FACULTY OF MEDICINE

ANESTHESIA AND INTENSIVE CARE DEPARTMENT

Hypovolemic Shock

Clinical case presentation with discussions about clinical signs,

diagnostic and treatment principles of hypovolemic shock
Clinical Case
Mr. Stevenson, age 81, comes to the emergency department looking frail and weak.
Although Mr. Stevenson is lethargic, he’s able to state he is under chemotherapy for a
pancreatic tumor and he has had:
 nausea,
 vomiting,
 watery diarrhea for the last 2 days
On inspection, you detect:
 poor skin turgor
 dry mucous membranes
His vital signs are:
 Heart Rate 130 beats/minute and regular;
 Blood Pressure, 62/30 mm Hg;
 Respiratory rate 26 breaths/minute
 Temperature 37° C. Is this patient in shock?
If Yes, What type of shock do you suspect?
Clinical Case
Mr. Stevenson, age 81, comes to the emergency department looking frail and weak.
Although Mr. Stevenson is lethargic, he’s able to state he is under chemotherapy for a
pancreatic tumor and he has had:
 nausea,
 vomiting,
 watery diarrhea for the last 2 days
On inspection, you detect: Non-haemorrhagic
 poor skin turgor Hypovolemic shock!
 dry mucous membranes
His vital signs are:
 Heart Rate 130 beats/minute and regular;
 Blood Pressure, 62/30 mm Hg;
 Respiratory rate 26 breaths/minute
 Temperature 37° C.
Let’s Remember:

1. What is hypovolemic shock?

2. What causes hypovolemic shock?
3. What is the pathophysiology of hypovolemic shock?
4. What are the symptoms of hypovolemic shock?
 1. What is hypovolemic shock?

Hypovolemic shock is a syndrome characterized by a

decrease in effective circulating blood volume (hypovolemia),
which results in lowering the pressure of effective tissue
perfusion and generalized cellular suffering.
2. What causes hypovolemic shock?

Hypovolemic shock results from

significant and sudden blood or fluid losses within the body.

 Hemorrhagic shock
 Non-haemorrhagic hypovolemic shock
2. What causes hypovolemic shock?

 Blood losses:
 bleeding from serious cuts or wounds
 bleeding from blunt traumatic injuries due to accidents
 internal bleeding from abdominal organs or ruptured 
 bleeding from digestive tract
 significant vaginal bleeding

Hemorrhagic shock
2. What causes hypovolemic shock?
 Digestive losses
(excessive vomiting, excessive or prolonged diarrhea, naso-gastric
drainage, digestive fistula)
 Renal loss
(diabetes mellitus, polyuria after diuretic overdose, osmotic agents,
resumption of diuresis after anuric renal failure)
 Skin loss
(excessive sweating after intense exercise, overheating, severe burns)
 Losses in "third space"
(peritonitis, intestinal occlusion, pancreatitis, ascites, pleurisy)
Non-haemorrhagic hypovolemic shock
 3. Pathophysiology
of hypovolemic shock
 3. Pathophysiology
of hypovolemic shock
HR AP CO CVP PVR Da-vO2 SvO2

Hypovolemic ↑    ↑ ↑ 
shock

Cardiogenic ↑   ↑ ↑ ↑ 
shock

Septic shock ↑  ↑N N   ↑
4. What are the symptoms of hypovolemic shock?
The symptoms of hypovolemic shock vary
with the severity of the fluid or blood loss.
However, all symptoms of shock are life-
threatening and need emergency medical
treatment.
Internal bleeding symptoms may be hard to
recognize until the symptoms of shock appear,
but external bleeding will be visible.
Symptoms of hemorrhagic shock may not
appear immediately.
Older adults may not experience these
symptoms until the shock progresses
significantly.
Some symptoms are more urgent than others.
4. What are the symptoms of hypovolemic shock?
Clinical signs common to all types of shock

