Академический Документы
Профессиональный Документы
Культура Документы
HIPOTENSI SYOK
Dr Wahyu Widjanarko SpJP FIHA
KASUS I
Apa terapinya?
a.
Fluid administration
b.
Inotropik
c.
Vasopressor
Kasus 2
Wanita 65 th datang datang dengan keluhan
sesak nafas, panas 3 hari yl. Fisik : KU lemah, TD :
80/50 mmHg, N : 130x/mnt, RR : 40x/mnt, t :
38,3C, Jantung : gallop +, Paru : ronchi +,
wheezing + kedua lap paru. Acral dingin. EKG :
SVT, R : cardiomegali, kongesti paru. Apa
diagnosanya?
a. Syok sepsis
b. Syok kardiogenik
c. Syok hipovolemik
Volume problem
Administer
Fluids
Blood transfusions
Cause-specific interventions
Consider vasopressors
Pump problem
Bradycardia
(see algorithm)
Rate problem
Tachycardia
(see algorithm)
Blood
pressure?
Next slide
Systolic BP
BP defines 2nd
line of action
(see below)
Systolic BP
<70 mmHg
Signs/symptoms
of shock
Norepinephrine
0.5 30 g/min IV
Systolic BP
70-100 mmHg
Signs/symptoms
of shock
Dopamine
5 15 g/kg per
minute IV
Systolic BP
70-100 mmHg
No Signs/symptoms
of shock
Dobutamine
2 20 g/kg per
minute IV
Systolic BP
>100 mmHg
Nitroglycerin
10 20 g/min IV
consider
Nitroprusside 0.1
5.0 g/kg per min IV
Acute decompensated HF or
Decompensation of chronic HF :
Symptoms and sign of AHF +, mild, not fulfil for
cardiogenic shock, pulmonary oedema or HT crisis.
II. Hypertensive AHF: symptoms and sign of HF
+ BP and preserved LV function with chest X-ray
pulmonary congestion.
III. Pulmonary oedem : Severe respiratory
distress, orthopnea and rales over the lungs, O2
saturation < 90% and verified by chest X-ray
Class II
Class III : Severe HF. Pulmonary oedema with rales in all lung
fields
Class IV : Cardiogenic shock. Sign BP ( 90 mmHg ), peripheral
vasoconstriction, oligouri, cyanosis and diaphoresis.
Clinical classification
P
e
r
f
u
s
i
o
n
Congestion : lungs
C
I
2
,
2
T
i
s
s
u
e
P
e
r
f
u
s
i
o
n
Diuretics
Vasodilators
normal
Pulmonary oedema
Fluid administration
N BP : Vasodilators
BP : Inotropics or vasopressor
Hypovolemic
Pulmonary congestion
PCWP18 mmHg
Cardiogenic shock
Normal
Consider other diagnosis
Normal
Abnormal
HEART FAILURE
Characterise type & severity
Laboratory test
Always
Routine haematology
Creatinine/Urea
Elektrolyte
Blood glucose
Troponin/ CKMB
Arterial blood gases
CRP D-dimer
Consider
Transaminases
Urinalysis
BNP or NT-proBNP
INR ( if anticoagulated or HF)
Outcome
Length of stay in the ICU
Duration of hospitalisation
Time to hosp. rea-dmission
Mortality
Tolerability
Low rate of withdrawal from Tx
Low incidence of adverse eff.
Laboratory
Haemodynamic
BUN and/or creatinine PCWP < 18 mmHg
S-bilirubin
CO or SV
Plasma BNP
Electrolyte and glucose N
Acute H
F
Definitive
diagnostic
Immediate
resuscitation
Diagnosis
algorithm
Pts distress or in
pain
Definitive
treatment
Y
N
N
N
FiO2,CPAP,
NIPPV
Y
N
Normal HR &
rhythm
If moribund
BLS,ALS
Analgesia or
sedasi
Pacing,
antiarrhytmi
Y
Y
Mean BP > 70
mmHg
Adequate preload
N
N
Vasodilators,
diuresis if volume
overload
Fluid challenge
Y
Adequate CO:
reversal of
metabolic acidosis,
SvO2 > 65%,
clinical sign of
adequate organ
perfusion
Inotropes or
further afterload
reduction
Reassess
frequently
B. Vasodilators systemic BP
Vasodilator
Indication
dosing
SE
AHF, BP adequate
Nitropruside HT crisis
1 10 mg/h
idem
0,3 5 g/kg/m
idem
C. Inotropic agents
Agents
Bolus
Infusion rate
Dobutamine
no 2 20 /kg/min ( )
Dopamine
no < 3 g/kg/min, renal effect ( )
3 5 g/kg/min, inotropic ( )
> 5 g/kg/min(), vasopressor (
Norepinephrine no
0,2 1,0 g/kg/min
Epinephrine
1 mg i.v at
resuscitati
on repeat
0,05 0,5 g/kg/min
ed 3-5 min
MATUR SUWUN