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Kuliah 8. Anestesi - Syok Dan Tata Laksananya
Kuliah 8. Anestesi - Syok Dan Tata Laksananya
Kuliah 8. Anestesi - Syok Dan Tata Laksananya
2
NUMBER OF PATIENTS = 43
10 14 20 13 6
100
% MORTALITY RATE
80
60
40
20
140 SURVIVED
120 +
+ + +
100
80
60
+
40
20
100
Percent
survival
80
60
40
20
0
0 30 60 90
Minutes
From: Stene JK, Grande CM, Gieseke A, 1991 5
UNSUR2 PEMBEDA PADA SHOCK UNSUR YANG
SAMA PADA
SYOK
SYOK SYOK SYOK SYOK - COMMON
HIPOVOLEMIA KARDIOGENIK ANAFILACTIC SEPTIK TERMINAL
- PERDARAHAN PATH WAY
- KEHILANGAN
CAIRAN
6
Bagan 6
PERTOLONGAN PADA SYOK PENDEKATAN TERPADU
BERORIENTASI FUNGSI / SISTIM
PARU
JAN
O2 TUNG
AIRWAY CIRCULATION
(A) BREATHING (C)
(B) BRAIN
2. TAHAP KEDUA
TETAPKAN DIAGNOSA DAN TERAPI DEFENITIF
7
Bagan 9
PARADIGMA : PADA SYOK KARENA PERDARAHAN PERFUSI
DAN OKSIGENASI JARINGAN DAPAT DIPERBAIKI
DENGAN TERAPI CAIRAN (HEMODILUSI) UNTUK
MENGEMBALIKAN VOLUME DARAH DAN
MENINGKATKAN CARDIAC OUTPUT (1964)
8
LANDASAN PEMIKIRAN HEMODILUSI ATAU TERAPI CAIRAN
9
PENGGUNAAN = CARDIAC X ISI O2 ISI O2
OKSIGEN OUTPUT DARAH DARAH
ARTERI VENA
PARU
JAN
O2 TUNG
AIRWAY CIRCULATION
(A) BREATHING (C)
(B) BRAIN
2. TAHAP KEDUA
TETAPKAN DIAGNOSA DAN TERAPI DEFENITIF
11
Bagan 9
MODEL PENDEKATAN TERPADU
BERORIENTASI SISTIM / FUNGSI
PENYEBAB
PERDARAHAN
POST PARTUM GANGGUAN
SISTIM / FUNGSI OBGIN
PECAHNYA
VARICESS EVOPHAGUS SYOK PERTAMA KEDUA PENY.
KARENA LIFE SUPPORT DIAGNOSA DALAM
FRAKTUR FEMUR PERDA - DAN
TERBUKA RAHAN PENGGANTIAN TERAPI BEDAH
VOLUME DEFENITIV
ORIENTASI FUNGSI /
SISTIM
12
Bagan 10
IMMEDIATE : CNS injury or heart
and great vessel injury
50
EARLY : Major hemorrhage
40
LATE : Infection and
30 multiorgan failure
20
10
0
0 1 2 3 4hr 1,2 5,6 weeks
Bagan 12
PRIMARY CARA
PREVENTION TERBAIK
HILANGKAN RESIKO
PENDEKATAN
KOMPREHENSIV SECONDARY CARA KEDUA
PADA SHOCK PREVENTION TERBAIK
DIAGNOSA &
TERAPI DINI
TERTIARY CARA
PREVENTION TERAKHIR
LIMIT THE DAMAGE
14
Bagan 13
Hershey / Lillehei (1964)
15
16
RECOGNITION OF SHOCK STATE
Tachycardia
Vasoconstriction
Cardiac Out Put
Narrow Pulse Pressure
MAP
Blood Flow
17
18
PITFALL IN SHOCK RECOGNITION
Extremes of age
Athletes
Pregnancy
Medications
Hematocrit / hemoglobin concentration
19
HCT : 45% HCT : 27% HCT : 45%
4 Plasma
HCT : 45%
Liters 3
2
Cells
Resuscitation
20
IVF ISF ICF
Perdarahan
ICF
IVF ISF
21
ECF SHIFT
Perdarahan
Squesterasi
22
MILD HEMORRHAGE
(<15% BV)
Stage I : vasoconstriction
Stage II
II a : Transcapillary refill ISF IVF
II b : Activation Reninangiotensin aldosteron
Sodium + water retension
23
CELLULAR / METABOLIC RESPONSE
Blood Loss
Inadequate
Perfusion
Cell injury
Further volume
alteration
Membrane changes
Fluid disturbance
change
Anaerobic
metabolism
