Ujian ICU 2

Pneumonia ec COVID 19 + Necrotomi Cruris Dextra

+ Post STSG

Hikmatiar
Reyki Yudho Husodo

Penguji : dr. Mayang Indah Lestari, SpAn (K)

Departemen Anestesi dan Terapi Intensif

Fakultas Kedokteran Universitas Sriwijaya - RSUP dr. Moh. Hoesin Palembang
2021
Identitas

Nama Tn. N

Med.Rec / Reg 1195153 / RI 21001359

Umur 44 tahun

Alamat Demang Lebar Daun

MRS 20 Februari 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

Kasus
PRIMARY
SURVEY Clear
Airway Nafas Spontan, 28x/m, Pola nafas thoracoabdominal,
Breathing WOB (+)
SpO2: 84% dengan NRM 15 L/M
Pemeriksaan Thorax : Pergerakan dada simetris, bunyi
paru vesikuler (+/+), ronchi (+/+)
TD : 130/90, HR: 118 x/menit regular, isi/tegangan
Circulation cukup, CRT < 2 detik, akral hangat.
Kesadaran E4 M6 V5
Disability

Departemen Anestesi dan Terapi Intensif

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

Positif
Pemeriksaan
CT PCR COVID19 (19/02/2021)
: 30,78

Pneumonia bilateral

Pemeriksaan Ro Thoraks (19/02/2021)

Departemen Anestesi dan Terapi Intensif

Kasus

Diagnosis Pneumonia ec COVID 19 + Necrotomi Cruris Dextra

+ Post STSG

Planning
- Rawat mini ICU BORANG
- Pemasangan NFNC

Departemen Anestesi dan Terapi Intensif

ICU HARI KE 1 (20-02-2021)
Tgl Objective Assessment Daily Assesment
24/01/2 CNS : E4M6V5 Pneumonia ec COVID 19 + Necrotomi Cruris F: Diet cair 4x300 kkal
CVS : TD: 140/90 mmHg A: Morfin
021 Dextra + Post STSG
S: Dexmedetomidin
N : 95 x/menit regular, tegangan/isi T: Padua score 3
cukup, Tanpa Support Lab AGD Improve score 4
Hb : 11.6 pH 7.417
on NFNC 60 lt/m FiO2 90% RR 20- Ht : 36 PCO2 35.1
H: head up 30°
22x/mnt U: Omeprazole 1x40 mg
Leu: 7.810 PO2 76.9 G: BSS : 198 mg/dl
SpO2 93-94% Plt : 238.000 SO2 95.7 B: Bowel sound (+) distensi(-)
Temp 36,3 C D/C 0/1/74/20/5 HCO3 22.8 I: Catheter (+), Infeksi(-)
GIT : distensi (-), Peristaltik Normal Na : 139 Lact 2.1 D:
K : 4.7 P/F 80.8 Medikamentosa
GUT : diuresis (+), • Meropenem 2gr/24j iv (E4)
Cl : 106
Urine output : 1 ml/kgbb/jam • Azitromisin 500 mg/24 j (E1)
Ur : 30 LDH 365
• Remdesivir 500 mg/24 j (H2)
Cr : 0.75 Feritin 2575.1 • Omeprazole 40mg/24j iv
Planning Alb : 3.0 CRP 240 • N-Acetylsistein 5gr/24j iv
• Cek lab lengkap PT : 12.5 / 14.20 Procalcitonin 0.25 • Vit C 500 mg/8j iv
• Cek kultur darah INR :0.87 • Vit. D 10.000 ui /24 j po
APTT 32.5 / 30.1 • Zinc 20mg/24j po
D DIMER 1.47 • Atrovastatin 20 mg/24 j po
Fibrinogen 749 / 275 • Dexamethason 6mg/24j (H1)
• Heparin nebu 15.000 +
Kesan AGD lidocaine
• Heparin 10.000 ui/24 jam
Hipoksemia Dexmedetomidin 0.2 mcg/kg/j
•
• Morfin 5 mcg/kg/j

