Transcript Interpreting ABGs

Interpreting ABGs
(or the ABCs of ABGs)
Suneel Kumar MD
Arterial Blood Gases
• Written in following manner:
–
–
–
–
pH/PaCO2/PaO2/HCO3
pH = arterial blood pH
PaCO2 = arterial pressure of CO2
PaO2 = arterial pressure of O2
HCO3 = serum bicarbonate
concentration
Oxygenation
• Hypoxia: reduced oxygen pressure in
the alveolus (i.e. PAO2)
• Hypoxemia: reduced oxygen
pressure in arterial blood (i.e. PaO2)
Hypoxia with Low PaO2
• Alveolar diffusion impairment
• Decreased alveolar PO2
– Decreased FiO2
– Hypoventilation
– High altitude
• R  L shunt
• V/Q mismatch
Hypoxia with Normal PaO2
• Alterations in hemoglobin
– Anemic hypoxia
– Carbon monoxide poisoning
– Methemoglobinemia
• Histotoxic hypoxia
– Cyanide
• Hypoperfusion hypoxia or stagnant
hypoxia
Alveolar—Arterial
Gradient
• Indirect measurement of V/Q
abnormalities
• Normal A-a gradient is 10 mmHg
• Rises with age
• Rises by 5-7 mmHg for every 0.10
rise in FiO2, from loss of hypoxic
vasoconstriction in the lungs
Alveolar—Arterial
Gradient
A-a gradient = PAO2 – PaO2
• PAO2 = alveolar PO2 (calculated)
• PaO2 = arterial PO2 (measured)
Alveolar—Arterial
Gradient
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•
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•
PAO2 = PIO2 – (PaCO2/RQ)
PAO2 = alveolar PO2
PIO2 = PO2 in inspired gas
PaCO2 = arterial PCO2
RQ = respiratory quotient
Alveolar—Arterial
Gradient
PIO2 = FiO2 (PB – PH2O)
• PB = barometric pressure (760 mmHg)
• PH2O = partial pressure of water vapor (47
mmHg)
RQ = VCO2/VO2
• RQ defines the exchange of O2 and CO2
across the alveolar-capillary interface
(0.8)
Alveolar—Arterial
Gradient
PAO2 = FiO2 (PB – PH2O) – (PaCO2/RQ)
Or
PAO2 = FiO2 (713) – (PaCO2/0.8)
Alveolar—Arterial
Gradient
• For room air:
PAO2 = 150 – (PaCO2/0.8)
• And assume a normal PaCO2 (40):
PAO2 = 100
Acid-Base
• Acidosis or alkalosis: any disorder
that causes an alteration in pH
• Acidemia or alkalemia: alteration in
blood pH; may be result of one or
more disorders.
Six Simple Steps
1. Is there acidemia or alkalemia?
2. Is the primary disturbance respiratory
or metabolic?
3. Is the respiratory problem acute or
chronic?
4. For metabolic, what is the anion gap?
5. Are there any other processes in anion
gap acidosis?
6. Is the respiratory compensation
adequate?
Henderson-Hasselbach
Equation
pH = pK + log [HCO3/PaCO2] x K
(K = dissociation constant of CO2)
Or
[H+] = 24 x PaCO2/HCO3
Henderson-Hasselbach
Equation
pH
7.20
7.30
7.40
7.50
7.60
[H+]
60
50
40
30
20
Step 1:
Acidemia or Alkalemia?
• Normal arterial pH is 7.40 ± 0.02
– pH < 7.38  acidemia
– pH > 7.42  alkalemia
Step 2:
Primary Disturbance
• Anything that alters HCO3 is a
metabolic process
• Anything that alters PaCO2 is a
respiratory process
Step 2:
Primary Disturbance
• If 6pH, there is either 5PaCO2 or
6HCO3
• If 5pH, there is either 6PaCO2 or
5HCO3
Step 3:
Respiratory Acute/Chronic?
• Acute:
rCO2 by 10  rpH by 0.08
• Chronic:
rCO2 by 10  rpH by 0.03
• Changes in CO2 and pH are in
opposite directions
Step 4:
For Metabolic, Anion Gap?
