fluid resuscitation.pdf
TRANSCRIPT
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Syok hemoragik:Resusitasi Cairan
DR Yefta Moenadjat, dr, SpBP(K)
Dep Medik Ilmu Bedah RSCMFKUI
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Latar Belakang
Konsep resusitasi cairan berubah sejalan deng
perkembangan iptekdok mengenai patofisiologi sytransportasi dan distribusi aircairan serta dampaknya
Banyak bukti [evidence] dihadirkan mengenai bahapemberian cairan dalam jumlah besar; terlebih: kllebih bermakna.
Kata kunci:Perubahan paradigma syok, resusitasi cairan (targ
endpoint), strategi.
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Syok
Circulatory Shock (Shock)
Kondisi mengancam jiwa yang terjadi karena ketidakcukupasubstrat yang dibutuhkan respirasi sel (aerob). Kondisi inidiawali oleh ketidakcukupan oksigen di jaringan.
Penyebab utama kematian pada penderita trauma.
Memiliki variasi menifestasi dengan kesamaan luaran;kesemuanya berhubungan dengan kegagalan sistem
sirkulasi.Contoh: Hipoksemiahenti jantung
Hipovolemia, Kardiogenik, Distributif, Anafilaktik
Hipovolemia,
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Syok Hipovolemia
Migrasi cairan (plasma)
ke jaringan interstisium
Migrasi leukosit
Hemokonsentrasi [Hb]Kehilangan
Cairan (plasma)
Selsel darah / [Hb
Luka Bakar Hemo
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Syok Hipovolemia
Hipovolemia:
Ketidakcukupan volume intravaskular distribusi cairan terganggu Hemokonsentrasi: [Hb]SaO2 (/N) Hemoragik: [Hb]SaO2
Perfusi sel
Aktivitas sel Rantai respirasi (mitokondria) O2: Gggan metabolisme (CHO, protei
lemak) ProduksiATPKehidupan sel
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Lipid bilayer
Pumps and channel
(Membranes protein)
Cytoskeleton
Glycoprotein
Receptors
Na+
K+
Glucose
TCACycle
PyruvateCytoplasma Acetyl CoA
NADH
FADH2
ATP
ATP
ATP
ATP
ATP
ATP
CO2H2O
Lactic Acid
Cell membrane
Mitochondrion
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Sistem sirkulasi kranial
Sistem sirkulasi paru kiri
Sistem sirkulasi hepar
Sistem sirkulasi sistem digestif
Sistem sirkulasi tubuh bagian bawah
Vena PulmonarDarah mengandung O2dibawa kembali ke jantung
AortaDarah mengandung O2dibawa ke seluruh tubuh
Arteri PulmonarDarah mengandung CO2dibawa ke paru
Arteriol
Kapiler
Venula
Sistem Sirkulasi ParuKananDarah melepaskan CO2 danmenyerap O2 di kapiler
VenaPortaDarah kaya akan nutrien berasal dari
sistem digestif dibawa ke hepar
Vena Cava InferiorDarah dari tubuh bagianbawah dibawa ke jantung
Vena Cava SuperiorDarah dari tubuh bagian atas
dibawa ke jantung
Sirkulasi PulmonaSirkulasi sistemik
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0
Vena Porta1.150 mL/min
(21%)
70 mL/min
(1.4%)
1.100 mL/min
(20%)
300 mL/min
(5%)
1.240 mL/min
(22%)
1.310 mL/min
(23%)
700 mL/min
(13%)
240 mL/min
(4%)
5.800 mL/min
(100%)
5.800 mL/min
(100%)
SSPUsus
Limpa
HeparKidney
Otot, kulit dan jar
adiposus
Jantung
Lung
Waktu iskemik setiap sel (organ berbeda)
Sistem
Sistem muskular
Ginjal
Usus
Portal
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Lingkaran setan perdarahan
Perdarahan
aktif
Trauma Mayor pada torso
Iatrogenik
Syok
seluler
Kerusakan
jaringan
Transfusi m
Aktivasi adhesi
ELT*
Defisiensi faktor
pembekuanPenyak
komorbi
Asidosis
metabolik
Hipotermia
Koagulopatia
progresif
*ELT: Endotel Leukosit Trombosit
**Koagulopatia: 1) Perdarahan, 2) Trombosis
TRIAS KEMATIAN
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Resusitasi Cairan
Definisi
1. Pemberian cairan isotonik intravena secara cepat untumengatasi defisit volume (volume replacement)
2. Pemberian cairan isotonik intravena pada pasien traumluka bakar, dan pasien hipotensif
3. Prosedur pemberian cairan intravena untuk tujuanrestorasi, revivaldan renewal.
Santry HP, Alam HB. Shock. 2010; 33(3): 22941
1. Dorlands Online Medical Dictionary. Available in website: http://www.dorlands.com2. McGrawHill Concise Dictionary of Modern Medicine. 2002 by The McGrawH
Companies, Inc.
