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