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"Latar Belakang: Morbiditas dan mortalitas akibat renjatan pada anak di seluruh dunia dilaporkan masih tinggi. Pengenalan dini dan tatalaksana yang tepat penting untuk menurunkan morbiditas dan mortalitas akibat renjatan. Indikator penting untuk mendeteksi hipoksia jaringan global adalah pengukuran saturasi oksigen mixed vein (SmvO₂) dari kateter arteri pulmonal atau vena sentral namun kedua pemeriksaan ini sulit dan invasif sehingga tidak rutin dilakukan. Near infrared spectroscopy (NIRS) merupakan alternatif pemeriksaan non invasif, real time, kontinu dan praktis untuk mengukur saturasi oksigen regional sekaligus menggambarkan saturasi oksigen vena global.Tujuan: Mengetahui kenaikan nilai NIRS serebral pascarenjatan teratasi serta korelasinya dengan perubahan parameter hemodinamik non invasif.

Metoda: Penelitian potong lintang pada anak usia 1 bulan-18 tahun yang mengalami renjatan di RSUPN Cipto Mangunkusumo, RSUD Pasar Rebo dan RSUD Tarakan pada bulan Maret-Juni 2019. Terhadap subjek yang mengalami renjatan dilakukan pengukuran NIRS serebral, MAP, serta pengukuran non invasif Cardiac Index (CI), Systemic Vascular Resistance Index (SVRI), Delivery Oxygen (DO₂), Inotrophy Index (INO), Stroke Volume Index (SVI) menggunakan Ultrasonic Cardiac Output Monitoring (USCOM) pada saat renjatan dan diulang ketika renjatan teratasi. Uji korelasi dilakukan untuk menilai hubungan antara perubahan nilai NIRS serebral dan parameter hemodinamik non invasif.

Hasil: Dari 32 subjek yang diteliti ditemukan peningkatan nilai NIRS serebral sebesar 27,7% pascarenjatan teratasi. Parameter hemodinamik, kecuali untuk SVRI, juga mengalami peningkatan pasca renjatan namun tidak berkorelasi dengan peningkatan nilai NIRS.

Simpulan: Hasil pengukuran NIRS serebral menggambarkan perfusi dan oksigenasi ke jaringan perifer namun tidak berkorelasi dengan parameter hemodinamik non invasif pada penelitian ini.

Kata kunci: Near infrared spectroscopy; parameter hemodinamik non invasif; renjatan; USCOM

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Background: Pediatric shock accounts for significant morbidity and mortality worldwide. Early recognition and timely intervention are critical for successful treatment of pediatric shock. A strong indicator of global tissue hypoxia by measuring mixed venous oxygen saturation from pulmonary artery catheter (PAC) or central vein catheter (CVC) is rarely used due to its highly invasive character. Near infrared spectroscopy (NIRS) is a noninvasive, real time, continuous and practical modality is a safe alternative for regional and global oxygen saturation measurement.

Objective: To evaluate the increment of cerebral NIRS post-resuscitation in pediatric shock and its correlation with noninvasive hemodynamic measurements.

Methods: This cross sectional study was conducted at Cipto Mangunkusumo Hospital, Pasar Rebo Hospital and Tarakan Hospital between March and June 2019. Children whose age ranged from1 month to 18 years admitted to Emergency Department (ED) or Pediatric Intensive Care Unit (PICU) due to shock were included. Measurement of cerebral NIRS, MAP, as well as Cardiac Index (CI), Systemic Vascular Resistance Index (SVRI), Delivery Oxygen (DO₂), Inotrophy Index (INO), Stroke Volume Index (SVI) using Ultrasonic Cardiac Output Monitoring (USCOM) were performed on admission and after resuscitation when the shock has resolved and the patients were stable. Correlation between cerebral NIRS and other noninvasive hemodynamic parameters were then analysed.

Results: There were 32 subjects participated in this research. Following resuscitation, cerebral NIRS measurements showed an increment of 27,7% compared to cerebral NIRS in shock state. All non invasive hemodynamic parameters, except for SVRI, were also increased after resuscitation but no correlation observed between these parameters to cerebral NIRS (p>0,005).

Conclusion: Cerebral NIRS is a sensitive parameter of peripheral perfusion but showed not correlation with hemodynamic parameters in this research."

