Bed Side Teaching

CELLULAR
PHYSIOLOGY IN
CRITICAL CARE

Pembimbing Klinik:

BAGIAN ILMU ANESTESI dr. Susi Handayani, Sp.An

RUMAH SAKIT MUHAMMADIYAH PALEMBANG
FAKULTAS KEDOKTERAN
UNIVERSITAS MUHAMMADIYAH PALEMBANG Vivi Rizki, S.Ked
2019 71.2017.058
Clinical Scenario
Riwayat Perjalanan Penyakit
– Seorang laki-laki Somalia berusia 31 tahun datang dengan keluhan nyeri pada
dada sejak dua hari yang lalu, keluhan disertai dengan sesak napas dan pusing.
– Pada riwayat penyakit terdahulu, pasien pernah menderita skizofrenia (dengan
pengobatan olanzapine). Pasien merupakan seorang Qat chewer dan sering
mengkonsumsi alcohol sebanyak lima sampai 6 kaleng bir dalam sehari.
– Pada saat dilakukan pemeriksaan, kesadaran pasien baik, pasien dapat
berorientasi dengan baik, RR 40 kali/menit, serta pada saat auskultasi terdapat
ronki pada basal paru kiri.
Pemeriksaan Khusus
Radiografi dada awal menunjukkan bayangan pada basal paru kiri.
Elektrokardiogram (EKG) menunjukkan depresi gelombang T lateral yang dinamis.

– pH : 7,37 – Cl−: 93
– PaO2 : 13,2 – Ureum: 1.9
– PaCO2 : 1,94 – Kreatinin: 97
– base excess (BE): 10.6. – Osmol: 269
– Hemoglobin (Hb): 12,4 – Troponin: 0,06
– Leukosit: 19,4, – creatine kinase: 143
– C-reaktif protein (CRP): 49 – tes fungsi hati: pembekuan
– Na: 122 – B12 dan folat, tes fungsi tiroid –
normal
Pertanyaan 1
– Apa diagnosis banding dan tatalaksana awal?
Follow Up Pasien
– Pasien memburuk dan diperiksa oleh tim medis.
Pada pemeriksaan didapatkan pasien tidak demam, Glasgow Coma Scale 15,
tenang, euvolaemic (2 l cairan intravena diberikan sejak masuk).
RR 35x/menit dan terdapat ronki pada basal paru kiri, SpO2 98%, HR
120x/menit, TD 110/50 mmHg, tekanan vena sentral meningkat 29 cm H2O,
SpO2 vena sentral 84%.
– Pada abdomen terlihat cembung. Pada palpasi tungkai masih didapatkan
denyut nadi tetapi akral dingin.
– Pada pemeriksaan urin didapatkan keton ++
– EKG menunjukkan depresi gelombang ST 1mm dan inversi gelombang-T V3–4.
Hyperemesis gravidarum, excessive vomiting in
pregnancy

affects approximately 0.3-3.0% of all pregnancies, but the

risk is considerably higher in pregnancies following a
hyperemetic pregnancy.

Factors affecting recurrence of hyperemesis gravidarum are as

yet insufficiently studied
Materials and Methods
– The data were compiled using Finnish health care registers with permission of
the Finnish National Institute for Health and Welfare
– Statistical analysis was performed with software (SAS System for Windows,
Version 9.4; SAS Institute Inc, Cary, NC).
– Inklusi  All pregnancies ending in delivery with a HG
discharge diagnosis in the first 20 weeks of pregnancy from
the years 2004 through 2011 were included in the study

– Eksklusi  Women who had only 1 pregnancy during the

study period (2642) and women who did not have
pregnancies after their first pregnancy with a HG diagnosis
(885) were excluded.
Results
We identified 1836 women Among these women,
who had at least 1 493 (26.9%) were diagnosed
subsequent pregnancy after with HG in at least 1 of their
their index HG pregnancy. following pregnancies,
and 1343 (73.1%) had no HG
diagnosis in any of their
following
pregnancies.
There were
333 women who had >1
pregnancy after the index
pregnancy, and among
them,
11% had a HG diagnosis in
all of their subsequent
pregnancies,
22% had a HG diagnosis in at
least 1 but not all of their
subsequent pregnancies,
and 67% had no HG
diagnosis in any of their
subsequent pregnancies.
In the comparison of the subsequent pregnancies, smoking was associated with
lower odds of recurring HG. Age of 36-40 years, living in a city with >100,000
inhabitants, ART, and female sex of the fetus were associated with higher odds of
recurring HG in the univariable analysis. Smoking (smoked, but quit in the first
trimester vs nonsmoking: adjusted OR, 0.32, P = .010; continued smoking after the
first trimester vs nonsmoking: adjusted OR, 0.38, P=.002) and female sex of the
fetus (adjusted OR, 1.29, P =.012) remained significant in the multivariable
analysis.
Comment
  In the Norwegian register study of 4796 women with HG, the recurrence rate of HG was lower
than ours, 15%
 In the British study, the recurrence rate was similar to ours, 26%, and their study period, 1997
through 2012, overlapped ours.

