1-Labs
of 49
Transcript of 1-Labs
-
7/21/2019 1-Labs
1/49
Labs July 2012
I must be out of my mind. Am I confused? Would I know? Who in their right mind sitsdown and writes things like this for the fun of it? Did I get all my meds for today? CanI at least have one hand loose?
This one took a while to put together as it re!uired a lot of looking"up on the part ofthe preceptor. #ot to love the web$
As usual please remember that this article is not meant to be the %nal word onanything or even comprehensive in any way. &urses at the bedside have to work onthe 'y and the things that they need to keep in their heads have to be practical andbrief ( not that this article is very brief but hopefully the items are. This informationis supposed to re'ect what a preceptor might teach a new orientee or maybe toanswer some of the !uestions that the orientee might come up with. )ach item in thisarticle is backed up by *apparently+ an average of not less than eight thousand pagesof reference material in ,- dierent languages ( I /ust tell what I know$ Pleasemake sure that you check your own references to verify lab/drug and toxicranges!
0et us know when you %nd errors and we1ll %2 them up right away. Thanks$
date note3 holy cow this one was torture. seful ti3 remember that if you1rereading this article online or on your computer you can click on any of the imagesgrab a corner and pull to make the image bigger easier to see.
"hat are some of the labs that we follow on our atients in the #$%&
4" Chemistries
4.4"The basics3 5Chem 467
4"4"43 8odium including 9ree Water De%cits and an 'xtremely$mortant (hing4"4":3 ;otassium
i. What does 5hemoly
-
7/21/2019 1-Labs
2/49
4":",3 Amylase4":"3 0ipase4":"@3 Ammonia4":"B3 Albumin
4",3 Henal 0abs
4","43 Creatinine Clearance4",":3 ric Acid4",",3 >yoglobin4","3 rinalysis4","@3 :"hour urine collections4","B3 urine electrolytes
4"3 Drug 0evels
4""43 Dilantin4"":3 alproate4"",3 Tegretol4""30ithium4""@3Theophylline4""B3Thiocyanate4""-3 ancomycin4""3 #entamicin4""F3 Digo2in4""463 Tacrolimus cyclosporine4""443 ;eaks Troughs and Handom 0evels
4"@3 To2 8creen ;anel >eds
4"@"43 Tylenol4"@":3 8alicylates4"@",3 Gpiates4"@"3 Cocaine4"@"@3 eniscellaneous4"@"463 A really cool thing.4"@"443 A scary story=
4"B3 Cardiac 0abs
" )lectrolytes
4"B"43 ;otassium4"B":3 >agnesium
2
-
7/21/2019 1-Labs
3/49
" Cardiac )nI?4"B"4,3 Eow many C;Js should be drawn and how far apart?4"B"43 What is troponin?4"B"4@3 What is the reference range for troponin?4"B"4B3 Eow often should troponins be drawn and how far apart?4"B"4-3 What is 5washout7?4"B"43 Can cardiac enI?4"B"4F3 What is h&; all about?4"B":63 What is C"reactive protein all about?
4"-3 0ipids
4"-"43 Total Cholesterol4"-":3 ED04"-",3 0D04"-"3 Triglycerides
:" Hespiratory 0abs3
:"43 A#s3
:"4"43 pG::"4":3 pCG::"4",3 pE:"4"3 bicarb
:":3 #s
:":"43 Can I believe what a # tells me?:":":3 What are central venous sats all about?:":",3 What1s the dierence between a central venous sat and a mi2edvenous sat?
:":3 Carbo2yhemoglobin:",3 >ethemoglobin:"3 What is an anion gap how do I calculate it and why is it listed here under5respiratory7 labs?
:""43 Acidoses:"":3 Alkaloses:"",3 Calculating the #ap
3
-
7/21/2019 1-Labs
4/49
:"@3 Alpha"4 Antitrypsin," 0iver 9unction Tests
,"43 A story. ","4"43 Cherry blossoms,":3 ilirubin3 direct indirect total
,", 3 A0T A8T,"@3 Alkaline ;hosphatase,"B-3 ;T and ;TT *Why are these here?+,"3 8;);,"F3 Eepatidites
,"F"43 Eepatitis A,"F":3 Eepatitis ,"F",3 Eepatitis C
( Eematology
"43 Eematocrit":3 White count
":"43 the dierential":":3 A true saying
",3 ;latelets
","43 Eeparin"Induced Thrombocyopenia
"3 Coagulation 8tudies
""43 ;T"":3 ;TT"",3 I&H
"@3 D"dimer"B3 DIC screen"-3 9ibrin 8plit ;roducts"3 9ibrinogen"F3 )8H"463 Coombs test
@" ID
@"43 Cultures@":3 8ensitivity Heports@",3 8ome speci%c tests3
@","43 TK A91s@",":3 In'uen@","-3 H8@","3 Eerpes testing@","F3 ranch"chain D&A and ;CH
4
-
7/21/2019 1-Labs
5/49
@","463 Jary >ullis@","443 0yme Disease and abesia
@"3 C89
@""43 Which kind of infection?
@"":3 8ome normal values for C89
@"@3 Gpportunistic Infections in the >IC
@"@"43 >H8A@"@":3 H)@"@",3 What are survey swab studies all about?@"@"3 C.diLcile@"@"@3 A suggestion for a study (should IC nurses be routinely screenedto see if they1re carriers of opportunistic infections? Anyone doing a>aster1s?
B" )ndocrine
B"43 Thyroid 8tudiesB":3 5Cort"stim7 testsB",3 TestosteroneB"3 eta Ec#
-" Immunology
-"43 A &ew Discovery " 5Anti"H&7 Antibodies-":3 A&A-",3 A&CA-"3 Hheumatoid 9actor-"@3 8cleroderma Antibody-"B3 Immunoglobulins
46" Gdds and )nds3
46"43 Tumor markers
46","43 ;8A46",":3 C)A
46":3 Eaptoglobin
44" A nice picture.
4:" Collecting lab specimens3
4:"43 lood Draws4:"4"43 peripheral sticks4:"4":3 specimens from arterial lines
4:"4":"43 A#s4:"4":":3Gther labs
4:"4",3 specimens from central lines4" #sK C sats
5
-
7/21/2019 1-Labs
6/49
:" What is a 5true7 mi2ed venous specimen?4:"4"3 blood cultures
4:":3 rines
4:":"43 A specimens4:":":3 rine cultures4:":",3 :"hour urine collections
4:",3 8putum 8pecimens
4:"" 8tool specimens
4:""43 stool for GM;4:"":3 stool for C.di4:"",3 stool for occult blood
"hat are some of the labs that we follow on our atients in the #$%&
There are a lot of labs out there and they come in a wide variety of 'avors. If younever got comfortable with fre!uently looking up lab results on the 'oors youNre
6
-
7/21/2019 1-Labs
7/49
probably going to have to get over that one !uickly since watching trends of onekind or another is about F6O of what we do in the IC3 labs vital signs eects ofmeds transfusions ( it all makes a dynamic picture that you have to learn to graspand follow as it changes.
