Biochemistry Profile

Hi all, I tried searching the internet for general information about the definition and interpretion of a biochemistry profile in general but there were not many good sites around. Nonetheless, I have made sense of what little I found and tried to come up with something coherent. Hope it makes sense to you.

Generally, a biochemistry profile refers to a report that shows biochemical properties (pH, osmolarity, composition, concentration of chemical substances) of bodily fluids like blood and urine.

It is used in the diagnosis and treatment of certain liver, heart and kidney diseases, acid-base imbalance, lipid metabolism disorders, endocrine disorders, metabolic or nutritional disorders.

Some examples of chemical substances measured in the blood (normal values):
• Bicarbonate (HCO3) (23-33mMol/ L)
• Blood Urea Nitrogen (BUN) (8-20mg/L)
• Calcium (8-10mg/dL)
• Cholesterol (<155mg/dl)
-Some examples of chemical substances measured in urine.
• Protein
• Glucose
• Nitrites
• Ketones
• Haemoglobin
• Bilirubin
• Urobilirubin

Let’s analyze Hazim’s biochemistry profile:

• Na (135-145mMol/dL) 119 - low
• K (3.5-5.0mMol/dL) 3.6 - normal
• Cl (95-105mMol/dL) 98 - normal
• HCO3 (24-30mMol/dL) 22 - slightly low
• Glucose (3.5-5.5mMol/dL) 8.0 - high
• Urea (2.5-6.7mMol/dL) 10.0 - high
• Creatinine (60-120 uMol/L) - normal

Important Notes:

Compare results to chart below.
Come up with a list of differential diagnosis.
Correlate results differential diagnosis with patient’s history. Is it likely to happen?
More tests are usually needed to confirm the diagnosis.
Biochemistry profile cannot tell us the whole picture.

Sources:

Medical Biochemistry at a Glance, Salway

http://www.nlm.nih.gov/medlineplus/ency/article/003579.htm

http://www.cdc.gov/nchs/data/nhanes/frequency/lab18doc.pdf

Contributed by John Lee

Effect on brain injury/surgery on plasma electrolyte level

The two most common electrolyte imbalances following brain injury are hypernatremia and hyponatremia


Brain injury is one of the most common types of traumatic injury. In critical care units, patients with moderate to severe brain injury are often intubated and sedated in an effort to diminish the workload of the brain. Agitation or restlessness is common in these patients and can be associated with fever, posturing, tachycardia, hypertension, and diaphoresis. This exaggerated stress response, known as sympathetic storming, occurs in 15% to 33% of patients with severe traumatic brain injury who are comatose (score on Glasgow coma scale [GCS] = 8). Sympathetic storming can occur within the first 24 hours after injury or up to weeks later. The precise mechanism for the increase in activity of the sympathetic nervous system is unknown, but the increased activity is thought to be a stage of recovery from severe traumatic brain injury. Normally the parasympathetic nervous system dampens the effects of increased activity of the sympathetic nervous system and returns the body to homeostasis. In sympathetic storming, this feedback does not occur and the individual is in an uncontrolled state of stress. Prolonged hypertension, arrhythmias, hyperglycemia, hyperthermia due to elevated metabolic rate, and hypernatremia from severe diaphoresis occur as a result of the sympathetic storm. Signs and symptoms vary from episode to episode and from individual to individual


HYPENATREMIA

Hypernatremia is a relatively common problem that can be produced either by the administration of hypertonic sodium solutions or, in almost all cases, by the loss of free water. However, persistent hypernatremia does not usually occur in these settings, because the ensuing rise in plasma osmolality stimulates both the release of antidiuretic hormone (ADH), thereby minimizing further water loss, and thirst, thereby increasing water intake [1-3]. The decrease in water loss and increase in water intake then lower the plasma sodium concentration back to normal.

This regulatory system is so efficient that the plasma osmolality is maintained within a range of 1 to 2 percent despite wide variations in sodium and water intake. Even patients with diabetes insipidus, who have often marked polyuria due to diminished ADH effect, maintain a near-normal plasma sodium concentration by appropriately increasing water intake.

