Transcript Critical Care Management

Critical Care Management
History
• 1950 iron lungs (polio and brain stem
paralysis)
• 1958 Peter Safar the first Intensive Care
Unit at Baltimore City Hospital
• 1970 Swan Ganz
Important facts in development
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Wars
Iron lungs
Dialysis
Defibrillators
Transplantation
Cost - benefit ratio?
• Acute Physiology and Chronic Health
Evaluation (APACHE)
• Therapeutic Intervention Scoring System
(TISS)
• Survival is inversely related to the severity
of illness and number of organ systems
affected
Ethical and Legal Issues
• What is justified?
• Reversability versus futility
• Decision must involve patients (or
guardian), family, hospital policies and law
• Withholding versus withdrawing
• DNAR orders
Critically ill patient
• Unstable conditions in whom small changes
in organ function may lead to a serious
deterioration in overall body function with
irrevesible organ damage and death.
• Monitoring: early to provide optimal
treatment and restore a more stable
physiologic condition to prevent damage
and death
Respiratory therapy
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Integral part of the critical care medicine
Oxygen therapy
Causes of hypoxia
Possitive pressure ventilation: CMV, AC,
IMV, SIMV, PSV, PCV, MMV, IRV, HFJV,
weaning from mechanical ventilation,
• Endotracheal intubation, sedation, paralysis,
Anesthesia for cardiovascular
surgery
• Cardiopulmonary bypass
• Hypothermia and myocardial preservation
• Anesthetic management: induction,
monitoring, prebypass period, cannulation,
bypass time, weaning from bypass,
postbypass period
• Vascular surgery
Basic parameters
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CO
V02
Preload
Afterload
Contractility
“Lucidotropic effect”
Frank-Starling
Case 1
• 55 y old man after circulatory arrest on the
street – resuscitated but uncouscious.
• How to transport, where to transport,
treatment?
Case 2
• 60 y old woman with a long history of
asthma.
• Came to GP with respiratory distress
(tachypnoe and cyanosis):
• Diagnosis?
• Monitoring?
• Treatment?
• Where to go?
Case 3
• 40 y old man injured in car accident: can
not breath, pain in the chest, conscious, RR
100/70, HR 120/min,
• Diagnosis, treatment, where to go?
Pressure-volume relationship
Regulatory mechanisms in
biology
• No complex research
• No proofs
• Lot of speculations
• Molecular biology
History
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1628 Harvey (passive)
1748 Radermacher (active)
1919 Krogh (heterogenic)
- tissue
- capillary
- chaos or homestais?
Altered myocardial states
Zmienione stany czynnościowe m. sercowego
Niedokrwienie/Reperfuzja
Zawał
Brak funkcji
Stunning
Czasowy brak funkcji
Hibernation
Odwracalny brak funkcji
Sequence of events
Frank-Starling
Shock states
• Cardiovascular management
• Understand mechanisms and
definition of shock states
• Signs of circulatory failure
• General principles of management
• Pharmacology and volume
treatment
Schematic representation of the
circulatory system
Basic functions of the circulatory
system
• Total (heart, veins, arteries)
• Heart (muscle, valves)
• Altered myocardial states
Definition of the circulatory
insufficiency
Complex picture: left ventricular and
neurohormonal dysfunction with signs of
limited exercise capacity, fluid retention and
increse mortality rate
Signs of circulatory insufficiency
• Changes in filling pressure
• Systolic and/or diastolic dysfunction
• Emptying disturbances
Compensation mechanisms
• Increase vascular volume
• Increase filling pressures
• Tachykardia
• Hypertrophia
Myocardial stunning
Classification
• Hypovolemic
• Obstructive
• Cardiogenic
• Distributive
• Endocrine
Clinical signs
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HR
BP
Temperature
Urine output
Pulse oximetry
Invasive monitoring
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Swan-Ganz
Pressure (PAP-PCWP)
Volume (CO)
Oxygenation (SvO2)
Definition of the ejection fraction
Calculations
• EDV=150 ml
• ESV=50 ml
• EF= 150-50/150 = 0.66 = 60-70%
Inotropic state
• Ino = fibre, tropos = movement
• Increase contractility = increase the power
of contraction (under preload, afterload and
HR)
• MV02
• Interaction between calcium and troponins
Preload
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Load just before contraction
Venous return
Increase LV
Increase power of contraction
Increase of the HR
Example: exercices or i.v. infusion
Relation to venous return
Afterload
• Systolic pressure
• Ventricular tension
• Periferal resistance
Relaxation failure
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30-40% pts
Definition: failure of filling
Examples:
pericarditis
degeneration
ischemia
stiffness
Treatment principles
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Preload
Contractility
Afterload
Oxygen delivery
Potential errors in preload estimation
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CVP (EF)
LVEDV (compliance)
LVEDP (MS,MI)
LAP (elevated pulmonary pressure)
PAOP (catheter position)
Drugs for treatment of circulatory
failure
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Vasodilators
Diuretics
Glycosides
Fosfodiesteraze inhibitors
Calcium synthetizers
Agonist beta and DM
Antagonists beta
Vasodilators
• ACE Inhibitors: captopril, enalapril
• Nitrovasodilatators: NTG, NPS,
molsidomina, hydralazyna
• Calcium channel blockers
• Potassium channel activators: diazoxide,
minoxidil, pinacidil, cromakalin
Nitrate sides of action
Inotropic drugs
Fosfodiesteraze inhibitors
• Amrinone (1,5 - 2,5 mg/ kg)
• Milrinone (10 x more powerful)
• increse of cAMP, calcium concentration and
sensitivity, blood vessels dilatation
• Main indication: diastolic dysfunction of the
heart
Calcium sensitizers
• Pinobendan, Simendan, Levosimendan
• Saving energy (ATP)
• No influence on calcium homeostasis
• Drug of choice in “myocardial stunning”
• Contraindication: diastolic dysfunction
Coronary flow
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CPP
• CBF =
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CVR
DP - LVEDP
CVR
Case 1
• 70 years old man 1 hour after car accident:
conscious, HR 130/min, ABP 80/60 mmHg,
CVP 1 mmHg, no diuresis.
Case 2
• 25 years old woman after penicillin
administration: collapse, ABP 70/40, HR
70/min, CVP 2 mmHg, rush on the skin.
Case 3
• 56 years old man 3 days after MI, dyspnea,
ABP 80/70, HR 110/min, CVP 10 mmHg,
PCWP 25 mmHg, oliguria.