Arterial Blood Gas Abnormalities Research Articles

Nursing Care Process for patients with Pneumonia and Arterial Hypertension in the Emergency Department of a hospital in Lima

The present study work was applied to a patient with a medical diagnosis: pneumonia and arterial hypertension in the emergency service. The objective of the present work was to apply the nursing care process to an older adult with Pneumonia. The assessment was carried out with the guide based on the 11 functional patterns of Marjori Gordon. After identifying the problems, 11 nursing diagnoses are enunciated taking into account the NANDA taxonomy and the following diagnoses are prioritized: Impairment of gas exchange related to changes in the capillary alveolus membrane evidenced by O2 Sat: 91% Abnormal arterial blood gas (PO2: 63 mmHg) abnormal respiratory pattern, respiratory rate 26 per minute, ineffective cleaning of the airways related to changes in the capillary alveolus membrane evidenced by altered respiratory pattern, altered respiratory rate and abnormal respiratory sounds, and CP Hypertension. Subsequently, planning is carried out using the NOC and NIC taxonomy, the interventions and planned activities are executed. The results obtained gave a score of +1, +2 and +2. It is concluded that the nursing care process is the application of care in a systematic and orderly manner, helping to provide quality care and humanism.

The Effects Of Wheat Pill Poisoning (Aluminum Phosphide) Dosage On Arterial Blood Gases And Their Clinical Outcome.

To analyse the effects of aluminum phosphide poisoning dosage on arterial blood gases and the clinical outcome. The cross-sectional study was conducted at the intensive care unit of Mardan Medical Complex, Mardan, Pakistan, from January 2021 to May 2022, and comprised patients of either gender who had attempted suicide using aluminum phosphide. Data was collected using a predesigned questionnaire. Data was analysed using SPSS 26. Of the 116 patients, 42(36.2%) were males and 74(63.8%) were females. There were 75(64.65) survivors; 31(41.33) males and 44(58.66) females with overall mean age 26.30±9.45 years. There were 41(35.35%) non-survivors; 11(26.82%) males and 30(73.18) females with overall mean age 28.21±11.16 years.During hospitalisation, the non- survivors showed drastically decreased levels of all arterial blood gas paramters with severe clinical outcomes (p<0.05). As the number of aluminum phosphide pills increased, the chance of survival decreased (p<0.05). The non-survivors spent an average of 32.51±16.02 hours in hospital (range: 6-59 hours). Patients who ingested more aluminum phosphide pills had more abnormal arterial blood gas parameter with severe clinical outcomes. Also, they had lower chance of survival and unfavourable response to treatment.

Concept Analysis of the Nursing Diagnosis of Impaired Spontaneous Ventilation in Critical Patients

Introduction: In nursing practice, this concept has been identified in studies that address the nursing diagnosis of impaired spontaneous ventilation. Nursing performance facing this unwanted human response is considered essential for the maintenance and control of vital signs, cardiovascular monitoring, gas exchange and respiratory pattern, as well as constant surveillance aimed at signs of hypoventilation and inadequate ventilation. Objective: To analyze the concept of impaired spontaneous ventilation in critically ill patients in an intensive care unit. Methodology: This study is a concept analysis, according to Walker’s and Avant’s method, conducted using an integrative review. All the referential steps were followed: concept selection, determining the objectives and proposals for concept analysis, identifying the possible uses of the concept, determining the defining attributes, identifying a model case, identifying a contrary case, and identifying the precedents and consequences of the concept. Results: A sample of 38 studies was selected. The following were identified as attributes: distress and fatigue, respiratory distress, tachycardia, hemodynamic instability, altered mental status, abnormal arterial blood gas results, dyspnea, anxiety, agitation, sweating, hypoxemia and hypercapnia. Antecedents: sex, age, oxygen saturation lower than 90%, diseases of the respiratory, cardiovascular, neurological, gastrointestinal, neuromuscular, and metabolic systems, respiratory infections, trauma, poisons, toxins, and sedatives. Consequences: increased heart rate, decreased partial oxygen saturation, increased use of respiratory muscles, dyspnea, increased metabolic rate and restlessness. The model case and the contrary case were used to illustrate the attributes, antecedents, and consequences. Conclusion: The study directed the strengthening of evidence about the phenomenon and demonstrated a strong occurrence in patients who need assistance in intensive care units, thus demanding critical care.

