Hypovolemic shock Case and discussion

1. Hypovolemic shockCase and discussion By R1 張家穎

2. A 38 y/o pregnant woman is diagnosed of placenta acreta. C/S was performed smoothly. She was then sent to our POR………………..

3. Check Abd.Sono. Keep obs. c/o:bil.leg pain. pulse:weak Remove bil.TAE pH: 7.464 pO2: 85.9 pCO2: 23.8 HCO3-: 17.2 O2Sat: 97.3 B.E.: -6.8 Na+: 138 K+: 4.6 Cl-: 114 Ca++: 0.99 Hb: 6.8 Hct: 20

5. Heart echo: hypovolemia.

6. 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

7. IHA: isoflurane producing profound vasodilatation. • Muscle relaxants: facilitate intubation. histamine release- atracurium. • Positive pressure ventilation- reduce preload.

8. Fluid resuscitation • “How much” is primary importance. • Further consideration is “What fluid”

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

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

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

12. 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.

13. 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 cerebral acidosis. • Oxygen-carrying capacity and coagulation.

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

15. 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.

17. 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.

18. 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.

19. 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.

20. 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

21. pT: 11.6/13.5 aPTT: 33.2/29.4

22. I need fluid therpy of this kind.

23. 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.

24. 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.

25. 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 injury. • Pts with head injury benefit more!

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

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

28. 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.

29. References. • Vasopressin in shock states Current Opinion in Anaesthesiology 2003;16(2):159-64 • Small-volume resuscitation: from experimental evidence to clinical 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.

30. Near “”the end” The end!

31. Wait~~~ Wait~~

33. 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!!