INTRODUCTION ------------------------
Woolf (1989) qualitatively divided into two types, namely pain physiological pain and pathological pain. The main difference between the two types of pain is that the pain is physiologically normal sensor that functions as a protective device body, while pain is a sensor of abnormal pathological someone suffer.
Pathological pain is a sensation that arises as a consequence of the existence or tissue damage caused by nerve damage. If the inflammatory process through the normal healing process so that disappeared in accordance with the healing referred to as adaptive pain, commonly known as acute pain. On the other hand, nerve damage in fact develop into intractable pain after healing is completed, referred to as maladaptive pain, and commonly known as neuropathic pain.
advanced
-------------------------- MAIN CONCEPT
Pain can be classified based on patofisiologinya (eg nosiseptif pain and neuropathic pain), etiology (eg, postoperative pain and cancer pain), or influenced areas (eg, headache and low back pain).
Nosiseptif pain caused by the activation or sensitization of peripheral nosiseptor which is a specific receptor that delivers noxious stimuli. Neuropathic pain is the result of an injury or acquired abnormalities in the peripheral or central neural structures.
Acute pain can be defined as pain produced by noxious stimuli because of an injury, disease process or structural abnormality of muscle or viscera. This pain almost always is nosiseptif.
Chronic pain is defined as persistent pain beyond the timeframe of a process of acute or exceed the achievement of a normal period of healing; periods can vary from one to six months. Chronic pain can be nosiseptif, neuropathic, or a combination thereof.
Modulation of peripheral pain occurs on nosiseptor, the spinal cord, or supra-spinal structures. Or the presence of this modulation can be facilitated.
Moderate to severe acute pain, depending on its location, can affect its function in the surrounding organs and has a role in perioperative morbidity or mortality.
Neural blockade with local anesthesia can be used to limit the pain mechanism, but more importantly, this blockade plays an important role in the management of patients with acute or chronic pain.
In general, the main role of antidepressants is to resolve complaints that patients with neuropathic pain such as neuralgia and neuropathy in diabetic postherpetik. This agent showed analgesic effects at lower doses than the doses antidepresannya effects.
Anticonvulsants are usually used in patients with neuropathic pain, particularly trigeminal neuralgia and diabetic neuropathy.
Stimulation of spinal corda most effective for neuropathic pain. The mechanism proposed is the activation and inhibition of descending modulating systems symphatetic outflow. Indications corda spinal stimulation that can be accepted include sympathetically mediated pain, spinal cord lesions with localized segmental pain, Phantom Limb pain, lower limb ischemia due to peripheral vascular penyakt, and adhesive arachnoiditis.
The use of combined local anesthetic and opioids is a very good technique for dealing with postoperative pain after a procedure involving the abdomen, pelvis, thorax and orthopedic.
Serious side effects from the use of epidural or intrathecal opioids is dose-dependent and depressed respiration. Most cases of respiratory depression occurred in patients who received therapy parenteral opioids or sedatives. Old-old patients or those who experience sleep apnea seems to be more susceptible to these side effects, requiring dose reduction.
Physical dependency occurs in all patients using large doses of opioids for long periods. This phenomenon could withdrawl dipresipitasi with opioid antagonist administration.
Multiple triggers can induce the occurrence of sympathetically Maintained pain, which often have overlooked or misdiagnosis. Patients often respond dramatically to the sympathetic block. Cure rate is very high (more than 90%) if therapy is initiated within one month since the discovery of symptoms.
DEFINITION and CLASSIFICATION OF PAIN -------------------
As with many other conscious stimulus, the perception of pain delivered by specialized neurons that act as receptors, detecting the stimulus, reinforcing and penghantar toward the central nervous system. The sensation is often didekripsikan as protopatik (noxious) and epikritik (non-noxious). Epiritik sensation (light touch, pressure, proprioception, and temperature differences) are indicated by a low threshold receptors that are generally delivered by a large nerve fibers bermielin. Conversely, protopatik sensation (pain) receptors characterized by a high threshold is delivered by the nerve fibers of smaller bermielin (A delta) and nerve fibers did not bermielin (C fibers).
According to the IASP (the International Association for the Study of Pain), pain is a "sensory and emotional experience unpleasant associated with tissue damage or potential damage." This definition describes the existence of a combination of an objective component, psychological aspects of pain as well as subjective and emotional factors. Response to pain can vary greatly between one person with another person and the same person at different times.
Terminology of "nosisepsi" taken from the word noci which means "injury", is used to describe the neural response to traumatic or noxious stimuli. All nosisepsi produce pain, but not all pain is the result nosisepsi. Many patients feel pain without a noxious stimulus. Therefore, clinically we divide pain into two categories: (1) acute pain, usually because nosisepsi and (2) chronic pain, perhaps because nosisepsi, but with the psychological and behavioral factors as the main factor.
A. Acute pain
Acute pain can be defined as pain caused by noxious stimuli because of an injury, disease process or abnormal function of muscle and viscera. Nature is almost always nosisepsi. Pain nosiseptif presented to detect, localize and restrict tissue damage. Four physiological processes involved are transduction, transmission, modulation and perception.
-Transduction
Nosiseptor potential changes to the current electro-biochemical / impulses along the axon. Occur due to the release of chemical mediators such as prostaglandins from damaged cells, from plasma bradykinin, histamine from mast cells, Platelet serotonin and substance P from the nerve endings.
-Transmission
Two step process nosiseptor pain impulses from peripheral nerves through the dorsal spinal cord toward Cutaneous cerebral cortex.
-Modulation
Internal control processes by the nervous system, can increase or reduce the pain impulses.
-Perception
SSP reconstruction results of pain impulses received. Reconstruction is the result of sensory nervous system, information on cognitive and emotional experiences.
This type of pain usually associated with a neuro-endocrine stress (sweating, pounding) is proportional to its intensity. This pain may be postoperative pain, obstetric pain, pain in acute medical illness (AMI, pancreatitis, kidney stones), etc.. Most acute pain can heal themselves (self-limited) or cure with medication for several days or weeks. When the pain failed to heal well because of abnormalities in the process of healing and the treatment is not adequate, can develop into chronic pain. Two types of acute pain - pain of somatic and visceral pain - differentiated according to origin of the pain and the clinical picture.
B. Chronic Pain
Chronic pain is defined as pain that settled over the time span of an acute process or a period exceeding the normal achievement of a cure; periods can vary from 1 up to 6 months. Chronic pain can be nosiseptif, neuropathic, or a combination thereof.
ANATOMY and PHYSIOLOGY NOSISEPSI ------------------
Pain pathways
There are three lines of neurons involved in pain
1. First order neurons; deliver the pain from the periphery to the spinal cord
2. Second order neurons; deliver the pain from the medulla to the thalamus spinals
3. Third order neurons; deliver the pain from the thalamus to the cortex,
Physiology Nosisepsi
1. Nosiseptor
- It is free of nerve fibers (free nerve endings / C fibers), the character of afferent (sensory)
- Receptor for temperature stimuli, mechanical and chemical; mainly excitatory on damaged tissue.
- Type:
Mekanonosiseptor; in touch and prick
Silent nosiseptor; on the inflammatory reaction
Polimodal mekano-heat-nosiseptor; the strong pressure, increased temperature (> 42 ° C and 2
Lamotrigine 24 25-400 20-20
Phenytoin 22200-600 10-20
Unknown topiramate 25-200 20-30
Valproic acid 50-100 6-16 750-1250
Corticosteroids
Glucocorticoids are widely used in pain management because of the effects of antiinflammatory and analgesic owned. This agent can be provided by topical, oral, or parenteral (intravenous, subcutaneous, intra-exchange, intraartikular, and epidural). Glucocorticoid excess can cause hypertension, hyperglycemia, increased susceptibility to infections, peptic ulcers, osteoporosis, aseptic necrosis of femoral caput, proximal myopati, cataracts, and (rarely) psychosis.
Route corticosteroid mineralocorticoid activity of glucocorticoid activity equivalent dose (mg) The half-life (hours)
Hydrocortisone O, I, T 1 1 20 8-12
Prednisone O 4 0.8 5 12-36
Prednisolone O, I 4 0.8 5 12-36
Methyl-prednisolone O, I, T 5 0.5 4 12-36
Triamcinolone O, I, T 5 0 4 12-36
Betamethasone O, I, T 25 0 0.75 36-72
Dexamethasone O, I, T 25 0 0.75 36-72
O: oral, I: injectable, T: Topical
Systemic Local Anaesthetics
Local anesthetic can be used systemically with neuropathic pain in patients. These agents produce central effects of sedation and analgesia. Lidocaine, procaine, and klorprokain is most commonly used agent, given the slow bolus and continuous infusion. Lidocaine given intravenously over 50-30 minutes for a total dose of 1-5 mg / kg. procaine 200-400 mg can be given intravenously over 1-2 hours. Klorprokain (i% solution) infused at 1 mg / kg / min for a total dose of 10-20 mg / kg. Monitoring should be done include electrocardiogram (ECG), blood pressure, respiration and mental status. Resuscitation tool should always be available. Signs of toxicity include tinnitus, slurring, and nistagmus esksesif sedation.
Thursday, May 27, 2010
Management of airway
Oxygen Therapy -----------------------------------
Oxygen is a substance which is very important in the lives of humans and other living creatures. Oxygen is required for normal breathing oganisme aerobics. Oxygen is 50% components of the planet earth, 21% component of the air we breathe, and 89% water component.
The aim is to overcome the oxygen therapy that tissue hypoxia occurs due to decreased arterial oxygen pressure. Patients rarely survive with arterial oxygen pressure values in the red region (pressure £ 25 mmHg).
Giving Oxygen Method
1. Variable performance
These uncontrolled administer oxygen therapy devices, Because the patient creates the inspired mixture by the act of breathing. Example: a nasal catheter, nasal cannula, mask shells with or without rebreathing bag.
clip_image001
Shell masks low capacity
clip_image001
Nasal cannula
images11
High capacity systems
(Non re-breathing mask)
images87
Nasal catheter
1. Fixed performances
These devices allow a controlled oxygen dosage. They create a constant proportion of water / oxygen mixture in excess of patient inspiratory flow rate and are independent of patient factors or the fit to the face. With gas flow constantly in excess of patient demand and with enhanced CO2 washout, rebreathing is virtually eliminated.
Venturi Mask Ventimask
Road Management Concepts ------------------------- Breath
Anatomy
Relations airway and the outside world got through two avenues:
1. À nose into the nasopharynx
2. Mouth à toward orofaring
Nose and mouth at the front separated by the palate palate durum and molle; in the rear united in hipofaring. Hipofaring toward the esophagus and larynx are separated by epiglotis toward the trachea. Larynx consists of the thyroid cartilage, krikoid, epiglotis, and a pair aritenoid, kornikulata and kuneiform.
Innervation
1. N. trigeminal (V), mensarafi nasal mucosa, palate (V-1), the maxillary (V-2), tongue and mandibular regions (V-3).
2. N. facial (seventh), mensarafi palate.
3. N. glossofaringeus (IX), mensarafi tongue, pharynx, palate and tonsils mole.
4. N. vagus (X), mensarafi epiglotis and the area around the vocal cords.
Airway obstruction
In the unconscious patient or in a state teranestesi supine position, muscle tone upper airway and genioglossus muscle is lost; so that the tongue will clog hipofaring and cause airway obstruction either total or partial. This situation often occurs and must be quickly found and corrected in several ways such as triple airway maneuvers (triple airway manuever), installation of equipment pharyngeal airway (pharyngeal airway), the installation of the appliance lid laryngeal airway (laryngeal mask airway), installation of pipe trachea ( endotracheal tube). Obstruction can also be caused by spasm of the larynx during light anesthesia and a painful stimulus or stimuli by secretions.
Signs of Airway Obstruction
1. Stridor
2. Nostril breath
3. Retracted trachea
4. Chest wall retraction
5. There was no expiratory air
Larynx spasms, or cramps
Occur because the vocal cords close partially or completely. This condition is usually caused by a mild anesthesia or in people who received stimulation of the pharynx.
Treatment:
1. Triple airway maneuver
2. Positive ventilation with oxygen 100%
Triple ----------------------------- airway maneuvers
Triple airway maneuvers consist of:
1. Head extension of a joint atlanto-occipital muscle
2. Mandible pushed forward on the second mandibular angle
3. Mouth opened
With this maneuver is expected to lift the tongue and airway free, so that gas or air smoothly into the trachea through the nose or mouth.
Step 2
Step 3
------------------- Various Kinds of breath Road Management Tool
Airway pharynx
If less successful triple maneuver, it can be fitted mouth-pharynx airway through the mouth (OPA, oro-pharyngeal airway) or nasal-pharyngeal airway through the nose (NPA, naso-pharyngeal aiway).
NPA: shaped like a round hole in the middle of the pipe is made of soft latex rubber. Installation must be careful to avoid the trauma and nasal mucosa, tube smeared with jelly.
OPA: Shaped pipe flattened curved like the letter C with a hole in the middle with one end wall stemmed with greater efforts to prevent interference with the hole when the patient bite patency; so that air flow remains assured.
OPA is also fitted with a pipe, or lid lring trachea to maintain patency of both the appliance bite patients.
Front lid
Lid face (face mask) led the air / gas from the anesthesia resuscitation equipment or systems of anesthesia to a patient airway. The shape is made such that when used for spontaneous breathing or with positive pressure and the gas leak did not enter all of the trachea through the mouth or nose. Lid shape varies depending on age face the patient and the manufacturer. Size 03 for a newborn; 02, 01, one for small children; 2, 3 for big kids, and 4, 5 to adult. Some uncovered face of a transparent material so that expiratory air look (sweating) or if there's vomit or lips looked pinched.
Larynx lid
Sungkup larynx (LMA, laryngeal mask airway) is a spoon-shaped tool airway consists of a large pipe perforated with the tip of the spoon that resembles dikembangkempiskan edges can be like a balloon on the pipe trachea. Pipestem LMA can be a hard pipe of polyvinyl or softening with a spiral to keep the hole remained patent.
Known two kinds of caps larynx:
1. Standard laryngeal lid with a breathing tube.
2. Laryngeal lid with two pipes: one standard and other breathing tube additional pipe connected with the distal end of the esophagus.
Face mask
Laryngeal mask airway (LMA)
LMA size and its allocation
Age Size Weight (kg)
1.0 Neonates <3
1.3 Infant 30-10
2.0 Small children 10-20
2.3 Child 20-30
3.0 Small Adults 30-40
4.0 Normal Adults 40-60
Adult large 5.0> 60
LMA installation mode can be done with or without the help laringoskop. Actually this tool is made for the purpose, among others, that can be mounted directly without the help of tools and can be used when the trachea intubation is forecast to experience difficulties. LMA was not able to replace the trachea intubation, but it lies between the front lid and trachea intubation.
Installation should be deep enough to wait anesthesia or paralytic muscles used to avoid the trauma of the oral cavity, pharynx, larynx. After the appliance is installed, to avoid being bitten his breathing tube, it can be mounted gauze rolls (bite block) or the oral pharyngeal breathing tube (OPA).
Pipe trachea
Pipe trachea (endotracheal tube) to take the gas anesthetic directly into the trachea and are usually made from polyvinyl chloride standard materials. Diameter hole in the pipe is expressed in millimeters. Because the trachea cross-section babies, children and adults are different - trachea cross-section babies and small children under the age of five years is almost spherical, while mature shaped like the letter D - is for babies and small children used without the cuff, whereas for big kids and adults with cuff so as not to leak.
Use cuff in infants and young children can create trachea mucous membrane trauma. If we want to use the pipe trachea with the cuff on the infant, we must use a trachea tube diameter size smaller and this makes the risk of airway resistance is greater. Pipe trachea can be inserted through the mouth (orotrakheal tube) or through the nose (nasotracheal tube). On the free market known several sizes and estimates the size required can be seen in the table below.
Pipe trachea and its allocation
Age Diameter (mm) Distance French Scale up lips (cm)
Premature 2.0 - 2.5 10 10
Neonates 2.5 - 3.5 12 11
1-6 months 3.0 - 4.0 14 11
½ - 1 year 3.5 - 4.0 16 12
1-4 years 4.0 - 5.0 18 13
4-6 years 4.5 - 5.5 20th 14th
6-8 year 5.0 - 5.5 22 15-16
80-10 years 5.5 - 6.0 24th 16-17
10 -12 years 6.0 - 6.5 26 17-18
12-14 years 6.5 - 7.0 28-30 18-22
Adult female 6.5 - 8.5 28-30 20-24
Adult male 05.07 - 10.0 32-34 20-24
How to choose a trachea tube for infants and young children:
The diameter of the pipe trachea (mm) = 4.0 + ¼ age (years)
Oro-trakheal pipe length (cm) = 12 + ½ age (years)
Naso-trakheal pipe length (cm) = 12 + ½ age (years)
Laryngoscopy and Intubation
Laryngeal function was to prevent foreign matter into the lungs. Laringoskop is a tool used to view the larynx directly so that we can enter the trachea tube well and correctly. Broadly speaking there are two kinds laringoskop:
1. Blades, leaf (blade), straight (Macintosh) for babies - children - adult
2. Curved blades (Miller, Magill) for big kids - adult
Difficulties associated with the trachea tube insert anatomical variations encountered.
laryngoscope
Intubation
Intubation trachea Indication
Intubation trachea trachea tube is put into action in the trachea via rima glottis, so that distal end located approximately in the middle trachea between the vocal cords, and trachea bifurcation. Indications vary and are generally classified as follows:
1. Maintain airway patency by any cause
Anatomical abnormalities, especially surgical, surgical special position, clearing the airway secretions, and others.
1. Facilitate positive ventilation and oxygenation
For example during resuscitation, allowing the use of relaxants with efficient, long-term ventilation.
1. Prevention of aspiration and regurgitation
Intubation difficulty
1. Short muscular neck
2. Prominent mandible
3. Maxillary / protruding front teeth
4. Invisible uvula
5. Temporo-mandibular joint movement limited
6. Limited motion of the cervical vertebrae
Complications of intubation
1. During intubation
- Traumatized teeth
- Laceration lips, gums, larynx
- Stimulate the sympathetic nervous (hypertension - tachycardia)
- Bronchial intubation
- Oesophageal intubation
- Aspirations
- Bronchial spasm
1. After ekstubasi
- Spasm of the larynx
- Aspirations
- Disruption fonasi
- Subglotis-glottis edema
- Infection of the larynx, pharynx, trachea
Ekstubasi
1. Ekstubasi postponed until the patient is fully awake, if:
- Will return menmbulkan intubation difficulty
- There is the risk of aspiration post ekstubasi
1. Ekstubasi done on the state of anesthesia is generally mild with notes will not occur spasm of the larynx.
2. Before ekstubasi, clean the oral cavity - the larynx - the pharynx of secretions and other liquids.
Comparative properties of airway equipment
Front lid lid Larynx trachea Pipe
Interventions should be held no need to hold No need to hold
Pretty good quality airway Very good or good enough
Access to the head neck Good Good Poor
Spontaneous ventilation is very short Procedure Procedure Procedure long long time
Ventilation control is very short Procedure Procedure Procedure very long time
------------------------------ Concept Mechanical Ventilation
In the medical field, mechanical ventilation is suau method to assist or replace spontaneous breathing. Mechanical ventilation is performed as a life saving action in CPR, intensive care, and anesthesia.
Clinical Use
Used in mechanical ventilation if spontaneous respiration is not obtained (apneu) or inadequate. This could be a result of intoxication, cardiac arrest, neurological disease, head trauma, respiratory muscle paralysis in Guillain-Barré syndrome, Myasthenia Gravis, spinal cord injury, or the effects of anesthetic and drugs Muscle relaxants. Various lung diseases (eg Pulmonum edema, COPD) or thorax trauma (eg broken ribs), and heart disease such as congestive heart failure, sepsis and shock can also hinder normal ventilation. Depending on circumstances, mechanical ventilation may be continued for several minutes or even several years.
Oxygen is a substance which is very important in the lives of humans and other living creatures. Oxygen is required for normal breathing oganisme aerobics. Oxygen is 50% components of the planet earth, 21% component of the air we breathe, and 89% water component.
The aim is to overcome the oxygen therapy that tissue hypoxia occurs due to decreased arterial oxygen pressure. Patients rarely survive with arterial oxygen pressure values in the red region (pressure £ 25 mmHg).
