Pathology of Dying Jan 2015

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Pathophysiology of dying

Eddy RahardjoGuru Besar Anestesiologi dan Reanimasi

Fak Kedokteran Univ AirlanggaRS Dr Sutomo Surabaya

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Seorang pasien dibawa ke IGD

• Kita periksa– tidak bergerak– tidak bernafas– suara jantung tidak terdengar– pupil midriasis

• Dx: DOA, dead on arrival Dx: DOA, dead on arrival

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• Karena dulu di Fak Kedokteran diajarkan tanda mati :tanda mati :– tidak sadar– tidak bergerak– tidak bernafas – tidak ada detak jantung

• Apakah orang yang Sdr anggap mati itu Apakah orang yang Sdr anggap mati itu “memang mati” atau “dianggap mati” ?“memang mati” atau “dianggap mati” ?

Mengapa Anda memberi diagnose: Mati?

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• Pada peradaban purbakala dulu …..• Orang tidak sadar, tidak bergerak,

tidak bernafas = mati• Orang purbakala ini berfikir:

Apakah “memang mati”? Atau mungkin Dx saya salah?

• Maka orang itu disimpan beberapa hariMaka orang itu disimpan beberapa hari• Jika tetap tidak sadar, tidak bergerak,

tidak bernafas = benar-benar mati• Barulah orang itu dikubur

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sekarang tahun 2000 Masehi ini, kita mencoba untuk menunda mati

• Orang tidak bergerak, tidak bernafas = belum tentu mati beri nafas buatan

• Jika nadi carotis tidak berdenyut = belum tentu mati pijat jantung

• Disimpan beberapa hari (di ICU)– tetap tidak sadar, tidak bergerak, – nafas dipompa mesin– jantung berdenyut karena dibantu obat

• Kapan pasien begini ini boleh dianggap mati ??Kapan pasien begini ini boleh dianggap mati ??

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• By understanding how people die– We can identify factors causing death

• We then know how to stop the dying process• We can reverse the dying process = reanimationWe can reverse the dying process = reanimation

The study of the critically ills

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HidupHidupnormalnormal

Traumaberat

Stroke, Infark

Infeksi berat

Critically ill

MatiMati

HidupHidupnormal kembalinormal kembali

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Basics for Life Support

• Apakah pasien yang dinyatakan “mati” Apakah pasien yang dinyatakan “mati”

itu benar mati?itu benar mati?

• Kenapa perlu Life Support ?– Agar pasien tidak “mati” prematur

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State of mindState of mind

which affectswhich affects

the way peoplethe way people

THINK - FEEL - ACTTHINK - FEEL - ACT

Past experienceAssumptionPerceptioninfluence

MINDSETMINDSET|

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sel otak matisel otak matisel otak rusaksel otak rusak

sel otak berhenti kerja

||||

tidak sadartidak sadaraliran darah aliran darah terhentiterhenti

limited reversibilitylimited reversibility

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• Setelah O2 untuk sel otak habis, pasien jatuh tidak sadar, tetapi masih bisa diselamatkan selama sel otak belum rusak

the viability of the brain defines human life.the viability of the brain defines human life.

• When O2 supply stops:When O2 supply stops:– dysfunction after 10-30 seconds – start of irreversible damage in 5-20 minutes

• After 5 minutes brain glucose stores and ATP are used up

Safar, 1986

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Process of anoxic brain injury

• Deprivation of substrate plus deprivation of oxygen injured neurons more than either one separately

• Injured neurons release cytotoxic compounds into the extracellular fluid, which might propagate injurymight propagate injury

• (Retinal) neurons tolerate up to 20 minutes of complete ischemic anoxia

Safar, 1986

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Is there any exception, that 20 minutes is maximum tolerance?

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ResusitasiResusitasi

Tenggelam 30 menit, Tenggelam 30 menit, tidak sadar, tidak bernafas, tidak sadar, tidak bernafas,

dingin, birudingin, biru

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| | | | | |1 2 3 4 5 minutes

MatiMati

Vegetative Vegetative statestate

RecoveryHidup

CardiacArrest

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Alive

Clinicaldeath

Cerebraldeath

Braindeath

Biologicaldeath

Vegetativestate

Fungsi :otak berfungsitubuh berfungsi

stopberfungsi

rusakberfungsi

matimatiberfungsiberfungsi

matimatimatimati

Mati adalah proses yang perlu waktuKalau kita sigap, ada kematian yang

“bisa dibatalkan”“bisa dibatalkan”

/63

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1. Clinical death• Apnea plus cardiac arrest, with

all cerebral activity suspended but not irreversibly sonot irreversibly so

• The early period of death, with early optimal resuscitation restoration of all vital organ restoration of all vital organ functions including normal functions including normal brain function is possiblebrain function is possible