Departemen Anestesi dan Terapi Intensif

ICU HARI KE 2 (21-02-2021)
Tgl Objective Assessment Daily Assesment
24/01/2 CNS : E4M6V5 Pneumonia ec COVID 19 + Necrotomi Cruris F: Diet cair 4x300 kkal
A: Morfin
021 CVS : TD: 117/78 mmHg Dextra + Post STSG
S: Dexmedetomidin
N : 85 x/menit regular, tegangan/isi T: Padua score 3
cukup, Tanpa Support Lab AGD Improve score 4
Hb : 11.5 pH 7.402 H: head up 30°
on NFNC 60 lt/m FiO2 80% RR 20- Ht : 36 PCO2 39.3 U: Omeprazole 1x40 mg
22x/mnt Leu: 5.620 PO2 43.8 G: BSS : 198 mg/dl
SpO2 93-94% Plt : 274.000 SO2 76.8 B: Bowel sound (+) distensi(-)
Temp 36,3 C D/C 0/0/78/19/3 HCO3 24.6 I: Catheter (+), Infeksi(-)
GIT : distensi (-), Peristaltik Normal Na : 135 Lact 2.4 D:
K : 4.7 BE -1.0 Medikamentosa
GUT : diuresis (+), • Meropenem 2gr/24j iv (E5)
Cl : 100
Urine output : 1 ml/kgbb/jam • Azitromisin 500 mg/24 j (E2)
Ur : 28
• Remdesivir 500 mg/24 j (H3)
Cr : 0.75 • Omeprazole 40mg/24j iv
Planning Alb : 2.8 • N-Acetylsistein 5gr/24j iv
• Pemberian anti-immunoglobulin 25 mg PT : 14.1 / 16.7 • Vit C 500 mg/8j iv
(0.3 mg/kg) selama 3 hari INR :1.05 • Vit. D 10.000 ui /24 j po
• Weaning HFNC APTT 31.5 / 33.5 • Zinc 20mg/24j po
D DIMER 0.31 • Atrovastatin 20 mg/24 j po
Fibrinogen 965 / 311 • Dexamethason 6mg/24j (H2)
BSS 159 • Heparin nebu 15.000 +
lidocaine
• Heparin 10.000 ui/24 jam
• Dexmedetomidin 0.2 mcg/kg/j
• Morfin 5 mcg/kg/j
• Gamaras 25 mg/ 24 j (H1)

Departemen Anestesi dan Terapi Intensif

ICU HARI KE 3 (22-02-2021)
Tgl Objective Assessment Daily Assesment
24/01/2 CNS : E4M6V5 Pneumonia ec COVID 19 + Necrotomi Cruris F: Diet cair 4x300 kkal
A: Morfin
021 CVS : TD: 120/78 mmHg Dextra + Post STSG
S: Dexmedetomidin
N : 68 x/menit regular, tegangan/isi T: Padua score 3
cukup, Tanpa Support Lab AGD Improve score 4
Hb : 10.6 pH 7.395 H: head up 30°
on NFNC 30 lt/m FiO2 70% RR 20- Ht : 32 PCO2 31.8 U: Omeprazole 1x40 mg
22x/mnt Leu: 7.250 PO2 151.6 G: BSS : 198 mg/dl
SpO2 95-06% Plt : 318.000 SO2 99.9 B: Bowel sound (+) distensi(-)
Temp 36,3 C D/C 0/0/84/11/5 HCO3 19.6 I: Catheter (+), Infeksi(-)
GIT : distensi (-), Peristaltik Normal Na : 138 Lact 4.3 D:
K : 4.7 BE -5.3 Medikamentosa
GUT : diuresis (+), • Meropenem 2gr/24j iv (E6)
Cl : 106
Urine output : 1 ml/kgbb/jam • Azitromisin 500 mg/24 j (E3)
Ur : 34
• Remdesivir 500 mg/24 j (H4)
Cr : 0.60 • Omeprazole 40mg/24j iv
Planning Alb : 2.8 • N-Acetylsistein 5gr/24j iv
• Weaning HFNC Bil. Tot 0.30 • Vit C 500 mg/8j iv
PT : 13.7 / 14.70 • Vit. D 10.000 ui /24 j po
INR :0.96 • Zinc 20mg/24j po
APTT 28.2 / 31.2 • Atrovastatin 20 mg/24 j po
D DIMER 1.6 • Dexamethason 6mg/24j (H3)
Fibrinogen 718 / 271 • Heparin nebu 15.000 +
BSS 160 lidocaine
• Heparin 10.000 ui/24 jam
• Dexmedetomidin 0.2 mcg/kg/j
• Morfin 5 mcg/kg/j
• Gamaras 25 mg/ 24 j (H2)

