HDM
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- What is the formula for MAP?
- 2/3 DBP + 1/3 SBP
- What is the formula for BP?
- CO x SVR
- What is the formula for CO?
- SV x HR
- What is the definition of preload?
- how much blood is going to the left ventricle (LV)
- What is left ventricular end diastolic volume (LVEDV)?
- volume right before systole reflects how much blood is going to be pumped out of the heart
- What can be used to estimate LVEDV?
- pulmonary capillary wedge pressure (PCWP)
- What is the definition of afterload?
- resistance of the LV
- What is used to estimate afterload?
- SVR
- What is the formula for cardiac index (CI)?
- CO/BSA
- What does a central venous catheter (CVC) measure?
- BP and fluid status
- What is a pulmonary arterial catheter useful for? (4)
-
1)volume status
2)volume performance
3)estimating O2 delivery and uptake
4)differentiating shock syndromes - What complications can be caused w/ the use of a pulmonary arterial catheter?
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1)premature atrial or ventricular contractions
2)pulmonary artery rupture - CO normal value
- 4.7L/min
- CI normal value
- 2.8-4.5 L/min/m2
- SV normal value
- 60-100 mL
- SVR normal value
- 900-1400 dynes*sec/cm5
- PCWP normal value
- 6-15 mmHg
- CVP normal value
- 2-6 mmHg
- MAP normal value
- 80-100 mmHg
- CI <2.2 means what?
- hypoperfusion
- PCWP >18 means what?
- pulmonary edema
- CI<2.2 AND PCWP >18 means what?
- cardiogenic shock
- CI<2.2 AND PCWP <18 means what?
- hypovolemic shock
- What are the pharmacologic goals for hemodynamic monitoring?
-
1)increase tissue perfusion
a)increase MAP >65mmHg
b)increase in CO
2)normalization of oxidative metabolism
a)return of aerobic metabolism - Examples of crystalloids
-
1)NS
2)LR - What are the advantages of crystalloids?
-
1)low cost
2)widely available - What are the disadvantages of crystalloids?
- 1)only 25-33% remian in intravascular space
- Examples of colloids?
-
1)albumin 5%
2)hetastarch 6% - What are the advantages of colloids?
- 1)range from 80-100% remain in intravascular space
- What are the disadvantages of colloids?
-
1)very expensive
2)may not be readily available - What are the treatment goals of managing hemodynamic instability?
-
1)maintain adequate circulation for tissue perfusion
a)MAP> 60-65 mmHg
b)SBP > 90 mmHg
c)CI > 2.2 L/min/m2
d)normal HR (<90bpm)
e)adequate UO (>0.5-1mL/kg/hr) - Physiological and hemodynamic effects of receptors: alpha1
-
1)arterial and venous vasoconstriction
2)increase SVR, increase MAP - beta1
-
1)increase contractility, chronotropy
2)increase CO, increase HR - beta2
-
1)arterial and venous vasodilation
2)decrease SVR - DA
-
1)vasodilation
2)insignificant increase in UO - VP
-
1)vasoconstriction, fluid retention, increase cortisol
2)increase SVR, increase MAP - What are pharmacological agents classified as vasopressors? (5)
-
1)dopamine
2)norepinephrine
3)epinephrine
4)phenylephrine
5)vasopressin - What are pharmacological agents classifed as inotropes? (4)
-
1)dopamine
2)dobutamine
3)milrinone
4)levosimendan - What are the effects of DA dose 0.5-3mcg/kg/min?
-
1)increase renal and mesenteric blood flow
2)inhibition of proximal tubule Na+ reabsorption - What are the effects of DA dose 3-10mcg/kg/min?
-
1)stimulation of beta receptors
a)increase CO, HR, contractility - What are the effects of DA dose 10-20mcg/kg/min?
-
1)stimulation of alpha1 receptors
a)increase in SVR, MAP - Dopamine adverse effects (5)
-
1)tachyarrhythmias
2)increase MVO2
3)peripheral ischemia
4)increase afterload and preload
5)pulmonary congestion - What receptors does norepinephrine act on?
-
1)stimulation of alpha1 receptors
-increase peripheral vasoconstriction => increase SVR
2)No effect on beta receptors
-increase inotropy, chronotropy
-smaller extent than a1 effects - What is the effect of pH on norepinephrine?
- decrease activity in acidosis (need to increase dose)
- norepinehrine dosing
- 2-50mcg/min titrated to MAP >65mHg
- What are the adverse effects of norepinephrine? (4)
-
1)increase afterload
2)peripheral ischemia
3)increase MVO2
4)cardiac arrhythmias - What receptors does phenylephrine have an effect on?
-
1)stimulation of alpha1 receptors
-increase in peripheral vasoconstriction
2)no effect on beta receptors - phenylephrine dosing
- 30-300mcg/min (max 200mcg/min) titrated to MAP >65mmHg
- phenylephrine adverse effects (6)
-
1)increase afterload
2)peripheral ischemia
3)myocardial ischemia
4)reflex bradycardia
5)peripheral bradycardia
6)hypertension - What receptors does epinephrine act on?
-
1)stimulation of alpha1 receptors
-increase peripheral vasoconstriction
2)stimulation of beta receptors
-increase in inotropy, chronotropy
-increase in peripheral vasodilation - epinephrine dosing
-
1)0.01-0.05mcg/kg/min
-beta1,2
-increase SVR, MAP????
2)>0.05mcg/kg/min
-alpha1, beta1
-increase in CO, HR, contractility??? - What are the side effects of epinephrine? (4)
-
1)increase MVO2
2)tachyarrhythmias
3)ischemia
4)lactic acidosis - What receptors does vasopressin act on?
-
1)stimulation of VP1
-peripheral vascoconstriction
2)stimulation of VP2
-sodium and water retention
-decrease UO
3)stimulation of VP3
-increase ACTH and cortisol production - Indication for vasopressin
- adjunct to other vasopressors in septic shock
- Benefits of vasopressin along with other vasopressors
- decrease dose of other vasopressors
- Vasopressin dosing
- 0.01-0.04units/min
- What are the side effects of vasopressin? (2)
-
1)decrease CO
2)myocardial and splanchnic ischemia - Inotrope pharmacology
-
-stimulation of beta receptor converts AMP -> cAMP which activates PKa which releases Ca++ from sarcoplasmic reticulum which binds to Tnc
-phosphodiesterase inhibitors inhibit cAMP -> AMP - What receptors does dobutamine act on?
-
1)stimulation of beta receptors
-increase inotropy and chronotropy
-small increase in peripheral vasodilation
2)stimulation of alpha1
-increase peripheral vasoconstriction
-to a MUCH SMALLER EXTENT than beta effects - dobutamine dosing
- 2.5mcg/kg/min (max 20) titrated to desired CI
- what are the adverse effects of dobutamine? (3)
-
1)increase MVO2
2)ventricular arrhythmias
3)hypotension - Milrinone MOA
-
1)phosphodiesterase type 3 inhibitor
-inhibit breakdown of cAMP in myocardium and vasculature
-increase contractility and peripheral vasodilation - milrinone bolus dose (optional)
- 50mcg/kg/IV over 10min
- milrinone infusion dosing
- 0.25-0.75mcg/kg/min
- milrinone dosing for renal adjustment
- 0.2-0.43mcg/kg/min base on CrCl
- milrinone adverse effects (5)
-
1)ventricular arrhythmias
2)hypotension
3)reflex tachycardia
4)thrombocytopenia
5)headache