Transcript Lab - Texas Children`s Hospital

LAB INTERPRETATION - THE ABCS OF CBCS
AND OTHER LABS (PART 1)
RUTH ABELT CPNP-AC/PC
APRIL 16, 2016
DISCLOSURES
• I HAVE NO FINANCIAL INTEREST TO REPORT
• I HAVE NO DISCLOSURES TO REPORT
OBJECTIVES
• THIS IS MEANT TO BE A 2 PART INTERACTIVE SESSION WHERE THE AUDIENCE WILL:
• 1. RECOGNIZE ABNORMALITIES IN COMPLETE BLOOD COUNT AND FORMULATE A DIFFERENTIAL
DIAGNOSIS BASED ON INTERPRETATION
• 2. RECOGNIZE AND VERBALIZE CAUSES AND TREATMENT STRATEGIES FOR ELECTROLYTE
ABNORMALITIES
• 3. RECOGNIZE ABNORMALITIES IN LIVER FUNCTION AND IDENTIFY POTENTIAL CAUSES
• 4. RECOGNIZE ABNORMALITIES IN INFECTIOUS DISEASE LABS AND FORMULATE A PLAN
• 5. ACTIVELY ENGAGE IN INTERPRETATION OF COMMON LABS THROUGH EXAMPLES OF CASE STUDIES
PART 1-A REVIEW OF THE BASICS
• CBC
• CHEM 7, 10
• LIVER AND PANCREAS FUNCTIONS
CBC-WHAT ARE WE LOOKING FOR?
NORMAL CBC VALUES
• RBC (AGE DEPENDENT)2.7-6.6 RANGE MILLION/MM3
• HCT 30-42%, HGB 12-16 GM/DL, MCH > 30PG/CELL, MCHC 28-33%, MCV AGE
DEPENDENT RANGE 70-121 FL, RDW 38.5-49
• PLATELETS 150-350, RBC DISTRIBUTION WIDTH AGE DEPENDENT <15-18, RETIC 0-3% 16MOS, >6MO 0.5-1.5%
• WBC 5-14K, SEG NEUTROPHIL 45-65%, BANDS 0-5%, EOS 15-40%, BASO 0-3%,
LYMPH 15-40%, MONO’S 2-8%
RED CELL INDICES
• MEAN CELL VOLUME-USEFUL IN EVALUATING ANEMIAS, POLYCYTHEMIAS
• INCREASED: MEGOBLASTIC ANEMIA, B12 DEF,
• DECREASED: IRON DEFICIENT ANEMIA, HEMOLYTIC ANEMIA, HEREDITARY SPHEROCYTOSIS,
MAJOR HEMOTOLOGIC DISOREDERS
• MEAN CELL HEMOGLOBIN CONCENTRATION:
• DECREASED IRON DEF, LEAD POISONING, THALASSEMIA
• RED CELL DISTRIBUTION WIDTH:
• INCREASED IRON DEF, FOLATE, B12 DEF, ALCOHOL ABUSE
WBC DIFF
• USEFUL IN INFECTION, INFLAMMATORY, MALIGNANCIES
• POLYS/SEGS: BACTERIAL, PARASITIC, ACUTE INFLAMMATORY DISORDERS,
METABOLIC (THYROID STORM), HEMATOLOGIC (LEUKEMIA’S), TISSUE
NECROSIS, DRUGS (HEPARIN, DIG)
• BANDS: INFLAMMATORY STATE, POST OP, NECROSIS
• DECREASED NEUTROPHILS: GRAM NEGATIVE SEPSIS, VIRAL HEPATITIS,
MEASLE, MONO, SPACE OCCUPYING BONE MARROW LESIONS, DRUGS,
LUPUS
WBC CONTINUED
• LYMPHOCYTES: INCREASED WITH VIRAL, CMV, HSV, MUMPS; BACTERIAL
PERTUSSIS, TYPHOID, SYPHILIS
• DECREASED LYMPHS: INCREASED/CHRONIC STEROIDS. ACUTE
INFECTIONS WITH INCREASED PLASMA CORTICOSTEROIDS.
• MONOCYTES: INFECTIONS, PARASITIC DISEASES (MALARIA)
• EOSINOPHIL: PARASITIC DISEASES, ALLERGIC DISEASES, FUNGAL
INFECTIONS
CLOSER LOOK AT CBC
• ANEMIA’S
• INFECTION
• ONCOLOGIC DISORDERS
• BLOOD DYSYNCHRONIES
ANEMIA: WORK UP AND CAUSES
• GATHER MORE INFORMATION AND IDENTIFY CAUSES:
• FERRITIN, IRON BINDING CAPACITY, RETICULOCYTE COUNT, LOW MEAN
CORPUSCULAR HGB CONCENTRATION (MCHC), MEAN CORPUSCULAR
VOLUME (MCV) MEAN CORPUSCULAR HGB (MCH), AND RED CELL
DISTRIBUTION WIDTH (RDW)
• REASONS FOR LOSSES OF BLOOD (GI, STOOL, ONCOLOGICAL ECT..)
ATTEMPTING TO DIFFERENTIATE MICROCYTIC ANEMIA
• RETICULOCYTE INDEX (RI) GREATER THAN 2 % =ADEQUATE BONE MARROW
INDEX
• RI LESS THAN 2% HYPOPROLIFERATION
• FERRITIN LEVEL
• GATHER MORE HISTORY: S/SX
• KOILONYCHIA-
QUESTION 1: WHAT DOES A FERRITIN LEVEL TELL US
IN GENERAL?