Departemen Anestesi dan Terapi Intensif

ICU HARI KE 4 (23-02-2021)
Tgl Objective Assessment Daily Assesment
24/01/2 CNS : E4M6V5 Pneumonia ec COVID 19 + Necrotomi Cruris F: Diet cair 4x300 kkal
A: Morfin
021 CVS : TD: 130/80 mmHg Dextra + Post STSG
S: Dexmedetomidin
N : 95 x/menit regular, tegangan/isi T: Padua score 3
cukup, Tanpa Support Lab AGD Improve score 4
Hb : 10.5 pH 7.395 H: head up 30°
on NFNC 30 lt/m FiO2 70% RR 20- Ht : 32 PCO2 31.8 U: Omeprazole 1x40 mg
22x/mnt Leu: 7.250 PO2 151 G: BSS : 198 mg/dl
SpO2 97% Plt : 318.000 SO2 99.9 B: Bowel sound (+) distensi(-)
Temp 36,3 C D/C 0/0/84/11/5 HCO3 24.7 I: Catheter (+), Infeksi(-)
GIT : distensi (-), Peristaltik Normal Na : 135 Lact 4.3 D:
K : 5.7 BE -5.5 Medikamentosa
GUT : diuresis (+), • Meropenem 2gr/24j iv (E7)
Cl : 98
Urine output : 1 ml/kgbb/jam • Azitromisin 500 mg/24 j (E4)
Ur : 28
• Remdesivir 500 mg/24 j (H5)
Cr : 0.75 • Omeprazole 40mg/24j iv
Planning Alb : 2.8 • N-Acetylsistein 5gr/24j iv
• Weaning HFNC PT : 13.7 / 14.7 • Vit C 500 mg/8j iv
INR : 0.96 • Vit. D 10.000 ui /24 j po
APTT 718 / 271 • Zinc 20mg/24j po
D DIMER 1.67 • Atrovastatin 20 mg/24 j po
Fibrinogen 718 / 271 • Dexamethason 6mg/24j (H4)
BSS 160 • Heparin nebu 15.000 +
lidocaine
• Heparin 10.000 ui/24 jam
Kesan AGD • Dexmedetomidin 0.2 mcg/kg/j
Hipoksemia • Morfin 5 mcg/kg/j
• Gamaras 25 mg/ 24 j (H3)