Giving Oxygen Method
1. Variable performance
These uncontrolled administer oxygen therapy devices, Because the patient creates the inspired mixture by the act of breathing. Example: a nasal catheter, nasal cannula, mask shells with or without rebreathing bag.
clip_image001
Shell masks low capacity
clip_image001
Nasal cannula
images11
High capacity systems
(Non re-breathing mask)
images87
Nasal catheter
1. Fixed performances
These devices allow a controlled oxygen dosage. They create a constant proportion of water / oxygen mixture in excess of patient inspiratory flow rate and are independent of patient factors or the fit to the face. With gas flow constantly in excess of patient demand and with enhanced CO2 washout, rebreathing is virtually eliminated.
Venturi Mask Ventimask
Road Management Concepts ------------------------- Breath
Anatomy
Relations airway and the outside world got through two avenues:
1. À nose into the nasopharynx
2. Mouth à toward orofaring
Nose and mouth at the front separated by the palate palate durum and molle; in the rear united in hipofaring. Hipofaring toward the esophagus and larynx are separated by epiglotis toward the trachea. Larynx consists of the thyroid cartilage, krikoid, epiglotis, and a pair aritenoid, kornikulata and kuneiform.
Innervation
1. N. trigeminal (V), mensarafi nasal mucosa, palate (V-1), the maxillary (V-2), tongue and mandibular regions (V-3).
2. N. facial (seventh), mensarafi palate.
3. N. glossofaringeus (IX), mensarafi tongue, pharynx, palate and tonsils mole.
4. N. vagus (X), mensarafi epiglotis and the area around the vocal cords.
Airway obstruction
In the unconscious patient or in a state teranestesi supine position, muscle tone upper airway and genioglossus muscle is lost; so that the tongue will clog hipofaring and cause airway obstruction either total or partial. This situation often occurs and must be quickly found and corrected in several ways such as triple airway maneuvers (triple airway manuever), installation of equipment pharyngeal airway (pharyngeal airway), the installation of the appliance lid laryngeal airway (laryngeal mask airway), installation of pipe trachea ( endotracheal tube). Obstruction can also be caused by spasm of the larynx during light anesthesia and a painful stimulus or stimuli by secretions.
Signs of Airway Obstruction
1. Stridor
2. Nostril breath
3. Retracted trachea
4. Chest wall retraction
5. There was no expiratory air
Larynx spasms, or cramps
Occur because the vocal cords close partially or completely. This condition is usually caused by a mild anesthesia or in people who received stimulation of the pharynx.
Treatment:
1. Triple airway maneuver
2. Positive ventilation with oxygen 100%
Triple ----------------------------- airway maneuvers
Triple airway maneuvers consist of:
1. Head extension of a joint atlanto-occipital muscle
2. Mandible pushed forward on the second mandibular angle
3. Mouth opened
With this maneuver is expected to lift the tongue and airway free, so that gas or air smoothly into the trachea through the nose or mouth.
Step 2
Step 3
------------------- Various Kinds of breath Road Management Tool
Airway pharynx
If less successful triple maneuver, it can be fitted mouth-pharynx airway through the mouth (OPA, oro-pharyngeal airway) or nasal-pharyngeal airway through the nose (NPA, naso-pharyngeal aiway).
NPA: shaped like a round hole in the middle of the pipe is made of soft latex rubber. Installation must be careful to avoid the trauma and nasal mucosa, tube smeared with jelly.
OPA: Shaped pipe flattened curved like the letter C with a hole in the middle with one end wall stemmed with greater efforts to prevent interference with the hole when the patient bite patency; so that air flow remains assured.
OPA is also fitted with a pipe, or lid lring trachea to maintain patency of both the appliance bite patients.
Front lid
Lid face (face mask) led the air / gas from the anesthesia resuscitation equipment or systems of anesthesia to a patient airway. The shape is made such that when used for spontaneous breathing or with positive pressure and the gas leak did not enter all of the trachea through the mouth or nose. Lid shape varies depending on age face the patient and the manufacturer. Size 03 for a newborn; 02, 01, one for small children; 2, 3 for big kids, and 4, 5 to adult. Some uncovered face of a transparent material so that expiratory air look (sweating) or if there's vomit or lips looked pinched.
Larynx lid
Sungkup larynx (LMA, laryngeal mask airway) is a spoon-shaped tool airway consists of a large pipe perforated with the tip of the spoon that resembles dikembangkempiskan edges can be like a balloon on the pipe trachea. Pipestem LMA can be a hard pipe of polyvinyl or softening with a spiral to keep the hole remained patent.
Known two kinds of caps larynx:
1. Standard laryngeal lid with a breathing tube.
2. Laryngeal lid with two pipes: one standard and other breathing tube additional pipe connected with the distal end of the esophagus.
Face mask
Laryngeal mask airway (LMA)
LMA size and its allocation
Age Size Weight (kg)
1.0 Neonates <3
1.3 Infant 30-10
2.0 Small children 10-20
2.3 Child 20-30
3.0 Small Adults 30-40
4.0 Normal Adults 40-60
Adult large 5.0> 60
LMA installation mode can be done with or without the help laringoskop. Actually this tool is made for the purpose, among others, that can be mounted directly without the help of tools and can be used when the trachea intubation is forecast to experience difficulties. LMA was not able to replace the trachea intubation, but it lies between the front lid and trachea intubation.
Installation should be deep enough to wait anesthesia or paralytic muscles used to avoid the trauma of the oral cavity, pharynx, larynx. After the appliance is installed, to avoid being bitten his breathing tube, it can be mounted gauze rolls (bite block) or the oral pharyngeal breathing tube (OPA).
Pipe trachea
Pipe trachea (endotracheal tube) to take the gas anesthetic directly into the trachea and are usually made from polyvinyl chloride standard materials. Diameter hole in the pipe is expressed in millimeters. Because the trachea cross-section babies, children and adults are different - trachea cross-section babies and small children under the age of five years is almost spherical, while mature shaped like the letter D - is for babies and small children used without the cuff, whereas for big kids and adults with cuff so as not to leak.
Use cuff in infants and young children can create trachea mucous membrane trauma. If we want to use the pipe trachea with the cuff on the infant, we must use a trachea tube diameter size smaller and this makes the risk of airway resistance is greater. Pipe trachea can be inserted through the mouth (orotrakheal tube) or through the nose (nasotracheal tube). On the free market known several sizes and estimates the size required can be seen in the table below.
Pipe trachea and its allocation
Age Diameter (mm) Distance French Scale up lips (cm)
Premature 2.0 - 2.5 10 10
Neonates 2.5 - 3.5 12 11
1-6 months 3.0 - 4.0 14 11
½ - 1 year 3.5 - 4.0 16 12
1-4 years 4.0 - 5.0 18 13
4-6 years 4.5 - 5.5 20th 14th
6-8 year 5.0 - 5.5 22 15-16
80-10 years 5.5 - 6.0 24th 16-17
10 -12 years 6.0 - 6.5 26 17-18
12-14 years 6.5 - 7.0 28-30 18-22
Adult female 6.5 - 8.5 28-30 20-24
Adult male 05.07 - 10.0 32-34 20-24
How to choose a trachea tube for infants and young children:
The diameter of the pipe trachea (mm) = 4.0 + ¼ age (years)
Oro-trakheal pipe length (cm) = 12 + ½ age (years)
Naso-trakheal pipe length (cm) = 12 + ½ age (years)
Laryngoscopy and Intubation
Laryngeal function was to prevent foreign matter into the lungs. Laringoskop is a tool used to view the larynx directly so that we can enter the trachea tube well and correctly. Broadly speaking there are two kinds laringoskop:
1. Blades, leaf (blade), straight (Macintosh) for babies - children - adult
2. Curved blades (Miller, Magill) for big kids - adult
Difficulties associated with the trachea tube insert anatomical variations encountered.
laryngoscope
Intubation
Intubation trachea Indication
Intubation trachea trachea tube is put into action in the trachea via rima glottis, so that distal end located approximately in the middle trachea between the vocal cords, and trachea bifurcation. Indications vary and are generally classified as follows:
1. Maintain airway patency by any cause
Anatomical abnormalities, especially surgical, surgical special position, clearing the airway secretions, and others.
1. Facilitate positive ventilation and oxygenation
For example during resuscitation, allowing the use of relaxants with efficient, long-term ventilation.
1. Prevention of aspiration and regurgitation
Intubation difficulty
1. Short muscular neck
2. Prominent mandible
3. Maxillary / protruding front teeth
4. Invisible uvula
5. Temporo-mandibular joint movement limited
6. Limited motion of the cervical vertebrae
Complications of intubation
1. During intubation
- Traumatized teeth
- Laceration lips, gums, larynx
- Stimulate the sympathetic nervous (hypertension - tachycardia)
- Bronchial intubation
- Oesophageal intubation
- Aspirations
- Bronchial spasm
1. After ekstubasi
- Spasm of the larynx
- Aspirations
- Disruption fonasi
- Subglotis-glottis edema
- Infection of the larynx, pharynx, trachea
Ekstubasi
1. Ekstubasi postponed until the patient is fully awake, if:
- Will return menmbulkan intubation difficulty
- There is the risk of aspiration post ekstubasi
1. Ekstubasi done on the state of anesthesia is generally mild with notes will not occur spasm of the larynx.
2. Before ekstubasi, clean the oral cavity - the larynx - the pharynx of secretions and other liquids.
Comparative properties of airway equipment
Front lid lid Larynx trachea Pipe
Interventions should be held no need to hold No need to hold
Pretty good quality airway Very good or good enough
Access to the head neck Good Good Poor
Spontaneous ventilation is very short Procedure Procedure Procedure long long time
Ventilation control is very short Procedure Procedure Procedure very long time
------------------------------ Concept Mechanical Ventilation
In the medical field, mechanical ventilation is suau method to assist or replace spontaneous breathing. Mechanical ventilation is performed as a life saving action in CPR, intensive care, and anesthesia.
Clinical Use
Used in mechanical ventilation if spontaneous respiration is not obtained (apneu) or inadequate. This could be a result of intoxication, cardiac arrest, neurological disease, head trauma, respiratory muscle paralysis in Guillain-Barré syndrome, Myasthenia Gravis, spinal cord injury, or the effects of anesthetic and drugs Muscle relaxants. Various lung diseases (eg Pulmonum edema, COPD) or thorax trauma (eg broken ribs), and heart disease such as congestive heart failure, sepsis and shock can also hinder normal ventilation. Depending on circumstances, mechanical ventilation may be continued for several minutes or even several years.
FLUID THERAPY, electrolytes & Transfusion
I. FLUID THERAPY
Introduction
By eating and drinking our body gets the water, electrolytes, carbohydrates, fats, vitamins and other substances. Within 24 hours the amount of water and electrolytes into and out through urine, feces, perspiration and breathing in adults steam about the same as in the table below.
Input (ml per 24 hours)
Output (ml per 24 hours)
Drink 800 - 1700 Urine 600 - 1600
Eating 500 -1000 Faeces 50-200
Oxidation 200-300 IWL 850-1200
Total 1500 - 3000 of 1500 - 3000
Fluid therapy is required if the body can not enter the water, electrolytes, and nutrients orally, for example on the state of the patient should be fasting a long time (for example because of surgery GI), bleeding a lot, hypovolemic shock, severe anorexia, nausea, vomiting continuously, etc. . With fluid therapy, water and electrolyte needs can be met. In addition, under certain circumstances, fluid therapy can be used as additional substances to include drugs and food regularly or can also be used to maintain acid-base balance.
Composition of Body Fluids
Water content at birth is around 75% BB and at the age of 1 month approximately 65% BB. The composition of body fluids in adult men is approximately 60% of body weight, while in adult women 50% BB. The rest are solid substances such as proteins, fats, carbohydrates, etc..
Water in the body are in several rooms, which amounted to 40% intracellular and extracellular by 20%. Extracellular fluid is a liquid contained in antarsel space (interstitial) equal to 15% and 5% plasma. Special antarsel fluid called cerebrospinal fluid, the liquid transeluler eg, joint fluid, peritoneal fluid, etc..
Intra-and extracellular fluid composition described in the table below:
CIS
CES
Plasma
Interstitial
Sodium
15
142
144
Potassium
150
4
4
Calcium
2
5
2.5
Magnesium
27
3
1.5
Clorida
1
103
114
HCO3
10
27
30
HPO4
100
2
2
SO4
20
1
1
Organic Acids
-
5
5
Water across the cell membrane easily, but other substances pass through it is difficult or requires a special process in order to cross it; therefore outside and electrolyte composition in different cells. Intracellular fluid contains many ions K, Mg and phosphate, whereas the extracellular fluid contains Na and Cl ions.
Plasma is blood minus blood cells such as erythrocytes, leukocytes and platelets. Serum is blood plasma minus clotting factors such as fibrinogen and protrombin. Hematocrit is a percentage of the volume of erythrocytes in the blood.
Water movement
Osmotic pressure is the pressure required to prevent leakage (diffusion) of fluid through a semipermeable membrane into another liquid that concentration is higher. Semipermeable membrane is a membrane that can pass water (solvent) but can not pass solutes such as proteins.
Plasma osmotic pressure was 285 ± 5 mOsm / L. Solution which has the same osmotic pressure is called an isotonic solution (eg 0.96% NaCl, dextran 5%, Ringer-Lactate), the solution has a lower osmotic pressure is called hypotonic solution (eg distilled water) and solutions that have a higher osmotic pressure is called condensation hypertonic.
Water Needs and Elekrolit
Basal fluid requirements (routine maintenance) is 30-40 ml / kg / day in adults. To determine the fluid requirements in children can use the following guidelines:
à 4 ml / kg / hour for the first weight 10 kg
à 2 ml / kg / hr added for the second weight 10 kg
à 1 ml / kg / hour for the remaining add further weight
Example
Patients with body weight 23 kg, hence the need basalnya fluid is:
(4 x 10) + (2 x 10) + (1 x 3) = 63 ml / hr
FLUID THERAPY
Definition
Fluid therapy is to maintain the action, replace the interior milieu within physiological limits.
Indication, among others:
- Acute loss of body fluids
- Loss of blood
- Anorexia
- Gastrointestinal disorders
Goal
The aim of fluid therapy described in the chart below.
Giving Techniques
The main priority in replacing the lost fluid volume is via the enteral route / physiology eg drinking or via NGT. For fluid therapy can be used in a short time the veins on the back of the hand, wrist area, forearm or cubital region. In small children and infants are often used areas of your foot, feet in front of the eyes or heads. Provision of fluid therapy in newborns can be done through the umbilical vein.
The use of needles anti-rust or anti trombogenik plastic catheters on peripheral veins usually need to be replaced every 1-3 days to avoid infection and jam drops. Giving intravenous fluids for more than three days should use big and long catheters inserted in the femoral vein, cubital vein, vena subclavia, external or internal jugular vein that ends as close as possible to the right atrium or the inferior or superior vena cava.
Nature-Substitute an Ideal Plasma Properties
The properties of the plasma is an ideal substitute:
* PH, pressure and viscosity comparable onkotik blood plasma
* Securities sufficient volume for a certain time period without the risk of overload on the cardiovascular system or edema
* Improving microcirculation and improve diuresis
* Do not disturb homeostasis
* Does not interfere with blood grouping and cross matching
* Accumulated a minimum of reticuloendothelial system
* Length of long-storage products
* Economical
Characteristics of Various Plasma Substitute
Criteria
Whole blood
Electrolyte solution
Albumin 20%
Dextran
40 +10
6% HES
Haemaccel
pH
7.3 to 7.4
5.5 to 6.5
6.47 to 7.2
4.5 to 5.7
5.0 to 7.0
7.0 to 7.6
The average BM
-
-
66 000
40 000
200 000 / 450,000
35 000
Physiological osmotic pressure of the Non-Iso-osmotic osmotic osmotic hyper-hyper-osmotic Iso-osmotic
Intravascular-interstitial fluid balance maintained edema Risk Dehydration Dehydration Repair Repair
Effective half-week A few days A few minutes A few days 12 hours 6-8 hours 4-6 hours
Disturbances in blood typing is usually not Pseudoaglu tinasi No No No No
There is the possibility of disruption of homeostasis (activation factor) Only pengence-bed-bed pengence Only Lowers Platelet function and coagulopathy Lowers Platelet function and coagulopathy Only dilution
Renal function
?
Recovery may be improved disturbed not found literature data Recovery
Overload cardiovascular Maybe Not Maybe Maybe Not likely No way
Possible side effects Anaphylaxis / incompatibility reaction kutis pulmonary edema, fever, hypotension while the need premedication Anaphylaxis Anaphylaxis or anaphylactic reaction to local skin reactions, hypotension while
Risk of transmission of viral diseases such as HIV, HBV, HCV No No No No No
Storage time 21 days 3 years 3-5 years 5 years 3 years 5 years
4-6 ° C storage temperature 2-25 ° C room temperature <25 ° C Room Temp Room Temp
Accumulation in RES No No No No Several weeks Several months
Advantages and Disadvantages of Plasma Substitute Various Preparations
1. 1. Whole blood
Excess
* The capacity of oxygen transport
* Capacity hemostatic
Shortage
* The provision of long
* Short storage time
* Minor to severe anaphylactic reactions
* Alloimunisasi
* Reaction hemolysis
* Reaction infection
* The viscosity increases
* Overload volume
* Hiperkalium, hiperkalsium, acidosis
Price * expensive
1. Electrolyte solution
Excess
* More easily available and cheap
* The composition similar to plasma (Ringer Acetate / Ringer Lactate)
* Can be stored in room temperature
* Free of anaphylactic reactions
* Complications of minimal
Shortage
* Edema can reduce chest wall ekspansibilitas
* Disturbed tissue oxygenation due to increased capillary and cell spacing
* Requires four times more volume
1. 3. Solution of human albumin
Excess
* The expansion of plasma volume without interstitial volume expansion
* Expansion of a larger volume
* A longer duration
* Better tissue oxygenation
* O2 alveolar-arterial gradient less
* The incidence of pulmonary edema or edema and lower systemic
Shortage
* Anaphylactic reaction
* Coagulopathy
* Albumin may aggravate myocardial depression shock patients
1. Dextran
Excess
* Securities or the volume of long length
* Anti-thrombotic effects
Shortage
* Expansion and dehydration ekstravaskuler interstitial compartment
* Impaired hemostasis
* Restrictions dose
* Fatal anaphylactic reactions
* Impaired renal function
* Accumulation in reticuloendothelial system
* Disturbances in blood grouping and cross matching
1. HES
Excess
* Securities or the volume of long length
* Anti-thrombotic effects
Shortage
* Expansion and dehydration ekstravaskuler interstitial compartment
* Impaired hemostasis
* Restrictions dose
* Fatal anaphylactic reactions
* Accumulation in reticuloendothelial system
1. Haemaccel
Excess
* Iso-osmotic
* Maintain fluid balance
* Securities optimal volume
* Improvement of renal function
* Does not interfere with hemostasis
* Does not interfere with blood grouping
* There was no accumulation in the RES
* Economical
Shortage
* Reaction anafilaktoid
Fluid Therapy Success
Fluid therapy which successfully described with the increase in cardiac index, oxygen transport and oxygen consumption as well as decreased pulmonary vascular resistance and systemic vascular resistance.
1. II. Electrolyte THERAPY
2. a. Hyponatremia
1. SODIUM
Definition: serum Na + levels below normal (<135 mEq / L)
Hyponatremia is divided into:
1) hyponatremia à artifactual false
Reported laboratory error caused by:
* Hyperglycemic
Correction value of sodium (any increase in blood glucose of 100 mg / dl to reduce the sodium by 1.7 mEq / L)
* Hiperlipidemi
The measured serum osmolality will be normal or greater than the calculated osmolality (OSM = [2 x Na] + [Glukosa/18] + [BUN / 2.8])
Second) à hipervolemia dilutional hyponatremia with total body water expansion
Hyponatremia is caused by impaired excretion of water, it appears as edema; eg CHF, renal impairment and nephrotic syndrome.
3) hypovolemic hyponatremia à exceeds sodium depletion, water depletion, eg in renal failure, hypothyroidism and Addison's disease.
4) à euvolemik hyponatremia sodium and water depletion in the number of comparable
This happened to lose water and sodium through the digestive tract (in vomit, suction nasogastrik, diarrhea), loss to third cavity (on burns, surgery), excessive sweating, kidney and adrenal diseases (in uncontrolled diabetes mellitus, hipoaldosteron, Addison's disease , the recovery phase of renal disease).
Clinical picture
* Clinical features and severity of hyponatremia depends on the initial speed.
* Symptoms are more pronounced in rapidly developing hyponatremia.
• If the plasma Na decreased 10 mEq / L within several hours, patients may be nausea, vomiting, headaches and muscle cramps.