• FERRITIN REFLECTS TOTAL BODY IRON STORES AND IS FIRST TO FALL IN IRON DEFICIENCY
RI < 2% -Underproduction
Low MCV
Microcytic
Normal MCV
Normocytic
High MCV
Macrocytic
RI GREATER THAN 2% INCREASE DESTRUCTION OF
LOSS
Increase LDH
Increased Bili
Decreased
Haptoglobin
Hemolysis
Acute blood loss
Trauma
Signs of bleeding
MICROCYTIC ANEMIAS
• IRON DEFICIENCY
• LOW IRON
• LOW FERRITIN
• INCREASED TOTAL IRON BINDING CAPACITY
• DECREASED TRANSFERRIN SAT
MICROCYTIC ANEMIAS
• THALESSEMIA’S
• NORMAL IRON STUDIES
• NORMAL TO INCREASED RETIC COUNTS
• BASOPHILIC STIPPLING
LETS PRACTICE WHAT WE LEARNED
• 10 MO INFANT ADMITTED WITH 1 DAY HISTORY FEVER, COUGH AND
CONGESTION WITH INCREASED WOB
• WHAT WOULD YOU LIKE TO KNOW?
10 MO INFANT ADMITTED WITH 1 DAY HISTORY
FEVER, COUGH AND CONGESTION WITH INCREASED
WOB
VITALS HR 140, RR 55, BP 80/45, SPO2 90 ON ROOM AIR
LABS SENT: CHEM 10, URINE, WINTER VIRAL PANEL, AND CBC
NO PAST MEDICAL HISTORY, NO SURGERIES, TERM, DEVELOPMENTALLY APPROPRIATE.
PE: NORMAL EXCEPT PALLOR IS NOTED, BREATH SOUNDS WITH RHONCHI THROUGHOUT ALL
FIELDS, TACHYCARDIA, CAP REFILL 2 SECONDS, NO MURMUR, NSR
LETS START WITH POSSIBLE DIFFERENTIAL DIAGNOSIS? WHAT OTHER IMPORTANT QUESTIONS
MIGHT YOU ASK IN THE H&P
DIGGING DEEPER
• COUGH AND CONGESTION FOR 1 DAY. SIBLING AT HOME IS ILL WITH SIMILAR
SYMPTOMS
• LIVES WITH MOTHER, FATHER, SIBLINGS, 2 DOGS, 1 TURTLE. FATHER AND MOTHER
SMOKE
• NO KNOWN ALLERGIES
• EATS BABY FOOD (FRUITS) AND DRINKS 7-8 BOTTLES OF MILK PER DAY.
• NO HISTORY OF EMESIS, DIARRHEA, BLOODY STOOLS
• ALLERGIES UP TO DATE
LAB RESULTS
• WINTER VIRAL PANEL POSITIVE FOR RSV, URINE NORMAL
• CHEM : NA 138, K 4, CL 104, CO2 24, BUN 7, CR. 0.6, MAG 2, PHOS 4
• CBC: WBC 5K, HGB 7, HCT 21, PLATELETS 240K S: 60%, B 2%, L 25, MCV
68 , MCHC 20, RDW60, FERRITIN 12
• WHAT'S YOUR DIAGNOSIS?
IRON DEFICIENCY ANEMIA
• MOST COMMON CAUSE OF IRON DEFICIENCY WORLD WIDE
• INGESTING LARGE VOLUMES OF COW’S MILK, LOW IRON CONTAINING PRODUCTS (MEAT,
GREEN VEG). BREAST FED INFANTS HAVE LESS INCIDENCE
• CLASSIC FINDINGS: LOW SERUM FE, HIGH IRON BINDING CAPACITY, LOW SERUM FERRITIN,
HIGH RED CELL DISTRIBUTION WIDTH. MICROCYTIC, HYPOCHROMIC, LOW RETIC COUNT
AND ELEVATED RDW
• FERRITIN REFLECTS TOTAL BODY IRON STORES AND IS FIRST TO FALL IN IRON DEFICIENCY
OBJECTIVES
• 2. RECOGNIZE
AND VERBALIZE CAUSES AND TREATMENT STRATEGIES
FOR ELECTROLYTE ABNORMALITIES
NORMAL CHEMISTRY VALUES
• NA 135-146, K 3.5-5.3, CL 95-110, CO2 22-30, BUN 5-20,
• CR <1MO 0.2-0.4, CHILD 0.3-0.7, TEEN 0.5-1.
• GLUCOSE 60-110,
• CA 9-11MG/DL, MG 1.8-2.2, PHOS 3.5-6,
• URIC ACID 2-7,
• AMYLASE 30-110 UNIT/L, LIPASE 20-140 UNIT/L
• SERUM OSMOLALITY 275-296;
• URINE 50-1400MOSM/KG
NAME COMMON CAUSES OF ELECTROLYTE
DISTURBANCES
• VOMITING
• DIARRHEA
• OSTOMY OUTPUT
• DIABETES INSIPIDUS
• DIURETIC USE
HELPFUL FORMULA’S
• SERUM OSMOLALITY- (2 X NA) + (GLUCOSE/18) + (BUN/2.8)
• ANION GAP: NA(MEQ/L) – (CL + HCO3)
• NA ELEVATION CALCULATION: 0.6 X (WT IN KG) X (TARGET SODIUMMEASURED SODIUM)=TOTAL MEQ SODIUM TO RAISE TO TARGET LEVEL
• NEW FORMULA FOR DETERMINING FREE WATER DEFICIT= (WT IN KG X
0.6) X1- (DESIRED NA/ACTUAL SODIUM) (1000ML/L)
5YR 20KG WITH RESTRICTIVE CARDIOMYOPATHY, RECURRENT
PERICARDIAL EFFUSIONS, TRACH AND VENT DEPENDENT WITH
CHRONIC RESPIRATORY FAILURE. ADMITTED WITH DECREASED
URINE OUTPUT
• PMH: HOSPITALIZED MULTIPLE TIMES, TRACH AND VENT PLACE AT 6 MONTHS OF AGE,
CLD, HIE
• MEDS: ENALAPRIL, CHOLORTHIAZIDE 250MG BID, XOPENEX NEB QID, LASIX 12MG BID
• SURGICAL HX: TRACH, GB FUNDO
• DIET: PEDIASURE WITH FIBER 4 CANS VIA GB DAILY WITH 20ML WATER FLUSH
• LABS SENT IN EC: CBC, CHEM
RESULTS
• NA 128, K 3.2, CL 80, CO2 33, BUN114, CR 1.59, CA 10, MG 2.2, PHOS
8, GLUCOSE 107
• CBC NORMAL
BASED ON THESE RESULTS WHAT IS YOUR CALCULATED ANION GAP?
