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DAFTAR ISI
1. Types of Respiratory Failure ......................................................................... 1
2. Clinical Criteria for Respiratory Failure ........................................................ 1
3. Clinical Sequelae of Hypokalemia and Hyperkalemia ................................. 2
4. Glasgow Coma Scale (GCS) ........................................................................... 2
5. Tatalaksana Kasus Tersangka DBD................................................................ 3
6. Tatalaksana Kasus DBD dengan Hemokonsentrasi 20 % .......................... 4 7. Algoritme Syok Hipovolemik DBD Tanpa Penyulit ...................................... 5
8. Algoritme Syok Hipovolemik DBD Dengan Penyulit ................................... 6
9. Kadar Kreatinin Plasma (mg%) Anak Normal ............................................... 7
10.Kadar Ureum Plasma (mmol/L) Anak Normal .............................................. 8
11.Rekomendasi Masukan Nutrien Untuk Anak dengan GGK .......................... 8
13.Cara menghitung jumlah IWL ........................................................................ 9
14.Kebutuhan Protein untuk nutrisi Parenteral .................................................... 9
15.Kebutuhan Kalori Untuk Nutrisi Parenteral ................................................... 9
16.Keadaan Yang Meningkatkan Kebutuhan Kalori ........................................... 9
17.Patofisiologi Sindrom Hepatorenal ................................................................ 9
18.Definisi GGA, Oliguria, Anuria, poliuria, Azotemia .................................... 10
19.Glasgow Pittsburgh Coma Scale (GPCS) ..................................................... 10
20.Kriteria Gagal Multi Organ ............................................................................ 11
21.Kriteria Mati Batang Otak / MBO (IDI, 1987) . ............................................ 12
22.Cara Pemberian / Koreksi NaCl & KCL, Ca Ranitire .................................. 12
23.Cara Koreksi Albumin .................................................................................. 13
24.Patokan jumlah Minum Neonatus Sesuai Kebutuhan Cairan ....................... 14
25.Anion Cap ..................................................................................................... 14
26.Mean Arterial Pressure (MAP) ..................................................................... 14
27Respiratory Index (RI) .................................................................................... 14
28.Transferin Saturation .................................................................................... 15
29.Body Mass Index (BMI) ............................................................................... 15
30.Analisa Gas Darah (BGA) ............................................................................ 16
31.Sepsis & SIRS .............................................................................................. 18
32Sindrom Disfungsi Multi Organ (MOD) Primer & Sekunder ...................... 19
33.Kriteria Diagnosis Sindrom MOD Pediatrik ................................................. 19
34.Gradasi SRPS Pediatrik Menurut Fisher & Fanconi (1996) .......................... 20
35.Gradasi Disfungsi Organ Pediatrik ............................................................... 21
36.Syarat Pemberian Dopamin .......................................................................... 22
37.Septic Shock Syndrome ................................................................................ 22
38.Bangsal Bayi Risiko Tinggi (BBRT) ............................................................ 22
39.Enzim-Enzim Hati, Ratio / Quontient de Ritis, Ratio SGPT / GDLH ........... 24
40.Sindroma Nefrotik ........................................................................................ 25
41.Normogram Klirens Kreatinin ...................................................................... 27
42.Osmolaritas .................................................................................................... 18
43.Pembacaan X-Foto Torax ................................................................................
44.Types Of Respiratory Failure 45.Koreksi Dopamin, vaskon/epineprin, manitol.. 46.DD anemia
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Findings Causes Examples
Type I
Hipoxia
Decreased PaO2
Normal PaCO2
Ventilation / Perfusion
defect
Positional (supine In bed),
ARDS, atelectasis, pneumonia,
pulmonary embolus,
brochopulmonary dysplasia.
Diffusion impairment Pulmonary edema, ARDS,
Interstitial pneumonia.
Shunt Pulmonary arteriovenous
Malformation, congenital
Adenomatoid malformation
Type II
Hipoxia
Hypercapnia
Decreased PaCO2
Increased PaCO2
Hypovention Neuromuscular disease (polio,
Guillain-Barre syndrome),
head trauma, sedation, chest
wall dysfunction (burns),
kyphosis, severe reactive
airways.
Sumber : Current Pediatric Diagnosis & treatment, 12th
ed, 1995.
