1. Interpreting ABGs (or the ABCs of ABGs) Suneel Kumar MD

2. Arterial Blood Gases Written in following manner: pH/PaCO 2 /PaO 2 /HCO 3 –pH = arterial blood pH –PaCO 2 = arterial pressure of CO 2 –PaO 2 = arterial pressure of O 2 –HCO 3 = serum bicarbonate concentration

3. Oxygenation Hypoxia: reduced oxygen pressure in the alveolus (i.e. P A O 2 ) Hypoxemia: reduced oxygen pressure in arterial blood (i.e. P a O 2 )

4. Hypoxia with Low PaO 2 Alveolar diffusion impairment Decreased alveolar PO 2 –Decreased FiO 2 –Hypoventilation –High altitude R  L shunt V/Q mismatch

5. Hypoxia with Normal PaO 2 Alterations in hemoglobin –Anemic hypoxia –Carbon monoxide poisoning –Methemoglobinemia Histotoxic hypoxia –Cyanide Hypoperfusion hypoxia or stagnant hypoxia

6. Alveolar—Arterial Gradient Indirect measurement of V/Q abnormalities Normal A-a gradient is 10 mmHg Rises with age Rises by 5-7 mmHg for every 0.10 rise in FiO 2, from loss of hypoxic vasoconstriction in the lungs

7. Alveolar—Arterial Gradient A-a gradient = P A O 2 – P a O 2 P A O 2 = alveolar PO 2 (calculated) P a O 2 = arterial PO 2 (measured)

8. Alveolar—Arterial Gradient P A O 2 = P I O 2 – (P a CO 2 /RQ) P A O 2 = alveolar PO 2 P I O 2 = PO2 in inspired gas P a CO 2 = arterial PCO 2 RQ = respiratory quotient

9. Alveolar—Arterial Gradient P I O 2 = FiO 2 (P B – P H2O ) P B = barometric pressure (760 mmHg) P H2O = partial pressure of water vapor (47 mmHg) RQ = V CO 2 /V O 2 RQ defines the exchange of O 2 and CO 2 across the alveolar-capillary interface (0.8)

10. Alveolar—Arterial Gradient P A O 2 = Fi O 2 (P B – P H2O ) – (P a CO 2 /RQ) Or P A O 2 = FiO 2 (713) – (P a CO 2 /0.8)

11. Alveolar—Arterial Gradient For room air: P A O 2 = 150 – (P a CO 2 /0.8) And assume a normal P a CO 2 (40): P A O 2 = 100

12. Acid-Base Acidosis or alkalosis: any disorder that causes an alteration in pH Acidemia or alkalemia: alteration in blood pH; may be result of one or more disorders.

13. Six Simple Steps 1.Is there acidemia or alkalemia? 2.Is the primary disturbance respiratory or metabolic? 3.Is the respiratory problem acute or chronic? 4.For metabolic, what is the anion gap? 5.Are there any other processes in anion gap acidosis? 6.Is the respiratory compensation adequate?

14. Henderson-Hasselbach Equation pH = pK + log [HCO 3 /PaCO 2 ] x K (K = dissociation constant of CO 2 ) Or [H + ] = 24 x PaCO 2 /HCO 3

15. Henderson-Hasselbach Equation pH 7.20 7.30 7.40 7.50 7.60 [H+] 60 50 40 30 20

16. Step 1: Acidemia or Alkalemia? Normal arterial pH is 7.40 ± 0.02 –pH < 7.38  acidemia –pH > 7.42  alkalemia

17. Step 2: Primary Disturbance Anything that alters HCO 3 is a metabolic process Anything that alters PaCO 2 is a respiratory process

18. Step 2: Primary Disturbance If  pH, there is either  PaCO 2 or  HCO 3 If  pH, there is either  PaCO 2 or  HCO 3

19. Step 3: Respiratory Acute/Chronic? Acute:  CO 2 by 10   pH by 0.08 Chronic:  CO 2 by 10   pH by 0.03 Changes in CO 2 and pH are in opposite directions

