Tata laksana ICU Krisis Miasthenia pada Pasien Tuberkulosis Paru dengan Penyulit Ventilator Associated Pneumonia (VAP)

Titik Setyawati, Reza Widianto Sujud, Indriasari Indriasari

Abstract


Krisis miastenia adalah eksaserbasi akut miastenia gravis dengan kelemahan yang  melibatkan otot-otot pernapasan sehingga terjadi kegagalan napas akut dan memerlukan dukungan ventilasi mekanik. Krisis miastenia merupakan komplikasi miastenia gravis yang paling berbahaya dan mengancam jiwa bila tidak segera ditangani. Timbulnya krisis miastenia dapat dipicu oleh berbagai faktor, di antaranya infeksi dan penggunaan antibiotik aminoglikosid. Tata laksana Intensive Care Unit (ICU) pasien krisis miastenia meliputi tata laksana terhadap kegawatan respirasi, tata laksana terhadap miastenia gravis, dan tata laksana terhadap faktor peyulit. Intubasi endotrakeal dan dukungan ventilasi mekanis merupakan pilihan utama tata laksana kegawatan respirasi. Plasmaparesis adalah salah satu metode terapi yang terbukti efektif dan efisien selain pemberian agen anticholinesterase, terapi imunomodulator cepat, agen imunosupresif, dan timektomi. Terapi standar untuk menanggulangi tuberkulosis paru dengan obat antituberkulosis berdasar atas pedoman penatalaksanaan tuberkulosis serta terapi ventilator associated pneumonia (VAP) dengan pilihan antibiotik sesuai dengan hasil kultur bakteri. Dukungan nutrisi yang adekuat juga diperlukan untuk menunjang keberhasilan terapi. Dengan assessment dini dan terapi yang adekuat diharapkan dapat memperbaiki prognosis pasien krisis miastenia. Pada laporan kasus ini kami sajikan tata laksana ICU pasien krisis miastenia gravis yang dipicu oleh tuberkulosis paru dengan penyulit VAP yang dirawat di ICU RSHS Bandung pada bulan Oktober–November 2019.

 

ICU Management of  Myasthenic Crisis in  Pulmonary Tuberculosis Patients with  Ventilator Associated Pneumonia Complications

Myasthenic crisis is an acute exacerbation of myasthenia gravis with a weakness that involves the respiratory muscles, leading to acute respiratory failure that requires mechanical ventilation support. Myasthenia crisis is the most dangerous and life-threatening complication of myasthenia gravis if not treated immediately. The emergence of myasthenic crisis can be triggered by various factors, including infection and aminoglycoside use. Intensive Care Unit (ICU) management of myasthenic crisis patients includes management of respiratory emergencies, management of myasthenia gravis, and management of complicating factors. Endotracheal intubation and mechanical ventilatory support are the main choices in the management of respiratory emergencies. Plasmaparesis is one of the proven and effective therapeutic methods in addition to anticholinesterase agent, rapid immunomodulatory therapy, immunosuppressive agent, and thymectomy. Standard therapy for treating pulmonary tuberculosis includes anti-tuberculosis drugs, as stated in tuberculosis management guidelines, and Ventilator Associated Pneumonia (VAP) therapy with antibiotic options according to bacterial culture results. Adequate nutritional support is also needed to support the success of therapy. With early assessment and adequate therapy, it is expected that the prognosis of myasthenic crisis patients will be improved. This case report presented  the management of myasthenia gravis crisis triggered by pulmonary tuberculosis with VAP complications in patients treated at the ICU of Dr. Hasan Sadikin General Hospital Bandung, Indonesia, from October to November 2019.


Keywords


Krisis miasthenia, plasmaparesis, tuberkulosis paru, ventilator associated pneumonia

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References


Farkas J. Myasthenia gravis and myasthenic crisis. Internet Book of critical care [diunduh 12 September 2019]. Tersedia dari: https://emcrit.org/ibcc/myasthenia/.

