Laporan Kasus ICU RSHS

Pasien Pasca Relaparatomi ec. Atonia Uteri

dengan AKI, Edema Paru, VAP dan Syok Sepsis

27 Juli
2010
Ps wanita 27 th G1H0A0
aterm dilakukan SC dengan
indikasi Ketuban pecah,
presentasi bokong dan gagal
induksi persalinan
Riwayat Hipertensi, penyakit
jantung disangkal
PEB () HELLP (-)
17.00 dilakukan SCTPP
Postop :
Anemis, BP 110/80, N 110x,
RR 24x/m S afebris
Abdomen tegang, darah
merembes dari vagina
USG abdomen : cairan bebas
intraabdomen, susp.
Perdarahan intraabdomen
ec. Atonia uter

28 Juli
2010
07.00 : dilakukan relaparotomi,
perdarahan intraabdomen
+2000cc, atonia uteri
Dilakukan histerektomi
supravagina
Postop ICU

Bed 6/ Ny. Heni/ 27 th / HP - 1

Tgl
28
Sept
2010

Objective
CNS : CM
CVS : TD = 120/80 mmHg (93)
tanpa support

Assessment
Post LE ai. Perdarahan
intra abdomen ec Atonia
Uteri Post SC + Post HSV
-AKI
--DIC

HR : 94-105X/mnt,
CVP : 10-15 cmH2O dg loading
RL 500cc
RR : 32-37x/m, NK O2 3lt
Saturasi 99 %
GIT : NGT + merah, distensi
(-), drain vagina 550cc/18jam
GUT : diuresis 234cc/18 jam
balans +3090cc

Planning
F : Puasa
A : Tramadol 50mg
S:T:H

Lab.
Hb 7.8/23/19700/29000
Gds: 108 Albumin 2.1
Ur/Cr 56/3.0, SGOT/SGPT
741/373, bil tot 0.57
Na 140 K 5.1 Cl 104 Ca 4.71
Mg 1.22
PT/APTT 21.6/53.8 INR 1.71
Fibr 138.7 Ddimer 6.6
AGD arteri.
7,14/20.6/ 97,1/6,9/
20,1/90,7

:Head up 45 derajat

U : Ranitidin 2x1 amp

G:Th :
-Cefotaxim 3x1 gr (1)
-Metronidazole 1x1500mg
-Tranfusi PRC 500, FFP 1000,
TC 5 U

Bed 6/ Ny. Heni/ 27 th / HP - 2

Tgl
29
Sept
2010

Objective
CNS: CM
CVS: TD: 90/79 mmHg (84)
Tanpa support
HR : 89 x/mnt
CVP: 15-18 mmHg

Assessment
Dx : Post LE ai. Perdarahan intra
abdomen ec Atonia Uteri Post
SC + Post HSV
-Edema Paru
-AKI
-DIC

RR : ronki +/+ NK O2 3lt, RR

16,SpO2 99%
Pkl 02.00 somnolen, TD
150/104, HR 104, RR 33x, Sat
88% dng NRM O2 12lt
Intubasi, VC TV 326-400, 18x.
FiO2 80-60%
S : 36,6C -37
GIT : NGT hitam, distensi (-),
TIA 14 cm H2O drain
900cc/24j
GUT : diuresis 413cc/24 jam
balans +775cc
APACHE 6SOFA 5 POD 7

Planning
F : Ensure 1000cc/24jam,
puasa
A : -Petidin 75mg drip 24j
S : -Midazolam 2mg/j
T:H : Head up 45

Hb : 7.8/23/14300/40000
Ur/Cr 87/3.5 SGOT/SGPT 1166
578 GDS 108
Na/K 137/6.4
Cl/Ca/Mg 105/4,09/1,47
PT/APTT 16.3/32.3 INR 1.3
AGD a :
7.463/36.4/196.9/26.3/2.4/94.6%
7.310/25.5/56.1/12.7/-12.6/86.3%

U : omeprazole 1x40mg
Ranitidin 2x1 amp
G:Th/
Cefotaxim 3x1gr (2)
Metronidazol 1x1500 (2)
Lasix 5mg/jam
Tranfusi PRC, FFP, TC
Konsul HD

Bed 6/ Ny. Heni/ 27 th / HP - 3

Tgl
30
Sept
2010

Objective
CNS : CM
CVS : TD 140/100 (110)
HR : 94 X / mnt
CVP 14 mmHg
RR: SIMV 10 PS10 PEEP
6 FiO2 45% Sat 97
Pkl 22.00 ekstubasi
sendiri, NRM 10 lt/mnt
Sat 99-100%
S : 36-37
GIT: distensi (-)
GUT: diuresis 388 cc /24j
balans 564

Assessment
Dx : : Post LE ai. Perdarahan
intra abdomen ec Atonia Uteri
Post SC + Post HSV
-Edema Paru
-AKI
-DIC

