This document discusses central venous pressure (CVP), including its indications, measurement sites, determinants, and limitations. Some key points:
- CVP is the pressure measured in central veins close to the heart and reflects right atrial pressure. It provides information about right ventricular preload but does not indicate blood volume.
- CVP can be measured through the internal jugular, femoral, or subclavian veins. Factors like cardiac function, vascular compliance, blood volume, and intrathoracic pressure determine CVP.
- While CVP provides data on circulatory equilibrium between the heart and veins, it does not predict fluid responsiveness or tissue perfusion. Dynamic variables obtained through fluid challenges or
Assessment of haemodynamics a critically ill patient and its management has always been a matter if debate. Over time a lot of studies and therapeutic interventions have been carried out. This presentation is a review of such interventions and their impact on the outcome.
Assessment of haemodynamics a critically ill patient and its management has always been a matter if debate. Over time a lot of studies and therapeutic interventions have been carried out. This presentation is a review of such interventions and their impact on the outcome.
fluid optimization concept based on dynamic parameters of hemodynamic monitoringSurendra Patel
Recent advances in hemodynamic monitoring to assess fluid responsiveness of patients in acute circulatory failure is based on dynamic parameters like SPV, PPV, SVV and PVI. These parameters are more accurate than static but needs advanced and sensitive monitoring tools.
fluid optimization concept based on dynamic parameters of hemodynamic monitoringSurendra Patel
Recent advances in hemodynamic monitoring to assess fluid responsiveness of patients in acute circulatory failure is based on dynamic parameters like SPV, PPV, SVV and PVI. These parameters are more accurate than static but needs advanced and sensitive monitoring tools.
Novel hemodynamic monitoring tool for major surgery and ICU patients. With minimally invasive doppler probe insertable through regular central line, Nilus is adding right side perspective back into hemodynamic monitoring.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
2. • CVP is the pressure measured in central veins close to the heart.
• Pressure measured at the junction of SVC & rt atrium & there are no
valves in between…..
• It is the back pressure for the return of blood to the heart.
3.
4. INDICATIONS
• CVP measurement
• Central venous oxygen saturation of SVC
• Major operative procedures – large fluid shifts
• Temporary hemodialysis
• Frequent venous blood sampling , inadequate peripheral venous
access
• Temporary pacing
• For vasoactive drugs, parenteral nutrition
• Aspirate intracardiac air – in surgeries with high risk for air embolism
5. INSERTION SITES
• Internal jugular – consistent,
predictable anatomy
• alignment with RA
• Palpable landmark & high
success rate
6. • FEMORAL VEIN :
• No risk of pneumo
• Ease of access – esp in pts with shock
• Higher rate of infect & venous thrombosis after prolonged catheterisation
• SUBCLAVIAN VEIN :
• Less collapsible during profound hypotension – anatomical grip on clavicle
• Complicatn higher
• CHEST X – RAY – DECREASES THE PROBABILITY OF COMPLICATIONS &
PROPER POSITIONING OF CATHETER TIP.
7. DETERMINANTS OF CVP
• Relationship between CO & CVP - 2 fold…..
• Applies to heart – frank starling law – cardiac function curve
• Applies to vascular system – Guyton – vascular law
• Intersection of cardiac & vascular function curves – state of
equilibrium – nothing but CVP – intact circulation
8. • When the heart is isolated from vascular system – CVP is nothing but
pressure on the walls of heart – especially rt heart – that sets the initial
length of sarcomeres based on compliance of the heart – frank starling law
• When venous return is isolated from heart – CVP determines the pressure
diff for the return of blood.
• So combining both – heart controls the return of blood by decreasing the rt
atrial pressure
• There is little change in upstream venous reservoir during cardiac cycle.
• So change in CVP in not just change in preload but rather equilibrium of
both functn.
9. Cardiac function curve
• Frank starlings law
• CO varies with preload ( CVP )
• Governing factors – afterload & contractility
• Functional limits – pericardium / cardiac cytoskeleton ( when
pericardium is absent )
• Importance
10. Venous return function
• Guyton – vascular function curve law
• CVP inversely proportional to CO
• Determinants – arterial & venous compliances
PVR & blood volume
• Limitations – CVP < 0 in spontaneous breathing pts ( or ) < pleural
pressure in pts on ventilator – veins become collapsed – vascular
waterfall
• importance
14. • Normal CVP – 0 to 7 mm Hg
• If CVP > 7 as in ventilated patients / rt heart failure – driving pressure
is close to zero… so no filling / preload – but CO doesn’t become zero
– due to parallel increase in venoconstrictor tone.
• If CVP < 0 may not increase the venous return – due to collapse of
vein at the level of diaphragm.
• Resistance to venous return is very less – but small changes have
major consequences in terms of flow becoz the pressure gradient is
very low
15. WHAT DOES CVP NOT
TELL US……..
• BLOOD VOLUME - Stressed
volume & unstressed
volume
16.
17. • 2ND reason – as it is the equilibrium – a change in either of these
alters the CVP for the same stressed volume.
• Increase in CVP – so there should be more upstream pressure in veins
& venules to maintain flow.
• This higher pressure causes fluid filtration – loss of stressed vol into
interstitial spaces.
• 3RD reason – doesn’t predict volume responsiveness.
18. HYPOVOLEMIA
• Absolute & relative hypovolemia
• Absolute – total circulating vol – decrease venous return , preload, CO
• Relative – inadequate distribution b/w stressed & unstressed volumes
19. PRINCIPLES
• Reference value & physiologic variations
• Reference value – phlebhotaxic axis
• The implementation of a ZERO reference is required before each
measurement.
• Interaction between CVP & ventilation through transmural pressure is
the cause of variations in CVP curves.
• In mechanically ventilated pts, ZERO reference point is equal to atm
pressure.
• No solutions hav ebeen proposed for the reliable & reproducible
measurement of CVP values under unphysiological conditions.
22. PROPER
MEASURMENT
• 5 cm below the sternal angle – approx. 5 cm
above the midpoint of rt atrium
• Mid-thoracic / mid-axillary point – easier to
identify but approx. 3 mm Hg higher than
sternal angle based measurement.
• Measured at the end-expiration becoz
pleural pressure is closest to atm pressure –
which doesn’t change during expiration &
neither CVP.
23.
24.
25. COMPLICATIONS
• Infection ( silver – sulfadiazine & chlorhexidine )
• Thrombosis
• Pneumothorax , hemothorax, chylothorax
• Air embolism – never ports are opened to atm while insertion
26. HOW TO USE
To measure the rt atrial
pressure – surrogate to
estimate the rt ventricular
preload – an indicator of
interaction between venoes
return & rt ventricular functn.
In spontaneously breathing
pts – decrease in CVP > 2 mm
Hg with inspiration indicates
fluid responsiveness.
Higher values of CVP also
predict the occurrence of of rt
heart failure such as in
pulmonary embolism – so
considered warning sign
27.
28. FUNCTIONAL HEMODYNAMIC MONITORING
• Hemodynamic monitoring is the act of assessing the cardiovascular
values, such as blood pressure, heart rate, and cardiac output, and their
patterns. Its clinical utility rests in defining variations from normal ranges
and the constellation of abnormal patterns that define specific pathological
cardiovascular states, such as hypovolemia, heart failure, and sepsis.
• Functional hemodynamic monitoring, on the other hand, is the assessment
of the dynamic interactions of hemodynamic variables in response to a
defined perturbation.
• Such dynamic responses result in emergent parameters of these
commonly reported variables that greatly increase the ability of these
measures to define cardiovascular state and predict response to therapy.
30. • Using functional hemodynamic monitoring we can answer four
imp & interrelated que of the patient
A) Are they volume responsive?
B) Are they in compensated shock?
C) Is their arterial tone increased, normal or decreased?
D) Is their heart able to sustain flow without high filling
pressures?
32. DYNAMIC VARIABLES
3 groups
• 1 st group – cyclic variations in stroke volume / related
hemodynamic parameters
• 2nd group – cyclic variations of non stroke volume related
hemodynamic parameters
• 3rd group – indices based on preload redistribution maneuvers
43. LIMITATIONS
• Only in ventilated patients
• In most studies TV – 8ml/kg
• Req constant R – R interval
• False positive rate in rt heart failure
• Intraabdominal pressures – invalidated – remains responsive even if
their PPV < 15 % & SVV < 10 %
• SVV has no predictive value in septic shock patients in PSV
ventilation
• Falsely elevated parameters in massive & rapid blood loss –
Berkenstadt et al – animal model
• Norad infusion – increase SVV & PPV independently from volemic
state & fluid responsiveness.
44. GROUP B INDICES
• Oscillations in great diameters vessels
• SVC collapses during mechanical inspiration – collapsibilty
index
• IVC distends during mechanical inspiration – distensibilty
index
• Some studies 100 % sensitivity & specificity
• Less invasive – M mode - transthoracic echo / abdominal U/S –
approx. 2cm inferior to junction with the RA
• IVC distensibilty index > 18 %
48. FOR SPONTANEOUS BREATHING PATIENTS
• PASSIVE LEG RAISE TEST :
• Angle 45 degrees – atleast one min
• Equivalent – 300 ml in a 70 kg pt
• CO increased by 10 % - volume responsive
• Autotransfusion
• Reversible fluid challenge
• Also aortic blood flow, carotid flow are measured
• Safer in arrythmic pts & spontaneous pts
• Also in ventilated pts
• Reduce sensitivity in pts with intraabdominal HTN
49.
50. • Dynamic changes in CVP :
decrease in CVP > 1 mm Hg during inspiration – fluid
responsive
Use of Valsalva maneuver to assess volume responsiveness
51. LIMITATIONS TO PREDICTING VOLUME RESPONSIVENESS
• Positive test doesn’t mean there is need for fluid resuscitation –
every pt under GA is virtually fluid responsive – but stable
hemodynamics – no need for fluid resuscitation
• When the test is positive – decision to give fluid depends on clinical
status & effective need to hemodynamic conditions
• No guarantee that fluid given to increase cardiac output reverse
tissue hypoperfusion
• No RCT on patient outcomes – only on evaluation of predictive value
• More efficient to use end points of fluid therapy based on
disappearance of preload responsiveness
52. EARLY IDENTIFICATION OF COMPENSATED SHOCK
• Why we need to identify early ?
• Sites for assessment of microcirculation – muscles and skin
blood flow – reason
• Tissue cardiovascular reserve – sensitive early warning measure
of impending CVS collapse
• Parameters – tissue oxygen saturation ( StO2 ) & vascular
occlusion test ( VOT ).
53. • StO2 – non invasive – NIRS – accurate & valid method
• Minimal risk
• Continuous in their measures
• Trending of states
• Assessing the severity of circulatory shock
• Absolute values – limited use – StO2 remain normal until tissue
hypoperfusion is quiet advanced
• So dynamic ischemic challenge – VOT
54.
55. • Parameters from StO2 graph
• Down slope / deoxygenation rate DxO2 – local metabolic rate &
effective local blood flow distribution
• StO2 recovery / reoxygenation rate RxO2 – local cardiovascular
reserve & microcirculatory flow
• Validated in septic & trauma pts
• Impairment of slopes – correlates to longer ICU stay in septic pts –
Mesquida et al
• Able to predict the need of interventions earlier - resuscitaion
56. ASSESSING ARTERIAL TONE ( Ea )
• Dynamic central arterial elastance – PPV / SVV
• Surrogate marker of vasomotor tone
• Assessment of effect of of volume loading on arterial pressure in
hypotensive shock pts – whose PPV fluid responsive
• Response to fluid challenge – CO increased but pts with normal
/ increased Ea increased arterial pressure
• Ea differentiates responders from non - responders
• Ea < 0.9 – severely vasodilated state