F.A.S.T.H.U.G I W. Aryabiantara

F.A.S.T.H.U.G

It’s a mnemonic memudahkan seorang praktisi medis dalam memberikan terapi (Jean-Louis Vincent)•F = Feeding•A = AnalgetiK•S = Sedasi•T = tromboemboli profilaksis•H = Head of bed elevasi•U = Ulcer proteksi•G = Glucouse kontrol

FEEDING

• Berikan nutrisi se-segera mungkin setelah resusitasi stabil

• Ideal <72 jam• Nutrisi dini menurunkan angka kematian secara

signifikan• Bisa enteral bisa parenteral

Postprandial Hypotension

Liver

Stomach

Spleen

Pancreas

Smallintestine

ColonAorta

HepaticPortalveinI

300

S

500

200

C

H700

500 1000

From Review of medical physiology, Ganong WF. 2001

Meal400

VASODILATATION

Decrease Venous Returndecrease Stroke Volumedecrease Blood Pressure

vasodilatation

Shock state

DIVERTED BLOOD FLOW HEART & BRAIN

Control of CV system

Spinchterclosed

Vasoconstriction

NORMALDIVERTED BLOOD SUPPLY HEART & BRAIN

LOW FLOW STATE / HAEMORRHAGIC SHOCK

FEEDINGFEEDING

Endogenous vasoconstrictor

2. Ischaemia-Reperfusion injury

Splanchnic Hypoperfusion

1. Gut mucosal barrier disruption

Increased mucosal permeability to bacteria / endotoxin

SIRS MODS

Cardiac failure:- AMI- CHF- Tamponade

Hypovolaemia:- Dehydration- Hemorrhage

Gut mucosal hypoperfusion

Cytokine/ROS

Resuscitation

Gareth Ackland, Michael PW Grocott and Michael G Mythen: Crit Care 2000, 4:269–281

Exogenousvasoconstrictor:NE, Epi, Dopa

The ‘gut-origin hypothesis’

ANALGESIA

• Dasar : nyeri adalah vital sign yang ke-5• Pasien dalam kondisi apapun tidak boleh nyeri• Rangsangan nyeri tersebut dapat mempengaruhi

pemulihan fisiologis dan psikologis kurang tidur, disfungsi paru dan respon stres imunosupresi, hiperkoagulabilitas, katabolisme protein dan meningkatkan oksigen miokard consumption

Repeated episodes of acute pain, localised Surgery / tissue inflammation / immobility Catheter/ apparatus discomfort / naso & orogastric

tubes Endotracheal intubation/ suctioning/ chest tubes Phlebotomy / vascular access / physiotherapy Routine turning & positioning the patient

Source of Pain in ICU

Emergency intubation

Sometimes use only sedation and relaxan

Local anesthetic so

metimes ineffective

Local anesthetic so

metimes ineffective

The most painfull..R

outine turning

Receiving Beta Bloker

Vitals was normal

Critical clinical practice guidelines;

pain assesment and response to therapy should be performed on a regular basis using a scale appropriate to the patient population.

The use of VAS and NRS is recommended

For patients who cannot communicate, pain should be assessed through subjective observation of;

Pain related behaviour

Physiological indicators

Assessment of pain in ICU

Pain Rating ScaleVisual Analogue ScaleNumeric Rating ScaleFaces ScaleMcGill Pain Questionnare

Assessment of pain in ICU

Assasement nyeri

Pharmacologic Management of pain in the ICU

Textbook critical care, M. Fink 2006

Fentanyl: Golden Standard for H

emodynamic stability

SEDASI

TROMBOEMBOLI PROFILAKSIS

Cara Mekanik :

• Perubahan posisi berbaring secara berkala, • Pijat rutin pada tungkai bawah• Early mobilisasi pada pasien sadar • Graduated compression stockings (GCS), • Intermittent pneumatic compression (IPC)

devices • Venous foot pump (VFP).

Terapi medikamentosa :

• dapat berupa Heparin 5000 Unit setiap 8 jam• Enoxaparin 30 Unit setiap 12 jam• Dalteparin 2500 - 5000 Unit setiap 24 jam• Fondaparinux 2,5 mg setiap 24 jam

Head of The Bed Up

• Kemiringan bed 45 derajat• Mencegah regurgitasi• Salah satu komponen bundle pencegahan VAP• Pressure cuff dijaga < 20 mmHg• Sub glotic suction, oral hygiene

ULCER PROTEKSI• H2 Antagonists seperti Cimetidine 300 mg oral

atau IV setiap 6-8 jam• Famotidine 20 mg oral atau IV setiap 12 jam, • Ranitidine 50 mg IV setiap 12 jam• Penghambat pompa proton seperti Lanzoprazole

30 mg setiap 24 jam, omeperazole 20 mg setiap 24 jam atau Pantoprazole 40 mg setiap 24 jam,

• Sucralfat 10 mg setiap 6 jam

Glucosa Control-Hyperglicemia meningkatkan morbiditas, mortalitas dan biaya perawatan.-Dengan mengontrol gula darah akan menurunkan insidens penyembuhan luka yang lama, resiko infeksi, gangguan motilitas usus, gangguan performa kardiovaskuler, resiko polineuropati dan resiko gagal ginjal akut.

- Target gula darah idealnya dipertahankan dilevel 140-180 mg/dL.-Strategi mempertahankan gula darah :Insulin continuous dapat dijalankan setelah 2 kali pemeriksaan dengan interval 1 jam, masih menunjukkan > 180 mg/dL (kadang-kadang memerlukan insulin bolus sebelumnya). Insulin yang digunakan yg short actingHindari penggunaan sub kutan jika hemodinamik pasien belum stabil

Ventilator Bundle

• Patient positioning Elevation Recommended elevation is 30-45 degrees

• Ventilator weaning Periodic “sedative interruptions” and daily assessment of readiness to extubate may reduce the duration of mechanical ventilation and the risk of VAP

ICU Bundle

• Peptic ulcer disease (PUD) prophylaxis Patients with respiratory failure have an increased risk of “stress ulcers” and associated gastrointestinal (GI) bleeding.

• Venous thromboembolism prophylaxis Patients with respiratory failure have an increased risk of deep vein thrombosis. Treatment with anticoagulants (e.g., heparin) has been shown to reduce this risk.