COVID 19 vaccine induced thrombotic thrombocytopenia, cerebral venous thrombosis and neurogenic stunned myocardium.

To the Editor, Vaccine-induced thrombotic thrombocytopenia (VITT) manifesting as cerebral venous thrombosis (CVT) is rare but life-threatening complication after COVID-19 vaccination.[1] Neurogenic stunned myocardium (NSM) is a phenomenon of cardiac abnormalities occurring due to sympathetic storm after acute neurological injury.[2] This case reporting is done after obtaining written informed consent. We describe rare manifestation of VITT, CVT, and NSM after COVID-19 vaccination and its successful management. A 19-year-old lady presented with altered sensorium for 2 days. Prior to her current visit, she had low-grade fever for 2 days and holocranial headache with vomiting for one week after COVID-19 vaccination with COVAXIN® (Bharat Biotech). On examination, she was drowsy, obeying simple commands on repeated asking, aphasic, with motor power of 3/5. Her pupils were equal and reactive. Respiratory and cardiovascular system examination was normal. Brain computed tomography showed left temporo-parietal CVT with raised intracranial pressure (ICP), midline shift to right and left transverse sinus thrombosis [Figure 1]. Laboratory tests revealed thrombocytopenia (platelet count 43,000/μL), elevated D-dimer (7457 ng/mL), and prolonged prothrombin time (18.8s). VITT associated CVT was diagnosed. In view of neurological status and imaging findings, she underwent emergency temporo-parieto-occipital decompressive craniectomy. She received four units of random donor platelet transfusion and three units of fresh frozen plasma before and during surgery. She was shifted to neuro-intensive care unit for elective ventilation and further management. VITT was managed with Fondaparinux and therapeutic plasma exchange (TPE). On 2nd postoperative day (POD), she developed persistent hypotension with tachycardia resistant to fluid therapy, with abnormal arterial blood gas (PaO2 = 40.9 mmHg, PaCO2 = 25.7 mmHg, pH = 7.48, SaO2 = 80.9%). Hence, norepinephrine was started, positive end expiratory pressure (PEEP) and fraction of inspired oxygen (FiO2) increased to 8 cm water and 0.7, respectively. Following this, her heart rate was 112/min, blood pressure was 112/80 mmHg, electrocardiogram showed sinus tachycardia and oxygen saturation was 90%. The FiO2 was gradually reduced with improvement in oxygenation. Transthoracic echocardiography (TTE) showed left ventricular global hypokinesia with ejection fraction of 34%. She was diagnosed with acute left ventricular failure from NSM. Dobutamine and furosemide infusion with oral ivabradine resulted in improvement and cardiovascular medications were tapered and stopped on 9th POD and trachea was extubated on 10th POD. After 24h observation, she was shifted to ward and subsequently discharged home with improved neurological status. Follow up TTE at discharge showed normal cardiac contractility.Figure 1: Contrast computed tomography of the brain showing large temporo-parietal hematoma due to cerebral venous thrombosis with midline shift, mass effect, and significant cerebral edema with loss of gray-white differentiationVITT is characterized as vaccine-induced immune syndrome of severe thrombosis, antibodies to platelet factor 4–polyanion complexes and thrombocytopenia.[3] VITT begins 5-10 days after vaccination and is diagnosed between 5 to 30 days.[4] It is associated with CVT, splanchnic vein thrombosis, deep venous and arterial thrombosis with thrombocytopenia, and elevated D-dimer. Treatment includes non-heparin anticoagulants such as indirect Xa inhibitors (fondaparinux, danaparoid), oral anticoagulants or thrombin inhibitors (argatroban, bivalirudin), and intravenous immunoglobulin or TPE. NSM is reported after stroke, traumatic brain injury, and subarachnoid hemorrhage but not after CVT. Catecholamine excess, systemic inflammation, and neuroendocrine derangements contribute to occurrence of NSM.[5] It is likely that the NSM in our patient was due to interplay of acute increase in ICP (neurogenic) from VITT-associated malignant CVT and systemic vaccine-induced complication-associated stress on the myocardium. Treatment is supportive to improve myocardial function and prevents cardiovascular complications including sudden death.[5] Ivabradine reduces heart rate and improves cardiac failure while dobutamine improves hemodynamic instability associated with NSM.[5,6] To conclude, VITT-associated CVT leading to NSC is rare and challenging to identify and manage. Management goals include reduction of acute intracranial hypertension, restoration of platelet function, anti-coagulation, and supporting cardiac function. Patient consent form Yes. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

