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LABORATORY INFORMATION HANDBOOK Department of Pathology and Laboratory Medicine Edited by Daylily S Ooi, MBBS, FRCPC & Marg Maddock, ART, MBA Contents Telephone list Critical values Abbreviations 2 4 Test Information 5-77 Anatomical Pathology, Biochemistry, Cytology, Hematology, Immunology, Microbiology, Transfusion Medicine Cultures Cytology FNA Biospy Serological tests 29 31 37 66 Transfusion Medicine 79-88 Products & Services Blood and blood Products Fractionation Products Appendix Antibodies Autoimmune diseases Chromosomal, DNA, Genetic Studies Enzymes Fluids Porphyria 82 86 89-102 89 92 93 98 101 102 The Ottawa Hospital 2002 Useful Telephone Numbers Pathologist On-Call: . . . . . . . . . . . . . . . . . OC 761-4221 (locating); OG 782-9308 Biochemist, Hematopathologist or Microbiologist On Call: . OC 761-4221; OG 737-8222 Riverside Campus Laboratory: . . . . . . . . . . . . . . . . . . . . . . . . . . . 738-8214 Campus Hours of Operation Anatomical OC (M–F) 0630–1700h 761-4344 Pathology / Autopsy services OG (M–F) 0800–1700h 737-8292 Cyto-Pathology Biochemistry and Hematology Bleeding Time Bone Marrows Telephone OC (M–F) 0800–1630h 761-4344 OG (M–F) 0800–1600h 737-8305 OC 24h 761-4247 Special Coag: 798-5555 x14190 OG 24h 737-8300; Stat Biochemistry: 737-8319, Hematology: 737-8275 798-5555 x13520 OC (M–F) 0800–1630h OG (M–F) 0800–1600h 737-8275 OC (M–F) 0830–1630h Reports: 761-4254 Booking: 798-5555 x 16216 OG (M–F) 0800–1600h Reports: 737-8355 Booking: 737-8275 Immunology Microbiology Hepatitis/Virology OC (M–F) 0800–1600h Reports: 761-4247 Inquiries: 798-5555 x 16367 OC (Daily) 0800–2000h 761-4454 OG (Daily) 0800–2000h 737-8322 761-4342; 1700–0800: 761-14328 OC 24h OG (Daily) 0800–2000h 737-8322 Point of Care OC (M–F) 0800–1600h 798-5555 x 13505 Tissue Typing OG (M–F) 0730–1630h TT, Flow cyto: 737-8277 DNA section: 737-8792 Tech cadaveric transplants: 737-8222 Transfusion Medicine OC 24h 761-4328 OG 24h 737-8302 Autologous Transfusion OC (M–Thurs) 0730-1530h 798-5555 x17483 Phlebotomy OC (M–F) 0800–1600h 798-5555 x 13424 (M–F) 0600–1130 Phlebotomist: (Page) 594-7784 OG Services Patient results and lab information 737-8310 OG (M–F) 0730-1700h 737-8306 OC 24h 761-4247 or 798-5555 x 16117 for archived (outpt) results OG 24h 737-8300 This handbook contains information useful for interpretation of laboratory tests 쐌 Expected values (reference intervals) in SI (Systeme Internationale) units. Where the quoted reference intervals are different from the computer reports, the latter is the updated version. 쐌 Conversion factors - from traditional units to SI units 쐌 Turnaround times (TAT): For the tests that are available round the clock, both stat and routine, no TATs are stated. Most automated chemistry and immunoanalyzer tests are in this category, and have TAT up to 3 hours. 쐌 Interferences stated may be characteristic of the method used. As methodologies change, some of the information may not be correct. 쐌 Prices: The prices have been included to give you an idea as to the relative costs of the tests. Single [$] sign tests are relatively cheap and easy to perform, whereas [$$$$$] tests are usually referred out at a high cost (>$100) and should be ordered only after consultation with a laboratory physician or scientist. 쐌 LMS (labour, materials, supervision) units are the basis for OHIP billing by laboratories. They are used for pricing of laboratory services for non-clinical testing. At time of publication, one LMS unit is 51.7 cents. Call the lab to confirm before grant submission. General Information on laboratory services For Transfusion Med services, please see under specific section (Page 79) RESTRICTED TESTS: Tests that are restricted are noted under Specimen. Consult as appropriate, failure to do so will delay work on the specimen. When testing is approved, write on req: “Attention or Approved by (name of staff)” Tests not listed are not available locally (unless they have been introduced after printing). Some uncommon tests may be available from reference labs; they are usually expensive and may have special collection requirements. SAMPLE COLLECTION: All samples must be labelled (minimum of patient’s name and unique number) and accompanied by a requisition. If the only identification is the requisition, it must be physically attached to the specimen container. Specimens for Transfusion Medicine must be labelled with a Transfusion Medicine requisition label, and accompanied by the requisition signed by phlebotomist. Instructions for completion of requisitions, sample labelling and transport, and types of requisitions are available in the WARD MANUAL. GETTING RESULTS: Results are available through the OACIS system, or by phoning the lab. Continued next page 1 STAT and Critical Results Biochemistry and Hematology: All critical results (see below and following pages) are phoned immediately; stat results are printed on expedite printers. CONFIDENTIALITY The Department of Laboratory Medicine goes to great effort to safeguard the confidentiality of laboratory results. For this reason, laboratory staff are not permitted to issue certain sensitive test results by telephone. They also have instructions to establish the authenticity of the recipient of the message. These security considerations apply particularly to STD test results. RESULTS THAT WILL BE PHONED: MICROBIOLOGY: All preliminary results considered urgent, such as: 쐌 Stat Gram stain results 쐌 CSF Gram stain results 쐌 Results of any staining procedures indicating serious infection 쐌 Positive blood culture results 쐌 Positive CSF culture and susceptibility test results 쐌 Other sterile site culture results 쐌 Positive culture results indicating serious or unusual infection requiring immediate treatment or special management precautions CRITICAL VALUES: Hematology: Result will be phoned immediately to physician or primary care nurse. For CBC, if parameter has been reported as critical within past 7 days, and remains critical, a repeat call will not be made. Hemoglobin Platelets WBC Blood film/smear <50 g/L >190 g/L <20 ´109/L >1000 ´109/L Granulocytes <0.5 ´109/L >40 ´109/L If not previously reported - Sickle cells, Malarial parasites, Intracellular bacteria - RBC fragments with thrombocytopenia INR >5.0 PTT >150s Fibrinogen Standard anti-Xa Bleeding time 2 <0.5 g/L >1.0 U/mL > 15 min Biochemistry Critical Values: Low pH Na+ K+ High <7.10 — <120 mmol/L >160 mmol/L <3.0 mmol/L (Dialysis pt: predialysis <3.5, postdialysis <2.5) >6.0 mmol/L (predialysis >6.5) Glucose <2.0 mmol/L >28.0 mmol/L Calcium <1.50 mmol/L >3.00 mmol/L Ionized Ca++ <0.80 mmol/L >2.00 mmol/L Magnesium <0.4 mmol/L >5.0 mmol/L Phosphate <0.4 mmol/L; predialysis <0.7 mmol/L — Bilirubin (Neonates <1m) >285 umol/L THERAPEUTIC DRUGS Acetaminophen Amikacin > 1000 umol/L Predose > 8 mg/L Carbamazepine >60 umol/L Digoxin >3.3 nmol/L Ethosuximide Gentamicin >1000 umol/L Predose > 2 mg/L Lithium >1.5 mmol/L Phenobarbital >200 umol/L Phenytoin >100 umol/L Primidone >60 umol/L Procainamide >70 umol/L Procainamide + NAPA >110 umol/L Salicylate >4.7 mmol/L Theophylline >110 umol/L Tobramycin Predose >2 mg/L Valproic acid >1000 umol/L Vancomycin Predose >15 mg/L 3 Abbreviations Time m w d h min s month week day hour minute second Volume L mL litre millilitre Number giga tera u (micro) n (nano) p (pico) f (femto) 109 1012 10-6 10-9 10-12 10-15 Measure g mol U IU gram mole Units International Units Vacutainers PST® (pale green) SST® (gold) Dark green Light blue Black Mauve Red Royal blue Cost of analysis: [$] < $5 [$$] $5–14 [$$$] $15–49 [$$$$] $50–100 [$$$$$] > $100 4 Abbreviations Auto Automated AAS Atomic Absorption Spectroscopy CBS Canadian Blood Services Chem Chemistry CV Coefficient of Variation (Reproducibility) % EDTA Ethylenediamine tetraacetic acid GC Gas chromatography HICL Hospitals-in-Common Laboratory Inc., Toronto (Reference Laboratory System) HPLC High Performance Liquid Chromatography IA Immunoassay IFIX Immunofixation LMS Labour, Management, Supplies (OHIP billing) OC Civic Campus OG General Campus PHL Public Health Lab RS Riverside Campus RT Room Temperature RIA Radioimmunoassay TAT Turnaround Time TM Transfusion Medicine TT Tissue Typing/DNA/Flow cytometry Lab 2 Appendix Plasma separator tube, contains lithium heparin Serum separator tube, contains thrombin activator Lithium heparin Sodium citrate (3.2%) Sodium citrate (buffered), used for ESR EDTA (potassium or sodium) No additive Low metal (contains sodium heparin) 2 See Appendix TEST INFORMATION: ABO and Rh TYPING, BLOOD GROUP TYPING Use: Determine patient ABO & Rh blood group prior to and post transfusion; detect ABO hemolytic disease of the newborn. Specimen: Mauve (7 mL) Rejection criteria: presence of abn protein, cold agglutinins; recent transfusions; leukemia, malignancy, positive direct antiglobulin test. Some bacteria may interfere with typing. TAT: Routine 1-3h, Stat 5 min Lab: TM Price: [$] LMS 18 ACETAMINOPHEN Use: For management of overdose only; restricted to ER, ICU, AMA Specimen: Therapeutic: Toxic level: Half-life: Serum/plasma SST/PST 66-199 umol/L Dependent on time post-ingestion and presence of hepatotoxicity (as low as 330 umol/L if >12h). Conversion factor: 2h (t½ >4h suggestive of hepatotoxicity) ug/mL ´ 6.6 = umol/L Method: Auto chem, CV 3%. Lab: Biochem Price: [$$] LMS 25 ACETONE see KETONES ACETYLCHOLINE RECEPTOR AB see ANTI-ACETYLCHOLINE RECEPTOR AB ACTIVATED PROTEIN C RESISTANCE, APC RESISTANCE Use: Investigation of familial thrombotic tendency (decreased) Specimen: Ref Interval: Plasma 2.0-2.7 (ratio) Light blue x 3 Transport on ice Method: TAT: 10d Functional test for co-factor. Lab: Hematol Price: [$$$] ADRENOCORTICOTROPIN, ACTH For ACTH stimulation test - see CORTISOL Specimen: Plasma Chilled mauve Transport on ice within 30 min Ref Interval: 08:00-09:00h 1.3-12.5 pmol/L Conversion factor: Comments: Method: TAT: 4w ng/L ´ 0.22 = pmol/L Ectopic ACTH >44 pmol/L. IRMA (DiaSorin), CV: 10% Lab: Biochem Price: [$$] LMS 120 5 ALANINE AMINOTRANFERASE, ALT, (SGPT) Specimen: Serum/plasma SST/PST Ref Interval: 14-63 U/L RS: 5-40 U/L Method: Lab: Biochem ALBUMIN, Serum Specimen: Serum/plasma Ref Interval: 35-48 g/L Conversion factor: Method: Lab: Biochem 2 Enzymes Auto chem, CV: 3%. Interferences: hemolysis () Price: [$] LMS 5 SST/PST g/dL ´ 10 = g/L Auto chem, CV: 2%. Price: [$] LMS 5 ALBUMIN, Urine (MICROALBUMIN) Specimen: Random, 24h or 4h morning (after first void) sample Not performed if total protein > 2 g/L. Expected values: Adults: Incr Overt Sample Normal excretion proteinuria 24h <14 15-300 >300 mg/d @ 2-23 >23 mg/mmol creat 4h; random <1 @ CDA guidelines: F:<2.8 M<2.0 mg/mmol creat Children: <3.4 mg/mmol creat Conversion factor: Method: TAT: M-F, 1d mg/d ´ 0.001 = g/d Turbidimetry, CV: 8%. Lab: OC Biochem Price: [$] ALDOLASE Specimen: Ref Interval: Serum, not plasma SST/red Adults: 1-8 U/L Method: TAT: 7d Auto chem, CV: 8%. Interferences: hemolysis (). Lab: HICL Price: [$] ALDOSTERONE Specimen: Serum SST/red Ref Intervals: On normal sodium diet: Supine >8 h: 28-445 pmol/L Upright >8 h: 110-860 pmol/L Low body sodium and erect posture aldosterone Conversion factor: Method: TAT: 14d ng/dL ´ 27.7 = pmol/L RIA (DPC), CV: 10% Lab: OC Biochem Price: [$$$] LMS 120 ALKALINE PHOSPHATASE, ALP Specimen: Serum/plasma Ref Intervals: Cord blood – 1w: Infant: Adolescent: Adult: Method: Lab: Biochem 6 Auto chem, CV: 2% Price: [$] LMS 5 SST/PST 2 Enzymes approximates adult values 2-3 ´ adult values up to 7 ´ adult values 38-126 U/L ALKALINE PHOSPHATASE ISOENZYMES Specimen: Serum/plasma SST/PST Performed only if ALP is > reference interval for age. Interpretation: Bone and liver fractions normally present. Placental isoenzyme present in 3rd trimester. Method: TAT: 10d Agarose gel electrophoresis with lectin Lab: OG Biochem Price: [$$] LMS 29 ALKALINE PHOSPHATASE, BONE SPECIFIC, BSAP Specimen: Serum/plasma red/green Restricted to Endocrinology, others consult Biochemist th Ref Interval: 95 percentile: Males 20 ug/L Females Premenop 14 ug/L Postmenopausal 22 (median 12) ug/L Method: TAT: 4w Auto IA (Beckman Access®, Ostase®) Lab: Biochem Price: [$$] ALLERGY TESTING see also RADIOIMMUNOSORBENT TEST Specify allergen – AVIAN (budgie and pigeon), FARMER’S LUNG Specimen: Expected value: Serum SST/red Undetected or absent allergen specific IgE (<0.35 kU/L) Method: TAT: 30d Radioallergosorbent assay Lab: HICL Price: [$$] ALPHA-1-ANTITRYPSIN, A1-AT Specimen: Serum Ref Interval: 0.9-1.7 g/L Conversion factor: Method: TAT: 7d SST/red mg/dL ´ 0.01 = g/L Immunonephelometry, CV:7% Interf: lipemia, gross hemolysis. Lab: OC Biochem Price: [$$] LMS 12 ALPHA-FETOPROTEIN, AFP, Serum Use: (1) Monitoring response in liver cancer, not for screening (2) MSS/IPS program Specimen: Expected Value: Serum/plasma <11 ug/L Comments: Up to 20 ug/L in pregnancy, rarely up to 200 ug/L. Open neural tube defect >400 ug/L. Also in cirrhosis, hepatitis. ng/mL = ug/L AutoIA (AxSYM®), CV: 6% Interf: heterophile antibodies (mice) Lab: OC Biochem Price: [$$] LMS 45 Conversion factor: Method: TAT: 7d (usu Fri) SST/PST ALUMINUM, AL3+, Plasma Specimen: Plasma Royal blue top Restricted to hemodialysis patients; consult Biochemist. Ref Interval: <371 nmol/L Patients on aluminum medications <1,100 nmol/L Conversion factor: Method: TAT: 30 d ug/L ´ 37.1 = nmol/L Atomic Absorption Spectroscopy Lab: HICL Price: [$$] 7 ALUMINUM, Urine Specimen: 24h urine in acid-washed bottle (Biochem) Restricted to hemodialysis patients; consult Biochemist. Ref Interval: <928 nmol/d TAT: 30 d AMIKACIN Specimen: Therapeutic: Toxic conc: Lab: HICL Price [$$] Serum/plasma SST/PST State if pre or post-dose Predose (mg/L) Postdose (mg/L) 5 – 10 20 – 35 >8 >35 (Guidelines only, consult Pharmacy) Conversion factor: Half-life: Method: TAT: M-F, 1d mg/L ´ 1.71 = umol/L 1.5-15 h IA (TDx/FLx®) Lab: OG Biochem Price: [$$$] LMS 40 AMINO ACIDS SCREEN see METABOLIC SCREEN AMINO ACIDS QUANTITATION, Serum Specimen: Serum/plasma SST/red/PST Restricted. Start with Urinary Metabolic Screen. Method: TAT: 7d Column chromatography Pharmacia Biochrom® Amino Acid Analyzer. Lab: CHEO Biochem Price: [$$$] LMS 200 AMINO ACIDS QUANTITATION, Urine Specimen: 24h urine no preservative, or with thymol added Restricted to neonates. Cystine ordered separately (see Cystine). Performed only if screen positive. Method: TAT: 7d See serum Lab: CHEO Biochem Price: [$$$] LMS 200 d AMINOLEVULINIC ACID, ALA (includes Porphobilinogen), Urine Use: Diagnosis of acute porphyrias (acute intermittent, variegata) and lead poisoning. Specimen: 2 Porphyrias Ref Interval: 24h urine in brown bottle with 7 g tartaric acid or Random 50 mL urine - send to lab immediately, or adjust pH to 5 with tartaric acid. Protect from light. ALA: PBG: Conversion factor: Method: TAT: 14d 8 0 - 50 umol/d 1-5 mmol/mol creat (not reliable if creat < 4 mmol/L) 0 – 9 umol/d 0.1-0.8 mmol/mol creat ALA: mg/dL ´ 7.63 = umol/L; mg/d ´ 0.763 = umol/d PBG: mg/d ´ 4.42 = umol/d BioRad® Ion exchange/colorimetric assay, CV 7%. Lab: OG Biochem Price: [$$$] LMS 25 AMITRIPTYLINE see TRICYCLIC ANTIDEPRESSANT QUANT AMMONIA, NH3 Specimen: Plasma PST/dark green on ice For stat, consult Biochem Lab. Ref Interval: > 3m old: 5-30 umol/L < 3m old: 10-55 umol/L Conversion factor: Comments: Method: TAT: M-F, 1d. mg/dL ´ 0.587 = umol/L At 25oC, in whole blood by 1 umol/L/min. Dry chemistry analyzer (Vitros®) Lab: CHEO Biochem Price: [$] LMS 39 AMNIOTIC FLUID see also FETAL LUNG MATURITY