Data Interpretation and Protocols
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Transcript of Data Interpretation and Protocols
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1. Cardiac catheterisation
SVC
RA 65% 4 LA 99% 6
RV 65 25/4 LV 98% 75/6
PA 65 25/15 AORTA 97% 75/50
Aorta > 94 % -acyanotic
o PA ( sao2) > SVC ----------- L -> R SHUNT
Pulm pressure high ---- large VSD / PDA
Normal ------ASD , Small VSD /PDA
o P A ( sao2) = SVC
LV pr > Ao ----- AS
RV pr > PA ------ PS
Asc Ao pr > desc ------ coarctation
< 94 % - CYANOTIC
o PA sao2 > Ao ----------- TGA
o PA pr
normal ------------
-fallot, Pr RV =LV
TGA , pr RV > LV
critical PS
High ------------ TGA +VSD, AVSD, EISSENMENGER
o LA sao2 decreased ---------- Tricuspid/ pulmonary atresia
2. ABGA
PH 7.35 -7.45 PCO2 4.5 -6 ( 35 -45 ) PO2 11-14 HCO3 -22-26 BE/BD - + /- 2
CBG All except po2 / VBG only Ph
Metab acidosis
Required
anion gap ,
lactic acid , osmolar gap,
-
urine anion gap, K , urine ph
Anion gap = Na +k ( hco3 + cl )= 12 +/- 2 ( 4 if k )
Osm gap = ( measured osm calc osm ) 2 Na + urea + glucose
Urine anion gap +ve ( Cl < Na + k )
High anion gap - Cl normal
Increased lactic acid
Poor perfusion hypoxia, shock, heart failure
Normal perfusion renal failure CRF , starvation
Normal lactic acid
High osm gap poison, toxin ( measured osm calc osm ) 2 Na + urea + glucose
Nl osm gap (< 10 ) DKA , IEM
Salicylate, PCM, ETHANOL,METHANOL, formaldehyde, metformin, NH4CL,ACETAZOLAMIDE
DKA Macidosis, high Na, low /N K , Low HCO3
NAGMA Increased Cl
Urine anion gap +ve ( Cl < Na + k )
Renal loss of HCO3 --- RTA
Low K , Urine Ph > 5.5 - Type 1
Low K , urine Ph < 5.5 - type 2
High k type 4
Urine anion gap ve ( CL> Na + k )
GI LOSS Of HCO3 --- persist diarrhoea
DURHAM ACETAZOLAMIDE , ADDISONS , GDM TYPE1
HCO3 Replacement = 0.3 *Wt *BD
Type 1 -distal Type 2 proximal
Urine ph > 5.8 never acid May be < 5.3
Severe hypokalemia K normal / low
Nephrocalcinosis
No increase in urine blood pco2 gradient
with nahco3 load
Increase
-
1-2 mmol/kg nahco3 Large dose
Obs uropathy
Nephrocalcinosis
Amphotericin, cyclosporin
Fanconi syndrome
Isolated / familial
Fanconi syndrome
Cystinosis ( not cystinuria
Tyrosinemia
Galactosemia
Lowe ( OCR )
WILSON
Lead, mercury, cadmium toxicity
Tetracycline, ifosfamide
Hyperchloremic NAGMA
Glycosuria normal glucose
Hypophosphatemia , low TRP, Rickets- no hypocalcemia
Hypokalemia
Growth faltering
Polyuria, polydipsia
Cystinosis transport of cysteine out of lysosome fanconi, recc conjunctivitis ( corneal crystals ,) photophobia, hypothyroid
Renal failure 8 yrs
White cell cysteinelevel
Supportive / cysteamine
METABOLIC ALKALOSIS
Look for - cl, BP, Urine cl, renin aldosterone
NORMOCHLOREMIC enteral /parenteral HCO3
Hypochloremic ( cl loss)
Normal BP
Urinary Cl >20 barter, gitelman
-
< 10 pseudo barter
High BP
Renin Aldosterone
Renal artery stenosis High High
Conns, adr tumor low High
Cushings, CAH, 11 b,
liddle
low low
Barter Na k 2 cl in thick asc limb
Polyuria, polydipsia
Mat polyhydramnios
Hypochloremic hypokalemic alkalosis ( cl unresponsive )
Renin, aldo increase ( vasc unresponsiveness )
Nl BP
Urine cl, na > 20 mmol
Urine calcium normal / high : nephrocalcinosis
Increased PGE2
Indomethacin / potassium supplements
Pseudo barter
Low urine Na , Cl < 10 (cl responsive )
o Cystic fibrosis
o Cong chloride diarhea
o Laxative abuse
o Cyclical vomiting
