CC Hemodynamics

Hemodynamics

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What are you most excited about for being in critical care?

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What are you most nervous about in critical care?

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If you could have one thing to help you these next weeks, what would it be?

Invasive Hemodynamic Monitoring

CVP

• Normal Value 2-6 mmHg

• "Preload"

• "Filling pressure"

​Things that increase CVP	​Things that decrease CVP
​heart failure	​Dehydration

​So what will your treatments be???

Invasive Hemodynamic Monitoring

SVR

• Normal Value 770-1500 dynes/sec/cm⁵

• "Afterload:

• "Resistance"

  diameter of vessel

  blood viscosity

  contractility

​Things that increase SVR	​Things that decrease SVR
vasoconstriction​	vasodilation​

​So what will your treatments be???

Invasive Hemodynamic Monitoring

CO

• Normal Value 4-8 L/min

• How much blood is pumped from the heart each min

​Things that increase CO	​Things that decrease CO
exercise	Coronary artery disease

​So what will your treatments be???

Invasive Hemodynamic Monitoring

SvO₂

• Normal Value 60-80%

• How much oxygen the body is using

• Tip:

  • Low-the body is using all the oxygen

  • High- body is not using the oxygen

​Things that increase SvO	​Things that decrease SvO
hypothermia	anemia (low hgb)

​So what will your treatments be???

Invasive Hemodynamic Monitoring

MAP

• Normal Value `65 mmHg

• Min the MAP must be for vital organ perfusion

​Things that increase MAP	​Things that decrease MAP
hypervolemia	hypovolemia

​So what will your treatments be???

Multiple Choice

A client presents to the ED with respiratory distress. Breathing is labored, O2 sat 89% on room air, BP 175/101 (125) mmHg, HR 132 bpm. Rales are heard in bilateral lungs and the client has + JVD. Which treatment would be most appropriate for this client initially?

• Morphine

• Furosemide

• Nitroprusside drip

• Dobutamine

Match

Match the treatment with the appropriate finding

• CVP 1

• SVR 1968

• SvO2 70

• MAP 56

• CO 2

Crystalloids

Nitroglycerine

Nothing, this is normal

epinephrine

Dobutamine

• Crystalloids

• Nitroglycerine

• Nothing, this is normal

• epinephrine

• Dobutamine

Multiple Choice

Invasive Hemodynamics: CVP/RA 16, PAP 36/22, PAOP 20, PVR 300, SVR 1800, CO 2.5, CI 1.5, SvO2 55%

• NS fluid bolus

• vasopressors

• inotropes

• oral beta blocker

Shocks

• ​Hypovolemic Shock (low volume)

• Obstructive Shock (can't get where needs to go)

• Cardiogenic Shock (heart isn't pumping effectively)

• Distributive (3 subtypes-vasodilation)

  • anaphylaxis

  • septic

  • neurogenic
    

Multiple Choice

22 y/o male admitted after MVC. Radiographic workup reveals subcapsular splenic hematoma. BP 74/37 (49), HR 138, RR 30,
O2 sat 97%, T 37.1C (98.7F), UOP 5ml/hr.
Physician placed a pulmonary artery catheter to
further assess hemodynamic status: CVP/RA 1,
PAP 14/5, PAOP 3, PVR 300, SVR 1700, CO 8.2, CI
5.0, SvO2 80%

What type of shock is this an how should the pt be treated?

• Obstructive shock; treat with thrombolytics and anticoagulation.
• Cardiogenic shock; treat with diuretics and beta-blockers.
• Hemorrhagic shock; treat with fluid resuscitation and possible surgical intervention.
• Septic shock; treat with antibiotics and vasopressors.

Multiple Choice

66 y/o female transferred to the ICU post-op AKA for gas gangrene of LLE (clostridium perfringens myonecrosis). ABP 81/42 (55), HR 130, RR 34, O2 sat 90%, T 38.8 oC (101.8 oF), UOP <5ml/hr. Norepinephrine gtt started, now ABP 90/45 (60). Physician placed a pulmonary artery catheter to further assess hemodynamic status: CVP/RA 1, PAP 13/6, PAOP 3, PVR 73, SVR 715, CO 9.2, CI 5.3, SvO2 80%

What type of shock and what treatment is the priority?

