Lab values beyond the numbers

1. Lab values beyond the numbers Toni Petrillo, MD

2. Objectives Ability to interpret a blood gas Recognition of abnormal Lab values Treatment of some of the more critical values

3. Overview Blood Gases Chemistries CBC�s CSF

4. Blood Gases pH PCO2 PO2 Base Excess O2 Sat

5. Blood Gases pH Normal : 7.35 - 7.45 ??pH = acidosis; ??pH = alkalosis

6. 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

7. Blood Gases Base Normal -3 to +3mMol/L Base excess indicates too much (metabolic alkalosis) Base deficit indicates too little buffer (metabolic acidosis)

8. 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

9. Blood Gases: Metabolic Acidosis Causes Renal losses of HCO3 GI Losses of HCO3 Uremia DKA Ingestion Aspirin ETOH

10. 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

11. 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

12. Blood Gases: Metabolic Alkalosis Causes cont Loss Of H+ vomiting Hypercalcemia chloride losing diarrhea

13. Blood Gases: Respiratory Alkalosis PCO2 ? For every PCO2 ?????mmHg ??pH 0.08 If metabolic compensation ? HCO3 Caused by excessive removal of CO2

14. Blood Gases: Respiratory Alkalosis Causes Respiratory Center Stimulation CNS (tumor, Infection) Anxiety/Stress Drugs Hypermetabolic States Fever Thyroid Mechanical Ventilation

15. Blood Gases: Examples 7.56 / 20/ 88/ -2 7.24/ 60/ 88/+2 7.55/ 40/88/ +15 7.12/ 40 /88 / -20

16. Blood Gases: Examples 7.30 / 60 / 88 / + 20 7.20/ 15 / 88/ -25

17. Chemistries (Basics) Sodium (Na+) Potassium (K+) Chloride (Cl-) Bicarb (HCO3-) BUN Creatinine (Cr) Glucose Calcium (Ca+)

18. Chemistries: Na+ Sodium Normal range 135-145mmol/L Life threatening < 120 >155 Can cause seizures, venous sinus thrombosis, CNS hemorrhage,

19. 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

20. Chemistries : Na+ Hypernatremia Diabetes Insipidus Diarrhea Dehydration Hypercalciuria Diabetes Hyperaldosteronism

21. 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

22. Chemistries: K+ Potassium Normal 3.4 - 4.7mmol/L Life threatening < 2.5 >6.5 Major complications Arrhythmia and EKG changes, weakness

23. 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

24. Chemistries: K+ and changes in EKG 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

25. 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

26. Chemistries: Cl - Chloride Normal 95-105mEQ/L Hypochloremia Metabolic Alkalosis Respiratory Acidosis CHF �Burns Hyperchloremia Metabolic Acidosis �Respiratory Alkalosis Dehydration �RTA

27. 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

28. 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

29. Chemistries: Cr Creatinine Normal: Child usually less than 1 Increased: Renal Dz Muscle necrosis hypovolemia

30. 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

31. 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

32. 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

33. 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

34. Chemistries: Ca+ Hypocalcemia renal failure hypoparathyroid pseudohypoparathyroid magnesium deficiency anticonvulsants Rickets Pancreatitis Blood transfusions

35. CBC�S White Blood cell = WBC Differential Segs / polys �Lymphocytes Eosinophils �Monocytes Basophils �Bands Hemoglobin Hematocrit Platelets

36. CBC: WBC

37. 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

38. 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

39. CBC: WBC Monocytes Elevated mumps malaria lymphomas Eosinophils Elevated Parasitic dz �T-Cell leukemia allergies �lupus

40. 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

41. 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

42. 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

43. CBC: Platelets Increased Platelets Reactive thrombocytosis infection splenectomy surgery/stress Inflammatory dz. Thrombocythemia myeloproliferative disorder Chronic granulocytic leukemia

44. CSF