Acute Pulmonary Edema in

Preeclampsia

Muhammad Alamsyah Aziz, dr, SpOG(K), KIC, M.Kes

Divisi Kedokteran Fetomaternal

FK UNPAD-RSHS Bandung

LOGO
 Introduction

Uncommon but life-threatening event

Pre-eclampsia remains an important
cause of hypertensive acute pulmonary
oedema in pregnancy
Preventive strategies include closed
clinical monitoring and restricted fluid
administration
Immediate management of acute
pulmonary oedema includes oxygenation,
ventilation and circulation control with
venodilators
 Pulmonary oedema

Significant cause of morbidity and

mortality in pregnant
The fourth most common form of
maternal morbidity
Characterised by sudden- onset
breathlessness
May be accompanied by agitation,
Reason for intensive care admission
May occur during the antenatal,
intrapartum or postpartum periods
Risk Factors
 Diagnosis

 Clinical symptoms : breathlessness,

orthopnoea, agitation, cough
 Signs : tachycardia, tachypnoea, crackles
and wheeze on chest auscultation, cardiac
S3 gallop rhythm and murmurs, decreased
oxygen saturation
 Typical chest X-ray features include upper
lobe redistribution, Kerley-B lines and
pulmonary infiltrates.
 Transthoracic echocardiography is the key
diagnostic and management tool
 Radiographic Features of Pulmonary Edema
( Ware BL, Matthay MA. N Engl J Med 2005; 353(26): 2788-2796 )
 Acute Pulmonary Oedema with
Hypertension

 Pre-eclampsia is a multisystem major

cardiovascular disease of pregnancy with
hypertension its main clinical manifestation
 Acute pulmonary oedema is a leading cause
of death in women with pre-eclampsia
 Pulmonary oedema may occur in up to
approximately 3% of women with pre-
eclampsia, with 70% of cases occurring after
birth
 It is associated with excessive fluid
administration and disease severity,
including HELLP and eclampsia
 The Management of Hypertensive Acute
Pulmonary Oedema in Preeclampsia

The goals of treatment are:

1 Reduce left ventricular preload

2 Reduce left ventricular afterload
3 Reduce ⁄ prevent myocardial ischaemia
4 Maintain adequate oxygenation and
ventilation with clearance of pulmonary
edema
 Immediate Management

Acute pulmonary oedema is a medical

emergency and should trigger an
emergency response
Electrocardiography, chest X-ray, blood
pressure, oxygen saturation, heart rate,
respiratory rate, temperature and fluid
balance monitoring should be considered
mandatory
Treatment
Acute
Pulmonary
Oedema
 Urgent reduction of critically high blood
pressure :
 Nitroglycerin (glyceryl trinitrate) is
recommended)
 It is given by intravenous infusion starting
at 5 lg.min, gradually increasing every 3–5
min to a maximum of 100 lg.min)
 An alternative agent, sodium nitroprusside,
the typical dose by infusion is 0.25–5.0
lg.kg.min)
 Intravenous furosemide (bolus 20–40 mg
over 2 min) is used to promote venodilation
and diuresis
If hypertension persists calcium channel
antagonist such as nicardipine or
nifedipine may be considered
Prazosin as well as hydralazine may also
be considered
Intravenous morphine 2–3 mg may also
be given as a venodilator and anxiolytic
Management
 Ilustrasi Kasus

 Nama : Ny. DM
 Jenis kelamin : Perempuan
 Umur/Tgl. Lahir : 19 tahun
 No. Rekam medis : XXXX-XXXX
 Berat badan : 49 kg
 Perawatan di ICU : 6 – 13 November 2013

14
 Alur Penatalaksanaan Pasien

Pasien
Masuk IGD Dilakukan pindah ke
Dirawat di
RSHS operasi ruang
(Kebidanan) SC cito ICU perawatan
kebidanan

6/11-13
5/11-13 13/11-13
Pk. 05.30 - 6/11-13 – 13/11-13
Pk. 15.00wib 06.45wib Pk. 18.00wib

