Tatalaksana Awal Koreksi Cairan
pada Kasus Syok
dr. Rudy Kurniawan, SpPD
Outline
1.Fisiologi dan komposisi cairan tubuh
2.Syok hipovolemik
3.Syok septik
4.Syok anafilaktik
5.KAD
6.Contoh kasus
DISTRIBUSI & KOMPOSISI
CAIRAN TUBUH
50% pada perempuan
atau obesitas
• Semi permeabel
• Permeabel terhadap air dan elektrolit Johnson RJ, Feehally J, Floege J.
7/5/2021 • 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
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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 → hypovolemia
or hypervolemia
What to • What type of hypovolemia →
shock or not shock
do? • Comorbidities and underlying
conditions → heart failure, chronic
kidney disease, geriatric
• Loading vs maintenance
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Hypovolemic Shock
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Syok
Hipovolemik
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Fluid
Resuscitation
• 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 → 600mL – 1200 mL dlm 1 jam
• Monitor tanda vital tiap 15 menit
• Responsiveness evaluation
• Tekanan darah, nadi
• diuresis, target >0.5 ml/kgbb/jam → BB 60kg = 30mL
• Respon → 7 ml/kgbb/jam (420mL) → 5ml/kgbb/jam (300mL) → cairan maintenance
• Bila tidak respon, bisa diulang hingga kristaloid 2000-2500 → + koloid
• Bila masih tidak respon dapat dikombinasi dg vasopresor
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Responsiveness Evaluation
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Maintenance Therapy
Holliday Segar Formula
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Septic Shock
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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.
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• 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
→0.7 (max 0.5 mg) (ulang tiap 5-15 menit)
→1-2 L kristaloid; 5-10 ml/kg pada 5-10 menit
pertama
→Steroid (prednisone 1mg/kgbb →70)
→Mp 80% x 70 = 56 mg, evaluate every 6-8 hours
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Diabetic Ketoacidosis
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Tn F 62 tahun datang ke IGD dengan keluhan lemas
memberat sejak 6 jam SMRS.
diabetes melitus (+), hipertensi (+) dan penyakit
jantung disangkal. OAD tidak teratur
demam, batuk berdahak, dan tidak nafsu makan
Kasus 4 sejak 3 hari terakhir.
Pada pemeriksaan fisik TD 110/60 mmHg, Nadi
118x/mnt, RR 28 x/mnt, pola napas Kussmaul, suhu
380C. GDS 440.
BB 60kg
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• Tentukan tipe syok dan
kondisi emergensinya
• KAD? Syok Sepsis?
• Cairan
• KAD 1L/jam
• Syok sepsis 30ml/kgBB →
1800 ml
• Bundle sepsis: laktat, kultur,
antibiotic, cairan ,
vasopresor
• Protokol KAD: cairan, insulin,
bikarbonat, kalium
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• Tn H 57 thn datang ke UGD dg sesak memberat 6
jam SMRS
• Pasien CKD st IV (eGFR 22)
Kasus 5 • 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? → 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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