Emergencies Internal Medicine and Morning Report notes · Emergencies Internal Medicine and Morning...
Transcript of Emergencies Internal Medicine and Morning Report notes · Emergencies Internal Medicine and Morning...
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Emergencies Internal Medicine
and
Morning Report notesRizal Hafiz
Edited : Nusa Purnawan Putra 2018
Margareth Gracia 2019
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Kegawatan Penyakit Dalam
1. Nefro2. Cardio
3. Gastro
4. Endokrin5. Pulmo6. Hema
7. Rheuma8. Tropik9. Geriatri
: CKD, ggg. Cairan & elektrolit, asam basa: SKA, aritmia, syok cardio, oedem pulmo akut: PSCBA, encephalopati hepar, pankreatitis akut: hipoglikemia, KAD, HONK, krisis tiroid: asma akut, hemoptoe, gagal nafas: febrile neutropeni, sindr lisis tumor, sindr paraneoplasia: SLE: DHF, sepsis: konfusio akut, hipertermi, stroke
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1. NEFROLOGI-HIPERTENSI
KEGAWATAN UREMIA(Tx utama = dyalisis)1. Asidosis metabolik :
koreksi bicnat bila pH<7 atau HCO3<12meq
0,5 x 0,3 x BE x BB (dalam 150cc D5% habis 4 jam) 1 flash bicnat 25meq
2. Hiperkalemi ringan-sedang (5,5-7,5) Ca polystirene 4 x 15 gr Berat (>7,5)
Ca Glukonas 0,5mg/KgBB Bicnat 45-90meq (BE x 0.5 x BB x 0.3)
HCO3 dalam D5% 1:1 -> 50 cc jalan 8-12 cc/jam 10-20 U insulin reguler dlm 25-50gr D40% habis 4 jam
kecepatan 12.5cc/jam
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Nefrologi
3. Overhidrasi : O2 masker Furosemid bolus 40-80 mg IV s/d 250 mg, lanjut Sp inj
Furosemide 5mg/jam IV Morfin 2,5mg IV
4. Hipertensi Emergency : diturunkan sesuai target dlm 1 jam Nikardipin
5mg/jam dinaikkan 2,5mg/5menit max 30mg/jam, target 25% MABP atau diastolik 110
Urgency : dgn antihipertensi oral, diturunkan dlm 24jam
5. Kejang uremik : diazepam 5-10mg iv pelan6. Perdarahan : dialisis7. Infeksi : antibiotik
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Hipertensi emergency
• Hipertensi emergensi : meningkatnya tekanan darah secara akut
dan cepat yang menyebabkan kerusakan organ target. Umumnya
tekanan diastolik > 120 mmHg. Penurunan tekanan darah 10% pada
1 jam pertama, dan tambahan 15% pada 12 jam selanjutnya.
• Hipertensi urgensi : tekanan diastolik > 120 mmHg tanpa disertai
kerusakan organ. Pengendalian tekanan darah diharapkan dalam 24 –
48 jam.
• Hipertensi berat : sistolik > 180 mmHg dan diastolik > 110 mmHg.
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End-Organ Damage Associated Hypertensive Emergencies
End-Organ Damage Type No of Cases (%)
Cerebral Infarction 26 (24.5)
Intracerebral or sub-arachnoid
hemorrhage5 (4.5)
Hypertensive encephalopathy 18 (16.3)
Acute pulmonary edema 24 (22.5)
Acute congestive heart failure 15 (14.3)
Acute myocardial infarction or unstable
angina pectoris13 (12.0)
Eclampsia 5 (4.5)
Aortic dissection 2 (2.0)
Zampaglione, et al. AHA ; 27 (1) : 144
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SIMPLE APPROACH TO HYPERTENSIVE CRISIS
BP > 220/120 mmHg
Neurological sign
(encephalopathy or stroke)
Retinopathy grade 3-4
Severe chest pain
(Ischemia or dissecting
aneurism)
Pulmonary edema
Eclampsia
Cathecolamine excess
Acute renal failure
Headache
No neurological signs
No target organ damage
EMERGENCY
URGENCY
Intravenous therapy
Identify the cause
In panic attacks or anxiety use
analgesic, anxiolytics
Otherwise use oral antihypertensive
agents
recheck in 6-24 hours
Captopril, clonidine, labetalol
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JNC 7 Recommendation for Hypertensive Emergency
Drugs Dosage Onset Duration
Sodium nitroprusside
0.25-10 ugr/kg/min Immediate 1-2 minutesafter infusion stopped
Nitroglycerin 5-500 ug/min 1-3 minutes 5-10 minutes
Labetolol HCl 20-80 mg every 10-15 min or 0.5-2mg/min
5-10 minutes 3-6 minutes
Fenoldopan HCl 0.1-0.3 ug/kg/min <5 minutes 30=60 minutes
Nicardipine HCl 5-15 mg/h 5-10 minutes 15-90 minutes
Esmolol HCl 250-500 ug/kg/min IV bolus, then 50-100 ug/kg/min by infusion; may repeat bolus after 5 minutes or increase infusion to 300 ug/min
1-2 minutes 10-30 minutes
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AHA 2007 Recommendation for
Hypertensive Emergency
Drug I.V. Bolus Dose Continous Infus Rate
Labetalol
Nicardipine
Esmolol
Enalapril
Hydralazine
Nipride
NTG
5 – 20 mg every 15’
NA
250 ug/kg IVP loading dose
1,25-5 mg IVP every 6 h
5 – 20 mg IVP every 30’
NA
NA
2 mg/min (max 300mg/d)
5-15 mg/h
25-300 ug/kg/m
NA
1,5-5 ug/kg/m
0,1-10 ug/kg/m
20-400 ug/m
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CHEST 2007 Recommendation for Hypertensive Emergency
Acute Pulmonary edema /Systolic dysfunction
Nicardipine, fenoldopam, or nitropruside combined withnitrogliceryn and loop diuretic
Acute Pulmonary edema/ Diastolic dysfunction
Esmolol, metoprolol, labetalol, verapamil, combined with low dose of nitrogliceryn and loop diuretics
Acute Ischemia Coroner Labetalol or esmolol combined with diuretics
Hypertensive encephalopaty Nicardipine, labetalol, fenoldopam
Acute Aorta Dissection Labetalol or combined Nicardipine and esmolol or combinenitropruside with esmolol or IV metoprolol
Preeclampsia, eclampsia Labetalol or nicardipine
Acute Renal failure / microangiopathic anemia
Nicardipine or fenoldopam
Sympathetic crises/ cocaineoveerdose
Verapamil, diltiazem, or nicardipine combined withbenzodiazepin
Acute postoperativehypertension
Esmolol, Nicardipine, Labetalol
Acute ischemic stroke/ intracerebral bleeding
Nicardipine, labetalol, fenoldopam
CHEST, 2007
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Obat yang tidak direkomendasikan untuk hipertensi krisis
• Nifedipine : penurunan tekanan darah yang cepat, sulit dikendalikan, menyebabkan iskhemia organ target
• Nitroglycerine : venodilator kuat, ‘preload’ dan ‘cardiac output’ turun, iskhemik organ target
• Hydralazine ; vasodilator kuat, sulit diprediksi, efek lama
• Diuretika : kecuali pada keadaan ‘volume overload’
Varon J and Marik PE. Critical Care 2003
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eGFR
eGFR laki-laki
𝑒𝐺𝐹𝑅 =140 − 𝑢𝑚𝑢𝑟 𝑥 𝑏𝑒𝑟𝑎𝑡 𝑏𝑎𝑑𝑎𝑛 (𝑘𝑔)
𝑆𝑒𝑟𝑢𝑚 𝑐𝑟𝑒𝑎𝑡𝑖𝑛𝑖𝑛 𝑥 72
eGFR wanita
𝑒𝐺𝐹𝑅 =140 − 𝑢𝑚𝑢𝑟 𝑥 𝑏𝑒𝑟𝑎𝑡 𝑏𝑎𝑑𝑎𝑛 (𝑘𝑔)
𝑆𝑒𝑟𝑢𝑚 𝑐𝑟𝑒𝑎𝑡𝑖𝑛𝑖𝑛 𝑥 72× 0,85
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Nefrologi
Gangguan keseimbangan cairan
1. Hipovolemik“air dan Na keluar dlm jumlah yg sama”
koreksi dgn RL/NaCl isotonik, jumlah dankecepatan disesuaikan dg klinis kehilangan cairan :
ringan (<20%)
sedang (20-40%) x6%xBB
berat (>40%)
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Nefro….
