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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
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
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
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
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
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
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
Objective
CNS: CM,
CVS: TD: 150/99 (120),
N: 110x/mnt
RR : 20x/mnt,
terhubung dgn SMNR 8
lt/mnt
SpO2 97%
S : 37
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%
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
Metronidazole 1x1500 mg
(6)
Lasix 5 mg/jam
- HD
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
Metronidazole 1x1500 mg
(6)
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
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
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%
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
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
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
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
Lasix 10 mg/jam
NTG 5 ug/mnt
Amlodipin 1x10mg
Konsul HD
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
Lasix 10 mg/jam
NTG 5 ug/mnt
Amlodipin 1x10mg
SLED
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
Piperacillin tazobactam
4x4.5g
Lasix 10 mg/jam
NTG 5 ug/mnt
Amlodipin 1x10mg
Kultur sputum, darah ulang
Tranfusi PRC 500cc
Tgl
13
Okt
2010
Objective
Assessment
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
Piperacillin tazobactam
4x4.5g (2)
Lasix 10 mg/jam
Tranfusi PRC 500cc
SLED
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
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%
A:
S : Midazolam 2mg/jam, MO 10
ug/kg/jam
T:
H : Head up 45 derajat
G:
Tx:
Piperacillin tazobactam
4x4.5g
(3)
Lasix 10 mg/jam
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
Piperacillin tazobactam
4x4.5g (4)
Lasix 10 mg/jam
Tranfusi PRC 500cc FFP
500cc
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
Lasix 20 mg/jam
Tranfusi FFP 500cc
Farmadol 1x1gr
SLED
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
Assessment
Planing
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:
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
Acute Renal
Failure:Pathophysiology
Damage to proximal tubule cells NaCl delivery to distal nephron. This
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)
Treatment Options
Vasoactive drugs :
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
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
Laboratory Testing
Electrocardiography
Elevated troponin levels
Measurement of electrolytes, the serum
Chest Radiography
Echocardiography
The first approach to assessing left
examination
electrocardiogram
measurement of plasma BNP
chest radiograph
transthoracic echocardiogram
pulmonary-artery catheter
Early HAP/VAP
Timing
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
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
INITIAL EMPIRIC
THERAPY FOR HAP,
VAP AND HCAP IN
PATIENTS WITH
LATE-ONSET
DISEASE OR RISK
FACTORS FOR
ATS/IDSA 2005
MULTIDRUGRESISTANT
PATHOGENS
Terima Kasih