Planing
F: D10 30cc/jam
A :S: - Midazolam 2 mg/jam
T: H: head up 45 derajat

Lab :Hb:11.2/33/15700/
50000 Na/K/Cl/Ca/Mg 137 /5.2 /
109 /4.5/1,64
Ur/Cr 159/4.9 Alb 2,5
AGD 7,295/33/57,9/-13,3 /131 /
90,6 GDS: 94
PT/APTT/INR d dimer
16.7/33.5/1.33/33.5
Post SLEDD 9.5/27/16700/30.000
Ur/Cr 66/2.5 Na136 K3.2 Cl99
Ca4.01 Mg 1.34

U: OMZ 1x40mg, Sucralfat 4x40cc

G: Th/ - Cefotaxim 3x1 gr (3)
- Metronidazol 1x1500mg (3)
- Lasix 20 mg/jam
- SLED 6 jam
- Tranfusi PRC, FFP, TC
- Kultur darah
- MgSO4,- CaCl 1 amp

Bed 6/ Ny. Heni/ 27 th / HP - 4

Tgl
1
Okt
2010

Objective
CNS: CM,
CVS: TD: 133/94 (105),
N: 81x/mnt
RR : 22x/mnt, terhubung
dgn SMNR 7 lt/mnt
SpO2 99%

Assessment
Dx : : Post LE ai. Perdarahan
intra abdomen ec Atonia
Uteri Post SC + Post HSV
-Edema Paru
-AKI
-DIC

Planing
F : DX 10 30cc/jam, residu +
A:
S : Midazolam 2mg jam
T
H : Head up 45

S : 37

GIT : Distensi (-)

GUT : Diuresis : 571/24jam
Balance +177/24j

Lab:
Hb/Ht/L/Tr:
9.5/27/16700/30000
GDS : 164
Ur/Cr : 66/2.53
Na/K/Cl/Ca/Mg:136/3,2/
99/4,01/1,34
AGD : 7,413/29,6/160,6/18,9/5,1/93%
SGOT/SGPT 413/ 428

U ; OMZ1x40 mg, Sucralfat

4x10cc
G:Th/
-Cefotaxim 3x1gr (4)
-- Metronidazol 1x1500mg
--Ca glukonas 1 amp
-- Aminofusin 500cc
-- D10 1000
--D40 100
-- Lasix 20 mg/jam

Bed 6/ Ny. Heni/ 27 th / HP - 5

Tgl
2
Okt
2010

Objective
CNS: CM,
CVS: TD: 150/99 (120),
N: 110x/mnt
RR : 20x/mnt,
terhubung dgn SMNR 8
lt/mnt
SpO2 97%
S : 37

GIT : Distensi (-)

GUT :
Diuresis : 2065/24jam
Balance -36cc/24j

Assessment
Dx : : Post LE ai. Perdarahan
intra abdomen ec Atonia Uteri
Post SC + Post HSV
-Edema Paru
-AKI
-DIC

Planing
F : Ensure 500cc
A:
S : Midazolam 2mg jam
T:
H : Head up 45

Lab:
Hb/Ht/L/Tr:
10.4/30/11400/55000
Ur/Cr : 121/3.96
Na/K/Cl/Ca/Mg:133/3,2/
98/4,35/1,9
AGD : 7,411/31.3/103,3/19,6/-4 /
93%

U ; OMZ1x40 mg, Sucralfat

4x10cc
G:Th/
-Cefotaxim 6x1gr (5)
-- Metronidazol 1x1500mg
--Ca glukonas 1 amp
--KCL 50 meq
-- Aminofusin 500cc
-- D10 1000
-- Lasix 20 mg/jam

Bed 6/ Ny. Heni/ 27 th / HP - 6

Tgl
3
Okt
2010

Objective
CNS: cm
CVS:TD: 151/95 (108)
HR: 109 x/mnt
CVP : 8 mmHg
RR : 23x/mnt dgn SMNR
8lt/mnt, sat 96%

Assessment
Post LE ai. Perdarahan
intra abdomen + Post SC
ai Letak Sungsang + Post
HSV
- Edema Paru
- AKI
- DIC

Planing
F : Diet bubur saring 1000 kal

A:
S:
T:
H : Head up 45 derajat

S :36,8
GIT : distensi (-)
GUT : diuresis :2675/24=105
cc/jam
Balance :-2537

Lab
Hb: 10,2/30/12700/53000
Na/K/Cl/Ca/Mg:131/3,3/98
/4,33/1,99 Ur/Cr : 140/4,8
AGD:
7,438/32,1/98.5/21,4/2,2/93,2%
Post HD :
Ur/Cr 112/3.84
Na133 K 3.1 Cl 98 Ca 4.27
Mg 1.84

U : Sucralfat 4x10, OMZ 1x40

G:
Tx:

Cefotaxime 6x1 gr (6)

Metronidazole 1x1500 mg
(6)

Nebu Nacl 3x/hr

flumucyl 3x1 sachet

Lasix 5 mg/jam
- HD

Bed 6/ Ny. Heni/ 27 th / HP - 7

Tgl
4
Okt
2010

Objective
CNS: cm
CVS:TD: 132/86 (99)
HR: 102 x/mnt
Support:CVP : 8 mmHg
RR : 18x/mnt dgn SMNR
8lt/mnt, sat 96%
Pkl 22.15 sesak, sat 88, ronki
+/+ sputum merah Intubasi
IPPV 14 PEEP 10 TV 500 FiO2
100
GIT : distensi (-)
GUT : diuresis :2335/24j
Balance :+252

