Lab values beyond the numbers
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Lab values beyond the numbers. Toni Petrillo, MD. Objectives. Ability to interpret a blood gas Recognition of abnormal Lab values Treatment of some of the more critical values. Overview. Blood Gases Chemistries CBC’s CSF. Blood Gases. pH PCO2 PO2 Base Excess O2 Sat. Blood Gases.

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Lab values beyond the numbers

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Lab values beyond the numbers

Toni Petrillo, MD


Objectives

  • Ability to interpret a blood gas

  • Recognition of abnormal Lab values

  • Treatment of some of the more critical values


Overview

  • Blood Gases

  • Chemistries

  • CBC’s

  • CSF


Blood Gases

  • pH

  • PCO2

  • PO2

  • Base Excess

  • O2 Sat


Blood Gases

  • pH

    • Normal : 7.35 - 7.45

    • pH = acidosis;

    • pH = alkalosis


Blood Gases

  • PCO2

    • Normal 35-45mmHg

      • Increased PCO2

        • Respiratory Acidosis

        • Compensated metabolic alkalosis

      • Decreased PCO2

        • Respiratory Alkalosis

        • Compensated metabolic acidosis

  • PO2

    • 80-100mmHg at sea level and RA


Blood Gases

  • Base

    • Normal -3 to +3mMol/L

    • Base excess indicates too much (metabolic alkalosis)

    • Base deficit indicates too little buffer (metabolic acidosis)


Blood Gases: Metabolic Acidosis

  • Metabolic Acidosis

    • for every drop of meq/l in HCO3 pH will decrease by 0.15

    • if respiratory compensation will have a in PCO2


Blood Gases: Metabolic Acidosis

  • Causes

    • Renal losses of HCO3

    • GI Losses of HCO3

    • Uremia

    • DKA

    • Ingestion

      • Aspirin

      • ETOH


Blood Gases: Respiratory Acidosis

  • PCO2 increased

    • PCO2 by 10mmHg will PHbyunits

    • If metabolic compensation occurs will have HCO3

  • Causes

    • Brain Depression: sedative, CHI

    • Neuromuscular : Myasthenia, Gullian Barre

    • Lungs: Pulmonary Edema, FB, Pneumonia, Pneumothorax, atelectasis

    • Other: Abdominal distention


Blood Gases: Metabolic Alkalosis

  • HCO3 increases

    • for every  meq/L will  pH by 0.15 units

    • If respiratory compensation PCO2

    • Related to conditions that have hypokalemia or loss of hydrogen Ion

    • Causes

      • Hypokalemia

        • GI: vomiting, Pyloric stenosis

        • Urine Loss: diuretics, antibiotics, Mg


Blood Gases: Metabolic Alkalosis

  • Causes cont

    • Loss Of H+

      • vomiting

      • Hypercalcemia

      • chloride losing diarrhea


Blood Gases: Respiratory Alkalosis

  • PCO2 

    • For every PCO2 mmHg pH 0.08

    • If metabolic compensation  HCO3

    • Caused by excessive removal of CO2


Blood Gases: Respiratory Alkalosis

  • Causes

    • Respiratory Center Stimulation

      • CNS (tumor, Infection)

      • Anxiety/Stress

      • Drugs

    • Hypermetabolic States

      • Fever

      • Thyroid

    • Mechanical Ventilation


Blood Gases: Examples

  • 7.56 / 20/ 88/ -2

  • 7.24/ 60/ 88/+2

  • 7.55/ 40/88/ +15

  • 7.12/ 40 /88 / -20


Blood Gases: Examples

  • 7.30 / 60 / 88 / + 20

  • 7.20/ 15 / 88/ -25


Chemistries (Basics)

  • Sodium (Na+)

  • Potassium (K+)

  • Chloride (Cl-)

  • Bicarb (HCO3-)

  • BUN

  • Creatinine (Cr)

  • Glucose

  • Calcium (Ca+)


