SHOCK

Hasanul Arifin
Bagian Anestesiologi dan Reanimasi
Fakultas Kedokteran USU
Medan

Hasanul, 2003
22/03/2018 1
 SHOCK
HYPOVEMIA
Hasanul Arifin

Departemen/SMF Anestesiologi dan Reanimasi

Fakultas Kedokteran USU
Medan
Hasanul, 2003
22/03/2018 2
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 Shock adalah kondisi saat mana transport
oksigen (DO2, delivery O2) ke jaringan gagal
memenuhi kebutuhan metabolik di jaringan
tersebut.

DO2 < VO2

IT IS NOT LOW BLOOD PRESSURE !!!
IT IS HYPOPERFUSION…..
22/03/2018 4
 Shock Hypovolemia
Shock yang terjadi ok. kurangnya volume
intravaskular oleh sebab apapun,
sehingga mekanisme hemodinamik gagal
menghasilkan DO2 untuk memenuhi VO2

22/03/2018 5
Classification of shock states
Type of shock Primary mechanism Clinical causes
Hy pov olemic Volume loss Ex ogenous
Blood loss due to hemorrhage
Plasma loss due to burn, inflammation
Fluid and electroly te loss due to v omiting, diarrhea,
dehy dration, osmolal diuresis [diabetes]

Endogenous
Ex trav asation due to inflammation, trauma, anaphy lax is,
snake v enom, pheochromocy toma

Cardiogenic Pump failure My ocardial infarction

Heart failure
Arrhy thmia
Intracardiac obstruction

Distributiv e [v asomotor
dy sfunction]
. High or normal Ex panded v enous capacitance Hy pody namic septic shock due to gram-negativ e enteric bacillary
resistance [pooling], CO normal or low Spinal shock, Narcotic ov er dose, barbiturate intox ication

. Low resistance Arteriov enous shunting
CO normal or high
Obstructiv e Ex tracardiac obstruction of
main channel of blood flow
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Pneumonia, peritonitis, abscess, reactiv e hy peremia
Vena cav al obstruction, pericarditis [cardiac tamponade]
pulmonary embolism, aorta dissecting aneury sm
Weil, MH et al : Cardiovascular System failure. In Principles and practice of
emergency medicine. Schwartz. GR [ed] WB. Saunders 1986 6
 Approach to various etiologic types of shock
Hemorrhagic Cardiogenic Traumatic Septic

Sign & Symptoms Sign & Symptoms Sign & Symptoms Sign & Symptoms
Pallor, fainting Pallor, fainting History & Physical Fever, chills
Skin clammy, cold Skin clammy, cold evidence of injury Skin warm
Tachycardia Arrhythmias Oliguria Tachycardia
Oliguria Oliguria Tachycardia Oliguria
Collapse Collapse Collapse Altered mental status
Collapse
Laboratory Laboratory Laboratory Laboratory
Hct, Hb Cardiac enzymes X-Rays, CT-scan [+] smears & culture
ECG
Pathophysiology Pathophysiology Pathophysiology Pathophysiology
Blood volume Cardiac output Direct injury to organ Peripheral resistance

Therapy Therapy Therapy Therapy

1. Fluids 1. Antiarrhythmic 1. Repair injury 1. Antibiotics
2. Blood 2. Vasopressors 2. Fluids 2. Fluids
3. Control Bleeding 3. Vasodilators 3. Blood 3. Drain abscess
Shoemaker, Textbook of Critical Care, third ed. 1995
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 CARDIOGENIC

OBSTRUCTIVE

O2
O2 SEPTIC

O2
HYPOVOLEMIK

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Pathophysiology of Shock Hypovolemi

Volume loss
Autonomic tone
Catecholamine release
Fluid shifts from
extracellular to
intravascular

Partial restoration
survival  Venous capacitance of intravascular
volume
 Heart rate

Intervention / stabilization

Maintenance of perfusion

Blood flow shunted to

vital organs
(heart,lung,brain)
Continued volume loss
Cellular hypoxia / anaerobic
metabolism

Survival / delayed morbidity / mortality

ATP production / lactic acidosis

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Intervention / stabilization
PATHOPHYSIO, CONT’N Cellular hypoxia /
anaerobic metabolism

Survival / delayed
morbidity / mortality
ATP production / lactic acidosis

Intervention / stabilization
Cellular function
impaired

Continued volume loss

Membrane porosity

Lysozymal leakage
Movement of fluid
from intravascular Cellular autodigestion
to interstitial
Irreversible spaces

shock
intervention
No. intervention
DEATH
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Physiologic principles
of fluid management

