M M ohamad Supriatna Toto Saputra ohamad Supriatna Toto Saputra , Dr, , Dr, Sp.A Sp.A Place & Date of Birth : Sumedang, 15-09-1970 Marital Status : Married, 2 children Mailing Address: Jl. Puspowarno Selatan No. 10, Semarang Office Address : Child Health Department, Faculty of Medicine Diponegoro University / Dr. Kariadi Job position : Staff of Pediatric Intensive Care Unit Phone: 62-24-7613724 (home) Fax : 62-24-8414296 (office) e-mail : [email protected]
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MMohamad Supriatna Toto Saputraohamad Supriatna Toto Saputra, Dr, Sp.A, Dr, Sp.A
Place & Date of Birth : Sumedang, 15-09-1970 Marital Status : Married, 2 children Mailing Address : Jl. Puspowarno Selatan No.
10, Semarang Office Address : Child Health Department,
Faculty of Medicine
Diponegoro University / Dr. Kariadi Job position : Staff of Pediatric Intensive Care Unit Phone : 62-24-7613724 (home) Fax : 62-24-8414296 (office) e-mail : [email protected]
Educational History
Period (month/year)
School’s name and Place (city) Degrees obtained
1976 - 1982 Mandalaherang Elementary School Sumedang, West Java, Indonesia
-
1982 -1985 Cimalaka Junior High SchoolSumedang, WestJava, Indonesia
1985 - 1988 Bandung Senior High SchoolBandung, West Java, Indonesia
-
1988 - 1996 Faculty of Medicine Diponegoro University Semarang
Medical Doctor
2000 - 2005 Faculty of Medicine Diponegoro University
Pediatrician
Course / Fellowship / Workshop
No Name of Visit Experience, Course and Education
Location Period
1. International symposium and workshop on Infectious and Tropical Diseases
Semarang, Indonesia
2008
2. Seminar and Workshop The Role of Professional and Parents in Caring Children with Mental Retardation and Autism
Semarang, Indonesia
2008
3. Symposium and Workshop Toward Better Nutrition for Children Health
Semarang, Indonesia
2008
4. Symposium and Workshop Nutrisi & Metabolik, Endokrinologi, Nefrologi, dan Neurologi
Semarang,Indonesia
2008
5. Workshop NIF Scientific Workshop 2007 Semarang, Indonesia
2007
6. Workshop Early Detection on Neurodevelopmental Disorders
Semarang, Indonesia
2007
7. International Symposium on Liver Transplantation
Singapore 2007
8. Workshop InnovativeAssessment in Pediatrics Training Program & Seminar on New Trend in Residency Training Program
Yogyakarta, Indonesia
2007
8. Training Management of Emergency Patient Semarang, Indonesia
2006
9. Advanced Pediatric Resuscitation Couse (APRC) Jakarta, Indonesia
2006
10. Advanced Course of Mecanical Ventilation (ACMV)
Jakarta,Indonesia
2006
11. Pelatihan Vaksinologi Dasar bagi Dokter Spesialis Anak
Semarang 2006
12. Neonatal Resuscitation Course (NRP) Bandung, Indonesia
2005
Course / Fellowship / Workshop
8. Training Management of Emergency Patient
Semarang, Indonesia
2006
9. Advanced Pediatric Resuscitation Couse (APRC)
Jakarta, Indonesia
2006
10. Advanced Course of Mecanical Ventilation (ACMV)
Jakarta,Indonesia
2006
11. Pelatihan Vaksinologi Dasar bagi Dokter Spesialis Anak
Semarang 2006
12. Neonatal Resuscitation Course (NRP) Bandung, Indonesia
2005
13. Pediatric FCCS Jakarta 2010
Pengelolaan Kegawatan Pengelolaan Kegawatan DBD AnakDBD Anak
Tatty ES ( 2004 ): Tatty ES ( 2004 ): hhemostatic & emostatic & vvascular ascular lleakage eakage ffactors actors ppredictor of redictor of sshock in hock in DHFDHF
