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

output

1100-1400 ml oral fuid

1200-1500 ml urine

800-1000 ml solid food

500-600 ml sweat

300 ml oxidative
metabolism

400 ml respiration
100-200 ml stool

Fluid Imbalance (hypovolemia)

input

output

Intake

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
20-80
5-30
100-120
Gastric

20-80

5-30

100-120

Bile

120-140

2-10

90-120

Ileostomy

100-140

5-15

80-120