Journal Onko

168
SURGICAL RESECTION OF THE PRIMARY TUMOUR IS ASSOCIATED WITH IMPROVED SURVIVAL IN PATIENTS WITH DISTANT METASTATIC BREAST CANCER AT DIAGNOSIS Dr. Elvida Christi Imelda

Transcript of Journal Onko

LAPORAN JAGA KAMIS 16 Desember 2010

Gambaran ttng kuala simpang dan RSUD Aceh Tamiang Aceh Tamiang kab pemekaran Aceh timur.RSUD Aceh Tamiang 3,5 jam dari Medan dan 8-10 jam dari Banda Aceh.Perbatasan Sumatera utara dan Aceh, 20 mnt dr perbatasan langkat Sumut.IntroductionDistant metastatic breast cancer is considered to be an incurable disease only treated with palliative intent.

Recent studies indicate that (complete) resection of the primary tumour significantly may prolong survival of patients with primary distant metastatic breast cancer Most of these studies did not rule out confoundingof their findings by the presence of co-morbidityless likely to undergo surgery

Patients and methods1.Patients The Eindhoven Cancer Registry (ECR) of the Comprehensive Cancer Centre South records data on all patients newly diagnosed with cancer in the south of the Netherlands.15 769 patients were diagnosed with breast cancer in the period 1993-2004.This study included the 728 patients with distantmetastatic disease at initial presentation (4.6%).The patients were staged according to the TNM system of the UICC.

patients who did not undergo surgery and/or for whom the postoperative tumour size was unknown,we used the clinical tumour size as measured on the mammogram or at palpation, to determine the T-classification. localization of metastatic disease and the number of metastatic sites was also recorded.

Co-morbidityRecords co-morbidity accordingto a slight adaptation of the list of serious diseases drawn up by Charlson.

important conditions were recorded: chronic obstructive pulmonary diseases (COPD), cardiovascular and cerebrovascular diseases, other malignancies (excluding basal cell carcinoma of the skin), and diabetes mellitus. Connective tissue diseases, rheumatoid arthritis, kidney, bowel, and liver diseases, dementia, tuberculosis and other chronic infections were also recordedStatistical analysesSurvival time was defined as the period between the date of diagnosis and the date of death or 1 July 2006 for the patients who were still alive.The log-rank test to evaluate significant differences between survival curves of surgically and non-surgically treated patients in univariate analyse.Stratified analyses to compare surgically and non-surgically treated patients in subgroups defined by age (1), presence of visceral metastases (yes or no) and co-morbidity (present or absent).multivariable Cox regression analysis the independent contribution of surgery of the primary tumourage, period ofdiagnosis, T-classification, number of metastatic sites, presence of visceral metastases, co-morbidity, use of locoregional radiotherapy and use of systemic therapy,clinical and postoperative axillary nodalnot included.Hazard ratios (HR) with 95% confidence intervals (CI)and p values were estimated with respect to the reference category for each co-variate.The SAS computer package (version 9.1) was used for all statistical analyses.Results

Results728 patients diagnosed with primary metastatic breast cancer, diagnosed in the period 1993-2004, 288 had surgery of the primary tumour.patients who had surgery of the primary tumour were younger than the patients whose primary tumour remained in situ. Patients who had surgery were also less likely to have concomitant diseases; 54% of the surgically treated patients had no co-morbidity versus 37% in the non-surgically treated patients.

Resultsthe proportion of patients with 2 or more concomitant diseases was smaller (11% vs. 19%).The use of loco-regional radiotherapy was higher among the patients who had surgery (34% vs 10%),systemic therapy (89% vs. 79%).

The proportion of patients who had surgery decreased, period 1993-199655%, in the period 1997-200039% and to 30% in the period 2001e2004 ( p < 0.0001).288 patients who received surgery, 85 had breast conserving surgery and 189 had mastectomy. Type of surgery could not be retrieved for 14 patients. Axillary dissection was performed in 190 patients, of whom 44 had breast-conserving surgery and 146 had mastectomy.Univariate analysesMedian survival of the patients who had surgery of their primary tumour was significantly longer than for the patientswho did not have surgery (31 vs. 14 months) andthe 5-year survival rates were 24.5% (95% CI 18.9-30.1) and 13.1% (95% CI 9.5-16.7),stratified analysis according to age, tumour size, number of metastatic sites, and localization of metastases (non-visceral or visceral) and presence of concomitant diseasesprolonged survival in all strata( p < 0.01)

patients who had surgery, no significant difference in overall survival was observed between those with breast-conserving surgery or mastectomy ( p 0.80).

Patients undergoing axillary dissection tended to have a better overall survival than those without axillary dissection, but this difference was restricted to the first year.Multivariable analyses

Surgery appeared to be an independent prognostic factor associated with overallsurvival (HR 0.62; 95% CI 0.51-0.76). The presence of concomitant diseases was associated with a worse survival, but this association was not statistically significant ( p 0.06).Did not demonstrate a significant associationbetween the type of surgery (i.e., breast-conserving surgery versus ablation) or use of axillary dissection on overall survival(p 0.59 and p 0.35, respectively)

