Hemorrhagic shock: treatment

Treatment of hemorrhagic shock is an extremely important task, for the solution of which the gynecologist should join forces with an anesthesiologist-resuscitator, and, if necessary, involve a hematologist-coagulologist.

To ensure the success of therapy should be guided by the following rule: treatment should begin as early as possible, be comprehensive, conducted taking into account the cause that caused bleeding, and the state of health of the patient that preceded him.

The complex of therapeutic measures includes the following:

1. Gynecological operations to stop bleeding.
2. Provision of anesthesia.
3. Immediate removal of the patient from a state of shock.

All listed activities should be carried out in parallel, clearly and quickly.

Perform operations quickly with adequate anesthesia. The scope of surgical intervention should provide reliable hemostasis. If you need to remove the uterus to stop the bleeding, then it should not be a mild one. Thoughts about the possibility to keep menstrual or reproductive functions in young women should not hamper the actions of the doctor. On the other hand, when the patient is in serious condition, the amount of surgery can not be unnecessarily increased. In the threatening state of the patient, surgical intervention is performed in 3 stages:

1. abdominal hemorrhage, stopping bleeding;
2. resuscitation measures;
3. continuation of the operation.

The end of the operative intervention for local hemostasis does not mean the simultaneous termination of anesthesia and mechanical ventilation, which are essential components in the ongoing complex therapy of shock, contributing to the elimination of a mixed form of acidosis.

One of the main methods of treating hemorrhagic shock is infusion-transfusion therapy, aimed at:

1. Replenishment of bcc and elimination of hypovolemia.
2. Increase in oxygen capacity of blood.
3. Normalization of rheological properties of blood and elimination of microcirculation disorders.
4. Biochemical and colloid osmotic correction of blood.
5. Elimination of acute coagulation disorders.

For the successful implementation of infusion-transfusion therapy in order to replenish BCC and restore tissue perfusion it is important to take into account the quantitative ratio of media, volumetric rate and duration of infusion.

The question of the number of infusion media necessary to excrete a patient from a hemorrhagic shock condition is not simple. Tentatively, it is decided on the basis of an estimate of recorded blood loss and clinical examination data. Taking into account the deposition and sequestration of blood in shock, the volume of fluids to be injected should exceed the estimated blood loss: with a blood loss of 1000 ml, 1.5 times; at a loss equal to 1500 ml, - 2 times; with a more massive blood loss - 2.5 times. The earlier the compensation for blood loss begins, the less liquid the stabilization of the state can be achieved. Usually, the effect of treatment is more favorable if about 70% of the lost volume is replenished in the first 1-2 hours.

More accurately, it is possible to judge the necessary amount of media to be administered during the therapy on the basis of an assessment of the state of the central and peripheral blood circulation. Sufficiently simple and informative criteria are the color and temperature of the skin, pulse, blood pressure, shock index, CVP and hourly diuresis.

The choice of infusion media depends on the volume of blood loss and the pathophysiological response of the patient's body to it. B. Their composition necessarily includes colloidal, crystalloid solutions and components of donor blood.

Taking into account the enormous importance of the time factor for successful treatment of hemorrhagic shock, at the initial stage of therapy it is necessary to use always available colloidal solutions with sufficiently high osmotic and oncotic activity. Such a preparation is polyglucin. Drawing fluid into the bloodstream, these solutions help mobilize the compensatory capabilities of the body and thus give time to prepare for subsequent blood transfusion, which must be started as soon as possible, but with the compulsory observance of all rules and regulations.

Preserved blood and its components (erythrocytic mass) remain the most important infusion media in the treatment of hemorrhagic shock, since at present only with their help it is possible to restore the disturbed oxygen transport function of the organism.

With massive hemorrhage (hematocrit index - 0.2 l / l, hemoglobin - 80 g / l), the globular volume of blood sharply decreases, which must be replenished, preferably using erythrocyte mass or erythrocyte suspension. It is permissible to transfuse fresh canned blood (up to 3 days storage), heated to 37 ° C.

Currently, they recommend replenishing 60% of blood loss with donor blood. In the process of continuous treatment should not pour more than 3,000 ml of blood because of the possibility of developing a syndrome of massive transfusion or homologous blood.

To comply with the regimen of hemodilution, hemotransfusion should be combined with the introduction of colloidal and crystalloid solutions in a ratio of 1: 1 or 1: 2. For hemodilution purposes, any solutions available to the physician can be used, using their qualitative characteristics in the desired direction. The blood-substituting solutions improve the rheological properties of the blood, reduce the aggregation of the formed elements and thereby return the deposited blood to the active circulation, improve the peripheral circulation. Similar properties are mostly possessed by preparations made on the basis of dextrans: polyglucin and reopolyglucin. Excess fluid is removed by forcing diuresis.

Adequate treatment of hemorrhagic shock requires not only a large number of infusion media, but also a significant rate of their introduction, the so-called volumetric infusion rate. In severe hemorrhagic shock, the volume infusion rate should correspond to 250-500 ml / min. II stage of shock requires infusion at a rate of 100-200 ml / min. This speed can be achieved either by jetting solutions into several peripheral veins, or by catheterization of the central veins. Rationally, to gain time, begin infusion by puncture the ulnar vein and immediately proceed to catheterize a large vein, a bowl of subclavian. The presence of a catheter in a large vein makes it possible to perform infusion-transfusion therapy for a long time.

The rate of liquid infusion, the choice of the ratio of the amount of injected blood, its components and blood substitutes, the elimination of excess fluid should be carried out under constant control of the patient's general condition (color and temperature of the skin, pulse, blood pressure, hourly diuresis), based on hematocrit, , CBS, ECG. The duration of the infusion therapy should be strictly individualized.

