Penatalaksanaan Syok Dr.tatty

8/11/2019 Penatalaksanaan Syok Dr.tatty

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PENATALAKSANAAN SYOK PADA ANAK

TATTY ERMIN SETIATI

SUB. BAGIAN PEDIATRI GAWAT DARURAT FK. UNDIP/RSUP

DR. KARIADI SEMARANG


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PENDAHULUAN

SINDROM KLINIS

KEGAGALAN SISTEM SIRKULASI

KEBUTUHAN OKSIGEN

NUTRIEN JARINGAN

DEFISIENSI AKUT

DITINGKAT SEL


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SYOK PADA ANAK :

Keadaan gawat darurat

morbiditas / mortalitas

80 hipovolemik

Syok kompensasisulit di D / o.k manifestasi klinis tak jelas ( refleks

simpatis

Redistribusi selektif al. daerah dari organ perifer non-vital ke

jantung, paru, otak )

Tujuan Primer Pengelolaan Syok :

- Preload ( resusitasi volume )

- Kontraktilitas

- Resistensi pada sistemik


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DEFINISI SYOK

SINDROM KLINIS AKIBAT KEGAGALAN SISTEM SIRKULASI UNTUK

MENCUKUPI :

Nutrisi

Oksigen

Pasokan

utilisasi

Metabolisme

Jaringan tubuh

Defisiensi 02 Seluler


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FUNGSI SISTEM SIRKULASI

Jantung

Pembuluh Darah

Volume Darah

Curah jantung

& adekuatAliran darah

Metabolisme

jaringan

Metabolit

Eliminasi Di Organ

Pembuangan


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PENGATURAN CURAH JANTUNG

DAN TEKANAN DARAH

PRELOAD CONTRACTILITY AFTERLOAD

HEART RATE STROKE VOLUME

CARDIAC OUTPUT SYSTEMIC VASCULAR RESISTANCE

BLOOD PRESSURE


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PENGANGKUTAN OKSIGEN

Cardiac Out Put Blood flow

Oxygen

Delivery

Blood O2Content

Hb Contentration

O2Bound to Hb

O2Dissolved in Plasma


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KLASIFIKASI SYOK

MENURUT ETIOLOGI

SYOK HIPOVOLEMIK

SYOK DISTRIBUTIF

SYOK KARDIOGENIK

SYOK SEPTIK

SYOK OBSTRUKTIF


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STADIUM SYOK

FASE I : KOMPENSASI

Mekanisme Kompensasi Tubuh refleksi simpatis

- Resistensi sistemik

: HR; kulit dingin, pucat, cap.refill terlambat, nadi lemah, tek.nadi

sempit

-

Tekanan darah ( N )

- Tekanan Diastolik

- Resistensi pembuluh darah splanknik

: Ginjal (Diuresis


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FASE II : DEKOMPENSASI (1)

-Mekanisme kompensasi gagal

- Metabolisme anaerobik

- Asam laktat

asidosis>>

terbentuk asam karbonat

intraseluler

- Kontraktilitas otot jantung

- Pompa Na K sel

Integritas membran sel

Kerusakan sel


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FASE II : DEKOMPENSASI (2)

Aliran darah lambat

Agregasi Trombosit

Pembentukan Trombus

Pendarahan

Pelepasan Mediator

Vasodilatasi Arterial

Kenaikan Permeabilitas Kapiler

VR


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Fase dekompensasi

Perfusi jaringan indekuat disertai hipotensi

Kesadaran menurun krn perfusi ke otakmenurun

Hipotensi sebagai tanda terakhir dari syok Untuk anak 1-10th:


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FASE III : IREVERSIBEL

Kerusakan / Kematian Sel

Disfungsi sistem multi organ

Cadangan fostat E. Tinggi

( Hepar, Jantung )

Tekanan darah tak terukur

Nadi tak teraba

Kesadaran

Anuria

GMO

klinis


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PERJALANAN PATOFISIOLOGI SYOK

