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118 Cards in this Set

  • Front
  • Back
How do you calculate MAP?
2/3 Diastolic + 1/3 Systolic
What is BP usually associated with?
Oxygen delivery and Tissue Perfusion
How do you CALCULATE BP?
CO x SVR
What is SVR?
Systemic Vascular Resistance
What two major hemodynamic components remain in balance to maintain adequate BP?
CO and SVR
DEFINITION of Cardiac Output
The volume of blood ejected per minute
How do you CALCULATE CO?
SV x HR
What are 3 components of Stroke Volume (SV)?
Preload
Afterload
Contractility
SV indicates the volume ejected during _________.
Systole
Definition of Preload
How much blood is going to the left ventricle
What is the main hemodynamic component that helps estimate preload?
Pulmonary capillary wedge pressure
(PCWP)
What is the significance of the Frank-Starling Curve?
It indicates that preload has a more significant effect on SV in normal hearts but its effect is diminished in those which heart failure.
What is the definition of Afterload?
Resistance of the Left Ventricle
What hemodynamic component best estimates Afterload?
SVR
Systemic Vascular Resistance
Describe use of CI?
Cardiac index normalizes CO to the persons body size
How do you calculate CI?
CO/BSA
Describe NON-invasive forms of hemodynamic monitoring
Vital signs (BP,HR)
Pulse oximetry (PaO2)
Transthoracic echocardiogram (TTE) - Measures ejection fraction
Describe Invasive forms of hemodynamic monitoring
1. Arterial line (PaO2)
2.Centra Venous Catheter (Measures BP (Fluid status of venous side)
3.Pulmonary arterial catheter
Describe 4 things that a Pulmonary Arterial Catheter is useful for
1.Volume status
2.Ventricular Performance
3.Estimating O2 delivery and uptake
4.Useful for differentiating shock syndromes
Describe effect on mortality of Pulmonary Arterial Catheter
No difference
What complications may arrise from the use of a Pulmonary Arterial Catheter?
Premature Atrial or Ventricular contractions and pulmonary artery rupture
In a basic way, describe what a PAC measures
Measures pulmonary capillary blood pressure --> How much fluid is going into the left ventricle.
Describe 6 things that PAC can measure directly
1.Central Venous Pressure
2.Pulmonary Artery Pressure
3.Pulmonary Capillary Wedge Pressure (PCWP)
4.Cardiac output
5.Mixed venous oxygen saturation (SVO2)
4 things that a PAC lets you calculate
1.SV
2.CI
3.SVR
4.Left Ventricular stroke work index
CVP
Centra Venous Pressure
PAP
Pulmonary Artery Pressure
PCWP
Pulmonary Capillarly Wedge Pressure
SVO2
Mixed Venous Oxygen Saturation
LV SWI
Left ventricular stroke work index
CO NORMAL VALUES
4.7
CI NORMAL VALUES
2.8-4.5 L/MIN/M2
SV NORMAL VALUES
60-100 ML
SVR NORMAL VALUES
900-1400 DYNES SEC/CM5
PCWP NORMAL VALUES
6-15 MMHG
CVP
2-6 MMHG
MAP NORMAL VALUES
80-100 MMHG
A high PCWP typically corresponds with what pulmonary condition?
Edema
Fluid status is typically indicated by what hemodynamic figure?
CVP
Cardiac Inotropy is typically indicated by what hemodynamic figure?
CI
O2 consumption is typically indicated by what hemodynamic figure?
SVO2
Organ Perfusion is typically indicated by what hemodynamic figure?
MAP
Preload is typically indicated by what hemodynamic figure?
PCWP
What is our goal MAP?
>65 mmhg (Normal 80-100)
What are our main pharmacologic goals?
Increase Perfusion (MAP/CO)
Normalization of Oxidative metabolism (Increase MAP/CO)
Describe why Acidosis can occur in a hemodynamically challenged patient?
