Managemen

Syok Hemoragik
Irfan Hamdani
Bagian Anestesiologi dan Reanimasi
Fakultas Kedokteran UMSU
Medan

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 KEHIDUPAN

• NAFAS
• MAKAN

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 Shock adalah kondisi saat mana transport
oksigen (DO2, delivery O2) ke jaringan gagal
memenuhi kebutuhan metabolik di jaringan
tersebut.

DO2 < VO2

IT IS NOT LOW BLOOD PRESSURE !!!
IT IS HYPOPERFUSION…..
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 KLASIFIKASI
• HYPOVOLEMIK
• KARDIOGENIK
• OBSTRUKTIF
• DISTRIBUTIF (SEPTIK)

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 CARDIOGENIC

OBSTRUCTIVE

O2
O2 SEPTIC

O2
HYPOVOLEMIK

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 SYOK
HYPOVOLEMIK

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 Pathophysiology of Shock Hypovolemi

Volume loss
Autonomic tone Fluid shifts from
extracellular to
Catecholamine release
intravascular

Partial restoration of
survival  Venous capacitance intravascular volume
 Heart rate

Intervention / stabilization

Maintenance of perfusion

Blood flow shunted to vital

organs (heart,lung,brain)

Continued volume loss

Cellular hypoxia / anaerobic
metabolism

Survival / delayed morbidity / mortality

ATP production / lactic acidosis

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Intervention / stabilization
PATHOPHYSIO, CONT’N
Cellular hypoxia /
anaerobic metabolism

Survival / delayed morbidity /

mortality
ATP production / lactic acidosis

Intervention / stabilization
Cellular function
impaired

Continued volume loss

Membrane porosity

Lysozymal leakage
Movement of fluid
from intravascular to Cellular autodigestion
interstitial spaces
Irreversible
shock
intervention
No. intervention
DEATH
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Physiologic principles of
fluid management

TOTAL BODY WATER : 60% TOTAL BODY WEIGHT

60 kg 36 L

9L 3L 24 L
ISF
ISF IVF ICF

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Jenis cairan yang beredar :
• Kristalloid ( D5W, RL, RA, NaCl )
• Kolloid ( Albumin, HES, Expafusin,
Gelatine)
• Cairan Nutrisi ( Intrafusin, Ivelip,
Triofusin)

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Physiologic principles of
fluid management

D5W
3L

9L 3L 24 L
750 ml 250 ml 2L

ISF
ISF IVF ICF

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Physiologic principles of
fluid management

RL,NaCl
3L

9L 3L 24 L
2250ml 750 ml

ISF
ISF IVF ICF

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Physiologic principles of
fluid management

Albumin-5%
1L

9L 3L 24 L
1L

ISF
ISF IVF ICF

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Physiologic principles of
fluid management

HES-6%
1L

9L 3L 24 L
1000ml

ISF
ISF IVF ICF

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Physiologic principles of
fluid management

Albumin-
25%
Volume expander 100 cc

9L 3L 24 L
400 500

ISF
ISF IVF ICF

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Physiologic principles of
fluid management

Haemacel
1L

9L 3L 24 L
300ml 700ml

ISF
ISF IVF ICF

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Physiologic principles of
fluid management

Perdarahan

ISF IVF ICF

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 EFEK SHOCK PADA TINGKATAN SEL

CELL MEMBRANE FAILURE:

• DIRECT
Endotoxin
Complement
• INDIRECT
Failure to maintain normal Na+, K+ or Ca2+ gradient LL D EATH
Decreased oxidative phosphorylation CE

OSMOTIC
GRADIENT

Na+ entry Water entry CELLULAR IMPAIRED

into cell into cell EDEMA INTRACELLULAR
METABOLISM
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 The Trimodal Distribution of Traumatic
Disease
50
Percent of trauma deaths

40

30

20

10

0 //
0 1 2 3 4.hrs 1-2 5-6 weeks
Time after injury
IMMEDIATE : CNS injury or Heart and great vessel injury
EARLY : Major hemorrhage
LATE : Infection and Multi Organ failure
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 Shock pada Trauma

Pneumothorax
Perdarahan Myocardial
Contussion
Hematothorax Spinal Shock
Cardiac Tamponade

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 The Golden Hour
is the time in which resuscitation of severely injured
patients must begin to achieve maximal survive

