Diagnosis dan Penanganan Syok hemorrhagi.

( Manajemen dan terapi cairan)

Sri rahardjo
Grha Sabha Pramana-Yogjakarta 29 Oktober 2010 15.00-15.30

Millennium Development Goals (MDGs 2015)

5. Meningkatkan Kesehatan Ibu AKI (Angka Kematian Ibu) Thn 2000 = 500.000 meninggal krn Persalinan 99 % = dinegara berkembang (Risk 175 x) Thn 2015 = dari AKI 1999 Indonesia = Prioritas Program

Pendahuluan

Worldwide Causes of Maternal Mortality

WHO Report on Maternal Health Indices , 2005

Has No available data.

Pendahuluan

Difference in maternal mortality across nations

The difference in maternal mortality rates across different
continents (1 per 16 in Africa and 1 per 300 in Latin America compared with 1 in 3700 in the USA) represent

NOT a difference in the but the divergence in the accessibility of medical care.

Pendahuluan

Obstetric Hemorrhage

T issue T rauma T hrombin T one

Syok Hemoragi

Syok Hemoragi

Shock Cascade in Haemorrhage

Hemorrhage Shock
decreased blood volume impaired macrocirculation
Inadequate perfusion Erythrocyte aggregation decreased cardiac output decreased oxygen delivery Septic shock

vasoconstriction

impaired micro circulation

tissue ischemia
Syok Hemoragi

endotoxin release bowel kidney

organ failure

GAMBARAN KLINIK SYOK HEMORAGI

SISTIM
SARAF PUSAT KARDIAL

SYOK DINI
PERUBAHAN STATUS MENTAL TAKIKARDI HIPOTENSI ORTOSTATIK OLIGOURI TAKIPNOE ANEMIA -

SYOK LANJUT
PERUBAHAN KESADARAN HIPOTENSI ARITHMIA GAGAL JANTUNG ANURI TAKIPNOE, GAGAL NAFAS GANGGUAN FUNGSI HEPAR PERDARAHAN MUKOSA KOAGULOPATI ASIDOSIS HIPOKALEMIA HIPOMAGNESEMIA

RENAL RESPIRASI HEPATIK GASTRO INTESTINAL HEMATOLOGI METABOLIK

Diagnosis

KLASIFIKASI SYOK HEMORAGI

Jml Perdarahan
Hilang darah (ml) Denyut nadi (bpm) Tekanan darah Pengisian kapiler Pernafasan Urine (ml/h) Status mental Kompensasi < 15 % <1000 <100 Normal Normal Normal >30 Normal atau agitasi Ringan 15 s/d 30 % 1000-1500 >100 Ortostatik Mungkin terlambat Peningkatan ringan 20-30 Agitasi Sedang 30 s/d 40 % 1500-2000 >120 Sangat turun Sering terlambat Takipnea sedang 5-20 Konfusi Berat > 40 % >2000 >140 Tidak terukur Selalu terlambat Takipneu nyata, Gagal Nafas Anuria Letargi, tidak sadar

Diagnosis

Therapy of Shock Hemoragi :

The primary treatment of Shock Haemorrhage are:
Management of the underlying injury or disease Adequate Ventilation & Oxygenation Immediate and Adequate Volume replacement Restoration of Tissue Perfusion
Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock

CVP denotes central venous pressure, MAP mean arterial pressure, and ScvO2 central venous oxygen saturation
Penanganan Volume 345:1368-1377 November 8, 2001 Number 19

TREATMENT CONCEPT OF SHOCK HAEMORRHAGE

ENHANCING PERFUSION / OXYGEN DELIVERY

DO2 = CO x CaO

Cardiac output

Arterial O2 content

Oxygen delivery/DO2 = HR X SV X Hb X S02 X 1.39 + 0.03 X PaO2

Inotropes :
Dopamin Dobutamin Norepinephrin Epinephrin

Fluids

Transfuse

Partially dependent on FIO2 and pulmonary status

Penanganan

Adequate Volume Replacement Restoration Blood Volume

Improve CO and BP Match systemic O2 needs with DO2 Increase DO2 Optimize O2 content of blood Reverse/prevent hypo perfusion
Adequate Ventilation and Oxygenation

