lab values beyond the numbers
Post on 20-Mar-2016
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Lab values beyond the numbers
Toni Petrillo, MD
Objectives
Ability to interpret a blood gasRecognition of abnormal Lab valuesTreatment of some of the more critical
values
Overview
Blood GasesChemistriesCBC’sCSF
Blood Gases
pHPCO2PO2Base ExcessO2 Sat
Blood Gases
pH Normal : 7.35 - 7.45 pH = acidosis; pH = alkalosis
Blood GasesPCO2
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 PHbyunits– 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-)BUNCreatinine (Cr)GlucoseCalcium (Ca+)
Chemistries: Na+
Sodium Normal range 135-145mmol/L Life threatening
• < 120• >155
Can cause seizures, venous sinus thrombosis, CNS hemorrhage,
Chemistries : Na+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+
Hypernatremia Diabetes Insipidus Diarrhea Dehydration Hypercalciuria Diabetes Hyperaldosteronism
Chemistries : Na+
Treatment is based partially on the causesif 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
Chemistries: K+
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+ and changes in EKGHyperkalemia
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+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: Cl -
Chloride Normal 95-105mEQ/L Hypochloremia
• Metabolic Alkalosis Respiratory 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
HemoglobinHematocritPlatelets
CBC: WBC
Birth 14d 1y 4y 8-21y adultWBC 9-30 5-20 6-18 5-15 4.5-
13.54.5-11
%poly 45 36 40 50 60 60lymh 30 53 53 40 30 32mono 12 8 5 8 8 4eos 2 2 1 1 1 3baso 1 1 1 1 1 1
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
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
12-16FHematocrit
Normal• 14-90d:35-49 •6m-1yr:30-40• 4-10yr: 31-43 •Adult:42-52M 37-47F
CBC: H/H
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: 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
Condition Color Cells Protien Glucose
Normal clear 0-10 (20)lymphs
< 45 2/3 serum(55-80)
Bacterial Turbid 100-10,000segs
50-500 very low
TB Turbid 10-500lymphs
50-500 low
Viral Clear 10-500lymphs
45-200 Normal
CNSBleed
Bloody increasedRBC
45-100 Normal
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