* If the plasma Na decreased 10 mEq / L in one hour can lead to severe headaches, lethargy, seizures, disorientation and coma.
* Perhaps the patient has signs of basic diseases (such as heart failure, Addison's disease).
* If hyponatremia occurs secondary to loss of fluids, there may be signs of shock such as hypotension and tachycardia.
Management of hyponatremia
* Overcome the basic disease
* Stop any drugs that contributed to the hyponatremia
* Correction of the long-standing hyponatremia gradually, whereas the more aggressive acute hyponatremia. Avoid excessive correction because it can cause central pontine myelinolysis
* Do not raise the serum Na is faster than 12 mEq / L in 24 hours in asymptomatic patients. If the patient is symptomatic, could increase by 1 to 1.5 mEq / L / hour until symptoms subside. To increase the amount of sodium required to raise serum sodium to 125 mEq / L used the formula:
Total Na (mEq) = [125 mEq / L - actual serum Na (mEq / L)] x TBW (in liters)
TBW (Total Body Water) = 0.6 x body weight (in kg)
* Solution can be a substitute for NaCl 3% or 5% (each containing 0.51 mEq / ml and 0.86 mEq / ml)
* In patients with expansion of extracellular fluid, diuretics may dperlukan
* Hyponatremia can be corrected with hypertonic NaCl (3%) with a speed of approximately 1 mL / kg per hour.
1. b. Hypernatremia
Definition: serum Na + above normal (> 145 mEq / L)
Causa
* Happen if hypotonic fluids lost are not replaced adequately.
* If you are not losing fluids through the kidneys (lost through the gastrointestinal tract, sweat or hyperventilation), urine osmolality greater than serum, and urine sodium will be <20 mEq / L.
* Urine osmolality less than or equal to imply the loss of serum through the kidneys (eg, diuretic therapy, osmotic diuresis, diabetes insipidus, acute tubular sekrosis, uropati post-obstruction, nephropathy hiperkalsemik).
* Hypernatremia can occur with hyperalimentation or other hypertonic fluids.
Signs and Symptoms
Muscle irritability, confusion, ataxia, tremors, convulsions and coma secondary to hypernatremia. Additional common secondary manifestation of the basic abnormalities and volume status (tachycardia and orthostatic hypotension with volume depletion; edema when there is excess fluid).
Management of hypernatremia
* Hypernatremia with volume depletion must be overcome by giving normal saline until hemodynamic stability. Furthermore, water deficit can be corrected with 5% dextrose or hypotonic NaCl.
* Hypernatremia with excess volume treated with diuresis, or if necessary by dialysis. Dextrose 5% and then given to replace the water deficit.
* Body of water deficit was estimated as follows:
Deficit = body water (TBW) for the desired (liter) - the body of water current
Body of water required = (who measured serum Na) x (water body current / normal serum Na)
Water body now = 0.6 x BB now (kg)
* Half of the calculated water deficit should be administered within the first 24 hours, and the remaining deficit is corrected within one or two days to avoid cerebral edema.
1. Potassium
Total body potassium approximate 50 mEq / kg, 98% contained in the cell. Decrease in serum levels of 1 mEq K + compared with 10% to 20% total body potassium deficit.
1. a. Hypokalaemia
Definition: K + serum levels below normal (<3.5 mEq / L)
Etiology
* Loss of K + via GI tract (eg vomiting, nasogastrik suction, diarrhea, malabsorption syndrome, laxative abuse)
* Diuretics
* K + intake from the diet is not enough
* Excessive excretion through the kidneys
* Maldistribusi K +
* Hiperaldosteron
Clinical features
Weak (especially the proximal muscles), maybe arefleksia, orthostatic hypotension, decreased gastrointestinal motility that cause ileus. Hiperpolarisasi myokard occurs in hypokalemia and can cause ventricular ectopic beats, Reentry phenomena, and conduction abnormalities. ECG frequently showed flat T waves, U waves and ST segment depression. Hypokalaemia is also causing an increase in sensitivity of heart cells and can lead to digitalis toxicity at therapeutic levels.
Management of hypokalaemia
* Potassium deficit is difficult or impossible to be corrected if there hipomagnesia. This often happens on wasteful use of diuretics potassium. Magnesium should be replaced if low serum.
* Oral therapy. K + supplementation (20 mEq KCl) should be given at the beginning of diuretic therapy. Recheck K + concentration from 2 to 4 weeks after supplementation began.
* Intravenous therapy should be used for severe hypokalemia and in patients who can not stand with oral supplementation. With the speed of the following:
o If the levels of serum K +> 2.4 mEq / L and no ECG abnormalities, K + can be given with a speed of 0 to 20 mEq / h with a maximum of 200 mEq per day.
o In children 0.5 to 1 mEq / kg / dose in one hour. Doses should not exceed the maximum adult dose.
1. b. Hyperkalemia
Definition: K + serum levels above normal (> 5.5 mEq / L)
Etiology
* Inadequate renal excretion; eg in acute or chronic renal failure, potassium-saving diuretics, ACE inhibitors.
* Expenses of potassium from the cell necrosis caused massive trauma (crush injuries), major surgery, burns, acute arterial embolism, hemolysis, gastrointestinal bleeding or rhabdomyolisis. Exogenous sources include potassium supplementation and salt replacement, blood transfusions and high doses of penicillin should also be considered.
* The shift from intra-to extracellular; eg acidosis, digitalization, deficiency of insulin or a rapid increase in blood osmolality.
* Adrenal insufficiency
* Pseudohiperkalemia. Secondary to hemolysis of blood samples or installation is too long torniket
* Hipoaldosteron
Clinical features
The most important effect is the change of heart eksitabilitas. ECG shows sequential changes along with the elevation of serum potassium. In the beginning, looked sharp T wave (K +> 6.5 mEq / L). This was followed by a PR interval extends, the P wave amplitude decreases, widened QRS complex (K + = 7 to 8 mEq / L). QT interval lengthening and finally lead to a sine-wave pattern. Ventricular fibrillation and asistole tend to occur in K +> 10 mEq / L. Other findings include paresthesias, weakness, and paralysis ascending arefleksia.
Management of hyperkalemia
* Continuous ECG monitoring is recommended if any ECG abnormalities or if the serum potassium> 7 mEq / L
* Calcium gluconate can be given iv as a 10 ml solution of 10% over 10 minutes to stabilize the cardiac conduction system myocard
* Sodium bicarbonate makes the blood becomes alkaline and causes potassium to move from extra to intracellular. Bic nat as much as 40 to 150 mEq NaHCO3 iv for 30 minutes or as an iv bolus in the emergency
* Insulin causes the displacement of potassium from extracellular to intracellular fluid. 5 to 10 units of regular insulin with one ampoule should be given 50% glucose iv for 5 minutes
* Dialysis may be needed in severe and refractory cases of hyperkalemia
* Restrictions potassium is indicated at an advanced stage renal failure (GFR <15 ml / min)
1. III. Transfusion
Body response to hemorrhage depends on the volume, speed, and duration of bleeding. State of the patient before the bleeding will affect the responses given.
In healthy adults, bleeding 10% total blood volume did not cause changes in physical signs. Pulse rate, blood pressure, circulation, peripheral and central venous pressure remained unchanged. Receptors in the heart will detect this and cause a decrease in the volume of vasomotor centers to stimulate the sympathetic nervous system which in turn causes vasoconstriction.
Decrease in arterial blood pressure at the tip of the capillary causes the displacement of fluid into the interstitial space is reduced. Decrease in renal perfusion caused water retention and Na + ions. This causes the blood volume returns to normal within 12 hours. Plasma protein levels rapidly became normal within two weeks, there'll also be generating extra hemopoesis erythrocytes. This compensation process is very effective until the bleeding as much as 30%.
On the bleeding that occurred under 50% or the hematocrit is still above 20%, blood loss can still be replaced with a liquid colloid with colloid or crystalloid combinations are similar in composition to the blood of Ringer Lactate. However if blood loss> 50%, usually required a transfusion.
To replace the lost blood can be used in the basic formula of blood transfusion, namely:
V = (target Hb - Hb initials) x 80% x BB
Donor Hb
1. 1. Red blood cell transfusions
Indications of a red blood cell transfusions
* Acute blood loss
If blood is lost due to trauma or surgery, then either the replacement of red blood cells and blood volume needed. If more than half the blood volume hlang, the complete blood should be given, if less than half, then concentrate red blood cells or plasma expander is given.
* Blood transfusion prabedah
* Iron deficiency Anema
Patients with iron deficiency can not be transfused, unless it is required for immediate surgery or who fail to respond to treatment at full therapeutic doses of oral iron.
* Anemia associated with chronic disorders
* Kidney failure
Severe anemia associated with renal failure should be treated with transfusions of red blood cells as well as with the human recombinant eritropoetin.
* Failure of bone marrow
Patients with bone marrow failure due to leukemia, cytotoxic treatment, or infiltrating malignancy will require not only red blood cells, but also other blood components.
* Patients who are dependent trasnfusi
Patients with severe thalassemia syndrome, aplastic anemia, and anemia requiring transfusion sideroblastik regularly every four to six weeks, so they are able to live a normal life.
Patients with sickle cell month *
Some people with this disease requires trasnfusi regularly, especially after the stoke, for "chest syndrome" recurrent life-threatening, and during pregnancy.
* Neonatal hemolytic disease
Neonatal hemolytic disease can also be an indication for transfusion substitute, if the neonate had severe hyperbilirubinemia or anemia.
Various components of red blood cells
Component
Packaging vol blood cells
Given volume
The main indication
A complete blood
0.35 to 0.45
510 ml
Acute massive blood loss
Fresh blood
0.35 to 0.45
510 ml
Can not be proven
Concentrated red blood cells
0.55 to 0.75
Approximately 200 ml
Chronic blood loss or anemia
Filtered blood
varies
varies
Non-hemolytic transfusion reactions and the prevention of HLA immunization prior to transplantation
Washed red blood cells
varies
varies
Non-hemolytic transfusion reaction to plasma proteins
Red blood cells frozen, thawed and washed
varies
vary, but usually <200ml
Patients with rare antibody
Criteria transfusion with RBC concentrates
* Hb <8 g%
* Hb 80-10 g%, accompanied by sign of disturbance normovolemia myocardial, cerebral, respiratory
Great * Bleeding> 10 ml / kg in the first 1 hour or 5 ml / kg in the first three hours
Problems associated with transfusion of red blood cells
1. Urgent problem
* Expenses teradi circulation if the blood transfused too quickly so that rapid replacement of fluid redistribution occurs, or if there is cardiac dysfunction. Central venous pressure increased, and in cases of severe left ventricular failure
* Leakage of potassium out of the red blood cells during storage. This hyperkalemia dieksaserbasikan for blood storage at room temperature for too long
* Massive transfusion may cause hypothermia, toxicity, citric acid load, and shrinkage Platelet and coagulation factors
* Hemolytic reaction may cause fever, tachycardia, insomnia, sore groin, rigor, vomiting, diarrhea, headache, hypotension, shock, and eventually acute renal failure and bleeding due to DIC
* Raksi non-hemolytic can cause urticaria, fever and severe anaphylactic reactions, although rare
1. Medium-term problem
* Local phlebitis can occur if the plastic kanula abandoned in the same place too long. Sometimes an infection by the Staphylococcus or corinebacterium
* Hypertension and / or spasm syndrome is sometimes found in patients with sickle cell and b thalassemia major who received regular transfusions
* Infection can be transmitted by transfusion
1. Long-term problem
Iron burden. Every unit of blood contains 250 mg of iron that can not be excreted body. Regular transfusions can often cause tertimbunnya iron in the body resulting in pigmentation, growth inhibition in young people, hepatic cirrhosis, diabetes, hipoparatiroid, heart failure, arrhythmias, and ultimately death. Treatment with iron chelation should be considered in these patients before serious organ damage occurs.
1. Platelets Transfusion and Granulocyt
Platelet and granulocyte transfusions are necessary for patients with life-threatening thrombocytopenia and netropenia caused by bone marrow failure. This situation is probably a direct result of disease sufferers, such as acute leukemia, anemia aplastika, or bone marrow transplant.
Platelet transfusion indication
* Failure of bone marrow by disease or treatment yangdisebabkan mielotoksik
* Abnormalities of thrombocyte function
* Thrombocytopenia due to dilution
* Shortcuts cardiopulmonary
* Autoimmune thrombocytopenia purpura
Adverse effects on Platelet transfusion
Adverse effects on Platelet transfusion is the emergence kerefrakteran platelets, aloimunisasi, transmission of the disease and sometimes graft versus host disease.
Indications of granulocyte transfusion
* Neutropenia persistent and severe infections - If the neutrophil count kept less than 0.2 x 109 / L and there is clear evidence of bacterial or fungal infections that can not be controlled with proper medication use antibotik within 48-72 hours.
* Abnormal neutrophil function and persistent infection
* Neonatal Sepsis
Granulocyte transfusion adverse effects
Detrimental effect on the incidence of transfusion of granulocytes is aloimunisasi, transmission of infection, lung infiltration, and a graft versus host disease.
Introduction
By eating and drinking our body gets the water, electrolytes, carbohydrates, fats, vitamins and other substances. Within 24 hours the amount of water and electrolytes into and out through urine, feces, perspiration and breathing in adults steam about the same as in the table below.
Input (ml per 24 hours)
Output (ml per 24 hours)
Drink 800 - 1700 Urine 600 - 1600
Eating 500 -1000 Faeces 50-200
Oxidation 200-300 IWL 850-1200
Total 1500 - 3000 of 1500 - 3000
Fluid therapy is required if the body can not enter the water, electrolytes, and nutrients orally, for example on the state of the patient should be fasting a long time (for example because of surgery GI), bleeding a lot, hypovolemic shock, severe anorexia, nausea, vomiting continuously, etc. . With fluid therapy, water and electrolyte needs can be met. In addition, under certain circumstances, fluid therapy can be used as additional substances to include drugs and food regularly or can also be used to maintain acid-base balance.
Composition of Body Fluids
Water content at birth is around 75% BB and at the age of 1 month approximately 65% BB. The composition of body fluids in adult men is approximately 60% of body weight, while in adult women 50% BB. The rest are solid substances such as proteins, fats, carbohydrates, etc..
Water in the body are in several rooms, which amounted to 40% intracellular and extracellular by 20%. Extracellular fluid is a liquid contained in antarsel space (interstitial) equal to 15% and 5% plasma. Special antarsel fluid called cerebrospinal fluid, the liquid transeluler eg, joint fluid, peritoneal fluid, etc..
Intra-and extracellular fluid composition described in the table below:
CIS
CES
Plasma
Interstitial
Sodium
15
142
144
Potassium
150
4
4
Calcium
2
5
2.5
Magnesium
27
3
1.5
Clorida
1
103
114
HCO3
10
27
30
HPO4
100
2
2
SO4
20
1
1
Organic Acids
-
5
5
Water across the cell membrane easily, but other substances pass through it is difficult or requires a special process in order to cross it; therefore outside and electrolyte composition in different cells. Intracellular fluid contains many ions K, Mg and phosphate, whereas the extracellular fluid contains Na and Cl ions.
Plasma is blood minus blood cells such as erythrocytes, leukocytes and platelets. Serum is blood plasma minus clotting factors such as fibrinogen and protrombin. Hematocrit is a percentage of the volume of erythrocytes in the blood.
Water movement
Osmotic pressure is the pressure required to prevent leakage (diffusion) of fluid through a semipermeable membrane into another liquid that concentration is higher. Semipermeable membrane is a membrane that can pass water (solvent) but can not pass solutes such as proteins.
Plasma osmotic pressure was 285 ± 5 mOsm / L. Solution which has the same osmotic pressure is called an isotonic solution (eg 0.96% NaCl, dextran 5%, Ringer-Lactate), the solution has a lower osmotic pressure is called hypotonic solution (eg distilled water) and solutions that have a higher osmotic pressure is called condensation hypertonic.
Water Needs and Elekrolit
Basal fluid requirements (routine maintenance) is 30-40 ml / kg / day in adults. To determine the fluid requirements in children can use the following guidelines:
à 4 ml / kg / hour for the first weight 10 kg
à 2 ml / kg / hr added for the second weight 10 kg
à 1 ml / kg / hour for the remaining add further weight
Example
Patients with body weight 23 kg, hence the need basalnya fluid is:
(4 x 10) + (2 x 10) + (1 x 3) = 63 ml / hr
FLUID THERAPY
Definition
Fluid therapy is to maintain the action, replace the interior milieu within physiological limits.
Indication, among others:
- Acute loss of body fluids
- Loss of blood
- Anorexia
- Gastrointestinal disorders
Goal
The aim of fluid therapy described in the chart below.
Giving Techniques
The main priority in replacing the lost fluid volume is via the enteral route / physiology eg drinking or via NGT. For fluid therapy can be used in a short time the veins on the back of the hand, wrist area, forearm or cubital region. In small children and infants are often used areas of your foot, feet in front of the eyes or heads. Provision of fluid therapy in newborns can be done through the umbilical vein.
The use of needles anti-rust or anti trombogenik plastic catheters on peripheral veins usually need to be replaced every 1-3 days to avoid infection and jam drops. Giving intravenous fluids for more than three days should use big and long catheters inserted in the femoral vein, cubital vein, vena subclavia, external or internal jugular vein that ends as close as possible to the right atrium or the inferior or superior vena cava.
Nature-Substitute an Ideal Plasma Properties
The properties of the plasma is an ideal substitute:
* PH, pressure and viscosity comparable onkotik blood plasma
* Securities sufficient volume for a certain time period without the risk of overload on the cardiovascular system or edema
* Improving microcirculation and improve diuresis
* Do not disturb homeostasis
* Does not interfere with blood grouping and cross matching
* Accumulated a minimum of reticuloendothelial system
* Length of long-storage products
* Economical
Characteristics of Various Plasma Substitute
Criteria
Whole blood
Electrolyte solution
Albumin 20%
Dextran
40 +10
6% HES
Haemaccel
pH
7.3 to 7.4
5.5 to 6.5
6.47 to 7.2
4.5 to 5.7
5.0 to 7.0
7.0 to 7.6
The average BM
-
-
66 000
40 000
200 000 / 450,000
35 000
Physiological osmotic pressure of the Non-Iso-osmotic osmotic osmotic hyper-hyper-osmotic Iso-osmotic
Intravascular-interstitial fluid balance maintained edema Risk Dehydration Dehydration Repair Repair
Effective half-week A few days A few minutes A few days 12 hours 6-8 hours 4-6 hours
Disturbances in blood typing is usually not Pseudoaglu tinasi No No No No
There is the possibility of disruption of homeostasis (activation factor) Only pengence-bed-bed pengence Only Lowers Platelet function and coagulopathy Lowers Platelet function and coagulopathy Only dilution
Renal function
?
Recovery may be improved disturbed not found literature data Recovery
Overload cardiovascular Maybe Not Maybe Maybe Not likely No way
Possible side effects Anaphylaxis / incompatibility reaction kutis pulmonary edema, fever, hypotension while the need premedication Anaphylaxis Anaphylaxis or anaphylactic reaction to local skin reactions, hypotension while
Risk of transmission of viral diseases such as HIV, HBV, HCV No No No No No
Storage time 21 days 3 years 3-5 years 5 years 3 years 5 years
4-6 ° C storage temperature 2-25 ° C room temperature <25 ° C Room Temp Room Temp
Accumulation in RES No No No No Several weeks Several months
Advantages and Disadvantages of Plasma Substitute Various Preparations
1. 1. Whole blood
Excess
* The capacity of oxygen transport
* Capacity hemostatic
Shortage
* The provision of long
* Short storage time
* Minor to severe anaphylactic reactions
* Alloimunisasi
* Reaction hemolysis
* Reaction infection
* The viscosity increases
* Overload volume
* Hiperkalium, hiperkalsium, acidosis
Price * expensive
1. Electrolyte solution
Excess
* More easily available and cheap
* The composition similar to plasma (Ringer Acetate / Ringer Lactate)
* Can be stored in room temperature
* Free of anaphylactic reactions
* Complications of minimal
Shortage
* Edema can reduce chest wall ekspansibilitas
* Disturbed tissue oxygenation due to increased capillary and cell spacing
* Requires four times more volume
1. 3. Solution of human albumin
Excess
* The expansion of plasma volume without interstitial volume expansion
* Expansion of a larger volume
* A longer duration
* Better tissue oxygenation
* O2 alveolar-arterial gradient less
* The incidence of pulmonary edema or edema and lower systemic
Shortage
* Anaphylactic reaction
* Coagulopathy
* Albumin may aggravate myocardial depression shock patients
1. Dextran
Excess
* Securities or the volume of long length
* Anti-thrombotic effects
Shortage
* Expansion and dehydration ekstravaskuler interstitial compartment
* Impaired hemostasis
* Restrictions dose
* Fatal anaphylactic reactions
* Impaired renal function
* Accumulation in reticuloendothelial system
* Disturbances in blood grouping and cross matching
1. HES
Excess
* Securities or the volume of long length
* Anti-thrombotic effects
Shortage
* Expansion and dehydration ekstravaskuler interstitial compartment
* Impaired hemostasis
* Restrictions dose
* Fatal anaphylactic reactions
* Accumulation in reticuloendothelial system
1. Haemaccel
Excess
* Iso-osmotic
* Maintain fluid balance
* Securities optimal volume
* Improvement of renal function
* Does not interfere with hemostasis
* Does not interfere with blood grouping
* There was no accumulation in the RES
* Economical
Shortage
* Reaction anafilaktoid
Fluid Therapy Success
Fluid therapy which successfully described with the increase in cardiac index, oxygen transport and oxygen consumption as well as decreased pulmonary vascular resistance and systemic vascular resistance.
