Volume and its relationship to cardiac output and venous return
S Magder, S Magder
Abstract
Volume infusions are one of the commonest clinical interventions in critically ill patients yet the relationship of volume to cardiac output is not well understood. Blood volume has a stressed and unstressed component but only the stressed component determines flow. It is usually about 30 % of total volume. Stressed volume is relatively constant under steady state conditions. It creates an elastic recoil pressure that is an important factor in the generation of blood flow. The heart creates circulatory flow by lowering the right atrial pressure and allowing the recoil pressure in veins and venules to drain blood back to the heart. The heart then puts the volume back into the systemic circulation so that stroke return equals stroke volume. The heart cannot pump out more volume than comes back. Changes in cardiac output without changes in stressed volume occur because of changes in arterial and venous resistances which redistribute blood volume and change pressure gradients throughout the vasculature. Stressed volume also can be increased by decreasing vascular capacitance, which means recruiting unstressed volume into stressed volume. This is the equivalent of an auto-transfusion. It is worth noting that during exercise in normal young males, cardiac output can increase five-fold with only small changes in stressed blood volume. The mechanical characteristics of the cardiac chambers and the circulation thus ultimately determine the relationship between volume and cardiac output and are the subject of this review.
Keywords: Capacitance; Cardiac output; Circulatory filling pressure; Compliance; Mean systemic filling pressure; Stressed volume; Time constants; Venous return.
Figures
References
- Patterson SW, Starling EH. On the mechanical factors which determine the output of the ventricles. J Physiol. 1914;48(5):357–79. doi: 10.1113/jphysiol.1914.sp001669.
- Guyton AC, Lindsey AW, Bernathy B, Richardson T. Venous return at various right atrial pressures and the normal venous return curve. Am J Physiol. 1957;189(3):609–15.
- Caldini P, Permutt S, Waddell JA, Riley RL. Effect of epinephrine on pressure, flow, and volume relationships in the systemic circulation of dogs. Circ Res. 1974;34:606–23. doi: 10.1161/01.RES.34.5.606.
- Permutt S, Caldini P. Regulation of cardiac output by the circuit: venous return. In: Boan J, Noordergraaf A, Raines J, editors. Cardiovascular system dynamics. 1. Cambridge, MA and London, England: MIT Press; 1978. pp. 465–79.
- Krogh A. The regulation of the supply of blood to the right heart. Skand Arch Physiol. 1912;27:227–48. doi: 10.1111/j.1748-1716.1912.tb00643.x.
- Magder S, Scharf SM. Respiratory-circulatory interactions in health and disease. 2. New York: Marcel Dekker, Inc; 2001. pp. 93–112.
- Magder S. An approach to hemodynamic monitoring: Guyton at the bedside. Crit Care. 2012;16:236–43. doi: 10.1186/cc11395.
- Permutt S, Wise RA. The control of cardiac output through coupling of heart and blood vessels. In: Yin FCP, editor. Ventricular/vascular coupling. New York: Springer; 1987. pp. 159–79.
- Deschamps A, Magder S. Baroreflex control of regional capacitance and blood flow distribution with or without alpha adrenergic blockade. J Appl Physiol. 1992;263:H1755–63.
- Deschamps A, Magder S. Effects of heat stress on vascular capacitance. Am J Physiol. 1994;266:H2122–9.
- Lindsey AW, Banahan BF, Cannon RH, Guyton AC. Pulmonary blood volume of the dog and its changes in acute heart failure. Am J Physiol. 1957;190(1):45–8.
- Guyton AC, Polizo D, Armstrong GG. Mean circulatory filling pressure measured immediately after cessation of heart pumping. Am J Physiol. 1954;179(2):261–7.
- Levy MN. The cardiac and vascular factors that determine systemic blood flow. Circ Res. 1979;44(6):739–47. doi: 10.1161/01.RES.44.6.739.
- Brengelmann GL. Counterpoint: the classical Guyton view that mean systemic pressure, right atrial pressure, and venous resistance govern venous return is not correct. J Appl Physiol. 2006;101(5):1525–6. doi: 10.1152/japplphysiol.00698a.2006.
- Astrand PO, Rodahl K. Physiological bases of exercise. Textbook of work physiology. Montreal: McGraw-Hill; 1977.
- Magder S, De Varennes B, Ralley F. Clinical death and the measurement of stressed vascular volume in humans. Am Rev Respir Dis. 1994;149(4):A1064.
- Drees J, Rothe C. Reflex venoconstriction and capacity vessel pressure-volume relationships in dogs. Circ Res. 1974;34:360–73. doi: 10.1161/01.RES.34.3.360.
- Rothe CF, Drees JA. Vascular capacitance and fluid shifts in dogs during prolonged hemorrhagic hypotension. Circ Res. 1976;38(5):347–56. doi: 10.1161/01.RES.38.5.347.
- Rothe CF. Reflex control of veins and vascular capacitance. Physiology Rev. 1983;63(4):1281–95.
- Robinson VJB, Smiseth OA, Scott-Douglas NW, Smith ER, Tyberg JV, Manyari DE. Assessment of the splanchnic vascular capacity and capacitance using quantitative equilibrium blood-pool scintigraphy. J Nucl Med. 1990;31:154–9.
- Samar RE, Coleman TG. Measurement of mean circulatory filling pressure and vascular capacitance in the rat. Am J Physiol. 1978;234(1):H94–100.