A case of post-COVID-19 mucormycosis with permanent pacemaker posted for functional endoscopic sinus surgery: Anaesthetic challenges.

Sir, The important perioperative challenges during surgical debridement for post-coronavirus disease (COVID)-19 rhino-orbital-cerebral mucormycosis include difficult airway, uncontrolled diabetes mellitus (DM), side effects of amphotericin B (AmB), presence of other comorbidities and post-COVID-19 systemic abnormalities including a decline in respiratory function.[1] We report the successful management of a patient with post-COVID-19 mucormycosis with a permanent pacemaker in situ posted for functional endoscopic sinus surgery (FESS) under general anaesthesia. A 70-year-old male with post-COVID-19 mucormycosis came with complaints of right-sided facial swelling and pain with nasal blockage. The patient when admitted for COVID-19 was given tablets favipiravir and prednisolone and discharged after 15 days. He had a history of syncopal attacks and was diagnosed as having a heart block 8 years back for which a permanent pacemaker had been inserted [Figure 1]. He was a known case of DM and hypertension, with a blood sugar of 490 mg/dL and urine ketones positive on admission, and was started on insulin to control the blood sugar. The airway examination showed Mallampati classification (MPC) grade 3 with a thyromental distance of 6.5 cm. Oedema and pain present on the maxillary and orbital regions limited the mouth opening. A preoperative arterial blood gas (ABG) analysis showed PaO2 60 mmHg, PaCO2 34 mmHg, and pH 7.4 and six-zone involvement on chest radiograph. The baseline oxygen saturation (SpO2) was 91% (room air) and the baseline heart rate was 70/min and regular. The electrocardiogram (ECG) showed ventricular pacing with wide QRS complexes [Figure 2]. The echocardiography showed degenerative changes with fair left ventricular systolic function (ejection fraction of 60%). The pacemaker was identified as VITATRON A20A1SR (mode VVIR) which was reprogrammed to asynchronous V000 mode prior to surgery. The defibrillator, transcutaneous pacing and crash cart trolley were kept ready. After pre-oxygenation, the patient was induced with intravenous fentanyl 50 μg, thiopentone 250 mg and rocuronium and tracheal intubation were facilitated with a C-MAC video laryngoscope. The patient was maintained on oxygen, nitrous oxide, isoflurane and vecuronium. He was extubated at the end of the procedure and shifted to the post-anaesthesia care unit. The pacemaker was programmed to its initial mode after surgery. The COVID-19 mucormycosis patients with a pacemaker in situ pose several challenges for an anaesthesiologist. Diabetic nephropathy, renal toxicity and electrolyte imbalance associated with inj. AmB are major concerns besides preoperative hypokalaemia, fever and hypotension.[2] Perioperative blood pressure, urine output, renal function and serum electrolyte monitoring is mandatory.Figure 1: Chest radiograph showing six zone involvement and a ventricular pacing systemFigure 2: Pacemaker spike precedes each QRS complex with LBBB, discordant ST segment and T waves- consistent with right ventricular pacingSupraglottic oedema, fungal debris in the oropharyngeal region and palatal perforation can lead to difficult mask ventilation and endotracheal intubation.[3] In our patient, the thyromental distance was less, the MPC was grade 3 and the mouth opening was restricted leading to an anticipated difficult airway. Hence, a C-MAC videolaryngoscope was used. Post-COVID-19 pulmonary fibrosis leads to breathlessness, dyspnoea, cough, fatigue, limited exercise tolerance and an abnormal ABG picture (low PaO2, high PaCO2, low SpO2).[4] The patient on preoperative oxygen therapy can desaturate during the laryngoscopy for which adequate pre-oxygenation and minimum time for laryngoscopy and intubation is the key. Hypoxaemia and hypercapnia can increase the pacing threshold, and thus, lead to the failure of the pacemaker to capture. Mucormycosis may exist with diabetic ketoacidosis and further treatment with AmB can lead to renal toxicity, acid-base and electrolyte disturbances (hypokalaemia, hyperkalaemia, hypomagnesemia) and hypovolaemia, which may precipitate arrhythmias. These conditions can cause perioperative interference with the pacemaker function leading to failure to capture and pacemaker dysfunction.[5] In addition, FESS is in proximity to the pacemaker and requires the use of cautery leading to electromagnetic interference.[6] Similarly, the microdebrider can lead to artefacts in the ECG mimicking ventricular tachycardia and even asystole. Hence, we converted the pacemaker to an asynchronous mode; nonetheless, pacemaker failure in the synchronous and asynchronous modes has been noted leading to hypotension, arrhythmias or cardiac arrest. Thus, a post-COVID-19 case of mucormycosis with suboptimal lung function, compromised airway, uncontrolled diabetes and an artificial cardiac pacemaker, posted for FESS was managed successfully with vigilant perioperative monitoring under general anaesthesia. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Effect of Closed Building Syndrome on Pulmonary Function

