CYANOSIS

This is a blue discoloration of the skin caused by 5 g or more of reduced haemoglobin per 100
ml of blood in the capillaries.

Cyanosis may be central or peripheral.

1.Cyanosis (central)
Central cyanosis only occurs when the oxygen saturation of arterial blood is less than
85%. Causes include:

• decreased PO2 of inspired air - high altitude

• hypoventilation
• parenchymal lung disease - massive pulmonary embolism, chronic airflow
limitation with cor pulmonale
• right to left cardiac shunt - congenital cyanotic heart disease

Central cyanosis may be simulated by methaemoglobulinaemia and

sulphaemoglobulinaemia. Also, a patient with polycythaemia may present with central
cyanosis.

Cyanosis (central, in children)

This is cyanosis that is caused by reduced oxygen satturation of the systemic
arterial blood.

Etiology
Possible causes include:

• cardiac shunt - where the venous blood enters the left side of the heart without
passing through the lungs, ie. a right to left shunt
• pulmonary shunt - where there is inadequate oxygenation of the blood as it passes
through unventilated alveoli

Associated features
Possible clinical features include:
 the warm mucous membranes are blue, for example the tongue, the inside of the
lips
 central cyanosis increases immediately on exercise which is not the case for
peripheral cyanosis
 often there is polycythaemia with an abnormally high haemoglobin and
haematocrit; this must not be confused with neonatal polycythaemia which may
mimic cyanosis
 clubbing is often seen in patients with central cyanosis
Note that the absolute discriminating feature between central and peripheral cyanosis is
obtained from testing the oxygen saturation of arterial blood.
In some conditions, particularly Fallot's tetralogy, there may be episodes of paroxysmal
hypercyanosis.

Cyanosis in neonates
Cyanosis is a presentation of a number of conditions in neonates, and is not solely
caused by cardiac disease.
Etiology
Cardiac and circulatory causes include:
 Transposition of the great arteries
 Stenosis or atresia of the pulmonary artery or tricuspid valve
 Total anomalous pulmonary venous return
 Persistent foetal circulation

Respiratory causes include:

 All causes of respiratory distress syndrome
 Birth asphyxia, birth injury or bleed
 Obstruction of the airway, for example in Pierre-Robin syndrome or choanal
atresia

Investigations
 In the absence of other clear clinical indicators, the nitrogen washout test may be
helpful.
 Other investigations for cyanotic heart disease such as echocardiography may also
be of use.

2.Cyanosis (peripheral)
This is due to poor peripheral circulation.
Possible causes:
 All causes of central cyanosis cause peripheral cyanosis
 Low cardiac output e.g. heart failure
 Vasoconstriction e.g. due to low ambient temperature, Raynaud's phenomenon
 Arterial obstruction e.g. atheroma
 Venous obstruction