Chemistries: Na+

  • Sodium

    • Normal range 135-145mmol/L

    • Life threatening

      • < 120

      • >155

    • Can cause seizures, venous sinus thrombosis, CNS hemorrhage,


Hyponatremia

Excessive H2O

Cirrhosis, CHF

Hypoalbuminemia

Nephrotic

Malnutrition

Vomiting/ Diarrhea

Diuretics

SIADH

Cerebral Salt Wasting

False

Hyperglycemia

Na+ decrease 1.6 meq/l for each increase in glucose over 100

hyperlipidemia

Na decrease by .002 x lipid (mg/dl

Chemistries : Na+


Chemistries : Na+

  • Hypernatremia

    • Diabetes Insipidus

    • Diarrhea

    • Dehydration

    • Hypercalciuria

    • Diabetes

    • Hyperaldosteronism


Chemistries : Na+

  • Treatment is based partially on the causes

  • if hypernatremic do not want to correct Na+ more than 10-15 meq per day

    • will increase risk of cerebral edema

    • 3-4 cc/kg of free water will decrease serum Na+ by 1 Meq/L

  • for acute symptomatic hyponatremia may use hypertonic saline 5-10 cc /kg


Chemistries: K+

  • Potassium

    • Normal 3.4 - 4.7mmol/L

    • Life threatening

      • < 2.5

      • >6.5

    • Major complications Arrhythmia and EKG changes, weakness


Hypokalemia

Diuretics

hypomagnesium

Licorice

RTA

V/D

Pyloric Stenosis

DKA

Antibiotics (ie: AmphoB)

Hyperkalemia

Acidosis

Renal Failure

Muscle necrosis

Blood Transfusions

Hemolysis

CAH

Chemistries: K+


Hyperkalemia

peaked T waves

Widening of QRS

loss of P wave

ST segment depression

bradycardia

ventricular arrhythmias

Hypokalemia

prominent u wave

ST segment depression

ventricular arrhythmias

Chemistries: K+ and changes in EKG


Treatment of Hypokalemia:

KCL bolus

0.3 - 1 meq / kg

no more than 0.6 meq/kg/hour

Treatment of Hyperkalemia:

Insulin and Glucose

NaHco3

Ca+

Kayexalate

Lasix

Albuterol

Chemistries: K+


Chemistries: Cl -

  • Chloride

    • Normal 95-105mEQ/L

    • Hypochloremia

      • Metabolic AlkalosisRespiratory Acidosis

      • CHF•Burns

    • Hyperchloremia

      • Metabolic Acidosis•Respiratory Alkalosis

      • Dehydration•RTA


Chemistries: HCO3-

  • Sodium Bicarbonate

    • Normal: 20-26 mEQ / L

    • Increased in Metabolic Alkalosis and Compensated Respiratory Acidosis

    • Decreased in Metabolic Acidosis and Compensated Respiratory Alkalosis

    • Causes previously discussed in blood gas section


Chemistries: BUN

  • Blood Urea Nitrogen

    • Normal: 5-20 mg/dl

    • Elevated Tissue Necrosis

      • Gi Bleed•High Protein Diet•Steroids

      • Shock•Dehydration •Diarrhea

      • Burns•Tissue Necrosis

    • Decreased

      • Anabolic Steroids•Malnutrition

      • Liver Dz•Pregnancy


Chemistries: Cr

  • Creatinine

    • Normal: Child usually less than 1

    • Increased:

      • Renal Dz

      • Muscle necrosis

      • hypovolemia


Chemistries: Glucose

  • Glucose

    • Normal: 60-115mg/dl (infants >40)

    • Hyperglycemia (AMS, Kusmal breathing)

      • diabetes•Pancreatitis

      • Cushing's dz •Pheochromocytoma

      • drugs (ie: Steroids, Epi)

    • Hypoglycemia (jitters, Sz, Sweating)

