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UNIT-II BIO CHEMICAL AND NON ELECTRICAL PARAMETER MEASUREMENT OBJECTIVES: To study of the acidity & alkalinity of the

he blood To study about different gases involved in a human body .

pH is a measurement of the acidity of the blood, reflecting the number of hydrogen ions present. Lower numbers mean more acidity; higher number mean more alkalinity. pH is Elevated (more alkaline, higher pH) with:

Hyperventilation Anxiety, pain Anemia Shock Some degrees of Pulmonary disease Some degrees of Congestive heart failure Myocardial infarction Hypokalemia (decreased potassium) Gastric suctioning or vomiting Antacid administration Aspirin intoxication

pH is Decreased (more acid, lower pH) with:


Strenuous physical exercise Obesity

Starvation Diarrhea Ventilatory failure More severe degrees of Pulmonary Disease More severe degrees of Congestive Heart Failure Pulmonary edema Cardiac arrest Renal failure Lactic acidosis Ketoacidosis in diabetes

pCO2 (Partial Pressure of Carbon Dioxide) reflects the the amount of carbon dioxide gas dissolved in the blood. Indirectly, the pCO2 reflects the exchange of this gas through the lungs to the outside air. Two factors each have a significant impact on the pCO2. The first is how rapidly and deeply the individual is breathing:

Someone who is hyperventilating will "blow off" more CO2, leading to lower pCO2 levels Someone who is holding their breath will retain CO2, leading to increased pCO2 levels

The second is the lungs capacity for freely exchanging CO2 across the alveolar membrane:

With pulmonary edema, there is an extra layer of fluid in the alveoli that interferes with the lungs' ability to get rid of CO2. This leads to a rise in pCO2.

With an acute asthmatic attack, even though the alveoli are functioning normally, there may be enough upper and middle

airway obstruction to block alveolar ventilation, leading to CO2 retention. Increased pCO2 is caused by:

Pulmonary edema Obstructive lung disease

Decreased pCO2 is caused by:


Hyperventilation Hypoxia Anxiety Pregnancy Pulmonary Embolism (This leads to hyperventilation, a more important consideration than the embolized/infarcted areas of the lung that do not function properly. In cases of massive pulmonary embolism, the infarcted or non-functioning areas of the lung assume greater significance and the pCO2 may increase.)

PO2 (Partial Pressure of Oxygen) reflects the amount of oxygen gas dissolved in the blood. It primarily measures the effectiveness of the lungs in pulling oxygen into the blood stream from the atmosphere. Elevated pO2 levels are associated with:

Increased oxygen levels in the inhaled air Polycythemia

Decreased PO2 levels are associated with:


Decreased oxygen levels in the inhaled air Anemia

Heart decompensation Chronic obstructive pulmonary disease Restrictive pulmonary disease Hypoventilation

CO2 Content is a measurement of all the CO2 in the blood. Most of this is in the form of bicarbonate (HCO3), controlled by the kidney. A small amount (5%) of the CO2 is dissolved in the blood, and in the form of soluble carbonic acid (H2CO3). For this reason, changes in CO2 content generally reflect such metabolic issues as renal function and unusual losses (diarrhea). Respiratory disease can ultimately effect CO2 content, but only slightly and only if prolonged. Elevated CO2 levels are seen in:

Severe vomiting Use of mercurial diuretics COPD Aldosteronism

Decreased CO2 levels are seen in:


Renal failure or dysfunction Severe diarrhea Starvation Diabetic Acidosis Chlorthiazide diuretic use

Base Excess or Base Deficit Whenever there is an accumulation of metabolically-produced acids, the body attempts to neutralize those acids to maintain a constant acidbase balance. This neutralizing is achieved by using up various "buffering" compounds in the blood stream, to bind the acids, disallowing them from contributing to more acidity. About half of these buffering compounds come from HCO3, and the other half from plasma and red blood cell proteins and phosphates. The words "base deficit" and "base excess" are equivalent and are generally used interchangeably. The only difference is that base deficit is expressed as a positive number and base excess is expressed as a negative number. A "Base Deficit" of 10 means that 10 mEqu/L of buffer has been used up to neutralize metabolic acids (like lactic acid). Another way to say the same thing would be the "Base Excess is minus 10." More Negative Values of Base Excess may Indicate:

Lactic Acidosis Ketoacidosis Ingestion of acids Cardiopulmonary collapse Shock

More Positive Values of Base Excess may Indicate:


Loss of buffer base Hemorrhage

Diarrhea Ingestion of alkali

Oxygen measures hemoglobin

Saturation the which is

(SO2) Normal Adult Arterial Values* of fully pH pCO2 pO2 CO2 Base SO2 7.35-7.45 35-45 torr >79 torr 23-30 mmol/L >94% 3 Excess/Deficit mEq/L

percent

combined with oxygen. While this measurement can be obtained from an arterial or venous blood sample, it's major attractive feature is that it can be obtained non-invasively through the "pulseoximeter." Normally, oxygen saturation on room air is in excess of 95%. With deep or rapid breathing, this can be increased to 98-99%. While breathing (40% oxygen-enriched 100%), the air oxygen and continuously of a use

Normal Adult Venous Values* pH pCO2 pO2 CO2 Base 7.31-7.41 41-51 torr 30-40 torr 23-30 mmol/L 75% 3 Excess/Deficit mEq/L SO2

saturation can be pushed to 100%. Oxygen Saturation will fall if:

Inspired oxygen levels are diminished, such middle as at increased altitudes.

