DAFTAR ISI

1. Types of Respiratory Failure ......................................................................... 1

2. Clinical Criteria for Respiratory Failure ........................................................ 1
3. Clinical Sequelae of Hypokalemia and Hyperkalemia ................................. 2
4. Glasgow Coma Scale (GCS) ........................................................................... 2
5. Tatalaksana Kasus Tersangka DBD................................................................ 3
6. Tatalaksana Kasus DBD dengan Hemokonsentrasi 20 % .......................... 4
7. Algoritme Syok Hipovolemik DBD Tanpa Penyulit ...................................... 5
8. Algoritme Syok Hipovolemik DBD Dengan Penyulit ................................... 6
9. Kadar Kreatinin Plasma (mg%) Anak Normal ............................................... 7
10.Kadar Ureum Plasma (mmol/L) Anak Normal .............................................. 8
11.Rekomendasi Masukan Nutrien Untuk Anak dengan GGK .......................... 8
13.Cara menghitung jumlah IWL ........................................................................ 9
14.Kebutuhan Protein untuk nutrisi Parenteral .................................................... 9
15.Kebutuhan Kalori Untuk Nutrisi Parenteral ................................................... 9
16.Keadaan Yang Meningkatkan Kebutuhan Kalori ........................................... 9
17.Patofisiologi Sindrom Hepatorenal ................................................................ 9
18.Definisi GGA, Oliguria, Anuria, poliuria, Azotemia .................................... 10
19.Glasgow Pittsburgh Coma Scale (GPCS) ..................................................... 10
20.Kriteria Gagal Multi Organ ............................................................................ 11
21.Kriteria Mati Batang Otak / MBO (IDI, 1987) . ............................................ 12
22.Cara Pemberian / Koreksi NaCl & KCL, Ca Ranitire .................................. 12
23.Cara Koreksi Albumin .................................................................................. 13
24.Patokan jumlah Minum Neonatus Sesuai Kebutuhan Cairan ....................... 14
25.Anion Cap ..................................................................................................... 14
26.Mean Arterial Pressure (MAP) ..................................................................... 14
27Respiratory Index (RI) .................................................................................... 14
28.Transferin Saturation .................................................................................... 15
29.Body Mass Index (BMI) ............................................................................... 15
30.Analisa Gas Darah (BGA) ............................................................................ 16
31.Sepsis & SIRS .............................................................................................. 18
32Sindrom Disfungsi Multi Organ (MOD) Primer & Sekunder ...................... 19
33.Kriteria Diagnosis Sindrom MOD Pediatrik ................................................. 19
34.Gradasi SRPS Pediatrik Menurut Fisher & Fanconi (1996) .......................... 20
35.Gradasi Disfungsi Organ Pediatrik ............................................................... 21
36.Syarat Pemberian Dopamin .......................................................................... 22
37.Septic Shock Syndrome ................................................................................ 22
38.Bangsal Bayi Risiko Tinggi (BBRT) ............................................................ 22
39.Enzim-Enzim Hati, Ratio / Quontient de Ritis, Ratio SGPT / GDLH ........... 24
40.Sindroma Nefrotik ........................................................................................ 25
41.Normogram Klirens Kreatinin ...................................................................... 27
42.Osmolaritas .................................................................................................... 18
43.Pembacaan X-Foto Torax ................................................................................
44.Types Of Respiratory Failure
45.Koreksi Dopamin, vaskon/epineprin, manitol..
46.DD anemia

[Type text]

Page 1

Findings
Type I
Hipoxia
Decreased PaO2
Normal PaCO2

Causes
Examples
Ventilation / Perfusion Positional (supine In bed),
defect
ARDS, atelectasis, pneumonia,
pulmonary embolus,
brochopulmonary dysplasia.
Diffusion impairment
Pulmonary edema, ARDS,
Interstitial pneumonia.
Shunt
Pulmonary arteriovenous
Malformation, congenital
Adenomatoid malformation
Type II
Hypovention
Neuromuscular disease (polio,
Guillain-Barre syndrome),
Hipoxia
head trauma, sedation, chest
Hypercapnia
wall dysfunction (burns),
Decreased PaCO2
kyphosis, severe reactive
Increased PaCO2
airways.
Sumber : Current Pediatric Diagnosis & treatment, 12th ed, 1995.
CLINICAL CRITERIA FOR RESPIRATORY FAILURE
Respiratory
Wheezing
Expiratory Grunting
Decreased or absent breath sounds
Flaring of alae nasi
Retractions of chest wall
Tachypnea, bradypnea, or apnea
Cyanosis
Cerebral
Restlessness
Irritability
Headache
Confusion
Convulsions
Coma
Cardiac
Bradycardia or excessive tachycardia
Hypotension or hypertension
General
Fatigue
Sweating
Sumber : Current Pediatric Diagnosis & Treatment, 12th ed,1995

[Type text]

Page 2

CLINICAL SEQUALAE
HYPOKALEMIA
Apathy, muscle weakness, paresthesias,
tetany
Depressed T ware, U Wave;ST segment
depression
Arrthytmias
Premature beats
Atrial or nodal tachycardia
Ventricular tachycardia or fibrilation

