Hypovolemic Shock and Massive Transfusion

Abstract

Hypovolemic shock occurs when the volume within the circulatory system becomes depleted to the extent that tissue perfusion becomes inadequate. In asanguineous hypovolemic shock, effective management is based on: establishing adequate intravenous or intraosseous access, administering fluids to replete the losses and improve cardiac output, monitoring fluid responsiveness, and tracking endpoints of resuscitation. Further study is needed to clarify: which crystalloid (normal saline vs balanced solution) is superior in certain instances, whether there is a role for albumin in hypovolemic shock subtypes, and what is the ideal timing and agent of pressors when shock persists despite fluid administration.

Hemorrhagic shock more specifically refers to hypovolemic shock secondary to acute blood loss. Principles of management incorporate those described above for asanguineous losses but further include: expedited anatomic control of bleeding, damage control surgery if operative intervention is indicated, and transfusion of blood products utilizing institutional massive transfusion algorithms, permissive hypotension, correction and reversal of factors augmenting shock, minimizing crystalloid administration, and administering antifibrinolytics when indicated. The ideal transfusion ratio of red blood cells: fresh frozen plasma : platelets to best approximate whole blood remains an area of active research, though evidence for a 1:1:1 ratio continues to accumulate. Point-of-care monitoring of the hemostatic system is becoming more accurate and easily implemented and can enable goal-directed transfusion after initial stabilization. Finally, underlying comorbidities and associated injuries should be considered when determining hemodynamic goals of resuscitation; however, existing recommendations (i.e. target blood pressure in head injury) are based off expert consensus in the absence of randomized control trials.