15
 Alur Penatalaksanaan
• Pasien
• Di rumah: 20 jam SMRS kejang ± 9-12 x, tidak
Di IGD RSHS: Sopor,
sadar. TD 160/140 mmHg, LN 112
• x/mnt,
Ke RSUD LP 18x/mnt S 36.8°C,
Bekasi : kejang 1x, j/p
O2,dbn, udem tungkai +.
diazepam,
• Lab: DPL 8,2/27,8/17.400/424.000, PT >120 (k11,5),
MgSO4, nifedipin.
APTT >180 (k34,2), prot urin 2+, Hb urin 3+, keton
• Sopor,
urin 4+, TD 180/110
D dimer mmHg,
0.6 mg/L, LN :120
fibrinogen x/mt,
325,2,
S 36°C.
Ur/Kr 15,5/1,14 SGOT/PT 31/6
• AGD : 8.1/27.6/22900/401000,
DPL 7,44/18.4/138.5/-9.1/12.7/99.3Alb 2.51,
• D/ Penurunan
GDS kesadaran
130, SGOT/PT ec eklampsia
31/11, antepartum,
Ur/kr 12/1,27,
G1 35-36mg, IUFD, anemia.
Na 142 K 4,5 Cl 103, Alb. urin 3+.
• O2, Nifedipin, MgSO4, NAC, vit C.
•• D/ G1P0A0 H 35-36 mg + eklampsia.
Konsul Mata, IPD, Neurologi, Anestesia : SC cito.
• Dirujuk ke RSHS karena fasilitas tidak lengkap.

Masuk IGD Dilakukan

RSHS operasi SC
(Kebidanan) cito

5/11-13
Pk. 15.00wib

16
 Alur Penatalaksanaan Pasien

• Praop: Somnolen, TD 160/90 mmHg, LN 108x/mnt,

LP 20x/mnt, S afebris, SpO2 99%, ASA 3 E.
• SC dengan anestesia umum.
• Intra op stabil : TDS 140-170 mmHg dan TDD 75-110
mmHg, LN 70-85 x/menit.
• Lama operasi: 1 jam 5 menit. Lama anestesia : 1 jam
15 menit.
• Cairan masuk : kristaloid 500 cc, darah 220 cc,
Cairan
Masuk keluar Dilakukan
IGD : urin 500 cc , perdarahan 400 cc.
RSCM operasi
(Kebidanan) SC cito

6/11-13
5/11-13
Pk. 05.30 -
Pk. 15.00wib
06.45wib

17
 Alur Penatalaksanaan Pasien

• Pasca op pasien masuk ICU IGD,

pola nafas ETT bagging + O2,
TD 120/90 mmHg LN 108x/mnt
LP 18x/mnt.
• Masalah: Pasca SC a/i eklampsia
antepartum, observasi kardiovaskular,
penurunan kesadaran dan kejang.

Masuk IGD Dilakukan

Dirawat di
RSHS operasi
(Kebidanan) SC cito ICU

5/11-13 6/11-13
6/11-13 –
Pk. 15.00wib Pk. 05.30 -
13/11-13
06.45wib
18
 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 1 2 3 4 5 6 7
BP HR RR
36 37 T(ºC)
200 200 50

Toraks
Foto

cvc

I C U H A R I K E – 1 ( 6/11 )
160 160 11.30 wib 40
kristaloid 250
120 120 cc/30 menit
30

80 80 20
09.30wib AGD :
7,273/13,6/161,4/-18,3/6,3/96,3
40 40
( PF : 403,5 ) 10

SIMV 12 PC14/PS12/p5/40% ..................................SIMV 10 PC10/PS10/p6/40%......................................... ......

