Penatalaksanan Penatalaksanan intensif intensif pasien pasien dengan dengan Penyakit Penyakit Tropik Tropik Berat Berat di di ICU ICU Dr . Dr .Dadik Dadik Wahyu Wahyu Wijaya Wijaya SpAn SpAn Departemen Departemen Anestesiologi Anestesiologi & & Reanimasi Reanimasi / / Instalasi Instalasi Pelayanan Pelayanan Intensif Intensif (ICU) (ICU) FK FK-USU / RSUP USU / RSUP H.Adam H.Adam Malik Malik - Medan Medan 1
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Common used as anticonvulsant in Common used as anticonvulsant in tetanus.tetanus.
Has sedative effectHas sedative effect
Dose of Diazepam vary 100Dose of Diazepam vary 100--400 mg/24 h 400 mg/24 h Dose of Diazepam vary 100Dose of Diazepam vary 100--400 mg/24 h 400 mg/24 h max until 2400mg/24 hmax until 2400mg/24 h
Preservative used can cause acidosis in Preservative used can cause acidosis in large doselarge dose
No/little effect on autonomic disturbanceNo/little effect on autonomic disturbance
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Magnesium SulfateMagnesium Sulfate
-- Pre synaptic neuromuscular blockerPre synaptic neuromuscular blocker
-- Blocks catecholamine release from nerve and Blocks catecholamine release from nerve and
adrenal medullaadrenal medulla
-- Reduce receptor responsiveness to release Reduce receptor responsiveness to release
catecholaminescatecholamines
-- It antagonizes calcium in myocardium and at It antagonizes calcium in myocardium and at
the neuromuscular junctionthe neuromuscular junction
Adult : a loading dose of 5 gram over 20 Adult : a loading dose of 5 gram over 20 minutes IV followed by 1g hourly minutes IV followed by 1g hourly increasing to 2.5 gram hourly when increasing to 2.5 gram hourly when necessary. Titrate to symptomsnecessary. Titrate to symptomsnecessary. Titrate to symptomsnecessary. Titrate to symptoms
Pediatrics : 100mg /kg/24 hours, can be Pediatrics : 100mg /kg/24 hours, can be increased when necessary. Titrate to increased when necessary. Titrate to symptomssymptoms
Sometimes MgSO4 is inadequate to be used alone, combination with benzodiazepine is also mandatory
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Monitoring of possible side effectsMonitoring of possible side effects
-- Patellar reflexPatellar reflexDiminished at the level of Magnesium >4 Diminished at the level of Magnesium >4 mmolmmol/L/L
-- Respiratory depression because of muscle Respiratory depression because of muscle paralysis (>Mg 6 paralysis (>Mg 6 mmolmmol/L)/L)
�� Terapi fisik (fisioterapi) karena pasien Terapi fisik (fisioterapi) karena pasien imobilisasi cukup lama. imobilisasi cukup lama.
�� VentilasiVentilasi mekanikmekanik
MANAGEMENTMANAGEMENT
�� VentilasiVentilasi mekanikmekanik
�� Metabolik : Nutrisi enteral , ditambah Metabolik : Nutrisi enteral , ditambah parenteral bila perlu.parenteral bila perlu.
�� Penggunaan inotropik dan atau Penggunaan inotropik dan atau vasopresorvasopresor
�� AntikoagulanAntikoagulan2424
3 major complications cause death3 major complications cause death
VentilatoryVentilatory restriction leading to respiratory restriction leading to respiratory VentilatoryVentilatory restriction leading to respiratory restriction leading to respiratory complication and sepsiscomplication and sepsis
In addition to the manifestations ofDHF Grade II :– Circulatory failurse manifested by
rapid and weak pulse, narrowingof pulse pressure (20 mmHg orless) or Hypotension with thepresence of cold clammy skinand restlessness
– Capillary relief time more thantwo seconds
Management
– Check haematocrits/platelet
– Initiate IV Therapy (5% D/NSS) 10 ml/kg/h– Check Haematocrit , vital signs, urine output every
hour.– If patient improves IV fluids should be reduced every
hour from 10 to 6 and from 6 to 3 ml/kg/h which can bemaintained up to 24 to 48 hours.
