Penatalaksanan Penatalaksanan intensif pasien dengan Penyakit

Penatalaksanan intensif pasien dengan
Penyakit Tropik Berat
di ICU
Dr .Dadik
.Dadik Wahyu Wijaya SpAn
Departemen Anestesiologi & Reanimasi / Instalasi
Pelayanan Intensif (ICU)
FKFK-USU / RSUP H.Adam Malik - Medan
1
Indikasi Umum Pasien dirawat di ICU
Berdasarkan Prioritas
Berdasarkan Diagnosis
Berdasarkan NilaiNilai-nilai Parameter
Hasil Laboratorium
2
Penyakit Tropik Berat (yang sering
di ICU :
Tetanus Berat (Severe Tetanus)
DHF Grade IIIIII-IV (DSS)
Malaria Berat (Severe Malaria)
3
TETANUS BERAT
4
Derajat Keparahan
(Severity Grading)
Philips
Dakar
Udwadia
Gambaran Klinis
Ablett
Blect
5
Philips Score
Waktu Masuk
Skor
Masa Inkubasi
> 14 hari
> 10 hari
5 – 10 hari
2 – 5 hari
< 48 jam
Imunisasi
Lengkap
< 10 tahun
> 10 tahun
Ibu diimunisasi
Tidak diimunisasi
Luka Infeksi
Tidak diketahui
Distal/perifer
Proksimal
Kepala
Badan
Komplikasi
Tidak ada
Ringan
Tidak membahayakan
Mengancam Nyawa (tidak langsung)
Mengancam nyawa
1
2
3
4
5
0
2
4
8
10
1
2
3
4
5
1
2
4
8
10
Selama Perawatan
Spasme
Hanya trismus
Kaku seluruh badan
Kejang terbatas
Kejang seluruh badan
Optistotonus
Frekuensi Spasme
6 x dalam 12 jam
Dengan rangsangan
Terkadang spontan
Spontan < 3x per 15 menit
Spontan > 3x per 15 menit
Suhu
36.7 - 37 C
37.1 – 37.7 C
37.8 – 38.2 C
38.3 – 38.8 C
> 38.8 C
Pernafasan
Sedikit berubah
Apnea saat kejang
Kadang apnea setelah kejang
Selalu apnea setelah kejang
Perlu trakeostomi
Total Skor
Derajat Keparahan
<9
9 - 18
>18
Ringan
Sedang
Berat
Skor
1
2
3
4
5
1
2
3
4
5
1
2
4
8
10
0
2
4
8
10
6
Ablett Classification of Severity
Grade I (mild)
Mild trismus, general spasticity, no respiratory compromise, no
spasms, no dysphagia
Grade 2 (moderate)
Moderate trismus, rigidity, short spasms, mild dysphagia, moderate
respiratory involvement, ventilatory frequency > 30
Grade 3 (severe)
Severe trismus, generalized rigidity, prolonged spasms, severe
dysphagia, apnoeic spells, pulse > 120, ventilatory frequency > 40
Grade 4 (very severe)
Grade 3 with severe autonomic instability
7
Derajat Keparahan hendaknya tidak
dipakai sebagai pedoman “Kaku
Kaku”” untuk
indikasi rawat ICU
Indikasi Rawat ICU bilamana caracara-cara
konvensional yang dilakukan di ruang
perawatan tidak berhasil mengatasi kejang
/spasme atau pasien mengalami
gangguan pernafasan akibat kejang atau
aspirasi,, atau telah terjadi gagal nafas
aspirasi
atau gangguan sistem lain yang
memerlukan terapi supportif.
supportif.
8
Clinical diagnosis of tetanus
Secure Airway
Tracheostomy
Benzodiazepines2
Midazolam
Diazepam
Antitoxin2
HIG im/it
Equine antitoxin im
Manage autonomic dysfunction
2
Antibiotics2
Metronidazole
1
Magnesium
Inotropes
2
Benzodiazepines
Bupivacaine
2
Morphine
2
Clonidine
Consider
DVT Prophylaxis1
2
Control Muscle Spasms
Benzodiazepines2
Dantrolene1
NDNMBA’s1
Baclofen2
Magnesium2
Full primary course of immunisation1
Flow diagram showing the management of tetanus.
1—limited evidence; 2—some evidence; 3—good evidence.
9
Therapeutic Management
Immunization
Wound debridement
Antibiotics
Control muscle spasm
Control Autonomic Disturbance
Other supportive therapy
10
MANAGEMENT
1. Neutralize toxin outside of CNS
- Human Tetanus Immune Globulin
HTIG)) 150 units/kg IM or 5,000HTIG
5,00010,000 units IV
- ATS 500 UI/kgBB intramuscular.
11
MANAGEMENT
2.