1. II. Electrolyte THERAPY
2. a. Hyponatremia
1. SODIUM
Definition: serum Na + levels below normal (<135 mEq / L)
Hyponatremia is divided into:
1) hyponatremia à artifactual false
Reported laboratory error caused by:
* Hyperglycemic
Correction value of sodium (any increase in blood glucose of 100 mg / dl to reduce the sodium by 1.7 mEq / L)
* Hiperlipidemi
The measured serum osmolality will be normal or greater than the calculated osmolality (OSM = [2 x Na] + [Glukosa/18] + [BUN / 2.8])
Second) à hipervolemia dilutional hyponatremia with total body water expansion
Hyponatremia is caused by impaired excretion of water, it appears as edema; eg CHF, renal impairment and nephrotic syndrome.
3) hypovolemic hyponatremia à exceeds sodium depletion, water depletion, eg in renal failure, hypothyroidism and Addison's disease.
4) à euvolemik hyponatremia sodium and water depletion in the number of comparable
This happened to lose water and sodium through the digestive tract (in vomit, suction nasogastrik, diarrhea), loss to third cavity (on burns, surgery), excessive sweating, kidney and adrenal diseases (in uncontrolled diabetes mellitus, hipoaldosteron, Addison's disease , the recovery phase of renal disease).
Clinical picture
* Clinical features and severity of hyponatremia depends on the initial speed.
* Symptoms are more pronounced in rapidly developing hyponatremia.
• If the plasma Na decreased 10 mEq / L within several hours, patients may be nausea, vomiting, headaches and muscle cramps.
* If the plasma Na decreased 10 mEq / L in one hour can lead to severe headaches, lethargy, seizures, disorientation and coma.
* Perhaps the patient has signs of basic diseases (such as heart failure, Addison's disease).
* If hyponatremia occurs secondary to loss of fluids, there may be signs of shock such as hypotension and tachycardia.
Management of hyponatremia
* Overcome the basic disease
* Stop any drugs that contributed to the hyponatremia
* Correction of the long-standing hyponatremia gradually, whereas the more aggressive acute hyponatremia. Avoid excessive correction because it can cause central pontine myelinolysis
* Do not raise the serum Na is faster than 12 mEq / L in 24 hours in asymptomatic patients. If the patient is symptomatic, could increase by 1 to 1.5 mEq / L / hour until symptoms subside. To increase the amount of sodium required to raise serum sodium to 125 mEq / L used the formula:
Total Na (mEq) = [125 mEq / L - actual serum Na (mEq / L)] x TBW (in liters)
TBW (Total Body Water) = 0.6 x body weight (in kg)
* Solution can be a substitute for NaCl 3% or 5% (each containing 0.51 mEq / ml and 0.86 mEq / ml)
* In patients with expansion of extracellular fluid, diuretics may dperlukan
* Hyponatremia can be corrected with hypertonic NaCl (3%) with a speed of approximately 1 mL / kg per hour.
1. b. Hypernatremia
Definition: serum Na + above normal (> 145 mEq / L)
Causa
* Happen if hypotonic fluids lost are not replaced adequately.
* If you are not losing fluids through the kidneys (lost through the gastrointestinal tract, sweat or hyperventilation), urine osmolality greater than serum, and urine sodium will be <20 mEq / L.
* Urine osmolality less than or equal to imply the loss of serum through the kidneys (eg, diuretic therapy, osmotic diuresis, diabetes insipidus, acute tubular sekrosis, uropati post-obstruction, nephropathy hiperkalsemik).
* Hypernatremia can occur with hyperalimentation or other hypertonic fluids.
Signs and Symptoms
Muscle irritability, confusion, ataxia, tremors, convulsions and coma secondary to hypernatremia. Additional common secondary manifestation of the basic abnormalities and volume status (tachycardia and orthostatic hypotension with volume depletion; edema when there is excess fluid).
Management of hypernatremia
* Hypernatremia with volume depletion must be overcome by giving normal saline until hemodynamic stability. Furthermore, water deficit can be corrected with 5% dextrose or hypotonic NaCl.
* Hypernatremia with excess volume treated with diuresis, or if necessary by dialysis. Dextrose 5% and then given to replace the water deficit.
* Body of water deficit was estimated as follows:
Deficit = body water (TBW) for the desired (liter) - the body of water current
Body of water required = (who measured serum Na) x (water body current / normal serum Na)
Water body now = 0.6 x BB now (kg)
* Half of the calculated water deficit should be administered within the first 24 hours, and the remaining deficit is corrected within one or two days to avoid cerebral edema.
1. Potassium
Total body potassium approximate 50 mEq / kg, 98% contained in the cell. Decrease in serum levels of 1 mEq K + compared with 10% to 20% total body potassium deficit.
1. a. Hypokalaemia
Definition: K + serum levels below normal (<3.5 mEq / L)
Etiology
* Loss of K + via GI tract (eg vomiting, nasogastrik suction, diarrhea, malabsorption syndrome, laxative abuse)
* Diuretics
* K + intake from the diet is not enough
* Excessive excretion through the kidneys
* Maldistribusi K +
* Hiperaldosteron
Clinical features
Weak (especially the proximal muscles), maybe arefleksia, orthostatic hypotension, decreased gastrointestinal motility that cause ileus. Hiperpolarisasi myokard occurs in hypokalemia and can cause ventricular ectopic beats, Reentry phenomena, and conduction abnormalities. ECG frequently showed flat T waves, U waves and ST segment depression. Hypokalaemia is also causing an increase in sensitivity of heart cells and can lead to digitalis toxicity at therapeutic levels.
Management of hypokalaemia
* Potassium deficit is difficult or impossible to be corrected if there hipomagnesia. This often happens on wasteful use of diuretics potassium. Magnesium should be replaced if low serum.
* Oral therapy. K + supplementation (20 mEq KCl) should be given at the beginning of diuretic therapy. Recheck K + concentration from 2 to 4 weeks after supplementation began.
* Intravenous therapy should be used for severe hypokalemia and in patients who can not stand with oral supplementation. With the speed of the following:
o If the levels of serum K +> 2.4 mEq / L and no ECG abnormalities, K + can be given with a speed of 0 to 20 mEq / h with a maximum of 200 mEq per day.
o In children 0.5 to 1 mEq / kg / dose in one hour. Doses should not exceed the maximum adult dose.
1. b. Hyperkalemia
Definition: K + serum levels above normal (> 5.5 mEq / L)
Etiology
* Inadequate renal excretion; eg in acute or chronic renal failure, potassium-saving diuretics, ACE inhibitors.
* Expenses of potassium from the cell necrosis caused massive trauma (crush injuries), major surgery, burns, acute arterial embolism, hemolysis, gastrointestinal bleeding or rhabdomyolisis. Exogenous sources include potassium supplementation and salt replacement, blood transfusions and high doses of penicillin should also be considered.
* The shift from intra-to extracellular; eg acidosis, digitalization, deficiency of insulin or a rapid increase in blood osmolality.
* Adrenal insufficiency
* Pseudohiperkalemia. Secondary to hemolysis of blood samples or installation is too long torniket
* Hipoaldosteron
Clinical features
The most important effect is the change of heart eksitabilitas. ECG shows sequential changes along with the elevation of serum potassium. In the beginning, looked sharp T wave (K +> 6.5 mEq / L). This was followed by a PR interval extends, the P wave amplitude decreases, widened QRS complex (K + = 7 to 8 mEq / L). QT interval lengthening and finally lead to a sine-wave pattern. Ventricular fibrillation and asistole tend to occur in K +> 10 mEq / L. Other findings include paresthesias, weakness, and paralysis ascending arefleksia.
Management of hyperkalemia
* Continuous ECG monitoring is recommended if any ECG abnormalities or if the serum potassium> 7 mEq / L
* Calcium gluconate can be given iv as a 10 ml solution of 10% over 10 minutes to stabilize the cardiac conduction system myocard
* Sodium bicarbonate makes the blood becomes alkaline and causes potassium to move from extra to intracellular. Bic nat as much as 40 to 150 mEq NaHCO3 iv for 30 minutes or as an iv bolus in the emergency
* Insulin causes the displacement of potassium from extracellular to intracellular fluid. 5 to 10 units of regular insulin with one ampoule should be given 50% glucose iv for 5 minutes
* Dialysis may be needed in severe and refractory cases of hyperkalemia
* Restrictions potassium is indicated at an advanced stage renal failure (GFR <15 ml / min)
1. III. Transfusion
Body response to hemorrhage depends on the volume, speed, and duration of bleeding. State of the patient before the bleeding will affect the responses given.
In healthy adults, bleeding 10% total blood volume did not cause changes in physical signs. Pulse rate, blood pressure, circulation, peripheral and central venous pressure remained unchanged. Receptors in the heart will detect this and cause a decrease in the volume of vasomotor centers to stimulate the sympathetic nervous system which in turn causes vasoconstriction.
Decrease in arterial blood pressure at the tip of the capillary causes the displacement of fluid into the interstitial space is reduced. Decrease in renal perfusion caused water retention and Na + ions. This causes the blood volume returns to normal within 12 hours. Plasma protein levels rapidly became normal within two weeks, there'll also be generating extra hemopoesis erythrocytes. This compensation process is very effective until the bleeding as much as 30%.
On the bleeding that occurred under 50% or the hematocrit is still above 20%, blood loss can still be replaced with a liquid colloid with colloid or crystalloid combinations are similar in composition to the blood of Ringer Lactate. However if blood loss> 50%, usually required a transfusion.
To replace the lost blood can be used in the basic formula of blood transfusion, namely:
V = (target Hb - Hb initials) x 80% x BB
Donor Hb
1. 1. Red blood cell transfusions
Indications of a red blood cell transfusions
* Acute blood loss
If blood is lost due to trauma or surgery, then either the replacement of red blood cells and blood volume needed. If more than half the blood volume hlang, the complete blood should be given, if less than half, then concentrate red blood cells or plasma expander is given.
* Blood transfusion prabedah
* Iron deficiency Anema
Patients with iron deficiency can not be transfused, unless it is required for immediate surgery or who fail to respond to treatment at full therapeutic doses of oral iron.
* Anemia associated with chronic disorders
* Kidney failure
Severe anemia associated with renal failure should be treated with transfusions of red blood cells as well as with the human recombinant eritropoetin.
* Failure of bone marrow
Patients with bone marrow failure due to leukemia, cytotoxic treatment, or infiltrating malignancy will require not only red blood cells, but also other blood components.
* Patients who are dependent trasnfusi
Patients with severe thalassemia syndrome, aplastic anemia, and anemia requiring transfusion sideroblastik regularly every four to six weeks, so they are able to live a normal life.
Patients with sickle cell month *
Some people with this disease requires trasnfusi regularly, especially after the stoke, for "chest syndrome" recurrent life-threatening, and during pregnancy.
* Neonatal hemolytic disease
Neonatal hemolytic disease can also be an indication for transfusion substitute, if the neonate had severe hyperbilirubinemia or anemia.
Various components of red blood cells
Component
Packaging vol blood cells
Given volume
The main indication
A complete blood
0.35 to 0.45
510 ml
Acute massive blood loss
Fresh blood
0.35 to 0.45
510 ml
Can not be proven
Concentrated red blood cells
0.55 to 0.75
Approximately 200 ml
Chronic blood loss or anemia
Filtered blood
varies
varies
Non-hemolytic transfusion reactions and the prevention of HLA immunization prior to transplantation
Washed red blood cells
varies
varies
Non-hemolytic transfusion reaction to plasma proteins
Red blood cells frozen, thawed and washed
varies
vary, but usually <200ml
Patients with rare antibody
Criteria transfusion with RBC concentrates
* Hb <8 g%
* Hb 80-10 g%, accompanied by sign of disturbance normovolemia myocardial, cerebral, respiratory
Great * Bleeding> 10 ml / kg in the first 1 hour or 5 ml / kg in the first three hours
Problems associated with transfusion of red blood cells
1. Urgent problem
* Expenses teradi circulation if the blood transfused too quickly so that rapid replacement of fluid redistribution occurs, or if there is cardiac dysfunction. Central venous pressure increased, and in cases of severe left ventricular failure
* Leakage of potassium out of the red blood cells during storage. This hyperkalemia dieksaserbasikan for blood storage at room temperature for too long
* Massive transfusion may cause hypothermia, toxicity, citric acid load, and shrinkage Platelet and coagulation factors
* Hemolytic reaction may cause fever, tachycardia, insomnia, sore groin, rigor, vomiting, diarrhea, headache, hypotension, shock, and eventually acute renal failure and bleeding due to DIC
* Raksi non-hemolytic can cause urticaria, fever and severe anaphylactic reactions, although rare
1. Medium-term problem
* Local phlebitis can occur if the plastic kanula abandoned in the same place too long. Sometimes an infection by the Staphylococcus or corinebacterium
* Hypertension and / or spasm syndrome is sometimes found in patients with sickle cell and b thalassemia major who received regular transfusions
* Infection can be transmitted by transfusion
1. Long-term problem
Iron burden. Every unit of blood contains 250 mg of iron that can not be excreted body. Regular transfusions can often cause tertimbunnya iron in the body resulting in pigmentation, growth inhibition in young people, hepatic cirrhosis, diabetes, hipoparatiroid, heart failure, arrhythmias, and ultimately death. Treatment with iron chelation should be considered in these patients before serious organ damage occurs.
1. Platelets Transfusion and Granulocyt
Platelet and granulocyte transfusions are necessary for patients with life-threatening thrombocytopenia and netropenia caused by bone marrow failure. This situation is probably a direct result of disease sufferers, such as acute leukemia, anemia aplastika, or bone marrow transplant.
Platelet transfusion indication
* Failure of bone marrow by disease or treatment yangdisebabkan mielotoksik
* Abnormalities of thrombocyte function
* Thrombocytopenia due to dilution
* Shortcuts cardiopulmonary
* Autoimmune thrombocytopenia purpura
Adverse effects on Platelet transfusion
Adverse effects on Platelet transfusion is the emergence kerefrakteran platelets, aloimunisasi, transmission of the disease and sometimes graft versus host disease.
Indications of granulocyte transfusion
* Neutropenia persistent and severe infections - If the neutrophil count kept less than 0.2 x 109 / L and there is clear evidence of bacterial or fungal infections that can not be controlled with proper medication use antibotik within 48-72 hours.
* Abnormal neutrophil function and persistent infection
* Neonatal Sepsis
Granulocyte transfusion adverse effects
Detrimental effect on the incidence of transfusion of granulocytes is aloimunisasi, transmission of infection, lung infiltration, and a graft versus host disease.
NUTRITIONAL THERAPY IN Criticality
-------------------- Nutrition Needs in Normal Condition
1. 1. Estimating caloric needs
Formulas TEE = BEE x AF x SF
TEE = total energy expenditure
BEE = basal energy expenditure
AF = activity factor
SF = stress factor
Empirical formula: 30-35 kcal / kg / day
BEE by Harris Benedict equation
Male
BEE = 66.47 + (13.75 x BB MLP kg) + (5.0 x TB MLP cm) - (6.67 x age in the year)
Woman
+ BEE = 655.1 (9.56 x BW MLP kg) + (1.85 cm x TB MLP) - (4.68 X age in the year)
1. 2. Estimating protein requirements
Age of amino acids
(G / kg / day)
Preterm neonates 3.0
Infants 0-1 years 05.02
Children 2-13 years 1.5 - 2.0
Teenagers 1.0 - 1.5
Adult 0.8 - 1.0
1. 3. Estimating the lipid requirement
Requirements of fat = 20% from the total caloric needs
Unsaturated fats: saturated fat = 2: 1
Composition: monounsaturated FA and essential fatty
Parenteral nutrition: fat as a source of calories and essential fatty acids (glycerol)
Dose: 1-3 g / kg / day
Not given when the blood triglyceride levels> 400 mg / dl
1. 4. Estimating the needs of vitamins and minerals
2. 5. Estimating fluid requirements
Age (years) liquid Needs
(Ml / kg / day)
Active young adults 16-30 40
Adults average 25-55 35
Patients older than 55-65 30
Elderly> 65 25
---------------- Nutritional Needs of Specific Clinical Condition
General Metabolic Stress - Trauma
Overall, the physiological response to trauma is an increase in biochemical and metabolic processes of normal, so that usually an increase in nutrient needs are quite large. If not received adequate nutritional support, many patients will lose weight and there complications that often prove fatal. The main objective of nutrition support therapy is to keep weight to a minimum in hopes of preventing complications and reducing morbidity and mortality.
Nutrition and energy needs
Energy requirement / total daily calories can be calculated from the sum of basal caloric needs (BMR), stress factors, physical activity, and specific dynamic action (SDA).
KK = JSC + FS + AF + SDA
KK = the total caloric requirement
CLA = basal caloric requirement
FS = factor of stress
AF = Physical activity
SDA = specific dynamic action
Basal caloric requirement is obtained by calculating BMR based on Harris-Benedict equation.
Stress factors assessed based on the assessment of nutritional status and metabolic status. To simplify, stress factors are categorized in:
* The degree of 10-30%, mild stress
* The degree of stress being 31-50%
* The degree of stress weight ³ 51%
Traumatic stress is classified into, so the stress factor for trauma is 31-50%. Multiple traumatic stress factor is 50%.
Physical activity: when a patient should be in bed, physical activity 10%, while when not in bed, physical activity was 20%.
SDA of food depending on the type of food provided. SDA parenteral nutrition is 0% while the SDA for enteral formulas and food peroral approximately 10-20%.
Protein
In the trauma occurred relatively constant protein catabolism that is 10-20% of energy output. Input protein for healthy people (0.8 to 1 g / kg / hr) did not provide for patients who are experiencing trauma because of an increase in protein turnover. Protein needs for patients with trauma when there is no kidney and liver disorders are 1.5 to 2 g / kg / hr, with non-nitrogen ratio of calories: nitrogen = 100:1.
Fat
Fat serves as a source of energy. Various studies indicate that administration of lipid emulsion for 30-40% of total calories is the optimal amount. To prevent deficiency of essential fatty acids, essential fatty acids need to be given as much of 4-8% of total calories daily.
Carbohydrate
Carbs also function as an energy source. Given the number of carbohydrates is reduced need for total calories derived from fat. In patients with trauma, carbohydrate is 40% of total daily calories.
Fluids and Electrolytes
Fluid requirements are ± 1 500 ml per m2 body surface area per day, then added if there was an increased insensible loss through perspiration, diarrhea, or feeding tubes.
Intracellular saline and electrolytes should be administered in adequate amounts. Levels of potassium, phosphorus and magnesium in plasma and whole body should be maintained to remain normal in order to get the expected response with the provision of nutritional support.
Vitamins and Trace Elements
Therefore an increase in metabolism, the need vitamn B increases. Thiamine and niacin needs related to caloric intake. In trauma, there is increased excretion of zinc (zinc) are assumed to come from the catabolism of muscle tissue. This condition can cause zinc deficiency, so that trauma patients need to receive supplemental trace elements.
Special Metabolic Stress
To be able to perform the role and functions in the body, nutrients through metabolic processes in stages, namely:
- Digestion (digestion)
- Uptake (absorption)
- Change (Degradation)
- The use of organs / cells (utilization)
- Spending the remaining substances (excretion)
Each phase of metabolism carried out by different organs, such as stage of digestion and absorption by the gastrointestinal organs. Changes are made primarily by the liver; use by all organs; expenditure remaining substances mainly by the kidneys and lower gastrointestinal tract.