WHAT IS YOUR SERUM OSMOLALITY?
WHAT ARE YOUR DERANGEMENTS?
HELPFUL FORMULA’S
• SERUM OSMOLALITY- (2 X NA) + (GLUCOSE/18) + (BUN/2.8)
• OUR CASE :NA 128, K 5, CL 80, CO2 33, BUN114, CR 1.59, CA 10, MG 2.2, PHOS 8,
GLUCOSE 107
• SERUM OSMO= (256) + (5.9) + (40.7)= 303 { 285-295 NL}
• ANION GAP: NA(MEQ/L) – (CL + HCO3)
• ANION GAP: 128-113=15 {10-14 NL}
• NO GAP: CONSIDER BICARB LOSS (GI, KIDNEY); GAP MUDPILES
OUR CASE: NA 128, K 5, CL 80, CO2 33, BUN114, CR
1.59
• ALL ABOUT H&P- MEDICATIONS
• SERUM OSMO ELEVATED, ION GAP SLIGHTLY ELEVATED
• BUN/CR EXTREMELY ELEVATED-AKI
• DX: HYPONATREMIA WITH ACUTE KIDNEY INJURY SECONDARY TO
DIURETIC TOXICITY.
CASE 2: 2MONTH OLD INFANT 6KG PRESENTS WITH
IRRITABILITY, AND NEW ONSET SEIZURE
• NA 112, K 5.2, CL 90, BUN 7, CR. 0.5
• WHAT IS THE PROBLEM? EMERGENT?
• MORE HISTORY
HYPONATREMIA: CAUSE AND EFFECT
• CAUSES: SIGNIFICANT SODIUM LOSS DUE TO GASTRO, EXCESSIVE OSTOMY OUTPUT,
DIURETICS, RENAL DISORDERS, WATER INTOXICATION, SYNDROME OF INAPPROPRIATE
ANTIDIURETIC HORMONE (SIADH)
• S/SX: IRRITABILITY, LETHARGY, N/V, SEIZURES, COMA, AND DEATH
• WHEN DO WE ACT AND HOW DO WE PROCEED?
QUESTION: WHEN SHOULD URGENT TREATMENT OF
SODIUM REPLACEMENT OCCUR
• A. ON PATIENTS WHOSE SODIUM IS LESS THAN 135
• B. ON PATIENTS HAVING SEIZURES AS A RESULT OF HYPONATREMIA
• C. ON ALL PATIENTS EXHIBITING NEUROLOGICAL CHANGES INCLUDING LETHARGY
AND/OR SEIZURE ACTIVITY
• D. ALL OF THE ABOVE
• E. B AND C
QUESTION: WHEN SHOULD URGENT TREATMENT OF
SODIUM REPLACEMENT OCCUR
• A. ON PATIENTS WHOSE SODIUM IS LESS THAN 135
• B. ON PATIENTS HAVING SEIZURES AS A RESULT OF HYPONATREMIA
• C. ON ALL PATIENTS EXHIBITING NEUROLOGICAL CHANGES INCLUDING LETHARGY
AND/OR SEIZURE ACTIVITY
• D. ALL OF THE ABOVE
• E. B AND C
TREATMENT OF HYPONATREMIA
• SERUM SODIUM LESS THAN 120MEQ/L
• GOAL IS TO CORRECT SODIUM TO 120-125 OR UNTIL SEIZURE STOP. INITIAL
CORRECTION IS RAPID (UNTIL SZ STOP)
• OVERALL CORRECTION IS GRADUAL, GOAL 0.5-1MEQ/L PER HOUR
• QUESTION-WHY IS IT IMPORTANT TO RAISE NA LEVELS SLOWLY??
• STUDIES IN ADULTS SHOW CENTRAL PONTINE OSMOTIC DEMYELINATION
QUESTION: WHICH IS THE APPROPRIATE IV SOLUTION
TO USE TO CORRECT FOR HYPONATREMIA?
• 1) RAPID INFUSIONS WITH 0.9% NS UNTIL NA >120
• 2) RAPID INFUSIONS WITH 0.45%NS UNTIL NA >120
• 3) RAPID INFUSIONS WITH 3% SALINE UNTIL >120
HYPERTONIC SALINE:
• ROUGH ESTIMATE 1.2ML/KG OF 3% SODIUM CHLORIDE WILL RAISE SODIUM LEVEL BY
~1-QUICK VERSION 1.2ML (KG) X (TARGET NA-SERM NA)
• CALCULATION: 0.6 X (WT IN KG) X (TARGET SODIUM-MEASURED SODIUM)=TOTAL MEQ
SODIUM TO RAISE TO TARGET LEVEL
• OUR RESULTS NA 112, K 5.2, CL 90, BUN 7, CR. 0.5
0.6(6KG) X (120-112)=3.6 X 8= 28.8 MEQ OF NA= 57.6 OF 3%NACL
• OR (1.2ML X 6KG)X (8)=58 ML OF 3%NACL SOLUTION
CORRECTION OF HYPONATREMIA
RAPID CORRECTION
CONTINUED CORRECTION OVER
24HRS
• 0.6 X (6KG) X (120-112)=28.8MEQ NA
• RAISE SODIUM TO 132 (12MEQ/DAY)
• EASIER FORMULA: 1.2ML X 6KG X 8=
57.6ML 3% NACL
• 0.6X(6KG)X(132-120)=43.2 MEQ/L
ADDITIONAL SODIUM NEEDED OVER 24
HOURS.
