Physiology of circulation II

Pavlina Buckova M.D.

12/2013
Hemodynamic
• Blood pressure
• Pulse pressure
• Mean arterial pressure
• Blood flow
 (ARTERIAL) BLOOD PRESSURE
• pressure exerted by circulating blood upon the walls
of blood vessels
• due to the pumping action of the heart

• maximum = systolic pressure

• minimum = diastolic pressure
Measurement
• Blood pressure values are generally reported
in millimetres of mercury (mmHg)
1. Invasive
2. Noninvasive
• Palpation
• Auscultatory
• Oscilometric
(arterial) Blood pressure
• differences in mean blood pressure are responsible for
blood flow from one location to another
• physical factors that influence arterial pressure:
P = Q. R
 volume of fluid (blood volume)
 resistance - related to vessel radius, vessel length, blood
viscosity, smoothness of the blood vessel walls

• mean blood pressure drops over the whole circulation

(although most of the fall occurs along the small arteries and arterioles, because
total cross sectional area increase = resistance decrease)
How Does Increased Fluid Volume Elevate the
Arterial Pressure?
Extracellular fluid
volume ↑

Blood Volume ↑

Mean circulatory
Filling pressure ↑

Venous return ↑

Cardiac output ↑

Arterial pressure ↑
Resistance
• resistance to flow that must be overcome to
push blood through the circulatory system
• systemic circulation - systemic vascular resistance (SVR) =
total peripheral resistance
• pulmonary circulation- pulmonary vascular resistance(PVR)
• determinant of vascular resistance:
 small arteriolar (= resistance arterioles) tone
 pre-capillary arterioles = autoregulatory vessels
 viscosity of the blood
• the vessel diameter controls resistance:
 vasoconstriction increases SVR
 vasodilation decreases SVR
Resistance
• is represented mathematically: R = ΔP/Q
R is TPR
ΔP is the change in pressure across the systemic
circulation from its beginning to its end(Mean
Arterial Pressure - Mean Venous Pressure)
Q is the flow through the vasculature (equal to cardiac
output)
Regulation of arterial pressure
• is not completely understood

• the following mechanisms of regulating arterial

pressure have been well-characterized:
 Baroreceptors in the high pressure receptor zones
 Baroreceptors in low pressure receptor zone
 RAAS
Baroreceptors in the high pressure receptor zones
• in the left and right carotid sinuses and in the aortic
arch
• detect changes in arterial pressure

• send signals ultimately to the medulla of the brain

stem (Rostral ventrolateral medulla)
• by way of the autonomic nervous system adjusts the
mean arterial pressure by altering:
 both the force and speed of the heart's contractions
 total peripheral resistance.
Baroreceptors in low pressure receptor zones
• in the venae cavae, pulmonary veins, atria
• result in feedback by regulating the secretion
of ADH, renin and aldosterone

• increase in blood volume

• increased cardiac output by the Frank–Starling law

of the heart

• increasing arterial blood pressure

Renin-angiotensin - aldosteron system (RAAS):
• long-term adjustment of arterial pressure
• allows the kidney to compensate for loss in blood
volume or drops in arterial pressure
• activates an endogenous vasoconstrictor - angiotensin II
• releases aldosteron in response to angiotensin II or high
serum potassium levels
• aldosterone stimulates sodium retention and potassium
excretion by the kidneys
• sodium determines the amount of fluid in vessels by osmosis

• increase fluid retention indirectly arterial pressure

Renal-Body Fluid System for Arterial
Pressure Control
Too much The blood volume &
extracellular fluid arterial pressure rise

The kidneys excrete The arterial

thr excess pressure back
extracellular fluid toward normal

Pressure diuresis: An increase in arterial pressure only a few mm Hg can

double the renal output of water
Pressure natriuresis: An increase in arterial pressure only a few mm Hg can
double the renal output of salt
How Does Increased Fluid Volume Elevate the
Arterial Pressure?
Extracellular fluid
volume ↑

Blood Volume ↑

Mean circulatory
Filling pressure ↑

Venous return ↑

Cardiac output ↑

Auto-regulation

Total peripheral
resistance ↑
Arterial pressure ↑
Importance of Salt in the Renal-Body Fluid
Schema for Arterial Pressure Regulation
• Excess salt in the body → The osmolality of the body fluid
increases → Stimulate the thirst center → Drink extra
amounts of water → Increases the extra-cellular fluid volume
• The increase in osmolality in the extracellular fluid →
Stimulate hypothalamus to secrete ADH → The kidney
reabsorb water from the renal tubular fluid → Increasing the
extracellular fluid volume.
• Increasing extracellular volume → Elevation of the arterial
pressure.
 PULSE PRESSURE
• the pressure difference between the systolic and
diastolic pressures
• pressure that is felt when feeling the pulse
• proportional to stroke volume
• inversely proportional to the compliance of the aorta

