Syok Clinical

8/11/2019 Syok Clinical

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Syokdan

Tatalaksana terapi cairanRahardjo.

s


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Klasifikasi :

1. Shock Hypovolemik : Shock o.k : Penurunan volume intravaskuler, misal : perdarahan, dehidrasi

2. Shock Kardiogenik : Shock o.k : Kegagalan pompa jantung, abnormalitas katub ataukah arritmia

3. Shock Obstruktif : Shock o.k : Hambatan aliran darah yg kembali kejantung ( venous return ), misal :

Tamponade jantung, konstriktif perikarditis, tension pneumothoraks

4. Shock Distributif : Shock o.k : Gangguan vasomotor mengakibatkan turunnya SVR diikuti Curah Jantung yang

tidak adekwat misal : Septic, Spinal, Nerogenic shock.


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TandaTanda Shock

1. Takikardia

2. Akral dingin

3. Kesadaran

4. Takipnea

5. Tensi

shock !


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KLASIFIKASISYOKHEMORAGIK

Kompensasi Ringan Sedang Berat

Hilangdarah(ml)

Denyutnadi

(bpm)

Tekanan darah

Pengisian kapiler

Pernafasan

Urine(ml/h)

Statusmental

100Ortostatik

Mungkin

terlambat

Peningkatan

ringan

2030

Agitasi

15002000

>120Sangatturun

Sering

terlambat

Takipnea

sedang

520

Konfusi

>2000

>140Tidakterukur

Selalu

terlambat

Takipneunyata,

GagalNafas

Anuria

Letargi,

tidaksadar

Diagnosis


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GAMBARAN

KLINIK

SYOK

HEMORHAGISISTIM SYOKDINI SYOKLANJUT

SARAFPUSAT PERUBAHAN

STATUS

MENTALPERUBAHAN

KESADARAN

KARDIAL TAKIKARDI

HIPOTENSIORTOSTATIK

HIPOTENSI

ARITHMIA

GAGAL JANTUNGRENAL OLIGOURI ANURI

RESPIRASI TAKIPNOE TAKIPNOE,GAGALNAFAS

HEPATIK GANGGUAN FUNGSI

HEPAR

GASTROINTESTINAL PERDARAHANMUKOSA

HEMATOLOGI ANEMIA KOAGULOPATI

METABOLIK

ASIDOSISHIPOKALEMIA

HIPOMAGNESEMIADiagnosis


8/37Penanganan

TatalaksanaSyok:

Penanganan

Syok

:

Tatalaksana

terhadap

Underlying

injury

or

Disease

Mengembalikan

Perfusi

Jaringan.

Segera

memberi

/

mengganti

Volume

Adekuat

Ventilation

&

Oxygenation

Adekuat


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Penangananterhadap Underlyinginjuryordisease

TatalaksanaSyok:


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ENHANCEMENTMICROCIRCULATIONBLOODFLOW

Arterioles

and

arterial

partofcapillaries

Venules

and

venouspart

of

capillaries

MengembalikanPerfusi

Jaringan

Penanganan

TatalaksanaSyok:


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PENTING !l VOLUME INTRAVASKULAR

l O2TRANSPORT

(ERITROSIT

)

JUMLAHOKSIGENYANGTERSEDIAUNTUKJARINGAN:

DO2=COX(SAT.O2XHbX1.39+PO2X0.003)

= 5 l/m X 20 l/mO2/100ml

= 1literO2/m

KEBUTUHAN=25%=250mlO2/m


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OxygenDelivery=

COxCaO2(HbxSpO2x1,39+0,003xPaO2)

O2content,O2extractingRatio,O2Consumption

DeterminanuntukTissueoxygenation

Komponen:CardiacOutput,Hb,

SpO2arterial&venousblood


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AdequateVentilationandOxygenation

TatalaksanaSyok:


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End Point of Resuscitation Therapy :

BasicClinicalSign: PatientResponses

HR

>

BPEvaluasithdPerfusi:

UOP(UrineOutPut)

CRT(CirculationPeripheral),

LOC(Level

of

Consciousness

)

Produksi Urin/jam

Tidak adekwatnya UOPberarti

Tidak adekwatnya resusitasi


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Advancedmethodsinclude

Metabolik

Serumlactate

pCO2

Base

deficit Mixedvenoussaturations

CVP : Preload.

AdvancedEvaluation

:

CO,CI,LAP,PAOP,LVSVWI

End Point of Resuscitation Therapy :


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KontroversialPoin

PeningkatanBPmeningkatkanresikoperdarahanpadakasus

perdarahan.

PemberianCairandanDarahakanmenurunkancoagulosi

MacamCairan:

Fluidvs.

non

fluid

(vasopressors,

etc.)

