Study
Objectives
· To define concepts such as anaphylactic shock, bloodflow, hydrostatic indifference
point, hypotension, mean
circulatory equilibrium pressure, mean transit time, and shock.
· To describe the principle of mass balance (Fick principle) for cardiac output
determination, the dilution principle (tracer or indicator bolus), the
isotope-wash-out-method, the venous occlusion plethysmography, and the mean
transit time method.
· To draw an
indicator dilution curve, an isotope-wash-out-curve and a plethysmography
curve with flow determinations.
· To calculate one
variable when relevant information is given.
· To explain the
control of bloodflow to the brain the myocardium, the kidneys, the muscles,
the gastrointestinal channel, the skin, and the foetus. To explain the
compensatory reactions to shock. To explain the cerebral ischaemic response.
· To use the
concepts in problem solving and case histories.
Principles
· The law of
conservation of matter (see Chapter
8). This
principle is used to measure bloodflow.
· Fick´s principle for determination of cardiac output (see Chapter
10).
· Poiseuille´s law.
When the radius of a vascular bed is doubled, its bloodflow may increase by as
much as 16 times. This is because of Poiseuille´s law (see Eq. 8-3).
Definitions
· Anaphylactic shock (anaphylaxis) refers to a severe allergic disorder in which the
cardiac output and the mean arterial pressure fall rapidly and drastically
(see Chapter 32).
· Hydrostatic
indifference point is the point in the
cardiovascular system, in which the pressure does not change with change of
body position.
· Hypotension. Severe
hypotension refers to a condition with a systolic blood pressure below 75 mmHg
(10 kPa).
· Mean circulatory
equilibrium pressure is a pressure of 1 kPa
measurable in all divisions of the circulatory system just after cardiac
arrest.
· Mean transit time for indicator particles in a system is equal to the sum of all transit times
for all single particles divided with their number.
· Shock is a clinical condition characterized by a gradual fall in arterial blood
pressure and rapid heart rate. Respiration is also rapid and the skin is
moist, pale or bluish-grey.
· Vasovagal syncope or emotional
fainting is a condition, where the fainting is caused by a strong
emotional activation of the parasympathetic nervous system via the
hypothalamus with bradycardia, vasodilatation and decreasing arterial
pressure.
Essentials
This
paragraph deals with 1. The coronary
bloodflow, 2. The regulation of coronary
bloodflow, 3. Brain bloodflow, 4. Skin & fat bloodflow, 5. The splancnic
circulation, 6. The foetal
circulation, 7. Fick’s principle, 8. The dilution principle, 9. Clearance,
10. The isotope-wash-out-method, 11.
The mean transit time, 12. Vascular
pressure reference (supine to standing).
1.
The coronary bloodflow
The
myocardial metabolism is an exclusively aerobic process under normal conditions. It depends on oxidative
phosphorylation in order to re-synthesise ATP. The O2 needs of the
myocardium are therefore great, even at rest. Exercise can increase the needs six-fold; however, the myocardium cannot extract a greater fraction of the O2 delivered, since the myocardial O2 extraction is already close to
maximum at rest. Thus the coronary bloodflow must rise importantly during
exercise in order to deliver the O2 needed.
Two
main coronary arteries arise from the aorta. The left main coronary artery (Fig. 12-1) divides into two major
branches: The left anterior descending
artery, which courses down the interventricular groove towards the apex of
the heart, and the left circumflex
artery, which courses leftward and posteriorly in the atrioventricular
groove to the postero-lateral wall of the left ventricle.
The right
coronary artery (Fig. 12-1) arises from the right aortic sinus and courses
rightward and posteriorly in the atrioventricular groove to reach the right
atrium, and via the posterior descending
artery to the posterior wall of the left ventricle and the lower part of
the interventricular septum. Later the right coronary artery also gives off
branches to the posterolateral wall of the left ventricle.
This
arrangement of coronary vessels exists in half of the population in western countries. In 30% of the population the posterior
descending artery arises from the right
coronary artery, and the posterior left ventricular branch arises from the left circumflex artery. In another
20% of the population the right coronary artery is small and supplies only the right atrium and the right
ventricle with blood, and all the blood supply to the left ventricle comes
from the left main coronary artery.
The
main arteries run along the epicardial surface and divide several times on the
surface of the heart before they send off small penetrating vessels forming a
network of intramural arteries, arterioles and capillaries in their way to the
endocardium. The myocardial capillaries feed into a net of intramural venules.
They drain eventually into the epicardial collecting veins. Right
ventricular venous blood drains into the right atrium. Left
ventricular venous blood drains into the coronary
sinus that empties in the right atrium, except for a small blood volume,
which drains into the left ventricle. The epicardial coronary vessels contain
a preponderance of constrictor receptors called adrenergic a-receptors, whereas the intramuscular and endocardial
coronary receptors have a preponderance of dilatator receptors called adrenergic b-receptors.
Fig. 12-1: Coronary bloodflow and receptors.
Due
to the contraction of the myocardium in systole, the myocardial bloodflow is
blocked and the heart receives its nutrition in the diastolic period (Fig.
10-7). The coronary bloodflow is phasic.
2.
The regulation of coronary bloodflow
The
coronary bloodflow is described before in Chapter 9 (paragraph 3) and in
relation to Fig. 10-7.
The
coronary bloodflow is mainly controlled by local
metabolic autoregulation, and sympathetic stimulation does not always
cause significant vasoconstriction. Accordingly, a moderate decrease in
arterial blood pressure down to 9.3 kPa (70 mmHg) does not significantly
reduce the bloodflow through the myocardium.
Unlike
skeletal muscle tissue, the myocardium cannot function anaerobically for
extended periods by building up an oxygen
debt. Thus, oxidative ATP synthesis must continuously match ATP
utilisation in the heart. At rest the heart produces 70% of its ATP from
oxidation of fatty acids and 30% from oxidation of carbohydrates.
During
exercise with lactate production by skeletal muscles, this lactate becomes an
important substrate for the myocardial metabolism, entering the tricarboxylic
acid cycle after conversion to pyruvate.
Catheterisation of
the venous sinus of the heart in healthy subjects at rest reveals a venous
haemoglobin saturation fraction of 0.30. Hence, 0.7 parts of the haemoglobin
concentration of the venous blood is desaturated. Thus, arterial blood with a
normal oxygen concentration (Cao2 of 200 ml per l) liberates (200
× 0.7) or 140 ml of oxygen per l to the myocardium. Variations in the
arteriovenous O2 content difference at the steep part of the O2-haemoglobin dissociation curve can only
change the myocardial O2 tension modestly. The extremely high O2 content difference of the heart at rest implies that a rise
in coronary bloodflow must be the main source of extra O2 to
the heart during exercise.
Most
of the blood entering the coronary circulation is delivered during the
diastolic phase. This is because the myocardial tissue pressure increases
during systole, and the contraction squeezes the blood/myocardium - in particular in the subendocardial layer. Therefore, the systolic
bloodflow through the inner layer of the left ventricular wall approach zero.
The duration of each diasole is reduced with increasing heart rate, so the
increased oxygen demands during exercise calls for a higher coronary artery
pressure in diastole in order to secure the necessary bloodflow.