20 20 0

CVP (cmH2O) 6-11-13,13.00 wib +15

MAP(mmHg) 98 100 110 99 99 Jantung kesan
128 107 114 113 membesar
110 110 112 121 118 108 117 105 95 98 103 114 108 125
SpO2 (%) 100 98 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100

F: CF 30 cc/jam + kristaloid 50 cc/jam

DPO, J/P dbn, udem tungkai + A: Pasca SC a/i eklampsia H-1 A: Tramadol 100 mg/ 8 jam (drip)
S: Propofol 50 mg/jam
10,2/33,6/32.900 /336.000 T: -
H: elevasi kepala 30⁰-45⁰
Ur/Kr : 16,3 / 0,68 P: ventilator, CT scan kepala U: Omeprazole 2 x 40 mg
SGOT 47 SGPT 12 E1 Ampisilin Sulbactam 4x1,5 g
G: -

GDS 159 Albumin 3,0 E1 Metronidazol 3x500 mg CM 2473 cc CK 1130 cc

Na 146 K 4,2 Cl 110 E1 Gentamycin 2x80 mg
PT : 10,5 (K 11,5) = 1,095 x
UO 0,9 cc/kgBB/jam
Amilodipin 1x10 mg, kaptopril 3x12,5 mg
APTT : 31 (K 31,9) = 1,029 x Inhalasi salbutamol+budesonide /6 jam BC + 1343 cc/23 jam
BK + 1343 cc
19
 7 8 9 10 11 12 13 14 15 16 17 18 19 20 8-11-13,
21 22 23 01.15
24 1wib2 3 4 5 6 7
7-11-13, 11.52 wib
BP HR
Infiltrat di37,8
2 RR
infiltrat37di 2 lap.paru
37,2 37,5 T(ºC)
200 200 lap.paru bertambah 50

Toraks

Toraks
CT scan

I C U H A R I K E – 2 ( 7/11 )
kepala
Foto

Foto
160 160
PCO2 gap: 4,1 (09.30wib) gelisah, 40

ScVO2: 74,7% ETT: frothy

120 120
sputum 30

80 80 20
06.00wib AGD :
7,44/37,5/152,6/2,8/26,2/99,4
40 40 10
( PF : 436 )

SIMV8PC8/PS8/p6/35%→p5/55%...................................................SIMV8PC10/PS10/p5/65%......PC10/10/p8/55%
20 20 0

CVP (cmH2O) +16,5 +11 +12 +10

MAP(mmHg)121 107 107 116 100 114 98 106 129 129 129 119 114 105 105 116 125 111 100 105 97 86 89
7
SpO2 (%) 100 97 97 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 98 98

DPO, P/ ronki +/+ A: Pasca SC a/i eklampsia H-2, F: MC 100 cc/jam + kristaloid 500 cc
A: Tramadol 100 mg/ 8 jam (drip)

(06.05) 7,98/26,3/11.400 /283.000 edema paru dd/ pneumonia. S: Propofol 50 mg/jam

T: -
H: elevasi kepala 30⁰-45⁰
Ur/Kr : 13,6 / 0,53 GDS 114 U: Omeprazole 2 x 40 mg
Na 145 K 3,5 Cl 109 P: Observasi perdarahan, G: GDS/24 jam

(12.20) 7,8 /24,4 /12.300 /276.000 CM 3011 cc (WB gol B 70 cc)

transfusi, balans cairan. CK 2060 cc
PT : 9,3 (K 10) = 0,93 x
E2 Ampisilin sulbactam 4x1,5 g UO 1,7 cc/kgBB/jam
APTT : 29,4 (K 30,9) = 0,95 x (furosemide 2 mg/j)
Fibrinogen 278,1 INR 0,84 D-Dimer 0,1
E2 Metronidazol 3x500 mg
BC + 951 cc BK + 2294 cc
E2 Gentamycin 1x240 mg FO 4,5%
20
 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 1 2 3 4 5 6 7
BP HR 38 38,5 38,2 38,3 38,2 38 37,8 RR
T(ºC)
200 200 Echo : global normokinetik, 50
fungsi sistolik RV dan LV baik ;

I C U H A R I K E – 3 ( 8/11 )
MPAP 27,02, SV 45, CO 4,9,
160 160 SVR 1692,2, EF 53%, TAPSE 19,3 40
Laktat 2,2
120 120 PCO2 gap 5,2 30
ScVO2 87,9%
80 80 20
(06.19wib) AGD:
40 40
7,42/46,2/128/6,3/30,6/98,9
10
(PF : 232,7)
PC10/10/p8/55%...............................................................SIMV10 PC10/PS10/p8/55%......................... .................
20 20 0