Septic Shock Cardiogenic Shock

Hypovolemic Shock

Capillary Leak MediatorsMyocardialDepression

Preload Vasodilatation Contractility

Cardiac OutputBlood Pressure

Sympathetic Discharge

Vasoconstriction,

HR Contractility

Improved Cardiacoutput and bloodpressure

COMPENSATED


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DECOMPENSATED

Myocardial perfusion

Myocardial O2Consumption

Cardiac Output

Mediator Release

Cell Function

Cell Death Death of Organism

Tissue Ischemia

Loss of Autoregulation of

Microcirculation

COMPENSATED

VasoconstrictionHR Contractility


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Syok hipovolemik

Primary Assessment: Finding A

B Takhipneu tanpa peWOB

C Takhikardi

Tek.Drh N/ hipotensi dgn

tek.nadi sempit

Nadi lemah,kecil /tak teraba

Pengisian kapiler lambat

kulit dingin,pucat

Kesadaran menurun

Oliguria

D Kesadaran menurun


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Distributive / Septic Shock

Distributive

shock

PRELOAD

N /

CONTRACTILITY

N /

AFTERLOAD

Variable


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SIRS

Core temp of >38.5C or 2SD above normal for age,

for chhildren


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SEPSIS :

SIRS in the presence of, or as a result of,

suspected or proven infection


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Severe sepsis

Sepsis plus either cardiovascular

dysfunction or ARDS

Or

Sepsis plus 2 or more other organ failures


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RF as sign of organ dysfunction

in sepsis PaO2/FiO2 65 mmHg or 20 mmHg abovebaseline

Proven need FiO2 >50% to maintain SaO2>92%

Need nonelective MV (invasive ornoninvasive)


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Septic shock

Sepsis and

Cardiovascular dysfunction despite

administration of isotonic iv boluses > 40

ml/kg in 1 hour


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Cardiovascular dysfunction

Hypotension (SBP


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Inadequate organ perfusion

Unexplained metabolic acidosis: base

deficit < 5meq/l

Increase arterial lactate > twice the upperlimit of normal

Oliguria: Urine output0.5 ml/kg/hour

Prolonged cap refill: > 5 second

Cor to peripheral temp gap > 3C


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III. SYOK KARDIOGENIK

Etiologi :

Pasca Bedah Penyakit Jantung Bawaan

Miokarditis

Infark / Iskemik Jantung

Kardiomiopati Primer / Sekunder

Hipoglikemia, Gangguan Metabolik

Asfiksia, Sepsis


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CARDIOGENICSHOCK

PRELOADVARIABLE

CONTRACTILITY

DECREASED

AFTERLOAD

INCREASED


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MEKANISME SYOK KARDIOGENIK

Cardiogenic

Shock

Contractility

CO

BPMetabolic acidosis, hypoxia,

Myocardial depressant factor

Compensatory mech.

Afterload

SVR


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SYOK KARDIOGENIK

Cardiac Ventricular Performance

Factor Determinant :

a. Frekuensi dan Irama Jantung

b. Preload dan Afterload

c. Kontraktilitas Miokard

Kompensasi Tubuh Self Perpetuating Cycle

Syok Progresif Memburuk


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Findings of Cardiogenic Shock

Primary Assessment Finding

A

B Tachypnea; WOB

C Tachycardia; N/low BP with

a narrow pulse pressure; weak or absent ofperipheral pulse; N and then weak central

pulses;Delayed cap refill with cool extremities;

Signs of CHF; cyanosis(CHD/pulm.edema); End-

organ Function ( Cold, pale skin, oliguria)

D Changes of mental status


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Cardiac tamponade

Muffled or diminished heart sound

Pulsus paradoxus(decrease in systolic BP by

more than 10 mmHg during inspiration

Distended neck vein

Note: Children following cardiac surgery,

D/ ndistinguishable from cardiogenic

shock, Echo: important


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Tension pneumothorax

Patients with chest trauma, or any intubated child

who deteorates suddenly during PPV

Hyperresonance on the affected side Diminished breath sounds on the affected side

Distended neck vein

Tracheal deviation towards contralateral side Rapid deteoration in perfusion and rapi change

from tachycardia to bradicardia


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MANIFESTASI KLINIS SYOK SEPTIK

STADIUM KOMPENSASI

- Resistensi Vaskuler

- Curah Jantung

- Takhikardia

- Ekstermitas Hangat

- Divresis Normal

STADIUM DEKOMPENSASI- Volume Intravaskuler

- Depresi Miokard

- Eksternal Dingin

- Gelisah, Anuria, Distres Respirasi

- Resistensi Vaskuler

- Curah Jantung

STADIUM IREVERSIBEL

- GMO


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PENATALAKSANAAN SYOK

1. 2.