AbstractBackground: Closed building syndrome affects pulmonaryfunction.Aim of Study: This study aimed to identify the effect ofclosed building syndrome on pulmonary function.Subjects and Methods: Eighty switch workers men withclosed building syndrome were included in this study. Theirage ranged from thirty to forty years old. They were recruitedfrom from El-Kasr El-Ainy University Hospital. Beforeinclusion in this study full description of study, proceduresfor each patient and written consent had been signed. All menpatients were evaluated with ventilatory function testing andarterial blood gases.Results: The mean values of age (year), weight (kg),height (cm), and BMI (kg/m2) were 34.34±3.11, 74.02±8.00,168.67±5.96, and 26.02±1.90, respectively in study group.Number (percentage) of normal and abnormal (hypoxic)arterial blood gases distributions were 77 (96.3%) and 3 (3.8%), respectively. Number (percentage) of normal, obstruc-tive and restrictive R. functions distributions were 54 (67.5%),11 (13.7%), and 15 (18.8%), respectively. The mean value oftotal working was 83.91±14.75 hours with minimum andmaximum values 6720.00 hour and 26880.00 hour, respec-tively. The mean value of respiratory functions was 87.09±14.38% with minimum and maximum values 60.20% and103.3%, respectively. There was strong negative correlationbetween total working time and respiratory functions (r=–0.68; p=0.0001; p < 0.05). There was strong negative correlationbetween total working time and respiratory functions. Theresults showed that there was significant relation betweenworking time and respiratory functions also, this means thatchange in the respiratory functions are consistent with changein total working time.Conclusion: There were significant relation betweenworking time and respiratory functions.

Comparison of Dexmedetomidine, Midazolam and Propofol for Sedation of Post-operative Patients on Mechanical Ventilation- A Open Label Randomised Control Trial

Mechanical Ventilation is a life-sustaining therapy for the treatment of patients with acute respiratory failure and indeed the advent of its use heralded the dawn of modern intensive care units. Many patients require ventilator support for respiratory insufficiency or abnormal Arterial Blood Gas

Disproportionally Impaired Diffusion Capacity Relative to Airflow Limitation in COPD

