Borders General Hospital · Borders General Hospital. Clinical Chemistry Department . Users...

Borders General Hospital

Clinical Chemistry Department

Users Handbook

This document will be reviewed and updated regularly. The most up to date revision of the handbook will always be available on NHS Borders Intranet. Users will be alerted by global e-mail and by the Intranet “News” page when a new version is published. All hard copies of this document should be considered uncontrolled. If you print any part of this document it is your responsibility to ensure that out of date copies are withdrawn and destroyed.

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Clinical Chemistry User Handbook - Version: 2.0. Index: Chemistry 6055. Printed: 12-Nov-2013 14:53

Authorised on: 20-Jun-2013. Authorised by: Colin Bruce. Policy Unique Reference: 87-35948132. Due for review on: 30-Jun-2014

Author(s): C Alastair Graham, John O'Donnell, C Jackie Scott

Document Modifications Version Date Description of Change Modified By 1.10 20/6/13 Section 5 –

Calprotectin, guidance added on minimum volume required Phenobarb, now analysed in Lothian, turnaround time amended Coeliac Screen, sample type amended from Brown/Orange to Brown Sirolimus, now analysed at ERI Turnaround times for referral tests now include an element of time for sample transport and return of paper results Section 8 – new guidance on treatment levels for paracetamol

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Index SECTION 1 .................................................................................................................................................... 6 DESCRIPTION OF SERVICE .................................................................................................................... 6

WHERE ARE WE? ......................................................................................................................................... 6 KEY CLINICAL CHEMISTRY STAFF: ............................................................................................................. 6 HOW TO CONTACT THE LABORATORY:......................................................................................................... 7

Contact during office hours ................................................................................................................... 7 Contact out of hours............................................................................................................................... 7

LABORATORY ACCESS ................................................................................................................................. 7 Access during office hours ..................................................................................................................... 7 Access Out of hours ............................................................................................................................... 7

AVAILABILITY OF CLINICAL ADVICE AND INTERPRETATION OF RESULTS..................................................... 7 LABORATORY HOURS .................................................................................................................................. 8 EMERGENCY SERVICE ONLY: ...................................................................................................................... 8 NOTIFICATION OF URGENCY DURING ROUTINE HOURS ................................................................................ 9

Emergency samples................................................................................................................................ 9 Priority samples ..................................................................................................................................... 9

TELEPHONED RESULTS ................................................................................................................................ 9 SECTION 2 .................................................................................................................................................. 11 OUT OF HOURS......................................................................................................................................... 11

OUT OF HOURS REQUESTING...................................................................................................................... 11 TESTS AVAILABLE OUT OF HOURS.............................................................................................................. 11

SECTION 3 .................................................................................................................................................. 13 REQUEST FORMS, REPORTS, SAMPLE COLLECTION, VOLUMES AND TRANSPORT ........ 13

INSTRUCTIONS FOR COMPLETION OF REQUEST FORMS AND SAMPLE LABELING: ........................................ 13 ADDING REQUESTS TO SAMPLES ALREADY IN THE LABORATORY............................................................... 13

Time limits for requesting additional examinations............................................................................. 14 DUPLICATE TIME LIMITS AND REQUESTING AN EARLY REPEAT .................................................................. 15 SAMPLE CONTAINERS, COLLECTION AND VOLUMES................................................................................... 16

Recommended order of draw of samples ............................................................................................. 16 BLOOD SAMPLES: ...................................................................................................................................... 16

Serum (B) 4.7 ml Blood sample: .......................................................................................................... 17 Plasma (O) (Lithium Heparin)............................................................................................................. 17 EDTA (R) : .......................................................................................................................................... 17 Fluoride (Y).......................................................................................................................................... 18 Paediatric/Neonatal samples:.............................................................................................................. 18 Blood gas studies: ................................................................................................................................ 19 Collection of Capillary Blood Gas Samples: ....................................................................................... 20

URINE SAMPLES:........................................................................................................................................ 21 Random Urine samples: (SMU)........................................................................................................... 21 24 Hour urine sample containers: ....................................................................................................... 21 24 Hour Urine Collection Procedure .................................................................................................. 21

FAECAL SAMPLES...................................................................................................................................... 22 CEREBROSPINAL FLUID SAMPLES............................................................................................................... 22 HANDLING OF KNOWN OR SUSPECTED HIGH RISK SAMPLES ....................................................................... 23 SAMPLE TRANSPORT AND REPORT DELIVERIES .......................................................................................... 25

Internal BGH arrangements ................................................................................................................ 25 Samples for Edinburgh laboratories .................................................................................................... 25 External Transport of emergency samples........................................................................................... 25

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SECTION 4 .................................................................................................................................................. 26 KEY FACTORS AFFECTING THE PERFORMANCE OF TESTS, AND THE INTERPRETATION OF RESULTS .............................................................................................................................................. 26

IDENTIFICATION ERRORS. .......................................................................................................................... 26 BIOLOGICAL VARIATION............................................................................................................................ 26 SPECIMEN TYPE ......................................................................................................................................... 26 SPECIMEN TIMING...................................................................................................................................... 26 SPECIMEN TRANSPORT/SAMPLE VULNERABILITY ..................................................................................... 27 ANALYTICAL FACTORS .............................................................................................................................. 28 DRUG INTERFERENCES............................................................................................................................... 28 RARE ANALYTICAL INTERFERENCES.......................................................................................................... 28

SECTION 5 CLINICAL CHEMISTRY LIST OF TESTS A-Z.............................................................. 29 (TURNAROUND TIMES QUOTED HERE INCLUDE AN ELEMENT OF TIME FOR SAMPLE TRANSPORT AND RETURN OF PAPER RESULTS. LOTHIAN RESULTS MAY BE AVAILABLE SOONER BY USING SCI STORE OR CLINICAL PORTAL. MISSING RESULTS WILL NOT BE INVESTIGATED BEFORE THESE TIME FRAMES) ........................... 29

SECTION 6 .................................................................................................................................................. 45 PLEURAL FLUID ANALYSIS ................................................................................................................. 45 SECTION 7 .................................................................................................................................................. 47 PAEDIATRIC/NEONATES....................................................................................................................... 47

REFERENCE RANGES ................................................................................................................................. 47 SECTION 8 .................................................................................................................................................. 48 THERAPEUTIC DRUG MONITORING AND DRUG OVERDOSE ................................................... 48

THERAPEUTIC DRUG MONITORING............................................................................................................ 48 PARACETAMOL/SALICYLATE OVERDOSE .................................................................................................. 49

SECTION 9 .................................................................................................................................................. 51 TEST RESULTS AFFECTED BY DIET.................................................................................................. 51

DIETARY REQUIREMENTS FOR URINE COLLECTION OF 5-HIAA ................................................................. 51 SECTION 10 ................................................................................................................................................ 52 USEFUL CALCULATIONS ...................................................................................................................... 52

ANION GAP................................................................................................................................................ 52 CA (CORRECTED)....................................................................................................................................... 52 CREATININE CLEARANCE .......................................................................................................................... 52 CREATININE CLEARANCE .......................................................................................................................... 52 EGFR ........................................................................................................................................................ 52 FAI (FREE ANDROGEN INDEX) .................................................................................................................. 52 LDL-CHOLESTEROL .................................................................................................................................. 52 OSMOLARITY............................................................................................................................................. 52

SECTION 11 ................................................................................................................................................ 53 REFERRAL LABORATORIES ................................................................................................................ 53

WGH-EDINBURGH .................................................................................................................................... 53 RI-EDINBURGH.......................................................................................................................................... 54 ROYAL HOSPITAL FOR SICK CHILDREN - EDINBURGH ............................................................................... 55 RI-GLASGOW ............................................................................................................................................ 56 NINEWELLS – DUNDEE .............................................................................................................................. 57 UNIVERSITY HOSPITAL OF WALES - CARDIFF............................................................................................ 57 WILLINK BIOCHEMICAL GENETICS LAB - MANCHESTER........................................................................... 58 ST. JAMES – LEEDS.................................................................................................................................... 58 IMMUNOLOGY - SHEFFIELD ....................................................................................................................... 59 CHILDREN'S HOSPITAL – SHEFFIELD.......................................................................................................... 59

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UNIVERSITY - BIRMINGHAM...................................................................................................................... 60 CITY HOSPITAL - BIRMINGHAM................................................................................................................. 60 QUEEN ELIZABETH HOSPITAL - BIRMINGHAM........................................................................................... 60 SOUTHMEAD HOSPITAL - BRISTOL ............................................................................................................ 61 GENERAL HOSPITAL - SOUTHAMPTON....................................................................................................... 61 KING'S COLLEGE HOSPITAL – LONDON ..................................................................................................... 62 GREAT ORMOND ST HOSPITAL - LONDON ................................................................................................. 62 CHARING CROSS HOSPITAL – LONDON...................................................................................................... 63 ST THOMAS HOSPITAL - LONDON ............................................................................................................. 63 UNIVERSITY COLLEGE HOSPITAL - LONDON ............................................................................................. 64

SECTION 12 ................................................................................................................................................ 65 DYNAMIC FUNCTION TESTS................................................................................................................ 65

SAFETY CONSIDERATIONS DURING ENDOCRINE METABOLIC TESTS.................................... 65 GLUCOSE TOLERANCE TEST ............................................................................................................. 66 INVESTIGATION OF HYPOGLYCAEMIC ADULTS.......................................................................... 67

Glucose/Insulin measurement .............................................................................................................. 67 Extended Glucose Tolerance ............................................................................................................... 67

INVESTIGATION OF SUSPECTED ACROMEGALY AND GIGANTISM ......................................... 68 Screening Test...................................................................................................................................... 68 ORAL GLUCOSE TOLERANCE TEST (TEST OF GH SUPPRESSION)............................................ 68

INPATIENT INVESTIGATION OF CUSHINGS SYNDROME ............................................................ 69 EXTENDED LOW/HIGH DOSE DEXAMETHASONE TEST .............................................................. 69 OUTPATIENT SCREEN FOR CUSHINGS SYNDROME ..................................................................... 70

• Serum Cortisol............................................................................................................................ 70 • Urine Free Cortisol .................................................................................................................... 70 • Overnight Dexamethasone Suppression Test ............................................................................. 70

INVESTIGATION OF HYPOTHALAMIC - PITUITARY ADRENAL HYPOFUNCTION.................. 71 Short Synacthen Stimulation Test......................................................................................................... 71 Prolonged (24h) Synacthen Test .......................................................................................................... 71

INVESTIGATION OF 1° HYPERALDOSTERONISM.......................................................................... 72 Renin/Aldosterone Ratio ...................................................................................................................... 72

HYPOTHALAMIC PITUITARY FUNCTION........................................................................................ 73 Hypopituitarism ................................................................................................................................... 73 Basal Investigations (LH, FSH, Testosterone, Prolactin, Cortisol, TSH and FT4) ............................ 73 TRH, LH-RH TEST OF HYPOTHALAMIC - PITUITARY FUNCTION.............................................. 74 CLONIDINE/TRH/GnRH TEST........................................................................................................... 75 CLONIDINE TEST (without TRH /GnRH) .......................................................................................... 75

HUMAN CHORIONIC GONADOTROPHIN (HCG) STIMULATION TEST .......................................................... 76 HYPOTHALAMIC - POSTERIOR PITUITARY FUNCTION – I.......................................................... 77

I.Fluid deprivation test......................................................................................................................... 77 HYPOTHALAMIC - POSTERIOR PITUITARY FUNCTION - II.......................................................... 78

II. DDAVP Test (1-desamino-8-D-arginine vasopressin) .................................................................... 78 DIABETES INSIPIDUS – OVERNIGHT SCREENING TEST............................................................... 79

SECTION 13 ................................................................................................................................................ 80 24HR URINE COLLECTION ................................................................................................................... 80

HOW TO COLLECT SPECIMENS FOR CREATININE CLEARANCE................................................ 80 HOW TO COLLECT SPECIMENS FOR METADRENALINE.............................................................. 80

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Section 1 Description of Service The Department provides a high quality, comprehensive, consultant-led Clinical Chemistry analytical service to clinicians throughout NHS Borders. The analytical and advisory service also includes research, development and teaching projects. This service is provided from the Area Laboratory at the Borders General Hospital site. Our departmental team consists of around twenty medical, scientific, clerical and support staff, responsible for processing in excess of 168,000 requests and 1,300,000 tests annually. The department is equipped with a range of modern analysers appropriate for our current and projected workload. These include: 2 x Beckman Coulter DXC 880i integrated general chemistry and immunoassay analysers 2 x ABL 800 Series Blood Gas analysers 1 x TOSOH G8 Glycated Haemoglobin analyser 1 x Sebia Minicapillary Electrophoresis system 1 x DS2 Elisa analyser Clinisys Labcentre laboratory information management system (LIMS).

The department is committed to providing a quality service, which includes regular internal quality assurance and participation in all appropriate, national external schemes. The laboratory is also committed to maintaining registration and compliance with all relevant accreditation bodies. Currently the department has achieved full compliance with the standards specified by Clinical Pathology Accreditation, and will only refer samples to other CPA accredited laboratories. The Clinical Pathology Accreditation is considered to be a hallmark of performance and offers reassurance to users of the service. Further information on quality may be found in the Laboratory Quality Manual available on request.

Where are we? The Laboratory Suite is situated on the second floor of the Borders General Hospital, on the corridor leading into Main Theatres, Recovery Area and Intensive Care Unit.

