University of Medicine and Pharmacy, Iasi School of Medicine ANESTHESIA and INTENSIVE CARE Conf. Dr.

Ioana Grigoras

MEDICINE 4th year English Program Suport de curs

HYPOVOLEMIC SHOCK

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 time

macrocirculatory reaction

decompensatory phenomena

microcirculatory reaction

Hypodynamic shock:

PATHOPHYSIOLOGY

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
Blood loss- ml
Blood loss-%

Class II
750-1500ml
15-30%

Class III
1500-2000ml
30-40%

Class IV
>2000ml
>40%

< 750ml
<15%

Pulse rate
BP

<100/min
N

< 100/min
N

120-140/min

>140/min

Pulse wave amplitude

Capillary refill

N
N

Respiratory rate
Urinary output Mental status

14-20/min
>30ml/or Mild anxiety

20-30/min
Oliguria Anxiety

30-40/min
Oligoanuria Confused

>40/min
Anuria Lethargy

DIFFERENTIAL DIAGNOSIS WITH OTHER FORMS OF SHOCK

HR BP CO CVP PAOP SVR Da-vO2 SvO2

Hypovolemic shock Cardiogenic shock Septic shock

N N

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

TREATMENT OF HYPOVOLEMIC SHOCK

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

TREATMENT OF HYPOVOLEMIC SHOCK

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)

TREATMENT OF HYPOVOLEMIC SHOCK

Volume replacement - Solutions for volume replacement
Isotonic crystalloid solutions Hypertonic crystalloid solutions Colloid solutions

Whole blood and red blood cells Fresh-frozen plasma Platelets

TREATMENT OF HYPOVOLEMIC SHOCK

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

TREATMENT OF HYPOVOLEMIC SHOCK

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

TREATMENT OF HYPOVOLEMIC SHOCK

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

TREATMENT OF HYPOVOLEMIC SHOCK

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..)

TREATMENT OF HYPOVOLEMIC SHOCK

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 i Ht, so

TREATMENT OF HYPOVOLEMIC SHOCK

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

TREATMENT OF HYPOVOLEMIC SHOCK

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