This publication is an updated translation of the fundamental guide of the famous professor of the University of Pennsylvania, USA P.Marino "The ICU Book", consists of 47 chapters and contains a large number of illustrations.
It provides information on complete hemodynamic and metabolic monitoring, pathophysiology of critical conditions, modern methods their diagnosis and treatment. Particular attention is paid to the choice of adequate treatment, which is very valuable given the tendency of many doctors to polypharmacy, leading to an increased risk of iatrogenic complications and an unreasonable increase in economic costs. The material is accompanied by numerous clinical examples and summarizing tables that facilitate the perception of information. The Appendix contains features of pharmacotherapy, doses and routes of administration of a number of drugs, schemes and algorithms for resuscitation and diagnostic measures, reference tables for calculating the various needs of the body, international systems assessment of the severity of the patient's condition, measures to prevent infections and hemodynamic profile.
The book will be useful not only to specialists in the field of intensive care and resuscitation, but also to doctors of other specialties, as well as senior students of medical institutes.
Section I. Physiological aspects of intensive care
activity of the heart
Oxygen transport
Assessment of gas exchange in the lungs at the bedside
Section II. Main problems and practical issues
Access to the central veins
Stress ulcers (stress ulcers)
hospital diarrhea
Treatment of thromboembolism
Section III. Invasive hemodynamic monitoring
Registration of blood pressure
Pulmonary artery catheterization
Wedging pressure
Section IV. clinical shock
Structural approach to the problem of clinical shock
Blood loss and hypovolemia
Acute heart failure
Septic shock and related syndromes
Cardiac arrest and brain damage
Section V. Practical aspects of some approaches used in resuscitation
The use of solutions of colloids and crystalloids in resuscitation
Principles of transfusion therapy
Platelets in critical conditions
Section VI. Heart rhythm disorders
Section VII. Acute respiratory failure
Pulmonary injury and edema
Non-invasive blood gas monitoring
oxygen therapy
Pharmacotherapy of respiratory failure
Section VIII. Artificial lung ventilation
Traditional mechanical ventilation
Types of ventilation
Intubation tubes, pulmonary barotrauma, latent positive end-expiratory pressure
Methods for the gradual cancellation of artificial ventilation of the lungs
Section IX. Acid-base disorders
Algorithms for interpreting indicators of the acid-base state
Lactic acid, lactic acidosis and ketoacidosis
metabolic alkalosis
Section X. Fluid and Electrolyte Disorders
Medical tactics for oliguria
Syndrome of disorders of water and sodium balance
Potassium
Magnesium: a hidden ion
calcium and phosphorus
Section XI. Nutrition and metabolism
Nutritional needs
Enteral (tube) nutrition
parenteral nutrition
Pathology of the adrenal glands and thyroid gland in patients in intensive care units
Section XII. Infectious diseases
hospital fever
hospital pneumonia
Sepsis due to catheterization
Urinary tract infections
Information about antibiotics
Section XIII. Appendix
The optimal (proper) weight of an adult (male)
The optimal (proper) weight of an adult (woman)
Basal metabolic rate
The content of trace elements in biological fluids
The content of vitamins in biological fluids
arterial blood gases
The concentration of drugs in the blood serum
Examples of drug incompatibilities
Examples of incompatibility of solutions for intravenous administration
Absorption of drugs when administered through the mouth and vein
Dobutamine
Dopamine
Lidocaine and novocainamide
Nitroglycerine
Sodium nitroprusside
Norepinephrine Hydrotartrate
Relief of hypertensive crises
resuscitation
Algorithm for the relief of ventricular fibrillation
Defibrillation
Heart rate recovery algorithm
Algorithm of measures for asystole
Algorithm of measures for bradycardia
Algorithm of measures for tachycardia
External cardiac massage
Cardioversion algorithm
Monitoring the effectiveness of CPR
Algorithm of measures for hypotension, shock and pulmonary edema
Emergency suppression of ventricular ectopic foci of excitation
Drugs that can be administered endotracheally
Determination of blood volume
Solutions of crystalloids
Colloidal solutions
Widespread hypertonic solutions
Blood transfusion agents
Glasgow severity score
Pittsburgh Brainstem Scale (PSSS)
Diagnosis of brain death
APACHE II
Infection Prevention
Body fluids and human ID virus transmission potential
Requirements for the individual protection of medical personnel from HIV infection
Results of monitoring HIV-infected patients
Hemodynamic parameters and equations
Hemodynamic parameters
Sample patient hemodynamic chart
download electronic medical book Intensive therapy Paul L. Marino download a book for free
Once a child is diagnosed with diabetes, parents often go to the library for information on the subject and are faced with the possibility of complications. After a period of worries about this, parents take another hit when they learn the statistics of diabetes-related morbidity and mortality.
Viral hepatitis in early childhood
Relatively recently, the hepatitis alphabet, which already included hepatitis viruses A, B, C, D, E, G, was replenished with two new DNA-containing viruses, TT and SEN. We know that hepatitis A and hepatitis E do not cause chronic hepatitis and that hepatitis G and TT viruses are likely to be "innocent spectators" that are transmitted vertically and do not infect the liver.
Measures for the treatment of chronic functional constipation in children
In the treatment of chronic functional constipation in children, important factors in the child's medical history must be considered; establish a good relationship between the health worker and the child-family for the proper implementation of the proposed treatment; much patience on both sides, with repeated assurances that the situation will gradually improve, and courage in cases of possible relapse, constitute the best way to treat children suffering from constipation.
Scientists study results challenge understanding of diabetes treatment
The results of a 10-year study have undeniably proven that frequent self-monitoring and maintaining blood glucose levels close to normal leads to a significant reduction in the risk of late complications caused by diabetes mellitus and a decrease in their severity.
Manifestations of rickets in children with impaired formation of the hip joints
In the practice of pediatric orthopedic traumatologists, the question of the need to confirm or exclude violations of the formation of the hip joints (hip dysplasia, congenital hip dislocation) in infants is often raised. The article shows an analysis of the examination of 448 children with clinical signs of violations of the formation of the hip joints.
Medical gloves as a means of ensuring infectious safety
Most nurses and doctors dislike gloves, and for good reason. In gloves, the sensitivity of the fingertips is lost, the skin on the hands becomes dry and flaky, and the tool strives to slip out of the hands. But gloves were and remain the most reliable means of protection against infection.
Lumbar osteochondrosis
It is believed that every fifth adult on earth suffers from lumbar osteochondrosis, this disease occurs in both young and old age.
Epidemiological control of health workers who had contact with the blood of HIV-infected
(to help medical workers of medical institutions)
AT guidelines the issues of monitoring medical workers who had contact with the blood of an HIV-infected patient are highlighted. Actions are proposed to prevent occupational HIV infection. A register of records and an act of an internal investigation were developed in case of contact with the blood of an HIV-infected patient. The procedure for informing higher authorities about the results of medical supervision of health workers who have been in contact with the blood of an HIV-infected patient has been determined. Are intended for medical workers of treatment-and-prophylactic establishments.
Chlamydial infection in obstetrics and gynecology
Genital chlamydia is the most common sexually transmitted disease. Worldwide, there has been an increase in chlamydia infections among young women who have just entered sexual activity.
Cycloferon in the treatment of infectious diseases
Currently, there is an increase in certain nosological forms of infectious diseases, primarily viral infections. One of the ways to improve treatment methods is the use of interferons as important nonspecific factors of antiviral resistance. Which include cycloferon - a low molecular weight synthetic inducer of endogenous interferon.
Dysbacteriosis in children
The number of microbial cells present on the skin and mucous membranes of the macroorganism in contact with external environment, exceeds the number of cells of all its organs and tissues combined. The weight of the microflora of the human body is on average 2.5-3 kg. The importance of microbial flora for a healthy person was first noticed in 1914 by I.I. Mechnikov, who suggested that the cause of many diseases are various metabolites and toxins produced by various microorganisms that inhabit the organs and systems of the human body. The problem of dysbacteriosis last years causes a lot of discussion with an extreme range of judgments.
