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);(493,40);(506,40);(493,13);(493,40);(13,600);(13,600);}}
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45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
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45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
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45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
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45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 1}}
{\sp{\sn fillColor}{\sv 526342}}
{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineColor}{\sv 0}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft4920\shptop10880\shpright5813\shpbottom11840\shpfhdr0\sh
pwr3\shpwrk0\shpfblwtxt1\shplid2029\shpz1\shpbxpage\shpbypage
{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 893}}
{\sp{\sn geoBottom}{\sv 960}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;500;(373,960);(373,960);(373,960);(373,946);(373,946)

;(373,933);(373,933);(373,920);(373,920);(360,920);(360,920);(360,906);(360,906)
;(360,906);(360,893);(360,893);(360,893);(360,880);(360,880);(360,866);(360,866)
;(360,866);(360,853);(360,853);(346,853);(346,840);(346,840);(346,840);(346,826)
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;(280,786);(280,786);(280,786);(280,786);(266,786);(266,786);(266,786);(266,786)
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;(160,826);(160,826);(146,826);(146,826);(133,826);(133,826);(133,826);(120,826)
;(120,826);(120,826);(106,826);(106,826);(106,826);(93,826);(93,826);(93,826);(9
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53,800);(53,800);(40,800);(40,786);(40,786);(26,786);(26,786);(26,773);(26,773);
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40,746);(53,746);(53,746);(66,746);(66,746);(80,733);(80,733);(93,733);(93,733);
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;(733,826);(720,826);(720,826);(720,826);(706,826);(706,826);(693,813);(693,813)
;(693,813);(680,813);(680,813);(666,813);(653,800);(653,800);(640,800);(640,786)
;(626,786);(626,786);(626,786);(626,786);(613,786);(613,786);(613,786);(613,786)
;(613,786);(600,786);(600,786);(600,786);(600,786);(600,786);(586,786);(586,786)
;(586,786);(586,786);(586,786);(573,800);(573,800);(573,800);(573,800);(573,800)
;(560,800);(560,800);(560,813);(560,813);(560,813);(546,813);(546,826);(546,826)
;(546,826);(546,826);(546,840);(546,840);(533,840);(533,853);(533,853);(533,853)
;(533,866);(533,866);(533,866);(533,880);(533,880);(533,893);(533,893);(520,893)
;(520,906);(520,906);(520,906);(520,920);(520,920);(520,920);(520,920);(520,933)

;(520,933);(520,946);(520,946);(520,960);(520,960);(520,960);(373,960);}}
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{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 1}}
{\sp{\sn fillColor}{\sv 526342}}
{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineColor}{\sv 0}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}

{\shp{\*\shpinst\shpleft4920\shptop10880\shpright5813\shpbottom11840\shpfhdr0\sh
pwr3\shpwrk0\shpfblwtxt1\shplid2030\shpz2\shpbxpage\shpbypage
{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 893}}
{\sp{\sn geoBottom}{\sv 960}}
{\sp{\sn shapePath}{\sv 4}}
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;(800,826);(786,826);(786,826);(786,826);(773,826);(773,826);(773,826);(760,826)

;(760,826);(760,826);(746,826);(746,826);(746,826);(733,826);(733,826);(720,826)
;(720,826);(720,826);(706,826);(706,826);(693,813);(693,813);(693,813);(680,813)
;(680,813);(666,813);(653,800);(653,800);(640,800);(640,786);(626,786);(626,786)
;(626,786);(626,786);(613,786);(613,786);(613,786);(613,786);(613,786);(600,786)
;(600,786);(600,786);(600,786);(600,786);(586,786);(586,786);(586,786);(586,786)
;(586,786);(573,800);(573,800);(573,800);(573,800);(573,800);(560,800);(560,800)
;(560,813);(560,813);(560,813);(546,813);(546,826);(546,826);(546,826);(546,826)
;(546,840);(546,840);(533,840);(533,853);(533,853);(533,853);(533,866);(533,866)
;(533,866);(533,880);(533,880);(533,893);(533,893);(520,893);(520,906);(520,906)
;(520,906);(520,920);(520,920);(520,920);(520,920);(520,933);(520,933);(520,946)
;(520,946);(520,960);(520,960);(520,960);(520,960);(440,960);}}
{\sp{\sn pSegmentInfo}{\sv 2;1000;16384;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;

45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;
45824;1;45824;1;45824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 0}}
{\sp{\sn lineWidth}{\sv 1484}}
{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineDashing}{\sv 0}}
{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft4946\shptop10893\shpright5786\shpbottom11840\shpfhdr0\sh
pwr3\shpwrk0\shpfblwtxt1\shplid2031\shpz3\shpbxpage\shpbypage
{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 840}}
{\sp{\sn geoBottom}{\sv 947}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;398;(413,0);(426,0);(426,0);(426,0);(426,0);(426,13);
(440,13);(440,26);(453,26);(466,40);(466,53);(480,80);(493,93);(506,106);(520,12
0);(520,133);(533,146);(546,173);(560,186);(573,200);(573,226);(586,240);(600,25
3);(613,280);(613,293);(626,306);(626,333);(640,346);(640,373);(653,386);(653,41
3);(666,426);(666,440);(666,466);(666,480);(666,493);(666,520);(666,533);(666,54
6);(666,573);(666,573);(653,586);(653,586);(653,600);(653,600);(640,613);(640,61
3);(640,626);(626,626);(626,626);(626,640);(626,640);(613,640);(600,653);(626,65
3);(626,653);(626,653);(640,653);(640,653);(640,653);(653,653);(653,653);(666,65
3);(666,653);(680,653);(680,653);(693,653);(693,666);(693,666);(706,666);(706,66
6);(706,666);(720,666);(720,680);(720,680);(720,680);(733,680);(733,693);(733,69
3);(733,693);(746,693);(746,706);(746,706);(746,706);(760,706);(760,720);(760,72
0);(773,720);(773,733);(786,733);(786,733);(786,733);(800,733);(800,746);(813,74
6);(826,746);(826,746);(840,746);(853,746);(840,746);(840,760);(840,760);(840,76
0);(826,760);(826,773);(826,773);(813,773);(813,773);(813,773);(813,786);(800,78
6);(800,786);(800,786);(786,786);(786,786);(786,800);(786,800);(773,800);(773,80
0);(773,800);(760,800);(760,800);(760,800);(760,800);(746,800);(746,800);(746,81
3);(733,813);(733,813);(733,813);(720,813);(720,813);(720,813);(706,800);(706,80
0);(706,800);(693,800);(693,800);(680,800);(680,800);(680,800);(666,800);(666,78
6);(653,786);(653,786);(653,786);(640,786);(640,786);(640,773);(626,773);(626,77
3);(626,773);(613,773);(613,773);(613,773);(600,773);(600,760);(600,760);(600,76
0);(586,760);(586,760);(586,760);(573,760);(573,760);(560,773);(560,773);(546,77
3);(546,773);(533,786);(533,786);(533,800);(520,800);(520,813);(506,813);(506,82
6);(506,840);(506,840);(506,853);(506,853);(506,853);(493,866);(493,866);(493,86
6);(493,880);(493,880);(493,880);(493,893);(493,893);(493,893);(493,906);(493,90
6);(493,906);(493,920);(493,920);(493,920);(493,920);(493,933);(493,933);(493,93
3);(493,933);(493,933);(360,933);(360,933);(360,933);(360,933);(360,933);(360,92
0);(360,920);(360,920);(360,920);(360,906);(360,906);(360,906);(360,893);(360,89
3);(346,893);(346,880);(346,880);(346,880);(346,866);(346,866);(346,866);(346,85
3);(346,853);(346,853);(346,840);(346,840);(333,826);(333,813);(333,813);(320,80
0);(320,800);(320,786);(306,786);(306,773);(293,773);(293,773);(280,773);(280,76
0);(266,760);(266,760);(266,760);(253,760);(253,760);(253,760);(240,760);(240,77
3);(240,773);(240,773);(226,773);(226,773);(226,773);(213,773);(213,773);(213,78
6);(200,786);(200,786);(186,786);(186,786);(186,786);(173,800);(173,800);(173,80
0);(160,800);(160,800);(146,800);(146,800);(146,800);(133,800);(133,813);(133,81
3);(120,813);(120,813);(120,813);(106,813);(106,813);(106,800);(93,800);(93,800)
;(93,800);(80,800);(80,800);(80,800);(80,800);(66,800);(66,800);(66,800);(53,786
);(53,786);(53,786);(53,786);(40,786);(40,786);(40,773);(26,773);(26,773);(26,77
3);(26,773);(13,760);(13,760);(13,760);(0,760);(0,746);(0,746);(13,746);(13,746)
;(26,746);(40,746);(40,746);(53,733);(53,733);(66,733);(66,733);(66,733);(80,720

);(80,720);(80,720);(93,706);(93,706);(93,706);(106,706);(106,693);(106,693);(10
6,693);(120,693);(120,680);(120,680);(120,680);(133,680);(133,666);(133,666);(14
6,666);(146,666);(146,666);(160,666);(160,653);(160,653);(173,653);(173,653);(18
6,653);(186,653);(200,653);(200,653);(213,653);(213,653);(213,653);(226,653);(22
6,653);(240,653);(226,640);(226,640);(226,640);(213,626);(213,626);(213,626);(21
3,613);(200,613);(200,600);(200,600);(186,586);(186,586);(186,573);(186,573);(17
3,546);(173,533);(173,520);(173,493);(173,480);(173,466);(186,440);(186,426);(18
6,413);(200,386);(200,373);(213,346);(213,333);(226,306);(226,293);(240,280);(25
3,253);(253,240);(266,226);(280,200);(293,186);(293,173);(306,146);(320,133);(33
3,120);(346,106);(360,93);(360,80);(373,53);(386,40);(400,26);(400,26);(413,13);
(413,13);(413,0);}}
{\sp{\sn pSegmentInfo}{\sv 2;798;16384;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 1}}
{\sp{\sn fillColor}{\sv 65331}}
{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineColor}{\sv 0}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}

{\shp{\*\shpinst\shpleft4946\shptop10893\shpright5786\shpbottom11840\shpfhdr0\sh
pwr3\shpwrk0\shpfblwtxt1\shplid2032\shpz4\shpbxpage\shpbypage
{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 840}}
{\sp{\sn geoBottom}{\sv 947}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;398;(413,0);(426,0);(426,0);(426,0);(426,0);(426,13);
(440,13);(440,26);(453,26);(466,40);(466,53);(480,80);(493,93);(506,106);(520,12
0);(520,133);(533,146);(546,173);(560,186);(573,200);(573,226);(586,240);(600,25
3);(613,280);(613,293);(626,306);(626,333);(640,346);(640,373);(653,386);(653,41
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3,120);(346,106);(360,93);(360,80);(373,53);(386,40);(400,26);(400,26);(413,13);
(413,13);(413,0);}}
{\sp{\sn pSegmentInfo}{\sv 2;798;16384;45824;1;45824;1;45824;1;45824;1;45824;1;4

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5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
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5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
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5824;1;45824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 0}}
{\sp{\sn lineWidth}{\sv 1484}}
{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineDashing}{\sv 0}}
{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft5120\shptop10880\shpright5373\shpbottom11480\shpfhdr0\sh
pwr3\shpwrk0\shpfblwtxt1\shplid2033\shpz5\shpbxpage\shpbypage
{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
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{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 253}}
{\sp{\sn geoBottom}{\sv 600}}
{\sp{\sn shapePath}{\sv 4}}
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{\sp{\sn pSegmentInfo}{\sv 2;360;16384;45824;1;45824;1;45824;1;45824;1;45824;1;4
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5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
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5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 1}}
{\sp{\sn fillColor}{\sv 526342}}
{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineColor}{\sv 0}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft5133\shptop11013\shpright5373\shpbottom11426\shpfhdr0\sh
pwr3\shpwrk0\shpfblwtxt1\shplid2034\shpz6\shpbxpage\shpbypage
{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 240}}
{\sp{\sn geoBottom}{\sv 413}}
{\sp{\sn shapePath}{\sv 4}}
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{\sp{\sn pSegmentInfo}{\sv 2;282;16384;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
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5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 1}}
{\sp{\sn fillColor}{\sv 655343}}
{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineColor}{\sv 0}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft5253\shptop11573\shpright5466\shpbottom11666\shpfhdr0\sh
pwr3\shpwrk0\shpfblwtxt1\shplid2035\shpz7\shpbxpage\shpbypage
{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 213}}
{\sp{\sn geoBottom}{\sv 93}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;167;(200,80);(173,13);(186,0);(213,80);(200,80);(160,
53);(146,26);(133,66);(160,53);(200,80);(200,80);(186,80);(173,93);(160,66);(133
,80);(120,93);(106,93);(133,13);(146,13);(186,80);(200,80);(200,80);(53,26);(53,
80);(66,80);(66,80);(66,80);(66,80);(66,80);(66,80);(66,80);(80,80);(80,80);(80,
80);(80,80);(80,80);(80,80);(80,80);(80,80);(80,80);(80,66);(80,66);(80,66);(80,
66);(80,66);(80,66);(80,66);(80,66);(80,66);(80,66);(93,66);(93,53);(93,53);(93,
53);(93,53);(93,53);(93,53);(93,53);(93,40);(93,40);(93,40);(93,40);(93,40);(93,
40);(93,40);(93,40);(93,40);(80,40);(80,26);(80,26);(80,26);(80,26);(80,26);(80,
26);(80,26);(80,26);(80,26);(80,26);(80,26);(80,26);(80,26);(80,26);(66,26);(66,
26);(66,26);(66,26);(66,26);(53,26);(200,80);(200,80);(40,13);(66,13);(80,13);(8
0,13);(80,13);(80,13);(80,13);(80,13);(80,13);(93,13);(93,13);(93,13);(93,13);(9
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66);(93,66);(93,80);(93,80);(93,80);(93,80);(93,80);(93,80);(93,80);(93,80);(93,
80);(93,80);(80,93);(80,93);(80,93);(80,93);(80,93);(80,93);(80,93);(80,93);(80,
93);(66,93);(66,93);(66,93);(66,93);(66,93);(40,80);(40,13);(200,80);(200,80);(0
,80);(13,0);(26,0);(13,80);(0,80);(200,80);(200,80);}}
{\sp{\sn pSegmentInfo}{\sv 2;336;16384;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
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5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
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5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
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5824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 1}}
{\sp{\sn fillColor}{\sv 655343}}
{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineColor}{\sv 0}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft5200\shptop11253\shpright5533\shpbottom11560\shpfhdr0\sh
pwr3\shpwrk0\shpfblwtxt1\shplid2036\shpz8\shpbxpage\shpbypage
{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 333}}
{\sp{\sn geoBottom}{\sv 307}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;129;(160,0);(173,0);(173,0);(186,0);(200,0);(200,0);(
213,13);(213,13);(226,13);(226,13);(240,13);(240,26);(253,26);(253,26);(266,40);
(266,40);(280,40);(280,53);(293,53);(293,66);(293,66);(306,80);(306,80);(306,93)
;(306,93);(320,106);(320,106);(320,120);(320,120);(320,133);(320,146);(320,146);
(320,160);(320,160);(320,173);(320,186);(320,186);(320,200);(320,200);(320,213);
(306,213);(306,226);(306,226);(306,240);(293,240);(293,253);(293,253);(280,266);
(280,266);(266,280);(266,280);(253,280);(253,293);(240,293);(240,293);(226,293);
(226,306);(213,306);(213,306);(200,306);(200,306);(186,306);(173,320);(173,320);
(160,320);(160,320);(146,320);(133,306);(133,306);(120,306);(120,306);(106,306);
(93,306);(93,293);(80,293);(80,293);(66,293);(66,280);(53,280);(53,280);(53,266)
;(40,266);(40,253);(26,253);(26,240);(26,240);(13,226);(13,226);(13,213);(13,213
);(13,200);(0,200);(0,186);(0,186);(0,173);(0,160);(0,160);(0,146);(0,146);(0,13
3);(0,120);(0,120);(13,106);(13,106);(13,93);(13,93);(13,80);(26,80);(26,66);(26
,66);(40,53);(40,53);(53,40);(53,40);(53,40);(66,26);(66,26);(80,26);(80,13);(93
,13);(93,13);(106,13);(120,13);(120,0);(133,0);(133,0);(146,0);(160,0);(160,0);}
}
{\sp{\sn pSegmentInfo}{\sv 2;260;16384;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
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5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4

5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 1}}
{\sp{\sn fillColor}{\sv 526342}}
{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineColor}{\sv 0}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft5200\shptop11253\shpright5533\shpbottom11560\shpfhdr0\sh
pwr3\shpwrk0\shpfblwtxt1\shplid2037\shpz9\shpbxpage\shpbypage
{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 333}}
{\sp{\sn geoBottom}{\sv 307}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;129;(160,0);(173,0);(173,0);(186,0);(200,0);(200,0);(
213,13);(213,13);(226,13);(226,13);(240,13);(240,26);(253,26);(253,26);(266,40);
(266,40);(280,40);(280,53);(293,53);(293,66);(293,66);(306,80);(306,80);(306,93)
;(306,93);(320,106);(320,106);(320,120);(320,120);(320,133);(320,146);(320,146);
(320,160);(320,160);(320,173);(320,186);(320,186);(320,200);(320,200);(320,213);
(306,213);(306,226);(306,226);(306,240);(293,240);(293,253);(293,253);(280,266);
(280,266);(266,280);(266,280);(253,280);(253,293);(240,293);(240,293);(226,293);
(226,306);(213,306);(213,306);(200,306);(200,306);(186,306);(173,320);(173,320);
(160,320);(160,320);(146,320);(133,306);(133,306);(120,306);(120,306);(106,306);
(93,306);(93,293);(80,293);(80,293);(66,293);(66,280);(53,280);(53,280);(53,266)
;(40,266);(40,253);(26,253);(26,240);(26,240);(13,226);(13,226);(13,213);(13,213
);(13,200);(0,200);(0,186);(0,186);(0,173);(0,160);(0,160);(0,146);(0,146);(0,13
3);(0,120);(0,120);(13,106);(13,106);(13,93);(13,93);(13,80);(26,80);(26,66);(26
,66);(40,53);(40,53);(53,40);(53,40);(53,40);(66,26);(66,26);(80,26);(80,13);(93
,13);(93,13);(106,13);(120,13);(120,0);(133,0);(133,0);(146,0);(160,0);(160,0);}
}
{\sp{\sn pSegmentInfo}{\sv 2;260;16384;45824;1;45824;1;45824;1;45824;1;45824;1;4
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5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
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5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 0}}
{\sp{\sn lineWidth}{\sv 1484}}
{\sp{\sn lineColor}{\sv 526342}}

{\sp{\sn lineDashing}{\sv 0}}

{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft5213\shptop11253\shpright5520\shpbottom11560\shpfhdr0\sh
pwr3\shpwrk0\shpfblwtxt1\shplid2038\shpz10\shpbxpage\shpbypage
{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 307}}
{\sp{\sn geoBottom}{\sv 307}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;129;(146,0);(160,0);(173,0);(173,0);(186,0);(186,0);(
200,0);(200,13);(213,13);(213,13);(226,13);(226,26);(240,26);(240,26);(253,40);(
253,40);(266,40);(266,53);(266,53);(280,53);(280,66);(280,66);(293,80);(293,80);
(293,93);(293,93);(293,106);(306,106);(306,120);(306,120);(306,133);(306,146);(3
06,146);(306,160);(306,160);(306,173);(306,173);(306,186);(293,186);(293,200);(2
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13,280);(200,293);(200,293);(186,293);(186,293);(173,293);(173,293);(160,293);(1
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3,280);(80,280);(80,280);(80,280);(66,266);(66,266);(53,266);(53,253);(40,253);(
40,253);(40,240);(26,240);(26,226);(26,226);(13,213);(13,213);(13,200);(13,200);
(13,186);(0,186);(0,173);(0,173);(0,160);(0,160);(0,146);(0,146);(0,133);(0,120)
;(0,120);(0,106);(13,106);(13,93);(13,93);(13,80);(13,80);(26,66);(26,66);(26,53
);(40,53);(40,53);(40,40);(53,40);(53,40);(66,26);(66,26);(80,26);(80,13);(80,13
);(93,13);(106,13);(106,0);(120,0);(120,0);(133,0);(133,0);(146,0);(146,0);}}
{\sp{\sn pSegmentInfo}{\sv 2;260;16384;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
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5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 1}}
{\sp{\sn fillColor}{\sv 655343}}
{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineColor}{\sv 0}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft5213\shptop11253\shpright5520\shpbottom11560\shpfhdr0\sh
pwr3\shpwrk0\shpfblwtxt1\shplid2039\shpz11\shpbxpage\shpbypage
{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 307}}
{\sp{\sn geoBottom}{\sv 307}}

{\sp{\sn shapePath}{\sv 4}}

{\sp{\sn pVerticies}{\sv 8;129;(146,0);(160,0);(173,0);(173,0);(186,0);(186,0);(
200,0);(200,13);(213,13);(213,13);(226,13);(226,26);(240,26);(240,26);(253,40);(
253,40);(266,40);(266,53);(266,53);(280,53);(280,66);(280,66);(293,80);(293,80);
(293,93);(293,93);(293,106);(306,106);(306,120);(306,120);(306,133);(306,146);(3
06,146);(306,160);(306,160);(306,173);(306,173);(306,186);(293,186);(293,200);(2
93,200);(293,213);(293,213);(280,226);(280,226);(280,240);(266,240);(266,253);(2
66,253);(253,253);(253,266);(240,266);(240,266);(226,280);(226,280);(213,280);(2
13,280);(200,293);(200,293);(186,293);(186,293);(173,293);(173,293);(160,293);(1
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3,280);(80,280);(80,280);(80,280);(66,266);(66,266);(53,266);(53,253);(40,253);(
40,253);(40,240);(26,240);(26,226);(26,226);(13,213);(13,213);(13,200);(13,200);
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);(93,13);(106,13);(106,0);(120,0);(120,0);(133,0);(133,0);(146,0);(146,0);}}
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5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
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5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 0}}
{\sp{\sn lineWidth}{\sv 1484}}
{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineDashing}{\sv 0}}
{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft5266\shptop11293\shpright5466\shpbottom11533\shpfhdr0\sh
pwr3\shpwrk0\shpfblwtxt1\shplid2040\shpz12\shpbxpage\shpbypage
{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 200}}
{\sp{\sn geoBottom}{\sv 240}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;249;(53,13);(40,13);(26,13);(13,13);(0,26);(0,26);(0,
40);(13,40);(26,40);(40,40);(53,40);(53,26);(66,26);(93,26);(120,26);(146,26);(1
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26,160);(26,160);(40,160);(40,160);(40,160);(40,160);(53,160);(53,160);(53,160);
(53,160);(66,160);(66,160);(66,160);(80,160);(80,160);(80,160);(80,160);(80,160)
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;(53,240);(53,240);(53,240);(66,240);(66,240);(93,226);(133,200);(160,186);(160,
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160);(173,160);(173,160);(173,160);(173,160);(173,160);(173,160);(173,160);(173,
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0,133);(80,133);(80,133);(80,133);(66,133);(66,133);(66,120);(66,120);(66,120);(
66,120);(66,120);(66,120);(80,120);(80,120);(80,120);(80,120);(80,120);(80,120);
(80,120);(80,120);(80,120);(80,120);(80,120);(80,120);(80,120);(80,120);(93,120)
;(93,106);(93,106);(93,106);(106,106);(106,106);(106,106);(133,106);(160,93);(17
3,80);(200,66);(200,53);(200,40);(186,26);(173,13);(160,0);(146,0);(120,0);(93,0
);(66,0);(53,13);}}
{\sp{\sn pSegmentInfo}{\sv 2;500;16384;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
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5824;1;45824;1;45824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 1}}
{\sp{\sn fillColor}{\sv 767}}
{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineColor}{\sv 0}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft5346\shptop11333\shpright5386\shpbottom11520\shpfhdr0\sh
pwr3\shpwrk0\shpfblwtxt1\shplid2041\shpz13\shpbxpage\shpbypage
{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 40}}

{\sp{\sn geoBottom}{\sv 187}}

{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;60;(13,0);(0,0);(0,13);(0,26);(13,26);(26,120);(26,12
0);(26,133);(26,133);(26,133);(26,133);(26,146);(26,146);(26,146);(26,160);(26,1
60);(26,160);(26,160);(26,160);(26,160);(26,160);(26,160);(26,173);(26,173);(26,
173);(26,173);(26,173);(26,173);(26,173);(26,186);(26,186);(26,186);(26,186);(26
,186);(26,186);(26,186);(26,186);(26,186);(40,186);(40,186);(40,186);(40,186);(4
0,186);(40,186);(40,186);(40,186);(40,186);(40,186);(40,186);(40,186);(40,186);(
40,186);(40,173);(53,160);(53,120);(53,26);(53,13);(40,0);(26,0);(13,0);}}
{\sp{\sn pSegmentInfo}{\sv 2;122;16384;45824;1;45824;1;45824;1;45824;1;45824;1;4
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5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
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5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;4
5824;1;45824;1;45824;1;45824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 1}}
{\sp{\sn fillColor}{\sv 526342}}
{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineColor}{\sv 0}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft5360\shptop11440\shpright5400\shpbottom11466\shpfhdr0\sh
pwr3\shpwrk0\shpfblwtxt1\shplid2042\shpz14\shpbxpage\shpbypage
{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 40}}
{\sp{\sn geoBottom}{\sv 26}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;5;(0,0);(40,0);(40,26);(0,26);(0,0);}}
{\sp{\sn pSegmentInfo}{\sv 2;12;16384;45824;1;45824;1;45824;1;45824;1;45824;2457
7;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 1}}
{\sp{\sn fillColor}{\sv 767}}
{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineColor}{\sv 0}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft0\shptop413\shpright306\shpbottom413\shpfhdr0\shpwr3\shp
wrk0\shpfblwtxt1\shplid2043\shpz15\shpbxpage\shpbypage
{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 306}}
{\sp{\sn geoBottom}{\sv 0}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;2;(306,0);(0,0);}}
{\sp{\sn pSegmentInfo}{\sv 2;5;16384;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 0}}
{\sp{\sn lineWidth}{\sv 15875}}
{\sp{\sn lineColor}{\sv 16777215}}
{\sp{\sn lineDashing}{\sv 0}}

{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 16777215}}

{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft10466\shptop413\shpright10760\shpbottom413\shpfhdr0\shpw
r3\shpwrk0\shpfblwtxt1\shplid2044\shpz15\shpbxpage\shpbypage
{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 294}}
{\sp{\sn geoBottom}{\sv 0}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;2;(0,0);(306,0);}}
{\sp{\sn pSegmentInfo}{\sv 2;5;16384;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 0}}
{\sp{\sn lineWidth}{\sv 15875}}
{\sp{\sn lineColor}{\sv 16777215}}
{\sp{\sn lineDashing}{\sv 0}}
{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 16777215}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft0\shptop14026\shpright306\shpbottom14026\shpfhdr0\shpwr3
\shpwrk0\shpfblwtxt1\shplid2045\shpz15\shpbxpage\shpbypage
{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 306}}
{\sp{\sn geoBottom}{\sv 0}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;2;(306,0);(0,0);}}
{\sp{\sn pSegmentInfo}{\sv 2;5;16384;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 0}}
{\sp{\sn lineWidth}{\sv 15875}}
{\sp{\sn lineColor}{\sv 16777215}}
{\sp{\sn lineDashing}{\sv 0}}
{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 16777215}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft10466\shptop14026\shpright10760\shpbottom14026\shpfhdr0\
shpwr3\shpwrk0\shpfblwtxt1\shplid2046\shpz15\shpbxpage\shpbypage
{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 294}}
{\sp{\sn geoBottom}{\sv 0}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;2;(0,0);(306,0);}}
{\sp{\sn pSegmentInfo}{\sv 2;5;16384;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 0}}

{\sp{\sn lineWidth}{\sv 15875}}

{\sp{\sn lineColor}{\sv 16777215}}
{\sp{\sn lineDashing}{\sv 0}}
{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 16777215}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft426\shptop0\shpright426\shpbottom293\shpfhdr0\shpwr3\shp
wrk0\shpfblwtxt1\shplid2047\shpz15\shpbxpage\shpbypage
{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 0}}
{\sp{\sn geoBottom}{\sv 293}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;2;(0,306);(0,0);}}
{\sp{\sn pSegmentInfo}{\sv 2;5;16384;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 0}}
{\sp{\sn lineWidth}{\sv 15875}}
{\sp{\sn lineColor}{\sv 16777215}}
{\sp{\sn lineDashing}{\sv 0}}
{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 16777215}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft426\shptop14146\shpright426\shpbottom14440\shpfhdr0\shpw
r3\shpwrk0\shpfblwtxt1\shplid2048\shpz15\shpbxpage\shpbypage
{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 0}}
{\sp{\sn geoBottom}{\sv 294}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;2;(0,0);(0,306);}}
{\sp{\sn pSegmentInfo}{\sv 2;5;16384;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 0}}
{\sp{\sn lineWidth}{\sv 15875}}
{\sp{\sn lineColor}{\sv 16777215}}
{\sp{\sn lineDashing}{\sv 0}}
{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 16777215}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft10346\shptop0\shpright10346\shpbottom293\shpfhdr0\shpwr3
\shpwrk0\shpfblwtxt1\shplid2049\shpz15\shpbxpage\shpbypage
{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 0}}
{\sp{\sn geoBottom}{\sv 293}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;2;(0,306);(0,0);}}

{\sp{\sn pSegmentInfo}{\sv 2;5;16384;45824;1;45824;32768}}

{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 0}}
{\sp{\sn lineWidth}{\sv 15875}}
{\sp{\sn lineColor}{\sv 16777215}}
{\sp{\sn lineDashing}{\sv 0}}
{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 16777215}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft10346\shptop14146\shpright10346\shpbottom14440\shpfhdr0\
shpwr3\shpwrk0\shpfblwtxt1\shplid2050\shpz15\shpbxpage\shpbypage
{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 0}}
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par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {DokterAnak Indones
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i0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {yang merupakan penyempurnaan Stand
ar Pelayanan Medis (SPM) IDAI 2005}\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\

par\pard\li893\ri0\sl-293\slmult0 \fs20\cf0\f0\charscalex100 {Digunakannya istil

ah Pedoman menggantikan Standar bertujuan agar penggunaan}\par\pard\li893\ri0\sl
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aikan dengan kemampuan masing-masing tempat}\par\pard\li893\ri0\sl-266\slmult0 \
fs22\cf0\f0\charscalex100 {pelayanan kesehatan, baik pada praktik pribadi maupun
di rumah sakit.}\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0
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tang Praktik Kedokteran, pada salah satu}\par\pard\li893\ri0\sl-266\slmult0 \fs
20\cf0\f0\charscalex100 {pasalnya menyatakan bahwa dokter dalam menyelenggarakan
praktik kedokteran wajib}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charsc
alex100 {mengikuti standar pelayanan kedokteran. Standar Pelayanan Kedokteran di
analogikan}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {dengan
Standar atau Pedoman Pelayanan Medis.}\par\pard\li893\ri0\sl-213\slmult0 \fs18\
cf0\par\pard\li893\ri0\sl-280\slmult0 \fs20\cf0\f0\charscalex100 {Standard atau
Pedoman Pelayanan Medis dibuat oleh perhimpunan profesi yang}\par\pard\li893\ri
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u dan teknologi kedokteran yang ada. Pedoman}\par\pard\li893\ri0\sl-266\slmult0
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r yang memberikan pelayanan}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\char
scalex100 {kesehatan perorangan yang mencakup lingkup pelayanan promotif, prev
entif, kuratif, }\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100
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menuhi}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {kebutuhan
kesehatan masyarakat.}\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li89
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ikaji dan dijabarkan oleh pihak Rumah Sakit menjadi}\par\pard\li893\ri0\sl-266\s
lmult0 \fs20\cf0\f0\charscalex100 {suatu standar operasional prosedur (SOP) sete
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x100 {Dokter dalam menjalankan tugas dan memberikan pelayanan medis harus sesuai
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3\margtsxn666\margbsxn293\pard\li3720\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li37
20\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li3720\ri0\sl-213\slmult0 \fs18\cf0\par
\pard\li3720\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li3720\ri0\sl-213\slmult0 \fs
18\cf0\par\pard\li3720\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li3720\ri0\sl-533\s
lmult0 \fs36\cf0\f0\charscalex100\b {Alergi Obat}\b0 \par\pard\li893\ri0\sl-213\
slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0
\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\l
i893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-280\slmult0 \fs22\cf0\f0
\charscalex100 {Alergi obat merupakan salah satu reaksi simpang obat yang dipera
ntarai oleh mekanisme}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex
100 {imunologi. Mekanisme yang mendasari alergi obat dapat berupa reaksi hiperse
nsitivitas}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {tipe 1
, 2, 3, atau 4. Alergi obat memerlukan paparan sebelumnya dengan obat yang sama
}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {atau terjadi aki
bat reaksi silang.}\par\pard\li893\ri0\sl-413\slmult0 \fs20\cf0\f0\charscalex100
{Pemberian label alergi obat pada anak sering menyebabkan penghindaran obat ter
tentu}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {sepanjang h
idup. Diagnosis alergi obat pada anak sulit karena kesulitan melakukan tes}\par
\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {kulit pada anak. Hal
ini sering menyebabkan}{ }\fs18\cf0\f0\charscalex100\i {overdiagnosis}\i0 { }\fs
22\cf0\f0\charscalex100 {alergi obat pada anak.}\par\pard\li893\ri0\sl-413\slmul
t0 \fs20\cf0\f0\charscalex100 {Beberapa survei yang cukup besar menunjukkan prev
alens alergi obat pada anak berkisar}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf
0\f0\charscalex100 {antara 2,8% sampai 7,5%. Penelitian meta-analisis pada 17 st
udi prospektif menunjukkan}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\chars
calex100 {proporsi penderita rawat inap karena alergi obat sekitar 2,1%, 39,3% m
erupakan reaksi}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {y
ang mengancam jiwa. Insidens reaksi simpang obat pada anak yang dirawat di rumah
}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {sakit sekitar 9,
5% dan pada penderita rawat jalan sekitar 1,5%.}\par\pard\li893\ri0\sl-213\slmul
t0 \fs18\cf0\par\pard\li893\ri0\sl-346\slmult0 \fs22\cf0\f0\charscalex100\b {Fak
tor risiko}\b0 \par\pard\li893\ri0\sl-306\slmult0 \fs22\cf0\f0\charscalex100 {Fa
ktor risiko yang terpenting adalah riwayat alergi sebelumnya dengan obat yang sa
ma. }\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {Pemberian pa
renteral dan topikal lebih sering menyebabkan sensitisasi. Dosis tunggal}\par\pa
rd\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {yang besar lebih jarang
menimbulkan sensitisasi daripada pemberian yang sering dan}\par\pard\li893\ri0\s
l-266\slmult0 \fs22\cf0\f0\charscalex100 {lama. Usia dewasa muda lebih mudah be
reaksi daripada bayi atau usia tua. Predisposisi}\par\pard\li893\ri0\sl-266\slm
ult0 \fs22\cf0\f0\charscalex100 {atopi tidak meningkatkan kemungkinan terjadinya
alergi obat, tetapi dapat menyebabkan}\par\pard\li893\ri0\sl-266\slmult0 \fs22
\cf0\f0\charscalex100 {reaksi alergi yang lebih berat. Infeksi virus tertentu se
perti HIV, Herpes, EBV, dan CMV}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\
charscalex100 {meningkatkan kemungkinan terjadinya alergi obat. }\par\pard\li893
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d\li893\ri0\sl-413\slmult0 \fs22\cf0\f0\charscalex100\b {Anamnesis}\b0 \par\pard
\li893\ri0\sl-306\slmult0 \fs22\cf0\f0\charscalex100 {Anamnesis yang terperinci
merupakan tahap awal terpenting untuk membuat diagnosis}\par\pard\li893\ri0\sl-2
80\slmult0 \fs22\cf0\f0\charscalex100 {alergi obat. Anamnesis meliputi formulasi
obat, dosis, rute, dan waktu pemberian (}\fs22\cf0\f0\charscalex100\b {Tabel}\b
0 \par\pard\li893\ri0\sl-280\slmult0 \fs22\cf0\f0\charscalex100\b {1}\b0 \fs22\c
f0\f0\charscalex100 {). Selain itu harus ditanyakan perjalanan, awitan, dan hila
ngnya gejala. Catatan medik}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\cha
rscalex100 {dan keperawatan harus diperiksa untuk mengkonfirmasi hubungan antar
a obat dan}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {gejala
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3\margtsxn666\margbsxn293\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893
\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pa
rd\li893\ri0\sl-466\slmult0 \fs22\cf0\f0\charscalex100\b {Pemeriksaan fisis}\b0
\par\pard\li893\ri0\sl-320\slmult0 \fs22\cf0\f0\charscalex100 {Pemeriksaan fisis
yang teliti dapat menentukan mekanisme yang mendasari reaksi obat. }\par\pard\l
i893\ri0\sl-280\slmult0 \fs22\cf0\f0\charscalex100 {Reaksi obat dapat terjadi si
stemik atau mengenai satu atau beberapa organ (}\fs22\cf0\f0\charscalex100\b {Ta
bel 2}\b0 \fs22\cf0\f0\charscalex100 {). }\par\pard\li893\ri0\sl-266\slmult0 \fs
22\cf0\f0\charscalex100 {Kulit merupakan organ yang sering terkena.}\par\pard\li
893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-346\slmult0 \fs22\cf0\f0\
charscalex100\b {Pemeriksaan penunjang}\b0 \par\pard\li893\ri0\sl-306\slmult0 \f
s22\cf0\f0\charscalex100 {Tes kulit dapat memberikan bukti adanya sensitisasi ob
at, terutama yang didasari}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\ch
arscalex100 {oleh reaksi tipe 1 (}\fs22\cf0\f0\charscalex100\i {IgE mediated}\i0
\fs22\cf0\f0\charscalex100 {). Namun demikian sebagian besar obat tidak diketah
ui}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {imunogen yang
relevan sehingga nilai prediktif tes kulit tidak dapat ditentukan. Penisilin}\p
ar\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {merupakan obat yang
sudah dapat ditentukan metabolit imunogennya. Tes kulit dapat}\par\pard\li893\
ri0\sl-266\slmult0 \*\tx1600\*\tx2906\fs22\cf0\f0\charscalex100 {berupa}\tab \fs
22\cf0\f0\charscalex100\i {skin prick test}\i0 \tab \fs22\cf0\f0\charscalex100 {
(SPT) atau tes intradermal. Tes intradermal lebih sensitif tapi}\par\pard\li89
3\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {kurang spesifik dibandingkan SP
T. Pemeriksaan penunjang lainnya antara lain: IgE spesifik, }\par\pard\li893\ri0
\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {serum tryptase, dan}{ }\fs18\cf0\f0\
charscalex100\i {cellular allergen stimulation test}\i0 \fs22\cf0\f0\charscalex1
00 { (CAST).}\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl360\slmult0 \fs22\cf0\f0\charscalex100\b {Tes Kulit}\b0 \par\pard\li893\ri0\sl-3
06\slmult0 \fs22\cf0\f0\charscalex100 {Tes kulit untuk preparat penisilin diperl
ukan metabolit imunogennya, }{ }\fs20\cf0\f0\charscalex100\i {major antigenic}\i
0 \par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100\i {determinant}\
i0 { }\fs22\cf0\f0\charscalex100 {yaitu}{ }\fs18\cf0\f0\charscalex100\i {penicyl
loil}\i0 \fs22\cf0\f0\charscalex100 {. Preparat}{ }\fs18\cf0\f0\charscalex100\i
{penicylloil}\i0 \fs22\cf0\f0\charscalex100 { untuk tes kulit dijual dengan nama
dagang }\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100\b \i {Pre
-Pen, }\b0 \i0 \fs22\cf0\f0\charscalex100 {sayangnya preparat ini belum ada di I
ndonesia sehingga tes kulit terhadap}\par\pard\li893\ri0\sl-266\slmult0 \fs22\c
f0\f0\charscalex100 {penisilin tidak dapat dilakukan di Indonesia.}\par\pard\li8
93\ri0\sl-413\slmult0 \fs22\cf0\f0\charscalex100 {Untuk obat dan antibiotika yan
g lain, belum ada preparat khusus untuk tes kulit. Untuk}\par\pard\li893\ri0\sl266\slmult0 \fs20\cf0\f0\charscalex100 {beberapa jenis antibiotika yang sering d
igunakan dan kita ragu apakah pasien alergi atau tidak, }\par\pard\li893\ri0\sl266\slmult0 \fs22\cf0\f0\charscalex100 {dapat dilakukan tes kulit dengan pengenc
eran yang tidak menimbulkan iritasi}{ }\fs18\cf0\f0\charscalex100\i {(nonirritat
ing }\i0 \par\pard\li893\ri0\sl-266\slmult0 \fs18\cf0\f0\charscalex100\i {concen
tration). }\i0 \fs22\cf0\f0\charscalex100 {Meskipun demikian, tes kulit untuk di

agnosis alergi obat terutama antibiotika }\par\pard\li893\ri0\sl-266\slmult0 \fs

22\cf0\f0\charscalex100\b \i {tidak dianjurkan}\b0 \i0 \fs22\cf0\f0\charscalex10
0 { karena nilai prediksi rendah. Kalau hasil tes positif, masih mungkin alergi}
\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {terhadap obat ter
sebut, tetapi kalau negatif belum tentu tidak alergi. }\par\pard\li893\ri0\sl-21
3\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-360\slmult0 \fs22\cf0\f0\charscalex100
\b \i {Graded Challenge}\b0 \i0 \par\pard\li893\ri0\sl-320\slmult0 \fs18\cf0\f0\
charscalex100\i {Graded challenge, }\i0 \fs22\cf0\f0\charscalex100 {tes provokas
i dengan dosis yang ditingkatkan, dilakukan dengan hati-}\par\pard\li893\ri0\sl266\slmult0 \fs22\cf0\f0\charscalex100 {hati pada pasien yang diragukan apakah
alergi terhadap sesuatu obat atau tidak. Tes}\par\pard\li893\ri0\sl-266\slmult0
\fs22\cf0\f0\charscalex100 {provokasi ini biasanya dilakukan secara oral. Anak y
ang jelas dan nyata menunjukkan}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\
charscalex100 {reaksi yang berat setelah terpajan dengan obat, tidak dilakukan t
es provokasi ini.}\par\pard\li893\ri0\sl-413\slmult0 \fs18\cf0\f0\charscalex100\
i {Graded challenge}\i0 { }\fs22\cf0\f0\charscalex100 {biasanya aman untuk diker
jakan, tetapi tetap dengan persiapan untuk}\par\pard\li893\ri0\sl-266\slmult0 \f
s22\cf0\f0\charscalex100 {mengatasi bila terjadi reaksi anafilaksis. Biasanya do
sis dimulai dengan 1/10 sampai 1/100}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf
0\f0\charscalex100 {dari dosis penuh dan dinaikkan 2 sampai 5 kali lipat setiap
setengah jam, sampai mencapai}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\ch
arscalex100 {dosis penuh. Bila pada waktu peningkatan dosis terjadi reaksi alerg
i, maka tes dihentikan}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscale
x100 {dan pasien ditata laksana seperti prosedur}{ }\fs22\cf0\f0\charscalex100 {
pengatasan reaksi alergi.}\par\pard\li893\ri0\sl-400\slmult0 \fs22\cf0\f0\charsc
alex100 {Tes provokasi dilakukan bila pemeriksaan lain negatif dan diagnosis ale
rgi obat masih}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {me
ragukan. Tujuan tes ini adalah untuk menyingkirkan sensitifitas terhadap obat da
n}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {menegakkan diag
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Jenson}\par\pard\li1266\ri0\sl-213\slmult0 \fs18\cf0\f0\charscalex100 {HB, Stant
on BF, editor. Nelson textbook of pediatrics. 18th ed . Philadelphia: Saunders;
2007. h. 990-3.}\par\pard\li893\ri0\sl-253\slmult0 \*\tx1266\fs18\cf0\f0\charsca
lex100 {2. }\tab \fs18\cf0\f0\charscalex100 {Rebelo GE, Fonseca J, Araujo L, D
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266\ri0\sl-226\slmult0 \fs18\cf0\f0\charscalex100 {confirmed diagnosis. Clin Exp
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\charscalex100 {3. }\tab \fs18\cf0\f0\charscalex100 {Orhan F, Karakas T, Cakir
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rd\li1266\ri0\sl-226\slmult0 \fs18\cf0\f0\charscalex100 {children. Pediatr Aller
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0\charscalex100 {4. }\tab \fs18\cf0\f0\charscalex100 {Lange L, Koningsbruggen S
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d\li1266\ri0\sl-226\slmult0 \fs18\cf0\f0\charscalex100 {character of allergic dr
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f0\f0\charscalex100 {Impicciatore P, Choonara I, Clarkson A, Provasi D, Pandolfi
ni C, Bonati M. Incidence of adverse drug}\par\pard\li1266\ri0\sl-226\slmult0 \f
s18\cf0\f0\charscalex100 {reactions in pediatric in/out-patients: a systematic r
eview and meta-analysis of prospective studies. Br}\par\pard\li1266\ri0\sl-213\s
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x100 {7. }\tab \fs16\cf0\f0\charscalex100 {AbererW, BircherA, RomanaA et al,. Dr
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3\margtsxn666\margbsxn293\pard\li3346\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li33
46\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li3346\ri0\sl-213\slmult0 \fs18\cf0\par
\pard\li3346\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li3346\ri0\sl-213\slmult0 \fs
18\cf0\par\pard\li3346\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li3346\ri0\sl-533\s
lmult0 \fs36\cf0\f0\charscalex100\b {Alergi Susu Sapi}\b0 \par\pard\li893\ri0\sl
-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li89
3\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\p
ard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-280\slmult0 \fs22\c
f0\f0\charscalex100 {Alergi susu sapi (ASS) adalah reaksi simpang terhadap prote
in susu sapi yang diperantarai}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\c
harscalex100 {reaksi imunologi. Istilah alergi yang dipergunakan dalam panduan
ini sesuai dengan}\par\pard\li893\ri0\sl-266\slmult0 \*\tx3760\*\tx6760\fs20\cf0
\f0\charscalex100 {definisi yang dikeluarkan oleh}\tab \fs20\cf0\f0\charscalex10
0\i {World Allergy Organization}\i0 \fs20\cf0\f0\charscalex100 {, yaitu}\tab \f
s20\cf0\f0\charscalex100 {alergi adalah reaksi}\par\pard\li893\ri0\sl-266\slmult
0 \fs20\cf0\f0\charscalex100 {hipersensitivitas yang diperankan oleh mekanisme i
munologi. Mekanisme tersebut bisa}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\
f0\charscalex100 {diperantarai oleh IgE (reaksi hipersensitivitas tipe I, reaksi
cepat) maupun non-IgE (reaksi}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\c
harscalex100 {hipersensitivitas tipe III atau IV, reaksi lambat). Alergi susu s
api yang tidak diperantarai}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\char
scalex100 {IgE lebih sering mengenai saluran cerna, sementara ASS yang diperant
arai IgE dapat}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {me
ngenai saluran cerna, kulit, dan saluran napas serta berhubungan dengan risiko t
inggi}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {timbulnya a
lergi saluran napas di kemudian hari seperti asma dan rinitis alergi.}\par\pard\
li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\p
ar\pard\li893\ri0\sl-386\slmult0 \fs26\cf0\f0\charscalex100\b {Diagnosis}\b0 \pa
r\pard\li893\ri0\sl-413\slmult0 \fs22\cf0\f0\charscalex100\b {Anamnesis}\b0 \par
\pard\li906\ri0\sl-306\slmult0 \*\tx1146\fs20\cf0\f0\charscalex100 {-}\tab \fs20

