MASALAH DIAGNOSIS &

MANJEMEN KASUS BEDAH ANAK

Dr dr AKHMAD MAKHMUDI SpB,SpBA

Pediatric Surgery Dept.Dr.Sardjito-Hospital /
Medicine School of Gadjah Mada University
GENERAL ASPECT

COMMON CLASSIFICATIONS OF THE DISEASE :

 (1) INFECTIONS
 (2) KONGENITAL ANOMALLY
 (3) NEOPLASMA
 (4) TRAUMA
 (5) DEGENERATIF
 INTRODUCTION

Patient can be different :

□ Surgical Problem - Operations
□ Medical Problem - Conservative

and in Surgical Problem, divided :

□ Emergencies : Acute abdomen
□ Electif
Everything will be simple
after systematized

I. Anamnesis: Chief complain

History
II.Physical Examinations:
Laboratory: blood, urine etc.
X ray’s plain
USG (noninvasive)
CTscan
MRI (Magnetic Resonance Imaging)

III. Diagnosis
IV. Treatment
VI. Prognosis
 Surgical Intestinal
Emergencies
 Gastroschisis
 Omphalocele
 Meckel’s diverticulum
 Diaphragmatic hernia
 Eventration of the diaphragm
 Esophageal atresia and
trachea esophageal fistula
 Hypertrophic pyloric stenosis Clinical manifestation as
 Atresia duodenum
Abdominal acute
 Pancreas annulare
 Meconium ileus
 Volvulus
 Anorectal anomalies
 Strangulated inguinal hernia
 Intussusceptions
 Meconium ileus
 Hirschsprung
 Appendicities
 Allogaritme
Management Patient
Anamnesis: Chief complain - symptoms
History
Resume Anamnesis
Physical Examinations:
Physical signs
Laboratory: blood, urine etc.
X ray’s – plain USG (non invasive)
- contras CTscan – MRI
Diagnosis
Treatment
Prognosis
Plain Foto Abdomen

LLd: Left Lateral Decubitus

Babygram
 Age, and the common cause of
alimentary tract obstruction
 Birth – Atresia (duodenum,ileum)
- Meconium ileus
- Volvulus neonatorum
- Hirchsprung disease
- atresia esofagus
- hernia diafragma
- gastroschizis
 3 weeks- Congenial Hypertrophyc Pyloric Stenosis
 6 – 9 month – Intussusception
 Teen-age – Appendicitis (Inflammatory mass)
- Intussusception of Meckel’s diverticulum
or polyp
 Young adult –Hernia and adhesion
 Adult – Hernia, adhesions, inflammation (appendicitis,Crohn’
disease), Carcinoma
 Elderly- Carcinoma, Inflammation (diverticilitis)
THE SUSPICIOUS CLINICALLY MANIFESTATION
A CONGENITAL ANOMALY

 RESPIRATORY DISTRESS
 HIPERSALIVASI
 GER > 8 WEEKS
 ICTERIC > 2 WEEKS
 ABDOMEN DISTENDED
 DELAY MECONIUM PASSAGE > 24 HOURS OR NOT
 GREENS STAINED-BILLIOUS VOMITING/FECULENT
 ANATOMICAL DEFECT
VACTERL
ANOMALIES ASSOCIATION:
 Vertebra
 Anal
 Cardiac
 Tracheal
 Esophageal
 Renal
 Limb
The most common issued update
GastroIntestinal Problem

 Abdominal pain
 Obstipation
 Distended abdomen
 Vomitus
 COMMON CASE IN
MALPRACTICE ISSUED
 ABDOMINAL PAIN DUE TO
APPENDICITIES
WHAT IS DIFFERENT
BETWEEN IN ADULT AND
CHILDREN?