"Latar belakang: Penentuan kebutuhan nutrisi secara tepat pada anak sakit kritis perludilakukan untuk menghindari underfeeding dan overfeeding. Rumus estimasi menjadidasar perkiraan kebutuhan energi jika kalorimetri indirek sebagai baku emas tidaktersedia. Akurasi rumus pada studi terdahulu sangat bervariasi dan dipengaruhi olehkarakteristik populasi setempat, sehingga akurasinya perlu diuji pada populasi Indonesia.Tujuan: Mengevaluasi akurasi rumus Schofield WH, Schofield W, dan WHOdibandingkan kalorimetri indirek, serta mengevaluasi dampak penambahan faktor stresterhadap akurasi.Metode: Penelitian deskriptif analitik potong lintang ini mengikutsertakan pasien anakyang menggunakan ventilasi mekanik Mei sampai Juli 2019. Analisis kesesuaiandilakukan dengan membandingkan perhitungan rumus Schofield WH, Schofield W, danWHO, dengan dan tanpa faktor stres terhadap pengukuran kalorimetri indirek.Hasil: Penelitian mengikutsertakan 52 subjek pada hari perawatan 1-5 di PICU denganmedian usia 5 tahun (1 bulan 10 hari hingga 17 tahun 9 bulan). Kebutuhan energi yangdiukur kalorimetri indirek adalah 60,7 ± 23,5 Kkal/kg/hari. Estimasi rumus SchofieldWH, Schofield W, dan WHO lebih rendah dari hasil pengukuran tersebut dengan %biasberturut-turut -13 ± 19, -15 ± 20, dan -16 ± 21. Nilai estimasi dan hasil pengukurankalorimetri indirek berkorelasi kuat (intraclass correlation coefficient r > 0,9) namuninterval kesesuaian (limit of agreement) dari %bias sangat lebar. Hanya 12 (23%) subjekyang memiliki nilai estimasi akurat sesuai dengan kalorimetri indirek. Pada populasipenelitian ini faktor stres meningkatkan akurasi rumus estimasi.Simpulan: Rumus Schofield WH, Schofield W, dan WHO tidak akurat sebagai estimasikebutuhan energi anak sakit kritis. Hasil prediksi rumus tersebut lebih rendah darikebutuhan aktual jika faktor stres tidak digunakan.

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Background: Accurate estimation of energy expenditure in critically ill children isimportant to avoid underfeeding and overfeeding. Prediction formula helps to estimateenergy expenditure when the gold standard indirect calorimetry is not available. Previousstudy on estimation accuracy yielded variable result in different populationcharacteristics, therefore the accuracy of prediction formula in Indonesian populationneeds to be evaluated.Objective: To assess the accuracy of Schofield WH, Schofield W, and WHO formulacompared to indirect calorimetry. To evaluate the impact of additional stress factor on theaccuracy of prediction formula.Methods: This is a descriptive analytic cross-sectional study on mechanically ventilatedcritically ill children held in May-July 2019. We analyze the agreement of measuredenergy expenditure using indirect calorimetry and estimated energy expenditurecalculated by Schofield WH, Schofield W, and WHO formula, with and withoutadditional stress factor.Results: This study included 52 subjects with median age 5 years old (1 month 10 days -17 years 9 months) on day 0-5 after they were admitted to PICU. Mean measuredenergy expenditure was 60,7 ± 23,5 Kcal/kg/day. All estimated energy expenditure bySchofield WH, Schofield W, and WHO were lower than measured energy expenditurewith % bias of -13 ± 19, -15 ± 20, and -16 ± 21, respectively. Estimated and measuredvalue have strong correlation (intraclass correlation coefficient r > 0.9) but the limit ofagreement interval is too wide. Only 12 (23%) subjects have accurate estimation ofenergy expenditure. In this population stress factor improves the accuracy of predictionformulas.Conclusion: Schofield WH, Schofield W, and WHO formula have poor accuracy inestimating energy expenditure in critically ill children. Without additional stress factor,the estimated value were lower than actual/measured energy expenditure"