3.
Brain bloodflow
The
blood reaches the brain through the internal carotid and the vertebral
arteries. The dominant control of cerebral bloodflow (CBF) is metabolic
autoregulation but also a pressure dependent myogenic autoregulation is
present. The smooth muscle walls of the small cerebral arteries respond
immediately to changes in the transmural pressure gradient. Hereby, the CBF is maintained constant despite changes in systolic
blood pressure between 80 and 160 mmHg (10.7-21.4 kPa). The small brain
vessels are metabolically regulated. Increased PaCO2 and reduced PaO2 dilatates brain vessels and increase CBF. CO2 (not H+)
passes the blood-brain barrier easily. The mean arterial pressure can double
without any appreciable rise in CBF. A neuropeptide released in response to
transient hypotension (calcitonin
gene-related peptide) is probably involved in the autoregulation.
The
vertebral arteries join to form the basilar artery, which forms the circle of
Willis together with blood from the internal carotids. When brain arterioles
dilatate the CBF increases, and since the brain tissue within the cranium is
relatively incompressible, the venous outflow must balance.
CBF is normally 55 FU in humans at rest. One FU is one ml of blood per min per
100 g of brain tissue. With a normal brain weight of 1300 g this value
corresponds to a total of (55 × 13) = 715 ml of blood per min. This
resting CBF and the oxygen uptake of the brain can double during cerebral activity and triple in active brain regions during an epileptic
attack (Chapter 7).
The
sympathetic nervous system plays a secondary role for the CBF. Some brain
vessels contract by sympathetic
stimulation. This neurogenic control only concerns the larger cerebral arterioles.
Some
degree of autoregulation is found in many other organs including the skeletal
muscle mass, the splancnic area, and the kidneys.
4.
Skin & fat bloodflow
Blood
flows through the skin and subcutaneous tissues in order to nourish the cells, and to regulate shell
temperature. Blood flows much faster through the arteriovenous anastomoses in
the skin of the face, the fingers and toes in a cold environment. The
sympathetic activity constricts the metarterioles that lead to the skin, so
the blood bypasses the cutaneous circulation. Hereby, the skin bloodflow can
fall from about 5 FU´s and approach zero. The heat content of the blood
returns to the body core, which helps to maintain the core temperature.
In a
warm environment, the sympathetic tone is minimal and the arterioles dilatate,
so that the skin perfusion can rise to perhaps 70 FU, and much energy is given
off to the atmosphere. Psychological
influence can cause one to blush or to have a white face, by changing a-adrenergic constrictor tone and through the effect of
local, vasoactive substances normally found in the skin. When a large fat
combustion occurs (during hunger and distance running), the fat bloodflow can
increase from 3 to 20 FU´s. Cold and warm environments alter the fat
perfusion just like the skin perfusion (Chapter 21). The sympathetic
regulation of the arteriolar tone in fat and skin tissue is also similar. The
sympathetic change in tone is not related to the classical baroreceptors.
5.
The splancnic circulation
The
splancnic area is drained (1.5 l per min) via the hepatic veins at rest, so all
blood passes through the liver. The liver receives more than one litre of
blood from the portal vein and less than 0.5 l from the hepatic artery each
minute. A special characteristic for the splancnic circulation is that two
large capillary beds are partially in series with one another forming a portal
system. The splancnic perfusion increases after meals, and decreases
during fasting and duration exercise. The sympathetic nervous system has a
tonic activity on splancnic vessels via a-adrenergic
nerve fibres. Vagal fibres dilatate the splancnic vessels. Haemorrhagic shock
can elicit a fatal splancnic hypoxia.
6.
The foetal circulation
The
foetus depends completely on the mother and her placenta. The placental
barrier can be passed by low molecular substances (nutrients, gasses and
waste) by diffusion.
The foetal haemoglobin (F) has a sigmoid dissociation curve, which is shifted to the
left relative to haemoglobin A for adult, because haemoglobin-F has a greater
affinity for oxygen than does adult haemoglobin (Chapter
15). Haemoglobin F is
not affected by 2,3-DPG. Foetal blood has a high haemoglobin concentration
(200 g l-1), so the foetus takes up large amounts of O2 in placenta. This occurs even at low PO2,
and the maximal value in the placental blood is only 6.7 kPa or 50 mmHg. Often
the foetus achieves an arterial oxygen concentration similar to that of the
mother.
Steroid
hormones, maternal thyroid hormones, and catecholamines cross the placental
barrier to the foetus. Peptide hormones cannot traverse the placental barrier,
except small peptides such as thyrotropin-releasing hormones (TRH) and
antidiuretic hormone (ADH).
Foetal
insulin contributes to anabolism and lipid storage. Human chorionic
somatomammotropin, prolactin, and IGF-2 are the most important growth factors
during foetal life. Foetal parathyroid hormone stimulates the transport of Ca2+ to the foetus.
The maternal
blood rich in O2 and nutrients is injected into the intervillous
spaces of the placenta via spiral arteries, and returns with CO2 and waste to the mother via veins draining to the uterine veins. The chorionic
villi dip into the internal sinuses of the placenta. The exchange of
nutrients, metabolic waste and gasses across the placental barrier occurs by
diffusion. Foetal blood rich in O2 and nutrients returns to the
foetus from the placenta in the umbilical veins. The placenta has a diameter
of 16-20 cm and the placental barrier has an area of about 10 m2.
The blood flowing in the umbilical veins continues in the ductus
venosus or the blood enters the foetal liver and then all blood is
gathered in the inferior caval vein.
The
80%-saturated blood from the umbilical veins flows into the foetus. The
saturation is reduced to 2/3 (67%) when passing through the oval communication
between the right and left atria (foramen
ovale) to reach the left ventricle (Fig. 12-2). The blood in the left
ventricle is mixed with desaturated blood from the lungs, whereby the oxygen
saturation is reduced to about 65% in the blood passing to the upper-body
foetal organs (brain and heart).
The
blood in the right ventricle (a mixture of blood mostly from the superior
caval vein, but also the coronary sinus and the inferior caval vein to some
extent) is only half-saturated. The foetal pulmonary vascular resistance is
high due to the compressed inactive lungs (Fig. 12-2). Thus, the major part of
the right ventricular output to the pulmonary artery bypasses the pulmonary
circulation and flows through a foetal channel (ductus
arteriosus) between the pulmonary trunk and into the descending aorta (Fig.
12-2).
When
the major part of the blood passes the ductus arteriosus and joins the left
ventricular output, the resulting oxygen saturation is around 60% in the blood
of the descending aorta reaching the lower part of the body and back to the
placenta in the umbilical arteries. This shunt delivers well-saturated
nutritive blood to upper-body foetal organs (brain and heart). Venous drainage
from these essential organs returns to the foetal heart in the superior vena
Cava. The right ventricle ejects the venous return.
Much
of the blood flowing in the descending aorta of the foetus is directed toward
the placenta, so venous drainage from all organs is shunted toward the
placenta, where wastes are eliminated from foetal blood, whereas O2 and nutrients are acquired. Maternal hypoxia and reduced venous return or
pressure on the umbilical vessels during birth reduces the oxygen supply to
the foetus, which is reflected as bradycardia.