Diagnosis and treatment of female genital infections
In recent years, throughout the world and in our country, there has been an increase in the incidence of sexually transmitted infections among the adult population and, which is of particular concern, among children and adolescents. The incidence of chlamydia and trichomoniasis is on the rise. According to WHO, trichomoniasis ranks first in frequency among sexually transmitted infections. Every year 170 million people fall ill with trichomoniasis in the world.
Intestinal dysbacteriosis in children
Intestinal dysbiosis and secondary immunodeficiency are increasingly common in the clinical practice of physicians of all specialties. This is due to changing living conditions, the harmful effects of the preformed environment on the human body.
Viral hepatitis in children
The lecture "Viral hepatitis in children" presents data on viral hepatitis A, B, C, D, E, F, G in children. All clinical forms of viral hepatitis, differential diagnosis, treatment and prevention that currently exist are given. The material is presented from modern positions and is designed for senior students of all faculties of medical universities, interns, pediatricians, infectious disease specialists and doctors of other specialties who are interested in this infection.
This book is a translation of the latest, third, world-famous edition of the fundamental manual written by University of Pennsylvania USA professor Paul Marino, "The ICU Book". It presents the most up-to-date and relevant information on hemodynamic and metabolic monitoring, on the pathophysiology of critical conditions, modern methods of their diagnosis and treatment. Particular attention is paid to the choice of adequate treatment, which is very valuable given the tendency of many doctors to polypharmacy, which increases the risk of iatrogenic complications and unreasonably increases economic costs. The material is accompanied by numerous clinical examples and summarizing tables that facilitate the perception of information. The appendices describe the features of pharmacotherapy, doses and routes of administration of a number of drugs, schemes and algorithms for resuscitation and diagnostic measures, reference tables for calculating the various needs of the body, international systems for assessing the severity of the patient's condition, measures to prevent infections and hemodynamic profile. The book will be useful not only to specialists in the field of intensive care and resuscitation, but also to doctors of other specialties, as well as senior students of medical institutes.
Foreword by the scientific editor to the publication in Russian
List of abbreviations
Basic scientific concepts
Circulation
Transport of oxygen and carbon dioxide
SECTION II
Preventive measures in critical conditions
Infection control in the intensive care unit
Preventive treatment of the gastrointestinal tract
Venous thromboembolism
SECTION III
Vascular access
Creation of venous access
Stay of the catheter in the vessel
SECTION IV
Hemodynamic monitoring
Blood pressure
Pulmonary artery catheterization
Central venous pressure and wedge pressure
Tissue oxygenation
Circulatory disorders
Bleeding and hypovolemia
Compensation with colloid and crystalloid solutions
Syndromes of acute heart failure
Heart failure
Infusion of hemodynamic drugs
SECTION VI
Critical conditions in cardiology
Early treatment of acute coronary syndrome
Tachyarrhythmias
SECTION VII
Acute respiratory failure
Hypoxemia and hypercapnia
Oximetry and capnography
Inhalation oxygen therapy
Acute respiratory distress syndrome
Severe airway obstruction
SECTION VIII
Artificial lung ventilation
Principles of artificial ventilation
Assisted ventilation modes
Patient on artificial lung ventilation
Cessation of artificial ventilation
SECTION IX
Acid-base disorders
Interpretation of the acid-base state
organic acidosis
metabolic alkalosis
SECTION X
Renal and electrolyte disorders
Oliguria and acute renal failure
Hypertonic and hypotonic states
calcium and phosphorus
SECTION XI
The practice of transfusion therapy in critical medicine
Anemia and RBC transfusion in the intensive care unit
Platelets in critical conditions
SECTION XII
Body temperature disorders
Hyper- and hypothermic syndromes
Fever
SECTION XIII
Inflammation and infection in the intensive care unit
Infection, inflammation and multiple organ failure
Pneumonia
Sepsis in the pathology of the abdominal cavity and small pelvis
Patients with immunodeficiency
Antibacterial therapy
SECTION XIV
Nutrition and metabolism
Metabolic Needs
Enteral tube feeding
parenteral nutrition
Adrenal and thyroid disorders
SECTION XV
Intensive Care in Neurology
Pain relief and sedation
Thinking disorders
Movement disorders
Stroke and related disorders
SECTION XVI
poisoning
Toxic reactions to drugs and antidotes to them
SECTION XVII
Applications
Appendix 1
Units of measurement and their conversion
Annex 2
Selected reference tables
Annex 3
Clinical scoring systems
Subject index
Critical Care ~ Paul L. Marino / Paul L. Marino. ""The ICU Book"" (2nd Ed) - Rus/1-2.JPG Intensive Care~Paul L. Marino/Paul L.Marino. ""The ICU Book"" (2nd Ed) - Rus/1-3.JPG Critical Care~Paul L. Marino. ""The ICU Book"" (2nd Ed) - Rus/1-4.JPG Critical Care~Paul L. Marino/Paul L.Marino. ""The ICU Book"" (2nd Ed) - Rus/1-5.JPG Critical Care~Paul L. Marino. ""The ICU Book"" (2nd Ed) - Rus/1-7.JPG Critical Care~Paul L. Marino. ""The ICU Book"" (2nd Ed) - Eng/1.html Table of Contents Cardiac Activity In this chapter, we look at the forces that influence the efficient functioning of the heart, the formation of its stroke volume, and their interaction under normal conditions and at various stages of development. heart failure. Most of the terms and concepts that you will meet in this chapter are well known to you, but now you can apply this knowledge at the bedside. MUSCLE CONTRACTION The heart is a hollow muscular organ. Despite the fact that skeletal muscles differ in structure and physiological properties from the heart muscle (myocardium), apparently they can be used in a simplified way to demonstrate the basic mechanical laws of muscle contraction. For this, a model is usually used in which the muscle is rigidly suspended on a support. 1. If a load is applied to the free end of the muscle, then the muscle will stretch and change its length at rest. The force that stretches the muscle before it contracts is referred to as preload. 2. The length that a muscle stretches after applying preload is determined by the “elasticity” of the muscle. Elasticity (elasticity) - the ability of an object to take its original shape after deformation. The more elastic the muscle, the less it can be stretched by preload. To characterize the elasticity of a muscle, the concept of “extensibility” is traditionally used; in its meaning, this term is the opposite of the concept of “elasticity”. 3. If a limiter is attached to the muscle, then it is possible to increase the load with additional weight without additional stretching of the muscle. With electrical stimulation and removal of the limiter, the muscle contracts and lifts both loads. The load that the contracting muscle must lift is referred to as afterload. Note that afterload includes preload. 4. The ability of a muscle to move the load is considered an index of the strength of muscle contraction and is defined by the term contractility. Table 1-1. Parameters that determine the contraction of a skeletal muscle Preload The force that stretches the muscle at rest (before contraction) Afterload The load that the muscle must lift during contraction Contractility The force of muscle contraction with constant pre- and afterload Extensibility The length by which preload stretches the muscle DEFINITIONS C positions of mechanics, muscle contraction is determined by several forces (Table. 1-1). These forces act on the muscle either at rest or during active contractions. At rest, the state of the muscle is determined by the applied preload and elastic properties (extensibility constituent parts ) tissue. During contraction, the state of the muscle depends on the properties of the contractile elements and the load to be lifted (afterload). Under normal conditions, the heart functions in a similar way (see below). However, when transferring the mechanical laws of muscle contraction to the activity of the heart muscle as a whole (i.e., its pumping function), the load characteristics are described in units of pressure, not force, in addition, blood volume is used instead of length. Pressure-Volume Curves The pressure-volume curves shown in Figure 1-2 illustrate the contraction of the left ventricle and the forces that affect this process. The loop inside the graph describes one cardiac cycle. CARDIAC CYCLE Point A (see Figure 1-2) is the start of ventricular filling when the mitral valve opens and blood flows from the left atrium. The volume of the ventricle gradually increases until the pressure in the ventricle exceeds the pressure in the atrium and the mitral valve closes (point B). At this point, the volume in the ventricle is the end-diastolic volume (EDV). This volume is similar to the preload on the model discussed above, since it will lead to stretching of the ventricular myocardial fibers to a new residual (diastolic) length. In other words, end-diastolic volume is equivalent to preload. Rice. 1-2 Pressure-volume curves for the left ventricle of an intact heart. 