SYOCK &

MANAGEMENT

EDDY SUPRIYADI
 Questions

1. Why is it important to identify the

stage of shock?

2. Why is it important to identify the

type of shock?
Learning Objectives

Define shock
Know the stages of shock
Know the classifications of shock
DD of etiology
Know the initial management of
shock
 What is shock?
Inadequate perfusion to meet tissue demands. A
progressive process.
Occurs in 2% of hospitalized patients.
Mortality 10% in children (without MODS), vs. 30-40% in adults. 1,2

In other words, a systemic reduction in tissue

perfusion decreased tissue O2 delivery.
A shift to less-efficient anaerobic metabolism, leading to lactic acidosis, occurs.

Initially, effects are reversible. Eventually:

Cell membrane ion pump dysfunction
Cellular edema, leakage of cells contents
Inadequate regulation of intracellular pH
Cell death, organ failure, cardiac arrest, and death.
 STADIUM SYOK
1. Kompensata
Takikardi, takipnea, akral dingin, pengisian kapiler >
2-3 detik
TD normal
Iritabilitas ringan
2. Dekompensata
Perfusi mikrovaskular , penurunan volume sirkulasi
efektif
Kulit mottled, pengisian kapiler makin lambat (>4
detik), TD
Oliguria
Agitasi, konfusi, hingga koma
3. Ireversibel
Kerusakan dan kematian organ ireversibel
 KLASIFIKASI SYOK
Jenis Syok Patofisiologi Etiologi
HIPOVOLEMIK Pe volume sirkulasi Perdarahan, dehidrasi,
perpindahan cairan (SN,
DSS)
KARDIOGENIK Pe kontraktilitas Kardiomiopati, penyakit
jantung bawaan
SEPTIK Vasodilatasi, pe Bakterial
permeabilitas, pe Viral
kontraktilitas Fungal
DISTRIBUTIF Vasodilatasi Sepsis, anafilaksis,
neurogenik
OBSTRUKTIF Obstruksi pada Intrakardiak
preload dan/atau (tamponade, koarktasio
afterload aorta)
Ekstrakardiak (tension
pneumothoraks, emboli
paru, massa
Physiologic profiles of shock states

Type of Shock Preload Cardiac Afterload Tissue

(PCWP) Output (SVR) Perfusion
(Mixed venous sat)

Hypovolemic
Distributive Or Or
= =
Cardiogenic *

Obstructive
Shock: General initial management

Children benefit from goal-directed therapy

to improve physiologic indicators within
first 6 hrs of presentation. 1,2
Early reversal of shock associated with 57%
decrease in mortality and morbidity regardless of
underlying etiology.
Observational study of 1422 children with shock transferred
from community hospitals to tertiary care pediatric facility. 3

Mortality 6% in children not in shock on admission

to PICU versus 19% for those in shock on arrival.
Observational study of 136 children with septic shock.4
 Tatalaksana Syok

Oxygen Delivery :

Cardiac X Arterial Oxygen Content

Output

HR X SV Hb X 1,3 X SaO2
4

Preloa Contractility Afterload

d
Blood Maximize
transfusions oxygenation

Fluid Vasodilators or Normalize

administrati vasopressors pH,pCO2 and
on temp
Inotrop
 Goal Directed Therapy
Resusitasi dilakukan dengan target tertentu yang
ditetapkan
Sasaran
Sasaran
Hemodinamik dan
Sasaran Klinis : Pemakaian Oksigen Biokimia :

Status mental HR normal Laktat < 2

normal tekanan perfusi mmol/L
Kualitas nadi Anion gap <
normal (MAP-CVP)
normal 16
Suhu sentral dan indeks syok
(HR/SBP) Troponin I (N)
perifer sama Creatinine
Cap refill < 2 SvcO2 70%
Jumlah urin > 1 AVDO2 2-3% clearance (N)
ml/kg/jam CI : > 2 L/mnt/m2
 Tatalaksana Awal
Bebaskan jalan napas dan O2 100%
Pasang akses vaskuler & ambil sampel
darah untuk laborat (terutama gula darah)
Bolus KRISTALOID/KOLOID isotonik 20-60
ml/kg sampai perfusi baik ATAU terdengar
ronki ATAU hepatomegali
Evaluasi (tanda klinis syok) setiap selesai
bolus
Koreksi hipoglikemi & hipokalsemi
 0
Tatalaksana Syok Pediatrik
meni Mengenal tanda syok
t Buka jalan napas, beri oksigen, pasang akses vaskular
Beri cairan resusitasi sambil evaluasi respon klinis, bolus 20 cc/kg
5
kristaloid/ koloid bisa diulang sampai 60 cc/kg, kecuali terdapat
meni
kelebihan cairan
t
Koreksi hipoglikemia
Syok tidak teratasi dengan cairan
Syok teratasi
15 resusitasi
Pantau dan atasi
menit Titrasi dopamin atau epinefrin, lakukan
penyebab syok
pemantauan

Syok tidak teratasi dengan cairan resusitasi dan dopamin atau epinefrin
Adakah risiko insufisiensi adrenal?

