Uremic Enche Rds 2

8/6/2019 Uremic Enche Rds 2

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ToxicToxic--Metabolic EncephalopathiesMetabolic Encephalopathies

(TME),(TME), termasuktermasuk11.. HepaticHepatic eencephalopathyncephalopathy22.. UremicUremic eencephalopathyncephalopathy

33..WernickeWernicke--Korsakoff encephalopathyKorsakoff encephalopathy44.. Toxic encephalopathiesToxic encephalopathies

55.. HypoxicHypoxic--ischemic encephalopathyischemic encephalopathy

RUSDIDJASRUSDIDJAS,, RAFITA RAMAYATIRAFITA RAMAYATI

OKE RINA RAMAYANI dan ROSMAYANTYOKE RINA RAMAYANI dan ROSMAYANTY


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DefinitionDefinition -- DefinisiDefinisi

Group of neurological disorders whose hallmark is anGroup of neurological disorders whose hallmark is analtered mental statusaltered mental status Kelainan syaraf ditandai dgnKelainan syaraf ditandai dgnperobahan mentalperobahan mental

Caused by failure of organs other than nervous systemCaused by failure of organs other than nervous systemor presence of an endogenous or exogenous toxin oror presence of an endogenous or exogenous toxin ordrugdrug Disebabkan ok gagal organ selain nervus system atauDisebabkan ok gagal organ selain nervus system atauok endogenous toxin, atau exogenous toxin atau obatok endogenous toxin, atau exogenous toxin atau obat22anan

BBB isolate brainBBB isolate brainBloodBrainBarierterisolasidariotak/BloodBrainBarierterisolasidariotak/

brainbrain Multifocal cortical disorderMultifocal cortical disorder-- KelainancortexygKelainancortexyg

multifactorialmultifactorial


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DeliriumDelirium

A confusional state with superimposed hyperactivity ofA confusional state with superimposed hyperactivity ofthe sympathetic limb of the autonomic nervous systemthe sympathetic limb of the autonomic nervous systemwith consequent signs including tremor, tachycardia,with consequent signs including tremor, tachycardia,diaphoresis, and mydriasisdiaphoresis, and mydriasis

-- KeadaanconfusionbercampurhyperactivitasdaricabangKeadaanconfusionbercampurhyperactivitasdaricabangsympatetikdarisyarafautonom, akibatnya:Tremor,sympatetikdarisyarafautonom, akibatnya:Tremor,tachycardia,diaphtachycardia,diapheeresisdanmydriasisresisdanmydriasis..

Confusion: inability to maintain a coherent stream ofConfusion: inability to maintain a coherent stream of

thought or actionthought or action-- Confusion:TidakmampumempertahankankesadConfusion:Tidakmampumempertahankankesadaaranran

berfikiratauberbuatberfikiratauberbuat


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TMETME Toxic Metabolic EnchephalopathyToxic Metabolic Enchephalopathy

Acute toxicAcute toxic--metabolic encephalopathy (TME):metabolic encephalopathy (TME):encompasses delirium and the acute confusionalencompasses delirium and the acute confusionalstatestate AkutTME ditemukanadaDeliriundanAkutTME ditemukanadaDeliriundan

keadaanconfusionkeadaanconfusion Acute condition of global cerebral dysfunctionAcute condition of global cerebral dysfunction

in the absence of primary structural brain diseasein the absence of primary structural brain disease

--PadakondisiakutditemukanglobalcerebralPadakondisiakutditemukanglobalcerebraldysfunctiontanpaadanyagangguanstrukturotakdysfunctiontanpaadanyagangguanstrukturotak


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TMETME

common among critically ill patientscommon among critically ill patientsSeringpdpenyakitygkritisSeringpdpenyakitygkritis

probably underrecognized and undertreatedprobably underrecognized and undertreated

--mungkinkarenatakdikenalidantakterditeksimungkinkarenatakdikenalidantakterditeksi

Most TME is reversible, making prompt recognition and treatmentMost TME is reversible, making prompt recognition and treatment

importantimportant-- KebanyakanTME reversible,perlupengenalan danpengobatancepatKebanyakanTME reversible,perlupengenalan danpengobatancepat

