Preventing hypovolemic shock

Edward Sandler, age 83, is admitted to the hospital with abdominal pain and GI bleeding. He’s scheduled for a colonoscopy later in the day.

History and assessment hints
When you enter Mr. Sandler’s room, he’s pale, diapho­ret­ic, and lethargic. He can answer simple questions and is oriented to person and place. His blood pressure is 58/30 mm Hg; his pulse rate, 60 beats/minute; and his respiratory rate, 28 breaths/minute. His baseline pulse rate is 65 beats/minute, and his baseline blood pressure is 128/68 mm Hg.

You note a large amount of bloody liquid stool in the bedside commode and suspect that his low blood pressure results from hypovolemia. As you monitor his blood pressure, you place him in a supine position and elevate his legs 45 degrees to improve venous return.

Call for help
Next, you activate the rapid response team (RRT) and have Mr. Sandler’s attending physician notified, while you stay with the patient and continue monitoring his vital signs. The RRT, which includes an intensive care unit (ICU) nurse and a respiratory therapist, arrives in 3 minutes. You give the nurse a brief patient history, and she requests a noninvasive blood pressure machine for frequent monitoring. The respiratory therapist begins by obtaining an oxygen saturation (SaO2) reading.

On the scene
Five minutes after the RRT arrives, Mr. Sandler’s blood pressure is 76/50 mm Hg; his pulse, 80 beats/minute; and his respiratory rate, 24 breaths/minute. His SaO2 is 88%, so the respiratory therapist administers oxygen at 2 L/minute via nasal cannula. The ICU nurse asks for stat hemoglobin and hematocrit measurements. To increase fluid volume, the nurse starts administering 1 L of sterile normal saline solution I.V.

The attending physician arrives and agrees with the RRT’s assessment and interventions. After 250 mL of the saline solution infuses, Mr. Sandler’s blood pressure is 91/53 mm Hg, and his pulse rate is 72 beats/minute. But he begins complaining about abdominal pain and asks for a bedpan. Then he expels 300 mL of bloody liquid stool with dark red clots.

The hemoglobin and hematocrit results are 8.2 mg/dL and 28%, respectively. The physician orders another 250 mL of normal saline solution and one unit of packed red blood cells. The patient’s blood pressure increases to 104/51 mm Hg, his pulse rate reaches 74 beats/minute, and he says he feels better. When the blood arrives from the blood bank, the ICU nurse inserts another I.V. line, and you begin the transfusion.

About 10 minutes after the blood transfusion begins, Mr. Sandler’s blood pressure is 113/63 mm Hg, and his pulse rate is 67 beats/minute. The abdominal pain and bloody stools stop.

The physician orders frequent assessments for the next hour and repeat hemoglobin and hematocrit measurements after the transfusion. You monitor the patient’s SaO2 continuously and vital signs every 15 minutes. An indwelling urinary catheter is placed to monitor urine output. About 1 hour after the transfusion, his vital signs are back to baseline, and his SaO2 is 94% on 2 L/minute of oxygen.

Education and follow-up
Later, you explain to Mr. Sandler that he experienced hypovolemia, a decrease in circulating blood volume caused by his loss of blood and diarrhea. A loss of one-fifth of normal blood volume produces hypovolemic shock, which can trigger life-threatening cellular dysfunction. But Mr. Sandler was lucky. He had a nurse who recognized hypovolemia early and responded before his condition became life-threatening.

Rosanne Mattiace is the Manager, Patient Care of the Intensive Care Unit, Cardiovascular Surgical Unit, Cardiac Rehab and Respiratory Therapy Department, of Susquehanna Health in Williamsport, Pennsylvania.

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