Hemodynamic Disorders, Hemodynamic Disorders, Thrombosis & Thrombosis & ShockShock

Edema Hyperemia and Congestion Hemorrhage Hemostasis & Thrombosis Embolism Infarction Shock

• EdemaEdema

EDEMAEDEMA

Fluid extravasations and Fluid extravasations and

accumulation in the accumulation in the

interstitial spaces interstitial spaces

EDEMAEDEMA

Increased fluid in theIncreased fluid in the interstitial tissue spacesinterstitial tissue spaces

Fluid may also accumulate in body cavities:body cavities:

1.1. HydrothoraxHydrothorax

2.2. HydropericardiumHydropericardium

3.3. Hydroperitoneum is also called Hydroperitoneum is also called AscitesAscites

Massive generalized edema is called Massive generalized edema is called AnasarcaAnasarca

Fluid HomeostasisFluid Homeostasis

Homeostasis is maintained by Homeostasis is maintained by

the the opposing effectsopposing effects of: of:

1.1. Vascular Hydrostatic Vascular Hydrostatic

PressurePressure

and and

2.2. Plasma Colloid Osmotic Plasma Colloid Osmotic

PressurePressure

Lymphatics

Edema Fluid = TRANSUDATEEdema Fluid = TRANSUDATE

A transudatetransudate is protein-poor (specific gravity <1.012)

An exudateexudate is protein-rich (specific gravity >1.020)

= (inflammatory edema)(inflammatory edema)

Pathophysiologic Categories of EdemaPathophysiologic Categories of Edema

I.Increased Hydrostatic Pressure

II.Reduced Plasma Oncotic Pressure

III.Inflammation

IV.Others

I. Increased Hydrostatic Pressure

Pathophysiologic Categories of EdemaPathophysiologic Categories of Edema

Increased Hydrostatic PressureIncreased Hydrostatic Pressure

1. Due to impaired venous returnvenous return

A)A) Localized:Localized:

Venous Thrombosis

B)B) Generalized:Generalized:

Congestive Heart Failure

2. Due o increased arteriolar dilatationarteriolar dilatation

Increased Hydrostatic PressureIncreased Hydrostatic Pressure

Congestive Heart Failure:Congestive Heart Failure:

““Generalized increaseGeneralized increase in venous pressure,

with resultant SYSTEMIC EDEMASYSTEMIC EDEMA occurs

MOST COMMONLYMOST COMMONLY in in CONGESTIVE HEART FAILURE”CONGESTIVE HEART FAILURE”

{*** Thus, Congestive Heart Failure is the most common cause of EDEMA due to {*** Thus, Congestive Heart Failure is the most common cause of EDEMA due to

Increased Hydrostatic Pressure}Increased Hydrostatic Pressure}

Congestive Heart FailureCongestive Heart Failure

Overall, there are TWO main effects...

1. Increased Central Venous Pressure

2. Decreased Renal Perfusion

Increased Hydrostatic PressureIncreased Hydrostatic Pressure::

Congestive Heart FailureCongestive Heart Failure

Mechanism:Mechanism:

The Pump is FAILING!!! Cardiac output

Blood backs up, first into the lungs

then into the venous circulation

increasing Central Venous Pressure (CVP)

increased capillary pressure (Hydrostatic Pressure)increased capillary pressure (Hydrostatic Pressure)

Leading to EdemaEdema

Congestive Heart Failure:Congestive Heart Failure:

& Decreased Renal Perfusion& Decreased Renal Perfusion

Congestive heart failure

Decreased Cardiac OutputDecreased Cardiac Output Decreased ARTERIAL blood volume

“Less arterial blood…Less renal perfusion...

The Kidney doesn’t see enough blood coming through …….

Congestive Heart Failure:Congestive Heart Failure:

& Decreased Renal Perfusion& Decreased Renal Perfusion

Decreased Renal Perfusion activates

the Renal Defense Mechanisms:Renal Defense Mechanisms:

1. Renin-Angiotensin-Aldosterone axis

Na & H2O Na & H2O

retentionretention

2. Renal Vasoconstriction

3. Increased Renal Anti-diuretic Hormone (ADH)

Congestive Heart Failure - Congestive Heart Failure - SummarySummary

CentralVenousPressure

Renal

Perfusion

Renin

Renal Vasoconstriction

ADH

Pathophysiologic Categories of EdemaPathophysiologic Categories of Edema

I.Increased Hydrostatic Pressure

II.Reduced Plasma Oncotic Pressure

III. Inflammation

IV. Other

II. Reduced Plasma Oncotic PressureII. Reduced Plasma Oncotic Pressure

Reduced PlasmaReduced PlasmaOsmotic PressureOsmotic Pressure

“…“…AlbuminAlbumin::

is the serum protein MOST responsible for the is the serum protein MOST responsible for the

maintenance of maintenance of colloid osmotic pressure.”colloid osmotic pressure.”

