Diare Dan Komplikasi
Diare Dan Komplikasi
K E G AWAT DA R U R ATA N
MEDIK
PRE TEST
Syok hipovolemik
Asidosis metabolik
GANGGUAN
KESEIMBANGAN
CAIRAN
KESEIMBANGAN CAIRAN
Osmolality plasma ↑
Thirst ↑ ADH ↑
Water ingestion ↑ Water excretion ↓
Water retention
Osmolalitas plasma ↓
Volume sirkulasi ↑
DEHIDRASI
• Tubuh kekurangan cairan
• Etiologi kekurangan cairan :
– Melalui saluran cerna
• Muntah
• Diare
• Perdarahan
– Melalui saluran kencing
• Pemakaian diuretik
• Penyakit ginjal
• diabetes
– Melalui kulit
• Luka bakar
• Keringat ↑↑
– Perpindahan ke ruang dalam badan
• Peritonitis
• Pankreatitis
Tanda dan Gejala dehidrasi :
Lesu Akral dingin
Tekanan darah menurun Mukosa kering
Nadi halus cepat Turgor menurun
Urin output menurun
Pengobatan :
• Sesuai penyakit dasar
• Pemberian cairan oral - parenteral
FLUID LOSS AND SHOCK
% Dehydration Examination Findings
<5 History of fluid loss, but no findings on
physical examination
5 Dry oral mucous membranes, but no
panting or pathological tachycardia
7 Mild to moderate decreased skin turgor,
dry oral mucous membranes, slight
tachycardia, and normal pulse pressure
10 Moderate to marked degree of decreased
skin turgor, dry oral mucous membranes,
tachycardia, and decreased pulse pressure.
12 Marked loss of skin turgor, dry oral mucous FLUID AND ELECTROLYTE THERAPY
(http://www.cvmbs.colostate.edu/clinsci/
4. Ukur Hematokrit
defisit cairan = 0,2 X BB {Ht / Ht normal - 1}
5. Ukur BJ plasma
SISTEM SKOR (DALDIYONO SCORE)
SIGNS & SYMPTOMS SKOR
1. Muntah 1
2. Vox cholerica 2
3. Apatis 1
4. Somnolen/sopor/koma 2
5. TDS ≤ 90 1
6. TDD ≤ 60 2 Defisit Cairan :
7. Nadi ≥ 120 mm/Hg 1 Skor / 15 x BB x 100
8. Nafas Kussmaul 1
9. Turgor ↓ 1
10. Facies Cholerica 2
11. Ekstremitas dingin 1
12. Jari tangan keriput 1
13. Sianosis 2
14. Umur > 50 tahun -1
15. Umur > 60 tahun -2
HYPOVOLEMIC
SHOCK
HYPOVOLEMIC SHOCK
DEFINITION
syndrom characterized by decreased circulating blood
volume (hypovolemia), which results in reduction of
effective tissue perfusion pressure and generalized cellular
dysfunctions.
Forms:
• Hemorrhagic shock
• Non-hemorrhagic hypovolemic shock
HYPOVOLEMIC SHOCK
CAUSES:
• Hemorrhagic:
External blood loss (wounds)
Exteriorization of internal bleeding (hematemesis, melena, epistaxis,
hemoptysis,etc.)
Internal bleeding (hemothorax, hemoperitoneum,etc. )
Traumatic shock
• Non-hemorrahagic:
Digestive losses (vomiting, diarrhea, nasogastric suction, billiary, digestive
fistula, etc )
Renal losses (diabetes mellitus, polyuria caused by diuretics overdose, osmotic
substances, polyuric phase of acute renal failure, etc.)
Skin losses (intense physical effort, overheated enviroment, burns, etc.)
Third space losses (peritonites, intestinal oclussion, pancreatits, ascitis pleural
effusions, etc.)
