PENATALAKSANAAN PASIEN STROKE HEMORRHAGIC DENGAN CHRONIC KIDNEY DISEASE DI INSTALASI GAWAT DARURAT: STUDI KASUS

Abstract

Latar belakang: Pasien chronic kidney disease (CKD) berisiko tinggi mengalami intracerebral hemorrhage (ICH). Penggunaan antikoagulan saat hemodialisis (HD) dapat memperbesar lesi serebral. Kasus: Penelitian ini menggunakan pendekatan studi kasus penatalaksanaan pasien ICH dengan CKD di IGD. Wanita usia 53 tahun datang dengan GCS E₂V₂M₅, tekanan darah 271/155 mmHg, heart rate75×/menit, SpO₂ 98%, dan respiration rate 20×/menit post HD tidak tuntas karena tekanan darah tinggi. Selama di IGD pasien mengalami muntah-muntah dan kejang. Pemeriksaan penunjang menunjukkan ICH pada lobus parietalis sinistra serta nilai ureum 85,3 mg/dL dan kreatinin 5,88 mg/dL. Manajemen: Pasien ICH membutuhkan hemostasis reversal, tetapi pasien mengalami CKD on HD rutin membutuhkan antikoagulan sehingga pasien diberikan injeksi asam traneksamat 500 mg. Posisi head up 30° dilakukan pada pasien untuk menurunkan tekanan intrakranial tanpa memberikan manitol karena kontradiktif pada pasien CKD. Perawat melakukan monitoring berkala terhadap status hemodinamik dan neurologis pasien. Hasil: Perawat sudah menerapkan manajemen peningkatan TIK, pencegahan aspirasi, dan monitoring tanda-tanda vital pasien secara kontinu. Hal ini dibuktikan dengan tekanan darah pasien menurun, tidak ada tanda peningkatan TIK, tidak terjadi kejang berulang, dan aspirasi. Kesimpulan: Intervensi yang dilakukan berhasil mencegah perburukan pasien meskipun nilai GCS pasien cenderung menetap saat pasien masuk ke IGD. Pemantauan tanda-tanda vital yang ketat serta pemberian intervensi yang cepat dan tepat di IGD sangat penting untuk mengoptimalkan luaran pasien. 

Kata Kunci: chronic kidney disease (CKD), instalasi gawat darurat (IGD), intracerebral hemorrhage (ICH), nursing care.

 Management of A Hemorrhagic Stroke Patient with Chronic Kidney Disease in the Emergency Department: A Case Study

ABSTRACT

Background: Patients with chronic kidney disease (CKD) exhibit a high risk of developing intracerebral hemorrhage (ICH). Furthermore, the routine use of anticoagulants during hemodialysis (HD) sessions can potentially exacerbate cerebral lesion expansion. Case: This study employed a case study approach evaluating the emergency department (ED) management of an ICH patient with comorbid CKD. A 53-year-old female presented to the ED with a Glasgow Coma Scale (GCS) score of E2V2M5. Upon admission, her vital signs revealed a blood pressure of 271/155 mmHg, heart rate of 75 beats per minute, SpO2 of 98%, and a respiratory rate of 20 breaths per minute, following an incomplete HD session due to severe hypertension. During her ED stay, the patient experienced recurrent vomiting and seizures. Diagnostic workups confirmed an ICH in the left parietal lobe, accompanied by elevated laboratory markers, including blood urea nitrogen (BUN) of 85.3 mg/dL and serum creatinine of 5.88 mg/dL. Management: Although ICH patients critically require hemostasis reversal, this patient’s condition was complicated by underlying CKD on routine HD, which conversely requires anticoagulation; consequently, tranexamic acid 500 mg was administered intravenously. A 30^o head-up position was maintained to reduce intracranial pressure (ICP) instead of administering mannitol, which is contraindicated in CKD patients. Nurses conducted continuous and rigorous monitoring of the patient's hemodynamic and neurological status. Results: The nursing team successfully implemented target interventions for increased ICP management, aspiration prevention, and continuous vital sign monitoring. These efforts were evidenced by a subsequent decrease in blood pressure, the absence of further signs of increased ICP, and the prevention of recurrent seizures or aspiration events. Conclusion: Prompt and appropriate emergency interventions successfully prevented further clinical deterioration, although the patient's GCS score remained relatively unchanged from admission. Strict vital sign monitoring combined with rapid, targeted interventions in the ED is paramount to optimizing clinical outcomes.

Keywords: Chronic Kidney Disease (CKD), Intracerebral Hemorrhage (ICH), Emergency Department (ED), Nursing Care