3 Shock&cub-who Ppt.pdf

Shock & WHO-CUB

Divisi Fetomaternal, Departemen Obstetri & Ginekologi FKUI / RSUPN - CM

QuickTime™ and a YUV420 codec decompressor are needed to see this picture.

Perdarahan Obstetri 

Respirasi



Sirkulasi ( Kegagalan sistem sirkulasi dalam

mempertahankan aliran yang adekuat pada organorgan vital sehingga timbul Anoxia) 

Trauma



Mengancam jiwa ibu dan janin

Shock The most common types of shock: Type of shock

Aetiology

Hypovolaemic shock

Acute loss of at least 20% of the circulating volume

Cardiogenic shock

Acute disease of the heart, e.g. severe myocardial infarction

Septic shock

Septic condition caused by infectious agents and their toxic products

Neurogenic shock

Head trauma, spinal cord injury

Anaphylactic shock

Repeated contact with or injection of antigenic substances

Shock Hemorrhagic Shock – Pathophysiology Stage 1: Compensated Stage Mechanism: Volume depletion due to bleeding

Body detects decrease in cardiac output

Sympathetic Nervous System is stimulated releasing Epinephrine and Norepinehrine to stimulate Alpha and Beta Receptors

Alpha = Vasoconstriction

Beta = Bronchodilation and Cardiac Stimulation

Shock Hemorrhagic (Classic) shock – Pathophysiology Stage 2: Progressive Stage Mechanism: Kidneys release anti-diuretic hormone which increases vasoconstriction by closing the capillary sphincters, greatly reducing peripheral circulation

Increased hypo-perfusion causes increase in metabolic acid build up

Shock Hemorrhagic (Classic) shock – Pathophysiology Stage 3: Irreversible Stage Mechanism: Compensatory mechanisms fail

Pre-capillary sphincters open releasing metabolic acids, micro-emboli and other wastes into circulation

Cell damage, organ failure and death occur

Shock The Course of Hypovolaemic Shock in Absence of Therapy Blood Pressure

Blood Pressure (mm Hg)

Heart Rate

Heart rate (min) 150

Bleeding

100

50

0

Compensation

Decompensation Shock Phases

Irreversibility

(Time)

Shock The Influence of Volume Replacement on Tissue Perfusion and Organ Function Tissue Perfusion

Cerebral Function (Body Control)

Pulmonary Function (O2 Supply)

Volume Replacement

Heart Function (cardiac output)

Liver Function (metabolism) Renal Function (Diuresis)

Tata Laksana Mengatasi Perdarahan Hebat 

Airway



Breathing



Circulation & hemorrhage control



Shock position



Replace blood loss



Stop / minimize the bleeding process

AIRWAY

Posisi Syok ANGKAT KEDUA TUNGKAI

300 - 500 cc darah dari kaki pindah ke sirkulasi sentral

Tatalaksana Kompresi Bimanual

Menghentikan Perdarahan Kondom intra uterin



Menghentikan Perdarahan Thrombogenic uterine pack 



Bobrowski RA, Jones TB. Obstet Gynecol 1995 May;85(5 Pt 2):836-7

Vaginal ligature of uterine arteries 

Philippe HJ, d'Oreye D, Lewin D. Int J Gynaecol Obstet 1997 Mar;56(3):267-70



Ligasi a hipogastrika



Histerektomi subtotal

Stepwise uterine devascularization AbdRabbo SA Am J Obstet Gynecol 1994 Sep;171(3):694-700

Menghentikan Perdarahan 

B-Lynch suture 

Dacus JV, Busowski MT, Busowski JD, Smithson S, Masters K, Sibai BM. J Matern Fetal Med 2000 MayJun;9(3):194-6



Ferguson JE, Bourgeois FJ, Underwood PB. Obstet Gynecol 2000 Jun;95(6 Pt 2):1020-2

Tatalaksana Perdarahan pasca Persalinan

Estimasi BB : ... 60 kg Estimasi Blood Volume : ... 70 ml/kg x 60 = 4200 ml Estimasi Blood Loss : .... % EBV = ..... ml

