cardiovascular parameters
TRANSCRIPT
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Cardiovascular Parameters
Normal Values
Cardiac Output (CO) 4 – 8 L/min
Cardiac Index (CI) 2.5 – 4 L/min
Systemic Vascular Resistance (SVR) 800 – 1400
Systemic Vascular Resistance Index (SVRI) 1500 – 2400
Pulmonary Capillary Wedge Pressure (PCWP)
Central Venous Pressure (CVP)
Pulmonary Artery Pressure (PAP) 20 – 30/6 – 15
11 ± 4
7 ± 2
Mixed Venous Oxygen Saturation (SvO2) 70 ± 5
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Life's Little Equations
CO = HR* x SV SVR = MAP / CO CI = CO / BSA SVRI = SVR x BSA
CaO2 = (Hgb x 1.34 x SaO
2) + (pO
2 x 0.003)
DO2 = CO x CaO
2
VO2 = CO x (CaO
2 –
CvO
2)
Normal DO2 : VO
2= 5 : 1
*HR decreases CO above 120 – 150bpm
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The Pump
Preload ~ ED length ↔ EDV ↔ filling pressure Afterload ~ SVR EDV: preload, ventricular distensibility ESV: afterload, ventricular contractility SV = LVEDV – LVESV Atrial kick 15 – 30% LVEDV EF = SV / EDV
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Shock
Types of Shock
CVP and PCWP CO SVRI
Hemorrhagic ↓ ↓ ↑Septic ↕ ↑ ↓
↑ ↓ ↑↓ ↓ ↓↕ ↓ ↓
Cardiogenic
Neurogenic
Hypoadrenal
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Shock
Adrenal Insufficiency− Acute – CV collapse unresponsive to IVF / pressors− Chronic – hyperpigmentation, weakness, wt loss,
↑K, ↓Na, fever, hypotension− Steroid potency
1x cortisone, hydrocortisone 5x prednisone, prednisolone, methylprednisolone 30x dexamethasone
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Shock
Neurogenic Shock− Loss of sympathetic tone− ↓HR, ↓BP, warm skin− Volume, then phenylephrine
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Shock
Hemorrhagic Shock− Initially, ↑diastolic pressure
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Shock
Cardiac Tamponade− ↓EDV, ↓SV, ↓CO = hypotension− Beck's triad
Hypotension, JVD, muffled heart sounds
− Pericardiocentesis blood does not clot
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Shock
Septic Shock− Early sepsis triad
Respiratory alkalosis, confusion, hyperglycemia
− Early gram negative sepsis ↓ insulin, ↑ glucose (impaired utilization)
− Late gram negative sepsis ↑ insulin, ↑ glucose (insulin resistance)
− Xigris: activated protein C fibrinolysis
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Emboli
Fat emboli s/p LE fx, procedure− Petechia, hypoxia, confusion− Sudan stain for fat in urine and sputum
PE− PAP >40, ↓pO
2 and pCO
2, respiratory alkalosis, CP,
cough, dyspnea, ↑HR, hemoptysis Air embolus
− Trendelenburg, left lateral decubitus, aspirate w/ central line or PA catheter
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Intra-Aortic Balloon Pump
Inflates on diastole− Improves coronary perfusion and SBP
Deflates on systole− Decreases afterload
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Receptors
Alpha-1
− Vascular smooth muscle contraction, gluconeogenesis, glycogenolysis
Alpha-2
− Venous smooth muscle contraction Beta-1
− Myocardium contraction and rate Beta-2
− Bronchial smooth muscle and vascular smooth muscle relaxation, increases insulin, glucagon, renin
Dopamine
− Relax renal and splanchnic smooth muscle
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Nifty Drugs
Dopamine− Low dose: renal dopamine− Moderate dose: heart beta− High dose: vascular alpha
Dobutamine− Low dose: beta-1 (contractility)− High dose: beta-2 (vasodilation, HR)
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Cool Drugs
Milrinone− Phosphodiesterase inhibitor (↑ cAMP)− ↑ Ca flux and ↑ myocardial contractility− Vasodilation
Phenylephrine− Alpha-1 vasoconstriction
Hydralazine− Alpha blocker
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Drugs, Drugs, Drugs...
Norepinephrine− Low dose: Beta-1− High dose: Alpha-1, Alpha-2− Splanchnic vasoconstrictor
Epinephrine− Low dose: Beta-1, Beta-2 (↓BP)− High dose: Alpha-1, Alpha-2
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Groovy Drugs
Isoproterenol− Beta-1, Beta-2− Arrhythmogenic!!
Vasopressin− V-1: vasoconstriction− V-2: water reabsorption− V-2: release Factor VIII and vWF
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Dynamite Drugs
Nipride− Arterial and venous dilator− Cyanide toxicity
Amyl nitrite, then sodium nitrite
Nitroglycerin− Venodilation decreases preload and myocardial
wall tension
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Pulmonary
Compliance = ∆V/∆P− ↓ in ARDS, fibrosis, pulmonary edema, reperfusion
injury Aging
− ↓ FEV1 and VC, ↑ FRC
V/Q− High ~ high− Low ~ low
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Ventilator
PEEP− Alveoli recruitment – improves FRC (O
2 reservoir)
− ↓ RA filling, ↓ CO, ↓ renal flow, ↑ PVR Minute ventilation = RR x TV
− Adjust pCO2
PS− Decrease work of breathing
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PFT
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Chronic Lung Disease
Restrictive− ↓ TLC, ↓ RV, ↓ FVC
− FEV1 ↕
Obstructive− ↑ TLC, ↑ RV, ↓ FEV
1
− FVC ↕
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Dead Space
Ventilation, but not perfused by pulmonary circulation
Normal airway to level of bronchiole (150cc) Increased by
− Drop in CO− PE− ARDS− High PEEP
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ARDS
Acute onset Bilateral infiltrates on chest radiograph PCWP < 18 mmHg or lack of clinical left
ventricular failure PaO2 / FiO2 < 300 mmHg = ALI PaO2 / FiO2 < 200 mmHg = ARDS Cellular-mediated inflammation, debris, ↑
gradient, ↑ shunt, ↓ compliance
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Aspiration
PH <2.5 and volume >0.4 cc/kg associated w/ severity
− Gastric acid prophylaxis Mendelson's syndrome – chemical pneumonitis Posterior RUL and Superior RLL
− Dependant when supine
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Atelectasis
Bronchial obstruction and respiratory failure Most common post op fever within 48 hrs Fever, tachycardia Risks
− COPD, Upper abdominal surgery, obesity Ambulate, incentive inspirometer, cough, deep
breathe
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Renal Failure
Indications for dialysis A, E, I, O, U
− Acidosis− Electrolyte K+− Ingestion: poisoning− Overload− Uremia / uremic coagulopathy
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Brian Death
Precludes diagnosis:− Uremia, T>30, BP<70/40, desaturation w/ apnea
test, drugs, metabolic derangements 6-12 hrs:
− No pain response, absent caloric reflex, absent oculocephalic reflex, positive apnea, no corneal reflex, no gag reflex, pupils F&D
Apnea test:− CO2 >60 or increase in CO2 by 20− If BP drops or pt desats, test terminated