Anda di halaman 1dari 23

SYOK

PADA ANAK

Dr.N.L.KD. DEWI SANGAWATI,SpA


SMF ANAK RSUD MATARAM

1
DEFINISI SYOK
 
SINDROM KLINIS AKIBAT KEGAGALAN SISTEM
SIRKULASI UNTUK MENCUKUPI :
 
 NUTRISI PASOKAN METABOLISME
 OKSIGEN UTILISASI JARINGAN TUBUH
 
FASE: KOMPENSASI
DEKOMPENSASI
IREVERSIBEL DEFISIENSI O2 SELULER
2
Etiologi Syok

Type Primary Insult Common Causes


Hypovolemic Decreased circulating Dehydration, hemorrhage,
blood vol capilarry leaks
Distributive Vasodilation -> venous Sepsis, anaphylaxis,
pooling -> decreased preload drug intoxication,
spinal cord injury
Obstructive Obstruction of cardiac Cardiac tamponade, tension
filling/out flow pneumothoracx, pulmonary
embolus
Cardiogenic Decreased contractility Congenital heart disease,
myocarditis, dysritmia
Dissociative O2 not released from CO poisoning,
hemoglobin methemoglobinemia 3
FUNGSI SISTEM SIRKULASI
 
 JANTUNG CURAH JANTUNG METABOLISME
 PEMB. DARAH ALIRAN DARAH ADEKUAT JARINGAN
 VOL. DARAH O2 DELIVERY
 
METABOLIT
 

ELIMINASI
DI ORGAN PEMBUANGAN

4
Pengaturan curah jantung dan tekanan darah

Preload Contractility Afterload

 
 
Heart rate Stroke volume

 
 
Cardiac output Systemic vascular resistance

Blood pressure 5
Shock

Hypotension

  Preload

Cellular hypoxia

 Intravasculer volume  Myocardial contractility


Anaerobic metabolism

 Membrane permeability

Metabolic by-products:
- lactic acid
- myocardial depressant factor
- endogeneous catecholamines
- adenine nucleotides
6
STADIUM SYOK

 KOMPENSASI
 DEKOMPENSASI
 IREVERSIBEL (PRETERMINAL)
PERJALANAN KLINIS BERSIFAT PROGRESIF

7
FASE I: KOMPENSASI
 KOMPENSASI TEMPORER
  SIMPATIS,  SVR,  TEKANAN NADI
 DISTRIBUSI SELEKTIF ALIRAN DARAH
  RETENSI NA & AIR
 KLINIS : * TAKHIKARDIA
* GADUH GELISAH
* KULIT PUCAT DINGIN
* PENGISIAN KAPILER >> 8
FASE 2: DEKOMPENSASI
 KOMPENSASI MULAI GAGAL
 HIPOPERFUSI  HIPOKSIA JAR.  METAB. ANAEROBIK
 GGN. METAB. SELULER
 PELEPASAN MEDIATOR : * VASODILATASI 
* PERMEABILITAS 
* DEPRESI MIOKARD 
* GGN KOAGULASI 
 KLINIS : TAKHIKARDIA  TEKANAN DARAH  TAKIPNU  PERFUSI
PERIFER  ASIDOSIS (+) OLIGURI (+)
TINGKAT KESADARAN 

9
FASE 3: IREVERSIBEL
 KOMPENSASI GAGAL
 CADANGAN ENERGI TUBUH 
 KERUSAKAN/KEMATIAN SEL  DISFUNGSI ORGAN
MULTIPEL
 KLINIS : * T.D TAK TERUKUR * NADI TAK TERABA
* TINGKAT KESADARAN * ANURIA (+)
* GAGAL MULTI ORGAN
DAN KEMATIAN

10
Manifestasi Klinis Syok

Clinical Signs Compensated Uncompensated Irreversible

Blood loss (%) Up to 25 25 - 40 > 40

Heart rate Tachycardia + Tachycardia ++ Tachy/bradycardia


Systolic BP N N or falling Plummeting
Pulse volume N/  +  ++
Capillary refill N/  +  ++
Skin Cool, pale Cold, mottled Cold, deathly pale
Respiratory rate Tachypnoea + Tachypnoea ++ Sighing rsp.
Mental state Mild agitation Lethargic Reacts only to pain
Uncooperative or unresponsive
11
GANGGUAN PERFUSI PERIFER
 CORE > PERIFER TEMP. ~ > 2O C
 CAPILLARY REFILL >> :
* NAIL BED PRESS
* BLANCHING SKIN TEST
 PRODUKSI URIN 
(N) BAYI = 2 ml/kg/jam
ANAK = 1 ml/kg/jam

12
TATALAKSANA RESUSITASI SYOK
RESUSITASI AWAL
 OKSIGEN 100% + VENTILATORY SUPPORT
 PASANG AKSES VASKULER (90 DETIK)
 FLUID CHALLENGE (20 ml/kg BB)
 SECEPATNYA < 10 MENIT
 DPT DIULANGI 2-3 KALI
 KRISTALOID/KOLOID
PEMANTAUAN AWAL
 RESPON THD FLUID CHALLENGE
 PANTAU PROD. URIN (KATETER)
 STAT. LAB/PENUNJANG 13
Monitoring
 State of consiousness-Glasgow Coma Scale
 Respiratory rate and character
 Cardiovascular parameters
 Skin and core temperature difference
 Pulse rate and volume
 Blood pressure
 Capillary perfusion time
 Central venous pressure - should be monitored in a patient
where there has been poor response to fluid therapy or with
established shock.
 Urinary output - urine bag, or preferably catheter; output
should be 1-2 ml/kg body weight
 Pulse oximetry 14
RESUSITASI LANJUT
BILA FLUID CHALLENGE NON RESPONSIVE
 INTUBASI & VENT. MEKANIK
 PASANG CVP & LOADING HATI-HATI
 KOREKSI EFEK INOTROPIK NEGATIF
Hb < 5 g/dl  PRC 10 ml/kg BB (Ht 40-50 vol %)
 OBAT INOTROPIK

