Stase TME Period 29 Aùgust – 11 September 2021

Stase TME Report

Period
Period 29
29 August
August 2021
2021 -11
-11 September
September 2021
2021
Stase TME Period 29 August – 11 September 2021

Admission
 Admission: 29 August -11 September 2021
No Tanggal Pasien Usia Problem Diagnosa Manajemen Kriteria
1 30/8/2021 Ny.D 53 B : spontan, simetris RR - Distres respirasi ec asidosis - Monitoring KU dan VS LOC3/
40x/m SpO2 96-97% O2 NRM metabolik - Head up 45 derajat LOC2 tidak
10 lpm - Hiperkalemi- AKI ec - Oksigenasi NRM 15 lpm, 45 memungki
C : TD : 144/113 mmhg, HR Obstruksi Uropati ec Susp derajat nkan
151x/m Transeksi Ureter Bilateral - Loading Furosemide 40mg karena
Iatrogenik - HD cito saat ini
- CAP - Koreksi Kalium penuh
- Balans cairan target uop 0.5-1
cc/kg/jam
2 31/8/2021 Ny.SK 70 B : spontan, simetris RR - Syok sepsis - Monitoring KU dan VS LOC 1
23x/m SpO2 97-99% O2 NK 2 - Anemia - Vascon cont 4mg/50cc titrasi
lpm, vesikuler +/+, ronkhi -/-, - AKI - Oksigenasi NK 2 lpm
wheezing -/- - Hipoalbumin - Transfusi PRC 1 kolf
C : TD : 73/53 mmhg, HR - Asidosis metabolik - Maintenance cairan dengan
120x/m nadi teraba kuat terkompensasi Plasbumin
angkat isi cukup, edem pitting - Balans cairan target uop 0.5-1
kedua tungkai cc/kg/jam, apabila < 0,5
cc/kgbb/jam dapat diberikan
furosemide 2x20 mg
 Admission: 29 August -11 September 2021
No Tanggal Pasien Usia Problem Diagnosa Manajemen Kriteria

3 1/9/2021 Ny.S 68th C: TD : 63/53 mmhg on - Syok sepsis - Monitoring KU dan VS- LOC1
support vascon dosis 0,3 - Hipokalemia - Oksigenasi NK 2 lpm
mcg/kgBB, dobutamin dosis - AKI - Loading cairan 1000cc kristaloid
5mcg/kgBB; 125x/m nadi - Hipoalbumin lanjutkan maintanence
teraba kuat angkat isi kurang - IHD - Balans cairan target uop 0.5-1
- DM tipe 2 cc/kg/jam- Perawatan dapat
dioptimalkan di bangsal
4 2/9/2021 Ny.K 36th B : RR 38x/m SpO2 98% NRM - ARDS ec pneumonia et Ca - Head up LOC1
15lpm pulmo metastase - O2 NRM 15lpm
- efusi pleura massif - Monitoring KU/VS
- B20 - Balans cairan target uop
- trombositopenia 0.5cc/kg/jam
- saat ini ICU penuh,saran paliatif
 Admission: 29 August -11 September 2021
No Tanggal Pasien Usia Problem Diagnosa Manajemen Kriteria
5 3/9/2021 Tn.S 50th C : TD : 78/44 mmhg, HR - Syok sepsis - Monitoring KU dan VS LOC2
112x/m - Sirosis hepatis ec hepatitis B - Head up 30 derajat
child pugh class B - Oksigenasi NK 3 lpm
- Anemia - Loading cairan kristaloid
- AKI 30cc/kgBB
- Asidosis Metabolik - Vascon titrasi
- Hipoglikemia - Inj D40% 2 Flask
- Koreksi Hb target 10 g/dL,
- Balans cairan target uop 0.5-1
cc/kg/jam
- kultur darah, ganti antibiotic
spektrum luas
6 3/9/2021 Tn.S 56th B : spontan, simetris RR 32- - ARDS derajat berat ec - Monitoring KU dan VS LOC1
37x/m SpO2 92-95% O2 NRM massa mediastinum - Head up 30 derajat
15 lpm - VCSS - Oksigenasi NRM 15 lpm
- Asidosis Respiratorik - Inf RL 20 tpm
- Saran perawatan paliatif
 Admission: 29 August -11 September 2021
No Tanggal Pasien Usia Problem Diagnosa Manajemen Kriteria
7 3/9/2021 Ny.R 49th C : TD : 68/43 mmhg, HR - Syok hipovolemi ec - Monitoring KU dan VS LOC1
120x/m perdarahan pervaginam - Head up 30 derajat
- Ca cervix stadium IV B, - Oksigenasi NRM 10 lpm
infiltrasi rectum & Buli - Transfusi PRC 1 kolf
- Anemia Gravis - Koreksi Hb target 10 g/dL, koreksi
- Hipoalbumin Albumin target 2,75
- Asidosis Metabolik - Balans cairan target uop 0.5-1
cc/kg/jam
- Saran Paliatif
8 3/9/2021 Ny.F 35th C : TD : 118/67 mmhg, HR - Asidosis metabolic - Monitoring KU dan VS LOC2
160x/m hiperchloremi - Head up 30 derajat
- Hipernatremia - Oksigenasi NRM 10 lpm
- AKI - Inf RL 20 tpm
- Koreksi Hb target 10 g/dL
- Koreksi Natrium target 135-140
- Balans cairan target uop 0.5-1
cc/kg/jam
 Admission: 29 August -11 September 2021
No Tanggal Pasien Usia Problem Diagnosa Manajemen Kriteria