20. Step 4: For Metabolic, Anion Gap? Anion gap = Na + - (Cl - + HCO 3 - ) –Normal is < 12

21. Increased Anion Gap Ingestion of drugs or toxins –Ethanol –Methanol –Ethylene glycol –Paraldehyde –Toluene –Ammonium chloride –Salicylates

22. Increased Anion Gap Ketoacidosis –DKA –Alcoholic –Starvation Lactic acidosis Renal failure

23. Step 4: For Metabolic, Anion Gap? If + AG, calculate Osm gap: Calc Osm = (2 x Na + ) + (glucose/18) + (BUN/2.8) + (EtOH/4.6) Osm gap = measured Osm – calc Osm Normal < 10 mOsm/kg

24. Nongap Metabolic Acidosis Administration of acid or acid- producing substances –Hyperalimentation –Nonbicarbonate-containing IVF

25. Nongap Metabolic Acidosis GI loss of HCO 3 –Diarrhea –Pancreatic fistulas Renal loss of HCO 3 –Distal (type I) RTA –Distal (type IV) RTA –Proximal (type II) RTA

26. Nongap Metabolic Acidosis Calculate urine anion gap: Urine AG = (Na + + K + ) – Cl - –Positive gap indicates renal impaired NH 4 + excretion –Negative gap indicates normal NH 4 + excretion and nonrenal cause

27. Nongap Metabolic Acidosis Urine Cl - < 10 mEq/l is chloride responsive and accompanied by “contraction alkalosis” and is “saline responsive” Urine Cl - > 20 mEq/l is chloride resistant, and treatment is aimed at underlying disorder

28. Step 5: Any other process with elevated AG? Calculate  gap, or “gap-gap”:  Gap = Measured AG – Normal AG (12)

29. Step 5: Any other process with elevated AG? Add  gap to measured HCO 3 –If normal (22-26), no other metabolic problems –If < 22, then concomitant metabolic acidosis –If > 26, then concomitant metabolic alkalosis

30. Step 6: Adequate respiratory compensation? Winter’s Formula Expected PaCO 2 = (1.5 x HCO 3 ) + 8 ± 2 –If measured PaCO 2 is higher, then concomitant respiratory acidosis –If measured PaCO 2 is lower, then concomitant respiratory alkalosis

31. Step 6: Adequate respiratory compensation? In metabolic alkalosis, Winter’s formula does not predict the respiratory response –PaCO 2 will rise > 40 mmHg, but not exceed 50-55 mmHg –For respiratory compensation, pH will remain > 7.42

32. Clues to a Mixed Disorder Normal pH with abnormal PaCO 2 or HCO 3 PaCO 2 and HCO 3 move in opposite directions pH changes in opposite direction for a known primary disorder

33. Case 1 A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak. His roommate has just returned from a semester in Africa. The patient had been observed admiring his roommate's authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare).

34. Case 1 138100 26 7.08/80/37

35. Case 1 What is the A-a gradient? A-a gradient = [150 – 80/0.8] - 37 A-a gradient = 13 Acidemia or alkalemia? Primary respiratory or metabolic? Acute or chronic? –  PCO 2 by 40 would  pH by 0.32

36. Case 1 What is the anion gap? AG = 138 – (100 + 26) AG = 12

37. Case 1 Acute respiratory acidosis

38. Case 2 A 42 year old diabetic female who has been on insulin since the age of 13 presents with a 4 day history of dysuria which has progressed to severe right flank pain. She has a temperature of 38.8ºC, a WBC of 14,000, and is disoriented.