CLINICAL CRITERIA FOR RESPIRATORY FAILURE
Respiratory
Wheezing
Expiratory Grunting
Decreased or absent breath sounds
Flaring of alae nasi
Retractions of chest wall
Tachypnea, bradypnea, or apnea
Cyanosis Cerebral
Restlessness
Irritability
Headache
Confusion
Convulsions
Coma Cardiac
Bradycardia or excessive tachycardia
Hypotension or hypertension General
Fatigue
Sweating
Sumber : Current Pediatric Diagnosis & Treatment, 12th
ed,1995
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CLINICAL SEQUALAE
HYPOKALEMIA HYPERKALEMIA
Apathy, muscle weakness, paresthesias, tetany
Depressed T ware, U Wave;ST segment depression
Arrthytmias
Premature beats
Atrial or nodal tachycardia
Ventricular tachycardia or fibrilation
Ascending paralysis, occasional tetany and parethesias, muscle
weakness
Peaked T ware, proloanged PR interval, ST segment depression,
wide QRS complex
Arrhytmias
Sinus Bradycardia
Atrioventricular block
Indioventricular tachycardia or fibrilation
Cardiac arrest
Sumber : Current Pediatric Diagnosis & Treatment, 12th
ed,1995
GLASGOW COMA SCALE (GCS)
A. Buka Mata : - Spontan - Dengan Perintah - Dengan Rangsang nyeri - Tak ada respons
B. Respons Motorik : - Menurut perintah - Menunjuk lokasi nyeri - Withdrawal flexi - Flexi abnormal - Lextensi - Tak ada respons
C. Respons Verbal : - Orientasi baik - Disorientasi / bicara kacau - Kata-kata tak tersusun - Suara saja - Tak ada respons
4
3
2
1
6
5 4
3
2
1
5
4
3
2
1
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Osmolaritas = 8,218
Na) x (2BUNGDS
BUN = 13,2
2 PlasmaU
(N : 272 - 290)
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TATALAKSANA KASUS TERSANGKA DBD
Tersangka DBD
Demam tinggi,
mendadak, terus menerus
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TATALAKSANA KASUS DBD I & II TANPA PENINGKATAN HEMATOKRIT
Sumber : DHF, diangnosis treatment, prevention and control 2nd
ed, Geneva WHO, 1997
DBD I & II tanpa peningkatan Ht
Gejala klinis : demam 2-7 hari, RL (+) atau perdarahan spontan
Lab. : Ht tak meningkat, trombositopenia ringan
Pasien masih dapat minum
Beri minum banyak 1-2 L/hr atau 1 sdm tiap 5 menit
Jenis minuman : air putih, teh manis, sirup, susu, oralit, jus
Bila suhu > 38,5o C beri PCT
Bila kejang beri antikonvulsif
Monitor gejala klinis & lab
Perhatikan tanda syok
Palpasi hati tiap hari
Ukur diuresis tiap hari
Awasi perdarahan
Periksa Hb, Ht, Trombosit tiap
6-12 jam
Perbaikan klinis & lab
Pulang
(Lihat kriteria memulangkan pasien)
Pasien tidak dapat minum
Pasien muntah terus menerus
Pasang infus NaCl 0,9% : D5% (1:3), tetesan rumatan BB
Periksa Hb, Ht, Trombosit tiap
6-12 jam
Ht naik dan / trombosit turun
Infus ganti RL (jumlah tetesan
disesuaikan, lihat Tatalaksana
kasus DBD dengan peningkatan
Hematokrit)
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TATALAKSANA KASUS DBD DENGAN HEMOKONSENTRASI 20%
DBD I dengan hemokonsentrasi 20% Cairan awal
RL/NaCl 0,9% atau RLD5%
NaCl 0,9 + D5% : 6-7 ml/kbBB/jam
Monitor TV, Hb, Ht & trombosit tiap
6 jam
Perbaikan
Tidak gelisah
Nadi kuat
Tekanan darah stabil
Diuresis cukup (12 ml/kbBB/jam)
Ht turun (2x pemeriksaan)
Tak ada perbaikan
Gelisah
Distress pernafasan
Frekuensi nadi naik
Ht tetap tinggi/naik
Tek. Nadi < 20 mmHg