High urine electrolyte loop diuretics
Gitelman ( like thiazide )
Distal tubule Na cl cotransporter
Hypocalciuria
Hypomagnesemia
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Resp acidosis INCREASE VENT PARAMETERS
Resp alkalosis ( low CO2 ) ------ DECREASE VR --- FiO2 ---- LAST pressure
Nonketotic hyperglycenimia R acidosis ( apnea )
UCD R alkalosis
Saliocylate R alkalosis --- m acidosis
Over-ventilation
High pH
with a Low PaCO2
Decrease the tidal volume
Do this first if the baby has good
chest movement and/or high
tidal volumes
Decrease the difference between the PIP
and PEEP (usually by decreasing the PIP)
Decrease the frequency Drop the rate.
If the gas is just a bit alkalotic, drop
by 5. If really alkalotic, you might
want to drop it by 10 or more.
it is futile to reduce the rate if the
baby is breathing above the back
up rate. So wean the pressure (or
VT) instead.
Under-ventilation
Low pH
with a High
PaCO2
Increase the tidal
volume
Do this first if the baby
has no chest movement
and/or low tidal
volumes
Increase the PIP till you get some chest
movement but look at the tidal volume
too.
In general, you should not increase the
PIP too high as you may find that the
tidal volume increases significantly. But
you need to give enough pressure to get
chest movement.
-
Increase the
frequency
Increase the rate. If a bit acidotic, increase by 5. If
really acidotic, you may need to increase it by 10 or
more.
For fast rates, it is really important that the
expiratory time is longer than the inspiratory time.
You may need to decrease the inspiratory time
accordingly.
If you find you need to give more than 70 breaths
per minute, think about HFOV as a ventilation
mode. Speak to the specialist on duty.
3. Water deprivation test (Miller-Moses) test
Central DI Idiopathic
Cranipharyngioma
Postop
Head trauma
Hereditary
Nephrogenic DI
Renal disease sickle cell,amyloidosis
Hypokalemia
Drugs lithium, ampho B, demeclocycline, orlistat
X linked nephrogenic DI
Treatment SIADH Meningitis, HIE
Pneumonia Carbamazepine Asthma, ventilation Lymphoma Bronchogenic carcinoma
Hyponatremia Inappropriate U osm > sr osm ( *** )
U Na > sodium intake ( > 20-30 ) Hypouricemia (
-
insipidus
Dilute urine ( < 200 mosm/kg ) U sp gvty < 1.005 Random Pl osm high > 287
Cerebral salt wasting (natriuretic peptide )
Hyponatremia Urine Na > 40 U na * U vol > Na intake ( equal in SIADH ) Hpouricema and High FE UA ( Persists even after correction of Na but not in SIADH) FE of phosphate high ( Not in SIADH )
Excessive water intake
Hyponatremia
pl osm less u osm less
Urine Na < 10 ?
Addisons Low Na , High K Hypoglycemia
Synacthen test
Cortisol < 450-500
Both DI & PSYCH POLYDYPSIA LOW urine osm
Water deprivation test ( nl U osm 800 )
Water deprivation for max 7 hours - wt, pulse BP, U osm hourly
Free access to fluid is permitted until the start of the test.
-
During the test, dry food is permitted but not fluid; at timed hourly intervals for up to 8 hours the following are measured:
weight
urine volume and osmolality
serum osmolality
2 mcg IM desmopressin is administered at the end of 8 hours. Urine is collected for a further 16
hours during which time fluid intake is allowed but restricted to a maximum of 1.5 times the urine
volume voided during the dehydration period. Blood is collected at the end of the 16 hours and plasma osmolality measured.
