Q.456. What are the clinical manifestations of hypovolemic shock?
INTENSIVE CARE NEPHROLOGY
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Q.456. What are the clinical manifestations of
hypovolemic shock?
A. C.P.: Early: No hypotension, orthostatic
hpt. is a reliable Sn., but : dry m.m. & dcr. skin turgor [Less
reliable but indicative of hypovolemia. Oliguria, peripheral cyanosis, smell of
acetone, brown discoloration of m.m. (Addisonian Sns.) due to adrenal failure,
cn also be found. Acidosis
due to incr. lactate production &
DIC.[ microthrombosis & MODF, cn be observed.
Q.457. How to diagnose?
A. Diagnosis: P.H. of trauma or blood
loss us.
the Iry cause, but Don’t overlook Sepsis, cardiogenic
shock,
upper & lower endoscopy, chest x-ray (hemothorax, tension pneumothorax),
peritoneal lavage (internal hge.), CBC, ECG., full bioch., P.t. & P.t.t.
Q.458. How to manage?
A. Management: The
Iry goal is to restore the blood circulation vol. [ 🠝 tissue perfusion & oxygenation, through a large pore (central) i.v. catheter, even before
diagnosis is made. Supanoral O2 delivery[ 🠝survival, but large
amount blood TX. [🠝mortality, as does the application of pulm. a. cath.[ 🠝M.R. We us. depend on [ B.P.-
s. lactate- metabolic acidosis.].
- O2 tension (expiratory), found to be incr. in septicemia[
an indicator of Dysoxia = [inability
to utilize O2], not hypoxia [ contribute to
acidosis & organ failure.
Q.459. What recent tools can be used in management of
hypovolemic shock?
A. I. “Gastric Tonometry”: nose [stomach[gastric
P.H.: A low Phi
(gastric PH),means two things: ✌
1) Early indicator of reduced global O2 delivery (as splanchnic bed us. prone to hypoperfusion
early) & hypoxia.
2) Intestinal mucosal hypoxia[incr. mucosal permeability [Loss
of mucosal barrier [ translocation of bacterial toxins & MODF.
II. Sublingual “Caprometry” [ for tissue perfusion [ not
widely used.
Q.460.What
else in management?
1) Dc. Ketoacidosis [ i.v. insulin.
2) Addisonian crises [i.v
hydrocortisone.
3) Lower G.I. bleeding [endoscopy/surgery.
4) Oesphageal varices [[Somatostatin], injection sclerotherapy or Sengstaken-blakmore tube.
5) Upper G.I. bleeding [
i.v. proton pump inhibitor,
electrocautery, laser coagulation é nasogastric tttpy.
Q.461. How to start fluid resuscitation for
hypovolemic shock?
A. Initially, both colloid (high molecular
wt.) & crystalloid (electrolyte solut-ion) cn be used. Isotonic crystalloid [N.S. 0.9 %, ½ N.S. 0.45 %, Ringer’s
solution (4
ml
Eq/L. K+ & 28 mEq. Lactate] [ used for volume expansion.
: Don’t use Ringer’s sol. in:
i. R.F. ➤ Hyperkalemia.
ii. Liver cell failure [dged liver cannot convert lactate to bicarbonate.
- Once isotonic crystalloid
infused [75 % of the vol. infused
enter the interstit-ial fluid &
25% remain intravascular.
: Large amounts of fluid are harmful:
i. Risk of A.P.O.
ii. Peripheral edema.
iii. Impaired healing of wounds.
Q.462. Explain
the role of colloid & hypertonic crystalloid in ttt. of hypo-volemic
shock?
A. Hypertonic crystalloid: 3 %, 5 %, 7.5 % [Sodium chloride]= Pl. expanders
a they act thr. moving
water fr. interstitium ➤ intravascular ➤Hypernatremia, water
retention & cell
dge.
- Colloid a Also, pl. expander, as
they’re macromolecules & retained intravascular greater
than isotonic crystals.
Q.463. What
are the colloids in common use?
A. Colloids:
1) Albumin: 69,000 dalton, hs ½ life=15-20 d., it serves as free radicle Scavenger &
incr. intravascular oncotic pressure a protect
the lung & other organs fr.
odema.
2) Dextran: ➤Colloid ag. prepared
fr. glucose polymer, dextran 40, 40.000 dalton, both 👉 histamine release fr. mast
cells a Anaphylactoid reaction.
3) Hydroxethyl starch: (Hetastarch)(HES 200)
& (HES 450)anatural starch of highly
branched glucopolymer .
4) Glycogen:200,-450,000 dalton, Pl. ½ life= 17 d.(vol. expander like albumin).
5) Penta starch: m.w. =260.000 a more
volume expansion .
6) Starch: Recently,
proved to reduce cpll. leak after trauma & ischemia odema formation. Both (HES )& (Pentastarch) ➤🠝🠝 Amylase.
7) Newly administrated solutions:[ Na Cl. 75 % +
Dextran 70]-[ NaCl + Dextran 60] – [N.S 7.5 + NES].
Q.464. Compare
colloid vs crystalloid?
A. Colloids a theoretically better & B.P. faster than crystalloids:
One L. Dextran 70 👉 🠝🠝 intravascular volume
by 800 ml.
One L. HES 👉 🠝🠝 ,, ,, ,,
by 750
ml.
One L.
Abumin 5% 👉 🠝🠝 ,, ,, ,,
by 500
ml.
One L.
N.S. 👉 🠝🠝 ,,
,, ,, by 180 ml.
-
Yet, in Sepsis 👉 Capill. leak , So, both [Albumin] & [N.S.] are equal.
-
Small amounts in AMI & to make A.P.O. é less incidence.
Q.465. What
are the “disadvantages’’ of colloids?
A. Disadvantages:
1)
Anaphylactoid reaction.
2)
Albumin 👉 –ve inotrope.
3)
Albumin 👉 impair
salt & water excretion.
4)
Colloid 👉 inhibit
coagulation system cascade.
5)
HES 👉 Risk
of AKI é sepsis
(inadequate
water supply).
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