Prevent further toxin release
- Early surgical debridement of
wounds
- Antibiotics : Metronidazole 500mg
8 hourly and Penicillin G 1 MU 66-8
hourly.
Heavily contaminated wound may
need additional antibiotics.
12
MANAGEMENT
3. Minimize the effects of toxin already
exists in CNS
- Control rigidity and spasm
- Respiratory support as necessary
- Control of autonomic dysfunction.
13
Drug used to control spasm and
autonomic disturbance
Benzodiazepine
Morphine
Muscle relaxant: vecuronium
vecuronium,, rocuronium
rocuronium,,
pancuronium
Magnesium sulfate
Dantrolen
Baclofen
Bupivacain,, atropine,
Bupivacain
14
Benzodiazepine
Common used as anticonvulsant in
tetanus.
Has sedative effect
Dose of Diazepam vary 100100-400 mg/24 h
max until 2400mg/24 h
Preservative used can cause acidosis in
large dose
No/little effect on autonomic disturbance
15
Magnesium Sulfate
- Pre synaptic neuromuscular blocker
- Blocks catecholamine release from nerve and
adrenal medulla
- Reduce receptor responsiveness to release
catecholamines
- It antagonizes calcium in myocardium and at
the neuromuscular junction
- Inhibits parathyroid hormone release
anticonvulsant-vasodilator
16
Dose
Adult : a loading dose of 5 gram over 20
minutes IV followed by 1g hourly
increasing to 2.5 gram hourly when
necessary. Titrate to symptoms
Pediatrics : 100mg /kg/24 hours, can be
increased when necessary. Titrate to
symptoms
Sometimes MgSO4 is inadequate to be used alone,
combination with benzodiazepine is also mandatory
17
Monitoring of possible side effects
- Patellar reflex
Diminished at the level of Magnesium >4 mmol
mmol/L
/L
- Respiratory depression because of muscle
paralysis (>Mg 6 mmol/L)
mmol/L)
- Bradyarrhythmia
Bradyarrhythmia,, hypotension
- Urine output
Low output causes drug accumulation
- Blood Calcium level, blood Magnesium level
should be checked regularly
- Overdose may cause sedation and anesthesia.
Day 4
Day 6
Magnesium can be a prospective
alternative for treatment of tetanus,
especially when there are mass
casualties since it reduces the need for
mechanical ventilation, however,
meticulous ICU monitoring is needed
with ready for use ventilator.
Gempa Yogyakarta
Others Drugs & Regiment
Obat pelemas otot (muscle relaxant)
intermittent bila diperlukan.
diperlukan.
Baclofen (beta – [4[4-chlorophenyl] gamma
amino butyric acid) sebagai P-GABA
receptor agonist, menghambat pelepasan
asetilkolin presinaps diotak,
diotak, diberikan
intrathekal
Propofol (1,6
(1,6--diisopropyl phenol) dapat
dipakai sebagai sedasi,
sedasi, dengan dosis
tritrasi..
tritrasi
22
Others Drugs & Regiment
Penghambat beta :
Propanolol,Labetolol,, Esmolol
Propanolol,Labetolol
Agonist alfaalfa-2 : Clonidine
Dexmedetomidine
Opioid kombinasi dengan sedative :
Morphine + midazolam atau diazepam
Sodium valproate
ACE Inhibitor
23
MANAGEMENT
Terapi supportif lainnya
Terapi fisik (fisioterapi) karena pasien
imobilisasi cukup lama.
Ventilasi mekanik
Metabolik : Nutrisi enteral , ditambah
parenteral bila perlu.
Penggunaan inotropik dan atau
vasopresor
Antikoagulan
24
3 major complications cause death
Ventilatory restriction leading to respiratory
complication and sepsis
Autonomic disturbance
Stress ulcer/gastric bleeding
25
DHF GR IIIIII-IV (DSS)
26
DF
DHF (Grades)
I
II
III
Febrile
Phase
(3-7 days)
Afebrile Phase
(Critical Stage)
Convalescent
Phase
RECOVERY
If Appropriate Treatment not provided, there is a high rist death
IV
Grading the Severity of Dengue Infection
DF/DHF
Grade*
DF
Symptoms
Laboratory
Fever with two or more of the
following signs : headache, retro –
orbital pain, myalgia, arthalgia
Leukopenia, Occasionally,
Thrombocytopenia, may be
present, no evidence of
plasma loss
DHF
I
Above signs plus positive Tourniquet
test
Thrombocytopenia, < 100,000,
Hct rise ≥ 20 %
DHF
II
Above signs plus spontaneous
bleeding
Thrombocytopenia, < 100,000,
Hct rise ≥ 20 %
DHF
III
Above signs plus circulatory failure
(weak pulse, hypotension,
restlessness)
Thrombocytopenia, < 100,000,
Hct rise ≥ 20 %
DHF
IV
Profound shock with undetectable
blood presure and pulse
Thrombocytopenia, < 100,000,
Hct rise ≥ 20 %
* DHF Grade III and IV are also called as Dengue Shock Syndrome (DSS)
Clinical Manifestation DSS
Increase of Vascular permeability :
Haemoconcentration,, Hypoalbuminemi,
Haemoconcentration
Hypoalbuminemi,
Hypoproteinemia,, Shock, Pleural
Hypoproteinemia
effusion
Thrombopathy
Hemorrhage
Coagulopathy
29
PENATALAKSANAAN
Afebrile phase
Manifestations
Duration two days
after febrile stage
In addition to the manifestations of
DHF Grade II :
– Circulatory failurse manifested by
rapid and weak pulse, narrowing
of pulse pressure (20 mmHg or
less) or Hypotension with the
presence of cold clammy skin
and restlessness
– Capillary relief time more than
two seconds
Profound shock with undetectable
pulse and blood pressure.