2. Dehidrasi“kehilangan air > Na” hipernatremi koreksi dg D5% sesuai kebutuhan :FD : 0,4xBBx ((Na Plasma/140)-1)kecepatan koreksi tdk >0,5meq/jam
Ex : pria 60kg, dehidrasi dg Na160meq, IWL 40cc/jam, UO 1,5L/24jam
Answ : Δ Na = 20kec.koreksi 20/0,5 = 40 jamFD : 0,4x60x((160/140)-1) = 3,42LIWL : 24X40ccUO :
= 0,96L= 1,5L
5,89L dlm 40 jam = 0,15L/jam
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Nefro…
Ggg keseimbangan elektrolit1. Natrium hipoNa :
Na>125 Na<125
: NaCl 3x500mg po: (135-X)x0,6xBB = … meq NaCl 3%
akut<48jam : 5meq dlm 1 jam I, selanjutnya 1meq/jam s/d Na 130meq
Kronik>48jam : perlahan 0,5meq/jam
Sediaan NaCl 3% = 500 ccKomposisi = Na 513 mEq/L, Cl 513 mEq/L, Tek Osm 1026
Rumus Osmolaritas:
Normal: 285-295
Osmolaritas = 2 x Na Serum +GDS
18+
BUN
2,8
Osmolaritas = 2 x Na Serum +GDS
18+
Ureum
6
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NefrologihiperNakoreksi dg D5% sesuai kebutuhan :FD : 0,4xBBx ((Na Plasma/140)-1) kecepatan koreksi tdk >0,5meq/jam
Ex : pria 60kg, dehidrasi dg Na160meq, IWL 40cc/jam, UO 1,5L/24jamAnsw : delta Na = 20kec.koreksi 20/0,5 = 40 jam
FD : 0,4x60x((160/140)-1) = 3,42LIWL : 24X40ccUO :
= 0,96L= 1,5L
5,89L dlm 40 jam = 0,15L/jam
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Nefrologi
2. Kalium hipoK
K>3,5 : KSR 3x1tab PO K<3,5 : (4,5-X)x0,4xBB = ..Y.. mEq/Lsediaan : inj 7,46% KCl, K 25mEq/25ml : Cl 25 mEq/25 mlKoreksi kecepatan 2 meq/jam(SP -> Y/2=Z) Y mEq habis dlm Z jam
hiperK ringan-sedang (5,5-7,5) Ca polystirene 4x15gr Berat (>7,5)
Inj Ca Glukonas 10% 0,5mg/KgBB Bicnat 45-90meq (BE x 0.5 x BB x 0.3)
HCO3 dalam D5% 1:1 -> 50 cc jalan 8-12 cc/jam 10-20 U insulin reguler dlm 25-50gr D40% habis 4 jam kecepatan 12.5cc/jam
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Nefrologi
3. MagnesiumHipoMg Ringan : renapar/aspar 3x1tab POhipoMg berat : inj MgSO4 40% @25cc Dosis 3gr (7.5cc) dlm D5% habis 3jam, dilanjut Dosis 6gr dlm 21jam (3-3-6-21)
4. CalciumHipoCa ringan : CaCO3 3x500mg POhipoCa berat :
Bolus Ca glukonas iv 10-30cc dlm D5% 150cc selama 10menit, dilanjut maintanace 0.5-2mg/kgBB/jam
hiperCa : hidrocortison 200-300mg iv selama 3-5 hari,furosemid, atasi volume defisit
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Nefrologi
Ggg. Keseimbangan Asam-basa
1. Konfirm BGA :
24(pCO2/HCO3) tdk lebih dr 10% pH x fc koreksi (setiap kenaikan 0,1 pH dikali 0,8 dan setiap turun 0,1 dikali 1,25)
2. Tentukan ggg asam-basa dgn melihat pH, pCO2 dan HCO3
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Nefrologi
3. Tentukan kompensasi :
Asidosis met : pCO2 : (1,5xHCO3)+8 ± 2
Asid resp : akut HCO3 1meq setiap pCO2 10
kronik HCO3 3,5meq setiap pCO2 10
Alk met : pCO2 : 40+0,7 (delta HCO3) ± 5
Alk resp : HCO3 2meq setiap pCO2 10 (akut)
: HCO3 5-7meq setiap pCO2 10 (kronik)
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Nefrologi
4. Jika asid met hitung anion gap AG : Na-(HCO3+Cl) (N + 2) AG
: KAD, intox metanol/salisilat AG : 2,5meq setiap alb 1gr/dlAG (N) hitung AG urin (Na+K)-Cl dlm urinjika (+), maka asid met dari Renal (RTA) jika (-), maka asid met dari TGI (diare)
5. Koreksi :asid met : 0,5x0,3xBExBBbicnatalk met: 0,3xBBx(HCO3-24)HCl/asetazolamid
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2. KARDIOLOGI
Sindrom koroner akut UAP & NSTEMI Tx=STEMI kecuali reperfusi STEMI
- oksigen (target spo2 94%), infus, monitor- nitrat ISDN : 2,5-10mg s.l bila nyeri
cedocard : 1-5mg/jamnitrogliserin 10-20mcg/min
- morfin : 2,5-5mg iv bolus
- aspirin loading 160mg (sebaiknya dikunyah) dilanjutkan 1x80mg- clopidogrel loading 300mg dilanjut 1x75mg
- heparin UFH : 60 IU/KgBB lanjut 12 IU/KgBB (target PTTK 1,5-2,5)
LMWH : Fondaparinux 1 x 2.5 mg sc- B blocker : Bisoprolol 1x2.5 mg PO- Atorvastatin 1x40 mg PO- Captopril 3 x 6.25 mg PO
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Cardio…
- reperfusi : Fibrinolitik : streptokinase 1,5 juta IU dlm D5% 100cc habis
dlm 1 jamDoor to needle<30min
Cath lab tdk ada/door to ballon>90min
Akses vaskuler sulit
Onset<3jam
Observasi PAHA (Perdarahan, Aritmia, Hipotensi, Alergi)
PCI :Door to ballon <90min
Killip 3-4
KI thd fibrinolitik
Onset>3jam
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Infark vent. Kanan
• Pertahankan pre load
• Ivfd NaCl 1-2L (jam I)200cc/jam (target CVP>10mmHg)
• Hindari nitrat dan furosemid
• Atasi AV block & bradikardi
• Beri inotropik jika dgn cairan cardiac output tdk meningkat
• Turunkan afterload (vasodilator)
• Reperfusi
• Lain2 sama
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Cardio..