 RED CURRENT YELLY OF

THE STOOL DUE TO
INTUSSUSCEPTION
 Differentiated of
Red Current Jelly Stool

 Intussusception/ Invagination
 Dysentri Amoebiasis
 Diverticle Meckel’s
 Inflamatory bowel Syndrome
OBSTIPASI

BAYI LAKI-LAKI UMUR 3 HARI

LAHIR SPONTAN, ATERM, IBU
G1P1A0, BB 2000 GRAM
KLINIS: KEMBUNG
MECONIUM >24 JAM

HIRCHSPRUNG DISEASE
(Megakolon)
ABDOMINAL PAIN
(SAKIT PERUT)
ABDOMINAL PAIN
(sakit perut)

APPENDISITIS

GASTRITIS ?
 “Setiap anak dengan keluhan sakit perut di
sekitar pusar (periumbilikal) harus dipikirkan
pertama kali adalah kemungkinan suatu
apendisitis, sampai terbukti bukan apendisitis”

 Penyakit usus buntu tidak selalu operasi,

apabila masih simpel/ sederhana dan penyakit
tidak berkembang - keluhan sakit perut
menghilang
 ABDOMINAL PAIN
MANIFEST DISORDERS
(Sakit perut bermakna suatu penyakit)

A.VISCERAL PAIN:
REFERRED PAIN NERVUS TH X
1. COLICKY/ CRAMPING PAIN -
SIMPLE OBSTRUCTION –
INTERMITTEN PAIN
2. CONSTANS PAIN- ISCHEMIC
TISSUE

B.SOMATIC PAIN
IRITATIVE PERITONEAL
PAIN ( DEFANS MUSCULER)
 Referred Visceral Pain

 Stimuli for pain appreciation are: sudden distention,

muscle spasm, chemical irritants, ischemia

 Normally referred pain to the dermatom supplied by

the posterior root through which the visceral afferent
impulses reach the cord, e.g.
foregut (T 7-9)epigastrium,
midgut (T 9-11)umbilical region,
hindgut (T11- L1)hypogastrium
 Symptoms and Signs
of Surgical Disease
HOLLOW ORGANS: Locations of
abdominal pain
1.INTESTINUM:a.FOREGUT,
b.MIDGUT,c.HIND GUT
1a 2. DUCTUS BILIARIS
2 3 3. DUCTUS PANCREATICUS
4. URINARY TRACT
5. TUBA FALLOPII
4 4

1b
-Gall bladder pain goes through to the back
4 4
5 and to the right, to reach the tip of the shoulder
5
-Stomach and duodenum pain straignt
4 4 through to the back
1c
-Pancreatic pain tends to go through to the
back but to the left
 Management of
Abdominal Pain

 Abdominal pain : visceral and somatic pain

 The features in the history of pain that must be elicited

1.History: Trauma - caused from solid + hollow organs
Non trauma – caused from hollow organs
2.Site
3. Time and mode of onset
4.Severity
5.Nature (burning,throbbing,stabbing,constricting,
colicky,aching)
 APPENDICITIS

 The appendiceal rupture rate

remains high among children
and range from 30% to 70% (
Ponsky TA et al., JAMA Oct.
27,2004)
 An appendix ruptured can lead to
peritonitis and abscess, that is
often delayed and misdiagnose
of appendicitis acute
 Objective: To investigate the
association between appendiceal
appendicolith as the risk of
appendiceal abscess-peritonitis

Moving pain periumbilical area (visceral pain)

to Mac Burney pin point (somatic pain)
 USG ABDOMINAL
(ultrasound abdominal)

Appendic: appendicolith
thick wall diameter 15,2
mm (normal < 6mm)
 BARIUM MEAL
(APPENDICOGRAM)
 APPENDICITIS
5 GRADE:
I SIMPLE
OBSTRUCTION
II SUPPURATIVE
III GANGREN
IV RUPTURE
V ABSCES
 CLINICAL APPENDICITIS
Invasive
Bacterial Viral

Lymphoid GALT-MALT,
Follicle “Peyeri” patch IMMUNOCOMPROMISE
Hyperplasia

Feces Ischemia
Partial Retensions APPENDI- Total (Vascular Rupture
Obstructions Intralumen COLITH Obstructions Compromise) Peritonitis Absces
(Anorexia, 74-78%, appendix (Vomiting 50%)
Nausea 61-92%)

Colicky Pain 80% Constan Pain

(Periumbilical) Low Residu Diet Mac Burney point
N Th X
Strangulation Pain

Caused of strangulation pain:

 Intussusception (Ileus
Invagination)
 Volvulus
 Malrotation
 Ileus strangulation (closed loop)
 Thrombo-emboli ( arterial,
venous)
 Major and minor criteria used in the case definition
for the diagnosis of intussusception

