MORNING CASE REPORT PEDIATRIC RESIDENCY PROGRAM – CHILD HEALTH DEPARTMENT MORNING CASE REPORT Thursday, March 03rd 2023 PATIENT IDENTITY • Name • Birthdate • Age • Sex • Address • Date of Admission • Referred from : DC : January, 06th 2010 : 13 years 2 months old : Boy : Jalan Kapten Naseh, No 3, Tasikmalaya : March 08th 2023 : Prasetya Bunda Hospital Referral Letter PATIENT`S PROFILE Assessment: Respiratory Distress Abnormal Normal Normal Level of Triage: Triage Level 3 Urgency MORNING CASE REPORT PPDS-1 ILMU KESEHATAN ANAK PRIMARY SURVEY Airway Airway Obstruction : No Breathing Respiratory Rate: 40 times/minute Subcostal Retraction (+), right VBS diminished at the level of ICS IV, pleural friction rub (-/-) crackles (+/+) Oxygen Saturation 90% room air, 97% O2 2 lpm nasal cannule Circulation Pulse rate 112 x/minute (regular, equal, adequate filling) Capillary Refill Time < 2 seconds Disability E4M6V5 ~ GCS 15 Exposure Temperature: 36,9 o C MORNING CASE REPORT PEDIATRIC RESIDENCY PROGRAM – CHILD HEALTH DEPARTMENT HISTORY TAKING Chief Complaint : Shortness of breath 6 weeks prior • Cough (+) • Visited General practitioner • Had given expectorant 1 month prior 2 weeks prior • Shortness of breath (+) • Cough (+) still persist • Fever (+) up and down • Shortness of breath (+) worsening • Cough (+) still persist • Fever (+) still persist • • • • Visited Pediatician Had given antipyretic drug Diagnosed as Tuberculosis Routinely consult every week Started Antituber culosis Drug Referred to Prasetya Bunda Hospital MORNING CASE REPORT PEDIATRIC RESIDENCY PROGRAM – CHILD HEALTH DEPARTMENT HISTORY TAKING 2 days prior • At Prasetya Bunda Hospital performed Chest X-Ray • Diagnosed as massive pleural effusion • Referred to thoracic surgeon 1 day prior Shortness of breath worsen Referred to Hasan Sadikin General Hospital Admission • Shortness of breath (+) worsen • Cough (+) still persist • Fever (+) still persist Admitted to Emergency Room Hasan Sadikin General Hospital (thoracic surgeon) Consulted to pediatric ER ADDITIONAL HISTORY TAKING • There was no history of hemoptysis, chest pain • There was a history of cough for more than 2 weeks • There was a history of decreasing body weight within the last 1 month, the patient had no change in appetite. • There is no history of previous contact to the TBC patient. • There is no history of similar symptoms in family or relatives. • There was no complaint of bluish around the mouth or tip of the fingers. • There was no exposure to cigarette smoke at home BIRTH HISTORY • Patient is the third child from P4A0 mother, term infant, spontaneously, by the midwife, the baby’s birth weight was 4000 grams. • The patient cry immediately after born and has no history of bluish around the mouth or fingers • During pregnancy, the mother had a routine check with the midwife and consumed multivitamins routinely. • There is no history of hypertension, bleeding, fever, or seizure during pregnancy. • Mother never had a TORCH panel examination during pregnancy. IMMUNIZATION HISTORY The patient had completed basic immunization. COVID-19 vaccination has been given twice NUTRITIONAL HISTORY Patient usually consumes family menu consist of rice, eggs, chicken or fish. Sometimes she eats vegetables and fruits DEVELOPMENTAL HISTORY The child’s development is appropriate for his age SOCIOECONOMIC STATUS • Father : 39 years-old, high school graduated, entrepreneur • Mother : 40 years-old, high school graduated, entrepreneur • Monthly income is Rp 8.000.000,• The patient lives in a permanent house with 3 other family members, the mother, and siblings. • The house has inadequate sunlight exposure but proper ventilation • Patient has not registered yet to the government insurance (BPJS) PEDIGREE MORNING CASE REPORT PEDIATRIC RESIDENCY PROGRAM – CHILD HEALTH DEPARTMENT PHYSICAL EXAMINATION General State Consciousness : Moderately ill : Compos mentis Vital Signs Blood Pressure Pulse Rate Respiratory Rate Temperature Oxygen Saturation : 110/70 mmHg : 112 x/minute, regular, equal, adequate filling : 40 x/minute : 36,9 o C : 90% room air, 97% Oksigen 2 lpm/nasal kanul ANTHROPOMETRICS • Body Height • Body Weight • MUAC : 148 cm : 28 kg : 15,5 cm • BMI for Age • Height for Age • MUAC for Age : -3,95 SD : -1,24 SD : severe wasting PHYSICAL EXAMINATION Head : Conjunctiva not anemic, sclera not icteric, perioral cyanosis (-), nasal flare (-) Neck: Multiple lymph nodes palpable, size 0,5-1 cm, mobile, supple, no tenderness, no redness MORNING CASE REPORT PEDIATRIC RESIDENCY PROGRAM – CHILD HEALTH DEPARTMENT PHYSICAL EXAMINATION Thorax: Front Back Inspection Assymmetrical movement Assymmetrical movement Percussion Dull percussion at right hemithorax at the level ICS IV, Sonor percussion at left hemithorax Dull percussion at right hemithorax at the level level ICS IV, Sonor percussion at left hemithorax Palpation Vocal fremitus decreased in right hemithorax (+) , normal in left hemothorax Vocal fremitus decreased in right hemithorax (+) Normal in left hemothorax Auscultation Vesicular Breath Sound decreased at ICS IV level Crackles (+/+), slem (-/-) Heart: S1S2 normal, no murmur, no gallop Vesicular Breath Sound decreased at ICS IV level Crackles (+/+), slem (-/-) MORNING CASE REPORT PEDIATRIC RESIDENCY PROGRAM – CHILD HEALTH DEPARTMENT PHYSICAL EXAMINATION Abdomen: Flat, soft, normal bowel sound The liver and spleen are not palpable Extremities: Warm, no edema, no acrocyanosis No BCG Scar Tanner Stage : G1P1 Lymph node : At regio inguinal and axilla: multiple lymph nodes palpable, size 0,5-1 cm, mobile, supple, no tenderness, no redness LABORATORY EXAMINATION Hasan Sadikin General Hospital March, 8th 2023 • Hemoglobin : 12,5 g/dL (13.0-16.0) • Hematocrite : 36,8 % (36.0-46.0) • Erythrocyte : 4,65 mil/uL (4.1-5.1) • Leukocyte : 11530 /mm3 (4500-13.000) • Thrombocyte : 511.000/mm3 (150.000-450.000) • MCV : 79.1 fl (78-108) • MCH : 26.9 pg (25-35) • MCHC • RDW- SD. • RDW-CV : 34.0 % : 39.2 fL : 14.0 % (31-37) (35.1–43.9) (11.5–14.5) • • • • • • • • • • • • CRP : 4,22 GDS : 76 LDH : 891 SGOT : 60 SGPT : 64 Protein total: 4.5 Albumin : 2,60 Globulin : 1,9 Ur/cr : 31,0/0,47 Anti HIV : Non reaktif AFP : no result -HCG : no result ( <0,3) (<140) (85-227) (15-37) (0-55) (6-8) (3,8-5,4) LABORATORY EXAMINATION Hasan Sadikin General Hospital March, 8th 2023 Differential Count (%) • Basophil • Eosinophil • Neutrophil band • Neutrophil segment • Lymphocyte • Monocyte • Total Neutrophil • Total Lymphocyte • Total Monocyte • Total Eosinophil • Total Basophil :0% : 0% :1% : 66 % : 21 % : 12 % : 7730 /uL. : 2420/uL : 1380/uL : 0/uL : 0/uL (0-1) (0-4) (3-5) (40-62) (27-40) (3-8) (2,110–8,890) (1260–3,350) (290–950) (0–40) (10–90) MORNING CASE REPORT PPDS-1 ILMU KESEHATAN ANAK Pleural Fluid Analysis • • • • • • • • • Hasan Sadikin General Hospital March, 8th 2023 serum LDH : 891 U/L (N: 81-234) Color : Red total serum protein : 4.5 g/dl (N: 6-8) Clarity : Cloudy : 2.6 g/dl (N: 3.8-5.4) LDH : 7500 U/L (N: <240) serum albumin Protein : 4500 mg/dl Glucose : 38 mg/dl Rivalta : Positive Cell count : 41189 cell/uL PMN : 60.8 % MN : 39.2 % MORNING CASE REPORT PEDIATRIC RESIDENCY PROGRAM – CHILD HEALTH DEPARTMENT Light Criteria • Ratio pleural fluid protein/ serum protein : 1000 • Ratio pleural fluid LDH/ serum LDH : 8.41 • Pleural fluid LDH : 7500 Pleural Fluid Gram Stain and Acid Fast Bacilli Smear Hasan Sadikin General Hospital March, 8th 2023 • • • • • • • • Gram positive rods Gram negative rods Gram positive coccus Gram negative coccus Leukocyte Epithel Yeast Acid fast bacilli : negative : negative : negative : negative : no result yet : no result yet : no result yet : negative MORNING CASE REPORT PEDIATRIC RESIDENCY PROGRAM – CHILD HEALTH DEPARTMENT Chest X-Ray (PA view) Hasan Sadikin General Hospital March, 8th 2023 Asymmetrical photo, adequate inspiration Visualized skeletal and soft tissue are within normal limits. Left deviation trachea. Cor is