Rusdian Nurmadi, MD, Anesthesiologist

IDI Wilayah Sumut, 2016

 Confusion

Tachypnoea

Temperature

Hypotension

Tachycardia
Oliguria
Perfusion
PRE-LOAD CONTRACTILITY AFTER-LOAD

STROKE VOLUME HEART-RATE

TOTAL
CARDIAC OUTPUT PERIPHERAL
RESISTANCE

BLOOD PRESSURE Tissue

Perfusion
 Therapeutic objectives in the
treatment of hypovolaemic shock
Hypovolaemia and Shock

decreased blood volume septic shock

decreased cardiac output
decreased oxygen delivery
impaired macrocirculation

vasoconstriction
Inadequate perfusion
endotoxin
Erythrocyte aggregation
release
impaired microcirculation
bowel
tissue ischemia organ failure
kidney
 Reduction in blood volume

Sympathetic Reduction in
Pain Release of venous return
catecholamine

Increase Tachycardia Peripheral Arterial

cardial vasoconstriction hypotension
contractility

Increased Reduced tissue

myocardial perfusion
oxygen demand

Anaerobic metabolism

Myocardial
failure Acidosis

Multi organ
failure
 Arrive in Emergency department

Evaluation and Assessment

Immediate surgery

Resuscitation
• Rapid restoration of oxygen delivery ICU
• Airway and ventilatory management • Early nutritional support
• Fluid resuscitation • Approriate use of antibiotic
• Cardiac optimization • Specific organ support

Surgery
• Timely management of tissue injury
• Damage Control laparotomy
• Early fracture fixation Reoperation
• Debride necrotic tissue (hematoma, • Identify septic focus (empiric
abscess, pancreas, etc.) laparotomy)
• Vigilance in preventing missed • Drain abscesses
injuries • Debride devitalized tissue
 MANAGEMENT OF
TRAUMATIC
PATIENTS

INITIAL ICU
RESUSCITATION MANAGEMENT

OPERATIVE
INTERVENTION
RESUSCITATIVE
PHASE
 RESUSCITATIVE
PHASE
1.Ensure adequate volume resuscitation in early
stages of treatment
2.Appropriate monitoring of volume
resuscitation, including the use of base deficit
and serum lactate measurement
3.Through evaluation of patients and the
avoidance of missed injuries or delays in
diagnosis
 HEMORRHAGIC
 Trauma
 Vascular
 Gastrointestinal
 Retro peritoneal
 Obstetric dan
Gynecology
EFFECTS OF
RAPID LOSS OF 2
LITERS OF
ISOTONIC FLUID.
INTRACELLULAR

FOR EXAMPLE, INTERSTITIAL

HEMORRHAGE THAT IV
OCCURS IN 15 OR 30
MINUTES.

SHOCK
HEMORRHAGE
Physiologic
principles of
fluid
management
ISF IVF ICF
PERKIRAAN KEHILANGAN DARAH
KELAS 1 KELAS 2 KELAS 3 KELAS 4
Kehilangan darah (ml) Sampai 750 750 - 1500 1500 - 2000 > 2000

Kehilangan darah Sampai 15 15 – 30 % 30 – 40 % > 40 %

(% volume darah) %
Denyut Nadi ( x / menit ) < 100 > 100 > 120 > 140

Tekanan Darah Normal Normal Menurun Menurun

Tekanan Nadi Normal atau Menurun Menurun Menurun

Naik
Frekwensi Pernafasan 14 - 20 20 - 30 30 - 40 > 35
( x / menit )
Produksi urine (ml/jam) > 30 20 - 30 5 – 15 Tidak
berarti
CNS (Status Mental) Sedikit Agak Cemas, Bingung,
Cemas Cemas Bingung Lesu
Penggantian Cairan Kristaloid Kristaloid Kristaloid Kristaloid
(Hukum 3 : 1) dan Darah dan Darah
DASAR PEMIKIRAN
PERDARAHAN

