Curiculum Vitae DR. Rahadian Indarto Susilo, dr SpBS(K)
Transcript of Curiculum Vitae DR. Rahadian Indarto Susilo, dr SpBS(K)
Curiculum Vitae
DR. Rahadian Indarto Susilo, dr SpBS(K)
• Fak Kedokteran Universitas Airlnggga 1996-2002
• PPDS Bedah Saraf Universitas Airlangga Surabaya 2003-2009
• Skull Base Fellow Program Keio University Tokyo Japan, 2009
• WFNS Grade A: Skull Base Fellowship Program Osaka City University, Japan. 2011
• Program S3 FK UNAIR 2019
• Neurooncology Division, Neurosurgery Department Universitas Airlangga - Dr. Sutomo General Hospital, Surabaya, 2009 - now
HP : 081 3260 79197 Email : [email protected] : 0822-6000-6070
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Prinsip Tatalaksana Pasien Trauma Kepaladi Ruang Rawat Inap
Dr. dr. Rahadian Indarto Susilo, Sp.BS (K)
Asclepio Edukasi Medika ©2020
Outline
1. Goal of neurotrauma case
2. Identification of secondary insult
3. Principal Management of neurotrauma patient
4. General Interventions
5. Post NEUROLOGICAL Interventions care
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GOALS OF NEUROTRAUMA CARE
to prevent secondary insults
• which may initiate or exacerbate secondary damage in a vulnerable central nervous system
early detection and treatment of complications.
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INTRA KRANIAL SECONDARY INSULT
EXTRA KRANIAL SECONDARY INSULT
CEDERA OTAK
SEKUNDER
• ICP, CPP•ISKEMIK-HIPOKSIK
•Kerusakan sel
•MORTALITAS•MORBIDITAS
CEDERA OTAK
PRIMER
Patofisiologi Cedera Otak
Normal
Tx adequad
AIRWAYBREATHING
CIRCULATION
TRAUMA KEPALA
DEKOMPENSASI KOMPENSASI
Gangguan Autoregulasi
Autoregulasi aliran darah otak (CBF)
50 140
CBF
MAP (mmHg)
Waktu normalstabil disini
Cedera otak merusak mekanisme autoregulasi
batas aman jadi lebih sempit
cedera
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Daerah PENUMBRA → HYPOPERFUSI
11
❑ Gangguan Perfusi (Hipoperfusi)Ok ADO menurun atau kompressi.
❑ ADO 10-18 ml/100gr/menit.(N=50ml/100gr/menit)
❑ Masih bisa reversible bila ditanganicepat dan tepat.
❑ Gangguan Perfusi berat( ADO sangat menurun atau kompressi ).
❑ ADO <10 ml/100gr/menit.(N=50ml/100gr/menit)
❑ irreversible
Abnormal
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Identification of SECONDARY INSULT
1. Extracranial → Systemic
2. Intracranial. →
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Primary Goal of Care prevention of secondary insult
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EVENT MAIN CAUSES ADVERSE EFFECT
HYPOXEMIA 1. Hypotension2. Aspiration atelectasis3. Pneumothorax4. Pneumonia5. Anemia
1. O2 delivery↓2. Risk of ischemic damage↑
HYPERCAPNIA (pCO2 ↑) 1. Respiratory depression CBV ↑ → ICP ↑
HYPOCAPNIA (pCO2 ↓) 1. Hyperventilation , spontaneousor induced
Cerebral vasocontriction→ Risk of ischemic damage↑
HYPOTENSION 1. Hypovolemia2. Cardiac failure3. Sepsis 4. Spinal cord injury
CPP↓ & CBF ↓Risk of ischemic damage↑
ANEMIA Blood loss 1. O2 delivery↓2. Risk of ischemic damage↑
HYPERTHERMIA Hypermetabolism, stress response, infection
energy depletion
HYPOTHERMIA Exposure, central dysregulation NeuroprotectiveCoagulopathy & electrolyte disturbance
Principal Management of neurotrauma patient
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PrincipalManagement of neurotrauma patient
Frequent assessment of neurological status (every 30 minutes, then hourly) for the first 24-48 hoursFrequent
Frequent vital signs Frequent
Limit care activities that increase ICPLimit
DO NOT cluster cares!DO NOT cluster
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Principal Management of neurotrauma patients :
Do it
Assess for pain and provide pain relief measures-narcotics mask LOC
Check drains for placement, patency - strict steriletechnique
Check dressing for drainage, CSF leak - strict sterile technique
Suction—limit to < 15 seconds; preoxygenate
Turn q 2 hrs (slow, gentle movements)
ROM exercises
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Principal Management of neurotrauma patient : family & referrals
Assess effect of ill family member on family Assess
Teach family to provide care to ill family memberTeach
Facilitate family communication and planningFacilitate