PATHOPHYSIOLOGY
Hypodynamic shock:
Macrocirculatory reaction:
• sympatho-adrenergic + humoral reaction (ADH, cortizol, SRAA)
o EFFECTS: centralisation of the circulation (compensatory effect)
worsening of tissular hypoperfusion (decompensatory effect)
Microcirculatory reaction:
• Alterations of capillary exchanges
o EFFECTS: transcapillary filling (compensatory effect)
capillary leak (decompensatory effect)
• Maldistribution of blood flow
o EFFECTS: preferential renal blood flow towards medular region (cortical
vasoconstriction)
• Abnormal peripheral oxygen extraction
o EFFECTS: early - increased (compensatory effect)
late - decreased (decompensatory effect)
• Rheologic changes
o EFFECTS: ↑ blood viscosity, blood flow, CID
• Endhotelial modifications
o EFFECTS: morpho-functional modifications
proinflamatory and procoagulatory status,
altered permeability
HYPOVOLEMIC SHOCK
CLINICAL SIGNS:
Intense thirst
Tachycardia
Tachypnea
Positive orthostatic test
Small pulse wave
hTA (blood hypotension)
Agitation, anxiety , confusion, coma
Oliguria
Cold extremities
Profuse sweating
Collapsed peripheral veins
Delayed return of color to the nail bed
+ History of hemorrhagic or non-hemorrhagic losses
CLASSIFICATION OF HYPOVOLEMIC SHOCK
BP N N
Hypovolemic
shock
↑ ↑ ↑
Cardiogenic
shock
↑ ↑ ↑ ↑ ↑
Septic shock
↑ ↑N N N ↑
ABBREVIATIONS:
• HR – heart rate
• BP – arterial blood pressure
• CO – cardiac output
• CVP –central venous pressure
• PAOP – pulmonary artery occlusion pressure
• SVR – systemic vascular resistance
• Da-v O2 – oxygen arterial-venous difference
• SvO2 – mixed venous blood oxygen saturation
HYPOVOLEMIC SHOCK
TREATMENT PRINCIPLES
• Initial treatment of shock states
• Causative treatment – STOP losses
• Volume repletion
• Inotropic therapy
• Vasomotor therapy
TREATMENT OF HYPOVOLEMIC SHOCK
• Causative treatment – STOP losses
– essential role
– surgical treatment (when appropriate)
– emergency surgery for ongoing hemorrhage
• Volume replacement
– Vascular access site
– Solutions for volume replacement
– Rhythm of administration
TREATMENT OF HYPOVOLEMIC SHOCK
• Volume replacement – SITE of VASCULAR ACCESS
– Peripheral vascular access
• Multiple access (2-4 veins)
• Large peripheral catheters
• External jugular vein
Advantages:
– Short time of instalation
– Requires basic knowledge and simple matherials
– Minor complications (hematomas, cutaneous seroma, etc.)
Disadvantages:
– The diameter of peripheral catheter must be adapted for peripheral veins dimensions
– Vascular access can be lost (restless patient, during transportation); must be changed at 24-48
hours;
– no catecholamines administration (except in emergency for a short time period,until a central
venous access is available)
– Central venous access
• After peripheral vascular access is established and volume replacement is initiated
Advantages:
– Reliable and long lasting venous access (7-10 days)
– Allows CVP measuring and guiding of treatment
– Allows the administration of catecholamines and hypertonic substances
Disadvantages:
– Risk of complication (at instalation – pneumothorax, cervical or mediastinal hematoma, cardiac
dysrhytmias; during utilization – infection, gas embolism)
TREATMENT OF HYPOVOLEMIC SHOCK
– Advantages:
• Good volume effect
• Long duration of volume effect
– Disadvantages:
• expensive
• risk for anaphylactic reactions
• interfere with blood groups determination
• can induce/ aggravate coagulation disorders
TREATMENT OF HYPOVOLEMIC SHOCK
Volume replacement
RHYTHM OF ADMINISTRATION
– Rhytm of administration depends on:
• Ongoing losses / stopped losses
• Rhytm of losses – rapid (minutes, hours) or slow (days) instalation
– For the patient with hypotension – normal saline (2000 ml in the first 15-30
minutes)
– after the first 15-30 minutes - volume replacement continues depending on
the clinical and hymodinamic parameters (BP, HR, etc..)
TREATMENT OF HYPOVOLEMIC SHOCK
Volume replacement –
MONITORING THE TREATMENT EFFICIENCY
– Clinical parameters
• normalisation of BP, HR, pulse amplitude, skin colour and
temperature, mental status, urinary output
– Hemodynamic parameters
• Normalization of CVP, PCPB, DC, RVS, so
– Laboratory parameters
• Normalization of acid-base balance, liver, renal tests, Hb, Ht
TREATMENT OF HYPOVOLEMIC SHOCK
• Inotropic support
– Only after volume replacement
– Used to improve cardiac output
– Dobutamine
• inotropic positive support
• peripheral arterial vasodilatation
TREATMENT OF HYPOVOLEMIC SHOCK
Vasopressor therapy
• NOT RECOMMENDED (may aggravate peripheral hypoperfusion and
metabolic acidosis)
EXCEPTIONS
• Only temporary
• In case of ongoing hemorrhage, which outruns the possibilities of
volume replacement
• Only until surgical procedure stops the hemorrhage (emergency surgical
treatment)
• Noradrenaline, dopamine, adrenaline
GANGGUAN
KESEIMBANGAN
ASAM BASA
CLİNİCAL EVALUATİON
• Patient history
• Clinical presentation
• Acidemia Hyperventilation
• Alkalemia Paresthesias and Tetany
• Laboratory: Blood acid-base status:
• Blood pH (4 º C, with anticoagulant, promptly),
• Urine pH
• Plasma and urine electrolyte concentration
• Lactate concentration
ACİDOSİS
• Clinical effects of severe acidosis: pH <7.2
• Cardiovascular system effects:
– Decreased myocardial contractility
– Decreased cardiac output
– Cardiac failure
– Hypotension
– Decreased hepatic and renal blood flow
– Centralization of effective blood volume
– Tissue hypoxia
– Pulmonary edema
METABOLİC ACİDOSİS
Hallmark is [HCO3-]
• Ketoacidosis (diabetic)
• Uremia (renal failure)
• Salicylate intoxication
• Starvation
• Methanol intoxication
• Alcohol ketoacidosis
• Unmeasured osmoles (intoxication)
• Lactic acidosis
SİMPLE DECOMPENSATED ACİD-BASE DİSORDERS