Major criteria
Minor criteria
 Level A1 of diagnostic certainty

Surgical criteria:

The demonstration of invagination of the intestine at surgery;

and/or
Radiological criteria: The demonstration of invagination of the
intestine by either air or liquid contrast enema;
or
The demonstration of an intra-abdominal mass by abdominal
ultrasound with specific characteristic featuresb that is proven to
be reduced by hydrostatic enema on post-reduction ultrasound;
and/or
Autopsy criteria:The demonstration of invagination of the
intestine.
 Level 2 of diagnostic certainty

Clinical criteria:

Two major criteria (see table for major and

minor criteria for diagnosis below);

Or

One major criteria and three minor criteria

(see table for major and minor criteria for
diagnosis below).
 Level 3 of diagnostic certainty

Clinical criteria:

Four or more minor criteria (see minor criteria for diagnosis

below).

Any level of diagnostic certainty

In the absence of surgical criteria with the definitive
demonstration of an alternative cause of bowel obstruction or
intestinal infarction at surgery
(e.g., volvulus or congenital pyloric stenosis).
 DIAGNOSIS

TYPICAL CLASSIC ANAMNESIS:

COLICKY & CRAMPING ABDOMINAL PAIN (100
%)
BILIOUS VOMITING ( 80% )
PALPABLE MASS ( 85% LATER )
CURRANT JELLY STOOL
A ( 95% INFANT, 65% OLDER CCHILDREN )
WELL BEING BABY (100% )

PLAIN ABDOMINAL RADIOGRAPHS

ULTRASONOGRAPHY
- DONUT SIGN
BARIUM ENEMA :
- DIAGNOSTIC TEST
- THERAPEUTIC PROCEDURE
COLON IN LOOP
B D
 DIFFERENTIAL DIAGNOSE
 INTUSSUSCEPTION
 VOLVULUS
 DIVERTICULITIS MECKEL`S
 ILEITIS
 AMOEBIASIS
 BOLUS ASCHARIASIS

TREATMENT:
1.NONOPERATIVE RECURRENT:
HYDROSTATIC REDUCTION BA – ENEMA REDUCTION 4 – 6 %
PNEUMATIC REDUCTION OPERATVE :MILKING PROCEDURE 3 %
BARIUM ENEMA REDUCTION :
CONTRA INDICATION : PERITONITIS,
SHOCK,ELECTROLYT IMBALANCE, UREMIA,
DISTENDED, OBSTRUCTIVE.
2. OPERATIVE
 STRANGULATION
(VASCULAR COMPROMISE)
STRANGULASI
VOLVULUS ILEOCOECAL
 Ax: STRANGULATED PAIN
 Px: STRANGULATED ILEUS
- SHOCK
 Tx: RESECTIONSSHORT
BOWEL SYNDROME

 SHORT BOWEL: IN FULL-TERM

NEONATE LESS THAN 75 CM OF
RESIDUAL SMALL INTESTINE OR
LESS THAN 40% OF THE NORMAL
SMALL INTESTINE ( WILLMORE )

 NORMAL INTESTINE: 27 WEEKS

GESTATION: 115 CM, 35 WEEKS “
: 250 CM DIAMETER 1,5 CM

 ADULT: 600-800CM, DIAMETER 4 CM

 VASKULER DISORDER
(THROMBOEMBOLI)

A One-week-old male baby

 Congenital Deffects
of the Abdominal Wall

 Omphalocele :failure return midgut into intraabdominal

covered by amnion avascular and warthon yelly
 Gastroschisis : herniasi/protusion midgut due defect
right paraumbilical diameter 4cm
 GIT HAEMORHAGE

 UPPER : MELAENA
 LOWER : HEMATOCHEZIA

RECTAL BLEEDING
LIGAMENTUM TREITZ LIMITED
 Diagnosis of conditions
which present with rectal bleeding

 Bleeding but no pain:

1. Blood mixed with stool = Carcinoma of colon
2. Blood streaked on stool = Corcinoma of colon
3. Blood after defaecation = Haemorrhoid
4. Blood and mucus = Colitis
5. Blood alone = diverticular disease
6. Melaena = Peptic ulceration
 Bleeding + pain = Fissure (or carcinoma of anal canal)
Intussusception
 Idiopathic in children below 2yrs
 Commonly between 6-9 months of age
 Red current jelly stools
 Screaming bouts
 Pallor
 Exhaustion
 Mobile mass in 80%
 Abdomen X-ray
 Barium enema
 Gas reduction / Laparotomy /
laparoscopic reduction
 Recurrence
 DIAGNOSIS

TYPICAL CLASSIC ANAMNESIS:

COLICKY & CRAMPING ABDOMINAL PAIN (100
%)
BILIOUS VOMITING ( 80% )
PALPABLE MASS ( 85% LATER )
CURRANT JELLY STOOL
A ( 95% INFANT, 65% OLDER CCHILDREN )
WELL BEING BABY (100% )

PLAIN ABDOMINAL RADIOGRAPHS

ULTRASONOGRAPHY
- DONUT SIGN
BARIUM ENEMA :
- DIAGNOSTIC TEST
- THERAPEUTIC PROCEDURE
COLON IN LOOP
B D
 DIFFERENTIAL DIAGNOSE
 INTUSSUSCEPTION
 VOLVULUS
 DIVERTICULITIS MECKEL`S
 ILEITIS
 AMOEBIASIS
 BOLUS ASCHARIASIS

TREATMENT:
1.NONOPERATIVE RECURRENT:
HYDROSTATIC REDUCTION BA – ENEMA REDUCTION 4 – 6 %
PNEUMATIC REDUCTION OPERATVE :MILKING PROCEDURE 3 %
BARIUM ENEMA REDUCTION :
CONTRA INDICATION : PERITONITIS,
SHOCK,ELECTROLYT IMBALANCE, UREMIA,
DISTENDED, OBSTRUCTIVE.
2. OPERATIVE
DISTENDED ABDOMEN
(KEMBUNG)
 Early Intestinal
Pathologic (Obstipasi)
 Obstipations
 Distended abdomen Caused Ileus
 Vomiting

 Colicy abdominal pain – simple ileus

 Strangulated pain - strangulated ileus
 Anorectal Continence and
Management of Constipation

 Colonic motility
 Defecations
 Continence  Gross-m.puborektalis
 Fine : m.sphincter

 Encopresis (soiling)
ANORECTAL FUNCTION
CLINICAL MANIFESTASIONS
 FREQUENCY OF- CLINICAL FEATURES
CLINICAL
FINDING FREQUENCY
 ABDOMINAL DISTENSION 99
 EXPLOSIVE DIARRHEA 82
 EMESIS 61
 FEVER 40
 LETHARGY 32
 HEMATOCHEZIA 6
 SHOCK 6
 GRADING HAEC
(Hirschsprung Associated Enterocolitis)

THREE GRADE THE SEVERITY OF HAEC

 GRADE I (34 %): MILD EXPLOSIVE DIARRHAE, MILD OR
MODERATE ABDOMINAl, DISTENSION,
NO SYSTEMIC MANIFESTASION
 GRADE II (5O%) :MODERATE EXPLOSIVE DIARRHAE,
MODERATE OR SEVERE ABDOMINAL
DISTENSION ASSOCIATED WITH MILD OR
MODERATE SYSTEMIC MANIFESTASION
 GRADE III ( 16%): EXPLOSIVE DIARRHAE,
MARKEDABDOMINAL DISTENSION;
SHOCK, OR IMPENDING PERFORATIONS
MANAGEMENT HAEC
MANAGEMENT AND FOLLOW -UP
- CONSERVATIVE :
NASOGASTRIC DRAINAGE, RECTAL TUBE
DECOMPRESSION, INTRAVENOUS FLUID,
ELECTROLYTES, AND ANTIBIOTIC (CLOSTRIDIUM
DIFFICILE : VANCOMYCIN OR METRONIDAZOLE)
RECTAL IRRIGATIONS 2 - 3 TIMES' DAILY 10 ML / KG
OF WARM SALINE SOLUTION. ENTERIC AND VIRAL,
STOOL CULTURES
Abdominal distension

 Remembered by using the letter “F”six times :

Fetus,Flatus, Faeces, Fat, Fluid ( free and
encysted), fibroids and other solid tumor