Provide accurate information to family regarding patient’s conditionProvide
Initiate referrals as needed, i.e. speech therapy, physical therapyInitiate
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General Interventions
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General Interventions
1. Respiratory
2. Cardiovascular
3. Nutrition
4. blood glucose
5. IV fluid
6. activity
7. pain
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General Interventions
1. Respiratory:
• Prevent atelectasis & pneumonia
• Maintain SaO2 > 94%
• Encourage incentive spirometry q 2 hours at least
2. Cardiovascular:
• Monitor cardiac rate & rhythm
• Monitor BPs
3. Nutrition:
• Begin with clear liquids, advance as tolerated
• Swallow evaluation
• Assess for nausea and vomiting, administer antiemetics as ordered.
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General Interventions
4. Blood Glucose:
• Hyperglycemia disrupts the blood-brain-barrier and increases edema
• Steroids increase blood glucose levels
• Monitor blood glucose levels before meals, at bedtime and as needed, administer hypoglycemic as needed
5. IV Fluids:
• Titrate IV fluids down once the patient is taking adequate food and liquids to prevent fluid overload & potential edema
• Do not use fluid with dextrose ?
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General Interventions
6. Activity:
• Early ambulation is important to prevent pneumonia, atelectesis, & DVTs
• Physical therapy and occupational therapy consults are strongly recommended
7. Pain:
• Assess pain every 4 hours using appropriate pain scale
• Administer ordered pain medications as needed
• Reassess pain up to 1 hour after giving pain medication
• Suggest alternative pain relief therapies (deep breathing, music, ice, darken room)
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Post neurosurgical intervention care
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Post NEUROLOGICAL
Interventions
Head dressing & incision care
• Monitor for drainage
• Change as needed, usually removed after 24 hours
• Monitor incision for signs of infection
• Keep staples or stitches dry
Drains
• Monitor amounts of drainage
• Maintain patency
• Know location of drain
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Patient Positioning
Elevate HOB 30 to 45 degrees for supratentorial surgery
Keep patient flat or slightly elevated if incision in posterior fossa (infratentorial)
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VentriculostomyExternal Ventricular Drainage (EVD)
• GOAL :
• Drains CSF
• Allows for intraventricular drug administration
• Measures pressure within vessels
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ICP monitoring
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ICP monitor : Intraventricle
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Postoperative Medications
Anticonvulsants
Corticosteroids → nontrauma cases
H2 blockers / PPI
Analgesics
Antibiotics
Nutrition
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Post op COMPLICATIONS
EXTRA CRANIAL → SYSTEMIC ( A – B – C)
INTRA CRANIAL → Neurosurgical complication
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Postoperative complications : extracranial
A – B → Respiratory Complications
• Atelectasis
• Hypoxia
• Pneumonia
• Neurogenic pulmonary edema
C → Hypovolemic shock
Infection
Fluid and electrolyte imbalances
• Dehydration
• Hyponatremia
• Hypernatremia
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Postoperative Complications:
intracranial
Increased intracranial pressure (ICP)
Hydrocephalus
Meningitis
Seizures
Cerebrospinal fluid (CSF) leak
Cerebral edema
Hematomas
• Subdural hematoma
• Epidural hematoma
• Subarachnoid hemorrhage
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Summary
Neuro care complex
Encompasses science and art of care
Requires technical expertise
Requires collaboration, communication, compassion
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Thank you
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Nutrisi
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Pemberian nutrisi
⚫Start : Protokol Neuroscience.
