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Syok HipovolemiaSyok Hipovolemia

Dr.Irfan Hamdani,Sp.An Dr.Irfan Hamdani,Sp.An Dept.Anestesiologi dan Terapi Intensif Dept.Anestesiologi dan Terapi Intensif 

Fak.Kedokteran UMSU Fak.Kedokteran UMSU 

Medan Medan 

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SyokSyok

 suatu kondisi dimana sistemsuatu kondisi dimana sistemkardiovaskular gagal dalamkardiovaskular gagal dalam

menghasilkan perfusi jaringanmenghasilkan perfusi jaringanyang adekuatyang adekuat

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Perfusi jaringan yang tidak adekuat akanPerfusi jaringan yang tidak adekuat akan

menghasilkan :menghasilkan :

• hipoksia celluler generalisatahipoksia celluler generalisata• gangguan berat metabolisme selulergangguan berat metabolisme seluler

•Kerusakan jaringanKerusakan jaringan

• gagal organgagal organ• kematiankematian

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Diagnosis SyokDiagnosis Syok

MAP < 60MAP < 60

 Klinis :Klinis :terdapat gejalaterdapat gejala

dan tandadan tandahipoperfusihipoperfusi jaringan jaringan

IT IS NOT LOW BLOOD PRESSURE !!!

IT IS HYPOPERFUSION…..

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GangguanGangguan

PompaPompa

 jantung jantung

Sistem sirkulasiSistem sirkulasi  Volume Volume

Gangguan aliran keGangguan aliran ke Jaringan Jaringan

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CELLULARCELLULAR

OXYGENOXYGENSUPPLYSUPPLY

CELLULARCELLULAROXYGENOXYGEN

DEMANDDEMAND

Impaired tissue perfusion occurs when anImpaired tissue perfusion occurs when animbalance develops between cellular oxygenimbalance develops between cellular oxygen

supply and cellular oxygen demandsupply and cellular oxygen demand..

PATHOPHYSIOLOGY OFPATHOPHYSIOLOGY OFSHOCK SYNDROMESHOCK SYNDROME

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PATHOPHYSIOLOGY OFPATHOPHYSIOLOGY OFSHOCK SYNDROMESHOCK SYNDROME

Cells switch from aerobic to anaerobic metabolismCells switch from aerobic to anaerobic metabolism

lactic acid productionlactic acid production

Cell function ceases & swellsCell function ceases & swells

membrane becomes more permeablemembrane becomes more permeable

electrolytes & fluids seep in & out of cellelectrolytes & fluids seep in & out of cell

Na+/K+ pump impairedNa+/K+ pump impaired

mitochondria damagemitochondria damage

cell deathcell death

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COMPENSATORY MECHANISMS:COMPENSATORY MECHANISMS: Sympathetic Nervous System (SNS)-Sympathetic Nervous System (SNS)-

 Adrenal Response Adrenal Response

 SNS - Neurohormonal responseSNS - Neurohormonal response

Stimulated by baroreceptorsStimulated by baroreceptorsIncreased heart rateIncreased heart rate

Increased contractilityIncreased contractility

Vasoconstriction (SVR-Afterload)Vasoconstriction (SVR-Afterload)

Increased PreloadIncreased Preload

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COMPENSATORY MECHANISMS:COMPENSATORY MECHANISMS:Sympathetic Nervous System (SNS)-Sympathetic Nervous System (SNS)-

 Adrenal Response Adrenal Response

SNS - Hormonal:SNS - Hormonal: Renin-angiotensionRenin-angiotension

systemsystem  Decrease renal perfusionDecrease renal perfusion

 Releases renin angiotension IReleases renin angiotension I

 Angiotension II potent vasoconstriction & Angiotension II potent vasoconstriction & Releases aldosterone adrenal cortexReleases aldosterone adrenal cortex

 Sodium & water retentionSodium & water retention

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COMPENSATORY MECHANISMS:COMPENSATORY MECHANISMS:

