SYOK HIPOVOLEMIKOleh :

Dr Jaka Satria, Sp An. M. Kes

TUJUANMenguraikan definisi syok dan menerapkan definisi ini di praktek / klinis

Mengenal sindroma klinik syok hipovolemik

Menerapkan prinsip prinsip terapi syok hipovolemik

Mengenal pertimbangan khusus dalam pemberian cairan bagi penderita syok hipovolemik

Skenario KlinikWanita, 19 th, nyeri perut, TD palpasi 80, N kecil 140 x/mnt, RR 38X/mnt cuping hidung, extremitas dingin, kesadaran , DX : KET TX : RL 2 lt dg cepat, siap op ambil contoh darah, 30 mnt kemudian TD 100/60, N 110, extremitas mulai hangat, HB 7,0 selama op + RL 1 lt dalam 30 mnt perdarahan 1 lt, TD akhir op 110/80 N 100 perfusi baik HB 6,0

Syok HipovolemikSejarah : dikaji intensif karena perang

Dunia I 1914 - 1918Dunia II 1939 - 1945Korea 1950 - 1953Vietnam 1957 - 1975

Pengetahuan Syok masih sangat gelapSyok a rude un hinging (perusakan dengan kasar sendi-sendi) of machinery of life.Syok the harbinger (pertanda akan datangnya) of death.Tahun 1970-an : Inadeguate blood flow to vital organs or filure of the cell of vital organs to utilize oxygen.Sekarang : gangguan pada parfusi dan oksigenasi pada jaringan atau sel.

DEFINISI SYOK ADALAHSuatu sindrom klinik dengan tanda berupa hipotensi, takikardi, kulit dingin, pucat basah, sianosis perifer, hiperventilasi perubahan status mental dan penurunan produksi urine

Trimodal distribution of deaths (from Trankey DD : Sci Am 249 : 28 : 35, 1983)01,25,6 weeksTime after injuryPercent of trauma deaths5040302010IMMEEDIATE : CNS Injury or heartand great vessel injuryEARLY : Major hemorrhageLATE : Infection and Multiorgan failure

UNSUR PEMBEDA PADA SHOCKSYOKHIPOVOLEMIASYOKKARDIOGENIKSYOKANAFILACTICSYOKSEPTIKUNSUR YG SM PD SYOKCOMMONTERMINALPATHWAYGANGGUAN UTAMA VOL DARAH DAYA POMPA JANTUNGVASODILATASIGGN PGGN O2 OLEH SELMEKANISME FIS DASARARAH UTM PENGELOLAANBAGAN : MODEL SEDERHANA SYOK

ETIOLOGIHYPOVOLEMIC HeorrhagicTraumaGastrointestinalRetroperitonealFluid Depletion (nonhemorrhagic)External Fluid lossDehydrationVomitingDiarrheaPolyuriaIntestinal fluid redistributionThermal injuryTraumaAnaphylaxis Increased vascular capacitance (venodilatation)SepsisAnaphylaksisToxins/drugs

TBW devided into 2 compartments1. Intracellular fluid 40%2. Extracellular fluid 20%- Interstitial fluid 15%- Intravascular fluid 5%IC Space

40%24 LIs Space

15%9 LIV Space

5%3 LCapillary wall(endothelial cells)Freely permeable to water and smallmolecules but notfor protein such asalbuminFISIOLOGI CAIRAN TUBUH

TBW: 60 % BBICF: 40 % BBECF: 20 % BB

EBV: IVF + Sel-sel: 5 % + 2 % = 7 % BB

Cth: BB 50 kgTBW: 30 LEBV: 3500 cc

Sistem kardiovaskuler

Fisiologi KardiovaskulerCO: SV X HRSV: Preloid, afthload, kontraktilitas miocardTD: Co X SVRCa O2: (SaO2 X Hb X 1,34) + PaO2 (0,003)DO2 : Co X Ca CaO2Cth : Hb 15 g/dl, SaO2 100%, CO 5 L/mntDO2: 50 X 15 X 1 X 1,34 = 1005 ml/mntVO2: 200 250 ml/mntBila Hb: 5 g/dl; CO 15 l/ mntMaka DO2: 150 X 5 X 1 X 1,34 = 1005 ml/mnt