AMNIOTIC FLUID SCAN: DELTA OD450, D450 Specimen: 3 mL amniotic fluid in plain tube, protect from light with foil, provide gestational age Expected value: Zone 1(Modified LILEY Prediction Curve) see graph Comments: Method: Lab: Biochem Zone reported only if gestational age >28 w Spectrophotometric scan. Interf: Hemoglobin, meconium or urine. Price: [$$] LMS 20 AMYLASE, Serum substitute with Lipase; avail only at RS Specimen: Serum/plasma SST/PST Ref Interval: 30-110 U/L TAT: M-F, 1d Lab: RS Biochem Price: [$] LMS 5 AMYLASE, Fluid Specimen: Pleural or peritoneal fluid. Urine amylase not available. Interpretation: Extremely high - pancreatitis, pancreatic pseudocyst. TAT: M-F, 1d Lab: RS Biochem Price: [$] LMS 5 ANDROSTENEDIONE Specimen: Serum SST/red Fasting sample recommended, for females collect 1w before or after menstrual period. Ref Interval: Males: 1.7-5.2 nmol/L Females: 1.7-7.0 nmol/L Conversion factor: TAT: 2-3w ng/mL ´ 3.49 = nmol/L (MW 286) Lab: HICL Price: [$$] LMS 75 Abbreviations: (complete list on page 4): TAT Turnaround time (from time of receipt) RS HICL Hospital-in-Common Lab (Toronto) OC LMS Labour, Management, Supplies (OHIP billing) OG Riverside Campus Civic Campus General Campus 9 ANGIOTENSIN CONVERTING ENZYME, ACE Specimen: Serum/plasma SST/PST not Mauve CSF Red Ref Interval: 11-44 U/L Comments: Method: TAT: 21d ¯ with steroid therapy. Reflects severity of sarcoidosis (91% of Stage III have elevated concentrations). á in Gaucher’s disease, leprosy, untreated hyperthyroidism, psoriasis, amyloidosis, histoplasmosis, mixed CTD. EMIT, CV: 10%. Interferences: Captopril (¯), heavy metals (¯) Lab: OC Biochem Price: [$$] ANION GAP Specimen: Ref Interval: Calculated from electrolyte values:[Na+] - [Cl-] - [HCO3 -] 5-12 mmol/L (potassium not included in equation) Comments: Most proteins are positively charged at physiologic pH, except for some monoclonal immunoglobulins. ANTI-ACETYLCHOLINE RECEPTOR ANTIBODIES, ACRA Specimen: Serum SST/red Restricted to Neurology; others consult Biochemist. Ref Interval: <0.4 nmol/L Comments: Method: TAT: 30 d Positive in >90% active generalized MG, ~60% ocular MG, <40% in remission. Radio-receptor immunoassay (IBL) Lab: HICL Price: [$$$$$] ANTI-BETA-2 GLYCOPROTEIN I, B2GP1 Use: Anti-phospholipid antibody syndrome. Specimen: Serum Comments: TAT: 4w Present in subgroup with negative anti-ACL and Lupus Ab. Lab: OG Hematol Red ANTIBODIES AGAINST TISSUES see individual antibodies under ANTIANTIBODIES AGAINST ORGANISMS see SEROLOGICAL TESTS ANTIBODY SCREEN/ IDENTIFICATION Use: Screening and detection of significant antibodies in patient’s serum, for transfusion and prenatals. Specimen: Comment: Mauve (7mL) Rejection criteria: SST, PST, gross hemolysis, unlabeled/improperly labeled specimen/requisition Performed with ABO and Rh grouping as part of the compatability testing. Patient’s serum is tested against reagent cells. Antibody is identified for positive screens. TAT: Routine 1-3h, Stat 45 min Lab: TM Price: [$$] ANTIBODY TITRE Use: Predict the severity of hemolytic disease of the newborn caused by significant red blood cell antibodies in maternal circulation. Specimen: 10 Mauve (7mL) Rejection criteria: SST, PST, gross hemolysis, unlabeled/improperly labeled specimen/requisition. Comment: NOT indicated for antibodies not associated with hemolytic disease of the newborn. A rising or falling titre is a significant indicator during pregnancy. TAT: Routine 24-48h Lab: TM Price: [$$] ANTI-CARDIOLIPIN/ANTIPHOSPHOLIPID ANTIBODIES Specimen: Serum SST/red (EDTA plasma also acceptable) For antiphospholipid synd., also order lupus anticoagulant Interpretation: Pos: 15-60 U/mL; Strongly pos: > 60 U/mL 2 Antibodies Method: TAT: 10 d Quantitative ELISA Lab: OC Imm/OG Hem Price: [$$$] ANTI-CENTROMERE ANTIBODIES see Antinuclear antibodies ANTI-DIURETIC HORMONE, VASOPRESSIN, ADH Specimen: Plasma Chilled PST/dark green Transport on ice immediately (Add 500 kIU/L Aprotinin if unable to centrifuge immediately). Ref. Interval: <7.5 pmol/L Method: TAT: 4w RIA Lab: HICL Price: [$$$] ANTI-DNASE B ANTIBODIES Use: Detection of streptococcus pyogenes infection Specimen Serum TAT: 2d Lab: CHEO Microbiol Price: [$$$] LMS 25 Red ANTI-dsDNA ANTIBODIES (double stranded) Specimen: Serum SST (min 2 mL) Performed only if ANA positive. Interpretation: Pos: 30-50 IU/mL Strongly pos: >300 IU/L 2 Antibodies, Autoimmune disease Method: TAT: 10 d Quantitative ELISA (Sanofi) Lab: OC Imm Price: [$$] ANTI-ENDOMYSIAL ANTIBODIES - see ANTI-TISSUE TRANSGLUTAMINASE ANTI-EXTRACTABLE NUCLEAR ANTIGEN ANTIBODIES, ANTI-ENA (SS-a/Ro, SS-b/La, RNP) Scl-70, Jo-1 must be requested specifically. Specimen: Serum SST/red Performed only if ANA positive 2 Antibodies, Autoimmune diseases Interpretation: ELISA screen: Neg: Not reactive with SS-a, SS-b, Sm or RNP. Pos: Antibodies present for antigen(s) indicated in report. TAT: 1w Lab: OC Imm Price: Screen: [$$] Titre [$$$] ANTI-GLOMERULAR BASEMENT MEMBRANE AB, ANTI-GBM Specimen: Serum SST/red Interpretation: Pos >20 EU 2 Antibodies Method: TAT: 3d Indirect immunofluorescence - monkey kidney Lab: OC Imm Price: Qual [$$$] Titre [$$$$$] 11 ANTI-HEMOPHILIAC FACTOR see FACTOR VIII ASSAY ANTI-HISTONE ANTIBODIES Specimen: Sample for ANA. Performed only if ANA is positive. Interpretation: 2 Antibodies; Autoimmune diseases TAT: 14d Lab: HICL Price: [$$$] ANTI-Jo-1 ANTIBODIES See ANTI-EXTRACTABLE NUCLEAR ANTIGEN ANTIBODIES and 2Antibodies; Autoimmune disease ANTI-MICROSOMAL (THYROID PEROXIDASE) ANTIBODIES Specimen: Serum SST/red Interpretation: 2 Antibodies Method: TAT: 7d Microtitre particle agglutination with serial dilution. Assay cross-reacts with thyroglobulin antibodies. Lab: OC Biochem Price: [$] LMS 6 ANTI-MITOCHONDRIAL ANTIBODIES see ANTI-TISSUE ANTIBODIES ANTI-NEUTROPHIL CYTOPLASMIC ANTIBODIES, ANCA Specimen: Serum SST/red (min 3 mL serum) For rapid screen within 1h - inform lab (798-5555 x16367). Method: Interpretation: TAT: 3d Screen: Indirect immunofluorescence at 1:20 dil using ethanol-fixed neutrophils. If cANCA or pANCA pattern, further testing with formalin-fixed neutrophils and ELISA. See page 90 2 Antibodies for method details and interpretation. ELISA Pos: >15 U Lab: OC Imm Price: Screen [$], Quant [$$$] ANTI-NUCLEAR ANTIBODIES, ANA – HOMOGENEOUS, SPECKLED, NUCLEOLAR, PERIPHERAL, CENTROMERE Specimen: Interpretation: Serum SST/red Pos: > 1:40 Positives increase with age. 2 Antibodies; Autoimmune diseases Method: Indirect immunofluorescence screened using Hep-2 cells at 1:40 dilution, titred if positive. Lab: OC Imm Price: Screen [$] Titre [$$] TAT: 3d ANTI-PARIETAL ANTIBODIES see ANTI-TISSUE ANTIBODIES ANTI-PEMPHIGUS/PEMPHIGOID ANTIBODIES Specimen: Serum SST/red Comments: TAT: 4d Negative or positive at ¼ and 1/16 dilutions. Lab: HICL Price: [$$] ANTI-Scl-70 ANTIBODIES see also ANTI-EXTRACTABLE NUCLEAR ANTIGEN ANTIBODIES Specimen: Serum SST/red Interpretation: Significant if undiluted sample is positive (Ouchterlony) 2 Antibodies; Autoimmune diseases TAT: 2w 12 Lab: OC Imm Price: Titre [$$$] ANTI-SMOOTH MUSCLE ANTIBODIES see ANTI-TISSUE ANTIBODIES ANTI-STREPTOLYSIN O, ASO Use: Streptococcus pyogenes infection Specimen: Serum Expected result: 0 –125 IU/mL SST/red TAT: Analyzed 2x/w Lab: CHEO Biochem ANTI-THYROGLOBULIN ANTIBODIES order ANTIMICROSOMAL ANTIBODIES ANTI-THROMBIN ASSAY Use: Thrombotic diathesis (thrombophlebitis or pulmonary emboli not associated with trauma, in young patients or without family history of thromboembolism). Specimen: Interpretation: Method: TAT: 10 d Plasma Light blue ´ 3 Transport on ice Patient not on heparin (interferes with assay) Normal - 0.85-1.25 U/mL Borderline low - inherited def (suggest family studies) Very low – fulminant DIC Chromogenic functional assay. Antigen assay done on patients with low functional assay results. Lab: Hematol Price: [$$] LMS 55 ANTI-TISSUE (MITOCHONDRIAL, SMOOTH MUSCLE, PARIETAL CELL) ANTIBODIES Specimen: Serum SST/red (min 3 mL serum) Interpretation: Negative; positive sera titred 2 Antibodies Method: TAT: 3d Indirect immunofluorescence using mouse stomach and kidney. Screened at 1:20 dilution, titred if positive Lab: OC Imm Price: Screen [$$] Titre [$$$] LMS 35per titre ANTI-TISSUE TRANSGLUTAMINASE, IgA Specimen: Serum SST/red Restricted to Gastroenterology; others consult Biochemist Ref Interval: < 20 KEU/L Comment: TAT: 2w Transglutaminase is the major autoantigen of endomysium Lab: HICL (McMaster) Price: [$$$] ANTI-Xa ACTIVITY Use: monitoring patients on standard heparin, LMWH and danaproid therapy Specimen: Therapeutic: Method: TAT: 1-2d Plasma Light blue Specify anticoagulant patient is on: · Standard Heparin (unfractionated) · Low Molecular Weight (LMWH) - Dalteparin (Fragmin) Enoxaparin (Lovenox), Tinzaparin (Innohep) · Danaproid (Orgaran) · Other Std Heparin: 0.35-0.70 IU/mL LMWH: range associated with specific type Chromogenic methodology Lab: Hematol Price: [$$$] 13 APO A1 and B not available; APO E See 2 Chromosomal Studies APPT see PARTIAL THROMBOPLASTIN TIME ARSENIC, As3+ Specimen: Restricted; consult Biochemist. For acute/ ongoing exposure (avoid shellfish or fish for 5d): 24h urine: acid washed bottle (from Biochem) Stomach contents: acid washed bottle from Lab For chronic exposure: Hair: 1 g cut close to the scalp [1" long, 0.3" dia bunch] Ref Interval: Urine: <70 umol/mol creat (total arsenic) Hair: <1 ug/g (referred to Mayo U.S.) Urine half-life Method: 4d Atomic absorption spectroscopy TAT: 1w Lab: HICL/Mayo Price: [$$$$] ASCORBIC ACID, VITAMIN C Specimen: Plasma Ref Interval: Method: TAT: 10d Dark green, transport on ice (store plasma immediately at –80oC) Males: 10-85 umol/L Females: 10-110 umol/L HPLC, CV 8% Lab: OG Biochem Price: [$$$] ASPARTATE AMINOTRANSFERASE, AST, (SGOT) Specimen: Serum/plasma SST/PST Ref Interval: 15-41 U/L RS: 10-40 U/L 2 Enzymes Method: Lab: Biochem Auto chem, CV 3% Interf: hemolysis () Price: [$] LMS 5 ASPERGILLUS see RADIOIMMUNOSORBENT TEST (A. fumigatus) AUTOPSY PATHOLOGY Refer to “Dealing with Patient Death Package”, a grey folder available at nursing stations. This information package includes Autopsy Consent Form, Certificate of Death (Form 1), Medical Certificate of Death (Form 16), Organ / Tissue Donation Consent Form, Checklists for physicians, nursing staff and relatives. BACTERIAL DIRECT ANTIGEN Use: Detection of CNS infection when gram stain and culture are negative but CSF profile is suggestive of bacterial infection. Specimen: CSF in Red vacutainer Restricted; consult Microbiologist. Lab: CHEO Microbiol Price: [$$$] BARBITURATE SCREEN, Urine Use: For management of overdose patients only Specimen: 14 Random urine, no preservatives Restricted to ICU, ER, AMA Reported as: Positive: barbiturate present - no indication of drug conc (dependant on urine concentration and assay cross-reactivity). Negative: does not exclude presence. Method: AutoIA (AxSYMÒ), cal to give pos with secobarbital 200 ug/L. Assay known to detect the following: amobarbital, aprobarbital, barbital (low x-reactivity), butabarbital, butalbital, butobarbital, cyclopentobarbital, pentobarbital, phenobarbital, secobarbital, talbutal, thiamylal (low), thiopental (low), vinylbital. No/minimal cross-reactivity with: acetaminophen, diazepam, methadone, phenytoin, promethazine, salicylate, theophylline. TAT: Stat or routine. Lab: OG Biochem Price: [$$] LMS 25 BENZODIAZEPINE SCREEN, Urine Use: For management of overdose patients only. Specimen: Reported as: Random urine, no preservatives Restricted to ICU, ER, AMA; others consult Biochemist. Positive: benzodiazepine present with no indication of drug conc - dependant on urine conc and assay reactivity. Negative does not exclude presence. Method: AutoIA (AxSYMâ), cal to give pos with nordiazepam at 200 ug/L No/minimal cross-reactivity with: acetaminophen, amitriptyline, amoxapine, carbamazepine, diphenhydramine, promethazine, ethchlorvynol, furosemide, haloperidol, methaqualone, phenytoin, propoxyphene, secobarbital, thioridazine, trazodone. TAT: Stat or routine Lab: OG Biochem Price: [$$] LMS 25 Concentrations and cross reactivity with assay (Ellenhorn’s Medical Toxicology, Fenton’s Poisoned Patient, JGDonnelly) Concb for pos Cross-reactivity with assay (active metabolites; % approx) Drug T½ (h) Alprazolam (Xanax)a 12 (9-15) 200 High (75%); OH-aprazolam 8-19 900 Low 10 (6-28) 1600 25 (10-49) 1000 19-60 650 Low (10%) nor-metabolite (20%), desmethyldiazepam, oxazepam (high) Variable (18-62%), demoxepam (low), nor-clobazam Low, esp metabolite (30%), 7-NH2 metabolite (15%) Low 32 (14-61) 200 9-25 400 80 (40-200) 400 Lorazepam (Ativan) 13 (8-25) 600 Medium (36%), desalkyflurazepam (medium), OH-flurazepam, flurazepam aldehyde Medium (30%) Loprazolam 11 (5-22) 260 High, desmethyldiazepam Bromazepam Chlordiazepoxide (Librium) Clobazam Clonazepam (Rivotril)a Demoxepam Diazepam (Valium) Flunitrazepam (Rohypnol) Flurazepam Medazepam 900 High (90%), nor-diazepam (100%), oxazepam, 3OH diazepam Medium Continued on next page 15 Drug Concb for pos Cross-reactivity with assay (active metabolites; % approx) Midazolam (Versed) 2 (1.5-2.5) Nitrazepam 26 (18-48) 350 Medium (45%), metabolite (15%) 7 (5-13) 200 High (60%) 0.6-2 200 High, desmethyldiazepam Temazepam 13 (7-17) 320 High (60%), oxazepam Triazolam (Halcion) 2.5 (2-5) 340 Medium (50%), 1-methyl-OH-triazolam Oxazepam (Serax) Prazepam a T½ (h) 1-methyl-OH-midazolam Toxicity occurs at low serum conc (<100 ug/L) b Min conc for positive result. BETA-hCG see CHORIONIC GONADOTROPIN BETA-2-MICROGLOBULIN Specimen: Serum SST/red Restricted to OCF and Hematologists. Ref Intervals: <60y: <170 nmol/L >60y: <220 nmol/L Method: TAT: 14d IA (IMxâ) Lab: HICL Price: [$$] BICARBONATE, TOTAL CARBON DIOXIDE, tCO2 Specimen: Serum/plasma SST/PST Ref Interval: 22-32 mmol/L Conversion factor: Method: mEq/L = mmol/L Auto chem, CV 3%. Conc ¯ on standing/storage. Lab: Biochem Price: [$] LMS 5 BILIRUBIN, DIRECT, CONJUGATED Specimen: Serum/plasma SST/PST Protect from light Ref Interval: 2-9 umol/L RS: 0-8 umol/L Conversion factor: Method: mg/dL ´ 17.1 = umol/L Auto chem, CV 6%. Interferences: hemolysis (¯). Lab: Biochem Price: [$] LMS 5 BILIRUBIN, NEONATAL Specimen: Capillary tube, green microtainer not EDTA Protect from light. Ref Interval: Potentially toxic concentrations: >285 umol/L Method: Lab: Biochem Spectrophotometry, CV 3%. Interferences: carotenoids (therefore not suitable for infants >14d). Price: [$] LMS 5 BILIRUBIN, TOTAL Specimen: Serum/plasma Ref Interval: 2-20 umol/L Method: Lab: Biochem 16 SST/PST (protect from light if delayed) Auto chem, CV 3%. Interferences: hemolysis (). Price:[$] LMS 5 BLEEDING TIME, BT Use: Platelet function disorders (congenital and acquired), von Willebrand’s disease. Specimen: Ref Interval: Tested at bedside. Phone Hematol (OC:13520, OG:78275). Patient prep: no ASA or NSAIDS in the previous 10d. CBC also required. 