• FLUID D5 0.45NS IN ADDITION TO
NORMAL MAINTENANCE FLUIDS
OTHER CAUSES HYPONATREMIA
• SIADH-LOW URINE OUTPUT, HYPONATREMIA, ELEVATED URINE SODIUM AND HIGH SPEC
GRAV. TREAT BY FLUID RESTRICTION
• COMMON CAUSES-CNS, PULMONARY (PNEUMONIA, EFFUSIONS), MEDICATIONS
(SSRI’S, SZ MEDICATIONS) AND ONCOLOGIC TUMORS
• WATER INTOXICATION: IMPROPER MIXING OF FORMULA, EXCESSIVE DILUTION TO
EXTEND FORMULA.
• OTHER DISEASE: CONGESTIVE HEART FAILURE, RENAL FAILURE FLUID OVERLOAD-TREAT
CAUSE.
10MO FEMALE 8KG: TRACH AND VENT DEPENDENT WITH HISTORY
OF CRANIOPHARYNGIOMA RESECTION, HIE, GLOBALLY
DEVELOPMENTALLY DELAYED AND GB DEPENDENCE ADMITTED WITH
DIARRHEA AND EMESIS
• MEDICATIONS: TEGRETOL, KEPPRA, MVI, PHENOBARBITAL, DESMOPRESSIN, SYNTHROID, XOPENEX,
DIASTAT PRN
• 3 DAY H/O VOMITING WITH FEEDS, DIARRHEA (NBNB), DECREASED RESPONSIVENESS, INCREASED
IRRITABILITY, INCREASED URINE OUTPUT, CAP REFILL 5 SECS, COOL MOTTLED, HR 185
• WHAT ARE YOUR FIRST ACTIONS TO BE TAKEN?
• CBC-HGB 14, HCT 40, WBC 6K, PLATELETS 220K
• AMYLASE 90, LIPASE 550
• NA 170, CL 120, K 5, GLUCOSE 88, CO2 18, BUN 8, CR.0.7
WHATS YOUR DIAGNOSIS?
• HYPERNATREMIA
• HYPOVOLEMIC SHOCK-SECONDARY TO VOMITING, DIARRHEA, INCREASED URINE OUTPUT
(CAUSE?)
• PANCREATITIS
• ALTERED LEVEL OF CONSCIOUSNESS
WHY IS IT IMPORTANT TO CORRECT HYPERNATREMIA
SLOWLY
A. AS SERUM SODIUM INCREASES SERUM OSMOLARITY INCREASES
B.
AS SERUM SODIUM INCREASES SERUM OSMOLARITY DECREASES
C. AS SERUM SODIUM INCREASES THERE IS AN INCREASE OF FLUID SHIFTS FROM
INTRACELLULAR TO EXTRACELLULAR SPACES
D. AS SERUM SODIUM INCREASES THERE IS AN INCREASE OF FLUID SHIFTS FROM
EXTRACELLULAR TO INTRACELLULAR SPACES
E.
B AND C
F.
A AND C
WHY IS IT IMPORTANT TO CORRECT HYPERNATREMIA
SLOWLY
A. AS SERUM SODIUM INCREASES SERUM OSMOLARITY INCREASES
B.
AS SERUM SODIUM INCREASES SERUM OSMOLARITY DECREASES
C. AS SERUM SODIUM INCREASES THERE IS AN INCREASE OF FLUID SHIFTS FROM
INTRACELLULAR TO EXTRACELLULAR SPACES
D. AS SERUM SODIUM INCREASES THERE IS AN INCREASE OF FLUID SHIFTS FROM
EXTRACELLULAR TO INTRACELLULAR SPACES
E.
B AND C
F.
A AND C
CBC-HGB 14, HCT 40, WBC 6K, PLATELETS 220K
AMYLASE 90, LIPASE 550
NA 170, CL 120, K 5, GLUCOSE 88, CO2 18, BUN 8, CR.0.7
• PRACTICE WHAT WE’VE LEARNED
• SERUM OSMO 2NA + GLUCOSE/18+ BUN/2.8
• 340 + 4.8+ 2.8=347.6 (ROUND TO 348) NORMAL 285-295
• FORMULA FOR DETERMINING FREE WATER DEFICIT= (WT IN KG X 0.6) X1- (DESIRED
NA/ACTUAL SODIUM) (1000ML/L)
• QUICK METHOD 4ML/KG FREE WATER WILL DROP SODIUM BY ~1MEQ/L
NA 170, CL 120, K 5, GLUCOSE 88, CO2 18, BUN 8,
CR.0.7
• CALCULATE OUR FREE WATER DEFICIT: PATIENT WT 8KG GOAL TO LOWER NA BY NO
MORE THAN 12 MEQ/L/DAY
• (8 X 0.6) X 1- (158/170) (1000ML/L)= (4.8 X 0.071)(1000)=340.8 ROUND UP 341ML
TO BE SLOWLY TO BRING DOWN SODIUM 0.5-1MEQ/HR.