1. Tachycardia
2. Hypotension
3. Tachypnea
4. Oliguria
5. Alteration of consciousness
4. What are the symptoms of hypovolemic shock?
Mild symptoms Severe symptoms

 fatigue  cold/pale skin

 profuse sweating  blue lips and fingernails
 headache  rapid, shallow breathing
 dizziness  rapid heart rate
 nausea  weak pulse
 low blood pressure
 little or no urine output
 confusion
 weakness
 lightheadedness
 loss of consciousness
Clinical Case

Early intervention is crucial to a positive outcome in a patient

with hypovolemic shock.
How do you treat Mr. Stevenson?
Treatment

1. Volemic Replenishment
2. Causal treatment - stopping losses

± Vasomotor therapy/Inotrop support

1. Volemic Replenishment

Basic Knowledge of:

 The administration routes used for volemic replenishment

 Devices used for venous access
 Venous access techniques
 Advantages/Disadvantages of different routes and devices
 Health and safety risk hazards of venous cannulation
 Volumetric replenishment solutions
Volemic Replenishment

Administration routes
 Peripheral - venous cannula
 Central – central venous catheter
 Devices used for peripheral venous access
 A cannula is composed of several parts:
o needle
o catheter
o bushing
o catheter hub and wings
o valve
o injection port and cap
o Luer connector
o needle grip
o ‘flashback chamber’ for visual confirmation
that the cannula has entered the vein.
o Luer-Lok™ plug and cap

 Modern peripheral cannula are made from polyurethane, and are latex free.
Devices used for peripheral venous access

The maximum flow rate depends on cannula size!

 Devices used for peripheral venous access
Cannula sizes and flow rate
Orange, Grey
unstable patients, emergency,
for rapid infusion of fluids, drugs,
blood products

Green, Pink
maintenance fluids, drugs, bloods

Blue, Yellow, Violet

pediatric and elderly patients
small, fragile veins

The maximum flow rate is very important if you are fluid resuscitating!
Sites of peripheral venous cannulation
The distal cephalic vein:
 normally large and well tethered,
 easy to cannulate.
Veins in the antecubital fossa:
 often large, easy to cannulate,
 obstruction of flow through the cannula
tends to occur if the elbow is flexed.
Veins on the underside of the arm and wrist:
 often painful when cannulated
Veins in the foot:
 tend to be painful and inconvenient for the
patient,
 are associated with a higher risk of phlebitis
and thromboembolism,
 can be used as a last resort.
External jugular vein:
 particularly useful in emergency situations
when IV access elsewhere is difficult.
Sites of peripheral venous cannulation

Choosing the ideal vein for cannulation should take into consideration:

 patient comfort and convenience

 mobility and fragility of the patient’s veins
 size of cannula required
 the patient’s non-dominant hand should be preferred.
 the back of the hand or lower arm should be chosen in most situations
 external jugular vein may be useful in emergency situations when iv access elsewhere
is difficult
Peripheral venous access technique

intravenous cannulation
Peripheral venous access Peripheral venous access
 Large-diameter peripheral venous cannula
 External jugular vein
 Multiple (2-4 veins)
Benefits:
 Short installation time
 It requires simple materials and knowledge
 Minor complications (hematoma,
subcutaneous serum, etc.)
Disadvantages:
 The diameter of the peripheral venous
catheter must be adjusted to the sizes of the
veins available
 Venous access may be lost
 Catecholamines can not be given
 Devices used for central venous access

A Central venous catheter Kit

is usually composed of:
1. central venous catheter
2 sliding clamp
3 guidewire with advancer
4 dilator
5 catheter clamp
6 introducer syringe
7 introducer needle
8 syringe needle
9 injection cap
Devices used for central venous access
Size:
 for pediatric use
 for adult use

Number of infusion channels:

 single infusion channel
 multiple infusion channels

Use:
 “Clasic” catheter
 Dialysis catheter
 Swan-Ganz catheter
 Portacath
The maximum flow rate depends on catheter type!
Sites of central venous catheter insertion
Central venous access technique

