Syokdan

Tatalaksana terapi cairanRahardjo.s

Aliran darah yang tidak Adekwat untuk memenuhi Kebutuhan Jaringan

Gangguan perfusi & oksigenasi jaringan akibat gangguan sirkulasi.

Jika tidak ditangani dengan baik akan berkembang menjadi Gagal Multi Organ dan akhirnya Kematian.

Difinisi

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.

TandaTandaShock

1. Takikardia

2. Akral dingin

3. Kesadaran 4. Takipnea

5. Tensi

shock !

KLASIFIKASISYOKHEMORAGIK

Kompensasi Ringan Sedang Berat

Hilangdarah(ml)Denyutnadi(bpm)Tekanan darahPengisian kapiler

Pernafasan

Urine(ml/h)

Statusmental

100OrtostatikMungkinterlambatPeningkatanringan

2030

Agitasi

15002000>120SangatturunSeringterlambatTakipneasedang

520

Konfusi

>2000>140TidakterukurSelaluterlambatTakipneunyata,GagalNafas

Anuria

Letargi,tidaksadar

Diagnosis

GAMBARANKLINIKSYOKHEMORHAGI

SISTIM SYOKDINI SYOKLANJUTSARAFPUSAT PERUBAHANSTATUS

MENTALPERUBAHANKESADARAN

KARDIAL TAKIKARDIHIPOTENSIORTOSTATIK

HIPOTENSIARITHMIAGAGAL JANTUNG

RENAL OLIGOURI ANURI

RESPIRASI TAKIPNOE TAKIPNOE,GAGALNAFAS

HEPATIK GANGGUAN FUNGSIHEPAR

GASTROINTESTINAL PERDARAHANMUKOSA

HEMATOLOGI ANEMIA KOAGULOPATI

METABOLIK ASIDOSISHIPOKALEMIAHIPOMAGNESEMIADiagnosis

Penanganan

TatalaksanaSyok:PenangananSyok:

TatalaksanaterhadapUnderlyinginjuryorDisease

MengembalikanPerfusiJaringan.

Segeramemberi/menggantiVolumeAdekuat

Ventilation&OxygenationAdekuat

Penanganan

PenangananterhadapUnderlyinginjuryordisease

TatalaksanaSyok:

ENHANCEMENTMICROCIRCULATIONBLOODFLOW

Arteriolesandarterialpartofcapillaries

Venulesandvenouspartofcapillaries

MengembalikanPerfusiJaringan

Penanganan

TatalaksanaSyok:

RestorasiVolumeDarahMeninkatkanCurahJantungdanTekananDarahMengkeseimbangkanO2needswithO2deliveryMengembalikan/MencegahOrganhypoperfusionOptimalisasikandunganO2darahMeningkatkanpenyampaianO2

AdekuatVolumeTatalaksanaSyok:

PENTING !l VOLUMEINTRAVASKULAR

l O2TRANSPORT(ERITROSIT)

JUMLAHOKSIGENYANGTERSEDIAUNTUKJARINGAN:

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

=5l/mX20l/mO2/100ml=1literO2/m

KEBUTUHAN=25%=250mlO2/m

OxygenDelivery =COxCaO2(HbxSpO2x1,39+0,003xPaO2)O2content,O2extractingRatio,O2Consumption

DeterminanuntukTissueoxygenation

Komponen:CardiacOutput,Hb,SpO2arterial&venousblood

AdequateVentilationandOxygenation

TatalaksanaSyok:

End Point of Resuscitation Therapy :

BasicClinicalSign: PatientResponses HR>BP EvaluasithdPerfusi:

UOP(UrineOutPut)CRT(CirculationPeripheral),LOC(LevelofConsciousness)

Produksi Urin/jamTidak adekwatnya UOPberartiTidak adekwatnya resusitasi

Advancedmethodsinclude Metabolik

Serumlactate pCO2 Basedeficit

Mixedvenoussaturations CVP :Preload. AdvancedEvaluation :CO,CI,LAP,PAOP,LVSVWI

End Point of Resuscitation Therapy :

KontroversialPoin

PeningkatanBPmeningkatkanresikoperdarahanpadakasusperdarahan.

PemberianCairandanDarahakanmenurunkancoagulosi MacamCairan:

Fluidvs.nonfluid(vasopressors,etc.) Bloodvs.nonbloodfluid Wholebloodvs.bloodcomponents Crystalloidsvs.colloidsvs.hypertonicsaline Albuminvs.syntheticcolloids

TujuanResusitasipadaUncontrolledHemorrhagicShock

Pasientetaphidupsampaiperdarahanterkontrol MencegahHemoragissyokdgnmemeliharaBPdanperfusijaringansampaiperdarahanterkontrol.