• QUICK METHOD: 4ML X 8KG X 12MEQ/L=384ML
OBJECTIVES
• THIS IS MEANT TO BE A 2 PART INTERACTIVE SESSION WHERE THE AUDIENCE WILL:
• 1. RECOGNIZE ABNORMALITIES IN COMPLETE BLOOD COUNT AND FORMULATE A DIFFERENTIAL
DIAGNOSIS BASED ON INTERPRETATION
• 2. RECOGNIZE AND VERBALIZE CAUSES AND TREATMENT STRATEGIES FOR ELECTROLYTE
ABNORMALITIES
• 3. RECOGNIZE ABNORMALITIES IN LIVER FUNCTION AND IDENTIFY POTENTIAL CAUSES
• 4. RECOGNIZE ABNORMALITIES IN INFECTIOUS DISEASE LABS AND FORMULATE A PLAN
• 5. ACTIVELY ENGAGE IN INTERPRETATION OF COMMON LABS THROUGH EXAMPLES OF CASE STUDIES
LIVER FUNCTION
• 1. FILTRATION AND STORAGE OF BLOOD
• 2. METABOLISM OF CARBS, PROTEINS, FATS, HORMONES, AND CHEMICALS/MEDICATIONS
• 3. FORMATION OF BILE
• 4. STORAGE OF VITAMINS AND IRON
• 5. FORMATION OF COAGULATION FACTORS
METABOLISM AND LIVER
• CARBS: STORAGE OF GLYCOGEN, CONVERSION OF GALACTOSE AND FRUCTOSE TO
GLUCOSE, GLUCONEOGENESIS
• FAT: OXIDATION OF FATTY ACIDS TO SUPPLY ENERGY, SYNTHESIS OF MOST LIPOPROTEINS,
CHOLESTEROL AND PHOSPHOLIPIDS
• SYNTHESIS OF FAT FROM PROTEINS AND CARBS
• PROTEIN: DEAMINATION OF AA, FORMATION OF UREA FOR REMOVAL OF AMMONIA,
FORMATION OF PLASMA PROTEINS
COAGULATION AND LIVER
• FIBRINOGEN
• PROTHROMBIN
• FACTOR 7
• VIT K IS REQUIRED BY THE METABOLIC PROCESS OF THE LIVER FOR THE FORMATION OF
PROTHROMBIN, FACTOR 7, 9 AND 10.
DETOXIFICATION
• SULFONAMIDES
• PENICILLIN'S, AMPICILLIN AND ERYTHROMYCIN
• ESTROGEN, CORTISOL AND ALDOSTERONE CHEMICALLY ALTERED AND EXCRETED BY LIVER,
DAMAGE CAN LEAD TO ACCUMULATION OF THESE HORMONES.
• MAJOR ROUTE FOR EXCRETING CALCIUM BY LIVER INTO BILE THEN FECES
LABS
• LIVER FUNCTION TEST
• AMMONIA
• COAGS
• ALBUMIN
• BILIRUBIN-HEME METABOLISM (INDIRECT) CARRIED BY ALBUMIN TO LIVER WHERE IT
IS CONJUGATED {DIRECT}(TO MAKE SOLUBLE), EXCRETED IN BILE
• MOST SENSITIVE TO DETECT PARENCHYMAL DISEASE
HEPATIC INJURY VS CHOLESTASIS
• HEPATOCYTE INJURY EXPECT ELEVATED AST/SGOT (ASPARATE AMINOTRANSFERASE)
• FOUND ALSO IN HEART, PANCREAS, SKELETAL MUSCLE (NOT LIVER SPECIFIC)
• ELEVATION IN ALANINE AMINOTRANSFERASE (ALT/SGPT) MORE SPECIFIC FOR
HEPATOCYTE INJURY
• ELEVATION IN BILIRUBIN SECONDARY TO DECREASED HEPATIC EXCRETION IN
CHOLESTASIS
• ALK PHOS GREATEST ELEVATION IN EXTRAHEPATIC OBSTRUCTION
TESTS FOR HEPATIC FUNCTION
• ALBUMIN-PROTEIN SYNTHESIS SLOWLY DECREASES IN LIVER FAILURE
• PT INCREASE WITH LIVER DYSFUNCTION-DUE TO SYNTHESIS OF COAG
FACTORS BY LIVER
• HEPATOCELLULAR INJURY-MARKEDLY INCREASED ALT& AST
NORMAL LIVER VALUES
• ALBUMIN 3.5-5, PREALBUMIN 7MO-3Y 2-36MG/DL, >3YR 12-40 MG/DL
• ALKALINE PHOSPHATASE 40-400 IU/L
• AMMONIA NEWBORN 21-95, 1M-12MO 18-74, 1-14Y 17-68
• CONJUGATED BILIRUBIN-0-0.4, TOTAL BILIRUBIN 0.1-1 (IF DIRECT BILI IS ELEVATED THINK
HEPATOBILIARY)
• GGT 8-78IU/L, LDH 110-145 UNIT/L
• ALT 7-56 IU/L, AST 5-35 IU/L
COAGULATION STUDIES
• FIBRINOGEN –RANGE 200-400MG/DL
• PT-RANGE 10 TO 13 SECONDS
• PTT -25-32
• D-DIMER , 0.4 UG/ML
• INR-0.8-1.2
12MO 10KG WITH H/O BILIARY ATRESIA S/P FAILED KASSAI, WITH
WORSENING JAUNDICE, LETHARGY, PRURITUS ADMITTED WITH ALTERED
LEVEL OF CONSCIOUSNESS
VITALS T 98.8, RR 38, HR 160, BP 85/50, SPO2 98% ON 1L
CT HEAD-NO BLEEDS, NO MIDLINE SHIFT, SLIGHT CEREBRAL EDEMA PRESENT
WHAT LABS WOULD YOU LIKE?
12MO 10KG WITH H/O BILIARY ATRESIA S/P FAILED KASSAI, WITH WORSENING
JAUNDICE, LETHARGY, PRURITUS ADMITTED WITH ALTERED LEVEL OF
CONSCIOUSNESS
• LIVER PANEL: AST 796, ALT 436, ALK PHOS 436, GGT 82, CON BILI 17.8, AMMONIA
156, UNCON BILI 2.2, ALBUMIN 2.7
• HGB 7.2, HCT 21, PLATELET 18K
• COAGS: FIBRINOGEN 68, INR 3, PT 25.8 (12-15 SEC) PTT 56.5 (20-36 SEC)
• WHATS OFF?
• WHAT PRODUCTS WOULD YOU GIVE?
