Physiology of Venous Return Cardiac Output

Guyton Model

Arifin
 PENDAHULUAN
JANTUNG KIRI VS JANTUNG KANAN

PRELOAD

KONTRAKTILITAS

AFTERLOAD

Penyakit jantung iskemik Syok hipovolemik

Penyakit jantung kongestif Syok kardiogenik
Syok distributif
Syok obstruktif
INTENSIVIST
???
Funk, Duane J, Eric Jacobsohn. The Role of Venous Return in Critical Illness and
Shock—Part I: Physiology. Critical Care Medicine 2013
 PENDAHULUAN
Jantung hanya dapat memompa ke arteri dari apa yang jantung terima

INPUT OUTPUT
(VR) (CO)

Jantung kanan Stroke Volume

Sirkulasi perifer Heart rate

 KARAKTERISTIK SISTEM VENA
1
DISTENSIBILITAS

(penambahan volume pada

setiap peningkatan 1 mmHg Distensibilitas sistemik vena 8x dibanding arteri
tekanan)
Distensibilitas pulmonal vena 6x dibanding arteri

2
KOMPLIANS

(total darah yang dapat Komplians vena 24x dibanding arteri

disimpan dalam sirkulasi
untuk setiap peningkatan
tekanan 1 mmHg) Vena adalah penampung darah
IDEAL
Guyton, Arthur C, John E. Textbook of Medical Physiology. 11th ed. Vascular Distensibility and Functions of the
Arterial and Venous Systems. 2006.
FUNCTION OF THE VENOUS SYSTEM
Distribution Of Blood In The Various Components Of The
Circulatory System

64%
 FRANK-STARLING LAW OF THE HEART

“AN INCREASE IN THE VOLUME OF BLOOD FILLING THE HEART STRETCHES

THE VENTRICULAR WALL, CAUSING CARDIAC MUSCLE TO CONTRACT
MORE FORCEFULLY AND STROKE VOLUME TO INCREASE.”
 FRANK STARLING CURVE IN CRITICALLY
ILL FLUID MANAGEMENT
flat
CVP 8-12 mmHg
GEDVI >800 Preload-Independence =
Wedge pressure Artinya, setiap peningkatan preload pada
SVV/PPV area ini TIDAK akan meningkatkan stroke
PLR Will increase the stroke volume volume, bahkan dapat menurunkan stroke
FluidVolume
Stroke Responsive, SV >10% steep volume yg akan menyebabkan “low cardiac
output”

Preload-dependence =
Artinya, setiap peningkatan preload by volume
loading pada area ini akan meningkatkan stroke
volume, sehingga cardiac output akan meningkat

Every increasing preload by volume loading

Preload
 THE IMPACT OF STARLING’S PRELOAD
DEPENDENCY TO FLUID MANAGEMENT
PHYSIOLOGY OF VOLUME
FLUID BOLUS RESUSCITATTION IN CRITICALL ILL
OR FLUID
RESPONSIVENESS
Glycocalix damage - Increased
CYSTALLOID permeability/gap
INFUSION

Leakage


Interstitial
hypovolemia
INCREASE FILLING Fluid shift
Plasma

PRESSURE  ATRIAL
NATRIURETIC
PEPTIDE (ANP)
LAUNCHED Lymph

In critical illness 
Urine output leakage >> lymph flow
decrease  STILL
HYPOPERFUSION  tissue edema
 WHAT ABOUT SEPSIS
PROTOCOL?

CRITIQUES OF EGDT
(RIVERS STUDY)
 EGDT IN THE TREATMENT OF SEVERE SEPSIS
AND SEPTIC SHOCK

Aggressive fluid resuscitation

achieving CVP 8-12 mmHg
using crystalloid then colloid

Rivers. NEJM 2001

OVERLOAD
 EVIDENCE SUPPORTING THE DELETERIOUS
EFFECTS OF AGGRESSIVE FLUID
RESUSCITATION IN SEPSIS

Marik, Bellomo. A rational approach to fluid therapy in sepsis. Review article. British Journal of Anaesthesia, 2015
 WHAT DETERMINES CARDIAC
OUTPUT?

