PePnatalaksananenatalaksananintensifintensifpasienpasiendengandenganPenyakitPenyakitTropikTropikBeratBeratdidiICUICUDr.Dr .DadikDadik WahyuWahyu WijayaWijaya SpAnSpAn DepartemenDepartemen AnestesiologiAnestesiologi && ReanimasiReanimasi // InstalasiInstalasi PelayananPelayanan IntensifIntensif (ICU)(ICU) FKFK--USU/RSUPUSU / RSUP H.AdamH.Adam MalikMalik --MedanMedan 11 PePnatalaksananenatalaksananintensifintensifpasienpasiendengandenganPenyakitPenyakitTropikTropikBeratBeratdidiICUICUDr.Dr .DadikDadik WahyuWahyu WijayaWijaya SpAnSpAn DepartemenDepartemen AnestesiologiAnestesiologi && ReanimasiReanimasi // InstalasiInstalasi PelayananPelayanan IntensifIntensif (ICU)(ICU) FKFK--USU/RSUPUSU / RSUP H.AdamH.Adam MalikMalik --MedanMedan 11 InIdikasindikasi UmumUmum PasienPasien dirawatdirawat didi ICUICU BerdasarkanBerdasarkan PrioritasPrioritas BerdasarkanBerdasarkan DiagnosisDiagnosis BerdasarkanBerdasarkan NilaiNilai--nilainilai ParameterParameter HasilHasil LaboratoriumLaboratorium 22 InIdikasindikasi UmumUmum PasienPasien dirawatdirawat didi ICUICU BerdasarkanBerdasarkan PrioritasPrioritas BerdasarkanBerdasarkan DiagnosisDiagnosis BerdasarkanBerdasarkan NilaiNilai--nilainilai ParameterParameter HasilHasil LaboratoriumLaboratorium 22 PePnyakitenyakit TropikTropik BeratBerat (yang(yang seringsering didi ICU:ICU : TetanusTetanus BeratBerat (SevereTetanus)(Severe Tetanus)()( ) DHFGradeIIIDHF Grade III--IV(DSS)IV (DSS) MalariaMalaria BeratBerat (SevereMalaria)(Severe Malaria) 33 PePnyakitenyakit TropikTropik BeratBerat (yang(yang seringsering didi ICU:ICU : TetanusTetanus BeratBerat (SevereTetanus)(Severe Tetanus)()( ) DHFGradeIIIDHF Grade III--IV(DSS)IV (DSS) MalariaMalaria BeratBerat (SevereMalaria)(Severe Malaria) 33 TETANUSBERATTETANUS BERATTETANUSBERATTETANUS BERAT 44 TETANUSBERATTETANUS BERATTETANUSBERATTETANUS BERAT 44 DeDrajaterajat KeparahanKeparahan (SeverityGrading(Severity Grading)) PhilipsPhilips DkD kDakarDakar UdwadiaUdwadia GambaranGambaran KlinisKlinis AblettAblett BlectBlect 55 DeDrajaterajat KeparahanKeparahan (SeverityGrading(Severity Grading)) PhilipsPhilips DkD kDakarDakar UdwadiaUdwadia GambaranGambaran KlinisKlinis AblettAblett BlectBlect 55 PhScorePjeparahan < 9 Ringan 18 Sedang >18 atBerilipshilips Score Waktu Masuk Skor Selama Perawatan Skor Masa Inkubasi > 14 hari > 10 hari 5 10 hari 2 5 hari < 48 jam 1 2 3 4 5 Spasme Hanya trismus Kaku seluruh badan Kejang terbatas Kejang seluruh badan Optistotonus 1 2 3 4 5 Imunisasi Lengkap < 10 tahun > 10 tahun Ibu diimunisasi Tidak diimunisasi 0 2 4 8 10 Frekuensi Spasme 6 x dalam 12 jam Dengan rangsangan Terkadang spontan Spontan < 3x per 15 menit Spontan > 3x per 15 menit 1 2 3 4 5 Luka Infeksi Suhu Total Skor Deraat K9 Luka Infeksi Tidak diketahui Distal/perifer Proksimal Kepala Badan 1 2 3 4 5 Suhu 36.7 37 C 37.1 37.7 C 37.8 38.2 C 38.3 38.8 C > 38.8 C 1 2 4 8 10 Komplikasi Tidak ada Ringan Tidak membahayakan Mengancam Nyawa (tidak langsung) Mengancam nyawa 1 2 4 8 10 Pernafasan Sedikit berubah Apnea saat kejang Kadang apnea setelah kejang Selalu apnea setelah kejang Perlu trakeostomi 0 2 4 8 10 66 PhScorePjeparahan < 9 Ringan 18 Sedang >18 atBerilipshilips Score Waktu Masuk Skor Selama Perawatan Skor Masa Inkubasi > 14 hari > 10 hari 5 10 hari 2 5 hari < 48 jam 1 2 3 4 5 Spasme Hanya trismus Kaku seluruh badan Kejang terbatas Kejang seluruh badan Optistotonus 1 2 3 4 5 Imunisasi Lengkap < 10 tahun > 10 tahun Ibu diimunisasi Tidak diimunisasi 0 2 4 8 10 Frekuensi Spasme 6 x dalam 12 jam Dengan rangsangan Terkadang spontan Spontan < 3x per 15 menit Spontan > 3x per 15 menit 1 2 3 4 5 Luka Infeksi Suhu Total Skor Deraat K9 Luka Infeksi Tidak diketahui Distal/perifer Proksimal Kepala Badan 1 2 3 4 5 Suhu 36.7 37 C 37.1 37.7 C 37.8 38.2 C 38.3 38.8 C > 38.8 C 1 