VOLUME DARAH
&
ERITROSIT HILANG

S/D 25 % > 30 %

SYOK EXITUS
 PENANGANAN SYOK PERDARAHAN
PENDERITA DATANG
DENGAN PERDARAHAN

PASANG INFUS UKUR TEKANAN DARAH, HITUNG NADI,

JARUM BESAR, NILAI PERFUSI, PRODUKSI URIN
SAMPEL DARAH

TENTUKAN ESTIMASI JUMLAH PERDARAHAN,

MINTA DARAH
RL, RA, NaCl 0,9 %
GUYUR CEPAT
S/D 2 – 4 X LOST VOLUME

HEMODINAMIK BAIK HEMODINAMIK JELEK

TDS > 100, NADI < 100 x/menit
PERFUSI HANGAT, KERING TERUSKAN CAIRAN
URIN : 0,5 – 1 ml/KgBB/jam S/D 2 – 4 X LOST VOLUME

A
HEMODINAMIK BAIK HEMODINAMIK JELEK

B C
AInfus dilambatkan
Biasanya tidak perlu pemberian transfusi

Jika Hb < 8 gr % , atau Hct < 25 %, berikan transfusi

B Tetapi bila sedang dilakukan tindakan pembedahan untuk
menghentikan perdarahan, tunda transfusi sampai sumber
perdarahan terkuasai

Berikan segera transfusi, bila golongan darah yang sama

C tidak tersedia, berikan PRC “O”. Bila pasien sudah
mendapat PRC “O” > 4 unit, transfusi selanjutnya tetap
berikan dengan golongan “O”, kecuali sudah lewat 14 hari
DEHIDRASI
 SYMPTOMS AND DEGREE OF DEHYDRATION

CLINICAL SIGNS DEGREE FLUID

DEFICIT

I - SKIN TURGOR MILD 3 – 5 % BW

-TACHYCARDIA
-THIRSTY, DRY TONGUE
II - SKIN TURGOR MODERATE 5 – 10 % BW
- TACHYCARDIA, WEAK PULSE
- THIRSTY, WRINKLED TONGUE
III - SKIN TURGOR SEVERE > 10 % BW
- WEAK PULSE, ALMOST NOT PALPABLE
- SEVERE HYPOTENSION
- SUNKEN EYES, WRINKLED TONGUE
- CYANOTIC ACRAL
- STUPOR, COMA, SHOCK
-MARKED DEPRESSED ANTERIOR
FONTANELLA
 TERAPI CAIRAN

MAINTENANCE
50CC/KgBB/HARI
REPLACEMENT

DEHIDRASI PERDARAHAN
 TATA LAKSANA
Dehidrasi berat Rehidrasi cepat
Rehidrasi lambat
8 jam I ½ defisit
Dehidrasi sedang

16 jam II ½ defisit
Dehidrasi ringan
 Case

Penderita pria 28 tahun , ditemukan tim

SAR di lereng gunung Sinabung, dengan
riwayat tersesat di hutan dan tidak makan
dan minum 3-4 hari, dengan turgor jelek. TD
70-palpasi ,nadi 158x. KU: Sangat lemah
perfusi .Perifer pucat dingin .Basah , akral
kebiruan,dingin,basah ,frekuensi nafas 38x
/i, nafas cuping hidung, kesadaran mulai
menurun. BB:50 kg.
How to manage this patient??
 TATA LAKSANA
Defisit cairan = 10/100 x 50.000 = 5000cc
Rehidrasi cepat
20-40cc/kgBB/1/2-1jam
Evaluasi hemodinamik
BURUK BAIK
T ≥100 mmHg
ULANGI N<100X/i
20-40CC/KgBB/JAM URINE≥1/2CC/KgBB/JAM
BAIK
REHIDRASI LAMBAT
 REHIDRASI LAMBAT

8 jam I : ½ defisit
+ maintenance
16 jam II: ½ defisit
+ maintenance
 THE NEXT STEP

HOW TO GIVE

WHAT TO GIVE

HOW MUCH TO GIVE

B
L
O
O
D

CRYSTALLOID COLLOID

ASERING (RA) Albumin

RL Plasma
RS Dextran
NaCl 0.9 % Gelatin
NaCl 7 % HES
 CRYSTALLOID
ADVANTAGES

 Balanced electrolyte composition

 Buffering capacity
(lactate/acetate)
 No risk of adverse reaction
 Minimal effect on haemostasis
 Promoting diuretics
 CRYSTALLOID
DISADVANTAGES / RISK
 Poor plasma volume support
 Large volume needed
 Overhydration or oedema
formation
 Reduced plasma COP
(Colloid Oncotic Pressure)
 COLLOID
ADVANTAGES

