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Samenvatting Bloedsomloop fysiologie
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Samenvatting bloedsomloop fysiologie, slides prof. Haemers
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INHOUDHoofdstuk 1: cardiovasculair systeem .................................................................................................................... 7
Inleiding ............................................................................................................................................................... 7
Rol van CV-systeem ............................................................................................................................................. 7
Organisatie van het CV-systeem ......................................................................................................................... 7
Hart ................................................................................................................................................................. 7
Bloedvaten ...................................................................................................................................................... 8
Bloed ............................................................................................................................................................... 8
Hartdebiet – cardiac output (CO) ................................................................................................................ 8
Gemiddelde arteriële bloeddruk (MAP) ...................................................................................................... 9
Perifere weerstand (SVR) ............................................................................................................................ 9
Feedbacksysteem ........................................................................................................................................ 9
Hoofdstuk 2: microcirculatie ................................................................................................................................. 10
Rol van microcirculatie ...................................................................................................................................... 10
Organisatie van microcirculatie ........................................................................................................................ 10
Drie groepen capillairen ................................................................................................................................ 11
Continuous capillary - tight ....................................................................................................................... 11
Fenestrted capillary – more leaky ............................................................................................................. 11
Sinusoidal capillary – leaky........................................................................................................................ 11
Uitwisseling van opgeloste stoffen (thv de capillairen) .................................................................................... 11
Gasuitwisseling.............................................................................................................................................. 11
Zuurstofextractie ....................................................................................................................................... 12
Weefselcilinder van Krogh .................................................................................................................... 12
Principe van Fick .................................................................................................................................... 12
Uitwisseling van kleine wateroplosbare stoffen ........................................................................................... 13
Wet van Fick .............................................................................................................................................. 13
Permeabiliteit orgaan = type capillair bed + oppervlakte capillairen ................................................... 13
Permeabiliteit kleine eiwitten: lading ................................................................................................... 13
Uitwisseling van macromoleculen (paracellulair / transcytose) ................................................................... 14
Transcytose ............................................................................................................................................... 14
Uitwisseling van water ...................................................................................................................................... 14
Convectie (Starling forces) ............................................................................................................................ 14
Starling hypothese .................................................................................................................................... 14
De capillaire hydrostatische druk .................................................................................................................. 15
De interstitiële hydrostatische druk .............................................................................................................. 15
De capillaire osmotische druk ....................................................................................................................... 15
1
, De interstitiële osmotische druk ................................................................................................................... 16
Verwijderen van extra vocht via lymfevaten .................................................................................................... 16
Lymfeflow ...................................................................................................................................................... 16
Interstitieel oedeem .......................................................................................................................................... 16
Hypoproteïnemie .......................................................................................................................................... 16
Verhoogde capillaire druk ............................................................................................................................. 17
Inflammatie injury ......................................................................................................................................... 17
Verlaagde lymfeflow ..................................................................................................................................... 17
De regeling van de microcirculatie .................................................................................................................... 18
Extrinsiek ....................................................................................................................................................... 18
Neurale factoren → AZS............................................................................................................................ 18
Humorale factoren .................................................................................................................................... 19
Intrinsiek ....................................................................................................................................................... 19
Lokale hormonen (paracrien) .................................................................................................................... 19
Metabolisme ............................................................................................................................................. 19
Endotheliale factoren ................................................................................................................................ 20
Myogene factoren ..................................................................................................................................... 20
Angiogenese .................................................................................................................................................. 21
Promotoren ............................................................................................................................................... 21
Inhibitoren................................................................................................................................................. 21
Hoofdstuk 3: elektrofysiologie + EKG .................................................................................................................... 22
Elektrische activiteit .......................................................................................................................................... 22
Componenten ............................................................................................................................................... 22