– If patients has already received one hour treatment of20 ml/kg/hr of IV fluids and vital signs are not stablecheck haematocrit again andtwo seconds
Profound shock with undetectablepulse and blood pressure.
check haematocrit again and– If haematocrit is increasing change IV fluid to colloidal
solution preferably Dextran or plasma at 10 ml/kg/hevery hr.
– If haematocrit is increasing from initial value give freshwhole blood transfusion, 10 ml/kg/h and continue fluidtherapy at 10 ml/kg/h and reducing it stepwise bringdown the volume to 3 ml/kg/h and maintain it up to 24 –48 hours.
– Initial IV therapy (5% D/NSS) 20 ml/kg as a bolus oneor two times
– Oxygen therapy should be given to all patients.– In case of continued shock colloidal fluids (Dextran or
Plasma) should be given at 10 – 20 ml/kg/hr.
Afebrile phase
Con Phase
Manifestation
Profound shock with undetectablePulse and blood pressure
Manifestation
Management
- If shock still persists and the haemotocrit level continues declining give fresh whole blood 10 ml/kg as a bolus
- Vital signs should be monitored every 30 –60 minutes
- In case of severe bleeding gives fresh whole blood 20 ml/kg as a bolus
- Give platelet rich plasma transfusion exceptionally when platelet counts are below 5.000 – 10.000 / mm3
- After blood transfusioncontinues fluid therapy at 10 ml/kg/h and reduce it stepwise to bring it down to 3 ml/kg/h and maintain in for 24 – 48 hrs
ManagementCon Phase
Duration 2 – 3 daysAfter recovery from critical/shock stage
Manifestation
- 6 – 12 hours after critical/shock stage some symptoms of respiratory distress (pleural effusion or arcites)
- 2-3 days after critical stage , strong pulse, normal blood pressure.
- Improved general condition/return of appetite.
- Good urine output- Stable haematocrit- Pletelet count > 50.000 per mm3
- Patient could bedischarged from hospital 2 – 3 days after critical stage
- Bradycardia/arrhytmia- Asthenia and depression (few
weeks) in adult
Management
- Rest for 1 – 2 days- Normal diet- No need for medication
Fluid Therapy in DSSFluid Therapy in DSS
The policy of initial fluid therapy in DSS The policy of initial fluid therapy in DSS
according to the according to the Department of Health Department of Health
and WHO until 2003 :and WHO until 2003 :
Crystalloid (Lactate Ringer), followed Crystalloid (Lactate Ringer), followed
with colloid (with colloid (DextranDextran) if not responded) if not responded
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Department of HealthDepartment of HealthIndonesian Intensive Care AssociationIndonesian Intensive Care Association
Indonesian Anesthesiology AssIndonesian Anesthesiology AssIndonesian Indonesian PaedPaed. Ass (2004). Ass (2004)
Review on the management of DHFReview on the management of DHFReview on the management of DHFReview on the management of DHF
Change the protocolChange the protocol
Include colloid MMWInclude colloid MMW--6% HES as alternative as 6% HES as alternative as
initial fluid resuscitation in DSSinitial fluid resuscitation in DSS
Distributed to the interstitial spaceDistributed to the interstitial space
Very short period in the intravascular spaceVery short period in the intravascular spaceVery short period in the intravascular spaceVery short period in the intravascular space
Need more fluid to maintain intravascular Need more fluid to maintain intravascular
volume volume �������� risk for interstitial edema / risk for interstitial edema /
-- Effective Effective and safe plasma substituteand safe plasma substitute