 Good intravascular persistence

 Moderate volume required
 Plasma COP moderately altered
 Minor risk of tissue oedema
 Enhanced microvascular blood
flow
 Moderation of SIRS
 COLLOID
DISADVANTAGES / RISK

 Volume overload

 Disturbed haemostasis
 Tissue accumulation
 Adverse effects on renal
function
 Anaphylactoid reaction
Physiologic principles
of fluid management

D5W
3L

9L 3L 24 L
750 ml 250 ml 2L
ISF
ISF IVF ICF
Physiologic principles
of fluid management
RL, RA,
NaCl

3L

9L 3L 24 L
2250ml 750 ml
ISF
ISF IVF ICF
Physiologic principles
of fluid management
PPF-5%
(Alb-5%)
1L

9L 3L 24 L
1L
ISF
ISF IVF ICF
Physiologic principles
of fluid management

HES-6%
1L

9L 3L 24 L
1L
ISF
ISF IVF ICF
Physiologic principles
of fluid management

Haemacel
1L

9L 3L 24 L
300ml 700ml
ISF
ISF IVF ICF
 A SIMPLE METHOD FOR DETERMINING
FLUID THERAPY

1. Estimate normal blood volume (BV)

2. Estimate % loss of blood volume
3. Calculate volume deficit (VD)
VD = BV x % Loss

4. Determine resuscitation volume (RV)

Whole Blood RV = VD
Colloid RV = 1,5 x VD
Crystalloid RV = 4 x VD
 EVALUASI TERAPI CAIRAN
DAN
PERFUSI ORGAN

A. UMUM
B.PRODUKSI URINE
C. KESEIMBANGAN
ASAM - BASA
 RESPON TERHADAP TERAPI CAIRAN AWAL
RESPON RESPON TANPA
CEPAT SEMENTARA RESPON
Tanda Vital Kembali ke Perbaikan sementara, Tetap
Normal Tensi dan Nadi Abnormal
kembali Turun
Dugaan Minimal Sedang, masih ada Berat
Kehilangan Darah (10 – 20%) (20 – 40 % ) ( > 40 % )
Kebutuhan Sedikit Banyak Banyak
Kristaloid
Kebutuhan Darah Sedikit Sedang - Banyak Segera

Persiapan Darah Type Specific dan Type Specific Emergency

Cross match
Operasi Mungkin Sangat Mungkin Hampir Pasti

Kehadiran Dini Ahli Perlu Perlu Perlu

Bedah
 KOMPLIKASI TERAPI
CAIRAN
 Pulmonary Edema

 Myocardium Edema
 Mesenteric Effects
 Integumentary
 Central Nervous System
Effects
 GOAL THE RESUSCITATIVE PHASE

 Restoration of an effective blood

volume

 Optimization of tissue perfusion

 Prevention of an ischemia-reperfusion
injury
 Ventilation Volume replacement Pharmacotherapy

VO2 baseline
DO2 oxygen consumption
MAP

CI oxygen delivery
COP cardiac index
BV colloid osmotic pressure
infusion blood volume

organ failure
survival critical
 SUCCESSFUL FLUID
THERAPY
Cardiac index CI
Oxygen delivery DO2
Oxygen consumption VO2

Vascular resistance…
pulmonary PVR
systemic SVR
MONITORING YANG
DIPERLUKAN
SEBAGAI PEDOMAN
DALAM
TERAPI CAIRAN
 ECG monitoring

 Pulse oxymetri
 Arterial catheter
 Pulmonary artery catheter
 Central venous catheter
 Urinary catheter
 CVP = 15 mm Hg
 BP – Systole ≥ 110 mmHg,
 MAP ≥ 65 mmHg
 Wedge pressure = 10 - 12 mmHg
 Cardiac index > 3 L/min/m2
 Oxygen uptake (Vo2) > 100mL/min/m2
 Blood lactate , < 2,5 mmol/L
 Base deficit -3 - + 3 mmol/L
 Urine 0,5 - 1 ml/kgBB/jam
 Konklusi
 Pengetahuan fisiologi dari kesimbangan
cairan dan elektrolit mutlak diperlukan

 Riwayat penyakit, pemeriksaan klinis dan

laboratorium sangat dibutuhkan dalam
menentukan strategi terapi resusitasi cairan

 Pemilihan cairan ditentukan berdasarkan

keadaan klinis pasien

 Diperlukan monitoring yang tepat dalam

THANKS FOR YOUR
ATTENTION………
MAULIATE
GODANG…