The basic idea is often really easy3 if some lab value is way out of line then
something having to do with the patient probably is too. Doh$ Pou donNt want to bewrong about this which is why the team will sometimes ask you to re"send a spec.Which of course is frustrating when you think that your #I"bleed patient isn)tlosinghis blood pressure because he forgot to drink his #atorade this morning orsomething...Hemember that basic physiology thing about how the body is made up ofsubsystems? That sort of basic sort of thing? The labs re'ect those systems and howtheyNre doing *or not doing+ at whatever it is that theyNre meant to do. 8implee2ample3 if the kidneys arenNt clearing nitrogenous wastes from the blood then thelevels of those wastes will rise ( makes sense to interpret that as kidney failureright?
ut nothing is ever as simple as youNd like it to be. >y son and I /ust bought anelderly motorcycle...*What? What do you mean QDonNt talk about the motorcycleQ?...What do you mean Qit has nothing to do with the topicQ?... ItNs got plenty to do withthe topic...youNre /ust /ealous Rcause...What do you mean you QwouldnNt get on that thing even ifQ?= so we had two !uadsin the unit last month so what?$+
Anyway for the IC newbie thereNs lots to learn as usual and also as usual the bestthing is /ust to try to get some idea of what youNre looking for and then toaccumulate mileage and e2perience ( then the things that you learn by reading willmake lots more sense. This is a pretty important point3 don*t try to memori+e itall at once ( come back and re"read this article a year from now. This is especiallytrue when it comes to motorcycles. 8ee the 'oat bowl in the carburetor... ow$
1, %hemistries3
There1s lots of chemistries out there but the basic ones are always easy to get andcan give you lots of clues about what youNre looking for. >aybe I can get one of thekids to draw the little diagram thingy.&ow hereNs the thing ( every day these kids come home from school3QEey kids whad1ya learn at school today?QQ&othing.Q And man you can sit there and ask them about school until your /aw /ustdrops right o but they /ust wonNt tell you a thing. Then later daughter S : wandersby where INm struggling to do some *probably+ really easy thing with the wordprocessor and she says3 QDad$$ se a te2t bo2$Q
The preceptor3 QWhatNs a te2t bo2?QD S :3 QEere /ust get up and let me show you.Q )ight lightning moves follow a nicebo2 or line drawing *as below+ appears and INm still in the dark. &ice drawing but stillin the dark. $never did that to my parents not once. )2cept that time with the cablebo2.
7
-
7/21/2019 1-Labs
8/49
&a C0 & glucose
J CG: Creatinine
Hight ( this is the little electrolyte drawing gatsy which makes it easy to rememberthe values that you want to write down someplace !uickly like on your scrub pants.
This is one of those doctor"ish things that nurses hate but actually *like lots of otherthings+ it isnNt hard to learn at all ( seven items? And you use them all the timeanyhow or most of them anyway ( and it makes things easy to write down.
0etNs take these guys one at a time and please remember that all this info is strictlyQfrom the hipQ " I mean you can keep on going and going with this stu and prettysoon youNre an endocrine fellow or something. 8o all this stu is Qwith a lot of liesthrown inQ as they say.
1,1, the basics- .%hem 10
1,1,1- odium/ a 3145 , 165 me7/l8-8odium is confusing ( like lots of things in the physiology world it doesnNt always dowhat you think itNs going to do or what you want it to do. I guess lots of things arelike that. In fact the motorcycle ...ow$
The basic idea is that sodium is a solute 'oating around in the serum solvent. If I
-
7/21/2019 1-Labs
9/49
What about other way? What if 8hmulewit< turns out to be one of those people *likemy dad+ who insists on drinking eight glasses of water a day? And what if his doctorputs him on a diuretic say twice a day for his swollen ankles because he wonNt stopdrinking them *Q#otta 'ush the kidneys$Q+?
*This ne2t part is probably mostly lies but it was e2plained to me this way once+3 itturns out that the loop diuretics make you dump not /ust potassium but all the othercations that 'oat around dissolved in the serum 3 sodium and hydrogen come tomind. *In fact whenever you hear the word QdiureticQ you should immediatelyrespond in your head with QJ$Q. Check the patient1s creatinine before you give any.Why?+Apparently people dump enough sodium in urine in response to diuretics to cause a
signi%cant drop ( actually I was told that you pee half"normal saline. What if you nowreplace the lost volume with pure water ( tap water or bottled? &o electrolytes in itat all. Pou can see whatNs coming right? " having dumped lots of sodium I
-
7/21/2019 1-Labs
10/49
1,1,2- Potassium/ ? 34
-
7/21/2019 1-Labs
11/49
When you send o a blood spec for chems the result you get is actually from theserum *which is why they call them um serum chemistries. Doh$+ &ot from withinthe red cells. A normal serum potassium level will be something like ,.@ to @ right?What if all the little red cells get busted ( hemoly
-
7/21/2019 1-Labs
12/49
This is a confusing one for those of us who only remember biochemistry as a badmemory. And I have a really bad memory in general. icarb is also described ascarbon dio2ide probably because they associate with each other in the carbonic acidreaction ( I seem to remember arrows pointing both ways indicating that thereaction could go forwards and backwards. *At the same time? I had a car like that innursing school.+
The important thing is that this number whether e2pressed as serum bicarb or asserum C6: *not %G2 which is something else+ indicates the amount of bicarbpresent in the blood available as QbuerQ.
This gets into acid"base balance which I think is going to re!uire an article of itNsown$ >eantime take a look at the section below on 5Anion #ap7 ( yeah like Iunderstand that stu ( under 5Hespiratory 0abs7.
1,1,C- F 310, 2C mg/dl8-
5lood rea &itrogen7 represents the amount of nitrogenous waste in the bloodwhich is supposed to be cleared by the kidneys. The & number always travelsaccompanied by its partner 1,1,H-creatinine 30
-
7/21/2019 1-Labs
13/49
Tight glucose management has gotten a whole lot of recognition lately as criticallyimportant in managing really sick people. It turns out from the studies that all sorts ofthings happen for the better if a patientNs glucose is kept under tight control ( as aresult weNve started to use insulin drips a whole lot in our >IC. Apparentlyeverything is aected from wound healing to recovery from septic infection tolength of stay etc. We run insulin drips at rates of something like one to ten units an
hour checking glucose with either chems to the lab or glucometers every two hourswith a goal range of 6 to 46.
8ometimes despite the closest monitoring insulin"drip patients get low. Eard toknow why maybe their tube feeds didn1t absorb when you turned them in the bed orsomething. The drip gets shut o and the patient either gets a half or a whole ampof D@6=DJA patients obviously come under the fre!uent"glucose"check category. Thesepeople often re!uire changes in I 'uid treatment every couple of hours and wecheck their electrolytes every two hours. We don1t use the same protocol though (DJA people get &;E somewhere along the line while the others may or may not.
i< @cetone 3ositive or negative8-
A DJA patient1s need for insulin does not go away once her blood glucose comesdown. Jetoacids can hang around for a long time afterwards ( maybe another 4:":hours I think and the acidemia they produce is > a happy thing. Continued insulintreatment is what will help the patient cook o the ketoacids so once the glucosegets down to a reasonable level the I hydration 'uid usually changes fromsomething like normal saline with some J to something like @O glucose with J ( theglucose keeps the blood sugar up now while the ketoacids get %2ed by the insulindrip which continues to run. 0ately they1ve started using &;E when the glucosenumbers get down towards normal. I wonder if the whole setup could be simpli%ed bygiving the patient a dose of lantus insulin on the way in the door= someone want to
do a study?