Discussionpatients with primary distant metastatic breast cancer who underwent surgical removal of the primary tumour had a median survival that was 16 months longer than for patients who did not undergo surgery.the patients with surgery were younger, had smaller tumours, were less likely to have co-morbidity, more than one metastatic site or visceral metastases and were more often treated in combination with loco-regional radiotherapyand/or systemic treatment.The impact of surgical resection of the tumour persisted in a multivariable analysisadjusting for these potential confounders, with a hazard ratio of 0.62 and a 95% confidence interval ranging from 0.51to 0.76.Among the surgically treated patients, no differencein overall survival was observed between those who underwent lumpectomy or mastectomy.proportion of patients with primary distant metastatic breast cancer undergoing surgery decreased from 55% in the period1993-1996 to 30% in the period 2001-2004Type of surgery and surgical marginsAll studies conducted to analyze the impact of local surgical therapy in women presenting with stage IV disease and an intact primary tumour show that surgical resection of the tumour is associated with a better prognosis.indicated that the improved survival remained limited to or was larger for those patients whose primary breast lesion had been removed with free surgical margins, No information on margin status was available.Co-morbidity and performance statusAdjusting for the presence of co-morbidity and age at the same time had little additional effect on the risk estimates, whencompared to adjusting for age alone.co-morbidity is not a very accurate descriptor of the general condition of a patient. Measures of general performance,such as the WHO scale or the Karnofsky score maybe more suitable, but will also not be sufficient to rule out the risk of residual confounding by other factors.

Timing of surgery and systemic treatmentNo information on timing of surgery was available for our study.After the metastatic work-up was completed, or could already have been identified at the time of surgery, with the primary aim of surgery being loco-regional tumour control.The first groupgenerally accepted and recommended in the treatment guidelines that there is no need for peri-operative screening for metastases in patients with a pre-operative diagnosis of early stage breast cancer without clinical signs of distant tumour spread.Chest Xray, bone scanning and liver ultrasound were generally recommendedfor patients with tumours larger than 5 cm (i.e.T3), tumours with direct extension to the chest wall or skin ie. T4a-d) and/or patients with evidence of extensive regional disease at clinical examination.In a recent study by Cady et al., it is suggested that most of the survival advantage for patients undergoing surgery is explained by case selection bias, meaning that patients with a good responseto initial systemic therapy are also more likely toundergo surgery than those with a poor response

Biological rationale behind the findingsthe beneficial effect of surgery is that lowering the tumour load will reduce the number of circulating tumour cells in the blood, which are an important source of new metastatic deposits. Number of circulating tumour cells is known to be an independent predictor progression-free survival and overall survival in patients with metastatic breast cancer.The removal of the primary tumour should be considered as part of a multimodal strategy to prevent dissemination of tumour cells, also including radiotherapy and systemic treatment.

Conclusionsurgical removal of the primary tumour is associated with a significantly longer survival time in patients with distant metastatic breast cancer at diagnosis.

The authors state that they have no conflict of interestEpidemiologi Insiden di Great Britain, bervariasi 1;4-6 kasus per 1000 lahir hidup.keseluruhan, ratio L: P 3:1,dgn bertambahnya usia, pd anak > 4 thn, perbedaan gender L: P 8:1. Intussusception paling sering terjadi pada usia 5-10 bln.Paling sering menjadi penyebab obstruksi intestinal pd pasien 5 bln-3thn. 25% operasi emergensi abdomen pada anak < 5thnoperasi intussusception, melebihi insiden operasi apendiks, walaupun jarang pd neonatus. jarang pd usia < 3bln dan > 3 thn. byk ditemukan bayi sehat dan mendapatkan makanan bergizi.PATOFISIOLOGI :SEGMEN USUS PROKSIMAL MASUK KE SEGMEN USUS DISTAL DISERTAI MESENTERIUM SEHINGGA TERJADI ANGULASI DAN PENEKANAN VENA-VENA YG MENIMBULKAN UDEM DINDING USUSPENEKANAN ARTERI KE SEGMEN USUS AKAN MENIMBULKAN ISKEMI SAMPAI NEKROSISetiology1.Idiopatik (primer intussusception)2. Sekunder intususepsi.

IdiopatikSebagian besar kasus intususepsi tdk mempunyai patologik lead pointklasifikasi idiopatik atau primer intususepsi.Berkaitan dgn hipertrophy peyers patches,didalam dinding ileum.Diawali dengan infeksi saluran pernafasan atas atau episode gastroenteritis,yang menyebabkan pembesaran jaringan limfoid.Adenovirus dan rotavirus menyebabkan > 50% kasus intussusception.Secondary intuseppsiLesi yang identifikasi sebagai lead pointbagian proksimal masuk ke bagian distal disebabkan oleh aktivitas periltastik.Sekunder intusepsi meningkat setelah umur 2 tahun2-12% anak-anak didapatkan lead point pada pembedahanBebarapa contoh lead points:Diverticulum meckelPembesaran kelenjar limfa mesenterikaTumor jinak atau ganas pada mesenterium atau intestine, termasuk limfoma dan polypMesenteric atau duplikasi kistaHematome submukosa yang terjadi pada patient dengan HSP dan coagulasi dyscrasiaPenkreas ektopikSuture dan staple sempanjang anastomoseHematome intestinal sekunder pada trauma abdomenBenda asingHemagiomaKaposi sarcomaPost-transplantasi kelainan lymphoprolifirativeLokasi yg tersering ileo colic 80-90% ileo ileal 15% jarang caeco colic, jejuno jejunalTANDA DAN GEJALA KLINISANANMNESIS :a. BAYI MENGALAMI SERANGAN NYERI ABDOMEN PERIODIK DIANTARA DUA SERANGAN BAYI TAMPAK NORMAl (Crampy abdominal pain)b.ORANGTUA BAYI MENGELUH DEFEKASI BERDARAH SECARA TIBA-TIBA DENGAN WARNA KHAS CURRANTS JELLY STOOLc. BAYI MENGALAMI MUNTAH-MUNTAH DAN PERUT KEMBUNGd. BAYI DIKELUHKAN SANGAT REWEL PADA SAAT TIMBUL SERANGAN NYERI ABDOMEN

