Shock & WHO-CUB

Divisi Fetomaternal, Departemen Obstetri & GinekologiFKUI / RSUPN - CM

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Perdarahan Obstetri

Respirasi

Sirkulasi ( Kegagalan sistem sirkulasi dalam

mempertahankan aliran yang adekuat pada organ-

organ vital sehingga timbul Anoxia)

Trauma

Mengancam jiwa ibu dan janin

Shock

The most common types of shock:

Type of shock Aetiology

Hypovolaemic shock Acute loss of at least 20% of the circulating

volume

Cardiogenic shock Acute disease of the heart, e.g. severe

myocardial infarction

Septic shock Septic condition caused by infectious agents

and their toxic products

Neurogenic shock Head trauma, spinal cord injury

Anaphylactic shock Repeated contact with or injection of

antigenic substances

ShockHemorrhagic Shock – Pathophysiology

Stage 1: Compensated Stage

Mechanism: Volume depletion due to bleeding

Body detects decrease in cardiac output

Sympathetic Nervous System is stimulated releasing Epinephrine and

Norepinehrine to stimulate Alpha and Beta Receptors

Alpha = Vasoconstriction Beta = Bronchodilation and

Cardiac Stimulation

ShockHemorrhagic (Classic) shock –

Pathophysiology

Stage 2: Progressive Stage

Mechanism: Kidneys release anti-diuretic hormone which increases

vasoconstriction by closing the capillary sphincters, greatly reducing

peripheral circulation

Increased hypo-perfusion causes increase in metabolic acid build up

ShockHemorrhagic (Classic) shock – Pathophysiology

Stage 3: Irreversible Stage

Mechanism: Compensatory mechanisms fail

Pre-capillary sphincters open releasing metabolic acids, micro-emboli

and other wastes into circulation

Cell damage, organ failure and death occur

Shock

The Course of Hypovolaemic Shock in Absence of Therapy

Blood Pressure (mm Hg)

Heart rate (min)

Bleeding150

100

50

0Compensation Decompensation Irreversibility

Shock Phases

Heart RateBlood Pressure

(Time)

ShockThe Influence of Volume Replacement on Tissue

Perfusion and Organ Function

Volume Replacement

Cerebral Function

(Body Control)Pulmonary Function

(O2 Supply)

Liver

Function

(metabolism)

Renal Function

(Diuresis)

Heart

Function

(cardiac output)

Tissue

Perfusion

Tata Laksana Mengatasi Perdarahan Hebat

Airway

Breathing

Circulation & hemorrhage control

Shock position

Replace blood loss

Stop / minimize the bleeding process

AIRWAY

Posisi Syok

ANGKAT

KEDUA

TUNGKAI

300 - 500 cc

darah dari kaki

pindah ke

sirkulasi sentral

Tatalaksana Kompresi Bimanual

Menghentikan

Perdarahan Kondom

intra uterin

Menghentikan

Perdarahan Thrombogenic uterine pack

Bobrowski RA, Jones TB. Obstet Gynecol 1995 May;85(5 Pt 2):836-7

Vaginal ligature of uterine arteries

Philippe HJ, d'Oreye D, Lewin D. Int J Gynaecol Obstet 1997 Mar;56(3):267-70

Ligasi a hipogastrika

Histerektomi subtotal

Stepwise uterine

devascularizationAbdRabbo SA Am J Obstet Gynecol 1994 Sep;171(3):694-700

Menghentikan

Perdarahan B-Lynch suture

Dacus JV, Busowski MT, Busowski JD, Smithson S, Masters K, Sibai BM. J Matern Fetal Med 2000 May-Jun;9(3):194-6

Ferguson JE, Bourgeois FJ, Underwood PB. Obstet Gynecol 2000 Jun;95(6 Pt 2):1020-2

Tatalaksana Perdarahan pasca Persalinan

Estimasi BB : ... 60 kg

Estimasi Blood Volume : ... 70 ml/kg x 60 = 4200 ml

Estimasi Blood Loss : .... % EBV = ..... ml

NORMO

VOLEMIA

-- 30% EBV

-- 15%

EBV-- 50%

EBV

TsystNadi

Perf

12080

hangat

100100

pucat

< 90> 120

dingin

< 60-70> 140 -

ttbbasah

EBL = perdarahan 600 1200 2000 ml

Infus RL 1200-2000 2500-5000 4000-8000 ml

Kristaloid vs Koloid Sebagai Cairan PenggantiKristaloid Koloid

Manfaat

Merembes ke komponen

ekstraselular

Mengurangi peningkatan cairan

paru

Meningkatkan fungsi organ

setelah operasi

Reaksi anafilaktik minimal

Kemungkinan dapat mengurangi

angka kematian

Lebih murah

Tetap berada di komponen

intravaskular

volume yang diperlukan

lebih sedikit

Meningkatkan transpor

oksigen ke jaringan,

kontraktilitas jantung dan

keluarannya

ResikoPredisposisi untuk terjadinya

edema pulmonalMahal

Choi et al 1999.

