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PENATALAKSANAANPENATALAKSANAANMALARIA BERAT 2011MALARIA BERAT 2011

Dr. Paul Harijanto, SpPD-KPTIDr. Paul Harijanto, SpPD-KPTI

RSU Bethesda GMIM TomohonRSU Bethesda GMIM Tomohon

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MORTALITYMORTALITY

0.1% case fatality rate provie0.1% case fatality rate proviepro!pt a" e#ective treat!e"tpro!pt a" e#ective treat!e"t

I"e#ective$ elayeI"e#ective$ elaye

 severesevere!alaria!alaria

Severe !alaria$ !ortality 1 & 20Severe !alaria$ !ortality 1 & 20

%%'"treate severe !alaria$'"treate severe !alaria$

al!ost al(ays fatalal!ost al(ays fatal

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PR)*N)SISPR)*N)SIS !alaria pro+"osis score ,MPS- 2.1/ 0.02 !alaria pro+"osis score ,MPS- 2.1/ 0.02

,A+e- 0.2 ,reat- 3 0.24 ,56- /.0,A+e- 0.2 ,reat- 3 0.24 ,56- /.0

,ere6ral- 0.7 ,Pre+"a"cy- 0.7,8e"tilator-,ere6ral- 0.7 ,Pre+"a"cy- 0.7,8e"tilator-

!alaria score for a9lts (as ,MSA- : 1,severe!alaria score for a9lts (as ,MSA- : 1,severe

a"ae!ia- 2 ,ac9te re"al fail9re- a"ae!ia- 2 ,ac9te re"al fail9re- /,Respiratory istress- 4 ,cere6ral !alaria-./,Respiratory istress- 4 ,cere6ral !alaria-.

 T;e MSA ra"+es fro! 0 to 10. T;e !ortality T;e MSA ra"+es fro! 0 to 10. T;e !ortality

(as 2% for MSA 0 & 2< 10% for MSA /&4$ 40%(as 2% for MSA 0 & 2< 10% for MSA /&4$ 40%

for MSA &= a" >0% for MSA ? or !ore. T;efor MSA &= a" >0% for MSA ? or !ore. T;ese"sitivity is 7>.>% a" positive preictivese"sitivity is 7>.>% a" positive preictive

val9e is >4.1% (;e" is ta@e" as t;e c9t o#val9e is >4.1% (;e" is ta@e" as t;e c9t o#

val9e.val9e.

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==

Female, 30years, admitted 18-10-2000, fever and

unconcious. Fever 7 days, chills and rigor. One day before

admission become unconcious and aundice. !he is

"regnant in 32-3# $ee%s. !he had no history of cough,

abdominal "ain , neither diarrhea. !he "assed small

amount of urin.&'amination (

!evere ill, delirium )*+!(&2 # 2/, "ale, aundice

Fever 38 +, .. 11080 mmg "ulse 124minute res"

22min. ear 5 6ung ( normal, 6iver 5 s"leen ( not "al"ableterus 2 finger above umbilicus.

Case rsup;YS/18-10-2000

 ;at Cs t;e appropriate ;istory "eee for ia+"osis D

Kas9s31a

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??

9estio" 9estio"

;at are t;e i"vesti+atio" to !a@e ia+"osis D;at are t;e i"vesti+atio" to !a@e ia+"osis D

Hb. 6.6 gr%; leucocyte 3700/ mm3; platelets 50.000/ mm3

Malaria smear falcip ring ++.

Bl.sugar 55 mg%;reum !"6 gr%; creatinine #$76 mg%$Bilirubin !6.7 mg%&irect !!.' mg%($)lbumin #.! gr%.

*arasite count 37' par/ #00 leuco

Kas9s316

FIA*N)SA D

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77

;at is t;e treat!e"t;at is t;e treat!e"t

)nti Malaria &rug ,)nti Malaria &rug ,)----..)----..

----..----..

ter management ,ter management ,----------------

----------------

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SE8ERE MALARIA 32010SE8ERE MALARIA 32010

DEFINITION : Patient, Plasmosium Asexual parasitemia,with oneor more CLINICAL or LABORATOR FEAT!RE" :

PRO"TRATION

Failure# to Fee#

I$PAIRED CON"CIO!"NE""

RE"PIRATOR DI"TRE""

$!LTIPLE CON%!L"ION", &'x( ') hrs

CIRC!LATOR COLLAP"E

*"+stoli - ./, hli#ren - 0/ 1

P!L$ONAR EDE$A * ra#iolo2+ 1

 ABNOR$AL BLEEDIN3 * spontaneus 14A!NDICE 5 other 6ital or2an

#+s7untion

8AE$O3LOBIN!RIA

"E%ERE ANAE$IA *- 0 2r9(0 91

8PO3LCAE$IA *-)/ m291 ACIDO"I" *- 0 mmol(L1

RENAL I$PAIR$ENT *& ; m291

8PERLACTATAE$IA *& 0mmol(L1

8PERPARA"ITE$IA *&'9( 091

WHO: Guidelines for the Treatment of Malaria 2010- second edition

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MALARIA BERATMALARIA BERATMALARIA SEREBRAL

MALARIA DGN BILIRUBIN > 3 MG%GAGAL GINJAL AKUT < 400 ml/24 jam & Krea > 3 m!%

"I#$GLIKEMI < 40 m!%

S$K SIST$LIK < 0 mm"! / A'a( < )0 mm"!

ANEMIA BERAT "B < ) !r% / " < *)%EDEMA #ARU / ARDS

#ERDARA"AN S#$NTAN / DI+

KEJANG BERULANG

ASID$SIS #, ) %

"I#ERTERMIA > 40 +

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PENGEBAB H ETI)L)*IPENGEBAB H ETI)L)*I

Plas!oi9! falcipar9!Plas!oi9! falcipar9!

Mie plas!oi9! , Jalcipar9!Mie plas!oi9! , Jalcipar9!

viva-viva-

Plas!oi9! vivaPlas!oi9! viva

Plasmodium knowlesiPlasmodium knowlesi

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PLASM)FI'M KN)LESIPLASM)FI'M KN)LESI

Si!ia" !alaria , Maccaca !9llata-Si!ia" !alaria , Maccaca !9llata-

'"9s9al prese"tatio" P. Malariae'"9s9al prese"tatio" P. Malariae Fia+"osis 6y PRFia+"osis 6y PR Ac9te iare$ a6o!i"al pai"$ a9"iceAc9te iare$ a6o!i"al pai"$ a9"ice

Al+i !alaria$ ;ypote"sio"Al+i !alaria$ ;ypote"sio"

Re"al fail9re$ respiratory fail9reRe"al fail9re$ respiratory fail9re

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B12) M))4) B14) *)2) 21)8) 9B12) M))4) B14) *)2) 21)8) 9

):) ):) 

A N A K DEWASA

Batuk  Sering Jarang

Kejang Sangat sering Sering

Ikterik  Jarang Sering

Lama sakit Pendek (1-2 hr Panjang (!-" hr

Lama k#ma Pendek (1-2 hr Panjang (2-$ hr%i&er&arasitemia Sering Jarang

%ig'ikemia Sering see'um )* Sering sesudah )*+%m'

,aga' ginja' Jarang Sering

ek.I.K naik  Sering+naik Jarang+ n#rma'Edema &aru Jarang Sering

Perdarahan Jarang ---1/ 0

,gn rain stem Leih sering Jarang

Seue'ae Neur#. 1/ 0 3 ! 0

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Sy"ro!es of severe !alariaSy"ro!es of severe !alaria

1. ;ilre"1. ;ilre"

