Lab values beyond the numbers

Toni Petrillo, MD

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

Overview
Blood Gases Chemistries CBCs CSF

Blood Gases
pH PCO2 PO2 Base Excess O2 Sat

Blood Gases
pH

Normal : 7.35 - 7.45 pH = acidosis; pH = alkalosis

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

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-) BUN Creatinine (Cr) Glucose Calcium (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

False Hyperglycemia
Na+ decrease 1.6 meq/l for each increase in glucose over 100

Vomiting/ Diarrhea Diuretics SIADH Cerebral Salt Wasting

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 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

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

Hyperkalemia

Diuretics hypomagnesium Licorice RTA V/D Pyloric Stenosis DKA Antibiotics (ie: AmphoB)

Acidosis Renal Failure Muscle necrosis Blood Transfusions Hemolysis CAH

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

Chemistries: K+
Treatment of Hypokalemia:

Treatment of Hyperkalemia:

KCL bolus 0.3 - 1 meq / kg no more than 0.6 meq/kg/hour

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 Dehydration Respiratory Alkalosis 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 Shock Burns High Protein Diet Dehydration Tissue Necrosis Steroids Diarrhea

Decreased
Anabolic Steroids Liver Dz Malnutrition 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 enzyme deficiency Malignancy 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

CBCS
White Blood cell = WBC

Differential
Segs / polys Eosinophils Basophils Lymphocytes Monocytes Bands

Hemoglobin Hematocrit Platelets

CBC: WBC
Birth WBC 9-30 14d 5-20 1y 6-18 4y 5-15 8-21y adult 4.5- 4.513.5 11 60 30 8 1 1 60 32 4 3 1

%
poly lymh mono eos baso 45 30 12 2 1 36 53 8 2 1 40 53 5 1 1 50 40 8 1 1

CBC: WBC
Increased neutrophils

Decreased neutrophils

physiologic
newborn,pregnancy

Infection
bacterial
typhiod septicemia

Pathologic
acute infection inflammatory dz metabolic disorder tissue necrosis drugs stress

Viral
Hepatitis flu mono measles

myeloid hypoplasia drugs

CBC: WBC
Increased Lymphocytes

Decreased Lymphocytes

Infection
Viral:
Hepatitis CMV mono HSV
mumps

Bacterial
Pertussis

Increased Corticosteroids immunodeficiency miliary Tb Lupus

Chronic Inflammation Metabolic Hematologic

ALL

CBC: WBC
Monocytes

Elevated
mumps malaria lymphomas

Eosinophils

Elevated
Parasitic dz allergies T-Cell leukemia lupus

CBC: Hemoglobin / Hematocrit

Hemoglobin

Normal 1 week: 13-20 6months 10.5-14.5 10years: 11-16

1 month: 11-17 1 year: 11-15 15years: 14-18M 12-16F

Hematocrit

Normal 14-90d:35-49 4-10yr: 31-43

6m-1yr:30-40 Adult:42-52M 37-47F

CBC: H/H
Increased Hct

Decreased Hct

Polycythemia
Heart Dz Chronic Hypoxia

Anemia
Iron Deficiency Malabsorbtion HgSS Toxin/drugs
Lead

High Altitude Hemoconcentration

Surgery Burns Dehydration

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
Normal Bacterial TB Viral CNS Bleed clear Turbid Turbid Clear Bloody

Cells
0-10 (20) lymphs

Protien
< 45

Glucose
2/3 serum (55-80) very low low Normal Normal

100-10,000 50-500 segs 10-500 lymphs 10-500 lymphs increased RBC 50-500 45-200 45-100