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SHOCK AND FLUID SHOCK AND FLUID
THERAPY IN SHOCK THERAPY IN SHOCK THERAPY IN SHOCK THERAPY IN SHOCK
Bambang Suryono SBambang Suryono S
LIFE THREATLIFE THREAT
Dimana saja!!Dimana saja!!
Kapan saja!!Kapan saja!!
Pada siapa saja!!Pada siapa saja!! Pada siapa saja!!Pada siapa saja!!
Life ThreatLife Threat
OrangOrang sehatsehat
TRAUMA/PENYAKIT MENDADAKTRAUMA/PENYAKIT MENDADAK
TERANCAM JIWATERANCAM JIWA
PENYELAMATAN PENYELAMATAN
TAHAP LIFE SUPPORTTAHAP LIFE SUPPORT
BASIC LIFE SUPPORTBASIC LIFE SUPPORT
ADVANCED LIFE SUPPORTADVANCED LIFE SUPPORT
PROLONGED LIFE SUPPORTPROLONGED LIFE SUPPORT PROLONGED LIFE SUPPORTPROLONGED LIFE SUPPORT
FLUID THERAPYFLUID THERAPY
..
SHOCKSHOCK
Inadequate tissue perfusion along with Inadequate tissue perfusion along with
cellular hypoxia and oxygen debt, which cellular hypoxia and oxygen debt, which
results in cellular dysfunction and is caused results in cellular dysfunction and is caused
by inadequate systemic oxygen delivery or by inadequate systemic oxygen delivery or by inadequate systemic oxygen delivery or by inadequate systemic oxygen delivery or
impairment of cellular oxygen uptakeimpairment of cellular oxygen uptake..
Stages of ShockStages of Shock
1. A 1. A nonprogressivenonprogressive stage (compensated)stage (compensated)
in which the normal circulatory mechanisms in which the normal circulatory mechanisms
eventually cause full recovery without help from eventually cause full recovery without help from
outside therapyoutside therapyoutside therapyoutside therapy
2. A 2. A progressive stage, progressive stage, in which, without in which, without therapy, the shock become steadily worse until therapy, the shock become steadily worse until
death.death.
3. An 3. An irreversible stageirreversible stage
EVALUATION OF SYMPTOMSEVALUATION OF SYMPTOMS
HISTORYHISTORY
In In hypovolemichypovolemic shock : blood loss, trauma, shock : blood loss, trauma,
fluid losses, dehydration, third spacing or fluid losses, dehydration, third spacing or
other fluid losses. other fluid losses. other fluid losses. other fluid losses.
HistoryHistory
In adult In adult drop Systolic BP > 40 mmHg drop Systolic BP > 40 mmHg significant hypotensionsignificant hypotension
General Symptoms of ShockGeneral Symptoms of Shock
CNS changes CNS changes
*Confusion, coma, combative behavior, *Confusion, coma, combative behavior,
agitation, stuporagitation, stupor
Skin changesSkin changes
*Cool, clammy, warm, diaphoresis*Cool, clammy, warm, diaphoresis
Cardiovascular Cardiovascular
*Increase or decrease heart rate, *Increase or decrease heart rate,
arrhythmia, angina, low high or normalarrhythmia, angina, low high or normal
cardiac output, changes in pulmonary pressurecardiac output, changes in pulmonary pressure
General symptoms of shockGeneral symptoms of shock
Pulmonary Pulmonary
*Increased RR, increase or decrease in*Increased RR, increase or decrease in
endend-- tidal CO2, decrease O2 saturation,tidal CO2, decrease O2 saturation,
increased pulmonary pressures,increased pulmonary pressures, increased pulmonary pressures,increased pulmonary pressures,
respiratory failure, decreased tidal volume,respiratory failure, decreased tidal volume,
decreased FRCdecreased FRC
RENALRENAL
*Decreased urine output, elevation in BUN and *Decreased urine output, elevation in BUN and creatininecreatinine levels, change in urine electrolyte levelslevels, change in urine electrolyte levels
Common effects of shock on organsCommon effects of shock on organs
SystemicSystemic : Capillary leak, formation of micro: Capillary leak, formation of micro
vascular shunts, cytokine releasevascular shunts, cytokine release
CardiovascularCardiovascular : circulatory failure,: circulatory failure,
depression of cardiovascular function,depression of cardiovascular function, depression of cardiovascular function,depression of cardiovascular function,
arrhythmiaarrhythmia
HaematologicHaematologic : : bone marrow suppression,bone marrow suppression,
coagulopathycoagulopathy, DIC, platelet, DIC, platelet
dysfunctiondysfunction
