himpunan riset covid19

dalam pemakaian APD. Sikap yang waspada ini Perawatan tidak menggunakan APD sesuai
bertujuan untuk mencegah masalah kecelakaan standar pada masa Pandemi Covid 19.
kerja atau resiko bahaya yang dapat muncul
ketika sedang melakukan pekerjaan di rumah PENGAKUAN
sakit. Dalam penelitian Banda (2015) dilaporkan, Penulis ingin berterimakasih kepada Pegawai di
dari 52 responden perawat yang bekerja di Rumah Sakit tempat penelitian ini diadakan,
BLUD Rumah Sakit Konawe sebagian besar khususnya kepada Tenaga Kesehatan ( Dokter,
(80,3%) responden berada pada kategori tidak Perawat, Radiografer, Analis Kesehatan )
patuh dalam menggunakan APD sesuai SOP (n sebagai responden penelitian. Penulis juga
= 30 orang), sedangkan sebagian kecil berada mengucapkan banyak terimakasih kepada
pada kategori patuh dalam menggunakan APD berbagai pihak yang telah membantu penelitian
sesuai SOP (n = 22 orang atau 19,7%). yang tidak dapat disebutkan satu persatu.

Penelitian Banda dapat disimpulkan bahwa DAFTAR PUSTAKA
berbanding terbalik dengan penelitian yang Peraturan menteri kesehatan republik indonesia
sudah dilakukan peneliti dalam hal penerapan
APD. Kepatuhan pemakaian APD oleh Tenaga nomor 27 tahun 2017. Pedoman
Kesehatan yang menangani pasien covid 19 pencegahan dan pengendalian infeksi di
ditunjang oleh ketersediaan APD yang lengkap fasilitas pelayanan kesehatan.
di Rumah Sakit tersebut. Adanya bantuan
anggaran dan hibah APD dari Pemerintah. Keputusan menteri kesehatan republik
Hibah APD dari Lembaga atau Organisasi
Swasta dan Masyarakat sangat membantu Indonesia nomor
untuk ketersediaan APD Rumah Sakit.
HK.01.07/menkes/104/2020. Penetapan
KESIMPULAN DAN SARAN
Implementasi kepatuhan pemakaian Alat infeksi novel coronavirus (infeksi 2019-
Pelindung Diri oleh Tenaga Kesehatan yang
menangani pasien Covid 19 di Rumah Sakit ncov) sebagai penyakit yang dapat
sudah sesuai dengan yang distandarkan oleh
Rumah Sakit. Jenis-jenis APD yang disediakan menimbulkan wabah dan upaya
oleh Rumah Sakit sudah sesuai dengan yang
distandarkan oleh Kementerian Kesehatan penanggulangannya.
dalam menangani pasien Covid 19.
Direktorat Jenderal Pencegahan dan
Jenis-jenis APD nya adalah Shoe Cover, Face Pengendalian Penyakit/P2P (2020).
Shields,Kacamata Goggle Masker Bedah, Pedoman pencegahan dan pengendalian
Sepatu Boots, Masker N95, ,Hazmat, Sarung coronavirus disesase (covid-19).
tangan Gynekolog, Sarung tangan pemeriksaan
(Examination Glove), Nurse Cap, Baju khusus Dirjen Kefarmasian dan Alat Kesehatan,
pegawai.Kepatuhan akan kewaspadaan yang Kementerian Kesehatan Republik
tinggi dari Tenaga Kesehatan terhadap virus Indonesia. ( 2020 ).Standar Alat
covid 19 untuk menjaga keselamatan dalam Pelindung Diri ( APD ).
bekerja. Sebaiknya kita semua harus selalu
meningkatkan kewaspadaan kita yaitu dengan Banda. I . (2015). Hubungan Perilaku Perawat
cara memakai APD, jaga jarak minimal 1 meter, Dengan Kepatuhan Menggunakan Alat
rajin cuci tangan dengan sabun dan air mengalir Perlindungan (APD) Sesuai Standart
atau bahan yang berbasis alkohol. Penelitian Operating Procedure (SOP) di Ruang
selanjutnya diharapkan meneliti faktor-faktor Rawat inap BLUD.
yang menyebabkan perawat di Ruang
Rumah Sakitt KONAWE Tahun 2015 (Diakses
pada tanggal 01 des 2020 dari:
http://sitedi.uho.ac.id/uploads_sitedi/G3IM
013007_sitedi_SKRIPSI%20IRFAN%
20BANDA%20PDF.pdf.).

Eret Sukaldo , Renata Komalasari , Shinta

Yuliana Hasibuan. (2017). Gambaran Salma Adilah Putri, Bagoes Widjanarko, Zahroh
penerapan alat pelindung diri di ruang Shaluhiyah (2018). Faktor-fakto yang
perawatan rumah sakit. berhubungan dengan tingkat kepatuhan
perawat terhadap penggunaan alat
Tien Zubaidah, Arifin, Yudha Afiat Jaya (2015). pelindung diri (apd) di rsup dr. kariadi
Pemakaian alat pelindung diri pada semarang (studi kasus di instalasi rawat
tenaga perawat dan bidan di rumah sakit inap merak).
pelita insani.
Ni Putu Emy Darma Yanti, Ida Ayu Md Vera
Nova Fridalni, Rini Rahmayanti (2018). Faktor- Susiladewi, Hary Pradiksa (2018).
faktor yang berhubungan dengan perilaku Gambaran motivasi bekerja perawat
Perawat dalam penggunaan alat dalam masa pandemi coronavirus disease
pelindung diri. (covid-19) di bali.



LOCAL ADAPTATION OF LAPAROSCOPIC SMOKE EVACUATOR IN COVID-19
PANDEMIC SITUATION

Adianto Nugroho1 Rofi Saunar1 Toar J. M. Lalisang2 Errawan Wiradisuria3

ABSTRACT 2. MATERIALS AND METHODS
The pandemic of COVID-19 has been a game We carried out laparoscopic surgery during the
changer in many aspects of medical care, COVID-19 pandemic with a homemade smoke
including laparoscopic surgery service. evacuation apparatus, consisting of a dual-
Uncertainty in the early pandemic has led to the chamber water sealed chest tube drainage
fear of doing laparoscopic surgery with regard to system, two suction catheter tubes, and filter
the possibility of SARS-COV-2 transmission (Figure 1). Outflow of CO2 from the abdomen
through surgical smoke. We carried out would pass through the filter and water sealed
laparoscopic surgery during the COVID-19 drainage system before being collected in the
pandemic with intention to test our local chamber of a slow suction apparatus (Figure 2).
adaptation of a laparoscopic smoke evacuator. Intra-abdominal pressure was set at 12 mm Hg
Twenty-five laparoscopic cases for digestive rather than the traditional 15 mm Hg. Table 1
surgery were performed with uneventful results. provides the cost estimation of the components.
In summary, a low cost local adaptation of
laparoscopic smoke and safe surgical behavior 3. RESULTS
should be the standard of care when delivering Twenty-five laparoscopic cases for digestive
laparoscopic surgery service in the pandemic surgery were performed in May - June 2020 in
era and forward. Fatmawati Central General Hospital operating
theater using our homemade smoke evacuation
KEYWORDS: COVID-19, laparoscopic, smoke apparatus and all of which were polymerase
evacuator chain reaction SARS-COV negative (Table 2).
All procedures were done with uneventful
1. INTRODUCTION results.
Surgical smoke and gas evacuation were things
we took for granted for a long time, despite its 4. DISCUSSION
potentially dangerous effect. The emergence of Surgical smoke is the gaseous by-product
COVID-19 pandemic has made us reconsider during surgery, as a result of tissue dissection or
the importance of a safe conduct of surgical cauterization by heat generating devices. The
smoke and gas evacuation in our daily practice. heat of diathermy or other devices causes the
This article aims to highlight some of the target cell membranes to rupture to
important aspects of surgical gas evacuation
and how local adaptation should be done in this
era of uncertainty.

FIGURE 1 Smoke evacuator apparatus consist of (A) suction catheter tubes, (B) filter, (C) water sealed
bottle

FIGURE 2 Flow of gas from (1) trocar to (2) water sealed drainage bottle with disinfection fluid, and (3)
out to suction
TABLE 1 Estimated cost of homemade smoke evacuation apparatus

their boiling point and generate a plume of smoke con- taining 95% water and 5% cellular debris which
was released into the atmosphere of the operating theater.1,2 The charring of cells as a result of
thermal necrosis also releases other harmful materials, including carbonized cell fragments and
gaseous hydrocarbons.1 The size of particulate produced is dependent upon the type of thermal
device, among which, electrocautery produces 0.07-0.1 μm particulate size, lasers produce 0.31 μm
TABLE 2 Patient characteristics of laparoscopic cases using homemade smoke evacuation apparatus
(n = 25)

particulate size and ultrasonic scalpels energy is used, since it has a larger particulate
produce 0.35-6.5 μm particulate size.3,4 size and relatively low temperature, which is
Surgical smoke has long been studied as a insufficient to inactivate virus. Several viruses
potential hazard, with aerosolized isolates are detected in surgical smoke, including human
including viral particles and carcinogens.2,3 papilloma virus, human immu- nodeficiency virus
Things are more problematic when ultrasonic and hepatitis B virus.2,5 Until recently, no study

has investigated SARS-CoV-2 or any other coro- evacuation during laparoscopic procedure.
navirus in this regard. However, considering that These devices were developed to provide a
SARS- CoV-2 has been shown in blood, stools better view during surgery and to reduce the risk
and urine, the risk of virus diffusion through of expo- sure to potentially harmful chemical
surgical smoke should not be excluded.3,5 compounds, but come with a relatively high
A smoke evacuation system in addition to room cost.9
venti- lation should be considered the first line of Recent reports by Bhattcharjee et al showed
defense against surgical smoke. When smoke is the util- ity of a cost-effective, innovative system
anticipated, a smoke evacuator with a 0.1 mm to achieve a slow egression of smoke and
filter should be activated during the procedure. aerosols in a laparoscopic cholecystectomy
The device (eg, wand, tubing) should be placed procedure.10 Similarly, we reported the use of
as close as possible to the surgical site to collect our local adaptation of a smoke evacuator
all traces of smoke.6 Contrary to popular beliefs appa- ratus in various laparoscopic digestive
in the early COVID-19 pandemic, which favor procedures dur- ing the peak of the pandemic
not to use laparoscopy because of the fear of (May - June 2020) in our country. The apparatus
high risk viral transmission from surgical plumes, consists of low cost items which are readily
actually laparoscopy has a potential benefit. Sur- available in operating theaters. No additional
gical smoke exists in both open and efforts were needed before and during surgery,
laparoscopy, but the closed cavity in a except for the preparation of the apparatus. The
laparoscopic environment enables smoke total operating times were also similar to our
control when the necessary precautions are usual practice. One of the important aspects in
taken.7 Some of the key factors of smoke the preparation is the training of surgical staff,
hazard control including evacuation of smoke regarding the importance of the apparatus and
only through filters, complete evacuation of how to assemble it. Once they got used to the
pneumoperitoneum prior to specimen extraction, assemble and disassemble process, the
conversion to open and pull-out of trocar and preparation time is reduced.In addition to the
last but not least, is the smart use of energy use of various smoke evacuation systems,
devices.7 attention to surgical behavior should also been
Consideration must be made regarding the taken into consideration. Hajibandeh et al have
possibility of gas leak during and after already highlighted the recommended safe
laparoscopic surgery. A study by Cahill et al behaviors during sur- gery with its rationale.11
showed three categories of gas leak during Some of the most important behaviors are the
laparoscopy, namely intentional, inadvertent and presence of the most experience laparoscopic
inbuilt gas leak. Intentional leak is caused by surgeon to ensure the minimization of operative
deliberate action, when venting the trocar into time, maintaining intra-abdominal pressure as
the room to clear smoke, reduce pressure and low as possible (<12 mm Hg) to aid artificial
conclude the procedure, when specimen is ventilation, and minimal size of incision with
extracted and when there is interruption of valve minimum number of incisions for port sites to
closure for specimen bag thread/drain minimize gas leakage and prevent aerosol
placement hap- pening across the valve. dispersion. In summary, a local adaptation of a
Inadvertent gas leak commonly occurs at skin- laparoscopic smoke evacuator is feasible with
trocar interface placement sites related to low cost and easy assembling. Together with
oversize incision and extreme movement / safe surgical behavior, these should be the
positioning of instrument. Those occurring standard of care when delivering laparoscopic
through trocars or instru- ments by design or surgery service.
mechanical failure / fatigue are con- sidered as
inbuilt gas leak.8 ACKNOWLEDGMENT
A review article by da Costa et al described We thank Dr. Toar JM Lalisang from Indonesian
several commercially available apparatuses that College of Digestive Surgery, and Dr. Errawan
employ mechan- ical filtering for smoke Wiradisuria from Indonesian Society of Endo-

Laparoscopic Surgeons for writing and reviewing smoke may be lower than for laparot- omy:
the manuscript.
a narrative review. Surg Endosc.
CONFLICT OF INTEREST
None. 2020;34(8):3298-3305.