\cf0\f0\charscalex100 {Alergi susu sapi dapat menyebabkan beragam gejala dan ke

luhan, baik pada saluran}\par\pard\li1146\ri0\sl-266\slmult0 \fs20\cf0\f0\charsc
alex100 {cerna, saluran napas, maupun kulit. Luasnya gejala yang timbul dapat m
empersulit}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {penge
nalan, menyebabkan}{ }\fs20\cf0\f0\charscalex100\i {misdiagnosis}\i0 \fs22\cf0\f
0\charscalex100 { atau kadang-kadang}{ }\fs18\cf0\f0\charscalex100\i {overdiagno
sis. }\i0 \par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs20\cf0\f0\charscalex100
{-}\tab \fs20\cf0\f0\charscalex100 {Awitan gejala ASS, waktu antar pemberian su
su sapi dan timbulnya gejala, dan jumlah}\par\pard\li1146\ri0\sl-266\slmult0 \fs
22\cf0\f0\charscalex100 {susu yang diminum hingga menimbulkan gejala.}\par\pard\
li906\ri0\sl-266\slmult0 \*\tx1146\fs20\cf0\f0\charscalex100 {-}\tab \fs20\cf0\f
0\charscalex100 {Riwayat atopi pada orangtua dan saudara kandung perlu ditanyak
an. Risiko atopi}\par\pard\li1146\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100
{meningkat jika ayah/ibu kandung atau saudara kandung menderita atopi, dan bahk
an}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {risikonya leb
ih tinggi jika kedua orangtua sama-sama penderita atopi. }\par\pard\li906\ri0\sl
-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex
100 {Riwayat atau gejala alergi sebelumnya.}\par\pard\li893\ri0\sl-213\slmult0 \
fs18\cf0\par\pard\li893\ri0\sl-346\slmult0 \fs22\cf0\f0\charscalex100\b {Gejala
pada saluran cerna}\b0 \par\pard\li906\ri0\sl-306\slmult0 \*\tx1146\fs20\cf0\f0\
charscalex100 {-}\tab \fs20\cf0\f0\charscalex100 {Edema dan gatal pada bibir, m
ukosa oral, dan faring terjadi jika makanan yang}\par\pard\li1146\ri0\sl-266\sl
mult0 \fs22\cf0\f0\charscalex100 {mensensitisasi kontak dengan mukosa.}\par\pard
\li906\ri0\sl-266\slmult0 \*\tx1146\*\tx7680\fs20\cf0\f0\charscalex100 {-}\tab \
fs20\cf0\f0\charscalex100 {Muntah dan/atau diare, terutama pada bayi,
bisa r
ingan, melanjut, atau}\tab \fs18\cf0\f0\charscalex100\i {intractable}\i0 \par\
pard\li1146\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {dan dapat berupa munt
ah atau buang air besar berdarah. Alergi susu sapi dapat}\par\pard\li1146\ri0\
sl-266\slmult0 \fs20\cf0\f0\charscalex100 {menyebabkan kolik infantil. Jika hip
ersensitivitas berat, dapat terjadi kerusakan}\par\pard\li1146\ri0\sl-266\slmul
t0 \fs22\cf0\f0\charscalex100 {mukosa usus, dehidrasi, ketidakseimbangan elektro
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22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Konstipasi kronik ya
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n metode}\tab \fs18\cf0\f0\charscalex100\i {crossover}\i0 \fs22\cf0\f0\charscale
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rd\li906\ri0\sl-466\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf
0\f0\charscalex100 {Pemeriksaan laboratorium tidak memberikan nilai diagnostik,
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ex100 {diagnosis klinis. Penurunan kadar albumin sugestif untuk enteropati; hipo
proteinemia}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {seri
ng terjadi bersama-sama dengan anemia defisieni besi akibat alergi susu sapi. }\
par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {Peningkatan tromb
osit, LED, CRP, dan leukosit tinja merupakan bukti adanya inflamasi}\par\pard\li
1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {tetapi tidak spesifik, sehin
gga nilai normal tidak dapat menyingkirkanASS. Leukositosis}\par\pard\li1146\ri0
\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {eosinofilik dapat dijumpai pada kedu
a tipe ASS.}\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-2

13\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-400\slmult0 \fs26\cf0\f0\charscalex10

0\b {Tata laksana}\b0 \par\pard\li893\ri0\sl-346\slmult0 \fs22\cf0\f0\charscalex
100 {Prinsip utama dalam tata laksana ASS adalah menghindari susu sapi
dan makanan yang}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100
{mengandung susu sapi sambil mempertahankan diet bergizi dan seimbang untuk bay
i dan}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {ibu yang me
nyusui. Pada bayi yang diberikan ASI eksklusif, ibu perlu mendapat penjelasan}\
par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {berbagai makanan
yang mengandung protein susu sapi yang perlu dihindari. Konsultasi}\par
\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {dengan ahli gizi perl
u dipertimbangkan. Pada anak yang mendapat susu formula, diberikan}\par\pard\li8
93\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {susu pengganti berupa susu ter
hidrolisis sempurna/ekstensif atau susu formula asam amino }\par\pard\li893\ri0\
sl-266\slmult0 \fs22\cf0\f0\charscalex100 {pada kasus yang berat. Susu formula k
edelai dapat dicoba untuk diberikan pada anak berusia}\par\pard\li893\ri0\sl-266
\slmult0 \fs20\cf0\f0\charscalex100 {di atas 6 bulan apabila susu terhidrolisis
ekstensif tidak tersedia atau terdapat kendala biaya. }\par\pard\li893\ri0\sl-21
3\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-386\slmult0 \fs22\cf0\f0\charscalex100
\b {Indikasi rawat}\b0 \par\pard\li906\ri0\sl-306\slmult0 \*\tx1146\fs22\cf0\f0\
charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Dehidrasi berat}\par\pard\li90
6\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\ch
arscalex100 {Gizi buruk}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0
\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Anafilaksis}\par\pard\li906\r
i0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\chars
calex100 {Anemia yang memerlukan transfusi darah}\par\pard\li893\ri0\sl-213\slmu
lt0 \fs18\cf0\par\pard\li893\ri0\sl-386\slmult0 \fs22\cf0\f0\charscalex100\b {Pr
ognosis}\b0 \par\pard\li893\ri0\sl-306\slmult0 \fs22\cf0\f0\charscalex100 {Pada
umumnya alergi susu sapi tidak menetap, sebagian besar penderita akan menjadi to
leran}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {sesuai deng
an bertambahnya usia. Umumnya diketahui bahwa ASS akan membaik pada usia 3}\par\
pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {tahun: sekitar 50% tol
eran pada usia 1 tahun, 70% usia 2 tahun, dan 85% usia 3 tahun. Pada}\par\pard\
li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {anak dengan alergi yang tid
ak diperantarai IgE, toleransi lebih cepat terjadi yaitu pada usia}\par\pard\li
893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {sekitar 1 tahun yang dapat di
buktikan dengan memakai metode uji provokasi. Pada anak}\par\pard\li893\ri0\sl-2
66\slmult0 \fs22\cf0\f0\charscalex100 {dengan alergi yang diperantarai IgE
sebaiknya pemberiannya ditunda lebih lama lagi dan}\par\pard\li893\ri0\sl266\slmult0 \fs22\cf0\f0\charscalex100 {untuk menentukan waktu yang tepat, dapat
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\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-386\slmult0 \
fs26\cf0\f0\charscalex100\b {Kepustakaan}\b0 \par\pard\li893\ri0\sl-293\slmult0
\*\tx1266\fs18\cf0\f0\charscalex100 {1. }\tab \fs18\cf0\f0\charscalex100 {Konsen
sus penatalaksanaan alergi susu sapi. UKK Alergi & Imunologi, Gastroenterohepato
logi, Gizi &}\par\pard\li1266\ri0\sl-226\slmult0 \fs18\cf0\f0\charscalex100 {Met
abolik IDAI 2009.}\par\pard\li893\ri0\sl-253\slmult0 \*\tx1266\fs18\cf0\f0\chars
calex100 {2. }\tab \fs18\cf0\f0\charscalex100 {Vandenplas Y, Brueton M, Dupont C
, Hill D, Isolauri E, Koletzko S, et al. Guidelines for the diagnosis}\par\pard\
li1266\ri0\sl-213\slmult0 \fs18\cf0\f0\charscalex100 {and management of cow\uc1\
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d\li893\ri0\sl-253\slmult0 \*\tx1266\fs18\cf0\f0\charscalex100 {3. }\tab \fs16\c
f0\f0\charscalex100 {Kemp AS, Hil DJ, Al en KJ, Anderson K, Davidson GJ, Day AS
, et al. Guidelines for the use of infant formulas}\par\pard\li1266\ri0\sl-213\s
lmult0 \fs16\cf0\f0\charscalex100 {to treat cow\uc1\u8217Xs milk protein allergy
: an Australian consensus panel opinion. MJA. 2008; 188: 109\uc1\u8211X12.}\par\
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{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 80}}
{\sp{\sn geoBottom}{\sv 227}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;13;(40,13);(40,160);(26,160);(26,13);(26,0);(40,0);(4
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{\sp{\sn pSegmentInfo}{\sv 2;28;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
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{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 1}}
{\sp{\sn fillColor}{\sv 526342}}
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{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft3840\shptop8146\shpright3840\shpbottom8306\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn pVerticies}{\sv 8;7;(13,13);(13,160);(0,160);(0,13);(0,0);(13,0);(13,13
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{\sp{\sn pSegmentInfo}{\sv 2;16;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
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{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
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{\sp{\sn fBehindDocument}{\sv 1}}

{\sp{\sn fLayoutInCell}{\sv 1}}}}
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn pVerticies}{\sv 8;7;(13,13);(13,160);(0,160);(0,13);(0,0);(13,0);(13,13
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{\sp{\sn pSegmentInfo}{\sv 2;16;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
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{\sp{\sn fFillOK}{\sv 1}}
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{\sp{\sn lineWidth}{\sv 2086}}

{\sp{\sn lineColor}{\sv 526342}}
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{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
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{\shp{\*\shpinst\shpleft2440\shptop8293\shpright2533\shpbottom8373\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
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{\shp{\*\shpinst\shpleft3306\shptop8240\shpright5106\shpbottom8493\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn pSegmentInfo}{\sv 2;12;16384;45824;1;45824;1;45824;1;45824;1;45824;2457

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{\shp{\*\shpinst\shpleft1693\shptop8373\shpright2973\shpbottom8626\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn geoRight}{\sv 93}}

{\sp{\sn geoBottom}{\sv 214}}
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{\sp{\sn pVerticies}{\sv 8;13;(53,0);(53,146);(53,160);(40,160);(40,146);(40,0);
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{\sp{\sn pSegmentInfo}{\sv 2;28;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
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{\shp{\*\shpinst\shpleft2480\shptop8626\shpright2493\shpbottom8786\shpfhdr0\shpw
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{\sp{\sn pVerticies}{\sv 8;7;(13,0);(13,146);(13,160);(0,160);(0,146);(0,0);(13,
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{\sp{\sn pSegmentInfo}{\sv 2;16;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
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{\sp{\sn pVerticies}{\sv 8;4;(93,0);(40,80);(0,0);(93,0);}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
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{\shp{\*\shpinst\shpleft3800\shptop8626\shpright3880\shpbottom8840\shpfhdr0\shpw
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{\sp{\sn pVerticies}{\sv 8;13;(40,0);(40,146);(40,160);(26,160);(26,146);(26,0);
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{\sp{\sn pSegmentInfo}{\sv 2;28;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
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{\shp{\*\shpinst\shpleft3840\shptop8626\shpright3840\shpbottom8786\shpfhdr0\shpw
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{\sp{\sn pVerticies}{\sv 8;7;(13,0);(13,146);(13,160);(0,160);(0,146);(0,0);(13,
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{\sp{\sn pSegmentInfo}{\sv 2;16;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
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{\sp{\sn fFillOK}{\sv 1}}
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{\sp{\sn lineDashing}{\sv 0}}

{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
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{\shp{\*\shpinst\shpleft1733\shptop8840\shpright3146\shpbottom9493\shpfhdr0\shpw
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{\shp{\*\shpinst\shpleft1733\shptop8840\shpright3146\shpbottom9493\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\shp{\*\shpinst\shpleft3306\shptop8626\shpright8413\shpbottom9560\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn pSegmentInfo}{\sv 2;12;16384;45824;1;45824;1;45824;1;45824;1;45824;2457
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{\sp{\sn fFillOK}{\sv 1}}

{\sp{\sn fFilled}{\sv 1}}
{\sp{\sn fillColor}{\sv 16777215}}
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{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft2146\shptop9493\shpright2146\shpbottom9693\shpfhdr0\shpw
r3\shpwrk0\shpfblwtxt1\shplid2429\shpz49\shpbxpage\shpbypage
{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 0}}
{\sp{\sn geoBottom}{\sv 200}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;2;(0,0);(0,200);}}
{\sp{\sn pSegmentInfo}{\sv 2;5;16384;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 0}}
{\sp{\sn lineWidth}{\sv 6258}}
{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineDashing}{\sv 0}}
{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft1920\shptop9693\shpright4786\shpbottom9693\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 2866}}
{\sp{\sn geoBottom}{\sv 0}}
{\sp{\sn shapePath}{\sv 4}}

{\sp{\sn pVerticies}{\sv 8;2;(0,0);(2866,0);}}

{\sp{\sn pSegmentInfo}{\sv 2;5;16384;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 0}}
{\sp{\sn lineWidth}{\sv 6258}}
{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineDashing}{\sv 0}}
{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft1880\shptop9680\shpright1973\shpbottom9906\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 93}}
{\sp{\sn geoBottom}{\sv 226}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;15;(53,13);(53,146);(53,160);(40,160);(40,146);(40,13
);(40,0);(53,0);(53,13);(93,146);(40,226);(0,146);(93,146);(53,13);(53,13);}}
{\sp{\sn pSegmentInfo}{\sv 2;32;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;2457
7;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 1}}
{\sp{\sn fillColor}{\sv 526342}}
{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineColor}{\sv 0}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft1920\shptop9680\shpright1933\shpbottom9853\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 13}}
{\sp{\sn geoBottom}{\sv 173}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;9;(13,13);(13,146);(13,160);(0,160);(0,146);(0,13);(0
,0);(13,0);(13,13);}}
{\sp{\sn pSegmentInfo}{\sv 2;20;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 0}}
{\sp{\sn lineWidth}{\sv 2086}}
{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineDashing}{\sv 0}}
{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft1880\shptop9826\shpright1973\shpbottom9906\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}

{\sp{\sn fFlipH}{\sv 0}}

{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 93}}
{\sp{\sn geoBottom}{\sv 80}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;4;(93,0);(40,80);(0,0);(93,0);}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 0}}
{\sp{\sn lineWidth}{\sv 2086}}
{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineDashing}{\sv 0}}
{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft4746\shptop9680\shpright4826\shpbottom9906\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 80}}
{\sp{\sn geoBottom}{\sv 226}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;14;(53,13);(53,160);(40,160);(26,160);(26,13);(26,0);
(40,0);(53,13);(80,146);(40,226);(0,146);(80,146);(53,13);(53,13);}}
{\sp{\sn pSegmentInfo}{\sv 2;30;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 1}}
{\sp{\sn fillColor}{\sv 526342}}
{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineColor}{\sv 0}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft4773\shptop9680\shpright4800\shpbottom9853\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 27}}
{\sp{\sn geoBottom}{\sv 173}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;8;(26,13);(26,160);(13,160);(0,160);(0,13);(0,0);(13,
0);(26,13);}}
{\sp{\sn pSegmentInfo}{\sv 2;18;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 0}}
{\sp{\sn lineWidth}{\sv 2086}}
{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineDashing}{\sv 0}}
{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}

{\sp{\sn lineType}{\sv 0}}

{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft4746\shptop9826\shpright4826\shpbottom9906\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 80}}
{\sp{\sn geoBottom}{\sv 80}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;4;(80,0);(40,80);(0,0);(80,0);}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 0}}
{\sp{\sn lineWidth}{\sv 2086}}
{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineDashing}{\sv 0}}
{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft1560\shptop9840\shpright3306\shpbottom10640\shpfhdr0\shp
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{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 1746}}
{\sp{\sn geoBottom}{\sv 800}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;5;(0,0);(0,800);(1746,800);(1746,0);(0,0);}}
{\sp{\sn pSegmentInfo}{\sv 2;12;16384;45824;1;45824;1;45824;1;45824;1;45824;2457
7;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 1}}
{\sp{\sn fillColor}{\sv 16777215}}
{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineColor}{\sv 0}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft1560\shptop9840\shpright3306\shpbottom10640\shpfhdr0\shp
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{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 1746}}
{\sp{\sn geoBottom}{\sv 800}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;5;(0,0);(0,800);(1746,800);(1746,0);(0,0);}}
{\sp{\sn pSegmentInfo}{\sv 2;12;16384;45824;1;45824;1;45824;1;45824;1;45824;2457
7;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 0}}

{\sp{\sn lineWidth}{\sv 6258}}

{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineDashing}{\sv 0}}
{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft1560\shptop11000\shpright4893\shpbottom11986\shpfhdr0\sh
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{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 3333}}
{\sp{\sn geoBottom}{\sv 986}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;5;(0,0);(0,986);(3346,986);(3346,0);(0,0);}}
{\sp{\sn pSegmentInfo}{\sv 2;12;16384;45824;1;45824;1;45824;1;45824;1;45824;2457
7;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 1}}
{\sp{\sn fillColor}{\sv 16777215}}
{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineColor}{\sv 0}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft1560\shptop11000\shpright4893\shpbottom11986\shpfhdr0\sh
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{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 3333}}
{\sp{\sn geoBottom}{\sv 986}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;5;(0,0);(0,986);(3346,986);(3346,0);(0,0);}}
{\sp{\sn pSegmentInfo}{\sv 2;12;16384;45824;1;45824;1;45824;1;45824;1;45824;2457
7;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 0}}
{\sp{\sn lineWidth}{\sv 6258}}
{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineDashing}{\sv 0}}
{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft4600\shptop5506\shpright4720\shpbottom5506\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 120}}
{\sp{\sn geoBottom}{\sv 0}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;2;(0,0);(106,0);}}

{\sp{\sn pSegmentInfo}{\sv 2;5;16384;45824;1;45824;32768}}

{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 0}}
{\sp{\sn lineWidth}{\sv 6258}}
{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineDashing}{\sv 0}}
{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft5693\shptop5506\shpright5866\shpbottom5506\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 173}}
{\sp{\sn geoBottom}{\sv 0}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;2;(0,0);(173,0);}}
{\sp{\sn pSegmentInfo}{\sv 2;5;16384;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 0}}
{\sp{\sn lineWidth}{\sv 6258}}
{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineDashing}{\sv 0}}
{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft2346\shptop10626\shpright2440\shpbottom11000\shpfhdr0\sh
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{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 94}}
{\sp{\sn geoBottom}{\sv 374}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;13;(53,13);(53,306);(40,306);(40,13);(40,0);(53,0);(5
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{\sp{\sn pSegmentInfo}{\sv 2;28;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
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{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 1}}
{\sp{\sn fillColor}{\sv 526342}}
{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineColor}{\sv 0}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft2386\shptop10626\shpright2400\shpbottom10933\shpfhdr0\sh
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{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 14}}

{\sp{\sn geoBottom}{\sv 307}}

{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;7;(13,13);(13,306);(0,306);(0,13);(0,0);(13,0);(13,13
);}}
{\sp{\sn pSegmentInfo}{\sv 2;16;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 0}}
{\sp{\sn lineWidth}{\sv 2086}}
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{\sp{\sn lineDashing}{\sv 0}}
{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft2346\shptop10906\shpright2440\shpbottom11000\shpfhdr0\sh
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{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 94}}
{\sp{\sn geoBottom}{\sv 94}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;4;(93,0);(53,93);(0,0);(93,0);}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 0}}
{\sp{\sn lineWidth}{\sv 2086}}
{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineDashing}{\sv 0}}
{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft7533\shptop7080\shpright7613\shpbottom7400\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 80}}
{\sp{\sn geoBottom}{\sv 320}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;14;(53,13);(53,240);(40,240);(26,240);(26,13);(26,0);
(40,0);(53,13);(80,226);(40,320);(0,226);(80,226);(53,13);(53,13);}}
{\sp{\sn pSegmentInfo}{\sv 2;30;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 1}}
{\sp{\sn fillColor}{\sv 526342}}
{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineColor}{\sv 0}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}

{\shp{\*\shpinst\shpleft7560\shptop7080\shpright7586\shpbottom7320\shpfhdr0\shpw
r3\shpwrk0\shpfblwtxt1\shplid2447\shpz67\shpbxpage\shpbypage
{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 26}}
{\sp{\sn geoBottom}{\sv 240}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;8;(26,13);(26,240);(13,240);(0,240);(0,13);(0,0);(13,
0);(26,13);}}
{\sp{\sn pSegmentInfo}{\sv 2;18;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 0}}
{\sp{\sn lineWidth}{\sv 2086}}
{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineDashing}{\sv 0}}
{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft7533\shptop7306\shpright7613\shpbottom7400\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn fFlipV}{\sv 0}}
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{\sp{\sn geoRight}{\sv 80}}
{\sp{\sn geoBottom}{\sv 94}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;4;(80,0);(40,93);(0,0);(80,0);}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 0}}
{\sp{\sn lineWidth}{\sv 2086}}
{\sp{\sn lineColor}{\sv 526342}}
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{\shp{\*\shpinst\shpleft4306\shptop1560\shpright6533\shpbottom1853\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 2227}}
{\sp{\sn geoBottom}{\sv 293}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;5;(0,0);(0,293);(2213,293);(2213,0);(0,0);}}
{\sp{\sn pSegmentInfo}{\sv 2;12;16384;45824;1;45824;1;45824;1;45824;1;45824;2457
7;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 1}}
{\sp{\sn fillColor}{\sv 16777215}}
{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineColor}{\sv 0}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft4306\shptop1560\shpright6533\shpbottom1853\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 2227}}
{\sp{\sn geoBottom}{\sv 293}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;5;(0,0);(0,293);(2213,293);(2213,0);(0,0);}}
{\sp{\sn pSegmentInfo}{\sv 2;12;16384;45824;1;45824;1;45824;1;45824;1;45824;2457
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{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 0}}
{\sp{\sn lineWidth}{\sv 6484}}
{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineDashing}{\sv 0}}
{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft5373\shptop1840\shpright5453\shpbottom2120\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 80}}
{\sp{\sn geoBottom}{\sv 280}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;9;(0,200);(26,200);(26,13);(40,0);(40,13);(40,200);(8
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{\sp{\sn pSegmentInfo}{\sv 2;20;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 1}}

{\sp{\sn fillColor}{\sv 526342}}

{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineColor}{\sv 0}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft5400\shptop1840\shpright5413\shpbottom2066\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn geoBottom}{\sv 226}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;8;(13,13);(13,213);(13,226);(0,226);(0,213);(0,13);(1
3,0);(13,13);}}
{\sp{\sn pSegmentInfo}{\sv 2;18;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
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{\sp{\sn fFillOK}{\sv 1}}
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{\sp{\sn lineWidth}{\sv 2048}}
{\sp{\sn lineColor}{\sv 526342}}
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{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
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{\sp{\sn fBehindDocument}{\sv 1}}
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{\shp{\*\shpinst\shpleft5373\shptop2040\shpright5453\shpbottom2120\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn pVerticies}{\sv 8;4;(80,0);(40,80);(0,0);(80,0);}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
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{\sp{\sn fFillOK}{\sv 1}}
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{\sp{\sn lineColor}{\sv 526342}}
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{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
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{\shp{\*\shpinst\shpleft3933\shptop2120\shpright7120\shpbottom2653\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn geoRight}{\sv 3187}}
{\sp{\sn geoBottom}{\sv 533}}
{\sp{\sn shapePath}{\sv 4}}

{\sp{\sn pVerticies}{\sv 8;5;(0,0);(0,533);(3186,533);(3186,0);(0,0);}}

{\sp{\sn pSegmentInfo}{\sv 2;12;16384;45824;1;45824;1;45824;1;45824;1;45824;2457
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{\sp{\sn fFillOK}{\sv 1}}
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{\sp{\sn fillColor}{\sv 16777215}}
{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineColor}{\sv 0}}
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{\shp{\*\shpinst\shpleft3933\shptop2120\shpright7120\shpbottom2653\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn geoRight}{\sv 3187}}
{\sp{\sn geoBottom}{\sv 533}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;5;(0,0);(0,533);(3186,533);(3186,0);(0,0);}}
{\sp{\sn pSegmentInfo}{\sv 2;12;16384;45824;1;45824;1;45824;1;45824;1;45824;2457
7;32768}}
{\sp{\sn fFillOK}{\sv 1}}
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{\sp{\sn lineWidth}{\sv 6484}}
{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineDashing}{\sv 0}}
{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineType}{\sv 0}}
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{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft2653\shptop2480\shpright3933\shpbottom2480\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 1280}}
{\sp{\sn geoBottom}{\sv 0}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;2;(1280,0);(0,0);}}
{\sp{\sn pSegmentInfo}{\sv 2;5;16384;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}
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{\sp{\sn lineWidth}{\sv 6484}}
{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineDashing}{\sv 0}}
{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
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{\shp{\*\shpinst\shpleft7120\shptop2480\shpright7960\shpbottom2480\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn geoRight}{\sv 840}}

{\sp{\sn geoBottom}{\sv 0}}
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{\sp{\sn pVerticies}{\sv 8;2;(840,0);(0,13);}}
{\sp{\sn pSegmentInfo}{\sv 2;5;16384;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}
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{\sp{\sn lineColor}{\sv 526342}}
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{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
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{\shp{\*\shpinst\shpleft2613\shptop2480\shpright2693\shpbottom2853\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn geoRight}{\sv 80}}
{\sp{\sn geoBottom}{\sv 373}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;9;(0,280);(26,280);(26,0);(40,0);(53,13);(40,280);(80
,280);(40,373);(0,280);}}
{\sp{\sn pSegmentInfo}{\sv 2;20;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}
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{\sp{\sn fillColor}{\sv 526342}}
{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineColor}{\sv 0}}
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{\shp{\*\shpinst\shpleft2640\shptop2480\shpright2666\shpbottom2786\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn geoRight}{\sv 26}}
{\sp{\sn geoBottom}{\sv 306}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;6;(26,13);(13,306);(0,306);(0,0);(13,0);(26,13);}}
{\sp{\sn pSegmentInfo}{\sv 2;14;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
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{\sp{\sn fFillOK}{\sv 1}}
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{\sp{\sn lineWidth}{\sv 2048}}
{\sp{\sn lineColor}{\sv 526342}}
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{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
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{\shp{\*\shpinst\shpleft2613\shptop2773\shpright2693\shpbottom2853\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}

{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
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{\sp{\sn geoRight}{\sv 80}}
{\sp{\sn geoBottom}{\sv 80}}
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{\sp{\sn pVerticies}{\sv 8;4;(80,0);(40,93);(0,0);(80,0);}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
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{\sp{\sn fFillOK}{\sv 1}}
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{\sp{\sn lineColor}{\sv 526342}}
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{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
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{\shp{\*\shpinst\shpleft7920\shptop2480\shpright8000\shpbottom2853\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn pVerticies}{\sv 8;9;(0,293);(26,293);(26,0);(40,0);(53,0);(53,293);(80,
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{\sp{\sn pSegmentInfo}{\sv 2;20;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
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{\sp{\sn fFillOK}{\sv 1}}
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{\shp{\*\shpinst\shpleft7946\shptop2480\shpright7960\shpbottom2786\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn pVerticies}{\sv 8;7;(26,0);(26,320);(13,320);(0,320);(0,0);(13,0);(26,0
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{\sp{\sn pSegmentInfo}{\sv 2;16;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
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{\sp{\sn lineColor}{\sv 526342}}
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{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}

{\sp{\sn lineType}{\sv 0}}

{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft7920\shptop2773\shpright8000\shpbottom2853\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn pVerticies}{\sv 8;4;(80,0);(40,93);(0,0);(80,0);}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
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{\sp{\sn fFillOK}{\sv 1}}
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{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineDashing}{\sv 0}}
{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
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{\sp{\sn fBehindDocument}{\sv 1}}
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{\shp{\*\shpinst\shpleft4813\shptop3360\shpright5786\shpbottom4040\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn pVerticies}{\sv 8;5;(0,0);(0,666);(973,666);(973,0);(0,0);}}
{\sp{\sn pSegmentInfo}{\sv 2;12;16384;45824;1;45824;1;45824;1;45824;1;45824;2457
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{\sp{\sn fFillOK}{\sv 1}}
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{\sp{\sn fillColor}{\sv 16777215}}
{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineColor}{\sv 0}}
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{\shp{\*\shpinst\shpleft4813\shptop3360\shpright5786\shpbottom4040\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn pVerticies}{\sv 8;5;(0,0);(0,666);(973,666);(973,0);(0,0);}}
{\sp{\sn pSegmentInfo}{\sv 2;12;16384;45824;1;45824;1;45824;1;45824;1;45824;2457
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{\sp{\sn fFillOK}{\sv 1}}
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{\sp{\sn lineWidth}{\sv 6484}}

{\sp{\sn lineColor}{\sv 526342}}
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{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
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{\shp{\*\shpinst\shpleft4693\shptop3813\shpright4813\shpbottom3813\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn pVerticies}{\sv 8;2;(0,0);(120,0);}}
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{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
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{\shp{\*\shpinst\shpleft5786\shptop3813\shpright5960\shpbottom3813\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn pVerticies}{\sv 8;2;(0,0);(173,0);}}
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{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
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{\shp{\*\shpinst\shpleft3093\shptop4666\shpright3186\shpbottom4880\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn pVerticies}{\sv 8;8;(0,133);(40,133);(40,0);(53,0);(53,133);(93,133);(4

0,213);(0,133);}}
{\sp{\sn pSegmentInfo}{\sv 2;18;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
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{\shp{\*\shpinst\shpleft3133\shptop4666\shpright3146\shpbottom4826\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn pVerticies}{\sv 8;7;(13,0);(13,146);(13,146);(0,146);(0,146);(0,0);(13,
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{\sp{\sn fFlipV}{\sv 0}}

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{\sp{\sn pVerticies}{\sv 8;9;(13,13);(13,186);(13,186);(13,200);(0,186);(0,13);(
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{\sp{\sn pSegmentInfo}{\sv 2;20;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
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{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineColor}{\sv 0}}

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{\sp{\sn pSegmentInfo}{\sv 2;5;16384;45824;1;45824;32768}}

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{\sp{\sn shapePath}{\sv 4}}

{\sp{\sn pVerticies}{\sv 8;5;(0,0);(0,253);(1000,253);(1000,0);(0,0);}}
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{\sp{\sn fFlipV}{\sv 0}}

{\sp{\sn rotation}{\sv 0}}
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{\sp{\sn fBehindDocument}{\sv 1}}

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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn geoBottom}{\sv 320}}

{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;9;(26,13);(26,320);(26,320);(13,320);(13,320);(0,13);
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{\sp{\sn pSegmentInfo}{\sv 2;20;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
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{\sp{\sn fFillOK}{\sv 1}}
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{\sp{\sn lineColor}{\sv 526342}}
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{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
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{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
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{\sp{\sn fFillOK}{\sv 1}}
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{\shp{\*\shpinst\shpleft6280\shptop5613\shpright9186\shpbottom6360\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn pSegmentInfo}{\sv 2;12;16384;45824;1;45824;1;45824;1;45824;1;45824;2457
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{\sp{\sn fFillOK}{\sv 1}}
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{\sp{\sn fillColor}{\sv 16777215}}
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{\sp{\sn shapeType}{\sv 0}}

{\sp{\sn fFlipH}{\sv 0}}
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{\sp{\sn pSegmentInfo}{\sv 2;12;16384;45824;1;45824;1;45824;1;45824;1;45824;2457
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{\sp{\sn fFillOK}{\sv 1}}
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{\shp{\*\shpinst\shpleft7733\shptop6360\shpright7733\shpbottom6853\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn pSegmentInfo}{\sv 2;5;16384;45824;1;45824;32768}}
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{\sp{\sn lineColor}{\sv 526342}}
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{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
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{\shp{\*\shpinst\shpleft7226\shptop6853\shpright8360\shpbottom6866\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn pVerticies}{\sv 8;2;(0,13);(1133,0);}}
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{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
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{\sp{\sn fBehindDocument}{\sv 1}}

{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft7173\shptop6853\shpright7266\shpbottom7106\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn pVerticies}{\sv 8;8;(0,173);(40,173);(40,0);(53,0);(53,173);(93,173);(5
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{\sp{\sn pSegmentInfo}{\sv 2;18;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
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{\sp{\sn fFillOK}{\sv 1}}
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{\shp{\*\shpinst\shpleft7213\shptop6853\shpright7226\shpbottom7040\shpfhdr0\shpw
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{\sp{\sn pVerticies}{\sv 8;7;(13,0);(13,186);(13,186);(0,186);(0,186);(0,0);(13,
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{\sp{\sn pSegmentInfo}{\sv 2;16;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
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{\shp{\*\shpinst\shpleft7173\shptop7026\shpright7266\shpbottom7106\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn lineWidth}{\sv 2048}}

{\sp{\sn lineColor}{\sv 526342}}
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{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
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{\shp{\*\shpinst\shpleft8320\shptop6853\shpright8400\shpbottom7080\shpfhdr0\shpw
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{\sp{\sn pVerticies}{\sv 8;10;(0,146);(26,146);(26,13);(40,0);(53,0);(53,13);(53
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{\sp{\sn pSegmentInfo}{\sv 2;22;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
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{\shp{\*\shpinst\shpleft8346\shptop6853\shpright8373\shpbottom7026\shpfhdr0\shpw
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{\sp{\sn pVerticies}{\sv 8;8;(13,13);(13,160);(13,160);(0,160);(0,13);(13,0);(13
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{\sp{\sn pSegmentInfo}{\sv 2;18;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
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{\shp{\*\shpinst\shpleft8320\shptop7000\shpright8400\shpbottom7080\shpfhdr0\shpw
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{\sp{\sn shapePath}{\sv 4}}

{\sp{\sn pVerticies}{\sv 8;4;(80,0);(40,80);(0,0);(80,0);}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
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{\shp{\*\shpinst\shpleft6973\shptop7106\shpright7733\shpbottom7480\shpfhdr0\shpw
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{\shp{\*\shpinst\shpleft6973\shptop7106\shpright7733\shpbottom7480\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\shp{\*\shpinst\shpleft7920\shptop7106\shpright8866\shpbottom7453\shpfhdr0\shpw
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{\sp{\sn fFlipV}{\sv 0}}

{\sp{\sn rotation}{\sv 0}}
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{\shp{\*\shpinst\shpleft7920\shptop7106\shpright8866\shpbottom7453\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\shp{\*\shpinst\shpleft7173\shptop7480\shpright7266\shpbottom7706\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn pVerticies}{\sv 8;10;(0,146);(40,146);(40,13);(40,0);(53,0);(53,13);(53
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{\sp{\sn pSegmentInfo}{\sv 2;22;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
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{\sp{\sn fFillOK}{\sv 1}}
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{\shp{\*\shpinst\shpleft7213\shptop7480\shpright7226\shpbottom7640\shpfhdr0\shpw

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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn pVerticies}{\sv 8;7;(13,13);(13,160);(0,160);(0,13);(0,0);(13,0);(13,13
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{\sp{\sn pSegmentInfo}{\sv 2;16;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
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{\shp{\*\shpinst\shpleft7173\shptop7613\shpright7266\shpbottom7706\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
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{\shp{\*\shpinst\shpleft8320\shptop7453\shpright8400\shpbottom7706\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn pVerticies}{\sv 8;9;(0,160);(26,160);(26,0);(40,0);(53,0);(53,160);(80,
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{\sp{\sn pSegmentInfo}{\sv 2;20;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
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{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineColor}{\sv 0}}

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{\shp{\*\shpinst\shpleft8346\shptop7453\shpright8373\shpbottom7640\shpfhdr0\shpw
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mn\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-213\slmult0 \fs18\c
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1346\ri0\sl-213\slmult0 \fs12\cf0\f0\charscalex100 {\uc1\u8226X}\fs12\cf0\f0\cha
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gan atau tanpa ruam }\par\pard\li1586\ri0\sl-160\slmult0 \fs12\cf0\f0\charscalex
100 {perianal), darah pada }\fs12\cf0\f0\charscalex100 {tinja}\fs12\cf0\f0\chars
calex100 { }\par\pard\li1346\ri0\sl-160\slmult0 \fs12\cf0\f0\charscalex100 {\uc1
\u8226X}\fs12\cf0\f0\charscalex100 { }\fs12\cf0\f0\charscalex100 {Anemia defisi
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10\cf0\f0\charscalex100 {\uc1\u8226X}\fs10\cf0\f0\charscalex100 { }\fs10\cf0\f0
\charscalex100 {Dermatitis atopik (DA), angioedema, }\par\pard\li1586\ri0\sl-160
\slmult0 \fs12\cf0\f0\charscalex100 {urtikaria}\fs12\cf0\f0\charscalex100 { }\pa
r\pard\li1346\ri0\sl-160\slmult0 \fs12\cf0\f0\charscalex100 {\uc1\u8226X}\fs12\c
f0\f0\charscalex100 { }\fs12\cf0\f0\charscalex100 {Pilek, batuk kronik, mengi }
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harscalex100 {\uc1\u8226X}\fs12\cf0\f0\charscalex100 { }\fs12\cf0\f0\charscalex
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t0 \fs12\cf0\f0\charscalex100 {selama lebih dari 3 minggu) }\fs12\cf0\f0\charsc
alex100 { }\par\pard\li1320\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1320\ri0\sl186\slmult0 \fs12\cf0\f0\charscalex100 {Diet }\fs12\cf0\f0\charscalex100 {elimin
asi dengan formula sus u terhidrolisa }\fs12\cf0\f0\charscalex100 {t}\fs12\cf0\f
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0 {ekstensif }\fs12\cf0\f0\charscalex100 {minimal 2 }\fs12\cf0\f0\charscalex100
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fs12\cf0\f0\charscalex100 {usuk k}\fs12\cf0\f0\charscalex100 {ulit }\fs12\cf0\f0
\charscalex100 { }\par\pard\li40\ri0\sl-160\slmult0 \fs12\cf0\f0\charscalex100 {
IgE Spesifik }\fs12\cf0\f0\charscalex100 { }\par\column\pard\li0\ri0\sl-160\slmu
lt0 \fs12\cf0\f0\charscalex100 {Satu/lebih gejala di }\fs12\cf0\f0\charscalex100
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f0\charscalex100 { }\fs12\cf0\f0\charscalex100 {Gagal tumbuh karena diare dan a
tau }\par\pard\li466\ri0\sl-160\slmult0 \fs12\cf0\f0\charscalex100 {regurgitasi,
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lmult0 \fs12\cf0\f0\charscalex100 {\uc1\u8226X}\fs12\cf0\f0\charscalex100 { }\f
s12\cf0\f0\charscalex100 {Anemia defisiensi besi karena kehilangan }\par\pard\li

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{protein, enteropati atau kolitis ulseratif kronik }\par\pard\li466\ri0\sl-160
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}\par\pard\li466\ri0\sl-160\slmult0 \fs12\cf0\f0\charscalex100 {histologi}\fs12\
cf0\f0\charscalex100 { }\par\pard\li213\ri0\sl-160\slmult0 \fs12\cf0\f0\charscal
ex100 {\uc1\u8226X}\fs12\cf0\f0\charscalex100 { }\fs12\cf0\f0\charscalex100 {DA
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cf0\f0\charscalex100 {atau gagal tumbuh atau }\fs12\cf0\f0\charscalex100 {anemia
defisiensi }\par\pard\li466\ri0\sl-160\slmult0 \fs12\cf0\f0\charscalex100 {besi
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harscalex100 {\uc1\u8226X}\fs12\cf0\f0\charscalex100 { }\fs12\cf0\f0\charscalex
100 {Laringoedema akut atau obstruksi bronkus }\par\pard\li466\ri0\sl-160\slmult
0 \fs12\cf0\f0\charscalex100 {dengan kesulitan bernapas }\fs12\cf0\f0\charscalex
100 { }\par\pard\li666\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li666\ri0\sl-320\sl
mult0 \fs12\cf0\f0\charscalex100 {Rujuk }\fs12\cf0\f0\charscalex100 {dokter spes
ialis anak konsultan
}\par\pard\sect\sectd\sbknone\pgwsxn10760\p
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mult0 \fs12\cf0\f0\charscalex100 {Tidak ada perbaikan }\fs12\cf0\f0\charscalex10
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12\cf0\f0\charscalex100 {iet eliminasi susu }\fs12\cf0\f0\charscalex100 { }\fs12
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}\par\pard\li0\ri0\sl-226
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2\cf0\f0\charscalex100 {asam amino minimal 2 }\fs12\cf0\f0\charscalex100 {-}\fs1
2\cf0\f0\charscalex100 {4 minggu}{\super \fs10\up2\cf0\f0\charscalex100\b {#}\b0
}\par\pard\sect\sectd\sbknone\pgwsxn10760\pghsxn14440\marglsxn666\margrsxn133\c
ols4\colno1\colw3400\colsr-0\colno2\colw3013\colsr-0\colno3\colw1026\colsr-0\col
no4\colw2520\pard\li1000\ri0\sl-320\slmult0 \fs12\cf0\f0\charscalex100 {\uc1\u82
26X}\fs12\cf0\f0\charscalex100 { }\fs12\cf0\f0\charscalex100 {Uji p}\fs12\cf0\f
0\charscalex100 {rovokasi terbuka }\fs12\cf0\f0\charscalex100 { }\par\pard\li100
0\ri0\sl-160\slmult0 \fs12\cf0\f0\charscalex100 {\uc1\u8226X}\fs12\cf0\f0\charsc
alex100 { }\fs12\cf0\f0\charscalex100 {Berikan susu formula }\fs12\cf0\f0\char
scalex100 {susu sapi }\par\pard\li1000\ri0\sl-160\slmult0 \fs12\cf0\f0\charsca
lex100 {
}\fs12\cf0\f0\charscalex100 {dibawah pengawasan }\fs12\cf0\f0\charsc
alex100 { }\par\column\pard\li0\ri0\sl-293\slmult0 \fs12\cf0\f0\charscalex100 {R
ujuk }\fs12\cf0\f0\charscalex100 {dokter spesialis anak konsultan
}\par\pard\li400\ri0\sl-173\slmult0 \fs12\cf0\f0\charscalex100 {D}\fs12\cf0\f0
\charscalex100 {iet eliminasi }\fs12\cf0\f0\charscalex100 { }\fs12\cf0\f0\charsc
alex100 {susu sapi
}\par\pard\li120\ri0\sl-160\slmult0 \fs12\cf0
\f0\charscalex100 {F}\fs12\cf0\f0\charscalex100 {ormula asam amino minimal 2 }\f
s12\cf0\f0\charscalex100 {-}\fs12\cf0\f0\charscalex100 {4 }\par\pard\li826\ri0\s
l-240\slmult0 \fs12\cf0\f0\charscalex100 {minggu}\fs18\cf0\f0\charscalex100\b {*
}\b0 \par\column\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-213\
slmult0 \fs18\cf0\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-186\slmult0 \fs12\cf0\f0\charscalex100
{Tidak ada }\par\pard\li0\ri0\sl-160\slmult0 \fs12\cf0\f0\charscalex100 {perbai
kan }\fs12\cf0\f0\charscalex100 { }\par\column\pard\li0\ri0\sl-213\slmult0 \fs18
\cf0\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-213\slmult0 \
fs18\cf0\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-160\slmul
t0 \fs12\cf0\f0\charscalex100 {Perbaikan }\fs12\cf0\f0\charscalex100 { }\par\pa
rd\sect\sectd\sbknone\pgwsxn10760\pghsxn14440\marglsxn666\margrsxn133\cols6\coln
o1\colw2453\colsr-0\colno2\colw1440\colsr-0\colno3\colw1026\colsr-0\colno4\colw1
520\colsr-0\colno5\colw1053\colsr-0\colno6\colw2466\pard\li1253\ri0\sl-240\slmul
t0 \fs12\cf0\f0\charscalex100 {Gejala (}\fs12\cf0\f0\charscalex100 {-) }\par\par
d\li1253\ri0\sl-293\slmult0 \fs12\cf0\f0\charscalex100 {D}\fs12\cf0\f0\charscale
x100 {iberikan }\par\pard\li1173\ri0\sl-160\slmult0 \fs12\cf0\f0\charscalex100 {
protein susu }\par\pard\li1213\ri0\sl-160\slmult0 \fs12\cf0\f0\charscalex100 {sa
pi dan di }\par\pard\li1306\ri0\sl-160\slmult0 \fs12\cf0\f0\charscalex100 {monit

or}\fs12\cf0\f0\charscalex100 { }\par\column\pard\li226\ri0\sl-160\slmult0 \fs12

\cf0\f0\charscalex100 {Gejala (+) }\fs12\cf0\f0\charscalex100 { }\par\pard\li0\r
i0\sl-213\slmult0 \fs12\cf0\f0\charscalex100 {Eliminasi protein }\par\pard\li0\r
i0\sl-160\slmult0 \fs12\cf0\f0\charscalex100 {susu sapi dari}\par\pard\li0\ri0\s
l-160\slmult0 \fs12\cf0\f0\charscalex100 {makanan selama}\par\pard\li0\ri0\sl-16
0\slmult0 \fs12\cf0\f0\charscalex100 {9-}\fs12\cf0\f0\charscalex100 {12 bulan da
n }\par\pard\li0\ri0\sl-160\slmult0 \fs12\cf0\f0\charscalex100 {minimal selama 6
}\par\column\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-213\slmu
lt0 \fs18\cf0\par\pard\li0\ri0\sl-200\slmult0 \fs12\cf0\f0\charscalex100 {Tidak
ada }\par\pard\li0\ri0\sl-160\slmult0 \fs12\cf0\f0\charscalex100 {perbaikan}\fs1
2\cf0\f0\charscalex100 { }\par\column\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\
pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-173\slmult0 \fs12\cf0\
f0\charscalex100 {Perbaikan }\fs12\cf0\f0\charscalex100 { }\par\column\pard\li2
6\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li26\ri0\sl-253\slmult0 \fs12\cf0\f0\cha
rscalex100 {Evaluasi }\par\pard\li0\ri0\sl-160\slmult0 \fs12\cf0\f0\charscalex10
0 {diagnosis }\fs12\cf0\f0\charscalex100 { }\par\column\pard\li186\ri0\sl-213\sl
mult0 \fs18\cf0\par\pard\li186\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li186\ri0\s
l-200\slmult0 \fs12\cf0\f0\charscalex100 {Uji }\par\pard\li0\ri0\sl-160\slmult0
\fs12\cf0\f0\charscalex100 {provok}\fs12\cf0\f0\charscalex100 {asi }\fs12\cf0\f0
\charscalex100 { }\par\pard\sect\sectd\sbknone\pgwsxn10760\pghsxn14440\marglsxn6
66\margrsxn133\cols5\colno1\colw2386\colsr-0\colno2\colw1533\colsr-0\colno3\colw
1040\colsr-0\colno4\colw1160\colsr-0\colno5\colw3840\pard\li1093\ri0\sl-213\slmu
lt0 \fs18\cf0\par\pard\li1093\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1093\ri0\s
l-213\slmult0 \fs18\cf0\par\pard\li1093\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li
1093\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1093\ri0\sl-200\slmult0 \fs14\cf0\f
0\charscalex100 {Modifikasi dari: }\par\column\pard\li66\ri0\sl-160\slmult0 \fs1
2\cf0\f0\charscalex100 {bulan}\fs12\cf0\f0\charscalex100 { }\par\pard\li0\ri0\sl
-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri
0\sl-160\slmult0 \fs12\cf0\f0\charscalex100 {Ulangi uji p }\fs12\cf0\f0\charscal
ex100 {rovokasi }\par\column\pard\li13\ri0\sl-266\slmult0 \fs12\cf0\f0\charscale
x100 {Evaluasi }\par\pard\li0\ri0\sl-160\slmult0 \fs12\cf0\f0\charscalex100 {dia
gnosis}\fs12\cf0\f0\charscalex100 { }\par\column\pard\li200\ri0\sl-266\slmult0 \
fs12\cf0\f0\charscalex100 {Uji }\par\pard\li0\ri0\sl-160\slmult0 \fs12\cf0\f0\ch
arscalex100 {Provok }\fs12\cf0\f0\charscalex100 {asi }\par\column\pard\li0\ri0\s
l-160\slmult0 \fs12\cf0\f1\charscalex100 {#:Bilaadamasalahdana/ketersediaan}\par
\pard\li120\ri0\sl-146\slmult0 \fs12\cf0\f1\charscalex100 {susu formula asam ami
no, dapat }\par\pard\li133\ri0\sl-160\slmult0 \fs12\cf0\f1\charscalex100 {dicoba
susu ter hidrolisat ekstensif }\fs12\cf0\f1\charscalex100 { }\par\pard\li0\ri0\
sl-173\slmult0 \fs12\cf0\f1\charscalex100 {* }{ }\fs12\cf0\f0\charscalex100 {Bil
a ada masalah dana dan }\par\pard\li133\ri0\sl-160\slmult0 \fs12\cf0\f0\charsca
lex100 {ketersediaan susu terhidrolisat }\par\pard\li133\ri0\sl-160\slmult0 \fs1
2\cf0\f0\charscalex100 {ekstensif dapat diberikan susu }\par\pard\li133\ri0\sl-1
60\slmult0 \fs12\cf0\f0\charscalex100 {formula kedelai dan monitor reaksi }\par\
pard\li133\ri0\sl-160\slmult0 \fs12\cf0\f0\charscalex100 {alergi (pada anak beru
sia > 6 bulan)}\par\pard\sect\sectd\sbknone\pgwsxn10760\pghsxn14440\marglsxn666\
margrsxn133\pard\li1093\ri0\sl-186\slmult0 \fs12\cf0\f0\charscalex100 {Vandenpla
s Y, dkk. Arch Dis Child. 2007:92;902-8}\par\pard\li1093\ri0\sl-186\slmult0 \fs1
4\cf0\f0\charscalex100 {Brill H. Can Fam Physician 2008;54:1258-64}\par\pard\li1
093\ri0\sl-186\slmult0 \fs12\cf0\f0\charscalex100 {Kemp AS, dkk. MJA. 2008;188:1
09-12}\par\pard\li2226\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li2226\ri0\sl-226\s
lmult0 \fs18\cf0\f0\charscalex100\b {Gambar 2.}\b0 \fs14\cf0\f1\charscalex100 {
Alur diagnosis dan tata laksana alergi susu sapi pada bayi}\par\pard\li3720\ri0\
sl-213\slmult0 \fs18\cf0\f1\charscalex100 {dengan PASI (susu formula)}\par\pard\
li6480\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li6480\ri0\sl-213\slmult0 \fs18\cf0
\par\pard\li6480\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li6480\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li6480\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li6480\ri0\sl-2
13\slmult0 \fs18\cf0\par\pard\li6480\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li648
0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li6480\ri0\sl-213\slmult0 \fs18\cf0\par\
pard\li6480\ri0\sl-413\slmult0 \*\tx8426\fs12\cf0\f0\charscalex100\i {Pedoman Pe
layanan Medis}\i0 \tab \fs22\cf0\f0\charscalex100 {9}\par\pard\sect\sectd\sbknon