TOTAL BODY WATER : 60% TOTAL BODY WEIGHT

60 kg 36 L

9L 3L 24 L

ISF
ISF IVF ICF

22/03/2018 Hasanul, 2002 11

Jenis cairan yang beredar :
• Kristalloid ( D5W, RL, RA, NaCl )
• Kolloid ( Albumin, HES,
Expafusin, Gelatine)
• Cairan Nutrisi ( Intrafusin, Ivelip,
Triofusin)

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Physiologic principles
of fluid management

D5W
3L

9L 3L 24 L
750 ml 250 ml 2L
ISF
ISF IVF ICF
22/03/2018 Hasanul, 2002 13
Physiologic principles
of fluid management

RL,NaCl

3L

9L 3L 24 L
2250ml 750 ml
ISF
ISF IVF ICF
22/03/2018 Hasanul, 2002 14
Physiologic principles
of fluid management

Albumin-
5%
1L

9L 3L 24 L
1L
ISF
ISF IVF ICF
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Hasanul, 2002
Physiologic principles
of fluid management

HES-6%
1L

9L 3L 24 L
1000ml
ISF
ISF IVF ICF
22/03/2018 Hasanul, 2002 16
Physiologic principles
of fluid management

Albumin-
25%
Volume expander 100 cc

9L 3L 24 L
400 500
ISF
ISF IVF ICF
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Hasanul, 2002
Physiologic principles
of fluid management

Haemacel
1L

9L 3L 24 L
300ml 700ml
ISF
ISF IVF ICF
22/03/2018 Hasanul, 2002 18
Physiologic principles
of fluid management

Perdarahan

ISF IVF ICF

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 EFEK SHOCK PADA TINGKATAN
SEL
CELL MEMBRANE FAILURE:
• DIRECT
Endotoxin
Complement
• INDIRECT
Failure to maintain normal Na+, K+ or Ca2+ gradient
Decreased oxidative phosphorylation

OSMOTIC
GRADIENT

Na+ entry Water CELLULAR IMPAIRED

into cell entry into EDEMA INTRACELLULA
cell R METABOLISM
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 The Trimodal Distribution of
Traumatic Disease
50
Percent of trauma deaths

40

30

20

10

0 //
0 1 2 3 4.hrs 1-2 5-6 weeks
Time after injury
IMMEDIATE : CNS injury or Heart and great vessel injury
EARLY : Major hemorrhage
LATE : Infection and Multi Organ failure
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Hasanul, 2002
 Shock pada
Trauma

Pneumothorax
Perdarahan Myocardial
Contussion
Hematothorax Spinal Shock
Cardiac Tamponade

22/03/2018 Hasanul, 2002 22

 The Golden Hour
is the time in which resuscitation of severely
injured patients must begin to achieve
maximal survive
R. Adams Cowley, MD

The lethal factor in shock is inadequate cellular oxygen

delivery, leads to irreversible anoxic cellullar injury that
kills a critical mass of cells

22/03/2018 Hasanul, 2002 23

 THE GOLDEN HOUR
Probability of Survival R. Adams Cowley, MD

100

80
% survival
60

40

20

0 minutes
30 60 90
Survival is related to severity and duration

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 Oxygen
Transport

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 DO2I = DO2/BSA = ml/min/m2

VO2I = oxygen uptake index

22/03/2018 = oxygen consumption index = >100 mlO2/min/m229
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 OXYGEN TRANSPORT
 CaO2 = SaO2 x Hb x 1.34 + PaO2x0.0031 ml/dl

 DO2 = CaO2 x CO x 10 ml/menit

 VO2 = [CaO2-CvO2] x CO ml/menit

 OUC = O2ER = VO2/DO2

Body Surface Area

Dubois Formula, BSA (m2) = Ht (cm)0.725 x Wt(kg)0.425 x 0.007184

Ht (cm) + Wt (kg) - 60
Jacobson Formula, BSA (m2) =
100
Contoh : BB, 80 kg, TB, 170 cm  BSA = 1.9 m2
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 OXYGEN TRANSPORT

Arterial blood Venous blood

CO = 5 L/m

DO2 = 1000 ml/m

Hb = 15 g/dl
SvO2 = 75%
SaO2 = 100%

CaO2 = 20.4 ml/dl CvO2 = 15.2 ml/dl

O2
VO2 = 250 ml/m

22/03/2018 O2ER = 25% 32

Hasanul -2006
 PRE-LOAD CONTRACTILITY AFTER-LOAD

STROKE VOLUME HEART-RATE

CARDIAC OUTPUT TOTAL

PERIPHERAL
RESISTANCE

BLOOD Tissue
PRESSURE Perfusion
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Hasanul, 2006
 PERDARAHAN

