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TATA LAKSANA

SYOK ANAFILAKTIF

Dr. T.Mamfaluti, MKes, SpPD


Sub. Alergi Imunologi
Bagian Ilmu Penyakit Dalam FK Unsyiah/RSUD Dr Zainoel Abidin
Banda Aceh
DEFINISI REAKSI ANAFILAKSIS

Biasanya
Reaksi alergi yg timbul secara
potensi mendadak dan
mengancam jiwa cepat
memburuk

Dengan obstruksi
Sering disertai
jalan nafas atau dengan gejala
hipotensi pada kulit
Reaksi Anafilaksis

Reaksi hipersensitivitas tipe 1

Sistemik

Mengancam hidup

Timbul beberapa menit

Gejala : Saluran Nafas, Kardiovaskular, Kulit, Saluran Cerna


Asal kata : ANAPHYLAXIS

Lawan kata : PROPHYLAXIS


ANAPHYLACTOID IgE
PREDISPOSISI : Sifat alergen
Atopik
Jalur pemberian obat
Genetik
Morbiditas dan Mortalitas Reaksi Anafilaksis

Indonesia ?
Inggris : prevalensi 1 dalam 3333 populasi
USA : 30 950 kasus per 100000/orang per
tahun
USA : 150 oleh makanan
400 800 oleh antibiotik
250 1000 oleh media kontras
MEDICATIONS
NSAID, aspirin,
antibiotics, opioid MISCELLANEOUS
analgesics, insulin, FOODS
HYMENOPTERA Latex, exercise,
protamine, general
Peanuts, tree VENOM gelatin,
anesthetics,
nuts, fish, menstruation,
streptokinase, blood Honeybees, fire
shellfish, milk, seminal fluid,
products, ants etc
eggs, bisulfites dialysis
progesterone,
membranes
radiocontrast media,
biologic agents,
immunotherapy

Adapted from Rusznak and Peebles.


Source : Semin Respir Crit Care Mes @ 2004 Thieme Medical Publisher
Immediate and Late phase reaction of type I hypersensitivity
IgE production Antigen

Promotion of B cell Immediate phase


differentiation and proliferation reaction
B cell Mast cell
IL-4 Histamine release
Several min 10 min
and PAF, LTC4, LTD4
IL-5 production from mast cell

LT
Th2

Differentiation IL-4 IL-5 IL-5 Activation of


Thymus Promotion of
differentiation Eosinophil
Promotion of Eosinophil
differentiation and proliferation
Differentiation
Th1 Th0 Late phase
reaction
Hematopoietic LTC4, PAF production
stem cell Eosinophil Eosinophil and EPO, ECP, MBP 6-12 hours
release from grunulocyte
Bone marrow
Leukocyte responses
Lipid mediators Adherence
LTB4
Chemotaxis
LTC4
IgE production
PAF
Mast Cell proliferation
PGD2
Eosinofil activation
Secretory granule
preformed mediators Fibroblast responses
Histamine Proliferation
Proteoglycans Vacuolation
Tryptase and chymase Globopentaosylceramide production
Carboxypeptidase A Collagen production
Cytokines
IL-3
IL-4 Substrate responses
IL-5 Activation of matrix
IL-6 metalloproteases
GM-CSF
Activation of coagulation cascade
IL-13
Activited Mast Cell IL-1
INF-
TNF- Microvascular responses
Augmented venular permeability
Leukocyte adherence
Constriction
dilatation
Gambaran Klinis

ONSET : - ~ INDIVIDUAL
- Detik Menit
Riwayat Allergen Parenteral, Peroral
20% : 6 12 jam Rekurens, bifasik
Rochester Epidemiologic study (1983 1987) :
150 kasus Kulit 100%, Sal. Nafas 69%,
Kardiovaskuler 41%, Sal. Cerna 24%
Saluran Nafas

Wheezing

Dyspnea
Upper respiratory
obstruction (angioedema)
Edema Laring (mengganjal,
serak, stridor insp.)

Rhinitis

Stridor
KELAINAN KULIT

Jarang sebagai
Tanda khas DD
gejala pertama

Urtikaria (lokal, general : < 48


Flushing
jam)

Angioedema Rasa terbakar, pedih,


tidak terasa
Kardiovaskuler

Dizzines
Syncope
Hypotension
Collapse
Loss of consciousness
Arrhythmia
Angina
Myocardial infark
Saluran Pencernaan

Mual Muntah

Kolik Diare
Gejala Lain (Jarang)

Inkontinensia Substernal Seizure


pain

Visual
abnormality DIC
Patients (N=133)
Symptom or Sign N %
Cutaneous
Urticaria 73 56
Angioedema 74 56
Pruritus 73 55
Flushing 48 36
Conjunctivitis or chemosis 30 23
Respiratory
Dyspnea 67 43
Throat tightness 37 28
wheezing 34 26
Rhinitis 22 17
Laryngeal edema 9 7
Hoarseness 9 7
Reproduced with permission from Yocum et al.

