CNA532 Anaesthetic & Recovery Nursing 1

Introduction

Hypovolemia is a severe condition that occurs when an individual loses one-fifth of his or her body’s blood or fluid supply. As a result, it becomes difficult for the heart to pump an adequate amount of blood to the body. Hypovolemia can result in the failure of organs in the body, and hence a patient suffering from it needs urgent medical attention. Children and the Old are more vulnerable to the disease. Firstly, Hypovolemia can occur. As a result internal bleeding, loss of blood from severe cuts or injuries attributed to accidents. Secondly, it can be caused by increased vaginal bleeding. Lastly, it may result due to loss of blood from the digestive tract. The loss of body fluids may occur due to increased sweating, high degree burns and excessive vomiting and diarrhea.

Blood plays a significant role in transporting oxygen as well as essential substances to the organs and tissues. In the event a person experiences increased bleeding, he or she lacks sufficient blood in the circulatory system for the heart to pump. When an individual loses essential substances in the body at a high rate than it can be replaced, vital organs seize to function, and the symptoms of shock appear which it makes a life-threatening condition. The mild symptoms of Hypovolemia include nausea, headache, fatigue, dizziness, and increased sweating. Severe symptoms include high heart rate, pale skin, weakness, rapid breathing, weak pulse, loss of consciousness, blue fingernails and lips, confusion and lightheadedness (Jensen, Brabrand, Vinholt, Hallas and Lassen, 2015, pp.60-67).

Marti et al. (2014, pp.46-51) conducted a retrospective, cross-sectional study that involved all the patients who were given serum potassium in April 2008  and March 2011 in finding out the prevalence rate of hypokalemia. The study included patients with severe hypokalemia, and their charts were reviewed from the emergency section. The study found out that hypokalemia is a usual problem presented by patients in the emergency section. The results from the survey indicate that of the 43805 patients, 4826 had the disease. Fifty-three patients suffered from severe hypokalemia; twenty-six patients had muscle pain and weakness while twenty patients showed had changes in electrocardiogram with the existence of a U wave accompanied by ventricular extrasystoles and ST segment. The fact there are high prevalence rates indicates that more research should be conducted to ensure that there are effective preventive and treatment methods to save a life.

Interventional Management

Patient Positioning

An American physiologist called Freidrich Trendelenburg invented Trendelenburg position. Although different studies indicate that this position is not sufficient enough, it stills remains the most common position to use. This position entails putting the head down, and the legs elevated. This position aims at increasing the movement of fluids in the circulatory system and increasing the functioning of the heart. The Trendelenburg position involves laying the patient flat on his or her back while lifting his or feet at a higher place than that of the head by 15-30 degrees and hence ensuring sufficient flow to the brain (Frost,  Mortensen,  Secher and Nielsen, 2017, pp.314-316).

Sing, O’Hara, Sawyer, and Marino (2014, pp.564-567) performed a prospective, self-controlled sequential design on eight post-operative patients indicating that high pressure that results from Trendelenburg position does not lead to the increase in the blood flow or the oxygenation of the tissues. The pulmonary artery wedge pressure was used to check for hypovolemia, and both the measurements for the Hemodynamic and oxygen transport variables were taken while the patient was lying down after the patient was placed in the Trendelenburg position. The results from the study indicate that there was an increase in both the arterial blood pressure and the pulmonary artery wedge pressure. However, the oxygen use, oxygen delivery, and the cardiac index did not change.

Herff (2017, pp.10-14) conducted a study with the use of five articles obtained from a search strategy in Medline and Embase databases searched via OvidSP interface in June 2010 to explain the cardiovascular effect of positioning the patients with the head facing down with a problematic vascular system. The studies included a little number of patients who were suffering from hypotension as a result of different causes, and all have some methodological faults. All the studies have one thing in common that is, lack of indicating the advantage of the Trendelenburg position on the cardiac output of the patients. There is some intimation that it may have an adverse effect that is clear on taking back the patient to a supine position. However, some studies indicate that this position is the most effective in treating hypovolemia. For instance, Sun (2015, pp1758-1759) asserts that merely raising a patients legs can help in neurogenic and cardiogenic shock while the Trendelenburg position can help treat hypovolemic shock.