Ada risiko Tidak ada risiko

60 Beri hidrokortison Jangan beri hidrokortison
menit
Syok belum teratasi

Cold shock Cold shock Warm shock

Tekanan darah normal Tekanan darah rendah Tekanan darah rendah
Milrinon dan cairan Cairan dan epinefrin Cairan dan norepinefrin
 1. Cairan
Boluses of isotonic crystalloids or
albumin of 20 ml/kg over 5-10
minutes esp in hypovolemic shock
Repeated boluses until therapeutic
endpoints are reached or presence of
rales or hepatomegaly for which
inotropic support be instituted
agaimana menilai terlalu banyak cairan

Pembesaran hati
Ronkhi basah halus tidak nyaring
Peningkatan tekanan vena jugularis
Foto toraks
Ultrasonografi vena cava inferior
Tanda Kelebihan Cairan dari foto
thoraks 1. Redistribusi vena-vena
pulmonalis,
kardiomegali, pedikel
vaskuler melebar
2. Edema intersisiel
(akibat fluid leakage)
gambaran
berkabut, Kerley line
(cairan di septum
interlobulus)
3. Edema alveoler
(akibat fluid leakage
ke alveoli)
 2. Blood Products
During resuscitation of low superior vena cava oxygen
saturation shock (< 70%), hemoglobin levels of 10 g/dL
are targeted. After stabilization and recovery from
shock and hypoxemia, then a lower target > 7.0 g/dL
can be considered reasonable

An RCT of early goal-directed therapy for pediatric

septic shock using the threshold hemoglobin of 10 g/dL
for patients with a SvcO2 saturation less than 70% in
the first 72 hrs of pediatric ICU admission showed
improved survival in the multimodal intervention arm
(SSC 2012)
 2. Vasoactive Agents
Inotropic :
cardiac output and contractility
Dopamine, dobutamine, and epinephrine work on
beta1 receptors in myocardium
Dopamine is considered first-line therapy for
patients who have fluid-refractory, hypovolemic,
or septic shock
Infants younger than 12 months of age may not
respond effectively to dopamine, in which case
epinephrine should be considered. Epinephrine
also should be added for children experiencing
dopamine-refractory hypovolemic or septic shock,
defined as persistent hypotension despite at least
Vasodilators :
Reduce pulmonary vascular resistance or SVR and
to improve cardiac output
Nitroprusside is a pure vasodilator used to
decrease afterload and improve coronary
perfusion in cardiogenic shock
Prostaglandin E1 is a potent vasodilator that
relaxes smooth muscle in the ductus arteriosus to
maintain patency
Inodilators :
The phosphodiesterase inhibitors (PDEIs) are an
important class of drugs, which mediate inotropy
and vasodilation by preventing hydrolysis of cAMP
(milrinone, amrinone, enoximone, pentoxyfilline)
Isoproterenol is an important inodilator with 1-
and 2-adrenergic activity. It is an important drug
in the treatment of heart block, refractory status
asthmaticus, and pulmonary hypertensive crisis
with right ventricular failure
 Vasopressors :
Phenylephrine is a pure -adrenergic receptor
agonist. Its primary role in children is for reversal
of tetralogy of Fallot spells, as well as in
distributive shock and septic shock presenting
with high CO and low SVR
At higher doses, dopamine and epinephrine have
increasing alpha-adrenergic effects, leading to
peripheral vasoconstriction and increased SVR
Dopamine : Low dosage : 2 5 g/kg/min; intermediate dosage : 5
10 g/kg/min; high dosage > 10 g/kg/min

Epinephrine : A low dosage (< 0.2 g per kg per minute) stimulates

both 1 and 2 effects. Dosages > 0.3 g per kg per minute are
associated with increased -adrenergic effects.
 3. Corticosteroids
Pasien tidak respons terhadap epinefrin dan NE

