Download - Hemorrhagic Shock (Anestesi)
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 1/44
Hasanul Arifin
Departemen Anestesiologi dan ReanimasiFakultas Kedokteran USU
Hemorrhagic Shockin the Injuried Patient
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 2/44
CaO2
• Oxygen Bound (HbO2)
•Oxygen dissolved (plasma)
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 3/44
CaO2 = Hb x SaO2 x 1.34 + PaO2 x 0.0031
Oxygen Bound (HbO2)
Oxygen dissolved (plasma)98%
2%
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 4/44
01/05/2013 4
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 5/44
01/05/2013 5
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 6/44
01/05/2013 6
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 7/44
Initial Management of
Hemorrhagic Shock
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 8/44
Pasien Trauma (dianggap menderita shock hypovolemia)
Hentikan Perdarahan, Ganti
Kehilangan Volume
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 9/44
Physical Examination
( ABCDE)• Airway & Breathing
• Keep the airway clear
• Ventilasi & Oksigenasi
• Beri O2 SpO2 96-98%
• Circulation ( kontrol perdarahan)
• Penekanan
• PASG (Pneumatic Anti shock Garment)
• Operatip
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 10/44
Physical Examination
( ABCDE)
• Disability (neurologi)
• Brain perfusion
• GCS
• Respon pupil
• Exposure
•Head to Too
• Cegah hypothermia ( penghangatan internal,
eksternal)
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 11/44
Tindakan lain
• Dekompressi ( Maag dilatation)
• Maag dilatasi vagal stimulation bradikardia,
hypotensi
•Risiko aspirasi
• Insersi NGT no besar untuk dekompressi, suction aktif
• Urinary Catheter
• Hematuria?
• Jumlah urine renal perfusion
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 12/44
iv. line
• 2 (dua) iv catheter no. besar (16G, 18G)
• Vena lengan bawah
•Kalau kesulitan, akses vena besar : v. subclavia
v. jugularis interna
v. femoralis
Sekalian ambil contoh darah (laboratorium)
Dilakukan oleh tenaga yang
terlatih, jangan sampai
menimbulkan komplikasi
( peneumothorax,
hematothorax, arterial
puncture )
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 13/44
Vein Selection
• Both upper limbs should be inspected to
identify possible veins for cannulation.
• Potential veins can then be palpated to assess
their condition.
• An ideal vein is ‘soft and bouncy’ when
palpated.
• Veins that are tender, thrombosed or hard
should be avoided
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 14/44
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 15/44
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 16/44
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 17/44
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 18/44
Device selection
•It is important to select the correct vascularaccess device for the patient’s specific clinical
situation
•PUR (polyurethane), modern, softer, causeless intimal damage and are kink resistant
which reduces the incidence of cannula failure
•PVC, Teflon, older materials are more rigid,higher incidence of thrombophlebitis.
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 19/44
equipment
•Infusion standart
• Fluid (RL, NaCl, etc)
• Infusion tubing
•The following equipment for cannulation should beassembled and placed on a clean tray:
• cannula, antiseptic, sterile gauze, sterile saline flush,
single or multiway adapter (primed with sterile saline)
with integral ‘needle-less’ device, sterile moisture-permeable transparent dressing, tape, and a small
sharps’ container.
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 20/44
Theoretical Maximum Flow Rates
Colour Gauge Flow
Yellow 24G 13 ml/min
Blue 22G 30 ml/min
Pink 20G 55 ml/min
Green 18G 80-100 ml/min
White 17G 135 ml/min
Grey 16G 180 ml/min
Orange or Brown 14G 270 ml/min
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 21/44
01/05/2013 21
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 22/44
01/05/2013 22
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 orincreased
Decreased Decreased Decreased
Respiratory Rate 14-20 20-30 30-35 >35
Urine out-put
[ml/hour]
>30 20-30 5-15 Negligible
Mental status/CNS Slightlyanxious
Midlyanxious
Anxiousandconfused
Confusedandlethargic
Estimated Fluid and Blood Losses Based on
Patient’s Initial Presentation
EBV = 70 ml/kg
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 23/44
Kegunaan Klinis
Tabel Prakiraan Kehilangan Darah• Dengan menyesuaikan tanda dan gejala dari penderita pada
tabel, dapat diperkirakan berapa kehilangan darah yang sdhterjadi.
