Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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 • • • • 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 – – – – – – – 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 • • • • 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 • • • • • 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: – – – – – CVP PA pressure PCWP CO SvO2 • Calculated: – Stoke volume/ index – Cardiac index – Systemic vascular resistance (SVR) – Pulmonary vascular resistance (PVR) – Oxygen delivery Formulas • • • • 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 • • • • • • • • • • • 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 • • • • • • • • • 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 • • • • • • • • • 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 • • • • • • • • • 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 • • • • • • • • • 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 • • • • • • • • • 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 • • • • • • • • • 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