Edema paru akut- O2 8-10 lpm masker rebreath- intubasi bila diperlukan- Posisi Semi fowler- morfin 2-5mg iv bolus pelan- inj furosemid 40 mg IV bolus
lanjut Sp Furosemide 0,5-1mg/KgBB/menit
- nitrogliserin 10-20mcg/min IV- nitropusside 0,5-5mcg/KgBB/min
- ACE i Captopril 3x6,25 mg PO- Laktulosa 3x1C PO- B bloker Kontra Indikasi
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Cardio..
SYOK
- Volume perbaiki defisit cairan, vassopress
- Irama atasi aritmia
- Pompa inotropik
2-20mcg/KgBB/min IVTDS 70-100 syok (-) : Dobutamin
syok (+) : dopamin
TDS <70 Norepinefrin 0,5-30mcg/min IV
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Cardio..
1. Edema Paru
2. Kardiomegali
3. PND / ortopnoe
4. S3 gallop
5. Rales
6. JVP meningkat
7. Distensi vena jugularis
CHF (Framingham Criteria)MAYOR MINOR
1. Hepatomegali
2. Efusi pleura
3. Edema tungkai
4. Batuk malam
5. DOE
6. Takikardia
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Cardio..
CHF• O2 target saturasi > 94%• Posisi setengah duduk• IVFD RL 10 tpm• Diet rendah garam, retriksi cairan• inj. Furosemid 40 mg/24 jam iv
– Bisa dilanjutkan Sp Furosemid 5-40 mg/jam
• Captopril 3x6.25 mg PO titrasi bertahap• Candesartan 4 mg/24 jam PO (bila ada kontraindikasi ACE-i)• Bisoprolol 1x2.5mg PO (kontraindikasi pada NYHA III-IV)• Sprinolacton 25mg/24 jam PO (bila refrakter terhadap diuretika)• Bila pasien gelisah : Inj Morfin 2-4 mg IV
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Cardio..
AritmiaTakiaritmia
- O,I,M
- stabil? (hipotensi? Kesadaran? Tanda syok? Nyeri dada? GJ akut?)
- stabil (-) sync cardioversion (AF 120-200J, SVT 50J, VT 100J)
- stabil (+) QRS lebar : amiodarone, adenosin
QRS sempit : vagal manuver, adenosin
*) adeosin hanya diberikan pd QRS teratur, reguler, monomorfik
dosis : 6mg-12mg-12mg bolus cepat diflush
*) amiodarone : 150mg dlm 100cc NaCl selama 10menit dilanjut 1mg/min dlm 6 jam0,5mg/min dlm 18jam
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Cardio..
Bradiaritmia
- O,I,M
- stabilobservasi
- tdk stabil
a) TPM (AV blok derajat 2 tipe 2, TAVB)
b) SA 0,5mg diulang tiap 5 min s/d max 3mg
respon (-)
dopamin 2-10mcg/KgBB/min
respon (-)
epinefrin 2-10mcg/min
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RAH : P pulmonum (tinggi >2,5 mm). Biasanya di stenosis trikuspid dan pulmonary HT (makanya namanya P pulmonum)
LAH : P mitral (lebar >2,5 kotak kecil/>0,10 ms dan bifida). Biasanya di mitral stenosis (makanya namanya P mitral)
RVH : R/S >1 di V1. Ada jg gambaran RAD dan S persisten di V6.
LVH : R di V6+S di V1/V2 >35 mm. Bisa jg R di V5/V6>25 mm.
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3. GASTROENTEROHEPATOLOGI
PSCBA• Etilogi tersering di INA : hipertensi portal, gastrtitis erosif, ulkus peptikum
Pengelolaan dasar
- Ass cepat status kegawatan (KU,GCS,TV, UO, syok?)
- Px Lab (DR, gol darah, cross match, studi koagulasi)
- Resusitasi Hemodinamik : kristaloid?Koloid? Tranfusi PRC? WB? Trombo? FFP?
Hatihati : pemberian cairan berlebihan dapat meningkatkan tekanan intraporta
Respirasi : jalan nafas? O2? Intubasi? NGT?
Monitoring ketat
- Pemeriksaan data dasar lengkap (Ax+PF+lab)
- obat anti sekresi asam, sitoproteksi
CHILD PUGH : ABAPE (Ascites Bilirubin Albumin Protrombintime Ensefalopati)
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Child Pugh Classification for severity in cirrhosis
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APRI Score
𝐴𝑃𝑅𝐼 =
𝐾𝑎𝑑𝑎𝑟 𝑆𝐺𝑂𝑇𝐵𝑎𝑡𝑎𝑠 𝑎𝑡𝑎𝑠 𝑘𝑎𝑑𝑎𝑟 𝑛𝑜𝑟𝑚𝑎𝑙 𝑆𝐺𝑂𝑇𝐽𝑢𝑚𝑙𝑎ℎ 𝑇𝑟𝑜𝑚𝑏𝑜𝑠𝑖𝑡 (109/𝐿)
× 100
Interpretasi:<0,5 menyingkirkan adanya kemungkinan fibrosis>1,5 terjadi fibrosis signifikan>2,0 kemungkinan sudah terjadi sirosis
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BCLC Score
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TANDA PHK
1. Gangguan Faal Hati– Sinstesis : Hipoalbumin (gama globulin), faktor
koagulasi (PPT, INR)– Metabolisme : Estrogen (hiperestrogenisme)– Ekskresi : Peningkatan bilirubin
2. Hipertensi Porta– Varises esophagus– Splenomegali– Ascites– Venektasi– Hemoroid
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Gastro.. Pengelolaan intensif/kontrol perdarahan Variceal
= VARISES VASOACTIV1.vasopressin : 0,5 U/min selama 20-60min2.somatostatin : 250mcg bolus250mcg/jam3.octreotid : 100mcg bolus 25-50mcg/jam hingga 2-5 hari atau sampai
perdarahan berhenti. CATATAN: 8 jam sebelum distop, berikan Propanolol 10mg/12 jam PO (target HR 55-70 x/menit)
ANTIBIOTIK1.Inj Cefotaxime 1gr/8jam IV2.Inj Ceftriaxone 1gr/24 jam IV
RESUSITASI : Fluid chalange kristaloid, lanjut D5% : Aminofusin 1:1 8-10 tpmINTAKE : Diet rendah garam 5gr/hariSPRINOLAKTON : Sprinolakton 100mg/24 jam, diberikan jika transudate
1.Cara pertama: dinaikkan bertahap per 4 hari jadi 200mg/24 jam, selanjutnya 300mg/24 jam
2. Cara kedua: tambahan dengan Inj Furosemide 40mg/24 jam ENDOSKOPI : Indikasi pada varises grade III, -Endoskopi cito STE/LVE SALVAGE : Bedah citoTIPS
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Gastro.. Pengelolaan definitive cari causa Transfusi PRC jika Hb < 8, target 8 atau lebih Antibiotik sesuai indikasi : Inj Ceftriaxone 2gr/24 jam IV Puasa 8 jam bebas perdarahan NON VARICEAL:
Inj Omeprazole 80 mg IV bolus, lanjut Inj 40mg/12 jam atau sp 8 mg/jam sampai 8 jam bebas perdarahan
Sukralfat 4x1C
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Gastro..