We check the acetone level every four hours until it goes negative. Pou1ll *hopefully+know that the situation is improving anyway since the serum A 3H
-
7/21/2019 1-Labs
14/49
1,1,D- erum %alcium 3
-
7/21/2019 1-Labs
15/49
1,1,D- Phoshorus 32aybe we could come up with a newproduct3 5&utra";hos"0o7 ( that would either replace or remove itself depending.*What1s that supposed to mean3 5Eusbands should be like that=7?+
1,2- ome other basic chems-
1,2,1- Lactate 30
-
7/21/2019 1-Labs
16/49
numbers of these patients going to the GH has really dropped ( I guess many of themdo better if left alone for a period of time. There1s a whole staging process forpancreatitis that I don1t know much about. Hanson1s scale?
1,2,5- @mmonia 311 E 45 mcmol/l8-
*All the e2perienced IC nurses give a big sigh when they see this one.+ Ammonia isone of the nasty substances that accumulates in the blood when the liver doesn1twork ( makes people encephalopathic. 8ome of us are like that even without theammonia. These folks often have a level in the :661s or higher and treatmentinvolves inducing lots of diarrhea with lactulose. *It really does seem like karmicrevenge=+>ake sure that you warm up the duoderm on the rectal bag before you put it on andit1ll stick much better ( I put it under my arm while prepping the patient1s um5area7. se a ra
-
7/21/2019 1-Labs
17/49
kidneys in rhabdomyolysis. Turns the urine an interesting color. Think about a bicarbdrip which helps protect them. Anybody know how that works?1,4,6- rinalysis-
We send o tons of these ( and they give back a lot of information. 8ome of the mainpoints3
- Color3 5straw colored7 is always nice. lood ( not so nice but we have fun withthe descriptions3 5Gh it1s a nice rose today but it was de%nitely merlotyesterday.7 Drugs like rifampin and pyridium can produce a really nice orange#atorade color. >ethylene blue can make urine a nice teal green. *5Pa tink dat1steal? &ah you dope dat1s like a!ua$ Totally$ Ea$ Eey Halphie dis guy tinks disheah color is teal ha ha$7+
- Turbidity3 is there stu 'oating around in it? Casts maybe? 9ungal clumps? (time to ask about an Ampho" irrigant even before the culture comes back. *Pousent both A and CM8 didn1t you?+
- pE3 very important sometimes as in rhabdomyolysis where large"scale muscledestruction releases lots and lots of myoglobin which will show up in the urineassuming the patient is making any since the stu is so nephroto2ic. The pE ofthe urine is kept above - with a bicarb drip.
- 8peci%c #ravity3 higher means more concentrated lower means more dilute.
- 8ediment3 any there? Any idea why?
- lood3 shouldn1t be any.
- acteria3 6 " 4Kml
- WCs3 6 ( ,Kml
- #lucose3 none. *Pes I take my glucophage and no I don1t check my bloodsugars often enough. #rrr.+
- Jetones3 also none.
- &itrite *indicates that bacteria are present+3 shouldn1t be any.
1,4,5- 26 hour urine collections
We do these sometimes to evaluate creatinine clearance and sometimes to measurethe e2cretion of metanephrines ( I think that1s right. When your patient ishypertensive tachycardic and there1s /ust no clear answer why they1ll want to rule
out a pheochromocytoma ( a functional adrenal tumor that sits there secretingpressors. *Eow do you think they invented pressors anyhow?+ 8ome of these have tobe collected in iced bottles sometimes with acid in them ( the smell is ratherimpressive.
1,4,C- rines for electrolytes
17
-
7/21/2019 1-Labs
18/49
I can1t say that I know how to interpret these very well but the point of sending theseis to try to %gure out how well the nephrons are working. 0et1s see= if the urinesodium is low that means the kidneys are holding on to sodium= so that means=the patient is dry? And the kidneys are holding onto water with the sodium? Which allassumes the kidneys are working=
Correspondents? Anyone want to look into this one for us?
1,6- :rug Levels
These de%nitely come under the heading of 5chems7 and we follow a lot of levels inthe unit. We do a lot of dose ad/ustment for renal failure ( digo2in and vancomycinare good e2amples. The list below was created using the most sophisticatedtechni!ue available3 5Gy Jathleen$ What do we send levels on?7
1,6,1- :ilantin 3(otal- 10 E 20mcg/ml8-
Pou should de%nitely know this one. Dilantin turns out to be one of the drugs that'oats around in two forms like calcium does3 free and albumin bound the free drugbeing the active part. In general it seems that following the total number is usuallyokay but changes in the serum albumin will change the bound levels of the drugmaking more or less of the free stu um free or actively available as in renal orliver disease states. &urses tend to let the physicians worry about calculatingcorrected levels ( it1s seems strange though to come across some dosage that theycalculated that comes out to something like :-.,: mg I ! 4 hours. Gr somethinglike that. 9ree dilantin is supposed to run around 1
-
7/21/2019 1-Labs
19/49
Tacrolimus is apparently something like a hundred times more powerful thancyclosporine. &ice$ oth these drugs can become to2ic in renal failure *uh=transplant working?+ ( so they need ad/ustment based on weight and&Kcreatinine= apparently the dosages also vary somewhat depending on whichorgan has been transplanted. >IC nurses probably have a pretty unrealistic view oftransplantation ( most of the patients we see with them have come in because
they1re failing=
1,6,11- PeaksI (roughsI and andoms-
There seems to be some confusion about peak and trough levels.Eere1s the way wedo it3 the trough gets drawn %rst /ust before a scheduled dose when the level shouldbe lowest *the trough of the drug"level graph.+
The peak gets drawn about @ minutes after a scheduled dose ends when the levelshould be highest.
Handomlevels are /ust that ( they1re drawn without any relation to the timing of thedoses. We follow a lot of random vancomycin levels because we have a lot of renalpatients who can1t clear it ( we say the dose /ust keeps going round and round=
1,5- (ox creen Panel #eds with to2ic ranges3
1,5,1- (ylenol 35 E 20 mcg/ml+ ;atient have a nice bron
-
7/21/2019 1-Labs
20/49
they1ll reach for anything that even resembles it3 antifreeethanol is converted to a couple of nasty metabolites3formic acid *5Halphie$ I told you not to eat that whole bo2 of chocolate"coveredants$7+ and formaldehyde.