2. PEMERIKSAAN FISIK : a.PADA FASE AWAL PENYAKIT PE- MERIKSAAN FISIK TIDAK BANYAK MEMPERLIHATKAN KELAINAN b.ABDOMEN MASIH TERLIHAT DATAR, NAMUN PADA PERABAAN TERDAPAT MASSA SEPERTI SOSIS c.PADA SAAT SERANGAN BISING USUS MENINGKATTrias klasik yaitu:crampy abdominal painCurrant jelly stoolPalpable mass

d. GEJALA DAN TANDA PERITONITIS SEPERTI DEFANS MUSKULER, BISING USUS MELEMAH DAPAT DITEMUKAN PADA PEMERIKSAAN FISIK ABDOMEN JIKA TELAH TERJADI KOMPLIKASI PERFORASI USUS e. PEMERIKSAAN REKTUM DAPAT TERABA PSEUDOPORTIO DAN SARUNG TANGAN MENGANDUNG DARAH BERCAMPUR LENDIRPENUNJANG DIAGNOSIS :RADIOLOGI : 1. FOTO POLOS ABDOMEN :ABDOMEN KANAN TERLIHAT AIRLESS, TERDAPAT GAMBARAN OBSTRUKSI USUS HALUS JIKA KASUS LANJUT

2. ULTRASONOGRAFI ABDOMEN : TERLIHAT GAMBARAN DONAT SIGN atau TARGET SIGN 3. ENEMA BARIUM : TERLIHAT GAMBARAN BERHEN-TINYA KONTRAS PADA DAERAH INTUSSUSEPTUM SEPERTI HURUF U DISEBUT CUPPING DAN GAMBARAN COILLED SPRING

Differential diagnosisHernia inkarserataInternal herniaAdhesive bandVolvulusDivertikel meckel

TERAPI DAN PENGELOLAAN :NON SURGIKAL : 1. SYARAT : TIDAK TERDAPAT TANDA-TANDA PERITONITIS DAN OBSTRUKSI USUS MEKANIS SECARA KLINIS DAN RADIO-LOGIS 2. TEKNIS PENGELOLAAN :a. BAYI TELAH DIPERSIAPKAN UNTUK TINDAKAN OPERASIb. PEMASANGAN INFUS, PIPA LAMBUNG DAN PEMBERIAN ANTIBIOTIKAc. NON SURGICAL DAN SURGICALd. NON SURGICALTHRAPEUTIK ENEMA YI: HIDROSTATIK DGN BARIUM, WATER SOLUBLE CONTRAS ATAU PNEUMATICMELALUI ANUS DIBERIKAN TEKANAN HIDROSTATIS.e. DENGAN PNEUMATIC REDUCTIONTATALAKSANA REDUKSI :BAYI TELAH DALAM KEADAAN SEDASI DENGAN SEDATIVA DLLNYABAHAN REDUKSI BARIUM DIMA-SUKKAN KEDALAM BOTOL YANG DITEMPAT PADA KETINGGIAN 90 CM DIATAS TEMPAT BAYI DAN MELALUI PIPA DIMASUKKAN BERTAHAP KE DALAM REKTUM MELALUI ANUS DENGAN TEKANAN HIDROSTATIS

3. MELALUI FLUOROSKOPI JALANNYA BARIUM DARI REKTUM DI IKUTI SAMPAI KE DAERAH SEGMEN USUS TEMPAT INTUSSUSEPTUM BERADA SEHINGGA TERLIHAT GAMBARAN CUPPING4. PEMBERIAN BARIUM DENGAN TEKA-NAN HIDROSTATIS DILANJUTKAN SAMPAI TERJADI REDUKSI, JIKA TIDAK TERJADI PEMBERIAN BARIUM DIHENTIKAN5. JIKA SELURUH KOLON DAPAT TER-ISI KONTRAS BARIUM DISEBUT WINDOW TERBUKAARTINYA REDUKSI TERISI6.PEMBERIAN KONTRAS DILANJUT KAN SAMPAI ILEUM TERMINALIS TERISI DAN GAMBARAN INI DISEBUT WINDOW TERISI MEMBUKTIKAN TIDAK TERDAPAT INTUSSUSEPSI PADA SEGMEN USUS HALUS

7. PARAMETER KLINIS REDUKSI DGN TEKANAN HIDROSTATIS BARIUM BERHASIL JIKA BAYI DEFEKASI DGN MENGELUARKAN BARIUM DAN PADA PEMERIKSAAN, ABOMEN KEMPES DISERTAI HILANGNYA TANDA-TANDA OBSTRUKSI INTESTINALIS

B. PEMBEDAHAN (SURGIKAL) : LAPAROTOMI EKSPLORASI: 1. PADA SEGMEN USUS YANG MASIH VITAL (VIABLE) DILAKUKAN REDUKSI SECARA MANUAL DGN TEHNIK MEMERAH SUSU SAPI (MILKING) SECARA HATI-HATI DAN GENTELMEN SAMPAI SEGMEN USUS TEREDUKSI TANPA KOMPLIKASI

