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  <head>
    <title>010-02 Haemodynamic phenotyping, oxygen debt, and staged resuscitation</title>
    <ownerName>Integrated Medical Foundations</ownerName>
  </head>
  <body>
    <outline text="Haemodynamic phenotyping and staged resuscitation">
      <outline text="Shock is a mismatch, not a pressure">
        <outline text="Hypotension neither necessary nor sufficient"/>
        <outline text="A young patient holds pressure while bleeding"/>
        <outline text="Chronic low pressure can be tolerated"/>
        <outline text="Dominant phenotype">
          <outline text="Preload failure reduces venous return"/>
          <outline text="Pump failure despite adequate filling"/>
          <outline text="Vasoplegia reduces tone and stressed volume"/>
          <outline text="Obstruction creates a mechanical barrier"/>
          <outline text="Microcirculatory failure wastes delivered blood"/>
        </outline>
        <outline text="Compensation hides severity"/>
        <outline text="Extraction reserve is finite"/>
      </outline>
      <outline text="Oxygen content and extraction">
        <outline text="Haemoglobin-bound oxygen dominates content"/>
        <outline text="Saturation useless without haemoglobin and flow"/>
        <outline text="Carbon monoxide misleads pulse oximetry"/>
        <outline text="Low venous saturation: flow, anaemia, hypoxaemia, demand"/>
        <outline text="High venous saturation does not prove perfusion">
          <outline text="Shunting, impaired extraction, mitochondrial failure"/>
        </outline>
        <outline text="Oxygen debt accumulates when supply lags demand"/>
        <outline text="Reperfusion washes metabolites into the circulation"/>
        <outline text="Temperature, glucose, calcium, acidity, coagulation"/>
        <outline text="One restored number is not recovery"/>
      </outline>
      <outline text="Lactate and acid-base context">
        <outline text="Rises when production exceeds clearance"/>
        <outline text="Catecholamine glycolysis raises it despite oxygen"/>
        <outline text="Liver failure, seizure, muscle, drugs, regional ischaemia"/>
        <outline text="Mechanism guides treatment, not the number alone"/>
        <outline text="Blind fluid loading can be the wrong answer"/>
        <outline text="Acidosis impairs contractility and vascular response"/>
        <outline text="Anion gap depends on albumin and method"/>
        <outline text="Hyperchloraemic acidosis from chloride-rich fluid"/>
      </outline>
      <outline text="Fluid responsiveness is not fluid need">
        <outline text="Stroke volume likely to rise after preload"/>
        <outline text="Responsive but already oedematous"/>
        <outline text="Non-responsive but still bleeding"/>
        <outline text="Static filling pressures predict poorly"/>
        <outline text="Passive leg raising is a reversible preload change"/>
        <outline text="Respiratory variation fails in common conditions"/>
        <outline text="Specify type, amount, rate, target, stop condition"/>
        <outline text="Convincing: stroke volume or perfusion improves"/>
        <outline text="Against repeating: crackles, hypoxaemia, venous pressure"/>
        <outline text="Composition follows the deficit being treated"/>
      </outline>
      <outline text="Vascular tone and vasoactive selection">
        <outline text="Pressure approximates output times resistance"/>
        <outline text="More resistance can mean less flow"/>
        <outline text="Vasopressor aids coronary flow but adds work"/>
        <outline text="Titrate to organ perfusion, not a universal target"/>
        <outline text="Norepinephrine raises arterial and venous tone"/>
        <outline text="Venoconstriction recruits unstressed volume"/>
        <outline text="Vasopressin acts outside the catecholamine pathway"/>
        <outline text="Epinephrine raises lactate and provokes arrhythmia"/>
        <outline text="Inotrope after filling and pressure are addressed"/>
        <outline text="Inodilators can deepen hypotension and persist"/>
        <outline text="Escalating dose means search for the cause"/>
      </outline>
      <outline text="Congestion and the right ventricle">
        <outline text="Sensitive to acute afterload rise"/>
        <outline text="Embolism, hypoxia, ventilatory pressure, lung disease"/>
        <outline text="Dilation raises wall stress and oxygen demand"/>
        <outline text="Tricuspid regurgitation and leftward septal shift"/>
        <outline text="Large boluses worsen the cycle"/>
        <outline text="Cautious preload, correct hypoxia and acidosis"/>
        <outline text="Systemic pressure for right-coronary perfusion"/>
        <outline text="Venous congestion injures organs">
          <outline text="Renal venous pressure narrows the gradient"/>
          <outline text="Hepatic and gut congestion impair drug handling"/>
        </outline>
      </outline>
      <outline text="Phases of resuscitation">
        <outline text="Rescue: mechanism-directed action on threats"/>
        <outline text="Optimisation: preload, pressure, output, carriage"/>
        <outline text="Stabilisation: prevent recurrence, reduce support"/>
        <outline text="De-resuscitation removes accumulated fluid"/>
        <outline text="Phases overlap and patients regress"/>
        <outline text="Capillary leak can make removal premature"/>
        <outline text="Balance, weight, ultrasound, kidney function"/>
      </outline>
      <outline text="Mechanical support and causal testing">
        <outline text="Devices differ in preload, afterload and flow"/>
        <outline text="Selection by cause, reversibility, ventricle, timing"/>
        <outline text="Support needs recovery, bridge or destination"/>
        <outline text="State the mechanism, choose a measurable test"/>
        <outline text="Revise when the response contradicts the model"/>
        <outline text="Pressure, flow, congestion, extraction improve together"/>
        <outline text="Endpoint is durable organ recovery with least harm"/>
      </outline>
    </outline>
  </body>
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