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FARMAKOLOGI-KLINIK HEMODYNAMIC

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  • Clinical Pharmacology and HEMODYNAMICS DISORDERS

    Sulanto Saleh-Danu R.,MD., SpFK.Dept. of Pharmacology & TherapyDiv.Clinical PharmacologyFac of Medicine, GMU. 21*

  • Objective.

    After following this lecture to be able to

    - understand whats the hemodynamic and hemodynamics

    - understand hemodynamics emergency

    - understand rational use of medicine (pharmacotherapy) in the situation of hemodynamics emergency *

  • HEMODYNAMICS.

    Is the study of the relationship between PRESSURE, RESISTANCE and the FLOW of BLOOD in the cardiovasluar system.( Aaronson, PI. & Ward J P T., 2000)Is the study of the movement of the blood and the forces concerned there in.( Doorlands Illustrated Medical Dictionary, 27th ed., 1988).Hemodynamic, pertaining to the movementsinvolved in the circulation of the blood. ( Doorlands Illustrated Medical Dictionary, 27th ed.,1988)*

  • (copy from :Aaronson,PI., Ward,J.P.T., 1999)CO = (MABP-CVP)/ TPR

    CO = cardiac output,MABP = mean arterial blood pressure,TPR = total peripheral resistance,CVP = central venous pressure

    *

  • AO = aortaLg. arteries = large arteriesSm.arteries = small arteriesART = arteriolesCAP = capillariesVEN = venuleSV = venousSm veins = small veinsLg veins = large veins *

  • HEMODYNAMIC EMERGENCYPRESSURE : - hypertension - hypotension RESISTANCY : - obtruction of vessel - peripheral vasoconstriction - massive bleedingFLOW OF THE BLOOD : - blood viscocity - angina/O2 supply*

  • HAEMODYNAMICSPRESSUREHypertension

    Hypotension

    - Stroke / CVA - Vital organ damages. - ShockRESISTANCEVasoconstriction.

    Obstruction

    FLOW OF BLOODScleroting of areteries

    Increase of velocity

    BLOOD PRESSURE*ThrombusEmboliHematokrit

  • * HYPOTENSION

    SHOCK

  • BLOOD PRESSUREHYPOTENSION

    SHOCK organs perfusion

    ORGANS / TISSUESDAMAGES

    EMERGENCYACTION

    *

  • BLOOD FLOWORGANSPERFUSION

    REVERSEIBLEIRREVERSIBLECELLULAR / TISSUE / ORGAN INJURY / DAMAGESDEATH

    CRITICAL PERIODE*

  • Classification of shock by mechanism and common causes.Hypovolemic shock Cardiogenic shockObstructive shockDistributive shock( Messina, L.M., et al., 2003 )*

  • HypovolemicshockReducedpreloadCardiogenicshockReducedSystolicperformanceObstructiveshockReduced Ability toFill ventricleIn diastoleDistributiveshockSevereMyocardialdepressionSevere Decrease inSystemicVascularresistanceDecrease inStroke volumeDecrease in COHypotensionSevere decrease inTissue & organ blood flowMultiple organ system failureMaldistributionOf blood flowIn microcircul.( Parrillo, JE., 1991 )*

  • Hypovolemic shockLoss of blood (hemorrhagic shock)

    - External hemorrhagic : trauma, gastrointestinal bleeding, etc. - Internal hemorrhagic : hematoma, hemothorax, hemoperitoneum.

    Loss of plasma : burns, exfoliative dermatitis.

    3. Loss of fluid and electrolytes - External : vomiting, diarrhea, excessive sweating, hyperosmolar states (diabetic ketoacidosis, nonketotic coma) - Internal ( third spacing) : Pancreatitis, Ascites, Bowel obstruction. *

  • *

  • Cardiogenic shock- Dysrhythmia : - Tachyarrhythmia - Bradyarrhythmia

    - Pump failure : secondary to myocardial infarction or other cardiomyopathy.

    - Acute valvular dysfunction (especially regurgitant lesions )

    - Rupture of ventricular septum or free ventricular wall*

  • Obstructive shock Tension pneumothorax

    Pericardial diseases ( tamponade, constriction)

    Diseases of pulmonary vasculature

    (massive pulmonary emboli, pulmonary hypertension)

    Cardiac tumor ( atrial myxoma )

    Left atrial mural thrombus

    - Obstructive valvular diseases (aortic or mitral stenosis) *

  • Distributive shock - Septic shock

    - Anaphylactic shock

    - Neurogenic shock

    - Vasodilator drugs

    - Acute adrenal insufficiency

    *

  • *TREATMENT and MANAGEMENT SHOCKGENERAL MEASURE :