PATOFISIOLOGI HIPOVOLOMI SYOKReduction of blood volume

PAIN Sympatetic ReductionRelease Venous CatecolaminReturn

IncreaseTachycardiPeriperialArterialCardialVasocontricHypotensionContractility

IncreaseReduction TissueCardial OxygenPerfusion

Anaerobic Metabolisme

Myocardial FailureAcidosisMulti Organ Failure

MEKANISME HOMEOSTASISDEHIDRASI / SYOKVOLUME CAIRAN TUBUH TURUNStressOsmol NaikGinjal HipopiseAldosteronADH naikReabsorbsi Na Air Naik

Volume cairan tubuh bertambah Osmol Turun ADH turun

Menyebabkan produksi urin meningkat/ encer

Gambaran Kompartmen Cairan :Hipovolomia :Absolut dehidrasi

Sepsis syokIntravasculer Intrasel >

Subjectiv dan tanda fisik : kulit yg dingin, basah, pucat, gangguan kesadaran, TD rendah (TDS < 90 mmHg / penurunan > 50 mmHg di bawah nilai base line) denyut nadi cepat dan lemah, Tek nadi < 20 mmHg.

Untuk BB 70 kg

Kelas IKelas IIKelas IIIKelas IVKehilangan darah (CC)750750-15001500-2000> 2000Kehilangan darah (% volume darah)15%15-30%30-40%> 40%HR< 100> 100> 120> 140TDNormalNormalT. NadiNormal atau RR14-2020-3030-40> 35Produk Urine (CC/jam)> 3020-305-15Tdk berartiCNS / Status mentalSedikit cemasAgak cemasCemas, bingungBingung, LesuPenggantian CairanKristaloidKristaloidKristaloid, koloiod darahKristaloid, koloiod ,darah

TUJUAN RESUSITASI JARINGANRESTORASI PERFUSI JARINGAN DAN PENGIRIMAN O2 KE SELMENGURANGI : ISKEMIA JARINGAN KEGAGALAN ORGANRUMUS : DO2 = CO X Hb X SO2 X 1,34 + (pO2 X 0,003)

TREATMENT CONCEPT OF SHOCKENHANCING PERFUSION / OXYGEN DELIVERY

Oxygen Delivery/DO2 = HR x SV x HbxSpO2 x 1.39 + 0.03 x PaO2 Arterial O2 ContentCardiac OutputInotropes :-Dopamin-Dobutamin-Norepinephrin-EpinephrinFluidsTransfusePartiallyDependent onFIO2 andPulmonarystatusDO2 = CO x CaO2ScvO2

020406080100306090MINUTESPERCENT SUVIVAL

Berikan O2 untuk atasi hipolsia jaringan memanipulasi O2 yang terlarut di plasma, walau nilainya kecil namun pada kondisi syok sangat bermanfaat.Perbaiki volume intravaskuler- Beri infus kristaloid 2 L dalam 10 menit CO- Pasang vena kateter yang terbesar- Tinggikan kaki 30 45 VRPemilihan cairan kristoloid, koloid darah tergantung kebutuhan pasien.Monitor nadi, sirkulasi perifer, TD tiap 5-10 menit pasang DC untuk efaluasi produk urine.

Penderita perdarahanPasang Infus jarum besarCatat perfusi, nadi, TD, RR, Produk Urine Ambil contoh darah, siapkan darah donor 500 1000 cc Infus RL / Nacl 0,9% asering 1000-2000 cc secepat mungkin max 30 - 60 menitDosis dapat diulang sampai 2 4 X Blood Lost (jika perfusi nadi, TD masih buruk)

Bila hemodinadik baik perfusi hangat, kering, merah TDC > 100, HR < 100, teruskan cairan tetesan main tenance biasanya tidak perlu tranfusiBila hemodinamik tetap buruk berikan lagi bolus 1000 cc sampai 2-4 X Blood lostBila kemudian HD Baik cek kadar Hb, bila < 8 g/dl dapat diberikan tranfusi pelan-pelan. Kalau TD baik tranfusi dapat ditunda sampai sumber perdarahan terkuasai.Bila HD tetap buruk tranfusi segera diberikan

RESPON TERHADAP PEMBERIAN CAIRAN AWAL

Respon CepatRespon SementaraTanpa ResponTanda VitalKembali normalPerbaikan sementara, TD, N kembali Tetap abnormalDugaan kehilangan darah Minimal, (10-20%)Sedang, (20-40%)Berat, > 40%Kebutuhan kristaloidSedikit BanyakBanyakKebutuhan darahSedikitSedikit - banyakSegeraPersiapan darahType Spesific & CrossmatchType Spesific EmergencyOperasiMungkinSangat mungkinHampir pastiKehadiran dini ahli bedahPerluPerluPerlu

