Diagnosis dan Manajemen
Syok
Irfan Hamdani
Dept. Anestesiologi FK UMSU
Shock
Always a symptom of primary cause
Inadequate blood flow to meet tissue
oxygen demand
May be associated with hypotension
Associated with signs of hypoperfusion:
mental status change, oliguria, acidosis
SHK 2
Kategori Syok
Cardiogenic
Hypovolemic
Distributive
Obstructive
SHK 3
Cardiogenic Shock
kontraktilitas jantung
menurun
Peningkatan tekanan
pengisian jantung,
penurunan SV,
penurunan CO,
peningkatan SVR
SHK 4
Hypovolemic Shock
Decreased cardiac output
Decreased filling pressures
Compensatory increase in
systemic vascular resistance
SHK 5
Distributive Shock
Normal or increased cardiac output
Low systemic vascular resistance
Low to normal filling pressures
Sepsis, anaphylaxis, neurogenic,
and acute adrenal insufficiency
SHK 6
Obstructive Shock
Decreased cardiac output
Increased systemic vascular
resistance
Variable filling pressures
dependent on etiology
Cardiac tamponade, tension
pneumothorax, massive
pulmonary embolus
SHK 7
Cardiogenic Shock Management
Treat arrhythmias
Diastolic dysfunction may
require increased filling
pressures
Vasodilators if not hypotensive
Inotrope administration
SHK 8
Cardiogenic Shock Management
Vasopressor agent needed if
hypotension present to raise
aortic diastolic pressure
Consultation for mechanical
assist device
Preload and afterload reduction
to improve hypoxemia if blood
pressure adequate
SHK 9
Hypovolemic Shock
Management
Volume resuscitation crystalloid,
colloid
Initial crystalloid choices
Lactated Ringers solution
Normal saline (high chloride may
produce hyperchloremic acidosis)
Match fluid given to fluid lost
Blood, crystalloid, colloid
SHK 10
Distributive Shock Therapy
Restore intravascular volume
Hypotension despite volume therapy
Inotropes and/or vasopressors
Vasopressors for MAP < 60 mm Hg
Adjunctive interventions dependent on
etiology
SHK 11
Obstructive Shock Treatment
Relieve obstruction
Pericardiocentesis
Tube thoracostomy
Treat pulmonary embolus
Temporary benefit from fluid
or inotrope administration
SHK 12
Fluid Therapy
Crystalloids
Lactated Ringers solution
Normal saline
Colloids
Hetastarch
Albumin
Gelatins
Packed red blood cells
Infuse to physiologic endpoints
SHK 13
Fluid Therapy
Correct hypotension first
Decrease heart rate
Correct hypoperfusion abnormalities
Monitor for deterioration of
oxygenation
SHK 14
Inotropic / Vasopressor Agents
Dopamine
Low dose (2-3 g/kg/min) mild inotrope
plus renal effect
Intermediate dose (4-10 g/kg/min)
inotropic effect
High dose ( >10 g/kg/min) vasoconstriction
Chronotropic effect
SHK 15
Inotropic Agents
Dobutamine
5-20 g/kg/min
Inotropic and variable chronotropic effects
Decrease in systemic vascular resistance
SHK 16
Inotropic / Vasopressor
Agents
Norepinephrine
0.05 g/kg/min and titrate to effect
Inotropic and vasopressor effects
Potent vasopressor at high doses
SHK 17
Inotropic / Vasopressor Agents
Epinephrine
Both and actions for inotropic
and vasopressor effects
0.1 g/kg/min and titrate
Increases myocardial O2 consumption
SHK 18
Therapeutic Goals in Shock
Meningkatkan deliveri O2
Mengoptimalkan O2 di darah
meningkatkan cardiac output and tekanan
darah
Menyesuaikan kebutuhan O2 sistemik dan
hantaran O2
Mencegah organ hypoperfusion
SHK 19
Oliguria
Marker of hypoperfusion
Urine output in adults
<0.5 mL/kg/hr for >2 hrs
Etiologies
Prerenal
Renal
Postrenal
SHK 20
Evaluation of Oliguria
History and physical examination
Laboratory evaluation
Urine sodium
Urine osmolality or specific gravity
BUN, creatinine
SHK 21
Evaluation of Oliguria
Laboratory Test
Prerenal
ATN
Blood Urea Nitrogen/
Creatinine Ratio
>20
1020
Urine Specific Gravity
>1.020
<1.010
Urine Osmolality (mOsm/L)
>500
<350
Urinary Sodium (mEq/L)
<20
>40
Fractional Excretion of Sodium (%)
<1
>2
SHK 22
