Fluid Resuscitation.pdf

7/26/2019 Fluid Resuscitation.pdf

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Syok hemoragik:Resusitasi Cairan

DR Yefta Moenadjat, dr, SpBP(K)

Dep Medik Ilmu Bedah RSCMFKUI


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Latar Belakang

Konsep resusitasi cairan berubah sejalan deng

perkembangan iptekdok mengenai patofisiologi sytransportasi dan distribusi aircairan serta dampaknya

Banyak bukti [evidence] dihadirkan mengenai bahapemberian cairan dalam jumlah besar; terlebih: kllebih bermakna.

Kata kunci:Perubahan paradigma syok, resusitasi cairan (targ

endpoint), strategi.


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Syok

Circulatory Shock (Shock)

Kondisi mengancam jiwa yang terjadi karena ketidakcukupasubstrat yang dibutuhkan respirasi sel (aerob). Kondisi inidiawali oleh ketidakcukupan oksigen di jaringan.

Penyebab utama kematian pada penderita trauma.

Memiliki variasi menifestasi dengan kesamaan luaran;kesemuanya berhubungan dengan kegagalan sistem

sirkulasi.Contoh: Hipoksemiahenti jantung

Hipovolemia, Kardiogenik, Distributif, Anafilaktik

Hipovolemia,


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Syok Hipovolemia

Migrasi cairan (plasma)

ke jaringan interstisium

Migrasi leukosit

Hemokonsentrasi [Hb]Kehilangan

Cairan (plasma)

Selsel darah / [Hb

Luka Bakar Hemo


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Syok Hipovolemia

Hipovolemia:

Ketidakcukupan volume intravaskular distribusi cairan terganggu Hemokonsentrasi: [Hb]SaO2 (/N) Hemoragik: [Hb]SaO2

Perfusi sel

Aktivitas sel Rantai respirasi (mitokondria) O2: Gggan metabolisme (CHO, protei

lemak) ProduksiATPKehidupan sel


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Lipid bilayer

Pumps and channel

(Membranes protein)

Cytoskeleton

Glycoprotein

Receptors

Na+

K+

Glucose

TCACycle

PyruvateCytoplasma Acetyl CoA

NADH

FADH2

ATP

ATP

ATP

ATP

ATP

ATP

CO2H2O

Lactic Acid

Cell membrane

Mitochondrion


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Sistem sirkulasi kranial

Sistem sirkulasi paru kiri

Sistem sirkulasi hepar

Sistem sirkulasi sistem digestif

Sistem sirkulasi tubuh bagian bawah

Vena PulmonarDarah mengandung O2dibawa kembali ke jantung

AortaDarah mengandung O2dibawa ke seluruh tubuh

Arteri PulmonarDarah mengandung CO2dibawa ke paru

Arteriol

Kapiler

Venula

Sistem Sirkulasi ParuKananDarah melepaskan CO2 danmenyerap O2 di kapiler

VenaPortaDarah kaya akan nutrien berasal dari

sistem digestif dibawa ke hepar

Vena Cava InferiorDarah dari tubuh bagianbawah dibawa ke jantung

Vena Cava SuperiorDarah dari tubuh bagian atas

dibawa ke jantung

Sirkulasi PulmonaSirkulasi sistemik


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0

Vena Porta1.150 mL/min

(21%)

70 mL/min

(1.4%)

1.100 mL/min

(20%)

300 mL/min

(5%)

1.240 mL/min

(22%)

1.310 mL/min

(23%)

700 mL/min

(13%)

240 mL/min

(4%)

5.800 mL/min

(100%)

5.800 mL/min

(100%)

SSPUsus

Limpa

HeparKidney

Otot, kulit dan jar

adiposus

Jantung

Lung

Waktu iskemik setiap sel (organ berbeda)

Sistem

Sistem muskular

Ginjal

Usus

Portal


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Lingkaran setan perdarahan

Perdarahan

aktif

Trauma Mayor pada torso

Iatrogenik

Syok

seluler

Kerusakan

jaringan

Transfusi m

Aktivasi adhesi

ELT*

Defisiensi faktor

pembekuanPenyak

komorbi

Asidosis

metabolik

Hipotermia

Koagulopatia

progresif

*ELT: Endotel Leukosit Trombosit

**Koagulopatia: 1) Perdarahan, 2) Trombosis

TRIAS KEMATIAN


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Resusitasi Cairan

Definisi

1. Pemberian cairan isotonik intravena secara cepat untumengatasi defisit volume (volume replacement)

2. Pemberian cairan isotonik intravena pada pasien traumluka bakar, dan pasien hipotensif

3. Prosedur pemberian cairan intravena untuk tujuanrestorasi, revivaldan renewal.

Santry HP, Alam HB. Shock. 2010; 33(3): 22941

1. Dorlands Online Medical Dictionary. Available in website: http://www.dorlands.com2. McGrawHill Concise Dictionary of Modern Medicine. 2002 by The McGrawH

Companies, Inc.

