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Ujian ICU 2

Respiratory Failure on Mechanical Ventilation + Pneumonia


ec COVID 19 + Hipertensi

Hikmatiar

Penguji : dr. Mayang Indah Lestari, Sp.An (K)

Departemen Anestesi dan Terapi Intensif


Fakultas Kedokteran Universitas Sriwijaya - RSUP dr. Moh. Hoesin Palembang
2021
Nama Tn. Y

Med.Rec / Reg 1195164 / RI 21001344


Identitas Umur 49 tahun

Alamat Demang Lebar Daun

MRS 17 Januari 2021

Departemen Anestesi dan Terapi Intensif


Kasus

Anamnesis

Keluhan utama: Sesak nafas sejak 3 hari SMRS, tidak dipengaruhi


posisi badan, sebelumnya pasien mengeluh demam terus menerus sejak
1 minggu SMRS. Pasien memiliki Riwayat kontak dengan pasien
COVID 19

Riwayat penyakit sistemik:


• disangkal

Departemen Anestesi dan Terapi Intensif


PRIMARY
SURVEY Clear
Airway Nafas Spontan, 28x/m, Pola nafas thoracoabdominal,
Breathing WOB (+)
SpO2: 84% dengan NRM 10L/M
Kasus Pemeriksaan Thorax : Pergerakan dada simetris, bunyi
paru vesikuler (+/+), ronchi (+/+)
TD : 130/90, HR: 106 x/menit regular, isi/tegangan
Circulation cukup, CRT < 2 detik, akral hangat.
Kesadaran E4 M6 V5
Disability

Departemen Anestesi dan Terapi Intensif


SECONDARY
SURVEY Konjungtiva anemis (-/-) Sklera Ikterik (-/-)
Kepala Massa (-)
Leher Cor : BJ 1 dan 2 Reguler, Murmur (-) Gallop (-)
Thorax Pulmo : Vesikuler (+/+) Ronchi (+/+) wheezing (-/-).
Kasus
Abdomen
datar, supel. BU (+/+), hepar dan lien tidak teraba.
Akral hangat, edema pretibial (-/-)
Ekstremitas

Departemen Anestesi dan Terapi Intensif


Kasus
Pemeriksaan Hematologi (17/1/2021)
Hb : 16,7 gr/dl
Ht : 50%
Leukosit : 5520 mm3
Trombosit : 156.000/mm3
D/C : 0/0/74/15/11

BSS : 143 U/L

Ur/Cr : 34/1,07 mg/dl


PT/APTT : 12,4 (15,1) / 32,0 (32,3)
INR : 0.86
Fibrinogen : 567 (287)
D Dimer : 2,09
Na/K : 139/4.0 meq/L
Ca : 8,6
CRP Kuantitatif : 87

Departemen Anestesi dan Terapi Intensif


Kasus
Pemeriksaan AGD (17/1/2021)
pH : 7,387
pCO2 : 39
pO2 : 59,9
SO2 : 90,3
HCO3 : 23,7
P/F Ratio : 99,8

Pemeriksaan PCR COVID19 (18/1/2021)


Positif
CT : 30,78

Pemeriksaan Ro Thoraks (18/1/2021)


Pneumonia bilateral

Departemen Anestesi dan Terapi Intensif


Diagnosis Respiratory Failure ec Pneumonia bilateral ec COVID
19

Planning
Kasus - Rawat mini ICU OGAN
- Pemasangan NIV

Departemen Anestesi dan Terapi Intensif


ICUHARIKE1

Tgl Objective Assessment Daily Assesment


24/01/2 CNS : E4M6V5 Respiratory Failure on Mechanical F: Diet cair 4x300ml
CVS : TD: 140/90 mmHg Ventilation A: -
021 S: -
N : 95 x/menit regular, tegangan/isi + Penumonia bilateral ec covid 19 +
T: Padua score 3
cukup, Tanpa Support hipertensi Improve score 4
on NIV PS 10 peep 10 FiO2 80% H: head up 30°
didapat RR 20-22x/mnt VT 450-500 Lab AGD U: Omeprazole 1x40 mg
Hb : 15.1 pH 7.390
SpO2 93-94% Ht : 45 PCO2 40.9
G: BSS : 198 mg/dl
Temp 36,3 C B: Bowel sound (+) distensi(-)
Leu: 11.810 PO2 75.3 I: Catheter (+), Infeksi(-)
GIT : distensi (-), Peristaltik Normal Plt : 341.000 SO2 97.0 D:
GUT : diuresis (+), D/C 0/0/90/5/5 HCO3 20.7 Azithromicin 500mg/24 jam
Urine output : 1,5 ml/kgbb/jam Na : 139 Lact 2.7 (E5)
K : 4.7 P/F 245 Meropenem 1gr/8jam (E1)
Cl : 106
Planning Ur : 30
Avigan 600mg/12jam (H4)
• Cek lab lengkap Cr : 0.75
• Cek kultur darah Medikamentosa
Alb : 3.0 • Meropenem 2gr/24jam iv
• Antibiotik meropenem 1gr/8jam (E1)
• Omeprazole 40mg/24jam iv
Kesan AGD • N-Acetylsistein 5gr/24jam
hipoksemia • Vit C 1gr/24jam
• Amlodipin 10mg/24jam
• Zinc 20mg/24jam
• Dexamethason 6mg/24jam

