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Initial Treatment of Shock in ER
Erwin Siregar
RS Jantung dan Pembuluh Darah
Harapan Kita
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Type of Shock
• Hypovolemic shock:– Haemorrhage
– Dehydration
• Septic shock
The 2nd National Symposium on Emergencies, August 28th, 2005
• Cardiogenic shock
• Neurogenic shock
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Hypovolemic shock
• Initial resuscitation important
– FLUID
– Drugs
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– Monitoring
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Body Fluids
• Water comprises about 60 % total body weight
• Extracellular fluid (20 % tbwt)
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• Extracellular fluid (20 % tbwt)– Interstitial (15 % tbwt)
– Intravascular (5 % tbwt)
– Transcellular (CSF, aqueous humour etc)
– Intracellular fluid (40 % tbwt)
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Distribution of Fluid
• 70 kg man (57 % water)
• Total 42 liters– Extracellular 14 liters (20 % of mass)
• Interstitial fluid ~ 11.2 liters
• Intravenous (plasma) ~ 2.8 liters
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• Intravenous (plasma) ~ 2.8 liters
– Intracellular 28 liters (40 % of mass)• Red blood cells ~ 2 liters
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Type of Fluids
• Crystalloid
• Colloid :– Isotonic colloid
– Hypertonic colloid
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– Hypertonic colloid
• Hypertonic saline
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Crystalloids
• True solutions
• Freely distributed across semi permeable membranes
• Plasma expansion < infused volume
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• Plasma expansion < infused volume
• Rapidly excreted
• Expansion ECF : PV ~ 4 : 1
• Limited duration of effect (+90 min)
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• Crystalloids– Extracellular space expanders
– Limited plasma volume expansion
– Maintain urine output
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– Maintain urine output
– Reduce plasma oncotic pressure
– Range of electrolyte content
– CHEAP
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Isotonic Colloids
• Suspension of large particles
• Generally limited to vascular compartment
• Volume for volume plasma expansion
• Excretion determined by molecular size
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• Excretion determined by molecular size
• Osmotic effect dependent on number of particles
• Duration of effect 2-12 hours
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Hypertonic colloid/ solutions
• Expansion of intravascular space
• Contraction of ECF
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Crystalloid vs Colloid ?
Colloid advantages
• Intravascular space expanders
• Volume for volume expansion
Colloid disadvantages
• Coagulation problem
• Variable electrolyte content
• Variable half life
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expansion
• Rapid resuscitations
• Maintain oncotic pressure
• Less tissue edema
• Less pulmonary edema
• Variable half life
• Adverse reactions
• EXPENSIVE !!!
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Early 1990
• Place of colloids firmly established
• Role of crystalloids being challenged: increased tissue oedema equated to
Crystalloid vs Colloid ?
The 2nd National Symposium on Emergencies, August 28th, 2005
increased tissue oedema equated to increased lung oedemaincreased brain oedema
• “The end of crystalloid era”
Twigley & Hilma, Anaesthesia, 1985
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So what went wrong ???
As colloids are not associated with an improvement in survival, and as they are more expensive than crystalloids, it is hard to see how their continued
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it is hard to see how their continued use in these patient types can be justified outside the context of randomized controlled trials
Cochrane Database Review, 2000
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How good are the crystalloids ?
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Is normal saline NORMAL ??
• Is 0.9 % saline isotonic ?– Normal plasma osmolality 280-290
mOsm/l– 0.9 % saline = 154 x 2 = 308 mOsm/l
• Is it physiological ?
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• Is it physiological ?– pH = 6.35– Chloride load can cause acidosis
• ABNORMAL SALINE ???