Diuresis kurang/tidak ada
Tetesan dikurangi
5 ml/kgBB/jam
Tanda vital
memburuk
Ht
Perbaikan
Tetesan dinaikkan
10-15 ml/kgBB/jam
(tetesan dinaikkan
bertahap)
Evaluasi 12-24 jam
Tanda vital tak stabil
Ht naik
Distress pernafasan Ht
Koloid
20-30 ml/kg
Tranfusi darah
segar 10 ml/kg
Perbaikan
Perbaikan
3 ml/kgBB/jam
IVFD stop pada 24-48 jam
Bila TV/Ht stabil & diuresis
cukup
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ALGORITME SYOK HIPOVOLEMIK DBD TANPA PENYULIT
Syok
Jalan nafas + O2
RL 20 ml/kg(6-10)
Perbaikan (+) Perbaikan (-)
Urine < 1ml/kg/jam
RL 20 ml/kg/10
RL 10
Ml/kg/10 Perbaikan (+) Perbaikan (-)
Urine > 1
ml/kg/jam
Urine < 1
ml/kg/jam
Urine < 1
ml/kg/jam
Anuria
Perbaikan (+)
Cairan pengganti
RL jumlah Ht
Cairan rumat
RL
20 ml/kg/10 Koloid
10 ml/kg/10
Perbaikan (-) Algoritme syok
hipovolemik DBD
dengan penyulit
CVP > 10 cmH2O CVP < 10 cmH2O
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ALGORITMESYOK HIPOVOLEMIK DBD DENGAN PENYULIT
PIM, KEBOCORAN HEBAT
Cvp < 10 cmH2O CVP > 10 cmH2O
CVP < 6 cmH2O CVP 6-10 cmH2) CVP > 10 cmH2
Koloid
4 ml/kg/10
Koloid
2 ml/kg/10
Koloid
1 ml/kg/10
Kalau perlu inotropik
vasodilator
Cari :
- Perdarahan - Sebab
hipovolemik lain CVP > 4
CVP 2 - 4
CVP < 4
Stop
Koloid 4 ml/kg/10
Koloid lain / kristaloid
Sesudah
Normovoilemik (+)
Inotropik, obat-obat lain
Perbaikan Gagal
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KADAR KREATIN PLASMA (MG%) ANAK NORMAL MENURUT UMUR & JENIS
KELAMIN
Umur
(tahun) Perempuan Laki-Laki
1 0,35 0,05 0,41 0,10
2 0,45 0,07 0,43 0,12
3 0,42 0,08 0,46 0,11
4 0,47 0,12 0,45 0,11
5 0,46 0,11 0,50 0,11
6 0,48 0,11 0,52 0,12
7 0,53 0,12 0,54 0,14
8 0,53 0,11 0,57 0,16
9 0,55 0,11 0,59 0,16
10 0,55 0,13 0,61 0,22
11 0,60 0,13 0,62 0,14
12 0,59 0,13 0,65 0,16
13 0,62 0,14 0,68 0,21
14 0,65 0,13 0,72 0,24
KADAR KREATIN PLASMA (MG%) ANAK NORMAL MENURUT UMUR & JENIS
KELAMIN
Umur
(tahun) Perempuan Laki-Laki
1 4,91 0,05 4,82 1,71
2 6,23 2,74 4,93 2,12
3 5,08 1,29 5,09 1,58
4 4,57 2,02 4,78 1,40
5 4,68 1,36 5,52 1,74
6 4,81 1,63 5,23 1,56
7 4,67 1,39 5,44 1,74
8 5,02 1,61 4,84 1,69
9 5,16 1,85 5,60 2,68
10 4,67 1,82 5,55 3,00
11 4,51 1,62 5,04 1,73
12 4,23 1,18 5,18 1,46
13 4,82 1,71 5,24 1,65
14 5,38 2,18 5,11 1,90
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REKOMENDASI MASUKAN NUTRIEN UNTUK ANAK DENGAN GAGAL GINJAL
KRONIK.
Umur
(tahun)
BB
(kg)
Energi
(kkal)
Protein
(g)
Ca
(mg)
P
(mg)
1-3 12,5 1230 14,5 350 270
4-6 17,8 1715 19,7 450 350
10-12 28,3 1970 28,3 550 450
11-14 () 43,0 2220 42,1 1000 775
11-14 () 43,8 1845 41,2 800 625
Sumber : Rigden, 1994
Cara menghitung jumlah Insesible Water Loss (IWL)
BB > 20 kg = 500 / 24 x jumlah jam (ml)
BB 2,5-20 kg = BB x 25/24 x jumlah jam (ml)
BB < 2,5 kg = BB x 50/24 x jumlah jam (ml)
KEBUTUHAN PROTEN UNTUK NUTRISI PARENTERAL PADA BAYI & ANAK
Kelompok Umur Asam Amino
(g/kgBB/hari)
Neonatus prematur
Bayi 0-1 tahun
Anak 2-13 tahun
Remaja
2,5-3,0
2,5
1,5-2,0
1,0-1,5
Sumber : Kerner JA, Parenteral Nutrition in Pediatriagl disease, 1996.
KEBUTUHAN KALORI UNTUK NUTRISI PARENTERAL
Umur
(Tahun)
Kebutuhan Kalori
( kkal/kgBB/hari)
0-1
1-7
7-12
12-18
90-120
75-90
60-75
30-60
Sumber : Kerner JA, Parenteral Nutrition in Pediatriagl disease, 1996.