CVP (cmH2O)+12,5 +12 +10 +8 +12 +9

MAP(mmHg)103 96 101 100 104 105 110 110 110 110 109 107 102 106 105 103 103 100 100 90 106 100 100
SpO2 (%) 98 99 99 100 100 100 100 97 97 97 97 95 98 97 100 100 100 100 100 100 100 100 100

DPO, P/ ronki +/+ A: Pasca SC a/i eklampsia H-3, F: MC 100 cc/jam + kristaloid 500 cc
A:Tramadol 100 mg/ 8 jam (drip)
DPL 8,9 /29,2 /13.000 /199.000 edema paru, sepsis berat dg S: Propofol 50 mg/jam
Ur/ Kr : 13,9 / 0,67 T: Heparin 5000 U/24 jam
pneumonia. H: elevasi kepala 30⁰-45⁰
Na 146 K 3,7 Cl 105 GDS 111 U: Omeprazole 2 x 40 mg

PT : 10,4 (K 10) = 1,04 x P: Balans cairan negatif,transfusi, G: GDS/24 jam

CM 2654 cc (07: PRC 191 cc)
APTT : 28,6 (K 30,9) = 0,92 x kultur darah, sputum, urin, BTA. CK 3280 cc
Fibrinogen 517,3 D-Dimer 0,4 E3 Ampisilin sulbactam 4x1,5 g UO 2,3 cc/kgBB/jam
T3/T4/TSH : 2,39/1,19/0,87 E3 Metronidazol 3x500 mg (furosemide 5mg/j)
Anti HIV : non reaktif BC – 626 cc BK + 1668 cc
E3 Gentamycin 1x240 mg FO 3,3 %
21
 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 1 2 3 4 5 6 7
BP HR RR
37,3 37 37 36,2 36,1 T(ºC)
200 200 50

I C U H A R I K E – 4 ( 9/11 )
160 160 40

120 120
PCO2 gap 7,9
ScVO2 79,6% 30

80 80 20
(06.25wib) AGD:
7,46/54,6/149,8/14,6/39,8/99,4
40 40 10
( PF 272 )

SIMV10 PC10/PS10/p8/55%..............................................................SIMV8 PC8/PS8/p5/50%.................... ..........

20 20 0

CVP (cmH2O)+7,5 +9 +8 +2 +8 +10

MAP(mmHg)108 101 101 92 87 96 98 103 99 104 97 103 100 101 94 96 96 89 89 85 85 97 105
SpO2 (%) 100 100 100 100 100 100 100 97 99 100 100 100 100 100 99 99 99 100 100 100 100 100 100

F: MC 100 cc/jam + kristaloid 500 cc

DPO, P/ ronki +/+ A: Pasca SC a/i eklampsia H-4 , A:Tramadol 100 mg/ 8 jam (drip)
S: Propofol 50 mg/jam
DPL 11,1/ 35/ 13.200/ 267.000 edema paru, sepsis berat dg T: Heparin 5000 U/24 jam
H: elevasi kepala 30⁰-45⁰
B/E/NB/NS/L/M 0/0/9/73/17/1 pneumonia. U: Omeprazole 2 x 40 mg
G: GDS/24 jam
Alb 2,78 GDS 97 P: Ganti antibiotika, restriksi
Na 145 K 3,3 Cl 95 cairan CM 2236 cc CK 1670 cc
UO 1,4 cc/kgBB/jam
PT : 10,5 (K 10,3) = 1,04 x E1 Meropenem 3x1 g (16: furosemide ↓ 2,5 mg/j)
APTT : 36,8 (K 28,7) = 1,3 x E1 Levofloksasin 1x750 mg BC + 566 cc BK + 2234 cc
FO 4,4 %
22
 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 1 2 3 4 5 6 7
BP HR PCT RR
36,2 36 36 36,8 36,6 T(ºC)
200 200 10,2 50