Treatment is way cool3 giving the patient ethanol will actually displace the methanol
in the metabolic pathway ( the bad stu then cooks o slowly and non"to2ically. Gncein a while we get a glass bottle of ( is it 46O ethanol? ( up from pharmacy and hangit at some carefully calculated rate that factors in the weight age gender andprobably the renal function of the intern ordering it=
1,5,- 'thylene Olycol- *5)thylene$ Pou stay out of that glycol$ Don1t make me getthe hose$7+
Another dangerous substance found around the house also appearing in antifree
-
7/21/2019 1-Labs
21/49
lumen. That sort of solved one problem ( but there we were running around the unitgetting dopplers large ; cus running around the bed cycling noninvasivepressures on his upper arms forearms upper legs lower legs ( getting ; readingsonce out of every three or four cycles maybe on tons of pressors all really lowreadings= what a scene. And &GGDP could hit an artery for either a blood gas or toplace an arterial line= and I mean we THI)D$ Gur resident team guys tried
anesthesia came up and tried the other anesthesia guy came up and tried ourattending tried all the while on *straight drips+ of levophed at 466mcgK minute neoat 4666 dopamine at I forget= %nally we got a ; cu to read on his left forearm Ithink it was. Terrible ;s ( and a venous blood gas from the femoral line showed a pEof B.F something. PowI= didn1t seem to be septic (no fever no white count= and then a family member mentioned %nally that he1deaten= what? EGW many tubes of toothpaste? Three?
Well= it was !uite a night. 8urgery %nally came up and actually did a cut"down at thebedside to place an arterial line ( something I1ve seen done e2actly once before in :6years ( they draped and prepped his wrist dissected that sucker out inserted acatheter sewed it in H)A0 good= and the ; was terrible$ And %nally we got an A#( and the ;E was still -.6,$ This is about %ve or si2 hours along now=
8o we did all the things you1d think of to correct the badness ( we ran a bicarb dripwe tried to run CE to clear the acidemia ( stupid catheter kinked as so often inlarge patients and the system went down within an hour= ran E#) amounts ofpressors ran in )&GH>G8 amounts of crystalloid= and I staggered home thatmorning at the end of my twelve hours left a trail of clothes and face"planted onthe bed. Woke up at about ,pm called Jatie to see what had happened=
Ee was %2ed$ Eey ( don1t ask >) what happened$ 9i2ed$ etter$ Ee was awake$>oving the e2tremities$ Ee1d W)A&)D G99 TE) ;H)88GH8$ All this in eight hours$)2tubated the ne2t day left the unit the day after that$
9luoridepoisoning. The attendings were amaore ectopy than before? 0ess? What labs mightyou think about in this situation? ;robably=
'lectrolytes%rst.
1,C,1- Potassium 34
-
7/21/2019 1-Labs
22/49
over reaching for lidocaine when my patient has a run of T. 8peaking of which (what should I be reaching for?+
EereNs a !uestion ( how are you going to give your patient a dose of potassium?Grally? Gn an empty stomach? What if your patient1s been vomiting? *What kind ofcardiac event might he be having?+ &ot orally? Eow about I? Eow dilute does the J
have to be ( you might have to give 46 me!s per hour through a peripheral vein in apretty large volume to keep from burning a hole in the patientNs arm. ut what if theteam doesn1t want to give volume ( maybe they want to diurese the patient instead?Well could you mi2 it with lotion and rub it on his back? Eow are you going to solvethis? *#o back and look at 1,1,2.+
The eect of repleting electrolytes can be really impressive3 lots of ectopy maysimply go away.
The other thing to worry about when giving J is the kidneys ( these guys usuallye2crete potassium at a fairly constant rateZ if they1re failing they won1t. 8o if yourpatient1s & and creatinine have been rising and his J is ,.: what should you do?>agnesium also turns out to be the treatment for 5polymorphic T7 which is eitherthe same as or %rst cousin to Torsades de pointes. Pou1ll see cardiologists tell theteams to keep a patient1s J greater than and their mag up around ,=
%ardiac 'n+ymes
1,C,4- "hat are cardiac en+ymes&
This is the myocardial infarction thing. The idea is that destroyed myocardiumreleases speci%c substances into the blood which can be measured ( nowadays theycall these the Qserum cardiac markersQ.
1,C,6- "hich cardiac en+ymes do we follow on our atients&9or a long time we followed creatinine phosphokinase levels3 QC;J7s and we stillsend them but recently we1ve started sending troponin levels as well and these arepretty much the standard now.
1,C,5- %an a atient have elevated en+ymes without having an #$&Well see that1s the thing. It turns out that almost any situation that causes muscularin/ury ( almost anywhere in skeletal muscle or the myocardium ( can cause a C;Jbump. Apparently not however for troponin which only shows up in myocardialin/ury.
1,C,C- %an a atient have an #$ without having elevated en+ymes&I don1t think so. Pou read about people having >I1s without developing !"waves (maybe because the events are physically very small ( but I don1t believe that aperson can sustain a muscular in/ury to the heart without releasing some amount ofen
-
7/21/2019 1-Labs
23/49
C;J is released into the blood whenever there is a muscular in/ury somewhere. &on"cardiac in/uries will release C;J3 de%brillation surgery trauma or seiin/ections. C;J begins to pop up in the period roughly " hours after an event andstarts dropping hours out.
1,C,- "hat is the reference range for %P?&
Gur lab uses a reference range of B6 " 66 unitsK liter. I know that I1ve seen patientsQrule inQ with a peak C;J Qinside the rangeQ ( say in the ,661s ( but the thing is thatthey show up positive for #F isoen+ymes which indicate speci%cally that the C;Jrelease is coming from myocardial tissue. They would presumably be troponin"positive as well.
1,C,D- "hat are isoen+ymes&It turns out that dierent muscle tissues produce dierent sub"species of C;J whenin/ured which can be measured and e2pressed as a percentage of the total amountof C;J that1s been released.
1,C,10- "hat is the =#F fraction=&Q>Q refers to the sub"species of C;J isoen percentage higher than ,O is a 5rule in7 forsome kind if cardiac in/ury. > isn1t always diagnostic of an >I speci%cally sinceother situations can cause tissue in/ury to the heart3 cardiac surgery or de%brillationor even chest compressions during C;H " you get the idea. Pou might see a rise inC;JK> in a patient whose chest had struck the steering wheel producing a QcardiaccontusionQ=everyone reading this has a seat belt on right? I wear mine in theshower but hey that1s /ust me.
1,C,11- "hat are ## and FF&
It1s been a while since I even saw these used but I think that >> isthe C;J isoenine isn1t. Wish it was.+http3KKwww.babelrock.comKnewsKimagesKbb[king./pg
1,C,12- :oes a higher %P? mean a larger #$&
That1s the idea ( but you have to make sure that you1re looking at the right kind ofC;J. If the > isoen QisoQ wasn1t there then you1d have to say that the C;J 5bump7 came fromskeletal muscle instead of the heart.
