SYOK HIPOVOLEMIK

DEPARTEMENT OF ANESTHESIOLOGIST , INTENSIVE CARE AND PAIN MANAGEMENT HASANUDDIN UNIVERSITY

2010

Andi Salahuddin

ShockShockShock is a Cardiovascular Derangement.

1. Deliver Oxygen and Metabolic Substrates

2. Remove Products of Cellular Metabolism

3. Thermoregulation

Definition:

A physiological state characterized by a significant, systemic reduction in tissue perfusion, resulting in decreased tissue oxygen delivery and insufficient removal of cellular metabolic products, resulting in tissue injury.

Classification of ShockClassification of Shock

1. Hypovolemic

2. Septic/Inflammatory ( Distributive )

3. Cardiogenic (Intrinsic, compressive & Obstructive)

4. Neurogenic

5. Anaphylactic

Hypovolemic ShockHypovolemic Shock•Decreased preload->small ventricular end-diastolic volumes -> inadequate cardiac generation of pressure and flow

•Causes:

1.Bleeding: trauma, GI bleeding, ruptured aneurysms, hemorrhagic pancreatitis

2.Dehydration :vomiting or diarrhea, Hyperglicemia, third spacing: intestinal obstruction, pancreatitis, cirrhosis.

3.Severe Burning.

Gejala klinisGejala klinis

.PatomekanismeDO2 = CaO2 x CO.

= Hbx1,39xSaO2+(PaO2x0,003) x SV x HR.Distribusi cairan tubuh ( t’utama organ vital )Homeostasis natrium & air . ( slide berikut )

SODIUM AND WATER HOMEOSTASIS SODIUM AND WATER HOMEOSTASIS AFTER INJURYAFTER INJURY

Summary of the endocrine responses to acute injury, which are directed towards maintaining perfusion of essential organs and retention of water and sodium.

Gejala klinisGejala klinisGejala klinisGejala klinisDefisit cairan interstitiel dengan gejala : - turgor kulit yang jelek - mata cekung - ubun-ubun cekung (bayi & anak) - mukosa bibir dan kornea kering

Defisit cairan intravaskular dengan gejala :

- hipotensi, takikardi - vena-vena kolaps - “Capillary refilled time” memanjang - oligouri - syok ( renjatan )

Defisit cairan interstitiel dengan gejala : - turgor kulit yang jelek - mata cekung - ubun-ubun cekung (bayi & anak) - mukosa bibir dan kornea kering

Defisit cairan intravaskular dengan gejala :

- hipotensi, takikardi - vena-vena kolaps - “Capillary refilled time” memanjang - oligouri - syok ( renjatan )

Markers: monitor UOP,CVP, BP, HR, Hct, CO, lactic acid and PCWP

Gejala obyektifGejala obyektif

Too muchPenyakit paru

Too littleTidak sembuh

dec. cordisedema

ShockGagal ginjal

R/

Problem

60% BB = Air

Penatalaksanaan ?

• Pathomechanism• Distribution of fluids• Fluid demand.• Crystalloid or colloid

40 % 15% 5%

ICF ISF IVF

Dextrose 5%

RL, NaCl 0.9%

Colloid-Blood-Plasma-Plasma expander

Distribution of Fluids

DEHIDRASI DITINJAU DARI DEHIDRASI DITINJAU DARI DEFISIT CAIRAN DEFISIT CAIRAN

1. Dehidrasi ringan ( defisit 4% BB )

2. Dehidrasi sedang ( defisit 8% BB )

3. Dehidrasi berat ( defisit 12% BB )

4. Syok ( defisit lebih dari 12% BB )

PERDARAHAN

Copyright ©2004 BMJ Publishing Group Ltd.

