4-hypovolemic-shock.ppt

HYPOVOLEMIC SHOCK
DEFINITION
 syndrom characterized by decreased circulating blood
volume (hypovolemia), which results in reduction of
effective tissue perfusion pressure and generalized
cellular dysfunctions.
Forms:
• Hemorrhagic shock
• Non-hemorrhagic hypovolemic shock

HYPOVOLEMIC SHOCK
CAUSES:
• Hemorrhagic:
External blood loss (wounds)
Exteriorization of internal bleeding (hematemesis, melena, epistaxis,
hemoptysis,etc.)
Internal bleeding (hemothorax, hemoperitoneum,etc. )
Traumatic shock
• Non-hemorrahagic:
Digestive losses (vomiting, diarrhea, nasogastric suction, billiary, digestive
fistula, etc )
Renal losses (diabetes mellitus, polyuria caused by diuretics overdose,
osmotic substances, polyuric phase of acute renal failure, etc.)
Skin losses (intense physical effort, overheated enviroment, burns, etc.)
Third space losses (peritonites, intestinal oclussion, pancreatits, ascitis
pleural effusions, etc.)

PATHOPHYSIOLOGY
Primary pathophysiological event
(reduction of ventricular filling volumes and pressures)
compensatory phenomena macrocirculatory reaction
time
decompensatory phenomena microcirculatory reaction

PATHOPHYSIOLOGY
Hypodynamic shock:
 Macrocirculatory reaction:
• sympatho-adrenergic + humoral reaction (ADH, cortizol, SRAA)
o EFFECTS: centralisation of the circulation (compensatory effect)
worsening of tisular hypoperfusion (decompensatory effect)
 Microcirculatory reaction:
• Alterations of capillary exchanges
o EFFECTS: transcapilary filling (compensatory effect)
capilary leak (decompensatory effect)
• Maldistribution of blood flow
o EFFECTS: preferential renal blood flow towards medular region (cortical
vasoconstriction)
• Abnormal peripheral oxygen extraction
o EFFECTS: early - increased (compensatory effect)
late - decreased (decompensatory effect)
• Rheologic changes
o EFFECTS: ↑ blood viscosity,  blood flow, CID
• Endhotelial modifications
o EFFECTS: morpho-functional modifications
proinflamatory and procoagulatory status,
altered permeability

HYPOVOLEMIC SHOCK
CLINICAL SIGNS:
 Intense thirst
 Tachycardia
 Tachypnea
– Positive orthostatic test
 Small pulse wave
 hTA (blood hypotension)
 Agitation, anxiety , confusion, coma
 Oliguria
 Cold extremities
 Profuse sweating
 Collapsed peripheral veins
 Delayed return of color to the nail bed
+ History of hemorrhagic or non-hemorrhagic losses

CLASSIFICATION OF HYPOVOLEMIC SHOCK
Class I Class II Class III Class IV
Blood loss- ml < 750ml 750-1500ml 1500-2000ml >2000ml
Blood loss-% <15% 15-30% 30-40% >40%
Pulse rate <100/min < 100/min 120-140/min >140/min
BP N N  
Pulse wave
amplitude
N   
Capillary refill N + + +
Respiratory rate 14-20/min 20-30/min 30-40/min >40/min
Urinary output >30ml/oră Oliguria Oligoanuria Anuria
Mental status Mild anxiety Anxiety Confused Lethargy

HR BP CO CVP PAOP SVR Da-vO2 SvO2
Hypovolemic
shock
↑     ↑ ↑ 
Cardiogenic
shock
↑   ↑ ↑ ↑ ↑ 
Septic shock
↑  ↑ N  N N   ↑
DIFFERENTIAL DIAGNOSIS
WITH OTHER FORMS OF SHOCK

ABBREVIATIONS:
• HR – heart rate
• BP – arterial blood pressure
• CO – cardiac output
• CVP –central venous pressure
• PAOP – pulmonary artery occlusion pressure
• SVR – systemic vascular resistance
• Da-v O2 – oxygen arterial-venous difference
• SvO2 – mixed venous blood oxygen saturation

HYPOVOLEMIC SHOCK
TREATMENT PRINCIPLES
• Initial treatment of shock states
• Causative treatment – STOP losses
• Volume repletion
• Inotropic therapy
• Vasomotor therapy

TREATMENT OF HYPOVOLEMIC SHOCK
• Causative treatment – STOP losses
– essential role
– surgical treatment (when appropriate)
– emergency surgery for ongoing hemorrhage