During the Crimean War 9lo and I used to call a small >I a QsubendoQ3 sub"endocardial meaning small and not all the way through the muscle wall*QtransmuralQ+. This kind of event usually went with a C;J peak of something lessthan a thousand3 66 @66 maybe. I think these are the >Is that nowadays are often
23
http://www.babelrock.com/news/images/bb_king.jpghttp://www.babelrock.com/news/images/bb_king.jpg -
7/21/2019 1-Labs
24/49
called Qnon !"waveQ events because the muscular in/ury isn1t big enough to generatethe dreaded evil !1s.
ig >I1s on the other hand are pretty unmistakable ( you may see C;J peaks of , "666 or more with an > fraction ( well what would it have to be? ,O *or more+ of,666 ( um=well one percent would be ,6 right? 8o ,O would be F6? 8o if the >
number came back at something like ,66 that would be 46O " de%nitely a cardiacevent. ;retty big one. X"waves for sure.
1,C,14- Aow many %P?s should be drawnI and how far aart&We usually send three C;J specs eight hours apart. If a cardiac patient has somesort of complicating event later on ( say a spell of a"%b or maybe recurrent painthen we1ll probably send another three sets to see if there1s been another in/ury. *Asmall C;J release is called a QleakQ and a really small release is called a QleakletQ.+
Hemember that C;Js are going to go way up in any situation that produces skeletalmuscle in/ury but the situation that really makes the numbers get scary isrhabdomyolysis( which I think got mentioned somewhere earlier. This is a prettydangerous scenario that shows up sometimes when someone1s been lying on the'oor say for a couple of days without moving ( maybe into2icated maybe after astroke something like that. We1ve seen C;Js get up into the range of 466666. ;rettyhigh.
1,C,16- "hat is troonin&It turns out that there1s an even more sensitive test for myocardial in/ury and hername is troponin. There are three types of troponin3 CTnI CTnC and CTnT which isthe one we use *we call it Qtroponin"tQ+.
It turns out that troponin is a really sensitive and accurate indicator of myocardialin/ury which makes it preferable to C;J since you can get knocked o your bikethree times a week and not release troponin until the frustration makes you have an>I. Troponin is a de%nitive indicator for non"!"wave >IZ there1s no confusion aboutwhether your C;J bump is coming from your broken arm or from the chest pain thatyou got when that idiot opened his door in front of you for the fourth time this month.
Troponin also stays elevated for something like a week after an >I so someone whocomes in four days after his event " when his wife %nally convinces him that hedoesn1t look so good " will still have diagnostic levels to prove what1s going on. Yustdidn1t want to miss the post"game show y1know.&othing1s perfect though and other conditions besides >I can make troponin rise3renal failure can cause the only 5false elevation7 of troponin that we1ve heard about.Gther causes of troponin release3 an episode of CE9 and obviously any myocardialin/ury besides an >I will do it too3 cardiac contusion de%brillation myocarditis
ablation *that1s where they burn out the W;W thing in the ); lab etc.+ but theimportant point is that there1s no confusion as to the source of the en
-
7/21/2019 1-Labs
25/49
be :.O of 4. I reali fraction is a hair under ,O "maybe not an >I? ut the troponin at the same time was 6.4 ( strictly speaking aQrule"inQ. The ne2t set of en fraction of .Oand a troponin of 6.4F. Eelpful. De%nitely a little >I.
1,C,1C- Aow often should troonins be drawnI and how far aart&We send troponins and C;JK>1s on the same schedule ( it1s the same red"top specevery hours times ,.1,C,1H- "hat is =washout=&
This is a QreperfusionQ phenomenon that you see when a patient gets clot"busted.isuali
-
7/21/2019 1-Labs
26/49
],.6 mgK liter have a higher risk for nasty cardiac events. 0ower3 \4.6 mgK literseems to be better.
1,H- Liids
A liid ro;leis made up of a number of tests3
1,H,1- total cholesterol 3N200mg/dl81,H,2- A:L 340,C0mg/dl81,H,4- L:L 3N1D0mg/dl81,H,6- (riglycerides 3N10mg/dl8
We send these as part of the workup on cardiac admissions and oftentimes ourpatients get a daily dose of one statin drug or another but we don1t follow themmuch as a matter of course. Gne e2ception3 patients on propofol get a lot of lipidfrom the emulsion that it1s made of ( sometimes the lipids are removed from their
T;& as a result.
We had a patient a while back who had some kind of incredible congenitalhyperlipidemia ( I forget what the numbers were e2actly but there was a whitesediment in his blood spec tubes. 8cary.
2, esiratory Labs-Gbviously the main topic here is blood gases. There1s more than you probably everwanted to know about blood gases in the fa! on 5ents and A#1s7 so take a lookover there for details but we can take a !uick overview3
2,1- @FOs-
2,1,1- G2 30 E 100 mm Ag8 3
This is the good stu ( this is what you1re trying to deliver. A rough rule of thumbthat1s often helpful if you1re trying to %gure out how your patient1s doing3 the pG:should be something like four or %ve times the 9iG:.
)2ample3 right now you1re breathing room air which has an 9iG: of :4O right?And if we stuck you for a blood gas your pG: should be something like 6"466which is roughly four or %ve times the 9iG: number. 8o if you intubated me put meon 466O and stuck me my pG: would be upwards of 66. I hope. The point is thene2t time someone tells you how great it is that your patient has a pG: of 6 andthey1re on 466O and 46 of ;)); you1ll know that 6 is actually really very lowcompared to where they ought to be. Eypo2ic. Hemember3 5o2ygenation7 means
/ust that3 how well the blood is getting o2ygen delivered from the alveoli.
2,1,2- %G2 345 E 65 mm Ag8-
This is the bad stu the stu you1re trying to get rid of. 5)2haust gas73 comes outof the tailpipe. *8o if you use Hed >an in your pipe and you e2hale blue smokedoes it mean you need a ring /ob? As for me /ust make me a D&H ( I had a crackedblock last year anyhow. It1s that diabetes man.+ Too much pCG: and the carbonicacid reaction goes the wrong way ( respiratory acidemia results. #et rid of toomuch and the reaction goes the other way ( respiratory alkalosis. Hemember that
26
-
7/21/2019 1-Labs
27/49
5ventilation7 refers speci%cally to how well your patient is clearing C6:. Dierentconditions often produce speci%c eects on blood gases3 patients in CE9 will usuallybe hypo2ic but won1t have much trouble ventilating. ;neumonia patients are theother way ( they may o2ygenate fairly well but they don1t ventilate good. Correctly.;roperly. Whatever.
