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
• Nonhemorrhagic 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, biliary,
digestive fistulas, etc )
 Renal losses (diabetes mellitus, polyuria caused by overdosing
diuretics, osmotics substances, polyuric phase of acute renal
failure, etc.)
 Cutaneous losses (intense physical effort, overheating enviroment,
burns, etc.)
 Third space losses (peritonites, intestinal oclussion, pancreatits,
ascite, 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 reaction + humoral reaction (ADH, cortizol,
SRAA)
o EFFECTS: centralisation of the circulation (compensatory)
worsening of tisular hypoperfusion (decompensatory)
 Microcirculatory reaction:
• Alterations of capillary exchanges
o EFFECTS: transcapilary filling (compensatory)
capilary leak (decompensatory)
• Maldistribution of blood flow
o EFFECTS: preferential renal blood flow towards medular region (cortical
vasoconstriction)
• Arterial-venous shunt
o EFFECTS: shunting of capilar territory (functional reality)
• 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
 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

TA N N ↓ ↓

Plus wave N ↓ ↓ ↓
amplitude

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 Lethargic

 DIFFERENTIAL DIAGNOSIS
WITH OTHER FORMS OF SHOCK

FC TA DC PVC PCPB RVP Da-vO2 SvO2

Hypovolemic ↑ ↓ ↓ ↓ ↓ ↑ ↑ ↓
shock

Cardiogenic ↑ ↓↓ ↓ ↑ ↑ ↑ ↑ ↓
shock

Septic shock ↑ ↓ ↑ N ↓N N ↓ ↓ ↑
 HYPOVOLEMIC SHOCK

TREATMENT PRINCIPLES
• Initial treatment of shock states
• Causal treatment – stop losses
• Volume repletion therapy
• 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 – vascular access site
– 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 established)
– 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:
– reduced capacity of volume replacement (for 1000ml infused – 250-300ml remain in
vessel, the rest is distributed in interstitial space)
– short duration of intravascular remanence
– risk of interstitial edema, metabolic hyperchloremic acidosis
-Hypertonic crystalloid solutions
• hypertonic saline (NaCl 7,4%)
• Advantages:
– resuscitation with small volume; water is atracted from interstitial space
– avoid fluid loading and edema formation
• Disadvantages:
– may result in acute pulmonary edema
TREATMENT OF HYPOVOLEMIC SHOCK

Solutions for vulume replacement

Colloid sollutions
• Dextrans: Dextran 70, Dextran 40
• Gelatines: Gelofusin, Haemacel, Eufusin
• Hetastarch: Haes, Voluven, Refortan
• Human albumin 5%, 20%
– Advantages:
• Good volume replacement
• large duration of intravascular remanence
– Disadvantages:
• expensive
• risk for anphylactic reactions
• interfere with blood groups determination
• can determine/ aggravate disorders of coagulation
 TREATMENT OF HYPOVOLEMIC SHOCK

Solution for volume replacement

Blood and blood products
• Only izogroup izoRh blood
• Only after restauration of intravascular volume with cristalloid /colloid
solutions;
• For correction of oxygen transport
• When the patient presents posthemorragic anemia (after volume replacement) or
when ongoing hemorrhage is present;
• In case of massive blood transfusion – fresh-frozen plasma and platelets are
administered
TREATMENT OF HYPOVOLEMIC SHOCK

• Volume replacement – Rhytm 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 efficiency

of treatment
– Clinical parameters (normalisation of BP, HR, pulse
amplitude, colour and temperature of teguments,
mental status, urinary output)
– Hemodynamic parameters (CVP, PCPB, DC, RVS,
etc.)
– Laboratory parameters ( acid-base ballance, Hb şi Ht)
TREATMENT OF HYPOVOLEMIC SHOCK

• Inotropic support
– Only after volume replacement
– Used to improve cardiac output
– Dobutamine ( inotropic positive support and
peripheral arterial vasodilatation)
TREATMENT OF HYPOVOLEMIC SHOCK

• Vasopressor therapy
– Vassopressors
• unadvisable (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