 Large solid tumors such as : fibroids,enlarged

liver/ spleen, polycystic kidneys,
retroperitoneal sarcomas
Ax: Normal passage of stool,
Px: Ballotement, shifting dullness, fluid thrill
and fluctuates
 Symptoms and Signs
of Surgical Disease
Vomiting
 Bile-free vomitus is hallmark of gastric outlet obstruction in
the infant. It is not always due to Hypertrophyc Pyloric
Stenosis (HPS). HPS causes projectile nonbilious vomiting
usually starting at 2 to 6 weeks of age and “failure to thrive”

 Bilious vomiting on the first day of life, without abdominal

distention, is the cardinal sign in patient with a duodenal
obstruction.
 Bilious vomiting after or much more the first week of life
(previously on the first day normal of life), is caused by
volvulus midgut malrotation
 ILEUS

Definition ileus
Classification ileus:
1. Manifestations Clinic
- Upper
- Lower : - Mechanic
- Functional
2. Radiologic (Post Barium meal,enema)
- Upper (forgut)
- Intermediate (midgut)
- Lower (hindgut)
THE DIGESTIVE SYSTEM

Primitive gut (foregut, midgut,and hindgut)

origin from dorsal part yolk sac in fourth weeks
 FOREGUT: PHARYNX, LOWER RESPIRATORY
TRACT, OESOPHAGUS, GASTER,
DUODENUM,PROXIMAL BILIARY TRACT,
LIVER,PANCREAS, BILIARY APPARATUS

 MIDGUT: DUODENUM(DISTAL BILE

DUCT),JEJUNUM,ILEUM,COECUM,VER MIFORM
APPENDIX, ASCENDING CO- LON,
2/3PROXIMALTRANVERSECOLON

 HINDGUT:1/3 DISTAL TRANSVERSE

COLON,DESCENT COLON, SIGMOID,
REKTUM,UPPER PART ANUS,
 ANATOMI GIT

Melaena

Gastric outlet

Ampulla of Vater

Lig.Treitz

Hemato
chezia

Peyery patchs of lymphoid Rectal

bleeding
 ILEUS PROBLEM

Vasa:
lymph,venous,artery

Normal
Ileus

Complications:
I.Third space syndrome
(Venous Obstruction)
Dehydrations – mild (5%deficit)
- moderate (10%) Tx/ Fluid resucitations
- severe (15%)
II.Abdomen compartment syndrome Tx/Naso Gastirc Tube(NGT), rectal tube
(distended abdomen- venous return disrturb) Decompressions operative
III.Sepsis
(fecal retentions-bactreial overgrowth-mucous Tx/ Antibiotic Drugs
barrier damage)
PROBLEM ILEUS ILEUS OBSTRUKTIF

Distensi usus Ekstravasasi cairan ke 3rd space

Menekan vasa usus Menekan diafragma vol. Sirkulasi sistemik dehidrasi

Iskemik usus Gangguan Oksigensi organ tak edekuat Vasokonstriksi perifer

pengembangan dada
(sesak nafas)
Translokasi kuman
ke Sirkulasi Sistemik Venus
Fungsi
Perfusi organ & ren Metab.Anaerob organ
return Pembuangan
panas
Dilepaskan endotoksin
(aktivasi koagulasi) HCO3 sel jaringan Pemumpukan laktat MODS Cardiac out
put

Konsumtif koagulopathi pH Iskemik Kompensasi

RR gagal
Faktor koagulopathi Nekrosis organ
Iskemik

DIC Asidosis metabolik MOF Gagal jantung Febris

 Monitoring Sign and symptoms of dehydration

Assessment Mild (5%) Moderate (10%) Severe( 15%)

Vital sign
Heart rate Normal Increased Tachycardia>130/min
Respiratory rate Normal Increased tachypnea
Blood pressure Normal Normal Hypotensive systolic <80

Capillary refill Normal 2 – 3 second >3 seconds

Mental Status Alert Irritable Lethargic

Skin
Color Pale Ashen Mottled
Turgor Normal Poor Tenting
Temperature Warm Cool Cool,clammy
Texture Normal Dry Doughy