Hemember that a pCG: in the si2ties can 5narcoti
-
7/21/2019 1-Labs
28/49
line ( e2cept this one1s a %beroptic sat sensor instead of a thermistor. Gr a ther">rs.Anyhow " if the number is low ( and they want it to be around H0K" then it meansthat either the tissues are e2tracting too much o2ygen being all stressed or thatthey1re not getting enough delivered in the %rst place. 8o ( is the patient1s crit ok?>ight need more carrying capacity. Is the patient all dilated centrally but clamped
down peripherally making lactate? Tank em up. Is the patient1s heart beingaected by the sepsis? Eappens= throw in the swan check the output. 0ow? Thinkabout dobutamine to increase the output= I personally hate that last one as thesepatients are already tachycardic and even saying the word 5dobutamine7 in theroom can put them into rapid A9= have they ever tried milrinone instead? Thewhole idea seems dumb though=
Hadical idea of the week ( how about /ust leaving them on 466O 9iG: for the %rstday? Gne day won1t kill em=
2,2,4- "hat*s the diQerence between a central venous sat and a mixedvenous sat&
8kip this one if you get di
-
7/21/2019 1-Labs
29/49
Eyperbaric also turns out to be the thing to do when your patient has the 5'esh (eating bacteria7 ( the group A streptococcal infections that are so scary. They1reapparently anaerobic and making a patient incredibly hyper"o2ic is /ust the thing tokill them o. &eat$
http3KKwww.hyperchamber.comKimagesKchamber6:./pg
2,6- #ethemoglobin 3goal- N6K8-
This is another substance that likes to bind to hemoglobin and that can interfere witho2ygen delivery if too much of it accumulates. This one appears when inhaled nitrico2ide therapy is used for pulmonary hypertension. *&ot nitrous ( ha ha$ ( why are myfeet so big? Emm that1s a big drill=+ Too much methemoglobin3 bad. I1ve never seenit happen.
2,5- "hat is an anion ga 310,16 m'7/l8I how do $ calculate itI and why is itlisted here under .resiratory&
Acid"base involves everything. After thinking about it and thinking about what to put
in this section I decided to leave it here under the heading of 5respiratory7 becausethe part of acid"base that you1re probably going to work with %rst is the ventilationkind ( but remember that the non"respiratory the metabolic components are /ust asimportant to think about. 8o maybe this will help you keep them both in mind.
Calculating an anion gap is supposed to help you %gure out what1s going on with yourpatient1s acid"base balance thing. 5Why the hell is he so acidotic?7 Gr alkalotic.
There are 5gap7 acidosis1s and 5non"gap7 acidosis1s.
After talking about the gap I1m going to confess that I don1t use it myself. &everhaving learned a lot of the horrible chemistry etc. that lies behind the ways thephysicians analy
-
7/21/2019 1-Labs
30/49
," Eas he been running the marathon? Again? 8end a lactate." Is he in renal failure? There are a couple of kinds of 5renal tubular
acidosis7.@" Is he in DJA? *Eow does that make acid? 8end the ketones.+B" Eas he gotten 4: liters of normal saline today? *Can someone
e2plain hyperchloremic acidosis to me? Change this guy to Hinger1s
0actate already$+-" Eas he been poisoned? Too much aspirin?
- Ee1s lost some bicarb3
4" Does he have an ileal loop? They can dump bicarb like mad.8odium too.
:" ;rofound diarrhea? They uh= dump bicarb like mad.," Eas he been climbing mountains and taking too much Diamo2?
*Dumps bicarb in the urine. Eey it could happen$ And monkeyscould=never mind.+
2,5,2- Alkaloses3
- 8he1s lost some acid3
4" Eas her tube been putting out liters and liters a day? *0osingEC0?+
:" Eas she been over"ventilated? *Eow does that make an alkalosis?+," Eas she been diuresed for several days running? *0oop diuretics
make the kidneys dump E ions as well as potassium. Acid lossright?+
- 8he1s gained some bicarb3
4" Eas she been getting into the family"si
-
7/21/2019 1-Labs
31/49
If you sedated me say with 6.@mg of morphine *I1m a very sensitive individual=wiping tear away+ and made my pCG: go up to @6 what would my pE normally do?Anybody remember the rule? If the pCG: changes 46 points the pE changes .6 ( sowith a pCG: of @6 my pE would be= -.,:.
ut this guy walks around with a high pCG: all the time. CG;D people never fullye2hale that1s on account of they1re obstructed right? Chronically? In the pulmones?They 5air trap7 ( so they never really get rid of their carbon dio2ide eectively.
Eis baseline gas would be something like @6 K@6K -.6 ( how come is that? I meanwhy does he have a normal pE?
It1s on account of he1s compensating ( remember compensating? And how does hedo that? y holding onto bicarb with his kidneys ( look3 his bicarb is wicked high.Compensated.
8o what happens when he comes in and you tube him? Ee1s probably been in troublefor a couple of days ( his pCG: has been even higher than usual and his kidneys are
/ust a"hangin1 on to every little bicarb molecule that goes by and he1s doin1 okaykeeping his pE fairly normal but his pCG: goes up a little more and a little moreand then bam$ &arced. 8tops breathing almost. #ets tubed.
8o okay ( we tube him and we ventilate him and we 5blow him down7 to a normalpCG:. ut by this time he1s saved up so much bicarb over the past couple of daysthat he1s got this enormous reserve of it 'oating around in his blood ( so if we blowhim down from his pCG: of about -@ that he1s been compensating for all this timewhat happens to his pE? Wicked alkalotic.
8o ( what to do? Well he1ll re"e!uilibrate in a few days ( it takes three or four daysfor the kidneys to straighten things out again *assuming that they work+. Gr we couldlet his pCG: rise some which would normali
-
7/21/2019 1-Labs
32/49
- That1s the gap. A normal gap is "4B. *m)!Kliter+.
- An e2ample of a 5gap7 acidosis would be one produced by high lactate( also I think DJA1s and some poisonings do it. The gap number getslarge ( ooo scary. Then when things get better the intern will look up
from the sheep1s entrails ( I mean the computer ( and tell you as ifhe1d invented the earth3 58ee the gap is closed.7 &ow we feel better=
As usual my e2planations will not be the same as those you get from your medicalteams ( and they probably shouldn1t be. Current book"knowledge is e2actly whatthey1re supposed to have and bedside e2perience is what you and I are supposed tohave and we1re supposed to put those together ( it often works out very well$
2,5- @lha,1 antitrysin
Worth mentioning. This is /ust really unpleasant. ;eople who don1t make enough ofthis for genetic reasons are prone to emphysema even if they don1t smoke. Gccursin something like one in @66 people. These folks apparently get severe lung disease
/ust by reading tobacco billboards=
4, Liver 9unction (ests
4,1- @ storyake sure you check blood products properly$ *What would you do ifyou thought your patient was reacting?+
5, $:-
5,1- %ultures- bloodI urineI sutumI stoolI %9 *Did I miss any?+
We send a lot of cultures ( maybe too many they tell us. We get routine culturereports back in one day %nals in three and the results include 5,2- sensitivityreorts as to which antibiotics the bug is sensitive to. These are starting to get scaryof late ( we had a patient recently whose decub wound was coloniethicillin3 H)8I8TA&T >etronidaAI coloni
-
7/21/2019 1-Labs
40/49
- 5,4,5- Miral Load-Another part of the EI test panel3 usually reported ashigh intermediate or low " depending on the test method used the numbersare variable. Yayne says that with the protease inhibitor cocktail some patients1levels come back 5undetectable7. Cool.