With the stabilization of the patient's condition, manifested in the disappearance of cyanosis, sharp pallor and sweating of the skin, restoration of blood pressure (systolic not lower than 11.79 kPa or 90 mm Hg) and normalization of pulse filling, disappearance of dyspnea, the hourly diuresis no less than 30-50 ml without its boosting, an increase in the hematocrit to 30% (0.3 l / l), you can proceed to the dropwise introduction of erythrocyte mass and liquid in a ratio of 2: 1, 3: 1. Drip administration of solutions should continue a day or more until the complete stabilization of all parameters of hemodynamics.

Metabolic acidosis accompanying hemorrhagic shock is usually correlated by dropwise intravenous injection of 150-200 ml of 4-5% sodium bicarbonate solution, in severe cases - by infusing 500 ml of a 3.6% solution of trihydroxymethyl-aminomethane (trisbuffer).

To improve oxidation-reduction processes, 200-300 ml of 10% glucose solution with adequate amounts of insulin (per 4 g of pure glucose substance 1 ED of insulin), 100 mg of cocarboxylase, vitamins of group B and C are shown.

After the elimination of hypovolemia against the background of improving the rheological properties of blood, an important component of normalizing microcirculation is the use of drugs that remove peripheral vasoconstriction. A good effect is the introduction of a 0.5% solution of novocaine in an amount of 150-200 ml with 20% glucose solution or other infusion media in a ratio of 1: 1 or 2: 1. Constriction of peripheral vessels can be eliminated by the introduction of spasmolytic drugs: papaverine hydrochloride (2% solution - 2 ml), no-spikes (2% solution - 2-4 ml), euphyllin (2.4% solution - 5-10 ml) ilch ganglioblokatorov type pentamine (0,5-I ml 0,5% solution drip with isotonic sodium chloride solution) and benzohexonium (1 ml 2.5% solution drip).

In order to reduce the resistance of the renal vessels and increase blood flow in them, it is possible to administer dopamine (dopamine, dopmin) as early and as long as possible: 25 mg of the drug (5 ml of 0.5% solution) is diluted in 125 mg of 5% glucose solution and poured intravenously at a rate 5-10 cap / min. The daily dose is 200-400 mg. To improve renal blood flow, a 10% solution of mannitol in an amount of 150-200 ml or sorbitol in an amount of 400 ml is indicated. For a quick diuretic effect, the mannitol solution is poured in at a rate of 80-100 cap / min. The introduction of all these means must be carried out under mandatory control of blood pressure, CVP and diuresis. If necessary, in addition to osmodiuretics saluretics are appointed - 40-60 mg of lasix.

Do not forget about the introduction of antihistamines: 2 ml of a 1% solution of dimedrol, 2 ml of a 2.5% solution of dilrazine (pispolphep) or 2 ml of a 2% solution of suprastin, which not only have a positive effect on metabolic processes, but also contribute to the normalization of microcirculation. An important component in treatment is the introduction of significant doses of corticosteroids, which improve the contractile function of the myocardium and exert an effect on the tone of peripheral vessels. A single dose of hydrocortisone - 125-250 mg, prednisalone - 30-50 mg; daily dose of hydrocortisone - 1-1.5 g. Cardiac funds are included in the complex of shock therapy after sufficient replenishment of BCC. Most often, 0.5-1 ml of a 0.5% solution of strophanthin or 1 ml of a 0.06% solution of Korglikona with 10-20 ml of a 40% solution of glucose is most often used.

Violations of the blood coagulation system accompanying the development of hemorrhagic shock should be corrected under the control of the coagulogram due to a significant variety of these disorders. Thus, during I and II stages of shock, there is an increase in the coagulation properties of the blood. In stage III (sometimes with II), consumption coagulopathy can develop with a sharp decrease in the content of procoagulants and with pronounced activation of fibrinolysis. The use of infusion solutions, devoid of coagulation factors and platelets, leads to an increasing loss of these factors, the level of which is reduced and as a result of bleeding. Thus, along with consumption coagulopathy, hemorrhagic shock is complicated by deficiency coagulopathy.

In view of what has been said, it is necessary to restore the coagulation capacity of blood by introducing the missing procoagulants with "warm" or "freshly citrated" blood, dry or native plasma, antihemophilic plasma, fibrinogen preparations or cryolrecipitate. If it is necessary to neutralize thrombin, an anticoagulant of direct action, heparin, can be used, fibrinolysis can be reduced by antifibrinolytic drugs: countercrital or gordox. Treatment of the DIC syndrome is performed under the control of a coagulogram.

As noted earlier, the time factor in the treatment of hemorrhagic shock is often decisive. The earlier treatment begins, the less effort and money is required to remove the patient from a shock condition, the better is the immediate and long-term prognosis. So, for-therapy compensated shock is sufficient to restore the volume of blood, to prevent acute renal failure (ARF), in some cases - to normalize CBS. In the treatment of decompensated reversible shock, it is required to use the entire arsenal of therapeutic measures. With the therapy of stage III shock, the maximum efforts of physicians are often unsuccessful.

Removal of a patient from a critical condition associated with hemorrhagic shock is the first stage of treatment. In the following days, therapy is continuing, aimed at eliminating the consequences of massive bleeding and preventing new complications. Medical actions in this period are directed to support the functions of the kidneys, liver and heart, to normalize water-salt and protein metabolism, increase globular volume of blood, prevent and treat anemia, prevent infections.

[1], [2], [3]