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rd\li906\ri0\sl-466\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf
0\f0\charscalex100 {Dapat ditemukan koilonikia, glositis, stomatitis angularis
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\charscalex100\i {protein-losing enteropathy}\i0 \par\pard\li906\ri0\sl-266\slmu
lt0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Rent
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rscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Gangguan pertumbuhan}\par\pard\li
906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\
charscalex100 {Penurunan aktivitas kerja}\par\pard\li893\ri0\sl-213\slmult0 \fs1
8\cf0\par\pard\li893\ri0\sl-346\slmult0 \fs22\cf0\f0\charscalex100\b {Pemeriksaa
n penunjang}\b0 \par\pard\li906\ri0\sl-306\slmult0 \*\tx1146\fs20\cf0\f0\charsca
lex100 {-}\tab \fs20\cf0\f0\charscalex100 {Darah lengkap yang terdiri dari: hemo
globin rendah; MCV, MCH, dan MCHC rendah. }\par\pard\li1146\ri0\sl-280\slmult0 \
fs18\cf0\f0\charscalex100\i {Red cell distribution width}\i0 \fs22\cf0\f0\charsc
alex100 { (RDW) yang lebar dan MCV yang rendah merupakan salah}\par\pard\li1146\
ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {satu skrining defisiensi besi. }\
par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \
fs22\cf0\f0\charscalex100 {Nilai RDW tinggi >14.5% pada defisiensi besi, bila R
DW normal (<13%) pada}\par\pard\li1346\ri0\sl-266\slmult0 \fs22\cf0\f0\charscale
x100 {talasemia}{ }\fs22\cf0\f0\charscalex100\i {trait}\i0 \fs22\cf0\f0\charscal
ex100 {. }\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex10
0 {-}\tab \fs22\cf0\f0\charscalex100 {Ratio MCV/RBC (Mentzer index) 13 dan bila
RDW index (MCV/RBC xRDW)}\par\pard\li1346\ri0\sl-266\slmult0 \fs22\cf0\f0\chars
calex100 {220, merupakan tanda anemia defisiensi besi, sedangkan jika kurang d
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n tanda talasemia}{ }\fs22\cf0\f0\charscalex100\i {trait}\i0 \fs22\cf0\f0\charsc
alex100 {.}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex1
00 {-}\tab \fs22\cf0\f0\charscalex100 {Apusan darah tepi: mikrositik, hipokromik
, anisositosis, dan poikilositosis.}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146
\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Kadar besi serum
yang rendah, TIBC, serum ferritin <12 ng/mL dipertimbangkan}\par\pard\li1146\ri
0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {sebagai diagnostik defisiensi besi}
\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \
fs22\cf0\f0\charscalex100 {Nilai retikulosit: normal atau menurun, menunjukkan p
roduksi sel darah merah yang}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\ch
arscalex100 {tidak adekuat}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0
\f0\charscalex100 {-}\tab \fs18\cf0\f0\charscalex100\i {Serum transferrin recept
or}\i0 \fs22\cf0\f0\charscalex100 { (STfR): sensitif untuk menentukan defisiensi
besi, mempunyai}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100
{nilai tinggi untuk membedakan anemia defisiensi besi dan anemia akibat penyakit
kronik}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {
-}\tab \fs22\cf0\f0\charscalex100 {Kadar}{ }\fs18\cf0\f0\charscalex100\i {zinc p
rotoporphyrin}\i0 { }\fs22\cf0\f0\charscalex100 {(ZPP) akan meningkat}\par\pard\
li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f
0\charscalex100 {Terapi besi}{ }\fs20\cf0\f0\charscalex100\i {(therapeutic trial
)}\i0 \fs22\cf0\f0\charscalex100 {: respons pemberian preparat besi dengan dosis
3 mg/}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {kgBB/hari
, ditandai dengan kenaikan jumlah retikulosit antara 5\uc1\u8211X10 hari diikut
i}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {kenaikan kadar
hemoglobin 1 g/dL atau hematokrit 3% setelah 1 bulan menyokong}\par\pard\li1146
\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {diagnosis anemia defisiensi besi
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\slmult0 \fs22\cf0\f0\charscalex100 {hematokrit dinilai kembali untuk menilai ke
berhasilan terapi. }\par\pard\li1693\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex1
00 {Pemeriksaan penunjang tersebut dilakukan sesuai dengan fasilitas yang ada. }
\par\pard\li893\ri0\sl-373\slmult0 \fs22\cf0\f0\charscalex100\b {Kriteria diagno
sis ADB menurut WHO}\b0 \fs22\cf0\f0\charscalex100 {:}\par\pard\li906\ri0\sl-266
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{Kadar Hb kurang dari normal sesuai usia}\par\pard\li906\ri0\sl-266\slmult0 \*\t

x1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Konsentrasi
Hb eritrosit rata-rata 31% (N: 32-35%)}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1
146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Kadar Fe serum
<50 g/dL (N: 80-180 g/dL)}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f
0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Saturasi transferin <15% (N:
20-50%)}\par\pard\li893\ri0\sl-280\slmult0 \fs22\cf0\f0\charscalex100 {Kriteria
ini harus dipenuhi, paling sedikit kriteria nomor 1, 3, dan 4. Tes yang pal
ing}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {efisien untuk
mengukur cadangan besi tubuh yaitu ferritin serum. Bila sarana terbatas, }\par\
pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {diagnosis dapat ditega
kkan berdasarkan:}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\chars
calex100 {-}\tab \fs22\cf0\f0\charscalex100 {Anemia tanpa perdarahan}\par\pard\l
i906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0
\charscalex100 {Tanpa organomegali}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\
fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Gambaran darah tep
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cf0\par\pard\li6480\ri0\sl-373\slmult0 \*\tx8320\fs12\cf0\f0\charscalex100\i {Pe
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li1693\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {Bila respons ditemukan, te
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0\f0\charscalex100 {Komposisi besi elemental:}\par\pard\li1693\ri0\sl-266\slmult
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pard\li1693\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {Ferous glukonas: 11,6
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ani}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\t
ab \fs22\cf0\f0\charscalex100 {Pendidikan kebersihan lingkungan}\par\pard\li893\
ri0\sl-440\slmult0 \fs22\cf0\f0\charscalex100 {Pencegahan sekunder}\par\pard\li9
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harscalex100 {Skrining ADB}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs20\cf
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0\charscalex100\i {American Academy of Pediatrics}\i0 \fs22\cf0\f0\charscalex100
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\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {kemudian, dan usia 24 bulan. Pad
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li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\
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par\pard\li1266\ri0\sl-213\slmult0 \fs16\cf0\f0\charscalex100 {Arceci RJ, Hann I
M, Smith OP, penyunting. Pediatric Hematology. Edisi ke-3. NewYork: Blackwell;20
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lt0 \fs14\cf0\f0\charscalex100 {Windiastuti E, Abdulsalam M, penyunting. Buku Aj
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0\sl-253\slmult0 \*\tx1266\fs18\cf0\f0\charscalex100 {7. }\tab \fs18\cf0\f0\char
scalex100 {Kazal LA. Prevention of iron deficiency in infants and toddlers. Am F
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0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-280\slmult0
\fs22\cf0\f0\charscalex100 {Dalam upaya memberikan pelayanan kesehatan paripurna
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calex100 {pembedahan}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs20\cf0\f0\ch
arscalex100 {-}\tab \fs20\cf0\f0\charscalex100 {Asuhan keperawatan (}\fs16\cf0\f
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f0\charscalex100 {perawatan biasa maupun intensif}\par\pard\li906\ri0\sl-266\slm

ult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Asu
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0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {kebutuhan pasien secara optimal}\pa
r\pard\li893\ri0\sl-373\slmult0 \fs20\cf0\f0\charscalex100 {Ketiga jenis asuhan
tersebut mempunyai peranan masing-masing tetapi saling berkaitan}\par\pard\li893
\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {dan saling memengaruhi. Oleh kar
ena itu, perlu dilakukan secara serasi dan terpadu. }\par\pard\li893\ri0\sl-266\
slmult0 \fs20\cf0\f0\charscalex100 {Selain itu, masih perlu ditunjang oleh berba
gai kegiatan pendukung antara lain manajemen, }\par\pard\li893\ri0\sl-266\slmult
0 \fs22\cf0\f0\charscalex100 {administrasi, instalasi farmasi, dll.}\par\pard\li
893\ri0\sl-413\slmult0 \fs22\cf0\f0\charscalex100 {Asuhan nutrisi yang dimaksud
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\slmult0 \fs22\cf0\f0\charscalex100 {pelayanan gizi (}\fs18\cf0\f0\charscalex100
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h instalasi gizi rumah}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscale
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gizi secara optimal atau upaya pemenuhan kebutuhan zat gizi dapat dilakukan deng
an}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {sebaik-baiknya
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sl-266\slmult0 \fs22\cf0\f0\charscalex100 {terdiri dari dokter, perawat, ahli gi
zi, dan ahli farmasi untuk: membuat diagnosis masalah}\par\pard\li893\ri0\sl-266
\slmult0 \fs22\cf0\f0\charscalex100 {nutrisi, menentukan kebutuhan nutrisi (}\f
s22\cf0\f0\charscalex100\i {requirement}\i0 \fs22\cf0\f0\charscalex100 {), memi
lih alternatif tentang cara}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\char
scalex100 {pemberian zat gizi, memilih alternatif bentuk sediaan zat gizi, dan m
elakukan evaluasi/}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100
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ri0\sl-386\slmult0 \fs22\cf0\f0\charscalex100\b {Diagnosis masalah nutrisi}\b0 \
par\pard\li893\ri0\sl-306\slmult0 \fs22\cf0\f0\charscalex100 {Diagnosis masalah
nutrisi pada pasien adalah hasil pengkajian/evaluasi status nutrisi}\par\pard\li
893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {yaitu tentang bagaimana statu
s gizi (seluruh fisik) pasien dan tentang status nutrien}\par\pard\li893\ri0\sl266\slmult0 \fs20\cf0\f0\charscalex100 {tertentu. Masalah nutrisi tersebut dapat
berkaitan dengan gangguan proses pencernaan, }\par\pard\li893\ri0\sl-266\slmult
0 \fs22\cf0\f0\charscalex100 {metabolisme, dan ekskresi nutrien pada berbagai pe
nyakit. }\par\pard\li893\ri0\sl-413\slmult0 \fs22\cf0\f0\charscalex100 {Masalah
tersebut mungkin saja telah terjadi sebelum pasien dirawat di rumah sakit}\par\p
ard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {atau dapat timbul pada
saat pasien sedang menjalani perawatan di rumah sakit. Masalah}\par\pard\li893\r
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3\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-413\slmult0 \fs22\cf0\f0\charscalex100
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3\margtsxn666\margbsxn293\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893
\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pa
rd\li893\ri0\sl-466\slmult0 \fs22\cf0\f0\charscalex100 {berlanjut menjadi nyata
sebagai defisiensi. Sebaliknya dapat juga terjadi kelebihan masukan}\par\pard\li
893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {zat gizi dari tingkat awal ke
lebihan sampai menjadi tingkat keracunan (toksisitas).}\par\pard\li893\ri0\sl-42
6\slmult0 \fs20\cf0\f0\charscalex100 {Pengkajian status nutrisi di klinik berbed
a dengan di masyarakat, karena meliputi 4}\par\pard\li893\ri0\sl-266\slmult0 \f
s20\cf0\f0\charscalex100 {cara pengkajian yaitu pemeriksaan klinis, analisis die
t, pemeriksaan antropometri, dan}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0
\charscalex100 {pemeriksaan laboratorium. Penentuan status gizi secara antropo
metris pada anak}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {
yang praktis adalah berdasarkan persentase berat badan (BB) aktual terhadap BB i

deal}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {(persentil-5

0 grafik tumbuh kembang) menurut tinggi badan (TB) saat pemeriksaan}\par\pard\li
893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {(Glodbloom, 2003). Status g
izi diklasifikasikan menurut Waterlow (1972) sebagai}\par\pard\li893\ri0\sl-266\
slmult0 \fs22\cf0\f0\charscalex100 {berikut:}\par\pard\li906\ri0\sl-266\slmult0
\*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Obesitas
= 120%}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {
-}\tab \fs20\cf0\f0\charscalex100\i {Overweight}\i0 \fs22\cf0\f0\charscalex100 {
= 110-120%}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex1
00 {-}\tab \fs22\cf0\f0\charscalex100 {Gizi Baik = 90-110%}\par\pard\li906\ri0\s
l-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscale
x100 {Gizi kurang = 70-90%}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0
\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Gizi buruk <70%}\par\pard\
li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-360\slmult0 \fs22\cf0\f
0\charscalex100\b {Menentukan kebutuhan zat gizi}\b0 \par\pard\li893\ri0\sl-320\
slmult0 \fs20\cf0\f0\charscalex100 {Kebutuhan zat gizi pada seorang pasien bersi
fat individual sehingga tidak sama dengan}\par\pard\li893\ri0\sl-266\slmult0 \fs
20\cf0\f0\charscalex100 {kecukupan gizi yang dianjurkan (RDA) atau kecukupan mas
ukan zat gizi yang dianjurkan}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\ch
arscalex100 {(RDI). Walaupun demikian penggunaan RDA dan RDI cukup memadai dalam
pelayanan}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {gizi/p
enyediaan makanan pasien pada umumnya. Pengertian kebutuhan zat gizi dalam}\par
\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {asuhan nutrisi adalah
kebutuhan terhadap masing-masing zat gizi yang perlu dipenuhi}\par\pard\li893\r
i0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {agar dapat mencakup 3 macam kebutu
han yaitu:}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs20\cf0\f0\charscalex10
0 {-}\tab \fs20\cf0\f0\charscalex100 {Untuk kebutuhan penggantian (}\fs20\cf0\f0
\charscalex100\i {replacement}\i0 \fs20\cf0\f0\charscalex100 {) zat gizi yang ke
kurangan (deplesi atau}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscal
ex100 {defisiensi)}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\char
scalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Untuk kebutuhan rumat (}\fs22\cf0\
f0\charscalex100\i {maintenance}\i0 \fs22\cf0\f0\charscalex100 {)}\par\pard\li90
6\ri0\sl-266\slmult0 \*\tx1146\fs20\cf0\f0\charscalex100 {-}\tab \fs20\cf0\f0\ch
arscalex100 {Untuk kebutuhan tambahan karena kehilangan (}\fs20\cf0\f0\charscale
x100\i {loss}\i0 \fs20\cf0\f0\charscalex100 {) dan tambahan untuk pemulihan}\par
\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {jaringan/organ yang
sedang sakit}\par\pard\li893\ri0\sl-360\slmult0 \fs22\cf0\f0\charscalex100 {Untu
k menentukan besarnya kebutuhan zat gizi yang diperlukan, harus ditegakkan dulu
}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {diagnosis gizi m
elalui beberapa pemeriksaan yang seringkali tidak sederhana. Oleh karena}\par\pa
rd\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {secara hukum, hak, we
wenang, dan tanggung jawab dalam membuat diagnosis berada}\par\pard\li893
\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {pada dokter, maka setiap dokter
diwajibkan membuat diagnosis gizi untuk menentukan}\par\pard\li893\ri0\sl-266\sl
mult0 \fs22\cf0\f0\charscalex100 {kebutuhan nutrisi yang berorientasi pada
pasien (tergantung jenis penyakit). Tahap}\par\pard\li893\ri0\sl-266\slmult0
\fs22\cf0\f0\charscalex100 {selanjutnya memerlukan kerjasama antar profesi
mulai dari diterjemahkannya resep}\par\pard\li893\ri0\sl-266\slmult0 \fs20\c
f0\f0\charscalex100 {nutrisi oleh dietisien ke dalam bentuk makanan atau oleh ah
li farmasi ke dalam bentuk }\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\char
scalex100 {nutrisi parenteral atau suplemen, selanjutnya perawat yang mengawasi
terjaminnya asupan }\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex10
0 {dari nutrisi tersebut serta respon dan toleransi pasien. Menentukan besarnya
kebutuhan}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {zat giz
i pada bayi dan anak dapat diperhitungkan dengan berbagai rumus. Kecukupan atau}
\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {adekuat tidaknya
pemenuhan kebutuhan dilihat kembali berdasarkan respon pasien. }\par\pard\li893\
ri0\sl-360\slmult0 \fs22\cf0\f0\charscalex100 {Secara umum dan sederhana, kebutu
han nutrisi bayi serta anak baik yang sehat dengan}\par\pard\li893\ri0\sl-266\sl
mult0 \fs22\cf0\f0\charscalex100 {status gizi cukup maupun yang berstatus gizi k

urang atau buruk atau bahkan gizi lebih atau}\par\pard\li6480\ri0\sl-213\slmult0

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ak gizi lebih atau obesitas yaitu}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f
0\charscalex100 {menggunakan rumus sebagai berikut:}\par\pard\li906\ri0\sl-266\s
lmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {u
mur dimana TB saat ini berada pada persentil-50 (lihat kurva TB/U)}\par\pard\li9
06\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\c
harscalex100 {persentil-50 BB menurut TB saat ini (lihat kurva BB/TB)}\par\pard\
li893\ri0\sl-400\slmult0 \fs20\cf0\f0\charscalex100 {Kebutuhan nutrisi pada anak
sakit dibedakan berdasarkan kondisi stres yang disebut}\par\pard\li893\ri0\sl-2
66\slmult0 \fs20\cf0\f0\charscalex100 {sebagai dukungan metabolik (}\fs20\cf0\f0
\charscalex100\i {metabolic support}\i0 \fs20\cf0\f0\charscalex100 {) dan non st
res yang disebut sebagai}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charsca
lex100 {dukungan nutrisi (}\fs20\cf0\f0\charscalex100\i {nutritional support}\i0
\fs22\cf0\f0\charscalex100 {). Selama periode stres metabolik, pemberian nutris
i}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {berlebihan (}\f
s18\cf0\f0\charscalex100\i {overfeeding}\i0 \fs22\cf0\f0\charscalex100 {) dapat
meningkatkan kebutuhan metabolisme di paru dan hati, }\par\pard\li893\ri0\sl-266
\slmult0 \*\tx7613\fs22\cf0\f0\charscalex100 {serta dapat berakhir dengan mening
katnya angka kematian. Komplikasi}\tab \fs18\cf0\f0\charscalex100\i {overfeedin
g}\i0 \par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {meliputi:}\
par\pard\li906\ri0\sl-306\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \f
s22\cf0\f0\charscalex100 {Kelebihan produksi CO}{\sub \fs12\cf0\f0\charscalex100
{2}}\fs22\cf0\f0\charscalex100 { yang meningkatkan ventilasi}\par\pard\li906\ri
0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charsc
alex100 {Edema paru dan gagal napas}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146
\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Hiperglikemia yan
g meningkatkan kejadian infeksi}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs2
2\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Lipogenesis karena pe
ningkatan produksi insulin}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0
\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Imunosupresi}\par\pard\li9
06\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\c
harscalex100 {Komplikasi hati: perlemakan hati, kolestasis intrahepatik}\par\par
d\li893\ri0\sl-306\slmult0 \fs22\cf0\f0\charscalex100 {Kebutuhan kalori serta pr
otein pasien dapat diperhitungkan dengan cara sebagai}\par\pard\li893\ri0\sl-266
\slmult0 \fs22\cf0\f0\charscalex100 {berikut:}\par\pard\li906\ri0\sl-266\slmult0
\*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Tentuka
n kebutuhan energi basal (}{ }\fs18\cf0\f0\charscalex100\i {Basal Energy Expendi
ture}\i0 \fs22\cf0\f0\charscalex100 { = BEE) (lihat tabel 6)}\par\pard\li906\ri0
\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charsca
lex100 {Tentukan faktor stres (lihat tabel 7)}\par\pard\li906\ri0\sl-266\slmult0
\*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Kebutuh
an kalori total = BEE x faktor stres}\par\pard\li906\ri0\sl-266\slmult0 \*\tx114
6\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Tentukan kebutuh
an protein pasien (sesuai dengan RDA)}\par\pard\li906\ri0\sl-266\slmult0 \*\tx11
46\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Kebutuhan prote
in total = RDA x faktor stres}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\
cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Evaluasi dan sesuaikan
kebutuhan berdasarkan hasil pemantauan}\par\pard\li893\ri0\sl-386\slmult0 \fs22\
cf0\f0\charscalex100 {Setelah terdapat perbaikan klinis dan melewati fase kritis
dari penyakitnya (setelah hari}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\
charscalex100 {ke 7-10), kebutuhan kalori serta protein perlu dinilai kembali me
nggunakan RDA karena}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex1
00 {diperlukan untuk tumbuh kejar (}\fs20\cf0\f0\charscalex100\i {catch-up growt

h}\i0 \fs22\cf0\f0\charscalex100 {).}\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf

0\par\pard\li893\ri0\sl-466\slmult0 \fs22\cf0\f0\charscalex100\b {Memilih altern
atif tentang cara pemberian zat gizi}\b0 \par\pard\li893\ri0\sl-306\slmult0 \fs2
2\cf0\f0\charscalex100 {Penentuan cara pemberian nutrisi merupakan tanggung jawa
b dokter yang merawat}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex
100 {pasien. Pemberian makan secara oral yang biasa dilaksanakan pada sebagian b
esar pasien}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {dalam
pelayanan gizi di rumah sakit merupakan cara pemberian zat gizi yang alami}\par
\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {dan ideal. Jika pasie
n tidak dapat secara alamiah mengkonsumsi makanan padat, maka}\par\pard\li893\ri
0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {dapat diberikan dalam bentuk makana
n cair. Apabila cara tersebut di atas tidak dapat}\par\pard\li893\ri0\sl-266\slm
ult0 \fs22\cf0\f0\charscalex100 {memungkinkan atau tidak dapat memenuhi zat gizi
secara lengkap, dalam pelaksanaan}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\
f0\charscalex100 {asuhan nutrisi terdapat dua macam alternatif yaitu pemberian n
utrisi secara enteral atau}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\chars
calex100 {parenteral. Kedua cara pemberian tersebut dikenal dengan istilah}{ }\f
s20\cf0\f0\charscalex100\i {nutritional support}\i0 \fs22\cf0\f0\charscalex100 {
atau}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {dukungan nu
trisi (lihat gambar 1).}\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li
893\ri0\sl-320\slmult0 \fs22\cf0\f0\charscalex100 {16 }{ }\fs12\cf0\f0\charsca
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3\margtsxn666\margbsxn293\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893
\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pa
rd\li893\ri0\sl-466\slmult0 \fs22\cf0\f0\charscalex100 {Nutrisi enteral terindik
asi jika pemberian makanan per oral dan keadaan lambung}\par\pard\li893\ri0\sl-2
66\slmult0 \fs20\cf0\f0\charscalex100 {tidak memungkinkan atau tidak dapat memen
uhi kebutuhan gizi dengan syarat fungsi}\par\pard\li893\ri0\sl-266\slmult0 \fs22
\cf0\f0\charscalex100 {usus masih baik. Rute nutrisi enteral dapat melalui oral
ataupun malalui pipa makanan. }\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\c
harscalex100 {Pemberian nutrisi enteral lebih aman, lebih mudah, dan lebih prakt
is jika dibandingkan}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex1
00 {dengan pemberian nutrisi parenteral. Keuntungan lain dari nutrisi enteral a
dalah}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {bentuknya f
isiologis dan komposisi zat gizinya lengkap. Meskipun hanya diberikan 10-}\par\p
ard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {15% dari kebutuhan kalo
ri total, nutrisi enteral dapat merumat struktur dan fungsi}\par\pard\li893\ri0
\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {intestinal (efek trofik).}\par\pard\
li893\ri0\sl-386\slmult0 \fs22\cf0\f0\charscalex100 {Nutrisi parenteral baru dip
ertimbangkan jika nutrisi enteral tidak memungkinkan. Rute}\par\pard\li893\ri0\s
l-266\slmult0 \fs22\cf0\f0\charscalex100 {nutrisi parenteral adalah melalui vena
perifer atau vena sentral.}\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\par
d\li893\ri0\sl-426\slmult0 \fs22\cf0\f0\charscalex100\b {Memilih alternatif bent
uk sediaan zat gizi}\b0 \par\pard\li893\ri0\sl-320\slmult0 \fs22\cf0\f0\charscal
ex100 {Perpaduanperkembanganilmugiziklinikdanteknologitelahmemungkinkandiciptaka
nnya}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {berbagaialte
rnatifdalamcaramemenuhikebutuhanpasien. Saatinitelahbanyakdiproduksi}\par\pard\l
i893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {dan diperdagangkan aneka rag
am hasil pengolahan zat gizi berupa makanan/minuman}\par\pard\li893\ri0\sl-266\s
lmult0 \fs22\cf0\f0\charscalex100 {buatan industri pangan, yang dikenal sebagai
makanan kemasan. Sebagai akibatnya, untuk}\par\pard\li893\ri0\sl-266\slmult0 \fs
22\cf0\f0\charscalex100 {mempersiapkan makanan pasien, saat ini tidak hanya berg
antung pada makanan buatan}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\chars
calex100 {rumah sakit sendiri (}\fs22\cf0\f0\charscalex100\i {home made}\i0 \fs2
2\cf0\f0\charscalex100 {). Jenis makanan kemasan tersebut lebih dikenal dengan}\
par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {nama dagangnya dib
andingkan dengan nama generiknya, sebagai contoh makanan cair}\par\pard\li893\ri
0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {(generik). Penggunaan makanan komer
sial tersebut lebih praktis dan efisien, serta tidak}\par\pard\li893\ri0\sl-266\
slmult0 \fs22\cf0\f0\charscalex100 {memerlukan banyak waktu dan tenaga dalam men
yiapkannya, meskipun memerlukan}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\
charscalex100 {biaya yang lebih mahal. Selain itu terdapat pula aneka ragam sed
iaan zat gizi buatan}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex1

00 {industri farmasi yang pemasarannya digolongkan sebagai zat gizi obat (}\fs20
\cf0\f0\charscalex100\i {medicinal nutrient}\i0 \fs22\cf0\f0\charscalex100 {). }
\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {Termasuk di dalam
nya adalah berbagai sediaan untuk penggunaan oral, suntikan, maupun}\par\pard\li
893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {infusuntuk memenuhi kebutuhan
mikronutrien (vitamin dan mineral), makronutrien}\par\pard\li893\ri0\sl-266\sl
mult0 \fs22\cf0\f0\charscalex100 {(karbohidrat, lemak, serta protein), serta air
. Zat gizi dalam bentuk obat-obatan tersebut}\par\pard\li893\ri0\sl-266\slmult0
\fs22\cf0\f0\charscalex100 {digunakan dalam asuhan nutrisi untuk melengkapi masu
kan zat gizi yang tidak dapat}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\ch
arscalex100 {dipenuhi melalui makanan.}\par\pard\li893\ri0\sl-320\slmult0 \fs22\
cf0\f0\charscalex100 {Pemilihan jenis formula yang digunakan sebagai nutrisi ent
eral pada pasien bayi dan anak}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\c
harscalex100 {tergantung pada faktor pasien (umur, diagnosis, masalah gizi yan
g terkait, kebutuhan}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex
100 {nutrisi, dan fungsi gastrointestinal) serta faktor formula (osmolalitas, }\
fs22\cf0\f0\charscalex100\i {renal solute load}\i0 \fs22\cf0\f0\charscalex100 {
=}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {RSL, kepekatan
serta kekentalan kalori, komposisi zat gizi: jenis serta jumlah karbohidrat, }\p
ar\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {protein dan lemak,
ketersediaan produk, serta harganya).}\par\pard\li893\ri0\sl-413\slmult0 \fs22\c
f0\f0\charscalex100 {Secara umum formula enteral pediatrik dikelompokkan berdasa
rkan usia konsumennya}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex
100 {yaitu bayi prematur, bayi aterm, anak usia 1-10 tahun, dan usia di atas 10
tahun. Formula}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {en
teral untuk anak berusia 1-10 tahun lebih padat kalori daripada formula bayi tet
api}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {mengandung ka
dar protein, natrium, kalium, klorida serta magnesium lebih rendah}\par\pard\
li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {dibandingkan formula entera
l untuk orang dewasa, sebaliknya kadar zat besi, seng, kalsium, }\par\pard\li893
\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {fosfor, dan vitamin D-nya lebih
tinggi. Oleh sebab itu, sebaiknya tidak menggunakan}\par\pard\li893\ri0\sl-26
6\slmult0 \fs22\cf0\f0\charscalex100 {formula enteral dewasa pada anak di bawah
usia 10 tahun. Jika terpaksa perlu dipantau}\par\pard\li6480\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li6480\ri0\sl-360\slmult0 \*\tx8320\fs12\cf0\f0\charscalex100
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3\margtsxn666\margbsxn293\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893
\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pa
rd\li893\ri0\sl-466\slmult0 \fs22\cf0\f0\charscalex100 {dengan ketat, karena ket
erbatasan kapasitas ginjal anak untuk mengkonsentrasikan dan}\par\pard\li893\ri0
\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {mengekskresikan nutrien, elektrolit
serta metabolit yang tidak dimetabolisme (RSL)}\par\pard\li893\ri0\sl-266\slmu
lt0 \fs20\cf0\f0\charscalex100 {dapat menyebabkan dehidrasi. Untuk memperkirakan
potensi RSL dari formula yang}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\c
harscalex100 {digunakan dapat memakai rumus sebagai berikut:}\par\pard\li893\ri0
\sl-413\slmult0 \fs20\cf0\f0\charscalex100 {Selain itu, perlu diberikan suplemen
tasi seng, besi, kalsium, fosfor, dan vitamin. Batas atas}\par\pard\li893\ri0\sl
-266\slmult0 \fs22\cf0\f0\charscalex100 {potensial RSL untuk bayi adalah 33 mOsm
/100 kkal formula.}\par\pard\li893\ri0\sl-413\slmult0 \fs20\cf0\f0\charscalex100
{Osmolalitas formula yang dimaksud di sini adalah konsentrasi partikel yang akt
if secara osmotik}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100
{(asam amino, karbohidrat, Dan elektrolit) per liter formula, dinyatakan dengan
mOsm/L. }\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {Osmolali
tas formula berpengaruh langsung pada lambung dan usus kecil, hiperosmolalitas}\
par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {berakibat tertari
knya air ke dalam saluran cerna untuk mengencerkan formula sehingga}\pa
r\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {mengakibatkan diare,
mual, kembung, atau kram. }\fs18\cf0\f0\charscalex100\i {The American Academy o
f Pediatrics}\i0 \fs22\cf0\f0\charscalex100 { (1979)}\par\pard\li893\ri0\sl-266\
slmult0 \fs22\cf0\f0\charscalex100 {merekomendasikan osmolalitas untuk formula b
ayi adalah = 460 mOsm. Formula enteral}\par\pard\li893\ri0\sl-266\slmult0 \fs22\
cf0\f0\charscalex100 {untuk orang dewasa umumnya aman dikonsumsi oleh anak yang

berusia di atas 10 tahun.}\par\pard\li893\ri0\sl-440\slmult0 \fs22\cf0\f0\charsc

alex100 {Prinsip pemilihan cairan nutrisi parenteral terutama pada usia <2 tahun
sebaiknya}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {menggu
nakan larutan asam amino khusus anak (misalnya Aminofusin Paed [Baxter], }\par\pa
rd\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {Aminosteril [Fresenius])
atau bayi (misalnya Primene 5% [Baxter], Aminosteril Infant}\par\pard\li893\ri0\s
l-266\slmult0 \fs22\cf0\f0\charscalex100 {[Fresenius]). Berdasarkan penelitian, n
eonatus yang mendapat cairan nutrisi parenteral}\par\pard\li893\ri0\sl-266\slmul
t0 \fs22\cf0\f0\charscalex100 {untuk dewasa mengalami peningkatan konsentrasi me
tionin, fenilalanin, dan glisin disertai}\par\pard\li893\ri0\sl-266\slmult0 \fs2
2\cf0\f0\charscalex100 {penurunan konsentrasi tirosin, sistein, dan taurin plasm
a dibandingkan dengan bayi yang}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\
charscalex100 {mengkonsumsi ASI. Salah satu kelebihan cairan nutrisi parenteral
yang didesain khusus}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex1
00 {untuk bayi dan anak adalah mengandung asam amino yang}{ }\fs18\cf0\f0\charsc
alex100\i {conditionally}\i0 \fs22\cf0\f0\charscalex100 { esensial pada}\par\par
d\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {bayi dan anak seperti sis
tein, histidin, tirosin, lisin, taurin, dan arginin, serta konsentrasi}\par\pard
\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {metionin, fenilalanin, ser
ta glisin yang lebih rendah dari cairan parenteral dewasa. }\par\pard\li893\ri0\
sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-386\slmult0 \fs22\cf0\f0\charscal
ex100\b {Evaluasi/pengkajian respons}\b0 \par\pard\li893\ri0\sl-306\slmult0 \fs2
2\cf0\f0\charscalex100 {Respon pasien terhadap pemberian makan/diet/zat gizi med
isinal dinilai dengan cara}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\chars
calex100 {melakukan berbagai jenis kegiatan evaluasi. Penilaian mencakup respon
jangka pendek}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {dan
jangka panjang. }\par\pard\li893\ri0\sl-413\slmult0 \fs22\cf0\f0\charscalex100
{Respon jangka pendek adalah daya terima (akseptansi) makanan/obat, toleransi sa
luran}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {cerna dan e
fek samping di saluran cerna. Respon jangka panjang adalah menilai penyembuhan }
\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {penyakit serta tu
mbuh kembang anak. Kegiatan evaluasi tersebut sebaiknya dilakukan pada}\par\par
d\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {setiap pasien dengan mela
kukan aktivitas pengamatan yang dicatat perawat, pemeriksaan }\par\pard\li893\ri
0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {fisis oleh dokter, analisis diet ol
eh ahli gizi, pemeriksaan laboratorium, dan antropometri}\par\pard\li893\ri0\sl266\slmult0 \fs22\cf0\f0\charscalex100 {sesuai dengan keperluan masing-masing pa
sien. Evaluasi ini diperlukan untuk menentukan}\par\pard\li893\ri0\sl-266\slmult
0 \fs20\cf0\f0\charscalex100 {kembali upaya pemenuhan kebutuhan zat gizi, karena
penentuan kebutuhan zat gizi dan }\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\
f0\charscalex100 {pemberiannya tidak diketahui pasti sampai teruji dampaknya pad
a pasien. }\par\pard\li893\ri0\sl-386\slmult0 \fs22\cf0\f0\charscalex100 {Kompli
kasi yang berkaitan dengan pemberian nutrisi enteral dapat dikelompokkan}\par\pa
rd\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {menjadi tiga kategori ya
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d\li893\ri0\sl-320\slmult0 \fs22\cf0\f0\charscalex100 {18 }{ }\fs12\cf0\f0\cha
rscalex100\i {Asuhan Nutrisi Pediatri}\i0 \par\pard\sect\sectd\sbkpage
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rd\li893\ri0\sl-466\slmult0 \fs22\cf0\f0\charscalex100 {jenis masalah serta tata
laksana masing-masing komplikasi tersebut.Komplikasi yang}\par\pard\li893\ri0\sl
-266\slmult0 \fs20\cf0\f0\charscalex100 {berkaitan dengan pemberian nutrisi pare
nteral dikelompokkan menjadi tiga kategori}\par\pard\li893\ri0\sl-266\slmult0 \f
s20\cf0\f0\charscalex100 {yaitu mekanis atau teknis, infeksi, dan metabolik. Kom
plikasi mekanis atau teknis adalah}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\
f0\charscalex100 {yang berhubungan dengan pemasangan kateter, antara lain pneumo
toraks, hematotoraks, }\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscale
x100 {tamponade jantung, atau malfungsi peralatan. Insidens sepsis akibat nutris
i parenteral}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {berk
isar 6-20%. Diagnosis serta tatalaksana dini komplikasi sepsis sangat menentukan
}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {prognosis, oleh
sebab itu setiap demam pada nutrisi parenteral ditatalaksana sebagai}\par\pard\l

i893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {sepsis sampai terbukti bukan

. Komplikasi metabolik akibat nutrisi parenteral yang}\par\pard\li893\ri0\sl-26
6\slmult0 \fs22\cf0\f0\charscalex100 {tersering adalah kolestasis, terutama pada
bayi yang mendapat nutrisi parenteral lebih}\par\pard\li893\ri0\sl-266\slmult0
\fs22\cf0\f0\charscalex100 {dari dua minggu.}\par\pard\li893\ri0\sl-373\slmult0
\fs22\cf0\f0\charscalex100\i {Refeeding syndrome}\i0 \fs22\cf0\f0\charscalex100
{ adalah salah satu komplikasi metabolik dari dukungan nutrisi}\par\pard\li893\
ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {pada pasien malnutrisi berat yang
ditandai oleh hipofosfatemia, hipokalemia, dan}\par\pard\li893\ri0\sl-266\slm
ult0 \fs22\cf0\f0\charscalex100 {hipomagnesemia. Hal ini terjadi sebagai akibat
perubahan sumber energi utama}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\c
harscalex100 {metabolisme tubuh, dari lemak pada saat kelaparan menjadi karbohid
rat yang diberikan}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100
{sebagai bagian dari dukungan nutrisi, sehingga terjadi peningkatan kadar insul
in serta}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {perpinda
han elektrolit yang diperlukan untuk metabolism intraseluler. Secara klinis pasi
en}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {dapat mengalam
i disritmia, gagal jantung, gagal napas akut, koma, paralisis, nefropati, dan}\p
ar\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {disfungsi hati. Ole
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893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {berat perlu diberikan secara
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b {Kepustakaan}\b0 \par{\trowd\trleft893\trkeep\trftsWidth1\trpaddl0\trpaddr0\tr
paddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrnone\clbrdrl\brdrnone\clbrdrb\brdrnone\
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ft3\clpadfr3\cellx1746 \pard\li0\ri0\sl-680\widctlpar\intbl \fs18\cf0\f2\charsca
lex100 {1. }\cell\clvertalt\clbrdrt\brdrnone\clbrdrl\brdrnone\clbrdrb\brdrnone\c
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ft3\clpadfr3\cellx9226 \pard\li0\ri0\sl-293\widctlpar\intbl \fs16\cf0\f0\charsca
lex100 {Sjarif DR. Asuhan nutrisi pediatri. In: PulunganAB, HendartoAR, Hegar B,
Oswari H, editors. Continuing}\par\pard\li0\ri0\sl-226\widctlpar\intbl \fs18\cf
0\f0\charscalex100 {Professional Development IDAI Jaya 2006: Nutrition Growth-D
evelopment.. 2006. Jakarta: Ikatan}\cell\row}{\trowd\trleft893\trkeep\trftsWidt
h1\trpaddl0\trpaddr0\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrnone\clbrdrl\brd
rnone\clbrdrb\brdrnone\clbrdrr\brdrnone\cltxlrtb\clNoWrap\clftsWidth3\clwWidth18
6\clpadt0\clpadr0\clpadft3\clpadfr3\cellx1746 \pard\li0\ri0\sl-373\widctlpar\int
bl \fs18\cf0\f2\charscalex100 {2. }\cell\clvertalt\clbrdrt\brdrnone\clbrdrl\brdr
none\clbrdrb\brdrnone\clbrdrr\brdrnone\cltxlrtb\clNoWrap\clftsWidth3\clwWidth742
6\clpadt0\clpadr0\clpadft3\clpadfr3\cellx9226 \pard\li0\ri0\sl--266\widctlpar\in
tbl \fs18\cf0\f0\charscalex100 {Dokter Anak Indonesia Cabang DKI Jakarta. 2006.}
\par\pard\li0\ri0\sl-253\widctlpar\intbl \fs18\cf0\f0\charscalex100 {A.S.P.E.N:
Board of directors: Clinical Pathways and algorithms for delivery of parenteral
and enteral}\par\pard\li0\ri0\sl-213\widctlpar\intbl \fs18\cf0\f0\charscalex100
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pard\li6480\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li6480\ri0\sl-213\slmult0 \fs1
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3\margtsxn666\margbsxn293\pard\li2666\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li26
66\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li2666\ri0\sl-213\slmult0 \fs18\cf0\par
\pard\li2666\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li2666\ri0\sl-213\slmult0 \fs
18\cf0\par\pard\li2666\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li2666\ri0\sl-533\s
lmult0 \fs36\cf0\f0\charscalex100\b {Bayi Berat Lahir Rendah}\b0 \par\pard\li893
\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pa
rd\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf
0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-280\slmult0
\fs22\cf0\f0\charscalex100 {Bayi berat lahir rendah (BBLR) adalah bayi dengan be
rat lahir kurang dari 2500 gram}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\
charscalex100 {tanpa memandang usia gestasi. Berat lahir adalah berat bayi yang
ditimbang dalam 1 jam}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex
100 {setelah lahir. BBLR dapat terjadi pada bayi kurang bulan (<37 minggu) atau
pada bayi}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {cukup b
ulan (}\fs18\cf0\f0\charscalex100\i {intrauterine growth restriction/}\i0 \fs22\
cf0\f0\charscalex100 {IUGR).}\par\pard\li893\ri0\sl-413\slmult0 \fs20\cf0\f0\cha
rscalex100 {Sampai saat ini BBLR masih merupakan masalah di seluruh dunia, karen
a menjadi salah}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {s
atu penyebab utama kesakitan dan kematian pada masa neonatal. Prevalens BBLR mas
ih}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {cukup tinggi t
erutama di negara-negara dengan sosio-ekonomi rendah. Secara statistik di}\par\p
ard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {seluruh dunia, 15,5% da
ri seluruh kelahiran adalah BBLR, 90% kejadian BBLR didapatkan}\par\pard\li893\r
i0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {di negara berkembang dan angka kem

atiannya 20-35 kali lebih tinggi dibanding pada bayi}\par\pard\li893\ri0\sl-266\

slmult0 \fs20\cf0\f0\charscalex100 {dengan berat lahir >2500 gram. Angka kejadia
n di Indonesia sangat bervariasi antara}\par\pard\li893\ri0\sl-266\slmult0 \fs22
\cf0\f0\charscalex100 {satu daerah dengan daerah lain, yang berkisar antara 9-30
%.}\par\pard\li893\ri0\sl-386\slmult0 \fs20\cf0\f0\charscalex100 {Penyebab terba
nyak terjadinya BBLR adalah kelahiran prematur. Faktor ibu adalah umur}\par\pard
\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {(<20 tahun atau >40 tahun)
, paritas, dan lain-lain. Faktor plasenta seperti penyakit}\par\pard\li893\ri
0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {vaskular, kehamilan ganda, dan la
in-lain, serta faktor janin juga merupakan penyebab}\par\pard\li893\ri0\sl-266\
slmult0 \fs22\cf0\f0\charscalex100 {terjadinya BBLR.}\par\pard\li893\ri0\sl-413\
slmult0 \fs22\cf0\f0\charscalex100 {Masalah yang sering timbul pada BBLR:}\par\p
ard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\c
f0\f0\charscalex100 {Masalah pernapasan karena paru-paru yang belum matur. }\par
\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22
\cf0\f0\charscalex100 {Masalah pada jantung}\par\pard\li906\ri0\sl-266\slmult0 \
*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Perdaraha
n otak}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {}\tab \fs22\cf0\f0\charscalex100 {Fungsi hati yang belum sempurna}\par\pard\li90
6\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\ch
arscalex100 {Anemia atau polisitemia}\par\pard\li906\ri0\sl-266\slmult0 \*\tx114
6\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Lemak yang sedik
it sehingga kesulitan mempertahankan suhu tubuh normal}\par\pard\li906\ri0\sl-26
6\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100
{Masalah pencernaan/toleransi minum}\par\pard\li906\ri0\sl-266\slmult0 \*\tx114
6\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Risiko infeksi}\
par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \f
s18\cf0\par\pard\li893\ri0\sl-333\slmult0 \fs26\cf0\f0\charscalex100\b {Diagnosi
s}\b0 \par\pard\li893\ri0\sl-413\slmult0 \fs22\cf0\f0\charscalex100\b {Anamnesis
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fs22\cf0\f0\charscalex100 {Jangan memandikan atau menyentuh bayi dengan tangan d
ingin}\par\pard\li1146\ri0\sl-280\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {}\tab \fs22\cf0\f0\charscalex100 {Ukur suhu tubuh sesuai jadwal pada}{ }\fs22\cf
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r\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs
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6\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\ch
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tab \fs22\cf0\f0\charscalex100 {Asi perah/}{ }\fs20\cf0\f0\charscalex100\i {term
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*\tx1346\fs20\cf0\f0\charscalex100 {-}\tab \fs20\cf0\f0\charscalex100 {Selanjutn
ya minum ditingkatkan jika memberikan toleransi yang baik: tambahan}\par\pard\l
i1346\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {0,5-1 mL, interval 1 jam, s
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0\charscalex100 {-}\tab \fs20\cf0\f0\charscalex100 {Setelah 2 minggu: Asi perah
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scalex100 {)/}\fs16\cf0\f0\charscalex100\i {full-strength preterm formula}\i0 \p
ar\pard\li1346\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {sampai berat badan
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calex100 {-}\tab \fs22\cf0\f0\charscalex100 {Berat lahir 1000-1500 g}\par\pard\l
i1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f
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66\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex10
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lmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {A
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la}\i0 \par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs20\cf0\f0\charscalex100 {
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n toleransi yang baik: tambahan}\par\pard\li1346\ri0\sl-266\slmult0 \fs22\cf0\f
0\charscalex100 {1-2 ml, interval 2 jam, setiap \uc1\u8805X24 jam}\par\pard\li11
46\ri0\sl-266\slmult0 \*\tx1346\fs20\cf0\f0\charscalex100 {-}\tab \fs20\cf0\f0\c
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l-453\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscale
x100 {Berat lahir 1500-2000 g}\par\pard\li1146\ri0\sl-280\slmult0 \*\tx1346\fs22
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lt0 \*\tx1346\fs20\cf0\f0\charscalex100 {-}\tab \fs20\cf0\f0\charscalex100 {Sela
njutnya minum ditingkatkan jika memberikan toleransi yang baik: tambahan}\par\p
ard\li1346\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {2-4 ml, interval 3 jam
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rd\li893\ri0\sl-413\slmult0 \*\tx1266\fs18\cf0\f0\charscalex100 {2. }\tab \fs18\
cf0\f0\charscalex100 {Rao R. Nutritional Management. Dalam: Gomella TL, Cunningh
am MD, Eyal FG, Tuttle D, penyunting. }\par\pard\li1266\ri0\sl-226\slmult0 \fs16
\cf0\f0\charscalex100 {Neonatology, management, procedures, on-call problems, di
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fs18\cf0\f0\charscalex100 {McGraw-Hill; 2004. h.77-108}\par\pard\li893\ri0\sl-25
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calex100 {. Dipresentasikan pada Pelatihan Bayi}\par\pard\li1266\ri0\sl-226\slmu
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rat (sepsis, gangguan napas berat)}\par\pard\sect\sectd\sbknone\pgwsxn10760\pghs
xn14440\marglsxn666\margrsxn133\cols4\colno1\colw4066\colsr-0\colno2\colw1306\co
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lt0 \fs18\cf0\par\pard\li893\ri0\sl-320\slmult0 \fs18\cf0\f0\charscalex100\b {Ta
bel 2. Pengukuran suhu tubuh}\b0 \par\pard\li946\ri0\sl-213\slmult0 \fs18\cf0\pa
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lmult0 \*\tx2946\fs18\cf0\f0\charscalex100\b {Frekuensi pengukuran}\b0 \tab \fs1
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r\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs1
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3\margtsxn666\margbsxn293\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893