1. Severe a"e!ia1. Severe a"e!ia

2. Meta6olic aciosis2. Meta6olic aciosis

/. ere6ral !alaria/. ere6ral !alaria

Eacer6ate 6yEacer6ate 6y ;ypovole!ia;ypovole!ia

;ypo+lyce!ia;ypo+lyce!ia salicylate toicitysalicylate toicity

Re"al fail9re rareRe"al fail9re rare

L9"+ i"9ryHARFS rareL9"+ i"9ryHARFS rare

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Sy"ro!es of severe !alariaSy"ro!es of severe !alaria

2. "o"3i!!9"e a9lts2. "o"3i!!9"e a9lts

M9ltior+a" fail9reM9ltior+a" fail9re5yperparasite!ia5yperparasite!ia

Ac9te re"al fail9reAc9te re"al fail9re a9"ice a9"ice

Meta6olic aciosisMeta6olic aciosis

5ypo+lyce!ia5ypo+lyce!ia

Ac9te respiratoryAc9te respiratoryistress sy"ro!eistress sy"ro!e

A"e!iaHt;ro!6ocytope"A"e!iaHt;ro!6ocytope"

iaia

ere6ral !alariaere6ral !alaria

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Pro+"ostic val9e fre9e"cy of SM i" a9lts H c;ilre"Pro+"ostic val9e fre9e"cy of SM i" a9lts H c;ilre"

+hildren +hildrendults dults+linical manifestations or6aboratory finding

rostration

9m"aired counciousness

:es"iratory distress ) acidotic breathing /ulti"le convulsions

+irculatory colla"se

ulmonary &dema )radiological/

bnormal bleeding

;aundice

aemoglobinuria 

!evere nemia 

+

+

++

+

+ +

++

+

+ +++

+

+

+

+

+

+ /

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lassiOcatio"s SM i" ;ilre"lassiOcatio"s SM i" ;ilre" *ro9p 1 ,re9ire pare"teral R S9pport.T -*ro9p 1 ,re9ire pare"teral R S9pport.T -

1.1. Prostratio" , i"a6ility to sit 9pri+;t-$ / s96s+ro9p Prostratio" , i"a6ility to sit 9pri+;t-$ / s96s+ro9p Prostrate 69t f9lly co"cio9sProstrate 69t f9lly co"cio9s

Prostrate (it; i!paire co"cio9s"ess "ot co!aProstrate (it; i!paire co"cio9s"ess "ot co!a

o ! a o ! a

2.2. Respiratory istress , aciotic 6reat;i"+Respiratory istress , aciotic 6reat;i"+ Mil & "asal ari"+ H or !il i"tercostal i"ra(i"+Mil & "asal ari"+ H or !il i"tercostal i"ra(i"+

Severe & !ar@ i"tercoctal i"ra(i"+ or eep acioticSevere & !ar@ i"tercoctal i"ra(i"+ or eep aciotic

*ro9p 2 ,a6le to ta@e oral R$ re9ire s9pervise- *ro9p 2 ,a6le to ta@e oral R$ re9ire s9pervise-

1.1. 5ae!o+lo6i" Q +r% or ;ae!atocrit Q 1%5ae!o+lo6i" Q +r% or ;ae!atocrit Q 1%2.2. : 2 co"v9lsio"s i" 24 ;o9rs : 2 co"v9lsio"s i" 24 ;o9rs

*ro9p / re9ire pare"teral T 6eca9se of*ro9p / re9ire pare"teral T 6eca9se of

persiste"t vo!iti"+$ "ot i" +ro9p 1 or 2.persiste"t vo!iti"+$ "ot i" +ro9p 1 or 2.

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Pe"ilaia" a(alPe"ilaia" a(al

A!a"@a" Air(ay$ Breat;i"+$ irc9latio"A!a"@a" Air(ay$ Breat;i"+$ irc9latio" Ti!6a"+ 6erat 6aa" 9"t9@ osis o6at Ti!6a"+ 6erat 6aa" 9"t9@ osis o6atPasa"+ i.v. li"ePasa"+ i.v. li"ePeri@sa +9la ara;$ 56$ ;it9"+ parasit$Peri@sa +9la ara;$ 56$ ;it9"+ parasit$

9re9!$ @reati"i"$ a"alisa +as ara;$9re9!$ @reati"i"$ a"alisa +as ara;$@aar asa! la@tat@aar asa! la@tat

Pe!eri@saa" Osi@ ya"+ teliti ter9ta!aPe!eri@saa" Osi@ ya"+ teliti ter9ta!ati"+@at @esaara" , *S -ti"+@at @esaara" , *S -'@9r 6ala"s caira" ya"+ tepat'@9r 6ala"s caira" ya"+ tepat

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M):)>1M1: 81?141M):)>1M1: 81?141

M))4)M))4) SPEIJI TREATMENTSPEIJI TREATMENT

ANTI MALARIAL FR'*SANTI MALARIAL FR'*S

)R*AN JAIL'RE TREATMENT)R*AN JAIL'RE TREATMENT

S'PP)RTI8E TREATMENTS'PP)RTI8E TREATMENT

ANILLARG TREATMENTANILLARG TREATMENT

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ANTI MALARIAL THERAPY FOR S.MANTI MALARIAL THERAPY FOR S.M

'ININE'ININE

'INIFINE'INIFINE

Artes9"ateH ARTS , i.v.H i.! H s9pp -Artes9"ateH ARTS , i.v.H i.! H s9pp -Arte!et;er H ARTM ,i.!.-Arte!et;er H ARTM ,i.!.-

Arte3et;er ,i.! -Arte3et;er ,i.! -

Arte!isi"i" , s9pp -Arte!isi"i" , s9pp -Fi;yro3arte!isi"i" , s9pp -Fi;yro3arte!isi"i" , s9pp -

Arteli"ate , i.v-Arteli"ate , i.v-

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81?141 M))4)81?141 M))4)

Re9ire pare"teral or s9ppossitoria treat!e"tRe9ire pare"teral or s9ppossitoria treat!e"t Fecrease parasite!ia rapilyFecrease parasite!ia rapily

Less sie e#ectLess sie e#ect

9i"i"e vs Arte!isi"i" , ARTM $ ARTS -9i"i"e vs Arte!isi"i" , ARTM $ ARTS -

ARTM tre" to ;ave lo( !ortality 69t co!aARTM tre" to ;ave lo( !ortality 69t co!a

recovery prolo"+$ !ore co"v9lsio"recovery prolo"+$ !ore co"v9lsio"

ARTS Better t;a" 9i"i"e , SE'AMAT -ARTS Better t;a" 9i"i"e , SE'AMAT -

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Dosis

41@MM1:212 2818 A ): M))4) 24>8 A441@MM1:212 2818 A ): M))4) 24>8 A4

41)M1: A 81?141 M))4)41)M1: A 81?141 M))4)

i.v. 2$4 !+H@+ BB paa a! 0$ a"i.v. 2$4 !+H@+ BB paa a! 0$ a" a! 12$ @e!9ia" ila"9t@a" a! 12$ @e!9ia" ila"9t@a" a! 24$ 47 st sa!pai ? ;ari. a! 24$ 47 st sa!pai ? ;ari.Fosis total 1? & 17 !+H ? ;ariFosis total 1? & 17 !+H ? ;ari, 1 A!p: =0 !+-, 1 A!p: =0 !+-

/.2 !+H@+ i! paa ;ari I i6a+i 2/.2 !+H@+ i! paa ;ari I i6a+i 2osis$ ila"9t@a" 1.= !+H@+Hosis$ ila"9t@a" 1.= !+H@+H;ari. TIFAK iv ,1 a!p : 70;ari. TIFAK iv ,1 a!p : 70!+-!+-

S9ppositories$ 10 !+H@+ at 0 4S9ppositories$ 10 !+H@+ at 0 4;r follo(e 6y ? !+H@+ at;r follo(e 6y ? !+H@+ at

24$/=$47 =0 ;rs24$/=$47 =0 ;rs..