CARDIAC OUTPUT
VENOUS RETURN

THE HEART CANNOT PUT OUT MORE

THAN WHAT IT GETS BACK FROM THE
LARGE RESERVOIR OF VOLUME IN THE
SYSTEMIC CIRCULATION

Circulatory Physiology: Cardiac Output And Its Regulation. A.C. Guyton.W.B. Saunders
Co. Philadelphia 1963
 WHAT DETERMINES CARDIAC
OUTPUT?
CARDIAC OUTPUT

RETURN FUNCTION CARDIAC FUNCTION

STROKE VOLUME X HR
AFTERLOAD
CVP
CENTRAL VENOUS
PRESSURE 1 PRELOAD
CONTRACTILITY

RVR 3
RESISTANCE TO VENOUS RETURN
DIAMETER VEIN CAVA AND BLOOD
VISCOSITY
2
GRADIENT PRESSURE
MCFP-CVP

MCFP
MEAN SYSTEMIC FILLING PRESSURE
 STRESSED VOLUME (NON-SPLANCHNIC
CIRCULATION)

Circulatory Physiology: Cardiac Output And Its Regulation. A.C. Guyton.W.B. Saunders
Co. Philadelphia 1963
WHY VENOUS RETURN?
 VENOUS RETURN
• The quantity of blood which returns to the heart from peripheral
circulatory system
• Three principal factors that affect venous return to the heart from
the systemic circulation:
– Right atrial pressure (RAP = CVP), which exerts a backward force on the
veins to impede flow of blood from the veins into the right atrium.
– Degree of filling of the systemic circulation (measured by the Mean
Circulatory Filling Pressure = MCFP), which forces the systemic blood
toward the heart (this is the pressure measured everywhere in the systemic
circulation when all flow of blood is stopped).
– Resistance to blood flow (RVR) between the peripheral vessels and the
right atrium.

1. Guyton AC: Determination of cardiac output by equating venous return curves with cardiac response curves. Physiol Rev
1955; 35:123–129
2. Guyton AC, Lindsey AW, Kaufmann BN: Effect of mean circulatory filling pressure and other peripheral circulatory factors on
cardiac out- put. Am J Physiol 1955; 180:463–468
GUYTON’S VENOUS RETURN CURVE
Recently dead dog:
TRANSFUSION a pump replacing the heart
INCREASE MCFP & RA  pump  Aorta
RAP/CVP MCFP changed by increasing or
VENOUS RETURN BECOMES
decreasing the total quantity of
ZERO WHEN THE RIGHT blood
ATRIAL PRESSURE RISES TO
EQUAL THE MEAN SYSTEMIC
FILLING PRESSURE

DETERMINANTS OF VENOUS RETURN:

• Right arterial ressure (Pra)
• Mean circulatory filling pressure
(MCFP)
MCFP SHOULD BE HIGHER THAN
RAP/CVP  GRADIENT PRESSURE 8
mmHg

AC Guyton. Determination of cardiac output by equating venous return curves with cardiac
response curves physiol Rev 1955; 35: 123-139
GUYTON COMBINED VENOUS RETURN CURVE WITH
STARLING’S CARDIAC FUNCTION CURVE

WORKING
POINT
VENOUS RETURN AND CARDIAC
liters/m2/min
OUTPUT

0
RIGHT ARTERIAL PRESSURE
mmHg
APPLICATION OF THE HAGEN-POISEUILLE’S LAW
TO THE LEFT HEART OUTPUT

BP = CO x SVR
Q = FLUID FLOW
CO = MAP - CVP P1 = UPSTREAM PRESSURE
SVR P2 = DOWNSTREAM PRESSURE
R = RESISTANCE TO FLOW
APPLICATION OF THE HAGEN-POISEUILLE’S LAW
TO THE LEFT HEART OUTPUT

-
CO =
CVP MAP

DOWNSTREAM
PRESSURE

BP = CO x SVR
SVR
UPSTREAM
PRESSURE

1. Guyton AC: Determination of cardiac output by equating venous return curves with cardiac
response curves. Physiol Rev 1955; 35:123–129
2. Guyton AC, Lindsey AW, Kaufmann BN: Effect of mean circulatory filling pressure and other
peripheral circulatory factors on cardiac output. Am J Physiol 1955; 180:463–468
APPLICATION OF THE HAGEN-POISEUILLE’S LAW
TO THE VENOUS CIRCULATION

-
VR = CO
CO = VR =
CVP

DOWNSTREAM
RVR PRESSURE

The driving force for VENOUS RETURN

(VR) is the PRESSURE GRADIENT between
the peripheral veins (MCFP) and the right
MCFP UPSTREAM
atrium (PRA)
PRESSURE