39. Case 2 13599 124.8 7.23/25/113

40. Case 2 What is the A-a gradient? A-a = [150 – 25/0.8] – 113 = 6 Acidemia or alkalemia? Primary respiratory or metabolic? What is the anion gap? AG = 135 – (99 + 12) = 24

41. Case 2 What is the  gap?  Gap = 24 – 12 = 12  Gap + HCO 3 = 12 + 12 = 24 –No other metabolic abnormalities Is the respiratory compensation appropriate? Expected PC O 2 = (1.5 x 12) + 8 ± 2 = 24 ± 2 –It is appropriate

42. Case 2 Acute anion gap metabolic acidosis (DKA)

43. Case 3 A 71 year old male, retired machinist, is admitted to the ICU with a history of increasing dyspnea, cough, and sputum production. He has a 120 pack-year smoking history, and quit 5 years previously. On exam he is moving minimal air despite using his accessory muscles of respiration. He has acral cyanosis.

44. Case 3 13593 30 7.21/75/41

45. Case 3 What is the A-a gradient? A-a = [150 – 75/.8] – 41 = 15 Acidemic or alkalemic? Primary respiratory or metabolic? Acute or chronic? –Acute  PCO 2 by 35 would  pH by 0.28 –Chronic  PCO 2 by 35 would  pH by 0.105 Somewhere in between

46. Case 3 What is the anion gap? AG = 135 – (93 + 30) = 12

47. Case 3 Acute on chronic respiratory acidosis (COPD)

48. Case 3b This same patient is intubated and mechanically ventilated. During the intubation he vomits and aspirates. He is ventilated with an FiO2 of 50%, tidal volumes of 850 mL, PEEP of 5, rate of 10. One hour later his ABG is 7.48/37/215.

49. Case 3b Why is he alkalotic with a normal PCO 2 ? –Chronic compensatory metabolic alkalosis and acute respiratory alkalosis

50. Case 4 A 23 year old female presents to the Emergency Room complaining of chest tightness and light- headedness. Other symptoms include tingling and numbness in her fingertips and around her mouth. Her medications include Xanax and birth control pills, but she recently ran out of both.

51. Case 4 135109 22 7.54/22/115

52. Case 4 What is the A-a gradient? A-a = [150 – 22/.8] – 115 = 8 Acidemia or alkalemia? Primary respiratory or metabolic? Acute or chronic? –Acute  CO 2 by 18 would  pH by 0.144 What is the anion gap? AG = 135 – (109 + 22) = 4

53. Case 4 Acute respiratory alkalosis (panic attack)

54. Case 5 72 year old woman admitted from a nursing home with one week history of diarrhea and fever. 133118 5 7.11/16/94

55. Case 5 What is the A-a gradient? A-a = [150 – 16/.8] – 94 = 36 Acidemia or alkalemia? Primary respiratory or metabolic? What is the anion gap? AG = 133 – (118 + 5) = 10 Is respiratory compensation adequate? PCO 2 = (1.5 x 5) + 8 ± 2 = 16 ± 2

56. Case 5 Non anion gap metabolic acidosis (diarrhea) Compensatory respiratory alkalosis

57. Case 6 A 27 year old pregnant alcoholic with IDDM is admitted one week after stopping insulin and beginning a drinking binge. She has experienced severe nausea and vomiting for several days.

58. Case 6 13670 19 7.58/21/104

59. Case 6 What is the A-a gradient? A-a = [150 – 21/.8] – 104 = 20 Acidemia or alkalemia? Primary respiratory or metabolic? What is the anion gap? AG = 136 – (70 + 19) = 47 What is the  gap?  Gap = 47-12 = 35  Gap + HCO 3 = 54

60. Case 6 Primary respiratory alkalosis (pregnancy) Anion gap metabolic acidosos (ketoacidosis) Nongap metabolic alkalosis (vomiting)

61. Case 7 35 year old male presents to the ER unconscious. 14570 23 7.61/24/78 Creat 6.1

62. Case 7 What is the A-a gradient? A-a = [150 – 24/.8] – 78 = 42 Acidemia or alkalemia? Primary respiratory or metabolic? What is the anion gap? AG = 145 – (70 + 23) = 52

