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    Case ICU: Dr. David Halim

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    RonaLd Jackson Sinaga
    Dr. Ade Nurse: Nurse A, Nurse B Thank you.

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    Case ICU: Dr. David Halim

    Uploaded by

    RonaLd Jackson Sinaga
    32 views20 pages
    Dr. Ade Nurse: Nurse A, Nurse B Thank you.

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    Dr. Ade Nurse: Nurse A, Nurse B Thank you.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    32 views20 pages

    Case ICU: Dr. David Halim

    Uploaded by

    RonaLd Jackson Sinaga
    Dr. Ade Nurse: Nurse A, Nurse B Thank you.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
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    Case ICU

    dr. David Halim


    Patient’s Identity

    Name : Mrs. E
    Age : 32 y.o
    Address : Lengkong, Kodya Bandung
    Education : Senior High School
    Job : Housewife
    Medical Record : 000158xxxx
    Admission day : Desember 23rd 2016, 19.08 p.m
    P3A0 term delivery
    by cesarean section
    Referred RSU due to previous
    from Bungsu cesarean section;
    placenta previae;
    haemorhagic shock
    Decrease of
    consciousness

    HIV (-) on
    Post C-section
    patient

    P3A0 Sutured
    on
    (LC 2, YC 0 placental
    day)
    bed
    Bleeding
    HIV (+) on during third
    husband, ARV stage of labor
    (+)
    (+4500 cc)

    Extubation (-)
    Obstetric History
    Parity Place Result Type of Delivery Gender Condition

    1 Muhamadiyah 2800 gram C-section Female 11 y.o,


    Hospital alive

    2 Bungsu 3200 gram C-section Female 7 y.o, alive


    Hospital

    3 Bungsu 3200 gram C-section Male 3 y.o, alive


    Hospital
    Additional Information

    •1st ♀ 20 y.o, Junior high school, housewife


    • ♂ 25 y.o, Junior high school, Private
    Marital worker
    •2nd ♀ 28 y.o, Junior high school, housewife
    Status • ♂ 34 y.o, Senior high school, Private
    worker
    Physical Abdominal Speculum Internal
    Exam Exam Exam Exam
    • Consciousness: • Soft, convex • Fluxus (-) • Within normal
    on drugs • Fundal height at • Fluor (-) limit
    • BP: 191/110 umbilcal level
    mmHg • Contraction
    • Respiration: adequate
    11x/mnt on • Abdominal
    bagging circumference:
    • Others within 111 cm
    normal limit • Other within
    normal limit
    Blood Gas
    Analysis
    Blood Chemical
    pH : 7.158
    Lactate: : 2.3mmol/L
    Hematology pCO2 : 42 mmHg
    Creatinine: 1.19 mg/dL
    Hb : 5.9 g/dL pO2 : 238 mmHg
    Total Bilirubin: 0.19
    Ht : 18 % mg/dL HCO3: 14.3 mEq/L
    L : 20900/mm3 SGOT : 85U/L TCO2 : 29.7mmol/L
    Tr : 104000/mm3 SGPT : 20 U/L
    Base excess: -14
    Ureum : 32 mg/dL mEq/L
    O2 Sat : 99.5%
    Lactate: 3.7
    Diagnosis

    Haemorrhagic shock due to early post


    partum haemorrhage
    due to suspect of placenta accrete in P3A0
    term delivery by C-section due to previous
    C-section; anemia
    Management

    • General condition stabilization


    • Methergin 3 x 0.125 mg i.v
    • Blood transfusion until Hb > 11 gr/dl
    • Observation
    • Plan to observe in intensive care
    unit
    Thorax Photo (29/12/2016)
    Kesan: Kardiomegali dengan
    tanda-tanda edema paru DD/
    bronkopneumonia
    Ultrasonography

     Enlarged Uterus
     Hyperechoic mass at
    uterine cavity
     Free fluid (-)
     Conclusion: hyperechoic
    mass at uterine cavity
    dd/ suspected of
    placenta accreta
    pH HCO3
    7.4 20
    7.35 19
    7.34 17
    7.3 15 15 14 15
    13
    7.25 7.24 7.24 7.25 10
    7.2
    7.15 7.15 7.16 5
    7.1 0
    7.05

    Base Excess
    0
    -2
    -4
    -6 -6
    -8
    -9
    -10 -10
    -11
    -12 -12 -12
    -14
    Laboratory Result (29/12/2016)

    Hb: 8.4 Na: 153


    Ht: 26 K: 3.5
    L: 8900 Cl: 116
    Tr: 165000 Ca: 4.14
    Cr: 5.4 Mg: 2.25
    Ur: 125 Lactate: 1.2
    What category of acid-base
    imbalance happened in this
    patients?
    Etiology?

    Problems Metabolic
    acidosis

    Management?
    Berend K, de Vries AP, Gans RO. Physiological approach to assessment of acid–base
    disturbances. N Engl J Med. 2014;371(15):1434-45.
    Type A – hypoxic (septic shock,
    mesenteric ischemia,
    hypoxemia, hypovolemic shock,
    carbon monoxide poisoning,
    cyanide)

    Berend K, de Vries AP, Gans RO. Physiological approach to assessment of acid–base


    disturbances. N Engl J Med. 2014;371(15):1434-45.
    Treat the
    Management?? underlying
    cause
    Ongoing Therapy

     Omeprazol 2x40 mg iv  Furosemid 20 mg/hour iv


     Tranexamic acid 3x1gr iv  Midazolam 5 mg.hour iv
     Vit K 3x20 mg iv  Tramadol 200 mg/day

     Metronidazol 1x500 mg  Paracetamol 4x1 gr iv


     Nor adrenalin 0.15
     Meropenem 3x1 gr iv
    mcg/hour
     Levofloxacin 1x750 mg iv  Dobutamin 3 mcg/hour
     Antrain 3x1 amp iv  Rocuronium 40 mcg/houre

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