2. Point B - the beginning of the contraction of the left ventricle with closed aortic and mitral valves (isometric contraction phase). The pressure in the ventricle rises rapidly until it exceeds the pressure in the aorta and the aortic valve opens (point B). The pressure at this point is similar to the afterload in the model discussed above, since it is applied to the ventricle after contraction (systole) has begun and is the force that the ventricle must overcome in order to “eject” the systolic (stroke) volume of blood. Therefore, aortic pressure is similar to afterload (actually, afterload consists of several components, but see below for more on this). 3. After the aortic valve opens, blood enters the aorta. When the pressure in the ventricle falls below the pressure in the aorta, the aortic valve closes. The force of contraction of the ventricle determines the volume of expelled blood at given values of pre- and afterload. In other words, the pressure at point G is a function of contractility if the values B (preload) and C (afterload) do not change. Thus, systolic pressure is analogous to contractility when preload and afterload are constant. When the aortic valve closes at point G, the pressure in the left ventricle decreases sharply (isometric relaxation period) until the next moment of opening of the mitral valve at point A, i.e. start of the next cardiac cycle. 4. The area bounded by the pressure-volume curve corresponds to the work of the left ventricle during one cardiac cycle (the work of force is a value equal to the product of the modules of force and displacement). Any processes that increase this area (for example, an increase in pre- and afterload or contractility) increase the impact work of the heart. Shock work is an important indicator, since it determines the energy expended by the heart (oxygen consumption). This issue is discussed in Chapter 14. STARLING CURVE A healthy heart is primarily dependent on the volume of blood in the ventricles at the end of diastole. This was first discovered in 1885 by Otto Frank on a specimen of a frog's heart. Ernst Starling continued these studies on the mammalian heart and in 1914 obtained very interesting data. On fig. 1-2 is a Starling (Frank-Starling) curve showing the relationship between EDV and systolic pressure. Notice the steep rising part of the curve. The steep slope of the Starling curve indicates the importance of preload (volume) in enhancing blood output from a healthy heart; in other words, with an increase in the blood filling of the heart in diastole and, consequently, with an increase in the stretching of the heart muscle, the force of heart contractions increases. This dependence is a fundamental law (“law of the heart”) of the physiology of the cardiovascular system, in which a heterometric (i.e., carried out in response to a change in the length of myocardial fibers) mechanism of regulation of heart activity is manifested. DESCENDING STARLING CURVE With an excessive increase in EDV, a drop in systolic pressure is sometimes observed with the formation of a descending part of the Starling curve. This phenomenon was originally explained by overstretching of the heart muscle, when the contractile filaments are significantly separated from each other, which reduces the contact between them necessary to maintain the force of contraction. However, the descending part of the Starling curve can also be obtained with an increase in afterload, and not only due to an increase in the length of the muscle fiber at the end of diastole. If afterload is maintained constant, then in order to decrease the stroke volume of the heart, the end-diastolic pressure (EDP) must exceed 60 mmHg. Since such pressure is rarely observed in the clinic, the meaning of the descending part of the Starling curve remains a matter of debate. Rice. 1-3. Functional curves of the ventricles. In clinical practice, there is not enough evidence to support the descending part of the Starling curve. This means that with hypervolemia, cardiac output should not decrease, and with hypovolemia (for example, due to increased diuresis), it cannot increase. Particular attention should be paid to this, since diuretics are often used in the treatment of heart failure. This issue is discussed in more detail in Chapter 14. HEART FUNCTIONAL CURVE In the clinic, the analogue of the Starling curve is the functional heart curve (Fig. 1-3). Note that stroke volume replaces systolic pressure, and EDV replaces EDV. Both indicators can be determined at the patient's bedside using a pulmonary artery catheterization (see Chapter 9). The slope of the functional curve of the heart is due not only to myocardial contractility, but also to afterload. As seen in fig. 1-3, decreasing contractility or increasing afterload decreases the slope of the curve. It is important to consider the influence of afterload, as it means that the functional curve of the heart is not a reliable indicator of myocardial contractility, as previously assumed [6]. DISTRIBUTION CURVES The ability of the ventricle to fill during diastole can be characterized by the relationship between pressure and volume at the end of diastole (EPV and EDV), which is shown in Fig. 1-4. The slope of the pressure-volume curves during diastole reflects ventricular compliance. Ventricular compliance = AKDO / AKDD. Rice. 1-4 Pressure-volume curves during diastole As shown in fig. 1-4, a decrease in extensibility will lead to a shift of the curve down and to the right, DPV will be higher for any DRC. Increasing stretch has the opposite effect. Preload - the force that stretches a muscle at rest is equivalent to the EDV, not the EDV. However, EDV cannot be determined by conventional methods at the bedside, and measurement of EDV is a standard clinical procedure for determining preload (see Chapter 9). When using PDD to evaluate preload, one should take into account the dependence of PDD on the change in extensibility. On fig. 1-4 it can be seen that the EPC can be increased, although the ERR (preload) is actually reduced. In other words, the KDD indicator will overestimate the value of preload with reduced ventricular compliance. CDD allows you to reliably characterize the preload only with normal (unchanged) ventricular compliance. Some therapeutic measures in critically ill patients can lead to a decrease in ventricular compliance (for example, mechanical ventilation with positive inspiratory pressure), and this limits the value of CPP as an indicator of preload. These issues are discussed in more detail in Chapter 14. AFTERLOAD Above, afterload was defined as the force that prevents or resists ventricular contraction. This force is equivalent to the stress that occurs in the wall of the ventricle during systole. The components of the transmural tension of the ventricular wall are shown in Fig. 1-5. Rice. 1-5. afterload components. According to Laplace's law, wall stress is a function of systolic pressure and chamber (ventricular) radius. Systolic pressure depends on the flow impedance in the aorta, while chamber size is a function of EDV (i.e., preload). It was shown on the model above that the preload is part of the afterload. VASCULAR RESISTANCE Impedance is a physical quantity characterized by the resistance of a medium to the propagation of a pulsating fluid flow. Impedance has two components: stretch, which prevents changes in flow velocity, and resistance, which limits the average flow velocity [b]. Arterial distensibility cannot be routinely measured, so arterial resistance (BP) is used to assess afterload, which is defined as the difference between mean arterial pressure (inflow) and venous pressure (outflow) divided by blood flow velocity (cardiac output). Pulmonary vascular resistance (PVR) and total peripheral vascular resistance (OPVR) are determined as follows: PVR = (Dla-Dlp) / SV; OPSS \u003d (SBP - Dpp) CB, where CO is cardiac output, Pla is the average pressure in the pulmonary artery, Dp is the average pressure in the left atrium, SBP is the average systemic arterial pressure, Dpp is the average pressure in the right atrium. The presented equations are similar to the formulas used to describe the resistance to