PEI PEI ffirst irst rrank , followed by ank , followed by aalbumin, Ht, lbumin, Ht, pproteinrotein
In the non survivors: In the non survivors: hhemostatic emostatic ddisturbances & isturbances & vvascular leakage factors ascular leakage factors continued to be abnormal leading to MOF continued to be abnormal leading to MOF and bleeding ( DIC ) and bleeding ( DIC )
SYOKSYOK
SINDROM KLINISSINDROM KLINIS
KEGAGALAN SISTEM SIRKULASIKEGAGALAN SISTEM SIRKULASI
Kerusakan / Kematian SelKerusakan / Kematian Sel Disfungsi sistem multi organDisfungsi sistem multi organ Cadangan fostat Cadangan fostat energienergi ttinggi inggi
( Hepar, Jantung )( Hepar, Jantung )
Tekanan darah tak terukurTekanan darah tak terukur Nadi tak terabaNadi tak teraba
Kesadaran Kesadaran AnuriaAnuriaGMOGMO
klinis
Tujuan Tujuan Pengelolaan SSDPengelolaan SSD
Meningkatkan transport OMeningkatkan transport O22 (DO (DO22) ke jaringan/sel: ) ke jaringan/sel:
Memperbaiki pra-beban dengan resusitasi volumeMemperbaiki pra-beban dengan resusitasi volume Meningkatkan kontraktilitas jantungMeningkatkan kontraktilitas jantung Menurunkan resistensi pembuluh darah Menurunkan resistensi pembuluh darah
Kristaloid (RL/RA/NaCl) Kristaloid (RL/RA/NaCl) Didistribusikan dan mengisisi kompartmen Didistribusikan dan mengisisi kompartmen
intersisialintersisial Tak memperbaiki sirkulasi mikroTak memperbaiki sirkulasi mikro Untuk mengisi volume intravaskuler perlu Untuk mengisi volume intravaskuler perlu
jumlah besarjumlah besar Dapat me Dapat me osmolaritas plasma & edema osmolaritas plasma & edema
serebri (1L RL membentuk 114 ml air)serebri (1L RL membentuk 114 ml air) Efek pro-koagulanEfek pro-koagulan efek samping efek samping
trombosis vena dalam dan emboli parutrombosis vena dalam dan emboli paru
Efek Koloid Sintetik yangEfek Koloid Sintetik yang MenguntungkanMenguntungkan
Kemampuan meningkatkan tekanan onkotikKemampuan meningkatkan tekanan onkotik
Zornow, MH et al.: Fluid Management In Zornow, MH et al.: Fluid Management In Patients With Traumatic Brain Injury. New Patients With Traumatic Brain Injury. New
ALGORITHM FOR FLUID MANAGEMENT IN DECOMPENSATED SHOCK (WHO 2009)
Hypotensive ShockFluid resuscitation with 20mL/kg isotonic crystalloid or colloid over 15 minutes
Try to obtain a HCT level before fluid resuscitation
ImprovementYES NO
Crystalloid/colloid 10 mL/kg/hr for 1 hour, then continue with :IV crystalloid 5-7 mL/kg/hr for 1-2 hours; reduce to 3-5 mL/kg/hr for 2-4 hours; reduce to 2-3 mL/kg/hr for 2-4 hoursIf patient improve, fluid can be reducedMonitor HCT 6-hourly
Stop at 48 hours
Review 1st HCT
HCT ↑ or high HCT ↓
Administer 2nd fluid bolus (colloid)
Consider occult/overt bleed
10-20 mL/kg over ½ to 1 hourInitiate transfusion
with fresh WB
improvement
YES NO
improvement
Repeat 2nd HCT
HCT ↑ or high HCT ↓
Administer 3rd fluid bolus (colloid)10-20 mL/kg over 1 hour
YES NO Repeat 3rd HCT
HCT ↑ or high HCT ↓
Fluid bolus/increase fluid
Consider occult/overt bleed
Initiate transfusion with fresh WB
DENGUE STUDIES IN CHILDREN
DENGUE SHOCK SYNDROME: CRITICAL CARE PERSPECTIVEDENGUE SHOCK SYNDROME: CRITICAL CARE PERSPECTIVE
DSS = = Septic Shock which caused by dengue virusCombination of hypovolemic, distributive (+ cardiogenic) shock
MANAGEMENT OF DSS: UNIQUE - SIMILAR TO SEPTIC SHOCK
EARLY GOAL DIRECTED THERAPY (SSC)
WCPIC Geneva, 2007
SUGGESTEDFLUID RESUSCITATION IN
DSS