Assessment
Post LE ai. Perdarahan
intra abdomen + Post SC
ai Letak Sungsang + Post
HSV
- Edema Paru
- AKI
- DIC

Planing
F : Diet Lunak

A:
S:
T:
H : Head up 45 derajat

Lab
Hb: 9,2/27/17300/66000
Na/K/Cl/Ca/Mg:132/3,4/99
/4,6/1,69
GDS 100
AGD:
7,446/32,3/134,9/21,9/1,6 /94,2%
Ur/Cr : 116/4,2
Kultur darah negatif

U : Sucralfat 4x10, OMZ 1x40

G:
Tx:

Cefotaxime 6x1 gr (6)

Metronidazole 1x1500 mg
(6)

Nebu Nacl 3x/hr

flumucyl 3x1 sachet

Lasix 5-20 mg/jam

NTG 5 ug/mnt
-Konsul HD cito

Bed 6/ Ny. Heni/ 27 th / HP - 8

Tgl
5
Okt
2010

Objective
CNS: DPO
CVS:TD: 139/96 (111)
HR: 138 x/mnt
Support:CVP : 16 mmHg
RR : IPPV 14 PEEP 10 TV 400
FiO2 70-45%

Assessment

Planing

Post LE ai. Perdarahan

intra abdomen + Post SC
ai Letak Sungsang + Post
HSV
-AKI
-Edema Paru +
Bronkopneumonia

F : Nefrisol 1000, ensure 500cc

A:
S : Midazolam 2mg/jam
T:
H : Head up 45 derajat

S 37-37.8
GIT : distensi (-)
GUT : diuresis :1675/24j
Balance :+1383cc/24j

Lab
Hb: 9,5/28/40100/118000
8.8/26/21.300/134.000
Na/K/Cl/Ca/Mg:134/3,7/99
/4,5/1,62 GDS 100
AGD:
7,446/32,3/134,9/21,9/1,6 /94,2%
Ur/Cr : 152/5.1
Cxray :
bronkopneumonia
CPIS : 6

U : Sucralfat 4x10, OMZ 1x40

G:
Tx:
Meropenem 3x1 gr (1)

Nebu Nacl 3x/hr

flumucyl 3x1 sachet

Lasix 15-20 mg/jam

NTG 5 ug/mnt
-Konsul HD
Kultur Sputum
-ECHO

Bed 6/ Ny. Heni/ 27 th / HP - 9

Tgl
6
Okt
2010

Objective
CNS: DPO
CVS:TD: 114/69 (80)
HR: 102 x/mnt
Support:CVP : 8 mmHg
RR : SIMV 6 PS 10 PEEP 10
TV 400 FiO2 45%

Assessment
Post LE ai. Perdarahan
intra abdomen + Post SC
ai Letak Sungsang + Post
HSV
-AKI
-Edema Paru +
Bronkopneumonia

Planing
F : Nefrisol 750cc, ensure
500cc
A:
S : Midazolam 2mg/jam
T : Heparin 2x5000 ui
H : Head up 45 derajat

S 37-37.8
GIT : distensi (-)
GUT : diuresis :1332/24j
Balance :-878cc/24j

Lab
Hb: 8.3/24/19700/136.000
Na/K/Cl/Ca/Mg:133/3,3/99
/4,41/1,81
GDS 132
AGD:
7,407/32,6/150,2/20,9/1,6 /94,4%
Ur/Cr : 171/5.67
ECHO : katup normal
, dimensi ruang jtg
normal, EF 62%

U : Sucralfat 4x10, OMZ 1x40

G:
Tx:

Meropenem 3x1 gr (2)

Nebu Nacl 3x/hr

flumucyl 3x1 sachet

Lasix 10-5 mg/jam

NTG 5 ug/mnt
Amlodipin 1x5mg
-Konsul HD

Bed 6/ Ny. Heni/ 27 th / HP - 10

Tgl
7
Okt
2010

Objective
CNS: DPO
CVS:TD: 114/69 (80)
HR: 102 x/mnt
Support:CVP : 8 mmHg
RR : CPAP ASB 10 PEEP 10
TV 400 FiO2 35%

Assessment
Post LE ai. Perdarahan
intra abdomen + Post SC
ai Letak Sungsang + Post
HSV
-AKI
-Edema Paru +
Bronkopneumonia

Planing
F : Nefrisol 1000cc, ensure
500cc
A:
S : Midazolam 4mg/jam
T : Heparin 2x5000 ui
H : Head up 45 derajat

S 37-38
GIT : distensi (-)
GUT : diuresis :1685/24j
Balance :+899cc/24j

Lab
Hb: 10.3/31/15800/116.000
Na/K/Cl/Ca/Mg:134/3.0/98
/4,41/1,77
GDS 121
AGD:
7,455/34,7/185,6/24/0.5 /
94,6%
Ur/Cr : 73/2.79
SGOT/PT : 34/70
Kultur sputum :
Acinetobacter baumanii

U : Sucralfat 4x10, OMZ 1x40

G:
Tx:

Meropenem 3x1 gr (3)

Nebu Nacl 3x/hr

flumucyl 3x1 sachet

NTG 5 ug/mnt
Amlodipin 1x5mg
PCT 3x500mg
SLED

Bed 6/ Ny. Heni/ 27 th / HP - 11

Tgl
8
Okt
2010

Objective
CNS: CM
CVS:TD: 165/95 (117)
HR: 102 x/mnt
Support:CVP : 9 mmHg
RR : CPAP ASB 10 PEEP 6 TV
400 FiO2 35%

Assessment
Post LE ai. Perdarahan
intra abdomen + Post SC
ai Letak Sungsang + Post
HSV
-AKI
-Edema Paru +
Bronkopneumonia

Planing
F : Nefrisol 1000cc, ensure
500cc
A:
S:
T : Heparin 2x5000 ui
H : Head up 45 derajat

S 37-37.8
GIT : distensi (-)
GUT : diuresis :1510/24j
Balance :+549cc/24j

Lab
Hb: 9.2/27/13000/146.000
Na/K/Cl/Ca/Mg:136/3.0/96
/4,22/1,68
GDS 121
AGD:
7,398/30,3/140,6/18.1/5.4 /94,1%
Ur/Cr : 73/2.79
C-xray: Edema paru
perbaikan
CPIS 7

U : Sucralfat 4x10, OMZ 1x40

G:
Tx:

Meropenem 3x1 gr (4)

Nebu Nacl 3x/hr

flumucyl 3x1 sachet

NTG 5 ug/mnt
Amlodipin 1x5mg
PCT 4x500mg
Sputum kultur ulang

Bed 6/ Ny. Heni/ 27 th / HP - 12

Tgl
9
Okt
2010

Objective
CNS: CM
CVS:TD: 148/104 (115)
HR: 112 x/mnt
CVP : 10 mmHg
RR : CPAP ASB 8 PEEP 5 TV
400 FiO2 35%

Assessment
Post LE ai. Perdarahan
intra abdomen + Post SC
ai Letak Sungsang + Post
HSV
-AKI
-Edema Paru +
Bronkopneumonia

Planing
F : Nefrisol 1000cc, ensure
500cc
A:
S:
T : Heparin 2x5000 ui
H : Head up 45 derajat

S 37-37.8
GIT : distensi (-)
GUT : diuresis : 1832/24j
Balance :+194cc/24j

Lab
DPL
9.3/30.8/11300/88.000
Na/K/Cl/Ca/Mg:135/3,3/98
/4.35/1.68
GDS 133
AGD:
7,427/30,8/162,5/20.0/3.2 /94.9%
Ur/Cr : 134/4.55

U : Sucralfat 4x10, OMZ 1x40

G:
Tx:

Meropenem 3x1 gr (5)

Nebu Nacl 3x/hr

flumucyl 3x1 sachet

NTG 5 ug/mnt
Amlodipin 1x5mg
PCT 3x500mg

Bed 6/ Ny. Heni/ 27 th / HP - 13

Tgl
10
Okt
2010

Objective
CNS: CM
CVS:TD: 144/80 (92)
HR: 130 x/mnt
CVP : 8-9 mmHg
RR : CPAP ASB 8 PEEP 5 TV
350 FiO2 35%

Assessment
Post LE ai. Perdarahan
intra abdomen + Post SC
ai Letak Sungsang + Post
HSV
-AKI
-Edema Paru +
Bronkopneumonia

Planing
F : Nefrisol 1000cc, ensure
500cc
A:
S:
T : Heparin 2x5000 ui
H : Head up 45 derajat

S 37-37.6
GIT : distensi (-)
GUT : diuresis :3810/24j
Balance :-967cc/24j

Lab
Hb:
10.1.3/30/16100/196.000
Na/K/Cl/Ca/Mg:136/3.7/99
/4,45/1.71
GDS 104
Ur/Cr : 147/4.6
Cxray : edema paru
perburukan
CPIS 7

U : Sucralfat 4x10, OMZ 1x40

G:
Tx:

Meropenem 3x1 gr (6)

Nebu Nacl 3x/hr

flumucyl 3x1 sachet

Lasix 10 mg/jam
NTG 5 ug/mnt
Amlodipin 1x10mg
Konsul HD

Bed 6/ Ny. Heni/ 27 th / HP - 14

Tgl
11
Okt
2010

Objective
CNS: CM
CVS:TD: 157/97 (121)
HR: 130 x/mnt
CVP : 10 mmHg
RR : CPAP ASB 8 PEEP8 FiO2
45%, SIMV12 PS 12 PEEP 12
TV 350 FiO2 80% SpO2 9496%
S 37-37.6
GIT : distensi (-)
GUT : diuresis :4255/24j
Balance :-3330cc/24j

Assessment
Post LE ai. Perdarahan
intra abdomen + Post SC
ai Letak Sungsang + Post
HSV
-AKI
-Edema Paru +
Bronkopneumonia

Planing
F : Nefrisol 1000cc, ensure
500cc, Nutricomp 82
A:
S : Midazolam 2-5mg/jam, MO
20 ug/kg/jam
T:
H : Head up 45 derajat

Lab
Hb: 9.1/28/15500/217.000
Na/K/Cl/Ca/Mg:135/3.1/10
1/4,67/1.56 GDS 135
Ur/Cr : 137/4.16
Kultur darah : steril
AGD :
7.421/27.3/48.3/17.4/6.2/83%
7.271/13.4/55.4/5.9/20.1/80.3
Cxray : edema paru

U : Sucralfat 4x10, OMZ 1x40

G:
Tx:

Meropenem 3x1 gr (7)

Nebu Nacl 3x/hr

flumucyl 3x1 sachet

Lasix 10 mg/jam
NTG 5 ug/mnt
Amlodipin 1x10mg
SLED

Bed 6/ Ny. Heni/ 27 th / HP - 15

Tgl
12
Okt
2010

Objective
CNS: CM
CVS:TD: 119/73 (85)
HR: 122 x/mnt
CVP : 10 mmHg
RR : SIMV12 PS 12 PEEP 12
TV 350 FiO2 80% SpO2 99%

Assessment
Post LE ai. Perdarahan
intra abdomen + Post SC
ai Letak Sungsang + Post
HSV
-AKI
-Edema Paru +
Bronkopneumonia

Planing
F : Nefrisol 1000cc, ensure
500cc, Nutricomp 82
A:
S : Midazolam 5mg/jam, MO 20
ug/kg/jam
T:
H : Head up 45 derajat

S 37-37.6
GIT : distensi (-)
GUT : diuresis :408/24j
Balance :+1812cc/24j

Lab
Hb: 6.7/20/8100/157.000
Na/K/Cl/Ca/Mg:138/4.0/
102/4.92/1.6 GDS 113
Ur/Cr : 43/1.63
AGD :
7.421/39.0/85.2/24.1/
0.3/93%
Cxray : edema paru
Kultur sputum :
Pseudomonas
aeroginosa

U : Sucralfat 4x10, OMZ 1x40

G:
Tx:

Piperacillin tazobactam
4x4.5g

Nebu Nacl 3x/hr

Fluimucyl 3x1 sac

Lasix 10 mg/jam
NTG 5 ug/mnt
Amlodipin 1x10mg
Kultur sputum, darah ulang
Tranfusi PRC 500cc

Bed 6/ Ny. Heni/ 27 th / HP - 16

Tgl
13
Okt
2010

Objective

CNS: somnolen, DPO

CVS:TD: 70-105/30-44(40-60)
NE 0.05-0.1 Dobu 5
HR: 115 x/mnt CVP:11-15
mmHg
RR : SIMV 8 PS 8 PEEP 8 TV
350 FiO2 50% SpO2 99%
CPAP-ASB 8 PEEP 8 TV 400
FiO2 65% SpO2 98%
S 37-37.6
GIT :distensi (-) NGT 605cc/24j
GUT : diuresis : 15cc/24j
SLED UF 3000cc
Balance :+736cc/24j

Assessment

Post LE ai. Perdarahan

intra abdomen + Post SC
ai Letak Sungsang + Post
HSV
-AKI
-Edema Paru +
Bronkopneumonia
-Septik syok

Planing
F : Nefrisol 1000cc, ensure
500cc, Nutricomp 82
A:
S : Midazolam 5mg/jam, MO 20
ug/kg/jam
T:
H : Head up 45 derajat

Lab
Hb: 7/21/7700/161.000
10/32/3300/118.000
Na/K/Cl/Ca/Mg:134/3.0/
98/4.3/1.85 GDS 105
Ur/Cr : 78/3.1, 37/1.76
Alb 2.2
AGD:7.362\42.5/170.1/23.
6/-1.2 /94.6%
CPIS 6, P/F 283

U : Sucralfat 4x10, OMZ 1x40

G:
Tx:

Piperacillin tazobactam
4x4.5g (2)

Nebu Nacl 3x/hr

Fluimucyl 3x1 sac

Lasix 10 mg/jam
Tranfusi PRC 500cc
SLED

Bed 6/ Ny. Heni/ 27 th / HP - 17

Tgl
14
Okt
2010

Objective
CNS: DPO
CVS:TD: 95/48 (58)
NE 0.1, Dobu 10, koloid 500cc
HR: 125 x/mnt
CVP : 13-15 mmHg
RR : SIMV 12 PS 10 PEEP 8
TV 350 FiO2 65% SpO2 96%

S 37-37.6
GIT : distensi + LP 101, , NGT
630cc coklat
GUT : diuresis : 30cc/24j
Balance : +116 cc/24j

Assessment

Planing

Post LE ai. Perdarahan

intra abdomen + Post SC
ai Letak Sungsang + Post
HSV
-AKI
-Edema Paru +
Bronkopneumonia
- Septik syok
- DIC

F : Puasa

Lab
Hb: 7.2/22/6300/56.000
Na/K/Cl/Ca/Mg:136/3.8/
100/4.14/1.67 GDS 105
Ur/Cr : 54/2.59 Alb 1.5
PT/APTT/INR18.8/60.5/1.5
Fib 272.9 D-dimer 5.7
Perdarahan hidung-mulut
SGOT/SGPT 362/26
Bil T/D/I 7.8/6.8/0.9
AGD :
7.237/48/81.5/19.7 /-6.6 /
91.3%

U : Sucralfat 4x10, OMZ 1x40

A:
S : Midazolam 2mg/jam, MO 10
ug/kg/jam
T:
H : Head up 45 derajat

G:
Tx:

Piperacillin tazobactam
4x4.5g
(3)

Nebu Nacl 3x/hr

Fluimucyl 3x1 sac

Lasix 10 mg/jam

Bed 6/ Ny. Heni/ 27 th / HP - 18

Tgl
15
Okt
2010

Objective
CNS: CM
CVS:TD: 95/30 (59)
NE 0.7-1.5 Dobu 10
HR: 140 x/mnt
CVP : 13-15 mmHg
RR : SIMV 12 PS 10 PEEP 8
TV 350 FiO2 60% SpO2 99%

Assessment
Post LE ai. Perdarahan
intra abdomen + Post SC
ai Letak Sungsang + Post
HSV
-AKI
-Edema Paru +
Bronkopneumonia
-Septik syok,
-DIC

Planing
F: Puasa

A:
S : Midazolam 2mg/jam
T:
H : Head up 45 derajat

S 37-37.6
GIT : distensi +
GUT : diuresis : 20cc/24j
Balance :+1491cc/24j

Lab
Hb: 6.8/21/4200/64.000
Na/K/Cl/Ca/Mg:136/4.5/
101/4.32/1.7 GDS 105
Ur/Cr : 122/4.41 Alb 1.5
PT/APTT/INR34.4/124.4/2.
72 Fib 242.9 D-dimer 6.8
SGOT/SGPT 1227/92
Bil T/D/I 10.4/8.23/1.8
AGD : 7.219/56/144.9/20.9
/-5.2/93.1% P/F 222
7.196/41.2/64.4/14.9/11.5/84.2

U : Sucralfat 4x10, OMZ 1x40

G:
Tx:

Piperacillin tazobactam
4x4.5g (4)

Nebu Nacl 3x/hr

Fluimucyl 3x1 sac

Lasix 10 mg/jam
Tranfusi PRC 500cc FFP
500cc

Bed 6/ Ny. Heni/ 27 th / HP - 19

Tgl
16
Okt
2010

Objective
CNS: DPO
CVS:TD: 117/60 (74) NE 1.5
Dobu 10 Koloid 1000cc
HR: 115 x/mnt
CVP : 13 mmHg
RR : IPPV 10 PEEP 8 RR 12 TV
350 FiO2 60% SpO2 99%

Assessment
Post LE ai. Perdarahan
intra abdomen + Post SC
ai Letak Sungsang + Post
HSV
-AKI
-Edema Paru +
Bronkopneumonia
-Septik syok
-DIC

Planing
F : Puasa

A:
S : Midazolam 5mg/jam, MO 20
ug/kg/jam
T:
H : Head up 45 derajat

S 38-38.6

GIT : distensi +
GUT : diuresis : 18cc/24j
SLED UF 3500cc
Balance : -1270cc/24j
USG abdomen : ascites, cairan
bebas

Lab
Hb: 8.1/24/4500/24.000
Na/K/Cl/Ca/Mg:137/5.2/
101/4.25/2.15 GDS 190
Ur/Cr : 167/5.24, 74/2.53
PT/APTT/INR25.4/29.9/2.0
Fib 306.2 D-dimer 6.4
Perdarahan hidung-mulut
AGD :
7.248/37.2/168.9/15.5/-10.2
/94.4% P/F 281.5
Kultur sputum :
Pseudomonas aeroginosa

U :OMZ 1x40 Metoclopramid

3x10
G:
Tx:

Tigecycline 2x50mg (1)

Nebu Nacl 3x/hr

Fluimucyl 3x1 sac

Lasix 20 mg/jam
Tranfusi FFP 500cc
Farmadol 1x1gr
SLED

Bed 6/ Ny. Heni/ 27 th / HP - 20

Tgl
17
Okt
2010

Objective
CNS: DPO
CVS:TD: 90/43 (55) NE 2 Dobu
10
HR: 125 x/mnt
CVP : 11-15 mmHg
RR : : IPPV 10 PEEP 8 RR 12
TV 350 FiO2 90-100% SpO2
94-69%
S 37-37.6
GIT : distensi + NGT 50cc
hijau
GUT : diuresis :8/14j
Balance : +1278cc/14j

Pkl 20.21 pasien

meninggal dengan
MOF ec. syok septik

Assessment

Planing

Post LE ai. Perdarahan

intra abdomen + Post SC
ai Letak Sungsang + Post
HSV
-AKI
-Edema Paru +
Bronkopneumonia
-Septik syok
-DIC

F : Puasa

Lab
Hb: 6.9/20/1200/6000
Na/K/Cl/Ca/Mg:141/3.8/
100/4.33/1.83 GDS 190
Ur/Cr : 167/5.24, 74/2.53
PT/APTT/INR22.9/45.9/1.8
1 Fib 229.3 D-dimer 5.3
Perdarahan hidung-mulut
AGD :
7.227/51.5/105.6/20.4/6.0 /92.5%

U : OMZ1x40 metoclopramid

A:
S : Midazolam 2mg/j
T:
H : Head up 45 derajat

G:
3x1
Tx:

Tigecycline 2x50mg (1)

Nebu Nacl 3x/hr

Fluimucyl 3x1 sac

Lasix 20 mg/jam
Tranfusi PRC 500cc FFP
500cc

TC10 U
Farmadol 1x1gr

Kidney
Autoregulation
Keeps RBV & GRF

constant
Renin increases
Angiotensin I,
then converted to
Angiotensin II
which constricts
the arterioles
increasing
hydrostatic
pressure returning
GFR to normal
Comprehensive
clinical nephrology.
London:
Mosby; 2000:15.4

ATN: Acute Tubular

Necrosis
Occurs when the kidneys are exposed

to prolonged warm ischemia followed

by reperfusion resulting in necrosis of
the proximal tubules
This state interferes with Glomerular
Filtration
Distal Nephron involvement is minimal

ARF: Acute Renal Failure

Over 57 different definitions
Generally accepted to be: A sudden decline

in both glomerular and tubular function,

resulting in the failure of the kidneys to
excrete nitrogen and waste products
with a corresponding failure to maintain
fluid, electrolyte and acid-base balance.
Classifications:
Prerenal (hypoperfusion)
Renal (intrinsic)
Postrenal (obstructive)

Acute Renal
Failure:Pathophysiology
Damage to proximal tubule cells NaCl delivery to distal nephron. This

causes disruption of feedback mechanism.

Casts (necrosis of tubular cells and sloughed basement membrane) clog
the lumen.
This will tubular pressure, with a resultant GFR , causes a leakage
of fluid through the tubular basement membrane.
ARF Clinical Findings
Azotemia
Hypervolemia
Classic electrolytes abnormalities: K + P++ Na + Ca ++
Metabolic Acidosis
Hypertension
AKI: Acute Kidney Injury
Changes in Urine Output & GFR are neither necessary nor sufficient for
the diagnosis of renal pathology or injury
Has been proposed to include the entire array of failing kidney syndrome
from minor changes to the need for renal replacement therapy
AKI is neither ATN nor ARF, but includes both

Arterial Vasodilatation and Renal Vasoconstriction in Patients with Sepsis

Schrier, R. W. et al. N Engl J Med 2004;351:159-169

Biomarkers
Conventional :
Urine Output
Creatinine
Urea
Urine Output :
Presence or absence does not necessarily denote malfunction
Generally thought to be an indicator of renal hemodynamics than renal
function
Lacks sensitivity & specificity
Recognized to be important = RIFLE
Measuring Urine Biochemistries :
Such as excretion of Sodium or Urea
Not sensitive enough for early AKI
Secretion studies infer that tubular function remains intact or constant;
however diuretics or clinical conditions (sepsis or rhabdomyolosis) may
alter this

New Biomarkers
Cystatin C (Serum)

Produced by all nucleated cells at constant rate

Filtered freely at the glomerulus due to a small molecular mass =
Cystatin C as GFR
Is not reabsorbed, secreted, nor metabolized in the proximal tubules.
Interleukin 18 (Urine)
Inflammatory cytokine
Exits the cell and enters urine via the proximal tubule
NGAL- Neurophil Gelatinase-Associated Lipocalin (Serum or
Urine)
Normally excreted @ low levels in the lungs, stomach, colon &
kidneys
Propagates with injured endothelium specific to the above organs
Rises with acute bacterial infections, COPD, asthma
Excreted in the Distal tubules
Kidney Injury Molecule (Urine)
Is a transmembrane protein excreted in the proximal tubule (e.g. IL18)
Most easily detected in trials of ischemic kidney disease

Treatment Options
Vasoactive drugs :

Rationale: In all regional circulation, kidneys included, blood flow is

pressure dependant outside of the forces of autoregulation.
When MAP falls below the autoregulatory threshold, the ability of
autoregulation to maintain organ blood flow is lost.
Norepinephrine :
Very effective in raising MAP in most circumstances, MAP controls
urine
function & output
However, it has been shown to RBF in Hypovolemic Hypotension
(Bellomo, 2008)
Has been shown to be more effective in restoring renal function
through
BP restoration than Dopamine (Martin, 2000)
Norepinephrine risk-benefit is the most advantageous in patients w/
AKI
(Bellomo, 2008)
Renal Replacement : IHD, SLEDD, CRRT

