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Syok Hypovolemik-IH FK
Syok Hypovolemik-IH FK
Dr.Irfan Hamdani,Sp.An
Dept.Anestesiologi dan Terapi Intensif
Fak.Kedokteran UMSU
Medan
Syok
suatu kondisi dimana sistem
kardiovaskular gagal dalam
menghasilkan perfusi jaringan
yang adekuat
2
Diagnosis Syok
MAP < 60
Klinis :
terdapat gejala
dan tanda
hipoperfusi
jaringan
Gangguan
Pompa
jantung
Sistem sirkulasi
Volume
Gangguan aliran ke
Jaringan
5
PATHOPHYSIOLOGY OF
SHOCK SYNDROME
CELLULAR
OXYGEN
SUPPLY
CELLULAR
OXYGEN
DEMAND
PATHOPHYSIOLOGY OF
SHOCK SYNDROME
Cells switch from aerobic to anaerobic metabolism
lactic acid production
Cell function ceases & swells
membrane becomes more permeable
electrolytes & fluids seep in & out of cell
COMPENSATORY MECHANISMS:
COMPENSATORY MECHANISMS:
Sympathetic Nervous System (SNS)Adrenal Response
SNS
- Hormonal: Renin-angiotension
system
angiotension I
Angiotension II
potent vasoconstriction &
Releases aldosterone adrenal cortex
Sodium & water retention
9
COMPENSATORY MECHANISMS:
Sympathetic Nervous System (SNS)-Adrenal
Response
SNS
Osmoreceptors
in hypothalamus stimulated
ADH released by Posterior pituitary gland
Vasopressor effect to increase BP
Acts on renal tubules to retain water
10
COMPENSATORY MECHANISMS
Sympathetic Nervous System (SNS)
Adrenal Response
SNS
Anterior
pituitary releases
adrenocorticotropic hormone (ACTH)
Stimulates adrenal Cx to release
glucorticoids
Blood sugar increases to meet increased
metabolic needs
11
IRREVERSIBLE
DEATH IMMINENT!!
12
Stages of Shock
DEATH IS IMMINENT!!!!
13
14
15
Clinical Presentation:
Generalized Shock
Vital signs
16
Clinical Presentation:
Generalized Shock
Mental status:
restless, irritable, apprehensive
17
Shock Syndromes
Hypovolemic
Cardiogenic
Shock
Shock
Distributive
Shock
[septic;anaphylactic;neurogenic]
Hypovolemic Shock
Loss of circulating volume Empty tank
decrease tissue perfusion general shock
response
ETIOLOGY:
19
Hypovolemic Shock
External loss of fluid
Fluid
loss: Dehydration
Blood
loss:
Hypovolemic Shock:
Internal fluid loss
Loss
of Intravascular integrity
Increased
capillary membrane
permeability
Decreased
(third spacing)
21
Pathophysiology of
Hypovolemic Shock
Decreased intravascular volume leads to.
Decreased venous return (Preload, RAP) leads
to...
Decreased ventricular filling (Preload, PAWP)
leads to.
Decreased stroke volume (HR, Preload, &
Afterload) leads to ..
Decreased CO leads to...(Compensatory
mechanisms)
Inadequate tissue perfusion!!!!
22
Clinical Presentation
Hypovolemic Shock
Tachycardia
and tachypnea
Weak, thready pulses
Hypotension
Skin cool & clammy
Mental status changes
Decreased urine output: dark &
concentrated
24
Hypovolemic Shock:
Hemodynamic Changes
Correlate with volume loss
Low
CO
Decreased RAP ( Preload)
Decreased PAD, PAWP
Increased SVR (Afterload)
25
Hypovolemic Shock
Initial Management
Management goal:
Restore circulating volume, tissue perfusion,
& correct cause:
Hemorrhage
Dehydration
27
Physiologic principles
of fluid management
Perdarahan
ISF
IVF
ICF
28
PRE-LOAD
CONTRACTILITY
STROKE VOLUME
CARDIAC OUTPUT
AFTER-LOAD
HEART-RATE
SYSTEMIC
VASCULAR
RESISTANCE
BLOOD
PRESSURE
29
Oxygen Transport
30
PERDARAHAN
HILANG VOLUME
HILANG ERITROSIT
THE FLUIDS
CRYSTALLOID
HYPERTONIC FLUID
NATURAL COLLOID
ARTIFICIAL COLLOID
BLOOD, COMPONENT
32
Physiologic principles
of fluid management
TOTAL BODY WATER : 60% TOTAL BODY WEIGHT
60 kg
9L
3L
ISF
ISF
IVF
36 L
24 L
ICF
33
Physiologic principles
of fluid management
3L
D5W
EDEMA
9L
2750ml
ISF
ISF
3L
24 L
250 ml
IVF
ICF
34
Physiologic principles
of fluid management
Require large volume
Cheaper
Fewer adverse side effects
But
CRYSTALLOID
3L
RL, RA,
NaCl 0.9%
EDEMA
9L
2250ml
ISF
ISF
3L
24 L
750 ml
IVF
ICF
35
Physiologic principles
of fluid management
Albumin-5%
1L
expensive
9L
3L
24 L
1L
ISF
ISF
IVF
ICF
36
Physiologic principles
of fluid management
More rapidly correct
hypovolemia
Maintain intravascular
oncotic pressure
More expensive than
crystalloid
9L
3L
HES-6%, 200/0.5
1L
24 L
1L
ISF
ISF
IVF
ICF
37
Physiologic principles
of fluid management
Subjected to recent
intensive investigation
Resuscitate rapidly,
reduced volume of fluid
7.5%-Hypertonic Saline
+ Dextran
500 ml
9L
3L
EDEMA
24 L
625 ml
ISF
ISF
IVF
ICF
38
Class II
Class III
Class IV
Blood-Loss[ml]
->750
750-1500
1500-2000
>2000
Blood-loss [%BV]
->15%
15-30%
30-40%
>40%
Pulse-Rate [x/min.]
<100
>100
>120
>140
Blood-Pressure
Normal
Normal
Decreased
Decreased
Pulse-Pressure
N or
increased
Decreased
Decreased
Decreased
Respiratory Rate
14-20
20-30
30-35
>35
>30
20-30
5-15
Negligible
Mental status/CNS
Slightly
anxious
Midly anxious
Anxious and
confused
Confused and
lethargic
BV = 70 ml/kg
39
Oxygen Transport
40
PRE-LOAD
CONTRACTILITY
STROKE VOLUME
CARDIAC OUTPUT
AFTER-LOAD
HEART-RATE
SYSTEMIC
VASCULAR
RESISTANCE
BLOOD
PRESSURE
41
Rahardjo.E, 1990
Hasanul, 2003
evaluasi
42
FLUID REPLACEMENT
3 : 1 Rule
Class I
Crystalloid
Class II
Crystalloid
+ Colloid ?
Class III Crystalloid
+Colloid, Blood
Class IV Crystalloid
+Colloid, Blood
43
1000 ml berdarah
3000 ml kristalloid
(RL, RA, NaCl 0.9%)
44
Management
selanjutnya
Rapid response,
perdarahan <20%
Transient response,
perdarahan 20-40% BV
ongoing loss
resusitasi tdk adekwat
RL, NaCl 0.9%, Kolloid, Darah ?
Minimal, no response
Tindakan bedah segera
Transfusi darah
45