1 1

Gangguan
Sirkulasi
Bagian Anestesiologi dan Reanimasi
FK Unsyiah RSUZA
Banda Aceh
2
Circulation
Circulation

Evaluation :
Evaluation :
Acral temperature (peripheral perfusion)
Acral temperature (peripheral perfusion)

warm and dry

warm and dry
Acral color
Acral color

pink
pink
Capillary refill
Capillary refill

2 seconds, compare to
2 seconds, compare to
examiners palm
examiners palm
Arterial pulsation
Arterial pulsation
!lood pressure
!lood pressure
"rine production
"rine production
3
Definition :
Definition :
Acute Circulatory Failure
Acute Circulatory Failure

Lo cardiac out!ut
Lo cardiac out!ut

Reduced organ "lood flo

Reduced organ "lood flo

#nade$uate tissue
#nade$uate tissue
!erfusion
!erfusion
4
#$%C& #'()*%+E
#$%C& #'()*%+E
Shock
Shock
is a condition in which the cardiovascular
is a condition in which the cardiovascular
system fails to perfuse tissues adequately
system fails to perfuse tissues adequately
An impaired cardiac pump, circulatory system,
An impaired cardiac pump, circulatory system,
and/or volume can lead to compromised blood
and/or volume can lead to compromised blood
flow to tissues
flow to tissues
Inadequate tissue perfusion can result in:
Inadequate tissue perfusion can result in:

generalized cellular hypoia !starvation"

generalized cellular hypoia !starvation"

widespread impairment of cellular metabolism

widespread impairment of cellular metabolism

tissue damage
tissue damage
organ failure
organ failure

death
death
5


Shock #ategories
Shock #ategories
Cardiogenic
Cardiogenic
%y!o&olemic
%y!o&olemic
Distri"uti&e
Distri"uti&e
'"structi&e
'"structi&e
$
6
#hock
#hock
Pathophysiology
Pathophysiology
*eduction in ,lood volume -./
*eduction in ,lood volume -./
deterioration in cardiac function
deterioration in cardiac function
$ypoperfusion leads to 0lo,al
$ypoperfusion leads to 0lo,al
deran0ement of ,ody function
deran0ement of ,ody function
!reakdown of cellular meta,olism 1
!reakdown of cellular meta,olism 1
microcirculatory homeostasis
microcirculatory homeostasis
Cardiovascular collapse
Cardiovascular collapse
7
S%I&'(ASI )*'+,*)-,.+I)
S%I&'(ASI )*'+,*)-,.+I)
/01,%*)SI,)
/01,%*)SI,)
2(,,- 3(,4 2(,,- 3(,4
1+,%*#%*- 1+,%*#%*-
/eart /eart
2rain 2rain
Adrenal/pituitary gland Adrenal/pituitary gland
2(,,- 3(,4 2(,,- 3(,4
-*#+*AS*- -*#+*AS*-
Skin Skin
&uscle &uscle
Splanchnic circulation Splanchnic circulation
+*S1,) /*&,-i)A&i.
+*S1,) /*&,-i)A&i.
REDISTRIBUSI ALIRAN DARAH REDISTRIBUSI ALIRAN DARAH
8
&*%A2,(I# +*S1,)S
&*%A2,(I# +*S1,)S
-ecreased -ecreased
blood volume blood volume
-ecreased #, -ecreased #,
#ellular hypoperfusion and #ellular hypoperfusion and
hypoia hypoia
Anaerobic glycolysis Anaerobic glycolysis
1yruvate converted to lactic acid 1yruvate converted to lactic acid
&*%A2,(I# A#I-,SIS
&*%A2,(I# A#I-,SIS
9

.idney .idney
Oliguric renal failure Oliguric renal failure
High output renal failure High output renal failure

(iver (iver
Lier failure Lier failure

5I tract 5I tract
!ailure of intestinal "arrier #sepsis$ !ailure of intestinal "arrier #sepsis$
"lee%ing& "lee%ing&

