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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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