• Tension (stretching) of the left ventricle after diastole
• Equivalent to Left Ventricle End Diastole Volume (LVEDV)
• Depends on venous return to the heart

• Resistance that the left ventricle must contract against to eject blood into the aorta
• Determined by resistance in vasculature
• Estimated by systemic vascular resistance (SVR)

• Vital signs (BP, HR, RR, temp)
• Pulse Oximetry (arterial O2 saturation - provides info regarding delivery of O2 to tissues)
• Transthoracic Echocardiography (functional status of the heart and heart valves - estimates ejection fraction)

• Arterial Line

Measures BP through a catheter

Meds cannot be administered through this line

• Central Venous Catheter 

Measures central venous pressure (CVP)

Meds can be delivered through this line

• Pulmonary Artery Catheter

AKA Swanz-Ganz catheter -- balloon flotation catheter inserted into pulomary artery

Allows assessment of right and left intracardiac pressure, CO, and provides IV access to draw mixed venous blood samples

Useful in diagnosing type of shock

• Transesophageal Echocardiography

Functional status of the heart and heart valves

Estimates Ejection Fraction and can determine mitral/tricuspid valve regurgitation

Helpful for technically difficult TTEs and for more accurate view of valves

• Equivalent to right atrial pressure
• Indicates the volume status of the right ventricle (right ventricular end diastolic pressure)
• CVP can be inaccurate (falsely elevated) in patients:

W/ pulmonary or cardiac disease

On mechanical ventilation

• Pulmonary Artery Systolic Pressure

Press. measured when pulmonary valve opens and blood pumps from the right ventricle into the pulmonary artery

• Pulmonary Artery Diastolic Pressure

Press. measured after pulmonary valve closes and blood travels from pulmonary artery into pulmonary capillaries

Elevation indicates pulmonary hypertension and/or pulmonary vascular resistance

• PCWP equilibrates with distal pressure on left side
• PCWP = Left Ventricular End Diastolic Pressure = Left Ventricular End Diastolic Volume
• PCWP estimates Preload

• Conditions that elevate PCWP:

Mitral stenosis

Pulmonary ven-occlusive disease

High levels of positive end-expiratory pressure w/ mechanical ventilation

• Indicates tissue perfusion and can be used to calculate O2 consumption
• Normal value ~ 70%
• Levels > 75-80% can indicate hyperdynamic state (sepsis, hyperthyroidism, alcohol withdrawal)
• Levels < 65% can indicate poor cardiac output states (cardiogenic shock)

• SVR = change in pressure/CO
• Estimates AFTERLOAD
• Increased SVR = Vasoconstriction
• Decreased SVR = Vasodilation

• Vasoconstriction of arteries and veins
• Increase SVR
• Increase MAP

• Increase contractility (inotropy)
• Tachycardia
• Increase CO
• Increase HR

• Vasodilation of arteries and veins
• Bronchodilation
• Decrease SVR

• Vasodilation
• Increase kidney perfusion
• Increase urine output?

• Vasoconstriction
• Increase SVR
• Increase urine output

• Dopamine
• Norepinephrine
• Epinephrine
• Phenylephrine
• Vasopressin

• Dobutamine
• Milrinone

MOA: stimulates DA, beta, and alpha receptors

As you increase the dose, DA -> Beta -> Alpha

Primary Uses:

1. Septic Shock (first line)
2. Cardiogenic Shock (usually with Dobutamine)
3. Hypotension refractory to fluids

MOA: Potent Alpha1 agonist and some Beta1 activity

Alpha:Beta --> 2-3:1

Primary Uses:

1. Septic Shock (first-line)

MOA: Mixed alpha and beta-agonist (1:1)

Primary Uses:

1. Refractory hypotension (LAST LINE)
2. Anaphylaxis
3. Cardiac arrest

MOA: Pure alpha agonist (No Beta)

Primary Uses:

1. Hypotension in pts w/ myocardial hypoxia
2. Refractory septic shock after NE or DA (2nd or 3rd line)
3. Quickly increases MAP (neurological pts needing increase in cerebral perfusion pressure)

MOA: Stimulates various subtypes of vasopressin receptors

V1 - arterial vasoconstriction

V2 - ADH (in shock - inc. urine output)

V3 - increase ACTH and cortisol production

Primary Uses:

1. Adjunct to other vasopressors for septic shock
2. Cardiac arrest

MOA: Pure Beta-agonist

Primary Uses:

1. Cardiogenic shock
2. Acute decompensated HF (short term use)
3. Septic shock if pt has poor ejection fraction

MOA: PDEI - vasodilation, increases contractility of heart

Primary Uses:

1. Cardiogenic shock (use w/ caution)
2. Acute decompensated HF
3. May be preferred over dobutamine if patient recently on Beta-blocker