Anaerobic metabolism begans to occur which produces acidotic byproducts that result in acidosis
3 Types of Fluid Replacements
1.Crystalloids
2.Colloids
3.Blood Products
Examples of Crystalloids
Normal Saline
Lactated Ringer
Advantage of Lactate ringer vs NS
Helps with acidosis since it gets converted into bicarb
Advantages of Crystalloids
1.Low Cost (1st option)
2.Widely Available
Disadvantages of Crystalloids
Only 25-33% remain in intravascular space (Want 80%)
Examples of Colloids
Albumin 5%
Heatstarch 6%
Advantages of Colloids
Range from 80-100% remain in intravascular space.
Disadvantages of Colloids
Very expensive
Not very readily available
When should you use Blood products for fluid replacement?
If there has been substantial blood loss of Hgb is down.
Examples of Blood Products
Whole Blood
Packed Red blood cells (PRBC)
Platelets
Cryoprecipitate (Factors 7, Protein C and S, etc...)
Treatment goals for Fluids to maintain adequate circulation for Tissue Perfusion
1. MAP >60-65
2. SBP >90mmHg
3. CI > 2.2L/min/m2
In terms of fluid treatment, what are some additional markers of adequate perfusion?
1.Normal HR (<90BPM)
2.Adequate urine output (>0.5-1ml/Kg/Hr)
3 Main Hemodynamic Components associated with Adequate Tissue Perfusion
MAP
SBP
CI
Must See Contraction!
Alpha-1 Physiologic Effect
Arterial and Venous Vasoconstriction
Beta-1 Physiologic Effect
Increase contractility, chronotropy
Beta-2 Physiologic Effect
Arterial and venous vasodilation
DA Physiologic Effect
Vasodilation
VP Physiologic effect
Vasoconstriction, fluid retention, increase in cortisol
Alpha-1 Hemodynamic Effect
+SVR
+MAP
Beta-1 Hemodynamic Effect
+CO, +HR
Beta-2 Hemodynamic Effect
-SVR
DA Hemodynamic Effect
?
Increased urine output
VP Hemodynamic effect
+SVR
+MAP
Name 5 Vasopressors
1.Dopamine
2.NE
3.EPI
4.PE
5.Vasopressin
Name 4 Inotropes
1.DA
2.Dobutamine
3.Milrinone
4.Levosimendan
What 3 receptors does DA effect?
1. DA Receptors
2. Beta-1 Receptors
3. Alpha-1 Receptors
Effects of DA on DA receptors
1.Mesenteric BF
2.Renal BF
3.Inhibits proximatl tubule Na reabsorption
Effects of DA on Beta receptors
1.Increase ionotropy, chronotropy (How hard and fast heart beats)
2.Small increase in peripheral vasodilation
Effects of DA on Alpha-1 receptors
1.Increases peripheral vasoconstriction
DA effect on DA receptors on Parameters
Increase in urine output
Effect of DA on Beta1 on parameters
+CO
+HR
+Contractility
Effect of DA on Alpha1 on parameters
+SVR
+MAP
Dopamine dose to affect DA receptors
0.5-3 mcg/kg/min
Dopamine dose to affect Beta2
3-10 mcg/kg/min
Dopamine dose to affect Alpha1
10-20 mcg/kg/min
When Dopamine affects Alpha-1, which other receptors does it feel up?
Beta1, but not DA
What renal implications exist for Dopamine
Basically, they used to dose therapy differently in oliguric patients based on its effect on DA renal receptors, however, not demonstrated to improve anything and it failed to demonstrate efficacy in critically ill patients.
Adverse effects of DA
Tachyarrhythmia (Beta1)
Increase afterload and preload
Increase myocardial oxygen demand (Can cause MI, D/C pressor ASAP)
Peripheral ischemia
Pulmonary congestion
Describe the effects of Norepinephrine
1.Stimulates Alpha-1 (Increase peripheral vasoconstriction +SVR)
2.No effect on Beta receptors
Describe what factor can affect effect of Norepinephrine.
Increase in dose required, acidosis decreases activity.