Boldt J. Clinical review: Crit Care. 2002; 6: 5259
http://www.dorlands.com/http://www.dorlands.com/


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Resusitasi Cairan

Masalah pada Resusitasi:

Pemberian sejumlah volume cairan isotonitidak sertamerta diikuti perbaikan perfusi

Pemberian cairan agresif

TD tidak merepresentasikan perfusPerbaikan TD (pada hipotensi) diikulepasnya bekuan darah perdarahaberulang


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The history

Tom Shires

Early aggressive resuscitation argued thatthe need for increasing cardiac output andoxygen delivery to maintain microvascularperfusion and oxygenation, exceeds any riskof accentuating hemorrhage and thereforetrauma victims in hypotensive hemorrhageshould receive large volumes of fluids asearly as possible (1970).

G. Tom Shires 1925- 20


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Resusitasi Cairan




"The injection of a fluid that will increase bloodpressure has dangers in itself. Hemorrhage

may not have occurred to a marked degree

because the blood pressure has been too low

to overcome the obstacle offered by a clot.

Myburgh JA, Mythen MG. Resuscitation fluids. Review article. N Engl

Med. 2013; 369;13:12431251


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Resusitasi Cairan




Volume efektif 1/3 volume yandiberikan

Cairan isotonik masif edeminterstisium masif (Kelebihan cairan sindroma rongga ketiga [fatal]


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Resusitasi Cairan




Asidosis (hiperkloremik) anion gap / SID[Stewart]

Gangguan pembekuan


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Resusitasi Cairan




Hipotermia [ATP] Asidosis [hiperkloremik]

Gangguan pembekuan [iatrogenik]

Pemicu mediator proinflamasi

TRIAS KEMATIAN


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Well, Wait weve always given fluids, Dr Shires told u

to do this. Anyway, it is just salt water, it cant possibly

hurt the patient, can it???


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Resusitasi Cairan


Pemberian sejumlah darah untuk perbaikaperfusi

Pemberian cairan koloid

Efek pengenceran (dilusi)

Gangguan pembekuan

Reaksi hipersensitivitas (sebagaimancairan isotonik)Kaczynski J, Wilczynska M, Hilton J, Fligelstone L. A literature revieEmerg Med Health Care. Open access.(http://creativecommons.org/licenses/by/3.0).

Velanovich V. A meta-analysis of mortality. Surgery 1989;105:65-71
http://creativecommons.org/licenses/by/3.0http://creativecommons.org/licenses/by/3.0


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Resusitasi Cairan

Kontra resusitasi agresif (2000s)

Hypotensive Resuscitation

Permissive Hypotension

Restrictive Fluid Resuscitation (


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The fluid resuscitation

Hypotensive resuscitation:

Such advice runs contrary to current teaching on themanagement of haemorrhagic shock in bothPrehospital and Advanced Trauma Life Supportmanuals, both of which advocate initial fluid therapy.

The authors' management of severely injured patienwith 'permissive hypovolaemia' is not commonly

practiced.

Dutton RP, Mackenzie CF, Scalea TM. J Trauma. 2002;52:11411146Jackson K , Nolan J. JICS. 2009;10(2):109114.Harris T, Rhys Thomas GO, Brohi K. BMJ 2012; 345.


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The new concept

The equilibrium

Balanced (fluid) Resuscitation


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Pendekatan Baru: Konsep keseimbangan

Konsep keseimbangan total

Larutan seimbang (balanced salt solution: elektrolit)

Morgan et al. Designing Balanced Crystalloids .Crit Care Resusc.2003; 5: 284-291

Hartmanna Plasmalytea Plasmalyte Ra

Sod ium 129 140 140

Chlor ide 109 98 103

Potassium 5 5 10

Calc ium 2 5

Magnesium 1.5 3

Lactate 29 8

Acetate 27 47

Gluconate 23

Effective SIDb 27 50 53

SID = strong ion differenceaBaxter (Australia)bSID values are in mEq/L, and asume stable plasma lactate concentration of 2mmol/L


