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Nama Pasien : ....................... Nama Pasien : ....................... Nama Pasien : .......................

Umur : ....................... Umur : ....................... Umur : .......................


BB : .......................Kg BB : .......................Kg BB : .......................Kg
DOPAMIN 200 mg / 50 cc DOPAMIN 400 mg / 50 cc DOPAMIN 200 mg / 50 cc
1 cc = 200 mg/50 = 4 mg = 4000 mcg 1 cc = 400 mg/50 = 8 mg = 8000 mcg 1 cc = 200 mg/50 = 4 mg = 4000 mcg
Dosis = ............. Mcg / KgBB / Menit Dosis = ............. Mcg / KgBB / Menit Dosis = ............. Mcg / KgBB / Menit
1 meg = 1 x BB X 60 = ........... cc / jam 1 mcg = 1 x BB X 60 = ........... cc / jam 1 mcg = 1 x BB X 60 = ........... cc / jam
4000 8000 4000
2 mcg = ............cc / jam 2 mcg = ............cc / jam 2 mcg = ............cc / jam
3 mcg = ............cc / jam 3 mcg = ............cc / jam 3 mcg = ............cc / jam
4 mcg = ............cc / jam 4 mcg = ............cc / jam 4 mcg = ............cc / jam
5 mcg = ............cc / jam 5 mcg = ............cc / jam 5 mcg = ............cc / jam
6 mcg = ............cc / jam 6 mcg = ............cc / jam 6 mcg = ............cc / jam
7 mcg = ............cc / jam 7 mcg = ............cc / jam 7 mcg = ............cc / jam
8 mcg = ............cc / jam 8 mcg = ............cc / jam 8 mcg = ............cc / jam
9 mcg = ............cc / jam 9 mcg = ............cc / jam 9 mcg = ............cc / jam
10 mcg = ............cc / jam 10 mcg = ............cc / jam 10 mcg = ............cc / jam
11 mcg = ............cc / jam 11 mcg = ............cc / jam 11 mcg = ............cc / jam
12 mcg = ............cc / jam 12 mcg = ............cc / jam 12 mcg = ............cc / jam
13 mcg = ............cc / jam 13 mcg = ............cc / jam 13 mcg = ............cc / jam
14 mcg = ............cc / jam 14 mcg = ............cc / jam 14 mcg = ............cc / jam
15 mcg = ............cc / jam 15 mcg = ............cc / jam 15 mcg = ............cc / jam
16 mcg = ............cc / jam 16 mcg = ............cc / jam 16 mcg = ............cc / jam
17 mcg = ............cc / jam 17 mcg = ............cc / jam 17 mcg = ............cc / jam
18 mcg = ............cc / jam 18 mcg = ............cc / jam 18 mcg = ............cc / jam
19 mcg = ............cc / jam 19 mcg = ............cc / jam 19 mcg = ............cc / jam
20 mcg = ............cc / jam 20 mcg = ............cc / jam 20 mcg = ............cc / jam
Nama Pasien : ....................... Nama Pasien : ....................... Nama Pasien : .......................
Umur : ....................... Umur : ....................... Umur : .......................
BB : .......................Kg BB : .......................Kg BB : .......................Kg
DOBUTAMIN 250 mg / 50 cc DOBUTAMIN 500 mg / 50 cc DOBUTAMIN 250 mg / 50 cc
1 cc = 250 mg/50 = 5 mg = 5000 mcg 1 cc = 500 mg/50 = 10 mg = 10000 mcg 1 cc = 250 mg/50 = 5 mg = 5000 mcg
Dosis = ............. Mcg / KgBB / Menit Dosis = ............. Mcg / KgBB / Menit Dosis = ............. Mcg / KgBB / Menit
1 mcg = 1 x BB X 60 = ........... cc / jam 1 mcg = 1 x BB X 60 = ........... cc / jam 1 meg = 1 x BB X 60 = ........... cc / jam
5000 10000 5000
2 mcg = ............cc / jam 2 mcg = ............cc / jam 2 mcg = ............cc / jam
3 mcg = ............cc / jam 3 mcg = ............cc / jam 3 mcg = ............cc / jam