At birth, PCO2 increases, and the first breath reduces the intrathoracic pressure in the
new-born, so placental blood is sucked into the baby (placental transfusion).
When the bloodflow through the umbilical vein ceases, the muscular sphincter
of the ductus venosus contracts. Massive sensory stimuli of the baby caused by
labour and delivery, cutaneous cooling after delivery, the falling PAO2 and rising PACO2 without the placenta, and withdrawal of a
placenta-produced respiratory inhibitor all adds up in activation of the
respiratory centre and maintaining breathing in the newborn. The newly
established air-liquid interface reduces pulmonary surface tension, which
eases the lung expansion.
Distension
of the lungs with air also distends pulmonary vessels, so pulmonary vascular
resistance (PVR) decreases
drastically. Hereby, pulmonary bloodflow increases. As a consequence,
bloodflow via ductus arteriosus slows, and pulmonary venous return to the
heart increases (Fig. 12-2).
Fig.
12-2: The foetal circulation.
The
left atrial pressure increases above that in the right atrium and the inferior
vena cava by the newly established decrease in pulmonary vascular resistance,
because of the large pulmonary bloodflow to the left atrium.
Occlusion
of the umbilical vein reduces the bloodflow to the right atrium, and occlusion
of the umbilical arteries increases the resistance to the left ventricular
output of blood. The resulting elimination of the pressure gradient across the
atria, abruptly closes the valve over the foramen
ovale, and the septal leaflets fuse within a couple of days.
The
low pulmonary vascular resistance reduces the pressure in the pulmonary
artery, whereas the aortic pressure rises. This reverses the flow of
oxygenated blood through the ductus
arteriosus. Within minutes after lung expansion, the muscular wall of the
ductus arteriosus constricts, and its closure is complete within 10 days.
Failure
of the foramen ovale or the ductus arteriosus to close gives rise to two
congenital cardiac abnormalities (see later in this Chapter).
Normal
arterial blood gas tensions are established by 30 minutes of age. Left atrial
pressure increases and foramen ovale closes soon after birth. This reverses the blood pressure gradient across the foramen ovale, so now the left
atrial pressure exceeds the right. When the umbilical cord is closed, and the
placental circulation is thus eliminated, the TPVR of the newborn increases. The decrease in pulmonary vascular resistance (PVR) and increase in TPVR means a great difference in the size of the blood pressures in the aorta and
in the pulmonary artery.
In
conclusion, the parallel foetal
circulation is transformed into a series
circulation in the baby. The foramen ovale and ductus venosus close within
3 days of birth (Fig. 12-2). The sharp
increase of O2 content (CaO2)
in the baby's blood is a potent and universal vasodilatator. The dramatic
changes in gas exchange affect cardiopulmonary and vascular regulation,
probably via local mediators such as arachidonic acid and prostacyclin.
7.
Fick’s principle
According
to the law of conservation of matter, mass or energy can neither be created nor destroyed (the principle of mass
balance). Adolph Fick applied
natural occurring indicators like O2 and CO2 when measuring cardiac output. Using O2 as an indicator and the law of mass balance, he claims that the O2 flux, taken up by the lung blood, plus the venous O2 flux to the
lung, must be equal to the O2 flux, which leaves the lung in the
oxygenated blood. Thereby, Fick proposed that the cardiac output could be
calculated according to Eq. 12-1.
A
classical example of the usefulness of Fick's principle is to consider the
data of a young healthy male at rest. The typical data for such a person are
an O2 uptake of 250 ml
STPD per min and an arteriovenous O2 content difference of 50 ml STPD per l of blood. According to Fick's principle, this male
can only satisfy his O2 demands, if 5 l of blood is oxygenated in
his lungs every minute. Thus, a cardiac bloodflow of 5 l per min is his
cardiac output.
The
oxygen concentration of mixed venous blood is usually obtained through a
venous catheter inserted up the median cubital vein, through the subclavian
vein, and finally into the right ventricle or pulmonary artery, where the
blood is well mixed. Arterial blood is easily obtained from the radial artery
(CaO2). The disappearance rate of oxygen from the respired air can
be recorded in a metabolic ratemeter as the oxygen uptake.
The
principle of mass balance is valid only for a system in steady state. Steady state is a state where the indicator is
administered at a constant rate, and is neither stored, mobilised, synthesised
nor used by the system, and where no shunts are present.
This
method has been used to measure a large increase in cardiac output in
different patient groups. For example, patients with anaemia have been found
to have higher cardiac output at rest.
8.
The dilution principle
When
an indicator bolus (mass or dose of tracer in weight or molar units) is instantaneously injected in the right side of the
heart, the indicator and blood will mix. The mixture leaves the right
ventricle through a well-mixed outlet, passes
the pulmonary circulation and then returns to the left side of the heart. The
indicator concentration during the first passage of any peripheral artery is
recorded continuously or by multiple sampling. The resulting curve is shown in
a semilog scale (Fig. 12-3). The indicator concentration (in mol/ml of blood)
reaches a peak and then decreases in a few seconds, before it again rises due
to indicator recirculation with the blood (Fig. 12-3). The first decrease in
concentration is assumed to be mono-exponential. Hence it is easy to
extrapolate to the concentration zero, and read the so-called first
passage time, T1. In this case the T1 is 9 s (Fig.
12-3). The mean concentration ( c mol/ml) of indicator in the period T1 seconds is determined by
planimetry.
The
average amount of indicator (in moles) leaving the left ventricle per second
in one ml of blood is c, hence c is given in mol/ml of blood. The volume of
blood (V) in which the indicator dose is distributed is dose/c. Since blood carries only c
mol of tracer in each ml, the heart needs at least a bloodflow of V ml (dose
in mol/ c) in order to carry the entire dose through the aortic orifice in T1 (9) seconds. Accordingly, the cardiac output per second is dose/(c*T1).
The product (c*T1) is
the area under the curve (Fig. 24-1). Thus the dose/area
ratio must be equal to the bloodflow (ml/second) leaving the left
ventricle.
Put simply, the
bloodflow (cardiac output in ml of blood per s or more convenient per min) can
be measured by dividing the dose of
indicator injected upstream by the area under
the
downstream concentration curve.
Fig.
12-3: The indicator dilution principle.
The
bloodflow equation is also called the dose/area
equation.
An
attractive choice of indicator is to use cold
saline, of known temperature and volume. A flexible catheter, with a
thermistor located at its tip, and an opening through which cold saline can
pass, is used. The catheter tip is advanced to the pulmonary artery, while the
opening supplies the right atrium with saline. The thermistor records the
downstream alterations in temperature as the saline bolus passes. This is the thermodilution
technique. This technique can be frequently repeated without having
harmful effects. Moreover, there is negligible recirculation, and the method
spares the patient the ordeal of an arterial puncture.
This
method is widely used. For example, interesting indicator dilution studies
have shown the pump effect of external cardiac massage to be modest.
9.
