de-Resuscitation for Acute Respiratory

Distress Syndrome

Thariq Emyl Taufik Hsb

Peserta Pendidikan Spesialis II Peminatan Terapi Intensif
Universitas Indonesia

Pembimbing
dr Sudarsono, SpAN KIC
Pendahulu
an
Definisi :
Berlin definition

An Acute, diffuse, inflamatory lung injury that

leads to increased pulmonary vascular
permeability, inceased lung weight and a loss of
aerated tissue.

et al JAMA
2012;307;2530
Epidemiolo
gi 74.500 death
(2005)
US cases 86 per 100.000 individual
20% pts icu meet criteria
ARDS
Morbidity/mortality
:

27% to 45 % mortality,most (80%) deaths attributed to non-

pulmonary organ failure or sepsis
Risk
Factor :
1. Advanced age, pre-existing organ dysfunction or chronic
medical illness
2. Pts with ARDS from direct lung injury has higher incidence of
death than those from non pulmonary

Emer med Clin N 34; 2016

Causes

ARDS network ptotocol 2008-

07
Pathofisiolo
gy
1. Avtivated cytocines

2.Cytocines attract neutrophil

3.ACM integrity lost

interstitiel and alveolus fills with
proteinaceous fluid

4.Surfactant can no longer

support alveolus

Nejm 2000
 Management
ARDS
1. Treat the underlying cause
2. Low tidal volume
ventilation
3. Use
peep
4. Monitor airway
pressure
5. Conservative fluid
management
6. Reduce potential
complication

Emer med Clin N 34; 2016

de-Resuscitation in
ARDS

Conservative fluid management improved lung function and shortened

mechanical ventilation times and ICU days without increasing non
pulmonary organ failures

N Engl J Med 2006;354

 de-Resuscitation in
ARDS
FACTT study
Mortality
Study for 1000 pts

Randomized to conservatives and liberal fluid

management strategy for 7 days
CVP < 4 mmHq versus CVP 10-14
mmHq
Cumulative fluid balance - 136 vs
+6992 ml
1. improved O2 indeks
2. increased ventilatory free
days
3. lenght of stay icu days
lebih pendek

Lancet; vol 388; november;

2016
Bagaimana melakukan de-resusitasi
?
1. PEEP sesuai IAP
2. Albumin
1. Teknik PAL (PEEP, Albumin, hyperonkotik
Lasix) 3. Lasix bolus 60 mg
lanjut 60 mg/jam

Manu L.N.G et al;Fluid overload;Anesthesiology Intensive Therapy;2014;vol 46;361-380

Manu L.N.G et al;Fluid overload;Anesthesiology Intensive Therapy;2014;vol 46;361-
380
 Semakin positif balans
kumulatif maka semakin
tinggi angka kematian
Bagaimana melakukan de-resusitasi
?
1. PEEP sesuai IAP
2. Albumin
1. Teknik PAL (PEEP, Albumin, hyperonkotik
Lasix) 3. Lasix bolus 60 mg
lanjut 60 mg/jam

1. HEMODINAMIK
STABIL
II.Diuretik

Neth J Crit Volume 16;feb

2016
Cas
e CXR
Anak 14 tahun, bb: 51 kg
no rekam medik: 02-27-
02-04
Pasien di rujuk dari RS lain dengan keluhan sesak dan
demam telah 3 hari
Apatis
Hemodinamik : TD: 124/86 Fn: 147 Rr: 38x/‘ SaO2:
88% dengan NRM 10L/‘
Rh +/+
D/ ARDS ec Sepsis ec
Pneumonia
 time
frame
pts apatis,
sesak hebat
Rawat icu MV MV MV
disertai SIMV 10
A/C tv 280 tv 280 rr 20 tv 280 rr 20 tv 280 rr 20peep 5 FiO2 extubasi
demam 39,3
rh +/+, SaO2 rr20 Tins 1,0 peep 8 peep 8 FiO2 peep 8 FiO2 cvc 8-10
50% 30%
88 % dgn NK peep 8 fiO2 FiO2 50% 40% cvc 11-14
10L/‘ 100% cvc 22-25 cvc 17-19 cvc 12-15
intubasi