Sympathetic Nervous System (SNS)-AdrenalSympathetic Nervous System (SNS)-Adrenal

ResponseResponse

SNS - Hormonal: Antidiuretic HormoneSNS - Hormonal: Antidiuretic Hormone

Osmoreceptors in hypothalamus stimulatedOsmoreceptors in hypothalamus stimulated

 ADH released by Posterior pituitary gland ADH released by Posterior pituitary gland

 Vasopressor effect to increase BP Vasopressor effect to increase BP

 Acts on renal tubules to retain water Acts on renal tubules to retain water

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COMPENSATORY MECHANISMSCOMPENSATORY MECHANISMS Sympathetic Nervous System (SNS)Sympathetic Nervous System (SNS)

 Adrenal Response Adrenal Response

SNS - Hormonal:SNS - Hormonal: Adrenal Cortex Adrenal Cortex Anterior pituitary releases Anterior pituitary releases

adrenocorticotropic hormone (ACTH)adrenocorticotropic hormone (ACTH)

Stimulates adrenal Cx to releaseStimulates adrenal Cx to release

glucorticoidsglucorticoids

Blood sugar increases to meet increasedBlood sugar increases to meet increased

metabolic needsmetabolic needs

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Failure of Compensatory ResponseFailure of Compensatory Response

Decreased blood flow to the tissues causesDecreased blood flow to the tissues causescellular hypoxiacellular hypoxia

 Anaerobic metabolism begins Anaerobic metabolism beginsCell swelling, mitochondrial disruption,Cell swelling, mitochondrial disruption,

and eventual cell deathand eventual cell death

If Low Perfusion States persists:If Low Perfusion States persists:

IRREVERSIBLEIRREVERSIBLE DEATH IMMINENT!!DEATH IMMINENT!!

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Stages of ShockStages of Shock Initial stage -Initial stage - tissues are under perfused, decreased CO,tissues are under perfused, decreased CO,increased anaerobic metabolism, lactic acid is buildingincreased anaerobic metabolism, lactic acid is building

Compensatory stageCompensatory stage -- Reversible. SNS activated by lowReversible. SNS activated by lowCO, attempting to compensate for the decrease tissueCO, attempting to compensate for the decrease tissue

perfusion.perfusion. Progressive stage -Progressive stage -Failing compensatory mechanisms:Failing compensatory mechanisms:profound vasoconstriction from the SNSprofound vasoconstriction from the SNS

ISCHEMIA Lactic acid production is highISCHEMIA Lactic acid production is high

metabolic acidosismetabolic acidosis Irreversible or refractory stage -Irreversible or refractory stage -Cellular necrosis andCellular necrosis andMultiple Organ Dysfunction Syndrome may occurMultiple Organ Dysfunction Syndrome may occur

DEATH IS IMMINENT!!!!DEATH IS IMMINENT!!!!

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Pathophysiology Systemic LevelPathophysiology Systemic Level

Net results of cellular shock:Net results of cellular shock: systemic lactic acidosissystemic lactic acidosis

decreased myocardial contractilitydecreased myocardial contractility

decreased vascular tonedecreased vascular tone

decrease blood pressure, preload, anddecrease blood pressure, preload, andcardiac outputcardiac output

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Clinical Presentation:Clinical Presentation:

Generalized ShockGeneralized Shock Vital signs Vital signs

HypotensiveHypotensive:(may be WNL or due to:(may be WNL or due to

compensatory mechanism)compensatory mechanism) < 90< 90mmHgmmHg

MAPMAP < 60 mmHg< 60 mmHg

 Tachycardia Tachycardia:: Weak and Thready pulse Weak and Thready pulse Tachypneic Tachypneic-blow off CO2-blow off CO2  RRespiratory alkalosisespiratory alkalosis

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Mental status:Mental status:  restless, irritable, apprehensiverestless, irritable, apprehensive  unresponsive, painful stimuli onlyunresponsive, painful stimuli only

Decreased Urine outputDecreased Urine output

Clinical Presentation:Clinical Presentation:

Generalized ShockGeneralized Shock

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1818

Shock SyndromesShock Syndromes

Hypovolemic ShockHypovolemic Shock

 blood blood

 VOLUME VOLUME

 problemproblem

Cardiogenic ShockCardiogenic Shock blood bloodPUMPPUMP problemproblem

Distributive ShockDistributive Shock[septic;anaphylactic;neurogenic][septic;anaphylactic;neurogenic]

 blood blood VESSEL VESSEL problemproblem

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Hypovolemic ShockHypovolemic Shock

Loss of circulating volume “Empty tank ”Loss of circulating volume “Empty tank ”

 decrease tissue perfusiondecrease tissue perfusion general shockgeneral shock

responseresponse

ETIOLOGY:ETIOLOGY:

Internal or External fluid lossInternal or External fluid loss

 Intracellular and extracellularIntracellular and extracellular

compartmentscompartmentsMost common causes:Most common causes:

 HemmorhageHemmorhage

 DehydrationDehydration

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Hypovolemic ShockHypovolemic Shock

External loss of fluidExternal loss of fluid

Fluid loss: DehydrationFluid loss: Dehydration  Nausea & omiting, diarr!ea, massie diuresis,Nausea & omiting, diarr!ea, massie diuresis,

e"tensie #urnse"tensie #urns

Blood loss:Blood loss:  trauma$ #lunt and penetratingtrauma$ #lunt and penetrating  BLOOD YOU SEEBLOOD YOU SEE  BLOOD YOUBLOOD YOU DON’TDON’T SEESEE 

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Hypovolemic Shock:Hypovolemic Shock:

Internal fluid lossInternal fluid loss

Loss of Intravascular integrityLoss of Intravascular integrity

Increased capillary membraneIncreased capillary membranepermeabilitypermeability

Decreased Colloidal Osmotic PressureDecreased Colloidal Osmotic Pressure (third spacing(third spacing))

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Pathophysiology ofPathophysiology of

Hypovolemic ShockHypovolemic ShockDecreased intravascular volume leads to….Decreased intravascular volume leads to….Decreased venous return (Preload, RAP) leadsDecreased venous return (Preload, RAP) leads

to...to...

Decreased ventricular filling (Preload, PAWP)Decreased ventricular filling (Preload, PAWP)

leads to….leads to….

Decreased stroke volume (HR, Preload, &Decreased stroke volume (HR, Preload, &

 Afterload) leads to ….. Afterload) leads to …..Decreased CO leads to...(CompensatoryDecreased CO leads to...(Compensatory

mechanisms)mechanisms)

Inadequate tissue perfusion!!!!Inadequate tissue perfusion!!!!

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 Assessment & Management Assessment & Management

S/S vary depending on severity of fluid loss:S/S vary depending on severity of fluid loss: 15%[750ml]-15%[750ml]- compensatory mechanismcompensatory mechanismmaintains COmaintains CO

15-30% [750-1500ml15-30% [750-1500ml- Hypoxemia, decreased- Hypoxemia, decreasedBP & UOPBP & UOP

30-40% [1500-2000ml]30-40% [1500-2000ml] -Impaired-Impairedcompensation & profound shock along withcompensation & profound shock along with

severe acidosissevere acidosis 40-50%40-50% - refactory stage:- refactory stage:

 loss of volume= deathloss of volume= death

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Clinical PresentationClinical Presentation

Hypovolemic ShockHypovolemic Shock Tachycardia and tachypnea Tachycardia and tachypnea

 Weak, thready pulses Weak, thready pulses

HypotensionHypotension

Skin cool & clammySkin cool & clammy

Mental status changesMental status changesDecreased urine output: dark &Decreased urine output: dark &

concentratedconcentrated

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Hemodynamic ChangesHemodynamic ChangesCorrelate with volume lossCorrelate with volume loss

Low COLow CODecreased RAP ( Preload)Decreased RAP ( Preload)

Decreased PAD, PAWPDecreased PAD, PAWP

Increased SVR (Afterload)Increased SVR (Afterload)

