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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 • • • • • 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 • • • • 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 • • • • • • • 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 • • • • • • 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 • • • • • HR BP Temperature Urine output Pulse oximetry Invasive monitoring • • • • 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 • • • • • • • 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 • • • • • • • 30-40% pts Definition: failure of filling Examples: pericarditis degeneration ischemia stiffness Treatment principles • • • • Preload Contractility Afterload Oxygen delivery Potential errors in preload estimation • • • • • CVP (EF) LVEDV (compliance) LVEDP (MS,MI) LAP (elevated pulmonary pressure) PAOP (catheter position) Drugs for treatment of circulatory failure • • • • • • • 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 • CPP • CBF = = • 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.