Cardiovascular Response to Anemia?12daysinmarch.com/wp-content/uploads/2017/02/the-Red-Cell...SV...
Transcript of Cardiovascular Response to Anemia?12daysinmarch.com/wp-content/uploads/2017/02/the-Red-Cell...SV...
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Cardiovascular Response to Anemia?
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Cardiovascular Response to Hypoxia?
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Cardiovascular Response to Anemia? Cardiovascular Response to Hypoxia?
Anemia = Low CaO2 = Tissue Hypoxia
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SV
Cardiovascular Response to Anemia?
If the purpose of RBCs are to deliver
oxygen, how will oxygen-deprived tissues respond?
Vasodilate!!!
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SV Cardiovascular Response to Anemia?
Vasodilate!!!
CO = HR x SV
If you vasodilate, what happens to afterload?
If afterload decreases, what happens to SV?
If SV increases, what happens to CO?
If SV increases, what happens to pulse pressure?
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SV Cardiovascular Response to Anemia?
Vasodilate!!!
CO = HR x SV
If you vasodilate, what happens to afterload?
If afterload decreases, what happens to SV?
If SV increases, what happens to CO?
If SV increases, what happens to pulse pressure?
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Low oxygen delivery to tissue/periphery:
Vasodilation Afterload SV due to Afterload (and blood viscosity)
CO due to SV (and HR via SNS) Pulse Pressure : SV x Compliance (aortic)
SV
Cardiac Response to Anemia
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Patient with Hgb 10 (12-15) and HCT of 30% (40-45)
A.
B.
C.
PaO2 SaO2 CaO2
CV Response to O2 Content: CO, SV, PP (pulse pressure)
FYI…example of ‘hi output failure’
SV, CO, PP
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Q. Stimulus to EPO: GFR or Anemia?
Hello Kidneys!
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Erythropoietin production (interstitial cells) driven by:
OXYGEN CONTENT
O2
(Hb 9 x 1.34) x 95-100% SaO2 + 0.3 = 12 ml O2/dl
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Erythropoietin production (interstitial cells) driven by:
OXYGEN CONTENT
O2
(Hb 9 x 1.34) x 95-100% SaO2 + 0.3 = 12 ml O2/dl
HIF
HIF
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Q. Stimulus to EPO: GFR or Anemia?
Yes, oxygen content drives EPO, not
GFR (they are dissociated)
This concept also explains the physiologic erythrocytosis seen in patients with chronic lung disease.
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Covered Material
• Measures of Oxygen Transport – PaO2 (mm Hg)
– SaO2 (%)
– CaO2 (ml O2/dL)
• Reviewed how anemia effects those measures
• Reviewed cardiovascular response to anemia
• Reviewed renal/erythropoietin response to CaO2
• Let’s review how abnormal oxygen binding (CO) and abnormal iron (Fe+3) impacts these measures.
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O2
O2
O2 O2
Carbon Monoxide (CarboxyHgb) CO
CO CO
CO
PaO2 unchanged (abundant amount of oxygen in atmosphere)
CO CO CO CO CO
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O2
O2
O2
O2
O2
O2
CO CO
CO CO
CO CO
Oxygen Saturation (SaO2) is
CO >>> O2 Binding Affinity
O2
O2
O2 has been displaced
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O2
O2
O2
O2
O2
O2
CO CO
CO CO
CO CO
Oxygen Saturation (SaO2) is
CO >>> O2 Binding Affinity
Normal
CO exposure
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O2
O2
O2 O2
Carbon Monoxide (CarboxyHgb) CO
CO CO
CO
Oxygen Content: [Hgb x 1.34 (no change)] x SaO2 + 0.3
CO CO CO CO CO
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Carbon Monoxide 200x affinity for Hgb
O2 dissociation curve left
History: Exposure PE: CNS depression
Skin color: cyanotic or cherry red???
Clinical Dx: CarboxyHgb level USMLE Dx: Oxygen Content
Rx: Oxygen
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Carbon Monoxide 200x affinity for Hgb
O2 dissociation curve left
History: Exposure PE: CNS depression
Skin color: cyanotic or cherry red???
