Penatalaksanan intensif pasien dengan

Penyakit Tropik Berat

di ICU

Departemen Anestesiologi & Reanimasi / Instalasi

Pelayanan Intensif (ICU)
FK-USU / RSUP H.Adam Malik - Medan

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Indikasi Umum Pasien dirawat di ICU

 Berdasarkan Prioritas
 Berdasarkan Diagnosis
 Berdasarkan Nilai-nilai Parameter
Hasil Laboratorium

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Penyakit Tropik Berat (yang sering
di ICU :
 Tetanus Berat (Severe Tetanus)
 Malaria Berat (Severe Malaria)
 DHF Grade III-IV (DSS)

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TETANUS BERAT

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 TETANUS adalah
Gangguan neurologis yang ditandai dengan
meningkatnya tonus otot dan spasme yang
disebabkan oleh tetano spasmin, suatu
toksin B yang kuat, yang dihasilkan oleh
Clostridium Tetani
CLOSTRIDIUM TETANI
Bakteri gram (+)
Anaerob
Bentuk Batang
Bergerak dan menghasilkan spora
berbentuk oval menyerupai raket
tenis
Tahan bertahun-tahun pada
lingkungan tertentu dan tahan
terhadap sinar matahari
Mechanism of Action of
Tetanus Toxin
TETANUS GENERALISATA

Bentuk yang paling sering terjadi

Karakteristik : tonus otot meningkat, kejang umum
Median onset setelah trauma 7 hari
Tanda khas pertama
 Trismus (Lock Jaw) akibat peningkatan tonus M Masseter
diikuti dysphagia, kekakuan dan nyeri otot leher, bahu dan
punggung yang menyebabkan Opistotonus.
 Kontraksi otot wajah menghasilkan ekspresi yang khas 
Risus Sardonicus.
 Kemudian terlibat otot abdomen dan proksimal
 Anggota gerak bawah, tangan dan kaki relatif jarang terlibat.
Beberapa pasien berkembang menjadi berat  Kejang
yang berulang sehingga terjadi Laryngospasm, Apnu,
Sianose, dan gangguan ventilasi. Kejang dapat terjadi
spontan/dipresipitasi  suara, cahaya, sentuhan.

Kadang pasien demam (60%), kesadaran baik, refleks

tendon meningkat.

Keterlibatan syaraf autonom : aritmia, fluktuasi TD

yang ekstrim, diaporesis, hiper/hipotermia, retensi urine.
Kadang terjadi cardiac arrest.

Komplikasi : aspirasi pneumoni, fraktur, ruptur otot,

DVT, emboli paru, dekubitus, rabdomiolisis.
Risus Sardonicus

Opistotonus
Trismus & Risus Sardonicus
The back muscles are more
powerful, thus creating the arc
backward

“Oposthotonus” by Sir
Charles Bell, 1809.
 Derajat Keparahan
(Severity Grading)

Philip
Dakar
Udwadia Gambaran Klinis
Ablett
Blect
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 Philips Score
Waktu Masuk Skor Selama Perawatan Skor
Masa Inkubasi Spasme
> 14 hari 1 Hanya trismus 1
> 10 hari 2 Kaku seluruh badan 2
5 – 10 hari 3 Kejang terbatas 3
2 – 5 hari 4 Kejang seluruh badan 4
< 48 jam 5 Optistotonus 5

Imunisasi Frekuensi Spasme

Lengkap 0 6 x dalam 12 jam 1
< 10 tahun 2 Dengan rangsangan 2
> 10 tahun 4 Terkadang spontan 3
Ibu diimunisasi 8 Spontan < 3x per 15 menit 4
Tidak diimunisasi 10 Spontan > 3x per 15 menit 5

Luka Infeksi Suhu

Tidak diketahui 1 36.7 - 37 C 1
Distal/perifer 2 37.1 – 37.7 C 2
Proksimal 3 37.8 – 38.2 C 4
Kepala 4 38.3 – 38.8 C 8
Badan 5 > 38.8 C 10

Komplikasi Pernafasan
Tidak ada 1 Sedikit berubah 0
Ringan 2 Apnea saat kejang 2
Tidak membahayakan 4 Kadang apnea setelah kejang 4
Mengancam Nyawa (tidak langsung) 8 Selalu apnea setelah kejang 8
Mengancam nyawa 10 Perlu trakeostomi 10

Total skor Derajat keparahan

<9 Ringan
9 – 18 Sedang
> 18 Berat
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Ablett Classification of Severity

Grade I (mild)
Mild trismus, general spasticity, no respiratory compromise, no
spasms, no dysphagia