2. JIKA TERJADI KOMPLIKASI PADA SAAT REDUKSI DENGAN TEHNIK MILKING MAKA TINDAKAN TERSE-BUT DIHENTIKAN, SEGERA DILAKU-KAN PROTEKSI AGAR KONTAMINASI INTRA PERITONEAL DIHINDARKAN. SEGMEN USUS YANG MENGALAMI KOMPLIKASI SEPERTI PERFORASI DAN ATAU LASERASI DIKELOLA SESUAI DENGAN KEBUTUHAN SAAT ITU KALAU PERLU RESEKSI 3.JIKA PADA WAKTU RONGGA PERI-TONIUM DIBUKA,DITEMUKAN TANDA-TANDA SEGMEN USUS MENGALAMI NEKROSIS SAMPAI GANGREN MAKA DILAKUKAN RESEKSI SEDANGKAN UNTUK ANASTOMOSIS TERGANTUNG INDIKASI DAN KONDISI PASIEN SAAT ITU JIKA TIDAK MEMUNGKINKAN RESEKSI,DILAKUKAN EKSTEORISASI 4. TINDAKAN DEFINITIF UNTUK ANAS-TOMOSIS ATAU MENGEMBALIKAN PATENSI USUS DIPERTIMBANGKAN UNTUK DIKERJAKAN SECEPATNYA SESUAI DENGAN KONDISI PASIEN DAN PERSYARATAN YANG HARUS DIPENUHI UNTUK ANASTOMOSIS SEGMEN USUS.PERAWATAN PASCA TERAPI ; PASCA REDUKSI NON SURGIKAL :1. PASIEN TETAP DIRAWAT UNTUK OBSERVASI DAN EVALUASI TANDA-TANDA RESIDIF DAN KOMPLIKASI SEPERTI PERITONITIS PERFORASI2. JIKA DALAM WAKTU 24 JAM PASCA REDUKSI TIDAK ADA KELAINAN PASIEN MINUM BERTAHAP3. PASCA REDUKSI HARI KE TIGA JIKA KEADAAN UMUM PASIEN BAIK, FUNGSU USUS BAIK (DEFEKA-SI,FLATUS), INTAKE PER ORAL CUKUP INFUS DAPAT DILEPAS 4. PASIEN DIPULANGKAN HARI KE 4 PASCA REDUKSI DENGAN SARAN AGAR ORANG TUA PASIEN ME-NGAWASI KEMUNGKINAN TERJADI KEKAMBUHAN DAN ATAU KOMPLI-KASIB. PASCA REDUKSI MANUAL MILKING :JIKA REDUKSI BERHASIL TANPA KOMPLIKASI PERAWATAN PASCA BEDAH SAMA SEPERTI REDUKSI NON SURGIKALJIKA TERJADI KOMPLIKASI MAKA PASIEN DI PUASAKAN SAMPAI 3 HARI DAN DIBERIKAN NUTRISI PARENTERAL YANG MEMADAI 3. PARAMETER KLINIS FUNGSI USUS DIPANTAU DENGAN BAIK JIKA FUNGSI USUS TELAH KEMBALI NORMAL PASIEN DIBERIKAN MAKANAN PER ORAL BERTAHAP

4.PASIEN DIPULANGKAN HARI KE 5 PASCABEDAH JIKA KEADAAN UMUM PASIEN BAIK INTAKE PER ORAL BAIK DENGAN SARAN KEPADA ORANG TUA PASIEN TENTANG TANDA-TANDA KEKAMBUHAN DAN C.PASCA RESEKSI USUS & ANASTOMOSIS DIPUASAKAN SEPERTI JIKA TERJADI KOMPLIKASI PADA MILKING MANUALTERHADAP PASIEN YANG DILAKUAN ANASTOMOSIS TERTUNDA PERAWATAN PASCABEDAH SEPERTI PASIEN DENGAN STOMA INTESTINALIS 3.PASIEN YANG DIKERJAKAN EKSTE-ORISASI SEMENTARA TETAP DALAM KONDISI SIAP OPERASI KE DUA UNTUK ANASTOMOSIS ATAU SECOND LOOK. PASIEN TETAP PUASA. 4.PEMBERIAN INFUS UNTUK NUTRISI DAN PEMBERIAN CAIRAN MAINTENANS, ANTIBIOTIKA DAN DIKERJAKAN PEMERIKSAAN LABO-RATORIUM SEPERTI KADAR Hb, PROTEIN ALBUMIN DARAHKomplikasi berhubungan intususepsi Perforasi selama reduksi nonoperatif.Luka terinfeksiHernia interna dan adhesion menyebabkan intestinal obstruksi.Sepsisperitonitis tdk terdeteksi.Hemoragik intestinal.Nekrosis dan perforasi usus.Rekurensi.prognosePrognose bagusjika diagnosa dan pengobatan awal atau lebih cepat.Klu terjadi komplikasikematianRekurensi rateintususepsi non operatif 10% sd 15%.Rekurensi dpt terjadi sampai 36 bln.Rekurensi setelah air enema dan barium enema 4% dan 10%.

Thank YouPX GDN GAINCISI DI SUPRA ATAU INFRAUMBILIKALISREKOMENDASIKAN INCISI INFRAU

TEHNIK OPERASI PX DGN GENERAL ANESTESI

Pertengahan bulan desember 2010SK Depkes: penempatan diRSUD Aceh Tamiang. Takut daerah konflik dan keamanan. Belum pernah ke Aceh. RUSD Aceh Tamiang baru terbentuk 8 thn.RSUD type C.Tenaga spesialis : Penyakit dalam dan untuk anak, obgyn, bedah serta PKresiden yang di rotasi 3 bln.2 kali seminggukunjungan Spesialis Jantung, paru, neuro dan mata.

Fasilitas Laboratorium, radiologi, Rehab medis.Ruangan : UGD, poliklinik bedah, Interna, Anak, Obgyn, neurologi, Mata, jantung dan paru serta poli umum. Ruangan perawatan: Vip, Kls 1, 2, 3, anak, Obgyn.Ok : Bedah, Obgyn dan Mata serta THT.Rumah dinas untuk dokter.

