soal workshop periop course november 2013(revisi)
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8/11/2019 SOAL Workshop Periop Course November 2013(REVISI)
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Workshop Perioperative Surgery
BITDEC, Denpasar Bali , November 2013
Poerwadi
Lulik
Airlangga
PEDIATRIC SKILL STATION
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Kasus 1
Bayi 17 hari dikonsulkan anda dengan perut kembung
Kelainan apa saja yang saudara fikirkan ?
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KELAINAN APA SAJA YANG DIPIKIRKAN ??????
Perut kembung, bayi (17 hari )
➔Dapat terjadi akibat kelainan :•Obstruksi usus distal/ bawaan : -Mekonium ileus-Atresia yeyunoileal-Penyakit Hirschsprung
-Atresia kolorektal/ anus•Perforasi usus :-Gaster-NEC
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Kasus 1
Bayi 17 hari dikonsulkan anda dengan perut kembung
Bagaimana Anamnese selanjutnya ?
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• Riwayat persalinan?
• Sejak kapan ?
• Mekonium ( keluar? Kapan? ) • Panas badan?, gejala lain ?
• Muntah ? ( kwalitas, kwantitas, sifat)
• Sudah diberi minum?, kapan?, apa?
Anamnesa selanjutnya : • Spontan, BBL 2kg, ketuban krh, AS 5-7.
• Sejak 2 hari lalu
• Muntah , keruh, berbau, tdk menyemprt
• Meko keluar hari 1, sekrang feses drh lendir
• Sudah diberi ASI hr ke 1, pisang kerok hr ke 2
• Tdk panas, tdk mau minum sejak 2 hr, lemah.
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Kasus 1
Bayi 17 hari dikonsulkan anda dengan perut kembung
Bagaimana Pemeriksaan Fisik ?
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Data Pemeriksaan Fisik
Keadaan Umum
• Tampak lethargis
• Fontala cekung, Pucat, ikterus
• Mata cowong
• Mukosa kering
• Kulit sklerema
• Nadi Kecil, lemah
• Tanda Vital :
RR : 36 x/m, HR : 156x/m,
TD: 50/30 mmHg, t : 38,6OC
• Abdomen :
Distensi (++), v v ektasi, merah,krepitasi(-), BU (-), massa (-), caira bebas (-),pekak hati (+)
• Anus (+) ditempat, colok dubur : feses
merah bata & lendir.
LOOK
LISTEN
FEEL
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Derajat Dehidrasi Signs & Symptons Mild 3-5% Moderate 6-9% Severe > 10%
General Thirsty, restless,
alert
Drowsy
Drowsy, limp, cold,
mottled
Peripheral pulses
Normal
Rapid and weak
Rapid, thready
Breathing
Normal
Deep, rapid
Deep, rapid
Fontanelle Normal Sunken Very sunken
Capillary Refill < 2 Seconds Prolonged 3-4 sec
Very prolonged > 4
sec
Mucous membrane
Moist
Dry
Very dry
Blood Pressure Normal Normal Hypotension
38
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Tanda shock
Nadi cepat dan lemah
Capillary refill time > 2 detik
Perfusi dingin, basah, pucat
Nafas cepatGelisah / kesadaran menurun
Produksi urine
Hipotensi adalah tanda lambat
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Hal hal Spesifik pada bayi :
1.Jalan nafas : leher pendek, lubang trakea sempit, mudah terjadilaringospame dan edema dengan manipulasi minimal,
2.Pernafasan : FRC kecil , TV kecil , surfaktan rendah (premature)hypoventilasi, periodik apneu ancaman desaturasi.
3.Reflek batuk belum sempurna mudah Aspirasi
Metabolik/Respiratorik Asidosis
Muntah-aspirasi
Compartment syndrome
Gangguan kardiovaskuler
Reperfusion syndrome
GANGGUAN VENTILASI & OKSIGENASI
GAGAL NAFAS
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Pertanyaan 1 :
Apa diagnosis pasien ini ?
