Tatalaksana Syok

Hipovolemik – septik – anafilaktik

dr. Rudy Kurniawan, SpPD

 Outline
1. Fisiologi dan komposisi cairan tubuh
2. Syok hipovolemik
3. Syok septik
4. Syok anafilaktik
5. Contoh kasus

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 DISTRIBUSI & KOMPOSISI
CAIRAN TUBUH

50% pada perempuan

atau obesitas

• Semi permeabel

• Permeabel terhadap air dan elektrolit Johnson RJ, Feehally J, Floege J.

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• Tdk permeabRuedlytKe/Arshcldeppedeiar/i2t1rJouns2i0t2&1 protein Comprehensive clinical nephrology.
Elseiver Saunder; 2015.
 Shock is a life-threatening condition that
occurs when the body is not getting enough
blood flow. Lack of blood flow means the cells
and organs do not get enough oxygen and
nutrients to function properly. Many organs can
be damaged as a result

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Type of Shock
Symptoms
Type of Shock and Clinical Features

Morozowich ST, Ramakrishna H. Pharmacologic agents for acute hemodynamic instability: Recent advances in the
management of perioperative shock- A systematic review. Ann Card Anaesth 2015;18:543-54.

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• ABC
• Address the cause à hypovolemia
or hypervolemia

What to • What type of hypovolemia à

shock or not shock

do? • Comorbidities and underlying

conditions à heart failure, chronic
kidney disease, geriatric
• Loading vs maintenance

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 Hypovolemic Shock

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 Crystalloids

• Saline (0.9% NaCl) and balanced crystalloids (lactated Ringer’s, ringer

acetate, Hartmann’s solution, Plasma-Lyte, Normosol, Isolyte) with or
without dextrose
• Lactated Ringer à unlikely to cause hyperchloremic metabolic acidosis
• Administered at a rate of 500-2000 mL/hour, depending on the severity
of deficit, degree of ongoing fluid loss and tolerance

Casey, J. D., Brown, R. M., & Semler, M. W. (2018). Resuscitation

fluids. Current opinion in critical care, 24(6), 512–518

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Crystalloids
compositions
Ringer acetate à
acetate 28, laktat 0

Ringerfundin: Na
145, K =4, Ca – 5,
Mg 2, Cl 127, asetat
24, maleat 5

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 Colloids

• Semisynthetic colloids (starches, gelatins, dextrans) and albumin

• Improved volume expansion (retention in the intravascular space)
• Albuminà 75% plasma colloid oncotic pressure
• VISEP, CRYSTMAS, 6S, and CHEST trials à hydroxyethyl starch might
increase the risk of acute kidney injury, need for renal replacement
therapy, or mortality

Casey, J. D., Brown, R. M., & Semler, M. W. (2018). Resuscitation

fluids. Current opinion in critical care, 24(6), 512–518

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 Casey, J. D., Brown, R. M., & Semler, M. W. (2018). Resuscitation
fluids. Current opinion in critical care, 24(6), 512–518

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 Dextran à risk of bleeding

Gelofusin à modified gelatin

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• Which access?

Intravenous •
•
What type?
What intravenous solution? Osm?
Access • Duration?

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Responsiveness Evaluation
Traditional
alertness, reduced tachycardia,
palpable pulse, diuresis, MAP>>
Advanced
Inferior Vena Cava, IVC collapsible index
End-diastolic volume index
Cardiac output
LV outflow tract à stroke volume
ystematic assessment of fluid
tion: secondary analysis of the
AN trial. Crit Care 24, 23 (2020)
 • Tn Ari 57 thn datang ke UGD dg keluhan diare 3hari,
frekuensi >5x/hari
Kasus 1 • BB 60 kg
• CM TD 90/60 mmHg; HR 110, lemah; RR 24x, suhu
37.2C, satO2 98% room air

