Curiculum Vitae DR. Rahadian Indarto Susilo, dr SpBS(K)

Curiculum Vitae

DR. Rahadian Indarto Susilo, dr SpBS(K)

• Fak Kedokteran Universitas Airlnggga 1996-2002

• PPDS Bedah Saraf Universitas Airlangga Surabaya 2003-2009

• Skull Base Fellow Program Keio University Tokyo Japan, 2009

• WFNS Grade A: Skull Base Fellowship Program Osaka City University, Japan. 2011

• Program S3 FK UNAIR 2019

• Neurooncology Division, Neurosurgery Department Universitas Airlangga - Dr. Sutomo General Hospital, Surabaya, 2009 - now

HP : 081 3260 79197 Email : [email protected] : 0822-6000-6070

@Tumor.Otak.Indonesia @Tumor_Otak Brain Tumor Indonesia

mailto:[email protected]

Prinsip Tatalaksana Pasien Trauma Kepaladi Ruang Rawat Inap

Dr. dr. Rahadian Indarto Susilo, Sp.BS (K)

Asclepio Edukasi Medika ©2020

Outline

1. Goal of neurotrauma case

2. Identification of secondary insult

3. Principal Management of neurotrauma patient

4. General Interventions

5. Post NEUROLOGICAL Interventions care


GOALS OF NEUROTRAUMA CARE

to prevent secondary insults

• which may initiate or exacerbate secondary damage in a vulnerable central nervous system

early detection and treatment of complications.


INTRA KRANIAL SECONDARY INSULT

EXTRA KRANIAL SECONDARY INSULT

CEDERA OTAK

SEKUNDER

• ICP, CPP•ISKEMIK-HIPOKSIK

•Kerusakan sel

•MORTALITAS•MORBIDITAS

CEDERA OTAK

PRIMER

Patofisiologi Cedera Otak

Normal

Tx adequad

AIRWAYBREATHING

CIRCULATION

TRAUMA KEPALA

DEKOMPENSASI KOMPENSASI

Gangguan Autoregulasi

Autoregulasi aliran darah otak (CBF)

50 140

CBF

MAP (mmHg)

Waktu normalstabil disini

Cedera otak merusak mekanisme autoregulasi

batas aman jadi lebih sempit

cedera


Daerah PENUMBRA → HYPOPERFUSI

11

❑ Gangguan Perfusi (Hipoperfusi)Ok ADO menurun atau kompressi.

❑ ADO 10-18 ml/100gr/menit.(N=50ml/100gr/menit)

❑ Masih bisa reversible bila ditanganicepat dan tepat.

❑ Gangguan Perfusi berat( ADO sangat menurun atau kompressi ).

❑ ADO <10 ml/100gr/menit.(N=50ml/100gr/menit)

❑ irreversible

Abnormal


Identification of SECONDARY INSULT

1. Extracranial → Systemic

2. Intracranial. →


Primary Goal of Care prevention of secondary insult


EVENT MAIN CAUSES ADVERSE EFFECT

HYPOXEMIA 1. Hypotension2. Aspiration atelectasis3. Pneumothorax4. Pneumonia5. Anemia

1. O2 delivery↓2. Risk of ischemic damage↑

HYPERCAPNIA (pCO2 ↑) 1. Respiratory depression CBV ↑ → ICP ↑

HYPOCAPNIA (pCO2 ↓) 1. Hyperventilation , spontaneousor induced

Cerebral vasocontriction→ Risk of ischemic damage↑

HYPOTENSION 1. Hypovolemia2. Cardiac failure3. Sepsis 4. Spinal cord injury

CPP↓ & CBF ↓Risk of ischemic damage↑

ANEMIA Blood loss 1. O2 delivery↓2. Risk of ischemic damage↑

HYPERTHERMIA Hypermetabolism, stress response, infection

energy depletion

HYPOTHERMIA Exposure, central dysregulation NeuroprotectiveCoagulopathy & electrolyte disturbance

Principal Management of neurotrauma patient


PrincipalManagement of neurotrauma patient

Frequent assessment of neurological status (every 30 minutes, then hourly) for the first 24-48 hoursFrequent

