Syok hemoragik:

Resusitasi Cairan
DR Yefta Moenadjat, dr, SpBP(K)
Dep Medik Ilmu Bedah RSCMFKUI

Latar Belakang
Konsep resusitasi cairan berubah sejalan dengan
perkembangan iptekdok mengenai patofisiologi syok,
transportasi dan distribusi aircairan serta dampaknya
Banyak bukti [evidence] dihadirkan mengenai bahaya
pemberian cairan dalam jumlah besar; terlebih: klinis
lebih bermakna.
Kata kunci:
Perubahan paradigma syok, resusitasi cairan (target,
endpoint), strategi.

Syok
Circulatory Shock (Shock)
Kondisi mengancam jiwa yang terjadi karena ketidakcukupan
substrat yang dibutuhkan respirasi sel (aerob). Kondisi ini
diawali oleh ketidakcukupan oksigen di jaringan.

Penyebab utama kematian pada penderita trauma.

Memiliki variasi menifestasi dengan kesamaan luaran;
kesemuanya berhubungan dengan kegagalan sistem
sirkulasi.
Contoh: Hipoksemiahenti jantung
Hipovolemia, Kardiogenik, Distributif, Anafilaktik

Syok Hipovolemia
Luka Bakar

Migrasi cairan (plasma)

ke jaringan interstisium
Migrasi leukosit
Hemokonsentrasi [Hb]

Hemoragik

Kehilangan
Cairan (plasma)
Selsel darah / [Hb]

Syok Hipovolemia
Hipovolemia:
Ketidakcukupan volume intravaskular
distribusi cairan terganggu
Hemokonsentrasi: [Hb] SaO2 (/N)
Hemoragik: [Hb] SaO2
Perfusi sel

Aktivitas sel
Rantai respirasi (mitokondria)
O2: Gggan metabolisme (CHO,
lemak)
Produksi ATP Kehidupan sel

protein,

Glucose

Glycoprotein

Na+

Cell membrane

Lipid bilayer

Receptors

Pumps and channel

(Membranes protein)

H2O

K+

CO2

Cytoskeleton
ATP

Cytoplasma

Pyruvate

Acetyl CoA

TCA
Cycle

ATP
ATP
ATP

Lactic Acid
ATP

Mitochondrion

NADH
FADH2

ATP

Sistem sirkulasi kranial

Sirkulasi Pulmonar
Sirkulasi sistemik
Aorta
Darah mengandung O2
dibawa ke seluruh tubuh
Arteriol
Arteri Pulmonar
Darah mengandung CO2
dibawa ke paru

Vena Pulmonar
Darah mengandung O2
dibawa kembali ke jantung

Kapiler
Venula
Sistem Sirkulasi Paru
Kanan
Darah melepaskan CO2 dan
menyerap O2 di kapiler

Sistem sirkulasi paru kiri

VenaPorta
Darah kaya akan nutrien berasal dari
sistem digestif dibawa ke hepar

Sistem sirkulasi hepar

Vena Cava Inferior

Darah dari tubuh bagian
bawah dibawa ke jantung

Vena Cava Superior

Darah dari tubuh bagian atas
dibawa ke jantung

Sistem sirkulasi sistem digestif

Sistem sirkulasi tubuh bagian bawah

SSP
Usus
Lung

700 mL/min
(13%)

1.100 mL/min
(20%)
Limpa

5.800 mL/min
(100%)
5.800 mL/min
(100%)
Jantung

Vena Porta
1.150 mL/min
(21%)

70 mL/min
(1.4%)

240 mL/min
(4%)

300 mL/min
(5%)

Hepar

Kidney

1.240 mL/min
(22%)

1.310 mL/min
(23%)

Waktu iskemik setiap sel (organ berbeda)

Otot, kulit dan jar

adiposus

Sistem

Waktu iskemia

Sistem muskular

8 jam

Ginjal

8 jam

Usus

1-2 jam

Portal

1-2 jam

Lingkaran setan perdarahan

Trauma Mayor pada torso

Perdarahan
aktif
Koagulopatia
progresif

Iatrogenik
TRIAS KEMATIAN

Syok
seluler

Hipotermia

Kerusakan
jaringan

Asidosis
metabolik

Transfusi masif
Aktivasi adhesi
ELT*
Defisiensi faktor
pembekuan
*ELT: Endotel Leukosit Trombosit
**Koagulopatia: 1) Perdarahan, 2) Trombosis

Penyakit
komorbid

Resusitasi Cairan
Definisi
1. Pemberian cairan isotonik intravena secara cepat untuk
mengatasi defisit volume (volume replacement)
1. Dorlands Online Medical Dictionary. Available in website: http://www.dorlands.com
2. McGrawHill Concise Dictionary of Modern Medicine. 2002 by The McGrawHill
Companies, Inc.

