Treatment of severe hypovolemia or hypovolemic shock in adults
- Jess Mandel, MD
Jess Mandel, MD
- Section Editor — Pulmonary Vascular Disease
- Professor of Medicine
- University of California, San Diego
- Paul M Palevsky, MD
Paul M Palevsky, MD
- Section Editor — Renal Failure
- Professor of Medicine
- University of Pittsburgh
- VA Pittsburgh Healthcare System
- Section Editors
- Richard H Sterns, MD
Richard H Sterns, MD
- Editor-in-Chief — Nephrology
- Section Editor — Fluid and Electrolytes
- Professor Emeritus
- University of Rochester School of Medicine and Dentistry
- Scott Manaker, MD, PhD
Scott Manaker, MD, PhD
- Section Editor — Critical Care
- Professor of Medicine
- University of Pennsylvania School of Medicine
Rapid volume repletion is indicated in patients with severe hypovolemia (ie, decreased peripheral perfusion, as indicated by delayed capillary refill and cool mottled extremities) or hypovolemic shock (ie, severe hypovolemia plus hypotension). Delayed therapy can lead to ischemic injury and possibly to irreversible shock and multiorgan system failure. Three issues generally need to be considered in this setting: the rate of fluid replacement; the type of fluid infused; and the role for buffer therapy in patients with concurrent lactic acidosis . Vasopressors (eg, norepinephrine) generally should not be administered, since they do not correct the primary problem and tend to further reduce tissue perfusion . (See "Use of vasopressors and inotropes".)
Treatment of hypovolemia is discussed here. Manifestations and diagnose of volume depletion are discussed separately. (See "Etiology, clinical manifestations, and diagnosis of volume depletion in adults".)
RATE OF FLUID REPLETION
It is not possible to precisely predict the total fluid deficit in a given patient with hypovolemic shock, particularly if fluid loss continues (eg, persistent bleeding or third space sequestration). In general:
●Initial – At least one to two liters of isotonic crystalloid are initially given as rapidly as possible in an attempt to restore tissue perfusion.
Early correction of the volume deficit is essential in hypovolemic shock to prevent the decline in tissue perfusion from becoming irreversible. Irreversible shock is associated with loss of vascular tone, a drop in systemic vascular resistance, pooling of blood in the capillaries and tissues, and an impaired response to vasoactive medications. (See "Definition, classification, etiology, and pathophysiology of shock in adults".)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Rose BD, Post TW. Clinical Physiology of Acid-Base and Electrolyte Disorders, 5th ed, McGraw-Hill, New York 2001. p.439.
- Nordin AJ, Mäkisalo H, Höckerstedt KA. Failure of dobutamine to improve liver oxygenation during resuscitation with a crystalloid solution after experimental haemorrhagic shock. Eur J Surg 1996; 162:973.
- Michard F, Teboul JL. Predicting fluid responsiveness in ICU patients: a critical analysis of the evidence. Chest 2002; 121:2000.
- Gunn SR, Pinsky MR. Implications of arterial pressure variation in patients in the intensive care unit. Curr Opin Crit Care 2001; 7:212.
- Bendjelid K, Romand JA. Fluid responsiveness in mechanically ventilated patients: a review of indices used in intensive care. Intensive Care Med 2003; 29:352.
- Magder S. Clinical usefulness of respiratory variations in arterial pressure. Am J Respir Crit Care Med 2004; 169:151.
- Kramer A, Zygun D, Hawes H, et al. Pulse pressure variation predicts fluid responsiveness following coronary artery bypass surgery. Chest 2004; 126:1563.
- Pinsky MR, Teboul JL. Assessment of indices of preload and volume responsiveness. Curr Opin Crit Care 2005; 11:235.
- Soubrier S, Saulnier F, Hubert H, et al. Can dynamic indicators help the prediction of fluid responsiveness in spontaneously breathing critically ill patients? Intensive Care Med 2007; 33:1117.
- Monnet X, Rienzo M, Osman D, et al. Passive leg raising predicts fluid responsiveness in the critically ill. Crit Care Med 2006; 34:1402.
