Lk, 60 thn, 40 kg

• KU : Perut membesar
• Telaah : Hal ini dialami pasien sejak 3 hari yang
lalu dan memberat dalam 1 hari ini. Nyeri pada
awalnya dirasakan di bagian perut bawah seperti
ditusuk – tusuk disertai perut terasa
penuh/begah, mual dan muntah, saat ini nyeri
dirasakan diseluruh lapangan perut, muntah (-),
demam (+), BAB/flatus tidak ada, BAK pekat.
• RPT : Appendectomy ec appendisitis akut
• RPO : Tidak ada
TIME SEQUENCE
 AMPLE
• A : Alergi obat/makanan (-)
• M : Medication (-)
• P : Past illness (+) Post Appendectomy
3 bulan yang lalu
• L : Last meal (25/11/2020)
• E : Tidak ada
 Penilaian Nyeri (Numeric Scale)

P : Saat diam dan perubahan posisi

Q : Seperti ditusuk – tusuk

R : Regio Abdomen

S : 2-3

T : Sejak 3 hari ini, terus – menerus

Foto Klinis
 Pemeriksaan Fisik di RB6 Tanggal
25/11/2020 Pukul 21.00 WIB
B1 airway : clear, RR : 26 x/i, SpO2= 98% via NRM 10 L/I SP : Vesikuler
ki=ka, ST : (-), MLP 1, GL: bebas, JMH > 3, Riw.
Asma/batuk/sesak/alergi : -/-/-/-
B2 Akral : H/M/K, TD : 100/70 mmHg, HR : 137 x/i, reg, T/V: cukup,
T : 37,5 C
B3 Sens : CM, pupil isokor ki=ka, diameter 3mm/3mm, RC +/+

B4 UOP (+) ; warna kuning pekat; vol: 100 cc

B5 Abdomen : Distensi, peristaltik (-), mual (-), muntah (-) Nyeri Tekan (+),
MMT (15.00 WIB)

B6 Edema (-) Fraktur (-)

 LABORATORIUM 25/11/2020

- Hb/Ht/L/Tr : 6,5/21/22.440/813.000
- PT/INR/APTT : 15 (13,5)/1,12/24(33)
- KGD adr : 123
- BUN/Ur/Cr : 52/111/0,82
- Na/K/Cl : 138/4,2/99
- Rapid COVID-19 IgM/IgG : Non reaktif/Non reaktif
Foto Thorax 25/11/2020
 Penanganan di RB6
1. Pasien dipuasakan  Pasang NGT
2. Informed consent  rencana pembiusan dan operasi
3. Ambil sampel darah, cross match untuk penyediaan
darah
4. IV line sudah terpasang dengan bore besar pastikan
lancar  Terpasang CVC
5. Nilai derajat dehidrasi dan rehidrasi  Pasang
kateter urine
6. Cek laboratorium
7. Beri antibiotik profilaksis
 Dehidrasi Berat
• Defisit cairan : 10% x BB = 10/100 X 40 x 1000=
4000 cc
Rehidrasi Cepat
30 cc/kgBB = 30 x 40 = 1200 cc/jam

