Pengenalan ICUZulkifli, dr., SpAn., MKesDepartement of Anesthesiology and ReanimationMedicine School, University of SriwijayaMohammad Hoesin Hospital Palembang 2008

PendahuluanScr potensial penyakit yg mengancam kehidupanMultidisiplin subspesialisKemampuan manajemen jalan napas, ventilasi mekanik, pemberian obat, resusitasi cairan dan monitoring.Pengetahuan fisiologi, patofisiologi dan farmakolgisertifikat

perawatdokterpasiensarana

Perawatan ICUMahal8-10 kapasitas bed total RSBiaya 20% dari biaya RSOutcome dipengaruhi :Berat penyakitCepat pulihStatus kesehatan sebelumnyaUmur

Ruangan ICULuasMempunyai penerangan tersendiri dan multipel outlet untuk elektrikOutlet untuk gas, O2, air dan suction perbedBedside monitor

Indikasi masukPaska operasi besar dan lamaOrgan disfungsiPaska henti jantungSyokIndikasi lain

Indikasi keluarSembuh/ membaikMeninggalMati batang otak, kecuali donor organMOF, sulit karena legal issues

Tindakan di ICUSupport th/ pemasangan invasifMengisi status keperawatan icuMengenal kegawatan pasien alat bantu : APACHE//GCSMencegah komplikasi di ICU - Kerusakan kulit dan mukosa - kerusakan muskuloskeletal - komplikasi paru

Terapi SuportifNeurologisHemodinamik/kardiovaskulerRespirasi/ pulmonerElektrolit dan metabolismeNutrisi

NeurologisCBF konstan autoregulasi pada MAP 50-130 mmHgInjuri autoregulasi tergangguPenilaian GCSFokus suportif :Optimalisasi CBF dan sisremik BFNormalisasi ICPCegah sekunder injuri

Perawatan Suportif Terapi umumVentilasi/airwayStabilitas hemodinamikKontrol kejang Kontrol ICPCegah spasmeCegah dan kontrol hipertermiaPosisi kepalaSteroid

Penilaian status CNSLesi GCSLab Scan

Cardiovaskuler/hemodinamikFaktor terpenting cardiac outputHR dan kontraktilitasVolume intravaskulerPreload AfterloadOksigen deliveri

CO = HR X SV

SV ditentukan oleh :Preload Echo PCWPAfterload SVRContratility Echo EF

Oxygen Delivery (D O2) D O2 = Ca O2 x C O x 10 = (Hb x 1.34 x Sa O2) + (PaO2 x 0,013) x C O x 10

Penatalaksanaan syokMeningkatkan CO :Terapi aritmiaPerbaikan preload, afterload dan cairanMemperbaiki kontraktilitas

Optimalisasi O2 delivery :HbPaO2

Terapi cairanInotropik dan vasopressor :DopaminDobutaminNorefinefrin dan efrinefrinMenurunkan kebutuhan O2

RespirasiPaling sering adalah Gagal napas akut (acute respiratory failure = ARF)2 tipe ARF :Type I Hypoxemic RF (PaO2 50mmHg) - with hypoxemic - without hypoxemic

Penyebab RFType I : mismatch ventilasi alveolar dan perfusi paruContoh :ALIEdema paru akutType II :Hipoventilasi alveolarContoh :Obstruksi jalan napasCNSPelemas otot

Manifestasi ARFARDS :Onset 12-72 jam setelah triggerRespiratory distressEdema paruPaO2 < 50 mmHgCPWP < 18 mmHgPaO2/FiO2 < 200 mmHg

Penanganan ARDSSuplemen O2Kanul nasalFace maskVentilasi mekanikfarmakologi

gangguan elektrolitPaling utama : Na+, K+, Ca++Potassium (3,5 5,5)HipoKalemia (K+ < 3,5)Penyebab : renal dan extra renalLoss Pergerakan traseluler Intake berkurangGejala : aritmia EKG abnormal ileus, dllTerapi : atasi penyebab, koreksi hipokalemia

HIPERKALEMIA (K+ >5,5mEq/L)Gejala : kelemahan otot dan jantungEKG : Gel T tinggi QT interval pendek

Th/ - Calcium - Glukosa + insulin - sodium biknat - Diuretik hemodialisa

HIPERNATREMIA ( Na+ >145 mEq/L )Penyebab : - Koma - Diuresis Diabetes insipidus - Keringat - Nasogastrik feeding hipertonik

Gejala : hiperrefleksi, letargi, kejang, koma

TH/ HipernatremiaWater & Na+ loss Water lossNa+ Ganti Cairan isotonisGanti defisit cairandiuretikGanti defisit cairanGanti defisit cairan