4 mcg = ............cc / jam 4 mcg = ............cc / jam 4 mcg = ............cc / jam
5 mcg = ............cc / jam 5 mcg = ............cc / jam 5 mcg = ............cc / jam
6 mcg = ............cc / jam 6 mcg = ............cc / jam 6 mcg = ............cc / jam
7 mcg = ............cc / jam 7 mcg = ............cc / jam 7 mcg = ............cc / jam
8 mcg = ............cc / jam 8 mcg = ............cc / jam 8 mcg = ............cc / jam
9 mcg = ............cc / jam 9 mcg = ............cc / jam 9 mcg = ............cc / jam
10 mcg = ............cc / jam 10 mcg = ............cc / jam 10 mcg = ............cc / jam
11 mcg = ............cc / jam 11 mcg = ............cc / jam 11 mcg = ............cc / jam
12 mcg = ............cc / jam 12 mcg = ............cc / jam 12 mcg = ............cc / jam
13 mcg = ............cc / jam 13 mcg = ............cc / jam 13 mcg = ............cc / jam
14 mcg = ............cc / jam 14 mcg = ............cc / jam 14 mcg = ............cc / jam
15 mcg = ............cc / jam 15 mcg = ............cc / jam 15 mcg = ............cc / jam
16 mcg = ............cc / jam 16 mcg = ............cc / jam 16 mcg = ............cc / jam
17 mcg = ............cc / jam 17 mcg = ............cc / jam 17 mcg = ............cc / jam
18 mcg = ............cc / jam 18 mcg = ............cc / jam 18 mcg = ............cc / jam
19 mcg = ............cc / jam 19 mcg = ............cc / jam 19 mcg = ............cc / jam
20 mcg = ............cc / jam 20 mcg = ............cc / jam 20 mcg = ............cc / jam
Nama Pasien : ....................... Nama Pasien : ....................... Nama Pasien : .......................
Umur : ....................... Umur : ....................... Umur : .......................
BB : .......................Kg BB : .......................Kg BB : .......................Kg
ADRENALIN 4 mg / 50 cc ADRENALIN 8 mg / 50 cc ADRENALIN 8 mg / 50 cc
1 cc = 4 mg/ 50 = 80 mcg 1 cc = 8 mg/ 50 = 160 mcg 1 cc = 8 mg/ 50 = 160 mcg
Dosis = ............. Mcg / KgBB / Menit Dosis = ............. Mcg / KgBB / Menit Dosis = ............. Mcg / KgBB / Menit
0,01 mcg = 0,1 x BB X 60 = ....... cc / jam 0,1 mcg = 0,1 x BB X 60 = ....... cc / jam 0,1 mcg = 0,1 x BB X 60 = ....... cc / jam
80 160 160
0,02 mcg = ............cc / jam 0,2 mcg = ............cc / jam 0,2 mcg = ............cc / jam
0,03 mcg = ............cc / jam 0,3 mcg = ............cc / jam 0,3 mcg = ............cc / jam
0,04 mcg = ............cc / jam 0,4 mcg = ............cc / jam 0,4 mcg = ............cc / jam
0,05 mcg = ............cc / jam 0,5 mcg = ............cc / jam 0,5 mcg = ............cc / jam
0,06 mcg = ............cc / jam 0,6 mcg = ............cc / jam 0,6 mcg = ............cc / jam
0,07 mcg = ............cc / jam 0,7 mcg = ............cc / jam 0,7 mcg = ............cc / jam
0,08 mcg = ............cc / jam 0,8 mcg = ............cc / jam 0,8 mcg = ............cc / jam
0,09 mcg = ............cc / jam 0,9 mcg = ............cc / jam 0,9 mcg = ............cc / jam
0,1 meg = ............cc / jam 1 meg = ............cc / jam 1 mcg = ............cc / jam
DOSIS INFUS INSULIN (unit/jam) DOSIS INFUS INSULIN (unit/jam)
KGD (mg/dl) KGD (mg/dl)
Algoritma Algoritma 2 Algoritma 3 Algoritma 4 Algoritma Algoritma 2 Algoritma 3 Algoritma 4
1 1
< 60 = hipoglikemi (harus < 60 = hipoglikemi (harus
diterapi dektrose) diterapi dektrose)