\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pa

rd\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-200\slmult0 \fs18\cf
0\f0\charscalex100\b {Tabel 3. Suhu inkubator yang direkomendasikan menurut bera
t dan umur bayi}\b0 \par\pard\li3146\ri0\sl-386\slmult0 \fs18\cf0\f1\charscalex1
00 {Suhu inkubator (}\fs10\cf0\f1\charscalex100 {o}\fs18\cf0\f1\charscalex100 {C
) menurut umur*}\par\pard\sect\sectd\sbknone\pgwsxn10760\pghsxn14440\marglsxn666
\margrsxn133\cols5\colno1\colw3146\colsr-0\colno2\colw813\colsr-0\colno3\colw160
0\colsr-0\colno4\colw1613\colsr-0\colno5\colw2786\pard\li946\ri0\sl-200\slmult0
\fs18\cf0\f1\charscalex100 {Berat bayi}\par\pard\li946\ri0\sl-320\slmult0 \fs20\
cf0\f1\charscalex100 {< 1500 g}\par\pard\li946\ri0\sl-266\slmult0 \fs20\cf0\f1\c
harscalex100 {1500-2000g}\par\pard\li946\ri0\sl-253\slmult0 \fs18\cf0\f1\charsca
lex100 {2100-2500g}\par\pard\li946\ri0\sl-266\slmult0 \fs20\cf0\f1\charscalex100
{>2500 g}\par\column\pard\li0\ri0\sl-253\slmult0 \fs18\cf0\f1\charscalex100 {35
}\par\pard\li0\ri0\sl-240\slmult0 \fs18\cf0\f1\charscalex100 {hari}\par\column\p
ard\li0\ri0\sl-253\slmult0 \fs18\cf0\f1\charscalex100 {34}\par\pard\li0\ri0\sl-2
40\slmult0 \fs18\cf0\f1\charscalex100 {11hr-3minggu}\par\pard\li0\ri0\sl-266\slm
ult0 \fs18\cf0\f1\charscalex100 {1-10hari}\par\pard\li0\ri0\sl-266\slmult0 \fs18
\cf0\f1\charscalex100 {1-2hari}\par\column\pard\li0\ri0\sl-253\slmult0 \fs18\cf0
\f1\charscalex100 {33}\par\pard\li0\ri0\sl-240\slmult0 \fs18\cf0\f1\charscalex10
0 {3-5minggu}\par\pard\li0\ri0\sl-266\slmult0 \fs18\cf0\f1\charscalex100 {11hr-4
minggu}\par\pard\li0\ri0\sl-266\slmult0 \fs18\cf0\f1\charscalex100 {3hr-3minggu}
\par\pard\li0\ri0\sl-253\slmult0 \fs18\cf0\f1\charscalex100 {1-2hr}\par\column\p
ard\li0\ri0\sl-253\slmult0 \fs18\cf0\f1\charscalex100 {32}\par\pard\li0\ri0\sl-2
40\slmult0 \fs18\cf0\f1\charscalex100 {>5 minggu}\par\pard\li0\ri0\sl-266\slmult
0 \fs18\cf0\f1\charscalex100 {>4 minggu}\par\pard\li0\ri0\sl-266\slmult0 \fs18\c
f0\f1\charscalex100 {>3 minggu}\par\pard\li0\ri0\sl-280\slmult0 \fs20\cf0\f1\cha
rscalex100 {>2 minggu}\par\pard\sect\sectd\sbknone\pgwsxn10760\pghsxn14440\margl
sxn666\margrsxn133\pard\li893\ri0\sl-240\slmult0 \fs16\cf0\f1\charscalex100 {* B
ila jenis inkubatornya berdinding tunggal, naikkan suhu inkubator 1}\fs10\cf0\f1
\charscalex100 { o}\fs18\cf0\f1\charscalex100 {Csetiapperbedaan7}\fs10\cf0\f1\ch
arscalex100 { o}\fs18\cf0\f1\charscalex100 {C antara}\par\pard\li893\ri0\sl-226\
slmult0 \fs18\cf0\f1\charscalex100 {suhu ruang dan inkubator.}\par\pard\li893\ri
0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\
li893\ri0\sl-226\slmult0 \fs16\cf0\f0\charscalex100\b {Tabel 4. Terapi cairan in
isial (ml/kghari)*}\b0 \par\pard\li946\ri0\sl-386\slmult0 \fs18\cf0\f1\charscale
x100 {Jumlahcairanrata-rata(ml/kg/hari)}\par\pard\sect\sectd\sbknone\pgwsxn10760
\pghsxn14440\marglsxn666\margrsxn133\cols3\colno1\colw5560\colsr-0\colno2\colw14
80\colsr-0\colno3\colw2920\pard\li946\ri0\sl-253\slmult0 \*\tx2426\*\tx4173\fs18
\cf0\f1\charscalex100 {Berat badan (kg)}\tab \fs18\cf0\f1\charscalex100 {Dekstro
sa(g/100ml)}\tab \fs18\cf0\f1\charscalex100 {<24 jam}\par\column\pard\li0\ri0\sl
-253\slmult0 \fs18\cf0\f1\charscalex100 {24-48jam}\par\column\pard\li0\ri0\sl-25
3\slmult0 \fs18\cf0\f1\charscalex100 {>48 jam}\par\pard\sect\sectd\sbknone\pgwsx
n10760\pghsxn14440\marglsxn666\margrsxn133\cols5\colno1\colw2426\colsr-0\colno2\
colw1746\colsr-0\colno3\colw1386\colsr-0\colno4\colw1480\colsr-0\colno5\colw2920
\pard\li946\ri0\sl-240\slmult0 \fs18\cf0\f1\charscalex100 {< 1}\par\pard\li946\r
i0\sl-253\slmult0 \fs18\cf0\f1\charscalex100 {1-1,5}\par\pard\li946\ri0\sl-240\s
lmult0 \fs18\cf0\f1\charscalex100 {>1,5}\par\column\pard\li0\ri0\sl-240\slmult0
\fs18\cf0\f1\charscalex100 {5-10}\par\pard\li0\ri0\sl-253\slmult0 \fs18\cf0\f1\c
harscalex100 {10}\par\pard\li0\ri0\sl-240\slmult0 \fs18\cf0\f1\charscalex100 {10
}\par\column\pard\li0\ri0\sl-240\slmult0 \fs18\cf0\f1\charscalex100 {100-150\uc1
\u8224X}\par\pard\li0\ri0\sl-253\slmult0 \fs18\cf0\f1\charscalex100 {80-100}\par
\pard\li0\ri0\sl-240\slmult0 \fs18\cf0\f1\charscalex100 {60-80}\par\column\pard\
li0\ri0\sl-240\slmult0 \fs18\cf0\f1\charscalex100 {120-150}\par\pard\li0\ri0\sl253\slmult0 \fs18\cf0\f1\charscalex100 {100-120}\par\pard\li0\ri0\sl-240\slmult0
\fs18\cf0\f1\charscalex100 {80-120}\par\column\pard\li0\ri0\sl-240\slmult0 \fs1
8\cf0\f1\charscalex100 {140-190}\par\pard\li0\ri0\sl-253\slmult0 \fs18\cf0\f1\ch
arscalex100 {120-160}\par\pard\li0\ri0\sl-240\slmult0 \fs18\cf0\f1\charscalex100
{120-160}\par\pard\sect\sectd\sbknone\pgwsxn10760\pghsxn14440\marglsxn666\margr
sxn133\pard\li946\ri0\sl-253\slmult0 \fs18\cf0\f1\charscalex100 {*Bayiyangberada
diinkubator.Bayiyangberadadiwarmerbiasanyamemerlukancairanlebihtinggi.}\par\pard

\li946\ri0\sl-253\slmult0 \fs18\cf0\f1\charscalex100 {\uc1\u8224XBayiberatlahirs

angatrendah(BBLSR)seringmemerlukancairanlebihtinggidariyangdianjurkan,dan}\par\p
ard\li946\ri0\sl-213\slmult0 \fs18\cf0\f1\charscalex100 {perlunya pengukuran ser
um elektrolit, urine output, dan berat badan yang lebih sering.}\par\pard\li893\
ri0\sl-253\slmult0 \fs18\cf0\f1\charscalex100 {Sumber: Doherty EG, Simmons CF. F
luid and Electrolyte Management. Dalam Cloherty JP, Eichenwaald EC,}\par\pard\li
893\ri0\sl-213\slmult0 \fs18\cf0\f1\charscalex100 {StarkAR,penyunting.Manualofne
onatalcare.Edisikeenam.Philadelphia:LippincottWilliams&Wilkins;}\par\pard\li893\
ri0\sl-213\slmult0 \fs18\cf0\f1\charscalex100 {2008.h.100-12}\par\pard\li893\ri0
\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\l
i893\ri0\sl-226\slmult0 \fs18\cf0\f0\charscalex100\b {Tabel 5. Jumlah cairan yan
g dibutuhkan bayi (ml/kg)}\b0 \par\pard\sect\sectd\sbknone\pgwsxn10760\pghsxn144
40\marglsxn666\margrsxn133\cols6\colno1\colw2640\colsr-0\colno2\colw1186\colsr-0
\colno3\colw1186\colsr-0\colno4\colw1200\colsr-0\colno5\colw1186\colsr-0\colno6\
colw2560\pard\li946\ri0\sl-413\slmult0 \fs20\cf0\f1\charscalex100 {Berat}\par\pa
rd\li946\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li946\ri0\sl-306\slmult0 \fs20\cf
0\f1\charscalex100 {> 1500 g}\par\pard\li946\ri0\sl-266\slmult0 \fs18\cf0\f1\cha
rscalex100 {< 1500 g}\par\column\pard\li0\ri0\sl-413\slmult0 \fs20\cf0\f1\charsc
alex100 {Umur (hari)}\par\pard\li0\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100
\b {1}\b0 \par\pard\li0\ri0\sl-253\slmult0 \fs20\cf0\f1\charscalex100 {60}\par\p
ard\li0\ri0\sl-266\slmult0 \fs20\cf0\f1\charscalex100 {80}\par\column\pard\li0\r
i0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\l
i0\ri0\sl-253\slmult0 \fs20\cf0\f0\charscalex100\b {2}\b0 \par\pard\li0\ri0\sl-2
53\slmult0 \fs20\cf0\f1\charscalex100 {80}\par\pard\li0\ri0\sl-266\slmult0 \fs20
\cf0\f1\charscalex100 {100}\par\column\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par
\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-253\slmult0 \fs20\cf0
\f0\charscalex100\b {3}\b0 \par\pard\li0\ri0\sl-253\slmult0 \fs20\cf0\f1\charsca
lex100 {100}\par\pard\li0\ri0\sl-266\slmult0 \fs20\cf0\f1\charscalex100 {120}\pa
r\column\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-213\slmult0 \
fs18\cf0\par\pard\li0\ri0\sl-253\slmult0 \fs20\cf0\f0\charscalex100\b {4}\b0 \pa
r\pard\li0\ri0\sl-253\slmult0 \fs20\cf0\f1\charscalex100 {120}\par\pard\li0\ri0\
sl-266\slmult0 \fs20\cf0\f1\charscalex100 {140}\par\column\pard\li0\ri0\sl-213\s
lmult0 \fs18\cf0\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-2
53\slmult0 \fs20\cf0\f0\charscalex100\b {5+}\b0 \par\pard\li0\ri0\sl-253\slmult0
\fs20\cf0\f1\charscalex100 {150}\par\pard\li0\ri0\sl-266\slmult0 \fs20\cf0\f1\c
harscalex100 {150}\par\pard\sect\sectd\sbknone\pgwsxn10760\pghsxn14440\marglsxn6
66\margrsxn133\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213
\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-200\slmult0 \fs18\cf0\f0\charscalex100\
b {Tabel 6.}\b0 { }\fs18\cf0\f0\charscalex100\b \i {Insensible Water Loss}\b0 \i
0 \fs18\cf0\f0\charscalex100\b { (IWL) pada bayi prematur}\b0 \par\pard\sect\sec
td\sbknone\pgwsxn10760\pghsxn14440\marglsxn666\margrsxn133\cols2\colno1\colw4293
\colsr-0\colno2\colw5666\pard\li946\ri0\sl-413\slmult0 \fs18\cf0\f0\charscalex10
0\b {Berat badan (gram)}\b0 \par\pard\li946\ri0\sl-266\slmult0 \fs20\cf0\f1\char
scalex100 {<750}\par\pard\li946\ri0\sl-240\slmult0 \fs20\cf0\f1\charscalex100 {7
50-1000}\par\pard\li946\ri0\sl-253\slmult0 \fs20\cf0\f1\charscalex100 {1001-1250
}\par\pard\li946\ri0\sl-266\slmult0 \fs20\cf0\f1\charscalex100 {1251-1500}\par\p
ard\li946\ri0\sl-266\slmult0 \fs20\cf0\f1\charscalex100 {1501-2000}\par\pard\li9
46\ri0\sl-266\slmult0 \fs20\cf0\f1\charscalex100 {2001-3250}\par\column\pard\li0
\ri0\sl-413\slmult0 \fs18\cf0\f0\charscalex100\b {IWL rata-rata (ml/kg/hari)}\b0
\par\pard\li0\ri0\sl-266\slmult0 \fs20\cf0\f1\charscalex100 {100-200}\par\pard\
li0\ri0\sl-240\slmult0 \fs20\cf0\f1\charscalex100 {60-70}\par\pard\li0\ri0\sl-25
3\slmult0 \fs20\cf0\f1\charscalex100 {50-60}\par\pard\li0\ri0\sl-266\slmult0 \fs
20\cf0\f1\charscalex100 {30-40}\par\pard\li0\ri0\sl-266\slmult0 \fs20\cf0\f1\cha
rscalex100 {20-30}\par\pard\li0\ri0\sl-266\slmult0 \fs20\cf0\f1\charscalex100 {1
5-20}\par\pard\sect\sectd\sbknone\pgwsxn10760\pghsxn14440\marglsxn666\margrsxn13
3\pard\li893\ri0\sl-240\slmult0 \fs18\cf0\f1\charscalex100 {Sumber:CunninghamMG.
BodyWater,Fluid,andElectrolytes.Dalam:GomellaTL,CunninghamMD,}\par\pard\li893\ri
0\sl-213\slmult0 \fs18\cf0\f1\charscalex100 {EyalFG,TuttleD,penyunting.Neonatolo
gy,management,procedures,on-callproblems,diseases,and}\par\pard\li893\ri0\sl-213
\slmult0 \fs18\cf0\f1\charscalex100 {drugs.Edisikeenam.NewYork:McGraw-Hill;2004.

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46\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li3746\ri0\sl-213\slmult0 \fs18\cf0\par
\pard\li3746\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li3746\ri0\sl-213\slmult0 \fs
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lmult0 \fs36\cf0\f0\charscalex100\b {Bronkiolitis}\b0 \par\pard\li893\ri0\sl-213
\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri
0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\
li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-280\slmult0 \fs22\cf0\f
0\charscalex100 {Menurut Wohl, bronkiolitis adalah inflamasi bronkioli pada bayi
<2 tahun. Berdasarkan}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscale
x100\i {guideline}\i0 { }\fs22\cf0\f0\charscalex100 {dari UK, bronkiolitis adala
h penyakit}{ }\fs18\cf0\f0\charscalex100\i {seasonal viral}\i0 \fs22\cf0\f0\char
scalex100 { yang ditandai dengan adanya}\par\pard\li893\ri0\sl-266\slmult0 \fs20
\cf0\f0\charscalex100 {panas, pilek, batuk, dan mengi. Pada pemeriksaan fisis di
temukan}{ }\fs16\cf0\f0\charscalex100\i {inspiratory}\i0 { }\fs20\cf0\f0\charsca
lex100\i {crackles}\i0 \fs20\cf0\f0\charscalex100 { dan/}\par\pard\li893\ri0\sl266\slmult0 \*\tx7613\fs20\cf0\f0\charscalex100 {atau}{ }\fs20\cf0\f0\charscalex
100\i {high pitched expiratory wheeze. }\i0 \fs20\cf0\f0\charscalex100 {Etiologi
bronkiolitis antara lain adalah}\tab \fs20\cf0\f0\charscalex100\i {Respiratory}
\i0 \par\pard\li893\ri0\sl-266\slmult0 \fs16\cf0\f0\charscalex100\i {SyncytialVi
rus}\i0 { }\fs20\cf0\f0\charscalex100 {(RSV) (tersering), }\fs16\cf0\f0\charscal
ex100\i {Rhinovirus, Adenovirus, Parainfluenzae virus, Enterovirus, }\i0 \fs20\c
f0\f0\charscalex100 {dan}\par\pard\li893\ri0\sl-266\slmult0 \fs18\cf0\f0\charsca
lex100\i {Influenzae virus. }\i0 \fs22\cf0\f0\charscalex100 {Bronkiolitis merupa
kan penyebab tersering perawatan rumah sakit pada}\par\pard\li893\ri0\sl-266\slm
ult0 \fs22\cf0\f0\charscalex100 {anak usia 2-6 bulan dan sering terjadi misdiagn
osis dengan asma.}\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri
0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-400\slmult0 \fs26\cf0\f0\charsc
alex100\b {Diagnosis}\b0 \par\pard\li893\ri0\sl-413\slmult0 \fs22\cf0\f0\charsca
lex100\b {Anamnesis}\b0 \par\pard\li906\ri0\sl-306\slmult0 \*\tx1146\fs22\cf0\f0
\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Sering terjadi pada anak beru
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i pada bayi berusia <1 tahun. Insidens}\par\pard\li1146\ri0\sl-266\slmult0 \fs22
\cf0\f0\charscalex100 {tertinggi terjadi pada usia 3-6 bulan.}\par\pard\li906\ri
0\sl-266\slmult0 \*\tx1146\fs20\cf0\f0\charscalex100 {-}\tab \fs20\cf0\f0\charsc
alex100 {Anak yang menderita bronkiolitis mengalami demam atau riwayat demam, na
mun}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {jarang terja
di demam tinggi.}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charsc
alex100 {-}\tab \fs18\cf0\f0\charscalex100\i {Rhinorrhea, nasal discharge}\i0 \
fs22\cf0\f0\charscalex100 { (pilek), sering timbul sebelum gejala lain seperti
batuk, }\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {takipne
, sesak napas, dan kesulitan makan.}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146
\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Batuk disertai ge
jala nasal adalah gejala yang pertama muncul pada bronkiolitis. Batuk}\par\pard\
li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {kering dan mengi khas untu
k bronkiolitis.}\par\pard\li906\ri0\sl-280\slmult0 \*\tx1146\*\tx2426\fs22\cf0\f
0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100\i {Poor feeding. }\i0 \tab \f
s22\cf0\f0\charscalex100 {Banyak penderita bronkiolitis mempunyai kesulitan maka
n yang}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {berhubung
an dengan sesak napas, namun gejala tersebut bukan hal mendasar untuk}\par\pard\
li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {diagnosis bronkiolitis}\pa
r\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs2
2\cf0\f0\charscalex100 {Bayi dengan bronkiolitis jarang tampak \uc1\u8221Xtoksik
\uc1\u8221X. Bayi dengan tampilan toksik seperti}\par\pard\li1146\ri0\sl-280\slm
ult0 \fs22\cf0\f0\charscalex100 {mengantuk, letargis, gelisah, pucat, }\fs22\cf0
\f0\charscalex100\i {motling}\i0 \fs22\cf0\f0\charscalex100 {, dan takikardi mem
butuhkan penanganan}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex1

00 {segera.}\par\pard\li893\ri0\sl-466\slmult0 \fs22\cf0\f0\charscalex100\b {Pem

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scalex100 {-}\tab \fs20\cf0\f0\charscalex100 {Napas cepat merupakan gejala utama
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0\cf0\f0\charscalex100 { (LRTI), }\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0
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lex100 {Retraksi dinding dada (subkosta, interkosta, dan supraklavikula) sering
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pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {membedakan bronkiolit
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i0\sl-440\slmult0 \fs22\cf0\f0\charscalex100 {30 }{ }\fs12\cf0\f0\charscalex10
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rd\li906\ri0\sl-466\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs18\cf
0\f0\charscalex100\i {Fine inspiratory crackles}\i0 \fs22\cf0\f0\charscalex100 {
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s}\i0 \fs20\cf0\f0\charscalex100 { lebih sering dikelompokkan sebagai}{ }\fs16\c
f0\f0\charscalex100\i {viral-induced wheeze}\i0 \par\pard\li1146\ri0\sl-266\slmu
lt0 \fs22\cf0\f0\charscalex100 {dibandingkan bronkiolitis.}\par\pard\li906\ri0\s
l-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscale
x100 {Di UK, }\fs20\cf0\f0\charscalex100\i {high pitched expiratory wheeze}\i0 \
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d\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {bronkiolitis, tapi bukan
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0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {bronkiolitis lebih ditekankan pada
adanya mengi.}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs20\cf0\f0\charscale
x100 {-}\tab \fs20\cf0\f0\charscalex100 {Apnea dapat terjadi pada bronkiolitis,
terutama pada usia yang sangat muda, bayi}\par\pard\li1146\ri0\sl-266\slmult0
\fs22\cf0\f0\charscalex100 {prematur, atau berat badan lahir rendah.}\par\pard\l
i893\ri0\sl-386\slmult0 \fs22\cf0\f0\charscalex100\b {Pemeriksaan Penunjang}\b0
\par\pard\li906\ri0\sl-306\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \
fs22\cf0\f0\charscalex100 {Saturasi oksigen}\par\pard\li906\ri0\sl-266\slmult0 \
*\tx1146\fs20\cf0\f0\charscalex100 {-}\tab \fs18\cf0\f0\charscalex100\i {Pulse o
ximetry}\i0 \fs20\cf0\f0\charscalex100 { harus dilakukan pada setiap anak yang d
atang ke rumah sakit dengan}\par\pard\li1146\ri0\sl-266\slmult0 \fs20\cf0\f0\cha
rscalex100 {bronkiolitis. Bayi dengan saturasi oksigen \uc1\u8804X92% membutuhka
n perawatan di ruang}\par\pard\li1146\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex
100 {intensif. Bayi dengan saturasi oksigen >94% pada udara ruangan dapat dipert
imbangkan}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {untuk
dipulangkan.}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex
100 {-}\tab \fs22\cf0\f0\charscalex100 {Analisis gas darah}\par\pard\li906\ri0\s
l-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscale
x100 {Umumnya tidak diindikasikan pada bronkiolitis. Pemeriksaan tersebut bergun
a untuk}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {menilai
bayi dengan distres napas berat dan kemungkinan mengalami gagal napas.}\par\pard
\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\
f0\charscalex100 {Foto toraks}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs20\
cf0\f0\charscalex100 {-}\tab \fs20\cf0\f0\charscalex100 {Foto toraks dipertimban
gkan pada bayi dengan diagnosis meragukan atau penyakit}\par\pard\li1146\ri0\sl266\slmult0 \fs22\cf0\f0\charscalex100 {atipikal. Foto toraks sebaiknya tidak d
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t0 \fs22\cf0\f0\charscalex100 {toraks pada bronkiolitis yang ringan tidak member
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fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Pemeriksaan virolo
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b \fs16\cf0\f0\charscalex100\i {Rapid diagnosis}\i0 \fs20\cf0\f0\charscalex100 {

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ffective}\i0 \fs20\cf0\f0\charscalex100 { karena mengurangi}\par\pard\li1146\ri0
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k, dan pemeriksaan mikrobiologi.}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs
22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Pemeriksaan bakterio
logi}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs20\cf0\f0\charscalex100 {-}\
tab \fs20\cf0\f0\charscalex100 {Pemeriksaan bakteriologi secara rutin (darah dan
urin) tidak diindikasikan pada}\par\pard\li1146\ri0\sl-266\slmult0 \fs20\cf0\f0
\charscalex100 {penderita bronkiolitis bakteriologi tipikal. Pemeriksaan bakte
riologi dari urin}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100
{dipertimbangkan pada bayi berusia <60 hari.}\par\pard\li906\ri0\sl-266\slmult0
\*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Hematol
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ab \fs20\cf0\f0\charscalex100 {Pemeriksaan darah lengkap tidak diindikasikan dal
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eactive protein}\i0 \fs22\cf0\f0\charscalex100 { (CRP)}\par\pard\li973\ri0\sl-26
6\slmult0 \*\tx1146\fs20\cf0\f0\charscalex100 { -}\tab \fs22\cf0\f0\charscalex10
0 {Penelitian yang ada merupakan penelitian retrospektif atau penelitian dengan
kualitas }\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {yang b
uruk dan tidak memberikan bukti yang cukup berhubungan dengan bronkiolitis.}\par
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rd\li893\ri0\sl-466\slmult0 \fs22\cf0\f0\charscalex100 {pemberian oksigen, }\fs2
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22\cf0\f0\charscalex100 {perawatan di rumah sakit.}\par\pard\li906\ri0\sl-266\sl
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0 {-}\tab \fs20\cf0\f0\charscalex100 {Bayi lahir prematur kemungkinan menderita}
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\charscalex100 { lebih tinggi}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\c
harscalex100 {daripada bayi cukup bulan.}\par\pard\li906\ri0\sl-266\slmult0 \*\t
x1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Kelainan jan
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00 {-}\tab \fs18\cf0\f0\charscalex100\i {Chronic lung disease of prematurity}\i0
\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab
\fs22\cf0\f0\charscalex100 {Orangtua perokok}\par\pard\li906\ri0\sl-266\slmult0
\*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Jumlah s
audara/berada di tempat penitipan}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\f
s22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Sosioekonomi rendah
}\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li893\ri0\sl-333\slmult0 \fs26\cf0\f0\charscalex100\b {Kepust
akaan}\b0 \par\pard\li893\ri0\sl-293\slmult0 \*\tx1266\fs16\cf0\f0\charscalex100
{1. }\tab \fs16\cf0\f0\charscalex100 {Wohl MEB. Bronchiolitis. Dalam: Cher
nick V, Kendig EL, penyunting. Kendig\uc1\u8217Xs disorders of the}\par\par
d\li1266\ri0\sl-213\slmult0 \fs18\cf0\f0\charscalex100 {respiratory tract in chi
ldren. Ed ke-7. Philadelphia: WB Saunders Co; 2006. h. 423-40.}\par\pard\li893\r
i0\sl-253\slmult0 \*\tx1266\fs18\cf0\f0\charscalex100 {2. }\tab \fs18\cf0\f0\cha
rscalex100 {Watt KD, Goodman DM. Wheezing in infant: bronchiolitis. Dalam: Behrm
an RE, Kliegman RM, Jenson}\par\pard\li1266\ri0\sl-213\slmult0 \fs18\cf0\f0\char
scalex100 {HB, Stanton BF, penyunting. Nelson textbook of pediatrics. Edisi ke-1
8. Philadelphia: WB Saunders Co; }\par\pard\li1266\ri0\sl-226\slmult0 \fs18\cf0\
f0\charscalex100 {2007. h. 1773-77.}\par\pard\li893\ri0\sl-253\slmult0 \*\tx1266
\fs18\cf0\f0\charscalex100 {3. }\tab \fs18\cf0\f0\charscalex100 {Scottish interc
ollegiate guidelines network. Bronkiolitis in children a national clinical guide
line [diakses}\par\pard\li1266\ri0\sl-213\slmult0 \fs18\cf0\f0\charscalex100 {ta
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ult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Pad
a hari ke 4-5 demam timbul ruam kulit, didahului oleh suhu yang meningkat lebih}
\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {tinggi dari semu
la. Pada saat ini anak dapat mengalami kejang demam. }\par\pard\li906\ri0\sl-266
\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100
{Saat ruam timbul, batuk dan diare dapat bertambah parah sehingga anak mengalami
}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {sesak napas ata
u dehidrasi. Adanya kulit kehitaman dan bersisik (hiperpigmentasi)}\par\pard\li1
146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {dapat merupakan tanda penyemb
uhan.}\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-333\slm
ult0 \fs22\cf0\f0\charscalex100\b {Pemeriksaan fisis}\b0 \par\pard\li893\ri0\sl306\slmult0 \fs22\cf0\f0\charscalex100 {Gejala klinis terjadi setelah masa tunas
10-12 hari, terdiri dari tiga stadium:}\par\pard\li973\ri0\sl-266\slmult0 \*\tx
1146\fs20\cf0\f0\charscalex100 { -}\tab \fs22\cf0\f0\charscalex100 {Stadium prod
romal: berlangsung 2-4 hari, ditandai dengan demam yang di kuti dengan}\par\pard
\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {batuk, pilek, faring mera
h, nyeri menelan, stomatitis, dan konjungtivitis. Tanda patognomonik}\par\pard\l
i1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {timbulnya enantema mukosa p
ipi di depan molar tiga disebut bercak Koplik. }\par\pard\li906\ri0\sl-266\slmul
t0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Stadi
um erupsi: ditandai dengan timbulnya ruam makulopapular yang bertahan selama}\pa
r\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {5-6 hari. Timbulnya
ruam dimulai dari batas rambut di belakang telinga, kemudian}\par\pard\li1146\r
i0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {menyebar ke wajah, leher, dan akhi
rnya ke ekstremitas.}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\ch
arscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Stadium penyembuhan (konvalesens
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22\cf0\f0\charscalex100 {menghilang sesuai urutan timbulnya. Ruam kulit menjadi
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alex100 {yang akan menghilang setelah 1-2 minggu.}\par\pard\li6480\ri0\sl-213\sl
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eses lengkap}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscale

x100 {-}\tab \fs22\cf0\f0\charscalex100 {Bronkopneumonia: dilakukan pemeriksaan

foto dada dan analisis gas darah}\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\pa
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6\cf0\f0\charscalex100\b {Tata laksana}\b0 \par\pard\li893\ri0\sl-413\slmult0 \f
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\*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Pengoba
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\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {nutrisi, antibiotik
diberikan apabila terjadi infeksi sekunder, antikonvulsi apabila terjadi}\par\pa
rd\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {kejang, dan pemberian v
itamin A}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100
{-}\tab \fs22\cf0\f0\charscalex100 {Tanpa komplikasi:}\par\pard\li1146\ri0\sl-26
6\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100
{Tirah baring di tempat tidur}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs2
2\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Vitamin A 100.000 IU,
apabila disertai malnutrisi dilanjutkan 1500 IU tiap hari}\par\pard\li1146\ri0\
sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscal
ex100 {Diet makanan cukup cairan, kalori yang memadai. Jenis makanan disesuaikan
dengan}\par\pard\li1346\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {tingkat
kesadaran pasien dan ada tidaknya komplikasi}\par\pard\li906\ri0\sl-266\slmult0
\*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Pengobat
an dengan komplikasi:}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\
charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Ensefalopati}\par\pard\li1373\
ri0\sl-266\slmult0 \*\tx1613\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\char
scalex100 {Kloramfenikol dosis 75 mg/kgbb/hari dan ampisilin 100 mg/kgbb/hari se
lama}\par\pard\li1613\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {7-10 hari}\
par\pard\li1373\ri0\sl-266\slmult0 \*\tx1613\fs22\cf0\f0\charscalex100 {-}\tab \
fs22\cf0\f0\charscalex100 {Kortikosteroid: deksametason 1 mg/kgbb/hari sebagai
dosis awal dilanjutkan}\par\pard\li1613\ri0\sl-266\slmult0 \fs22\cf0\f0\charscal
ex100 {0,5 g/kgbb/hari dibagi dalam 3 dosis sampai kesadaran membaik (bila pembe
rian}\par\pard\li1613\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {lebih dari
5 hari dilakukan}{ }\fs22\cf0\f0\charscalex100\i {tappering off}\i0 \fs22\cf0\f0
\charscalex100 {)}\par\pard\li1373\ri0\sl-266\slmult0 \*\tx1613\fs22\cf0\f0\char
scalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Kebutuhan jumlah cairan dikurangi
kebutuhan serta koreksi terhadap}\par\pard\li1613\ri0\sl-266\slmult0 \fs22\cf0\f
0\charscalex100 {gangguan elektrolit}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx13
46\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Bronkopneumonia
}\par\pard\li1440\ri0\sl-266\slmult0 \*\tx1613\fs20\cf0\f0\charscalex100 { -}\ta
b \fs22\cf0\f0\charscalex100 {Kloramfenikol 75 mg/kgbb/hari dan ampisilin 100 mg
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f0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Oksigen 2 liter/menit}\p
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0 \par\pard\li893\ri0\sl-306\slmult0 \fs22\cf0\f0\charscalex100 {Pasien dirawat
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0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {hiperpireksia (suhu>39.0}\fs
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harscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {kejang}\par\pard\li906\ri0\sl-2
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rd\li893\ri0\sl-466\slmult0 \fs22\cf0\f0\charscalex100\b {Pemantauan dan konsult
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-}\tab \fs22\cf0\f0\charscalex100 {Pada kasus campak dengan komplikasi bronkopne
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arscalex100 {dipantau terhadap adanya infeksi tuberkulosis (TB) laten. Pantau ge
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{lakukan uji tuberkulin setelah 1-3 bulan penyembuhan.}\par\pard\li906\ri0\sl-2

66\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex10
0 {Pantau keadaan gizi untuk gizi kurang/buruk, konsultasi pada Divisi Nutrisi
&}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {Metabolik.}\pa
r\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-346\slmult0 \fs2
2\cf0\f0\charscalex100\b {Faktor risiko terjadinya komplikasi}\b0 \par\pard\li89
3\ri0\sl-306\slmult0 \fs22\cf0\f0\charscalex100 {Campak menjadi berat pada pasie
n dengan gizi buruk dan anak berumur lebih kecil.}\par\pard\li906\ri0\sl-266\slm
ult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Dia
re dapat diikuti dehidrasi}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0
\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Otitis media}\par\pard\li9
06\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\c
harscalex100 {Laringotrakeobronkitis (}\fs22\cf0\f0\charscalex100\i {croup}\i0 \
fs22\cf0\f0\charscalex100 {)}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\c
f0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Bronkopneumonia}\par\par
d\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0
\f0\charscalex100 {Ensefalitis akut, terjadi pada 2-10/10.000 kasus dengan angka
kematian 10-15 %}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\*\tx4266\fs22\cf0
\f0\charscalex100 {-}\tab \fs20\cf0\f0\charscalex100\i {Subacute sclerosing pane
ncephalitis}\i0 \tab \fs22\cf0\f0\charscalex100 {(SSPE): suatu proses degenerat
if susunan saraf}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100
{pusat dengan gejala karakteristik terjadi deteriorisasi tingkah laku dan intele
ktual yang}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {diiku
ti dengan kejang. Disebabkan oleh infeksi virus yang menetap, timbul beberapa}\p
ar\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {tahun setelah infe
ksi dan merupakan salah satu komplikasi campak awitan lambat. }\par\pard\li1146\
ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {Terjadi pada 1/25.000 kasus, meny
ebabkan kerusakan otak progresif dan fatal.}\par\pard\li893\ri0\sl-213\slmult0 \
fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-333\s
lmult0 \fs26\cf0\f0\charscalex100\b {Kepustakaan}\b0 \par\pard\li893\ri0\sl-293\
slmult0 \*\tx1266\fs18\cf0\f0\charscalex100 {1. }\tab \fs18\cf0\f0\charscalex100
{American Academy of Pediatrics. Measles. Dalam: Pickering LK, Baker CJ, L
ong SS,
McMillan JA, }\par\pard\li1266\ri0\sl-226\slmult0 \fs18\cf0\f0\charsc
alex100 {penyunting. Red Book: 2006 Report of the committee in infectious diseas
es. Edisi ke-27. Elk Grove}\par\pard\li1266\ri0\sl-213\slmult0 \fs18\cf0\f0\char
scalex100 {Village, IL. American Academy of Pediatrics; 2006, h. 441-52.}\par\pa
rd\li893\ri0\sl-253\slmult0 \*\tx1266\fs18\cf0\f0\charscalex100 {2. }\tab \fs16\
cf0\f0\charscalex100 {Samuel LK. Measles (Rubeola). Dalam: Anne AG, Peter JH, Sa
muel LK, penyunting. Krugman\uc1\u8217Xs infectious}\par\pard\li1266\ri0\sl-213\
slmult0 \fs18\cf0\f0\charscalex100 {diseases of children. Edisi ke-11. Philadelp
hia; 2004. h. 353-68.}\par\pard\li893\ri0\sl-253\slmult0 \*\tx1266\fs18\cf0\f0\c
harscalex100 {3. }\tab \fs18\cf0\f0\charscalex100 {Maldonado YA. Rubeola virus
(measles and subacute sclerosing panencephalitis). Dalam: Long SS, }\par\pard\
li1266\ri0\sl-213\slmult0 \fs18\cf0\f0\charscalex100 {Pickering LK, Prober CG, p
enyunting. Principles and practice of pediatric infectious diseases. Edisi}\par\
pard\li1266\ri0\sl-226\slmult0 \fs18\cf0\f0\charscalex100 {ke- 2. Philadelphia,
PA: Elsevier Science; 2003, h.1148-55.}\par\pard\li893\ri0\sl-240\slmult0 \*\tx1
266\fs18\cf0\f0\charscalex100 {4. }\tab \fs18\cf0\f0\charscalex100 {Maldonado YA
. Measles. Dalam: Behrman RE, Kliegman RM, Jenson HB, penyunting. Nelson textboo
k}\par\pard\li1266\ri0\sl-226\slmult0 \fs18\cf0\f0\charscalex100 {of pediatrics.
Edisi ke-17. Philadelphia: Saunders; 2004, h. 1026-32.}\par\pard\li6480\ri0\sl213\slmult0 \fs18\cf0\par\pard\li6480\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li64
80\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li6480\ri0\sl-213\slmult0 \fs18\cf0\par
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\pard\li2853\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li2853\ri0\sl-213\slmult0 \fs

18\cf0\par\pard\li2853\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li2853\ri0\sl-533\s
lmult0 \fs36\cf0\f0\charscalex100\b {Defek Septum Atrium}\b0 \par\pard\li893\ri0
\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\l
i893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\pa
r\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-280\slmult0 \fs2
2\cf0\f0\charscalex100 {Setiap defek pada septum atrium, selain paten foramen o
vale, disebut defek septum}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\char
scalex100 {atrium (DSA). Secara anatomis, terdapat tiga tipe DSA yaitu: defek se
kundum, defek}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {pri
mum, dan defek tipe sinus venosus. Defek septum atrium mencakup lebih kurang 5-}
\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {10% penyakit jant
ung bawaan. Defek septum atrium tipe sekundum merupakan bentuk}\par\pard\li893\r
i0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {kelainan terbanyak (50% sampai 70%
), diikuti tipe primum (30%), dan sinus venosus}\par\pard\li893\ri0\sl-266\slm
ult0 \fs20\cf0\f0\charscalex100 {(10%). Kebanyakan DSA terjadi sporadis tetapi
pada beberapa keluarga ada peranan}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\
f0\charscalex100 {faktor genetik.}\par\pard\li893\ri0\sl-386\slmult0 \fs20\cf0\f
0\charscalex100 {Pada defek sekundum kurang dari 3 mm yang didiagnosis sebelum u
sia 3 bulan, penutupan}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscale
x100 {secara spontan terjadi pada 100% pasien pada usia 1 tahun. Defek 3 sampai 8
mm}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {menutup pada
usia 1 tahun pada 80% pasien, dan defek lebih besar dari 8 mm jarang}\par\pard\li
893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {menutup spontan. Defek ini da
lam perjalanannya dapat mengecil, menetap, atau meski}\par\pard\li893\ri0\sl-266
\slmult0 \fs22\cf0\f0\charscalex100 {jarang, melebar. Defek sinus venosus dan pr
imum tidak mengalami penutupan spontan.}\par\pard\li893\ri0\sl-213\slmult0 \fs18
\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-386\slmul
t0 \fs26\cf0\f0\charscalex100\b {Diagnosis}\b0 \par\pard\li893\ri0\sl-413\slmult
0 \fs22\cf0\f0\charscalex100\b {Anamnesis}\b0 \par\pard\li893\ri0\sl-306\slmult0
\fs20\cf0\f0\charscalex100 {Sebagian besar bayi dan anak asimtomatik. Bila pira
u cukup besar, maka pasien mengalami}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf
0\f0\charscalex100 {sesak napas (terutama saat beraktivitas), infeksi paru berul
ang, dan berat badan sedikit}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\cha
rscalex100 {kurang. }\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893
\ri0\sl-360\slmult0 \fs22\cf0\f0\charscalex100\b {Pemeriksaan fisis}\b0 \par\par
d\li906\ri0\sl-306\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0
\f0\charscalex100 {Anak dapat tampak kurus, tergantung derajat DSA.}\par\pard\li
906\ri0\sl-266\slmult0 \*\tx1146\fs20\cf0\f0\charscalex100 {-}\tab \fs20\cf0\f0\
charscalex100 {Pada auskultasi, S2 melebar dan menetap pada saat inspirasi maup
un ekspirasi}\par\pard\li1146\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {dis
ertai bising ejeksi sistolik di daerah pulmonal. Pada pirau kiri ke kanan yang b
esar}\par\pard\li1146\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {dapat terde
ngar bising diastolik pada tepi kiri sternum bagian bawah akibat stenosis}\par\p
ard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {trikuspid relatif.}\pa
r\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-360\slmult0 \fs2
2\cf0\f0\charscalex100\b {Pemeriksaan penunjang}\b0 \par\pard\li906\ri0\sl-306\s
lmult0 \*\tx1146\fs20\cf0\f0\charscalex100 {-}\tab \fs20\cf0\f0\charscalex100 {E
lektrokardiografi: deviasi sumbu QRS ke kanan (+90 sampai 180}\fs10\cf0\f0\char
scalex100 {o}\fs20\cf0\f0\charscalex100 {), hipertrofi }\par\pard\li1146\ri0\sl
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0 \*\tx1146\fs18\cf0\f0\charscalex100 { -}\tab \fs20\cf0\f0\charscalex100 {Foto
toraks: kardiomegali dengan pembesaran atrium kanan dan ventrikel kanan. Arteri}
\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {pulmonalis tampa
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\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-440\slmult0 \fs22\cf0\f0\charsca
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f}\par\pard\li1266\ri0\sl-213\slmult0 \fs18\cf0\f0\charscalex100 {secundum atria

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18\cf0\par\pard\li2720\ri0\sl-466\slmult0 \fs36\cf0\f0\charscalex100\b {Defek Se
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i0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard
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par\pard\li893\ri0\sl-280\slmult0 \fs22\cf0\f0\charscalex100 {Defek Septum Ventr
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x100 {Berdasarkan fisiologinya DSV dapat diklasifikasikan menjadi: (1) DSV defek
kecil dengan}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {res
istensi vaskular paru normal; (2) DSV defek sedang dengan resistensi vaskular pa
ru}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {bervariasi; (3
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ard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {sampai sedang; (4) DSV
defek besar dengan resistensi vaskular paru yang tinggi.}\par\pard\li893\ri0\sl213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893
\ri0\sl-333\slmult0 \fs26\cf0\f0\charscalex100\b {Diagnosis}\b0 \par\pard\li893\
ri0\sl-413\slmult0 \fs22\cf0\f0\charscalex100\b {Anamnesis}\b0 \par\pard\li906\r
i0\sl-306\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\chars
calex100 {DSV kecil umumnya menimbulkan gejala ringan atau tanpa gejala (asimtom
atik), anak}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {tamp
ak sehat. }\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex10
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cf0\f0\charscalex100 {yang kurang}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\f
s22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Pada DSV defek besa
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\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Pada DSV kecil, didap
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dapat tidak terdengar atau jika terdengar sangat pendek; }\par\pard\li1146\ri0\s
l-266\slmult0 \fs22\cf0\f0\charscalex100 {dapat terdengar bising holosistolik da
ri katup trikuspid akibat insufisiensi trikuspid.}\par\pard\li893\ri0\sl-213\slm
ult0 \fs18\cf0\par\pard\li893\ri0\sl-360\slmult0 \fs22\cf0\f0\charscalex100\b {P
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scalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Pada defek kecil gambaran radiolog
is menunjukkan ukuran jantung normal dan}\par\pard\li1146\ri0\sl-266\slmult0 \fs
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t0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Pada
defek sedang tampak pembesaran jantung dan peningkatan vaskular paru. }\par\pard
\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\
f0\charscalex100 {Pada foto PA tampak bayangan jantung melebar ke arah bawah dan
kiri akibat}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {pem
besaran hipertrofi ventrikel kiri yang disertai peningkatan vaskularisasi paru.}
\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-320\slmult0 \
fs24\cf0\f0\charscalex100 {Elektrokardiografi}\par\pard\li906\ri0\sl-266\slmult0
\*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Pada ba
yi, gambaran EKG sering tidak jelas menunjukkan kelainan. }\par\pard\li906\ri0\s
l-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscale
x100 {Pada DSV defek kecil, EKG biasanya normal. }\par\pard\li906\ri0\sl-266\slm
ult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Pad
a defek sedang, sering didapatkan hipertrofi ventrikel kiri, akibat pirau kiri k
e kanan}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {yang aka
n menyebabkan beban tekanan pada ventrikel kiri; sering tidak didapatkan}\par\pa
rd\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {hipertrofi ventrikel ka
nan. }\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}
\tab \fs22\cf0\f0\charscalex100 {Pada penderita DSV besar dengan tekanan ventrik
el kiri dan kanan yang sama, selain}\par\pard\li1146\ri0\sl-266\slmult0 \fs20\cf
0\f0\charscalex100 {tampak gambaran hipertrofi ventrikel kiri juga didapatkan hi
pertrofi ventrikel kanan. }\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\char
scalex100 {Bila telah terjadi hipertensi pulmonal maka hipertrofi ventrikel kana
n tampak makin}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {m
enonjol, bahkan hipertrofi ventrikel kiri dapat menghilang.}\par\pard\li893\ri0\
sl-493\slmult0 \fs24\cf0\f0\charscalex100 {Ekokardiografi}\par\pard\li893\ri0\sl
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ek septum ventrikel untuk mengetahui lokasi}\par\pard\li893\ri0\sl-266\slmult0 \
fs22\cf0\f0\charscalex100 {dan besar/ukuran defek.}\par\pard\li893\ri0\sl-213\sl
mult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\s
l-373\slmult0 \fs26\cf0\f0\charscalex100\b {Tata laksana}\b0 \par\pard\li906\ri0
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lex100 {Anak dengan DSV kecil biasanya asimtomatik dan tidak memerlukan obat ata
u}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {tindakan bedah

saat awal. Pada anak asimptomatik, tindakan penutupan dapat}\par\pard\li1146\

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ar\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs
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jantung simtomatik}\par\pard\li1146\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex10
0 {perlu diberikan obat anti gagal jantung (antidiuretik, vasodilator (ACE inhi
bitor), }\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {digoksi
n; (lihat Bab \uc1\u8220XGagal Jantung pada Anak\uc1\u8221X). Jika pengobatan me
dis gagal maka}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {p
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\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {terhadap terapi
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lex100 {-}\tab \fs22\cf0\f0\charscalex100 {Tindakan bedah, dapat dilakukan pada
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alex100 { -}{ }\fs20\cf0\f0\charscalex100 {Tanpa bedah: penggunaan alat untuk
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ard\li1346\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {katup atrioventrikular
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sl-266\slmult0 \fs22\cf0\f0\charscalex100 {jauh di apeks tindakan ini menjadi pi
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146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Nutrisi tambah
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l}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {tidak dapat men
gecil atau menutup spontan.}\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\par
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\f0\charscalex100\b {Kepustakaan}\b0 \par\pard\li893\ri0\sl-293\slmult0 \*\tx126
6\fs18\cf0\f0\charscalex100 {1. }\tab \fs16\cf0\f0\charscalex100 {Park MK. Pedia

tric cardiology for practitioners, edisi ke-5. Philadelphia: Mosby; 2008.h.166-7

2.}\par\pard\li893\ri0\sl-240\slmult0 \*\tx1266\fs18\cf0\f0\charscalex100 {2. }\
tab \fs16\cf0\f0\charscalex100 {JoshiVM, Sekhavat S. Acyanotic congenital heart
disease. Dalam: VetterVL, penyunting. Pediatric cardiology: }\par\pard\li1266\ri
0\sl-226\slmult0 \fs16\cf0\f0\charscalex100 {the requisites in pediatrics. Phila
delphia: Elsevier Mosby; 2006. h. 79-96}\par\pard\li893\ri0\sl-253\slmult0 \*\tx
1266\fs18\cf0\f0\charscalex100 {3. }\tab \fs16\cf0\f0\charscalex100 {Keane JF, F
lyer DC. Ventricular septal defect. Dalam: Keane JF, Lock JE, Flyer DC, penyunti
ng. NADAS\uc1\u8217X}\par\pard\li1266\ri0\sl-213\slmult0 \fs18\cf0\f0\charscalex
100 {pediatric cardiology. Edisi ke-2. Philadelphia: Elsevier Saunders; 2006. h.
527-47.}\par\pard\li893\ri0\sl-253\slmult0 \*\tx1266\fs18\cf0\f0\charscalex100
{4. }\tab \fs18\cf0\f0\charscalex100 {Mullins EC. Cardiac catheterization in con
genital heart disease: pediatric and adult. Massachusetts: }\par\pard\li1266\ri0
\sl-213\slmult0 \fs18\cf0\f0\charscalex100 {Blackwell Publishing;2006. h. 803-41
.}\par\pard\li893\ri0\sl-253\slmult0 \*\tx1266\fs18\cf0\f0\charscalex100 {5. }\t
ab \fs18\cf0\f0\charscalex100 {McDaniel NL,Gutgesell HP. Ventricular Septal Defe
cts. Dalam: Allen HD, Driscoll DJ, Shady RE, Feltes}\par\pard\li1266\ri0\sl-213\
slmult0 \fs18\cf0\f0\charscalex100 {TF, penyunting. Moss and Adams\uc1\u8217X
heart disease in infants, children, and adolescents. Philadelphia: }\par\pard
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(HDN). Dengan}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {dit
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nsi}\par\pard\li893\ri0\sl-266\slmult0 \*\tx5973\fs22\cf0\f0\charscalex100 {vita
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f0\f0\charscalex100 {(VKDB). Defisiensi kompleks protrombin didapat}{ }\fs18\cf0
\f0\charscalex100\i {(APCD, Acquired Prothrombine Complex}\i0 \par\pard\li893\ri
0\sl-266\slmult0 \fs22\cf0\f0\charscalex100\i {Deficiency)}\i0 { }\fs22\cf0\f0\c
harscalex100 {adalah bentuk lanjut dariVKDB dan disebut juga sebagai defisiensi
kompleks}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {protromb
in sekunder. Etiologi penyakit ini adalah defisiensi vitamin K yang dialami}\pa
r\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {oleh bayi karena : (
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0\f0\charscalex100 {intrakranial merupakan 80%-90% manifestasi klinis dari DKPD
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893\ri0\sl-413\slmult0 \fs22\cf0\f0\charscalex100\b {Anamnesis}\b0 \par\pard\li8
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harscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Minum ASI, tidak mendapat vitam
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scalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Kejang fokal}\par\pard\li893\ri0\s
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lmult0 \fs22\cf0\f0\charscalex100\b {Pencegahan}\b0 \par\pard\li893\ri0\sl-306\s
lmult0 \fs22\cf0\f0\charscalex100 {Injeksi vitamin K1 dengan dosis 1 mg IM pada
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893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-400\slmult0 \fs26\cf0\f0\
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18\cf0\f0\charscalex100 {1. }\tab \fs18\cf0\f0\charscalex100 {Isarangkura P. Vit
amin K prophylaxis in newborn babies. J Paediatr Obstet Gynecol. 1991;17:5-9.}\p
ar\pard\li893\ri0\sl-240\slmult0 \*\tx1266\fs16\cf0\f0\charscalex100 {2. }\tab \
fs14\cf0\f0\charscalex100 {Sutor AH, Kries R, Cornelissen EA, Mc Ninch AW, Andre
w M.Vitamin K deficiency bleeding (VDKB) in}\par\pard\li1266\ri0\sl-226\slmult0
\fs18\cf0\f0\charscalex100 {infancy. ISTH Pediatric/Perinatal Subcommitee Intern
ational Society on Thrombosis and Haemostasis. }\par\pard\li1266\ri0\sl-213\slmu
lt0 \fs18\cf0\f0\charscalex100 {Thromb Haemost. 1999;81: 456-61.}\par\pard\li893
\ri0\sl-253\slmult0 \*\tx1266\fs18\cf0\f0\charscalex100 {3. }\tab \fs18\cf0\f0\c
harscalex100 {AmericanAcademy of Pediatrics.Committee on fetus and newborn. Cont
roversies concerning vitamin}\par\pard\li1266\ri0\sl-226\slmult0 \fs18\cf0\f0\ch
arscalex100 {K and the newborn. Pediatrics. 2003;112:191-2. }\par\pard\li893\ri0
\sl-240\slmult0 \*\tx1266\fs18\cf0\f0\charscalex100 {4. }\tab \fs18\cf0\f0\chars
calex100 {Pemberian profilaksis vitamin K pada bayi baru lahir. HTA Indonesia 20
03. Departemen Kesehatan RI.}\par\pard\li893\ri0\sl-253\slmult0 \*\tx1266\fs18\c
f0\f0\charscalex100 {5. }\tab \fs18\cf0\f0\charscalex100 {Shearer MJ. Review: Vi
tamin K deficiency bleeding (VDKB) in early infancy. Bllod reviews. In press. }\
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3\margtsxn666\margbsxn293\pard\li3506\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li35
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\pard\li3506\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li3506\ri0\sl-213\slmult0 \fs
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lmult0 \fs36\cf0\f0\charscalex100\b {Demam Tanpa}\b0 \par\pard\li3053\ri0\sl-453
\slmult0 \fs36\cf0\f0\charscalex100\b {Penyebab yang Jelas}\b0 \par\pard\li893\r
i0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard
\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\
par\pard\li893\ri0\sl-440\slmult0 \fs22\cf0\f0\charscalex100 {Demam tanpa penyeb
ab yang jelas adalah gejala demam akut dengan penyebab yang}\par\pard\li893\ri0\
sl-266\slmult0 \fs20\cf0\f0\charscalex100 {tidak jelas sesudah anamnesis dan pem
eriksaan fisis secara teliti dalam periode demam}\par\pard\li893\ri0\sl-266\slmu
lt0 \fs22\cf0\f0\charscalex100 {kurang dari 7 hari. Demam adalah keadaan dimana
suhu rektal > 38}\fs12\cf0\f0\charscalex100 {0}\fs22\cf0\f0\charscalex100 {C.}\p
ar\pard\li893\ri0\sl-413\slmult0 \fs20\cf0\f0\charscalex100 {Demam pada anak mer
upakan 15% dari kunjungan pasien di Poliklinik dan 10% kunjungan}\par\pard\li893
\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {di Unit Gawat Darurat. Sebagian
besar anak berumur kurang dari 3 tahun. Umumnya}\par\pard\li893\ri0\sl-266\slmul
t0 \fs20\cf0\f0\charscalex100 {penyebab demam diidentifikasi berdasarkan anamnes
is dan pemeriksaan fisis. Demam}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\
charscalex100 {pada anak umumnya disebabkan oleh virus yang dapat sembuh sendiri
, tetapi sebagian}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100
{kecil dapat berupa infeksi bakteri serius seperti meningitis bakterialis, bakt
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a bakterialis, infeksi saluran kemih, enteritis bakteri, infeksi tulang dan send
i.}\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult
0 \fs18\cf0\par\pard\li893\ri0\sl-373\slmult0 \fs26\cf0\f0\charscalex100\b {Diag
nosis}\b0 \par\pard\li893\ri0\sl-426\slmult0 \fs22\cf0\f0\charscalex100\b {Anamn
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22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Adanya gejala:}\par\
pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22
\cf0\f0\charscalex100 {nyeri menelan}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx13
46\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {nyeri telinga}\
par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \
fs22\cf0\f0\charscalex100 {batuk, sesak napas}\par\pard\li1146\ri0\sl-266\slmult
0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {muntah
, diare}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100
{-}\tab \fs22\cf0\f0\charscalex100 {nyeri/menangis waktu buang air kecil}\par\pa
rd\li893\ri0\sl-426\slmult0 \fs22\cf0\f0\charscalex100\b {Pemeriksaan fisis}\b0
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20.000/l.}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {Catatan
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b \fs22\cf0\f0\charscalex100 {Pada anak dengan suhu 39}\fs12\cf0\f0\charscalex10

