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Hypovolemic Shock

Classifications of Shock
Hypovolemic shock Cardiogenic shock Obstructive shock Distributive shock

Hypovolemic Shock
Loss of circulating volume Empty tank decrease tissue perfusion general shock response Etiology:
Internal or External fluid loss Intracellular and extracellular compartments

Most common causes:


Hemorrhage Dehydration

Hypovolemic Shock
External loss of fluid Fluid loss
Nausea & vomitting Diarrhoea Massive diuresis

Plasma loss
Extensive burns

Blood loss
Blunt Penetrating

Hypovolemic Shock
Internal fluid loss Loss of vascular integrity Increased capillary membrane permeability Decreased Colloidal Osmotic Pressure (third spacing)

Imbalances Result From:


Illness Altered fluid intake Prolonged vomiting or diarrhea

Fluid Intake
Average adult intake
2200-2700 ml/day
Oral : 1100-1400 Solid foods : 800-1000 Oxidative metabolism : 300
By-product of cellular metabolism of ingested foods

Fluid Intake (cont)


Must be alert At risk for dehydration:
Extreme of age Neurological disorders Psychological disorders

Fluid Output Regulation


Kidneys
Major regulatory organ
Receive about 180 liters of blood/day to filter Produce 1200-1500 ml of urine

Skin
Regulated by sympathetic nervous system
Activates sweat glands
Sensible or insensible-500-600 ml/day Directly related to stimulation of sweat glands

Respiration
Insensible
Increases with rate and depth of respirations, oxygen delivery
About 400 ml/day

Gastrointestinal tract
In stool
Average about 100-200 ml/day GI disorders may increase or decrease it.

Fluid Balance
input
1100-1400 ml oral fuid 800-1000 ml solid food 300 ml oxidative metabolism

output
1200-1500 ml urine

500-600 ml sweat
400 ml respiration 100-200 ml stool

Fluid Imbalance (hypovolemia)


input
Intake

output
Urine Sweat Resp. Diarrhoea Vomitting Bleeding Internal fluid loss

Clinical Presentation
Tachycardia and tachypnea Weak, thready pulses Hypotension Skin cool & clammy Mental status changes Decreased urine output: dark & concentrated

Dehydration
Irritability Increased HR with Confusion decreased BP Dizziness Weakness Extreme thrist Fever Dry skin & mucus membranes Sunken eyeballs Poor skin turgor Decreased urine output

Assessing/Managing Fluid Status


Measuring I & O
Difficult

Daily weight
Same day Same clothes, etc same scale

Assessing/Managing Fluid Status



Insert Foley catheter to monitor I & O Monitor vital signs closely IV therapy Monitor labs: Na+, serum osmolarity, urine specific gravity Provide skin & oral care frequently Auscultation of breath sounds ABGs for fluid overload Diuretics if fluid overload

Assessing Fluid Status


Labs
Creatinine - measure of renal function BUN - not as reliable

Severe Hypovolemia
is a consequence of

Trauma Dehydration Shock syndrome - sepsis, cardiac Hemorrhage - intra-operative blood loss
Each cause may respond differently to different type of fluid Hypotension may be a late sign of Hypovolemia

Compensatory Mechanisms
Redistribution of blood flow
Heart Brain

Redistribution of blood volume


Intracellular Interstitial

Neurohormonal renin-angiotensin
double edge sword

The reservoirs: ECF and Microcirculation

The Circulatory System (s)


> 250m Macrocirculation
50% of blood volume Hb Plasma Mixed end products

< 250m Microcirculation


50% of blood volume Control local flow Hb Plasma Hemostasis mediators Hemodynamic mediators Inflammatory mediators Oxygen transport

Microcirculation
Endothelium cells or organ

Role of regulation, signal transduction, proliferation


and repair. Nitric Oxide production Endothelin Rheology and cell adhesion Leukocyte activation Clotting Lysis Regulation of oxygen transport and more

Management of Hypovolemia
Current old Therapy is directed towards Optimize Macrocirculation Optimize Oxygen delivery
New - future Therapy is directed towards Optimize the Microcirculation Reducing the effect compensatory mechanisms

Management
Five major principles Prompt recognition Do not rely on BP!! Early institution of supportive measures
ABC Restore circulating volume

Determine primary problem leading to shock. Early correction of primary underlying problem.
Control vomitting, diarrhoea, hemorrhage

Management of complications.

Monitoring the Circulation


Vital signs PAWP and cardiac index Arterial and venous oxygen admixture Gastric and other tissue oxygen and/or carbon dioxide tension Base deficit and lactate levels No direct measure of effects of hypovolemia on cell survival
Shoemaker WC et al. CCM 1999;27(10)

Shock Management Airway


Does the patient need tracheal intubation?
Most pts. w/ fully developed shock require intubation and mechanical vent.
Resp. muscles require disproportionate share of total cardiac output during shock. Mental status often abnormal severely Pulmonary complications including ARDS

Shock Management Initial therapy for hypotension


Aggressive therapy indicated for BP < 90 syst.; 40 < baseline; or MAP < 50-60. Two large bore IVs and poss. central venous line (large bore introducer 8.5 fr If no evidence of cardiogenic pulmonary edema, trial of volume expansion and vasopressor therepy

Shock Management Initial therapy for hypotension


Initially, 1-2 litres crystalloid or 500-750 of colloid during the first hour. Severe BP drop is disasterous to brain and heart. Use vasopressor initially, even in hypovolemic shock, in order to keep MAP > 50-60 until caught up w/ volume.

Shock Management Initial therapy for hypotension


Rate and type of on-going fluid administration depends on:
Clinical scenario - Clinical response

Presence of pulmonary edema (cardiac or non-cardiac) is strong contraindication to more fluid admin without more hemodynamic informations

Shock Management Use of SG catheter


Should be employed to
Sort out type of shock Guide therapy Sort out confusing dilemmas (eg, hypotension with pulmonary infiltrates)

Shock Management Endpoint of Resuscitation


Reversal of previous abnormalities. Cerebral, renal function improvement BP up, HR down, improved 02 Improving base deficits, MV02 up

Monitor response of therapies!

Shock Management Outcome and Mortality


Dependant on
Severity. Duration. Underlying cause. Pre-morbid organ disease / function. Reversibility of clinical syndrome.

Dehydration
Mild (3-5% BW) Moderate (5-8% BW) Severe (> 8% BW)

Volume Replacement
Maintenance fluids Replace deficit:
Rapid : iv bolus Intermediate : replace deficit over 6-8 hrs Slow : remainder over 16-18 hrs

Replace ongoing losses: Insensible losses, GI losses, renal losses, burns. Fluid Na K+ Cl e.g.:
Gastric Bile 20-80 120-140 5-30 2-10 100-120 90-120

Ileostomy

100-140

5-15

80-120

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