"Latar belakang: Pilihan terapi terbaik untuk gagal hati terminal adalah transplantasi hati (TH). Setelah transplantasi seorang anak akan mempunyai hati dengan fungsi normal, namun tidak berarti menjadi anak yang sehat. Pasca TH anak akan berada dalam kondisi kronis dengan morbiditas tersendiri.Tujuan: Mengetahui perbedaan Quality of Life anak dengan penyakit hati kronis (PHK) yang dilakukan TH dengan yang tidak secara kuantitatif.Metode: Penelitian ini merupakan studi potong lintang terhadap anak pasca TH minimal selama 1 tahun dan anak PHK yang merupakan kandidat TH berusia 2-18 tahun. Subjek pasca TH diambil secara konsekutif, kelompok PHK minimal berjumlah setara dengan dengan kelompok pasca TH. Kedua kelompok dilakukan penilaian Quality of Life (QoL) menggunakan kuesioner PedsQLTM4.0 dalam Bahasa Indonesia yang telah divalidasi. Rerata nilai PedsQLTM4.0 pada anak sehat adalah 82,92+15,55 dan 83,91+12,47 masing-masing untuk proksi orangtua (OT) dan penilaian anak (A). Pada kondisi kronis rerata PedsQLTM,4.0 untuk proksi OT dan A masing-masing adalah 73,14+16,46 dan 74,16+15,38. Nilai yang lebih tinggi menunjukkan QoL yang lebih baik. Nilai <1 SD adalah batas anak memerlukan intervensi terkait QoL nya.Hasil: Kesintasan 1 dan 5 tahun pasca TH anak di RSCM adalah 85,4% dan 79,3%. Subjek pasca TH proporsi kelompok usia terbanyak adalah 5-7 tahun (66,7%), median usia 6 tahun 7,5 bulan; diagnosis dasar terbanyak adalah atresia bilier (84,6%). Pada subjek PHK kelompok usia terbanyak adalah 2-4 tahun (46,3%), median usia 9 tahun, penyebab terbanyak adalah kelainan vaskular (29,3%). Rerata total QoL subjek pasca TH 1 tahun lebih tinggi dibandingkan dengan subjek PHK.Kesimpulan: Rerata nilai total QoL 39 subjek pasca TH lebih baik dibandingkan 41 subjek PHK kandidat TH baik berdasarkan proksi OT maupun A secara bermakna. Penilaian QoL proksi OT dan anak menyimpulkan dimensi terbaik adalah fungsi sosial dan terendah fungsi sekolah. Pada penelitian ini QoL tidak dipengaruhi oleh status gizi, infeksi CMV/ EBV, ataupun rejeksi.

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Background: Liver transplantation (LT) is the best-known treatment for terminal chronic liver disease (CLD). Following a LT procedure, the patient will have a functional liver but is not considered as healthy child. Post LT, the patient will remain in a chronic condition with its own morbidity.

Objective: To distinguish Quality of Life (QoL) distinction between terminal CLD patient who underwent LT and not.

Methods: A cross-sectional study was conducted on 39 subjects consisting of 1 year LT survivor patient and 41 LT candidate children, aged 2-18 years. Liver recipient subjects were taken consecutively, equal amount CLD subjects were collected. Both groups were assessed for Quality of Life (QoL) using the validated PedsQLTM4.0 questionnaire in Indonesian. PedsQLTM4.0 cut-off point average scores in healthy children (population) are 82.92+15.55 and 83.91+12.47 each representing parent proxy (P) and child self-assessment (C). In chronic conditions children, cut off point average score of PedsQLTM4.0 for P and C were 73.14+16.46 and 74.16+15.38 respectively. Higher values ​​indicate better QoL. One standard deviation below the population mean was explored as a cut-off point score for an at-risk status of impaired QoL.

Results: The 1 and 5 years-survival rate of LT children in RSCM were respectively 85.4% and 79.3%. Liver recipient subjects mostly consist of 5-7 years (66.7%) age group, median age was 6 years and 7.5 months; and the most prevalent diagnosis was biliary atresia (84.6%). In CLD, a portion of 2-4 years old age group (46.3%) was the dominant, the median was 9 years, and the most common diagnosis was vascular disorders (29.3%). Higher QoL score in post-transplant subjects was observed.

Conclusion: LT children’s QoL was significantly higher than children who were candidate for LT, according to parent proxy and child self-assessment. Based on both parent proxy and child-assessment, social function was observed to have the best the QoL function and school function scored the lowest. In this study, QoL of liver recipient children were not affected by nutritional status, CMV or EBV infection, nor rejection."

