Hypovolemic Shock

Shock
Vascular compartments: TBW (60% of IBW) Total Body Water

ICW (40%) Intracellular Water

ECW (20%) Extracellular Water Interstitium (1/3) Plasma (2/3)

Shock
Loss of circulating blood volume Normal Blood Volume: - 7% IBW in adults - 9% IBW in kids

Understanding Shock
Inadequate systemic oxygen delivery activates autonomic responses to maintain systemic oxygen delivery
Sympathetic nervous system
NE, epinephrine, dopamine, and cortisol release
Causes vasoconstriction, increase in HR, and increase of cardiac contractility (cardiac output)

Renin-angiotensin axis
Water and sodium conservation and vasoconstriction Increase in blood volume and blood pressure

Understanding Shock
Cellular responses to decreased systemic oxygen delivery ATP depletion ion pump dysfunction Cellular edema Hydrolysis of cellular membranes and cellular death Goal is to maintain cerebral and cardiac perfusion Vasoconstriction of splanchnic, musculoskeletal, and renal blood flow Leads to systemic metabolic lactic acidosis that overcomes the bodys compensatory mechanisms

Global Tissue Hypoxia

Endothelial inflammation and disruption Inability of O2 delivery to meet demand Result:
Lactic acidosis Cardiovascular insufficiency Increased metabolic demands

Multiorgan Dysfunction Syndrome (MODS)

Progression of physiologic effects as shock ensues
Cardiac depression Respiratory distress Renal failure DIC

Result is end organ failure

Shock
Hypovolemic Septic

Cardiogenic (Obstructive)
Neurogenic Adrenal

Hypovolemic Shock
Definition: Reduction in intravascular volume leading to insufficient oxygen delivery to cells (mitochondria)

Site of fluid loss Skin

Mechanism of loss Thermal or chemical burn, sweating from excessive heat exposure Vomiting or diarrhea Diabetes mellitus or insipidus, adrenal insufficiency, saltlosing nephritis, polyuric phase after acute tubular damage, and use of potent diuretics Increased capillary permeability secondary to inflammation or traumatic

GI tract Kidneys

Intravascular fluid lost to the extravascular space

Hypovolemic Shock
Reduced intravascular volume? No oxygen delivery! No aerobic metabolism!

Then Metabolic acidosis (lactic acid production) Endoplasmic recticulum swelling Mitochondrial damage Cell Death!

EFFECTIVE RESUSCITATION

Assessment of Stages of Shock

% Blood Volume loss < 15% 15 30% 30 40% >40%

HR
SBP Pulse Pressure Cap Refill Resp CNS Treatment

<100
N N or < 3 sec 14 - 20 anxious
12L crystalloid, + maintenance

>100
N, DBP, postural drop

>120

>140

> 3 sec 20 - 30 v. anxious

>3 sec or absent

absent >35 lethargic

30 - 40 confused

2L 2 L crystalloid, re-evaluate, crystalloid, re- replace blood loss 1:3 evaluate crystalloid, 1:1 colloid or blood products. Urine output >0.5 mL/kg/hr

Hypovolemic Shock
Hemorrhagic shock (3 categories) 1. Compensated:
0-20% of blood loss Blood pressure is maintained via increased vascular tone and increased blood flow to vital organs

Hypovolemic Shock
The bodys response: Compensated shock vasoconstriction! Baroreceptor mediated

Increased epinephrine, vasopressin, angiotensin Results in:

Tachycardia Tachypnea Lowered pulse pressure Slightly lowered urine output

Hypovolemic Shock
The Organs who win: Brain Heart Kidneys Liver The Organs who lose: Skin GI tract Skeletal Muscle

Hypovolemic Shock
The body will make whatever adjustsments it can to maintain. Adequate Cardiac Output
Brain and heart perfusions remain near normal while other less critical organ systems are, in proportion to the blood volume deficit, stressed by ischemia.

Hypovolemic Shock
2. Uncompensated:
20-40% loss of blood volume Decrease in BP Tachycardia

Hypovolemic Shock
The bodys response: Uncompensated shock The intravascular volume deficit exceeds the capacity of vasoconstrictive mechanisms to maintain systemic perfusion pressure. Increased cardiac output Increased respiration Sodium retention

Hypovolemic Shock
3. Lethal exsanguination:
40% loss of blood volume

Profound hypotension and inability to perfuse vital organs

Hypovolemic Shock
Management:

ABCs of trauma (AIRWAY is always first!) Control hemorrhage (splint the limb!!) Obtain IV access and resuscitate with fluids and blood
2 liters crystalloid for adults 20 cc/kg crystalloid x 2 for kids
Normal saline Ringers Lactate solution Plasmalyte
Require 3:1 replacement of volume loss

Long term critical care management

Hypovolemic Shock
Your management goals AFTER securing the ABCs: STOP THE BLEEDING! RESTORE VOLUME! CORRECT ANY ELECTROLYTE/ACID-BASE DISTURBANCES!

Hypovolemic Shock
Volume Resuscitation ~ What are my goals? 1. Rapid Responder
Give 500cc-1 Liter crystalloid rapid improvement of BP/HR/Urine output < 20% blood loss Surgery consult

Hypovolemic Shock
Volume Resuscitation ~ What are my goals? 2.Transient Responder
Give 500cc-1 Liter crystalloid improves briefly then deteriorates 20-40% blood loss Continue crystalloid infusion +/- Blood Surgery consult

Hypovolemic Shock
Volume Resuscitation ~ What are my goals? 3. Non Responder
Give 2 Liters crystalloid/ 2 units Blood no response > 40% blood loss STAT Surgery consult!

Hypovolemic Shock
Is my volume resuscitation adequate/inadequate? Urine output Vital signs Skin perfusion Pulse Oximetry

References
Clinical Anesthesia 4th Ed. Morgan et al. Lange Medical / McGraw Hill, 2006, P.242-250 SAFE Investigators. NEJM 2004; 350: 2247 56