C^3

[c2the3rd]

Just some thoughts related to the broad topic of mental health. Forgive me as this will probably be long and I will likely go off on a few tangents. I'm not the greatest at expressing my thoughts, okay? I’m an INTJ and have always been better with books than sharing with others.

Motivation for living:  Okay, so I've had depression before and even had suicidal thoughts at one point in my life. Now this doesn't mean that I am an expert in the subject. Oh no. I do not claim to know jack about other people's situations. How could I really? I am not them and have not shared their experiences. There is one thing that I know though. In order to climb out of that pit, you need more than just the love of others. You need to live because you have your own dreams and love yourself enough to allow yourself to go for them, even if there is a chance you may fail. With successes or failures, you then need to dare to dream up more. As such, you need purpose in life and to be able to allow yourself to enjoy the journey of life itself with all its flaws. Now I'm not saying that having others' love is not essential to this however. On the contrary, people need support. Having the love of family and friends means that there is even more hope for a person because it means that there is something good about that person which they know and love. With their help, they can even help a person to see these good points which perhaps they had never even noticed about themselves. Doing so could help that person to begin loving themselves again. But as stated, their support can only ever be that. Support. The way that they see themselves as a whole has to change because living for others alone for most is not enough. If you are loved one of somebody that is having suicidal thoughts, please remember these truths, lend your support, and help your loved one to seek counseling. You alone cannot be a person's cure, so do not bear that burden alone.

Living solely for others:  Is this humanly possible? I think not. There's some good TED talks on this. Everybody alive has at least some internal reason for living. But what of those people in history who have lived altruistically, giving their everything for others? Let me ask-Was there ever really such a person that lived their entire life for other people? Does altruism really exist? Jesus Christ may be who Christians think of. I will just say this:  Nobody on this green earth is Jesus Christ, so we cannot be expected to live like him. But what about parents? Parents live for their children, right? ...But even they still have their own personal reasons for going on. Maybe they are living vicariously through their children. Maybe they derive satisfaction from being a good parent. Maybe there are several other reasons, but be it personal satisfaction or planning for the afterlife or whatever, we are human and the only way we can ever live is as humans-For ourselves!

One more topic that is related a bit more to the first and is the big reason for all these thoughts being penned, err, typed-Psychiatric counseling:  It's always surprising to me how much people resist seeking help. It is true that people in society do still negatively stereotype psychiatric patients. It's such ignorance that society should be ashamed of. It doesn't help anyone. What does it mean to have mental illness even? I really wish people would start thinking of it as something more physical. Because it is. It is illness just like any other physical illness. Read up a bit on neurobiology and you will understand. Genetic, environmental, chemical changes and early life experiences physically alter the way people think. But no. Society likes to slap labels on people such as "defective" and "incurable.” Thus, people are so scared of being labeled as a "nut job" or being "permanently locked up" or rejected that they don't seek help on their own and often vehemently resist anyone who even suggests that they do; even when they are in an obvious crisis. It's really bad.

For those depressed, they choose bottle everything up and try to live with it on their own, but in the end it's really too much and then, boom, they do something drastic. They need to seek help. Chemical means can help, but they also need someone to talk with that allows them to be completely honest. And sometimes people can try to open up to others, be it a counselor or a friend or family member, and it does not help. This may be for a number of reasons. Maybe the family member or friend cannot lend them the support that they need because it is too much for them themselves to deal with. Perhaps they don't see it as something serious, writing it off because "everybody has problems." Maybe they just don't know what to say and start avoiding that person because they feel inadequate to help. Perhaps the counselor could not connect with the individual. Counselors or psychiatrists don't always say the right things. They are only human, too, after all. The great thing about seeking professional help though is that if what they are doing is not helping, all they have to do is see someone else! When they finally get help, when they actually feel free to let those walls down and open up, it’s a truly amazing thing; like night and day. People in crisis have so much fear and resistance and think nothing can help them…But then they actually seek help and after it all are glad that they went. Then they continue working towards gaining control by going to outpatient meetings, continuing counseling, and taking medications. Those that stick with it, climb out of that pit and go on to live their lives, perhaps even going on to help others that face similar challenges.

Okay, enough for now. Tired. Bed time.