Key Clinical Chemistry Staff: Dr John O’Donnell Consultant Clinical Chemist ext 26259 Mrs Dianne Keddie Diagnostic Services Manager ext 26428 Miss Jackie Scott Dep’t Manager – Clinical Chemistry ext 26238

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How to contact the laboratory: Contact during office hours During office hours the following numbers should be used. Tel No. BGH Extension Borders General Hospital 01896 826000 Clinical Chemistry Lab. 01896 826244 26244 Clinical Chemistry Add-On Request Service

01896 826228 26228

Laboratory Enquiries/Office 01896 826240 26240 Laboratory Office Fax 01896 826237

Results should be viewed electronically wherever possible but if they are required over the phone, the Clinical Chemistry number should be used. (01896 826244) Contact out of hours The clinical chemistry department operates an on-call analytical service Bleep 6244 directly, or ask the switchboard to contact the Biomedical Scientist on-call. The Clinical Chemistry Consultant on call can be contacted for clinical advice at any time via the hospital switchboard.

Laboratory access Access during office hours During normal office hours (Monday to Friday 9 a.m. to 5 p.m., the laboratory reception is staffed. Samples may be left in the sample reception area, and queries will be forwarded to individual departments by the receptionist. It is important to notifiy the receptionist if an urgent sample analysis is required. Access Out of hours Out of hours access to the laboratory is restricted to authorised holders of electronic swipe cards. Card holders are permitted to enter the outer double doors of the lab, and ‘post’ samples through the letter box in the inner set of doors. Samples require prior notification to the on-call biomedical scientist, and their delivery announced with a brief ring of the sample delivery bell

Availability of clinical advice and interpretation of results During normal opening hours, the Clinical Chemistry Consultant may be contacted within BGH at speed dial 26259, by external call 01896 826259, or by mobile telephone via the BGH switchboard. Out of hours, the Clinical chemistry Consultant on call may be contacted for clinical advice at any time via the hospital switchboard. The on call rota is supported by Lothian Hospitals.

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Laboratory hours Routine Service: Monday to Friday 9 a.m. to 5 p.m. The Laboratory is fully staffed on weekdays and is open for the receipt of samples for routine, emergency and for special investigations. Limited Service: Saturday/Sunday 9 a.m. to 12 noon Public Holidays 9 a.m. to 5 p.m. On Saturday/Sunday mornings the department can only accept samples for processing which are required that day for the immediate clinical care of patients. Samples for routine investigations should not be sent to the laboratory on these mornings.

Emergency Service Only: Weeknights 5 p.m. to 9 a.m. Saturday 12 noon to Sunday 9 a.m. Sunday 12 noon to Monday 9 a.m For details of the service outwith normal working hours see Section 2 Out of Hours

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Notification of Urgency during routine hours

Emergency samples Due to the large numbers of routine samples received in the department during normal laboratory hours, the doctor initiating an emergency request must notify the laboratory by telephone or in person (see contact details above) that an emergency sample is coming. Only grossly abnormal or unexpected results shall be telephoned. All other results will be made available on the laboratory computer system as soon as possible, without notifying the requestor. See Telephoned Results Table

Priority samples Accelerated analysis is offered for priority samples when a rapid turnaround time is required. During normal working hours, an orange “PRIORITY” sticker applied to the request form will accelerate this analysis and the laboratory need not be notified. Results will be reported on the laboratory computer (Labcentre) usually within 1 hour. These labels are available from Clinical chemistry.

Telephoned results Abnormal results of clinical significance will normally be telephoned. Electronic communication of results has decreased the requirement for telephoned results, as these are available via the laboratory computer. On receipt of a result that does not fit with the clinical presentation, please contact the relevant laboratory for result investigation, verification and/or interpretation. The following table is a guideline to results that will be phoned by the Laboratory. Please note these ranges refer to unexpected results e.g. a urea of 30mmol/L would not be phoned in a patient with known renal failure whose urea is always 30mmol/L

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Table of telephone ranges for UNEXPECTED results

ANALYTE FOR OFFICE HOURS GP AND OPD, AND WARDS AT ALL TIMES

OUT OF HOURS GP AND OPD RESULTS TO BE PHONED TO BECS

SODIUM <120 and >150 <120 and >150 POTASSIUM <2.8 and >6.0 <2.5 and >6.5 POTASSIUM (DIALYSIS UNIT)

Dialysis Unit do not want potassium phoned, they check all results.

TOTAL CO2 <10 <10 UREA >20.0 >30.0 CREATININE >300 >500 CORRECTED CALCIUM

<2.00 and >3.00 >3.5

ALT >1000 CK >3000 >5000 GLUCOSE (WARD ONLY)

<2.5

GLUCOSE (ALL NON DIABETIC)

>20.0 >25.0

GLUCOSE (DIABETIC)

>30.0 (check bicarbonate)

AMYLASE >450 >450 URATE >0.35 in pregnancy MAGNESIUM <0.5 and >1.5 <0.4 ETHANOL 300 (all positives for <18yrs) SALICYLATE All positive results PARACETAMOL All positive results LACTATE >6.0 THEOPHYLLINE >25 >25 PHENYTOIN >25 >25 PHENOBARB >50 AMMONIA All abnormal results IRON In overdose LITHIUM >1.0 >2.0 DIGOXIN >3.0 >4.0 TSH >50 fT4 >50 pO2 <7.0 pCO2 >8.0 pH <7.2 Cortisol <100 (NB Non-suppressed level) Prolactin >2000 (JGO) QHCG PAU when requested CSF Protein Adult >400 Child >800 Neonate >1200 NEONATES Ammonia All abnormal results Total Bilirubin TB >300 @ any age

TB >100 @ 24h, TB >50 @ 10 Days Back to index

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Section 2 Out of Hours

Out of hours requesting The Laboratory provides an ‘ on call’ analytical service ‘Out of hours’ from 5pm to 9am Monday to Friday, and 12noon Saturday through to 9am Monday. A ‘no bleep’ service operates between 5pm -8pm weeknights for emergency samples.

Emergency samples are analysed by contacting the out of hours Biomedical Scientist. Bleep 26244 directly, or ask the switchboard to contact the Biomedical Scientist on-call. Only grossly abnormal or unexpected results shall be telephoned. All other results will be made available on the laboratory computer system as soon as possible, without notifying the requestor. See Telephoned Results Table 5pm to 8pm weeknights, with the exception of blood gas samples, there is no need to notify the department, results will be available within 1 hour of sample receipt. Batch samples, there is no need to contact the Laboratory for batch samples as all samples received up until the batch start time will be analysed and the results will be available on the computer system within the hour. Any requests received with a priority sticker will be analysed in the batches. The on-call BMS need not be notified. See times on the page above Some tests are only available as part of the batches. Please use the batching system as this will allow the Biomedical Scientist on-call to concentrate on processing samples where the results are genuinely required for the immediate management of the patient. Every day 23.00 07.30 Saturday and Sunday only 11.00 14.00 17.00

Tests available out of hours

Tests available for the immediate management of all patients U&E Calcium Amylase Lactate ABG / Cord pH / Foetal scalp pH Preg test Glucose CSF Troponin-I

(N.B. if the admission troponin is elevated, the 12 hour sample can be analysed at the next batch)

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Tests available in addition for the immediate management of certain patients

Neonates Pre-Eclampsia

Overdose

Head Injury

Convulsion

Rhabdo-myolysis

Ammonia Uric acid Paracetamol Ethanol Magnesium CK Bilirubin PCR Salicylate Glucose Magnesium Ethanol Conj bili CK CRP Carbamazepine Phenytoin Fe Lithium Paraquat (sent

to ERI)

Tests available at batch times only

CRP in adults Fluid samples LFT Urine electrolytes LD Magnesium UA Phosphate

Digoxin (for urgent management of the patient, not routine monitoring) available at 2pm on Saturday and Sunday only

Any test falling outwith the above criteria or not listed above can be discussed with the Consultant Biochemist on call. The Clinical Chemistry Consultant on call can be contacted for clinical advice at any time via the hospital switchboard.

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Section 3 Request forms, Reports, Sample collection, Volumes and Transport Instructions for completion of request forms and sample Labeling: Please refer to Laboratory Sample Identification Protocol on the Laboratory intranet site, General: Links to guidelines and information. http://intranet/resource.asp?uid=15231

Adding requests to samples already in the laboratory The lab receives a significant number of telephone requests for supplementary tests to be added to samples already in the laboratory. This can be very disruptive, particularly out-of-hours and can result in delays in analysis and reporting of other results. There are 3 ways that requests for these supplementary tests can be notified to Clinical Chemistry, please include the patient’s CHI and/or laboratory reference numbers together with the patient’s name and test required. For routine ‘add on’ requests:

A) email your add-on request directly to [email protected], B) Phone extension number 26228 and you will be transferred to a voicemail

service, where you will be asked to provide the required information. Please speak clearly as any unintelligible requests will not be able to be processed.

C) Use the GREEN Clinical Chemistry add-on slip

The supplementary request will be processed as soon as possible during routine working hours. Emergency/out of hours add-on requests should be phoned through to 26244, or bleep 26244 during the out-of-hours period. Please note that CRP and LD are not part of the emergency test repertoire, however if a green add on slip is sent during the out of hours period they will be run at the next batch time. Email and voice mail are not checked out of hours. THESE OPTIONS ARE FOR CLINICAL CHEMISTRY USE ONLY. Haematology and Microbiology will be rejected. These departments should be contacted directly for add on requests.

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http://intranet/microsites/index.asp?siteid=64&uid=12

http://intranet/resource.asp?uid=15231

mailto:[email protected]

Time limits for requesting additional examinations Samples are normally stored for approximately 3 days (dependent on available storage space) then discarded. It may not be possible to make additional requests if the requested analyte is labile, the sample has not been separated from its cells overnight, or the sample has been transferred to an external laboratory. Add on requests for Troponin can only be accepted within 24hrs of taking the sample. Back to index

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Duplicate time limits and requesting an early repeat Repeat only after (DAYS) Bence Jones protein 28 Calprotectin 90 Cholesterol 60 Cholesterol –(HDL) 60 Cholesterol –(LDL) 60 Coeliac screen (Anti-tTG IgA) 180 CRP (C-reactive protein) 3 Electrophoresis 28 Ferritin 28 Folate 28 HbA1c 90 Immunoglobulins 28 Iron 28 Transferrin 28 Triglycerides 60 Troponin-I should not be repeated unless further

chest pain TSH 28 Vitamin B12 28 Vitamin D 365

Early repeats are permitted and an early repeat request form should be completed and sent with the sample. If you know you are requesting an early repeat, sending a completed form with your sample will reduce delay. This form can be downloaded from the intranet: http://intranet/resource.asp?uid=18062

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Sample containers, collection and volumes Please ensure that the correct sample container is used, that it is properly closed and that neither the sample tube nor request form are contaminated by spillage. Samples must be placed in a sealed , transparent transport bag with the request form separate from the sample container, before sending to the laboratory Please do not place samples from more than one patient in the same bag, or place samples destined for different departments in the same bag.

Contaminated samples will be rejected.

Recommended order of draw of samples In order to decrease the possibility of sample contamination, it is recommended to take samples in the following order if more than one sample type is collected during one bleed: 1. Blood culture bottles 2. Tubes with no additives (serum gel) 3. Coagulation tubes 4. Other tubes with additives Please consult the lab if not sure about sample type or order of collection before bleeding a patient

Blood samples: (B) Brown cap No anticoagulant provides SERUM. (O) Orange cap Lithium Heparin provides PLASMA. (Y) Yellow cap Fluoride for HbA1c, lactate, glucose and hydroxybuterate. (R) Red EDTA for certain drugs and hormones. Section 5 lists the sample requirements for each test.

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Serum (B) 4.7 ml Blood sample:

Plasma (O) (Lithium Heparin)

Volume: One full tube is usually sufficient for routine requests but if a large variety of tests, or tests referred to another laboratory, are requested then 2 or more tubes may be required. Contact the Laboratory for advice. EDTA (R) :

EDTA preservative is required for certain drugs and hormones, see section 5 for details Volume: One full tube is usually sufficient, section 5 lists where extra tubes are required

Plasma is required for some of the unstable peptide hormones (e.g. gastrin, calcitonin). However, plasma is unsuitable for several tests including PSA, qualitative HCG, salicylate and protein electrophoresis. In addition, its poor storage properties often make it unsuitable for any of the analyses not performed on the day of receipt.

SERUM is the sample required for the majority of analyses (clotted samples with gel separation). All tests that can be done on gel tubes can also be done on tubes without any additive or gel. Please remember that we can perform the individual tests that you require and by restricting requests to these you save us reagent costs and analytical time. Volume: One full tube is usually sufficient for routine requests but if a large variety of tests, or tests referred to another laboratory, are requested then 2 or more tubes may be required. Contact the Laboratory for advice.

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Fluoride (Y)

PLEASE NOTE in most cases adult sample tubes, complete with cap, are placed directly on laboratory analysers. Tubes with insufficient sample cannot be placed directly on the analyser and incur additional costs through extra consumables and extra staff time. They are also analysed at the end of the working day to prevent sample evaporation on the analysers at busy times. Please provide full sample tubes wherever possible. Back to index Paediatric/Neonatal samples:

Volume: The yield from a centrifuged paediatric/neonatal sample varies immensely from patient to patient. It is therefore difficult to state a required volume of blood for requested tests. A full 1.2 mL tube is desirable but when a smaller sample is obtained, laboratory staff will endeavour to analyse paediatric/neonatal samples for as many of the requested tests as possible.

Back to index

Note: Small capillary conical Lithium-Heparin tubes are for bilirubin, glucose or HbA1c only. The tube must be completely filled for bilirubin and glucose Unsuitable for other profiles due to low sample volume.

Fluoride preservative is required for HbA1c, lactate, glucose and hydroxybuterate measurement. Serum samples received within 4 hours of collection can be analysed for glucose however samples received after this time require fluoride preservative. Volume: One full tube is usually sufficient

Heparinised blood (O) yields a larger volume of plasma than the serum obtained from an equivalent volume of clotted blood and is the preferred sample when the volume of blood available is limited.

