What is the management of hypovolemic shock?

Management of Hypovolemic Shock

The first-line treatment for hypovolemic shock is rapid fluid resuscitation with isotonic crystalloids (preferably Ringer's lactate), administered as boluses of 20 ml/kg in the first hour, while simultaneously addressing the underlying cause of volume loss. 1

Initial Assessment and Recognition

• Evaluate for signs of hypoperfusion: prolonged capillary refill time (≥2 seconds), cool extremities, altered mental status, tachycardia, and oliguria 2, 1
• Assess blood pressure - hypotension (systolic BP <80 mmHg) is often a late sign that complicates approximately 25% of cases with severe acidosis 2
• Measure serum lactate when available as a marker of shock severity and adequacy of resuscitation 1
• Delayed capillary refill time is a reasonable prognostic indicator, especially in children with decreased consciousness 2

Fluid Resuscitation

Initial Phase

• Begin with isotonic crystalloids (Ringer's lactate or normal saline) 2, 1
• For adults with signs of shock: administer 500-1000 ml boluses of crystalloids over 30 minutes 1
• For children: administer boluses of up to 20 ml/kg over 5-10 minutes 2, 1
• Pediatric advanced life support guidelines recommend up to 60 ml/kg fluid resuscitation during treatment of hypovolemic and septic shock 2
• Obtain venous access as quickly as possible, preferably with large-bore catheters 1, 3

Monitoring and Adjustment

• Titrate fluid administration based on clinical response: normalization of heart rate, blood pressure, capillary refill time, mental status, and urine output 1
• Therapeutic targets include: capillary refill time <2 seconds, age-appropriate normal blood pressure, normal pulses without difference between peripheral and central, warm extremities, and urine output >1 ml/kg/hr 1
• Monitor for signs of volume overload: hepatomegaly, pulmonary rales, increased jugular venous pressure 2, 1
• If signs of volume overload develop, reduce infusion rate and consider inotropic support 2, 1

Vasopressors and Inotropic Support

• If hypotension persists despite adequate fluid resuscitation, administer vasopressors to maintain target arterial pressure 2
• Norepinephrine is the first-line vasopressor for shock after adequate fluid resuscitation 2, 1, 4
• For norepinephrine administration: dilute 4 mg in 1000 ml of 5% dextrose solution (4 mcg/ml), starting at 2-3 ml/minute (8-12 mcg/minute) and titrate to maintain adequate blood pressure 4
• In previously hypertensive patients, aim to raise blood pressure no higher than 40 mmHg below the pre-existing systolic pressure 4
• Consider inotropic support in the presence of myocardial dysfunction 2
• For children who are not responsive to fluid resuscitation, begin peripheral inotropic support until central venous access can be obtained 2

Special Considerations

• In hemorrhagic shock, rapid control of bleeding is the priority alongside fluid resuscitation 1, 5
• For patients with severe hemorrhagic shock requiring massive transfusion, use a ratio of red blood cells, plasma, and pooled platelets of 4:4:1 5
• In children with severe hemolytic anemia who are not hypotensive, blood transfusion is considered superior to crystalloid or albumin bolusing 2
• For patients at risk of fluid intolerance (heart failure, advanced age), perform frequent clinical assessment to detect pulmonary edema 1

Common Pitfalls and Precautions

• Avoid excessive fluid administration without evaluating response, as this can lead to volume overload and pulmonary edema 1
• Do not delay vasopressor therapy when fluid resuscitation is inadequate to restore tissue perfusion 2
• When initiating mechanical ventilation in patients with severe acidosis, avoid rapid rise of PCO2 even to normal levels before acidosis has been partially corrected 2
• Gradually reduce norepinephrine infusions, avoiding abrupt withdrawal 4
• Always suspect and correct occult blood volume depletion when patients remain hypotensive despite high doses of vasopressors 4