monitoring hemodynamics-lost in translation
DESCRIPTION
fractals and hemodynamics are brought together just for the fun of it!TRANSCRIPT
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MONITORIZAREA HEMODINAMICA
SUUB
2013
Cosmin Balan
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Lost in translation…
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Unii sunt inca pierduti
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Lost in translation
A cloud is made of billows upon billows
upon billows that look like clouds.As you
come closer to a cloud you don’t get something
smooth,but irregularities at a smaller scale.
Benoit Mandelbrot
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Fractali si power-law
1
2
3
4 6
5
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Fractali si power-law
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Fractali si power-law
• Pattern self-similar
• Iteratie la infinit
• Marime nontopologica-euclidiana ci
fractala
• Forma complexa,neregulata
• Matematic functii nederivabile
• Sunt descriptibili matematic prin
ecuatii de tip power-law
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Fractali si power-law
11.5•200=2300 28•100=2800 70•50=3500
Cat de lunga este coasta Marii Britanii?
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Fractalii sunt viata
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Dimensiunea fractala
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Box counting
Studiu in cancerul oral-melanom
Patrate mai mari patrate mai
putine
Relatie de tip power law intre
numarul de patrate si marimea
patratului
Power law e afisata de fractalitate
tgα=dlogN/dlog1/S
tgα=1.4181
N=S-1.4181
D=-1.4181
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Viata inseamna SOC
Avalansele pot fi intelese doar
intelegand intregul
Avalansele pot fi descrise din
punct de vedere al relatiei marime-
numar prin power law
Gramajoara de nisip e un exemplu
de complexitate
Ea sta intr-o stare de criticalitate
auto-organizata
Coeficientul power-law este -1
Evolutia in timp a avalanselor are
un profil descris matematic de tip
power-law(marime vs intervale de
timp)
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SOC peste tot
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Extinctions of all sizes,including mass extinctions,may
be a simple consequence of ecosystem dynamics.
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Fuga dupa asteroid
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MODS si “GOOD HEALTH”- ordine de
stabilitate
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Fractali in fiziologie
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Fractalitate temporala
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Fractali in fiziologie
Bela Suki
‘Fluctuations and power
laws in pulmonary
physiology’
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Monitorizam propriul model!
Pompa
Tesut
Abdomen-Lung
interaction
Heart-Lung
interaction
Volemie
Circuit venos
Circuit arterial
Model
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Guytonian view
U=I•R
ΔP=R•D
MAP-PVC=SVR•CO
CO= f(LVEDV)
Pes=f(HR,SV,SVR)
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MSFP
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MSFP
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Modularea MSFP
Volumul creste intoarcerea venoasa.
Acelasi tip de curba este valabil pentru
cresterea tonusului vasomotor(scaderea
capacitantei).
Scaderea SVR muta MSFP in aval si
astfel RVR scade=>VR
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Modularea MSFP
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Modulare simultana cu Frank
Starling
Suprapunerea celor doua
curbe nu este matematic
corecta.
Ramane un element didactic.
Pe abscisa se afla o presiune
pentru curba venoasa si
o diferenta presionala pentru
curba Frank Starling(presiune
transmurala).
Pcrit=>
colaps
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Frank Starling si RV
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STRESSED volume
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MSFP-fluid si venotonus dependenta
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MSFP-adaptabil pe seama capacitantei
venoase
Dupa Gelman S. Aox=aortic cross-clamping
Capacitanta▼ Capacitanta▲
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Partitionarea trunchiului vascular
Pao,Pms,Pcv,Dc=monito
-rizabile
Creste debitul cardiac
prin efect inotrop direct
Scade Pms
Scade Rv
RA RV
Pao Pms Pcv
U=I•R
ΔP=R•D
Pao-Pms=Ra•D
Pms-Pcv=Rv•D
Rv+Ra=Rsys
α •Tgα=(Pao-Pcv)/Rsys
•Tgα=(Pms-Pcv)/Rv
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Altfel spus…
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De ce ai monitoriza MSFP?
Este un bun indicator de volemie
Poate fi un indicator dinamic al capacitantei venoase
Poate fi folosit pentru estimarea compliantei
vasculare
Concomitent masurat cu PVC,pot fi folosite pentru
aprecierea functiei pompei si a responsivitatii la fluid
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‘Masurarea’ MSFP in STI
• MSFP-Pcv=Rv•Dc
• MSFP-Pcv1=Rv•Dc1
• MSFP-Pcv2=Rv•Dc2
• 2 necunoscute Rv si MSFP
• 2 ecuatii
• Rv=(Pcv2-Pcv1)/(Dc1-Dc2)
Maas,Pinsky 2009
•MSFP-Pcv1=Rv•Dc1
Dc1
Pcv1
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Masurarea Cs cu MSFP
• C=ΔV/ ΔP
• C= ΔV/Pmsfa
• C= (ΔV+Vx)/Pmsfb
Vx
Pmsf
a Pmsfb
Maas,Pinsky 2009
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Modelul Parkin
“The Navigator systematizes
cardiovascular management
to simplify cognitive tasks,
reduce side effects and to
ensure better achievement
of therapeutic targets.”