Anion gap = Na+ - (Cl- + HCO3-)
– Normal is < 12
Increased Anion Gap
• Ingestion of drugs or toxins
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–
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–
–
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Ethanol
Methanol
Ethylene glycol
Paraldehyde
Toluene
Ammonium chloride
Salicylates
Increased Anion Gap
• Ketoacidosis
– DKA
– Alcoholic
– Starvation
• Lactic acidosis
• Renal failure
Step 4:
For Metabolic, Anion Gap?
• If + AG, calculate Osm gap:
Calc Osm = (2 x Na+) + (glucose/18) +
(BUN/2.8) + (EtOH/4.6)
Osm gap = measured Osm – calc Osm
Normal < 10 mOsm/kg
Nongap Metabolic
Acidosis
• Administration of acid or acidproducing substances
– Hyperalimentation
– Nonbicarbonate-containing IVF
Nongap Metabolic
Acidosis
• GI loss of HCO3
– Diarrhea
– Pancreatic fistulas
• Renal loss of HCO3
– Distal (type I) RTA
– Distal (type IV) RTA
– Proximal (type II) RTA
Nongap Metabolic
Acidosis
• Calculate urine anion gap:
Urine AG = (Na+ + K+) – Cl– Positive gap indicates renal impaired
NH4+ excretion
– Negative gap indicates normal NH4+
excretion and nonrenal cause
Nongap Metabolic
Acidosis
• Urine Cl- < 10 mEq/l is chloride
responsive and accompanied by
“contraction alkalosis” and is “saline
responsive”
• Urine Cl- > 20 mEq/l is chloride
resistant, and treatment is aimed at
underlying disorder
Step 5: Any other process
with elevated AG?
• Calculate rgap, or “gap-gap”:
rGap = Measured AG – Normal AG (12)
Step 5: Any other process
with elevated AG?
• Add rgap to measured HCO3
– If normal (22-26), no other metabolic
problems
– If < 22, then concomitant metabolic
acidosis
– If > 26, then concomitant metabolic
alkalosis
Step 6: Adequate
respiratory compensation?
Winter’s Formula
Expected PaCO2 = (1.5 x HCO3) + 8 ± 2
– If measured PaCO2 is higher, then
concomitant respiratory acidosis
– If measured PaCO2 is lower, then
concomitant respiratory alkalosis
Step 6: Adequate
respiratory compensation?
• In metabolic alkalosis, Winter’s
formula does not predict the
respiratory response
– PaCO2 will rise > 40 mmHg, but not
exceed 50-55 mmHg
– For respiratory compensation, pH will
remain > 7.42
Clues to a Mixed
Disorder
• Normal pH with abnormal PaCO2 or
HCO3
• PaCO2 and HCO3 move in opposite
directions
• pH changes in opposite direction for
a known primary disorder
Case 1
• A 24 year old student on the 6 year
undergraduate plan is brought to the
ER cyanotic and profoundly weak. His
roommate has just returned from a
semester in Africa. The patient had
been observed admiring his
roommate's authentic African
blowgun and had scraped his finger
on the tip of one of the poison darts
(curare).
Case 1
138
100
26
7.08/80/37
Case 1
• What is the A-a gradient?
A-a gradient = [150 – 80/0.8] - 37
A-a gradient = 13
• Acidemia or alkalemia?
• Primary respiratory or metabolic?
• Acute or chronic?
5PCO2 by 40 would 6pH by 0.32
Case 1
• What is the anion gap?
AG = 138 – (100 + 26)
AG = 12
Case 1
• Acute respiratory acidosis
Case 2
• A 42 year old diabetic female who
has been on insulin since the age of
13 presents with a 4 day history of
dysuria which has progressed to
severe right flank pain. She has a
temperature of 38.8ºC, a WBC of
14,000, and is disoriented.
Case 2
135
99
4.8
12
7.23/25/113
Case 2
• What is the A-a gradient?
A-a = [150 – 25/0.8] – 113 = 6
• Acidemia or alkalemia?
• Primary respiratory or metabolic?
• What is the anion gap?
AG = 135 – (99 + 12) = 24
Case 2
• What is the rgap?
rGap = 24 – 12 = 12
rGap + HCO3 = 12 + 12 = 24
– No other metabolic abnormalities
• Is the respiratory compensation
appropriate?