Certain metabolic encephalopathies, including those caused byCertain metabolic encephalopathies, including those caused bysustained hypoglycemia and thiamine deficiency (Wernicke'ssustained hypoglycemia and thiamine deficiency (Wernicke'sencephalopathy), may result in permanent structural brain damage ifencephalopathy), may result in permanent structural brain damage if

untreateduntreated--BeberapaTBeberapaTMME termasukygdisebabkanolehhypoglycemiadanE termasukygdisebabkanolehhypoglycemiadandefisiensiBdefisiensiB11((Wernicke'sencephalopathyWernicke'sencephalopathy)bisamenyebabkan)bisamenyebabkankerusakanotakygpermanenkerusakanotakygpermanen


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Clinical manifestationsClinical manifestations TMETME

Mental status abnormalities :range from subtle to deep comaMental status abnormalities :range from subtle to deep coma

--StatusMentalabnormalmulaidariygringanStatusMentalabnormalmulaidariygringandeepcomadeepcoma Impaired orientation, cognition, memory, affect, perception , judgementImpaired orientation, cognition, memory, affect, perception , judgement

Gangguanorientasi, cognition/dayaingat, ganggpersepsi,Gangguanorientasi, cognition/dayaingat, ganggpersepsi,pengambilankesimpulan.pengambilankesimpulan.

Pupils: sluggish, small, irregularPupils: sluggish, small, irregular pupil mata lambat,kecildaniregulerpupil mata lambat,kecildanireguler

Eye movement: disconjugate gazeEye movement: disconjugate gaze

--GerakanMataconjugasiGerakanMataconjugasi Motor: increase in toneMotor: increase in tone

-- TonusmotorikmeninggiTonusmotorikmeninggi Spasticity with extensor plantar responseSpasticity with extensor plantar response

--SpastisitasdgnresponsplaSpastisitasdgnresponsplanntarygextensitarygextensi


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PathophysiologyPathophysiology TMETME

Normal neuronal activity requires a balanced environment ofNormal neuronal activity requires a balanced environment ofelectrolytes, water, amino acids, excitatory and inhibitoryelectrolytes, water, amino acids, excitatory and inhibitoryneurotransmitters, and metabolic substratesneurotransmitters, and metabolic substrates

--AktivitasNeuronygnormalmemerlukanbalansdariElektrolit,Air,AktivitasNeuronygnormalmemerlukanbalansdariElektrolit,Air,

AminoAcid,rangsAminoAcid,rangsaangdaninhibisineurotransmitterdansubstangdaninhibisineurotransmitterdansubstannsisimetabolikmetabolik....

normal blood flow, normal temperature, normal osmolality, andnormal blood flow, normal temperature, normal osmolality, andphysiologic pH are required for optimal central nervous systemphysiologic pH are required for optimal central nervous systemfunctionfunction

--Normalbloodflow,normaltempratur,normalosmolalitydanfisiologikNormalbloodflow,normaltempratur,normalosmolalitydanfisiologikpHygoptimalfungsiCNSpHygoptimalfungsiCNS


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11.. Hepatic encephalopathyHepatic encephalopathy

Liver disease causes encephalopathy byLiver disease causes encephalopathy by 22

mechanisms :mechanisms :

-- Peny. Hati menyebabkan encephalopathy dgn

Peny. Hati menyebabkan encephalopathy dgn 22

caracara

11--Hepatocellular failureHepatocellular failure --11. Gagal Hati. Gagal Hati

22--Diversion of toxins from hepatic portal vein intoDiversion of toxins from hepatic portal vein intothe systemic circulationthe systemic circulation 22.. DiversitoxindariDiversitoxindari

HepardariVenaportaekesirkuasisystemikHepardariVenaportaekesirkuasisystemik


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Precipitating factorsPrecipitating factors

GI bleedGI bleed -- PerdarahanGEPerdarahanGE

Drug inducedDrug induced -- Drug InducedDrug Induced Excess dietary proteinExcess dietary protein-- KelebihandietproteinKelebihandietprotein