63. Case 7 What is the  gap?  Gap = 52 - 12 = 40  Gap + HCO 3 = 63 –Nongap metabolic alkalosis

64. Case 7 Respiratory alkalosis Anion gap metabolic acidosis (renal failure) Nongap metabolic alkalosis

65. Bonus Case #1 51 year old man with polysubstance abuse, presented to ER with 3-4 day h/o N/V and diffuse abdominal pain. Reports no EtOH or cocaine in 2 weeks. He has been taking “a lot” of aspirin for pain. Denies dyspnea, but has been tachypneic since arrival.

66. Bonus Case #1 Afebrile, P 89, R 20, BP 142/57. Lethargic but arrousable, easily aggitated. Lungs clear, and abdomen is soft with mild tenderness in LUQ and LLQ.

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

68. Bonus Case #1 What is the A-a gradient? A-a = [150 – 15/.8] – 107 = 25 Acidemia or alkalemia? Primary respiratory or metabolic? What is the anion gap? AG = 126 – (93 + 11) = 22 Anion gap metabolic acidosis

69. Bonus Case #1 What is the  gap?  Gap = 22 - 12 = 10  Gap + HCO 3 = 21 Nongap metabolic acidosis What is the osmolar gap? Calc Osm = 2x126 + 218/18 + 58/2.8 Calc Osm = 265 Osm gap = 272 – 265 = 7

70. Bonus Case #1 Respiratory alkalosis (aspirin) Anion gap metabolic acidosis (aspirin) Nongap metabolic acidosis

71. Bonus Case # 2 20 year old college student brought to the ER by his fraternity brothers because they cannot wake him up. He had been in excellent health until the prior night.

72. Bonus Case #2 Afebrile, P 118, R 32, BP 120/70. Anicteric sclerae, pupils 8mm and poorly responsive to light. Fundoscopic exam with slight blurring of discs bilaterally and increased retinal sheen. Remainder of exam unremarkable.

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

74. Bonus Case #2 What is the A-a gradient? A-a = [150 – 24/.8] – 108 = 12 Acidemia or alkalemia? Primary respiratory or metabolic? What is the anion gap? AG = 142 – (98 + 10) = 34 Anion gap metabolic acidosis

75. Bonus Case #2 What is the  gap?  Gap = 34 - 12 = 22  Gap + HCO 3 = 32 Nongap metabolic alkalosis

76. Bonus Case #2 What is the osmolar gap? Calc Osm = 2x142 + 108/18 + 14/2.8 + 45/4.6 Calc Osm = 305 Osm gap = 348 - 305 = 43 Is the respiratory compensation adequate? PCO 2 = (1.5 x 10) + 8 ± 2 = 23 ± 2

77. Bonus Case #2 Anion gap metabolic acidosis with elevated osmolar gap (methanol) Nongap metabolic alkalosis Compensatory respiratory alkalosis

78. Bonus Case #3 A 23 year old man presents with confusion. He has had diabetes since age 12, and has been suffering from an intestinal flu for the last 24 hours. He has not been eating much, has vague stomach pain, stopped taking his insulin, and has been vomiting. His glucose is high.

79. Bonus Case #3 13080 10 7.20/25/68

80. Bonus Case #3 What is the A-a gradient? A-a = [150 – 25/.8] – 68 = 51 Acidemia or alkalemia? Primary respiratory or metabolic? What is the anion gap? AG = 130 – (80 + 10) = 40 Anion gap metabolic acidosis

81. Bonus Case #3 What is the  gap?  Gap = 40 - 12 = 28  Gap + HCO 3 = 38 Nongap metabolic alkalosis Is the respiratory compensation adequate? PCO 2 = (1.5 x 10) + 8 ± 2 = 23 ± 2