Pmsa = 0.96•RAP+0.04•MAP+0.96•1/26•SVRnBW•CO
EH=(Pmsa-RAP)/Pmsa
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Frank Starling -recapitulare-
Capacitatea inimii de a-si creste forta de contractie
ca raspuns la cresterea presarcinii.
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Responsivitatea la fluid
-Frank-Starling-
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Responsivitatea la fluid
-Frank Starling-
De ce parametrii statici presionali nu sunt indicatori de responsivitate la fluid.
Parametrii statici volumetrici sunt mai apropiati de ceea ce inseamna Lsarcomer.
dP=dV/C
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Principiile responsivitatii la fluid
Administrezi fluid avand drept scop cresterea debitului cardiac.
Cresterea debitului cardiac trebuie individualizata(unde e necesar).
Administrezi fluid atunci cand pacientul ar raspunde la acesta
prin cresterea debitului cardiac(reiese necesitatea de a prezice).
Ai nevoie de 2 ventriculi preload-dependenti.
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Heart-lung interaction
Respiratie spontana
Inspir
Creste preload RV
Scade afterload RV
Creste afterload LV
Scade preload LV
scade preload RV
creste afterload RV
scade afterload LV
creste preload LV
Expir
Ventilatie mecanica
Inspir
Creste preload RV
Scade afterload RV
Creste afterload LV
Scade preload LV
Expir
scade preload RV
creste afterload RV
scade afterload LV
creste preload LV
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Heart-lung interaction
Creste RV afterload
Scade RV preload
Creste LV preload
Scade LV afterload
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Decalaj indus de timpul de tranzit
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Cum se traduce asta la patul bolnavului?
PPV SVV PEPV AoBFV EEP SVC CI IVC DI
INDICI DE RESPONSIVITATE INRUDITI
-DINAMICI-
13% 11% 17% 12% 15% 18% 36%
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Dinamic vs static in predictia
responsivitatii la fluid
Michard 2000
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Sensibilitatea TA la presarcina
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Sensibilitatea TA la presarcina
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Sensibilitatea TA la presarcina
Ees=tgα=Pes/(EDV-SV-Vo)
Ea=tgβ=Pes/SV
Pes=a•(Ved-Vo) unde
a=1/(1/Ea+1/Ees)
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Sensibilitatea TA la presarcina
PPV SVV
PPV/SVV=
Eadyn
0.89
Eadyn echivaleaza cu tonus vasomotor.
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Sensibilitatea la presarcina
Pentru Eadyn>0.89 cresterile tensionale pentru
acelasi SVV sunt mai pronuntate si denota un tonus
vasomotor mai accentuat.
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Limitele SVV/PPV in
predictia responsivitatii la fluid.
Aritmii (SV mult neregulat)
VT mic (dPpl prea mic)-ex.ARDS
Rata respiratorie mare
Cord pulmonar (PVR mare)
IAP mare (Ecw mare=>dPpl f.mare)
Respiratie spontana
Doze mari de vasopresoare
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PLR
Autotransfuzie de aprox.300ml sange
Masurare continua de CO!
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PLR-CO vs PP
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PLR si CVP
Necesar un minim de 2mmHg in ∆PVC
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EEP-pauza end expiratorie
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MAP-IAP>60mmHg MAP-2IAP ?
PICCO
SVV/PPV- cut off?
ECW mult crescuta
EDPVR mult “saltata”
Sdr. de compartiment abdominal
PLR nu merge
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“Masurarea” debitului cardiac
Dilution
technique
Echo
transeso
Pulse Contour
analysis
Debit Cardiac
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PICCO
2 catetere-unul venos central si altul arterial
2 metode complementare-dilutie si PCA
Pe cateterul venos se injecteaza un indicator
Pe cateterul arterial se citeste conc. indicatorului
si se analizeaza unda arteriala
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PICCO
O galeata cu apa Vx pura
4 mg indicator
Concentratia indicatorului devine 2
Care este volumul de apa?
Vx= cantitate indicator/Δconcentratie
Flux=Vx/timp
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PICCO
AUC
AUC=Δconc. medie•timp
Volum=cantitate indicator/ Δconcentratie medie
CO=Volum/timp
CO=cantitate indicator/AUC
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PICCO
AUC
Cantitate
AUC
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PICCO
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PICCO -distributia fluidului indicator-
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PICCO -compartimente-
ITTV=CO•MTT
PTV=CO•Dst
GEDV=ITTV-PTV
ITBV=1.25•GEDV
EVLW=ITTV-ITBV
PVPI=EVLW/PBV CFI=CI/GEDVI GEF=4•SV/GEDV
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PICCO -analiza undei arteriale-
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PICCO
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PICCO
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PICCO -plan terapeutic-
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Hemosonic 100
Debit Aod/Debit total=70%
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Socul hipovolemic
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Socul cardiogen
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Socul septic
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Socul obstructiv -pneumotorax in tensiune-
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Socul obstructiv
-compresie de VCI-
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Socul spinal
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