HypokalmeiaHypokalmeia -- HypokalemiaHypokalemia

ConstipationConstipation -- ConstipasiConstipasi InfectionsInfections -- InfeksiInfeksi


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22.. Uremic encephalopathyUremic encephalopathy

Coexistence of signs of nervous system depression (obtundation)Coexistence of signs of nervous system depression (obtundation)and neural excitation (twitching, myoclonus, agitation andand neural excitation (twitching, myoclonus, agitation andseizures)seizures)

--Bersamaangejala DepresiNervoussystemBersamaangejala DepresiNervoussystem

DuDuee to:to: OlehkarenaOlehkarena Progressive azotemiaProgressive azotemia

Azotemiayg cepatmeningkatAzotemiayg cepatmeningkat( seringpadapeny. Ginjal)(seringpadapeny. Ginjal)

Effect of treatment :dialysis disequilibrium syndrome, dementiaEffect of treatment :dialysis disequilibrium syndrome, dementiafrom aluminum accumulationfrom aluminum accumulation

--EffekpengbatanDialysis,dysequilibriumsyndromEffekpengbatanDialysis,dysequilibriumsyndrom Complication of transplantation and immunosupressionComplication of transplantation and immunosupression

--KomplikasidariTransplantasidanimunosupresionKomplikasidariTransplantasidanimunosupresion


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Disorders of glucose metabolismDisorders of glucose metabolism

-- Gangg. Metaboline GlucoseGangg. Metaboline Glucose

HypoglycemiaHypoglycemia -- HypoglycemiaHypoglycemia

NonNon--ketotic hyperosmolar comaketotic hyperosmolar coma ComaokNonComaokNon

Ketotic HyperosmolarKetotic Hyperosmolar


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33..WernickeWernicke--Korsakoff encephalopathyKorsakoff encephalopathy okok

Chronic alcoholismChronic alcoholism --Kronic alkoholismKronic alkoholism

Hyperemesis gravidarumHyperemesis gravidarum --HyperemesisGravidHyperemesisGravid

MalignancyMalignancy --MalignancyMalignancy

GI surgeryGI surgery --GEsurgeryGEsurgery

HDHD --HD/HemodyalisisHD/Hemodyalisis

Prolonged intravenousProlonged intravenous --InInttravenousFeedinglamaravenousFeedinglamafeedingfeeding

Anorexia nervosaAnorexia nervosa -- AnorexianervosaAnorexianervosa

AIDSAIDS --AIDSAIDS


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WernickeWernicke--Korsakoff encephalopathyKorsakoff encephalopathy

Triad of :Triad of : ada Trias (ada Trias ( 33 tanda)tanda)

ConfusionConfusion --11.C.Confusiononfusion-- bingungbingung

OpthalmoplegiaOpthalmoplegia --22.Ophthalmoplegia.Ophthalmoplegia

AtaxiaAtaxia --33.Ataxia.Ataxia

Pathology : small hemorrhages in periventricular grey matter aroundPathology : small hemorrhages in periventricular grey matter aroundaqueduct,aqueduct,33rdrd andand 44ththventriclesventricles

Patologi:adaperdarahankecilPatologi:adaperdarahankecil22pdperiventricle, greymattersekitarpdperiventricle, greymattersekitaraqueducktus, Ventriclekeaqueducktus, Ventricleke33 dandan44..

TreatmentTreatment : Thiamine: Thiamine -- ThiamineThiamine

glucoseglucose --GlucoseGlucose


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44.. Toxic encephalopathiesToxic encephalopathies

Oleh karena:Oleh karena:

AlcoholAlcohol

SalicylaytesSalicylaytes AcetaminophenAcetaminophen

BarbituratesBarbiturates


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55..HypoxicHypoxic--ischemic encephalopathyischemic encephalopathy

brain utilizes oxygen to metabolize glucose. It cannot storebrain utilizes oxygen to metabolize glucose. It cannot storeoxygen and survives only for minutes after its oxygen supply isoxygen and survives only for minutes after its oxygen supply isreduced below critical levels.reduced below critical levels. OtakmemerlukanoxygenutkOtakmemerlukanoxygenutkmetabolismeglucosedantidakmampumensuplayoxygen,hanyametabolismeglucosedantidakmampumensuplayoxygen,hanyabertahanbbrpmenitsesudahoxygemsuppayberkurang.bertahanbbrpmenitsesudahoxygemsuppayberkurang.