HYPERKALEMIA
Ascending paralysis, occasional
tetany and parethesias, muscle
weakness
Peaked T ware, proloanged PR
interval, ST segment depression,
wide QRS complex
Arrhytmias
Sinus Bradycardia
Atrioventricular block
Indioventricular tachycardia or
fibrilation
Cardiac arrest
Sumber : Current Pediatric Diagnosis & Treatment, 12th ed,1995
GLASGOW COMA SCALE (GCS)
A. Buka Mata :
- Spontan
- Dengan Perintah
- Dengan Rangsang nyeri
- Tak ada respons
B. Respons Motorik :
- Menurut perintah
- Menunjuk lokasi nyeri
- Withdrawal flexi
- Flexi abnormal
- Lextensi
- Tak ada respons
C. Respons Verbal :
- Orientasi baik
- Disorientasi / bicara kacau
- Kata-kata tak tersusun
- Suara saja
- Tak ada respons

[Type text]

4
3
2
1
6
5
4
3
2
1
5
4
3
2
1

Page 3

Osmolaritas = (2 x Na)

GDS BUN

18
2,8

U 2 Plasma
2,13
(N : 272 - 290)

BUN =

[Type text]

Page 4

TATALAKSANA KASUS TERSANGKA DBD

Tersangka DBD
Demam tinggi,
mendadak, terus menerus
<7 hari, tanpa ISPA,
badan lemah & lesu

Kedaruratan (+)
Tanda syok
Muntah terus menerus
Kejang
Kesadaran
Muntah darah
Berak hitam

Kedaruratan (-)
Uji torniket
Positif
Trombosit
<100.000

Negatif
Trombosit
>100.000

Rawat jalan
Parasetamol
Kontrol tiap hari
sampai demam (-)

Rawat inap

Segera bawa
ke RS

Nilai tanda klinis,

trombosit & Ht bila
demam menetap setelah
hari sakit ke-3

Rawat jalan
Minum banyak 1,5 L/hr
Parasetamol
Kontrol tiap hari sampai demam (-)
Periksa Hb, Ht, trombosit tiap kali hari (a)
minim
Perhatian untuk orang tua
Pesam bisa timbul tanda syok, yaitu : gelisah,
lemah, kaki/tangan dingin, sakit perut, berak
hitam, BAK kurang
Lab : Hb, Ht naik & trombosit turun

[Type text]

Page 5

TATALAKSANA KASUS DBD I & II TANPA PENINGKATAN HEMATOKRIT

DBD I & II tanpa peningkatan Ht

Gejala klinis : demam 2-7 hari, RL (+) atau perdarahan spontan
Lab.
: Ht tak meningkat, trombositopenia ringan

Pasien masih dapat minum

Beri minum banyak 1-2 L/hr
atau 1 sdm tiap 5 menit
Jenis minuman : air putih, teh
manis, sirup, susu, oralit, jus
Bila suhu > 38,5o C beri PCT
Bila kejang beri antikonvulsif

Monitor gejala klinis & lab

Perhatikan tanda syok
Palpasi hati tiap hari
Ukur diuresis tiap hari
Awasi perdarahan
Periksa Hb, Ht, Trombosit tiap
6-12 jam

Perbaikan klinis & lab

Pasien tidak dapat minum

Pasien muntah terus menerus
Pasang infus NaCl 0,9% : D5%
(1:3), tetesan rumatan BB
Periksa Hb, Ht, Trombosit tiap
6-12 jam

Ht naik dan / trombosit turun

Infus ganti RL (jumlah tetesan

disesuaikan, lihat Tatalaksana
kasus DBD dengan peningkatan
Hematokrit)

Pulang
(Lihat kriteria memulangkan pasien)

Sumber : DHF, diangnosis treatment, prevention and control 2 nd ed, Geneva WHO, 1997

[Type text]

Page 6

TATALAKSANA KASUS DBD DENGAN HEMOKONSENTRASI 20%

DBD I dengan hemokonsentrasi 20%
Cairan awal
RL/NaCl 0,9% atau RLD5%
NaCl 0,9 + D5% : 6-7 ml/kbBB/jam

Monitor TV, Hb, Ht & trombosit tiap

6 jam

Perbaikan
Tidak gelisah
Nadi kuat
Tekanan darah stabil
Diuresis cukup (12
ml/kbBB/jam)
Ht turun (2x pemeriksaan)

Tetesan dikurangi
5 ml/kgBB/jam

Tanda vital
memburuk
Ht

Tak ada perbaikan

Gelisah
Distress pernafasan
Frekuensi nadi naik
Ht tetap tinggi/naik
Tek. Nadi < 20 mmHg
Diuresis kurang/tidak ada

Tetesan dinaikkan
10-15 ml/kgBB/jam
(tetesan dinaikkan
bertahap)

Perbaikan
Evaluasi 12-24 jam
Perbaikan
3 ml/kgBB/jam

IVFD stop pada 24-48 jam

Bila TV/Ht stabil & diuresis
cukup

Tanda vital tak stabil

Ht

Ht naik
Distress pernafasan

Koloid
20-30 ml/kg

Tranfusi darah
segar 10 ml/kg

Perbaikan

[Type text]

