Pendidikan Kedokteran Berkelanjutan ILMU KESEHATAN ANAK IV PENANGANAN TERKINI KEGAWATAN PADA ANAK The Sunan Hotel, 15-16 Maret 2014 H. B. Soebagyo, MD, Pediatrician Kegawatan Pada Diare dengan Dehidrasi Berat Gastroenterology & Hepatology Division Child Health Departement Sebelas Maret University/Dr. Moewardi Hospital Surakarta
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Pendidikan Kedokteran Berkelanjutan
ILMU KESEHATAN ANAK IV
PENANGANAN TERKINI KEGAWATAN PADA ANAKThe Sunan Hotel, 15-16 Maret 2014
H. B. Soebagyo, MD, Pediatrician
Kegawatan Pada Diare dengan
Dehidrasi Berat
Gastroenterology & Hepatology DivisionChild Health DepartementSebelas Maret University/Dr. Moewardi Hospital Surakarta
Diarrhea in The 21th Century
• Second most common cause of morbidity and mortality worldwide
• Worldwide- 1.5 billion episodes of diarrhea occur annually
- and 1.5 - 2.5 million deaths occur annually among children aged <5 years
• Indonesia (2000)- About 60 million episodes of diarrhea occur annually
- 1-5% of total diarrhea among children -> develop chronic diarrhea
- Highest prevalence among children aged 6-24 month, due to oral phases & bad hygiene
Keadaan umum Baik, sadar Gelisah, rewel Lesu, lunglai atau
tidak sadar
Mata Normal Cekung Sangat cekung
Air mata Ada Tidak ada Kering
Mulut dan lidah Basah Kering Sangat kering
Rasa haus Minum biasa,
tidak haus
Haus, ingin minum
banyak
Malas minum atau
tidak bisa minum
Periksa : turgor Kembali cepat Kembali lambat Kembali sangat
lambat
Hasil pemeriksaan Tanpa dehidrasi Dehidrasi
ringan/sedang
(Bila ada 1 tanda
ditambah 1 atau
lebih tanda lain)
Dehidrasi berat
(Bila ada 1 tanda
ditambah 1 atau
lebih tanda lain)
Terapi Rencana Terapi A Rencana Terapi B Rencana Terapi C
Pemeriksaan Penunjang
(jika ada indikasi)
• darah lengkap, serum elektrolit,
• analisa gas darah, glukosa darah,
• kultur dan tes kepekaan terhadap antibiotika
Darah
• Makroskopik
• MikroskopikTinja
• Urinlaisa
• Kultur UrinUrin
5 PILAR TATALAKSANA
DIARE PADA ANAK
1. Rehydration (fluid management)
2. Re-feed as soon as rehydration is accomplished
3. Zinc 10-20 mg daily x 14 days
4. Antibiotics as indicated
5. Education-Communication
WHO, 2002
Tatalaksana Rehidrasi
Two phases of fluid management in acute diarrhea:
1. Rehydration phase, in which water and electrolytes are administered as oral rehydration solution (ORS)/IV fluid to replace existing losses
2. Maintenance phase, which includes both replacement of ongoing fluid and electrolyte losses and adequate dietary intake
Tatalaksana Rehidrasi
Tanpa Dehidrasi
• ORALIT– 5-10 ml/kg tiap kali BAB
atau muntah
• Pemberian diet makanan seperti biasa
Dehidrasi Ringan-Sedang
• TAHAP REHIDRASI– Oralit 75ml/kgBB/3jam
– Cairan IV apabila muntah terus menerus
• TAHAP MAINTENANCE – Mengganti setiap
kehilangan cairan
– Oralit 5-10ml/kgBB tiap BAB atau muntah
• Diet makanan seperti biasa
Rehidrasi pada Dehidrasi Sedang
• A randomized trial of ORS versus IV rehydration demonstrated shorter stays in EDs and improved parental satisfaction with oral rehydration
Atherly-John YC, Cunningham SJ, Crain EF. 2002
• Nasogastric (NGT) feeding allows continuous administration of fluid at a slow, steady rate, particularly for patients with persistent vomiting or oral ulcers
• Rapid rehydration by nasogastric fluid can be well-tolerated, more cost-effective, and associated with fewer complications than IV rehydration
