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SyokM. Hafidz Azhari
Humairah
Ayun Puji lestari
Coni Senopadang
Pembimbing: dr Rapto Hardian, Sp.An
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Syok
Merupakan sindrom multifaktorialhipoperfusi jaringan perifer dan sentralhipoksia seluler dan disfungsi organ multipel.
Perfusi menurun secara sistemik dengan gejalayg jelas hipotensi
Prognosis: derajat syok, durasi, organ yangterpengaruh, disfungsi organ sebelumnya
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Patofisiologi
Hipoksia
seluler
shock
perfusi
jaringan
Hipoksia seluler permeabilitasvaskuler radikal super oksidarespon inflamasi kerusakan sellebih lanjut kerusakan multi-organ
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Diagnosis
Heart rate: takikardi bradikardi BP: Hipotensi severe volume loss and
shock Temp: hypothermia severe hypovolemic
and septic shock Urin output: early guide of hypovolemia and
end organ response (renal) to shock.Delayed vital sign
Pulse oxymetry early indicator ofhypoxemia, invalid in hypothermic patient
Vital
Sign
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Cardiac outputcardiac function,measured by PAC
Systemic vascularresistance index(SVRI)
Cardiacflow
variable
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Hemodynamic variablesMeasured variable Unit Normal
Range
Systolic blood pressure (SBP) mmHg 90-140
Diastolic blood pressure (DBP) mmHg 60-90
Systolic pulmonary blood pressure (PAS) mmHg 15-30
Diastolic pulmonary blood pressure (PAD) mmHg 4-12
Pulmonary artery occlusion pressure (PAOP) mmHg 2-12
Central venous pressure (CVP) mmHg 0-8
Heart Rate (HR) Beats/min 50-100
Cardiac output (CO) L/min 4-6
Right ventricular ejection fraction (RVEF) Fraction 0,4-0,6
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Calculated variable Unit Normal range
Mean arterial pressure (MAP) mmHg 70-105
Mean pulmonary artery pressure(MPAP)
mmHg 9-16
Cardiac index (CI) L/min/m2 2,8-4,2
Stroke volume (SV) ML/beat Varies
Stroke volume index (SVI) mL/beat/m2 30-65
Systemic vascular resistance index(SVRI)
Dynes 1.600-2.400
Pulmonary vascular resistance index(PVRI)
Sec/cm-5 250-340
Left ventricular stroke work index
(LVSWI)
g m/m2 45-62
Right ventricular stroke work index(RVSWI)
g m/m2 7-12
Right ventricular end-diastolic workindex (RVEDWI)
mL/m2 60-100
Body surface area (BSA) m2 varies
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Resuscitation end point
Cellular hypoxia anaerobic metabolism lacticacid >> severity of shock
Rate of clearance of lactate better marker ofadequate resuscitation
Lactic acid
production
The amount of base required to titrate whole bloodto a normal pH
Elevated base deficit severity of shockBase deficit
The mesenteric organ will have earlier and greaterhypoperfusion than other organ system
Gastric tonometry early indicator ofhypoperfusion
IntramucosalpH monitoring
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Syok hipovolemik
Loss of blood(hemorrhagic shock)
External hemorrhage Trauma
Gastrointestinal tractbleeding
Internal hemorrhage
Hematoma Hemothorax or
hemoperitoneum
Loss of plasma
(luka bakar)
Loss of Fluid andelectrolyte
- External Vomiting
Diarrhea
- Internal (third-spacing)
Pacreatitis
Ascites
Bowel obstruction
Kehilangan volume intravaskular yang bersirkulasi dan penurunancardiac preload
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Grades of hypovolemic shock
Sign &symptom
Class I Class II Class III Class IV
Blood loss(mL)
Up to 750 750-1500 1500-2000 >2000
%Bloodvolume
Up to 15 15-30 30-40 >40
Pulse rate 100 >120 >140
Bloodpressure
N N
Capillary refill N
RR N 20-30 30-40 >35Urinaryoutput(ml/hr)
>30 20-30 5-15 Negligible
Mental status Mild anxiety Anxiety Confused Lethargic
Fluidreplacement
Crystalloid Crystalloid Crystalloid +blood
Crystalloid +blood
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Syok hipovolemik
Rapid infusion of multiple liters of crystalloid
Large-bore venous access and central access isneeded
If haemorrhage shock after 2-3 liters of fluid blood is transfused + source of bleeding needs
to be controlled Vasoconstrictor rarely needed
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An initial,warmed fluidbolus is given asrapidly as possible. The usual dose is 1-2 liters
for an adult and 20 ml/kg for a pediatricpatient.