Fontanelle Flat Depressed Sunken

Mucous membrane Dry\ Very dry Parched

± tears no tears

Eyes Normal sunken Darkened Soft Sunken

Thirst Increased Intense Intense if conscious

Urine Output Normal Decreased Minimal

Concentrated very concentrated
(1-2ml/kgbb/hour)
 HIGH GIT OBSTRUCTION
 GASTRIC OUTLET OBSTRUCTION
- HPS ( HYPERTROPHIC PYLORIC STENOSIS )*
- ANTHRAL WEB*
- PYLORIC MUCOSA PROLAPS*
 DUODENAL OBSTRUCTION
- ATRESIA/STENOSIS DUODENUM*
- PANCREAS ANNULARE*
- LADD`S MEMBRANE*
 MECHANICAL LOWER GIT
OBSTRUCTION
 MECONIUM ILEUS*
 MECONIUM PLUG SYNDROME*
 NEONATAL SMALL LEFT COLON SYNDROME*
 MALROTATION WITH VOLVULUS*
 INCARCERATED HERNIA*
 JEJUNOILEAL ATRESIA*
 COLONIC ATRESIA*
 INTESTINAL DUPLICATION*
 INTUSSUSCEPTION*
 HERNIA INGUINALIS*
 FUNCTIONAL LOWER GIT
OBSTRUCTION
 SEPSIS
 NEC (NECROTICANS ENTERO COLITIS)*
 INTRACRANIAL HEMORRHAGE*
 HYPOTHYROIDISM
 MATERNAL DRUG INGESTION OR ADDICTION
 HYPERMAGNESEMIA
 HYPOKALEMIA
 MORBUS HIRSCHSPRUNG*
 Fluids Resuscitation
Programs

The fluids compartement :

-First : Intracellular Physiologist
-Seconds : Extracellular :-Plasma intravascular circulatory
-Interstitial cell

-Non Functional
Thirds space : 1. Cavum intra peritoneal (abdomen)
2. Cavum inra pleural (thorax)

The Fluids: Resusitations:-Kristaloid: ringer Lactate, asering,saline

-Koloid: plasbumin
Nutrisions: Dextrose 5%,Aminofusin 5%, Intralipid 20%
TERAPI NUTRISI PARENTERAL
 EBB PHASE :-HIPOVOLEMIA
- CAIRAN RESUSITASI RL/ ASERING
 FLOW PHASE : NORMOVOLEMIA
CAIRAN NUTRISI:
 KH : D5, D10
 PROTEIN : ASAM AMINO 2,5%, 5%,10%
 LEMAK : LIPID 20%
 ELEKTROLIT: KAEN I B, 3A, 3B
 MINERAL
 Reasoning
Fluids Program 6 hours

 Gold standart periodic ileus

 Intra vascular Ringer’s lactate are to resist
in oncotyic pressure poor conditions
(hypo albuminemia)
 Shock 1 hour program

Fourth step management:

1. The kind fluids
2. The fluids quantity
3. The giving methode of fluid : intravenous perifir
or central
4. Monitoring evaluations every 1 hours
TOTAL BODY WATER ( ASHCRAFT )

UMUR %

Gestasional – 12 minggu 94
12 minggu – 32 minggu 80
Aterm
3-5 hari 78
-3 – 5
Neonatus 75 - 80
Children 65 - 75
Young Man 60
Young Woman 50
Over 60 years man 50
Over 60 years women 45
 MAINTENANCE ( ASHCRAFT )

* Daily Fluid Requirements

Weight Volume

Premature (< 2kg ) 150 ml / kg

Neonatus & infant (2-10 kg ) 100ml/kg for first 10kg
Infant & children (10-20kg ) 1000ml+50ml/kg over 10 kg
Children ( > 20 kg ) 1500ml+20ml/kg over 20 kg
 Jumlah cairan :

1. Defisit cairan / dehidrasi

a. Dehidrasi Ringan : 5% ( 50ml/kgbb x TBW )
b . Dehidrasi Sedang : 10% (100ml/kgbb x TBW )
c. Dehidrasi Berat : 15% (150ml/kbbb x TBW )
* Tonisitas darah:Hipotonis,isotonis,hipertonis
2. Maintenance
Neonatus: 24 jam post operatif dikurangi 30%
3. Perkiraan cairan hilang dalam 24 jam
( on going loss )