• (120 – 80 = 40 mmHg)
Low (Narrow) Pulse Pressure
• abnormally low if it is less than 25% of the systolic
value
• the most common cause of a low (narrow) pulse
pressure is a drop in left ventricular stroke volume:
• significant blood loss
• shock
• aortic valve stenosis
• cardiac tamponade
• congestive heart failure …
High (Wide) Pulse Pressure
• increases with exercise due to increased stroke volume,
simultaneously with total peripheral resistance drops
• healthy values up to 100 mmHg
• most individuals:
 systolic pressure progressively increases
 diastolic pressure remains about the same
• very aerobically athletic individuals
 the diastolic pressure will progressively fall
 this facilitates a much greater increase in stroke volume at a
lower mean arterial pressure = enables much greater aerobic
capacity and physical performance
 diastolic drop reflects a much greater fall in total peripheral
resistance of the muscle arterioles
Consistently high values
• consistently greater than 100 mmHg

• Atherosclerosis
• Arteriovenous fistula
• Chronic aortic regurgitation
• Thyrotoxicosis
• Fever
• Anemia
• Pregnancy
• Endocarditis
• Raised intracranial pressure…..
 MEAN ARTERIAL PRESSURE
• the average arterial pressure during a single cardiac
cycle
• considered to be the perfusion pressure seen
by organs in the body
• normally between 70 to 110 mmHg
• greater than 60 mmHg is enough to sustain the
organs
• below this number for an appreciable time, vital organs will not get enough Oxygen
perfusion, and will become ischemic
 BLOOD FLOW
• Volume of fluid movement per unit time

F= v.A ….F= flow, v= velocity, A= area

when fluid enters narrow section of tube, volume of fluid ( F2) that passes cross
section (A2) must be equal the volume (F1) that had passes cross section A1.
The velocity (V2) in narrow section would increase.
F1= F2 ….. V1. A1 = v2. A2

• Velocity of blood decrases as blood flows to smaller vessels , because

total cross sectional area increase
• As blood continues toward bigger veins, velocity increase again
 BLOOD FLOW
• Relationship between flow and pressure:
Difference in blood pressure are responsible for blood flow
Pressure of blood decrases as blood flows to smaller vessels , because total cross sectional
area increase = resistance decrease

F, Q = flow P = pressure R= resistance

Hagen–Poiseuille equation
Local Regulation of Blood Flow
• tissues and organs are able to regulate their own blood
supply in order to meet their metabolic and functional
needs
• local regulatory mechanisms act independently
of extrinsic (neural, hormonal) control mechanisms

• main factor of local regulation is metabolic mechanism

• Others: myogenic and endothelial mechanisms

• balance between local regulatory mechanisms and

extrinsic factors in vivo determines the vascular tone and
therefore the blood flow
Local Regulation of Blood Flow
Local Regulation of Blood Flow
• if a vascular bed has a high degree of autoregulation,
then the new steady-state flow may be very close to
normal
• Different organs display varying degrees of
autoregulatory behavior:
 The renal, cerebral, coronary circulations - excellent
autoregulation
 skeletal muscle and splanchnic circulations - moderate
autoregulation
 cutaneous circulation - little or no autoregulatory
capacity
Blood Flow Through Tissues During Exercise
• lood flow is matched with the metabolic needs
• flow through exercising skeletal muscles can be 15
to 20 times greater than through resting muscles
– resting - 20% to 25% of the capillaries are open
– exercise - 100% of the capillaries are open
• local, nervous, and hormonal regulatory
mechanisms
Blood Flow Through Tissues During Exercise
• local regulatory mechanism:
– release of vasodilator substances (lactic acid, carbon dioxide,
potassium ions) dilation of precapillary sphincters

• nervous regulatory mechanism:

– sympathetic stimulation
• hormonal regulatory mechanism:
– epinephrine released from the adrenal medulla
 vasoconstriction in the blood vessels of the skin and
viscera
 vasodilation of blood vessels in skeletal muscles
 elevated heart rate and stroke volume
Blood Flow Through Tissues During Exercise
• movement of skeletal muscles compresses veins great
increase of venous return to the heart
• increased preload and increased sympathetic
stimulation of heart
• elevated heart rate and stroke volume
• elevated the cardiac output
• blood pressure usually increases by 20 to 60 mm Hg
(which helps sustain the increased blood flow through
skeletal muscle blood vessels)
Pulse Pressure during exercise
• increases with exercise due to increased stroke volume,
simultaneously with total peripheral resistance drops
• healthy values up to 100 mmHg
• most individuals:
 systolic pressure progressively increases
 diastolic pressure remains about the same
• very aerobically athletic individuals
 the diastolic pressure will progressively fall
 this facilitates a much greater increase in stroke volume at a
lower mean arterial pressure = enables much greater aerobic
capacity and physical performance
 diastolic drop reflects a much greater fall in total peripheral
resistance of the muscle arterioles
Blood Flow Through Tissues During Exercise
• sympathetic stimulation decrease in the blood flow through the
skin at the beginning of exercise

