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Diagnosis dan Manajemen

Syok

Diagnosis dan Manajemen

Syok

Irfan Hamdani

Dept. Anestesiologi FK UMSU

Irfan Hamdani

Dept. Anestesiologi FK UMSU

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SHK 2

Shock

Shock

• Alwas a smptom of primar ca!se

• Inade"!ate #lood flow to meet tiss!e

o$gen demand• Ma #e associated with hpotension

• Associated with signs of hpoperf!sion%

mental stat!s change& olig!ria& acidosis

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SHK '

 

Kategori Syok 

Kategori Syok

• (ardiogenic

• Hpo)olemic

• Distri#!ti)e

• *#str!cti)e

• (ardiogenic

• Hpo)olemic• Distri#!ti)e

• *#str!cti)e

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SHK +

(ardiogenic Shock

(ardiogenic Shock

• kontraktilitas ,ant!ng

men!r!n

• -eningkatan tekanan

pengisian ,ant!ng&

pen!r!nan S&

pen!r!nan (*&

peningkatan S/

• kontraktilitas ,ant!ng

men!r!n

• -eningkatan tekanan

pengisian ,ant!ng&

pen!r!nan S&

pen!r!nan (*&

peningkatan S/

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SHK 0

Hpo)olemic Shock

• Decreased cardiac o!tp!t

• Decreased filling press!res

• (ompensator increase in

sstemic )asc!lar resistance

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SHK 1

Distri#!ti)e ShockDistri#!ti)e Shock

• ormal or increased cardiac o!tp!t

• 3ow sstemic )asc!lar resistance

• 3ow to normal filling press!res

• Sepsis& anaphla$is& ne!rogenic&

and ac!te adrenal ins!fficienc

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SHK 4

*#str!cti)e Shock*#str!cti)e Shock

• Decreased cardiac o!tp!t

• Increased sstemic )asc!lar

resistance

• aria#le filling press!resdependent on etiolog

• (ardiac tamponade& tension

pne!mothora$& massi)e

p!lmonar em#ol!s

• Decreased cardiac o!tp!t

• Increased sstemic )asc!lar

resistance

• aria#le filling press!resdependent on etiolog

• (ardiac tamponade& tension

pne!mothora$& massi)e

p!lmonar em#ol!s

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SHK 5

(ardiogenic Shock Management(ardiogenic Shock Management

• 6reat arrhthmias

• Diastolic dsf!nction ma

re"!ire increased filling

press!res

• asodilators if not hpotensi)e

• Inotrope administration

• 6reat arrhthmias

• Diastolic dsf!nction ma

re"!ire increased filling

press!res

• asodilators if not hpotensi)e

• Inotrope administration

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SHK 7

(ardiogenic Shock Management

• asopressor agent needed if

hpotension present to raise

aortic diastolic press!re

• (ons!ltation for mechanicalassist de)ice

• -reload and afterload red!ction

to impro)e hpo$emia if #lood

press!re ade"!ate

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SHK 89

Hpo)olemic Shock

Management

Hpo)olemic Shock

Management

• ol!me res!scitation : crstalloid&

colloid

• Initial crstalloid choices

 – 3actated /inger;s sol!tion

 – ormal saline lood& crstalloid& colloid

• ol!me res!scitation : crstalloid&

colloid

• Initial crstalloid choices

 – 3actated /inger;s sol!tion

 – ormal saline lood& crstalloid& colloid

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SHK 88

Distri#!ti)e Shock 6herap

• /estore intra)asc!lar )ol!me

• Hpotension despite )ol!me therap

 – Inotropes and?or )asopressors

• asopressors for MA- @ 19 mm Hg

• Ad,!ncti)e inter)entions dependent on

etiolog

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SHK 82

*#str!cti)e Shock 6reatment*#str!cti)e Shock 6reatment

• /elie)e o#str!ction

 – -ericardiocentesis

 –6!#e thoracostom

 – 6reat p!lmonar em#ol!s

• 6emporar #enefit from fl!id

or inotrope administration

• /elie)e o#str!ction

 – -ericardiocentesis

 – 6!#e thoracostom

 – 6reat p!lmonar em#ol!s

• 6emporar #enefit from fl!id

or inotrope administration

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SHK 8'

Fl!id 6herapFl!id 6herap

• (rstalloids – 3actated /inger;s sol!tion

 – ormal saline

• (olloids

 – Hetastarch

 – Al#!min

 – elatins

• -acked red #lood cells• Inf!se to phsiologic endpoints

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SHK 8+

Fl!id 6herap

• (orrect hpotension first

• Decrease heart rate

• (orrect hpoperf!sion a#normalities• Monitor for deterioration of

o$genation

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SHK 80

Inotropic ? asopressor Agents

• Dopamine

 – 3ow dose

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SHK 81

Inotropic Agents

• Do#!tamine

 – 0B29µ

g?kg?min

 – Inotropic and )aria#le chronotropic effects

 – Decrease in sstemic )asc!lar resistance

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SHK 84

Inotropic ? asopressor

Agents• orepinephrine

 – 9.90 µg?kg?min and titrate to effect

 – Inotropic and )asopressor effects

 – -otent )asopressor at high doses

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SHK 85

Inotropic ? asopressor Agents

• pinephrine

 – >oth and β actions for inotropic

and )asopressor effects

 – 9.8µ

g?kg?min and titrate

 – Increases mocardial *2 cons!mption

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SHK 87

  6herape!tic oals in Shock 6herape!tic oals in Shock

• Meningkatkan deli)eri *2

• Mengoptimalkan *2 di darah

•  meningkatkan cardiac o!tp!t and tekanan

darah• Menes!aikan ke#!t!han *2 sistemik dan

hantaran *2

•  Mencegah organ hpoperf!sion

• Meningkatkan deli)eri *2

• Mengoptimalkan *2 di darah

•  meningkatkan cardiac o!tp!t and tekanan

darah• Menes!aikan ke#!t!han *2 sistemik dan

hantaran *2

•  Mencegah organ hpoperf!sion

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SHK 29

*lig!ria

• Marker of hpoperf!sion• Urine o!tp!t in ad!lts

@9.0 m3?kg?hr for C2 hrs

• tiologies – -rerenal

 – /enal

 – -ostrenal

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SHK 28

)al!ation of *lig!ria 

• Histor and phsical e$amination

• 3a#orator e)al!ation

 – Urine sodi!m

 – Urine osmolalit or specific gra)it

 – >U& creatinine

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SHK 22

)al!ation of *lig!ria)al!ation of *lig!ria

3a#orator 6est -rerenal A6

>lood Urea itrogen? C29 89:29

  (reatinine /atio

Urine Specific ra)it C8.929 @8.989

Urine *smolalit