HIPONATREMIA ( Na+

HIPOCALCEMIA ( Ca++

HIPERCALCEMIA ( Ca++ >10,5mg/dL)Th/ - Rehidrasi + diuretik - calcitonin 2-8 U/kg - atau pamidronate 60-90 mg ivHIPERMAGNESIA ( Mg++ >2,1 mEq/L Th/ - stop intake magnesium - ca glukonas - diuretik + D5NS1/2

HIPOMAGNESIA (Mg++ 1,7 mEq/L)Th/ - Asimptomatis : magnesium oral/im - kejang : magnesium iv 1-2 g selama 15-60 mntHIPERFOSFATEMIA ( PO4 >4,5 mg/dL) Th/ antasidHipofosfatemia ( PO4 < 2,5 mg/dLTh/ - Potasium/sodium fosfat drip 6-12 jam

GANGGUAN METABOLIK Hyperglycemic Syndromes - Mengancam jiwa jika diikuti oleh :1. Diabetic Ketoacidosis (DKA) 2. Hyperglycemic Hyperosmolar Nonketotic Syndrome Clinical - Osmotic Diuresis Dehydration- Weakness- CNS Manifestation- Odor to the Breath

Terapi - Goal : - Memperbaiki keseimbangan cairan & Elektrolit - Insulin - Identifikasi Faktor pencetus - NS. 20 ml/ kg 1 jam pertama diikuti NS 0,5 % sbg maintenance - Insulin (route infusion) 5-10 IU diikuti dg 0,1 IU /kg/HR

NutrisiKebutuhan kalori protein, KH dan lipidProtein 4 kkalKH 4 kkalLipid 9 kkalPasien icu hipermetabolik kebutuhan nutrisi meningkat cenderung malnutrisi

Kebutuhan nutrisi selama stressKHMinimal 100 ghari untuk mencegah ketosisantara30%-40% total kaloriGlucose intake tidak boleh lebih 5 mg/kg/min Fat20%-35% total kaloriintravenous lipid infusion: 1.0 -1.5 g/kg/dayMonitor triglyceride level Protein1.2-2.0 g/kg/hari selama stress20%-30% total kalori selama stress

Nutrisi Enteral danParenteral Enteral NutritionOral supplementsTube feedingParenteral NutritionTotalPeripheral

Scoring di icu GCS :

EYE Spontaneous = 4 To Voice = 3 To Pain = 2 None = 1 Verbal Response Oriented = 5 Confused = 4 Inappropriate words = 3 Incomprehensible sounds = 2 None = 1 Motor Response Obeys commands = 6 Localizes pain = 5 Withdraws from pain = 4 Flexor posturing to pain = 3 Extensor posturing to pain = 2 None = 1

APACHE (Acute Physiology and Chronic Health Evaluation)Sistem klasifikasi untuk semua pasien icu2 komponen :Chronic health evaluation Acute Physiology Score

APACHE II(Acute Physiology And Chronic Health Evaluation)

Name of PatientMedical Rec. NoDate of ExamIntensivist

Temperature (C) Mean Arterial Pressure (mmHg) Heart RateRespiratory RateIf FIO2 >= 0,5 : (A-a) O2 If FIO2 < 0,5 : PaO2 If no A.B.Gs : Serum HCO3-(mmol/L) Arterial pH Serum Sodium (mmol/L) Serum Potassium (mmol/L) Serum Creatinine With Acute Renal FailureSerum Creatinine Without Acute Renal FailureHt (%) W.B.C (x103/ mm3 )Glasgow Coma Score Age Apache II Chronic Organ Insufficiency immuno-compromised

Predicted death rate Logit = -3,517+( Apache II) * 0,146 Predicted Death Rate

Delivery of appropriate substrates or macronutients is essential. Patients require at least 100g of glucose per day during metabolic stress to prevent ketosis. During hypermetabolic stress, a carbohydrate level of 30%-40% of total calories is recommended. Glucose intake should not exceed 5 mg/kg/min.

Barton RG. Nutr Clin Pract 1994;9:127-139. ASPEN Board of Directors. JPEN 2002;26 Suppl 1:22SA.Once nutritional requirements are established, the physician must determine the appropriate mode of nutrition therapy. In this course we have learned that early intervention with optimal nutrition therapy can have a significant impact on improved patient outcomes. We have focused primarily on enteral nutrition therapy, because it is the preferred method for nutritional support.As a general rule, IF THE GUT WORKS, USE IT!