Rehidrasi Lambat
8 jam I = ½ deficit + maintenance = 2000 cc + 640 cc =
2640 cc
16 jam II = ½ deficit + maintenance = 2000 cc + 1280
cc = 3280 cc
• PBW : 50 + 0,91 (158-152,4) = 55,096
• Hb (10-6,5) X 40 x 3 = 420 cc PRC
 Diagnosis : Total Mechanical Bowel
Obstruction ec Tumor Colon Ascending
• Tindakan : Laparatomy
• PS ASA : 4E (Anemia, Trombositosis, Sepsis)
• Anestesi : GA-ETT
• Posisi : Supine
 Problem List Aktual
Problem
Actual
1.Operasi emergency + gangguan peristaltik
 gastric emptying time memanjang 
anggap lambung penuh bahaya aspirasi
2.Pasien dengan kondisi abdomen distensi
3.Pasien dengan kemungkinan perforasi 
operasi lama dan butuh relaksasi otot
abdomen
4. Pasien dengan sepsis  volume
intravaskular kurang (kehilangan cairan dan
elektrolit-third space loss)
5. Pasien nyeri seluruh lapangan perut
Solve
NPO sejak direncanakan operasi, pasang NGT
(dekompresi)
Pasang NGT, NGT terbuka untuk dekompresi,
suction aktif sebelum induksi.
Pilihan anestesi dgn GA-ETT (RSI). Hindari
penggunaan N2O dapat berdifusi ke
rongga-rongga usus dan peritoneum
dilatasi usus—penurunan sphlanchnic blood
flow
Pastikan pasien dalam normovolume sebelum
induksi hitung nilai CVP
Analgetik adekuat
 Problem List Aktual
Problem
Potensial
1.Pasien abdomen distensipotensial
aspirasi
2.Operasi relaparatomy  penguapan
besar
3.Operasi lama Hipotermia
4.Balance Anestesia
5.Pasien Leukositosis
Solve
Suction aktif, intravena induction, RSI
Balans cairan penguapan 6-8 cc/kg
ditambah dengan maintenance
4.2.1/kg, target urine output perjam 1-
2 cc/kgbb, ingatkan operator untuk
membungkus hollow organ untuk
mengurangi evaporasi
Hangatkan cairan infus, hangatkan
cairan pembilas
Monitoring Hemodinamik, sedasi
cukup, analgetika adekuat, relaksasi
cukup, operator nyaman
Pemberian antibiotik yang adekuat
 Problem List Aktual
Masalah Pemecahan
• Pasien dengan distensi abdomen  •Berikan oksigen,
elevasi diafragma FRC menurun  •Suction aktif sebelum induksi, sellick manuver,
sesak nafas. posisi head up saat induksi, jangan beri ventilasi
positif

• Pasien dengan sepsis 1 Hour 1.Oksigenisasi

Sepsis Bundle 2.Perbaiki Hemodinamik
a. Terapi Cairan (syok berkaitan dengan veno
dilatasi capillary leakage preload tidak
adekuat
b. Vasopressor (bila pemberian cairan gagal,
diberi vasopressor
c. Inotropik (resusitasi cairan yang adekuat
akan terjadi hiperdinamik harus diimbangi
dengan kontraktikitas miokardium sehingga
diperlukan inotropk untuk memperbaiki cardiac
output
3.Turunkan suhu bila demam
4. Antibiotika
Problem
Problem List Aktual
Pasien dengan sligt hipoalbumin , albumin
berfungsi menjaga tekanan onkotik
Pasien hiponatremia, akan rawan untuk
mengalami peningkatan cairan intraseluler
Resiko perdarahan  Hitung EBV
(Estimated Blood Volume)
Persiapan hipotensi diakibatkan SIRS
Solve
Hati-hati pemberian cairan , koreksi albumin,
dan pemberian nutrisi tinggi protein
hati-hati pemberian cairan kristaloid berlebih
• EBV = 70 x 60 = 4200 cc
• EBL 10 % = 420 cc
• EBL 20 % = 840 cc
• EBL 30 % = 1260 cc
• Persiapan Inj. Norepinefrin 8 mg dalam
50 cc NaCl 0.9% dosis titrasi mulai dari
dosis terendah (0.05 mcg)
 Problem List Potensial
Masalah Pemecahan

•Pasien dengan tindakan laparatomi  •Beri analgetik kuat

insisi tinggi  nyeri post operasi •Fisioterapi nafas  mencegah retensi
sputum
•Infeksi

•Antibiotik adekuat
•Inj. Ceftriaxone 2 gr/24 jam
•Inj. Levofloxacin 750 mg/24 jam
 Problem List Potensial
Masalah
Pasien dengan tindakan laparatomy ,
penguapan besar dan resiko hipotermia
Insisi tinggi  nyeri akut post op
Potensial infeksi post operasi
Pasien dilakukan tindakan GA dengan
laparatomi
Pemberian cairan durante operasi
Pemecahan
Monitoring balans cairan, pakai blanket
penghangat, hangatkan cairan infus, nilai UOP per
jam 0,5-1 cc/kgbb
Pemberian analgetik adekuat  multimodal
analgesia. pilihan opioid+nsaid/paracetamol
Pemberian AB empirik dan dilakukan kultur dan
sensitivitas
Balans cairan  kelebihan cairan menyebabkan
edema usus hipoksia seluler iskemik
permeabilitas meningkat translokasi bakteri
sepsis
 Pemeriksaan Fisik di KBE
• Airway : clear, RR: 24 x/i, SP: Vesikular, ST: -, S/G/C: -/-/-, Malampati 1, JMH > 3
cm, GL bebas. SpO2= 98% via NRM 10 L/i
• Akral : H/M/K, TD: 100/60 mmHg, HR: 135 x/i, reguler, T/V: cukup, T : 37,3 C

