血液量減少、循環血液量減少、血液量不足、血液量減少症、循環血液量減少症

WordNet

a blood disorder consisting of a decrease in the volume of circulating blood (同)hypovolaemia
of or relating to a decrease in the volume of circulating blood (同)hypovolaemic

Wikipedia preview

出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2015/05/17 06:53:16」(JST)

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In physiology and medicine, hypovolemia (also hypovolaemia, oligemia or shock) is a state of decreased blood volume; more specifically, decrease in volume of blood plasma.^[1]^[2] It is thus the intravascular component of volume contraction (or loss of blood volume due to things such as hemorrhaging or dehydration), but, as it also is the most essential one, hypovolemia and volume contraction are sometimes used synonymously.

Hypovolemia is characterized by salt (sodium) depletion and thus differs from dehydration, which is defined as excessive loss of body water.^[3]

Causes

Common causes of hypovolemia are^[4]

Loss of blood (external or internal bleeding or blood donation^[5])
Loss of plasma (severe burns^[6]^[7] and lesions discharging fluid)
Loss of body sodium and consequent intravascular water; e.g. diarrhea or vomiting
Vasodilation (involving widening of blood vessels) such as trauma leading to dysfunction of nerve activity on blood vessels and inhibition of the vasomotor center in the brain or drugs such as vasodilators typically used to treat hypertensive individuals.

Excessive sweating is not a cause of hypovolemia, because the body eliminates significantly more water than sodium.^[8]

Diagnosis

Clinical symptoms may not be present until 10–20% of total whole-blood volume is lost.

Hypovolemia can be recognized by tachycardia, diminished blood pressure,^[9] and the absence of perfusion as assessed by skin signs (skin turning pale) and/or capillary refill on forehead, lips and nail beds. The patient may feel dizzy, faint, nauseated, or very thirsty. These signs are also characteristic of most types of shock.

Note that in children, compensation can result in an artificially high blood pressure despite hypovolemia. Children will typically compensate (maintain blood pressure despite loss of blood volume) for a longer period than adults, but will deteriorate rapidly and severely once they do begin to decompensate. This is another reason (aside from initial lower blood volume) that even the possibility of internal bleeding in children should almost always be treated aggressively.

Also look for obvious signs of external bleeding while remembering that people can bleed to death internally without any external blood loss. ("Blood on the floor, plus 4 more" = intrathoracic, intraperitoneal, retroperitoneal, pelvis/thigh)

Also consider possible mechanisms of injury that may have caused internal bleeding such as ruptured or bruised internal organs. If trained to do so and the situation permits, conduct a secondary survey and check the chest and abdomen for pain, deformity, guarding, discoloration or swelling. Bleeding into the abdominal cavity can cause the classical bruising patterns of Grey Turner's sign or Cullen's sign.

Stages of hypovolemic shock

Usually referred to as "Class" of shock. Most sources state that there are 4 stages of hypovolemic shock,^[10] however a number of other systems exist with as many as 6 stages.^[11]

The 4 stages are sometimes known as the "Tennis" staging of hypovolemic shock as the stages of blood loss (under 15% of volume, 15-30% of volume, 30-40% of volume and above 40% of volume) mimic the scores in a game of tennis: 15, 15-30, 30-40 and 40.^[12] It is basically the same as used in classifying bleeding by blood loss.

Stage 1

Up to 15% blood volume loss (750 mL)
Compensated by constriction of vascular bed
Blood pressure maintained
Normal respiratory rate (12-20 breaths per minute)
Pallor of the skin (paleness)
Normal mental status^[13] to slight anxiety
Normal capillary refill^[13] (less than 2 seconds)
Normal urine output^[13]

Stage 2

15–30% blood volume loss (750–1500 mL)
Cardiac output cannot be maintained by arterial constriction
Tachycardia >100bpm
Increased respiratory rate (more than 20 respirations per minute)
Systolic blood pressure maintained
Increased diastolic blood pressure
Narrow pulse pressure (gap between the systolic and diastolic pressure)
Pale, cold, and clammy skin as blood flow is directed away to major organs such as the heart, lungs, and brain
Mildly anxious/Restless
Delayed capillary refill^[13]
Urine output of 20-30 milliliters/hour^[13]

Stage 3

30–40% blood volume loss (1500–2000 mL)
Systolic BP falls to 100mmHg or less
Marked tachycardia (increased heart rate) >120 bpm
Marked tachypnea (increased rate of respiration) >30 respirations per minute
Alteration in mental status (confusion,^[13] anxiety, agitation)
Sweating with cool, pale skin
Delayed capillary refill^[13]
Urine output of approximately 20 milliliters/hour^[13]

