Hemodynamics and Shock

NUCO 4220 Spring 2014

Tissue and Organ Perfusion

Influenced by Amount of O2 in arteries that reaches cell (how much pumped from heart reaches cells)

Factors that Influence MAP

- Heart - Size of vascular bed - Volume of blood w/in vessels

MAP (Mean Arterial Pressure)

Mean arterial pressure
SVR x CO (+CVP: often negligible) OR [(2Xdiastolic) + systolic] / 3 (never calculate) Norm: 70-110 mmHg - avg BP (more direct measure than cuff)

- Arterial pressure when heart pumping

- An indicator of perfusion

- MAP > 60 to perfuse kidneys, brain and coronary arteries (gut takes hit early)
- MAP 101 = good perfusion
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Arterial Line
2 uses: get blood, get MAP Change tube q96h

Sterile dressings last about a wk

*Dont memorize waveform*

jeffreymlevinemd.com

Arterial Line Set Up

500ml Norm Saline (not always w/ heparin, risk for HIT) Pressure Bag to force fluid against artery (which pushes stuff out) All sit in transducer holder, leveled at right atrium
aic.cuhk.edu.hk 5

Transducer placement
Plastic holder often on HOB bc always has to be zeroed to give accurate read
0 it every shift so dont get atmospheric pressure

Phlebostatic Axis:
4th intercostal space and mid-axillary (btw interiorposterior diameter) @ right atrium

CVP or RA Pressure
MAP = central core BP CVP/RA = central venous pressure (comes from RA) Long line inserted subclavian (jugular/femoral risk infxn) Tip in RA gives sense of fluid thats been returned to heart from body
Ex: low UO, so measure how much of bolus circulating well

How much blood to pulmonary arteries to get oxygenated Norm: 2-8

CVP
Norm 2-8 mm Hg

Guidelines:
8-12 to avoid hypovolemia (ex: burn) >12 if pt on mechanical vent
PEEP volutrauma can compress capillaries and decr vol to heart (and CO)give extra vol so vessels less likely to collapse

Level to RA and 0 every shift

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Swan Ganz Catheter

RA to RV up into pulm vasculature Risk perforate lung, valve, artery, infxn, dysrhythmias (block), etc.

nlm.nih.gov

Swan Ganz Catheter

Most have 6 ports Can deliver inotrope into heart immediately Can get CVP
Only way to continuously monitor pulm artery pressure

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Swan-Ganz Measurements (mmHg)

R Atrium (CVP) Right Ventricle
Systolic 15-30 Diastolic 3-8

Pulmonary Artery
How constricted or dilated is pulm pressure

Pulmonary Wedge (L. Atrium) Indirect

2-15 Wedge off pressure for a moment and get reflective value of LA (based on build-up in RA?)

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Pulmonary Artery Pressure

Systolic 15-25 Diastolic 8-15 Mean 10-20 Pulm HTN = PAP > 25 Is pulm system vasoconstricted? Ex: improve CO by giving fluid, but if still low, get PAP:
High PAP (constricted), fluid cant get through resistance w/ same vol & speed to produce CO on other side (tx: vasodilate) CVP can look good but still low perfusion, giving lots of fluids risks pushing into RHF 12

Also obtained from cardiac cath

Pulmonary Artery Pressure

Heart Failure Sepsis Clot
Low flow not necessarily r/t constriction Clot in pulm vasculature would cause low flow

Effectiveness of Tx/ Meds

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Mixed Venous Oxygen

% of reduced hgb left after tissue oxygen extraction
How much O2 left on hgb after it blood has circulated

Blood gets O2 in pulm vasculature, pumps to body, and has lowest O2 right before entering again

SvO2 Norm value 60 - 80%.