- 5,4,C- %#M E 3resence of antibodies and/or the virus8
Gpportunistic viral infection. ;regnant nurses? Check up on this one ( I thinkthe last guidelines we saw said that universal precautions do make it safe tocare for these patients
- 5,4,H- M
I think this one is detected by viral cultures. H8 itself is not the danger to thepregnant nurses ( it1s the ribavirin that we treat them with that1s really verydangerous to the babies=
- 5,4,- Aeres cultures
We send herpetic cultures sometimes ( the lesions show up orally on somepatients and I think they hang around for about a week ( less if treated withtopical and maybe systemic acyclovir. Gnce in a while a C89 culture will comeback positive diagnosing herpes encephalitis ( not fun.
- 5,4,D- Franch,chain :@ and P%I .olymerase chain reaction- Theseare two methods used to 5provide more evidence7 when the cultures aren1tde%nitive. I understand that ;CH is used to replicate D&A material nowadays tohelp identify organisms that might otherwise not show up in the dish. erycool.
- 5,4,10- ?ary #ullis- Another interesting thing about ;CH is its inventor3 thescientist who won the &obel ;riullis. Ee1s apparentlyfond of sur%ng and thought up the ;CH idea while driving on the Californiahighway in his Eonda Civic. *With or without his boards?+ Ee won the pri
-
7/21/2019 1-Labs
41/49
acterial infections3 mostly neutrophils glucose less than :.6 mmolKliter " bacteriaeat up the csf glucose and virii don1t.
5,6,2 ome normal values for %93 here1s another case where some of thetests should go somewhere else maybe like chemistry but they1re relevant here.
The point is that things overlap for important reasons.
-glucose3 6"@ mgKdl
-opening pressure3 @6"46 mm E:6
-white cells3 not many i.e. less than @ per cc ( lots of whites may also point totumor activity.
- red cells3 none unless the 0; is traumatic
-color3 should be crystal clear ( a yellow tint *52anthochromia7 whichapparently means 5yellow tint7+ means either red cells have been in the csf or
/aundice or maybe eating too many carrots. Cloudy csf often points tobacterial meningitis.
- ;rotein3 not much compared to the serum maybe ,@mgKdl. Increased amountsof protein in the csf might mean a breakdown in the blood"brain barrierpointing to infection in'ammation or even tumor activity.
- *I don1t think I have a blood"brain barrier. What were we talking about? m "where1s my bag of carrots?+
5,5- Gortunistic $nfections in the #$%
8eems to me that we should do an article on these infections all to itself. Emm.
All these guys are either positive or negative by culture= one of the bigproblems with them is that they1re starting to mutate towards the more deadly. Itlooks like some of the really strict precaution regimens really do work to containthese but there are so many gaps ( I mean I alcohol my hands every couple ofminutes it seems like but what about when Halph the arrogant intern wanders inand out of the room no gown no gloves with his air of importance bearing him inand out ( what does he have a bug barrier of power surrounding him orsomething? Gr the housekeeping guy who sometimes doesn1t change glovesbetween rooms but wears the same pair all around the unit? Gr the lady whoreads the numbers o the tube feed pumps? Gr= there are handwashingmonitors out there now and it1s probably a good thing too=
5,5,1- #@( lives in the nares? 8ome impressive percentage of the wholepopulation carries these guys around in the nose=it makes sense that if this bugis starting to be responsible for wound infections and it1s > sensitive toanco= then we have rather a problem.
5,5,2- M'
41
-
7/21/2019 1-Labs
42/49
8ame idea. This one lives in the gut. >igrates to interesting places (5translocation7 they call it which I think means 5migrates to interesting places.7
5,5,4- "hat are survey studies all about&
#ot to see who1s got these bugs on their way into the >IC and who1s pickedthem up while staying here. ;ositive conversion is > a happy thing$
5,5,6- %< :iScile
This one is even tougher to kill than we thought ( it survives a 0G time out inthe environment ( encapsulated is it? #ot to do handwashing A&D alcohol forthis one.
5,5,5- @ subTect for a study- should $% nurses be routinely screened tosee if they*re carriers of oortunistic infections&
5m= you1re going to culture me WE)H) now?7 It1s hard to imagine that we1renot all carriers of these bugs by now=
C, 'ndocrine- We send these often enough to mention them3
C,1- (hyroid studies3
We usually send the 5panel73 T, T and T8E are the ones that come to mind. #ot tohave enough T8E coming from the pituitary otherwise the thyroid won1t make theother ones. We give synthroid to patients who need it usually because they1ve beendiagnosed on the outside and come in with it listed in their history. Hecently we had apatient in my2edema coma which got the resident teams very e2cited ( severehypothyroid. 8he got intravenous thyroid treatment something I don1t think I1ve everseen before. Cool.
C,2- .%ort,stim tests-
These are to %gure out if your patient1s adrenals are working which turns out tomatter in sepsis treatment. Do adrenals shut down in sepsis? 8ome septic patientswho don1t respond properly get treated with steroids which used to be absoluteheresy back in the day.
A baseline cortisol level gets sent ( why always in the morning? 8ome circadian thingthere. *After working nights for :6 years they1d have a hard time with mine.+ Thenthe patient is given a dose of I ACTE also known as co"syntropin ( then after an
hour the cortisol level is remeasured to see how well the adrenals responded.8ometimes you1ll see a seriously hypoadrenal patient wean o pressors after beingstarted on I hydrocortisone. Impressive.
C,4- (estosterone- *5Po I1m a donor for that stu man$7+ Couldn1t resist. I don1tthink I1ve ever sent one.
42
-
7/21/2019 1-Labs
43/49
C,6- Feta AcO
Gnce in a while we1ll send one of these often to make sure that say some youngunconscious patient isn1t pregnant before we give some drug or treatment that mightbe dangerous to the baby.
H, $mmunology-
H,1- @ ew :iscovery , .@nti, @ntibodies-
Immune problems in general involve testing for problems in 5self"recognition7 " acondition which a_icts many nurses. I believe that this may be caused by 5Anti"H&Antibodies7. I propose a research study3 5Eealing Gur ;ain3 )2ploring 0evels of Anti"H& Antibodies in a Eospital ;opulation of &urses ;hysicians and Assorted 9amily>embers3 Do We Immune"Gppress Gurselves?7Emm. >aybe the Therapeutic Touch people could help us out here ( 59eel the aurahealing the antibodies=7 Po keep your hands o my aura man$
H,2- @@-
*&o not that one.+ 5Anti"nuclear antibodies7. These can show up in patients with anumber of disease states3 lupus rheumatoid arthritis scleroderma and also aftercertain chemical e2posures. The result is reported as a titer3 the patient1s serum isdiluted and the last dilution that still shows the antibody is the result ( i.e. 43:6 or43B6. Eigher would presumably be worse ( the antibody is still detectable at higherlevels of dilution.
H,4- @%@-
5Anti"&eutrophilic Cytoplasmic Antibody7 ( also auto"imune"produced. Titer reults.This tests for a variety of unpleasant rheumatologic conditions3 Wegener1sgranulomatosis polyarteritis nodosa glomerulonephritis " rheumatologic things.