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 be
maintained up to 24 to 48 hours.
– If patients has already received one hour treatment of
20 ml/kg/hr of IV fluids and vital signs are not stable
check haematocrit again and
– If haematocrit is increasing change IV fluid to colloidal
solution preferably Dextran or plasma at 10 ml/kg/h
every hr.
– If haematocrit is increasing from initial value give fresh
whole blood transfusion, 10 ml/kg/h and continue fluid
therapy at 10 ml/kg/h and reducing it stepwise bring
down 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 one
or 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
Manifestation
Profound shock with undetectable
Pulse and blood pressure
Con Phase
Duration 2 – 3 days
After 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
- 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
Management
- Rest for 1 – 2 days
- Normal diet
- No need for medication
Fluid Therapy in DSS
The policy of initial fluid therapy in DSS
according to the Department of Health
and WHO until 2003 :
Crystalloid (Lactate Ringer), followed
with colloid (Dextran
(Dextran)) if not responded
32
Department of Health
Indonesian Intensive Care Association
Indonesian Anesthesiology Ass
Indonesian Paed.
Paed. Ass (2004)
Review on the management of DHF
Change the protocol
Include colloid MMWMMW-6% HES as alternative as
initial fluid resuscitation in DSS
33
Volume Replacement Therapy
Crystalloids
Colloids
Lactated Ringer's
Normal Saline
Albumin
PPL
Gelatin
solutions
Dextran
solutions
HES
solutions
34
Crystalloid (RL, RA, NaCL)
NaCL)
Distributed to the interstitial space
Very short period in the intravascular space
Need more fluid to maintain intravascular
volume risk for interstitial edema /
pulmonary edema
35
Colloid
– HES: ( MW 100.000100.000-300.000 kD ): Sealing
effect +, good intravascular volume effect,
longer duration in the intravascular space, ↑
DO2, ↑VO2
– Dextran : LMW colloid (40.000(40.000-70.000 kD
kD))
with good preservation volume effect, no
sealing effect,
effect, increase anaphylactic
reaction
36
Hydroxyethyl Starch (HES)
- Effective and safe plasma substitute
- HES broad range of MW, from very small until
several hundred thousand Dalton
- Classification of HES (by in vitro) according to
MW:
- HIGH MOLECULAR WEIGHT (HMW) → 450 K Da
- MEDIUM MOLECULAR WEIGHT (MMW) → 200 K Da
- LOW MOLECULAR WEIGHT (LMW) → 70 K Da
Sealing effect : HES with 100–
100–300.000 D MW
Effect of HES on Blood Coagulation
HMW--HES more effect on blood coagulation
HMW
(vWF,
vWF, factor VIII)
LMW (HES 70/0.5/4)/MMW(HES
70/0.5/4)/MMW(HES 200/0.5/6)
200/0.5/6) did
not affect on blood coagulation
Possible dilutional coagulation effect : PT, aPTT
(significant prolongation after HMWHMW-HES 480)
Fluid Resuscitation in DSS
Primary importance in the management
of hypoperfusion state
Goal of therapy
↑ Tissue DO2
↑ Blood Pressure
↑ VO2
Colloid
MMW
Reversing Lactic Acidosis
39
Study on DSS using colloid (HES )
as initial fluid resuscitation
Tatty E. Setiati
(2000)
Different
RESULT
Herminia L. Cifra
(2001)) H
(2001
Different
method of
study
40
RL group
Colloid group
(HAES Steril 6%)
7.9+/- 2.6
2.3 +/- 2
Ventilators days
8 +/- 1.1
4.0 +/- 0.71
Pleural effusion
30
_
Duration of
shock
( Hour)
M2/Mod7/S21
ALI /PaO2/FiO2=200-250
4
1
ARDS
6
2
PaO2/FiO2 < 200
Conclusion
Evidenced showed that endothelial dysfunction
lead to vascular leakage and hemostatic
disturbances occurred in DSS
MMW which has a sealing effect could
minimizing vascular leakage, good preservation
volume effect, and lowering mortality
MMW HES can be used as alternative for initial
fluid resuscitation in DSSS
DSSS
42
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.
