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