A study conducted by Pickett, Bridges, Kritek, and Whitney (2017, pp.32-47) evaluates the effectiveness of the PLR position. This position is critical in helping the Nurses identify the patients that need intravenous fluids in hypovolemia. A non-systematic review was conducted, and the PubMed and Medline databases were used. The keywords used in the search include shock, blood flow, fluid responsiveness, and stroke volume. The results indicate that the PLR is a perfect indicator of a patient’s response to intravenous fluids since the blood flow is directed out of the lower limbs as well as the abdomen.  This results in high right and left cardiac autotransfusion and as a result, increasing the cardiac output and stroke volume.

PLR is essential since it has the potential of increasing the blood flow of around 300ml from the lower limbs and can improve further if the patient is placed in a semi-sitting position because it also ensures blood flow in the abdominal region. The hemodynamic effect of using the PLR position increases in the semi-sitting position as opposed to the supine one. Cardiac index rises more in the semi-sitting position than the supine position. This is because blood is assembled from the splanchnic compartment (He and Liu, 2013, pp.1668-1668).

Research done by Gok, Sarkilar, Kilicaslan, Yosunkaya, and Uzun (2015 p.19037) indicates that hypovolemia is a standard clinical issue. Both Trendelenburg position and Passive leg raising referred to as PLR is undertaken in the primary treatment while anticipating fluid resuscitation. In this study, the hemodynamic outcome of Trendelenburg and PLR were evaluated to establish which position has the most suitable result for the Cardiac output of the patient. Prospective studies between the year 1960 and 2010 in both hypovolemic and normovolemic patients to find out the hemodynamic outcome in an estimated 10minutes of a change in posture from the supine position. 13 studies (n=246) were used for Trendelenburg position and 21 studies (n=431) for PLR position. There was an increase in the mean arterial pressure from the Trendelenburg position.

There was an increase in 9% in the cardiac output in one minute of placing the patient laying down with the head tilted. In a range of 2 and 10minutes, the cardiac output decreased to4 5% from the baseline. Cardiac output increased with 6% during one minute of the elevation of the leg of the patient. The effect continued after this period of 0.17litres per min. Trendelenburg and PLR position resulted in a rise in the cardiac output, but the effect was prolonged after one minute in the Passive Leg Raising position. Although the nurses and doctors commonly use the Trendelenburg position, PLR seems the best first intervention measure in the treatment of hypovolemia (Gok et al., 2015, p.19037).

Use of crystalloid or colloid infusions

In the recent years, there has been a change from the use of the static model that categorizes shock by the use of the percentage of the loss of blood volume the dynamic model that classifying shock by observing the response to the previous intravenous fluid resuscitation. This helps in comprehending the level of any present volume loss of blood and bleeding. Secondly, it helps identify if there is a need for surgery or blood transfusion and examine the likelihood of cases of non-hemorrhagic such as pericardial tamponade and tension pneumothorax that may result to lack of response (Mandal, 2016, p.54).

Nurses ensure that bleeding has stopped or is reduced while ensuring that the patient has sufficient oxygen delivery to the body tissues and hence reducing the likelihood of inflammation, the organ dysfunction, and hypoxia. This minimizes the application of interventions such as blood transfusion, fluid resuscitation, and vasopressors. Even though fluid resuscitation is the initial procedure in restring tissue perfusion, it continues to raise controversy regarding whether crystalloids and colloid should be utilized. Other questions that continue to be raised include the type of fluid resuscitation to be used and the best method of ensuring that the ideal way of ensuring that traumatic coagulopathy does not occur (Bouglé, Harrois & Duranteau, 2013, p.1).