0 {0}\fs22\cf0\f0\charscalex100 {C disertai hitung jenis leukosit tidak terlalu
tinggi, }\par\pard\li1346\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {tidak d
isertai distres respirasi, takipne, ronki atau suara napas melemah maka}\par\
pard\li1346\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {kemungkinan pneumonia
dapat disingkirkan}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\ch
arscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Umur dapat dipakai sebagai predi
ksi penyebab pneumonia}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0
\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Pneumonia oleh virus paling b
anyak dijumpai pada umur 2 tahun pertama}\par\pard\li1146\ri0\sl-266\slmult0 \*\
tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Foto dada s
ering kali tidak selalu membantu dalam menentukan diagnosis}\par\pard\li1346\ri0
\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {pneumonia}\par\pard\li1146\ri0\sl-26
6\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100
{Pneumonia dan bakteremia jarang terjadi bersamaan (< 3%)}\par\pard\li906\ri0\s
l-213\slmult0 \fs18\cf0\par\pard\li906\ri0\sl-280\slmult0 \*\tx1146\fs22\cf0\f0\
charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 { Gastroenteritis (GE) bakteria
l}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\ta
b \fs22\cf0\f0\charscalex100 {Umumnya ditandai dengan muntah dan diare}\par\pard
\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0
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lt0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Buan
g air besar darah lendir biasanya karena GE bakterial}\par\pard\li906\ri0\sl-213
\slmult0 \fs18\cf0\par\pard\li906\ri0\sl-306\slmult0 \*\tx1146\fs22\cf0\f0\chars
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fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Pemeriksaan fisis:
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}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs20\cf0\f0\charscalex100 {-}\tab
\fs20\cf0\f0\charscalex100 {Untuk mendeteksi bakteremia tersembunyi hitung neutr
ofil absolut lebih sensitif}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\cha
rscalex100 {dari hitung leukosit atau batang absolut }\par\pard\li906\ri0\sl-26
6\slmult0 \*\tx1146\fs20\cf0\f0\charscalex100 {-}\tab \fs20\cf0\f0\charscalex100
{Hitung absolut neutrofil > 10.000/l meningkatkan risiko bakteremia menjadi}\par
\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {8-10%
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d\li906\ri0\sl-266\slmult0 \*\tx1146\fs20\cf0\f0\charscalex100 {-}\tab \fs20\cf0
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bakteremia dapat}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100
{berkembang menjadi infeksi bakteri yang berat, terutama pada anak yang terliha
t}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {sakit berat}\p
ar\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-426\slmult0 \fs
26\cf0\f0\charscalex100\b {Tata laksana}\b0 \par\pard\li893\ri0\sl-426\slmult0 \
fs22\cf0\f0\charscalex100\b {Medikamentosa}\b0 \par\pard\li906\ri0\sl-306\slmult
0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Anak y
ang tidak tampak sakit tidak perlu pemeriksaan laboratorium maupun dirawat}\par\

pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {dan tidak perlu diber

i antibiotik}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex
100 {-}\tab \fs22\cf0\f0\charscalex100 {Apabila dari anamnesis, pemeriksaan fisi
s, dan laboratorium menunjukkan hasil risiko}\par\pard\li1146\ri0\sl-266\slmult0
\fs20\cf0\f0\charscalex100 {tinggi untuk terjadinya bakteremia tersembunyi, ha
rus segera diberikan antibiotik}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0
\charscalex100 {setelah pengambilan sediaan untuk biakan}\par\pard\li906\ri0\sl266\slmult0 \*\tx1146\fs20\cf0\f0\charscalex100 {-}\tab \fs20\cf0\f0\charscalex1
00 {Catatan: terutama bila hitung leukosit > 15.000/l atau hitung total neutrofil
absolut}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {> 10.00
0/l}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\ta
b \fs22\cf0\f0\charscalex100 {Pemberian antibiotik secara empirik harus memperhi
tungkan kemungkinan}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex1
00 {peningkatan resistensi bakteri}\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\
par\pard\li893\ri0\sl-320\slmult0 \fs22\cf0\f0\charscalex100\b {Antibiotik pilih
an}\b0 \par\pard\li893\ri0\sl-306\slmult0 \fs22\cf0\f0\charscalex100 {Secara emp
irik antara lain:}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\chars
calex100 {-}\tab \fs22\cf0\f0\charscalex100 {Amoksisilin 60 \uc1\u8211X100 mg/kg
bb/hr atau}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex10
0 {-}\tab \fs22\cf0\f0\charscalex100 {Seftriakson 50 \uc1\u8211X75 mg/kgbb/hr ma
ksimum 2 g/hr}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscale
x100 {-}\tab \fs22\cf0\f0\charscalex100 {Bila alergi terhadap kedua obat tersebu
t, pilih obat lain sesuai dengan hasil uji}\par\pard\li1146\ri0\sl-266\slmult0
\fs22\cf0\f0\charscalex100 {resistensi bila perlu rujuk ke Dokter Spesialis Kons
ultan Infeksi dan Penyakit Tropis}\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\p
ar\pard\li893\ri0\sl-346\slmult0 \fs22\cf0\f0\charscalex100\b {Indikasi rawat}\b
0 \par\pard\li906\ri0\sl-306\slmult0 \*\tx1146\fs20\cf0\f0\charscalex100 {-}\tab
\fs20\cf0\f0\charscalex100 {Anak dengan risiko rendah dan orangtua yang koopera
tif dapat berobat jalan dengan}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\
charscalex100 {pengamatan setiap hari sampai demam turun}\par\pard\li906\ri0\sl266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex1
00 {Demam sebagai prediktor bakteremia tersembunyi}\par\pard\li906\ri0\sl-266\sl
mult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {39
,0 - 39,4}\fs12\cf0\f0\charscalex100 {0}\fs22\cf0\f0\charscalex100 {C: < 2%}\pa
r\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs
22\cf0\f0\charscalex100 {39,4 - 40,0}\fs12\cf0\f0\charscalex100 {0}\fs22\cf0\f0\
charscalex100 {C: 2-3%}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f
0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {40,0 - 40,5}\fs12\cf0\f0\cha
rscalex100 {0}\fs22\cf0\f0\charscalex100 {C: 3-4%}\par\pard\li1146\ri0\sl-266\s
lmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {4
0,5}\fs12\cf0\f0\charscalex100 {0}\fs22\cf0\f0\charscalex100 {C: 4-5%}\par\pard
\li6480\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li6480\ri0\sl-373\slmult0 \*\tx832
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lmult0 \fs36\cf0\f0\charscalex100\b {Demam Tifoid}\b0 \par\pard\li893\ri0\sl-213
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0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\
li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-280\slmult0 \fs22\cf0\f
0\charscalex100 {Demam tifoid merupakan penyakit endemis di Indonesia yang diseb
abkan oleh infeksi}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100
{sistemik}{ }\fs22\cf0\f0\charscalex100\i {Salmonella typhi}\i0 \fs22\cf0\f0\ch
arscalex100 {. Prevalens 91% kasus demam tifoid terjadi pada umur 3-19}\par\par
d\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {tahun, kejadian meningkat
setelah umur 5 tahun. Pada minggu pertama sakit, demam}\par\pard\li893\ri0\sl-2
66\slmult0 \fs20\cf0\f0\charscalex100 {tifoid sangat sukar dibedakan dengan peny
akit demam lainnya sehingga untuk memastikan}\par\pard\li893\ri0\sl-266\slmult0
\fs22\cf0\f0\charscalex100 {diagnosis diperlukan pemeriksaan biakan kuman untuk
konfirmasi.}\par\pard\li893\ri0\sl-400\slmult0 \*\tx7200\fs20\cf0\f0\charscalex1
00 {Sembilan puluh enam persen (96%) kasus demam tifoid disebabkan}\tab \fs18\cf
0\f0\charscalex100\i {S. typhi}\i0 \fs20\cf0\f0\charscalex100 {, sisanya}\par\
pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {disebabkan oleh}{ }\fs
16\cf0\f0\charscalex100\i {S. paratyphi. }\i0 { }\fs20\cf0\f0\charscalex100 {Ku
man masuk melalui makanan/minuman, setelah melewati}\par\pard\li893\ri0\sl266\slmult0 \fs20\cf0\f0\charscalex100 {lambung kuman mencapai usus halus (ileum
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harscalex100\i {plaque}\i0 { }\fs20\cf0\f0\charscalex100 {Peyeri). Kuman ikut al
iran limfe mesenterial ke}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charsc
alex100 {dalam sirkulasi darah (bakteremia primer) mencapai jaringan RES (hepar,
lien, sumsum tulang}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex1
00 {untuk bermultiplikasi). Setelah mengalami bakteremia sekunder, kuman mencapa

i sirkulasi}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {darah

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ari.}\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmu
lt0 \fs18\cf0\par\pard\li893\ri0\sl-400\slmult0 \fs26\cf0\f0\charscalex100\b {Di
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0 {-}\tab \fs20\cf0\f0\charscalex100 {Demam naik secara bertahap tiap hari, menc
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cf0\f0\charscalex100 {pertama, minggu kedua demam terus menerus tinggi}\par\pard
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f0\charscalex100 {Anak sering mengigau (delirium), malaise, letargi, anoreksia,
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00 {Pada demam tifoid berat dapat dijumpai penurunan kesadaran, kejang, dan ikte
rus}\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-360\slmul
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\pard\li2746\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li2746\ri0\sl-213\slmult0 \fs
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lmult0 \fs36\cf0\f0\charscalex100\b {Diabetes MelitusTipe-1}\b0 \par\pard\li893\
ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\par
d\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0
\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-280\slmult0 \
fs22\cf0\f0\charscalex100 {Diabetes melitus (DM) adalah penyakit metabolik yang
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0\f0\charscalex100 {akibat adanya gangguan pada sekresi insulin, kerja insulin,
atau keduanya. Hal ini mengakibatkan}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf
0\f0\charscalex100 {terjadinya gangguan metabolisme karbohidrat, lemak, dan prot
ein. Diabetes melitus tipe 1 }\par\pard\li893\ri0\sl-293\slmult0 \fs22\cf0\f0\ch
arscalex100 {(DMT1) terjadi akibat kerusakan sel}{ }\fs22\cf0\f0\charscalex100 {
\uc1\u946X}\fs22\cf0\f0\charscalex100 {-pankreas sehingga terjadi defisiensi ins
ulin secara}\par\pard\li893\ri0\sl-280\slmult0 \fs22\cf0\f0\charscalex100 {absol
ut. Proses kerusakan sel}{ }\fs22\cf0\f0\charscalex100 {\uc1\u946X}\fs22\cf0\f0
\charscalex100 {-pankreas dapat terjadi akibat proses autoimun maupun}\par
\pard\li893\ri0\sl-293\slmult0 \fs22\cf0\f0\charscalex100 {penyebab lain yang ti
dak diketahui (idiopatik). Hal ini tidak termasuk kerusakan}{ }\fs22\cf0\f0\char
scalex100 {\uc1\u946X}\fs22\cf0\f0\charscalex100 {-pankreas}\par\pard\li893\ri0\
sl-266\slmult0 \fs22\cf0\f0\charscalex100 {yang disebabkan oleh keadaan khusus s
eperti}{ }\fs18\cf0\f0\charscalex100\i {cystic fibrosis}\i0 { }\fs22\cf0\f0\char
scalex100 {dan defek mitokondria.}\par\pard\li893\ri0\sl-320\slmult0 \fs20\cf0\f
0\charscalex100 {Secara global DMT1 ditemukan pada 90% dari seluruh diabetes pad
a anak dan remaja. }\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex10
0 {Di Indonesia insidens tercatat semakin meningkat dari tahun ke-tahun, teruta
ma dalam}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {5 tahun
terakhir. Jumlah penderita baru meningkat dari 23 orang per tahun di tahun}\par\
pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {2005 menjadi 48 orang

per tahun di tahun 2009.}\par\pard\li893\ri0\sl-413\slmult0 \fs22\cf0\f0\charsca

lex100 {Untuk penderita baru DMT1 terdapat 3 pola gambaran klinis saat awitan: k
lasik, }\fs18\cf0\f0\charscalex100\i {silent diabetes, }\i0 \par\pard\li893\ri0\
sl-266\slmult0 \fs20\cf0\f0\charscalex100 {dan ketoasidosis diabetik (KAD). Di n
egara-negara dengan kewaspadaan tinggi terhadap DM, }\par\pard\li893\ri0\sl-266\
slmult0 \fs22\cf0\f0\charscalex100 {bentuk klasik paling sering dijumpai di klin
ik dibandingkan bentuk yang lain. Di Indonesia 33,3}\par\pard\li893\ri0\sl-266\s
lmult0 \fs22\cf0\f0\charscalex100 {% penderita baru DMT1 didiagnosis dalam bentu
k KAD, sedangkan bentuk}{ }\fs18\cf0\f0\charscalex100\i {silent diabetes}\i0 \pa
r\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {paling jarang dijump
ai; biasanya diketahui karena skrining/penelitian atau pemeriksaan khusus}\par\p
ard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {karena salah seorang ke
luarga penderita telah menderita DMT1 sebelumnya.}\par\pard\li893\ri0\sl-213\slm
ult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl
-373\slmult0 \fs26\cf0\f0\charscalex100\b {Diagnosis}\b0 \par\pard\li893\ri0\sl413\slmult0 \fs22\cf0\f0\charscalex100\b {Anamnesis}\b0 \par\pard\li893\ri0\sl-3
06\slmult0 \fs22\cf0\f0\charscalex100 {Bentuk klasik:}\par\pard\li906\ri0\sl-266
\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100
{Polidipsi, poliuri, polifagi. Poliuria biasanya tidak diutarakan secara lang
sung oleh}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {orangt
ua kepada dokter, yang sering dikeluhkan adalah anak sering mengompol, }\par\pa
rd\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {mengganti popok terlalu
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\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {tertutup popok, dan anak terlihat de
hidrasi.}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100
{-}\tab \fs22\cf0\f0\charscalex100 {Penurunan berat badan yang nyata dalam waktu
2-6 minggu disertai keluhan lain yang}\par\pard\li1146\ri0\sl-266\slmult0 \fs22
\cf0\f0\charscalex100 {tidak spesifik}\par\pard\li906\ri0\sl-266\slmult0 \*\tx11
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r\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {Pada kasus KAD: }\pa
r\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs2
2\cf0\f0\charscalex100 {Awitan gejala klasik yang cepat dalam waktu beberapa har
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rd\li893\ri0\sl-466\slmult0 \fs22\cf0\f0\charscalex100\b {Pemeriksaan fisis dan
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alex100 {-}\tab \fs22\cf0\f0\charscalex100 {Tanpa disertai tanda gawat darurat}\
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badan kronik}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscal
ex100 {-}\tab \fs22\cf0\f0\charscalex100 {\uc1\u8220XIrritable\uc1\u8221X dan pe
nurunan prestasi sekolah}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\
f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Infeksi kulit berulang}\par
\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs2
2\cf0\f0\charscalex100 {Kandidiasis vagina terutama pada anak wanita prepubertas
}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab
\fs22\cf0\f0\charscalex100 {Gagal tumbuh}\par\pard\li1146\ri0\sl-266\slmult0 \*
\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Berbeda de
ngan DMT2 yang biasanya cenderung gemuk, anak-anak DMT1 biasanya}\par\pard\li134
6\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {kurus}\par\pard\li906\ri0\sl-32
0\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100
{Disertai tanda gawat darurat (KAD \uc1\u8211X dibahas pada bab tersendiri)}\pa
r\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs
22\cf0\f0\charscalex100 {Penurunan berat badan yang nyata dalam waktu cepat}\par
\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs2

2\cf0\f0\charscalex100 {Nyeri perut dan muntah berulang}\par\pard\li1146\ri0\sl266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex1

00 {Dehidrasi sedang sampai berat namun anak masih poliuria}\par\pard\li1146\ri0
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lex100 {Sesak napas, napas cepat dan dalam (Kussmaul) disertai bau aseton}\par\p
ard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\
cf0\f0\charscalex100 {Gangguan kesadaran}\par\pard\li1146\ri0\sl-266\slmult0 \*\
tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Renjatan}\p
ar\pard\li906\ri0\sl-333\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs
22\cf0\f0\charscalex100 {Kondisi yang sulit didiagnosis (sering menyebabkan kete
rlambatan diagnosis KAD)}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\
f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Pada bayi atau anak <2-3 ta
hun}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\
tab \fs22\cf0\f0\charscalex100 {Hiperventilasi: sering didiagnosis awal sebagai
pneumonia atau asma berat}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0
\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Nyeri perut: sering dikira
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charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Poliuri dan enuresis: sering d
idiagnosis awal sebagai infeksi saluran kemih}\par\pard\li1146\ri0\sl-266\slmult
0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Polidi
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-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex
100 {Muntah berulang: sering didiagnosis awal sebagai gastroenteritis}\par\pard\
li906\ri0\sl-333\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f
0\charscalex100 {Harus dicurigai sebagai DMT2}\par\pard\li1693\ri0\sl-266\slmult
0 \fs20\cf0\f0\charscalex100 {Adanya gejala klinis poliuri, polidipsi, dan polif
agi yang disertai dengan hal-hal di}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf
0\f0\charscalex100 {bawah ini harus dicurigai sebagai DMT2:}\par\pard\li1146\ri0
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lex100 {Obesitas}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\chars
calex100 {-}\tab \fs22\cf0\f0\charscalex100 {Usia remaja (>10 tahun)}\par\pard\l
i1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f
0\charscalex100 {Adanya riwayat keluarga DMT2}\par\pard\li1146\ri0\sl-266\slmult
0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Penand
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\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Kadar C-peptida normal atau t
inggi}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {}\tab \fs22\cf0\f0\charscalex100 {Ras atau etnik tertentu (Pima \uc1\u8211X Indi
an, Arab)}\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-320
\slmult0 \fs22\cf0\f0\charscalex100\b {Pemeriksaan penunjang}\b0 \par\pard\li906
\ri0\sl-306\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\cha
rscalex100 {Kadar gula darah sewaktu: }\fs22\cf0\f0\charscalex100 {>200 mg/dL (1
1,1 mmol/L). Pada penderita asimtomatis}\par\pard\li1146\ri0\sl-266\slmult0 \fs2
2\cf0\f0\charscalex100 {ditemukan kadar gula darah puasa lebih tinggi dari norma
l dan uji toleransi glukosa}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\cha
rscalex100 {terganggu pada lebih dari satu kali pemeriksaan.}\par\pard\li906\ri0
\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charsca
lex100 {Kadar gula darah puasa: }\fs22\cf0\f0\charscalex100 {>126 mg/dL (yang di
maksud puasa adalah tidak ada asupan}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\c
f0\f0\charscalex100 {kalori selama 8 jam).}\par\pard\li906\ri0\sl-266\slmult0 \*
\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Kadar gula
darah 2 jam pasca toleransi glukosa: }\fs22\cf0\f0\charscalex100 {>200 mg/dL (1
1,1 mmol/L).}\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-346\slmult0 \fs22\cf0\f0\charscalex1
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manfaat}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {untuk me
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ar\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {menilai perubahan
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6\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {DM dengan tujuan mencegah terja
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\*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Penanda
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par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {hasil pemeriksaan
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ard\li893\ri0\sl-400\slmult0 \fs26\cf0\f0\charscalex100\b {Tata laksana}\b0 \par
\pard\li893\ri0\sl-346\slmult0 \fs22\cf0\f0\charscalex100 {Diabetes mellitus tip
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cf0\f0\charscalex100 {keluarga harus terus menerus dilakukan. Penatalaksanaan di
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r\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-320\slmult0 \fs2
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n.}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs20\cf0\f0\charscalex100 {-}\ta
b \fs20\cf0\f0\charscalex100 {Jenis insulin berdasar lama kerjanya yang bisa dig
unakan: ultrapendek, pendek, }\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0
\charscalex100 {menengah, panjang, dan mix (campuran menengah-pendek).}\par\pard
\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\
f0\charscalex100 {Dosis anak bervariasi berkisar anatara 0,7 \uc1\u8211X 1,0 U/k
g/hari. Dosis insulin ini berkurang}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf
0\f0\charscalex100 {sedikit pada waktu remisi dan kemudian meningkat pada saat p
ubertas. Pada follow up}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charsca
lex100 {selanjutnya dosis dapat disesuaikan dengan hasil monitoring glukosa dara
h harian.}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100
{-}\tab \fs22\cf0\f0\charscalex100 {Saat awal pengobatan insulin diberikan 3\uc
1\u8211X4 kali injeksi (kerja pendek). Setelah}\par\pard\li1146\ri0\sl-266\slmu
lt0 \fs22\cf0\f0\charscalex100 {diperoleh dosis optimal diusahakan untuk memberi
kan regimen insulin yang sesuai}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0
\charscalex100 {dengan kondisi penderita.}\par\pard\li906\ri0\sl-266\slmult0 \*\
tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Regimen ins
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r\pard\li1146\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {tergantung dari: um
ur, lama menderita, gaya hidup (kebiasaan makan, jadwal latihan, }\par\pard\li11
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lmult0 \fs22\cf0\f0\charscalex100 {protein dan sumber energi dari lemak <30%.}\p
ar\pard\li973\ri0\sl-266\slmult0 \*\tx1146\fs18\cf0\f0\charscalex100 { -}\tab \f
s20\cf0\f0\charscalex100 {Jadwal: 3 kali makan utama dan 3 kali makanan kecil. T
idak ada pengaturan makan khusus }\par\pard\li1146\ri0\sl-266\slmult0 \fs20\cf0\
f0\charscalex100 {yang dianjurkan pada anak, tetapi pemberian makanan yan
g mengandung banyak serat}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\ch
arscalex100 {seperti buah, sayuran, dan sereal akan membantu mencegah lonjakan k
adar glukosa darah.}\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\
ri0\sl-320\slmult0 \fs22\cf0\f0\charscalex100\b {Olahraga}\b0 \par\pard\li906\ri
0\sl-306\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charsc
alex100 {Olahraga tidak memperbaiki kontrol metabolik, akan tetapi membantu meni
ngkatkan}\par\pard\li1146\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {jatidir
i anak, mempertahankan berat badan ideal, meningkatkan kapasitas kerja jantung,
}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {mengurangi terj
adinya komplikasi jangka panjang, membantu kerja metabolisme}\par\pard\li1146\r
i0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {tubuh sehingga dapat mengurangi ke
butuhan insulin.}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charsc
alex100 {-}\tab \fs22\cf0\f0\charscalex100 {Yang perlu diperhatikan dalam berola
hraga adalah pemantauan terhadap kemungkinan}\par\pard\li1146\ri0\sl-266\slmult0
\fs22\cf0\f0\charscalex100 {terjadinya hipoglikemia atau hiperglikemia saat ata
u pasca olahraga, sehingga mungkin}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0
\f0\charscalex100 {memerlukan penyesuaian dosis insulin.}\par\pard\li906\ri0\sl266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex1
00 {Jenis olahraga disesuaikan dengan minat anak. Pada umumnya terdiri dari pema
nasan}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {selama 10
menit, dilanjutkan 20 menit untuk latihan aerobik seperti berjalan atau}\par\par
d\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {bersepeda. Olahraga haru
s dilakukan paling sedikit 3 kali seminggu dan sebaiknya}\par\pard\li1146\ri0\sl
-266\slmult0 \fs22\cf0\f0\charscalex100 {dilakukan pada waktu yang sama untuk m
emudahkan pemberian insulin dan}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f
0\charscalex100 {pengaturan makan. Lama dan intensitas olahraga disesuaikan deng
an toleransi anak. }\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\cha
rscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Asupan cairan perlu ditingkatkan
sebelum, setelah, dan saat olahraga. }\par\pard\li893\ri0\sl-213\slmult0 \fs18\c

f0\par\pard\li893\ri0\sl-293\slmult0 \fs22\cf0\f0\charscalex100\b {Edukasi}\b0 \

par\pard\li906\ri0\sl-306\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \f
s22\cf0\f0\charscalex100 {Penyuluhan dan tata laksana merupakan bagian integral
terapi. Diabetes mellitus tipe}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\
charscalex100 {1 merupakan suatu life long disease. Keberhasilan untuk mencapai
normoglikemia}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {sa
ngat bergantung dari cara dan gaya hidup penderita/keluarga atau dinamika keluar
ga}\par\pard\li1146\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {sehingga peng
endalian utama metabolik yang ideal tergantung pada penderita sendiri. }\par\par
d\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {Kegiatan edukasi harus t
erus dilakukan oleh semua pihak, meliputi pemahaman dan}\par\pard\li1146\ri0\sl266\slmult0 \fs22\cf0\f0\charscalex100 {pengertian mengenai penyakit dan komplik
asinya serta memotivasi penderita dan}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\
cf0\f0\charscalex100 {keluarganya agar patuh berobat.}\par\pard\li906\ri0\sl-266
\slmult0 \*\tx1146\fs20\cf0\f0\charscalex100 {-}\tab \fs20\cf0\f0\charscalex100
{Edukasi pertama dilakukan selama perawatan di rumah sakit yang meliputi: }\par\
pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {pengetahuan dasar men
genai DM tipe 1 (terutama perbedaan mendasar dengan DM}\par\pard\li893\ri0\sl-21
3\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-440\slmult0 \fs22\cf0\f0\charscalex100
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3\margtsxn666\margbsxn293\pard\li1146\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li11
46\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1146\ri0\sl-213\slmult0 \fs18\cf0\par
\pard\li1146\ri0\sl-466\slmult0 \fs22\cf0\f0\charscalex100 {tipe lainnya mengena
i kebutuhan insulin), pengaturan makan, insulin (jenis, dosis, cara}\par\pard\li
1146\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {penyuntikan, penyimpanan, ef
ek samping, dan pertolongan pertama pada kedaruratan}\par\pard\li1146\ri0\sl-266
\slmult0 \fs22\cf0\f0\charscalex100 {medik akibat DM tipe 1 (hipoglikemia, pembe
rian insulin pada saat sakit). }\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs2
2\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Edukasi selanjutnya b
erlangsung selama konsultasi di poliklinik. Selain itu penderita}\par\pard\li114
6\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {dan keluarganya diperkenalkan d
engan sumber informasi yang banyak terdapat di}\par\pard\li1146\ri0\sl-266\slmul
t0 \fs22\cf0\f0\charscalex100 {perpustakaan, media massa maupun internet.}\par\p
ard\li893\ri0\sl-466\slmult0 \fs22\cf0\f0\charscalex100\b {Pemantauan mandiri}\b
0 \par\pard\li906\ri0\sl-306\slmult0 \*\tx1146\fs20\cf0\f0\charscalex100 {-}\tab
\fs20\cf0\f0\charscalex100 {Oleh karena DM tipe 1 merupakan penyakit kronik dan
memerlukan pengobatan}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscal
ex100 {seumur hidup, maka pasien serta keluarganya harus dapat melakukan pemanta
uan}\par\pard\li1146\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {kadar glukos
a darah serta penyakitnya di rumah. Hal ini diperlukan karena sangat}\par\pard\l
i1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {menunjang upaya pencapaian
normoglikemia. Pemantauan dapat dilakukan secara}\par\pard\li1146\ri0\sl-266\sl
mult0 \fs22\cf0\f0\charscalex100 {langsung (darah) dan secara tidak langsung (ur
in).}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\
tab \fs22\cf0\f0\charscalex100 {Pemeriksaan glukosa darah secara langsung lebih
tepat menggambarkan kadar glukosa}\par\pard\li1146\ri0\sl-266\slmult0 \fs20\cf0\
f0\charscalex100 {pada saat pemeriksaan. Pemeriksaan sebaiknya dilakukan secara
teratur pada saat}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100
{awal perjalanan penyakit, pada setiap penggantian dosis insulin, atau pada saa
t sakit.}\par\pard\li893\ri0\sl-453\slmult0 \fs22\cf0\f0\charscalex100\b {Indika
si rawat inap}\b0 \par\pard\li906\ri0\sl-306\slmult0 \*\tx1146\fs22\cf0\f0\chars
calex100 {-}\tab \fs22\cf0\f0\charscalex100 {Penderita baru (terutama <2 tahun)
yang memulai terapi insulin}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf
0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Ketoasidosis diabetikum (
KAD)}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\
tab \fs22\cf0\f0\charscalex100 {Dehidrasi sedang sampai berat}\par\pard\li906\ri
0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charsc
alex100 {Penderita dalam persiapan operasi dengan anestesi umum}\par\pard\li973\
ri0\sl-266\slmult0 \*\tx1146\fs20\cf0\f0\charscalex100 { -}\tab \fs22\cf0\f0\cha
rscalex100 {Hipoglikemia berat (kesalahan pemberian dosis insulin atau dalam kea
daan sakit berat)}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs20\cf0\f0\chars
calex100 {-}\tab \fs20\cf0\f0\charscalex100 {Keluarga penderita yang tidak siap

melakukan rawat jalan (memerlukan edukasi}\par\pard\li1146\ri0\sl-266\slmult0 \f

s22\cf0\f0\charscalex100 {perawatan mandiri)}\par\pard\li893\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li893\ri0\sl-520\slmult0 \fs26\cf0\f0\charscalex100\b {Kepust
akaan}\b0 \par\pard\li893\ri0\sl-293\slmult0 \*\tx1266\fs18\cf0\f0\charscalex100
{1. }\tab \fs18\cf0\f0\charscalex100 {UKK Endokrinologi Anak dan Remaja IDAI. D
ata registrasi diabetes mellitus tipe 1 tahun 2009.}\par\pard\li893\ri0\sl-240\s
lmult0 \*\tx1266\fs18\cf0\f0\charscalex100 {2. }\tab \fs18\cf0\f0\charscalex100
{UKK Endokrinologi Anak dan Remaja IDAI. Konsensus nasional pengelolaan diabetes
mellitus tipe-1}\par\pard\li1266\ri0\sl-226\slmult0 \fs18\cf0\f0\charscalex100
{di Indonesia. Jakarta: PP IDAI; 2009.}\par\pard\li893\ri0\sl-253\slmult0 \*\tx1
266\fs18\cf0\f0\charscalex100 {3. }\tab \fs18\cf0\f0\charscalex100 {American Dia
betes Association. Type 2 diabetes in children and adolescents. Diabetes Care.
}\par\pard\li1266\ri0\sl-213\slmult0 \fs18\cf0\f0\charscalex100 {2000;23:381-9.
}\par\pard\li893\ri0\sl-253\slmult0 \*\tx1266\fs18\cf0\f0\charscalex100 {4. }\ta
b \fs18\cf0\f0\charscalex100 {Bangstad HJ. Insulin treatment. Pediatr Diabet. 20
07:8:88\uc1\u8211X102.}\par\pard\li893\ri0\sl-240\slmult0 \*\tx1266\fs18\cf0\f0\
charscalex100 {5. }\tab \fs18\cf0\f0\charscalex100 {Australian Paediatric Endocr
ine Group. Clinical practice guidelines: type 1 diabetes in children and}\par\pa
rd\li1266\ri0\sl-226\slmult0 \fs18\cf0\f0\charscalex100 {adolescents. Australian
Government \uc1\u8211X National Health and Medical Research Council; 2005.}\par
\pard\li893\ri0\sl-240\slmult0 \*\tx1266\fs16\cf0\f0\charscalex100 {6. }\tab \fs
14\cf0\f0\charscalex100 {Sperling MA. Diabetes Mellitus. Dalam: Sperling MA, pen
yunting. Pediatric endocrinology. Philadelphia: }\par\pard\li1266\ri0\sl-226\slm
ult0 \fs18\cf0\f0\charscalex100 {Saunders; 2002. h. 323-60.}\par\pard\li893\ri0\
sl-253\slmult0 \*\tx1266\fs18\cf0\f0\charscalex100 {7. }\tab \fs16\cf0\f0\charsc
alex100 {Nancy AC, Lawrence MD. Definition, diagnosis, and classification of dia
betes in youth. Dalam: Dabelea}\par\pard\li1266\ri0\sl-213\slmult0 \fs18\cf0\f0\
charscalex100 {D, J Klingensmith G, penyunting. Epidemiology of pediatric and ad
olescent diabetes. NewYork: Informa}\par\pard\li1266\ri0\sl-226\slmult0 \fs18\cf
0\f0\charscalex100 {Healthcare; 2008. h.1-19.}\par\pard\li893\ri0\sl-240\slmult0
\*\tx1266\fs18\cf0\f0\charscalex100 {8. }\tab \fs18\cf0\f0\charscalex100 {Craig
ME. ISPAD Clinical practice consensus guidelines 2006\uc1\u8211X2007: definit
ion, epidemiology, and}\par\pard\li1266\ri0\sl-226\slmult0 \fs18\cf0\f0\charsc
alex100 {classification. Pediatr Diabet. 2006;7:343\uc1\u8211X51.}\par\pard\li64
80\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li6480\ri0\sl-213\slmult0 \fs18\cf0\par
\pard\li6480\ri0\sl-386\slmult0 \*\tx8320\fs12\cf0\f0\charscalex100\i {Pedoman P
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cf0\f0\charscalex100 {Haller MJ, Atkinson MA, Schatz D. Type 1 diabetes mellitus
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}\par\pard\li1266\ri0\sl-213\slmult0 \fs18\cf0\f0\charscalex100 {J Klingensmith
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orma}\par\pard\li1266\ri0\sl-226\slmult0 \fs18\cf0\f0\charscalex100 {Healthcare;

2008. h. 103-16.}\par\pard\li893\ri0\sl-240\slmult0 \fs18\cf0\f0\charscalex100
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ses tanggal 8}\par\pard\li1266\ri0\sl-213\slmult0 \fs18\cf0\f0\charscalex100 {Ok
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1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Tanda ganggua
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00 {Umur di atas 12 bulan: 30 mL/kgBB dalam jam pertama, dilanjutkan 70 mL/kgBB}
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0\sl-466\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charsc
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\fs22\cf0\f0\charscalex100 {Hipernatremia (Na >155 mEq/L)}\par\pard\li1373\ri0\s
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0\charscalex100 {dekstrose 5% salin. Penurunan kadar Na tidak boleh lebih dari 1
0 mEq per hari}\par\pard\li1373\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {k
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fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Hiponatremia (Na <
130 mEq/L)}\par\pard\li1373\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {Kadar
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\pard\li1373\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {hiponatremia dilakuk
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4 jam}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {}\tab \fs22\cf0\f0\charscalex100 {Hiperkalemia (K >5 mEq/L)}\par\pard\li1373\ri0
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fs22\cf0\f0\charscalex100 {Hipokalemia (K <3,5 mEq/L)}\par\pard\li1373\ri0\sl-26
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cf0\f0\charscalex100 { -}\tab \fs22\cf0\f0\charscalex100 {3,5 - kadar K terukur
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f0\charscalex100 {Umur di bawah 6 bulan: 10 mg per hari}\par\pard\li1146\ri0\sl266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex1
00 {Umur di atas 6 bulan: 20 mg per hari}\par\pard\li906\ri0\sl-480\slmult0 \*\t
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calex100 {dipuasakan, makanan diberikan sedikit-sedikit tapi sering (lebih kuran
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2\cf0\f0\charscalex100 {Antibiotik diberikan bila ada indikasi, misalnya disentr
i (diare berdarah) atau kolera. }\par\pard\li1373\ri0\sl-266\slmult0 \fs22\cf0\f
0\charscalex100 {Pemberian antibiotik yang tidak rasional akan mengganggu keseim
bangan flora usus}\par\pard\li1373\ri0\sl-266\slmult0 \*\tx7360\fs22\cf0\f0\char
scalex100 {sehingga dapat memperpanjang lama diare dan}{ }\fs18\cf0\f0\charscale
x100\i {Clostridium difficile}\i0 \tab \fs22\cf0\f0\charscalex100 {akan tumbuh}\
par\pard\li1373\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {yang menyebabkan
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ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {tidak rasional dapat mempercepat
resistensi kuman terhadap antibiotik. Untuk}\par\pard\li1373\ri0\sl-266\slmult0
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n data sensitivitas setempat, bila}\par\pard\li1373\ri0\sl-266\slmult0 \fs20\cf0
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100 {Antiparasit}\par\pard\li1373\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100

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par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {sangat haus, diar
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ren with acute diarrhea in India. N Engl J Med. }\par\pard\li1266\ri0\sl-213\sl
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6\slmult0 \fs20\cf0\f0\charscalex100 {bayi lahir. Pada bayi cukup bulan penutupa
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mult0 \fs22\cf0\f0\charscalex100 {bayi lahir dan secara lengkap dalam 2 s
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cf0\f0\charscalex100 {banyak dari laki-laki (3:1). Insidens makin bertambah deng
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arscalex100 {Kegagalan penutupan duktus pada bayi cukup bulan terjadi akibat kel
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i0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {kongestif, pneumonia berulang, pen

yakit obstruktif paru, dan endokarditis infektif.}\par\pard\li893\ri0\sl-213\slm
ult0 \fs18\cf0\par\pard\li893\ri0\sl-466\slmult0 \fs26\cf0\f0\charscalex100\b {D
iagnosis}\b0 \par\pard\li893\ri0\sl-413\slmult0 \fs22\cf0\f0\charscalex100\b {An
amnesis}\b0 \par\pard\li906\ri0\sl-306\slmult0 \*\tx1146\fs22\cf0\f0\charscalex1
00 {-}\tab \fs22\cf0\f0\charscalex100 {Gambaran klinis tergantung pada besarnya
pirau kiri ke kanan (dari aorta desenden}\par\pard\li1146\ri0\sl-266\slmult0 \fs
22\cf0\f0\charscalex100 {ke arteri pulmonalis)}\par\pard\li906\ri0\sl-266\slmult
0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Pada D
AP kecil pasien asimtomatik}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf
0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Pada DAP sedang, biasanya
gejala timbul pada usia 2 bulan atau lebih yang berupa}\par\pard\li1146\ri0\sl266\slmult0 \fs22\cf0\f0\charscalex100 {kesulitan makan, infeksi saluran napas b
erulang, tetapi berat badan masih dalam batas}\par\pard\li1146\ri0\sl-266\slmult
0 \fs22\cf0\f0\charscalex100 {normal atau sedikit berkurang}\par\pard\li906\ri0\
sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscal
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0\charscalex100\b {Pemeriksaan penunjang}\b0 \par\pard\li893\ri0\sl-373\slmult0
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i. Makin besar}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {pi
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t}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {memperlihatkan
arus kontinu dari aorta ke A. pulmonalis melalui DAP.}\par\pard\li893\ri0\sl-213
\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-533\slmult0 \fs26\cf0\f0\charscalex100\
b {Tata laksana}\b0 \par\pard\li893\ri0\sl-413\slmult0 \fs22\cf0\f0\charscalex10
0\b {Medikamentosa}\b0 \par\pard\li906\ri0\sl-306\slmult0 \*\tx1146\fs22\cf0\f0\
charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Pada neonatus prematur diberik
an indometasin atau ibuprofen oral atau IV dengan}\par\pard\li1146\ri0\sl-266\sl
mult0 \fs22\cf0\f0\charscalex100 {dosis dan cara pemberian bervariasi:}\par\pard
\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0
\f0\charscalex100 {Cara pertama adalah memberikan indometasin oral atau IV 0,2 m
g/kgBB sebagai}\par\pard\li1346\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {d
osis awal. Pada bayi <48 jam berikan dosis kedua dan ketiga sebesar 0,10 mg/}\pa
r\pard\li1346\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {kgBB dengan interva
l 24 jam. Pada bayi berusia 2-7 hari dosis kedua dan ketiga}\par\pard\li1346\ri0
\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {adalah 0,2 mg/kgBB, sedangkan pada b
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s22\cf0\f0\charscalex100 {0,25 mg/kgBB.}\par\pard\li1146\ri0\sl-266\slmult0 \*\t
x1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Cara lain ad
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1346\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {5-7 hari. Pemberian 5-7 har
i dianjurkan untuk mencegah pembukaan kembali}\par\pard\li1346\ri0\sl-266\slmult
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\par\pard\li1346\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {hari. Pada bayi
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1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Belakangan in
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fs22\cf0\f0\charscalex100 {adalah: }\par\pard\li1146\ri0\sl-266\slmult0 \*\tx134
6\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Prosedur pengoba
tan gigi (termasuk manipulasi jaringan gusi)}\par\pard\li1146\ri0\sl-266\slmult0
\*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Insisi
atau biopsi mukosa saluran napas (contohnya, tonsilektomi)}\par\pard\li1146\ri0\
sl-266\slmult0 \*\tx1346\fs20\cf0\f0\charscalex100 {-}\tab \fs20\cf0\f0\charscal
ex100 {Prosedur gastrointestinal atau traktus urinarius jika terdapat infeksi pa
da saluran}\par\pard\li1346\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {terse
but. Profilaksis tidak diperlukan untuk prosedur esofagogastroduonenoskopi}\par\
pard\li1346\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {atau kolonoskopi.}\pa
r\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs20\cf0\f0\charscalex100 {-}\tab \fs
20\cf0\f0\charscalex100 {Prosedur yang melibatkan kulit, struktur kulit atau jar
ingan muskuloskeletal yang}\par\pard\li1346\ri0\sl-266\slmult0 \fs22\cf0\f0\char
scalex100 {terinfeksi.}\par\pard\li893\ri0\sl-346\slmult0 \fs20\cf0\f0\charscale

x100 {Untuk profilaksis sebelum tindakan tersebut di atas, antibiotik diberikan

30-60 menit}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {sebel
umnya. Obat yang dianjurkan adalah amoksisilin 50 mg/kgBB oral dosis tunggal}\p
ar\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {atau ampisilin/cefa
zolin/ceftriakson 50 mg/kgBB IV/IM jika pasien tidak dapat minum}\par\pard\li893
\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {obat oral. Pada pasien yang aler
gi terhadap penisilin, dapat diberikan sefaleksin (50 mg/}\par\pard\li893\ri0\sl
-266\slmult0 \fs20\cf0\f0\charscalex100 {kgBB), klindamisin (20 mg/kgBB), azit
hromisin/klaritromisin (15 mgBB/kg) oral atau}\par\pard\li893\ri0\sl-266\slmult0
\fs22\cf0\f0\charscalex100 {sefazolin, klindamisin, seftriakson IM/IV.}\par\par
d\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-333\slmult0 \fs22\cf0
\f0\charscalex100\b {Penutupan tanpa pembedahan}\b0 \par\pard\li893\ri0\sl-306\s
lmult0 \fs22\cf0\f0\charscalex100 {Bila duktus tidak menutup dengan medikamentos
a (bayi prematur) atau pada bayi aterm, }\par\pard\li893\ri0\sl-266\slmult0 \fs2
2\cf0\f0\charscalex100 {setelah usia 3 bulan, penutupan dapat dilakukan dengan p
emasangan}{ }\fs22\cf0\f0\charscalex100\i {device}\i0 { }\fs22\cf0\f0\charscalex
100\i {(coil}\i0 \fs22\cf0\f0\charscalex100 { atau}\par\pard\li893\ri0\sl-266\sl
mult0 \fs22\cf0\f0\charscalex100\i {Amplatzer Ductal Occluder)}\i0 \fs22\cf0\f0\
charscalex100 { secara transkateter. Anjuran saat ini adalah DAP kecil (<3}\par\
pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {mm) ditutup dengan Gia
nturco}{ }\fs22\cf0\f0\charscalex100\i {stainless coil}\i0 \fs22\cf0\f0\charscal
ex100 {, sedangkan untuk DAP sedang dan besar}\par\pard\li893\ri0\sl-266\slmult0
\fs22\cf0\f0\charscalex100 {(4-10 mm) ditutup dengan}{ }\fs20\cf0\f0\charscalex
100\i {Amplatzer ductal occluder}\i0 \fs22\cf0\f0\charscalex100 { (ADO). Biasany
a ADO dilakukan}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {j
ika BB >6 kg sedangkan}{ }\fs22\cf0\f0\charscalex100\i {coil}\i0 \fs22\cf0\f0\ch
arscalex100 { dapat dilakukan jika BB >4 kg (Gambar 1).}\par\pard\li893\ri0\sl-2
13\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-346\slmult0 \fs22\cf0\f0\charscalex10
0\b {Penutupan dengan pembedahan}\b0 \par\pard\li906\ri0\sl-306\slmult0 \*\tx114
6\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Pada neonatus (p
rematur atau cukup bulan) dengan gagal jantung, penutupan DAP}\par\pard\li1146\r
i0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {dengan pembedahan harus dilakukan
secepatnya.}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex1
00 {-}\tab \fs22\cf0\f0\charscalex100 {Pada bayi tanpa gagal jantung, tindakan
intervensi dapat ditunda sampai mencapai}\par\pard\li1146\ri0\sl-266\slmult0 \fs
22\cf0\f0\charscalex100 {berat badan ideal (di atas 6 kg). Tindakan dapat dilaku
kan kapan saja, tetapi jika bayi}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f
0\charscalex100 {mengalami gagal jantung, hipertensi pulmonal, atau pneumonia
berulang, operasi}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex10
0 {harus dilakukan sesegera mungkin. Intervensi bedah perlu dilakukan apabila be
ntuk}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {anatomis DA
P tidak memungkinkan untuk dilakukan pemasangan}{ }\fs22\cf0\f0\charscalex100\i
{device.}\i0 \par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex
100 {-}\tab \fs22\cf0\f0\charscalex100 {Pada pasien anak/dewasa bila belum terja
di hipertensi pulmonal, maka langsung}\par\pard\li1146\ri0\sl-266\slmult0 \fs22
\cf0\f0\charscalex100 {dilakukan tindakan intervensi penutupan duktus.}\par\pard
\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\
f0\charscalex100 {Penutupan duktus tidak dikerjakan apabila telah terjadi hipert
ensi pulmonal yang}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex10
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d\li6480\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li6480\ri0\sl-373\slmult0 \*\tx83
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{\sp{\sn fFillOK}{\sv 1}}
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{\sp{\sn lineWidth}{\sv 10021}}

