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118 Cards in this Set
- Front
- Back
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How do you calculate MAP?
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2/3 Diastolic + 1/3 Systolic
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What is BP usually associated with?
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Oxygen delivery and Tissue Perfusion
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How do you CALCULATE BP?
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CO x SVR
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What is SVR?
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Systemic Vascular Resistance
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What two major hemodynamic components remain in balance to maintain adequate BP?
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CO and SVR
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DEFINITION of Cardiac Output
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The volume of blood ejected per minute
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How do you CALCULATE CO?
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SV x HR
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What are 3 components of Stroke Volume (SV)?
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Preload
Afterload Contractility |
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SV indicates the volume ejected during _________.
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Systole
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Definition of Preload
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How much blood is going to the left ventricle
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What is the main hemodynamic component that helps estimate preload?
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Pulmonary capillary wedge pressure
(PCWP) |
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What is the significance of the Frank-Starling Curve?
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It indicates that preload has a more significant effect on SV in normal hearts but its effect is diminished in those which heart failure.
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What is the definition of Afterload?
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Resistance of the Left Ventricle
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What hemodynamic component best estimates Afterload?
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SVR
Systemic Vascular Resistance |
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Describe use of CI?
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Cardiac index normalizes CO to the persons body size
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How do you calculate CI?
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CO/BSA
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Describe NON-invasive forms of hemodynamic monitoring
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Vital signs (BP,HR)
Pulse oximetry (PaO2) Transthoracic echocardiogram (TTE) - Measures ejection fraction |
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Describe Invasive forms of hemodynamic monitoring
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1. Arterial line (PaO2)
2.Centra Venous Catheter (Measures BP (Fluid status of venous side) 3.Pulmonary arterial catheter |
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Describe 4 things that a Pulmonary Arterial Catheter is useful for
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1.Volume status
2.Ventricular Performance 3.Estimating O2 delivery and uptake 4.Useful for differentiating shock syndromes |
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Describe effect on mortality of Pulmonary Arterial Catheter
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No difference
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What complications may arrise from the use of a Pulmonary Arterial Catheter?
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Premature Atrial or Ventricular contractions and pulmonary artery rupture
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In a basic way, describe what a PAC measures
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Measures pulmonary capillary blood pressure --> How much fluid is going into the left ventricle.
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Describe 6 things that PAC can measure directly
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1.Central Venous Pressure
2.Pulmonary Artery Pressure 3.Pulmonary Capillary Wedge Pressure (PCWP) 4.Cardiac output 5.Mixed venous oxygen saturation (SVO2) |
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4 things that a PAC lets you calculate
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1.SV
2.CI 3.SVR 4.Left Ventricular stroke work index |
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CVP
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Centra Venous Pressure
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PAP
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Pulmonary Artery Pressure
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PCWP
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Pulmonary Capillarly Wedge Pressure
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SVO2
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Mixed Venous Oxygen Saturation
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LV SWI
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Left ventricular stroke work index
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CO NORMAL VALUES
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4.7
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CI NORMAL VALUES
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2.8-4.5 L/MIN/M2
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SV NORMAL VALUES
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60-100 ML
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SVR NORMAL VALUES
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900-1400 DYNES SEC/CM5
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PCWP NORMAL VALUES
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6-15 MMHG
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CVP
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2-6 MMHG
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MAP NORMAL VALUES
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80-100 MMHG
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A high PCWP typically corresponds with what pulmonary condition?
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Edema
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Fluid status is typically indicated by what hemodynamic figure?
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CVP
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Cardiac Inotropy is typically indicated by what hemodynamic figure?
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CI
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O2 consumption is typically indicated by what hemodynamic figure?
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SVO2
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Organ Perfusion is typically indicated by what hemodynamic figure?
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MAP
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Preload is typically indicated by what hemodynamic figure?
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PCWP
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What is our goal MAP?
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>65 mmhg (Normal 80-100)
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What are our main pharmacologic goals?