Pyramidal cells in Sommer's sector of the hippocampus, PurkinjePyramidal cells in Sommer's sector of the hippocampus, Purkinjecells of the cerebellum, and pyramidal cells of the third and fifthcells of the cerebellum, and pyramidal cells of the third and fifthlayers of the cerebral cortex are vulnerable to even moderatelayers of the cerebral cortex are vulnerable to even moderatedegrees of anoxiadegrees of anoxia PyramidalseldiHypocampus;PurkinyeseldiPyramidalseldiHypocampus;Purkinyeseldi

cerebelumdanpyramidalseldilapisankecerebelumdanpyramidalseldilapisanke44 dandan55 dicerebralcortexdicerebralcortexmudanrusakokamoxiamudanrusakokamoxia....


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HIEHIE (Hypoxic Ischemic Encepjalopathy),(Hypoxic Ischemic Encepjalopathy),timbul akibat;timbul akibat;

11..Anoxic anoxiaAnoxic anoxia consists of low arterial oxygen content andconsists of low arterial oxygen content andtension. This may be secondary to decreased oxygen in thetension. This may be secondary to decreased oxygen in theenvironment or inability for oxygen to enter the circulatoryenvironment or inability for oxygen to enter the circulatorysystem as in pulmonary diseasesystem as in pulmonary disease

22..Anemic anoxiaAnemic anoxiaconsists of low oxygen content in theconsists of low oxygen content in theblood secondary to decreased hemoglobin content.blood secondary to decreased hemoglobin content.

33..Ischemic anoxiaIschemic anoxiadescribes a state of insufficient cerebraldescribes a state of insufficient cerebralblood flow. "Lowblood flow. "Low--flow states" may be secondary toflow states" may be secondary tocardiovascular collapse or conditions of increased vascularcardiovascular collapse or conditions of increased vascularresistance as in stroke orresistance as in stroke or migrainemigraine


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HIEHIE

Result from a number of conditions such as:Result from a number of conditions such as:

--Akibatdaribbrpkondisiseperti;Akibatdaribbrpkondisiseperti;

Cardiac arrestCardiac arrest --HentiJantungHentiJantung CO intoxicationCO intoxication -- IntoxikasicarbonIntoxikasicarbon

monomonoxxydayda

Septic shockSeptic shock --SeptiSepticc ShockShock


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Prognosis and ComplicationsPrognosis and Complications

postpost--arrest coma longer than three days carriedarrest coma longer than three days carried

an unfavorable prognosisan unfavorable prognosis

--ComalebihdariComalebihdari33 hariprognosiskurangbhariprognosiskurangbaaikik Individuals with the best chance of recovery hadIndividuals with the best chance of recovery had

preserved brainstem function following thepreserved brainstem function following the

initial insultinitial insult--PenderitaygsembuhokfungsibrainsstembaikPenderitaygsembuhokfungsibrainsstembaik


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ManagementManagement Enchephalopathy, obatEnchephalopathy, obat

sesuai dgn penyebab!sesuai dgn penyebab! Diagnostic difficulty: drugs, sepsisDiagnostic difficulty: drugs, sepsis

--Diagnosissukar;kalauakibatobatDiagnosissukar;kalauakibatobat22an/sepsisan/sepsis

Continuos monitoringContinuos monitoring

--TerusmenerusdimonitorTerusmenerusdimonitor Watch for complications:Watch for complications:

--AwasikomplikasiyangmunculAwasikomplikasiyangmuncul

CT brainCT brain

--CTscanCTscan

LPLP

-- LPLP

EEGEEG

--EEGEEG


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TERIMA KASIHTERIMA KASIH

Uremic Enche Rds 2

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