      • Malaria•liver dz•Malignancy

      • enzyme deficiency•Malnutrition


Chemistries: Glucose

  • Treatment of Hypoglycemia

    • Neonate or child: 0.5 to 1 gram / kg

      • if using D25 would be 2-4 cc / kg

        • dilute D50 1:1 with sterile water

      • if using D10 5-10 cc / kg

        • dilute D50 1:4

    • Adult: ampule of D50


Chemistries: Glucose

  • Treatment of Hyperglycemia

    • Fluid bolus 10cc/kg NS

    • insulin 0.05u - 1 unit/kg

    • If diabetic in DKA be very judicious of fluid administration and no NHCO3 unless cardiac instability


Chemistries: Ca+

  • Calcium

    • Normal 8-11mg/dl

    • Panic Value:<7 or > 12 (tetni, Sz, arrhythmia)

    • Hypercalcemia (CHIMPS)

      • C= Cancer

      • H= Hyperthyroid

      • I= Iatrogens

      • M= Multiple Myeloma

      • P= Primary Hyperparathyroid

      • S= Sarcoid


Chemistries: Ca+

  • Hypocalcemia

    • renal failure

    • hypoparathyroid

    • pseudohypoparathyroid

    • magnesium deficiency

    • anticonvulsants

    • Rickets

    • Pancreatitis

    • Blood transfusions


CBC’S

  • White Blood cell = WBC

    • Differential

      • Segs / polys•Lymphocytes

      • Eosinophils•Monocytes

      • Basophils•Bands

  • Hemoglobin

  • Hematocrit

  • Platelets


CBC: WBC


Increased neutrophils

physiologic

newborn,pregnancy

Pathologic

acute infection

inflammatory dz

metabolic disorder

tissue necrosis

drugs

stress

Decreased neutrophils

Infection

bacterial

typhiod

septicemia

Viral

Hepatitis–mono

flu–measles

myeloid hypoplasia

drugs

CBC: WBC


Increased Lymphocytes

Infection

Viral:

Hepatitis–mono

CMV–HSV

Bacterial

Pertussis–mumps

Chronic Inflammation

Metabolic

Hematologic

ALL

Decreased Lymphocytes

Increased Corticosteroids

immunodeficiency

miliary Tb

Lupus

CBC: WBC


CBC: WBC

  • Monocytes

    • Elevated

      • mumps

      • malaria

      • lymphomas

  • Eosinophils

    • Elevated

      • Parasitic dz•T-Cell leukemia

      • allergies•lupus


CBC: Hemoglobin / Hematocrit

  • Hemoglobin

    • Normal

      • 1 week: 13-20•1 month: 11-17

      • 6months 10.5-14.5•1 year: 11-15

      • 10years: 11-16•15years: 14-18M

        12-16F

  • Hematocrit

    • Normal

      • 14-90d:35-49•6m-1yr:30-40

      • 4-10yr: 31-43•Adult:42-52M 37-47F


Increased Hct

Polycythemia

Heart Dz

Chronic Hypoxia

High Altitude

Hemoconcentration

Surgery

Burns

Dehydration

Decreased Hct

Anemia

Iron Deficiency

Malabsorbtion

HgSS

Toxin/drugs

Lead

Infection

Malaria

CMV

Cancer

CBC: H/H


CBC: Platelets

  • Platelets

    • Normal: 150-450 thousand

    • Decreased platelets

      • Decreased production

        • Marrow Depression: Aplastic Anemia, Radiation

        • Marrow infiltration: Leukemia

        • Congenital: Wiskott Aldrich, immune deficiencies

      • Increased destruction

        • autoimmune: ITP, Mono, SLE

        • Coagulopathies: DIC, HUS, TTP

        • Drugs


CBC: Platelets

  • Increased Platelets

    • Reactive thrombocytosis

      • infection

      • splenectomy

      • surgery/stress

      • Inflammatory dz.

    • Thrombocythemia

      • myeloproliferative disorder

      • Chronic granulocytic leukemia


CSF


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