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Volume koloid seimbang dengan volumreplacement memberi keuntungan (statkeseimbangan asambasa)

Formula larutan HES 6% 130kDa:RL 1memperbaiki perfusi ke mukosa gaster(asesmen gastric tonometry) lebih baik

dibanding HES 6% (130kDa) saja

The balanced concept of fluid resuscitation . Editorial. Brit J Anaesth. 2007. 99 (3): 31215James MF, Michell WL, Joubert IA, Nicol AJ, Navsaria PH, Gillespie RS: Resuscitation withhydroxyethyl starch improves renal function and lactate clearance in penetrating trauma in arandomized controlled study: the FIRST trial (Fluids in Resuscitation of Severe Trauma). Br J Anae2011, 107:693-702


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Tatalaksana syok:

Perbaikan O2delivery: PRC

Mencegah/mengatasi koagulopati:

Seluler = Trombosit

Humoral = FFP

Hindari:

Hyperfibrinolysis = TXA danHypofibrinogenemia = Cryoprecipitate

Transfusi masif

Clinical Review. Early fluid resuscitation in severe trauma. BMJ 2012;345:e5752


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Resusitasi awal:

RL (maksimum 1000 mL) dan PRC.

Keuntungan pemberian produk darah di awalmembawa banyak keuntungan.

Perdarahan masif:

Clinical Review. Early fluid resuscitation in severe trauma. BMJ 2012;345:e5752

Chambers et al . Coagulopathy in treated trauma patients. Am J Clin Pathol 2011;136:370

PRC : Trombosit : FFP

1 1 1

0.51.3 g/un1020 mL/kg (1

~ 230mL)

2040 x 109/L1 unit ~ 60mL

1 unit/bag ~ 300mL4mL X kg X Hb g/dL


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Tidak terlalu cepat, tidak terlalulambat..

focused on "golden hour" utk pra RS (ATLS 9th)

Seni resusitasi

Tidak kekurangan, tidak kelebihan.

Seni resusitasi

McSwain NE, Champion HR, Fabian TC, Hoyt DB, Wade CE, Eastridge BJ, State of the art of fluidresuscitation 2010: prehospital and immediate transition to the hospital. J Trauma. 2011 ;70(5Suppl):S2-10.Richardson RG. The art of resuscitation. J R Soc Med 1990;.83(11):753. PMC1292936Burdett et al. Perioperative buffered versus non-buffered fluid administration for surgery in adults.

Cochrane Anaesthesia Group . The Cochrane Collaboration. John Wiley & Sons, Ltd. 2003


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PemantauanMentation

Skin perfusion / mottling

Cold extremities (and cold knees)

Capillary refill

Mean arterial pressure

Urine output, urine sodium and osmolarity

Cerebral and abdominal perfusion pressures

Blood lactate

Arterial pH, BE, and HCO3-

Mixed venous oxygen saturation SmvO2(or ScvO2)Mixed venous pCO2Tissue pCO2 (sublingual capnometry, gastric tonometry)

Skeletal muscle tissue oxygenation (StO2, NIRS)

Marik et al. Hemodynamic parameters to guide fluid therapy. Annals of Intensive Ca


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Miller TE. Perioperative Medicine 2013, 2:13http://www.perioperativemedicinejournal.com/content/2/1/13
http://www.perioperativemedicinejournal.com/content/2/1/13http://www.perioperativemedicinejournal.com/content/2/1/13


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ATLS 9th edition

Initial resuscitation:

1000 mL (NOT 2000 mL)

The goal of resuscitation is

to treat hypotension BUT

perfusion

Balanced resuscitation

Such a resuscitation stratemay be a bridge to but is a

not a substitute for

definitive surgical control of

bleeding (page 63-64).

ATLS

approach to thetrauma pat ient

ATLS express guidelines, not

protocols Can be applied at Trauma Centers

as well Local protocols: inspired by

ATLS; they should considerstructural, diagnostic andprofessional resources


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Strategi

Pendekatan pada syok hemoragik:

Damage control resuscitation terdiri dari:

1. Awal: RL maksimum 1000mL

2. Pengendalian sumber perdarahan

3. Pemberian awal PRC, FFP dan Trombosit rasio1:1:1

4. Hindari pemberian kristaloid berlebihan

5. Prevensi dan tatalaksana hipohermia, hipokalsemia,asidosis dan koagulopatia

6. Hypotensive resuscitation


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