SYOK HIPOVOLEMIK

AMALIAH HARUMI KARIM

PATOFISIOLOGI
The microcirculatory changes associated with shock
The phenomenon of transcapillary refill means that
are complex and difficult to study. Although
the
some mediators such as catecholamines, angiotensin
body can have fluid losses exceeding normal plasma
autoregulatory changes II, arginine vasopressin, and endothelin-1 cause
volume. These responses cause alterations in
involving smaller blood vessels. vasoconstriction, other mediators, such as adenosine
stroke volume, heart rate, and peripheral vascular
and nitric oxide, yield vasodilation. These
resistance so that blood pressure and hence tissue
changes result in hypoperfusion or hyperperfusion,
perfusion can be maintained
depending on the organs involved.

hormones (eg,
When the cause of circulatory insufficiency continues As these
unabated, local adrenocorticotropic hormone, angiotensin,
microcirculatory changes fail to maintain adequate
catecholamines, and vasopressin) that cause sodium
mechanisms eventually fail to provide adequate organ perfusion, more widespread sympathetic
and
compensation, and macrocirculatory changes ensue nervous system activation and vasoconstriction ensue.
water retention by the kidneys are released

With increasing volume depletion, blood flow to the fluid shifting from the interstitial space to the
heart (preload) is decreased, with subsequent intravascular
activation of baroreceptors and chemoreceptors space occurs through a phenomenon known as
leading to sympathetic discharge transcapillary refill
 Even assuming general
circulation is restored,
capillaries may not function
properly due to ongoing edema
and ischemia

Failure to respond to
sympathetic stimulation and fluid
administration is indicative of the
vasodilation that occurs in the
final phase of circulatory failure
leading to death
 Tekanan onkotik adalah gaya tarik sifat atau sistem koloid agar air tetap beradda di dalam plasma darah di
intravaskular
Tekanan hidrostatik adalah tekana yang dihasilkan oleh cairan pada dinding mbuluh darah
 Proteins act as oncotic agents in each of these spaces to attract fluid, whereas hydrostatic forces push
fluid into or out of the vessels.
 The bodys compensatory mechanisms may have beneficial and harmful consequences
For example,
cardiac output can be increased substantially by increases in stroke volume or heart rate. Although
this may be useful for providing blood flow to inadequately perfused tissues, it may cause large
increases in oxygen consumption by the heart that could aggravate preexisting ischemia in patients
with underlying coronary artery disease (CAD)
 Another example is the sympathetic nervous system
mediated vasoconstriction that causes blood to shift from the skin, skeletal muscle, and some internal
organs such as the kidneys and GI tract to organs (eg, heart and brain) that are less tolerant of
inadequate flow. If the vasoconstriction continues unabated, the hypoperfused organs eventually
become damaged. Figure 24-2 provides an overview of the compensatory changes that occur with a
loss of circulating blood volume.
 Activation of compensatory mechanisms with loss of circulatory volume. Certain stages may be
absent, depending on a number of factors, such as age, preexisting disease states, and cause of
circulatory insufficiency. (ACTH, adrenocorticotropin; ANP, atrial natriuretic peptide; BP, blood
pressure; CO, cardiac output; HR, heart rate; PVR, peripheral vascular resistance; RR, respiratory rate.)
 In addition to the more acute implications of
hypovolemia and attendant complications,
reperfusion damage is likely to occur, particularly
after prolonged resuscitation attempts

In addition
to edematous obstruction of capillaries and
oxygen-free radical damage of cell membranes, a
number of cellular (eg, white blood cells and
platelets) and humoral (eg, procoagulants,
anticoagulants, complement, and kinins)
components are activated, causing the release of
other
inflammatory mediators.