Nadi < 100/ menitTDS> 90 mmHgCVP5-8 cm H2OProduk Urin :- Dewasa 0,5 cc /kg BB/jam- Anak 1 cc /kg BB / jam- < 1 th 2 cc /kg BB /jamDO2 = CO X Hb X SO2 X 1,34 + (pO2 X 0,003) dalam batas normal

KONSEP BARUPERMISSIVE HYPOTENSION

Pasien tetap sadarNadi terabaSBP 90 mmHgMAP 50-60 mmHgSaO2 > 92 %

Lar gula dalam air D5%, 10%, 40% martos 10Lar Kristaloid murni NaCL 0,9%, RL, Asering resusitasiLar Kristaloid + gula RD5, KAEN3B, 3A, Mg3, tutofusin rumatanLar Koloid hetastarch, gelatin, dextran, albumin, dllLar Nutrisi parenteral triofusin, aminofusin,Panamin G dll

TERAPI CAIRANResusitasiRumatanKristaloidKoloidAir + Elektrolit + NutrisiMengganti kehilangan akut(Syok, dehidrasi, hipovolemik)Memasok kebutuhan harian

700 cc 300 cc

Pemilihan Cairan IntravenaKristaloid 3:1

Koloid 1:1

Koloid VS Kristaloid(Area Persetujuan)

KoloidKristaloidAna Philaktoid+-Efisiensi+++Harga++++Hemodilusi+++++Osmotik++++

KRISTALOIDKeuntungan Komposisi elektrolit seimbangTidak ada resiko alergiTidak mempengaruhi hemostasisMengakibatkan terjadinya diuresisMurah

KRISTALOIDKerugian Perlu 3-4 x jumlah perdarahanBisa mengakibatkan oedemMengakibatkan TOP berkurangHypothermiaLama kerja +/- 90 menitNaCl 0.9 % : asidosis hiperchloremia

KOLOIDKeuntungan Tetap berada dalam volume intavaskular Kebutuhan sama dengan jumlah darah yang hilang Meningkatkan TOP Resiko oedem minimalMeningkatkan aliran darah microvaskular

KOLOIDKerugian Kelebihan beban cairan Menganggu hemostasis Mempengaruhi fungsi ginjal Reaksi anafilaktoid Mahal

Efek Volume Infus 1 Lt Cairan pada Kompartemen Tubuh

LarutanVol PlasmaVol InterstisialVol Intra Sel0,9 % NaCL275825- 1005% Dextrosa85255660Albumin 5%100000Haemaccel7003000Gelafundin100000Plasmafusin100000Dextran 401600- 260140Dextran 701300- 130170Expafusin100000Haes steril 6%100000Haes steril 10%1450- 4500

LarutanWaktu6 % / 10% HES 200 / 0.54 8 jam6 % HES 200 / 0.68 12 jam 6 % hes 450 / 0.78 12 jam6 % Dextran 706 8 jam10 % Dextran 403,5 4,5 jam4 % Plasmafusin4 6 jam5 % albumin (500 ml)3,5 4,5 jam25 % albumin (100 ml)3,5 4,5 jamGelatin 1,5 2 jam

TRANFUSI :- Bila Hb < 7 mg/ dL (Ht < 21 %)- Jarang bila Hb > 10 mg / dL (Ht 30%)- 7 < Hb < 10 mg/L : manfaat tidak jelas !

RISIKO TRANSMISI VIRAL & BAKTERIALMODULASI IMUN SEKUNDER

CRITICALPerlu TransfusiTOLERABLEOPTIMALSPECIAL CASE

Tua > 60 th, sepsis

DM, StrokeHb = 5Hb = 8Hb = 10Hb = 12 ???

Hemodilusi aman : HCT >25 %Pendapat lain 20%Ada masalah jantung koroner : HCT > 30%4-8 mgg kader Hb kembali normal3-4 hr kadar albumin kembali normalAnemia tidak disertai hipovolemik HCT > 15%Penyembuhan luka tidak terganggu

Pictures with reflection and blurred background(Basic)