Stage 4

Loss greater than 40% (>2000 mL)
Extreme tachycardia (>140^[13]) with weak pulse
Pronounced tachypnea
Significantly decreased systolic blood pressure of 70 mmHg or less
Decreased level of consciousness, lethargy,^[13] coma^[13]
Skin is sweaty, cool, and extremely pale (moribund)
Absent capillary refill^[13]
Negligible urine output^[13]
Survival is extremely unlikely

Treatment

Minor hypovolemia from a known cause that has been completely controlled (such as a blood donation from a healthy patient who is not anemic) may be countered with initial rest for up to half an hour. Oral fluids that include moderate sugars and electrolytes are needed to replenish depleted sodium ions. Furthermore the advice for the donor is to eat good solid meals with proteins for the next few days. Typically, this would involve a fluid volume of less than one liter, although this is highly dependent on body weight. Larger people can tolerate slightly more blood loss than smaller people.

More serious hypovolemia should be assessed by a physician.

First aid

External bleeding should be controlled by direct pressure. If direct pressure fails, a tourniquet should be used in the case of severe hemorrhage that cannot be controlled by direct pressure. Tourniquet use in civilian first-aid, is now advocated as part of the C-ABC approach. Other techniques such as elevation and pressure points are not always effective but should still be attempted. As a rule of thumb, anywhere you can feel a pulse can be used as a pressure point to stop bleeding (with the obvious exception of the carotid pulses). If a first-aid provider recognizes internal bleeding the life-saving measure to take is to immediately call for emergency assistance.

Field care

Emergency oxygen should be immediately employed to increase the efficiency of the patient's remaining blood supply. This intervention can be life-saving. ^[14]

The use of intravenous fluids (IVs) may help compensate for lost fluid volume, but IV fluids cannot carry oxygen in the way that blood can, however blood substitutes are being developed which can. Infusion of colloid or crystalloid IV fluids will also dilute clotting factors within the blood, increasing the risk of bleeding. It is current best practice to allow permissive hypotension in patients suffering from hypovolemic shock^[15] both to ensure clotting factors are not overly diluted but also to stop blood pressure being artificially raised to a point where it "blows off" clots that have formed.

Hospital treatment

If the hypovolemia was caused by medication, the administration of antidotes may be appropriate but should be carefully monitored to avoid shock or the emergence of other pre-existing conditions^{[citation needed]}.

Fluid replacement is beneficial in hypovolemia of stage 2, and is necessary in stage 3 and 4.^[13] Blood transfusions coupled with surgical repair are the definitive treatment for hypovolemia caused by trauma^{[citation needed]}. See also the discussion of shock and the importance of treating reversible shock while it can still be countered.

For a patient presenting with hypovolemic shock in hospital the following investigations would be carried out:

Blood tests: U+Es/Chem7, FBC, Glucose, Cross-match
Central Venous Line/Blood Pressure
Arterial line/Arterial Blood Gases
Urine output measurements (via urinary catheter)
Blood pressure
SpO2 Oxygen saturations

The following interventions would be carried out:

IV access
Oxygen as required
Surgical repair at sites of hemorrhage
Inotrope therapy (Dopamine, Noradrenaline) which increase the contractility of the heart muscle
Fresh frozen plasma/whole blood

History

Historically a term desanguination (from Latin sanguis, blood) was in use, meaning a massive loss of blood. The term was widely used by the Hippocrates in traditional medicine practiced in the Greco-Roman civilization and in Europe during the Middle Ages. The word was possibly used to describe the lack of personality (by death or by weakness) that often occurred once a person suffered hemorrhage or massive blood loss.

In cases in which loss of blood volume is clearly attributable to bleeding (as opposed to, e.g., dehydration), most medical practitioners of today prefer the term exsanguination for its greater specificity and descriptiveness, with the effect that the latter term is now more common in the relevant context.^[16]