[c2the3rd]

Getting tryptophan to the brain

When you consume sugars or carbs with a high glycemic index you release more insulin. This increase in insulin causes your skeletal muscles to uptake more amino acids, including LNAA (large neutral amino acids), tyrosine, phenylalanine, and free tryptophan, leaving your plasma levels of these low. 

Having lower plasma levels of these amino acids means that less of them are available to cross the blood brain barrier, the only exception being tryptophan. Normally, all of these amino acids compete with each other to bind on transport proteins which help them to cross the BBB. Tryptophan is the exception because while all the other amino acids are being pushed into skeletal muscle cells, some of it is bound to albumin (weakly). This protein-bound tryptophan is thus free to monopolize the carrier proteins and cross into the brain, where it can later be converted to 5-HTP which is then converted to 5-HT, or serotonin, which lifts your mood and can make you less hungry. Cool. This is why sugar makes us so happy.

Tryptophan does have some competition for being bound to albumin though. Nonesterified fatty acids, or NEFAs, actually bind more strongly to albumin, so if these are in high levels in the plasma, tryptophan will not be bound to as much albumin. Insulin has an effect on NEFA levels, too though, as it causes NEFAs to enter adipocytes, leaving the albumin behind. So when you have more insulin, tryptophin has more albumin to bind to, so less of it is taken up into skeletal muscle and more of it can get to your brain and become serotonin. This is why you feel happy after eating lots of sugar. 

Ingesting tryptophan itself could have the same outcome. Without those other amino acids around to compete for the transport proteins, more tryptophan, whether it was bound to albumin or not, could cross the BBB. But what can you eat that has no other amino acids besides tryptophan?

When you eat proteins, even if they have a large amount of tryptophan, you still have a mix of the other amino acids. These other amino acids, particularly the large neutral amino acids, take up more of those transport proteins. This means resulting in higher amounts of tryptophan left in the plasma and less getting to your brain.

[c2the3rd]

Nondepolarizing vs depolarizing neuromuscular blockers

Just thinking about the 2 groups

You should not give cholinesterase inhibitors to those getting succinylcholine (a depolarizing neuromuscular blocker) as they will just prolong the effects (because pseudocholinesterase AKA plasma cholinesterase is what actually breaks down succinylcholine and eliminates it).

With nondepolarizing neuromuscular blockers you can give cholinesterase inhibitors (should give in the event of overdose).  Nondepolarizing blockers quickly dissociate from the neuromuscular receptors (vs depolarizing which stays bound) and are then eliminated by hepatic metabolism and renal excretion. Cholinesterase inhibitors block the enzyme (cholinesterase) that breaks down acetylcholine at the synapse and thus cause you to have an increase in acetycholine with then competes with the nondepolarizing blockers at the neuromuscular receptors.  The receptors show preference for ACh and eventually the nondepolarizing blockers are all eliminated. The exception is atracurium.  It is nondepolarizing as well but is instead eliminated similarly to succinylcholine (with pseudocholinesterase rather then with hepatic breakdown and renal elimination). One should avoid giving cholinesterase inhibitors while using it as well because they will potentiate its effects and could lead to toxicity.

There is no listed cure for succinylcholine overdose. I'm not sure about atracurium. That makes succinylcholine worrisome. That, and finding out that malignant hyperthermia is actually fairly prevalent. [My 2nd cousins all have had that reaction. O.O There's that familial tendency.] Death by overheating or respiratory depression. Yikes. Let's not even talk about the other side effects.

[c2the3rd]

ABG Interpretation Notes

 Arterial pH=Measure of hydrogen ion concentration which is affected by respiratory and renal function.

Normal pH of blood is 7.35-7.45**

A pH of <7.35 is acidosis (more acidic means a lower pH)

A pH of >7.45 is alkalosis

**Bolded are the three values needed to assess whether a person has an acid-base imbalance.

ABGs=Arterial blood gases--These values are used to evaluate acid-base balance.  Everybody needs to know these:

HCO3- (bicarbonate)=22-26 mEq/L (or mmol/L**) Base

PaCO2 (partial pressure of carbon dioxide)=35-45 mEq/L (or mmol/L)** Acid

The causes of acid-base imbalance are either respiratory or metabolic in origin:

      Respiratory imbalances: 

Too much CO2 buildup causes acidosis (Ex: When you hypoventilate, you retain more and more CO2).