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Increase Perfusion (MAP/CO)
Normalization of Oxidative metabolism (Increase MAP/CO) |
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Describe why Acidosis can occur in a hemodynamically challenged patient?
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Anaerobic metabolism begans to occur which produces acidotic byproducts that result in acidosis
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3 Types of Fluid Replacements
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1.Crystalloids
2.Colloids 3.Blood Products |
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Examples of Crystalloids
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Normal Saline
Lactated Ringer |
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Advantage of Lactate ringer vs NS
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Helps with acidosis since it gets converted into bicarb
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Advantages of Crystalloids
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1.Low Cost (1st option)
2.Widely Available |
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Disadvantages of Crystalloids
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Only 25-33% remain in intravascular space (Want 80%)
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Examples of Colloids
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Albumin 5%
Heatstarch 6% |
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Advantages of Colloids
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Range from 80-100% remain in intravascular space.
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Disadvantages of Colloids
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Very expensive
Not very readily available |
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When should you use Blood products for fluid replacement?
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If there has been substantial blood loss of Hgb is down.
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Examples of Blood Products
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Whole Blood
Packed Red blood cells (PRBC) Platelets Cryoprecipitate (Factors 7, Protein C and S, etc...) |
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Treatment goals for Fluids to maintain adequate circulation for Tissue Perfusion
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1. MAP >60-65
2. SBP >90mmHg 3. CI > 2.2L/min/m2 |
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In terms of fluid treatment, what are some additional markers of adequate perfusion?
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1.Normal HR (<90BPM)
2.Adequate urine output (>0.5-1ml/Kg/Hr) |
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3 Main Hemodynamic Components associated with Adequate Tissue Perfusion
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MAP
SBP CI Must See Contraction! |
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Alpha-1 Physiologic Effect
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Arterial and Venous Vasoconstriction
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Beta-1 Physiologic Effect
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Increase contractility, chronotropy
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Beta-2 Physiologic Effect
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Arterial and venous vasodilation
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DA Physiologic Effect
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Vasodilation
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VP Physiologic effect
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Vasoconstriction, fluid retention, increase in cortisol
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Alpha-1 Hemodynamic Effect
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+SVR
+MAP |
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Beta-1 Hemodynamic Effect
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+CO, +HR
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Beta-2 Hemodynamic Effect
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-SVR
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DA Hemodynamic Effect
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?
Increased urine output |
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VP Hemodynamic effect
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+SVR
+MAP |
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Name 5 Vasopressors
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1.Dopamine
2.NE 3.EPI 4.PE 5.Vasopressin |
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Name 4 Inotropes
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1.DA
2.Dobutamine 3.Milrinone 4.Levosimendan |
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What 3 receptors does DA effect?
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1. DA Receptors
2. Beta-1 Receptors 3. Alpha-1 Receptors |
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Effects of DA on DA receptors
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1.Mesenteric BF
2.Renal BF 3.Inhibits proximatl tubule Na reabsorption |
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Effects of DA on Beta receptors
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1.Increase ionotropy, chronotropy (How hard and fast heart beats)
2.Small increase in peripheral vasodilation |
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Effects of DA on Alpha-1 receptors
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1.Increases peripheral vasoconstriction
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DA effect on DA receptors on Parameters
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Increase in urine output
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Effect of DA on Beta1 on parameters
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+CO
+HR +Contractility |
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Effect of DA on Alpha1 on parameters
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+SVR
+MAP |
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Dopamine dose to affect DA receptors
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0.5-3 mcg/kg/min
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Dopamine dose to affect Beta2
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3-10 mcg/kg/min
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Dopamine dose to affect Alpha1
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10-20 mcg/kg/min
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When Dopamine affects Alpha-1, which other receptors does it feel up?
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Beta1, but not DA
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What renal implications exist for Dopamine
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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.
