What is the management of hypovolemic shock?

From the Guidelines

The management of hypovolemic shock should prioritize the administration of balanced crystalloids, such as lactated Ringer's solution, at 20-30 mL/kg as a bolus, reassessing after each bolus, as this approach has been associated with reduced mortality in critically ill patients 1.

Key Principles

• Initial treatment involves establishing two large-bore intravenous access lines (16-18 gauge) to facilitate rapid fluid administration.
• Crystalloid fluids, such as normal saline or Lactated Ringer's solution, are recommended for initial fluid resuscitation, with an initial bolus of 20-30 mL/kg, reassessing after each bolus 1.
• For severe hemorrhagic shock, blood product transfusion is essential, starting with packed red blood cells (PRBCs) and following a 1:1:1 ratio of PRBCs, fresh frozen plasma, and platelets for massive transfusions.
• Vasopressors like norepinephrine (starting at 0.05-0.1 mcg/kg/min) may be temporarily needed if fluid resuscitation alone is insufficient, but their use should be cautious and guided by hemodynamic monitoring 1.

Monitoring and Adjustments

• Continuous monitoring of vital signs, urine output (goal >0.5 mL/kg/hr), lactate levels, and base deficit helps guide resuscitation adequacy.
• Definitive management requires identifying and controlling the source of fluid loss, whether surgical intervention for hemorrhage, antibiotics for sepsis (starting with broad-spectrum coverage), or other cause-specific treatments.
• Avoid excessive fluid administration once hemodynamic stability is achieved, as this can lead to complications like pulmonary edema and compartment syndromes.

Underlying Cause

• Early intervention is critical as prolonged shock leads to cellular damage, multi-organ dysfunction, and increased mortality.
• The choice of vasoactive drugs depends upon the aetiology and pathophysiology of the hypotensive episode, with norepinephrine being a common choice for hypovolemic, cardiogenic, and obstructive shock 1.

From the FDA Drug Label

For treatment of hypovolemic shock, the volume administered and the speed of infusion should be adapted to the response of the individual patient. Plasbumin-25 is hyperoncotic and on intravenous infusion will expand the plasma volume by an additional amount, three to four times the volume actually administered, by withdrawing fluid from the interstitial spaces, provided the patient is normally hydrated interstitially or there is interstitial edema. If the patient is dehydrated, additional crystalloids must be given, or alternatively, Albumin (Human) 5%, USP (Plasbumin®-5) should be used.

The management of hypovolemic shock involves administering albumin (IV), with the volume and speed of infusion adapted to the individual patient's response.

• The patient's hemodynamic response should be monitored, and precautions against circulatory overload should be observed.
• If the patient is dehydrated, additional crystalloids must be given, or alternatively, Albumin (Human) 5%, USP (Plasbumin®-5) should be used 2 2.
• The total dose should not exceed the level of albumin found in the normal individual, i.e., about 2 g per kg body weight in the absence of active bleeding.

From the Research

Management of Hypovolemic Shock

The management of hypovolemic shock involves the restoration of blood volume and the maintenance of adequate blood pressure. The following are key points to consider:

• Fluid resuscitation is a critical component of the management of hypovolemic shock, with the goal of restoring blood volume and maintaining adequate blood pressure 3, 4, 5, 6, 7.
• The choice of fluid for resuscitation depends on various factors, including the severity of the shock, the presence of comorbidities, and the availability of fluids 3, 4, 5, 6, 7.
• Crystalloids, such as saline or lactated Ringer's solution, are commonly used for fluid resuscitation in hypovolemic shock, but colloids, such as albumin or hydroxyethyl starch, may also be used in certain situations 3, 4, 5, 6, 7.
• Hypertonic saline solutions may be effective in the treatment of hypovolemic shock, particularly in cases where there is a need for rapid volume expansion 4, 5, 6.

Fluid Resuscitation Strategies

The following are key points to consider when developing a fluid resuscitation strategy for hypovolemic shock:

• The use of a restrictive fluid resuscitation strategy, where the amount of fluid administered is limited to the minimum necessary to restore blood pressure and perfusion, may be beneficial in reducing complications such as acute respiratory distress syndrome and abdominal compartment syndrome 5, 6.
• The use of dynamic parameters, such as stroke volume variation and pulse pressure variation, to guide fluid resuscitation may be more reliable than static parameters, such as central venous pressure and pulmonary capillary wedge pressure 5.
• The choice of fluid for resuscitation should be based on the individual patient's needs and the underlying cause of the shock, rather than a one-size-fits-all approach 3, 4, 5, 6, 7.

Monitoring and Adjunctive Therapies

The following are key points to consider when monitoring and managing adjunctive therapies for hypovolemic shock:

• Close monitoring of the patient's hemodynamic status, including blood pressure, heart rate, and urine output, is essential to guide fluid resuscitation and adjust therapy as needed 3, 4, 5, 6, 7.
• The use of vasoactive medications, such as norepinephrine or dopamine, may be necessary to support blood pressure and perfusion in cases where fluid resuscitation is insufficient 3, 4, 5.
• The use of blood products, such as packed red blood cells or fresh frozen plasma, may be necessary in cases where there is significant blood loss or coagulopathy 3, 4, 5, 7.