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PENATALAKSANAAN Pts DENGAN

HIPOTENSI SYOK
Dr Wahyu Widjanarko SpJP FIHA

KASUS I

Laki-2 75 th datang dengan keluhan lemah, nyeri dada 1


minggu tidak mau makan, muntah, Fisik : TD 70/40
mmHg N : 120x/mnt lemah, t : 38C, keringat dingin.
Jantung paru normal, acral dingin. R : N, EKG : normal
sinus rhythm, apa diagnosanya?
a. Syok hipovolemik
b. Syok septik
c. Syok kardiogenik

Apa terapinya?
a.

Fluid administration

b.

Inotropik

c.

Vasopressor

Kasus 2
Wanita 65 th datang datang dengan keluhan
sesak nafas, panas 3 hari yl. Fisik : KU lemah, TD :
80/50 mmHg, N : 130x/mnt, RR : 40x/mnt, t :
38,3C, Jantung : gallop +, Paru : ronchi +,
wheezing + kedua lap paru. Acral dingin. EKG :
SVT, R : cardiomegali, kongesti paru. Apa
diagnosanya?
a. Syok sepsis
b. Syok kardiogenik
c. Syok hipovolemik

Clinical Signs: shock, hypoperfusion, congestive heart


failure, acute pulmonary edema
Most likely problem?

Acute pulmonary edema

1st Acute Pulmonary Edema


Furosemide IV 0.5 1.0 mg/kg
Morphine IV 2 4 mg
Nitroglycerin SL
Oxygen/intubation as needed

Volume problem

Administer
Fluids
Blood transfusions
Cause-specific interventions
Consider vasopressors

Pump problem

Bradycardia
(see algorithm)

Rate problem

Tachycardia
(see algorithm)

Blood
pressure?

Next slide

Systolic BP
BP defines 2nd
line of action
(see below)

Systolic BP
<70 mmHg
Signs/symptoms
of shock

Norepinephrine
0.5 30 g/min IV

Systolic BP
70-100 mmHg
Signs/symptoms
of shock

Dopamine
5 15 g/kg per
minute IV

Systolic BP
70-100 mmHg
No Signs/symptoms
of shock
Dobutamine
2 20 g/kg per
minute IV

2nd Acute Pulmonary Edema


Nitroglycerin/nitroprusside if BP >100 mmHg
Dopamine if BP = 70-100 mmHg, signs/symptoms of shock
Dobutamine if BP >100 mmHg, no signs/symptoms of shock

Further diagnostic / therapeutic


considerations
Pulmonary artery catheter
Intra-aortic balloon pump
Angiography for AMI / ischemia
Additional diagnostic studies

Systolic BP
>100 mmHg

Nitroglycerin
10 20 g/min IV
consider
Nitroprusside 0.1
5.0 g/kg per min IV

ACUTE HEART FAILURE with several distinct


clinical condition
I.

Acute decompensated HF or
Decompensation of chronic HF :
Symptoms and sign of AHF +, mild, not fulfil for
cardiogenic shock, pulmonary oedema or HT crisis.
II. Hypertensive AHF: symptoms and sign of HF
+ BP and preserved LV function with chest X-ray
pulmonary congestion.
III. Pulmonary oedem : Severe respiratory
distress, orthopnea and rales over the lungs, O2
saturation < 90% and verified by chest X-ray

IV. Cardiogenic shock : Tissue hypoperfusion


induced by HF after corection filling pressure. BP ( SBP <
90 mmHg or mean arterial BP > 30 mmHg), low urine
output ( < 0,5 ml/kg hr ), pulse rate > 90bpm, organ
congestion +/-, low CO severe cardiogenic shock.
V. High output failure : CO, HR ( arrhytmia,
thyrotoxicosis, anemia, iatrogenic ), warm peripheries,
pu;monary congestion, BP as in septic shock.
VI. Right heart failure : low output syndrome with
JVP, hepatomegaly and hypotension

THE KILLIP CLASSIFICATION ( Clinical


estimate )
Class I

: no HF, no clinical sign of cardiac decompensation

Class II

: HF, rales, S3 gallop, pulmonary venous HT, pulmo


congestion with wet rales up to half of the lung fields

Class III : Severe HF. Pulmonary oedema with rales in all lung
fields
Class IV : Cardiogenic shock. Sign BP ( 90 mmHg ), peripheral
vasoconstriction, oligouri, cyanosis and diaphoresis.