Departemen Anestesi dan Terapi Intensif

ICU HARI KE 5 (24-02-2021)
Tgl Objective Assessment Daily Assesment
24/01/2 CNS : E4M6V5 Pneumonia ec COVID 19 + Necrotomi Cruris F: Diet cair 4x300 kkal
A: Morfin
021 CVS : TD: 140/90 mmHg Dextra + Post STSG
S: Dexmedetomidin
N : 95 x/menit regular, tegangan/isi T: Padua score 3
cukup, Tanpa Support Lab AGD Improve score 4
Hb : 10.7 pH 7.417 H: head up 30°
on NFNC 30 lt/m FiO2 60% RR 22- Ht : 34 PCO2 30.6 U: Omeprazole 1x40 mg
24x/mnt Leu: 16.250 PO2 42.3 G: BSS : 198 mg/dl
SpO2 94-95% Plt : 330.000 SO2 77.1 B: Bowel sound (+) distensi(-)
Temp 36,3 C D/C 0/0/92/5/3 HCO3 19.9 I: Catheter (+), Infeksi(-)
GIT : distensi (-), Peristaltik Normal Na : 139 Lact 2.8 D:
K : 4.9 P/F 60.34 Medikamentosa
GUT : diuresis (+), • Meropenem 2gr/24j iv (E8)
Cl : 104
Urine output : 1 ml/kgbb/jam • Azitromisin 500 mg/24 j (E5)
Ur : 28
• Remdesivir 500 mg/24 j (H6)
Cr : 0.75 • Omeprazole 40mg/24j iv
Planning Alb : 2.8 • N-Acetylsistein 5gr/24j iv
Weaning HFNC PT : 17.0 / 16.0 Vit C 500 mg/8j iv
•
INR :1.26 • Vit. D 10.000 ui /24 j po
APTT 30.5 / 32.6 • Zinc 20mg/24j po
D DIMER 2.48 • Atrovastatin 20 mg/24 j po
Fibrinogen 670 / 314 • Dexamethason 6mg/24j (H5)
BSS 121 • Heparin nebu 15.000 +
lidocaine
• Heparin 10.000 ui/24 jam
Kesan AGD • Dexmedetomidin 0.2 mcg/kg/j
Hipoksemia • Morfin 5 mcg/kg/j
• Gamaras 25 mg/ 24 j (H4)

Departemen Anestesi dan Terapi Intensif

ICU HARI KE 6 (25-02-2021)
Tgl Objective Assessment Daily Assesment
30/01/ CNS : E4M6V5 Pneumonia ec COVID 19 + F: Diet cair 4x300 kkal
2021 CVS : TD: 140/90 mmHg Necrotomi Cruris Dextra + Post A: Morfin
S: Dexmedetomidin
N : 95 x/menit regular, tegangan/isi STSG
T: Padua score 3
cukup, Tanpa Support Improve score 4
on NFNC 30 lt/m FiO2 60% RR Lab AGD
H: head up 30°
Hb : 15.8 pH 7.391
20-22x/mnt Ht : 47 PCO2 35.7 U: Omeprazole 1x40 mg
SpO2 95% Leu: 16.670 PO2 65.4 G: BSS : 198 mg/dl
Temp 36,3 C B: Bowel sound (+) distensi(-)
Plt : 397.000 SO2 92,7
GIT : distensi (-), Peristaltik Normal I: Catheter (+), Infeksi(-)
D/C 0/3/83/8/5 HCO3 22.6
D:
GUT : diuresis (+), Na : 139 Lact 2
Medikamentosa
Urine output : 1 ml/kgbb/jam K : 4.8 P/F 93,4
• Meropenem 2gr/24j iv (E8)
Planning Cl : 107
• Azitromisin 500 mg/24 j (E5)
Ur : 45 • Remdesivir 500 mg/24 j (H6)
Cr : 0.65 • Omeprazole 40mg/24j iv
Bil tot : 0,8 • N-Acetylsistein 5gr/24j iv
Alb : 3 • Vit C 500 mg/8j iv
• Vit. D 10.000 ui /24 j po
• Zinc 20mg/24j po
• Atrovastatin 20 mg/24 j po
Kesan AGD
• Dexamethason 6mg/24j (H5)
Hipoksemia
• Heparin nebu 15.000 + lidocaine
• Heparin 10.000 ui/24 jam
• Dexmedetomidin 0.2 mcg/kg/j
• Morfin 5 mcg/kg/j
• Gamaras 25 mg/ 24 j (H5)

Departemen Anestesi dan Terapi Intensif

TERIMA KASIH