• Kemudian kita dapat memperhitungkan berapa jumlah cairan
yang harus diberikan untuk resusitasi• Bila post resisitasi belum ada tanda perbaikan, maka
kemungkinan :
– Ongoing loss
– Prakiraan ada kesalahan (BB tidak sesuai, kurang jeli menilai tanda dan
gejala – Ada tambahan kehilangan cairan lain selain perdarahan
– Shock bukan ok. perdarahan
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 24/44
Initial Fluid Therapy
• Tujuan :
• mengisi intravaskular dalam waktu singkat preload mekanisme
hemodinamik
• Cairan :
• Kristalloid• Ringer Lactat
• Ringer Asetat
• NaCl 0.9%
• Rule : 3 for 1 (1000 mL perdarahan ganti 3000 mL)
• Kolloid rule 1 : 1 ( 500 mL perdarahan ganti 500 mL)
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 25/44
01/05/2013 25
TOTAL BODY WATER : 60% TOTAL BODY WEIGHT
36 L
ISF
60 kg
9L
ISF IVF ICF
3L 24 L
Physiologic principles of
fluid management
Hasanul, 2002
ISF = Interstisial Fluid
IVF = Intravascular Fluid
ICF = Intracellular Fluid
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 26/44
Physiologydefinition
• Crystalloid is the term commonly
applied to solutions that do not
contain any high-molecular-weight
compounds and thus have an oncoticpressure of zero
• Colloid is the term used to denote
solutions that have an oncoticpressure similar to that of plasma.
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 27/44
01/05/2013 27
Jenis cairan yang beredar :
• Kristalloid ( D5W, RL, RA, NaCl )
• Kolloid ( Albumin, HES, Expafusin,
Gelatine)
• Cairan Nutrisi ( Intrafusin, Ivelip,
Triofusin)
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 28/44
01/05/2013 28
ISF
9L
ISF IVF ICF
3L 24 L750 ml 250 ml 2 L
D5W
3L
Physiologic principles of
fluid management
Hasanul, 2002
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 29/44
01/05/2013 29
ISF
9L
ISF IVF ICF
3L 24 L2250ml 750 ml
RL,NaCl
3L
Physiologic principles of
fluid management
Hasanul, 2002
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 30/44
01/05/2013 30
ISF
9L
ISF IVF ICF
3L 24 L1L
Albumin-5%
1 L
Physiologic principles of
fluid management
Hasanul, 2002
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 31/44
01/05/2013 31
ISFISF IVF ICF
3L 24 L1000ml
HES-6%1L
Physiologic principles of
fluid management
Hasanul, 2002
9L
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 32/44
01/05/2013 32
ISF
9L
ISF IVF ICF
3L 24 L500
Albumin-25%
100 cc
Physiologic principles of
fluid management
Hasanul, 2002
400
Volume expander
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 33/44
01/05/2013 33
ISFISF IVF ICF
3L 24 L700ml
Haemacel1L
Physiologic principles of
fluid management
Hasanul, 2002
9L300ml
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 34/44
01/05/2013
34
FLUID REPLACEMENT
3 : 1 RuleClass I Crystalloid
Class II Crystalloid+ Colloid ?
Class III Crystalloid
+Colloid, BloodClass IV Crystalloid
+Colloid, Blood Hasanul, 2009
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 35/44
01/05/2013 35
Pola kerja penanganan shock
perdarahan
Penderita datang dengan
perdarahan
Pasang infus jarum kaliber
besar (16G, 18G), ambil
sample darah
Ukur tekanan darah, hitung
nadi, nilai perfusi, produksi
urine
Tentukan estimasi jumlahperdarahan, minta darah
Guyur cepat Ringer Laktat atau NaCl
0.9% [hangat, 390C] 3x prakiraan lost-
volume [1-2 liter] evaluasi
Hasanul, 2009
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 36/44
• Pulse-Rate [x/min.]
• Blood-Pressure
• Pulse-Pressure
• Respiratory Rate
• Urine out-put [ml/hour]
• Mental status/CNS
normal
e v a l u a s i
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 37/44
5/1/2013 37
Thank you for listening
and to be continued
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 38/44
01/05/2013 38
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
Perdarahan >40%
Tindakan bedah segera
Transfusi darah
Hasanul, 2003
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 39/44
01/05/2013 39
Efek volume infus 1 L cairan Kolloid pada
kompartement tubuh [BB,70kg]
L a r u t a 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 -
Hasanul, 2003
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 40/44
01/05/2013 40
TRANSIENT RESPONSE,
DARAH BELUM DATANG,
KOLLOID
1:1
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 41/44
01/05/2013 41
Transfusion, indications
• Indications for transfusion in normovolemic
anemia,
– VO2 < normal range (indicating an oxygen debt) – Blood lactate > 4 mmol/L
– O2ER > 0.5
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 42/44
01/05/2013 42
Transfusi,
Target 7 - 9g%
Rule of -
5ml Whole-Blood = 5 x delta Hb x BB
contoh:
BB 60 kg, Hb 6g%, WB yang dibutuhkan = 5 x 3 x 60
= 900 ml
= 4 bag [unit]
Hasanul, 2009
7/30/2019 Hemorrhagic Shock (Anestesi)
http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 43/44
01/05/2013 43
Why does hypothermia happen?