Page 7

ALGORITME SYOK HIPOVOLEMIK DBD TANPA PENYULIT

Syok

Jalan nafas + O2
RL 20 ml/kg(6-10)

Perbaikan (+)

Perbaikan (-)

Urine
< 1ml/kg/jam

RL 20 ml/kg/10

RL 10
Ml/kg/10

Perbaikan (+)

Urine > 1
ml/kg/jam
Perbaikan (+)
Cairan pengganti
RL jumlah Ht

Urine < 1
ml/kg/jam

RL
20 ml/kg/10

Perbaikan (-)

Urine < 1
ml/kg/jam

Anuria

Koloid
10 ml/kg/10

Cairan rumat

Perbaikan (-)

CVP < 10 cmH2O

[Type text]

Algoritme syok
hipovolemik DBD
dengan penyulit
CVP > 10 cmH2O

Page 8

ALGORITMESYOK HIPOVOLEMIK DBD DENGAN PENYULIT

PIM, KEBOCORAN HEBAT

Cvp < 10 cmH2O

CVP > 10 cmH2O

CVP < 6 cmH2O

CVP 6-10 cmH2)

CVP > 10 cmH2

Koloid
4 ml/kg/10

Koloid
2 ml/kg/10

Koloid
1 ml/kg/10
Kalau perlu inotropik
vasodilator

Cari :
- Perdarahan
- Sebab
hipovolemik lain

CVP > 4

Stop

CVP 2 - 4

Koloid 4 ml/kg/10

CVP < 4

Koloid lain / kristaloid

Sesudah
Normovoilemik (+)

Inotropik, obat-obat lain

Perbaikan

[Type text]

Gagal

Page 9

KADAR KREATIN PLASMA (MG%) ANAK NORMAL MENURUT UMUR & JENIS
KELAMIN
Umur
(tahun)
1
2
3
4
5
6
7
8
9
10
11
12
13
14

Perempuan

Laki-Laki

0,35 0,05
0,45 0,07
0,42 0,08
0,47 0,12
0,46 0,11
0,48 0,11
0,53 0,12
0,53 0,11
0,55 0,11
0,55 0,13
0,60 0,13
0,59 0,13
0,62 0,14
0,65 0,13

0,41 0,10
0,43 0,12
0,46 0,11
0,45 0,11
0,50 0,11
0,52 0,12
0,54 0,14
0,57 0,16
0,59 0,16
0,61 0,22
0,62 0,14
0,65 0,16
0,68 0,21
0,72 0,24

KADAR KREATIN PLASMA (MG%) ANAK NORMAL MENURUT UMUR & JENIS
KELAMIN
Umur
Perempuan
Laki-Laki
(tahun)
1
4,91 0,05
4,82 1,71
2
6,23 2,74
4,93 2,12
3
5,08 1,29
5,09 1,58
4
4,57 2,02
4,78 1,40
5
4,68 1,36
5,52 1,74
6
4,81 1,63
5,23 1,56
7
4,67 1,39
5,44 1,74
8
5,02 1,61
4,84 1,69
9
5,16 1,85
5,60 2,68
10
4,67 1,82
5,55 3,00
11
4,51 1,62
5,04 1,73
12
4,23 1,18
5,18 1,46
13
4,82 1,71
5,24 1,65
14
5,38 2,18
5,11 1,90

[Type text]

Page 10

REKOMENDASI MASUKAN NUTRIEN UNTUK ANAK DENGAN GAGAL GINJAL

KRONIK.
Umur
BB
Energi
Protein
Ca
P
(tahun)
(kg)
(kkal)
(g)
(mg)
(mg)
1-3
12,5
1230
14,5
350
270
4-6
17,8
1715
19,7
450
350
10-12
28,3
1970
28,3
550
450
11-14 ()
43,0
2220
42,1
1000
775
11-14 ()
43,8
1845
41,2
800
625
Sumber : Rigden, 1994
Cara menghitung jumlah Insesible Water Loss (IWL)
BB > 20 kg = 500 / 24 x jumlah jam (ml)
BB 2,5-20 kg = BB x 25/24 x jumlah jam (ml)
BB < 2,5 kg = BB x 50/24 x jumlah jam (ml)

KEBUTUHAN PROTEN UNTUK NUTRISI PARENTERAL PADA BAYI & ANAK

Asam Amino
Kelompok Umur
(g/kgBB/hari)
Neonatus prematur
2,5-3,0
Bayi 0-1 tahun
2,5
Anak 2-13 tahun
1,5-2,0
Remaja
1,0-1,5
Sumber : Kerner JA, Parenteral Nutrition in Pediatriagl disease, 1996.
KEBUTUHAN KALORI UNTUK NUTRISI PARENTERAL
Umur
Kebutuhan Kalori
(Tahun)
( kkal/kgBB/hari)
0-1
90-120
1-7
75-90
7-12
60-75
12-18
30-60
Sumber : Kerner JA, Parenteral Nutrition in Pediatriagl disease, 1996.
KEADAAN YANG MENINGKATKAN KEBUTUHAN KALORI
Keadaan
Peningkatan (%)
1. Demam
12% tiap kenaikan 1oC di atas 37oC
2. Gagal jantung
15-25
3. Operasi besar
20-30
4. Luka bakar
Sampai 100
5. Sepsis berat
40-50
6. Gagal tumbuh
50-100
7. Malnutrisi berat
50-100
Sumber : IC Susanto, Pedoman nutrisi parenteral pada anak, Konika XI, 1999

[Type text]

Page 11

HUBUNGAN PATOFISIOLOGI ANTARA HATI & GINJAL PADA SINDROM

HEPATORENAL
Klirens hati
HATI

Endotoksin ?

