BAGIAN ANESTESIOLOGI BAGIAN ANESTESIOLOGI FAKULTAS KEDOKTERAN UNIVERSITAS FAKULTAS KEDOKTERAN UNIVERSITAS

ANDALASANDALAS

NASMAN PUARNASMAN PUAR

Introduction

Life-threatening condition Result from a number of primary

causes Be aware of physiologic effects

of shock Be able to detect Report the development or

worsening of this very serious condition

Hypovolemic shock

Cardiogenic

shock

Anaphylacticshock

Septicshock

Neurogenicshock

Definitions of shock types:

Definition of Shock

A state of inadequate tissue perfusion resulting in decreased amount of oxygen to vital tissues and organs leading to reduced removal of waste products of metabolism

Diagnosis of ShockEarly Recognition Physiological Diagnosis

Weak, thready Weak, thready pulsepulse

Cold, clammy Cold, clammy skinskin

Altered mental Altered mental statusstatus

Unstable vital Unstable vital signssigns

CyanosisCyanosis

Subjective Symptoms and

Imprecise Signs:• Hypotension• Acidosis• Oliguria• Collapse• Reduced

Oxygen Delivery

Objective haemodynamic signs

Classification of Hypovolemic Shock*

Blood loss

Blood volume

Heart rate

Blood pressure

Pulse pressure

Urine output

Class I

< 750 ml

< 15%

< 100

Normal

Normal

> 30 ml/hr

Class II

750-1500 ml

15-30%

> 100

Normal

Decressed

20-30 ml/hr

Class III

1500-2000 ml

30-40%

> 120

Normal to

Decreased

5-15 ml/hr

Class IV

> 2000 ml

> 40%

> 140

Decreased

Decreased

nil

T. James Gallagher, 1995

Treatment for Hypovolemic Shock

Maintain airway Control bleeding Baseline vital signs Level of consciousness

Goals - Increase tissue perfusion and oxygenation status

Vascular volume deficit management

Goal therapy of shock

Restoration of Cardiac Index, DO2, VO2

( optimized to maintain body metabolic requirement )

Improved tissue perfusion

Delivery O2 = COxHbxSpO2x1,34 +(0,003xPaO2)

Left ventricularend diastolic volum e

intrathoracic pressure

preload afterload contractility

Cardiac Output

SVR = 80 x ( MAP –CVP )

CO

CO = Stroke vol xHR

Intravascular Volume

RESUSCITATIONRESUSCITATION MAINTENANCEMAINTENANCE

NUTRITIONNUTRITIONCrystalloidCrystalloid

1. Replace acute loss (hemorrhage, GI loss, 3rd space etc)

1. Replace acute loss (hemorrhage, GI loss, 3rd space etc)

1. Replace normal loss (IWL + urine+ faecal)2. Nutrition support

1. Replace normal loss (IWL + urine+ faecal)2. Nutrition support

ELECTROLYTESELECTROLYTES

FLUID THERAPYFLUID THERAPY

Colloid

colloid or crystalloid ?

Normovolemia

Lactated

Ringer's,

Normal

Saline

AlbuminFFP

GelatinHES Dextr

an

Crystalloids

Colloidsnatural

synthetic

Composition of Crystalloid & Coloid SolutionsJenisJenis NaNa ClCl KK CaCa MgMg Lact/Lact/

AcetatAcetatlain2lain2

NaCl0.9%NaCl0.9% 154154 151544

-- -- -- -- --

Ring LaktRing Lakt 138138 111122

44 55 -- Lakt/28Lakt/28 --

ExpafusinExpafusin 138138 121255

44 33 Lakt/20Lakt/20 HES/40000HES/40000

Haes st 6% Haes st 6% ,10%,10%

154154 151544

-- -- -- -- HES/HES/200000200000

HemacelHemacel 145145 141455

5,15,1 6,26,255

-- -- PolygelinePolygeline

GelafundinGelafundin 142142 8080 -- 1,41,4 -- -- Gelatin/Gelatin/3500035000

Dextran LDextran L 130130 101088

44 2,72,7 -- Lakt/28Lakt/28 Dextran40Dextran40

NaCl 3%NaCl 3% 500500 505000

-- -- -- -- --

Colloid vs. Crystalloid

ECF ECF

ICF ISF PlasmaICF ISF Plasma

3 : 1

• Ringer acetate• Ringer lactate• NaCl 0.9%

IsotonicIsotonic

ICF ISF PlasmaICF ISF Plasma

D5W N4

NaCl 0.45%

ICF > ECF ICF > ECF

40 : 15 : 5

Hypotonic Hypotonic

+ Hyponatremia

+ hyperglicemia

Plasma Plasma

ICF ISF PlasmaICF ISF Plasma

colloidscolloids

hyperoncotic

Colloids contain large, oncotically active molecules.

natural products (eg, albumin, FFP) Semisynthetic (gelatine, starches or dextrans).

more impermeable to intact capillary membranes than crystalloids.

smaller volumes of colloids than crystalloids are required for fluid resuscitation.