ETHICS STATEMENT Cahill RA, Dalli J, Khan M, Flood M, Nolan K.
Informed consent was obtained from the patient
for pub- lication of this report. Ethics committee Solving the prob- lems of gas leakage at
approval was not required for this report.
laparoscopy. Br J Surg. 2020;107(11):1401-
ORCID
Adianto Nugroho https://orcid.org/0000-0001- 1405. https://dx.doi.org/10.1002/bjs.11977.
9066- 8685
Rofi Saunar https://orcid.org/0000-0003-4723- [Epub online ahead of print].
2071
da Costa KM, Saxena AK. Coronavirus disease
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https://dx.doi.org/10. 1002/bjs.11772. [Epub

online ahead of print]

Manuscript title:

THE IMPACT OF CORONAVIRUS DISEASE 2019 PANDEMIC ON PEOPLE WITH
DIABETES IN INDONESIA: A CROSS SECTIONAL NATIONAL SCALE WEB-
SURVEY

Authors:
Ida Ayu Kshanti MD,1 Marina Epriliawati MD,1 Md Ikhsan Mokoagow MD, M.Med.Sci,1 Jerry
Nasarudin MD,1 Nadya Magfira MD2

Affiliations:
1. Department of Internal Medicine, Fatmawati General Hospital, Indonesia
2. Diabetes Integrated Care Center, Fatmawati General Hospital, Indonesia

Corresponding author:
Ida Ayu Kshanti
Emai: [email protected]
Affiliation: Department of Internal Medicine, Fatmawati General Hospital, Indonesia. Jl. RS.
Fatmawati Raya No.4, RW.9, West Cilandak., Cilandak, South Jakarta, Jakarta, Indonesia 12430

LIST OF ABBREVIATIONS
COVID 19: Coronavirus disease 2019 CI: Confidence Interval
DFU: diabetic foot ulcer
ISE: Indonesian Society of Endocrinology LSSR: large social scale Restriction
NHI: National Health Insurance NMW: National Minimum Wage OAD: Oral Anti Diabetics
PR: prevalence ratio
PWD: People with Diabetes RP: Rupiah

ABSTRACT
Background: As the country with the 7th largest number of People with Diabetes (PWD) in the world,
the COVID-19 pandemic, and the Large Social Scale Restriction (LSSR) policy taken by the Indonesian
government to reduce the number of COVID-19 transmissions is estimated to interfere diabetes
management and will increase the incidence of diabetes complications. This study aims to determine
the difficulties of diabetes management and its impact on diabetes morbidity during the COVID-19
pandemic in Indonesia.
Methodology: This study is a cross-sectional study using a national scale web survey. This research
was conducted in Indonesia enrolling 1,124 PWD aged 18 years or older. Diabetes complications are
defined as any incidence of hypoglycaemia, or Diabetic Foot Ulcer (DFU), or hospital admission
experienced by PWD in Indonesia during the COVID-19 pandemic. The correlation between diabetes
management difficulties and diabetes-related complications was measured using a modified cox
regression test.
Results: Diabetes management difficulties were experienced by 69.8% of PWD in Indonesia. The
difficulties include attending diabetes consultation 30.1%, access to diabetes medication 12.4%,
checking blood sugar levels 9.5%, controlling diet 23.8%, and performing regular exercise 36.5%.
Diabetes-related complications occurred in 24.6% of subjects. Those who had diabetes management
difficulties during the COVID-19 pandemic are prone to have diabetes complications by 1.4 times
greater (PR: 1.41, 95% CI: 1.09-1.83) than those who did not.
Conclusion: The COVID-19 pandemic and LSSR have a substantial impact on diabetes management
and indirectly increased diabetes morbidity in Indonesia.
Keywords: Diabetes, COVID-19, Indonesia, Impact

INTRODUCTION contracting COVID 19 are present both in
Coronavirus disease 2019 (COVID-19) caused patients and some health care providers. LSSR
by the Severe Acute Respiratory Coronavirus have rendered patients physically less active or
Syndrome-2 virus has been declared a public unable to exercise. Also, maintaining the
health emergency and global pandemic by WHO required dietary becomes more difficult. In a
on March 11, 2020. [1] COVID-19 has a very worst-case scenario oral anti-diabetic drugs
diverse clinical spectrum, from asymptomatic to and/or insulin were more difficult to obtain. [9]
severe symptoms characterized by fever and The impact of this policy may bring about more
pneumonia that can be fatal. [2] As of August severe impact on PWD than the COVID 19
11, 2020, COVID- 19 has infected 19,936,210 disease per se.
people worldwide with a global Case Fatality This study assesses the wider impact of COVID-
Ratio (CFR) of 3.67%. [3] COVID-19 can affect 19 pandemic beyond the effects of the disease
anyone, but subjects with comorbidities such as itself. We assessed the impact of social
diabetes have a greater risk of contracting restriction policies and the enactment of COVID-
COVID-19 and a higher mortality rate than 19 as a public health emergency, particularly its
subjects without diabetes. [4] impact on PWD. Furthermore, this research may
From a demographic perspective, Indonesia is provide basis for decision making by the
the fourth most populous country in the world government to optimize diabetes management,
after China, the United States and India. [5] With especially during the COVID- 19 pandemic in
a large population, as many as 10.7 million Indonesia. The purpose of this study was to
people or 6.2% of the total population are determine the difficulties faced by PWD during
People with Diabetes (PWD), this make the COVID-19 pandemic in Indonesia and their
Indonesia ranks 7th in the country with the impact on morbidity. This study also assesses
highest number of PWD in the world. [6] If this the solutions taken by PWD in response to
condition is not handled seriously, Indonesia will difficulties on diabetes management during the
remain in the same position in the next 10 years. COVID-19 pandemic.
[6] According to WHO data in 2016, diabetes is
one of the main causes of death in Indonesia. [7] METHODS
In general, diabetes management in Indonesia 1. Study Design and Sample
includes education, dietary management, This study is a cross-sectional study using a
physical activity, and pharmacological therapy. national scale web-survey. Flyers containing
Comprehensive management in PWD is invitations to become research respondent were
required to prevent complications. given to the professional organization (ISE,
On March 2, 2020, Indonesia reported the first Indonesian Medical Association, Indonesia
case of COVID-19. Since the first case Society of Internal Medicine, Indonesia Diabetes
discovery until August 11, 2020, 130,718 people Association and Indonesia Diabetes Educators
in Indonesia have been diagnosed with COVID- Association) which would then be given to PWD.
19 and 4.5% of these cases have died (5,880 The survey was conducted for two weeks during
people). [3] As an effort to deal with pandemics the period of 21 July 2020-4 August 2020. This
and public health emergencies, Indonesia has study involved all PWD in Indonesia who lived in
imposed a regional quarantine in the form of Indonesia during March - July 2020 and were
large-scale social restrictions (LSSR) on not being hospitalized when filling out the
affected cities and provinces. The Indonesian questionnaire. To find out the relationship
Society of Endocrinology (ISE/ PERKENI) has between difficulties during the COVID-19
issued recommendations for PWD to stay at pandemic and the incidence of complications
home and maintain physical distance to reduce during the COVID-19 pandemic with a study
exposure to viral carriers. [8] However, this power of 95% and a 95% confidence interval, a
policy poses an unfavourable impact on the sample of 970 diabetes mellitus patients was
management of diabetes. Face-to-face needed.
consultations are largely avoided. The fear of

2. Research Variables and Outcomes their families. As many as 35% of patients felt
Difficulties during the pandemic period were that they live far away from the health facility
defined as any kind of difficulties that were where they regularly attended for diabetes
subjectively endured/experienced by the PWD treatment. Also, the majority of patients went to
(difficulties in attending health consultation, or the facility using private vehicles. The diabetes
checking blood sugar levels, or obtaining profile of the subjects can be seen in Table 2.
diabetes drugs, or maintaining diet control, or The majority of respondents had been
performing exercise). Complications were diagnosed with diabetes for more than three
defined as any experiences of hypoglycaemia or years and visited a hospital for diabetes
Diabetes Foot Ulcers (DFU) or hospitalisation treatment. As many as 74.02% of respondents
during the COVID-19 pandemic in Indonesia. received oral anti-diabetic drug therapy and as
many as 40.3% of patients received insulin
3. Data Sources therapy. In this study, 77.85% of the total
This study uses primary data in the form of a number of respondents usually had, at least,
questionnaire containing gender, age, one consultation in three months before the
occupation, income, health insurance, COVID-19 pandemic.
transportation, residence, and distance to the
health facility. Working condition were classified 2. Impact of the COVID-19 Pandemic on
into work from home and work from the office. Diabetes Morbidity
The distance to the health facility is a subjective
measure of distance from home to the control In this study, 24.56% of the total respondents
place according to the subject. This study also admitted that they had diabetes complications
measured diabetes profile which included during pandemic (hypoglycaemia 12.90%, DFU
duration of diagnosis, diabetes treatment, 7.38%, and hospital admission 6.76%). About
diabetes control facility, and numbers of medical 70% of PWD experienced difficulties during the
consultation during the pandemic. COVID-19 pandemic, which include attending
diabetes consultation (30.07%), access to
4. Statistical Methods diabetes medication (12.37%), checking blood
The relationship between difficulties and the sugar levels (9.52%), controlling diet (23.75%)
incidence of complications during the COVID-19 and performing regular exercise (36.48%).
pandemic was measured by assessing the Multivariate analysis results show an increased
prevalence ratio (PR) and 95% confidence incidence of diabetes complications by 1.41
interval (CI) using a modified cox-regression times during the COVID 19 pandemic (95% CI:
test. 1.09-1.83) (Table 3). Other factors that play a
role on increasing number of incidences were
RESULTS found in PWD under 60 years of age (PR: 1.44,
1. Characteristics of Subjects 95% CI: 1.12-1.85) and those receiving insulin
This study included 1,124 PWD from 34 therapy (PR: 2.23, 95% CI: 1.75-2.85).
provinces in Indonesia (Figure 1). The
characteristics of the subjects in this study can 3. How People with Diabetes in Indonesia
be seen in Table 1. The proportion of male Cope with Difficulties of Diabetes
includes 54.89% of the total respondents, almost Management During Pandemic
60% of the respondents are in productive age,
less than a quarter of the respondents have an The study shows that, the majority of PWD did
income below the National Minimum Wage not take any action in maintaining/resolving their
(NMW), and almost 80% of the total diabetes health-related problems during the
respondents receive treatment using National COVID pandemic in Indonesia. These include as
Health Insurance (NHI)/ Badan Penyelenggara many as 50.59% of respondents who had
Jaminan Sosial (BPJS). In this study, the difficulty in attending diabetes consultation,
majority of patients were married and lived with 60.75% who had difficulty in checking blood
sugar levels, and 30.94% who had difficulty in
obtaining anti-diabetes drugs or insulin. (Table