Arte!eterArte!eter

FR'*SFR'*S SIFE EJJETSSIFE EJJETS

Arte!isi"i"Arte!isi"i"

ARTES'NATE

Ne9rotoicity i"a"i!al "ot ;9!a"

5) 200= AS is t;e reco!!e"e JIRST 5)IE i" area

lo( tra"s!issio"

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Dosis ARTEMISININ PADA MALARIADosis ARTEMISININ PADA MALARIA

BERAT BERAT 

0 JAM 12. 24. 47. ?2. Ma ? ;ari

2.4M+HK+BB

2.4M+HK+BB

2.4M+HK+BB

2.4M+HK+BB

2.4M+HK+BB

ARTESUNATE I.V/ I.M

* ARTEMETER , hanya I.M , dosis ,! "#/$# BB

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SE'AMAT

8S

A'AMAT

( 2005, Lance, !"s #

2010$ La"cet$ Nov -

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A'AMATA'AMAT

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A'AMATA'AMAT, Africa" 'i"i"e Artes9"ate MAlaria Trial -, Africa" 'i"i"e Artes9"ate MAlaria Trial -

Findings 5425 children were enrolled; 2712 were assigned to artesunate andFindings 5425 children were enrolled; 2712 were assigned to artesunate and

2713 to quinine2713 to quinine. 230 )8/ "atients assigned to artesunate. 230 )8/ "atients assigned to artesunate treatmenttreatment dieddied compared withcompared with 247 )10/ assigned to ?uinine247 )10/ assigned to ?uinine treatment odds ratio !"#$treatment odds ratio !"#$

strati%ied %or stud& site 0'75( )5* +, 0'-3.0')0;strati%ied %or stud& site 0'75( )5* +, 0'-3.0')0; relative reductionrelative reduction 22,22,

)5* +, /'1.3-'); p0'0022)5* +, /'1.3-'); p0'0022

9ncidence of neurological se?uelae9ncidence of neurological se?uelae did not di%%er signi%icantl& etweendid not di%%er signi%icantl& etweengroups( ut the deelopmentgroups( ut the deelopment of coma )@=1832 A3B $ith artesunateof coma )@=1832 A3B $ith artesunate vsvs

91/1768 [5·1%] with quinine91/1768 [5·1%] with quinine; OR 0·69 ,; OR 0·69 , )5* +, 0'4).0')5; p0'0231()5* +, 0'4).0')5; p0'0231(

convulsions )22#2712 A8Bconvulsions )22#2712 A8B vs 273/2713 [10·1%] vs 273/2713 [10·1%] ; OR 0·80,; OR 0·80,0'--.0')7;0'--.0')7;

p0'01))( andp0'01))( and deterioration of the coma score )1@@2712 A@Bdeterioration of the coma score )1@@2712 A@B vsvs

 208/2713 [7·7%]; 208/2713 [7·7%]; "# 0'7/( 0'-4.0')7; p0'0245"# 0'7/( 0'-4.0')7; p0'0245 $ere all significantly less $ere all significantly less

fre?uent in artesunate reci"ients than in ?uinine reci"ients.fre?uent in artesunate reci"ients than in ?uinine reci"ients.

ost-treatment hy"oglycaemiaost-treatment hy"oglycaemia  was also less %requent in patients assigned was also less %requent in patients assigned

to artesunate than in those assigned to quinine to artesunate than in those assigned to quinine #82712 A1B#82712 A1B vsvs 75/271375/2713

 [2·8%]  [2·8%] ; OR 0·63, 0·43– ; OR 0·63, 0·43– 0')1; p0'01340')1; p0'0134

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ARTESUNATE

I.V / I.M

1 Jl : =0 !

ARTEMETHER I.M1 A!p : 70!+

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RE+$MMENDED D$SES $ ANTIRE+$MMENDED D$SES $ ANTI

MALARIAL DRUGS $R TREATMENT $MALARIAL DRUGS $R TREATMENT $

SE5ERE/+EREBRAL MALARIASE5ERE/+EREBRAL MALARIA

5ypo+lyce!ia$5ypo+lyce!ia$

c;i"c;o"is!$c;i"c;o"is!$

ti""it9s$ ;eari"+ti""it9s$ ;eari"+i!pair!e"t$i!pair!e"t$

"a9sea$ ysp;oria$"a9sea$ ysp;oria$

vo!iti"+$ prolo"+evo!iti"+$ prolo"+e

T i"terval$T i"terval$

ysr;yt;!ias$ysr;yt;!ias$;ypote"sio";ypote"sio"

20 !+ of i;yroc;lorie saltH@+20 !+ of i;yroc;lorie saltH@+

6y iv i"f9sio" over 4 ;r$ t;e"6y iv i"f9sio" over 4 ;r$ t;e"

after loai"+$ follo(e 6y 10after loai"+$ follo(e 6y 10!+H@+ over 4 ;r every 7 ;r.!+H@+ over 4 ;r every 7 ;r.

Patie"ts s;o9l "ot receivePatie"ts s;o9l "ot receive

9i"i"e or !eo9i"e (it;i"9i"i"e or !eo9i"e (it;i"

last 24 ;rlast 24 ;r

 Alter"atively$ ? !+ of saltH@+Alter"atively$ ? !+ of saltH@+

ca" 6e i"f9se over a perioca" 6e i"f9se over a perioof /0 !i"$ follo(e 6y 10 !+of /0 !i"$ follo(e 6y 10 !+

saltH@+ over a perio of 4 ;r$saltH@+ over a perio of 4 ;r$

oror

10 !+ of saltH@+ ,00 !+ for10 !+ of saltH@+ ,00 !+ for

a9lt- 6y i.v i"f9sio" over 7 ;ra9lt- 6y i.v i"f9sio" over 7 ;r

co"ti"o9sly / a ayco"ti"o9sly / a ay

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#e'!aa' K'a "+l/67,6r(lr6 8are'eral#e'!aa' K'a "+l/67,6r(lr6 8are'eral

00 44 99 *2*2 *:*: 2020 2424

La6'!La6'!

20 m!/(!BB I5 ';/*007200 ml/4 jam20 m!/(!BB I5 ';/*007200 ml/4 jam

Bera a6a' =- K!Bera a6a' =- K!

Ta( 8a(a K'a/Me;l' 24 jam eelm'?aTa( 8a(a K'a/Me;l' 24 jam eelm'?a

T6a( la'j a aa @T/@T1 '- 8a'ja'!T6a( la'j a aa @T/@T1 '- 8a'ja'!

