Shock

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Fluid Resuscitation

In Shock
AABHAS ANAND
122016101003
Primary Aim:ABC(Airway,Breathing,Circulation)

● It is to ensure patent airway and adequate oxygenation


and ventilation.
● Once airway and breathing are assessed and
controlled,attention is directed towards cardiovascular
resuscitation.
Conduct of Resuscitation:

● Resuscitation should not be delayed in order to definitively diagnose the


source of shock state or type of shock.(However timing and nature of
resuscitation will depend upon type of shock,timing and severity of insult.)
● Rapid clinical examination will provide adequate clues to make an appropriate
first determination.
● If there is initial doubt about cause of shock,it is safer to assume the cause as
hypovolaemic shock,and similarly hypovolaemia should be assumed due to
hemorrhage until this has been excluded.(We should initiate fluid resuscitation
and then assess the response.)
● Patients with active bleeding,it is counterproductive to
initiate high volume fluid therapy without controlling
site of hemorrhage.(dilution of coagulation factors).
● Therefore operative hemorrhage control should
not be delayed and resuscitation should proceed in
parallel with surgery.
● Similarly in case of bowel obstruction and
hypovolaemic shock,firstly we should adequately
resuscitate patient and then go for surgery.(it can
exacerbate inflammatory response and result in
end organ insult).
Fluid Therapy:

● In all cases of shock,regardless of


classification,hypovolaemia and inadequate preload must
be addressed before other therapy such as ionotropic drugs
or chromotropic drugs.(It may land patient in state of
unresuscitatable shock due to ischemia and
unresponsiveness to resuscitation.)
● First line therapy is intravenous access and intravenous
fluids.Access should be through short,wide-bore
catheters that allow rapid infusion of fluids.
● Long,narrow lines,such as central venous catheters are
more appropriate for monitoring than fluid
replacement.
Type of Fluids:

● There is no ideal resuscitation fluid.(HOW AND WHEN)


● In most studies of shock resuscitation there is no overt difference in
response or outcome between crystalloids(normal
saline,Hartmann’s solution,Ringer lactate) or colloids(albumin
etc).
● Oxygen carrying capacity of both crystalloids and colloids is
zero.
● If blood is being lost,ideal replacement fluid is blood,although
crystalloids therapy may be required while awaiting blood products.
● NOTE:Hypotonic solution(dextrose etc.) are poor volume
expanders and thus should not be used in treatment of shock
unless the deficit is free water loss(diabetes insipidus) or
patients are sodium overloaded (cirrhosis).
Dynamic Fluid Response:

● Assessment of shock status dynamically by cardiovascular response to rapid


administration of fluid bolus.
● In total,250-500mL of fluid is rapidly administered(over 5-10 minutes) and
cardiovascular responses in terms of heart rate,blood pressure and central
venous pressure are observed.
● We will grade patient in three groups:
1. Responders
2. Transient responders
3. Non-responders
Responders:

● These patients have sustained improvement in their cardiovascular status.


● This implies these patients are not actively losing fluid but require filling to a
normal volume status.
Transient Responders:

● Patients shows improvement but condition reverts back to previous state over next
10-20minutes.
● These patients have moderate ongoing fluid losses (either hemorrhage or further
fluid shift reducing intravascular fluid).
Non-Responders:

● These patients are severely volume depleted and are likely to have major ongoing
loss of intravascular volume,usually due to persistent uncontrolled hemorrhage.
THANK YOU

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