{\sp{\sn lineColor}{\sv 526342}}
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{\sp{\sn pSegmentInfo}{\sv 2;12;16384;45824;1;45824;1;45824;1;45824;1;45824;2457

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{\sp{\sn shapePath}{\sv 4}}

{\sp{\sn pVerticies}{\sv 8;5;(0,0);(0,706);(1133,706);(1133,0);(0,0);}}
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{\sp{\sn shapeType}{\sv 0}}

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{\sp{\sn rotation}{\sv 0}}

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{\sp{\sn lineDashing}{\sv 0}}

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3\margtsxn666\margbsxn293\pard\li3866\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li38
66\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li3866\ri0\sl-213\slmult0 \fs18\cf0\par
\pard\li3866\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li3866\ri0\sl-213\slmult0 \fs
18\cf0\par\pard\li3866\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li3866\ri0\sl-533\s
lmult0 \fs36\cf0\f0\charscalex100\b {Ensefalitis}\b0 \par\pard\li893\ri0\sl-213\
slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0
\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\l
i893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-280\slmult0 \fs22\cf0\f0
\charscalex100 {Ensefalitis adalah infeksi jaringan otak yang dapat disebabkan o
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\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {sisa pada pasien yang
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ensefalitis herpes simpleks dan varisela}\par\pard\li893\ri0\sl-266\slmult0 \fs
22\cf0\f0\charscalex100 {yang dapat diobati. }\par\pard\li893\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li893\ri0\sl-520\slmult0 \fs26\cf0\f0\charscalex100\b {Diagn
osis}\b0 \par\pard\li893\ri0\sl-360\slmult0 \fs22\cf0\f0\charscalex100\b {Anamne
sis}\b0 \par\pard\li906\ri0\sl-306\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {
-}\tab \fs22\cf0\f0\charscalex100 {Demam tinggi mendadak, sering ditemukan hiper
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{-}\tab \fs22\cf0\f0\charscalex100 {Penurunan kesadaran dengan cepat. Anak agak
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cf0\f0\charscalex100 {ensefalopati, kejang, dan kesadaran menurun.}\par\pard\li9
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harscalex100 {Kejang bersifat umum atau fokal, dapat berupa status konvulsivus.
Dapat ditemukan}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {
sejak awal ataupun kemudian dalam perjalanan penyakitnya. }\par\pard\li893\ri0\s
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cf0\f0\charscalex100 {-}\tab \fs20\cf0\f0\charscalex100 {Seringkali ditemukan hi
perpireksia, kesadaran menurun sampai koma dan kejang. }\par\pard\li1146\ri0\sl
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}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab

\fs22\cf0\f0\charscalex100 {Ditemukan gejala peningkatan tekanan intrakranial.
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scalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Gejala serebral lain dapat beranek
a ragam, seperti kelumpuhan tipe}\tab \fs22\cf0\f0\charscalex100\i {upper}\i0 \
tab \fs22\cf0\f0\charscalex100\i {motor}\i0 \par\pard\li1146\ri0\sl-266\slmult0
\fs22\cf0\f0\charscalex100\i {neuron}\i0 \fs22\cf0\f0\charscalex100 { (spastis,
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harscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Darah perifer lengkap. Pemerik
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harscalex100 {dosis tinggi metil-prednisolon 15 mg/kg/hari dibagi setiap 6 jam s

elama 3 \uc1\u8211X 5 hari dan}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\c
harscalex100 {dilanjutkan prednison oral 1 \uc1\u8211X 2 mg/kg/hari selama 7 \uc
1\u8211X 10 hari.}\par\pard\li893\ri0\sl-400\slmult0 \fs22\cf0\f0\charscalex100
{Jika keadaan umum pasien sudah stabil, dapat dilakukan konsultasi ke Departeme
n}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {Rehabilitasi Me
dik untuk mobilisasi bertahap, mengurangi spastisitas, serta mencegah}\par\pard\
li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {kontraktur. }\par\pard\li89
3\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-373\slmult0 \fs22\cf0\f0\ch
arscalex100\b {Pemantauan pasca rawat}\b0 \par\pard\li893\ri0\sl-306\slmult0 \fs
20\cf0\f0\charscalex100 {Gejala sisa yang sering ditemukan adalah gangguan pengl
ihatan, palsi serebral, epilepsi, }\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\
f0\charscalex100 {retardasi mental maupun gangguan perilaku. Pasca rawat pasien
memerlukan pemantauan}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex
100 {tumbuh-kembang, jika terdapat gejala sisa dilakukan konsultasi ke departeme
n terkait}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {(Rehabi
litasi medik, mata dll) sesuai indikasi. }\par\pard\li893\ri0\sl-213\slmult0 \fs
18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-373\slm
ult0 \fs26\cf0\f0\charscalex100\b {Kepustakaan}\b0 \par\pard\li893\ri0\sl-293\sl
mult0 \*\tx1266\fs18\cf0\f0\charscalex100 {1. }\tab \fs18\cf0\f0\charscalex100 {
Whitley RJ, Kimberlin DW. Viral encephalitis. Pediatr Rev. 1999;20:192-8.}\par\p
ard\li893\ri0\sl-253\slmult0 \*\tx1266\fs18\cf0\f0\charscalex100 {2. }\tab \fs18
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. }\tab \fs18\cf0\f0\charscalex100 {Bale JF. Viral infection of the nervous syst
em. Dalam: Swaiman KF, Ashwal S, Ferriero DM, penyunting. }\par\pard\li1266\ri0\
sl-213\slmult0 \fs18\cf0\f0\charscalex100 {Pediatric neurology principles and pr
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6\ri0\sl-226\slmult0 \fs18\cf0\f0\charscalex100 {1630.}\par\pard\li893\ri0\sl-21
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}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {dini dan waktu m
emulai pengobatan. Virus herpes simpleks tipe 1 umumnya ditemukan}\par\pard\li89
3\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {pada anak, sedangkan tipe 2 ban
yak ditemukan pada neonatus. }\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\p
ard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-373\slmult0 \fs26\c
f0\f0\charscalex100\b {Diagnosis}\b0 \par\pard\li893\ri0\sl-413\slmult0 \fs22\cf
0\f0\charscalex100\b {Anamnesis}\b0 \par\pard\li893\ri0\sl-306\slmult0 \fs22\cf0
\f0\charscalex100 {Ensefalitis herpes simplek dapat bersifat akut atau subakut.}
\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs20\cf0\f0\charscalex100 {-}\tab \
fs20\cf0\f0\charscalex100 {Fase prodromal menyerupai influensa, kemudian diikut
i dengan gambaran khas}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscal
ex100 {ensefalitis (demam tinggi, kejang, penurunan kesadaran).}\par\pard\li906\
ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\char
scalex100 {Sakit kepala, mual, muntah, atau perubahan perilaku.}\par\pard\li893\
ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-360\slmult0 \fs22\cf0\f0\char
scalex100\b {Pemeriksaan fisis}\b0 \par\pard\li893\ri0\sl-306\slmult0 \fs20\cf0\
f0\charscalex100 {Kesadaran menurun berupa sopor-koma sampai koma (40% kasus) da
n gejala}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {peningka
tan tekanan intrakranial. Hampir 80% memperlihatkan gejala neurologis fokal}\par
\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {berupa hemiparesis, p
aresis nervus kranialis, kehilangan lapangan penglihatan, afasia, dan}\par\pard\
li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {kejang fokal. Gejala serebr
al lain dapat beraneka ragam, seperti kelumpuhan tipe}{ }\fs22\cf0\f0\charscalex
100\i {upper}\i0 \par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100\i
{motor neuron}\i0 \fs22\cf0\f0\charscalex100 { (spastis, hiperrefleks, refleks
patologis, dan klonus). }\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\l
i893\ri0\sl-346\slmult0 \fs22\cf0\f0\charscalex100\b {Pemeriksaan penunjang}\b0
\par\pard\li906\ri0\sl-306\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \
fs22\cf0\f0\charscalex100 {Gambaran darah tepi tidak spesifik}\par\pard\li906\ri
0\sl-266\slmult0 \*\tx1146\fs20\cf0\f0\charscalex100 {-}\tab \fs20\cf0\f0\charsc
alex100 {Pemeriksaan cairan serebrospinal memperlihatkan jumlah sel meningkat (9
0%) yang}\par\pard\li1146\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {berkisa
r antara 10-1000 sel/mm3 dengan predominan limfosit. Pada 50% kasus dapat}\par\p
ard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {ditemukan sel darah me
rah. Protein meningkat sedikit sampai 100 mg/dl sedangkan}\par\pard\li1146\ri0\s
l-266\slmult0 \fs22\cf0\f0\charscalex100 {glukosa normal.}\par\pard\li906\ri0\sl
-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex
100 {Elektroensefalografi (EEG) dapat memperlihatkan gambaran yang khas, yaitu}{

}\fs22\cf0\f0\charscalex100\i {periodic}\i0 \par\pard\li1146\ri0\sl-266\slmult0

\*\tx2160\*\tx3280\*\tx4173\fs20\cf0\f0\charscalex100\i {lateralizing}\i0 \tab
\fs22\cf0\f0\charscalex100\i {epileptiform}\i0 \tab \fs22\cf0\f0\charscalex100\i
{discharge}\i0 \tab \fs22\cf0\f0\charscalex100 {atau perlambatan fokal di area
temporal atau}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {fr
ontotemporal. Sering juga EEG memperlihatkan gambaran perlambatan umum yang}\par
\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {tidak spesifik.}\par
\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18
\cf0\par\pard\li893\ri0\sl-373\slmult0 \fs22\cf0\f0\charscalex100 {70 }{ }\fs1
4\cf0\f0\charscalex100\i {Ensefalitis Herpes Simpleks}\i0 \par\pard\sect\sectd\s
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\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li906\ri0\sl-213\slmult0 \fs18\cf0\par\pa
rd\li906\ri0\sl-466\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs20\cf
0\f0\charscalex100\i {Computed tomography}\i0 \fs22\cf0\f0\charscalex100 { (}\fs
18\cf0\f0\charscalex100\i {CT-Scan}\i0 \fs22\cf0\f0\charscalex100 {) kepala teta
p normal dalam tiga hari pertama setelah}\par\pard\li1146\ri0\sl-266\slmult0 \fs
22\cf0\f0\charscalex100 {timbulnya gejala neurologi, kemudian lesi hipodens munc
ul di regio frontotemporal.}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\*\tx209
3\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {T2-}\fs22\cf0\f0
\charscalex100\i {weight}\i0 \tab \fs22\cf0\f0\charscalex100\i {magnetic resonan
ce imaging}\i0 \fs22\cf0\f0\charscalex100 { (}\fs22\cf0\f0\charscalex100\i {MRI
}\i0 \fs22\cf0\f0\charscalex100 {) dapat memperlihatkan lesi hiperdens}\par\pard
\li1146\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {di regio temporal paling
cepat dua hari setelah munculnya gejala. Dapat pula}\par\pard\li1146\ri0\sl-266
\slmult0 \fs20\cf0\f0\charscalex100 {memperlihatkan peningkatan intensitas signa
l pada daerah korteks dan substansia}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\c
f0\f0\charscalex100 {alba pada daerah temporal dan lobus frontalis inferior. }\p
ar\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs
18\cf0\f0\charscalex100\i {Polymerase chain reaction}\i0 \fs22\cf0\f0\charscalex
100 { (}\fs20\cf0\f0\charscalex100\i {PCR}\i0 \fs22\cf0\f0\charscalex100 {) liku
or dapat mendeteksi titer antibodi virus herpes}\par\pard\li1146\ri0\sl-266\slmu
lt0 \fs22\cf0\f0\charscalex100 {simpleks (VHS) dengan cepat. }\fs20\cf0\f0\chars
calex100\i {PCR}\i0 \fs22\cf0\f0\charscalex100 { menjadi positif segera setelah
timbulnya gejala dan}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex
100 {pada sebagian besar kasus tetap positif selama 2 minggu atau lebih.}\par\pa
rd\li906\ri0\sl-266\slmult0 \*\tx1146\fs20\cf0\f0\charscalex100 {-}\tab \fs20\cf
0\f0\charscalex100 {Pemeriksaan titer serum darah terhadap IgG - IgM HSV-1 dan
HSV-2 dapat menunjang}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscale
x100 {diagnosis walaupun tidak dapat menyingkirkan diagnosis pasti. }\par\pard\l
i893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-373\slmult0 \fs26\cf0\f0
\charscalex100\b {Tata Laksana}\b0 \par\pard\li893\ri0\sl-360\slmult0 \fs22\cf0\
f0\charscalex100\b {Medikamentosa}\b0 \par\pard\li906\ri0\sl-320\slmult0 \*\tx11
46\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Asiklovir 10 mg
/kgBB setiap 8 jam selama 10-14 hari, diberikan dalam infus 100 ml}\par\pard\li1
146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {NaCl 0,9% minimum dalam 1 jam
. Dosis untuk neonatus 20 mg/kgBB setiap 8 jam}\par\pard\li1146\ri0\sl-266\slmul
t0 \fs22\cf0\f0\charscalex100 {selama 14-21 hari. }\par\pard\li906\ri0\sl-266\sl
mult0 \*\tx1146\fs20\cf0\f0\charscalex100 {-}\tab \fs20\cf0\f0\charscalex100 {Pa
da kasus alergi terhadap asiklovir atau VHS resisten, dapat diberikan vidarabin
15}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {mg/kgBB/hari
selama 14 hari.}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charsca
lex100 {-}\tab \fs22\cf0\f0\charscalex100 {Monitor keseimbangan cairan dan elekt
rolit, tata laksana kejang dan peningkatan}\par\pard\li1146\ri0\sl-266\slmult0
\fs22\cf0\f0\charscalex100 {tekanan intrakranial. }\par\pard\li906\ri0\sl-266\s
lmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {P
asien sebaiknya dirawat di ruang rawat intensif. Jika keadaan umum pasien sudah}
\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {stabil, dapat di
lakukan konsultasi ke departemen rehabilitasi medik untuk mobilisasi}\par\pard\l
i1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {bertahap, mengurangi spasti
sitas, serta mencegah kontraktur. }\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\
fs20\cf0\f0\charscalex100 {-}\tab \fs20\cf0\f0\charscalex100 {Pada keadaan yang
meragukan pasien dapat diberikan tata laksana ensefalitis herpes}\par\pard\li114

6\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {simpleks sampai terbukti bukan.

}\par\pard\li893\ri0\sl-426\slmult0 \fs22\cf0\f0\charscalex100\b {Pemantauan Pas
ca Rawat}\b0 \par\pard\li893\ri0\sl-306\slmult0 \fs20\cf0\f0\charscalex100 {Geja
la sisa yang sering ditemukan adalah epilepsi, retardasi mental maupun gangguan}
\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {perilaku. Pasca r
awat pasien memerlukan pemantauan tumbuh-kembang, jika terdapat}\par\pard\li893\
ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {gejala sisa dilakukan konsultasi
ke departemen terkait sesuai indikasi. Kadang dijumpai}\par\pard\li893\ri0\sl-26
6\slmult0 \fs22\cf0\f0\charscalex100 {sindrom koreoatetosis 1 bulan pasca perawa
tan.}\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-426\slmu
lt0 \fs26\cf0\f0\charscalex100\b {Kepustakaan}\b0 \par\pard\li893\ri0\sl-293\slm
ult0 \*\tx1266\fs18\cf0\f0\charscalex100 {1. }\tab \fs18\cf0\f0\charscalex100 {W
hitley RJ, Kimberlin DW. Viral encephalitis. Pediatr Rev. 1999;20:192-8.}\par\pa
rd\li893\ri0\sl-213\slmult0 \*\tx1266\fs18\cf0\f0\charscalex100 {2. }\tab \fs18\
cf0\f0\charscalex100 {Waggoner-Fountain LA, Grossman LB. Herpes simplex virus. P
ediatr Rev. 2004;25:86-92.}\par\pard\li893\ri0\sl-226\slmult0 \*\tx1266\fs18\cf0
\f0\charscalex100 {3. }\tab \fs18\cf0\f0\charscalex100 {Lewis P, Glaser CA. Ence
phalitis. Pediatr Rev. 2005;26:353-63}\par\pard\li893\ri0\sl-213\slmult0 \*\tx12
66\fs18\cf0\f0\charscalex100 {4. }\tab \fs16\cf0\f0\charscalex100 {Bale JF. Vira
l infection of the nervous system. Dalam : Swaiman KF, Ashwal S, Ferriero DM, pe
nyunting. }\par\pard\li1266\ri0\sl-226\slmult0 \fs18\cf0\f0\charscalex100 {Pedia
tric neurology principles and practice. Edisi ke-4. Philadelphia:Mosby; 2006. h.
1595-1630.}\par\pard\li893\ri0\sl-213\slmult0 \*\tx1266\fs16\cf0\f0\charscalex1
00 {5. }\tab \fs14\cf0\f0\charscalex100 {Maria BL, Bale JF. Infection of the ner
vous system. Dalam : Menkes JH, Sarnat HB, Maria BL, penyunting. }\par\pard\li12
66\ri0\sl-226\slmult0 \fs18\cf0\f0\charscalex100 {Child neurology. Edisi ke-7. P
hiladelphia: Lippincott Williams & Wilkin;2006. h. 433-526.}\par\pard\li893\ri0\
sl-213\slmult0 \*\tx1266\fs18\cf0\f0\charscalex100 {6. }\tab \fs18\cf0\f0\charsc
alex100 {Fenichel GM. Clinical pediatric neurology. Edisi ke-6. Philadelphia: Sa
unders Elsevier; 2009. h.49-78. }\par\pard\li6480\ri0\sl-213\slmult0 \fs18\cf0\p
ar\pard\li6480\ri0\sl-373\slmult0 \*\tx8320\fs12\cf0\f0\charscalex100\i {Pedoman
Pelayanan Medis}\i0 \tab \fs22\cf0\f0\charscalex100 {71}\par\pard\sect\sectd\sb
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13\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li4013\ri0\sl-213\slmult0 \fs18\cf0\par
\pard\li4013\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li4013\ri0\sl-213\slmult0 \fs
18\cf0\par\pard\li4013\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li4013\ri0\sl-533\s
lmult0 \fs36\cf0\f0\charscalex100\b {Enuresis}\b0 \par\pard\li893\ri0\sl-213\slm
ult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl
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3\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-280\slmult0 \fs22\cf0\f0\ch
arscalex100 {Enuresis adalah istilah untuk anak yang mengompol minimal dua kali
dalam seminggu }\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {d
alam periode paling sedikit 3 bulan pada usia 5 tahun atau lebih, yang tidak dis
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obat-obatan. Enuresis berlangsung melalui proses berkemih yang normal (}\fs22\c
f0\f0\charscalex100\i {normal }\i0 \par\pard\li893\ri0\sl-266\slmult0 \fs18\cf0\
f0\charscalex100\i {voiding}\i0 \fs22\cf0\f0\charscalex100 {), tetapi pada tempa
t dan waktu yang tidak tepat, yaitu berkemih di tempat tidur atau }\par\pard\li8
93\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {menyebabkan pakaian basah, dan
dapat terjadi saat tidur malam hari (enuresis nokturnal}\par\pard\li893\ri0\sl266\slmult0 \fs20\cf0\f0\charscalex100 {monosimtomatik), siang hari (enuresis di
urnal) ataupun pada siang dan malam hari. Istilah }\par\pard\li893\ri0\sl-266\sl
mult0 \fs20\cf0\f0\charscalex100 {enuresis primer digunakan pada anak yang belum
pernah berhenti mengompol sejak masa }\par\pard\li893\ri0\sl-266\slmult0 \fs20\
cf0\f0\charscalex100 {bayi, sedangkan enuresis sekunder digunakan pada anak beru
sia lebih dari 5 tahun yang }\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\cha
rscalex100 {sebelumnya pernah bebas masa mengompol minimal selama 12 bulan.}\par
\pard\li893\ri0\sl-373\slmult0 \fs22\cf0\f0\charscalex100 {Pada umumnya anak ber
henti mengompol sejak usia 2 tahun. Pada usia 3 tahun, 75%}\par\pard\li893\ri0\sl
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lam hari. Pada usia 5 tahun, sekitar 10-15% anak }\par\pard\li893\ri0\sl-266\slm
ult0 \fs20\cf0\f0\charscalex100 {masih mengompol paling tidak satu kali dalam se

minggu. Pada usia 10 tahun masih ada }\par\pard\li893\ri0\sl-266\slmult0 \fs22\c

f0\f0\charscalex100 {sekitar 7%, sedang pada usia 15 tahun hanya sekitar 1% anak
yang masih mengompol.}\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li8
93\ri0\sl-413\slmult0 \fs22\cf0\f0\charscalex100\b {Langkah promotif/preventif}\
b0 \par\pard\li906\ri0\sl-306\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\ta
b \fs22\cf0\f0\charscalex100 {Perlu ditekankan pada orangtua bahwa enuresis, ter
utama enuresis nokturnal bukan}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\
charscalex100 {kelainan psikogenik.}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146
\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Jangan menghukum
anak bila mengompol.}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\ch
arscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Tingkatkan motivasi anak agar ti
dak mengompol. Perlu diberi pujian atau penghargaan}\par\pard\li1146\ri0\sl-266\
slmult0 \fs22\cf0\f0\charscalex100 {pada setiap keberhasilan bebas mengompol.}\p
ar\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs
22\cf0\f0\charscalex100 {Bila mengalami kegagalan penanganan jangan sampai putus
asa atau menyerah, coba}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charsc
alex100 {lagi dengan berbagai metode alternatif.}\par\pard\li893\ri0\sl-213\slmu
lt0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl426\slmult0 \fs26\cf0\f0\charscalex100\b {Diagnosis}\b0 \par\pard\li893\ri0\sl-4
13\slmult0 \fs22\cf0\f0\charscalex100\b {Anamnesis}\b0 \par\pard\li893\ri0\sl-30
6\slmult0 \fs22\cf0\f0\charscalex100 {Anamnesis yang cermat memakai}{ }\fs22\cf0
\f0\charscalex100\i {check list}\i0 \fs22\cf0\f0\charscalex100 { yang berisi ant
ara lain:}\par\pard\li973\ri0\sl-266\slmult0 \*\tx1146\fs20\cf0\f0\charscalex100
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dapat berkemih sendiri, frekuensi dan lama }\par\pard\li1146\ri0\sl-266\slmult0
\fs22\cf0\f0\charscalex100 {berkemih, pancaran urin, keluhan saat berkemih, ban
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\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Perihal mengompol: sia
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l-266\slmult0 \fs22\cf0\f0\charscalex100 {rasa malu akibat mengompol, pola tidur
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l-440\slmult0 \fs22\cf0\f0\charscalex100 {72 }{ }\fs14\cf0\f0\charscalex100\i
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3\margtsxn666\margbsxn293\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893
\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pa
rd\li893\ri0\sl-466\slmult0 \fs22\cf0\f0\charscalex100\b {Pemantauan}\b0 \par\pa
rd\li973\ri0\sl-320\slmult0 \*\tx1146\fs20\cf0\f0\charscalex100 { -}\tab \fs22\c
f0\f0\charscalex100 {Penanganan enuresis sangat kompleks dan berlangsung lama, o
leh sebab itu perlu informasi }\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\
charscalex100 {yang adekuat dan rinci kepada anak dan orangtuanya serta kerja sa
ma yang baik.}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscale
x100 {-}\tab \fs22\cf0\f0\charscalex100 {Untuk menilai respons pengobatan perlu
memakai kartu catatan harian. Respons}\par\pard\li1146\ri0\sl-266\slmult0 \fs22
\cf0\f0\charscalex100 {pengobatan disebut komplit bila diperoleh keberhasilan be
rkurangnya hari\uc1\u8211Xtidur}\par\pard\li1146\ri0\sl-266\slmult0 \fs20\cf0\f0
\charscalex100 {bebas mengompol sampai 90% dalam pengamatan minimal 2 minggu pen
gobatan. }\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {Respon
s parsial adalah bila keberhasilan antara 50-90%. Bila keberhasilan kurang dari}
\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {50% disebut non

responder. Bila respons komplit masih berlanjut 6 bulan atau lebih}\par\pard\li1

146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {setelah pengobatan dihentikan
maka disebut respons berlanjut.}\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\pa
r\pard\li893\ri0\sl-320\slmult0 \fs22\cf0\f0\charscalex100\b {Tumbuh kembang}\b0
\par\pard\li906\ri0\sl-306\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab
\fs22\cf0\f0\charscalex100 {Bila diagnosis enuresis sudah ditegakkan dengan tepa
t dan diyakini tidak ditemukan}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\
charscalex100 {kelainan organik yang nyata, anak dan orangtua perlu diyakinkan
bahwa masalah}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {en
uresis bukan masalah psikogenik, tidak ada masalah pelik, dan semua bisa ditanga
ni}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {dengan kerja
sama yang baik antara dokter, pasien, dan keluarganya sehingga}\par\pard\li114
6\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {diharapkan enuresis tidak akan
mengganggu tumbuh kembang anak.}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs2
2\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Beberapa petunjuk pra
ktis}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}
\tab \fs22\cf0\f0\charscalex100 {Pengobatan berlangsung lama, perlu kepatuhan te
rhadap instruksi pengobatan.}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\
cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Bila monoterapi kurang
berhasil, terapi kombinasi dapat dianjurkan.}\par\pard\li1146\ri0\sl-266\slmult0
\*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Jangan
memakai antidepresan trisiklik seperti Imipramin.}\par\pard\li1146\ri0\sl-266\sl
mult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Ja
ngan menyerah. Bila menemui kegagalan, berikan waktu 3-6 bulan istirahat}\par\
pard\li1346\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {sebelum memakai metod
e pengobatan lainnya.}\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li89
3\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-346\slmult0 \fs26\cf0\f0\ch
arscalex100\b {Kepustakaan}\b0 \par\pard\li893\ri0\sl-293\slmult0 \*\tx1266\fs18
\cf0\f0\charscalex100 {1. }\tab \fs18\cf0\f0\charscalex100 {Boris NW, Dalton R.
Vegetative disorder. Dalam: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, }\pa
r\pard\li1266\ri0\sl-213\slmult0 \fs18\cf0\f0\charscalex100 {penyunting. Nelson
textbook of pediatrics. Edisi ke-18. Philadelphia: Saunders; 2007. h. 113-5.}\pa
r\pard\li893\ri0\sl-253\slmult0 \*\tx1266\fs18\cf0\f0\charscalex100 {2. }\tab \f
s18\cf0\f0\charscalex100 {Evans J, Shenoy M. Disordrs of micturition. Dalam:
Webb N, Postlethwaite R, penyunting. Clinical}\par\pard\li1266\ri0\sl-213\slm
ult0 \fs18\cf0\f0\charscalex100 {paediatric nephrology. Edisi ke-3. Oxford: Univ
ersity Press; 2003. h. 163-78. }\par\pard\li893\ri0\sl-253\slmult0 \*\tx1266\fs1
8\cf0\f0\charscalex100 {3. }\tab \fs18\cf0\f0\charscalex100 {Sekarwana N. Enures
is. Dalam: Alatas H, Tambunan T, Trihono PP, Pardede SO, penyunting. Buku ajar}\
par\pard\li1266\ri0\sl-213\slmult0 \fs18\cf0\f0\charscalex100 {nefrologi anak. E
disi ke-2. Jakarta; IDAI: 2002. h. 291-308.}\par\pard\li893\ri0\sl-253\slmult0 \
*\tx1266\fs18\cf0\f0\charscalex100 {4. }\tab \fs18\cf0\f0\charscalex100 {Robson
WL. Clinical practice, evaluation, and management of enuresis. N Eng J Med. 2009
;14:1429-}\par\pard\li1266\ri0\sl-213\slmult0 \fs18\cf0\f0\charscalex100 {36.}\p
ar\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs
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lmult0 \fs36\cf0\f0\charscalex100\b \i {Failure to Thrive}\b0 \i0 \par\pard\li89
3\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\p
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\fs18\cf0\f0\charscalex100\i {Failure to thrive}\i0 \fs22\cf0\f0\charscalex100
{ (FTT) adalah suatu keadaan yang ditandai dengan kenaikan berat badan}\par\pard

\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {(BB) yang tidak sesuai den

gan seharusnya, tidak naik (}\fs22\cf0\f0\charscalex100\i {flat growth}\i0 \fs22
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afik pertumbuhan). Istilah yang}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\
charscalex100 {lebih tepat adalah}{ }\fs18\cf0\f0\charscalex100\i {fail to gain
weight, }\i0 \fs22\cf0\f0\charscalex100 {tidak tepat jika diterjemahkan sebagai
gagal tumbuh, }\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {ka
rena dalam hal ini yang dinilai hanyalah berat badan terhadap umur pada minimal
2}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {periode penguku
ran, sedangkan tinggi badan dan lingkar kepala yang juga merupakan}\par\pard\li8
93\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {parameter pertumbuhan mungkin
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ult0 \fs22\cf0\f0\charscalex100 {adalah perpindahan posisi berat badan terhadap
umur yang melewati lebih dari 2}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f
0\charscalex100 {persentil utama atau 2 standar deviasi ke bawah jika diplot pad
a grafik BB menurut}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex10
0 {umur. FTT juga belum tentu gizi kurang atau gizi buruk. FTT bukanlah suatu di
agnosis}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {melainkan
gejala yang harus dicari penyebabnya.}\par\pard\li893\ri0\sl-213\slmult0 \fs18\
cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-333\slmult
0 \fs26\cf0\f0\charscalex100\b {Diagnosis}\b0 \par\pard\li893\ri0\sl-413\slmult0
\fs22\cf0\f0\charscalex100\b {Anamnesis}\b0 \par\pard\li893\ri0\sl-306\slmult0
\fs22\cf0\f0\charscalex100 {Oleh karena FTT merupakan suatu gejala, maka perlu d
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s22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Asupan kalori yang
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rscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Anemia (misal, defisiensi Fe)}\pa
r\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs
22\cf0\f0\charscalex100 {Masalah psikososial (misal apatis)}\par\pard\li1146\ri0
\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charsca
lex100 {Kelainan sistem saraf pusat (SSP) (misal hidrosefalus, tumor)}\par\pard\
li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\
f0\charscalex100 {Infeksi kronik (misal infeksi saluran kemih, sindrom imunodefi
siensi didapat)}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charsc
alex100 {-}\tab \fs22\cf0\f0\charscalex100 {Gangguan gastrointestinal (misal nye
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harscalex100 {Gangguan pada proses makan}\par\pard\li1146\ri0\sl-266\slmult0 \*\
tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Masalah psi
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f0\charscalex100 {)}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\ch
arscalex100 {-}\tab \fs18\cf0\f0\charscalex100\i {Cerebral palsy}\i0 \fs22\cf0\f
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0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charsc
alex100 {Anomali kraniofasial (misal atresia koana, bibir dan sumbing langitan,
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ar\pard\li1346\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100\i {glossoptosis}\i0
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2\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Sesak napas (misal pe
nyakit jantung bawaan, penyakit paru)}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1
346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Kelemahan otot
menyeluruh (misal miopati)}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\c
f0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Fistula trakeoesofageal}
\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab
\fs22\cf0\f0\charscalex100 {Sindrom genetik (misal Sindrom Smith-Lemli-Opitz)}\p
ar\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \f
s22\cf0\f0\charscalex100 {Sindrom kongenital (misal}{ }\fs18\cf0\f0\charscalex10
0\i {fetal alcohol syndrome}\i0 \fs22\cf0\f0\charscalex100 {)}\par\pard\li1146\r
i0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\chars

calex100 {Paralisis palatum molle}\par\pard\li6480\ri0\sl-453\slmult0 \*\tx8320\

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2\cf0\f0\charscalex100 {Asidosis tubular ginjal}\par\pard\li1373\ri0\sl-266\slmu
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harscalex100 { -}\tab \fs22\cf0\f0\charscalex100 {Pemeriksaan antropometri (mini
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arscalex100 {rd}\fs22\cf0\f0\charscalex100 { , 5}\fs12\cf0\f0\charscalex100 {th}
\fs22\cf0\f0\charscalex100 { , 10}\fs12\cf0\f0\charscalex100 {th}\fs22\cf0\f0\ch
arscalex100 { , 25}\fs12\cf0\f0\charscalex100 {th}\fs22\cf0\f0\charscalex100 { ,
50}\fs12\cf0\f0\charscalex100 {th}\fs22\cf0\f0\charscalex100 { , 75}\fs12\cf0\f
0\charscalex100 {th}\fs22\cf0\f0\charscalex100 { , 90}\fs12\cf0\f0\charscalex100
{th}\fs22\cf0\f0\charscalex100 {, 95}\fs12\cf0\f0\charscalex100 {th}\fs22\cf0\f
0\charscalex100 {, 97}\fs12\cf0\f0\charscalex100 {th}{\sub \fs22\cf0\f0\charscal
ex100 {)}}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs20\cf0\f0\charscalex100
{-}\tab \fs20\cf0\f0\charscalex100 {Mencari penyakit yang mungkin mendasari, mi
salnya penyakit jantung, paru, endokrin, }\par\pard\li1146\ri0\sl-266\slmult0 \f
s22\cf0\f0\charscalex100 {neurologis, dan lain-lain.}\par\pard\li1213\ri0\sl-266
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par\pard\li1346\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {dan endokrin sepe
rti hiperplasia adrenal kongenital, hipotiroid. Pada keadaan ini perlu}\par\pard
\li1346\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {dilakukan pengukuran}{ }\
fs18\cf0\f0\charscalex100\i {arm span, lower segment (LS), upper segment (US), }
\i0 \fs22\cf0\f0\charscalex100 {rasio US/LS}\par\pard\li1213\ri0\sl-266\slmult0
\fs20\cf0\f0\charscalex100 { -}{ }\fs22\cf0\f0\charscalex100 {Bila ditemukan mas
alah pertambahan lingkar kepala, pikirkan kelainan neurologis }\par\pard\li893\r
i0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-320\slmult0 \fs22\cf0\f0\chars
calex100\b {Pemeriksaan penunjang}\b0 \par\pard\li893\ri0\sl-306\slmult0 \fs22\c
f0\f0\charscalex100 {Pemeriksaan laboratorium hanya bermanfaat bila terdapat tem
uan signifikan pada}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex10
0 {anamnesis dan pemeriksaan fisis. Pemeriksaan laboratorium meliputi darah pe
rifer}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {lengkap, la
ju endap darah, urinalisis (pH, osmolalitas, elemen seluler, glukosa, dan keton)
, }\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {kultur urin,
tinja untuk melihat parasit dan malabsorpsi, ureum dan kreatinin serum, }\par\p
ard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {analisis gas darah, ele
ktrolit termasuk kalsium dan fosfor, tes fungsi hati termasuk protein}\par\pard\
li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {total dan albumin. Pemeriks
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\f0\charscalex100 { dilakukan bila ada indikasi}\par\pard\li893\ri0\sl-266\slmul
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Bila dicurigai kelainan jantung, dapat dilakukan pemeriksaan ekokardiografi. Bil

a dicurigai}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {kelai
nan paru, dapat dilakukan pemeriksaan foto Rontgen dan uji Mantoux. Bila dicurig
ai}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {kelainan endok
rin atau tulang, dapat dilakukan pemeriksaan usia tulang dan bone survey. }\par\
pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {Bila dicurigai kelaina
n neurologis, dapat dilakukan pemeriksaan computed tomography}\par\pard\li893\ri
0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {(CT) scan kepala. }\par\pard\li893\
ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\par
d\li893\ri0\sl-373\slmult0 \fs26\cf0\f0\charscalex100\b {Tata laksana}\b0 \par\p
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eriode kritis pertumbuhan dan perkembangan, dan intervensi}\par\pard\li893\ri0\s
l-266\slmult0 \fs22\cf0\f0\charscalex100 {dini pada anak dengan FTT akan memaksi
malkan hasil. Syarat utama tata laksana FTT}\par\pard\li893\ri0\sl-266\slmult0 \
fs22\cf0\f0\charscalex100 {adalah mengenali penyebab yang mendasari dan memperba
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arscalex100 {tata laksana pada semua anak FTT adalah diet tinggi kalori untuk}{
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dan}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {pemantauan j
angka panjang untuk melihat adanya gejala sisa.}\par\pard\li893\ri0\sl-213\slmul
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\fs22\cf0\f0\charscalex100 {sehari}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146
\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Pastikan pemberia
n makanan cukup}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charsca
lex100 {-}\tab \fs22\cf0\f0\charscalex100 {Hindari \uc1\u8221Xngempeng\uc1\u8221
X, bila berlanjut dan mendominasi asupan makanan maka hentikan}\par\pard\li1146\
ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {pemberian ASI dan tingkatkan asup
an susu formula atau MP-ASI}\par\pard\li893\ri0\sl-386\slmult0 \fs20\cf0\f0\char
scalex100\i {Bottle Feeding}\i0 \par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs2

2\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Berikan susu formula

yang tepat: }\fs22\cf0\f0\charscalex100\i {starting up}\i0 \fs22\cf0\f0\charscal
ex100 { untuk yang berusia di bawah 6 bulan dan}\par\pard\li1146\ri0\sl-266\slmu
lt0 \fs18\cf0\f0\charscalex100\i {follow-on}\i0 \fs22\cf0\f0\charscalex100 { (fo
rmula lanjutan) untuk usia 6-36 bulan}\par\pard\li906\ri0\sl-266\slmult0 \*\tx11
46\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Pastikan cara p
elarutan dilakukan dengan benar}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs2
2\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Jika perlu dapat dibe
rikan formula khusus yang tinggi kalori misalnya formula prematur}\fs22\cf0\f0\c
harscalex100\i {,}\i0 \par\pard\li1146\ri0\sl-266\slmult0 \fs18\cf0\f0\charscale
x100\i {after discharge formula, }\i0 \fs22\cf0\f0\charscalex100 {formula tinggi
kalori, formula elemental, dll}\par\pard\li893\ri0\sl-400\slmult0 \fs22\cf0\f0\
charscalex100 {Pemberian makanan pada balita}\par\pard\li906\ri0\sl-266\slmult0
\*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {3 kali m
akan dan 2 kali}{ }\fs22\cf0\f0\charscalex100\i {snack}\i0 \fs22\cf0\f0\charscal
ex100 { bergizi per hari}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f
0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Susu sebanyak 480-960 mL per
hari}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}
\tab \fs22\cf0\f0\charscalex100 {Stop pemberian jus, }\fs22\cf0\f0\charscalex100
\i {punch}\i0 \fs22\cf0\f0\charscalex100 {, soda sampai berat badan normal}\par
\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22
\cf0\f0\charscalex100 {Hentikan pemberian makan secara paksa}\par\pard\li906\ri0
\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charsca
lex100 {Perhatikan lingkungan tempat memberikan makan }\par\pard\li893\ri0\sl-21
3\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\r
i0\sl-373\slmult0 \fs26\cf0\f0\charscalex100\b {Kepustakaan}\b0 \par\pard\li893\
ri0\sl-293\slmult0 \*\tx1266\fs18\cf0\f0\charscalex100 {1. }\tab \fs18\cf0\f0\ch
arscalex100 {Krugman SD, Dubowitz H. Failure to thrive. Am Fam Physician. 2003;
68:879-86.}\par\pard\li893\ri0\sl-240\slmult0 \*\tx1266\fs18\cf0\f0\charscalex10
0 {2. }\tab \fs18\cf0\f0\charscalex100 {Zenel JA. Failure to thrive: A general p
ediatrician\uc1\u8217Xs perspective. Pediatr Rev. 1997;18:371-8.}\par\pard\li893
\ri0\sl-253\slmult0 \*\tx1266\fs18\cf0\f0\charscalex100 {3. }\tab \fs18\cf0\f0\c
harscalex100 {Olsen EM. Failure to thrive: still a problem in definition. Clin P
ediatr. 2006;45:1-6.}\par\pard\li893\ri0\sl-253\slmult0 \*\tx1266\fs18\cf0\f0\ch
arscalex100 {4. }\tab \fs18\cf0\f0\charscalex100 {Wright JM. Identification and
management of failure to thrive: a community perspective. Arch Dis}\par\pard\li1
266\ri0\sl-213\slmult0 \fs18\cf0\f0\charscalex100 {Child. 2000;82:5\uc1\u8211X9.
}\par\pard\li893\ri0\sl-253\slmult0 \*\tx1266\fs18\cf0\f0\charscalex100 {5. }\ta
b \fs18\cf0\f0\charscalex100 {Gahagan S. Failure to thrive: A consequences of un
dernutrition. Pediatr Rev. 2006;27:e-11.}\par\pard\li893\ri0\sl-213\slmult0 \fs1
8\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmu
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\ri0\sl-306\slmult0 \fs22\cf0\f0\charscalex100 {78 }{ }\fs12\cf0\f0\charscalex
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lmult0 \fs36\cf0\f0\charscalex100\b {Gagal Jantung}\b0 \par\pard\li893\ri0\sl-21
3\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\r
i0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard
\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-280\slmult0 \fs22\cf0\
f0\charscalex100 {Gagal jantung pada bayi dan anak adalah suatu sindrom klinis
yang ditandai oleh}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100
{ketidakmampuan miokardium memompa darah ke seluruh tubuh untuk memenuhi}\par\p
ard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {kebutuhan metabolisme t
ubuh termasuk kebutuhan untuk pertumbuhan. Gagal jantung}\par\pard\li893\ri0\sl266\slmult0 \fs20\cf0\f0\charscalex100 {dapat disebabkan oleh penyakit jantung b
awaan maupun didapat yang diakibatkan oleh}\par\pard\li893\ri0\sl-266\slmult0 \f
s20\cf0\f0\charscalex100 {beban volume}{ }\fs20\cf0\f0\charscalex100\i {(preload
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100\i {(afterload)}\i0 \fs20\cf0\f0\charscalex100 { yang berlebih, atau penuruna

n}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {kontraktilitas

miokard. Penyebab lain misalnya adalah takikardia supraventrikular, blok}\par\pa
rd\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {jantung komplit, anemia
berat, kor pulmonal akut, dan hipertensi akut. }\par\pard\li893\ri0\sl-213\slmul
t0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-3
60\slmult0 \fs26\cf0\f0\charscalex100\b {Diagnosis}\b0 \par\pard\li893\ri0\sl-42
6\slmult0 \fs22\cf0\f0\charscalex100\b {Anamnesis}\b0 \par\pard\li906\ri0\sl-306
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{Sesak napas terutama saat beraktivitas. Sesak napas dapat mengakibatkan kesulit
an}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {makan/minum d
an, dalam jangka panjang, gagal tumbuh}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1
146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Sering berkeri
ngat (peningkatan tonus simpatis)}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\f
s22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Ortopnea: sesak naf
as yang mereda pada posisi tegak}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs
22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Dapat dijumpai mengi
}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab
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k mata}\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-346\sl
mult0 \fs22\cf0\f0\charscalex100\b {Pemeriksaan fisis}\b0 \par\pard\li1146\ri0\s
l-306\slmult0 \fs22\cf0\f0\charscalex100 {Tanda gangguan miokard}\par\pard\li906
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rscalex100 {Takikardia: laju jantung >160 kali/menit pada bayi dan >100 kali/me
nit pada}\par\pard\li1146\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {anak (s
aat diam). Jika laju jantung >200 kali/menit perlu dicurigai ada takikardia}\pa
r\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {supraventrikular.}\
par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \f
s22\cf0\f0\charscalex100 {Kardiomegali pada pemeriksaan fisis dan/atau foto tora
ks.}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\t
ab \fs22\cf0\f0\charscalex100 {Peningkatan tonus simpatis: berkeringat, gangguan
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pard\li1146\ri0\sl-306\slmult0 \*\tx1693\fs22\cf0\f0\charscalex100 {- }\tab \fs2
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rd\li893\ri0\sl-466\slmult0 \fs22\cf0\f0\charscalex100 {semua kasus yang tidak k
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gan ini cukup banyak digunakan karena}\par\pard\li893\ri0\sl-266\slmult0 \fs22\c
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par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \
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ia mempermudah terjadinya}\par\pard\li1346\ri0\sl-266\slmult0 \fs22\cf0\f0\chars
calex100 {toksisitas digoksin}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22
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\*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Pemberia
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s22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Dosis rumat diberik
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\ri0\sl-213\slmult0 \fs18\cf0\f0\charscalex100 {2000; 11:321-9 }\par\pard\li893
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rscalex100 {th}\fs18\cf0\f0\charscalex100 { ed. Philadelphia: Mosby; 2008. h. 46
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\tab \fs18\cf0\f0\charscalex100 {Burch M. Heart failure in the young. Heart. 200
2;88:198-202.}\par\pard\li893\ri0\sl-240\slmult0 \*\tx1266\fs18\cf0\f0\charscale
x100 {4. }\tab \fs18\cf0\f0\charscalex100 {Bernstein D.Heart Failure. Dalam: Beh
rman RE, Kliegman RM, Jenson HB, penyunting. NelsonTextbook}\par\pard\li1266\ri0
\sl-226\slmult0 \fs18\cf0\f0\charscalex100 {of Pediatrics. Edisi ke-16. Philadel
phia : Saunders Company; 2000. h. 1440-4. }\par\pard\li893\ri0\sl-240\slmult0 \*
\tx1266\fs18\cf0\f0\charscalex100 {5. }\tab \fs18\cf0\f0\charscalex100 {Tortorie
llo TA. Hemodynamic adaptive mechanism in heart failure. Dalam :Chang AC, Tow
bin, JA, }\par\pard\li1266\ri0\sl-226\slmult0 \fs18\cf0\f0\charscalex100 {penyu
nting. Heart failure in children and young adults. Philadelphia: Saunders Elsevi
er; 2006. h. 60-84}\par\pard\li893\ri0\sl-240\slmult0 \*\tx1266\fs18\cf0\f0\char
scalex100 {6. }\tab \fs18\cf0\f0\charscalex100 {Davies MK, Gibbs CR, Lip GYH. AB
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0\sl-253\slmult0 \*\tx1266\fs18\cf0\f0\charscalex100 {7. }\tab \fs18\cf0\f0\char
scalex100 {Wilkinson J. Assessment of the infant and child with suspected hear
t disease. Dalam: Robinson MJ, }\par\pard\li1266\ri0\sl-226\slmult0 \fs16\cf0\
f0\charscalex100 {Roberton DM, penyunting. Practical Paediatrics. Edisi ke-4. Ed
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is M, Supriatmo, }\par\pard\li1266\ri0\sl-226\slmult0 \fs18\cf0\f0\charscalex100
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ex100 {Challenge 2006; 2006 May 1-4; Medan, Indonesia. Medan: Ikatan Dokter
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nting. }\par\pard\li1266\ri0\sl-226\slmult0 \fs18\cf0\f0\charscalex100 {Essentia
l Pediatric Cardiology. New York: McGraw-Hill; 2004. h. 98-105.}\par\pard\li893\
ri0\sl-240\slmult0 \fs16\cf0\f0\charscalex100 {10. Advani N. Penatalaksanaan ga
gal jantung pada anak. Dalam: Updates in pediatric emergencies. Jakarta: }\par\
pard\li1266\ri0\sl-226\slmult0 \fs18\cf0\f0\charscalex100 {Balai Penerbit FKUI;
2002. h. 87-94.}\par\pard\li893\ri0\sl-253\slmult0 \fs16\cf0\f0\charscalex100 {1
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ren. Dalam: Chang AC, }\par\pard\li1266\ri0\sl-213\slmult0 \fs18\cf0\f0\charscal
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2}}\fs22\cf0\f0\charscalex100 { kurang dari 50 mmHg saat bernapas dalam udara ru
ang. Dalam praktik}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100
{sehari-hari, keputusan untuk memberikan bantuan ventilator tidak dapat didasa
rkan}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {atas batasan
ini saja. Penyebab gagal napas dan beratnya penyakit yang mendasari selalu}\par
\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {harus menjadi pertimb
angan pula.}\par\pard\li893\ri0\sl-293\slmult0 \fs22\cf0\f0\charscalex100 {Penye
bab gagal napas antara lain:}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\c
f0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Gangguan pada dinding da
da, abdomen dan diafragma, contoh: }\par\pard\li1146\ri0\sl-266\slmult0 \*\tx134
6\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {trauma atau pasc
a bedah, ascites}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\chars
calex100 {-}\tab \fs22\cf0\f0\charscalex100 {Kelainan intra-abdomen}\par\pard\li
1373\ri0\sl-266\slmult0 \*\tx1613\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0
\charscalex100 {tumor intra-abdomen}\par\pard\li1373\ri0\sl-266\slmult0 \*\tx161
3\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {organomegali}\pa
r\pard\li1373\ri0\sl-266\slmult0 \*\tx1613\fs22\cf0\f0\charscalex100 {-}\tab \fs
22\cf0\f0\charscalex100 {nyeri pasca bedah}\par\pard\li1146\ri0\sl-266\slmult0 \
*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Kelainan
kongenital}\par\pard\li1373\ri0\sl-266\slmult0 \*\tx1613\fs22\cf0\f0\charscalex1
00 {-}\tab \fs22\cf0\f0\charscalex100 {Gastroschisis}\par\pard\li1373\ri0\sl-266
\slmult0 \*\tx1613\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100
{Omphalocele}\par\pard\li1373\ri0\sl-266\slmult0 \*\tx1613\fs22\cf0\f0\charscale
x100 {-}\tab \fs22\cf0\f0\charscalex100 {Kelainan bentuk toraks}\par\pard\li1373
\ri0\sl-266\slmult0 \*\tx1613\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\cha
rscalex100 {Hernia diafragmatika (dapat disertai hipoplasi paru)}\par\pard\li137
3\ri0\sl-266\slmult0 \*\tx1613\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\ch
arscalex100 {Skoliosis}\par\pard\li906\ri0\sl-293\slmult0 \*\tx1146\fs22\cf0\f0\
charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Gangguan pada pleura, contoh:}
\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab
\fs22\cf0\f0\charscalex100 {Pneumotoraks}\par\pard\li1146\ri0\sl-266\slmult0 \*\
tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Efusi pleur
a}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\ta