60-70 0 0 0 0 60-70 0 0 0 0
70-109 0,2 0,5 1 1,5 70-109 0,2 0,5 1 1,5
110-119 0,5 1 2 3 110-119 0,5 1 2 3
120-149 1 1,5 3 5 120-149 1 1,5 3 5
150-179 1,5 2 4 7 150-179 1,5 2 4 7
180-209 2 3 5 9 180-209 2 3 5 9
210-239 2 4 6 12 210-239 2 4 6 12
240-269 3 5 8 16 240-269 3 5 8 16
270-299 3 6 10 20 270-299 3 6 10 20
300-329 4 7 12 24 300-329 4 7 12 24
330-359 4 8 14 28 330-359 4 8 14 28
>360 6 12 16 28 >360 6 12 16 28
SLIDING SCALE / 4 JAM
GDS INJEKSI NOVORAPID / UNIT
151-200 4
201-250 8
251-300 12
301-350 18
>351 20
GDS < 150 Novorapid tidak diinjeksikan
Nama Pasien : ....................... Nama Pasien : ....................... Nama Pasien : .......................
Umur : ....................... Umur : ....................... Umur : .......................
BB : .......................Kg BB : .......................Kg BB : .......................Kg
PHENTANYL 0.1 mg / 10 cc PHENTANYL 0.1 mg / 10 cc PHENTANYL 0.1 mg / 10 cc
1 amp = 2 cc = 0.1 mg/ 10 = 100 mcg 1 amp = 2 cc = 0.1 mg/ 10 = 100 mcg 1 amp = 2 cc = 0.1 mg/ 10 = 100 mcg
Dosis = ............. Mcg Dosis = ............. Mcg Dosis = ............. Mcg
12,5 mcg = 12,5 = ....... cc / jam 12,5 mcg = 12,5 = ....... cc / jam 12,5 mcg = 12,5 = ....... cc / jam
10 10 10
25 mcg = ............cc / jam 25 mcg = ............cc / jam 25 mcg = ............cc / jam
50 mcg = ............cc / jam 50 mcg = ............cc / jam 50 mcg = ............cc / jam

Nama Pasien : ....................... Nama Pasien : ....................... Nama Pasien : .......................