-- HES HES �������� broad range of MW, from very small until broad range of MW, from very small until
several hundred thousand Daltonseveral hundred thousand Dalton
-- Classification of HES (by in vitro) according to Classification of HES (by in vitro) according to -- Classification of HES (by in vitro) according to Classification of HES (by in vitro) according to MW:MW:-- HIGH MOLECULAR WEIGHT (HMW) HIGH MOLECULAR WEIGHT (HMW) →→ 450 K 450 K DaDa
-- MEDIUM MOLECULAR WEIGHT (MMW) MEDIUM MOLECULAR WEIGHT (MMW) →→ 200 K 200 K DaDa
-- LOW MOLECULAR WEIGHT (LMW) LOW MOLECULAR WEIGHT (LMW) →→ 70 K 70 K DaDa
Sealing effectSealing effect : HES with 100: HES with 100––300.000 D MW300.000 D MW
Effect Effect of HES on Blood Coagulationof HES on Blood Coagulation
HMWHMW--HES HES ��������more effect on blood coagulation more effect on blood coagulation
((vWFvWF, factor VIII), factor VIII)
LMW (HES 70/0.5/4)/LMW (HES 70/0.5/4)/MMW(HES 200/0.5/6MMW(HES 200/0.5/6) ) �������� did did LMW (HES 70/0.5/4)/LMW (HES 70/0.5/4)/MMW(HES 200/0.5/6MMW(HES 200/0.5/6) ) �������� did did
not affect on blood coagulationnot affect on blood coagulation
Possible Possible dilutionaldilutional coagulation effect : PT, coagulation effect : PT, aPTTaPTT
(significant prolongation after HMW(significant prolongation after HMW--HES 480)HES 480)
Fluid Resuscitation in DSSFluid Resuscitation in DSS
Primary importance in the management Primary importance in the management
of of hypoperfusionhypoperfusion statestate
Goal of therapyGoal of therapyGoal of therapyGoal of therapy
Study on DSS using colloid (HES ) Study on DSS using colloid (HES ) as initial fluid resuscitationas initial fluid resuscitation
Tatty E. Tatty E. SetiatiSetiati Different
RESULTTatty E. Tatty E. SetiatiSetiati
(2000)(2000)
HerminiaHerminia L. L. CifraCifra
(2001(2001) H) H
RESULT
Different
method of
study
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RL group Colloid group (HAES Steril 6%)
Duration of
shock ( Hour)
7.9+/- 2.6 2.3 +/- 2
Ventilators days 8 +/- 1.1 4.0 +/- 0.71
Pleural effusion 30M2/Mod7/S21
_
ALI /PaO2/FiO2=200-250 4 1
ARDSPaO2/FiO2 < 200
6 2
ConclusionConclusion
Evidenced showed that endothelial dysfunction Evidenced showed that endothelial dysfunction
lead to vascular leakage and lead to vascular leakage and hemostatichemostatic
disturbances occurred in DSSdisturbances occurred in DSS
MMW which has a sealing effect could MMW which has a sealing effect could MMW which has a sealing effect could MMW which has a sealing effect could
minimizing vascular leakage, good preservation minimizing vascular leakage, good preservation
volume effect, and lowering mortalityvolume effect, and lowering mortality
MMW HES can be used as alternative for initial MMW HES can be used as alternative for initial
fluid resuscitation in DSSfluid resuscitation in DSSS S
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What not to do in DSS
Do not give Aspirin or Ibuprofen for treatment of fever.
Avoid giving intravenous therapy before there is evidence of haemorrhage and bleeding.
Avoid giving blood transfusion unless indicated, reduction in haematocrit or severe bleeding.in haematocrit or severe bleeding.
Avoid giving steroids. They do not show any benefit.
Do not use antibiotics
Do not change the speed of fluid rapidly, i.e. avoid rapidly increasing or rapidly slowing the speed of fluids.
Insertion of nasogastric tube to determine concealed
bleeding or to stop bleeding (by cold lavage) is not
recommended since it is hazardous.