Results may be interpreted as:
urine osmolality after fluid
deprivation
urine osmolality after
desmopressin
diagonosis
less than 300 mosmol/ greater than 800 mosmol/kg cranial diabetes
insipidus
less than 300 mosmol/ less than 300 mosmol/kg nephrogenic
diabetes
insipidus
greater than 800 mosmol/kg greater than 800 mosmol/kg primary
polydipsia
U osm between 300 -800 Below 800 Partial DI or
Primary
poydypsia
Pl osm > 290 mosm /kg inapp low urinary osm ------- diabetis insipidus
Iniatial u osm low increases with test ------ psychogenic polypsia
If urinary osm < 200 mosm/kg ---- confirmed DI Urinary osm < 800 mosm/kg --- DI Eg urinary osm 800 , pl osm 250 mosm /kg --- psychogenic polydipsia
Stop the test if wt falls 5% ( 3% in children ) , sr osm > 295mosm/kg , urine< 300
mosm/kg
If sr osm > 290 mosm/kg & u osm < 290 mosm /kg test not required
-
Pseudohyponatremia -- (Isotonic)
1. Hyperlipidemia (Serum Triglycerides >1500 mg/dl) 2. Hyperproteinemia (Serum Protein > 10 g/dl)
4. Synacthen test
Cortisol > 450 -550 nmol /L at 30 min after synth ACTH
CORTISOL - increase in morning and decrease at midnight
5. Hypernatremic dehydration in new born
If significantly hypovolaemic (eg shocked), use isotonic fluid (0.9% saline) to restore circulating volume Otherwise, give hypotonic fluids (0.45% saline, 5% dextrose, oral water),
Water deficit (L) = TBW x ((serum [Na+] (mmol/L)/145) - 1) x weight Replacement volume (in L) = TBW deficit X [1 1 - (Na concentration in IVF mEq/L 154 mEq/L)]
Eg 3.4 kg 10 day with sodium 160 used 0.9% NS deficit =0.6 x (160 /145 1) = 0.06 l/kg = 0.211 L Replacement volume=0.211 X (1) = 0.211 L = 210 ml replaced over 24- 48 hours
Otherwise simple 0.6* bw * excess Na / Na content in fluid * 1000 ml
6. T3, T4, TSH , TPO AB pregnancy , non compliant , graves, hypothyroidism, HASHIMOTOS,
TSH secreting pit tumor
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Pregnancy increase thyroid H. BP ------
increase in total T3 , T4
But normal free level
( also in clofibrate, chronic heroin, excess
estrogen )
GC, ANDROGEN, Phenytoin/CBZ Decrease THBP
NON compliant with treatment in
hypothyroidism
High TSH But T 4 normal
Graves RI Uptake increased, autoab to TPO/TG
TSH sec pit tumour TSH Normal / increased
DEQUERVAINS ESR high ,RI uptake low
HASHIMOTOS High titre of antithyroid ab ( antiTG )
PRETERM Very low T4 , TSH normal
6 weeks term level
Sick thyroid syndrome Normal free T4 And raised TSH
TSH response to TRH Rise at 20 min ----fall by 60 min
Contionued rise at 60 min hypothalamic
damage
Low baseline TSH Secondary
Raised TSH - PRIMARY
Free T3 5 -10
FREE T4 10 -22
TSH 0.4 -5
7. Ca PO4 , PTH, ALK PO4ase pseudo hypopth, hypopth 1 , 1* hyperpth, FHH, VIT D EXCESS,