Umur : ....................... Umur : ....................... Umur : .......................
BB : .......................Kg BB : .......................Kg BB : .......................Kg
PHENTANYL 0.1 mg / 10 cc PHENTANYL 0.1 mg / 10 cc PHENTANYL 0.1 mg / 10 cc
1 amp = 2 cc = 0.1 mg/ 10 = 100 mcg 1 amp = 2 cc = 0.1 mg/ 10 = 100 mcg 1 amp = 2 cc = 0.1 mg/ 10 = 100 mcg
Dosis = ............. Mcg Dosis = ............. Mcg Dosis = ............. Mcg
12,5 mcg = 12,5 = ....... cc / jam 12,5 mcg = 12,5 = ....... cc / jam 12,5 mcg = 12,5 = ....... cc / jam
10 10 10
25 mcg = ............cc / jam 25 mcg = ............cc / jam 25 mcg = ............cc / jam
50 mcg = ............cc / jam 50 mcg = ............cc / jam 50 mcg = ............cc / jam
Nama Pasien : ....................... Nama Pasien : ....................... Nama Pasien : .......................
Umur : ....................... Umur : ....................... Umur : .......................
BB : .......................Kg BB : .......................Kg BB : .......................Kg
NOR EPINEPRINE 4 mg / 50 cc NOR EPINEPRINE 4 mg / 50 cc NOR EPINEPRINE 4 mg / 50 cc
1 cc = 4 mg/ 50 = 80 mcg 1 cc = 8 mg/ 50 = 80 mcg 1 cc = 8 mg/ 50 = 80 mcg
Dosis = ............. Mcg / KgBB / Menit Dosis = ............. Mcg / KgBB / Menit Dosis = ............. Mcg / KgBB / Menit
0,01 mcg = 0,1 x BB X 60 = ....... cc / jam 0,1 mcg = 0,1 x BB X 60 = ....... cc / jam 0,1 mcg = 0,1 x BB X 60 = ....... cc / jam
80 80 80
0,02 mcg = ............cc / jam 0,2 mcg = ............cc / jam 0,2 mcg = ............cc / jam
0,03 mcg = ............cc / jam 0,3 mcg = ............cc / jam 0,3 mcg = ............cc / jam
0,04 mcg = ............cc / jam 0,4 mcg = ............cc / jam 0,4 mcg = ............cc / jam
0,05 mcg = ............cc / jam 0,5 mcg = ............cc / jam 0,5 mcg = ............cc / jam
0,06 mcg = ............cc / jam 0,6 mcg = ............cc / jam 0,6 mcg = ............cc / jam
0,07 mcg = ............cc / jam 0,7 mcg = ............cc / jam 0,7 mcg = ............cc / jam
0,08 mcg = ............cc / jam 0,8 mcg = ............cc / jam 0,8 mcg = ............cc / jam
0,09 mcg = ............cc / jam 0,9 mcg = ............cc / jam 0,9 mcg = ............cc / jam
0,1 meg = ............cc / jam 1 meg = ............cc / jam 1 mcg = ............cc / jam

Nama Pasien : ....................... Nama Pasien : ....................... Nama Pasien : .......................


Umur : ....................... Umur : ....................... Umur : .......................
BB : .......................Kg BB : .......................Kg BB : .......................Kg
NOR EPINEPRINE 4 mg / 50 cc NOR EPINEPRINE 4 mg / 50 cc NOR EPINEPRINE 4 mg / 50 cc
1 cc = 4 mg/ 50 = 80 mcg 1 cc = 8 mg/ 50 = 80 mcg 1 cc = 8 mg/ 50 = 80 mcg
Dosis = ............. Mcg / KgBB / Menit Dosis = ............. Mcg / KgBB / Menit Dosis = ............. Mcg / KgBB / Menit
0,01 mcg = 0,1 x BB X 60 = ....... cc / jam 0,1 mcg = 0,1 x BB X 60 = ....... cc / jam 0,1 mcg = 0,1 x BB X 60 = ....... cc / jam
80 80 80
0,02 mcg = ............cc / jam 0,2 mcg = ............cc / jam 0,2 mcg = ............cc / jam
0,03 mcg = ............cc / jam 0,3 mcg = ............cc / jam 0,3 mcg = ............cc / jam
0,04 mcg = ............cc / jam 0,4 mcg = ............cc / jam 0,4 mcg = ............cc / jam
0,05 mcg = ............cc / jam 0,5 mcg = ............cc / jam 0,5 mcg = ............cc / jam
0,06 mcg = ............cc / jam 0,6 mcg = ............cc / jam 0,6 mcg = ............cc / jam
0,07 mcg = ............cc / jam 0,7 mcg = ............cc / jam 0,7 mcg = ............cc / jam
0,08 mcg = ............cc / jam 0,8 mcg = ............cc / jam 0,8 mcg = ............cc / jam
0,09 mcg = ............cc / jam 0,9 mcg = ............cc / jam 0,9 mcg = ............cc / jam
0,1 meg = ............cc / jam 1 meg = ............cc / jam 1 mcg = ............cc / jam

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