*0 m!/(!BB*0 m!/(!BB

I5 '; 200 ml/4 jamI5 '; 200 ml/4 jam

6la'! a8 9 jam6la'! a8 9 jamI'; ('! 9 jamI'; ('! 9 jam

a'8a ('aa'8a ('a

I'; ('! 9 jamI'; ('! 9 jam

a'8a ('aa'8a ('a

CAKTU JAMCAKTU JAM

Sa'6ar6Sa'6ar6

*0 m!/(!BB I5*0 m!/(!BB I5

';/200 ml/4 jam';/200 ml/4 jam

SEELA% KESADA)AN 4E4BAIK+DAPA 4IN54 6SEELA% KESADA)AN 4E4BAIK+DAPA 4IN54 6

,ANI PE)-7)AL 1/ 4,+K,BB+8 JA4,ANI PE)-7)AL 1/ 4,+K,BB+8 JA4

SA4PAI %A)I KE-"SA4PAI %A)I KE-"

APABILA SEELA% $8 JA4APABILA SEELA% $8 JA4

KEADAAN IDAK 4E4BAIK 6KEADAAN IDAK 4E4BAIK 6

,9S EAP+4E4B5)5K ,9S EAP+4E4B5)5K 

BILI)5BIN + K)EAININ NAIK BILI)5BIN + K)EAININ NAIK 

5)IN K5)AN, + AK ADA5)IN K5)AN, + AK ADA

 

D7SIS DI5)5NKAN :/-!/0D7SIS DI5)5NKAN :/-!/0

*0 m!/(!BB*0 m!/(!BB

I5 '; 200 ml/4 jamI5 '; 200 ml/4 jam

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Dextrose 09

Kina

$iro#rips

//='//

Pi22+

Ba>Cairan

$aintenane

@)4) *1MB14):@)4) *1MB14):

:):) *)2)*)2)M))4) B14)M))4) B14)

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#e'!aa' K'a "+l/67,6r(lr6 8are'eral#e'!aa' K'a "+l/67,6r(lr6 8are'eral

00 44 *2*2 *:*: 2020 2424

CAKTU JAMCAKTU JAM

)00 m! K'a "+l * am8)00 m! K'a "+l * am8

6alam )00 11 Dere )%6alam )00 11 Dere )%)00 m! K'a "+l * am8)00 m! K'a "+l * am8

6alam )00 11 Dere )%6alam )00 11 Dere )%)00 m! K'a "+l * am8)00 m! K'a "+l * am8

6alam )00 11 Dere )%6alam )00 11 Dere )%

SEELA% KESADA)AN 4E4BAIK+DAPA 4IN54 6SEELA% KESADA)AN 4E4BAIK+DAPA 4IN54 6

,ANI PE)-7)AL 1/ 4,+K,BB+8 JA4,ANI PE)-7)AL 1/ 4,+K,BB+8 JA4

SA4PAI %A)I KE-"SA4PAI %A)I KE-"

APABILA SEELA% $8 JA4APABILA SEELA% $8 JA4

KEADAAN IDAK 4E4BAIK 6KEADAAN IDAK 4E4BAIK 6

,9S EAP+4E4B5)5K ,9S EAP+4E4B5)5K 

BILI)5BIN + K)EAININ NAIK BILI)5BIN + K)EAININ NAIK 

5)IN K5)AN, + AK ADA5)IN K5)AN, + AK ADA

 

D7SIS DI5)5NKAN :/-!/0D7SIS DI5)5NKAN :/-!/0

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Pe"yes9aia" osis paa +a"++9a" J9"+si )r+a"Pe"yes9aia" osis paa +a"++9a" J9"+si )r+a"

Tida$ %&'() %&ny&s)aian dosis oa+ d&'ia+ a'+&"isininTida$ %&'() %&ny&s)aian dosis oa+ d&'ia+ a'+&"isinin%ada #an##)an -)n#si ha+i dan a+a) #ina(%ada #an##)an -)n#si ha+i dan a+a) #ina( Dosis $ina %a'&n+&'a( di+)')n$an / s&+&(ah 01 a"Dosis $ina %a'&n+&'a( di+)')n$an / s&+&(ah 01 a"

%&"&'ian %ada 2%&"&'ian %ada 2

3a#a( #ina( a$)+3a#a( #ina( a$)+ 3an##)an -)n#si ha+i3an##)an -)n#si ha+i Tida$ ada %&'ai$an $(inis s&+&(ah 01 a"Tida$ ada %&'ai$an $(inis s&+&(ah 01 a" Bi(a %asi&n s)dah h&"odia(isis +ida$ %&'()Bi(a %asi&n s)dah h&"odia(isis +ida$ %&'()

%&n#)'an#an dosis $ina%&n#)'an#an dosis $ina 

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Pe"+o6ata" B9!il MalariaPe"+o6ata" B9!il Malaria

BeratBerat

 Tri!ester 2 3/ $ 9ra"teH post part9!  Tri!ester 2 3/ $ 9ra"teH post part9! Artes9"ate i.v 2$4 !+H@+ BB a! 0$ 12$Artes9"ate i.v 2$4 !+H@+ BB a! 0$ 12$

24$ 47 st$ 6ila saarH 6isa !i"9!24$ 47 st$ 6ila saarH 6isa !i"9!

o6at +a"ti oral sa!pai & ? ;ari. Bilao6at +a"ti oral sa!pai & ? ;ari. Bila

oral artes9"ate 2 !+H@+ BB i6eri@a"oral artes9"ate 2 !+H@+ BB i6eri@a"sa!pai ;ari @e3? ,ars cli"a!yci"-sa!pai ;ari @e3? ,ars cli"a!yci"-

 Tri!ester 1 Ki"a 5l peri"f9s$ 20 Tri!ester 1 Ki"a 5l peri"f9s$ 20

!+H@+ BB osis a(al a" 10 !+H@+ BB!+H@+ BB osis a(al a" 10 !+H@+ BBsela"9t"yasela"9t"ya

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Pe"+o6ata" la"9ta"Pe"+o6ata" la"9ta" S&+&(ah %asi&n sada'/4U "&"ai$, +5. A6a( %a'&n+&'a(S&+&(ah %asi&n sada'/4U "&"ai$, +5. A6a( %a'&n+&'a(

da%a+ di)ah d#n. T5. O'a(. P&n#oa+an %a'&n+&'a( "ini"a(da%a+ di)ah d#n. T5. O'a(. P&n#oa+an %a'&n+&'a( "ini"a( 5 %&"&'ian 7 8, 9 dan 90 a" : 5 %&"&'ian 7 8, 9 dan 90 a" :

Di+&')s$an d&n#an 2Di+&')s$an d&n#an 2 A;T dosis (&n#$a% 7s&(a"a ha'i:2 AL , AS < A=A;T dosis (&n#$a% 7s&(a"a ha'i:2 AL , AS < A= A'+&s)na+&/a'+&"&+h&' +a. 7+o+a( > ha'i : < do$sisi$(in ?A'+&s)na+&/a'+&"&+h&' +a. 7+o+a( > ha'i : < do$sisi$(in ?

@ 4# BB $a(i s&ha'i s&(a"a > ha'i@ 4# BB $a(i s&ha'i s&(a"a > ha'i 4ina +a.7+o+a( > ha'i: < do$sisi$(in > ha'i4ina +a.7+o+a( > ha'i: < do$sisi$(in > ha'i

Ba#i )"i(, ana$?ana$ 2 do$sisi$(in di#an+i d&n#anBa#i )"i(, ana$?ana$ 2 do$sisi$(in di#an+i d&n#an$(inda"isin 8 "#/4# BB 9 $a(i s&ha'i$(inda"isin 8 "#/4# BB 9 $a(i s&ha'i

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Pe"+o6ata" pre3referalPe"+o6ata" pre3referal

Fia"9r@a" se6el9! !er99@ setia@"yaFia"9r@a" se6el9! !er99@ setia@"yaosis perta!a o6at a"ti!alaria pare"teralosis perta!a o6at a"ti!alaria pare"teral

s9a; i6eri@a".s9a; i6eri@a".

)6at ya"+ ipili; )6at ya"+ ipili; Arte!et;er i.!. ata9 Artes9"ate i.!.Arte!et;er i.!. ata9 Artes9"ate i.!. Artes9"ate ata9 arte!isi"i" s9positoriaArtes9"ate ata9 arte!isi"i" s9positoria Ki"a i.!.Ki"a i.!. Ki"a i.v. ,ia!pi"+i pet9+as !eis - DDKi"a i.v. ,ia!pi"+i pet9+as !eis - DD

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A 27years ol lay 9"co"cio9s fever si"ce Q 24 ;o9rs 6efore a!issio" i")" > Septe!6er 2002 at 10.00 a.!.