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Blood gas studies:

Read the syringe package label before commencing procedure. Ensure the plunger is pulled back prior to sampling

Arterial blood samples must be collected anaerobically into the special blood gas syringes provided, and the following procedure should be observed.

Puncture artery and allow arterial pressure to fill the syringe to at least 1 ml, avoiding air bubbles in sample. Remove the needle and fit the luer tip cap. Gently mix the gas syringe before dispatching to lab to prevent clotting. Label the syringe with a hand written label (sticky tape or small label available from the Laboratory) and transport immediately to the laboratory. Misleading results can be obtained from samples kept more than 20 minutes at room temp. If any delay is envisaged, place the sample in ice. Do not send syringe with needle still attached or the sample will be rejected.

Samples older than 30 minutes will not be analysed Back to index

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Collection of Capillary Blood Gas Samples:

The importance of good sampling technique is fundamental to obtaining a high quality result, as the lack of a good quality capillary blood sample is the weakest link in the analytical chain. Analyse within 10 minutes.

The failure to provide a sample of reasonable quality may be attributable to several causes:

• failure to wipe away the first drop of blood – the first drop of blood should not be included in the collection of capillary samples (the first drop is rich in tissue fluid clot activators).

• Inadequate mixing of sample – The sample must be adequately mixed. This is important for all capillary blood gas samples. When taking the sample, loosely mount a capillary cap on one end of the capillary. Insert a mixing wire in the capillary and allow it to slide to the same end as the loosely mounted capillary cap. Take blood sample in the opposite end of the capillary to the wire. Tighten the capillary cap, then tightly mount a capillary cap on the other end of the capillary. Using a magnet, the sample should be mixed as soon as the blood has been collected. The mixing should be continued in transit to the laboratory (Rotate the tube back and forth between the tips of your fingers, instead of moving the blood back and forth along the tube). Air exposure must also be kept to an absolute minimum, to ensure that gas values don’t change, so ensure that your capillary is full and has been sealed with caps.

• The use of Vaseline – It can alter the blood results, and it can clog the pathway of the analyser

• Scooping- Blood which has smeared or dribbled away from the puncture site should never be scooped up. There are two reasons for this, (1) It may have started to clot , (2) Scooping partially coagulated blood may also cause haemolysis.

• Time taken to sample – The phlebotomist/doctor/nurse should always try to be as quick and efficient as possible when collecting capillary blood

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Urine samples:

(SMU) Sarstedt Monovette urine collection tube system (24P) 24 hour urine container (plain) (24A) 24 hour urine container (with acid) It is essential that the urine sample is collected into the correct container and preservative otherwise the results may be invalid. See individual tests for recommended containers. Random Urine samples: (SMU)

24 Hour urine sample containers:

For randon urine samples, Clinical Chemistry will only accept samples collected by the Sarstedt Monovette urine collection tube system. Monovette collection packs are ordered from Area Stores stores, and includes all the disposables as well as an information leaflet on how to collect a sample. From the 1st June 2010, Universal containers will be rejected for random urine samples

24hour urine containers are ordered from Area Stores and can be plain or ‘with acid’ depending on the test required.

24 Hour Urine Collection Procedure

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Faecal Samples

Back to index Cerebrospinal fluid samples

If three aliquots of sample are obtained, the second sample is sent for biochemical analysis.

Specimen Requirement 0.5 ml in 20 ml Universal Container or 0.2 ml in 2 ml plain tube. The CSF sample should be sent in a sterile container directly to the laboratory when a total protein and glucose estimation can be performed (Fluoride tube for CSF is not normally required except when CSF Lactate is requested). A blood glucose MUST be measured at the same time in order to interpret the CSF glucose.

Faecal sample containers are available from Area Stores.

If a Xanthochromia request is necessary, then a fourth sample must be sent to the laboratory with protection from light (preferably wrap in aluminium foil, or seal in a thick paper envelope)

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Handling of known or suspected high risk samples

All biological samples are potentially hazardous. The Code of Practice for the prevention of Infection in Clinical Laboratories and Post Mortem Rooms (The Howie Report, 1978) classified biological samples into 4 groups according to the level of hazard present. See table below.

CARE should be taken in the withdrawal of blood and transport of any samples to the laboratory. “Risk” patients’ notes are marked with a clinical alert sticker on the outside and an Inoculation Risk label on the clinical alert insert sheet. This is only following laboratory confirmation of the presence of blood borne virus infection in that patient. High-risk samples are discarded immediately after analysis. HIGH RISK SAMPLES Risk Group 4

The most infectious, involving the “haemorrhagic fevers” such as Ebola, Lassa etc. Any suspicion of these diseases MUST immediately be notified to the Consultant Microbiologist and Consultant Physician. The relevant clinical protocol MUST then be followed. No samples, other than a malaria film if relevant, should be requested until discussed with the Laboratory Consultants.

Risk Group 3 (Category B1)

The most frequent group of high-risk samples sent to the laboratory and includes: - a. Patients known to be Hepatitis BsAg positive. b. Patients, known, or suspected, to be suffering from infective hepatitis, including Hepatitis C. c. Patients suspected of being carriers of HIV (the AIDS virus). d. Patients, known, or suspected, to be suffering from tuberculosis.

Transport to lab The normal laboratory sample containers are adequate for these samples. They should be placed within the plastic bag attached to the laboratory request form as usual but then this MUST be placed within a “Biohazard” plastic bag, sealed but not stapled, (i.e. Double Bagged).

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Phlebotomy Phlebotomists may take blood from risk patients only if they are given sufficient information to inform them of the risk. All samples from high-risk patients should be distinctly identified by ticking HIGH RISK box and adequate written indication of the risk written on the Request Form. Withdrawal of blood – Correctly fitting gloves and plastic aprons should be available for staff taking blood on the wards. Surgical-type gloves should be worn for all parenteral procedures and used only once. Used needles MUST be placed in a rigid “Sharps” container immediately after use and sent for incineration. Sample tubes must be filled to the mark to prevent unnecessary opening of the sample within the department. Transfer of laboratory samples All samples from high-risk patients should be distinctly identified by ticking the HIGH RISK box and adequate indication of the risk written on the Request Form. The normal laboratory sample containers are adequate for these samples. They should be placed within the plastic bag attached to the laboratory request form as usual. Then detach form, place this bag within a “Biohazard” plastic bag, sealed but not stapled, (i.e. Double Bagged), and finally place request form in side pocket of Biohazard bag. This is ideal for blood and small urine samples. Large bags are available for other samples (e.g. 24 hour Urine samples). Laboratory requests Please keep requests from high-risk patients to the minimum required for immediate management of the patient. In the event of a patient in one of the high-risk groups being admitted to BGH as an emergency, the laboratory will perform tests (the minimum deemed necessary by the clinician) as normal. In such a situation the admitting clinician must inform the BMS doing the tests of the degree of risk he judges to be present, and must label the samples appropriately. Sharps injury policy Information on the procedure for dealing with sharps injuries can be found in the Occupational Health & Safety Manual. Needlestick Policy (See intranet for detail)

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http://intranet/Doc_Library/Public/Clinical_Services/Occ_Health/occ_health_manual/14_needlestick_policy_gpg.pdf

Sample transport and report deliveries

Internal BGH arrangements

The internal arrangements for sample collection and report delivery are currently under review. Completed reports will be returned to the wards when all analyses are completed. Interim results are available on the laboratory computer. Approximately half of the laboratory workload is generated from outside hospitals and general practitioners. These samples arrive by courier from 12.30 p.m. onwards and the afternoons are largely devoted to the analysis of these samples. See intranet for courier timetables. Samples for Edinburgh laboratories

Routinely these are collected from the Laboratory at 12.15 p.m. to be transported by the Edinburgh Courier at 12.30 p.m. External Transport of emergency samples The laboratory is not responsible for transporting emergency samples from Health Centres or Cottage Hospitals, the requesting doctor should arrange transport and notify the Laboratory that the sample is coming. (Section 1, Notification of Urgency) Back to index

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Section 4

Key factors affecting the performance of tests, and the interpretation of results Preanalytical factors are an important source of variation or errors in clinical laboratory measurements.

Identification errors. There is a policy on the Laboratory intranet site which deals with labelling of samples, Please refer to Laboratory Sample Identification Protocol on the Laboratory intranet site, General: Links to guidelines and information.


Biological variation Most measured analytes will have some degree of natural biological variation. This may be trivial as in the case of say sodium or calcium, to quite big swings in some hormonal assays such as cortisol which have significant diurnal patterns of change. Interpretative comments will tend to take account of only the most significant variances such as in diurnal variation or natural rhythmical cycles such as the menstrual cycle.

Specimen type Most samples analysed in the laboratory will be serum. This is simply clotted blood taken in a gel tube and subsequently centrifuged and the supernatant layer (serum) then aspirated by instrumentation and analysed. However, some analytes require plasma sample for ideal measurement (EDTA, Lithium Heparin, or fluoride oxalate tubes). All analytes, with required tubes, for all sample types are listed in the table in Section 5.

Specimen timing For the most part, samples can be taken at anytime. Logistical convenience with clinical and laboratory operational issues usually lead to samples being taken early in the day for early analysis and return of results. We would strongly recommend that routine samples should be taken as early as possible in the day to allow early return of results. Some analytes (eg glucose) require fasting samples. This invariably requires a 10-14 hour overnight fast (no food, only water). Samples for therapeutic drug monitoring or toxicology are often time dependant and these are highlighted in the table below and in Section 8. Some other specific dynamic function tests require multiple timed samples. When carrying out such a test, please refer to the appropriate protocol in Section 10. In these situations always use the correct time on sample (eg 8.30am) NOT time zero or time 30mins. Please note that request forms containing a mixture of fasting and random requests, will always be defaulted to Random.

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http://intranet/microsites/index.asp?siteid=64&uid=12


Specimen Transport/Sample Vulnerability When taking samples, be aware of the time of sample collection and approximately how long samples take to get to laboratory. All blood samples for Clinical Chemistry should be stored at Room Temperature (Never put in fridge or freezer) prior to transport. Secondary Care

• Be aware that most chemistry values will deteriorate to some extent AFTER 6 HOURS. In particular, K is vulnerable to significant change (will increase)

• Note that BLOOD GASES deteriorate after 20 minutes (unless on ice) therefore have to be transferred to the laboratory immediately.

• Certain hormones require centrifugation and freezing within a specified time limit, see Section 5 for analyte details.

Primary Care Same day specimens

• all analytes should be acceptable but be aware that most chemistry values will deteriorate AFTER 6 HOURS

• K is vulnerable to significant change (will increase) but should be acceptable in vast majority of cases.

• Troponin must be received same day, and must be analysed same day. Normal processing of troponin samples by lab will not be sufficient to allow analysis next day (this is adequate for most other analytes).

Next day specimens

• K is unacceptable and will not be reported. • Sodium – will tend to fall over time (usually not significant) • Bilirubin (will tend to go down) • Phosphate – will tend to rise • Creatinine – will tend to rise • Enzymes (ALT. ALP, GGT) will tend to reduce over time, but unlikely to be

significant. • AST and LD are found in RBCs, they rise rapidly in serum over time in the

sample and are therefore unacceptable and will not be reported. • Please note that there are a number of vulnerable analytes at about 24 hours,

but in the main the results will be clinically acceptable and reported normally • Most proteins and hormones are stable including TFTs, B12 and Folate. See

section 5 for time limits on unstable hormones. 2nd day or later In general we do not want to receive samples this late. Most analytes will be unacceptable. Therefore, we would recommend avoiding Friday Pm for sample collection. Samples received after 48 hours will most likely be discarded.

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Analytical factors Haemolysis, jaundice and lipaemia, commonly interferes with laboratory tests. Haemolysed and jaundiced samples respectively produce red and yellow colouration of the specimen which masks or enhances the colour development of the assay, leading to an inaccurate result. Current Laboratory analysers measure the level of haemolysis, jaundice and lipaemia and rules within the Laboratory Computer System will warn or remove results likely to be affected by these interfering substances. Grossly haemolysed or lipaemic samples will not be analysed.

Drug interferences Drugs rarely interfere with biochemical analysis. If results are unusual or are clinically unexpected, a discussion with the Consultant Clinical Biochemist (Dr O’Donnell) may be helpful. However, some hormonal analysis, 5HIAA, and catecholamine estimation are very sensitive to drug interferences. Tests of adrenal function are affected by steroid usage and again clarification with the laboratory protocol should occur prior to analysis. If unsure, please contact Dr O’Donnell.