Nager AL, Wang VJ.2002
ORALIT
Standard ORS solution(mEq or mmol/l)
Reduced osmolarity ORS solution
(mEq or mmol/l)
Glucose 111 75
Sodium 90 75
Chloride 80 65
Potassium 20 20
Citrate 10 10
Osmolarity 311 245
1 Sachet Oralit 200 cc
Pemilihan cairan IVCairan Na Cl K Ca Asetat laktat Dekst Kal Osm
Asering 130 109 4 3 28 - - - 273
RL 130 109 4 3 - 28 - - 273
RD 147 155 4 4.5 - - 50 200 589
NaCl 0,9% 154 154 - - - - - - 300
KaEN 3A 60 50 10 - - 20 27 108 290
KaEN 3B 50 50 20 - - 20 27 108 290
KaEN 1B 38.5 38.5 - - - - 37.5 150 285
D ½ S 77 77 - - - - 50 200 428
D ¼ S 38.5 38.5 - - - - 50 200 353
TATALAKSANA
DEHIDRASI BERAT
TAHAP I30ml/kg
TAHAP II70ml/kg
< 1 tahunHabis dalam 1 jam
30ml/kg/jamHabis dalam 5 jam
70ml/kg/5jam
> 1 tahunHabis dalam 0,5 jam
30ml/kg/0,5 jamHabis dalam 2,5 jam
70ml/kg/2,5 jam
EVALUASI
28
REHIDRASI TAHAP I
REHIDRASI TAHAP II
EVALUASI
Dehidrasi (-)Dehidrasi
Ringan SedangDehidrasi Berat
CairanMaintenace
Tatalaksanadehidrasi
ringan-sedang
Ulangi tahap I dan II
• Severe dehydration constitutes a medical emergency requiring immediate IV or intraosseousrehydration
• As soon as the severely dehydrated patient's level of consciousness returns to normal, therapy can usually be changed to the oral route, with the patient taking by mouth the remaining estimated deficit
Dehidrasi Berat
disertai SYOK
“Berkurangnya volume cairan intravaskuleryang menyebabkan kegagalan sistem sirkulasiuntuk mempertahankan perfusi yang adekuatke organ vital”
No Oxygen Delivery↓
Tidak adametabolisme aerobik
• Asidosis Metabolik (produksiasam laktat)
• Endoplasmic reticulum swelling• Mitochondrial damage• CELL DEATH
Dehidrasi Berat
disertai SYOKKenali Tanda Kegagalan Sirkulasi
Dehidrasi Berat
disertai SYOK (Tatalaksana)
Constitutes a medical emergency and requires immediate IV/intraosseous fluid resuscitation
20 ml/kg of acetated ringers, lactated ringers or normal saline should be administered in 10 minutes until pulse, perfusion and
mental status returns to normal
With frail or severely malnourish infants smaller amounts (10ml/kg) are recommend because of their reduced ability of
increasing the cardiac output
No response to IV therapy should raise suspicion for septic shock, metabolic, cardiac or neurologic disorders
EVALUASI
I. 20ml/kg/secepatnya (10 menit) cairankristaloid
II. Jika belum berespon bisa diulangsampai 3 kali
Tatalaksana Syok Hipovolemik
EVALUASI RESPON (Tanda vital kembali
normal)
(-)(+)
Pertimbangkan septic shock, metabolic, cardiac or
neurologic disorders
Nilai Ulang Derajat DehidrasiTatalaksana Sesuai Derajat
Dehidrasi
Gangguan Elektrolit
•kadar natrium plasma > 150 mmol/L
Hipernatremia
•Kadar natrium plasma < 130 mmol/L
Hiponatremia
•kadar K > 5 mEq/L
Hiperkalemia
•kadar K < 3,5 mEq/L
Hipokalemia
Indikasi Pemeriksaan Elektrolit :• Dehidrasi Berat• Dehidrasi Sedang dengan Tanda Gangguan ElektrolitWAKTU PEMERIKSAAN : Setelah dehidrasi teratasi
PENCEGAHAN
DIARE
PENCEGAHAN DIARE
(WHO 1990)
Pemberian ASI yang
Benar
MemperbaikiMakananSapihan
BanyakMenggunakan
Air Bersih
MencuciTangan
PenggunaanJamban
Cara Yang Benar
MembuangTinja Bayi
ImunisasiCampak dan
Rotravirus
TERIMA KASIH
KEBUTUHAN CAIRAN
PADA ANAK
• Perhitungan Darrow
– [10kg pertama] x 100 ml
– [10kg kedua] x 50 ml
– [10kg sisanya] x 20 ml
• 1 Hari : 100 ml x KgBBBB <10kg
• 1 Hari : 1000 ml + [50 ml x (kgBB-10kg)]BB 10-20 kg
• 1 Hari : 1500 ml + [20 ml x (kgBB-20kg)BB > 20 kg