(46) syok - dr. maya.pptx
TRANSCRIPT
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SyokMaya TariganDepartemen Ilmu Penyakit Dalam FK Unika Atma Jaya
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• Wanita 69 tahun dibawa ke IGD oleh keluarganya karena ditemukan tidak sadar 1 jam yang lalu di rumah.
• RPD : Hipertensi, DM , dan stroke 2 tahun yang lalu– PF:
• Kesadaran : E2M2V3• TD : 100/60 mmHg• N : 124 x/mnt• P : 28x/mnt• S : 38,7 C
Kasus
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Kasus
1. Apakah pasien ini mengalami syok?
2. Apa jenis syok yang dialami pasien ini?
3. Apa yang akan Anda lakukan untuk mengatasi kondisi syok pada pasien ini?
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What ??
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Syok
‘Kegagalan sirkulasi akut’Keadaan di mana sirkulasi gagal menyediakan
oksigen yang cukup agar sel dapat berfungsi optimal
Weil MH, 1979
Henri LeDran : ‘choc’1827 -George Guhtrie : ‘shock’ Respon fisiologis terhadap injuri
Vincent JL, Ince C, Bakker J, 2012
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How ??
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Identifikasi Klinis
1. Klinis 2.Hemodinamik
3.Penanda biokimia
Vincent JL, De Backer DJ, 2013
TDS < 90 mmHgMAP <70 mmHg
>2mEq/L
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Patofisiologi
Vincent JL, De Backer DJ, 2013Vincent JL, Ince C, Bakker J, 2012
Hipovolemia
• Perdarahan (internal, eksternal)
• Dehidrasi
Kardiogenik
• Infark miokard• Kardiomiopati
tahap lanjut• Penyakit katup• Aritmia
maligna
Obstruktif
• Emboli paru• Tamponade• Tension
pneumothorax• Diseksi aorta
Distributif
• Respon inflamasi (mediator) :sepsis, anafilaksis
↓ curah jantung transport O2 inadekuatResistensi vaskuler
sistemik ↓ gangguan ekstraksi O2
Volume Pompa Pembuluh darah besar
Pembuluh darah kecil
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Patofisiologi
• Kombinasi : Syok distributif akibat
sepsis : + hipovolemia dan syok kardiogenik akibat depresi miokard
Vincent JL, De Backer DJ, 2013Vincent JL, Ince C, Bakker J, 2012
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Syok Hipovolemik
Vincent JL, De Backer DJ, 2013
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Syok Kardiogenik
Vincent JL, De Backer DJ, 2013
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Syok Obstruktif
Vincent JL, De Backer DJ, 2013
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Syok Distributif
Vincent JL, De Backer DJ, 2013
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Patofisiologi
• Gangguan sel pada mikrosirkulasi :– Disfungsi endotel– Disfungsi eritrosit– Aktivasi leukosit– Koagulopati– Gangguan otot polos
vaskuler disfungsi regulasi otonom
– Depresi mitokondria
Vincent JL, Ince C, Bakker J, 2012
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Patofisiologi
Harrison’s 17th ed
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Identifikasi Klinis
• Penilaian klinis :– 3 jendela– JVP– Edema perifer
• Ekokardiografi :– Efusi perikard– Ukuran dan fungsi ventrikel kiri– Dimensi V.cava– Curah sekuncup
Vincent JL, De Backer DJ, 2013
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Identifikasi Klinis
Vincent JL, De Backer DJ, 2013
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Prinsip Tatalaksana
Ventilation Infuse
Pump
Vincent JL, De Backer DJ, 2013Vincent JL, Ince C, Bakker J, 2012
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Ventilation
• Terapi oksigen ↑penghantaran O2 – Hati-hati eksesif : vasokonstriksi, pembentukan radikal
O2
• Pulse oxymetry : tidak andal AGD• Ventilasi mekanik : dispnoe berat, hipoksemia,