• as the body temperature increases - temperature receptors in

the hypothalamus are stimulated
• action potentials in sympathetic nerve fibers causing
vasoconstriction decrease vasodilation of blood vessels in the
skin
• the skin turns a red or pinkish color

• excess heat is lost as blood flows through the dilated blood

vessels
Reaction to stress
Cortex

Formatio retikularis

VMC (vasomotor center)

Simpathetic activation of heart

Elevated heart rate and stroke volume

High blood pressure
SHOCK
 SHOCK
• life-threatening medical condition
• due to an inadequate tissue level of oxygen
• progresses by a positive feedback mechanism
• once shock begins, it tends to make itself worse
• immediate treatment!!!!
• signs of shock are:
– low blood pressure
– rapid heartbeat
– signs of poor end-organ perfusion (peripheral shut down)
SHOCK
• Hypovolemic
• Distributive ( septic, anaphylactic)
• Cardiogenic
• Obstructive
Four stages of shock
• Initial
• Compensatory
• Progressive
• Refractory
Initial
hypoperfusion causes hypoxia

slows down entry of pyruvate into the Krebs cycle

accumulation of pyruvate

converted to lactate by lactate dehydrogenase

lactate accumulates

lactic acidosis
Compensatory
• employing physiological mechanisms - neural, hormonal
and bio-chemical mechanisms - in an attempt to reverse
the condition
• acidosis hyperventilation
• hypotension release of epinefrin, norepinefrin
• RAAS is activated and ADH is released to conserve fluid
via the kidneys
• these hormones cause the vasoconstriction of
the kidneys,gastrointestinal tract and other organs
divert blood to the heart, lungs and brain
• The lack of blood to the renal system causes the characteristic
low urine production.
 epinefrin norepinefrin
Predominately increase in heart
predominately vasoconstriction
rate

mild increase in heart rate small effect on the vascular tone

increase in blood pressure

Progressive - compensatory mechanisms begin
to fail
decreased perfusion of the cells

anaerobic metabolism continues

increasing the body's metabolic acidosis

the arteriolar smooth muscle and precapillary sphincters relax

blood remains in the capillaries

hydrostatic pressure increases + histamine release

leakage of fluid and protein into the surrounding tissues

blood concentration and viscosity increase

causing sludging of the micro-circulation

Refractory
• vital organs have failed and the shock can no longer be
reversed
• cell death is occurring and death will occur imminently

• much cellular ATP has been degraded into adenosine in

the absence of oxygen
• adenosine easily perfuses out of cellular membranes into
extracellular fluid
• cells can only produce adenosine at a rate of about 2% of
the cell's total need per hour
• restoring oxygen is futile at this point because there is
no adenosine to phosphorylate into ATP
Circulation in
organs
Circulation in heart
Circulation in brain
• Relies on continuous blood flow – interruption of
flow for 5-10s causes loss of consciousnes
• Cerebral autoregulation is very effective
– Flow is determined by factors in brain itself
– Flow remains constant in wide range of systemic pressure
– Vasculature is very sensitive to changes in CO2 (increase
CO2 – vasodilatation)
Circulation in lungs
• Blood flow is controled locally by alveolar gas
tension
– O2 and CO2 in alveoli vasoconstriction

• Low pressure, low resistance circulation

– Pressure in heart influence pressure in pulmonary
circulation
– High pressure in heart/ lungs - pulmonary oedema
Circulation in splanchnic
• Arterial blood flow to liver
+
• Portal system = vessels of inestine and spleen portal
vein liver
• In responds to incresed metabolic activity (after meal)
blood flow doubls in intestine
• Participates in regulation of circulating volume and
systemic blood pressure
• f.e.hypovolemia – reduced splanchnic circulation redistribution of blood
to heart and brain
• Liver cirhosis = obstruction of flow in liver – congestion in splanchnic
Circulation in skin
• Skin has small nutrient requirements – supply of
nutrients is not chief factor in blood flow regulation
• The primary function of cutaneous blood flow
regulation – maitnance of constant body
temperature

• Two types of resistance vessels:

– Arterioles
– Arteriovenous anastomoses
Circulation in skin
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