1. A. Digestibility Channels Organ Disorders
The main function of the GI tract are digestion and absorption by secreting enzymes specific for each nutrient. Upper gastrointestinal tract mainly absorb major nutrients; whereas lower GI tract mainly absorbs water, minerals and some vitamins.
1. B. Liver Disorders
Liver is an important organ in the process of degradation of nutrients because it is a major organ that metabolizes nutrients and secreting enzymes that play a role in the metabolism of carbohydrates, proteins and fats and are responsible for 20% basal metabolism. Liver to synthesize several plasma proteins that are important and bile salts and play a role in detoksikasi.
Penyekit liver disorders can be grouped into
- Acute liver disease such as hepatitis virus
- Chronic liver disease such as liver cirrhosis
1. C. Kidney Disorders
Renal excretion represents the largest organ and also as an organ regulating body fluid balance. Disturbances in the kidneys will cause interference with the excretion of the remains of the metabolism especially the metabolism of protein and fluid and electrolyte disturbances.
Enteral Nutrition Therapy -----------------------------
Enteral nutrition compared to parenteral Benefits
1. Physiological
Enteral nutrition is physiological, because the food enters the body through normal digestive tract, so that the function and structure of the digestive equipment is maintained. In contrast, total parenteral nutrition can cause atrophy of the small intestine mucosa and pancreas, especially in providing long because the food into your hearts beyond the appliance digestibility (by pass from the outside in the liver).
1. More effective
Enteral nutrition is more effective. This is evidenced by rapid weight gain and N balance are fast becoming positive. In addition, the rapid increase in the immunity will be found on enteral nutrition.
1. Less complications
Complications of enteral nutrition is much lower when compared with parenteral nutrition. Parenteral nutrition in addition to requiring strict monitoring, complication-komplkasi of sepsis, thrombosis, hematoma, metabolic disorders such as pneumothoraks and hypoglycemia or hyperglycemia was not uncommon.
1. High calorie convenient
With high-calorie enteral nutrition needs of more than 3000 kcal / day which can be easily filled with parenteral very difficult to achieve without complications and a watchful eye. This high caloric needs in patients with hipermetabolik such as sepsis, multiple trauma, or burns. In addition, the provision of high-calorie parenteral nutrition often cause fatty liver are not observed in enteral nutrition.
1. The technique is easy
Installation of gastric sonde can be easily performed by any doctor or nurse without stringent sterility requirements. While parenteral administration must be given through a large vein that is located profundal with high sterility. IBHS only be done by a trained doctor.
1. Low costs
Enteral nutrition on average 10-20 times cheaper than parenteral nutrition.
Terms of enteral nutrition
1. Has a caloric density tnggi
Because enteral nutrition should be given through a small sonde, it must be liquid so easily through the sonde. In order for this liquid enteral nutrition still have enough calories, then it must have a high caloric density. Thus, with the volume that is not too large, the number of calories was achieved. The ideal calorie density is 1 kcal / ml liquid.
1. Balanced nutritional content
That is, the minimum amount for basic needs (2000 kcal) should already contain all the components of essential nutrients such as proteins, amino acids, fats, vitamins, electrolytes and other elements in accordance with the number of needs.
1. Has the same osmolarity osmolarity of body fluids
An enteral nutrition which has a high osmolarity easily cause diarrhea because your body fluids will be drawn into lumen of the intestine. Therefore, the ideal osmolarity is 350-400 m osmol, according to the osmolarity of extracellular fluids.
1. Easy resorption
Raw materials an enteral nutrition should consist of the components ready absorbed or at least very little need for digestive activity can be absorbed. In other words, the molecules are small.
1. Without or less contain fiber and lactose
An enteral nutrition should have little or no contain fiber to be effective and efficient. Enteral nutrition that contains a lot of fiber will be the bulk which in turn will increase the frequency of defecation.
To avoid lactose intolerance often occurs in people with malnutrition, enteral nutrition should be a less or without containing lactose, or lactose content of only the highest 0.5% of the total karbohdrat.
1. Enteral nutrition that is free from materials that contain purine and cholesterol
Technical procedures enteral nutrition / diet sonde
1. Election sonde
Before the 1980s sonde which is available generally made of polyethylene, PVC or latex. Lack of-sonde sonde is in addition to a large diameter, sonde easily become stiff after pelemasnya substances discharged (after 24 hours of usage), is also not resistant to the influence of gastric or duodenal fluid. Which becomes rigid sonde will be very annoying because apart from the patient feels uncomfortable can also cause erosion or airway injury, or gastrointestinal tract.
Currently-sonde sonde used for enteral nutrition made from silicone or polyurethane, which in addition to the small diameter (2.5 mm), supple and long-lasting flexibility and resistance to gastric fluid and duodenal fluid.
1. Techniques of enteral nutrition
Techniques of a drop is the most secure. Old patterns that give scara bolus contains many complications such as vomiting, regurgitation to aspiration into the lungs, especially in patients with a decreased consciousness or in patients who lie down. In order to reduce the above complications, the patient should be positioned a half-sitting for enteral nutrition.
To maintain accuracy and drops of liquid enteral nutrition assessment can be used in a portable pump. In order to keep receiving bowel tolerance, enteral nutrition fluid levels should be increased gradually. Starting with a dilution of ½ on the first day, then dilutions of two thirds on the second day and full dose on the third day onwards, while supervising and evaluating complaints and symptoms that arise.
1. Caloric requirement
Basal metabolic needs can be calculated with Broca index, as follows:
BMR = stress index (height - 100) x 20
Stress index: - post-surgical + 10% BMR
- Fracture of multiple + 25-30% BMR
- Sepsis, each increase of 1 ° +10% BMR
So, a 165 cm height without stress has a BMR (165-100) x20 = 1300 kcal. By adding 10-20% of the required BMR caloric requirements can be obtained when the activity is very limited. While at a high catabolic state required the addition of 30-100% of BMR requirements.
1. Monitoring
Progress or deterioration of general condition patients were evaluated every day, including fluid and electrolyte balance when there are facilities. Measurement of weight or upper arm circumference (lla) each week represents an objective parameter.
In addition, laboratory examination is necessary, among others:
a. Blood: Hb, Hmt, leukocyte
b. Serum: glucose, urea, total protein, albumin, total
c. Routine urine volume and
Indications of enteral nutrition
Surgical indications, ie, post-surgical:
- Mouth
- Esophagus
- Gastric
- Bile duct
- Colon
Non-surgical indications:
- Anorexia
- Severe depression
- Traumatic head / brain
- Extensive burns
- Sepsis
- Cancer patients
- Malabsorption / maldigesti
- Fistulas
- Patients with extreme calorie needs
Enteral nutrition Kontrandikasi
- Vomiting
- Ileus
- An acute gastrointestinal bleeding
- Peritonitis
- Post-surgical Atoni
Complications of enteral nutrition
1. Mechanical complications
Mechanical complications associated with sondenya own that can be experienced dislocation or obstruction.
1. Complications of chemical
This is related to the osmolarity and chemical composition of enteral nutrition fluids that are too high. Nausea to vomiting and stomach cramps or diarrhea is a prominent symptom.
1. Complications bacteriological
Contamination with gram-negative bacteria at the time of the provision of enteral nutrition or plastic bags can cause septic shock.
1. Metabolic complications
Hypertonic dehydration can occur if the composition of nutrients enteralnya memilki high osmolarity. Giving levels gradually can reduce this complication.
Parenteral Nutrition Therapy ---------------------------
Parenteral nutrition is the delivery of nutrients through the veins. Mode of administration can be via a peripheral vein (peripheral parenteral nutrist) or central vein (total parenteral nutrition).
The conditions require parenteral nutrition
- Ileus obstruction
- Peritonitis
- Fistulas enterokutan
- Severe malabsorption syndrome
- Vomitus
- Severe diarrhea
- Malnutrition protein or protein-calorie
- Malignancy
Indications of parenteral nutrition
- Disturbed gastrointestinal function (not able to digest or absorb food)
- NPO> 3-5 days
- Supplementation of enteral nutrition
Contraindication to parenteral nutrition
Parenteral nutrition should not be given in circumstances of crisis such as hemodynamic shock or dehydration are not yet resolved
The approach used in parenteral nutrition is 4 Right - 1 Alert
1. Right patient
Every patient that is not enough or no oral intake, parenteral nutrition should immediately get (NPE). NPE total dose should be given more slowly (beginning the third day) because a large metabolic load. This is true in patients with trauma, sepsis, extensive post-surgical, preeclampsia, eklampsi, etc..
1. Precise indication
When should NPE can be given? When not given? When selected NPE NPE total and partial when selected?
NPE partial doses can be given very early, ie 24 hours after trauma or crisis can be overcome gravity. This 24-hour period is a time of Ebb-phase, a period of stabilization in which the stress hormone levels are still high. Cells resistant to insulin and glucose levels increased. In severe cases the patient's condition, the more slowly the total NPE can begin. Before the relaxed state is achieved, the total NPE will only add stress to the patient. Quiet phase was characterized by decreasing levels of cortisol, catecholamines and glucagon.
1. Appropriate drugs / substrates
Materials used nutrients are carbohydrates, amino acids, fat emulsion, minerals and vitamins.
1. Right dose
Quebbeman (1982) found in patients with severe trauma and sepsis are experiencing catabolism, resting energy expenditure ranged kkal/m2/hari 1000. This is equivalent to 1700 kcal in patients 70 kg with 1.73 m2 of body area or approximately 25 kcal / day. In order to draw N is not too negative, given a minimum of 20 kcal / kg / day. Appropriate dose should be measured. Dose can then be increased gradually by observing changes in blood sugar levels, the general state of the patient, examination of the concentration of potassium and sodium.
For the avoidance of hyperglycemia, increased glucose 5% to 20% must be gradual "start low, go slow". Glucose load stimulates pancreatic insulin release. If other fluids interspersed glucose solution then likely fluctuating blood sugar levels insulin karean overshoot from time to time. So that fluctuations in blood sugar levels vary as minimum as possible, divided equally carbohydrate solution in 24 hours.
1. Wary of side effects
In contrast to healthy people who can manage the balance of food and her own needs, of patients with special nutritional assistance was forced to accept all that is given. If options or incorrect dose, or by giving false, complications that may arise will cause morbidity and even death.
1. Frequently encountered complication is hyperglycemia
Hyperglycemia generally occurs if the pattern of "start low, go slow" is not followed. This disorder can be accompanied by an osmotic diuresis and hyperosmolar state. In extreme cases, coma can occur.
1. Tromboflebitis easy to follow inflammatory irritation
Plasma osmolarity of 300 mOsm. The higher the osmolarity, the easier it happened tromboflebitis, even thromboembolism. Peripheral venous can receive up to 900 mOsm. For liquids> 900-1000 mOsm if necessary more than five days, should use central venous (vena cava, subclavia, jugular) in which the blood flows so fast that the speed of the dense liquid droplets NPE could not damage the vein. 900-1000 mOsm fluids for short term 3-5 days can still be given via the venous hand but do not give through leg veins. Prone to venous leg deep vein thrombosis and thromboembolism. Osmolarity can be reduced by mixing liquids using infusion sets branched.
Complications of parenteral nutrition
- Technical complications associated with catheterization, such as pneumothoraks, air embolism
- Complications of infection characterized by fever as phlebitis, infection at the installation site
- Complications associated with metabolic disorders of glucose balance (hyper / hypo), electrolytes (hypokalemia, hyperkalemia)
1. 1. Estimating caloric needs
Formulas TEE = BEE x AF x SF
TEE = total energy expenditure
BEE = basal energy expenditure
AF = activity factor
SF = stress factor
Empirical formula: 30-35 kcal / kg / day
BEE by Harris Benedict equation
Male
BEE = 66.47 + (13.75 x BB MLP kg) + (5.0 x TB MLP cm) - (6.67 x age in the year)
Woman
+ BEE = 655.1 (9.56 x BW MLP kg) + (1.85 cm x TB MLP) - (4.68 X age in the year)
1. 2. Estimating protein requirements
Age of amino acids
(G / kg / day)
Preterm neonates 3.0
Infants 0-1 years 05.02
Children 2-13 years 1.5 - 2.0
Teenagers 1.0 - 1.5
Adult 0.8 - 1.0
1. 3. Estimating the lipid requirement
Requirements of fat = 20% from the total caloric needs
Unsaturated fats: saturated fat = 2: 1
Composition: monounsaturated FA and essential fatty
Parenteral nutrition: fat as a source of calories and essential fatty acids (glycerol)
Dose: 1-3 g / kg / day
Not given when the blood triglyceride levels> 400 mg / dl
1. 4. Estimating the needs of vitamins and minerals
2. 5. Estimating fluid requirements
Age (years) liquid Needs
(Ml / kg / day)
Active young adults 16-30 40
Adults average 25-55 35
Patients older than 55-65 30
Elderly> 65 25
---------------- Nutritional Needs of Specific Clinical Condition
General Metabolic Stress - Trauma
Overall, the physiological response to trauma is an increase in biochemical and metabolic processes of normal, so that usually an increase in nutrient needs are quite large. If not received adequate nutritional support, many patients will lose weight and there complications that often prove fatal. The main objective of nutrition support therapy is to keep weight to a minimum in hopes of preventing complications and reducing morbidity and mortality.
Nutrition and energy needs
Energy requirement / total daily calories can be calculated from the sum of basal caloric needs (BMR), stress factors, physical activity, and specific dynamic action (SDA).
KK = JSC + FS + AF + SDA
KK = the total caloric requirement
CLA = basal caloric requirement
FS = factor of stress
AF = Physical activity
SDA = specific dynamic action
Basal caloric requirement is obtained by calculating BMR based on Harris-Benedict equation.
Stress factors assessed based on the assessment of nutritional status and metabolic status. To simplify, stress factors are categorized in:
* The degree of 10-30%, mild stress
* The degree of stress being 31-50%
* The degree of stress weight ³ 51%
Traumatic stress is classified into, so the stress factor for trauma is 31-50%. Multiple traumatic stress factor is 50%.
Physical activity: when a patient should be in bed, physical activity 10%, while when not in bed, physical activity was 20%.
SDA of food depending on the type of food provided. SDA parenteral nutrition is 0% while the SDA for enteral formulas and food peroral approximately 10-20%.
Protein
In the trauma occurred relatively constant protein catabolism that is 10-20% of energy output. Input protein for healthy people (0.8 to 1 g / kg / hr) did not provide for patients who are experiencing trauma because of an increase in protein turnover. Protein needs for patients with trauma when there is no kidney and liver disorders are 1.5 to 2 g / kg / hr, with non-nitrogen ratio of calories: nitrogen = 100:1.
Fat
Fat serves as a source of energy. Various studies indicate that administration of lipid emulsion for 30-40% of total calories is the optimal amount. To prevent deficiency of essential fatty acids, essential fatty acids need to be given as much of 4-8% of total calories daily.
Carbohydrate
Carbs also function as an energy source. Given the number of carbohydrates is reduced need for total calories derived from fat. In patients with trauma, carbohydrate is 40% of total daily calories.
Fluids and Electrolytes
Fluid requirements are ± 1 500 ml per m2 body surface area per day, then added if there was an increased insensible loss through perspiration, diarrhea, or feeding tubes.
Intracellular saline and electrolytes should be administered in adequate amounts. Levels of potassium, phosphorus and magnesium in plasma and whole body should be maintained to remain normal in order to get the expected response with the provision of nutritional support.
Vitamins and Trace Elements
Therefore an increase in metabolism, the need vitamn B increases. Thiamine and niacin needs related to caloric intake. In trauma, there is increased excretion of zinc (zinc) are assumed to come from the catabolism of muscle tissue. This condition can cause zinc deficiency, so that trauma patients need to receive supplemental trace elements.
Special Metabolic Stress
To be able to perform the role and functions in the body, nutrients through metabolic processes in stages, namely:
- Digestion (digestion)
- Uptake (absorption)
- Change (Degradation)
- The use of organs / cells (utilization)
- Spending the remaining substances (excretion)
Each phase of metabolism carried out by different organs, such as stage of digestion and absorption by the gastrointestinal organs. Changes are made primarily by the liver; use by all organs; expenditure remaining substances mainly by the kidneys and lower gastrointestinal tract.
1. A. Digestibility Channels Organ Disorders
The main function of the GI tract are digestion and absorption by secreting enzymes specific for each nutrient. Upper gastrointestinal tract mainly absorb major nutrients; whereas lower GI tract mainly absorbs water, minerals and some vitamins.
1. B. Liver Disorders
Liver is an important organ in the process of degradation of nutrients because it is a major organ that metabolizes nutrients and secreting enzymes that play a role in the metabolism of carbohydrates, proteins and fats and are responsible for 20% basal metabolism. Liver to synthesize several plasma proteins that are important and bile salts and play a role in detoksikasi.
Penyekit liver disorders can be grouped into
- Acute liver disease such as hepatitis virus
- Chronic liver disease such as liver cirrhosis
1. C. Kidney Disorders
Renal excretion represents the largest organ and also as an organ regulating body fluid balance. Disturbances in the kidneys will cause interference with the excretion of the remains of the metabolism especially the metabolism of protein and fluid and electrolyte disturbances.
Enteral Nutrition Therapy -----------------------------
Enteral nutrition compared to parenteral Benefits
1. Physiological
Enteral nutrition is physiological, because the food enters the body through normal digestive tract, so that the function and structure of the digestive equipment is maintained. In contrast, total parenteral nutrition can cause atrophy of the small intestine mucosa and pancreas, especially in providing long because the food into your hearts beyond the appliance digestibility (by pass from the outside in the liver).
1. More effective
Enteral nutrition is more effective. This is evidenced by rapid weight gain and N balance are fast becoming positive. In addition, the rapid increase in the immunity will be found on enteral nutrition.
1. Less complications
Complications of enteral nutrition is much lower when compared with parenteral nutrition. Parenteral nutrition in addition to requiring strict monitoring, complication-komplkasi of sepsis, thrombosis, hematoma, metabolic disorders such as pneumothoraks and hypoglycemia or hyperglycemia was not uncommon.
1. High calorie convenient
With high-calorie enteral nutrition needs of more than 3000 kcal / day which can be easily filled with parenteral very difficult to achieve without complications and a watchful eye. This high caloric needs in patients with hipermetabolik such as sepsis, multiple trauma, or burns. In addition, the provision of high-calorie parenteral nutrition often cause fatty liver are not observed in enteral nutrition.
1. The technique is easy
Installation of gastric sonde can be easily performed by any doctor or nurse without stringent sterility requirements. While parenteral administration must be given through a large vein that is located profundal with high sterility. IBHS only be done by a trained doctor.
1. Low costs
Enteral nutrition on average 10-20 times cheaper than parenteral nutrition.
Terms of enteral nutrition
1. Has a caloric density tnggi
Because enteral nutrition should be given through a small sonde, it must be liquid so easily through the sonde. In order for this liquid enteral nutrition still have enough calories, then it must have a high caloric density. Thus, with the volume that is not too large, the number of calories was achieved. The ideal calorie density is 1 kcal / ml liquid.
1. Balanced nutritional content
That is, the minimum amount for basic needs (2000 kcal) should already contain all the components of essential nutrients such as proteins, amino acids, fats, vitamins, electrolytes and other elements in accordance with the number of needs.
1. Has the same osmolarity osmolarity of body fluids
An enteral nutrition which has a high osmolarity easily cause diarrhea because your body fluids will be drawn into lumen of the intestine. Therefore, the ideal osmolarity is 350-400 m osmol, according to the osmolarity of extracellular fluids.
1. Easy resorption
Raw materials an enteral nutrition should consist of the components ready absorbed or at least very little need for digestive activity can be absorbed. In other words, the molecules are small.
1. Without or less contain fiber and lactose
An enteral nutrition should have little or no contain fiber to be effective and efficient. Enteral nutrition that contains a lot of fiber will be the bulk which in turn will increase the frequency of defecation.
To avoid lactose intolerance often occurs in people with malnutrition, enteral nutrition should be a less or without containing lactose, or lactose content of only the highest 0.5% of the total karbohdrat.
1. Enteral nutrition that is free from materials that contain purine and cholesterol
Technical procedures enteral nutrition / diet sonde
1. Election sonde
Before the 1980s sonde which is available generally made of polyethylene, PVC or latex. Lack of-sonde sonde is in addition to a large diameter, sonde easily become stiff after pelemasnya substances discharged (after 24 hours of usage), is also not resistant to the influence of gastric or duodenal fluid. Which becomes rigid sonde will be very annoying because apart from the patient feels uncomfortable can also cause erosion or airway injury, or gastrointestinal tract.
