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Shock Rational Blood Transfusion Practice on Patient Bleeding at Obstetric & Gynecology Ali Sungkar Divisi Fetomaternal, Departemen Obstetri & Ginekologi FKUI / RSUPN - CM
Shock
Hemorrhagic Shock - Pathophysiology
The most common types of shock: Type of shock
Aetiology
Hypovolaemic shock
Acute loss of at least 20% of the circulating volume
Cardiogenic shock
Acute disease of the heart, e.g. severe myocardial infarction
Septic shock
Septic condition caused by infectious agents and their toxic products
Neurogenic shock
Head trauma, spinal cord injury
Anaphylactic shock
Repeated contact with or injection of antigenic substances
Shock
Hemorrhagic (Classic) shock - Pathophysiology
Stage 1: Compensated Stage Mechanism: Volume depletion due to bleeding
Body detects decrease in cardiac output
Sympathetic Nervous System is stimulated releasing Epinephrine and Norepinehrine to stimulate Alpha and Beta Receptors
Alpha = Vasoconstriction
Stage 2: Progressive Stage Mechanism: Kidneys release anti-diuretic hormone which increases vasoconstriction by closing the capillary sphincters, greatly reducing peripheral circulation
Increased hypo-perfusion causes increase in metabolic acid build up
Beta = Bronchodilation and Cardiac Stimulation
Shock
Shock
Hemorrhagic (Classic) shock - Pathophysiology Stage 3: Irreversible Stage
The Course of Hypovolaemic Shock in Absence of Therapy
Blood Pressure (mm Hg) Heart rate (min)
Blood Pressure
Heart Rate
Mechanism: Compensatory mechanisms fail 150 Bleeding
Pre-capillary sphincters open releasing metabolic acids, micro-emboli and other wastes into circulation
100
50
Cell damage, organ failure and death occur 0
(Time) Compensation
Decompensation
Irreversibility
Shock Phases
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Shock The Influence of Volume Replacement on Tissue Perfusion and Organ Function Cerebral Function (Body Control) Tissue Perfusion
Pulmonary Function (O2 Supply)
Volume
Replacement Renal Function (Diuresis)
Liver Function (metabolism)
Heart Function (cardiac output)
Perdarahan Obstetri
Kegagalan Sirkulasi Perdarahan:
Respirasi Sirkulasi
(
Kegagalan
sistem
sirkulasi dalam mempertahankan aliran yang adekuat pada organ-organ vital sehingga timbul Anoxia)
Trauma
Mengancam jiwa ibu dan janin
Tata Laksana Mengatasi Perdarahan Hebat
Airway
Breathing
Circulation
Shock position
Replace blood loss
Stop / minimize the bleeding process
and
Pada awal kehamilan (aborsi, kehamilan ektopik, kehamilan mola) Pada akhir kehamilan atau persalinan (plasenta previa, solusio placenta, ruptura uteri) Sesudah kelahiran bayi (ruptura uteri, atonia uteri)
AIRWAY
hemorrhage control
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Posisi Syok ANGKAT KEDUA TUNGKAI
Tindakan simultan Pada Syok Tatalaksana
Nilai fundus
Simultan dengan ABC
Atonia merupakan penyebab utama Perdarahan Post partum
300 - 500 cc darah dari kaki pindah ke sirkulasi sentral
Tatalaksana
:
Jika lembek masase bimanual
singkirkan inversio uteri
mungkin terdapat trauma traktus bagian bawah
evakuasi bekuan darah dari vagina dan servik
membutuhkan eksplorasi manual pada saat ini
- Kompresi Bimanual
Menghentikan Perdarahan Kondom intra uterin
Menghentikan Perdarahan
RA, Jones TB. Obstet Gynecol 1995 May;85(5 Pt 2):836-7
Vaginal ligature of uterine arteries Philippe
AbdRabbo SA Am J Obstet Gynecol 1994 Sep;171(3):694-700
Thrombogenic uterine pack Bobrowski
Stepwise uterine devascularization
HJ, d'Oreye D, Lewin D. Int J Gynaecol Obstet 1997 Mar;56(3):267-70
Ligasi a hipogastrika Histerektomi subtotal
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Tatalaksana Perdarahan Pasca Persalinan
Menghentikan Perdarahan
B-Lynch suture Dacus
JV, Busowski MT, Busowski JD, Smithson S, Masters K, Sibai BM. J Matern Fetal Med 2000 May-Jun;9(3): 194-6 JE, Bourgeois FJ, Underwood PB. Obstet Gynecol 2000 Jun;95(6 Pt 2):1020-2
Ferguson
Estimasi BB : ... 60 kg Estimasi Blood Volume : ... 70 ml/kg x 60 = 4200 ml Estimasi Blood Loss : ... . % EBV = ... .. ml
Kristaloid vs Koloid Sebagai Cairan Pengganti: Hasil Manfaat
Tsyst Nadi
120 80
Perf
hangat
NORMO VOLEMIA
EBL = perdarahan Infus RL
100 100
< 90 > 120
pucat
dingin
-- 15% EBV
600 1200-2000
-- 30% EBV
1200 2500-5000
< 60-70 > 140 ttb
basah
-- 50% EBV
2000 ml 4000-8000 ml
Resiko
Kristaloid
Koloid
Merembes ke komponen ekstraselular Mengurangi peningkatan cairan paru Meningkatkan fungsi organ setelah operasi
Tetap berada di komponen intravaskular volume yang diperlukan lebih sedikit Meningkatkan transpor oksigen ke jaringan,
Reaksi anafilaktik minimal Kemungkinan dapat mengurangi angka kematian Lebih murah
kontraktilitas jantung dan keluarannya
Predisposisi untuk terjadinya edema pulmonal
Mahal
Choi et al 1999.