direct electric current (Ohm's law), i.e. there is an analogy between hydraulic and electrical circuits. However, the behavior of a resistor in an electrical circuit will differ significantly from that of a fluid flow impedance in a hydraulic circuit due to the presence of ripple and capacitive elements (veins). TRANSMURAL PRESSURE True afterload is a transmural force and therefore includes a component that is not part of the vascular system: pressure in the pleural cavity (cleft). Negative pleural pressure increases afterload because it increases transmural pressure at a given intraventricular pressure, while positive intrapleural pressure has the opposite effect. This may explain the decrease in systolic pressure (stroke volume) during spontaneous inspiration, when the negative pressure in the pleural cavity decreases. The effect of pleural pressure on cardiac performance is discussed in Chapter 27. In conclusion, there are a number of problems with vascular resistance as an indicator of afterload, since experimental data suggest that vascular resistance is an unreliable indicator of ventricular afterload. The measurement of vascular resistance can be informative when vascular resistance is used as a determinant of blood pressure. Due to the fact that the mean blood pressure is a derivative of cardiac output and vascular resistance, the measurement of the latter helps to investigate the hemodynamic features of arterial hypotension. The use of TPVR for the diagnosis and treatment of shock conditions is discussed in Chapter 12. CIRCULATION IN HEART FAILURE Circulatory regulation in heart failure can be described if we take cardiac output as an independent value, and KPP and TPVR as dependent variables (Fig. 1-6). As cardiac output decreases, there is an increase in KDD and OPSS. This explains the clinical signs of heart failure: Increased EBP = venous congestion and edema; Increased VR = vasoconstriction and hypoperfusion. At least in part, these hemodynamic changes result from activation of the renin-angiotensin-aldosterone system. The release of renin in heart failure is due to a decrease in renal blood flow. Then, under the action of renin, angiotensin I is formed in the blood, and from it, with the help of an angiotensin-converting enzyme, angiotensin II, a powerful vasoconstrictor that has a direct effect on blood vessels. The release of aldosterone from the adrenal cortex caused by angiotensin II leads to a delay in the body of sodium ions, which contributes to an increase in venous pressure and the formation of edema. PROGRESSIVE HEART FAILURE Indicators of hemodynamics in progressive heart failure are shown in fig. 1-7. The solid line indicates the graphical dependence of cardiac output on preload (ie, the functional curve of the heart), the dotted line - cardiac output on OPSS (afterload). The intersection points of the curves reflect the relationships of preload, afterload, and cardiac output at each stage of ventricular dysfunction. Rice. 1-6. Influence of cardiac output on final 1-7. Changes in hemodynamics with cardiac diastolic pressure and general peripheral insufficiency. H - normal, Y - moderate cardiac vascular resistance. insufficiency, T-severe heart failure 1. Moderate heart failure As ventricular function worsens, the slope of the functional heart curve decreases, and the intersection point shifts to the right along the TPVR-CO curve (afterload curve) (Fig. 1-7). In the early stage of moderate heart failure, there is still a steep slope in the EPP-SV curve (preload curve), and the intercept (point Y) is located on the flat part of the afterload curve (Fig. 1-7). In other words, in moderate heart failure, ventricular activity is dependent on preload and independent of afterload. The ability of the ventricle to respond to preload in moderate heart failure means that blood flow levels can be maintained, but at higher than normal filling pressures. This explains why the most prominent symptom in moderate heart failure is dyspnea. 2. Severe heart failure As cardiac function declines further, ventricular activity becomes less dependent on preload (i.e., the slope of the cardiac function curve decreases) and cardiac output begins to decline. The functional curve of the heart shifts to the steep part of the afterload curve (point T) (Fig. 1-7): in severe heart failure, ventricular activity does not depend on preload and depends on afterload. Both factors are responsible for the decrease in blood flow seen in the advanced stages of heart failure. The role of afterload is especially great, since arterial vasoconstriction not only reduces cardiac output, but also reduces peripheral blood flow. The increasing importance of afterload in the development of severe heart failure is the basis for its treatment with peripheral vasodilators. This issue is discussed in more detail below (Chapter 14). REFERENCES Berne RM, Levy MN. Cardiovascular physiology, 3rd ed. St. Louis: C.V. Mosby, 1981. Little R.C. Physiology of the heart and circulation, 3rd ed. Chicago: Year Book Medical Publishers, 1985. Reviews by Parmley WW, Talbot L. Heart as a pump. In: Berne RM ed. Handbook of physiology: The cardiovascular system. Bethesda: American Physiological Society, 1979; 429-460. Braunwald E, Sonnenblick EH, Ross J Jr. Mechanisms of cardiac contraction and relaxation. In: Braunwald E. ed. heart disease. A textbook of cardiovascular medicine, 3rd ed. Philadelphia: W.B. Saunders, 1988; 383-425. Weber K, Janicki JS, Hunter WC, et al. The contractile behavior of the heart and its functional coupling to the circulation. Prog Cardiovasc Dis 1982; 24:375-400. Rothe C.F. Physiology of venous return. Arch Intern Med 1986; 246:977-982. Katz AM. The descending limb of the Starling curve and the failing heart. Circulation 1965; 32:871-875. Nichols WW, Pepine CJ. Left ventricular afterload and aortic input impedance: Implications of pulsatile blood flow. Prog Cardiovasc Dis 1982; 24:293-306. Harizi RC, Bianco JA, Alpert JS. Diastolic function of the heart in clinical cardiology. Arch Intern Med 1988; 148:99-109. Robotham JL, Scharf SM. Effects of positive and negative pressure ventilation on cardiac performance. Clin Chest Med 1983; 4:161-178. Lang RM, Borow KM, Neumann A, et al. Systemic vascular resistance: An unreliable index of left ventricular afterload. Circulation 1986; 74:1114-1123. Zeiis R, Flaim SF. Alterations in vasomotor tone in congestive heart failure. Prog Cardiovasc Dis 1982; 24:437-459. Cohn JN, Franciosa JA. Vasodilator therapy of cardiac failure (first of two parts). N Engin Med 1977; 297:27-31. Dzau VJ, Colucci WS, Hollenberg NK, Williams GH. Relation of the renin-angiotensin-aldosterone system to clinical state in congestive heart failure. Circulation 1981; 63:645-651. Contents Critical Care~Paul L. Marino/Paul L. Marino. ""The ICU Book"" (2nd Ed) - Rus/10-1.JPG Critical Care~Paul L. Marino. ""The ICU Book"" (2nd Ed) - Rus/10-2.JPG Critical Care~Paul L. Marino/Paul L.Marino. ""The ICU Book"" (2nd Ed) - Rus/10-3.JPG Critical Care~Paul L. Marino/Paul L.Marino. ""The ICU Book"" (2nd Ed) - Rus/10-4.JPG Intensive Care~Paul L. Marino/Paul L.Marino. ""The ICU Book"" (2nd Ed) - Rus/10.html 10 Wedge pressure The exact sciences are dominated by the idea of relativity B. Paccell Pulmonary capillary wedge pressure (PWPC) is traditionally used in the practice of critical care medicine, and the term “wedge pressure ” has already become quite familiar to doctors. Despite the fact that this indicator is used quite often; it is not always critically comprehended. This chapter identifies some of the "limited" applications of DZLK and discusses the misconceptions that arise when using this indicator in clinical practice. MAIN FEATURES There is an opinion that the DZLK is a universal indicator, but this is not so. Below is a description of this parameter. DZLK: Determines the pressure in the left atrium. It is not always an indicator of preload on the left ventricle. May reflect pressure in nearby alveoli. It does not allow accurate assessment of hydrostatic pressure in the pulmonary capillaries. It is not an indicator of transmural pressure. Each of these statements is detailed below. Additional information about DZLK can be obtained from the reviews. WEDGING PRESSURE AND PRELOAD The DZLK is used to determine the pressure in the left atrium. The information obtained makes it possible to assess intravascular blood volume and left ventricular function. DZLK MEASUREMENT PRINCIPLE The DZLK measurement principle is shown in fig. 10-1. The balloon at the distal end of the catheter inserted into the pulmonary artery is inflated until obstruction occurs. This will cause a column of blood to form between the end of the catheter and the left atrium, and the pressure at the two ends of the column will balance. The pressure at the