Macrocirculation: Macrocirculation: Mental status Mental status Pulse Pressure >20 mmHgPulse Pressure >20 mmHg MAP normal for ageMAP normal for age SaO2 >92%, SvcO2 >70% SaO2 >92%, SvcO2 >70% Warm extremities Warm extremities Temperature cor-toe < 2”Temperature cor-toe < 2” Capillary refill time <2” Capillary refill time <2” Diuresis >1 ml/kg/hrDiuresis >1 ml/kg/hr
End point of DSS rapid resuscitation:End point of DSS rapid resuscitation:
Microcirculation:Serum lactate
< 2mmol/l
Hypoperfusion Reperfusion
MMikrosirkulasiikrosirkulasi
deBaker, Am J Respir Crit Care Med 166:98–104,2002
Fluid responsive
Refractory shockPlace pulmonary artery catheter and direct fluid,
inotrope,vasopressor,vasodilator, and hormonal therapies to attain normal MAP-CVP and CI > 3.3 and < 6.0 L/min/m2
Place pulmonary artery catheter and direct fluid, inotrope,vasopressor,vasodilator, and hormonal therapies to attain normal
MAP-CVP and CI > 3.3 and < 6.0 L/min/m2
Figure 4. Stepwise management of hemodynamic support with goals of normal perfusion and perfusion pressure (MAP-CVP) in infants and children with septic shock. Proceed to next step if shock persists.
Give hydrocortisoneGive hydrocortisone
At Risk of Adrenal Insufficiency? Catecholamine-resistant shock Not at Risk?
Titrate epinephrine for cold shock, norepinephrine for warm shock to normal MAP-CVP and SVC O2 saturation > 70%
Titrate epinephrine for cold shock, norepinephrine for warm shock to normal MAP-CVP and SVC O2 saturation > 70%
Fluid refractory-dopamine resistant shock
Establish central venous access, begin dopamine therapy and establish arterial monitoring
Establish central venous access, begin dopamine therapy and establish arterial monitoring
Fluid refractory shock
Push 20cc/kg isotonic saline or colloid boluses up to and over 60 cc/kgCorrect hypoglycemia and hypocalcemia
Push 20cc/kg isotonic saline or colloid boluses up to and over 60 cc/kgCorrect hypoglycemia and hypocalcemia
Recognize decreased mental status and perfusion.Maintain airway and establish access according to PALS guidelines.
Recognize decreased mental status and perfusion.Maintain airway and establish access according to PALS guidelines.
Observe in PICUObserve in PICU
Consider ECMOConsider ECMO
0 min 5 min
60 min
15 min
Normal Blood Pressure Low Blood Pressure Low Blood Pressure Cold Shock Cold Shock Warm Shock SVC O2 sat < 70% SVC O2 sat < 70%
Do not give hydrocortisoneDo not give hydrocortisone
Add vasodilator or Type III PDE inhibitor Norepinephrine
with volume loading
Volume and Epinephrine Volume and (vasopressin or angiotensin)
Persistent Catecholamine-resistant shock
UNUSUAL MANIFESTATIONS AND COMPLICATIONS
Ensefalopati dengue Ensefalopati dengue
• Dijumpai pada 3% kasus DBD dengan mortalitas tinggi (50%)
• Insiden tersering pada anak < 2 tahun• Dicurigai ensefalopati dengue pada DBD disertai
penurunan kesadaran dengan syok maupun tidak dengan kejang maupun tidak
• Syok berkepanjangan• Perdarahan saluran cerna berat• Gangguan fungsi hati berat• Overload cairan
Hasil lab yang menunjang diagnosisHasil lab yang menunjang diagnosis
SGOT dan SGPT ↑ (SGOT dan SGPT ↑ (> > 200 U/l)200 U/l) Bilirubin direk kadang meningkatBilirubin direk kadang meningkat PT dan PTT meningkatPT dan PTT meningkat Kadar gula darah ↑Kadar gula darah ↑ Kadar amoniak ↑Kadar amoniak ↑ AlkalosisAlkalosis Imbalance elektrolit (Na, K )Imbalance elektrolit (Na, K ) LP bila ada kecurigaan infeksi intrakranialLP bila ada kecurigaan infeksi intrakranial
