soal workshop periop course november 2013(revisi)

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



Kasus 1

Bayi 17 hari dikonsulkan anda dengan perut kembung

Kelainan apa saja yang saudara fikirkan ?



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



Kasus 1


Bagaimana Anamnese selanjutnya ?



• 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.



Kasus 1


Bagaimana Pemeriksaan Fisik ?



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



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



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



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



Pertanyaan 1 :

Apa diagnosis pasien ini ?

1. PENYAKIT HIRSCHSPRUNG2. PERITONITIS GENERALISATA

3. NECROTIZING ENTEROCOLITIS4. INVAGINASI



Pertanyaan 2 :

Pemeriksaan Penunjang Apayang diperlukan untuk

menegakkan diagnosis

penyakit ini?



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.



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



……. RADIOLOGICAL FINDINGS

Pneumoperitoneum – free air in the

peritoneal cavity

secondary to

perforation – falciform ligament may

be outlined

➔ “football” sign

SURGICAL EMERGENCY



– 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



Pertanyaan 3 :

Apakah PermasalahanUtama yang aktual pada

pasien ini ?



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.



Pertanyaan 4 : Tentukan staging

pasien ini ?



BELL STAGING CRITERIA



Pertanyaan 5 :

Bagaimanapenatalaksanaan

perioperatif pasien ini ?



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



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 ).



– 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



Respons Time



Pertanyaan 6 :Bagaimana

melakukan rehidrasi

pada pasien ini ?



Kebutuhan Cairan Perioperatif

1. Kebutuhan Rumatan (Maintenance)

2. Kebutuhan Pengganti (Replacement) : – defisit prabedah (preop deficit)

– defisit yang berjalan (ongoing losses)

Penatalaksanaan dehidrasi



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



PRODUKSI URINE tiap J M

TLS

CS



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



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



Pertanyaan 7 :

Kapan pasien

dilakukan operasi ?



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



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

soal workshop periop course november 2013(revisi)

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