syok fk umsu 2012
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Diagnosis dan Manajemen
Syok
Diagnosis dan Manajemen
Syok
Irfan Hamdani
Dept. Anestesiologi FK UMSU
Irfan Hamdani
Dept. Anestesiologi FK UMSU
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SHK 2
Shock
Shock
• Alwas a smptom of primar ca!se
• Inade"!ate #lood flow to meet tiss!e
o$gen demand• Ma #e associated with hpotension
• Associated with signs of hpoperf!sion%
mental stat!s change& olig!ria& acidosis
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SHK '
Kategori Syok
Kategori Syok
• (ardiogenic
• Hpo)olemic
• Distri#!ti)e
• *#str!cti)e
• (ardiogenic
• Hpo)olemic• Distri#!ti)e
• *#str!cti)e
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SHK +
(ardiogenic Shock
(ardiogenic Shock
• kontraktilitas ,ant!ng
men!r!n
• -eningkatan tekanan
pengisian ,ant!ng&
pen!r!nan S&
pen!r!nan (*&
peningkatan S/
• kontraktilitas ,ant!ng
men!r!n
• -eningkatan tekanan
pengisian ,ant!ng&
pen!r!nan S&
pen!r!nan (*&
peningkatan S/
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SHK 0
Hpo)olemic Shock
• Decreased cardiac o!tp!t
• Decreased filling press!res
• (ompensator increase in
sstemic )asc!lar resistance
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SHK 1
Distri#!ti)e ShockDistri#!ti)e Shock
• ormal or increased cardiac o!tp!t
• 3ow sstemic )asc!lar resistance
• 3ow to normal filling press!res
• Sepsis& anaphla$is& ne!rogenic&
and ac!te adrenal ins!fficienc
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SHK 4
*#str!cti)e Shock*#str!cti)e Shock
• Decreased cardiac o!tp!t
• Increased sstemic )asc!lar
resistance
• aria#le filling press!resdependent on etiolog
• (ardiac tamponade& tension
pne!mothora$& massi)e
p!lmonar em#ol!s
• Decreased cardiac o!tp!t
• Increased sstemic )asc!lar
resistance
• aria#le filling press!resdependent on etiolog
• (ardiac tamponade& tension
pne!mothora$& massi)e
p!lmonar em#ol!s
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SHK 5
(ardiogenic Shock Management(ardiogenic Shock Management
• 6reat arrhthmias
• Diastolic dsf!nction ma
re"!ire increased filling
press!res
• asodilators if not hpotensi)e
• Inotrope administration
• 6reat arrhthmias
• Diastolic dsf!nction ma
re"!ire increased filling
press!res
• asodilators if not hpotensi)e
• Inotrope administration
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SHK 7
(ardiogenic Shock Management
• asopressor agent needed if
hpotension present to raise
aortic diastolic press!re
• (ons!ltation for mechanicalassist de)ice
• -reload and afterload red!ction
to impro)e hpo$emia if #lood
press!re ade"!ate
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SHK 89
Hpo)olemic Shock
Management
Hpo)olemic Shock
Management
• ol!me res!scitation : crstalloid&
colloid
• Initial crstalloid choices
– 3actated /inger;s sol!tion
– ormal saline lood& crstalloid& colloid
• ol!me res!scitation : crstalloid&
colloid
• Initial crstalloid choices
– 3actated /inger;s sol!tion
– ormal saline lood& crstalloid& colloid
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SHK 88
Distri#!ti)e Shock 6herap
• /estore intra)asc!lar )ol!me
• Hpotension despite )ol!me therap
– Inotropes and?or )asopressors
• asopressors for MA- @ 19 mm Hg
• Ad,!ncti)e inter)entions dependent on
etiolog
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SHK 82
*#str!cti)e Shock 6reatment*#str!cti)e Shock 6reatment
• /elie)e o#str!ction
– -ericardiocentesis
–6!#e thoracostom
– 6reat p!lmonar em#ol!s
• 6emporar #enefit from fl!id
or inotrope administration
• /elie)e o#str!ction
– -ericardiocentesis
– 6!#e thoracostom
– 6reat p!lmonar em#ol!s
• 6emporar #enefit from fl!id
or inotrope administration
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SHK 8'
Fl!id 6herapFl!id 6herap
• (rstalloids – 3actated /inger;s sol!tion
– ormal saline
• (olloids
– Hetastarch
– Al#!min
– elatins
• -acked red #lood cells• Inf!se to phsiologic endpoints
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SHK 8+
Fl!id 6herap
• (orrect hpotension first
• Decrease heart rate
• (orrect hpoperf!sion a#normalities• Monitor for deterioration of
o$genation
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SHK 80
Inotropic ? asopressor Agents
• Dopamine
– 3ow dose
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SHK 81
Inotropic Agents
• Do#!tamine
– 0B29µ
g?kg?min
– Inotropic and )aria#le chronotropic effects
– Decrease in sstemic )asc!lar resistance
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SHK 84
Inotropic ? asopressor
Agents• orepinephrine
– 9.90 µg?kg?min and titrate to effect
– Inotropic and )asopressor effects
– -otent )asopressor at high doses
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SHK 85
Inotropic ? asopressor Agents
• pinephrine
– >oth and β actions for inotropic
and )asopressor effects
– 9.8µ
g?kg?min and titrate
– Increases mocardial *2 cons!mption
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SHK 87
6herape!tic oals in Shock 6herape!tic oals in Shock
• Meningkatkan deli)eri *2
• Mengoptimalkan *2 di darah
• meningkatkan cardiac o!tp!t and tekanan
darah• Menes!aikan ke#!t!han *2 sistemik dan
hantaran *2
• Mencegah organ hpoperf!sion
• Meningkatkan deli)eri *2
• Mengoptimalkan *2 di darah
• meningkatkan cardiac o!tp!t and tekanan
darah• Menes!aikan ke#!t!han *2 sistemik dan
hantaran *2
• Mencegah organ hpoperf!sion
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SHK 29
*lig!ria
• Marker of hpoperf!sion• Urine o!tp!t in ad!lts
@9.0 m3?kg?hr for C2 hrs
• tiologies – -rerenal
– /enal
– -ostrenal
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SHK 28
)al!ation of *lig!ria
• Histor and phsical e$amination
• 3a#orator e)al!ation
– Urine sodi!m
– Urine osmolalit or specific gra)it
– >U& creatinine
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SHK 22
)al!ation of *lig!ria)al!ation of *lig!ria
3a#orator 6est -rerenal A6
>lood Urea itrogen? C29 89:29
(reatinine /atio
Urine Specific ra)it C8.929 @8.989
Urine *smolalit
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