1. Guyton AC: Determination of cardiac output by equating venous return curves with cardiac
response curves. Physiol Rev 1955; 35:123–129
2. Guyton AC, Lindsey AW, Kaufmann BN: Effect of mean circulatory filling pressure and other
peripheral circulatory factors on cardiac output. Am J Physiol 1955; 180:463–468
 KARAKTERISTIK SISTEM VENA
100 cc X-ratus cc

300 cc

X-ratus cc

PENAMPUNG DARAH

50-200 cc

Guyton, Arthur C, John E. Textbook of Medical Physiology.11th

ed. Vascular Distensibility and Functions of the Arterial and
Venous Systems. 2006
 KONSEP CURAH JANTUNG STARLING
1894 ALIRAN BALIK VENA FUNGSI JANTUNG

PRELOAD

KONTRAKTILITAS

AFTERLOAD

Bagaimana sirkulasi sistemik LAJU NADI

secara mekanik menentukan aliran
balik vena ??

Peters G, J. W.Mack and G.Lister. The importance of the peripheral circulation in critical illnesses. Intensive Care Med 2001
 KONSEP CURAH JANTUNG Guyton
1957 ALIRAN BALIK VENA FUNGSI JANTUNG

PRELOAD
CVP/Pra
TEKANAN VENA
SENTRAL 3 KONTRAKTILITAS

Rvr 2
RESISTENSI ALIRAN BALIK VENA AFTERLOAD
DIAMETER VENA CAVA DAN
VISKOSITAS DARAH

MCFP
TEKANAN PENGISIAN SISTEMK RATA RATA
 STRESSED VOLUME (SIRKULASI NON- 1 LAJU NADI
SPLANKNIK)

Peters G, J. W.Mack and G.Lister. The importance of the peripheral circulation in critical illnesses. Intensive Care Med 2001
 Aliran balik vena (VR)
Definisi : jumlah total dari seluruh aliran darah yang mengalir dari jaringan-
jaringan tubuh pada sirkulasi perifer

VS (Stressed Volume)
setiap volume darah yang dapat mengakibatkan
peningkatan tekanan intravaskular

MCFP VU (Unstressed Volume)

8-10mmHg
VS volume darah yang mengisi pembuluh darah namun tidak
menyebabkan peningkatan tekanan intravaskular
VU
MCFP (Tekanan Pengisian Sistemik Rata-rata)
Tekanan yang terbentuk di dalam kompartemen stressed
volume

- Peters G, J. W.Mack and G.Lister. The importance of the peripheral circulation in critical illnesses. Intensive Care Med 2001
- Magder S. Counter Point: the classical Guyton view that mean systemic pressure, right atrial pressure, and venous resistance
govern venous return is/is not correct. J Appl Physiol 2006
 FAKTOR YANG MEMPENGARUHI MCFP

MCFP
VS

VU

MCFP
VS MCFP VS
MCFP VS
VU VU
VU

DISTRIBUSI VU INFUS VOLUME

KOMPLIANS VENA VOLUME DARAH INTRAVASKULAR
Peters G, J. W.Mack and G.Lister. The importance of the peripheral circulation in critical illnesses. Intensive Care Med 2001
 FAKTOR YANG MEMPENGARUHI MCFP

Komplians turun
Tekanan

VU turun

Infus volume

MCFP

Unstressed volume Stressed volume

Volume

Peters G, J. W.Mack and G.Lister. The importance of the peripheral circulation in critical illnesses. Intensive Care Med 2001
 ALIRAN BALIK VENA (VR)
VR

PLATEAU

5
MCFP

0
-8 -4 0 4 8 Pra

Pompa jantung melemah  Pra   VR 

Aliran balik vena menjadi nol saat tekanan atrium kanan +7 mmHg

Plateau aliran balik vena : saat Pra -2 mmHg

Guyton, Arthur C, John E. Textbook of Medical Physiology. 11th ed. Cardiac Output, Venous Return and Their Circulation. 2006
 EFEK PERUBAHAN MCFP TERHADAP VR

VR

MCFP turun MCFP naik

0
-4 0 +4 +8 +12 Pra

Makin banyak sistem vena terisi darah maka makin mudah untuk darah dapat
mengalir masuk ke jantung, dan sebaliknya

Guyton, Arthur C, John E. Textbook of Medical Physiology. 11th ed. Cardiac Output, Venous Return and Their Circulation. 2006
 Resistensi Aliran Balik Vena (Rvr)
VR