I C U H A R I K E – 5 ( 10/11 )
160 160 40
Laktat 1,4
120 120 CO2 gap 5 30
ScVO2 84,1%
80 80 20
(06.19wib) AGD:
40 40 7,45/53,6/203,3/12,8/38/99,7
10
(PF : 406)
SIMV8/PC12/PS10/p8/50%................................................................45%..............SIMV10/PC10/PS10/p5/40%..
20 20 0

CVP (cmH2O)+3,5 +2,5 +9 +6,5 +3,5

MAP(mmHg)105 92 94 95 85 81 92 94 92 85 83 85 91 90 111 109 107 108 98 95 92 105 111
SpO2 (%) 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 99 100 100 99

F: MC 50 cc/jam + kristaloid 500 cc

A:Tramadol 100 mg/ 8 jam (drip)
DPO, P/ ronki +/+ S: Propofol 50 mg/jam, midazolam 1mg/j
Na 144 K 3,8 Cl 97 GDS 106 P: restriksi cairan. T: Heparin 5000 U/24 jam → stop
H: elevasi kepala 30⁰-45⁰
Biakan +res aerob urin : (8/11) steril U: Omeprazole 2 x 40 mg
G: GDS/24 jam
E2 Meropenem 3x1 g
A: Pasca SC a/i eklampsia H-5, E2 Levofloksasin 1x750 CM 2327 cc CK 1785 cc
UO 1,5 cc/kgBB/jam
edema paru, sepsis dgn
(furosemide 2,5 mg/j)
pneumonia (perbaikan). BC + 542 cc BK + 2776 cc
FO 5,5 %
23
 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 1 2 3 4 5 6 7
11-11-13, 12.55 wib
BP HR RR
Infiltrat di 25,2
200 200
37PCT
lap. paru 36 38,9 T(ºC)
50
sedikit berkurang

toraks

I C U H A R I K E – 6 ( 11/11 )
T-Piece
Foto
160 160 40

PCO2 gap 3,5

120 120
ScVO2 90,6% 30

80 80 20

AGD :
40 40 7,47/51,8/162,9/14/38,9/99,5
10
PF : 465

PS 8/p5/35%..............................................PS10/p5/35%.......................SIMV10 PC10/PS10/p5/40%........... ..........

20 20 0

CVP (cmH2O)+5 +3 +9
MAP(mmHg) 83 106 100 92 88 112 90 85 77 80 79 88 85 85 96 108 89 94 95 98 95 98 85
SpO2 (%) 100 100 100 100 98 100 100 100 100 100 100 100 89 91 92 100 100 100 100 100 100 100 100

F: MC 100 cc/jam + kristaloid 500 cc

DPO, P/ ronki +/+ (min) A: Pasca SC a/i eklampsia H-6 ,
A: Tramadol 100 mg/ 8 jam (drip)
S: Propofol 50 mg/jam, midazolam 1mg/jam
Ur / Kr : 18,4 / 0,44 edema paru, sepsis dg
T: -
H: elevasi kepala 30⁰-45⁰
Ca 9,4 Mg 1,19 pneumonia (perbaikan).
U: Omeprazole 2 x 40 mg
G: GDS/24 jam
Na 144 K 3,8 Cl 97 P: Weaning ventilator, kultur CM 1921 cc CK 1250 cc
GDS 107 sputum. UO 1 cc/kgBB/jam
SGOT/PT 20/50 E3 Meropenem 3x1 g (furosemide 1 mg/j)
E3 Levofloksasin 1x750 mg BC + 671 cc BK + 3447 cc
FO 6,8 %
24
 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 1 2 3 4 5 6 7
BP HR RR
36,5 36 36 37 T(ºC)

ekstubasi
200 200 50

I C U H A R I K E – 7 ( 12/11 )
160 160 40
Laktat 1,2
120 120 PCO2 gap 1,5
30
ScVO2 89,3%

80 80 20
AGD:
40 40 7,49/49,3/132,7/10,7/35,9/99,1
10
( PF : 379 )

