Hemorrhagic shock - Treatment

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

To ensure the success of therapy, it is necessary to follow the following rule: treatment should begin as early as possible, be comprehensive, and be carried out taking into account the cause of the bleeding and the patient’s health condition preceding it.

The complex of treatment measures includes the following:

1. Gynecological operations to stop bleeding.
2. Provision of anesthetic assistance.
3. Directly bringing the patient out of a state of shock.

All of the above activities must be carried out in parallel, clearly and quickly.

Operations must be performed quickly with adequate pain relief. The scope of the surgical intervention must ensure reliable hemostasis. If it is necessary to remove the uterus to stop bleeding, this should be done without delay. Thoughts about the possibility of preserving menstrual or reproductive functions in young women should not slow down the doctor's actions. On the other hand, if the patient's condition is serious, the scope of the operation should not be excessively expanded. If the patient's condition is threatening, the surgical intervention is performed in 3 stages:

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

The end of surgical intervention for the purpose of local hemostasis does not mean the simultaneous end of anesthesia and mechanical ventilation, which are the most important components in the ongoing complex therapy of shock, helping to eliminate the 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. Increasing the oxygen capacity of the blood.
3. Normalization of blood rheological properties and elimination of microcirculation disorders.
4. Biochemical and colloid osmotic blood correction.
5. Elimination of acute coagulation disorders.

For successful implementation of infusion-transfusion therapy with the aim of replenishing the BCC and restoring tissue perfusion, it is important to take into account the quantitative ratio of media, the volume rate and duration of infusion.

The question of the amount of infusion media required to bring the patient out of hemorrhagic shock is not simple. It is approximately decided on the basis of an assessment of the recorded blood loss and clinical examination data. Taking into account the deposition and sequestration of blood during shock, the volume of infused fluids should exceed the volume of the expected blood loss: with a blood loss of 1000 ml - 1.5 times; with a loss of 1500 ml - 2 times; with more massive blood loss - 2.5 times. The earlier the replacement of blood loss begins, the less fluid it is possible to achieve stabilization of the condition. Usually, the effect of treatment is more favorable if about 70% of the lost volume is replenished in the first 1-2 hours.

A more accurate assessment of the required amount of administered media can be made during therapy based on an assessment of the state of the central and peripheral circulation. Quite simple and informative criteria are the color and temperature of the skin, pulse, arterial pressure, shock index, central venous pressure, and hourly diuresis.

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

Considering the enormous importance of the time factor for successful treatment of hemorrhagic shock, at the initial stage of therapy it is necessary to use colloidal solutions with sufficiently high osmotic and oncotic activity that are always at hand. Polyglucin is such a drug. By attracting fluid into the bloodstream, these solutions help mobilize the body's compensatory capabilities and thus provide time to prepare for subsequent blood transfusion, which must be started as quickly as possible, but with mandatory compliance with all rules and instructions.

Preserved blood and its components (erythrocyte mass) remain the most important infusion media in the treatment of hemorrhagic shock, since at present only with their help can the impaired oxygen transport function of the body be restored.

In case of massive bleeding (hematocrit index - 0.2 l/l; hemoglobin - 80 g/l), the globular volume of blood decreases sharply and must be replenished, preferably using red blood cell mass or red blood cell suspension. Transfusion of fresh preserved blood (up to 3 days of storage), heated to 37 °C, is acceptable.

Currently, it is recommended to replace 60% of blood loss with donor blood. During continuous treatment, no more than 3000 ml of blood should be infused due to the possibility of developing massive transfusion syndrome or homologous blood.

To comply with the controlled hemodilution regime, blood transfusion must be combined with the introduction of colloid and crystalloid solutions in a ratio of 1:1 or 1:2. For the purposes of hemodilution, any solutions available to the physician can be used, using their quality characteristics in the desired direction. Blood substitute solutions improve the rheological properties of blood, reduce the aggregation of formed elements and thereby return the deposited blood to active circulation, improve peripheral circulation. Such properties are most often possessed by drugs made on the basis of dextrans: polyglucin and rheopolyglucin. Excess fluid is removed by forcing diuresis.

Adequate treatment of hemorrhagic shock requires not only a large amount of infusion media, but also a significant rate of their administration, the so-called volumetric infusion rate. In severe hemorrhagic shock, the volumetric infusion rate should be 250-500 ml/min. Stage II shock requires infusion at a rate of 100-200 ml/min. This rate can be achieved either by jet injection of solutions into several peripheral veins or by catheterization of central veins. It is rational to start infusion by puncture of the ulnar vein and immediately proceed to catheterization of a large vein, usually the subclavian, in order to gain time. The presence of a catheter in a large vein makes it possible to carry out infusion-transfusion therapy for a long time.