Rare analytical interferences Occasionally, some assays are prone to immunological interference. This cannot be predicted and is usually detected with odd and inexplicable results. If doubt occurs in some test results, particularly hormonal tests (although it can also affect troponin rarely), then a discussion with Dr O’Donnell is indicated Back to index

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Section 5 Clinical Chemistry List of Tests A-Z

(Turnaround times quoted here include an element of time for sample transport and return of paper results. Lothian results may be

available sooner by using SCI store or Clinical Portal. Missing results will not be investigated before these time frames) Turnaround time (routine hours) Test (+ special requirements) Sample

type Reference Range

Urgent In-P GP/ Out-P Hyperlinks

ACE – Angiotensin Converting Enzyme

Brown 16 – 63 U/L n/a 10 days 10 days WGH-E

ACTH Transport to lab immediately Additional Brown tube required for cortisol

Red 0 – 50 ng/L n/a 7 days 7 days RI-E

Alanine Aminotransferase

Brown 10 – 42 U/L 1 hour 4 hours 24 hours

Aldosterone (random sample)

no requirement for supine / erect / ambulant status of patient. Additional Brown tube required for cortisol and potassium

Brown/ Orange

For Renin/ Aldosterone Ratio, please contact the Consultant Biochemist before taking samples

n/a 21 days 21 days WGH-E

Albumin Brown 36 – 47 1 hour 4 hours 24 hours

Alkaline Phosphatase Brown 26 – 100 U/L 1 hour 4 hours 24 hours α-1-Antitrypsin

Brown/ Orange

Phenotype Incidence % Usual values Pi MM 87 1.10 – 2.10 g/L Pi MS 8 0.93 – 1.66 g/L Pi MZ 4 0.66 – 1.28 g/L Pi SZ 0.2 0.62 – 0.74 g/L Pi ZZ 0.0003 0.07 – 0.20 g/L


α-Fetoprotein – Tumour marker Brown

Tumor marker < 5 kU/L n/a 8 days 8 days

α-Fetoprotein – Pregnancy (see CUB screen) Aluminium

Orange NON GEL

See interpretation on printed report n/a 21 days 21 days RI-G

Amino-acids Orange See individual report n/a 21 days 21 days RHSC

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Turnaround time (routine hours) Test (+ special requirements) Sample type

Reference Range Urgent In-P GP/ Out-P

Hyperlinks

Amino-acids – Urine (send urine to lab immediately for preservative to be added)

Urine ( SMU)

See individual report n/a 21 days 21 days RHSC

Ammonia The laboratory MUST be contacted before taking sample to ensure pre analysis checks are performed within the department

Orange Male Female

15 – 55 11 – 48

μmol/L μmol/L

1 hour n/a n/a

Amylase Brown 10 – 95 U/L 1 hour 4 hours 24 hours

Amylase – Urine Urine ( SMU)

Contact Dr O’Donnell before requesting n/a 24 hours 24 hours

Androstenedione Brown/ Orange

Pre-pubertal Adult Male Adult Female

< 2 2 – 11 2 – 13

nmol/L nmol/L nmol/L

n/a 14 days 14 days RI-G

Anion Gap calculation 7 – 17 mmol/L 1 hour 4 hours 24 hours useful calculations

Arterial Blood Gas pH pCO2 PO2 HCO3 B.E. O2 Sat.

7.36 – 7.44 4.6 – 6.1 12 – 15 21 – 27 - 4 - +4 96 – 98

kPa kPa mmol/L mmol/L %

30mins 30mins n/a

AST (Aspartate-Aminotransferase) Brown 10 – 42 U/L n/a 4 hours 24 hours

Arsenic Urine (SMU)

< 30 nmol/mmol creatinine


Bence Jones protein Urine (SMU)

Not detected normally n/a 8 days 8 days

Beta-2-Microglobulin Brown See individual report n/a 10 days 10 days Immu-B

β-HCG – pregnancy Brown See individual report 1 hour 4 hours 24 hours

β-HCG – Tumour marker MOLE follow up arranged through Dundee samples do not come to BGH

Brown/ Orange

Male Female

< 5 < 5

U/L U/L

n/a 7 days 7 days RI-E

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Hyperlinks

Bicarbonate (CO2 )

Brown 24 – 30 mmol/L 1 hour 4 hours 24 hours

Bile Acids

Brown < 14 μmol/L n/a 7 days 7 days RI-E

Bilirubin Samples should not be stored in direct sunlight

Brown Male Female

5 – 25 2 – 17

μmol/L μmol/L

1 hour 4 hours 24 hours

Bilirubin-conjugated Samples should not be stored in direct sunlight

Brown < 5 μmol/L 1 hour 4 hours 24 hours

Biotinidase Orange See individual report n/a 21 days 21 days RHSC

CA 125

Brown 0 – 35 kU/L n/a 4 days 4 days CA 19-9

Brown See individual report n/a 10 days 10 days Immu-Sh

Calcitonin Fasting:Take to lab without delay

Orange 30 – 120 ng/L n/a 21 days 21 days RI-G

Calcium For Corrected Calcium calculation, follow the hyperlink

Brown 2.12 – 2.62 mmol/L 1 hour 4 hours 24 hours useful calculations

Calcium - urine Urine 24Acid

low Ca diet 1.2 - 3.7 mmol/24h n/a 24 hours 24 hours

Carbamazepine

Brown 4 – 12 mg/L 4 hours 4 days 4 days TDM

Calprotectin (faecal) Sample pot must be 1/5th full

random stool

0 – 50 μg/g stool n/a 14 days 14 days

Carboxyhaemoglobin GPs can send a FULL 1.2mL orange tube

blood gas sample

non-smokers nausea/giddiness unconsciousness

<1.5 15 – 20 > 40

% % %

30mins 30mins 24 hours

Carnitine Guthrie test spots

See individual report n/a 21 days 21 days GOSH-L

Catecholamines (Paediatric) *Special container available from Laboratory

* Noradrenaline Adrenaline HVA HMMA Dopamine

< 0.25 < 0.08 < 11 < 6 < 0.7

μmol/mmol creat

μmol/mmol creat

μmol/mmol creat

μmol/mmol creat

μmol/mmol creat

n/a 21 days 21 days St.J-Le

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Hyperlinks

CDT (Carbohydrate Deficient Transferrin) (Alcohol dependency) (ADULTS)

Brown See individual report n/a 21 days 21 days Kings-L

CEA (Carcino-Embryonic Antigen) Brown 0 – 3 ug/L n/a 4 days 4 days Ceruloplasmin Brown/

Orange 140 – 380 mg/L n/a 7 days 7 days RI-E

Chitotriosidase Red 4 - 80 μmol/L/h n/a 21 days 21 days Childrn-M

Chloride Brown 100 – 107 mmol/L 1 hour 4 hours 24 hours Chloride – urine Urine random variable n/a 24 hours 24 hours

Cholestenone Fasting

Brown/Orange

5 – 35 ng/L n/a 21 days 21 days WGH-E

Cholesterol based on ATP III Guidelines

Brown

Optimal Borderline High High

< 4.0 < 5.2 5.2 – 6.2 > 6.2

mmol/L mmol/L mmol/L mmol/L

n/a 4 hours 24 hours

Cholesterol –(HDL) based on ATP III Guidelines

Brown

Low High

< 0.4 > 0.6

mmol/L mmol/L


Cholesterol –(LDL) based on ATP III Guidelines

calculation

Optimal Above Optimal Borderline High High Very High

< 2.6 2.6 – 3.3 3.3 – 4.1 4.1 – 4.9 > 4.9

mmol/L mmol/L mmol/L mmol/L mmol/L

n/a 4 hours 24 hours useful calculations

Cholinesterase

Brown Organophosphate poisoning Scoline sensitivity Dibucaine no. Fluoride no. Ro no.

4100 – 9900 600 – 1400 77 – 83 50 – 68 94 – 98

U/L U/L


Chromium – whole blood Only available to Hip replacement patients

7.5 mL EDTA

See individual report n/a 21 days 21 days RI-G

Chromium - urine Urine (SMU)

< 6 nmol/mmol creatinine


Chromogranin A&B

See Intestinal peptide screen C.Cross-L

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Hyperlinks

Chromogranin A (Tumour marker), Fasting sample. Bring sample to the Laboratory immediately

7.5 mL EDTA/ Orange

See individual report n/a 14 days 14 days Immu-Sh

Citrate Urine (SMU)/ Urine 24Plain

See individual report n/a 14 days 14 days South-H

Cobalt – whole blood Only available to Hip replacement patients

7.5 mL EDTA


Cobalt - urine Urine (SMU)

< 2.1 nmol/mmol creatinine


Coeliac screen (Anti-tTG IgA) Brown Normal Abnormal

<15 >=15

AU AU

n/a 7 days 7 days

Copper Requires a separate unique sample to prevent contamination

Orange – NON GEL


Copper - Urine Sterilin RT35/C38 or Technical Service Consultants RT41on urine containers must be used

Urine 24Acid


Cortisol Brown 08h00 23h00

170 – 640 < 220

nmol/L nmol/ L


Cortisol - urine

Urine (SMU)

<25 umol/mmol creat


C-peptide Bring sample to the Laboratory immediately

Orange 0.3 – 1.2 μmol/L Same day by special arrangement

14 days 14 days WGH-E

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Hyperlinks

Creatinine

Brown serum 60 – 110 μmol/L 1 hour 4 hours 24 hours

Urine 24Plain

Urine creat 10 – 20 mmol/24h Creatinine - urine Creat. Clearance Requires paired serum and 24hr urine sample

Urine 24Plain

Creat clearance 80 – 120 ml/min.

n/a 24 hours 24 hours Creat clear. collection useful calculations

Creatine Kinase

Brown

Male Female

24 – 195 24 – 170

U/L U/L


CRP (C-reactive protein)

Brown 0 – 10 mg/L 1 hour 4 hours 24 hours

glucose 60% – 80 % plasma glucose CSF analysis CSF Protein: At birth Neonate All others

400 – 1200 200 – 800 150 – 450

mg/L mg/L mg/L

1 hour 4 hours n/a

CUB screen

Brown See individual report n/a 7 days 7 days WGH-E

Cyclosporin Trough Sample

Red Guide range, depends on clinical condition

90 – 225 nmol/L n/a 7 days 7 days RI-E

TDM

Cystine By special arrangement only (send urine to lab immediately for preservative to be added)

Urine (SMU)


Dehydroepiandrosterone Sulphate (DHEA-S)

Brown/Orange

Neonates Infants and children Adult: Male Female < 50 y

0.5 – 7 < 2 2 – 9 2 –11

μmol/L μmol/L μmol/L μmol/L


Digoxin 6 – 24h.post dose

Brown Therapeutic Toxic

1.0 – 2.0 > 3.0

μg/L μg/L

4 hours 24 hours 24 hours TDM

Drugs of Abuse – BCAT patients only Samples need to be double bagged and labelled as High-Risk

Urine (SMU)

Semi-quantitative (See individual report) n/a 24 hours 24 hours

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Hyperlinks

eGFR (CKD Stages) calculation

Stage 1 Stage 2 Stage 3 Stage 4 Stage 5

> 60 > 60 30 – 59 15 – 29 < 15

ml/min/1.71 m2

ml/min/1.71 m2

ml/min/1.71 m2

ml/min/1.71 m2

ml/min/1.71 m2

1 hour 4 hours 24 hours http://www.renal.org/whatwedo/InformationResources/CKDeGUIDE/AbouteGFR.aspx

Elastase random stool (Blue)

Normal Mod. Pancreatic insufficiency Severe Pancreatic insufficiency

> 200 100 – 200 < 100

μg/g stool μg/g stool μg/g stool


Erythropoietin Orange See individual report n/a 14 days 14 days NineW-D

Ethanol

Brown/ Yellow

Not detected normally (90 mg% = 20 mmol/L) or (1mg/dL x 0.217 = 1 mmol/L) Not for medico-legal purposes


FAI (Free Androgen Index)

calculation Male Female

36 – 156 < 7

useful calculations

Ferritin

Brown Male Female (<50) (>50)

22 – 300 12 – 220 15 – 260

μg/L μg/L μg/L


Folate Brown 3 – 20 μg/L n/a 24 hours 24 hours

Free Fatty Acids Yellow See individual report n/a 7 days 7 days RHSC

S-Free Light Chains Brown See printed report n/a 10 days 10 days Immu-B

FSH Brown Pre pubertal Adult Male

AdultFemale: Early follicular Mid-cycle Luteal Post-menopausal

0.5 – 3.0 1.5 – 9.0

3.0 – 9.0 < 20.0 3.0 – 9.0 30 – 115

U/L U/L

U/L U/L U/L U/L


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Hyperlinks

FT3 Brown 3 – 6 pmol/L n/a 4 days 4 days

FT4 Brown 8 – 20 pmol/L n/a 24 hours 24 hours

Galactose-1-Phosphate Uridyl-Transferase Sample must be received before 11am

Orange < 20 μmol/hr/g Hb n/a 7 days 7 days RHSC

γ-Glutamyl Transferase (GGT) Brown Male Female

7 – 35 6 – 30

U/L U/L


Gastrin Fasting, transport to lab immediately on ice

7.5mL EDTA (red)

30 – 120 ng/L n/a 21 days 21 days RI-G

Glucose Yellow Normal Fasting 120 min Impaired Fasting 120 min Diabetic Fasting 120 min Gestational Fasting 120 min

< 6.1 < 7.8 6.1 – 6.9 7.8 – 11.0 ≥ 7.0 ≥ 11.1 >5.0 >8.5

mmol/L mmol/L mmol/L mmol/L mmol/L mmol/L mmol/L mmol/L

1 hour

4 hours 24 hours

Glucose - CSF white 60% – 80 % plasma glucose 1 hour 4 hours n/a

Growth Hormone Brown/Orange

See individual report


HbA1c

Yellow Non-diabetic Diabetic – ideal target

20 – 42 < 58

mmol/mol mmol/mol

48 hours 48 hours 48 hours

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Hyperlinks

Haemochromatosis DNA Screen 2 x Red See individual report n/a 21 days 21 days NineW-D

5 – HIAA Dietary requirements, see hyperlink

Urine 24Acid

10 – 42 μmol/24h n/a 21 days 21 days WGH-E

Diet

Hyaluronic acid Research method

Brown < 75 ng/L n/a 45 days 45 days RI-E

Hydroxybutyrate

Yellow See individual report n/a 10 days 10 days RHSC

Immunoglobulins IgG IgA IgM

Brown 5.0 – 13.0 0.5 – 4.0 0.3 – 2.2

g/L g/L g/L


IgG Subclasses

Brown See individual report n/a 14 days 14 days RI-E

Insulin (glucose< 3mmol/L) Transport to lab immediately

Orange Insulin Insulin/Glucose Ratio

2 – 25 < 10

mU/L Same day by special arrangement

14 days 14 days WGH-E

IGF-1 (Insulin Growth Factor-1)