The net effect is that hypernatremia primarily occurs in those patients who cannot express thirst normally: infants; and adults with impaired mental status. The latter most often occurs in the elderly, who also appear to have diminished osmotic stimulation of thirst.

Hospitalized persons, whether old or young, can become hypernatremic as a result of an inadequate fluid prescription and/or impaired thirst.

Hypernatremia due to water loss is called dehydration. This is different from hypovolemia in which both salt and water are lost.



HYPONATREMIA
Hyponatremia develops as a syndrome of inappropriate secretion of antidiuretic hormone (SIADH) or cerebral salt-wasting syndrome (CSWS). 1-3 SIA[DH is characterized by dilutional hyponatremia, and CSWS is characterized by natriuresis as a result of increased serum levels of natriuretic hormone.4 Diabetes insipidus presents with polyuria, serum hypernatremia and hyperosmolarity, and urine hypo-osmolarity, whereas CSWS is associated with polyuria, serum hyponatremia and hypo-osmolarity, and elevated urinary sodium and hyperosmolarity. Serum hyponatremia, serum hypo-osmolarity, urinary sodium exceeding 25 mmol/l, and euvolemia are typical findings in SIADH.


Symptoms of hyponatremia include:

nausea, abdominal cramping, and/or vomiting
headache
edema (swelling)
muscle weakness and/or tremor
paralysis
disorientation
slowed breathing
seizures
coma


-Hyponatremia (Low Na2+ levels) is common with head injury.
-Caused by inappropriate secretion of ADH, leading to increased water retention
-leads to cerebral oedema, and worsens neurologic outcome
-occurs on 5% to 33% of adults with head injury
-25% prevalence in children with head injury
-Polyurea occurs as well


sources:

Burkhard Simma, MD*§, René Burger, MD*, Markus Falk, MSC, Peter Sacher, MD†,
Timo Torresani, PhD‡, and Sergio Fanconi, MD* The Release of Antidiuretic Hormone Is Appropriate in
Response to Hypovolemia and/or Sodium Administration in
Children with Severe Head Injury: A Trial of Lactated
Ringer’s Solution Versus Hypertonic Saline

ww.anesthesia-analgesia.org/cgi/reprint/92/3/641.pdf

https://www.healthatoz.com/healthatoz/Atoz/common/standard/transform.jsp?requestURI=/healthatoz/Atoz/ency/electrolyte_disorders.jsp

http://findarticles.com/p/articles/mi_qa3912/is_199903/ai_n8836003

http://ccn.aacnjournals.org/cgi/content/full/27/1/30




Prepared by Chris Sim

Treatment & Management of Brain Injury

Yo dawgs, just to let you know, most of my information was taken from the first link provided (see sources below). I have summarized very succintly the information, coz' if I didn't, it would have taken far more space. I don't believe any of you will click on the link, but I have, on my own discretion, taken what I believe is most important to post here. This is a disclaimer so just in case anything comes out in exam, don't come running to me... *insert a very nice smiley face here* Now, on with the show:

Process:

1. First aid
2. ICU
3. Acute Rehabilitation Unit
4. Sub-acute Rehabilitation Unit
5. Day Treatment (Day Rehab or Day Hospital)
6. Outpatient Therapy
7. Home Health Services
8. Community Re-entry
9. Independent Living Programs
10. Brain Injury Support Groups

First aid (Emergency care until help arrives)

1. Call for help (999)
2. ABC, CPR
3. ABC okay, but the person is unconscious: treat as if there is a spinal injury. Stabilize the head and neck by placing your hands on both sides of the person's head, keeping the head in line with the spine and preventing movement.
4. Stop any bleeding by firmly pressing a clean cloth on the wound. If you suspect a skull fracture, DO NOT apply direct pressure to the bleeding site, and DO NOT remove any debris from the wound. Cover the wound with sterile gauze dressing.
5. If the person is vomiting, roll the head, neck, and body as one unit to prevent choking.
   