• Sens : CM, pupil isokor, ø 3mm/3mm, RC +/+

• UOP (+) warna kuning pekat

• Abdomen: Abdomen : Distensi, peristaltik (-), mual (-), muntah (-) Nyeri Tekan
(+), MMT (15.00 WIB)
• Oedem (-), Fraktur (-)
Pre Operasi
• Cairan preoperasi : RL 1000 cc

• Persiapan Alat : (STATICS), monitor, tiang

infus, bantal intubasi, blanket warmer, penghangat
cairan

• Persiapan Obat : Obat-obatan GA

Obat-obatan emergency
Persiapan Alat dan Obat
Suction, Warmer, dan Blanket
Warmer
 TEKNIK ANESTESI
• Suction aktif
• Head up 30º
• Preoksigenasi 8 lpm selama 5 menit
• Premedikasi dengan Inj. Fentanyl 80 mcg
• Induksi dengan Ketamin 50 mg  Nystagmus (+)  Sleep Non
Apnoe  Intubasi dengan ETT no.7 cuff (+)  SP kanan=kiri 
fiksasi
• Maintenance dengan O2:Air 2L:2L Sevofluran 0,8-1,2%vol
• Maintenance dengan Fentanyl 50 mcg/30 menit
 TEKNIK ANESTESI - RSI
PREPARATION
•Pasien posisi supine, ganjal kepala dengan bantal intubasi
•Head up 30 derajat
•Suction aktif
PREOKSIGENASI : O2 8 lpm selama 3-5 menit
PREMEDIKASI : Fentanil 80 mcg.
PARALYSIS WITH INDUCTION : Induksi ketamine 50 mg 
nystagmus (+)  Sellick Manouver (PROTECTION)
PLACEMENT : Intubasi ETT no 7.5, Cuff (+), Suara Pernafasan
kanan = kiri, sambungkan ke mesin anestesi
POST INTUBATION MANAGEMENT
•Maintenance O2 2 L: Air 2 l
•Fentanil 50 mcg/ 30 menit
 Hemodinamik
• Pre Induksi • Durante
Post Induksi
Durante Operasi
 Durante Operasi
• Lama operasi : 1 jam 30 menit
• TDS : 110 – 130 mmHg
• TDD : 60 – 80 mmHg
• HR : 70 – 120 x/menit
• SpO2 : 96-100%

• Pre op : RL : 500 cc
• Durante op : RL : 1000 cc

• Perdarahan : + 50 cc
• Penguapan 2 cc/kgbb/jam : 100 cc
• UOP : 50 cc/jam
 Pemeriksaan Fisik Post Operasi di ICU
• Airway : clear, RR: 18-20 x/i, SP: Vesikular, ST: -, S/G/C: -/-/-, Malampati 1, JMH >
3 cm, GL bebas. SpO2= 99%
• Akral : H/M/K, TD: 120/80 mmHg, HR: 100 x/i, reguler, T/V: cukup, T : 36,8 C

• Sens : dpo, pupil isokor, ø 3mm/3mm, RC +/+

• UOP (+) warna kuning

• Abdomen: Soepel, luka operasi tertutup verban

• Oedema (-), Fraktur (-)

 Terapi Post Operasi
• Bed Rest, Head Up 30 derajat
• Diet TPN via CVC
• IVFD RL 20 gtt/ menit
• Inj. Ceftriakson 2gr/24 jam
• Inj. Norepinefrin 8mg/50cc nacl 0.9% (titrasi)
• Inj. Fentanyl 300mcg/50cc nacl 0.9% (titrasi 3cc/jam)
• Inj. Parasetamol 1gr/8 jam
• Inj. Ondansentron 4mg/12 jam (k/p)
• Inj. Omeprazole 40mg/12 jam
• Monitoring kesadaran, TD, RR, HR, SpO2, UOP Post operasi di ICU
• Rencana pemeriksaan Darah Rutin, AGDA, KGD ad random,
Elektrolit, RFT
Foto Post Operasi di ICU
TERIMA KASIH
TIM JAGA
 Menentukan Derajat Dehidrasi