PS 5/p5/35%.......6L............ps5/p5/35%............6L..................................................................... .................
20 20 0

CVP (cmH2O)+9,5 +10 +8 +3

MAP(mmHg) 92 92 94 94 87 111 99 99 109 86 92 75 83 70 85 79 88 99 103 111 98 98 98
SpO2 (%) 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100

F: MC 100 cc/jam + kristaloid 350 cc

A:Tramadol 100 mg/ 8 jam (drip)
DPO → (22.00) CM A: Pasca SC a/i eklampsia H-7, S: Propofol 50 mg/jam, midazolam 1mg/j
T: -
P/ ronki -/- wh -/- edema paru, sepsis dg H: elevasi kepala 30⁰-45⁰
U: Omeprazole 2 x 40 mg
DPL 10,3 /33,7 / 9002 /296.000 pneumonia (perbaikan). G: GDS/24 jam
Albumin 2,89 P: Ekstubasi, balans negatif CM 1615 cc CK 1620 cc
Na 143 K 4,9 Cl 97 UO 1,3 cc/kgBB/jam
GDS 107 E4 Meropenem 3x1 g (furosemide 5 mg/j)
CD3+CD4+ 756 (410-1590) E4 Levofloksasin 1x750 mg BC - 5 cc/24 jam BK + 3442 cc
FO 6,8 %
25
 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 1 2 Infiltrat
3 4 di
5 ke6 dua7 lap.
BP HR RR
36,8 37,1 37,3 Paru berkurang
T(ºC)
200 200 PCT 1,86 Edema paru perbaikan 50

I C U H A R I K E – 8 ( 13/11 )
160 160 40
PCO2gap 3
120 120
ScVO2 83%
30

80 80 20
AGD:
40 407,48/45/156,9/12,7/37,1/99,5
10

Pindah
6L......................................3L.............................
20 20 ruangan 0

CVP (cmH2O)+2 −1 +4
MAP(mmHg) 94 106 96 89 89 89 99 89 101 106 82
SpO2 (%) 100 100 100 100 100 100 100 100 100 100 100

F: MC 100cc/jam → bubur saring

CM (8/11) Biakan+res aerob darah dan A:Tramadol 100 mg/ 8 jam (drip)
S: -
j/p dbn urin: steril. Sputum: Acinetobacter T: -
H: elevasi kepala 30⁰-45⁰
baumanii (anitratus) U: Omeprazole 2 x 40 mg
G: GDS/24 jam
Sensitif : Colistin
Na 141 K 4,5 Cl 90,5
A: Pasca SC a/i eklampsia H-8, CM 938 cc CK 590 cc
GDS 107 UO 1,1 cc/kgBB/jam
sepsis perbaikan
Ca 9,6 Mg 1,92 (furosemide 5 mg/j)
P: Pindah ruangan
( 21.24 wib : laktat 2,6 PCT 1,31 ) BC+348 cc/11 jam BK +3790 cc
E5 Meropenem 3x1 g
FO 7,5 %
E5 Levofloksasin 1x750 mg 26
14-11-13, 08.49 wib
(ruang perawatan kebid.), kel :
Sakit kepala + Gangguan visual

(7/11, 17.00wib, CT-Scan Kepala)

Neurologi: lesi oksipital dekstra suspek perdarahan
27
dd/ massa (rencana MRI kepala dan EEG)
DISKUSI KASUS

LOGO
 Dasar Diagnosis

 Hamil 35-36 minggu.

 Hipertensi berat : TD awal 180/110 mmHg.
 Protein urin 3+.
 Kejang dan penurunan kesadaran.
 Brain CT-Scan : Lesi oksipital dekstra
susp. Perdarahan ? DD/ massa.

Eklampsia
Antepartum

29
 Penanganan Utama

Delivery of the fetus and

placenta is the definitive
management of severe Pada Pasien ini :
preeclampsia. Once severe
disease has been established
PEB/Eklampsia
and is progressing, delivery
of the fetus and placenta
Pengendalian
Nifedipin
must be accomplished to limit
Tekanan darah
maternal risk .