Blood Gas Abbreviations BE Base (positive Excess

Upper

or

airway

obstruction exists (such as

during an acute asthmatic attack)

number) or Base Deficit (negative number) HCO3 PO2 PaO2 Bicarbonate Partial Partial of PvO2 Pressure Pressure in H2CO3 Carbonic Acid of Oxygen Oxygen

Significant disease across membrane.

alveolar

lung

exists, the

interfering alveolar

with the free flow of oxygen

Oxygen Saturation will rise if:

Arterial Blood Deep occurs

or

rapid

breathing

Partial of

Pressure in

Oxygen

Inspired oxygen levels are increased, such as breathing from a 100% oxygen source

Venous Blood PCO2 Partial of Dioxide PaCO2 Partial of Dioxide Arterial Blood PvCO2 Partial of Dioxide Venous Blood SO2 SaO2 Oxygen Saturation Oxygen Saturation Arterial Blood SvO2 Oxygen Saturation in in Pressure Carbon in Pressure Carbon in Pressure Carbon

Venous Blood TCO2 Total Carbon Dioxide Content Normal Adult Arterial Values*pH pCO2 pO2 CO2 Base Excess/Deficit SO2 7.35-7.45 35-45 torr >79 torr 23-30 mmol/L 3 mEq/L >94%

Normal Adult Venous Values* pH pCO2 pO2 CO2 Base Excess/Deficit SO2 Blood Gas Abbreviations BE HCO3 PO2 PaO2 PvO2 PCO2 Base Excess (positive number) or Base 7.31-7.41 41-51 torr 30-40 torr 23-30 mmol/L 3 mEq/L 75%

Deficit (negative number) Bicarbonate Partial Pressure of Oxygen Partial Pressure of Oxygen in Arterial Blood Partial Pressure of Oxygen in Venous Blood Partial Pressure of Carbon Dioxide Blood PvCO2 Partial Pressure of Carbon Dioxide in Venous H2CO3 Carbonic Acid

PaCO2 Partial Pressure of Carbon Dioxide in Arterial

Blood SO2 SaO2 SvO2 Oxygen Saturation Oxygen Saturation in Arterial Blood Oxygen Saturation in Venous Blood

TCO2 Total Carbon Dioxide Content Capillary Electrophoresis OBJECTIVES: To analysis of both large and small molecules. To study the types & applications

Capillary electrophoresis (CE) is electrophoresis performed in a capillary tube [13]. It is the most efficient separation technique available for the analysis of both large and small molecules. The transformation of conventional electrophoresis to modern CE was spurred by the production of inexpensive narrow-bore capillaries for gas chromatography (GC) and the development of highly sensitive on-line detection methods for high performance liquid chromatography (HPLC). The basic instrumental set-up, which is illustrated in Figure 1, consists of a high voltage power supply (0 to 30 kV), a fused silica (SiO2) capillary, two buffer reservoirs, two electrodes, and an on-column detector. Sample injection is accomplished by temporarily replacing one of the buffer reservoirs with a

sample vial. A specific amount of sample is introduced by controlling either the injection voltage or the injection pressure. The unprecedented resolution of CE is a consequence of the techniques extremely high efficiency. The separation efficiency of CE and other high-resolution techniques such as chromatography and field-flow fractionation is modeled by the van Deemter equation, which relates the plate height, H, to the velocity, x,of the carrier gas or liquid along the separation axis, x.

Col orimetry relatively inexpensive

fast, requiring a set of standard solutions quantitative coloured solutions or compounds

qualitative &

a type of absorption spectroscopy limited to

Atomic Absorption Spectroscopy (AAS)

expensive fast, requiring a set of standard solutions quantitative a type of absorption spectroscopy that can be used for all metals and metalloids (semi-metals)

UV-Visible Spectroscopy

expensive

fast,

requiring

set

of

standard

solutions

qualitative & quantitative

a type of absorption spectroscopy

limited to coloured solutions or compounds

SPECTROPHOTOMETERS Spectrophotometers use monochromatic dispersion elements to vary the wavelengths.

continuously variable wavelength selection

light source is UV or VIS

Optical Path of Single Beam Spectrophotometers

Steps for the use of a single beam spectrophotometer 1. 2. 3. 4. 5. Set the wavelength. Select readout display to the desired mode ( %T, A, Conc). Set the readout display to 0 %T (no light) (shutter closed). Insert the reference cell which contains the solvent and set the readout display to 100 %T (shutter open). Insert the sample dissolved in the solvent and read %T from the display. Advantages of single beam spectrophotometer

Wavelengths easily selected Low cost

Disadvantages of single beam spectrophotometer

Cannot easily be used for absorption spectra (point by point). Changes in light intensity cause variations in readout. Changes in solvent causes variations. Changes in wavelengths cause variations and % T and has to be reset at 0 %T and 100 %T.

1) Given the following arterial blood gas values: pH: 7.56 PaCO2: 31 mm Hg HCO3: 27 mEq/l PaO2: 56 mm Hg What is(are) the most likely acid-base state(s) in the patient? a) acute respiratory alkalosis b) chronic respiratory alkalosis c) respiratory alkalosis and metabolic alkalosis d) respiratory acidosis and metabolic acidosis e) respiratory alkalosis and metabolic acidosis Answer: c The subject is hyperventilating with an elevated pH, indicating respriratory alkalosis. However, with hyperventilation bicarbonate goes down from the

simple excretion of CO2 in the hydration equation; CO2 + H2O <----> HCO3- + H+. As CO2 is excreted both bicarbonate and hydrogen ion fall. With simple hyperventilation and no other acid base disorder the HCO3should fall slightly from the normal value of 24 mEq/L, and be about 22-23 mEq/L. In this example it is 27 mEq/L, indicating a comcomitant mild metabolic alkalosis. 2) A healthy young woman, toward the end of a mile run in the gym, has increased her heart rate by 50% over baseline. At that point, which one of the following statements is least likely to be true. a) She is tachypneic and/or hyperpneic. b) She is hyperventilating. c) Her alveolar ventilation is increased above its resting baseline value. d) Her CO2 production is increased above its resting baseline value. e) Her PaO2 is normal. Answer: b Hyperventilation is defined excess alveolar ventilation for CO2 production, which always leads to a low PaCO2 (if the subject starts from normal value of @40 mm Hg). It is NOT the same as tachypnea or hyperpnea. Since this healthy young woman has increased her heart rate with exercise, she has surely increased her CO2 production as well, and as a result her respiratory rate to blow it off. Thus she is tachypneic and or hyperpneic in order to

increase her alveolar ventilation, which is necessary to excrete her excess metabolic CO2 production. She should NOT be hyperventilating though, as her increase in CO2 production will be balanced by increased alveolar ventilation, leaving PaCO2 unchanged. All of this is explained in the 4 Most Important Equations in Clinical Medicine (PaCO2 Equation). 3) Which of the following changes will most increase arterial oxygen delivery? a) PaO2 from 60 to 95 mm Hg b) cardiac output from 4 to 5 L/min c) hemoglobin from 9 to 10 grams% d) atmospheric pressure from 1 to 2 atmospheres e) arterial pH from 7.30 to 7.50 Answer: b Oxygen increasing delivery delivery neglible the increase in same SaO2 delivery CaO2 is about oxygen 9% and content O2 x cardiac about output. the same.

a) This change in PaO2 will increase SaO2 from about 90% to 98%, in effect delivery b) This is a 25% increase in cardiac output, which will increase oxygen 25%. percentage, and oxygen 11%. content. c) This is an 11% increase in oxygen content, which will increase O2 d) This change will increase PaO2 from about 100 to 200 mm Hg, for a e) This change will shift the O2 dissociation curve to the left and increase SaO2 slightly, perhaps by 2-3%.