Ringan Sedang Berat

Gejala
(Def: 3-5 % BB) (Def: 6-8% BB) (Def: > 10 %BB)
Turgor Kulit Berkurang Turun Sangat Turun
Lidah N Kecil-Keriput Lunak Kecil-Keriput Lunak
Mata N Cowong Sangat Cowong
Ubun-ubun N Cekung Sangat Cekung
Rasa Haus + + +
Nadi N/↑ ↑↑ Tak Teraba
Lemah Kecil
Tensi N/↓ ↓↓ N/turun
Urine out put ↓ ↓↓ Pekat ↓↓↓ (-)
Definitions (ACCP/SCCM, 1991)

• Systemic Inflamatory Response Syndrome

(SIRS): The systemic inflammatory
response to a variety of severe clinical
insults (For example, infection).

• Sepsis: The systemic inflammatory

response to infection.
 SIRS is manifested by two or more of the
following conditions:
• Temperature >38 degrees Celsius or <36
degrees Celsius.
• Heart rate>90 beats per minute.
• Respiratory rate>20 breaths per minute or
PaCO2<32mmHg.
• White blood cell count > 12,000/cu mm,
<4,000/ cu mm, or >10% band forms.
 Criteria for Severe SIRS
Must meet criteria for SIRS, plus 1 of the following:

• Altered mental status

• SBP<90mmHg or fall of >40mmHg from baseline
• Impaired gas exchange (PaO2/FiO2 ratio<200-250)
• Metabolic acidosis (pH<7.30 & lactate > 1.5 x upper limit
of normal)
• Oliguria (<0.5mL/kg/hr) or renal failure
• Hyperbilirubinemia
• Coagulopathy (platelets < 80,000-100,000/mm3, INR
>2.0, PTT >1.5 x control, or elevated fibrin degredation
products)
Definitions (ACCP/SCCM)

• Sepsis:
• Known or suspected infection, plus
• >2 SIRS Criteria.
• Severe Sepsis:
• Sepsis plus >1 organ dysfunction.
• MODS.
• Septic Shock.
 Definitions (ACCP/SCCM):
• Septic Shock: Sepsis induced with
hypotension despite adequate resuscitation
along with the presence of perfusion
abnormalities which may include, but are not
limited to lactic acidosis, oliguria, or an acute
alteration in mental status.
 Definitions (ACCP/SCCM):
• Multiple Organ Dysfunction Syndrome
(MODS): The presence of altered organ
function in an acutely ill patient such that
homeostasis cannot be maintained without
intervention.
 Therapeutic Strategies in Sepsis
• Optimize Organ Perfusion
• Expand effective blood volume.
• Hemodynamic monitoring.
• Early goal-directed therapy.
• 16% reduction in absolute risk of in-house
mortality.
• 39% reduction in relative risk of in-house
mortality.
• Decreased 28 day and 60 day mortality.
• Less fluid volume, less blood transfusion, less
vasopressor support, less hospital length of stay.
 Therapeutic Strategies in Sepsis
• Optimize Organ Perfusion
• Pressors may be necessary.
• Compensated Septic Shock:
– Phenylephrine
– Norepinephrine
– Dopamine
– Vasopressin
• Uncompensated Septic Shock:
– Epinephrine
– Dobutamine + Phenylephrine / Norepinephrine
 Therapeutic Strategies in Sepsis
• Control Infection Source

• Drainage
• Surgical
• Radiologically-guided

• Culture-directed antimicrobial therapy

• Support of reticuloendothelial system

• Enteral / parenteral nutritional support
• Minimize immunosuppressive therapies
Therapeutic Strategies in Sepsis
• Support Dysfunctional Organ Systems

• Renal replacement therapies (CVVHD, HD).

• Cardiovascular support (pressors, inotropes).

• Mechanical ventilation.

• Transfusion for hematologic dysfunction.

• Minimize exposure to hepatotoxic and

nephrotoxic therapies.
Evidence-Based Sepsis Guidelines
Evidence-Based Sepsis Guidelines
 Prognosis
Overall mortality from SIRS/sepsis in the U.S. is
approximately 20%. Mortality is roughly linearly
related to the number of organ failures, with
each additional organ failure raising the
mortality rate by 15%.

