Q1: With two words, identify the specific type of hypovolemic shock in this patient.
Hemorrhagic shock.
Q2: Based on the patient’s clinical manifestations, approximately how much of her total blood volume has been lost?
The patient has a heart rate of 128 bpm and a respiratory rate of 37 (Bruyere, 2012) . Her blood pressure is significantly reduced (80/55) and her capillary refill is markedly delayed (7-8 seconds) (Bruyere, 2012) . The patient also presents with confusion and diaphoresis. These manifestations are thus typical of class III blood loss in which patients are deemed to have lost about thirty to forty percent of their total blood volume (Pascual & Cannon, 2017) .
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Q3: How many units of whole blood are minimally required?
The patient has a hematocrit of twenty-five percent (Bruyere, 2012) . In hemorrhagic shock, one of the treatment goals entails the maintenance of hematocrit above thirty percent. Based on this goal, it is evident that the patient has a deficit of five percent. Literature suggests that one unit of whole blood or packed red blood cells results in a three-percent increase of hematocrit in adults (Pascual & Cannon, 2017) . Accordingly, the patient would require at least two units of whole blood to restore her hematocrit to appropriate levels.
Q4: Is it necessary that sodium bicarbonate be administered to the patient at this time?
The administration of sodium bicarbonate at this stage would be unwarranted since the patient’s arterial pH is 7.31. Sodium bicarbonate should only be used in cases where the pH is less than 7.20 (Pascual & Cannon, 2017) .
Q5: Are arterial blood gas results improving or deteriorating?
The patient’s ABG results are improving. Her partial pressure of oxygen has increased to 82 mmHg from 53 mmHg while that of carbon IV oxide has decreased to 38 mmHg from 52 mmHg (Bruyere, 2012) . Additionally, the patient’s oxygen saturation has improved form 84 percent on room air to 95% percent on the three liters of oxygen administered (Bruyere, 2012) .
Q6: Based on urine output rate, in which class of hypovolemic shock can the patient be categorized at this time?
On catheterization, 180 ml of urine was obtained. However, only 14 ml of urine was obtained over the next hour (Bruyere, 2012) . These urine output values are indicative of class III hypovolemic shock in which urine outputs of 5 to 20 ml/hour are recorded (Pascual & Cannon, 2017) .
Q7: Explain the pathophysiology of the abnormal BUN and Cr.
The reduced cardiac output associated with hypovolemic shock results in reduced renal perfusion and hence acute kidney injury. Consequently, there is reduced glomerular filtration rate and a derangement of blood urea and nitrogen, and creatinine levels. (Pascual & Cannon, 2017) .
Q8: Does the patient have a blood clotting problem?
The patient does not appear to a clotting problem as the PT and aPTT are within normal ranges (Bruyere, 2012) .
Q9: Explain the pathophysiology of the abnormal serum glucose concentration.
Studies have established a link between acute injury and hyperglycemia. In trauma, it has been hypothesized that the sympatho-adrenal system is activated as a stress response (Clemmer, Xiang, Lu, Mittwede, & Hester, 2014) . This causes an increase in plasma levels of glucocorticoids and catecholamines which trigger hyperglycemia, glucose intolerance, and insulin resistance (Marik & Bellomo, 2013) .
Q10: Based on clinical signs after surgery, in which class of hypovolemic shock can the patient be categorized at this time?
Based on the patient’s vitals and urine output post-surgery, she can be categorized in class II which is typified by blood loss of about fifteen to thirty percent of the total blood volume and urine output of more than 20 ml/hour.
References
Bruyere, H. (2012). 100 Case Studies in Pathophysiology . New York: Lippincott Williams & Wilkins.
Clemmer, J. S., Xiang, L., Lu, S., Mittwede, P. N., & Hester, R. L. (2014). β2 -adrenergic regulation of stress hyperglycemia following hemorrhage in the obese Zucker rat. Physiological Reports , 2 (12), e12215. https://doi.org/10.14814/phy2.12215
Marik, P. E., & Bellomo, R. (2013). Stress hyperglycemia: an essential survival response! Critical Care , 17 (2), 305. https://doi.org/10.1186/cc12514
Pascual, J. L., & Cannon, J. W. (2017). Hemorrhagic shock: recognition, pathophysiology and management . New York: Nova Biomedical.