- Teboul JL, Monnet X. Prediction of volume responsiveness in critically ill patients with spontaneous breathing activity. Curr Opin Crit Care 2008; 14:334.
- Finfer S, Bellomo R, Boyce N, et al. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 2004; 350:2247.
- Schierhout G, Roberts I. Fluid resuscitation with colloid or crystalloid solutions in critically ill patients: a systematic review of randomised trials. BMJ 1998; 316:961.
- Erstad BL, Gales BJ, Rappaport WD. The use of albumin in clinical practice. Arch Intern Med 1991; 151:901.
- Alderson P, Schierhout G, Roberts I, Bunn F. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev 2000; :CD000567.
- Annane D, Siami S, Jaber S, et al. Effects of fluid resuscitation with colloids vs crystalloids on mortality in critically ill patients presenting with hypovolemic shock: the CRISTAL randomized trial. JAMA 2013; 310:1809.
- Schramko A, Suojaranta-Ylinen R, Kuitunen A, et al. Hydroxyethylstarch and gelatin solutions impair blood coagulation after cardiac surgery: a prospective randomized trial. Br J Anaesth 2010; 104:691.
- Wiedermann CJ. Hydroxyethyl starch--can the safety problems be ignored? Wien Klin Wochenschr 2004; 116:583.
- Gattas DJ, Dan A, Myburgh J, et al. Fluid resuscitation with 6 % hydroxyethyl starch (130/0.4 and 130/0.42) in acutely ill patients: systematic review of effects on mortality and treatment with renal replacement therapy. Intensive Care Med 2013; 39:558.
- Zarychanski R, Abou-Setta AM, Turgeon AF, et al. Association of hydroxyethyl starch administration with mortality and acute kidney injury in critically ill patients requiring volume resuscitation: a systematic review and meta-analysis. JAMA 2013; 309:678.
- Haase N, Wetterslev J, Winkel P, Perner A. Bleeding and risk of death with hydroxyethyl starch in severe sepsis: post hoc analyses of a randomized clinical trial. Intensive Care Med 2013; 39:2126.
- Virgilio RW, Rice CL, Smith DE, et al. Crystalloid vs. colloid resuscitation: is one better? A randomized clinical study. Surgery 1979; 85:129.
- Riddez L, Hahn RG, Brismar B, et al. Central and regional hemodynamics during acute hypovolemia and volume substitution in volunteers. Crit Care Med 1997; 25:635.
- McIlroy DR, Kharasch ED. Acute intravascular volume expansion with rapidly administered crystalloid or colloid in the setting of moderate hypovolemia. Anesth Analg 2003; 96:1572.
- Drobin D, Hahn RG. Volume kinetics of Ringer's solution in hypovolemic volunteers. Anesthesiology 1999; 90:81.
- Weaver DW, Ledgerwood AM, Lucas CE, et al. Pulmonary effects of albumin resuscitation for severe hypovolemic shock. Arch Surg 1978; 113:387.
- Choi PT, Yip G, Quinonez LG, Cook DJ. Crystalloids vs. colloids in fluid resuscitation: a systematic review. Crit Care Med 1999; 27:200.
- Taylor AE. Capillary fluid filtration. Starling forces and lymph flow. Circ Res 1981; 49:557.
- Gallagher TJ, Banner MJ, Barnes PA. Large volume crystalloid resuscitation does not increase extravascular lung water. Anesth Analg 1985; 64:323.
- Zarins CK, Rice CL, Peters RM, Virgilio RW. Lymph and pulmonary response to isobaric reduction in plasma oncotic pressure in baboons. Circ Res 1978; 43:925.
- Rackow EC, Falk JL, Fein IA, et al. Fluid resuscitation in circulatory shock: a comparison of the cardiorespiratory effects of albumin, hetastarch, and saline solutions in patients with hypovolemic and septic shock. Crit Care Med 1983; 11:839.
- Bunn F, Alderson P, Hawkins V. Colloid solutions for fluid resuscitation. Cochrane Database Syst Rev 2001; :CD001319.
- Wilkes MM, Navickis RJ. Patient survival after human albumin administration. A meta-analysis of randomized, controlled trials. Ann Intern Med 2001; 135:149.