Hypothermia is one of the worst prognostic

signs. Patients presenting with SIRS and
hypothermia have an overall mortality of ~80%.
 Treatment
• Fluid Resuscitation

• Vasopressors
• Antibiotics
• Eradication of infection

• Ventilatory support, activated protein C,

steroids, glycemic control, nutrition
 Treatment
(Fluid Resuscitation)
• Rapid, large volume infusions are generally indicated
in all patients with septic shock.

• Some patients require up to 10L of crystalloid in the

first 24 hours, with an average requirement of 4-6L.

• Although resuscitation with colloid will necessitate

less overall volume of fluid, there is no difference
between patients treated with colloid versus
crystalloid in the development of pulmonary edema,
length of stay, or survival.
 Treatment
(Vasopressors)

• These are second line agents in the treatment

of septic shock (after volume resuscitation).

• A goal MAP should be 60-65mmHg, although

urine output, mental status, and skin
perfusion are better variables to use in
monitoring adequate perfusion.
 Treatment
(Antibiotics)
• Empiric antibiotic therapy should be instituted
immediately after appropriate cultures have
been drawn, taking into consideration the likely
source of infection,

• In general, therapy should include two effective

agents from different classes, for example, a
beta-lactam and an aminoglycoside
 Treatment
(Mechanical Ventilation)

• Nearly all patients with septic shock require

supplemental oxygen, and approximately 80%
require mechanical ventilation.

• Use of mechanical ventilation not only may

improve oxygenation, but the necessary
sedation +/- paralysis may improve organ
perfusion by diverting blood flow away from
the diaphragm.
 Treatment
(Activated Protein C)

• The PROWESS trial showed that patients who

received a 96hr infusion of APC within 24 hours of
presentation had a statistically lower 28-day
mortality rate (25% vs. 31%).
• Treatment was of greater benefit in the most acutely
ill patients (APACHE II score ≥ 25).
• APC has been found to not be cost effective in those
patients with APACHE II scores <25 or in those with
relatively low life-expectancy even in the event of
survival from sespis.
Protocol for Early Goal Directed Therapy in
Septic Shock

(Adapted from NEJM 2001;

345:1368-77, in which
patients receiving this goal-
directed therapy had im-
proved in-hospital mortality
compared to those with
“standard” therapy, 31% to
47%.)
Sepsis Bundle 2018
 Estimated Fluid and Blood Losses Based on
Patient’s Initial Presentation
Class I Class II Class III Class IV
Blood-Loss[ml] ->750 750-1500 1500-2000 >2000

Blood-loss [%BV] ->15% 15-30% 30-40% >40%

Pulse-Rate [x/min.] <100 >100 >120 >140

Blood-Pressure Normal Normal Decreased Decreased

Pulse-Pressure N or Decreased Decreased Decreased

increased

Respiratory Rate 14-20 20-30 30-35 >35

Urine out-put >30 20-30 5-15 Negligible

[ml/hour]