⚫Acuan
24 – 48 jam
Apakah ada atau tidak stres metabolik ?
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Stres Metabolik
Kasus neurosurgery :
o GCS turun/coma,
o Hipertensi, hipotensi/syok,
o Febris,
o Keringat dingin,
o Hipoventilasi.
o Dll.
Pemeriksaan
Penunjang : serum
o Cortisol.
o Glukagon
o Glukosa
Penunjang : Urine
o UUN
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Pemberian Nutrisi TBI
• Substrak energi.
• Jalur pemberian :
Prinsip : “If the gut works, use it.”
o Karbohidrato Lemako Proteino Vitamin, mineral dan trace element
o Parenteral atau Enteral atau Kombinasi
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Pemberian Nutrisi TBI⚫Substrak nutrisi :
o Karbohidrat,Umumnya diberikan 40-60% dari total kcal,
Substrak 4 (3.4 kcal/g).
Dosis ; Max 7 g/kgBB/hari
Pada kasus tertentu hanya diberi tidak lebih 50%
o LemakUmumnya diberikan 20 - 40% dari total kcal,
Substrak 9 kcal/g.
Dosis ; Max 1 g/kgBB/hari
Pada kasus tertentu boleh diberi s/d 45%.
Dipersyaratkan pem triglicerida,
Sediaan dalam bentuk LCT & MCT+LCT
Pemberian Nutrisi TBI⚫Substrak nutrisi :
o ProteinUmumnya diberikan dari total kcal,
Substrak 4 kcal/g.
Dosis ; 1.5-2 (Max 2.5) g / kgBB/ hari
Pada kasus tertentu hanya diberi < 1g/kgBB/hari
AA Essensial, AA Nonessensial & Conditional AA.
o VitaminStandart : Multivitamin (kecuali Vit K).
Vit K direkomendasikan 2-4 mg/minggu, bukan sebagai
antikoagulan.
o Trace elemen (Zinc, copper,chromium dll)
Pertimbangkan penambahan zinc pada kasus acute catabolic stress,
penyembuhan luka (2-5mg/hari).
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Pemberian Nutrisi TBI
• Kebutuhan cairan
• Osmolaritas cairan nutrisi
Perifer → Cairan dengan osmolaritas < 900 mOsm
Central → Cairan dengan osmolaritas > 900 mOsm
• Immunonutrition
Masih “pro and con”
Hati-hati, metabolisme Glutamin → GlutaminGlutamat
30-50 ml/kgBB/24 jam
Glutamin
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Monitor1X sehari 2X/minggu 1x seminggu
Cairan lambung(6jam)
Serum Glucose Serum phosphorus Serum albumin
BAB Serum elektrolit Serum calcium Nitrogen balance(optional)
Edema Serum BUN Serum magnesium Indirect calorimetry(optional)
Balance cairan Serum creatinine Berat badan
Bedside ICU handbook,TTSH ed 2nd 2007
1X seminggu
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Rangkuman
Managemen pada TBI, One thing to remember !
Ketika penderita mengalami TBIBeri obat dan kalau perlu pembedahan.
Untuk pemulihan atau penyembuhanBeri nutrisi yang tepat dan baik.Prevalen malnutrisi di RS U.S.A 30% -50%.
Fokus, cermatlah dalam memberi terapi nutrisi.
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KASUS 1
Penghitungan Cairan dan Nutrisi pada pasien trauma kepala
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• Wanita 39 tahun dengan cedera otak ringan
• Riwayat muntah dan tidak sadar <5 menitpaska kejadian
• Saat ini anda rawat di ruangan untukobservasi perawatan hari ke-1
Kasus 1
• Berapa cairan yang perlu diberikan ?
