LAPORAN

JAGA ICU
COVID-19 PPDS
Anestesiologi FK
SENIN ULM

27
SEPTEMBER
2021
BED 4/ NY FATHUL JANNAH/ 59 thn / 55 kg/ TB 160 cm/ BMI 21,5/ HO 20/ HP ICU 6
Assessment Therapy
9Subjective & Objective
F : IVFD D51/4 NS 1500cc/ 24jam
S) terventilator, NGT kehitaman (+), demam (-) Covid 19 derajat kritis + resfar 25 cc/jam
ARDS berat A: pct 1gr k/p
O)
DM type 2 S: 
B1 : Air way on venti mode VC SIMV, VT 400, FiO2 100%, I:E ratio 1:2,1, RR 24, PS 15, PEEP 10, PS 20, Flow 40 CAP severe T:-
AKI H: Head up 30
RR total 36x/mnt SPO2 93 %
Sepsis U: Omeprazole 8mg/jam
B2 :TD 119/63 mmHg HR 118×/mnt on NE 0,1 mcg/kgbb/mnt, dopamine, CVP 7 CMH20 Anemia G: GDS berkala(248/264/248)
novorapid 1 ui/jam
B3 : Ramsay 5 on midazolam 5mg/jam + icunez
B4 : BAK via DC 950cc/24 jam,, BC +493,4 cc/ 24 jam
B5 : Ma/mi ,puasa, NGT (+) kehitaman 200 cc/ 24 jam
B6 : akral hangat, suhu 36,4

swab PCR 22/9/2021 22/9/2021 23/9/2021 24/9/2021 25/9/2021 26/9/2021 27/9/2021 Planning: Injeksi
di rs mawar Hb 9,4 AGD Hb 9,5 Pt/aptt Hb 8,9 PT/APTT PTT 12.8 •Evaluasi Urin Output + Balance Inj. remdesivir 1x100mg( H5)
positif tgl Ht 32 Ph 7,47 Ht 32,1 12,8/28,6 Ht 31,6 17.2/38.4 APTT > Inj. meropenem 2x1 gr (H6)
Lekosit 16,9 Cairan /shift
15/9/2021 PO2 38 Lekosit 20,9 Lekosit 19,3 INR 1.64 32.1 •Evaluasi vital sign, tanda2 Inj. Moxifloxacin 1x400mg (H7)
Trombosit 489
PCO2 39,7 Trombosit 559 AGD Trombosit 423 Ph 7.317 inj.dexametasone 1x7,5mg
Hasil IL-6
PTT 12,2
HCO3 28,9 PTT 32,3 PH 7,316 PTT 15,7 PCO2 55.9 AGD
distress nafas dan tanda2
APTT 24,2 Inj. SNMC 2 x 1 amp dlm ns 100
tgl BE 5 APTT >100 PO2 54 APTT > 26,4 TCO2 30.0 PH 7.317 perdarahan Inj. Painless 4x1
GDS 181
22/9/2021 SGOT 71 O2 Sat 76 SGOT 50 PCO2 63 Albuminn 2,7 PO2 77.0 PO2 77.0 •cek AGD, PT/APTT per hari Drip Paracetamol 3x 1gr (kp)
4,13 SGPT 128 FiO2 100 SGPT 88 HCO3 32,5 Bil tot/Direct/ HCO3 28.3 PCO2 55.9 •Kumbah lambung/ 8 jam SP NE 0,25cc/jam
Alb 3,5 P/F 38 Ur/cr 130/1,58 O2 Sat 85 Indrect 1,29/ O2 Sat 92.0 HCO3 28.3 •Usul pemasangan CVC SP Dopamin 5mg/jam
MDT Na 150 BE 6 0,8/0,49 BE 2.0 O2 Sat 92.0
Morfologi K 3,2 AGD FIO2 100 SGOT 69 FIo2 100 BE 2.0 Per Oral
dalam batas Cl 107 PH 7,481 P/F 54 SGPT 49 FIO2 100
Ur/cr 147/2,02 Vit D 1x1000 IU
normal PO2 30 Ur/cr 105/1,69 P/F 77 Zinc 1x20 mg
LDH 123
PCO2 40,3 Lbio 2x1 sach
AGD HCO3 30,2 AGD Hp Pro 3x1
PH 7,546 O2 Sat 64 PH 7,283 Sucralfat 3x1C
PO2 35 BE 7 PO2 55
PCO2 37,8 FIO2 100 PCO2 70,2
HCO3 32,8 P/F 30 HCO3 32,2
O2 Sat 76 O2 Sat 75
BE 10 BE 6
FIO2 90 FIO2 100
P/F 38
P/F 55
3/9/2021 21/9/2021
23/9/2021
27/9/2021
 Pemenuhan energi menurut Rule of Thumb
= 25 - 30 kkal/kgBB/hari
= 1750 - 2100 kkal
 Basal Energy Expenditure (BEE) Formula Harris – Benedict
= 655+ (9,5X 55 kg) + 1,8 X 155 cm) – (4,6 x 57)
= 1194,3 kkal
 Pemenuhan kebutuhan energi = BEE x Faktor stress
= 1194,3 x 1,3 = 1552,5 kkal

 Kebutuhan cairan dalam 24 jam = 2200 cc

 
TERIMA KASIH