4). for DFU is 6.3% (95% CI: 5.4% -7.3%). [11]
Given the limitations of this study, the total
DISCUSSION prevalence of DFU in diabetes in Indonesia is
This study shows that nearly 70% of PWD in likely higher than what was found in this study.
Indonesia experienced difficulties in managing However, it can be concluded that when
diabetes during the COVID-19 pandemic. As compared with the prevalence rates for DFUs
many as 24.6% of these subjects experienced worldwide, the prevalence of DFU in Indonesia
complications related to their diabetes including during the pandemic period was higher.
DFU (7.4%), hypoglycaemia (12.9%), and In this study, the incidence of hypoglycaemia
hospitalisation (6.8%). In this study, subjects was reported at 12.9% in all subjects.
who experienced difficulties during the COVID- Worldwide, the incidence of hypoglycaemia is
19 pandemic had an increased risk to develop 45% for mild-moderate hypoglycaemia and 6%
diabetes complications by 1.4 times more often for severe hypoglycaemia. [12] In a cohort study
than those who did not during the COVID-19 held in Indonesia, the incidence of
pandemic. In dealing with the difficulties afflicted hypoglycaemia was found in 99.4% of subjects
by PWD during the COVID-19 pandemic in with Type 2 Diabetes Mellitus (T2DM) (59%
Indonesia, only less than half of the respondents severe) and 100% in subjects with Type 1
took the initiative to utilize available online Diabetes Mellitus (T1DM) (76% severe). [13]
resources/information or to contact a doctor for Interestingly, as many as 62.17% of patients
consulting their health conditions. However, with T1DM and 82.4% of T2DM patients in
more than half of respondents answered that Indonesia were unaware of their hypoglycaemic
they did nothing and just let their condition conditions. [13] Apart from the fact that the
deteriorate. Moreover, more than a third of PWD hypoglycaemia events in this study is subjective,
discontinue their medication during the COVID- the lack awareness of hypoglycaemia in PWD in
19 pandemic. This study has some limitation Indonesia could explain why the incidence of
including reporting of complication during hypoglycaemia in our study is low. When viewed
pandemic limited to DFU, hospital admission, or from the perspective of hospital admission, the
hypoglycaemia. The Questionnaire was incidence of hospitalisation during the pandemic
answered subjectively by respondents. Hence, among PWD in this study was 6.76%. When
the observations may have had some biases. compared to COVID-19 cases, 18% of patients
Furthermore, the condition of unawareness experienced severe clinical manifestations and
towards DFU and undetected/undocumented required hospitalization while severe cases
low or subclinical blood sugar levels, which were occurred in 44% of COVID-19 patients with
not assessed objectively, could result in an diabetes comorbidity.[4] Although the
overall lower number of complications than what hospitalisation rate for PWD in this study was
actually occurred. This study shows that the quite low, actual numbers may have been higher
COVID-19 pandemic in Indonesia has had a due to the limited timeframe during which the
substantial impact on the management of data were acquired (4 months since pandemic
diabetes. At least one in four PWD experienced began). In addition, lower hospitalisation rate
complications during the COVID- 19 pandemic may have also arisen from selection bias of the
in Indonesia. In this study, the prevalence of study. During the COVID-19 pandemic, the
DFU in diabetics in Indonesia was found in 7.4% majority of PWD experienced difficulties in
of the total respondents. Until now, there is no managing their disease. These various
national data on the prevalence of diabetes difficulties increased the incidence of diabetes
complications in Indonesia. However, a single- complications for almost 1.5
centre study showed the prevalence of DFU
incidence in the population treated at a tertiary
hospital in Indonesia was 16.7% with an
amputation rate of 10.7%.
[10] Meanwhile, the worldwide prevalence rate

times. At present, although the number of cases households in Indonesia have access to the
and deaths due to COVID-19 continues to internet and only 39.90% of individuals use the
increase, the death and cases of diabetes in internet. However, as an opportunity, 121 out of
Indonesia are still much higher than COVID-19. 100 residents are cellular telephone users, this
[3,7] Putting aside comprehensive management means that 21 residents have more than one
of chronic diseases and mainly focusing on cellular contact. [18] Although many are
COVID-19 may potentially be harmful. For this unprepared in facing these changes, the
reason, rapid and sustainable changes in the collaboration between the government in
health sector to reduce the impact of COVID-19 providing infrastructure and health service
pandemic on general health specifically in providers including clinicians as the vanguard is
chronic disease is needed. [14] necessary. The use of audio-only telemedicine
Virtual consultation that eliminates the need for may be applicable in Indonesia, especially in
physical meetings is a solution that has been provinces with inadequate internet access.
implemented by many countries in the world, Further research is certainly needed to assess
including Indonesia. [15] In Indonesia, ISE has the effectiveness and implementation of
provided recommendations to avoid direct telemedicine in health services during the
consultation and suggested remote consultation COVID-19 pandemic in Indonesia and how it will
for diabetic patients when applicable. [8] be sustainable in the future.
However, only less than half of the PWD in However, beyond the readiness of the
Indonesia used it, while the remaining subjects government and health service providers in
remained idle, allowing their condition to developing telemedicine, it is also important to
deteriorate. In contrast, since the COVID-19 improve public health literacy. Improving health
pandemic, doctors in People’s Republic of China literacy requires collaborative efforts, involving
have shifted their services to telemedicine, and various stakeholders. A person with poor health
the number of patients being served are more literacy has a poor health status as well. [20]
than 100 people per day per doctor, which Therefore, good health literacy is needed by
exceeds the number that could be handled PWD to manage their health and make the right
before the pandemic era. [15] The United health decisions to achieve favourable disease
States, Italy, and South Africa are also outcomes. [21, 22] Health literacy in diabetes
implementing the same approach, and even can be improved by increasing knowledge on
audio-only telemedicine service is provided as self-efficacy and self-care in diabetes
one solution although its effectiveness is still management. [23, 24] Utilizing technology to
under study in the United States. [16] facilitate education on various aspects of
The concept of telemedicine is not new, even diabetes management especially during the
though the quality of virtual services will not be pandemic may offer solution to improve health
the same as direct meetings and physical literacy in the society. [25]
examinations, changes due to the COVID-19
pandemic must be made because we still don't CONCLUSION
know when this pandemic will end. [14, 19] To The results of this study may be generalized to
create wide coverage of telemedicine services in all diabetes patients in Indonesia and in other
Indonesia, various barriers are identified; as an countries whose demographics, economies, and
archipelago country, health services in geographies are similar to Indonesia. This
Indonesia are not evenly distributed.[17] The research can ultimately provide
health expenditure is less than 5% and the recommendations to various stakeholders
universal health coverage does not yet cover the including clinicians and PWD in the form of (1)
entire population. [17] Acknowledging the COVID-19 pandemic has substantial impact
infrastructure condition of information and on diabetes management and increases
technology, 98% of fibre optic backbone is diabetes complications, (2) the use of
available on the Island of Java, but it is not yet in telemedicine in diabetes management needs to
the island of Maluku-Papua. Only 66.2% of be strengthened and may offer a solution to

overcome difficulties experienced by PWD authors read and approved the final manuscript.
during the COVID-19 pandemic, cooperation
between the government and health service Reference
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PWD is necessary, (4) health organizations and
government need to collaborate to formulate Coronavirus disease 2019 (COVID-19)
standards or guidelines for diabetes services Situation Report- 67. 2020.
during a pandemic and, (5) improving health 2. Liu Y, Yan L-M, Wan L, Xiang T-X, Le A,
literacy with technology-based health promotion Liu J-M, Peiris M, Poon LLM, Zhang W:
may provide a solution to reduce the incidence Viral dynamics in mild and severe cases of
of diabetes-related complications during a COVID-19. The Lancet Infectious Diseases
pandemic. 2020, 20(6):656-657.
3. World Health Organization (WHO):
DECLARATIONS Coronavirus Disease (COVID-19) Situation
Ethical approval Report-204. 2020.
This study was approved by the research ethics 4. Sanyaolu A, Okorie C, Marinkovic A,
committee of Fatmawati General Hospital Patidar R, Younis K, Desai P, Hosein Z,
11/KPP/VII/2020. Informed consent was Padda I, Mangat J, Altaf M: Comorbidity
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Bulletin 2011, December Quarter 2011.
Availability Of Data And Materials 6. International Diabetes Federation (IDF): IDF
The original data from this study and the Diabetes Atlas Ninth Edition 2019.
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Diabetes Country Profile: Indonesia. World
Competing Interests Health Organization 2016.
The authors declare they have no competing 8. Perkumpulan Endokrinologi Indonesia
interests (PERKENI): Pernyataan Resmi dan
Rekomendasi Pengangan Diabetes Mellitus
Funding di era Pandemi COVID-19. PERKENI 2020,
This research did not receive any specific grant IV(239).
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or not for profit sector for diabetes care in India during COVID19
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Rose TC, Gray LJ, Davies MJ, Khunti K: the COVID-19 Pandemic: We Can't Put the
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19.Klonoff DC: Telemedicine for Diabetes After

Figure 1. Distribution of Subjects According to Regions in Indonesia

Table 1. Demographic Characteristics of the Subjects Frequency (n) Presentation (%)
Variable
Sex 507 54.89
Male 617 45.11
Female
Age 144 12.81
18-40 years 514 45.73
466 41.46
> 40-60 years
> 60 years 604 53.74
Occupation 259 49.81
Does Not Work 261 50.19

Work from Home 238 21.17
Work from Office 464 41.28
Income 208 18.51
< Rp. 2.000.000 214 19.04

Rp. 2.000.000-Rp.5.000.000 880 78.30
Rp. 5.000.000-Rp.10.000.000 78 6.94
> Rp. 10.000.000 64 5.69
Health Insurance
National Health Insurance 978 87.01
43 3.83
Other Insurance 103 9.16
Pay with Own Money
Marriage 861 76.60
Married 16 1.42
106 9.43
Single 141 12.54
Ever been married
Transportation to Health Facility 936 83.27
Private vehicle 183 16.28
5 0.44
By foot
Online Transportation 731 65.04
Public transportation 393 34.96
Residence
Live with family

Live alone
Live in a boarding house/ institution
Distance to Health Facility
Close

Far

*Rp: Rupiah (IDR)

Table 2. Diabetes Profile Frequency (n) Presentation (%)
Variable
253 22.51
Diabetes Duration 257 22.86
< 3 years 233 20.73
> 3-5 years 381 33.90

> 5-10 years 21 1.87
4.98
> 10 years 52.85
Diabetes Medication 19.13
21.17
Do not know
7.74
No pharmacological treatment 56 67.88
OAD 594 5.69
Insulin 215 10.85
OAD and Insulin 238 7.65
Health Facility for Diabetes Treatment 0.18
None 87
2.67
Hospital 763 58.45
6.14
Public health centre 64 10.59
8.27
Private clinic 122 6.32
7.56
Private practice 86

Midwife / nurse 2

Number Of Regular Consultations Before The Pandemic

More than once in a month 30

Once in a month 657

Once in 2 months 69

Once in 3 months 119

Once in 6 months 93

Once in a year 71

Never 85

OAD: Oral Anti Diabetics

Table 3. Relationship between Difficulties During the COVID-19 Pandemic and Diabetes Complications
in People with Diabetes in Indonesia

Variable Complications n (%) PR Crude PR Adjusted (95%
CI)
Present Not Present (95% CI)
1.41 (1.09-1.83)
276 (24.56) 848 (75.44) 1.00
1.44 (1.12-1.85)
Difficulties in diabetes 1.00

management 2.24 (1.75-2.85)
1.00
Present 194 (70.29) 485 (57.19) 1.55 (1.23-1.95) *

Not Present 82 (29.71) 363 (42.81) 1.00

Sex

Male 124 (44.93) 383 (45.17) 0.99 (0.81-1.22)

Female 152 (55.07) 465 (54.83) 1.00

Age

< 60 years 186 (67.39) 472 (55.66) 1.46 (1.17-1.83) *

> 60 years 90 (32.61) 376 (44.34) 1.00

Occupation

Work from Office 54 (41.86) 207 (52.94) 0.71 (0.53-0.97) *

Work from Home/

Unemployed/Retired 75 (58.14) 184 (47.06) 1.00

Income

Below NMW 73 (26.45) 165 (19.46) 1.34 (1.07-1.68) *

NMW/ above NMW 203 (73.55) 683 (80.54) 1.00

Health Insurance

NHI 38 (13.77) 104 (12.26) 1.10 (0.82-1.48)

Other 238 (86.23) 744 (87.74) 1.00

Residence

Live alone 46 (16.67) 137 (16.16) 1.03 (0.78-1.35)

Live with family/ other 230 (83.33) 711 (83.84) 1.00

Distance to Health Facility

Far 109 (39.49) 284 (33.49) 1.21 (0.99-1.50)

Close 167 (60.51) 564 (66.51) 1.00

Diabetes Duration

> 5 years 163 (59.06) 451 (53.18) 1.20 (0.97-1.48)

< 5 years 113 (40.94) 397 (46.82) 1.00

Diabetes Medications

Insulin 168 (60.87) 285 (33.61) 2.30 (1.87-2.84) *

Others 108 (39.13) 563 (66.39) 1.00

Health Facility for Diabetes

Treatment

Hospital 188 (68.12) 575 (67.81) 1.01 (0.81-1.26)

Others 88 (31.88) 273 (32.19) 1.00

Number Of Regular Consultations Before The Pandemic

> Once in 3 months 59 (21.38) 190 (22.41) 0.96 (0.74-1.23)

< Once in 3 months 217 (78.62) 658 (77.59) 1.00

Table 4. How People with Diabetes in Indonesia Cope with Difficulties of Diabetes Management During

Pandemic

Variables Frequency (n) Presentation (%)

Difficulties in attending diabetes consultation 338 30.7
Disregard the condition/indifference 171 50.59

