Shavindri Prasadini De Silva

Kursk State Medical University

4th year 1st semester
Group 26
 DEFINITION
 ETIOLOGICAL FACTORS
 MECHANISM
 PATHOGENESIS
 SYMPTOMS
 TREATMENT
 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

 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.)
 Intense thirst
 Tachycardia
 Tachypnea
 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
 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

BP N N  

Pulse 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 Lethargy

 HR BP CO CVP PAOP SVR Da-vO2 SvO2

Hypovolemic
shock
↑     ↑ ↑ 

Cardiogenic
shock
↑   ↑ ↑ ↑ ↑ 

Septic shock
↑  ↑N 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
 Initial treatment of shock states
 Causative treatment – STOP losses
 Volume repletion
 Inotropic therapy
 Vasomotor therapy
 Causative treatment – STOP losses
◦ essential role
◦ surgical treatment (when appropriate)
◦ emergency surgery for ongoing hemorrhage
 volume replacement
◦ Vascular access site
◦ Solutions for volume replacement
◦ Rhythm of administration
 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)
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
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
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..)
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 şi Ht, so
 Inotropic support
◦ Only after volume replacement
◦ Used to improve cardiac output
◦ Dobutamine
 inotropic positive support
 peripheral arterial vasodilatation
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