hypovolemic shock

[katiebry1031]

ok we are doing the shock stages in nursing right now, and our instructor have us questions to work in and this is one i just cant get and its driving me crazy. i need some input.

The ICU nurse is caring for a patient in hypovolemic shock. What is a serious complication the nurse knows to monitor the patient for?

1.) anaphylaxis

2.) decreased o2 consumption

3.) abdominal compartment syndrome

4.) decreased serum osmolality

ok so i know that your 02 will actually increase not decrease bc in any forms of shock, its a decrease of 02 getting to the tissues so supplemental o2 is actually more necessary, as shock all ends up in decreased tissue perfusion. i am sure his needs for o2 consumption would actually increase. it cant be serum osmolality because of the fact that with hypovolemia you are actually dehydrated so that would mean you are given fluids to maintain your intake and your levels are increased when you have fluid overload. oh wait so does that mean if you are given NACL or LR solution, you could actually be given too much so that would monitor your serum osmolality to make sure you are not in fluid overload? that actually makes a little sense. i know that serum osmolality monitores your dehydration and monitors how much blood volume you have. decreased serum osmolality means overhydration increased means dehydration.

[ckh23, BSN, RN]

I'm going to say #2. You are on the right track with your rational for oxygen. The tissues will need more o2, but actual o2 consumption will be decreased because of hypo-perfusion. Tissue that is not being perfused is not getting the oxygen it needs and will begin anaerobic metabolism to continue cellular function. As less oxygen is being consumed by the tissues, you will see an increase in SVO2 and therefore decrease in oxygen consumption. That basically means there is decreased oxygen exchange on the cellular level so the o2 stays in the blood.

[nurseprnRN, BSN, RN]

... and that means trouble with a capital t! once your cells are sick enough or poorly perfused enough that they aren't able to suck any oxygen out of the blood, they're gonna start to die.

[Esme12, ASN, BSN, RN]

It's actually abdominal compartment syndrome.

Abdominal compartment syndrome is mainly a problem in post-surgical, trauma, and burn patients, and percutaneous decompression is a reasonable approach for patients not in hemorrhagic / hypovolemic shock (open surgical decompression achieves more rapid and definitive results). But occurs in septic and hypovolemic shock due to the enormous amount of fluids administered.

Compartment syndrome is well known in the extremities, where increased pressure within a closed fascial space depresses capillary perfusion pressure to a level that cannot maintain tissue viability. The effects of elevated intra abdominal pressure are less well recognized. Normally, the abdominal pressure is about 5 mm Hg. The intra abdominal pressure may increase with acute and substantial accumulation of fluid within the abdomen.

“Abdominal compartment syndrome” is defined as intra abdominal pressure of at least 20 mm Hg with dysfunction of at least one thoracoabdominal organ . In nearly all cases, there is some amelioration of organ function after decompressive laparotomy. Primary abdominal compartment syndrome results from injury or disease in the abdominopelvic region, such as after liver transplantation or pelvic fractures.

Secondary abdominal compartment syndrome occurs from disease originating from outside the abdomen, such as from major burns or sepsis or hypokalemia and fluid resuscitation.

http://www.ajronline.org/content/189/5/1037.full

For any concern for IAH(intra abdominal hypertension), transduce a bladder pressure. If IAH (>12 mm Hg) or ACS (>20 mm Hg + organ dysfunction) is present, there’s fluid in the belly, and the patient is not in shock, ask interventional radiology or GI to place a pigtail catheter (or do it yourself). Failure to drain 1,000 mL and reduce intra-abdominal pressure by 9 mm in the first 4 hours should prompt urgent re-evaluation for open surgical decompression.

Intra-abdominal hypertension (defined as a sustained urinary bladder pressure > 12 mm Hg) may be an under-recognized problem in the ICU, especially in patients after abdominal surgery or who have gone massive volume resuscitation with blood and/or fluids (think hemorrhage, burns and sepsis). When high abdominal pressures (> 20 mm Hg sustained) cause organ failure and/or shock, it’s called abdominal compartment syndrome.

Here is an excellent article/CEU for ACS and IAH.

http://ajcc.aacnjournals.org/content/12/4/367.full.pdf

[nurseprnRN, BSN, RN]

cool beans! thanks, esme!