2&3 modification to Fluid intake ( see table )

TABLE : MODIFICATION TO FLUID INTAKE

Decrease Adjustment

Humidified Inspired air X 0.75

Basal state (eg pa ralysed ) X 0.7
High ADH (IPPV,brain injury ) X 0.7
Hypothermia - 12 % per C
High room humidity x 0.7
Renal failure x 0.3 (+urine output )
 Increase
Full activity + oral feeds X 1.5
Fever + 12 % per C
Room temperature > 31 C + 30 % per C
Hyperventilation X 1.2
Neonate - preterm (1-1.5 kg ) X 1.2
- radiant heater X 1.5
- photo terapy X 1.5
Burn - first day + 4% per 1%
area burn
- Subsequently + 2% per 1%
area burn
 KASUS :
 PASIEN BAYI USIA 1 tahun(BB 10 KG) DENGAN ILEUS
DISERTAI DEHIDRASI BERAT DAN FEBRIS SUHU 400C,
ASIDOSIS METABOLIK DAN ANEMIA. HASIL LAB.HB 8G%,
ALBUMIN 2 G/DL, K+ 2 MEQ/L, NA+ 160 MEQ/L,
TROMBOSIT 50000 MM2/DL.( TBW 70%, t normal 36,5C)

TERANGKAN PENATALAKSANAAN LENGKAP dalam 6 jam?

 JUMLAH CAIRAN
1. MAINTENANCE = 1000ML:4= 250ML
2. KOREKSI DEHIDRASI =15%X10X70%x1000 = 1050 ML
3. KOREKSI SUHU ( SUHU NORMAL 36,5OC)
= 3,5X12%X1000ML = 420 ML
4. TOTAL FLUIDS REQUIREMENT= 1720 ML/6 JAM
= 1720/360 = 4,8 ml/menit
= 96 drops/menit

INFUS MAKRO = 20 drops/Menit

INFUS MIKRO = 60 drops/Menit
 KASUS ANAK
 Laki-laki umur 1 tahun BB 6 kg, TB 60cm Dx: Ileus dengan Dehidrasi
berat, febris 40oC dan malnutrisi berat.
Perhitungan:
(1) Gangguan 3 stabilitas: ebb phase (RL/ ASERING)
Program cairan 6 jam: 1kcal = 1ml kebutuhan cairan
- Jumlah cairan: maintenens = 150 ml
dehidrasi 15% = (150x6x70%) = 630 ml
febris 40oC = 216 ml
- Total resusitasi cairan = 996 ml
(2) Bila kondisi stabil (flow phase): cairan nutrisi kenaikan bertahap
- KH : KAEN 3A = 450 ml
- PROTEIN : AMINOFUSIN 5% = 120 ml
- LEMAK : LIPID 20% = 30 ml
(3) Malnutrisi berat : 2 x BEE = 500 kcal/hari
 SYNOPSIS
Malformations
Disruptions Hollow viscus obstruction: G I Tract
Deformations Ileus simple -mild : anorexia Ureter
Syndrome Colicky pain -Moderate : nausea Billiary Tract
-Severe : vomiting Pancreatic Tract
(intermittent) Tuba Fallopii
Congenital
anomaly
Upper ileus:
Hypo volumic shock -vomiting> Pylorus (Gastric outlet)
-mild distention Duodenum Obstructions
Morbus Obstipation (epigastric)
HIrschsprung Distention
Ileus Vomiting
Lower Ileus: Mechanical Ileus
-vomiting<
- significant
whole distention Functional Ileus
Contiuous pain Ileus Strangulation
/Ischemic pain (Vascular compromise)
(anoksia)

HAEC Peritonitis Acute Abdomen

(toxic Megacolon)
(Emergencies)

Septic shock
Anal Bleeding
(melena,hematozesia, fresh)
Everything will be simple after
systematized

 Medical problem
 Surgical proble - Elective
- Emergencies
Anamnesis: Chief complain
History
Physical Examinations:
Laboratory: blood, urine etc.
X ray’s – plain
contras
USG (non invasive)
CTscan – MRI
Diagnosis
Treatment
Prognosis