difficult to assess. The right heart border is covered by the consolidation. The right sinus and diaphragm are covered by consolidation. Left sinus and diaphragm are within normal limits Pulmo: - Right hilus is covered by consolidation. The left hilus is superposition to cardiac shadow - Bronchovasculer pattern partly normal - A homogeneous opaque sluble in the right upper to lower hemithorax that pushes the trachea and mediastinum to the left Conclusion: Massive right pleura effusion MORNING CASE REPORT PEDIATRIC RESIDENCY PROGRAM – CHILD HEALTH DEPARTMENT Chest X-Ray (PA view) Hasan Sadikin General Hospital March, 8th 2023 (post chest tube thoracotomy) Asymmetrical photo, inadequate inspiration Visualized skeletal and soft tissue are within normal limits. Trachea in the middle Cor is not enlarge The right sinus and diaphragm are covered by consolidation. Left sinus and diaphragm are within normal limits Pulmo: - Right hilus is covered by consolidation. The left hilus is within normal limit - Bronchovasculer pattern partly increase - A homogeneous opaque sluble in the right upper to lower hemithorax decreasing - A lucent avascular at right upper hemithorax Conclusion: Right pneumothorax Right pleural effusion improvement No cardiomegaly MORNING CASE REPORT PEDIATRIC RESIDENCY PROGRAM – CHILD HEALTH DEPARTMENT Differential Diagnosis 1. Bronchopneumonia + Right Pleural Effusion Post CTT insertion POD 2 due to Malignancy + Suspect Mediastinal Tumor (Lymphoma Dd/Thymoma/Dd, Germ Cell Carcinoma)+ Pulmonary Tuberculosis on OAT Week 4-5 + Marasmic 2. Bronchopneumonia + Right Pleural Effusion Post CTT insertion POD 2 due to Tuberculosis + Suspect Mediastinal Tumor (Lymphoma Dd/Thymoma/Dd, Germ Cell Carcinoma)+ Pulmonary Tuberculosis on OAT Week 4-5 + Marasmic 3. Bronchopneumonia + Right Pleural Effusion Post CTT insertion POD 2 due to Parapneumonia + Suspect Mediastinal Tumor (Lymphoma Dd/Thymoma/Dd, Germ Cell Carcinoma)+ Pulmonary Tuberculosis on OAT Week 4-5 + Marasmic MORNING CASE REPORT PEDIATRIC RESIDENCY PROGRAM – CHILD HEALTH DEPARTMENT Working Diagnosis Bronchopneumonia + Right Pleural Effusion Post CTT insertion POD 2 due to DD/ Malignancy, Tuberculosis, Parapneumonia + Suspect Mediastinal Tumor (Lymphoma Dd/Thymoma/Dd, Germ Cell Carcinoma)+ Pulmonary Tuberculosis on OAT week 4-5 + Marasmic MORNING CASE REPORT PEDIATRIC RESIDENCY PROGRAM – CHILD HEALTH DEPARTMENT MANAGEMENT • Tuberculosis isolation ward • Fluid requirement Holiday Segar 1660 ml/day • Caloric requirement RDA 60kcal/kgbw (severe malnourished) 1680 kcal/day, consist of regular meals 3 times/day • Oxygenation 2 lpm via nasal canule • Ceftriaxone 1 gram IV per 12 hours • Paracetamol 300 mg per 4-6 hours if t>38 C • Rifampicin 1 x 450 mg orally • Isoniniazid 1 x 300 mg orally • Piranzinamid 1 x 1000 mg orally • Ethambutol 1 x 600 mg orally • Prednison 5 mg 4-4-3 orally MORNING CASE REPORT PEDIATRIC RESIDENCY PROGRAM – CHILD HEALTH DEPARTMENT Suggestion Examination • Work up for tuberculosis (Mantoux Test, sputum rapid molecular test, sputum M. tb culture, sputum BTA) • cuPleural fluid culture, rapid molecular test • Pleural fluid histopathology • Blood culture • Chest CT-Scan with contrast • Contact investigation • FNAB from the lymph node a/r colli • ADA test MORNING CASE REPORT PEDIATRIC RESIDENCY PROGRAM – CHILD HEALTH DEPARTMENT PROGNOSIS • Quo ad vitam : dubia ad bonam (doubtful, tend to be good) • Quo ad functionam : dubia ad bonam (doubtful, tend to be good) • Quo ad sanationam : dubia ad bonam (doubtful, tend to be good) MORNING CASE REPORT PEDIATRIC RESIDENCY PROGRAM – CHILD HEALTH DEPARTMENT Follow Up 09/03/2023, 05.00 a.m S O A P : Shortness of breath decreased, cough still persist, no fever : Blood pressure: 90/60 mmHg, Heart rate : 112 x/mnt RR: 38 x/mnt, Temperature: 37.9 oC SpO2: 98% O2 1 lpm nasal canule : Bronchopneumonia + Right Pleural Effusion due to DD/ Malignancy (Lymphoma Dd/Thymoma/Dd, Germ Cell Carcinoma), Tuberculosis, Parapneumonia + Suspect mediastinal tumor+ Pulmonary Tuberculosis on OAT week 4-5 + Marasmic : Continue therapy Before MCR Diagnosis Bronchopneumonia + Right Pleural Effusion Post CTT insertion POD 2 due to DD/ Malignancy, Tuberculosis, Parapneumonia + Suspect Mediastinal Tumor (Lymphoma Dd/Thymoma/Dd, Germ Cell Carcinoma)+ Pulmonary Tuberculosis on OAT week 4-5 + Marasmic Suggested examination Work up for tuberculosis (Mantoux Test, sputum rapid molecular test, sputum M. tb culture, sputum BTA) Pleural fluid culture, rapid molecular test Pleural fluid histopathology Blood culture Chest CT-Scan with contrast Contact investigation FNAB from the lymph node a/r colli ADA Test Management Tuberculosis isolation ward Fluid requirement Holiday Segar 1660 ml/day Caloric requirement RDA 60kcal/kgbw (severe malnourished) 1680 kcal/day, consist of regular meals 3 times/day Oxygenation 2 lpm via nasal canule Ceftriaxone 1 gram IV per 12 hours Paracetamol 300 mg per 4-6 hours if t>38 C Rifampicin 1 x 450 mg orally Isoniniazid 1 x 300 mg orally Piranzinamid 1 x 1000 mg orally After MCR MORNING CASE REPORT PEDIATRIC RESIDENCY PROGRAM – CHILD HEALTH DEPARTMENT THANK YOU THANK YOU LAPORAN MCR SEBELUMNYA MCR 25 Februari 2023 An. M. Arvi, laki-laki, 3 tahun DPJP Utama: Divisi Alergi Immunologi s DPJP Pendamping: Infeksi dan Penyakit Tropis, Nutrisi dan Penyakit Metabolik, Hemato-Onkologi, Ortopedi Masuk RS: 24 Februari 2023 Lama perawatan: 13 hari Tempat Perawatan: Kenanga 1 Diagnosis Awal: Juvenile Idiopathic arthritis DD/ Septic arthritis + Demam Tifoid + Anemia ec infeksi dd/ defisiensi Fe + perawakan pendek Diagnosis Saat ini : Juvenile Idiopathic arthritis tipe oligoartritis DD/ tipe sistemik DD/ Septic arthritis + Demam Tifoid + Anemia ec infeksi dd/ defisiensi Fe + perawakan pendek Diagnosis Utama: Diagnosis Utama: Juvenile idiopathic arthritis (M08.00) Diagnosis Tambahan: • Septic Arthritis (M00.862) • Demam tifoid (A01.0) • Anemia ec infeksi (D64.9) • Perawakan pendek (R62.52) Tindakan yang telah diberikan: Pasien mendapat tatalaksana: - Pemeriksaan darah (90.5) - Kebutuhan cairan 850 ml/hari - Rontgen thorax (87.44) - Kebutuhan kalori RDA 850 kcal/hari - Rontgen Genu (405) - Ceftriaxone 1x550 mg IV (H12) - Pemasangan infus (99.18) - Ibuprofen 3x100 mg PO - Urinalisa (791) - Kultur darah (90.53) - Work up Tuberkulosis (V74.1) Pasien masih dirawat di Ruang Kenanga 1 MORNING CASE REPORT PEDIATRIC RESIDENCY PROGRAM – CHILD HEALTH DEPARTMENT TERIMA KASIH THANK YOU Konsulen On-call Konsulen On-site CR PICU NICU Senior Anthurium Senior Ruangan Junior Anthurium Junior Ruangan : dr. Aris Primadi, Sp.A(K) : dr. Erni Nuraeni. Sp.A : Bunga Nirwani : Diana Nubatonis : Indah Ceria Wiradiana : Mutiara Dewi : Namiroh Samiyah : Citra Saraswati Asep Munawir Sidik : Ismiana Fatimah Modjaningrat Rani Pramita TIM JAGA IGD Supervisor : Intan Leonita Junior IGD : Dyah Ayu Shinta Lesmanawati Fezia Tiffani Kartikaning Candra Ayesha Marcely KAPASITAS RUANGAN Anthurium Level 1 Alamanda HCU Anturium Non Infeksi HCU Anturium Infeksi Kenanga 1 Kenanga 2 HCU Asnawati NICU PICU Kemuning 3 Kemuning 4 Kemuning 5 RIK Parahyangan 3 RIIKK Transit IRI = Terisi 3 = Terisi 1 = Terisi 12 = Terisi 15 = Terisi 37 (Kapasitas 45) = Terisi 36 (Kapasitas 46) = Terisi 5 (Kapasitas 5) = Terisi 10 (Kapasitas 11) = Terisi 7 (Kapasitas 7) = 2 orang = 1 orang = 1 orang = 1 orang = 3 orang = 1 orang Pasien yang dioperkan oleh tim Jaga sebelumnya Pasien baru oleh tim jaga Pasien yang masuk ke ruangan oleh tim jaga Pasien yang dipulangkan oleh tim jaga Pasien dirujuk ke rumah sakit lain Pasien yang pulang atas permintaan sendiri Pasien yang meninggal Pasien konsul Pasien yang dioperkan ke divisi ERIA (termasuk rawat bersama) : 4 orang : 6 orang : 3 orang : 1 orang : 0 orang : 0 orang : 1 orang : 1 orang : 6 orang Pasien Baru 1. Fariz, laki-laki, 4 bulan DK/Diare Akut ec dd/ Disentriform; Non Disentriform Tanpa Dehidrasi 2. Nizmah, perempuan, 12 tahun 11 bulan DK/ Angiofibrosarcoma a/r