penatalaksanaan pts dengan hipotensi
DESCRIPTION
IITRANSCRIPT
PENATALAKSANAAN Pts DENGAN PENATALAKSANAAN Pts DENGAN HIPOTENSI HIPOTENSI SYOK SYOK
Dr Wahyu Widjanarko SpJP FIHADr Wahyu Widjanarko SpJP FIHA
KASUS I
Laki-2 75 th datang dengan keluhan lemah, nyeri dada 1 minggu tidak mau makan, muntah, Fisik : TD 70/40 mmHg N : 120x/mnt lemah, t : 38°C, keringat dingin. Jantung paru normal, acral dingin. Rð : N, EKG : normal sinus rhythm, apa diagnosanya?
a. Syok hipovolemikb. Syok septikc. Syok kardiogenik
Apa terapinya?
a. Fluid administration
b. Inotropik
c. Vasopressor
Kasus 2
• Wanita 65 th datang datang dengan keluhan sesak nafas, panas 3 hari yl. Fisik : KU lemah, TD : 80/50 mmHg, N : 130x/mnt, RR : 40x/mnt, t : 38,3°C, Jantung : gallop +, Paru : ronchi +, wheezing + kedua lap paru. Acral dingin. EKG : SVT, Rð : cardiomegali, kongesti paru. Apa diagnosanya?
a. Syok sepsisb. Syok kardiogenikc. Syok hipovolemik
Clinical Signs:Clinical Signs: shock, hypoperfusion, congestive heart shock, hypoperfusion, congestive heart failure, acute pulmonary edemafailure, acute pulmonary edema
Most likely problem?Most likely problem?
Acute pulmonary edemaAcute pulmonary edema Volume problemVolume problem Pump problemPump problem Rate problemRate problem
11stst – Acute Pulmonary Edema – Acute Pulmonary EdemaFurosemideFurosemide IV 0.5 – 1.0 mg/kgIV 0.5 – 1.0 mg/kgMorphine Morphine IV 2 – 4 mgIV 2 – 4 mgNitroglycerin Nitroglycerin SLSLOxygenOxygen/intubation as needed/intubation as needed
AdministerAdminister• FluidsFluids• Blood transfusionsBlood transfusions• Cause-specific interventionsCause-specific interventionsConsiderConsider vasopressors vasopressors
BradycardiaBradycardia(see algorithm)(see algorithm)
TachycardiaTachycardia(see algorithm)(see algorithm)
Blood Blood pressure?pressure?
Next slide
Systolic BPSystolic BPBP defines 2BP defines 2ndnd line of action line of action (see below)(see below)
Systolic BPSystolic BP<70 mmHg<70 mmHgSigns/symptoms Signs/symptoms of shockof shock
Systolic BPSystolic BP70-100 mmHg70-100 mmHgSigns/symptoms Signs/symptoms of shockof shock
Systolic BPSystolic BP70-100 mmHg70-100 mmHgNoNo Signs/symptoms Signs/symptoms of shockof shock
Systolic BPSystolic BP>100 mmHg>100 mmHg
• NorepinephrineNorepinephrine0.5 – 30 µg/min IV0.5 – 30 µg/min IV
• DopamineDopamine5 – 15 µg/kg per 5 – 15 µg/kg per minute IVminute IV
• DobutamineDobutamine2 – 20 µg/kg per 2 – 20 µg/kg per minute IVminute IV
• NitroglycerinNitroglycerin10 – 20 µg/min IV10 – 20 µg/min IV
considerconsider• Nitroprusside Nitroprusside 0.1 – 0.1 –
5.0 µg/kg per min IV5.0 µg/kg per min IV
22ndnd – Acute Pulmonary Edema – Acute Pulmonary Edema• Nitroglycerin/nitroprusside if BP >100 mmHgNitroglycerin/nitroprusside if BP >100 mmHg• Dopamine if BP = 70-100 mmHg, signs/symptoms of shockDopamine if BP = 70-100 mmHg, signs/symptoms of shock• Dobutamine if BP >100 mmHg, no signs/symptoms of shockDobutamine if BP >100 mmHg, no signs/symptoms of shock
Further diagnostic / therapeutic Further diagnostic / therapeutic considerationsconsiderations
• Pulmonary artery catheterPulmonary artery catheter• Intra-aortic balloon pumpIntra-aortic balloon pump• Angiography for AMI / ischemiaAngiography for AMI / ischemia• Additional diagnostic studiesAdditional diagnostic studies
ACUTE HEART FAILURE with several distinct clinical condition
I. Acute decompensated HF or Decompensation of chronic HF : Symptoms and sign of AHF +, mild, not fulfil for cardiogenic shock, pulmonary oedema or HT crisis.
II. Hypertensive AHF: symptoms and sign of HF + BP ↑ and preserved LV function with chest X-ray pulmonary congestion.
III. Pulmonary oedem : Severe respiratory distress, orthopnea and rales over the lungs, O2 saturation < 90% and verified by chest X-ray
IV. Cardiogenic shock : Tissue hypoperfusion induced by HF after corection filling pressure. ↓ BP ( SBP < 90 mmHg or ↓ mean arterial BP > 30 mmHg), low urine output ( < 0,5 ml/kg hr ), pulse rate > 90bpm, organ congestion +/-, low CO → severe cardiogenic shock.
V. High output failure : ↑ CO, ↑ HR ( arrhytmia, thyrotoxicosis, anemia, iatrogenic ), warm peripheries, pu;monary congestion, ↓ BP as in septic shock.