2 4 8 10 Komplikasi Tidak ada Ringan Tidak membahayakan Mengancam Nyawa (tidak langsung) Mengancam nyawa 1 2 4 8 10 Pernafasan Sedikit berubah Apnea saat kejang Kadang apnea setelah kejang Selalu apnea setelah kejang Perlu trakeostomi 0 2 4 8 10 66 Grade I (mild) Mild trismus, general spasticity, no respiratory compromise, no spasms, no dysphagia Grade 2 (moderate) Ablett Classification of Severity Grade 2 (moderate) Moderate trismus, rigidity, short spasms, mild dysphagia, moderate respiratory involvement, ventilatory frequency > 30 Grade 3 (severe) Severe trismus, generalized rigidity, prolonged spasms, severe dysphagia, apnoeic spells, pulse > 120, ventilatory frequency > 40 Grade 4 (very severe) Grade 3 with severe autonomic instability 77 Grade I (mild) Mild trismus, general spasticity, no respiratory compromise, no spasms, no dysphagia Grade 2 (moderate) Ablett Classification of Severity Grade 2 (moderate) Moderate trismus, rigidity, short spasms, mild dysphagia, moderate respiratory involvement, ventilatory frequency > 30 Grade 3 (severe) Severe trismus, generalized rigidity, prolonged spasms, severe dysphagia, apnoeic spells, pulse > 120, ventilatory frequency > 40 Grade 4 (very severe) Grade 3 with severe autonomic instability 77 DeDalarajaterajat KeparahanKeparahan hendaknyahendaknya tidaktidak dipakaidipakai sebagaisebagai pedomanpedoman KakuKaku untukuntuk indikasiindikasi rawatrawat ICUICU IndikasiIndikasi RawatRawat ICUICU bilamanabilamana caracara--caracara konvensionkonvensionl yangyang dilakukandilakukan didi ruangruangkonvensionalkonvensional yangyang dilakukandilakukan didi ruangruang perawatanperawatan tidaktidak berhasilberhasil mengatasimengatasi kejangkejang //spasmespasme atauatau pasienpasien mengalamimengalami gangguangangguan pernafasanpernafasan akibatakibat kejangkejang atauatau aspirasiaspirasi,, atauatau telahtelah terjaditerjadi gagalgagal nafasnafas atauatau gangguangangguan sistemsistem lainyanglain yang memerlukanmemerlukan terapiterapi supportifsupportif.. 88 DeDalarajaterajat KeparahanKeparahan hendaknyahendaknya tidaktidak dipakaidipakai sebagaisebagai pedomanpedoman KakuKaku untukuntuk indikasiindikasi rawatrawat ICUICU IndikasiIndikasi RawatRawat ICUICU bilamanabilamana caracara--caracara konvensionkonvensionl yangyang dilakukandilakukan didi ruangruangkonvensionalkonvensional yangyang dilakukandilakukan didi ruangruang perawatanperawatan tidaktidak berhasilberhasil mengatasimengatasi kejangkejang //spasmespasme atauatau pasienpasien mengalamimengalami gangguangangguan pernafasanpernafasan akibatakibat kejangkejang atauatau aspirasiaspirasi,, atauatau telahtelah terjaditerjadi gagalgagal nafasnafas atauatau gangguangangguan sistemsistem lainyanglain yang memerlukanmemerlukan terapiterapi supportifsupportif.. 88 Clinical diagnosis of tetanus Secure Airway Tracheostomy Benzodiazepines2 Midazolam Diazepam Antitoxin2 HIG im/it Equine antitoxin im Antibiotics2 Metronidazole Manage autonomic dysfunction Flow diagram showing the management of tetanus. 1limited evidence; 2some evidence; 3good evidence. Magnesium 2 Inotropes 1 Benzodiazepines 2 Bupivacaine 2 Morphine 2 Clonidine 2 Consider DVT Prophylaxis1 Control Muscle Spasms Benzodiazepines2 Dantrolene1 NDNMBAs1 Baclofen2 Magnesium2 Full primary course of immunisation1 99 Clinical diagnosis of tetanus Secure Airway Tracheostomy Benzodiazepines2 Midazolam Diazepam Antitoxin2 HIG im/it Equine antitoxin im Antibiotics2 Metronidazole Manage autonomic dysfunction Flow diagram showing the management of tetanus. 