2.5-9.5min TAT: M-F, 4h Lab: Hematol Price: [$$] LMS 15 BLOOD FILM/SMEAR see FILM BLOOD GASES and pH, measured O2 saturation Specimen: Arterial, venous, mixed venous and cord blood. Remove air bubbles, remove needle, cap nozzle and label specimen. Transport on ice. Venous samples, filled green vacutainer may be used. Ref Interval: Adult Umbilical cord Arterial Venous Arterial 7.36-7.44 7.33-7.41 7.13-7.39 pCO2 mmHg 35-45 38-47 28-66 pO2 mmHg 80-90 20-50 9-38 HCO3 [calculated] mmol/L 22-27 23-27 12-27 ± 2.5 ± 2.5 -14.0 to 0.4 95-99% 60-85% pH Base excess mmol/L O2 saturation [calculated] Comments: For every 10 mmHg of pCO2 change, HCO3- changes by: Acidosis metabolic: (¯ pCO2) ¯ 8 mmol/L respiratory: ( pCO2) 1 mmol/L Alkalosis metabolic: ( pCO2) 17 mmol/L respiratory: (¯ pCO2) ¯ 2 mmol/L Conversion factor: kPa ´ 7.5 = mmHg Method: Ion-selective electrodes, CV 1%, instrument also measures Hb, COHb, MetHb, whole bld electrolytes, iCa, glucose, lactate. Factors affecting: At room temp/h: pH ¯ 0.03, pCO2 5 mmHg pO2 ¯ 6 mmHg. At 4oC, pO2 may in plastic syringes (permeability of plastic) Lab: OC Biochem/OG: CP Lab(ICU) Price: [$] LMS Abbreviations: (complete list on page 4): Auto Automated Chem Chemistry Analyzer CV Coefficient of Variation (reproducibility) CoHb Carboxyhemoglobin MetHb Methemoglobin Ionized calcium iCa min h d w m CP OC OG RS PST SST Cardio-Pulmonary Civic Campus General Campus Riverside Campus Pale Green Top Gold top minutes hour day week month 17 BODY FLUID CELL COUNT Specimen: Ascitic, pleural, peritoneal, pericardial, synovial fluid. Mauve not SST (min 1 mL) State source and specific tests required. Test includes: RBC, WBC count and differential if WBC >10x106/L. Cultures, cytology and chemical studies must be requested separately and with separate specimens. See body fluid CULTURE and CYTOLOGY (Effusions). Interpretation: Lymphocytes - assoc with TB, tumours, lymphomas, lymphatic leukemia, RA, post-pneumonia effusions. Neutrophils - assoc with acute infective processes. Eosinophils - assoc with tumors, infarcts, LE, RA, rheumatic fever, parasites, post-pneumonia effusions, pneumothorax. Lab: Hematol Price: [$$] BONE MARROW ASPIRATE, BONE MARROW BIOPSY Specimen: Aspiration and biopsy by medical staff. Phone Hematol (OC:16216, OG:78275) for technologist. Patient history information essential for proper morphologic interpretation. Indicate if cultures, biopsy, cytogenic studies or special requests needed. Also order CBC and Retic count (Whole blood in Mauve). Test includes: Leishman stain, iron stain. Biopsy: routine stains. Films available for review in Hematology Lab. Interpretation: Normal marrows should contain stainable iron. Myeloid:Erythroid ratio normally 3 to 1. Morphologic interpretation reported. TAT: M-F, 2-3d Lab: Hematol Price: [$$] C1 ESTERASE INHIBITOR, C1-INH Specimen: Serum SST/red Ref Interval: 0.21-0.39 g/L Conversion factor: TAT: 14d mg/dL ´ 0.01 = g/L Lab: HICL Price:[$$] LMS 12 CA-125 see CANCER ANTIGEN 125 CAFFEINE Use: Monitoring of neonates treated with theophylline for apnea Specimen: Therapeutic: Toxic conc: Serum 40-100 umol/L > 250 umol/L Conversion factor: Method: ug/mL ´ 5.2 = umol/L Syva EMITâ, CV 8%. TAT: Daily Lab: CHEO Biochem Price:[$$] 18 SST/red (morning if result same day) CALCITONIN Specimen: Expected Value: Comments: TAT: 30 d Serum Chilled Red Transport on ice <100 ng/L, may be lower in women. Following pentagastrin stimulation: <200 ng/L C cell hyperplasia/tumour not likely 200-500 ng/L C cell hyperplasia likely >500 ng/L Medullary thyroid carcinoma likely See 2 Chromosomal Studies - ret proto-oncogene. Lab: HICL Price: [$$$] LMS 120 CALCIUM (TOTAL), Ca++ Specimen: Serum/plasma Ref Interval: 2.23-2.58 mmol/L SST/PST Conversion factor: Factors affecting: mg/dL ´ 0.25 = mmol/L mEq/L ´ 0.5 = mmol/L Total Ca ¯ 0.2 mmol/L for every 10 g/L ¯ in alb (from 40 g/L). Method: Auto chem, CV 2% Interf: EDTA (¯¯), Oxalate (¯). Lab: Biochem Price:[$] LMS 5 CALCIUM (TOTAL) 24h Urine Specimen: 24h urine, no preservative or 20 mL 6M HCl Ref Interval: 2.5-7.5 mmol/d or <0.1mmol/kg body weight/d Conversion factor: TAT: M-F, 1d mg/d ´ 0.025 = mmol/d Lab: Biochem Price: [$] LMS 5 CALCIUM, IONIZED FREE Specimen: Whole blood PST/dark green Filled to line Low heparin syringe (7 USP/3mL) with bld gas analysis Serum SST/red Transport on ice Ref Interval: 1.15-1.40 mmol/L Conversion factor: Method: Lab: Biochem mg/dL ´ 0.25 = mmol/L mEq/L ´ 0.5 = mmol Ion selective electrodes, CV 1%. Interferences: heparin (¯), prolonged storage at RT () because of pH ¯ Price: [$] LMS 20 CALCULI ANALYSIS, RENAL Reported as: Calcium oxalate, calcium phosphate, struvite, calcium carbonate, uric acid, ammonium urate, cystine or combination. Method: TAT: 21d Chemical methods for calcium, magnesium, ammonium, cystine, carbonate, phosphate, urate and oxalate. Interferences: Silicates, Indinavir can give slight positivity for oxalate test. Lab: OC Biochem Price:[$$] LMS 15 CALCULI, BILIARY not available Abbreviations: (complete list on page 4): Auto Automated Chem Chemistry Analyzer CV Coefficient of Variation (reproducibility) PST SST Mauve Pale green, Li Heparin Gold, thrombin activator EDTA 19 CANCER ANTIGEN-125, CA-125 Use: Monitoring ovarian cancer, NOT screening. Elevated in 80% of ovarian cancer. Specimen: Expected Value: Serum < 35 U/mL SST/red Sample at mid cycle Plasma half-life: Method: Following ablative surgery - 5d, prolonged t½ (>20d) is associated with poorer survival. - up to 3x ULN at menses;in peritoneal inflammatory process AutoIA (AxSYMâ), CV 6%. Interf: heterophile antibodies to mice. TAT: 1w Lab: OG Biochem Price:[$$] CANNABINOID SCREEN, TETRAHYDROCANNABINOIDS, THC Specimen: Random urine Reported as: Positive at 50 ug/L of 11-nor-d-9-tetrahydrocannabinol -9-carboxylic acid. Also detects 11-nor-d-8-THC-9-COOH (non-psychoactive major metabolite), 11-OH-d-9-THC, cannabinol Metabolism: Bioavailability: oral 5-20%, smoking 18-50%, higher with heavy use. Peak conc 5-12h after smoking. Mainly hepatic metabolism with many metabolites, concentrations depend on type of flower, twigs or oil ingested. Half-life: 25h (4d after repeated use). May be pos 1-5d after stopping low use, 3-6d after high use; up to 2m in heavyuse obese subjects Clinical toxicity: Disturbance in thought process, time perception, short-term memory; ataxia. High doses cause disorientation, paranoia, sensory distortion. Prolonged high dose – sinus tachycardia, impaired alveolar macrophage activity and lung function. Method: AutoIA (AxSYMâ) Cross-reactivity : Nil with cocaine metabolite (benzoylecgonine), caffeine, codeine, ibuprofen, nicotine/cotinine, ASA, secobarbital. Cross-reacts with ketoconazole. Interferences: bleach (¯), detergents. TAT: M-F, 1d, stat avail. Lab: OG Biochem Price: [$$] LMS 35 CARBAMAZEPINE Specimen: Serum/plasma SST/PST Draw trough level (12h after last dose) Therapeutic: 17-47 umol/L; lower when used with other antiepileptics Toxic conc: >60 umol/L, lower for children Erythromycin can raise concentration and cause toxicity Conversion factor: Clinical toxicity: Peak conc: Half-life: Method: Lab: Biochem ug/mL ´ 4.2 = umol/L Mild: diplopia, nystagmus, ataxia, dizziness. Mod: (42-126 umol/L) somnolence, hallucinations, myoclonus, hyperreflexia, vomiting, urinary retention, involuntary movements. Severe: (>168 umol/L): arrhythmias, coma, respiratory failure, hypotension. Rarely, hepatic damage, blood dyscrasia, osteomalacia, hypothyroidism. 4-8h, longer in overdose 16-26h in long term therapy AutoIA (AxSYMâ), CV 4%. Cross-reactivity: desipramine (++). Price:[$$] LMS 35 CARBON DIOXIDE, TOTAL see BICARBONATE 20 CARBOXYHEMOGLOBIN, COHb Specimen: Whole blood Dark green or Mauve Expected levels: Non-smokers: 0-2% Smokers: 2-10% Toxic conc: 10-30 %: headache, peripheral vasodilation 30-50 %: severe headache, weakness, dizziness 50-60 %: syncope, coma, fits, Cheyne-Stokes resp. 60-70 %: depressed cardiac and respiratory function 70-80 %: cardiac and respiratory failure, death Sources: Smoke - cigarette, auto, fire Use of paint stripper (methylene chloride) in enclosed space. Half-life: 5-6h at room air, 1h at 100% O2, 25 min at hyperbaric O2 (3 atm). Method: Co-oximetry, CV 2%. Lab: OC: Biochem, OG: CP Lab (ICU) Price:[$] LMS 15 CARCINOEMBRYONIC ANTIGEN, CEA Use: Monitoring metastatic breast cancer on treatment, and metastatic colorectal cancer on adjuvant therapy post-resection. Not for screening. Specimen: Interpretation: Serum/plasma SST/PST Complete CEA (Cancer Ontario) form Healthy <3.0 ug/L, smokers may have slight increases. >20 ug/L in symptomatic patient strongly suggestive of cancer and metastasis. Following surgery, elevated concentrations beyond 6w is suggestive of residual tumour. May be elevated in other malignancies – breast, GI, liver, lung, ovarian, pancreatic and prostatic cancer. Method: AutoIA(AxSYMâ),CV 7%. Interf: heterophile antibodies (to mice). TAT: 7d Lab: OG Biochem Price: [$$], funded by OCTRF for categories listed above. CAROTENE, ß-CAROTENE Specimen: Serum Red top, not SST Protect from light with foil Ref Interval: 1.0-5.5 umol/L Conversion factor: Method: ug/dL ´ 0.019 = umol/L Manual extraction into hexane. CV 10%. TAT:14d Lab: OC Biochem Price:[$$] LMS 16 CATECHOLAMINES, Plasma To be done as Clonidine Suppression Test. Indicated when urinary VMA and metanephrine results are equivocal. Restricted to Endocrinologists. CATECHOLAMINES, Urine Order VMA, METANEPHRINES; or consult Biochemist CD4/CD8 see FLOW CYTOMETRY CEREBROSPINAL FLUID, CSF see GLUCOSE, TOTAL PROTEIN, LACTATE, OLIGOCLONAL BANDING (includes IgG and albumin quantitation), CULTURES, CYTOLOGY 21 CEREBROSPINAL FLUID – CELL COUNT Test Includes: Appearance, RBC, WBC and diff. if WBC >10 ´ 106/L. Specimen: 3 sterile Red top (min 1mL each). Label and number tubes (counts are done on last tube). To arrive in lab within 1h Order cytology, cultures, chemistry, serology separately (tubes 1 and 2 may be used). Expected values: Appearance: clear, colourless fluid Leukocytes (mononuclear): adult:0-10 ´ 10 6/L neonates: 0-30 ´ 10 6/L Erythrocyte: <10 ´ 10 6/L Presence of more than few RBCs may indicate cerebral or subarachnoid hemorrhage or traumatic tap. TAT: Stat Lab: Hematol Price: [$$] CERULOPLASMIN, COPPER OXIDASE Specimen: Serum SST/red Ref Interval: Adult: 220-580 mg/L Conversion factor: Method: Comments: TAT: 7d mg/dL ´ 10 = mg/L Immunonephelometry (Beckman Immage®), CV 5%. Interf: marked lipemia <140 mg/L seen with Wilson’s disease (high liver copper). Seen with infections (late acute-phase protein), liver disease, oral contraceptive use. Lab: OC Biochem Price: [$$] LMS 19 CH100 see COMPLEMENT, TOTAL HEMOLYTIC CHLAMYDIA TRACHOMATIS see also SEROLOGICAL TESTS Specimen: Cervix and male urethral swab (use swab from Chlamydia PCR collection kit, Amplicor®), or first void urine. TAT: 4d Lab: Microbiol Specimen: Eye swab, conjunctival scraping. Use Chlamydia trachomatis MicroTrak collection kit, Syva®, slide from Microbiol TAT: 1d Lab: Microbiol Price: [$$] Price: [$$] - CHLORIDE, Cl , Serum Specimen: Serum/plasma Ref Interval: 101-111 mmol/L Conversion factor: Method: Lab: Biochem 22 SST/PST mEq/L = mmol/L Auto chem, CV 2%. Interf: bromide (), n-acetylcysteine (), L-dopa (¯) Price: [$] LMS 5 CHLORIDE, Urine Specimen: Random or 24h urine collected with no preservative Ref Interval: 110-250 mmol/d TAT: Stat, M-F for 24h collects Lab: Biochem Price: [$] LMS 5 CHLORIDE, Feces Specimen: Liquid fecal material only TAT: M-F, same day Lab: Biochem CHOLESTEROL, TOTAL Specimen: Serum/plasma Ref Interval: Risk for CAD (NCEP guidelines): SST/PST Low <5.2 Moderate 5.2-6.2 High risk >6.2 mmol/L See HDLC for Canadian Working Group guidelines Conversion factor: Method: Lab: Biochem mg/dL ´ 0.026 = mmol/L Auto chem, enzymatic. CV 2%. Price: [$] LMS 5 CHOLESTEROL, HIGH DENSITY LIPOPROTEIN, HDL-C Specimen: Serum/plasma SST/PST Risk for CAD: High risk: <1.0 mmol/L (NCEP Guidelines) Negative risk: >1.6 mmol/L (Canadian Working Group guidelines, CMAJ 2000;162:1441) Target Levels (all 3) Risk factors Risk level 10y CAD risk LDLC (mmol/L) TC:HDLC Trig (mmol/L) > 4 or CAD Very high > 40% <2.5 <4 <2 <3 High 20-39% <3.0 <5 <2 <2 Moderate 10-19% <4.0 <6 <2 <1 Low <10% <5.0 <7 <3 Conversion factor: mg/dL ´ 0.026 = mmol/L Method: Auto chem, direct enzymatic. CV 3%. Interferences: marked lipemia (triglycerides >12 mmol/L no result). Price: [$] LMS 18 Lab: Biochem CHOLESTEROL, LOW DENSITY LIPOPROTEIN, LDL-C Calculated using Friedewald equation: LDL-C = Total Cholesterol – HDLC – Triglyceride/2.2 (all values in mmol/L). Not reliable with rising triglycerides, and not reported for trig>4.5 mmol/L. For measured LDL-C see LIPOPROTEIN ANALYSIS by ULTRACENTRIFUGATION Risk for CAD Target Low < 3.4 Mod 3.4-4.1 High >4.1mmol/L (NCEP guidelines) Low risk pts < 3.5 High risk <2.5 (for detailed targets see HDL-C) Abbreviations: (complete list on page 4): NCEP National Cholesterol Education Prgm (NIH) CAD Coronary artery disease CV Coefficient of Variation (reproducibility) HICL Hospital-in-Common (Toronto) OC OG SST PST Civic General Gold Top Pale Green Top 23 CHOLINESTERASE, PSEUDOCHOLINESTERASE, PHENOTYPING Specimen: Serum SST (avoid hemolysis) For phenotyping, collect >48 h after scoline administration. In organophosphate poisoning, symptoms usually occur at levels 50-75% of normal (order total only). Ref Interval: 0 – 6 m: 6 m – 5 yr: Adults: 25% of adult levels 1.3 to 1.5x adult levels 4.88-12.00 kU/L Inhibition (%) by CE (kU/L) Genotype Dibucaine Fluoride Normal E u Eu 4.8–12.0 81–86 77–82 Heterozygous E u Ea 2.3–9.4 67–79 77–83 Homozygous Scoline 77-85 Sensitivity to Scoline rarely sensitive 1:500 sensitive E u Ef 3.4–8.5 77–82 70–77 1:200 sensitive Eu E s 3.6–5.6 83–86 77–82 1:1000 sensitive E a Ea 0.7–3.1 15–25 80–89 very sensitive Ef E f 3.6 72 54 sensitive Ea E f 2.7–4.6 54–66 66–70 sensitive Es Es 0–0.1 3–14 24–48 very sensitive Comments: Low conc seen with liver disease and following scoline administration, plasmapheresis, cardiopulmonary bypass, and in patients with liver disease TAT: 7d for typing, total available stat if required Lab: CHEO Biochem Price: [$$] LMS 30 CHORIONIC GONADOTROPHIN b-subunit, ß-hCG, Serum Specimen: Serum/plasma SST/PST Ref Interval: Female: Premenopausal, nonpregnant: <5 IU/L Postmenopausal: <20 IU/L Weeks from LMP 3–4 IU/L 9 – 130 4–5 75 – 2,600 5–6 850 – 20,800 6–7 4,000 – 100,200 7 – 12 11,500 – 289,000 12 – 16 18,300 – 137,000 16 – 29 1,400 – 53,000 29 – 41 940 – 60,000 Conversion factor: 2nd IS ´ 2 = 1st IRP or 3rd IS, mIU/mL = IU/L Comments: Method: Measures intact and free b-subunit. Discriminatory zone (using vaginal U/S): 1,000-2,000 IU/L. AutoIA (AxSYMâ), CV 5%. Interf: heterophile Ab (to mice) Lab: Biochem Price: [$$] LMS 30 24 CHORIONIC GONADOTROPIN b-subunit, Urine Specimen: Random urine. Note: kits are also available in ER, FMC, E1 PAU, SDCU, Nuclear Med Comments: Lab: Biochem Positive at ~10 IU/L (10-12d after conception). Price: [$] CHROMOSOMAL STUDIES see 2 Chromosomal studies CHYLOMICRONS not available. Chylomicronemia frequently present when serum triglycerides >15 mmol/L, and when sample reported as lipemic. CIRCULATING ANTICOAGULANT INHIBITOR - see MIXING TEST CIRCULATING IMMUNE COMPLEXES not available CITRATE, Urine Specimen: 24h urine in 20 mL 6M HCl Ref Interval: 0.8-6.0 mmol/d (approximates urinary calcium) Conversion factor: Method: TAT: 4 w mg/dL ´ 52.9 = umol/L Auto chem, colorimetric assay Lab: OC Biochem Price: [$] CLOMIPRAMINE see TRICYCLIC ANTIDEPRESSANT QUANT CLOSTRIDIUM DIFFICILE TOXIN TESTING Use: Major cause of antibiotic-assoc diarrhea and colitis, pseudomembranous colitis. Specimen: Stool in sterile screw-top container. In lab before noon. TAT: M-F, 1d Lab: Microbiol Price: [$$] COCAINE METABOLITES (Benzoylecgonine), Urine Specimen: Random urine Reported as: Positive for benzoylecgonine (main metabolite) at 0.3 mg/L Presence of drug indicates previous exposure and does not correlate with blood concentrations or degree of impairment. Metabolism: Well absorbed orally (60-80%, peak 1-1½h), nasally (60-80%, peak 1-2h), by inhalation (32-77%, peak 3-25 min). T½: cocaine 0.5-1.5h, benzoylecgonine 