(ung (ung
'apillary lea( associate% )ith or cause% 'apillary lea( associate% )ith or cause%
"y sepsis an% infection "y sepsis an% infection
*3*. S/,#. 1A-A %I)5.A%A)
*3*. S/,#. 1A-A %I)5.A%A)
,+5A)
,+5A)
10
11
12
13
14
15
Clinical
Clinical
si0ns of
si0ns of
shock
shock
*apid ,reathin0
*apid ,reathin0
Cold, clammy and pale to cyanotic
Cold, clammy and pale to cyanotic
skin
skin
Capillary refill time 2 2 seconds
Capillary refill time 2 2 seconds
16
*apid pulse 2 133
*apid pulse 2 133
!4 5 63/133 mm$0
!4 5 63/133 mm$0
Consciousness
Consciousness
a00itated to
a00itated to

coma
coma
4ulse pressure narrows
4ulse pressure narrows
784 low (external 9u0ularis vein)
784 low (external 9u0ularis vein)
"rine production
"rine production
<
<
3:; ml.k0.hour
3:; ml.k0.hour
Clinical
Clinical
si0ns of
si0ns of
shock
shock
17
!leedin0 and si0ns
!leedin0 and si0ns
(adult patient)
(adult patient)
!leedin0
!leedin0
5 <;3 ml <;3/1;33ml
5 <;3 ml <;3/1;33ml
2
2
1;33ml
1;33ml
Cap: refill
Cap: refill
normal
normal
prolon0ed
prolon0ed
prolon0ed
prolon0ed
4ulse rate
4ulse rate
5 133
5 133
2 133
2 133
2
2
123
123
#ystolic !4
#ystolic !4
normal
normal
normal
normal
decrease
decrease
!reathin0
!reathin0
normal
normal
23/=3
23/=3
2 =3/
2 =3/
>3
>3
Consciousness
Consciousness
normal
normal
a0itated
a0itated
a0itated
a0itated
.coma
.coma
18
Cardiac Output
Venous Return
Perfusion
A V
Hypovolemic Shock =
problem of circulati! volume "eficiecy
VR
CO
bleeding
4800 = 60 # 80ml
4800 = 120 # 40ml
$% = fre& # Stroke 'olume
'(
$%
19
+ana0ement of severe ,leedin0
+ana0ement of severe ,leedin0
Airway
Airway
(- C/spine control)
(- C/spine control)
!reathin0
!reathin0
(-%xy0en if availa,le)
(-%xy0en if availa,le)
Circulation
Circulation


and
and


hemorrha0e
hemorrha0e
control
control
#hock position
#hock position
*eplace ,lood loss
*eplace ,lood loss
Arrest . minimi?e the ,leedin0 process
Arrest . minimi?e the ,leedin0 process
20


@herapeutic Aoals in #hock
@herapeutic Aoals in #hock
Bncrease %
Bncrease %
2 2
delivery
delivery
%ptimi?e %
%ptimi?e %
2 2
content of ,lood
content of ,lood
Bmprove cardiac output and
Bmprove cardiac output and
,lood pressure
,lood pressure
+atch systemic %
+atch systemic %
2 2
needs with %
needs with %
2 2
delivery
delivery
*everse.prevent or0an hypoperfusion
*everse.prevent or0an hypoperfusion
21
'ar%iac Output * S+R
1ipe , +ascular
1ump 6
Heart
7olume ,
Bloo%
Hypoole-ic
Shoc(
'ar%iogenic
Shoc(
Distri"utie
Shoc(
Inotropes
#Do"$Dop$A%r$A-r&
+asopressor # NE$PE$A%r$Dop&
!lui%s
O"structie
Shoc(
Release
ta-pona%e$etc
Bloo% Pressure
22
%+*A%&*)% #,)#*1% ,3 S/,#.
%+*A%&*)% #,)#*1% ,3 S/,#.
*)/A)#I)5 1*+3'SI,) / ,805*) -*(I7*+0 *)/A)#I)5 1*+3'SI,) / ,805*) -*(I7*+0
,ygen delivery/-, ,ygen delivery/-,
9 9
6 6 /+ 8 S7 /+ 8 S7 8 8 /b 8 S: /b 8 S:
9 9
8 ;<=> ? /b 8 8 ;<=> ? /b 8
pa, pa,
9 9
#ardiac #ardiac
output output
Arterial Arterial
, ,
9 9

content content
3luids 3luids
%ransfus %ransfus
e e
1artially 1artially
dependent dependent
on 3I, on 3I,
9 9
and and
pulmonary pulmonary
status status
Inotropes Inotropes
-,
9
6 #, #a,
9
23
#hock position
#hock position
Raise
both legs
300 ) 500 ml of bloo"
i the le!* +ill be *hifte"
to+ar" cetral circulatio
rai*e
,hi* i* the &uicke*t help
+hich ca be provi"e"
every+here
24
!leedin0 patient
!leedin0 patient
estimate ,lood loss estimate ,lood loss
C
C
shock position
shock position
insert 2 lar0e ,ore iv catheter
insert 2 lar0e ,ore iv catheter

