Hypovolemic shock Case and discussion by sammyc2007

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									Hypovolemic shock
Case 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………………..

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

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.

• 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 acidbase equilibrium. 2. 3:1 ratio. • Colloid- controversy. • Dextrose solutions- possibility of increasing cerebral 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 coagulopathydilutional 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 omittedhyperglycemia-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 injury. • 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 catecholamineresistant 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 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.

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!!


								
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