.. Hepatic Hepatic : liver insufficiency, elevation of: liver insufficiency, elevation of
liver enzyme levels, liver enzyme levels, coagulopathycoagulopathy
NeuroendocrineNeuroendocrine : change in mental status, : change in mental status,
adrenal suppression, insulinadrenal suppression, insulin
resistance, thyroid dysfunctionresistance, thyroid dysfunction
Renal :Renal : renal insufficiency, change in urinerenal insufficiency, change in urine Renal :Renal : renal insufficiency, change in urinerenal insufficiency, change in urine
electrolyte levels, elevation of BUN electrolyte levels, elevation of BUN
and and creatininecreatinine levelslevels
Cellular :Cellular : cellcell--toto--cell dehiscence, cellularcell dehiscence, cellular
swelling, mitochondrial dysfunction,swelling, mitochondrial dysfunction,
cellular leakcellular leak
Hypovolemic shockHypovolemic shock
Cause :Cause : depletion of fluid in the intravascular depletion of fluid in the intravascular space (hemorrhage, vomiting, diarrhea, space (hemorrhage, vomiting, diarrhea, dehydration, capillary leak or a combinationdehydration, capillary leak or a combination))
SIRSSIRS capillary leakcapillary leak SIRSSIRS capillary leakcapillary leak
Findings : Findings : decreased CO, decreased PCWP, decreased CO, decreased PCWP, increase SVRincrease SVR
Echo :Echo :decreased rightdecreased right--sided filling, decreased sided filling, decreased stroke volume, increase aortic diameterstroke volume, increase aortic diameter
PerdarahanPerdarahan
Kehilangan akut darah dari sistim sirkulasiKehilangan akut darah dari sistim sirkulasi
Estimated blood volume /EBV:Estimated blood volume /EBV:
* Adult : 7% BW * Adult : 7% BW male 70 ml/kgmale 70 ml/kg
female 65 ml/kg female 65 ml/kg female 65 ml/kg female 65 ml/kg
*Children : 8*Children : 8--9% BW9% BW
The Role of FluidsThe Role of Fluids
Optimal organ function requires the twoOptimal organ function requires the two--
way movement of substrates and cell way movement of substrates and cell
products products between the circulatory system and between the circulatory system and the cells themselves.the cells themselves.the cells themselves.the cells themselves.
ClassificationClassification of of infusinfusion fluidsion fluids
11.D.Dextrose/glukose/fruktoseextrose/glukose/fruktose solutionsolution
2.2.CCrryystalstallloid : oid : RResusesusccitaitattiion fluidon fluid (Ringer (Ringer
laktat, Ringer asetat)laktat, Ringer asetat)
Maintenance fluid:Maintenance fluid:
Kaen 3A, Kaen 3B, Kaen MG3Kaen 3A, Kaen 3B, Kaen MG3
Tutofusin OPSTutofusin OPS
3.3.CColollloid : Dextran 40 ,70, Gelatin, Hydroxy oid : Dextran 40 ,70, Gelatin, Hydroxy
ethylethyl--starch, starch, artificial bloodartificial blood
InfusInfusion fluidsion fluids
4.4.ParenteralParenteral nutritionnutrition : : ccarboharbohyydratdratee,,
protein/protein/amino acidsamino acids
lipid, lipid,
combinationcombination
TriofusinTriofusin, , TriofusinTriofusin EE--1000, 1000, AminofusinAminofusin,,
AminolebanAminoleban, , LipovenousLipovenous
5.5.Blood productsBlood products : albumin, FFP, SPPS,: albumin, FFP, SPPS,
cryoprecipitatecryoprecipitate
CrystalloidCrystalloid
Expand the plasma volume by about 200 ml Expand the plasma volume by about 200 ml
perper--liter infused liter infused diluting circulating proteins, diluting circulating proteins, plasma COPplasma COP
Potentially harmful interstitial Potentially harmful interstitial overhydrationoverhydration Potentially harmful interstitial Potentially harmful interstitial overhydrationoverhydration
Crystalloid need to be administered at volumes 3 Crystalloid need to be administered at volumes 3
to 5to 5--folds greater than of (folds greater than of (isooncoticisooncotic) colloids ) colloids
to achieve comparable plasma volumes and to achieve comparable plasma volumes and resuscitation endpointsresuscitation endpoints
Infusion management: Infusion management:
A rational strategyA rational strategy Two different therapies for two different diagnosis Two different therapies for two different diagnosis
fluid substitution and fluid resuscitation.fluid substitution and fluid resuscitation.