Expected PCO2 = (1.5 x 12) + 8 ± 2 = 24 ± 2
– It is appropriate
Case 2
• Acute anion gap metabolic acidosis
(DKA)
Case 3
• A 71 year old male, retired machinist,
is admitted to the ICU with a history
of increasing dyspnea, cough, and
sputum production. He has a 120
pack-year smoking history, and quit 5
years previously. On exam he is
moving minimal air despite using his
accessory muscles of respiration. He
has acral cyanosis.
Case 3
135
93
30
7.21/75/41
Case 3
• What is the A-a gradient?
A-a = [150 – 75/.8] – 41 = 15
• Acidemic or alkalemic?
• Primary respiratory or metabolic?
• Acute or chronic?
– Acute 5PCO2 by 35 would 6pH by 0.28
– Chronic 5PCO2 by 35 would 6pH by 0.105
• Somewhere in between
Case 3
• What is the anion gap?
AG = 135 – (93 + 30) = 12
Case 3
• Acute on chronic respiratory acidosis
(COPD)
Case 3b
• This same patient is intubated and
mechanically ventilated. During the
intubation he vomits and aspirates.
He is ventilated with an FiO2 of 50%,
tidal volumes of 850 mL, PEEP of 5,
rate of 10. One hour later his ABG is
7.48/37/215.
Case 3b
• Why is he alkalotic with a normal
PCO2?
– Chronic compensatory metabolic
alkalosis and acute respiratory alkalosis
Case 4
• A 23 year old female presents to the
Emergency Room complaining of
chest tightness and lightheadedness. Other symptoms include
tingling and numbness in her
fingertips and around her mouth. Her
medications include Xanax and birth
control pills, but she recently ran out
of both.
Case 4
135
109
22
7.54/22/115
Case 4
• What is the A-a gradient?
A-a = [150 – 22/.8] – 115 = 8
• Acidemia or alkalemia?
• Primary respiratory or metabolic?
• Acute or chronic?
– Acute 6CO2 by 18 would 5pH by 0.144
• What is the anion gap?
AG = 135 – (109 + 22) = 4
Case 4
• Acute respiratory alkalosis (panic
attack)
Case 5
• 72 year old woman admitted from a
nursing home with one week history
of diarrhea and fever.
133
118
5
7.11/16/94
Case 5
• What is the A-a gradient?
A-a = [150 – 16/.8] – 94 = 36
• Acidemia or alkalemia?
• Primary respiratory or metabolic?
• What is the anion gap?
AG = 133 – (118 + 5) = 10
• Is respiratory compensation
adequate?
PCO2 = (1.5 x 5) + 8 ± 2 = 16 ± 2
Case 5
• Non anion gap metabolic acidosis
(diarrhea)
• Compensatory respiratory alkalosis
Case 6
• A 27 year old pregnant alcoholic with
IDDM is admitted one week after
stopping insulin and beginning a
drinking binge. She has experienced
severe nausea and vomiting for
several days.
Case 6
136
70
19
7.58/21/104
Case 6
• What is the A-a gradient?
A-a = [150 – 21/.8] – 104 = 20
• Acidemia or alkalemia?
• Primary respiratory or metabolic?
• What is the anion gap?
AG = 136 – (70 + 19) = 47
• What is the rgap?
rGap = 47-12 = 35
rGap + HCO3 = 54
Case 6
• Primary respiratory alkalosis
(pregnancy)
• Anion gap metabolic acidosos
(ketoacidosis)
• Nongap metabolic alkalosis (vomiting)
Case 7
• 35 year old male presents to the ER
unconscious.
145
70
23
7.61/24/78
Creat 6.1
Case 7
• What is the A-a gradient?
A-a = [150 – 24/.8] – 78 = 42
• Acidemia or alkalemia?
• Primary respiratory or metabolic?
• What is the anion gap?
AG = 145 – (70 + 23) = 52
Case 7
• What is the rgap?
rGap = 52 - 12 = 40
rGap + HCO3 = 63
– Nongap metabolic alkalosis
Case 7
• Respiratory alkalosis
• Anion gap metabolic acidosis (renal
failure)
• Nongap metabolic alkalosis
Bonus Case #1
• 51 year old man with polysubstance
abuse, presented to ER with 3-4 day
h/o N/V and diffuse abdominal pain.
