Treatment of Hypovolemic Shock in Adults
Immediately initiate aggressive fluid resuscitation with isotonic crystalloids (normal saline or lactated Ringer's), administering at least 30 mL/kg within the first hour through large-bore IV access, with norepinephrine as first-line vasopressor if hypotension persists despite adequate fluid administration. 1, 2
Immediate Vascular Access and Initial Resuscitation
Establish large-bore intravenous access immediately, preferably with 10-gauge catheters or 8 Fr introducer catheters that can deliver 1,200-1,400 mL/minute when connected to large-bore tubing (5.0 mm internal diameter), or use intraosseous access if IV placement is difficult 1, 3
Administer isotonic crystalloids (normal saline or lactated Ringer's solution) as first-line therapy with initial boluses of 500-1,000 mL over 15-30 minutes, targeting at least 30 mL/kg within the first hour 1, 2
Reassess clinical perfusion parameters after each fluid bolus before administering additional volume 1
Critical Monitoring During Resuscitation
Monitor tissue perfusion markers beyond blood pressure alone, as compensatory vasoconstriction can temporarily maintain blood pressure despite profound tissue hypoperfusion 1:
Assess capillary refill time (target <2 seconds), peripheral pulse quality, skin temperature and mottling, mental status, and urine output (target >0.5 mL/kg/hour) 1, 2
Measure serum lactate immediately if available, as it serves as the most reliable marker of shock severity, with levels ≥4 mmol/L indicating severe shock requiring aggressive intervention 1
Watch vigilantly for signs of fluid overload after each bolus, including new pulmonary rales/crackles, hepatomegaly, jugular venous distension, or increased work of breathing 1
Vasopressor Support
Initiate norepinephrine as first-line vasopressor if hypotension persists despite 30 mL/kg crystalloid administration, targeting mean arterial pressure (MAP) ≥65 mmHg 1, 2
Vasopressors may be required transiently even while fluid resuscitation is ongoing in patients with profound hypotension to maintain minimal perfusion pressure to vital organs 1
Fluid Selection: Crystalloids vs Colloids
Use isotonic crystalloids as first-choice fluid for initial resuscitation, as the evidence consistently shows no mortality advantage of colloids over crystalloids in adults, despite colloids being significantly more expensive and carrying risks of anaphylaxis and infection 4:
Only one-fourth of infused crystalloid remains intravascular, but the SAFE Study demonstrated that the volume ratio of albumin to saline needed to maintain stable circulation was only 1.4, providing minimal clinical advantage 4
While hypertonic saline solutions (7.5% NaCl) can provide more rapid initial hemodynamic improvement and require less total volume, they do not improve survival to hospital discharge or 28-30 day mortality compared to isotonic fluids 5, 6
Colloids (albumin, hetastarch) may be considered when large amounts of fluids are required due to longer duration in circulation, but they are much more expensive (albumin costs approximately $152/L vs $1.60/L for saline) and carry additional risks 4
Therapeutic Endpoints
Target clinical endpoints rather than arbitrary hemodynamic numbers 1, 2:
- Warm dry extremities with capillary refill <2 seconds
- Strong peripheral pulses equal to central pulses
- Normal mental status
- Urine output >0.5 mL/kg/hour
- MAP ≥65 mmHg
- Lactate normalization (most objective marker of adequate resuscitation) 1, 2
Critical Pitfalls to Avoid
Do not rely solely on blood pressure to guide therapy, as patients with cold extremities and poor perfusion require aggressive resuscitation even if blood pressure temporarily stabilizes through compensatory vasoconstriction 1
Do not continue fluid boluses without reassessing for overload after each administration, as patients can develop pulmonary edema while still being intravascularly depleted 1
Do not delay vasopressor initiation in profound hypotension while waiting to complete full fluid resuscitation, as some perfusion pressure is needed to maintain vital organ function 1