Chat with health providers via non health

applications 62 18.34

Call health providers for a consultation 32 9.47

Consultation with health providers via health

applications/ internet 73 21.60

Difficulties in checking blood sugar levels 107 9.52

Left alone (do not check blood sugar levels) 65 60.75

Buy a glucometer 35 32.71

Borrow glucometer from friends / relatives 7 6.54

Difficulties in obtaining diabetes medications 139 12.37

Left alone (do not take medicine) 43 30.94
Buy medicine at pharmacies / online / internet

applications 78 56.12

Ask friends / family to buy medicine 11 7.91

Change medication without consultation 5 3.60

Consult a doctor / educator / nurse via

application / internet to get a prescription 2 1.44

HEMOPERFUSION AS AN ADJUVANT THERAPY IN SEVERE COVID-19
IN HEMODIALYSIS PATIENTS : EXPERIENCE FROM FATMAWATI GENERAL

HOSPITAL

Elizabeth Yasmine Wardoyoa*, Anggraini Permata Saria, Aryan Yohanes Djojoa, Johannes Sarwonoa, Nikko Darnindrob,
Jerry Nasarudinb, Marina Epriliawatib, Md Ikhsan Mokoagowb, Giri Ajib, Krishna Adi Wibisanab, Anak Agung Arie Widyastutib

aNephrology Division, Department of Internal Medicine, Fatmawati General Hospital, Jakarta, Indonesia
bCOVID-19 team, Department of Internal Medicine, Fatmawati General Hospital, Jakarta, Indonesia Email:
[email protected]

ABSTRACT on our clinical experience, timing of HP
Background. Mortality rate among delivery is crucial and should be performed in
maintenance hemodialysis (HD) patients with early phase of ARDS with early increase of
COVID-19 is alarmingly high. In Fatmawati inflammatory marker. This measure may
General Hospital, most of HD patients with prevent the requirement for intubation in
COVID- 19 presented with moderate and patients with severe COVID-19. Combination
severe acute respiratory distress syndrome use of HP-HD on maintenance HD patients
(ARDS). Hemoperfusion (HP) is a blood with COVID-19 is promising that merits further
purification therapy used to remove cytokines investigations.
and inflammatory mediators to prevent ARDS Keywords: hemodialysis, hemoperfusion,
and organ failure. Hemoperfusion was hemoadsorption, COVID-19, resin, cytokine
performed in HD patients whom have not storm
developed to severe ARDS. Methods. We
report three cases of COVID-19 in INTRODUCTION
maintenance HD patients. HP and HD were Mortality rate among maintenance
performed in two consecutive days when hemodialysis (HD) patients with COVID-19 is
patient developed early ARDS as indicated by alarmingly high.1 Hemoperfusion (HP) is a
inflammatory markers elevation. HD and HP blood purification therapy used to remove
were conducted by using high-flux dialyzer and cytokines and inflammatory mediators.2,3 In our
neutral macroporous resin cartridge HA-330, hospital, HP was performed in HD patients with
respectively, for 4 hours. All patients received severe COVID-19 when clinical condition
standard of care i.e. anti-viral agent, worsened. Severity of the disease was
unfractionated heparin, empirical antibiotic, assessed by room air SpO2, PaO2/FiO2 ratio
acetylcysteine, glucocorticoids, vitamin C, and and C-reactive protein (CRP). HD and HP
calcitriol. Result. All three ARDS patients who were conducted for 4 hours by using high-flux
had HP were subsequently managed without dialyzer and neutral macroporous resin
intubation. Case 2 was on high flow nasal cartridge HA-330 (Jafron Biomedical
cannula while case 1 and 3 were on non- Company, China), respectively. All patients
rebreathing oxygen mask. After HP, C-reactive received standard of care i.e. anti-viral agent,
protein (CRP), PaO2/FiO2 ratio and chest X- unfractionated heparin, empirical antibiotic,
ray were improved. Case 1 and 2 had less acetylcysteine, glucocorticoids and vitamin C.
dependency to oxygen supplementation and
were discharged from the hospital. Case 3 also CASES
had improvement after HP but then developed Case 1. Female, 42 years old came with
septic shock due bacterial infection few days shortness of breath and fever 1 day before
afterwards and succumbed to the disease. admission. She was on maintenance
Conclusion. Improvement in CRP levels, hemodialysis for 2 years. She came with
PaO2/FiO2 ratio and chest-X ray were Modified Sequential Organ Failure Assessment
observed after two sessions of HP-HD. Based (mSOFA) score of 7 and PaO2/FiO2 ratio 155.

Laboratory studies showed leucocyte 8100/l, CoV-2. On day 5, her shortness of breath
absolute lymphocyte count (ALC) 729/ml, progressed, room air SpO2 88%, PaO2/FiO2
neutrophil-lymphocyte ratio (NLR) 9.3, CRP ratio 130, CRP elevated to 32 mg/dl. High flow
30.7 mg/dl, procalcitonin 5.4 ng/ml, LDH 919 nasal cannula with FiO2 70% was
u/l, lactate 1.2 mmol/l, Ferritin 9,555 ng/ml, d- administered. HP-HD were then performed on
dimer 3,040 ng/ml, and positive PCR SARS- day 6 and 7. After the first and second HP-HD,
CoV-2. She was on HD thrice weekly and her CRP, PaO2/FiO2 ratio, and chest X- ray were
clinical condition was improved. On day 5, 7 improved. She was subsequently stepped
and 11 CRP were decreased to 33.2 mg/dl, down to general ward in day 15, and later was
28.6 mg/dl and 4 mg/dl, respectively. On day discharged on day 20.
17, she developed severe shortness of breath
with room air SpO2 85%, PaO2/FiO2 114 and Case 3. Male, 67 years old presented with
CRP elevation (19.8 mg/dl). HD and HP were shortness of breath for 12 hours before
then was initiated on day 18 and admission. He had hypertension and was on
19. After the first HP-HD, CRP decreased to maintenance hemodialysis for 8 months.
12.4 mg/dl and PaO2/FiO2 increased to 163. Initially, he had mSOFA score of 7, PaO2/FiO2
Following the second HP, CRP and PaO2/FiO2 ratio 206. Laboratory studies showed leukocyte
were further improved to 7 mg/dl and 178, 1,0300/l, ALC 1,030/l, NLR 8.7, CRP 3 mg/dl,
respectively (Graph 1). The next day, CRP procalcitonin 4.11 ng/ml, LDH 520 u/l, lactate
decreased to 3.3 mg/dl, room air SpO2 was 1.4 mmol/l, d-dimer 3,814 ng/ml, and positive
95%, and chest X-ray (Figure 1) also PCR SARS-CoV-2. He had regular HD on
improved. Patient was then discharged on day alternating days. On day 5, his respiratory
35. condition deteriorated with room air SpO2 83%,
PaO2/FiO2 141 and elevated CRP 26.9 mg/dl.
Case 2. Female, 44 years old presented with HD and HP were performed on day 5 and 6.
cough and shortness of breath 2 days before After the first and second HP, CRP PaO2/FiO2
admission. She was a maintenance ratio, and chest X-ray were improved.
hemodialysis patient for 5 years. She came Klebsiella pneumoniae was found in his blood
with mSOFA score of 8 and PaO2/FiO2 ratio culture. Despite antibiotic escalation, his
150. Laboratory studies demonstrated clinical condition was worsened on day 15. His
leucocyte 1,100/ml, ALC 88/ml, NLR 10.5, clinical condition progressed into septic shock
CRP 2.1 mg/dl, procalcitonin >32 ng/ml, LDH while procalcitonin level remained high.
447 u/l, lactate 1.0 mmol/l, ferritin 1,614 ng/ml, Ultimately, he succumbed to the disease on
d-dimer 850 ng/ml and positive PCR SARS- day 17.

Graph 1. PaO2/FiO2 ratio and CRP level pre and post HP

Figure 1. Chest X-ray pre and post hemoperfusion. a,c,e. CXR pre-HP; b, d, f CXR post-HP.

DISCUSSION appeared later than case 2 and 3. This finding
Hemoperfusion was reported to be beneficial suggests systemic cytokine release can
when conducted with HP machine or combined appear in different timing between patients.
with CRRT in severe COVID-19.4,5 Due to Inflammatory marker close observation along
limitation in number of CRRT machines in our with clinical condition is crucial hence
hospital and stable hemodynamic condition of facilitating early detection of deterioration that
these patients, we initiated HP with HD requires prompt treatment. HP was suggested
machine. Timing for HP is critical to yield an to be performed in 2-1-1 order.3 Due to
optimal outcome. CRP elevation and limitation of cartridges in our hospital, we
deterioration of clinical condition in case 1 modified the protocol by assessing the

requirement of HP for individual patient. We and chest-X ray were observed after two
found improvement in PaO2/FiO2 ratio, CRP sessions of HP-HD. Based on our clinical
level, and chest X-ray after second HP and we experience, timing of HP delivery is crucial and
did not continue to third HP. should be performed in early phase of ARDS
with early increase of inflammatory marker.
CONCLUSION This measure may prevent the requirement for
Improvement in CRP levels, PaO2/FiO2 ratio intubation in patients with severe COVID-19.

HASIL PENELITIAN
PENGGUNAAN SITOSTATIKA PADA PASIEN KANKER DEWASA DI RUANG KEMOTERAPI RSUP

FATMAWATI
PERIODE BULAN JANUARI SAMPAI JUNI TAHUN 2020

Peneliti :
Apt. Dra. Magdalena Niken Oktovina, M.Si.

NIP : 196710201997032001
INSTALASI FARMASI

RUMAH SAKIT UMUM PUSAT FATMAWATI TAHUN 2020

KATA PENGANTAR

Puji dan syukur Penulis panjatkan kepada Tuhan Yang maha Esa atas berkat dan kasihNya
sehingga penelitian ini dapat diselesaikan. Penelitian ini berjudul “Penggunaan Sitostatika Pada Pasien
Kanker Dewasa di Ruang Kemoterapi RSUP Fatmawati Periode bulan Januari sampai Juni Tahun
2020”. Tujuan penelitian ini adalah untuk menambah literatur terkait penggunaan sitostatika dan
sebagai keikutsertaan dalam khasanah penelitian di ruang lingkup RSUP Fatmawati tempat penulis
menjalankan pelayanan kefarmasian sebagai seorang Farmasi Klinik.

Penulisan hasil penelitian ini, juga tidak terlepas dari dukungan berbagai pihak. Oleh karena itu,
Penulis mengucapkan terimakasih atas semua dukungan semua pihak baik Direktur Utama RSUP
Fatmawati beserta jajarannya, Kepala Diklit dan jajarannya, Teman teman Instalasi farmasi dan
khususnya di ruang pencampuran obat sitostatik, serta para perawat di ruang kemoterapi. Tidak lupa
kepada suami dan ketiga putra terkasih (Lukas, Daud dan Indra) sehingga semua dapat berjalan
dengan lancar.

Penulis menyadari bahwa masih banyak kekurangan yang terdapat dalam penulisan hasil penelitian
ini, maka sangat berharap mendapat masukan dalam bentuk saran dan kritikan yang membangun agar
dikemudian hari penelitian terkait sitostatika lebih berkembang terutama dalam aplikasi di dunia
kesehatan dan ilmu pengetahuan.

