KELAINAN SISTEM HEMODINAMIK PRESENTASI SAR
- 3. Hemodynamic disorders 3 Interstitial fluid is the balance between •capillary hydrostatic pressure which tends to encourage water to enter the interstitium •plasma oncotic pressure which tends to encourage water to leave the interstitium •lymphatic drainage which allows water and proteins to leave the interstitium
- 6. Hemodynamic disorders 6 Edema •The abnormal accumulation of fluid in interstitial compartment •In capillary: Balance between hydrostatic pressure and oncotic (colloid osmotic) pressure
- 7. Hemodynamic disorders 7 Mechanisms of Edema •Increased Capillary Hydrostatic Pressure •Decreased Plasma Oncotic Pressure •Lymphatic obstruction • Sodium Retention Increased Capillary Permeability
- 8. Hemodynamic disorders 8 Capillary Hydrostatic pressure •Nail bed capillaries: 35 mmHg at arteriolar end and 15 mmHg at venous end Mean 28 mmHg •Hydrostatic pressure gradient: Intra-capillary hydrostatic pressure – interstitial fluid hydrostatic pressure
- 9. Hemodynamic disorders 9 Increased Capillary Hydrostatic Pressure •increased hydrostatic pressure in the capillary bed leads to increased rate of fluid loss into the intestitium •this is most commonly associated with impeded outflow through venous system (increased venous back pressure) •Examples: congestive heart failure, portal hypertension; localized: venous thrombosis, varicose veins, pressure from outside (tumours)
- 10. Hemodynamic disorders 10 Oncotic pressure •Capillary wall usually impermeable to plasma proteins and other colloids •Only water and small solutes cross capillary wall •These colloids exert an osmotic pressure of about 25 mmHg •The colloid osmotic pressure due to the plasma colloids = oncotic pressure
- 11. Hemodynamic disorders 11 Decreased Plasma Oncotic Pressure •reduced plasma proteins (especially albumin) lead to reduced osmotic reabsorption of interstitial fluid back into capillaries •less common than edema due to sodium retention •generaly not clinically apparent until albumin levels are less than 2 g/l (normal 4 – 5 g/l) •associated with : loss of proteins (nephrotic syndrome, protein losing enteropathies, burns) or decreased production of albumin (liver failure, protein malnutrition)
- 12. Hemodynamic disorders 12 Lymphatic drainage •lymphatic vessels begin as blind ended capillaries in the interstitium •they collect excess fluid (about 2ml/min) and the small amount of protein that accumulate in the interstitium; this fluid is returned to the venous circulation via thoracic duct
- 13. Hemodynamic disorders 13 Lymphatic obstruction •obstruction of lymphatics prevents removal of excess interstitial fluid produces localized edema depending upon which lymphatic drainage is obstructed •examples: tumours (esp. metastatic to lymph nodes) , surgical removal of lymphatics (radical mastectomy) fibrosis and scaring (post- inflammatory or post-radiation) parasites (filariasis)
- 14. Hemodynamic disorders 14 Sodium • sodium is the major determinant of the osmolarity of extracellular fluid • sodium therefore is a major influence in extracellular fluid volume • sodium levels are primarily controlled by renal excretion, which is influenced by – atrial natriuretic factor (increases sodium excretion) – renin-angiotensin system (increases sodium retention) – sympathetic nervous system (increases sodium retention)
- 15. Hemodynamic disorders 15 Sodium retention •increased sodium increased extracellular fluid → volume; that means – a proportinal increase in interstitial fluid – increased blood volume → increased hydrostatic pressure •usually occurs on the basis of impaired renal excretion of sodium (decreased blood flow to the kidneys, renal disease)
- 16. Hemodynamic disorders 16 Increased Capillary Permeability •leads to loss of fluid and protein into interstitium •usually produces localized edema •associated with inflammation (blisters, hives), burns, allergic reaction
- 18. Hemodynamic disorders 18 Organ specific •Brain : Cerebral edema •Lung: Intra-alveolar = pulmonary edema, intra-pleural = pleural effusion •Peritoneum = ascites •Severe generalized edema=anasarca
- 20. Hemodynamic disorders 20 •Maintenance of blood fluidity within the vascular system is an important human physiological process •The term ‘haemostasis’ refers to the normal response of the vessel to injury by forming a clot that serves to limit haemorrhage
- 21. Hemodynamic disorders 21 •Thrombosis is pathological clot formation that results when haemostasis is excessively activated in the absence of bleeding (‘haemostasis in the wrong place’) •Essential components of fluidity, haemostasis and thrombosis are the blood flows produced by the cardiac cycle, the vascular endothelium and the blood itself
- 25. Hemodynamic disorders 25 Primary Hemostasis
- 26. Hemodynamic disorders 26 Secondary Hemostasis
- 27. Hemodynamic disorders 27 Thrombus & Antithrombotic events
- 28. SHOCK
- 29. Hemodynamic disorders 29 Definition •Shock is a state of acute cardiovascular or circulatory failure. It leads to decreased delivery of oxygenated blood to the body's organs and tissues or impaired oxygen utilization by peripheral tissues, resulting in end-organ dysfunction
- 31. Hemodynamic disorders 31 Diagnosis of shock • Altered cognition/agitation • Hypothension • Tachypnea • Tachycardia • Prolonged capillary refill time • Oliguria
- 34. Hemodynamic disorders 34 Hypovolaemic shock • due to inadequate circulating fluid volume • Causes • divided to haemorrhagic or non-haemorrhagic (major burns; gastrointestinal losses: vomiting, fistulas; urinary losses: diabetes, diabetes insipidus; evaporative losses with fever, abdominal surgery) • Management • fluid resuscitation • haemorrhagic cause: transfusion of red cells and blood products 1:1:1 for red cells, FFP, platelet • review source of bleeding and stop bleeding promptly • use of hemostatic agent
- 35. Hemodynamic disorders 35 Cardiogenic shock • due to cardiac pump failure resulting from myocardial or valvular failure • Causes • acute coronary syndrome • arrhythmia, myocardial contusions post-trauma; myocarditis; acute valvular dysfunction; cardiomyopathy • Management • ACS: reperfusion by fibrinolytics or PCI • control arrhythmia: pharmacological, electrical : cardioversion • optimise preload by fluid • observation of CVP/BP trend • inotropic support
- 36. Hemodynamic disorders 36 Distributive shock • due to peripheral vascular dilatation causes a fall in peripheral resistance. The cardiac output is often increased but the perfusion of vital organs is comprised because the body loses its ability to distribute blood properly (vasoplegia) • Causes: septic shock; anaphylaxis; neurogenic shock Management: • Fluid resusitation • Septic shock: prompt antibiotics, source control • Inotropic support: start when BP is refractory to fluid. Usually nor- adrenaline for septic shock • Anaphylaxis: SC/ IV adrenaline
- 37. Hemodynamic disorders 37 Obstructive shock • due to obstruction of great vessels or heart that impedes the blood flow • Causes • cardiac tamponade; tension pneumothorax; pulmonary or air embolism • Mangement • Promt relief of obstruction: e.g. pericardiocentesis for tamponade, chest drain for tension pneumothorax • Fluid and inotrope are for temporary support
- 38. Hemodynamic disorders 38 Management of Shock •Early recognition and prompt treatment of the underlying cause of shock •Ensure oxygenation and maintain perfusion •Usually aim for MAP 65mmHg ≥ •u/o 0.5ml/kg/hr ≥
- 39. ALHAMDULILLAH