Hypovolemic shockHypovolemic shockCase and discussion

By R1 張家穎

A 38 y/o pregnant woman is diagnosed of placenta acreta.

C/S was performed smoothly.

She was then sent to our POR………………..

Check Abd.Sono.

Keep obs.

c/o:bil.leg pain.

pulse:weak

Remove bil.TAEpH: 7.464pO2: 85.9pCO2: 23.8HCO3-: 17.2O2Sat: 97.3B.E.: -6.8Na+: 138K+: 4.6Cl-: 114Ca++: 0.99Hb: 6.8Hct: 20

Heart echo: hypovolemia.

Anesthetic induction

• Hypovolemic pts are sensitive to the vasodilating and negative inotropic effects of anesthetic drugs.

• Spinal or epidural anesthesia- sympathetic blockade.

• IV induction agents:

thiopental and propofol - SVR and myocardial contractility.

Etomidate, ketamine, large dose of opioids.prefer

• IHA: isoflurane producing profound vasodilatation.

• Muscle relaxants: facilitate intubation.

histamine release- atracurium.

• Positive pressure ventilation- reduce preload.

Fluid resuscitation

• “How much” is primary importance.

• Further consideration is “What fluid”

Fluid resuscitation for the trauma patient Resuscitation 2001;48(1):57-69

Intraoperative fluid management - what and how much? Chest 1999;115(5 Suppl):S106-12

Fluid resuscitation for the trauma patient Resuscitation 2001;48(1):57-69

Goals

• Proper intravascular volume is the foundation for cardiovascular function.

• Maintenance of renal function.

• Avoidance of lung water accumulation.

• Minimizing splanchnic and hepatic circulatory insufficiency.

• Ensuring GI integrity-prevent endotoxemia.

Fluid therapy

• Crystaloid- N.S v.s. L.R.

1. potential effect on electrolyte and acid-

base equilibrium.

2. 3:1 ratio.• Colloid- controversy.• Dextrose solutions- possibility of increasing cer

ebral acidosis.• Oxygen-carrying capacity and coagulation.

Intraoperative fluid management - what and how much? Chest 1999;115(5 Suppl):S106-12

• The existence of congestive heart failure and pul. edema is a major cause of perioperative morbidity and mortality.

• Minimize severe hypotension and hypoperfusion during anesthetic induction.

Electrolyte and Acid-Base Balance

• Na+, K+, Cl- are the principal electrolytes affected by the choice of crystalloid solution.

• NS: hyperchloremic metabolic acidosis.

• LR: lactate-metabolic alkalosis.

Ca++-limited in blood transfusion.

Colloid

A number of conflicting studies~~

• Comparing with crystalloid resuscitation, colloids will increase extravascular lung water and worsen pul. Function.

• Colloids reduce the incidence of pul. Edema.

• Lymphatic flow can increase by up to 20 times.

Oxygen-carrying capacity.

DO2=CaO2*C.O.

CaO2=SaO2*Hb*1.31+0.003*PaO2.

• No difference between restrictive transfusion (Hb: 7-9) and liberal transfusion (Hb: 10-12).

• Pre-existing cardiopulmonary function is unknown and the concentration of Hb. changes rapidly during resuscitation.

Coagulation factor

• Causes for depletion: hemodilution, intravascular consumption, bone marrow depression, hypersplenism.

• Most common intra-OP coagulopathy- dilutional thrombocytopenia.

• FFP• Platelate• Cryoprecipitate- factor 8.13, fibrinogen• Whole blood

pT: 11.6/13.5

aPTT: 33.2/29.4

I need fluid therpy of this kind.

Nutrition, glucose

• Avoidance of hyperglycemia and hypoglycemia is of increased concern in pts with DM and ES”L”D.

• Dextrose solutions are generally omitted-hyperglycemia-induced hyperosmolarity,

osmotic diuresis and cerebral acidosis.

Fluid warming

• Hypothermia (B.T.<35℃):

• The oxyhaemoglobin dissociation curve is shifted to the left.

• Shivering compounds the lactic acidosis.

• Increase bleeding.

• Increase the risk of infection.

• Increase the risk of cardiac morbid events.

Small volume resuscitation

• Rapid infusion of a small dose (4 ml/kg B.W.) of 7.2%-7.5% NaCl/colloid solution.

• Endogenous fluid shift along the osmotic gradient form the intracellular to the intravascular compartment.

• Immediate BP, SVR.• Reduction of postischemic reperfusion inju

ry.• Pts with head injury benefit more!

Small-volume resuscitation: from experimental evidence to clinical routine. Advantages and disadvantages of hypertonic solutions Acta Anaesthesiologica Scandinavica 2002;46(6):625-38

Small-volume resuscitation: from experimental evidence to clinical routine. Advantages and disadvantages of hypertonic solutions Acta Anaesthesiologica Scandinavica 2002;46(6):625-38

Vasopressin in shock states.

• Exogenous vasopressin injection

arterial BP and SVR

• Vasopressin at a dosage of 2-6 U/hr is effective in reversing catecholamine-resistant vasodilatory shock due to sepsis or after CPB.

References.• Vasopressin in shock states

Current Opinion in Anaesthesiology 2003;16(2):159-64 • Small-volume resuscitation: from experimental evidence to clini

cal routine. Advantages and disadvantages of hypertonic solutions Acta Anaesthesiologica Scandinavica 2002;46(6):625-38

• Fluid management of the trauma patient Current Opinion in Anaesthesiology 2001;14(2):221-5

• Fluid resuscitation for the trauma patient Resuscitation 2001;48(1):57-69

• Intraoperative fluid management - what and how much? Chest 1999;115(5 Suppl):S106-12

• Lange clinical Anesthesiology, 3rd edition.

Near “”the end”

The end!

Wait~~~

Wait~~

• No more use of nasal canula. SaO2:97%

• Mild dyspnea when rapid iv. Loading.

• Not any memory of POR and 2nd emergent surgery.

• She is happy with her husband and twin babies.

Bye!!Bye!!