HILANG VOLUME
HILANG ERITROSIT

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 SHOCK
 B1, nafas sesak, RR , cuping hidung
 B2, HR , nadi halus cepat, TD. N/
Pulse-press. , perfusi dingin, pucat, basah,
capill.refill > 2 det., lactic-acid

• B3, anxious, confused, lethargy

• B4, urine out-put , <0.5 ml/kg/jam, pekat

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Hasanul, 2003
 Estimated Fluid and Blood Losses
Based on Patient’s Initial Presentation
Class I 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 Decreased Decreased Decreased

increased
Respiratory Rate 14-20 20-30 30-35 >35

Urine out-put [ml/hour] >30 20-30 5-15 Negligible

Mental status/CNS Slightly Midly Anxious and Confused and

anxious anxious confused lethargic

BV = 70 ml/kg Hasanul, 2003

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 FLUID REPLACEMENT
3 : 1 Rule
Class I Crystalloid
Class II Crystalloid
+ Colloid ?
Class III Crystalloid
+Colloid, Blood
Class IV Crystalloid
+Colloid, Blood
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 Pola kerja penanganan
shock perdarahan
Hasanul, 2003

Penderita datang
dengan perdarahan

Pasang infus jarum Ukur tekanan darah, hitung

kaliber besar (16G, 18G), nadi, nilai perfusi, produksi
ambil sample darah urine

Tentukan estimasi jumlah

perdarahan, minta darah

Guyur cepat Ringer Laktat atau

NaCl 0.9% [hangat, 390C] 3x
prakiraan lost-volume [1-2 liter] evaluasi
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 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
Hasanul, 2003
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Efek volume infus 1 L cairan Kolloid pada
kompartement tubuh [BB,70kg]
Laruta n Vol. plasma Vol. interstetial Vol.intrasel

Albumin-5% 1000 - -
PPF [Plasma Protein
Fraction-5%] 1000 - -
Gelafundin 1000 - -

Haemacel 700 +300 -

Dextran-40 1600 -260 -340

Dextran-70 1300 -130 -170

Expafusin 1000 - -

Haes-steril-6% 1000 - -

Haes-steril-10% 1450 -450 -

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 TRANSIENT RESPONSE,
DARAH BELUM DATANG,

KOLLOID
1:1

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 Transfusion, indications
 Indications for transfusion in normovolemic
anemia,
• VO2 < normal range (indicating an oxygen debt)
• Blood lactate > 4 mmol/L
• O2ER > 0.5

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 Transfusi,
Target 7 - 9g%

Rule of - 5

ml Whole-Blood = 5 x delta Hb x BB

contoh:
BB 60 kg, Hb 6g%, WB yang dibutuhkan = 5 x 3 x 60
= 900 ml
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= 4 bag [unit]
Hasanul, 2003
 End point of volume
resuscitation
 CVP = 15 mmHg
 Wedge pressure = 10-12 mmHg
 CI > 3 L/min/m2
 Oxygen uptake (VO2) >100 ml/min/m2
 Blood lactate < 4 mmol/L
 Base defisit -3 to +3

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The ICU BOOK 2ed , Marino.PL
 Therapeutic Goals in Shock
 Optimize O2 content of blood
 Improve cardiac output and
blood pressure
 Increase O2 delivery
 Match systemic O2 needs with O2
delivery
 Reverse/prevent organ hypoperfusion

22/03/2018 The ICU BOOK 2ed , Marino.PL 45

 kasus
 Laki-laki 45 th, 70 kg, KLL, fr. Femur kanan tertutup, pada
pemeriksaan , TD 95/70,
 HR 128x/m, RR 36 x/m, dipanggil mengantuk, urine pekat
sedikit, paha kanan digerakkan sakit dan membengkak.
 Diagnosa ?
 Penanganan?

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 penanganan

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Terima Kasih …
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 Transient response,
darah belum datang.
Perdarahan pada
 Usia tua
 Ibu hamil

 Pasca bedah major (reseksi-

anastomose)
 Varices esofagus

 Anak-anak

Plasmanate®
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 Plasma Protein Fraction
( PPF-5%), Plasmanate®
100 ml Plasmanate®
Mengandung :
• 4.4gr Human Albumin
• 0.6gr alfa dan beta globulin
• 0.05 gr gamma globulin
• Natrium 145mEq/L
• Kalium 0.25 mEq/l
• Chlorida 100 mEq/L

22/03/2018 Hasanul, 200251

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