LAPORAN JAGA ICU

Sabtu, 10 Maret 2018

DPJP: dr. Deiby Wuisan, Sp.An

Coass: Rando, Evan, Rachmad, Ramdan, Cindy,
Nizra, Andreas
 Bed 3. JE/L/66 th

O: B1: RR : 24x/m, SpO2: 97% via face mask 12 LPM

sp.vesikuler , rh+/+, wh-/-
B2: TD = 126/94 mmHg, Nadi : 97x/m, reguler, isi cukup,
Suhu : 36,5 C BJ I-II reguler, bising(-).
B3: GCS= E2M4V1, pupil bulat isokor, diameter 3mm RC
+/+
B4: Kateter(+) urine output: 300cc/4 jam. IVFD line I RL
500 cc/hari
B5: NGT(+), Abd : datar, lemas, BU(+) normal
B6: Akral hangat CRT <2 detik, edema -/-
A : - Post gagal napas on ventilator
- Sepsis ec. urosepsis dd pneumonia
- Post sitoreduktif adrenalektomi + torakolaparotomi
P : - H6 Linezolid 600 mg/12 jam IV drips (1 jam)
- H6 Mikafungin 100 mg (2 vial)/24 jam IV
- Ranitidin 50 mg/12 jam IV
- Paracetamol 500 mg/8 jam per NGT
- Furosemid 5-20 mg/jam IV SP
- H1 Aztreonam loading 2 gram (ST dulu) lanjut 2 gr/8 jam (drips
IV 3 jam)
- Norepinefrin 0,05-2 mcg/kgBB/menit IV SP
- Nebulisasi combivent + NaCl 0,9%/6 jam
 Pemeriksaan Laboratorium (08-03-2018)
• Bilirubin total : 1,04
• Hemoglobin : 11,8
• Bilirubin direct : 0,57
• Hematokrit : 37%
• GDS : 194
• Leukosit : 18500
• Albumin : 2,95
• Trombosit : 360 x 10^3
• Natrium : 132
• Eritrosit : 4,19 x 10^6
• Kalium : 2,95
• SGOT/SGPT : 33/25
• Klorida : 92
• Ureum : 31
• PT : 18”
• Creatinin : 0,8
• INR : 1,61”
• ”
• APPT : 32,2”
 Bed 4. KM/P/77 th

O: B1: RR : 24x/m, SpO2: 100% via facemask 12 LPM

sp.vesikuler , rh+/+, wh-/-
B2: TD = 141/65 mmHg, Nadi : 86x/m, reguler, isi cukup,
Suhu : 36,5 C BJ I-II reguler, bising(-).
B3: GCS= E2M4V2, pupil bulat isokor, diameter 3mm RC
+/+
B4: Kateter(+) urine output: 20cc/4 jam. IVFD line I RL,
line II Clinimix+Clinoleic 125 cc/hari, line III NS+norepinefrin
B5: NGT(+), Abd : datar, lemas, BU(+) normal
B6: Akral hangat CRT <2 detik, edema -/-
A : - Penurunan kesadaran ec sepsis dd KAD
- Sepsis ec urosepsis dd pneumonia
- KAD
- AKI superimposed CKD
- Hepatopati
- Hiponatremia
- Trombositopenia
- Hiperurisemia
P : - Allopurinol 100 mg tab/24 jam per NGT
- Asam folat 400 mg/12 jam per NGT
- Curcuma 1 tab/8 jam per NGT
- H4 Meropenem 1 gr/8 jam drips 3 jam  adjusted dose 500 mg tiap 12
jam (drips 3 jam)
- Raniditine 50 mg/12 jam
- Furosemide 5-20 mg/jam IV SP
- Esomeprazole 8 mg/ jam IV SP
- Norepinefrin dosis tinggi 100-200 mcg/kgBB/hari IV SP (target MAP
70)
- GDS/6 jam
- Nebulisasi NaCl 0,9%/8 jam
 Pemeriksaan Laboratorium (08-03-2018)
• AGD Vena (Suhu 37)
• Hemoglobin : 11,7
• pH 7,3
• Hematokrit : 36,4%
• pCO2 16,1
• Leukosit : 32500
• pO2 60
• Trombosit : 43 x 10^3
• Becf -18
• Eritrosit : 3,64 x 10^6
• HCO3 8
• Asam urat : 11,5
• TCO2 9
• Kolesterol tot ; 54
• sO2 90%
• HDL :6
• Lactat 12,08
• LDL : 26
• Trigliserida : 110
• HbA1c : 10%
 Bed 5. RD/L/60 th