Hettiaratchy, S. et al. BMJ 2004;329:101-103

Wallace rule of nines

PENGUKURAN LUAS LUKA BAKAR

TERAPI CAIRAN

Resusitasi

Rumatan

Kristaloid Koloid

Air + Elektrolit + Nutrisi

Mengganti kehilangan akut

(Syok, dehidrasi, hipovolemik)

Memasok kebutuhan

harian

ResuscitationResuscitation= Reverse The Dying Process= Reverse The Dying Process

Fluid Resuscitation

UGD

Krisis Napas

Krisis Sirkulasi

O2, Napas Buatan

Cairan & Obat-obat vasoaktif

5% : haus, mukosa kering5-10% : turgor, tensi, nadi>10% : SHOCK, urine = 0

DEFISIT

50% 50% 8 jam 16 jam

REHIDRASI

++ Maintenance

Untuk pasien tanpa syok

M = Maintenance

Laki-laki 60 tahun, berat badan 50 kgD/ CVA, coma, paralytic ileus

M : 50 kg x 50 mL = 2500 mL50 kg x 3 mEq = 150 mEq Na = 1000 mL RL/ RD

+ 1500 mL D5/ D10

Bila ragu-ragu kurangi 20%Setelah 24 jam, cek urine !

Rumatan / Kg / Hari

AIR30-50

ml

Na2-4 mEq

K1-2 mEq

NUTRISI

PROTEIN

0,5-1 gr

KALORI20-30 KCal

Rumatan

Normal asupan

oral

Normal pengerluara

n urine

IWL

25 ml / Kg

30-50 ml / Kg

Demam

Extra

Kehilangan

abnormal

R/

Perdarahan Usus

Tanda dehidrasiStatus traumaDerajat shock

EBL = klass trauma 4 - 8 - 12% BB

RL/NS

Transfusi Hb < 8 RL/NS saja

Perdarahan

RL 2-4 x loss

Ikuti perfusi – nadi – tensi

HD baik HD jelek

Hb > 8 mg/dL Hb < 8 mg/dL

Cairan Pelan-pelan

TransfusiPelan-pelan

Transfusi cepat

The CrystalloidsThe CrystalloidsCrystalloids are a group of intravenous fluid in which may be: Ionic solution

– Ringer lactate/ acetate– NaCl physiologic (0.9% saline)– Hartman’s solution– Etc• Mostly iso-osmolar = isotonic• Cheap, easy to manufacture• Has no immunologic reaction• Mainly confined to the extracellular fluid

Non ionic– Dextrose 5%– Maltose 10%– Etc• Distributed to intracellular space

Electrolyte Comparison Electrolyte Comparison Between RL & NaCl 0.9%Between RL & NaCl 0.9%

Na+ K+ Ca+ Cl- Lactate Osm.

Plasma 140 4 5 103 - 300

Ringer Lactate 130 4 3 109 28 273

NaCl 154 - - 154 - 308

The ColloidsThe Colloids

Colloids are fluids which contain oncotic

particles, therefore exert an oncotic pressure Blood Plasma Albumin Artificial colloids = plasma expander

– Gelatins, from collagen (Haemaccel & Gelofusine)– Dextran is a polysaccharides (Dextran 70 & 40) – HES (Hydroxyethyl starch) e.g. hemohes 6% / 10%

Dewasa Anak-anak

Cairan 30-50 cc / Kg BBSesuai berat badan

Natrium

2-3 mEq / Kg BB 2-4 mEq / Kg BB

Kalium 1-2 mEq / Kg BB 2,5 mEq / Kg BB

Kebutuhan Air dan Elektrolit / Hari

Dewasa Anak Bayi

Kehilangan air

42 ml / 100 kalKulit = 800 mlParu = 400 ml

300-600 ml / hari

75-300 ml / h

Keringat 10-20 ml / 100 kal (aktifitas

minimal)50 ml / 100 kal (aktifitas berat)

- Tidak bermakna

Urine 84 ml / 100 kal = 1500 ml

90 ml / 100 kal = 500-800 ml

100 ml / 100 kal = 200-500

ml

Feses 4 ml / 100 kal 4 ml / 100 kal 4 ml / 100 kal

Insensible Water Loss

Dikutip dari : Fluids and Electrolytes, Collins 1996

Kehilangan Kandungan rata-rata

(mmol/L)

Cairan pengganti yg sesuai

Na +

K +

Darah 140 4Ringer asetat / RL / NaCl 0,9 % / Koloid / Produk darah

Plasma 140 4Ringer asetat / RL / NaCl 0,9 % / Koloid

Rongga ketiga 140 4 Ringer asetat / RL / NaCl 0,9 %

Nasogastrik 60 10 NaCl 0,45 % + KCl 20 mEq / L

Sal cerna atas 110 5-10NaCl 0,9 % (periksa K + dengan teratur)