The basis considerations:The basis considerations:
1.Save the endothelial 1.Save the endothelial glycocalyxglycocalyx from degradation due to from degradation due to 1.Save the endothelial 1.Save the endothelial glycocalyxglycocalyx from degradation due to from degradation due to
hyperinfusionhyperinfusion
2.Substitute fluid loss or dehydration using crystalloid 2.Substitute fluid loss or dehydration using crystalloid
infusionsinfusions
3.Replace volume loss or 3.Replace volume loss or hypovolemiahypovolemia with colloidal with colloidal
tetrastarchtetrastarch solutions until normalization of solutions until normalization of the circulating the circulating
blood volumeblood volume
ColloidColloid The intravascular COP after colloid infusion is influenced The intravascular COP after colloid infusion is influenced
by baseline COP, the degree of by baseline COP, the degree of hemodilutionhemodilution and the COP and the COP
of the infused volume and its plasma retention, determined of the infused volume and its plasma retention, determined
by the molecular weight distribution.by the molecular weight distribution.
Albumin solutions are Albumin solutions are monodispersemonodisperse (MW of 69 (MW of 69 kDakDa)) Albumin solutions are Albumin solutions are monodispersemonodisperse (MW of 69 (MW of 69 kDakDa))
Gelatins are Gelatins are polydispersepolydisperse and in excess of 75% of the and in excess of 75% of the
molecules are to be smaller than the renal threshold of 30 molecules are to be smaller than the renal threshold of 30
kDakDa..
ColloidColloid HydroxyHydroxy--ethylethyl--starch solutions is very starch solutions is very polydispersepolydisperse, ,
defined by degree of substitution and by MW.defined by degree of substitution and by MW.
The greater of degree of substitution The greater of degree of substitution the greater the greater
the resistance of degradation the resistance of degradation prolongs the prolongs the effectiveness of HES as a plasma expandereffectiveness of HES as a plasma expandereffectiveness of HES as a plasma expandereffectiveness of HES as a plasma expander
Colloid with a low COP50/COP10 ratio will be lost Colloid with a low COP50/COP10 ratio will be lost
more rapidly from intravascular spacemore rapidly from intravascular space
The resulting sealing effect may attenuate fluid The resulting sealing effect may attenuate fluid
extravasationextravasation independently of the COP by albumin.independently of the COP by albumin.
Replace Normal Replace Normal
Hypotonic infusionHypotonic infusion
5% dextrose 5% dextrose
increases ICF > ECFincreases ICF > ECF
ICF ISF PlasmaICF ISF Plasma
Replace Normal loss (IWL + urine)
Replace Normal loss (IWL + urine)
85 ml85 ml255 ml255 ml660 ml660 ml
Cairan
Infus IsotonicInfus Isotonic
Ringers acetate
Ringers lactate Normal saline
Ringers acetate Ringers lactate Normal saline
increases ECFincreases ECF
ICF ISF PlasmaICF ISF Plasma
Replace acute/abnormalloss
Replace acute/abnormalloss
800 ml 200 ml
RL 2liter/15 menit
PerdarahanPerdarahan
MulaiMulai segerasegera resusitasiresusitasi cairancairan agressifagressif::
Rule 3:1 Rule 3:1 untukuntuk perdarahanperdarahan akutakut
PengobatanPengobatan disesuaikandisesuaikan dengandengan responrespon
pasienpasien padapada terapiterapi awalawalpasienpasien padapada terapiterapi awalawal
