, 22
 Difference of crystalloid and
colloid
FEATURE
CRYSTALLOID COLLOID BENEFIT
(NaCl, RL, R Asetat, R (Gelatin, HES)
Fundin)
No COP → leaks COP relative high →
- volume effect I.V 20-25% restore I.V Colloid →
- duration effect in I.V 30 -volume effect I.V 70- resuscitate faster
minutes 145%
end of infusion. --duration effect in I.V 2-
6 hours end of infusion.

4 - 5 L crystalloid ~ 1 L 1 L colloid ~ 1 L blood Volume of colloid

blood High dose → no risk of smaller than
High dose → risk of lung lung edema crystalloid→ Avoid
edema edema
23
COP: Colloid Oncotic Pressure
 Crystalloid
Advantage Disadvantage
Ringer 1. Composition similar plasma Lactate metabolisme slower
lactate electrolite than acetate, because only
2. Contain precursor bicarbonate metabolisme in the liver
lactate
3. Cheap

Ringer 1. Composition similar plasma More expensive compare to

acetate electrolite RL
2. Contain precursor bicarbonate
acetate
3. Metabolisme in all tissues (esp.
muscle)
NaCl 0,9% For hiponatremia, hipochloremia Does not contain precursor
condition bicarbonate, not for acidosis
24
 Colloid solution
Characteristic of various different colloids
used for plasma support
Advantage Disadvantage
Gelatin 1. Isotonic iso-oncotic 1. Mostly stayed in the
-Haemaccel 2. Volume effect: 2 – 3 hours gastrointestinal than in the
-Gelafundin 3. Blood coagulation mechanism not intravascular
-Gelafusine impaired 2. Chill and anaphylaxis reactions
4. Do not induced antibody
5. Excreted through gastrointestinal &
kidney
Hydroxy 1.6%HES Isotonic iso-oncotic Blood coagulation impaired
Ethyl Starch 10%HES Isotonic hiper-oncotic >1500 ml/day or
-6% HES 2. No infection > 30ml/kgBW/day
-10% HES
3. No anaphylaxis reaction
4. Volume effect 200/0,5 : 4 – 8 jam
Volume effect 200/0,6 : 8 – 12 jam
Volume effect 400/7 : 8 – 12 jam
25
 Colloid solution
Characteristic of various different colloids
used for plasma support

Advantage Disadvantage
Dextran 1. Isotonic hiper-oncotic 1. Hipersensitivity reaction
-10%D40 2. Increase intravascular volume & 2. Coagulation impairment (>
-6%D70 absorb extravascular 1000ml/day or >30ml/kg/day)
-Plasmafusin 3. Volume effect 6%D70: 6-8 hours, 3. Acute renal failure
4% 10%D40: 3.5-4 hours, plasmafusin 4. Contraindication for DIC
4%:4-6 hours
4. Excreted through kidney

Albumin Half life 16 hours, efective as 1. Volume > 20ml/kg/day

-5% albumin plasma volume expander may cause increased
25% albumin volume intravascular
more than volume
infused
2. Expensive 26
 Dung et al, Clin Inf Dis 1999; 29:787–94

Fluid Replacement in Dengue Shock Syndrome: A Randomized, Double-Blind

Comparison of Four Intravenous-Fluid Regimens

Comparison 4 fluid (Resusitasi) : NS, RL, Dextran 70, Gelatin

-->minor differences in clinical responses, All children Recovered

27
 Gelofusin
Dextran 70

Dextran 70

Gelofusin

RL

Dextran 70

28
 Ngo et al, Clin Inf Dis 2001;
32

➔Comparison Dextran-- Gelatin --RL----NS

➔time recover from shock, time achive cardivasc stability,requirement rescue coloid)

no clear advantages

➔when only the most severe cases(presenting pulse pressure<10 mmHg) : Grup gelatin,
significantly fewer had a recovery time > 1 hour compared to those who received
29
Ringer’s lactate
 Wills et al, N Engl J Med 2005,
353;9
Comparison of Three Fluid Solutions for Resuscitation
in Dengue Shock Syndrome

Efektif RL = koloid (rescue kristaloid/koloid)

Pulse Presure RL-- HES-
10-20mmHg DEXTRAN
Waktu stabilitas kardiovaskular RL>Koloid

Pulse Presure HES- Efektif 6% HES = Dextran (kardiovaskular

≤10mmHg DEXTRAN stability, rescue koloid)

Adverse event Dextran vs Hes 8% vs 0,5%(allergic type reaction)

30
 Kalayanarooj, J Med Assoc Thai 2008; 91:S97–103

Choice of Colloidal Solution in Dengue Hemorrhagic Fever Patients

Patients : Severe DSS no response to cristaloid

Intervention : 10% HES

Comparator : 10% Dextran 40

Outcome effectiveness, impact on renal function and haemostasis and any complications

Efektivitas HES = Dextran 40 (dosis & volume fluid required, perubahan Hct)
no allergic reactions or interference with renal function or haemostasis