Aalcip , +gamet

Hb. !#.3Bl. 8ugar ,

!05 mg%Bill. 2ir, 6.7Bill.in&ir, !.8> ,!7# u8>* , !0u>> , "' u/)l.*", 36@reat , !.5 pH , 7."H@3 , #3.'p# , '0

p@#, 37B.1C.,< 0. , 3.#@8A ,@ell ; #00ymp. ,"

3

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;&'&'a( Ma(a'ia 6i+h in-i(+'a+& o+h ()n#

MM13/

@estD

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01 ho)'s a-+&' )inin& +'&a+"&n+ MM134

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 TREATMENT )J )R*AN JAIL'RE TREATMENT )J )R*AN JAIL'RE

1:@1*H)*)HE/ @:?8:1:@1*H)*)HE/ @:?8:41:) A)4141:) A)41

)@288)@288

HE*>E@)1M)HE*>E@)1M)HE*14B4B:)1M)HE*14B4B:)1M)

418*4)4E A)41418*4)4E A)41

HE*1:8:HE*1:8: 81*8881*88

81?141 ):)1M)81?141 ):)1M)

A'TE KIFNEG IN'RG ,AKI-A'TE KIFNEG IN'RG ,AKI-

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A'TE KIFNEG IN'RG ,AKI-A'TE KIFNEG IN'RG ,AKI-

Malaria relate Ac9te Ki"ey I"9ry ,MAKI-Malaria relate Ac9te Ki"ey I"9ry ,MAKI-

Pe"9r9"a" f9"+si +i"al ala! 47 a! Pe"9r9"a" f9"+si +i"al ala! 47 a! Pe"i"+@ata" ser9! @reati"i" 0./ !+HL$ ata9Pe"i"+@ata" ser9! @reati"i" 0./ !+HL$ ata9

Pe"i"+@ata" ser9! @reati"i" 0% a" "ilaiPe"i"+@ata" ser9! @reati"i" 0% a" "ilai

asar$ ata9asar$ ata9Pe"9r9"a" 9ri" o9tp9t 0. !lH@+Ha! 9"t9@ =Pe"9r9"a" 9ri" o9tp9t 0. !lH@+Ha! 9"t9@ =

 a! a!

5) ser9! @reati"i" / !+HL5) ser9! @reati"i" / !+HLSeri"+ paa !alaria e(asa a" ara"+Seri"+ paa !alaria e(asa a" ara"+

paa a"a@paa a"a@

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P'LM)NARG MANIJESTATI)N IN MALARIAP'LM)NARG MANIJESTATI)N IN MALARIA

5istorically 5istorically Bro"c;iticBro"c;itic

P"e9!o"icP"e9!o"ic

Bro"c;op"e9!o"icBro"c;op"e9!o"ic

Ac9te L9"+ I"9ry ,ALI-Ac9te L9"+ I"9ry ,ALI-

Ac9te Respiratory FistressAc9te Respiratory Fistress

Sy"ro!e ,ARFS-Sy"ro!e ,ARFS-

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A.R.F.SA.R.F.S

)cc9rs i" P. Jalcipar9!$ P. 8iva$ P. )vale D P.)cc9rs i" P. Jalcipar9!$ P. 8iva$ P. )vale D P.K"o(lesiK"o(lesi

o!!o" i" a9lt t;a" c;ilre"$ pre+"a"cy a"o!!o" i" a9lt t;a" c;ilre"$ pre+"a"cy a"

"o"3i!!9"e"o"3i!!9"e

Mec;a"is! I"crease alveolar cappilaryMec;a"is! I"crease alveolar cappilary

per!ea6ilityper!ea6ility  i"travasc9lar 9i loss i"to t;ei"travasc9lar 9i loss i"to t;e

l9"+sl9"+s

Prese"tatio" i"itial prese"tatio" or after i"itiatio"Prese"tatio" i"itial prese"tatio" or after i"itiatio"

treat!e"ttreat!e"t

li"ical ac9te o"set ysp"eali"ical ac9te o"set ysp"ea  respiratory fail9rerespiratory fail9re

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LINIAL JINFIN*LINIAL JINFIN* Ma"ifest a6r9pt o"set ysp"oea$ co9+;$ ti+;t"ess i"Ma"ifest a6r9pt o"set ysp"oea$ co9+;$ ti+;t"ess i"

t;e c;est t;at pro+resses rapily over a fe( ;o9rst;e c;est t;at pro+resses rapily over a fe( ;o9rs Fisorie"tatio" a" a+itatio" is fre9e"tly prese"t.Fisorie"tatio" a" a+itatio" is fre9e"tly prese"t.

P;ysical ea!i"atio"P;ysical ea!i"atio" si+"s of respiratory istress , air si+"s of respiratory istress , air

;9"+er$ 9se of accessory !9scles of respiratio"$;9"+er$ 9se of accessory !9scles of respiratio"$

s9praster"al a" i"tercostal i"ra(i"+ -$ ce"tral a"s9praster"al a" i"tercostal i"ra(i"+ -$ ce"tral a"perip;eral cya"osis ,arterial ;ypoae!ia-$ 6asalperip;eral cya"osis ,arterial ;ypoae!ia-$ 6asal

crepitatio"s a" epiratory (;eei"+.crepitatio"s a" epiratory (;eei"+.

I" t;ese patie"ts$ ;i+; parasitae!ia$ac9te re"al fail9re$I" t;ese patie"ts$ ;i+; parasitae!ia$ac9te re"al fail9re$

;ypo+lyce!ia$ !eta6olic aciosis$ isse!i"ate;ypo+lyce!ia$ !eta6olic aciosis$ isse!i"atei"travasc9lar coa+9latio" ,FI-$ a" 6acterial sepsisi"travasc9lar coa+9latio" ,FI-$ a" 6acterial sepsis

9s9ally co3eist.9s9ally co3eist.

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;est raio+rap;y ;est raio+rap;y Bilateral fro"tal opacities ,alveolarBilateral fro"tal opacities ,alveolar

patter"-$ i"crease i"terstitial !ar@i"+spatter"-$ i"crease i"terstitial !ar@i"+s

 T;e cariac sie is 9s9ally "or!al T;e cariac sie is 9s9ally "or!al

Rarely$ t;ic@e"i"+ of l9"+ Oss9res$Rarely$ t;ic@e"i"+ of l9"+ Oss9res$

i"terlo69lar septal li"esi"terlo69lar septal li"es

Ple9ral e#9sio"Ple9ral e#9sio"

I" assiste ve"tilator I" assiste ve"tilator co!plicatio"s p"e9!ot;ora$co!plicatio"s p"e9!ot;ora$

p"e9!o!eiasti"9! $ p"e9!o"ia !ay occ9rp"e9!o!eiasti"9! $ p"e9!o"ia !ay occ9r

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>1:14) 8**4?1>1:14) 8**4?1

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>1:14) 8**4?1>1:14) 8**4?1

M1)8418M1)8418 Patie"ts s;o9l 6e treate i" a" I'Patie"ts s;o9l 6e treate i" a" I'

I" e"e!ic areas treat!e"t s;o9l 6eI" e"e!ic areas treat!e"t s;o9l 6eco!!e"ce as early as possi6le$ so!eti!esco!!e"ce as early as possi6le$ so!eti!es