Too little CO2 causes alkalosis (Ex: When you hyperventilate you breathe off too much CO2).             

      Metabolic imbalances:

Metabolic alkalosis is caused by vomiting (lose too much stomach  acid [hydrogen ions] compared to HCO3), NG suctioning, excess HCO3 intake, hypokalemia (low blood potassium causes hydrogen ions in the blood to shift into cells in exchange for the potassium inside the cells, thus lowering the pH), and low chloride.

Metabolic acidosis is caused by diarrhea (lose HCO3- base), renal failure (kidneys cannot remove excess hydrogen), lactic acidosis with tissue hypoxia (anaerobic metabolism), starvation, DKA, and excess acid intake (salicylate overdose).

Steps to determine imbalance:

The very first step should be looking at the pH value. Is it within the normal limit of 7.35-7.45? If not, it is either acidosis (<7.35) or alkalosis (>7.45).

The next step is to determine whether the ABGs are abnormal in order to find out the cause of the imbalance. 

****Remember ROME

                                        Respiratory Opposite:

What happens with the pH value is the opposite of what happens with PaCO2.

(An increase in PaCO2 [acid] leads to a decreased pH)

(A decrease in PaCO2 [acid] leads to an increased pH)

                                        Metabolic Equal   

What happens with the pH value is the same with what happens with the HCO3-).

(A decrease in HCO3- [base] leads to a decreased pH)  

(An increase in HCO3- [base] leads to an increased pH)

And ask:

Is HCO3- within the normal 22-26 range? Abnormal values mean that the cause is metabolic OR that the body is trying to compensate for a respiratory imbalance.

If you have pH<7.35 (acidosis) with a normal PaCO2 and a HCO3- <22, the cause is METABOLIC.

If you have pH>7.45 (alkalosis) with a normal PaCO2 and a HCO3->26, the cause is METABOLIC.

If you have pH<7.35 (acidosis) with an increased HCO3, this doesn’t match ROME (Metabolic Equal)! So this cannot be the cause of the imbalance and is thus COMPENSATION by the body.  Now if you look at the PaCO2, you should see that it is increased as it is the cause of the acidosis.

If you have pH>7.45 (alkalosis) with a decreased HCO3, this also doesn’t match ROME. So this is the body COMPENSATING.  Now if you look at the PaCO2, you should see it as decreased as it is the cause of the alkalosis.

Is PaCO2 within the normal 35-45 range? Abnormal values mean that the cause is respiratory OR that the body is trying to compensate for a metabolic imbalance.

If you have pH<7.35 (acidosis) with a PaCO2>45, the cause is RESPIRATORY.

If you have pH>7.45 (alkalosis) with a PaCO2<35, the cause is RESPIRATORY. 

If you have a pH<7.35 (acidosis) with a PaCO2<35, this does not follow ROME  (Respiratory Opposite), so the cause cannot be respiratory and the abnormal PaCO2 value is due to the body COMPENSATING for a metabolic cause (if you look at the HCO3-, you should see that it is abnormally low [<22].

If you have a pH>7.45 (alkalosis with a PaCO2>45, this also doesn’t follow ROME. The cause of the imbalance must be metabolic. The PaCO2 is abnormally high to COMPENSATE for the increased pH.  Look to see that the HCO3- value is abnormally high [>26].

It is possible to have metabolic and respiratory causes both contributing to the acid-base imbalances. You can have metabolic and respiratory acidosis at the same time, same with metabolic and respiratory alkalosis. If this occurs, ROME works with both the PaCO2 and the HCO3- values when comparing them to the pH. The madness.

        3.   The final step is to determine whether compensation mechanisms   are complete or incomplete. This part is easy. If it is complete, you will see a normal pH value between 7.35-7.45, but see imbalances in PaCO2 or HCO3-.

  Whew!

  Here is the link to a great website for practice:

http://www.vectors.cx/med/apps/abg.cgi

I like it because it gives you explanations for each problem. Sit down with the ABG values and the pH values in front of you and take it over and over until you have it down.  Then you will never be confused about it again. :)