Cellulaire elektrofysiologie ................................................................................................................................ 22
Actiepotentiaal (AP) ...................................................................................................................................... 22
Belang ionenkanalen ................................................................................................................................. 23
Fast response AP ....................................................................................................................................... 24
Slow response AP ...................................................................................................................................... 25
Refractaire periode ................................................................................................................................... 25
Vulnerabele periode.................................................................................................................................. 26
Conductie ...................................................................................................................................................... 26
Geleidingssnelheid (dromotropie) ............................................................................................................ 26
Normale depolarisatiesequentie ............................................................................................................... 26
Abnormale depolarisatiesequentie ........................................................................................................... 27
Modulatie van het hartritme ........................................................................................................................ 27
Regulatie van de sinusknoop (chronotropie) ............................................................................................ 27
Normale hartfrequentie ............................................................................................................................ 27
2
, Regulatie door autonoom zenuwstelsel ................................................................................................... 28
Cellulaire mechanismen ............................................................................................................................ 28
EKG .................................................................................................................................................................... 28
Wat en doel ................................................................................................................................................... 28
Nomenclatuur ............................................................................................................................................... 29
Deflexies .................................................................................................................................................... 29
Segmenten ................................................................................................................................................ 29
Intervallen ................................................................................................................................................. 30
Elementaire begrippen .................................................................................................................................. 30
Potentiaalverschillen ................................................................................................................................. 30
Dipoolmodel van het hart ......................................................................................................................... 30
Registratie van vectoren ........................................................................................................................... 30
Twaalf afleidingen ..................................................................................................................................... 31
Normale EKG ................................................................................................................................................. 32
P-golf: depolarisatie van atria ................................................................................................................... 32
PR-interval: AV-geleiding........................................................................................................................... 32
QRS-complex: depolarisatie van ventrikels ............................................................................................... 32
T-golf: repolarisatie van ventrikels ............................................................................................................ 32
QT-interval: som depolarisatie en repolarisatie ........................................................................................ 33
Inleiding tot ritmestoornissen (aritmie) ........................................................................................................ 33
Ischemie ........................................................................................................................................................ 35
Acuut coronair syndroom ......................................................................................................................... 35
Cellulaire elektrofysiologische veranderingen .......................................................................................... 36
Expressie van ischemie.............................................................................................................................. 36
Expressie van necrose ............................................................................................................................... 37
Hart: complexe 3D-structuur ........................................................................................................................ 37
Hoofdstuk 4: het hart als een pomp ..................................................................................................................... 38
Hartcyclus .......................................................................................................................................................... 38
Duur .............................................................................................................................................................. 38
4 fasen + veranderingen in druk en EKG ....................................................................................................... 38
Fase 1: opening van AV-klep ..................................................................................................................... 38
Fase 2: isovolumetrische contractie .......................................................................................................... 39
Fase 3: ejectie ............................................................................................................................................ 39
Fase 4: isovolumetrische relaxatie ............................................................................................................ 39
Belang atriale contractie (atrial kick) ........................................................................................................ 39
Veranderingen in flow en harttonen............................................................................................................. 40
Veranderingen in morfologie ........................................................................................................................ 40
3
, Rechts vs links ............................................................................................................................................... 40
Pulsatiele flow ............................................................................................................................................... 41
Mechanische impedantie .......................................................................................................................... 41
Windkessel ................................................................................................................................................ 41
Drukgolf ......................................................................................................................................................... 41
Veneuze drukgolven ...................................................................................................................................... 42
Retrograde actie van hartcyclus ................................................................................................................ 42
Ademhalingscyclus .................................................................................................................................... 43
Contractie van skeletspieren ..................................................................................................................... 43
Dynamica pompwerking + regulatie ................................................................................................................. 43