15

10
Pra=MCFP
5

0
-4 0 +4 +8 +12 Pra

Peningkatan Tekanan vena < Rvr  jika Rvr   VR 

Penurunan resistensi ½ x  VR  2 X

Saat Pra = MCFP  berapapun resistensinya, VR tetap NOL

Guyton, Arthur C, John E. Textbook of Medical Physiology. 11th ed. Cardiac Output, Venous Return and Their Circulation. 2006
 KURVA GUYTON
VR/CO
(l/mnt)
5

3 B

2 A

1 C

Pra
-4 0 4 8 12 (mmHg)

Titik A : perpotongan CO-VR normal

Titik A ke B : transfusi cairan  MCFP   CO 

Titik A ke C : hipovolemik/hemorrhagik/sepsis  MCFP   CO 

William R.H. Clinical review: Guyton - the role of mean circulatory filling pressure and right atrial pressure in controlling cardiac
output.Critical Care 2010
 KURVA GUYTON
VR/CO
(l/mnt)
5

E
2 A
D
1 C

Pra
-4 0 4 8 12 (mmHg)

Titik A ke D : gagal jantung  kurva kontraktilitas , Pra   CO 

Titik D ke A : gagal jantung + inotropik  kontraktilitas   CO 

Titik D ke E : gagal jantung + cairan/vasopressor  MCFP   CO 

William R.H. Clinical review: Guyton - the role of mean circulatory filling pressure and right atrial pressure in controlling cardiac
output.Critical Care 2010
 SYOK HIPOVOLEMIK
VR/CO A
(l/mnt)
Pmsf
5 Vs
Vt
4 Vu

3 A
C
A-B
B
2
Pmsf Vs
1
VT
Pra Vu
0 4 8 (mmHg)

Titik A ke B : hipovolemia akut  VS , VT   MCFP  B-C

(tanpa pengaruh release katekolamin & Rvr)
Pmsf
Vs
Titik B ke C : katekolamin endogen  venokonstriksi  VU Vt
ke VS  MCFP  Vu

Funk, Duane J, Eric Jacobsohn. Role of the Venous Return in Critical Illness and Shock: Part II—Shock and Mechanical Ventilation. Critical
Care Medicine. Februari 2013
 SYOK HIPOVOLEMIK
VR/CO
(l/mnt)
B-C
5

4 E Pmsf Vs VT
3 D A
C Vu
B
2

Pra D-E
0 4 8 (mmHg)
Vs
Titik C ke D : katekolamin endogen  kontraktilitas  Vt
 VR  Vu

Titik D ke E : cairan  hemodilusi Rvr  VR 

sitokin + NO  Rvr 
Funk, Duane J, Eric Jacobsohn. Role of the Venous Return in Critical Illness and Shock: Part II—Shock and Mechanical Ventilation. Critical
Care Medicine. Februari 2013
 SYOK KARDIOGENIK
VR/CO
A
(l/mnt) normal
5 Pmsf , Vt 
Vs
Vt
4 normal
A
Vu
3
A-B
B C
2 kontraktilitas 
Vs
1 Vt
Pra Vu
0 4 8 (mmHg)
Titik A ke B : gagal jantung  kontraktilitas   Pra 
B-C
 VR 
Pmsf
Titik B ke C : katekolamin endogen/cairan  MCFP   Vs
 VR  sedikit (titik flat portion)
(Penambahan cairan lebih lanjut berisiko edema paru) Vu

Funk, Duane J, Eric Jacobsohn. Role of the Venous Return in Critical Illness and Shock: Part II—Shock and Mechanical Ventilation. Critical
Care Medicine. Februari 2013
 SYOK KARDIOGENIK
VR/CO B-C
(l/mnt) normal
Pmsf , Vt  Pmsf 
5 Vs
4 normal
A kontraktilitas  +
Vu
E dobutamine/milrinone
3 D