Tanda perdarahanTanda perdarahan
KlasKlas II (BB 70 Kg)(BB 70 Kg) ----------------------------------------------------------------------------------------------------------------------
PerdarahanPerdarahan ml ml sampaisampai 750750
PerdarahanPerdarahan (%BV) (%BV) sampaisampai 15%15%
NadiNadi < 100< 100
TensiTensi NormalNormal
TekTek NadiNadi (mmHg) (mmHg) Normal Normal atauatau naiknaik TekTek NadiNadi (mmHg) (mmHg) Normal Normal atauatau naiknaik
NafasNafas 14 14 -- 2020
Urine ml/jam Urine ml/jam > 30> 30
SSP/status mental SSP/status mental sedikitsedikit CemasCemas
PenggantianPenggantian cairancairan KristaloidKristaloid
((hukumhukum 3:1)3:1)
Tanda perdarahanTanda perdarahan
Klas IIKlas II ----------------------------------------------------------------------------------------------------------------------
Perdarahan ml 750Perdarahan ml 750--15001500
Perdarahan (%BV) 15Perdarahan (%BV) 15--30%30%
Nadi >100Nadi >100
Tensi NormalTensi Normal Tensi NormalTensi Normal
Tek Nadi (mmHg) TurunTek Nadi (mmHg) Turun
Nafas 20Nafas 20--3030
Urine ml/jam 20Urine ml/jam 20--3030
SSP/status mental Cemas sedangSSP/status mental Cemas sedang
Penggantian cairan KristaloidPenggantian cairan Kristaloid
(hukum 3:1)(hukum 3:1)
Tanda perdarahanTanda perdarahan
KlasKlas IIIIII ----------------------------------------------------------------------------------------------------------------------
PerdarahanPerdarahan ml 1500ml 1500--20002000
PerdarahanPerdarahan (%BV) 30(%BV) 30--40%40%
NadiNadi > 120> 120
TensiTensi TurunTurun TensiTensi TurunTurun
TekTek NadiNadi (mmHg) (mmHg) TurunTurun
NafasNafas 3030--4040
Urine ml/jam 5Urine ml/jam 5--1515
SSP/status mental SSP/status mental CemasCemas gelisahgelisah
PenggantianPenggantian cairancairan KristaloidKristaloid & & darahdarah
((hukumhukum 3:1)3:1)
Tanda perdarahanTanda perdarahan
Klas IVKlas IV ----------------------------------------------------------------------------------------------------------------------
Perdarahan ml >2000Perdarahan ml >2000
Perdarahan (%BV) >40%Perdarahan (%BV) >40%
Nadi >140Nadi >140
Tensi turunTensi turun Tensi turunTensi turun
Tek Nadi (mmHg) turunTek Nadi (mmHg) turun
Nafas >35Nafas >35
Urine ml/jam tak adaUrine ml/jam tak ada
SSP/status mental gelisah/letargiSSP/status mental gelisah/letargi
Penggantian cairan kristaloid & Penggantian cairan kristaloid & darahdarah (hukum 3:1)(hukum 3:1)
Perdarahan bermaknaPerdarahan bermakna
perlu konsultasi BEDAHperlu konsultasi BEDAHperlu konsultasi BEDAHperlu konsultasi BEDAH
..
Keputusan PengobatanKeputusan Pengobatan
Respon pasien pada resusitasi cairan Respon pasien pada resusitasi cairan
merupakan penentu terapi berikutnyamerupakan penentu terapi berikutnya
INGATINGAT
Bedakan antara Bedakan antara hemodinamik stabilhemodinamik stabil dan dan Bedakan antara Bedakan antara hemodinamik stabilhemodinamik stabil dan dan
hemodinamik normalhemodinamik normal
Keputusan TerapiKeputusan Terapi
ResponRespon cepatcepat
*< 20% *< 20% perdarahanperdarahan
**StabilStabil : : responrespon padapada penggantianpenggantian cairancairan
**LanjutkanLanjutkan monitormonitor **LanjutkanLanjutkan monitormonitor
**EvaluasiEvaluasi dandan konsultasikonsultasi bedahbedah
Keputusan TerapiKeputusan Terapi
ResponRespon transienttransient
2020--40% 40% perdarahanperdarahan
TidakTidak stabilstabil : : memburukmemburuk setelahsetelah terapiterapi cairancairan