AliveAlive

ClinicalClinicaldeathdeath

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2. Cerebral death– Cortical death,

irreversible necrosis, particularly the neocortex

– Coma but spontaneous breathing

– Associated with deep Associated with deep vegetative statevegetative state

AliveAlive

CerebralCerebraldeathdeath

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Persistent Vegetative State

• Social death (apallic syndrome)• Irreversible brain damage, remains

unconscious and unresponsive, but has an active EEG and some intact reflexes

• This is to be distinguished from – cerebral death (EEG is silent) – brain death (all cranial nerve reflexes and spontaneous

breathing are absent)

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3. Brain death– Cerebral death plus necrosis

of the rest of the brain– Most medical and legal authorities define “death” in

terms of brain death, though the heart is still beating and

artificial ventilation is maintained.

– organ transplant from brain-dead-heart-beating donor

AliveAlive

Braindeath

Biological death

4. Biological death– Pan-organic death =

real death

– Organ transplant from cadaver

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Konsep-konsep dalam Life Support

• Apnea ≠ mati– beri nafas buatan

• Cardiac arrest ≠ mati– pijat jantung, DC shock– “heart to good to die”

• Coma ≠ mati– brain resuscitation– “brain to good to die”

CPR

CPCR

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Life Support (dulu)

• A - airway • B - Breathing• C - circulation

– Safar, Bircher et al 1968

A-B-C ATLS 1978

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Life Support (sekarang)

• A - airway • B - Breathing• C – circulation• D – defibrillation, drug• E – ECG, arrhythmia control

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Basics for Life Supports

• CPR is to buy time– membeli waktu agar pasien masih sempat

hidup untuk diberi terapi definitif /causal

• CPR must be provided by ALL medical CPR must be provided by ALL medical specializationspecialization

• CPR for everyone, CPR by everyoneCPR for everyone, CPR by everyone®®

/63

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30%30%20%20%

5%5%

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5%5%

Mengapa mengejar survival yang hanya 5% ?Tehnologi yang berkembang menjanjikan hasil lebih baik

Hypothermia

Extra corporeal membrane oxygenation(ECMO)

30%30%20%20%

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Decreasing level of ATP ----------------------

Ventricular fibrillation ------------------ Fine VF Asystole

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mm

ol/k

g d-

w ATPATP

Base Line VF CC Post Resusc 10 min 6 min 60 min

* p<0.05 vs BL

* * * 20--

30--

If you can not increase the production of ATPThen try to reduce its usage

Hypothermia

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EarlyAccess

EarlyB L S

EarlyDefib

Early A L S

The chain of SurvivalThe chain of Survival

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Pijat jantung yang baik, hanya mencapai 30% dari Cardiac Output Normal

Push hardPush hard- 4-5 cm

Push fastPush fast-100 x pm

Pijat 30 xNafas 2 x

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• In sudden adult cardiac arrest, ventricular fibrillation (VF) happens in 2/3 of all

• VF is fatal unless defibrillation is given. • CPR does not stop VF but CPR extends the

window of time in which defibrillation can be effective.

• CPR provides a trickle of oxygenated blood to the brain and heart and keeps these organs alive until defibrillation can shock the heart into a normal rhythm.

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• If CPR is started within 4 minutes of collapse and defibrillation provided within 10 minutes 40% chance of survival.

• CPR followed by defibrillation within 2 to 3 minutes of collapse up to 50% survival rates

• With each minute of delay, chance of survival decreases by 7 - 10 percent.

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Early defib / early DC shock meningkatkan survival

• Kalau ada Defib tersedia, segerakan melakukan DC shock

• Pijat jantung dikerjakan sambil menunggu siapnya DC shock

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• Anda tidak harus jadi ahli Resusitasi / CPR

• Tetapi Anda bisa berperan banyak untuk mencegah agar pasien jangan sampai perlu CPR

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Pathophysiology of Dying and Reanimation (Safar, 1984)

mengajarkan “Knowledge and Skill Proficiency”

1.1. Primary Prevention:Primary Prevention: – Cegah jangan Cardiac Arrest Cegah jangan Cardiac Arrest – Pelajari Peri-arrest managementPelajari Peri-arrest management

2.2. Secondary Prevention:Secondary Prevention:– Jika Cardiac arrest, maka cepat aktifasi Jika Cardiac arrest, maka cepat aktifasi

Early BLSEarly BLS, , Early DefibEarly Defib, , Early ALSEarly ALS – ROSC in less than 5 minutesROSC in less than 5 minutes

3.3. Tertiary Prevention:Tertiary Prevention:– Setelah ROSC Setelah ROSC Prolonged Life Support di ICU Prolonged Life Support di ICU – to bring recovery with good quality of lifeto bring recovery with good quality of life