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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 : 38°C, keringat dingin. Jantung paru normal, acral dingin.
Rð : 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 : 38,3°C, Jantung : gallop +,
Paru : ronchi +, wheezing + kedua lap paru. Acral dingin.
EKG : SVT, Rð : 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 Volume problem Pump problem Rate problem

1st – Acute Pulmonary Edema Administer Bradycardia Tachycardia


Furosemide IV 0.5 – 1.0 mg/kg • Fluids (see algorithm) (see algorithm)
Morphine IV 2 – 4 mg • Blood transfusions
Nitroglycerin SL • Cause-specific interventions Blood
Oxygen/intubation as needed Consider vasopressors pressure?

Next slide 
Systolic BP Systolic BP Systolic BP Systolic BP Systolic BP
BP defines 2nd <70 mmHg 70-100 mmHg 70-100 mmHg >100 mmHg
line of action Signs/symptoms Signs/symptoms No Signs/symptoms
(see below) of shock of shock of shock

• Norepinephrine • Dopamine • Dobutamine • Nitroglycerin


0.5 – 30 µg/min IV 5 – 15 µg/kg per 2 – 20 µg/kg per 10 – 20 µg/min IV
minute IV minute IV consider
• Nitroprusside 0.1 –
5.0 µg/kg per min 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
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
A B
e
r Dry and warm Wet and warm
f
u L C
s Dry and cold Wet and cold
i
o
n Congestion : lungs
The forrester classification ( haemodynamic
characteristic )
T
i
s
C s Diuretics
normal
u Vasodilators
I
e
2 Pulmonary oedema
, P
2 e Fluid administration N BP : Vasodilators
r ↓ BP : Inotropics or vasopressor
f Hypovolemic
u Cardiogenic shock
s
i
Pulmonary congestion
o
n PCWP18 mmHg
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/X- Normal


ray ?
Consider other diagnosis
Abnormal
Evaluate cardiac function by Normal
Echocardiography
Abnormal
HEART FAILURE
Selected test ( angio, haemo moni )
Characterise type & severity
Laboratory test

Always Consider

• Routine haematology Transaminases


• Creatinine/Urea Urinalysis
• Elektrolyte BNP or NT-proBNP
• Blood glucose INR ( if anticoagulated or HF)
• Troponin/ CKMB
• Arterial blood gases
• CRP D-dimer
Treatment goals : Improve clinical symptoms and
outcomes.

● Clinical ● Outcome
↓ Symptoms ↓ Length of stay in the ICU
↓ Clinical sign ↓ Duration of hospitalisation
↓ BW ↑ Time to hosp. rea-dmission
↑ Diuresis ↓ Mortality
↑ Oxygenation ● 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 If moribund BLS,ALS

Y Analgesia or sedasi
Diagnosis algorithm Pts distress or in pain
N
N
N ↑ FiO2,CPAP, NIPPV

Definitive treatment ArterialO sat > 95%


Y
N Pacing, antiarrhytmi
Normal HR & rhythm
Y
Y Vasodilators, diuresis
Mean BP > 70 mmHg if volume overload
N
N Fluid challenge
Adequate preload
Y

Adequate CO: reversal N Inotropes or further


of metabolic acidosis, afterload reduction
SvO2 > 65%, clinical
sign of adequate organ Reassess frequently
perfusion Y
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 µg/m hypotens,


headace

ISDN AHF, BP adequate 1 – 10 mg/h idem

Nitropruside HT crisis 0,3 – 5 µg/kg/m idem


C. Inotropic agents

Agents Bolus Infusion rate

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