awalawal awalawal
LanjutkanLanjutkan cairancairan dandan darahdarah
EvaluasiEvaluasi dandan konsultasikonsultasi bedahbedah
PerdarahanPerdarahan berlanjutberlanjut : : operasioperasi
Keputusan terapiKeputusan terapi
TakTak adaada responrespon (minimal)(minimal)
> 40% > 40% perdarahanperdarahan
TakTak adaada responrespon padapada terapiterapi cairancairan
SingkirkanSingkirkan kemungkinankemungkinan shock shock SingkirkanSingkirkan kemungkinankemungkinan shock shock
nonnon-- hemorrhagikhemorrhagik
OperasiOperasi segerasegera
Diagnosis & pengobatanDiagnosis & pengobatan
PitfallsPitfalls
**TensiTensi tidaktidak samasama dengandengan cardiac outputcardiac output
**UmurUmur
**AtlitAtlit **AtlitAtlit
**HipotermiHipotermi
**PengobatanPengobatan
**PacuPacu--jantungjantung
Differential DiagnosisDifferential Diagnosis
Distributive shockDistributive shock
HypovolemicHypovolemic shockshock
Obstructive shockObstructive shock
CardiogenicCardiogenic shockshock CardiogenicCardiogenic shockshock
DDDD
HypovolemicHypovolemic shockshock Dehydration (low fluid intake, diarrhea, bowel Dehydration (low fluid intake, diarrhea, bowel
obstruction, sweating or diabetes obstruction, sweating or diabetes insipidusinsipidus))
DiuresisDiuresis (diuretics, hyperglycemia)(diuretics, hyperglycemia) DiuresisDiuresis (diuretics, hyperglycemia)(diuretics, hyperglycemia)
Capillary leak and third spacing (burns, sepsis, Capillary leak and third spacing (burns, sepsis,
pancreatitis, surgical stress) pancreatitis, surgical stress)
Hemorrhage (trauma , GIT bleeding, fractures, Hemorrhage (trauma , GIT bleeding, fractures,
vascular injuries, ectopic pregnancy, etc)vascular injuries, ectopic pregnancy, etc)
AnemiaAnemia
Management and TherapyManagement and Therapy
The basic goal of shock therapy is the restoration The basic goal of shock therapy is the restoration of effective perfusion to vital organs and tissue of effective perfusion to vital organs and tissue before the onset of cellular injury.before the onset of cellular injury.
Basic resuscitation Basic resuscitation ::
1.Rapid placement of a 1.Rapid placement of a largelarge-- bore bore i.vi.v line line or a or a 1.Rapid placement of a 1.Rapid placement of a largelarge-- bore bore i.vi.v line line or a or a highhigh--flow central line as a route for fluid flow central line as a route for fluid resuscitationresuscitation
2. 2. Secure the airway Secure the airway and and on on mechanical ventilation mechanical ventilation if necessary highif necessary high--flow oxygenation flow oxygenation oxygen oxygen saturation > 92% & PaO2 > 60saturation > 92% & PaO2 > 60
Put Put 3.Foley catheter 3.Foley catheter
Fluid resuscitationFluid resuscitation
2/3 crystalloid + 1/3 colloid2/3 crystalloid + 1/3 colloid
Loss of blood volume:Loss of blood volume:
> 25% > 25% erythrocyte concentrationerythrocyte concentration
> 60% > 60% 4 erythrocyte concentration4 erythrocyte concentration > 60% > 60% 4 erythrocyte concentration4 erythrocyte concentration
+ FFP+ FFP
> 80% > 80% polytransfusionpolytransfusion + AT < 50.000+ AT < 50.000
+ + thrombocytethrombocyte
Massive red blood cell transfusion Massive red blood cell transfusion microfiltermicrofilter
. . Diagnose and treat underlying cause Diagnose and treat underlying cause
concomittantly.concomittantly.