VI. Right heart failure : low output syndrome with ↑ JVP, hepatomegaly and hypotension
THE KILLIP CLASSIFICATION ( Clinical estimate )
Class I : no HF, no clinical sign of cardiac decompensation
Class II : HF, rales, S3 gallop, pulmonary venous HT, pulmo congestion with wet rales up to half of the lung fields
Class III : Severe HF. Pulmonary oedema with rales in all lung fields
Class IV : Cardiogenic shock. Sign ↓BP ( ≤ 90 mmHg ), peripheral vasoconstriction, oligouri, cyanosis and diaphoresis.
Clinical classificationClinical classification
A
Dry and warm
B
Wet and warm
L
Dry and cold
C
Wet and cold
C o n g e s t i o n : l u n g s
Perfusion
The forrester classification The forrester classification ( haemodynamic ( haemodynamic characteristic )characteristic )
normal
Pulmonary oedema
HypovolemicCardiogenic shock
Pulmonary congestion
PCWP18 mmHg
DiureticsVasodilators
Fluid administration N BP : Vasodilators↓ BP : Inotropics or vasopressor
Tissue
Perfusion
C
I
2,2
Diagnostic algorithm Diagnostic algorithm ( clinical assesment, pts hx, ( clinical assesment, pts hx, ECG, X-ray, O2 saturation,CRP, electrolytes, Cr, BNP )ECG, X-ray, O2 saturation,CRP, electrolytes, Cr, BNP )
Suspected Acute Heart FailureSuspected Acute Heart FailureAssess symptoms & sign
Heart disease ?ECG/BNP/X-ray ?
Evaluate cardiac function by Echocardiography
HEART FAILURE
Characterise type & severity
Consider other diagnosis
Selected test ( angio, haemo moni )
Abnormal
Abnormal
Normal
Normal
Laboratory test
A l w a y s Consider
• Routine haematology Transaminases• Creatinine/Urea Urinalysis• Elektrolyte BNP or NT-proBNP• Blood glucose INR ( if anticoagulated or HF)• Troponin/ CKMB• Arterial blood gases• CRP D-dimer
Treatment goals : Improve clinical symptoms and outcomes.
● Clinical● Outcome↓ Symptoms ↓ Length of stay in the ICU↓ Clinical sign ↓ Duration of hospitalisation↓ BW ↑ Time to hosp. rea-dmission↑ Diuresis ↓ Mortality↑ Oxygenation ● Tolerability
Low rate of withdrawal from Tx Low incidence of adverse eff.
● Laboratory ● Haemodynamic↓ BUN and/or creatinine ↓ PCWP < 18 mmHg↓ S-bilirubin ↑ CO or SV↓ Plasma BNPElectrolyte and glucose N
Initial management : Instrumentation and choice of Tx ≈ clinical priorities
• O2 face mask or by CPAP ( SpO2 target 94-96%)• i.v diuretic with loop diuretic• Vasodilatation by nitrate or nitropruside• i.v fluid ≈ sign of low filling pressure• Concomitant metabolic and organ spec.cond.are treated ≈
Dx work up & lab.status.• Correct hypoxia &↑CO, renal perfusion, Na excretion &
urinary output.Ultrafiltration or dialysis if diuretic resistance• Tertiary tx with devices may be indicated, IABP, ventilation,
or circulatory assist or heart transplantation
Steps of care and treatment algorithm in AHF
Acute H F
Immediate resuscitation
If moribund BLS,ALS
Definitive diagnostic
Diagnosis algorithm
Definitive treatment
Pts distress or in pain
ArterialO sat > 95%
Normal HR & rhythm
Analgesia or sedasi
↑ FiO2,CPAP, NIPPV
Pacing, antiarrhytmi
Y
N
N
Y
N
Y
N
Y
Mean BP > 70 mmHg
Adequate preload
Adequate CO: reversal of metabolic acidosis, SvO2 > 65%, clinical sign of adequate organ perfusion
Vasodilators, diuresis if volume overload
Fluid challenge
Inotropes or further afterload reduction
Reassess frequently
Y
N
N
Y
N
Y
Specific pharmalogical treatments : Based of the pharmacodynamic, pharmacokinetics, potential interaction, side effects,
and toxicity
A. Diuretics i.v in the acute phaseSeverity of fluid retent. Diuretic Dose(mg) CommentsModerate Furosemide or 20 – 40 ≈ symptoms
Moni. Na/K,cr,BPSevere Furosemide or 40 – 100 i.v
Furosemide inf. 5 – 40 mg/h better than HBDRefractory Add HCTZ 25-50 td better HD loop
Add spirono 25-50 od if not RFRefract to furos +HCTZ Add dopamine f renal vaso ultrafilt or HD
dilatation + dobutamine
B. Vasodilators ≈ systemic BP
Vasodilator Indication dosing SE
5-mononitrae AHF,BP is adequate 20 – 200 µg/m hypotens, headace
ISDN AHF, BP adequate 1 – 10 mg/h idem
Nitropruside HT crisis 0,3 – 5 µg/kg/m idem
C. Inotropic agents
Agents Bolus Infusion rate
Dobutamine no 2 – 20 µ/kg/min ( β )Dopamine no < 3 µg/kg/min, renal effect ( β )
3 – 5 µg/kg/min, inotropic ( β )> 5 µg/kg/min(β), vasopressor
(αNorepinephrine no 0,2 – 1,0 µg/kg/minEpinephrine 1 mg i.v at
resuscitati on repeat 0,05 – 0,5 µg/kg/min ed 3-5 min
MATUR SUWUN