Forced expiratory volume in 1 s (FEV1) is a standard physiological index of chronic obstructive pulmonary disease (COPD), but reflects emphysema and vascular abnormalities less sensitively than diffusion capacity for carbon monoxide (DLCO). This study tested whether a disproportionally impaired DLCO relative to FEV1 (FEV1 z-score>-3 and DLCO z-score≤-3) is a common functional COPD phenotype associated with distinct clinical and structural features and the prognosis of two cohorts. The cross-sectional analyses of the Korea COPD Subgroup Study (KOCOSS) cohort (multicenter study in Korea) included 743 males with COPD whose DLCO was available. The cross-sectional and longitudinal analyses of the Kyoto University Cohort (single-center study in Japan) included 195 males with COPD who were prospectively followed for 10 years. A disproportionally impaired DLCO relative to FEV1 was observed in 29% and 31% of patients in the KOCOSS and Kyoto University cohorts, respectively. In the multivariable analysis, the disproportionally impaired DLCO was associated with worse symptoms, shorter 6-minute walking distance, paraseptal and centrilobular emphysema on computed tomography, and reduced arterial oxygen and carbon dioxide pressures compared to the reference (FEV1 z-score>-3 and DLCO z-score>-3). In the multivariable Cox proportional hazard model, a higher long-term mortality was observed in the disproportionally impaired DLCO group than in the reference group (hazard ratio [95% confidence interval] = 3.09 [1.52–6.29]) and similar to the DLCO z-score≤-3 and FEV1 z-score≤-3 group. The disproportionally impaired DLCO relative to FEV1 is common and associated with increased symptoms, emphysema, arterial blood gas abnormalities, and increased long-term mortality in patients with COPD.

Arterial Blood Gas as a Prognostic Indicator in Patients with Sepsis

AbstractAbnormal arterial blood gas (ABG) among patients with sepsis is an important prognostic indicator. All-cause mortality was the highest among patients with respiratory acidosis (4/9 = 44.4%), followed by those having metabolic acidosis (3/8 = 37.5%). Median length of hospital and intensive care unit stay was 15.75 days and 6.25 days for those with abnormal ABG and 11 and 3.5 days among those with normal ABG. Median health-care expenditure at the time of discharge or death of the patient was the highest in patients with respiratory acidosis ($14,473) and least in patients with normal ABG ($3,384) (average expenditure among patients with abnormal ABG was [$10,059]).

Suspected anaphylaxis after intravenous administration of cefuroxime (Zinacef) in two dogs, with descriptions of arterial blood gas abnormalities over time

Two cases of suspected anaphylaxis occurred in the authors’ hospital within two weeks of each other. The first, a six-year-and-four-month-old border collie, presented for thoracic wall resection. Once anaesthetised, 20...

Root causes and outcomes of postoperative pulmonary complications after abdominal surgery: a retrospective observational cohort study

BackgroundPostoperative pulmonary complications (PPCs) contribute significantly to overall postoperative morbidity and mortality. In abdominal surgery, PPCs remain frequent. The study aimed to analyze the profile and outcomes of PPCs in patients submitted to abdominal surgery and admitted in a Portuguese polyvalent intensive care unit.MethodsFrom January to December 2017 in the polyvalent intensive care unit of Hospital Garcia de Orta, Almada, Portugal, we conducted a retrospective, observational study of inpatients submitted to urgent or elective abdominal surgery who had severe PPCs. We evaluated the perioperative risk factors and associated mortality. Logistic regression was performed to find which perioperative risk factors were most important in the occurrence of PPCs.ResultsSixty patients (75% male) with a median age of 64.5 [47–81] years who were submitted to urgent or elective abdominal surgery were included in the analysis. Thirty-six patients (60%) developed PPCs within 48 h and twenty-four developed PPCs after 48 h. Pneumonia was the most frequent PPC in this sample. In this cohort, 48 patients developed acute respiratory failure and needed mechanical ventilation. In the emergency setting, peritonitis had the highest rate of PPCs. Electively operated patients who developed PPCs were mostly carriers of digestive malignancies. Thirty-day mortality was 21.7%. The risk of PPCs development in the first 48 h was related to the need for neuromuscular blocking drugs several times during surgery and preoperative abnormal arterial blood gases. Median abdominal surgical incision, long surgery duration, and high body mass index were associated with PPCs that occurred more than 48 h after surgery. The American Society of Anesthesiologists physical status score 4 and COPD/Asthma determined less mechanical ventilation needs since they were preoperatively optimized. Malnutrition (low albumin) before surgery was associated with 30-day mortality.ConclusionPPCs after abdominal surgery are still a major problem since they have profound effects on outcomes. Our results suggest that programs before surgery, involve preoperative lifestyle changes, such as nutritional supplementation, exercise, stress reduction, and smoking cessation, were an effective strategy in mitigating postoperative complications by decreasing mortality.