Reports no EtOH or cocaine in 2
weeks. He has been taking “a lot” of
aspirin for pain. Denies dyspnea, but
has been tachypneic since arrival.
Bonus Case #1
• Afebrile, P 89, R 20, BP 142/57.
Lethargic but arrousable, easily
aggitated. Lungs clear, and abdomen
is soft with mild tenderness in LUQ
and LLQ.
Bonus Case #1
126
93
58
3.4
11
1.8
218
UA 1+ ketones
Acetone negative
Lactate 6.9
EtOH 0
Osm 272
7.46/15/107
Bonus Case #1
• What is the A-a gradient?
A-a = [150 – 15/.8] – 107 = 25
• Acidemia or alkalemia?
• Primary respiratory or metabolic?
• What is the anion gap?
AG = 126 – (93 + 11) = 22
Anion gap metabolic acidosis
Bonus Case #1
• What is the rgap?
rGap = 22 - 12 = 10
rGap + HCO3 = 21
Nongap metabolic acidosis
• What is the osmolar gap?
Calc Osm = 2x126 + 218/18 + 58/2.8
Calc Osm = 265
Osm gap = 272 – 265 = 7
Bonus Case #1
• Respiratory alkalosis (aspirin)
• Anion gap metabolic acidosis (aspirin)
• Nongap metabolic acidosis
Bonus Case # 2
• 20 year old college student brought
to the ER by his fraternity brothers
because they cannot wake him up. He
had been in excellent health until the
prior night.
Bonus Case #2
• Afebrile, P 118, R 32, BP 120/70.
Anicteric sclerae, pupils 8mm and
poorly responsive to light.
Fundoscopic exam with slight blurring
of discs bilaterally and increased
retinal sheen. Remainder of exam
unremarkable.
Bonus Case #2
142
98
4.3
10
14
108
UA negative
EtOH 45
Osm 348
7.22/24/108
Bonus Case #2
• What is the A-a gradient?
A-a = [150 – 24/.8] – 108 = 12
• Acidemia or alkalemia?
• Primary respiratory or metabolic?
• What is the anion gap?
AG = 142 – (98 + 10) = 34
Anion gap metabolic acidosis
Bonus Case #2
• What is the rgap?
rGap = 34 - 12 = 22
rGap + HCO3 = 32
Nongap metabolic alkalosis
Bonus Case #2
• What is the osmolar gap?
Calc Osm = 2x142 + 108/18 + 14/2.8 + 45/4.6
Calc Osm = 305
Osm gap = 348 - 305 = 43
• Is the respiratory compensation
adequate?
PCO2 = (1.5 x 10) + 8 ± 2 = 23 ± 2
Bonus Case #2
• Anion gap metabolic acidosis with
elevated osmolar gap (methanol)
• Nongap metabolic alkalosis
• Compensatory respiratory alkalosis
Bonus Case #3
• A 23 year old man presents with
confusion. He has had diabetes since
age 12, and has been suffering from
an intestinal flu for the last 24
hours. He has not been eating much,
has vague stomach pain, stopped
taking his insulin, and has been
vomiting. His glucose is high.
Bonus Case #3
130
80
10
7.20/25/68
Bonus Case #3
• What is the A-a gradient?
A-a = [150 – 25/.8] – 68 = 51
• Acidemia or alkalemia?
• Primary respiratory or metabolic?
• What is the anion gap?
AG = 130 – (80 + 10) = 40
Anion gap metabolic acidosis
Bonus Case #3
• What is the rgap?
rGap = 40 - 12 = 28
rGap + HCO3 = 38
Nongap metabolic alkalosis
• Is the respiratory compensation
adequate?