1limited evidence; 2some evidence; 3good evidence. Magnesium 2 Inotropes 1 Benzodiazepines 2 Bupivacaine 2 Morphine 2 Clonidine 2 Consider DVT Prophylaxis1 Control Muscle Spasms Benzodiazepines2 Dantrolene1 NDNMBAs1 Baclofen2 Magnesium2 Full primary course of immunisation1 99 ThntTuranceuerapeuticManagemeherapeutic Management ImmunizationImmunization WounddebridementWound debridement AntibioticsAntibiotics ControlmusclespasmControl muscle spasm ControlAutonomicDistbControl Autonomic Distrbance OthersupportivetherapyOther supportive therapy 1010 ThntTuranceuerapeuticManagemeherapeutic Management ImmunizationImmunization WounddebridementWound debridement AntibioticsAntibiotics ControlmusclespasmControl muscle spasm ControlAutonomicDistbControl Autonomic Distrbance OthersupportivetherapyOther supportive therapy 1010 MAMdefCNSdiniNAGEMENTANAGEMENT 1.1. NeutralizetoxinoutsioNeutralize toxin outsie of CNS --HumanTetanus ImmuneGlobulHuman Tetanus Immune Globuln HTIGHTIG)) 150units/kgIMor5,000150 units/kg IM or 5,000-10,000units IV10,000 units IV --ATSATS 500UI/kgBBintramuscular.500 UI/kgBB intramuscular. 1111 MAMdefCNSdiniNAGEMENTANAGEMENT 1.1. NeutralizetoxinoutsioNeutralize toxin outsie of CNS --HumanTetanus ImmuneGlobulHuman Tetanus Immune Globuln HTIGHTIG)) 150units/kgIMor5,000150 units/kg IM or 5,000-10,000units IV10,000 units IV --ATSATS 500UI/kgBBintramuscular.500 UI/kgBB intramuscular. 1111 22.. PrsePtot eventfurthertoxinrelearevent further toxin release --EarlysurgicaldebridemenfEarly surgical debridemenof woundswounds MANAGEMENTMANAGEMENT --Antibiotics:Antibiotics : MetronidazoleMetronidazole 500mg500mg 8hourlyandPenicillinG1MU68 hourly and Penicillin G 1 MU 6--88 hourly.hourly. HeavilycontaminatedwoundmayHeavily contaminated wound may needadditionalantibiotics.need additional antibiotics. 1212 22.. PrsePtot eventfurthertoxinrelearevent further toxin release --EarlysurgicaldebridemenfEarly surgical debridemenof woundswounds MANAGEMENTMANAGEMENT --Antibiotics:Antibiotics : MetronidazoleMetronidazole 500mg500mg 8hourlyandPenicillinG1MU68 hourly and Penicillin G 1 MU 6--88 hourly.hourly. HeavilycontaminatedwoundmayHeavily contaminated wound may needadditionalantibiotics.need additional antibiotics. 1212 MAMftxinalreadyf NAGEMENTANAGEMENT 3.3. Minimizetheeffects ooMinimize the effects otoxin already exists inCNSexists in CNS --Controlrigidity andspasmControl rigidity and spasm --Respiratory supportas necessaryRespiratory support as necessary --Controlofautonomic dysfunction.Control of autonomic dysfunction. 1313 MAMftxinalreadyf NAGEMENTANAGEMENT 3.3. Minimizetheeffects ooMinimize the effects otoxin already exists inCNSexists in CNS --Controlrigidity andspasmControl rigidity and spasm --Respiratory supportas necessaryRespiratory support as necessary --Controlofautonomic dysfunction.Control of autonomic dysfunction. 1313 DrpasmandDugusedtocontrolsrug used to control spasm and autonomicdisturbanceautonomic disturbance BenzodiazepineBenzodiazepine MorphineMorphine Musclerelaxant:Muscle relaxant: vecuroniumvecuronium,, rocuroniumrocuronium,, pancuroniumpancuronium MagnesiumsulfateMagnesium sulfate DantrolenDantrolen BaclofenBaclofen BupivacainBupivacain,atropine,, atropine, 1414 DrpasmandDugusedtocontrolsrug used to control spasm and autonomicdisturbanceautonomic disturbance BenzodiazepineBenzodiazepine MorphineMorphine Musclerelaxant:Muscle relaxant: vecuroniumvecuronium,, rocuroniumrocuronium,, pancuroniumpancuronium MagnesiumsulfateMagnesium sulfate DantrolenDantrolen BaclofenBaclofen BupivacainBupivacain,atropine,, atropine, 1414 BeBicnvulsantiniisnianeanzodiazepineenzodiazepine CommonusedasantoCommon used as antconvulsant in tetanus.tetanus. HassedativeeffectHas sedative effect DoseofDiazepamvary100Dose of Diazepam vary 100--400mg/24h400 mg/24 h maxuntil2400mg/24hmax until 2400mg/24 h PreservativeusedcancauseacidosiPreservative used can cause acidoss in largedoselarge dose No/littleeffectonautonomicdisturbcNo/little effect on autonomic disturbnce 1515