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Answer
• Syok hipovolemik
• Loading 500 mL kristaloid <15 menit (akses vena besar lebih baik), 18G, 16G
• 10 – 20 ml/kg bb/jam à 600mL – 1200 mL dlm 1 jam
• Monitor tanda vital tiap 15 menit
• Responsiveness evaluation
• Tekanan darah, nadi
• diuresis, target >0.5 ml/kgbb/jam à BB 60kg = 30mL
• Respon à 7 ml/kgbb/jam (420mL) à 5ml/kgbb/jam (300mL) à cairan maintenance
• Bila tidak respon, bisa diulang hingga kristaloid 2000-2500 à + koloid
• Bila masih tidak respon dapat dikombinasi dg vasopresor

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Responsiveness Evaluation
Maintenance Therapy
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 Septic Shock

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The Evolution of Sepsis Bundle
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 • Tn B 37 datang ke UGD dg keluhan sesak memberat
sejak 1 hari SMRS
• Tampak sakit berat, E4, M4, V4
Kasus 2 • CM TD 80/60 mmHg; HR 112, lemah,reguler; RR 28x,
suhu 38.8C, satO2 98% room air
BB 60/TB 165cm
• PF: ronki basah kasar di kedua lapangan paru

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 •Pemeriksaan Penunjang apa
Kasus 2 yang diperlukan?

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Pemeriksaan
Penunjang
• Hb 10.4 g/dL
• Leukosit: 23.800/mm3;
neutrophil 84%
• Trombosit: 165.000/mm3
• LED: 40 mm
• Ureum: 52 mg/dL
• Creatinin: 1.4
• GDS: 208

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 Anaphylactic Shock

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 Establish intravenous access using needles or
catheters with wide-bore cannula (14-16
gauge). Consider giving 1-2 L of 0.9%
(isotonic) saline rapidly (e.g 5-10 mL/kg in
the first 5-10 minutes to an adult, 10 ml/kg
to a child)

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• Corticosteroids reduce the length of hospital stay, but did not reduce revisits to the emergency
department.
• There was no consensus on whether corticosteroids reduce biphasic anaphylactic reactions.
• no compelling evidence to support or oppose the use of corticosteroid in emergency treatment of
anaphylaxis.
• antihistamines and cortisone reduce inflammation of air passages and improve breathing.
 • Tn D 44 datang ke UGD dg keluhan sesak memberat
sejak 1 jam SMRS, disertai mata sembab
• Pasien mengaku minum antibiotik (tidak tahu
namanya)
Kasus 3 • CM TD 90/60 mmHg; HR 112, lemah,reguler; RR 24x,
suhu 36.8C, satO2 98% room air

• BB 70/TB 175cm
• PF: angioedema

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 • Stop dan identifikasi antibiotik
• ABC
• Injeksi epinefrin IM 0.01 mg/kgBB
à0.7 (max 0.5 mg) (ulang tiap 5-15 menit)

à1-2 L kristaloid; 5-10 ml/kg pada 5-10 menit

pertama
àSteroid (prednisone 1mg/kgbb à70)
àMp 80% x 70 = 56 mg, evaluate every 6-8 hours

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 • Tn H 57 thn datang ke UGD dg sesak memberat 6
jam SMRS
• Pasien CKD st IV (eGFR 22)
Kasus 4 • TD 90/60 mmHg; HR 110, lemah; RR 24x, suhu
38.2C, satO2 98% room air, kesadaran: delirium
• JVP+, edema tungkai +

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• Hipo/eu/hypervolemia? à hypervolemia
• Acute on CKD
• Diuresis? (normal 0.5ml/kg/jam) (daily fluid balance)
• Perlu diuretik? Tidak semua kasus respon dengan diuretik
• Vasopressor + diuretik
• Pencetus? Infeksi/metabolik/ds
• Syok sepsis dd et kardiogenik

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 c

11/6/2021 dr. Rudy K, SpPD/DCC/Diabetesi setelah Ramadan