KEADAAN YANG MENINGKATKAN KEBUTUHAN KALORI
Keadaan Peningkatan (%)
1. Demam 2. Gagal jantung 3. Operasi besar 4. Luka bakar 5. Sepsis berat 6. Gagal tumbuh 7. Malnutrisi berat
12% tiap kenaikan 1oC di atas 37
oC
15-25
20-30
Sampai 100
40-50
50-100
50-100
Sumber : IC Susanto, Pedoman nutrisi parenteral pada anak, Konika XI, 1999
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HUBUNGAN PATOFISIOLOGI ANTARA HATI & GINJAL PADA SINDROM
HEPATORENAL
Sumber : KorulaJ, Hepatorenal syndrome in : Liver and biliary disease, 1996.
GGA : Penurunan faal ginjal secara tiba-tiba disertai timbunan bahan metabolisme
nitrogen & gangguan imbang cairan elektrolit
Oliguria : - Urin pada anak < 300 ml/m2/24 jam (Arbus dkk, 1994).
- Urin pada neonatus < 0,5 ml/kgBB/24 jam (chevalier, 1994).
Anuria : Keluaran urin (-);
Arti luas : urin < 1 ml/kgBB/24 jam (arbus dkk,1994)
Poliuria (konteks GGA) :
Keluaran urin normal atau banyak (>2 ml/kgBB/24 jam) pada keadaan kadar
ureum / kreatinin meningkat secara tiba-tiba (Bock, 1992).
Azotemia : Penimbunan abnormal metabolit nitrogen dalam darah yang dinyatakan oleh
kadar ureum darah yang tinggi.
Uremia : kompleks gejala yang menunjukkan gangguan faal organ tubuh
karena ginjal gagal melakukan tugasnya (Arbus dkk, 1994).
HATI
Klirens hati
Volume efektif
Endotoksin ?
Lain-lain ?
ADH Protaglandin
ginjal Renin Outflow
Simpatetik
Klirens
Air bebas
Vasokonstriksi ginjal
Angiotensin Reabsorpsi
Aldosteron
Signal ?
GINJAL
Reabsorpsi tubuler
Na ?
?
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GLASGOW PITTSBURGH COMA SCALE (GPCS)
A. Buka Mata : Spontan Dengan perintah Dengan rangsang nyeri Tak ada respons
B. Respons Motorik : Menurut perintah Reaksi setempat/tunjuk lokasi Withdrawal reflex/flexi Flexi abnormal Extensi Tak ada respons
C. Respons Verbal : Orientasi baik Disorientasi / bicara kacau Kata-kata tak tersusun Suara saja Tak ada respons
D. Respons Pupil terhadap Cahaya : Normal Lambat Respons tak simetris Besar tak sama Tak ada sama
E. Reflex Saraf Otak Tertentu : Semua ada Reflex bulu mata (-) Reflex cornea (-) Dolls eye Reflex cranial (-)
F. Kejang : Tak ada Kejang fokal Umum, intermiten Umum, kontinyu Flaksid
G. Nafas Spontan : Normal Periodik Hiperventilasi sentral Irreguler / hipoventilasi Apnea
4
3
2
1
6
5
4
3
2
1
5
4
3
2
1
5
4
3
2
1
5
4
3
2
1
5
4
3
2
1
5
4
3
2
1
Total = A + B + C + D + E + F + G
Nilai Tertinggi = 35
Nilai terendah = 7
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KRITERIA GAGAL MULTI ORGAN
A. Kardivaskuler : HR < 54 x/menit MAP 49 mmHg Takikardi ventrikuler / fibrilasi ventrikel pH 7,24, PaO2 49
B. Respirasi : RR < atau > 49 x/menit PaCO2 50 mmHg AaDO2 350
C. Renal : Urine 479 cc/hari atau 159 cc/8jam BUN 100 mg/100 cc Kreatinin 3,5 mg/100 cc
D. Hematologi Lekosit 1000 Trombosit 20.000
E. SSP / Neurologi : GPCS 6, tanpa sedasi
F. Hepar Bilirubin > mg% PPT > 4 (dari kontrol)
KRITERIA MATI BATANG OTAK/MBO (IDI, 1987)
1. Hipotermia (t < 35oC) 2. GPCS < 3. Reflex batang otak :
- Pupil dilatasi maksimal - Reflex cahaya -/- - Reflex okulosefalik / Dolls eye (-) - Reflex corrtea -/- - Reflex muntah (-) - Reflex batuk (-)