Brown/Orange

See individual report for age appropriate range n/a 14 days 14 days RI-G

Intestinal peptide screen Fasting Sample Transport to lab immediately on ice

2 large EDTA (BTS tubes) On ice

See individual report n/a 21 days 21 days C.Cross-L

Intrinsic Factor Antibodies Will be reflexed on first low B12 result (<160 ng/L)

Brown Qualitative analysis n/a 14 days 14 days

Iron

Brown Male Female

14 – 32 10 – 28

μmol/L μmol/L

n/a (1hr in overdose only)

4 hours 24 hours

Lactate

Yellow 0.6 – 2.4 mmol/L 1 hour 4 hours 24 hours

Lactate Dehydrogenase Brown 260 – 500 U/L 1 hour 4 hours 24 hours

Lamotrigine Orange non gel

See individual report n/a 21 days 21 days St.T-L

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Hyperlinks

Laxative Screen 2 x Urine (SMU)

Qualitative analysis to detect laxative abuse

n/a 28 days 28 days City-B

Lead

7.5mL EDTA (red)

< 0.5

μmol/L


LH Brown Pre pubertal Adult Male Adult Female: Early follicular Mid-cycle Luteal Post-menopausal

0.5 – 1.2 1.5 – 9.0 2.5 – 9.0 < 30 2.5 – 9.0 30 – 115

U/L U/L U/L U/L U/L U/L

n/a (fertility tracking 4hrs)

24 hours 24 hours

Lithium (8h.post dose)

Brown 0.6 – 1.0 mmol/L 1 hour 4 days 4 days TDM

Lysosomal Enzymes By special arrangement only, contact the Laboratory

Red See individual report n/a 56 days 56 days RHSC

Magnesium

Brown 0.75 – 1.0 mmol/L 1 hour 4 hours 24 hours

Metanephrine Urine 24Acid

Metadrenaline Normetadrenaline

0.3 – 1.7 0.4 – 3.4

μmol/24h μmol/24h

n/a 21 days 21 days WGH-E Urine collection

Methotrexate Please contact the Laboratory in advance. Sample must be received before 10am

Brown 48 hour level 72 hour level

< 1.0 < 0.1

μmol/L μmol/L

24 hours 7 days 7 days RHSC

Microalbumin reserved for Type-1 DM only

Urine (SMU)

< 3.0 mg/mmolCreat n/a 4 days 4 days

Mucopolysaccharides Urine (SMU)


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Hyperlinks

Oestradiol Brown

Pre pubertal Adult Male Adult Female: Early follicular Mid-cycle Luteal Post-menopausal

< 70 < 200 110 – 180 550 – 1650 370 – 770 < 150

pmol/L pmol/L pmol/L pmol/L pmol/L pmol/L

n/a (fertility tracking 4hrs)

8 days 8 days

Oligoclonal bands Requires concomitant Serum & CSF samples

Brown + CSF

Albumin IgG IgG Index

90 – 270 10 – 40 0.4 – 0.65

mg/L mg/L


Organic acids (send urine to lab immediately for preservative to be added)

Urine (SMU)


Osmolality Brown 280 – 290 mOsmol/kg 24 hours 48 hours 48 hours

Osmolality - Urine Urine (SMU)

>600m Osmol/Kg 24 hours 48 hours 48 hours

Oxalate (send urine to lab immediately on completion for preservative to be added)

Urine 24Plain

0.04 – 0.49 mmol/24h n/a 14 days 14 days WGH-E

Paracetamol 4h. Post intake

Brown (see HYPERLINK) 1 hour 4hrs 24 hours OD

PTH (Parathyroid hormone) Must reach the lab within 4 hours

Red 1.10 – 7.5 pmol/L n/a 24 hours 24 hours

Peroxisomal Enzymes Please refer to VLCFA (very long chain fatty acids)

Phenylalanine Orange/Brown

20 – 130 μmol/L n/a 21 days 21 days RHSC

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Hyperlinks

Phenytoin Sample timing not critical

Brown Toxic

10 – 20 > 20

mg/L mg/L

4 hours 4 days 4 days TDM

Phenobarbitone Sample timing not critical

Brown Children Adults

15 – 35 15 – 40

mg/L mg/L

n/a 7 days 7 days TDM RHSC

Phosphate Brown 0.8 – 1.4 mmol/L 1 hour 4 hours 24 hours

Phosphate - Urine Urine 24Acid

15 – 50 mmol/24h n/a 24 hours 24 hours

Phytanic Acid Please refer to VLCFA (very long chain fatty acids)

Porphobilinogen Fresh sample, protected from light

Urine (SMU)

Not detected normally


Red Blood/Red Blood Cell 0.4 – 1.7 μmol/L n/a 10 days 10 days Univ-C

Urine (SMU)

Total: Total Porph:Creat

< 303 < 27

nmol/L nmol/mmol

n/a 10 days 10 days Univ-C

Porphyrins Fresh samples, protected from light

random stool

10 – 200 nmol/g dry wgt n/a 10 days 10 days Univ-C

Potassium Brown 3.5 – 5.0 mmol/L 1 hour 4 hours 24 hours

Potassium - Urine Urine 24Plain

25 – 100 mmol/24h n/a 24 hours 24 hours

Pregnancy Test Urine (SMU)

Qualitative analysis to detect pregnancy

2 hours 4 hours 24 hours

17-OH Progesterone Orange/Brown

Normal infants > 4 days

Stressed premature infants Congenital adrenal hyperplasia

<13 <40 >50

nmol/L nmol/L nmol/L

same day by special arrangement

21 days 21 days RI-G

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Progesterone Brown Ovulatory > 30 nmol/L

n/a 8 days 8 days

Prolactin Brown 60 – 390 mU/L n/a 8 days 8 days

Protein Brown 60 – 80 g/L 1 hour 4 hours 24 hours

Protein:Creat. Urine (SMU)

< 15 mg/mmol creat 4 hours 24 hours 24 hours http://www.renal.org/whatwedo/InformationResources/CKDeGUIDE/Proteinuria.aspx

Protein – Urine Urine 24Plain

< 100 mg/24h n/a 24 hours 24 hours

Protein – CSF White At birth Neonate All others

400 – 1200 200 – 800 150 – 450

mg/L mg/L mg/L

1 hour 4 hours n/a

Protein Electrophoresis

Brown See individual report n/a 8 days 8 days

PSA (Prostate Specific Antigen) Brown < 4.0 μg/L 4 hours 8 hours 8 hours

Quinidine Trough level + Dose information required

Brown See individual report n/a 10 days 10 days Kings-L

Renin Requires 2 brown tubes for concurrent cortisol, aldosterone and potassium measurement

7.5mL EDTA (red)

no requirement for supine / erect / ambulant status of patient For Renin/ Aldosterone Ratio, please contact the Consultant Biochemist before taking samples


Salicylate > 4h. post intake

Brown 150 – 300 mg/L 1 hour 4hrs 24 hours TDM OD

Selenium

2 x Orange


Sirolimus Trough level

Red See individual report n/a 10 days 10 days RI-E

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http://www.renal.org/whatwedo/InformationResources/CKDeGUIDE/Proteinuria.aspx










Hyperlinks

SHBG – (Sex Hormone Binding Globulin) (Also see Free Androgen Index)

Brown Male Female

6 – 45 30 – 120

nmol/L nmol/L


Sodium Brown 135 – 145 mmol/L 1 hour 4 hours 24 hours

Sodium – Random Urine Urine (SMU

random variable n/a 24 hours 24 hours

Sodium – 24hr Urine Urine 24Plain

24 hour sample

100 – 200

mmol/24h


Steroid Screen

Urine (SMU)/ 24Plain


Stone analysis (calculus)

stone See individual report n/a 14 days 14 days UCL

Strontium Research only

Orange NON GEL

See individual report n/a 28 days 28 days South-H

Sweat Test Performed by specialist Nurse in Paediatrics only

Sweat See individual report 24 hours 7 days 7 days RHSC

Tacrolimus Trough level

Red 5 – 15 μg/L n/a 7 days 7 days RI-E TDM

Testosterone (9 – 11 am)

Brown Male Female

10 – 30 0.8 – 2.8

nmol/L nmol/L

n/a 8 days 8 days

Theophylline Take prior to next dose


Thiopurine Methyl Transferase (TPMT) Red Normal Carrier Deficient

25 – 50 10 – 25 < 10

nmol/h/ml rbc nmol/h/ml rbc nmol/h/ml rbc

n/a 14 days 14 days St.T-L

Thyroglobulin

Brown < 5 μg/L n/a 28 days 28 days WGH-E QEHB

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Hyperlinks

Trace Metal & Micronutrient Screen Available to Renal Dialysis patients only, Mon – Thurs only

Special tube available from renal dialysis

See individual report n/a 21-28 days

21-28 days

RI-G

Transferrin

Brown 1.9 – 4.0 g/L n/a 4 hours 24 hours

Triglycerides

Brown Normal High hypertriglyceridemic Very High

< 1.70 1.70 – 2.25 2.26 – 5.64 > 5.64

mmol/L mmol/L mmol/L mmol/L


Trimethylamine Contact the Laboratory before starting Overnight urine sample

Urine 24Plain

See individual report n/a 28 days 28 days Chldrn-Sh

Troponin-I Baseline and 12 hrs post cardiac event

Brown/ Orange

Normal < 0.05 μg/L 1 hour 4 hours 24 hours

Tryptase Screen for anaphylactic reaction, Samples to be taken at 0 and 24hr Transport to lab immediately

Red See individual report n/a 14 days 14 days RI-E

TSH Brown 0.3 – 5.0 mU/L n/a 24 hours 24 hours

TSH Receptor Antibodies (TRAB) Brown 0 – 1.5 U/L n/a 10 days 10 days RI-E

Urate

Brown Male Female

0.12 – 0.42 0.12 – 0.36

mmol/L mmol/L


Urate - Urine Urine 24Acid

(normal diet) 1.2 - 3.0 mmol/24h n/a 24 hours 24 hours

Urea

Brown 2.5 – 6.6 mmol/L 1 hour 4 hours 24 hours

Valproate Take prior to next dose


VLCFA (Very Long Chain Fatty Acids)

Brown/ Orange

0 – 16 μmol/L n/a 21 days 21 days Bristol

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Hyperlinks

Vitamin A Sensitive to light Samples accepted Mon-Thurs only

Orange Non GEL

1.0 – 2.8 μmol/L n/a 28 days 28 days RI-G

Vitamin B1 (Thiamin) Available Mon-Thurs only

Orange Non GEL/ EDTA

Normal

Subclinical deficiency

Clinically deficient

275-675

150-275

<150

ng/g/Hb

ng/g/Hb

ng/g/Hb


Vitamin B2 (Riboflavin)

Fasting sample Sensitive to light Samples accepted Mon-Thurs only


1.0 – 3.4 nmol/g/Hb n/a 28 days 28 days RI-G

Vitamin B6 (Pyridoxal phosphate)

Fasting sample Sensitive to light Samples accepted Mon-Thurs only


250-680 pmol/g/Hb n/a 28 days 28 days RI-G

Vitamin B12

Brown 160 – 800 ng/L


Vitamin D-25 (OH) Brown Winter Summer

15 – 50 15 – 100

nmol/L nmol/L


Vitamin E

Sensitive to light Samples accepted Mon-Thurs only

Orange Non GEL

15 – 45 μmol/L n/a 28 days 28 days RI-G

Xanthochromia screen Sample 4, Protect from light At least 12 hours post suspected SAH Requires brown tubes for concurrent protein and bilirubin measurement

CSF See individual report

n/a 24 hours Monday to Friday, 72 hours over W/E

24 hours Monday to Friday, 72 hours over W/E

Zinc Transport to lab immediately

Orange NON GEL

10 – 18 μmol/L n/a 28 days 28 days RI-G

Back to index

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Section 6 Pleural Fluid Analysis Please refer to references for more comprehensive discussion, this is only a brief summary. Typical characteristics of pleural fluid

The appearance and any odor should be noted

Pleural fluid haematocrit is helpful in the diagnosis of haemothorax. • If the haematocrit is more than half the peripheral haematocrit, the patient has a

haemothorax, • If the pleural fluid haematocrit is < 1%, the blood in the fluid is not significant

Grossly bloody pleural fluid is usually due to: • Malignancy • Pulmonary embolus with infarction • Trauma • Benign asbestos pleural effusions • Post-cardiac injury syndrome (PCIS)

Differentiating between fluid exudates and transudate Total protein (with normal serum total protein)

• < 25 g/L – transudate • >35 G/l – exudate • Between 25 and 35g/L – equivocal.