Demands on an ‘ideal’ Synthetic Colloids:(which does not exist!)

inexpensive and free of infectious agents available in unlimited quantities stable for long periods of time colloid osmotic pressure and viscosity like plasma completely degradable and eliminated via kidneys no longtime storage in the organs No negative impact on liver- kidney or immune

function sufficient volume effect and duration free of coagulation disorders free of toxic, allergic and antigenic reactions

Tetrastarch

(0.4)

Pentastarch (0.5)

Hetastarch (0.7)

HES 130 /0.4 HES 200 /0.5 HES 450

/0.7

(Based on degree of substitution)

(Based on Molecular weight)

High molecular weight

HES

Medium Molecular weight

HES

Low molecular weight

HES

HES 450 / 0.7

HES 470 /0.7

HES 200 /0.5

HES 200 /0.62

HES 40 /0.5

HES 70 /0,5

HES 110 /0,5

HES 130 /0,4

HespanPlasmasteril

Hemohes,Haes-steril

ElohesPentaspan

Hespander, Rheohes,Voluven, Venofundin

1.

2.

HES = Hydroxethylstarch

(Not all HES are the same!)

Gelatin Solutions

(Not all Gelatin Solutions are the same!)

Polygeline

(urea linked/diisocyanate)

Oxypolygeline

(OPG)

Gelofusine,

Gelafundin,Haemaccel

Gelifundol

Mw= 30 000 dalton Mw= 35 000 Mw= 30 000

4% 3.5% 4%

Modified Fluid Gelatin(MFG)(succinylated)

Average initial volume effect /average duration of volume effect(in hypovolemic volunteers)

0 50 100

150

200

(%)

3.5 % Polygeline

4% Modified Fluid Gelatin6% HES 200/0.5

6% Dextran 706% HES 200/0.62 and HES 450/0.710% HES 200/0.45 and 0.5

10% Dextran 40

~70%

~ 100 %

1oo%

145 %

~ 190 %

~2-3h

~3-4h

~ 4h

~ 3-4h

~ 7-9h~ 4h

Effects of solutions onhaemostasis and

coagulationGelatins HES Dextrans

Factor VIII, vWF

Platelets adhesion aggregation

Thrombus formation

Blood typing

No effect

No effect

No clinical effect

No effectIn emergency situations blood typing prior to infusion!

tim

e

An urban Emergency DepartmentAn urban Emergency Department 263 patients263 patients Severe sepsis or septic shockSevere sepsis or septic shock Therapy for 6 hours before transfer to Therapy for 6 hours before transfer to

ICUICU Standard therapy (N=133)Standard therapy (N=133) Therapy guided by ScvOTherapy guided by ScvO22 catheter catheter

(N=130)(N=130)

Mortality reduced from 46.5% Mortality reduced from 46.5% to 30.5%!to 30.5%!

Rivers E.: Early goal-directed therapy in the treatment of severe sepsis and septic shock NEJM 2001; 345:1368-

1379

Rivers E.: Early Goal-Directed Rivers E.: Early Goal-Directed Therapy In The Treatment Of Therapy In The Treatment Of Severe Sepsis And Septic Severe Sepsis And Septic ShockShock

Algorithm for Study GroupAlgorithm for Study Group

NEJM 2001;345:1368NEJM 2001;345:1368

Oncoticpressure

Increased IVvolume

Venous flow-back(preload)

Improvedrheology

Arterial oxygenconcentration

Flow resistance

Cardiacoutput

Keep the fluidin the IVS

CO DO 2 c OCaO2

Hematocrit

Hemodilution

Effects of Synthetic Colloids

Blood loss (%)

Colloids + crystalloids

100908070605040302010

+ PRC +FFP +platelets

0

Adapted from Adams, H.A. 1996

Cryst.+colloids

Replacement of blood losses“ Step by step”

volume - oxygen carriers - plasmatic coagulation - cellular coagulation

Conclusion :The decision on what synthetic colloid should be selected has to be made considering the pro and cons of each specific solution and the specific conditions of each individual patient on a case to case basis!