Diare 120 25 NaCl 0,9 % / KCl 20 mEq / L

KEHILANGAN CAIRAN & PILIHAN PENGGANTI

Nama Produk

Na +

K + Mg ++

Cl - HPO4 -

Laktat

Dextrose (g/l)

Kalori (kcal/

l)

Plasma 140 4 - - - - - -

Ringer Laktat

130 4 - 109 - 28 - -

NaCl 0,9 % 154 - - 154 - - - -

Dextrose 5%

- - - - - - 27,0 108

JENIS CAIRAN RUMATAN

M /kg/hari

Air30-50 mL

Na2-4 mEq

K1-2 mEq

Nutrients

Protein0,5-1 gram

Kalori20-30 kkal

M + R

Wanita 25 tahun, 50 kgD/ Hiperemesis gravidarumMuntah 1000 mL/ hari, minum (-), makan (-)

M : 50 kg x 50 mL = 2500 mL50 kg x 3 mEq = 150 mEq Na = 1000 mL RL/ RD

+ 1500 mL D5/ D10

R : 1000 mL 50% RL/RD/NS50% D5

Total 24 jam 1500 mL RL/ RD + 2000 mL D5/D10

Dehidrasi = ECF deficitBB 50 kg: ileus, peritonitis, GE

M = 2500 mL + R (defisit)

Dehidrasi 5% BB = 2500 mLInterstitial sign +++

50% - 8 jam ……… 50% - 16 jam

R 1250 + M 800 …. R 1250 + M 1700

Dehidrasi 10% BB = 5000 mLPlasma sign +++

20-40 mL/kg diguyur 1-2 jam

Jam I : 1000-2000 mL guyur

Sisa: 50% - 8 jam ……… 50% - 16 jam

R 2000 + M 800 …. R 2000 + M 1700

Dehidrasi = ECF deficitBB 50 kg: ileus, peritonitis, GE

M = 2500 mL + R (defisit)

Rehidrasi cepat

RL/NS cepatBolus 20 mL/kg dalam 30-60 menitKalau perlu diulang

IVF stabil

Tensi >100, nadi <100Perfusi hangat kering

Sisa defisit lebih lambat

RESUSITASI CAIRANRESUSITASI CAIRAN luka bakarluka bakar

Charles Baxter, di Rumah Sakit Parkland di Barat Daya Universitas Medical Center, Dallas pada tahun 1960-an

Formula Parkland, menggunakan kristaloid 4 ml/kgBB/%TBSA/24 jam setelah kejadian luka bakar, 1/2 total cairan diberikan dalam 8 jam pertama, sisanya dalam 16 jam.

Pilihan cairan: RL

JELASKAN PENATALAKSANAAN CAIRANNYA :JELASKAN PENATALAKSANAAN CAIRANNYA :

1.WANITA 30 THN, BB=50KG, MUAL, MUNTAH 1.WANITA 30 THN, BB=50KG, MUAL, MUNTAH SERING. KLINIS = SYOK, NADI : 130 SERING. KLINIS = SYOK, NADI : 130 X/MNT,LEMAH, TDK BERISI. TD : TDK X/MNT,LEMAH, TDK BERISI. TD : TDK TERUKUR. TERUKUR. 2.LAKI2 17 THN, BB: 50 KG KECELAKAAN 2.LAKI2 17 THN, BB: 50 KG KECELAKAAN MOTOR, DARAH BERCECERAN DI TKP. MOTOR, DARAH BERCECERAN DI TKP. KLINIS: GELISAH& BINGUNG, TD: 70/40 KLINIS: GELISAH& BINGUNG, TD: 70/40 MMHG, NADI> 120X/MNT, P: 30-40X/MNT. OUP: MMHG, NADI> 120X/MNT, P: 30-40X/MNT. OUP: 5-15 ML/JAM.5-15 ML/JAM.3.LAKI2 50 THN BB: 50 KG, LUKA BAKAR PD 3.LAKI2 50 THN BB: 50 KG, LUKA BAKAR PD LENGAN ATAS KANAN DEPAN, DADA, PAHA LENGAN ATAS KANAN DEPAN, DADA, PAHA KANAN. KANAN.

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