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Signs of Recovery
Stable pulse, blood pressure and breathing rate
Normal temperature
No evidence of external or internal bleeding
Return of appetiteReturn of appetite
No vomiting
Good urinary output
Stable haematocrit
Convalescent confluent petechiae rash
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SEVERE MALARIASEVERE MALARIASEVERE MALARIASEVERE MALARIA
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What is severe malaria?
Severe malaria is the serious or life-threatening
form of falciparum malaria which needs active
appropriate patient management.
According to WHO criteria in 1990, severe malaria
patients have asexual forms of Plasmodium
falciparum on a blood film and may have any one
or more of the following manifestations and
complications :
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1. Cerebral malaria (unrousable coma not
attributable to any other cause)
2. Severe normocytic anemia (haematocrit <15% or hemoglobin <5 g/dl)
3. Acute renal failure (urine output <400 ml/24 3. Acute renal failure (urine output <400 ml/24 hours in adults or 12 ml/kg/24 hours in children, failing to improve after redydration and
serum creatinine >265 mmol/l (3 mg/dl))
4. Pulmonary edema or adult respiratory distress syndrome (ARDS)
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5. Hypoglyceamia (whole blood glucose <2.2
mmol or l40 mg/dl)
6. Circulatory collapse, shock: hypotension
(systolic blood pressure <50mmHg in children
aged 1-5 years or <70 mmHg in adults), with
cold clammy skin or core-skin temperature
difference >10 °C)
7. Spontaneous bleeding/disseminated
intravascular coagulation (DIC)
8. Repeated generalized convulsions
9. Acidaemia (arterial pH <7.25) or acidosis
(plasma bicarbonate <15 mmol/l)
10. Macroscopic haemoglobinuria
11. Post-mortem confirmation of diagnosis4848
WHO MULTICENTER STUDY ON SEVERE MALARIA IN UNDER WHO MULTICENTER STUDY ON SEVERE MALARIA IN UNDER FIVES IN 10 AFRICAN COUNTRIES (1230 CASES, 1999 FIVES IN 10 AFRICAN COUNTRIES (1230 CASES, 1999 –– 2000)2000)
PREVALENCE OF SIGNS AND SYMPTOMSPREVALENCE OF SIGNS AND SYMPTOMS
SIGNS AND SYMPOMS NUMBER %
SEVERE ANEMIA 666 54.1SEVERE ANEMIA 666 54.1
PROSTRATION 371 30.2
CONVULSIONS 279 22.7
CEREBRAL MALARIA 218 17.7
HYPOGLYCEMIA 162 13.2
HYPOGLOBINURIA 41 3.3
JAUNDICE 21 1.7
RESPIRATORY DISTRESS 12 1.0
DISSEMINATED INTRAVASCULAR 1 0.08
COAGULATION
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Different clinical manifestation between adults and children with severe malaria
Adult Children
Cough Uncommon early symptom Common early symptom
Convulsions Indicate cerebral involvement May indicate cerebral
involvement or hypoglycemia,
but may be non – specific
consequence of fever
Duration of symptoms Commonly several days Usually 1 – 2 days onlybefore features of severebefore features of severedisease develop
Jaundice Common Uncommon
Time from start of Usually quinine 2 – 4 days Usually 1 – 2 daystreatment to resolutionof coma in cerebral malaria
Hypoglycemia Relatively uncommon CommonUsually quinine-induced (especially in pregnancy)
Pulmonary edema Common RareRenal failure Common RareNeurological sequelae Uncommon Occur in about 10% of cases
after cerebral malaria
ManagementManagement
· Parenteral antimalarials.
· IV fluid administration.
· Vital signs monitoring every 4 hours.
· Blood check up for malaria parasite every day until disappearance of parasitemia.day until disappearance of parasitemia.
· Monitoring clinical signs and symptoms of severe malaria that may occur later.
· Record conscious level every 4 hours and urine output every 8 hours.