Describe dosing of Norepinephrine
2-50 mcg/min (Max 200 mcg/min)
Titrate dose to MAP > 65mmHg
Adverse effects of NE
1. Increased afterload (+SVR)
2. Cardiac arrythmias
3. Peripheral Ischemia
4. + Myocardial oxygen demand (Not as much as DA)
Describe effects of Phenylephrine
Stimulation of Alpha-1 receptors (increase peripheral vasoconstriction)

No effect on beta receptors
(No effect on myocardial demand)
Describe dosing of Phenylephrine
30-300 mcg/min (max 200mcg/min)
Dose titrated to MAP > 65
Adverse effects of Phenylephrine
1.+Afterload
2.Reflex Bradycardia
3.Peripheral Bradycardia
4.Peripheral ischemia (HORRIBLE, worse than EPI, will amputate fingers/toes if used for more than 4-5 days, 2nd line agent)
5.Myocardial ischemia
6.Hypertension
Effects in EPI
Stimulation of Alpha-1 Receptors
Stimulation of Beta2
-->Increased inotropy,chronotropy
-->Increased peripheral vasodilation
Dosing for Beta1 and Beta2 FOR EPI
0.01-0.05
Effect for Beta1 and Beta2
FOR EPI
Increase in SVR, MAP
Dosing for Alpha1, Beta1 for EPI
>0.05
Effect of Alpha1, Beta1 for EPI
+CO
+HR
Contractility
EPI Adverse Effects
Increased myocardial demand
Tachyarrhythmia
Ischemia
Lactic Acidosis
Which agent is an Antidiuretic hormone?
Vasopressin
What receptors dose Vasopressin hit?
VP1->Peripheral Vasoconstriction
VP2->Na/H2O restriction, Decrease urine output
VP3->Increase ACTH and cortisol
Use of Vasopressin
Adjunct to other vasopressors, it allows reduction of dose of other vasopressors.
Vasopressin Dosing
0.01-0.04 units/min
ADR of Vasopressin
1.Decreased CO
2.Myocardial and splanchnic ischemia (Necrotic bowel)
For what receptors do we use Dobutamine predominantly?
Beta effects
Effects of Dobutamine
1. Stimulation of Beta receptors (+Inotropy/Chronotropy, +CO), small increase in peripheral vasodilation
2.Stimulation of alpha-1 receptors (Increase in peripheral vasoconstriction(minimal), much smaller effect than beta.
Dobutamine dosing
2.5 mcg/kg/min
MAX 20mcg/kg/min
Tritate to desired CI
ADR of Dobutamine
1.Ventricular Arrhythmias
2.Hypotension
3.+Myocardial oxygen demand
Does Dobutamine effect SVR?
No
Does Dobutamine affect CO?
Yes
ADR of Dobutamine
Ventricular arrythmias
Hyoptension
Myocardial oxygen demand
Milrinone Effects
PDE-3 Inhibitor
1.Stops breakdown of cAMP in myocardium and vasculature

2.+Contractility and Peripheral vasodilation (-BP)
Milrinone Dosing
BOLUS(OPTIONAL)-50mcg/kg/IV over 10min

Infusion 0.25-0.75mcg/kg/min
Renal adjustment 0.2-0.43mcg/kg/min based on CrCl
Adverse Effects of Milrinone
1.Hypotension
2.Ventricular Arrhythmias
3.Headache
4.Thrombocytopenia
5.Reflex Tachycardia
Effect of Levosimendan
1.Calcium sensitizing of myocardial tissues
2.Some PDE3 inhibitory activity (+Contractility and peripheral vasodilation)
(NOT APPROVED IN US-->USED IN EUROPE)
Dosing for Levosimendan
Currently not approved for use in the US
0.1-0.2mcg/kg/min used in studies of cardiogenic and septic shock
Adverse effects of Levosimendan
Hypotension
Headache
Reflex Tachycardia
Vasopressin Receptor Effect
Decrease urine output
Beta-2 receptor stimulation effects
Decrease in SVR
Alpha-1 receptor stimulation effects
Increase in SVR and MAP
Beta-1 receptor stimulation effects
Increase in CO and HR