Boldt J. Clinical review: Crit Care. 2002; 6: 5259
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Resusitasi Cairan
Masalah pada Resusitasi:
Pemberian sejumlah volume cairan isotonitidak sertamerta diikuti perbaikan perfusi
Pemberian cairan agresif
TD tidak merepresentasikan perfusPerbaikan TD (pada hipotensi) diikulepasnya bekuan darah perdarahaberulang
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The history
Tom Shires
Early aggressive resuscitation argued thatthe need for increasing cardiac output andoxygen delivery to maintain microvascularperfusion and oxygenation, exceeds any riskof accentuating hemorrhage and thereforetrauma victims in hypotensive hemorrhageshould receive large volumes of fluids asearly as possible (1970).
G. Tom Shires 1925- 20
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Resusitasi Cairan
Masalah pada Resusitasi:
Pemberian sejumlah volume cairan isotonitidak sertamerta diikuti perbaikan perfusi
Pemberian cairan agresif
"The injection of a fluid that will increase bloodpressure has dangers in itself. Hemorrhage
may not have occurred to a marked degree
because the blood pressure has been too low
to overcome the obstacle offered by a clot.
Myburgh JA, Mythen MG. Resuscitation fluids. Review article. N Engl
Med. 2013; 369;13:12431251
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Resusitasi Cairan
Masalah pada Resusitasi:
Pemberian sejumlah volume cairan isotonitidak sertamerta diikuti perbaikan perfusi
Pemberian cairan agresif
Volume efektif 1/3 volume yandiberikan
Cairan isotonik masif edeminterstisium masif (Kelebihan cairan sindroma rongga ketiga [fatal]
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Resusitasi Cairan
Masalah pada Resusitasi:
Pemberian sejumlah volume cairan isotonitidak sertamerta diikuti perbaikan perfusi
Pemberian cairan agresif
Asidosis (hiperkloremik) anion gap / SID[Stewart]
Gangguan pembekuan
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Resusitasi Cairan
Masalah pada Resusitasi:
Pemberian sejumlah volume cairan isotonitidak sertamerta diikuti perbaikan perfusi
Pemberian cairan agresif
Hipotermia [ATP] Asidosis [hiperkloremik]
Gangguan pembekuan [iatrogenik]
Pemicu mediator proinflamasi
TRIAS KEMATIAN
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Well, Wait weve always given fluids, Dr Shires told u
to do this. Anyway, it is just salt water, it cant possibly
hurt the patient, can it???
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Resusitasi Cairan
Masalah pada Resusitasi:
Pemberian sejumlah darah untuk perbaikaperfusi
Pemberian cairan koloid
Efek pengenceran (dilusi)
Gangguan pembekuan
Reaksi hipersensitivitas (sebagaimancairan isotonik)Kaczynski J, Wilczynska M, Hilton J, Fligelstone L. A literature revieEmerg Med Health Care. Open access.(http://creativecommons.org/licenses/by/3.0).
Velanovich V. A meta-analysis of mortality. Surgery 1989;105:65-71
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Resusitasi Cairan
Kontra resusitasi agresif (2000s)
Hypotensive Resuscitation
Permissive Hypotension
Restrictive Fluid Resuscitation (
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The fluid resuscitation
Hypotensive resuscitation:
Such advice runs contrary to current teaching on themanagement of haemorrhagic shock in bothPrehospital and Advanced Trauma Life Supportmanuals, both of which advocate initial fluid therapy.
The authors' management of severely injured patienwith 'permissive hypovolaemia' is not commonly
practiced.
Dutton RP, Mackenzie CF, Scalea TM. J Trauma. 2002;52:11411146Jackson K , Nolan J. JICS. 2009;10(2):109114.Harris T, Rhys Thomas GO, Brohi K. BMJ 2012; 345.