Encephalopati hepatikumPencetus : GI bleeding, elektrolit, metabolik,
infeksi, konstipasi, azotemi, drug (sedatif), diet tinggi prot
Patfis :- Peningkatan permeabilitas sawar darah otak
- Adanya substansi neurotoksin
- Ggg. Fx neurotransmiter
- Ggg. Suplai energi otak
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Gastro..
Klinis :
- derajat I : perubahan pola tidur
II : apatis/somnolen
III : sopor
IV : koma
- flapping tremor
- foetor hepatikum
Lab : studi koagulasi, DR, GDS, elektrolit, Ur, Cr, amoniak
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Gastro..
Management:
- Supportif : cairan, elektrolit, AB
- Spesifik• Menurunkan prod amoniak :
– Diet : prot 0,7gr/KgBB/hari, 45kal/BB/hari
– Infus AARC (Asam amino rantai cabang) 0.2-1.2gr/kgBB/hari
– Sterilisasi usus : laktulosa 30ml/8 jam PO,
– Antibiotik : neomisin 250mg/6jam PO
– Bisa digunakan metronidazole 500mg/8jam IV
• Terapi ggg transport as.amino : levodopa, bromokriptin
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Gastro..
HEPATORENAL SYNDROME
Peningkatan kreatinin 1.5 kali dari nilai normal
USG Ginjal normal
Pasien tidak mengalami syok
TATALAKSANA (VASA)Vasoaktif
Norepinepfrin
Antibiotik
StopStop diuretik,
propranolol, evaluasi 3 hari
Albumin Dikoreksi 20-60
gram per hari
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Gastro..
Pankreatitis akut Etiologi
- struktural ( batu empedu, spasm singter oddi)- toxin (alkohol, azatriopin, furosemid)- infeksi- metabolik (hiperTG, hiperCa)- vaskuler (atherosklerosis)- kongenital, idiopatik
Patfis :- fase inflamasi : fc pencetusaktivasi dini zimogen autodigesti pankreas- fase SIRSsepsis- fase MODS
Berdasar PA :1. pankreatitis akut intertitial2. pankreatitis akut nekrotik hemoragik
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Gastro..
Klinis : nyeri perut hebat mendadak, tdk berkurang dg analgetik biasa, mual, muntah, obstipasi, demam
Grey Turner : ekimosis besar di pinggang dan pungung, Cullen sign : ekimosis besar di umbilicus-> perdarahan dari pancreas
Lab : amilase darah & urn, lipase serum, CRP, DR, albumin, LDH, elektrolit, BGA
Imaging : USG abd, CT scan abd, ERCP
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Gastro..Management :1. Supportif- Resusitasi cairan (bisa sampai dengan 10L/hari)- Nutrisi (puasakan pasien -> TPN), elektrolit- Analgetik kuat : pethidin, KI : morfin (spasm sfi.oddi)- AB (quinolon, imipenem)- Bantuan respirasi- Monitoring (Pro HCU)- PPI: Inj Omeprazole 80mg/IV bolus lanjut Sp 8mg/jam IV- Antiemetik : Metoklopramide 10mg/8 jam IV2. Menekan prod. Enz. Pankreas- NGT : dekompresi, menurunkan gastrin- Menurunkan as lambung- Glukagon, kalsitonin, approtinin : menurunkan enz pankreas- Somatostatin: ocreotid 50mcg/8 jam SC- Memutus rantai SIRS
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Gastro..
Causatif :
- ERCP
- sfingterektomi
- stop alkohol
indikasi bedah :
1. perburukan dlm 72 jam tx intensif
2. sepsis
3. peritonitis
4. obst. sal,. Empedu
5. perdarahan intestinal >500cc/24jam
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Kadar Albumin Darah
Kadar Protein Darah=Kadar Albumin Ascites
Kadar Protein Ascites
Serum Albumin Ascites Gradient
SAAG < 1,1 Non PortalSAAG > 1,1 Portal
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LABORATORIUM KAD HONK
Glukosa plasma (mg/dl) > 250 > 600
pH < 7.3 > 7.3
HCO3 serum (mEq/L) < 15 > 20
Keton urine 3+ 1+
Keton serum (+) pengenceran 1:2 (-) pada pengenceran 1:2
Osmolalitas serum (mOsm/Kg) Bervariasi 330
Natrium serum (mEq/L) 130 – 140 145 – 155
Kalium serum (mEq/L) 5 – 6 4 – 5
BUN (mg/dl) 18 - 25 20 - 40
Panduan klinik praktis untuk membedakan KAD & HONK
Dengan pengertian sekitar 30% penderita KAD dapat
Tampil dalam kondisi HONK
4. ENDOKRINOLOGI METABOLIK
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Endo..
Tujuan terapi :
- menurunkan glukosa darah
- koreksi cairan dan elektrolit
- menghilangkan fc pencetus
• Infeksi
• Penghentian insulin
• New onset DM
- menghilangkan keton dari darahKAD
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Endo..Rehidrasi
NaCl1 jam I : 2L
1 jam II : 1L
Insulin (short/rapid acting)- Cepat menurunkan glukosa
- Tdk menyebabkan hipoglikemi
Bolus Insulin 0.1 U/kgBB IV, dilanjut Sp insulin0,1U/kgBB/jam,
Bila GDS tdk turun 50-75mg/dldosis naik 2x s/d100U/jam
bila GDS turun<250, dosis turun ½, infus ganti D5%(mencegah hipoglikemi + menghilangkan ketonemia)
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Endo..sliding scale :GDS < 100 :
Insulin 0 unit (D5%)GDS 101 – 150 : Insulin 0,5 unit (nacl )GDS 151 – 200 : Insulin 1 unit (nacl)GDS 201 – 250 : Insulin 2 unit (nacl)GDS 251 – 300 : Insulin 3 unit (nacl)GDS 301 – 350 : Insulin 4 unit (nacl)GDS >350 : Insulin 5 unit (nacl)
Antibiotik
Supportif : elektrolit, asam basa, nutrisi
Koreksi asid met : 0,5x0,3xBExBBbicnat
Kalium : drip dimulai bersamaan dengan
drip insulin, dosis 25 mEq/6 jam.