mandibula sinistra + Ulkus a/r buccalis sinistra ec Massa Tumor Terinfeksi + Malnutrisi berat 3. Zoeya Mafaza, perempuan, 1 bulan DK/ Dehidrasi Ringan sedang ec chronic vomitus ec susp stenosis pylorus + Diare akut ec disentriform dd/ nondisentriform Pasien Baru 4.An. Faradisa Khanza, perempuan, 7 bulan Dk/ Kejang Demam Kompleks + Suspek ISK + DD/ PDA,VSD 5.An. Syahdan, Laki-laki, 9 tahun 11 bulan Dk/ Gagal Jantung Sedang+ Suspek Ebstein Anomaly + Suspek Cardiomyopathy Dilatasi+ Mild Pericardial Effusion + Perawakan Pendek 6.An. Darin, perempuan, 3 tahun DK/ Kejang demam sederhana + Gastroenteritis akut tanpa dehidrasi + Suspek Infeksi Saluran Kemih DAFTAR PASIEN YANG BELUM BISA MASUK RUANGAN 1. King Aarav, laki-laki, 4 bulan DK/ Bronkopneumonia e.c Pneumocytis jirovecii Pneumonia DD/CMV Pneumonia + Discarded COVID-19 + Presumtif HIV Infection + Suspek TBC Paru + Mikrosefali + Marasmus + Perawakan Sangat Pendek 2. Dika, laki-laki, 13 tahun DK/ Bronopneumonia + Efusi pleura dextra ec DD/ Keganasan (Lymphoma Dd/Thymoma/Dd, Germ Cell Carcinoma), TBC Paru, Parapneumonia + Suspek Tumor Mediastinum + TBC Paru pengobatan minggu 4-5 + Marasmus 3. Zoeya Mahfa, 1 bulan, cholestadid d DK/ Dehidrasi Ringan Sedang et causa Chronic Vomitus et causa Susp Stenosis Pylorus + Diare Akut et causa Disentriform DD/ Nondisentriform DAFTAR PASIEN YANG BELUM BISA MASUK RUANGAN 4.An. Faradisa Khanza, perempuan, 7 bulan Dk/ Kejang Demam Kompleks + Suspek ISK + DD/ PDA,VSD 5.An. Syahdan, Laki-laki, 9 tahun 11 bulan Dk/ Gagal Jantung Sedang+ Suspek Ebstein Anomaly + Suspek Cardiomyopathy Dilatasi+ Mild Pericardial Effusion + Perawakan Pendek 6.An. Darin, perempuan, 3 tahun DK/ Kejang demam sederhana + Gastroenteritis akut tanpa dehidrasi + Suspek Infeksi Saluran Kemih Pasien Observasi Tidak ada Pasien Meninggal 1. Hafiz Muhammad Altafarizki DK/ Respiratory Failure + Tekanan Tinggi Intrakranial + Status Epileptikus ec Perdarahan Intrakranial ec Gangguan Koagulasi + Dehidrasi Ringan Sedang ec Vomitus (Teratasi) + Low Intake + Infeksi Sitomegalovirus + Cholestasis Jaundice ec Ekstrahepatal ec Suspek Atresia Bilier DD/ Intrahepatal ec (1) Infeksi Sitomegalovirus (2) Kista Hepar + Elevated Liver Enzyme ec Underlying Disease + Anemia ec Underlying Disease + Mikrosefal + Malnutrisi Pasien Konsul Dika Candra, laki-laki, 13 tahun DK/ Efusi pleura dextra ec DD/ Keganasan, TBC Paru, Parapneumonia + Suspek Tumor Mediastinum + TBC Paru pengobatan minggu 4-5 + Marasmus Data Stagnansi Pasien Anak di IGD Anak Nama/Usia/Jenis Kelamin Dika Candra Laki-laki 13 tahun 2 bulan Zoeya Mafaza Perempuan 1 tahun King Aarav Laki-laki 4 bulan Diagnosis Tanggal Masuk RS Hari Perawatan di IGD Efusi pleura dextra ec DD/ Keganasan, TBC Paru, Parapneumonia + Suspek Tumor Mediastinum + TBC Paru pengobatan minggu 4-5 + Marasmus Dehidrasi Ringan sedang ec chronic vomitus ec susp stenosis pylorus + Diare akut ec disentriform dd/ nondisentriform 08/3/2023 2 hari 08/3/2023 2 hari Bronkopneumonia e.c Pneumocytis jirovecii Pneumonia DD/Cytomegalo virus Pneumonia + Discarded COVID-19 + Presumtif HIV Infection + Suspek TBC Paru + Mikrosefali + Marasmus + Perawakan Sangat Pendek 08/3/2023 2 hari Divisi Rawat Bersama Data Stagnansi Pasien Anak di IGD Anak Nama/Usia/Jenis Kelamin Diagnosis Tanggal Masuk RS Hari Perawatan di IGD Faradisa Khanza Perempuan 7 bulan Kejang Demam Kompleks + Suspek ISK + DD/ PDA,VSD 09/3/2023 1 hari Syahdan Laki-laki 11 bulan Gagal Jantung Sedang+ Suspek Ebstein Anomaly + Suspek Cardiomyopathy Dilatasi+ Mild Pericardial Effusion + Perawakan Pendek 09/3/2023 1 hari Darrin Perempuan 3 tahun Kejang demam sederhana + Gastroenteritis akut tanpa dehidrasi + Suspek Infeksi Saluran Kemih 09/3/2023 1 hari Divisi Rawat Bersama TERIMA KASIH • • • • • • • • • • Total pasien isolasi COVID di Gedung Kemuning : 0 pasien (terdiri dari 0 pasien dewasa, 0 pasien anak, 0 pasien neonatus) Pasien Anak dan Neonatus yang berada di Kemuning: 0 pasien Pasien Anak Confirmed: 0 pasien Pasien Anak Suspek : - pasien Pasien Anak Discarded: - pasien Pasien Anak Sembuh: - pasien Pasien Neonatus Suspek: - pasien Pasien Neonatus Confirmed: - pasien Pasien Neonatus Confirmed (sembuh): - pasien Pasien Neonatus discarded Covid-19: - pasien • • • • • • Total Pasien di ISO Covid IGD : 0 pasien Pasien anak dan neonatus confirmed : - pasien Pasien anak dan neonatus suspek : - pasien Pasien dewasa confirmed: - pasien Pasien dewasa suspek : - pasien Pasien dewasa probable: - pasien Acute Hepatitis of Unknown Origin Tidak ada GANGGUAN GINJAL AKUT PROGRESIF ATIPIKAL (GgGAPA) (ATYPICAL PROGRESSIVE ACUTE KIDNEY INJURY) Tidak ada TERIMA KASIH pneumonia DEFINISI : Infeksi akut pada jaringan paru (alveoli), ditandai dengan adanya napas cepat dan/atau tarikan dinding dada bagian bawah ke dalam (TDDK) Angka kematian tinggi pada balita Tahun 2018 : Insidensi 1.400 kasus per 100.000 anak per tahun. Angka kematian > 800.000 anak per tahun. Di Indonesia, pada tahun 2015, insidensi pneumonia pada balita adalah sebesar 63,45%. Provinsi yang memiliki temuan pneumonia tertinggi adalah Jawa Barat, Jawa Timur, DKI Jakarta, Banten, dan Nusa Tenggara Barat Scotta MC, Marostica P.J.C, Stein R. Pneumonia in children. Dalam: Wilmott R, Deterding R., Li A, Ratjen F, Siy P, Zar H.J., et al, editors. Kendig’s Disorder of the Respiratory Tract in Children. Ninth Ed. 2019. 25:427–38 CLASSIFICATION OF PNEUMONIA (WHO REVISION 2014) Pneumonia • Cough • Fast breathing • With/without chest wall retraction Severe Pneumonia • Pneumonia • With danger signs WHO. Revised WHO classification and treatment of childhood pneumonia at health facilities. 2014 Not able to drink Lethargic/ unconsciousness Persistent vomiting Stridor in calm child Convulsion Severe malnutrition WHO. Revised WHO classification and treatment of childhood pneumonia at health facilities. 2014 ETIOLOGI Pneumonia dapat disebabkan oleh bakteri, virus, jamur, dan parasit Streptococcus pneumoniae dan Haemophylus influenza merupakan penyebab tersering pneumonia pada balita Koinfeksi beberapa kuman sering terjadi (mencapai 75%) Scotta MC, Marostica P.J.C, Stein R. Pneumonia in children. Dalam: Wilmott R, Deterding R., Li A, Ratjen F, Siy P, Zar H.J., et al, editors. Kendig’s Disorder of the Respiratory Tract in Children. Ninth Ed. 2019. 25:427–38 ETIOLOGI Neonatus 1-6 bulan 6-12 bulan 1-5 tahun Virus Di atas 5 tahun Streptococcus grup B Virus Virus Virus Bakteri enterik gram Streptococcus pneuoniae Streptococcus pneuoniae Mycoplasma pneumoniae Mycoplasma pneumoniae Haemophylus influenza Haemophylus influenza Streptococcus pneuoniae Streptococcus pneuoniae Staphylococcus aureus Staphylococcus aureus Chlamydia pneumoniae Chlamydia pneumoniae Moraxella catarrhalis Moraxella catarrhalis negatif RSV Chlamidya trachomatis Ureaplasma urealyticum Bordetella pertusis Scotta MC, Marostica P.J.C, Stein R. Pneumonia in children. Dalam: Wilmott R, Deterding R., Li A, Ratjen F, Siy P, Zar H.J., et al, editors. Kendig’s Disorder of the Respiratory Tract in Children. Ninth Ed. 2019. 25:427–38 Penegakan diagnosis ANAMNESIS Saat pasien datang, tanyakan kepada orangtua : • berapa usia anak • apakah anak mengalami batuk atau kesulitan bernapas dan sejak kapan muncul keluhan tersebut • apakah anak bisa minum atau menetek • apakah anak pernah mengalami mengi dan apakah berulang • apakah anak demam dan sejak kapan muncul demam • apakah anak kejang • apakah anak merintih Kementerian Kesehatan Republik Indonesia. Tatalaksana Pneumonia Balita di Fasilitas Kesehatan Tingkat Pertama. Jakarta: Kementerian Kesehatan Republik Indonesia Direktorat Jenderal Pencegahan dan Pengendalian Penyakit; 2017. Penegakan diagnosis PEMERIKSAAN FISIK Dilakukan saat anak tenang, head to toe Lihat apakah ada napas cepat, sianosis, TDDK, head nodding, penurunan kesadaran, dan kejang Dengarkan apakah ada ronkhi, stridor, mengi, atau merintih. Kementerian Kesehatan Republik Indonesia. Tatalaksana Pneumonia Balita di Fasilitas Kesehatan Tingkat Pertama. Jakarta: Kementerian Kesehatan Republik Indonesia Direktorat Jenderal Pencegahan dan Pengendalian Penyakit; 2017. Usia Anak Frekuensi Napas Cepat < 2 bulan ≥ 60 kali/menit 2 bulan - < 12 bulan ≥ 50 kali/menit 12 bulan – 59 bulan ≥ 40 kali/menit Old Management Process Current Pneumonia Management (WHO revision 2014) WHO. Revised WHO classification and treatment of childhood pneumonia at health facilities. 