SARCOIDOSIS
Primary hypoPTH Low calcium, high phos
-
Low PTH
Normal alk po4
Primary hyper PTH High Ca , low Phos
High PTH /n
High alk po4
U ca/cr high
Uric acid high
F. Hypocalciuric
hypercalcemia
High calcium
Phos/PTH/ alk po4 normal
NO Rx
PseudohypoPTH
( end organ resist)
Low calcium, high phos
PTH N/ INCREASED
ALK PO4 N/ incr
4TH
AND 5TH
metacarpal/
metatarsal
shortening,ectopic calcifn
Pseudo pseudo hypo pth Phenotype + BIochem N
VIT D EXCESS High ca & phos
Alk po4 Normal
PTH low
Exogenous PO4 EXCESS LOW ca . high phos
PTH normal
sarcoidosis high calcium, low po4
High alk po4
High vit D
IMMOBILISATION High ca/po4
Low PTH
NL 25 OH VIT D
PROX RTA HypoPO4 Rickets + acidosis
+ urine ph < 5.5
Distal RTA Vit D dep rickets
RENAL OD High po4
High alk po4
High PTH
Decrease 1,25 dioh vitd
Acidosis+
-
Nutritional rickets
(VIT D DEFF)
Low calcium/po4 , high PTH
25 OH VIT D low
1,25 DIOH VITD - NORMAL
LIVER DISEASE LOW LOW
Vit dep rickets type 1 (1
alpha oh ase deff)
Normal Low 1,25 dioh
VIT DEP TYPE 2 ( END ORGAN
RESIST )
HIGH
VIT D RESISTANT ( X LINKED
HYPOPO4 )
N
LOW PO4,
NORMAL CALCIUM, Normal
PTH
N
INCREASED u po4
8. Pheochromocytoma
( MEN 2 , NF 1 , VHL ) --- parox headache, recurrent sweat , nausea, palpitations, wt loss,
hypertension
24 HR urine VMA, HMMA
MIBG, CT abdomen
Carcinoid syndrome
5HIAA 24 hr urine
HT, Flushing, diarrhoea
Chronic PS/TR
Cushing syndrome
Hypokalemia , increase aldo
Metab alkalosis
Hypoglycaemia
Pigmentation ACTH PIT ADENOMA
24 Hr u CORTISOL
Dexamethasone sup test
9. Qp :Qs
Qp:Qs = ( Ao SVC) / (PV PA ) Saturations
-
Ao = 100, PV = 100 So (100-SVC/100-PA)
Eg. 100 (88) / 100 (95) = 2.5 LARGE VSD
Normally, this ratio is 1 because, normally, the volume of blood that is pumped to the lungs (Qp) is equal to the volume of blood that is pumped to the body (Qs).
In patients with left-to-right shunts, the QpQs ratio is greater than 1.
In general, a QpQs ratio of 1.5 or less is considered a small shunt; a QpQs ratio of 1.5 to 2.0 is considered a moderate shunt; and a QpQs ratio of more than 2 is considered a large shunt
10. QTc
Bazett's Formula
Corrected QT (QTC) = QT Interval / Sq rt (RR interval)
Normal QTc _ 440 msec.
Eg. QT 2 Sq RR 10 Sq 2* 0.2 / 10*0.2 = 0.4 / 2 =0.4/1.4 =0.35
Bazett's Formula- not accurate, and over-corrects at high heart rates and under-corrects at low heart rates.
11. LH/ FSH/PROLACTIN/ ESTROGEN PCOS, Pregnancy, pit tumor, 1*ov failure,
LH 2-10
FSH 2-10
PROLACTIN 50-450
ESTRADIOL 130 -600
PROLACTINOMA Prolactin > 2000
Pregnancy High PROLACTIN Elevated estradiol
PCOS 1
Non classical CAH
CUSHINGS
TESTOSTERONE MILD INCREASE
-
Non classical CAH 17 0H Prog > 33 nmol/l
12. PT/ APTT/BT
a.