1. PENYAKIT HIRSCHSPRUNG2. PERITONITIS GENERALISATA
3. NECROTIZING ENTEROCOLITIS4. INVAGINASI
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Pertanyaan 2 :
Pemeriksaan Penunjang Apayang diperlukan untuk
menegakkan diagnosis
penyakit ini?
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Pertanyaan 2 :
Pemeriksaan Penunjang Apa yang dperlukan untuk menegakkan
diagnosis penyakit ini?
A. Chest X ray
C. Abd USG.
B. Abd X ray, labs ( CBC,CRP, elektr, DIC panel, blood gases ).
D. Abdominal parasentese.
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RADIOLOGICAL FINDINGS
• Pneumatosis Intestinalis
– hydrogen gas within the
bowel wall
• product of bacterial
metabolisma. linear streaking pattern
• more diagnostic
b. bubbly pattern
• appears like retainedmeconium
• less specific
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……. RADIOLOGICAL FINDINGS
Pneumoperitoneum – free air in the
peritoneal cavity
secondary to
perforation – falciform ligament may
be outlined
➔ “football” sign
SURGICAL EMERGENCY
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– neutropenia/
– elevated WBC – thrombocytopenia
Hasil Darah Lengkap
Hb : 6,3 g/dL
HCT : 23 % Leu : 15.000 cmm
Tro : 7.000 cmm
LED : 36 / 40
BT : 2’10” CT : 7’30”
BUN : 48
Creat : 5,6
Hasil Kimia Klinik
Analisa Gas Darah
pH : 7,20 pCO2 : 25 mmHg
pO2 : 70 mmHg
BE : -12
HCO3- : 8
SaO2 : 92%
CRP : 114
Na+ : 115 meq/L
K+ : 5,7 meq/L
Cl- : 88 Meq/L
LABORATORY FINDINGS
• Acidosis
– metabolic
• Hyperkalemia
– increased
secondary torelease from
necrotic tissue
Positive cultures blood
CSF
urine
stool
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Pertanyaan 3 :
Apakah PermasalahanUtama yang aktual pada
pasien ini ?
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Pertanyaan 3 :
Apakah Permasalahan Utama yang aktual pada pasien ini ?
A. Ileus obstruksi
B. Peritonitis
C. Sepsis, MOF.
D. Oligouria dan gagal ginjal akut
NEC problems :
The main problems are confirmed NEC and to treat it as an acuteabdomen with impending or septic peritonitis.➔ The goal ofmanagement are to prevent progression of disease, intestinalperforation, and shock.
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Pertanyaan 4 : Tentukan staging
pasien ini ?
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BELL STAGING CRITERIA
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Pertanyaan 5 :
Bagaimanapenatalaksanaan
perioperatif pasien ini ?
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Pertanyaan 5 :
Bagaimana penatalaksanaan perioperatif pasien ini ?
A. Puasa total, dekompresi (OGT,RT), rehidrasi, koreksi defisit
cairan/elektr/asodosis, komponen darah, TPN
B. Antibiotika (gram pos/neg/anaer), inotropic
D. Semua hal tersebut diatas.
C. Oksigenasi ( ET, respirator ), Serial foto abd & X ray.
Treatment Bell stage 2 are :
Medical : resussistation, stabilization, bowel decompression,TPN , oxygenation, Antibiotics, total fasting
Closed observation
Surgical : serial Xray stationer, pneumatosis intestinalis/ porta
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Management.
•The main principle of management for confirmedNEC is to treat it as an acute abdomen withimpending or septic peritonitis.
•The goal is to prevent progression of disease,intestinal perforation, and shock.
•If NEC occurs in epidemic clusters preventsabd distention, closed observation, supportive (ABC, nutrition, blood component correction ).