A study conducted by Annane et al. (2013, pp. 1809-1817) on patients with hypovolemia in the intensive care unit regarding the use of either crystalloids and colloids did not cause a notable difference concerning 28-day mortality rates in the patients. A recent study conducted by the Cochrane meta-analysis did not show that colloids decrease the risk of mortality in comparison to resuscitation using crystalloids. Colloids are advantageous in that they can create a fast and long-lasting plasma expansion and can rapidly attain maximum circulation due to enhanced oncotic pressure (Alderson, 2010).

Although some published articles reveal certain advantages over some intravenous and new evidence of possible harm to the critically ill individuals, the colloidal fluids continue to be the choice of a majority of Nurses and doctors in perioperative fluid therapy. Polygeline has an effect of an estimated 2-3 hours inside the intravascular vessel. A considerable amount of gelatin improves intracellular edema as a consequence of reduced plasma osmolality due to the decrease in the concentration of chlorine in the solvent (Alvis-Miranda, Castellar-Leones, and Moscote-Salazar, 2014, p.3).

Additionally, the increased renal elimination of gelatins can intensify diuresis that needs to be refilled with enough crystalloid infusion to ensure that dehydration does not occur. Gelatin infusion can also lead to an increase in the viscosity of the blood and accelerate red blood cell aggregation. Current research shows that an acceleration in acute kidney injury and the utilization of renal replacement therapy is related to the use of hydroxyethyl starch (Zarychanski et al., 2013, pp.678-688). Even though there is the lack of sufficient evidence and the likelihood for dose-related adverse effects, the use of gelatin and HES ought to be avoided (Haase et al., 2013, p.f839).

Research indicates that the adverse health effects of the colloids as resuscitation fluids. Saline (0.9% NaCl), is often used for fluid resuscitation as it is cheap to purchase. However, using huge volumes of crystalloids that are rich in chlorine in the treatment of trauma and perioperative patients can result to hyperchloremic metabolic acidosis which may lead to an increase in the acute kidney injury due to reduced blood flow in the renal system and renal cortical hyperfusion. The use of balanced salt suspensions does not cause adverse effects to patients (Young et al., 2015), pp.1701-1710).

Majority of resuscitation fluids have the potential of resulting to interstitial edema mainly under medical situations where the fluids are used exceedingly. Resuscitation with the use of crystalloid solution requires a higher volume and can lead to tissue edema as well as abdominal compartment syndrome (Kwan, Bunn, Chinnock and Roberts, 2014). Current evidence indicates that there is no existence of perfect resuscitation fluid. Therefore, it is essential for the Nurse to check the patient’s reaction to the volume infusion (Eastwood et al., 2016).

The use of fluid resuscitation approach results in poor outcome compared to the goal-directed method. Selecting the fluid to aid in the resuscitation of patients is often a hard decision for the Medics to make in both the anesthesia and critical care setting. The type of fluid chosen by the medic hugely depends on his or her preference. There is need to develop a new kind of fluids that can aid in increased oxygen- carrying ability by the aid of hemoglobin-based oxygen carriers) with more attention on decreasing the pro-inflammatory outcomes of fluids (Myburgh and Mythen, 2013, pp.1243-1251).

Singh & Ali (2016), conducted a study on how efficient and safe polygeline is in the treatment in hypovolemia caused as a result of a traumatic injury indicates that the drug is safe and efficient in rectifying hemodynamic instability. The use of the drug led to a timely and notable improvement in the hemodynamic parameters. The study was a non-comparative study on adult patients suffering from hypovolemia as a result of traumatic injury administered with polygeline. Efficacy was assessed by taking note of the variation in the signs and symptoms of hypovolemia. Safety, on the other hand, was evaluated by noting the occurrence of adverse events. Polygeline drug is obtained degraded gelatin and is currently used in India in patients with hypovolemia a consequence of trauma. The drug has a half-life of an estimated 2-6 hours which can be higher in patients suffering from renal impairment. There are limited data concerning the use of polygeline in the treatment of patients with hypovolemia as a result of the fracture of the long bone (Singh, Ali, and Shetty, 2017, p.116).