B C B-D
2 kontraktilitas 

1 Vs
Vt
Pra
(mmHg) Vu
0 4 8

Titik B ke D : gagal jantung + inotropik/inodilator 

kontraktilitas , vasodilatasi  VR  parsial
D-E

Titik D ke E : cairan + inotropik  MCFP , Rvr  (dilusi), Pmsf 

Vs
kontraktilitas   VR 
Funk, Duane J, Eric Jacobsohn. Role of the Venous Return in Critical Illness and Shock: Part II—
Vu
Shock and Mechanical Ventilation. Critical Care Medicine. Februari 2013
 SYOK DISTRIBUTIF
VR/CO A
normal
(l/mnt)
5 Pmsf
Vs Vt
4 normal Vu
A
3
Pmsf , Rvr 
C A-B
2
Pmsf , Rvr (n) B Pmsf Vs
1 Vt
Vu >>
Pra
0 4 8 (mmHg)
Titik A ke B : produksi NO  venodilatasi v.kecil  B-C
VS ke VU  MCFP   VR 
Titik B ke C : (I) dilatasi v. besar  Rvr   VR  Vs
Vt
(II) hemokonsentrasi  viskositas  
Vu
Rvr   VR 
FINAL : dilatasi > hemokonsentrasi  VR  parsial
Funk, Duane J, Eric Jacobsohn. Role of the Venous Return in Critical Illness and Shock: Part II—Shock and Mechanical Ventilation. Critical
Care Medicine. Februari 2013
 SYOK DISTRIBUTIF
C-D
VR/CO Pmsf 
normal Vs
(l/mnt) Pmsf (n), Rvr 
5
Vu
4 normal D Kontraktillitas 
A E
3
Pmsf , Rvr 
C
D-E
2 F Kontraktilitas 
Pmsf , Rvr (n) B Pmsf 
Vs
1

Pra Vu
0 4 8 (mmHg)

Titik C ke D : Cairan  VS ++  MCFP , Rvr   VR  

D-E
Titik D ke E : kontraktilitas   Pra   VR  ≈ baseline Pmsf 
(efek resusitasi cairan menutupi penurunan kontraktilitas) Vs

Titik F : kontraktilitas   cairan tidak mampu Vu

kompensasi  VR 
Funk, Duane J, Eric Jacobsohn. Role of the Venous Return in Critical Illness and Shock: Part II—Shock and Mechanical Ventilation. Critical
Care Medicine. Februari 2013
 KESIMPULAN

• Pendekatan terhadap fisiologi kardiovaskular yang menilai baik jantung

maupun elemen-elemen pembuluh darah berguna untuk seorang
intensivis untuk dapat memberi terapi yang tepat

• Arthur Guyton memperkenalkan perubahan paradigma cara kerja sistem

sirkulasi yang memungkinkan kita dapat menganalisa interaksi kompleks
yang terjadi antara fungsional jantung dan aliran balik vena

• Guyton menunjukkan bahwa aliran balik vena tergantung pada

 sirkulasi perifer (MCFP),
 tekanan atrium kanan (Pra/CVP)
 resistensi aliran balik vena (Rvr)
 KESIMPULAN
• Pada pendekatan Guyton, pemberian cairan, inotropik dan vasopressor
mempertimbangkan tidak hanya faktor jantung namun juga sirkulasi sistemik yang
mempengaruhi aliran balik vena

ALIRAN BALIK
CURAH JANTUNG FUNGSI JANTUNG
VENA
MCFP – Pra Stroke volume X HR
Rvr

MCFP Pra Rvr Preload Afterload

Kontraktilitas
Cairan/vasopr Inotropik/ Venodilator
essor Inodilator
Cairan/vasopr Inotropik/ Vasopressor/ Inotropik/
essor Inodilator vasodilator pacing
APPROACH TO MANAGEMENT OF HYPOTENSION
GUYTON VS STARLING:
SIMILAR THERAPY DIFFERENT PATHOPHYSIOLOGY

STARLING’S LAW: CO = MAP – CVP

SVR

HYPOTENSION =  CARDIAC OUTPUT x  SYSTEMIC VASCULAR RESISTANCE

VASODILATORY SHOCK
 HEART RATE  STROKE VOLUME

BRADYCARDIA  PRELOAD  CONTRACTILITY AFTERLOAD

ATROPINE, PACING FLUID INOTROPE VASOPRESSOR

TRANSFUSION

GEORGE 2016
APPROACH TO MANAGEMENT OF HYPOTENSION
GUYTON VS STARLING:
SIMILAR THERAPY DIFFERENT PATHOPHYSIOLOGY

GUYTON’S THEORY: VR = CO = MCFP – CVP

RVR

HYPOTENSION =  VENOUS RETURN x  RESISTANCE TO VENOUS

RETURN (RVR)

GRADIENT  VENOUS RETURN

 CVP  MCFP
PRESSURE

HEART HYPOVOLEMIA VASODILATORY SHOCK

FAILURE Low total blood VENODILATATION
volume Normal total blood
volume

INOTROPE FLUID VASOPRESSOR VASODILATOR

TRANSFUSION

GEORGE 2016