To reproduce the picture effects on this slide, do the following:On the Home tab, in the Slides group, click Layout, and then click Blank.On the Insert tab, in the Images group, click Picture.In the Insert Picture dialog box, select a picture and then click Insert.Select the picture. Under Picture Tools, on the Format tab, in the Size group, click the arrow below Crop, point to Crop to Shape, and then under Rectangles click Round Diagonal Corner Rectangle.Also under Picture Tools, on the Format tab, in the Size group, click the Size and Position dialog box launcher. In the Format Picture dialog box, resize or crop the image so that the height is set to 2 and the width is set to 2.4. To crop the picture, click Crop in the left pane, and in the right pane, under Crop position, enter values into the Height, Width, Left, and Top boxes. To resize the picture, click Size in the left pane, and in the right pane, under Size and rotate, enter values into the Height and Width boxes.Also in the Format Picture dialog box, click Reflection in the right pane, and in the Reflection pane, in the Presets list, click Half Reflection, Touching.On the Insert tab, in the Images group, click Picture. In the Insert Picture dialog box, select a different picture and then click Insert. Repeat this process until there are three pictures on the slide.Select the second picture. Under Picture Tools, on the Format tab, in the Size group, click the Size and Position dialog box launcher. In the Format Picture dialog box, resize or crop the image so that the height is set to 2 and the width is set to 2.4. To crop the picture, click Crop in the left pane, and in the right pane, under Crop position, enter values into the Height, Width, Left, and Top boxes. To resize the picture, click Size in the left pane, and in the right pane, under Size and rotate, enter values into the Height and Width boxes.Select the third picture. Under Picture Tools, on the Format tab, in the Size group, click the Size and Position dialog box launcher. In the Format Picture dialog box, resize or crop the image so that the height is set to 2 and the width is set to 2.4. To crop the picture, click Crop in the left pane, and in the right pane, under Crop position, enter values into the Height, Width, Left, and Top boxes. To resize the picture, click Size in the left pane, and in the right pane, under Size and rotate, enter values into the Height and Width boxes.Select the first picture. On the Home tab, in the Clipboard group, click Format Painter. With the Format Painter cursor, on the slide, click the second picture.Select the first picture. On the Home tab, in the Clipboard group, click Format Painter. With the Format Painter cursor, on the slide, click the third picture.Press and hold CTRL, and then select all three pictures. On the Home tab, in the Drawing group, click Arrange, point to Align, and then do the following:Click Align Selected Objects.Click Align Middle.

To reproduce the background effects on this slide, do the following:On the Insert tab, in the Images group, click Picture.In the Insert Picture dialog box, select a picture and then click Insert.Select the picture. Under Picture Tools, on the Format tab, in the Size group, click the Size and Position dialog box launcher. In the Format Picture dialog box, resize or crop the image so that the height is set to 7.5 and the width is set to 10. To crop the picture, click Crop in the left pane, and in the right pane, under Crop position, enter values into the Height, Width, Left, and Top boxes. To resize the picture, click Size in the left pane, and in the right pane, under Size and rotate, enter values into the Height and Width boxes.Also in the Format Picture dialog box, click Artistic Effects in the left pane, and in the Artistic Effects pane, do the following:Click the button next to Presets and then click Blur (second row, fifth option from the left).In the Radius box, enter 30.On the Home tab, in the Drawing group, click Shapes, and under Rectangles click Rectangle (first option from the left).Drag to draw a rectangle on the slide.Select the rectangle. Under Drawing Tools, on the Format tab, in the Size group, enter 7.5 into the Height box and enter 10 into the Width box.Also under Drawing Tools, on the Format tab, in the Shape Styles group, click Shape Fill, point to Gradients, and then click More Gradients. In the Format Shape dialog box, click Fill in the left pane, select Gradient fill in the Fill pane, and then do the following:In the Type list, select Radial.In the Direction list, select From Center.Under Gradient stops, click Add gradient stops or Remove gradient stops until two stops appear in the slider.Also under Gradient stops, customize the gradient stops as follows:Select the first stop from the left in the slider, and then do the following: In the Position box, enter 0%.Click the button next to Color, and then under Theme Colors click White, Background 1 (first row, first option from the left).In the Transparency box, enter 60%.Select the second stop from the left in the slider, and then do the following:In the Position box, enter 100%.Click the button next to Color, and then under Theme Colors click White, Background 1 (first row, first option from the left).In the Transparency box, enter 0%.Also in the Format Shape dialog box, click Line Color in the right pane, and in the Line Color pane select No Line.Select the shape. On the Home tab, in the Drawing group, click Arrange, point to Align, and then do the following:Click Align to slide.Click Align Middle.Click Align Center.On the Home tab, in the Drawing group, click Arrange, and then click Send to Back.Select the background picture. On the Home tab, in the Drawing group, click Arrange, and then click Send to Back.

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