References

^ MedicineNet > Definition of Hypovolemia Retrieved on July 2, 2009
^ TheFreeDictionary.com --> hypovolemia Citing Saunders Comprehensive Veterinary Dictionary, 3 ed. Retrieved on July 2, 2009
^ MedicineNet > Definition of Dehydration Retrieved on July 2, 2009
^ Sircar, S. Principles of Medical Physiology. Thieme Medical Pub. ISBN 9781588905727
^ Danic B, Gouézec H, Bigant E, Thomas T (June 2005). "[Incidents of blood donation]". Transfus Clin Biol (in French) 12 (2): 153–9. doi:10.1016/j.tracli.2005.04.003. PMID 15894504.
^ http://www.totalburncare.com/orientation_burn_shock.htm
^ http://www.patient.co.uk/doctor/Resuscitation-in-Hypovolaemic-Shock.htm
^ http://highered.mcgraw-hill.com/sites/dl/free/0077262514/621682/Saladin_24_Ext_Outline.doc
^ http://www.stagesofshock.com/stage3/index.html
^ http://dynamicnursingeducation.com/class.php?class_id=47&pid=18
^ http://www.stagesofshock.com/stage1/index.html
^ Greaves, Ian; Porter, Keith; Hodgetts, Timothy et al., eds. (2006). Emergency Care: A Textbook for Paramedics. Elsevier Health Sciences. p. 229. ISBN 9780702025860. |displayeditors= suggested (help)
^ ^a ^b ^c ^d ^e ^f ^g ^h ⁱ ^j ^k ^l ^m ⁿ Elizabeth D Agabegi; Agabegi, Steven S. (2008). Step-Up to Medicine (Step-Up Series). Hagerstwon, MD: Lippincott Williams & Wilkins. ISBN 0-7817-7153-6.
^ Takasu A, Prueckner S, Tisherman SA, Stezoski SW, Stezoski J, Safar P. (2000), Effects of increased oxygen breathing in a volume controlled hemorrhagic shock outcome model in rats., PMID 10959021
^ http://www.trauma.org/archive/resus/permissivehypotension.html Permissive Hypotension
^ L. Geeraedts Jr., H. Kaasjager, A. van Vugt, and J. Frölke,. "Exsanguination in trauma: A review of diagnostics and treatment options". Injury 40 (1): 11–20. doi:10.1016/j.injury.2008.10.007.

External links

CRISP Thesaurus 00004050
DDB 29217

UpToDate Contents

全文を閲覧するには購読必要です。 To read the full text you will need to subscribe.

1. 成人における体液量減少の病因、臨床症状、および診断 etiology clinical manifestations and diagnosis of volume depletion in adults
2. 成人における重症循環血液量減少または循環血液量減少性ショックの治療 treatment of severe hypovolemia or hypovolemic shock in adults
3. 小児における血液量減少症（脱水）の臨床的評価および診断 clinical assessment and diagnosis of hypovolemia dehydration in children
4. 水分バランス異常（低ナトリウム血症および高ナトリウム血症）および
ナトリウムバランス異常（循環血液量減少および浮腫）の一般原則 general principles of disorders of water balance hyponatremia and hypernatremia and sodium balance hypovolemia and edema
5. 急性腎障害（急性腎不全）のマネージメントの概要 overview of the management of acute kidney injury acute renal failure

English Journal

The viscous behaviour of HES 130/0.4 (Voluven(®)) and HES 260/0.45 (Pentaspan (®)).

Walker AM, Lee K, Dobson GM, Johnston CR.SourceDepartment of Mechanical and Manufacturing Engineering, University of Calgary, 2500 University Dr. N.W., Calgary, AB, T2N 1N4, Canada, walkeram@ucalgary.ca.
Canadian journal of anaesthesia = Journal canadien d'anesthesie.Can J Anaesth.2012 Mar;59(3):288-294. Epub 2011 Dec 20.
PURPOSE: Several fluids are available for volume therapy to address hypovolemia. We focus on two hydroxyethyl starches (HES) available for volume expansion in Canada, HES 130/0.4 (Voluven(®)) and HES 260/0.45 (Pentaspan(®)). Although information is available regarding their pharmacokinetic and ris
PMID 22183297

Predictors of pulmonary edema formation during fluid loading in the critically ill with presumed hypovolemia*.

Aman J, Johan Groeneveld AB, van Nieuw Amerongen GP.SourceFrom the Departments of Physiology (JA, GPvNA) and Intensive Care (JG), Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, the Netherlands.
Critical care medicine.Crit Care Med.2012 Mar;40(3):793-9.
OBJECTIVES: : It is largely unknown why extravascular lung water may increase during fluid loading in the critically ill with presumed hypovolemia. In this study we evaluated the hemodynamic predictors of such an increase.DESIGN: : A prospective observational study.PATIENTS: : Sixty-three presumed h
PMID 22080639

Japanese Journal

A Rare Case of Chiari Type-1 Malformation Accompanied by Symptomatic Cerebrospinal Fluid Hypovolemia: Comparison of Congenital Chiari Type-1 Malformation and Acquired Chiari Malformation Secondary to Cerebrospinal Fluid Hypovolemia: Case Report

HATAE Ryusuke,KOHRI Ryusuke,MAEDA Kazushi,MIYAZONO Masayuki
Neurologia medico-chirurgica 54(7), 558-562, 2014
… We considered the possibilities of cerebrospinal fluid (CSF) hypovolemia and congenital Chiari type-1 malformation as being responsible for her headache. … There seems no previous report which described successful differentiation of pre-existing congenital Chiari type-1 malformation from the acquired one caused by symptomatic CSF hypovolemia. …
NAID 130004448324