Goals of Renal Replacement in

the Critically Ill
Control of acid base
Control of Sodium, Potassium, Magnesium,

Calcium & Phosphate

Control of Intravascular volume
Control of Extravascular volume
Euthermia

Pulmonary Edema :
Microvascular Fluid Exchange in the Lung
Cardiogenic Pulmonary edema (also termed hydrostatic or
hemodynamic edema)
Increased hydrostatic pressure in the pulmonary capillaries
elevated pulmonary venous pressure
increased left ventricular end-diastolic pressure and left atrial

pressure

As left atrial pressure rises further (>25 mm Hg)

edema fluid breaks through the lung epithelium
flooding the alveoli with protein-poor fluid

Noncardiogenic pulmonary edema (also known as increasedpermeability pulmonary edema, acute lung injury, or acute
respiratory distress syndrome)
increase in the vascular permeability of the lung
resulting in an increased flux of fluid and protein into the lung

interstitium and air spaces

Difficult to distinguish because of their similar clinical manifestations

Cardiogenic pulmonary edema

ischemia with or without myocardial infarction
exacerbation of chronic systolic or diastolic heart failure, and
dysfunction of the mitral or aortic valve
paroxysmal nocturnal dyspnea or orthopnea
Noncardiogenic pulmonary edema
pneumonia
sepsis
aspiration of gastric contents
major trauma associated with the administration of multiple
blood-product transfusions
Cardiogenic pulmonary edema
auscultation of an S3 gallop
a murmur consistent with valvular stenosis or regurgitation
elevated neck veins, an enlarged and tender liver, and
peripheral edema
cool extremities
Noncardiogenic pulmonary edema
abdominal, pelvic, and rectal examinations are important
warm extremities

Laboratory Testing
Electrocardiography
Elevated troponin levels
Measurement of electrolytes, the serum

osmolarity, and a toxicology screen

Serum amylase and lipase
BNP is secreted predominantly by the cardiac

ventricles in response to wall stretch or increased

intracardiac pressures
BNP level greater than 500 pg per milliliter indicates
that heart failure is likely (positive predictive value,
>90 percent)
BNP can also be secreted by the right ventricle, and
moderate elevations have been reported in patients
with acute pulmonary embolism, cor pulmonale, and

Chest Radiography

Echocardiography
The first approach to assessing left

ventricular and valvular function in patients

in whom the history, physical and
laboratory examinations, and the chest
radiograph do not establish the cause of
pulmonary edema
Less sensitive in identifying diastolic
dysfunction
Does not rule out cardiogenic pulmonary
edema

Conclusions and Recommendations

Treatment can be provided while the

diagnostic steps are taken

begin with a careful history and physical

examination
electrocardiogram
measurement of plasma BNP
chest radiograph
transthoracic echocardiogram
pulmonary-artery catheter

Early HAP/VAP
Timing

Within five days of

admission or mechanical
ventilation

Bacteriology S. pneumoniae

H. influenzae
Methicillin-sensitive S.
aureus
Susceptible gramnegative bacteria

Prognosis

Late HAP/VAP
Five days or more after
admission or mechanical
ventilation

P. aeruginosa
Acinetobacter
Methicillin-resistant S.
aureus
Other multi-resistant
organisms

Less severe, little impact on Higher attributable mortality

outcome
and morbidity
Mortality minimal

(American Thoracic Society/IDSA. Am J Respir Crit Care Med 2005;171:388416)

Diagnosing HAP/VAP
Clinical
approach:
CPIS clinical

pulmonary
infection score
Quantitative

prediction model
using clinical
criteria
May improve
clinical diagnosis
of HAP
72%-85%
sensitive,
85%-91%
specific
Only validated in
several small
studies

Quantitative culture approach:

bronchoscopic protected

specimen brush (103 CFU/ml)

~67% sensitive, 95% specific
bronchoalveolar lavage (104
CFU/ml)
~73% sensitive, 82% specific
quantitative endotracheal
aspirate (105 CFU/ml)
38-100% sensitive, 14-100%
specific
Antibiotic use more appropriate
and accurate

Terapi antibiotika empirik awal untuk pasien dengan HAP,

atau VAP pada pasien tanpa faktor risiko patogen MDR
bacteria yang diketahui, onset awal dan dengan semua
derajat penyakit
Patogen potensial
Streptococcus pneumoniae
Haemophilus influenzae
Methicillin sensitive Staphylococcus
aureus
Basil gram negatif enterik sensitif
terhadap antibiotika
Escherichia coli
Klebsiella pneumoniae
Enterobacter spp
Proteus spp
Serratia marcesens

Antibiotika yang direkomendasi

Ceftriaxone
atau
Levofloxacin, moxifloxacin, atau
ciprofloxacin
atau
ampicillin / sulbactam
atau
ertapenem

INITIAL EMPIRIC
THERAPY FOR HAP,
VAP AND HCAP IN
PATIENTS WITH
LATE-ONSET
DISEASE OR RISK
FACTORS FOR
ATS/IDSA 2005
MULTIDRUGRESISTANT
PATHOGENS

Sepsis - Acute Organ Dysfunction

Terima Kasih