O: B1: RR : 18x/m, SpO2 100% on ventilator

sp.vesikuler , rh+/+, wh-/-
B2: TD = 160/90 mmHg, Nadi : 83x/m, reguler, isi cukup,
Suhu : 36 C BJ I-II reguler, bising(-).
B3: GCS= E2M1Vx (ventilator), pupil bulat isokor, diameter
3mm RC +/+
B4: Kateter(+) urine output: 100 cc/jam. IVFD line I EAS
Pfrimmer 250 cc/hari
B5: NGT(+), Abd : datar, lemas, BU(+) normal
B6: Akral hangat CRT <2 detik, edema -/-
A : - Multiple ICH traumatik regio temporal dextra (H-16)
- Contusio cereberi regio frontal sinistra
- Fraktur segmental os frontal sinistra
- Fraktur linear os zigomatikus sinistra
- Fraktur linear os maxilla sinistra
- Pneumoencephalus
- Combutio ec listrik
- Hepatopaty
- Anemia
- Trombositopenia
- Leukositosis
P : - Bedrest + elevasi kepala 30
- Sucralfat syr 1 gr (20 cc)/6 jam per NGT
- N-asetilsistein 200 mg/8 jam per NGT
- Zinc 20 mg/12 jam per NGT
- Vit C 200 mg (4 tab)/12 jam per NGT
- H3 Tygesiklin 50 mg/12 jam IV
- H10 Amikasin 1250 mg/24 jam (hari terakhir)
- Omeprazole 40 mg/12 jam
- Paracetamol 1 gr/8 jam IV
- Fentanyl 25-50 mcg/jam IV SP
- Midazolam 2-5 mcg/ jam IV SP
- Norepinefrin 0,05-1,5 mcg/kgBB/menit IV SP titrasi hingga target
MAP>65
- Rawat luka di dada dan perut/24 jam
- Nebulisasi NaCl 0,9% + Combivent/ 6 jam
 Pemeriksaan Laboratorium (08-03-2018)
• GDS : 64
• Hemoglobin : 8,5
• Albumin : 2,15
• Hematokrit : 27,9%
• Natrium : 137
• Leukosit : 8800
• Kalium : 4,39
• Trombosit : 277 x 10^3
• Klorida : 91
• Eritrosit : 2,92 x 10^6
• Ureum : 86
• Creatinin : 0,8
• ”
 Bed 6. WS/P/60 th