Penulis
November 2020

DAFTAR ISI

KATA PENGANTAR ....................................................................................................................... ii
DAFTAR ISI .....................................................................................................................................iii
DAFTAR TABEL............................................................................................................................ iv
DAFTAR GAMBAR......................................................................................................................... v
ABSTRACT..................................................................................................................................... vi
ABSTRAK ........................................................................................................................................vii
BAB I PENDAHULUAN ................................................................................................................. 1
1.1............................................................................................................................... Lata

r Belakang................................................................................................................................ 1
1.2............................................................................................................................... Rum

usan Masalah........................................................................................................................... 3
1.3............................................................................................................................... Tuju

an Penelitian ............................................................................................................................ 3
1.4............................................................................................................................... Manf

aat Penelitian ........................................................................................................................... 4
BAB II TINJAUAN PUSTAKA ....................................................................................................... 5
BAB III METODE PENELITIAN ...................................................................................................... 24
BAB IV HASIL DAN PEMBAHASAN ............................................................................................. 28
BAB V KESIMPULAN DAN SARAN ............................................................................................. 41
DAFTAR PUSTAKA........................................................................................................................ 43

DAFTAR TABEL

Tabel 2.1 Beberapa Contoh Paduan Obat Sitostatik Yang Lazim Digunakan............................. 13
Tabel 2.2 Tabel Penggolongan dan Jenis Sitostatika ................................................................. 14
Tabel 2.3 Potensi Emetogenik Obat Sitostatika .......................................................................... 20
Tabel 2.4 Sitostatika Dengan Pemberian Antiemetik .................................................................. 21
Tabel 3.1 Definisi Operasional Penelitian ................................................................................... 27
Tabel 4.1 Tabel Karakteristik Pasien Kanker Berdasarkan Jenis Kelamin.................................. 29
Tabel 4.2 Tabel Karakteristik Pasien Kanker Berdasarkan Usia................................................. 30
Tabel 4.3 Tabel Karakteristik Pasien Kanker Berdasarkan Ruang Rawat................................... 30
Tabel 4.4 Tabel Karakteristik Pasien Kanker Berdasarkan Diagnosa Penyakit .................. 31
Tabel 4.5 Tabel Karakteristik Pasien Kanker Berdasarkan Golongan Sitostatika ................. 32
Tabel 4.6 Tabel Karakteristik Pasien Kanker Berdasarkan Jenis Sitostatika .............................. 34
Tabel 4.7 Tabel Hubungan Karakteristik Sampel Penelitian Terhadap
Penggunaan Sitostatika .............................................................................................. 35

DAFTAR GAMBAR

Gambar 1. Kerangka Teori. ............................................................................................................ 23
Gambar 2. Kerangka Konsep Penelitian......................................................................................... 24
Gambar 3. Grafik Garis Linear Antar KarakteristikDan Sitostatika

Berdasarkan Golongan Dan Jenis Obat ........................................................................ 35

THE USED OF CYTOSTATICS IN ADULT CANCER PATIENTS IN THE CHEMOTHERAPY ROOM
OF FATMAWATI GENERAL HOSPITAL FOR JANUARY TO JUNE 2020

ABSTRACT
Chemotherapy is one of the treatment modalities for systemic cancer which is often chosen,
especially to treat advanced, local and metastatic cancers. The administration of cytostatics is carried
out in a special room to avoid exposure to cytostatics and for the safety of patients and officers giving
cytostatics. The administration of cytostatics is adjusted to the diagnosis of cancer. Therefore, the
researcher wanted to know how the use of cytostatics in cancer patients in the Chemotherapy room of
Fatmawati Hospital, especially in adult patients.
This study aims to determine the characteristics of adult cancer patients who undergo chemotherapy
in the chemotherapy room, and the use of cytostatics based on drug class and type, and how the
characteristics of adult patients relate to the use of cytostatics.
The research method was carried out by taking data from adult patients diagnosed with cancer and
administering chemotherapy from January to June 2020 in the chemotherapy room by paying attention
to inclusion and exclusion criteria.
The results showed 1272 adult patients who administered chemotherapy and 3785 cytostatic
preparations from January to June 2020. From the evaluation, it was found that the most cancer patient
characteristics based on gender were 78.22% women with an age range of ≥40 - 60 years of 60.14 %
and the most disease diagnoses were breast cancer at 50.63%. The use of cytostatics based on group
is antimetabolite with pyrimidine analogues (Fuorouracil (5-FU) and Gemcitabine) and folic acid
analogues (Methotrexate) with a value of 28.22%. The highest use of cytostatic types was Fluorouracil
(5-FU), which was 19.47%. The relationship between patient characteristics and use of cytostatics is in
gender, age and indication of drug use (disease diagnosis).
The results of this study are very useful considering the scarcity of literature due to the limited
implementation units that carry out the provision of sitostatics such as Fatmawati General Hospital.
Therefore, it can be suggested for further research related to the relationship between drug use and
cancer diagnosis in the context of drug availability and cost analysis, as well as evaluation of the side
effects that occur when administering cytostatics through documented interviews with patients.

Keyword : Chemotherapy, Sitostatics, Cancer, Fatmawati General Hospital.

PENGGUNAAN SITOSTATIKA PADA PASIEN KANKER DEWASA DI RUANG KEMOTERAPI RSUP
FATMAWATI PERIODE BULAN JANUARI SAMPAI JUNI TAHUN 2020

ABSTRAK
Kemoterapi merupakan salah satu modalitas pengobatan pada kanker secara sistemik yang sering
dipilih terutama untuk mengatasi kanker stadium lanjut, lokal maupun metastatis. Pemberian sitostatika
dilakukan pada ruangan khusus untuk menghindari paparan sitostatika dan untuk keamanan pasien
dan petugas pemberi sitostatika. Pemberian sitostatika disesuaikan dengan diagnosa penyakit kanker.
Oleh karena itu, Peneliti ingin mengetahui bagaimana Penggunaan Sitostatika pada pasien Kanker di
ruang Kemoterapi RSUP Fatmawati terutama pada pasien dewasa.
Penelitian ini bertujuan untuk mengetahui karakteristik pasien kanker dewasa yang menjalankan
kemoterapi di ruang kemoterapi,dan penggunaan Sitostatika berdasarkan Golongan dan Jenis obat,
serta bagaimana hubungan karakteristik pasien dewasa dengan penggunaan sitostatika.
Metode penelitian dilakukan dengan mengambil data pasien dewasa yang terdiagnosa penyakit
kanker dan menjalankan pemberian kemoterapi bulan Januari sampai Juni tahun 2020 diruang
kemoterapi dengan memperhatikan kriteria inklusi dan eksklusi.
Hasil penelitian didapat 1272 pasien dewasa yang menjalankan pemberian kemoterapi dan 3785
sediaan sitostatika pada bulan Januari sampai Juni tahun 2020. Dari evaluasi diperoleh karakteristik
pasien kanker terbanyak berdasarkan jenis kelamin adalah perempuan 78,22 % dengan kisaran usia
≥40 - 60 tahun sebesar 60,14% dan diagnosa penyakit terbanyak adalah Kanker payudara sebesar
50,63%. Penggunaan sitostatika berdasarkan golongan adalah antimetabolit dengan analog pyrimidin
(Fuorouracil (5-FU) dan Gemcitabine) dan analog asam folat (Methotrexate) dengan nilai sebesar
28.22%. Penggunaan jenis sitostatika terbanyak adalah Fluorouracil (5-FU) yaitu sebesar 19,47%.
Hubungan karakteristik pasien dengan penggunaan sitostatika terdapat pada jenis kelamin, usia dan
indikasi penggunaan obat (diagnosa penyakit)
Hasil penelitian ini sangat bermanfaat mengingat masih jarangnya literature dikarenakan
terbatasnya unit pelaksana yang melaksanakan pemberian sitostatika sepeerti RSUP Fatmawati. Oleh
karena itu, dapat disarankan untuk penelitian lanjutan terkait hubungan penggunaan obat dengan
diagnosa penyakit kanker dalam rangka ketersediaan obat dan analisa biaya, serta evaluasi efek
samping yang terjadi saat pemberian sitostatika memalului wawancara yang terdokumentasi terhadap
pasien.

Kata Kunci : Kemoterapi, Sitostatika, Kanker, RSUP Fatmawati

BAB I PENDAHULUAN

1.1 Latar Belakang pengobatan pada kanker secara sistemik yang
Penyakit kanker menjadi salah satu penyakit sering dipilih terutama untuk mengatasi kanker
kronis yang peningkatannya cukup tinggi saat stadium lanjut, local maupun metastatis.
ini. Menurut World Health Organization atau Kemoterapi sangat penting dan dirasakan besar
WHO (2014) kanker merupakan suatu istilah manfaatnya karena bersifat sistemik
umum yang menggambarkan penyakit pada mematikan/membunuh sel-sel kanker dengan
manusia berupa munculnya sel-sel abnormal cara pemberian melalui infuse, dan sering
dalam tubuh yang melampaui batas. Sel-sel menjadi pilihan metode efektif dalam mengatasi
tersebut dapat menyerang bagian tubuh lai kanker terutama kanker stadium lanjut lokal
(WHO, 2014). Menurut statistik Amerika Serikat, (Desen, 2008). Teknik pemberian kemoterapi
kanker menyumbang sekitar 23% dari total ditentukan dari jenis keganasan dan jenis obat
jumlah kematian di negara tersebut dan menjadi yang diperlukan (Adiwijono, 2006).
penyakit kedua paling mematikan setelah Kemoterapi pasien kanker dilakukan dengan
penyakit jantung (Anand, Kunnumakara, pemberian sitostatika yang umumnya berupa
Sundaram, Harikumar, Tharakan, Lai, dan kombinasi dari beberapa obat yang diberikan
Aggarwal, 2008). Setiap 11 menit ada satu secara bersamaan dengan jadwal yang telah
orang penduduk dunia yang meninggal karena ditentukan. Sitostatika dapat membunuh sel
kanker dan setiap tiga menit ada satu penderita kanker, namun juga memberi pengaruh
kanker baru. Fakta lain menunjukkan bahwa kepada sel-sel normal, terutama yang cepat
lima besar kanker yang diderita adalah kanker membelah atau cepat tumbuh seperti rambut,
leher rahim, kanker payudara, kanker ovarium, lapisan mukosa usus dan sumsum tulang.
kanker kulit, dan kanker rektum (Rasjidi, 2009). Beberapa efek samping yang terjadi pada
Badan Kesehatan dunia (WHO) pemberian sitostatika umumnya gangguan mual
mengestimasikan bahwa 84 juta orang dan muntah sebagai efek samping frekuensi
meninggal akibat kanker dalam rentang waktu terbesar (Yusuf, 2007).
2005 dan 2015, dengan perkiraan setiap Pemberian sitostatika dilakukan pada ruangan
tahunnya 12 juta di seluruh dunia orang akan khusus untuk menghindari paparan sitostatika
menderita kanker dan 7,6 juta diantaranya dan untuk keamanan pasien dan petugas
meninggal dunia. Kejadian kanker terjadi lebih pemberi sitostatika. Pemberian sitostatika
cepat di negara miskin dan berkembang. disesuaikan dengan diagnosa penyakit kanker.
Data International Agency for Research on Oleh karena itu, Peneliti ingin mengetahui
Cancer (IARC), mendapatkan 85% dari kasus bagaimana Penggunaan Sitostatika pada pasien
kanker di dunia yang berjumlah 493.000 dengan Kanker di ruang Kemoterapi RSUP Fatmawati.
jumlah 273.000 kasus kematian terjadi di
negara-negara berkembang (Savitri, dkk, 2015). 1.2 Rumusan Masalah
Dinyatakan bahwa terdapat 15 persen dari 190- Bagaimana penggunaan sitostatika pada
200 ribu penderita kanker baru di Indonesia
setiap tahunnya (International Union Against pasien kanker yang diberikan di ruang
Cancer/UICC, 2009). Sistem Informasi Rumah kemoterapi RSUP Fatmawati periode Januari
Sakit (SIRS) 2007, menyatakan kejadian kanker sampai Juni 2020.
di Indonesia sebanyak 8.227 kasus atau 16,85%
dan pada tahun 2008, 12 juta pasien yang baru 1.3 Tujuan Penelitian
terdiagnosis kanker dan lebih dari 7 juta pasien 1. Tujuan Umum
meninggal akibat kanker. Pada tahun 2030 Mengevaluasi penggunaan sitostatika dengan
diperkirakan terjadi kasus kanker sebanyak 20 kriteria pasien kanker yang menjalankan
hingga 26 juta pasien dan 13 hingga 17 juta kemoterapi di ruang kemoterapi RSUP
pasien meninggal akibat kanker. Fatmawati.
Kemoterapi merupakan salah satu modalitas
2. Tujuan Khusus

a. Mengetahui karakteristik pasien kanker sitostatika dan diagnosa kanker terbanyak
yang menjalankan kemoterapi di ruang yang menjalankan kemoterapi di RSUP
kemoterapi. Fatmawati
b. Instalasi Farmasi
b. Mengetahui penggunaan Sitostatika Sebagai dasar dalam pemilihan jenis dan
berdasarkan Golongan dan Jenis obat. jumlah sitostatika untuk ketersediaan obat
di RSUP Fatmawati
c. Hubungan Penyakit kanker dengan c. Masyarakat
penggunaan sitostatika. Memberikan informasi dan wawasan bagi
masyarakat dalam penggunaan obat
3. Manfaat Penelitian sitostatik pada pasien kanker.
a. Rumah Sakit Umum Pusat Fatmawati
Sebagai gambaran terhadap jenis