Tsyst Nadi Perf

120 80 hangat

NORMO VOLEMIA

EBL = perdarahan Infus RL

100 100 pucat -- 15% EBV

< 90 > 120 dingin

-- 30% EBV

< 60-70 > 140 ttb

basah

-- 50% EBV

600 1200-2000

1200 2500-5000

2000 ml 4000-8000 ml

Kristaloid vs Koloid Sebagai Cairan Pengganti Kristaloid

Koloid

Manfaat

Merembes ke komponen ekstraselular Mengurangi peningkatan cairan paru Meningkatkan fungsi organ setelah operasi Reaksi anafilaktik minimal Kemungkinan dapat mengurangi angka kematian Lebih murah

Tetap berada di komponen intravaskular volume yang diperlukan lebih sedikit Meningkatkan transpor oksigen ke jaringan, kontraktilitas jantung dan keluarannya

Resiko

Predisposisi untuk terjadinya edema pulmonal

Mahal

Choi et al 1999.

The Clinical Use of Blood WHO Sub – Regional Workshop

Estimating Allowable Blood Loos Clinical condition Healthy

Average

Poor

Percentage Methode Acceptabel loss of blood vol

30%

20%

10%

Haemodilution Method Lowest Acceptable Hb

9 mg / dl

10 mg / dl

11 mg / dl

Lowest acceptable Ht

27%

30%

33%

Blood Loss

% Loss of blood Volume

< 20 %

> 20 %

Equivalent Adult fluid Volume

Replacement Fliud

Up to 1 Liter

Crystalloid ( e.g. 0,9 % saline )

More than 1 liter

Crystalloid and / or Colloid Red Cell

Starting Transfusion 



Warming of blood is not necessary for routine tx . Warming increasing metabolism, reduce 2,3-DPG & risk bacterial growth Indication for warming blood: 

Adult receiving over 50 ml/kg/hr



Child receiving over 14 ml/kg/hr



Exchange tranfusion



Rapid infusion CVP lines



Presence of cold aglutinines

Starting Transfusion 

Prohibited to addition drugs & medications to blood bag/set EXCEPT normal Saline.



Do not use dextrose 5% or Ringer Lactate.



Use 170 u standard filter.



Transfusion must be completed in 4 hours. 

Hemodynamically stable

2 hours



Hemodynamically unstable 4 hours

Autologous Blood 





Pre Operative Blood Donation 

Min Hb 11 gr



1 Unit ( 10-15% Blood vol) 5-7 days



35 days-2 days, iron suppl

Acute Normovolemic Haemodilution 

During surgery ( 4 hours )



Monitoring, Replace fluid : crystaloid 1:3, Colloid 1:1

Blood Salvage 

Direct tranfusion

Don’ts for Blood Transfusion



Don’t Use blood from non-licensed.



Don’t delay initiation of blood transfusion.



Don’t Warm blood in an monitored fashion.



Don’t Use routine pre-transfusion medication.

Don’ts for Blood Transfusion



Don’t transfuse over more 4 hours.



Don’t leave patients unmonitored.



Don’t add any medication to blood bag



Don’t forget to return unused blood to blood bank

for disposal

Don’ts for Blood Transfusion  





Don’t ask for all the blood bag at one time Don’t Use unmonitored refrigerator for storage Don’t Use one transfusion set for more than 4 hours / more than 4 unit of blood Don’t wet outlet port of blood bag while warming or thawing

Don’ts for Blood Transfusion 

Don’t store platelets in a refrigerator



Don’t be complacement while checking identifiying information



Don’t Use blood from immediate relatives unless irradiated

Transfusion Reactions Immediate

Hemolytic

Febrile Hemolytic Transfusion Reaction

Delayed

Non-hemolytic

Allergic

Infections

Hyper- Kalemia & Acidosis

Acute Lung Injury

Allergic

Hypocalcemia

“Practice Safe Transfusion”

Informed Consent

Standardized Guidelines

Adverse Event Reporting

Error and Incident Reporting

“Errors

can be prevented by designing systems that make it hard for people to do the wrong thing and easy for people to do the right thing”…… To Error is Human, Building a Safer Health System

Summary  Components  Indications

 Transfusion

Reactions

Rujukan 





ACOG. Hemorrhagic shock. Educational Bulletin #235, 1997. Choi PT-L et al. 1999. crystalloid vs. colloids in fluid resuscitation: A systematic review. Critical Care Medicine 27( 1): 200-210. Scheirhout and Roberts 1998. Fluid resuscitation with colloid or crystalloid in critically ill patients: A systematic review of randomized trials. BMJ 316:961-964.



MNH Post Partum Hemorrage.



The Clinical Use of Blood, WHO 2002.

Terima Kasih