4) Given the following arterial blood gas values: pH: 7.40 PaCO2: 20 mm Hg HCO3: 12 mEq/l What is(are) the most likely acid-base state(s) in the patient? a) metabolic acidosis with full compensation b) respiratory alkalosis with full compensation c) metabolic acidosis and respiratory alkalosis d) metabolic acidosis and metabolic alkalosis e) normal acid-base state Answer: c A normal pH with abnormal PaCO2 or HCO3 indicates two or more acid base disorders. Full compensation (back to baseline) is never achieved with a single acid-base disorder. 5) All of the following are true about SpO2 as measured by pulse oximeters that utilize two wavelengths of light (i.e., most pulse oximeters in use today) except: a) Can can be normal even when PaCO2 is >200 mm Hg. b) Is not affected by anemia.

c)

Does

not

differentiate

oxyhemoglobin

from

carboxyhemoglobin. d) Is not affected by excess methemoglobin. e) Requires a detectable pulse. Answer: d SpO2 falls in the presence of excess methemoglobin, approimately 1/2 percent for every percent of MetHb. Thus 10% MetHb will give about a 5% decline in SpO2. All the other statements are true. 6) All of the following are true about non-arterial assessment of oxygenation and acid-base balance except: a) if venous CO2 (measured as part of standard electrolyte panel) is truly abnormal, the patient has some type of acid-base disorder. b) in a hemodynamically stable patient, venous blood gases measured from central venous blood can be used to assess acidbase status. c) venous blood can be used in lieu of arterial blood to measure blood carboxyhemoglobin. d) the bicarbonate gap, which is (Na+ - Cl- - 39), can diagnose a metabolic alkalosis even when there is increased anion gap. e) in a stable patient with normal lungs, the difference between PaCO2 and end-tidal PCO2 is 10 to 15 mm Hg. Answer: e

In a normal person end tidal PCO2 is equal to PaCO2. All other statements are true. 7) One or more of the following statements (A, B, C) about PaO2 may be correct. Choose the single letter answer (a - e) that reflects which statement(s) is(are) correct. A) If the lungs and heart are normal, then PaO2 is affected only by not factors that affect affect alveolar PO2. PaO2. B) In a person with normal heart and lungs, anemia should C) The reason PaO2 falls with increasing altitude is because barometric pressure falls. a) only A) is correct. b) A) and B) are correct. c) A) and C) are correct. d) B) and C) are correct e) A), B) and C) are correct. Answer: e All 3 statements are correct. 8) A patient presents with the following arterial blood gases, drawn on room air (FIO2 = .21). pH: 7.40

PCO2: 40 mm Hg PO2: 82 mm Hg HCO3: 24 mEq/L Which of the following statements is most accurate? a) The patient does not have an acid-base disorder. b) To determine if there is an acid base disorder you need to know the measured serum bicarbonate, since the HCO3 from blood gases is only a calculation. c) Need to know patient's respiratory rate, as PaCO2 may be inappropriately "normal" and signify a respiratory acidosis. d) A patient can have normal blood gases if two metabolic acidbase disorders oppose to give normal bicarbonate. e) The PaO2 is lower than predicted for a patient breathing room air. Answer: d Metabolic acidosis and metabolic alkalosis can co-exist, so the patient ends up with a normal HCO3 and PaCO2. Serum electrolytes can make the diagnosis by showing increased anion gap; in the presence of normal HCO3, increased AG would indicate the two disorders. See also Question 14. 9) A patient with respiratory failure has the following arterial blood gases (FIO2 = .21, sea level): pH: 7.20

PCO2: 70 mm Hg PO2: 60 mm Hg SaO2: 86% Which of the following is the least likely cause of these abnormal blood gases? a) congestive heart failure b) narcotic overdose c) myasthenia gravis d) flail chest e) Guillain Barre' Syndrome Answer: a All of these conditions can lead to respiratory acidosis, but congestive heart failure would be least likely to do so without increasing the A-a O2 difference. Alveolar PO2 in this example is .21(760-43) - 1.2(PaCO2) = 15084 = 66. Thus the (PAO2 - PaO2), or so-called 'A-a gradient' is normal at about 6 mm Hg. Since the other conditions can cause respiratory acidosis without involving the lung parenchyma, and thus without raising (PAO2 PaO2), CHF is the correct answer. 10) A 42-year-old man is admitted to the hospital with dehydration and hypotension. Electrolytes show:

Na+ 165 mEq/L K+ Cl4.0 mEq/L 112 mEq/L CO2 32 mEq/L

No arterial blood gas is obtained. Which statement best applies about this patient's acid-base status? a) Electrolytes indicate the presence of metabolic acidosis. b) Electrolytes indicate the presence of metabolic alkalosis. c) Electrolytes indicate the presence of both metabolic acidosis and metabolic alkalosis. d) Need serum albumin to make any clinically useful assessment of his metabolic acid-base disorders. e) Need serum lactate to make any clinically useful assessment of his metabolic acid-base disorders. Answer: c His anion gap is Na - (CO2 + Cl) = 165 - (32+112) = 21, indicating a metabolic acidosis. His bicarbonate gap is (Na - Cl - 39) = 165 - 112 - 39 = 14, which indicates a metabolic alkalosis. Note that it is not necessary to actually calculate a bicarbonate gap, since the elevated serum CO2 (32 mEq/L) in the presence of anion gap acidosis is enought to signify concomitant metabolic alkalosis. Of course without blood gas measurements you don't know which process is predominant, but it is clear from the electrolytes that both metabolic disorders are present. You don't need to measure albumin nor lactate to make this determination.