- Roberts I, Blackhall K, Alderson P, et al. Human albumin solution for resuscitation and volume expansion in critically ill patients. Cochrane Database Syst Rev 2011; :CD001208.
- Albumin Reviewers (Alderson P, Bunn F, Li Wan Po A, Li L, Blackhall K, Roberts I, Schierhout G). Human albumin solution for resuscitation and volume expansion in critically ill patients. Cochrane Database Syst Rev 2011; :CD001208.
- Perel P, Roberts I, Ker K. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev 2013; :CD000567.
- Opperer M, Poeran J, Rasul R, et al. Use of perioperative hydroxyethyl starch 6% and albumin 5% in elective joint arthroplasty and association with adverse outcomes: a retrospective population based analysis. BMJ 2015; 350:h1567.
- Bellomo R, Morimatsu H, French C, et al. The effects of saline or albumin resuscitation on acid-base status and serum electrolytes. Crit Care Med 2006; 34:2891.
- SAFE Study Investigators, Finfer S, McEvoy S, et al. Impact of albumin compared to saline on organ function and mortality of patients with severe sepsis. Intensive Care Med 2011; 37:86.
- SAFE Study Investigators, Australian and New Zealand Intensive Care Society Clinical Trials Group, Australian Red Cross Blood Service, et al. Saline or albumin for fluid resuscitation in patients with traumatic brain injury. N Engl J Med 2007; 357:874.
- Brunkhorst FM, Engel C, Bloos F, et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med 2008; 358:125.
- Wiedermann CJ. Systematic review of randomized clinical trials on the use of hydroxyethyl starch for fluid management in sepsis. BMC Emerg Med 2008; 8:1.
- Wiedermann CJ, Dunzendorfer S, Gaioni LU, et al. Hyperoncotic colloids and acute kidney injury: a meta-analysis of randomized trials. Crit Care 2010; 14:R191.
- Myburgh JA, Finfer S, Bellomo R, et al. Hydroxyethyl starch or saline for fluid resuscitation in intensive care. N Engl J Med 2012; 367:1901.
- Mutter TC, Ruth CA, Dart AB. Hydroxyethyl starch (HES) versus other fluid therapies: effects on kidney function. Cochrane Database Syst Rev 2013; :CD007594.
- Perner A, Haase N, Guttormsen AB, et al. Hydroxyethyl starch 130/0.42 versus Ringer's acetate in severe sepsis. N Engl J Med 2012; 367:124.
- Morgan TJ. The meaning of acid-base abnormalities in the intensive care unit: part III -- effects of fluid administration. Crit Care 2005; 9:204.
- O'Dell E, Tibby SM, Durward A, Murdoch IA. Hyperchloremia is the dominant cause of metabolic acidosis in the postresuscitation phase of pediatric meningococcal sepsis. Crit Care Med 2007; 35:2390.
- Gheorghe C, Dadu R, Blot C, et al. Hyperchloremic metabolic acidosis following resuscitation of shock. Chest 2010; 138:1521.
- Young P, Bailey M, Beasley R, et al. Effect of a Buffered Crystalloid Solution vs Saline on Acute Kidney Injury Among Patients in the Intensive Care Unit: The SPLIT Randomized Clinical Trial. JAMA 2015; 314:1701.
- Severs D, Hoorn EJ, Rookmaaker MB. A critical appraisal of intravenous fluids: from the physiological basis to clinical evidence. Nephrol Dial Transplant 2015; 30:178.
- Krajewski ML, Raghunathan K, Paluszkiewicz SM, et al. Meta-analysis of high- versus low-chloride content in perioperative and critical care fluid resuscitation. Br J Surg 2015; 102:24.
- Yunos NM, Bellomo R, Hegarty C, et al. Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. JAMA 2012; 308:1566.
- Yunos NM, Bellomo R, Glassford N, et al. Chloride-liberal vs. chloride-restrictive intravenous fluid administration and acute kidney injury: an extended analysis. Intensive Care Med 2015; 41:257.
- Waikar SS, Winkelmayer WC. Saving the kidneys by sparing intravenous chloride? JAMA 2012; 308:1583.