- Vit K 0,3 mg/kgBB- Asam amino rantai pendek- Ringer asetat- Tranfusi darah bila ada indikasi- H2 blocker bila terjadi perdarahan
saluran cerna- Hemodialisis bila diperlukan
- Vit K 0,3 mg/kgBB- Asam amino rantai pendek- Ringer asetat- Tranfusi darah bila ada indikasi- H2 blocker bila terjadi perdarahan
saluran cerna- Hemodialisis bila diperlukan
Pengelolaan Pengelolaan TIK ↑TIK ↑
- Restriksi cairanRestriksi cairan- MMemperbaiki gangguan elektrolitemperbaiki gangguan elektrolit- Memperbaiki alkalosisMemperbaiki alkalosis- Kortikosteroid bila tidak ada perdarahanKortikosteroid bila tidak ada perdarahan- Manitol Manitol - Mempertahankan kadar gula darah > 60 mg%Mempertahankan kadar gula darah > 60 mg%
- Restriksi cairanRestriksi cairan- MMemperbaiki gangguan elektrolitemperbaiki gangguan elektrolit- Memperbaiki alkalosisMemperbaiki alkalosis- Kortikosteroid bila tidak ada perdarahanKortikosteroid bila tidak ada perdarahan- Manitol Manitol - Mempertahankan kadar gula darah > 60 mg%Mempertahankan kadar gula darah > 60 mg%
DENGUE vs JEDENGUE vs JEDenguDenguee
JEJE
•Defisit neurologisDefisit neurologis•Penurunan kesadaran atau Penurunan kesadaran atau
kejang terjadi sejak awal masuk kejang terjadi sejak awal masuk RSRS•Ig MIg M
±±±±
Ig M + Ig M + denguedengue
++++
Ig M Ig M + JE+ JE
Gagal Hati Akut Gagal Hati Akut
- Kerusakan hepatosit akibat virus dengueKerusakan hepatosit akibat virus dengue- Klinis : ikterik disertai peningkatan kadar Klinis : ikterik disertai peningkatan kadar
enzyme hatienzyme hati- Dapat disebabkan Dapat disebabkan overover--usesuses obat-obatan obat-obatan- Terdapat faktor genetik yang mendasari Terdapat faktor genetik yang mendasari
((Reye syndrome)Reye syndrome)- Dapat disebabkan syok berkepanjanganDapat disebabkan syok berkepanjangan
Gagal Ginjal Akut Gagal Ginjal Akut
Dapat disebabkan oleh :Dapat disebabkan oleh :- Syok berkepanjanganSyok berkepanjangan- Hemolisis akut dengan hemoglobulinuriaHemolisis akut dengan hemoglobulinuria
- G6PD Deficiency- G6PD Deficiency
- Hemoglobulinopathy- Hemoglobulinopathy- Dihubungkan dengan fase lanjut DBDDihubungkan dengan fase lanjut DBD- Obat – obatan Nephrotoxic Obat – obatan Nephrotoxic
Miokarditis Miokarditis Biasanya muncul saat recoveryBiasanya muncul saat recovery Sering terjadi pada anak berumur > 10 tahunSering terjadi pada anak berumur > 10 tahun Manifestasi klinis : Manifestasi klinis :
- Bradikardi Bradikardi - Irama iregulerIrama ireguler- DDapat terjadi gagal jantungapat terjadi gagal jantung Tidak ada terapi spesifik kecuali bila HR < 50x/’ Tidak ada terapi spesifik kecuali bila HR < 50x/’
The rational used of fluid therapy in DSS is to The rational used of fluid therapy in DSS is to use the fluid that has good intravascular filling use the fluid that has good intravascular filling effect and safety profileeffect and safety profile..
EGDT can be adopted in the management of EGDT can be adopted in the management of DSSDSS..
End point of resuscitation is improvement of End point of resuscitation is improvement of macrocirculation and micricmacrocirculation and micricoorculation guidence rculation guidence by CVP, ScvO2,MAP, serum lactic acid levelby CVP, ScvO2,MAP, serum lactic acid level..