R. Adams Cowley, MD

The lethal factor in shock is inadequate

cellular oxygen delivery, leads to irreversible
anoxic cellullar injury that kills a critical mass
of cells

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 THE GOLDEN HOUR
Probability of Survival R. Adams Cowley, MD

100

80
% survival
60

40

20

0 minutes
30 60 90
Survival is related to severity and duration

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 Oxygen
Transport
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 OXYGEN TRANSPORT
• CaO2 = SaO2 x Hb x 1.34 + PaO2x0.0031 ml/dl

• DO2 = CaO2 x CO x 10 ml/menit

• VO2 = [CaO2-CvO2] x CO ml/menit

• OUC = O2ER = VO2/DO2

• DO2I= CaO2 x CO x 10/BSA ml/m2/menit

Body Surface Area (BSA)

Dubois Formula, BSA (m2) = Ht (cm)0.725 x Wt(kg)0.425 x 0.007184

Ht (cm) + Wt (kg) - 60
Jacobson Formula, BSA (m ) = 2
100
Contoh : BB, 80 kg, TB, 170 cm  BSA = 1.9 m2
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 OXYGEN TRANSPORT

Arterial blood Venous blood

CO = 5 L/m
Hb = 15 g/dl
DO2 = 1000 ml/m

SvO2 = 75%
SaO2 = 100%

CaO2 = 20.4 ml/dl CvO2 = 15.2 ml/dl

O2
VO2 = 250 ml/m

O2ER = 25%
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 PRE-LOAD CONTRACTILITY AFTER-LOAD

STROKE VOLUME HEART-RATE

TOTAL PERIPHERAL
CARDIAC OUTPUT
RESISTANCE

BLOOD PRESSURE Tissue Perfusion

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Hasanul, 2006 IH - Managemen Syok Hemoragik 27
 PERDARAHAN

HILANG VOLUME
HILANG ERITROSIT

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 SHOCK
• Respiratory System, nafas sesak, RR , cuping hidung
• CV System, HR , nadi halus cepat, TD. N/
Pulse-press. , perfusi dingin, pucat, basah,
capill.refill > 2 det., lactic-acid

• CNS System, anxious, confused, lethargy

• Urinary tract, urine out-put , <0.5 ml/kg/jam,

pekat

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 Estimated Fluid and Blood Losses Based on
Patient’s Initial Presentation
Class I Class II Class III Class IV
Blood-Loss[ml] ->750 750-1500 1500-2000 >2000

Blood-loss [%BV] ->15% 15-30% 30-40% >40%

Pulse-Rate [x/min.] <100 >100 >120 >140

Blood-Pressure Normal Normal Decreased Decreased

Pulse-Pressure N or Decreased Decreased Decreased

increased
Respiratory Rate 14-20 20-30 30-35 >35

Urine out-put [ml/hour] >30 20-30 5-15 Negligible

Mental status/CNS Slightly Midly Anxious and Confused and

anxious anxious confused lethargic

BV = 70 ml/kg
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 FLUID REPLACEMENT
3 : 1 Rule
Class I Crystalloid
Class II Crystalloid
+ Colloid ?
Class III Crystalloid
+Colloid, Blood
Class IV Crystalloid
+Colloid, Blood
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 Pola kerja penanganan shock
perdarahan

Penderita datang dengan

perdarahan

Pasang infus jarum kaliber Ukur tekanan darah, hitung

besar (16G, 18G), ambil nadi, nilai perfusi, produksi
sample darah urine

Tentukan estimasi jumlah

perdarahan, minta darah

Guyur cepat Ringer Laktat atau NaCl

0.9% [hangat, 390C] 3x prakiraan lost-
volume [1-2 liter] evaluasi
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 Management selanjutnya
• RAPID RESPONSE,
PERDARAHAN <20%
• TRANSIENT RESPONSE,
PERDARAHAN 20-40% BV
ONGOING LOSS
RESUSITASI TDK ADEKWAT
RL, NACL 0.9%, KOLLOID, DARAH ?
• MINIMAL, NO RESPONSE
TINDAKAN BEDAH SEGERA
TRANSFUSI DARAH

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Efek volume infus 1 L cairan Kolloid pada
kompartement tubuh [BB,70kg]
Laruta n Vol. plasma Vol. interstetial Vol.intrasel