Hemophylia APTT prolonged PT normal
Von willebrand disease Type 1
Ristocetin cofactor activity decreased Decreased factor 8 Decreased Vwf Bleeding time N / ^ APTT N / ^
2b thrombocytopenia ( hyperactive vwf ) increased LDRIPA 2M ( Plat binding Fn ) normal factor 8 2N Autosomal haemophilia
Vitamin k dependent bleeding
PT , APTT Both increased TT Normal Platelet, fibrinogen, FDP normal
Isolated PT Increased HDN, Liver failure, warfarin Isolated APTT increased VWD, Hemophilia,heparin,
lupus anticoag PT, APTT, TT all increased DIC,
heparin in tube Afibrinogenemia Factor 2 deff
13. Iron TIBC ,Transferrin sat, Lead poisoning
Fe TIBC Transferrin saturation
(nl 30 %)
Ferritin
IDA Low increased Decreased Decreased
Beta thal N /high N N Slight Incr
Sideroblastic
anemia
High/N LOW/N 100% HIGH
Chr disease Low low N N/INCREASED
IDA
Decreased ferritin earliest
Decreased transferrin saturation
-
Increase ratio of Zn protoporphyrin / heme
Increased soluble transferrin receptors
Decreased MCV
Decreased HB
G6pd deff
Decreased pl haptoglobin
Increased pl methemalbumin
Hemoglobinuria
Heinz bodies
14. CAH
Cong adrenal hyperplasia
21-Hydroxylase Deficiency
hyponatremia and hyperkalemia;
hypotension
Low glucose Metab acidosis
virilization of girls & ambiguous genitalia & dark scrotum in boys.
Increased 17 OH prog > 1000 ng /dl
Reduced 11 deoxy cortisol
11-b-Hydroxylase Deficiency
salt retention, hypertension & hypokalemic alkalosis.
(suppressed plasma renin activity
virilization of the female fetus.
elevation of serum 11-Deoxycortisol and 11-deoxycorticosterone.
17-a-Hydroxylase deficiency
salt retention, hypertension & hypokalemic alkalosis.
Undervirilization
genitalia is ambiguous in boys.
3BETA HSD DEFF:
SALT WASTING
CLITOROMEGALY IN FEMALE
INCREASED DHEA
-
MALE HYPOSPADIASIS
15. LUNG FUNCTION , FEVI,FVC,
OBSTRUCTIVE ( ASTHMA /
CF)
RESTRICTIVE
FVC
FEV1
FEV1/FVC N > 80%
PEFR
FEF25-75
Flow volume curve Concave Small volume
DMD FVC
GBS- VITAL CAPACITY
CF - FEV1
OBSTRUCTIVE FEV1 Decreased FVC - Normal
Restrictive -- both decreased
Mixed FEV1 DECREASED MORE ---- FVC DECREASED
CYSTIC FIBROSIS MIXED
ASTHMA FEF 25-75 BEST MEASURE FOR SMALL AIRWAY
But PEFR is easy ( measures only large airway )
16. AUDIOGRAM
< 40 DB LOSS CONDUCTIVE DEAFNESS
-
o---O----O Right air cond
xxx left air
[ -- [-- [-- [ right bone
]--]--] left bone
17. Weber / rinne
Rinne Right Rinne left weber
-ve +ve Right Rt Cond HL
-ve +ve left Lt SNHL
+ve +ve left Right SNHL
-ve -ve central B/L CHL /SNHL
-ve -ve Left Left CHL & Right
sNHL
18. Tympanogram
-
Right ear hypermobile ossicular discontinuity or normal
Flat tympanogram --- otitis media
19. EEG
SSPE - Large amplitude periodic slow wave cx
-
BRE U/L Centrotemporal spike
JME Generalised irregular spike cx
-
Lennox gestaut generalised multiple discharges of spike wave and polyspike cx
20. Mg/kg/min GDR = 10*Dextrose% *ml/hour / 6 * BW
0.9% ns = 150 mmol/l
0.18% = 30
Na req newborn = 4 mmol/kg
21. Glassgow coma scale
-
22. ,
OXYG INDEX = MAP*FIO2 / Pao2 kpa = *7.5
23. . glucagon stimulation test
An adequate cortisol response is defined as a rise of greater than 200 nmol/L to above 600
nmol/L. The value of 600 nmol/L is used to exclude adrenal insufficiency in view of variation
between analytical methods.
An adequate GH response is a rise to a value greater than 20 mU/L (
24. .