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.
43
Signs of Recovery
Stable pulse, blood pressure and breathing rate
Normal temperature
No evidence of external or internal bleeding
Return of appetite
No vomiting
Good urinary output
Stable haematocrit
Convalescent confluent petechiae rash
44
SEVERE MALARIA
45
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 :
46
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
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)
47
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 diagnosis
48
WHO MULTICENTER STUDY ON SEVERE MALARIA IN UNDER
FIVES IN 10 AFRICAN COUNTRIES (1230 CASES, 1999 – 2000)
PREVALENCE OF SIGNS AND SYMPTOMS
SIGNS AND SYMPOMS
SEVERE ANEMIA
PROSTRATION
CONVULSIONS
CEREBRAL MALARIA
HYPOGLYCEMIA
HYPOGLOBINURIA
JAUNDICE
RESPIRATORY DISTRESS
DISSEMINATED INTRAVASCULAR
COAGULATION
NUMBER
666
371
279
218
162
41
21
12
1
%
54.1
30.2
22.7
17.7
13.2
3.3
1.7
1.0
0.08
49
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
before features of severe
disease develop
Commonly several days
Usually 1 – 2 days only
Jaundice
Common
Uncommon
Time from start of
treatment to resolution
of coma in cerebral malaria
Usually quinine 2 – 4 days
Usually 1 – 2 days
Hypoglycemia
Relatively uncommon
Usually quinine-induced
(especially in pregnancy)
Common
Pulmonary edema
Renal failure
Neurological sequelae
after cerebral malaria
Common
Common
Uncommon
Rare
Rare
Occur in about 10% of cases
Management
· Parenteral antimalarials.
· IV fluid administration.
· Vital signs monitoring every 4 hours.
· Blood check up for malaria parasite every
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.
51
Antimalarial drug doses in severe malaria
Hospital
ICU
Chloroquine-resistant
P falcipanum
Chloroquine – sensitive
P falcipanum
Quinine
Quinine dihydrochloride
7 mg salt/kg infused over
30 min followed by
Immediately 10 mg/kg
Over 4 h: or 20 mg salt/kg
Infused over 4 h
Maintenance dose: 10 mg
Salt/kg infused over 2-8 h
At 8 h intervals
Health Clinic :
No Intravenous
Infusion Possible
Quinine dihydrochloride
20 mg salt/kg diluted 1 : 2 with sterile
water given by split injection into both
anterior thighs. Maintenance dose : 10
mg/kg 8 hourly
Arteminisim derivative :
a) Artemether 3.2 mg/kg
Stat By im injection
Followed by 1.6 mg/kg
Daily
a) Artesunate 2.4 mg/kg stat
By iv injection followed by 1.2
mg/kg daily
As for Hospital ICU :
Artesunate can also be
Given by im injection
Chloroquine
Chloroquine 10 mg base/kg
Infused iv at constant rate over 8 hr
followed by 15 mg base/kg over 24 hr
Chloroquine 3.5 mg
Base kg 6-hourly or 2.5 mg
base/kg 4 hourly by im or sc injection.
Total dose 25 mg base/kg
Rural health clinic :
No injection facilities
Artesunate rectocap :
10 mg/kg daily
Artemisinin suppository
20 mg/kg at 0 and 4 h
Then daily
Chloroquine 10 mg/kg daily
Or nasogastric chloroquine as for
oral regimen
Poor prognostic features in
severe malaria
Clinical findings
Deep Coma
Repeated convulsions
Respiratory distress (rapid, deep, laboured, stertorous,
breathing often with intercostals recession)
Significant bleeding
Laboratory findings
Biochemistry
Hypoglycemia
Hyperlactatemia
Acidosis
Serum creatitine
Total bilirubin
Liver enzymes
Muscle enzymes
Urate
Hematology
Leucocytosis
Severe anemia
Coagulopathy
Parasitology
Hyperparasitemia
< 2.2 mmol/l
> 5 mmol/l
arterial pH<7.3 venous plasma HCO3 < 15 mmol/l
>265 µmol/l
> 50 µmol/l
SGOT (AST) x 3 upper limit of normal
SGPT (ALT) x 3 upper limit of normal
5 – Nucleotidase
CPK
Myoglobin
> 600 µmol/l
>12.999/µl
PCV < 15 %
Platelet < 50.000/µl
PT prolonged > 3 s
Prolonged PPT
Fibrinogen <200 mg/dl
> 100.000/µl
- increased mortality
> 500.00/µl
- high mortality
>20% of parasites are pigment – containing trophozoites and schizonts
>5% of neutrophils contain visible malaria pigment
55