Further circulation Organ Lactic
changes dysfunction acid
24
HEMORRHAGIC SHOCK
Most common
Loss of circulating blood volume
Normal blood volume:
Adult : 6-7% of ideal weight
Child : 8-9% of ideal weight
25
ASSESSMENT & MANAGEMENT
Circulation
Assess (Class I, II, III, IV)
Control Haemorrhage
Prompt Treatment
26
ASSESSMENT & MANAGEMENT
27
CLASSIFICATION OF HEMORRHAGE
Class I IV
Not absolute
Only a clinical guide
Subsequent treatment determined by patient
response
28
Table 1. ESTIMATED FLUID AND BLOOD LOSSES *)
Based on Patients Initial Presentation
(For a 70 kg man)
CLASS I CLASS II CLASS III CLASS IV
Blood Loss (mL) Up to 750 750 1500 1500 2000 > 2000
Blood Loss
Up to 15% 15 30 % 30 40 % > 40 %
(% Blood Vol)
Pulse Rate < 100 > 100 > 120 > 140
Anxious, Confiused,
CNS / Mental Status Slightly anxious Mildly anxious
confused lethargic
Intraosseous
Obtain blood for crossmatch
30
Short Catheter
200
100
Diameter 14 ga 16 ga 16 ga 16 ga
Length 2 in 2 in 5,5 in 12 in
31
32
MANAGEMENT FLUID THERAPY
33
THERAPEUTIC DECISIONS
34
Table 2. RESPONSES TO INITIAL FLUID RESUSCITATION *)
Rapid Transient No
Response Response Response
Transient improve-
Vital Signs Return to normal ment; recurrence of Remain abnormal
BP and HR
Emergency blood
Blood Preparation Type and crossmatch Type specific
release
Need for Operative
Possibly Likely Highly likely
Intervension
Early Presence of
Yes Yes Yes
Surgeon
Warmed fluids
Crossmatch, PRBC
Type-specific
Type O, Rh-negative
Autotransfusion
Coagulopathy
36
Catheter Dimension
16 gauge diameter
100 2 inches in length
Flow rate
(mL/min)
50
37
REEVALUATE ORGAN PERFUSION
MONITOR :
Vital signs
CNS Status
Skin perfusion
Urinary output
Pulse oximetry
End Tidal CO2
Oxygen Extraction
Acid base
38
RESUSCITATION / EVALUATION
Urinary output :
Adults : 0,5 ml/kg/hour
Child : 1 ml/kg/hour
Infant : 2 ml/kg/hour
Inadequate output suggests inadequate
resuscitation
39
30
20
ET CO2
(mmHg)
10
1 2 3 4 5
Volume Infused (Liters)
40
SaO2 SvO2 SaO2 SvO2
41
AVOIDING COMPLICATION
Fluid overload
Invasive monitoring (ICU)
CVP
Pulmonary artery catheter
Other problems :
Resuscitation induced haemorrhage
Post resuscitation injury
No Reflow phenomenon
Reperfusion injury
42
CVP CATHETER
43
CVP MONITORING
44
45
46
47
FLUID CHALLENGE TEST
( Rule 2 5 )
CVP
Kenaikan C V P
Treatment
Stop the cause / bleeding
Restore volume and perfusion
50
5% 15 % 40 %
Na Na K
D5% Koloid
RL / NS
51
IVF ISF ICF
Non
Perdarahan
IVF
ICF
ISF
IVF ICF
ISF 52
ASSESSMENT & MANAGEMENT
Recognize shock
Stop the bleeding !
Resplenish intravascular volume
Restore organ perfussion
53
THERAPEUTIC DECISIONS
Rapid Response
54
THERAPEUTIC DECISIONS
Transient Response
55
THERAPEUTIC DECISIONS
Minimal to No Response
56
57
58
59
60
61
62
63