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– neutropenia/
– elevated WBC – thrombocytopenia
Hasil Darah Lengkap
Hb : 6,3 g/dL
HCT : 23 % Leu : 15.000 cmm
Tro : 7.000 cmm
LED : 36 / 40
BT : 2’10” CT : 7’30”
BUN : 48
Creat : 5,6
Hasil Kimia Klinik
Analisa Gas Darah
pH : 7,20 pCO2 : 25 mmHg
pO2 : 70 mmHg
BE : -12
HCO3- : 8
SaO2 : 92%
CRP : 114
Na+ : 115 meq/L
K+ : 5,7 meq/L
Cl- : 88 Meq/L
LABORATORY FINDINGS
• Acidosis
– metabolic
• Hyperkalemia
– increased
secondary torelease from
necrotic tissue
Positive cultures blood
CSF
urine
stool
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Respons Time
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Pertanyaan 6 :Bagaimana
melakukan rehidrasi
pada pasien ini ?
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Kebutuhan Cairan Perioperatif
1. Kebutuhan Rumatan (Maintenance)
2. Kebutuhan Pengganti (Replacement) : – defisit prabedah (preop deficit)
– defisit yang berjalan (ongoing losses)
Penatalaksanaan dehidrasi
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Penatalaksanaan dehidrasia. Estimasi Cairan Defisit
b. Rehidrasi
Dehidrasi 10%, 10 kg
ECD : 100 ml x 10 = 1000 ml
Penilaian kembali status klinis
membaik
8 jam pertama : 50% sisa cairan defisit
+ fluid maintenance
16 jam kedua : 50% rest fluid deficit
+ fluid maintenance
Tidak membaik
Ulangan : 20 ml/kg/20-30’
Nilai kembali
- Respiration
- Circulation
- Mental status
Choice of the fluid :
Rehydration : Isotonic crystalloid
Maintenance : Hypotonic crystalloid
Cairan pertama resusitasi : 20ml/kg (20-30’)
posisi shock, pasang infus jarum besar 2 buah
Contoh : seorang anak 10 kg, dinilai dehidrasi
berat dengan estimasi10%
49
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PRODUKSI URINE tiap J M
TLS
CS
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I. MAINTENANCE
1.Maintenance fluid and caloric requirements of neonate /newborn
Age
Day 1
Day 2
Day 3
Day 4
Day 5
Vol (mL/kg/day)
50 – 80
80 – 100
100 – 120
120 – 150
150
Energy (KCal/kg/day)
40 – 50
50 – 70
70 -90
90 – 110
110 – 120
Source: Holiday MA, Segar WE; The maintenance need
for water in parenteral fluid therapy padiatrics
MAINTENANCE
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2. Hourly and Daily Maintenance Fluid Requirementsof Children
MAINTENANCE......
Weight (kg)
<10
10-20
>20
Day
100mL/kg
1000mL + 50 mL/kg
1500 ml + 20 mL/kg
Hour
4mL/kg
40mL + 2 mL/kg
60 mL + 1 mL/kg
Maintenance fluid requirements
For example :a 25 kg child would required
1000 ml + 500 ml + 100 ml = 1600 ml
Holliday & Segar Method
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Pertanyaan 7 :
Kapan pasien
dilakukan operasi ?
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Pertanyaan 7 :
Kapan pasien dilakukan operasi ?
A.Ada indikasi bedah, Pasien stabil, terehidrasi baik, produksiurine (1-2 ml/kg/hari)
B. pH 7.3 -7.5 , HCO3- < 30 , Cl- >88 meq/L , K >3.2 meq/L
D. Semua di atas benar
C. Osmolaritas serum < 1.020
It is safe to perform the surgery when vital signs are stable, pH is between 7.3
and 7.5, hemoglobin is more than 10 gm, serum chloride is more than 88
mEq/L, bicarbonate is less than 30 mmol/L, potassium is more than 3.2 mEq/L,urine output is satisfactory (1-2 ml/kg/hr), and a specific gravity of the urine is
less than 1.020. Only after the infant has met the above criteria should
he or she be taken to the operating room.
SANDRA WEISS RIX, CRNA, CCRN, BA
San Diego, California
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Surgical treatment
Surgical Consult
– suspected or proven NEC – indications for surgery:
• clinical deterioration
– despite medical management• fixed intestinal loop on serial x-rays
• Pneumatosis intestinalis / portal;
pneumoperitoneum
• positive paracentesis
• Erythema / crepitus of abdominal wall
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