15
PEMANTAUAN LANJUT
 CARI PENYEBAB SYOK (CXR, KONSULTASI)
 EVALUASI FUNGSI SIST. ORGAN LAIN :
 ATN/PRE RENAL FAILURE
 ARDS
 CARDIAC FUNCTION
 GGN. KOAGULASI/DIC
 ORGAN-ORGAN LAIN

16
CHILD IN SHOCK
 
 
(1) OXYGEN (2) CRYSTALLOID
20 ml/kg)
  IMPROVEMENT

NO IMPROVEMENT  
 

NO IMPROVEMENT (3) CRYSTALLOID - INCREASE MABP


(20 ml/kg) - NORMALIZATION HR
- IMPROVED PERFUSION
- URINE OUTPUT > 1 ml/kg/hr
URINARY CATHETER
 

ESTABLISH CVP ESTABLISH ETIOLOGY,


ETIOLOGY,
OBSERVATION
 
CVP < 5 Torr CVP > 5 Torr
 
 
CRYSTALLOID INFUSION NO IMPROVEMENT 1. CORRECT
ACIDOSIS
UNTIL CVP - 5 Torr
  2. Co. GLUCOSE

3. INTROPIC
IMPROVEMENT ABG, HT, NaK, GLUC Ca,

STROKE VOLUME
SUPPORT
SWAN GANZ CATHETER
 
ESTABLISH ETIOLOGY CO, RAP, PAP, POAP
CONFIRM SOURCE
OF FLUID LOSS
CENTRAL VENOUS PRESSURE
17
Stadium syok septik dan manifestasi klinis
Stadium Tanda Klinis Gang fisiologis Biokimiawi

Warm Shock perfusi perifer (N)  Smv O2 hipokarbia


(Hiperdinamik) kulit hangat kering  VO2 hipoxia
HR  nadi bounding  CO kadar laktat 
 suhu / (tak stabil)  SVR hiperglikemia
RR , gg. kesadaran

Cold Shock sianosis  CO hipoxia


(Hipodinamik) kulit dingin lembab  SVR asidosis metab
nadi kecil, lemah  CVP koagulopati
HR , Oliguria  Smv O2 hipoglikemi
shallow breathing
pe  kesadaran

MOSF bergantung sistem Koma sesuai


yang terkena ARDS, CHF, RF jenis
GI bleeding/DIC organ failure
18
TATALAKSANA SYOK SEPTIK
 AB BROAD SPECTRUM  SESUAI KULTUR
 RESUSITASI CAIRAN : KOLOID/KRISTALOID
 OBAT INOTROPIK : DOBUTAMIN + DOPAMIN

ISOPRENALIN/ADRENALIN
  SVR  VASODILATASI PERIFER
 KOREKSI : - HIPO/HIPERGLIKEMI
- ASAM BASA
- ELEKTROLIT
19
TATALAKSANA SYOK ANAFILAKTIK
 STOP ALERGEN PENYEBAB + ADRENALIN (IM)
 AIR WAY & RESPIRATION ADEKUAT
 WHEEZING  NEBULASI ADRENALIN/SALBUTAMOL
 OBSTRUKSI  INTUBASI/SURGICAL AIRWAY
 SIRKULASI & HEMODINAMIK
 VASOPRESOR : ADRENALIN (10 g/kg BB)
 FLUID LOADING : KRISTALOID (20 ml/kg BB/IV-IO)
 RE ASSESSMENT ABC RESUSITASI
 WHEEZING (+)  NEBULASI SALBUTAMOL
BILA PERLU (+) HIDROKORTISON (IV)
(+) AMINOPILIN/SALBUTAMOL DRIP
 SYOK BERLANJUT : KOLOID + INOTROPIK 20
TATALAKSANA SYOK KARDIOGENIK
 OKSIGENASI ADEKUAT
 KOREKSI GGN ASAM BASA & ELEKTROLIT
 KURANGI RASA SAKIT & ANSIETAS
 ATASI DISRITMIA JANTUNG
 KELEBIHAN PRELOAD : DIURETIKA
 KONTRAKTILITAS: FLUID CHALLENGE SESUAI CVP/POAP
OBAT
INOTROPIK (+)
  BEBAN AFTERLOAD (SVR ) : VASODILATOR
 KOREKSI PENYEBAB PRIMER 21
Key points in management
 Remember BP and pulse are unreliable indicators in early
septic shock
 Look for minor degrees of mental impairment (anxiety,
restlessness)
 Do not delay treatment, try to prevent the onset of
hypotension, metabolic acidosis, and hypoxia
 Give adequate fluids early in treatment, especially colloids
 Do not use inotropic agents until the patient has received
adequate fluid therapy
 Monitor blood glucose, gases, and pH, and treat
appropriately
22
23