9 3/9/2021 Tn.AS 61th A : Gurgling (+)B : spontan, - Distress nafas ec aspirasi - - Monitoring KU dan VS LOC3
simetris RR 32x/m SpO2 37% CKD stg V on HD Rutin - Intubasi
O2 NRM 15 lpm - Anemia - Inf RL 10 tpm
- Hipoalbumin - Balans cairan target uop 0.5-1
- Hiperkalemia cc/kg/jam
- Asidosis Metabolik

10 4/9/2021 Ny.R 49th C : TD : 68/43 mmhg, HR - Syok hipovolemi ec - Monitoring KU dan VS LOC1
120x/m perdarahan pervaginam - Head up 30 derajat
- Ca cervix stadium IV B, - Oksigenasi NRM 10 lpm
infiltrasi rectum & Buli - Transfusi PRC 1 kolf
- Anemia Gravi - Koreksi Hb target 10 g/dL, koreksi
- Hipoalbumin Albumin target 2,75
- Asidosis Metabolik - Balans cairan target uop 0.5-1
cc/kg/jam
- Saran Paliatif
 Admission: 29 August -11 September 2021
No Tanggal Pasien Usia Problem Diagnosa Manajemen Kriteria

11 10/9/2021 Ny.C 27th C : TD : 118/67 mmhg, HR - Impending Krisis Hipertiroid - Monitoring KU dan VS LOC2
160x/m - G1P0A0 UK 30 mgg dengan - Head up 30 derajat
IUFD - inf RL 20 tpm
- Pankreatitiis akut - Oksigenasi NRM 10 lpm
- Vomitus Profuse - Lugol 8 tetes
- Asidosis Metabolik - PTU 200mg
- Propanolol 10 mg
- Balans cairan target uop 0.5-1
cc/kg/jam
- Terapi asidosis metabolik sesuai
TS UPD
Case Report
 Case Presentation
Patient identity Tn.S/P/50 thn MR:01-98-58-05
Arrival Jumat, 3/9/2021
Chief compaint Hipotensi
Case Hipotensi
From Bugenvil 1

Pasien panggilan TME dengan hipotensi, pasien rujukan dengan hematemesis melena,
sirosis hepatis child pugh class B, hepatitis B. 1 bulan SMRS pasien mengeluhkan nyeri
perut dirasakan perut makin membesar kemudian periksa ke dokter dikatakan sakit liver
dengan terapi: hyosin 3x1, propranolol 2x10 mg, sucralfate 3x1, spironolactone 1x200mg.
HMRS keluhan pasien BAB hitam (+) 4 kali sehari, muntah darah (+), mual (+), nyeri perut
(+)
Case Presentation
Primary Survey