意識障害を伴う重症脳脊髄液減少症の治療経験

横須賀公彦,平井聡,高井洋樹,西山徹,松下展久,戸井宏行,松原俊二,平野一宏,宇野昌明
Japanese Journal of Neurosurgery 23(2), 156-163, 2014
脳脊髄液減少症 (低髄液圧症候群, 脳脊髄液漏出症) の中に重篤な経過をとる症例があり, われわれは1死亡例を本誌にて報告した. 重症例では症状が急速に悪くなることが多く, 迅速な治療が求められる. しかし, 多くの症例で硬膜下血腫を合併しており, 増悪因子が脳脊髄液減少によるものなのか硬膜下血腫によるものかを判断することはしばしば困難である. われわれは, 重症例における治療方針を考え, 3症 …
NAID 130003397697

Barium Peritonitis in Small Animals

KO Jae Jin,MANN F. A. (Tony)
Journal of Veterinary Medical Science, 2014
… Barium sulfate leakage results in hypovolemia and hypoproteinemia by worsening the exudation of extracellular fluid and albumin. …
NAID 130003391261

Related Pictures

★リンクテーブル★

リンク元	「低ナトリウム血症」「NSAID腎症」「5H5T」「血液量減少」「血液量不足」

「低ナトリウム血症」

Hypovolemia
Classification and external resources
ICD-10	E86, R57.1, T81.1
ICD-9	276.52
MedlinePlus	000167
MeSH	D020896

　　[★]

英: hyponatremia
同: 低Na血症
関: ナトリウム、高ナトリウム血症、電解質異常

定義

血清ナトリウムが134mEq/L以下の病態。(正常の下限は135mEq/Lとされる)
水とナトリウムのバランスという観点で、2つに分けられる

1. 希釈性低ナトリウム血症 dilutional hyponatremia
2. ナトリウム欠乏性低ナトリウム血症 sodium depletion hyponatremia

疫学

日常臨床上最も頻度の高い水・電解質異常

入院患者の3%、集中治療室患者の30%(IMD)

分類

低ナトリウム血症

偽性低ナトリウム血症

等張性低ナトリウム血症
高張性低ナトリウム血症
低張性低ナトリウム血症：狭義の低ナトリウム血症

病型

ICU.525

循環血減少性低ナトリウム血症：下表で[2]に相当

利尿・副腎不全：　尿中Na > 20mEq
嘔吐・下痢　　　　：　尿中Na < 20mEq

等容量性低ナトリウム血症：細胞外液は増加していないが、水の方が多くなった状態。臨床的に浮腫が無い。下表で[1]に相当

SIADH　　　　：尿浸透圧 > 100 mOsm/L
心因性多飲症　：尿浸透圧 < 100 mOsm/L

循環血増加性低ナトリウム血症：細胞外液にナトリウムと水が増加しており、なおかつ水の方が多い病態：下表で[3]に相当

腎不全　　　　：　尿中Na > 20mEq
心不全・肝不全：　尿中Na < 20mEq

IMD

[1] 細胞外液量増加：組織間質に非常に多量の水と多量のナトリウムが移動。移動する原因は血液のうっ滞、膠質浸透圧の低下など

うっ血性心不全、肝硬変、末期腎不全など。

うっ血性心不全や腹水を伴う肝硬変では、圧受容器が循環血液量の減少を検出してバソプレシンを分泌する(cases.200)

[2] 細胞外液量減少：ナトリウム喪失による。

消化管からの喪失(下痢、嘔吐、腸閉塞など)、熱傷、利尿薬の過剰投与、腎疾患、副腎不全など。

[3] 細胞外液量正常：ナトリウムの摂取・排泄は変わらないが、水が異常に蓄積されるため？　←　最も多いらしい

内分泌疾患(副腎不全、抗利尿ホルモン(ADH)不適合分泌症候群(SIADH)、甲状腺機能低下症)、薬物、水中毒(心因性多飲)など。

[4] 偽性低Na血症

高浸透圧性：高血糖、マンニトール投与など。
正浸透圧性：脂質異常症(高脂血症)、高蛋白血症など。

水とナトリウムのバランスによる分類

	水	Na	体液	摂取と排出はどうなのか？				脱水所見
				IN →○		OUT 　○→
希釈性低ナトリウム血症	過剰	-	多い	[3]	⇒○→	[3]	→○→	無し
					心因性多飲症、低張輸液過多		SIADH
ナトリウム欠乏性低ナトリウム血症	-	過少	少ない		→○→	[2]	→○⇒	有り
					摂食不能		腎性(Addison病、塩類喪失性腎炎、利尿薬の使用) 腎外性(下痢・嘔吐、熱傷、腸閉塞)
	大過剰	過剰				[1]		無し
							うっ血性心不全肝硬変ネフローゼ