Debitul cardiac. Dr. Kovacs Judit CEEA 2013
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1 Debitul cardiac Dr. Kovacs Judit CEEA 2013
2 Definiţie Cantitatea de sânge ejectat/ minut DC = VB x FC Vincent JL, Crit Care 2009
3 Contracţia atrială Presarcină Întoarcerea Ven. Volemie Compl. Ventr. P.intrator. P.intraperic. DC Debitul cardiac Cal. şi cant. proteinelor contractile Calitatea rec.-lor Catecolamine Ef. Bowditch ph O2/ ATP Contractilitate Frank-Starling Efect Anrep VB FC SN. Simp. SN. Parasimp. Ca Temp. Corp. Hormoni tiroidieni Postsarcină P transmurală P intratoracică RVS RVP Impedanţa vasculară
4 Frecvenţa cardiacă SN simpatic Catecolamine SN parasimpatic Rec. adrenergici β1 Rec. colinergici M2 Reflexul Bainbridge dilatare atrială (întoarcerea venoasă) stimularea nodului SA Hormonii tiroidieni Ca Sex, vârstă Condiţia fizică Temperatura corporeală
5 Frecvenţa cardiacă Bradiaritmii < 50/ min VED Depinde de VB (ex. sportivi) Tahiaritmii > 150/ min VED Ischemie mioc. Umplere ventr.
6 Frecvenţa cardiacă Efectul Bowditch / efectul Treppe FC contractilitatea miocardică activitatea canalelor de Ca tip L Ca citosolic Antiportul 3Na + /Ca ++ Ca intracelular devine ineficient Ca citosolic inotropismul Dacă FC > 150/ min Ischemie mioc. Umplere ventr. Contractilitatea miocardică VB
7 Volumul bătaie = Volumul ejectat într-o contracţie VB = VED VES _ Dependent de: Presarcină Postsarcină Contractilitatea miocardică
8 Presarcina = sarcina care tensionează (întinde) miocardul în repaus la o nouă dimensiune = V (sau P) ventriculului la sfârşitul diastolei VED (PED ~ PA)
9 Presarcina Depinde de: Umplerea ventriculară Întoarcerea venoasă status volemic, P intratoracică, P intrapericardică, poziţia corpului, tonusul venos, pompa musculară Contracţia atrială % Sincronicitate A-V Complianţa ventriculară - VED / PED HVS, ischemie mioc., P intratoracice mari compl. ventr. PED gradientul de P umplerea card. VED DC Postsarcina VED ( VES + V din întoarcerea venoasă)
10 Presarcina Legea Frank -Starling: Contractilitatea depinde de lungimea fibrei musculare creşte sensibilitatea Troponinei la la Ca
11 Presarcina
12 Postsarcina = forţa care se opune contracţei ventriculare = tensiunea dezvoltată transmural (în peretele ventricular) în timpul sistolei Postsarcina σ = P. r/2h (Laplace) Tensiunea transmurală Presiunea sistolică Presiunea Impedanţa aortei intratoracică Complianţa arterială Rezistenţa arterială Raza ventriculară Volumul telediastolic (presarcina)
13 Depinde de: Postsarcina Impedanţa vasculară Complianţa R vasculare RVS = (TAm PAD)/ DC RVP = (TAP PAS)/ DC Rec. β 2 Rec. α 1 Catecolamine, vasopresina,..., NO P intratoracică + P transmurală facilitează golirea VS pao 2, paco 2 ph, ac. lactic Temperatura
14 Postsarcina
15 Postsarcina Efectul Anrep = Autoreglare intrinsecă a miocardului TA VES + VB DC Efectul Anrep - postsarcina contractilitatea Postsarcină travaliul cardiac necesarul de O 2
16 Relaţia dintre presarcină, postsarcină şi VB/DC Curbele de presiune-volum A= deschiderea mitralei AB umplerea ventriculară BC contracţia izovolumetrică (AO şi VM închise) B = VED = presarcina C = deschiderea AO CD ejecţia D = închiderea AO DA relaxarea izovolumetrică
17 Contractilitatea = velocitatea scurtării fibrei musculare la o presarcină şi postsarcină constante Depinde de: Interacţiunea dintre proteinele contractile Nivelul de Ca intracelular Oxigenare adecvată/ ATP ph Droguri inotrop +, - Calitatea receptorilor SN simpatic SN parasimpatic Catecolamine Presarcina Postsarcina Frecvenţa cardiacă
18 Contractilitatea
19 Contractilitatea
20 Contractilitatea
21 Controlul funcţiei cardiace Reglare neuronală Rec. Adrenergici: β1, α1, M Reglare hormonală Hormonii tiroidieni Angiotensina I şi II inotrop+, cronotrop + Peptida natriuretică stimulează guanilciclaza şi cgmp Aldosteron - reabsorbţia de Na şi apă, produce fibroză ventriculară Adrenomedullin cronotrop +, producţia NO
22 Controlul funcţiei cardiace debitul cardiac (CO) activare neuro-umorală sistemul simpato-adrenergic sistemul renină-angiotensină-aldosteron receptorii β receptorii α reabsorbţie de Na retenţie de apă contractilitatea tahicardie postsarcina presarcina densitatea rec. β necesarul de O 2 oferta de O 2 vasoconstricţie CO CO edem interstiţial ischemie miocardică PAP perfuzia tisulară PaO 2 acidoză acidoză contractilitatea miocardică
23 Bibliografie 1. Kaplan JA. Kaplan s cardiac anesthesia. 5 th ed. Cardiac physiology.. 2. Mohrman DE, Heller LJ. Lange cardiovascular physiology The heart pump. 3. Guyton and Hall. Textbook of Medical Physiology. 11 th edition. Heart muscle; the Heart as a pump and function of the Heart valves. 4. Ganong WF. 22 nd edition. The heart as a pump. 5. Miller RD. Miller s Anesthesia. 7 th edition. Cardiac physiology. 6. Vincent JL, Understanding cardiac output, Crit Care, Braunwald s Heart Disease, 7 th edition
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