"Penggunaan antibiotik yang tidak rasional menyebabkan resistensi antibiotik di seluruh dunia. Berbagai upaya telah dilakukan untuk mencegah resistensi antibiotik. Penelitian ini bertujuan untuk melakukan evaluasi hubungan antara penggunaan antibiotik sesuai rekomendasi Pedoman Penggunaan Antibiotik (PPAB) dengan luaran klinis, luaran laboratorium, lama rawat dan luaran sekunder yang membaik pada anak dengan infeksi yang di rawat di ruang intensif anak. Penelitian ini menggunakan desain kohort retrospektif pada anak usia 1-18 tahun yang mendapat terapi antibiotik. Hasil penelitian, dari 85 anak, terdapat 126 penggunaan antibiotik, rerata usia 4,9 tahun, sebaran profil bakteri Gram negatif lebih banyak dibanding Gram positif, sebaran penggunaan antibiotik empiris sesuai rekomendasi PPAB (69,8%) menurut alur Gyssens merupakan kategori 0 (penggunaan antibiotik tepat). Berdasarkan analisis bivariat, variabel luaran klinis, luaran laboratorium, lama rawat dan luaran sekunder tidak  memiliki hubungan bermakna dengan penggunaan antibiotik sesuai PPAB (p>0,05). Sebagai saran, sosialisasi rutin oleh tim PPRA, evaluasi panduan PPAB terus diperbarui tiap 3-6 bulan sesuai data uji kepekaan antibiotik terbaru. Penelitian lebih lanjut diperlukan untuk evaluasi penggunaan antibiotik, secara prospektif dengan subyek yang lebih banyak, durasi lebih lama, kriteria inklusi yang lebih spesifik tanpa komorbid untuk memperkuat rekomendasi penggunaan antibiotik yang sesuai PPAB.

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The irrational use of antibiotics causes antibiotic resistance worldwide. Various attempts have been made to prevent antibiotic resistance. This study aims to evaluate the relationship between the use of antibiotics according to PPAB recommendations and improved clinical outcomes, laboratory outcomes, length of stay and secondary outcomes in children with infections treated in the pediatric intensive care unit. This study used a retrospective cohort design in children aged 1-18 years who received antibiotic therapy. The results of the study, of 85 children, there are 126 antibiotic use, the mean age was 4,9 years, the distribution of Gram-negative bacteria profiles was more than Gram-positive, the distribution of empirical antibiotic use according to PPAB recommendations 69.8% according to the Gyssens flow is category 0 (appropriate use of antibiotics). Based on bivariate analysis, the clinical outcome variables, length of stay, laboratory outcomes and secondary outcomes had a p value > 0.05 which were statistically not significantly different to have a relationship with the use of antibiotics according to PPAB. As a suggestion, regular socialization by the PPRA team and evaluation of the PPAB guidelines are continuously updated every 6 months according to the latest antibiotic sensitivity test data. Further research is needed to evaluate the use of antibiotics, prospectively with more subjects, longer duration, more specific inclusion criteria without comorbidities to strengthen recommendations for the use of antibiotics according to PPAB."

"Latar belakang: Sepsis merupakan penyebab kematian dan kesakitan utama di unit perawatan intensif anak. Pemberian bolus cairan masih menjadi pilihan utama dalam mengatasi renjatan sepsis dan digunakan pada panduan tata laksana internasional. Terapi bolus cairan bertujuan memperbaiki pasokan oksigen dengan meningkatkan curah jantung. Bukti yang mendukung panduan tersebut sangat terbatas sehingga menimbulkan kontroversi.Tujuan: Menilai perubahan pasokan oksigen, indeks curah jantung dan hemoglobin pada anak renjatan sepsis yang mendapat bolus cairan saat resusitasi.Metode: Penelitian observasional terhadap 35 subyek dari Februari-Mei 2019 di unit perawatan intensif anak Rumah Sakit Cipto Mangunkusumo (RSCM), Rumah Sakit Umum Daerah (RSUD) Tarakan dan Pasar Rebo Jakarta. Subyek dipilih secara consecutive sampling dan ditata laksana sampai selesai sesuai prosedur yang berlaku.Hasil: Terdapat 23 dari 35 subyek yang mendapat  cairan bolus sampai 40 mL/kg dan 12 subyek hanya mendapat 20 mL/kg. Tidak terdapat perubahan indeks curah jantung dan pasokan oksigen sebelum dan sesudah pemberian cairan bolus (p= 0,235 dan p=0,340). Terdapat perubahan kadar Hb setelah pemberian cairan bolus (p=0,002).Simpulan: Penurunan kadar hemoglobin terjadi setelah pemberian cairan bolus tetapi tidak terbukti menyebabkan perubahan indeks curah jantung dan pasokan oksigen pada penelitian ini.

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Background: Sepsis is a leading cause of morbidity and mortality in children with a worldwide prevalence in pediatric intensive care units. Fluid bolus (FB) is a first line therapy for resuscitation of septic shock and has been recommended in international guidelines. FB aimed to increase delivery oxygen with increasing cardiac output. The supporting evidence based are still limited and controversy.

