SHOCK & Resusitasi Cairan

SHOCK & RESUSITASI CAIRAN

DEFINITION

• Shock is a multifactorial syndrome leading to systemic and localized tissue hypoperfusion and resulting in cellular hypoxia and multiple organ dysfunction

DESCRIPTION

• Perfusion may be decreased systemacally with obvious signs such as hypotension

• Perfusion may be decreased because of maldistribution as in septic shock where systemic perfusion may appear elevated

DESCRIPTION

Prognosis is determined by• degree of shock, • duration of shock, • number of organ affected,• previous organ dysfunction and• possibly some genetic predispositition

CLASSIFICATION OF SHOCK

1. Hypovolemic shock2. Obstructive shock3. Cardiogenic shock4. Distributive shock

HYPOVOLEMIC SHOCK

• Loss of circulating intravascular volume and decrease in cardiac preload

• May be from hemorrhage : trauma, gastrointestinal bleeding, nontraumatic internal bleeding (aneurysm, ectopic rupture), vaginal bleeding

HYPOVOLEMIC SHOCK

• May be from nonhemorrhagic fluid loss from;• gastrointestinal tract (vomiting, diarrhea,

fistula),• urinary loss (hyperglycemia with

glucosuria), • evaporative loss (fever, hyperthermia)• intestinal fluid shifts (third spacing as with a

bowel obstruction)

HYPOVOLEMIC SHOCK

Clinical sign

• Depend on volume lost

• Symptoms include: tachycardia, hypotension, decreased urine output, mental status changes, tachypnea

Classification hypovolemic shock

Based on 70 kg

Class.1 Class.2 Class.3 Class.4

Blood loss (ml)

> 750 750 – 1.500 1.500-2.000 >2.000

Blood vol (%) > 15 15 - 30 30 - 40 > 40

Pulse rate < 100 > 100 > 120 >140

Blood pressure

normal normal decreased decreased

Capillary refill

normal decreased decreased decreased

Classification hypovolemic shock

Based on 70 kg

Class.1 Class.2 Class.3 Class.4

Respiratory rate

normal 20 - 30 30 - 40 distress

Urinary output (ml/hr)

> 30 20 - 30 5 -15 < 10

Mental status

Mild anxiety Anxiety Confused lethargic

Fluid replacement

Crysalloid Crystalloid Crystalloid + blood

Crystalloid + blood

DIAGNOSIS

• VITAL SIGN.• Heart rate• Blood pressure• TemSperature• Urine output• Pulse oxymetri

• Patient with normal or near normal signs, 50-85% are still in shock

HEART RATE (HR)

• TACHYCARDIA is an early sign of significantvolume loss in shock.

• The heart rate of young patient or those on β blockers may be not increase

• Bradycardia after prolonged hypotension precludes cardiovascular collapse

BLOOD PRESSURE (BP)

• HYPOTENSION and narrowing pulse pressure are a sign of severe volume loss and shock.

• Mean arterial pressure (MAP) is a better guide to therapy than systolic BP

TEMPERATURE

• Hyperthermia, normothermia, hypothermia may be present in shock.

• Hypothermia is a sign of severe hypovolemic and septic shock

URINE OUTPUT

• Early guide of hypovolemia and end organ response (renal) to shock.

• This is a delayed vital sign because 1 to 2 hours are needed to obtain an acurate measure

PULSE OXIMETRY

• Continuously measured and early indicator of hypoxemia but may be invalid in hypothermic patients

INVASIVE HEMODYNAMIC MONITORING

1. Arterial catheters2. Central venous catheters

(CVc)3. Pulmonary arterial catheters

(PAc)


•Arterial catheters; give continuous blood pressure measurement.

•Central venous catheters (CVc); gives continuous central venous pressure (CVP) measurement.

Arterial catheter insertion


• Pulmonary arterial catheters (PAc) can measure CVP, right arterial (RA) pressure, pulmonary artery pressure (PAp), pulmonary arterial occlusion pressure (PAOp / wedge pressure), cardiac output (CO).

• PAc will help guide aggresive resuscitation in patient with severe shock

Pulmonary artery catheter

Typical pressure waveform PA catheter

CARDIAC OUTPUT – CARDIAC INDEX

• Cardiac output (CO) or Cardiac index (CI) reflect cardiac function and can be directly measured by a PAC.

• Optimizing CI can be increased by increasing preload , increasing contractility or decreasing afterload

HEMODYNAMIC VARIABLES

VARIABLE UNIT NORMAL RANGE

Systolic BP (SBP) mmHg 90 -140

Diastolic BP (DBP) mmHg 60 - 90

Systolic pulmonary blood pressure (PAS) mmHg 15 - 30

Diastolic pulmonary blood pressure (PAD) mmHg 4 - 12

Pulmonary artery occlusion pressure (PAOP)

mmHg 2 - 12

MEASURED VARIABLE



Central venous pressure (CVP) mmHg 0 - 8

Heart rate (HR) Beats/min 50 - 100

Cardiac output (CO)L/min 4 - 6

Right ventricular ejection fraction (RVEF) fraction 0,4 – 0,6

MEASURED VARIABLE



Mean arterial pressure (MAP)

mmHg 70 - 105

Mean pulmonary artery pressure (MPAP) mmHg 9 - 16

Cardiac Index (CI) L/min/m2 2,8 - 4,2

Stroke volume (SV) ML/ beat varies

Stroke volume index (SVI) mL/ beat/ m2 30 - 65

CALCULATED VARIABLE

TREATMENT

• Rapid recognition and restoration of perfusion is the key to preventing multiple organ dysfunction and death.

• In all forms of shock, rapid restoration of preload with infusion of fluids is the first treatment

TREATMENT

• Crystalloid is first infused and then blood is infused if shock is secondary to hemorrhage.

• Early diagnosis of the etiology is essential and further treatment of the shock depends on its etiology.

TREATMENTHypovolemic shock

• Rapid infusion of crystalloid, large-bore venous acces is needed and central access may be necessary .

• Blood tranfused after 2-3 liter crystalloid, if the cause is hemorrhage. The source of bleeding needs to be controlled

Basic management

• The initial therapy of choice: replacement of intravascular volume.

• Physical examination may provide valuable information about the intravascular volume status (clear lung field and flat neck vein suggest a need for additional fluid resuscitation in the hypotensive patient).

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SHOCK & Resusitasi Cairan