Determinants of Cardiac Output

and Principles of Oxygen

Delivery
Scott V Perryman, MD PGY-III
• Principle of Continuity:

• Conservation of mass in a closed hydraulic system

• Blood is an incompressible fluid
• Vascular system is a closed hydraulic loop
• Vol ejected from left heart = vol received in R heart
 Preload
• Preload: load imposed on a muscle before
the onset of contraction

• Muscle stretches to new length

• Stretch in cardiac muscle determined by

end diastolic volume
Preload
 Preload
• At bedside, use EDP as surrogate for
ventricular preload

– i.e. assume EDV = EDP

 Preload
• How can we measure EDP?

Pulmonary Capillary Wedge Pressure

 PCWP
• How does wedge pressure work?

– A balloon catheter is advanced into PA

– Balloon at the tip is inflated
– Creates static column of blood between
catheter tip and left atrium
– Thus, pressure at tip = pressure in LA
 PCWP
• Only valid in Zone 3 of lung where:

– Pc > PA

• Catheter tip should be above left atrium

• Not usually a problem since most flow in Zone 3
• Can check with lateral x-ray
• Will get high respiratory variation if in Zone 1 or 2
 Preload
• Ventricular function is mostly determined
by the diastolic volume

• Relationship between EDV/EDP and

stroke volume illustrated by ventricular
function curves
 Ventricular Compliance
• Cardiac muscle stretch determined by EDV

• Also determined by the wall compliance.

• EDP may overestimate the actual EDV or true

preload
Cardiac Output and EDV
 Effect of Heart Rate

• With increased heart rate, we get

increased C.O….to a point.

• Increased HR also decreases filling time

 Contractility
• The ability of the cardiac muscle to
contract (i.e. the contractile state)

• Reflected in ventricular function curves

 Afterload
• Afterload: Load imposed on a muscle at the
onset of contraction

• Wall tension in ventricles during systole

• Determined by several forces

– Pleural Pressure
– Vascular compliance
– Vascular resistance
 Pleural Pressure
• Pleural pressures are transmitted across
the outer surface of the heart

– Negative pressure increases wall tension.

Increases afterload
– Positive pressure Decreases wall tension.
Decreases afterload
 Impedence
• Impedence = total force opposing flow

• Made up of compliance and resistance

• Compliance measurement is impractical in

the ICU

• Rely on resistance
 Vascular Resistance
• Equations stem from Ohm’s law: V=IR

Voltage represented by change in pressure

Intensity is the cardiac output

• SVR = (MABP – CVP)/CO

• PVR = (MPAP – LAP)/CO

 Oxygen Transport
• Whole blood oxygen content based on:

• hemoglobin content and,

• dissolved O2

Described by the equation:

CaO2 = (1.34 x Hb x SaO2) + (0.003 x PaO2)

 Oxygen Content
• Assuming 15 g/100ml Hb concentration
• O2 sat of 99%

Hb O2 = 1.34 x 15 x 0.99 = 19.9 ml/dL

For a PaO2 of 100

Dissolved O2 = 0.003 x 100 = 0.3 ml/dL

 Oxygen Content
• Thus, most of blood O2 content is
contained in the Hb

• PO2 is only important if there is an

accompanying change in O2 sat.

• Therefore O2 sat more reliable than PO2

for assessment of arterial oxygenation
 Oxygen Delivery

• O2 delivery = DO2 = CO x CaO2

• Usually = 520-570 ml/min/m2

 Oxygen Uptake
• A function of:

– Cardiac output

– Difference in oxygen content b/w arterial and

venous blood

VO2 = CO x 1.34 x Hb (SaO2 – SvO2) 10

 Oxygen Extraction Ratio
• VO2/DO2 x 100

• Ratio of oxygen uptake to delivery

• Usually 20-30%

• Uptake is kept constant by increasing

extraction when delivery drops.
 Critical Oxygen Delivery
• Maximal extraction ~ 0.5-0.6

• Once this is reached a decrease in delivery =

decrease in uptake

• Known as ‘critical oxygen delivery’

• O2 uptake and aerobic energy production is now

supply dependent = dysoxia
 Tissue Oxygenation
• In order for tissues to engage in aerobic
metabolism they need oxygen.

• Allows conversion of glucose to ATP

• Get 36 moles ATP per mole glucose

 Tissue Oxygenation

• If not enough oxygen, have anaerobic

metabolism

• Get 2 moles ATP per mole glucose and

production of lactate

• Can follow VO2 or lactate levels