In the study, the males with a mean age of 33.67 years were the most affected by none fractures. The patients with hypovolemia as a result of long bone fracture showed positive changes after the intravenous administration of polygeline. Generally, the drug resulted in an improvement in skin changes, dry tongue, and pallor. The increase in blood pressure and heart rate was related to the advancement in signs such as dehydration of the skin and tongue and hence showing that there was an advancement in the hemodynamic stability as a result of correcting hypovolemia (Shah, Singh, Kala and Shetty, 2018, pp.1432-1437). The heart rate and blood pressure improvement occurred after an hour. Approximately 90% of the patients acquired other intravenous fluids. However, the likelihood of the adverse effects of the treatment should be examined (Singh & Ali, 2016)

Possible medications

The initial treatment of hypovolemia includes the replacement of both fluid and blood. Some secondary drugs can also be used. In the event the patient is in too much pain or suffering, the doctor can administer a painkiller such as morphine to reduce the pain. The drug works by preventing the pain signals from moving along the nerves to the brain. The side effects that may arise from the medicine include lack of sleep, constipation and feeling ill. Morphine cannot be used in treating expectant mothers, patients who have an injury on the head, patients with adrenal gland problems, minimum thyroid levels, and kidney or liver issues. Morphine has a potential of causing pain if administered in high doses. Vasopressin can also be used under certain circumstances to reduce internal hemorrhaging. The treatment has enormous risks due to the potential effects it has on the heart. Drugs such as octreotide and somatostatin can help in decreasing gastrointestinal hemorrhaging. Some stimulants like epinephrine and dopamine can be used to elevate the heartbeat.

In conclusion, the primary goals after the first contact with a hypovolemic patient include ensuring sufficient oxygen delivery that is by improving ventilation, elevating the oxygen saturation of the patients’ blood and bringing back the patient’s blood flow. The second goal is ensuring that there is no further loss of blood while the third goal is restoring the fluid. Also, it is also important to determine the patient’s disposition as quickly as possible. The high prevalence of hypovolemia shows that this is a common problem and hence more research needs to be undertaken to identify the prevention measures and timely treatment to help reduce mortality that results from the disease.

References

Alderson, 2010. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database of Systematic Reviews.

Alvis-Miranda, H.R., Castellar-Leones, S.M. and Moscote-Salazar, L.R., 2014. Intravenous fluid therapy in traumatic brain injury and decompressive craniectomy. Bulletin of Emergency & Trauma, 2(1), p.3.

Annane, D., Siami, S., Jaber, S., Martin, C., Elatrous, S., Declère, A.D., Preiser, J.C., Outin, H., Troché, G., Charpentier, C. and Trouillet, J.L., 2013. Effects of fluid resuscitation with colloids vs crystalloids on mortality in critically ill patients presenting with hypovolemic shock: the CRISTAL randomized trial. Jama, 310(17), pp.1809-1817.

Bouglé, A., Harrois, A. & Duranteau, J., 2013. Resuscitative strategies in traumatic hemorrhagic shock. Annals of Intensive Care, 3(1), p.1.

Eastwood, G.M., Parke, R., Peck, L., Young, H., Paton, E., Zhang, L., Zhu, G., Tanaka, A., Glassford, N.J. and Bellomo, R., 2016. Intravenous fluid bolus therapy: a bi-national survey of critical care nurses’ self-reported practice. Anaesthesia & Intensive Care, 44(1).

Frost, H., Mortensen, C.R., Secher, N.H. and Nielsen, H.B., 2017. Postoperative volume balance: does stroke volume increase in Trendelenburg’s position?. Clinical physiology and functional imaging, 37(3), pp.314-316.