Grade 2 (moderate)
Moderate trismus, rigidity, short spasms, mild dysphagia, moderate
respiratory involvement, ventilatory frequency > 30

Grade 3 (severe)
Severe trismus, generalized rigidity, prolonged spasms, severe
dysphagia, apnoeic spells, pulse > 120, ventilatory frequency > 40

Grade 4 (very severe)

Grade 3 with severe autonomic instability

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 Derajat Keparahan hendaknya tidak
dipakai sebagai pedoman “Kaku” untuk
indikasi rawat ICU

 Indikasi Rawat ICU bilamana cara-cara

konvensional yang dilakukan di ruang
perawatan tidak berhasil mengatasi kejang
/spasme atau pasien mengalami
gangguan pernafasan akibat kejang atau
aspirasi, atau telah terjadi gagal nafas
atau gangguan sistem lain yang
memerlukan terapi supportif.
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 Clinical diagnosis of tetanus

Secure Airway
Tracheostomy

Benzodiazepines2
Midazolam
Diazepam
Antitoxin2
HIG im/it
Equine antitoxin im

Antibiotics2
Metronidazole
Manage autonomic dysfunction
2 1
Magnesium Inotropes
2
Benzodiazepines Consider
2
Bupivacaine DVT Prophylaxis1
2 Control Muscle Spasms
Morphine
2
Clonidine Benzodiazepines2 Dantrolene1

NDNMBA’s1 Baclofen2
Magnesium2

Full primary course of immunisation1

Flow diagram showing the management of tetanus.

1—limited evidence; 2—some evidence; 3—good evidence. 17
Therapeutic Management

Immunization
Wound debridement
Antibiotics
Control muscle spasm
Control Autonomic Disturbance
Other supportive therapy

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MANAGEMENT

1. Neutralize toxin outside of CNS

- Human Tetanus Immune Globulin
HTIG) 150 units/kg IM or 5,000-
10,000 units IV
- ATS 500 UI/kgBB intramuscular.

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MANAGEMENT
2. Prevent further toxin release
- Early surgical debridement of
wounds
- Antibiotics : Metronidazole 500mg
8 hourly and Penicillin G 1 MU 6-8
hourly.
Heavily contaminated wound may
need additional antibiotics.
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MANAGEMENT

3. Minimize the effects of toxin already

exists in CNS
- Control rigidity and spasm
- Respiratory support as necessary
- Control of autonomic dysfunction.

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Drug used to control spasm and
autonomic disturbance

Benzodiazepine
Morphine
Muscle relaxant: vecuronium, rocuronium,
pancuronium
Magnesium sulfate
Dantrolen
Baclofen
Bupivacain, atropine,
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Benzodiazepine

Common used as anticonvulsant in

tetanus.
Has sedative effect
Dose of Diazepam vary 100-400 mg/24 h
max until 2400mg/24 h
Preservative used can cause acidosis in
large dose
No/little effect on autonomic disturbance
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Magnesium Sulfate
- Pre synaptic neuromuscular blocker
- Blocks catecholamine release from nerve and
adrenal medulla
- Reduce receptor responsiveness to release
catecholamines
- It antagonizes calcium in myocardium and at
the neuromuscular junction
- Inhibits parathyroid hormone release
anticonvulsant-vasodilator
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Dose
Adult : a loading dose of 5 gram over 20
minutes IV followed by 1g hourly
increasing to 2.5 gram hourly when
necessary. Titrate to symptoms
Pediatrics : 100mg /kg/24 hours, can be
increased when necessary. Titrate to
symptoms
Sometimes MgSO4 is inadequate to be used alone,
combination with benzodiazepine is also mandatory
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Monitoring of possible side effects
- Patellar reflex
Diminished at the level of Magnesium >4 mmol/L
- Respiratory depression because of muscle
paralysis (>Mg 6 mmol/L)
- Bradyarrhythmia, hypotension
- Urine output
Low output causes drug accumulation
- Blood Calcium level, blood Magnesium level
should be checked regularly
- Overdose may cause sedation and anesthesia.
Day 4 Day 6
 Magnesium can be a prospective
alternative for treatment of tetanus,
especially when there are mass
casualties since it reduces the need for
mechanical ventilation, however,
meticulous ICU monitoring is needed
with ready for use ventilator.
Gempa Yogyakarta
Others Drugs & Regiment
Obat pelemas otot (muscle relaxant)
intermittent bila diperlukan.
Baclofen (beta – [4-chlorophenyl] gamma
amino butyric acid) sebagai P-GABA
receptor agonist, menghambat pelepasan
asetilkolin presinaps diotak, diberikan
intrathekal
Propofol (1,6-diisopropyl phenol) dapat
dipakai sebagai sedasi, dengan dosis
tritrasi.
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Others Drugs & Regiment
Penghambat beta :
Propanolol,Labetolol, Esmolol
Agonist alfa-2 : Clonidine
Dexmedetomidine
Opioid kombinasi dengan sedative :
Morphine + midazolam atau diazepam
Sodium valproate
ACE Inhibitor
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MANAGEMENT
Terapi supportif lainnya
 Terapi fisik (fisioterapi) karena pasien
imobilisasi cukup lama.
 Ventilasi mekanik
 Metabolik : Nutrisi enteral , ditambah
parenteral bila perlu.
 Penggunaan inotropik dan atau
vasopresor
 Antikoagulan
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3 major complications cause death

