shock

agus setiyana,m.d.
cardiac anesthetist
acls provider
fccs provider
Atls provider
Schock (ger), scoc (old ger.): push,
thrust, vibration, fright
Choc (1810): Prussian cavalry attack

Shock (medical) : 1st half 18th century,
english translation of Le Drans book and
french medical terms secousse, coup
saisissement, and commotion

a state of general depression of
the nervous system induced by a
severe injury or by a powerful
disturbance of the emotional
centres.
Carr, JW. The Practitioners Guide.New York: Longmans, 1902;865-66.
The importance of fluids in non-bleeding persons was
not initially recognized!
Shock:
Adams H.A. et al.: Intensivmed 38:541-553 (2001):

Hypovolemic shock
is a state of insufficient perfusion of vital
organs with consecutive imbalance of oxygen
supply and -demand
due to an intravascular volume deficiency
with critically impaired cardiac preload

Hypovolemic shock
Definitions of shock types:
Hypovolemic
shock
Cardiogenic
shock
Anaphylactic
shock
Septic
shock
Neurogenic
shock
Konsekuensi shock
Impaired celluler Impaired capillary perf
O2 uptake/utilization

cell hypoxia ( anaerobic metabolism)

Lactic acidosis

decreased ATP production

Failure of the Na-K pump

cellular swelling

lysosomal rupture

CELL Death Organ Failure
Shock pd System Organ
GI Tract
Ggn permeabilitas usus , berakibat ;
Translokasi bakteri enteric & toxin ke circulasi
motilitas usus, berakibat ileus paralitik
Ulcerasi pada gaster dan usus
Ggn absorpsi nutriens
Pelepasan mdf dr iskemik pankreas
Muskulus skeletalis
Produksi asam laktat berlebih asidosis
metabolik
Katabolisme sel otot me sbg sumber energi
Kelelahan otot-otot pernafasan
Sistem Immune
Ggn sistem kekebalan
Rentan terhadap infeksi
Kulit
Ggn penyembuhan luka
Resiko perlukaan
Liver
Awalnya ; pemecahan glycogen, me gluconeogenesis
me kadar glukosa darah
Lanjut ; me penyimpanan glukosa & ggn
gluconeogenesis
Selanjutnya hypoglikemia
Ggn metabolisme protein dan lemak
Ggn konversi asam laktat oleh hepar asidosis
metabolik
me pembentukan & ekskresi bile dr bilirubin me
serum bilirubin mild jaundice
Ggn netralisasi toxin bakterial & sisa metabolit spt
amonia
Ggn sel Kupffer utk membersihkan bakteri pd sirkulasi
Ginjal
Awalnya ; me GFR. Aldosteron & ADH
mempertahankan kadar garam dan air
me urine output.
Lanjut ; ATN nekrosis kortek renalis
Gagal gnjal permanen
Hematologis
me platelet dan faktor pembekuan,oleh krn ;
1. Pemakaian akibat aktivasi cascade proses
pembekuan DIC
2. Hemodilusi o.k. penggantian cairan
3. me fungsi platelet o.k. sepsis & hipothermia
Paru paru
V Q mismatch ggn oksigenasi
me ventilasi alveolar retensi CO2 &
hipoksia
Pembentukan mikrothrombi pd kapiler
pulmonal & keluarnya mediator2 ARDS
Jantung
Awalnya ; me stimulasi simphatis me rate
& kontraksi ventrikuler
Lanjut ; me CPP & keluarnya mdf ggn
kontraksi
Predisposisi terjadi arrhytmia
Infark transmural & subendocardial
Otak
Awalnya ; release norepinephrine dan
adrenalin eksitasi CNS
Lanjut ; me CPP ggn fungsi serebral
Bila mempengaruhi brainstem ggn
vasomotor & ventilasi
Akhirnya ;
1. Penumpukan asam laktat di otak
2. Odema serebri o.k. masuknya Natrium & air
3. Destruksi sel membrane
4. Ggn neurotransmiter
5. Irreversible brain damage
Tahapan shock

1. Fase I : Shock terkompensasi
me rate & kontraksi ventrikuler untuk
optimalisasi MAP & CO
Vasokonstriksi vena sistemik me venous
return & pengisian ventrikel
Vasokonstriksi arteri sistemik mengalihkan
aliran darah ke organ2 vital, hipoperfusi
perifer ditandai dengan kulit yg dingin dan
pucat, me urine output, kelemahan otot.

2. Fase II : Dekompensasi Shock
Hipotensi
Iskhemia serebral ; ggn kesadaran
Iskhemia myocard ; arrhytmia, perubahan
ST T iskhemia, me cardic output ditandai
hilangnya pulsasi perifer
me asam laktat, asidosis metabolik berat
Capillary leakage

Fase III : Irreversible Shock
Systemic hypoperfusion
Leaky, porous capillaries
Resusitasi cairan tak banyak membantu
hanya mengisi sirkulasi perifer
Kerusakan & nekrosis organ2 vital
Translokasi toksin dan kuman hingga tampak
septic
Resusitasi jarang berhasil
Bila berhasil ,px akan meninggal o.k. MOF
Pembagian shock;
1. Shock hipovolemik ;
1. Bleeding / haemorrhagic
2. GI losses ( vomit,diare,dehidrasi,3
rd
spaces
losses )
3. Reperfusion injury
4. Burn
5. Sepsis
Merupakan jenis shock terbanyak, ditandai dg deplesi
volume intravaskuler
Hypovolemic Shock
Blood Pressure
Cardiac Output /
CO
Stroke
Volume / SV
Contractility Afterload
Heart Rate
Systemic
Vascular
Resistance (SVR)
Preload
Klasifikasi shock hemorrhage

