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1. Staff Education

Educate all staff caring for patients before, during and after procedures about:

  • normal post-procedural fluid requirements (Siparsky 2016)
  • signs and symptoms of shock (Gaieski & Mikkelsen, 2018, “Evaluation”)
  • potential causes of procedure-associated shock and related risk factors
  • causes/risk factors for procedures certain staff may be specifically involved with (see examples in the References section: Additional Guidelines – Condition Specific Guidelines which may be helpful in the prevention of shock). These factors may relate to the patient, procedure or healthcare environment. 
For example, hemorrhagic shock, perhaps the most common cause of hypovolemic shock in surgical patients, can be categorized according to the severity of acute blood loss as per Table 2 below (American College of Surgeons, 2018). 

  Table 2: Signs and Symptoms of Hemorrhage by Class


Class I

Class II (Mild)

Class III (Moderate)

Class IV (Severe)

Approximate blood loss





Heart rate



Blood pressure


Pulse pressure

Respiratory rate


Urine output


Glasgow Coma Scale score

Base deficit*

0 to -2 mEQ/L

-2 to -6 mEq/L

-6 to-10 mEq/L

-10 mEq/L or less

Need for blood products




Massive Transfusion Protocol

*Base excess is the quantity of base (HCO3-, in mEQ/L) that is above or below the normal range in the body. A negative number is called a base deficit and indicates metabolic acidosis.

Data from:  Mutschler A, Nienaber U, Brockamp T. et al. A critical reappraisal of the ATLS classification of hypovolaemic shock: does it really reflect clinical reality? Resuscitation 2013, 84:309-313.

2.   Perioperative Blood Management (PBM)

Assessment and Management Peri-operative bleeding, the most common cause of post-procedural hypovolemic shock, requires specific recognition. Best practices relating to perioperative patient blood management and postoperative hemorrhage may include

Perioperative Blood Management (PBM), whereby pre- intra- and post- procedure strategies are targeted to minimize the risk of perioperative blood loss and transfusion requirements.   (American Society of Anesthesiologists et al 2015; Clevenger et al. 2015; Graetz & Nuttall, 2017; Hohmuth et al. 2014; National Blood Authority, 2012). For additional information, please refer to the Hospital Harm Improvement Resource - Procedure Associated Anemia-Hemorrhage.

One approach, supported by the American Society of Anesthesiologists (2015), recommends:

A. Patient Evaluation

Review previous medical records and interview the patient or family to identify history of previous blood transfusion, drug-induced coagulopathy or thrombotic events, and the presence of congenital coagulopathy or of risk factors for organ ischemia. Review available laboratory test results including Hb, Hct, and coagulation profiles. Order additional laboratory tests depending on a patient’s medical condition. Conduct a physical examination of the patient. If possible, perform the preoperative evaluation well enough in advance to allow for proper patient preparation.

Additional resources regarding Patient Evaluation:

  1. Identifying bleeding risk and managing patients with bleeding disorders (of coagulation or platelet function) (AHRQ, 2013, PSI; Chee et al. 2008; De Hert et al. 2011; Douketis et al. 2012; Koscielny et al. 2004)
  2. Identifying risk factors and mitigating practices for post-procedural blood loss (WHO, 2009)

B. Preadmission Patient Preparation

Consider administration of erythropoietin with or without iron when possible to reduce the need for allogeneic blood in selected patient populations. Administer iron to patients with iron deficiency anemia if time permits. In consultation with an appropriate specialist, discontinue anticoagulation therapy for elective surgery. If clinically possible, discontinue non-aspirin antiplatelet agents for a sufficient time in advance of surgery, except for patients with a history of percutaneous coronary interventions. Consider the risk of thrombosis versus the risk of increased bleeding when altering anticoagulation status. Assure that blood and blood components are available for patients when significant blood loss or transfusion is expected. When autologous blood is preferred, the patient may be offered the opportunity to donate blood before admission only if there is adequate time for erythropoietic reconstitution.