Clinical classification

P
e
r
f
u
s
i
o
n

Dry and warm

Wet and warm

Dry and cold

Wet and cold

Congestion : lungs

The forrester classification ( haemodynamic


characteristic )

C
I
2
,
2

T
i
s
s
u
e
P
e
r
f
u
s
i
o
n

Diuretics
Vasodilators

normal

Pulmonary oedema
Fluid administration

N BP : Vasodilators
BP : Inotropics or vasopressor

Hypovolemic

Pulmonary congestion
PCWP18 mmHg

Cardiogenic shock

Diagnostic algorithm ( clinical assesment, pts hx,


ECG, X-ray, O2 saturation,CRP, electrolytes, Cr, BNP )
Suspected Acute Heart Failure

Assess symptoms & sign

Heart disease ?ECG/BNP/Xray ?


Abnormal
Evaluate cardiac function by
Echocardiography

Normal
Consider other diagnosis
Normal

Abnormal
HEART FAILURE
Characterise type & severity

Selected test ( angio, haemo moni )

Laboratory test
Always

Routine haematology
Creatinine/Urea
Elektrolyte
Blood glucose
Troponin/ CKMB
Arterial blood gases
CRP D-dimer

Consider
Transaminases
Urinalysis
BNP or NT-proBNP
INR ( if anticoagulated or HF)

Treatment goals : Improve clinical symptoms and


outcomes.
Clinical
Symptoms
Clinical sign
BW
Diuresis
Oxygenation

Outcome
Length of stay in the ICU
Duration of hospitalisation
Time to hosp. rea-dmission
Mortality
Tolerability
Low rate of withdrawal from Tx
Low incidence of adverse eff.

Laboratory
Haemodynamic
BUN and/or creatinine PCWP < 18 mmHg
S-bilirubin
CO or SV
Plasma BNP
Electrolyte and glucose N

Initial management : Instrumentation and choice of


Tx clinical priorities

O2 face mask or by CPAP ( SpO2 target 94-96%)


i.v diuretic with loop diuretic
Vasodilatation by nitrate or nitropruside
i.v fluid sign of low filling pressure
Concomitant metabolic and organ spec.cond.are treated
Dx work up & lab.status.
Correct hypoxia &CO, renal perfusion, Na excretion &
urinary output.Ultrafiltration or dialysis if diuretic resistance
Tertiary tx with devices may be indicated, IABP, ventilation,
or circulatory assist or heart transplantation

Steps of care and treatment algorithm in


AHF

Acute H
F
Definitive
diagnostic

Immediate
resuscitation

Diagnosis
algorithm

Pts distress or in
pain

Definitive
treatment

ArterialO sat >


95%

Y
N
N
N

FiO2,CPAP,
NIPPV

Y
N

Normal HR &
rhythm

If moribund
BLS,ALS
Analgesia or
sedasi

Pacing,
antiarrhytmi
Y

Y
Mean BP > 70
mmHg
Adequate preload

N
N

Vasodilators,
diuresis if volume
overload
Fluid challenge

Y
Adequate CO:
reversal of
metabolic acidosis,
SvO2 > 65%,
clinical sign of
adequate organ
perfusion

Inotropes or
further afterload
reduction

Reassess
frequently

Specific pharmalogical treatments : Based of the


pharmacodynamic, pharmacokinetics, potential interaction, side effects,
and toxicity
A. Diuretics i.v in the acute phase
Severity of fluid retent. Diuretic
Dose(mg) Comments
Moderate
Furosemide or 20 40
symptoms
Moni. Na/K,cr,BP
Severe
Furosemide or 40 100 i.v
Furosemide inf. 5 40 mg/h better than HBD
Refractory
Add HCTZ
25-50 td
better HD loop
Add spirono
25-50 od if not RF
Refract to furos +HCTZ Add dopamine f renal vaso ultrafilt or HD
dilatation + dobutamine

B. Vasodilators systemic BP
Vasodilator

Indication

dosing

SE

5-mononitrae AHF,BP is adequate 20 200 g/m hypotens,


headace
ISDN

AHF, BP adequate

Nitropruside HT crisis

1 10 mg/h

idem

0,3 5 g/kg/m

idem

C. Inotropic agents
Agents

Bolus

Infusion rate

Dobutamine
no 2 20 /kg/min ( )
Dopamine
no < 3 g/kg/min, renal effect ( )
3 5 g/kg/min, inotropic ( )
> 5 g/kg/min(), vasopressor (
Norepinephrine no
0,2 1,0 g/kg/min
Epinephrine
1 mg i.v at
resuscitati
on repeat
0,05 0,5 g/kg/min
ed 3-5 min

MATUR SUWUN