5-8 h; positive for 3d average; ?up to 3w in very high-dosage user. Clinical toxicity: Coronary vasospasm, respiratory depression, seizures, rhabdomyolysis, acidosis, hepatotoxicity, nephrotoxicity. Method: AutoIA (AxSYMâ) 쐌 Minimal cross-reactivity with cocaine, ecgonine, and cocaethylene (formed when cocaine is used with ethanol) 쐌 No cross-reactivity with acetaminophen, alprazolam, amitriptyline, amoxacillin, atenolol, caffeine, cannabinoid, carbamazepine, cimetidine, diazepam, doxepine, furosemide, thiazides, nicotine, phenytoin, theophylline 쐌 Interferences: bleach (¯), detergents TAT: M-F, 1d; stat avail. Lab: OG Biochem Price: [$$] 25 COLD AGGLUTININ SCREEN Use: Diagnostic in primary atypical pneumonia, mycoplasma pneumonia, hemolytic anemia, gangrene, cirrhosis, Raynaud’s disease and some viral and infectious diseases. Specimen: Comment: Mauve (7mL) Titre can be done for antibody quantitation. Normal healthy individuals have titres to 64 TAT: 24h Lab: TM Price: [$] LMS 15 COLLOID OSMOTIC PRESSURE Specimen: Serum preferred whole blood (result ~2mmHg lower) SST/red (Mauve/dark green for whole blood) Restricted to ICU and HI; others consult Biochemist. Ref Interval: 20-36 mm Hg Conversion factor: Method: kPa ´ 7.5 = mm Hg Colloid Osmometer (Wescor®) Lab: OC Biochem Price: [$$] COMPLEMENT, C3 and C4 Specimen: Serum Ref Interval: C3: 0.8-1.5 g/L Conversion factor: Method: TAT: 7d SST/red C4: 0.16-0.38 g/L mg/dL ´ 0.01 = g/L Immunoneph (Beckman Immage®), CV: C3 6% C4 3%. Lab: Biochem Price: [$$] LMS 12 each COMPLEMENT, TOTAL HEMOLYTIC, CH100 Specimen: Serum SST Transport on ice Interpretation: Normal 1:80 and 1:160 Low normal 1:40 Abnormal low 1:5, 1:10, 1:20 Confirm low titres with C3 and C4 quantitation. Method: TAT: 7d Titre at 100% lysis of a standard suspension of sheep RBC. Lab: OC Imm Price: [$$] LMS 50 COMPLETE BLOOD COUNT, CBC, HEMOGRAM Specimen: Whole blood Mauve (not hemolyzed / clotted) Microtube (300 uL) for neonates Reference Intervals: Males Females Units Leucocytes (WBC) 3.00-10.5 3.00-10.5 x 109/L 130-170 115-155 g/L Hemoglobin (Hgb) Hematocrit (Hct) 0.380-0.500 0.350-0.450 Mean Corpuscular Volume (MCV) 80-100 fL Mean Corpuscular Hgb (MCH) 27-34 pg 315-365 g/L Mean Corpuscular Hgb Conc (MCHC) Red Cell Distribution Width (RDW) Platelet Count 26 11.5 -15.5 % 125-400 x 109/L Reference Intervals: RBC Count Males Females Units 4.30-5.60 3.80-5.10 x 1012/L Granulocytes 2.0-7.5 x 109/L Lymphocytes 1.0-4.0 x 109/L Monocytes 0.10-1.00 x 109/L Eosinophils 0.0-0.5 x 109/L Basophils 0.0-0.1 x 109/L TAT: daily Lab: Hematol Price: [$$] LMS 16 COPPER, Plasma, Cu++ Specimen: Plasma Royal blue (from Biochem) Ref Interval: Male: 11.0-22.0 umol/L Female: 9.0-27.0 umol/L Conversion factor: TAT: 14d ug/dL ´ 0.16 = umol/L Lab: HICL Price:[$$] LMS 40 COPPER, Urine Specimen: 24h urine in acid washed plastic bottle (from Biochem) Ref Interval: 55-283 nmol/d ( seen in Wilson’s disease) Conversion factor: TAT: 14d ug/d ´ 16 = nmol/d Lab: HICL Price: [$$] LMS 40 CORTISOL, Serum Specimen: Serum/plasma SST/PST Ref Interval: 08:00h: 165-828 nmol/L 23:00h:~half morning conc Functional: Dexamethasone suppression test:(1 mg at midnight) Expected: 0800 cortisol:<138 nmol/L or >50% drop testing Cosyntropin (ACTH) test: 250 ug cosyntropin i.v., collect samples for cortisol at 0, 30 and 60m Expected response: cortisol >2x basal level or >200 nmol/L Conversion factor: Method: TAT: 7d ug/dL ´ 27.6 = nmol/L AutoIA(Elecsysâ). Interf: prednisolone, methylprednisolone, 6-ß-hydroxycortisol, 21deoxycortisol. Minimal X-reactivity with dexamethasone, 11 deoxycortisol, prednisone. Lab: OC Biochem Price: [$$] LMS 35 CORTISOL, Free Urinary Sample: 24h urine, no preservative (refrigerated) or in 5 g boric acid Ref Interval: 30-200 nmol/d Conversion factor: Method: TAT: 7d ug/d ´ 2.8 = nmol/d As for serum, following extraction, CV 10%. Lab: OC Biochem Price: [$$] LMS 35 COXSACKIE VIRUS see VIRAL CULTURES C PEPTIDE Specimen: Expected Value: Serum/plasma red/green not SST/PST Collect after overnight fast. Restricted; consult Biochemist. 298-1324 pmol/L TAT: 21d Lab: HICL Price: [$$] LMS 60 27 C REACTIVE PROTEIN, CRP Use: Inflammatory diseases. Not high sensitivity assay used for CAD risk assessment. Specimen: Expected Value: Serum <8 mg/L Conversion factor: Method: mg/dL ´ 10 = mg/L Immunonephelometry (Beckman Immage®), CV 3%. IFCC Standardized. Interferences: lipemia, gross hemolysis Lab: OC Biochem Price: [$$] LMS 6 TAT: 7d SST/red CREATINE KINASE, CK, Creatine Phosphokinase, (CPK) Specimen: Serum/plasma SST/PST 2 Enzymes Ref Interval: Male: 20-215 U/L Female: 20-160 U/L At CK >3,500 U/L, myoglobinuria may occur. Method: Lab: Biochem Auto chem, CV 5%. Interferences: hemolysis (). Price: [$] LMS 5 CREATINE KINASE ISOENZYMES, CK-MB not available, replace with Troponin T CREATININE, Serum Specimen: Serum/plasma SST/PST Ref Interval: Male: 62-106 umol/L Female: 35-88 umol/L RS: 60-125 umol/L Conversion factor: Method: Lab: Biochem mg/dL ´ 88.4 = umol/L Auto chem (rate, Jaffe’s method), CV 2%. Interf: Acetoacetate, Cefaclor, Cefoxitin, Cephalothin (), Bilirubin (¯). Price: [$] LMS 5 CREATININE, Urine Specimen: Random or 24h urine with no preservative or 20 mL HCL Ref Interval: Male: 7.1-17.7 mmol/d Female: 5.3-15.9 mmol/d Conversion factor: mg/d ´ 0.0088 = mmol/d TAT: M-F, 1d, stat avail Lab: Biochem Price: [$] LMS 5 CREATININE CLEARANCE, CrCl, ECC Specimen: 24h urine + serum/plasma, collected as above For Cockcroft-Gault CrCl, order CCCGM (males) or CCCGF (females) with S creat request and include patient’s weight. Ref Interval: Male: 1.42-2.08 mL/s/1.73 m2 body surface area Female: 1.25-1.92 mL/s/1.73 m2 body surface area Increased in pregnancy and obesity. Calculation: ECC = [urine creat (mmol/d)/ serum creat (umol/L)] x 11.6 Results reported are not corrected for surface area. mL/min ´ 0.017 = mL/s Lab: Biochem Price: [$] LMS 15 Conversion factor: TAT: M-F, 1d CROSSMATCH see TYPE and CROSSMATCH Abbreviations: (complete list on page 4): [$] <$5 [$$$] $15-49 [$$$$$] >$100 28 PST SST Mauve Pale green, Li Heparin Gold, thrombin activator EDTA CRYOFIBRINOGEN Specimen: Phone (798-5555x16216) for instructions. Serum+Plasma Red x 2 + Mauve x 2. Keep warm Expected Result: Negative at 40°C and 32°C Method: Visual screen followed by semiquantitative RID for positives. TAT: 2d if neg, 7d if pos Lab: OC Imm Price Screen/Quant: [$/$$$] LMS 5/30 CRYOGLOBULINS Specimen: Phone (798-5555x16216) for instructions. Serum Red x 2 Keep warm Expected Result: Negative at 40°C and 32°C. Positives typed for immunoglobulin class and quantitated. Method: Visual screen followed by semiquantitative RID for positives. TAT: 2d if neg, 7d if pos Lab: OC Imm Price Screen/Quant: [$/$$$] LMS 5/30 CRYPTOCOCCUS DIRECT ANTIGEN TEST Specimen: CSF in red vacutainer. Restricted; consult Microbiologist. TAT: 1d Lab: Microbiol Price: [$$$$] CULTURES see also VIRAL CULTURES Routine culture consists of 쐌 Gram’s stain. Negative Gram stains do not mean cultures will be negative. 쐌 Aerobic culture and identification with susceptibility testing of cultured pathogens. Specific cultures: by specific request (if appropriate) or if source site indicates anaerobic, Legionella, fungal, Mycobacterial and Mycoplasma infection. Comments on blood and fluid cultures (see Ward Manual for details) 쐌 Volume of blood (8-10 mL) most important for optimizing blood culture. 쐌 No more than 2 sets (aerobic+anaerobic) of blood cultures in 24h period, except in endocarditis (collect additional aerobic culture sample). 쐌 Where there is insufficient sample, the aerobic sample is more important. 쐌 Blood cultures: number of isolates relative to number of cultures important. 쐌 Skin commensals, esp coagulase -ve Staphylococci and Corynebacteria sp., may be pathogenic in presence of foreign body, including i.v. line. 쐌 Sterile sites: all growth reported. Interpret according to clinical findings. 쐌 For sites other than blood, presence of inflammatory reaction useful indicator of significance. 쐌 Neg cultures do not exclude infection, pos do not always indicate infection. Susceptibility data for Ottawa Hospital 2001 (% susceptible) Ps aeruginosa (non-CF) Acinetobacter 39 0 0 0 0 0 94 0 0 0 0 0 Cefotaxime 98 98 Ceftazidime 99 98 88 83 Serratia 0 96 Citrobacter 72 Cefazolin Enterobacter 86 Ampicillin Klebsiella E. coli Coag. neg Staph 100 Gram negative Enterococcus S. Aureus (not MRSA) Gram positive Continued on next page 29 Gram positive Cefuroxime Ciprofloxacin Clindamycin 85 Cloxacillin 100 39 Cotrimoxazole 98 58 Erythromycin 85 34 Gram negative 96 94 96 94 97 84 82 92 87 94 97 93 94 99 72 34 Gentamicin 97 98 98 96 95 88 Meropenem 100 100 100 100 100 97 92 Piperacillin 72 89 72 71 83 77 84 Pip / Tazo 97 94 Penicillin 17 90 Tobramycin 98 98 94 96 Vancomycin 100 100 99 쐌 Avoid using vancomycin and ceftazidime to reduce risk of resistant strains. 쐌 All Enterococci are resistant to cephalosporins. 쐌 The main current resistance problems(worldwide) are: Methicillin-resistant Staphylococcus aureus (MRSA), Penicillin-resistant Streptococcus pneumoniae (PRSP), Extended spectrum ß-lactamases (ESBL), Vancomycin-resistant Enterococcus (VRE), Ampicillin-resistant Enterococcus (ARE), Multidrug-resistant Mycobacterium tuberculosis (MDR-Tb). Recently hospitalized (<72h) or Outpatients 쐌 쐌 쐌 C&S x 1 (Shigella, Salmonella, Campylobacter, E. Coli 0157, Yersinia) Clostridium difficile x 1 Ova & parasites if appropriate Hospitalized patients - > 72h after admission 쐌 Clostridium difficile x 1 not available; order Parathyroid hormone CYCLOSPORIN A, CsA Specimen: Whole blood Mauve (Dark green acceptable) Therapeutic: Varies with transplant type and time since transplant Half life: Clinical toxicity: Variable Nephrotoxicity, hepatotoxicity, neurotoxicity, hypertension, tremors, infection, malignancy, hirsutism, gingival hypertrophy. Method: Auto IA (AxSYMâ), CV 8%. Low cross-reactivity with metabolites AxSYM = 0.73TDx = 0.996 EMIT (varies in patients, dependent on proportion of metabolites) TAT: Same day if spec in lab before 10:00h Lab: Biochem Price: [$$$] Abbreviations: (complete list on page 4): Auto Automated Chem Chemistry Analyzer CV Coefficient of Variation (reproducibility) HICL Hospital-in-Common (Toronto) IA Immunoassay 30 OC OG OG TT PST SST Civic General General Tissue Typing Pale Green Top Gold Top CYSTINE, Urine, SCREEN and QUANTITATION Specimen: Random or 24h urine (no preservative). State if patient is Solubility known cystinuric. Ref Int: Cystine: 5-24 umol/mmol creat Aim for <840 umol/L (regardless of pH) Arginine: 1-10 umol/mmol creat Lysine: 16-72 umol/mmol creat Ornithine: 2-9 umol/mmol creat Method: Sample screened using cyanide-nitroprusside test, positive samples are quantitated by IEC Penicillamine (¯) thiola (¯). mg/L ´ 4.2 = umol/L Conversion factor: TAT: 7d Lab: CHEO Biochem Price: [$$$] LMS 8 for screening CYTOLOGY (See also Fine needle aspiration biopsy) Specimen: See table for collection instructions. Label container/slides with source site, laterality (if applicable) and patient’s name. Send to Cytology Lab. Requisition: Lab 09 -411390 Provide appropriate clinical information (e.g. differential Results: diagnoses; history of malignancy, drugs, radiation therapy, alcohol abuse; radiographic findings). Results usually available within 24-48h Sample Type Body fluids (pleural, peritoneal, pericardial, synovial) Brushings (bladder, bronchial, esophageal, gastric, oropharyngeal, ureteral) Cerebrospinal fluid Procedure OC: Collect in 50 mL disposable screw-top tubes with green fixative (1 or 2 tubes) – do not use vacutainers 쐌 For synovial fluid crystals, send in red top vacutainer to Biochem OG: 25-50 mL in specimen container, add equal vol of 50% ethanol. Brush lesional area OC/OG: Cut ~10 cm above proximal brush tip, remove outer sheath. Drop immediately into appropriate fixative 쐌 Post-bronchoscopy sputum should be collected as it sometimes yields more diagnostic cells than during bronchoscopy. State source (e.g. LP, shunt) For suspected lymphoma, send also specimen to Tissue Typing Lab for surface marker determination. OC: Collect 2-5 mL red-top vacutainer. 08:30-16:30h Mon-Fri: Send on ice immediately. After hours, add equal volume of green fixative and fridge. OG: 2-5 mL in clean plastic tube, add equal volume of 50% ethanol 쐌 쐌 Cervical/Vaginal see Papanicolaou Smear Continued on next page 31 Sample Type Procedure Nipple discharge If both breasts, label slides as to laterality and submit separately, with 2 requisitions Express material by gentle massage and stroking toward nipple. Touch droplets with labeled glass slide and drop in 95% ethanol or use Cytospray®. Continue as long as secretion is obtained. Sputum – early Collect on 3 consecutive days, not 24h specimens Have patient rinse mouth, and cough deeply. Do not collect saliva. OC: Collect in wide mouth plastic jar with green fixative. OG: Collect in plastic container with 50% ethanol morning DEEP COUGH spec Urine – voided, catheterized bladder, ureteral 쐌 Voided: collect ~3h after last void. First morning voids are not suitable (long exposure of cells to urine). OC: Collect in 50 mL disposable screw-top tube with green fixative. OG: collect in plastic container, add equal vol 50% ethanol 쐌 For CMV, viral culture more appropriate. OC: Collect in Red vacutainer, largest volume possible. Send immediately to Cytology Lab. Phone 16834/ 13312 to inform lab. OG: Collect vitreous fluid in plastic container, add equal vol 50% ethanol. Smear conjunctival scrapings on labeled glass slide and Cytospray®. Phone 78305/ 72508 to inform lab. Vitreous fluid/ conjunctival scrapings Washings (bladder, bronchial, esophageal, Gl tract) OC: Collect in 50 mL disposable screw-cap tube with green fixative. OG: Collect in container with equal volume of 50% alcohol. CYTOMEGALOVIRUS (CMV) by PCR see also SEROLOGICAL TESTS, TRANSMISSIBLE DISEASE TESTING, VIRAL CULTURES Use: Immunocompromised hosts Specimen: TAT: 1w Whole blood Mauve 7 mL x 2 Lab: CHEO Virology Price: [$$$$] Do also EBV and HHV6; for others - discuss with Microbiologist DANAPROID - see ANTI-Xa D-DIMER Use: Detects cross-linked fibrin derivatives. Increased levels associated with DIC, recent surgery, recent thrombolytic treatment and thrombosis. Specimen: Interpretation: Plasma Light blue Specify anticoagulant if applicable <200 ug/L is negative for DVT/PE when used with clinical model Lab: Hematol Price: [$] LMS 30 Abbreviations: (complete list on page 4): Auto Automated Chem Chemistry Analyzer CV Coefficient of Variation (reproducibility) 32 OC OG OG TT Civic General General Tissue Typing DEHYDROEPIANDROSTERONE SULPHATE, DHEAS Specimen: Serum SST/red (Mauve, PST also acceptable) Ref Interval: (tentative) Male Female 20-34y 4.3-13.4 2.7-11.0 umol/L 35-54 1.2-11.6 1.0- 9.1 > 55 0.4- 8.0 0.3- 6.7 Conversion factor: Method: ng/mL ´ 0.0027= umol/L AutoIA (Elecsys®) TAT: 14d Lab: OC Biochem Price: [$$] LMS 40 DEOXYCORTISOL not available DESIPRAMINE see TRICYCLIC ANTIDEPRESSANT QUANT DIGOXIN Specimen: Therapeutic: Toxic conc: Conversion factor: Half life: Clinical toxicity: Method: Lab: Biochem Serum/plasma SST/PST For trough value draw sample >18h postdose 1.0-2.6 nmol/L (trough) >3.3 nmol/L (age, hypokalemia, hypoxia, acid-base balance, thyroid and renal status affect toxicity) ng/mL ´ 1.3 = nmol/L 26-52h; increased in renal impairment CVS: arrhythmia, AV dissoc; GI: anorexia, nausea/vomiting, diarrhoea; CNS: visual, headaches, weakness, psychosis. AutoIA (AxSYM®), CV 5%. Digibind™(). fluorescein (), digoxin-like immunoreactive factors (), and digitoxin (slight ) Price: [$$] LMS 28 DIRECT ANTIGLOBULIN TEST Use: Detect in vivo red cell sensitization due to IgG and/or complement. Diagnostic in autoimmune or non-immune diseases, transfusion reaction or hemolytic disease of the newborn. Specimen: Mauve (7mL) TAT: Routine 1-3h, Stat 15 min Lab: TM Price: [$] LMS DISACCHARIDASE, INTESTINAL not available DISOPYRAMIDE restricted – consult Biochemist DNA TESTING see 2 Chromosomal Studies DONATH-LANDSTEINER TEST consult Hematologist DOXEPIN see TRICYCLIC ANTIDEPRESSANT QUANT DRUG SCREEN see individual assays - BARBITURATES, BENZODIAZEPINES, CANNABINOIDS, COCAINE, and OPIATES screens. For amphetamine - consult Biochemist. EOSINOPHIL IN BODY FLUID Specimen: Sputum specimen or urine specimen. Interpretation: Presence indicates allergic or parasitic disease; increased in urine in interstitial nephritis. TAT: M-F, 1d Lab: Hematol Price: [$] LMS 3 33 EPSTEIN-BARR VIRUS (EBV) by PCR see also SEROLOGICAL TESTS Use: Immunocompromised host only Specimen: Whole blood Mauve (7 mL) CSF Red top Store at 4oC Throat washings: Patient to cough, gargle with saline and collect gargle in sterile screw-top bottle; store at 4oC 쐌 Indicate date of onset and clinical condition 쐌 Consult with Microbiologist TAT: 1w Lab: CHEO Virology Price: [$$$$] ERYTHROPOIETIN Specimen: Serum/plasma SST/PST (not EDTA). Transport in iced water immediately. Recommended sample draw time 07:30-12:00. Ref Interval: Restricted; consult Biochemist. 