2. Pemberian cairan isotonik intravena pada pasien trauma,

luka bakar, dan pasien hipotensif
Boldt J. Clinical review: Crit Care. 2002; 6: 5259

3. Prosedur pemberian cairan intravena untuk tujuan

restorasi, revival dan renewal.
Santry HP, Alam HB. Shock. 2010; 33(3): 22941

Resusitasi Cairan
Masalah pada Resusitasi:
Pemberian sejumlah volume cairan isotonik
tidak sertamerta diikuti perbaikan perfusi
Pemberian cairan agresif
TD tidak merepresentasikan perfusi;
Perbaikan TD (pada hipotensi) diikuti
lepasnya bekuan darah perdarahan
berulang

The history
Tom Shires
Early aggressive resuscitation argued that
the need for increasing cardiac output and
oxygen delivery to maintain microvascular
perfusion and oxygenation, exceeds any risk
of accentuating hemorrhage and therefore
trauma victims in hypotensive hemorrhage
should receive large volumes of fluids as
early as possible (1970).

G. Tom Shires 1925- 2007

Resusitasi Cairan
Masalah pada Resusitasi:
Pemberian sejumlah volume cairan isotonik
tidak sertamerta diikuti perbaikan perfusi
Pemberian cairan agresif
"The injection of a fluid that will increase blood
pressure has dangers in itself. Hemorrhage
may not have occurred to a marked degree
because the blood pressure has been too low
to overcome the obstacle offered by a clot.
Myburgh JA, Mythen MG. Resuscitation fluids. Review article. N Engl J
Med. 2013; 369;13:12431251

Resusitasi Cairan
Masalah pada Resusitasi:
Pemberian sejumlah volume cairan isotonik
tidak sertamerta diikuti perbaikan perfusi
Pemberian cairan agresif
Volume efektif 1/3 volume yang
diberikan
Cairan isotonik masif edema
interstisium masif (Kelebihan cairan)
sindroma rongga ketiga [fatal]

Resusitasi Cairan
Masalah pada Resusitasi:
Pemberian sejumlah volume cairan isotonik
tidak sertamerta diikuti perbaikan perfusi
Pemberian cairan agresif
Asidosis (hiperkloremik)
anion gap / SID [Stewart]
Gangguan pembekuan

Resusitasi Cairan
Masalah pada Resusitasi:
Pemberian sejumlah volume cairan isotonik
tidak sertamerta diikuti perbaikan perfusi
Pemberian cairan agresif
Hipotermia [ATP]
Asidosis [hiperkloremik]
Gangguan pembekuan [iatrogenik]
TRIAS KEMATIAN

Pemicu mediator proinflamasi

Well, Wait weve always given fluids, Dr Shires told us

to do this. Anyway, it is just salt water, it cant possibly
hurt the patient, can it???

Resusitasi Cairan
Masalah pada Resusitasi:
Pemberian sejumlah darah untuk perbaikan
perfusi
Pemberian cairan koloid
Efek pengenceran (dilusi)
Gangguan pembekuan
Reaksi hipersensitivitas (sebagaimana
cairan isotonik)
Kaczynski J, Wilczynska M, Hilton J, Fligelstone L. A literature review.
Emerg Med Health Care. Open access.
(http://creativecommons.org/licenses/by/3.0).
Velanovich V. A meta-analysis of mortality. Surgery 1989;105:65-71.

Resusitasi Cairan
Kontra resusitasi agresif (2000s)

Hypotensive Resuscitation
Permissive Hypotension
Restrictive Fluid Resuscitation (<150 mL)
Targeted Resuscitation (Novel Hybrid Resuscitation)
Controlled Resuscitation
Controlled Hypotension
Damage Control Resuscitation (SBP of 90 mmHg)

Cotton et al. Ann Surg.2011;254:598-605

Morrison et al. J Trauma.2011;70:652-663

The fluid resuscitation

Hypotensive resuscitation:
Such advice runs contrary to current teaching on the
management of haemorrhagic shock in both
Prehospital and Advanced Trauma Life Support
manuals, both of which advocate initial fluid therapy.
The authors' management of severely injured patients
with 'permissive hypovolaemia' is not commonly
practiced.

Dutton RP, Mackenzie CF, Scalea TM. J Trauma. 2002;52:11411146

Jackson K , Nolan J. JICS. 2009;10(2):109114.
Harris T, Rhys Thomas GO, Brohi K. BMJ 2012; 345.

The new concept

The equilibrium

Balanced (fluid) Resuscitation

Pendekatan Baru: Konsep keseimbangan

Konsep keseimbangan total
Larutan seimbang (balanced salt solution: elektrolit)
Hartmanna

Plasmalytea

Plasmalyte Ra

Sodium

129

140

140

Chloride

109

98

103

Potassium

10

Calcium

Magnesium

1.5

Lactate

29

Acetate

27

47

Gluconate

23

Effective SIDb

27

50

53

SID = strong ion difference

aBaxter (Australia)
bSID values are in mEq/L, and asume stable plasma lactate concentration of 2
mmol/L

Morgan et al. Designing Balanced Crystalloids .Crit Care Resusc.