6efore positive parasitolo+y6efore positive parasitolo+y

Patie"ts s;o9l 6e (ei+;e so t;at ose ofPatie"ts s;o9l 6e (ei+;e so t;at ose of

a"ti !alarial ca" 6e calc9latea"ti !alarial ca" 6e calc9late I8 9is s;o9l 6e +ive" to !ai"tai" 9iI8 9is s;o9l 6e +ive" to !ai"tai" 9i

6ala"ce a" caloric re9ire!e"ts. A ce"tral6ala"ce a" caloric re9ire!e"ts. A ce"tral

li"e a" !o"itori"+ of ce"tral ve"o9sli"e a" !o"itori"+ of ce"tral ve"o9s

press9re !ay 6e "ecessary$ especially i"press9re !ay 6e "ecessary$ especially i"elerly. All i"ta@e s;o9l 6e recore caref9llyelerly. All i"ta@e s;o9l 6e recore caref9lly

Air(ay$ )y+e" re9ire!e"tAir(ay$ )y+e" re9ire!e"t

 Treat ;yperpyreia Treat ;yperpyreia

>1:14) 8**4?1

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>1:14) 8**4?1>1:14) 8**4?1

M1)8418M1)8418 'ri"ary cat;eteriatio" s;o9l 6e 9se to !o"itor'ri"ary cat;eteriatio" s;o9l 6e 9se to !o"itor

o9tp9to9tp9t

Patie"ts s;o9l 6e o6serve for vo!iti"+. ToPatie"ts s;o9l 6e o6serve for vo!iti"+. To

e"s9re patie"ts safety$ cot3sies !ay 6e re9iree"s9re patie"ts safety$ cot3sies !ay 6e re9ire

Re+9lar re3positio"i"+ of patie"t is "ecessary toRe+9lar re3positio"i"+ of patie"t is "ecessary to

preve"t evelop!e"t of press9re sorespreve"t evelop!e"t of press9re sores

Naso+astric t96e s;o9l 6e avoie 6eca9se of t;eNaso+astric t96e s;o9l 6e avoie 6eca9se of t;e

ris@ of aspiratio"ris@ of aspiratio" M)NIT)RIN* *S 8ITAL SI*NM)NIT)RIN* *S 8ITAL SI*N

LAB JB$ *L')SE$ PAR.)'NT$ REATININE$ 'RE'M$LAB JB$ *L')SE$ PAR.)'NT$ REATININE$ 'RE'M$

BL))F *AS$ 'RINE S.*$ S)FI'M$ P)TASSI'M.BL))F *AS$ 'RINE S.*$ S)FI'M$ P)TASSI'M.

PRE8ENT S5)K$ SEPTIAEMIA$ AIF)SIS$ ARFS$PRE8ENT S5)K$ SEPTIAEMIA$ AIF)SIS$ ARFS$

5GP)*LGAEMIA$ ASPIRATI)N$ BEFS)RES.5GP)*LGAEMIA$ ASPIRATI)N$ BEFS)RES.

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KEG S'EEF J)R MANA*IN*KEG S'EEF J)R MANA*IN*

SE8ERE MALARIASE8ERE MALARIA

Acc9racy ia+"osis , !icroscopic &6ioc;e!ical -

Malaria r9+ , to co!6at resiste"cy -

A6ility to treat or+a" fail9re , I' Meical e9ip!e"t -

*oo !a" po(er, "9rses 333 octor -

*oo referral syste!

T t t S M l iT t t S M l i

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 Treat!e"t Severe Malaria Treat!e"t Severe Malaria

3201032010

Severe Malaria is a !eical e!er+e"cySevere Malaria is a !eical e!er+e"cyA9lt Artes9"ate iv H i!A9lt Artes9"ate iv H i!

;ilre" Artes9"ate ivHi!$ 9i"i"e;ilre" Artes9"ate ivHi!$ 9i"i"e

ivHi!$ Arte!eter i!ivHi!$ Arte!eter i!*ive Pare"teral at least 24 ;o9rs*ive Pare"teral at least 24 ;o9rs

S(ict; to oral AT$ artes9"ate S(ict; to oral AT$ artes9"ate

cli"a!yci"Hoycycli"$ 9i"i"e lHcli"a!yci"Hoycycli"$ 9i"i"e lH If "ot posi66le$ +ive pre3referal R$ t;e"If "ot posi66le$ +ive pre3referal R$ t;e"

referre i!!eiatelyreferre i!!eiately

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'NT'K F)KTER SPESIALIS'NT'K F)KTER SPESIALIS

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)@si+e"asi)@si+e"asi

Pe"ce+a;a" @ea"+ iaepa!$Pe"ce+a;a" @ea"+ iaepa!$

l9!i"al$ lar+actill9!i"al$ lar+actil

Me"ce+a; tra9!aH at9;Me"ce+a; tra9!aH at9;

Me"+atasi a"iety$ eliri9! stateMe"+atasi a"iety$ eliri9! state

#e'a'!a'a' ';e' ereral#e'a'!a'a' ';e' ereral

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o"v9lsio"so"v9lsio"s

I.v. iaepa! 10 !+ &a9lt or rectalI.v. iaepa! 10 !+ &a9lt or rectal0.31.0 !+H@+0.31.0 !+H@+

i.! parale;ye o.1 !+H@+ & a9lti.! parale;ye o.1 !+H@+ & a9lt

Repeate co"v3 c;lor!et;iaolRepeate co"v3 c;lor!et;iaoli"f9ssio" 0.7 %$i"f9ssio" 0.7 %$

P;e"ytoi" !+H@+ i.v. 20 !i"9tesP;e"ytoi" !+H@+ i.v. 20 !i"9tes

Josp;e"ytoi" ?. !+H@+ i.v U20Josp;e"ytoi" ?. !+H@+ i.v U20!"9tes!"9tes

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PENAN*ANAN IKTERIK PENAN*ANAN IKTERIK  Tia@ aa ya"+ @;9s9s Tia@ aa ya"+ @;9s9s

5ati3;ati ;ipo+li@e!ia5ati3;ati ;ipo+li@e!ia

5ati3;ati ter;aap perara;a"5ati3;ati ter;aap perara;a"Pe!6eria" vit. K paa i@ter9s ya"+Pe!6eria" vit. K paa i@ter9s ya"+

ala!H ta"a perara;a" 10 !+Hala!H ta"a perara;a" 10 !+H

;ari sela!a / ;ari.;ari sela!a / ;ari.

'la"+i 6ilir96i"$ S*)TH S*PT ;ari @e'la"+i 6ilir96i"$ S*)TH S*PT ;ari @e

3/3/

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35 t$ pria$2emam 3 a8& mnum @

M48 6

5GP)*LGAEMIA , Bl S 40 % -

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5GP)*LGAEMIA , Bl. S9+ar Q 40 !+% -5GP)*LGAEMIA , Bl. S9+ar Q 40 !+% -

o!a$ 20 30 !l 0% etrose i.v. & 10o!a$ 20 30 !l 0% etrose i.v. & 10

!i"9tes , ro9ti"e is "ot reco!!e"e -!i"9tes , ro9ti"e is "ot reco!!e"e - I"f9ssio" 10 % etrose , c;ilre" & %I"f9ssio" 10 % etrose , c;ilre" & %

etrose- & 6e(are ;ypo"atre!iaetrose- & 6e(are ;ypo"atre!ia

5ypo+lycae!ia !ay evelope Fay 1 333 ?5ypo+lycae!ia !ay evelope Fay 1 333 ?