PCO2 = (1.5 x 10) + 8 ± 2 = 23 ± 2
Bonus Case #3
• Anion gap metabolic acidosis (DKA)
• Metabolic metabolic alkalosis
(emesis)
• Compensatory respiratory alkalosis
Pulmonary Artery Catheters
Suneel Kumar MD
History
• In 1929, German surgical trainee
Werner Forssman experimented on
human cadavers
• Found that it was easy to guide a
urologic catheter from arm veins into
the right atrium
History
• Forssmann went as far as to dissect
the veins of his own forearm and
guided a urologic catheter into his
right atrium
• Used fluoroscopic control and a mirror
• Was able to walk to get a chest x-ray
• For his trouble, he was fired
• Eventually was awarded the Nobel
Prize in 1956
History
• Jeremy Swan and William Ganz from
Cedars-Sinai developed a balloonguided catheter placement
• Published in NEJM in August 1970
• Idea came to Swan while watching
sail boats moving quickly on a calm
day
• Neither the physicians nor the
manufacturer were able to patent the
balloon catheter
Functional Cardiac Anatomy
Uses of PA and Arterial
Catheters
• Allows assessment of both RV and LV
during diastolic and systolic phases
• Allows use of PCWP which is used to
reflect the degree of pulmonary
congestion
• Allows in assessment of blood flow
(CO) and tissue oxygenation (SvO2)
Use of PA Catheter
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To establish diagnosis
To guide therapy
To monitor response to therapy
To assess determinants of tissue
oxygenation
Indications
• Diagnosis of shock
• Differentiate high vs
low pressure
pulmonary edema
• Diagnosis of PPH
• Assessment of
response to
medications for PPH
• Diagnosis of valvular
heart disease,
intracardiac shunts,
cardiac tamponade,
and PE
• Monitoring and
management of
complicated AMI
• Assessing
hemodynamic
response to therapies
• Management of MOF
and/or severe burns
• Management of
hemodynamic
instability after cardiac
surgery
• Aspiration of air
emboli
Indications
Contraindications
• Tricuspid or pulmonic valve
mechanical protheses
• Right heart mass (thrombus or tumor)
• Tricuspid or pulmonic valve
endocarditis
Approaches to Access
Approaches to Access
Approaches to Access
Approaches to Access
Insertion Technique
Proper Position
Coiled PA Catheter
Distal Cath Tip
Lung Zones of West
Lung Zones of West
PA > Pa > Pc
Pa > PA > Pc
Pa > Pc > PA
Static Column of Blood to LA
During Diastole:
• Tricuspid and mitral valves are open
• Blood leaves the atria and fill the
ventricles
• Pressure between the atria and
ventricles equalize
At End-Diastole:
• Mean RA pressure equalizes with the
RV end-diastolic pressure
• PA diastolic and PCWP equalize with
the LV end-diastolic pressure
Mean RA = RV EDP
PA EDP and PCWP = LV EDP
CVP/RA Waveform
• Three positive
waves:
– a wave (usually
largest)
– c wave (may not be
seen)
– v wave
CVP/RA Waveform
• a wave is with atrial contraction
• c wave is with closure of tricuspid valve
• v wave is with blood filling atrium with tricuspid valve
is closed
CVP/RA Waveform
CVP/RA Waveform and EKG
• a wave in PR interval
• c wave at end of QRS,
in RST junction
• v wave after T wave
Measuring Mean CVP
• Final filling of the ventricle occurs
during atrial contraction (a wave)
• Therefore, average the a wave on the
CVP/RA waveform
Measuring the Mean CVP
RV Waveform
• Sharp upstroke during systole, and
downstroke during diastole
RV Waveform
RV Waveform
RV to PA
• As the catheter goes past the
pulmonic valve:
– The systolic pressure is about the same
and now has a dicrotic notch (from
closure of pulmonic valve)
– The diastolic pressure increases
RV to PA
PA Waveform
• PA systole within T wave
• PA diastole at end of QRS
PCWP Waveform
• Inflation of the balloon stops forward blood
flow
• Creates a static column of blood between the
catheter tip and the LA
PCWP Waveform
• Has a waveform characteristic of the
RA, primarily with a waves and v waves
• Mean PCWP is close to PA diastolic
pressure
PCWP Waveform and EKG
• a wave near end or
after QRS
• v wave well after T
wave
Mean PCWP Measurement
• Final filling of the left ventricle occurs
during atrial contraction
• Therefore, measure the average of
the a wave
• Measure at the end of expiration
Mean PCWP Measurement
12 + 6 / 2 = 9
PCWP at End Expiration
Waveform Review
Calculating Cardiac Output
• Cardiac output done by thermodilution
• Known saline bolus (5-10 mL) at
known temperature (usually < 25oC)
injected via the proximal lumen
• Thermistor at end of SC catheter
measures the change in temperature
• Change in temperature is inversely
proportional to the CO
Calculating Cardiac Output
Calculating Cardiac Output
• Stewart-Hamilton formula:
CO = (vol of injectate) x (blood temp –
injectate temp) x (computation
constant) / (change in blood temp as
a function of time, or AUC)
Types of Shock
CO
PCWP
SVR
Cardiogenic
6
5
5
Hypovolemic
5/6
6
5
5
N/6
6
Septic / Distributive
Cardiogenic Shock
• Severely decreased cardiac output
• Extracardiac obstructive shock (e.g.