Pikirkan insufisiensi adrenal
Pada anak, insufisiensi adrenal absolut jika kadar kortisol
< 18 mcg/dl
Faktor risiko :
Paparan steroid sebelumnya (dalam 6 bulan terakhir)
Pasien dengan purpura fulminan
Pasien dengan penyakit sistem syaraf pusat
Terapi :
Pada sakit kritis : hidrokortison 2 mg/kgBB dalam 4 dosis terbagi
atau 0,18 mg/kgBB/mnt selama 7 hari target kortisol 30 mg/dL
Pada syok hidrokortison 50 mg/kgBB dilanjutkan infus kontinyu
selama 24 janm dengan dosis 0,18 mg/kgBB/mnt
 SYOK SEPTIK
INTERNATIONAL CONSENSUS DEFINITIONS -
PEDIATRIC SEPSIS
Severe sepsis: Sepsis plus 1 of the following:
1 Cardiovascular organ dysfunction, defined as:
Despite >40 mL/kg of isotonic intravenous fluid in 1 hour:
Hypotension <5th percentile for age or SBP <2 SD below
normal for age OR
Need for vasoactive drug to maintain blood pressure OR
2 of the following:
Unexplained metabolic acidosis: base deficit > 5 mEq/L
Increased arterial lactate: >2 times upper limit of normal
Oliguria: urine output <0.5 mL/kg/hr
Prolonged capillary refill: >5 sec
Core to peripheral temperature gap >3oC
2 Acute respiratory distress syndrome (ARDS): as
defined by the presence of a Pao2/Fio2 ratio 300 mm Hg,
bilateral infiltrates on chest radiograph, and no evidence of
left heart failure OR
Sepsis plus 2 or more organ dysfunctions (respiratory,
renal, neurologic, 27
hematologic, or hepatic)
 Septic Shock
Recognize
Recognize decreased
decreased mental
mental status
status and
and perfusion.
perfusion.
0 Maintain
Maintain airway,
airway, begin
begin high
high flow
flow oxygen,
oxygen, establish
establish IV/IO
IV/IO access
access
min

5 Initial
Initial resuscitation
resuscitation :: Push
Push 20cc/kg
20cc/kg isotonic
isotonic saline
saline or
or colloid
colloid boluses
boluses upup to
to
min and
and over
over 60
60 cc/kg
cc/kg until
until perfusion
perfusion improves
improves oror unless
unless rales
rales or
or
hepatomegaly
hepatomegaly develop
Fluid refractorydevelop
shock
Correct
Correct hypoglycemia and hypocalcemia, begin
hypoglycemia and
Shock hypocalcemia,
not begin antibiotic
antibiotic
Fluid reversed?
15 Fluid refractory
refractory shock
shock :: Begin
Begin inotrope
inotrope IV/IO,
IV/IO, use
use ketamine
ketamine or or atropine
atropine
min IV/IO/IM
IV/IO/IM to
to obtain
obtain central
central access
access and
and airway
airway if
if needed
needed
Reverse
Reverse cold shock by titrating central dopamine, or if resistant
cold shock by titrating central dopamine, or if resistant titrate
titrate
central
central epinephrine
epinephrine
Reverse
Reverse warm
warm shock
shock byby titrating
not central
titrating
Shock central norepinephrine
norepinephrine
reversed?
60 min Catecholamine -resistant shock : begin hidrocortisone if at risk or
absolute adrenal insufficiency
Monitor CVP in PICU, attain normal CVP-MAP and ScvO2 >
70%
Cold
Cold shock
shock with
with normal
normal BP
BP Cold
Cold shock
shock with
with low
low BP
BP Warm
Warm shockshock with
with low
low BP
BP
1.Titrate fluid and
1.Titrate fluid and 1. Titrate fluid
1. Titrate fluid and and 1. Titrate fluid and
1. Titrate fluid and NE, NE,
epinephrine,
epinephrine, ScvO2
ScvO2 > > epinephrine, ScvO2
epinephrine, ScvO2 > > ScvO2
ScvO2 > > 70%
70%
70%,
70%, Hb>10
Hb>10 g/dL
g/dL 70%,
70%, Hb>10
Hb>10 g/dLg/dL 2.
2. If
If still
still hypotensive
hypotensive
2.If
2.If ScvO2
ScvO2 << 70%
70% add
add 2.
2. If
If still
still hypotensive
hypotensive consider
consider vasopressine,
vasopressine,
vasodilator
vasodilator with
with volume
volume consider
consider NE NE terlipressin
terlipressin or or
loading, consider
loading, consider 3. If ScvO2 < 70% consider
3. If ScvO2 < 70% consider angiotensin
angiotensin
levosimendan
levosimendan dobutamine, milrinone,
dobutamine, milrinone, 3.
3. If ScvO2
If ScvO2 < < 70%
70% consider
consider
Shock
levosimendan not low
levosimendan low dose
dose epinephrine
epinephrine
Persistent
Persistent cathecolamine
cathecolamine resistant shock :: reversed?
resistant shock Rule
Rule outout and
and correct
correct pericardial
pericardial effusion,
effusion, pneumothorax
pneumothorax and
and
intraabdominal
intraabdominal pressure
pressure > > 12
12 mmHg
mmHg .. Consider
Consider pulmonary
pulmonary artery,
artery, PICO,
PICO, and
and or or doppler
doppler ultrasound
ultrasound to
to
guide fluid, inotrope, and hormonal therapy. Goal CI > 3,3 <
guide fluid, inotrope, and hormonal therapy. Goal CI > 3,3 < 6 L/mnt/m26 L/mnt/m2
Shock not reversed? REFRACTORY SHOCK
Antibiotics
Cold shock and Warm shock
Syok yang ditandai dengan penurunan
perfusi, perubahan status mental, pengisian
kembali kapiler > 2 detik, diuresis < 1
ml/kgBB/jam, yang disertai dengan