PART 2
• COMPLETE REVIEW OF THE BASICS WITH INFECTIOUS DISEASE
• ACID BASE BALANCE: BLOOD GAS INTERPRETATION
• ACTIVELY ENGAGE IN CASE STUDIES FROM PRESENTATION TO
DIAGNOSIS, INCLUDING INTERPRETATION OF LABS
OBJECTIVES
• THIS IS MEANT TO BE A 2 PART INTERACTIVE SESSION WHERE THE AUDIENCE WILL:
• 1. RECOGNIZE ABNORMALITIES IN COMPLETE BLOOD COUNT AND FORMULATE A DIFFERENTIAL
DIAGNOSIS BASED ON INTERPRETATION
• 2. RECOGNIZE AND VERBALIZE CAUSES AND TREATMENT STRATEGIES FOR ELECTROLYTE
ABNORMALITIES
• 3. RECOGNIZE ABNORMALITIES IN LIVER FUNCTION AND IDENTIFY POTENTIAL CAUSES
• 4. RECOGNIZE ABNORMALITIES IN INFECTIOUS DISEASE LABS AND FORMULATE A PLAN
• 5. ACTIVELY ENGAGE IN INTERPRETATION OF COMMON LABS THROUGH EXAMPLES OF CASE STUDIES
COMMON INFECTIOUS DISEASES IN INFANTS AND
CHILDREN
• RSV, HUMAN METAPNEUMOVIRUS, RHINOVIRUS
• OTITIS MEDIA
• SEPSIS
• GASTROENTERITIS
• UTI
BASED ON COMMON DISEASES WHAT DIAGNOSTICS
WOULD YOU LIKE?
• VIRAL PANEL
• CHEMISTRY , CBC
• STOOL STUDIES
• LP
• URINE
• BLOOD CULTURES
TRICK QUESTION
• NEED MORE HISTORY
• JUST BECAUSE WE HAVE TEST AVAILABLE DOES NOT MEAN WE
NEED TO ORDER IT.
• WILL IT CHANGE OUR MANAGEMENT
2 MONTH OLD FEMALE FEVER 102, HR 188, RR 42,
IRRITABLE, DECREASED UOP
• MORE IRRITABLE FOR LAST 2 DAYS, CONSOLES BUT CRIES MORE OFTEN THAN
USUAL. NO S/SX OF COUGH OR CONGESTION
• FEWER DIAPERS, NOT INTERESTED IN BOTTLE AS MUCH BUT WILL EVENTUALLY
TAKE IT.
• NO DIARRHEA, NO VOMITING, GASSY (BUT SO IS HER FATHER)
• NOBODY AT HOME SICK, ATTENDS DAY CARE
LAB RESULTS
• UA: CLOUDY SPEC GRAV 1.020, PH 6.0, PRO NEG., GLUC. NEG, HGB NEG.,
NITRITE POS., LEUKOCYTE POSITIVE
• URINE CULTURE > 100,000CFU E.COLI
• LEUKOCYTOSIS, BANDEMIA
• WHAT NOW??
CHOICE OF ANTIBIOTICS
• APPROXIMATELY 50 PERCENT OF E. COLI ARE RESISTANT TO AMOXICILLIN OR AMPICILLIN.
• INCREASING RATES OF E. COLI RESISTANCE TO FIRST-GENERATION CEPHALOSPORINS (EG,
CEPHALEXIN), AMOXICILLIN-CLAVULANATE OR AMPICILLIN-SULBACTAM, AND TRIMETHOPRIMSULFAMETHOXAZOLE
• THIRD-GENERATION CEPHALOSPORINS (EG, CEFPODOXIME, CEFDINIR,, CEFOTAXIME,
CEFTRIAXONE) AND AMINOGLYCOSIDES (EG, GENTAMICIN, AMIKACIN) ARE APPROPRIATE
FIRST-LINE AGENTS FOR EMPIRIC TREATMENT OF UTI IN CHILDREN
AMERICAN ACADEMY OF PEDIATRICS
• THE AMERICAN ACADEMY OF PEDIATRICS (AAP) RECOMMENDS RBUS FOR ALL
INFANTS AND CHILDREN 2 TO 24 MONTHS FOLLOWING THEIR FIRST FEBRILE
UTI
• THE 2011 AAP CLINICAL PRACTICE GUIDELINE RECOMMENDS POSTPONING
VCUG UNTIL THE SECOND FEBRILE UTI IN CHILDREN 2 TO 24 MONTHS OF AGE
UNLESS THERE ARE ATYPICAL OR COMPLEX CLINICAL CIRCUMSTANCES OR RUS
ABNORMAL
20MONTH OLD COUGH, CONGESTION, FEVER 103,
DECREASED APPETITE, IRRITABILITY DIFFICULTY
WAKING UP THIS MORNING
• GENERAL: LETHARGIC, PALE, MONITORS: T:103.2, HR190, RR 16, SAT 82, BP
69/42, CAP REFILL 6 SECS, COLD MOTTLED EXTREMITIES, DIMINISHED
PERIPHERAL PULSES
• WHAT ARE YOUR FIRST ACTIONS?
RESUSCITATE
• SIGNS OF SHOCK
• COMPENSATED OR DECOMPENSATED
• LABS
• ADDITIONAL HISTORY
MORE HISTORY
• PREVIOUSLY HEALTHY UNTIL ABOUT A WEEK AGO BEGAN WITH COUGH AND
CONGESTION, OVER LAST FEW DAYS IRRITABLE, DECREASED ORAL INTAKE,
VOMITING TODAY
• PARENTS DO NOT BELIEVE IN IMMUNIZATIONS
• NO MEDICATIONS
• ATTENDS DAY CARE
LUMBAR PUNCTURE
• CSF: GRAM STAIN-GRAM + DIPLOCOCCI
• GLUCOSE-<20 ( SERUM GLUCOSE 85)
• PROTEIN - >500
• WBC >2000/MM3 90%PMN
• OPENING PRESSURE 27MM
MORE PIECES TO THE PUZZLE
• CRP-USEFUL FOR SCREENING FOR INFLAMMATORY AND INFECTIOUS
DISORDERS. ACUTE PHASE REACTOR. USEFUL IN FIRST 24 HOURS OF DISEASE IN
COMBO WITH ESR. (ESR PEAKS LATER)
• PROCALCITONIN-HELPFUL IN DETECTING SEVERE BACTERIAL, FUNGAL,
PARASITIC AND SEPTIC INFECTIONS. EARLY MARKER FOR INFECTIOUS
ETIOLOGY. PEAKS AND IS DETECTED SOONER THAN CRP
IT’S ALL ABOUT THE BASE: OR IS IT?
