hemorrhagic shock (anestesi)

7/30/2019 Hemorrhagic Shock (Anestesi)

http://slidepdf.com/reader/full/hemorrhagic-shock-anestesi 1/44

Hasanul Arifin

Departemen Anestesiologi dan ReanimasiFakultas Kedokteran USU

Hemorrhagic Shockin the Injuried Patient



CaO2

• Oxygen Bound (HbO2)

•Oxygen dissolved (plasma)



CaO2 = Hb x SaO2 x 1.34 + PaO2 x 0.0031

Oxygen Bound (HbO2)

Oxygen dissolved (plasma)98%

2%



01/05/2013 4



01/05/2013 5



01/05/2013 6



Initial Management of

Hemorrhagic Shock



Pasien Trauma (dianggap menderita shock hypovolemia)

Hentikan Perdarahan, Ganti

Kehilangan Volume



Physical Examination

( ABCDE)• Airway & Breathing

• Keep the airway clear

• Ventilasi & Oksigenasi

• Beri O2 SpO2 96-98%

• Circulation ( kontrol perdarahan)

• Penekanan

• PASG (Pneumatic Anti shock Garment)

• Operatip



Physical Examination

( ABCDE)

• Disability (neurologi)

• Brain perfusion

• GCS

• Respon pupil

• Exposure

•Head to Too

• Cegah hypothermia ( penghangatan internal,

eksternal)



Tindakan lain

• Dekompressi ( Maag dilatation)

• Maag dilatasi vagal stimulation bradikardia,

hypotensi

•Risiko aspirasi

• Insersi NGT no besar untuk dekompressi, suction aktif

• Urinary Catheter

• Hematuria?

• Jumlah urine renal perfusion



iv. line

• 2 (dua) iv catheter no. besar (16G, 18G)

• Vena lengan bawah

•Kalau kesulitan, akses vena besar : v. subclavia

v. jugularis interna

v. femoralis

Sekalian ambil contoh darah (laboratorium)

Dilakukan oleh tenaga yang

terlatih, jangan sampai

menimbulkan komplikasi

( peneumothorax,

hematothorax, arterial

puncture )



Vein Selection

• Both upper limbs should be inspected to

identify possible veins for cannulation.

• Potential veins can then be palpated to assess

their condition.

• An ideal vein is ‘soft and bouncy’ when

palpated.

• Veins that are tender, thrombosed or hard

should be avoided



Device selection

•It is important to select the correct vascularaccess device for the patient’s specific clinical

situation

•PUR (polyurethane), modern, softer, causeless intimal damage and are kink resistant

which reduces the incidence of cannula failure

•PVC, Teflon, older materials are more rigid,higher incidence of thrombophlebitis.



equipment

•Infusion standart

• Fluid (RL, NaCl, etc)

• Infusion tubing

•The following equipment for cannulation should beassembled and placed on a clean tray:

• cannula, antiseptic, sterile gauze, sterile saline flush,

single or multiway adapter (primed with sterile saline)

with integral ‘needle-less’ device, sterile moisture-permeable transparent dressing, tape, and a small

sharps’ container.



Theoretical Maximum Flow Rates

Colour Gauge Flow

Yellow 24G 13 ml/min

Blue 22G 30 ml/min

Pink 20G 55 ml/min

Green 18G 80-100 ml/min

White 17G 135 ml/min

Grey 16G 180 ml/min

Orange or Brown 14G 270 ml/min



01/05/2013 21



01/05/2013 22

Class I Class II Class III Class IV

Blood-Loss[ml] ->750 750-1500 1500-2000 >2000

Blood-loss [%BV] ->15% 15-30% 30-40% >40%

Pulse-Rate [x/min.] <100 >100 >120 >140

Blood-Pressure Normal Normal Decreased Decreased

Pulse-Pressure N orincreased

Decreased Decreased Decreased

Respiratory Rate 14-20 20-30 30-35 >35

Urine out-put

[ml/hour]

>30 20-30 5-15 Negligible

Mental status/CNS Slightlyanxious

Midlyanxious

Anxiousandconfused

Confusedandlethargic

Estimated Fluid and Blood Losses Based on

Patient’s Initial Presentation

EBV = 70 ml/kg



Kegunaan Klinis

Tabel Prakiraan Kehilangan Darah• Dengan menyesuaikan tanda dan gejala dari penderita pada

tabel, dapat diperkirakan berapa kehilangan darah yang sdhterjadi.