Cold shock
Warm shock
Pulsasi perifer
Pulsasi perifer
berkurang,
cukup kuat,
mottled, akral
disertai flush
dingin
Carcillo JA. Task Force Members, ACCM. Crit Care Med. 2002;30:1-13
 Syok refrakter cairan :
Syok persisten dengan cairan resusitasi >60 ml/kgBB
Syok resisten katekolamin :
Syok persisten meskipun dengan pemberian katekolamin
kerja langsung (epinefrin atau norepinefrin)
Syok refrakter katekolamin :
Syok yang memerlukan dopamin > 10 mcg/kg/mnt atau
epinefrin/NE dengan dosis berapapun selama >24 jam
untuk mempertahankan perfusi yang baik atau perfusi
tetap buruk dan tekanan darah tetap rendah meski telah
diberi epinefrin atau NE
Syok refrakter :
Syok yang persisten meski telah menggunakan inotropik,
vasopresor, vasodilator, upaya metabolik dan hormonal
 General initial management

Overall goal: Normalization of BP and tissue

perfusion.

Physiologic indicators that should be targeted

include:1
Blood pressure: Normal (defined in next slide).
Quality of central and peripheral pulses: Strong, distal
pulses equal to central pulses.
Skin perfusion: Warm, with capillary refill 1-2 seconds.
Mental status: Normal.
Urine output: >1 mL/kg per hour, once effective
circulating volume is restored.
Shock: Evaluation pearls
Tachycardia? - Non-specific early finding. Investigate further.

Skin changes? - Typically, prolonged cap refill (vasoconstriction) with

compensated shock. Flash refill with early distributive shock and with
irreversible shock.

Impaired mental status? - Defining mental status as accurately as

possible (GCS) is key to monitoring progression. Assess for yourself --
dont rely on other providers.

Oliguria? - Watch for decreased GFR; re-order meds accordingly.

Hypotension? - Late finding. Dont accept from others that BP is

normal. Widened pulse pressure (>40 mmHg)? - May be present in
distributive shock, aortic insufficiency, AVMs, Cushings reaction
 Highlights for specific classes, etiologies1
Hypovolemic shock
Give colloid after crystalloid if
capillary leak,
hypoalbuminemia.
Do not delay PRBCs if suspect
hemorrhage.
Septic shock
If not improved after 60 ml/kg
crystalloid, consider pressors.
Dopamine (5-15 mcg/kg/min
STAT to the bedside) is first-
line.
Norepinephrine if warm shock
(vasodilated).
Epinephrine if cold shock
(vasoconstricted).
Consider dexamethasone.
Cardiogenic shock
Consider in any patient
worsening with fluid
therapy.
Dopamine first-line agent.
Consider milrinone if
diastolic dysfunction,
dobutamine if increased
SVR leading to organ
dysfunction.
Obstructive shock
Causes of obstructive
shock require specific
interventions
Chest tube for tension
pneumothorax; removal
of fluid for tamponade;
PGE for ductal-dependent
Take-Home Points

Shock is a progressive process.

Intervene early.

Identifying the stage and classification of

shock is important.
Stage: Compensated, uncompensated, or irreversible?
Classification: Hypovolemic, distributive, cardiogenic, or
obstructive?

Management should be directed at

normalizing tissue perfusion and blood
pressure.
Consider using the consensus-based goal-directed algorithm
for shock management.
Terima Kasih