LD (with normal serum LD) • If fluid LDH > 3 times the upper reference limit – exudate • If fluid LDH < 2 times the upper ref limit – transudate • If fluid LDH between 2 and 3 times upper ref limit still equivocal and will be reported

as such Differentiation between chylothorax and pseudochylothorax If suspected, fluid should be sent for triglycerides and cholesterol

Chylothorax – Triglycerides > 1.24 mmol/L Cholesterol < 5.18 mmol/L

Pseudochylothorax – Triglycerides < 0.56 mmol/L Cholesterol > 5.18 mmol/L

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Other analytes:

pH – in an infected effusion a pH of < 7.2 indicates the need for drainage Glucose - < 3.3 mmol/L found in exudative effusions, but variable < 1.2 – 1.7 mmol/L in rheumatoid arthritis Amylase – Only if acute pancreatitis or rupture of the oesophagus is possible Amylase > upper reference limits for serum, or fluid/serum > 1.0 indicates

elevated amylase. References: Maskell NA, et.al. BTS guidelines for the investigation of a unilateral pleural effusion in adults. Thorax 2003;58(Suppl III):ii8-ii17. Tarn A, Lapworth R. Biochemical analysis of pleural fluid: what should we measure? [Review]. Ann Clin Bioch 2001; 38:311-322. Back to Section 5 Back to index

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Section 7 Paediatric/Neonates

Reference Ranges

Reference Range Test (+ special requirements) Neonatal Paediatric

Albumin* 32 - 47 33 - 50 g/L Ammonia* <115 <70 μmol/L ALT** 10 – 80 10 – 42 U/L ALP** < 600 < 350 U/L Amylase** < 90 < 300 U/L Bilirubin* < 200 < 26 μmol/L Calcium* 1.6 - 3.0 2.12 - 2.85 mmol/L Creatine Kinase** < 350 < 200 U/L Creatinine* 30 - 80 30 – 80 μmol/L Glucose* 2.2 - 5.0 3.9 – 7.0 mmol/L GGT** < 60 < 30 U/L IgG** 4 – 17 3 – 14 g/L IgA** 0.01 - 0.15 0.5 - 2.8 g/L IgM** 0.05 - 0.40 0.3 - 2.2 g/L Iron* 5 - 23 4 - 26 μmol/L Lactate* 0.5 - 3.0 0.6 - 2.4 mmol/L LDH** < 2000 < 1000 U/L Magnesium* 0.6 – 1.1 0.6 – 1.1 mmol/L Phosphate* 0.8 – 2.6 1.0 – 2.1 mmol/L Protein* 38 - 66 42 - 77 g/L Thyroxine – (FT4)* 6 – 80 10 – 30 pmol/L Triiodothyronine - (FT3)* ND 3.6 – 6.9 nmol/L TSH* 0.5 - 25 0.5 – 6.0 U/L Urea * 1.4 - 5.5 2.7 – 7.2 mmol/L CSF protein* 100 - 350 < 150 mg/L

• *Ranges derived from reference ranges of Edinburgh Hospital for sick Children • **Ranges derived from manufacturers recommendations

For neonatal samples please indicate the order of priority of the requests, especially if the sample volume is small, so that the most relevant analyses are performed first. Glucose analysis may be performed on a lithium heparin sample if the sample is sent to the laboratory within 30 minutes. The yellow fluoride tubes should only be used for samples taken outwith the hospital or for late outpatient clinics The lab can be contacted for sample volumes to be worked out as needed on individual patients. Back to Section 5 Back to index

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Section 8 Therapeutic Drug Monitoring and Drug Overdose

Therapeutic Drug Monitoring The timing of sample collection can be important when assessing therapeutic response in relation to dosage, and samples taken at the incorrect time with regards to drug dose can give very misleading results. Drug Time post

dose Therapeutic range

Toxic range Time to steady state

Carbamazepine(B) just before dose

4 - 12 >15 mg/L 7 days

Cyclosporin just before dose

90 - 225 7 days

Digoxin 6 - 24 hours 0.8 - 2.0 >3.0 μg/L 7 days Lithium 8 - 18 hours 0.6 - 1.0 >2.0 mmol/L 7 days Phenobarbitone not critical 15 - 35

15 - 40 children adults

20 days 20 days

Phenytoin not critical 10 - 20 >20 mg/L 14 days Salicylate just before

dose 150 - 300 >500 mg/L 7 days

Tacrolimus just before dose

5 – 15 μg/L 2 days

Theophylline 4 hours (slow) 8 - 20 >25 mg/L 2 days Valproate just before

dose 60 - 100 >120 mg/L 3 days

PLEASE STATE THE DRUG DOSE AND TIME POST DOSE. This is essential in order to interpret the therapeutic drug level. Please note: Anti-epileptic drug levels are run twice a week. Back to Section 5 Back to index

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Paracetamol/Salicylate Overdose Sample collection: Samples collected less than 4 hours after drug overdose are unlikely to be helpful in determining whether active treatment is indicated as there may be some delay in achieving peak levels. Paracetamol Overdose: The following graph provides a guide to initiate active treatment with acetylcysteine when a timed serum paracetamol concentration is available. It provides the serum paracetamol levels above which liver damage can be expected unless active treatment is instituted, regardless of risk factors for hepatotoxicity. Acetylcysteine treatment is also indicated irrespective of serum paracetamol level in circumstances where the overdose is staggered or there is doubt over the time of paracetamol ingestion.

These guidelines on paracetamol overdose were issued by the Commission on Human Medicines, 3rd Sep 2012. Further information can be found on the MHRA website: http://www.mhra.gov.uk/Safetyinformation/Safetywarningsalertsandrecalls/Safetywarningsandmessagesformedicines/CON178225

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http://www.mhra.gov.uk/Safetyinformation/Safetywarningsalertsandrecalls/Safetywarningsandmessagesformedicines/CON178225

http://www.mhra.gov.uk/Safetyinformation/Safetywarningsalertsandrecalls/Safetywarningsandmessagesformedicines/CON178225

Salicylate Overdose: In very large overdoses blood salicylate levels can continue to rise for up to 24 hours following ingestion. Blood levels should be determined 4 - 6 hours following overdose and if appropriate repeated several hours later. Tests available as required for immediate management of the patient Therapeutic level of Salicylate (mg/L) Analgesia / Antipyresis < 100 mg/L Anti-inflammatory 150 - 300 mg/L Back to Section 5 Back to index

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Section 9 Test Results Affected by Diet

Dietary requirements for urine collection of 5-HIAA This test is done by the Department of Clinical Biochemistry at the Western General Hospital in Edinburgh, and they have set out a couple of special instructions for when urine is collected for 5-HIAA. The urine should be collected over a period of 24 hours in a container containing a small amount of acid (please read the leaflet accompanying the container very carefully for more information). Certain foods and medicines MUST be avoided during the collection period (and preferably 4 days prior to collection). These include: Foods: Aubergines (eggplant), avocados, bananas, pineapples, red plums, pineapples tomatoes, walnuts and certain cough syrups (all products containing serotonin MUST be avoided). Medicines: Paracetamol, cough medication, phenothiazine tranquilizers. Back to Section 5 Back to index

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Section 10 Useful calculations USEFUL CALCULATIONS Anion Gap (mmol/L) (Na+ + K+) – (CO2 + Cl-)

Ca (corrected) Serum-Ca2+ + (40 – S-Albumin)0.02

Creatinine Clearance (ml/min) (serum and urine samples)

U-Creat (x 1000) x 24h.urine vol.(ml.) S-Creatinine x 1440

Creatinine Clearance (Male) (serum sample only) (Female)

(140 – Age) x Weight (kg) Serum Creatinine x 0.82 (140 – Age) x Weight (kg) Serum Creatinine

eGFR (MDRD 4 variable) See www.renal.org/eGFR for detail

FAI (Free Androgen Index) Testosterone x 100 .

Sex hormone Binding Globulin

LDL-Cholesterol

LDL = TC – HDL – Trig/5

Osmolarity (mmol/L) 2(Na+) + K+ + Glucose + Urea

Back to Section 5 Back to index

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http://www.renal.org/eGFR

Section 11 Referral Laboratories WGH-Edinburgh Dept. of Clinical Biochemistry Western General Hospitals NHS Trust Crewe Road Edinburgh, EH4 2XU 0131 537 1900 (general enquiries) The following tests are analysed at this Laboratory: ACE Aldosterone Alpha-1-Antitrypsin Cholestenone C-Peptide CUB Screening (Combined ultrasound and Biochemical Screening) For Down’s Syndrome Elastase 5-HIAA Diet Insulin Metanephrines Oligoclonal bands Oxalate Porphobilinogen Renin Thyroglobulin Back to Section 5 Back to index

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RI-Edinburgh

Royal Infirmary Edinburgh 51, Little France Crescent Edinburgh EH16 4SA Dept of Clinical Biochemistry General Enquiries 0131 242 7777 (6879 Duty Biochemist) The following tests are analysed at this Laboratory: ACTH Bile Acids Ceruloplasmin Cholinesterase Cyclosporin Dehydroepiandrosterone Sulphate (DHEA-S) Growth Hormone HCG (Tumour) Sirolimus Tacrolimus TRAB (TSH Receptor Antibodies) Department of Medicine General Enquiries 0131 242 2462 The following tests are analysed at this Laboratory: Hyaluronic Acid Clinical Immunology Edinburgh and S.E. Scotland B.T.S. General Enquiries 0131 242 7525/7529 The following tests are analysed at this Laboratory: Tryptase (anaphylactic screen) IgG subclasses Back to Section 5 Back to index

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Royal Hospital for Sick Children - Edinburgh Paediatric Biochemistry Dept. Royal Hospital for Sick Children Sciennes Road Edinburgh EH9 1LF 0131 536 0403 (general enquiries) The following tests are analysed at this Laboratory: Amino Acids Amino Acids (urine) Biotinidase Cystine Free Fatty Acids Galactose-1-Phosphate Uridyl-Transferase (GALIPUT) Hydroxybutyrate Lysosomal enzymes Methotrexate Muccopolysaccharides Organic Acids (urine) Phenylalanine Phenobarbitone Sweat Test Back to Section 5 Back to index

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RI-Glasgow Dept of Clinical Biochemistry Glasgow Royal Infirmary Glasgow G4 0SF General Enquiries 0141 211 4288 The following tests are analysed at this Laboratory: Aluminium Androstenedione Arsenic Calcitonin Chromium Cobalt Copper Copper (Urinary) Gastrin Insulin Growth Factor 1 (IGF1) Lead 17-OH Progesterone Selenium Sex Hormone Binding Globulin Steroid Profile – Urine Trace Metal & Micronutrient Screen UFC (Urinary Free Cortisol) Vitamin A Vitamin B1 (Thiamin) Vitamin B2 (Riboflavin) Vitamin B6 (Pyridoxal phosphate) Vitamin D-25 (OH) Vitamin E Zinc Back to Section 5 Back to index

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Ninewells – Dundee Ninewells Hospital Dundee DD1 9SY

Department of Biochemical Medicine General Enquiries 01382 632 602 The following tests are analysed at this Laboratory: Erythropoetin - (EPO)

Human Genetics Department of Pathology General Enquiries 01382 496261 The following tests are analysed at this Laboratory: Haemochromatosis Screen Back to Section 5 Back to index

University Hospital of Wales - Cardiff Porphyria Service Department of Medical Biochemistry & Immunology, University Hospital of Wales Heath Park Cardiff CF14 4XW

General Enquiries 02920 74 2637 The following tests are analysed at this Laboratory: Porphyrins Back to Section 5

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Willink Biochemical Genetics Lab - Manchester Willink Unit, Genetic Medicine 6th Floor, St Mary’s Hospital Oxford Road Manchester M13 9WL

General Enquiries 0161 701 2137 / 8 The following tests are analysed at this Laboratory: Chitotriosidase Back to Section 5 Back to index St. James – Leeds Department of Clinical Biochemistry St. James University Hospital Beckett St LEEDS LS9 7TF General Enquiries 0113 2064565 The following tests are analysed at this Laboratory: Catecholamine (Paediatric) Back to Section 5

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Immunology - Sheffield Immunology Department and Protein Reference Unit P.O. BOX 894 Sheffield S5 7YT General Enquiries 0114 271 5715 The following tests are analysed at this Laboratory: Ca 19-9 Chromogranin A (Tumour Marker) Back to Section 5 Back to index

Children's Hospital – Sheffield Dept of Clinical Chemistry and Newborn Screening Sheffield Children's NHS Trust Western Bank Sheffield S10 2TH General Enquiries 0114 271 7404 The following tests are analysed at this Laboratory: Trimethylamine Back to Section 5 Back to index

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University - Birmingham

Clinical Immunology Service University of Birmingham PO Box 1894 Vincent Drive Edgebaston BIRMINGHAM B15 2SZ General Enquiries 0121 414 3824 The following tests are analysed at this Laboratory: Beta 2 Microglobulin (B2M) Free Light Chains (serum)

City Hospital - Birmingham

Department of Clinical Biochemistry City Hospital Birmingham West Midlands B18 7QH General Enquiries 0121 554 3801 The following tests are analysed at this Laboratory: Laxative Screen

Queen Elizabeth Hospital - Birmingham

University Hospitals Birmingham NHS Foundation Trust, Clinical Laboratory Services, Level Minus 1, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2 WB General Enquiries 0121 627 2000 The following tests are analysed at this Laboratory: Thyroglobulin Back to Section 5 Back to index

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Southmead Hospital - Bristol Blood Sciences and Bristol Genetics Southmead Hospital Westbury on Trym Bristol BS10 5NB General Enquiries 0117 323 5556 The following tests are analysed at this Laboratory: Phytanic Acid Very Long Chain Fatty Acids Back to Section 5 Back to index General Hospital - Southampton Trace Element Unit Division of Laboratory Medicine Southampton University Hospital NHS Trust Mail Point 804 Southampton General Hospital Tremona Road Southampton SO16 6YD General Enquiries 023 80 796427 The following tests are analysed at this Laboratory: Citrate Strontium Back to Section 5 Back to index

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King's College Hospital – London King's College Hospital London SE5 9RS Dept of Clinical Biochemistry General Enquiries 020 3299 3856 The following tests are analysed at this Laboratory: Carbohydrate Deficient Transferrin (Alcohol Dependancy) (Adults) Toxicology Unit Bessemer Wing General Enquiries 020 3299 5881 The following tests are analysed at this Laboratory: Quinidine Back to Section 5 Back to index

Great Ormond St Hospital - London Biochemistry laboratory Great Ormond St Hospital for Sick Children London WC1N 3JH General Enquiries 0207 829 8624 The following tests are analysed at this Laboratory: Carnitine (Free and Acetyl-) Back to Section 5 Back to index