Control bleeding as quickly as possible

Restoration of Tissue Perfusion

ENHANCEMENT MICRO CIRCULATION BLOOD FLOW

Penanganan

End Point of Resuscitation Therapy : Basic Clinical Sign: Patient Responses

HR > BP Perfusion Evaluation
UOP (Urine Out Put) CRT (Circulation Peripheral ), LOC ( Level of Consciousness )

Produksi Urin/jam Tidak adekwatnya UOP berarti Tidak adekwatnya resusitasi

Monitoring

End Point of Resuscitation Therapy : Advanced methods include

Metabolic
Serum lactate pCO2 Base deficit

Mixed venous saturations

CVP Advanced Evaluation : Preload. : CO,CI,LAP, PAOP,LVSVWI

Monitoring

NEW CONCEPT
PERMISSIVE HYPOTENSION
Controversial Points

Pasien tetap sadar Nadi teraba SBP 90 mmHg MAP 50-60 mmHg SaO2 > 92%

Monitoring

MANAJEMEN TERAPI CAIRAN

B L O O D CRYSTALLOID

COLLOID

RL RA NaCl 0.9 % NaCl 3 %

Cairan

Albumin Plasma Dextran Gelatin HES

Body Fluid Compartments

Total body water = 60 % of body weight (BW)
2/3 1/3

Intracellular water = 40 % of BW

Extracellular water = 20 % of BW

Intravasc.vol (5 % of BW)
Cairan

HIPOTESA STARLING
Recall Starlings Law of the Capillaries which explains fluid and solute movements from Ch. 19

= =

K { (Pc Pt) - (c - t) } P -
Absolut Hipovolumia

Cairan

Fluid ISOTONIC

Konsentrasi Partikel Dalam Larutan Sama

Efek Tidak ada pergerakan cairan melalui membran semipermiabel Tidak menyebabkan pembengkakan/pengkerutan Sel

HYPERTONIC Lebih Besar

Menyebabkan pergerakan air intrasel keluar Sel akan mengkerut Menyebabkan air ekstrasel masuk ke intrasel Menyebabkan sel akan membengkak

HYPOTONIC

Lebih Kecil

KRISTALOID Keuntungan
Komposisi elektrolit seimbang Tidak ada resiko alergi Tidak mempengaruhi hemostasis Mengakibatkan terjadinya diuresis Murah

KRISTALOID Kerugian
Perlu 3-4 x jumlah perdarahan Bisa mengakibatkan udem Mengakibatkan TOP berkurang. Hypothermia Lama kerja + 90 menit NaCl 0.9% : asidosis hiperchloremia

Cairan

RL 2liter/15 menit

Upaya mengurangi kebocoran kapiler agar hipovolemia dapat dikoreksi Molekul lebih besar daripada pori dan menahan air intravaskuler
albumin (koloid alamiah) dextran atau gelatin (koloid sintetik) HES (koloid sintetik)

Molekul menutup pori (sealing effect) ? Molekul menjauhi pori dengan muatan listrik ?
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KOLOID
KEUNTUNGAN
Tetap berada dalam volume intravaskular Kebutuhan sama dengan jumlah darah yang hilang Meningkatkan TOP, mobilitas interstiiel ke intravaskuler. Resiko udem minimal Meningkatkan aliran darah microvaskular

KOLOID
KERUGIAN Kelebihan beban cairan Mengganggu hemostasis Mempengaruhi fungsi ginjal Reaksi anafilaktoid Mahal

H2O
Na

HES

HES Hydroxyethyl starch

HES

Cl

H2O

27

Dextran Dextran

Dextran

28

(-) (-) (-) (-) (-) (-) (-) (-) (-) (-) (-) (-)

(-) (-) (-)

Repelling Effect: Negatively charged endothelial cells repell negatively charged Gelatin molecules Result: Longer and Stronger Volume effect

(-)

(-)

(-)

(-)
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RESUME
Tujuan Tx Cairan pada Syok Hemorrhagi 1. Kristaloid Isotonus kolloid (Balance Approach) 2. Volume Intra Vaskuler normal hemodinamik stabil 3. Mengganti keluarnya cairan interstitial / intra sel. 4. Memperbaiki aliran mikrosirkulasi Perfusi baik. 5. Oksigenasi sel terpenuhi metabolisme tetap baik. 6. Koreksi terhadap gangguan asam basa.