The document discusses ventricular dysfunction in critically ill patients. It begins by outlining how left ventricular function is connected to tissue oxygenation through a series of physiological relationships. It then examines the left ventricular pressure-volume relationship and how indices like ESPVR and EDPVR relate to contractility and compliance. Various factors that can cause decreased contractility leading to systolic dysfunction are explored, including reversible acute causes and chronic conditions. Management strategies to address systolic dysfunction like increasing preload, contractility, and decreasing afterload are summarized. The complex interplay between preload and ventricular compliance is also discussed.
Fluid management and Fluid Responsiveness in ICCU / ICU at ASMIHA workshop 2018Isman Firdaus
It is very important for cardiologist or intensivist to determined fluid overload vs loss fluid. Misconception of hypervolemic and hypovolemic state was very important.
Fluid management and Fluid Responsiveness in ICCU / ICU at ASMIHA workshop 2018Isman Firdaus
It is very important for cardiologist or intensivist to determined fluid overload vs loss fluid. Misconception of hypervolemic and hypovolemic state was very important.
This workshop will outline the basic principles of extracorporeal life support made easy by key-experts in the field. During the course delegates will gain a good understanding of ECMO in the following areas: Theoretical concepts, basic physiology and pathophysiology, cardiac and respiratory support and monitoring, alarm settings and monitoring, role of cardiac ultrasound during ECMO, newest technologies, circuits and devices, practical hands-on sessions and simulations.
Steve Bernard speaks at a meeting on 4/2/14 in Sydney on the reality of ECMO CPR at The Alfred in Melbourne, Victoria, and the upcoming CHEER study.
Exciting times!
See Intensive Care Network for the talk and more.
A brief yet comprehensive coverage of ICU role in ECMO cases. Presentation has been prepared in order to help ICU fellows and registrars to understand the importance of their role and to know necessary actions they have to take in case of need.
Selective Aortic Arch Perfusion -
Summary by: Jim Manning
Selective Aortic Arch Perfusion (SAAP) is an endovascular-extracorporeal perfusion resuscitation technique designed specifically to treat cardiac arrest. SAAP involves the blind insertion of a large-lumen balloon occlusion catheter into the descending thoracic aortic arch via a femoral artery. With the SAAP catheter balloon inflated in the thoracic aorta, the heart and brain are relatively isolated for resuscitative perfusion through the SAAP catheter lumen with an oxygen-carrying fluid (such as blood, hemoglobin-based oxygen carrier or fluorocarbon emulsion). SAAP promotes restoration of spontaneous circulation (ROSC) by the heart while protecting the brain from further ischemic insult. SAAP can be used to treat both hemorrhage-induced traumatic cardiac arrest and medical, non-traumatic cardiac arrest.
In traumatic cardiac arrest, SAAP provides the combination of (1) thoracic aortic balloon occlusion for control of hemorrhage below the diaphragm, (2) rapid volume replacement in hemorrhage-induced hypovolemia to restore normovolemia and (3) perfusion of the heart and brain in an effort to achieve ROSC. SAAP also allows titration of small doses of intra-aortic adrenaline or other medications to achieve ROSC.
In medical cardiac arrest, SAAP catheter balloon occlusion of the thoracic aorta limits the distribution of oxygenated perfusate toward the heart and brain. Since medical cardiac arrest patients are not typically hypovolemic, SAAP with an exogenous oxygen-carrier is a volume loading intervention that can only be used for a short time period (5-10 min). If ROSC is not achieved with the limited volume of exogenous oxygen-carrier, femoral venous access during initial SAAP infusion allows venous blood withdrawal for continued SAAP support to promote ROSC without further volume loading (autologous blood SAAP or, essentially, aortic arch ECMO). Intra-aortic adrenaline and anti-reperfusion agents can also be used. Even if ROSC is not rapidly achieved, SAAP serves as a bridge that limits hypoperfusion until cannulation for full body ECMO can be achieved.
This workshop will outline the basic principles of extracorporeal life support made easy by key-experts in the field. During the course delegates will gain a good understanding of ECMO in the following areas: Theoretical concepts, basic physiology and pathophysiology, cardiac and respiratory support and monitoring, alarm settings and monitoring, role of cardiac ultrasound during ECMO, newest technologies, circuits and devices, practical hands-on sessions and simulations.
Steve Bernard speaks at a meeting on 4/2/14 in Sydney on the reality of ECMO CPR at The Alfred in Melbourne, Victoria, and the upcoming CHEER study.
Exciting times!
See Intensive Care Network for the talk and more.
A brief yet comprehensive coverage of ICU role in ECMO cases. Presentation has been prepared in order to help ICU fellows and registrars to understand the importance of their role and to know necessary actions they have to take in case of need.
Selective Aortic Arch Perfusion -
Summary by: Jim Manning
Selective Aortic Arch Perfusion (SAAP) is an endovascular-extracorporeal perfusion resuscitation technique designed specifically to treat cardiac arrest. SAAP involves the blind insertion of a large-lumen balloon occlusion catheter into the descending thoracic aortic arch via a femoral artery. With the SAAP catheter balloon inflated in the thoracic aorta, the heart and brain are relatively isolated for resuscitative perfusion through the SAAP catheter lumen with an oxygen-carrying fluid (such as blood, hemoglobin-based oxygen carrier or fluorocarbon emulsion). SAAP promotes restoration of spontaneous circulation (ROSC) by the heart while protecting the brain from further ischemic insult. SAAP can be used to treat both hemorrhage-induced traumatic cardiac arrest and medical, non-traumatic cardiac arrest.
In traumatic cardiac arrest, SAAP provides the combination of (1) thoracic aortic balloon occlusion for control of hemorrhage below the diaphragm, (2) rapid volume replacement in hemorrhage-induced hypovolemia to restore normovolemia and (3) perfusion of the heart and brain in an effort to achieve ROSC. SAAP also allows titration of small doses of intra-aortic adrenaline or other medications to achieve ROSC.
In medical cardiac arrest, SAAP catheter balloon occlusion of the thoracic aorta limits the distribution of oxygenated perfusate toward the heart and brain. Since medical cardiac arrest patients are not typically hypovolemic, SAAP with an exogenous oxygen-carrier is a volume loading intervention that can only be used for a short time period (5-10 min). If ROSC is not achieved with the limited volume of exogenous oxygen-carrier, femoral venous access during initial SAAP infusion allows venous blood withdrawal for continued SAAP support to promote ROSC without further volume loading (autologous blood SAAP or, essentially, aortic arch ECMO). Intra-aortic adrenaline and anti-reperfusion agents can also be used. Even if ROSC is not rapidly achieved, SAAP serves as a bridge that limits hypoperfusion until cannulation for full body ECMO can be achieved.
Discussion of oxygen delivery and consumption principles in critical illness with the golden rules of resuscitation
Edward Omron MD, MPH, FCCP
Pulmonary, Critical Care, and Internal Medicine
Morgan Hill, CA 95037
ventilator waveforms are graphical representation of pulmonary physiology, mechanics and patient ventilator interaction. optimal patient ventilator interaction is needed to balance two goals of mechanical ventilation, safety and comfort.
The enormous world of microorganism source antibiotics to mankind in the war against pathogenic microbes. These microbes in turn tilt the balance to their favor by acquiring resistance against antibiotics, through borrowed genes from a pool widely distributed in the microbial world itself. This collateral damage of misuse of antibiotics on one patient is not limited to that patient, but affects whole society, through expansion of environmental resistome. Both antibiotics and resistance are secondary metabolites involved in varied process, with existence history of million years. Therefore, any antibiotic that would be discovered in future, resistance against it would already be existing in microbial world, which will be acquired by the target bacteria sooner or later. The fight against infection cannot not be won with antibiotics, but truce may be attained through infection control and antibiotic stewardship.
Biological screening of herbal drugs: Introduction and Need for
Phyto-Pharmacological Screening, New Strategies for evaluating
Natural Products, In vitro evaluation techniques for Antioxidants, Antimicrobial and Anticancer drugs. In vivo evaluation techniques
for Anti-inflammatory, Antiulcer, Anticancer, Wound healing, Antidiabetic, Hepatoprotective, Cardio protective, Diuretics and
Antifertility, Toxicity studies as per OECD guidelines
Normal Labour/ Stages of Labour/ Mechanism of LabourWasim Ak
Normal labor is also termed spontaneous labor, defined as the natural physiological process through which the fetus, placenta, and membranes are expelled from the uterus through the birth canal at term (37 to 42 weeks
The French Revolution, which began in 1789, was a period of radical social and political upheaval in France. It marked the decline of absolute monarchies, the rise of secular and democratic republics, and the eventual rise of Napoleon Bonaparte. This revolutionary period is crucial in understanding the transition from feudalism to modernity in Europe.
For more information, visit-www.vavaclasses.com
Unit 8 - Information and Communication Technology (Paper I).pdfThiyagu K
This slides describes the basic concepts of ICT, basics of Email, Emerging Technology and Digital Initiatives in Education. This presentations aligns with the UGC Paper I syllabus.
Macroeconomics- Movie Location
This will be used as part of your Personal Professional Portfolio once graded.
Objective:
Prepare a presentation or a paper using research, basic comparative analysis, data organization and application of economic information. You will make an informed assessment of an economic climate outside of the United States to accomplish an entertainment industry objective.
Model Attribute Check Company Auto PropertyCeline George
In Odoo, the multi-company feature allows you to manage multiple companies within a single Odoo database instance. Each company can have its own configurations while still sharing common resources such as products, customers, and suppliers.
A Strategic Approach: GenAI in EducationPeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
Synthetic Fiber Construction in lab .pptxPavel ( NSTU)
Synthetic fiber production is a fascinating and complex field that blends chemistry, engineering, and environmental science. By understanding these aspects, students can gain a comprehensive view of synthetic fiber production, its impact on society and the environment, and the potential for future innovations. Synthetic fibers play a crucial role in modern society, impacting various aspects of daily life, industry, and the environment. ynthetic fibers are integral to modern life, offering a range of benefits from cost-effectiveness and versatility to innovative applications and performance characteristics. While they pose environmental challenges, ongoing research and development aim to create more sustainable and eco-friendly alternatives. Understanding the importance of synthetic fibers helps in appreciating their role in the economy, industry, and daily life, while also emphasizing the need for sustainable practices and innovation.
Honest Reviews of Tim Han LMA Course Program.pptxtimhan337
Personal development courses are widely available today, with each one promising life-changing outcomes. Tim Han’s Life Mastery Achievers (LMA) Course has drawn a lot of interest. In addition to offering my frank assessment of Success Insider’s LMA Course, this piece examines the course’s effects via a variety of Tim Han LMA course reviews and Success Insider comments.
2. How much have we deciphered Mother Nature?
“And the LV volume is a surrogate for LV wall tension
And the LV wall tension a surrogate for LV stroke volume
And the LV stroke volume determines CO
And the LV CO is a surrogate for tissue blood flow
And tissue blood flowis a surrogate for tissue oxygenation
And the tissue oxygenation is a surrogate for ATP generation
And ATP generation powers cellular function”
critical care clinic
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5. LV PRESSURE VOLUME CURVE
LVESPVR - index of contractility
150
LV Pressure
100
50
LVESDVR - index of compliance
LV volume
50
130
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6. ESPVR
index of contractility
All ESPV points lie along a line
All ejection from different diastolic volumes end on ESPVR
ESPVR shifts to left when contractility increases
decreased ejection at any given preload and afterload
ESPVR shifts to right when contractility decreases
increased ejection at any given preload and afterload
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7. EDPVR
index of compliance
All EDPV points lie along a line
EDPVR shifts to left and up when ventricular compliance decreases
diastolic dysfunction
EDPVR shifts to right and down when ventricular compliance increases
dilated cardiomyopathy
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11. Decreased Contractility = ventricular systolic dysfunction
Considering normal preload, afterload and ventricular compliance
LVESPVR
150
c-d= stroke volume
130-50= 80
d
d’
50
Isovolemic contraction
c
isovolemic relaxation
LV Pressure
100
a
a’
c-d’= stroke volume
130-80= 50
LVESDVR
b
LV volume
50
80
130
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12. Decreased Contractility = ventricular systolic dysfunction
Increased LVESV: decreased SV and EF
EF or FS dependent on
Preload
Contractility
afterload
Increased LV end systolic volume
with
Normal or decreased afterload
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15. Decreased Contractility = ventricular systolic dysfunction
Causes:
Acute
Respiratory acidosis
causes intracelluar acidosis
Significantly decreases contractility at PaCO2 level of 60
Chronic respiratoryacidosis leads to metabolic compensation
leading to nearly normal intracellular pH
Metabolic acidosis
Less effect as minimal change in intracellular pH
Only metabolic anions permeate cell membrane
Organic anions like lactate, ketoacides do not easliy cross cell membrane
Lactic acidosis begins to depress contractility at pH 7.1 to 7.2
but even at pH 7.0 this depression is quiet small
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16. Decreased Contractility = ventricular systolic dysfunction
Causes:
Acute
Ionized hypocalcemia
Massive PRBC transfusion: citrate bind to Ca
Lactic acid also binds to Ca
Bicarbonate infusion also decreased Ca
Hypokalemia or hyperkalemia
Hypomagnesimia
hypophosphatemia
Bicarbonate infusion
Increases PaCO2: decreases intracellular pH
Increased lactic acid production: by increasing rate limiting step of glycolysis
Decreases ionized Calcium
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17. Decreased Contractility = ventricular systolic dysfunction
Causes:
Acute
Proinflammatory cytokines
TNF ᾳ, IL 1, 2, 6
Increased NO production
Reactive oxygen intermediates
Released by leucocytes
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32. Increasing preload
at normal s.albumin and normal pulmonary capillary permeability
pulmonary starts to develop at Ppaw value of 20-25 mmHg
In critically ill patients s. albumin is decreased and pulmonary capillary permeability
Is increased
Pulmonary oedema will develop at lower Ppaw
Ppaw has many reasons to increase in critically ill patients
Optimal Ppaw has to be identifies which leads to increased stroke volume
With minimal or no pulmonary oedema formation
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33. Increasing preload
In critically ill patients without previous cardiac dysfunction major factor limiting
cardiac output is limited venous return
Limited venous return
Increased venous capacitance: increase unstressed volume
Positive pressure ventilation
Ventricular diastolic dysfunction
Venous return can be increased with
Ionotropes and vasopressors: increase MSFP and decreased resistance to VR
Volume expansion: increasing stressed volume
Benefit and safety margin of vasopressor vs volume expansion has to be evaluated
To avoid ineffective flogging of empty heart
To avoid flooding of lungs and interstitial tissues
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38. Decreased ventricular compliance: diastolic dysfunction
End diastolic volume decreased: decreased SV and EF
EF or FS dependent on
Preload
Contractility
afterload
decreased LV end diastolic volume
with
Normal or increased Pra/ LVEDP
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39. Decreased ventricular compliance: diastolic dysfunction
In the absence of Echocardiography
Should be suspected
when decreased LV pump function is not responding to
fluid expansion/ vasopressors, ionotropic agents and reduction of afterload
Cardiac output is unusually sensitive to changes in heart rate
Late diastolic filling of LV is small in stiff LV
little contribution in EDV by this phase
Increase in HR has less impact on reduction in EDV and therefore SV
Increase in HR, increases C.O. ( CO= SV *HR)
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44. Some facts
right ventricle is thin walled pump, with large radius of curvature
Built for lowpressure system: afterload
Right venricle contraction moves sequentially
from apex to pulmonary outflowtract like peristaltic pump
During diastole RV at normal diastolic pressure lies belowits stressed volume
allowing it to increase preload
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46. RV incrased afterload
Management
•
Management of acute cause
•
Management of ventricular interdependence
Decrease parallel coupling of LV and RV
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47. Some facts to remember
In heart failure, evidence of dependent pulmonary crackles on physical examination,
suggest that LV filling pressure is elevated, usually to more than 20-25mmHg.
However in Chronic heart failure crackles may not be heard even at
Pla more than 30 mmHg as pulmonary lymphatic drainage is increased.
Interstitial odema clearance lags decrease in Pla by hours,
so rapid decrease in Pla is not accuratelyreflected by pulmonary auscultation.
Even before diuresis is established, frusemide reduces Pla by a
venodilatory effect and also reduced intrapulmonary shunt
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48. “The success of intensive care is not,
therefore, to be measured only by the statistics of survival,
as though each death were a medical failure.
It is to be measured by the quality of lives preserved or restored;
and by the quality of the dying of those in whose interest it is to die;
and by the quality of human relationships involved in each death.”
Gordon Dunstan
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