Clearance
Clearance
is a theoretical tool for estimating bloodflow in the kidney and other organs. Clearance is the volume of blood
plasma, which is totally cleared each
minute of a given indicator by a specific organ (eg, renal clearance). The
extraction (E) is the fraction of substance, which is extracted from the total
amount transported to the organ per minute (Eq. 12-3).
Clearance
for para-amino hippuric acid (PAH) at low plasma concentrations is a measure
of the renal plasma flow (RPF –
see Chapter 25). The high hepatic extraction of bromsulphalein or of indocyanine is used to estimate the splancnic
perfusion.
10.
The isotope-wash-out-method
A
lipid-soluble indicator, such as 133Xenon dissolved in saline, is
injected in the tibialis anterior muscle (* in Fig. 12-4 and Eq. 12-4). At
steady state, the tracer concentration in the venous blood (Cv) is
assumed to be the average blood
concentration, and Ctis the mean tissue concentration.
Fig.
12-4: Isotope (133Xe) wash out from the gastrocnemius muscle
before, during and after walk on a treadmill. Upper curve is when the femoral
artery is occluded - lower curve is from the healthy leg.
The fractional
fall in the mean tissue concentration of Xenon (Ctis) per time
unit (dt) is constant during the
whole elimination period (a rate constant = ln 2/T½). The flow/Wtis (weight of tissue) is a perfusion coefficient in FU (ml of blood per min and
per 100 g tissue). The fall in mean tissue concentration per time unit (ratio
dCtis/Ctis ) is measurable as T½ on the skin
surface at the Xenon deposit in muscle tissue with a scintillation detector (Fig. 12-4 and Eq. 12-4).
The
method (see Eq. 12-4) is used clinically to detect peripheral vascular
diseases. An example is intermittent
claudication that refers to constricting pain arising during activity of
any muscle group but most commonly in the calf muscles. The hypoxic pain and
cramp appear after having walked a certain distance and is promptly relieved
by rest. The cause is femoral occlusion due to arteriosclerosis with insufficient local bloodflow and ischaemic
hypoxia (Fig. 12-4).
11.
The mean transit time
The mean
transit time (tmean) for indicator particles in a system with
the volume, V, is equal to the sum of all transit times for all single
particles divided with their number.
This
concept is used in a wide variety of indicator methods (Eq.
12-5).
By
means of intravascular catheters it is possible to measure the partial circulation time through most parts of the circulation. For a healthy
adult at rest the normal ranges include the following: arm-ear 8-12 s,
arm-lung 5-7s, and lung-ear 3-5 s.
12.
Vascular pressure reference
The
heart is not always the correct reference point for blood pressure
measurements. The elastic properties of the vascular tree differ throughout
the body.
Actually,
the point in which the pressure does not change with change of body position is approximately 5 cm beneath the diaphragm during
expiratory relaxation (Fig. 12-5). This is called the hydrostatic
indifference point (HIP). Above
this horizontal level, all vascular pressures are lower in the erect than in
the recumbent position. The subatmospheric intrathoracic pressure counteracts
venous collapse, so the intrathoracic veins remain open and the atrial
pressures are zero in the erect position. The veins of the neck and face are
collapsed. The venous sinuses of the brain are kept open by attachment to the
surrounding tissues, and their pressures are around -1.3 kPa (-10 mmHg) in the
erect position.
Fig. 12-5: The hydrostatic indifference point (HIP)
in an adult male. The subject changes position from recumbent to erect.
HIP
must not be mixed up with the mean
circulatory equilibration pressure, which is a pressure of 1 kPa (6 mmHg)
measurable in all divisions of the circulatory system just after cardiac
arrest. This is also called the mean
circulatory filling pressure, because it is a determinant of the venous
return.
When a supine person arise, his
TPVR
increases, the systolic blood pressure falls andthe diastolic blood pressure rises. Thus,
the pressure amplitude falls, but
the mean arterial
pressure is unchanged. The stroke volume is reduced more than the heart rate
rises, so the cardiac output will decrease when attending the standing
position.
An
elegant way of studying circulatory consequences of standing is by use of lower-body-negative-pressure (LBNP). LBNP applied to a recumbent subject simulates the circulatory
effects of standing.
The
venous return to the heart is dependent upon the body position, and upon the
total blood volume. The venous return is also dependent upon the venous
compliance and upon the sympathetic tone in the venous system and in the
arteriolar system.
When
a person is located on a tilt table in a horizontal position, his blood
pressures in a superficial vein on the feet is approximately 1.6 kPa (12 mmHg)
and in the femoral veins 0.8 kPa (6 mmHg). When the person is turned upright
towards the vertical plane, the venous pressure increases by the hydrostatic
column up to the hydrostatic
indifference point (HIP) just below the heart as long as he is not
standing and using his skeletal muscle pump. If the tilt table is turned, so
the head of the person is downward (Trendelenburg
position), then the venous pressure increases in neck and head. The
Trendelenburg position is rational during neck and head surgery. With the head
upward the patient risks air embolism,
if blood vessels are cut during neck and head surgery due to the
subatmospheric pressure in the vessels.
Pathophysiology
This
paragraph deals with 1. Shock and 2.
Congenital heart disease.
1.
Shock
Shock is defined as a
clinical condition characterised by a gradual fall in arterial pressure and a
rapid heart rate. Respiration is also rapid and the skin is pale, moist and
grey. The general circulatory insufficiency causes the bloodflow to vital
tissues to be inadequate, so delivery of oxygen and other nutrients as well as
elimination of waste products is insufficient.
In
principle the circulatory insufficiency can be caused by disorders in the
heart (cardiac insufficiency with imminent or manifest cardiogenic shock) or in the vessels (vascular insufficiency
developing into vascular shock).
The cardiogenic
shock can be caused by restricted ventricular filling (bi- or tricuspidal
stenosis, pericardial fibrosis, or cardiac tamponade);
the cause can also be myocardial disorders (infarctions, myocarditis etc) or
restricted/ineffective ventricular ejection in in cases wwith semilunar
stenosis/insufficiency or shunts.
The vascularly
generated shock is caused by loss of blood or other fluids (absolute
hypovolaemia) or by vasodilatation (relative hypovolaemia). Absolute
hypovolaemia is caused by blood loss, plasma loss (burns or other denuding
conditions, ascites, hydrothorax etc) or dehydration (water deprivation,
severe diarhoea or vomiting, excessive sweating, intestinal obstruction with
luminal fluid accumulation, urinary loss of proteins/salt/water, excessive use
of diuretics, hypoaldosteronism etc). Relative
hypovolaemia, sometimes with
universal vasodilatation, is released by endotoxins (septic shock from viral
or bacterial infections), anaphylactic shock (see Chapter
32) or by a neurogenic
vasodilatation (neurogenic shock by severe pains or stress, anaesthetics or
brain stem lesions close to the vasoconstrictor centre).