Albumin-5% 1000 - -
PPF [Plasma Protein
Fraction-5%] 1000 - -
Gelafundin 1000 - -

Haemacel 700 +300 -

Dextran-40 1600 -260 -340

Dextran-70 1300 -130 -170

Expafusin 1000 - -

Haes-steril-6% 1000 - -

Haes-steril-10% 1450 -450 -

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 TRANSIENT RESPONSE,
DARAH BELUM DATANG,

KOLLOID
1:1

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 Transfusion, indications
• Indications for transfusion in normovolemic
anemia,
– VO2 < normal range (indicating an oxygen debt)
– Blood lactate > 4 mmol/L
– O2ER > 0.5

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Transfusi,
Target 7 - 9g%

Rule of - 5
ml Whole-Blood = 5 x delta Hb x BB

contoh:
BB 60 kg, Hb 6g%, WB yang dibutuhkan = 5 x 3 x 60
= 900 ml
11-11-2014 = 4 bag [unit]
IH - Managemen Syok Hemoragik 37
 End point of volume resuscitation

• CVP = 15 mmHg
• Wedge pressure = 10-12 mmHg
• CI > 3 L/min/m2
• Oxygen uptake (VO2) >100 ml/min/m2
• Blood lactate < 4 mmol/L
• Base defisit -3 to +3

11-11-2014
The ICU BOOK 2ed , Marino.PL
IH - Managemen Syok Hemoragik 38
 Therapeutic Goals in Shock
• Optimize O2 content of blood
• Improve cardiac output and
blood pressure
• Increase O2 delivery
• Match systemic O2 needs with O2
delivery
• Reverse/prevent organ hypoperfusion

The ICU BOOK 2ed , Marino.PL

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 Kasus
• Laki-laki 45 th, 70 kg, KLL, fr. Femur kanan tertutup, pada pemeriksaan ,
TD 95/70,
• HR 134x/m, RR 36 x/m, dipanggil mengantuk, urine pekat, volume sedikit,
paha kanan digerakkan sakit dan membesar.
• Diagnosa ?
• Penanganan?

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 Dx: fr.,femur kanan, syok
hypovolemik (perdarahan)
 % EBV

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 ESTIMATED FLUID AND BLOOD LOSSES
BASED ON PATIENT’S INITIAL PRESENTATION
Class I Class II Class Class IV
III
Blood-Loss[ml] ->750 750-1500 1500-2000 >2000

Blood-loss [%BV] ->15% 15-30% 30-40% >40%

Pulse-Rate [x/min.] <100 >100 >120 >140

Blood-Pressure Normal Normal Decreased Decreased

Pulse-Pressure N or Decreased Decreased Decreased

increased
Respiratory Rate 14-20 20-30 30-35 >35

Urine out-put [ml/hour] >30 20-30 5-15 Negligible

Mental status/CNS Slightly Midly Anxious and Confused and

anxious anxious confused lethargic

BV = 70 ml/kg
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 Penangangan
• Oxygenasi 
– 2L/menit nasal prong
– atau oksigen mask 5-6 L/menit
• Kateter urine
• Infus 2 tangan kanan & kiri no.18G
• Replacement Cairan :
– RL hangat
– Kolloid
– Transfusi

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 Perhitungan
• Perdarahan klas III,  30% EBV
• EBV : 70x70 = 4900 mL
• 30% EBV = 30% x 4900 = 1470 mL (1500 mL)
• Replacement cairan kristalloid, RL 3x blood loss
• RL = 3x1500 = 4500 mL ( 9 fls ) hangatkan
• Setelah mendapat RL keadaan membaik, 

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Terima Kasih …

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Transient response,
darah belum datang.

Perdarahan pada
• Usia tua
• Ibu hamil
• Pasca bedah major (reseksi-anastomose)
• Varices esofagus
• Anak-anak

Plasmanate®
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(1:1)
IH - Managemen Syok Hemoragik 46
Plasma Protein Fraction
( PPF-5%), Plasmanate®

100 ml Plasmanate®
Mengandung :

– 4.4gr Human Albumin

– 0.6gr alfa dan beta globulin
– 0.05 gr gamma globulin
– Natrium 145mEq/L
– Kalium 0.25 mEq/l
– Chlorida 100 mEq/L IH - Managemen Syok Hemoragik
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