o,tain ,lood sample for cross matchin0 o,tain ,lood sample for cross matchin0
C
C
infuse *D 1333
infuse *D 1333
(- 1333 prn)
(- 1333 prn)
Warm, pink, dry perfusion
pulse !""
#P$syst % !""
&
Slo'er infusion
#ad perfusion
pulse %!"", #P$syst !""
&
Add more R(
up to 2) 4 # e*t- bloo" lo**
25
Docation 1 Estimation of ,lood loss
Docation 1 Estimation of ,lood loss
Closed Eemur fracture
Closed Eemur fracture


1:;/2
1:;/2
litre
litre
Closed @i,ia fracture
Closed @i,ia fracture
3:;
3:;
litre
litre
4elvic fracture
4elvic fracture


=
=
litre
litre
$emothorax
$emothorax
2 litre
2 litre
*i, fracture (each)
*i, fracture (each)
1;3 ml
1;3 ml
Found, fist si?e
Found, fist si?e
;33 ml
;33 ml
!lood clot, fist si?e
!lood clot, fist si?e
;33 ml
;33 ml
26
Concealed hemorrha0e
Concealed hemorrha0e

Bntra/a,dominal
Bntra/a,dominal (liver, (liver,
spleen, arteries) spleen, arteries)
4leural cavities
4leural cavities
4elvis
4elvis
Don0 ,ones
Don0 ,ones (esp: femur) (esp: femur)
#calp
#calp (children) (children)
27
Bnternal ,leedin0 (example: liver rupture)
1: #urvival depends on Guick infusion and prompt sur0ery
2: Bf ,leedin0 remains uncontrolla,le, do sta0ed operation
()ama0e Control #ur0ery)
28
Bnsert lar0e ,ore needle in lar0e veins
Bnsert lar0e ,ore needle in lar0e veins
1: 8ena cu,iti, ,asilica
2: 8ena 9u0ularis ext

.3- 'ea *ubclavia/
.4- 'ea *aphea ma!a/
0
29
intra/osseus infusion at ti,ia
intra/osseus infusion at ti,ia
(only for (aCl, *in0ers Dactate, *in0ers Acetate)
(only for (aCl, *in0ers Dactate, *in0ers Acetate)
1o2t i3ect
So"ium bicarboate
30
2(,,- %+A)S3'SI,)
2(,,- %+A)S3'SI,)
considered when
considered when

$emodynamic remains unsta,le

$emodynamic remains unsta,le
despite HadeGuateI fluid replacement
despite HadeGuateI fluid replacement

$emo0lo,in 5 < 0.dl

$emo0lo,in 5 < 0.dl
and patient still losin0
and patient still losin0
,lood
,lood
31
3luid infusion
3luid infusion

Colloids or crystalloidsJ
Colloids or crystalloidsJ
Consider hypotensive resuscitation
Consider hypotensive resuscitation
if ,leedin0 is not under control or
if ,leedin0 is not under control or
sur0ery needs lon0er time to
sur0ery needs lon0er time to
proceed,
proceed,
K3/63 mm$0 systolic
K3/63 mm$0 systolic
seems reasona,le
seems reasona,le
L)
L)

*) do not over resuscitate to normal values
32
3luid infusion
3luid infusion

Farm all infusion fluid (=KC) since hypothermia 5 Farm all infusion fluid (=KC) since hypothermia 5
=;C results in coa0ulation a,normalities =;C results in coa0ulation a,normalities
Bn case infusion B# (%@ availa,le, consider oral fluid Bn case infusion B# (%@ availa,le, consider oral fluid
replacement if patient is conscious or naso0astric replacement if patient is conscious or naso0astric
fluid therapy: fluid therapy:

Dow concentration of 0lucose . salt Dow concentration of 0lucose . salt

)iluted cereal porrid0e )iluted cereal porrid0e

33
SH%$4
.hypovolemic5 car"io!eic/
6
metabolic aci"o*i*
6
"o ot !ive
7a)bicarboate
Consider )a$bicarbonate only if
$ p* +,!" -increase to +,!.$+,/"0
$ #1 % $!" -reduce to $.0
%l" formula for 8icarb
193 # 8: # 8;
i* ite"e" for
<cute (eal =ailure
7%, for *hock pt*
34
J
J
<y >ue*tio?
35