The study group may thus have differed from the general
population and possible bias toward overestimation of
the recurrence cannot be excluded, or, since their study
was small (57 pregnancies after an earlier hyperemetic
pregnancy), the difference may stem from general
variation. The discovery of potential HG-associated
candidate genes has provided a new element for
predicting recurrence of HG. For instance, the G allele of
the gene GDF is more frequently found among HG
patients compared to symptom-free women
(approximately 80% vs 70%), as well as the A allele of
the gene IGFBP7 (approximately 70% vs 65%), and thus
examining these associations in the context of recurring
hyperemesis will be of interest
in theory, recurrence of hyperemesis may be more
common among those with a genetic predisposition to
the condition. However, since the alleles associated with
HG are found in more than half of women without HG,
too, it is not yet possible to estimate whether the genes
would explain the observed one-fourth chance of
recurrence. Maternal factors that have earlier been found
to be associated with HG in general, such as parity or BMI,
did not give constant results in our study setting, and
warrant more studies. Smoking showed a consistent
association with recurrence of HG.
Meaning of the study
– Knowledge about the recurrence of HG in a subsequent pregnancy is of
importance, since severe HG may have an effect on family planning and mother-
child relationship. Some factors affecting HG recurrence can be identified, but
there is not yet a reliable way to predict whether HG will reoccur in a
subsequent pregnancy. The lack of a trend toward HG getting more likely with
each new pregnancy is encouraging. Even though it is challenging to estimate
the recurrence risk of HG in a subsequent pregnancy by evaluating the
conditions in a woman’s first HG pregnancy, knowing that HG does not
necessarily reoccur may be reassuring when considering a new pregnancy.
Review of Journal
Review of Journal Entries
• Title: Yes

• Authors and Institutions: Yes

• Abstract: yes

• Background: yes

• Methode: yes

• Result: yes

• Comment: yes

• Meaning of the sudy: yes

• Reference: Vancouver

• Attachment: no
PICO
Population

The population in this study was taken

from 2004 to 2011, with the criteria of a
woman who has a history of pregnancy
and is now diagnosed with
hyperemesis gravidarum taken from
hospital data in Finland
 Indikator
Comparison

No intervention and comparison

were carried out in this study
Outcome

This study identified 1836 patients who had at least 1 subsequent

pregnancy after suffering from HEG. There were 493 (26.9%) diagnosed
with HEG at least 1 of his pregnancies, and 1343 (73.1%) patients with
no diagnosis of HEG. 2267 patients with HEG diagnosis and 554 of
them were recurrent HEGs. The overall recurrence rate of HEG is 24%.
Outcome

In a comparison of subsequent pregnancies, smoking was associated with a

lower likelihood of recurrence of HEG, ages 36-40 years, residing in cities
with> 100,000 population, ART, and female fetuses associated with risk
factors for recurrent HEG in univariable analysis. Smoking (smoking, but
quitting during the first trimester compared to not smoking: odd ratio, 0.32 P
= 0.01; continued smoking after the first trimester compared to not smoking,
OR 0.38 P = 0.002) and female fetuses (OR 1, 29 P = 0.12) remained
significant in multivariable analysis.
VIA
Validity

– Research question
Is the data collected in accordance with the purpose of the research?
Yes. Data taken is in accordance with the research objectives. This study used a data analysis
design of all pregnancies in Finland from 2004 to 2011, with the criteria of a woman who had a
history of pregnancy and was now diagnosed with hyperemesis gravidarum taken from hospital
data (1836 women, 4103 pregnancies; 1836 index pregnancies and 2267 subsequent
pregnancies )
– Are the inclusion and exclusion criteria in this research clearly defined?
Yes. The inclusion criteria in this study were the criteria of a woman who had
a history of pregnancy and was now diagnosed with hyperemesis
gravidarum. While the exclusion criteria are patients who are not pregnant
after their first pregnancy with a diagnosis of HEG.
– Are the research subjects explained in detail?
Yes. The subjects in this study were women with HEG diagnosis with or
without hospitalization. Patients with a history of 1 pregnancy during the
study (2642) and patients who were not pregnant after their first pregnancy
with a diagnosis of HEG (885) were excluded. Data on maternal,
environmental and related factors regarding pregnancy in all pregnancies
ended in deliveries obtained from the Finnish medical birth register.
Pregnancy, parity, BMI, smoking, quitting smoking during the first trimester.
Randomization
– Was the randomization list concealed from patients, clinicians, and researchers?

Yes. In this study the patient did not know that he was the subject of this study.

Interventions and co-interventions

– Were the perfomed interventions described in sufficent detail to be followed by other?

In this study the research subject was not intervened.

Importancy
– Is this study is important?
Yes, this research is important because the results of this study can reduce the incidence
of recurrent HEG.
Applicability

– Is your environment so different from the one in study that the methods could not be use there?
The environment in this study is different from the environment in Indonesia. However, the
same method can still be used in research conducted in Indonesia.
Conclusion

Based on the study of the journals that have been done, it can
be concluded that this journal is valid, important and applicable
so that this journal can be used as a reference.
Thank You