10/15/09
Shock
Rational Blood Transfusion Practice on Patient Bleeding at Obstetric & Gynecology Ali Sungkar Divisi Fetomaternal, Departemen Obstetri & Ginekologi FKUI / RSUPN - CM
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 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
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 (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
The Course of Hypovolaemic Shock in Absence of Therapy
Blood Pressure Heart Rate Blood Pressure (mm Hg)
Heart rate (min) 150 Bleeding 100
50
(Time) 0
Compensation Decompensation Irreversibility Shock Phases
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Shock
The Influence of Volume Replacement on Tissue Perfusion and Organ Function
Cerebral Function (Body Control)
Tissue Perfusion Pulmonary Function
(O2 Supply)
Volume Replacement
Renal Function Liver Function
(Diuresis) (metabolism)
Heart Function (cardiac output)
Perdarahan Obstetri
Kegagalan Sirkulasi
Respirasi
Sirkulasi ( Kegagalan sistem
sirkulasi
dalam mempertahankan aliran yang adekuat pada organ-organ vital sehingga timbul Anoxia) Trauma
Mengancam jiwa ibu dan janin
Tata Laksana
Mengatasi Perdarahan Hebat
Airway Breathing
Circulation and hemorrhage control Shock position
Replace blood loss
Stop / minimize the bleeding process
Perdarahan:
Pada awal kehamilan (aborsi,
kehamilan
ektopik, kehamilan mola)
Pada akhir kehamilan atau
persalinan
(plasenta previa, solusio placenta, ruptura uteri)
Sesudah kelahiran bayi (ruptura
uteri,
atonia uteri)
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Posisi Syok
ANGKAT KEDUA TUNGKAI 300 - 500 cc darah dari kaki pindah ke sirkulasi sentral Tatalaksana - Kompresi Bimanual
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
Tindakan simultan Pada Syok
Tatalaksana : Nilai fundus
Simultan dengan ABC
Atonia merupakan penyebab utama Perdarahan Post partum
Jika lembek masase bimanual singkirkan inversio uteri
mungkin terdapat trauma traktus bagian bawah
evakuasi bekuan darah dari vagina dan servik
membutuhkan eksplorasi manual pada saat ini
Menghentikan
Perdarahan
Kondom intra uterin
Stepwise uterine devascularization
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Tatalaksana Perdarahan
Menghentikan Perdarahan
B-Lynch suture
Dacus JV, Busowski MT, Busowski JD, Smithson S, Masters K, Sibai BM. J Matern Fetal Med 2000 May-Jun;9(3): 194-6
Ferguson JE, Bourgeois FJ, Underwood PB. Obstet Gynecol 2000 Jun;95(6 Pt 2):1020-2
Estimasi BB : ... 60 kg
Estimasi Blood Volume : ... 70 ml/kg x 60 = 4200 ml Estimasi Blood Loss : ... . % EBV = ... .. ml Tsyst 120 100 < 90 < 60-70 Nadi 80 100 > 120 > 140 - ttb
Perf hangat pucat dingin basah NORMO -- 15% -- 30% -- 50%
EBV EBV
Pasca Persalinan
Kristaloid vs Koloid Sebagai
Cairan Pengganti: Hasil
Kristaloid Koloid
Manfaat Merembes ke komponen Tetap berada di komponen ekstraselular intravaskular
Mengurangi peningkatan cairan volume yang diperlukan
paru lebih sedikit
Meningkatkan fungsi organ Meningkatkan transpor setelah operasi oksigen ke jaringan,
VOLEMIA EBV
EBL = perdarahan 600 1200 2000 ml Infus RL 1200-2000 2500-5000 4000-8000 ml
Resiko
Reaksi anafilaktik minimal kontraktilitas jantung dan Kemungkinan dapat keluarannya
mengurangi angka kematian Lebih murah
Predisposisi untuk terjadinya Mahal edema pulmonal
Choi et al 1999.
The Clinical Use of Blood
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Blood Loss
% Loss of blood Equivalent Adult Replacement
Volume Fluid Volume Fluid
< 20 % Up to 1 Liter Crystalloid ( e.g. 0,9 % saline )
> 20 % More than 1 liter Crystalloid and / or Colloid/ Red Cell
Estimating Allowable Blood Loos
Clinical condition
Healthy Average Poor
Percentage Methode Acceptabel 30 % 20 % 10 % loss of blood vol Haemodilution Method Lowest 9 mg / dl 10 mg / dl 11 mg / dl Acceptable Hb Lowest 27 % 30% 33% acceptable Ht
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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
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
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
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
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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 store platelets in a refrigerator
Don’t be complacement while checking identifiying information
Don’t Use blood from immediate
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
Transfusion Reactions
Immediate Delayed
Hemolytic Non-hemolytic Infections Allergic
Hyper- Kalemia & Hypo-
relatives unless irradiated Febrile Allergic
Acidosis calcemia Hemolytic
Transfusion Acute Lung Injury
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“Practice Safe Transfusion”
Informed Consent Adverse Event
Reporting
Standardized Guidelines
Error and Incident Reporting
Summary
“Errors can be prevented by designingsystems 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
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.
Components