Post on 25-Nov-2015
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