11) A 30-year-old man, previously healthy, is brought to the ED after suffering smoke inhalation. Measured carboxyhemoglobin is 20% and hemoglobin content = 15 gm%. He has following blood gas values: PaO2: pH: SaO2: 96% (calculated) Exam shows clear lungs to auscultation and his chest x-ray is normal. From this information alone, you can determine that: a) His actual SaO2 is much lower than the calculated value. b) There is no lung abnormality present, though pulmonary disease could develop in the ensuing 24 hours. c) He has a mild metabolic acidosis associated with an increased anion gap. d) His arterial oxygen content is in the normal range. e) None of the above. Answer: a Given 20% carboxyhemoglobin, his actual SaO2 (which is the % of hemoglobin bound to oxygen) cannot be more than 80%. As to: b), a lung abnormality could be present, especially since his (PAO2-PaO2) is somewhat increased; c) no electrolyte information is given, so you don't know if he has an increased anion gap; d) no hemoglobin content is given, so you don't know his oxygen content; e) is incorrect, since a) is the 80 mm Hg 32 (on room mm 7.34 air at sea Hg level)

PaCO2:

answer. 12) Below are two sets of blood gases: Patient A: pH 7.48, PaCO2 34 mm Hg, PaO2 85 mm Hg, SaO2 95%, Hemoglobin 7 gm% Patient B: pH 7.32, PaCO2 74 mm Hg, PaO2 55 mm Hg, SaO2 85%, Hemoglobin 15 gm% Which is the most correct statement? a) B is more hypoxemic because PaO2 is lower than A. b) B is more hypoxemic because SaO2 is lower than A. c) A is more hypoxemic because A-a gradient is higher than B. d) A is more hypoxemic because O2 content is lower than B. e) The differences balance out and neither A nor B is more hypoxemic than the other. Answer: d Hypoxemia means low oxygen content in the blood. If you don't have oxygen content, then you might use PaO2 and/or SaO2 as a surrogate for assessing hypoxemia, but here you do have oxygen content information. The oxygen contents are (excluding contribution of dissolved O2): Patient A: Patient B: 1.34 x 7 x .95 = 8.91 ml O2/dl 1.34 x 15 x .85 = 17.09 ml O2/dl

Clearly, Patient A is more hypoxemic despite having a higher PaO2 and SaO2 than Patient B. 13) State which one of the following situations would be expected to lower a patient's arterial PO2. a) b) affinity the affinity carbon of of monoxide normal normal anemia poisoning hemoglobin hemoglobin c) an abnormal hemoglobin that holds oxygen with half the d) an abnormal hemoglobin that holds oxygen with twice e) lung disease with more than a normal amount of ventilation-perfusion imbalance Answer: e PaO2 is unaffected by anemia or anything to do with hemoglobin binding. PaO2 is a function of what's inhaled (Alveolar PO2) and the state of lung architecture; the latter is defined by ventilation-perfusion abnormality (which includes right to left shunting) and diffusion barrier to oxygen transfer. By far the most common cause of low PaO2 is ventilation-perfusion imbalance -- the mechanism in virtually all acute and chronic lung diseases. 14) A 40 year-old patient is admitted to the ICU with the following lab values: BLOOD pH: PCO2: HCO3: PO2: 88 mm Hg (on room air) 38 24 mm GASES 7.40 Hg mEq/L

ELECTROLYTES, Na: K: Cl: CO2: BUN: Creatinine: 8.7 mg%

BUN 149 3.8 100 24 110

&

CREATININE mEq/L mEq/L mEq/L mEq/L mg%

Which statement best describes the disorder(s)? a) Normal electrolytes, normal blood gases b) Abnormal electrolytes and abnormal blood gases c) Metabolic acidosis d) Metabolic alkalosis e) Metabolic acidosis and metabolic alkalosis Answer: e Electrolytes are not normal, since the anion gap is increased: AG = 149 (100+24) = 25. Thus, there is at least a metabolic acidosis. Furthermore, since CO2 is "normal" at 24, desite an increased anion gap, there must also be a metabolic alkalosis. See also Question 8. 15) All of the following are true about cyanosis except: a) For cyanosis to manifest there needs to be 5 gm% of deoxygenated higher SaO2 hemoglobin values than in the capillaries. with anemia. b) Patients with normal hemoglobin manifest cyanosis at patients c) Cyanosis can be caused by excess methemoglobin,

which d) For methemoglobin has to generally

is to cause be cyanosis, <80 mm

HbFe+3. the PaO2 Hg.

e) Some drugs may cause cyanosis without causing vasoconstriction, or any impairment in PaO2, SaO2, or oxygen content. Answer: d Methemoglobin can cause cyanosis with a normal PaO2. All the other statements are true. See e-medicine topic on cyanosis 16) Since the early 1980s, climbers have summited Mt. Everest without supplemental oxygen. Since the barometric pressure on the summit is only 253 mm Hg, summiting (without extra O2) has only been possible due to prolonged acclimitization at altitude and profound hyperventilation. Indeed, if a a climber maintained PaCO2 of 40 mm Hg and an alveolar-arterial PO2 difference of 5 mm Hg, what would be his/her theoretical PaO2? a) b) c) d) e) -10 mm Hg Answer: e Here you use the alveolar gas equation: PAO2 = .21 (253-47) - 1.2 (40) = 43 - 48 = - 5 mm Hg Since the alveolar-arterial PO2 difference is 5 mm Hg, that would make the 25 15 5 -5 mm mm mm mm Hg Hg Hg Hg

arterial PO2 (PaO2) = -10 mm Hg! Climbers have summited without supplemental O2 by virtue of profound, sustained hyperventilation, to level of @ 7 mm Hg. Thus PAO2 = .21 (253-47) - 1.2 (7) = 43 - 8 = 35 mm Hg Again, since the alveolar-arterial PO2 difference is 5 mm Hg, that would gives a PaO2 on the summit of @ 30 mm Hg - extremely low but survivable. 17) All are true about excess carbon monoxide except: a) b) c) d) lowers lowers the shifts the oxygen lowers the arterial dissociation curve the oxygen oxygen to the left PaO2 saturation content

e) is not accounted for when SaO2 is calculated from arterial blood gas measurements Answer: b CO shifts the O2 dissociation curve left-ward, lowers SaO2 and oxygen content, and is not accounted for in the calcuation of SaO2 from PaO2 measurement. CO does not affect PaO2. 18) A mountain climber ascends from sea level to 18,000 feet over a two day period, without supplemental oxygen. With ascent all of the following factors will decrease except: a) Fraction b) c) of inspired Barometric PaO2 oxygen (FIO2) pressure