Setelah pemeriksaan elektrolit selanjutnya :
pH Koreksi HCO3 (mEq)
< 7 100
7 – 7.1 50
> 7.1 0 K+ Koreksi K+
< 3.0 Drip KCl 50 mEq/6 jam
3.0 – 4.5 Drip KCl 25 mEq/6 jam
4.5 – 5.5 Drip KCl 25 mEq/12 jam
> 5.5 Drip distop
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Endo..
Krisis tiroid
Trias klinis :
1. menghebatnya tanda hipertiroid
2. penurunan kesadaran
3. hiperpireksia
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Endo..
Supportif : cairan, elektrolit, nutrisi, oksigenasi
Koreksi hipertiroid
- blok sintesis PTU 600-1000mg, dilanjut 200mg/4jam, max 1000-1500mg
- mencegah sekresi tiroid lugol 8 tetes/6jam
- hambat konversi T4-T3 propranolol 20-40mg/6jam PO
Insuf adrenal relatifhidrokortison 100mg/12jam
AntipiretikParasetamol 500mg/8jam
KI : aspirin, kompetitif tiroksin thd prot binding
Bila AF Digoxin 0.25mg/8jam PO
Atasi pencetus
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Endo..
Koma miksedemKlinis : riwayat hipotiroid ditambah :
-penurunan kesadaran
- hipoventilasi
- hipotermi
- bradikardi
- hipoglikemi
- hiponatremi
Pencetus : infeksi, post OP, obat narkotik/hipnotik
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Endo..
Management :
Supportif
- Levotiroksin (T4) 300-500mcg bolus iv50mcg/hari atau
T3 25mcg/8jam12,5mcg/8jam
- Hidrokortison 100mg/12jam
- atasi fc pencetus
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Klasifikasi Diabetic Foot Ulcer – Wagner Classification
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5. PULMONOLOGI
Hemoptisis Ekspektorasi dahak yg mengandung bercak darah
dan berasal dari sal nafas bag bawah Hemoptisis masif :
- batuk darah >600cc/24jam- <600cc/24jam tp Hb<10gr%- >250cc/24jam, Hb>10gr tp tdk berhenti dlm obs selama 48 jam
Etiologi : 95% berasal dari a. bronkialis-TB paru- aspergilosis- bronkhiektase- abses paru- pneumonia-Ca paru
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Pulmo..
Asma BronkhialO2 max 8lpm Inhalasi B2 agonis dosis tinggi
- salbutamol 5mg/inhalasi- terbutalin 10mg
Steroid IV dosis tinggi- prednison 60mg/hidrokortison 200mg- maintanance : hidrokortison 200mg/6jam
Bronkodilator- aminofilin 250mg dlm 30 menit- salbutamol 200mcg/terbutalin 250mcg
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Pulmo..
Dampingi pasien sampai ada respon
Bila respon baiknebulasi/6jam
Bila respon buruk ulangi nebulasi + ipaproprium bromid 0,5mg dan Injmetilprednisolon 62.5mg/12 jam IV
Bila msh belum respon jg pertimbangkan :
-bolus aminofilin 5mg/kgBB dalam 30 menit,
dilanjut drips aminofilin 0,5mg/kgBB/jam
-salbu/terbutalin 2-30mcg/min
Evaluasi
- APE dipanttau 4x/hari sampai kondisi stabil
- BGA/6jam
- kadar aminofilin serum, kalium, GDS
Kontraindikasi : SEDATIF!!
Antibiotik diberikan sesuai indikasi
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Pulmo..
Indikasi ICU :PO2<60mmHg dg O2 60%
PCO2>50mmHg menetap dlm 6 jam
Tanda kelelahan
Penurunan kesadaran
Henti nafas
Indikasi pulang :APE>75% prediksi
Variasi diurnal <25%
Sesak malam hari (-)
Obat pulang:1. Inhalasi B2 agonis2. Salbutamol 3x2 mg PO3. Metilprednisolon 2x 4 mg
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Family Practice Management -AAFP
CURB 65 Pneumonia Severity Index
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Tanda / Gejala Ringan Sedang Berat AncamanGagal Nafas
Sesak nafas BerjalanDapat terlentang
BerbicaraLebih suka duduk
IstirahatMembungkuk
Berbicara Membuat kalimat Membuat frase Membuat kata
Kesadaran Mungkin gelisah Selalu gelisah Selalu gelisah Mengantuk ataubingung
Laju pernafasan Meningkat Meningkat > 30/menit
Otot tambahan retraksisuprasternal
Tidak Biasa ada Biasa ada Pergerakan poradok torako abdominal
Wheezing Sedang sering padasaat ekspirasi
keras Sangat keras Tidak ada wheezing.
Nadi/menit < 100 100 - 120 > 120 Bradikardi
Pulsus paradoksus < 10 mmHg 10 – 25 mmHg > 25 mmHg Tidak adaDicurigai adanyakelelahan
otot nafas.
APE > 80% 60 – 80 % < 60 %
PaO2 Normal > 60 mmHg < 60 mmHg
PaCO2 < 45 mmHg < 45 mmHg > 45 mmHg
SaO2% > 95 % 91 – 95 % <90 %
Klasifikasi beratnya asma eksaserbasi
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Karakteristik TERKENDALITERKENDALI
SEBAGIAN
TIDAK
TERKENDALI
Gejala siang hari Tidak ada (2x /
< per minggu)
> 2 x perminggu Tiga atau lebih
gambaran dari asma
terkendali sebagian
muncul beberapa
minggu
Pembatasan aktivitas Tidak ada Ada
Gejala malam hari
/terbangun
Tidak ada Ada
Perlu reliever Tidak ada (2x /
< per minggu)
> 2 x perminggu
Fungsi paru PEF/ VEF1 normal < 80% prediksi
Eksaserbasi Tidak ada Satu / > per tahun Beberapa kali dalam
beberapa minggu
BERDASAR TINGKAT PENGENDALIAN ASMA
Istilah terkendali mengindikasikan pencegahan bahkan pengobatan
KLASIFIKASI ASMA
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TUJUAN Mencapai dan mempertahankan kontrol klinis
OBAT-OBATAN
GOL RELIEVERS GOL CONTROLLERS
rapid acting β2 agonist
inhalasi
Glukokortikosteroid inhalasi
dan sistemik
Antikolinergik inhalasi Leukotriene modifiers
Teophiline short acting Long acting β2 agonist +
glukokortikosteroid inhalasi
rapid acting β2 agonist oral Teophiline SR
Steroid sparing sistemik
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GLUKOKORTIKOSTEROID INHALASI
OBATDosis harian
rendah (μg)
Dosis harian
sedang (μg)
Dosis harian tinggi
(μg)
Beclomethasone
dipropionat
200 – 500 > 500 – 1000 > 1000 – 2000
Budesonide 200 – 400 > 400 – 800 > 800 -1600
Ciclesonide 80 – 160 > 160 – 320 > 320 – 1280
Flunisolide 500 – 1000 > 1000 – 2000 > 2000
Fluticasone 100 – 250 > 250 – 500 > 500 - 1000
Mometasone furoate 100 – 250 > 400 – 800 > 800 - 1200
Triamcinolone
acetonide
200 - 400 > 1000 – 2000 > 2000
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Pulmo..
