Hypovolemic hypotension

Management objectives include limiting further fluid loss (source control) and restoring intravascular and extravascular fluid volumes ( Table 6). To facilitate aggressive fluid therapy, at least two large venous cannulas are inserted. Placement of a sheath introducer into a major jugular or subclavian vessel also allows quick insertion of a right heart catheter if necessary.

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'wW <n hw»i><i -rUftMMh rtwii'i^i^iip ~*~im i^T+H"

fi HÉ 1WÉI IVHnMI "h rffciflKfl Ii ñ Lf-I.rr"

T^fH hHÉ| { ■ |l I - Ih. .I-T.r, r.' ■ ■ —J— Mnd r. L . I Ml.

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'wW <n hw»i><i -rUftMMh rtwii'i^i^iip ~*~im i^T+H"

fi HÉ 1WÉI IVHnMI "h rffciflKfl Ii ñ Lf-I.rr"

Table 6 Therapeutic management of hypovolemia

Beyond the basic principles of resuscitation, pulmonary gas exchange, fluid and red blood cell transfusion therapy, and pharmacological interventions should also be optimized. Adequate monitoring and assessment of clinical and diagnostic markers of organ function are essential. Situations with extremely high and protracted blood loss can sometimes be controlled only by use of a high-rate rapid infusion device. In class III and IV hemorrhage, and after additional hemodilution due to fluid therapy, the infusion of asanguineous fluids alone is often ineffective in accomplishing resuscitation goals.

Infusion of blood components, rather than whole-blood preparations, is now standard practice. Red blood cell transfusions are used to maintain a sufficient O 2 transport capacity, while fresh frozen plasma and platelets are given to ensure adequate coagulation. The decision to use fresh frozen plasma or platelets is never drawn from biochemical markers of coagulation or the platelet concentration alone but is taken in conjunction with clinical evidence of insufficient coagulation.

Patients with hypovolemic hypotension sometimes fail to restore perfusing pressures and O2 delivery despite aggressive fluid resuscitation. The clinician must consider whether there is ongoing, yet unrecognized, fluid loss or other causes of 'refractory' hypotension. There may also be coexistent cardiac disease (acute or chronic) which limits the appropriate responses to intravascular volume restoration. When blood pressure has not been restored with aggressive fluid resuscitation, sympathomimetics with predominantly vasoconstricting actions may be employed until the definitive cause of this 'unresponsive' shock state has been established and managed.

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