Lain-lain ?

ADH

Klirens
Air bebas

Volume efektif
Renin

Protaglandin
ginjal

Reabsorpsi

Outflow
Simpatetik

Angiotensin

Vasokonstriksi ginjal
Signal ?
?
GINJAL
Reabsorpsi tubuler
Na

Aldosteron
?

Sumber : KorulaJ, Hepatorenal syndrome in : Liver and biliary disease, 1996.

GGA

: Penurunan faal ginjal secara tiba-tiba disertai timbunan bahan metabolisme

nitrogen & gangguan imbang cairan elektrolit
Oliguria
: - Urin pada anak < 300 ml/m2/24 jam (Arbus dkk, 1994).
- Urin pada neonatus < 0,5 ml/kgBB/24 jam (chevalier, 1994).
Anuria
: Keluaran urin (-);
Arti luas : urin < 1 ml/kgBB/24 jam (arbus dkk,1994)
Poliuria (konteks GGA) :
Keluaran urin normal atau banyak (>2 ml/kgBB/24 jam) pada keadaan kadar
ureum / kreatinin meningkat secara tiba-tiba (Bock, 1992).
Azotemia : Penimbunan abnormal metabolit nitrogen dalam darah yang dinyatakan oleh
kadar ureum darah yang tinggi.
Uremia : kompleks gejala yang menunjukkan gangguan faal organ tubuh
karena ginjal gagal melakukan tugasnya (Arbus dkk, 1994).

[Type text]

Page 12

GLASGOW PITTSBURGH COMA SCALE (GPCS)

A. Buka Mata :
Spontan
4
Dengan perintah
3
Dengan rangsang nyeri
2
Tak ada respons
1
B. Respons Motorik :
Menurut perintah
6
Reaksi setempat/tunjuk lokasi
5
Withdrawal reflex/flexi
4
Flexi abnormal
3
Extensi
2
Tak ada respons
1
C. Respons Verbal :
Orientasi baik
5
Disorientasi / bicara kacau
4
Kata-kata tak tersusun
3
Suara saja
2
Tak ada respons
1
D. Respons Pupil terhadap Cahaya :
Normal
5
Total = A + B + C + D + E + F + G
Lambat
4
Nilai Tertinggi = 35
Respons tak simetris
3
Nilai terendah = 7
Besar tak sama
2
Tak ada sama
1
E. Reflex Saraf Otak Tertentu :
Semua ada
5
Reflex bulu mata (-)
4
Reflex cornea (-)
3
Dolls eye
2
Reflex cranial (-)
1
F. Kejang :
Tak ada
5
Kejang fokal
4
Umum, intermiten
3
Umum, kontinyu
2
Flaksid
1
G. Nafas Spontan :
Normal
5
Periodik
4
Hiperventilasi sentral
3
Irreguler / hipoventilasi
2
Apnea
1

[Type text]

Page 13

KRITERIA GAGAL MULTI ORGAN

A. Kardivaskuler :
HR < 54 x/menit
MAP 49 mmHg
Takikardi ventrikuler / fibrilasi ventrikel
pH 7,24, PaO2 49
B. Respirasi :
RR < atau > 49 x/menit
PaCO2 50 mmHg
AaDO2 350
C. Renal :
Urine 479 cc/hari atau 159 cc/8jam
BUN 100 mg/100 cc
Kreatinin 3,5 mg/100 cc
D. Hematologi
Lekosit 1000
Trombosit 20.000
E. SSP / Neurologi :
GPCS 6, tanpa sedasi
F. Hepar
Bilirubin > mg%
PPT > 4 (dari kontrol)
KRITERIA MATI BATANG OTAK/MBO (IDI, 1987)
1. Hipotermia (t < 35oC)
2. GPCS <
3. Reflex batang otak :
- Pupil dilatasi maksimal
- Reflex cahaya -/- Reflex okulosefalik / Dolls eye (-)
- Reflex corrtea -/- Reflex muntah (-)
- Reflex batuk (-)
4. Apnea
5. Tes atropin (-) 0,02 mg/kgBB (iv), nadi > 5x/menit
6. EEG isoelektrik/fid

[Type text]

Page 14

CARA PEMBERIAN NACL & KCL

Sediaan :
NaCl 5% (RSDK)
1cc = 0,855 mEq
KC: (RSDK)
1cc = 1,3 mEq
NaCl Otsuka
1cc = 1 mEq
KCL Otsuka
1cc = 1 mEq
Dosis maintenance Na / K : 2 mEq / kgBB / 24 jam
1. Preparat RSDK :
2 x BB
500
Na
x
0,855 Keb.cairan
K