- Rothe C. Venous system: physiology of the capacitance vessels. In: Shepherd JT, Abboud FM, editors. Handbook of physiology. The cardiovascular system. Section 2. III. Bethesda: American Physiological Society; 1983. pp. 397–452.
- Hainsworth R, Karim F, McGregor KH, Rankin AJ. Effects of stimulation of aortic chemoreceptors on abdominal vascular resistance and capacitance in anaesthetized dogs. J Physiol. 1983;334:421–31. doi: 10.1113/jphysiol.1983.sp014503.
- Hainsworth R, Karim F, McGregor KH, Wood LM. Hind-limb vascular-capacitance responses in anaesthetized dogs. J Physiol. 1983;337:417–28. doi: 10.1113/jphysiol.1983.sp014632.
- Appleton C, Olajos M, Morkin E, Goldman S. Alpha-1 adrenergic control of the venous circulation in intact dogs. J Pharmacol Exp Ther. 1985;233:729–34.
- Mitzner W, Goldberg H. Effects of epinephrine on resistive and compliant properties of the canine vasculature. J Appl Physiol. 1975;39(2):272–80.
- Greenway CV, Dettman R, Burczynski F, Sitar S. Effects of circulating catecholamines on hepatic blood volume in anesthetized cats. Am J Physiol. 1986;250:H992–7.
- Brooksby GA, Donald DE. Dynamic changes in splanchnic blood flow and blood volume in dogs during activation of sympathetic nerves. Circ Res. 1971;24(3):227. doi: 10.1161/01.RES.29.3.227.
- Guyton AC. Determination of cardiac output by equating venous return curves with cardiac response curves. Physiol Rev. 1955;35:123–9.
- Permutt S, Riley S. Hemodynamics of collapsible vessels with tone: the vascular waterfall. J Appl Physiol. 1963;18(5):924–32.
- Guyton AC, Adkins LH. Quantitative aspects of the collapse factor in relation to venous return. Am J Physiol. 1954;177(3):523–7.
- Fessler HE, Brower RG, Wise RA, Permutt S. Effects of positive end-expiratory pressure on the canine venous return curve. Am Rev Respir Dis. 1992;146(1):4–10. doi: 10.1164/ajrccm/146.1.4.
- Holt JP, Rhode EA, Kines H. Pericardial and ventricular pressure. Circ Res. 1960;VIII:1171–80. doi: 10.1161/01.RES.8.6.1171.
- Magder S. Starling resistor versus compliance. Which explains the zero-flow pressure of a dynamic arterial pressure-flow relation? Circ Res. 1990;67:209–20. doi: 10.1161/01.RES.67.1.209.
- O'Rourke MF. The arterial pulse in health and disease. Am Heart J. 1971;82(5):687–702. doi: 10.1016/0002-8703(71)90340-1.
- Mitzner W, Goldberg H, Lichtenstein S. Effect of thoracic blood volume changes on steady state cardiac output. Circ Res. 1976;38(4):255–61. doi: 10.1161/01.RES.38.4.255.
- Magder S, Guerard B. Heart-lung interactions and pulmonary buffering: lessons from a computational modeling study. Respir Physiol Neurobiol. 2012;182(2-3):60–70. doi: 10.1016/j.resp.2012.05.011.
- Magder S, Veerassamy S, Bates JH. A further analysis of why pulmonary venous pressure rises after the onset of LV dysfunction. J Appl Physiol. 2009;106(1):81–90. doi: 10.1152/japplphysiol.90618.2008.
- Permutt S, Bromberger-Barnea B, Bane HN. Alveolar pressure, pulmonary venous pressure, and the vascular waterfall. Med Thoracalis. 1962;19:239–60.
- Stene JK, Burns B, Permutt S, Caldini P, Shanoff M. Increased cardiac output following occlusion of the descending thoracic aorta in dogs. Am J Physiol. 1982;243:R152–8.
- Green JF. Mechanism of action of isoproterenol on venous return. Am J Physiol. 1977;232(2):H152–6.
- Berlin DA, Bakker J. Starling curves and central venous pressure. Crit Care. 2015;19:55. doi: 10.1186/s13054-015-0776-1.
- Notarius CF, Levy RD, Tully A, Fitchett D, Magder S. Cardiac vs. non-cardiac limits to exercise following heart transplantation. Am Heart J. 1998;135:339–48.
- Datta P, Magder S. Hemodynamic response to norepinephrine with and without inhibition of nitric oxide synthase in porcine endotoxemia. Am J Resp Crit Care Med. 1999;160(6):1987–93. doi: 10.1164/ajrccm.160.6.9808019.
- Thiele RH, Nemergut EC, Lynch C., III The physiologic implications of isolated alpha 1 adrenergic stimulation. Anesth Analg. 2011;113(2):284–96. doi: 10.1213/ANE.0b013e3182124c0e.
- Magder S. Phenylephrine and tangible bias. Anesth Analg. 2011;113(2):211–3. doi: 10.1213/ANE.0b013e318220406a.
- Thiele RH, Nemergut EC, Lynch C., III The clinical implications of isolated alpha 1 adrenergic stimulation. Anesth Analg. 2011;113(2):297–304. doi: 10.1213/ANE.0b013e3182120ca5.
Source: PubMed