Departemen Anestesi dan Terapi Intensif


ICUHARIKE3

Tgl Objective Assessment Daily Assesment


26/01/2 CNS : E4M6V5 Respiratory Failure on Mechanical F: Diet cair 4x300ml
CVS : TD: 139/72 mmHg Ventilation A: -
021 S: Dexmedetomidin 0,2-
N : 85 x/menit regular, tegangan/isi + Penumonia bilateral ec covid 19 +
0,7mcg/kg/jam
cukup, Tanpa Support hipertensi T: Padua score 4
on NIV PS 5 peep 8 FiO2 80% Improve score 7
didapat RR 20-22x/mnt VT 450-500 Lab AGD H: head up 30°
Hb : 15.1 pH 7.433
SpO2 93-94% Ht : 45 PCO2 28.1
U: Omeprazole 1x40 mg
Temp 36,3 C G: BSS : 132 mg/dl
Leu: 14.950 PO2 79.8 B: Bowel sound (+) distensi(-)
GIT : distensi (-), Peristaltik Normal Plt : 380.000 SO2 97.2 I: Catheter (+), Infeksi(-)
GUT : diuresis (+), D/C 0/2/92/2/4 HCO3 19.0 D:
Urine output : 1,5 ml/kgbb/jam Na : 136 Lact 2.0 Azithromicin 500mg/24 jam
K : 5.0 P/F 99,7 (E7)
Cl : 106
Planning Bil tot : 0,9
Meropenem 1gr/8jam (E3)
• Swab evaluasi 2 Avigan 600mg/12jam (H6)
Ur : 34
• R/ tranfusi plasma konvalesen Cr : 0.71 Medikamentosa
Alb : 2.8 • Tranfusi plasma konvalesen
1
• Omeprazole 40mg/24jam iv
Kesan AGD • N-Acetylsistein 5gr/24jam
Mix alkalosis respiratorik kronis dengan • Vit C 1gr/24jam
acidosis metabolic + hipoksemia • Amlodipin 10mg/24jam
• Heparin 10.000u/24jam
• Zinc 20mg/24jam
• Dexamethason 6mg/24jam

Departemen Anestesi dan Terapi Intensif


ICUHARIKE5

Tgl Objective Assessment Daily Assesment


28/01/2 CNS : E4M6V5 Respiratory Failure on Mechanical F: Diet cair 4x300ml
CVS : TD: 121/72 mmHg Ventilation A: sufentanyl 0,02mcg/kg/jam
021 S: Dexmedetomidin 0,2-
N : 87 x/menit regular, tegangan/isi + Penumonia bilateral ec covid 19 +
0,7mcg/kg/jam
cukup, Tanpa Support hipertensi T: Padua score 4
on NIV PS 10 peep 10 FiO2 80% Improve score 7
didapat RR 20-22x/mnt VT 350-450 Lab AGD H: head up 30°
Hb : 15.3 pH 7.402
SpO2 93% Ht : 46 PCO2 35.2
U: Omeprazole 1x40 mg
Temp 36,3 C G: BSS : 155 mg/dl
Leu: 18.010 PO2 73.2 B: Bowel sound (+) distensi(-)
GIT : distensi (-), Peristaltik Normal Plt : 406.000 SO2 95,1 I: Catheter (+), Infeksi(-)
GUT : diuresis (+), D/C 0/0/94/3/3 HCO3 20.3 D:
Urine output : 1,5 ml/kgbb/jam Na : 151 Lact 1.2 Meropenem 1gr/8jam (E5)
K : 4.9 P/F 91,5 Avigan 600mg/12jam (H8)
Cl : 106
Planning Vancomycin 1gr/8jam (D1)
• R/ tranfusi plasma konvalesen 2 Ur : 58
• Vancomycin 1gr/8jam Medikamentosa
Cr : 0.73 • Tranfusi plasma konvalesen
Alb : 2.9 2
• Omeprazole 40mg/24jam iv
• N-Acetylsistein 5gr/24jam
Kesan AGD • Vit C 1gr/24jam
Hipoksemia • Amlodipin 10mg/24jam
• Heparin 15.000u/24jam
• Zinc 20mg/24jam
• Dexamethason 6mg/24jam