Currently-sonde sonde used for enteral nutrition made from silicone or polyurethane, which in addition to the small diameter (2.5 mm), supple and long-lasting flexibility and resistance to gastric fluid and duodenal fluid.
1. Techniques of enteral nutrition
Techniques of a drop is the most secure. Old patterns that give scara bolus contains many complications such as vomiting, regurgitation to aspiration into the lungs, especially in patients with a decreased consciousness or in patients who lie down. In order to reduce the above complications, the patient should be positioned a half-sitting for enteral nutrition.
To maintain accuracy and drops of liquid enteral nutrition assessment can be used in a portable pump. In order to keep receiving bowel tolerance, enteral nutrition fluid levels should be increased gradually. Starting with a dilution of ½ on the first day, then dilutions of two thirds on the second day and full dose on the third day onwards, while supervising and evaluating complaints and symptoms that arise.
1. Caloric requirement
Basal metabolic needs can be calculated with Broca index, as follows:
BMR = stress index (height - 100) x 20
Stress index: - post-surgical + 10% BMR
- Fracture of multiple + 25-30% BMR
- Sepsis, each increase of 1 ° +10% BMR
So, a 165 cm height without stress has a BMR (165-100) x20 = 1300 kcal. By adding 10-20% of the required BMR caloric requirements can be obtained when the activity is very limited. While at a high catabolic state required the addition of 30-100% of BMR requirements.
1. Monitoring
Progress or deterioration of general condition patients were evaluated every day, including fluid and electrolyte balance when there are facilities. Measurement of weight or upper arm circumference (lla) each week represents an objective parameter.
In addition, laboratory examination is necessary, among others:
a. Blood: Hb, Hmt, leukocyte
b. Serum: glucose, urea, total protein, albumin, total
c. Routine urine volume and
Indications of enteral nutrition
Surgical indications, ie, post-surgical:
- Mouth
- Esophagus
- Gastric
- Bile duct
- Colon
Non-surgical indications:
- Anorexia
- Severe depression
- Traumatic head / brain
- Extensive burns
- Sepsis
- Cancer patients
- Malabsorption / maldigesti
- Fistulas
- Patients with extreme calorie needs
Enteral nutrition Kontrandikasi
- Vomiting
- Ileus
- An acute gastrointestinal bleeding
- Peritonitis
- Post-surgical Atoni
Complications of enteral nutrition
1. Mechanical complications
Mechanical complications associated with sondenya own that can be experienced dislocation or obstruction.
1. Complications of chemical
This is related to the osmolarity and chemical composition of enteral nutrition fluids that are too high. Nausea to vomiting and stomach cramps or diarrhea is a prominent symptom.
1. Complications bacteriological
Contamination with gram-negative bacteria at the time of the provision of enteral nutrition or plastic bags can cause septic shock.
1. Metabolic complications
Hypertonic dehydration can occur if the composition of nutrients enteralnya memilki high osmolarity. Giving levels gradually can reduce this complication.
Parenteral Nutrition Therapy ---------------------------
Parenteral nutrition is the delivery of nutrients through the veins. Mode of administration can be via a peripheral vein (peripheral parenteral nutrist) or central vein (total parenteral nutrition).
The conditions require parenteral nutrition
- Ileus obstruction
- Peritonitis
- Fistulas enterokutan
- Severe malabsorption syndrome
- Vomitus
- Severe diarrhea
- Malnutrition protein or protein-calorie
- Malignancy
Indications of parenteral nutrition
- Disturbed gastrointestinal function (not able to digest or absorb food)
- NPO> 3-5 days
- Supplementation of enteral nutrition
Contraindication to parenteral nutrition
Parenteral nutrition should not be given in circumstances of crisis such as hemodynamic shock or dehydration are not yet resolved
The approach used in parenteral nutrition is 4 Right - 1 Alert
1. Right patient
Every patient that is not enough or no oral intake, parenteral nutrition should immediately get (NPE). NPE total dose should be given more slowly (beginning the third day) because a large metabolic load. This is true in patients with trauma, sepsis, extensive post-surgical, preeclampsia, eklampsi, etc..
1. Precise indication
When should NPE can be given? When not given? When selected NPE NPE total and partial when selected?
NPE partial doses can be given very early, ie 24 hours after trauma or crisis can be overcome gravity. This 24-hour period is a time of Ebb-phase, a period of stabilization in which the stress hormone levels are still high. Cells resistant to insulin and glucose levels increased. In severe cases the patient's condition, the more slowly the total NPE can begin. Before the relaxed state is achieved, the total NPE will only add stress to the patient. Quiet phase was characterized by decreasing levels of cortisol, catecholamines and glucagon.
1. Appropriate drugs / substrates
Materials used nutrients are carbohydrates, amino acids, fat emulsion, minerals and vitamins.
1. Right dose
Quebbeman (1982) found in patients with severe trauma and sepsis are experiencing catabolism, resting energy expenditure ranged kkal/m2/hari 1000. This is equivalent to 1700 kcal in patients 70 kg with 1.73 m2 of body area or approximately 25 kcal / day. In order to draw N is not too negative, given a minimum of 20 kcal / kg / day. Appropriate dose should be measured. Dose can then be increased gradually by observing changes in blood sugar levels, the general state of the patient, examination of the concentration of potassium and sodium.
For the avoidance of hyperglycemia, increased glucose 5% to 20% must be gradual "start low, go slow". Glucose load stimulates pancreatic insulin release. If other fluids interspersed glucose solution then likely fluctuating blood sugar levels insulin karean overshoot from time to time. So that fluctuations in blood sugar levels vary as minimum as possible, divided equally carbohydrate solution in 24 hours.
1. Wary of side effects
In contrast to healthy people who can manage the balance of food and her own needs, of patients with special nutritional assistance was forced to accept all that is given. If options or incorrect dose, or by giving false, complications that may arise will cause morbidity and even death.
1. Frequently encountered complication is hyperglycemia
Hyperglycemia generally occurs if the pattern of "start low, go slow" is not followed. This disorder can be accompanied by an osmotic diuresis and hyperosmolar state. In extreme cases, coma can occur.
1. Tromboflebitis easy to follow inflammatory irritation
Plasma osmolarity of 300 mOsm. The higher the osmolarity, the easier it happened tromboflebitis, even thromboembolism. Peripheral venous can receive up to 900 mOsm. For liquids> 900-1000 mOsm if necessary more than five days, should use central venous (vena cava, subclavia, jugular) in which the blood flows so fast that the speed of the dense liquid droplets NPE could not damage the vein. 900-1000 mOsm fluids for short term 3-5 days can still be given via the venous hand but do not give through leg veins. Prone to venous leg deep vein thrombosis and thromboembolism. Osmolarity can be reduced by mixing liquids using infusion sets branched.
Complications of parenteral nutrition
- Technical complications associated with catheterization, such as pneumothoraks, air embolism
- Complications of infection characterized by fever as phlebitis, infection at the installation site
- Complications associated with metabolic disorders of glucose balance (hyper / hypo), electrolytes (hypokalemia, hyperkalemia)
HEALTHY HOSPITAL SEEN FROM CULTURE perceptual
INTRODUCTION
Health development as one of national development efforts directed to achieve the awareness, willingness and ability to live healthy for every citizen in order to achieve optimal health status. And so that health becomes everybody's dream all his life. But illness is something that can not be denied though sometimes they can be prevented or avoided. The concept of healthy and sick actually not so absolute and universal because there are other factors outside the clinical reality that affecting mainly socio-cultural factors. Both understanding interplay and understanding that one can only be understood in the context of understanding the other.
Many scholars of philosophy, biology, anthropology, sociology, medicine, and other fields of science have tried to give understanding about the concept of healthy and sick evaluated from their respective disciplines. Healthy and sick problem is a process associated with the ability or inability of humans beradap-tation to the environment either through biological, psychological and socio cultural.
Act No.23, 1992 on Health states that: Health is a prosperous state of body, soul and social life that enable socially and economically unproductive. In this sense, the health should be viewed as one unified whole composed of elements of physical, mental and social and mental health within it is an integral part of health. Definition of pain: a person is said to hurt when he suffered a chronic disease (chronic), or other health problems that cause work activities / activities disrupted. Although a person sick (everyday terms) such as colds, runny nose, but if he had not bothered to carry out its activities, it is considered not ill.
HEALTH AND ILLNESS PROBLEMS
Health problems is a complex problem which is the resultant of various environmental problems that are natural or man-made problems, socio-cultural, behavioral, population, genetics, and so forth. Public health degrees are referred to as the psycho socio somatic health well being, is the resultant of four factors:
1. Environment or the environment.
2. Behavior or behavior, between the first and the second is connected with the ecological balance.
3. Heredity or offspring that are influenced by population, population distribution, and so forth.
4. Health care services such as health programs that are preventive, promotive, curative and rehabilitative.
Of the four factors mentioned above, environmental and behavioral factors that most influence (dominant) to level of community health status. Ill behavior, role and the role of patient pain is influenced by factors such as social class, ethnic origin and culture differences. So the same health threats (defined clinically), depending on these variables can cause different reactions among patients.
Understanding of illness can be explained by naturalistic etiology in terms of impersonal and systematic, that pain is one state or one thing that is caused by disruption of the human body systems. The statement about this knowledge in the classical tradition of Greece, India, China, shows a model of balance (equilibrium model) a person is considered healthy if the main elements of hot and cold in the body in a state of balance. The main elements are included in the concept of humors, ayurveda dosha, yin and yang. Department of Health has launched a new policy based on health paradigm
1. Health paradigm is
How to view or mindset that health development is holistic, proactive, anticipatory, by looking at health issues as a problem that is influenced by many factors in a dynamic and cross-sectoral, in an area that is oriented to the improvement of maintenance and protection of the population to stay healthy and healing not only people who are sick. At its core health paradigm provides the main focus of the policy are prevention and health promotion, providing support and allocation of resources to keep a healthy stay healthy but still seek immediate ill health. In principle, the policy is to put emphasis on community health activities than on treating disease. Understanding of the disease have been developed that have a biomedical and socio cultural connotations
In English the word was known disease and illness while in the Indonesian language, both understanding it is called disease. Seen from the socio cultural aspects there are big differences between these two terms. With disease or dysfunction is intended adaptation of biological processes and psikofisiologik in an individual, with the illness referred to the reaction of personal, interpersonal, and cultural to the illness or feeling uncomfortable
The doctors diagnose and treat disease, whereas patients had illness that can be caused by disease, illness was not always accompanied by organic or functional disorders of the body.
This paper is a literature review that discusses the health-illness knowledge on cultural and social aspects of human behavior, and specifically on the interaction between some of these aspects which have influence on health and disease. In a cultural context, the so-called healthy in a healthy culture is not necessarily also in other cultures. Here can not be ignored any valuation factor or factors that are closely related to the value system.
HEALTHY CONCEPT BY CULTURE COMMUNITY HOSPITAL
Healthy term contains many cargo cultural, social and professional understanding of the diverse. First from the point of view of medicine, health is closely associated with pain and disease. In fact it is not that simple, sound must be viewed from various aspects. WHO's view of various aspects of health.
WHO definition (1981): Health is a state of complete physical, mental and social well-being, and note merely the absence of disease or infirmity. WHO defines health as the notion of a perfectly good state of physical, spiritual, and social welfare of a person.
To the extent where someone can be considered complete physical?, By medical experts, medical anthropology is seen as a discipline biobudaya who pays attention to those aspects of biological and socio-culture of human behavior, particularly about ways of interaction between the two throughout the history of human life that affect health and disease. The disease itself is determined by culture: this is because the disease is the social recognition that one can not reasonably run its normal role. Ways of life and human lifestyles are phenomena that can be associated with the emergence of various diseases, besides the results of different cultures can also cause disease.
Community and traditional healers embracing two concepts of cause of illness, namely: Naturalistic and Personalistik. The cause is Naturalistic ie a person suffering from pain caused by environment, food (one meal), living habits, imbalances in the body, including trust as incoming wind chills and congenital disease. The concept of healthy pain embraced traditional healers (Battra) similar to those adopted for the local community, ie, a condition associated with a state agency or state body disorders and symptoms. Healthy for a person means a state of normal, natural, comfortable, and able to perform daily activities with a passion. While the illness is considered as a state body that is less pleasant, even perceived as an ordeal that causes a person unable to perform everyday activities as well as healthy people.
While the emergence of the concept considers Personalistik disease (illness) is caused by the intervention of an active agent that can form non-human beings (ghosts, spirits, ancestors or evil spirits), or human beings (witches, fortune-teller).
Tracing cultural values, for example concerning the introduction of leprosy and the way maintenance. Leprosy has been known by the ethnic Makasar long time. The existence of the term kaddala sikuyu (leprosy crabs) and kaddala massolong (leprosy is melted), is an expression of that support that leprosy is endemic have been in a long time among the community.
Results of qualitative and quantitative research on cultural values Soppeng district, in conjunction with leprosy (Kaddala, BGS.) In Bugis society show that arise and are strictly diamalkannya leprophobia because according to one cultural figure, in marriage advice old people there, said kaddala come included. Mentioned that if there is a violation to have sex when the wife is menstruating, they (the bride) will be cursed and suffer from leprosy / kaddala. The idea that aims to create great moral in a new family, follow the process of developing communication in society and become the concept of leprosy patients as the person in sin. Understanding the patient as a result of sins of the mother-father are suffering due leprophobia early. Low self-esteem of people with low self-esteem started families who feel tainted when one family member suffering from leprosy. Accused of sinning intercourse when the wife is menstruating for a fanatical Islam is perceived as psychosomatic trauma load is very heavy.
Parents, family is refusing her son was diagnosed with leprosy. In the study of Health Service Use in the Province of East Kalimantan and West Nusa Tenggara (1990), the results of focus group discussions in East Kalimantan showed that the child otherwise sick if crying continues, the body sweats, do not want to eat, not sleep, fussy, haggard. For adults, a person otherwise ill when he could not work, unable to walk, not malaise, chills, headache, malaise, anemia, cough, nausea, diarrhea. While the results of discussion groups in West Nusa Tenggara showed that visits sick children from the physical state of body and behavior that is if the show symptoms such as hot, cold cough, diarrhea, vomiting, itching, wounds, dental swelling, yellow body, leg and abdominal swelling .
A traditional healer who also accept the view of modern medicine, has an interesting knowledge about the problem of ill-health. For him, the meaning of illness are as follows: bodily pain means there are signs of the disease in the body such as high fever, weak eyesight, not strong working, trouble eating, disturbed sleep, and the body is weak or ill, the wish was lying or just rest. Mental illness does not exist on the signs on his body, but can be known by asking the unseen. In a healthy person, his movements agile, powerful work, the normal body temperature, eating and sleeping normally, vision light, bright eyes, do not complain listless, weak, or sick-sick body.
Sudarti (1987) outlines some regions descriptive perceptions in Indonesia about illness and disease, people assume that the pain is a state of individuals experienced a series of physical problems that cause discomfort. Sick child's behavior is marked with a fussy, crying and no appetite. Adults are considered sick if lethargic, unable to work, loss of appetite, or "dry bag" (no money). Furthermore, classifying the cause of sick society into three parts, namely:
1. Because the effects of natural phenomena (heat, cold) on the human body
2. Foods are classified into hot and cold food.
3. Supernatural (spirits, witchcraft, demons, etc..).
To treat pain that is included in the first and second groups, can be used in medicines, herbs, massage, scrape, food taboos, and help health workers. To cause pain to the three must be requested assistance shaman, Kyai and others. Thus, efforts to overcome it depends on their belief in the cause of illness. Some examples of diseases in babies and children as follows:
a. Sick with a fever and heat.
The reason is the change in the weather, rain, wrong meal, or catch a cold. Treatment is a way to compress with ice, Oyong, white pumpkin cold or influenza drug purchases. In Indramayu say cool although the symptoms of heat illness is high, so the heat down. Tampek diseases (measles) is also called sick cool because the symptoms of heat loss.
b. Sick diarrhea (diarrhea).
The cause is wrong to eat, eat nuts too much, eating spicy food, eating shrimp, fish, children increased their versatility, stale milk, dilute, and others. Birds in the example of traditional medicine with the chewed guava leaves, shoots his mother and given to his son (Bima Nusa Tenggara Barat) is another drug Sugar Salt Solution (LGG), Oralit, Ciba pills and others. Sugar Salt Solution was known simply not appropriate mixture proportions.
c. Spasm pain
Society in general stated that fever and seizures caused by a ghost. In Sukabumi called ghost pliers, while in West Sumatra caused by evil ghosts. Indramayu in treatment is to go to a shaman or put the baby down-covered bed nets.
d. Tampek illness (measles)
The reason is that children exposed to heat in, children bathed during the heat, or kesambet. In Indramayu treat mothers with children with acid membalur kawak, give to drink honey and lemon or give suwuk leaves, which according to the trust can suck disease.
DISEASE EVENTS
The disease is a complex phenomenon which adversely affect human life. Human behavior and way of life can be a cause of various diseases both in age and in the primitive society that are very advanced civilization and culture.
Viewed from the aspect of disease is biological abnormalities various human organs, while in terms of societal ill considered a behavioral deviation from normative social situation. Deviations can be caused by abnormalities of organs biomedical or human environment, but also can be caused by emotional disorders and psychosocial individuals concerned. Emotional and psychosocial factors are essentially the result of environmental or human ecosystems and human or cultural customs.
The concept of disease incidence by health sciences depending on the type of disease. In general, this conception is determined by various factors such as parasites, vectors, humans and their environment. Anthropologists from the definition of health that may be mentioned to the ecology-oriented, concerned with the reciprocal relationship between humans and the natural environment, illness behavior and the ways the disease affects the behavior of its cultural evolution through the feedback process (Foster, Anderson, 1978).
The disease can be viewed as an element in the human environment, as seen in sickle-cell trait (sickle-cell) among the population of West Africa, an adaptive evolutionary changes, which provide relative immunity to malaria. Sickle cell trait was not a threat, even a desirable characteristic because it gives high protection against the Anopheles mosquito bites.
For the people of Dani in Papua, the disease can be a positive social symbol, which are given specific values. Aetiology of disease can be explained by magic, but also as a result of sin. Social symbol can also be a source of disease. In modern civilization, the relationship between symbols of social and health risks often seem obvious, such as teenage smoking.
A study of the relationship between psychiatry and anthropology in the context of social change written by Rudi schoo (1994), based on his own experiences as a psychiatrist, one of the following case: A woman who was old enough reumatiknya treated only with vitamins and fish oil alone and believe the illness will cured. According to the patient's illness caused by "dirty blood" therefore the only way of healing is by eating clean food, that is `mutih '(plus the vitamins necessary to prevent vitamin deficiency) until the blood becomes clean again. For a doctor's opinion does not make sense, but that's the fact that there is in society.
Health development as one of national development efforts directed to achieve the awareness, willingness and ability to live healthy for every citizen in order to achieve optimal health status. And so that health becomes everybody's dream all his life. But illness is something that can not be denied though sometimes they can be prevented or avoided. The concept of healthy and sick actually not so absolute and universal because there are other factors outside the clinical reality that affecting mainly socio-cultural factors. Both understanding interplay and understanding that one can only be understood in the context of understanding the other.
Many scholars of philosophy, biology, anthropology, sociology, medicine, and other fields of science have tried to give understanding about the concept of healthy and sick evaluated from their respective disciplines. Healthy and sick problem is a process associated with the ability or inability of humans beradap-tation to the environment either through biological, psychological and socio cultural.
Act No.23, 1992 on Health states that: Health is a prosperous state of body, soul and social life that enable socially and economically unproductive. In this sense, the health should be viewed as one unified whole composed of elements of physical, mental and social and mental health within it is an integral part of health. Definition of pain: a person is said to hurt when he suffered a chronic disease (chronic), or other health problems that cause work activities / activities disrupted. Although a person sick (everyday terms) such as colds, runny nose, but if he had not bothered to carry out its activities, it is considered not ill.
