An acute, generalized state of inadequate perfusion of critical organs Serious pathophysiological consequences, including death USUALLY but not always associated with hypotension (SBP

Hemodynamics and Shock Flashcards by Willis Richardson

Hemodynamic instability

hypotension, change in mental status, and signs of shock

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Hypotension

mean arterial pressure (MAP)

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Mean Arterial Pressure

MAP

80 – 100 mmHg

MAP =DBP + 1/3 (SBP-DBP)***

Better mesured for t
Need at least 65 in order for your organs to have adequate organ perfusiotn

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Cardiac Output

4 – 7 L/min

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Cardiac Index (CI)

2.8 – 3.6 L/min/M2

CO/body surface area

–>corrected CO for weight

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Pulmonary Artery Occlusion Pressure
a.k.a. Pulmonary capillary wedge pressure

12-15 mmHg

Measure the pressure of L ventricle at the end of diastole. The heart is filled with the maximum volume of blood. Learn patients volume status.

indicates preload
pressure in left ventricle

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Systemic Vascular Resistance

SVR

1300 – 2100 dynes-s/cm5

SVR- constriction/dilation of blood vessels

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SHOCK

An acute, generalized state of inadequate perfusion of critical organs

Serious pathophysiological consequences, including death
USUALLY but not always associated with hypotension (SBP

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o Signs of poor/reduced perfusion:

Hypotension
• Increased HR and RR
• Cold extremities
• Mental status change or unconscious
• Reduced urine output (worsening renal function)-increase in ScR
• Lactic acidosis

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Shock: hypovolemic

Low vascular volume

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Shock: Distributive

Septic or anaphylactic: vasodilation

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Shock: Cardiogenic

poor heart function

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• Vasopressors (“vasoconstrictors”)

Route and titrating frequency?

Administered via continuous infusion

Frequent dosing adjustments may be necessary
(titration) every 5-15minutes

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Can Vasopressors be used in Central line?

phentolamine (antidote)

YES or else

Tissue necrosis with extravastation:
o To avoid: administer through a central line

o Treat extravasation with intradermal administration of
10-15 ml of saline and** 5-10 mg of phentolamine**

 • Phentolamine: blocks alpha-adrenergic receptors
  causing vasodilation and minimizes necrosis

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α1 - Vasoconstriction

α2- Vasoconstriction

β1 - inotropic (contractility) and chronotropic (HR)


β2- vaso-/Brocodilation

DA - Vasodialtion in the kidney, Heart, and GI

α1 - Vasoconstriction

α2- Vasoconstriction

β1 - inotropic (contractility) and chronotropic (HR)


β2- vaso-/Brocodilation

DA - Vasodialtion in the kidney, Heart, and GI

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Dopamine

Central line line

DOC if low risk of arrhtymias
-Large DA and B1 activity

AE:
**Worst for Tachycardisa–>B1
peripheral vasoconstriction–>a1

Arrhythmias, tachycardia, peripheral and gut ischemia/ necrosis

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Epinephrine
Catecholamines

Central line line

(Adrenaline®)

Large a1 and B activity (less B2)

AE:
hyperglycemia**
hypokalemia*

Agitation, tremor, headache, Arrhythmias, tachycardia hyperglycemia, peripheral and gut ischemia/ necrosis, “K+

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Norepinephrine
Catecholamines
Central line line

(Levophed®)

often 1st line: a and b activity.

generally additive therapy to dopamine for septic shock

AE:
Hyperglycemia**

Agitation, headache, tremor–>B
peripheral/gut ischemia–>a

Hypokalemia**

Phenylephrine

Noncatecholamines

Central line line

Neosynephrine

Only alpha- a

indicated if hypotensive with tachyarrhthmia (no B1 effects)

Vasopression

Antidiuretic hormone

V1 Receptors – located in smooth muscle in blood vessels, hepatocytes, platelets, and on some cells in kidney

V2 Receptors: located in the renal collecting duct

Higher doses restricted in shock due to AEs

AE:

Decreased CO and circulation to skin and GI tract
peripheral ischemia
Hyponatremia**

May decrease CO and circulation to skin and GI tract (high doses > 0.04 units/min), decreased splanchnic circulation (high doses > 0.04 units/min), peripheral ischemia, hyponatremia

0.01-0.04 units/min (higher doses NOT recommended in shock–>Will cause auto amputee??? Vasopressors

Inotropes

Dobutamine

Milrinone

Dobutamine

2min half-life
hepatic metabolism
B and a1 activity
two isomers: (+) -> B-activity, (-) –>a

used in low CO states

-> CI Left Ventricular dysfunction
-> Shock

AE: Tachycardia, arrhythmias, hypotension (rarely), angina, premature ventricular beats