ICU
Goals: stabilize the patient and prevent further injury

• Adequate oxygen supply to the brain and the rest of the body
• maintain blood flow to the brain
• control blood pressure
• stabilize the airway
• assist in breathing or perform CPR if necessary
• treat associated injuries

Specialized treatment team

• Neurologist: Primary treating physician
• Neurosurgeons: remove blood clots, haematomas (e.g. subdural), intracerebral haemorrhages, perform procedures to relieve increased pressure within the skull
• Intensivists: physicians staffing the ICU
• Respiratory therapists: to monitor respiratory functions
• Specialized nurses & technicians: e.g. radiological technicians
• Trauma specialists: treat associated injuries
  

Equipment in the ICU

• A Ventilator (Also called a Respirator) is a machine that helps a person breathe (as patient may unable to breathe on his/her own) - provides Oxygen
• A tube is placed through the person’s mouth to the trachea: Intubation
• Intravenous lines (IVs): tubes placed in a person’s veins to deliver medications and fluids to the person’s body
• Arterial lines: tubes placed in a person’s arteries to measure blood pressure
• A Foley Catheter is used to collect and monitor a person’s urine output (patient may be unable to control bladder functions
• A rubber tube is inserted into the person’s bladder. This allows urine to move from the bladder, through the tube, and to a container at the end of the tube
• A Nasogastric Tube (NG Tube) is used to deliver medication and nutrients directly to a person’s stomach (patient may be unable to swallow on his/her own)
• A tube is placed through a person’s nose or mouth and ran through the swallowing passage (the esophagus), to the stomach
• An ECG machine monitors a person’s heart.
• A Pulse Oximeter is a small clamp-like device placed on a person’s finger, toe, or earlobe. The Pulse oximeter measures the amount of oxygen in the blood stream.
• An Intracranial Pressure (ICP) Monitor is a device attached to a person’s head with a monitor that indicates the amount of pressure in the brain.
• When the brain is injured it may swell (oedema: subsides within a few days/weeks, but a few minutes or hours of excessive ICP can cause permanent damage).
• When the brain swells, the brain has no place to expand. This can cause an increase in intracranial pressure (the pressure within the skull).
• If the brain swells and has no place to expand, this can cause brain tissues to compress, causing further injury (as blood is prevented from circulating adequately in the brain tissue, causing damage to brain cells)
• ICP can be measured with an intraventricular probe or catheter inserted through the skull into the fluid-filled chambers (ventricles) within the brain. Placement of the ICP catheter is usually guided by CT scan.
• If ICP is elevated, drugs that may decrease ICP (MOA: draw fluid out of the brain and into blood vessels, decrease brain’s metabolic requirements, increase blood flow to injured tissues) include mannitol and barbiturates. NO halothane (cerebrovascular dilator).
• Surgery for elevated ICP:
  
• If severe brain swelling, the elevated pressure can be relieved temporarily by surgically removing a portion of the skull to allow swollen tissues to bulge out, reducing the risk for pressure-induced damage.
  
• A build up of fluid may also cause the ventricles in brain to experience blockage. A ventriculostomy may be needed. A shunt is inserted to drain the fluid build-up (hydrocephalus), causing the ventricles to shrink and restoring normal function to brain cells.

Acute Rehabilitation Unit
When persons are medically stable and have reached a point in recovery where they are able to participate in therapy, they may be transferred to an inpatient Acute Rehabilitation setting.

Goals: assist persons with brain injuries to achieve their highest level of independent life skills used in activities of daily living; detect complications early; prevent additional injury

Acute Rehab Team

A Psychiatrist: the leader for the rehabilitation treatment team; makes referrals to the various therapies and medical specialists as needed. The physiatrist works with the rehabilitation team, the person with a brain injury, and the family to develop the best possible treatment plan.