82. Bonus Case #3 Anion gap metabolic acidosis (DKA) Metabolic metabolic alkalosis (emesis) Compensatory respiratory alkalosis

84. Pulmonary Artery Catheters Suneel Kumar MD

85. History In 1929, German surgical trainee Werner Forssman experimented on human cadavers Found that it was easy to guide a urologic catheter from arm veins into the right atrium

86. History Forssmann went as far as to dissect the veins of his own forearm and guided a urologic catheter into his right atrium Used fluoroscopic control and a mirror Was able to walk to get a chest x-ray For his trouble, he was fired Eventually was awarded the Nobel Prize in 1956

87. History Jeremy Swan and William Ganz from Cedars-Sinai developed a balloon- guided catheter placement Published in NEJM in August 1970 Idea came to Swan while watching sail boats moving quickly on a calm day Neither the physicians nor the manufacturer were able to patent the balloon catheter

88. Functional Cardiac Anatomy

89. Uses of PA and Arterial Catheters Allows assessment of both RV and LV during diastolic and systolic phases Allows use of PCWP which is used to reflect the degree of pulmonary congestion Allows in assessment of blood flow (CO) and tissue oxygenation (SvO 2 )

90. Use of PA Catheter To establish diagnosis To guide therapy To monitor response to therapy To assess determinants of tissue oxygenation

91. Indications Diagnosis of shock Differentiate high vs low pressure pulmonary edema Diagnosis of PPH Assessment of response to medications for PPH Diagnosis of valvular heart disease, intracardiac shunts, cardiac tamponade, and PE Monitoring and management of complicated AMI Assessing hemodynamic response to therapies Management of MOF and/or severe burns Management of hemodynamic instability after cardiac surgery Aspiration of air emboli

92. Indications

93. Contraindications Tricuspid or pulmonic valve mechanical protheses Right heart mass (thrombus or tumor) Tricuspid or pulmonic valve endocarditis

94. Approaches to Access

98. Insertion Technique

99. Proper Position

100. Coiled PA Catheter

101. Distal Cath Tip

102. Lung Zones of West

103. P A > P a > P c P a > P A > P c P a > P c > P A

104. Static Column of Blood to LA

105. During Diastole: Tricuspid and mitral valves are open Blood leaves the atria and fill the ventricles Pressure between the atria and ventricles equalize

106. At End-Diastole: Mean RA pressure equalizes with the RV end-diastolic pressure PA diastolic and PCWP equalize with the LV end-diastolic pressure

107. Mean RA = RV EDP

108. PA EDP and PCWP = LV EDP

109. CVP/RA Waveform Three positive waves: –a wave (usually largest) –c wave (may not be seen) –v wave

110. CVP/RA Waveform a wave is with atrial contraction c wave is with closure of tricuspid valve v wave is with blood filling atrium with tricuspid valve is closed

111. CVP/RA Waveform

112. CVP/RA Waveform and EKG a wave in PR interval c wave at end of QRS, in RST junction v wave after T wave

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

114. Measuring the Mean CVP

115. RV Waveform Sharp upstroke during systole, and downstroke during diastole

116. RV Waveform

118. RV to PA As the catheter goes past the pulmonic valve: –The systolic pressure is about the same and now has a dicrotic notch (from closure of pulmonic valve) –The diastolic pressure increases

119. RV to PA

120. PA Waveform PA systole within T wave PA diastole at end of QRS

121. PCWP Waveform Inflation of the balloon stops forward blood flow Creates a static column of blood between the catheter tip and the LA

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

123. PCWP Waveform and EKG a wave near end or after QRS v wave well after T wave

124. Mean PCWP Measurement Final filling of the left ventricle occurs during atrial contraction Therefore, measure the average of the a wave Measure at the end of expiration