C. Preprocedure Preparation

Implement evidence informed protocols for/regarding:

  1. patient blood management

  2. reversal of anticoagulants

  3. the use of antifibrinolytics for prophylaxis of excessive blood loss

  4. the use of Acute Normovolemic Hemodilution (ANH)

D. Intraoperative and Postoperative Management of Blood Loss

Implement  evidence informed protocols for/regarding:

  1. allogeneic red blood cell transfusion
  2. reinfusion of recovered red blood cells
  3. intraoperative and postoperative patient monitoring
  4. treatment of excessive bleeding

    Additional resources regarding intraoperative and postoperative management of blood loss:
  1. Timely management of post-procedural shock and overall management of blood loss. (Hrymak et al. 2017; Cecconi et al. 2014; Gaieski & Mikkelsen, 2018; Rhodes et al. 2017; Vincent et al. 2013)
  2. Overall management of blood loss (AHRQ, 2013; PSI 09; Dagi, 2005)
  3. Management of major hemorrhage and massive transfusion protocol. (Balvers et al. 2015; Callcut et al. 2016; Hunt et al. 2015; Kozek-Langenecker et al. 2017; McDaniel et al. 2014; Porteous, 2015; Association of Anaesthetists of Great Britain and Ireland, 2010)

3.    Sepsis Management

As for other causes of procedure-associated shock, providers must be educated about anticipating, preventing, early recognition and timely intervention of a sepsis syndrome. For details, please refer to the Sepsis Hospital Harm Improvement Resource. An update from the same group has been recently published (Rhodes et al. 2017).

4. Organizational Practices

Organizational practices that promote and facilitate the prevention, early recognition and timely management intervention of procedure related shock may span over a wide spectrum of care processes and, as mentioned previously, will vary according to patient case mix, procedures performed and the environment in which they are performed.

Early warning signs of deteriorating condition are often unrecognized, leading to devastating results. Research shows that virtually all critical inpatient events are preceded by warning signs that occur approximately six-and-a-half hours in advance. On the Canadian Patient Safety Institute’s webpage –  Deteriorating Patient Condition, you will find information, tools and resources to not only help you recognize deteriorating patient condition, but what you can do to act on it as a member of the public, a healthcare provider or leader. 

According to AHRQ’s Patient Safety Indicator Postoperative hemorrhage or hematoma (2013), a first step is to engage key preoperative/perioperative/procedure personnel, including nurses, physicians and other providers, surgical technicians, and representatives from the quality improvement department to adapt, adopt or develop evidence-based protocols for care of the patient preoperatively, intraoperatively, and postoperatively.

The above team:

  • Identifies the purpose, goals, and scope and defines the target population for this guideline.
  • Analyzes problems with guidelines compliance, identifies opportunities for improvement, and communicates best practices to frontline teams.
  • Monitors measures that would indicate if changes are leading to improvement, identifies process and outcome metrics, and tracks performance using these metrics.
  • Determines appropriate facility resources for effective and permanent adoption of practices.

    An example of organizational practices for the early recognition of procedure-associated shock is:
  • Early Warning Signs (EWS): consider developing a standard set of criteria or EWS that will be used to trigger notification of the responsible physician of possible procedure-associated shock. Incorporate these into a tool designed to provide standardized documentation of all pertinent details of the event. This tool will provide the data to track patient characteristics, processes, and outcomes for continuous quality improvement.
  • Policy: establish a policy to empower nurses to rapidly escalate up the chain of authority to reach the responsible physician or practitioner/provider (example: limit time to five-minute wait after initial page before moving to notify next higher level of authority).
  • Education: provide educational sessions to all clinical staff on the pilot units (nurses, residents, attending physicians, other providers, respiratory therapists, patient care technicians,certified nursing assistants, etc.) in the use of the early warning signs criteria, required documentation, and policy for rapid escalation up the chain of authority to notify responsiblephysician or practitioner/provider.

    At a broader level, the organization may:

Conduct Clinical and System Reviews

Given the broad range of potential causes of complications from procedure-associated shock, in addition to the recommendations listed above, we recommend conducting clinical and system reviews to identify latent causes and determine appropriate recommendations.

If your review reveals that your cases of procedure-associated shock are linked to specific processes or procedures, you may find guidelines related to the specific procedure in the Additional Resources section. 

Clinical and System Reviews, Incident Analyses

Occurrences of harm are often complex with many contributing factors. Organizations need to:

  1. Measure and monitor the types and frequency of these occurrences.
  2. Use appropriate analytical methods to understand the contributing factors.
  3. Identify and implement solutions or interventions that are designed to prevent recurrence and reduce risk of harm.
  4. Have mechanisms in place to mitigate consequences of harm when it occurs.

    To develop a more in-depth understanding of the care delivered to patients, chart audits, incident analyses and prospective analyses can be helpful in identifying quality improvement opportunities. Links to key resources for analysis methods are included in Resources for Conducting Incident and/or Prospective Analyses section of the Introduction to the Hospital Harm Improvement Resource.

    Chart audits are recommended as a means to develop a more in-depth understanding of the care delivered to patients identified by the Hospital Harm measure. Chart audits help identify quality improvement opportunities.

    Useful resources for conducting clinical and system reviews: