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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!!