5.0 - 29.5 U/L Comment: TAT: 14d Hemolysed sample or EDTA not suitable Lab: HICL Price: [$$] Specimen: Serum/plasma Ref Interval: (tentative) Males: 28-156 pmol/L Females: Follicular 46-807 Ovulatory 315-1828 Luteal 161-774 Pregnancy (1st Trimester) 789 - > 15781 pmol/L Postmenopausal <73 pmol/L Comment: Conversion factor: Osteoporosis associated with conc <60 pmol/L pg/mL ´ 3.67 = pmol/L Method: AutoIA (Elecsysâ) Estradiol II. Lowest limit of detection 20 pmol/L. Lab: Biochem (OC,OG) Price: [$$] LMS 55 TAT: Daily SST/PST/Mauve ESTROGEN-PROGESTERONE RECEPTORS, ER-PR Specimen: Breast carcinoma tissue, fresh or in 10% neutral buffered formalin. The results may be influenced by overfixation, thus a fresh specimen transported by Stat porter is preferable. Notify lab (OC: 13531, OG: 72059) prior to transport to ensure optimal handling of fresh specimens. Method: TAT: 4d Immunohistochemistry (semi-quantitative) Lab: Surgical Pathology ETHOSUXIMIDE Specimen: Serum/plasma Therapeutic: 280-710 umol/L Toxic conc: >1,000 umol/L Half-life: Conversion factor: TAT: 2d 34 SST/Red/PST/green 33 ± 6 h ug/mL ´ 7.1 = umol/L Lab: HICL Price: [$$] LMS 35 ETHYL ALCOHOL, ETHANOL, ETOH Specimen: Serum/plasma SST/PST Legal limit: 17 mmol/L = 0.08 g/dL = 80 mg/dL Toxic conc: >90 mmol/L coma; >120 death Consider dialysis at >65 mmol/L Half-life: Conversion factor: Method: Lab: Biochem 0.24 ± 0.1h, elimination rate: 100 mg/kg/h mg/dL ´ 0.22 = mmol/L; g/dL ´ 217 = mmol/L OC: Auto chem, CV 3% Interf: High lactate+LD; OG: AxSYMâ Price: [$] LMS 43 ETHYLENE GLYCOL Specimen: Serum/plasma SST/PST Performed stat only if osmolal gap@ is increased Toxic conc: >2 mmol/L, lethal >20, consider dialysis at >8 mmol/L 쐌 Ethanol-load patients while awaiting results Half-life: Comments: Conversion factor: Method: Lab: OC Biochem @ 3h (in absence of ethanol) Ca oxalate crystals in urine consistent with toxicity. Common source: radiator antifreeze; lethal dose ~100 mL mg/dL ´ 0.16 = mmol/L Gas chromatography, performed in conjunction with isopropanol, methanol, and acetone. CV 10%. Price: [$$] LMS 45 (2´Na - gluc - urea - ethanol - measured osmolality; if >0, osmolal gap is present). EUGLOBULIN CLOT LYSIS TIME, CLOT LYSIS TIME Specimen: Phone lab (OC:14190, OG:78329) prior to collection. Light blue Transport on ice Expected Value: Comments: TAT: M-F, 1-2d (must be analyzed within 30 min) >60 min clot lysis seen with severe liver disease, intravascular coagulation or after streptokinase administration. Lab: Hematol Price: [$$] LMS 10 FACTOR ASSAYS (II, V, VII, X, XI, XII) Specimen: Plasma Light blue ´ 3 Transport on ice. Patient should not be on anticoagulant therapy. Order INR, PTT and Plt count prior. Consult strongly recommended. Ref Interval: Factor II 0.55-1.55 X 0.70 - 1.70 U/mL V 0.50-1.50 XI 0.50 - 1.40 VII 0.65-1.65 XII 0.65 - 1.65 Method: TAT: 10d Detects specific coagulation factor activity. Lab: Hematol Price: [$$] LMS 55 each FACTOR V Leiden Genotyping See 2 Chromosomal Studies. Abbreviations: (complete list on page 4): 2 Appendix (pages 89-102) OC OG Civic Campus General Campus 35 FACTOR VIII ASSAY, ANTI-HEMOPHILIAC, HEMOPHILIA A FACTOR Specimen: Plasma Light blue ´ 3 Transport on ice Phone Special Coag (OC:14190, OG:78329) Ref Interval: 0.5-1.50 U/mL Method: TAT:10d; Stat 1-2d Measures specific factor deficiency such as in classic hemophilia, von Willebrand’s disease. Lab: Hematol Price: [$$$] LMS 55 FACTOR VIII or IX INHIBITOR, HEMOPHILIAC INHIBITOR Specimen: Serum Red top x 2 Transport on ice Comment: TAT: 10d 1 Bethesda unit = amount that will inactivate 50% of factor activity in 2h Lab: Hematol Price: [$$$$$] FACTOR IX, PTA, HEMOPHILIA B ASSAY Specimen: Plasma Light blue ´ 3 Transport on ice Arrange for elective surgery patients (OC:14190, OG:78329). Ref Interval: 0.7-1.7 U/mL F IX may be increased in patients on oral contraceptives. Method: Measures specific coagulation factor activity. TAT: M-F, routine 10 d, stat 1-2d Lab: Hematol Price: [$$$] FACTOR XIII, FIBRIN STABILIZING FACTOR Use: Evaluation of bleeding disorders. Homozygotes may present with umbilical stump bleeding, life-long bleeding tendency with poor wound healing Specimen: Expected Value: Plasma Light blue ´ 3 No lysis within 24h TAT: qual 1-2d, quant 4w Transport on ice Lab: Hematol Price: [$] LMS 5 FATTY ACIDS, VERY LONG CHAIN, VLCFA Use: Diagnosis of peroxisome biogenesis disorders – Zellweger’s, Adrenoleukodystrophy, Adrenomyeloneuropathy, Refsum’s Disease Specimen: Interpretation: TAT: 21d FECAL FAT Specimen: Restricted; consult Biochemist. Serum/plasma SST or Mauve Send to Biochem immediately. saturated and monosaturated C26 and C24 aliphatic acids with ¯ C22:0 seen with peroxisome disorders Lab: HICL (Chedoke-McMaster) Price: [$$] Ref Interval: 3d fecal collect in pre-weighed can (from Biochem) Patient should be on >75g/d fat during collection. Quantitated only in solid or semisolid, dark-coloured stools if total weight >500 g. Liquid samples not analyzed. 2.0-7.0 g/d Conversion factor: TAT: 14d mmol/d ´ 0.28 = g/d Lab: HICL Price: [$$] LMS 72 Testing done: 36 FERRITIN Specimen: Ref Interval: Conversion factor: Method: Comments: Lab: Biochem Serum/plasma SST/PST (not Mauve) Male: 16-320 ug/L Female: premenopausal 10-190 postmenopausal 10-230 ng/mL = ug/L AutoIA (AxSYMâ), CV 5%. Iron deficiency usually associated with levels <10 ug/L. Iron overload associated with levels >1350 ug/L. ¯ with recent blood loss, unsupplemented pregnancy. in iron therapy, inflammation, malignancy, hepatic disorders, juvenile rheumatoid arthritis Price: [$$] LMS 28 FETAL LUNG MATURITY, FLM Specimen: Amniotic fluid 1mL, with no visible blood or meconium; icteric samples cannot be analyzed. Interpretation: Immature: <39 mg surfactant/g albumin For diabetics <70 Method: Lab: Biochem FIBRINOGEN Specimen: Ref Interval: Functional test: measures surfactant activity (TDxFLxâ) CV 4%. Interferences: urine (), blood (¯) and meconium (¯) Price: [$$] Plasma Light blue Specify anticoagulant patient is on. 1.90-4.50 g/L Comments: ¯ congenital fibrinogenemia, DIC, fibrinolytic disorders, severe liver disease with inflammation, pregnancy and oral contraceptive use Lab: Hematol Price: [$] LMS 28 FILM, BLOOD SMEAR FOR RBC MORPHOLOGY Specimen: Whole blood Mauve TAT: 24hr Lab: Hematol Price: [$$] FINE NEEDLE ASPIRATION BIOPSY, FNAB Requisition: Lab 09 -411390 Include pertinent clinical information and collection time Phone for Cytotechnologists OC: M-F 0830-1530h Phone 16834, 13312 or 17651 OG: M-F 0800-1500h Phone 78305 or 72508 Biopsies in Radiology, OR: Make appointment for Cytotechnologist to attend Breast: OC: Breast clinic: make direct smears and rinse needle contents in green fixative. Other sites: Rinse needle contents in green fixative (50 mL screw-cap tube). OG: arrange for tech (or expel and rinse needle in 50% ethanol). Continued next page 37 Lung: OC: (prep by Radiology Staff) 쐌 For EM and Immunocytochemistry, several passes needed. 쐌 Smears - place aspirate onto labeled glass slide, place another labeled slide over and work slides back and forth to distribute cells evenly. Separate and place in Coplin Jar with 95% ethanol. 쐌 Rinse needle in balanced electrolyte solution (50 mL screw-cap tube). 쐌 Send both immediately to Cytology Laboratory. OG: arrange for Cytotechnologist to attend Thyroid, Salivary glands, prostate, testes, abdominal, adrenal, kidney, liver, lymph nodes, pancreas, retroperitoneal tissue, abdominal fat. 쐌 Make appointment for Cytotechnologist to attend Renal transplants (for rejection, nephrotoxicity, immune activation or infection) OG: Notify Pathologist and cytotechnologist (78305 or 72508) 24h prior, and the lab 30 min prior to procedure and when abdomen is prepared FK506 see TACROLIMUS FLOW CYTOMETRY All testing by appt only. OC: 16216, OG: 78277. Indicate diagnosis on requisition Immunophenotyping: Restricted to hematologist/hematopathologist Use: Diagnosis of leukemias, lymphomas, immunodeficiency, AIDS Specimen: Whole blood OG: Mauve x 1 OC: Mauve x 2 + Dark green (no gel) x 2 Bone marrow: 2 mL in Mauve Lymph node: Workshop or McCoy’s medium Aspirates: 5 mL in Dark green Fluids: 5 mL in Dark green (Na heparin) TAT: M-Th am, 1d Lab: OC Hematol/OG TT Price: [$$$$$] CD4 count, CD4/CD8 ratio Use: Monitor HIV patients Specimen: TAT: M-F, 2d Whole blood Lab: OG TT Mauve x 1 Price: [$$$$] T and B cell Crossmatch Use: Live donor-recipient compatibility, more sensitive than AHG-CDC test Specimen: TAT: M-F, 6-12h Donor: Mauve x 4 Lab: OG TT Recipient: Red (10 mL) not SST Price: [$$$$$] FOLATE, Serum and Erythrocyte Specimen: Serum SST/red RBC folate Mauve or dark green Ref Interval: Serum: >15 nmol/L RBC: 215-1292 nmol/L Conversion factor: Method: Comments: ng/mL ´ 2.266 = nmol/L IRMA (BioRad), CV 5%. Avoid hemolysis in sample collection. RBC folate corrected for plasma volume. Serum folate is not acutely affected by diet and supplements. TAT: 7d Lab: Biochem 38 Price: [$$] LMS 40 FOLLICLE STIMULATING HORMONE, FOLLITROPIN, FSH Specimen: Serum/plasma SST/PST Ref Interval: Male: 1-8 IU/L (2nd IRP 78/549) Female: Follicular: 4-13 Midcycle: 5-22 Luteal: 2-13 Postmenopausal: 20-138 Method: TAT: 7d AutoIA (AxSYMâ), CV 6%. Interf: lipemia () Lab: Biochem Price: [$$] LMS 28 FRAGMIN - see ANTI-Xa FREE ERYTHROCYTE PROTOPORPHYRIN see 2 Porphyria FUNGUS Specimen: Blood: Test: TAT: days to 4w Fungal stain performed routinely where appropriate. Lab: Microbiol Price: [$$] Aerobic BAC-T-ALERT bottle. Indicate fungal culture. CSF: Red vacutainer Skin, hair, Obtain black paper from Microbiol, wrap nails: specimen securely. Other sites: Sterile screw-cap container or sterile swab GAMMA GLUTAMYL TRANSFERASE, GGT, (GGTP) Specimen: Serum/plasma SST/PST Ref Interval: 7-50 U/L Comment: Method: Lab: Biochem GASTRIN Specimen: Ref Interval: Comment: TAT: 4 w GENTAMICIN Specimen: Phenobarbital, warfarin, ethanol may induce GGT. 2 Enzymes Auto chem, CV 4%. Interferences: moderate hemolysis (). Price: [$] LMS 5 Serum SST/red Must arrive in laboratory within 1h. Fast 10 h for basal level. Fasting:<90 ng/L Random: <200 ng/L : cimetidine, antral distension, postvagotomy, atropic gastritis, gastric Ca, gastric ulcer, pernicious anemia, renal failure. Lab: HICL Price: [$$$] LMS 75 Therapeutic: Toxic conc: Serum/plasma SST/PST State if pre- or postdose, or random (peak: draw 30 min post-infusion or 60 min post-injection or oral dose) Predose <2 mg/L; postdose conc varies, based on use. Predose >2 mg/L Postdose >10 mg/L Half-life: Toxicity: Conversion factor: Method: Lab: Biochem 1.5h (to 15h, prolonged in renal failure) Nephrotoxicity, ototoxicity, neuromuscular block mg/L ´ 2.09 = umol/L AutoIA (AxSYMâ), CV 3%. Price: [$$] LMS 40 39 GLUCAGON Specimen: Ref Interval: Restricted; consult Biochemist. Fast 14h. Special collection protocol. Plasma: prechilled Mauve vacutainer, add aprotinin to sample. Transport on ice immediately 150-300 ng/L TAT: 30d Lab: HICL Price: [$$] GLUCOSE-6-PHOSPHATE DEHYDROGENASE, G6PD Specimen: Whole blood Mauve TAT: M-F, 3d CBC, RBC Morphology and Retic count must also be ordered Lab: Hematol Price: [$$] LMS 65 GLUCOSE, Blood Specimen: Serum/plasma SST/PST Ref Interval: Normal Diabetes control (CDA Guidelines) Optimal Suboptimal Inadequate Fasting: 3.8 - 6.0 4.0 - 7.0 7.1-10.0 >10.0 1-2h post meal: 4.4 - 7.0 5.0 -11.0 11.1-14.0 >14.0 Factors affecting: Conversion factor: Method: Lab: Biochem At RT, whole blood glucose ¯ ~ 0.5 mmol/h mg/dL ´ 0.055 = mmol/L Auto chem, CV 3%, (glucose meters available in most wards). Price: [$] LMS 5 GLUCOSE, Cerebrospinal fluid Specimen: CSF sterile red top (min 0.5 mL) Ref Interval: 2.7 – 4.4 mmol/L (~0.6 ´ serum conc) Lab: Biochem Price: [$] LMS 6 GLUCOSE TOLERANCE SCREEN for Gestational Diabetes Use: In pregnant women >25y, or <25y with predisposition (obese, Aboriginal/Hispanic/Asian/African descent, family history or previous history of DM, macrosomia BW >4 kg). Protocol: Interpretation: (CDA Guidelines) Between 24-28w gestation. 50 g glucose any time of day 1h: > 7.8 mmol/L – suspicious, suggest tolerance test > 11.1 mmol/L – gestational diabetes GLUCOSE TOLERANCE TEST Patient prep: At least 150 g carbohydrate for 3d prior. Discontinue meds (where possible) that affect glucose tolerance. Do not perform on patients with fasting hyperglycemia Procedure: Perform in morning, patient seated and not smoking. Collect fasting sample (0h), give 75g glucose p.o.