F.A.S.T.H.U.

G
I W. Aryabiantara

F.A.S.T.H.U.G
Its a mnemonic memudahkan seorang
praktisi medis dalam memberikan terapi
(Jean-Louis Vincent)
F = Feeding
A = AnalgetiK
S = Sedasi
T = tromboemboli profilaksis
H = Head of bed elevasi
U = Ulcer proteksi
G = Glucouse kontrol

FEEDING
Berikan nutrisi se-segera mungkin
setelah resusitasi stabil
Ideal <72 jam
Nutrisi dini menurunkan angka
kematian secara signifikan
Bisa enteral bisa parenteral

Postprandial Hypotension
500
700
C

Liver

vasodilatation

200
400

Stomach
Spleen
Meal

1000

Decrease Venous Return

decrease Stroke Volume
decrease Blood Pressur
VASODILATATION

Pancreas

500
S

Aorta

300
I

Small
intestine
Colon

From Review of medical physiology, Ganong WF.

2001

Hepatic
Portal
vein

LOW FLOW STATE / HAEMORRHAGIC

SHOCK
Shock state

NORMAL

Control of
CV system

Spinchter
closed

Vasoconstriction

DIVERTED BLOOD FLOW

HEART & BRAIN

DIVERTED BLOOD SUPPLY

HEART & BRAIN

G
FEEDING
N
I
D
E
FE

The gut-origin hypothesis

Cardiac failure:

Hypovolaemia:
- Dehydration
- Hemorrhage

Endogenous vasoconstrictor

Splanchnic Hypoperfusion

AMI
CHF
Tamponade

Exogenous
vasoconstrictor:
NE, Epi, Dopa

Resuscitation

Gut mucosal hypoperfusion

Ischaemia-Reperfusion injury
1. Gut mucosal barrier disruption
Increased mucosal permeability
to bacteria / endotoxin

Cytokine/RO
S

SIRS

MODS

Gareth Ackland, Michael PW Grocott and Michael G Mythen: Crit Care 2000, 4:269281

ANALGESIA
Dasar : nyeri adalah vital sign yang ke-5
Pasien dalam kondisi apapun tidak boleh
nyeri
Rangsangan nyeri tersebut dapat
mempengaruhi pemulihan fisiologis dan
psikologis kurang tidur, disfungsi paru
dan respon stres imunosupresi,
hiperkoagulabilitas, katabolisme protein
dan meningkatkan oksigen miokard
consumption

Source of Pain in
ICU

Repeated episodes of acute pain, localised

Surgery / tissue inflammation / immobility

Catheter/ apparatus discomfort / naso &

orogastric tubes

Endotracheal intubation/ suctioning/ chest

tubes

Phlebotomy / vascular access /

physiotherapy

Routine turning & positioning the patient

n da
o
i
t se
a
b ly
on
e

n
o
i
t

d
an

la
re

n
xa

c
Lo

c
Lo

a
l
a

th
s
e

ic
t
e

m
so

a
l
a

im
t
e

es

st
e
n

ic
t
e

so

e
iv
t
ec
f
ne

im
t
e

es

e
iv
t
ec
f
ne

e
Th

u
nf
i
pa
t
os
m

o
R
.
ll.

e
in
t
u

r
tu

ng
i
n

was normal

c
e
R

ng
i
v
ei

ta
e
B

er
k
o
Bl

Assessment of
pain
in
ICU
Critical clinical practice guidelines;
pain assesment and response to therapy should be

performed on a regular basis using a scale

appropriate to the patient population.
The use of VAS and NRS is recommended
For patients who cannot communicate, pain should

be assessed through subjective observation of;

Pain related behaviour
Physiological indicators

Assessment of
pain in ICU Pain Rating Scale
Visual Analogue
Scale
Numeric Rating
Scale
Faces Scale
McGill Pain
Questionnare

Assasement nyeri

Pharmacologic Management
of pain in the ICU

Textbook critical care, M. Fink 2006

an
t
n
Fe

o
G
:
yl

n
e
ld

rd
a
nd
a
St

rH
o
f

y
od
em

y
lit
i
ab
t
s
ic
m
na

SEDASI

TROMBOEMBOLI PROFILAKSIS

Cara Mekanik :
Perubahan posisi berbaring secara
berkala,
Pijat rutin pada tungkai bawah
Early mobilisasi pada pasien sadar
Graduated compression stockings
(GCS),
Intermittent pneumatic compression
(IPC) devices
Venous foot pump (VFP).

Terapi medikamentosa :
dapat berupa Heparin 5000 Unit
setiap 8 jam
Enoxaparin 30 Unit setiap 12 jam
Dalteparin 2500 - 5000 Unit setiap 24
jam
Fondaparinux 2,5 mg setiap 24 jam

Head of The Bed Up

Kemiringan bed 45 derajat
Mencegah regurgitasi
Salah satu komponen bundle
pencegahan VAP
Pressure cuff dijaga < 20 mmHg
Sub glotic suction, oral hygiene

ULCER PROTEKSI
H2 Antagonists seperti Cimetidine 300
mg oral atau IV setiap 6-8 jam
Famotidine 20 mg oral atau IV setiap 12
jam,
Ranitidine 50 mg IV setiap 12 jam
Penghambat pompa proton seperti
Lanzoprazole 30 mg setiap 24 jam,
omeperazole 20 mg setiap 24 jam atau
Pantoprazole 40 mg setiap 24 jam,
Sucralfat 10 mg setiap 6 jam

Glucosa Control
-Hyperglicemia meningkatkan morbiditas,
mortalitas dan biaya perawatan.
-Dengan mengontrol gula darah akan
menurunkan insidens penyembuhan luka
yang lama, resiko infeksi, gangguan
motilitas usus, gangguan performa
kardiovaskuler, resiko polineuropati dan
resiko gagal ginjal akut.

- Target gula darah idealnya

dipertahankan dilevel 140-180 mg/dL.
-Strategi mempertahankan gula darah :
Insulin continuous dapat dijalankan
setelah 2 kali pemeriksaan dengan
interval 1 jam, masih menunjukkan >
180 mg/dL (kadang-kadang memerlukan
insulin bolus sebelumnya). Insulin yang
digunakan yg short acting
Hindari penggunaan sub kutan jika
hemodinamik pasien belum stabil

Ventilator Bundle

Patient positioning Elevation

Recommended elevation is 30-45
degrees
Ventilator weaning Periodic sedative
interruptions and daily assessment
of readiness to extubate may reduce
the duration of mechanical ventilation
and the risk of VAP

ICU Bundle
Peptic ulcer disease (PUD) prophylaxis
Patients with respiratory failure have an
increased risk of stress ulcers and
associated gastrointestinal (GI) bleeding.
Venous thromboembolism prophylaxis
Patients with respiratory failure have an
increased risk of deep vein thrombosis.
Treatment with anticoagulants (e.g.,
heparin) has been shown to reduce this
risk.