Interpreting ABGs (or the ABCs of ABGs)

1
Interpreting ABGs(or the ABCs of ABGs)

• Suneel Kumar MD

2
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

3
Oxygenation

• Hypoxia reduced oxygen pressure in the alveolus
  (i.e. PAO2)
• Hypoxemia reduced oxygen pressure in arterial
  blood (i.e. PaO2)

4
Hypoxia with Low PaO2

• Alveolar diffusion impairment
• Decreased alveolar PO2
• Decreased FiO2
• Hypoventilation
• High altitude
• R ? L shunt
• V/Q mismatch

5
Hypoxia with Normal PaO2

• Alterations in hemoglobin
• Anemic hypoxia
• Carbon monoxide poisoning
• Methemoglobinemia
• Histotoxic hypoxia
• Cyanide
• Hypoperfusion hypoxia or stagnant hypoxia

6
AlveolarArterial 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

7
AlveolarArterial Gradient

• A-a gradient PAO2 PaO2
• PAO2 alveolar PO2 (calculated)
• PaO2 arterial PO2 (measured)

8
AlveolarArterial Gradient

• PAO2 PIO2 (PaCO2/RQ)
• PAO2 alveolar PO2
• PIO2 PO2 in inspired gas
• PaCO2 arterial PCO2
• RQ respiratory quotient

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AlveolarArterial 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)

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AlveolarArterial Gradient

• PAO2 FiO2 (PB PH2O) (PaCO2/RQ)
• Or
• PAO2 FiO2 (713) (PaCO2/0.8)

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AlveolarArterial Gradient

• For room air
• PAO2 150 (PaCO2/0.8)
• And assume a normal PaCO2 (40)
• PAO2 100

12
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.

13
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?

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Henderson-Hasselbach Equation

• pH pK log HCO3/PaCO2 x K
• (K dissociation constant of CO2)
• Or
• H 24 x PaCO2/HCO3

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Henderson-Hasselbach Equation

• pH
• 7.20
• 7.30
• 7.40
• 7.50
• 7.60

• H
• 60
• 50
• 40
• 30
• 20

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Step 1Acidemia or Alkalemia?

• Normal arterial pH is 7.40 0.02
• pH lt 7.38 ? acidemia
• pH gt 7.42 ? alkalemia

17
Step 2Primary Disturbance

• Anything that alters HCO3 is a metabolic process
• Anything that alters PaCO2 is a respiratory
  process

18
Step 2Primary Disturbance

• If 6pH, there is either 5PaCO2 or 6HCO3
• If 5pH, there is either 6PaCO2 or 5HCO3

19
Step 3Respiratory 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

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Step 4For Metabolic, Anion Gap?

• Anion gap Na - (Cl- HCO3-)
• Normal is lt 12

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Increased Anion Gap

• Ingestion of drugs or toxins
• Ethanol
• Methanol
• Ethylene glycol
• Paraldehyde
• Toluene
• Ammonium chloride
• Salicylates

22
Increased Anion Gap

• Ketoacidosis
• DKA
• Alcoholic
• Starvation
• Lactic acidosis
• Renal failure

23
Step 4For 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 lt 10 mOsm/kg

24
Nongap Metabolic Acidosis

• Administration of acid or acid-producing
  substances
• Hyperalimentation
• Nonbicarbonate-containing IVF

25
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

26
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

27
Nongap Metabolic Acidosis

• Urine Cl- lt 10 mEq/l is chloride responsive and
  accompanied by contraction alkalosis and is
  saline responsive
• Urine Cl- gt 20 mEq/l is chloride resistant, and
  treatment is aimed at underlying disorder

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Step 5 Any other process with elevated AG?

• Calculate rgap, or gap-gap
• rGap Measured AG Normal AG (12)

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Step 5 Any other process with elevated AG?

• Add rgap to measured HCO3
• If normal (22-26), no other metabolic problems
• If lt 22, then concomitant metabolic acidosis
• If gt 26, then concomitant metabolic alkalosis

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Step 6 Adequate respiratory compensation?