O: B1: RR : 14x/m, SpO2: 100% on ventilator

sp.vesikuler , rh+/+, wh-/-
B2: TD = 120/70 mmHg, Nadi : 105x/m, reguler, lemah,
Suhu : 36,3 C BJ I-II reguler, bising(-).
B3: GCS= E2M4Vx, pupil bulat isokor, diameter 3mm RC
+/+
B4: Kateter(+) urine output: 30cc/4 jam. IVFD line I
(Norepinefrinn 0,05-1 mcg), line II (Vasopressin), Line III (RL)
B5: NGT(+) hematemesis, Abd : datar, lemas, BU(+) normal
B6: Akral dingin CRT > 2 detik, edema -/-
A : - ARDS
- Penurunan kesadaran ec ensefalopati uremikum + sepsis
- AKI superimposed CKD on HD
- Sepsis ec urosepsis dd/ pneumonia
- Anemia ec renal
- Hematemesis ec. Stress ulcer
P : - O2 adekuat
- Line I IVFD esomeprazole 8 mg/jam (H2)
- Line II IVFD NaCl 0,9% + Norepinefrin 0,7 mcg/kgBB/jam
- Line III D5 + EAS Pfrimmer 14 tpm
- E2 Meropenem 500 mg/24 jam (drip dalam 3 jam)
- Cek GDS 2 porsi
- Nebulisasi NaCl 0,9% + Combivent/6 jam
 Pemeriksaan Laboratorium (08-03-2018)
• Bilirubin total : 0,57
• Hemoglobin : 7,9
• Bilirubin direct : 0,15
• Hematokrit : 24,2%
• GDS : 124
• Leukosit : 29100
• Albumin : 3,69
• Trombosit : 103 x 10^3
• Natrium : 135
• Eritrosit : 2,89 x 10^6
• Kalium : 5,3
• SGOT/SGPT : 74/25
• Klorida : 106
• Ureum : 430
• PT : 19,1”
• Creatinin : 21
• INR : 1,74”
• ”
• APPT : 32,9”
 Pemeriksaan Laboratorium (08-03-
2018)
• AGD arteri
• pH 7,12
• PCO2 19,6
• PO2 160
• HCO3 6,4
• TCO2 7
• sO2 99%
 Bed 7. RS/L/29 th

O: B1: RR : 17x/m, SpO2: 100% on ventilator

sp.vesikuler , rh+/+, wh-/-
B2: TD = 130/70 mmHg, Nadi : 70x/m, reguler, isi cukup,
Suhu : 36,7 C BJ I-II reguler, bising(-).
B3: GCS= E2M4Vx, pupil bulat isokor, diameter 3mm RC
+/+
B4: Kateter(+) urine output: 10cc/4 jam. Muntah 100 cc.
IVFD line I (Aminofluid), line II (NS + Fentanyl), Line III (NS
+ midazolam)
B5: NGT(+) hematemesis, Abd : datar, lemas, BU(+) normal
B6: Akral hangat CRT < 2 detik, edema -/-
A : - Gagal napas on ventilator
- Penurunan kesadaran ec stroke iskemik dd emboli dd ensefalopati
uremikum - CKD 5 on HD
- DMT 2
- CHF fc I-II ec HHD
- Anemia renal
- Hematemesis ec stress ulcer
- Periode hipoglikemia
- Pneumonia dextra
P : - Sucralfat syr 10 ml/6 jam per NGT
- Adalat oros 30 mg/24 jam (pagi) per NGT
- Micardis 80 mg/24 jam (malam) per NGT
- Asam folat 400 mg tab/24 jam per NGT
- Gabapentin 300 mg/12 jam IV
- H2 vancomycin 500 mg/48 jam
- Esomeprazol 8 mg/jam IV SP
- Midazolam 1-5 mcg/jam IV SP
- Fentanyl 25-50 mcg/jam IV SP
- Vit K 1 amp/8 jam IV
- Asam tranexamat 1000 mg/6 jam IV
- Nicardipin 0,5-6 mcg/kgBB/ment (target MAP 90-100)
- Paracetamol 1 gr drips/ 8 jam k/p
- Novorapid drips dosis titrasi
- GDS/jam
- Nebulisasi Combivent + NaCl 0,9%/6 jam
• Skor APACHE 25 – Mortality 53,3%
• SOFA -9
• NUTRIC - 4 low risk
 Pemeriksaan Laboratorium (08-03-2018)
• Bilirubin total : 0,73
• Hemoglobin : 8,9
• Bilirubin direct : 0,27
• Hematokrit : 26,9%
• GDS : 125
• Leukosit : 26300
• Albumin : 3,24
• Trombosit : 185 x 10^3
• Natrium : 141
• Eritrosit : 3,12 x 10^6
• Kalium : 3,24
• SGOT/SGPT : 16/10
• Klorida : 106
• Ureum : 122
• PT : 17”
• Creatinin : 8,7
• INR : 1,49”
• ”
• APPT : 22”
 Bed 9. TTT/L/75 th