Gagal Nafas Etiologi :
1. hipoventilasi
2. ventilasi/perfusi missmatch
3. shunt
4. kombinasi 1-3
GN tipe I (hipoksemi)
- paru gagal memenuhi keb O2, eliminasi CO2 msh normal- etiologi : kelainan intrapulmoner (V/Q missmatch,
shunting, ggg difusi/alveolar block)
- PaO2 <50 ; PCO2 normal/turun
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Pulmo..
GN tipe II
- etiologi : kelainan extraparu (hipoventilasi), V/Q missmatch, kombinasi
- PaO2 turun; PCO2>50
ARDS (acute Respiratory distress syndrome)
sindrom yg ditandai peningkatan permeabilitas
membran alveo-kapiler disertai kerusakan difus dan akumulasi cairan yg mengandung protein dlm parenkim paru
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Pulmo..
Fase eksudatif : edema intertitial & alveolar, nekrosis pneumosittipe I
Fase proliferatif : proliferasi pneumosit tipe II Fase fibrosis : pembentukan kolagen, fibrotisasi parenkim paru
Kriteria Diagnosis:1. Riwayat pencetus.2. Hipoksemia refrakter dengan terapi oksigen
PaO2/FiO2 <200 .3. X Foto thorak : infiltrat bilateral difus.4. Tidak ada gejala edema paru kardiogenik dan tekanan baji ≤ 18 mmHg.
Pada ARDS nilai AaDO2 >300.
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PATOGENESIS• Pada keadaan normal terdapat keseimbangan
antara tekanan onkotik dan hidrostatik antarakapiler paru dan alveolar.
• Teraktivasinya kaskade inflamasi yang berasal dari suatu fokus kerusakan jaringan tubuh. Neutrofil yang teraktivasi akan melepaskan toksin / sitokin.Sebagai hasilnya: kerusakan endotel → Peningkatan permeabilitas kapiler alveoli.
• Alveoli penuh eksudat kaya protein, banyak neutrofil dan sel inflamasi → membran hialin
• Pada tahap awal terjadi peningkatan kandungan cairan jaringan interstisial antara kapiler dan alveoli
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Penatalaksanaan
1.Mengobati penyakit dasarnya
2.Penatalaksanaan suportifA. Continuous positive airways pressure (CPAP).
Tidak boleh terlalu tinggi→ trauma. Diberikan dengan tidal volume 8-9ml/kgbb.
B. Management cairan dan hemodinamik Restriksi cairan: ↓ edema pulmo. Keseimbangan antara tata laksana ARDS dan volumeintravaskuler.
C. Terapi surfaktanD. Vasodilator pulmonal : NO inhalasiE. Glukokortikoidfase akut.
Belum dilakukan secara rutin/jangka lama: karena peningkatan resikoinfeksi.
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RESEP TB
SEDIAAN
100, 300
450, 600
500
400, 500
1000
Vitamin B6 = 10mg, 25mg, 100mg per 12/24 jam
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6. REUMATOLOGI
SLE
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6. REUMATOLOGI
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2
1
0
0
0
0
3
1
2
2
2
1
2
2
12
1
2
2
2
1
2
2
12
Total = 29
This score consists of an evaluation of patient’s skin thickness rated by
clinical palpation using a 0–3 scale (0=normal skin; 1=mild thickness;
2=moderate thickness; 3=severe thickness with inability to pinch the skin
into a fold) for each of 17 surface anatomic areas of the body: face,
anterior chest, abdomen, (right and left separately) fingers, forearms,
upper arms, tights, lower legs, dorsum of hands and feet. These individual
values are added and the sum is defined as the total skin score
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7. TROPIK INFEKSI
SEPSIS
1. ABC
2. Q-Sofa
3. Cairan 30cc/jam dalam 24 jam
4. Kultur sebelum pemberian AB
5. Inj Antibiotik broad spectrum
6. Prokalsitonin, laktat
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7. TROPIK INFEKSI
DENGUE SHOCK SYNDROME
INDIKASI RAWAT INAP
1. Peningkatan hematocrit atau
2. Trombosit < 100.000
3. Alarm sign (+)– Nyeri perut
– Muntah berkepanjangan
– Akumulasi cairan
– Perdarahan mukosa
– Letargi/lemah
– Hepatomegali > 2 cm
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MALARIA BERAT
• Penurunan kesadaran
• Tidak bisa makan
• Muntah profuse
• Anemia Hb < 5
• Hipoglikemia
• Asidosis metabolik
7. TROPIK INFEKSI
TATALAKSANA1. Inj Artesunat 2.4mg/kgBB
(jam ke 0, 12, 24), selanjutnya tiap 24 jam sampai pasien dapat minum obat.
2. DHP 3 tab/ hari -> lanjut 7 hari pemberian
3. Primakuin1. Falsi : 0.75 mg/kgBB/hari
(hari pertama saja)
2. Vivax : 0.25 mg/kgBB/hari
(selama 14 hari)
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TIFOID TOKSIKDemam tifoid disertai gangguan kesadaran dengan atau tanpa kelainanneurologis lainnya, dan hasil pemeriksaan LCS normal.
TATALAKSANA
1. Kloramfenikol 4 x 500mg IV
2. Ampisilin 4 x 1 gr IV
3. Prednison 1 x 40 mg IV
Jika delirium, koma, syok:
Inj Deksametason 3mg/kgBB IV, dilanjut 1mg/kgBB per 6 jam
7. TROPIK INFEKSI
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FEBRILE NEUTROPENIA
7. TROPIK INFEKSI
3x1 gr IV
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8. GERIATRI
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>18 Low Risk18-14 Medium risk14-10 High Risk<10 Very High Risk
Skala Norton – Resiko Dekubitus
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9. HEMATOLOGI
SINDROM LISIS TUMOR 1. Hiperurisemia2. Hiperkalemia3. Hiperfosfatemia4. Hipokalsemia
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9. HEMATOLOGI
TrombosisTrombofilia atau Hiperkoagulabilitas adalah merupakan suatu kondisi dimana terdapat peningkatan risiko untuk terjadinya trombosis.