(1.75g/kg BW for children up to 75g). Collect samples at 1 and 2h post-load. Fridge samples if delivery to lab is delayed. Continued on next page 40 Expected values: ADULTS 0h CDA Guidelines (CMAJ 1998;159:S1-29). Concentrations in mmol/L Normal IGT@ Diabetes Mellitus <6.1 <7.0 > 7.0 1h 2h Gestational Diabetes > 5.3 > 10.6 <7.8 7.8-11.0 Random 11.0 > 8.9 > 11.0 + symptoms If only 1 criteria met, diagnosis is impaired glucose tolerance of pregnancy @ IGT=impaired glucose tolerance. Category of impaired fasting glucose (6.1-7.0 mmol/L) does not have microvascular risk, but has risk of DM and CAD. GLYCATED HEMOGLOBIN see HEMOGLOBIN A1c GONOCOCCUS, GC Specimen: Cervix or male urethra. Sterile swab in transport media. For other sites, GC screen must be specifically requested TAT: 2d Lab: Microbiol Price: [$] GROWTH HORMONE, hGH Specimen: Serum SST/red Ref Interval: <15 mIU/L Criteria of GH def in children: <8 mIU/L post stimulation. Conversion factor: Method: TAT: 7d ug/L ´ 2.25 = mIU/L IRMA (Nichols Inst), CV 5%. Lab: OC Biochem Price: [$$] LMS 40 HAM’S (ACID SERUM, Paroxysmal Nocturnal Hemoglobinuria, Serum lysis) TEST Use: Confirmation of intravascular hemolysis. Screen with Sucrose Lysis test. Specimen: Yellow ACD + Dark green heparin Phone Hematol (OG:78329) for appointment. TAT: M-F, 2d Lab: Hematol HAPTOGLOBIN Specimen: Serum Ref Interval: 0.36-1.95 g/L Conversion factor: Method: TAT: 7d Price: [$$] LMS 18 SST/red mg/dL ´ 0.01 = g/L Immunoneph (Immage®), CV: 5%. Interf: marked lipemia Lab: Biochem Price: [$$] LMS 15 hCG see CHORIONIC GONADOTROPIN HDL-C see CHOLESTEROL, HDL HELICOBACTER PYLORI, H pylori see SEROLOGICAL TESTS HEMOGLOBIN see COMPLETE BLOOD COUNT Abbreviations: (complete list on page 4): TAT Turnaround time (from time of receipt) RS HICL Hospital-in-Common Lab (Toronto) OC LMS Labour, Management, Supplies (OHIP billing) OG ACD Acid Citrate Dextrose Riverside Campus Civic Campus General Campus 41 Hemoglobin A1c, HbA1c, (Glycated hemoglobin) Specimen: Whole blood Mauve/dark green Ref Interval: 0.048-0.060 (4.8% to 6%) Optimal control: Suboptimal: Inadequate: Method: TAT: 2d <0.070 0.070-0.084 >0.084 Turbidimetric immunoinhibition, CV 4%. No interference from HbF, S or C. Lab: Biochem Price: [$$] LMS 22 HEMOGLOBIN INVESTIGATION, HbA2, HbF and VARIANTS Specimen: Whole blood Mauve CBC, blood film should also be requested Expected Value: Hb A2: 1.8-3.6% 3.7-3.9% gray area 4.0-10.0% ß-Thalassemia trait Hb F: 0.2-2.0% Comments: Method: TAT: 10d Also detects HbS, C, D, E Hb A2 in b -Thal minor, may normalize in iron deficiency HbF: adult levels by the age of 2y. Hb H may not be detected. If Hb S suspected, order sickle cell screening test HPLC Lab: Hematol Price: [$$$] LMS 34 HEMOGLOBIN, FETAL SCREEN Use: Determine if blood in fecal material or vomitus is of fetal or maternal origin Specimen: Fecal material or vomitus with visible blood. Restricted to SCN TAT: 1d Lab: Biochem Price: [$] LMS 20 HEMOGLOBIN, PLASMA Specimen: Plasma PST/dark green/EDTA Use larger needle to avoid hemolysis State if patient has Ventricular Assist Device (VAD) Ref Interval: 0-150 mg/L (usually <50 mg/L) Method: Spectrophotometric scan, CV 4%. Interferences: bilirubin (¯) Factors affecting: Method: In vitro hemolysis (occurring during phlebotomy or transport) Spectrophotometric scan, CV 4%. Interferences: bilirubin (¯) TAT: 2d, (available Stat, but restricted to patients with VAD, COR, CRR, CSU, Urology) Lab: OC Biochem Price: [$$] HEMOSIDERIN Specimen: Random urine (fresh early morning preferred) TAT: 1d Lab: Biochem Price: [$] HEPARIN ASSAY - see ANTI-Xa HEPARIN INDUCED THROMBOCYTOPENIA, HIT Specimen: Consult Coagulation Laboratory OC:14190, OG: 78329. Red top x 2 42 HEPATITIS SEROLOGY see SEROLOGICAL TESTS, TRANSMISSIBLE DIS TESTING HEPATITIS C by PCR see also SEROLOGICAL TESTS, TRANSMISSIBLE DIS. Specimen: Whole blood Red Restricted; consult Microbiologist. TAT: 1w Lab: CHEO Virology Price: [$$$$$] HERPES SIMPLEX VIRUS by PCR Use: HSV encephalitis Specimen: CSF sterile red top Restricted; consult Microbiologist. Clinical picture and CSF profile must suggest diagnosis. TAT: 1w Lab: CHEO Virology HISTAMINE Specimen: Price: [$$$$$] Ref. Interval: Plasma Chilled Mauve. Transport on ice immediately. Avoid hemolysis Restricted; consult Biochemist. <10 nmol/L TAT: 30d Lab: HICL Price: [$$] LMS 90 HLA ANTIBODY SCREEN, PANEL REACTIVE ANTIBODY (PRA), LYMPHOCYTIC ANTIBODIES Use: Used with HLA typing for transplant donor selection Specimen: Reported: Serum Red (not SST) Positive results reported as % TAT: every 2nd Monday of each month, results available 7-10d after. Lab: OG TT Price: [$$$$$] HLA, LYMPHOCYTE, T and/or B CELL CROSSMATCH Phone OG TT (737-8277) to arrange Test: Use Specimen TAT Auto crossmatch Detect auto T or B cell antibodies. (Not SST or PST) Red (10 mL) If positive, DTT crossmatch to Dark green (10 mL) x 4 distinguish IgM Ab from IgG 12-24h Living donors Determine compatibility of (related/unrelated) donor and recipient 48-72h Cadaveric donors Auto-granulocyte Autoimmune diseases – detects / lymphocyte Ab autoAb at 15oC and room temp Red (10 mL) Dark green (10 mL) x 8 Mauve (5 mL) x 2 8-12h Red (10 mL) Green (10 mL) x 4 12-24h HLA-A, B, C TYPING Use: Matching for organ transplantation Specimen: Whole blood Green 10 mL (more if WBC low) By appointment only (737-8277) TAT: M-F, 2-3d Lab: OG TT Price: [$$$$$] 43 HOMOCYST(E)INE Use: Investigating thrombotic tendency and in patients with premature CAD without traditional risk factors. Specimen: Increased risk: Factors affecting: Method: TAT: 5d Plasma Mauve Transport on ice immediately Overnight fasting specimen preferred Restricted to Hematologists (for investigation of thrombophilia); others consult Biochemist. Males: >13 umol/L Females: >10 umol/L in whole blood on standing; folate, B12 and pyridoxine deficiencies/antagonists; oral hypoglycemics; renal failure IA (AxSYMâ), CV 6% Lab: OC Biochem Price: [$$] HOMOGENTISIC ACID Specimen: Random urine (freshly voided) Method: TAT: 2d Visual observation of darkening on standing. Other reducing substances (melanin, phenylketones) may give similar reaction. Lab: Biochem Price: [$] HOMOVANILLIC ACID (HVA), Urine Specimen: 24h urine in 20 mL 6M HCl (same sample as VMA, Metanephrines, 5HIAA) Reference Int: 0–1 y <15 umol/d <20 umol/mmol creatinine 2–4 y <26 <14 5–9 y <30 <9 10–19 y <40 <8 >19 y <46 <5 Method: TAT: 7d HPLC, CV 5% Lab: OG Biochem Price: [$$$] HTLV see SEROLOGICAL TESTS, TRANSMISSIBLE DISEASE TESTING HUMAN IMMUNODEFICIENCY VIRUS, HIV, by PCR see also SEROLOGICAL TESTING, TRANSMISSIBLE DISEASE TESTING Specimen: TAT: up to 2w Specimen: TAT: up to 2w Whole blood Mauve Collect Sun-Wed mornings Send to Microbiol immediately at room temp. Phone lab OC: 14454, OG: 78322. Specimen must arrive in Toronto within 48h. Lab: PHL Whole blood , VLM) Mauve Send to Microbiol immediately Lab: CHEO Virology 5-HYDROXYINDOLE ACETIC ACID, 5-HIAA Specimen: 24h urine collected in 20 mL 6M HCl Avoid high serotonin diet for 2d prior and during collection; cough mixtures (guanefesin), acetaminophen, large amts of coffee, cola, excessive smoking during collection 44 Ref Interval: <43 umol/d (carcinoids usually excrete >120 umol/d) Conversion factor: mg/d ´ 5.23 umol/d Method: HPLC, CV 5% TAT: 7d Lab: OG Biochem Price: [$$] LMS 50 Serotonin content (ug/g) of foods (Feldman J M et al Am J Clin Nutr 1985;45:639). High butternut (400), black walnut (300), English walnut (90), pecans (30), plantain (30),pineapple (17),banana (15), kiwi (6), plum (6), tomato (3) Moderate (1-2 ug/g) avocado(Calif), cantaloupe , date, grapefruit, filbert, brazil-nut (0.1-1 ug/g) avocado (Fla), broccoli, cauliflower, eggplant, figs, honeydew, black olives, spinach, almonds The following excretion by 5 umol/L: ½ banana, 2 kiwi, 1 black walnut, 1½ English walnuts, 8 pecans, 1 tomato, 1/20 pineapple, 5½ Haas avocados, 170 filberts. 17-HYDROXY PROGESTERONE Specimen: Serum SST/red Ref Interval: Male 1.5-7.5 nmol/L Female: TAT: 14d Lab: HICL 1.0-13.0 nmol/L Price:[$$] LMS 60 HYDROXYPROLINE not available, see TELOPEPTIDES IMIPRAMINE see TRICYCLIC ANTIDEPRESSANT QUANT IMMUNOFIXATION, IFIX (replaces IMMUNOELECTROPHORESIS) Specimen: Serum or urine (random) SST/red not PST Order serum PROTEIN ELECTROPHORESIS or urine for LIGHT CHAINS. IFIX performed if abnormal bands are present and not previously typed. Provide clinical history. Method: TAT: 7d Sebia Hydrasysâ Tested with: G, A, M, kappa, lambda antisera Lab: OC Imm Price: [$$] LMS 120 IMMUNOGLOBULIN E, IgE see also RADIOIMMUNOSORBENT TEST Specimen: Serum SST/red Ref Interval: <288 ug/L, (children: 10-20% of adult values) A low value does not exclude presence of specific IgE Ab Conversion factor: Method: TAT: 4 w IU/mL ´ 2.4 = ug/L IA (IMxâ), CV 6%. Measures total IgE. Lab: OC Biochem Price: [$$] LMS 28 IMMUNOGLOBULIN G,A,M, IgG, IgA, IgM Specimen: Serum SST/red Ref Interval: IgG 7.5–15.6 g/L IgA 0.8–4.5 g/L IgM 0.4–2.7 g/L Method: TAT: 7d Immunoneph (Immageâ), CV: 5%. Interf: marked lipemia; inaccuracies may occur with high conc of monoclonal immunoglobulin, especially IgM. Lab: Biochem Price: [$$] LMS 15 each 45 IgG SUBCLASSES Specimen: Serum Ref Interval: IgG1 (Adults) IgG2 IgG3 IgG4 TAT: 3w SST/red Restricted; consult Biochemist 3.15-8.55 g/L 0.64-4.95 g/L 0.23-1.96 g/L 0.11-1.57 g/L Lab: CHEO Biochem Price: [$$$] IMMUNOPHENOTYPE ASSESSMENT see FLOW CYTOMETRY INFECTIOUS MONONUCLEOSIS SCREENING TEST, MONOTEST, MONOSPOT, HETEROPHILE ANTIBODIES Specimen: Serum SST/red Also order CBC and Differential. Comments: 쐌 Detects heterophile antibodies to infectious mononucleosis. 쐌 Titres do not correlate with severity or stage of disease. Usually elevated by 6-10d of illness and may remain detectable for up to 1y (usual 4-8w). 쐌 10% of EBV-induced mononucleosis may not be positive. 쐌 10% may be caused by other agents (CMV, adenovirus, rubella, viral hepatitis and toxoplasmosis). 쐌 Diagnosis should be made with > 2 of the following: 쐌 typical clinical findings 쐌 typical serologic findings 쐌 Presence of variant lymphocytes in the peripheral blood TAT: Stat 1h; Routine 24h INSULIN Specimen: Ref Interval: Conversion factor: Method: TAT: 7d Lab: Hematol Serum SST/red Fasting sample preferred. Fasting: <216 pmol/L (1st IRP 66/304) Insulin:Glucose ratio <35 mIU/L ´ 7.18 = pmol/L AutoIA (AxSYMâ), CV 10%. Interference: hemolysis (¯) Lab: OC Biochem Price: [$$] LMS 40 INSULIN-LIKE GROWTH FACTOR-1, IGF-1, SOMATOMEDIN-C Specimen: Serum SST/red (Mauve acceptable) Restricted to Endocrinologists; others consult Biochemist. Ref Interval: 16-39 y: 122-400 ug/L 40-54 y: 75-306 ug/L >54 y: 48-225 ug/L TAT: 14d Lab: HICL Price: [$$] INTERNATIONAL NORMALIZED RATIO, INR Use: Monitoring coumadin therapy, assessment of liver disease, and screening for factor deficiency or inhibition in the extrinsic pathway. Specimen: Ref Interval: Target values: Plasma Light blue (4.5 mL) Specify anticoagulant therapy. 0.9-1.2 For coumadin therapy: DVT: 2-3, Prosthetic heart value: 3-4 TAT: Stat, 1h; Routine daily, 4h 46 Lab: Hematol Price: [$$] LMS 12 IRON, Fe++ Specimen: Serum/plasma SST/PST Sample in morning where possible Ref Interval (am): Males: 11-28 umol/L Females: Conversion factor: Factors affecting: Method: Lab: Biochem 7-26 umol/L ug/dL ´ 0.18 = umol/L Wide intraindividual variation, conc may fall by 50% in afternoon Auto chem, ferrozine method, CV 3%. Interf: i.v. iron, hemolysis, lipemia, desferoxamine (¯). Price: [$] LMS 34 (includes IBC) IRON BINDING CAPACITY, IBC, TIBC Specimen: Serum/plasma SST/PST Ref Interval: 45-75 umol/L. Iron saturation: Males: 20-55 % Females: 15-50% Conversion factor: Lab: Biochem ug/dL ´ 0.18 = umol/L Price: [$] LMS 34 (includes Fe) ISOPROPYL ALCOHOL, ISOPROPANOL Specimen: Serum/plasma SST/PST Analyzed stat only if osmolal gap@ is increased Toxic conc: Symptoms: >17 mmol/L Toxic: >33 mmol/L Lethal: 50-68 mmol/L Conversion factor: Comments: g/dL ´ 166 = mmol/L Lethal dose: 150-240 mL Common sources: rubbing alcohol, nail polish remover. Metabolizes to acetone; no toxic metabolites. Method: GC in conjunction with ethylene glycol and methanol, CV 5%. TAT: Stat, routine 1d Lab: OC Biochem Price: [$$] LMS 40 @ 2 ´Na – Glu – Urea – osmolality; gap is increased if >0 17 KETOSTEROIDS and 17-KETOGENIC STEROIDS not available For assessment of adrenal androgen secretion - serum DHEA sulphate. For glucocorticoid function - serum cortisol and/or 24h urinary free cortisol. For adrenogenital syndrome - serum 17-OH progesterone and progesterone. KETONES, SERUM (Rothera’s test) Specimen: Serum/plasma SST/PST Interpretation: Positive 1:32 suggests severe ketonemia. Method: Lab: Biochem Colour reaction with sodium nitroprusside, reported as positive to highest serial dilution. Detects acetoacetate and acetone, NOT b-OH-butyrate. False pos with captopril, mesna, substances with sulphydryl groups. Price: [$] LMS 3 KETONES, URINE Note: Roche Diagnostics’ Chemstripâ 5L are available on many wards. Specimen: Random urine Continued on next page 47 Method: Lab: Biochem Detects acetoacetate and acetone, not b-OH-butyrate. Pos at 1.5 mmol/L acetoacetate. False pos with captopril, mesna, substances with sulphydryl groups. Ketonuria can occur in starvation and isopropanol ingestion. KLEIHAUER TEST, KLEIHAUER-BETKE STAIN Use: To determine extent of transplacental fetal to maternal hemorrhage. Volume of fetal blood is calculated to determine Rh immune globulin dosage Specimen: Whole blood (maternal) Mauve Expected value: Fetal cells absent, FMH <5 mL Method: TAT: daily, 1d HbF resists acid elution Lab: Hematol Price: [$$] LMS 18 LACTATE, LACTIC ACID Specimen: Plasma PST/dark green not SST Fill tube, transport on ice Ref Interval: Venous (at rest): 0.5-2.2 mmol/L Comments: Method: Lab: Biochem Rises in whole blood with storage. Auto chem, CV 3%. Price: [$] LMS 27 LACTATE DEHYDROGENASE, LD, (LDH) Specimen: Serum/plasma SST/PST Ref Interval: 98-192 U/L (adults) RS: 265-609 U/L Method: Lab: Biochem Auto chem, CV 4%. Interferences: hemolysis (áá) Price: [$] LMS 10 LACTATE DEHYDROGENASE ISOENZYME not available LACTOSE INTOLERANCE Specimen: Serum/plasma SST/PST Protocol: Collect fasting and 30m after 50g oral lactose load samples Expected values: In lactose intolerance, glucose increases <1.1 mmol/L LAXATIVE, URINE SCREEN see PHENOLPHTHALEIN URINE SCREEN LDL CHOLESTEROL see CHOLESTEROL, LDL LE CELLS (discontinued, replaced by ANTI-NUCLEAR ANTIBODIES) LEAD, Blood, Pb Specimen: Whole blood Royal blue (from Biochem) Ref Interval: Children <16y and premenopausal women: Normal: <0.48 umol/L Potentially toxic: Not established Men and postmenopausal women: Normal: <0.72 umol/L Potentially toxic: >1.90 umol/L Toxic: Cut-off for lead industry workers to be removed from workplace: >1.45 umol/L, premenopausal women >0.48 umol/L Conversion factor: TAT: 14d 48 ug/dL ´ 0.048 = umol/L Lab: HICL Price: [$$] LMS 40 LEAD, Urine Specimen: Ref Interval: Conversion factor: TAT: 14d 24h urine collected in acid washed bottle from lab. Chelation test: 24h urine collected following 1 g Ca-EDTA <600 nmol/d Post 1g calcium-EDTA: <5 umol/d ug/d ´ 4.8 = nmol/d Lab: HICL Price: [$$] LMS 40 LECITHIN/SPHINGOMYELIN RATIO not available, use FETAL LUNG MATURITY LEGIONELLA CULTURE and DIRECT FLUORESCENT ANTIBODY STAINING see also SEROLOGICAL TESTING Specimen: Bronchial washings, chest drainage, lung tissue, pleural fluid in sterile screw-cap bottle. Cultures: must be specifically requested (routinely done on lung tissue). For fluorescent Ab staining – consult Microbiologist. TAT: 7d Lab: Microbiol Price: [$$$] : LEUKEMIA / LYMPHOMA PROFILE see FLOW CYTOMETRY LEUKOCYTE ALKALINE PHOSPHATASE SCORE, LAP, NAP Use: Differentiating chronic granulocytic leukemia from reactive conditions Specimen: Normal Score: Capillary blood collected by lab (OC: 13520; OG:78329) Male: 22-124 Female: 33-149 Factors affecting: Elevated levels are seen in pregnancy, polycythemia, bacterial infections and in inflammatory processes. Lab: Hematol TAT: M-F, 1-2d LIGHT CHAINS, Urine Specimen: Random urine Method: TAT: 4d Sample concentrated and electrophoresed. Any abnormal bands, not previously typed, will be identified by immunofixation with anti-G, A, M, kappa, lambda antiserum. Lab: OG Biochem/OC Imm Price: [$$] LMS 50 LIPASE, PANCREATIC Specimen: Serum/plasma Ref Interval: 22-51 U/L Comments: Method: Lab: Biochem Longer T½ than amylase. Not excreted in urine. Macrolipasemia very rare; rarely increased in non-GI disorders. Auto chem, enzymatic colorimetric assay, CV 4%. Price: [$] LMS 22 Abbreviations: (complete list on page 4): Auto Chem HICL SST/PST 2 Enzymes Automated Chemistry Analyzer Hospital-in-Common Laboratory (Toronto) OC Civic OG General Royal bl Low metal 49 LIPOLYTIC ACTIVITY, POSTHEPARIN, PHLA Book test with Metabolic Function Testing Lab (798-5555 x16750). Patient must have normal PTT and INR prior to testing, and not on ASA. Ref Interval: Hepatic TG lipase activity: 4-31 umol oleate/mL plasma/h Lipoprotein lipase activity: 4-26 Total PHLA: 11-55 Method: Measurement of radio-tagged fatty acids generated by lipase activity, CV 10%. Lab: OC Biochem/Function Testing Lab Price: [$$$] TAT: 21d LIPOPROTEIN (a) not available LIPOPROTEIN ANALYSIS by ULTRACENTRIFUGATION Use: Investigation of hypertriglyceridemia. Specimen: Serum Comments: Method: VLDL-C/serum Tg >0.7 suggests Type III hyperlipidemia. Following ultracentrifugation, triglycerides and cholesterol are measured in the various fractions. Lab: OC Biochem/Function Testing Lab Price: [$$$] LMS 50 TAT: 7d SST/red ´ 3 LIPOPROTEIN ELECTROPHORESIS not available LITHIUM, Li+ Specimen: Therapeutic: Toxic conc: Conversion factor: Half-life: Toxicity: Serum SST not PST/dark green (contains Li Heparin) Collect sample >12h post dose or just before next dose. Trough: 0.5-1.4 mmol/L Mild toxicity: 1.5-2.5 mmol/L Serious: 2.6-3.6 mmol/L Lethal: >3.6 mmol/L Toxicity increases with hyponatremia and renal failure. Method: mEq/L = mmol/L 14-33h CNS: tremor, parasthesia, incontinence, slurred speech blurred vision, headache, seizures, cranial nerve involvement, somnolence, confusion, coma, acute dystonia. CVS: arrhythmia, ECG changes, CV collapse. Renal: albuminuria, oliguria, polyuria, glycosuria, dehydration, edema; Misc: allergic vasculitis, metallic taste. Ion-selective electrode, CV 2%. Lab: OG Biochem Price: [$$] LMS 10 LOVENOX - see ANTI-Xa LOW MOLECULAR WEIGHT HEPARIN ACTIVITY see ANTI-Xa LUPUS ANTICOAGULANT Use: Investigation of autoimmune processes with thrombophilia, congenital heart block, recurrent abortion Specimen: Plasma Light blue ´ 2 Transport on ice immediately Anti cardiolipin assay should also be requested. TAT: 10d Lab: Hematol 50 Price: [$$] LMS 28 LUTEINIZING HORMONE, LUTROPIN, LH Specimen: Serum/plasma SST/PST Ref Interval: Male: 2-12 IU/L (1st IRP 68/40) Female: Follicular: 1-18 IU/L Ovulatory: 24-105 Luteal: 1-20 Postmenopausal:15-62 Conversion factor: mIU/mL = IU/L Method: AutoIA (AxSYMâ), CV 6%. Interf: lipemia () TAT: 7d; stat avail. Lab: Biochem Price: [$$] LMS 28 LYMPHOCYTE CROSSMATCH see HLA CROSSMATCH MAGNESIUM, Serum, Mg++ Specimen: Serum/plasma SST/PST Ref Interval: 0.74-1.03 mmol/L Therapeutic: On i.v. MgSO4 1.7-3.1 mmol/L, toxicity risk at >5 mmol/L. Conversion factor: Method: Lab: Biochem mg/dL ´ 0.41 = mmol/L Auto chem, CV 3%. Interferences: Moderate hemolysis (). Price: [$] LMS 5 MAGNESIUM, Urine Specimen: 24h urine with no preservative or in 20 mL 6M HCl Ref Interval: 3.0-5.0 mmol/d <0.5 mmol/d for hypomagnesemia Method: Lab: Biochem Auto chem, CV 3%. Interferences: Hemolysis (). Price: [$] LMS 5 MALARIA SMEAR Use: Diagnosis of malaria, evaluation of febrile illnesses of unknown origin. Specimen: Comments: Whole blood Mauve top Transport to lab immediately Note in clinical chart recent travels and history of malaria (including species). The laboratory notifies Infection Control of positive cases. TAT: Preliminary report 4h, speciation: 24h Lab: Hematol Price: [$$] LMS 15 MARIJUANA see CANNABINOID SCREEN MATERNAL SERUM SCREENING, MSS – serum estriol, AFP, ßhCG Use: Replaced by IPS (see next page) Specimen: TAT: 2d Serum SST/red Complete MATERNAL ALPHA-FETOPROTEIN form LAB 273 (08-88) Lab: CHEO Biochem Price: Funded by MOH Abbreviations: (complete list on page 4): TAT Turnaround time (from time of receipt) CHEO HICL Hospital-in-Common Lab (Toronto) OC LMS Labour, Management, Supplies (OHIP billing) OG MOH Ministry of Health & Long Term Care Children’s Hospital Civic Campus General Campus 51 INTEGRATED PRENATAL SCREENING, IPS – Serum PregnancyAssociated Plasma Protein-A (PAPP-A), estriol, AFP, ßhCG Use: Prenatal screening for neural tube defect and Down’s syndrome. Replaces MSS Note: Proceed only with the informed choice of patient. High risk patients (family/past history of NTD or Down’s syndrome) should be referred to medical geneticist. See 2 Chromosomal Studies Specimen: Serum red Complete INTEGRATED PRENATAL SCREENING form Specimen 1: collect between10 and 13+6 wks of gestation Specimen 2: collect between 15 and 18+6 wks of gestation TAT: 2d after 2nd specimen is received MELANIN Specimen: Method: TAT: 2d Lab: CHEO Biochem Fresh urine Observation of urine darkening on standing; other reducing substances (e.g. phenylketones) may give similar reaction. Lab: Biochem Price: [$] MERCURY, Blood, Hg++ Use: Assessment of organic Hg poisoning. Not useful for assessment of poisoning from dental fillings or inorganic Hg exposure >4d prior. Specimen: Ref Interval: Whole blood Royal blue (from Biochem) Restricted; consult Biochemist. 0-50 nmol/L, chronic exposure: up to 1000 nmol/L Conversion factor: TAT: 21d ug/dL ´ 49.9 = nmol/L Lab: HICL Price: [$$] LMS 30 MERCURY, 24h URINE Use: Assessment of ongoing and previous (<4w) exposure to inorganic Hg and Hg metal (by inhalation). Not useful for assessment of Hg poisoning from dental fillings. Specimen: Ref Interval: 24h urine collected in acid washed bottle from Biochem <20 nmol/d, chronic exposure: up to 2000 nmol/d excretion seen with high fish consumption. Conversion factor: TAT: 21d ug/dL ´ 4.99 = nmol/d Lab: HICL Price: [$$] LMS 30 METABOLIC SCREEN, URINE and SERUM Use: Screen for inborn errors of metabolism - reducing substances, glucose, ketones, a-ketoacids, homocystine, cystine, tyrosine, phenylalanine, mucopolysaccharides. Specimen: Random urine: collect without preservative or in 0.25g thymol (min vol 5 mL). Keep refrigerated. Serum: SST Restricted to Neonates. Method: Screen with chemical tests and chromatography. If positive amino-acid quantitation will be performed if indicated. Lab: CHEO Biochem Price: [$$$$] TAT: 3d 52 METANEPHRINES Specimen: 24h urine in 20 mL 6M HCl (same sample as VMA, 5HIAA). No diet restriction; avoid large amounts of caffeine. Minimum of 2 consecutive collects, preferably during hypertensive episode. Ref Interval: Metanephrines: Male: 0.2-1.7 umol/d Female: 0.2-1.2 Normetanephrines: Male: 18-36y: 0.5-3.8 umol/d >36y: 0.8-4.4 Female: 18-36y: 0.6-2.5 >36y: 0.7-3.4. Conversion factor: Comment: Method: TAT: 7d mg/dL ´ 5.5 = umol/d Higher levels seen in hypertensives, use of MAO inhibitors and hydralazine derivatives. HPLC Lab: OG Biochem Price: [$$$] LMS 75 METHEMOGLOBIN Specimen: Whole blood Dark green/PST Transport on ice (MetHb very unstable) Ref Interval: <1.5% of total hemoglobin Method: Spectrophotometry (hemoximeter) Lab: OC: Biochem/OG: CP Lab (ICU) Price: [$] LMS 21 METHOTREXATE Specimen: Serum/plasma SST/PST State number of hours postdose on requisition Toxic conc: On low-dose leucovorin: at 24h >10 umol/L; 48h >1 umol/L; 72h >0.1 umol/L Higher toxicity risk if half-life >3.5h during the first 24h Half-life: Comment: Method: TAT: M-F, 1d. 8-15h (terminal phase) MTX <0.02 umol/L required for resumption of DNA synthesis. IA (TDx/Flxâ). Measures some minor metabolites, not 7-OH MTX. Lab: CHEO Biochem Price: [$$] LMS 35 METHYL ALCOHOL / METHANOL Specimen: Serum/plasma SST/PST Performed stat only if osmolal gap@ is increased. Toxic conc: >10 mmol/L if ethanol is not present. Consider dialysis at >16 mmol/L Conversion factor: Comments: g/dL ´ 312 = mmol/L; mg/dL ´ 0.3 = mmol/L Ethanol-load immediately in suspected methanol poisoning. Lethal dose: 60-240 mL; 10 mL may cause blindness. Common sources: windshield washer fluid, gasline antifreeze. Method: GC in conjunction with ethylene glycol and isopropanol. CV 5% TAT: Stat, routine 1d Lab: OC Biochem Price: [$$] LMS 40 @ 2xNa – Glu – Urea – osmolality; gap is increased if >0 53 METHYLENE TETRAHYDROFOLATE REDUCTASE see 2 Chromosomal Studies MIXING TEST Use: to investigate unexplained prolonged INR or APTT. Specimen: Plasma Light blue x 3 TAT: 24h Lab: Hematol Price: [$$] MONOSPOT TEST see INFECTIOUS MONONUCLEOSIS MUCOPOLYSACCHARIDES see METABOLIC SCREEN MYCOBACTERIA, ACID FAST BACTERIA, TUBERCULOSIS – CULTURES, DIRECT MICROSCOPY Specimen: Blood in BACTEC 13A bottle (obtain from Micro Lab); all other specimens in sterile screw-cap bottle. Collect 3 sputum specimens at least 1d apart, early morning for urine and sputum OC: sent to PHL. Direct microscopy will be done on respiratory specimens. OG/RS: send to Microbiol Lab. MYCOPLASMA CULTURE see also SEROLOGICAL TESTS Specimen: Respiratory specimen: in sterile containers or swabs in transport medium Urogenital specimen: as sterile swab in transport medium TAT: 21d for respiratory, 5d for urogenital Lab: PHL MYOGLOBIN, PLASMA not available – consult Biochemist MYOGLOBIN, URINE Specimen: Random urine Comments: Detects only frank myoglobinuria. Consider myoglobinuria if CK >3500 U/L and urine dipstick is positive for blood. Lab: Biochem Price: [$$] LMS 30 N-ACETYLPROCAINAMIDE see PROCAINAMIDE NORTRIPTYLINE see TRICYCLIC ANTIDEPRESSANT QUANT OCCULT BLOOD Note: Slides for testing are available on some wards. Specimen: Random feces Method: Detection of peroxidase activity. Interf: rare-cooked red meat (), peroxidase-containing vegetables (), iron pills (), menstrual fluid (), Vitamin C (¯) Lab: Biochem Price: [$] LMS 3 TAT: M-F, 1d Abbreviations: (complete list on page 4): TAT Turnaround time (from time of receipt) RS HICL Hospital-in-Common Lab (Toronto) OC LMS Labour, Management, Supplies (OHIP billing) OG PHL 54 Riverside Campus Civic Campus General Campus Public Health Lab OLIGOCLONAL BANDS in Cerebrospinal fluid Specimen: CSF (min 1mL) + SST blood Interpretation: PAG-isoelectric focusing: Negative: < 2 typical bands in CSF; or if >2 bands are present, the bands correspond with bands in serum. Positive: > 2 typical bands in CSF Atypical: > 2 bands seen, but pattern not typical. Interpret in light of clinical findings. Oligoclonal bands seen in: Multiple sclerosis (85-90%), SSPE (90%), neurosyphilis (80%), bacterial or viral meningoencephalitis (40%), necrotizing encephalitis, Herpes zoster and H simplex encephalitis, Guillain-Barre synd., meningeal carcinomatosis, toxoplasmosis, myasthenia gravis, other neurologic diseases Quantitative IgG and albumin measurements: IgG: 0.010-0.034 g/L CSF IgG:Albumin 9-26 IgG index 35-69 TAT: 21d Lab: OG Biochem Price: [$$$] OPIATE SCREEN Specimen: Random urine Detects: Morphine, hydromorphone, codeine, oxycodone Reported as: Positive at minimum detection level (>300 ug/L morphine) Half-lives: Method: Note: TAT: M-F, 1d Morphine ~2h, Codeine 3h, Heroin 60-90 min. Assay detects the following (with approx. cross-reactivities of): codeine (94-120%), heroin (55%), dihydrocodeine (60%), dihydromorphine (47-108%), ethylmorphine (85%), hydrocodone (47-120%), hydromorphone (37-114%), levorphanol (8-79%), 6-monoacetylmorphine (45-96%), morphine (100%), morphine glucuronide (45%), nalorphine (0-14%), naloxone (0-3%), oxycodone (0-24%), oxymorphone (0-18%), thebaine (7-63%), promethazine (0-35%) No/minimal cross-reactivity: alphaprodine, anileridine, dextromethorphan, diphenoxylate, meperidine, methadone, nicotine, pentazocine, promethazine, propoxyphene. Positive tests can result from poppy seeds ingestion (morphine content ranges from 2 to 251mg/g) Lab: OG Biochem Price: [$$] OSMOLALITY, Serum Specimen: Serum SST/red Ref Interval: 280-295 mmol/kg water Comments: Method: Lab: Biochem Calc osmolality = 2 ´ [Na+] + [urea] + [gluc] (all in mmol/L) Osmolal gap: measured minus calc osmo; normal <2 mmol/L Freezing point depression, CV: 2% Price: [$$] LMS 10 55 OSMOLALITY, Urine Specimen: Random or 24h urine (no preservative) Ref Interval: 50-1400 mmol/kg water (interpret in light of serum osmo) Lab: Biochem Price: [$$] LMS 10 OSMOTIC FRAGILITY, ERYTHROCYTE (RED CELL) FRAGILITY Use: Confirmation of spherocytes in hereditary spherocytosis Specimen: Whole blood Dark green ´ 2 By appointment only (OC:16216, OG:78329) Mon-Thur Expected values: Mean cell fragility (MCF) Fresh: 0.40-0.45 % NaCl Incubated:0.47-0.58 % NaCl Comment: TAT: M-Th, 2-3d All causes of spherocytosis (i.e. AIH anemia) give pos results. Lab: Hematol Price: [$$$] OVA and PARASITES Specimen: Feces, body fluids in SAF fixative container. Collect daily or q2-3d x 3 Interference: TAT: 1-2w Antacids, antibiotics, barium, bismuth cpds, kaolin, mineral oil. Lab: Microbiol Price: [$$] OXALATE, 24h URINE Specimen: 24h urine in 20 mL 6M HCl Ref Interval: Male: 155-527 umol/d Females: 128-345 umol/L Comments: Conversion factor: Method: TAT: 14d High oxalate foods: rhubarb, spinach, beets, Swiss chard, tea. mg/d ´ 11.1 = umol/d Enzymatic (Sigma) assay, CV 8%. Interf: excessive vitamin C. Lab: OC Biochem Price: [$$] LMS 40 OXYGEN, pO2 , OXYGEN SAT. see BLOOD GASES and pH PAP (Papanicolaou) SMEAR Requisition: Lab form 09 -411390 Provide information – Date of test; Age; LMP; Day of cycle; Hormone use; history of malignancy, gyne surgery, cryosurgery/laser, radiation therapy, chemotherapy; colposcopic findings; IUCD; abnormal vaginal bleeding; previous abnormal PAP (give dates). Procedure Endocervical sampling and cervical scrape recommended for collection in all cases. For lesions of vagina, vulva - scrapings. 쐌 Use non-powdered gloves of sample: 쐌 Insert speculum without lubricant 쐌 Use an Ayers spatula or similar instrument. Obtain material: Cervix: Scrape around the whole squamo-columnar junction. Endocervix: (this area is very important): Obtain material with (a) Cytobrush inserted high into cervical os, or (b) endocervical aspiration. 56 Vaginal: Use the paddle end of the spatula to scrape. Mid portion of lateral wall: for CYTOHORMONAL (Maturation Index) evaluation (patient must not have douches within past 24h). Posterior fornix: for DUB or post-menopausal bleeding. 