2 x BB
500
x
1,3
Keb.cairan

2. Preparat Otsuka :

K / Na 2x BB x

500
Keb.cairan

Dosis koreksi Na (Indikasi : bila Na < 120 mEq/L)

1. Preparat RSDK :
Na

(120 x) x BB x 0,6
(cc )
0,855

2. Preparat Otsuka :
Na = (120 - x) X BB x 0,6 (cc)
Keterangan :
X : nilai Na Sekarang
Cara pemberian : - darah 6 jam
- dalam 18 jam
Cara Koreksi Albumin
BB x 40
Alb AK x
x2
100
AK x BB x 0,8 (gram)
Keterangan : AK = (Albumin yang diharapkan albumin sekarang)
Contoh koreksi albumin :
Koreksi x gram
Misal koreksi dengan albumin 25%
= 100/25 X (x) gram = . Cc
Plasma albumin 100 cc = 3,5 gram
PATOKAN JUMLAH MINUM NEONATUS SESUAI KEBUTUHAN CAIRAN
Kebutuhan cairan
Kebutuhan cairan
Umur (hari)
Umur (hari)
(cc/kgBB/hari)
(cc/kgBB/hari)
[Type text]

Page 15

1
2
3
4
5
6
7

80
90
100
110
125
135
150

8
9
10
11
12
13
14

155
160
165
175
185
195
200

Anion Gap
= (Na (Cl + HCO3))
Normal = 12 2

Sistolik (2 x diastolik)
3
Normal = Umur (< 70 mmHg)
3 - 6 bulan mmHg
6 12
mmHg
14
mmHg
4 10
mmHg
Mean Arterial Pressure (MAP)

Re spirator Index x / RI ( Nilai shunting alvcolar )

AaDO2
PaO 2

Normal < 0,1

Transferin Saturation =
Normal anak
Bayi
Dewasa

SI
x 100%
TIBC

= 16%
=9%
= 30%

BB
TB 2
= 16 25 (idealnya = 18)
= 25 30
> 30

Body Mass Index ( BMI )

Normal
Gizi lebih
Obesitas

[Type text]

Page 16

rutin : warna, kekeruhan, reduksi, protein, sedimen

Faal ginjal berdasarkan normogram (kreatinin plasma & umur)
Faal ginjal normal klirens kreatinin (Kkr) 95 ml/menit/1,73 m3
B. Selama perawatan RS :
Harian
: urin tampung 24 jam, imbang cairan, diuresis, BB & LP
2x / mgg (Senin & Kamis) :
- urin rutin
- Esbach (urin tampung 24 jam)
Mingguan : Ht, Ureum, kreatinin sampai nilainya normal
Bulanan :
- Hb, Ho Lekosit, LED, hitung jenis.
- Ureum, kreatinin
- Total protein, albumin, globulin
- Kolesterol
Perhitungan formula Y
Pedoman perhitungan
Klinis

Edema
+ = (+ 0,2239)
-=0
Hematuria
+ = (-0, 0721)
-=0
C3 (ic globulin)
Menurun = (- 0,6511)
Normal = 0
Serum kreatinin (mg%)
- ( . X 0,0990)
Serum albumin (g%)
- (.. X 0,0580)
Konstanta (+ 0,9295)
Formula Y =

Formula Y 0,85
> 0,85

[Type text]

Pasien A (MPGN)
Edemia, hematuria, C3 normal,
serum kreatinin 1,2mg%, serum
albumin 2,4mg%

Pasien B (SNKM)
Edema, hematuria, C3 normal,
serum kreatinin 0,8 mg%,
serum albumin 1,4 mg%

+ 0,2239

+ 0,2239

- 0,0721

- 0,00721

- 0,1089

- 0,0792

- 0,1392

- 0,0812

+ 0,9295
0,8332

+ 0,9295
0,9209

: MPGN (Membranoproliferatif glomerulonefritis)

: SNKM (Sindroma nefrotik kelainan minimal)

Page 17

Normogram Faal Ginjal Anak

Untuk memprediksi klirens kreatinin (KKr) anak dengan faal ginjal campuran (normal dan
terganggu ringan sampai sedang) pada umur 24 168 tahun.
(Lydia Kosnadi, Lab. IKA FK UNDIP, RSUP Dr. Kariadi, Semarang. 1996).
Cara mempergunakan :
Tentukan nilai kadar kreatinin plasma (PKr) pada garis di kiri dan nilai umur (bulan) pada
garis di kanan, selanjut tariklah garis melalui keduanya. Titik potong garis penghubung
dengan garis di tengah adalah nilai (KKr).

MANAGEMENT OF HYPERKALEMIA IN VLBW INFANTS

3.

Maintenance fluids : 80 100 cc/kg/day DSW. If blood sugar is > 100 m%, begin regular
insulin infusion in normal saline ( 20 units regular insulin in 100ml NS), 0,1
units/kg/hour (=0.5 cc/kg/hr). Titrate infusion rate to keep blood sugar 100-200 mg%.
Blood sugar should be monitored every hour until stable, then every two hours. If blood
sugar > 200 mg%, or if serum potassium continues to rise, increase insulin infusion rate
by 0.05U/kg/hr (=0.25cc/kg/hr). if blood sugar falls to < 100 mg%, insulin infusion
should be stopped. Any changes in insulin infusion rate should be followed be a blood
sugar within one hour.
Additional treatment for hyperkalemia.