Dewanto G, Suwono, WJ, Riyanto B, Turana Y. Panduan praktis diagnosis dan tatalaksana penyakit saraf. Jakarta: EGK; 2019.

Sathasivam S. Diagnosis and management of myasthenia gravis. Progress Neurol Psychi. 2014;1:6–14.

Vernino S, Lennon VA. Autoantibody profiles and neurological correlations of thymoma. Clin Cancer Res. 2004;10(21):7270–5.

Ghandi K, Moore A, Rosiere, L. Management of myasthenia crisis in the ED [internet]. 2019 [diunduh 13 September 2019]. Tersedia dari: http://www.nuemblog.com/blog/myasthenia.

Departemen Kesehatan RI. Pedoman diagnosis dan penatalaksanaan tuberkulosis di Indonesia. Jakarta: Depkes RI; 2013.

Ou SM, Liu CJ, Chang YS, Hu YW, Chao PW, Chen TJ, dkk. Tuberculosis in myasthenia gravis. Intern J Tubercul Lung Dis. 2013;17(1):79–84.

Pangalila FJ, Priyanti ZS, Crisma AA, Lilil S. Enty. Pedoman antibiotik empirik di ruang rawat intensif. Edisi pertama. Jakarta: PERDICI; 2019. hlm. 22–36.

Pradian E. Plasmaparesis. Dalam: Pradian E, Maskoen TT, Mansjoer A, Sugiarto A, penyunting. Continous renal replacement therapy (CRRT) & plasmapheresis. Jakarta: PERDICI; 2018. hlm. 28–33.

Wendell L, Levine JM. Myasthenic crisis. Neurohospitalist. 2011;1(1):16–22.

Godoy D, Mello L, Masotti L, Napoli M. The myasthenic patient in crisis: an update of the management in Neurointensive Care Unit. Arquivos Neuro-Psiquiatria. 2013;71(9A):627–39.

Lindberg DM. Lung protective strategy for acute respiratory distress syndrome saves lives. NEJM. 2017;1(1):3–17.

Koroshetz WJ. National institute of neurogical disorders and stroke [internet]. 2019 [diunduh 12 September 2019]. Tersedia dari: www.myastenia.org

Meriggioli M, Sanders D. Muscle autoantibodies in myasthenia gravis: beyond diagnosis?. Expert Rev Clin Immunol. 2012;8(5):427–38.

Sanders D, Wolfe G, Benatar M, Evoli A, Gilhus N, Illa I , dkk. International consensus guidance for management of myasthenia gravis. Neurology. 2016;87(4):419–25.

Venkataramaiah S, Kamath S. Management of myasthenia gravis. J Neuroanaesthesiol Crit Care. 2019;06(02):153–9.

Kalil A, Metersky M. Management of adults with hospital acquired and ventilator associated pneumonia: clinical practice guidelines by the Infectious Disease Society of America and American Thorax Society. Clin Infect Dis. 2016;63(1):1–51.

Rovina R. Prinsip penggunaan antibiotik pada penyakit kritis. Dalam: Pangalila FJV, penyunting. Penatalaksanaan infeksi pada penderita penyakit kritis. Edisi ke-1. Jakarta: PERDICI; 2013. hlm. 47–55.

Yang KS, Yamaji K. Plasma adsorption in critical care. Ther Aphen. 2002;6(3):184–8.

Mandawat A. Outcome of plasmapharesis in myasthenia ravis: delayed therapy is not forable. Muscle Nerve. 2011;43(4):578–84.

Gelfand EW. Intravenous immune globulin autoimmune and inflammatory diseases. N Engl J Med. 2012;367:2015–25.

Thomas EH, Bronze MS. Tuberculosis (TB) treatment and management. Medscape. 2020;21(2):28–46.

Wardhani RA. Patofisiologi diagnosis dan dlasifikasi TBC. Departemen Ilmu Kedokteran Komunitas Okupasi dan Keluarga. Jakarta: FK UI; 2002.




DOI: https://doi.org/10.15851/jap.v8n2.2052

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