KSM Anestesiologi dan Terapi Intensif

RSUD Dr Moewardi / FK UNS

DEFINITION

SHOCK

Failure to
deliver and/or
utilise adequate
amounts of
oxygen

AETIOLOGY
Cardiogenic
Distributive
Obstructive
Hypovolemic
Combination

Cardinal Signs
Change in mental status
Heart rate > 90 beats per minute
Hypotension
Respiratory rate > 20
Hypothermia - Core body temperate less than 36C (96.8F)
Pulse oximetry - Relative hypoxemia
Decreased urine output

DISTRIBUTIVE SHOCK

Etiology

SIRS -SEPSIS
Anaphylaxis
Adrenal Insufficiency
Reactions to drugs or toxins
Heavy metal poisoning
Hepatic insufficiency
Neurogenic shock

SIRS - SEPSIS

Laboratory Evaluation
Complete blood count (CBC) with differential
Urinalysis
Electrolytes
Blood urea nitrogen (BUN) - Creatinine
Glucose

Cultures
Arterial blood gas
Serum lactate

MANAGEMENT

Surviving Sepsis Campaign Early Goal

Directed Therapy (EGDT)
Supply

Oxygen
Vascular Access
Fluid Resuscitation
Vasoactive agents

Manage precipitating illness or injury

Source Control & Antibiotics
Monitoring ICU admission

VASOPRESSORS

Dopamine ,
Precautions :

Target MAP
65 mm Hg

Norepinephrine
(preferred)

Dobutamine or
epinephrine

Increase HR and
myocardial oxygen
demand
HI-DOSE
arrhythmia

Refractory
shock
Vasopressin
infusion

VASOPRESSIN
Normally produced by posterior
pituitary gland.
Vasopressinergic receptors (V1, V2) sympathetic
terminals

Septic shock and following cardiopulmonary bypass

Inflammation Vasopressin
Low doses of infused vasopressin improve
catecholamine responsiveness,
0.03-0.04 units/minute

No proven benefit in mortality

CORTICOSTEROID
Fluid resuscitation and vasopressor
hemodynamic

instability
Intravenous hydrocortisone 50 mg per 6 Hours

AETIOLOGY ANAPHYLAXIS

In hospital :

Outside hospital:

injection of drugs
blood products
plasma substitutes
contrast media
latex products or chlorhexidine.

ingestion of foods
Food additives
Insect stings
Drugs (less common)

Ag yang terikat IgE pada mast sel atau basofil

Degranulasi

- Histamin
- PAF
-Vasodilatasi
- Permeabilitas
- Bronchokontriksi

- Prostaglandin
- Leukotrien
- Adenosin
- Serotonin

 Reaksi

anafilaktoid

Reaksi Ag-Ab tanpa IgE

Hasil degranulasi = sama
Efek = sama
Klinis = sama

B. GAMBARAN KLINIS

Ditandai : Perubahan mendadak pada

- Permeabilitas vaskuler
- Hipereaktiv bronchus

Komplek gejala pada :

- Sistem saluran napas
- Sistem kardiovaskuler
- Sistem saluran cerna
- Mata
- Kulit

Sendiri-sendiri / gabungan

CLINICAL SIGN

Angioedema
Urticarial
rash
Wheezing

Respiratory
distress

Paling sering
pada kulit dan sistem kardiovaskuler

Pada reaksi yang fatal

oedem laring dan hipotensi berat

Gejala bervariasi : ringan berat

Perjalanan klinis bervariasi : cepat lambat

Gambaran klinis
Berhubungan dengan tempat masuk Ag
Jumlah Ag yang masuk
Kecepatan absorbsi
Derajad hipersensitivitas penderita

Pathogenesis
Vasodilatation
Capillary leak of plasma
endogenous hypovolaemia
reduced venous return
lowered cardiac output

Treatment

Oxygenation :
Intubation & Mechanical
ventilation
Facemask

angioedema or laryngeal
oedema
severe bronchospasm
apnoea
cardiac arrest.

Treatment

Epinephrine
Drug of choice

Community acquired
anaphylaxis
I.M 0.31.0 mg
IM produces higher
levels > SC

Severe shock IV
injection of 35 ml
of 1:10.000
A second dose and
infusion if necessary

OTHER SYMPATHOMIMETIC-AMINES

No-response to fluid loading

and epinephrine:
Norepinephrine
Methoxamine
Phenylephrine
vasopressin

COLLOIDS
Plasma expanders Correct acute vasodilatation and
leakage of fluid from the intravascular space
Colloid remain in the vascular compartment earlier and for longer
than Crystalloid
Less Volume than Crystalloids
CVP monitoring and haematocrit if neccesary

BRONCHOSPASM
First line : Epinephrine , if neccesary :
Nebulised salbutamol
Aminophylline 56 mg/kg IV over 30 minutes
Other agents :
Volatile anaesthesia
Ketamine
magnesium sulphate

OBAT LAINOther Medications

CORTICOSTEROIDS

ANTIHISTAMINES

Steroids have no
proven benefit but
also no evidence
of harm
Refractory
bronchospasm ??

For localised nonsevere reactions

Or angioneurotic
oedema in severe
reactions

MATURNUWUN