Cegahtindakanlainygpotensialmemperjelekperdarahanatauhemoragisyok

KontrolperdarahanAsquicklyaspossible

KONSEPBARU

PERMISSIVEHYPOTENSION

PasientetapsadarNaditerabaSBP90mmHg

MAP5060mmHgSaO2>92%

TERAPICAIRANPADASYOKHEMORRHAGI

TujuanResusitasiCairan; MenujuNormovolumidanHDstabil.

MemeliharaadekuatColloidOncoticPressure

MemeliharakeseimbangandankomposisiKompartemenCairanTubuh.

RLRA

NaCl0.9%NaCl3%

AlbuminPlasmaDextranGelatinHES

COLLOIDCRYSTALLOID

BLOOD

Body Fluid Compartments

Total body water = 60 % of body weight (BW)

2/3

Intracellular water= 40 % of BW

1/3

Extracellular water

= 20 % of BW

Plasma (5 % of BW)

Extracellular water

= 20 % of BW

PresenterPresentation NotesIn a healthy adult total body water equals approximately 60 % of body weight. Two thirds or 40 % of body weight is intracellular water and the remaining third is extracellular water. One fifth of the extracellular water or approximately 4 % of body weight is intravascular water. In a healthy person body fluid volumes are influenced by age, weight, body habitus and gender. A healthy male adult of 70 kg has 42 liters of body water of which 28 l is intracellular and 14 l is extracellular water; approximately 3 l is intravascular water.

increases ICF > ECFincreases ICF > ECF

ICF ISF PlasmaICF ISF Plasma

Replace Normal loss (IWL + urine)Replace Normal loss (IWL + urine)

Hypotonic infusionHypotonic infusion 5% dextrose 5% dextrose

85 ml85 ml255 ml255 ml660 ml660 ml

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

KRISTALOID

Keuntungan

Komposisi elektrolit seimbang Tidak ada resiko alergi Tidak mempengaruhi hemostasis Mengakibatkan terjadinya diuresis Murah

Kerugian

) Perlu 3-4 x jumlah perdarahan) Bisa mengakibatkan udem ) Mengakibatkan TOP berkurang.) Hypothermia) Lama kerja + 90 menit) NaCl 0.9% : asidosis hiperchloremia

KRISTALOID

050

100

150

200

250

D5WLactatedRingers

Albumin5 %

Volume (ml)

Prough, Anesthesiology Clinics of North America (1996)

Administration of 250 ml of fluid

ICVISV

PV

Prough, Anesthesiology Clinics of North America (1996)

Administration of 250 ml of fluid

Volume (ml)

ICVISV

PV

-750

-500

-250

0

250

500

750

1000

D5W LR Alb 5% Alb 25%

KOLOID

KEUNTUNGAN

Tetapberadadalamvolumeintravaskular Kebutuhansamadenganjumlahdarahyang

hilang MeningkatkanTOP Resikoudemminimal Meningkatkanalirandarahmicrovaskular

KERUGIAN

Kelebihan beban cairan Mengganggu hemostasis Mempengaruhi fungsi ginjal Reaksi anafilaktoid Mahal

KOLOID

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

SERUMHALF-LIFE

PLASMAVOLUME

EXPANSION***

ONCOTICPRESSURE**

AVERAGEMOLECULAR

WEIGHT * (DALTONS)FLUID

CHARACTERISTICS OF INTRAVENOUS COLLOID FLUIDS

Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic ShockCVPdenotescentralvenouspressure,MAPmeanarterialpressure,andScvO2

centralvenousoxygensaturationVolume 345:1368-1377 November 8, 2001 Number 19

TREATMENT CONCEPT OF SHOCKENHANCING PERFUSION / OXYGEN DELIVERY

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

Cardiac output

Arterial O2content

FluidsTransfuse Partially

dependent on FIO2 and

pulmonary status

Inotropes :DopaminDobutaminNorepinephrinEpinephrin

DO2 = CO x CaO2

ScvO2

Syok dan Tatalaksana terapi cairanSlide Number 2Klasifikasi : Tanda Tanda Shock Slide Number 5Slide Number 6GAMBARAN KLINIK SYOK HEMORHAGISlide Number 8Slide Number 9Slide Number 10 Slide Number 12Oxygen Delivery = CO x CaO2 (Hb x SpO2 x 1,39 + 0,003xPaO2) O2content, O2 extracting Ratio, O2 Consumption End Point of Resuscitation Therapy :End Point of Resuscitation Therapy :Kontroversial PoinTujuan Resusitasi pada Uncontrolled Hemorrhagic ShockKONSEP BARUTERAPI CAIRAN PADA SYOK HEMORRHAGISlide Number 21Slide Number 22Slide Number 23Slide Number 24Slide Number 25Slide Number 26Slide Number 27Slide Number 28Slide Number 29Slide Number 30Slide Number 31Slide Number 32Slide Number 33Slide Number 34Slide Number 35Slide Number 36Slide Number 37