HEALTH AND ILLNESS PROBLEMS
Health problems is a complex problem which is the resultant of various environmental problems that are natural or man-made problems, socio-cultural, behavioral, population, genetics, and so forth. Public health degrees are referred to as the psycho socio somatic health well being, is the resultant of four factors:
1. Environment or the environment.
2. Behavior or behavior, between the first and the second is connected with the ecological balance.
3. Heredity or offspring that are influenced by population, population distribution, and so forth.
4. Health care services such as health programs that are preventive, promotive, curative and rehabilitative.
Of the four factors mentioned above, environmental and behavioral factors that most influence (dominant) to level of community health status. Ill behavior, role and the role of patient pain is influenced by factors such as social class, ethnic origin and culture differences. So the same health threats (defined clinically), depending on these variables can cause different reactions among patients.
Understanding of illness can be explained by naturalistic etiology in terms of impersonal and systematic, that pain is one state or one thing that is caused by disruption of the human body systems. The statement about this knowledge in the classical tradition of Greece, India, China, shows a model of balance (equilibrium model) a person is considered healthy if the main elements of hot and cold in the body in a state of balance. The main elements are included in the concept of humors, ayurveda dosha, yin and yang. Department of Health has launched a new policy based on health paradigm
1. Health paradigm is
How to view or mindset that health development is holistic, proactive, anticipatory, by looking at health issues as a problem that is influenced by many factors in a dynamic and cross-sectoral, in an area that is oriented to the improvement of maintenance and protection of the population to stay healthy and healing not only people who are sick. At its core health paradigm provides the main focus of the policy are prevention and health promotion, providing support and allocation of resources to keep a healthy stay healthy but still seek immediate ill health. In principle, the policy is to put emphasis on community health activities than on treating disease. Understanding of the disease have been developed that have a biomedical and socio cultural connotations
In English the word was known disease and illness while in the Indonesian language, both understanding it is called disease. Seen from the socio cultural aspects there are big differences between these two terms. With disease or dysfunction is intended adaptation of biological processes and psikofisiologik in an individual, with the illness referred to the reaction of personal, interpersonal, and cultural to the illness or feeling uncomfortable
The doctors diagnose and treat disease, whereas patients had illness that can be caused by disease, illness was not always accompanied by organic or functional disorders of the body.
This paper is a literature review that discusses the health-illness knowledge on cultural and social aspects of human behavior, and specifically on the interaction between some of these aspects which have influence on health and disease. In a cultural context, the so-called healthy in a healthy culture is not necessarily also in other cultures. Here can not be ignored any valuation factor or factors that are closely related to the value system.
HEALTHY CONCEPT BY CULTURE COMMUNITY HOSPITAL
Healthy term contains many cargo cultural, social and professional understanding of the diverse. First from the point of view of medicine, health is closely associated with pain and disease. In fact it is not that simple, sound must be viewed from various aspects. WHO's view of various aspects of health.
WHO definition (1981): Health is a state of complete physical, mental and social well-being, and note merely the absence of disease or infirmity. WHO defines health as the notion of a perfectly good state of physical, spiritual, and social welfare of a person.
To the extent where someone can be considered complete physical?, By medical experts, medical anthropology is seen as a discipline biobudaya who pays attention to those aspects of biological and socio-culture of human behavior, particularly about ways of interaction between the two throughout the history of human life that affect health and disease. The disease itself is determined by culture: this is because the disease is the social recognition that one can not reasonably run its normal role. Ways of life and human lifestyles are phenomena that can be associated with the emergence of various diseases, besides the results of different cultures can also cause disease.
Community and traditional healers embracing two concepts of cause of illness, namely: Naturalistic and Personalistik. The cause is Naturalistic ie a person suffering from pain caused by environment, food (one meal), living habits, imbalances in the body, including trust as incoming wind chills and congenital disease. The concept of healthy pain embraced traditional healers (Battra) similar to those adopted for the local community, ie, a condition associated with a state agency or state body disorders and symptoms. Healthy for a person means a state of normal, natural, comfortable, and able to perform daily activities with a passion. While the illness is considered as a state body that is less pleasant, even perceived as an ordeal that causes a person unable to perform everyday activities as well as healthy people.
While the emergence of the concept considers Personalistik disease (illness) is caused by the intervention of an active agent that can form non-human beings (ghosts, spirits, ancestors or evil spirits), or human beings (witches, fortune-teller).
Tracing cultural values, for example concerning the introduction of leprosy and the way maintenance. Leprosy has been known by the ethnic Makasar long time. The existence of the term kaddala sikuyu (leprosy crabs) and kaddala massolong (leprosy is melted), is an expression of that support that leprosy is endemic have been in a long time among the community.
Results of qualitative and quantitative research on cultural values Soppeng district, in conjunction with leprosy (Kaddala, BGS.) In Bugis society show that arise and are strictly diamalkannya leprophobia because according to one cultural figure, in marriage advice old people there, said kaddala come included. Mentioned that if there is a violation to have sex when the wife is menstruating, they (the bride) will be cursed and suffer from leprosy / kaddala. The idea that aims to create great moral in a new family, follow the process of developing communication in society and become the concept of leprosy patients as the person in sin. Understanding the patient as a result of sins of the mother-father are suffering due leprophobia early. Low self-esteem of people with low self-esteem started families who feel tainted when one family member suffering from leprosy. Accused of sinning intercourse when the wife is menstruating for a fanatical Islam is perceived as psychosomatic trauma load is very heavy.
Parents, family is refusing her son was diagnosed with leprosy. In the study of Health Service Use in the Province of East Kalimantan and West Nusa Tenggara (1990), the results of focus group discussions in East Kalimantan showed that the child otherwise sick if crying continues, the body sweats, do not want to eat, not sleep, fussy, haggard. For adults, a person otherwise ill when he could not work, unable to walk, not malaise, chills, headache, malaise, anemia, cough, nausea, diarrhea. While the results of discussion groups in West Nusa Tenggara showed that visits sick children from the physical state of body and behavior that is if the show symptoms such as hot, cold cough, diarrhea, vomiting, itching, wounds, dental swelling, yellow body, leg and abdominal swelling .
A traditional healer who also accept the view of modern medicine, has an interesting knowledge about the problem of ill-health. For him, the meaning of illness are as follows: bodily pain means there are signs of the disease in the body such as high fever, weak eyesight, not strong working, trouble eating, disturbed sleep, and the body is weak or ill, the wish was lying or just rest. Mental illness does not exist on the signs on his body, but can be known by asking the unseen. In a healthy person, his movements agile, powerful work, the normal body temperature, eating and sleeping normally, vision light, bright eyes, do not complain listless, weak, or sick-sick body.
Sudarti (1987) outlines some regions descriptive perceptions in Indonesia about illness and disease, people assume that the pain is a state of individuals experienced a series of physical problems that cause discomfort. Sick child's behavior is marked with a fussy, crying and no appetite. Adults are considered sick if lethargic, unable to work, loss of appetite, or "dry bag" (no money). Furthermore, classifying the cause of sick society into three parts, namely:
1. Because the effects of natural phenomena (heat, cold) on the human body
2. Foods are classified into hot and cold food.
3. Supernatural (spirits, witchcraft, demons, etc..).
To treat pain that is included in the first and second groups, can be used in medicines, herbs, massage, scrape, food taboos, and help health workers. To cause pain to the three must be requested assistance shaman, Kyai and others. Thus, efforts to overcome it depends on their belief in the cause of illness. Some examples of diseases in babies and children as follows:
a. Sick with a fever and heat.
The reason is the change in the weather, rain, wrong meal, or catch a cold. Treatment is a way to compress with ice, Oyong, white pumpkin cold or influenza drug purchases. In Indramayu say cool although the symptoms of heat illness is high, so the heat down. Tampek diseases (measles) is also called sick cool because the symptoms of heat loss.
b. Sick diarrhea (diarrhea).
The cause is wrong to eat, eat nuts too much, eating spicy food, eating shrimp, fish, children increased their versatility, stale milk, dilute, and others. Birds in the example of traditional medicine with the chewed guava leaves, shoots his mother and given to his son (Bima Nusa Tenggara Barat) is another drug Sugar Salt Solution (LGG), Oralit, Ciba pills and others. Sugar Salt Solution was known simply not appropriate mixture proportions.
c. Spasm pain
Society in general stated that fever and seizures caused by a ghost. In Sukabumi called ghost pliers, while in West Sumatra caused by evil ghosts. Indramayu in treatment is to go to a shaman or put the baby down-covered bed nets.
d. Tampek illness (measles)
The reason is that children exposed to heat in, children bathed during the heat, or kesambet. In Indramayu treat mothers with children with acid membalur kawak, give to drink honey and lemon or give suwuk leaves, which according to the trust can suck disease.
DISEASE EVENTS
The disease is a complex phenomenon which adversely affect human life. Human behavior and way of life can be a cause of various diseases both in age and in the primitive society that are very advanced civilization and culture.
Viewed from the aspect of disease is biological abnormalities various human organs, while in terms of societal ill considered a behavioral deviation from normative social situation. Deviations can be caused by abnormalities of organs biomedical or human environment, but also can be caused by emotional disorders and psychosocial individuals concerned. Emotional and psychosocial factors are essentially the result of environmental or human ecosystems and human or cultural customs.
The concept of disease incidence by health sciences depending on the type of disease. In general, this conception is determined by various factors such as parasites, vectors, humans and their environment. Anthropologists from the definition of health that may be mentioned to the ecology-oriented, concerned with the reciprocal relationship between humans and the natural environment, illness behavior and the ways the disease affects the behavior of its cultural evolution through the feedback process (Foster, Anderson, 1978).
The disease can be viewed as an element in the human environment, as seen in sickle-cell trait (sickle-cell) among the population of West Africa, an adaptive evolutionary changes, which provide relative immunity to malaria. Sickle cell trait was not a threat, even a desirable characteristic because it gives high protection against the Anopheles mosquito bites.
For the people of Dani in Papua, the disease can be a positive social symbol, which are given specific values. Aetiology of disease can be explained by magic, but also as a result of sin. Social symbol can also be a source of disease. In modern civilization, the relationship between symbols of social and health risks often seem obvious, such as teenage smoking.
A study of the relationship between psychiatry and anthropology in the context of social change written by Rudi schoo (1994), based on his own experiences as a psychiatrist, one of the following case: A woman who was old enough reumatiknya treated only with vitamins and fish oil alone and believe the illness will cured. According to the patient's illness caused by "dirty blood" therefore the only way of healing is by eating clean food, that is `mutih '(plus the vitamins necessary to prevent vitamin deficiency) until the blood becomes clean again. For a doctor's opinion does not make sense, but that's the fact that there is in society.
HEALTHY CONCEPTS - ILLNESS
A. Understanding
1. Healthy according to WHO 1974
Health is the perfect state of physical, mental, social, not just freedom from disease, disability and weakness.
2. Law treatments were: N0. 23/1992 on health
health is a prosperous state of the body (physical), soul (spiritual) and social that allows every person living in a socially and economically productive.
3. Pepkin's
Health is a state of dynamic balance between form and function of the body that can make adjustments, so that it can overcome the interference from outside.
4. According to Law No.3/1961 mental health is a condition that allows the development of physical, intellectual, emotional and optimal development of a person's current state of harmony with others.
5. Social health is an ability to live together with the community surrounding.
6. Physical health is a state where physical form and function, there is no disturbance to enable development psychological, and social and can carry out daily activities optimally.
In accordance with a healthy understanding of the above can be concluded that health consists of three dimensions: physical, psychological and social can be interpreted more positively, in other words that a person is given the opportunity to develop the broadest capabilities brought from birth to obtain or interpret healthy .
Although there are a lot of the definition, the concept of health is not standard or standard and is absolutely unacceptable and the public. What is considered normal by someone still might be considered abnormal by others, each person / group / community has its own benchmark in interpreting health. Many people live healthy despite lacking economic status, living place that is dirty and noisy, they do not complain of interference even after weighed badanya below normal weight. This explanation shows that the concept is relatively healthy varied widely among people, although in one room / area.
Healthy can not be interpreted something static, settled on a particular condition, but healthy things to be considered a dynamic phenomenon. Health as a spectrum is a condition between the body and mental flexibility that is engaged in a range that is always fluctuating or swinging toward and away from the peak of happiness in life than a perfectly healthy state.
Healthy as a spectrum, Pepkins defines health as the state of dynamic equilibrium of the body and its functions as a result of the dynamic adjustment of the forces that tend to be disturbed. Body someone works actively to defend themselves in order to stay healthy, so health should always be maintained. Here are steps health spectrum:
Positive Health
Better Health
Freedom from Sickness
Spectrum
Health
Unrecognized Sickness
Mild Sickness
Severe Sickness
Death
Concept of Illness
A. Understanding
1. Perkins defines pain as an unpleasant situation that happened to someone so that someone aktivtas cause disruption of daily activities both physical, spiritual and social
2. R. Susan defining illness is the lack of harmony between the environment and individuals.
3. Home Oxford Dictionary defines pain as a condition of the body organ or part of the body where its function is disturbed or deviant.
Healthy situation - Sick
A. Continuum Healthy - sick
The health status of a person is located between the two poles of "optimal health and" death ", which are dynamic. When the health of someone moving kekutub death then someone was in the area of pain (illness area) and when moving towards healthy health status (optimal well being), then someone in the area of health (wellness area).
Healthy deaths
Illness Wellness area area
B. Maintaining the health status
1. In accordance with the nature of a dynamic healthy-sick, then the person can be divided into optimal health, a little healthier, a little sick, very sick and died.
2. When someone in the area needs to be healthy then primary prevention (primary prevention), which include health promotion and specific protection is to prevent illness.
3. When someone in the area of pain needs to be secondary and tertiary prevention is early diagnosisand promt treatment, disability limitation and rehabilitation.
C. Factors that influence ill health perunbahan
A. Blum, suggests there are 6 factors that affect the healthy-sick status, namely:
1. Political factors include safety, pressure, oppression, etc..
2. Human behavioral factors including human needs, human habits, customs.
3. Include genetic heredity, disability, ethnicity, risk fator, race, etc..
4. Factor health services, including the attempts promotive, preventive, curative and rehabilitative.
5. Environmental factors include air, water, rivers etc..
6. Socioeconomic factors including education, employment etc..
D. Prevention Level
In a further development to address health issues including disease prevention known three stages:
Primary prevention: health promotion (health promotion) and special protection (specific protection).
Secondary prevention: early diagnosis and immediate treatment (early diagnosis and the prompt treatment), restrictions on disability (disability limitation)
Tertiary Prevention: rehabilitation.
1. Primary prevention has not been done on the individual's illness, the efforts were:
a. Promotion of health / health promotion aimed at improving the body's resistance to health problems.
b. Special protection (specific protection): specific efforts to prevent the transmission of certain diseases, eg, by immunization, increasing the skills of adolescents to prevent the solicitation and use of narcotics to cope with stress and others.
2. Secondary prevention performed during the individual's onset of illness
a. Early diagnosis and immediate treatment (early diagnosis and prompt treatment), the main purpose of this action is one) to prevent the spread of disease when the disease is a contagious disease, and 2) to treat and stop the disease process, heal the sick and prevent the occurrence of complications and disability .
b. Restrictions disability (disability limitation) at this stage the defects that occur overcome, especially to prevent the disease become sustainable until the cause of the flaw is much worse.
3. Tertiary Prevention
a. Rehabilitation, in this process sought to be defective in pain do not become barriers so that individuals who suffer from can function optimally physically, mentally and socially.
The third scheme of prevention efforts that can be seen in the figure two. In the course of the disease picture of two processes are distinguished on a) the phase prior to the sick: that is marked by a balance between agents (germs of disease, hazardous materials), the host / body and environment and b) phase, people started getting sick: who eventually recover or die.
Figure two: The level of disease prevention (source: Leavel and Clark, 1958)
Health promotion through interventions at the host / body of people such as eating a balanced nutritious diet, healthy behavior, improve the quality of the environment to prevent diseases such as eliminating the breeding of disease germs, reduce and prevent air pollution, eliminate the breeding of disease vectors such as standing water become breeding places of Aedes mosquitoes, or against a disease agent such as for example by giving an antibiotic to kill germs.
Special protection is done through specific actions such as immunization or protection in hazardous industrial materials and noise. To conduct mouthwash-gargle with flour to prevent condensation of caries in teeth. Whereas against germs such as washing hands with an antiseptic solution before surgery to prevent infection, wash hands with soap before eating to prevent diarrheal diseases.
Early diagnosis through screening processes such as breast cancer screening, cervical cancer, the presence of certain diseases during pregnancy, so that treatment can be done during the early and due to the bad will be prevented.
Sometimes the boundaries of the three stages of prevention is not obvious that there are overlapping activities can be classified in the special protection and but also can be classified in the early diagnosis and treatment of precancerous lesions as soon as treatment in the womb may include early treatment can also special protection.
In addition to the prevention of primary, secondary and tertiary health care among physicians, nurses and public health practitioners known as the five levels of prevention, also known as the four phases of activities to address public health problems, the four stages (Rossenberg, Mercy and Annest, 1998) is:
What is the problem (surveillance). Identify the problem, what's the problem, when it happens, where, who the person is, how it happened, when did that happen if anything to do with the season or period.
Why did it happen (Identification of risk factors). Why is it easier to happen to anyone in particular, what factors increase the incidence (risk factors) and what factors reduce the occurrence of (protective factor).
What works carried out (evaluation of interventions). On the basis of the two previous steps, can the design effort needs to be done to prevent problems, deal with patients and perform immediate relief efforts and assistance to help victims and assess the success of the action in preventing and tackling the problem.
How to expand effective interventions (for implementing large scale). Once known effective interventions, further action is how to implement interventions in various places and settings, and develop resources to implement them.
Figure 3. Four stages of public health activities
Problem
Response
Source: Rossenberg, and Annest Mercy, 1998
1. Healthy according to WHO 1974
Health is the perfect state of physical, mental, social, not just freedom from disease, disability and weakness.
2. Law treatments were: N0. 23/1992 on health
health is a prosperous state of the body (physical), soul (spiritual) and social that allows every person living in a socially and economically productive.
3. Pepkin's
Health is a state of dynamic balance between form and function of the body that can make adjustments, so that it can overcome the interference from outside.
4. According to Law No.3/1961 mental health is a condition that allows the development of physical, intellectual, emotional and optimal development of a person's current state of harmony with others.
5. Social health is an ability to live together with the community surrounding.
6. Physical health is a state where physical form and function, there is no disturbance to enable development psychological, and social and can carry out daily activities optimally.
In accordance with a healthy understanding of the above can be concluded that health consists of three dimensions: physical, psychological and social can be interpreted more positively, in other words that a person is given the opportunity to develop the broadest capabilities brought from birth to obtain or interpret healthy .
Although there are a lot of the definition, the concept of health is not standard or standard and is absolutely unacceptable and the public. What is considered normal by someone still might be considered abnormal by others, each person / group / community has its own benchmark in interpreting health. Many people live healthy despite lacking economic status, living place that is dirty and noisy, they do not complain of interference even after weighed badanya below normal weight. This explanation shows that the concept is relatively healthy varied widely among people, although in one room / area.
Healthy can not be interpreted something static, settled on a particular condition, but healthy things to be considered a dynamic phenomenon. Health as a spectrum is a condition between the body and mental flexibility that is engaged in a range that is always fluctuating or swinging toward and away from the peak of happiness in life than a perfectly healthy state.
Healthy as a spectrum, Pepkins defines health as the state of dynamic equilibrium of the body and its functions as a result of the dynamic adjustment of the forces that tend to be disturbed. Body someone works actively to defend themselves in order to stay healthy, so health should always be maintained. Here are steps health spectrum:
Positive Health
Better Health
Freedom from Sickness
Spectrum
Health
Unrecognized Sickness
Mild Sickness
Severe Sickness
Death
Concept of Illness
A. Understanding
1. Perkins defines pain as an unpleasant situation that happened to someone so that someone aktivtas cause disruption of daily activities both physical, spiritual and social
2. R. Susan defining illness is the lack of harmony between the environment and individuals.
3. Home Oxford Dictionary defines pain as a condition of the body organ or part of the body where its function is disturbed or deviant.
Healthy situation - Sick
A. Continuum Healthy - sick
The health status of a person is located between the two poles of "optimal health and" death ", which are dynamic. When the health of someone moving kekutub death then someone was in the area of pain (illness area) and when moving towards healthy health status (optimal well being), then someone in the area of health (wellness area).
Healthy deaths
Illness Wellness area area
B. Maintaining the health status
1. In accordance with the nature of a dynamic healthy-sick, then the person can be divided into optimal health, a little healthier, a little sick, very sick and died.
2. When someone in the area needs to be healthy then primary prevention (primary prevention), which include health promotion and specific protection is to prevent illness.
3. When someone in the area of pain needs to be secondary and tertiary prevention is early diagnosisand promt treatment, disability limitation and rehabilitation.