Step-by-step guide: central venous access. (a) Sterilising insertion site with a commercially available preparation of 2% chlorhexidine gluconate in 70%
isopropyl alcohol. (b) Patient draped with ‘aperture’ sterile drape. (c) Using a draped US probe to identify insertion landmarks. (d) Infi ltrating local
anaesthetic (1% lidocaine) around identifi ed insertion site. (e) Aspirating blood from internal jugular. (f) Using wire introducer.(g) Guidewire inserted through
needle. (h) Guidewire in situ. (i) Cutting down onto wire with scalpel. (j) Dilating over guidewire. (k) Inserting central line over guidewire. (l) Ensuring
guidewire is securely held as central line is introduced. (m) Line inserted to 15 cm depth. (n) Aspirating all ports of line (fl ashback can be clearly seen). (o)
Placing secure clips over wire. (p) Clips sutured into position to secure wire. (q) Line dressed clearly showing insertion site.
Central venous access
Benefits:
 Safe and lasting venous access
 Allows catecholamines and hypotonic
substances to be administered
Disadvantages:
 Risk of complications
(on installation - pneumothorax, cervical or
mediastinal hematoma, rhythm disorders)
(in use - infection, gas embolism)
Clinical Case
You start monitoring Mr. Stevenson
 Heart Rate
 Blood Pressure
 Respiratory Rate
 Urine output
You establish a good peripheral venous access
 2 Large-diameter peripheral venous cannula: 16G, 18G
 External jugular line of 16G
You start making preparation for a central venous catheter insertion

What solutions do you use for volemic replenishment?

Volemic Replenishment solutions

 Isotonic crystalline solutions

 Hypertonic crystalline solutions
 Colloidal solutions
 Whole blood and red blood cell count
 Concentrated fresh plasma
 Platelet concentrate
Volemic Replenishment solutions
Isotonic crystalline solutions

 Physiological saline (0.9% NaCl)

 Ringer's solution
 Lactated Ringer's solution

 Benefits:
The most widespread, cheap
 Disadvantages:
 The low volumetric recovery capacity (per 1000ml perfused - 250-300ml remain
in the vessel, the rest diffuses interstitial)
 The duration of small intravascular retention
 Risk of interstitial edema, hypercloric metabolic acidosis
Volemic Replenishment solutions
Colloidal solutions:

 Gelatin: Gelofusin, Haemacel,

 Hydroxyethylamide: Haes, Voluven, Refortan
 Human albumin 5%, 20%

Benefits:
 Good volumics recovery
 The duration of high intravascular retention
Disadvantages:
 Expensive
 Risk of allergic reactions
 It interferes with the determination of blood groups
 Can cause / aggravate clotting disorders
Volemic Replenishment solutions

Blood and blood products

 Only blood izogrup izoRh

 When the patient has post-haemorrhagic

anemia or in case of ongoing bleeding

 In massive transfusion - Frozen fresh plasma

and thrombocytopenic concentrate
You start volemic replenishment through the peripheral lines using an
isotonic crystalline solution (Lactated Ringer's solution)

How much fluids do you administer?

How fast do You administer the solution?
Volemic Replenishment solutions

The rate of administration depends on:

 Losses lost
 Loss rate - fast installation or slow (days)
Clinical Case
You start volemic replenishment with Lactated Ringer's solution
using the peripheral venous lines (2 Large-diameter peripheral venous
cannula: 16G, 18G, one external jugular line of 16G).

How do you monitor the effectiveness of the treatment?

Monitoring the effectiveness of the treatment
Clinical parameters
 Heart Rate – decrease?
 Pulse amplitude – increase?
 Arterial Pressure – increase/normalization?
 Color and temperature of the skin
 Mental status - improve?
 Urinary flow – increase?
Hemodynamic parameters
 CO – increase?
 CVP – increase?
 SvO2 – increase?
Laboratory parameters
 Lactat – decrease?
 Hb and Ht, electrolytes, acid-base balance
2. Causal treatment - stopping losses
 nausea,
 vomiting,
 watery diarrhea for the last 2 days

 Antiemetic drugs
 Promote restauration of normal gut flora
 ….