Capital Hospital Islamabad

Critical Care Medicine

Principles of Management
Refers to a medical or surgical condition in which rapid fluid loss results in multiple organ failure
Definition
due to inadequate circulating volume and subsequent inadequate perfusion
GI Losses Diarrhea, Vomiting, External Drainage
Skin Losses Heat stroke, burns, dermatologic conditions
Renal Losses Excessive drug induced or osmotic diuresis, salt
Non Hemorrhagic
wasting nephropathies, hypoaldosteronism
Third space Postoperative and trauma, intestinal obstruction, crush
Losses injury, pancreatitis, cirrhosis
Trauma Blunt or penetrating trauma
Types GI Bleeding Varices, peptic ulcer
Operative Intraoperative & post operative bleeding
Organ based Ruptured aortic or LV aneurysm, aortic-enteric fistula,
Hemorrhagic hemorrhagic pancreatitis
Iatrogenic Inadvertent biopsy of AV malformation or LV
Tumors or abscess erosion into major vessels, postpartum hemorrhage,
uterine or vaginal hemorrhage, spontaneous peritoneal hemorrhage from
bleeding diathesis
Pulse Respiratory
Class HR Systolic BP Others
Pressure Rate
I Elevated or Normal Normal Normal Capillary refill >3secs
(0-15% loss) normal
II >100/min Minimal Decreased 20-24/min Capillary refill-delayed,
Classification of (15-30% loss) drop Skin-cool/clammy
Hemorrhagic >120/min <90mmHg, Markedly >35/min Capillary refill-delayed,
III
Shock Thready >20-30% decreased Altered mentation,
(30-40% loss)
drop Oliguria
>120/min <90mmHg <25mmHg >35/min Capillary refill-delayed,
IV Comatose/drowsy,
(>40% loss) Skin-cold & pale,
Anuric
There are five major sites of bleeding which can cause hemorrhagic shock in a patient,
Major Sites of
Thoracic Cavity, Peritoneal Cavity, Retroperitoneal Cavity (pelvic), External Hemorrhage and
Hemorrhage Muscle/Subcutaneous tissue (long bone fracture)
Clinical Hypotension, Tachycardia, Oliguria, Mental status changes, Cool skin,
Signs of shock
Manifestations of metabolic acidosis
Hypovolemic Signs of Reduced Skin turgor, sunken eyes, dry mucous membranes, dry tongue,
Shock Hypovolemia Severe pallor (hemorrhagic shock)
Airway & breathing Maintain airway as indicated / Ensure adequate breathing
The major principle in management is early IV access. In hypovolemic shock
Basic Principles Circulation it is advisable to obtain large bore (14 or 16 G) peripheral IV access rather
of management than central venous access.
The basic goal of management in hypovolemic shock is to optimize
Oxygen delivery
peripheral oxygen delivery to the tissues
 Management of Hypovolemia
ICU Management of hypovolemic shock requires that the following parameters be monitored
on a strict and regular basis.
Monitoring Blood pressure MAP> 65mmHg CVP 8-12 mm Hg (Off MV) 12-15 mmHg(On MV)
Urine OP >0.5 ml/kg/hr O2ER & ScVO2 < 40% or 0.4 / >70%
Hb & Hct >8 g/dl />35% (in hemorrhagic shock) Lactate To assess resucitation
Hemodynamic >0.12 or > 50% PPV(pulse pressure >13%
IVC Index or variation)
parameters collapsibility
(indicating Hypovolemia) SPV/dPP >15%
In hypovolemic shock there are three major types of fluids which can be used,
Crystalloids – Saline solutions, Ringer’s lactate and chloride restricted fluids
Fluid Resuscitation Colloids – gelatin based solutions, albumin solutions
Blood products – PRBCs, blood substitutes
Choice of replacement fluid should be according to the fluid lost
The choice of fluid in non hemorrhagic shock should be primarily
Crystalloids crystalloids.Crystalloids which can be used are – 0.9% Normal saline or
Ringer’s Lactate
Primary fluid of choice is usually normal saline although its chloride content is
higher than the physiologic level
Normal
Disadvantage with saline is that with large volumes the patient can develop
Saline
non anion gap hyperchloremic metabolic acidosis, in addition there is a
chance of developing pulmonary edema with large volumes of fluid
Better option than normal saline where there are chances of developing
Non Hemorrhagic
hyperchloremia. Avoid use in situations where there is pre existing
Shock Ringer’s
hyperkalemia.
Lactate
Disdvantage is that it can case metabolic alkalosis in large volumes due to
conversion of lactate into bicarbonate
Colloids can be used in hypovolemic shock to rapidly improve intravascular
volume.Amount required is 4 times less than crystalloids
Newer studies promote the use of colloids in hypovolemic shock however
Colloids
validation of data is required before their use is recommended. Avoid usage in
those situations where there is intracellular volume depletion (such as
gastroenteritis etc) as it will further cause dehydration
The first fluid to be used in active bleeding is usually a colloid which may be
Colloids
gelatin based.
Transfusion of blood products is the first line in management of hemorrhagic
shock.Usually PRBCs are preferred product for transfusion
Blood
Initiate massive blood transfusion protocol if > 4 PRBCs are transfused in one
products
Hemorrhagic Shock hour or > 10 PRBCs are transfused in 24 hours
If crossmatched blood is not available, use O- PRBCs in emergent situations
Control of the bleeding is a primary principle of management.
Control of Evaluate and manage the active bleeding e.g
bleeding Trauma – Surgical intervention to control bleeding
Upper GI bleed – variceal banding etc
Once the fluid status is corrected and the hemodynamics are still not
within the desired range, pressor support may be added. Pressor
Norepinephrine &
Vasopressors support may also be used initially as a stop gap measure while fluid
Dopamine
resuscitation is carried out
Norepinephrine : 0.05 – 2 ug/kg/min & Dopamine: 10 – 20 ug/kg/min