Terapi Oksigen
Elektrolit
z Ventilator
Pada primary survey harus diperiksa EKG, pulse oximetry, monitoring karbon dioksida,
and penilaian respiratory rate, and penilaian AGD
ATLS 10th edition 2018, PRIMARY SURVEY WITH SIMULTANEOUS RESUSCITATION PAGE 9, 10
Ventilatory
z
rate, Capnography, and arterial blood
gases
ATLS 10th edition 2018, CHAPTER 1, ADJUNCTS TO THE PRIMARY SURVEY WITH RESUSCITATION PAGE 11
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Kriteria sindrom distress pernafasan
akut
Onset akut
Pao2:Fio2 <200
Bilateral infiltrates
Penyebab:
Contoh:
Contoh:
Hypoventilation: - sedatives/sedation/opiates
Pneumonia
Pulmonary oedema
Asthma
z
RESPIRATORY ALKALOSIS
Contoh:
Anxiety
Respiratorik? Kompensasi
Nilai pH?
Metabolik? ?
Tastota, F. 1994 Assessing A.B.G.s: Maintaining the delicate balance. Nursing94 24, 5, 34-44
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1. Berapa pH?
1. Alkalosis? (>7.45)
2. Acidotic? (<7.35)
Tastota, F. 1994 Assessing A.B.G.s: Maintaining the delicate balance. Nursing94 24, 5, 34-44
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2. What’s happening with the respiratory system (CO2) and the metabolic
systems (HCO3-)?
If the problem is in the lungs (respiratory) the CO2 will be heading in the
opposite direction of the pH. For example: respiratory acidosis: The pH
will be low pH 7.22 and the CO2 will be high CO2 55mmhg
If the problem is metabolic the HCO3 will head in the same direction as
the pH For example: metabolic alkalosis: The pH will be high - 57.55 and
the HCO3- will also be high HCO3- 535mmol/L. Note: an easy way to
remember for a “M”etabolic problem, think “M” as in the pH will head in the
sa”M”e direction as the HCO3-. For respiratory the pH will head in the
“O”pposite direction as the C”O”2.
Tastota, F. 1994 Assessing A.B.G.s: Maintaining the delicate balance. Nursing94 24, 5, 34-44
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No compensation: pH remains abnormal, and the ‘other’ value (where the problem
isn’t occurring, i.e. CO2 or HCO3-) will remain normal or has made no attempt to help
normalise the pH. For example: in uncompensated metabolic acidosis: pH
67.23, HCO3- 6 15mmol/L, and the CO2 will be normal at 40mmHg.
Full compensation The pH is normal, as the ‘other’ value is abnormal and has been
successful in normalising the pH. For example: Fully compensated metabolic
acidosis pH 7.38, HCO3- 615mmol/L and the CO2 630mmHg 6
Tastota, F. 1994 Assessing A.B.G.s: Maintaining the delicate balance. Nursing94 24, 5, 34-44
z
No compensation: pH remains abnormal, and the ‘other’ value (where the problem
isn’t occurring, i.e. CO2 or HCO3-) will remain normal or has made no attempt to help
normalise the pH. For example: in uncompensated metabolic acidosis: pH
67.23, HCO3- 6 15mmol/L, and the CO2 will be normal at 40mmHg.
Full compensation The pH is normal, as the ‘other’ value is abnormal and has been
successful in normalising the pH. For example: Fully compensated metabolic
acidosis pH 7.38, HCO3- 615mmol/L and the CO2 630mmHg 6
Tastota, F. 1994 Assessing A.B.G.s: Maintaining the delicate balance. Nursing94 24, 5, 34-44
NAME DEFINITION VALUE
pH z
Refers to hydrogen ion (H+) levels, hence the ‘H’ in pH. H+ levels are important because a lack of (deficit) or too much 7.35 - 7.45
(excess) will tell you if the patient is acidotic or alkolotic. One confusing point about pH is that it is an INVERSE ratio, which
means that the more H+ present, the lower the pH and vice versa.
Acid Can give away a H+ or can separate (dissociate) hydrogen from its ion, so the hydrogen is not positive and therefore no 20 parts base /
longer an acid. 1 part acid
Acids are end products of metabolism and must be buffered or excreted to achieve a normal pH
Base Unlike Acids, bases can accept a H+ and bond with hydrogen. They are all negative and like to ‘buffer’ body acids.
Base excess/ Represents an increase or decrease in the amount of base compared with the amount of acids present -2 to +2mmol/L
Base deficit
HCO3 Concentration of hydrogen carbonate in blood. Used to determine along with pH and CO2 source of acid base imbalance. 22-26mmol/L
pCO2 Carbon dioxide partial pressure (tension). Reflects alveolar ventilation as it diffuses across the alveolar capillary membrane 35-45 mmhg
and “blown off”.
paO2 Arterial oxygen tension. In other words how well the lungs are able to pick up oxygen, i.e. supply, but not demand (this is 75-100mmhg
shown in a mixed venous gas, discussed later).
Lactate When cells no longer have enough O2 for ‘normal’ aerobic metabolism (cell hypoxia) Anaerobic metabolism takes over 0.5 - 2.0mmol/L
resulting in lactate production, leading to lactic acidosis
The Blood Gas Handbook, 2005. Radiometer Medical ApS RadiometerCopenhagen, Bronshoj
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Terapi oksigen
z
Indikasi
Severe trauma.
Pneumothorax absorption.
The use of some O2 delivery devices (e.g., nasal cannulas and nasopharyngeal
catheters in neonates and pediatric patients that have nasal obstructions)
Oxygen toxicity
Oxidative stress
Retinopathy of prematurity
Absorption atelectasis
Hypoxia can exist even though hypoxemia has been corrected with oxygen therapy?
Contoh:
Pada tingkat jarungan dimana o2 tidak mampu mencapai sel akibat blockade arteri
If the partial pressure of O2 (PaO2) is less than the level predicted for the
individual’s age, hypoxemia is said to be present.
Hemoglobin deficiencies.
The primary goal of oxygen therapy is to treat hypoxemia. However, a very small number of
patients with Chronic Obstructive Pulmonary Disease (COPD) have sensitivity to higher levels
of O2. Target saturation for patients at risk of hypercapneic respiratory failure is 88-92% (BTS,
2011) unless otherwise prescribed, pending blood gas results.
If you are unsure if a patient has a sensitivity to O2, the main goal is to treat
hypoxemia.
For more information on best practice guidelines for the treatment of COPD please
visit the Canadian Thoracic Society’ Canadian Respiratory Guidelines for COPD
website.
Oxygen carried in the blood is reversibly bound to the hemoglobin. A very tiny amountof free
oxygen gas dissolved in the plasma. Dissolved oxygen gas exerts a pressure inthe vasculature
that can be measured from a blood sample (e.g., an arterial blood gasABG)). This measurement
is known as the partial pressure of oxygen in the arterialblood and is represented by the
hemoglobin. Avery small amount of oxygen gas is transported dissolved in the plasma. This
dissolved O2 can be measured utilizing a small sample of arterial blood. This measurement is
The partial pressure of oxygen in the venous blood returning to the lung (PVO2) approximates 40mmHg,
there is a pressure gradient for diffusion of oxygen into the blood of about 60 mmHg.
Theoretically, the partial pressure in the capillary blood should rise to equal the partial pressure of oxygen
in the alveolus and therefore the partial pressure of oxygen in the arterial blood (PaO2) should
approximate 100mmHg “the PaO2 of healthy individuals breathing air at sea level is always approximately
5-10 mmHg less than the calculated PaO2. Two factors account for this difference: (1) right to left shunts in
the pulmonary and cardiac circulation, and (2) regional differences in the pulmonary ventilation and blood
flow” (Kacmarek, Stoller, Heuer,
2013, p. 255). Normal PaO2 is expected to range from 90-95mmHg however, in clinical practice
normoxemia in adults and children is defined as 80-100 mmHg.
Neonates have a lower actual PaO2 than adults and children. In neonates normoxemia is 50-80mmHg
due to anatomical shunts at birth and the nature of fetal hemoglobin
Some of the pathophysiologic factors affecting the gas exchange of oxygen include:
the flow of oxygen into the lungs, down to the alveoli (hypoventilation and hyperventilation);
the flow of blood into the lungs to the pulmonary capillaries (vasoconstriction, thrombosis);
the carrying content of the blood (SaO2 and PaO2) e.g. sickle cell anemia, carbon
monoxide poisoning, hypoxemia;
the thickness of the alveolar-capillary membrane (e.g., pulmonary fibrosis, pneumonia); and
Low flow oxygen delivery devices provide a variable FiO2 depending on the
patient’s/client’s inspiratory demands. As the inspiratory demands increase, ambient air
is entrained and the FiO2 is diluted.
Nasal Cannula
Nasal Catheter
Transtracheal Catheter
Simple Mask
Non-Rebreather Mask
High flow oxygen delivery devices will provide a fixed FiO2 (0.24 - 1.0) regardless of the
patient’s/client’s inspiratory demands.
CPAP/APAP Machines;
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Ventilator Mekanik
z
Indikasi Pemasangan
Gangguan Oksigenasi :
Hipoksik hipoksia : disebabkan oksigen yang masuk kurang
mis. menghirup CO2 pada kebakaran, pneumoni, contusio paru
Stagnan hipoksia : o.k gangguan pada jantung menyebabkan
edema paru : AMI,cardiomyopathy, hypertensi heart disease.
Anemia hipoksia : pada perdarahan hebat dimana belum ada
tindakan tranfusi.
Histotoksik hipoksia: disebabkan pemakaian oksigen yang
tinggi pada psn sepsis.
34
z
Indikasi Lain
mencegah atelektasis
menurunkan TIK
anestesia
35
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TERMINOLOGY
Parameter:
TERMINOLOGI
Variabel yang sering digunakan:
Jumlah udara yang diberikan kepada pasien dalam setiap kali napas mL/ menit
TERMINOLOGY
Inspiratory time:
♣ Ekspirasi
Ekspirasi-inspirasi
z
Weaning (Disapih)
Gelisah
Takhikardia
Tensi naik
z
Penutup
Ventilator alat life supporting sangat diperlukan
Mode ventilaton harus tepat agar pertukaran gas yg adekuat tercapai
Harus diperlukan monitoring
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KOREKSI
ELEKTROLIT
HIPONATREMIA
z
Contoh :
• Etiologi
Definisi:
Hipernatremia adalah
kelebihan konsentrasi
natrium dalam darah
(>150mEq/L). Disebabkan
dari kehilangan cairan atau
intake natrium yang tinggi.
Schwartz Principle of Surgery 10th Edition
zTanda dan Gejala
Schwartz Principle of Surgery 10th Edition
Tatalaksana
z
Contoh :
Schwartz Principle of Surgery 10 th Edition; Fluid and Electrolyte Management of the Surgical Patient by G. Tom Shires III
HIPERKALEMIA
z
Schwartz Principle of Surgery 10 th Edition; Fluid and Electrolyte Management of the Surgical Patient by G. Tom Shires III
TATA LAKSANA HIPERKALEMIA
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Natrium Bikarbonat
Indikasi
PO, IV : digunakan untuk mengalkalinisasi urine dan mendorong ekskresi obat tertentu bila terjadi
overdosis (fenobarbital, aspirin).
Kerja obat sebagai agen pengalkalinisasi dengan melepaskan ion bikarbonat.· Setelah pemberian
oral, melepaskan bikarbonat, yang mampu menetralkan asam lambung.
Schwartz Principle of Surgery 10 th Edition; Fluid and Electrolyte Management of the Surgical Patient by G. Tom Shires III
TATA LAKSANA HIPERKALEMIA
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Kontraindikasi:
Hipokalsemia.
Gagal ginjal
IV (Dewasa, anak-anak, dan neonates): 1 mEq dapat diulang 0.5 mEq/kg tiap 10 menit
PO (dewasa): 48 mEq (4g) di awal. Kemudian 12 – 24 jam mEq (1-2 g) tiap 4 jam (sampai 48 mEq tiap 4 jam)
atau 1 sendok teh bubuk tiap 4 jam sesuai kebutuhan
Pemberian kalium secara oral pada KCL 7,46% Dalam 1 ampul mengandung 25 meq/25cc
Schwartz Principle of Surgery 10 th Edition; Fluid and Electrolyte Management of the Surgical Patient by G. Tom Shires III
CONTOH KASUS
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Pasien wanita, 26 th, lemah tungkai Data pada manusia :
bawah kanan dan kiri, riwayat diare 6x
Dewasa :
per hari selama 3 hari, Kalium 2,5
Masuk melalui mulut dalam fase akut : 2
Tata laksana kondisi hIpokalemia :
sampai 2.5 mmol/kg dapat sebabkan
hiperkalemia