Sodium bicarbonate, 1-3 mEq/kg IV over 3-5 minutes;

Calcium gluconate (10%), 0.3-0.5 cc/kg IV over 2-5 minutes.

1.

2.

Note : calcium gluconate is not compatible with sodium bicarbonate

Algorithm for the Management of Hyperkalemia in Extremely Low Birthweight Infants

[Type text]

Page 18

HIGH FREQUNCY JET VENTILATION

Jet ventilation should be considered when there is a need for high frequency and oscillation is
contraindicated (listen in the preceding section), such aas in air leak or asymetric lung
disease. The jet ventilator can also be used for alvec recruitment by finding the Optimal
PEEP.
Finding Optimal PEEP During High Frequency Jet Ventilation
(from Bunnell, Inc.)
Bagan :

[Type text]

Page 19

Commonly Used NICU Drugs

Note : refer to the red three-ring binder or the pharmacy references in the attending office for
more information.
INDEX
Acyclovir
Ampicillin
Caffeine
Cefotaxime
Ceftriaxone

Chlorothiazide
Dexamethasone
Enaiapril
Erythomycin
Furosemide

Gentamicin
HepatitisB
Indomethacin
Lorazepam
Metociopramide

Metolazone
Morphine
Pancuronium
Phenobarbital
Phenytoin

Ranitidine
Surfactant
Spironolactone
Theophylline
Vancomycin

Acyclovir
IV : 30-60 mg/kg/day q8h infuse over 60 minutes
Ampicillin
Body weight
< 2000 gm
> 2000 gm

Age 0-7 days

100-200 mg/kg/dayq12h
150-300 mg/kg/dayq8h

Age > 7 days

150-300 mg/kg/dayq8h
200-400 mg/kg/dayq6h

Maximum dose for meningitis is 100mg/kg/dose at recommended interval for age

Caffeine
UWMC compounds Caffeine citrate (20ng/mL), this is equal to caffeine base (10mg/mL)
IV or PO :
Loading dose 20mg/kg
Maintenance dose 5-7.5 mg/kg q24h
Therapeutic range (5-20mcg/mL) draw 2 hours after 3 rd maintenance dose, then on an as
needed basis
Cefotaxime
Age
0-7 days
> 7days
> 30 days

Dose
100mg/kg/day
150mg/kg/day
200mg/kg/day

Interval
q12h
q8h
q6h

Ceftriaxone
Age
0-7 days
> 7days

Dose
50mg/kg/day
100mg/kg/day

Interval
q24h
q12h

[Type text]

Page 20

Clorothiazide
IV or PO : 20-40mg/kg/dayq12h

Dexamethasone
IV or PO : starting dose 0.5 mg/kg/dayq12h, then taper per 14,21 or 42 day protocol
Glucocorticoid

Equlvaient Gluco
dose (mg) corticoid
potency
Cortisone
25
0.8
Hydrocortisone
20
1
Prednisone
5
4
Prednisolone
5
4
Methylprednisolone 4
5
Dexamethasone
0.75
20-30
Betamethasone
0.6-0.75
20-30

Mineralo
cortoid
potency
2
2
1
1
0
0
0

Plasma
t (min)

DOA
(hr)

30
80-118
60
115-212
78-188
110-210
300+

8-12
8-12
18-36
18-36
18-36
36-54
36-54

Enalaprili
IV : 5-10 g/kg/dose given q8-24h
PO : 0.05-0.1 mg/kg/dayq12-24h
Erythomycin
IV or PO :
Age/Weight
< 7 days
> 7 days
> 2000gm

Dose
10/mg/kg
10 mg/kg
10 mg/kg

Interval
q12h
q8h
q6-8h

Furosemide
IV : 0.5-1 mg/kg
PO : 1-2 mg/kg
Gentamicin
2.5 mg/kg/dose

Therapeutic range

q24h < =34 weeks and <= 1250 gm

q18h < =34 weeks and >= 1250 gm
q12h > 34 weeks
Peak : 6-12 g/mL
Trough :<2 g/mL

HepatitisB
Immune Globulin : 0.5 mL IM
Vaccine : 10 mcg/0.5mL IM (EngerixB )
[Type text]

Page 21

Indomethacin
Prophylaxis
IV : 0.1 mg/kg/dose X4 doses (12,24,28 and 72 hours of age)
Treatment
Q12h X3 doses IV :
Age
48 hrs
2-7 days
> 7days

Dose #1
0.2mg/kg
0.2mg/kg
0.2mg/kg

Dose #1
0.1mg/kg
0.2mg/kg
0.25mg/kg

Dose #3
0.1mg/kg
0.2mg/kg
0.25mg/kg

Lorazepam
IV or PO : 0.05-0.1mg/kg/dose q3-6h
Metoclopramide
IV or PO : 0.1mg/kg/dose q6h
Metolazone
PO : 0.2-0.4mg/kg/day Rarely used at doses <0.4mg/kg/day
Morphine
IV bolus : 0.05-0.1mg/kg q2-4h pm
Continuous infusion
Age
0-7 days
<37 weeks or
severe hepatic or
renal Impalrment
> 7 days term Infant