SURVEY FINDINGS RESUSCITATION EVALUATION

AIRWAY Clear - Clear

BREATHING spontan, simetris RR Nasal kanul 3lpm SpO2 99%

24x/m SpO2 97% RA

CIRCULATION TD : 78/44 mmhg, HR Pasang iv line 2 jalur TD 89/50mmhg

112x/m Resusitasi cairan HR 118x
30cc/kgBB

DISABILITY E4M6V5 - Compos mentis

 Case Presentation
Secondary Survey
SUBJECTIVE OBJECTIVE ASSESSMENT PLAN
History Pasien panggilan TME dengan hipotensi, pasien rujukan dengan hematemesis melena, 1. Syok sepsis 1. Monitoring KU dan VS
sirosis hepatis child pugh class B, hepatitis B. 1 bulan SMRS pasien mengeluhkan nyeri 2. Sirosis hepatis ec 2. Head up 30 derajat
perut dirasakan perut makin membesar kemudian periksa ke dokter dikatakan sakit liver hepatitis B child 3. Oksigenasi NK 3 lpm
dengan terapi: hyosin 3x1, propranolol 2x10 mg, sucralfate 3x1, spironolactone pugh class B 4. Loading cairan
1x200mg. HMRS keluhan pasien BAB hitam (+) 4 kali sehari, muntah darah (+), mual 3. Anemia kristaloid 30cc/kgBB
(+), nyeri perut (+), HT (-), DM (-) 4. AKI 5. Vascon titrasi
5. Asidosis 6. Inj D40% 2 Flask
Metabolik 7. Koreksi Hb target 10
6. Hipoglikemia g/dL,
Vital sign TD 89/50; HR 118; RR 24; SpO2 99%; t 36 8. Balans cairan target
Neurologic E4V5M6, pupil isokor 3/3, light reflex +/+, lateralization -/- meningeal sign - uop 0.5-1 cc/kg/jam
9. Saran perawatan LOC
2 HCU,
Respiratory Vesikuler +/+ Wh -/- Rh -/- ekspirasi memanjang-/- 10. kultur darah, ganti
Cardiovascular S1/S2 Reguler, Murmur (-) antibiotic spektrum
luas
Gastrointestinal Distended (+), venektasi (-), NT (+) ulu hati, peristaltic (+) 10 kpm 11. Edukasi keluarga-
Extremities Edema -/-, CRT 3 detik 12. Lain-lain sesuai TS
DPJP
Laboratories AGD= FiO2: 30%; pH: 7,14; PO2: 110; PCO2: 22,3; HCO3: 7,6; BE: -21; Lac: 14,46;
SPO2: 97; Pf ratio: 366
Darah= AL/AT : 10,7/232; Hb/Ht : 7,9/22,7; Ur/cr : 81,2/3,57; GDS/Alb: 28/3,35; Na/K/Cl:
144/4.72/104; Procal: 5,97
Imaging Ro Tho : c/p dbn
Literature Review
Definition
Sepsis is now defined as life-threatening organ dysfunction caused
by a dysregulated host response to infection.

e f in i ti o n
E P S IS D
S
2004 2008 2012 2017
Septic shock is a subset of sepsis with circulatory and cellular/metabolic
dysfunction associated with a higher risk of mortality
TOOLS FOR IDENTIFYING HIGH RISK

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Literature Review

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What are the End Points of Resuscitation in septic shock
patients?
 Septic Shock
Management

HEMODYNAMIC INFECTION DETECTION

STABILIZATION & CONTROL

Blood Lactate Blood cultures

IV fluids Vasoactive agent ? Antibiotics Source control ?

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 Septic Shock
Intravenous fluid resuscitation
?
Capillary
Vasoplegi
leak
a

SEPTIC SHOCK
Vasodilatory

Distributive
(maldistribution)

No volume loss !!!

