BAGIAN ANESTESIOLOGI BAGIAN ANESTESIOLOGI FAKULTAS KEDOKTERAN UNIVERSITAS FAKULTAS KEDOKTERAN UNIVERSITAS
ANDALASANDALAS
NASMAN PUARNASMAN PUAR
Introduction
Life-threatening condition Result from a number of primary
causes Be aware of physiologic effects
of shock Be able to detect Report the development or
worsening of this very serious condition
Hypovolemic shock
Cardiogenic
shock
Anaphylacticshock
Septicshock
Neurogenicshock
Definitions of shock types:
Definition of Shock
A state of inadequate tissue perfusion resulting in decreased amount of oxygen to vital tissues and organs leading to reduced removal of waste products of metabolism
Diagnosis of ShockEarly Recognition Physiological Diagnosis
Weak, thready Weak, thready pulsepulse
Cold, clammy Cold, clammy skinskin
Altered mental Altered mental statusstatus
Unstable vital Unstable vital signssigns
CyanosisCyanosis
Subjective Symptoms and
Imprecise Signs:• Hypotension• Acidosis• Oliguria• Collapse• Reduced
Oxygen Delivery
Objective haemodynamic signs
Classification of Hypovolemic Shock*
Blood loss
Blood volume
Heart rate
Blood pressure
Pulse pressure
Urine output
Class I
< 750 ml
< 15%
< 100
Normal
Normal
> 30 ml/hr
Class II
750-1500 ml
15-30%
> 100
Normal
Decressed
20-30 ml/hr
Class III
1500-2000 ml
30-40%
> 120
Normal to
Decreased
5-15 ml/hr
Class IV
> 2000 ml
> 40%
> 140
Decreased
Decreased
nil
T. James Gallagher, 1995
Treatment for Hypovolemic Shock
Maintain airway Control bleeding Baseline vital signs Level of consciousness
Goals - Increase tissue perfusion and oxygenation status
Vascular volume deficit management
Goal therapy of shock
Restoration of Cardiac Index, DO2, VO2
( optimized to maintain body metabolic requirement )
Improved tissue perfusion
Delivery O2 = COxHbxSpO2x1,34 +(0,003xPaO2)
Left ventricularend diastolic volum e
intrathoracic pressure
preload afterload contractility
Cardiac Output
SVR = 80 x ( MAP –CVP )
CO
CO = Stroke vol xHR
Intravascular Volume
RESUSCITATIONRESUSCITATION MAINTENANCEMAINTENANCE
NUTRITIONNUTRITIONCrystalloidCrystalloid
1. Replace acute loss (hemorrhage, GI loss, 3rd space etc)
1. Replace acute loss (hemorrhage, GI loss, 3rd space etc)
1. Replace normal loss (IWL + urine+ faecal)2. Nutrition support
1. Replace normal loss (IWL + urine+ faecal)2. Nutrition support
ELECTROLYTESELECTROLYTES
FLUID THERAPYFLUID THERAPY
Colloid
colloid or crystalloid ?
Normovolemia
Lactated
Ringer's,
Normal
Saline
AlbuminFFP
GelatinHES Dextr
an
Crystalloids
Colloidsnatural
synthetic
Composition of Crystalloid & Coloid SolutionsJenisJenis NaNa ClCl KK CaCa MgMg Lact/Lact/
AcetatAcetatlain2lain2
NaCl0.9%NaCl0.9% 154154 151544
-- -- -- -- --
Ring LaktRing Lakt 138138 111122
44 55 -- Lakt/28Lakt/28 --
ExpafusinExpafusin 138138 121255
44 33 Lakt/20Lakt/20 HES/40000HES/40000
Haes st 6% Haes st 6% ,10%,10%
154154 151544
-- -- -- -- HES/HES/200000200000
HemacelHemacel 145145 141455
5,15,1 6,26,255
-- -- PolygelinePolygeline
GelafundinGelafundin 142142 8080 -- 1,41,4 -- -- Gelatin/Gelatin/3500035000
Dextran LDextran L 130130 101088
44 2,72,7 -- Lakt/28Lakt/28 Dextran40Dextran40
NaCl 3%NaCl 3% 500500 505000
-- -- -- -- --
Colloid vs. Crystalloid
ECF ECF
ICF ISF PlasmaICF ISF Plasma
3 : 1
• Ringer acetate• Ringer lactate• NaCl 0.9%
IsotonicIsotonic
ICF ISF PlasmaICF ISF Plasma
D5W N4
NaCl 0.45%
ICF > ECF ICF > ECF
40 : 15 : 5
Hypotonic Hypotonic
+ Hyponatremia
+ hyperglicemia
Plasma Plasma
ICF ISF PlasmaICF ISF Plasma
colloidscolloids
hyperoncotic
Colloids contain large, oncotically active molecules.
natural products (eg, albumin, FFP) Semisynthetic (gelatine, starches or dextrans).
more impermeable to intact capillary membranes than crystalloids.
smaller volumes of colloids than crystalloids are required for fluid resuscitation.
