CYANOSIS

BY DR NAGANATH NARASIMHAN PREM

Definition
It is defined as the bluish discoloration of

the skin and the mucous membranes,

resulting from an increase in the reduced
Haemoglobin or of haemoglobin
derivatives in the small vessels of those
areas.
Cyanosis is derived from the colour cyan,

which comes from kyanous, the Greek word

for blue.

Sites to detect cyanosis

Lips
Nail beds
Ears
Malar Prominences
Palms and Soles
Tongue
Mucous membranes of gum,soft

palate,cheeks

Factors altering cyanosis

Colour of the cutaneous pigment
Thickness of the skin
State of cutaneous capillaries
Cyanosis becomes apparent when the

concenteration of the reduced haemoglobin

in capillary blood vessels exceeds 40 g/l or
4g/dl

Types of Cyanosis
Central Cyanosis
Peripheral Cyanosis
Mixed Cyanosis
Other Types
Enterogenous/Pigment Cyanosis
Differential Cyanosis
Acrocyanosis
Orthocyanosis

Central Cyanosis:-

Decreased arterial oxygen saturation

Decreased atmospheric pressure-High altitude
Impaired pulmonary function
Alveolar hypoventilation
Pulmonary ventilation perfusion imbalance
Impaired oxygen diffusion
Anatomic Shunts ASD,VSD,PDA
Congenital Heart Diseases-Fallots

Tetrology,TGA
Pulmonary AV fistulas
Mutiple small intrapulmonary shunts
Haemoglobin Abnormalities

Mechanism

Decreased arterial oxygen saturation due to

marked decrease in oxygen tension in the

arterial blood(arterial PaO2 is reduced)
Sites-

Tongue (margins & undersurface)

Inner aspect of lips
Mucous membranes of gums,soft

palate,cheeks

Peripheral Cyanosis
Decreased Cardiac Output
Cold Exposure
Redistribution Of blood from extremities
Arterial Obstruction-embolus,raynauds

phenomenon
Venous Obstruction-thrombophlebitis,SVC
syndrome
Frost bite
CCF,shock,Peripheral Circulatory Failure
Hyperviscosity -Multiple
myeloma,Polycythemia
Peripheral Vascular Diseasesatherosclerosis,buergers

Mechanism

Arterial blood saturation normal,but oxygen

unsaturation at venous end of capillary

Reduced cardiac output->peripheral
vasoconstriction->slow speed of circulation
in extremities
Sites
Tip of nose
Ear lobules
Outer aspect of lips,chin,cheek
Tips and nailbeds of fingers,toes
Palms,soles

Mixed Cyanosis
Cardiogenic shock+ pulmonary oedema
CCF due to lt.sided heart failure
Polycthemia (rare)
Orthocyanosis
Present in upright position due to hypoxia

occuring in erect posture in Pulmonary

Arteriovenous Malformation

Enterogenous/pigment cyanosis
Due to presence of excessive

sulphaemoglobin(>0.5g/dl),methaemoglobin(
>1.5g/dl
Causes
Hereditary haemoglobin M disease
Poisoning by aniline dyes
Drugsnitratres,nitrites,phenacetin,sulphonamides
Carboxyhaemoglobinaemia

Differential Cyanosis
Hands red (less blue) and feet blue seen in

PDA with reversal of shunt (Differential

Cyanosis)
L

R
shunt

Pulmonary
hypertension

Reversal
of shunt

R to L
Desaturated blood from the
ductus enters the aorta distal
to the left subclavian artery,
sparing the brachiocephalic

Hands blue and feet red seen in Coarctation

of Aorta with TGA(Reverse Differential

Cyanosis
Intermittent Cyanosis seen in Ebsteins

Anomaly

Central Vs Peripheral
Cyanosis
SITES

TONGUE,ORAL
CAVITY

TONGUE
UNAFFECTED

HANDSHAKE

FEELS WARM

FEELS COLD

APPLICATION OF
WARMTH,COLD

NO CHANGE

WARMTH-CYANOSIS
INCR,COLDDECREASES

APPLICATION PURE
O2

MAY IMPROVE

NO RESPONSE

CLUBBING,POLYCYTHA USUALLY PRESENT

EMIA

ABSENT

PULSE VOLUME

MAYBE HIGH

LOW VOL

DYSPNOEA

PT BREATHLESS

NO RESPIRATORY
PROBLEM

Acrocyanosis
Condition in which there is arterial

vasoconstriction,and secondary dilation of

capillaries and venules with resulting
persistant cyanosis of the hands and less
fequently the feet.
Primary
Secondary

Approach to a patient with Cyanosis

Time and onset of cyanosis,Birth /infancy

usually congenital heart diasease.

Differentiation of Central and Peripheral
Cyanosis very important
Clubbing presence/abscense noticed
Peripheral cyanosis clubbing absent
PaO2 and SaO2 should be determined in
patients where in mechanism is obscured.
Spectroscopic Examination to be done

Cyanosis

Psuedocyanosis
Bluish tinge to the skin and or mucous

membranes that is not associated with either

Hyoxemia or Peripheral Vasoconstriction
Metals
Drugs