Cardiovascular Disturbances

(Perspective Guyton)
in Post-Cardiac Surgery

Arif Mansjoer

Cardiac ICU, Unit Pelayanan Jantung Terpadu RSCM

Divisi Kardiologi, Departemen Ilmu Penyakit Dalam FKUI/RSCM
Arif Mansjoer
• Pekerjaan
• Staf Cardiac ICU PJT RSCM (2008 - …)
• Staf Div Kardiologi Dep IPD FKUI/RSCM (2008 - …)
• Staf ICU RS Jantung Jakarta (2013 - …)

• Pendidikan
• Spesialis Penyakit Dalam, FKUI 2005
• Konsultan Kardiovaskular, FKUI 2017
• Konsultan Intensive Care, FKUI 2008
• Magister Epidemiologi, FKM UI 2004
Outline

• Cardiovascular physiology

• Cardiovascular disturbances

• Post-cardiac surgery circulatory shock

Cardiovascular Physiology
Cardiovascular Physiology
• Oxygen delivery
• To meet aerobic metabolism
• Component:
• Cardiac output
• Hemoglobin
• O2 saturation
Cardiovascular Physiology
• Blood pressure (pressure gradient)
• To meet flow
• Component
• Cardiac output
• Systemic vascular resistance
Cardiovascular Physiology
• Cardiac output
• Heart rate
• Stroke volume
• Preload
• Contractility
• Afterload
Cardiovascular Physiology
• Cardiac output
• ~ pressure gradient between MAP and CVP
• ~ 1 / systemic vascular resistance
• CO = (MAP-CVP) / SVR
Cardiovascular Physiology
• Cardiac output
• Vascular
• Arteries
• Capillaries
• Venous
• Stress volume → mean systemic filling pressure
(MSFP)
• Unstress volume
Cardiovascular Physiology
• Cardiac output
• Vascular
• Venous return
• ~ pressure gradient between MCFP and RAP
• ~ 1 / venous resistance
• VR = (MCFP – RAP) / Rv
Cardiovascular Physiology
• Cardiac output
• Vascular
• Venous return
• ~ pressure gradient between MCFP and RAP
• ~ 1 / venous resistance
• VR = (MCFP – RAP) / Rv
• Cardiac output = venous return
• Venous return = (P msf – P ra) / Rv

P msf = (Vt – Vo) / C Rv = 8 . ⴄ . l / π.r4

Cardiovascular Physiology
• Cardiac output and RAP curve
Cardiovascular Physiology
• Venous return and RAP curve
Cardiovascular Physiology
• Cardiac output/venous return dan RAP curve
Cardiovascular Disturbance
• Cardiovascular patophysiology
• Hypotension (low blood pressure)
• Low cardiac output
• Hipovolemic
• Poor contractility
• Low systemic vascular resistance
• Vasodilatation
Cardiovascular Disturbance
• Preload : Hypovolemic shock
• Afterload : Distributive shock
• Contractility : Cardiogenic shock
• Flow : Obstructive shock
Post-cardiac surgery
circulatory shock
Cardiac surgery
• Preoperative: patient risk, cardiac problem
• Intraoperative: procedure risk
• Anaesthesia
• Surgical
• Cardiopulmonary bypass machine
• Postoperative:
• Stabilisation
• Support
• Monitoring
• Weaning
Low blood pressure
• Artifact of measurement
• Hypovolemic shock
• Distributive shock
• Cardiogenic shock
• Obstructive shock
Artifact of measurement
Arterial blood pressure measurement is
inaccurate:
• Diagnostic strategy: Compare with non-invasive
measurement and physical examination
• Management:
• Re-zero and recalibrate the arterial line
• Resite arterial line or change the transducer
Hypovolemic shock
• Blood loss post-operative
• Massive diuresis
Hypovolemic shock
 Cardiac output →
SVR

Pra

Stressed volume
Venous return 
Rv
Unstressed volume
 Cardiac output →
SVR

Pra

Venous return  Stressed volume

Rv
Unstressed volume

Blood loss
Massive diuresis
 Cardiac output →
SVR

Pra

Venous return  Stressed volume

Rv
Unstressed volume

Blood loss
Vs 
Massive diuresis
 Cardiac output →
SVR

Pra

Venous return  Stressed volume

Rv
Unstressed volume

Blood loss
Pmsf  Vs 
Massive diuresis
 Cardiac output →
SVR

Pra

Venous return  Stressed volume

Rv
Unstressed volume

Blood loss
VR  Pmsf  Vs 
Massive diuresis
CO 

Cardiac output →
SVR

Pra

Venous return  Stressed volume

Rv
Unstressed volume

Blood loss
VR  Pmsf  Vs 
Massive diuresis
CO  BP 

Cardiac output →
SVR

Pra

Venous return  Stressed volume

Rv
Unstressed volume

Blood loss
VR  Pmsf  Vs 
Massive diuresis
CO  BP 

Cardiac output →
SVR

Pra

Venous return  Stressed volume

Rv
Unstressed volume

Blood loss
VR  Pmsf  Vs 
Massive diuresis
Distributive shock
• SIRS post cardiopulmonary bypass machine
• Transfusion reaction
• Drug reaction
• Anaphylaxis
Distributive shock
 Cardiac output →
SVR