< 60 if cells/organs need more Ex: in marathon, cells need more O2, so pull free O2 from body, and wont see immediate drop in SaO2 and SvO2?? but septic pt wont have that O2 reserve and see quick drop in SaO2
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Oxygen Delivery
Hgb O2 saturation CO

http://www.bing.com/images/search?q=oxygen+delivery+cells&FORM=BIFD#focal=88d8a54e16da437f9dc6864efb8e 15 19f2&furl=http%3A%2F%2Fwww.oneminutecure.com%2FDissociationHemoglobinOxygen.jpg

CO = Heart Rate x Stroke Volume

Heart Rate Stroke Volume (SV)
Fluid from LV left over after final LV contraction
Amount of vol of blood being pumped to tissues Norm CO = 4-8L/min

End-Diastolic Vol minus EndSystolic Vol

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Stroke Volume
Measurement of Vol using Echocardiogram
How much making it out to tissues Gives info of how circulating, how well its squeezing on inotrope (can actually see contraction/squeeze), see color-coded arterial & venous flow

Used to assess vol response to fluids and meds

Esophageal Doppler*****
Probe into esophagus near heart gives good output

Non-invasive Doppler: THE FUTURE

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Shock
- Side-effect (syndrome/condition) r/t how much vol circulating to perfuse organs - Decr blood vol w/o constricted capillary bed can lead to shock
- Ex: hemorrhage (losing vol), so if capillary bed doesnt constrict and MAP doesnt incr, organs will die quickly - Capillary beds dilate excessively, go into shock bc not enough tension/resistance to perfuse organs - Compensate early one (ie capillaries constrict when vol decr), but if doesnt, go into shock fast

It is a widespread abnormal cellular metabolism that occurs when the human need for oxygenation and tissue perfusion is not met to the level needed to maintain cell function. All body organs are affected and either work harder to compensate or fail due to hypoxia
Iggy, Chapter 39, pp 826

Blood Volume, Capillary Bed & MAP

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Hypoperfusion
Cellular hypoxia (w/ build-up of lactic acid)
Cell death r/t hypoxia cause incr lactic

Aerobic (with O2) metabolism anaerobic (without O2) metabolism lactate and H+ ions lactic acidosis (metabolic)

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Lactate
0.5 1 mmol/L: Normal 2 mmol/L: Slight elevation 2 5 mmol/L: Mild-moderate > 5 mmol/L: Lactic acidosis (with low pH)

**Concern when above 2 Get ABG w/ lactate tells to what degree body didnt or no longer able to compensating
Lactic acid means no compensation need to intervene 21

Hypoxia Tolerance
Heart, Brain, Kidney cant tolerate hypoxemia Skin, Skeletal Muscles can tolerate hypoxia for awhile

Liver = middle rode tolerance

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4 Types of Shock
Hypovolemic (low vol)
Give fluids

Cardiogenic
Ex: MI impairs CO

Distributive (anything that affects periph vasc)

Septic Anaphylactic Neurogenic

Obstructive (rare)
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Stages of shock (Iggy, Table 39-3)

Early (preshock)
MAP decr by 5-10 HR up a little to incr CO and compensate Some vasoconstriction

Compensatory (**identify & intervene**)

MAP decr 10-15 HR up (whats pt baseline), decr UO Ned to reverse quickly before tissue death

Progressive
Compensatory mechanisms fail MAP decr 20-40 , severe hypoxemia, poor CO & UO

Refractory
Almost impossible to reverse MODS
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Hypovolemic Shock Fluid Depletion

Extreme dehydration: Dehydration = vol loss (expect incr CO (w/ incr HR & BP) and capillary constriction When cant compensate, MAP decr Blood loss: Losing O2 carrying capacity Cant compensate long Tx: Pressure bag fluids Central line (access and CVP read) If hemorrhage: start fluids before blood arrives (even if not 25 type & screen yet)

Cardiogenic Shock Direct Pump Failure

So much cardiac damage that pump doesnt work Low CO, so capillaries need to vasoconstrictor to maintain circulating vol Dont give extra vol bc dont have mechanism to help w/ CO Dont give inotrope, bc it make heart squeeze too much and further cardiac cell death Tx: cath lab and/or LVAD type pumps until transplant (if needed)
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IABC: Intra-aortic counterpulsation (Intraaortic balloon pumpIABP)

Cardiac cycle Increase coronary perfusion Decrease afterload

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Distributive Shock: Massive Vasodilation

Leaking vessels Spinal cord injury: Nerve innervation affects constriction, cant hold tone Losing fluid to tissues

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Distributive Shock
Septic Anaphylactic
Epi-pen is vasoconstrictor

Neurogenic Too many opioids or drugs affecting tone(?) Tx:

Lots of vasodilation: incr vol (to fill space) or incr CO (to incr pressure) Potentially get inotrope Correct underlying condition
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Sepsis Bundles:
Surviving Sepsis Campaign (2008)
Element 1: Measure serum lactate (act if >2) Element 2: Get blood cultures prior to giving broad-spectrum antibx Element 3: Administer antibx w/in 3hrs of ED & 1hr of Non-ED admit Element 4: Tx hypotension and lactate w/ fluids. Maintain MAP> 65. Use vasopressors for ongoing hypotension. - Give liters of fluids, once MAP >65, stop boluses, but continue fluids Element 5: Maintain CVP > 8mmHg and Mixed Venous O2 > 65%
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Sepsis Management Bundle

Evidence-based goal is to perform all indicated tasks 100% of time w/in first 24 hrs of presentation

1. Administer low dose steroids

r/t inflammatory mediators

2. Maintain glucose control

lower limit of norm but <180mg/dl

3. Maintain inspiratory plateau pressure (IPP) <30cm H2O for mechanically ventilated pts.

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Assessment
CV status shock 1st sign of Musculoskeletal
Tolerates hypoxia well, so see late changes Decr movement and strength As MAP drops, pulse pressure low (less palpable)

Renal
Decr UO

CNS also an early sign

Something off Incr neuron firing: twitch, agitated, anxious

Respiratory
Incr RR Metab acidosis so resp kicks in to compensate (blow off CO2)

Lab values H/H, Lactic acid, K+

Get ABGs after other tasks Adjust K+ quickly (if hyperkalemia, glucose or Ca+ (?) to send K+ intracellularly, can give kaexolate later) 32

Integumentary
Cool skin, diaphoresis, slow cap refill,

Management
Oxygen therapy need O2 IV therapy Crystalloids, Colloids, Blood Hemodynamic monitoring MAP,CVP, (SV) Drug therapy Vasoconstrictors, Inotropes, Myocardial perfusion agents Treat underlying condition
If anaphylaxis, give epi; if MI, etc.

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Practice
Which client should the nurse evaluate for neural-induced distributive shock? A. The 25-year-old receiving 500 mg of penicillin IV. B. The 47-year-old with sudden-onset severe chest pain and dyspnea. C. The 21-year-old who has received 4 mg of morphine IV for acute pain. D. The 82-year-old who has had severe vomiting and diarrhea for 2 days.
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Case Study
A 53-yr old man is s/p open reduction of right forearm after falling from a tree while trimming it. PMH: mild hypertension, 15 # underweight. PSH: smokes two packs of cigarettes and drinks a six-pack of beer daily. VS : BP, 142/90; HR 86; RR 18; O2 Sat 97%. Exam: forearm dressing is dry & intact, fingers are warm & pink with good cap refill. He responds to his name, but does not open his eyes. 1. Are any indications of shock currently present?
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It is now 15 minutes later, BP 140/92; HR 92; RR 18, O2 Sat 95%. Dressing is dry & intact, fingers are slightly cool, and cap refill is slightly slower than baseline assessment. He is awake and tells you that his right arm hurts and that he is thirsty. You administer the prescribed analgesic by injection. 2. Are any indications of shock currently present? . 3. What should you check regarding the coolness of the fingers? 4. Should you give him sips of water?
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 15 minutes later, VS are BP 132/96; HR 100; RR 22. Pain is better but he is very thirsty, light-headed & mildly nauseous. He reports belcheing. Postop orders state: Remove IV after 1000 mL has infused, if stable 5. Are any of the changes in VS a cause for concern? 6. Could the changes in VS be related to either his pain or the analgesic? 7. Where should you look for postop bleeding? 8. Should you remove his IV at this time? 9. Should retake VS in 15 minutes?
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10 minutes later: BP, 106/80; HR 112; RR 26, O2 Sat 90%. You start to check his cap refill, he says Josey (his wifes name), bring me a bucket, I feel sick. He vomits a large amount of bright red blood. 10. What vital sign changes are consistent with shock? 11. What stage of shock is present? 12. What is the most likely cause of the bleeding? 13. Is there anything the nurse could have done differently to identify shock earlier?
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