end of the catheter then becomes equal to the pressure in the left atrium. This principle expresses the hydrostatic equation: Dk - Dlp = Q x Rv 10-1. The principle of measuring DZLK. The lungs are divided into 3 functional zones based on the ratio of alveolar pressure (Ralv), mean pressure in the pulmonary artery (avg.Pla) and pressure in the pulmonary capillaries (Dc). DZLK allows you to accurately determine the pressure in the left atrium (Dlp) only when Dk exceeds Rav (zone 3). Further explanations in the text. where Dk is the pressure in the pulmonary capillaries, Dlp is the pressure in the left atrium, Q is the pulmonary blood flow, Rv is the resistance of the pulmonary veins. If Q = 0, then Dk - Dlp = 0 and, consequently, Dk - Dlp = DZLK. The pressure at the end of the catheter at the time of balloon occlusion of the pulmonary artery is called LEP, which, in the absence of an obstruction between the left atrium and the left ventricle, is considered equal to the left ventricular end-diastolic pressure (LVDD). LEFT VENTRICULAR END-DIASTOLIC PRESSURE AS A CRITERIA FOR PRELOAD In Chapter 1, resting myocardial preload is defined as the force that stretches the heart muscle. For an intact ventricle, preload is end-diastolic volume (EDV). Unfortunately, EDV is difficult to determine directly at the patient's bedside (see Chapter 14), so an indicator such as end-diastolic pressure (EDP) is used to assess preload. Normal (unchanged) left ventricular distensibility makes it possible to use CDV as a measure of preload. This is represented in the form of stretch curves (see Figure 1-4 and Figure 14-4). Briefly, this can be summarized as follows: LVDD (LVL) is a reliable indicator of preload only when left ventricular compliance is normal (or unchanged). The assumption that ventricular compliance is normal or unchanged in adult patients in intensive care units is unlikely. At the same time, the prevalence of impaired diastolic function in such patients has not been studied, although in some conditions their ventricular distensibility is undoubtedly changed. Most often this pathology is observed due to positive pressure mechanical ventilation, especially when the inspiratory pressure is high (see Chapter 27). Myocardial ischemia, ventricular hypertrophy, myocardial edema, cardiac tamponade, and a number of drugs (calcium channel blockers, etc.) can also change ventricular compliance. When ventricular compliance is reduced, an increase in DPLD will be seen in both systolic and diastolic heart failure. This issue is discussed in detail in Chapter 14. WEDGING PRESSURE AND HYDROSTATIC PRESSURE DZLK is used as an indicator of hydrostatic pressure in the pulmonary capillaries, which makes it possible to assess the possibility of developing hydrostatic pulmonary edema. However, the problem is that DZLK is measured in the absence of blood flow, including in capillaries. Peculiarities of dependence of DZLK on hydrostatic pressure are shown in fig. 10-2. When the balloon at the end of the catheter is deflated, the blood flow is restored, and the pressure in the capillaries will be higher than the DZLK. The magnitude of this difference (Dk - DZLK) is determined by the values of blood flow (Q) and resistance to blood flow in the pulmonary veins (Rv). Below is the equation of this dependence (note that, unlike the previous formula, this one has DZLK instead of Dlp): Dk - DZLK - Q x Rv. If Rv = 0, then Dk - DZLK = 0 and, consequently, Dk = DZLK. Rice. 10-2. Difference between hydrostatic pressure in the pulmonary capillaries (Dk) and DZLK. The following important conclusion follows from this equation: DZLK is equal to the hydrostatic pressure in the pulmonary capillaries only when the resistance of the pulmonary veins approaches zero. However, the pulmonary veins create most of the total vascular resistance in the pulmonary circulation because the resistance of the pulmonary arteries is relatively low. The pulmonary circulation is carried out under conditions of low pressure (due to the thin-walled right ventricle), and the pulmonary arteries are not as rigid as the arteries of the systemic circulation. This means that the main part of the total pulmonary vascular resistance (PVR) is created by the pulmonary veins. Animal studies have shown that the pulmonary veins generate at least 40% of the PVR [6]. These ratios in humans are not exactly known, but are probably similar. If we assume that the resistance of the venous part of the pulmonary circulation is 40% of the PVR, then the decrease in pressure in the pulmonary veins (Dc - Dlp) will be 40% of the total pressure drop between the pulmonary artery and the left atrium (Dla - Dlp). The above can be expressed by the formula , assuming that DZLK is equal to Dlp. Dk - DZLK = 0.4 (Dla - Dlp); Dk \u003d DZLK + 0.4 (Dla - DZLK). In healthy people, the difference between Dk and DPLD approaches zero, as shown below, because pulmonary artery pressure is low. However, with pulmonary hypertension or increased pulmonary venous resistance, the difference may increase. This is illustrated below with adult respiratory distress syndrome (ARDS), in which pressure increases in both the pulmonary artery and the pulmonary veins (see Chapter 23). DZLK is taken equal to 10 mm Hg. both in normal conditions and in ARDS: DZLK = 10 mm Hg. Normal Dk \u003d 10 + 0.4 (15 - 10) \u003d 12 mm Hg. With ARDS, Dk \u003d 10 + 0.6 (30 - 10) \u003d 22 mm Hg. If the average pressure in the pulmonary artery increases by 2 times, and venous resistance - by 50%, then the hydrostatic pressure exceeds DZLK by more than 2 times (22 versus 10 mm Hg). In this situation, the choice of treatment is influenced by the method of assessing the hydrostatic pressure in the pulmonary capillaries. If the calculated capillary pressure (22 mm Hg) is taken into account, then therapy should be aimed at preventing the development of pulmonary edema. If DZLK is taken into account as a criterion for Dk (10 mm Hg), then no therapeutic measures are indicated. This example illustrates how the DZLK (more precisely, its incorrect interpretation) can be misleading. Unfortunately, the resistance of the pulmonary veins cannot be directly determined, and the above equation is practically not applicable to a particular patient. However, this formula gives a more accurate estimate of the hydrostatic pressure than the DZLK, and therefore it is advisable to use it until a better estimate of Dk exists. CHARACTERISTICS OF OCCLUSION PRESSURE The decrease in pressure in the pulmonary artery from the moment of occlusion of the blood flow by the balloon is accompanied by an initial rapid drop in pressure, followed by a slow decrease. The point separating these two components is proposed to be considered equal to the hydrostatic pressure in the pulmonary capillaries. However, this notion is debatable as it is not supported mathematically. Moreover, it is not always possible to clearly separate the fast and slow components of pressure at the patient's bed (personal observations of the author), so the issue requires further study. ARTIFACTS CAUSED BY CHEST PRESSURE chest on DZLK is based on the difference between intraluminal (inside the vessel) and transmural (transmitted through the vascular wall and represents the difference between intra- and extravascular pressure) pressure. Intraluminal pressure is traditionally considered a measure of vascular pressure, but it is transmural pressure that influences preload and edema development. Alveolar pressure can be transmitted to the pulmonary vessels and change intravascular pressure without changing transmural pressure, depending on several factors, including the thickness of the vascular wall and its extensibility, which, of course, will be different in healthy and sick people. When measuring DZLK to reduce the effect of pressure in the chest on DZLK, the following should be remembered. In the chest, the vascular pressure recorded in the lumen of the vessel corresponds to transmural pressure only at the end of exhalation, when the pressure in the surrounding alveoli is equal to atmospheric (zero level). It must also be remembered that the vascular pressure that is recorded in intensive care units (i.e. intraluminal pressure) is measured relative to atmospheric pressure (zero) and does not accurately reflect transmural pressure until tissue pressure approaches atmospheric pressure. This is especially important when the shifts associated with breathing are recorded during the determination of DZLK (see below). CHANGES ASSOCIATED WITH BREATHING The effect of chest pressure on LDLP is shown in Fig. 10-3. This action is associated with a change in pressure in the chest, which is transmitted to the capillaries. The true (transmural) pressure on this record may be constant throughout the respiratory cycle. DZLK, which