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Ringer’s vs Saline
• No real difference in most situations
• Sodium and acid load from saline
• Lactate’s in Ringer only important in the presence of liver failure
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the presence of liver failure
• Ringer’s low in sodium and osmolality (275 mOsm/L)
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Key Point on Crystalloids
• Large volume are frequently required
• Large volume of abnormal solutions may produce abnormality
• Some evidence of brain edema
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• Some evidence of brain edema
• Saline :– Hypernatremia and acidosis
• Ringer’s– Hyponatremia and alkalosis
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Hypertonic Salines (7.5 %)
• High osmolality (2400 mOsm/l)• Small volume resuscitation• Reduces cerebral no-reflow in CPR
– Fischer M, Resusctitaion, 1996• Decreases brain water in head injury
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• Decreases brain water in head injury– Sheik AA, Crit Care Med, 1996
• Effective for a limited period only– Favre Schweiz, Med Wochenschnr, 1996
• Reversed trauma-induced immunosuppresion– Coimbra R, J Surg Res, 1996
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Colloids
• Plasma protein fractions
• Gelatins
• Dextrans
• Starches
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• Starches
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Plasma Derived Colloids
• Plasma (FFP, cryoprecipitate)– Coagulations problem only
• Albumin
• Plasma protein fractions /SHS
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• Plasma protein fractions /SHS
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Albumin
• Expensive
• No evidence of benefit
• Some evidence of harm
• ANZICS SAFE study :
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• ANZICS SAFE study :– 7000 patients randomized to Alb or NS
– Increased mortality with albumin ( p< 0.05) in trauma (more intracerebral bleeding)
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Gelatins
• Moderate molecular weight28-35 kDa
• Short duration of actions2 – 4 hrs
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2 – 4 hrs
• Minimal coagulation disturbances
• Significant allergic riskHaemacel > Gelofusin
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Dextran
• MW 40 – 70 kDa
• Prolonged duration of effect
• Improved microcirculation
• Significant impairment of
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• Significant impairment of coagulation
• Small anaphylactoid risk
• Some risk of renal dysfunction
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Starches
• Range of molecular weight70-450 kDadetermines properties
• Long to very long duration
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• Long to very long duration
• May improve microcirculation and endothelial function
• Moderate to small coagulation effect
• Minimal anaphylactoid risk
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Colloid, summary
• Gelatins,– Short term volume effect– Minimal effect on coagulation– No dose limitation
• Dextrans,– Medium term volume effect
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– Medium term volume effect– Significant coagulant inhibition– Renal effect with Dex40– Limit 15 ml/kg/24 hr
• HES– Medium to long term volume effect– Minimal to moderate coagulation effect– Limit 33 ml/kg/24hr (6%) or 20 ml (10 %)
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Fluid Balance Consequences in Early Shock
• Mobilization of ECF
• Hemodilution of plasma– ? Coagulation effect
– Gradual fall in Hb
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– Gradual fall in Hb
• Maintenance of vascular space at the expense of the ECF
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Late shock
• Capillary leak
• Loss of plasma volume
• Tissue edema
• Organ edema (lung, kidney)
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• Organ edema (lung, kidney)
• Multiple Organ Failure
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OBJECTIVES
• Early, complete restoration of tissue oxygenation
• Minimal biochemical disturbances
• Preservation of renal function
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• Preservation of renal function
• Avoidance of transfusion complications
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Fluid Choices
• Well-balanced resuscitation fluid resembling extracellular fluid
• Rapid volume expansion of intravascular space
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intravascular space
• Sustained expansion
• No sugar
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Problems with BLOOD
• Disease• Biochemical abnormalities :
– Hypernatremia– Acidosis– Hyperkalaemia
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– Hyperkalaemia– Hypocalcaemia
• Delayed effects :– Metabolic alkalosis– Hypokalaemia– Immunomodulation