b \fs22\cf0\f0\charscalex100 {Hemotoraks}\par\pard\li906\ri0\sl-360\slmult0 \*\t

x1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Gangguan neu
romuscular, contoh:}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\ch
arscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Obat (overdosis salisilat, amin
oglikosida, suksametonium, opiat, obat anestesi}\fs22\cf0\f0\charscalex100\b
\i {,}\b0 \i0 \par\pard\li1346\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100\b \
i {nondepolarizing muscle relaxants}\b0 \i0 \fs22\cf0\f0\charscalex100 {)}\par\p
ard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\
cf0\f0\charscalex100 {Gangguan endokrin dan metabolik, contoh: diabetik ketoas
idosis, hipertiroid, }\par\pard\li1346\ri0\sl-266\slmult0 \fs22\cf0\f0\charscal
ex100 {hipokalsemia, hipofosfatemia, hipokalemia}\par\pard\li1146\ri0\sl-266\slm
ult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Inf
eksi, contoh: ensefalitis, tetanus, guillain barre, sepsis}\par\pard\li1146\ri0\
sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscal
ex100 {Lesi intracranial, contoh: tumor, perdarahan}\par\pard\li1146\ri0\sl-266\
slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {
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18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-466\slm
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3\margtsxn666\margbsxn293\pard\li906\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li906
\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li906\ri0\sl-213\slmult0 \fs18\cf0\par\pa
rd\li906\ri0\sl-466\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf
0\f0\charscalex100 {Gangguan parenkim paru, contoh:}\par\pard\li1146\ri0\sl-266\
slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {
Penumonia bacterial}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\ch
arscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Penumonia viral}\par\pard\li1146
\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\cha
rscalex100 {Penumonia karena Pneumocystis carinii}\par\pard\li1146\ri0\sl-266\sl
mult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Pe
numonia akibat Legionella pheumophila}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1
346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Pneumonia hidr
okarbon}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100
{-}\tab \fs22\cf0\f0\charscalex100 {Atelektasis}\par\pard\li1146\ri0\sl-266\slmu
lt0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Edem
a paru}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {
-}\tab \fs22\cf0\f0\charscalex100 {ARDS}\par\pard\li1146\ri0\sl-266\slmult0 \*\t
x1346\fs22\cf0\f0\charscalex100 {-}\tab \fs20\cf0\f0\charscalex100\i {Smoke inha
lation}\i0 \par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex10
0 {-}\tab \fs22\cf0\f0\charscalex100 {Gangguan pada jalan napas, contoh:}\par\pa
rd\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\c
f0\f0\charscalex100 {Croup}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf
0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Bacterial tracheitis}\par
\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs2
2\cf0\f0\charscalex100 {Epiglotitis}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx134
6\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Kelainan congeni
tal pembuluh darah besar (aorta, arteri inominata, carotis comunis}\par\pard\li1
346\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {kiri, arteri pulmonalis kiri
atau arteri subklavia kanan yang menekan trakea)}\par\pard\li1146\ri0\sl-266\slm
ult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Abs
es retrofaringeal}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\char
scalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Abses paratonsilar}\par\pard\li114
6\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\ch
arscalex100 {Aspirasi benda asing}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\
fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Asthma bronchial}\
par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \f
s18\cf0\par\pard\li893\ri0\sl-333\slmult0 \fs26\cf0\f0\charscalex100\b {Diagnosi
s}\b0 \par\pard\li893\ri0\sl-413\slmult0 \fs22\cf0\f0\charscalex100\b {Anamnesis
}\b0 \par\pard\li893\ri0\sl-306\slmult0 \fs20\cf0\f0\charscalex100 {Mengingat pe
nyebab gagal napas sangat beragam, anamnesis spesifik harus dilakukan}\par\pard
\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {sesuai kecurigaan penyebab
nya. Secara garis besar beberapa pertanyaan berikut perlu}\par\pard\li893\ri0\sl
-266\slmult0 \fs22\cf0\f0\charscalex100 {dilakukan pada setiap keluhan sesak pad

a anak:}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {
-}\tab \fs22\cf0\f0\charscalex100 {Sesak terjadi secara akut atau sudah lama}\pa
r\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs2
2\cf0\f0\charscalex100 {Apakah pernah mengalami sesak serupa?}\par\pard\li906\ri
0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charsc
alex100 {Apakah anak dalam pengobatan tertentu?}\par\pard\li906\ri0\sl-266\slmul
t0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Apaka
h disertai demam?}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\chars
calex100 {-}\tab \fs22\cf0\f0\charscalex100 {Apakah terdapat riwayat tersedak at
au trauma?}\par\pard\li893\ri0\sl-333\slmult0 \fs20\cf0\f0\charscalex100 {Kemung
kinan diagnosis obstruksi jalan napas atas berdasar angka kejadian, gejala dan}
\par\pard\li893\ri0\sl-280\slmult0 \fs22\cf0\f0\charscalex100 {usia dapat diliha
t pada}{ }\fs22\cf0\f0\charscalex100\b {Tabel 1}\b0 \fs22\cf0\f0\charscalex100 {
. Penyebab obstruksi jalan napas bawah tersering pada}\par\pard\li893\ri0\sl-266
\slmult0 \fs22\cf0\f0\charscalex100 {balita adalah bronkiolitis, asma bronkial,
dan obstruksi akibat benda asing.}\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\p
ar\pard\li893\ri0\sl-346\slmult0 \fs22\cf0\f0\charscalex100\b {Pemeriksaan fisis
}\b0 \par\pard\li893\ri0\sl-306\slmult0 \fs22\cf0\f0\charscalex100 {Beberapa tan
da spesifik antara lain:}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f
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\li6480\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li6480\ri0\sl-333\slmult0 \*\tx832
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b \fs22\cf0\f0\charscalex100 {Peningkatan resistensi jalan napas (contohnya pada
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arscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Takikardia}\par\pard\li1146\ri0\
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calex100 {-}\tab \fs22\cf0\f0\charscalex100 {Sianosis}\par\pard\li893\ri0\sl-213
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pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {Untuk pemantauan selan
jutnya saat ini telah berkembang alat pantau non-invasif seperti}\par\pard\li893
\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100\i {pulse oxymeter}\i0 { }\fs22\cf
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ard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\c
f0\par\pard\li893\ri0\sl-373\slmult0 \fs26\cf0\f0\charscalex100\b {Tata laksana}
\b0 \par\pard\li893\ri0\sl-360\slmult0 \fs22\cf0\f0\charscalex100 {Tata laksana
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00 {(guedel), penyangga}{ }\fs18\cf0\f0\charscalex100\i {nasopharyngeal}\i0 { }\

fs20\cf0\f0\charscalex100\i {airway}\i0 \fs22\cf0\f0\charscalex100 {, atau pipa
endotrakea.}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex1
00 {-}\tab \fs22\cf0\f0\charscalex100 {Terapi oksigen}\par\pard\li1146\ri0\sl-26
6\slmult0 \fs22\cf0\f0\charscalex100 {Berbagai teknik tersedia untuk memberikan
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\cf0\f0\charscalex100 {satu pun yang dapat disebut terbaik karena pemilihannya h
arus disesuaikan secara}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charsca
lex100 {individual terhadap situasi klinis dan kondisi pasien. Ketika memilih p
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00 {seorang klinisi harus mempertimbangkan kebutuhan FiO}{\sub \fs12\cf0\f0\char
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w}\i0 { }\fs22\cf0\f0\charscalex100 {inspirasi, kenyamanan}\par\pard\li1146\ri0\
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}\tab \fs22\cf0\f0\charscalex100\i {compliance)}\i0 \fs22\cf0\f0\charscalex100 {
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i0 \par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {antara lain a
dalah:}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {
-}\tab \fs22\cf0\f0\charscalex100 {Kanul nasal: dipergunakan untuk memberikan ok
sigen dengan laju aliran rendah. }\par\pard\li1346\ri0\sl-266\slmult0 \fs22\cf0\
f0\charscalex100 {Konsentrasi oksigen bervariasi dengan perubahan laju aliran in
spirasi (}\fs18\cf0\f0\charscalex100\i {inspiration}\i0 \par\pard\li1346\ri0\sl266\slmult0 \fs20\cf0\f0\charscalex100\i {flow rate)}\i0 \fs22\cf0\f0\charscalex
100 { pasien. Pada neonatus, aliran oksigen maksimum dianjurkan tidak melebihi}\
par\pard\li1346\ri0\sl-320\slmult0 \fs22\cf0\f0\charscalex100 {2 L/menit. FiO}{\
sub \fs12\cf0\f0\charscalex100 {2}}\fs22\cf0\f0\charscalex100 { inspirasi yang d
ihasilkan amat bergantung pada pola napas pasien.}\par\pard\li1146\ri0\sl-280\sl
mult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs18\cf0\f0\charscalex100\i {
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memberikan konsentrasi oksigen }\par\pard\li1346\ri0\sl-320\slmult0 \fs22\cf0\f
0\charscalex100 {yang stabil pada neonatus atau bayi kecil. FiO}{\sub \fs12\cf0\
f0\charscalex100 {2}}\fs22\cf0\f0\charscalex100 { hingga 100% dapat diberikan de
ngan}\par\pard\li1346\ri0\sl-280\slmult0 \fs22\cf0\f0\charscalex100 {laju aliran
oksigen yang sesuai. Bukaan pada}{ }\fs18\cf0\f0\charscalex100\i {oxygen hood}\
i0 \fs22\cf0\f0\charscalex100 { tidak boleh ditutup dengan}\par\pard\li1346\ri0\
sl-266\slmult0 \fs22\cf0\f0\charscalex100 {plastik atau bahan lain agar tidak te
rjadi retensi karbon dioksida.}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs2
2\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Masker: beberapa tip
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fs22\cf0\f0\charscalex100 {oksigen yang diinginkan dan mencegah terhisapnya kemb
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{-}\tab \fs22\cf0\f0\charscalex100 {Masker oksigen sederhana}{ }\fs22\cf0\f0\ch
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onsentrasi oksigen}\par\pard\li1613\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex10
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f0\f0\charscalex100 {2. }\tab \fs16\cf0\f0\charscalex100 {Stone R, Elmore GD. Ox
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arscalex100 {Sesakakutdisertaidemamtinggi}\par\pard\li0\ri0\sl-280\slmult0 \fs22
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lmult0 \fs36\cf0\f0\charscalex100\b {Glomerulonefritis Akut
}
\b0 \par\pard\li3066\ri0\sl-453\slmult0 \fs36\cf0\f0\charscalex100\b {Pasca Stre
ptokokus}\b0 \par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893
\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-440\slmult0 \fs20\cf0\f0\cha
rscalex100 {Glomerulonefritis akut pasca streptokokus (GNAPS) adalah suatu sind
rom nefritik}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {akut
yang ditandai dengan timbulnya hematuria, edema, hipertensi, dan penurunan}\
par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {fungsi ginjal (azo
temia). Gejala-gejala ini timbul setelah infeksi kuman streptokokus}\par\pard\l
i893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {beta hemolitikus grup A di s
aluran nafas bagian atas atau di kulit. GNAPS terutama}\par\pard\li893\ri0\sl266\slmult0 \fs20\cf0\f0\charscalex100 {menyerang anak usia sekolah dan jarang m
enyerang anak usia <3 tahun. Laki-laki lebih}\par\pard\li893\ri0\sl-266\slmult0
\fs20\cf0\f0\charscalex100 {sering daripada perempuan dengan perbandingan 2:1. G
NAPS merupakan penyakit yang}\par\pard\li893\ri0\sl-266\slmult0 \*\tx1640\fs22\c
f0\f0\charscalex100 {bersifat}\tab \fs22\cf0\f0\charscalex100\i {self limiting}\
i0 \fs22\cf0\f0\charscalex100 {, tetapi dapat juga menyebabkan gagal ginjal aku
t. Sebagian besar}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100
{pasien (95%) akan sembuh, tetapi 5% di antaranya dapat mengalami perjalanan pe
nyakit}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {yang membu
ruk dengan cepat.}\par\pard\li893\ri0\sl-373\slmult0 \fs20\cf0\f0\charscalex100
{Penyakit ini timbul setelah adanya infeksi oleh kuman Streptokokus beta hemolit
ikus di}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {saluran n
afas atas dan kulit, sehingga pencegahan dan pengobatan infeksi saluran nafas}\p
ar\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {atas dan kulit dapa
t menurunkan kejadian penyakit ini. Dengan perbaikan kesehatan}\par\pard\li893\
ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {masyarakat, maka kejadian penyaki
t ini dapat dikurangi.}\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li8
93\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-386\slmult0 \fs26\cf0\f0\c
harscalex100\b {Diagnosis}\b0 \par\pard\li893\ri0\sl-426\slmult0 \fs22\cf0\f0\ch
arscalex100\b {Anamnesis}\b0 \par\pard\li906\ri0\sl-306\slmult0 \*\tx1146\fs22\c
f0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Riwayat infeksi saluran
nafas atas (faringitis) 1-2 minggu sebelumnya atau infeksi kulit}\par\pard\li114
6\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {(pyoderma) 3-6 minggu sebelumny

a.}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\ta

b \fs22\cf0\f0\charscalex100 {Umumnya pasien datang dengan hematuria nyata (}\fs
22\cf0\f0\charscalex100\i {gross hematuria}\i0 \fs22\cf0\f0\charscalex100 {) ata
u sembab di}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {kedu
a kelopak mata dan tungkai}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0
\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Kadang-kadang pasien datan
g dengan kejang dan penurunan kesadaran akibat}\par\pard\li1146\ri0\sl-266\slmul
t0 \fs22\cf0\f0\charscalex100 {ensefalopati hipertensi}\par\pard\li906\ri0\sl-26
6\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100
{Oligouria/anuria akibat gagal ginjal atau gagal jantung.}\par\pard\li893\ri0\s
l-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-333\slmult0 \fs22\cf0\f0\charscale
x100\b {Pemeriksaan fisis}\b0 \par\pard\li906\ri0\sl-306\slmult0 \*\tx1146\fs22\
cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Sering ditemukan edema
di kedua kelopak mata dan tungkai dan hipertensi}\par\pard\li906\ri0\sl-266\slmu
lt0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Dapa
t ditemukan lesi bekas infeksi di kulit}\par\pard\li906\ri0\sl-266\slmult0 \*\tx
1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Jika terjadi
ensefalopati, pasien dapat mengalami penurunan kesadaran dan kejang.}\par\pard\l
i906\ri0\sl-266\slmult0 \*\tx1146\fs20\cf0\f0\charscalex100 {-}\tab \fs20\cf0\f0
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ab \fs22\cf0\f0\charscalex100 {Komplemen C3 menurun pada hampir semua pasien pad
a minggu pertama. }\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\char
scalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Jika terjadi komplikasi gagal ginj
al akut, didapatkan hiperkalemia, asidosis metabolik, }\par\pard\li1146\ri0\sl-2
66\slmult0 \fs22\cf0\f0\charscalex100 {hiperfosfatemia, dan hipokalsemia.}\par\p
ard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\c
f0\par\pard\li893\ri0\sl-386\slmult0 \fs26\cf0\f0\charscalex100\b {Tata laksana}
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lmult0 \fs20\cf0\f0\charscalex100 {Diuretik diberikan untuk mengatasi retensi ca
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2\cf0\f0\charscalex100 {Pengobatan GNAPS umumnya bersifat suportif. Tirah baring
umumnya diperlukan jika}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charsca
lex100 {pasien tampak sakit, misalnya terjadi penurunan kesadaran, hipertensi at
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efritis diberikan terutama bila terdapat retensi cairan dan penurunan fungsi gin
jal. }\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {Jika terdap
at komplikasi seperti gagal ginjal, ensefalopati hipertensi, gagal jantung, edem

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ar\pard\li1266\ri0\sl-226\slmult0 \fs16\cf0\f0\charscalex100 {Jenson HB, Stanton
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}\tab \fs18\cf0\f0\charscalex100 {Noer MS. Glomerulonefritis.. Dalam: Alatas H,
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3\margtsxn666\margbsxn293\pard\li3880\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li38
80\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li3880\ri0\sl-213\slmult0 \fs18\cf0\par
\pard\li3880\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li3880\ri0\sl-213\slmult0 \fs
18\cf0\par\pard\li3880\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li3880\ri0\sl-533\s
lmult0 \fs36\cf0\f0\charscalex100\b {Hemofilia}\b0 \par\pard\li893\ri0\sl-213\sl
mult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\s
l-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li8
93\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-280\slmult0 \fs22\cf0\f0\c
harscalex100 {Hemofilia adalah penyakit gangguan pembekuan darah yang bersifat h
erediter. Hemofilia}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex10
0 {A disebabkan kekurangan faktor VIII, sedangkan hemofilia B disebabkan kekura
ngan}\par\pard\li893\ri0\sl-266\slmult0 \*\tx5333\fs22\cf0\f0\charscalex100 {fak
tor IX.}{ }\fs22\cf0\f0\charscalex100 {Hemofilia A dan B diturunkan secara}\tab
\fs22\cf0\f0\charscalex100\i {sex (X)-linked recessive.}\i0 \fs22\cf0\f0\charsca
lex100 { Pada kurang}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex
100 {lebih 20% kasus tidak ditemukan riwayat keluarga.}\par\pard\li893\ri0\sl-41
3\slmult0 \fs20\cf0\f0\charscalex100 {Insidens hemofilia A adalah 1:5000-10000 k
elahiran bayi laki-laki, sedangkan hemofilia}\par\pard\li893\ri0\sl-266\slmult0
\fs20\cf0\f0\charscalex100 {B adalah 1:30.000-50.000 kelahiran bayi laki-laki. D
iperkirakan terdapat sekitar 400.000}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf
0\f0\charscalex100 {penderita hemofilia di seluruh dunia. Di Indonesia dengan ju
mlah penduduk kurang lebih}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\chars
calex100 {220 juta jiwa, diperkirakan terdapat sekitar 20.000 penderita hemofili
a, tetapi hingga}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {
Desember 2007 baru tercatat 1130 pasien hemofilia (Data dari Himpunan Masyarakat
}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {Hemofilia Indone
sia).}\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slm
ult0 \fs18\cf0\par\pard\li893\ri0\sl-373\slmult0 \fs26\cf0\f0\charscalex100\b {D
iagnosis}\b0 \par\pard\li893\ri0\sl-413\slmult0 \fs22\cf0\f0\charscalex100\b {An
amnesis}\b0 \par\pard\li893\ri0\sl-306\slmult0 \fs22\cf0\f0\charscalex100 {Secar
a klinis perdarahan pada hemofilia A maupun B tidak dapat dibedakan. }\par\pard\
li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f
0\charscalex100 {Perdarahan}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346\fs20\c
f0\f0\charscalex100 {-}\tab \fs20\cf0\f0\charscalex100 {Perdarahan dapat terjadi
spontan atau pasca trauma/operasi. Berdasarkan aktivitas}\par\pard\li1346\ri0\s
l-266\slmult0 \fs20\cf0\f0\charscalex100 {kadar faktor VIII/IX, hemofilia dapat
diklasifikasikan menjadi ringan, sedang, dan}\par\pard\li1346\ri0\sl-266\slmu
lt0 \fs22\cf0\f0\charscalex100 {berat. (Lihat Tabel 1).}\par\pard\li1146\ri0\sl266\slmult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex1
00 {Perdarahan yang dapat ditemukan dan memerlukan penanganan serius:}\par\pard\
li1373\ri0\sl-266\slmult0 \*\tx1613\fs20\cf0\f0\charscalex100 {-}\tab \fs20\cf0\
f0\charscalex100 {Perdarahan sendi, yaitu sekitar 70-80% kasus hemofilia yang d
atang dengan}\par\pard\li1613\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {per
darahan akut. Sendi yang mengalami perdarahan akan terlihat bengkak dan}\par\par
d\li1613\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {nyeri bila digerakkan.}\
par\pard\li1373\ri0\sl-266\slmult0 \*\tx1613\fs22\cf0\f0\charscalex100 {-}\tab \
fs22\cf0\f0\charscalex100 {Perdarahan otot/jaringan lunak (10-20% kasus)}\par\pa
rd\li1373\ri0\sl-266\slmult0 \*\tx1613\fs20\cf0\f0\charscalex100 {-}\tab \fs20\c
f0\f0\charscalex100 {Perdarahan intrakranial akan ditemukan tanda-tanda peningka
tan tekanan}\par\pard\li1613\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {intr
akranial seperti muntah, penurunan kesadaran, dan kejang}\par\pard\li1373\ri0\sl
-266\slmult0 \*\tx1613\fs20\cf0\f0\charscalex100 {-}\tab \fs20\cf0\f0\charscalex
100 {Perdarahan mata, saluran cerna, leher/tenggorok, perdarahan akibat traum
a}\par\pard\li1613\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {berat dan sind
rom kompartmen akut.}\par\pard\li906\ri0\sl-440\slmult0 \*\tx1146\fs20\cf0\f0\ch

arscalex100 {-}\tab \fs20\cf0\f0\charscalex100 {Riwayat kelainan yang sama dalam

keluarga, yaitu saudara laki-laki pasien atau saudara}\par\pard\li1146\ri0\sl-2
66\slmult0 \fs22\cf0\f0\charscalex100 {laki-laki dari ibu pasien. Seorang ibu di
duga sebagai}{ }\fs18\cf0\f0\charscalex100\i {carrier obligat}\i0 \fs22\cf0\f0\c
harscalex100 { bila ia mempunyai}\par\pard\li1146\ri0\sl-266\slmult0 \fs20\cf0\f
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ebih saudara laki-laki}\par\pard\li1146\ri0\sl-266\slmult0 \fs20\cf0\f0\charscal
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3\margtsxn666\margbsxn293\pard\li1146\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li11
46\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1146\ri0\sl-213\slmult0 \fs18\cf0\par
\pard\li1146\ri0\sl-466\slmult0 \fs22\cf0\f0\charscalex100 {faktor VIII beserta
kadar antigen faktor VIII. Pembawa sifat ini juga dapat diketahui}\par\pard\li11
46\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {melalui pemeriksaan genetik.}\
par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \f
s22\cf0\f0\charscalex100 {Seorang bayi harus dicurigai menderita hemofilia jika
ditemukan bengkak atau}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscal
ex100 {hematoma pada saat bayi mulai merangkak atau berjalan. Pada anak yang leb
ih besar}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {dapat t
imbul hemartrosis di sendi lutut, siku, atau pegelangan tangan.}\par\pard\li893\
ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-333\slmult0 \fs22\cf0\f0\char
scalex100\b {Pemeriksaan fisis}\b0 \par\pard\li893\ri0\sl-306\slmult0 \fs22\cf0\
f0\charscalex100 {Tergantung letak perdarahan, misalnya:}\par\pard\li906\ri0\sl266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex1
00 {Perdarahan sendi: bengkak dan nyeri daerah sendi}\par\pard\li906\ri0\sl-266\
slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {
Perdarahan intrakranial: tanda peningkatan tekanan intrakranial}\par\pard\li906\
ri0\sl-266\slmult0 \*\tx1146\fs20\cf0\f0\charscalex100 {-}\tab \fs20\cf0\f0\char
scalex100 {Pada perdarahan berat dapat terjadi pucat, syok hemoragik, dan penu
runan}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {kesadaran}
\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-333\slmult0 \
fs22\cf0\f0\charscalex100\b {Pemeriksaan penunjang}\b0 \par\pard\li893\ri0\sl-30
6\slmult0 \fs20\cf0\f0\charscalex100 {Pada pemeriksaan darah tepi dapat ditemuka
n penurunan kadar hemoglobin bila}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f
0\charscalex100 {terjadi perdarahan masif, misalnya pada perdarahan intrakrania
l atau perdarahan}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100
{saluran cerna yang berat.}\fs20\cf0\f0\charscalex100 {Terdapat pemanjangan masa
pembekuan (}\fs20\cf0\f0\charscalex100\i {clotting time}\i0 \fs20\cf0\f0\charsc
alex100 {/CT)}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {dan
masa tromboplastin parsial (}\fs22\cf0\f0\charscalex100\i {activated partial th
romboplastin time}\i0 \fs22\cf0\f0\charscalex100 {/APTT) dengan}\par\pard\li893\
ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {masa protrombin (}\fs20\cf0\f0\ch
arscalex100\i {prothrombin time}\i0 \fs20\cf0\f0\charscalex100 {/PT) yang normal
. Diagnosis pasti adalah dengan}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0
\charscalex100 {pemeriksaan kadar faktor VIII dan faktor IX.}\par\pard\li893\ri0
\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-320\slmult0 \fs22\cf0\f0\charsca
lex100\b {Kriteria diagnosis}\b0 \par\pard\li893\ri0\sl-306\slmult0 \fs22\cf0\f0
\charscalex100 {Untuk memudahkan diagnosis, terdapat beberapa kriteria yang dapa
t membantu, yaitu:}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\char
scalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Kecenderungan terjadi perdarahan y
ang sukar berhenti setelah suatu tindakan, atau }\par\pard\li1146\ri0\sl-266\slm
ult0 \fs22\cf0\f0\charscalex100 {timbulnya hematom atau hemartrosis secara spon
tan atau setelah trauma ringan}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22
\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Riwayat keluarga}\par\
pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\tab \fs22\
cf0\f0\charscalex100 {Masa pembekuan memanjang, masa tromboplastin parsial meman
jang}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\fs22\cf0\f0\charscalex100 {-}\
tab \fs22\cf0\f0\charscalex100 {Diagnosis pasti: kadar aktivitas faktor VIII/IX
di bawah normal}\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\
sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-346\slmult0 \fs26\cf0\f0\charscal
ex100\b {Tata laksana}\b0 \par\pard\li893\ri0\sl-360\slmult0 \fs22\cf0\f0\charsc

alex100 {Tata laksana pasien hemofilia harus bersifat komprehensif dan multidisi
plin, melibatkan}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {
tenaga medis di bidang hematologi, bedah ortopedi, gigi, psikiatri, rehabili
tasi medis, }\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {sert
a unit transfusi darah. Tata laksana komprehensif akan menurunkan morbiditas dan
}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {memberikan hasil
yang lebih baik.}\par\pard\li893\ri0\sl-400\slmult0 \fs22\cf0\f0\charscalex100
{Prinsip umum penanganan hemofilia}\par\pard\li906\ri0\sl-266\slmult0 \*\tx1146\
fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Pencegahan terjadi
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ex100 {-}\tab \fs22\cf0\f0\charscalex100 {Tata laksana perdarahan akut sedini mu
ngkin (dalam waktu kurang dari 2 jam)}\par\pard\li906\ri0\sl-266\slmult0 \*\tx11
46\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Tata laksana pe
rdarahan berat di rumah sakit yang mempunyai fasilitas pelayanan}\par\pard\li114
6\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {hemofilia yang baik}\par\pard\l
i6480\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li6480\ri0\sl-213\slmult0 \fs18\cf0\
par\pard\li6480\ri0\sl-280\slmult0 \*\tx8320\fs12\cf0\f0\charscalex100\i {Pedoma
n Pelayanan Medis}\i0 \tab \fs22\cf0\f0\charscalex100 {93}\par\pard\sect\sectd\s
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ard\li1146\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {VIII/IX (lihat tabel 2
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i0\sl-346\slmult0 \fs22\cf0\f0\charscalex100\b {Evaluasi dan pemantauan komplika
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\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {A yang membentuk
antibodi atau inhibitor terhadap faktor VIII kurang lebih sebanyak }\par\pard\li
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asi kodon berhubungan dengan insidens}\par\pard\li893\ri0\sl-266\slmult0 \fs22\
cf0\f0\charscalex100 {inhibitor faktor VIII yang lebih tinggi. }\par\pard\li893\
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0\f0\charscalex100 {faktor VIII/IX. Bila kadarnya <5 BU (Bethesda Unit) disebut
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alex100 {sedangkan bila >5 BU disebut inhibitor titer tinggi.}\par\pard\li893\ri
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endah biasanya dapat diatasi dengan menaikkan dosis }\par\pard\li893\ri0\sl-266\
slmult0 \fs22\cf0\f0\charscalex100 {faktor VIII hingga 2-3 kali, sedangkan untuk
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fs22\cf0\f0\charscalex100 {pemberian faktor VIII}{ }\fs22\cf0\f0\charscalex100\i
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0 {konsentrat kompleks protrombin teraktivasi}{ }\fs20\cf0\f0\charscalex100\i {(
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0 \fs18\cf0\f0\charscalex100\i {aPCC),}\i0 \fs22\cf0\f0\charscalex100 { atau fak
torVIIa rekombinan. Konsultasi dengan ahli hematologi dalam tata laksana}\par\pa
rd\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {pasien dengan kelainan i
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scalex100 {Di beberapa negara maju pernah dilakukan}\tab \fs22\cf0\f0\charscalex
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ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {mengatasi adanya inhibitor pada p
asien hemofilia, antara lain adalah protokol Malmo, }\par\pard\li893\ri0\sl-266\
slmult0 \*\tx2413\fs22\cf0\f0\charscalex100 {protokol Bonn, }\tab \fs22\cf0\f0\c
harscalex100 {dan pemberian F VIII dengan dosis 25 IU/kg selang sehari, dengan}
\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {keberhasilan yang
bervariasi antara 60-87% namun biayanya sangat mahal.}\par\pard\li893\ri0\sl-21
3\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\r
i0\sl-386\slmult0 \fs26\cf0\f0\charscalex100\b {Kepustakaan}\b0 \par\pard\li893\
ri0\sl-293\slmult0 \*\tx1266\fs18\cf0\f0\charscalex100 {1. }\tab \fs18\cf0\f0\ch
arscalex100 {Montgomey RR, Gill JC, Scott JP. Hemophilia and vonWillebrand disea
se. Dalam: Nathan DG, Orkin SH, }\par\pard\li1266\ri0\sl-213\slmult0 \fs18\cf0\f
0\charscalex100 {penyunting. Nathan and Oski\uc1\u8217Xs hematology of infancy a
nd childhood. Edisi ke-6. Tokyo: WB Saunders}\par\pard\li1266\ri0\sl-226\slmult0
\fs18\cf0\f0\charscalex100 {Company;2003. h.1631-69.}\par\pard\li893\ri0\sl-240
\slmult0 \*\tx1266\fs18\cf0\f0\charscalex100 {2. }\tab \fs18\cf0\f0\charscalex10
0 {Friedman KD, Rodgers GM. Inherited coagulation disorders. Dalam: Greer JP
, Foerster J, Lukens}\par\pard\li1266\ri0\sl-226\slmult0 \fs18\cf0\f0\charscal
ex100 {JM, Rodgers GM, Paraskevas F, Glader B, penyunting. Wintrobe\uc1\u821
7Xs clinical hematology. Edisi ke 11. }\par\pard\li1266\ri0\sl-213\slmult0 \fs1
8\cf0\f0\charscalex100 {Philadelphia: Lippincott Williams & Wilkins;2004. h.1620
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mult0 \*\tx8320\fs12\cf0\f0\charscalex100\i {Pedoman Pelayanan Medis}\i0 \tab \f
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calex100 {Stanton BF, penyunting. Nelson textbook of pediatrics. Edisi ke-18. Ph
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arscalex100 {2007. h.2066-74.}\par\pard\li893\ri0\sl-253\slmult0 \*\tx1266\fs18\
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d\li1266\ri0\sl-213\slmult0 \fs18\cf0\f0\charscalex100 {Federation of Hemophilia
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53\slmult0 \*\tx1266\fs18\cf0\f0\charscalex100 {8. }\tab \fs18\cf0\f0\charscalex
100 {Negrier C, Gomperts ED. Considerations in the management of patients with
haemophilia and}\par\pard\li1266\ri0\sl-226\slmult0 \fs18\cf0\f0\charscalex100
{inhibitors. Haemophilia. 2006;12:2-3.}\par\pard\li893\ri0\sl-240\slmult0 \*\tx1
266\fs18\cf0\f0\charscalex100 {9. }\tab \fs18\cf0\f0\charscalex100 {Verbruggen B
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e}\par\pard\li1266\ri0\sl-226\slmult0 \fs18\cf0\f0\charscalex100 {Nijmegen modif
ication of the Bethesda assay for factor VIII:C inhibitors: improved specificit
y and}\par\pard\li1266\ri0\sl-213\slmult0 \fs18\cf0\f0\charscalex100 {reliabilit
y. Thromb Haemost. 1995;73:247-51.}\par\pard\li893\ri0\sl-253\slmult0 \fs18\cf0\
f0\charscalex100 {10. Lusher JM, Shapiro SS, Palascak JE, Rao AV, Levine PH
, Blatt PM. Efficacy of prothrombin-complex}\par\pard\li1266\ri0\sl-213\slmult
0 \fs18\cf0\f0\charscalex100 {concentrates in hemophiliacs with antibodies to fa
ctor VIII: A multicenter therapeutic trial. New Engl}\par\pard\li1266\ri0\sl-226
\slmult0 \fs18\cf0\f0\charscalex100 {J Med. 1980;303:421-5.}\par\pard\li893\ri0\
sl-240\slmult0 \fs18\cf0\f0\charscalex100 {11. Lusher JM, Roberts HR, Davignon
G, Joist JH, Smith H, Shapiro A, dkk. A randomized, double-blind}\par\pard\li126
6\ri0\sl-226\slmult0 \fs18\cf0\f0\charscalex100 {comparisonof two dosage levels
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66\ri0\sl-213\slmult0 \fs16\cf0\f0\charscalex100 {mucocutaneous haemorrhages in
persons with haemophilia A or B, with and without inhibitors. }\par\pard\li1266
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pard\li893\ri0\sl-253\slmult0 \fs18\cf0\f0\charscalex100 {12. Nilsson IM, Bernt
orp E, Zettervall O. Induction of immune tolerance in patients with hemophilia a
nd}\par\pard\li1266\ri0\sl-213\slmult0 \fs18\cf0\f0\charscalex100 {antibodies to
factor VIII by combined treatment with intravenous IgG, cyclophosphamide, and f
actor}\par\pard\li1266\ri0\sl-226\slmult0 \fs18\cf0\f0\charscalex100 {VIII. N En
g J Med. 1988;318:947-50.}\par\pard\li893\ri0\sl-240\slmult0 \fs18\cf0\f0\charsc
alex100 {13. Brackmann HH, Gormsen J. Massive factor VIII infusion in haemophil
ia with factor VIII inhibitor, high}\par\pard\li1266\ri0\sl-226\slmult0 \fs18\cf
0\f0\charscalex100 {responder. Lancet. 1977;2:933.}\par\pard\li893\ri0\sl-240\sl
mult0 \fs18\cf0\f0\charscalex100 {14. Mauser-Bunschoten EP, Nieuwenhuis HK, R
oosendaal G, van den Berg HM. Low-dose immune}\par\pard\li1266\ri0\sl-226\slmu
lt0 \fs18\cf0\f0\charscalex100 {tolerance induction in hemophilia A patients wit
h inhibitors. Blood. 1995;86:983-8.}\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0
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sl-240\slmult0 \fs18\cf0\f0\charscalex100 {Gastrointestinal }\par\pard\li1013\ri
0\sl-240\slmult0 \fs18\cf0\f0\charscalex100 {-I}\fs18\cf0\f0\charscalex100 {nisi
al}\fs18\cf0\f0\charscalex100 { }\par\pard\li1013\ri0\sl-226\slmult0 \fs18\cf0\f
0\charscalex100 {-P}\fs18\cf0\f0\charscalex100 {emelihar}\fs18\cf0\f0\charscalex
100 {aan}\fs18\cf0\f0\charscalex100 { }\par\pard\li1013\ri0\sl-213\slmult0 \fs18
\cf0\par\pard\li1013\ri0\sl-253\slmult0 \fs18\cf0\f0\charscalex100 {Ginjal }\fs1
8\cf0\f0\charscalex100 { }\par\pard\li1013\ri0\sl-226\slmult0 \fs18\cf0\f0\chars
calex100 {Laserasi dalam}\fs18\cf0\f0\charscalex100 { }\par\pard\li1013\ri0\sl-2
13\slmult0 \fs18\cf0\par\pard\li1013\ri0\sl-253\slmult0 \fs18\cf0\f0\charscalex1
00 {Operasi mayor}\fs18\cf0\f0\charscalex100 { }\par\pard\li1013\ri0\sl-226\slmu

lt0 \fs18\cf0\f0\charscalex100 {-P}\fs18\cf0\f0\charscalex100 {re}\fs18\cf0\f0\c

harscalex100 {-}\fs18\cf0\f0\charscalex100 {operasi}\fs18\cf0\f0\charscalex100 {
}\par\pard\li1013\ri0\sl-226\slmult0 \fs18\cf0\f0\charscalex100 {-P}\fs18\cf0\f
0\charscalex100 {asca}\fs18\cf0\f0\charscalex100 {-}\fs18\cf0\f0\charscalex100 {
operasi}\par\pard\li1013\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1013\ri0\sl-213
\slmult0 \fs18\cf0\par\pard\li1013\ri0\sl-266\slmult0 \fs18\cf0\f0\charscalex100
{Ekstraksi gigi}\fs18\cf0\f0\charscalex100 { }\par\pard\li1013\ri0\sl-226\slmul
t0 \fs18\cf0\f0\charscalex100 {-S}\fs18\cf0\f0\charscalex100 {ebelum tindakan}\f
s18\cf0\f0\charscalex100 { }\par\pard\li1013\ri0\sl-240\slmult0 \fs18\cf0\f0\cha
rscalex100 {-S}\fs18\cf0\f0\charscalex100 {etelah tindakan}\fs18\cf0\f0\charscal
ex100 { }\par\pard\li1013\ri0\sl-213\slmult0 \fs16\cf0\f0\charscalex100 {Keteran
gan : }\fs16\cf0\f0\charscalex100 { }\par\column\pard\li0\ri0\sl-226\slmult0 \fs
18\cf0\f0\charscalex100 {20-40 }\par\pard\li0\ri0\sl-226\slmult0 \fs18\cf0\f0\ch
arscalex100 {10-20 }\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\
sl-253\slmult0 \fs18\cf0\f0\charscalex100 {50-80 }\par\pard\li0\ri0\sl-226\slmul
t0 \fs18\cf0\f0\charscalex100 {30-50 }\par\pard\li0\ri0\sl-226\slmult0 \fs18\cf0
\f0\charscalex100 {20-40 }\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li
0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-266\slmult0 \fs18\cf0\f0\char
scalex100 {30-50 }\par\pard\li0\ri0\sl-240\slmult0 \fs18\cf0\f0\charscalex100 {1
0-20 }\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li0\ri0\sl-266\slmult0 \fs18\cf0\f0\charscalex100 {30-50 }\p
ar\pard\li0\ri0\sl-226\slmult0 \fs18\cf0\f0\charscalex100 {10-20 }\par\pard\li0\
ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-253\slmult0 \fs18\cf0\f0\charsc
alex100 {20-40 }\par\pard\li0\ri0\sl-226\slmult0 \fs18\cf0\f0\charscalex100 {2040 }\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-213\slmult0 \
fs18\cf0\par\pard\li0\ri0\sl-266\slmult0 \fs18\cf0\f0\charscalex100 {60-80 }\par
\pard\li0\ri0\sl-226\slmult0 \fs18\cf0\f0\charscalex100 {30-40 }\par\pard\li0\ri
0\sl-226\slmult0 \fs18\cf0\f0\charscalex100 {20-30 }\par\pard\li0\ri0\sl-240\slm
ult0 \fs18\cf0\f0\charscalex100 {10-20 }\par\pard\li0\ri0\sl-213\slmult0 \fs18\c
f0\par\pard\li0\ri0\sl-240\slmult0 \fs18\cf0\f0\charscalex100 {50 }\par\pard\li0
\ri0\sl-240\slmult0 \fs18\cf0\f0\charscalex100 {20-40 }\par\column\pard\li0\ri0\
sl-226\slmult0 \fs18\cf0\f0\charscalex100 {1-2 }\par\pard\li0\ri0\sl-226\slmult0
\fs18\cf0\f0\charscalex100 {3-5}\fs10\cf0\f0\charscalex100 {# }\par\pard\li0\ri
0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-253\slmult0 \fs18\cf0\f0\charscal
ex100 {1-3 }\par\pard\li0\ri0\sl-226\slmult0 \fs18\cf0\f0\charscalex100 {4-7 }\p
ar\pard\li0\ri0\sl-226\slmult0 \fs18\cf0\f0\charscalex100 {8-14}\fs10\cf0\f0\cha
rscalex100 {^ }\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-21
3\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-266\slmult0 \fs18\cf0\f0\charscalex100 {
1-3 }\par\pard\li0\ri0\sl-240\slmult0 \fs18\cf0\f0\charscalex100 {4-7 }\par\pard
\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\
pard\li0\ri0\sl-266\slmult0 \fs18\cf0\f0\charscalex100 {1-3 }\par\pard\li0\ri0\s
l-226\slmult0 \fs18\cf0\f0\charscalex100 {4-7 }\par\pard\li0\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li0\ri0\sl-253\slmult0 \fs18\cf0\f0\charscalex100 {3-5 }\par\
pard\li0\ri0\sl-226\slmult0 \fs18\cf0\f0\charscalex100 {5-7 }\par\pard\li0\ri0\s
l-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\r
i0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-280\slmult0 \fs18\cf0\f0\charsca
lex100 {1-3 }\par\pard\li0\ri0\sl-226\slmult0 \fs18\cf0\f0\charscalex100 {4-6 }\
par\pard\li0\ri0\sl-240\slmult0 \fs18\cf0\f0\charscalex100 {7-14 }\par\pard\li0\
ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\
li0\ri0\sl-266\slmult0 \fs18\cf0\f0\charscalex100 {1-3* }\par\column\pard\li0\ri
0\sl-226\slmult0 \fs18\cf0\f0\charscalex100 {15-30 }\par\pard\li0\ri0\sl-226\slm
ult0 \fs18\cf0\f0\charscalex100 {10-20 }\par\pard\li0\ri0\sl-213\slmult0 \fs18\c
f0\par\pard\li0\ri0\sl-253\slmult0 \fs18\cf0\f0\charscalex100 {50-80 }\par\pard\
li0\ri0\sl-226\slmult0 \fs18\cf0\f0\charscalex100 {30-50 }\par\pard\li0\ri0\sl-2
26\slmult0 \fs18\cf0\f0\charscalex100 {20-40 }\par\pard\li0\ri0\sl-213\slmult0 \
fs18\cf0\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-266\slmul
t0 \fs18\cf0\f0\charscalex100 {30-50 }\par\pard\li0\ri0\sl-240\slmult0 \fs18\cf0
\f0\charscalex100 {10-20 }\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li
0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-266\slmult0 \fs18\cf0\f0\char
scalex100 {30-50 }\par\pard\li0\ri0\sl-226\slmult0 \fs18\cf0\f0\charscalex100 {1

0-20 }\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-253\slmult0

\fs18\cf0\f0\charscalex100 {15-30 }\par\pard\li0\ri0\sl-226\slmult0 \fs18\cf0\f
0\charscalex100 {15-30 }\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\
ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-266\slmult0 \fs18\cf0\f0\charsc
alex100 {50-70 }\par\pard\li0\ri0\sl-226\slmult0 \fs18\cf0\f0\charscalex100 {3040 }\par\pard\li0\ri0\sl-226\slmult0 \fs18\cf0\f0\charscalex100 {20-30 }\par\par
d\li0\ri0\sl-240\slmult0 \fs18\cf0\f0\charscalex100 {10-20 }\par\pard\li0\ri0\sl
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0 {40 }\par\pard\li0\ri0\sl-240\slmult0 \fs18\cf0\f0\charscalex100 {20-30 }\par\
column\pard\li0\ri0\sl-226\slmult0 \fs18\cf0\f0\charscalex100 {1-2 }\par\pard\li
0\ri0\sl-226\slmult0 \fs18\cf0\f0\charscalex100 {3-5}\fs10\cf0\f0\charscalex100
{# }\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-253\slmult0 \
fs18\cf0\f0\charscalex100 {1-3 }\par\pard\li0\ri0\sl-226\slmult0 \fs18\cf0\f0\ch
arscalex100 {4-7 }\par\pard\li0\ri0\sl-226\slmult0 \fs18\cf0\f0\charscalex100 {8
-14}\fs10\cf0\f0\charscalex100 {^}\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par
\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-266\slmult0 \fs18\cf0
\f0\charscalex100 {1-3 }\par\pard\li0\ri0\sl-240\slmult0 \fs18\cf0\f0\charscalex
100 {4-7 }\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-213\slm
ult0 \fs18\cf0\par\pard\li0\ri0\sl-266\slmult0 \fs18\cf0\f0\charscalex100 {1-3 }
\par\pard\li0\ri0\sl-226\slmult0 \fs18\cf0\f0\charscalex100 {4-7 }\par\pard\li0\
ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-253\slmult0 \fs18\cf0\f0\charsc
alex100 {3-5 }\par\pard\li0\ri0\sl-226\slmult0 \fs18\cf0\f0\charscalex100 {5-7 }
\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-213\slmult0 \fs18
\cf0\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-280\slmult0 \
fs18\cf0\f0\charscalex100 {1-3 }\par\pard\li0\ri0\sl-226\slmult0 \fs18\cf0\f0\ch
arscalex100 {4-6 }\par\pard\li0\ri0\sl-240\slmult0 \fs18\cf0\f0\charscalex100 {7
-14 }\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li0\ri0\sl-266\slmult0 \fs18\cf0\f0\charscalex100 {1-3* }\par
\pard\sect\sectd\sbknone\pgwsxn10760\pghsxn14440\marglsxn666\margrsxn133\cols2\c
olno1\colw6480\colsr-0\colno2\colw3480\pard\li1013\ri0\sl-200\slmult0 \fs16\cf0\
f0\charscalex100 {*dapat diberikan lebih lama bila respons inadekuat}\fs16\cf0\f
0\charscalex100 { }\par\pard\li1053\ri0\sl-213\slmult0 \fs10\cf0\f0\charscalex10
0 {#}\fs14\cf0\f0\charscalex100 { }\fs14\cf0\f0\charscalex100 {dapat diberikan l
ebih lama sebagai profila}\fs14\cf0\f0\charscalex100 {ks}\fs14\cf0\f0\charscalex
100 {is selama fisioterapi}\fs14\cf0\f0\charscalex100 { }\par\pard\li1013\ri0\sl
-213\slmult0 \fs14\cf0\f0\charscalex100 {^ dapat diperpanjang hingga 21 hari bil
a diperlukan}\fs14\cf0\f0\charscalex100 { }\par\column\pard\li0\ri0\sl-213\slmul
t0 \fs18\cf0\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-213\s
lmult0 \fs18\cf0\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-2
13\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\
sl-293\slmult0 \*\tx1840\fs12\cf0\f0\charscalex100\i {Pedoman Pelayanan Medis}\i
0 \tab \fs22\cf0\f0\charscalex100 {97}\par\pard\sect\sectd\sbknone\pgwsxn10760\p
ghsxn14440\marglsxn666\margrsxn133\pard\sect\sectd\sbkpage
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3\margtsxn666\margbsxn293\pard\li3493\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li34
93\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li3493\ri0\sl-213\slmult0 \fs18\cf0\par
\pard\li3493\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li3493\ri0\sl-213\slmult0 \fs
18\cf0\par\pard\li3493\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li3493\ri0\sl-533\s
lmult0 \fs36\cf0\f0\charscalex100\b {Hepatitis Akut}\b0 \par\pard\li893\ri0\sl-2
13\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\
ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\par
d\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-280\slmult0 \fs22\cf0
\f0\charscalex100 {Hepatitis adalah suatu keradangan hati atau kerusakan dan nek
rosis sel hepatosit. Secara}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\char
scalex100 {klinis hal ini ditandai dengan peningkatan kadar transaminase. Menuru
t lamanya waktu}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {t
erinfeksi hepatitis dibagi menjadi hepatitis akut dan kronis. Dikatakan hepatiti
s kronis}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {apabila
berlangsung lebih dari 6 bulan. }\par\pard\li893\ri0\sl-413\slmult0 \fs20\cf0\f0
\charscalex100 {Penyebab dari hepatitis yaitu virus hepatotropik, virus non- hep
atotropik, bakteri atau}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscal
ex100 {jamur, autoimun, toksin obat, herbal, gangguan perfusi, dll.}\par\pard\li
893\ri0\sl-426\slmult0 \fs20\cf0\f0\charscalex100 {Infeksi virus hepatitis A ata
u sering disebut hepatitis A banyak ditemukan di seluruh}\par\pard\li893\ri0\sl-

