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Cyanosis is a bluish or purplish tinge to the skin and mucous membranes.
Cyanosis of nail beds.
Cyanotic lips in a woman with hypoxia.
Before the era of rapid blood gas analysis, clinicians often assessed hypoxemia on clinical grounds alone, primarily by looking for cyanosis in the perioral area and fingers.1 Clinical assessment of hypoxemia is now known to be notoriously unreliable for the following reasons: y A host of factors, from natural skin pigment to room lighting, can affect detection of cyanosis. As with many other physical examination findings, significant interobserver variation occurs in detecting cyanosis.2Physicians may diagnose cyanosis as an indicator of hypoxemia when the patient has normal oxygen saturation; alternatively, physicians may miss cyanosis when it should be present (the patient has very low oxygen saturation with normal hemoglobin).3 Approximately 5 g/dL of unoxygenated hemoglobin in the capillaries generates the dark blue color appreciated clinically as cyanosis. For this reason, patients who are anemic may be hypoxemic without showing any cyanosis. Ancillary signs and symptoms of hypoxemia (eg, tachycardia, tachypnea, mental status changes) are nonspecific and of no value in reliably detecting hypoxemia. For example, patients may be dyspneic at rest for reasons other than hypoxemia (ie, they have normal PaO2 and SaO2). Conversely, many patients who are chronically hypoxemic (low PaO2 and/or low SaO2) are perfectly lucid and without any obvious physical signs of their low oxygen state (at least while at rest).
Most often. Khalil H: How much reduced hemoglobin is necessary to generate central cyanosis?Chest 1990 Jan. cyanosis is detected in the lips and fingers. From Martin L.5 At the same time. the threshold SaO2 level for manifesting cyanosis is lowered to about 73% (PaO2 38 mm Hg). arterial blood gas determination. Each diagonal line represents a different hemoglobin content (g/dL). capillary. some measurement of the oxygen level is necessary (eg. and arterial reduced hemoglobin (RHB. one should not rely on the absence of cyanosis as reassurance that hypoxemia is not present. which can occur at varying values of the 2 parameters that are measured most commonly. For example. . When hemoglobin content is 9 g/dL (hematocrit approximately 27%). the patient would certainly have other manifestations of hypoxemia (eg. y y Oxygen and hemoglobin values at which central cyanosis occurs: The threshold for central cyanosis is a capillary reduced hemoglobin content of 5 g/dL. pulse oximetry). With a hemoglobin content of less than 9 g/dL. patients with normal hemoglobin manifest cyanosis at higher SaO2 values than patients with anemia. The vertical axis shows values for venous.4 For this reason. Refer to Media File 3 below and consider the following examples: y A patient whose hemoglobin content is 15 g/dL (hematocrit approximately 45%) would not generate 5 g/dL of reduced (ie. deoxygenated) hemoglobin in the capillaries translates into a reduced hemoglobin content of 3. No reliable alternative is available to measurement of PaO2 or SaO2 when diagnosing hypoxemia or assessing the need for supplemental oxygen therapy. the patient would likely succumb from hypoxemia before cyanosis became evident.97(1):182-5. At this level of hypoxemia. If hypoxemia is suspected for any reason. mental status changes) apart from cyanosis. central cyanosis can manifest when SaO2 is 85% in a patient with a hemoglobin of 15 g/dL. deoxygenated) hemoglobin in the capillaries until his/her SaO2 level reached about 85% (PaO2 50 mm Hg).4 g/dL in arterial blood. g/dL blood).Generation of Cyanosis The requirement of 5 g/dL of reduced (ie. arterial oxygen saturation (SaO2) and arterial hemoglobin content. respiratory symptoms. and the horizontal axis shows a percent saturation of hemoglobin in arterial blood (SaO2) along with corresponding PaO2 (mm Hg).