C. Factors that influence ill health perunbahan
A. Blum, suggests there are 6 factors that affect the healthy-sick status, namely:
1. Political factors include safety, pressure, oppression, etc..
2. Human behavioral factors including human needs, human habits, customs.
3. Include genetic heredity, disability, ethnicity, risk fator, race, etc..
4. Factor health services, including the attempts promotive, preventive, curative and rehabilitative.
5. Environmental factors include air, water, rivers etc..
6. Socioeconomic factors including education, employment etc..
D. Prevention Level
In a further development to address health issues including disease prevention known three stages:
Primary prevention: health promotion (health promotion) and special protection (specific protection).
Secondary prevention: early diagnosis and immediate treatment (early diagnosis and the prompt treatment), restrictions on disability (disability limitation)
Tertiary Prevention: rehabilitation.
1. Primary prevention has not been done on the individual's illness, the efforts were:
a. Promotion of health / health promotion aimed at improving the body's resistance to health problems.
b. Special protection (specific protection): specific efforts to prevent the transmission of certain diseases, eg, by immunization, increasing the skills of adolescents to prevent the solicitation and use of narcotics to cope with stress and others.
2. Secondary prevention performed during the individual's onset of illness
a. Early diagnosis and immediate treatment (early diagnosis and prompt treatment), the main purpose of this action is one) to prevent the spread of disease when the disease is a contagious disease, and 2) to treat and stop the disease process, heal the sick and prevent the occurrence of complications and disability .
b. Restrictions disability (disability limitation) at this stage the defects that occur overcome, especially to prevent the disease become sustainable until the cause of the flaw is much worse.
3. Tertiary Prevention
a. Rehabilitation, in this process sought to be defective in pain do not become barriers so that individuals who suffer from can function optimally physically, mentally and socially.
The third scheme of prevention efforts that can be seen in the figure two. In the course of the disease picture of two processes are distinguished on a) the phase prior to the sick: that is marked by a balance between agents (germs of disease, hazardous materials), the host / body and environment and b) phase, people started getting sick: who eventually recover or die.
Figure two: The level of disease prevention (source: Leavel and Clark, 1958)
Health promotion through interventions at the host / body of people such as eating a balanced nutritious diet, healthy behavior, improve the quality of the environment to prevent diseases such as eliminating the breeding of disease germs, reduce and prevent air pollution, eliminate the breeding of disease vectors such as standing water become breeding places of Aedes mosquitoes, or against a disease agent such as for example by giving an antibiotic to kill germs.
Special protection is done through specific actions such as immunization or protection in hazardous industrial materials and noise. To conduct mouthwash-gargle with flour to prevent condensation of caries in teeth. Whereas against germs such as washing hands with an antiseptic solution before surgery to prevent infection, wash hands with soap before eating to prevent diarrheal diseases.
Early diagnosis through screening processes such as breast cancer screening, cervical cancer, the presence of certain diseases during pregnancy, so that treatment can be done during the early and due to the bad will be prevented.
Sometimes the boundaries of the three stages of prevention is not obvious that there are overlapping activities can be classified in the special protection and but also can be classified in the early diagnosis and treatment of precancerous lesions as soon as treatment in the womb may include early treatment can also special protection.
In addition to the prevention of primary, secondary and tertiary health care among physicians, nurses and public health practitioners known as the five levels of prevention, also known as the four phases of activities to address public health problems, the four stages (Rossenberg, Mercy and Annest, 1998) is:
What is the problem (surveillance). Identify the problem, what's the problem, when it happens, where, who the person is, how it happened, when did that happen if anything to do with the season or period.
Why did it happen (Identification of risk factors). Why is it easier to happen to anyone in particular, what factors increase the incidence (risk factors) and what factors reduce the occurrence of (protective factor).
What works carried out (evaluation of interventions). On the basis of the two previous steps, can the design effort needs to be done to prevent problems, deal with patients and perform immediate relief efforts and assistance to help victims and assess the success of the action in preventing and tackling the problem.
How to expand effective interventions (for implementing large scale). Once known effective interventions, further action is how to implement interventions in various places and settings, and develop resources to implement them.
Figure 3. Four stages of public health activities
Problem
Response
Source: Rossenberg, and Annest Mercy, 1998
Acute Coronary Syndromes / Acute coronary syndrome
Definition
Acute coronary Syndromes shown to some conditions. The group consists of:
1. Unstable angina
2. Non ST segment elevation Myocardial Infarction (NSTEMI)
3. ST Segment Elevation Myocardial Infarction (STEMI)
Disease process occurs because:
1. Bleeding in the plaque. Plaque causes swelling and a decrease in arterial lumen cross-sectional area.
2. Contraction of smooth muscle in artery walls. This contraction causes contractions in the lumen of the artery.
3. Thrombus formation on the surface of the plaque. This can cause partial blockage of the artery lumen until complete.
The all cause a decrease of blood flow to the myokardium.
Stable angina
Signs and Symptoms
Signs and symptoms of ACS in principle the same. In general, patients menyeluh:
1. Chest pain described as: a. Cramped, b. Pain such as indigestion,
c. As a fall, d. As there is a chest bandage, e. There is a case of people sitting on the chest
2. Pain spreading to the left hand, both hands and / or to the chin.
3. Pain likely be followed by: a. Sweating, b. Shortness of breath, c. Nausea and vomiting
Stable angina pain occurs only during exercise and there are fast disappearing at rest.
Unstable angina
Unlike stable angina, unstable angina was defined as occurrence of one or more of the following events: 1. Angina that occurs at a certain time period ranging from several days and increased in the attack. The increase was due to fewer trigger factors or less. This condition is often referred to as crescendo angina. 2. Incidence of recurrent angina episode and often unpredictable. Unstable angina does not trigger because the sport is not so clear. Usually occurs within a short time and disappear spontaneously or may be lost temporarily by drinking virgin glyceryl trinitrate (GTN), a sub lingual. 3. No originators and chest pain that extends. No evidence of infarction myokardial
Signs and Symptoms
1. Chest pain described as: a. Cramped, b. Pain such as indigestion,
c. As a fall, d. As there is a chest bandage, e. There is a case of people sitting on the chest
2. Pain spreading to the left hand, both hands and / or to the chin.
3. Pain likely be followed by: a. Sweating, b. Shortness of breath, c. Nausea and vomiting
Assessment
The main complaint is felt and assessment of vital signs. Always using ABCDE assessment principles.
Airway
1. Assess and maintain airway
2. Do the head tilt, chin lift
3. Use a respirator if needed
4. Consider referring to a part of anesthesia for intubation performed if it can not properly maintain the airway.
Breathing
1. Assess oxygen saturation using pulse oximeter with the aim of maintaining oxygen saturation more than 92%.
2. Give oxygen with high alirang via bag-valve-mask Ventilation.
3. Review of Respiratory
4. Perform system checks penapasan
5. Perform chest x-ray examination
Circulation
1. Assess heart rate and rhythm.
2. Measuring blood pressure
3. Perform EKG - may be normal but usually there is ST depression
4. Put Access IV (intravenous)
5. Do blood tests, heart or troponin enjim depending on local protocol (enjim and troponin are usually not elevated in unstable angina.
6. Remember MONA
a. Morphine - given five mg IV
b. Oxygen - high flow
c. Nitrate - give sublingual
d. Aspirin - 300 mg given
7. Consider giving low molecular weight heparin until the patient was free of pain within 24 hours.
8. Consider to give Clopidogrel 300 mg followed by 75 mg per day given
Disability
1. Assess the level kesaddaran using AVPU.
Exposure
1. Perform health checks and a history of illness when the patient is stable.
NON-ST elevation myocardial infarction
In some patients with NSTEMI, they have a high risk for coronary artery congestion, which can cause myocardial damage is more extensive and arrhythmias that can cause death. The risk for occurrence of traffic jams can occur in the first few hours and disappear in line with the time
Signs and Symptoms
1. Chest pain described as: a. Cramped, b. Pain such as indigestion,
c. As a fall, d. As there is a chest bandage, e. There is a case of people sitting on the chest
2. Pain spreading to the left hand, both hands and / or to the chin.
3. Pain likely be followed by: a. Sweating, b. Shortness of breath, c. Nausea and vomiting
Assessment
Chief complaint and vital signs assessments. Medical assistance should be done immediately. Perform assessment using ABCDE principles:
Airway
1. Assess and maintain airway
2. Make a tilt head, chin lift if necessary
3. Use a tool in freeing the airway if necessary
4. Consider referring to a part of anesthesia for intubation performed if not able to maintain airway.
Breathing
1. Assess oxygen saturation using pulse oximeter in order to maintain oxygen saturation of more than 92%.
2. Give alirang oxygen with a high through-valve-mask bags Ventilation.
3. Assess the number of respiratory
4. Perform system checks penapasan
5. Perform chest x-ray examination
Circulation
1. Assess heart rate and rhythm.
2. Measuring blood pressure
3. Perform EKG - may be normal but usually there is ST depression
4. Put Access IV (intravenous)
5. Do blood tests, heart or troponin enjim depending on local protocol (number enjim and troponin myokardial usually indicates the level of damage).
6. Monitor blood sugar
7. Remember MONA: a. Morphine - give 5 mg IV, b. Oxygen - high flow, c. Nitrate - give sublingual, d. Aspirin - 300 mg given
8. Consider giving low molecular weight heparin to patients free of pain within 24 hours.
Nine. Consider to give Clopidogrel 300 mg followed by 75 mg per day given
10. Consider giving beta blockers and statins must be taken into account
Disability
1. Assess the level kesaddaran using AVPU.
Exposure
1. Perform health checks and a history of illness when the patient is stable. Patients with less NSTEMI is not allowed to drive a vehicle within 4 (four) weeks.
ST elevation myocardial infarction
STEMI occurred because a complete blockage in coronary arteries. If not done the treatment can cause further myocardial damage. In high-risk acute phase for patients experiencing ventricular fibrillation or takhikardi which can cause death. Medical assistance should be done immediately.
Signs and symptoms
1. Chest pain described as: a. Cramped, b. Pain such as indigestion,
c. As a fall, d. As there is a chest bandage, e. There is a case of people sitting on the chest
2. Pain spreading to the left hand, both hands and / or to the chin.
3. Pain likely be followed by: a. Sweating, b. Shortness of breath, c. Nausea and vomiting
Airway
1. Assess and maintain airway
2. Do the head tilt, chin lift if necessary
3. Use a tool in freeing the airway if necessary
4. Consider referring to a part of anesthesia for intubation performed if the airway can not be maintained.
Breathing
1. Assess oxygen saturation using pulse oximeter in order to maintain oxygen saturation of more than 92%.
2. Give oxygen with high alirang through bag-valve-mask Ventilation.
3. Assess the number of respiratory
4. Perform system checks penapasan
5. Perform chest x-ray examination
Circulation
1. Kaji heart rate and rhythm.
2. Measure blood pressure
3. Perform EKG - ST elevation acute or bundle branch block (LBBB) newly added by myokardial infarct signs is an indication for reperfusion therapy performed.
4. The characteristic ECG in STEMI
a. Anterior / anteroseptal - seen in V1-V4
b. Inferior - seen in II, III and aVF
c. Lateral - look at the V5-V6 and I and aVL
d. posterior - anterior reciprocal changes in leads
5. Put Access IV (intravenous)
6. Do blood tests, heart or troponin enjim depending on local protocol (number enjim and troponin usually indicates the level of damage myokardial).
7. Monitor blood sugar
8. Remember MONA
a. Morphine - give 5 mg IV
b. Oxygen - high flow
c. Nitrate - give sublingual
d. Aspirin - 300 mg given
Nine. Consider giving low molecular weight heparin until the patient was free of pain within 24 hours.
10. Consider to give Clopidogrel 300 mg followed by 75 mg per day given
11. Assess the possibility of giving thrombolysis - a drug commonly used are:
a. streptokinase - 1.5 million units in normal saline 100 MLS
b. alteplase - infuskan 15 mg bolus then 0.75 mg / kg during the first hour
c. reteplase - 10 units bolus then 10 units after 30 minutes
d. tenecteplase - 30-50 mg (6.000 to 10.000 units) bolus
12. All patients were referred immediately to memelukan cardiologist
Disability
1. Kaji kesaddaran level by using AVPU.
Exposure
Perform health checks and a history of illness when the patient is stable. Patients with less NSTEMI are not allowed to drive a vehicle within 4 (four) weeks.
Acute coronary Syndromes shown to some conditions. The group consists of:
1. Unstable angina
2. Non ST segment elevation Myocardial Infarction (NSTEMI)
3. ST Segment Elevation Myocardial Infarction (STEMI)
Disease process occurs because:
1. Bleeding in the plaque. Plaque causes swelling and a decrease in arterial lumen cross-sectional area.
2. Contraction of smooth muscle in artery walls. This contraction causes contractions in the lumen of the artery.
3. Thrombus formation on the surface of the plaque. This can cause partial blockage of the artery lumen until complete.
The all cause a decrease of blood flow to the myokardium.
Stable angina
Signs and Symptoms
Signs and symptoms of ACS in principle the same. In general, patients menyeluh:
1. Chest pain described as: a. Cramped, b. Pain such as indigestion,
c. As a fall, d. As there is a chest bandage, e. There is a case of people sitting on the chest
2. Pain spreading to the left hand, both hands and / or to the chin.
3. Pain likely be followed by: a. Sweating, b. Shortness of breath, c. Nausea and vomiting
Stable angina pain occurs only during exercise and there are fast disappearing at rest.
Unstable angina
Unlike stable angina, unstable angina was defined as occurrence of one or more of the following events: 1. Angina that occurs at a certain time period ranging from several days and increased in the attack. The increase was due to fewer trigger factors or less. This condition is often referred to as crescendo angina. 2. Incidence of recurrent angina episode and often unpredictable. Unstable angina does not trigger because the sport is not so clear. Usually occurs within a short time and disappear spontaneously or may be lost temporarily by drinking virgin glyceryl trinitrate (GTN), a sub lingual. 3. No originators and chest pain that extends. No evidence of infarction myokardial
Signs and Symptoms
1. Chest pain described as: a. Cramped, b. Pain such as indigestion,
c. As a fall, d. As there is a chest bandage, e. There is a case of people sitting on the chest
2. Pain spreading to the left hand, both hands and / or to the chin.
3. Pain likely be followed by: a. Sweating, b. Shortness of breath, c. Nausea and vomiting
Assessment
The main complaint is felt and assessment of vital signs. Always using ABCDE assessment principles.
Airway
1. Assess and maintain airway
2. Do the head tilt, chin lift
3. Use a respirator if needed
4. Consider referring to a part of anesthesia for intubation performed if it can not properly maintain the airway.
Breathing
1. Assess oxygen saturation using pulse oximeter with the aim of maintaining oxygen saturation more than 92%.
2. Give oxygen with high alirang via bag-valve-mask Ventilation.
3. Review of Respiratory
4. Perform system checks penapasan
5. Perform chest x-ray examination
Circulation
1. Assess heart rate and rhythm.
2. Measuring blood pressure
3. Perform EKG - may be normal but usually there is ST depression
4. Put Access IV (intravenous)
5. Do blood tests, heart or troponin enjim depending on local protocol (enjim and troponin are usually not elevated in unstable angina.
6. Remember MONA
a. Morphine - given five mg IV
b. Oxygen - high flow
c. Nitrate - give sublingual
d. Aspirin - 300 mg given
7. Consider giving low molecular weight heparin until the patient was free of pain within 24 hours.
8. Consider to give Clopidogrel 300 mg followed by 75 mg per day given
Disability
1. Assess the level kesaddaran using AVPU.
Exposure
1. Perform health checks and a history of illness when the patient is stable.
NON-ST elevation myocardial infarction
In some patients with NSTEMI, they have a high risk for coronary artery congestion, which can cause myocardial damage is more extensive and arrhythmias that can cause death. The risk for occurrence of traffic jams can occur in the first few hours and disappear in line with the time
Signs and Symptoms
1. Chest pain described as: a. Cramped, b. Pain such as indigestion,
c. As a fall, d. As there is a chest bandage, e. There is a case of people sitting on the chest
2. Pain spreading to the left hand, both hands and / or to the chin.
3. Pain likely be followed by: a. Sweating, b. Shortness of breath, c. Nausea and vomiting
Assessment
Chief complaint and vital signs assessments. Medical assistance should be done immediately. Perform assessment using ABCDE principles:
Airway
1. Assess and maintain airway
2. Make a tilt head, chin lift if necessary
3. Use a tool in freeing the airway if necessary
4. Consider referring to a part of anesthesia for intubation performed if not able to maintain airway.
Breathing
1. Assess oxygen saturation using pulse oximeter in order to maintain oxygen saturation of more than 92%.
2. Give alirang oxygen with a high through-valve-mask bags Ventilation.
3. Assess the number of respiratory
4. Perform system checks penapasan
5. Perform chest x-ray examination
Circulation
1. Assess heart rate and rhythm.
2. Measuring blood pressure
3. Perform EKG - may be normal but usually there is ST depression
4. Put Access IV (intravenous)
5. Do blood tests, heart or troponin enjim depending on local protocol (number enjim and troponin myokardial usually indicates the level of damage).
6. Monitor blood sugar
7. Remember MONA: a. Morphine - give 5 mg IV, b. Oxygen - high flow, c. Nitrate - give sublingual, d. Aspirin - 300 mg given
8. Consider giving low molecular weight heparin to patients free of pain within 24 hours.
Nine. Consider to give Clopidogrel 300 mg followed by 75 mg per day given
10. Consider giving beta blockers and statins must be taken into account
Disability
1. Assess the level kesaddaran using AVPU.
Exposure
1. Perform health checks and a history of illness when the patient is stable. Patients with less NSTEMI is not allowed to drive a vehicle within 4 (four) weeks.
ST elevation myocardial infarction
STEMI occurred because a complete blockage in coronary arteries. If not done the treatment can cause further myocardial damage. In high-risk acute phase for patients experiencing ventricular fibrillation or takhikardi which can cause death. Medical assistance should be done immediately.
Signs and symptoms
1. Chest pain described as: a. Cramped, b. Pain such as indigestion,
c. As a fall, d. As there is a chest bandage, e. There is a case of people sitting on the chest
2. Pain spreading to the left hand, both hands and / or to the chin.
3. Pain likely be followed by: a. Sweating, b. Shortness of breath, c. Nausea and vomiting
Airway
1. Assess and maintain airway
2. Do the head tilt, chin lift if necessary
3. Use a tool in freeing the airway if necessary
4. Consider referring to a part of anesthesia for intubation performed if the airway can not be maintained.
Breathing
1. Assess oxygen saturation using pulse oximeter in order to maintain oxygen saturation of more than 92%.
2. Give oxygen with high alirang through bag-valve-mask Ventilation.
3. Assess the number of respiratory
4. Perform system checks penapasan
5. Perform chest x-ray examination
Circulation
1. Kaji heart rate and rhythm.
2. Measure blood pressure
3. Perform EKG - ST elevation acute or bundle branch block (LBBB) newly added by myokardial infarct signs is an indication for reperfusion therapy performed.
4. The characteristic ECG in STEMI
a. Anterior / anteroseptal - seen in V1-V4
b. Inferior - seen in II, III and aVF
c. Lateral - look at the V5-V6 and I and aVL
d. posterior - anterior reciprocal changes in leads
5. Put Access IV (intravenous)
6. Do blood tests, heart or troponin enjim depending on local protocol (number enjim and troponin usually indicates the level of damage myokardial).
7. Monitor blood sugar
8. Remember MONA
a. Morphine - give 5 mg IV
b. Oxygen - high flow
c. Nitrate - give sublingual
d. Aspirin - 300 mg given
Nine. Consider giving low molecular weight heparin until the patient was free of pain within 24 hours.
10. Consider to give Clopidogrel 300 mg followed by 75 mg per day given
11. Assess the possibility of giving thrombolysis - a drug commonly used are:
a. streptokinase - 1.5 million units in normal saline 100 MLS
b. alteplase - infuskan 15 mg bolus then 0.75 mg / kg during the first hour
c. reteplase - 10 units bolus then 10 units after 30 minutes
d. tenecteplase - 30-50 mg (6.000 to 10.000 units) bolus
12. All patients were referred immediately to memelukan cardiologist
Disability
1. Kaji kesaddaran level by using AVPU.
Exposure
Perform health checks and a history of illness when the patient is stable. Patients with less NSTEMI are not allowed to drive a vehicle within 4 (four) weeks.
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