BAB II TINJAUAN PUSTAKA

2.1 Penyakit Kanker getah bening, dan lemak.
1. Definisi Kanker b. Karsinoma adalah jenis kanker yang paling
Kanker merupakan suatu penyakit atau
kelainan pada tubuh sebagai akibat dari sel-sel umum, dan terbentuk pada jaringan epitel
tubuh yang tumbuh dan berkembang abnormal seperti kulit, dan lapisan rongga.
di luar batas kewajaran (Junaidi, 2007). c. Denokarsinoma adalah kanker yang
Kanker adalah suatu penyakit yang terbentuk pada sel epitel yang
disebabkan oleh pertumbuhan sel-sel jaringan menghasilkan cairan atau lendir yang
tubuh yang tidak normal. Sel- selkan kerakan meyerupai jaringan kelenjar seperti usus
berkembang dengan cepat, tidak terkendali, besar, prostat, danovarium.
dan terus membelah diri, selanjutnya masuk d. Limfoma adalah kanker yang dimulai pada
ke jaringan di sekitarnya (invasive) dan terus limfosit (sel T atau sel B) yang terbentuk di
menyebar melalui jaringan ikat, darah, dan kelenjar getah bening dan merupakan
menyerang organ-organ penting serta saraf bagian dari sistem kekebalan tubuh.
tulang belakang. Dalam keadaan normal, sel e. Leukimia adalah kanker yang berasal dari
hanya akan membelah diri jika ada jaringan pembentuk darah sumsum tulang.
penggantian sel-sel yang telah mati dan rusak. f. Myeloma adalah kanker yang berasal dari
Sebaliknya, sel kanker akan membelah terus sel plasma sumsum tulang. Sel- sel plasma
meskipun tubuh tidak memerlukannya, menghasilkan beberapa protein yang
sehingga akan terjadi penumpukan sel baru. ditemukan dalam darah. (National Cancer
Penumpukan sel tersebut mendesak dan Institute,2015).
merusak jaringan normal, sehingga
mengganggu organ yang ditempatinya 2. Patofisiologi
(Mangan, 2009). Organ tubuh manusia memiliki beberapa jenis
Menurut National Cancer Institute terdapat sel yang akan tumbuh dan membelah secara
lebih dari 100 jenis kanker. Jenis kanker terkontrol untuk menghasilkan lebih banyak sel
biasanya dinamai terkait organ atau jaringan yang dibutuhkan oleh tubuh. Ketika sel
dimana kanker terbentuk. Misalnya, kanker menjadi tua dan rusak, sel-sel tersebut akan
paru-paru dimulai di sel paru-paru. Kanker mati dan diganti dengan sel-sel baru.
dapat di klasifikasikan berdasarkan jenis dari Kematian sel ini disebut apoptosis. Ketika
sel tertentu yaitu sarkoma, karsinoma, proses ini rusak, kanker akan mulai terbentuk
adenokarsinoma, limfoma, dan leukimia: jadi sel tumbuh dan tidak terkendali disebut
a. Sarkoma adalah kanker yang terbentuk mutasi DNA (deoxyribose nucleic acid)
pada jaringan tulang dan lunak seperti (National Cancer Institute,2015).
tulang rawan, pembuluh darah, pembuluh

3. Manifestasi Klinis 1. Zatkimia
Menurut National Cancer Institute gejala klinis
kanker bervariasi tergantung jenis atau lokasi Banyak zat kimia yang ditambahkan
kanker:
a. Nyeri dapat terjadi akibat tumor yang dalam makanan dapat memicu kanker,

meluas menekan saraf dan pembuluh misalnya bahan pengawet, pemanis
darah di sekitarnya. Nyeri juga disebabkan
ketakutan dan kecemasan. buatan, dan pewarna buatan.
b. Perdarahan atau pengeluaran cairan yang
tidak wajar, misalnya muntah berdarah, 2. Radiasi
mimisan terus menerus, dan cairan puting
susu mengandung darah. Radiasi panjang gelombang tertentu,
c. Perubahan kebiasaan buang air besar
d. Penurunan berat badan secara drastis yang disebut radiasi pengion, memiliki
e. Gangguan pencernaan
f. Luka yang tidak sembuh cukup energi untuk merusak DNA dan

Pengenalan gejala kanker dapat dilakukan menyebabkan kanker.
sendiri dengan cara WASPADA yang
merupakan kependekan dari istilah-istilah 3. Virus
sebagai berikut:
W = Waktu buang air besar atau kecil ada Beberapa agen infeksius, termasuk virus,
perubahan kebiasaan atau terganggu.
A = Alat pencernaan terganggu dan susah bakteri, dan parasit, dapat menyebabkan
menelan.
S = Suara serak dan batuk yang tidak kunjung kanker atau meningkatkan risiko kanker.
sembuh.
P = Payudara atau ditempat lain ada benjolan. Beberapa virus dapat mengganggu sinyal
A = Andeng-andeng atau tahi lalat berubah
sifat, menjadi semakin besar dangatal. sehingga menyebabkan pertumbuhan sel
DA = Darah atau lendir yang tidak normal
keluar dari lubang-lubang tubuh. (Mangan, dan proliferasi. Beberapa infeksi bisa
2009)
melemahkan sistem kekebalan tubuh,
4. Faktor Resiko
Beberapa faktor risiko yang dapat membantu sehingga tubuh kurang mampu melawan
pertumbuhan kanker:
a. Faktor Genetik infeksi penyebab kanker lainnya.
Kanker disebabkan oleh perubahan pada gen
tertentu yang mengubah cara fungsi sel. 4. Hormon
Beberapa perubahan genetik bisa terjadi
secara alami ketika replikasi DNA selama Hormon estrogen yang berlebih juga
proses pembelahan sel atau penyebab lain
adalah akibat terpapar lingkungan yang dapat meningkatkan kanker kandungan
merusak DNA. Paparan ini termasuk zat kimia
dalam asap tembakau, atau radiasi, seperti dan payudara sedangkan hormon
sinar ultraviolet dari sinar matahari.
progesteron dapat mencegah timbulnya
b. Faktor karsinogen, diantaranya zat kimia,
radiasi, virus, dan hormon. kanker endotrium, tetapi meningkatkan

risiko kanker payudara.

c. Faktor perilaku/gaya hidup, diantaranya

yaitu merokok, pola makan yang tidak

sehat, mengkonsumsi alkohol, dan kurang

aktivitas fisik

1. Merokok memiliki risiko kanker karena

rokok dan asap rokok memiliki banyak

bahan kimia yang merusak DNA.

2. Pola makan yang tidak sehat

3. Mengkonsumsi alkohol dapat

meningkatkan risiko kanker mulut,

tenggorokan, kerongkongan, laring, hati,

dan payudara.

4. Kurang aktivitas fisik

(Kementerian Kesehatan RI, 2015;

National Cancer Institute, 2015).

5. Penanganan Kanker
Penanganan kanker ada bermacam-macam,
antara lain dengan pembedahan, radioterapi,
obat-obatan sitostatika (kemoterapi),
imunoterapi, pengobatan dengan hormon, dan
hipertemi (Tjay dan Rahardja, 2007).

a. Pembedahan.

Hanya dilakukan pada tumor tunggal yang samping yang lebih merugikan dibanding
belum menyebar dengan jalan mengeluarkan manfaatnya, pengobatan harus dihentikan.
secara radikal. Risikonya adalah penyebaran Contoh obat : Dietilstillbestrol, Etinilestradiol,
sel- sel tumor ke jaringan dan pembuluh di Megestrol acetate, Tamoxifen dan lain-lain
sekitarnya akibat pemotongan (Tjay dan (Tjay dan Rahardja, 2007).
Rahardja, 2007).
f. Hipertermi.
b. Radiasi. Penanganan tumor dengan kalor sebagai
Dengan sinar radioaktif (radioterapi) terapi tambahan (adjuvant therapy) untuk
“membakar” dan memusnahkan sel-sel memperkuat efek radiasi. Kalor dari 43-44ºC
tumor. Alat-alat megavolt 4-25 MV, SL-25’, bekerja mematikan langsung sel-sel tumor
Racetract Microtron MM50. Radiasi intern terutama dalam lingkungan asam dan
menggunakan sumber radioaktif dua radio kekurangan oksigen. Karena pemanasan
isotop iridium dan cesium. Cara ini lama dan seksama, secara teknis sulit sekali,
memungkinkan radiasi langsung “dari dalam” maka hingga kini khusus digunakan pada
dengan dosis tinggi tanpa merugikan tumor-tumor di permukaan kulit, mammae,
jaringan sekitarnya. Kedalam tumor kelenjar leher (Tjay dan Rahardja, 2007).
dimasukkan dengan pembiusan tabung-
tabung kecil yang diisi dengan elemen- g. Geneterapi.
elemen radioaktif (Tjay dan Rahardja, 2007). Inaktivasi dari gen-gen tertentu berperan
penting pada pertumbuhan liar dari tumor.
c. Kemoterapi. Pada binatang percobaan, gen p53 sudah
Sitostatika atau obat kemoterapi mempunyai dapat dimasukkan ke dalam sel tumor
risiko tingkat emetogenik yang bervariasi. dengan efek terhentinya pertumbuhan.
Pasien yang menerima kemoterapi dengan Geneterapi dewasa ini sedang
tingkat emetogenik high, moderate, dan low, dikembangkan di banyak Pusat Riset Kanker
berarti mual-muntah terjadi pada 90%, 30- (Tjay dan Rahardja, 2007).
90%, dan 10-30% pasien (Dipiro et al, 2005).
6. Kemoterapi
d. Imunodulator Kemoterapi adalah jenis pengobatan kanker
Kelompok obat ini digunakan untuk menekan yang menggunakan obat kanker (sitostatika)
reaksi jaringan terhadap cangkokan dan untuk membunuh sel kanker. Berbeda dengan
untuk mengobati beberapa penyakit pembedahaan atau radiasi yang bersifat
autoimun. Kerja obat ini tidak spesifik setempat, kemoterapi bersifat sistemik.
sehingga sel darah tepi harus dipantau, dan Sehingga kemoterapi merupakan pilihan
dosis harus disesuaikan. Contoh obat : pertama untuk menangani kanker yang sudah
Interferon ∂, Interferon β, Interferon γ (Tjay menjalar dan menyebar ke bagian tubuh lain
dan Rahardja, 2007). (Calabresi dan Bruce, 2012).
Cara pemberian kemoterapi. Kemoterapi dapat
e. Anti Kanker hormonal & antagonisnya. diberikan dengan berbagai macam cara
Terapi hormon memegang peranan penting sebagai berikut:
dalam pengobatan kanker pada organ-organ a) Kemoterapi sebagai terapi primer : Sebagai
yang pertumbuhannya sangat bergantung
pada hormon, misalnya payudara, prostat, terapi utama yang dilaksanakan tanpa
dan endometrium. Pengobatan ini bukan radiasi dan pembedahan terutama pada
bersifat kuratif, tetapi bersifat paliatif yang kasus kanker jenis koriokarsinoma,
kadang pada sebagian pasien menekan leukemia dan limfoma.
penyakit sampai bertahun- tahun. Respon b) Kemoterapi adjuvant : Pengobatan
klinik dan toksisitas harus dipantau ketat, dan tambahan pada pasien yang telah
bila penyakit berkembang atau timbul efek mendapatkan terapi lokal atau paska
pembedahan atau radiasi.

c) Kemoterapi neoadjuvant : Pengobatan d) Kemoterapi kombinasi : Kemoterapi yang
tambahan pada pasien yang akan
mendapat terapi lokal atau mendahului diberikan bersamaan dengan radiasi pada
pembedahan dan radiasi.
kasus karsinoma lanjut.

Tabel 2.1 Beberapa Contoh Paduan Obat Sitostatik Yang Lazim Digunakan (Guyton and Hall,
1997 dalam skripsi Arima, 2006).

