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SAJIAN KASUS SULIT Imam Mulyanto LLA L1 HR ( Relaps ) FEBRILE NEUTROPENIA

SAJIAN KASUS SULIT Imam Mulyanto LLA L1 HR ( Relaps ) FEBRILE NEUTROPENIA. Rg 111. (2). (3). (4). (5). Stop. Kultur Urin (22/11/11) Enterobacter cloacae >100000 kuman / mL Antimikroba Lini 1 Chloramphenicol ........................... R

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SAJIAN KASUS SULIT Imam Mulyanto LLA L1 HR ( Relaps ) FEBRILE NEUTROPENIA

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  1. SAJIAN KASUS SULITImam MulyantoLLA L1 HR (Relaps)FEBRILE NEUTROPENIA

  2. Rg 111 (2) (3) (4) (5) Stop KulturUrin (22/11/11) Enterobacter cloacae >100000 kuman/mL AntimikrobaLini 1 Chloramphenicol........................... R Cotrimoxazole............................. R Gentamicin................................ R Kanamycin................................. R Nalidic Acid.............................. R Nitrofurantoin............................ R Tetracycline.............................. R AntimikrobaLini 2 Amikacin.................................. R Aztreonam................................. R Sulbactam/Ampicillin...................... R Pipemidic acid............................ R Cephalothin............................... R Cefotaxime................................ R Amox. + Clavulanic Acid................... R Ceftriaxone............................... R Ceftazidime............................... R Cefoperazone.............................. R Ciprofloxacin............................. S Piperacillin/Tazobactam................... I Cefoperazone/Sulbactam.................S Netilmicin................................ R AntimikrobaKhusus Ertapenem................................. S Cefepime.................................. S Cefpirome................................. S Tigecycline............................... I Fosfomycin................................ S Meropenem................................. S Imipenem.................................. S Levofloxacin.............................. S Gatifloxacin.............................. R 40oC Kultur Darah (22/11/11) : Steril Analisis Feces KarakteristikTinja Makroskopik Cair + Lendir + Baubusuk -- Padat + Darah -- WrnKuning – hijau Lembek + Berminyak + Mikroskopik Leuko ++ Bakteri + Lemak + Eri -- parasit -- Amylum ++ PemeriksaanTerinci • A. PH 7,0 B. GulaNegatif • Lemak (Mikroskopis) + • 3. Pengecatan Gram • Basil gram negcocci + Diagnosis InfeksiUsusolehbakteri gram negative InfeksiUsusolehjamur Anjuranpengobatan Antibiotika Antimikotik RondeHematologi Ceftazidimdosisbiasa Analisis feces Hematologi Lanjutkanterapiceftazidimdosisbiasa Follow up hasilanalisis feces Hati-hatidehidrasi 39oC K. Urin K. Drh Analisis feces 38oC UrinLengkap WarnaKuning KejernihanJernih SedimenLeukosit1-2 /LPB Eritrosit 0-1/LPB SilinderNegatif SelEpitel 1+ Kristal negatif BakteriaNegatif Lain-lain Negatif BeratJenis ≤ 1.005 pH6.0 Protein Negatif GlukosaNegatif KetonNegatif NitritNegatif Leukosit Esterase Negatif DPL Hb : 8,7 g/dL Ht : 26,1 vol% Leu : 940/uL Tr : 36000/uL Hj : -/-/1/65/34 ANC 9,4 37oC Ur 7 mg/dL Cr 0.30 mg/dL SGPT 45 U/L SGOT 50 U/L PT 13.2 detik (Kontrol : 12.3 detik)↑1,07 x APTT 50.4 detik (Kontrol : 33.8 detik) ↑ 1,49 x Prokalsitonin 0.21 ng/mL Bilirubin Total 0.54 mg/dL BilirubinDirek 0.12 mg/dL BilirubinIndirek0.42 mg/dL Albumin4.48 g/dL Hematologi Karenapasienmasihdemamdanberdasarkanhasilkultursertahasilanalisistinjamakadiberikan Cefepimedosis sepsis dannistatin Prof Armen (via telp) Bolehdiberikancefepime, observasi 3 hari, bilatidakperbaikan, evaluasiulang 36oC DPL Hb 9,2 g/dL ANC 60,9 Ht 28,2 vol% Tr 24,000 /uL Leu 1,070 /uL MCV/VER 89,0 fL MCH/HER 29,0 pg MCHC/KHER 32,6 g/dL HitungJenis -/0,9/3/5,7/40/8