Diturunkan
DidapatVirchow’s Triad (1856)
Venous stasis Vascular injury Hypercoagulability
Acquired Inherited
ARTERIAL VENOUS
Abnormalities of
blood vessels
(atherosclerosis)
Abnormalities of
blood flow
Hypercoagulability
Risk factors:
Hypertension,
Diabetes,
Hyperlipidemia
Risk factors:
immobility, surgery,
age, cancer, etc.
PATHOGENESIS
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PLATELET
BLEEDINGTHROMBOSIS
COAGULATION
INHIBITOR
FIBRINOLYSIS
INHIBITOR
VESSELS
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CLINICAL FEATURES
RISK FACTORS
CLINICAL FEATURES
ALTERNATIVE DIAGNOSIS
++
DVT MORE LIKELY DVT LESS LIKELY
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MODIFIED PRETEST PROBABILITY FOR DVT
• Tenderness along entire deep vein 1.0
• Swelling of the entire leg 1.0
• >3cm difference in calf circumference 1.0
• Pitting edema 1.0
• Collateral superficial veins 1.0
• Active cancer 1.0
• Prolonged immobility or paralysis 1.0
• Recent surgery or major medical illness 1.0
• Alternative diagnosis -2.0
Score>2: high, 1-2: moderate, <1: low probability
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Pulmonary Embolism
Dyspnoea, chest pain
Syncope
Hemoptysis
RR >20/m, tachycardia
Wheezing
Pulmonary hypertension
Right heart failure
Signs of DVT
DVT
PE
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DIAGNOSIS OF PULMONARY EMBOLISM
Pulmonary angiography
Helical CT
Ventilation-perfusion scan
Diagnostic test positive for DVT
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CLINICAL PROBABILITY FOR PE
DVT suspected
Clinical features of DVT 3
Recent prolonged immobility or surgery 1.5
Active Cancer 1
History for DVT or PE 1.5
Hemoptysis 1
Resting heart rate > 100 beat/min 1.5
No alternative explanation for acute
breathlessness or pleuritic chest pain
3
>6 high (60%); 2-6 moderate (20%); <1.5 low (3-4%) Turpie AGG, 2002
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Hema..
DIC
• DIC is an acquired syndrome, characterized by intravascular activation of coagulation and deposition of fibrin within the micovasculature
• DIC leads to organ ischaemia and infarction
The consumption of clotting factors and plateletsin the diffusely distributed thrombi may lead to ahemorrhagic diathesis and clinical bleeding.
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CAUSES DICINFECTIONS:• Gram-negative or Gram-positive septicemia (endotoxin)• Viruses(e.g. Epstein-Barr virus, cytomegalovirus, human
immunodeficiency virus)• Miliary tuberculosis• Fungi• Parasites (malaria, Toxoplasma spp.)
RELEASE OF TISSUE FACTOR• Malignancy, especially if disseminated• Obstetric complications:
abruptio placentae amniotic fluid embolism eclampsia and pre-eclampsia retained dead fetus
• Extensive trauma, burn, surgery• Large aortic aneurysm• Snake, spider venoms• Acute hemolytic transfusion reactions
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CLINICAL PRESENTATION: ACUTE DIC
• Acute DIC occurs with endotoxemia, extensive tissue trauma, preeclampsia, placental abruption or amniotic fluid embolism.
• Also in patients experiencing hypotension or shock for any reason: difficult surgical procedure, massive stroke, heart attack
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SCORE GLOBAL COAGULATION TEST RESULTS:
Platelet count
>100.000=0, <100.000=1, <50.000=2
D-Dimer
no increase (<500)=0, moderate (500-1000)=2, strong
(>1000)=3
Prolonged prothrombin time (PT)
<3sec.=0, 4-6sec.=1, >6sec=2
Fibrinogen level
<100mg/dl=1, >100mg/dl=0
Calculate score
If ≥5: overt DIC; If <5: suggestive for non-overtDIC: repeat next 1-2 days
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MANAGEMENT OF DIC
• Treatment of underlying disease (sepsis)
• Blood component (cryoprecipitate and platelet) substitution therapy
• Anticoagulants (chronic DIC)
• Restoration of anticoagulant pathways:
ATIII, PCa
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Anemia Mikrositik Hipokromik
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Anemia Normositik Normokromik
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DOSIS OBAT EMERGENCY
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NOREPINEPRIN 4 MGKg/mi
kro 0,01 0,02 0,03 0,04 0,05 0,06 0,07 0,08 0,09 0,1 0,11 0,12 0,13 0,14 0,15
40 0,3 0,6 0,9 1,2 1,5 1,8 2,1 2,4 2,7 3 3,3 3,6 3,9 4,2 4,5
45 0,338 0,675 1,013 1,35 1,688 2,025 2,363 2,7 3,038 3,375 3,713 4,05 4,388 4,725 5,063
50 0,375 0,75 1,125 1,5 1,875 2,25 2,625 3 3,375 3,75 4,125 4,5 4,875 5,25 5,625
55 0,413 0,825 1,238 1,65 2,063 2,475 2,888 3,3 3,713 4,125 4,538 4,95 5,363 5,775 6,188
60 0,45 0,9 1,35 1,8 2,25 2,7 3,15 3,6 4,05 4,5 4,95 5,4 5,85 6,3 6,75
65 0,488 0,975 1,463 1,95 2,438 2,925 3,413 3,9 4,388 4,875 5,363 5,85 6,338 6,825 7,313