Source : Semin Respir Crit Care Mes @ 2004 Thieme Medical Publisher
Patients (N=133)
Symptom or Sign N %
Oral and gastrointestinal
Intraoral angioedema 20 15
Emesis 12 9
Nausea 12 9
Abdominal cramps 11 8
Dysphagia 7 5
Oral prurius 5 4
Diarrhea 1 1
Cardiovascular
Tachycardia 36 27
Presyncope 20 15
Hypotension 15 11
Syncope 4 3
Shock 7 5
Chest pain 4 3
Bradycardia 2 2
Orthostatis 2 2
Reproduced with permission from Yocum et al.
Source : Semin Respir Crit Care Mes @ 2004 Thieme Medical Publisher
DIAGNOSIS

Secara klinis !!

Riwayat (Alergen, Onset)


Pemeriksaan Fisik : Gambaran Klinik
DIAGNOSIS BANDING

Penyebab lain dari Syok,


Hipotensi dan
Respiratory Distress
LABORATORIUM

IgE Test

Tryptase Test
TERAPI

Evaluasi Tanda
Medikamentosa
Vital
Terapi
1. Epinephrine
Vasokontriksi, bronkhodilator, permeabilitas
vaskuler, sintesa mediator
Sedini mungkin
Tidak dapat diganti yang lain !
Im/ Sc iv
2. Oksigen
3. Infus replacement cairan
4. Vasopressor (Dopamine) ditambahkan ?
Terapi
5. Nebulizer tambahan untuk Bronchospasme
6. Intubasi/Trakheotomi lihat hipoksia progresif ?
7. Antihistamin kel. Kulit, sal. Cerna
8. Aminofilin tambahan untuk Bronchospasme
9. Kortikosteroid >< Rekuren/prolong Reaction
10. Terapi Aritmia
11. CVP ?
Table 3 Suggested Management of Anaphylactic Shock

1. Lie flat, elevate legs/Trendelenburg position, high-flow oxygen, support


airway and assist ventilation as required
2. Administer IM epinephrine 0.01 mg/kg (max 0.5 mg) into the anterolateral
thigh and proceed to obtain wide-bore intravenous access.
(if IV access is present and patient is in an appropriate environment, may omit
IM epinephrine and proceed directly to intravenous infusion of epinephrine)
3. Once IV access is available, commence rapid volume resuscitation with
Normal Saline or Hartmanns Solution (20 ml/kg start under pressure,
repeated as necessary).
4. If remains hypotensive despite above steps, consider in the following
sequence :
a) Intravenous infusion of epinephrine using an infusion pump (Table 2)
b) Intravenous bolus of atropine, if there is significant bradycardia
c) Intravenous bolus of vasoconstrictor (e.g. Mataraminol, Methoxamine,
Vasopressin)
d) Further investigation/monitoring (central/pulmonary artery cannulation,
echocardiography) to monitor intravascular volume and cardiac function
e) Intravenous glucagon, milrinone/amrinone and/or mechanical support (intra
aortic ballon pump) if remain hypotensive with a suspicion of cardiac failure
rather than volume depletion/vasodilation. Cardiac support may be more
likely to be required if there is coexisting beta-blockade or underlying
cardiac disease.

Source : Curr Opin Allergy Clin Immunol @ 2005 Lippincott Williams & Wilkins
Tabel 2.
1. Epinephrine Infusion
1 mg in 100 ml (1:100 000, 10 g/ml) intravenously by infusion pump
commence at 30 100 ml/h (5-17 g/min)according to reaction severity
titrate up or down according to response and side effects, aiming for
lowest effective infusion rate
tachycardia, tremor and pallor in the setting of a normal or raised blood
pressure are signs of epinephrine toxicity; consider a reduction in infusion
rate
stop infusion 30 min after resolution of all symptomps and signs
continue observation for at least 2 h after ceasing infussion (longer for
severe or complicated reactions); discharge only if remains symptom-free
2. Normal saline rapid infusion
1000 ml (pressurized) infused over 1-3 min and repeat as necessary
give if hypotension is severe or does not respond promptly to epinephrine

Reprinted with permission from the BMU.

Source : Curr Opin Allergy Clin Immunol @ 2005 Lippincott Williams & Wilkins
Pencegahan Tersedia Kit
Siaga

Anamnesa : Penting !
Riwayat alergi/anafilaksis
(walau tidak menjamin !!)
Cari alergennya
Awas reaksi silang
Skin Test : Harus dilakukan pada zat
yang bisa alergen

Prick Skin Test/


Ideal Scratch Test
Tidak menjamin
Monitor post
Desensitisasi ?
exposure

Edukasi untuk Epinephrine


yang resiko ! Autoinjector Kit
Berat reaksi

Lamanya onset

Edema Laring

Syok

Waktu antara onset klinik dan dimulai terapi