Ventilatory restriction leading to respiratory

complication and sepsis
Autonomic disturbance
Stress ulcer/gastric bleeding

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SEVERE MALARIA

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Adult Anopheles

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Plasmodium falciparum

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What is severe malaria?

Severe malaria is the serious or life-threatening

form of falciparum malaria which needs active
appropriate patient management.

According to WHO criteria in 1990, severe malaria

patients have asexual forms of Plasmodium
falciparum on a blood film and may have any one
or more of the following manifestations and
complications :
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1. Cerebral malaria (unrousable coma not
attributable to any other cause)

2. Severe normocytic anemia (haematocrit <15%

or hemoglobin <5 g/dl)

3. Acute renal failure (urine output <400 ml/24

hours in adults or 12 ml/kg/24 hours in children,
failing to improve after rehydration and serum
creatinine >265 mmol/l (3 mg/dl))

4. Pulmonary edema or adult respiratory distress

syndrome (ARDS)
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 5. Hypoglyceamia (whole blood glucose <2.2
mmol or l40 mg/dl)
6. Circulatory collapse, shock: hypotension
(systolic blood pressure <50mmHg in children
aged 1-5 years or <70 mmHg in adults), with
cold clammy skin or core-skin temperature
difference >10 °C)
7. Spontaneous bleeding/disseminated
intravascular coagulation (DIC)
8. Repeated generalized convulsions
9. Acidaemia (arterial pH <7.25) or acidosis
(plasma bicarbonate <15 mmol/l)
10. Macroscopic haemoglobinuria
11. Post-mortem confirmation of diagnosis
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 WHO MULTICENTER STUDY ON SEVERE MALARIA IN UNDER
FIVES IN 10 AFRICAN COUNTRIES (1230 CASES, 1999 – 2000)
PREVALENCE OF SIGNS AND SYMPTOMS

SIGNS AND SYMPOMS NUMBER %

SEVERE ANEMIA 666 54.1

PROSTRATION 371 30.2
CONVULSIONS 279 22.7
CEREBRAL MALARIA 218 17.7
HYPOGLYCEMIA 162 13.2
HYPOGLOBINURIA 41 3.3
JAUNDICE 21 1.7
RESPIRATORY DISTRESS 12 1.0
DIC 1 0.08

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Different clinical manifestation between adults and
children with severe malaria
Management
· Parenteral antimalarials.
· IV fluid administration.
· Vital signs monitoring every 4 hours.
· Blood check up for malaria parasite every
day until disappearance of parasitemia.
· Monitoring clinical signs and symptoms of
severe malaria that may occur later.
· Record conscious level every 4 hours and
urine output every 8 hours.
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 Poor prognostic features in
severe malaria

Clinical findings
 Deep Coma
 Repeated convulsions
 Respiratory distress (rapid, deep, laboured, stertorous,
breathing often with intercostals recession)
 Significant bleeding
Laboratory findings
Biochemistry
 Hypoglycemia < 2.2 mmol/l
 Hyperlactatemia > 5 mmol/l
 Acidosis arterial pH<7.3 venous plasma HCO3 < 15 mmol/l
 Serum creatitine >265 µmol/l
 Total bilirubin > 50 µmol/l
 Liver enzymes SGOT (AST) x 3 upper limit of normal
SGPT (ALT) x 3 upper limit of normal
5 – Nucleotidase
 Muscle enzymes CPK
Myoglobin
 Urate > 600 µmol/l

Hematology
 Leucocytosis >12.999/µl
 Severe anemia PCV < 15 %
 Coagulopathy Platelet < 50.000/µl
PT prolonged > 3 s
Prolonged PPT
Fibrinogen <200 mg/dl

Parasitology
 Hyperparasitemia > 100.000/µl - increased mortality
> 500.00/µl - high mortality
 >20% of parasites are pigment – containing trophozoites and schizonts
 >5% of neutrophils contain visible malaria pigment