H,6- heumatoid 9actor-
Also a titer(based test that indicates the presence of an antibody this time forrheumatoid arthritis positive in -6"6O of cases usually at ] 436.
H,5- cleroderma @ntibody-
Apparently not so useful as it only shows up in :6O of patients with the disease.;hooey. Then again would I really want to know? I guess so.
H,C- $mmunoglobulins-
I wish I knew more about this stu. Immunoglobulins turn out to be the proteinsmade by plasma cells in the bone marrow " they attack antigens introduced byspeci%c invaders like bacteria or foreign chemicals. Immunoglobulins get theabbreviation 5Ig7 *pronounced 5eye"gee7+ and there are %ve main kinds3 Ig#*gamma+ Ig> *mu+ IgA *alpha+ Ig) *epsilon+ and IgD *delta+. These guys takevarious forms and do a number of dierent things but basically their /ob is to huntdown and help kill o invading micro"organisms.
43
-
7/21/2019 1-Labs
44/49
I know that I1ve hung Ig# in the past but it seems to have been pretty rare and Iforget what for.
10, Gdds and 'nds- A few of these that don1t seem to %t easily into othercategories310,1- (umor #arkers
;8A *the prostate one+ and C)A *the colorectal one ( also marks for others+ are theonly two that come to mind ( I1m sure that there are lots others. &ot sent very oftenmostly as part of a screening workup when the underlying disease process isn1t clear.
10,2- Aatoglobin-
This one1s always been a mystery to me but it doesn1t turn out to be too hard ( it1san indicator of hemolysis. Turns out that haptoglobin is a protein made by the liverthat binds to the small fraction of hemoglobin that 'oats around unbound to any redcells ( normally a very small amount which would only make sense. This normallysmall amount increases when red cells start to hemoly
-
7/21/2019 1-Labs
45/49
Gh sure all our patients have
veins this good.
http3KKwww.medtrng.netKefmbKhandbook4Kvacutainer./pg
12,1,2- ecimens from arterial lines
What if you need to draw labs on your patient every hour? Eyponatremic sei
-
7/21/2019 1-Labs
46/49
Eere1s how the docs do it the respiratory therapists do it and nurses in some otherhospitals do it.
Which blood vessel are they sticking here?
http3KKwww.pcca.netKimagesKA#[;icture./pg
12,1,2,2- Gther labs
Gther labs are drawn with a vacutainer o the arterial stopcock /ust like A#1s are.
Hemember that you have to waste something like ,cc because there1s a couple ofinches of line tubing between the stopcock and the patient and you don1t want tosend that to the lab right?
12,1,4- secimens from central lines
This is a 5manifold7 ( theygo on the ends of theinfusion lines that weattach to central line ports.Gr sometimes /ust a single
stopcock=. anyhow youcan take a syringe andaspirate your specimenfrom the central linescrewing the syringe ontoone of the female luerconnectors.
http3KKwww.smtl.co.ukKDatacardsKIKimagesKmanifold":"tap.gif
We usually draw these specs from the 5distal port7 of the central line.
$mortant!It1s worth remembering however what1s going on along the length ofthat central line. Pou1ll remember of course from your careful reading of the 9AXarticle on central lines that they have ports emerging at various spots along theirlength= so let1s visuali
-
7/21/2019 1-Labs
47/49
The trick is3 stop your T;& or D46W infusion before you draw these specs. Don1t turnthe pump o ( what if you forget to restart it? Yust put it on 5hold7 then it1ll remindyou that it wants to be turned back on after you1re done.
Would you stop your pressor infusion the same way?
1, MFOs/ %M sats
We draw our #1s K central venous sat specs from the distal port of the C;catheter. Which one is that anyhow?
2, "hat is a .true mixed venous secimen&
I think we talked a bit about this somewhere up above ( there1s lots of argumentabout whether you can believe the central venous sat drawn from the distal portof an HA line or if it has to come from the distal port of a ;A line. I let the big guysworry about that and I /ust draw the spec from wherever they tell me to.
12,1,6- blood cultures
We usually send two sets two bottles each from twodierent peripheral sites. I usually draw these with abutter'y and a vacutainer swapping the bottles after @cceach.
http3KKwebcls.utmb.eduKsamplecoursesKbactKactKimagesK;C664./pg
A few points3
- Do you want to get your patient1s blood cultures )9GH) or A9T)H youstart their antibiotics?
- It1s > a good thing to send 5routine7 blood cultures ( say when yourpatient spikes a new temp to 46 from a line that1s already in him. Theidea is that you1re culturing the line and not the patient. Although ifthere1s nowhere else to draw from then you1ll probably have to=
- It I8 ok to send cultures from new lines ( they should be the %rst"everspec drawn from them however.
- Which bottle do you spike %rst?
47
http://webcls.utmb.edu/samplecourses/bact/Bact/images/PC001.jpghttp://webcls.utmb.edu/samplecourses/bact/Bact/images/PC001.jpg -
7/21/2019 1-Labs
48/49
- We1ve been told repeatedly that we send too many of these ( talk tothe team. If your patient spikes every day and has been 5pan"cultured7 within : hours you probably shouldn1t be repeating thespecs yet.
-
lood cultures need to be drawn with special attention to thespecimens. 0ike any other venipuncture site you have to swab in thecircular motion away from the site then ( and again there1s alwaysargument ( we prep the bottle tops with iodine after we pop the capso. 8ome places use alcohol. 8ome places like you to change needleson your blood syringe between bottles some don1t=
12,2- rines
12,2,1- @ secimens
It think they need @cc for a A spec ( we send them in clean tubes. Clean specs notsterile..
Pou can drop some urine from the urimeterdrain for these.
Eere.
http3KKwww.bardmedical.comKurologyKmetertour:Kbag.html
12,2,2- rine cultures
These are very sterile specs. There1s a littleport on the urine drain tubing for these. Pouswab the port with whatever prep they tell you
to ( alcohol betadine chlorhe2idene (whichever ( and then draw your spec. Guradapters are needle"less but back in the daywe needled specs out of these.
48
http://www.bardmedical.com/urology/metertour2/bag.htmlhttp://www.bardmedical.com/urology/metertour2/bag.html -
7/21/2019 1-Labs
49/49
The port is here ( hard to see in the picture.
12,2,4- 26,hour urine collections
&ot sterile.
ig bottle
8ometimes these guys are iced sometimes not.
http3KKwww.rush.eduKrmlKimagesK:hrurcon.Y;#
12,4- utum
Couldn1t %nd a picture of the one we use whichattaches to the inline suction device on the venttubing=
http3KKwww.nerbe"plus.deKukprodKgrp66,6.htm
12,6, tool secimens
Well gotta do it. 0ittle sterile cup= oh and check a guaiac while you1re at it.
12,6,1- stool for GUP
We don1t see a whole lot of ova and parasites but they1re absolutely out there.npleasant but a lot of the them are totally curable. Wear shoes when crossingstreams in Africa. Gr in &ew Yersey.
12,6,2- stool for %