Demands on an ‘ideal’ Synthetic Colloids:(which does not exist!)
inexpensive and free of infectious agents available in unlimited quantities stable for long periods of time colloid osmotic pressure and viscosity like plasma completely degradable and eliminated via kidneys no longtime storage in the organs No negative impact on liver- kidney or immune
function sufficient volume effect and duration free of coagulation disorders free of toxic, allergic and antigenic reactions
Tetrastarch
(0.4)
Pentastarch (0.5)
Hetastarch (0.7)
HES 130 /0.4 HES 200 /0.5 HES 450
/0.7
(Based on degree of substitution)
(Based on Molecular weight)
High molecular weight
HES
Medium Molecular weight
HES
Low molecular weight
HES
HES 450 / 0.7
HES 470 /0.7
HES 200 /0.5
HES 200 /0.62
HES 40 /0.5
HES 70 /0,5
HES 110 /0,5
HES 130 /0,4
HespanPlasmasteril
Hemohes,Haes-steril
ElohesPentaspan
Hespander, Rheohes,Voluven, Venofundin
1.
2.
HES = Hydroxethylstarch
(Not all HES are the same!)
Gelatin Solutions
(Not all Gelatin Solutions are the same!)
Polygeline
(urea linked/diisocyanate)
Oxypolygeline
(OPG)
Gelofusine,
Gelafundin,Haemaccel
Gelifundol
Mw= 30 000 dalton Mw= 35 000 Mw= 30 000
4% 3.5% 4%
Modified Fluid Gelatin(MFG)(succinylated)
Average initial volume effect /average duration of volume effect(in hypovolemic volunteers)
0 50 100
150
200
(%)
3.5 % Polygeline
4% Modified Fluid Gelatin6% HES 200/0.5
6% Dextran 706% HES 200/0.62 and HES 450/0.710% HES 200/0.45 and 0.5
10% Dextran 40
~70%
~ 100 %
1oo%
145 %
~ 190 %
~2-3h
~3-4h
~ 4h
~ 3-4h
~ 7-9h~ 4h
Effects of solutions onhaemostasis and
coagulationGelatins HES Dextrans
Factor VIII, vWF
Platelets adhesion aggregation
Thrombus formation
Blood typing
No effect
No effect
No clinical effect
No effectIn emergency situations blood typing prior to infusion!
tim
e
An urban Emergency DepartmentAn urban Emergency Department 263 patients263 patients Severe sepsis or septic shockSevere sepsis or septic shock Therapy for 6 hours before transfer to Therapy for 6 hours before transfer to
ICUICU Standard therapy (N=133)Standard therapy (N=133) Therapy guided by ScvOTherapy guided by ScvO22 catheter catheter
(N=130)(N=130)
Mortality reduced from 46.5% Mortality reduced from 46.5% to 30.5%!to 30.5%!
Rivers E.: Early goal-directed therapy in the treatment of severe sepsis and septic shock NEJM 2001; 345:1368-
1379
Rivers E.: Early Goal-Directed Rivers E.: Early Goal-Directed Therapy In The Treatment Of Therapy In The Treatment Of Severe Sepsis And Septic Severe Sepsis And Septic ShockShock
Algorithm for Study GroupAlgorithm for Study Group
NEJM 2001;345:1368NEJM 2001;345:1368
Oncoticpressure
Increased IVvolume
Venous flow-back(preload)
Improvedrheology
Arterial oxygenconcentration
Flow resistance
Cardiacoutput
Keep the fluidin the IVS
CO DO 2 c OCaO2
Hematocrit
Hemodilution
Effects of Synthetic Colloids
Blood loss (%)
Colloids + crystalloids
100908070605040302010
+ PRC +FFP +platelets
0
Adapted from Adams, H.A. 1996
Cryst.+colloids
Replacement of blood losses“ Step by step”
volume - oxygen carriers - plasmatic coagulation - cellular coagulation
Conclusion :The decision on what synthetic colloid should be selected has to be made considering the pro and cons of each specific solution and the specific conditions of each individual patient on a case to case basis!
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