125. Mean PCWP Measurement 12 + 6 / 2 = 9

126. PCWP at End Expiration

127. Waveform Review

130. Calculating Cardiac Output Cardiac output done by thermodilution Known saline bolus (5-10 mL) at known temperature (usually < 25 o C) injected via the proximal lumen Thermistor at end of SC catheter measures the change in temperature Change in temperature is inversely proportional to the CO

131. Calculating Cardiac Output

132. Stewart-Hamilton formula: CO = (vol of injectate) x (blood temp – injectate temp) x (computation constant) / (change in blood temp as a function of time, or AUC)

133. Types of Shock COPCWPSVR Cardiogenic  Hypovolemic // Septic / Distributive  N/ 

134. Cardiogenic Shock Severely decreased cardiac output Extracardiac obstructive shock (e.g. cardiac tamponade) has equalization of pressures RAP = RV diastolic = PA diastolic = PCWP RA with minimal x and y descents, and elevation in mean RAP Loss of PA respiratory variations

135. Constrictive Pericarditis Limited early diastolic filling Causes a plateau in the RV pressure “Square root sign” RAP has a “M” or “W” configuration a and v waves accentuated with rapid x and y descents Due to rheumatic disease, TB, metastatic carcinoma, prior chest XRT, or open heart surgery

136. Constrictive Pericarditis

137. Hypovolemic Shock Due to decreased blood volume Usually from hemorrhage or volume depletion

138. Distributive / Septic Shock Due to peripheral vasodilation Other causes include anaplylaxis, neurogenic shock, Addisonian crisis, toxic shock syndrome, cirrhosis, and myxedema coma

139. Information from PA Catheter Directly: –CVP –PA pressure –PCWP –CO –SvO 2 Calculated: –Stoke volume/ index –Cardiac index –Systemic vascular resistance (SVR) –Pulmonary vascular resistance (PVR) –Oxygen delivery

140. Formulas SVR = (MAP – CVP) / CO PVR = (MPAP – PCWP) / CO SV = CO / HR CaO 2 = (1.39 x Hb x SaO 2 ) + (0.003 x PaO 2 ) DO 2 = CaO 2 x CO

141. Normal Values SvO2 Stoke volume Stroke index Cardiac output Cardiac index MAP CVP PCWP PA pressures SVR PVR 60-75% 50-100 mL/beat 25-45 mL/beat/m 2 4-8 L/min 2.5-4.0 L/min/m 2 70-110 mmHg 2-6 mmHg 8-12 mmHg 15-30 / 0-10 mmHg 900-1400 dynes. sec/cm 5 40-150 dynes. sec/cm 5

142. Case # 1 A 65 year old man with COPD required intubation for respiratory failure. He was placed on AC. Shortly after intubation, he developed hypotension and a SG catheter was placed, but a PCWP could not be obtained.

143. Case # 1 RA 4, sat 76% RV 45/0, sat 76% PA 45/20, mean 28, sat 77% PCWP ??? BP 90/60, mean 70 CO 5.7 SVR 928 7.44 / 34 / 110, sat 99% Mixed venous 7.38 / 42 / 44, sat 77%

144. Case # 2 A 58 year old male is admitted to the CCU as a r/o MI. Developed respiratory distress.

145. Case # 2 RA 6, sat 65% RV 55/0, sat 66% PA 55/30, mean 45, sat 66% PCWP ???, sat 91% BP 110/80, mean 90 CO 5.0 SVR 1,344 7.44 / 35 / 80, sat 91% Mixed venous 7.40 / 40 / 36, sat 66%

146. Case # 2

147. Case # 3 A 55 year old female is admitted with chest pain and shock. The EKG shows acute ischemic changes in the inferior limb leads. What is the diagnosis, and how would you treat her?