P9s;e 0% etrose if "ecessaryP9s;e 0% etrose if "ecessary

*l9ca+o" i"ectio"*l9ca+o" i"ectio"

8ia "aso+astric $ 6e(are +astric iste"sio"8ia "aso+astric $ 6e(are +astric iste"sio"

I" perito"eal ialysis$ a +l9cose i" ialysisI" perito"eal ialysis$ a +l9cose i" ialysis9i9i

So!atostati" a"alo9e octreotie ,Sa"ostati"-So!atostati" a"alo9e octreotie ,Sa"ostati"-

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Malaria Reti"opat;yMalaria Reti"opat;y

A. *a!6ara" reti"a paape"erita !alaria sere6ral*S 14$ e"+a" a"e!ia 567.2 +r%. Ta!pa@ +a!6ara"perara;a" a" papilee!a.B. *a!6ara" reti"a paape"erita !alaria sere6ral*S 7$ ee!apar9 a"e!a! @e"ci"+ ;ita!. Ta!pa@ +a!6ara" pe!9ti;a"reti"a.( $aude %&, 'eare !%, eall, )rans* %* Soc* )rop*$ed +", 200., 105-1#

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)ppropriate )nti1M1: )@1 2:1E :G4E 

Jl9i Fi9reticsJl9i Fi9retics

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Jl9i Fi9reticsJl9i Fi9retics

)li+9riaH e;yrate i"f9ssio" of N.)li+9riaH e;yrate i"f9ssio" of N.

sali"e 20 !lH @+ BH =0 !i"9tessali"e 20 !lH @+ BH =0 !i"9tesa9sc9ltatio"$ 8P o6servatio"H 200 !la9sc9ltatio"$ 8P o6servatio"H 200 !l

8P !o"itori"+ , 0 33 -8P !o"itori"+ , 0 33 -

No 9ri"e 3No 9ri"e 3 i9retic c;alle"+ei9retic c;alle"+e

J9rose!ie 40 !+ i"itially$ "o 9ri"eJ9rose!ie 40 !+ i"itially$ "o 9ri"e  100 !+$ 200 !+$ 400 !+ every /0100 !+$ 200 !+$ 400 !+ every /0

!i"9tes$ "o 9ri"e $ opa!i"e 2. & !i"9tes$ "o 9ri"e $ opa!i"e 2. & 9+H @+H !i" , "o i!prove o9tco!e -9+H @+H !i" , "o i!prove o9tco!e -

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F)PAMINEF)PAMINE

2. 9+H@+H !i" i!prove RBJ i"e2. 9+H@+H !i" i!prove RBJ i"e/? % a" cariac o9tp9t / %/? % a" cariac o9tp9t / %

10 9+H@+H !i"10 9+H@+H !i"  N)TN)T

Epi"ep;ri"e$ opa!i"e $ "o role i"Epi"ep;ri"e$ opa!i"e $ "o role i"

re"al oy+e" s9pplyre"al oy+e" s9pply

8asopressi"e D8asopressi"e D

Al69!i" DDAl69!i" DD

FIALGSISFIALGSIS

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FIALGSISFIALGSISEarly ialysis i!prove s9rvivalEarly ialysis i!prove s9rvival

I"ter!itte"t 5F ,ailyH alter"ati"+-I"ter!itte"t 5F ,ailyH alter"ati"+-o"ti"9o9s ve"ove"o9s ;e!oOltratio"o"ti"9o9s ve"ove"o9s ;e!oOltratio"

o"ti"9o9s artriove"o9s ;e!oOltratio"o"ti"9o9s artriove"o9s ;e!oOltratio"

Perito"eal ialysis LESS e#ectivePerito"eal ialysis LESS e#ective

I"icatio"s I"icatio"s li"ical 9re!ic sy!pto!s$ vol9!e overloali"ical 9re!ic sy!pto!s$ vol9!e overloa

, p9l!. Ee!a$ co"+est ;eart fail9re -$ pericarial, p9l!. Ee!a$ co"+est ;eart fail9re -$ pericarialr96.r96.

La6 5)/ Q 1 !eH L$ K =. !eHLLa6 5)/ Q 1 !eH L$ K =. !eHL

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*eritoneal &ialysis

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y in malariait renal failure

"5 yrs female$ rianis$:o$ feFer$ tire&.Aalcip ++$ Hb. !3.7$ . 73reum #!!$ @reat. 7.0mg

Bill.tl. !.7" mg%>lucose !#' mg%>@8 !52ay 3 , ureum !33$ creat2ay 6 , ureum !0"$ @reat2ay #. *.count 302ay 3. *.count 32ay ". *.count 52ay 5 6 , smear , negati2ialysis 2! 6 .2eat on &ay 7.

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Ae9acy of FialysisAe9acy of Fialysis

Fialysis is co"siere ae9ateFialysis is co"siere ae9ate

(;e" t;e post3ialysis creati"i"e(;e" t;e post3ialysis creati"i"e

a" 9rea levels ecrease to 0% ora" 9rea levels ecrease to 0% or

less of t;e preialysis val9es.less of t;e preialysis val9es.

M):)>1M1: A )@1 418*4)4EM):)>1M1: A )@1 418*4)4E

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M):)>1M1: A )@1 418*4)4EM):)>1M1: A )@1 418*4)4E

284188 8E:24M1284188 8E:24M1

*4:@*18 ,*4:@*18 ,I 1arly 2iagnosisI 1arly 2iagnosis

I 4api& 4C anti

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Ma"a+e!e"t ALIH ARFSMa"a+e!e"t ALIH ARFS

I'I' S9pporte preve"t "osoco!ial i"fectio"$ *I 6lee$S9pporte preve"t "osoco!ial i"fectio"$ *I 6lee$

t;ro!6o3e!6olis!< ae9ate "9tritio"al e"teral i"ta@et;ro!6o3e!6olis!< ae9ate "9tritio"al e"teral i"ta@e

Mo"itori"+ oy+e" sat9ratio"Mo"itori"+ oy+e" sat9ratio"

Jl9i V co"servative V , 1/=Jl9i V co"servative V , 1/=  4>1 !l- $ 8P 7 & 124>1 !l- $ 8P 7 & 12!!5+.!!5+.

Are"ali"e is 6est avoie a" ot;er vasopressors s9c;Are"ali"e is 6est avoie a" ot;er vasopressors s9c;

as opa!i"e s;o9l 6e preferreas opa!i"e s;o9l 6e preferre

Spo"ta"eo9s ve"tilatio" a face !as@ (it; a ;i+; )2 toSpo"ta"eo9s ve"tilatio" a face !as@ (it; a ;i+; )2 to

eliver JI)2 of 9p to 0. to 0.=.eliver JI)2 of 9p to 0. to 0.=.

JI )2 0.=$ PAP 10 c! 52)JI )2 0.=$ PAP 10 c! 52)  !ec;a"ical ve"tilator!ec;a"ical ve"tilator

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@erebral Malaria$ resisten uinine $ 4espiratory Aailure

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CM-ARDS, RSUP 2000

 in Mana&o Hospital

9ndications for "ro"hylactic mechanical ventilation before9ndications for "ro"hylactic mechanical ventilation before

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9ndications for "ro"hylactic mechanical ventilation before9ndications for "ro"hylactic mechanical ventilation before

severe malaria "atients deteriorate to res"iratory failure Csevere malaria "atients deteriorate to res"iratory failure C

Nrmal 5ale I'61a' ;r M-5

Re8rar? rae *2 7 20 > 3)

Re8rar? m1le re8rar? aler'a'/8ara61al

  a6me'

T6al lme ml/(! :) 7 ) < *)

E5* ml/(! ) 7 *00 < *)I'8re6 $2 1m"2$ ) 7 *00 < *)

#a $2 rr ) 7 *00 < 0?!e' ma(

#A7aD$2 rr 2) 7 :) > 4)0

M'e e' l/m' > 90 > *0 a re

#a+$2rr 3) 7 4) -> ))5D/5T 0-2)70-40 > 0-:

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M1)B@ )@288M1)B@ )@288

)cc9r i" )cc9r i" 3 ac9te re"al fail9re3 ac9te re"al fail9re3 ;ypovolae!ia3 ;ypovolae!ia3 s;oc@3 s;oc@3 p9l!o"ary oee!a3 p9l!o"ary oee!a3 ;yperparasite!ia3 ;yperparasite!ia

Ma"a+e!e"t Ma"a+e!e"t W FialysisW FialysisW So.6icar6o"ate if p5Q ?.1$ 6e(areW So.6icar6o"ate if p5Q ?.1$ 6e(are

  of soi9! overloaof soi9! overloa  P9l! ee!aP9l! ee!a

W Prevera6le T5AM tris ,;yroy!et;yl-3W Prevera6le T5AM tris ,;yroy!et;yl-3a!i"oa!i"o!et;a"$ "o soi9!!et;a"$ "o soi9!