31
Resusitasi awal koloid→ rapid improvement→ effect transien
Mayoritas DSS --shock ringan-moderate berespon baik dengan
terapi konvensional crystalloids
Ringer’s lactate, sediaan murah & aman, terapi pilihan DSS
shock moderate, intervensi koloid lbh awal tidak diperlukan
Sebagian kecil membutuhkan terapi lbh agresif dengan koloid
Shock berat/refrakter -->Koloid hiperonkotik. Dextran vs HES? --
>HES lbh dipilih karena reaksi simpang rendah
32
 Indikasi Pemberian Koloid
25% kasus DSS anak perlu koloid
Syok tidak teratasi dlm 60 mnt (maksimal 90 mnt)
Masih diperdebatkan perlu tidaknya ´early coloid resuscitation´
pada kasus syok berat
Dosis 10-30 ml/kgBB/ jam
Melalui jalur infusan berbeda dengan cairan rumatan

33
 Sindrom Syok Dengue Dekompensasi
• Berikan oksigen 2-4L/menit
• Periksa hematokrit, AGD, gula darah, kalsium, perdarahan (A-B-C-S)
• Kristaloid atau koloid 10-20ml/kg.BB dalam 10-20 menit

Y Syok Tidak
a teratasi
IVFD 10ml/kg.BB, 1-2 Evaluasi Ht, AGD, gula darah,
jam kalsium, perdarahan (ABCS)
Koreksi asidosis, hipoglikemia,
Tanda vital stabil hipokalsemia
Turunkan IVFD bertahap Ht naik Ht turun
7, 5, 3 , dan 1,5
ml/kg.BB/jam Bolus ke-2 dg kristaloid atau
Koloid 10-20ml/kg.BB Perdaraha
dalam 10-20 menit
Stop IVFD Tidak jelas n
maksimal 48 jam
setelah syok Koloid 10-20ml/kg.BB
teratasi dalam 10-20menit, jika syok Transfusi
UKK IPT 2014, WHO 2011 menetap dianjurkan transfusi 34 darah
 KESIMPULAN
1) Shock pada DSS ´reversible & short duration´ (rembesan
plasma 24-48 jam) If timely and adequate volume replacement
is given

2) Tentukan Syok terkompensasi atau dekompensasi --> Tuntunan

pemberian pengobatan yg lebih cepat & terarah

3) Mayoritas DSS --> Shock ringan-moderate

4) Tidak ada evidence koloids lbh superior dari kristaloid dalam

resusitasi, koloid digunakan Dengue Shock Berat
5) Rekomendasi WHO* pertimbangkan starch/HES (koloid 35
36
 Demam Dengue

• Demam 2–7 hari mendadak tinggi, bifasik.

• Manifestasi perdarahan spontan (petekie, purpura,
ekimosis, epistaksis, perdarahan gusi,
hematemesis/melena) atau uji tourniquet positif.
• Nyeri kepala, mialgia, artralgia, nyeri retroorbita.
• Ada kasus DBD di lingkungan
• Leukopenia <4.000/mm3
• Trombositopenia <100.000/mm3

DIAGNOSIS KLINIS DD : demam + min 2 kriteria

UKK IPT 2014, WHO 2011 37
 Demam Berdarah Dengue
• Kriteria klinis
– Demam mendadak tinggi 2-7 hari
– Manifestasi perdarahan
(min.tourniquet positif)
– Pembesaran hati
– Nyeri kepala, mialgia, artralgia,
nyeri retroorbital
– Ada kasus DBD di lingkungan
– Gangguan sirkulasi
DIAGNOSIS KLINIS DBD : demam + 2 kriteria klinis dan 2 kriteria lab
• Kriteria laboratorium
– Trombosit < 100.000
– Hemokonsentrasi (kenaikan HT
>20%) atau ada bukti kebocoran
plasma lain (seperti efusi pleura,
asites), penurunan serum
protein/albumin/kolesterol
38
UKK IPT 2014, WHO 2011
 Demam Berdarah Dengue

Hepatomegali Kebocoran plasma

• 2-4 cm bawah arkus kosta • efusi pleura

• tidak disertai ikterus
• lebih sering ditemukan pada
DSS
• peningkatan nilai hematokrit
• penurunan kadar protein
plasma terutama albumin
• menimbulkan syok
hipovolemi

39
 Sindrom Syok Dengue (DSS)
Syok Syok tidak
Profound shock
terkompensasi terkompensasi
• Takikardi • Takikardi, nadi • Nadi tidak
• Takipnea lemah teraba
• Tekanan nadi • Hipotensi • Tekanan darah
<20 mmHg • Penyempitan tidak terukur
• Capillary refill tekanan nadi
time (CRT) > 2’ • Hiperpnea atau
• Kulit lembab Kussmaul
• Penurunan • Sianosis
diuresis • Akral dingin
• Gelisah
40
Karakteristik Koloid volume support

41
 A-B-C-S Examination
Abbreviation Lab exam Note
A – Acidosis Blood gas Indicate prolonged shock, multi organ failures
analysis Examined: liver function, BUN, ureum,
creatinin.
B – Bleeding Hematocrit If Ht dropped compared to previous value or
not rising, cross match for blood transfusion
soon
C – Calcium Electrolyte Ca++ Hypocalcemia always occur in all DHF cases
but asymptomatic. In severe or complicated
case is indicated.
S – Blood sugar Blood sugar Most severe cases have poor appetite and
(dextrostix) vomiting
Those with liver dysfunction hypoglycemia.
Some cases may have hyperglycemia.
Note: profound shock or have complications, and cases with no clinical 42
improvement
43
Algorithm for Fluid
Management in
Refractory Shock-late
presenter
(WHO 2009)

44