2014 MANAGEMENT OF PNEUMONIA Pneumonia (cough, fast breathing, with/without chest wall retracton) First-line drug: Oral Amoxicillin Dosage: 40 mg/kgBB/dose; 2 doses/day (80 mg/kgBB/day) Duration: 5 days At area with lower HIV rate: 3 days Consider for referral or use the second-line treatment Fail to cure? (no improvement in 3-5 days) WHO. Revised WHO classification and treatment of childhood pneumonia at health facilities. 2014 MANAGEMENT OF PNEUMONIA The consideration in choosing management Comparison of efficacy of antibiotic: Amoxicillin/procaine penicillin >> kotrimoxazole Co-amoxiclav >> amoxicillin Oral Amoxicillin = Penicilin IV Penicilin + Gentamicin IV >> Chloramphenicole IV Pneumonia with chest wall retraction: Out-patient with oral amoxicillin is still safe Oral amoxicillin is as effective as Penicillin IV 1. WHO. Revised WHO classification and treatment of childhood pneumonia at health facilities. 2014 2. Kabra SK, Lodha R, Pandey RM. Antibiotics for community-acquired pneumonia in children. Cochrane Database of Systematic Reviews. 2010; (3): CD004874. Amoxicillin/penicilin procain >> kotrimoxazole Co-amoxiclav >> amoxicillin Amoxicillin oral = Penicilin IV Penicilin + Gentamicin IV >> Chloramphenicole IV MANAGEMENT OF PNEUMONIA The consideration in choosing management Comparison of efficacy based on duration: 3 days therapy = 5 days therapy 1. 2. WHO. Revised WHO classification and treatment of childhood pneumonia at health facilities. 2014 Haider BA, Saeed MA, Bhutta ZA. Short-course versus long-course antibiotic therapy for nonsevere community-acquired pneumonia in children aged 2 months to 59 months. Cochrane Database of Systematic Reviews. 2008; CD:005976 Antibiotic therapy 3 days therapy is as effective as 5 days therapy Management of pneumonia Amoxicillin is more effective in high dose AAP & AAFP Recommendation: Amoxicillin oral 75-100 mg/kgBB/day for CAP WHO (revised) recommendation (2014) : Pneumonia (including pneumonia with chest retraction): Amoxicillin 80 mg/kgBB/day; divided into 2 dosage; orally Amoxicillin 2x per day is as effective as 3-4x per day Lieberthal AS et al. The diagnosis and management of acute otitis media. American Academy of Pediatrics and American Academy of Family Physicians. Pediatrics. 2013; 131:e964–99. doi: 10.1542/ peds.2012–3488 . WHO. Revised WHO classification and treatment of childhood pneumonia at health facilities. 2014 Amoxicillin 2x per day is as effective as 3-4x per day MANAGEMENT FOR SEVERE PNEUMONIA Severe Pneumonia (cough, fast breathing, with/without chest wall retraction, with danger signs) First-line Therapy: Ampicillin/Penicillin + Gentamicin IV Dosage: Ampicillin 50 mg/kgBB OR benzyl penicillin 50.000 U/kgBB IM/IV every 6 hours (4x/day) for at least 5 days Gentamicin 7,5 mg/kgBB IM/IV 1x/day for at least 5 days Second-line Therapy: Ceftriaxone IV Fail to cure? (no improvement within 5 days) WHO. Revised WHO classification and treatment of childhood pneumonia at health facilities. 2014 MANAGEMENT OF PNEUMONIA Considerations in choosing the management: Ampicillin + Gentamicin or Ceftriaxone also recommended for severe pneumonia on patient with HIV infection 1. WHO. Revised WHO classification and treatment of childhood pneumonia at health facilities. 2014. 2. Punpanich W et al. Systematic review on the etiology and antibiotic treatment of pneumonia in human immunode ciency virus-infected children. Pediatric Infectious Diseases Journal. 2011; 30:e192– 202. doi:10.1097/INF.0b013e1822d989c Ampicillin + Gentamicin or Ceftriaxone is first line therapy for severe pneumonia on patient with HIV infection Klasifikasi pneumonia berdasarkan Integrated Management of Childhood Illness Penegakan diagnosis Jika ditemukan anak : • • • • • • • • • Tidak bisa minum Letargi Kejang Sianosis Stridor saat tenang Tangan dan kaki teraba dingin Head nodding Merintih Gizi buruk Sakit sangat berat Kementerian Kesehatan Republik Indonesia. Tatalaksana Pneumonia Balita di Fasilitas Kesehatan Tingkat Pertama. Jakarta: Kementerian Kesehatan Republik Indonesia Direktorat Jenderal Pencegahan dan Pengendalian Penyakit; 2017. Pemeriksaan penunjang Tidak ada pemeriksaan laboratorium khusus Leukosit, C reactive protein (CRP), dan procalcitonin biasanya meningkat pada pneumonia bakterial Gambaran radiologi : bervariasi (normalkelainan) Gambaran umum foto toraks : konsolidasi Scotta MC, Marostica P.J.C, Stein R. Pneumonia in children. Dalam: Wilmott R, Deterding R., Li A, Ratjen F, Siy P, Zar H.J., et al, editors. Kendig’s Disorder of the Respiratory Tract in Children. Ninth Ed. 2019. 25:427–38 TATALAKSANA PNEUMONIA Pneumonia yang tidak berat : Amoksisilin oral 80 mg/kg/hari dibagi dalam 2 dosis selama 5 hari Pneumonia berat - Ampisilin 50 mg/kg atau benzil penisilin 50.000 unit/kg secara intravena atau intramuskular selama minimal 5 hari - Gentamisin 7,5 mg/kg/hari secara intravena selama minimal 5 hari Jika terjadi kegagalan terapi, dapat diberikan antibiotik lini kedua, yaitu seftriakson Scotta MC, Marostica P.J.C, Stein R. Pneumonia in children. Dalam: Wilmott R, Deterding R., Li A, Ratjen F, Siy P, Zar H.J., et al, editors. Kendig’s Disorder of the Respiratory Tract in Children. Ninth Ed. 2019. 25:427–38 MANAGEMENT OF PNEUMONIA WHO. Revised WHO classification and treatment of childhood pneumonia at health facilities. 2014 Kriteria PulangKriteria Pulang • Perbaikan klinis • Tidak mengalami panas badan dalam 12-24 jam • Saturasi oksigen >90% dengan udara kamar dalam 12-24 jam • Kardirespiratori dan status mental dalam kondisi stabil • Dapat mentoleransi pengobatan per oral dan orang tua mampu merawat anak di rumah • Nafsu makan baik • Untuk anak yang terpasang chest tube sebelumnya, tube harus sudah terlepas 12-24 jam sebelum pulang Gereige,Rani S., Laufer,Pablo Marcelo. Pediatric in reviews: Pneumonia.2013:438-454 PERJALANAN PENYAKIT TBC MILIARY TB • TB suggestive chest x-ray • Positive tuberculin skin test Osteoarticular TB Adult type TB Lymphadenitis Reactive pleural effusion Marais et al. Tuberculosis in Children. 2014 Microbiology of community- and hospital-acquired pleural infection Manifestasi Klinis PARAPNEUMONIA ● ● ● ● ● ● ● ● ● ● ● ● Gejala klinis sama dengan pneumonia Demam tinggi menetap Batuk Dyspnea Nyeri dada akibat peradangan pleura, saat inspirasi atau batuk, dapat menjalar ke bahu atau perut Muntah Anoreksia Malaise dan letargi Berbaring miring pada sisi yang sakit Asimetris dengan ketertinggalan gerak Suara vesikular menurun Perkusi tumpul/redup ABSES PARU ● ● ● ● ● ● ● ● ● ● ● ● ● Demam Batuk Dyspnea Nyeri dada Muntah Anoreksia, mual, muntah Malaise dan letargi Asimetris dengan ketertinggalan gerak Localized reduction air entry Suara vesikular menurun Berkembang dengan lamban, seringkali lebih berbahaya Perkusi tumpul/redup Bisa ada crackles pada auskultasi dada PNEUMOTORAK • Nyeri dada (pada area • • • pneumothoraks) nyeri bersifat mendadak intens mulai dari bahu, biasanya hilang dalam 24 jam meskipun tanpa pengobatan dan tidak beresolusi Dispnea, takipnea, takikardia, sianosis Pemeriksaan fisik dada cembung, ketinggalan gerak, vokal fremitus menurun, hipersonor, vesikuler menurun pd bagian pneumothoraks Pada pneumothorax <15% dari luas hemithorax takikardi, pemeriksaan fisik normal Parapneumonia Fase 1 Fase 2 Fase 1 fase eksudatif/fase akut fase transisional/fibropurulen fase kronis atau organisasi Minggu 2 Minggu 1 Akumulasi cairan dan invasi bakteri melewati endotelium yang rusak mempercepat reaksi imun meningkatkan migrasi neutrofil, mengaktivasi