Hemodynamics & Shock States Overview
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Questions and Answers

What is the relationship between Cardiac Output (CO) and Systemic Vascular Resistance (SVR) in regards to arterial blood pressure (BP)?

  • CO and SVR are inversely proportional to BP. Increased CO and SVR lead to lower BP.
  • CO is inversely proportional to BP, while SVR is directly proportional to BP. Increased CO leads to lower BP, while increased SVR leads to higher BP.
  • CO is directly proportional to BP, while SVR is inversely proportional to BP. Increased CO leads to higher BP, while increased SVR leads to lower BP.
  • CO and SVR are directly proportional to BP. Increased CO and SVR lead to higher BP. (correct)

    • What does the Frank-Starling Law of the heart describe?

  • The relationship between afterload and stroke volume.
  • The relationship between preload and afterload.
  • The relationship between heart rate and stroke volume.
  • The relationship between preload and stroke volume. (correct)

    • What is the calculation used to determine Cardiac Index (CI)?

  • Cardiac Output (CO) multiplied by stroke volume.
  • Cardiac Output (CO) multiplied by heart rate.
  • Cardiac Output (CO) divided by body surface area in square meters. (correct)
  • Cardiac Output (CO) divided by body weight in kilograms.

    • What is the Stroke Volume Variation (SVV) a measure of?

    <p>The responsiveness of the heart to fluid administration. (B)</p> Signup and view all the answers

    Which of these is an advantage of using an A-line (arterial line) for monitoring blood pressure compared to waveform analysis?

    <p>An A-line is less prone to artifact and provides a more reliable blood pressure measurement. (A)</p> Signup and view all the answers

    What is the cardiac index (CI) of a 27-year-old female patient who is 5'2" and 45 kg, with a cardiac output (CO) of 4.2 L/min?

    <p>2.96 L/min/m2 (D)</p> Signup and view all the answers

    What physiological factor, depicted in the diagram, does stroke volume variation (SVV) primarily indicate?

    <p>Preload responsiveness (A)</p> Signup and view all the answers

    Which of the following conditions would decrease preload?

    <p>Blood loss (B)</p> Signup and view all the answers

    Which of the following is NOT a direct measure of contractility?

    <p>Left ventricular end-diastolic pressure (LVEDP) (A), Cardiac output (CO) (C), Stroke volume index (SVI) (D)</p> Signup and view all the answers

    Which of the following would be an accurate representation of the relationship between preload and cardiac output, according to the provided information?

    <p>Increased preload leads to increased cardiac output (A)</p> Signup and view all the answers

    Based on the provided content, what is the primary difference between measuring stroke volume (SV) using an A-line and waveform analysis?

    <p>A-line measures SV directly, while waveform analysis uses indirect methods (C)</p> Signup and view all the answers

    Which of the following factors, depicted in the diagram, directly influence cardiac output (CO)?

    <p>Heart rate and Stroke Volume only (D)</p> Signup and view all the answers

    Which of the following conditions would lead to an increase in systemic vascular resistance (SVR)?

    <p>Hypovolemia (B)</p> Signup and view all the answers

    Which of the following is NOT a factor that contributes to increased afterload?

    <p>Increased preload (D)</p> Signup and view all the answers

    According to the Frank-Starling curve, what happens to stroke volume (SV) when preload increases?

    <p>SV increases (C)</p> Signup and view all the answers

    Which of the following is a true statement regarding systemic vascular resistance (SVR)?

    <p>SVR is determined by the diameter of blood vessels. (C)</p> Signup and view all the answers

    What is the normal range for systemic vascular resistance (SVR)?

    <p>800-1200 dyne·sec/cm^3 (A)</p> Signup and view all the answers

    What is the primary mechanism by which the autonomic nervous system influences systemic vascular resistance (SVR)?

    <p>Controlling blood vessel diameter (A)</p> Signup and view all the answers

    How does an increase in systemic vascular resistance (SVR) impact cardiac output?

    <p>Cardiac output decreases (A)</p> Signup and view all the answers

    Which of the following is NOT a factor that influences cardiac output?

    <p>Body temperature (A)</p> Signup and view all the answers

    In the context of the Frank-Starling mechanism, why would an increase in afterload decrease stroke volume?

    <p>Because afterload increases the resistance the heart has to overcome, reducing the amount of blood ejected (D)</p> Signup and view all the answers

    Flashcards

    Systole

    The phase of the heartbeat when the heart muscle contracts and pumps blood.

    Cardiac Output (CO)

    Amount of blood ejected from the left ventricle in one minute; normal range is 4 - 7 L/min.

    Heart Rate (HR)

    The number of heartbeats per minute; impacts cardiac output and overall health.

    Stroke Volume (SV)

    The volume of blood pumped from the left ventricle per heartbeat; influenced by preload, afterload, and contractility.