The reduced
delivery of oxygen and nutrients to virtually all cells of the body, is
consequential: The mitochondria synthesise less ATP, the Na+-K+-pump
operates insufficiently, the metabolic processing of nutrients is depressed
which profoundly depresses muscular contractions, and finally digestive
enzymes destruct the damaged cells. Glucose transport across the cell
membranes in the liver and in the skeletal muscles is depressed including a
severe inhibition of the actions of insulin and other hormones (Chapters 26 and 30). During progressive shock the metabolism is reduced and thus the heat
energy, so the body temperature tends to decrease, if the patient is not kept warm.
Compensatory mechanisms in
shock are called negative feedback mechanisms, because they operate to counteract the fall in blood pressure.
Baroreceptor responses and many hormonal control systems, that tend to raise
the falling blood pressure, are examples of negative feedback (Fig.
12-6). The
gain of a feedback system is defined as the ratio of the response to the
stimulus itself.
Decompensatory mechanisms exaggerate the primary fall in blood pressure. This is called positive
feedback. A positive feedback mechanism can lead to a vicious
cycle and death, if its gain is above one. Two examples with ischaemic
brainstem depression and cardiac depression are shown in Fig. 12-6.
Shock is divided into 3
stages by severity:
1A. Mild shock is a
condition, where compensatory reactions can cure the patient without external
help. A latent shock is produced when a healthy blood donor delivers more than
the usual 500 ml of blood for transfusion, but the volume is often replaced
within an hour. A number of negative feedback mechanisms oppose the induced
changes of shock. The fall in MAP and pulse pressure reduces the stimulation
of the high-pressure baroreceptors in the carotid sinus and the aortic arch.
The negative stimulation of the cardiovascular control centres in the
brainstem enhances the sympathetic tone (and reduces the vagal tone) leading
to increased heart rate and contractility as well as to arteriolar and venous
constriction mainly in the skin, skeletal muscles and the splancnic area. The
bloodflow favours the brain and the heart as long as possible.
An
array of other compensatory reactions are given in Fig.
12-6: Increased
vascular permeability, reduced capillary pressure with autotransfusion from the interstitial fluid, thirst and drinking
followed by absorption of fluid from the gastrointestinal tract, and release
of powerful vasoconstrictors such as adrenaline, angiotensin II, vasopressin
etc.
Catecholamines and enkephalins are released from chromaffine granules in the adrenal medulla.
Catecholamines increase the heart rate and the cardiac output by stimulation
of the adrenergic b1-receptors
in the myocardium. Catecholamines constrict vessels all over the body by
stimulating a1-receptors located on the surface of vascular smooth muscles.
ADH
(vasopressin) is secreted from the
posterior pituitary gland in response to shock, because the sinoaortic baroreceptors are under-stimulated. Vasopressin is a modest vasoconstrictor
and a strong antidiuretic hormone. The increased ADH secretion causes
increased fluid reabsorption by the kidneys and restores blood pressure and
volume.
Renin is secreted from the juxtaglomerular apparatus, when blood pressure and renal
perfusion falls drastically. Renin acts on the plasma protein,
angiotensinogen, to form inactive angiotensin I, which is transformed to the
powerful vasoconstrictor, angiotensin II by angiotensin converting enzyme, ACE. The most likely trigger of the renin-angiotensin-aldosterone
cascade is described in Chapter 24. - The rise in normal plasma-[K+]
due to the ischaemia of shock also releases aldosterone.
ACTH
and b-endorphins are released into the blood from the anterior pituitary gland Chapter
26) in
response to haemorrhage or other forms of stress. ACTH and endorphins both
exaggerates and restricts the development of shock. These opioids depress the
brainstem control centres that normally mediate autonomic responses to stress.
Hence, naloxone (an opioid antagonist) improves the circulation and increases
the rate of survival from life-threatening shock. - On the other hand, ACTH
has a small aldosterone and a strong cortisol stimulating effect.
Initially,
the bleeding patient suffers from hypercoagulability.
Thromboxane A2 (TxA2)
aggregates thrombocytes, and the aggregate releases more TxA2. This
positive feedback prolongs the clotting tendency. In this phase anticoagulants
(heparin) reduce the mortality from shock.
Fig. 12-6: Development of shock conditions. Effects,
effectors and reactions are shown.
1B. Serious shock leads
to myocardial damage, because the
arterial pressure is too low to secure a coronary bloodflow adequate for
nutrition. Myocardial contractility is depressed, and the ventricular function
curve shifts to the right (Fig. 10-5B).
Loss
of more than 35% of the total blood volume of a healthy person is a threat, if
the loss is unaided by blood transfusion. An arterial blood pressure below 8
kPa, where there is no additional baroreceptor response can stimulate the
chemoreceptors of the carotid body and increase ventilation. The sucking
effect of the low inspiratory pressure improves the venous return to the
heart.
Cerebral ischaemia is
consequential at arterial pressures below 5 kPa. The cerebral hypoxia elicts a
generalised and powerful sympathetic stimulation with a pronounced
arteriolar-and venous-constriction. Further hypoxia in the brainstem activates
the vagal centres resulting in bradycardia.
1C. Irreversible shock is a terminal condition, where all therapy is frustraneous. Nothing can save
the patient. The progressive deterioration becomes irreversible at a blood
loss of more than 50% of the total blood volume. The drastic fall in arterial
blood pressure reduces the renal glomerular filtration pressure below the
critical level, so filtration is diminished or abolished, leading to abolish
urine output (anuria). The low cardiac output and bloodflow result in stagnant
hypoxia of all mitochondria. Hypoxia increases lactic acid liberation. Renal
failure with tubular necrosis prevents excretion of excess H+. The
high H+-concentration further depresses the myocardium, reduces
blood pressure and thus the tissue bloodflow. This aggravates the metabolic
acidosis - a classical vicious cycle
(Fig. 12-6).
In
the later stage of haemorrhagic shock, there is fibrinolysis and prolonged coagulation time (hypocoagulability).
Hence, heparin therapy can be lethal.
The
phagocytic activity of the reticulo-endothelial system (RES) is depressed
during shock. Endotoxins constantly enter the blood from the bacterial,
intestinal flora of a healthy person. The macrophages of the RES (Chapter 32)
normally inactivate these endotoxins and release mediators such as hydrolases,
proteases, oxygen free radicals, coagulation factors, prostaglandins,
thromboxanes and leucotrienes. Some of these mediators modulate the
temperature control and hormone secretion.
Following
loss of half the total blood volume the shock patient must have lost about 50%
of his circulating macrophages, and control substances modulating the
phagocytic activity of RES. The depressed defence mechanisms in RES result in
an endotoxic shock which aggravates the haemodynamic shock - a vicious cycle.
The
patient loose consciousness and falls into a state of stupor or of coma.
A
severe shock becomes irreversible, when the high-energy phosphate stores of
the liver and heart are depleted. All of the creatine phosphate is degraded
and almost all ATP has been degraded to ADP, AMP and eventually to the even
more efficient vasodilatator, adenosine.
Adenosine diffuses out of the cells and into the circulation, where it is
converted into hypoxanthine and uric acid, a substance that cannot re-enter
the cells. Cellular depletion of high-energy phosphate is probably causing the
final state of irreversibility.