266\slmult0 \fs20\cf0\f0\charscalex100 {dunia terutama di negara berkembang dan

Indonesia dikatagorikan oleh WHO pada}\par\pard\li893\ri0\sl-266\slmult0 \fs22\c
f0\f0\charscalex100 {area endemisitas tinggi. Anak-anak sangat berperan terhadap
penularan hepatitis A ini, }\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\cha
rscalex100 {manifestasi klinis pada anak-anak yang terinfeksi virus hepatitis A
ini sangat bervariasi}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex
100 {mulai tanpa gejala klinis sampai hepatitis fulminan. Sebagian besar anak ya
ng terinfeksi}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {vir
us hepatitis A ini adalah asimptomatik.}\par\pard\li893\ri0\sl-386\slmult0 \fs22
\cf0\f0\charscalex100 {Infeksi virus Hepatitis B atau hepatitis B masih merupaka
n masalah global. WHO}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex
100 {memasukkan Indonesia pada area dengan endemisitas sedang sampai tinggi. Man
ifestasi}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {klinis s
eseorang yang terinfeksi virus hepatitis B bervariasi dari asimptomatik menjadi}
\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {kronis, hepatiti
s akut kemudian sembuh atau berlanjut menjadi kronis atau menjadi}\par\pard\li89
3\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {hepatitis fulminan. Yang perlu
diperhatikan adalah bahwa kronisitas sangat tergantung}\par\pard\li893\ri0\sl-26
6\slmult0 \fs22\cf0\f0\charscalex100 {umur saat terinfeksi, makin muda terinfek
si makin tinggi kronisitasnya. Bayi yang}\par\pard\li893\ri0\sl-266\slmult0 \fs
22\cf0\f0\charscalex100 {terinfeksi virus hepatitis B dari ibu pada saat dalam k
andungan atau intrauterin maupun}\par\pard\li893\ri0\sl-266\slmult0 \fs20\cf0\f0
\charscalex100 {terinfeksi pada saat persalinan, kurang lebih 95% asimptomatik d
an akan menjadi kronis, }\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charsca
lex100 {sisanya 5% dapat menimbulkan manifestasi klinis akut.}\par\pard\li893\ri
0\sl-386\slmult0 \fs22\cf0\f0\charscalex100 {Infeksi virus Hepatitis C jarang di
laporkan pada populasi anak. Infeksi hepatitis D tidak}\par\pard\li893\ri0\sl-26
6\slmult0 \fs22\cf0\f0\charscalex100 {dapat terjadi tanpa superinfeksi oleh hepa
titis B. Penularan hepatits D biasanya terjadi}\par\pard\li893\ri0\sl-266\slmult
0 \fs22\cf0\f0\charscalex100 {di dalam keluarga pada daerah padat penduduk terut
ama di negara berkembang. Infeksi}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f
0\charscalex100 {hepatitis D dan E pada anak juga jarang dilaporkan di Indonesia
.}\par\pard\li893\ri0\sl-400\slmult0 \fs22\cf0\f0\charscalex100 {Fokus pembahasa
n pada pedoman ini adalah hepatitis A, B dan C}\par\pard\li893\ri0\sl-213\slmult
0 \fs18\cf0\par\pard\li893\ri0\sl-413\slmult0 \fs22\cf0\f0\charscalex100\b {Diag
nosis}\b0 \par\pard\li893\ri0\sl-306\slmult0 \fs22\cf0\f0\charscalex100 {Perjala
nan klasik hepatitis virus akut meliputi stadium prodormal berupa flu like}\par\
pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {syndrome yang diikuti
stadium ikterus. Pada stadium ikterus IN gejala2 pada stadium}\par\pard\li893\ri
0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {prodormal berkurang disertai muncul
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ard\li893\ri0\sl-373\slmult0 \fs22\cf0\f0\charscalex100 {98 }{ }\fs16\cf0\f0\c
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3\margtsxn666\margbsxn293\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893
\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pa
rd\li893\ri0\sl-466\slmult0 \fs22\cf0\f0\charscalex100\b {Anamnesis}\b0 \par\par
d\li893\ri0\sl-320\slmult0 \*\tx1133\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0
\f0\charscalex100 {Anamnesis ditujukan terhadap adanya gejala klasik hepatitis a
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lex100 {hepatitis akut akibat virus hepatotropik hanya dapat diketahui dengan pe
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lex100 {-}\tab \fs20\cf0\f0\charscalex100 {Manifestasi hepatitis A akut bervaria
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lt0 \fs22\cf0\f0\charscalex100 {khas, gejala khas yang klasik sampai hepatitis f
ulminan.}\par\pard\li893\ri0\sl-266\slmult0 \*\tx1133\fs20\cf0\f0\charscalex100
{-}\tab \fs20\cf0\f0\charscalex100 {Anak dapat dicurigai menderita hepatitis A a
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\charscalex100 {berhubungan dengan saluran cerna dan ditemukan faktor risiko mi
salnya pada}\par\pard\li1133\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {kead
aan adanya outbreak atau diketahui adanya sumber penularan. Onset hepatitis}\par
\pard\li1133\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {A biasanya terjadi s
ecara tiba tiba, dimulai dengan keluhan sistemik yang tidak khas}\par\pard\li113

3\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {seperti demam, malaise, nausea,

emesis, anorexia, dan rasa tidak nyaman pada perut. }\par\pard\li1133\ri0\sl-26
6\slmult0 \fs22\cf0\f0\charscalex100 {Gejala prodromal ini seringkali ringan dan
tidak diketahui pada bayi dan anak. lkterus}\par\pard\li1133\ri0\sl-266\slmult0
\fs22\cf0\f0\charscalex100 {pada anak-seringkali tidak begitu tampak dan sexing
hanya bisa dideteksi dengan}\par\pard\li1133\ri0\sl-266\slmult0 \fs22\cf0\f0\ch
arscalex100 {pemeriksaan petanda serologi.}\par\pard\li893\ri0\sl-266\slmult0 \*
\tx1133\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Hepatitis
B akut pada beberapa dapat didahului dengan gejala prodromal mirip serum}\par\pa
rd\li1133\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {sickness yang ditandai
dengan athralgia, arthritis}\par\pard\li893\ri0\sl-266\slmult0 \*\tx1133\fs22\cf
0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Faktor risiko penularan p
erlu ditanyakan meski kadang sulit ditemukan.}\par\pard\li893\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li893\ri0\sl-293\slmult0 \fs22\cf0\f0\charscalex100\b {Pemer
iksaan fisik}\b0 \par\pard\li893\ri0\sl-306\slmult0 \*\tx1133\fs22\cf0\f0\charsc
alex100 {-}\tab \fs22\cf0\f0\charscalex100 {Dapat ditemukan ikterus, hepatomegal
i, nyeri tekan diabdomen kuadran kanan atas}\par\pard\li1133\ri0\sl-266\slmult0
\fs22\cf0\f0\charscalex100 {akibat meregangnya capsula hepatis}\par\pard\li893\r
i0\sl-266\slmult0 \*\tx1133\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\chars
calex100 {Kadang ditemukan demam}\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\pa
r\pard\li893\ri0\sl-400\slmult0 \fs22\cf0\f0\charscalex100\b {Pemeriksaan penunj
ang}\b0 \par\pard\li893\ri0\sl-306\slmult0 \*\tx1133\fs22\cf0\f0\charscalex100 {
-}\tab \fs22\cf0\f0\charscalex100 {Adanya hepatitis akut ditunjukkan dengan adan
ya transaminase yang meningkat}\par\pard\li1133\ri0\sl-266\slmult0 \fs22\cf0\f0\
charscalex100 {terutama ALT dan mungkin disertai adanya kadar bilirubin yang men
ingkat terutama}\par\pard\li1133\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {
pada adanya kolestasis.}\par\pard\li893\ri0\sl-266\slmult0 \*\tx1133\fs22\cf0\f0
\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Untuk menenwkan virus mana ya
ng bertanggung jawab terhadap hepatitis akut}\par\pard\li1133\ri0\sl-266\slmult0
\fs22\cf0\f0\charscalex100 {adalah dengan melakukan pemeriksaan serologi yang d
apat menunjukkan akut dan}\par\pard\li1133\ri0\sl-266\slmult0 \fs22\cf0\f0\chars
calex100 {khas untuk masing-masing virus.}\par\pard\li893\ri0\sl-266\slmult0 \*\
tx1133\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Hepatitis a
kut virus A : IgM anti- HVA postif, hepatitis akut virus B : IgM anti HBc}\par\p
ard\li1133\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {positif, Anti- HVC dan
RNA virus hepatitis C. - Berikut adalah petanda diagnostik}\par\pard\li1133\ri0
\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {dari masing-masing virus hepatitis.}
\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-320\slmult0 \
fs22\cf0\f0\charscalex100\b {Tata laksana}\b0 \par\pard\li893\ri0\sl-306\slmult0
\*\tx1133\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Tidak a
da terapi spesifik untuk hepatitis akut, tats laksana suportif dengan asupan}\pa
r\pard\li1133\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {kalori yang cukup.}
\par\pard\li893\ri0\sl-266\slmult0 \*\tx1133\fs22\cf0\f0\charscalex100 {-}\tab \
fs22\cf0\f0\charscalex100 {Pemantauan ditujukan pada hepatitis yang dapat melanj
ut menjadi kronis yaitu}\par\pard\li1133\ri0\sl-266\slmult0 \fs22\cf0\f0\charsca
lex100 {hepatitis B dan C untuk memastikan tidak terjadi kronisitas.}\par\pard\l
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par\pard\li6480\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li6480\ri0\sl-453\slmult0
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lt0 \fs18\cf0\par\pard\li946\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li946\ri0\sl200\slmult0 \fs14\cf0\f1\charscalex100 {PetandahepatitisB}\par\pard\li946\ri0\sl
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lmult0 \fs18\cf0\par\pard\li0\ri0\sl-213\slmult0 \fs14\cf0\f1\charscalex100 {Ant
ibodi(subklas-IgG)terhadap}\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\f1\charsca
lex100 {HVA}\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-213\s
lmult0 \fs18\cf0\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-2
26\slmult0 \fs18\cf0\f1\charscalex100 {AntigenpermukaanHVB,ditemukan}\par\pard\l
i0\ri0\sl-226\slmult0 \fs14\cf0\f1\charscalex100 {pads permukaan virus yang utuh
dan}\par\pard\li0\ri0\sl-213\slmult0 \fs14\cf0\f1\charscalex100 {padaserumsebag
aipartikelbebas}\par\pard\li0\ri0\sl-213\slmult0 \fs14\cf0\f1\charscalex100 {(sp
eris atau tubuler)}\par\column\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li
0\ri0\sl-213\slmult0 \fs14\cf0\f1\charscalex100 {Menunjukan riwayat infeksi HVA.
}\par\pard\li0\ri0\sl-213\slmult0 \fs14\cf0\f1\charscalex100 {Memastikanpaparant
erdahuludanimunitas}\par\pard\li0\ri0\sl-213\slmult0 \fs14\cf0\f1\charscalex100
{terhadap HVA}\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-213
\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-226\slmult0 \fs14\cf0\f1\charscalex100 {M
enunjukkan infeksi dengan HVB (akut maupun}\par\pard\li0\ri0\sl-226\slmult0 \fs1
6\cf0\f1\charscalex100 {kronis)}\par\pard\sect\sectd\sbknone\pgwsxn10760\pghsxn1
4440\marglsxn666\margrsxn133\cols2\colno1\colw2573\colsr-0\colno2\colw7386\pard\
li946\ri0\sl-253\slmult0 \fs18\cf0\f1\charscalex100 {HbcAg}\par\pard\li946\ri0\s
l-213\slmult0 \fs18\cf0\par\pard\li946\ri0\sl-253\slmult0 \fs18\cf0\f1\charscale
x100 {HbeAg}\par\column\pard\li0\ri0\sl-253\slmult0 \*\tx2573\fs18\cf0\f1\charsc
alex100 {AntigenintiHVB,ditemukanpadainti}\tab \fs14\cf0\f1\charscalex100 {Tidak
dideteksi pada serum}\par\pard\li0\ri0\sl-213\slmult0 \*\tx2573\fs14\cf0\f1\cha
rscalex100 {virus yang utuh}\tab \fs14\cf0\f1\charscalex100 {(hanya pada jaringa
n liver)}\par\pard\li0\ri0\sl-253\slmult0 \*\tx2573\fs14\cf0\f1\charscalex100 {A
ntigenBehepatitis,antigensolubel}\tab \fs14\cf0\f1\charscalex100 {Menunjukkaninf
eksiHVBaktif;Berkorelasi}\par\pard\li0\ri0\sl-213\slmult0 \*\tx2573\fs14\cf0\f1\
charscalex100 {yang diproduksi selama pembelahan}\tab \fs14\cf0\f1\charscalex100
{denganreplikasiHBV;persistenselama6-8minggu}\par\pard\li0\ri0\sl-213\slmult0 \
*\tx2573\fs18\cf0\f1\charscalex100 {HbcAg}\tab \fs14\cf0\f1\charscalex100 {menun
jukkankarierkronisataupenyakithati}\par\pard\li2573\ri0\sl-213\slmult0 \fs16\cf0
\f1\charscalex100 {kronis}\par\pard\sect\sectd\sbknone\pgwsxn10760\pghsxn14440\m
arglsxn666\margrsxn133\cols3\colno1\colw2573\colsr-0\colno2\colw2573\colsr-0\col
no3\colw4813\pard\li946\ri0\sl-253\slmult0 \fs18\cf0\f1\charscalex100 {Anti-HBs}
\par\pard\li946\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li946\ri0\sl-253\slmult0 \
fs16\cf0\f1\charscalex100 {Anti-HBc}\par\pard\li946\ri0\sl-213\slmult0 \fs18\cf0
\par\pard\li946\ri0\sl-240\slmult0 \fs18\cf0\f1\charscalex100 {Anti-HBcIgM}\par\
pard\li946\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li946\ri0\sl-213\slmult0 \fs18\
cf0\par\pard\li946\ri0\sl-253\slmult0 \fs18\cf0\f1\charscalex100 {Anti-Hbe}\par\
pard\li946\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li946\ri0\sl-213\slmult0 \fs18\
cf0\par\pard\li946\ri0\sl-253\slmult0 \fs18\cf0\f1\charscalex100 {DNA VHB}\par\p
ard\li946\ri0\sl-253\slmult0 \fs14\cf0\f1\charscalex100 {PetandahepatitisC}\par\
pard\li946\ri0\sl-253\slmult0 \fs18\cf0\f1\charscalex100 {Anti-HVC}\par\pard\li9
46\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li946\ri0\sl-253\slmult0 \fs18\cf0\f1\c
harscalex100 {RNA VHC}\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li89
3\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\p
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r\column\pard\li0\ri0\sl-253\slmult0 \fs14\cf0\f1\charscalex100 {Antiboditerhada
pHbsAgsubklas}\par\pard\li0\ri0\sl-213\slmult0 \fs14\cf0\f1\charscalex100 {IgM d
an IgG}\par\pard\li0\ri0\sl-253\slmult0 \fs14\cf0\f1\charscalex100 {Antiboditota
lterhadapantigeninti}\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\f1\charscalex100
{HBVB(HbcAg)}\par\pard\li0\ri0\sl-240\slmult0 \fs16\cf0\f1\charscalex100 {Antib
odiIgMterhadapHBcAg}\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\
sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-253\slmult0 \fs14\cf0\f1\charscalex
100 {AntiboditerhadapHBeAg}\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\l
i0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-253\slmult0 \fs14\cf0\f1\cha
rscalex100 {DNA dari HVB}\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0
\ri0\sl-293\slmult0 \fs14\cf0\f1\charscalex100 {Andbodi terhadap VHC}\par\pard\l
i0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-253\slmult0 \fs18\cf0\f1\cha
rscalex100 {RNA HVC}\par\column\pard\li0\ri0\sl-253\slmult0 \fs14\cf0\f1\charsca
lex100 {Menunjukkan penyembuhan dari infeksi HVB dan}\par\pard\li0\ri0\sl-213\sl
mult0 \fs14\cf0\f1\charscalex100 {imunitas}\par\pard\li0\ri0\sl-253\slmult0 \fs1
4\cf0\f1\charscalex100 {MenunjukkaninfeksiHBVaktif(akutdankronis)}\par\pard\li0\
ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-240\slmult0 \fs14\cf0\f1\charsc
alex100 {PenunjukawaluntukinfeksiHVBakut;meningkat}\par\pard\li0\ri0\sl-226\slmu
lt0 \fs14\cf0\f1\charscalex100 {padafaseakutkemudianmenurun(4-6bulan);}\par\pard
\li0\ri0\sl-213\slmult0 \fs14\cf0\f1\charscalex100 {tidakadapadainfeksikronisHVB
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menjadianti-Hbe)}\par\pard\li0\ri0\sl-226\slmult0 \fs14\cf0\f1\charscalex100 {me
nunjukkanresolusidarifaseaktifpada}\par\pard\li0\ri0\sl-213\slmult0 \fs14\cf0\f1
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cf0\par\pard\li0\ri0\sl-293\slmult0 \fs14\cf0\f1\charscalex100 {Menunjukkanpapar
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charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Pemeriksaan darah tepi lengkap
, analisis gas darah, elektrolit (K}\fs12\cf0\f0\charscalex100 {+}\fs22\cf0\f0
\charscalex100 {, Na}\fs12\cf0\f0\charscalex100 {+}\fs20\cf0\f0\charscalex100 {
, Mg, Ca), }\par\pard\li1346\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {as
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ard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-520\slmult0 \fs26\c
f0\f0\charscalex100\b {Kepustakaan}\b0 \par\pard\li893\ri0\sl-320\slmult0 \*\tx1
266\fs18\cf0\f0\charscalex100 {1. }\tab \fs18\cf0\f0\charscalex100 {Margolin JF,
Poplack DG. Acute lymphoblastic leukemia. Dalam: Pizzo PA, Poplack DG, penyunti
ng. }\par\pard\li1266\ri0\sl-213\slmult0 \fs18\cf0\f0\charscalex100 {Principles
and practice of pediatric oncology. Edisi ke-4. Philadelphia: Lippincott-Raven P
ublisher;2002. }\par\pard\li1266\ri0\sl-226\slmult0 \fs18\cf0\f0\charscalex100 {
h.409-62.}\par\pard\li893\ri0\sl-253\slmult0 \*\tx1266\fs18\cf0\f0\charscalex100
{2. }\tab \fs18\cf0\f0\charscalex100 {Crist WM, Pullen DJ, Riviera GK. Acute ly
mphoid leukemia. Dalam: Fernbach DJ, Vietti TJ, penyunting. }\par\pard\li1266\ri
0\sl-213\slmult0 \fs18\cf0\f0\charscalex100 {Clinical pediatric Oncology. Edisi
ke-4. St. Louis: Mosby Year Book;1991. h.305-36. }\par\pard\li893\ri0\sl-253\slm
ult0 \*\tx1266\fs18\cf0\f0\charscalex100 {3. }\tab \fs18\cf0\f0\charscalex100 {H
ussein M, Cullen K. Metabolic emergencies. Dalam: Jonston PG, Spence RAJ, penyun
ting. Oncologic}\par\pard\li1266\ri0\sl-213\slmult0 \fs18\cf0\f0\charscalex100 {
Emergencies. Edisi pertama. New York: Oxford University press;2002. h.51-74.}\pa
r\pard\li893\ri0\sl-253\slmult0 \*\tx1266\fs18\cf0\f0\charscalex100 {4. }\tab \f
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\fs18\cf0\f0\charscalex100 {CP, penyunting. Oncologic Emergencies. Edisi pertam
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{\sp{\sn pVerticies}{\sv 8;5;(1493,0);(0,0);(0,1066);(1493,1066);(1493,0);}}
{\sp{\sn pSegmentInfo}{\sv 2;12;16384;45824;1;45824;1;45824;1;45824;1;45824;2457
7;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 0}}
{\sp{\sn lineWidth}{\sv 8573}}
{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineDashing}{\sv 0}}
{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft1880\shptop4866\shpright1880\shpbottom4866\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;1;(0,0);}}
{\sp{\sn pSegmentInfo}{\sv 2;4;16384;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}
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{\sp{\sn lineWidth}{\sv 8573}}
{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineDashing}{\sv 0}}
{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
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{\shp{\*\shpinst\shpleft2866\shptop6680\shpright4013\shpbottom7066\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn rotation}{\sv 0}}

{\sp{\sn geoRight}{\sv 1147}}
{\sp{\sn geoBottom}{\sv 386}}
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{\sp{\sn pVerticies}{\sv 8;5;(0,0);(0,386);(1133,386);(1133,0);(0,0);}}
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{\sp{\sn fFillOK}{\sv 1}}
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{\shp{\*\shpinst\shpleft2866\shptop6680\shpright4013\shpbottom7066\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn pVerticies}{\sv 8;5;(1133,0);(0,0);(0,386);(1133,386);(1133,0);}}
{\sp{\sn pSegmentInfo}{\sv 2;12;16384;45824;1;45824;1;45824;1;45824;1;45824;2457
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{\sp{\sn fFillOK}{\sv 1}}
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{\shp{\*\shpinst\shpleft2866\shptop6680\shpright2866\shpbottom6680\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn pSegmentInfo}{\sv 2;4;16384;45824;24577;32768}}
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{\sp{\sn lineColor}{\sv 526342}}
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{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
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{\sp{\sn fBehindDocument}{\sv 1}}
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{\shp{\*\shpinst\shpleft3413\shptop4360\shpright3520\shpbottom6693\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}

{\sp{\sn fFlipH}{\sv 0}}
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{\sp{\sn geoRight}{\sv 107}}
{\sp{\sn geoBottom}{\sv 2333}}
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{\sp{\sn pVerticies}{\sv 8;16;(53,13);(53,2253);(53,2253);(53,2253);(53,2253);(5
3,2253);(53,13);(53,0);(53,0);(53,0);(53,13);(106,2226);(53,2333);(0,2226);(53,1
3);(53,13);}}
{\sp{\sn pSegmentInfo}{\sv 2;34;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
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824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 1}}
{\sp{\sn fillColor}{\sv 526342}}
{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineColor}{\sv 0}}
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{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
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{\shp{\*\shpinst\shpleft3586\shptop4773\shpright5080\shpbottom6493\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn geoRight}{\sv 1494}}
{\sp{\sn geoBottom}{\sv 1720}}
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{\sp{\sn pVerticies}{\sv 8;5;(0,0);(0,1720);(1493,1720);(1493,0);(0,0);}}
{\sp{\sn pSegmentInfo}{\sv 2;12;16384;45824;1;45824;1;45824;1;45824;1;45824;2457
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{\sp{\sn fFillOK}{\sv 1}}
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{\sp{\sn fillColor}{\sv 16777215}}
{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineColor}{\sv 0}}
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{\sp{\sn fBehindDocument}{\sv 1}}
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{\shp{\*\shpinst\shpleft3586\shptop4773\shpright5080\shpbottom6493\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn geoRight}{\sv 1494}}
{\sp{\sn geoBottom}{\sv 1720}}
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{\sp{\sn pVerticies}{\sv 8;5;(1493,0);(0,0);(0,1720);(1493,1720);(1493,0);}}
{\sp{\sn pSegmentInfo}{\sv 2;12;16384;45824;1;45824;1;45824;1;45824;1;45824;2457
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{\sp{\sn fFillOK}{\sv 1}}
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{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
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{\sp{\sn fArrowheadsOK}{\sv 0}}

{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft3586\shptop4773\shpright3586\shpbottom4773\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn pSegmentInfo}{\sv 2;4;16384;45824;24577;32768}}
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{\shp{\*\shpinst\shpleft5533\shptop5066\shpright6520\shpbottom5640\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn pVerticies}{\sv 8;5;(0,0);(0,573);(986,573);(986,0);(0,0);}}
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{\shp{\*\shpinst\shpleft5533\shptop5066\shpright6520\shpbottom5640\shpfhdr0\shpw
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{\sp{\sn fFillOK}{\sv 1}}
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{\sp{\sn lineDashing}{\sv 0}}

{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
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{\shp{\*\shpinst\shpleft5533\shptop5066\shpright5533\shpbottom5066\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn pVerticies}{\sv 8;1;(0,0);}}
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{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
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{\shp{\*\shpinst\shpleft6360\shptop5746\shpright7853\shpbottom6533\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn pVerticies}{\sv 8;5;(0,0);(0,786);(1493,786);(1493,0);(0,0);}}
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{\shp{\*\shpinst\shpleft6360\shptop5746\shpright7853\shpbottom6533\shpfhdr0\shpw
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{\sp{\sn pSegmentInfo}{\sv 2;12;16384;45824;1;45824;1;45824;1;45824;1;45824;2457
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{\sp{\sn fFillOK}{\sv 1}}

{\sp{\sn fFilled}{\sv 0}}

{\sp{\sn lineWidth}{\sv 8573}}
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{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
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{\shp{\*\shpinst\shpleft6360\shptop5746\shpright6360\shpbottom5746\shpfhdr0\shpw
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{\shp{\*\shpinst\shpleft2746\shptop2133\shpright8240\shpbottom2133\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn pVerticies}{\sv 8;2;(0,0);(5493,0);}}
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn pVerticies}{\sv 8;16;(66,13);(66,106);(53,106);(53,106);(53,106);(53,10

6);(53,13);(53,0);(53,0);(53,0);(66,13);(106,80);(53,186);(0,80);(66,13);(66,13)
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{\sp{\sn pSegmentInfo}{\sv 2;34;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
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{\shp{\*\shpinst\shpleft4533\shptop2160\shpright4640\shpbottom2346\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn pVerticies}{\sv 8;16;(53,13);(53,106);(53,106);(53,106);(53,106);(53,10
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{\sp{\sn pSegmentInfo}{\sv 2;34;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
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{\sp{\sn fFillOK}{\sv 1}}
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{\shp{\*\shpinst\shpleft6466\shptop2120\shpright6573\shpbottom2320\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn pVerticies}{\sv 8;16;(66,13);(66,106);(53,106);(53,106);(53,106);(53,10
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{\sp{\sn pSegmentInfo}{\sv 2;34;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
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{\sp{\sn fFillOK}{\sv 1}}
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{\shp{\*\shpinst\shpleft8186\shptop2120\shpright8293\shpbottom2320\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn geoRight}{\sv 107}}
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{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;16;(66,13);(66,106);(53,106);(53,106);(53,106);(53,10
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{\sp{\sn pSegmentInfo}{\sv 2;34;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
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{\sp{\sn fFillOK}{\sv 1}}
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{\shp{\*\shpinst\shpleft2693\shptop2866\shpright2800\shpbottom3186\shpfhdr0\shpw
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{\sp{\sn shapeType}{\sv 0}}
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{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 107}}
{\sp{\sn geoBottom}{\sv 320}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;16;(66,13);(66,226);(53,226);(53,226);(53,226);(53,22
6);(53,13);(53,0);(53,0);(53,0);(66,13);(106,213);(53,320);(0,213);(66,13);(66,1
3);}}
{\sp{\sn pSegmentInfo}{\sv 2;34;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 1}}
{\sp{\sn fillColor}{\sv 526342}}
{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineColor}{\sv 0}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft2320\shptop4346\shpright2440\shpbottom4893\shpfhdr0\shpw
r3\shpwrk0\shpfblwtxt1\shplid4722\shpz50\shpbxpage\shpbypage
{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 120}}
{\sp{\sn geoBottom}{\sv 547}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;16;(66,13);(66,453);(53,466);(53,466);(53,466);(53,45
3);(53,13);(53,0);(53,0);(53,0);(66,13);(106,440);(53,546);(0,440);(66,13);(66,1
3);}}
{\sp{\sn pSegmentInfo}{\sv 2;34;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45

824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 1}}
{\sp{\sn fillColor}{\sv 526342}}
{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineColor}{\sv 0}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft4533\shptop2973\shpright4640\shpbottom3333\shpfhdr0\shpw
r3\shpwrk0\shpfblwtxt1\shplid4723\shpz51\shpbxpage\shpbypage
{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 107}}
{\sp{\sn geoBottom}{\sv 360}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;16;(53,0);(66,266);(53,280);(53,280);(53,280);(53,266
);(40,13);(40,0);(40,0);(53,0);(53,0);(106,253);(53,360);(0,253);(53,0);(53,0);}
}
{\sp{\sn pSegmentInfo}{\sv 2;34;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 1}}
{\sp{\sn fillColor}{\sv 526342}}
{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineColor}{\sv 0}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft2320\shptop3773\shpright2440\shpbottom3960\shpfhdr0\shpw
r3\shpwrk0\shpfblwtxt1\shplid4724\shpz52\shpbxpage\shpbypage
{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 120}}
{\sp{\sn geoBottom}{\sv 187}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;16;(66,13);(66,106);(53,106);(53,106);(53,106);(53,10
6);(53,13);(53,0);(53,0);(53,0);(66,13);(106,80);(53,186);(0,80);(66,13);(66,13)
;}}
{\sp{\sn pSegmentInfo}{\sv 2;34;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 1}}
{\sp{\sn fillColor}{\sv 526342}}
{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineColor}{\sv 0}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft3240\shptop3773\shpright3346\shpbottom4000\shpfhdr0\shpw
r3\shpwrk0\shpfblwtxt1\shplid4725\shpz53\shpbxpage\shpbypage
{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}

{\sp{\sn rotation}{\sv 0}}

{\sp{\sn geoRight}{\sv 106}}
{\sp{\sn geoBottom}{\sv 227}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;16;(66,13);(53,133);(53,133);(53,146);(53,133);(40,13
3);(53,13);(53,0);(53,0);(66,0);(66,13);(106,120);(53,226);(0,120);(66,13);(66,1
3);}}
{\sp{\sn pSegmentInfo}{\sv 2;34;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 1}}
{\sp{\sn fillColor}{\sv 526342}}
{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineColor}{\sv 0}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft2373\shptop3786\shpright3306\shpbottom3786\shpfhdr0\shpw
r3\shpwrk0\shpfblwtxt1\shplid4726\shpz54\shpbxpage\shpbypage
{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 933}}
{\sp{\sn geoBottom}{\sv 0}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;2;(0,0);(920,0);}}
{\sp{\sn pSegmentInfo}{\sv 2;5;16384;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 0}}
{\sp{\sn lineWidth}{\sv 8573}}
{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineDashing}{\sv 0}}
{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft5440\shptop1986\shpright5440\shpbottom2146\shpfhdr0\shpw
r3\shpwrk0\shpfblwtxt1\shplid4727\shpz55\shpbxpage\shpbypage
{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 0}}
{\sp{\sn geoBottom}{\sv 160}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;2;(0,0);(0,160);}}
{\sp{\sn pSegmentInfo}{\sv 2;5;16384;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 0}}
{\sp{\sn lineWidth}{\sv 8573}}
{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineDashing}{\sv 0}}
{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}

{\shp{\*\shpinst\shpleft2813\shptop3653\shpright2813\shpbottom3786\shpfhdr0\shpw
r3\shpwrk0\shpfblwtxt1\shplid4728\shpz56\shpbxpage\shpbypage
{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 0}}
{\sp{\sn geoBottom}{\sv 133}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;2;(0,0);(0,133);}}
{\sp{\sn pSegmentInfo}{\sv 2;5;16384;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 0}}
{\sp{\sn lineWidth}{\sv 8573}}
{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineDashing}{\sv 0}}
{\sp{\sn fLine}{\sv 1}}{\sp{\sn lineColor}{\sv 526342}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft8160\shptop3146\shpright8266\shpbottom3906\shpfhdr0\shpw
r3\shpwrk0\shpfblwtxt1\shplid4729\shpz57\shpbxpage\shpbypage
{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 106}}
{\sp{\sn geoBottom}{\sv 760}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;16;(66,13);(66,666);(53,680);(53,680);(53,680);(53,66
6);(53,13);(53,0);(53,0);(53,0);(66,13);(106,653);(53,760);(0,653);(66,13);(66,1
3);}}
{\sp{\sn pSegmentInfo}{\sv 2;34;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 1}}
{\sp{\sn fillColor}{\sv 526342}}
{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineColor}{\sv 0}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft6400\shptop3093\shpright6506\shpbottom3386\shpfhdr0\shpw
r3\shpwrk0\shpfblwtxt1\shplid4730\shpz58\shpbxpage\shpbypage
{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 106}}
{\sp{\sn geoBottom}{\sv 293}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;16;(66,13);(66,213);(53,213);(53,213);(53,213);(53,21
3);(53,13);(53,0);(53,0);(53,0);(66,13);(106,200);(53,306);(0,200);(66,13);(66,1
3);}}
{\sp{\sn pSegmentInfo}{\sv 2;34;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}

{\sp{\sn fFilled}{\sv 1}}

{\sp{\sn fillColor}{\sv 526342}}
{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineColor}{\sv 0}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft4893\shptop3906\shpright5000\shpbottom4093\shpfhdr0\shpw
r3\shpwrk0\shpfblwtxt1\shplid4731\shpz59\shpbxpage\shpbypage
{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 107}}
{\sp{\sn geoBottom}{\sv 187}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;16;(53,13);(53,106);(53,106);(53,106);(53,106);(53,10
6);(53,13);(53,0);(53,0);(53,0);(53,13);(106,80);(53,186);(0,80);(53,13);(53,13)
;}}
{\sp{\sn pSegmentInfo}{\sv 2;34;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 1}}
{\sp{\sn fillColor}{\sv 526342}}
{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineColor}{\sv 0}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft3960\shptop3933\shpright4066\shpbottom4133\shpfhdr0\shpw
r3\shpwrk0\shpfblwtxt1\shplid4732\shpz60\shpbxpage\shpbypage
{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 106}}
{\sp{\sn geoBottom}{\sv 200}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;16;(66,13);(66,106);(53,106);(53,106);(53,106);(53,10
6);(53,13);(53,0);(53,0);(53,0);(66,13);(106,80);(53,186);(0,80);(66,13);(66,13)
;}}
{\sp{\sn pSegmentInfo}{\sv 2;34;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 1}}
{\sp{\sn fillColor}{\sv 526342}}
{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineColor}{\sv 0}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft6786\shptop4146\shpright6893\shpbottom4386\shpfhdr0\shpw
r3\shpwrk0\shpfblwtxt1\shplid4733\shpz61\shpbxpage\shpbypage
{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 107}}

{\sp{\sn geoBottom}{\sv 240}}

{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;16;(53,13);(66,160);(53,160);(53,160);(53,160);(53,16
0);(40,13);(53,0);(53,0);(53,0);(53,13);(106,133);(53,240);(0,133);(53,13);(53,1
3);}}
{\sp{\sn pSegmentInfo}{\sv 2;34;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 1}}
{\sp{\sn fillColor}{\sv 526342}}
{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineColor}{\sv 0}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft5893\shptop4173\shpright6000\shpbottom4373\shpfhdr0\shpw
r3\shpwrk0\shpfblwtxt1\shplid4734\shpz62\shpbxpage\shpbypage
{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 107}}
{\sp{\sn geoBottom}{\sv 200}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;16;(66,13);(66,106);(53,106);(53,106);(53,106);(53,10
6);(53,13);(53,0);(53,0);(53,0);(66,13);(106,80);(53,186);(0,80);(66,13);(66,13)
;}}
{\sp{\sn pSegmentInfo}{\sv 2;34;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 1}}
{\sp{\sn fillColor}{\sv 526342}}
{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineColor}{\sv 0}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft5893\shptop4760\shpright6000\shpbottom5066\shpfhdr0\shpw
r3\shpwrk0\shpfblwtxt1\shplid4735\shpz63\shpbxpage\shpbypage
{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 107}}
{\sp{\sn geoBottom}{\sv 306}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;16;(66,13);(66,226);(53,226);(53,226);(53,226);(53,22
6);(53,13);(53,0);(53,0);(53,0);(66,13);(106,200);(53,306);(0,200);(66,13);(66,1
3);}}
{\sp{\sn pSegmentInfo}{\sv 2;34;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 1}}
{\sp{\sn fillColor}{\sv 526342}}
{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineColor}{\sv 0}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}

{\sp{\sn fBehindDocument}{\sv 1}}

{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft3960\shptop4466\shpright4066\shpbottom4786\shpfhdr0\shpw
r3\shpwrk0\shpfblwtxt1\shplid4736\shpz64\shpbxpage\shpbypage
{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 106}}
{\sp{\sn geoBottom}{\sv 320}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;16;(53,13);(66,226);(53,240);(53,240);(53,240);(53,22
6);(40,13);(53,0);(53,0);(53,0);(53,13);(106,213);(53,320);(0,213);(53,13);(53,1
3);}}
{\sp{\sn pSegmentInfo}{\sv 2;34;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 1}}
{\sp{\sn fillColor}{\sv 526342}}
{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineColor}{\sv 0}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft6880\shptop4760\shpright6986\shpbottom5720\shpfhdr0\shpw
r3\shpwrk0\shpfblwtxt1\shplid4737\shpz65\shpbxpage\shpbypage
{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 106}}
{\sp{\sn geoBottom}{\sv 960}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;16;(53,13);(66,866);(53,880);(53,880);(53,880);(53,86
6);(40,13);(53,0);(53,0);(53,0);(53,13);(106,853);(53,960);(0,853);(53,13);(53,1
3);}}
{\sp{\sn pSegmentInfo}{\sv 2;34;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 1}}
{\sp{\sn fillColor}{\sv 526342}}
{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineColor}{\sv 0}}
{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft4453\shptop6933\shpright6040\shpbottom7493\shpfhdr0\shpw
r3\shpwrk0\shpfblwtxt1\shplid4738\shpz66\shpbxpage\shpbypage
{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 1587}}
{\sp{\sn geoBottom}{\sv 560}}
{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;5;(0,0);(0,560);(1586,560);(1586,0);(0,0);}}
{\sp{\sn pSegmentInfo}{\sv 2;12;16384;45824;1;45824;1;45824;1;45824;1;45824;2457
7;32768}}

{\sp{\sn fFillOK}{\sv 1}}

{\sp{\sn fFilled}{\sv 1}}
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{\sp{\sn pVerticies}{\sv 8;16;(53,200);(53,93);(53,80);(53,80);(53,80);(66,93);(
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charscalex100 {Hipertensi adalah nilai rata-rata tekanan darah sistolik dan atau
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charscalex100 {ke-95 berdasarkan jenis kelamin, usia, dan tinggi badan pada peng
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ium 2 bila tekanan darah lebih dari persentil ke-99 ditambah 5 mmHg. }\par\pard\
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atau lebih, krisis hipertensi didefinisikan sebagai tekanan}\par\pard\li893\ri0\
sl-266\slmult0 \fs22\cf0\f0\charscalex100 {sistolik \uc1\u8805X180 mmHg dan atau
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i0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {ukuran tersebut namun telah timbul
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0\charscalex100 {daripada hipertensi primer dan hampir 80% penyebabnya berasal d
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f0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Hipertensi ringan-sedang
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l-266\slmult0 \fs20\cf0\f0\charscalex100 {dari penyakit yang mendasarinya sepert
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0 \*\tx1133\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Tekana
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pard\li1133\ri0\sl-280\slmult0 \fs22\cf0\f0\charscalex100 {kali sehari)}\fs22\cf
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dapat ditambah dengan vasodilator golongan}{ }\fs22\cf0\f0\charscalex100\i {cal
cium-}\i0 \par\pard\li1133\ri0\sl-266\slmult0 \fs18\cf0\f0\charscalex100\i {chan
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par\pard\li1133\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {tercapai tekanan
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i1133\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {2 kali sehari; bila tensi t
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ujukan spesialis lainnya, dll)}\b0 \par\pard\li893\ri0\sl-306\slmult0 \fs22\cf0\
f0\charscalex100 {Dirujuk ke dokter spesialis mata untuk mendeteksi kelainan ret
ina. Rujuk ke dokter}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex1
00 {nefrologi anak bila tidak berhasil dengan pengobatan atau terjadi komplikasi
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\fs22\cf0\f0\charscalex100\b {Pemantauan}\b0 \par\pard\li893\ri0\sl-373\slmult0
\fs24\cf0\f0\charscalex100 {Terapi}\par\pard\li893\ri0\sl-320\slmult0 \fs22\cf0
\f0\charscalex100 {Pemantauan ditujukan pada komplikasi yang timbul.}\par\pard\l
i893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {Terapi berhasil bila memenuh
i kriteria: }\par\pard\li893\ri0\sl-266\slmult0 \*\tx1133\fs22\cf0\f0\charscalex
100 {-}\tab \fs22\cf0\f0\charscalex100 {Tekanan diastolik turun di bawah persent
il ke-90.}\par\pard\li893\ri0\sl-266\slmult0 \*\tx1133\fs22\cf0\f0\charscalex100
{-}\tab \fs22\cf0\f0\charscalex100 {Efek samping obat minimal.}\par\pard\li893\
ri0\sl-266\slmult0 \*\tx1133\fs20\cf0\f0\charscalex100 {-}\tab \fs20\cf0\f0\char
scalex100 {Pemberian obat untuk mengontrol tekanan darah hanya diperlukan dalam
jumlah}\par\pard\li1133\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {sedikit.}
\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-360\slmult0 \
fs24\cf0\f0\charscalex100 {Tumbuh kembang}\par\pard\li893\ri0\sl-306\slmult0 \fs
20\cf0\f0\charscalex100 {Anak umumnya menderita hipertensi sekunder. Proses tum
buh kembang dapat}\par\pard\li893\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100
{dipengaruhi oleh penyakit primernya.}\par\pard\li893\ri0\sl-213\slmult0 \fs18\c
f0\par\pard\li893\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li893\ri0\sl-426\slmult0
\fs28\cf0\f0\charscalex100\b {Kepustakaan}\b0 \par\pard\li893\ri0\sl-293\slmult
0 \*\tx1266\fs18\cf0\f0\charscalex100 {1. }\tab \fs16\cf0\f0\charscalex100 {Bahr
un D. Hipertensi Sistemik. Dalam: Alatas H, Tambunan T, Trihono PP, Pardede PP,
penyunting. Buku}\par\pard\li1266\ri0\sl-226\slmult0 \fs18\cf0\f0\charscalex100
{ajar nefrologi anak. Edisi ke-2. Jakarta: Balai Penerbit FKUI; 2002. h. 242-90.
}\par\pard\li893\ri0\sl-240\slmult0 \*\tx1266\fs18\cf0\f0\charscalex100 {2. }\ta
b \fs18\cf0\f0\charscalex100 {Alatas H. Ensefalopati Hipertensi. Dalam: Kumpulan
Makalah Kegawatdaruratan pada Penyakit Ginjal. }\par\pard\li1266\ri0\sl-226\slm
ult0 \fs18\cf0\f0\charscalex100 {2006. Ikatan Dokter Anak Indonesia.}\par\pard\l
i893\ri0\sl-240\slmult0 \*\tx1266\fs18\cf0\f0\charscalex100 {3. }\tab \fs18\cf0\
f0\charscalex100 {National High Blood Pressure Education ProgramWorking Group on
High Blood Pressure in Children}\par\pard\li1266\ri0\sl-226\slmult0 \fs18\cf0\f
0\charscalex100 {and Adolescents. The fourth report on diagnosis, evaluation and
treatment of high blood pressure in}\par\pard\li1266\ri0\sl-213\slmult0 \fs18\c
f0\f0\charscalex100 {children and adolescent. Pediatrics 2004;114:555-76.}\par\p
ard\li893\ri0\sl-253\slmult0 \*\tx1266\fs18\cf0\f0\charscalex100 {4. }\tab \fs18

\cf0\f0\charscalex100 {Task Force on Blood Pressure Control in Children. Report

of the second task force on blood pressure}\par\pard\li1266\ri0\sl-226\slmult0 \
fs18\cf0\f0\charscalex100 {control in children. Pediatrics 1987;79:1-25. }\par\p
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calex100 {hal-hal sebagai berikut:}\par\pard\li1146\ri0\sl-266\slmult0 \*\tx1346
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t0 \fs22\cf0\f0\charscalex100 {yang lebih tinggi, sebaliknya bila menggunakan m
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ga memberikan}\par\pard\li1346\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {ru
angan yang cukup untuk melekatkan bel stetoskop di daerah fossa cubiti, }\par\pa
rd\li1346\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {sedangkan panjang kanto
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ult0 \*\tx1346\fs22\cf0\f0\charscalex100 {-}\tab \fs22\cf0\f0\charscalex100 {Per
iksa terlebih dahulu spigmomanometer yang digunakan, apakah ada kerusakan}\par\p
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ni akan mempengaruhi hasil}\par\pard\li1346\ri0\sl-266\slmult0 \fs22\cf0\f0\cha
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sedangkan}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {pada a
nak yang lebih kecil pengukuran dilakukan dalam posisi telentang. Tekanan}\par\p
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a lengan atas dan paha, untuk mendeteksi ada atau tidaknya}\par\pard\li1146\ri0\
sl-266\slmult0 \fs22\cf0\f0\charscalex100 {koarktasio aorta. Untuk mengukur teka
nan darah, cara yang lazim digunakan adalah}\par\pard\li1146\ri0\sl-266\slmult0
\fs22\cf0\f0\charscalex100 {cara indirek dengan auskultasi. }\par\pard\li906\ri
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alex100 { Manset yang cocok untuk ukuran anak dibalutkan kuat-kuat pada 2/3 pan
jang lengan}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {atas
. Tentukan posisi arteri brachialis dengan cara palpasi pada fossa cubiti. Bel}
\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {stetoskop kemudi
an ditaruh di atas daerah tersebut. Manset dipompa kira-kira 20}\par\pard\li1146
\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {mmHg di atas tekanan yang diperl
ukan untuk menimbulkan sumbatan pada arteri}\par\pard\li1146\ri0\sl-266\slmult0
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calex100 {kecepatan 2-3 mmHg/detik sampai terdengar bunyi suara lembut. Bunyi su
ara lembut}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {yang

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rd\li1146\ri0\sl-266\slmult0 \fs20\cf0\f0\charscalex100 {sistolik. Fase 1 kemudi
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6\slmult0 \fs22\cf0\f0\charscalex100 {dan akhirnya menghilang (fase 5). Pada ana
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fs22\cf0\f0\charscalex100 {digunakan sebagai petunjuk tekanan diastolik. }\par\p
ard\li906\ri0\sl-453\slmult0 \fs22\cf0\f0\charscalex100\i { The Second task For
ce on Blood Pressure Control in Children}\i0 \fs22\cf0\f0\charscalex100 { menga
njurkan untuk}\par\pard\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {me
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\li1146\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {untuk anak-anak usia 13 t
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