70 0,525 1,05 1,575 2,1 2,625 3,15 3,675 4,2 4,725 5,25 5,775 6,3 6,825 7,35 7,875
75 0,563 1,125 1,688 2,25 2,813 3,375 3.938 4,5 5,063 5,625 6,188 6,75 7,313 7,875 8,438
80 0,6 1,2 1,8 2,4 3 3,6 4,2 4,8 5,4 6 6,6 7,2 7,8 8,4 9
85 0,638 1,275 1,913 2,55 3,188 3,825 4,463 5,1 5,738 6,375 7,013 7,65 8,288 8,925 9,563
90 0,675 1,35 2,025 2,7 3,375 4,05 4,725 5,4 6,075 6,75 7,425 8,1 8,775 9,45 10,13
NOREPINEPRIN 8 MGKg/mi
kro 0,01 0,02 0,03 0,04 0,05 0,06 0,07 0,08 0,09 0,1 0,11 0,12 0,13 0,14 0,15
40 0,15 0,3 0,45 0,6 0,75 0,9 1,05 1,2 1,35 1,5 1,65 1,8 1,95 2,1 2,2545 0,169 0,338 0,506 0,675 0,844 1,013 1,181 1,35 1,519 1,688 1,856 2,025 2,194 2,363 2,53150 0,188 0,375 0,563 0,75 0,938 1,125 1,313 1,5 1,688 1,875 2,063 2,25 2,438 2,625 2,81355 0,206 0,413 0,619 0,825 1,031 1,238 1,444 1,65 1,856 2,063 2,269 2,475 2,681 2,888 3,09460 0,225 0,45 0,675 0,9 1,125 1,35 1,575 1,8 2,025 2,25 2,475 2,7 2,681 2,925 3,16965 0,244 0,488 0,731 0,975 1,219 1,463 1,706 1,95 2,194 2,438 2,681 2,925 3,169 3,413 3,65870 0,263 0,525 0,788 1,05 1,313 1,575 1,838 2,1 2,363 2,625 2,888 3,15 3,413 3,675 3,93875 0,281 0,563 0,844 1,125 1,406 1,688 1,969 2,25 2,531 2,813 3,094 3,375 3,656 3,938 4,21980 0,3 0,6 0,9 1,2 1,5 1,8 2,1 2,4 2,7 3 3,3 3,6 3,9 4,2 4,585 0,319 0,638 0,956 1,275 1,594 1,913 2,231 2,55 2,869 3,188 3,506 3,825 4,144 4,463 4,78190 0,338 0,675 1,013 1,35 1,688 2,025 2,363 2,7 3,038 3,375 3,713 4,05 4,388 4,725 5,063
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DOPAMINKg/Mikro 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1540 0,6 1,2 1,8 2,4 3 3,6 4,2 4,8 5,4 6 6,6 7,2 7,8 8,4 9
45 0,675 1,35 2.025 2,7 3.375 4,05 4.725 5,4 6.075 6,75 7.425 8,1 8.775 9,45 10,13
50 0,75 1,5 2,25 3 3,75 4,5 5,25 6 6,75 7,5 8,25 9 9,75 10,5 11,25
55 0,825 1,65 2.475 3,3 4.125 4,95 5.775 6,6 7.425 8,25 9.075 9,9 10,73 11,55 12,36
60 0,9 1,8 2,7 3,6 4,5 5,4 6,3 7,2 8,1 9 9,9 10,8 11,7 12,6 13,5
65 0,975 1,95 2.925 3,9 4.875 5,85 6.825 7,8 8.775 9,75 10,73 11,7 12,68 13,65 14,63
70 1,05 2,1 3,15 4,2 5,25 6,3 7,35 8,4 9,45 10,5 11,55 12,6 13,65 14,7 15,75
75 1.125 2,25 3.375 4,5 5.625 6,75 7.875 9 10,13 11,25 12,38 13,5 14,63 15,75 16,88
80 1,2 2,4 3,6 4,8 6 7,2 8,4 9,6 10,8 12 13,2 14,4 15,6 16,8 18
85 1.275 2,55 3.825 5,1 6.375 7,65 8.925 10,2 11,48 12,75 14,03 15,3 16,58 17,85 19,13
90 1,35 2,7 4,05 5,4 6,75 8,1 9,45 10,8 12,15 13,5 14,85 16,2 17,55 18,9 20,25
DOBUTAMINKg/Mi
kro 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
40 0,48 0,96 1,44 1,92 2,4 2,88 3,36 3,84 4,32 4,8 5,28 5,76 6,24 6,72 7,2
45 0,54 1,08 1,62 2,16 2,7 3,24 3,78 4,32 4,86 5,4 5,94 6,48 7,02 7,56 8,1
50 0,6 1,2 1,8 2,4 3 3,6 4,2 4,8 5,4 6 6,6 7,2 7,8 8,4 9
55 0,66 1,32 1,98 2,64 3,3 3,96 4,62 5,28 5,94 6,6 7,26 7,92 8,58 9,24 9,9
60 0,72 1,44 2,16 2,88 3,6 4,32 5,04 5,76 6,48 7,2 7,92 8,64 9,36 10,08 10,8
65 0,78 1,56 2,34 3,12 3,9 4,68 5,46 6,24 7,02 7,8 8,58 9,36 10,14 10,92 11,7
70 0,84 1,68 2,52 3,36 4,2 5,04 5,88 6,72 7,56 8,4 9,24 10,08 10,92 11,76 12,6
75 0,9 1,8 2,7 3,6 4,5 5,4 6,3 7,2 8,1 9 9,9 10,8 11,7 12,6 13,5
80 0,96 1,92 2,88 3,84 4,8 5,76 6,72 7,68 8,64 9,6 10,56 11,52 12,48 13,44 14,4
85 1,02 2,04 3,06 4,08 5,1 6,12 7,14 8,16 9,18 10,2 11,22 12,24 13,26 14,28 15,3
90 1,08 2,16 3,24 4,32 5,4 6,48 7,56 8,64 9,72 10,8 11,88 12,96 14,04 15,12 16,2
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NICARDIPINKg/mikro 0,1 0,2 0,3 0,4 0,5 0,6 0,7 0,8 0,9 1 1,1 1,2 1,3 1,4 1,5
40 1,2 2,4 3,6 4,8 6 7,2 8,4 9,6 10,8 12 13,2 14,4 15,6 16,8 1845 1,35 2,7 4,05 5,4 6,75 8,1 9,45 10,8 12,15 13,5 14,85 16,2 17,55 18,9 20,2550 1,5 3 4,5 6 7,5 9 10,5 12 13,5 15 16,5 18 19,5 21 22,555 1,65 3,3 4,95 6,6 8,25 9,9 11,55 13,2 14,85 16,5 18,15 19,8 21,45 23,1 24,7560 1,8 3,6 5,4 7,2 9 10,8 12,6 14,4 16,2 18 19,8 21,6 23,4 25,2 2765 1,95 3,9 5,85 7,8 9,75 11,7 13,65 15,6 17,55 19,5 21,45 23,4 25,35 27,3 29,2570 2,1 4,2 6,3 8,4 10,5 12,6 14,7 16,8 18,9 21 23,1 25,2 27,3 29,4 31,575 2,25 4,5 6,75 9 11,25 13,5 15,75 18 20,25 22,5 24,75 27 29,25 31,5 33,7580 2,4 4,8 7,2 9,6 12 14,4 16,8 19,2 21,6 24 26,4 28,8 31,2 33,6 3685 2,55 5,1 7,65 10,2 12,75 15,3 17,85 20,4 22,95 25,5 28,05 30,6 33,15 35,7 38,2590 2,7 5,4 8,1 10,8 13,5 16,2 18,9 21,6 24,3 27 29,7 32,4 35,1 37,8 40,5
NTGAmp/Mikro 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100
1 1,5 3 4,5 6 7,5 9 10,5 12 13,5 15 16,5 18 19,5 21 22,5 24 25,5 27 28,5 302 0,75 1,5 2,25 3 3,75 4,5 5,25 6 6,75 7,5 8,25 9 9,75 10,5 11,3 12 12,8 13,5 14,3 153 0,5 1 1,5 2 2,5 3 3,5 4 4,5 5 5,5 6 6,5 7 7,5 8 8,5 9 9,5 104 0,38 0,75 1,13 1,5 1,88 2,25 2,63 3 3,38 3,75 4,13 4,5 4,88 5,25 5,63 6 6,38 6,75 7,13 7,55 0,3 0,6 0,9 1,2 1,5 1,8 2,1 2,4 2,7 3 3,3 3,6 3,9 4,2 4,5 4,8 5,1 5,4 5,7 6
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