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Charing Cross Hospital – London Clinical Biochemistry & Medical Oncology Charing Cross Hospital London W6 8RF General Enquiries 020 3313 5353 The following tests are analysed at this Laboratory: Chromogranin A (Gut Hormone) Chromogranin B (Gut Hormone) Intestinal peptide screen (Gastrin, Glucagon, Pancreatic Peptide, VIP) Back to Section 5 Back to index

St Thomas Hospital - London

St. Thomas' Hospital Lambeth Palace Road London SE1 7EH Medical Toxicology Laboratory 3rd Floor, Block 7, South Wing General Enquiries 020 7188 8689 The following tests are analysed at this Laboratory: Lamotrigine (Lamictal) Purine Laboratory 4th Floor, North Wing General Enquiries 020 7188 1266 / 020 7188 1265 The following tests are analysed at this Laboratory: Thiopurine Methyl Transferase (TPMT) Back to Section 5 Back to index

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University College Hospital - London Department of Biomedical Medicine University College Hospital 60 Whitfield Street London W1T 4EU General Enquiries 020 3447 9405 The following tests are analysed at this Laboratory: Stone (Calculus) Analysis Back to Section 5 Back to index

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Section 12 Dynamic Function Tests SAFETY CONSIDERATIONS DURING ENDOCRINE METABOLIC TESTS Any dynamic or provocative test has potential for side effects or adverse reactions, although these are uncommon in experienced hands and if appropriate precautions are taken. Precautions, contraindications and adverse reactions should be reviewed before any test is undertaken. Staff must have detailed knowledge of the particular test protocol and provocative agents to minimize potential adverse events and any queries regarding patient suitability brought to the attention of the Consultant/GP in charge of the patient. Important adverse reactions in various tests include:

• hypoglycaemia • dehydration • minor reactions to provocative agents e.g., nausea, vomiting • allergic or anaphylactic reaction to provocative agent • cannula related complications – blood loss, infection • hypotension

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GLUCOSE TOLERANCE TEST

The diagnosis of diabetes mellitus in a symptomatic patient requires a random plasma glucose concentration (>2 h.pp) of more than 11.1 mmol/L on 2 separate occasions, or preferably an elevated random glucose confirmed by a fasting glucose (> 10 hr.) of more than 7.0 mmol/L.

ORAL GLUCOSE TOLERANCE TEST

If there is a clinical suspicion of diabetes with the Plasma Glucose levels on random sampling between 6.0 - 11.1 mmol/L, and/or the fasting glucose level between 6.0 and 7.0 mmol/L, proceed to an oral glucose tolerance test. The fasting patient should be resting, may not smoke during the test and should have been on a normal diet for three to four days. A fasting venous sample is withdrawn for plasma glucose estimation and a glucose load of 75g is given, in at least 300 ml of water. The glucose can be obtained from pharmacy. Despite previous practice, lucozade should NOT be used. A second venous sample is taken 2 hours post dose. Both sample times being carefully written on blood tubes and request form.

Diabetes is confirmed if the fasting glucose > 7.0 mmol/L or 2-h level > 11.1 mmol/L Impaired glucose tolerance when 2h level is between 7.8 – 11.1 mmol/L (Impaired fasting glucose when fasting glucose is between 6.0 – 7.0, although the clinical relevance of this is unclear. Most authorities simply recommend further periodic fasting sampling.)

Summary of Oral Glucose Tolerance Test

Fasting

(mmol/L)

2 Hours

(mmol/L)

Diabetes Unlikely < 6.0 < 7.8

Impaired Glucose Tolerance 7.8 - 11.0

Impaired Fasting Glucose 6.1 – 6.9

Diabetic > 7.0 > 11.1

Gestational Diabetes > 5.0 > 8.5

Reviewed JO’D Jul 2012

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INVESTIGATION OF HYPOGLYCAEMIC ADULTS

The diagnosis of hypoglycaemia requires the laboratory confirmation of a low blood glucose (< 3.0 mmol/L), when the presence of an inappropriately elevated fasting Insulin level confirms Insulinoma, (having excluded sulphonylurea and exogenous insulin administration (C-peptide useful).)

Glucose/Insulin measurement Test Protocol - The test should be repeated on three separate occasions. The patient (in-patient/outpatient) MUST be fasted overnight. Lithium Heparin ( 2 x 2 ml ) samples are sent immediately to the Clinical Chemistry Laboratory for glucose measurement and two aliquots stored frozen for Insulin + C - peptide.

Interpretation - Plasma glucose must be less than 3.0 mmol/L (ideally < 2.5 mmol/L)

The ratio Insulin (mU/L) Glucose (mmol/L) - 1.7 is normally <5 in Obesity 5 - 10 in Insulinoma >30

Extended Glucose Tolerance This test is used to assess the dynamics of glucose absorption and metabolism in conditions where the fasting glucose is within the reference range, but isolated hypoglycaemic episodes have been observed or recorded.

Test Protocol

The patient should be fasted overnight and throughout the test.

Water is allowed as required and the patient encouraged to be mobile.

Sample 1 Fasting sample for glucose. (2ml Yellow F tube)

75 g glucose given orally (in 300mL water).

Further Samples At 30 minute intervals for at least 3 hours, then hourly until notification of completion of test. (5 - 8 hours).

Each sample must be labelled with name, DOB and/or CHI, and time taken and sent to Clin Chem laboratory on completion of test. Samples can be sent during the test if hypoglycaemia is suspected clinically

Interpretation - Functional (reactive) hypoglycaemia can develop 2 - 4 hours after a meal or glucose load, and the ‘dumping syndrome’ occasionally seen after gastrectomy. Documentation of the hypoglycaemic episode is often all that is required and Insulin levels are not normally useful. The finding of an elevated Insulin/glucose ratio at a fasting plasma glucose level of < 3.0 mmol/L suggests excessive Insulin production.


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INVESTIGATION OF SUSPECTED ACROMEGALY AND GIGANTISM

Screening Test A random GH level of < 2mU/L makes the diagnosis of acromegaly highly unlikely.

ORAL GLUCOSE TOLERANCE TEST (TEST OF GH SUPPRESSION) Patient preparation The patient should be fasted overnight, but out-patients travelling a long distance may be allowed tea without sugar on rising. If information from glucose levels is also required, the test should be preceded by three days on a normal diet containing at least 150 g carbohydrate per day.

Procedure 1. Insert an indwelling IV catheter at least 30 min before the start of the test. 2. The patient should be resting before the test and must neither eat nor smoke during

the test. 3. The patient should sit up, or rest lying on the right side following the oral glucose

load. The patient should not lie flat, nor on the left side. -5 Basal measurements (1.2 mL orange heparinised blood tube x 2) 0 Give oral glucose, 75g (in 300mL water) 30 Collect blood via IV catheter (1.2 mL orange heparinised blood tube) 60 Collect blood via IV catheter (1.2 mL orange heparinised blood tube) 90 Collect blood via IV catheter (1.2 mL orange heparinised blood tube) 120 Collect blood via IV catheter (1.2 mL orange heparinised blood tube) 150 Collect blood via IV catheter (1.2 mL orange heparinised blood tube) Label all samples with name, DOB and CHI, and TIME and send to Laboratory immediately after last sample for glucose and growth hormone measurement. Interpretation Most normal individuals show suppression of at least one GH level to <2 mU/l, whereas in most cases of gigantism and acromegaly, GH levels fail to suppress from their high initial fasting levels, and indeed may show a paradoxical rise in response to glucose. Reviewed JO’D Jul 2012 Back to index

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INPATIENT INVESTIGATION OF CUSHINGS SYNDROME

EXTENDED LOW/HIGH DOSE DEXAMETHASONE TEST This test will only be sanctioned for consultant endocrinologists

Before commencing this investigation, there should be evidence that the screening tests for Cushings syndrome are abnormal or borderline. At least 2 days should have elapsed since any steroid therapy. Day 0 11 pm Blood Cortisol

Day 1 Basal samples 9 am Plasma ACTH (EDTA) + serum cortisol (Brown serum gel)

EMU for urinary free cortisol (PLAIN Universal)

Give 0.5 mg Dexamethasone (orally) 6 hourly for 48 hours.

Day 2 9 am serum Cortisol

Day 3 9 am Plasma ACTH (EDTA) + serum cortisol (Brown serum gel)


Give 2.0 mg Dexamethasone (orally) 6 hourly for 48 hours.

Day 4 9 am serum cortisol (Brown serum gel)

Day 5 9 am Plasma ACTH (EDTA) + serum cortisol (Brown serum gel)


Interpretation -

Cortisol ACTH

Stress/obesity Suppressed cortisol (< 50 nmol/L) Normal or ↓

Pituitary dependent ≅ 50% suppression ↑

Adrenal carcinoma not suppressed ↓

Ectopic ACTH not suppressed ↑↑

NB ACTH is an unstable analyte. The is sample taken into Red top EDTA tube and delivered IMMEDIATELY to Clinical Chemistry for centrifugation and storage at –20 C. Reviewed JO’D Jul 2012 Back to index

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OUTPATIENT SCREEN FOR CUSHINGS SYNDROME

• Serum Cortisol A random serum cortisol is difficult to interpret as elevated levels are seen in stress,

obesity and due to oral contraceptive pill, whereas a serum cortisol level within the

reference range does not exclude Cushings. (Ref range 170 - 640 nmol/L)

An early sign in Cushings Syndrome is a loss of diurnal rhythm of cortisol with an

elevated midnight cortisol. (Ref. range midnight cortisol < 220 nmol/L) The midnight

sample is difficult to collect as an outpatient.

• Urine Free Cortisol A plain 24 hour urine is required (ref. range 20-180 nmol/24hrs.) Elevated levels are

found in Cushings.

• Overnight Dexamethasone Suppression Test

An oral dose of dexamethasone (1mg) is given between 22.00 h and midnight and in the

morning the following samples collected:

o 10ml aliquot (plain universal) of the first urine passed on rising for Urine Free

Cortisol.

o A serum sample (9.00 am.) for serum cortisol. (does not need to be fasting).

Interpretation

The serum cortisol should be suppressed to <50 nmol/L (< 100 nmol/L acceptable)

The urine cortisol should be suppressed to <10 μmol/mole creatinine.


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INVESTIGATION OF HYPOTHALAMIC - PITUITARY ADRENAL HYPOFUNCTION

Short Synacthen Stimulation Test This test is an important investigation in cases of suspected adrenal insufficiency.

Patient Preparation The test can be performed as an outpatient procedure; the patient need not be fasted.

Procedure • Collect 5ml venous blood into a serum gel tube (brown cap) for basal serum cortisol

estimation. • Inject the contents of one ampoule of synacthen (250μg) intravenously or

intramuscularly. • Collect a second 5ml blood sample 30 minutes after synacthen injection.

Interpretation In normal subjects the plasma cortisol level should rise by at least 200 nmol/L to achieve a 30 minutes cortisol of at least 500 nmol/L.

Prolonged (24h) Synacthen Test This test will only be performed with express permission of a Consultant Chemical Pathologist and a Consultant Endocrinologist Patient Preparation If the patient has been started on steroid replacement therapy for presumed Addisons Disease, prolonged ACTH stimulation remains a valid test of adrenocortical function as long as the medication is changed from hydrocortisone to dexamethasone. Fludrocortisone therapy can be continued. Please inform the Clinical Chemistry Department BEFORE commencing.

Procedure • A baseline serum cortisol is measured (along with a sample for ACTH if appropriate –Red Cap EDTA tube). NB ACTH is an unstable analyte. This sample is taken into Red top EDTA tube and delivered IMMEDIATELY to Clinical Chemistry for centrifugation and storage at -20 c. • 1mg Synacthen depot is injected intramuscularly with serum cortisol samples taken at

1h, 2h,4h, 8h and 24h post injection.

Interpretation A normal response shows a gradual rise in serum cortisol to achieve a peak value at 4 – 8h of > 700 nmol/L A failure to respond, or an initial response at 60 min which is not sustained, indicates primary adrenal failure. In secondary adrenocortical insufficiency there is a gradual rise to a peak at 24h (eg pituitary failure or prolonged corticosteroid therapy). Adrenal atrophy may show no response but will have elevated ACTH


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INVESTIGATION OF 1° HYPERALDOSTERONISM Renin/Aldosterone Ratio Investigations for Primary hyperaldosteronism should be fully discussed with Consultant Chemical pathologist before proceeding.

Samples

The preferred initial screening method is a renin-aldosterone ratio. Samples for renin should be taken into red top 7.5mL EDTA tube

Samples for aldosterone, cortisol and Na+ /K+, should be taken into a serum gel tube (Brown

cap)

(Both samples taken immediately to the laboratory where Renin and Aldosterone samples are centrifuged and frozen.).

The results will be fully interpreted by consultant as part of final report.


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HYPOTHALAMIC PITUITARY FUNCTION

Hypopituitarism Anterior pituitary failure may affect one, more than one or all of the hormones of the anterior lobe of the pituitary gland. Hormone loss may occur concurrently or in sequence. Hypothalamic pituitary disease may also cause posterior pituitary failure, and diabetes insipidus. Basal Investigations (LH, FSH, Testosterone, Prolactin, Cortisol, TSH and FT4) NB It is essential that BOTH TSH and FT4 are requested as a TSH value within the reference range does NOT exclude hypopituitarism. Basal measurement of anterior pituitary hormones and a short synacthen test will provide diagnostic information in the majority of cases of suspected hypopituitarism.

However, the concentrations of TSH, T4, LH, FSH and testosterone (oestradiol) can fall significantly with severe illness.

A high FSH (and LH) in a post menopausal female suggests intact pituitary function, a low level is consistent with pituitary disease.

Basal growth hormone levels are of limited value since 50% of healthy subjects will have undetectable fasting levels.