Oksigenasi

CaO2

SaO295100 %

Sistem K.V

a. Preload

( resusitasi volume )

b. Atasi Disritmia

c. Koreksi keseimbanganasam - basa

Jalan nafas Oksigen Anxietas


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TERAPI CAIRAN PADA SYOK

AKSES VENA (90 detik); Tak berhasil IO

KRISTALOID dan atau KOLOID10 30 ml / kg B.B (6-10 menit)

diulang 2 3 kali

SYOK SEPTIK

60

100ml / kg B.B(dalam 6 jam pertama) THE 1st CONSENSUS CONFERENCE

on CCM 1997(SYOK SEPTIK)a. Koloid

terapi inisial, dilanjutkan koloid/kristaloidb. Dipandu : respons klinis,perfusi, perifes, tvs,

tekanan sistem,MAP


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Algoritme Terapi Cairan Pada Syok

Suspected shock

Hypovolemia, Hypoperfusion, Tachycardia

10 30 mL Cryst/Colloid / kg / 6 10 min

Normotensive

Hypotensive

In Sepsis :

Antibiotics,Imunotheraphy

In Anaphylaksis :

Catekolamin,steroid,antihistamin

Urine > 1 ml/kg/hr

10-20 mLcrys orcoll/kg/10min

AnuriaUrine < 1 ml/kg/hr

Urine output < 1 ml/kg/hr

Reevaluated 10 mL X.tal/kg 10 mL X.tal/kg 1020 mL X.tal/kg


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Reevaluated 10 mL X.tal/kg 10 mL X.tal/kg 10-20 mL X.tal/kg

Improved

Reevaluated

Improved

Reevaluated

Hypotensive, urine < 1 mL/kg/hr

CVP < 10 mmHg CVP,Cardiac status,chest X-Ray,Echocardiography

CVP > 10 mmHg

Afterload reduction,inotropic support,consider pulmonary

10-20 mL X.tal/kg

Reevaluated


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Early Goal Directed

Therapy pada Syok Septik Early aggressive fluid therapy (Crystaloid or

colloid)In EMU, within 6 hours of admission

Vasopressors & Inotropic drugs when resistance tofluid therapy

End points: Good peripheral perfusionConciousness, Capillary feeling time < 2, Warmextremities, MAP/Pulse pressure N for age, CVP8-12 mmHg, Diuresis > 2ml/kg SvcO2 > 70%

Admission to PICU when stabilized


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Fluid Therapy

in Sepsis and Septic Shock

Type of FluidColloid

Crystalloid

Volume60 100 ml/kg

(6 hours)

CO , Restore BPMOF

Inotropic

Vasopressor


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Efek volume infus 1 L koloid pada kompartemen tubuh (70 kg)

Larutan Vol. Plasma Vol. Inters I.Intrasel

Albumin 5% 1000 - -

Hemacel 700 300 -

Gelafundin 1000 - -

Plasmafusin 1000 - -

Dextran 40 1600 (-260) (-340)

Dextran 70 1300 (-130) (-170)

Expafusin 1000 - -HAES steril 6% 1000 - -

HAES steri10% 1450 (-450) -


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ADRENAL INSUFFISIENSI PADA SYOK

SEPTIK

KORTIKOSTEROID

Pada syok septik, bila refrakter thdp

dopamin/adrenalin/nor-adrenalin

mungkin terjadi INSUFISIENSI ADRENAL

Hydrocortisone 50mg (bolus),

dilanjutkan 1-2 mg/kgBB/ 24 jam; 5-7

hari


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IMUNOTERAPI

Tranfusi tukar pada sepsis :

- memperbaiki oksigenasi jantung

- mengeluarkan mediator dan endotokin

Immunoglobulin (I.V) pada sepsis

Hemofiltrasi dan Plasmafiltrasi :

mengeluarkan endotoksin, mediator

mengurangi respons inflamasi sistemik (SIRS)


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FUNGSI ORGAN

A. PARU :

Suplai Oksigen adekuat

- Intubasi/pemasangan V. mekanik dini pada syok

septik

- Pemberian cairan resusitasi, bila terlalu banyak/

agresif

resiko tinggi edema paru

B. OTAK :

- Hindari hipoksia, hipoglikemia

- Hindari hiperkapnea dengan ventilator)

- Pertahankan perfusi serebral :

a. volume intravaskular

b. CO

c. Hb/tekanan darah adekuat

- Pemantauan kadar Na serum, koreksi hati-hati


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FUNGSI ORGAN (lanjutan)

C. SIRKULASI SPLANKHNIK / SALURAN CERNA

- Resusitasi volume, optimalisai CO, tekanan darah

- Koreksi hipotensi vasopresor/inotropik)

- NUTRISI ENTERAL DINI

D. GINJAL

- Resusitasi volume, optimalisasi CO, tekanan darah

- Koreksi hipotensi

- Koreksi hipoksia dan anemia berat

- Hindari obat-obatan nefrotoksik


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TATALAKSANA SYOK KARDIOGENIK

Oksigenasi Adekuat

Koreksi GGN Asam Basa dan Elektrolit

Kurangi Rasa Sakit dan Ansietas

Atasi Disritmia Jantung

Kelebihan Preload : Diuretika

Kontraktilitas : Fluid Challenge Sesuai CVP/POAP

Obat Inotropik +)

Beban Afterload SVR

) : Vasodilator

Koreksi Penyebab Primer


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Commonly Used Cardiovascular lanjutan)

Drug Dose

( ug/kg/min )

Comment

Dobutamine( - and - adrenergic )

1

20 Positive inotropic effect withminimal changes in heart rate orsystemic vascular resistance

Amrinone 1 10 Initial bolus infusion may berequired. Limited data available in

childrenVasodilators

Nitroprusside 0.005 8 Balanced arterial and venous dilator.May result in thiocyanate or cyanidetoxicity

Phentolamine 1

20 Causes dilatation of arterial andvenus beds. Indirect inotropic effectmay cause compensatory tachycardia

Nitroglicerine 0.5 20 Venus dilator. Dose not wellestablished for infants and children


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MONITORING

State of Consiousness-Glasgow Coma Scale

Respiratory Rate and Character

Cardiovascular Parameters :

a. Skin and Core Temperature Difference

b. Pulse Rate and Volume

c. Blood Pressure

d. Capillary Perfusion Time

e. Central Venous Pressure Should Be Monitored in

Patient Where There Has Been Poor Response

To Fluid Therapy Or With Established Shock

Urinary Output-Urine Bag, Or Preferably Catheter; Output

Should Be 1-2 ml/kg Body Weight

Pulse Oximetry

SvcO2


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KEY POINTS IN MANAGEMENT

Remember BP and pulse are unreliable indicators inearly septic shock

Look for minor degrees of mental impairment(anxiety,restlessness)

Do not delay treatment, try to prevent the onset ofhypotension, metabolic acidosis, and hypoxia

Give adequate fluids early in treatment, especiallycolloids

Do not use inotropic agents until the patients hasreceived adequate fluid therapy

Monitor blood glucose, gases, and PH, and treatappropriately


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RINGKASAN/KESIMPULAN

Syok merupakan keadaan gawat darurat, seringditemukan pada anak

Morbiditas dan mortalitas syok masih tinggi Syok hipovolemik, paling sering terjadi pada anak

(80%), sisanya syok kardiogenik

Diagnosis syok dini sulit, tetapi penting diketahui melaluipemahaman patofisiologi syok (stadium kompensasi,

dekompensasi dan ireversibel) Pengelolaan syok bertujuan meningkatkan DO2 melalui

pe

CO yaitu :

1. Memperbaiki prabeban dengan resusitasi volume

2. Me

kontraktilitas jantung dan

3. Me SVR

Dengan pemahaman patofisiologi, diagnosis dini danmemperhatikan key management syok, diharapkandapat me mortalitas syok


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