Milrinone

Half-life: 1-2hours
Renal (need lower in renal dysfunction)

PDE-3 inhibitor to enhance contractility

AE: Hypotension, arrhythmias

Hypovolemic Shock: Causes

Blood loss (shot wounds)

Fluid sequestered within a compartment of the body due to loss of oncotic pressure or increased capillary permeability

Fluid lost from urine, diarrhea/vomiting, skin (burns) o Hemodynamic effects

Hypovolemic Shock: Hemodynamic effects

Decreased: MAP, CVP, PCWP, CO, SVR Increased: SVR

Hypovolemic Shock: Treatment

Plasma expanders - 1st line - -> NSS or Lactated ringer (isotonic crystalloid) - ->albumin (colloids) - ->Blood: if caused by blood loss Vasopressor--Last line -->vessel are already contracted to compensate for loss of BP

Hypovolemic Shock: Monitoring

HR, BP, lactate, and Scr

Distributive Shock: Septic Shock Cause

Infection - Gram (+) most common

Distributive Shock: Septic Shock Risk factors

Elderly ``` Immunosuppressed states (AIDS, cancer, transplant, chronic immunosuppressing medications) ``` Malnutrition Alcoholism Chronic organ failure

Definition of Systemic inflammatory response syndrome (SIRS)

**Patient must have two or more of the following:** WBC ≥ 12,000 or WBC ≤ 4,000 or bands > 10% Hyperthermia (≥38°C or 100.4°F) or hypothermia (≤36°C or 96.8°F) (PaCO2 ≤32 mmHg) RR ≥20 Mechanical ventilation for an acute respiratory process Heart rate ≥ 90 beats/min

Sepsis

SIRS + infection

Severe Sepsis

Sepsis + organ dysfunction

Septic Shock

1 or 2 or 3 + Fluid refractory hypotension

Distributive Shock: Septic Shock Pathophysiology

``` (1) Bacteria toxins cause-->Macrophages recognize the infection and (over)react and release inflammatory mediators. --> TNF-α --> IL-1 --> IL-6 ``` 1. Vasodilation 2. Vascular endothelial injury resulting in activation of the coagulation cascade 3. o Fluid to leak out of vasculature and into tissues

Distributive Shock: Septic Shock Hemodynamic Effects

Decreased: MAP, CVP, PCWP, SVR Increased: CO

S/S Early sepsis

``` Fever or hypothermia Rigors or chiles Tachycardia Tachypnea Hypoxia Hyperglycermia Myalgias ```

S/S Late sepsis (evidence of organ failure

Increase Lactate* Increase LFTs* Pulmonary failure* Decrease urine output/increase Scr Hypotension Thrombocytopenia COMA

Treatment (Surviving Sepsis Guidelines)

Prompt diagnosis and identification of pathogen causing infection Early administration of antibiotics Adequate organ perfusion (CVP > 8 and MAP > 65, lactate

Distributive Shock: Septic Shock Antimicrobial therapy

Blood cultures should be sent before antimicrobial therapy is initiated as well as cultures from any other site that is suspected as causing the infection --Blood must be sent immediately; start antimicrobial empirically within 1 hour*** (IV therapy)

Distributive Shock: Septic Shock (1) Fluids

Fluide challenge: Administer 30 ml/kg of NNS or Lactated Ringers -->Continue giving until goals met or signs of volume overload Albumin - 2nd line Blood due to loss Monitoring: Sodium/chloride (crystalloids only), BP, HR, CVP, lactate, urine output, pulmonary edema, heart failure, edema

(2)Vasopressors/inotropes

Noreperienpherine: 1st line for hypotension in septic shock Dopamine: alternative if at low risk of arrhythmias--> low dose not useful. “Renal-dose dopamine” not useful (

(2) Vasopressors/inotropes Goals and Monitor

MAP>65 BP, HR, potassium, glucose, peripheral/splanchnic vasoconstriction

(3) Steroids Adminstration (period) And Monitoring and Goals

Recommended to administer intravenous hydrocortisone in septic shock patients refractory to (1) fluids and (2) vasopressors --> (Hydrocortisone 50mg IV)** every 6 hours or as continuous at 8 mg/hr Goals: MAP > 65, avoid adverse effects, discontinuation of vasopressors Monitoring: BP, glucose, mental status, fluid retention, infection, GI ulceration

(4) Insulin Goal and monitor

Glucose elevate by EPI--> (precaution) *Continuous infusion with short-acting insulin (regular or lispro)* ***Goal: blood glucose