Physical Therapists evaluate and treat a person’s ability to move the body; improves physical function by addressing muscle strength, flexibility, endurance, balance, and coordination (walking, getting in and out of bed, on and off a toilet, or in and out of a bathtub)

Occupational Therapists use purposeful activities as a means of preventing, reducing, or overcoming physical and emotional challenges (feeding, swallowing, grooming, bathing, dressing etc)

Speech/Language Pathologists evaluate a person’s ability to express oneself (speech, written, or otherwise expressed) and comprehend what is seen or heard. Swallowing issues may also be addressed.

Rehabilitation Nurses attempt to maintain the person’s medical status, anticipate potential complications, and work on goals to restore a person's functioning.

Case Managers/Social Workers are responsible for assuring appropriate and cost-effective treatment and the facilitation of discharge planning.

Recreational Therapists provide activities to improve and enhance self-esteem, social skills, motor skills, coordination, endurance, cognitive skills, and leisure skills.

Neuropsychologists focus on thinking skills, behavior, and emotional processing.

Aquatic Therapists are occupational therapists, physical therapists, or recreational therapists with specialized training to provide therapy in a heated water pool.

Subacute Rehabilitation

• Less intensive level of rehabilitation services, over a longer period of time
• Skilled nursing facility or nursing home.

Day Treatment provides rehabilitation in a structured group setting during the day and allows the person with a brain injury to return home at night.

Outpatient Therapy

• Following acute rehabilitation or sub-acute rehabilitation, a person with a brain injury may continue to receive outpatient therapies to meet continued goals.
• Additionally, a person with a brain injury that was not severe enough to require inpatient hospitalization may attend outpatient therapies to address functional impairments.

Home Health Services
Some hospitals and rehabilitation companies provide rehabilitation therapies within the home for persons with brain injury.

Community re-entry programs generally focus on developing higher level motor, social, and cognitive skills in order to prepare the person with a brain injury to return to independent living and potentially to work. Persons who participate in the program typically live at home.

Independent Living programs provide housing for persons with brain injury, with the goal of regaining the ability to live as independently as possible.

Brain Injury Support Groups can help individuals with brain injury and their loved ones cope and increase their knowledge about brain injury issues. Support group members can provide valuable emotional support because of their experiences and understanding of the impact of brain injury. Brain injury support groups are also a good place to network and learn from others--what they have done in similar situations.

Medications (refer to handout for specific information)
Medications for persons with brain injury are carefully selected, prescribed, and monitored by the physician on an individual basis (overlapping all stages).

With brain injury, the cell’s ability to produce neurotransmitters is reduced either by interference with production, release or absorption. These chemical changes alter the brain’s ability to process information. Medications prescribed after a brain injury improves the brain’s natural ability to produce and utilize neurotransmitters. The medications act as a cast for the neuron to allow more normal activity during recovery. In situations where the neuron fails to recover its function, medications then are used as splints to allow the most normal neuron function possible.

Analgesics may be used for pain relief and pain management.
Anti-Anxiety Agents may lesson feelings of uncertainty, nervousness, and fear.
Anti-Coagulants may be used to prevent blood clots.
Anti-Convulsants may be used to prevent seizures.
Anti-Depressants may be used to treat symptoms of depression.
Anti-Psychotics may be used to target psychotic symptoms of combativeness, hostility, hallucinations, and sleep disorders.
Muscle Relaxants may be used to reduce muscle spasms or spasticity.
Sedative-Hypnotic Agents may be used to induce sleep or depress the central nervous system in areas of mental and physical response, awareness, sleep, and pain.
Stimulants may be used to increase levels of alertness and attention.

Sources:
http://www.biausa.org/Pages/what_is_the_rehab_process.html
http://www.biausa.org/word.files.to.pdf/good.pdfs/good.text.only/RoadToRehab6.txt
http://www.nlm.nih.gov/medlineplus/ency/article/000028.htm#visualContent
http://www.birf.info/home/library/med-procede/med-pro-compev.html
http://www.neurologychannel.com/tbi/treatment.shtml
http://www.neuroitu.co.uk/page10.html - for pictures of haematomas and haemorrhage

Renal Physiology

Note: All these points are considered important since they are already being condensed. No any particular part will be highlighted for your special attention. Thanks.