14/10 14/10 16/10 18/10 19/10 20/10

15/10
jam 07 jam 10
Hari 1 14/10

intubasi

topangan:-
albumin 2,4

1. Meropenem
3x1 gr
2. Amikasin 1x1 gr
1600 bk: +580 3. mo;dor 1;1
7,31/43,80/118/-4,10/21,7/98,6
4. Enteral 8x50 cc
8,2/24,9/5300/27 5. Kaen 1B 1080
cc
Pct: 5,56 0,8
Hari 2 15/10 Lasik 5
cvc mg/jam

22-25cmh2o

1. Meropenem
3x1 gr
1850/24 jam 2. Amikasin 1x1 gr
7,40/40,5/103/0,6/23,3/97% 3. mo;dor 1;1
4. enteral 8x50 cc
5. Kaen 1B 1080
cc
+1030cc
Hari 3
16/10

17-19cmh2o

1. Meropenem
4460/24 jam BK -675 3x1 gr
2. Amikasin 1x1 gr
7,41/40,7/171,2/26,40/1,7/99,9 3. mo;dor 1;1
4. Lasik 5 mg/jam
hari ke-4
17/10

12-16

1. Meropenem
3x1 gr
2600/24 jam 2. Amikasin 1x1 gr
3. mo;dor 1;1
-3200 cc
4. enteral 8x75 cc
5. Kaen 1b 1050
cc
6. Lasik 5 mg/jam
hari-5 18/10

Albumin 2,8
11-
15cmh2o

1. Meropenem
3x1 gr
2. Amikasin 1x1 gr
3700/24 jam 3. mo;dor 1;1
-4900 cc 4. emteral 8x
100cc
5. Kaen ib 900 cc
6. Lasik 5 mg/jam
hari-6 19/10

11-14

1. Meropenem
3x1 gr
2. Amikasin 1x1 gr
3. mo;dor 1;1
4. enteral 8x100
5. kalbamin 10%
2500cc/24 jam 500cc
-4500 cc 6. Lasik 5 mg/jam
hari-7 20/10

extubasi

8-10 cmh2o
1. Meropenem
3x1 gr
2. Amikasin 1x1 gr
3. mo;dor 1;1
2600/24 jam 4. enteral 8x100
5. Kalbamin
-4650 cc
500cc/24 jam
6. Lasik 5 mg/jam
Diskusi CXR

ARDS

P/f ratio:
Bilateral opacity 118
Onset 3 hari
no history of cardiac
failure
 Sepsis ec
Pneumonia
Infeksi + 2 qsofa qsofa + infeksi :
✔︎
1. mental status
✔︎
2. RR> 22x
3. Sistolik pressure < 100
infiltrat Septic shock :
MAP > 65 with vasopressor+ infiltrat
PCT: laktat > 2
5,25
 Sepsi
s
Antibiotik ✔︎

✔︎
✔︎
✔︎

✔︎

✔︎
de-resusitasi
Hari 1 2 3 4 5 6 7

CVP 22-25 17-19 12-15 11-14 8-10 4

E
P/F 118 171 342 k
s
t
t
PEEP 8 Konservative
8 8CVC < 88 vs Liberal
5 CVC 14
u
Konservative diuretik b
Mv lebih pendek a
fiO2 60-100% 50% 50% 40% 30% s
P/f ratio lebih baik i
lama rawat icu lebih pendek
urin 1600 1850 4460 2600 3700 2500 3750

BK +580 +1030 -675 -3200 -4900 -4500 -4650

Furosemide 5 mg/jam laktat 0,8
topangan -
 CXR

✔ ✔︎
14/10 ✔︎
14/10 15/10 ✔︎
16/10 ✔︎
17/10 ✔︎
19/10
︎

Furosemide 5 mg/jam
 CXR

✔ ✔︎
14/10 ✔︎
14/10 15/10 ✔︎
16/10 ✔︎
17/10 ✔︎
19/10
︎

Furosemide 5 mg/jam
 Kesimpulan
1. Pemberian cairan pada kasus ARDS
merupakan isu yang komplek dan merupakan
salah satu kunci keberhasilan dalam terapi ARDS

2. Teknik PAL salah satu teknik de-resusitasi dalam

penanganan kasus ARDS

3. Penggunaan diuretik dapat dimulai sejak didiagnosis

ARDS dengan catatan hemodinamik dan parameter perfusi
normal
4. CVC dapat dijadikan acuan untuk melakukan
deresusitasi