Gilbert
Crigler najar
Dubin Johnson
Rotor
25. Statistics
Confidence interval
95% Confidence interval - mean 1.96 SEM
SD = Sq rt variance SEM =SD/ sq rt N
SD, SEM used only in normal distribution
If Confidence interval contains 0 or 1 p > 0.05 ( not significant ) If CI not contains 0 or 1 ----- significant
( for odds ratio , Relative risk ----1 : weighted mean difference ---- 0 )
-
diseased Not diseased Exposd a B Non exposed c D
Absolute risk a/a+b & c/c+d Risk difference / absolute risk reduction
A B ( 0 No difference ) NNT ( No. of pts to be treated to get 1 benefit )
1/ARR
Relative risk / risk ratio Proportion of 1 group/ prop of other group (a/a+b) / c/c+d)
Relative risk reduction ( like RR but in control group )
( 1-RR ) *100 (Control event rate expt event rate )/control event rate
Odds ratio a/c / b/d = ad/bc
Cross over study Only for chronic disease/ fewer - not cured/ temporary relief No carryover effect
Increase the power of the study Paired t test ( continuous variable )
Case control- cross sectional- cohort
Null hypothesis
NH is true NH is false Accept null hypothesis ok !! alpha Reject 1 beta Ok
Type 1 error rejecting wrongly BETA Type !! error accepting wrongly ALPHA
Small sample size ---- lead to type !! error ---- less power Power of a study = probability (%) of correctly rejecting (1 beta )
-
Continuous variables 1. Normal distribution (mean of 2 group) >2 groups
Cross over trial Paired t test ANOVA ( Analysis of variance) 2 independent
groups Unpaired t test
2. Non normal distribution Small number ( median of 2 group )
Wilcoxon matched pair test Mann whittney U test
Kruskal wall ANOVA
Categorical variables ( binary ) 1 binary outcome ( compare proportions or
% ) Chisquare
2
small number Extreme %
Fisher exact test
3 Paired sample Mc Nemar test
Disease + No disease Test + Test -
26. . murmurs
Aortic stenois ESM Right USE Radiates to neck
Coarctation Syst murmur USE TO BACK Lt BP < Rt BP
Pulm stenosis
-
27. .ecg
QRS 100 msec narrow
WPW DELTA WAVE PROMINENT IN LEAD AVF AND V4
28. .
HOCM f/h sudden death
collapse during exercise
Prol QT Spont recovery in seconds
AS
VASOVAGAL SYNCOPE Prolonged standing Erect and supine BP, TILT
table test
29. .
3 mths Lifting head and chest
5 mths Roll over front to suoine
-
6Mths Sit with support
Lift chest on extended arms
1 year Walk with hand held
2 YEARS Walk up/down stairs 2 foot /steps.
Climb on furniture
Try kick ball
3 mths Hand regards
6 months Reach for / transfer objects Mouthing
15 mths Put things into container
To and fro scribbles
3 years Thread large beads
Circle 3 yrs, cross
Tower of 8 cubes
Draw head hands without trunk
Kick ball well
Scissors???
-
4 yrs Thread large beads
Square , plus
Tower 10 cubes , steps 6 bricks
Approx. thumb with each finger
Hop on preferred foot
Copy OX TH
5 yrs Count fingers with index finger of other hand
Hop forward
3 yrs 4 5 Head-legs
4 yrs 6(7) 7 Trunk
5 yrs 11 12 Head body legs, eyes
mouth nose
6 13 14
7 16 17
8 18 19(20)
-
4 weeks VEP
6 WEEKS Optokinetic nystagmus
6 mths Reach for toys
1 yr Preferential looking test
2 - 3 yrs Identification of toys
3 yrs Stycar letter matching 3 m
5 yrs Snellen
3 mths Turns to voice
9 mths Intonated babble
1 year Meaningful word
2 yr 2 word sentence, name objects
Telegraphic speech
3 yrs 3 word sentence, tell name , age, sex
Count to 10
4 yrs Tell stories, full name, address
5 yrs Fluent speech, tell address
3 Weeks startles
3 mths Calm with carers voice
6 mths Babbles
-
9 mths Peek a boo
1 yr Responds to come here
18 mths Solitary
2 yrs Spectator
3 yrs Pretend ( small container as car )
4 yrs Imaginative (use toys to create real life sitns cop and robbery )
5 yrs Role play ( car is driven)
6 yrs Fantasy play