O: B1: RR : 17x/m, SpO2: 100% via nasal canule 4 LPM

sp.vesikuler , rh+/+, wh-/-
B2: TD = 120/70 mmHg, Nadi : 80x/m, reguler, Suhu : 36,5
BJ I-II reguler, bising(-).
B3: GCS= E2M4V2, pupil bulat isokor, diameter 3mm RC
+/+
B4: Kateter(+) urine output: 50cc/ jam. IVFD line I (RL 500
cc/hari), line II (NS + Norepinefrin)
B5: NGT(+) , Abd : datar, lemas, BU(+) normal
B6: Akral hangat CRT < 2 detik, edema +/+
A : - Post gagal nafas on ventilator
- Penurunan kesadaran ec. Cerebral infarct H-24
- Sepsis ec. pneumonia
- Dekubitus grade IV
- AKI superimposed CKD
- CKD perbaikan
- Hipoalbuminemia + hiponatremia + Hipokalemia
- Anemia ec. Chronic disease
P : - Ampisilin-sulbaktam 3 gr/8 jam IV
-
 Pemeriksaan Laboratorium (08-03-2018)

• Hemoglobin : 7,4
• Hematokrit : 23,3%
• Leukosit : 13900
• Trombosit : 163000
• Eritrosit : 2,71 x 10^6
 Bed 10. SM/L/40 th

O: B1: RR : 16x/m, SpO2: 100% on ventilator

sp.vesikuler , rh+/+, wh-/-
B2: TD = 118/73 mmHg, Nadi : 81x/m, reguler, kuat angkat,
isi cukup, Suhu : 39,3 C BJ I-II reguler,
bising(-).
B3: GCS= E1VxM1, pupil bulat isokor, diameter 3mm RC
+/+
B4: Kateter(+) urine output: 50cc/4 jam. IVFD line I (NS +
midazolam), line II (NS + Norepinefrin)
B5: NGT(+) hematemesis , Abd : datar, lemas, BU(+) normal
B6: Akral hangat CRT < 2 detik
A : - Gagal nafas on ventilator
- Post bronkoskopi
- Post hematopneumothoraks bilateral post aff WSD
- Atelektasis pulmo sinistra
- Contusio paru
- Multiple fracture costae + flail chest
- AKI perbaikan
P : - Bisoprolol 5 mg/24 jam (jika HR >100, TD> 100/70)
- Allopurinol 100 mg/24 jam (malam)
- N-asetilsistein 200 mg/8 jam
- H5 Cefepim 2 gr/8 jam (drips 3 jam)
- H5 Ciprofloxacin 400 mg/8 jam (drips 1 jam)
- Mikafungin 100 mg/24 ham (drips 1 jam)
- Paracetamol 1 gr tiap 8 jam k/p
- Fentanyl 25-50 mcg/1 ham IVSP (target BPS 3)
- Midazolam 1-5 mg/jam IV SP (target RASS 2)
- Norepinefrin 0,05 – 1,5 mcg/kgBB/menit IV k/p (target MAP ≥ 65
mmHg)
- Cek GDS/6 jam
- Nebulisasi NaCl 0,9% + Combivent/6 jam
 Pemeriksaan Laboratorium (07-03-2018)