CAM

Natural therapy
Includes diet, exercise, naturopathy, herbalism, natural hygiene, homeopathy, massage therapy, relaxation techniques (eg. Yoga, Tai Chi), acupuncture, sauna, aromatherapy, and ayurveda medicine.

Head injuries:
Deficit in memory –siberian ginseng, rosemary leaf, peppermint leaf
Learning and memory – tyrosine, pyridoxine, phosphatidylserine
Anger management, anxiety, frustration or depression – St. Johnswort, passionflower, Siberian ginseng, Calamun Root, Prickly Ash Bark
Muscle contraction – acetylcholine (give choline and Vitamin B5)

Acupuncture – pain impulses are blocked from reaching spinal cord or brain
Massage – restoration of proper joint function and strengthening supporting muscles and soft tissues. Stretches and loosens muscle and connective tissue and improves blood flow. Reduces pain by blocking pain impulses from reaching brain.
Cranio-sacral therapy – gentle soft touch no greater than 5 grams to release constrictions in the craniosacral system which improves function of CNS. Used in traumatic brain injuries, motor-coordination impairment
________________________________________________________________________
Aromatherapy
- use of aromatic plant oils for psychological and physical wellbeing.
- may be used as topical application, massage, inhalation or water immersion.
- different aromas and chemical constituents of the oils can produce different emotional
and physiological reactions.
- used to alleviate symptoms of digestive problems, eczema, headaches, insomnia, stress,
relief of pain, care for the skin, alleviate tension and fatigue, promote relaxation, affects
mood
- little evidence that it effectively prevents or cures illness.

People respond to the sense of smell on an emotional level more strongly than any other sense. For example, a single aroma can trigger a whole string of forgotten memories. The area of the brain associated with smell is the same area as that associated with memory. The olfactory nerves are located within the nasal cavity and respond to particular aromas. They send the information to the part of the brain where memory and emotions lie. This area connects with another part of the brain (hypothalamus and pituitary gland) which governs our hormonal systems. These aromas trigger a variety of chemical actions within the body, including the release of specific chemicals. Enkephalin reduces pain and creates a feeling of well-being. Endorphins also reduce pain and induce sexual feelings. Serotonin helps relax and calm. Because the olfactory nerves are a direct extension of the brain's limbic system, reaction to smell is relayed immediately.

After brain injury, patients need to regain strength. Aromatherapy found to help regain strength, improve joint mobility, decrease physical tension.

In the plant, the essence molecules act as regulators and messengers, protect from parasites and disease, role in fertilization, assist adaptation to environment

Things to keep in mind:
Some oils are toxic eg. camphor, wintergreen
Some are very potent and should not be swallowed or applied undiluted to the skin.
Most should not be consumed
Some oils can be dangerous during pregnancy or to certain people with certain conditions eg. epilepsy and high blood pressure
Some people may be sensitive to aromatic plant oils. May have allergic reaction such as skin rashes. Eg. eucalyptus, ginger etc.

Sources:
http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Aromatherapy?OpenDocument
http://www.aromatherapy.com/aromatherapyoverview.html
http://news.scotsman.com/edinburgh.cfm?id=600962006
http://healing.about.com/od/diseasesandhealthissues/a/tbi_5.htm
http://www.tbirecovery.org/Overview.html

(Posted by: Vivian)

Tasks for week 12

Shantz- Link between brain surgery with administration of normal saline+5% dextrose ( 1Liter)

Lawrence- Importance of Na+ level, what happens if Na+ level flunctuates

Madhura- Research and Management of Brain Injury

Christine- Tonicity, a brief explanation

Chris- Effect of brain injury/surgery on plasma electrolyte level

Ji Keon- Role of Kidney in H20 and Na+ balance

Vivien- CM effectivity; aromatherapy, natural therapy

Sri- Types of brain injury

John- Biochemistry profile: Definition and interpretation of results