Objective: To evaluate the changing of delivery oxygen (DO₂), cardiac index (CI) and hemoglobin (Hb) in pediatric septic shock after fluid bolus in resuscitation.

Methods: An observational study of 35 subject that conducted from February till May 2019 in Pediatric Intensive Care Unit (PICU) Rumah Sakit Cipto Mangunkusumo (RSCM), Rumah Sakit Umum Daerah (RSUD) Tarakan and Pasar Rebo Jakarta. The selection of subject with inclusion criteria through consecutive sampling and managed according to standard operating procedure.

Result: There were 23 from 35 subject got 40 mL/kg and 12 subject got 20 mL/kg fluid bolus only. There were no changing of DO₂ and CI after FB (p=0.235;p=0.340) then there was changing of hemoglobin after FB (p=0.002).

Conclusion: Hemoglobin decreases after FB without change of CI and DO₂ can be proved in this study."

"Latar belakang: Duktus arteriosus persisten signifikan hemodinamik (DAPsh) ditandai dengan peningkatan aliran darah paru dan penurunan aliran darah sistemik. Hipoperfusi sitemik yang menyebabkan penurunan oksigenasi jaringan dapat dideteksi menggunakan near-infrared spectroscopy (NIRS) yang dipasang di area serebral, renal, dan abdomen.Tujuan: Mencari nilai diagnsotik dari NIRS serebral, renal, dan abdominal dalam mendeteksi dini DAPsh pada bayi <32 minggu.Metode: Sebanyak 43 subjek bayi prematur dilakukan pemantauan dengan memasang NIRS serebral, renal, dan abdomen pada 3 jam pertama selama 72 jam. Semua subjek dilakukan pemeriksaan dengan ekokardiografi dalam 24 jam pertama untuk menilai adanya DAPsh. Kriteria ekokardiografi yang digunakan termasuk parameter oversirkulasi paru dan pola aliran doppler di serebral, renal, dan abdominal. Nilai rerata dari NIRS selama 72 jam dibandingkan antara kelompok DAPhs dan non-DAPhs.Hasil: Terdapat 10 subjek dengan DAPsh dan 33 subjek tanpa DAPsh. Median dari nilai RrSO2 pada kelompok dengan DAPsh lebih rendah dibanding kelompok tanpa DAPsh, 72 (44-87) vs 78 (48-89) (p=0,044). Dengan menggunakan kurva ROC, nilai titik potong < 74% memiliki sensitivitas sebesar 80% dan spesifisitas sebesar 70%. Sedangkan nilai CrSO2 dan SrSO2 tidak bermakna secara statistik.Simpulan: Nilai RrSO2 < 74% dapat memprediksi adanya DAPsh pada bayi <32 minggu.

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Background: Hemodynamically significant patent ductus arteriosus (hsPDA) is characterised by systemic hypoperfusion and pulmonary overcirculation. Systemic hypoperfusion with subsequent decrease of tissue oxygenation can be detected using near-infrared spectroscopy (NIRS) applied at the cerebral, renal, and abdominal areas.

Objective: To seek the diagnostic value of cerebral, renal, and splanchnic NIRS to detect hsPDA in infants < 32 weeks of gestation.

Methods: Forty-three very preterm infants (birth weight <1500 gr and gestational age <32 weeks) were monitored continuously with cerebral, renal, and abdominal NIRS within three hours after birth for 72 hours. All infants were prospectively evaluated using echocardiography to detect hsPDA within 24 hours after birth daily during the NIRS application. Echocardiography criteria to diagnose hsPDA included indices of pulmonary overcirculation and organ Doppler pattern at cerebral, renal, and splanchnic. The mean value of regional NIRS during its application was compared between the hsPDA and no- hsPDA groups.

Results: Of 43 infants, there were 10 infants with hsPDA and 33 with no hsPDA. A lower median of mean RrSO2 was noted in hsPDA groups compared to no-hsPDA groups, 72 (44-87) vs 78 (48-89), respectively (p=0.044), while no significant difference was found in CrSO2 and SrSO2. Using ROC curves, Mean RrSO2 < 74% identified an hsPDA with a sensitivity of 80% and specificity of 70%, while CrSO2 and SrSO2 were not significant

Conclusion : Low RrSO2 <74% was associated with the presence of hsPDA in infants < 32 weeks of gestation."