Hypovolemic Shock:Hypovolemic Shock:

l h kH l iSh k

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Initial ManagementInitial Management

Management goal:Management goal:Restore circulating volume, tissue perfusion,Restore circulating volume, tissue perfusion,& correct cause& correct cause::

Early Recognition- Do not relay on BP! (30%Early Recognition- Do not relay on BP! (30%fluid loss)fluid loss)

Control hemorrhageControl hemorrhage

Restore circulating volumeRestore circulating volume Optimize oxygen deliveryOptimize oxygen delivery Vasoconstrictor if BP still low after volume Vasoconstrictor if BP still low after volume

loadingloading

Hypovolemic ShockHypovolemic Shock

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Restore circulating volumeRestore circulating volume

HemorrhageHemorrhage

DehydrationDehydration

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ISFISF IVFIVF ICFICF

Physiologic principlesPhysiologic principles

of fluid managementof fluid management

PerdarahanPerdarahan

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PRE-LO!PRE-LO! CO"#RC#ILI#$CO"#RC#ILI#$ F#ER-LO!F#ER-LO!

S#RO%E VOL&'ES#RO%E VOL&'E (ER#-R#E(ER#-R#E

CR!IC OPCR!IC OP S$S#E'ICS$S#E'IC

VSC&LRVSC&LR

RESIS#"CERESIS#"CE

)LOO!)LOO!

PRESS&REPRESS&RE

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Oxygen TransportOxygen Transport

CaOCaO22 = (SaO= (SaO22 x Hb x 1.34) + (PaO x Hb x 1.34) + (PaO22 x 0.003) x 0.003)

DODO22 = CO x CaO= CO x CaO22

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PERDARAHANPERDARAHAN

HILANG VOLUMEHILANG VOLUME

HILANG ERITROSITHILANG ERITROSIT

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THE FLUIDSTHE FLUIDS

 CRYSTALLOIDCRYSTALLOID

HYPERTONIC FLUIDHYPERTONIC FLUIDNATURAL COLLOIDNATURAL COLLOID

 ARTIFICIAL COLLOID ARTIFICIAL COLLOID

BLOOD, COMPONENTBLOOD, COMPONENT

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 TOTAL BODY WATER : 60% TOTAL BODY WEIGHT TOTAL BODY WATER : 60% TOTAL BODY WEIGHT

*+ L*+ L

IS

+, kg+, kg

LL

ISFISF IVFIVF ICFICF

*L*L ./ L./ L

Physiologic principlesPhysiologic principles

of fluid managementof fluid management

PhysiologicprinciplesPhysiologicprinciples

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IS

LL

ISFISF IVFIVF ICFICF

*L*L ./ L./ L.01,ml.01,ml .1, ml.1, ml

Physiologic principlesPhysiologic principlesof fluid managementof fluid management

EDEMAEDEMA

3LD5W

PhysiologicprinciplesPhysiologicprinciples

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RYSTALLO!DRYSTALLO!D

RL, RA,RL, RA,

NaCl 0.9%NaCl 0.9%

IS

LL

ISFISF IVFIVF ICFICF

*L*L ./ L./ L..1,ml..1,ml 01, ml01, ml

Physiologic principlesPhysiologic principlesof fluid managementof fluid management