Mental status/CNS Slightly Midly Anxious Confused

anxious anxious and and
confused lethargic

59
 AIRWAY MANAGEMENT:
“7 Ps of RSI”

1. Preparation:
a. Monitor pulse oximetry, blood pressure (BP), cardiac rhythm
b. At least one functioning (IV) line (preferably two)
c. BVM, Yankauer suction, end tidal carbon dioxide (CO₂) capnography
d. Functioning laryngoscope with blade of choice
e. Endotracheal tube [man: 7.5mm, woman 7.0mm internal diameter
(ID); pediatric: use length‐based (Broselow tape) system or rough
guide [four plus age (in years) divided by 4], check cuff, load and
shape stylet, 10mL syringe
f. All RSI medications ready to be administered
g. Assess for possible difficult airway
2. Preoxygenation:
3 minutes of normal tidal volume breathing or eight vital capacity
breaths with 100% oxygen (O₂) [use non‐rebreathing (NRB)
oxygen mask if 100% O₂ source not available]: prevents
desaturation during intubation
3. Pretreatment:
a. Lidocaine 1.5 mg/kg IV – reduces intracranial and
bronchospastic response to laryngoscopy in patients with
elevated intracranial pressure (ICP) or reactive airway disease
b. Fentanyl 3 μg/kg IV (over 1 minute) – reduces sympathetic
response [elevated heart rate (HR) and blood pressure (BP)] to
intubation in patients with elevated ICP, intracranial
hemorrhage, cardiac ischemia, or aortic dissection
c. Vecuronium bromide 0.01 mg/kg IV (or pancuronium bromide) –
blunts ICP elevation caused by succinylcholine in patients with
elevated ICP
d. Atropine: Consider pretreatment with atropine in children
under age one
4. Paralysis with induction:
a. One of the following induction agents (or equivalent) given rapid IV
push prior to paralysis:
i. Etomidate 0.3 mg/kg IV
ii. Ketamine hydrochloride 1.5 mg/kg IV
iii. Propofol 1‐2mg/kg IV
b. Paralytic agent by IV push immediately after induction agent:
i. Succinylcholine 1.5 mg/kg IV
ii. Rocuronium 1 mg/kg IV if succinylcholine contraindicated (see
table below)
5. Protection:
a. Sellick maneuver (firm pressure on cricoid cartilage to prevent gastric
regurgitation) should be applied as soon as consciousness lapses and be
maintained throughout intubation until tube placement confirmed
6. Placement:
a. Insert endotracheal tube with direct visualization of the vocal cords
b. Inflate cuff
c. Confirm endotracheal tube is in the trachea using end tidal CO₂
capnography
d. Auscultate lungs bilaterally to ensure right mainstem intubation has not
occurred
e. Secure endotracheal tube with tape
f. Release Sellick maneuver
7. Post‐intubation management:
a. Chest x‐ray to assess placement of endotracheal tube (tip should be at
mid trachea)
b. Long‐acting sedatives and, if necessary, paralytics
i. Lorazepam 0.05 mg/kg IV for sedation
ii. Vecuronium 0.1 mg/kg IV for paralysis
c. Initiate mechanical ventilation
d. Sedative: Propofol bolus/drip
 Teknik Anestesi RSI

MONITOR,PULSE OXIMETRY, BLOOD PRESSURE

IV LINE YANG BERFUNGSI, BVM, LARINGOSKOP
PREPARATI DENGAN BLADE NO 3, ETT NO 7, SEMUA OBAT YANG
DIPERLUKAN. POSISIKAN PASIEN HEAD UP 30∙,
ON SUCTION AKTIF
(5 menit)

PREOKSIGE
NASI DENGAN OKSIGEN 6-8 LPM SELAMA 3-5 MENIT

(5 menit)

PRETREATM
FENTANIL 100 MCG
ENT
(3 menit)
 PARALYSIS
WITH PROPOFOL 80 MG (EYE LID -),
INDUCTION ROCURONIUM 60 MG
(start)

PROTECTION
SELLICK MANUEVER
(20-30 detik)

PLACEMENT INTUBASI DENGAN ETT NO 7, CUFF

(45 detik) +, SP KA=SP KIRI

Isofluran 1% , O2:Air = 2L:2L

POST INTUBATION
MANAGEMENT MAINTENANCE , FENTANIL 50 MCG/30
MENIT, ATRACURUM 10 MG/30 MENIT
RSI
 Total Parenteral Nutrisi
TB : 150 cm
BB : 45kg

• PBW = 45,5 + 0,91 (150 – 152,4 cm) = 43kg

• TPN
• Kebutuhan cairan per 24 jam
[(4x10)+(2x10)+(1x25)/jam]x24jam=2040cc
• BEE = 25 -30 X 45Kg = 1125 – 1350 kkal
• REE = 1,2 x BEE
= 1,2 x 1350 = 1620kkal
H1 = 60 % x 1620 = 972kkal
Karbohidrat = 60 % x 972 kkal = 583 kkal
Lipid = 40 % x 972 kkal = 388 kkal
Protein = 0,6 – 1,2 x 45kg = 27 – 54gr/hari
 SKEMA PEMBERIAN CAIRAN
CONTOH KASUS Dehidrasi berat
BB : 50 KG ESTIMASI KEHILANGAN CAIRAN
SHOCK 10% X 50kg = 5L = 5000 ML
Guyur 20-30 CC/KG (½ -1jam)
= 1000-1500 CC
CEK HEMODINAMIK

MEMBAIK TETAP/BURUK
guyur Ulang 20-30cc/kg (½ -1jam)
Guyur STOP!
Ganti MAINTENANCE

MEMBAIK TETAP BURUK

50% 50% Guyur Ulang 20-30cc/kg

8 jam 16 jam (½ -1jam)

+ CAIRAN MAINTENANCE
HIPOVOLEMIA ATASI SHOCK

-DEHIDRASI + SHOCK
GUYUR 20-30 CC/KG
(% x BB) 10-20 MENIT (DEWASA)
-PERDARAHAN 30-60 MENIT (ANAK)
(% x EBV)
-LUKA BAKAR
(luasxBBx4) MASIH SHOCK ?