Di aceh tamiang 5hari kerja (sabtu minggu libur)Tempat kerja Ruangan, Poliklinik, Ok dan UGD.Rata rata pasien di ruangan perawatan 12 perhari. px di poli 15 perhari. tindakan operasi 2-3 px/hari. kasus di ruangan Head injury.Ok : appendisitis, Hernia, peritonitis, FAM, tumor jinak, Fraktur, BBB. kesimpulan Aceh yang menakutkan Sangat aman.Terima kasih

SS: (GCS E1V1M2)Kepala : CH (+) R. frontal (S), R. ocipitalis(S) Mata : Midriasis +/+, RP -/-THT : Otorea -/-, Rhinorea -/-Leher: Jejas (-), Thorak : Simetris, D et S, jejas (-) Cor: S1S2 tunggal reguler murmur (-) Po: Ves +/+, Rh -/-, Wh -/-Abd: Jejas (-), Distensi (-), BU (+) NExtr: Akral hangat 79Ass:CKBSusp perdarahan Intracerebral

Lab: WBC 24,1/RBC 4,01/HGB 12,7/ HCT 37,0/PLT 357PH 7,32/ Pco2 52/pO2 52/Hct 50,0/HCO3 26,8/ TCO2 28,4/BE(B) -0,30/SO2C 83/THBC 15,5Na 137/K 3,0Px penunjang : CT-Scan kepalaCervical AP/LatThorax APPelvis AP80

Dx:CKBSDH frontotemporoparietal SSAHEdema cerebri

Tx:Oksigeasi 8 lt/mntNeuroprotectorAnalgetikantibiotik

15.00Os Apneu Bagging + ResusitasiMata: Pupil midriasis +/+, RP -/-15.10 Asystole RJP ( 10 menit)15.15Pasien meninggalPrimary brain damageCKBSDH frontotemporoparietal SSAHEdema cerebri

Agus Sugiartawan Made/L/17 thT.arr: 14.30T.acc: 20.00Ax:Pasien datang sadar mengeluh nyeri pada kaki kiri setelah terbakar 12 hari SMRS. Os sebelumnya berobat ke mantri selama 3 hari dan setelah perban dilepas os menaburi lukanya dengan daun teh kering, badan panas (+) 2 hari y.l.MOI: Os bekerja dibengkel menabrak kaleng berisi bensin dan secara tak sengaja teman membuang puntung rokok sehingga kaki os terbakar.PS:A: ClearB: Spontan, RR 20 x/mntC: Stabil, TD 110/70 mmHg, N 88 x/mntD: AlertSS (GCS E4V5M6)Kepala: CH (-)Mata: RP +/+, isokorTHT: Otorhea -/-, rhinorhea -/-Thorax: Simetris, Combustio Gr II A 4 %, Bula (+) Cor: S1S2 tunggal, reguler, murmur (-) Po: Ves +/+, Rh -/-, Wh-/-Abdomen: Dist (-), BU (+) NExt: ~ st lokalisSt. lokalisR. Cruris SL : Krusta (+), bula (-), jar. Granulasi (-), PUS (+)F : nyeri tekan(+)M: Rom angkle bebas. Combutio gr II-III 8% + infeksi sekunder

Assesment:Combustio Gr II B-III 9%

Penunjang:DL, Kimia darah, AGD elektrolit

LabWBC 15,7/RBC 5,39/HGB 15,4/HCT 44,3/PLT 562SGOT 36,47/SGPT 20,31/Alb 3,16/BUN 9,14/Crea 0,226/GDS 146,5Alb 3,49/ Bun 12,2/ Creat 0,69/GDS 102,8/Na 134,7/K 4,08Diagnosis: Combustio Gr II B-III 9 %

Tx:P/ Debridement G.A.AntibiotikAnalgetikVit C

Kawitra kd / L / 16 thtarr: 16.30 tacc: 13.30 AX :Os. datang tidak sadar setelah mengalami KLL 3 jam SMRS. Riwayat sadar (-), Muntah (-). Os rujukan RS Sanjiwani dengan diagnosis CKSMOI: Os pengendara sepeda motor ditabrak sepeda motor dari arah belakang, terjatuh dengan kepala membentur aspal.

PS:A: LapangB: Spontan, RR: 24 x/mntC: Stabil, T: 130/90 mmHg, HR: 88 x/minD: Pain responSS GCS: E2V2M5 Kepala : CH (-) , jejas (-) Mata : RP +/+ isokor, THT: rhinore -/-, otorhea +/- C-spine/ neck : jejas (-)Thorak : simetris , jejas (-) Po : ves +/+, rh -/-, wh -/- Cor : S1S2 reg, mur2 (-) Abdomen : Jejas (-),Distensi (-), BU (+) N, Defans (-)Ekstremitas : Akral hangatAss: CKSSusp perdarahan intracerebral Lab: WBC /RBC 4,01/HGB 12,7/ HCT 37,0/PLT 357PH 7,32/ Pco2 52/pO2 52/Hct 50,0/HCO3 26,8/ TCO2 28,4/BE(B) -0,30/SO2C 83/THBC 15,5Na 137/K 3,0 Pemeriksaan penunjang :CT scan kepala

Dx - CKS- SDH- Oedem Cerebri- Fr. Basis CraniiTx : Observasi KU, TV dan penurunan GCS

Nendi Ni Wayan/P/61 thT.arr: 17.15T.acc: 09.15Ax:Pasien datang sadar, rujukan RSU Negara dengan dx/ trauma tumpul abdomen. Os mengeluh nyeri pada seluruh perut sejak 3 jam SMRS setelah mengalami KLL. Riw pingsan (-), mual (-), muntah (-), badan panas (-).MOI: Pasien membonceng sepeda motor, menabrak sepeda motor lain dan os terjatuhPS:A: ClearB: Spontan, RR 22 x/mntC: Stabil, TD 70/40 mmHg, N 110 x/mnt Syok hipovolumikResusitasi cairan gagal surgical resusitasi Ruptur hepar gr IV zona III-IV