Laboratory: Laboratory:
CrossmatchingCrossmatching
Hb/Hct/ATHb/Hct/AT
Electrolyte, creatinineElectrolyte, creatinine Electrolyte, creatinineElectrolyte, creatinine
BGA & pH, lactate, coagulation parameterBGA & pH, lactate, coagulation parameter
Transaminases, albuminTransaminases, albumin
General goals for support of shock patientsGeneral goals for support of shock patients
Hemodynamic supportHemodynamic support
MAP > 60MAP > 60--65 mmHg65 mmHg
PCWP= 15PCWP= 15--18 mmHg18 mmHg
Cardiac index > 2.1 L/min per m2 of body surface Cardiac index > 2.1 L/min per m2 of body surface
area for area for cardiogeniccardiogenic and obstructive shockand obstructive shock
Cardiac index > 4.0 L/min per m2 body surface Cardiac index > 4.0 L/min per m2 body surface
area for septic, traumatic, or hemorrhagic shockarea for septic, traumatic, or hemorrhagic shock
General goalsGeneral goals
Optimization of oxygen deliveryOptimization of oxygen delivery
HbHb level > 10 g/dllevel > 10 g/dl
Arterial oxygen saturation > 92%Arterial oxygen saturation > 92%
Reversal of organ system dysfunctionReversal of organ system dysfunction
Maintain urine output > 0.5 ml/kg per hourMaintain urine output > 0.5 ml/kg per hour
A Fluid ChallengeA Fluid Challenge
A diagnostic intervention designed to give A diagnostic intervention designed to give
an indication of whether a patient with an indication of whether a patient with
hemodynamic compromise will benefit from hemodynamic compromise will benefit from
further fluid replacementfurther fluid replacementfurther fluid replacementfurther fluid replacement
To administer a preTo administer a pre--determined volume of iv determined volume of iv
fluid over a short period of time while fluid over a short period of time while
measuring a change in the patientmeasuring a change in the patients s cardiovascular parameterscardiovascular parameters
The aim:The aim:
To differentiate hypovolemia, or relative To differentiate hypovolemia, or relative
hypovolemia, which might improve with hypovolemia, which might improve with
further fluid, further fluid, fromfrom cardiac failure or a full cardiac failure or a full further fluid, further fluid, fromfrom cardiac failure or a full cardiac failure or a full
intravascular volume in which case further fluid intravascular volume in which case further fluid
will not improve things and may cause will not improve things and may cause
deteriorationdeterioration
Indication fluid challengeIndication fluid challenge
Cardiac index 120 bpmbpm
OliguriaOliguria (urine output < 25(urine output < 25--30 ml/hr)30 ml/hr)
Lactic acidosisLactic acidosis Lactic acidosisLactic acidosis
Oxygen delivery < 600 ml/min/m2Oxygen delivery < 600 ml/min/m2
Cool extremitiesCool extremities
The need for The need for vasoactivevasoactive drugdrug
Pulmonary Pulmonary arteriarteri occlusive pressure (PAOP) < 18 mmHgocclusive pressure (PAOP) < 18 mmHg
The Surviving Sepsis Resuscitation Bundle The Surviving Sepsis Resuscitation Bundle
recommends: 1000 ml crystalloid or 300recommends: 1000 ml crystalloid or 300--500 ml 500 ml
of colloid over 30 minutes.of colloid over 30 minutes.
In ICU : 250 ml colloid run 5In ICU : 250 ml colloid run 5--10 minutes10 minutes In ICU : 250 ml colloid run 5In ICU : 250 ml colloid run 5--10 minutes10 minutes
ProtocolProtocol
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
CVP PAOP ACTIONCVP PAOP ACTION
mmHg mmHgmmHg mmHg
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
During fluid challenge increase > 5 Increase > 7 Stop infusion,During fluid challenge increase > 5 Increase > 7 Stop infusion,
WAIT & reassessWAIT & reassess
Following fluid challenge increase 3Following fluid challenge increase 3--5 Increase 35 Increase 3--7 WAIT & reassess7 WAIT & reassessFollowing fluid challenge increase 3Following fluid challenge increase 3--5 Increase 35 Increase 3--7 WAIT & reassess7 WAIT & reassess
Following fluid challenge increase < 3 Increase < 3 Safe to repeat fluid Following fluid challenge increase < 3 Increase < 3 Safe to repeat fluid
bolus if indicatedbolus if indicated
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Balans CairanBalans Cairan
Tiap pemberian cairan harus dibuat balans Tiap pemberian cairan harus dibuat balans
cairan: tiap 6 atau 8 jam, dihitung total tiap 24 cairan: tiap 6 atau 8 jam, dihitung total tiap 24
jam.jam.
Semua cairan masuk dihitung: oral dan infusSemua cairan masuk dihitung: oral dan infus Semua cairan masuk dihitung: oral dan infusSemua cairan masuk dihitung: oral dan infus
Setiap cairan keluar dihitung: urine, Setiap cairan keluar dihitung: urine,
muntah/NGT, diare, drain, IWL (insensibel muntah/NGT, diare, drain, IWL (insensibel
water loss)water loss)
Fluid resuscitation in traumatic shockFluid resuscitation in traumatic shock::
1. ABC1. ABC
2. Restored tissue oxygenation2. Restored tissue oxygenation
3. Avoid / prevent tissue injury3. Avoid / prevent tissue injury 3. Avoid / prevent tissue injury3. Avoid / prevent tissue injury
4. Monitor vital sign4. Monitor vital sign
5. Collaboration to allied surgeon5. Collaboration to allied surgeon