is determined at the end of exhalation, with artificial ventilation of the lungs (ALV) is represented by the lowest point, and with spontaneous breathing - the highest. Electronic pressure monitors in many intensive care units record pressure at 4 second intervals (corresponding to 1 wave pass through the oscilloscope screen). At the same time, 3 different pressures can be observed on the monitor screen: systolic, diastolic and average. Systolic pressure is the highest point in each 4-second interval. Diastolic is the lowest pressure, and mean corresponds to the average pressure. In this regard, DZLK at the end of exhalation with independent breathing of the patient is determined selectively by the systolic wave, and with mechanical ventilation - by the diastolic wave. Note that the mean pressure is not recorded on the monitor screen as the breath changes. Rice. 10-3. Dependence of DZLK on changes in breathing (spontaneous breathing and mechanical ventilation). The transmural phenomenon is determined at the end of expiration, it coincides with the systolic pressure during spontaneous breathing and with the diastolic pressure during mechanical ventilation. POSITIVE END PRESSURE In breathing with positive end expiratory pressure (PEEP), alveolar pressure does not return to atmospheric pressure at the end of exhalation. As a result, the value of DZLK at the end of exhalation exceeds its true value. PEEP is created artificially or it may be characteristic of the patient himself (auto-PEEP). Auto - PEEP is the result of incomplete expiration, which often occurs during mechanical ventilation in patients with obstructive pulmonary disease. It must be remembered that auto-PEEP with mechanical ventilation often remains asymptomatic (see Chapter 29). If an agitated patient with tachypnea has an unexpected or inexplicable increase in DLL, then auto-PEEP is considered the cause of these changes. The phenomenon of auto-PEEP is described in more detail at the end of Chapter 29. The effect of PEEP on PDZLK is ambiguous and depends on lung compliance. When registering DZLK against the background of PEEP, it is necessary to reduce the latter to zero, and without disconnecting the patient from the respirator. By itself, disconnecting the patient from the ventilator (PEEP mode) can have various consequences. Some researchers believe that this manipulation is dangerous and leads to a deterioration in gas exchange. Others report only the development of transient hypoxemia. The risk that occurs when the patient is disconnected from the respirator can be significantly reduced by creating a positive pressure during ventilation, when PEEP is temporarily stopped. There are 3 possible reasons for the increase in DZLK during PEEP: PEEP does not change transmural capillary pressure. PEEP leads to compression of the capillaries, and against this background, DZLK represents pressure in the alveoli, and not in the left atrium. PEEP affects the heart and reduces the distensibility of the left ventricle, which leads to an increase in DZLK with the same EDV. Unfortunately, it is often impossible to identify one or another reason for the change in DZLK. The last two circumstances may indicate hypovolemia (relative or absolute), for the correction of which infusion therapy is necessary. ZONES OF THE LUNG The accuracy of the determination of DZLK depends on the direct communication between the end of the catheter and the left atrium. If the pressure in the surrounding alveoli is higher than the pressure in the pulmonary capillaries, then the latter are compressed and the pressure in the pulmonary catheter, instead of the pressure in the left atrium, will reflect the pressure in the alveoli. Based on the ratio of alveolar pressure and pressure in the pulmonary circulation system, the lungs were conditionally divided into 3 functional zones, as shown in Fig. 10-1, sequentially from the tops of the lungs to their bases. It should be emphasized that only in zone 3 the capillary pressure exceeds the alveolar one. In this zone, the vascular pressure is the highest (as a result of a pronounced gravitational influence), and the pressure in the alveoli is the lowest. When registering DZLK, the end of the catheter should be located in zone 3 (below the level of the left atrium). In this position, the influence of alveolar pressure on the pressure in the pulmonary capillaries is reduced (or eliminated). However, if the patient is hypovolemic or ventilated with high PEEP, this condition is not necessary [I]. Without x-ray control directly at the patient's bedside, it is almost impossible to pass a catheter to zone 3, although in most cases, due to the high blood flow velocity, it is in these areas of the lungs that the end of the catheter reaches its destination. On average, out of 3 catheterizations, only in 1 case the catheter enters the upper zones of the lungs, which are located above the level of the left atrium [I]. WELL PRESSURE ACCURACY IN CLINICAL CONDITIONS There is a high probability of obtaining an erroneous result when measuring the WLL. In 30°/o cases there are various technical problems , and in 20% errors occur due to incorrect interpretation of the received data. The nature of the pathological process can also affect the accuracy of the measurement. Some practical issues related to the accuracy and reliability of the results obtained are considered below. VERIFICATION OF THE OBTAINED RESULTS Position of the end of the catheter. Usually catheterization is carried out in the position of the patient lying on his back. In this case, the end of the catheter with blood flow enters the posterior sections of the lungs and is located below the level of the left atrium, which corresponds to zone 3. Unfortunately, portable X-ray machines do not allow taking pictures in direct projection and thereby determining the position of the catheter, therefore, it is recommended to use for this purpose lateral view [I]. However, the significance of X-rays taken in the lateral projection is doubtful, since there are reports in the literature that the pressure in the ventral areas (located both above and below the left atrium) practically does not change compared to the dorsal ones. In addition, such an x-ray examination (in the lateral projection) is difficult to perform, expensive and possibly not in every clinic. In the absence of x-ray control, the following change in the pressure curve, which is associated with breathing, indicates that the catheter did not enter zone 3. With mechanical ventilation in the PEEP mode, the value of DZLK increases by 50% or more. Oxygenation of blood in the field of measurement of DZLK. To determine the location of the catheter, it is recommended to draw blood from its end with an inflated balloon. If the hemoglobin saturation of the blood sample with oxygen reaches 95% or more, then the blood is considered arterial. In one paper, it is indicated that in 50% of cases the measurement area of the DZLK does not satisfy this criterion. Consequently, its role in reducing the error in the measurement of DSLC is minimal. At the same time, in patients with lung pathology, such oxygenation may not be observed due to local hypoxemia, and not to the incorrect position of the end of the catheter. It seems that a positive result of this test can help, and a negative result has almost no prognostic value, especially in patients with respiratory failure. We use continuous monitoring of mixed venous oxygen saturation, which has become commonplace in our intensive care unit, to measure LDLP, without increasing morbidity or cost. The shape of the atrial pressure curve. The shape of the DLL curve can be used to confirm that DLL reflects left atrial pressure. The curve of pressure in an auricle is presented on fig. 10-4, which also shows a parallel ECG recording for clarity. The following components of the intra-atrial pressure curve are distinguished: A-wave, which is caused by atrial contraction and coincides with the P wave of the ECG. These waves disappear with atrial fibrillation and flutter, as well as with acute pulmonary embolism. X-wave, which corresponds to the relaxation of the atrium. A pronounced decrease in the amplitude of this wave is observed with cardiac tamponade. The C-wave marks the beginning of the contraction of the ventricle and corresponds to the moment when the mitral valve begins to close. The V-wave appears at the moment of ventricular systole and is caused by the indentation of the valve leaflets into the cavity of the left atrium. Y-descending - the result of rapid emptying of the atrium, when the mitral valve opens at the beginning of diastole. With cardiac tamponade, this wave is weakly expressed or absent. A giant V-wave during atrial pressure recording corresponds to mitral valve insufficiency. These waves