Gok, F., Sarkilar, G., Kilicaslan, A., Yosunkaya, A. and Uzun, S.T., 2015. Comparison of the effect of the Trendelenburg and passive leg raising positions on internal jugular vein size in critically ill patients. International journal of clinical and experimental medicine, 8(10), p.19037.

Haase, N., Perner, A., Hennings, L.I., Siegemund, M., Lauridsen, B., Wetterslev, M. and Wetterslev, J., 2013. Hydroxyethyl starch 130/0.38-0.45 versus crystalloid or albumin in patients with sepsis: systematic review with meta-analysis and trial sequential analysis. Bmj, 346, p.f839.

He, H.W. and Liu, D.W., 2013. Passive leg raising: influence of blood pressure transducer site. Intensive care medicine, 39(9), pp.1668-1668.

Herff, H., 2010. Influence of Ventilation Strategies on Hemodynamics in Hypovolemic Shock. Applied Technologies in Pulmonary Medicine, pp.10–14.

Jensen, H.K., Brabrand, M., Vinholt, P.J., Hallas, J. and Lassen, A.T., 2015. Hypokalemia in acute medical patients: risk factors and prognosis. The American journal of medicine, 128(1), pp.60-67.

Kwan, I., Bunn, F., Chinnock, P. and Roberts, I., 2014. Timing and volume of fluid administration for patients with bleeding. Cochrane database of systematic reviews, (3).

Mandal, M., 2016. Ideal resuscitation fluid in hypovolemia: The quest is on and miles to go!. International journal of critical illness and injury science, 6(2), p.54.

Marti, G., Schwarz, C., Leichtle, A.B., Fiedler, G.M., Arampatzis, S., Exadaktylos, A.K. and Lindner, G., 2014. Etiology and symptoms of severe hypokalemia in emergency department patients. European journal of emergency medicine, 21(1), pp.46-51.

Myburgh, J.A. and Mythen, M.G., 2013. Resuscitation fluids. New England Journal of Medicine, 369(13), pp.1243-1251.

Pickett, J.D., Bridges, E., Kritek, P.A. and Whitney, J.D., 2017. Passive Leg-Raising and Prediction of Fluid Responsiveness: Systematic Review. Critical care nurse, 37(2), pp.32-47.

Shah, S., Singh, A., Kala, S. and Shetty, R., 2018. Polygeline in patients with hypovolemia caused by accidental trauma: a prospective, multicentric, safety study. International Surgery Journal, 5(4), pp.1432-1437.

Sing, R.F., O’Hara, D., Sawyer, M.A. and Marino, P.L., 2014. Trendelenburg position and oxygen transport in hypovolemic adults. Annals of emergency medicine, 23(3), pp.564-567.

Singh, A. & Ali, S., 2016. Current neurology and neuroscience reports. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4795357/ [Accessed September 27, 2018].

Singh, A., Ali, S. and Shetty, R., 2017. Effectiveness and safety of polygeline in patients with hypovolemia due to trauma. Journal of emergencies, trauma, and shock, 10(3), p.116.

Sun, R.L., 2015. Trendelenburg?s Position in Hypovolemic Shock. AJN, American Journal of Nursing, 71(9), pp.1758–1759.

Young, P., Bailey, M., Beasley, R., Henderson, S., Mackle, D., McArthur, C., McGuinness, S., Mehrtens, J., Myburgh, J., Psirides, A. and Reddy, S., 2015. Effect of a buffered crystalloid solution vs saline on acute kidney injury among patients in the intensive care unit: the SPLIT randomized clinical trial. Jama, 314(16), pp.1701-1710.

Zarychanski, R., Abou-Setta, A.M., Turgeon, A.F., Houston, B.L., McIntyre, L., Marshall, J.C. and Fergusson, D.A., 2013. Association of hydroxyethyl starch administration with mortality and acute kidney injury in critically ill patients requiring volume resuscitation: a systematic review and meta-analysis. Jama, 309(7), pp.678-688.