• Kapan dan apa diet yang sesuai untukpasien ini ?
Simulasi Kasus
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Kebutuhan cairan harian, rumus
• 100 ml/kgbb untuk 10 kg pertama dalam 24 jam, kemudian
• 50 ml/kgbb untuk 10 kg beriuikutnya dalam 24 jam, kemudian
• 20 ml/kgbb untuk kg sisa dalam 24 jam (usia <60 tahun) ; (>60 tahun 15 ml/kgbb)
Kasus 1
Kebutuhan cairan harian, rerata
35-50 ml/kgbb (dewasa),
30 ml/kgbb (usia tua)
*Demam : tiap kenaikan 1o ditambah 12,5% ; Berkeringat : menigkat 10 -25% ; Hiperventilasi : meningkat 10-60%
Evaluasi apakah tercukupi
Nadi, suhu, tekanan darah, turgor, prod. Urin (0,5-1 cc/kgbb/menit)
SADAR
Hitung kebutuhan cairan→ Tentukan target
Laki-laki 50 kg → 2100 ml/24 jam
→ 1750 – 2500 ml/24 jam
IntravenaPer oral
TIDAK SADAR ?
Personde
Cairan Isotonik
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Kebutuhan nutrisi harian
Berdasarkan formula Harris Benedict, basal energy expenditure (BEE):
1.Pria : 66,47 + 13,75 (KgBB) + 5 (cmTB) – 6,7 (usia) =…kcal/hari
2.Wanita: 65,51 + 9,56 (KgBB) + 1,85 (cmTB) – 4,68 (usia) =…kcal/hari
Kasus 1
SADAR atau TIDAK SADAR ?
Nutrisi
Puasa ??
Early feeding better
Kebutuhan nutrisi harian
COR = 30 kcal/kgbb/24 jam
COS = 35 kcal/kgbb/24 jam
COB = 40 kcal/kgbb/24 jam
Laki-laki 50kg → 1.335 kcal/hari
→ 1.500 kcal/hari (COR) – 1750 kcal/hari (COS) – 2000 kcal/hari (COB)
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KASUS 2
Penganan pasien Kejang pasca trauma kepala
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Kasus 2
• Pria, 29 th post KLL sepeda motor
• Saat ini sedang anda rawat di ruangan untuk observasi dengancedera otak ringan
• Dilaporkan perawat kejang….!!!
Kejang
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Kasus 2
Stabillisasi ABC
Putus kejang
Cegah kejang
Diazepam• 1 ampul (10 mg) dicairkan 10 cc,
diberikan perlahan IV• Supposituria
PhenitoinLoading dose 500 mg dalam 10 menitMaintenance dose 3x100 mg
Pastikan lidah tidak tergigitAmankan lingkungan sekitar pasien
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Kasus 2
Profilaksis anti kejang
Warning sign (boleh diberikan profilaksis anti
kejang)
1. GCS < 10
2. Kontusio kortikal
3. Fraktur depresi
4. EDH, SDH, ICH
5. Trauma tembus kepala
6. Kejang dalam 24 jam setelah cedera otak
Intrakranial Ekstrakranial
1. Serum elektrolit
2. Gula darah
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KASUS 3
Penanganan Pasien dengan
Penurunan Kesadaran
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Kasus 3
• Pria, 19 th perawatan hari ke-1 post KLL tertabrak motor
• Dilaporkan perawat mengalamipenurunan kesadaran mendadakperawatan hari pertama di ruangan!!
• TD 110/65, HR 89, RR regular 22, Spo2 98%, t 36,6
• GCS E4V5M6 → E3V3M5
• Pupil bulan anisokor 3/5 mm, reflek cahaya turun sisikiri
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Kasus 3
Stabillisasi ABC
Identifikasi penyebab LOC (Cedera otak sekunder)
Tatalaksana
Intrakranial Ekstrakaranial
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Terimakasih
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