• volume replacement
– Vascular access site
– Solutions for volume replacement
– Rhythm of administration

• Volume replacement – SITE of VASCULAR ACCESS
– Peripheral vascular access
• Multiple access (2-4 veins)
• Large peripheral catheters
• External jugular vein
Advantages:
– Short time of instalation
– Requires basic knowledge and simple matherials
– Minor complications (hematomas, cutaneous seroma, etc.)
Disadvantages:
– The diameter of peripheral catheter must be adapted for peripheral veins dimensions
– Vascular access can be lost (restless patient, during transportation); must be changed at 24-48
hours;
– no catecholamines administration (except in emergency for a short time period,until a central
venous access is available)
– Central venous access
• After peripheral vascular access is established and volume replacement is initiated
Advantages:
– Reliable and long lasting venous access (7-10 days)
– Allows CVP measuring and guiding of treatment
– Allows the administration of catecholamines and hypertonic substances
Disadvantages:
– Risk of complication (at instalation – pneumothorax, cervical or mediastinal hematoma, cardiac
dysrhytmias; during utilization – infection, gas embolism)

• Volume replacement - Solutions for volume
replacement
– Isotonic crystalloid solutions
– Hypertonic crystalloid solutions
– Colloid solutions
– Whole blood and red blood cells
– Fresh-frozen plasma
– Platelets

Solutions for volume replacement
-Isotonic crystalloid solutions
• Normal saline (NaCl 0,9 %), Ringer solution, lactated Ringer solutions
• Advantages:
– easy available
– cheap
– reduced risks
• Disadvantages:
– Small volume effect (out of 1000ml infused solution – 250-300ml remains
intravascullarly, the rest is distributed to the interstitial space)
– short duration of volume effect
– risk of interstitial edema, metabolic hyperchloremic acidosis
-Hypertonic crystalloid solutions
• hypertonic saline (NaCl 7,4%)
• Advantages:
– Efficient blood volume resuscitation with small solution volume (water is atracted
from interstitial space )
– Avoidance of fluid overload and peripheral edema
• Disadvantages:
– may result in acute pulmonary edema

Solutions for volume replacement
Colloid sollutions
• Dextrans: Dextran 70, Dextran 40
• Gelatines: Gelofusin, Haemacel, Eufusin
• Hetastarch: Haes, Voluven, Refortan
• Human albumin 5%, 20%
– Advantages:
• Good volume effect
• Long duration of volume effect
– Disadvantages:
• expensive
• risk for anaphylactic reactions
• interfere with blood groups determination
• can induce/ aggravate coagulation disorders

Solution for volume replacement
Blood and blood products are not volume solutions
• Only isogroup isoRh blood
• Only after restauration of intravascular volume with cristalloid /colloid
solutions;
• For correction of oxygen transport
• In case of posthemorragic anemia (after volume replacement) or
ongoing hemorrhage
• In case of massive blood transfusion – add fresh-frozen plasma and
platelet concentrate

Volume replacement
RHYTHM OF ADMINISTRATION
– Rhytm of administration depends on:
• Ongoing losses / stopped losses
• Rhytm of losses – rapid (minutes, hours) or slow (days) instalation
– For the patient with hypotension – normal saline (2000 ml
in the first 15-30 minutes)
– after the first 15-30 minutes - volume replacement
continues depending on the clinical and hymodinamic
parameters (BP, HR, etc..)

Volume replacement –
MONITORING THE TREATMENT EFFICIENCY
– Clinical parameters
• normalisation of BP, HR, pulse amplitude, skin colour and
temperature, mental status, urinary output
– Hemodynamic parameters
• Normalization of CVP, PCPB, DC, RVS, so
– Laboratory parameters
• Normalization of acid-base balance, liver, renal tests, Hb şi Ht, so

• Inotropic support
– Only after volume replacement
– Used to improve cardiac output
– Dobutamine
• inotropic positive support
• peripheral arterial vasodilatation

Vasopressor therapy
• NOT RECOMMENDED (may aggravate peripheral
hypoperfusion and metabolic acidosis)
EXCEPTIONS
• Only temporary
• In case of ongoing hemorrhage, which outruns the
possibilities of volume replacement
• Only until surgical procedure stops the hemorrhage
(emergency surgical treatment)
• Noradrenaline, dopamine, adrenaline

4-hypovolemic-shock.ppt

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4-hypovolemic-shock.ppt