• Kemudian kita dapat memperhitungkan berapa jumlah cairan

yang harus diberikan untuk resusitasi• Bila post resisitasi belum ada tanda perbaikan, maka

kemungkinan :

– Ongoing loss

– Prakiraan ada kesalahan (BB tidak sesuai, kurang jeli menilai tanda dan

gejala – Ada tambahan kehilangan cairan lain selain perdarahan

– Shock bukan ok. perdarahan



Initial Fluid Therapy

• Tujuan :

• mengisi intravaskular dalam waktu singkat preload mekanisme

hemodinamik

• Cairan :

• Kristalloid• Ringer Lactat

• Ringer Asetat

• NaCl 0.9%

• Rule : 3 for 1 (1000 mL perdarahan ganti 3000 mL)

• Kolloid rule 1 : 1 ( 500 mL perdarahan ganti 500 mL)



01/05/2013 25

TOTAL BODY WATER : 60% TOTAL BODY WEIGHT

36 L

ISF

60 kg

9L

ISF IVF ICF

3L 24 L

Physiologic principles of

fluid management

Hasanul, 2002

ISF = Interstisial Fluid

IVF = Intravascular Fluid

ICF = Intracellular Fluid



Physiologydefinition

• Crystalloid is the term commonly

applied to solutions that do not

contain any high-molecular-weight

compounds and thus have an oncoticpressure of zero

• Colloid is the term used to denote

solutions that have an oncoticpressure similar to that of plasma.



01/05/2013 27

Jenis cairan yang beredar :

• Kristalloid ( D5W, RL, RA, NaCl )

• Kolloid ( Albumin, HES, Expafusin,

Gelatine)

• Cairan Nutrisi ( Intrafusin, Ivelip,

Triofusin)



01/05/2013 28

ISF

9L

ISF IVF ICF

3L 24 L750 ml 250 ml 2 L

D5W

3L


fluid management

Hasanul, 2002



01/05/2013 29

ISF

9L

ISF IVF ICF

3L 24 L2250ml 750 ml

RL,NaCl

3L


fluid management

Hasanul, 2002



01/05/2013 30

ISF

9L

ISF IVF ICF

3L 24 L1L

Albumin-5%

1 L


fluid management

Hasanul, 2002



01/05/2013 31

ISFISF IVF ICF

3L 24 L1000ml

HES-6%1L


fluid management

Hasanul, 2002

9L



01/05/2013 32

ISF

9L

ISF IVF ICF

3L 24 L500

Albumin-25%

100 cc


fluid management

Hasanul, 2002

400

Volume expander



01/05/2013 33

ISFISF IVF ICF

3L 24 L700ml

Haemacel1L


fluid management

Hasanul, 2002

9L300ml



01/05/2013

34

FLUID REPLACEMENT

3 : 1 RuleClass I Crystalloid

Class II Crystalloid+ Colloid ?

Class III Crystalloid

+Colloid, BloodClass IV Crystalloid

+Colloid, Blood Hasanul, 2009



01/05/2013 35

Pola kerja penanganan shock

perdarahan

Penderita datang dengan

perdarahan

Pasang infus jarum kaliber

besar (16G, 18G), ambil

sample darah

Ukur tekanan darah, hitung

nadi, nilai perfusi, produksi

urine

Tentukan estimasi jumlahperdarahan, minta darah

Guyur cepat Ringer Laktat atau NaCl

0.9% [hangat, 390C] 3x prakiraan lost-

volume [1-2 liter] evaluasi

Hasanul, 2009



• Pulse-Rate [x/min.]

• Blood-Pressure

• Pulse-Pressure

• Respiratory Rate

• Urine out-put [ml/hour]

• Mental status/CNS

normal

e v a l u a s i



5/1/2013 37

Thank you for listening

and to be continued



01/05/2013 38

Management selanjutnya• Rapid response,

perdarahan <20%

• Transient response,

perdarahan 20-40% BV

ongoing loss

resusitasi tdk adekwat

RL, NaCl 0.9%, Kolloid, Darah ?

• Minimal, no response

Perdarahan >40%

Tindakan bedah segera

Transfusi darah

Hasanul, 2003



01/05/2013 39

Efek volume infus 1 L cairan Kolloid pada

kompartement tubuh [BB,70kg]

L a r u t a n Vol. plasma Vol. interstetial Vol.intrasel

Albumin-5% 1000 - -

PPF [Plasma Protein

Fraction-5%] 1000 - -

Gelafundin 1000 - -

Haemacel 700 +300 -

Dextran-40 1600 -260 -340

Dextran-70 1300 -130 -170

Expafusin 1000 - -

Haes-steril-6% 1000 - -

Haes-steril-10% 1450 -450 -

Hasanul, 2003



01/05/2013 40

TRANSIENT RESPONSE,

DARAH BELUM DATANG,

KOLLOID

1:1



01/05/2013 41

Transfusion, indications

• Indications for transfusion in normovolemic

anemia,

– VO2 < normal range (indicating an oxygen debt) – Blood lactate > 4 mmol/L

– O2ER > 0.5



01/05/2013 42

Transfusi,

Target 7 - 9g%

Rule of -

5ml Whole-Blood = 5 x delta Hb x BB

contoh:

BB 60 kg, Hb 6g%, WB yang dibutuhkan = 5 x 3 x 60

= 900 ml

= 4 bag [unit]

Hasanul, 2009



01/05/2013 43

Why does hypothermia happen?



Hypothermia

Casualties who are hypovolemic quickly

become hypothermic.

Body temperatures below 91° F causes the

vicious triad. – Hypothermia

– Acidosis

– Coagulopathy

hemorrhagic shock (anestesi)

Documents