4. Apnea 5. Tes atropin (-) 0,02 mg/kgBB (iv), nadi > 5x/menit 6. EEG isoelektrik/fid
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CARA PEMBERIAN NACL & KCL
Sediaan :
NaCl 5% (RSDK) 1cc = 0,855 mEq
KC: (RSDK) 1cc = 1,3 mEq
NaCl Otsuka 1cc = 1 mEq
KCL Otsuka 1cc = 1 mEq
Dosis maintenance Na / K : 2 mEq / kgBB / 24 jam 1. Preparat RSDK :
Keb.cairan
500x
0,855
BBx2Na
Keb.cairan
500x
1,3
BBx2K
2. Preparat Otsuka :
Keb.cairan
500xBB2xNa/K
Dosis koreksi Na (Indikasi : bila Na < 120 mEq/L) 1. Preparat RSDK :
)(0,855
0,6xBBxx)(120Na cc
2. Preparat Otsuka :
Na = (120 - x) X BB x 0,6 (cc)
Keterangan :
X : nilai Na Sekarang
Cara pemberian : - darah 6 jam - dalam 18 jam
Cara Koreksi Albumin
(gram)0,8xBBxAK
2x100
40xBBxAKAlb
Keterangan : AK = (Albumin yang diharapkan albumin sekarang) Contoh koreksi albumin :
Koreksi x gram
Misal koreksi dengan albumin 25%
= 100/25 X (x) gram = . Cc Plasma albumin 100 cc = 3,5 gram
PATOKAN JUMLAH MINUM NEONATUS SESUAI KEBUTUHAN CAIRAN
Umur (hari) Kebutuhan cairan
(cc/kgBB/hari) Umur (hari)
Kebutuhan cairan
(cc/kgBB/hari)
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1 2
3
4
5
6
7
80 90
100
110
125
135
150
8 9
10
11
12
13
14
155 160
165
175
185
195
200
Anion Gap
= (Na (Cl + HCO3))
Normal = 12 2
3
diastolik) x (2 Sistolik (MAP) Pressure ArterialMean
Normal = Umur (< 70 mmHg) 3 - 6 bulan mmHg 6 12 mmHg 1 4 mmHg 4 10 mmHg
2
2)(/Re
PaO
AaDOalvcolarshuntingNilaiRIxIndexspirator
Normal < 0,1
Transferin Saturation = %100xTIBC
SI
Normal anak = 16%
Bayi = 9 %
Dewasa = 30%
2)(
TB
BBBMIIndexMassBody
Normal = 16 25 (idealnya = 18) Gizi lebih = 25 30 Obesitas > 30
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rutin : warna, kekeruhan, reduksi, protein, sedimen
Faal ginjal berdasarkan normogram (kreatinin plasma & umur)
Faal ginjal normal klirens kreatinin (Kkr) 95 ml/menit/1,73 m3
B. Selama perawatan RS :
Harian : urin tampung 24 jam, imbang cairan, diuresis, BB & LP
2x / mgg (Senin & Kamis) : - urin rutin - Esbach (urin tampung 24 jam)
Mingguan : Ht, Ureum, kreatinin sampai nilainya normal
Bulanan : - Hb, Ho Lekosit, LED, hitung jenis. - Ureum, kreatinin - Total protein, albumin, globulin - Kolesterol
Perhitungan formula Y Pedoman perhitungan Pasien A (MPGN) Pasien B (SNKM)
Klinis Edemia, hematuria, C3 normal,
serum kreatinin 1,2mg%, serum
albumin 2,4mg%
Edema, hematuria, C3 normal,
serum kreatinin 0,8 mg%,
serum albumin 1,4 mg%
Edema
+ = (+ 0,2239)
- = 0
+ 0,2239 + 0,2239
Hematuria
+ = (-0, 0721)
- = 0
- 0,0721 - 0,00721
C3 (ic globulin)
Menurun = (- 0,6511)
Normal = 0
0 0
Serum kreatinin (mg%)
- ( . X 0,0990) - 0,1089 - 0,0792
Serum albumin (g%)
- (.. X 0,0580) - 0,1392 - 0,0812
Konstanta (+ 0,9295) + 0,9295 + 0,9295
Formula Y = 0,8332 0,9209
Formula Y 0,85 : MPGN (Membranoproliferatif glomerulonefritis) > 0,85 : SNKM (Sindroma nefrotik kelainan minimal)
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Normogram Faal Ginjal Anak
Untuk memprediksi klirens kreatinin (KKr) anak dengan faal ginjal campuran (normal dan
terganggu ringan sampai sedang) pada umur 24 168 tahun. (Lydia Kosnadi, Lab. IKA FK UNDIP, RSUP Dr. Kariadi, Semarang. 1996).