Clinical Dx: CarboxyHgb level USMLE Dx: Oxygen Content
Rx: Oxygen
PaO2: no change SaO2: decreased CaO2: decreased
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Covered
• Measures of Oxygen Transport – PaO2
– SaO2
– CaO2
• Reviewed how anemia effects those measures
• Reviewed cardiovascular response to anemia
• Reviewed renal/erythropoietin response to CaO2
• Let’s review how abnormal oxygen binding (CO) and abnormal iron (Fe+3) impacts these measures.
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O2 O2
O2
O2
O2 O2
O2
O2
O2 O2
O2
O2
Oxygen Saturation (SaO2)
Oxygen freely diffuses into RBCs SaO2 measures Hgb binding sites bound to oxygen
FE+2 FE+2
FE+2
Fe+2
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O2 O2
O2
O2
O2 O2
O2
O2
O2 O2
O2
O2
Oxygen Saturation (SaO2)
Oxygen freely diffuses into RBCs SaO2 measures Hgb binding sites bound to oxygen
FE+2 FE+2
FE+2
Fe+2 Fe+3
Methemoglobinemia
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O2
O2
O2
O2 O2
O2
O2
O2
O2
O2
O2
FE+3
FE+3
FE+3
Methemoglobinemia Ferrous (Fe+2) Ferric (Fe+3)
Drugs
O2
Oxygen Content?
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O2
O2
O2
O2 O2
O2
O2
O2
O2
O2
O2
Oxygen Saturation (SaO2)
FE+3
FE+3
FE+3
Methemoglobinemia Ferrous (Fe+2) Ferric (Fe+3)
Drugs
O2
No Change in PaO2
Oxygen Content?
No Change in Hgb: [Hgb x 1.34]
Oxygen Content
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Dapsone Antifolate (PABA antagonist)
Indication: Leprosy, PCP ppx, DH AE (>10%): MetHgb, hemolysis (G6PD)
Leprosy
Bug: mycobacterium leprae Painless, nonhealing skin lesions
Rx: Dapsone and Rifampin
Q. Patient is given a drug for nonhealing skin lesions and…
PABA
DHF
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Methemoglobinemia Fe+3 is unable to bind oxygen Remaining Fe+2 has increased affinity (shift curve left)
History: Offending drug
(esp dapsone/sulfa, nitrates, topical anesthetics)
PE: cyanosis/’dusky’ ‘chocolate brown blood’ (in OR)
Data: (in box) Rx: Methylene blue (electron acceptor)
Special Notes:
Cyanide poisoning and nitroprusside
Rx: Methylene blue (electron acceptor)
PaO2 unchanged SaO2 Oxygen Content MetHgb level
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Methemoglobinemia Fe+3 is unable to bind oxygen Remaining Fe+2 has increased affinity (shift curve left)
History: Offending drug
(esp dapsone/sulfa, nitrates, topical anesthetics)
PE: cyanosis/’dusky’ ‘chocolate brown blood’ (in OR)
Data: (in box) Rx: Methylene blue (electron acceptor)
Special Notes:
Cyanide poisoning and nitroprusside
Rx: Methylene blue (electron acceptor)
PaO2 unchanged SaO2 Oxygen Content MetHgb level
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Material Covered
• Measures of Oxygen Transport – PaO2
– SaO2
– CaO2
• Reviewed how anemia effects those measures
• Reviewed cardiovascular response to anemia
• Reviewed renal/erythropoietin response to CaO2
• Let’s review how abnormal oxygen binding (CO) and abnormal iron (Fe+3) impacts these measures.
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Material Covered
• Measures of Oxygen Transport – PaO2
– SaO2
– CaO2
• Reviewed how anemia effects those measures
• Reviewed cardiovascular response to anemia
• Reviewed renal/erythropoietin response to CaO2
• Let’s review how abnormal oxygen binding (CO) and abnormal iron (Fe+3) impacts these measures.
Don’t be stubborn!