Bloodvs.nonbloodfluid

Wholebloodvs.bloodcomponents

Crystalloidsvs.

colloids

vs.

hypertonic

saline

Albuminvs.syntheticcolloids


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KONSEPBARU

PERMISSIVEHYPOTENSION

Pasientetapsadar

Naditeraba

SBP90mmHg

MAP5060mmHg

SaO2>92%


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TERAPI

CAIRAN

PADA

SYOK

HEMORRHAGITujuanResusitasiCairan;

MenujuNormovolumi

dan

HD

stabil.

MemeliharaadekuatColloidOncoticPressure

Memeliharakeseimbangan

dan

komposisi

KompartemenCairanTubuh.


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RL

RANaCl0.9%

NaCl3%

Albumin

PlasmaDextran

Gelatin

HES

COLLOIDCRYSTALLOID

B

L

O

O

D


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Body Fluid CompartmentsTotal body water = 60 % of body weight (BW)

2/3

Intracellular water= 40 % of BW

1/3

Extracellularwater

= 20 % of BW

Plasma (5 % of BW)

Extracellularwater

= 20 % of BW


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increases ICF > ECFincreases ICF > ECF

ICF ISF PlasmaICF ISF Plasma

Replace Normalloss (IWL + urine)

Replace Normalloss (IWL + urine)

Hypotonic infusionHypotonic infusion 5% dextrose 5% dextrose

85 ml85 ml255 ml255 ml660 ml660 ml


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increases ECFincreases ECF

ICF ISF PlasmaICF ISF Plasma

Replace acute/abnormalloss

Replace acute/abnormalloss

Infus IsotonicInfus Isotonic

800 ml 200 ml

Ringers acetate

Ringers lactate Normal saline

Ringers acetate

Ringers lactate Normal saline


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KRISTALOID

Keuntungan

Komposisi elektrolit seimbang

Tidak ada resiko alergi

Tidak mempengaruhi hemostasis

Mengakibatkan terjadinya diuresis Murah


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Kerugian

Perlu 3-4 x jumlah perdarahan

Bisa mengakibatkan udem Mengakibatkan TOP berkurang.

Hypothermia

Lama kerja + 90 menit

NaCl 0.9% : asidosis hiperchloremia

KRISTALOID


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0

50

100

150

200

250

D5WLactatedRingers

Albumin5 %

Volume(ml)

Prough, Anesthesiology Clinics of North America (1996)

Administration of 250 ml of fluid

ICV

ISV

PV


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KOLOID

KEUNTUNGAN

Tetapberada

dalam

volume

intravaskular

Kebutuhansamadenganjumlahdarahyang

hilang

MeningkatkanTOP

Resikoudemminimal

Meningkatkanaliran

darah

microvaskular


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KERUGIAN

Kelebihan beban cairan

Mengganggu hemostasis

Mempengaruhi fungsi ginjal

Reaksi anafilaktoid

Mahal

KOLOID


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16 hr

16 hr

17 day

10 hr

6 hr

12 hr

0.7 1.3

4.0 5.0

1.0 1.3

1.5

1.0 1.5

0.8

20 mm Hg

70 Mm Hg

30 Mm Hg

40 Mm Hg

40 Mm Hg

40 Mm Hg

69.000

69.000

69.000

120.000

26.000

41.000

5 % ALBUMIN

25 % ALBUMIN

6 % HETASTARCH

10 % PENTASTARCH

10 % DEXTRAN-40

6 % DEXTRAN-70

SERUM

HALF-LIFE

PLASMA

VOLUME

EXPANSION***

ONCOTIC

PRESSURE**

AVERAGE

MOLECULAR

WEIGHT * (DALTONS)FLUID

CHARACTERISTICS OF INTRAVENOUS

COLLOID FLUIDS


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http://content.nejm.org/http://content.nejm.org/content/vol345/issue19/images/large/03f2.jpeg


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Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock

CVP

denotes

central

venous

pressure,

MAP

mean

arterial

pressure,

and

ScvO2centralvenousoxygensaturation

Volume 345:1368-1377 November 8, 2001 Number 19
http://content.nejm.org/http://content.nejm.org/content/vol345/issue19/images/large/03f2.jpeg


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TREATMENT CONCEPT OF SHOCK

ENHANCING PERFUSION / OXYGEN DELIVERY

Oxygen delivery/DO2 = HR X SV X HbXSp02X1.39 + 0.03 X PaO2

Cardiacoutput

Arterial O2content

FluidsTransfuse Partially

dependent onFIO2 and

pulmonary

status

Inotropes :Dopamin

Dobutamin

Norepinephrin

Epinephrin

DO2 = CO x CaO2

ScvO2


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