• ABG: 7.08, 80, 26
• CBC: WBC: 30K, HGB 7, HCT 22, PLT 22, S 30, B 35
• LACTATE 6, CRP 10MG/DL, PROCALCITONIN 145NG/ML
• INR 2.3, FIBRINOGEN 150, D-DIMER >2, PT 23, PTT 42
• CHEM NA: 138, K 3.5, CL 105, CO2 25, BUN 10, CR 0.45
PUTTING IT ALL TOGETHER
• FINAL GRAM STAIN RESULTS: STREP PNEUMO MENINGITIS
• BLOOD CULTURE POSITIVE FOR STREP PNEUMO
• URINE NEGATIVE
• COAGULOPATHIC, DIC
• RESPIRATORY ACIDOSIS –RESPIRATORY FAILURE WITH HYPOXIA AND HYPERCARBIA
DIAGNOSIS
• SEPTIC SHOCK SECONDARY TO STREPTOCOCCUS PNEUMONIAE BACTEREMIA
• MENINGITIS SECONDARY TO STREPTOCOCCUS PNEUMONIAE
• RESPIRATORY FAILURE WITH HYPERCARBIA AND HYPOXEMIA REQUIRING INTUBATION
• DIC
SHORT TERM GOALS
• PCP OFFICE
• EC
• PICU
SHORT/LONG TERM GOALS
• GENERAL WARD
• REHAB-PATIENTS
• HOME
• SCHOOL
GOT GAS? I CAN HELP
• GOLD STANDARD-WHEN YOU REALLY WANT TO KNOW
• ABG: PH 7.35-7.45, CO2 35-45, PO2 70-100, HCO3 19-25 SPO2 90-95
• THE MOST ACCURATE WAY TO MEASURE OXYGENATION AND VENTILATION (PACO2) AS WELL
AS ACID BASE STATUS
• CBG: PH 7.35-7.45 CBG OK FOR PH IN REGARDS TO CORRELATION WITH ABG, ONLY
MODERATELY COMPARABLE TO CO2 WORST FOR PO2
• VBG: VENOUS GAS CO2 AVERAGES 6-8 POINTS HIGHER THAN ARTERIAL. STRONGLY
AFFECTED BY LOCAL CIRCULATION AND METABOLIC STATUS
CATEGORIES
• RESPIRATORY ACIDOSIS-LOW PH, HIGH CO2, NORMAL TO HIGH BICARB
• RESPIRATORY ALKALOSIS-HIGH PH, LOW CO2, NORMAL TO LOW BICARB
• METABOLIC ACIDOSIS-LOW PH, LOW CO2 , LOW HCO3
• METABOLIC ALKALOSIS- HIGH PH, HIGH CO2, HIGH HCO3
• HELPFUL HINTS FOR EVERY 10 POINT RISE/FALL IN CO2 EXPECT PH TO CHANGE BY
0.08; FOR EVERY 10 POINT RISE/FALL IN HCO3 EXPECT PH TO CHANGE BY 0.15
8WK TERM INFANT WITH INCREASED WORK OF BREATHING,
RETRACTIONS, CONGESTION NOTED TO BE RSV + IN PCP OFFICE
• HR 198, RR 86, SPO2 ON ROOM AIR 84%, BP 58/28 CAP REFILL 5
SECONDS, COLD HEAD BOBBING, INTERCOSTAL AND SUBCOSTAL
RETRACTIONS
• WHAT ARE YOUR FIRST STEPS?
• LABS?
8WK TERM INFANT WITH INCREASED WORK OF BREATHING,
RETRACTIONS, CONGESTION NOTED TO BE RSV + IN PCP
OFFICE
• GIVE BOLUS NS 20MG/KG, PLACE ON OXYGEN PREPARE FOR IMPENDING
RESPIRATORY FAILURE AND INTUBATION.
• ABG: PH 7.16/CO2 70, PAO2 85, HCO3 22
• INTERPRETATION OF GAS?
• 1)LOOK AT PH ACID OR ALKALOTIC?
• 2) CO2 HIGH OR LOW?
• 3) HCO3 HIGH, LOW OR NORMAL?
ABG: PH 7.16/CO2 70, PAO2 85, HCO3 22
• RESPIRATORY ACIDOSIS-IMPENDING RESPIRATORY FAILURE REQUIRES IMMEDIATE
INTERVENTION.
• ACTIVATE EMS (IF YOU HAVEN’T ALREADY)
• SUCTION
• APPLY OXYGEN
OBJECTIVES
• THIS IS MEANT TO BE A 2 PART INTERACTIVE SESSION WHERE THE AUDIENCE WILL:
• 1. RECOGNIZE ABNORMALITIES IN COMPLETE BLOOD COUNT AND FORMULATE A DIFFERENTIAL
DIAGNOSIS BASED ON INTERPRETATION
• 2. RECOGNIZE AND VERBALIZE CAUSES AND TREATMENT STRATEGIES FOR ELECTROLYTE
ABNORMALITIES
• 3. RECOGNIZE ABNORMALITIES IN LIVER FUNCTION AND IDENTIFY POTENTIAL CAUSES
• 4. RECOGNIZE ABNORMALITIES IN INFECTIOUS DISEASE LABS AND FORMULATE A PLAN
• 5. ACTIVELY ENGAGE IN INTERPRETATION OF COMMON LABS THROUGH EXAMPLES OF CASE STUDIES
5YR MALE 22KG 2 DAY HISTORY OF SORE THROAT, COUGH
AND CONGESTION. WENT TO SCHOOL AND WAS HAVING
DIFFICULTY BREATHING
• MOTHER GAVE BREATHING TREATMENT NEB AT HOME WITH NO IMPROVEMENT
• RECEIVED 2 MORE WITH NO IMPROVEMENT MOTHER CALLED TO COME HOME FROM WORK
• BROUGHT TO EC
• TRIAGE: PALE, INCREASED WORK OF BREATHING UNABLE TO COMPLETE FULL SENTENCES,
DIAPHORETIC, RETRACTIONS, SATURATIONS 83%, HR 118, RR 44
YOU ARE THE APP IN CHARGE OF THIS PATIENT
• WHAT IS YOUR APPROACH?