especially to nitrite or nitrate-containing compounds (eg. can also cause methemoglobinemia. Methemoglobin (metHb). the cyanosis that comes withmethemoglobinemia is not related to reduced hemoglobin but to oxidized hemoglobin. therefore.6 In this situation. arterial oxygen saturation is reduced by the same amount that metHb is increased. Other Causes of Cyanosis Other causes of cyanosis include the following: y Methemoglobin o Normal hemoglobin unbound to oxygen is called reduced hemoglobin and is symbolized HbFe+2. nitroglycerin) and to some topical anesthetics. is HbFe+3. Normally. o MetHb imparts an intense bluish tinge to the skin.Cyanosis of nail beds. cyanosis is evident in both the fingers and the toes. . as much as 2% of hemoglobin is in the form of metHb.9 Dapsone.7. the oxidized form of hemoglobin. but SaO2 level (measured by pulse oximetry) is much lower in the toes. A case report of Eisenmenger syndrome (interrupted aortic arch with ventricular septal defect) in a 31year-old pregnant woman discusses the rare condition of differential cyanosis. Dahshan and Donovan report a case of severe methemoglobinemia from topical benzocaine in a toddler.8Methemoglobinemia usually occurs as a drug reaction. Cyanotic lips in a woman with hypoxia. Because metHb is unable to bind with oxygen. a drug used in HIV and non-HIV conditions.
. silver iodide. a new generation of pulse oximeters that uses 8 wavelengths of light does have the ability to measure carboxyhemoglobin and metHb (Barker 2006). o Unlike metHb. silver nitrate. chloroquine hydrochloride).y y y Although excess metHb reduces the measured SaO2. and SaO2. Most causes are related to metals (eg. Note that standard pulse oximeters. obtain a pulse oximetry or arterial blood gas measurement. the iron moiety remains in the reduced state (HbFe+2). o Sulfhemoglobin is similar to metHb in causing low SaO2 but not affecting PaO2 and in imparting an intense bluish color to the skin. o One report describes a girl with intensely blue skin from food coloring. Peripheral cyanosis o Peripheral cyanosis is a dusky or bluish tinge to the fingers and toes and may occur with or without central cyanosis (ie. MetHb can be measured in a co-oximeter. phenothiazines. To be sure of the diagnosis. Pseudocyanosis o Pseudocyanosis is a bluish tinge to the skin and/or mucous membranes that is not associated with either hypoxemia or peripheral vasoconstriction. which measure SaO2 using 2 wavelengths of light.of light does have the ability to measure COHb and metHb.12 Consider pseudocyanosis when the patient has no cardiopulmonary symptoms and the skin does not blanch under pressure. A low PaO2 in a patient with excess metHb suggests a concomitant pulmonary problem. However. lead) or drugs (eg. do not measure metHb (or carboxyhemoglobin). a companion to the blood gas machine available in most hospital blood gas laboratories.10 Sulfhemoglobin o Sulfhemoglobinemia is a rare condition caused by sulfur binding with hemoglobin so that oxygen cannot be bound. peripheral cyanosis is caused by peripheral vasoconstriction. One report describes blue-gray discoloration in a man who for years ingested colloidal silver for a urinary tract infection11 . silver. amiodarone. hemoglobin content. The co-oximeter also measures carboxyhemoglobin. with or without hypoxemia). o Multimedia Media file 1: Cyanosis of nail beds. as determined by blood gas analysis. this is because metHb does not affect transfer of oxygen from the atmosphere to the lungs. his oxygen levels were normal. o When unaccompanied by hypoxemia. PaO2 is not affected.
capillary.(Enlarge Image) Media file 2: Cyanotic lips in a woman with hypoxia. Khalil H: How much reduced hemoglobin is necessary to generate central cyanosis?Chest 1990 Jan. Each diagonal line represents a different hemoglobin content (g/dL).97(1):182-5. which can occur at varying values of the 2 parameters that are measured most commonly. central cyanosis can manifest when SaO2 is 85% in a patient with a hemoglobin of 15 g/dL. For example. and the horizontal axis shows a percent saturation of hemoglobin in arterial blood (SaO2) along with corresponding PaO2 (mm Hg). (Enlarge Image) (Enlarge Image) Media file 3: Oxygen and hemoglobin values at which central cyanosis occurs: The threshold for central cyanosis is a capillary reduced hemoglobin content of 5 g/dL. . arterial oxygen saturation (SaO2) and arterial hemoglobin content. and arterial reduced hemoglobin (RHB. g/dL blood). The vertical axis shows values for venous. From Martin L.
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