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Hemodynamic Failure March 2016
Hemodynamic Failure March 2016
Copotoiu Ruxandra
2
Anatomy and physiology
Supply/delivery vs demand
•DO2/min
•Oxygen content CaO2
– Arterial (20.1 ml/dL) & venous (15.5 ml/dL)
– CaO2=1.38xHgbxSaO2 + 0.0031xPaO2
•Cardiac output
•X 10 (ml/min)
Consumption (VO2)
•Arterial – venous
– CO x Hgbx13.8x(SaO2-SvO2)
– 200-250 ml/min
3
Anatomy and physiology
• Oxygen extraction fraction/index
– 20-30%
– CaO2-CvO2/CaO2x100
• SvO2
– 1-(VO2/DO2)x10
• Relationship delivery/use
Oxygen debt
VO2
DO2 4
Functional anatomy
Right Left
•Receives •Receives oxygenated
deoxygenated blood blood
•Low pressure system •High pressure system
•Volume pump •Pressure pump
•RV thin walls, •LV thick walls, conical
crescent shape shape
•Biphasic coronary •Diastolic coronary
perfusion perfusion
5
Cardiac output
• CO = HR x SV
HR 60-100 bpm
SV 60-100 ml/b
• SV = EDV – ESV
• EF = (SV/EDV) x 100
– right 40-60%
– left 60-75%
6
Preload
• Amount of myocardial fibre strech at the end of
diastole
• VOLUME vs
• PRESSURE (influence of compliance)
– Left
• LAFP 6-12 mmHg
• PAOP
• LAP
– Right
2-6 mmHg
• RAP
• CVP
• Relationship between myocardial fibre length and
force of contraction 7
Ventricular compliance
Pressure
Volume
8
Ventricular compliance
Decreased Increased
•Ischemia •Dilated
• afterload cardiomyopathies
•Hypertension • afterload
•Inotropes •vasodilators
•Restrictive cardiomyopathies
• intrathoracic pressure
• pericardial pressure
• abdominal pressure
9
Afterload
• Tension developed by the myocardial muscle
fibers during ventricular systolic ejection
• Resistance/impedance/pressure that the
ventricule must overcome to eject its blood
volume
• Determined by
– SV
– Size/wall thickness of the ventricle
– Vascular impedance
• RVS 800-1200
• RVP < 250
• TRANSMURAL !!!!!
10
Contractility/Inotropism
11
Hemodynamic events during
inspiration
PRELOAD
• ITP: mobilizes blood from pulmon veins into the
RV
• ITP: RV afterload LZ & RV filling
AFTERLOAD
• Right
– Unchanged for N lung
for stiff lung
• Left
14
if filling is unchanged
Normal pressures (mmHg)
15
Normal pressures (mmHg)
Location Abbreviation Mean value Limits
Pulmonary PCWP 9 5-16
capillary
Left atrium PAS/LAP 7 4-12
Left ventricle PSVS 130 90-140
systole
Left ventricle LVEDP 7 4-12
diastole
Brachial a TAs 130 90-140
syst
Brachial a TAd/dBP 70 60-90
diast
Brachial a TAm 85 70-105
mean 16
Relationship between cavitary
pressures
1mmHg = 1,36cmH2O
1 cm H2O = 0,74mmHg
1kPa = 7,5mmHg = 10,2cmH2O
17
Hemodynamic parameters
Parameter Abbreviation Formula Units Limits
Cardiac DC, CO Measure l/min 5-6
output
Cardiac index IC, CI CO/BSA l/min/m2 2,8-4,2
Heart rate FC, HR Measure bpm 60-90
19
Golden rules
• CVP does not reflect RVEDV
•
• PAOP does not reflect R(L)VEDV
21
BP
NIBP oscillometric
Underestimates
Sys BP
pulse pressure calculations
mean values during HBP
Overestimates
Diast BP
During hipopressure = bias for clinical decisions
Complications
Compartment syndrome
22
Arterial catheterization
23
Influence of the position of the patient
on the exhibited values of BP
24
Arterial lines - means
Over the
needle
technique
25
Arterial curve
26
Arterial waveform
27
Complications
• Distal ischemia
• Pseudoaneurism
• Arterio-venous fistula
• Infections
• Arterial ambolization
• Peripherral neuropathy
• Misinterpretation of data
• Misuse of equipment
28
Complication of an arterial line
insertion
29
30
Central venous catheterization
Internal jugular vein
31
Central venous catheterization
32
CVP lines - pneumothorax
33
Central venous lines
34
ScvO2
35
Dilution
36
37
38
System
39
Lung zone palcement
40
41
Pulmonary artery catheter
42
Pressures during the PA catheter
insertion
43
PiCCO
44
PiCCO2
45
PiCCO2
46
PiCCO Plus
47
48
Clinical evaluation
49
Heart failure
50
Forrester classification
Hemodynamic subsets
51
Forrester classification
Therapy and outcome
52
Inotropic therapy
• USA
– Low output syndrome
– Left ventricular systolic dysfunction
– Systolic blood pressure < 90 mmHg despite
adequate filling pressure
• Europe
– BP < 100 mmHg
Inotropic therapy
EPINEPHRINE
Inotropic therapy
DOPAMINE
Inotropic therapy
DOBUTAMINE
Inotropic therapy
DOPEXAMINE
Inotropic therapy
ISOPROTERENOL (ISOPRENALINE)
Inotropic therapy
PHOSPHODIESTERASE INHIBITORS
Inotropic therapy
CALCIUM SENSITIZERS
Inotropic therapy
On trial
• Istaroxime
Inhibits the Na/K ATPase
Inotrop & lusitrop effects