Cl I II III IV
BL(ml) >750 750-
1500
1500-
2000
2000
%BL/BV >15 15-30 30-40 40
Nadi <100 >100 >120 140
BP N N
PP N /
Ca Ref te N + + +
RR N 20-30 30-40 40
Ur out ml/hr 30 20-30 5-15
CNS Slight Mild Anx,con
fus
Conf,
lethar
Fl Repl Cr Cr /Co Cr,Co,Bl Cr,Co,Bl
2. Shock kardiogenik
Infark myocard
Cardiomyopathy
Penyakit katub jantung
Burn & sepsis
Shock diakibatkan kegagalan sistem pompa
jantung ( cardiac output ) o.k. defek pd fungsi
jantung

Cardiogenic Shock
Blood Pressure
Cardiac Output /
CO
Stroke
Volume / SV
Preload Afterload
Heart Rate
Systemic
Vascular
Resistance (SVR)
Faktor2 pd Cardiac Output
Variabel assessment
Heart rate perabaan pulsasi
& rhythm pulse oximetry
E C G
Preload
Right heart CVP, JVP, liver
Left heart DOE, orthopnea, Arterial
BP, PAOP
Afterload Mean Arterial BP,SVR
Contractility Ejection Fraction,
Echocardiography
3. Shock distributif
Shock anaphylactic
Shock neurogenic
Reperfusion injury
Burn & sepsis
Terjadi hipovolemia relatif o.k. adanya pooling
cairan tubuh di venous parifer dan rongga
non vaskuler ( kebocoran )
Pada anafilaksis terjadi vasodilatasi hebat sbg
konsekuensi reaksi anafilaksis
Circulatory Shock

Blood Pressure
Cardiac Output /
CO
Stroke
Volume / SV
Preload Afterload
Heart Rate
Systemic
Vascular
Resistance (SVR)
Shock neurogenik
Terjadi vasodilatasi sebagai akibat hilangnya tonus
otot pembuluh darah.
Regulasi tonus hilang setelah cedera CNS dan cedera
spinal letak tinggi.
Shock sepsis
Merupakan sebab terbanyak shock distributif
antigen dan toxin bakterial dlm aliran darah
memicu cascade reaksi inflamasi release
inflammatory mediators;
Vasodilatasi sistemik
Capillary leakage
Abnormal koagulasi ; DIC , spontaneus systemic
hemorrhagic, etc.
4. Shock obstruktif
Tension pneumothorak
Tamponade cardiac
Embolus pulmonair
Lebih sering diakibatkan trauma
Resusitasi cairan dan penggunaan inotropik
hanya membantu sementara waktu
Tindakan pembedahan untuk pengurangi
tekanan merupakan pilihan
Tata laksana
penyebabab primer
Oksigenasi
Resusitasi cairan
Stabilisasi
Spesifik ;
Pembedahan
Antibiotika
Inotropik, vasokonstriktor, antiarrhytmia
IABP


Fluid Therapy
RESUSCITATION MAINTANANCE
Electrolite Coloid Crystalloid Nutrition
Replacement of an acute
loss (hemoragic, GI loss,
3
rd
space)
1. Normal Requirement
2. Nutrition support
Repair
Preload Contractility
Afterload
Vasoconstriction
Tissue Perfusion
CO = SV x HR
Treatment Concept of Shock
Enhancing perfusion / Oxygen Delivery
DO
2
= CO x CaO
2

O
2
delivery/ DO
2
= HR x SV x Hb x SaO
2
x 1.34 + Hb x PaO
2

Cardiac
Output
Arterial O
2
content
Inotropik
Contractility
Vasoactive
Fluids
Preload
Afterload
Transfuse Partially
dependent on
FIO
2
&
pulmonary
status
Volume Replacement Therapy
Crystalloids Colloids
Lactated Ringers
Normal Saline
Hypertonic
Sodium Lactate
Albumi
n
Gelatin
Dextra
n
HES
Dextrose (free water)









Vascul
ar
space
water added to intravascular space
Expansions of total body water no volume effect
ECF
Isotonic crystalloids








ECF








K
t
= 250 ml.min
-1
Svensen et.al, Br.J.Anaesth,
1998
ECF
Vascul
ar
space
K
t
Proportional expansion of intra- and
extravascular spaces
Crystalloids added to intravascular space
Hypertonic Solutions








ECF






ECF
Vascul
ar
space
Expansion of intravascular space
Contraction of ECF
Hypertonic fluid added to intravascular space
Crystalloids solutions are
distributed over the intire
Extracellular space.
And therefore crystalloids are indicated and
most effective when this space is depleted.
Colloids
Advantages:
Good IVVP
Prolonged plasma volume support
Moderate volume needed
Minimal risk of tissue edema
Enhances micovascular flow
Colloids
Disadvantages:
Risk of volume overload
Adverse effect on hemostasis
Adverse effect on renal function
Anaphylactic reaction
Expensive
Characteristics of colloids
Product Name Conc.% Oncotic
Pressure
Initial
Expansion
%
Stays
(days)
Max.
dose
Hemost.
Albumin 4,5 20 80-100 200-400 0
Dext70 Macrod 6 60-70 120 30-40 1.5g/kg +++
Dext40 Rheom 10 170-190 200 6 1.5g/kg +++
Gelatin Gelfusin 3-4 42 70-90 7 0-+
HES450/0
.7
Plasmas6 6 24-30 100 120-182 20ml/kg +++
HES200/0
.5
Hesteril 6 30-37 100 3-4 33ml/kg +
HES130/0
.4
Voluven 6 36 100-110 50ml/kg 0-+
Changes in volume of body
compartments during fluid infusion
Compartment Glucose 5% NaCl 0.9% Colloids
Intravascular





Interstitial





-
Intracellular



-