148. Case # 3 RA 14, sat 55% RV 30/15, mean 20, sat 55% PA 30/11, mean 20, sat 55% PCWP BP 90/60, mean 70 CO 2.5 SVR 1,792 7.38 / 35 / 85, sat 90% Mixed venous 7.34 / 41 / 32, sat 55%

149. Case # 4 A 50 year old male presents with syncope and shock. Room air ABG is obtained.

150. Case # 4 RA 15, sat 48% RV 45/0, sat 48% PA 45/20, mean 28, sat 49% PCWP 7 BP 50/50, mean 60 CO 2.5 SVR 1,440 7.32 / 32 / 59, sat 89% Mixed venous 7.28 / 38 / 28, sat 49%

151. Case # 5 A 65 year old male with a two day history of weakness, dizziness, and dyspnea on exertion. On physical, noted to have a resting tachycardia. Chest x-ray shows a mediastinal mass.

152. Case # 5 RA 20, sat 71% RV 45/19, sat 71% PA 45/20, mean 28, sat 72% PCWP 20, sat 96% BP 90/70, mean 77 CO 4.0 SVR 1,140 7.39 / 38 / 85, sat 96% Mixed venous 7.38 / 40 / 40, sat 72%

153. Case # 6 A 112 year old male presents with tachypnea, confusion, and hypotension.

154. Case # 6 RA 2, sat 69% RV 42/0, sat 69% PA 45/15, mean 25, sat 70% PCWP 8, sat 85% BP 70/40, mean 50 CO 6.5 SVR 592 7.55 / 32 / 50, sat 85% Mixed venous 7.40 / 38 / 37, sat 70%

155. Case # 7 A 45 year old alcoholic with abdominal pain and hypotension. Chest x-ray shows a large, globular heart and a left pleural effusion. The Hct 45%.

156. Case # 7 RA 1, sat 49% RV 20/0, sat 49% PA 20/10, mean 13, sat 49% PCWP 4 BP 80/50, mean 60 CO 3.0 SVR 1,576 7.34 / 30 / 80 Mixed venous 7.31 / 38 / 28, sat 49%

157. Case # 8 24 hours later, the prior patient in Case #7 becomes tachypneic. What complication has occurred?

158. Case # 8 RA 4, sat 64% RV 45/0, sat 64% PA 45/25, mean 32, sat 65% PCWP 12 BP 110/70, mean 85 CO 6.1 SVR 1,064 7.46 / 32 / 55, sat 89% Mixed venous 7.40 / 31 / 35, sat 65%

159. Case # 9 A 98 year old male with confusion and hypotension. What kind of shock does he have?

160. Case # 9 RA 12, sat 47% RV 40/12, sat 48% PA 40/30, mean 33, sat 49% PCWP 29, sat 90% BP 80/50, mean 60 CO 2.5 SVR 1,536 7.30 / 45 / 60, sat 90% Mixed venous 7.26 / 50 / 28, sat 49%

161. Case # 10 35 year old female with an abnormal chest x-ray and dyspnea on exertion. What is the diagnosis?

162. Case # 10 RA 8, sat 84% RV 60/0, sat 85% PA 45/20, mean 28, sat 86% PCWP 10, sat 99% BP 120/80, mean 95 CO 9.4 SVR 744 7.40 / 40 / 99, sat 99% Mixed venous 7.38 / 42 / 54, sat 86%

163. Case # 11 A 38 year old female presents with chest pain and dyspnea.

164. Case # 11 RA 8, sat 65% RV 110/10, sat 66% PA 90/50, mean 63, sat 67% PCWP 12, sat 98% BP 110/70, mean 83 CO 3.2 SVR 1,872 7.41 / 30 / 90, sat 98% Mixed venous 7.37 / 33 / 37, sat 67%

165. Case # 12 18 year old female presents with exertional syncope.

166. Case # 12 RA 15, sat 78% RV 110/27, sat 90% PA 80/40, mean 60, sat 91% PCWP 28 BP 120/80, mean 95, sat 99% CO 20 SVR 800 7.40 / 40 / 99, sat 99% Mixed venous 7.38 / 42 / 79, sat 91%

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