cardiac tamponade) has equalization
of pressures
• RAP = RV diastolic = PA diastolic =
PCWP
• RA with minimal x and y descents,
and elevation in mean RAP
• Loss of PA respiratory variations
Constrictive Pericarditis
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Limited early diastolic filling
Causes a plateau in the RV pressure
“Square root sign”
RAP has a “M” or “W” configuration
a and v waves accentuated with rapid
x and y descents
• Due to rheumatic disease, TB,
metastatic carcinoma, prior chest
XRT, or open heart surgery
Constrictive Pericarditis
Hypovolemic Shock
• Due to decreased blood volume
• Usually from hemorrhage or volume
depletion
Distributive / Septic Shock
• Due to peripheral vasodilation
• Other causes include anaplylaxis,
neurogenic shock, Addisonian crisis,
toxic shock syndrome, cirrhosis, and
myxedema coma
Information from PA Catheter
• Directly:
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CVP
PA pressure
PCWP
CO
SvO2
• Calculated:
– Stoke volume/
index
– Cardiac index
– Systemic vascular
resistance (SVR)
– Pulmonary
vascular resistance
(PVR)
– Oxygen delivery
Formulas
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•
•
•
SVR = (MAP – CVP) / CO
PVR = (MPAP – PCWP) / CO
SV = CO / HR
CaO2 = (1.39 x Hb x SaO2) + (0.003 x
PaO2)
• DO2 = CaO2 x CO
Normal Values
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SvO2
Stoke volume
Stroke index
Cardiac output
Cardiac index
MAP
CVP
PCWP
PA pressures
SVR
PVR
60-75%
50-100 mL/beat
25-45 mL/beat/m2
4-8 L/min
2.5-4.0 L/min/m2
70-110 mmHg
2-6 mmHg
8-12 mmHg
15-30 / 0-10 mmHg
900-1400 dynes.sec/cm5
40-150 dynes.sec/cm5
Case # 1
• A 65 year old man with COPD
required intubation for respiratory
failure. He was placed on AC.
• Shortly after intubation, he developed
hypotension and a SG catheter was
placed, but a PCWP could not be
obtained.
Case # 1
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RA 4, sat 76%
RV 45/0, sat 76%
PA 45/20, mean 28, sat 77%
PCWP ???
BP 90/60, mean 70
CO 5.7
SVR 928
7.44 / 34 / 110, sat 99%
Mixed venous 7.38 / 42 / 44, sat 77%
Case # 2
• A 58 year old male is admitted to the
CCU as a r/o MI.
• Developed respiratory distress.
Case # 2
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RA 6, sat 65%
RV 55/0, sat 66%
PA 55/30, mean 45, sat 66%
PCWP ???, sat 91%
BP 110/80, mean 90
CO 5.0
SVR 1,344
7.44 / 35 / 80, sat 91%
Mixed venous 7.40 / 40 / 36, sat 66%
Case # 2
Case # 3
• A 55 year old female is admitted with
chest pain and shock.
• The EKG shows acute ischemic
changes in the inferior limb leads.
• What is the diagnosis, and how would
you treat her?
Case # 3
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RA 14, sat 55%
RV 30/15, mean 20, sat 55%
PA 30/11, mean 20, sat 55%
PCWP
BP 90/60, mean 70
CO 2.5
SVR 1,792
7.38 / 35 / 85, sat 90%
Mixed venous 7.34 / 41 / 32, sat 55%
Case # 4
• A 50 year old male presents with
syncope and shock.
• Room air ABG is obtained.
