0521779407-19 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:21
1342 Shock■Hypovolemic:
➣Investigate and control all possible sources of hemorrhage Con-
sider NG lavage
Side Effects & Complications
■Fluids
➣Crystalloids: NaCl associated with hyperchloremic metabolic
acidosis and coagulopathy
➣Albumin: Expensive; beneficial for preexisting hypoalbumine-
mic states (ESLD, malnutrition)
➣PRBC, FFP: Blood-borne disease transmission; transfusion reac-
tion
■Vasopressors: Splanchnic ischemia when hypovolemia uncorrected
■Inotropes: Increased myocardial oxygen consumption, similar risk
profile to vasopressors
■Balloon Pump: gas embolization, limb ischemia
Contraindications
■Absolute:
➣Balloon Pump: Aortic regurgitation, femoral vascular disease,
atrial fibrillation, aortic vascular disease
■Relative:
➣Fluids: Pulmonary edema, CHF
➣Vasopressors: Persistent hypovolemia
➣Inotropes: Tachycardia, ventricular arrhythmia.
Myocardial ischemia may resolve with enhanced inotropy and
systemic perfusion. Consider therapeutic trial to treat myocar-
dial ischemiafollow-up
During Treatment
■Monitor serial lactate level and anion gap
■Monitor hypotension
■Administer fluids until CVP or PA pressures are adequate
■Increased A-aDO 2 (onset of pulmonary edema) may indicate opti-
mization of ventricular filling. Consider inotropes to further enhance
CO
■Monitor CO; titrate fluid and vasoactive agent to achieve Cardiac
Index of 2.0 L/min/m^2
Routine
■Monitor Urine Output, serum creatinine
■Address etiology of hypoperfusion