Cara mempergunakan :
Tentukan nilai kadar kreatinin plasma (PKr) pada garis di kiri dan nilai umur (bulan) pada
garis di kanan, selanjut tariklah garis melalui keduanya. Titik potong garis penghubung
dengan garis di tengah adalah nilai (KKr).
MANAGEMENT OF HYPERKALEMIA IN VLBW INFANTS
1. Maintenance fluids : 80 100 cc/kg/day DSW. If blood sugar is > 100 m%, begin regular insulin infusion in normal saline ( 20 units regular insulin in 100ml NS), 0,1
units/kg/hour (=0.5 cc/kg/hr). Titrate infusion rate to keep blood sugar 100-200 mg%.
2. Blood sugar should be monitored every hour until stable, then every two hours. If blood sugar > 200 mg%, or if serum potassium continues to rise, increase insulin infusion rate
by 0.05U/kg/hr (=0.25cc/kg/hr). if blood sugar falls to < 100 mg%, insulin infusion
should be stopped. Any changes in insulin infusion rate should be followed be a blood
sugar within one hour.
3. Additional treatment for hyperkalemia.
Sodium bicarbonate, 1-3 mEq/kg IV over 3-5 minutes;
Calcium gluconate (10%), 0.3-0.5 cc/kg IV over 2-5 minutes.
Note : calcium gluconate is not compatible with sodium bicarbonate
Algorithm for the Management of Hyperkalemia in Extremely Low Birthweight Infants
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HIGH FREQUNCY JET VENTILATION
Jet ventilation should be considered when there is a need for high frequency and oscillation is
contraindicated (listen in the preceding section), such aas in air leak or asymetric lung
disease. The jet ventilator can also be used for alvec recruitment by finding the Optimal PEEP.
Finding Optimal PEEP During High Frequency Jet Ventilation
(from Bunnell, Inc.)
Bagan :
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Commonly Used NICU Drugs
Note : refer to the red three-ring binder or the pharmacy references in the attending office for
more information.
INDEX
Acyclovir Chlorothiazide Gentamicin Metolazone Ranitidine
Ampicillin Dexamethasone HepatitisB Morphine Surfactant
Caffeine Enaiapril Indomethacin Pancuronium Spironolactone
Cefotaxime Erythomycin Lorazepam Phenobarbital Theophylline
Ceftriaxone Furosemide Metociopramide Phenytoin Vancomycin
Acyclovir
IV : 30-60 mg/kg/day q8h infuse over 60 minutes
Ampicillin
Body weight Age 0-7 days Age > 7 days
< 2000 gm 100-200 mg/kg/dayq12h 150-300 mg/kg/dayq8h
> 2000 gm 150-300 mg/kg/dayq8h 200-400 mg/kg/dayq6h
Maximum dose for meningitis is 100mg/kg/dose at recommended interval for age
Caffeine
UWMC compounds Caffeine citrate (20ng/mL), this is equal to caffeine base (10mg/mL)
IV or PO :
Loading dose 20mg/kg
Maintenance dose 5-7.5 mg/kg q24h
Therapeutic range (5-20mcg/mL) draw 2 hours after 3 rd maintenance dose, then on an as
needed basis
Cefotaxime
Age Dose Interval
0-7 days 100mg/kg/day q12h
> 7days 150mg/kg/day q8h
> 30 days 200mg/kg/day q6h
Ceftriaxone
Age Dose Interval
0-7 days 50mg/kg/day q24h
> 7days 100mg/kg/day q12h
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Clorothiazide
IV or PO : 20-40mg/kg/dayq12h
Dexamethasone
IV or PO : starting dose 0.5 mg/kg/dayq12h, then taper per 14,21 or 42 day protocol
Glucocorticoid Equlvaient
dose (mg)
Gluco
corticoid
potency
Mineralo
cortoid
potency
Plasma
t (min)
DOA
(hr)
Cortisone 25 0.8 2 30 8-12
Hydrocortisone 20 1 2 80-118 8-12
Prednisone 5 4 1 60 18-36
Prednisolone 5 4 1 115-212 18-36
Methylprednisolone 4 5 0 78-188 18-36
Dexamethasone 0.75 20-30 0 110-210 36-54
Betamethasone 0.6-0.75 20-30 0 300+ 36-54
Enalaprili
IV : 5-10 g/kg/dose given q8-24h PO : 0.05-0.1 mg/kg/dayq12-24h
Erythomycin
IV or PO :
Age/Weight Dose Interval
< 7 days 10/mg/kg q12h
> 7 days 10 mg/kg q8h
> 2000gm 10 mg/kg q6-8h
Furosemide
IV : 0.5-1 mg/kg
PO : 1-2 mg/kg
Gentamicin
2.5 mg/kg/dose q24h < =34 weeks and = 1250 gm
q12h > 34 weeks
Therapeutic range Peak : 6-12 g/mL Trough :
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Indomethacin
Prophylaxis
IV : 0.1 mg/kg/dose X4 doses (12,24,28 and 72 hours of age)
Treatment
Q12h X3 doses IV :
Age Dose #1 Dose #1 Dose #3
48 hrs 0.2mg/kg 0.1mg/kg 0.1mg/kg
2-7 days 0.2mg/kg 0.2mg/kg 0.2mg/kg
> 7days 0.2mg/kg 0.25mg/kg 0.25mg/kg
Lorazepam
IV or PO : 0.05-0.1mg/kg/dose q3-6h
Metoclopramide
IV or PO : 0.1mg/kg/dose q6h
Metolazone
PO : 0.2-0.4mg/kg/day Rarely used at doses
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Protocol for NAS (starting dose for consistant scores)
Administer orally q3h with feeds.