MEMBAIK GUYUR LAGI YA TIDAK

- SISA DEFISIT
-MAINTENANCE
DWS (4x10)+(2x10)+(1x10)cc/jam
ANAK: 10kg I (100cc/kg/hr), 10kg II (50cc/kg/hr); 10kg III (20cc/kg/hr)
 Sindrom Mendelson
• Sindrom mendelson adalah suatu kumpulan gejala yang disebabkan oleh aspirasi
cairan lambung selama anastesi umum. Hal ini dapat terjadi jika :
• pH cairan yang masuk <2,5 volume aspirasi lebih besar dari 0,3 ml/kg BB ( 20-25 ml
pada orang dewasa)
• Gejala klinis :
• Takipneu
• Takikardi
• Wheezing / ronkhi
• Sianosis

• Komplikasi :
1. Edema paru
2. Syok
3. Pneumonia
4. ARDS
5. Bronkiektasis
Determinants of Oxygen Delivery (DO2)
Sunder-
Plasman Hb 7-15
(1968)
Jika faal
kardiopulmoner
normal
|
Hb 7 -15 gm/dl
Hct 20-40%

Kapasitas
transport O2
sama
 DEHIDRASI MENURUT KRITERIA PIERCE

Ringan Sedang Berat

CNS Normal Mengantuk, apatis, Refleks tendon

haus respon lambat, ↓anestesi, akral distal,
anoreksia, aktivitas ↓ stupor-coma
CV Takikardia Takikardia, hipotensi Sianosis, hipotensis, akral
ortotastik, nadi lemah, dingin, nadi tidak teraba,
vena kolaps detak jantung jauh

Jaringan Mukosa lidah Mukosa lidah kering, Atonia, mata cowong,

mengering, turgor IIdah kecil, lunak dan turgor ↓↓↓
turun keriput, turgor ↓↓
Urine Pekat Pekat, Sedikit Oliguria

DefIsit 3-5 % BB 6-8 % BB 10% BB

 PERKIRAAN KEHILANGAN CAIRAN DAN DARAH
KELAS 1 KELAS KELAS KELAS
2 3 4
Kehilangan darah Sampai 750 - 1500 - > 2000
(ml) 750 1500 2000
Kehilangan darah Sampai 15 15 – 30 % 30 – 40 > 40 %
(% volume darah) % %
Denyut Nadi ( x / < 100 > 100 > 120 > 140
menit )
Tekanan Darah Normal Normal Menurun Menurun
Tekanan Nadi Normal Menurun Menurun Menurun
atau Naik
Frekwensi Pernafasan 14 - 20 20 - 30 30 - 40 > 35
( x / menit )
Produksi urine > 30 20 - 30 5 – 15 Tidak
(ml/jam) berarti
CNS (Status Mental) Sadar Agak Cemas, Bingung,
penuh Cemas Bingung Lesu
Penggantian Cairan Kristaloid Kristaloid Kristaloi Kristaloid
(Hukum 3 : 1) d dan dan Darah
Darah
Penangan awal pasien ileus

Nachter ( puasa )
Infuse
Decompresi (NGT)
Antibiotik
Cara membaca foto thorak
1.Pastikan identitas pasien
2.Menilai kualitas film ( pastikan foto diambil saat inspirasi maksimal, pastikan cahaya
yang cukup sehingga bisa membedakan tulang belakang tubuh dengan ruang antar
tulang belakang
3.Analisa gambar : Airway : yaitu memeriksaa saluran pernapasan
Bone : memeriksa tulang region
thorak. Apakah ada fraktru dan kelainan
Cardiac : melihat jantung, terutama
ukuran besar jantung
Diafragma : melihat dari kedua sisi
dari sinus costafrenikus.
passive leg raising test
Tilt Test