W Pyr9vate e;yro+e"ase activator ic;loro &W Pyr9vate e;yro+e"ase activator ic;loro &  acetateacetate

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5GP)TENSI)N ,al+i !alaria-5GP)TENSI)N ,al+i !alaria-

@auses, gram < Fe bacteriaemia$@auses, gram < Fe bacteriaemia$

MAMA

Management ,Management ,

!. @?* , 0

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5IPERPARASITEMIA5IPERPARASITEMIA

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5IPERPARASITEMIAS

INFIKASI Ec;a"+e Tra"sf9ssio" INFIKASI Ec;a"+e Tra"sf9ssio" Parasite!ia /0%$ ta"pa @o!pli@asiParasite!ia /0%$ ta"pa @o!pli@asiParasite!ia 10%$ Malaria 6eratParasite!ia 10%$ Malaria 6eratParasite!ia 10% +a+al o6at 12 & 24 Parasite!ia 10% +a+al o6at 12 & 24 Parasite!ia 10% pro+"osa ele@ 9siaParasite!ia 10% pro+"osa ele@ 9sia

la"9t$ aa"ya sio" r; tepi.la"9t$ aa"ya sio" r; tepi.5) 200= "o co"se"s9s5) 200= "o co"se"s9s

  "o reco!!e"atio""o reco!!e"atio"

ila "arasit D = >, "ada daerah transmisi rendah ta% stabilatau hi"o endemi%

Pe"atala@sa"aa"Pe"atala@sa"aa"

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Pe"atala@sa"aa"Pe"atala@sa"aa"

;iperparasite!ia;iperparasite!ia Re@o!e"asi 5) 200= Re@o!e"asi 5) 200= 5iperparasite!ia ta"pa ta"a3ta"a !alaria5iperparasite!ia ta"pa ta"a3ta"a !alaria

6erat lai""ya apat iterapi e"+a" o6at6erat lai""ya apat iterapi e"+a" o6at

erivat arte!isi"i" oral$ e"+a" syarat erivat arte!isi"i" oral$ e"+a" syarat

Pasie" ;ar9s i!o"itor @etat sela!a 47 a!Pasie" ;ar9s i!o"itor @etat sela!a 47 a!

perta!a setela; !9lai terapiperta!a setela; !9lai terapi

 i@a pasie" tia@ apat peroral$ se+era terapi i@a pasie" tia@ apat peroral$ se+era terapi

pare"teralpare"teral

Pasie" "o"3i!9" e"+a" ;iperparasite!ia 20Pasie" "o"3i!9" e"+a" ;iperparasite!ia 20

% ;ar9s !e"apat terapi pare"teral% ;ar9s !e"apat terapi pare"teral

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or"ersto"e of Ma"a+e!e"t Sepsisor"ersto"e of Ma"a+e!e"t Sepsis

earl "oal direced 3erap earl "oal direced 3erap   lun" 4proeced enilaion,lun" 4proeced enilaion,

6road specrum ani6ioic6road specrum ani6ioic

aciaed proein Caciaed proein C

1/1/

 

i i i 6i i i ;ilI i ti A ti 6i ti i ;il

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I"icatio"s A"ti36iotic i" ;ilre"I"icatio"s A"ti36iotic i" ;ilre"

(it; SM(it; SM

;ilre" (it; local 6acterial;ilre" (it; local 6acterial

I"fectio"I"fectio"

;ilre" (it; severe;ilre" (it; severe respiraorrespiraor

disressdisress  ;ilre" (it; s;oc@;ilre" (it; s;oc@

;ilre" (it; co!a H;ilre" (it; co!a H

e"cep;alopat;y (;ere l9!6ale"cep;alopat;y (;ere l9!6al

p9"ct9re "ot o"ep9"ct9re "ot o"e

Mani%estasi 6ompliasi 8indaan awal

 TINFAKAN TER5AFAP K)MPLIKASI

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p

+oma malaria sereral 9ertahanan osigenasi( letaan pada sisi tertentu( sampingan pen&ealain dari coma hipogliemi( stroe( sepsis( diaetes coma( uremia( gangguaneletrolit (hindari oat ta erman%aat( intuasi ila perlu

:iperpiresia 8urunan suhu adan dengan ompress( %an( air condition( antipiretia

+onulsieagal >in

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A well trained Malaria team in Emergency Unit, Timika Hospital

*))): *)))41:

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*))): *)))41:

Er 9aul :ari

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ase Malaria $ co!plicatease Malaria $ co!plicate

1 years (o!e"$ a!itte (it; ;istory 41 years (o!e"$ a!itte (it; ;istory 4ays fever (it; 6reat;less$ te!p /?.$ays fever (it; 6reat;less$ te!p /?.$BP 10H100$ p9lse 107 resp. /=H!e"itBP 10H100$ p9lse 107 resp. /=H!e"it

No ;istory of FM$ 5pt 3$ previo9sNo ;istory of FM$ 5pt 3$ previo9sa!issio"a!issio"

 12 ;rs after ;ospitaliatio" BP ?0H0$12 ;rs after ;ospitaliatio" BP ?0H0$p9lse 120H!i"$ te!p /.=$ K9ss!a9lp9lse 120H!i"$ te!p /.=$ K9ss!a9l

6reat;i"+6reat;i"+X3ray;eart e"lar+e$ l9"+s clear$ E* X3ray;eart e"lar+e$ l9"+s clear$ E*

si"9s tac;ycaria$ "o evie"ce of i"farctsi"9s tac;ycaria$ "o evie"ce of i"farct

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56 1=$/ $ B 1?>00H9L$ Fi# Le9co 56 1=$/ $ B 1?>00H9L$ Fi# Le9co

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3H3H72H1>H3$ Tro!6o 10>.000. Malaria3H3H72H1>H3$ Tro!6o 10>.000. Malariafalcipar9! $ 1100H 200 B$ 6l.falcipar9! $ 1100H 200 B$ 6l.

S9+ar 5I $101!+%$ >00!+%$ Bil.S9+ar 5I $101!+%$ >00!+%$ Bil. Total2.4?$ 6il irect1.1 !+%$9re9! Total2.4?$ 6il irect1.1 !+%$9re9!7=.4 !+%$ creati"i"e 2.7?!+%$7=.4 !+%$ creati"i"e 2.7?!+%$soi9! 124 !eHL$ potassi9! =./soi9! 124 !eHL$ potassi9! =./

!eHL!eHL 9estio" 9estio" Fia+"osis D , / iss9e -Fia+"osis D , / iss9e -Priority treat!e"t DPriority treat!e"t D

A"ti3!alaria DA"ti3!alaria D Terapi ia6etes D Terapi ia6etes D5e!oy"a!ic D ,aira"-5e!oy"a!ic D ,aira"-

; l l i f i l f i