Morfologie..................................................................................................................................................... 43
Cellulaire functie ........................................................................................................................................... 43
Passieve lengte .......................................................................................................................................... 43
Actieve lengte............................................................................................................................................ 43
Evaluatie pompwerking..................................................................................................................................... 44
Meten van volume ........................................................................................................................................ 44
Ejectiefractie ............................................................................................................................................. 44
Meten van druk ............................................................................................................................................. 44
Meten van volume + druk ............................................................................................................................. 44
Arbeid van het hart ................................................................................................................................... 45
Meten van flowsnelheden ............................................................................................................................ 45
Pathologie ..................................................................................................................................................... 46
Regulatie pompwerking .................................................................................................................................... 46
Preload .......................................................................................................................................................... 46
Diastolische functie ....................................................................................................................................... 47
Bijdrage pericard ....................................................................................................................................... 47
Lusitropie................................................................................................................................................... 47
Afterload ....................................................................................................................................................... 48
Contractiliteit ................................................................................................................................................ 48
Interactie pompwerking ................................................................................................................................ 49
Cardiale functie ................................................................................................................................................. 49
Hoofdstuk 5: regeling bloeddruk en hartdebiet.................................................................................................... 50
Inleiding ............................................................................................................................................................. 50
CV controle = controle van MAP ................................................................................................................... 51
Korte termijnscontrole MAP ............................................................................................................................. 51
Baroreceptor feedbackloop (primair) ........................................................................................................... 51
Coördinatie door medulla oblongata ........................................................................................................ 52
4
, Effector ...................................................................................................................................................... 52
Adrenerge receptoren ............................................................................................................................... 53
Chemoreceptor feedbackloop (secundair) ................................................................................................... 53
Regeling cardiac output .................................................................................................................................... 54
Neurale regeling ............................................................................................................................................ 54
Stretchreceptoren ..................................................................................................................................... 54
Effectief circulerend volume (ECV) ........................................................................................................... 55
Matching van veneuze retour en hartdebiet .................................................................................................... 55
Centraal veneuze druk (CVP)......................................................................................................................... 55
Venomotor tonus (bloedvolume).............................................................................................................. 55
Arteriolaire tonus ...................................................................................................................................... 56
Vasculaire + cardiale curve ........................................................................................................................ 56
(Middel)lange termijnscontrole ........................................................................................................................ 57
Vasoactieve stoffen ....................................................................................................................................... 57
Regulerende stoffen van ECF (ECV) ............................................................................................................... 57
Hypertensie ................................................................................................................................................... 58
Behandeling .............................................................................................................................................. 58
Hoofdstuk 6: regeling bloeddruk .......................................................................................................................... 59
Controle regionale bloedflow ........................................................................................................................... 59
Hersenen ........................................................................................................................................................... 59
Microcirculatie .............................................................................................................................................. 59
Invloed van ICP op perfusie ....................................................................................................................... 60
Autonome innervatie ................................................................................................................................ 60
Metabole lokale controle .......................................................................................................................... 60
Myogene lokale controle .......................................................................................................................... 61
Hart ................................................................................................................................................................... 61
Coronaire circulatie ....................................................................................................................................... 61
Autonome innervatie ................................................................................................................................ 61
Myocardiaal metabolisme ......................................................................................................................... 62
Myogene respons ...................................................................................................................................... 63
Hartspiercontractie ................................................................................................................................... 63
Ischemie ........................................................................................................................................................ 63