The
cerebral bloodflow is now so low that the function of the cardiovascular
brainstem centres is depressed. The loss of sympathetic tone leads to cardiac
depression with terminal bradyardia and vasodilatation with falling peripheral
resistance. The fall in arterial pressure intensifies the damage, and a
vicious cycle is established.
Two types of shock deserve special consideration:
Anaphylactic
shock (anaphylaxis with relative hypovolaemia)
is a severe allergic disorder in which the cardiac output and the mean
arterial pressure fall rapidly and drastically due to relative hypovolaemia.
As soon as an antigen to which the patent is sensitive, has entered the blood
the antigen-antibody reaction (Chapter 32) triggers release of histamine
from basophilic cells in the blood and mast cells in the tissues. Histamine
dilatates arterioles and most peripheral vessels. This results in falling
arterial pressure and increased capillary permeability with rapid loss of
plasma water into the interstitial fluid.
Septic
shock (relative hypovolaemia). Septic shock or
blood poisoning is a widespread bloodborn bacterial infection - often life
threatening. Examples are gas gangrene bacilli spreading from a gangrenous
limb, colon bacilli with endotoxin spreading into the blood from infected
kidneys (pyelonephritis), and fulminant
peritonitis due to acute abdominal disease. Frequent causes of fulminant
peritonitis are rupture of the infected gut or the uterus, and rupture of the
uterine tube due to extrauterine pregnancy. Septic shock is characterized by
tremendously high fever, high cardiac output, marked vasodilatation, red cell
agglutination, disseminated intravascular coagulation withmicroclots spread
all over the circulatory system. When the clotting factors are used up,
internal haemorrhages occur. Endotoxins produce vasodilatation, induce
synthesis of nitric oxide (NO) synthase in the vascular smooth musculature.
Overproduction of NO may contribute to the vasodilatation and the depressed
myocardial contractility found in septic shock. The high cardiac output is due
to a high stroke volume and a high heart rate. The diastolicpressure is low
and the systolic pressure is high until endotoxins begin to inhibit myocardial
contractility seriously. Now the condition is in a vicious cycle, which is
often fatal.
Therapy keypoints are:
First
of all the cause has to be
established in order to give the appropriate therapy.
1. Head-down
position (placing the patient’s head below the level of the heart) is
the immediate therapy of haemorrhagic and neurogenic shock.
2. Haemorrhagic
arrest (closing the abdominal aorta with the pressure of a fist, or
blocking the bleeding from an artery with a finger) is often life saving when
applied without unnecessary delay.
3. Replacement
transfusions. The best possible therapy of haemorrhagic shock is whole
blood transfusion. The best treatment of shock caused by plasma loss is plasma
transfusion, and the best therapy of dehydration shock is transfusion with the
appropriate solution of electrolytes.
4. Oxygen breathing is always helpful in shock with insufficient delivery of oxygen.
-
Sympathomimetic drugs (noradrenaline, adrenaline etc) are often beneficial in neurogenic and
anaphylactic shock. They are seldom useful in haemorrhagic shock, where the
sympathetic nervous system is already activated to its maximum.
2.
Congenital heart disease
On
a global scale approximately 1% of live births result in congenital
heart disease. The mother may have suffered from rubella infection, abuse
of drugs or alcohol, exposure to influential radiation or other factors
causing genetic or chromosomal abnormalities.
Two
pathophysiological phenomena occur: Right-to-left shunting of blood results in cyanosis, clubbing of
fingers, reduced growth in children, exertion
syncope, and paradoxical emboli from veins to systemic arteries. Children
with Steno-Fallot´s tetralogy (Fig. 12-7) use squatting. The advantage of squatting for the children is improved
cerebral oxygenation as the position reduces the right-to-left shunt.
Left-to-right
shunts in the heart result in pulmonary hypertension, because of persistently increased pulmonary
bloodflow and vascular resistance (the so-called Eisenmenger response - frequently caused by ventricular septal
defect).
Three
classical congenital heart diseases are Steno-Fallot´s tetralogy, Coarctation
of the aorta, and persistent ductus arteriosus.
Steno-Fallots
tetralogy
The
four elements suggested by the name tetralogy are: 1. Ventricular septal
defect, 2. Overriding aorta (ie, the aortic orifice is located above the
ventricular septal defect and therefore receives blood from both ventricles),
3. Pulmonary stenosis (right ventricular outflow obstruction), and 4. Right
ventricular hypertrophy.
The
pulmonary stenosis causes a high right ventricular pressure, and as this
pressure supersedes the left ventricular pressure there is a right-to-left
shunting of blood through the ventricular septal defect. The mixed blood
passes through the overriding aorta, and the patient is cyanotic with all the
hypoxic consequences described above (eg, exertion syncope, squatting, small
stature, finger clubbing and polycythaemia). The children are tired and
dyspnoeic, and growth is retarded although they often demonstrate a surprising
appetite, because of the enormous cardiac work. Complete surgical correction
is possible.
Fig.
12-7: Three common congenital heart disorders.
Coarctation
of the aorta
Coarctation is a narrowing of the aorta distal to the
insertion of ductus arteriosus (Fig. 12-7), and often associated with stenosis of the aortic orifice (a bicuspid aortic valve). The
obstructed aortic bloodflow forces blood through collateral arteries such as
the intercostal and periscapular arteries. The high blood pressure may cause
nose bleeds and headaches, and the low distal bloodflow may cause claudication
and cold legs.
Turbulent
bloodflow through the coarctation is often recognized as a forceful systolic
murmur even on the back.
Surgical
excision of the coarctation with end-to-end
anastomosis must be performed in childhood, because a low renal bloodflow,
maintained over years, frequently results in irreversible systemic
hypertension
Persistent ductus arteriosus (PDA)
In
the foetus the ductus arteriosus leads blood into the systemic circulation
instead of through the unexpanded lungs. Hereby, the foetal blood is
oxygenated during its passage of the placenta. At birth, the expansion of the
lungs with atmospheric air triggers contraction and closure of ductus
arteriosus by constriction of its muscular wall. Premature babies and children
borne by mothers, who suffered from rubella in the first trimester, are often
born with PDA.
A PDA shunts blood from the aorta to
the pulmonary artery throughout the cardiac cycle (Fig.
12-7). This is because
the aortic pressure is much higher (150/80 mmHg) than that of the pulmonary
artery (40/20 mmHg or 5.3/2.7 kPa).
The
condition may be symptom-less for years, but a large shunt increases the work
of the left ventricle and causes left heart failure, which increases the risk
of pulmonary congestion and oedema. The person is easily
fatigued even from moderately strenuous exercise.
The
frequency of infective endocarditis is increased in PDA. Infective endocarditis commonly occurs on congenitally or
rheumatically damaged valves. The endocardium also suffers from jet lesions
located on the endocardial surface opposite to a shunt with a high driving
pressure. This is common for all types of congenital heart disease apart from
atrial septal defect, where the driving shunt pressure is too small to damage
the endocardium.
The
continuous shunting of turbulent blood causes a continuous machinery murmur
best heard below the left clavicle.
Surgical
ligation of the duct should be performed as
early as possible.
The
general trend today is an increasing survival rate of congenital heart
disease. Adults living with congenital heart disease for years may present
themselves as cardiac arrhythmias resistant to standard therapy or at autopsy
following sudden cardiac death.