Prolactin levels > 1000 mU/L require pituitary and hypothalamic imaging. (having excluded stress, pregnancy, primary hypothyroidism and drug effects – see below)

Drugs affecting serum prolactin concentration

Increased Prolactin

Decreased Prolactin

Dopamine receptor-blocking agents Dopamine agonists Phenothiazines (e.g. chlorpramazine, perphenazine, fluphenazine)

L-dopa

Butyrophenones (e.g. haloperidol) Apomorphine Bentzamides (e.g. sulpride, metoclopramide domperidone)

Ergot derivatives (e.g. bromocriptine, lisuride, lergotrile)

Pinozide Nomitensine Opiates Clonidine Dopamine depleting drugs (e.g. methyldopa, reserpine)

Serotonin antagonists (e.g. methysergide)

Histamine receptor antagonists (e.g. Cimetidine)

Monoamine oxidase inhibitors (short term)

Monoamine oxidase inhibitors (long term)

Some oestrogens


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TRH, LH-RH TEST OF HYPOTHALAMIC - PITUITARY FUNCTION This test only to be requested by Consultant Endocrinologists *Please note that occasionally isolated TRH and Gn RH tests may be requested. Again this should only be requested by Consultant Endocrinologists. Patient Preparation The patient need not be fasted, and no special preparation is required. Procedure Obtain Thyrotrophin Releasing Hormone (TRH) - 200 μg Gonadotrophin Releasing Hormone (Gn RH) - 50 μg Time -5 Collect blood for basal measurements of TSH, FT4, Prolactin, and LH/FSH (4.7 mL

Brown serum gel) Time 0 Inject IV. the TRH, and LH-RH *(only one will be injected in individual

tests) Time 20 Collect blood (4.7 mL Brown serum gel) for:

• TSH (for the combined and TRH test), • Prolactin (for all tests), • LH/FSH(for the combined and Gn RH test) (5 mL Brown serum gel)

Time 60 Collect blood (4.7 mL Brown serum gel) for:

• TSH (for the combined and TRH test), • Prolactin (for all tests), • LH/FSH(for the combined and Gn RH test) (5 mL Brown serum gel)

The samples should be labelled with name, DOB and CHI, and time of sample Interpretation TSH the 20 minute level is at least 2mU/l greater than basal achieving a result of 4.0- 30 mU/L. LH/FSH LH expect 4 x increase in basal to 10 - 40 U/L. FSH expect 2 x increase in basal to 2 - 14 U/L (M), 5-25 U/L (F) Reviewed by JO’D Aug 2012 Back to index

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CLONIDINE/TRH/GnRH TEST This test only to be requested by Consultant Paediatric Consultant

Patient Preparation the patient should be fasted overnight (4h for infants) and should have had height and weight measured for the determination of surface area.

Test Procedure A fasting sample is taken into a brown serum gel tube and the following administered:

• Clonidine 0.15 mg/sq.m. as Dixarit tablets (.025 mg dose rounded up if necessary) taken with a small sugar-free drink.

• TRH 7 μg/kg up to a maximum of 200 μg i.v.

• GnRH 50 μg i.v. and the following samples are taken for 150 minutes into Brown serum gel tubes.

Time Volume GH FSH/LH TSH PROLACTIN CORTISOL FT4 TESTO 0 5 ml X X X X X X X 20’ 5 ml X X X X 30’ 2 ml X 60’ 5 ml X X X X 90’ 2 ml X 120’ 2 ml X 150’ 2 ml X The samples should be labelled with name, DOB and CHI, and time of sample. The samples are relatively stable and should be taken to the Clinical Chemistry laboratory at the end of the test.

CLONIDINE TEST (without TRH /GnRH) This reduced version of the test measures only the GH response to CLONIDINE at 30 min. intervals until 150 min. Time Volume GH TSH CORTISOL FT4 0 5 ml X X X X 30’ 2 ml X 60’ 2 ml X 90’ 2 ml X 120’ 2 ml X 150’ 2 ml X

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Human Chorionic Gonadotrophin (HCG) Stimulation Test This test only sanctioned by a Consultant Paediatric Endocrinologist In the normal male child HCG increases the testicular secretion of testosterone. This test therefore examines the capacity of the Leydig cells to respond to HCG and secrete testosterone. It is used in the investigation of delayed puberty in boys and in some cases of undescended testes. It can also be useful in the differentiation of male hypogonadism, the testicular feminisation syndrome and inborn errors of androgen synthesis. Note that HCG cross-reacts in most LH assays, and if sample for LH are to be taken (e.g. as part of a gonadrotrophin hormone stimulation test), then this must be done before the HCG is administered. Procedure: 1. No special preparation of the patient is necessary. On the first day (day 1) collect blood

(minimum 1.0 ml in 1.2mL orange (LiHep) tube) for testosterone assay at 0900 – 1000 h and send this to the laboratory. Write on the request form “HCG Test Day 1”.

2. Give HCG (children younger than 14 years 1500 iu, adults and children older than 14

years 3000 iu) by intramuscular injection. The full HCG dose may be dissolved in 0.5 ml normal saline to make injection less painful.

3. On the next two days (days 2 and 3) give HCG (children younger than 14 years 1500 iu,

adults and children older than 14 years 3000 iu) by intramuscular injection at about 1000 h.

4. On the last two days (days 4 and 5) collect blood for testosterone assay at 0900 – 1000

h, (minimum 1.0 ml in 1.2mL orange (LiHep) tube). Send each sample to the laboratory (by van or post if the samples are taken by the child’s GP). Write on the request forms “HCG Test Day 4” and “HCG Test Day 5” respectively.

Interpretation: A normal Leydig cell response is indicated by a significant increase in plasma testosterone (to at least 5 nmol/l) following the HCG injections. Reviewed JO’D Jul 2012 Back to index

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HYPOTHALAMIC - POSTERIOR PITUITARY FUNCTION – I This test only to be sanctioned by a Consultant Endocrinologist

I.Fluid deprivation test • Smoking is forbidden on the day of the test, both before it starts and during its

performance. The patient may have a light breakfast, but no tea or coffee. • Start the test at 0830h. No fluids are allowed from then until the end of the test.

Constant supervision is needed to prevent surreptitious water drinking. • Vasopressin (DDAVP) should be obtained from Pharmacy in case the test needs to be

prolonged to test for nephrogenic diabetes insipidus. • Weigh the patient at the start of the test and again 4, 6, 7 and 8 hours later. Weight

loss of 3% or more indicates that severe dehydration has occurred and that the test should be stopped as soon as one more set of blood and urine samples has been collected.

• Collect and label blood and urine samples as follows: - Urine sample Period of urine

collection Blood Time of blood

collection U1 0830 - 0930 h B1 (Brown serum gel) 0900 h U2 1130 - 1230 h U3 1430 - 1530 h U4 1530 - 1630 h B2 (Brown serum gel) 1600 h

The urine should be collected in 8.5mL Sarstedt Monovette urine collection tube (yellow) and labelled with name, DOB and CHI, and the period of collection. Interpretation

Normally, there is no increase in plasma osmolality.(Reference values 280 - 290 mosmol/kg), whereas the urine osmolality rises to more than 600 mosmol/kg during the test.

Patients with diabetes insipidus due to hypothalamic or pituitary disease, or nephrogenic diabetes insipidus, show an increase in plasma osmolality during the test, to more than 300 mosmol/kg, and a low urine osmolality (200 - 400 mosmol/kg usually).

Patients with psychogenic polydipsia have a plasma osmolality that is initally low but which rises to normal during the test. Urine osmolality in these patients may increase to 600 mosmol/kg, but concentrating power is often impaired.


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HYPOTHALAMIC - POSTERIOR PITUITARY FUNCTION - II

II. DDAVP Test (1-desamino-8-D-arginine vasopressin)

If the urine osmolality fails to reach 600 mosmol/kg in the fluid deprivation test (in-patient procedure), a DDAVP test should be performed as an immediate sequel to the fluid deprivation test to test for nephrogenic diabetes insipidus. The procedure is as follows: - • On completion of the fluid deprivation test, at 1630h, and after allowing fluids in moderation to alleviate dehydration, DDAVP (10 - 20 ug intranasally, or 2 - 4 ug intramuscularly) is given, and urine collected in hourly samples for a further 4 hours, as follows:- Urine Sample Period of urine collection U5 1700 - 1800 h U6 1800 - 1900 h U7 1900 - 2000 h U8 2000 - 2100 h These 4 samples can be collected at home. They should be collected in 8.5mL Sarstedt Monovette urine collection tube (yellow) and labelled with name, DOB and CHI, and the period of collection. This test may be performed the next day if more appropriate. No patient preparation is required and urine samples could be collected at hourly intervals after a morning Desmopressin dose. Interpretation of DDAVP test: In hypothalamic or pituitary disease giving rise to diabetes insipidus, there is a marked increase in urine osmolality, to more than 600 mosmol/kg, in response to DDAVP. However, there is no significant increase in patients with nephrogenic diabetes insipidus. Reviewed JO’D Jul 2012 Back to index

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DIABETES INSIPIDUS – OVERNIGHT SCREENING TEST This test should not be performed before discussion with a Consultant Endocrinologist or the Consultant Chemical Pathologist. This test is potentially dangerous and should NOT be recommended for children or patients who are physically or mentally incapacitated Before commencing the Overnight screening test it is recommended that a measure of the patient’s daily Urine Volume is obtained. If this is less than 2.5 Litres (the volume of a urine container) Diabetes Insipidis is unlikely. The test may be performed at home with the proviso that the patient is informed that the test should be stopped if he/she becomes excessively thirsty. He/she should then be admitted for a ward supervised fluid deprivation test. The patient is allowed no food or fluids after 10 pm until the completion of the test. Sample 1 (8.5mL Sarstedt Monovette urine collection tube (yellow))- On rising, the patient collects an aliquot of the first urine passed and empties bladder - recording name, DOB and/or CHI, and time of collection on container. Sample 2 (8.5mL Sarstedt Monovette urine collection tube (yellow)) FASTING/THIRSTING IS CONTINUED and the patient collects a second urine sample 1 - 2 hours later, again recording name, DOB and/or CHI, and time on sample. Both samples to be sent together for Osmolality measurement. Interpretation - A urine Osmolality > 600 mosmol/kg in either sample excludes diabetes insipidus. Patients with values below 600 mosmol/kg probably require a full fluid deprivation test. Reviewed JO’D Jul 2012 Back to index

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Section 13 24hr urine collection

HOW TO COLLECT SPECIMENS FOR CREATININE CLEARANCE

CREATININE CLEARANCE measurement is used as a measure of kidney function and requires a timed (usually 24 hours) collection or urine and a blood sample taken during, or at the end of the urine collection period.

The blood sample and 24 hour urine collection should be clearly labelled with YOUR NAME, DOB and DATE and TIME OF COLLECTION. Whenever possible these samples should be sent together to the Clinical Chemistry Laboratory.

The Accuracy of the final result depends largely on YOUR urine collection being a true timed collection.

24 HOUR URINE COLLECTION URINE CONTAINER – A plain container (no preservative) is suitable for CREATININE CLEARANCE, although an Acid preservative (2M HC1) may be used. If Acid preservative used, PLEASE DO NOT EMPTY OUT THE ACID OR WASH THE CONTAINER

(a) At the commencement of the 24 hour collection period (e.g. 8.00 a.m.) you should empty YOUR bladder as normal. This urine should NOT be collected into your container. This time is now written on the urine container along with the date and YOUR NAME, ready to start your collection. DO NOT EMPTY OUT THE ACID FROM YOUR CONTAINER.

(b) ALL Urine you pass over the next 24 hours MUST be collected into the urine container.

(c) At the end of the 24 hour collection period (e.g. 8.00 a.m.) you should empty your bladder and ADD this to the urine collection.

(d) Please take your completed urine collection to your GP Surgery/Health Centre and ask for a blood sample to be taken for serum creatinine.

(e) Your doctor will send the urine specimen, blood sample and request form to the Clinical Chemistry Laboratory.

PRECAUTIONS:

Dilute Hydrochloric acid is an irritant to eyes, skin and respiratory system. In case of contact with skin wash wish water. In case of contact with eyes rinse with water and obtain medical advice. Back to index

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HOW TO COLLECT SPECIMENS FOR METADRENALINE METADRENALINE measurement is used as a screen for a possible cause of hypertension requires a timed (usually 24 hours) collection of urine. The 24 hour urine collection should be clearly labelled with YOUR NAME and DATE OF COLLECTION. The Accuracy of the final result depends largely on YOUR urine collection being a true timed collection. 24 HOUR URINE COLLECTION URINE CONTAINER - A urine container containing Acid (25 ml 2M Hydrochloric acid) MUST be used for the urine collection.

PLEASE DO NOT EMPTY OUT THE ACID OR WASH THE CONTAINER. (f) At the commencement of the 24 hour collection period (e.g. 8.00 a.m.) you should

empty YOUR bladder as normal. This urine should NOT be collected into your container. This time is now written on the urine container along with the date and YOUR NAME, ready to start your collection.

(g) ALL Urine you pass over the next 24 hours MUST be collected into the urine

container. (h) At the end of the 24 hour collection period (e.g. 8.00 a.m.) you should empty your

bladder and ADD this to the urine collection. (i) Please take your completed urine collection to your GP Surgery/Health Centre and

ask for a blood sample to be taken for serum creatinine. (j) Your doctor will send the urine specimen, blood sample and request form to the

Clinical Chemistry Laboratory. PRECAUTIONS: Dilute Hydrochloric acid is an irritant to eyes, skin and respiratory system. In case of contact with skin wash wish water. In case of contact with eyes rinse with water and obtain medical advice. Back to index

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Borders General Hospital · Borders General Hospital. Clinical Chemistry Department . Users...

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Transcript of Borders General Hospital · Borders General Hospital. Clinical Chemistry Department . Users...