A decrease in osmotic pressuredecrease in osmotic pressure can result from:

1. Protein Loss

or or

22 Protein Synthesis

Reduced PlasmaReduced PlasmaOsmotic PressureOsmotic Pressure

1.1. Increased albumin loss: Increased albumin loss:

Nephrotic Syndrome

Increased permeability of the glomerular capillary wall

loss of protein

2.2. Reduced albumin synthesis Reduced albumin synthesis

Cirrhosis

Protein malnutrition

Pathophysiologic Categories of EdemaPathophysiologic Categories of Edema

I.Increased Hydrostatic Pressure

II.Reduced Plasma Oncotic Pressure

III.Inflammation

IV.Other

III. InflammationIII. Inflammation

Pathophysiologic Categories of EdemaPathophysiologic Categories of Edema

I.Increased Hydrostatic Pressure

II.Reduced Plasma Oncotic Pressure

III.Inflammation

IV.OthersIV. OthersIV. Others::- Lymphatic Obstruction- Sodium & water retention

Lymphatic ObstructionLymphatic Obstruction

Impaired lymphatic drainage with resultant

lymphedemalymphedema

usually localized

usually due to: INFLAMMATION INFLAMMATION

or

NEOPLASTIC OBSTRUCTION NEOPLASTIC OBSTRUCTION

Lymphatic ObstructionLymphatic Obstruction

FilariasisFilariasis –

A parasitic infection affecting

inguinal lymphatics resulting

in elephantiasis

Lymphatic Obstruction Lymphatic Obstruction

NeoplasticNeoplastic

Resection and/or radiation to axillary lymphatics in

breast cancer patients can lead to -- arm edemaarm edema

Carcinoma of breast with obstruction of superficial

lymphatics can lead to edema of breast skin -- --with an

unusual appearance:

““peau d’orange” (orange peel)peau d’orange” (orange peel)

EDEMA - EDEMA - SummarySummary

INCREASEDHYDROSTATICPRESSURE

Congestive Heart FailureAscitesVenous Obstruction

DECREASED ONCOTICPRESSURE

Nephrotic SyndromeCirrhosisProtein Malnutrition

INCREASEDPERMEABILITY

Inflammation

LYMPHATICOBSTRUCTION

InflammatoryNeoplastic

HEART LIVER KIDNEY

GENERALIZED EDEMAGENERALIZED EDEMA

HEART LIVER KIDNEY

EdemaEdemaMorphologyMorphology

Dependent EdemaDependent Edema is a prominent

feature of Congestive Heart Failure

Facial EdemaFacial Edema is often the initial

manifestation of Nephrotic

Syndrome

Subcutaneous EdemaSubcutaneous Edema

Edema of the subcutaneous tissue is most easily detected GrosslyGrossly (not microscopically)

Push your finger into it

and a depression remains

EdemaEdema

Clinical Correlation:Clinical Correlation:

Subcutaneous EdemaSubcutaneous Edema

Annoying but Points to Underlying Disease

However, it can impair wound healing or it can impair wound healing or

clearance of Infectionclearance of Infection

EdemaEdemaMorphologyMorphology

Pulmonary EdemaPulmonary Edema

is most frequently seen in Congestive Heart FailureCongestive Heart Failure

May also be present in renal failure, adult respiratory

distress syndrome (ARDS), pulmonary infections and

hypersensitivity reactions

Pulmonary Edema Pulmonary Edema

Gross:Gross:

The Lungs are typically 2-3 times the normal weight Cross sectioning causes an outpouring of frothy, outpouring of frothy,

sometimes blood-tinged fluidsometimes blood-tinged fluid

Pulmonary Edema

Normal

EdemaEdema

Clinical Correlation:Clinical Correlation:

Pulmonary EdemaPulmonary Edema

May cause deathdeath by interfering with Oxygen and

Carbon Dioxide exchange

Creates a favorable environment for infectioninfection THINK it resembles “Culture Media”!!!

Edema of the BrainEdema of the Brain

Trauma, Abscess, Neoplasm, Infection

(Encephalitis due to say… West Nile Virus), etc

Clinical Correlation: Clinical Correlation: Edema of the BrainEdema of the Brain

The big problem is: There is no place for the fluid to go!

Herniation into the foramen magnum will kill