Departemen Anestesi dan Terapi Intensif


ICUHARIKE7

Tgl Objective Assessment Daily Assesment


30/01/2 CNS : E4M6V5 Respiratory Failure on Mechanical F: Diet cair 4x300ml
CVS : TD: 121/72 mmHg Ventilation A: sufentanyl 0,02mcg/kg/jam
021 S: Dexmedetomidin 0,2-
N : 87 x/menit regular, tegangan/isi + Penumonia bilateral ec covid 19 +
0,7mcg/kg/jam
cukup, Tanpa Support hipertensi T: Padua score 4
on NIV PS 10 peep 10 FiO2 80% Improve score 7
didapat RR 24x/mnt VT 450 Lab AGD H: head up 30°
Hb : 15.8 pH 7.391
SpO2 92% Ht : 47 PCO2 35.7
U: Omeprazole 1x40 mg
Temp 36,3 C G: BSS : 155 mg/dl
Leu: 16.670 PO2 65.4 B: Bowel sound (+) distensi(-)
GIT : distensi (-), Peristaltik Normal Plt : 397.000 SO2 92,7 I: Catheter (+), Infeksi(-)
GUT : diuresis (+), D/C 0/3/83/8/5 HCO3 22.6 D:
Urine output : 1,5 ml/kgbb/jam Na : 139 Lact 2 Vancomycin 1gr/8jam (D3)
K : 4.8 P/F 93,4
Cl : 107
Planning Medikamentosa
• Omeprazole 40mg/24jam iv
Ur : 45 • N-Acetylsistein 5gr/24jam
Cr : 0.65 • Vit C 1gr/24jam
Bil tot : 0,8 • Amlodipin 10mg/24jam
Alb : 3 • Heparin 15.000u/24jam
• Zinc 20mg/24jam
• Nebu heparin 10.000 +
Kesan AGD Ventolin + fulmicort
Hipoksemia • Dexamethason 6mg/24jam

Departemen Anestesi dan Terapi Intensif


ICUHARIKE9

Tgl Objective Assessment Daily Assesment


1/02/ CNS : E4M6VT Respiratory Failure on Mechanical F: Diet cair 4x300ml
CVS : TD: 115/70 mmHg Ventilation A: sufentanyl 0,02mcg/kg/jam
2021 S: Dexmedetomidin 0,2-
N : 72 x/menit regular, tegangan/isi + Penumonia bilateral ec covid 19 +
0,7mcg/kg/jam
cukup, Tanpa Support hipertensi T: Padua score 4
on PSIMV 20 PS 10 peep 10 FiO2 80% Improve score 7
didapat RR 22x/mnt VT 450 Lab AGD H: head up 30°
SpO2 94% Hb : 14.8 pH 7.415 U: Omeprazole 1x40 mg
Ht : 45 PCO2 35.0 G: BSS : 155 mg/dl
Temp 36,3 C Leu: 16.020 PO2 76.5 B: Bowel sound (+) distensi(-)
GIT : distensi (-), Peristaltik Normal Plt : 298.000 SO2 96 I: Catheter (+), Infeksi(-)
GUT : diuresis (+), D/C 0/5/81/8/6 HCO3 22.4 D:
Urine output : 1,5 ml/kgbb/jam Na : 136 Lact 2,5 Vancomycin 1gr/8jam (D5)
K : 4.2 P/F 85 Cotrimoxazol 960mg/12jam
Cl : 111 (D2)
Planning
- Swab evaluasi Ur : 28 Medikamentosa
Cr : 0.64 • Omeprazole 40mg/24jam iv
- Kultur sputum Bil total : 0,6 • N-Acetylsistein 5gr/24jam
- Immunoglobulin intravena 15gram Alb : 2,7 • Vit C 1gr/24jam
• Amlodipin 10mg/24jam
PT/APTT/INR 17,1(16)/84,2(32,6)/1,9 • Heparin 15.000u/24jam
Fibr: 321(314) • Zinc 20mg/24jam
Ddimer:3,47 • Nebu heparin 10.000 +
Ventolin + fulmicort
Kesan AGD • Immunoglobulin
Hipoksemia 15mg/24jam
• Dexamethason 6mg/24jam

Departemen Anestesi dan Terapi Intensif


TERIMA KASIH