Agreement and Correlation of Arterial and Venous Blood Gas Analysis in a Diverse Population

Introduction: Agreement and correlation of arterial blood gases (ABGs) and venous blood gases (VBGs) at near normal values are well described but have not been well validated at extremes of values. We evaluated the agreement and correlation of ABG and VBG at extremes of values and assessed the utility of VBG as a screening tool. Methods: We performed a retrospective, observational study of ABG and VBG collected at the same time. Statistical analysis included Bland-Altman plot analysis, Pearson correlations, and sensitivity/specificity tests. For limits of agreement (LOA), we set a threshold of ±0.10 units for pH and ±2.4 mm Hg for partial pressure of carbon dioxide (pCO2). A threshold of 80% sensitivity was considered appropriate for VBG to be used as a screening tool for abnormal ABG values. Results: There were 1684, 1744, and 1769 paired pH, pCO2, and HCO3¯ results, respectively. Mean difference (MD) for arterial and venous pH was 0.017 (95% confidence interval [CI]: 0.014-0.020; 95% LOA: −0.11 to 0.15), and Pearson correlation was 0.78 ( P &lt; .0001). At venous pH &lt;7.35, MD was 0.025 (95% CI: 0.019-0.030; 95% LOA: −0.12 to 0.17). Sensitivity of venous pH &lt;7.35 identifying arterial pH &lt;7.35 was 85.0%. MD for arterial and venous pCO2 was −2.5 (95% CI: −2.9 to −2.0; 95% LOA: −21.7 to 16.8), and Pearson correlation was 0.70 ( P &lt; .0001). At venous pCO2 &gt;45 mm Hg, MD was −4.1 (95% CI: −4.9 to −3.3; 95% LOA: −25.7 to 17.5). Sensitivity of venous pCO2 &gt;45 mm Hg identifying arterial pCO2 &gt;45 mm Hg was 67.6%. MD for arterial and venous HCO3¯ was −0.3 (95% CI: −0.4 to −0.2; 95% LOA: −4.8 to 4.2), and Pearson correlation was 0.90 ( P &lt; .0001). Conclusions: Venous blood gases cannot reliably replace ABGs due to poor agreement in acidemia and hypercarbia. Venous blood gases can be used as a screening tool for acidemia but are unsuitable for hypercarbia.

Critically ill systemic lupus erythematosus patients referred to the intensive care unit of Fayoum University Hospital: Frequency, complications and outcome

Aim of the workTo determine the frequency of critical complications of systemic lupus erythematosus (SLE) admitted to the intensive care unit (ICU), study the risk factors and outcome. Patients and methodsFifty SLE patients consequently admitted to the ICU were prospectively studied. The SLE Disease Activity Index (SLEDAI) was assessed. ResultsThe mean age of the patients was 29.3 ± 8.7 years; they were 42 females (84%) and disease duration of 4.9 ± 3.4 years. The overall mortality was 24% (12 patients) and tended to be higher in males (37.5% vs 21.5%). The commonest causes of death were infection (p < 0.001) and pulmonary complications (p = 0.04) in all non-survivors. Metabolic acidosis was significantly increased in deceased patients (75%) compared to survivors (23.7%) (p = 0.003). Cardiac and CNS complications were significantly increased in non-survivors (p = 0.04 and p = 0.03 respectively). Acute renal failure was significantly more frequent in mortality case 9/12 compared to survivors (28.9%) (p = 0.007) as well as abnormal arterial blood gases (100% vs 57.9%; p = 0.005). The SLEDAI was significantly increased in non-survivors (41.8 ± 8.2) compared to survivors (21.4 ± 5.1) (p = 0.001). There was a significant correlation between mortality and SLEDAI (r = 0.58, p = 0.001) and inversely with the pH (r = −0.38, p = 0.01). On multiple regression, only increasing SLEDAI was a significant predictor of mortality (β0.26, OR 1.29, 95%CI 1.12–1.49; p < 0.0001). Mortality prediction by SLEDAI showed at a cut-off of 28.5; sensitivity 84% and specificity 90% (p = 0.001). ConclusionSLE patients admitted to the ICU are at an increased risk of mortality especially those with high disease activity. The main causes of mortality were infection, respiratory, cardiac and neurological complications.