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Adverse effects of DA
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Tachyarrhythmia (Beta1)
Increase afterload and preload Increase myocardial oxygen demand (Can cause MI, D/C pressor ASAP) Peripheral ischemia Pulmonary congestion |
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Describe the effects of Norepinephrine
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1.Stimulates Alpha-1 (Increase peripheral vasoconstriction +SVR)
2.No effect on Beta receptors |
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Describe what factor can affect effect of Norepinephrine.
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Increase in dose required, acidosis decreases activity.
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Describe dosing of Norepinephrine
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2-50 mcg/min (Max 200 mcg/min)
Titrate dose to MAP > 65mmHg |
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Adverse effects of NE
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1. Increased afterload (+SVR)
2. Cardiac arrythmias 3. Peripheral Ischemia 4. + Myocardial oxygen demand (Not as much as DA) |
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Describe effects of Phenylephrine
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Stimulation of Alpha-1 receptors (increase peripheral vasoconstriction)
No effect on beta receptors (No effect on myocardial demand) |
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Describe dosing of Phenylephrine
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30-300 mcg/min (max 200mcg/min)
Dose titrated to MAP > 65 |
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Adverse effects of Phenylephrine
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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 |
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Effects in EPI
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Stimulation of Alpha-1 Receptors
Stimulation of Beta2 -->Increased inotropy,chronotropy -->Increased peripheral vasodilation |
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Dosing for Beta1 and Beta2 FOR EPI
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0.01-0.05
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Effect for Beta1 and Beta2
FOR EPI |
Increase in SVR, MAP
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Dosing for Alpha1, Beta1 for EPI
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>0.05
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Effect of Alpha1, Beta1 for EPI
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+CO
+HR Contractility |
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EPI Adverse Effects
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Increased myocardial demand
Tachyarrhythmia Ischemia Lactic Acidosis |
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Which agent is an Antidiuretic hormone?
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Vasopressin
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What receptors dose Vasopressin hit?
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VP1->Peripheral Vasoconstriction
VP2->Na/H2O restriction, Decrease urine output VP3->Increase ACTH and cortisol |
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Use of Vasopressin
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Adjunct to other vasopressors, it allows reduction of dose of other vasopressors.
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Vasopressin Dosing
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0.01-0.04 units/min
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ADR of Vasopressin
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1.Decreased CO
2.Myocardial and splanchnic ischemia (Necrotic bowel) |
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For what receptors do we use Dobutamine predominantly?
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Beta effects
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Effects of Dobutamine
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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. |
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Dobutamine dosing
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2.5 mcg/kg/min
MAX 20mcg/kg/min Tritate to desired CI |
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ADR of Dobutamine
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1.Ventricular Arrhythmias
2.Hypotension 3.+Myocardial oxygen demand |
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Does Dobutamine effect SVR?
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No
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Does Dobutamine affect CO?
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Yes
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ADR of Dobutamine
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Ventricular arrythmias
Hyoptension Myocardial oxygen demand |
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Milrinone Effects
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PDE-3 Inhibitor
1.Stops breakdown of cAMP in myocardium and vasculature 2.+Contractility and Peripheral vasodilation (-BP) |
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Milrinone Dosing
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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 |
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Adverse Effects of Milrinone
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1.Hypotension
2.Ventricular Arrhythmias 3.Headache 4.Thrombocytopenia 5.Reflex Tachycardia |
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Effect of Levosimendan
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1.Calcium sensitizing of myocardial tissues
2.Some PDE3 inhibitory activity (+Contractility and peripheral vasodilation) (NOT APPROVED IN US-->USED IN EUROPE) |
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Dosing for Levosimendan
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Currently not approved for use in the US
0.1-0.2mcg/kg/min used in studies of cardiogenic and septic shock |
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Adverse effects of Levosimendan
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Hypotension
Headache Reflex Tachycardia |
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Vasopressin Receptor Effect
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Decrease urine output
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Beta-2 receptor stimulation effects
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Decrease in SVR
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Alpha-1 receptor stimulation effects
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Increase in SVR and MAP
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Beta-1 receptor stimulation effects
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Increase in CO and HR
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