SS Kepala: CH (-) Mata: RP +/+, isokorTHT: Otorhea -/-, rhinorhea -/-Thorax: Simetris, Jejas (-) Cor: S1S2 tunggal, reguler, murmur (-) Po: Ves +/+, Rh -/-, Wh-/-Abdomen: I: distensi (+), drain prod(+) Au: BU (-) Pal: defans muscular (-) Per: TympaniExt: Akral hangat

Lab:WBC 21,5/RBC 2,35/HGB 7,0/HCT 19,9/PLT 269SGOT 396,70/SGPT 307,6/BUN 18,35/Crea 1,398/GDS 122,9/Na 138,4/K 3,97

Diagnosis:Trauma tumpul abdomen e.c. ruptur hepar grade IV zona III-IV

Tx:Primer hecting+packingRawat terapi intensif

Melky Puka/L/26 thTarr : 21.30Tacc : 21.00 Ax:Pasien datang tidak sadar, setelah mengalami KLL 30 menit SMRS. Riwayat sadar (-), muntah (+). Riw. Minum alkohol (+)MOI : Pasien pengendara sepeda motor dan terjatuh sendiri

PS : A: ClearB : Spontan, RR24 x/mntC : Stabil, TD 130/80 mmHg N 98 x/mntD : pain respon

104SS: (GCS E2V2M5)Kepala : CH (-) Maxillofacial: V appertum rima oris uk 2 cm.Mata : RP +/+, isokorTHT : Otorea -/-, Rhinorea -/-Leher: Jejas (-), nyeri (-)Thorak : Simetris, jejas (-) Cor: S1S2 tunggal reguler murmur (-) Po: Ves +/+, Rh -/-, Wh -/-Abd: Jejas (-), Distensi (-), BU (+) NExtr: Akral hangat 105Ass:CKSSusp perdarahan intrakranialLab: WBC /RBC 4,01/HGB 12,7/ HCT 37,0/PLT 357PH 7,32/ Pco2 52/pO2 52/Hct 50,0/HCO3 26,8/ TCO2 28,4/BE(B) -0,30/SO2C 83/THBC 15,5/Na 137/K 3,0Px penunjang : CT-Scan kepalaCervical AP/LatThorax APPelvis AP106

Dx:CKSSAHAlcoholic stageV. Appertum rima oris

Tx:WT/HTNeuroprotectorAnalgetikObservasi ketat VS, tanda peningkatan TIK dan penurunan GCSReposisi dengan GA + Skin traksi

Rusna I Ketut/L/37 thTarr : 22.30Tacc : 19.30 Ax:Pasien datang tidak sadar, setelah mengalami KLL 3 jam SMRS. Riwayat sadar (-), muntah (-). Os merupakan rujukan RSUD Tabanan dg dx/ CKBMOI : Pasien pejalan kaki ditabrak motor dari samping dan terjatuh dengan kepala membentur aspal.

PS : A: ClearB : Spontan, RR24 x/mntC : Stabil, TD 110/80 mmHg N 78 x/mntD : pain respon

111SS: (GCS E2V2M5)Kepala : CH (+) occipital Mata : RP +/+, isokorTHT : Otorea -/-, Rhinorea -/-Leher: Jejas (-), nyeri (-)Thorak : Simetris, jejas (-) Cor: S1S2 tunggal reguler murmur (-) Po: Ves +/+, Rh -/-, Wh -/-Abd: Jejas (-), Distensi (-), BU (+) NExtr: Akral hangat 112Ass:CKSSusp perdarahan intrakranialLab: WBC 10,8/RBC 4,21/HGB 13,7/ HCT 37,0/PLT 347PH 7,22/ Pco2 49/pO2 50/Hct 52,0/HCO3 28,8/ TCO2 29,4/BE(B) -1,30/SO2C 93/THBC 15,5/ Na 137/K 3,0Px penunjang : CT-Scan kepalaCervical AP/LatThorax APPelvis AP113

Dx:CKSLaserasi bifrontalEDH minimal occipital DEdema cerebriFractur basis craniiTear drop fracture cervical

Tx:NeuroprotectorAnalgetikObservasi ketat VS, tanda peningkatan TIK dan penurunan GCS

Konsul

Ridwan/L/40 tahunAnamnesisPasien dikonsulkan dari bagian neurologi dengan penurunan kesadaran e.c. encephalitis

St PresentTD: 100/60 mmHgRR: 24 x/mntN: 90 x/mnttax: 36,9 CSt Generalis (GCS E2V2M4)Mata: RP +/+ isokor Konjungtiva pucat -/-, ikt -/-THT : Kesan tenangThoraks: Cor: S1S2 tunggal reguler murmur (-) Po: Ves +/+, Rh -/-, Wh -/-Abdmen: Dist (-), BU (+) NExt: Akral hangatPenunjang:CT Scan kepala dengan kontras

Lab:WBC 7,4/RBC 4,12/HGB 13,1/HCT 40,1/PLT 112SGOT 28/SGPT 16/Alb 4/BUN 42/Crea 0,83/GDS 130/ Na 150/K 4

121

Dx:Fr/ depresif os frontalisFr/ basis craniiPneumocelAerocel

Tx:P/ elevasiSepala I Made/L/39 tahunAnamnesisPasien dikonsulkan dari bagian neurologi dengan SOL serebri susp abses cerebri +empiyema dd/ toxoplasmosis