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    Cardiac Index (CI)

    Cardiac output normalized to body surface area; normal range is 2.8 - 3.6 L/min/m2.

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    Frank Starling Curve

    Describes the relationship between stroke volume and preload of the heart.

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    Afterload

    The resistance the heart must overcome to eject blood.

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    Increased Afterload Effects

    Higher afterload results in decreased cardiac output.

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    Systemic Vascular Resistance (SVR)

    Resistance to blood flow in the systemic circulation.

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    Normal SVR Range

    Normal systemic vascular resistance ranges from 800 to 1200 dyne·sec/cm3.

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    Impact of SVR on Cardiac Output

    Increased SVR results in decreased cardiac output.

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    Preload

    The initial stretching of the cardiac muscle prior to contraction.

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    Cardiac Output (CO) Factors

    Determined by heart rate and stroke volume.

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    Stroke Volume Index (SVI)

    Stroke volume adjusted for body surface area; SVI = SV/BSA.

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    Stroke Volume Variation (SVV)

    Measurement indicating preload responsiveness in mechanically ventilated patients.

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    Contractility

    Intrinsic strength of the myocardium during systole; refers to inotropy.

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    Study Notes

    Hemodynamics & Shock States

    • Hemodynamics is the study of blood flow in the body
    • Shock is acute circulatory failure, insufficient oxygen supply to tissues

    Supplemental Materials

    • Hoffman EW, Basics of cardiovascular hemodynamic monitoring, Clin Pharm 1982;16(9):657-64.
    • Moranville MP, Mieure KD, Santayana EM, Evaluation and management of shock states, J Pharm Pract 2011;24(1):44-60.
    • MedCram 16-minute review of cardiogenic, hypovolemic, & distributive shock: https://youtu.be/CbM4UihE1TQ

    Note

    • PCWP is used in place of LVEDP
    • JVP is used instead of CVP

    Hemodynamics

    • Normal hemodynamics are crucial for understanding disease states
    • Blood pressure, cardiac output, and stroke volume are key parameters influencing arterial blood pressure

    Learning Objectives

    • Define the hemodynamic parameters that influence arterial blood pressure, cardiac output, and stroke volume.
    • Describe relationships between hemodynamic parameters using Frank Starling Curves.

    Cardiac Output (CO)

    • Amount of blood ejected from the left ventricle per minute
    • Normal range: 4-7 L/min
    • Cardiac Index (CI): CO normalized to body surface area
    • Normal range: 2.8-3.6 L/min/m²

    If CO = 4.2 L/min...

    • 27-year-old male (6'2", 85 kg, BSA 2.11): CI = 1.99 L/min/m²
    • 27-year-old female (5'2", 45 kg, BSA 1.42): CI = 2.96 L/min/m²

    Cardiac Output Factors

    • Heart rate (HR): influences cardiac output
    • Stroke volume (SV): influenced by preload, afterload, and contractility
    • Preload: stretch of the myocardium before contraction
    • Afterload: resistance the heart must overcome to eject blood
    • Contractility: intrinsic strength of myocardium during systole

    Preload

    • Stretch of the myocardium prior to contraction
    • Increases with total blood volume, venous return
    • Decreases with poor ventricular or venous compliance, tachycardia, or blood loss
    • Represents a patient's volume status (e.g., left ventricular end-diastolic pressure (LVEDP))

    Afterload

    • The "load" the heart must overcome to eject blood
    • Increased with systemic vascular resistance (SVR), aortic pressure, and aortic valve stenosis

    Systemic Vascular Resistance (SVR)

    • Resistance to blood flow caused by systemic vasculature
    • Controlled by autonomic nervous system
    • Normal range: 800-1200 dyne-sec/cm³
    • Cooler skin temperature with ↑SVR

    Arterial Blood Pressure

    • Systolic pressure: maximal aortic pressure during ejection (systole)
    • Diastolic pressure: lowest aortic pressure during relaxation (diastole)
    • Normal range: reported in mmHg

    Mean Arterial Pressure (MAP)

    • Average arterial pressure during one cardiac cycle
    • Normal range: 80-100 mmHg

    Central Venous Pressure (CVP)

    • Pressure in the superior and inferior vena cava near right atrium
    • Right atrial pressure (RAP) ≈ CVP
    • Normal range: 2-6 mmHg (12-16 mmHg if ventilated)

    Normal Ranges

    • Cardiac Output (CO): 4-7 L/min
    • Cardiac Index (CI): 2.8-3.6 L/min/m²
    • Systemic Vascular Resistance (SVR): 800-1200 dyne-sec/cm³
    • Systolic Blood Pressure (SBP): 110-130 mmHg
    • Mean Arterial Pressure (MAP): 80-100 mmHg
    • Central Venous Pressure (CVP): 2-6 mmHg