Frequent vital signs Frequent

Limit care activities that increase ICPLimit

DO NOT cluster cares!DO NOT cluster


Principal Management of neurotrauma patients :

Do it

Assess for pain and provide pain relief measures-narcotics mask LOC

Check drains for placement, patency - strict steriletechnique

Check dressing for drainage, CSF leak - strict sterile technique

Suction—limit to < 15 seconds; preoxygenate

Turn q 2 hrs (slow, gentle movements)

ROM exercises


Principal Management of neurotrauma patient : family & referrals

Assess effect of ill family member on family Assess

Teach family to provide care to ill family memberTeach

Facilitate family communication and planningFacilitate

Provide accurate information to family regarding patient’s conditionProvide

Initiate referrals as needed, i.e. speech therapy, physical therapyInitiate


General Interventions



1. Respiratory

2. Cardiovascular

3. Nutrition

4. blood glucose

5. IV fluid

6. activity

7. pain



1. Respiratory:

• Prevent atelectasis & pneumonia

• Maintain SaO2 > 94%

• Encourage incentive spirometry q 2 hours at least

2. Cardiovascular:

• Monitor cardiac rate & rhythm

• Monitor BPs

3. Nutrition:

• Begin with clear liquids, advance as tolerated

• Swallow evaluation

• Assess for nausea and vomiting, administer antiemetics as ordered.



4. Blood Glucose:

• Hyperglycemia disrupts the blood-brain-barrier and increases edema

• Steroids increase blood glucose levels

• Monitor blood glucose levels before meals, at bedtime and as needed, administer hypoglycemic as needed

5. IV Fluids:

• Titrate IV fluids down once the patient is taking adequate food and liquids to prevent fluid overload & potential edema

• Do not use fluid with dextrose ?



6. Activity:

• Early ambulation is important to prevent pneumonia, atelectesis, & DVTs

• Physical therapy and occupational therapy consults are strongly recommended

7. Pain:

• Assess pain every 4 hours using appropriate pain scale

• Administer ordered pain medications as needed

• Reassess pain up to 1 hour after giving pain medication

• Suggest alternative pain relief therapies (deep breathing, music, ice, darken room)


Post neurosurgical intervention care



Post NEUROLOGICAL

Interventions

Head dressing & incision care

• Monitor for drainage

• Change as needed, usually removed after 24 hours

• Monitor incision for signs of infection

• Keep staples or stitches dry

Drains

• Monitor amounts of drainage

• Maintain patency

• Know location of drain


Patient Positioning

Elevate HOB 30 to 45 degrees for supratentorial surgery

Keep patient flat or slightly elevated if incision in posterior fossa (infratentorial)


VentriculostomyExternal Ventricular Drainage (EVD)

• GOAL :

• Drains CSF

• Allows for intraventricular drug administration

• Measures pressure within vessels


http://images.google.com/imgres?imgurl=http://uscneurosurgery.com/graphics/complications/procedures/ventriculostomy/ventriculostomy-sewing-gome.jpg&imgrefurl=http://uscneurosurgery.com/patient%20education/risks%20complications/procedure/risks%20complications%20ventriculostomy.htm&h=500&w=580&sz=55&tbnid=TNFzSsITX4EJ:&tbnh=113&tbnw=131&start=2&prev=/images?q=ventriculostomy&hl=en&lr=&sa=N

ICP monitoring


ICP monitor : Intraventricle




Postoperative Medications

Anticonvulsants

Corticosteroids → nontrauma cases

H2 blockers / PPI

Analgesics

Antibiotics

Nutrition


Post op COMPLICATIONS

EXTRA CRANIAL → SYSTEMIC ( A – B – C)

INTRA CRANIAL → Neurosurgical complication


Postoperative complications : extracranial

A – B → Respiratory Complications

• Atelectasis

• Hypoxia

• Pneumonia

• Neurogenic pulmonary edema

C → Hypovolemic shock

Infection

Fluid and electrolyte imbalances

• Dehydration

• Hyponatremia

• Hypernatremia


Postoperative Complications:

intracranial

Increased intracranial pressure (ICP)

Hydrocephalus

Meningitis

Seizures

Cerebrospinal fluid (CSF) leak

Cerebral edema

Hematomas

• Subdural hematoma

• Epidural hematoma

• Subarachnoid hemorrhage


Summary

Neuro care complex

Encompasses science and art of care

Requires technical expertise

Requires collaboration, communication, compassion


Thank you


Nutrisi


Pemberian nutrisi

⚫Start : Protokol Neuroscience.