The resulting reperfusion injury may range from The lungs are frequently the first system affected
readily reversible organ either by excessive fluid resuscitation or by the
dysfunction to multiple-organ failure and death mediators of secondary reperfusion injury
 Although the basic pathophysiology is similar for the various causes of hypovolemic shock, there are
unique considerations relative to each. For example, whereas isolated head injuries associated with
trauma typically do not result in substantial blood loss or shock, long bone or pelvic fractures may
sequester several liters of blood. Patients with traumatic or thermal injuries, as well as postoperative
patients, may have substantial fluid accumulation in sites where the fluid cannot be readily
transferred back into blood vessels (ie, third-spaced fluid) for maintaining pressure. With these types
of injuries, prompt control of compressible bleeding sources with rapid patient transfer to the
hospital for definitive treatment may preclude the cascade of events leading to shock
 However, the elderly patient may
have orthostatic changes in blood pressure that are not well tolerated by organs such as the kidneys.
Unfortunately, this same elderly patient may not have common signs and symptoms of volume
depletion, such as skin turgor changes or thirst, but instead may have more subtle changes (eg,
mental status alterations)
 Commercially available carbohydrate/electrolyte drinks
generally are more palatable than water and may promote earlier recovery. The rationale for
combining carbohydrates with sodium is based on the cotransport absorption mechanism in the
intestinal tract. With diarrheal states in particular, sodium absorption is impaired. Because water
follows sodium, the diarrhea is likely to continue despite oral crystalloid fluid administration until the
intestinal pathology resolves
 However, when dextrose and sodium are combined in 1:1 equimolar
amounts, both are absorbed via the cotransport mechanism, which also allows for absorption of
water. This concept forms the basis for the World Health Organizations (WHO) oral rehydration
solution, which contains 75 mmol/L of dextrose, 75 mmol/L of sodium, 20 mmol/L of potassium, 65
mmol/L of chloride, and 10 mmol/L of citrate for a total osmolarity of 245 mOsm/L.3 Commercially
available nonprescription rehydration drinks for children in the United States also have an osmolarity
of approximately 250 mOsm/L but typically contain 50 mmol/L or less of sodium, and the dextroseto-
sodium ratio often is 3:1.
 How these differences between commercially available formulations and
the WHO rehydration formula might affect hospitalization rates is unclear, but ad hoc attempts to
alter the commercially available products to make them more consistent with the WHO formula may
be dangerous and are not recommended.
 One
interesting method of fluid administration that has been investigated in elderly patients is
subcutaneous infusion, or hypodermoclysis. With hypodermoclysis, common dextrose- and sodiumcontaining
fluids typically given by the IV route are given by subcutaneous infusion at sites such as
the upper arm, chest, abdomen, or thigh, depending on factors such as patient or provider
preference. Hyaluronidase has been used as a spreading agent to facilitate fluid absorption by this
route, but its benefit versus risk profile has yet to be clearly elucidated; in particular, allergic reactions
with this agent have been a concern, although a recombinant form is now available that has the
potential for fewer reactions compared with the older bovine-derived products. Hypodermoclysis is
not used commonly in the United States, probably because of concerns of adverse effects that were
found in early studies that used excessively hypotonic or hypertonic solutions, as well as issues
related to reimbursement when considered in ambulatory, home, or palliative care settings.
DRUG TREATMENTS OF FIRST CHOICE

Dextrose-in-water solutions may be appropriate for uncomplicated dehydration caused by water

