Hemodynamic Disorders, Thrombosis & Shock

1. Hemodynamic Disorders, Thrombosis & Shock Edema Hyperemia and Congestion Hemorrhage Hemostasis & Thrombosis Embolism Infarction Shock • Edema

2. EDEMA Fluid extravasations and accumulation in the interstitial spaces

3. EDEMA Increased fluid in theinterstitial tissue spaces • Fluid may also accumulate in body cavities: • Hydrothorax • Hydropericardium • Hydroperitoneum is also called Ascites • Massive generalized edema is called Anasarca

4. Fluid Homeostasis • Homeostasis is maintained by the opposing effects of: • Vascular Hydrostatic Pressure • and • Plasma Colloid Osmotic Pressure Lymphatics

5. Edema Fluid = TRANSUDATE • A transudate is protein-poor (specific gravity <1.012) • An exudate is protein-rich (specific gravity >1.020) = (inflammatory edema)

6. Pathophysiologic Categories of Edema I. Increased Hydrostatic Pressure II. Reduced Plasma Oncotic Pressure III. Inflammation IV. Others I. Increased Hydrostatic Pressure

7. Pathophysiologic Categories of Edema Increased Hydrostatic Pressure Due to impaired venous return Localized: Venous Thrombosis Generalized: Congestive Heart Failure Due o increased arteriolar dilatation

8. Increased Hydrostatic Pressure Congestive Heart Failure: “Generalized increase in venous pressure, with resultant SYSTEMIC EDEMA occurs MOST COMMONLY in CONGESTIVE HEART FAILURE” {*** Thus, Congestive Heart Failure is the most common cause of EDEMA due to Increased Hydrostatic Pressure}

9. Congestive Heart Failure Overall, there are TWO main effects... 1.Increased Central Venous Pressure 2. Decreased Renal Perfusion

10. Increased Hydrostatic Pressure: Congestive Heart Failure Mechanism: • The Pump is FAILING!!!  Cardiac output • Blood backs up, first into the lungs  then into the venous circulation  increasing Central Venous Pressure (CVP)  increased capillary pressure (Hydrostatic Pressure) • Leading to Edema

11. Congestive Heart Failure: & Decreased Renal Perfusion • Congestive heart failure  Decreased Cardiac Output Decreased ARTERIAL blood volume  “Less arterial blood…Less renal perfusion... The Kidney doesn’t see enough blood coming through …….

12. Congestive Heart Failure: & Decreased Renal Perfusion Decreased Renal Perfusion activates the Renal Defense Mechanisms: • Renin-Angiotensin-Aldosterone axis  Na & H2O retention • Renal Vasoconstriction • Increased Renal Anti-diuretic Hormone (ADH)

13. Renin ADH Central Venous Pressure Renal Perfusion Renal Vasoconstriction Congestive Heart Failure - Summary

14. Pathophysiologic Categories of Edema I. Increased Hydrostatic Pressure II. Reduced Plasma Oncotic Pressure III. Inflammation IV. Other II. Reduced Plasma Oncotic Pressure

15. Reduced Plasma Osmotic Pressure • “…Albumin: is the serum protein MOST responsible for the maintenance of colloid osmotic pressure.” • A decrease in osmotic pressure can result from: •  Protein Loss or •  Protein Synthesis

16. Reduced Plasma Osmotic Pressure Increased albumin loss: Nephrotic Syndrome Increased permeability of the glomerular capillary wall  loss of protein Reduced albumin synthesis Cirrhosis Protein malnutrition

17. Pathophysiologic Categories of Edema I. Increased Hydrostatic Pressure II. Reduced Plasma Oncotic Pressure III. Inflammation IV. Other III. Inflammation

18. Pathophysiologic Categories of Edema I. Increased Hydrostatic Pressure II. Reduced Plasma Oncotic Pressure III. Inflammation IV. Others IV. Others: - Lymphatic Obstruction - Sodium & water retention

19. Lymphatic Obstruction • Impaired lymphatic drainage with resultant lymphedema • usually localized • usually due to: • INFLAMMATION or • NEOPLASTIC OBSTRUCTION

20. Lymphatic Obstruction • Filariasis – • A parasitic infection affecting inguinal lymphatics resulting in elephantiasis

21. Lymphatic Obstruction Neoplastic • Resection and/or radiation to axillary lymphatics in breast cancer patients can lead to -- arm edema • Carcinoma of breast with obstruction of superficial lymphatics can lead to edema of breast skin -- --with an unusual appearance: “peau d’orange” (orange peel)

22. EDEMA - Summary • HEART • LIVER • KIDNEY INCREASED HYDROSTATIC PRESSURE Congestive Heart Failure Ascites Venous Obstruction DECREASED ONCOTIC PRESSURE Nephrotic Syndrome Cirrhosis Protein Malnutrition LYMPHATIC OBSTRUCTION Inflammatory Neoplastic INCREASED PERMEABILITY Inflammation

23. GENERALIZED EDEMA • HEART • LIVER • KIDNEY

24. Dependent Edema is a prominent feature of Congestive Heart Failure Facial Edema is often the initial manifestation of Nephrotic Syndrome Subcutaneous Edema Edema of the subcutaneous tissue is most easily detected Grossly (not microscopically) Push your finger into it and a depression remains EdemaMorphology

25. Edema Clinical Correlation: Subcutaneous Edema • Annoying but Points to Underlying Disease • However, it can impair wound healing or clearance of Infection

26. EdemaMorphology Pulmonary Edema is most frequently seen in Congestive Heart Failure May also be present in renal failure, adult respiratory distress syndrome (ARDS), pulmonary infections and hypersensitivity reactions

27. Pulmonary Edema Gross: • The Lungs are typically 2-3 times the normal weight • Cross sectioning causes an outpouring of frothy, sometimes blood-tinged fluid

28. Normal Pulmonary Edema

29. Edema Clinical Correlation: Pulmonary Edema • May cause death by interfering with Oxygen and Carbon Dioxide exchange • Creates a favorable environment for infection • THINK it resembles “Culture Media”!!!

30. Edema of the Brain • Trauma, Abscess, Neoplasm, Infection (Encephalitis due to say… West Nile Virus), etc

31. Clinical Correlation: Edema of the Brain • The big problem is: There is no place for the fluid to go! • Herniation into the foramen magnum will kill