⚫Acuan

24 – 48 jam

Apakah ada atau tidak stres metabolik ?


Stres Metabolik

Kasus neurosurgery :

o GCS turun/coma,

o Hipertensi, hipotensi/syok,

o Febris,

o Keringat dingin,

o Hipoventilasi.

o Dll.

Pemeriksaan

Penunjang : serum

o Cortisol.

o Glukagon

o Glukosa

Penunjang : Urine

o UUN


Pemberian Nutrisi TBI

• Substrak energi.

• Jalur pemberian :

Prinsip : “If the gut works, use it.”

o Karbohidrato Lemako Proteino Vitamin, mineral dan trace element

o Parenteral atau Enteral atau Kombinasi


Pemberian Nutrisi TBI⚫Substrak nutrisi :

o Karbohidrat,Umumnya diberikan 40-60% dari total kcal,

Substrak 4 (3.4 kcal/g).

Dosis ; Max 7 g/kgBB/hari

Pada kasus tertentu hanya diberi tidak lebih 50%

o LemakUmumnya diberikan 20 - 40% dari total kcal,

Substrak 9 kcal/g.

Dosis ; Max 1 g/kgBB/hari

Pada kasus tertentu boleh diberi s/d 45%.

Dipersyaratkan pem triglicerida,

Sediaan dalam bentuk LCT & MCT+LCT

Pemberian Nutrisi TBI⚫Substrak nutrisi :

o ProteinUmumnya diberikan dari total kcal,

Substrak 4 kcal/g.

Dosis ; 1.5-2 (Max 2.5) g / kgBB/ hari

Pada kasus tertentu hanya diberi < 1g/kgBB/hari

AA Essensial, AA Nonessensial & Conditional AA.

o VitaminStandart : Multivitamin (kecuali Vit K).

Vit K direkomendasikan 2-4 mg/minggu, bukan sebagai

antikoagulan.

o Trace elemen (Zinc, copper,chromium dll)

Pertimbangkan penambahan zinc pada kasus acute catabolic stress,

penyembuhan luka (2-5mg/hari).


Pemberian Nutrisi TBI

• Kebutuhan cairan

• Osmolaritas cairan nutrisi

Perifer → Cairan dengan osmolaritas < 900 mOsm

Central → Cairan dengan osmolaritas > 900 mOsm

• Immunonutrition

Masih “pro and con”

Hati-hati, metabolisme Glutamin → GlutaminGlutamat

30-50 ml/kgBB/24 jam

Glutamin


Monitor1X sehari 2X/minggu 1x seminggu

Cairan lambung(6jam)

Serum Glucose Serum phosphorus Serum albumin

BAB Serum elektrolit Serum calcium Nitrogen balance(optional)

Edema Serum BUN Serum magnesium Indirect calorimetry(optional)

Balance cairan Serum creatinine Berat badan

Bedside ICU handbook,TTSH ed 2nd 2007

1X seminggu


Rangkuman

Managemen pada TBI, One thing to remember !

Ketika penderita mengalami TBIBeri obat dan kalau perlu pembedahan.

Untuk pemulihan atau penyembuhanBeri nutrisi yang tepat dan baik.Prevalen malnutrisi di RS U.S.A 30% -50%.

Fokus, cermatlah dalam memberi terapi nutrisi.


KASUS 1

Penghitungan Cairan dan Nutrisi pada pasien trauma kepala


• Wanita 39 tahun dengan cedera otak ringan

• Riwayat muntah dan tidak sadar <5 menitpaska kejadian

• Saat ini anda rawat di ruangan untukobservasi perawatan hari ke-1

Kasus 1

• Berapa cairan yang perlu diberikan ?