The Clinical Use of Blood WHO Sub - Regional Workshop
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Blood Loss % Loss of blood Volume
Equivalent Adult Fluid Volume
Replacement Fluid
< 20 %
Up to 1 Liter
Crystalloid ( e.g. 0,9 % saline )
> 20 %
More than 1 liter
Crystalloid and / or Colloid / Red Cell
Estimating Allowable Blood Loos Clinical condition Healthy
Average
Poor
Percentage Methode Acceptabel loss of blood vol
30 %
20 %
10 %
Lowest Acceptable Hb
9 mg / dl
10 mg / dl
11 mg / dl
Lowest acceptable Ht
27 %
30%
33%
Haemodilution Method
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Starting Transfusion
Starting Transfusion
Warming of blood is not necessary for routine tx . Warming
increasing metabolism, reduce 2,3-DPG & risk bacterial growth
Do not use dextrose 5% or Ringer Lactate.
Use 170 u standard filter.
Transfusion must be completed in 4 hours.
Indication for warming blood:
Adult receiving over 50 ml/kg/hr
Child receiving over 14 ml/kg/hr
Exchange tranfusion
Rapid infusion CVP lines
Presence of cold aglutinines
Autologous Blood
Pre Operative Blood Donation
Acute Normovolemic Haemodilution
Min Hb 11 gr 1 Unit ( 10-15% Blood vol) 5-7 days 35 days-2 days, iron suppl During surgery ( 4 hours ) Monitoring, Replace fluid : crystaloid 1:3, Colloid 1:1
Blood Salvage
Prohibited to addition drugs & medications to blood bag/set EXCEPT normal Saline.
Hemodynamically stable
2 hours
Hemodynamically unstable 4 hours
Don’ts for Blood Transfusion
Don’t Use blood from non-licensed.
Don’t delay initiation of blood transfusion.
Don’t Warm blood in an monitored fashion.
Don’t Use routine pre-transfusion medication.
Direct tranfusion
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Don’ts for Blood Transfusion
Don’ts for Blood Transfusion
Don’t transfuse over more 4 hours.
Don’t leave patients unmonitored.
Don’t add any medication to blood bag
Don’t forget to return unused blood to
Don’t ask for all the blood bag at one
Don’t Use unmonitored refrigerator for
time
storage
Don’t Use
one transfusion set for more than
4 hours / more than 4 unit of blood
blood bank for disposal
Don’t wet outlet port of blood bag while warming or thawing
Transfusion Reactions
Don’ts for Blood Transfusion
Don’t store platelets in a refrigerator
Immediate
Delayed
Don’t be complacement while checking identifiying information
Hemolytic
Non-hemolytic
Don’t Use blood from immediate relatives unless irradiated
Febrile Hemolytic Transfusion Reaction
Allergic
Infections
Allergic
Hyper- Kalemia &
Hypo-
Acidosis
calcemia
Acute Lung Injury
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“Practice Safe Transfusion”
Informed Consent
Standardized Guidelines
Adverse Event Reporting
Error and Incident Reporting
Summary “Errors can be prevented by designing systems that make it hard for people to do the wrong thing and easy for people to do the right thing”…… To Error is Human, Building a Safer Health System
Components Indications Transfusion
Reactions
Rujukan
ACOG. Hemorrhagic shock. Educational Bulletin #235, 1997.
Choi PT-L et al. 1999. crystalloid vs. colloids in fluid resuscitation: A systematic review. Critical Care Medicine 27 ( 1): 200-210.
Scheirhout and Roberts 1998. Fluid resuscitation with colloid or crystalloid in critically ill patients: A systematic review of randomized trials. BMJ 316:961-964.
MNH Post Partum Hemorrage.
The Clinical Use of Blood, WHO 2002.
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