occur as a result of the reverse flow of blood through the pulmonary veins, which can even reach the cusps of the pulmonary valve. Rice. 10-4. Schematic representation of the atrial pressure curve versus ECG. Explanation in the text. A high V-wave leads to an increase in the average DZLK to a level exceeding the diastolic pressure in the pulmonary artery. In this case, the value of the average DZLK will also exceed the value of the filling pressure of the left ventricle, therefore, for greater accuracy, it is recommended to measure the pressure in diastole. A high V-wave is not pathognomonic for mitral insufficiency. This wave is also observed with left atrial hypertrophy (cardiomyopathy) and high pulmonary blood flow (ventricular septal defect) VARIABILITY Values of DPLD in most people fluctuate within 4 mmHg, but in some cases their deviation can reach 7 mmHg Statistically significant change in DPLD should exceed 4 mmHg DPLD AND LVDD In most cases, the LVLD value corresponds to the LVDD value [I], but this may not be the case in the following situations: 1. In aortic valve insufficiency.In this case, the LVDD level exceeds that of the LVLD, because the mitral valve closes prematurely due to retrograde blood flow 2. Atrial contraction with a rigid ventricular wall leads to rapid three increase in KDD with premature closure of the mitral valve. As a result, DLLK is lower than LVDLV [I]. 3. In case of respiratory insufficiency, the value of DZLK in patients with pulmonary pathology may exceed the value of KDDLV. A possible mechanism for this phenomenon is the reduction of small veins in the hypoxic zones of the lungs, therefore, in this situation, the accuracy of the results obtained cannot be guaranteed. The risk of such an error can be reduced by placing the catheter in areas of the lungs that are not involved in the pathological process. REVIEWS Marini JJ, Pulmonary artery occlusion pressure: Clinical physiology, measurement and interpretation. Am Rev Respir Dis 1983; 125:319-325. Sharkey SW. Beyond the wedge: Clinical physiology and the Swan-Ganz catheter. Am J Med 1987; 53:111-122. Raper R, Sibbald WJ. Misled by the wedge? The Swan-Ganz catheter and leftventric-ular preload. Chest 1986; 59:427-434. Weidemann HP, Matthay MA, Matthay RA. Cardiovascular-pulmonary monitoring in the intensive care unit (part 1). Chest 1984; 55:537-549. CHARACTERISTIC FEATURES Harizi RC, Bianco JA, Alpert JS. Diastolic function of the heart in clinical cardiology. Arch Intern Med 1988; 145:99-109. Michel RP, Hakim TS, Chang HK. Pulmonary arterial and venous pressures measured with small catheters. J Appi Physiol 1984; 57:309-314. Alien SJ, Drake RE, Williams JP, et al. Recent advances in pulmonary edema. Crit Care Med 1987; 15:963-970. Cope DK, Allison RC, Parmentier JL, ef al. Measurement of effective pulmonary capillary pressure using the pressure profile after pulmonary artery occlusion. Crit Care Med 1986; 14:16-22. Seigel LC, Pearl RG. Measurement of the longitudinal distribution of pulmonary vascular resistance from pulmonary artery occlusion pressure profiles. Anesthesiology 1988; 65:305-307. CHEST PRESSURE ARTIFACTS Schmitt EA, Brantigan CO. Common artifacts of pulmonary artery and pulmonary artery wedge pressures: Recognition and management. J Clin Monit 1986; 2:44-52. Weismann IM, Rinaldo JE, Rogers RM. Positive end-expiratory pressure in adult respiratory distress syndrome. N Engi J Med 1982; 307:1381-1384. deCampo T, Civetta JM. The effect of short term discontinuation of high-level PEEP in patients with acute respiratory failure. Crit Care Med 1979; 7:47-49. WELL PRESSURE ACCURACY Morris AH, Chapman RH, Gardner RM. Frequency of technical problems encountered in the measurement of the pulmonary artery wedge pressure. Crit Care Med 1984; 12:164-170. Wilson RF, Beckman B, Tyburski JG, et al. Pulmonary artery diastolic and wedge pressure relationships in critically ill patients. Arch Surg 1988; 323:933-936. Henriquez AH, Schrijen FV, Redondo J, et al. Local variations of pulmonary arterial wedge pressure and wedge angiograms in patients with chronic lung disease. Chest 1988; 94:491-495. Morris AH, Chapman RH. Wedge pressure confirmation by aspiration of pulmonary capillary blood. Crit Care Med 1985; 23:756-759. Nemens EJ, Woods S.L. Normal fluctuations in pulmonary artery and pulmonary capillary wedge pressures in acutely ill patients. Heart Lung 1982; P:393-398. Johnston WE, Prough DS, Royster RL. Pulmonary artery wedge pressure may fail to reflect left ventricular end-diastolic pressure in dogs with oleic acid-induced pulmonary edema. Crit Care Med 1985:33:487-491. Contents Critical Care~Paul L. Marino/Paul L. Marino. ""The ICU Book"" (2nd Ed) - Rus/11-1.JPG Critical Care~Paul L. Marino. ""The ICU Book"" (2nd Ed) - Rus/11-2.JPG Critical Care~Paul L. Marino. ""The ICU Book"" (2nd Ed) - Rus/12-1.JPG Intensive Care~Paul L. Marino. ""The ICU Book"" (2nd Ed) - Rus/12-2.JPG Critical Care~Paul L. Marino. ""The ICU Book"" (2nd Ed) - Rus/12-3.JPG Critical Care~Paul L. Marino/Paul L.Marino. ""The ICU Book"" (2nd Ed) - Rus/12.html 12 Structural Approach to Clinical Shock pulmonary artery) and is carried out in two stages. This approach does not define shock as hypotension or hypoperfusion, rather it presents it as a state of inadequate tissue oxygenation. The ultimate goal of this approach is to achieve a correspondence between the delivery of oxygen to the tissues and the level of metabolism in them. Normalization of blood pressure and blood flow is also considered, but not as an end goal. The fundamental provisions that are used in our proposed approach are set out in chapters 1, 2, 9, and are also considered in the works (see the end of this chapter). In the present book, in approaching the shock problem, there is one central theme : strive to always clearly determine the state of tissue oxygenation. The shock "lurks" in the latter, and you will not detect it by listening to the organs of the chest cavity or measuring the pressure in the brachial artery. It is necessary to search for new approaches to the problem of shock. The “black box” approach, which is widely used to determine damage in technology, is applicable, in our opinion, to the study of complex pathological processes in the human body. GENERAL CONCEPTS Our approach is based on the analysis of a number of indicators that can be represented as two groups: “pressure/blood flow” and “oxygen transport”. Indicators of the “pressure/blood flow” group: 1. Wedge pressure in the pulmonary capillaries (PWPC); 2. Cardiac output (CO); 3. Total peripheral vascular resistance (OPSS). Indicators of the “oxygen transport” group: 4. Oxygen delivery (UOg); 5. Oxygen consumption (VC^); 6 The content of lactate in the blood serum. 1. At stage I, a set of parameters “pressure/blood flow” is used to determine and correct the leading hemodynamic disorders. The indicators combined into such a group have certain values, on the basis of which it is possible to characterize the entire complex (in other words, describe or create a small hemodynamic profile, “formula”), which is used to diagnose and evaluate the effectiveness of treatment. The ultimate goal of this stage is to restore blood pressure and blood flow (if possible) and to establish the underlying cause of the pathological process. II. At stage II, the effect of the initial therapy on tissue oxygenation is assessed. The purpose of this stage is to achieve a correspondence between the oxygen consumption of the tissues and the level of metabolism in them, for which an indicator such as the concentration of lactate in the blood serum is used. The oxygen delivery is changed (if necessary) to correct the VO2 value. STAGE I: SMALL HEMODYNAMIC PROFILES (“FORMULAS”) For simplicity, we consider that each factor from the “pressure/flow” group of indicators plays a leading role in one of the main types of shock, as, for example, is shown below. Parameter Type of shock Cause DZLK Hypovolemic Blood loss (more precisely, a decrease in BCC, as in bleeding or dehydration CO Cardiogenic Acute myocardial infarction CVR Vasogenic Sepsis The relationship between DZLK, SV and OPSS is normally considered in Chapter 1. Small hemodynamic profiles characterizing the 3 main types of shock are shown in fig. 12-1. Rice. 12.1 Small hemodynamic profiles ("formulas") that characterize the 3 main types of shock HYPOVOLEMIC SHOCK In this case, a decrease in ventricular filling (low LVLD) is of paramount importance, leading to a decrease in CO, which in turn causes vasoconstriction and an increase in TPVR. In view of the above, the “formula” of hypovolemic shock will have the following form: low DZLK / low CO / high TPVR. CARDIOGENIC SHOCK In this case, the leading factor is a sharp decrease in CO followed by stagnation of blood in the pulmonary circulation (high DZLK) and peripheral vasoconstriction (high TPVR). The “formula” of cardiogenic shock has the following form: high DZLK / low CO / high OPSS. VASOGENIC SHOCK - A feature of this type of shock is a drop in the tone of the arteries (low OPSS) and, to varying degrees, veins (low DZLK). Cardiac output is usually high, but its magnitude can vary considerably. The “formula” of vasogenic shock has the following form: low DZLK / high CO / low OPSS. The value of DZLK may be normal if the venous tone is not changed or the stiffness of the ventricle is increased. These cases are discussed in chapter 15. The main causes of vasogenic shock are: 1. Sepsis/multiple organ failure. 