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Physiology Hemodynamics Map SVR X Co
Physiology Hemodynamics Map SVR X Co
Physiology Hemodynamics Map SVR X Co
Hemodynamics
MAP = SVR x CO
Pulse pressure- created by SV on top of a DBP within a compliant vascular tree → aorta is responsible for most of compliance
↑ pulse pressure d/t increased SV or poor compliance of aorta
Systemic vascular resistance
80 converts dyne/s/cm5
SVR = 80 x (MAP-CVP)/CO
from mmHg and L/min
Most drugs ↓ SVR
Inversely proportional to 4th power of radius
Most of resistance is d/t arterioles
PAC to obtain values to calculate SVR
Cardiac Output
CO = HR x SV
↓ CO more difficult to treat
Measure with thermodilution and TEE
Heart rate
Tachy or brady leads to hypotension
Excessive Bradycardia ↓ CO
Tachycardia ↓ filling time for LV→ ↓ CO and hypotension
Ejection fraction
End diastolic volume
Normal 60-70%
Preload
ie. EDV
measure with TEE or LA pressure, PCWP, pulmonary artery diastolic pressure
CVP measures filling pressures on Right side correlates with left side if no Pulmonary dz
Stiff heart → steeper rise of pressure with increased volume
Low preload caused by venodilation and hypovolemia; others: tension ptx, cardiac tamponade ( manifested by pulsus paradoxus),
pulmonary embolism
Frank-Starling mechanism
Increased pumping action of heart with increased filling
Afterload
Largely determined by SVR
↑ SVR → ↑ cardiac filling pressure, ↓ SV, EF, and CO
↓ SVR → ↑ emptying time and ↓ filling pressure
Contractility
Force of contraction independent of preload and afterload
Causes of ↓ contractility:
o Myocardial ischemia, anesthetic drugs, CM, prior MI, valvular heart dz
Cardiac reflexes
Autonomic nervous system
o SA and AV nodes
o Sympathetic stimulation → ↑ HR through beta1
o Parasympathetic suppression →↑ HR
Baroreceptors
o Carotid sinus and aortic arch
o Activated by ↑ SBP → stimulates stretch ® → signal thru vagus and glossopharyngeal n. → CNS
o Altered by HTN
o Typical response: ↓ HR
o Vagal stimulation → ↓ inotropy and reflex vasodil.
o Bainbridge reflex: atrial stretch → ↑ HR to match CO to venous return
Chemo®:
o Carotid sinus
o Arterial hypoxiemia → SNS stilumation
o Oculocardia reflex, bradycardia w/ stretch of abdominal vescera; cushing reflex: brady w/ ↑ICP
Coronary blood flow
60-70% extraction of O2
Cannot ↑ extraction as reserve mech
Primary compensation: Vasodilatation to ↑ blood flow
Coronary reserve: ability to ↑ flow over baseline (adenosine, NO, adrenergic stim)
Diastole: heart perfusion → DBP – LVEDP [RV is perfused in diastole and systole]
Pulmonary circulation
Pulmonary artery pressure {2-12 mmHg}
o ↓ than SBP b/c of ↓ PVR
Pulmonary vascular resistance
o Resistance in larger vessels, small arteries, and capillary bed
o Phys model: distension and recruitment of capillaries
↑ PAP → distention and recruitment → ↑ cross-sectional area and ↓ PVR
o Hypoxic pulmonary vasoconstriction
Response to low PaO2
Divert blood away from poorly ventilated areas →↓shunt
o Pulmonary emboli- ↑ PVR
o Arterial thickening- primary pulm HTN, cirrhotic liver
Zones of the lung
o Zone 1: no blood flow despite ventilation; usually doesn’t exist; occurs with PPV or low PAP
o Zone 2: flow is proportional to difference b/w PAP and airway pressure
o Zone 3: flow is proportional to difference b/w PAP and venous pressure
Pulmonary edema
o Hydrostatic pulm edema from ↑ LV pressures
o Capillary leak
Pulmonary gas exchange
Oxygen
Arterial hypoxemia- reflects gas exchange
o Measurements of oxygenation
Oxygemoglobin dissociation curve
P50 = 26.8 mmHg
Right shift: acidosis, hypothermia, ↓ 2,3 DPG
→ facilitate unloading
Normal PvO2 40 mmHg ~ 75% SaO2
PaCO2 = k (VCO2/VA)
o Rebreathing
Exhausted CO2 absorbents, malfunction expiratory valves
o ↑ CO2 production
Tourniquet, insufflation, thyroid storm, fever, MH
o ↑ dead space
Anatomic, alveolar, phys
↑ in emphysema, cystic fibrosis, PE, hemorrhagic shock, ↑ airway pressure, and ↑ PEEP
Bohr equation: Vd/Vt = (PaCO2 – PECO2) / PaCO2
Normal: 25-30%
o Hypoventilation
PaCO2 = 40, PvCO2 = 46
PaCO2 ↑ 6 mmHg/1st minute; 3mmHg thereafter
o Ddx of ↑ arterial CO2 partial pressure
Pulmonary mechanics
Static properties
o FRC is natural balance pt b/w chest wall and lungs
o Static compliance = Vt/(Pplat - PEEP)
Dynamic properties and airway resistance
o Resistance determined by radius
o Small airways no cartilaginous structure or muscle
o Dynamic compliance = Vt/(PAP – PEEP)
Contol of breathing
Central integration and rhythm generation
Central chemoreceptors
o Ventrolateral medullary surface respond to pH and PCO2
Peripheral chemoreceptors
o Carotid bodies
o Respond to ↓ PO2, ↑ PCO2 and ↓ pH
o Exposed to arterial blood
Hypercapnic ventilator response
o Central and peripheral
o Brainstem response is slow
Hypoxic ventilator response
o Peripheral response ↑ventilation with ↓ PaO2 and ↓ SaO2
o Central response: ↓ ventilation
Effects of anesthesia- depressant effects
o Volatiles ↓ excitatory neurotransmission
Disorders of ventilatory control
o Primary central alveolar hypoventilation syndrome, morbid obese, sleep apnea
o Periodic breathing: peripheral recetpros activated by mild arterial hypoxemia → continual overcorrection/undercorrection
Integration of the heart and lungs
O2 delivery
DO2 = CO x CaO2
O2 extraction
= (CaO2-CvO2)/CaO2
o Anemia
o Metabolic demand