    ABC VENTILATION Oxygen supply Advanced Cardiogenic Life Support (ACLS) Folley Catheter urinary output Laboratory : blood count electrolyt glucose blood gas analyse coagulation parameter blood group bacterial cultur

    CENTRAL VENOUS PRESSURE ( CVP ) or

    PULMONARY CAPILLARY WEDGE PRESSURE (PCWP)

  • *3. VOLUME REPLACEMENT. I.V. LINE ( better use TRANFUSION SET ) HEMORRHAGIC SHOCK : BLOOD SUBSTITUTES / WHOLE BLOOD / PBRC (Packed Blood Red Cells) + isotonic solution preventing increase of Hmt. HYPOVOLEMIC SHOCK : Rapid bolus ISOTONIC CRISTALLOID 1 L CARDIOGENIC SHOCK : ISOTONIC CRISTALLOID ( smaller volume ) SEPTIC SHOCK : Large volume ISOTONIC CRISTALLOID.

    SHOCK in TRAUMA CAPITIS HYPERTONIC SALINE (7.5%) plus DEXTRAN.

  • *MEDICATIONS

    4.1. VASOACTIVE THERAPY : INOTROPIC agents VASOPRESSOR agents - AFTER ADEQUATE FLUID RESUSCITATION - DEPENDS ON CARDIAC OUTPUT Agents : - Dobutamine - Nor-adrenaline/Nor-epinephrine - Adrenaline/Epinephrine - Dopamine - Vasopressin ( antidiuretic hormon /ADH ) DISTRIBUTIVE/VASODILATOR SHOCK

    4.2. CORTICOSTEROID SEPTIC SHOCK 4.3. Activated Protein C as antithrombotic, profibrinolytic and Anti-inflamatory ( SEPTIC SHOCK) 4.4. ANTIBIOTIC DEFINITIVE THERAPY in SEPTIC SHOCK 4.5. SODIUM BICARBONATE SEPTIC SHOCK with LACTIC ACIDOSIS

  • DRUGS USED IN NON-CARDIOGENIC SHOCK Cathecholamines and sympathomimetic amines:

    adrenaline (epinephrine); noradrenaline (norepinephrine); isoprenaline (isoproterenol); dopamine; dobutamine; etc.

    - others : glucagon; naloxone; corticosteroids; etc. First of all : do not forget insert the iv line. *

  • PRINCIPLES SHOCK MANAGEMENT :

    ALLEVIATING THE PRECIPITATING CAUSE OF SHOCK;

    TREATING THE HAEMODYNAMIC AND

    METABOLIC CONSEQUENCES;

    3. MANAGING THE SECONDARY MEDICAL COMPLICATIONS ( renal failure; pulmonary oedema etc.)(Benowitz, N.L., et al., 1997) see lecture: shock management.*

  • *HYPERTENSION

    PREVENT

    VITAL ORGAN FAILURE

  • *

  • BLOOD PRESSURE

    HYPERTENSIONClassification Systolic Diastolic (mmHg) (mmHg)

    Normotension (normal) < 120 and/or < 80Prehypertension 120 139 and/or 80 89 Stage 1 Hypertension 140 159 and/or 90 99 Stage 2 Hypertension 160 179 and/or 100 109

    Stage 3 ( severe) HT 180 - 209 and/or 110 119

    Stage 4 (very severe) HT > 210 and/or > 120 ( JNC V & VII, 2003) emergency

    *

  • HYPERTENSION CONSEQUENCIESORGAN DAMAGES : - KIDNEYS eg. Renal Failure - EYES ( RETINA) eg. Retinopathia /Blindness - BRAIN eg. CVA ( Stroke )/ TIA - HEART eg. LVH,MI, Heart Failure

    DEATH*

  • MANAGEMENT VERY SEVERE HYPERTENSION(HYPERTENSIVE EMERGENGY). MUST BE BALANCE RISK AND EFFICACY URGENT REDUCTION BP : hypertensive encephalopathy;

    acute hypertensive heart failure; dissecting aneurysma; etc. SHOULD BE HOSPITALIZED INITIAL GOAL : REDUCE BP BY NO MORE THAN 25 % WITHIN

    FIRST 2 HOURS; BP:160/100 mmHg within next 2-6 hours until at least 24 hours. *

  • PHARMACOTHERAPY.

    PARENTERAL : 1. sodium nitroprusside 0.3 microgram /kg/minute iv for 10 minutes then increase/decrease 0.3 microgram/kg/minute every 5-10 minutes reach the maintain BP level.

    ALTERNATIVELY,

    2 diazoxide 30 mg iv, increase as necessary in 30 60 mg bolus dose at 5 to 10 minute interval, up to 300 mg;

    3. hydralazine 5 to 10 mg slowly i.v.repeat at 20 minute interval;

    4. clonidine 1

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