kaskade koagulasi peningkatan prokoagulan dan menekan aktivitas fibrinolitik deposisi fibrin dan lokulasi cairan Terjadi inflamasi pleura meningkatkan permeabilitas pengumpulan cairan eksudat jumlah sedikit di kavum pleura ● Analisis cairan pleura : cairan serous atau keruh, LDH (<1000), lekosit rendah, glukosa (>40) dan pH (>7.20) dalam batas normal ● Efusi dapat kembali normal dengan antibiotik, tidak perlu kateter dada ● ● → dan steril ● ● pH cairan pleura dan konsentrasi glukosa menurun karena penggunaan glukosa secara anaerob oleh neutrofil dan bakteri. Lisis neutrofil meningkatkan konsentrasi laktat dehidrogenase ke nilai yang seringkali melebihi 1000 unit internasional/L. Minggu 3-4 Resorpsi cairan pleura dan proliferasi fibroblas perlengketan (entrapment) parenkim membran inelastik akan terbentuk terhambatnya pengembangan paru ● Pneumonia dengan komplikasi Efusi parapneum onik • Efusi pleura krn infeksi paru • Sederhana /simple, steril Efusi parapneumo nik terlokalisasi • Septasi di dlm efusi • Lokulasi disebabka n oleh akumulasi protein dalam cairan Empiema Adanya organisme bakteri pada pewarnaan Gram dan/atau cairan yang sangat purulen di rongga pleura Complicated parapneumonic effusion Radiologis Pleuro Pneumonia Rontgen Dada USG • Efusi parapneumonic: sudut kostofrenikus tumpul dan tanda meniskus. • Efusi besar white out yang lengkap, sehingga tidak bisa mengidentifikasi tingkat keterlibatan parenkim • Fase awal pneumonia nekrotikan: lesi kavitasi berisi cairan kepadatan = paru-paru terkonsolidasi yang berdekatan tidak bisa teridentifikasi pada Rontgen dada • Pencitraan utama yang digunakan untuk mengevaluasi rongga pleura • Dapat mendeteksi efusi pleura kecil/sedikit • Dapat memperkirakan ukuran efusi, • Deteksi Septasi yang fibrinous • Dapat membedakan efusi pleura dari konsolidasi paru, dan abses paru perifer dari empiema. • USG Doppler dapat mendeteksi perubahan nekrotik secara dini dan dapat menilai respons terhadap pengobatan CT Scan dengan Kontras • Pemeriksaan penunjang pilihan. • Dapat lebih mempelihatkan rongga dinding tebal berisi cairan. • Dapat membedakan abses dari empiema, necrotizing pneumonia, sequestration, pneumatocele, kelainan kongenital yang mendasari • Tes pilihan untuk memandu prosedur drainase invasif 1. Pabary et al. Complicated pneumonia in children. Breathe. 2013;9:211-22. 2. Scotta et al. Pneumonia in Children. Kendig’s Disorders of the Resp. Tract in Children. 9th ed. 2019 Rontgen Dada USG Small parapneumonic effusion Moderate – large parapneumonic effusion Suggested approach for CT chest interpretation • A full review of the patient's history and examination. • Check the patient characteristics match those of the patient to be reviewed. Previous imaging may be compared with the most recent scan to aid diagnosis. • Identify the orientation of the lung images on the film. The axial image is displayed as if you are looking at the patient from the feet end of the bed. Coronal and sagittal views can be reconstructed as long as the original slices are thin and contiguous (Fig. 5). • A systematic approach ensures that abnormalities are identified. Easily identifiable anatomical structures will allow the clinician to gain orientation. The ability to scroll through the imaging helps with dynamic assessment and anatomical differentiation. Zhai K, Lu Y, Shi HZ. Tuberculous pleural effusion. J Thorac Dis. 2016;8(7):E486E494. doi:10.21037/jtd.2016.05.87 Algoritme efusi pleura PENDEKATAN EFUSI PLEURA MODIFIED LIGHT CRITERIA PENDEKATAN EFUSI PLEURA CAIRAN PLEURA PENDEKATAN EFUSI PLEURA Hipoalbuminemia pada pasien TBC PENDEKATAN EFUSI PLEURA Pathogen microorganism in lungs Pneumonia is inflammation process in lungs Alveolus filled by fluid (normally by air) DEFINITION Lower Infiltrate oxygenation Death image on thorax imaging Clinical signs: fast breathing and lower chest wall retraction Scotta MC, et al. Pneumonia in Children. In: Wilmott R, et al., editors. Kendig’s Disorders of the Respiratory Tract in Children. 9th ed. Elsevier; 2018. p. 427–38. Who is Vulnerable Younger children and baby Immunocompromised children • Related to imperfect immune system • Malnutrition • HIV/AIDS • Coincidence with another infection/ diseases Environmental Factors • Highly polluted environment • Exposure to Cigarette smoke WHO. Pneumonia The Forgotten Killer of Children. 2006 DIAGNOSIS FOR PNEUMONIA Signs and Symptoms of Pneumonia Fast Breathing Cough Chest wall retraction ? Age Breathing frequency < 2 months > 60 times/minute 2 – 12 months > 50 times/minute 1 – 5 years > 40 times/minute WHO. Revised WHO classification and treatment of childhood pneumonia at health facilities. 2014 Classification of pneumonia (OLD) (children aged 2 months – 5 years old) Non-Pneumonia Pneumonia Severe Pneumonia Very severe Pneumonia • Cough and fever • No sign of pneumonia (no fast breathing) • Cough and fast breathing • Without chest wall retraction • Pneumonia • With chest wall retraction • Severe pneumonia • With danger sign WHO. Revised WHO classification and treatment of childhood pneumonia at health facilities. 2014 CLASSIFICATION OF PNEUMONIA (OLD VERSION) (FOR CHILDREN AGED 2 MONTHS – 5 YEARS OLD) UPDATED PNEUMONIA CLASSIFICATION WHO. Revised WHO classification and treatment of childhood pneumonia at health facilities. 2014 CLASSIFICATION OF PNEUMONIA (WHO REVISION 2014) Pneumonia • Cough • Fast breathing • With/without chest wall retraction Severe Pneumonia • Pneumonia • With danger signs WHO. Revised WHO classification and treatment of childhood pneumonia at health facilities. 2014 Not able to drink Lethargic/ unconsciousness Persistent vomiting Stridor in calm child Convulsion Severe malnutrition WHO. Revised WHO classification and treatment of childhood pneumonia at health facilities. 2014 MANAGEMENT OF PNEUMONIA Death in Pneumonia: due to severe pneumonia or comorbid diseases Management of pneumonia consist of: Early Identification Proper drugs administration Appropriate referral Availability of higher level management (at referral site) WHO. Revised WHO classification and treatment of childhood pneumonia at health facilities. 2014 Old Management Process Current Pneumonia Management (WHO revision 2014) WHO. Revised WHO classification and treatment of childhood pneumonia at health facilities. 2014 MANAGEMENT OF PNEUMONIA Pneumonia (cough, fast breathing, with/without chest wall retracton) First-line drug: Oral Amoxicillin Dosage: 40 mg/kgBB/dose; 2 doses/day (80 mg/kgBB/day) Duration: 5 days At area with lower HIV rate: 3 days Consider for referral or use the second-line treatment Fail to cure? (no improvement in 3-5 days) WHO. Revised WHO classification and treatment of childhood pneumonia at health facilities. 2014 MANAGEMENT OF PNEUMONIA The consideration in choosing management Comparison of efficacy of antibiotic: Amoxicillin/procaine penicillin >> kotrimoxazole Co-amoxiclav >> amoxicillin Oral Amoxicillin = Penicilin IV Penicilin + Gentamicin IV >> Chloramphenicole IV Pneumonia with chest wall retraction: Out-patient with oral amoxicillin is still safe Oral amoxicillin is as effective as Penicillin IV 1. WHO. Revised WHO classification and treatment of childhood pneumonia at health facilities. 2014 2. Kabra SK, Lodha R, Pandey RM. Antibiotics for community-acquired pneumonia in children. Cochrane Database of Systematic Reviews. 2010; (3): CD004874. Amoxicillin/penicilin procain >> kotrimoxazole Co-amoxiclav >> amoxicillin Amoxicillin oral = Penicilin IV Penicilin + Gentamicin IV >> Chloramphenicole IV MANAGEMENT OF PNEUMONIA The consideration in choosing management Comparison of efficacy based on duration: 3 days therapy = 5 days therapy 1. 2. WHO. Revised WHO classification and treatment of childhood pneumonia at health facilities. 2014 Haider BA, Saeed MA, Bhutta ZA. Short-course versus long-course antibiotic therapy for nonsevere community-acquired pneumonia in children aged 2 months to 59 months. Cochrane Database of Systematic Reviews. 