2003; 5: 284-291

Pendekatan Baru: Konsep keseimbangan

Konsep keseimbangan total
Volume koloid seimbang dengan volume
replacement memberi keuntungan (status
keseimbangan asambasa)
Formula larutan HES 6% 130kDa:RL 1:1
memperbaiki perfusi ke mukosa gaster
(asesmen gastric tonometry) lebih baik
dibanding HES 6% (130kDa) saja

The balanced concept of fluid resuscitation . Editorial. Brit J Anaesth. 2007. 99 (3): 31215
James MF, Michell WL, Joubert IA, Nicol AJ, Navsaria PH, Gillespie RS: Resuscitation with
hydroxyethyl starch improves renal function and lactate clearance in penetrating trauma in a
randomized controlled study: the FIRST trial (Fluids in Resuscitation of Severe Trauma). Br J Anaesth
2011, 107:693-702

Pendekatan Baru: Konsep keseimbangan

Konsep keseimbangan total
Tatalaksana syok:
Perbaikan O2 delivery: PRC
Mencegah/mengatasi koagulopati:
Seluler = Trombosit
Humoral = FFP
Hindari:
Hyperfibrinolysis = TXA dan
Hypofibrinogenemia = Cryoprecipitate
Transfusi masif
Clinical Review. Early fluid resuscitation in severe trauma. BMJ 2012;345:e5752

Pendekatan Baru: Konsep keseimbangan

Konsep keseimbangan total
Resusitasi awal:
RL (maksimum 1000 mL) dan PRC.
Keuntungan pemberian produk darah di awal
membawa banyak keuntungan.

Perdarahan masif:

PRC

1
1 unit/bag ~ 300mL
4mL X kg X Hb g/dL

Trombosit
1
2040 x 109 /L
1 unit ~ 60mL

FFP
1

0.51.3 g/unit
1020 mL/kg (1 bag
~ 230mL)

Clinical Review. Early fluid resuscitation in severe trauma. BMJ 2012;345:e5752

Chambers et al . Coagulopathy in treated trauma patients. Am J Clin Pathol 2011;136:364370

Pendekatan Baru: Konsep keseimbangan

Konsep keseimbangan total
Tidak terlalu cepat, tidak terlalu
lambat..
focused on "golden hour" utk pra RS (ATLS 9th)
Seni resusitasi

Tidak kekurangan, tidak kelebihan..

Seni resusitasi

McSwain NE, Champion HR, Fabian TC, Hoyt DB, Wade CE, Eastridge BJ, State of the art of fluid
resuscitation 2010: prehospital and immediate transition to the hospital. J Trauma. 2011 ;70(5
Suppl):S2-10.
Richardson RG. The art of resuscitation. J R Soc Med 1990;.83(11):753. PMC1292936
Burdett et al. Perioperative buffered versus non-buffered fluid administration for surgery in adults.
Cochrane Anaesthesia Group . The Cochrane Collaboration. John Wiley & Sons, Ltd. 2003

Pendekatan Baru: Konsep keseimbangan

Pemantauan
Mentation
Skin perfusion / mottling
Cold extremities (and cold knees)
Capillary refill
Mean arterial pressure
Urine output, urine sodium and osmolarity
Cerebral and abdominal perfusion pressures
Blood lactate
Arterial pH, BE, and HCO3 Mixed venous oxygen saturation SmvO2 (or ScvO2)
Mixed venous pCO2
Tissue pCO2 (sublingual capnometry, gastric tonometry)
Skeletal muscle tissue oxygenation (StO2, NIRS)

Marik et al. Hemodynamic parameters to guide fluid therapy. Annals of Intensive Care 2011, 1:1

Miller TE. Perioperative Medicine 2013, 2:13

http://www.perioperativemedicinejournal.com/content/2/1/13

ATLS 9th edition

ATLS
approach to the
trauma patient

ATLS express guidelines, not

protocols
Can be applied at Trauma Centers
as well
Local protocols: inspired by
ATLS; they should consider
structural, diagnostic and
professional resources

Initial resuscitation:
1000 mL (NOT 2000 mL)
The goal of resuscitation is not
to treat hypotension BUT
perfusion
Balanced resuscitation

Such a resuscitation strategy

may be a bridge to but is also
not a substitute for
definitive surgical control of
bleeding (page 63-64).

Strategi
Pendekatan pada syok hemoragik:
Damage control resuscitation terdiri dari:
1. Awal: RL maksimum 1000mL
2. Pengendalian sumber perdarahan
3. Pemberian awal PRC, FFP dan Trombosit rasio1:1:1
4. Hindari pemberian kristaloid berlebihan
5. Prevensi dan tatalaksana hipohermia, hipokalsemia,
asidosis dan koagulopatia
6. Hypotensive resuscitation

. Terima Kasih