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Lab values beyond the numbers. Objectives. Recognition of abnormal Lab values Treatment of some of the more critical values. CBC, diff. CBC’S. White Blood cell = WBC Differential Segs / polys •Lymphocytes Eosinophils •Monocytes Basophils •Bands Hemoglobin Hematocrit Platelets.
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Objectives • Recognition of abnormal Lab values • Treatment of some of the more critical values
CBC’S • White Blood cell = WBC • Differential • Segs / polys •Lymphocytes • Eosinophils •Monocytes • Basophils •Bands • Hemoglobin • Hematocrit • Platelets
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
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
CBC: WBC • Monocytes • Elevated • mumps • malaria • lymphomas • Eosinophils • Elevated • Parasitic dz •T-Cell leukemia • allergies •lupus
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
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
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
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
CBC: Platelets • Increased Platelets • Reactive thrombocytosis • infection • splenectomy • surgery/stress • Inflammatory dz. • Thrombocythemia • myeloproliferative disorder • Chronic granulocytic leukemia
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
B12, Folate • Folate (ng/dl) 3.6 – 20 • B12 (pg/ml) 200-800
Stool/Exam (S/E) • ×3 (ova, parasite, …) • Occult Blood
Inflammatory Index • ESR • hs CRP
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
Chemistries: Cr • Creatinine • Normal: Child usually less than 1 • Increased: • Renal Dz • Muscle necrosis • hypovolemia
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
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)
Glucose, fasting (mg/dl) 60 - 110 • Glucose (2 hours postprandial) (mg/dl) Up to 140 • Hemoglobin A1c 6 - 8
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.
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
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
Uric Acid • Uric acid (male) 2.0 - 8.0 mg/dl (female) 2.0 - 7.5 mg/dl
Cu, Ceruloplasmin, zinc • Copper 70-155mcg/dl • Ceruloplasmin 23-43mg/dl • Zinc 0.85-1.25mcg/ml
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
Chemistries: Ca+ • Hypocalcemia • renal failure • hypoparathyroidism • magnesium deficiency • anticonvulsants • Rickets • Pancreatitis • Blood transfusions
25 hydroxy vitamin D >30nmol/l • T3, T4, TSH, Free thyroxin • Alb • PTH • Mg • P
Lipids • Cholesterol • HDL (good cholesterol) • Ratio • LDL (badcholesterol) • Triglycerides