2008; CD:005976 Antibiotic therapy 3 days therapy is as effective as 5 days therapy Management of pneumonia Amoxicillin is more effective in high dose AAP & AAFP Recommendation: Amoxicillin oral 75-100 mg/kgBB/day for CAP WHO (revised) recommendation (2014) : Pneumonia (including pneumonia with chest retraction): Amoxicillin 80 mg/kgBB/day; divided into 2 dosage; orally Amoxicillin 2x per day is as effective as 3-4x per day Lieberthal AS et al. The diagnosis and management of acute otitis media. American Academy of Pediatrics and American Academy of Family Physicians. Pediatrics. 2013; 131:e964–99. doi: 10.1542/ peds.2012–3488 . WHO. Revised WHO classification and treatment of childhood pneumonia at health facilities. 2014 Amoxicillin 2x per day is as effective as 3-4x per day MANAGEMENT FOR SEVERE PNEUMONIA Severe Pneumonia (cough, fast breathing, with/without chest wall retraction, with danger signs) First-line Therapy: Ampicillin/Penicillin + Gentamicin IV Dosage: Ampicillin 50 mg/kgBB OR benzyl penicillin 50.000 U/kgBB IM/IV every 6 hours (4x/day) for at least 5 days Gentamicin 7,5 mg/kgBB IM/IV 1x/day for at least 5 days Second-line Therapy: Ceftriaxone IV Fail to cure? (no improvement within 5 days) WHO. Revised WHO classification and treatment of childhood pneumonia at health facilities. 2014 MANAGEMENT OF PNEUMONIA Considerations in choosing the management: Ampicillin + Gentamicin or Ceftriaxone also recommended for severe pneumonia on patient with HIV infection 1. WHO. Revised WHO classification and treatment of childhood pneumonia at health facilities. 2014. 2. Punpanich W et al. Systematic review on the etiology and antibiotic treatment of pneumonia in human immunode ciency virus-infected children. Pediatric Infectious Diseases Journal. 2011; 30:e192– 202. doi:10.1097/INF.0b013e1822d989c Ampicillin + Gentamicin or Ceftriaxone is first line therapy for severe pneumonia on patient with HIV infection MANAGEMENT OF PNEUMONIA WHO. Revised WHO classification and treatment of childhood pneumonia at health facilities. 2014 Kriteria PulangKriteria Pulang • Perbaikan klinis • Tidak mengalami panas badan dalam 12-24 jam • Saturasi oksigen >90% dengan udara kamar dalam 12-24 jam • Kardirespiratori dan status mental dalam kondisi stabil • Dapat mentoleransi pengobatan per oral dan orang tua mampu merawat anak di rumah • Nafsu makan baik • Untuk anak yang terpasang chest tube sebelumnya, tube harus sudah terlepas 12-24 jam sebelum pulang Gereige,Rani S., Laufer,Pablo Marcelo. Pediatric in reviews: Pneumonia.2013:438-454 pneumonia DEFINISI : Infeksi akut pada jaringan paru (alveoli), ditandai dengan adanya napas cepat dan/atau tarikan dinding dada bagian bawah ke dalam (TDDK) Angka kematian tinggi pada balita Tahun 2018 : Insidensi 1.400 kasus per 100.000 anak per tahun. Angka kematian > 800.000 anak per tahun. Di Indonesia, pada tahun 2015, insidensi pneumonia pada balita adalah sebesar 63,45%. Provinsi yang memiliki temuan pneumonia tertinggi adalah Jawa Barat, Jawa Timur, DKI Jakarta, Banten, dan Nusa Tenggara Barat Scotta MC, Marostica P.J.C, Stein R. Pneumonia in children. Dalam: Wilmott R, Deterding R., Li A, Ratjen F, Siy P, Zar H.J., et al, editors. Kendig’s Disorder of the Respiratory Tract in Children. Ninth Ed. 2019. 25:427–38 ETIOLOGI Pneumonia dapat disebabkan oleh bakteri, virus, jamur, dan parasit Streptococcus pneumoniae dan Haemophylus influenza merupakan penyebab tersering pneumonia pada balita Koinfeksi beberapa kuman sering terjadi (mencapai 75%) Scotta MC, Marostica P.J.C, Stein R. Pneumonia in children. Dalam: Wilmott R, Deterding R., Li A, Ratjen F, Siy P, Zar H.J., et al, editors. Kendig’s Disorder of the Respiratory Tract in Children. Ninth Ed. 2019. 25:427–38 ETIOLOGI Neonatus 1-6 bulan 6-12 bulan 1-5 tahun Virus Di atas 5 tahun Streptococcus grup B Virus Virus Virus Bakteri enterik gram Streptococcus pneuoniae Streptococcus pneuoniae Mycoplasma pneumoniae Mycoplasma pneumoniae Haemophylus influenza Haemophylus influenza Streptococcus pneuoniae Streptococcus pneuoniae Staphylococcus aureus Staphylococcus aureus Chlamydia pneumoniae Chlamydia pneumoniae Moraxella catarrhalis Moraxella catarrhalis negatif RSV Chlamidya trachomatis Ureaplasma urealyticum Bordetella pertusis Scotta MC, Marostica P.J.C, Stein R. Pneumonia in children. Dalam: Wilmott R, Deterding R., Li A, Ratjen F, Siy P, Zar H.J., et al, editors. Kendig’s Disorder of the Respiratory Tract in Children. Ninth Ed. 2019. 25:427–38 Penegakan diagnosis ANAMNESIS Saat pasien datang, tanyakan kepada orangtua : • berapa usia anak • apakah anak mengalami batuk atau kesulitan bernapas dan sejak kapan muncul keluhan tersebut • apakah anak bisa minum atau menetek • apakah anak pernah mengalami mengi dan apakah berulang • apakah anak demam dan sejak kapan muncul demam • apakah anak kejang • apakah anak merintih Kementerian Kesehatan Republik Indonesia. Tatalaksana Pneumonia Balita di Fasilitas Kesehatan Tingkat Pertama. Jakarta: Kementerian Kesehatan Republik Indonesia Direktorat Jenderal Pencegahan dan Pengendalian Penyakit; 2017. Penegakan diagnosis PEMERIKSAAN FISIK Dilakukan saat anak tenang, head to toe Lihat apakah ada napas cepat, sianosis, TDDK, head nodding, penurunan kesadaran, dan kejang Dengarkan apakah ada ronkhi, stridor, mengi, atau merintih. Kementerian Kesehatan Republik Indonesia. Tatalaksana Pneumonia Balita di Fasilitas Kesehatan Tingkat Pertama. Jakarta: Kementerian Kesehatan Republik Indonesia Direktorat Jenderal Pencegahan dan Pengendalian Penyakit; 2017. Usia Anak Frekuensi Napas Cepat < 2 bulan ≥ 60 kali/menit 2 bulan - < 12 bulan ≥ 50 kali/menit 12 bulan – 59 bulan ≥ 40 kali/menit Klasifikasi pneumonia berdasarkan Integrated Management of Childhood Illness Klasifikasi pneumonia Revised WHO Penegakan diagnosis Jika ditemukan anak : • • • • • • • • • Tidak bisa minum Letargi Kejang Sianosis Stridor saat tenang Tangan dan kaki teraba dingin Head nodding Merintih Gizi buruk Sakit sangat berat Kementerian Kesehatan Republik Indonesia. Tatalaksana Pneumonia Balita di Fasilitas Kesehatan Tingkat Pertama. Jakarta: Kementerian Kesehatan Republik Indonesia Direktorat Jenderal Pencegahan dan Pengendalian Penyakit; 2017. Pemeriksaan penunjang Tidak ada pemeriksaan laboratorium khusus Leukosit, C reactive protein (CRP), dan procalcitonin biasanya meningkat pada pneumonia bakterial Gambaran radiologi : bervariasi (normalkelainan) Gambaran umum foto toraks : konsolidasi Scotta MC, Marostica P.J.C, Stein R. Pneumonia in children. Dalam: Wilmott R, Deterding R., Li A, Ratjen F, Siy P, Zar H.J., et al, editors. Kendig’s Disorder of the Respiratory Tract in Children. Ninth Ed. 2019. 25:427–38 TATALAKSANA PNEUMONIA Pneumonia yang tidak berat : Amoksisilin oral 80 mg/kg/hari dibagi dalam 2 dosis selama 5 hari Pneumonia berat - Ampisilin 50 mg/kg atau benzil penisilin 50.000 unit/kg secara intravena atau intramuskular selama minimal 5 hari - Gentamisin 7,5 mg/kg/hari secara intravena selama minimal 5 hari Jika terjadi kegagalan terapi, dapat diberikan antibiotik lini kedua, yaitu seftriakson Scotta MC, Marostica P.J.C, Stein R. Pneumonia in children. Dalam: Wilmott R, Deterding R., Li A, Ratjen F, Siy P, Zar H.J., et al, editors. Kendig’s Disorder of the Respiratory Tract in Children. Ninth Ed. 2019. 25:427–38 PNEUMONIA PADA COVID-19 COVID-19 pada anak : 4,7-7,6% dari seluruh kasus Di Indonesia : sekitar 7,76% Data kejadian pneumonia pada COVID-19 masih terbatas Dari penelitian, angka kejadian pneumonia pada COVID19 adalah sekitar 60%, sebagian besar gejala ringan Kementerian Kesehatan Republik Indonesia. Tatalaksana Pneumonia Balita di Fasilitas Kesehatan Tingkat Pertama. Jakarta: Kementerian Kesehatan Republik Indonesia Direktorat Jenderal Pencegahan dan Pengendalian Penyakit; 2017. World Health Organization. COVID-19 Weekly Epidemiological Update. World Health Organization. 2020 [online]. Tersedia dari: https://covid19.who.int/ KOINFEKSI PADA COVID-19 Infeksi virus kerusakan epitel saluran pernapasan Meningkatkan risiko terjadinya infiltrasi bakteri Pneumonia Massey B.W., Jayathilake K., Meltzer HY. Respiratory Microbial Co-Infection With SARS-CoV-2. Front. Microbiol. 2020. 11:2079. Morbiditas dan mortalitas meningkat Memicu reaksi imun berlebihan Massey et al koinfeksi pada COVID-19 adalah sebesar 86%. Patogen terbanyak adalah S. aureus, Epstein-Barr virus, Human Herpes Virus 6, M. Catarrhalis, dan K. Pneumonia GEJALA KLINIS COVID-19 Spektrum gejala klinis COVID-19 sangat luas Asimptomatik hingga gejala berat yang membutuhkan perawatan intensif Gejala yang sering adalah demam, batuk, sesak napas, nyeri menelan, nyeri kepala, diare, dan muntah Gejala COVID-19 menyerupai gejala pneumonia Secara klinis sulit dibedakan Guo Y, Xia W, Peng X, Shao J. Features discriminating COVID-19 from community-acquired pneumonia in pediatric patients. 2020 [online]. Front Pediatr. 8:602083. Tersedia dari: doi: 10.3389/fped.2020.602083 Pemeriksaan penunjang LABORATORIUM Pada kasus ringan tidak khas Pada kasus berat dapat terjadi peningkatan : Leukosit Trombositopenia terjadi Neutrofil pada 4% kasus LDH SGOT SGPT Bilirubin toral Meningkatkan risiko Kreatinin luaran yang buruk Cardiac troponin D-dimer Prothrombin time Procalcitonin C-reactive protein (CRP) PEMERIKSAAN RADIOLOGI CT scan toraks ground glass opacity Yu Guo et al. Kelainan radiologis terjadi pada 70% kasus, sebagian besar unilateral, pada lobus paru bawah. PEMERIKSAAN MIKROBIOLOGI Standar baku emas : PCR SARS-CoV-2 Wulandari D.A., Susanah S. Pemeriksaan penunjang pada COVID-19. Dalam : Nataprawira H.M.N., Garna H. (editor) Pandemi Coronavirus Disease-19 (COVID-19). Departemen /KSM Ilmu Kesehatan Anak Fakultas Kedokteran Universitas Padjadjaran. 2020. 121-52. Penapisan pneumonia pada covid-19 GEJALA PNEUMONIA • Rawat ruang isolasi • Periksa PCR SARSCoV-2 Suspek COVID-19 PCR SARS-CoV-2 (+) PCR SARS-CoV-2 (-) Confirmed COVID-19 Ulangi PCR dengan interval > 24 jam Positif Confirmed COVID-19 Negatif Discarded COVID-19 Burhan E., Susanto A.D., Isbaniah F., Nasution S.A., Ginanjar E., Pitoyo C.W., dkk., editor. Pedoman tatalaksana COVID-19. Edisi 3. Jakarta: Perhimpunan Dokter Paru Indonesia, Perhimpunan Dokter Spesialis Kardiovaskular Indonesia, Perhimpunan Dokter Spesialis Penyakit Dalam Indonesia. Perhimpunan Dokter Anestesiologi dan Terapi Intensif Indonesia, Ikatan Dokter Anak Indonesia; 2020. Klasifikasi berdasarkan gejala Tanpa gejala Pasien tidak memiliki gejala apa pun namun hasil PCR SARS-CoV-2 positif Ringan Pasien dengan adanya gejala, namun bukan gejala pneumonia virus atau hipoksia. Sedang Pada pasien remaja, gejala berupa demam, batuk, sesak, dan napas cepat dengan saturasi ≥ 93% pada udara ruang. Pada anak, gejala dapat berupa batuk atau sulit bernapas disertai napas cepat atau TDDK namun tidak ada tanda pneumonia berat atau tanda bahaya. Berat/pneumonia berat Pada pasien remaja, gejala berupa demam, batuk, sesak, dan napas cepat, ditambah satu dari : frekuensi napas > 30 kali/menit, distres napas berat, atau saturasi < 93% pada udara ruang. Pada anak, gejala berupa batuk atau kesulitan bernapas disertai salah satu dari tanda berikut : • Sianosis sentral atau saturasi < 93% • Distres napas berat (napas cepat, grunting, tarikan dinding dada yang sangat berat) • Tanda bahaya umum : ketidakmampuan minum/menyusu, letargi atau penurunan kesadaran, atau kejang. Kritis Pasien dengan acute respiratory distress syndrome (ARDS), sepsis atau syok sepsis Burhan E., Susanto A.D., Isbaniah F., Nasution S.A., Ginanjar E., Pitoyo C.W., dkk., editor. Pedoman tatalaksana COVID-19. Edisi 3. Jakarta: Perhimpunan Dokter Paru Indonesia, Perhimpunan Dokter Spesialis Kardiovaskular Indonesia, Perhimpunan Dokter Spesialis Penyakit Dalam Indonesia. Perhimpunan Dokter Anestesiologi dan Terapi Intensif Indonesia, Ikatan Dokter Anak Indonesia; 2020. TATALAKSANA PNEUMONIA PADA COVID-19 Tatalaksana Umum • Terapi oksigen • Asupan nutrisi dan cairan yang cukup • Isolasi di ruang tekanan negatif Tatalaksana Khusus Terapi antibiotik Antibiotik diberikan sesuai panduan WHO Pilih antibiotik yang pemberiannya jarang Oseltamivir: < 1 tahun : 3 mg/kg/dosis setiap 12 jam < 15 kg : 30 mg setiap 12 jam 12-23 kg : 45 mg tiap 12 jam 23-40 kg : 60 mg setiap 12 jam > 40 kg : 75 mg setiap 12 jam Lopinavir/ritonavir 14 hari- 6 bulan : 16 mg/kg/dosis 15-25 kg : 50-200 mg/kg/dosis 26-35 kg : 75-300 mg/kg/dosis > 35 kg : sesuai dosis dewasa Tetapi antivirus • Oseltamivir • Lopinavir/ritonavir • Remdesivir Burhan E., Susanto A.D., Isbaniah F., Nasution S.A., Ginanjar E., Pitoyo C.W., dkk., editor. Pedoman tatalaksana COVID-19. Edisi 3. Jakarta: Perhimpunan Dokter Paru Indonesia, Perhimpunan Dokter Spesialis Kardiovaskular Indonesia, Perhimpunan Dokter Spesialis Penyakit Dalam Indonesia. Perhimpunan Dokter Anestesiologi dan Terapi Intensif Indonesia, Ikatan Dokter Anak Indonesia; 2020. KRITERIA PULANG Secara Umum • Perbaikan klinis, termasuk bebas demam, aktivitas kembali normal, dan nafsu makan membaik, minimal 12-24 jam. • Saturasi oksigen dengan menggunakan pulse oximetry > 90% pada udara ruang minimal 12-24 jam. • Pasien dengan penurunan kesadaran telah kembali ke kesadaran awal. • Pasien yang terpasang chest tube, dapat dipulangkan 12-24 jam setelah selang dilepas tanpa adanya perburukan. • Orangtua pasien telah mengerti cara pemberian obat di rumah Pada COVID-19 Memenuhi kriteria selesai isolasi Bradley J.S., Byington C.L, Shah S.S., Alverson B., Carter E.R., Horrison C., et al. The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Disease Society and the Infectious Disease Society of America. Clin Infect Dis. 2011;53(7):e25–76. Manajemen Putus Obat IDSA Guideline 2016 MILIARY TB • TB suggestive chest x-ray • Positive tuberculin skin test Osteoarticular TB Adult type TB Lymphadenitis Reactive pleural effusion Marais et al. Tuberculosis in Children. 2014 Mantoux • Pemeriksaan atau uji tuberkulin dilakukan untuk mengidentifikasi seorang anak terinfeksi tuberkulosis atau adanya kontak dengan penderita tuberkulosis. Uji tuberkulin digunakan untuk menapis infeksi tuberkulosis atau digunakan untuk mendiagnosis tuberkulosis namun bersamaan dengan pemeriksaan diagnostik lain seperti pemeriksaan tes cepat molekuler dan resistensi rifampisin • Pemeriksaan ini diberikan secara intradermal dengan memberikan antigen mycobacterium yang dapat menimbulkan reaksi hipersensitivitas tipe IV • Larutan yang digunakan adalah 5 tuberculin units (TU) tuberculin PPD-S atau 2 TU tuberculin PPD RT 23 sebagai alternatif. Larutan diberikan sebanyak 0.1ml • Seorang anak yang tidak mengalami indurasi pada uji tuberkulin tidak menyingkirkan diagnosis tuberkulosis. • Uji tuberkulin dinilai positif pada: • 1. Anak dengan imunikompromais seperti HIV atau gizi buruk dengan indurasi &gt;5mm • 2. Anak dengan atau tanpa riwayat vaksin BCG dengan indurasi &gt;10mm • Pemeriksaan ini dapat menunjukkan false positive pada kondisi berikut: • 1. Kesalahan interpretasi uji tuberkulin • 2. Riwayat vaksin BCG • 3. Infeksi non-tuberculous mycobacterium • Pemeriksaan ini dapat menunjukkan false negative pada kondisi berikut: • 1. Kesalahan interpretasi atau kesalahan prosedur uji tuberkulin • 2. Penyimpanan larutan tuberkulin • 3. Malnutrisi berat • 4. Infeksi HIV • 5. Infeksi virus lain (campak), infeksi bakteri (tifoid) IGRA • Dilakukan melalui pemeriksaan darah untuk identifikasi adanya respon pada antigen Mycobacterium tuberculosis (Mtb) • Pada pemeriksaan IGRA diidentifikasi jumlah Interferon gamma yang dihasilkan sebegai responn sel T pada antigen Mtb • Pemeriksaan IGRA positif ditemukan pada anak dengan tuberkulosis laten yang diketahui dari tidak adanya temuan klinis sakit tuberkulosa, anak tinggal di daerah endemik atau tingginya pajanan tuberkulosa, namun hasil uji tuberkulin atau IGRA positif • Hasil positif pada IGRA tidak menunjukkan diagnosis tuberkulosis, sehingga bila hasil pemeriksaan IGRA negatif maka belum dapat disingkirkan diagnosa tuberkulosis. • Terdapat 2 jenis pemeriksaan darah untuk mengetahu infekesi tuberkulosa (IGRA) yaitu QuantiFERON®-TB dan T-SPOT®TB Criteria for Suspected MDR-TB • History of previous treatment within the past 6-12 months • Close contact with a person known to have MDR-TB, including household and school contacts • Close contact with a person who has died from TB, failed TB treatment, or is nonadherent to TB treatment • Failure to improve clinically after 2-3 months of first-line TB treatment, including persistence of positive smears or cultures, persistence of symptoms, and failure to gain weight 1. Kementrian Kesehatan Republik Indonesia. Petunjuk teknis manajemen dan tatalaksana TB anak. Jakarta: Kemkes RI; 2016. 2. Curry International Tuberculosis Center and California Departement of Public Health. Drug resistant tuberculosis: a survival guide for clinicians. 2016 3. Sentinel Project. Management of multidrug-resistant tuberculosis in children: a field guide. Edisi ketiga; 2016. 4. Mukherjee A, dkk, . Expert Opinion on Pharmacotherapy 2017:18(5);1595–1606. TB Classification based on M.tuberculosis drug sensitivity test Xpert MTB/RIF Sensitivity: 91.1% (100% in positive AFB and 71.4% negative AFB), with specificity: 98.9%, negative predictive value (NPV): 99.7%, dan positive predictive value (PPV): 100% Bila hasil TCM negatif dan kondisi anak stabil Gambaran rontgen toraks sugestif TBC 219 Reticulocyte Haemoglobin equivalent (RET-He) • • • • Diagnosis & monitor Anemia Defisiensi Fe Deteksi tercepat perubahan status Fe daripada Hb & indeks eritrosit Mengetahui ketersediaan suplai Fe untuk eritropoiesis saat ini Ret-He rendah: Zat Fe kurang/tidak tersedia utk eritropoiesis 220 • • • • • Sering digunakan bersama Ferritin untuk penilaian cadangan Fe Inflamasi: Ferritin meningkat cross-check dengan CRP Ret-He rendah & ferritin N/tinggi: defisiensi Fe fungsional Ret-He rendah & ferritin rendah: defisiensi Fe Monitoring terapi eritropoietin/Fe I.V: Ret-He meningkat terapi berhasil 221 • RDW besarnya variasi ukuran eritrosit, Normal = 13,2+0,9 RDW pada eritrosit anisositosis (ukuran eritrosit) menggambarkan proses eritropoiesis aktif 222 Klasifikasi Anemia Skrining Hb ↓ CBC: MCV- MCH Mikrositik, hipokromik Normositik, normokromik MCV < 80 fL MCV 80-95 fL MCH < 27 pg MCH ≥ 27 pg Anemia defisiensi besi Anemia hemolitik Thalassemia Anemia krn peny. kronis Anemia krn peny. kronis Anemia krn perdarahan Keracunan timbal Penyakit ginjal Anemia sideroblastik Defisiensi campuran Kegagalan sumsum tulang Makrositik Apus darah tepi Indeks retikulosit MCV > 95 fL Megaloblastik: defisiensi vitamin B12 atau folat Non-megaloblastik: alkohol, peny.hati, peny. hati mielodisplasia anemia aplastik • • • Lee SW, Kang YA, Yoon YS, Um S, Lee SM, Yoo C, et al. The prevalence and evolution of anemia associated with tuberculosis. J Korean Med Sci. 2006;21(12):1028–32. Wigati R, Windiastuti E, Hegar B. Using iron profiles to identify anemia of chronic disease in anemic children with tuberculosis. Paediatr Indones. 2011;51(4):217–22. Jude A, Donatus M. Anaemia of chronic disease : an in-depth review. Med Princ Pract. 2017;26:1–9 • • Jude A, Donatus M. Anaemia of chronic disease : an in-depth review. Med Princ Pract. 2017;26:1–9. Weiss G. Iron metabolism in the anemia of chronic disease. Biochim Biophys Acta. Elsevier B.V.; 2009;1790(7):682–93. Susanah S. Transfusi Darah Rasional Pada Anak, Aplikasi Klinis. 1st ed. Garna H, editor. Bandung: Badan Penerbit Ikatan Dokter Anak Indonesia Cabang Jawa Barat; 2019. Anemia: kadar hemoglobin hematokrit eritrosit Anemia (WHO): 6 bulan–< 6 tahun: <11 g/dL 6 tahun–12 tahun : <12 g/dL < normal sesuai usia Anemia Nilai hematologis bayi, anak, dan dewasa ____________________________________________________ Usia Hb (g/dL) Ht (%) Retikulosit MCV(fL) rerata rentang rerata rentang rerata nilai terrendah ________________________________________________________________________ Tali pusat 16,8 13,7-20,1 55 2 minggu 16,5 13,0-20,0 3 bulan 12,0 9,5-14,5 36 6 bln–6 thn 12,0 10,5-14,0 7–12 thn 13,0 11,0-16,0 45-65 50 31-41 37 38 5,0 42-66 1,0 33-42 34-40 110 1,0 1,0 1,0 70-74 76-80 Dewasa: Perempuan 14 12,0-16,0 42 37-47 1,6 80 Laki-laki 16 14,0-18,0 47 42-52 1,6 80 _________________________________________________________________________ • RDW besarnya variasi ukuran eritrosit, Normal = 13,2+0,9 RDW pada eritrosit anisositosis (ukuran eritrosit) menggambarkan proses eritropoiesis aktif 235 Klasifikasi Anemia Skrining Hb ↓ CBC: MCV- MCH Mikrositik, hipokromik Normositik, normokromik MCV < 80 fL MCV 80-95 fL MCH < 27 pg MCH ≥ 27 pg Anemia defisiensi besi Anemia hemolitik Thalassemia Anemia krn peny. kronis Anemia krn peny. kronis Anemia krn perdarahan Keracunan timbal Penyakit ginjal Anemia sideroblastik Defisiensi campuran Kegagalan sumsum tulang Makrositik Apus darah tepi Indeks retikulosit MCV > 95 fL Megaloblastik: defisiensi vitamin B12 atau folat Non-megaloblastik: alkohol, peny.hati, peny. hati mielodisplasia anemia aplastik Pendahuluan Definisi •Tindakan medis🡪memberikan oksigen dengan konsentrasi lebih tinggi dari konsentrasi oksigen di udara Indikasi, dosis dan cara pemberian yang tepat •Instruksi: kecepatan aliran, sistem pemberian dan pemantauan efek terapi Fisiologi Faktor-faktor yang berperan dalam oksigenasi yang adekuat: •FiO2 •Pertukaran udara pada alveoli •Kandungan oksigen dalam vena •Distribusi ventilasi-perfusi O2 ditranspor dari paru ke dalam jaringan tubuh O2 bergerak menuju ke daerah yang memiliki perbedaan tekanan, seperti: •Dari alveolar ke dalam darah •Dari darah arteri ke dalam jaringan tubuh •Ke dalam sel dan mitokondria Fisiologi Oksigen yang telah berdifusi ke dalam darah🡪dialirkan ke seluruh tubuh Hantaran oksigen= curah jantung (CO) x kandungan oksigen arteri Kandungan O2 dalam darah= O2 terlarut + O2 terikat Hb •Oksigen terlarut dalam plasma •PaO2 (mmHg) × 0,003 mL •Terikat dengan Hb •Hb × 1.34 × saturasi O2 Kurva Disassosiasi Hemoglobin Tujuan terapi oksigen Memberi oksigenasi ke dalam jaringan tubuh pada FiO2 yang terendah Mengatasi hipoksemia Menurunkan upaya nafas Mengurangi kerja miokardium Indikasi Hipoksemia •Bayi dan anak: PaO2 <60 mmHg atau SaO2 <90% (udara ruangan) •Neonatus: PaO2 <50 mmHg atau SaO2 <88% Keadaan akut yang dicurigai terjadi hipoksemia •Syok •Trauma berat Pedoman Klinik pedoman Klinik Pemberian Terapi Oksigen Panduan dosis awal pemberian oksigen: •Henti jantung dan napas •Hipoksemia , PaCO2 <40 mmHg •Hipoksemia , PaCO2 ≥40 mmHg FiO2 100% FiO2 40–60% FiO2 mulai 24% Alat pemberian oksigen Kanula nasal (aliran 0,5-6 l/m, FiO2 24-50%) Sungkup sederhana (aliran 6-10 l/m, FiO2 35-55%) Sungkup nonrebreathin g(aliran 6-10 l/m, FiO2 sampai 70%) Sungkup venturi (aliran 6-10 l/m, FiO2 24-50%) Sungkup nonrebreathing(aliran 610 l/m, FiO2 sampai 100%) Head box (aliran 10-15 l/m, FiO2 sampai 8090%) Kanula Nasal FiO2 sukar diukur dan bervariasi (fluktuatif) Dipengaruhi 3: •Volume anatomik reservoar •Aliran oksigen •Pola nafas penderita Perhitungan FiO2 yang dibutuhkan •FiO2 = Vol O2 inspirasi + Vol O2 reservoir + Vol O2ruangan • Vol tidal Sungkup Venturi ◻ Prinsip Kerja: oksigen aliran rendah dialirkan dengan cepat melalui pemancar ◻ Lubang-lubang pada sisi dalam tabung dan pemancar 🡪 menyebabkan udara masuk dengan kecepatan tinggi Perbedaan Sungkup Venturi dan Sungkup Sederhana Warna FiO2 (%) Aliran (Flow) O2 (L) Flow total Biru 24 4 105 Kuning 28 6 68 Putih 31 8 63 Hijau 35 10 56 Pink 40 12 50 Oranye 50 12 33 Pemantauan Terapi Oksigen Klinis: •Tingat kesadaran, frekuensi nafas, frekuensi jantung, tekanan darah, sirkulasi perifer, dan ada tidaknya sianosis Laboratoris: •Noninvasif: pulse oxymeter •Invasif: analisa gas darah Komplikasi terapi oksigen •Toksisitas seluler akibat hiperoksemia Penghentian Terapi Oksigen •Bila oksigenasi arteri adekuat dengan bernafas udara ruangan (PaO2 >60 mmHg, SaO2 >90%)