• Kapan dan apa diet yang sesuai untukpasien ini ?

Simulasi Kasus


Kebutuhan cairan harian, rumus

• 100 ml/kgbb untuk 10 kg pertama dalam 24 jam, kemudian

• 50 ml/kgbb untuk 10 kg beriuikutnya dalam 24 jam, kemudian

• 20 ml/kgbb untuk kg sisa dalam 24 jam (usia <60 tahun) ; (>60 tahun 15 ml/kgbb)

Kasus 1

Kebutuhan cairan harian, rerata

35-50 ml/kgbb (dewasa),

30 ml/kgbb (usia tua)

*Demam : tiap kenaikan 1o ditambah 12,5% ; Berkeringat : menigkat 10 -25% ; Hiperventilasi : meningkat 10-60%

Evaluasi apakah tercukupi

Nadi, suhu, tekanan darah, turgor, prod. Urin (0,5-1 cc/kgbb/menit)

SADAR

Hitung kebutuhan cairan→ Tentukan target

Laki-laki 50 kg → 2100 ml/24 jam

→ 1750 – 2500 ml/24 jam

IntravenaPer oral

TIDAK SADAR ?

Personde

Cairan Isotonik


Kebutuhan nutrisi harian

Berdasarkan formula Harris Benedict, basal energy expenditure (BEE):

1.Pria : 66,47 + 13,75 (KgBB) + 5 (cmTB) – 6,7 (usia) =…kcal/hari

2.Wanita: 65,51 + 9,56 (KgBB) + 1,85 (cmTB) – 4,68 (usia) =…kcal/hari

Kasus 1

SADAR atau TIDAK SADAR ?

Nutrisi

Puasa ??

Early feeding better

Kebutuhan nutrisi harian

COR = 30 kcal/kgbb/24 jam

COS = 35 kcal/kgbb/24 jam

COB = 40 kcal/kgbb/24 jam

Laki-laki 50kg → 1.335 kcal/hari

→ 1.500 kcal/hari (COR) – 1750 kcal/hari (COS) – 2000 kcal/hari (COB)


KASUS 2

Penganan pasien Kejang pasca trauma kepala


Kasus 2

• Pria, 29 th post KLL sepeda motor

• Saat ini sedang anda rawat di ruangan untuk observasi dengancedera otak ringan

• Dilaporkan perawat kejang….!!!

Kejang


Kasus 2

Stabillisasi ABC

Putus kejang

Cegah kejang

Diazepam• 1 ampul (10 mg) dicairkan 10 cc,

diberikan perlahan IV• Supposituria

PhenitoinLoading dose 500 mg dalam 10 menitMaintenance dose 3x100 mg

Pastikan lidah tidak tergigitAmankan lingkungan sekitar pasien


Kasus 2

Profilaksis anti kejang

Warning sign (boleh diberikan profilaksis anti

kejang)

1. GCS < 10

2. Kontusio kortikal

3. Fraktur depresi

4. EDH, SDH, ICH

5. Trauma tembus kepala

6. Kejang dalam 24 jam setelah cedera otak

Intrakranial Ekstrakranial

1. Serum elektrolit

2. Gula darah


KASUS 3

Penanganan Pasien dengan

Penurunan Kesadaran


Kasus 3

• Pria, 19 th perawatan hari ke-1 post KLL tertabrak motor

• Dilaporkan perawat mengalamipenurunan kesadaran mendadakperawatan hari pertama di ruangan!!

• TD 110/65, HR 89, RR regular 22, Spo2 98%, t 36,6

• GCS E4V5M6 → E3V3M5

• Pupil bulan anisokor 3/5 mm, reflek cahaya turun sisikiri


Kasus 3

Stabillisasi ABC

Identifikasi penyebab LOC (Cedera otak sekunder)

Tatalaksana

Intrakranial Ekstrakaranial


Terimakasih


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Curiculum Vitae DR. Rahadian Indarto Susilo, dr SpBS(K)

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