deprivation, but isotonic crystalloid (sodium-containing) solutions should be used for forms of
circulatory insufficiency that are associated with hemodynamic instability
 In the latter situation, IV
solutions with sodium concentrations approximating normal serum sodium values usually are
indicated because they cause more expansion of the intravascular and interstitial spaces compared
with dextrose solutions
 Lactated Ringer and normal saline solutions are examples of
such crystalloid solutions that frequently need to be administered in large volumes when given to
patients with more severe forms of hypovolemia. A large amount of fluid does not mean a single
bolus volume typically used as fluid challenge in a critically ill patient. An isolated bolus (eg, 250-500
mL) in a young adult trauma patient is unlikely to cause a substantial change in blood pressure or
acidbase balance
 Therefore, multiple fluid boluses usually are often needed in such patients to
achieve hemodynamic stability in the perioperative period. On the other hand, overly aggressive fluid
administration should be avoided, especially in patients with heart failure or impending pulmonary
edema.
 The choice between normal saline and lactated Ringer solutions for hypovolemia is largely based on
clinician preference and adverse effect concerns (Table 24-5). Lactated Ringer solution has been
recommended for patients with hemorrhage because it is unlikely to cause the hyperchloremic
metabolic acidosis and possibly acute kidney injury due to excess chloride administration that is seen
with infusions of large volumes of normal saline. But concerns have been raised relative to the
proinflammatory effects (eg, neutrophil activation) of the d-isomer form of lactate that is contained
along with the l-isomer in commercially available racemic isomer solutions. There are advocates for
the use of lactated Ringer solution containing only l-isomer lactate, particularly for more severe forms
of hemorrhagic shock, since it avoids the proinflammatory effects of the racemic solution, while
avoiding the hyperchloremia associated with normal saline.17 Additionally, other substitutes for
racemic lactate such as ketone or pyruvate have shown beneficial effects on neutrophil activation and
gene expression in vitro and are the subject of ongoing studies.
 In contrast to isotonic crystalloid solutions that
have substantial interstitial distribution within minutes of IV administration, colloids remain in the
intravascular space for hours or days, depending on factors such as the size of the colloid molecules
and capillary permeability. Examples of colloids used as plasma expanders in the United States
include albumin, hydroxyethyl starch, and much less commonly, dextran.
 Albumin is known as a
monodisperse colloid because all its molecules are of the same molecular size and weight (~67,000
Da), whereas hydroxyethyl starch and dextran solutions are polydisperse compounds with molecules
of varying molecular size that are roughly proportional to molecular weight (weight-averaged
molecular weights of 600,000 Da [range 450,000-800,000 Da] for 6% hetastarch in normal saline
450/0.75, 670,000 Da [range 450,000-800,000 Da] for 6% hetastarch in lactated electrolyte 670/0.75,
130,000 Da [range 110,000-150,000 Da] for 6% tetrastarch in normal saline 130/0.4, 40,000 Da [range
10,000-90,000 Da] for dextran 40, or 70,000 to 75,000 Da [range 20,000-200,000 Da] for dextran 70 or
dextran 75, respectively). I
 The size and weight
differences of the colloids have important implications for the distribution of the products because
lower-molecular-weight substances are retained in the intravascular space for a shorter period of
time as a result of more rapid leakage across the vessel membrane. The theoretical benefit common
to all colloids is based on their increased molecular weight (average molecular weight in the case of
hydroxyethyl starch and dextran) that corresponds to increased intravascular retention time in the
absence of increased capillary permeability compared with crystalloids. Even in patients with intact
capillary permeability, small and intermediate size colloid molecules such as albumin eventually will
leak through capillary membranes with a few notable exceptions (eg, those in the central nervous
system and glomeruli).
 The primary adverse effect
concern of all colloids is fluid overload, which is an extension of their pharmacologic action. Another
adverse effect of increasing concern is renal dysfunction that seems to be related to hyperoncotic
(eg, 25%) albumin and other starch and dextran products. The mechanism of this adverse effect may
be related to alteration of normal glomerular oncotic pressure differences or formation of lesions in
the kidney
 There is no widespread agreement on the upper limit of osmolarity for hypertonic sodium solutions
that are given by peripheral vein infusion under emergent conditions, but 600 or 900 mOsm/L is the
usual recommended upper limit for prolonged IV infusions.
 For example, the lower chloride concentration in lactated Ringer would
usually make it preferred over normal saline in patients with a hyperchloremic metabolic acidosis,
while the increased osmolarity of normal saline would usually make it preferred over lactated Ringer
in a patient with increased intracranial pressure.
 FIGURE 24-4
Hypovolemia protocol for adults. Normal saline (or a lower chloride-containing isotonic crystalloid)
may be used instead of lactated Ringer solution. This protocol is not intended to replace or delay
therapies such as surgical intervention or blood products for restoring oxygen-carrying capacity or
hemostasis. For the resuscitation of patients with trauma prior to bleeding control, usually no more
than 1 L of crystalloid should be given initially in an attempt to use the minimal amount of fluid
necessary to maintain perfusion and not exacerbate bleeding. If available, some measurements can
be used in addition to those listed in the algorithm, such as mean arterial pressure or pulmonary
artery catheter recordings. The latter can be used to assist in medication choices (eg, agents with
primary pressor effects may be desirable in patients with normal cardiac outputs, whereas dopamine
or dobutamine may be indicated in patients with suboptimal cardiac outputs). Lower maximal doses
of the medications in this algorithm should be considered when pulmonary artery catheterization is
not available. See text for an in-depth discussion of these and other issues involved in this protocol.
(CHF, congestive heart failure; LR, lactated Ringer solution.)