• Winters 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

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Step 6 Adequate respiratory compensation?

• In metabolic alkalosis, Winters formula does not
  predict the respiratory response
• PaCO2 will rise gt 40 mmHg, but not exceed 50-55
  mmHg
• For respiratory compensation, pH will remain gt
  7.42

32
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

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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).

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Case 1
138
100
26
7.08/80/37
35
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

36
Case 1

• What is the anion gap?
• AG 138 (100 26)
• AG 12

37
Case 1

• Acute respiratory acidosis

38
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.

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Case 2
135
99
12
4.8
7.23/25/113
40
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

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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

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Case 2

• Acute anion gap metabolic acidosis (DKA)

43
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.

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Case 3
135
93
30
7.21/75/41
45
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

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Case 3

• What is the anion gap?
• AG 135 (93 30) 12

47
Case 3

• Acute on chronic respiratory acidosis (COPD)

48
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.

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Case 3b

• Why is he alkalotic with a normal PCO2?
• Chronic compensatory metabolic alkalosis and
  acute respiratory alkalosis

50
Case 4

• A 23 year old female presents to the Emergency
  Room complaining of chest tightness and
  light-headedness. 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.

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Case 4
135
109
22
7.54/22/115
52
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

53
Case 4

• Acute respiratory alkalosis (panic attack)

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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
55
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

56
Case 5

• Non anion gap metabolic acidosis (diarrhea)
• Compensatory respiratory alkalosis

57
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.

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Case 6
136
70
19
7.58/21/104
59
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

60
Case 6

• Primary respiratory alkalosis (pregnancy)
• Anion gap metabolic acidosos (ketoacidosis)
• Nongap metabolic alkalosis (vomiting)

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Case 7

• 35 year old male presents to the ER unconscious.

145
70
Creat 6.1
23
7.61/24/78
62
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

63
Case 7

• What is the rgap?
• rGap 52 - 12 40
• rGap HCO3 63
• Nongap metabolic alkalosis

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Case 7

• Respiratory alkalosis
• Anion gap metabolic acidosis (renal failure)
• Nongap metabolic alkalosis

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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.

66
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.

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Bonus Case 1
126
93
58
218
11
3.4
1.8
UA 1 ketones Acetone negative Lactate 6.9 EtOH
0 Osm 272
7.46/15/107
68
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

69
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

70
Bonus Case 1

• Respiratory alkalosis (aspirin)
• Anion gap metabolic acidosis (aspirin)
• Nongap metabolic acidosis

71
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.

72
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.

73
Bonus Case 2
142
98
14
108
10
4.3
UA negative EtOH 45 Osm 348
7.22/24/108
74
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

75
Bonus Case 2

• What is the rgap?
• rGap 34 - 12 22
• rGap HCO3 32
• Nongap metabolic alkalosis

76
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

77
Bonus Case 2

• Anion gap metabolic acidosis with elevated
  osmolar gap (methanol)
• Nongap metabolic alkalosis
• Compensatory respiratory alkalosis

78
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.

79
Bonus Case 3
130
80
10
7.20/25/68
80
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

81
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

82
Bonus Case 3

• Anion gap metabolic acidosis (DKA)
• Metabolic metabolic alkalosis (emesis)
• Compensatory respiratory alkalosis

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Pulmonary Artery Catheters

• Suneel Kumar MD

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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

86
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

87
History

• Jeremy Swan and William Ganz from Cedars-Sinai
  developed a balloon-guided 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

88
Functional Cardiac Anatomy
89
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)

90
Use of PA Catheter

• To establish diagnosis
• To guide therapy
• To monitor response to therapy
• To assess determinants of tissue oxygenation

91
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

92
Indications
93
Contraindications

• Tricuspid or pulmonic valve mechanical protheses
• Right heart mass (thrombus or tumor)
• Tricuspid or pulmonic valve endocarditis

