RNSG 1341 Module:
Postoperative shock and hemorrhage
In the immediate postoperative period shock can occur usually from low circulating
blood volume. This may be from hemorrhage in the operating room or postoperatively.
More commonly it is from fluid shifts out of the vascular bed. The patient has been given
large volumes of fluid in the OR, but the fluid has left the vascular space.
The patient experiences a downward trend in the blood pressure with an increase in the
heart rate, in an attempt to compensate the diastolic pressure may raise as the systolic
prssure is dropping. You can look for a sudden drop of the systolic after seeing the rise in
diastolic pressure. Initially the heart rate increases; after the cardiac output becomes so
low that there is an oxygen deficit to cardiac muscle the pulse will drop as the condition
becomes worse. The urine output declines because of inadequate circulation to the
kidneys. The usual treatment is to give a bolus of normal saline (200 cc over 15 to 30
minutes) which usually brings the blood pressure up and increases urinary output.
Normal saline is used because it will stay in the vascular bed.
Blood loss in the OR is usually less than 500 cc (15% of the blood volume). This is
within the range that the body can compensate for without adverse effects on the vital
signs. 500 cc of blood loss will result in a drop of one gram of hemoglobin. However you
have to consider the patient’s fluid status. If the blood is concentrated you would see less
of a drop in hemoglobin.
In the first 24-48 hours the patient should be carefully monitored for hemorrhage. The
vital signs are an important component of this assessment. Also assess the dressing and
under the patient. Sometime hemorrhage can drain under the patient without visible
external evidence on the dressing. Assess for intra-abdominal hemorrhage by looking for
abdominal distention, absence of bowel sounds, and a hard board-like abdomen.
Hemorrhage around major arteries can produce symptoms associated with occlusion of
the artery. Hemorrhage in a thigh or hip results in distention (because of the size of the
thigh, significant hemorrhage can occur before it is detected.)