St PresentTD: 150/120 mmHgRR: 20 x/mntN: 84 x/mnttax: 36,9 CSt Generalis (GCS E4V5M6)Mata: RP +/+ isokor Konjungtiva pucat -/-, ikt -/-THT : Kesan tenangThoraks: Cor: S1S2 tunggal reguler murmur (-) Po: Ves +/+, Rh -/-, Wh -/-Abdmen: Dist (-), BU (+) NExt: Hemiparese DPenunjang:CT Scan kepala dengan kontras

Lab:WBC 22,4/RBC 4,12/HGB 14,1/HCT 42,1/PLT 252SGOT 42,6/SGPT 90,1/Alb 4/BUN 34/Crea 0,6/GDS 209/ Na 134/K 4,4pH 7,4 /pCO2 45/pO2 77/HCT 48/HCO3 30,6/ TCO2 32/BE 5,5/SO2C 96/THBC 14,9/ Na 136/K4,4

127

Dx:SOL Serebri suspect abses serebri + empiyema

Tx:P/ reseksiMulyadi/L/45 tahunAnamnesisPasien dikonsulkan dari bagian neurologi dengan penurunan kesadaran e.c. ICB + IVH

St PresentTD: 150/1000 mmHgRR: 24 x/mntN: 88 x/mnttax: 36,9 CSt Generalis (GCS E2V2M5)Mata: RP +/+ isokor Konjungtiva pucat -/-, ikt -/-THT : Kesan tenangThoraks: Cor: S1S2 tunggal reguler murmur (-) Po: Ves +/+, Rh -/-, Wh -/-Abdmen: Dist (-), BU (+) NExt: Akral hangatPenunjang:CT Scan kepala

Lab:WBC 16,4/RBC 6,02/HGB 17,0/HCT 49,1/PLT 312SGOT 23,77/SGPT 42,63/BUN 10,81/Crea 0,83pH 7,41/pCO2 34/pO2 89/Hct 54/HCO3 21,6/TCO2 22,6/BE(B) -2,2/SO2C 97/THbc 16,7/Na 134/K 3,3132

Dx:ICBIVH

Tx:P/ Trepanasi-Evakuasi clotHCUHermes sutjipto / L / 17thMRS : 14/12/2010Dx : Stroke Hemoragik ICB fossa posteriorDM + Susp DHF gr I + Susp HHD

Tx:Trepanasi evakuasi clot ( 14/12/10 )

136S: ApatisO: GCS : E2V3M5 T 150/85 mmHg, N 85 x/mnt, RR 18x/min ,SO2 100%, T : 36,4C.Kepala: luka terawat, drain (+) prod cc/24 jamMata: RP +/+ isokor,pupil 3/3 mm, konj pucat -/-THT : terpasang NGT (+)Thorax: Simetris Cor: S1S2 tunggal, reg, murmur (-). Po: ves +/+, Rh -/-, Wh -/-Abdomen : I : dist (-) A : BU (+) N Pa : defans musc (-)Ext : akral hangatCM : 2700 cc/24 jamCK: 2600 cc/24 jam

137Lab : WBC 11,2/Hb 11,4/Hct 31,2/ Plt 83pH 7,40/pCO2 53/pO2 107/HCT 56 /BE 6,1/TCO2 34,2/HCO3 32,4/BE 6,1/ Sat 98/Na 134/K 4,2

Ass :Post trepanasi evakuasi clotStabil

Tx:Weaning138

139Nengah Budhi Mahardika/L/22 thMRS : 16/12/2010Dx : CKBEDH Parietotemporobasal SOedem cerebriSusp VSD + Eisenmenger syndrome

Tx:Trepanasi + Evakuasi klot (16/12/10)

140S: DPOO: T 100/60 mmHg, N 120 x/mnt, RR 12 x/min, FiO2 100%, PEEP 5, TV 500 CVCKepala: Luka operasi terawat, drain (+) prod minimalMata: RP +/+ anisokor OS>OD, , konj pucat -/-THT : OTT (+), NGT (+)Thorax: Simetris Cor: S1S2 tunggal, reg, murmur (-). Po: ves +/+, Rh -/-, Wh -/-Abdomen : Distensi (-), BU (+) dbN, nyeri tekan (-)Ext : Akral hangatCM : 2730 cc/24 jamCK: 2350 cc/24 jam

141Lab : WBC 17,7/RBC 5,8/HGB 20,8/HCT 58,9/PLT 202pH 7,57/pCO2 22/pO2 54/HCT 40 /HCO3 20/TCO2 20,9/BE -0,2/THbc 12,4/TCO2 23,7/SO2 92/Na 196/K 3,4

Ass :

Tx:142

143I Gst Ngrh Ari Sudewa / L / 28thMRS : 16/12/2010Dx : CKBSDH Temporo parietal SFr Depresive parietal DFr. Basis craniiPneumothorax D

Tx:Torakostomi + WSDVentilator support

144S: DPOO: T 129/89 mmHg, N 140 x/mnt, PC 25, TV 600, RR 12 x/mnt,, FiO2 100%, PEEP 7 SO2 100%,.Kepala: cephal hematome (-)Mata: RP +/+ anisokor S > DTHT : terpasang NGT(+) kecoklatan, OTT (+)Thorax: Simetris Cor: S1S2 tunggal, reg, murmur (-). Po: ves +/+, Rh -/-, Wh -/- Abdomen : distensi (-), BU (+), defans (-)Ext : akral hangatCM : 3365 cc/24 jamCK: 3520 cc/24 jam

145Lab : WBC 21,7/Hb 17,0/Hct 46,7/ Plt 226pH 7,57/pCO2 35/pO2 86/HCT 55 /HCO3- 32,1/ TCO2 22,2/ BE(B) 9,6/ SO2c 100%/ THbc 17,1/ Na 142/ K 3,8