No Jenis obat dan cara pemberian Penggunaan

CAF

1. Cyclophospamid,i.v.,500mg/m2, 1 hari Kanker Payudara
Doxorubicin (Adreamycin), i.v.,50 mg/m2, 1hari Kanker Alat Kelamin

Fluorouracil,.i.v., 500mg/m2, 1hari Kanker Ovari

CAV

2. Cyclophospamid,.i.v., 45mg/m2, 1hari
Doxorubicin (/,dreamycin).,i.v.,50mg/m2, 1hari

Vincristin,i.v.,1,4 mg/m2(max;2mg), 1 hari

CAP

3. Cisplatin, i.v., 50 mg/m2, 1 hari
Cyclophospamid,i.v.,500 mg/m2, 1 hari

Doxorubicin (Adreamycin),i.v., 50 mg/m2, 1 hari

7. Sitostatika
Sitostatika yang digunakan sebagai kemoterapi dapat digolongkan seperti pada tabel dibawah ini :

Tabel 2.2. Tabel Penggolongan dan Jenis Sitostatika (Lexi, Drug Information Handbook for

Oncology)

GOLONGAN OBAT KLASIFIKASI JENIS / NAMA OBAT

Mechlorethamine

Nitrogen Mustards Cyclophosphamide
Ifosfamide Melphalan

Chlorambucil

Ethylenamine And Methylenamine Altretamine Thiotepa
Derivatives

Agen Pengalkil Alkyl Sulfonates Busulfan

Nitrosoureas Carmustine Lomustine

Dacarbazine

Triazenes Procarbazine

Temozolomide

The Platinum-Containing Cisplatin Carboplatin

Antineoplastic Agents Oxaliplatin

Methotrexate

Anti Folat Pemetrexed
Pralatrexate

Trimetrexate

Azathioprine

Cladribine

Analog Purin Fludarabine

Anti-Metabolit Mercaptopurine
Thioguanine

Azacitidine

Capecitabine

Cytarabine Decitabine

Analog Pirimidin Floxuridine

Fluorouracil

Gemcitabine

Trifluridine/Tipracil

Vincristine

Plant alkaloid Vinca Alkaloid Vinorelbine

Vinblastine

Alkaloid Lain Vindesin Sulfat
Etoposide

GOLONGAN OBAT KLASIFIKASI JENIS / NAMA OBAT

Antitumour Antibiotics Bleomycin
Dactinomycin,
Taxane Daunorubicin,
Doxorubicin,
Platinum Epirubicin Idarubicin,
Analog Mitomycin,
Mitoxantrone,
Hormonal Plicamycin, Valrubicin
Paclitaxel Docetaxel
Miscellaneous agent Cabazitaxel
Cisplatin Carboplatin

Oxaliplatin
Camptothecin
Topotecan Irinotecan
Tamoxifen Letrozole
Anastrozole
Exemestane

Mitotane,
Omacetaxine,
Pomalidomide,
Tagraxofusp,

Telotristat,
Temsirolimus,
Thalidomide,

Venetoclax
Asparaginase
(Pegaspargase),
Bexarotene, Eribulin,
Everolimus,
Hydroxyurea,
Ixabepilone,
Lenalidomide,

1. Beberapa jenis sitostatika yang banyak siklosfofamid sangat luas. Obat ini sering
digunakan digunakan dalam kombinasi dengan
a. Chyclophosphamid. Chyclophosphamid metotreksat atau doksorubisin dan
diberikan secara oral atau intravena. fluorourasil sebagai terapi ajuvan setelah
Dosis yang dianjurkan sangat bervariasi, pembedahan karsinoma payudara
sebagai senyawa tunggal dosis harian (Goodman dan Gilman, 2008).
oral 100 mg/m2 untuk 14 hari dianjurkan Adakalanya terjadi radang mukosa
untuk pasien-pasien dengan neoplasma kandung kemih dengan perdarahan.
yang lebih rentan, seperti limfoma, dan Guna menghindari hal ini, maka pasien
leukemia kronis. Dosis lebih tinggi perlu minum banyak air selama terapi.
sebesar 500 mg/m2 secara intra vena tiap Dosis oral 50-200 mg sehari tiap 7-14
3 hingga 4 minggu dalam kombinasi hari, intravena 10-15 mg/kg/hari setiap 3-
dengan obat lain yang sering diberikan 7 hari (Tjay dan Rahardja, 2007).
pada pengobatan kanker payudara dan b. Metotreksat (MTX) Obat ini menghambat
limfoma. Spektrum klinis aktivitas reduksi dari asam folat menjadi

tetrahydrofolic acid (THFA) dengan jalan Hodgkin dan non Hodgkin bila digunakan
pengikatan pada enzim reduktase. THFA bersama dengan siklosfamid, vinkristin,
penting sekali bagi sintesa DNA dan prokarbazin, dan obat- obat lain. Dosis
pembelahan sel. Antagonis folat ini yang dianjurkan 60-75 mg/m2 (Goodman
adalah sitostatika pertama yang efektif dan Gilman, 2008).
pada leukemia limfe akut dan kanker g. Cisplatin. Tersedia untuk pemberian
chorion yang sudah tersebar dengan dosis intra vena. Dosis lazim 20mg/m2 per
sekitar 80% penyembuhan. Dosis hari selama 5 hari atau 100 mg/m2
tergantung pada jenis kanker dan diberikan sekali setiap 4 minggu. Dosis
keadaan pasien oral 5-30 mg sehari sebesar 40 mg/m2 setiap hari 5 hari
selama 5 hari (Tjay dan Rahadja, 2007). berturut-turut. Kombinasi kemoterapi
c. Fluorourasil : 5-FU, Efudix. Antagonis dengan sisplatin, bleomisin, setoposid
pirimidin ini merintangi sintesa DNA dan vinblastin bersifat kuratir untuk 85%
melalui saingan dengan pirimidin. Obat ini pasien kanker testis stadium lanjut. Obat
banyak digunakan untuk tumor yang ini juga bermanfaat untuk karsinoma
sudah menyebar dari buah dada, usus ovarium, khususnya jika digunakan
besar dan poros usus (rectum), juga dari bersama paklitaksel, sikofosfamid, atau
lambung, hati, pankreas, dan lain-lain. doksorabisin (Goodman dan Gilman,
Efektivitasnya (20-30%) diperbesar 2008).
dengan terapi kombinasi. Dosis 10-15 h. Carboplatin. Carboplatin adalah salah
mg/kg intravena selama 4-6 hari (Tjay satu alternatif yang efektif untuk pasien
dan Rahardja, 2007) dengan tumor responsif yang tidak dapat
d. Paclitaxel : Taxol, Obat baru dari menolerasi cisplatin karena gangguan
kelompok taxan ini terdapat dalam jumlah fungsi ginjal, mual yang sukar hilang,
kecil sekali (1:13.5000) di kulit pohon kerusakan pendengaran yang parah
cemara Taxus brevifolia. Kini diperoleh neuropati. Pemberian secara infus
secara semi sintesis dari suatu zat intravena selama setidaknya 15 menit.
pelopornya (baccatine) yang diperoleh Dosis lazim adalah 360 mg/m2 diberikan
dari jarum-jarum Taxus baccata. sekali tiap 28 hari. Carboplatin kini
Berkhasiat sitotoksis dengan jalan diijinkan untuk digunakan dalam
menghambat mitosi dan mengikat suatu kombinasi dengan paklitaksel atau
protein, yang menghalangi apoptosis. siklofosfamid pada pasien kanker ovarium
Obat ini digunakan khusus pada kanker lanjut (Goodman dan Gilman, 2008).
ovarium dan kanker mamae yang
tersebar setelah terapi dengan cisplatin 2. Antiemetik
gagal. Dosis infus i.v 135 mg/m2 sehari Antiemetika secara umum digunakan untuk
(Tjay dan Rahardja, 2007). mencegah mabuk di perjalanan, efek
e. Docetaxel (Taxotere). Adalah derivate samping dari beberapa analgetik opioid dan
dengan efek dan mekanisme kerja yang kemoterapi yang mengarah pada penyakit
sama dan lebih kurang 2x lebih aktif kanker. Impuls yang berasal dari otak untuk
daripada paclitaxel, bersifat sangat lipofil memulai muntah kadang terjadi tanpa
dan tidak larut dalam air. Dosis : infus didahului perasangan mual (Guyton dan Hall,
i.v 100 mg/m2 permukaan badan dari 1997). Antiemetika dapat menutupi
larutan 0,3-0,9 g/l setiap 3 minggu (Tjay penyebab muntah bekerja dengan
dan Rahardja, 2007). menghambat lokasi reseptor yang
f. Doxorubicin. Doksorubisin hidroklorida berhubungan dengan emesis. Antiemetika
(Adriamycin Rubex) efektif pada leukemia berdasarkan mekanisme kerjanya dapat
akut dan limfoma ganas, sejumlah tumor dibedakan menjadi tiga kelompok besar dan
solid khususnya kanker payudara. Efektif beberapa obat tambahan yaitu :
untuk pengobatan penyakit limfoma

setelah kemoterapi (Gruenberg,2004).

a) Antikolinergika: Efeknya berdasarkan sifat

antikolinergisnya dan mungkin juga Muntah terjadi akibat dari stimulasi dari pusat

karena blok adereseptor-H1 di CTZ. muntah dan berlangsung menurut beberapa

b) Antagonis Dopamin: Terdapat sejumlah mekanisme. Empat bagian susunan

obat yang menyebabkan mual dan emetogenik pada obat sitostatika antara lain :

muntah sebagai efek samping akibat a. Mual muntah akut. Biasanya terjadi saat

rangsangan langsung CTZ atau pemberian sitostatika. Tanpa pengobatan

rangsangan mukosa lambung. Zat-zat ini antiemetik, obat sitostaika dengan potensi

berdaya melawan mual. mual muntah sedang sampai berat

c) Antagonis Serotonin : Mekanisme diperkirakan dapat menyebabkan mual

kelompok zat ini belum begitu jelas, tetapi muntah yang berulang atau terus

mungkin karena blokade serotonin yang menerus.

memicu refleks muntah dari usus halus b. Mual muntah tertunda menggambarkan

dan rangsangan terhadap CTZ. Terutama keterlambatan mual muntah akibat

efektif selama hari pertama dari terapi penggunaan terapi sitostatika cisplatin.

dengan sitostatika yang bersifat Terjadi 2 – 6 hari setelah terapi.

emetogen kuat, juga pada radioterapi. c. Mual muntah yang berlarut, biasanya

untuk obat sitostatika emetogenik sedang

Berdasarkan onsetnya mual-muntah seperti cyclophospamid dosis 500 mg

umumnya dibagi menjadi 3 tipe yaitu : dapat menyebabkan mual muntah selama

1) Tipe antisipatori : munculnya sebelum 2- 3 hari.

mulai seri kemoterapi sitostatika diberikan d. Antisipator mual muntah. Ini terjadi pada

akibat rangsangan bau, pandangan, dan pasien yang sudah merasa mual atau

suara di ruang terapi, seringkali muncul rasa tidak enak di perut dan cemas,

setelah seri 3-4 karena pengalaman mual padahal obat sitostatika belum diberikan.

dan muntah tipe akut tertunda. Sebagai pasien dapat menekan rasa

2) Tipe akut : munculnya ≤ 24 jam setelah tersebut dengan latihanrelaksasi (Jeffery

kemoterapi et al, 1998)

3) Tipe tertunda : munculnya ≥ 24 jam

Tabel 2.3.Potensi Emetogenik Obat Sitostatika (Dipiro et al, 2005).

Efek timbulnya Obat sitostatika

emetogenik

Cisplatin

High (90%) Berat Akut
Tertunda / delayed

Dactinomycin,Cytarabine (dosis tinggi)

Cyclophosphamid

Moderate (30 – 90%) Carboplatin

Sedang Doxorubicin

Daunorubicin

Etoposide

Fluorouracil

Hydroxyurea

Low (10-30%) Ringan Metotrexat
Vinblastine

Vincristine

Melphalan (PO, dosis ringan)

Mercaptipurine

Tabel 2.4 Sitostatika Dengan Pemberian Antiemetik (Jeffery et al, 1998).

Obat Sitostatika Sebelum Sitostatika Setelah Sitostatik

Emetogenik berat Dexametason 8-20 Metoklopramid 10-40 mg atau
Cisplatin > 50 mg/ml mg dengan penambahan dexametason untuk 5 hari
(dosis awal 8 mg selama 5 hari, untuk 2
IV 1 – 3 jam Ondansetron 8 mg
hari dosis 4 mg.)

Emetogenik Sedang Dexametason 8- 20 Metoklopramid atau prokhlorperazin
Cyclophosphamid mg dengan sesuai dosis untulk 1- 3 hari

Doxorubicin ondansentron 8 mg

Emetogenik Ringan Dexamethasone 8- Metoklopramid atau prokhlorperazin
Flourouracl 20 mg

3. Penggunaan Obat
Penggunaan obat merupakan suatu tindakan pemberian obat sesuai dengan pasien, indikasi, obat,
dosis serta rute dan waktu pemberian. Instruksi pemberian obat tertulis pada resep dan protokol
pemberian obat kemoterapi serta lembar penggunaan obat. Penggunaan obat dapat dilakukan
evaluasi sebagai suatu proses untuk menyediakan informasi mengenai hasil penilaian atas
permasalahan yang ditemukan (Husni, 2010).Evaluasi merupakan riset untuk mengumpulkan,
menganalisis, dan menyajikan informasi yang bermanfaat mengenai objek evaluasi, selanjutnya
menilainya dan membandingkannya dengan indikator evaluasi dan hasilnya dipergunakan untuk
mengambil keputusan mengenai objek evaluasi tersebut (Wirawan, 2012). Evaluasi pada
penggunaan obat merupakan program jaminan mutu yang terstruktur dan terus-menerus secara
organisatoris diakui yang ditujukan untuk menjamin bahwa obat yang digunakan secara tepat, aman
dan efektif (Brown, 2006). Tahap-tahap dalam pelaksanaan evaluasi penggunaan obat adalah
menetapkan penanggung jawab; mengkaji pola penggunaan obat; menetapkan obat yang akan
dievaluasi; menetapkan kriteria penggunaan obat; mengumpulkan dan mengorganisasikan data;
mengevaluasikan penggunaan obat; menetapkan tindakan untuk solusi masalah atau perbaikan
penggunaan obat; menilai efektivitas tindakan perbaikan dan mendokumetasikannya; dan
mengkomunikasikan informasi yang relevan kepada profesional terkait (Brown, 2006).