d) e) Arterial hydrogen ion concentration Answer: a

PaCO2

FIO2 is the same at all breathable altitudes. The barometric pressure falls with altitude, and as a consequence PaO2 falls and the climber hyperventilates. Hyperventilation results in low PaCO2 and increased pH (reduced hydrogen ion concentration). 19) You are scuba diving to a depth of 99 feet in the ocean, breathing compressed air from a tank. At this depth, compared to the surface, your arterial PO2 will be approximately: a) b) c) d) 2x 3x 4x the the the the surface surface surface same value value value

e) dependent on amount of air pressure in the tank Answer: d Each 33 feet of depth in sea water doubles the ambient pressure; thus at 99 feet of depth the ambient pressure is 4x the surface pressure, and PaO2 will be about 4x that at sea level. 20) While all of the following conditions could possibly be managed without measuring arterial blood gases, in which one would blood gases be most helpful? a) A 40-year-old woman suffering an asthma exacerbation. Her peak expiratory flow rate is 65% of predicted and SpO2 is 95% on room air.

b) A 17-year-old-high school student who presents to the ED with hyperpnea and tachypnea; history reveals he became "excited" during a church service. He has some tetanic contractions of his hands, his lungs are clear and pulse oxygen saturation is 98% on room air. c) A 68-year-old hypertensive patient has been feeling "weak" for a few days. She has been taking her anti-hypertensive medications. Electrolyte measurements show:

Na+ 148 mEq/L K+ Cl4.0 mEq/L 102 mEq/L CO2 24 mEq/L

d) A 24-year-old insulin-dependent diabetic comes to the ED, complaining of lethargy; she has not used insulin in several days. Her pulse oximeter oxygen saturation on room air is 98%. Lab values show:

Glucose 750 mg% Na+ K+ CO2 ClUrine 135 mEq/L 4.5 mEq/L 10 mEq/L 100 mEq/L 4+ ketones

e) A 25 year old woman comes to the ED with chest pain. She does not smoke. SaO2 is 96% on room air and V/Q scan is read as low probability for pulmonary embolism. EKG is normal. Answer: c The patient has an anion gap metabolic acidosis and a metabolic alkalosis (see also Questions 8 and 14). Blood gases will be helpful to determine which disorder is predominant. Patients a, b, d and e can be treated without measuring blood gases. Patient d, in particular, reflects a typical case of diabetic ketoacidosis, with anion gap of 25 mEq/L. It is not necessary to measure or follow blood gases in such a patient, as long as there is response to insulin along with a rise in AG and fall in serum CO2. 21) The factor 0.863 in the PCO2 equation: a) equates dissimilar units for CO2 production and alveolar ventilation and d) into total factors mm or in Hg used for PCO2. b) accounts for the difference between alveolar ventilation minute base ventilation. excess. c) accounts for the dissolved fraction of carbon dioxide. e) is not explained by any of the above. Answer: a The PaCO2 equation, PaCO2=VCO2/VA, results in units of mm Hg. The factor 0.863 converts CO2 production units (ml/min) and alveolar ventilation units (L/min) into mm Hg. 22) The limit of human hyperventilation is a PaCO2 of about 8 mm Hg. What is the highest PaO2 (mm Hg) a patient with

normal lungs could achieve breathing room air (FIO2=.21) at sea level? a) b) c) d) e) 150 Answer: c The abbreviated alveolar gas equation gas be used to answer this question: PAO2 = FIO2 (BP - 47) - 1.2 (PaCO2) PAO2 = .21 (760-47) - 1.2 (8) PAO2 = 149.7 - 9.6 = 140.1. Thus the alveolar PO2 is 140, but arterial PO2 will be somewhat lower due to the normal PAO2 - PaO2 difference. Assuming a normal PAO2-PaO2 of 5 mm Hg, the highest value would be about 135 mm Hg. 23) A 45 year-old-man is treated in a hyperbaric chamber for severe carbon monoxide toxicity. Assume he is breathing 100% oxygen at 3 atmospheres of pressure, that he has normal lungs, and that hemoglobin=15 gm%, carboxyhemoglobin=40%. What is his approximate arterial oxygen content in ml/dl? a) b) c) d) e) 21 10 13 15 20 100 122 135 142

Answer: c or d Here you use the oxygen content equation. In this situation you need to include the contribution by PaO2, since it is considerably higher in a hyperbaric environment. Since the subject has normal lungs, PaO2 should be 3x normal PaO2 while breathing 100% oxygen. PaO2 on 100% oxygen with normal lungs should be around 600 mm Hg. Therefore at 3 atmospheres, PaO2 should be around 1800 mm Hg. Also, with 3 atmospheres of pressure at 100% oxygen, all the available hemoglobin binding sites will be fully saturated. However, since 40% of the sites are bound with CO (COHb = 40%), the actual SaO2 will only be 60%. Thus: CaO2 = 1.34 x Hgb x SaO2 + (.003 x PaO2) CaO2 = 1.34 x 15 x .60 + (.003 x 1800) CaO2 = 12.06 + 5.4 = 17.46 ml O2/dl Because this is between 15 and 20, either answer is accepted as correct. 24) Which one of the following statements is not true? a) If nothing else changes, as PaCO2 goes up alveolar PO2 and arterial PaO2 always respiratory alkalosis. e) The SaO2 is related to hemoglobin-bound arterial acidosis or PO2 also goes metabolic go down. increases. down. acidosis+metabolic b) PaO2 is inversely related to blood pH: as pH goes up c) If PaCO2 increases while HCO3- remains unchanged, pH d) A high bicarbonate could reflect metabolic alkalosis or

oxygen content on a linear scale (i.e., a straight-line relationship). Answer: b While all the other relationships are physiologic, there is no such physiologic relationship between PaO2 and pH. True, if pH went up because of hyperventilation and the subject has normal lungs, then you would expect PaO2 to also increase. However, pH could go up because of metabolic alkalosis, which might lead to increased PaCO2 and a decreased PaO2. Or, the patient could hyperventilate and PaO2 could go down because of lung disease. There is simply no physiologic relationship that can predict direction of PaO2 when pH changes. 25) Which one of the following sets of blood gas values most likely represents a lab or transcription error? (PaCO2 and PaO2 in mm Hg, HCO3 in mEq/L, SaO2 in %. Assume all blood gases drawn at sea level.) pH a) 7.40 b) 7.22 c) 7.59 PaCO2 HCO3 75 20 25 265 33 45 8 23 28 24 PaO2 SaO2 FIO2 70 160 60 200 90 75 98 90 96 60 0.21 0.50 0.28 1.00 0.21

d) 6.65 e) 7.48

Answer: a* A lab or transcription error is evident when the values do not fit known physiology. a) doesn't fit because the PaO2 is too high for this degree of hypoventilation:

Alveolar PO2 = .21 (760 - 47) - 1.2 (75) = 150-90 = 60 mm Hg. In a clinical situation you would never have a PaO2 of 70 mm Hg when alveolar PO2 is only 60 mm Hg. (This could theoretically happen in a sudden decompression at altitude, in which case oxygen would be leaving the blood to enter the atmosphere. In that situation you wouldn't be checking blood gases!). b) reflects severe metabolic acidosis with increased PaO2 on a high FIO2. c) reflects hyperventilation with some hypoxemia. d) has been reported as an extreme example of hypercapnic oxygenation. e) shows a much lower SaO2 than expected from the PaO2, and suggests carbon monoxide toxicity. *When the quiz was first posted I had my own transcription error! The PaCO2 in blood gas set 'a' was incorrectly given as 40 mm Hg, invalidating the answer. (When scored for prizes all answers to this question were accepted.)

Tie Breaker 26) A 54-year-old man with chronic obstructive pulmonary disease is seen in the Emergency Department for respiratory distress. Arterial blood gases show: pH 7.38, PaCO2 70 mm Hg, PaO2 38 mm Hg, SaO2 52% on room air (FIO2=.21, at sea level). At the same time, his oxygen saturation measured by pulse oximetry (SpO2) is 65%. Explain, in physiologic terms, reason(s) for both the low PaO2 and low SaO2. PaO2 is reduced from two physiologic causes: increased PaCO2 and ventilation-perfusion imbalance. Note that with pure hypoventilation to PaCO2 of 70 mm Hg (e.g., CNS depression with normal lungs), the resulting

PaO2 should be about 60 mm Hg. This is determined by the alveolar gas equation: PAO2 = .21(760-47) - 1.2(70) = 66 mm Hg Assuming a normal A-aO2 difference of about 6 mm Hg gives a PaO2 of 60 mm Hg, which is much higher than the actual PaO2 of 38 mm Hg. The reason has to be an additional physiologic cause, which is ventilationperfusion imbalance. Both physiologic causes of the patient's low PaO2 are a result of COPD. SaO2 is reduced because of the reduced PaO2 AND also from elevated carbon monoxide (CO) level; the latter is inferred because the SaO2 of 52% is lower than predicted from an oxygen dissociation curve based on normal pH and PaCO2 of 70 mm Hg. While elevated PaCO2 will shift the O2 dissociation slightly to the right (lowering SaO2 for a given PaO2), PaCO2 of 70 mm Hg with pH of 7.38 should give an SaO2 in the mid to high 60s. Note that elevated CO level shifts the O2 dissociation curve to the left, but that slight increase in SaO2 for a given PaO2 is miniscule compared to the absolute reduction in SaO2 brought on by excess COHb; it is essentially 1 for 1; for every percent increased COHb, SaO2 decreases by one percent.

Flame Photometry

Flame photometry (more accurately called flame atomic emission spectrometry) is a branch of atomic spectroscopy in which the species examined in the spectrometer are in the form of atoms. The other two branches of atomic (AAS, spectroscopy see are atomic absorption Atomic spectrophotometry Standardbase technique:

Absorption Spectrophotometry) and inductively coupled plasma-atomic emission spectrometry (ICP-AES, a relatively new and very expensive technique not used in Standardbase experiments). In all cases the atoms under investigation are excited by light. Absorption techniques measure the absorbance of light due to the electrons going to a higher energy level. Emission techniques measure the intensity of light that is emitted as electrons return to the lower energy levels. Flame photometry is suitable for qualitative and quantitative determination of several cations, especially for metals that are easily excited to higher energy levels at a relatively low flame temperature (mainly Na, K, Rb, Cs, Ca, Ba, Cu).

The flame photometers are relatively simply instruments (fig. 1.). There is no need for source of light, since it is the measured constituent of the

sample that is emitting the light. The energy that is needed for the excitation is provided by the temperature of the flame (2000-3000 C), produced by the burning of acetylene or natural gas (or propane-butane gas) in the presence of air or oxygen. By the heat of the flame and the effect of the reducing gas (fuel), molecules and ions of the sample species are decomposed and reduced to give atoms, e.g.: Na+ + e- ? Na. Atoms in the vapour state give line spectra. (Not band spectra, because there are no covalent bonds hence there are not any vibrational sub-levels to cause broadening).

Cardiac Output
OBJECTIVES: To study of the operation of heart To study about the output of a heart in a human body .

Defn: vol of blood pumped by the heart per min CO = SV x HR Norm ~ 5 l/min Cardiac index corrected for body surface area Affected by : Met. Rate pregnancy, hyperthyroid, septic Preload / contractility / afterload Clinical indicators of CO imprecise Affected by anaesthetic agents used in everyday practice Provides estimate of: whole body perfusion oxygen delivery left ventricular function Persistently low CO assoc. with poor outcome

Methods: Fick method Dilution techniques dye / thermal / lithium Pulse contour analysis- LiDCO & PiCCO Oesophageal doppler TOE Transthoracic impedance plethysmography Inert gas through flow Non-invasive cardiac output measurement Fick Principle: measure volume displacement 1st proposed 1870 the total uptake or release of a substance by an organ is the product of the blood flow through that organ and the arteriovenous concentration difference of the substance CO = O2 consumption (ml/min) art mixed venous O2 conc. (ml/l) Limited by cumbersome equipment, sampling errors, need for invasive monitoring and steady-state haemodynamic and metabolic conditions Indicator dilution techniques An indicator mixed into a unit volume of constantly flowing blood can be used to identify that volume of blood in time, provided the indicator remains in the system between injection and measurement and mixes completely in the blood

Blood pressure
OBJECTIVES: To study the blood flow within the human body

To

study

necessity

of

human

body

blood

pressure

measurements.

