Hemodynamics Part 1

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Pressures

Hemodynamics

Study of the movement of blood and its relationship with:

Cardiac function Pulmonary and systemic blood pressures Resistance throughout the entire Cardiovascular system

Brain

Lungs Veins (Flexible Compliant Pipes)

Arteries (Stiff Inflexible Pipes) Pre-capillary Sphincters

Blood flow from

Circulation:

high to low pressure

(remind you of anything?)

Liver Stomach Pancreas Intestines Kidneys Arterioles Skin Muscle

The Cardiovascular Hemodynamic System

RV RA (2) 20 4

Mean pressures in red LV LUNGS LA (3)

9% of blood volume

AORTA

(13) (7)

(90)

SYSTEMIC ARTERIES
low compliance 13% of blood volume

VEINS (8)
high compliance 64% of blood volume

(20) CAPILLARY BEDS

(40) ARTERIOLES

7% of blood volume Flow (Q) = upstream pressure downstream pressure resistance

Pressures we can measure

Arterial Blood Pressure Central Venous Pressure Pulmonary Artery Pressure Left Atrial Pressure

Arterial Blood Pressure

Pressure = Flow x Resistance

Flow = how fast stroke volume exits heart Resistance =diameter of vessels (SVR)

Measurements can be

Non-invasive Invasive with indwelling catheter

Normal Values:

Waveform from A-line

Ej ect ion

If unable to see dicrotic notch may be dampened, pressure may be falsely low

Arterial Pressure cont

Pulse Pressure

Difference between Systolic and Diastolic pressure NORMAL = 30-40 Depends on SV and arterial compliance

Low SV = decreased pulse pressure

Mean Airway Pressure

Average pressure NORMAL = 80-100mmHg

MAP = Systolic + (2 * Diastolic) 3

Central Venous Pressure (CVP)

A Catheter is placed with the tip lying in the Superior vena cava or Right Atrium Measures mean Right Atrial Pressure (RAP)

Indications:
blood volume and guide fluid replacement

To assess circulating

Other Benefits: blood draw &

Factors affecting CVP

Blood Volume status

Volume must be enough to fill vascular space If right heart pump is OK, CVP reflects vascular volume

Heart capabilities how well can it pump? Venous tone (which changes vascular Resistance and space)

LUN GS RV
RA

LV
LA

Tissue

LUN GS RV
RA

LV
LA

Tissue

CVP will Increase with:

Fluid overload Right heart failureSevere left heart failureLarge Pulmonary EmboliPulmonary hypertension PEEP - how much?

LUNGS

RV

LV

R A

L A

Tissue

CVP will Decrease with:

Hypovolemia (dehydration, Blood loss) Vasodilation (Shock)

At ri al c

on t ra ct i
Cl Va osur lve e o f

on

AV

CVP waveform
Ve ntr i cu lar sy st o le

CVP

Complications:

Pneumothorax, bleeding, infection, thrombus, air embolus

PA Catheter

Balloon tipped catheter placed with the tip lying in the Pulmonary Artery

Can obtain both right and left heart pressures Used for CO determination Can obtain Mixed Venous samples Some have SvO2 and pacing capabilities

Distal Port Balloon Port Proximal Port

Thermister

Proximal Port Measures:

Distal Port Measures:

Pressures obtainable:

CVP (RAP) PA (Systolic, diastolic and mean) PCWP (PAOP) This reflects Left heart fuiinction

PA Catheter Placement and Waveforms

(CVP)

CVP 2-6

RV 2030

PAP 20-30 6-15

PCWP 4-12

Pulmonary Artery Pressure

This is the Pulmonary BP

Systole pressure depends on:

Stroke volume, rate of blood flow (force of contraction), and resistance of pulmonary vasculature

The mean PAP is the average pressure in the pulmonary system

Its used to help determine Pulmonary Vascular Resistance (PVR) and is used to assess how much work the R ventricle must push against (Afterload)

Normal value is: 20-30 6-15 Mean : 10-20mmHg

Pulmonary Artery Pressure Measurement

Indications

Hemodynamically unstable patients Cardiogenic shock, sepsis Unstable thoracic surgery patients Same as CVP but with the additional: Dys-rhythmia (mostly during placement) Pulmonary infarct if it wedged in PA

Complications

Pulmonary Artery Pressure

PA Pressures will Increase with:

Increased Pulmonary resistance

PE, pulm hypertension, COPD (cor pulmonale)

Increased contractility of heart PEEP how much?

PA pressures will Decrease with:

Decreased resistance Decreased Stroke volume

Pulmonary Capillary Wedge Pressure (PCWP, PAOP, Wedge)

Represents mean Left Atrial Pressure (LAP)

Indicates Left ventricular function

With the balloon inflated, the wedged PAC creates a channel with no blood flow from the catheter tip to the left atrium, thus allowing indirect measurement of the left atrial pressure.

Normal: 2-12 mmHg

PCWP, PAOP

All connected without flow; read as one

LUN GS RV
RA

LV
LA

Tissue

Definitions

Preload - Ventricular end diastolic volume / Pressure - the amount of stretch of

ventricle

RV preload indicator is =____________(pressure) LV preload indicator is = ____________ (pressure)

Afterload - resistance to ventricular emptying during systole or

the amount of pressure the left ventricle must generate to squeeze blood into the aorta. RV afterload = ____________ (Pressure) LV afterload = _____________(Pressure)

Starlings Law of the Heart and Contractility

Starlings Law: The greater the EDV (preload), the more blood comes out of the heart until

SV
(left ventricular performance)

u contractility

normal contractility
SV at Preload X - u contractility SV at Preload X - N contractility SV at Preload X - d contractility

State of Myocardial Contractility: Determines the amount of blood (SV) that comes out of the heart at a given preload

d contractility (heart failure)

Preload X

Preload
(venous return or EDV)

SVR and PVR

Resistance - the sum of all forces that oppose blood flow due to:

Length of vasculature (L) Blood viscosity (V) The largest variable is Vessel RADIUS Vessel radius (r) (MAP RAP) * 80 / CO

Systemic Vascular Resistance (SVR): Pulmonary Vascular Resistance (PVR)

(Mean PAP LAP) * 80 / CO

Similarities

How do you calculate Resistance on a ventilator?

Change in airway pressure / flow Same thing here:

change in vascular pressure / CO (flow)

The Cardiovascular Hemodynamic System

RV RA

Mean pressures in red LV LUNGS LA AORTA

(2)

(13)

(3)

9% of blood volume

(90)
SYSTEMIC ARTERIES
low compliance 13% of blood volume

VEINS
high compliance 64% of blood volume

CAPILLARY BEDS

ARTERIOLES

7% of blood volume Flow (Q) = upstream pressure downstream pressure resistance

SVR

PVR

(95-5)mmHg*80 / 5L =1440 dyne-sec/cm5

Normal = 800-1200

(15-5)mmHg*80 / 5 =160 dyne-sec/cm5

Normal = <250

Notice the SVR is about 9 times as high as the PVR, hence the thicker left ventricle does more work

Ventricular Volumes - Definitions

End Diastolic Volume (EDV)
Volume at the end of diastole (end of ventricular filling). In a healthy heart this is directly proportional to venous return

Stroke Volume (SV) = CO / HR Ejection Fraction (EF) = SV EDV

ED V

Systole

Homework state whether the pressures in each will go up, down or stay the same.
CVP PAP PCWP

Normal = Right ventricular failure Left ventricular failure Pulmonary hypertension Non-cardiogenic pulmonary edema (ARDS) Mitral valve stenosis or insufficiency Pulmonary Embolism