EDEMAEDEMA

3L

Require large volumeRequire large volume

CheaperCheaper

Fewer adverse side effectsFewer adverse side effects

But…………But…………

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IS

LL

ISFISF IVFIVF ICFICF

*L*L ./ L./ L2L2L

Physiologic principlesPhysiologic principles

of fluid managementof fluid management

 Albumin-5% Albumin-5%1 L1 Lexpensiveexpensive

Physiologic principlesPhysiologic principles

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IS

LL

ISFISF IVFIVF ICFICF

*L*L ./ L./ L2L2L

Physiologic principlesPhysiologic principles

of fluid managementof fluid management

HES-6%, 200/0.5HES-6%, 200/0.51 L1 L

•More rapidly correctMore rapidly correcthypovolemiahypovolemia

•Maintain intravascularMaintain intravascular

oncotic pressureoncotic pressure

•More expensive thanMore expensive thancrystalloidcrystalloid

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ISISFISF IVFIVF ICFICF

*L*L ./ L./ L

Physiologic principlesPhysiologic principles

of fluid managementof fluid management

LL

7.5%-Hypertonic Saline7.5%-Hypertonic Saline+ Dextran+ Dextran500 ml500 ml

625 ml625 ml

EDEMAEDEMA 

Subjected to recentintensive investigation

Resuscitate rapidly,reduced volume of fluid

Reduce cerebral edema

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!lass I!lass I !lass II!lass II !lass III!lass III !lass I"!lass I"

#lood$%oss&ml'#lood$%oss&ml' $(750$(750 750$1500750$1500 1500$20001500$2000 (2000(2000

#lood$loss &)#"'#lood$loss &)#"' $(15)$(15) 15$30)15$30) 30$40)30$40) (40)(40)

*ulse$+ate &-min.'*ulse$+ate &-min.' /100/100 (100(100 (120(120 (140(140

#lood$*ressure#lood$*ressure ormalormal ormalormal ecreasedecreased ecreasedecreased

*ulse$*ressure*ulse$*ressure or orincreasedincreased

ecreasedecreased ecreasedecreased ecreasedecreased

+espiratory +ate+espiratory +ate 14$2014$20 20$3020$30 30$3530$35 (35(35

rine out$put &ml-our'rine out$put &ml-our' (30(30 20$3020$30 5$155$15 eliibleeliible

ental status-!Sental status-!S SlitlySlitlyaniousanious

idly aniousidly anious  nious and nious andconusedconused

!onused and!onused andletaricletaric

Estimated Fluid and )lood LossesEstimated Fluid and )lood Losses

)ased on Patient3s Initial Presentation)ased on Patient3s Initial Presentation

#" 70 ml-#" 70 ml-

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Oxygen TransportOxygen Transport

CaOCaO22 = (SaO= (SaO22 x Hb x 1.34) + (PaO x Hb x 1.34) + (PaO22 x 0.003) x 0.003)

DODO22 = CO x CaO= CO x CaO22

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PRE-LO!PRE-LO! CO"#RC#ILI#$CO"#RC#ILI#$ F#ER-LO!F#ER-LO!

S#RO%E VOL&'ES#RO%E VOL&'E (ER#-R#E(ER#-R#E

CR!IC OPCR!IC OP S$S#E'ICS$S#E'IC

VSC&LRVSC&LR

RESIS#"CERESIS#"CE

)LOO!)LOO!

PRESS&REPRESS&RE

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Pola ker4a penangananPola ker4a penanganan

shock perdarahanshock perdarahan

*enderita datan*enderita datan

denan perdaraandenan perdaraan

*asan inus :arum*asan inus :arum

aliber besar ;16

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  LU!D REPLAE"ENT

LU!D REPLAE"ENT

# : $ Rule

 : $ Rule

lass !lass ! rystalloidrystalloid

  lass !!lass !! rystalloidrystalloid  %% olloid &olloid & 

lass !!!lass !!! rystalloidrystalloid

  %%olloidolloid' Blood' Bloodlass !(lass !( rystalloidrystalloid

  %%olloidolloid' Blood' Blood

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1000 ml berdarah

3000 ml kristalloid

(RL, RA, NaCl 0.9%)

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"ana)e*ent

ana)e*ent

 

selan+utnya

elan+utnya

+apid response,+apid response,perdaraan /20)perdaraan /20)

>ransient response,>ransient response,

perdaraan 20$40) #"perdaraan 20$40) #"

onoin lossonoin loss

resusitasi td ade?atresusitasi td ade?at

+%, a!l 0.9),+%, a!l 0.9), @olloid@olloid, ara A, ara A

inimal, no responseinimal, no response>indaan beda seera>indaan beda seera

>ransusi dara>ransusi dara