    Stroke Volume (SV) and Variation (SVV)

    • Volume of blood ejected from the ventricle during contraction
    • Stroke volume index (SVI): SV/BSA, range 33-47 ml/beat/m²
    • SVV: indicates preload responsiveness (in mechanically ventilated patients) • SVV < 10% = Not fluid responsive • SVV > 10-15% = Fluid responsive

    Contractility

    • Intrinsic strength of myocardium during systole (inotropy)
    • Not directly measured

    Frank Starling Curve

    • Relationship between preload and stroke volume
    • Increase in preload will result in a proportional increase in stroke volume, to a point

    Hemodynamic Monitoring

    • Comparing non-invasive methods (heart rate, blood pressure, skin temperature, urine output) to invasive methods (arterial lines, Swan-Ganz catheters, FloTrac, or LIDCO)
    • Arterial pulse pressure waveform analysis aids in shock classification

    Invasive- Arterial Line (“A-line”)

    • Continuous measurement of SBP, DBP, and MAP for increased accuracy during shock

    Arterial Pulse Pressure Waveform Analysis (FloTrac or LIDCO)

    • Continuous measurements of hemodynamics (CO, CI, SVV, and SVR) to assist in shock classification

    Swan Ganz

    • Pulmonary artery catheter (PAC) measures right heart pressures
    • Pulmonary wedge pressure (PCWP): indirect estimate of LVEDP
    • Normal range: 6-12 mmHg

    Mixed Venous Oxygen Saturation (SvO2)

    • Percent of O2 returning to right side of the heart after tissue extraction
    • Normal range: 60-75%
    • <60% = Cardiogenic shock

    • 75% = Distributive shock

    Shock Subsets

    • Hypovolemic: reduced blood volume (blood loss, dehydration)
    • Cardiogenic: impaired heart function (massive MI, aortic stenosis)
    • Distributive: widespread vasodilation (septic shock, anaphylaxis, neurogenic shock)
    • Obstructive: physical obstruction to blood flow (cardiac tamponade, massive pulmonary embolus)

    Management of Shock

    • Predicting how hemodynamic parameters will change with therapeutic interventions, including isotonic crystalloids, inotropes, vasodilators, diuretics, and vasopressors
    • Designing individualized treatment plans based on the specific shock subset

    Patient Case Examples

    • Case-specific data for patient assessment and diagnosis of shock and required interventions and management

    Non-hemorrhagic Hypovolemic Shock Summary

    • Multifactorial plasma loss from burns, pancreatitis, peritonitis, vomiting or diarrhea
    • IV fluids needed, isotonic crystalloids (Lactated Ringer's) first line
    • Resuscitation recommendations vary

    Fluid Compartments

    • Total body water (TBW): 2/3 intracellular fluid, 1/3 extracellular
    • Extracellular fluid (ECF): 1/3 interstitial fluid, 1/4 intravascular fluid

    Fluid Tonicity

    • Table showing various fluids, their tonicity, and associated electrolyte/osmolality values

    Practice Fluid Compartments

    • Illustration demonstrating the division of total body water into intracellular and extracellular compartments, and further division into interstitial and intravascular compartments, with approximated volumes
    • Table indicating the different percentages for each fluid compartment

    Case Details for Patient #2, #3, and #4

    • Subsets (warm and wet, cold and dry, cold and wet) and interventions based on hemodynamic data

    Distributive Shock

    • Clinical presentations including low SVR
    • Treating underlying cause and supplementing blood volume

    Inotropic Therapy (Subset III and IV)

    • Indicated for patients experiencing hypoperfusion despite adequate fluid volume (low MAP and/or SBP)
    • Additional symptoms including altered mental status and worsening renal function

    Vasodilators

    • Used as an adjunct for managing dyspnea, specifically subsets II, III, IV; includes nitroglycerin, sodium nitroprusside, and hydralazine

    Diuretics (Subset II)

    • Used to reduce preload (right/CVP, left/LVEDP) and hence unload the heart
    • Example: furosemide, bumetanide

    Cardiogenic Shock

    • Persistent hypotension despite fluid administration
    • Reflects poor cardiac output or perfusion of tissue
    • Elevation of LVEDP and CVP

    Forrester Classification of Cardiogenic Shock

    • Categorization of subsets (I-IV) includes hemodynamic parameters (CI, PCWP) and clinical status (warm/dry, warm/wet, cold/dry, cold/wet)

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    Related Documents

    Hemodynamics & Shock PDF

    Description

    Explore the key concepts of hemodynamics and the various types of shock states. This quiz will cover parameters influencing arterial blood pressure, cardiac output, and stroke volume, and their significance in understanding cardiovascular health. Test your knowledge on the normal hemodynamic values and their roles in disease states.

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