Airway
Pengendalian
Breathing
MgSO4
Kejang

SC
Terminasi
Linton DM, Anthony J. Int Care Med 1997; 23: 248-255
Park JS et al. Pre-eclampsia Etiology and Clinical Practice; 2007, 437-450
Cipolla MJ, Kraig RP. Fetal Matern Med Rev 2011; 22(02): 91-108

30
 ICU
MASALAH
•Eklampsia (Riwayat
kejang, penurunan KOMPLIKASI
kesadaran)
•Kardiovaskular • Edema paru
• Pneumonia

LOGO
 Edema Paru

Edema
 Sering terjadi parujam
48-72 pada pasien
pasca ini
melahirkan,
terjadi karena
mungkin pada hari ke 2 perawatan
mobilisasi di ICU
cairan ekstravaskular.
 Penyebab: gagal ventrikel kiri, kebocoran kapiler
Echo : global normokinetik,
paru dan penurunan perbedaan
fungsi sistolik tekanan
RV dan LV baik ; onkotik
MPAP 27,02, SV 45, CO 4,9, SVR 1692,2, EF 53%, TAPSE 19,3
koloid.
 Tekanan onkotik koloid pada kehamilan 34-36
Penyebab kardiogenik dapat disingkirkan, jadi pada
minggu:pasien
22 mmHg, setelah
ini diduga non kelahiran:
kardiogenik: 18 mmHg
dan turunpermeabilitas
gangguan menjadi 14 (kebocoran
mmHg pada preeklampsia
kapiler paru dan
(N: 25-28 mmHg).tekanan onkotik koloid)
penurunan

Engelhardt T, MacLennan FM. International Journal of Obstetric Anesthesia 1999; 8: 253-259

32
 Penanganan

Penelitian ???
Edema Paru
Statin
Non Kardiogenik •
• Gene and
mesenchymal
stem cells

Strategi Cairan
Ventilasi Konservatif

• Ventilasi Non Invasif

• Restriksi cairan
Pemantauan
• VentilasiCairan
Mekanik →
• Diuretik
Ventilasi Proteksi Paru

Perina DG. Emerg Med Clin N Am 2003; 21: 385–393

Matthay et al. Translational Respiratory Medicine 2013; 1: 10
Fanelli V et al. J Thorac Dis 2013; 5(3): 326-334

33
Normal Infiltrat Infiltrat Perbaikan
baru bertambah

Pemantauan Infeksi
Pneumonia

1(6) 2(7) 3(8) 4(9) 5(10) 6(11) 7(12) 8(13)

37,8- 36,1- 36,8-
Suhu 36-37 37-37,8 36-36,8 36-38,9 36-37
38,5 37,3 37,3
Hari ke 3 terjadi
penurunan
Lekosit PF ratio (232,7)
32.900 11.400 13.000 13.200 9002
disertai :
S ≥ 38°C, lekosit 13.000 1,86
PCT 14,97 10,2 5,2
PCT 14,97 dan CPIS 6 (1,31)
PF ratio 403,5 436 232,7 272 406 465 379 348

CPIS 1 1 6 2
Ampi-sul. Ampi-sul. Ampi-sul.
Metronid Metronid Metronid Mero. Mero. Ganti antibiotik,
Mero. Mero. Mero.
Antibiotik Gentam. Gentam. Gentam. Levo. Levo. respon Levo.
Levo. klinik baik
Levo.
34
Perbaikan
 Kesimpulan

 Pada eklampsia terjadi disfungsi endotel berupa

peningkatan permeabilitas vaskular yang rentan untuk
terjadi adverse conditions (Fluid overload, sepsis berat,
AKI sampai gagal multi organ).

 Penanganan edema paru non kardiogenik dengan strategi

cairan konservatif dan evaluasi oksigenasi jaringan sangat
bermanfaat dalam menghindari kejadian fluid overload
dan hipoperfusi jaringan.

 Penanganan pneumonia dengan guide prokalsitonin

sangat bermanfaat dalam menunjang penilaian klinik.

35
 Terima Kasih

36