Terminal
heart failure is now managed by heart-lung
transplantation.
Equations
· The Fick cardiac output equation states that the cardiac
output is calculated from the ratio between alveolar oxygen uptake and
arteriovenous oxygen content difference:
Eq.
12-1: Q° =
V° O2/(CaO2 - Cv O2 ); [ml STPD*min-1/ml blood*min-1]. The last oxygen
concentration is in mixed venous blood.
· The law of mass balance is applied to both bloodflow and
oxygen flux in Eq. 14-7 and 14-8. The flow and flux relations implies the
following shunt equation:
Eq.
12-2: Q°shunt/ Q°total = (CaO2 - Cc´02)/(Cv O2 - Cc´02).The
last oxygen concentration is in pulmonary end-capillary blood.
· Clearance is the volume of blood plasma, which is totally
cleared each minute of a given indicator by a specific organ (renal
clearance). The extraction (E) is the fraction of substance that is extracted
from the total amount transported to the organ per minute.
Eq. 12-3: E = Q° (Ca - Cv) /( Q° × Ca) ; E = (Ca - Cv) / Ca
· The
isotope-wash-out-method. A homogenous muscle
tissue of the weight, Wtis, is presumed. A lipid-soluble indicator
such as 133Xenon dissolved in saline, is injected in the tibialis
anterior muscle (* in Fig. 12-4). At
steady state, the tracer concentration in the venous blood (Cv) is
assumed to be the average blood concentration, and Ctis the mean
tissue concentration. A distribution coefficient is introduced: Ctis/Cv = l,
which is known for Xenon. The decrease of the mass of indicator in the tissue
per time unit (dt) must be equal to the mass supplied (which is zero) minus
the mass of indicator leaving the tissue in the venous blood. The principle of
mass balance provides the following equation:
(Wtis × dCtis) = [mass
supplied minus mass eliminated].
(Wtis × dCtis) = (- Cv × Flow× dt) or Wtis × dCtis/Ctis = (- Cv/Ctis × Flow × dt).
Eq. 12-4: dCtis/Ctis = - Flow × dt/(Wtis × l).
The fractional fall in the mean
tissue concentration of Xenon (Ctis) per time unit (dt) is constant
during the whole elimination period (a rate constant = ln 2/T½).
Flow/Wtis is a perfusion coefficient in FU (ml of blood per min and
per 100 g tissue). The ratio dCtis/Ctis is measurable as
T½ on the skin surface above the Xenon deposit in fat or muscle
tissue with a scintillation detector.
· The volume equation for a cylindrical system implies that
the flow per second (Q° s)
and its volume (V) is related by tmean:
Eq.
12-5: tmean = V/ Q°s.
Self-Assessment
Multiple
Choice Questions
I.
Each of the following five statements have True/False options:
A. The
capillaries have the greatest cross-sectional area of the systemic
circulation.
B. The
systemic arterioles offer the greatest vascular resistance to bloodflow.
C. The sympathetic regulation of the arteriolar tone in fat and skin
tissue depends upon the classical baroreceptors.
D. Increased
compliance in the venous system means decreased venous return.
E. The lactate produced by skeletal muscles
during exercise is not an important substrate for the myocardial metabolism.
II. Each of
the following five statements have True/False options:
A. Vasopressin is a strong
antidiuretic hormone and a modest vasoconstrictor.
B. ACTH and b-endorphins
are released into the blood from the posterior pituitary gland in response to
haemorrhage or other forms of stress.
C. Fulminant peritonitis is a
frequent form of acute abdominal disease.
D. With the head of the patient downward, the patient risks air embolism
if blood vessels are cut during neck and head surgery.
E. Hypotension and
ischaemic hypoxia depresses myocardial contractility.
Case History A
20-year old soldiers, body weight 70 kg, is brought
to the field hospital with a
profusely bleeding gun wound in the left shoulder. The skin is cold and wet, the arterial pressure is 65/ 40 mmHg, and the heart frequency is
144 beats per min (bpm). There is no diuresis.
The
bleeding is stopped by ligation of the bleeding arteries, and blood
transfusions are given instantly (2 litres of whole blood with a normal packed
cell volume, PCV, of 0.45). Hereby, the arterial pressure increases to a
steady level of 105/70 mmHg, and the heart rate is reduced to 100 bpm. The
condition of the soldier is clearly improved and his cardiac output is
measured to 3.5 l per min.
24
hours later the soldier had a relapse, and his PCV was measured to 0.35. The
PCV is corrected for trapped plasma, and assumed representative for the body
as a whole (ie whole body haematocrit).
1.
Describe the initial cardiovascular events leading to the shock condition.
2. Describe the effect
of the blood transfusions.
3. Calculate the order
of size of the blood loss.
4. Was the blood
transfusion therapy sufficient?
Case History B
A male, 21 years old, is located in the supine body
position. He has a cardiac output of 5.4 l per min at rest, a circulating
blood volume in the pulmonary circulation of 650 ml and in the systemic
circulation of 4750 ml. His total
mass of skeletal muscle is 35 kg. The muscular perfusion is 3 ml of blood per
min per 100 g of muscle tissue (3 FU), and the mean passage time in the
muscular capillaries is 5 s.
1. Calculate
the mean transit time for all red blood cells in the total circulatory system.
2. Calculate
the mean transit time for the pulmonary circulation only.
3. Calculate the total perfusion of the skeletal
muscle mass at rest (ml/min) and calculate the bloodflow per second.
4. Calculate the functioning capillary volume in the
muscular capillaries.
Case History C
A 64-year old male normally has a body weight of 74
kg, a total blood volume of 5 l and a blood [haemoglobin] of 10 mmol per l
(mM). One day he suddenly vomits large quantities of fresh blood. For two days
his stools have been tarry. The last weeks have been stressful at work. The
patient calls his doctor and the emergency ward at the hospital is alerted.
Due to an incompetent local ambulance service, the patient is brought to
hospital without delay by taxi. Here, the mean arterial blood pressure is
below 10 kPa (75 mmHg) and falling. The heart rate is above 150 beats per min
and rising. The blood [haemoglobin] is 5 mM measured one hour after the first
massive blood loss.
The
emergency team immediately institute transfusion of blood. The following 8
days the patient receives three transfusions of blood and at least 10 l of
physiological saline. On the second day his [haemoglobin] has increased to 7.2
mM, but on the third day it falls again to 5 mM. On the 4th day at the
hospital the patient develops high fever (maximum 40.6 oC), and a
broad-spectrum antibiotic program is started without delay. On the 8th day at
hospital the patient has normal temperature, but he develops watery swellings
of legs and lower abdomen, in spite of pronounced urination. The body weight
is now 80 kg.
1.
What is the most likely cause of the haemorrhage?
2.
Estimate the size of his blood loss.
3.
Why did the patient develop high fever?
4.
Why did the patient accumulate water?