Dose
10-20mcg/kg/hr
10mcg/kg/hr

20-40mcg/kg/hr

Switch from IV to PO
Multiply IV by 3 then give of the calculated dose and increase as needed remember you
may be converting a continuous IV drip to q3h PO

[Type text]

Page 22

Protocol for NAS (starting dose for consistant scores)

Administer orally q3h with feeds.
Finnegan
8-10
11-13
14-16
>= 17

Mg/kg/day
0.32
0.48
0.64
0.80

mL/kg/day
0.8
1.2
1.6
2.0

Pancurunium
IV : 0.1mg/kg q1-4h prn
Phenobarbital
IV or PO :
Loading dose -20 mg/kg
Maintenance dose 2.5-5mg/kg/dayq21h
Therapeutic range : (15-40 mcg/mL) draw 12 hrs after dose, then follow as needed
Phenytoin
IV:
Loading dose:20mg/kg (may into 2 doses q20min to decrease cardiotoxicity risk)
Maintenance dose : 5-8 mg/kg/dayq12h
Therapeutic range : (10-20 mcg/mL) draw levels 8-12hrs after dose
Ranitidine
IV: 2mg/kg/dayq12 max. dose : 5mg/kg/day (IV or PO)
Surfactant
Beractant (Survanta ); 4mL/kg per ETT q6h x 4 doses in 48 hours (=100mg
phosphollipid/kg)
Colfosceril (Exosurf ): 5mL/kg/ per ETT q12h x 3 doses in 48 hours (non formulary)
Spironolactone
PO: 1-3 mg/kg/dayq8h

[Type text]

Page 23

Theophylline
Please do not use aminophylline
IV or PO:
Loading dose : 4-6mg/kg
Maintenance dose : 3-6mg/kg/day q8h
Therapeutic range : (6-12mcg/mL) draw levels 2 hrs after dose
Weight/Age
<1250 gm
1250-2000 gm
>2000 gm or > 31 days

Dose
15 mg/kg/day
30mg/kg/day
30-45 mg/kg/day

Interval
q24h
q12h
q12h

Therapeutic range
Peak : 30-40mcg/mL
Trough : 5-10mcg/mL

[Type text]

Page 24

COMMONLY USED DRUGS FOR INFANTS IN THE NICU

Antibiotic & Antifungals I Gentamicin Dosing Table
Bagan

[Type text]

Page 25

Gambar

Biochemistry of Billrubin
Flour configuration possible 4Z, I5E, 4E, 15Z & 4E, 15E
Water Insoluble due to Internal H-bonding
Phototherapy can change the configuration
Fetal/Neonatal vs. Adult Billirubin Metabolism
Production :
Daily production: 6-8 mg/kg (vs. 3-4mg/Kg)
RBC volume is high (High: 16-18 gm% vs. 12-14gm%)
RBC life span is shorter (90 days vs. 120 days)
Larger fraction of shunt billrubin (25% vs. 10%)
Transport & Hepatic Uptake:
Lower concertration of albumin
Lower affinity for billrubin
Competitive inhibition of binding sites (fatty adds, other, anions, antibiotics etc.)
Lower concertration of ligandins
Competitive inhibition of ligandins
Configuration of Excretion :
Lower concertration of transferase
Lower USPGA levels (less diglucuronides; more monoglucuronides formed0
Beyond first week, billiary excretion is the rate limiting step for billirubin clearance.
Glucuronyl Transferase Ontogency
First appears at 16 weeks
Between 17 & 30 weeks, the level is 0.1% adult, but functionally active
Between values reached between 6 to 14 weeks, independent of gestation
Inducrible phenobarb, phenytoin, billirubinm aspirin

Enterohepatic circulation
More monoglucuronides easily deconjugated
High levels of -glucuronidase in the lumen (detectable at weeks of gestation)
Absence of bacteria in the GIT less convension to urobillinoids
Large billrubin pool in the meconium (1gm contains 1mg of billrubin)
[Type text]

Page 26

Epidemiology of Neonatal Jaudice

Chemical hyperbiilrubinemia (> 2mg%) almost universal
Clinical jaundice (> 5mg%)
65% of fullterm, 80% of preterm
Exaggerated hyperbillirubinemia (> 12.8mg%)
4% Afro American
6-10 Caucasion
25% Asian (> 20mg in 2%)
Effect of Race
Highers incidence of hemoglobinopathies (e.g.Hgb E), enzyme deficiencies (G5PD)
? Genetic defect in conjugation
? Role of herbal medications
Higher incidence of breastfeeding
Higher -glucuronidase levels
Effect of type of Feeding
2/3 rd will have chemical jaundice for 2-3 wks
TSB > 12mg% in 12% (vs.4% formula fed)
Decreased billirubin clearance
Inborn errors of billirubin metabolism : Criggler-Najjar type I % II, Gilberts
Other inborn errors of metabolism, tyrosenemia, galactosemia.
Drugs and hormones: hypothyrolism, hypopituitarism
Pathological Causes of direct Hyperbillrubinemia
Hepatobillary Disorders
Billary Atresia-ideopathic, syndromic
Hepatitis: Ideopathic, TPN
Choledochal cyst
Severe hemolytic jaundice
Infections
Intrauterine (TORCH)
Extraturine, sepsis, UTI
Inborn Errors of Metabolism
Cystic fibrosis, galactosemia, Alpha-1 AT deficiency
Gambar