• PHONE A FRIEND?
LABS
• ABG: 7.14, CO2 90, PAO2 148, HCO3 30
• INTERPRETATION? RESPIRATORY ACIDOSIS
• CHEM NORMAL
• UA NEGATIVE
• RESPIRATORY PANEL NEGATIVE
• DIAGNOSIS?
TREATMENT PLAN
• ADMISSION TO ???
• TREATMENT PLAN
• EDUCATION
• FOLLOW UP
5 YR OLD WITH 1 MONTH H/O 6 POUND WEIGHT LOSS,
ABDOMINAL PAIN, NOW WITH VOMITING AND FATIGUE
• PMH: TERM, PREVIOUSLY HEALTHY, NO MEDICAL CONDITIONS, NO SURGERIES
• IN SCHOOL AND GETTING ALONG WELL WITH OTHERS
• NOTED TO BE THIRSTY ALL THE TIME, EATS A LOT BUT NOT GAINING WEIGHT.
• PE: QUIET CHILD, TACKY MM, DRY LIPS, LUNGS CTA TACHYPNEA PRESENT TACHYCARDIC
FOR AGE, ABD: EPIGASTRIC PAIN ON PALPATION, C/O N/V.
• CBC, CHEM 10, VBG
RED FLAGS
• NA 148, K 3.0, CL 110, CO2 6, BUN 7, CR 0.7 GLUCOSE 700
• CBC WITHIN NORMAL LIMITS
• VBG: 7.19, 22, 6, -18
• ABNORMALITIES IN CHEMISTRY? GAP OR NO GAP?
• INTERPRET BLOOD GAS (EVEN THOUGH ITS VENOUS)
• POSSIBLE THOUGHTS BASED ON WHAT YOU KNOW?
12YR WITH ALL ON ROUTINE VISIT FOR LAB WORK
AND FOLLOW UP
• ALLI WAS TALKATIVE AND INTERACTIVE AT START OF VISIT.
• HER PORT WAS ACCESSED, FLUSHED AND LABS DRAWN
• ALLI REPORTED FEELING “CHILLS, SKIN WAS FLUSHED AND SHE WAS SHIVERING WHEN YOU
RETURNED TO THE ROOM”
• VITALS : TEMP 102.2, HR 115, RR 36, SAT 96, BP 80/40
• WHAT’S GOING ON?
EXPLAIN
• MOST LIKELY DIAGNOSIS
• THINGS TO CONSIDER? CHEMO? IMMUNOSUPPRESSION
• LABS?
• ANTIBIOTICS
• TUBES? YES OR NO
2 MONTH OLD WITH 3 DAY HISTORY OF COUGH
AND CONGESTION
• PARENTS SICK WITH COUGH, CONGESTION. GRANDMOTHER HAS HAD COUGH FOR ABOUT A
MONTH WON’T SEEM TO GO AWAY
• TERM, NO COMPLICATIONS
• COUGHING SPELLS CAN’T CATCH HIS BREATH, TURNS BLUE SOMETIMES
• TAKES BOTTLES 3 OUNCES EVERY 3 HOURS, 10 DIAPERS A DAY
DIFFERENTIAL DIAGNOSIS
• LABS
• TREATMENT
PERTUSSIS
• AZITHROMYCIN-INFANTS LESS THAN 6 MONTHS 10MG/KG/DOSE DAILY FOR 5 DAYS
• WILL NEED TO TREAT CLOSE CONTACTS
• EDUCATE ON BOOSTERS FOR ADULTS AND TEENS-TETANUS DIPHTHERIA ACELLULAR PERTUSSIS
(TDAP)
GRAND TETONS
QUESTIONS??
REFERENCES
• BEHRMAN, R., & KLEIGMAN (2002). NELSON ESSENTIALS OF PEDIATRICS. (4TH ED.) IN CHAPTER 11 THE
GASTROINTESTINAL TRACT (PP 500-513). PHILADELPHIA: PA: SAUNDERS
• ENGRON, B., FLERLAGE, J (2015). THE JOHNS HOPKINS HOSPITAL: THE HARRIET LAND HANDBOOK (29TH ED.).
PHILADELPHIA, PA: SAUNDERS
• REUTER-RICE, K., & BOLICK, B. (2012) PEDIATRIC ACUTE CARE: A GUIDE FOR INTERPROFESSIONAL PRACTICE. IN
CHAPTER 26: GASTROINTESTINAL DISORDERS (PP491-540). BURLINGTON, MA: JONES & BARTLETT LEARNING
• THE SOCIETY OF CRITICAL CARE MEDICINE. (2008). PEDIATRIC FUNDAMENTAL CRITICAL CARE SUPPORT.
CHAPTER 9: FLUID AND ELECTROLYTES(PP1-23). MOUNT PROSPECT, IL: SOCIETY OF CRITICAL CARE MEDICINE
REFERENCES
Subcommittee on Urinary tract infection, steering committee on
Quality improvement and management, Roberts KB. Urinary tract
infection: clinical practice guideline for the diagnosis and
management of the initial UTI in febrile infants and children 2 to
24 months.
Pediatrics. 2011;128(3):595.