Lab values beyond the numbers

2. Lab values beyond the numbers

3. Objectives • Recognition of abnormal Lab values • Treatment of some of the more critical values

4. CBC, diff

5. CBC’S • White Blood cell = WBC • Differential • Segs / polys •Lymphocytes • Eosinophils •Monocytes • Basophils •Bands • Hemoglobin • Hematocrit • Platelets

8. CBC: WBC

9. Increased Neutrophils physiologic newborn, pregnancy Pathologic acute infection inflammatory dz metabolic disorder tissue necrosis drugs stress Decreased neutrophils Infection bacterial typhiod septicemia Viral Hepatitis –mono flu –measles myeloid hypoplasia drugs CBC: WBC

10. Increased Lymphocytes Infection Viral: Hepatitis –mono CMV –HSV Bacterial Pertussis –mumps Chronic Inflammation Metabolic Hematologic ALL Decreased Lymphocytes Increased Corticosteroids immunodeficiency miliary Tb Lupus CBC: WBC

11. CBC: WBC • Monocytes • Elevated • mumps • malaria • lymphomas • Eosinophils • Elevated • Parasitic dz •T-Cell leukemia • allergies •lupus

12. CBC: Hemoglobin / Hematocrit • Hemoglobin • Normal • 1 week: 13-20 •1 month: 11-17 • 6months 10.5-14.5 •1 year: 11-15 • 10years: 11-16 •15years: 14-18M 12-16F • Hematocrit • Normal • 14-90d:35-49 •6m-1yr:30-40 • 4-10yr: 31-43 •Adult:42-52M 37-47F

13. Increased Hct Polycythemia Heart Dz Chronic Hypoxia High Altitude Hemoconcentration Surgery Burns Dehydration Decreased Hct Anemia Malabsorbtion Toxin/drugs Lead Infection Malaria CMV Cancer CBC: H/H

14. NL MCV, MCH • Retic count: • High: • Blood loss • Hemolysis • Low: • WBC & Plt: • Low: • Marrow failure • Leukemia, AA (drug, toxin,…) • High/NL: • Systemic disease • Infection, renal disease, Malignancy, chronic disease Anemia • High MCV, MCH • Hyperchromic, macrocytic • Folate, B12 • Early post-bleed period (high retic count) • Low MCV, MCH • Hypochromic, microcytic • Fe deficiency (90%) • Thalassemia • Lead poisoning • Anemia of chronic disease

15. CBC: Platelets • Platelets • Normal: 150-450 thousand • Decreased platelets • Decreased production • Marrow Depression: Aplastic Anemia, Radiation • Marrow infiltration: Leukemia • Congenital: Wiskott Aldrich, immune deficiencies • Increased destruction • autoimmune: ITP, Mono, SLE • Coagulopathies: DIC,… • Drugs

16. CBC: Platelets • Increased Platelets • Reactive thrombocytosis • infection • splenectomy • surgery/stress • Inflammatory dz. • Thrombocythemia • myeloproliferative disorder • Chronic granulocytic leukemia

17. Case-study

18. Ferritin, TIBC, Serum Iron, Transferrin • Total iron binding capacity (TIBC) 250 - 420  mcg/dl • Transferrin > 200 mg/dl • Iron  (mcg/dl) 65 – 150 • Ferritin  (ng/ml) 13 - 300

19. B12, Folate • Folate  (ng/dl) 3.6 – 20 • B12 (pg/ml) 200-800

20. Stool/Exam (S/E) • ×3 (ova, parasite, …) • Occult Blood

21. Inflammatory Index • ESR • hs CRP

22. Chemistries: BUN • Blood Urea Nitrogen • Normal: 5-20 mg/dl • Elevated • GI Bleed •High Protein Diet •Steroids • Shock •Dehydration •Diarrhea • Burns •Tissue Necrosis Renal Dz • Decreased • Anabolic Steroids •Malnutrition • Liver Dz •Pregnancy

23. Chemistries: Cr • Creatinine • Normal: Child usually less than 1 • Increased: • Renal Dz • Muscle necrosis • hypovolemia

24. Chemistries: Glucose • Glucose • Normal: 60-110mg/dl (infants >40) • Hyperglycemia • diabetes •Pancreatitis • Cushing's dz •Pheochromocytoma • drugs (ie: Steroids) • Hypoglycemia • Malaria •liver dz •Malignancy • enzyme deficiency •Malnutrition

25. Types of glucose tests • Random Blood sugar (not fasting) • Fasting Blood sugar (nothing to eat or drink except H2O for 12 hrs) • Glucose Tolerance Test (Starts fasting, then given sweet drink and measured over time) • Hemoglobin A1c (Measures glucose control over 3 month)

26. Glucose, fasting  (mg/dl) 60 - 110 • Glucose (2 hours postprandial)  (mg/dl) Up to 140 • Hemoglobin A1c 6 - 8

27. Diabetes • Casual plasma glucose concentration >200 mg/dl + symptoms of diabetes. Casual is defined as any time of day without regard to time since last meal. The classic symptoms of diabetes include polyuria, polydipsia and unexplained weight loss. • • FPG >126 mg/dl. Fasting is defined as no caloric intake for at least 8 h. • • 2-hour post-load glucose >200 mg/dl during an OGTT.

28. Chemistries: Glucose • Treatment of Hypoglycemia • Neonate or child: 0.5 to 1 gram / kg • if using D25 would be 2-4 cc / kg • dilute D50 1:1 with sterile water • if using D10 5-10 cc / kg • dilute D50 1:4 • Adult: ampule of D50

29. Chemistries: Glucose • Treatment of Hyperglycemia • Fluid bolus 10cc/kg NS • insulin 0.05u - 1 unit/kg • If diabetic in DKA be very judicious of fluid administration and no NHCO3 unless cardiac instability

30. Case-study

31. Uric Acid • Uric acid    (male) 2.0 - 8.0 mg/dl                (female) 2.0 - 7.5 mg/dl

32. Case - study

33. Cu, Ceruloplasmin, zinc • Copper 70-155mcg/dl • Ceruloplasmin 23-43mg/dl • Zinc 0.85-1.25mcg/ml

34. Chemistries: Ca+ • Calcium • Normal 8-11mg/dl • Panic Value:<7 or > 12 (tetni, Sz, arrhythmia) • Hypercalcemia (CHIMPS) • C= Cancer • H= Hyperthyroid • I= Iatrogens • M= Multiple Myeloma • P= Primary Hyperparathyroid • S= Sarcoid

35. Chemistries: Ca+ • Hypocalcemia • renal failure • hypoparathyroidism • magnesium deficiency • anticonvulsants • Rickets • Pancreatitis • Blood transfusions

37. Case-study

38. 25 hydroxy vitamin D >30nmol/l • T3, T4, TSH, Free thyroxin • Alb • PTH • Mg • P

44. Case-study

45. Lipids • Cholesterol • HDL (good cholesterol) • Ratio • LDL (badcholesterol) • Triglycerides

50. Case-study