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Blood
• Limit transfusions
• Transfusion threshold < 7 g/dL
• Maintenance leve 7-9 g/dL
• Older patients and those with
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• Older patients and those with ischemic heart disease may need higher Hb
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Timing of Resuscitation
• Do not delay transfer for resuscitation
• Priority is arrest of hemorrhage
• Commence aggressive resuscitation once control of bleeding is imminent
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once control of bleeding is imminent
Pepe et al, Emerg Med Clin North Am, 1998
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• Controlled fluid resuscitation• Balance hypoperfusion vs bleeding risk• Anemia than hypovolemia• Not yet proven that colloids reduce
mortality in trauma patients
Timing of Resuscitation
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mortality in trauma patients• In SIRS, HES may reduce capillary leak• HS solutions may benefit head injuries• Hemoglobin-based oxygen carriers may be
useful in future
Nolan, Resuscitation, 2001
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Selection of Fluids
• Early aggressive crystalloid therapy (2-3 liters RL, 0.9 % saline)
• Colloids if needed :– Short duration colloid if volume
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– Short duration colloid if volume requirement is temporary
– Long acting colloid otherwise
• Red blood cells if Hct < 25• FFP, cryoprecipitate only for
coagulation problems
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DRUGS
• Inotropes :– Dobutamine
– Dopamine
– Adrenaline
• Vasopressors
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• Vasopressors– Noradrenaline
– Adrenaline
– Vasopressin
– Phenylephrine
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MONITORING
• Non invasive– NIBP– Urine output– HR– Capillary filling
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– Capillary filling – Pulse oxymetry
• Invasive– Arterial line– CVP– PA pressure (Swan
Ganz catheter)
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DOBUTAMINDOBUTAMIN
• Agonis β-1 yang poten
• Kontraktilitas miokard ↑• Heart Rate sedikit ↑
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• Heart Rate sedikit ↑• Efek vasodilatasi ringan :
inodilator
• Memperbaiki perfusi splanknikus
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Dopamin
• Dosis kecil – sedang ( sampai 7 µg/kgBB/mnt ) β-adrenergik
• Dosis besar α- adrenoreseptor ↑ � vasokonstriksi
Dopamin : inotropik + vasokonstriktor
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• Kerugian :– Takikardia : iskemia miokard ; hati-hati– Dapat menyebabkan “steal effect” pada GI tract– Dapat mengganggu fungsi “pituitary gland” & tiroid– Dapat mempunyai efek immunosupresif
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NORADRENALIN NORADRENALIN (VASCON(VASCON®®))
• Neurotransmitter postsynaps adrenergic
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adrenergic
• Stimulasi α-1 dan β-1 adrenoreseptor
• Dosis rendah : efek β
• Vasokonstriksi dan MAP ↑
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ADRENALINADRENALIN
• Mempunyai aktivitas β-1, β-2, dan α-1 yang poten
• Pada sepsis MAP ↑ oleh karena CO ↑ (stroke volume ↑)
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• Kerugian :
–Kebutuhan O2 miokard ↑–Laktat serum ↑
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VASOPRESIN (ADH)VASOPRESIN (ADH)
• Dapat dipakai sebagai vasokonstriktor bila vaso
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vasokonstriktor bila vaso konstriktor katekolamin tidak berhasil
• Mengurangi perfusi splanknikus
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FENILEFRINFENILEFRIN
• α-1 agonis murni
• Sebagai vasokonstriktor tidak menyebabkan takikardia
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menyebabkan takikardia
• Sering dipakai di anestesi dan ICU untuk mengatasi dilatasi
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SEKALI LAGI !!SEKALI LAGI !!
Pasien HipotensifTentukan
ResusitasiTarget PCWP Persisten Hipotensi
Persisten hipotensi, tambahkan vasopresin
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TentukanTarget MAP
ResusitasiCairan
PCWP≥15mmHg
Persisten HipotensiTambah Noradrenalin
MAP N, oliguria, CO↓, Tambah dobutamin,
dopamin
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Conclusion
• Initial treatment in ER ,is Critical and very important to avoid further complications (organs, etc)
• Knowledge of presenting shock is of paramount importance
• Familiar with characteristics of various
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• Familiar with characteristics of various resuscitation fluids – Blood is used if absolutely necessary
• Knowledge of inotropes and vasopressors• Ability to use invasive monitors an
advantage
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