  3. (3) (4) (5) (6) (7) 40oC Hematologi Antibiotiklanjut Jikabesokbelumperbaikanrencanamasukmeropenem 39oC Kulturdarah jamur 38oC (3) UrinLengkap WarnaKuning KejernihanJernih Sedimen Leukosit 1-2 /LPB Eritrosit 0-1 /LPB SilinderNegatif SelEpitel + Kristal negatif BakteriaNegatif BeratJenis 1.005 pH 6.0 Protein Negatif GlukosaNegatif KetonNegatif Darah / HbNegatif BilirubinNegatif NitritNegatif Leukosit Esterase Negatif (4) (5) Hematologi DPL dan Urine lengkapulang Konsulnefrologi Hematologi Berikanfluconazole Kulturdarahjamur 37oC Nefrologi Masihmungkinpenyebabinfeksiselain ISK Belumperlugantiantibiotik Periksaurinulang TC 3 U DPL Hb 8.6 g/dL ANC 71 Ht 26.1 vol% Tr 11.000 /uL Leu 3.550 /uL HitungJenis -/-/2/64,5/33,5 MCV/VER 88.2 fL MCH/HER 29.1 pg MCHC/KHER 33.0 g/dL 36oC

  4. Isolasi (9) (10) (11) (stop) 40oC (2) 39oC Hematologi Pasiendemam, tambahkan IVFD untukkoreksisuhu Tambahkanlactulaxuntukmencegahfisuraani Tambahkanterapimetronidazol Hematologi Pasienmasihdemam Rencanagantimeropenem 38oC (7) (8) Hematologi LanjutCefepimehingga 14 hari Cekulang DPL danprokalsitonin (9) (10) (11) Prof. Armen Pasiendengan AB lini III (cefepime) yang sesuaidenganhasilsensitivitaskultururin; isolate Enterobacter cloacae Lanjutkancefepimehinggaharike – 9 Belumsetujupenggunaanmeropenem (Stop) (3) 37oC (2) DPL Hb 6.3 g/dL ANC 11,7 Ht 19.1 vol% Tr 32.000 / µL Leu 2.940 /µL Hit jns -/-/0,4/79,9/19,7 MCV/VER 87.6 fL MCH/HER 28.9 pg MCHC/KHER 33.0 g/dL Prokalsitonin 0.39 ng/mL Hematologi Kesan sepsis AB gantimeropenem Kulturdarahdankultururinsebelumnya TC II 3 U TC III 3 U 36oC Kulturdarah Kultururin

  5. (4) (5) (6) (7) (8) (13) (14) (15) (16) (17) 40oC (4) (5) (6) (7) (8) Hematologi BMP ulang 39oC DPL Hb 8.5 g/dL ANC 0 Ht 25.2 vol% Tr 5000/uL Leu 4.490 /uL MCV/VER 84.6 fL MCH/HER 28.5 pg MCHC/KHER 33.7 g/dL Hit jns -/-/-/88/- Blast 12 % 38oC Nutrisidanmetabolik Dapatdiberikan full TPN Oral tidakkontraindikasi TPN diberikan GIR 2 37oC BMP 36oC TC II3 U PRC WE 100 ml TC I3 U

  6. 40oC (3) (4) (5) (6) Hematologi DPL – PCT periksaulangsetelahtranfusi TC KonsulInfeksi InfeksiTropis Stop meropenem, amikasindanfluconazol Berikancefoperazonesulbactamdosis sepsis 39oC Hematologi Terapilanjut Pemberian lipid tergantungdivisinutrisidanmetabolik Ureum 21 mg/dL Creatinin 0,3 mg/dL SGPT (ALT) 31 U/L SGOT (AST) 54 U/L PT 14.1 Kontrol 12.1 detik APTT 44.6 detikKontrol 33.1 detik KulturdarahSteril KultururinAcinetobacter sp 34.000 Bilirubin Total 0.51 mg/dL BilirubinDirek 0.15 mg/dL BilirubinIndirek 0.36 mg/dL Albumin 4.47 g/dL 38oC InfeksiTropis Stop meropenem, amikasindanfluconazol Berikancefoperazonesulbactamdosis sepsis Hematologi Tranfusi PRC target Hb 12 Pertimbangkanamphotericin B Ambilhasil BMP Nutrisidan metabolic Lipid tetapdiberikanuntukmencegahcatabolic state agar target kaloriterpenuhi, walautanpatranfusitrombosit serial 37oC Kulturdarah Kultururin InfeksiTropis Teruskanpemberiancefoperazonesulbactamdanamikasin klinispasienmasihbaik Pemberian anti jamurmenungguresponantibiotik BMP GambaranRelaps TC III3 U 36oC

  7. Masalah • Febrile Neutropenia • Sumberinfeksi ? • ISK ? • Infeksiususolehbakteri / jamur ? • Bakteremia ? Sepsis? • Antibiotik • Cefoperazonesulbactam ? • Anti jamur • Amphotericin B ?

  8. Nutrisi • Intake << • Melena enteral (-) • Kebutuhankalori minimal ?

  9. TERIMA KASIH

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