[Type text]

Page 27

Readmission differential Diagnosis of Jaundice

Diagnosis
No cause / breast feeding
ABO hemolytic disease
Cephalohematoma
Anti E hemolysis
Galactosemia
Sepsis

%
95
3.5
1
0.3
0.3
0

Neurotoxicity of Billirubin
Billirubin encephalopathy vs. kernicterus
Higher risk with high serum billrubin levels and burder, but prediction is not absolute
Billrubin albumin binding, permeability of the blood brain barrier and pH are other
variables
Risk higher with hemolytic jaundice (30%-50% of untreated), but also can occur with
other conditions (10-15% in G6PD deficiency)
Has been reported in jaudice associated with breastfeeding, usually with high levels
(~40mg%)
Re emergence of Kernicterus in Fullterm Infants
Since 1991, 42 cases have been reported
Some due to G6PD deficiency
Factors responsible:
Decreased physician concern about evaluation and treatment of jaundice in the breast
fed infant
Early hospital discharge without adequate parental preparation or follow up
85% of the readmission (1-4% of early discharges; 109,000 infants annually) is because
of jaundice
Predicting Billrubin Encephalopathy (criteria for treatment)
Total Serum Billrubin levels
Most commonly used in the US
AAP recommendation is solely based on this
Risk of Kernicterus high if TSB > 30 mg% (95% risk of death/permanent sequelae if
> 35mg%) and risk low if < 20mg%
Phototherapy recommendation based on TSB levels :
VLBW : >12 mg%
LBW : >15mg%
Fullterm : >17-20mg%
Drawbacks of Using TSB level
Toxic effects may not be related to TSB level
No direct correlation between TSB levels and IQ/Neurotoxicity
Laboratory variations TSB estimation
Diurnal variation in TSB levels

[Type text]

Page 28

Surrogates for TSB

Extent of cutaneous icterus
Transcutaneous billrubinometry
Perspex jaundice meter
Drawbacks
Need experience
Not used in preterm, and dark skinned
Not useful after treatment
Treatment
Fed on free Billrubin levels
safe free Billrubin levels :
13 nmol/L for < 1500 Gm
17 nmol/L for < 2500 Gm
Prediction of Encephalopathy;
100% Sensitivity and 96% (<1500 Gm) to 98 (<2500 Gm) Specifity
Used in Japan
Not easily available
Fed on Albumin Billrubin Binding Capacity
May be useful in preterm infants and sick infants
Treatment indicated when binding capacity is reduced
Most of the currently available tests are semiquantitative
Not much used in the US
Delta TcB and risk factors for kernicterus
Fed on Clinical Criteria

Healthy
Sick

<1000
10
10

1000-1249
13
10

1250-1499
15
13

1500-1999
17
15

2000-2500
18
17

>2500+ & >37 w

20
18

Jar <7, hypoxia+Axidosis, Hypothemia, Hypoalbuminemia, hypoglycemia, sepsis, sudden,

clinical deterioration
Treatment at lower billrubin levels in hemolytic anemia (is some antenatally)
Fed on Billrubin Production Rates
Rate of billrubin rise
Phototherapy: if >0.3 mg/hr
Exchange tranfusion: if > 0.5mg/hr ( <24hr); 1mg/hr (with intensive phototheraphy)
Rate of CO production:
Treat if end tidal CO is > 2ppm
On Neurophysiological Tests
Brain Stem Auditory Evoked Response
[Type text]

Page 29

Prolongation of latency of wave I, abnormal interpeak latencies, I-II and/or I-V,

decreased amplitude of wave I, III, and V
Abnormalities correlate with free billrubin (no abnormality if < 17nmol/L), than with
total billrubin levels
Reversible with exchange transfusion or with intense phototherapy

Magnetic Resonance Imaging and Spectroscopy

Most of the MRI finding have been described after the development of kernicterus
MRS findings have not been described in humans yet
Cry Analysis
Computer analysis of cry characteristics correlate with BAER findings
Still a research tool
Parmacologic
1. HO inhibitors

Macam- macam ANEMIA :

1. Anemia Normositik-Normokromik:
- anemia aplastik
- anemia pada penyakit kronis
- anemia hemolitik
2. Anemia Makrositik :
- anemia megaloblastik (def vit B12 dan asam folat)
- anemia anemia hemolitik (asam folat kurang)
- Down syndrome
- Chronic liver disease
3. Anemia Mikrositik Hipokromik :
- anemia def besi
- Thalasemia
- anemia sideroblastik
- anemia pada penyakit kronik
- keracunan
- def vit B6.

[Type text]

Page 30

[Type text]

Page 31