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The new concept
The equilibrium
Balanced (fluid) Resuscitation
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Pendekatan Baru: Konsep keseimbangan
Konsep keseimbangan total
Larutan seimbang (balanced salt solution: elektrolit)
Morgan et al. Designing Balanced Crystalloids .Crit Care Resusc.2003; 5: 284-291
Hartmanna Plasmalytea Plasmalyte Ra
Sod ium 129 140 140
Chlor ide 109 98 103
Potassium 5 5 10
Calc ium 2 5
Magnesium 1.5 3
Lactate 29 8
Acetate 27 47
Gluconate 23
Effective SIDb 27 50 53
SID = strong ion differenceaBaxter (Australia)bSID values are in mEq/L, and asume stable plasma lactate concentration of 2mmol/L
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Pendekatan Baru: Konsep keseimbangan
Konsep keseimbangan total
Volume koloid seimbang dengan volumreplacement memberi keuntungan (statkeseimbangan asambasa)
Formula larutan HES 6% 130kDa:RL 1memperbaiki perfusi ke mukosa gaster(asesmen gastric tonometry) lebih baik
dibanding HES 6% (130kDa) saja
The balanced concept of fluid resuscitation . Editorial. Brit J Anaesth. 2007. 99 (3): 31215James MF, Michell WL, Joubert IA, Nicol AJ, Navsaria PH, Gillespie RS: Resuscitation withhydroxyethyl starch improves renal function and lactate clearance in penetrating trauma in arandomized controlled study: the FIRST trial (Fluids in Resuscitation of Severe Trauma). Br J Anae2011, 107:693-702
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Pendekatan Baru: Konsep keseimbangan
Konsep keseimbangan total
Tatalaksana syok:
Perbaikan O2delivery: PRC
Mencegah/mengatasi koagulopati:
Seluler = Trombosit
Humoral = FFP
Hindari:
Hyperfibrinolysis = TXA danHypofibrinogenemia = Cryoprecipitate
Transfusi masif
Clinical Review. Early fluid resuscitation in severe trauma. BMJ 2012;345:e5752
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Pendekatan Baru: Konsep keseimbangan
Konsep keseimbangan total
Resusitasi awal:
RL (maksimum 1000 mL) dan PRC.
Keuntungan pemberian produk darah di awalmembawa banyak keuntungan.
Perdarahan masif:
Clinical Review. Early fluid resuscitation in severe trauma. BMJ 2012;345:e5752
Chambers et al . Coagulopathy in treated trauma patients. Am J Clin Pathol 2011;136:370
PRC : Trombosit : FFP
1 1 1
0.51.3 g/un1020 mL/kg (1
~ 230mL)
2040 x 109/L1 unit ~ 60mL
1 unit/bag ~ 300mL4mL X kg X Hb g/dL
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Pendekatan Baru: Konsep keseimbangan
Konsep keseimbangan total
Tidak terlalu cepat, tidak terlalulambat..
focused on "golden hour" utk pra RS (ATLS 9th)
Seni resusitasi
Tidak kekurangan, tidak kelebihan.
Seni resusitasi
McSwain NE, Champion HR, Fabian TC, Hoyt DB, Wade CE, Eastridge BJ, State of the art of fluidresuscitation 2010: prehospital and immediate transition to the hospital. J Trauma. 2011 ;70(5Suppl):S2-10.Richardson RG. The art of resuscitation. J R Soc Med 1990;.83(11):753. PMC1292936Burdett et al. Perioperative buffered versus non-buffered fluid administration for surgery in adults.
Cochrane Anaesthesia Group . The Cochrane Collaboration. John Wiley & Sons, Ltd. 2003
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Pendekatan Baru: Konsep keseimbangan
PemantauanMentation
Skin perfusion / mottling
Cold extremities (and cold knees)
Capillary refill
Mean arterial pressure
Urine output, urine sodium and osmolarity
Cerebral and abdominal perfusion pressures
Blood lactate
Arterial pH, BE, and HCO3-
Mixed venous oxygen saturation SmvO2(or ScvO2)Mixed venous pCO2Tissue pCO2 (sublingual capnometry, gastric tonometry)
Skeletal muscle tissue oxygenation (StO2, NIRS)
Marik et al. Hemodynamic parameters to guide fluid therapy. Annals of Intensive Ca
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Miller TE. Perioperative Medicine 2013, 2:13http://www.perioperativemedicinejournal.com/content/2/1/13
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ATLS 9th edition
Initial resuscitation:
1000 mL (NOT 2000 mL)
The goal of resuscitation is
to treat hypotension BUT
perfusion
Balanced resuscitation
Such a resuscitation stratemay be a bridge to but is a
not a substitute for
definitive surgical control of
bleeding (page 63-64).
ATLS
approach to thetrauma pat ient
ATLS express guidelines, not
protocols Can be applied at Trauma Centers
as well Local protocols: inspired by
ATLS; they should considerstructural, diagnostic andprofessional resources
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Strategi
Pendekatan pada syok hemoragik:
Damage control resuscitation terdiri dari:
1. Awal: RL maksimum 1000mL
2. Pengendalian sumber perdarahan
3. Pemberian awal PRC, FFP dan Trombosit rasio1:1:1
4. Hindari pemberian kristaloid berlebihan
5. Prevensi dan tatalaksana hipohermia, hipokalsemia,asidosis dan koagulopatia
6. Hypotensive resuscitation
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