Finnegan Mg/kg/day mL/kg/day
8-10 0.32 0.8
11-13 0.48 1.2
14-16 0.64 1.6
>= 17 0.80 2.0
Pancurunium
IV : 0.1mg/kg q1-4h prn
Phenobarbital
IV or PO :
Loading dose -20 mg/kg
Maintenance dose 2.5-5mg/kg/dayq21h
Therapeutic range : (15-40 mcg/mL) draw 12 hrs after dose, then follow as needed
Phenytoin
IV:
Loading dose:20mg/kg (may into 2 doses q20min to decrease cardiotoxicity risk)
Maintenance dose : 5-8 mg/kg/dayq12h
Therapeutic range : (10-20 mcg/mL) draw levels 8-12hrs after dose
Ranitidine
IV: 2mg/kg/dayq12 max. dose : 5mg/kg/day (IV or PO)
Surfactant
Beractant (Survanta ); 4mL/kg per ETT q6h x 4 doses in 48 hours (=100mg
phosphollipid/kg)
Colfosceril (Exosurf ): 5mL/kg/ per ETT q12h x 3 doses in 48 hours (non formulary)
Spironolactone
PO: 1-3 mg/kg/dayq8h
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Theophylline
Please do not use aminophylline
IV or PO:
Loading dose : 4-6mg/kg
Maintenance dose : 3-6mg/kg/day q8h
Therapeutic range : (6-12mcg/mL) draw levels 2 hrs after dose
Weight/Age Dose Interval
2000 gm or > 31 days 30-45 mg/kg/day q12h
Therapeutic range
Peak : 30-40mcg/mL
Trough : 5-10mcg/mL
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COMMONLY USED DRUGS FOR INFANTS IN THE NICU
Antibiotic & Antifungals I Gentamicin Dosing Table
Bagan
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Gambar
Biochemistry of Billrubin
Flour configuration possible 4Z, I5E, 4E, 15Z & 4E, 15E
Water Insoluble due to Internal H-bonding
Phototherapy can change the configuration
Fetal/Neonatal vs. Adult Billirubin Metabolism
Production :
Daily production: 6-8 mg/kg (vs. 3-4mg/Kg)
RBC volume is high (High: 16-18 gm% vs. 12-14gm%)
RBC life span is shorter (90 days vs. 120 days)
Larger fraction of shunt billrubin (25% vs. 10%)
Transport & Hepatic Uptake:
Lower concertration of albumin
Lower affinity for billrubin
Competitive inhibition of binding sites (fatty adds, other, anions, antibiotics etc.)
Lower concertration of ligandins
Competitive inhibition of ligandins
Configuration of Excretion :
Lower concertration of transferase
Lower USPGA levels (less diglucuronides; more monoglucuronides formed0
Beyond first week, billiary excretion is the rate limiting step for billirubin clearance.
Glucuronyl Transferase Ontogency
First appears at 16 weeks
Between 17 & 30 weeks, the level is 0.1% adult, but functionally active
Between values reached between 6 to 14 weeks, independent of gestation
Inducrible phenobarb, phenytoin, billirubinm aspirin
Enterohepatic circulation
More monoglucuronides easily deconjugated
High levels of -glucuronidase in the lumen (detectable at weeks of gestation)
Absence of bacteria in the GIT less convension to urobillinoids
Large billrubin pool in the meconium (1gm contains 1mg of billrubin)
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Epidemiology of Neonatal Jaudice
Chemical hyperbiilrubinemia (> 2mg%) almost universal
Clinical jaundice (> 5mg%)
65% of fullterm, 80% of preterm
Exaggerated hyperbillirubinemia (> 12.8mg%)
4% Afro American
6-10 Caucasion
25% Asian (> 20mg in 2%)
Effect of Race
Highers incidence of hemoglobinopathies (e.g.Hgb E), enzyme deficiencies (G5PD)
? Genetic defect in conjugation
? Role of herbal medications
Higher incidence of breastfeeding
Higher -glucuronidase levels
Effect of type of Feeding
2/3 rd will have chemical jaundice for 2-3 wks
TSB > 12mg% in 12% (vs.4% formula fed)
Decreased billirubin clearance
Inborn errors of billirubin metabolism : Criggler-Najjar type I % II, Gilberts
Other inborn errors of metabolism, tyrosenemia, galactosemia.