• Cardiogenic shock; priority treatment is vasopressors.
• Septic shock; priority treatment is fluids and possibly vasopressors.

• Hypovolemic shock; priority treatment is blood transfusion.
• Obstructive shock; priority treatment is surgical intervention.

Multiple Choice

A 68-year-old patient with suspected septic shock is admitted to the ICU. The nurse notes the following:

• BP: 82/48 mmHg,

  HR: 118/min,

  RR: 26/min,

  SpO₂: 93%,

  Temperature: 39.2°C (102.6°F),

  Skin: Warm and flushed,

  CVP: 3 mmHg,

  SVR: 550 dynes/sec/cm⁵,

  Cardiac output: 8.2 L/min

• What type of shock is this and which intervention is appropriate?

• Distributive Shock; Administer IV isotonic fluids and prepare to initiate a vasopressor if hypotension persists.

• Cardiogenic Shock; Administer IV diuretics to decrease preload and reduce cardiac workload.

• Cardiogenic Shock; Administer a beta-blocker to decrease the heart rate and myocardial oxygen demand.

• Distributive Shock; Restrict IV fluids and administer a vasodilator to further decrease systemic vascular resistance.

Multiple Choice

24 y/o male was transferred to the ICU from ER after an anaphylaxis reaction and requiring intubation. ABP 92/52 (64), HR 114, RR 14, O2 sat 90%, T 37.0C. The physician placed a pulmonary artery catheter to further assess hemodynamic status: CVP/RA 1, PAP 18/9, PAOP 2, SVR 715, CO 3.1, SvO2 88%

What type of shock and what is the priority treatment?

• Anaphylactic shock , stopping the allergic reaction

• Septic shock, beginning antibiotics

• Cardiogenic shock, place on inotropes

• Hypovolemic shock, initiate colloids

Multiple Choice

32 y/o male admitted after fall from roof resulting in T4 spinal cord injury (SCI). Vitals are as follows: ABP 86/52 (63), HR 42, RR 36, O2 sat 90%, T 36.1 oC (97.0 oF), with warm/dry skin. Pulmonary artery catheter readings include: CVP/RA 1, PAP 20/5, PAOP 4, PVR 115, SVR 600, CO 3.5, CI 2.3, SvO2 60%

What type of shock and what is priority treatment?

• Hypovolemic shock; priority treatment is oxygen therapy.
• Cardiogenic shock; priority treatment is diuretics.
• Septic shock; priority treatment is broad-spectrum antibiotics.
• Neurogenic shock; priority treatment is fluid resuscitation and vasopressors.

Multiple Choice

45 y/o male involved in a motorcycle crash with extensive chest trauma and absent breath sounds on the left side and muffled heart sounds. Vitals are as follows: ABP 72/42 (55), HR 119, RR 35, O2 sat 72% on 100NRB, T 36.0 C. Pulmonary artery catheter readings include: CVP/RA 1, PAP 15/7, PAOP 3, SVR 1954, CO 2.5, CI 2.3, SvO2 55%

What do you suspect is happening? What is the priority treatment?

• Cardiogenic shock; priority treatment is inotropic support.
• Tension pneumothorax; priority treatment is chest decompression.
• Septic shock; priority treatment is broad-spectrum antibiotics.
• Hypovolemic shock; priority treatment is fluid resuscitation.

Multiple Choice

56 y/o female transferred to the ICU for septic UTI + for E. Coli. ABP 7536 (51), HR 135, RR 31, O2 sat 92%, T 38.8 oC (101.8 oF), UOP < 7ml/hr. Vasopressin gtt started, now ABP 82/45 (57). Physician placed a pulmonary artery catheter to further assess hemodynamic status: CVP/RA 1, PAP 13/6, PAOP 3, SVR 765, CO 8.2, CI 5.3, SvO2 86%

What type of shock is this?

• Hypovolemic shock
• Septic shock
• Cardiogenic shock
• Obstructive shock