Case # 4
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RA 15, sat 48%
RV 45/0, sat 48%
PA 45/20, mean 28, sat 49%
PCWP 7
BP 50/50, mean 60
CO 2.5
SVR 1,440
7.32 / 32 / 59, sat 89%
Mixed venous 7.28 / 38 / 28, sat 49%
Case # 5
• A 65 year old male with a two day
history of weakness, dizziness, and
dyspnea on exertion.
• On physical, noted to have a resting
tachycardia.
• Chest x-ray shows a mediastinal
mass.
Case # 5
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RA 20, sat 71%
RV 45/19, sat 71%
PA 45/20, mean 28, sat 72%
PCWP 20, sat 96%
BP 90/70, mean 77
CO 4.0
SVR 1,140
7.39 / 38 / 85, sat 96%
Mixed venous 7.38 / 40 / 40, sat 72%
Case # 6
• A 112 year old male presents with
tachypnea, confusion, and
hypotension.
Case # 6
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RA 2, sat 69%
RV 42/0, sat 69%
PA 45/15, mean 25, sat 70%
PCWP 8, sat 85%
BP 70/40, mean 50
CO 6.5
SVR 592
7.55 / 32 / 50, sat 85%
Mixed venous 7.40 / 38 / 37, sat 70%
Case # 7
• A 45 year old alcoholic with
abdominal pain and hypotension.
• Chest x-ray shows a large, globular
heart and a left pleural effusion.
• The Hct 45%.
Case # 7
•
•
•
•
•
•
•
•
•
RA 1, sat 49%
RV 20/0, sat 49%
PA 20/10, mean 13, sat 49%
PCWP 4
BP 80/50, mean 60
CO 3.0
SVR 1,576
7.34 / 30 / 80
Mixed venous 7.31 / 38 / 28, sat 49%
Case # 8
• 24 hours later, the prior patient in
Case #7 becomes tachypneic.
• What complication has occurred?
Case # 8
•
•
•
•
•
•
•
•
•
RA 4, sat 64%
RV 45/0, sat 64%
PA 45/25, mean 32, sat 65%
PCWP 12
BP 110/70, mean 85
CO 6.1
SVR 1,064
7.46 / 32 / 55, sat 89%
Mixed venous 7.40 / 31 / 35, sat 65%
Case # 9
• A 98 year old male with confusion and
hypotension.
• What kind of shock does he have?
Case # 9
•
•
•
•
•
•
•
•
•
RA 12, sat 47%
RV 40/12, sat 48%
PA 40/30, mean 33, sat 49%
PCWP 29, sat 90%
BP 80/50, mean 60
CO 2.5
SVR 1,536
7.30 / 45 / 60, sat 90%
Mixed venous 7.26 / 50 / 28, sat 49%
Case # 10
• 35 year old female with an abnormal
chest x-ray and dyspnea on exertion.
• What is the diagnosis?
Case # 10
•
•
•
•
•
•
•
•
•
RA 8, sat 84%
RV 60/0, sat 85%
PA 45/20, mean 28, sat 86%
PCWP 10, sat 99%
BP 120/80, mean 95
CO 9.4
SVR 744
7.40 / 40 / 99, sat 99%
Mixed venous 7.38 / 42 / 54, sat 86%
Case # 11
• A 38 year old female presents with
chest pain and dyspnea.
Case # 11
•
•
•
•
•
•
•
•
•
RA 8, sat 65%
RV 110/10, sat 66%
PA 90/50, mean 63, sat 67%
PCWP 12, sat 98%
BP 110/70, mean 83
CO 3.2
SVR 1,872
7.41 / 30 / 90, sat 98%
Mixed venous 7.37 / 33 / 37, sat 67%
Case # 12
• 18 year old female presents with
exertional syncope.
Case # 12
•
•
•
•
•
•
•
•
•
RA 15, sat 78%
RV 110/27, sat 90%
PA 80/40, mean 60, sat 91%
PCWP 28
BP 120/80, mean 95, sat 99%
CO 20
SVR 800
7.40 / 40 / 99, sat 99%
Mixed venous 7.38 / 42 / 79, sat 91%
Suggested Websites
• www.pacep.org
• http://www.edwards.com/Products/PA
Catheters/CatheterizationTechniques.
htm