94
Approaches to Access
95
Approaches to Access
96
Approaches to Access
97
Approaches to Access
98
Insertion Technique
99
Proper Position
100
Coiled PA Catheter
101
Distal Cath Tip
102
Lung Zones of West
103
Lung Zones of West
PA gt Pa gt Pc
Pa gt PA gt Pc
Pa gt Pc gt PA
104
Static Column of Blood to LA
105
During Diastole

• Tricuspid and mitral valves are open
• Blood leaves the atria and fill the ventricles
• Pressure between the atria and ventricles equalize

106
At End-Diastole

• Mean RA pressure equalizes with the RV
  end-diastolic pressure
• PA diastolic and PCWP equalize with the LV
  end-diastolic pressure

107
Mean RA RV EDP
108
PA EDP and PCWP LV EDP
109
CVP/RA Waveform

• Three positive waves
• a wave (usually largest)
• c wave (may not be seen)
• v wave

110
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

111
CVP/RA Waveform
112
CVP/RA Waveform and EKG

• a wave in PR interval
• c wave at end of QRS, in RST junction
• v wave after T wave

113
Measuring Mean CVP

• Final filling of the ventricle occurs during
  atrial contraction (a wave)
• Therefore, average the a wave on the CVP/RA
  waveform

114
Measuring the Mean CVP
115
RV Waveform

• Sharp upstroke during systole, and downstroke
  during diastole

116
RV Waveform
117
RV Waveform
118
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

119
RV to PA
120
PA Waveform

• PA systole within T wave
• PA diastole at end of QRS

121
PCWP Waveform

• Inflation of the balloon stops forward blood flow
• Creates a static column of blood between the
  catheter tip and the LA

122
PCWP Waveform

• Has a waveform characteristic of the RA,
  primarily with a waves and v waves
• Mean PCWP is close to PA diastolic pressure

123
PCWP Waveform and EKG

• a wave near end or after QRS
• v wave well after T wave

124
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

125
Mean PCWP Measurement
12 6 / 2 9
126
PCWP at End Expiration
127
Waveform Review
128
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129
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130
Calculating Cardiac Output

• Cardiac output done by thermodilution
• Known saline bolus (5-10 mL) at known temperature
  (usually lt 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

131
Calculating Cardiac Output
132
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)

133
Types of Shock
CO PCWP SVR
Cardiogenic 6 5 5
Hypovolemic 5/6 6 5
Septic / Distributive 5 N/6 6
134
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

135
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

136
Constrictive Pericarditis
137
Hypovolemic Shock

• Due to decreased blood volume
• Usually from hemorrhage or volume depletion

138
Distributive / Septic Shock

• Due to peripheral vasodilation
• Other causes include anaplylaxis, neurogenic
  shock, Addisonian crisis, toxic shock syndrome,
  cirrhosis, and myxedema coma

139
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

140
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

141
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

142
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.

143
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

144
Case 2

• A 58 year old male is admitted to the CCU as a
  r/o MI.
• Developed respiratory distress.

145
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

146
Case 2
147
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?

148
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

149
Case 4

• A 50 year old male presents with syncope and
  shock.
• Room air ABG is obtained.

150
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

151
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.

152
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

153
Case 6

• A 112 year old male presents with tachypnea,
  confusion, and hypotension.

154
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

155
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.

156
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

157
Case 8

• 24 hours later, the prior patient in Case 7
  becomes tachypneic.
• What complication has occurred?

158
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

159
Case 9

• A 98 year old male with confusion and
  hypotension.
• What kind of shock does he have?

160
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

161
Case 10

• 35 year old female with an abnormal chest x-ray
  and dyspnea on exertion.
• What is the diagnosis?

162
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

163
Case 11

• A 38 year old female presents with chest pain and
  dyspnea.

164
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

165
Case 12

• 18 year old female presents with exertional
  syncope.

166
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

167
Suggested Websites

• www.pacep.org
• http//www.edwards.com/Products/PACatheters/Cathet
  erizationTechniques.htm

168
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