Ass :

Tx:146

147I Wayan Sediana/L/ 30 thMRS : 15/12/2010Dx : Trauma tumpul abdomen ec ruptur hepar Gr III zone 3, 4

Tx:Laparotomi eksplorasi primer hacting (15/12/10)

148S: Nyeri luka operasi (+), flatus (-)O: GCS E4V5M6 T 133/81 mmHg, N 106 x/mnt, RR 20 x/mnt, spontan, O2 NC 5 L/mnt, tax 36,5 CKepala: dbNMata: RP +/+ isokor, konjungtiva pucat -/-, ikterus -/-THT : kesan tenangThorax: Cor: S1S2 tunggal, reg, murmur (-). Po: ves +/+, Rh -/-, Wh -/- Abdomen : I: distensi (-), Drain (+) 150 cc/minimal, Au: BU (+) N, Per: Tympani Pal: Defans (-), nyeri tekan (-)UG: DK (+) prod ccExt : akral hangatCM : cc/24 jamCK: cc/24 jam

149Lab : WBC 21,1/HGB 11,6/Hct 34,8SGOT 399,4/SGPT 438,9/Alb 2,7/BUN 10,5/Crea 0,7/GDS 208/Na 133,6/K 4,2

Ass :

Tx:150

151RTINi Ketut Nik/P/52 th MRS : 13/12/2010Dx : Abscess paranephric DBt Ren D/SHN Sedang DUrosepsisACKDTx:Incisi drainage + nefrostomy D153S: CMO TD 150/74 mmHg, N 72 x/mnt, RR 16 x/mnt, SPT.SM. Sat O2 99%, Tax : 36,2C.Mata: RP +/+ isokor, konj pucat -/-THT : NGT dekompresi (+) prod minimal kehijauanThorax: Simetris Cor: S1S2 tunggal, reg, murmur (-). Po: ves +/+, Rh -/-, Wh -/-Abdomen : dist (-), BU (+) NFlankD: Luka post op terawat , Nefrostomy (+) prod 200 cc/ jam kemerahanGE : DK (+) kuning jernihExt : akral hangatCM : 2470 cc/24 jamCK: 2400cc/24 jam

154Lab : pH 7,2/pCO2 54/pO2 159/HCO3 22,4/BE -5,1/Na 151/K 3,4WBC 17,3/HGB 9,1/HCT 24,7/PLT 425BUN 54,96/ SC 1,57

Ass : Anemia

P/transfusi PRC Lanjutkan perawatan intensif155

156Ulania Harismayanti/ P/ 17 th MRS : 15/12/2010Dx : Meduloblastoma + Metastase CervicalTx:Observasi

157S: DPOO: T 85/55 mmHg, N 72 x/mnt, RR 18 x/mntDuo PAP 10, FiO2 40%, PEEP 5, Sat O2 98%, T : 36,3c Mata: RP +/+ isokor, konj pucat -/-THT: NGT (+) feedingThorax: Simetris Cor: S1S2 tunggal, reg, murmur (-). Po: ves +/+, Rh -/-, Wh -/- Abdomen : dist (-), BU (+)N, NT (-)Ext : Tetraplegia Motorik 0000 00000000 0000 SensorikN NN NCM : 2050 cc/24 jamCK: 1400cc/24 jam

158Lab : WBC 15,8/Hb 11,3/Hct 32,5/ Plt 268pH 7,5/ pCO2 23/ pO2 245/ HCT 33/ TCO2 22/ BE 1,3/ Na 138/ K 3Alb 3,6/ BUN 16,6/ Cr 0,4/ BS 117/ Na 137/ K 3,2

Ass :Meduloblastoma + Metastase Cervical

P/ Lanjut perawatan intensif159

160I Md Karyana/L/6 tahun MRS : 8/12/2010Dx : Burst abdomenMultipel ileum perforasi Abses pelvisTx:Laparotomy- reseksi anastomosis ileostomy-bogotta bag (11.12.2010)Laparatomy-debridement-reseksi-end to end anastomosis (15-12-10)

161S: CM, panas (-), nyeri (-)O: KU lemah T 103/73 mmHg, N 102 x/mnt, RR 26 x/mnt, SO2 100%, T : 37C.Mata: RP +/+ isokor, konj pucat -/-THT : terpasang NGT dekompresi (+) prod 50 cc/24jam warna kehijauan Thorax: Simetris Cor: S1S2 tunggal, reg, murmur (-). Po: ves +/+, Rh -/-, Wh -/- Abdomen : I : dist (-), Luka post op terawat (+), ileostomy fungsi baik, faeces pd bogotta bag (-), drain prod 20 cc/24jam, serous hemoragik A : BU (+) lemah Pa : defans musc (-)UG: DK prod 1000 cc/24 jamExt : akral hangatCM : 1200 cc/24 jamCK: 2000 cc/24 jam

162Lab : WBC 14,5/Hb 11/Hct 31,5/ Plt 435SGOT 28,57/ SGPT 5,7/ Alb 3/ BUN 17,57/ Cr 0,25/ BS 219,9/ Na 138/ K 3,4

Ass : Post laparotomi- reseksi ileum + anastomosis ileostomi Stabil

P: TPN Prawatan intensive lanjut163

164Pasien MeninggalGari /L/30 tahunMRS: 18/12/2010Dx: CKB SDH frontotemporoparietal S SAH Edema cerebriCOD: Primary brain damage (07.40)Nendi Ni Wayan /P/61 tahunMRS: 18/12/2010 (17.15)Dx: Ruptur hepar grade IV zona III-IV

COD: Prolonged Syok (19/12/2010 pkl.01.40)Terima Kasih