The Clinical Use of BloodWHO Sub – Regional Workshop

Estimating Allowable Blood LoosClinical condition

Healthy Average Poor

Percentage Methode

Acceptabel loss

of blood vol30% 20% 10%

Haemodilution Method

Lowest

Acceptable Hb9 mg / dl 10 mg / dl 11 mg / dl

Lowest

acceptable Ht27% 30% 33%

Blood Loss

% Loss of blood

Volume

Equivalent

Adult fluid

Volume

Replacement

Fliud

< 20 % Up to 1 LiterCrystalloid ( e.g.

0,9 % saline )

> 20 % More than 1 liter

Crystalloid and /

or Colloid

Red Cell

Starting Transfusion Warming of blood is not necessary for routine tx . Warming

increasing metabolism, reduce 2,3-DPG & risk bacterial growth

Indication for warming blood:

Adult receiving over 50 ml/kg/hr

Child receiving over 14 ml/kg/hr

Exchange tranfusion

Rapid infusion CVP lines

Presence of cold aglutinines

Starting Transfusion

Prohibited to addition drugs & medications to blood bag/set EXCEPT normal Saline.

Do not use dextrose 5% or Ringer Lactate.

Use 170 u standard filter.

Transfusion must be completed in 4 hours.

Hemodynamically stable 2 hours

Hemodynamically unstable 4 hours

Autologous Blood

Pre Operative Blood Donation

Min Hb 11 gr

1 Unit ( 10-15% Blood vol) 5-7 days

35 days-2 days, iron suppl

Acute Normovolemic Haemodilution

During surgery ( 4 hours )

Monitoring, Replace fluid : crystaloid 1:3, Colloid 1:1

Blood Salvage

Direct tranfusion

Don’ts for Blood Transfusion

Don’t Use blood from non-licensed.

Don’t delay initiation of blood transfusion.

Don’t Warm blood in an monitored fashion.

Don’t Use routine pre-transfusion medication.

Don’ts for Blood Transfusion

Don’t transfuse over more 4 hours.

Don’t leave patients unmonitored.

Don’t add any medication to blood bag

Don’t forget to return unused blood to blood bank

for disposal

Don’ts for Blood Transfusion

Don’t ask for all the blood bag at one time

Don’t Use unmonitored refrigerator for

storage

Don’t Use one transfusion set for more

than 4 hours / more than 4 unit of blood

Don’t wet outlet port of blood bag while

warming or thawing

Don’ts for Blood Transfusion

Don’t store platelets in a refrigerator

Don’t be complacement while checking identifiying

information

Don’t Use blood from immediate relatives unless

irradiated

Transfusion Reactions

Immediate Delayed

Hemolytic Non-hemolytic

HemolyticTransfusion

Reaction

FebrileAllergic

Hypo-calcemia

Hyper- Kalemia & Acidosis

Acute Lung Injury

Infections Allergic

“Practice Safe Transfusion”

Informed Consent Standardized Guidelines

Adverse EventReporting

Error and IncidentReporting

“Errors can be prevented by designing systems that make it hard for people to do the wrong thing and easy for people to do

the right thing”……

To Error is Human, Building a Safer Health System

Summary

Components

Indications

Transfusion Reactions

Rujukan

ACOG. Hemorrhagic shock. Educational Bulletin #235,

1997.

Choi PT-L et al. 1999. crystalloid vs. colloids in fluid

resuscitation: A systematic review. Critical Care Medicine

27( 1): 200-210.

Scheirhout and Roberts 1998. Fluid resuscitation with

colloid or crystalloid in critically ill patients: A systematic

review of randomized trials. BMJ 316:961-964.

MNH Post Partum Hemorrage.

The Clinical Use of Blood, WHO 2002.

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