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 Monitoring fluid management
R O S E
RESUSCITATION OPTIMIZATION STABILIZATIO EVACUATION
N
Minimum monitoring :
 Blood Pressure SBP MAP MAP MAP
 Heart Rate + + + +
 Capillary Refill + + + +
 Lactate + + + +
 Urine Output - + + +
 Fluid Balance - + + +

 CVP - ±/? - -
 ScvO2 - + - -
 Fluid responsiveness - + - -
 Cardiac Output - + - -
(PPV,SPV,SVV)
Br J Anaesth. 2014 Nov;113(5):740-7
N Engl J Med 2013;369:1726-34 rudy manalu
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Sepsis improvement program:
- Sepsis screening
- Education
- Measurement of sepsis bundle performance + patient outcomes
- Action

Meta-analysis (50 studies): These programs were associated with better adherence
to sepsis bundles along with a reduction in mortality
(OR 0,66: 95 % CI 0,61 - 0,72)
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• q-SOFA - 3 variables to predict death + prolonged ICU stay in patients with known
or suspected sepsis.

• Q-SOFA not an ideal screening tools for sepsis

• Only 24 % of infected patients had a q-SOFA score 2 or 3

• These patients accounted for 70 % of poor outcomes

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• The association of lactate level with mortality in patients with suspected
infection and sepsis is well established.

• The lactate cutoffs determining an elevated level ranged from 1.6-2.5 mmol/L,
although diagnostic characteristic were similar regardless of the cutoff

• Sensitive range from 66-83%, with specificities ranging from 80-85%.

• However, lactate alone is neither sensitive nor specific enough to role-in or role –out
the diagnosis on its own.

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• Timely, effective fluid resuscitation is crucial for the stabilization of sepsis-induced
tissue hypoperfusion in sepsis and septic shock.

• Previous guidelines recommend innitiating appropriate resuscitation upon

recognition of sepsis or septic shock and having a low threshold for commencing it
in those patients where sepsis is not proven but is suspected.

• Although the evidence stems from observational studies, this recommendation is

considered a best
andpractice
there are now new data suggesting that a change is needed.

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• No prospective interventional studies that compare the different volumes for initial
resuscitation.

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Dynamic Measures:

• Passive leg raising (PLR) + cardiac output (CO) measurement

• Stroke volume (SV)
• Stroke volume variation (SVV)

Better diagnostic accuracy at predicting fluid responsiveness

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Adjunct measure of perfusion / guidance of fluid resus:

• Dynamic measures over static measures

- Meta-analysis : Dynamic assessment to guide fluid therapy was associated with:

- mortality (RR 0.59; 95% CI 0.42 - 0.83)
- ICU length of stay (MD-1.16 days; 95 % CI – 1.97 to -0,36)
- duration of mechanical ventilation (-2.98h; 95 % CI -5.08 to 0.89)

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• Reducing lactate levels.

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• When advanced hemodynamic monitoring is not available, alternative measures of
organ perfusion may be used to evaluate the effectiveness and safety of volume
administration .

• Temperature of the extremities, skin mottling and capillary refill time (CRT) have
been validated and shown to be reproducible signs of tissue perfusion.

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 • Unchanged from 2016 guidelines.

• Increasing MAP therefore usually results in increased driver of venous return and CO.
• Previous SSC guidelines recommended targeting a MAP o greater than 65 mmHg for
initial resuscitation.

• The recommendation was based principally on a RCT in septic shock comparing

patients were given vasopressors to target a MAP of 65-70 mmHg, versus a target 80-
85 mmHg. This study found no difference in mortality.

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 Summary
• Shock is defined as acute circulatory failure with inadequate or
inappropriately distributed tissue perfusion resulting in generalized
cellular hypoxia.

• Septic shock is another form of distributive shock.

• The aim of resuscitation is to prevent shock worsening and to

restore the circulation to level that meets the body’s tissue oxygen
requirements.

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 Summary

• End points of resuscitation: goal of resuscitation is to maximize

survival and minimize morbidity.

• Resuscitation endpoints can be divided into two groups, macro

circulation and microcirculation.

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 Summary
• Septic Shock:

- treatment and resuscitation begin immediately (recommendation)

- at least 30 mL/kg IV crystalloid fluid should be given within
the first 3 hours of resuscitation (suggestion)
- using dynamic measures to guide fluid resuscitation (suggestion)
- measuring blood lactate for adults suspected of having
sepsis (suggestion)
- guiding resuscitation to decrease serum lactate (suggestion)
- using capillary refill time to guide resuscitation as an
adjunct to other measures of perfusion (suggestion)
- target mean arterial pressure of 65 mmHg (recommendation)
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terimakasih