Pra

Stressed volume
Venous return 
Rv
Unstressed volume
 Cardiac output →
SVR

Pra

Stressed volume
Venous return 
Rv
Unstressed volume

Vasodilatation
 Cardiac output →
SVR

Pra

Venous return  Stressed volume

Rv
Unstressed volume

Vo  Vs Vasodilatation
 Cardiac output →
SVR

Pra

Venous return  Stressed volume

Rv
Unstressed volume

Pmsf  Vo  Vs Vasodilatation
 Cardiac output →
SVR

Pra

Venous return  Stressed volume

Rv
Unstressed volume

VR  Pmsf  Vo  Vs Vasodilatation
CO 

Cardiac output →
SVR

Pra

Venous return  Stressed volume

Rv
Unstressed volume

VR  Pmsf  Vo  Vs Vasodilatation
CO  BP 

Cardiac output →
SVR

Pra

Venous return  Stressed volume

Rv
Unstressed volume

VR  Pmsf  Vo  Vs Vasodilatation
CO  BP 

Cardiac output →
SVR

Pra

Venous return  Stressed volume

Rv
Unstressed volume

VR  Pmsf  Vo  Vs Vasodilatation
Cardiogenic shock
• Post-operative stunning
• Graft failure, residual regurgitation
• Myocardial infarction
Cardiogenic shock
 Cardiac output →
SVR

Pra

Stressed volume
Venous return 
Rv
Unstressed volume
 Cardiac output →
SVR

Pra

Stressed volume
Venous return 
Rv
Unstressed volume

Poor Contractility
 Cardiac output →
SVR

Pra

Stressed volume
Venous return 
Rv
Unstressed volume

Congestion Poor Contractility

 Cardiac output →
SVR

Pra

Stressed volume
Venous return 
Rv
Unstressed volume

Pra  Congestion Poor Contractility

 Cardiac output →
SVR

Pra

Stressed volume
Venous return 
Rv
Unstressed volume

VR  Pra  Congestion Poor Contractility

CO 

Cardiac output →
SVR

Pra

Stressed volume
Venous return 
Rv
Unstressed volume

VR  Pra  Congestion Poor Contractility

CO  BP 

Cardiac output →
SVR

Pra

Stressed volume
Venous return 
Rv
Unstressed volume

VR  Pra  Congestion Poor Contractility

CO  BP 

Cardiac output →
SVR

Pra

Stressed volume
Venous return 
Rv
Unstressed volume

VR  Pra  Congestion Poor Contractility

Obstructive shock
• Cardiac tamponade
• Tension pneumothorax
• Pulmonary embolism
Obstructive shock
 Cardiac output →
SVR

Pra
Ppl

Stressed volume
Venous return 
Rv
Unstressed volume
 Cardiac output →
SVR

Pra
Ppl

Stressed volume
Venous return 
Rv
Unstressed volume

Tension pneumothorax
 Cardiac output →
SVR

Pra
Ppl

Stressed volume
Venous return 
Rv
Unstressed volume

Cardiac compliance
Tension pneumothorax
 Cardiac output →
SVR

Pra
Ppl

Stressed volume
Venous return 
Rv
Unstressed volume

Ppl Cardiac compliance

Tension pneumothorax
 Cardiac output →
SVR

Pra
Ppl

Stressed volume
Venous return 
Rv
Unstressed volume

Ppl Cardiac compliance

VR  Tension pneumothorax
 Cardiac output →
SVR

Pra
Ppl

Stressed volume
Venous return 
Rv
Unstressed volume

Ppl Cardiac compliance

VR  Tension pneumothorax
Lung collaps, hypoxia
 Cardiac output →
SVR

Pra
Ppl

Stressed volume
Venous return 
Rv
Unstressed volume

Ppl Cardiac compliance

VR  Tension pneumothorax
PVR Lung collaps, hypoxia
 Cardiac output →
SVR

Pra
Ppl

Stressed volume
Venous return 
Rv
Unstressed volume

Ppl Cardiac compliance

VR  Tension pneumothorax
Rv PVR Lung collaps, hypoxia
 Cardiac output →
SVR

Pra
Ppl

Stressed volume
Venous return 
Rv
Unstressed volume

Ppl Cardiac compliance

VR  Tension pneumothorax
Rv PVR Lung collaps, hypoxia
CO 

Cardiac output →
SVR

Pra
Ppl

Stressed volume
Venous return 
Rv
Unstressed volume

Ppl Cardiac compliance

VR  Tension pneumothorax
Rv PVR Lung collaps, hypoxia
CO  BP 

Cardiac output →
SVR

Pra
Ppl

Stressed volume
Venous return 
Rv
Unstressed volume

Ppl Cardiac compliance

VR  Tension pneumothorax
Rv PVR Lung collaps, hypoxia
CO  BP 

Cardiac output →
SVR

Pra
Ppl

Stressed volume
Venous return 
Rv
Unstressed volume

Ppl Cardiac compliance

VR  Tension pneumothorax
Rv PVR Lung collaps, hypoxia
Cardiac disturbances (perspective
Guyton) in post cardiac surgery patients
• Cardiac output is not just about “heart rate
and stroke volume”
• Cardiac output is determined by the
interaction of “cardiac function” and “return
function”
• In post-cardiac surgery, there are several
mechanism of shock which affect the venous
return then cardiac output
Terima kasih
Email: arif.mansjoer@gmail.com