Anti-agineuze medicatie ............................................................................................................................... 64
Skeletspier ......................................................................................................................................................... 64
Microvasculaire eenheid ............................................................................................................................... 64
Autonome regeling.................................................................................................................................... 65
Spierpomp ................................................................................................................................................. 65
5
, GI-stelsel............................................................................................................................................................ 65
Microcirculatie .............................................................................................................................................. 65
Counter-current O2-uitwisseling ............................................................................................................... 65
Regulatie: postprandiale hyperemie ......................................................................................................... 66
Regulatie: autonome controle .................................................................................................................. 66
Regulatie: splanchnische circulatie ........................................................................................................... 66
Regulatie: inspanning – bloeding .............................................................................................................. 66
Bloedvoorziening lever .................................................................................................................................. 67
Huid ................................................................................................................................................................... 67
Apicale huid ................................................................................................................................................... 68
Non-apicale huid ........................................................................................................................................... 68
Hoofdstuk 7: integratieve fysiologie ..................................................................................................................... 69
Inleiding ............................................................................................................................................................. 69
Systeemanalyse: effect van noradrenaline (NA) ........................................................................................... 69
Subsystemen en niet-circulatoire systemen spelen ook een rol................................................................... 69
Aanpassing aan rechtopstaan ........................................................................................................................... 70
Effect van bloed redistributie ........................................................................................................................ 70
Orthostatische respons ................................................................................................................................. 70
Niet-uniforme verdeling bloedvolume ...................................................................................................... 71
Niet-uniforme distensibiliteit van de venen.............................................................................................. 71
Spierpompen ............................................................................................................................................. 71
Autonome reflexen ................................................................................................................................... 71
Emotionele stress .............................................................................................................................................. 71
Fight-or-flight respons ................................................................................................................................... 71
Syncope ......................................................................................................................................................... 71
Inspanning ......................................................................................................................................................... 72
Types skeletspiervezels ................................................................................................................................. 72
Energiesystemen ........................................................................................................................................... 73
Spiercontractie .............................................................................................................................................. 73
Centraal veneus systeem (CVS) ................................................................................................................. 73
Type inspanning ........................................................................................................................................ 74
Bloeding ............................................................................................................................................................ 74
Compensatiemechanismen ........................................................................................................................... 75
Herstel van BP ........................................................................................................................................... 75
Herstel van intravasculair volume ............................................................................................................. 75
Oefeningen ............................................................................................................................................................ 77
EKG’s ................................................................................................................................................................. 78
6
, BLOED & BLOEDSOMLOOP: FYSIOLOGIE
HOOFDSTUK 1: CARDIOVASCULAIR SYSTEEM
INLEIDING
- Organisatie van cardiovasculair systeem (CV-systeem)
o Hart
o Bloedvaten
o Bloed
- Fundamentele elementen die bloedflow doorheen hart en bloedvaten bepalen
o CO: cardiale output
o MAP: gemiddelde arteriële bloeddruk
o SVR: systeem vasculaire weerstand
- Belang van controlesystemen
ROL VAN CV-SYSTEEM
Primair:
- Distributie van nutritie (glucose, O2) voor cellen
- Verwijderen van afvalproducten (CO2, lactaat)
Secundair:
- Verspreiden van chemische signalen
o Hormonen
o Neurotransmitters
- Rol in homeostase van de lichaamstemperatuur
o Transport van warmte van centraal naar lichaamsoppervlakte
- Rol in afweer
ORGANISATIE VAN HET CV-SYSTEEM
- Pomp = hart
o 300 g
o Linker – rechter hart
- Circulerende vloeistof = bloed
- Leidingen = bloedvaten
Circulatie:
- Li hart → systeemcirculatie → aorta (45 mmHg, hoge druk)
- Re hart → pulmonaal circulatie → a pulmonalis → longen (15 mmHg, lage druk)
HART
Pulsatiele pomp
- Systole = moment van de cardiale cyclus waarbij hart gaat samentrekken en bloed gaat ejecteren
7
, - Diastole = moment van de cardiale cyclus waarbij de hartspier gaat ontspannen en hart gaat vullen
met bloed
Pompt bloed in de bloedvaten → levert druk
- RA: 2 mmHg
- RV: druk opbouwen tot 15 mmHg door a pulmonalis
- LA: 8 mmHg
- LV: druk opbouwen tot 95 mmHg door aorta
In serie geschakeld → indien 1 van de pompen faalt, dan komt de andere pomp ook in de problemen
BLOEDVATEN
4 onderdelen:
- Aorta + grote bloedvaten: verantwoordelijk voor distributie van bloed naar organen
- Arteriolen: weerstand opbouwen in CV-systeem → bepalen naar welke delen van organen het bloed
gaat stromen
- Capillairen: uitwisseling
- Venen + venulen: 60% van totale bloedvolume is capaciteit → weghalen bij de huid en gebruiken om
andere organen te bevloeien
BLOED
Total body water (60% lichaamsgewicht) → 3 compartimenten in verbinding:
- Intracellulair: 30 l
- Interstitieel: 12 l
- Plasma 3 l
Bloedstroom wordt aangedreven door pomp → druk leveren tegen een weerstand
ΔP
- Vereenvoudigde formule: F =
R
o F = constante flow
o P = constante druk
o R = rechte buis met weerstand
MAP⋅(−CVP)
- Realiteit: CO =
SV
o Hart = constante drukgenerator → proberen MAP cte te houden
o Variabele flow en weerstand → ifv fysiologische omstandigheden
HARTDEBIET – CARDIAC OUTPUT (CO)
Formule: CO = HR ⋅ SV
- CO (cardiale output): hoeveelheid bloed door ventrikel gepompt in 1 minuut
o Gem: 5 l/min
- HR (hartdebiet): aantal contracties van het ventrikel in 1 minuut
o Gem: 70 slagen/min
- SV (slagvolume): hoeveelheid bloed geëjecteerd door ventrikel per contractie
o Gem: 70 ml/slag
8
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