• Hemoglobin : 10,1 AGD Arteri

• Hematokrit : 32,5% pH : 7,46
• Leukosit : 16000 PCO2 : 43,3
• Trombosit : 121000 PO2 : 153
• Eritrosit : 3,56 x 106 HCO3 : 32,6
• GDS : 264 TCO2 : 34
• Albumin : sO2 : 99%
• Natrium : 147 FIO2 : 40
• Kalium : 3,38
• Klorida : 103
 Bed 11. YP/P/56 th
O: B1: RR : 15x/m, SpO2: 100% via nasal canul 2 LPM
sp.vesikuler, rh+/+,
wh-/-
B2: TD = 120/70 mmHg, Nadi : 100x/m, reguler, kuat
angkat, isi cukup, Suhu : 36,9 C BJ I-II reguler,
bising(-).
B3: GCS= E2M4V2, pupil bulat isokor, diameter 3mm RC
+/+
B4: Kateter (+) terpasang. Urine output 200cc/4 jam. IVFD
RL 500 cc/hari
B5: NGT(+), Abd : datar, lemas, BU(+) normal
B6: Akral hangat CRT < 2 detik, edema -/-
A : - Post gagal napas on ventilator
- VAP
- Post-laparotomi ec. Peritonitis ec perforasi hollow viscus
- Hipoalbuminemia
P : - N-asetilsistein 200 mg/8 jam per NGT
- Bisoprolol 2,5 mg/24 jam (tidak diberikan jika MAP<65)
- H14 Meropenem 1 gr/8 jam (drips 3 jam)  stop hari ini
- H4 Tigesiklin 50 mg/12 jam IV
- H6 Mikafungin 100 mg/24 jam (drips dalam NaCl 0,9% 100cc)
- Paracetamol 1 gr/8 jam k/p
- Ranitidine 50 mg/12 jam IV
- Midazolam 1mg/jam IV SP (target RASS 0)
- Rehabilitasi medik/24 jam
- Nebulisasi NaCl 0,9% + Combivent/8 jam
 Pemeriksaan Laboratorium (07-03-2018)

• Hemoglobin : 9,9 AGD Arteri

• Hematokrit : 31,2% pH : 7,57
• Leukosit : 19200 PCO2 : 30,8
• Trombosit : 964 PO2 : 101
• Eritrosit : 3,49 x 106 HCO3 : 28,4
• Ureum : 62 TCO2 : 24
• Creatinin : 0,4 sO2 : 99%
• GDS : 113 FIO2 : 40
• Albumin : 3,11
• Natrium : 137
• Kalium : 3,78
• Klorida : 92,7
 Bed 17. AL/P/46 th

O: B1: RR : 30x/m, SpO2: 98% via face mask 8 LPM

sp.vesikuler, rh+/+, wh-/-
B2: TD = 108/54 mmHg, Nadi : 98x/m, reguler, kuat angkat,
isi cukup, Suhu : 36,1 C BJ I-II reguler,
bising(-).
B3: GCS= E4M6V4, pupil bulat isokor, diameter 3mm RC
+/+
B4: Kateter (+) terpasang. Urine output 250cc/4 jam. IVFD
Ringerfundin 100cc/hari  4,2 cc/jam
B5: NGT(+), Abd : datar, lemas, BU(+) normal
B6: Akral hangat CRT < 2 detik, edema -/-
A : - Penurunan kesadaran ec ensefalopati dd ensefalitis
- TB paru putus obat
- DMT2 terkontrol
- Susp.myelodysplastic syndrome
- Post hipoglikemia + hipoksia
P : - N-asetilsistein 200 mg/8 jam per NGT
- Gliseril trinitrat 2,5 mg/12 jam per NGT
- KSR 600 mcg/8 jam per NGT
- Asam folat 400 mcg/12 jam per NGT
- B1-B6-B12 1 tab/8 jam per NGT
- H3 Levofloxacin 750 mg/24 jam (drips 90 menit)
- Omeprazole 40 mg/12 jam
- Paracetamol 1 gr /8 jam k/p
- Furosemidee 5-20 mg/ jam IV SP (target BK nol dan MAP >65)
- Novorapid 10 unit tiap jam 12.00, 18.00, 06.00
- Levemir 16 unit tiap jam 22.00
- GDS 4 porsi
- Nebulisasi NaCl 0,9% + Combivent/8 jam
 Pemeriksaan Laboratorium (07-03-2018)

• Hemoglobin : 8,8 AGD Arteri

• Hematokrit : 30,2% pH : 7,542
• Leukosit : 6500 PCO2 : 37,1
• Trombosit : 43 x10^3 PO2 : 94
• Eritrosit : 3,38 x 10^6 HCO3 : 31,9
• Natrium : 159 TCO2 : 33
• Kalium : 2,93 sO2 : 98%
• Klorida : 118 FIO2 : 40
TERIMA KASIH