The utility of abnormal initial arterial blood gas values in determining clinical futility of trauma cases with severe hemorrhage

BackgroundPatients who experience trauma with severe hemorrhage requiring immediate surgery and massive blood transfusion often present with markedly abnormal laboratory values. These cases require valuable resources; however, little is known regarding prognostic factors that correlate with mortality. The purpose of this study was to determine whether abnormal initial arterial blood gas (ABG) pH, a marker for severe blood loss, could serve as a prognostic indicator for these patients. MethodsAn IRB approved retrospective study was performed at LAC+USC Medical Center Level I Trauma Center. Data was collected from trauma patients with severe hemorrhage admitted between June 2015 and April 2016 who were immediately admitted to the OR following entry into the ER. Baseline variables of age, sex and mechanism of trauma were collected. The pH readings from the initial three ABG data were obtained, and mortality was determined for each patient. ResultsWe identified 247 patients, 84.2% of which were male. Ages ranged from 1 to 91years (average=38.4). Overall mortality was 13.8%. The average initial pH value for non-survivors (7.10±0.13) was significantly lower than for survivors (7.34±0.07) [p<0.001]. Among patients whose initial three ABG pH values averaged ≤7.15, the survival rate was 8.7%. Ten patients had any single recorded pH value≤6.91. The mortality rate among these patients was 90%. ConclusionsConsideration should be given to initial pH values when resuscitating “red blanket” patients. However, the pH values alone cannot reliably be used to determine clinical futility in individual patients in the early period after injury.

Management of Respiratory Failure.

The management of acute respiratory failure varies according to the etiology. A clear understanding of physiology of respiration and pathophysiological mechanisms of respiratory failure is mandatory for managing these patients. The extent of abnormality in arterial blood gas values is a result of the balance between the severity of disease and the degree of compensation by cardiopulmonary system. Normal blood gases do not mean that there is an absence of disease because the homeostatic system can compensate. However, an abnormal arterial blood gas value reflects uncompensated disease that might be life threatening.

Arterial blood gases predict long-term prognosis in stage I non-small cell lung cancer patients.

BackgroundPreoperative hypercapnia and hypoxemia are reportedly risk factors for postoperative complications. This study aimed to establish the long-term survival risk associated with abnormal preoperative arterial blood gases (ABGs) in patients with non-small cell lung cancer (NSCLC).MethodsThis study involved 414 patients with stage I NSCLC who underwent lobectomy/bilobectomy with mediastinal lymph node dissection. The patients were divided into groups with normal (n = 269) and abnormal (n = 145) ABGs.ResultsThe patients in the normal ABG group (median age 67 years) were significantly younger than those in the abnormal ABG group (median age 70 years). There were no significant differences between the groups in gender, performance status, pathological stage, histology, postoperative complications, or preoperative comorbidity, except for chronic obstructive pulmonary disease/pulmonary fibrosis. The 3-, 5- and 10-year survival rates in the normal and abnormal ABG groups were 87, 77 and 56, and 78 , 63 and 42 %, respectively (p = 0.006). According to multivariate analysis, age, gender, performance status, non-adenocarcinoma, differentiation of resected tumor, pathological stage, any prior tumor and abnormal ABGs (risk ratio, 1.61) were independent prognostic factors.ConclusionsAbnormal ABGs predict long-term survival risk in patients with NSCLC, which is important for planning therapeutic strategies.

Short Term Outcome of Neonates Born With Abnormal Umbilical Cord Arterial Blood Gases.