asidemia menetap– (+) : ↓ O2 demand dari otot pernafasan
↑ tekanan intratorakal ↓ afterload– ↓↓ Tekanan arteri setelah pemasangan ventilasi
mekanik : hipovolemik dan ↓ curah jantungVincent JL, De Backer DJ, 2013
Vincent JL, Ince C, Bakker J, 2012
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Infuse
• Resusitasi cairan : ↑ aliran mikrovaskuler & curah jantung– Bahkan pada syok kardiogenik
• Fluid-challenge test1. Tipe cairan : kristaloid 2. Kecepatan : 200-500 ml dalam 20-30 mnt3. Objektif : ↑TD, ↓N, ↑UO4. Batas aman : edema paru
Vincent JL, De Backer DJ, 2013Vincent JL, Ince C, Bakker J, 2012
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Pump
• Agen vasoaktif , 3 macam :1. Vasopresor2. Inotropik3. Vasodilator
Vincent JL, De Backer DJ, 2013Vincent JL, Ince C, Bakker J, 2012
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Pump
1. Vasopresor– Dapat digunakan sedini mungkin (resusitasi) dan
dihentikan sesegera mungkin ketika hipovolemi terkoreksi
– Lini I : agonis adrenergik• Onset kerja cepat• Potensi tinggi• T ½ pendek dosis mudah disesuaikan
Vincent JL, De Backer DJ, 2013Vincent JL, Ince C, Bakker J, 2012
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Pump
1. Vasopresor
Vincent JL, De Backer DJ, 2013
(+) (-)
α - Adrenergik ↑ tonus vaskuler, TD
↓ curah jantung, aliran darah di jaringan (terutama hepatosplanknik)
β - Adrenergik ↑ aliran darah ↑ denyut jantung, kontraktilitas iskemia miokard
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Pump
Overgaard CB, Dzavik V 2008Vincent JL, De Backer DJ, 2013
↑MAP
1
2
↑dosis
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Pump
2. Inotropik
Overgaard CB, Dzavik V 2008Vincent JL, De Backer DJ, 2013
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Pump
Overgaard CB, Dzavik V 2008Vincent JL, De Backer DJ, 2013
• Inotropik + vasodilator•↑ efek dobutamin•Berguna pada kondisi reseptor β adrenergik down regulated (mis: penggunaan β-blocker lama)
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Pump
3. Vasodilator• ↓ afterload ↑ curah jantung• (+) : tidak meningkatkan demand O2 miokard• (-) : ↓tekanan arteri
Vincent JL, De Backer DJ, 2013
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Target Tatalaksana
Vincent JL, De Backer DJ, 2013
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Target Tatalaksana
Vincent JL, De Backer DJ, 2013
Tekanan arteri
• MAP : > 65-70 mmHg• Disesuaikan dengan klinis pasien
Curah jantung dan
penghantaran oksigen
• Svo2/Scvo2 >70%
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Early Goal Directed Therapy
Rivers E dkk, 2001SSC guidelines 2012
•Sepsis berat : sepsis + disfungsi organ atau hipoperfusi jaringan
•Syok sepsis : hipotensi menetap akibat sepsis setelah resusitasi cairan yang adekuat
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Target Tatalaksana
Vincent JL, De Backer DJ, 2013
Kadar laktat darah
• > 3 mmol/L : ↓min 20% dalam 2 jam ↓mortalitas
Variabel mikrosirku
lasi• Daerah sublingual
• Orthogonal polarization spectral, sidstream dark-field imaging
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Further Rading
Rivers E dkk, 2001SSC guidelines 2012
1. Vincent JL, De Backer D. Circulatory shock. N Engl J Med 2013; 369: 18: 1726-34
2. Vincent JL, Ince C, Bakker J. Clinical review: circulatory shock- an update: a tribute to professoe max harry weil. Critical Care 2012; 16: 239
3. Shock and cardiac arrest dalam Harrison’s: Principles of Internal Medicine 17th ed
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Departemen Ilmu Penyakit Dalam- FK Unika Atma Jaya