Pelajari tentang Shock & WHO-CUB

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International

Shock & WHO-CUB

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International

Perdarahan Obstetri

 Respirasi

 Sirkulasi ( Kegagalan sistem sirkulasi dalam mempertahankan aliran yang

adekuat pada organ-organ vital sehingga timbul Anoxia)

 Trauma

 Mengancam jiwa ibu dan janin

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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

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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

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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

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International 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

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International Shock

The Course of Hypovolaemic Shock in Absence of Therapy

Blood Pressure (mm Hg) Heart rate (min)

Bleeding 150

100

50

0 Compensation Decompensation Irreversibility

Shock Phases

Heart Rate Blood Pressure

(Time)

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Tata Laksana

Mengatasi Perdarahan Hebat

 Airway

 Breathing

 Circulation & hemorrhage control

 Shock position

 Replace blood loss

 Stop / minimize the bleeding process

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International AIRWAY

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Posisi Syok

ANGKAT KEDUA TUNGKAI

300 - 500 cc darah dari kaki

pindah ke sirkulasi sentral

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Tatalaksana

Kompresi Bimanual

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m Menghentikan

Perdarahan Kondo

intra uterin

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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

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Stepwise uterine devascularization

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

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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

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Tatalaksana

Perdarahan pasca Persalinan

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Estimasi BB : ... 60 kg

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

NORMO VOLEMIA

-- 30%

EBV -- 15%

EBV -- 50%

EBV Tsyst

Nadi Perf

12080 hangat

100100 pucat

< 90

> 120 dingin

< 60-70

> 140 -

basahttb

2000 ml EBL =perdarahan

Infus RL

600

1200-2000

1200

2500-5000 4000-8000 ml

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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.

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The Clinical Use of Blood

WHO Sub – Regional Workshop

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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%

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Blood Loss

% Loss of blood Volume

Equivalent Adult fluid

Volume

Replacement Fliud

< 20 % Up to 1 Liter Crystalloid ( e.g.

0,9 % saline )

> 20 % More than 1 liter

Crystalloid and / or Colloid Red

Cell

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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

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Starting Transfusion

 Prohibited to addition drugs &

medications to blood bag / set EXCEPT normal Saline.

 Do not use dextrose 5% / RingerLactate.

 Use 170 u standard filter.

 Transfusion must be completed in 4 hours.

 Hemodynamically stable 2 hours

 Hemodynamically unstable 4 hours

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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

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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 .

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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

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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

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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

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Transfusion Reactions

Immediate Delayed

Hemolytic Non- hemolytic

Hemolytic Transfusion

Reaction Febrile

Allergic Hypo-

calcemia

Hyper- Kalemia &

Acidosis Acute Lung Injury

Infections Allergic

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“ Practice Safe Transfusion ”

Informed Consent

Standardized Guidelines

Adverse Event Reporting Error and Incident Reporting

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“ 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

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Summary

 Components

 Indications

 Transfusion Reactions

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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.

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International

Pelajari tentang Shock & WHO-CUB

Shock & WHO-CUB

Perdarahan Obstetri

Shock

Tata Laksana

Mengatasi Perdarahan Hebat

Posisi Syok

Tatalaksana

Kompresi Bimanual

m Menghentikan

Perdarahan Kondo

intra uterin

Menghentikan Perdarahan

Stepwise uterine devascularization

Menghentikan Perdarahan

Kristaloid vs Koloid

Sebagai Cairan Pengganti

The Clinical Use of Blood

Estimating Allowable Blood Loos

Blood Loss

Starting Transfusion

Starting Transfusion

Autologous Blood

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 ’ 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

“ Practice Safe Transfusion ”

“ 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 ” ……

Summary

 Components

 Indications

 Transfusion Reactions

Rujukan

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