4. Kerangka Teori
Kerangka teori pada penelitian ini menerangkan tentang dasar penelitian yang dilakukan, dimana
dapat digambarkan sebagai berikut :

Gambar 1. Kerangka Teori

Sumber : (Junaidi, 2007, Mangan, 2009, Tjay dan Rahardja, 2007, Dipiro et al, 2005 dan Goodman
dan Gilman, 2008)

BAB III
METODE PENELITIAN

3.1. Desain Penelitian
Desain penelitian dibuat sesuai kerangka konsep yang berdasarkan Kerangka Teori
penelitian.Kerangka konsep adalah suatu uraian dan visualisasi tentang hubungan atau kaitan antara
konsep-konsep atau variabel-variabel yang akan diamati atau diukur melalui penelitian yang akan
dilakukan (Notoatmodjo, 2012).

Gambar 2. Kerangka Konsep Penelitian

3.2. Tempat dan Waktu Penelitian dalam penelitian ini adalah pasien kanker yang
Penelitian dilakukan di RSUP Fatmawati dilakukan kemoterapi dengan pemberian
terhadap pasien kanker di ruang Kemoterapi sitostatika pada bulan Januari sampai Juni
yang telah menjalankan kemoterapi pada bulan tahun 2020.
Januari sampai Juni tahun 2020.Waktu
penelitian bulan Agustus Tahun 2020. 3.4. Besar Sampel
Untuk menentukan besar sampel digunakan
3.3. Populasi dan Sampel Penelitian rumus perhitungan besar sampel dalam menguji
Populasi adalah pasien kanker yang hipotesis di satu populasi digunakan rumus
dikemoterapi di ruang kemoterapi. Sampel Slovin (Sevilla, Consuelo G.et. Al, 2001).

n = Jumlah Sampel
N = Jumlah Populasi
e2 = Batas Toleransi Kesalahan
Pada penelitian ini tidak menggunakan hipotesa, sehingga sampel diambil sesuai kriteria inklusidan
eksklusi.

3.5 Kriteria Inklusi dan Eksklusi
3.5.1 Kriteria Inklusi
1. Pasien kanker
2. Pasien Kanker yang mendapatkan sitostatika
3. Pemberian sitostatika pada bulan Januari sampai Junitahun 2020 di ruang kemoterapi
4. Usia lebih dari 18 tahun dan tidak hamil

3.5.2 Kriteria Eksklusi
1. Data tidak lengkap
2. Pasien Batal di Kemoterapi
3. Usia kurang dari 18 tahun

3.6 Teknik Pengumpulan Data
Kegiatan pengumpulan data sampel yang dilakukan dalam penelitian diperoleh dari ruang kemoterapi
dan ruang pencampuran sitostatika diwilayah kerja RSUP Fatmawati.

3.7 Karakteristik Sampel Penelitian
Karakteristik merupakan gambaran dari sampel yang dapat berbentuk apa yang saja yang ditetapkan
oleh peneliti. (Sugianto, 2013). Karakteristik pada penelitian ini merupakan variable bebas, yaitu :
1. Jenis kelamin
2. Usia
3. Ruang rawat
4. Diagnosa Penyakit
5. Sitostatika
6. Hubungan diagnosa dengan obat sitostatika

Variabel Tabel 3.1 Definisi Operasional Penelitian Alat Skala
Definisi operasional Parameter dan Kategori ukur pengukuran

Variabel Independen

Identitasuntuk a. Laki-laki Lembar
b.Perempuan observasi
Jenis kelamin membedakan antara laki- Nominal
a. ≥ 18 - 20 tahun Lembar Interval
laki dan perempuan b. ≥20 - 40 tahun observasi Nominal
c. ≥40 - 60 tahun Nominal
Usia merupakan umur d. ≥60 - 80 tahun
e. ≥ 80 tahun Nominal
seseorang yang dilihat dari

Usia tanggal lahir yang tertera
pada identitas pasien di

Rekam Medis Pasien yang

terkena Penyakit Kanker.

Jalur masuk pasien ke Lembar
Observasi
Ruang Rawat ruang kemoterapi atau asal Ruang Rawat Pasien
resep obat kemoterapi

Diagnosa Penyakit Kanker yang Jenis Penyakit kanker Lembar
Penyakit tertera pada protocol observasi
pemberian obat kemoterapi

Sitostatika Sitostatika yang digunakan b.Sitostatika sesuai Lembar
berdasarkan diagnosa golongan observasi
pasien yang tertera pada berdasarkan
resep dan protokol literature Drugs of
pemberian kemoterapi Oncology
a. Golongan sitostatika
b. Jenis Sitostatika c.Sitostatika sesuai
jenis obat
berdasarkan
literature Drugs of
Oncology

3.7 Analisis Data
Dalam penelitian ini, analisa yang dilakukan dengan menggunakan analisis deskriptif sebagai
gambaran karakteristik sampel penelitian dan Bivariat dalam mengetahui hubungan penggunaan
sitostatika dengan penyakit kanker. (Notoatmodjo,2012)

BAB IV
HASIL DAN PEMBAHASAN

Pelayanan Kemoterapi di RSUP Fatmawati pencampuran menggunakan teknik aseptis
Rumah Sakit Umum Pusat (RSUP) Fatmawati dispensing, sehingga dapat meminimalisir
menyelenggarakan pelayanan Kemoterapi kontaminan pada produk hasil pencampuran
kepada pasien Kanker dengan terapi pemberian yang diberikan kepada pasien.
sitostatika parenteral di ruang pelayanan Sitostatika yang sudah siap diberikan diantar ke
Kemoterapi yang terletakdi gedung rawat inap ruang kemoterapi dengan container tertutup
Teratai lantai 1. Gedung Teratai juga melayani oleh petugas farmasi, dan dilakukan serah
pencampuran sitostatika secara terpusat di terima dengan perawat penerima obat
Ruang Pencampuran Sitostatika yang terletak kemoterapi di ruang pemberian obat kanker.
pada area Depo Farmasi Teratai Lantai 1. Penyiapan sediaan kemoterapi rata-rata setiap
Semua pasien baik rawat jalan maupun rawat hari untuk pasien dewasa 35 sediaan dan untuk
inap yang akan menerima terapi sitostatika anak 6 sediaan. Pelayanan pencampuran ini
parenteral, resep dan protocol pencampuran dilakukan pada setiap hari kerja jam 7.30
sitostatika sudah diterima oleh tenaga farmasi sampai 14.00 dan selanjutnya mempersiapkan
utnuk dilakukan pengkajian obat dan persiapan perbekalan farmasi untuk hari berikutnya.
obat serta alkes.
Pada hari pemberian terapi, tenaga farmasi 4.1 Hasil Penelitian
sebelum melakukan pencampuran, akan Sampel Penelitian
menghubungi perawat ruang kemoterapi untuk
konfirmasi kesiapan pasien terkait kondisi klinik Sampel penelitian adalah pasien dewasa yang
pasien. Kondisi pasien yang tidak mendapatkan pemberian sitostatika di ruang
memungkinkan untuk pemberian terapi maka kemoterapi baik yang berasal dari ruang Rawat
pencampuran sediaan kemoterapi tidak Jalan maupun Rawat Inap di RSUP Fatmawati
dilakukan. Pembatalan pemberian terapi atas pada bulan Januari sampai Juni Tahun 2020,
instruksi dokter yang bertugas di ruang yang kemudian dievaluasi pada penelitian ini.\
kemoterapi. Pencampuran sitostatika dilakukan
pada ruangan bertekanan negatif sehingga tidak 4.1.1 Karakteristik pasien kanker yang
terjadi paparan obat kemoterapi kepada petugas menjalankan kemoterapi di ruang kemoterapi
pencampuran dan area luar. Teknik 4.1.1.aJenis kelamin

Tabel 4.1. Tabel Karakteristik Pasien Kanker Berdasarkan Jenis Kelamin

Jenis kelamin terbanyak yang menjalankan kemoterapi pada bulan Januari sampai Juni Tahun 2020
adalah perempuan sebesar 78,22 %.

4.1.1.b Usia
Tabel 4.2. Tabel Karakteristik Pasien Kanker Berdasarkan Usia
Usia pasien terbanyak yang menjalankan kemoterapi pada bulan Januari sampai Juni Tahun 2020
adalah pada usia 40 tahun sampai 60 tahun sebesar 60,14%

4.1.1.c Ruang Rawat
Tabel 4.3. Tabel karakteristik pasien kanker berdasarkan ruang rawat

Pasien terbanyak yang menjalankan kemoterapi pada bulan Januari sampai Juni Tahun 2020 berasal
dari Ruang rawat inap sebesar 62,74% dimana pasien banyak berasal dari ruang lantai 2 GPS sebesar
22,68%.

4.1.1.d Diagnosa Penyakit
Tabel 4.4. Tabel karakteristik pasien kanker berdasarkan diagnose penyakit

Diagnosa penyakit terbanyak yang menjalankan kemoterapi pada bulan Januari sampai Juni Tahun
2020 adalah kanker payudara sebesar 50,63%.
4.1.2 Penggunaan Sitostatika berdasarkan Golongan dan Jenis obat.
4.1.2.a Golongan Sitostatika
Tabel 4.5. Tabel karakteristik pasien kanker berdasarkan golongan sitostatika

Golongan Sitostatika terbanyak yang diberikan kepada pasien kemoterapi pada bulan Januari sampai
Juni Tahun 2020 adalah Golongan Antimetabolite kanker sebesar 28,22%.

4.1.2.b Jenis Sitostatika
Tabel 4.6. Tabel karakteristik pasien kanker berdasarkan jenis sitostatika

Sitostatika terbanyak yang digunakan pada periode bulan Januari sampai Juni tahun 2020 adalah 5-FU
(Fluorourasil) sebesar 19,47%.

4.1.3 Hubungan karakteristik sampel terhadap sitostatika

Tabel 4.7. Tabel Hubungan karakteristik sampel penelitian terhadap penggunaan sitostatika

Hubungan karakteristik dilakukan secara sederhana dengan melihat grafik garis linear antar
karakteristikdan sitostatika baikgolongan maupun jenis obat.

10
0

80

60

40

20

0 Februar Maret April Mei Jun
Janua

Perempua ≥40 - 60 Lt. 2 Rawat
Rawat Jalan Kanker Payudara Fluorouracil (5-FU)

Tidak terdapat hubungan antara ruang rawat, rawat inap dan rawat jalan terhadap penggunaan
sitostatika.

4.2. Pembahasan Penelitian 4.2.1.b Usia
Pada karakteristik usia dianalisa dengan skala
4.2.1Karakteristik pasien kanker yang interval 20 tahun. Hasil menunjukan bahwa
menjalankan kemoterapi di ruang kemoterapi pada 6 bulan pertama tahun 2020 terdapat nilai
4.2.1.a Jenis kelamin terbanyak pada usia 40 tahun sampai 60 tahun
Selama 6 bulan pertama tahun 2020, pasien yaitu 765 sampel dari 1272 sampel atau 60,14%
perempuan lebih banyak menjalankan dari total yang menjalankan kemoterapi. Periode
kemoterapi di RSUP Fatmawati yaitu sebesar usia tersebut merupakan usia produktif baik
995 orang dari 1272 pasien yang menjalankan perempuan ataupun laki-laki dalam menjalankan
kemoterapi, atau senilai 78,22%. Penyakit kehidupan. Rentang usia penderita kanker di
kanker terbanyak di Indonesia adalah Kanker Indonesia lebih cepat dibandingkan negara lain
payudara dan kanker leher rahim. di Kaukasia. Pengaruh kurangnya aktivitas fisik
(http://sehatnegeriku.kemkes.go.id/; 31Januari dapat merupakan penyebab cepatnya kejadian
2019) Keduanya merupakan penyakit kanker kanker di Indonesia.
pada perempuan. Oleh karena itu pasien kanker
perempuan di RSUP Fatmawati merupakan
sampel dengan jenis kelamin terbanyak.