Case History D
A
small girl, borne with ventricular septal defect, pulmonary stenosis,
overriding aorta and a right to left shunt through the septal defect is
examined with cardiac catheterisation. The oxygen concentrations in her blood
are 138, 195, and 220 ml per l in the pulmonary artery, brachial artery and
pulmonary veins, respectively. Her oxygen uptake at rest is 164 ml per min,
and she has polycythaemia with a blood haemoglobin of 164.2 g per l. The girl has a 30% right-to-left shunt through the
septal defect and directly to the overriding aorta.
1.What
is the diagnosis?
2.
Calculate the oxygen concentration in the pulmonary veins and estimate the
saturation degree.
3.
Calculate the bloodflow through the lungs.
4.
Calculate the total bloodflow through the aorta assuming that the lung
bloodflow (Q°lung ) and
the shunt bloodflow (Q°shunt )
equals the total cardiac output, Q°total .
5.
Estimate the size of the venous return.
6.
Is it likely that this patient develops cyanosis? Calculate the concentration
of reduced haemoglobin in mean capillary blood.
Case History E
A male, 18 years old, suspect of congenital heart
disease, is examined at the hospital. His body weight is only 60 kg and he has
always abstained from exercise. The patient is tall and slim, although he is
always hungry and is actually eating more than normal. Cardiac catheterisation
is performed with the patient resting in the supine position, and reveals the
following: Mixed venous blood from the right ventricle and from the pulmonary
artery (CvO2 ): 160, arterial blood from the aorta (CaO2 )
195, and blood from the right atrium 130 ml STPD l-1. The oxygen
uptake (V°O2 ) at
rest is 310 ml STPD per min.
1. Calculate the cardiac
output (Q°)
from the right ventricle.
2. Calculate the Q° from
the left ventricle.
3. Provide arguments for
a certain cardiac abnormality, which explains the findings.
4. Why has the patient
always avoided exercise?
5. Why is the patient
slim although he is eating a lot and not performing exercise?
Try
to solve the problems before looking up the answers.
Highlights
· The coronary
bloodflow is mainly controlled by local metabolic autoregulation. Accordingly, a moderate decrease in arterial blood pressure down to 9.3
kPa (70 mmHg) does not significantly reduce the bloodflow through the
myocardium.
· The blood reaches the
brain through the internal carotid and the vertebral arteries. The dominant
control of cerebral bloodflow (CBF) is autoregulation. The sympathetic nervous
system plays a secondary role.
· Some
degree of autoregulation is found in many other organs including the skeletal
muscle mass, the splancnic area, and the kidneys.
· CBF is normally 55 FU
in humans at rest. One Flow Unit (FU) is one ml of blood per min per 100 g of
brain tissue. This resting CBF and the oxygen uptake of the brain can double
during cerebral activity and triple in active brain regions during an
epileptic attack. Brain vessels are metabolically regulated. Increased PaCO2,
and reduced PaO2 dilatate brain vessels and increase CBF.
· Blood flows through
the skin and subcutaneous tissues in order to nourish the cells, and to
regulate shell temperature. Blood flows much faster through the arteriovenous
anastomoses in the skin of the face, the fingers and toes in a cold
environment. The sympathetic activity constricts the metarterioles that lead
to the skin, so the blood bypasses the cutaneous circulation.
· Psychological
influence can cause one to blush or to have a white face, by changing a-adrenergic
constrictor tone and via the effect of local, vasoactive substances normally
found in the skin.
· When a large fat
combustion is occurring (eg, hunger and distance running), the fat bloodflow
can increase from 3 FU to 20 FU. Cold and warm environments alter the fat
perfusion just like the skin perfusion.
· The placental barrier
has an area of 10 m2, and can be passed by low molecular substances
(nutrients, gasses, and waste) by diffusion. The foetal haemoglobin (F) has a
dissociation curve that is shifted to the left relative to adult haemoglobin,
and F is not affected by 2,3-DPG..
· Foetal blood has a
high haemoglobin concentration, so the foetus takes up large amounts of O2 in placenta.
· Much of the blood
flowing in the descending aorta of the foetus is directed toward the placenta,
so venous drainage from all organs is shunted toward the placenta, where
wastes are eliminated from foetal blood, whereas O2 and nutrients
are acquired.
· The parallel foetal
circulation is transformed into a series circulation in the baby. The foramen
ovale and ductus venosus close within 3 days of birth, and the ductus
arteriosus closes within 10 days. The sharp increase of O2 content
(CaO2)
in the baby's blood is a potent and universal vasodilatator. The dramatic
changes in gas exchange affect cardiopulmonary and vascular regulation,
probably via local mediators such as arachidonic acid and prostacyclin.
· When a supine person
arise, his TPVR increases, the systolic blood pressure falls and the diastolic
blood pressure rises. Thus the pulse pressure amplitude falls, the MAP is
unchanged. The stroke volume is reduced more than the heart rate rises, so the
cardiac output will decrease in the standing position.
· The bloodflow
(cardiac output in ml of blood per s or more convenient per min) can be
measured by dividing the dose of indicator injected upstream by the area under
the downstream concentration curve.
· Clearance is the
volume of blood plasma. Which is totally cleared each minute of a given
indicator by a specific organ.
· Catecholamines
constrict vessels all over the body by stimulating a1-receptors located on the surface of vascular smooth muscles.
· ADH (vasopressin) is
secreted from the posterior pituitary gland in response to shock, because the
sinoaortic baroreceptors are under-stimulated. Vasopressin is a modest
vasoconstrictor and a strong antidiuretic hormone.
· The enzyme renin is
secreted from the juxtaglomerular apparatus, when blood pressure and renal
perfusion falls drastically. Renin acts on the plasma protein,
angiotensinogen, to form inactive angiotensin I, which is converted to the
powerful vasoconstrictor, angiotensin II by ACE in the lungs.
· Angiotensin II is a
powerful stimulator of the aldosterone secretion from the renal cortex.
Aldosterone promotes the reabsorption of Na+ and increases the
secretion of K+ and H+ in the distal tubular system of
the kidneys. Water follows by osmosis, so the extracellular volume is
increased.
· ACTH and b-endorphins
are released into the blood from the anterior pituitary gland in response to
haemorrhage or other forms of stress.
· Septic shock or blood
poisoning is a widespread bloodborn bacterial infection - often
life-threatening. Examples are gas gangrene bacilli spreading from a
gangrenous limb, colon bacilli with endotoxin spreading into the blood from
infected kidneys, and fulminant peritonitis due to acute abdominal disease.
· Haemorrhagic arrest
(haemostasis) is often life saving in shock, when applied without unnecessary
delay.
· Replacement
transfusions. The best possible therapy of haemorrhagic shock is whole blood
transfusion, of shock caused by
plasma loss plasma transfusion,
and of dehydration shock transfusion with the appropriate solution of
electrolytes.
· Oxygen breathing is
helpful in shock with insufficient delivery of oxygen.
· Sympathomimetic drugs
(noradrenaline, adrenaline etc) are often beneficial in neurogenic and
anaphylactic shock. They are seldom useful in haemorrhagic shock.
Further
Reading
Calver, A., J. Collier and P.
Vallance. "Nitric oxide and cardiovascular control." Experimental
Physiology 78: 303-326, 1993.
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