3-for-1 rule replace each mililiter of blood
loss with 3 mL of crystalloid fluid Assess the patients response to fluidresuscitation
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Response to Initial Fluid ResuscitationRapidResponse
TransientResponse
No Response
Vital Sign Return to Normal Transientimprovement,recurrent of BPand HR
Remain abnormal
Estimated bloodloss
Minimal (10%-20%)
Moderate andongoing (20%-40%)
Severe (>40%)
Need for morecrystalloid
Low High High
Need for blood Low Moderate to high Immediate
Blood preparation Type and crossmatch
Type-specific Emergency bloodrelease
Need foroperative
intervention
Possibly Likely Highly likely
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Grades of dehydrationMild < 5% Moderate 5-
10%Severe >10%
Pulse rate N
Blood pressure N N
Respiratory rate N N Rapid
Capillary return 5 seconds
Urine Output N Negligible/absent
Mucous membran Moist Dry Parched
CNS/mentalstatus
N/restless Drowsy Lethargic/comatose
5% dehydration = loss of 5 ml of fluid per 100 g body weight or 50 ml per kg
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Estimating Maintenance FluidRequirementWeight Rate
For the first 10 kg 4 ml/kg/h
For the next 10-20 kg Add 2 ml/kg/h
For each kg above 20 kg Add 1 ml/kg/h
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Ringanatau
Sedang
Beratatau
Syok
Dibagi rata
dlm 24 jam
PERUBAHAN :
-Gx Klinis
-Hematokrit
-Plasma elektrolit
-CVP
Tahap I (rehidrasi cepat) :
20-40 cc/KgBB/1-2 jam
Tahap II :
sisa defisit 6 jam sisanya 16-17 jam
Klasifikasi
Pemberian
Cairan
Defisit
+ Maintenance
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Contoh:
Pasien pria, BB 50 kg, mengalami dehidrasimoderate (dehidrasi 5%)
Jawab:
Estimated Fluid Therapy
5% dehydration= 50 x 50 = 2500 ml/ 24 h = 105
ml/hMaintenance = 40+20+ 30 = 90 ml/h
Rehydration + maintenance = 195 ml/h
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Syok Obstruktif
Disebabkan oleh obstruksi mekanis thd cardiac outputdgn penurunan perfusi sistemik
Penyebab:
a. Cardiac tamponadeb. Tension pneumothorax
c. Emboli paru masif
d. Emboli udara
Tanda: distensi vena jugularis, muffled heart sound(tamponade), suara nafas unilateral (pneumothorax)
Tx: memaksimalkan preload dan mengatasi obstruksi
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Syok obstruktif
Penyebab harus diidentifikasi dan ditanganisecepatnya:
a. Pericardiocentesis/ pericardiotomy cardiactamponade
b. Needle decompression/ tube thoracostomy
tension pneumothoraxc. Ventilatory and cardiac support
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Syok kardiogenik
Disebabkan karena kegagalan pompa
Penyebab: extensive myocardial infarction (>>),reduced contractility (cardiomyopathy, sepsisinduced) aortic stenosis, mitral stenosis, atrialmyxoma, acute valvular failure, and cardiac
dysrythmias. Tx: memaksimalkan preload dan kerja jantung,menurunkan after load.
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Syok kardiogenik
Optimize preload with infusion of fluids
Optimize contractility with inotropes
Adjust afterload to maximize CO
Diuresis indicated in patient with heartfailure
PAC guide therapy Identifiy and treat the underlying cause
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Syok distributif
Disebabkan oleh vasodilatasi sistemik krnpenyebab yg muncul (infeksi, anafilaksis)
hipoperfusi sistemik dan atau cardiac output. Syok distributif ditingkatkan oleh respon
inflamasi
Terjadi hipoksia seluler karena gangguan fungsimitokondria.
Penyebab lain: anaphylaxis, severe trauma,severe liver dysfunction, and neurogenic shock.
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Neurogenic shock trauma MS servikal disertaihilangnya tonus simpatis vaskuler.
Gejala: hipotensi, bradikardi, ekstremitas hangat
Tx: volume dan vasokonstriktor
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Syok anafilaksis Anafilaksis: reaksi alergi yg berat terhadap
rangsangan apapun, onset mendadak (
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Sepsis
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P di t i ti h k
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Pediatric septic shock
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