Pressure

vs. Flow: Essential Concepts

Cali, Colombia

Gustavo A. Ospina Tascón, M.D., Ph.D.

Intensivista – Internista – Ciencias Biomédicas, Ph.D.
Departamento de Cuidado Intensivo - Fundación Valle del Lili
Translational Lab for Critical Care and Advanced Surgery - Universidad ICESI
Cali, Colombia
Oxygen Balance
Oxygen consumption (VO2) /oxygen delivery
(DO2) dependency
1.965
Lactate
VO2 ERO2
ERO2 critical
SvO2 0.75

Normal
250 0.50

ERO2
DO2 Critical 0.25

0 400 500 1000

Cain SM: Appearance of excess lactte in anesthetized dogs during anemic and hypoxic QO2
hypoxia. Am J Physiol 209:604-608, 1965
Oxygen Balance

oVO
2 / nVO
2 = Index of global performance
When < 1 : shock

oDO
2 / nDO
2 = Index of circulatory performance
When < 1 : circulatory failure

oEO
2 / nEO
2 = Index of tissue performance
When < 1 : tissue failure
 Shock is best defined as a life-
threatening, generalized form of acute
circulatory failure associated with
inadequate oxygen utilization by the
cells.

Intensive Care Med (2014) 40:1795–1815

 PUMP

Venous VESSELS
return

MICROCIRCULATION
Arterial Pressure Lactate
Cardiac Output SvO2
DO2 Cv-aO2/Da-vO2

Hemodynamic Metabolic

Shock Resuscitation
Clinical
Capillary Refill Time
Mottling
Oliguria
Altered consciousness
Skin coldness
 Giving Fluids: An Act of Faith ? …
When I Increase Increase Pre- Increase
Give Increase Pmsf Venous charge Cardiac
Return Output
FLUIDs

Increase
Intercapillary Distances Oxygen is Microcirculatory blood flow Oxygen
are Adequate Well distribution is Convective
distributed homogeneous Transport to
tissues (DO2)

Oxygen gradient Respiration

Oxygen reach the (cytoplasma-to-
Oxygen Difuses Correctly machinary is OK
cell mitochondria) is
enough

Cell Respires
Improving Macro Hemodynamics

Tissue Perfusion

Cell Respiration
 Is the cardiovascular
dysfunction in shock a
problem of pressure or
flow ?
Hales S. Royal Society of London. 2. 1733.
Coupling Pressures And Flow

(P1 – P2) . r4 . π
Q =
8 . η . ι

Q = Flow
P1 = In Pressure
P2 = Out Pressure
r = Radius
η = Viscosity
ι = Longitude
 (P1 – P2)
Q =
R

Handbook of physiology. Section 2: The Cardiovascular System. Vol IV: Microcirculation Part 2.
Circulation Research 1989;65:224-236

Dobutamine

Rest

Propranolol
Am J Physiol 1961; 201:117–122

≠ Activity
rates
GASTROENTEROLOGY 1987;93:12-20
Auto regulation of Organ Blood Flow
Auto regulation of Organ Blood Flow
Auto regulation of Organ Blood Flow
Auto regulation is altered in
chronic hypertension
 NORMAL
Organ Blood Flow

HYPERTENSION

mmHg
MAP
Auto regulation is altered in
sepsis / septic shock
Nw-nitro-L-arginine (NNLA), an inhibitor of
nitric oxide synthesis

methylene blue (MB), an inhibitor of soluble
guanylate-cyclase.

Cardiovascular Research 35 (1997): 368–376

Intensive Care Med ︎(2001) 27: 1231-1234
Why should I give a
vasopressor ?
 (P1 – P2)
Q =
R

Handbook of physiology. Section 2: The Cardiovascular System. Vol IV: Microcirculation Part 2.
Duration and the Degree of
Hypotension in Septic
Shock Are Associated with
Increased Mortality
Intensive Care Med (2005) 31:1066–1071
Intensive Care Med (2005) 31:1066–1071
Intensive Care Med (2009) 35:1225–1233
J Trauma. 2008;64:1188–1195
J Trauma. 2008;64:1188–1195
 How much are
vasoactive drugs used ?
Journal of Critical Care (2011) 26, 532.e1–532.e7
Journal of Critical Care (2011) 26, 532.e1–532.e7
Do we must target some
arterial pressure level ?
Critical Care 2007, 11:R67
Crit Care Med 2000; 28:2729–2732
Crit Care Med 2005; 33:780–786
Crit Care Med 2005; 33:780–786
Pre Bacteremia Bacteremia

Intensive Care Med (2005) 31:1558–1563

Intensive Care Med (2005) 31:1558–1563
 NORMAL
Organ Blood Flow

65 85 mmHg
MAP
N Engl J Med 2014;370:1583-93
N Engl J Med 2014;370:1583-93
 NORMAL
Organ Blood Flow

HYPERTENSION

65 85 mmHg
MAP
Why should I give a
vasodilator ?
 Waterfall
Phenomenon
Greger Windhorst (auth.) Comprehensive Human
Physiology_ From Cellular Mechanisms to
Integration 1st Ed 1996
Handbook of physiology. Section 2: The Cardiovascular System. Vol IV: Microcirculation Part 2.
Handbook of physiology. Section 2: The Cardiovascular System. Vol IV: Microcirculation Part 2.
 Anesth Analg 2012;114:803–10

Venous Return
10 curve

4
Pmsf Pcc Ra = MAP – Pcc / CO

2
Rs = MAP – Pcv / CO

20 40 60 80 100

Pcv (mmHg) Pa (mmHg)

Error in calculated resistance
produced by ignoring arterial critical
closing pressure

Crit Care Med 2014; 42:1241–1251

Theoretical pressure-flow lines at
rest and with vasodilation.

Crit Care Med 2014; 42:1241–1251

Should we increase Arterial
Pressure to improve tissue
Perfusion in hemorrhage ??
HR: 115
AP: 85/50
HR: 115
AP: 105/60
HR: 115
AP: 85/52
Handbook of physiology. Section 2: The Cardiovascular System. Vol IV: Microcirculation Part 2.
Starling resistor effect
 (P1 – P2)
Q =

R 0 -10

P2 – P1 = +10

+3 -7

+7 -3
 0 -10 P2 – P1 = +10

(P1 – P2)
Q =

+3 -7 R
Intensive Care Medicine Experimental (2015) 3:11
Intensive Care Medicine Experimental (2015) 3:11
CHEST 2003; 124:688–698
CHEST 2003; 124:688–698
 Effect of pressure on
Microcirculatory Blood
Flow
•  28 septic shock patients
•  Life-threatening hypotension and
low diastolic arterial pressure.

Intensive Care Med (2010) 36:1882–1889

•  28 septic shock patients
•  Life-threatening hypotension and
low diastolic arterial pressure.

Intensive Care Med (2010) 36:1882–1889



Critical Care 2011, 15:R222



Intensive Care Med (2010) 36:1882–1889

Septic Shock
(n=20)

Critical Care 2009, 13:R92

Septic Shock
(n=20)

Critical Care 2009, 13:R92

 NORMAL
Organ Blood Flow

50 65 85 mmHg
MAP
 NORMAL
Organ Blood Flow

65 85 mmHg
MAP
ANDROMEDA – SHOCK Study
ClinicalTrials.gov Identifier: NCT03078712