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 (normalkelainan)
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 (normalkelainan)
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%)