2. Postoperative condition. 3. Pancreatitis. 4. Trauma. 5. Acute adrenal insufficiency. 6. Anaphylaxis. COMPLEX COMBINATIONS OF HEMODYNAMIC INDICATORS These three main hemodynamic parameters, combined in different ways, can create more complex profiles. For example, the “formula” might look like this: normal DLL/low CO/high VR. However, it can be presented as a combination of two main “formulas”: 1) cardiogenic shock (high DZLK / low CO / high VR) + 2) hypovolemic shock (low DZLK / low CO / high VR). There are a total of 27 small hemodynamic profiles (since each of the 3 variables has 3 more characteristics), but each can be interpreted on the basis of 3 main “formulas”. INTERPRETATION OF SMALL HEMODYNAMIC PROFILES (“FORMULAS”) The information possibilities of small hemodynamic profiles are shown in Table. 12-1. First, the leading circulatory disorder should be determined. So, in the case under consideration, the characteristics of the indicators resemble the “formula” of hypovolemic shock, with the exception of the normal value of TPVR. Therefore, the main hemodynamic disturbances can be formulated as a decrease in circulating blood volume plus low vascular tone. This determined the choice of therapy: infusion and drugs that increase peripheral vascular resistance (for example, dopamine). So, each of the main pathological processes, accompanied by circulatory disorders, will correspond to a small hemodynamic profile. In table. 12-1 such disorders were a decrease in circulating blood volume and vasodilation. * The concept of “vasogenic shock” is not found in Russian literature. A sharp drop in the tone of arterial and venous vessels is observed in acute adrenal insufficiency, anaphylactic shock, in the late stage of septic shock, multiple organ failure syndrome, etc. turn by a drop in vascular tone, as well as a decrease in the volume of circulating blood. Collapse develops most often as a complication of serious diseases and pathological conditions. Distinguish (depending on etiological factors) infectious, hypoxemic. pancreatic, orthostatic collapse, etc. - Approx. ed. Table 12-1 Use of small hemodynamic profiles Information Example Profile formed Pathological process definition Targeted therapy Possible causes Dopamine, if necessary Adrenal insufficiency Sepsis Anaphylaxis NORMALIZATION OF BLOOD CIRCULATION The following scheme shows what therapeutic measures can be used to correct hemodynamic disorders. The pharmacological properties of the drugs mentioned in this section are discussed in detail in chapter 20. To simplify, the drugs and their action are described quite briefly and simply, for example, alpha: vasoconstriction (i.e. stimulation of a-adrenergic receptors gives a vasoconstrictive effect), (beta: vasodilation and increased cardiac activity (i.e. stimulation of beta-adrenergic receptors causes vasodilatation, and the heart - an increase in heart rate and force). in an increase in DZLK or up to 18-20 mm Hg, or to a level equal to the colloid osmotic pressure (COP) of plasma Methods for measuring COP are discussed in part 1 of Chapter 23. 2. Low CO a. High TPVR Dobutamine b Normal VR Dopamine Selective (beta-agonists like dobutamine (beta1-agonist) indicated for low cardiac output without hypotension and. Dobutamine is less valuable in cardiogenic shock, as it does not always increase blood pressure; but, by reducing OPSS, it significantly increases cardiac output. In cases of severe arterial hypotension (beta-agonists, together with some alpha-adrenergic agonists, are most suitable for increasing blood pressure, since stimulation of a-adrenergic receptors of blood vessels, causing them to narrow, will prevent a decrease in peripheral vascular resistance in response to an increase in CO. 3. Low peripheral vascular resistance a. Decreased or normal CO alpha-, beta-agonists b. High CO alpha-agonists* * Vasoconstrictors should be avoided whenever possible, as they increase systemic blood pressure at the expense of tissue perfusion due to arteriolar spasm. -agonists are preferred over selective alpha agonists, which can cause severe vasoconstriction.Dopamine is often used in combination with other drugs, in addition, by stimulating special dopamine receptors on vascular smooth muscle, it causes them to expand, which allows you to save blood flow to the kidneys. It should be noted that the arsenal of medicines, essential about influencing blood circulation during shock is small. You have to basically limit yourself to the drugs listed below. Expected effect Drugs Beta: increased cardiac activity Dobutamine alpha, beta and dopamine receptors: cardiotonic effect and expansion of renal and mesenteric vessels Dopamine in medium doses alpha vasoconstriction, increased blood pressure Large doses of dopamine Presence of dopamine in medium doses of cardiotonic activity, combined with an effect on the resistance of regional vessels, and in high - pronounced alpha-adrenergic properties makes it a very valuable anti-shock drug. It is possible that the effectiveness of dopamine decreases after several days of administration due to the depletion of noradrenaline, which it releases from the granules of presynaptic nerve endings. In some cases, norepinephrine can replace dopamine, for example, if there is a need to quickly obtain a vasoconstrictor effect (particularly in septic shock) or to increase blood pressure. It should be remembered that in case of hemorrhagic and cardiogenic shock with a sharp drop in blood pressure, norepinephrine cannot be used (due to a deterioration in the blood supply to tissues), and infusion therapy is recommended to normalize blood pressure. In addition, the above drugs stimulate metabolism and increase the need for energy in tissues, while their energy supply is in jeopardy. POST-resuscitation injury The period following the restoration of systemic blood pressure may be accompanied by ongoing ischemia and progressive organ damage. The three post-resuscitation injury syndromes are briefly presented in this section to highlight the importance of monitoring tissue oxygenation and justify the usefulness of stage II in the management of shock. UNRESTORED BLOOD FLOW The phenomenon of non-restoration of blood flow (no-reflow) is characterized by persistent hypoperfusion after resuscitation in ischemic stroke. It is believed that this phenomenon is due to the accumulation of calcium ions in vascular smooth muscle during ischemia caused by vasoconstriction, which then persists for several hours after resuscitation. The vessels of the brain and internal organs are especially susceptible to this process, which significantly affects the outcome of the disease. Ischemia of the internal organs, in particular the gastrointestinal tract, can disrupt the mucosal barrier of the intestinal wall, which makes it possible for the intestinal microflora to enter the systemic circulation through the intestinal wall (translocation phenomenon). Persistent cerebral ischemia causes a permanent neurological deficit, which may explain the prevalence of brain disorders after resuscitation of patients with cardiac arrest [6]. In the long term, the phenomenon of non-restoration of blood flow clinically manifests itself as a syndrome of multiple organ failure, often leading to death. REPERFUSION INJURY Reperfusion injury differs from the phenomenon of non-restoration of blood flow, since in this case the blood supply is restored after an ischemic stroke. The fact is that during ischemia, toxic substances accumulate, and during the period of restoration of blood circulation, they are washed out and carried by the blood stream throughout the body, getting into distant organs. As is known, free radicals and other reactive oxygen species (superoxide anion radical, hydroxyl radical, hydrogen peroxide and singlet oxygen), as well as products of lipid peroxidation (LPO) can change membrane permeability and thereby cause metabolic shifts at the cellular and tissue levels. . (Free radicals are particles that have unpaired electrons in the outer orbit and therefore have a high chemical reactivity.) 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