Drugs and hormones: hypothyrolism, hypopituitarism
Pathological Causes of direct Hyperbillrubinemia
Hepatobillary Disorders
Billary Atresia-ideopathic, syndromic
Hepatitis: Ideopathic, TPN
Choledochal cyst
Severe hemolytic jaundice
Infections
Intrauterine (TORCH)
Extraturine, sepsis, UTI
Inborn Errors of Metabolism
Cystic fibrosis, galactosemia, Alpha-1 AT deficiency
Gambar
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Readmission differential Diagnosis of Jaundice
Diagnosis %
No cause / breast feeding 95
ABO hemolytic disease 3.5
Cephalohematoma 1
Anti E hemolysis 0.3 Galactosemia 0.3
Sepsis 0
Neurotoxicity of Billirubin
Billirubin encephalopathy vs. kernicterus
Higher risk with high serum billrubin levels and burder, but prediction is not absolute
Billrubin albumin binding, permeability of the blood brain barrier and pH are other variables
Risk higher with hemolytic jaundice (30%-50% of untreated), but also can occur with other conditions (10-15% in G6PD deficiency)
Has been reported in jaudice associated with breastfeeding, usually with high levels (~40mg%)
Re emergence of Kernicterus in Fullterm Infants
Since 1991, 42 cases have been reported
Some due to G6PD deficiency
Factors responsible:
Decreased physician concern about evaluation and treatment of jaundice in the breast fed infant
Early hospital discharge without adequate parental preparation or follow up
85% of the readmission (1-4% of early discharges; 109,000 infants annually) is because of jaundice
Predicting Billrubin Encephalopathy (criteria for treatment)
Total Serum Billrubin levels
Most commonly used in the US
AAP recommendation is solely based on this
Risk of Kernicterus high if TSB > 30 mg% (95% risk of death/permanent sequelae if > 35mg%) and risk low if < 20mg%
Phototherapy recommendation based on TSB levels :
VLBW : >12 mg%
LBW : >15mg%
Fullterm : >17-20mg%
Drawbacks of Using TSB level
Toxic effects may not be related to TSB level
No direct correlation between TSB levels and IQ/Neurotoxicity
Laboratory variations TSB estimation
Diurnal variation in TSB levels
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Surrogates for TSB
Extent of cutaneous icterus
Transcutaneous billrubinometry
Perspex jaundice meter
Drawbacks
Need experience
Not used in preterm, and dark skinned
Not useful after treatment Treatment
Fed on free Billrubin levels
safe free Billrubin levels :
13 nmol/L for < 1500 Gm
17 nmol/L for < 2500 Gm Prediction of Encephalopathy;
100% Sensitivity and 96% ( 0.5mg/hr ( 2ppm
On Neurophysiological Tests
Brain Stem Auditory Evoked Response
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Prolongation of latency of wave I, abnormal interpeak latencies, I-II and/or I-V, decreased amplitude of wave I, III, and V
Abnormalities correlate with free billrubin (no abnormality if < 17nmol/L), than with total billrubin levels
Reversible with exchange transfusion or with intense phototherapy
Magnetic Resonance Imaging and Spectroscopy
Most of the MRI finding have been described after the development of kernicterus
MRS findings have not been described in humans yet
Cry Analysis
Computer analysis of cry characteristics correlate with BAER findings
Still a research tool
Parmacologic
1. HO inhibitors
Macam- macam ANEMIA :
1. Anemia Normositik-Normokromik:
- anemia aplastik
- anemia pada penyakit kronis
- anemia hemolitik
2. Anemia Makrositik :
- anemia megaloblastik (def vit B12 dan asam folat)
- anemia anemia hemolitik (asam folat kurang)
- Down syndrome
- Chronic liver disease
3. Anemia Mikrositik Hipokromik :
- anemia def besi
- Thalasemia
- anemia sideroblastik
- anemia pada penyakit kronik
- keracunan
- def vit B6.
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