4-hypovolemic-shock.ppt

Hypovolemic shock

1. HYPOVOLEMIC SHOCK

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

3. HYPOVOLEMIC SHOCK
CAUSES:
•Hemorrhagic:
External blood loss(wounds)
Exteriorization of internal bleeding (hematemesis, melena, epistaxis,
hemoptysis,etc.)
Internalbleeding (hemothorax, hemoperitoneum,etc.)
Traumaticshock
•Non-hemorrahagic:
Digestive losses (vomiting, diarrhea,nasogastricsuction, billiary, digestive
fistula, etc )
Renal losses (diabetesmellitus, polyuriacaused by diuretics overdose,
osmoticsubstances, polyuric phase of acute renal failure, etc.)
Skin losses(intense physical effort, overheated enviroment, burns, etc.)
Third space losses(peritonites, intestinaloclussion, pancreatits, ascitis
pleural effusions, etc.)

4. PATHOPHYSIOLOGY
Primary pathophysiological event
(reduction of ventricular filling volumesandpressures)
compensatory phenomena macrocirculatory reaction
time
decompensatory phenomena microcirculatory reaction

5. PATHOPHYSIOLOGY
Hypodynamicshock:
Macrocirculatory reaction:
•sympatho-adrenergic+ humoralreaction (ADH, cortizol, SRAA)
oEFFECTS: centralisation of the circulation(compensatory effect)
worsening of tisular hypoperfusion (decompensatory effect)
Microcirculatory reaction:
•Alterations of capillary exchanges
oEFFECTS: transcapilaryfilling (compensatory effect)
capilary leak(decompensatory effect)
•Maldistribution of blood flow
oEFFECTS: preferential renal blood flowtowards medularregion (cortical
vasoconstriction)
•Abnormal peripheral oxygen extraction
oEFFECTS: early -increased (compensatory effect)
late -decreased (decompensatory effect)
•Rheologicchanges
oEFFECTS: ↑ blood viscosity, blood flow, CID
•Endhotelialmodifications
oEFFECTS: morpho-functionalmodifications
proinflamatoryand procoagulatory status,
alteredpermeability

6. HYPOVOLEMIC SHOCK
CLINICAL SIGNS:
Intense thirst
Tachycardia
Tachypnea
–Positive orthostatictest
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 ofhemorrhagic ornon-hemorrhagiclosses

7. CLASSIFICATIONOFHYPOVOLEMIC SHOCK
ClassI ClassII 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 rate14-20/min 20-30/min 30-40/min >40/min
Urinary output >30ml/oră Oliguria Oligoanuria Anuria
Mentalstatus Mild anxiety Anxiety Confused Lethargy

8. HRBPCOCVP PAOPSVRDa-vO
2SvO
2
Hypovolemic
shock
↑ ↑ ↑ 
Cardiogenic
shock
↑↑ ↑↑ ↑ 
Septicshock
↑↑N NN   ↑
DIFFERENTIAL DIAGNOSIS
WITH OTHER FORMS OF SHOCK

9. ABBREVIATIONS:
•HR–heart rate
•BP–arterial blood pressure
•CO–cardiacoutput
•CVP–centralvenous pressure
•PAOP–pulmonary artery occlusion pressure
•SVR–systemic vascular resistance
•Da-v O
2–oxygen arterial-venous difference
•SvO
2 –mixed venous blood oxygen saturation

10. HYPOVOLEMIC SHOCK
TREATMENTPRINCIPLES
•Initial treatment of shock states
•Causative treatment –STOP losses
•Volume repletion
•Inotropic therapy
•Vasomotor therapy

11. TREATMENT OF HYPOVOLEMICSHOCK
•Causativetreatment –STOP losses
–essential role
–surgicaltreatment (when appropriate)
–emergency surgery for ongoing hemorrhage

12. TREATMENT OF HYPOVOLEMICSHOCK
•volume replacement
–Vascular access site
–Solutions forvolume replacement
–Rhythm of administration

13. TREATMENT OF HYPOVOLEMICSHOCK
•Volume replacement–SITE ofVASCULAR ACCESS
–Peripheral vascular access
•Multipleaccess (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)
–Centralvenous 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:
–Riskof complication(at instalation–pneumothorax,cervical ormediastinalhematoma, cardiac
dysrhytmias; during utilization–infection, gas embolism)

14. TREATMENT OF HYPOVOLEMICSHOCK
•Volume replacement-Solutions for volume
replacement
–Isotonic crystalloid solutions
–Hypertonic crystalloid solutions
–Colloidsolutions
–Whole blood and red blood cells
–Fresh-frozen plasma
–Platelets

15. TREATMENT OF HYPOVOLEMICSHOCK
Solutions for volume replacement
-Isotonic crystalloid solutions
•Normal saline(NaCl 0,9 %),Ringersolution,lactated Ringer solutions
•Advantages:
–easy available
–cheap
–reduced risks
•Disadvantages:
–Small volume effect (out of 1000ml infusedsolution –250-300ml remains
intravascullarly, the rest is distributed to the interstitial space)
–short duration of volume effect
–riskof interstitialedema,metabolic hyperchloremicacidosis
-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

16. TREATMENT OF HYPOVOLEMICSHOCK
Solutions for volume replacement
Colloidsollutions
•Dextrans: Dextran 70, Dextran 40
•Gelatines:Gelofusin, Haemacel, Eufusin
•Hetastarch: Haes, Voluven, Refortan
•Humanalbumin 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

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

18. TREATMENT OF HYPOVOLEMICSHOCK
Volume replacement
RHYTHMOF ADMINISTRATION
–Rhytmof administrationdepends on:
•Ongoing losses/ stopped losses
•Rhytmof losses–rapid(minutes, hours) or slow (days)instalation
–For the patientwithhypotension –normal saline (2000ml
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..)

19. TREATMENT OF HYPOVOLEMICSHOCK
Volume replacement–
MONITORING THE TREATMENT EFFICIENCY
–Clinical parameters
•normalisation of BP, HR, pulseamplitude, skin colour and
temperature,mentalstatus, urinary output
–Hemodynamicparameters
•Normalization of CVP, PCPB, DC, RVS, so
–Laboratory parameters
•Normalization of acid-base balance, liver, renal tests, Hb şi Ht, so

20. TREATMENT OF HYPOVOLEMICSHOCK
•Inotropic support
–Only after volume replacement
–Used to improve cardiac output
–Dobutamine
•inotropicpositive support
•peripheral arterial vasodilatation

21. TREATMENT OF HYPOVOLEMICSHOCK
Vasopressor therapy
•NOT RECOMMENDED (may aggravate peripheral
hypoperfusionandmetabolicacidosis)
EXCEPTIONS
•Onlytemporary
•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