Why bother to check blood pressure? For each 20 mm rise in systolic blood pressure or 10 mm rise in diastolic blood pressure over 115/75: Risk of stroke increases Risk of heart disease doubles Risk of renal failure increases

Systolic and diastolic blood pressure : Systolic blood pressure is the highest pressure in the arteries, just after the heart beats Diastolic blood pressure is the lowest pressure in the arteries, just before the heart beats Blood pressure is measured indirectly by blood pressure cuff (sphygmomanometer)

Inflating cuff increases pressure until it cuts off arterial circulation to the arm Deflating cuff, decrease pressure by 2 to 3 mm of mercury per second until blood first enters the artery, creating turbulence; this causes a sound with each heartbeat Sounds continue with each heartbeat until pressure lowers to the lowest pressure in the artery; then turbulence stops, so the sound stops

Systolic blood pressure is the cuff pressure at the first sounds; diastolic is the cuff pressure just before the sounds stop Phase 1: sharp thuds, start at systolic blood pressure Phase 2: blowing sound; may disappear entirely (the auscultatory gap ) Phase 3: crisp thud, a bit quieter than phase 1 Phase 4: sounds become muffled Phase 5: end of sounds -- ends at diastolic blood pressure

Make sure the cuff is the right size - its width should be at least 40% of the arm's circumference. The cuff will overestimate blood pressure if too small and underestimate if too large. Place the cuff snugly on patient's proximal arm, on skin ( not cloth), centered over the brachial artery (most cuffs have markings) Support the patient's arm at heart level, using your arm or a desk Your patient should sit in the chair for 5 minutes before BP is measured, and should have no caffeine or nicotine for 30 minutes before (JAMA 273, p.1211-1218, 1995)

With fingers palpating radial or brachial artery, inflate cuff rapidly until you can't feel the pulse, then 20 mm higher Release cuff at 2 to 3 mm Hg per second until you again feel the pulse; this is the palpable systolic pressure Wait 30 seconds before measuring blood pressure Measuring palpable pressure first avoids risk of seriously underestimating blood pressure because of the auscultatory gap (mistaking Korotkoff phase 3 for phase 1). Many doctors skip this step for time reasons and instead pump cuff to 200 mm Hg at the next step) Phase 2 of the Korotkoff sounds can be inaudible - especially in older patients with systolic hypertension, who are at especially high risk of stroke. Inflating the cuff until you don't hear sounds can give you a reading of 140/86 when the patient's actual blood pressure is 220/86. Most physicians are pressed for time, so they instead inflate the cuff to 200 mm, which is beyond the auscultatory gap in most patients. But palpable systolic blood pressure is, according to research, more reliable. Place bell of stethoscope (diaphragm is acceptable) over brachial artery Rapidly pump the cuff to 20 to 30 mm Hg above palpable systolic pressure Release pressure in the cuff by 2 to 3 mm Hg per second and listen for Korotkoff sounds, including systolic (first) and diastolic (last) Record as systolic/diastolic. Check in both arms the first time you check a patient's blood pressure. It may differ by 10 mm Hg or more.

If the sounds continues to zero, record diastolic blood pressure as the point when sounds become muffled (phase 4) over zero: e.g. 130/70/0, or just as 130/70.

Rate Number of beats in 30 seconds x 2 Bounding, strong, or weak (thready) Regular or irregular need three readings on two occasions to diagnose Strength Regularity You

hypertension, unless blood pressure is very high Normal blood pressure in children is: 102/55 at 1 year, 112/69 at 5 years, 119/78 at 10 years Normal: <120/<80 Prehypertensive: 120-139/80-89 Stage 1 hypertension: 140-159/90-99 Stage 2 hypertension: >160/>100 Blood pressures in adults (JNC VII: JAMA 289:2560-72, 2003):

Adult: 60 to 100 Newborn: 120-170 1 year: 80-160 3 years: 80-120 6 years: 75-115 10 years: 70-110 1.What is blood pressure? 2.What are the types of Pressure? 3.What is the normal values of human body?

4.what is hypertension?

OBJECTIVES: To study the breathing of human body To study measurement technique of respiration

How to measure: observe rise and fall of chest In infants, count for 60 seconds; in adults, 15 or 30 seconds Normal respiration: Adults: 12 to 20 Children: newborn 30-80 1 year 20-40 3 years 20-30 6 years 16-22 Rate Number of breaths in 30 seconds x 2 Quality Character of breathing Rhythm Regular or irregular Effort Normal or labored Noisy respiration Normal, stridor, wheezing, snoring, gurgling Depth

Shallow or deep

Breathing is controlled by the medulla of the brainstem. It repeatedly triggers contraction of the diaphragm initiating inspiration. The rate of breathing changes with activity level in response to carbon dioxide levels, and to a lesser extent, oxygen levels, in the blood. Carbon dioxide lowers the pH of the blood.

Modifying

Respiration

Voluntary control; emotions; changes in blood pH, carbon dioxide, and oxygen levels; stretch of the lungs; movements of the limbs (proprioception); and stimuli such as touch, temperature, and pain can affect the respiratory center and modify respiration.

A plus sign (+) indicates an increase in respiration, and a minus (-) sign indicates a decrease in respiration.

Temperature measurement techniques


OBJECTIVES: To know the temperature measurement techniques To study the levels of temperature of human body

In the ferrous foundries ladle temperature varies above1700 C. At his temperature continuous measurement is difficult. Therefore dip ype immersion pyrometer technique is widely used. Immersion pyrometer Circuitry consist (EMC), of metal housing, Electronic Measurement metal lance, Thermocouple

connected to the circuitry by means of compensating cables which passes through the lance. When thermocouple dip into the molten metal, it gives milli volts output. These milli volts are carried to the EMC, where the signal (mv) is amplified and processed to give direct digital output. The processing of the signal is done by various techniques. Peak latching, Plateau Detection, Continuous tracking are some of these techniques. Peak Latching: As the name indicates the technique involves latching of the peak temperature and displaying it. In an induction furnace due to its nature hot spots are generated that moves randomly across the molten metal. Generally the temperature at the hot spot is always higher than the molten metal temperature. If the Thermocouple comes into contact with the hot spot then this reading is latched by the EMC and displayed. Thus temperature at the hot spot is not correct representation of the entire bath temperature. Therefore peak latching is not world wide accepted for use in measuring molten metal temperature in induction furnaces. Continuous tracking: In this technique temperature is displayed continuously as it senses. So you do not get stable display of temperature. So it is difficult to know, when to remove lance. Temperature recording is fully dependent on operator skill and it can not separate out hot spot temperature and true temperature. So it is not suitable for ferrous foundries. Plateau detection technique:

In this technique transient response of sensor and system is ignored. Steady state response is monitored and confirmed by taking several samples. Once it fits in its detection criteria the temperature is displayed. The operator can remove the lance to prevent it from melting in the molten metal bath. This technique displays correct temperature and ignores incorrect readings by giving error messages. Thus there is no possibility of hot spot measurement in this technique. This operation is completed in 1-3 sec in case of single dip paper tube thermocouple tips and 3-8 sec in case of Multi dip thermocouple tips. It ensures life of receptacle (connector for tip and lance).

Transient response phenomenon is very common term in the field of process instrumentation i. e. how system (including sensor) responds for any sudden change is characterized by this terminology. In case of Immersion Pyrometer, as we are suddenly inserting thermocouple inside the molten metal bath; its response could be like shown in Fig 1 or Fig 2 as it depends on various factors. True Peak Temperature Peak Temperature Temperature

Time Fig.1

Time Fig. 2

Normal track mode, time based & PEAK LATCH temperature indicator fails to identify & measure the true temperature. For molten metal temperature measurement only, PLATEAU

DETECTION TECHNIQUE is recommended & accepted worldwide, In case, if there is a HOT SPOT with molten metal in the furnace, the temperature at HOT SPOT is more than the rest of the molten metal. If you are using ordinary PEAK LATCH INDICATOR type pyrometer, it displays this HOT SPOT temperature, which may be more by 20-25 degree centigrade. In such condition you may face the problem of COLD POURING, as the actual temperature is less by 20-25 deg. But in case of PLATEAU DETECTION TECHNIQUE, as soon as thermocouple is dipped into molten metal, first peak temperature is ignored and it ensures 7 constant readings for a period of one second & declares true temperature readings. It ignores false readings due to furnace hot spot, noise, and transient response & once it detects steady state temperature i.e. flat temperature it will be displayed.

Pulse Measurement

OBJECTIVES: To study of the importance of pulse . To study of Measurement of pulse .

Definition of Pulse Pulse is the rhythmic expansion and contraction of an artery caused by the impact of blood pumped by the heart. The pulse can be felt with the fingers at different pulse pressure points throughout the body and heard through a listening device called a stethoscope. In this survey you will use the radial pulse (at the wrist) and the brachial pulse (inside of arm at the elbow), to obtain the pulse and blood pressure measurements. Locating the Pulse Points After explaining the procedure to the SP, the interviewer will locate the brachial and radial pulse points in the right arm. (See Exhibits 10 and 11). Locating the radial pulse: With the right palm of the hand of the SP turned upward, place the first two fingers of your hand on the outer part of the crease of the wrist. Press firmly. You will feel a pulsating motion under your fingers. This is the radial pulse. Locating the brachial pulse: Again, with the right palm of the SP turned up, and the arm straightened (slightly bent at the elbow), place the first two fingers of your hand on the inner third (side toward the body) of the crease of the elbow. Press firmly and hold for five seconds. If the brachial pulse is still not felt, begin again from the center of the arm and work your way toward the innermost (toward the body) part of the elbow fold crease. You should be able to feel the brachial pulse by using this method. Both pulse and

blood pressure will be measured in the same arm. The right arm will always be used unless specific conditions prohibit its use. Use the following guidelines: If the radial pulse is apparent, whether or not the brachial pulse can be felt, proceed with the measurement of the first blood pressure. If the radial pulse cannot be felt in the right arm, use the left arm. If the radial pulse cannot be felt in either arm, the blood pressure procedure should be terminated and this noted on the Blood Pressure Measurement form.

Pulse Measurement With the elbow and forearm resting comfortably on a table and the palm of the hand turned upward (See Exhibit 10) the radial pulse is felt and counted for 30 seconds exactly. The number of beats in 30 seconds is recorded on the Blood Pressure Measurement form. If you are unable to measure the pulse using the radial pulse, attempt to count the pulse using the brachial pulse. If the pulse cannot be counted because of an irregular or erratic beat, ask the SP if he or she is aware of the problem. If the SP replies in the negative, try to take the pulse again counting for 30 seconds. If the difficulty is still present, say: "I find it difficult to measure your pulse. You may wish to have your physician check it." Describe the difficulty on the Blood Pressure Measurement form. Procedures to Enhance the Brachial Pulse Sounds If you are having difficulty hearing the blood pressure sounds, there are three methods which can be used to increase the intensity and loudness of the sounds: 1. Reduce room noise. 2. Have the SP raise his/her arm and forearm for at least 60 seconds. Lower, inflate the cuff, and take the BP immediately. If raising the arm is difficult for the subject, use Method 3. 3. Instruct the SP to open and close his/her fist 8 to 10 times. Inflate the cuff and take the BP immediately. If it was necessary to use one of these enhancement methods, make sure you record the method you used. 1. Auscultatory Auscultatory Gap An auscultatory gap is the fading or disappearance of sound after the first sounds are heard. The sound then reappears at a level well above the diastolic pressure. The radial pulse can still be felt during the silent phase and the gap usually occurs between Phases I and II. This phenomenon is seen more frequently in older subjects and only rarely in

children. This means that in an adult with an auscultatory gap, the real systolic pressure may be missed and read as a much lower BP. For example: Real systolic is 172 but sounds fade at 168 and reappear at 152 and disappear at 98. If the correct procedure (inflating to MIL) for BP measurement is not used, this subjects BP may be read as 152/98 instead of 172/98. The only way to avoid this error is to obtain the MIL before BP measurement. There is an exception here, though. The rule is to deflate the cuff 20 mm Hg below the last sound. Even if you deflate 20 mm Hg below last sound you would only deflate to 148 and think BP is 172/168. Therefore, whenever the blood pressure fades very shortly after hearing the systolic, deflate the cuff to zero.

What is pulse count indicate? What is the nature of measurement? What is the normal pulse value? What is the time required to count the pulse?