Background:Umbilical arterial blood gas (UABG) analysis is more objective than other methods for predicting neonatal outcome. Acidemic neonates may be at risk for unfavorable outcome after birth, but all neonates with abnormal arterial blood gas (ABG) analysis do not always have poor outcome.Objectives:This study was carried out to determine the short term outcome of the neonates born with an abnormal ABG.Patients and Methods:In a cohort prospective study 120 high risk mother-neonate pairs were enrolled and UABG was taken immediately after birth. All neonates with an umbilical cord pH less than 7.2 were considered as case group and more than 7.2 as controls. Outcomes like need to resuscitation, admission to newborn services and/or NICU), seizure occurrence, hypoxic ischemic encephalopathy (HIE), delayed initiation of oral feeding and length of hospital stay were recorded and compared between the two groups. P value less than 0.05 was considered as being significant.Results:Comparison of short term outcomes between normal and abnormal ABG groups were as the fallowing: need for advanced resuscitation 4 vs. 0 (P = 0.001), NICU admission 16 vs. 4 (P = 0.001), convulsion 2 vs. 0 (P = 0.496), HIE 17 vs. 4 (P = 0.002), delay to start oral feeding 16 vs. 4 (P = 0.001), mean hospital stay 4 vs. 3 days (P = 0.001). None of the neonates died in study groups.Conclusions:An umbilical cord PH less than 7.2 immediately after birth can be used as a prognostic factor for unfavorable short term outcome in newborns.

Four steps to interpreting arterial blood gases.

This article examines acid-base balance and the interpretation of arterial blood gases (ABG). The article begins with a brief revision of related physiology, followed by a description of the primary disorders associated with acid-base imbalance. The normal ranges and the significance of abnormal ABG results are explored. The article concludes by providing an easy to follow four-step guide to ABG interpretation with practice examples presented in the CPD task section.

Variability of oxygenation in possible hepatopulmonary syndrome: effects of requiring two abnormal arterial blood gas results for diagnosis.

Hepatopulmonary syndrome (HPS) affects 10-32 % of patients with cirrhosis and is defined by liver abnormalities, intrapulmonary vascular dilatations (IPVDs), and abnormal oxygenation. However, published criteria for abnormal oxygenation are inconsistent. We sought to evaluate variation in oxygenation over time and to compare various diagnostic criteria for validity, based on their diagnostic stability over time and ability to identify patients with clinically relevant findings. We retrospectively analyzed oxygenation and diffusion capacity in patients with liver abnormalities and IPVDs who had ≥ 2 arterial blood gases (ABGs) at the University of Toronto or Universite de Montreal. We compared the performance of nine possible oxygenation criteria for HPS and for each explored whether validity improved when requiring two consecutive abnormal ABGs on different days. Mean PaO2 was 68.4 mmHg and annual within-patient coefficient of variation 6.3 % (58 patients). Applying published criteria, 8.6-15.5 % of patients initially diagnosed with HPS no longer met the criterion for HPS on a subsequent ABG (re-classified). Requiring two consecutive abnormal ABGs on different days: (1) reduced the proportion of re-classified patients (9/9 criteria); (2) identified patients with more rapid progression in hypoxemia and greater difference in rate of progression between HPS and non-HPS (7/9 criteria); and (3) identified patients with lower diffusion and a larger difference in diffusion between HPS and non-HPS (8/9 criteria). Oxygenation is variable in this population, and requiring two abnormal results might reduce misdiagnosis and better differentiate patients with and without HPS according to clinically relevant markers of disease.

An Update on Domiciliary Non-Invasive Ventilation

Chronic respiratory failure (CRF) should be considered a syndrome defined by arterial blood gas abnormalities. Domiciliary non-invasive ventilation (NIV) is an increasingly used intervention to curtail the detrimental effects of CRF in individuals with a broad range of cardiorespiratory disorders. Progress in the provision, monitoring and improvement in patient centred outcomes with NIV has simply been staggering over the last decade. Despite this, questions still remain in terms of the ideal mode of delivery, the most efficient techniques to monitor its effectiveness, and the timing of NIV initiation for several of the more common diseases which can require NIV support. There are a number of mechanisms accounting for the reduced ventilation that is apparent during sleep, even in normal subjects. This represents a particularly unique physiological state whereby changes in upper airway resistance control of respiration and changes in lung mechanics have an impact on the adequacy of tidal volume breathing. Abnormal respiratory events tend to occur specifically during sleep, and so NIV which is appropriate for the awake patient may not be suitable when asleep at night. These factors need to be kept in mind both for the optimal timing of NIV, and the manner in which it should be monitored. This article aims to provide an overview of current concepts in the appropriate mode of delivery of NIV, discusses the patient groups who benefit from its application, highlights challenges with interface design, and aspects that need to be kept in mind in terms of the optimal monitoring of NIV