The rate of fluid infusion, the choice of the ratio of the amount of blood administered, its components and blood substitutes, the elimination of excess fluid should be carried out under constant monitoring of the general condition of the patient (color and temperature of the skin, pulse, arterial pressure, hourly diuresis), based on the assessment of hematocrit, CVP, acid-base balance, ECG. The duration of infusion therapy should be strictly individualized.

When the patient's condition stabilizes, which is expressed in the disappearance of cyanosis, severe pallor and sweating of the skin, restoration of arterial pressure (systolic not lower than 11.79 kPa, or 90 mm Hg) and normalization of pulse filling, disappearance of dyspnea, achievement of the hourly diuresis value of not less than 30-50 ml without forcing it, an increase in the hematocrit index to 30% (0.3 l/l), it is possible to proceed to the drip administration of red blood cell mass and fluid in a ratio of 2:1, 3:1. Drip administration of solutions should continue for a day or more until all hemodynamic indices are completely stabilized.

Metabolic acidosis accompanying hemorrhagic shock is usually correlated with intravenous drip administration of 150-200 ml of 4-5% sodium bicarbonate solution, in severe cases - infusion of 500 ml of 3.6% trihydroxymethylaminomethane (Trisbuffer) solution.

To improve oxidation-reduction processes, it is recommended to administer 200-300 ml of 10% glucose solution with adequate amounts of insulin (1 U of insulin per 4 g of pure glucose), 100 mg of cocarboxylase, and vitamins B and C.

After hypovolemia is eliminated against the background of improved rheological properties of blood, an important component of microcirculation normalization is the use of drugs that relieve peripheral vasoconstriction. A good effect is achieved by introducing 0.5% novocaine solution in an amount of 150-200 ml with 20% glucose solution or other infusion media in a ratio of 1:1 or 2:1. Peripheral vascular constriction can be eliminated by introducing antispasmodic drugs: papaverine hydrochloride (2% solution - 2 ml), no-shpa (2% solution - 2-4 ml), euphyllin (2.4% solution - 5-10 ml) or ganglion blockers such as pentamine (0.5-1 ml of 0.5% solution drip with isotonic sodium chloride solution) and benzohexonium (1 ml of 2.5% solution drip).

In order to reduce the resistance of the renal vessels and increase blood flow in them, it is necessary to administer dopamine (dopamine, dopmin) as early and for 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 infused intravenously at a rate of 5-10 drops/min. The daily dose is 200-400 mg. To improve renal blood flow, it is indicated to administer a 10% mannitol solution in an amount of 150-200 ml or sorbitol in an amount of 400 ml. For a rapid diuretic effect, the mannitol solution is infused at a rate of 80-100 drops/min. The administration of all these agents must be carried out under mandatory monitoring of arterial pressure, central venous pressure and diuresis. If necessary, in addition to osmotic diuretics, saluretics are prescribed - 40-60 mg of lasix.

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

Blood coagulation disorders accompanying the development of hemorrhagic shock must be corrected under the control of a coagulogram due to the significant diversity of these disorders. Thus, at stages I and II of shock, an increase in the coagulation properties of the blood is noted. At stage III (sometimes at stage II), consumption coagulopathy may 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 as a result of bleeding. Thus, along with consumption coagulopathy, hemorrhagic shock is complicated by deficiency coagulopathy.

Taking into account the above, it is necessary to restore the blood coagulation capacity by introducing the missing procoagulants with "warm" or "freshly citrated" blood, dry or native plasma, antihemophilic plasma, fibrinogen or cryol recipitate preparations. If it is necessary to neutralize thrombin, the direct-acting anticoagulant heparin can be used, and to reduce fibrinolysis, antifibrinolytic drugs: contrical or gordox. Treatment of DIC syndrome is carried out under the control of a coagulogram.

As noted earlier, the time factor in the treatment of hemorrhagic shock is often decisive. The earlier the treatment begins, the less effort and resources are required to bring the patient out of shock, the better the immediate and remote prognosis. Thus, for the treatment of compensated shock, it is sufficient to restore blood volume, prevent acute renal failure (ARF), and in some cases normalize acid-base balance. In the treatment of decompensated reversible shock, it is necessary to use the entire arsenal of therapeutic measures. In the treatment of stage III shock, the maximum efforts of doctors are often unsuccessful.

Removing the patient from a critical condition associated with hemorrhagic shock is the first stage of treatment. In the following days, therapy continues aimed at eliminating the consequences of massive bleeding and preventing new complications. Medical actions in this period are aimed at supporting the functions of the kidneys, liver and heart, normalizing water-salt and protein metabolism, increasing the globular volume of blood, preventing and treating anemia, and preventing infections.

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