쐌 쐌 쐌 쐌 쐌 Place material from each site on labeled (pt’s name in pencil) slide. When all sites have been collected, quickly spread material thinly over slide with paddle end of spatula. Fix immediately with Cytospray®. Spread vaginal pool material over fixed posterior fornix scraping and re-fix. One well prepared slide is better than multiple scanty ones. Reporting: Common diagnoses in the Bethesda System include: 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 Within normal limits. Benign cellular changes, e.g., secondary to specific infections (e.g., Candida, Herpes), radiation therapy, other inflammatory processes. ASCUS: Atypical squamous cells of undetermined significance. Recommendation is often made for a repeat smear in 6m. LSIL: Low grade squamous intraepithelial lesion. Corresponds to HPV effects with or without CIN 1. Recommendation is often made for colposcopy. HSIL: High grade squamous intraepithelial lesion. Corresponds to CIN 2 or CIN 3. Recommendation for Colposcopy. Positive for malignancy. Endocervical cell dysplasia or adenocarcinoma in situ. Endocervical curettage or biopsy should be done. AGCUS: atypical glandular cells of undetermined significance. Recommendation for either repeat smear in 6m, endocervical curettage or cervical biopsy. Cytologically benign endometrial cells in postmenopausal women. Further investigation, including D&C, if clinically indicated PARATHYROID HORMONE, INTACT, iPTH Specimen: Plasma Mauve (5 mL) Transport on ice within 45 min Also order serum calcium. Ref Interval: 1.6-6.9 pmol/L. Interpret in relation to serum calcium. Conversion factor: Method: TAT: 21d pg/mL ´ 0.106 = pmol/L AutoIA (Elecsysâ) Interf: Heterophil Ab to mouse Lab: Biochem Price: [$$$] LMS 120 PARTIAL THROMBOPLASTIN TIME, PTT, APTT Use: (1) Monitor standard heparin therapy (2) Screen for defects in intrinsic pathway. Specimen: Plasma Light blue Expected values: 24-36s, heparin therapy 60-100s Comments: Specify anticoagulant therapy Lab: Hematol Price: [$$] LMS 14 Abbreviations: (complete list on page 4): s seconds min minutes hours h days d months m AutoIA Interf CIN HPV Automated immunoassay Interference (analytical) Cervical intraepithelial neoplasia Human papillomavirus 57 PATHOLOGY, SURGICAL TISSUES & BIOPSIES 쐌 쐌 쐌 쐌 Submit in 10% neutral buffered formalin in a container able to accommodate the tissue and at least 5 volumes of fixative. For suspected malignant lymphoma, submit fresh tissue moistened with saline (NO FIXATIVE). Label container with source site, laterality (if applicable), patient’s name and unique number (addressograph label). Complete Surgical Pathology Requisition, labeled with patient demographic information. Provide appropriate clinical information (e.g. differential diagnosis, history of malignancy, clinical and radiographic findings, etc.). Send to Surgical Pathology Lab. For fresh tissue not in fixative, send STAT by porter. Notify lab (OC: 13531; OG 72059) prior to transport. TAT: small biopsies 24-48h, larger tissues 72h PHENCYCLIDINE SCREEN not available. Consult Biochemist. PHENOBARBITAL see also BARBITURATE SCREEN Specimen: Serum/plasma SST/PST Draw trough level (12h postdose) Therapeutic: 65-172 umol/L Toxic conc: >200 umol/L; toxicity increases with renal failure. Consider dialysis at >430 umol/L Conversion factor: Half-life: Clinical toxicity: Method: Lab: Biochem ug/mL ´ 4.3 = umol/L 3-4d CNS: dizziness, headache, nausea, vomiting, depression, ataxia, confusion, paradoxical excitation, somnolence CVS: hypotension AutoIA (AxSYMâ), CV 6%, cross-reactivities: up to 20% with p-hydroxyphenobarbital (major metabolite) and its glucuronide Price: [$$] LMS 35 PHENOLPHTHALEIN URINE SCREEN Use: Detection of phenolphthalein laxative abuse. Specimen: Early morning urine ´ 3, preferably after weekend Method: TAT: 3d Qualitative using detection of colour formation with alkali Lab: OC Biochem Price: [$] PHENYTOIN, DILANTIN Specimen: Serum/plasma SST/PST Oral: draw trough (12h postdose) IV: >2h postdose, IM: >4h postdose Therapeutic: Trough: 40-80 umol/L Toxic conc: >100 umol/L Conversion factor: Half-life: Clinical toxicity: Method: Lab: Biochem 58 ug/mL ´ 4.0 = umol/L 20-40 h CNS: nystagmus, ataxia, hyperreflexia, twitching, dyskinesia, dysarthria, confusion, dizziness, coma, respiratory depression. CVS: V Fib, cardiovascular depression. GI: vomiting, constipation. Dermatologic, hematologic AutoIA (AxSYMâ), CV 6%, cross-reacts with fosphenytoin (early metabolite) Price: [$$] LMS 35 PHOSPHATE, Serum, PO43Specimen: Serum/plasma SST/PST Ref Interval: 0.78-1.53 mmol/L At <0.3 mmol/L, hemolysis and neuromuscular complications may occur. Conversion factor: Method: Lab: Biochem mg/dL ´ 0.32 = mmol/L Auto chem, CV: 2% Price: [$] LMS 5 PHOSPHATE, 24h Urine Specimen: 24h urine with no preservative, or 20 mL 6M HCl. Ref Interval: 13-42 mmol/d Conversion factor: TAT: M-F, 1d mg/d ´ 0.032= mmol/d Lab: Biochem Price: [$] LMS 5 PLASMINOGEN ASSAY Use: Determines plasminogen and plasmin activity. Specimen: Ref Interval: Plasma Light blue ´ 3 0.55-1.25 U/mL Comments: In trauma, MI, malignant diseases ¯ in infants, adv hepatic cirrhosis, DIC, thrombolytic therapy Lab: Hematol Price: [$$] LMS 55 TAT: M-F, 10d Transport on ice PLATELET AGGREGATION Use: Von Willebrand’s disease, storage pool disease, Bernard-Soulier syndrome and other platelet function abnormalities. Specimen: Mauve, Hematology consult strongly recommended Collected by Hematol - call for appt (OC:14190, OG:78329) 쐌 No anti-inflammatory or antiplatelet drugs for 1w prior to test 쐌 Platelet count should be >75 ´ 109 /L. 쐌 State appropriate clinical and drug history TAT: Routine M-F, 1-2d Lab: Hematol Price [$$$] LMS 12 per additive PLATELET ANTIBODIES Use: Test includes platelet typing and antibody determination. Performed on patients with immune thrombocytopenia, neonatal immune thrombocytopenia (maternal antibodies), platelet refractoriness Specimen: Adults: Mauve (30 mL) Children: (Mauve 10 mL) Comment: Contact Hematologist on call for booking with CBS. TAT: 2w, Stat same day Lab: CBS through TM PLATELET COUNT see COMPLETE BLOOD COUNT PNEUMOCYSTIS CARINII Specimen: Induced sputum, bronchial wash or BAL (lavage). Lab: Done in OG Microbiology Lab by direct fluorescent antibody test – Stat available with approval of Microbiologist. PORPHOBILINOGEN see AMINOLEVULINIC ACID 59 PORPHOBILINOGEN DEAMINASE, Erythrocytes Specimen: Whole blood Dark green Protect from light, do not freeze Ref Interval: 20-43 umol/L erythrocyte/h 2 Porphyrias Method: TAT: 14d Enzymatic, CV 5% Lab: OG Biochem Price: [$$$] PORPHYRIN, plasma, urine and feces Specimen: Plasma (heparinized) PST/dark green 2 Porphyria 24h urine in 5g Na2CO3 in brown bottle, protect from light Random urine 50 mL in 0.25g Na2CO3, send immediately (has to be pH 8) Feces random Plasma Ref Int: Uroporphyrin I Uroporphyrin III Heptacarboxyl III Hexacarboxyl III Pentacarboxyl III Coproporphyrin I Coproporphyrin III Copro III: Copro I Protoporphyrin Copro I : Proto nmol/L 0-11 0-3 0-5 0-2 0-2 0-10 0-12 Urine nmol/d 0-44 0-20 0-16 0-2 0-2 5-90 15-242 2.6-5.3 umol/ mol creat 0.4-3.9 0.0-2.0 0.0-1.3 0.0-0.7 0.0-1.0 0.3-8.5 1.7-26 Feces nmol/g dry wt 0-5 0-1 0-1 0-1 0-1 0-13 0-12 (not reliable if U creat <4 mmol/L) 0-38 0.63 Conversion factor: Uroporphyrin: ug/d ´ 1.20 = nmol/d; Coproporphyrin: ug/d ´ 1.53 = nmol/d Method: HPLC; CV 5-15% TAT: Screen: M-F, 1d, Quant: 7d Lab:OG Biochem Price: [$$$] LMS 75 (blood), 60 (urine), 90 (feces) PORPHYRIN, ERYTHROCYTE PROTOPORPHYRIN, FEP Use: Erythropoietic protoporphyria (EPP), lead poisoning and some anemias. Specimen: Ref Interval: Whole blood Mauve (not SST/PST) Protect from light Adult: 0.4-1.0 umol/L RBC 2 Porphyrias Comments: Method: TAT: 7d Diagnosis of EPP will be confirmed by erythrocyte fluorescence Solvent extraction, CV 10% Lab: OG Biochem Price: [$$$] LMS 75 POTASSIUM, Serum, Whole blood, K+ Specimen: Serum/plasma SST/PST Blood: heparinized syringe (done with blood gas analysis) Ref Interval: 3.6-5.1 mmol/L (see Critical Values) Serum > whole blood or plasma because of cellular release of potassium during clotting. Conversion factor: Factors affecting: Method: Lab: Biochem 60 mEq/L = mmol/L Hemolysis (), leucocytosis: >100 ´ 109/L (), thrombocytosis: >600 ´ 109/L (). Ion-selective electrodes, CV: 2%. Price: [$] LMS 5 POTASSIUM, Urine Specimen: Random urine or 24h collected with no preservative Ref Interval: Normokalemia: 25-125 mmol/d Hypokalemia: <35 mmol/d (>10 mmol/L suggests renal loss, <10 mmol/L suggests ¯ intake or extrarenal loss). Conversion factor: mEq/d = mmol/d TAT: Stat; 24h collect – routine M-F Lab: Biochem Price: [$] LMS 5 POTASSIUM, Feces Specimen: Liquid fecal material TAT: M-F, 1d Lab: Biochem PRENATAL SCREEN Includes ABO and Rh, antibody screen, antibody identification if screen positive, and antibody titre. Use: Determine mother’s eligibility for Rh immune globulin, identify the risk and severity of hemolytic disease of newborn. Specimen: Comments: Mauve (7 mL) TAT: 1-3h Lab: TM See Transfusion Med - Fractionated Products Immune globulin PRIMIDONE includes PHENOBARBITAL (active metabolite) Specimen: Serum/plasma SST/PST Therapeutic: 23-55 umol/L Toxic conc: >60 umol/L; toxicity increases with renal failure. Conversion factor: ug/mL ´ 4.6 = umol/L Half-life (primidone): 4-12h Clinical toxicity: Similar to phenobarbital, also dermatologic and hematologic side-effects. TAT: M-F, 1d Lab: HICL Price: [$$$] LMS 35 PROCAINAMIDE includes N-ACETYL PROCAINAMIDE (NAPA) Specimen: Serum/plasma SST/PST Draw trough (12h after last dose) Therapeutic: Trough: 17-43 umol/L Toxic conc: >70 umol/L for procainamide >110 umol/L for procainamide + NAPA Toxicity increases with renal and cardiac failure. Conversion factor: Comments: Half-life: Clinical toxicity: Lab: HICL ug/mL ´ 4.3 = umol/L NAPA (major metab), has antiarrhythmic activity equiv to PA. “Fast” and “slow” acetylators genetically determined. In renal impairment NAPA is retained with ¯ PA:NAPA ratio PA: 3h NAPA: 6h CVS: hypotension, bradycardia, wide QRS complex, V Fib, junctional tachycardia, conduction delay. CNS: lethargy, confusion, convulsions, psychosis. GI: Nausea/vomiting, .diarrhoea, bitter taste; Renal: oliguria. Price: [$$$] LMS 35 61 PROGESTERONE, P4 Specimen: Serum/plasma SST/PST For suspected abnormal pregnancies, order also ß-hCG Ref Interval: State previous ßhCG result and LMP on requisition. Females: Follicular phase: 0.5-4.5 nmol/L Luteal phase: 6.0-60.0 nmol/L Pregnancy – see algorithm for suspected abn pregnancies Conversion factor: µg/L ´ 3.18 = nmol/L Method: AutoIA (Elecsysâ) Progesterone II. CV: <10%. Lab: Biochem Price: [$$] LMS 28 쐌 In Assisted Rep Technology patients, <40 nmol/L usually assoc with nonviability 쐌 Clinical judgement must be used in assessing viability of pregnancy. Ref: Perkins SL, Muataz A-R, Claman P. Progesterone in non-viable pregnancies. Fertil and Steril 2000 PROGESTERONE, 17 HYDROXY see HYDROXY PROGESTERONE PROGESTERONE RECEPTOR see ESTROGEN-PROGESTERONE RECEPTOR PROLACTIN Specimen: Ref Interval: Serum/plasma SST/PST Male: 2-19 ug/L (3rd IRP 84/ 500) Female: 1-24 ug/L Conversion factor: ng/mL = µg/L Method: AutoIA (AxSYMâ), CV 6%. Interf: lipemia () TAT: 7d; if required stat, consult lab Lab: Biochem Price: [$$] LMS 28 Abbreviations: (complete list on page 4): IRP Turnaround time (from time of receipt) TAT Hospital-in-Common Lab (Toronto) HICL Labour, Management, Supplies (OHIP billing) OC LMS Coeff of Variation (reproducibility) OG CV 62 International Reference Preparation Civic Campus General Campus PROSTATE SPECIFIC ANTIGEN, TOTAL, PSA Use: Diagnosis and monitoring of patients with prostatic cancer; not for screening. Specimen: Serum SST/red For patients following radical prostatectomy, order usPSA (=ultrasensitive PSA, measurable conc will be confirmed) <4 ug/L (Stanford PSA Reference Material 90:10) Ref Interval: Causes of elevations:>100´ ULN: Prostatic Ca 50´ ULN: Post biopsy, post TURP 10´: BPH, acute renal failure, prostatitis 5´: Ac MI <2´: Prostatic massage, rectal examination Method: AutoIA (AxSYMâ), CV 6%. Interf: lipemia () TAT: M-F, 1d Lab: OC Biochem Price: [$$] LMS 0 PROSTATE SPECIFIC ANTIGEN, FREE or COMPLEXED not available PROSTATIC ACID PHOSPHATASE , PAP not available PROTEIN C / PROTEIN S Use: Recurrent thrombosis/ thromboembolism – congenital deficiency of protein C, S Specimen: Ref Interval: Plasma Light blue (4.5 mL) ´ 3 Transport on ice Functional Antigen Protein C 0.75-1.45 0.70-1.20 Protein S 0.54-1.17 0.57-1.21 Antigen assay performed only if functional assay is abnormal. Comments: May be falsely low in patients on oral anticoagulants. TAT: Functional 10d, Antigen 3w Lab: Hematol Price: [$$] PROTEIN, Serum Specimen: Serum/plasma SST/PST Ref Interval: 61-79 g/L RS: 60-85 g/L Conversion factor: Method: g/dL ´ 10 = g/L Auto chem, CV 4%. Interf:dextran (), gross hemolysis (). Lab: Biochem Price: [$] LMS 5 PROTEIN, 24h Urine Specimen: 24h urine collected with no preservative Ref Interval: <0.15 g/d Conversion factor: Method: mg/d ´ 0.001 = g/d Auto chem, CV 5%. TAT: M-F, 1d Lab: Biochem Price: [$] LMS 5 PROTEIN, Cerebrospinal fluid Specimen: CSF sterile red top (min vol 0.5 mL) Ref Interval: 0.12-0.60 g/L Conversion factor: Method: Lab: Biochem mg/L ´ 0.001 = g/L Auto chem, CV 4%. Protein 0.10 g/L per 1000 ´109/L RBC. Price: [$] 63 PROTEIN ELECTROPHORESIS, Serum, SPE For urine see LIGHT CHAINS Specimen: Serum SST/red, not PST State if patient on anticoagulants. Ref Interval: Albumin: 35-52 g/L (serum) Alpha-1-globulins: 1-3 Alpha-2-globulins: 6-11 Beta-globulins: 5-10 Gamma-globulins: 6-14 Conversion factor: Comments: Method: mg/dL ´ 0.01 = g/L Abnormal bands, not previously typed, will be identified by IFIX. Fibrinogen, severe hyperlipidemia and hemolysis may give spurious bands. OC: Sebia Hydrasys® OG: Beckman Paragon® TAT: 4d Lab: OC Imm/OG Biochem Price: [$$] LMS 36 PROTHROMBIN TIME see INTERNATIONAL NORMALIZED RATIO (INR) PROTHROMBIN VARIANT GENE see 2 Chromosomal Studies PROTRIPTYLINE see TRICYLIC ANTIDEPRESSANT SCREEN and QUANT PYRUVATE KINASE, PK Use: Investigation of hemolytic anemia (rare cause) Specimen: Ref Interval: Whole blood Mauve Transport on ice Normal, subnormal sera will be titred. Comments: TAT: 1w Blood transfusion within the last 3 m invalidates results Lab: OG Hematol (78329) Price: [$$] RADIOIMMUNOSORBENT test for ALLERGEN-SPECIFIC IgE, RAST Specimen: Serum SST/red Ref Interval: Undetected or absent allergen specific IgE (< 0.35 kU/L) Unless otherwise specified, antigen used is A fumigatus. Testing available against penicillins, dust & mites, foods, animal proteins, venoms, molds, trees, grasses, and occupational chemicals (i.e. latex). TAT: 30 d Lab: HICL Price: [$$] RBC MORPHOLOGY, BLOOD SMEAR - see FILM REDUCING SUBSTANCES – REDUCING SUGARS, KETOACIDS, HOMOGENTISIC ACID Specimen: Random urine TAT: M-F, 1d Lab: Biochem Price: [$] Abbreviations: (complete list on page 4): IFIX Immunofixation TAT Turnaround time (from time of receipt) LMS Labour, Management, Supplies (OHIP billing) Appendix (pages 89-102) 2 64 RS Riverside Campus OC Civic Campus General Campus OG Hospital-in-Common Lab HICL OC Imm Civic Immunology RENIN ACTIVITY, PLASMA, PRA Specimen: Plasma Chilled mauve Transport on ice Ref Interval: Mean (SD) in ng/L/s during upright posture Normotensive Hypertensive Control 1.66 (1.0) 0.91 (1.0) 4h post 80 mg furosemide 5.81 (3.3) 1.95 (1.9) Low sodium intake 8.77 (4.2) 3.38 (4.7) High sodium intake 0.8 (0.6) 0.56 (0.6) Angiotensin I RIA kit insert, Rainen Assay System, DuPont Medical Products Split renal vein PRA: for condition to be surgically correctable 1) Ratio of PRA from the 2 renal veins should be >1.5 2) Conversion factor: Factors affecting: Method: TAT: 14d renal v. PRA - IVC PRA = 0 for normal, ³0. 5 for diseased kidney IVC PRA ng/mL/h ´ 0.28 = ng/L/s Liver disease, oral contraceptives may ¯ angiotensinogen resulting in lower PRA values. Mineralocorticoid antagonists, captopril (¯) RIA quant of angiotensin formed at 37oC, CV: 10-20% Lab: OC Biochem Price: [$$$] LMS 75 REPTILASE CLOTTING TIME Use: Evaluation of disturbance in fibrin formation, dysfibrinogenemia Specimen: Plasma Light blue Restricted; consult Clinical Hematologist. Expected values: 18-22s Comments: TAT: M-F, 10d Not affected by heparin Lab: Hematol Price: [$$] LMS 10 RETICULOCYTE COUNT, RETIC COUNT Use: Evaluation of erythropoietic activity and response to hematinic therapy . Specimen: Ref Interval: Whole blood 25-100 ´ 109/L Mauve Comments: TAT: daily, 2d in hemorrhage and hemolytic anemia, ¯ in red cell hypoplasia Lab: Hematol Price: [$$] LMS 13 Rh TYPING see ABO and RH TYPING RHEUMATOID FACTOR, RF Specimen: Serum Expected: <20 kIU/L Comments: Method: TAT: 7d SST/red in rheumatoid arthritis, mixed CTD, viral diseases, bacterial infections Immunonephelometry (Beckman Immage®) Lab: Biochem Price: [$$] LMS 6 65 RISTOCETIN COFACTOR ASSAY Use: Functional assay for von Willebrand’s factor Specimen: Ref Interval: Plasma 0.5-1.5 U/mL Comments: TAT: 10d Blood group should be specified. Lab: Hematol Price [$$$] RUBELLA IgG Specimen: Reported as: Method: TAT: 7d Light blue ´ 3 Transport on ice Serum/plasma SST/PST Absent (antibody <10 IU/L) Present (antibody >10 IU/L) AutoIA (AxSYMâ), CV 6% Lab: OC Biochem Price: [$$] LMS SALICYLATE Use: Management of toxicity only. Specimen: Therapeutic: Toxic conc: Serum/plasma SST/PST <2.2 mmol/L >4.7 mmol/L, consider dialysis at >5.8 mmol/L Conversion factor: Half-life: mg/dL ´ 0.07 = mmol/L Dose dependent: Low dose: 2-3h; Therapeutic:12h; High dose: 15-20 h. Enteric coated preps have later/prolonged kinetics CNS: initial hyperventilation (resp alkalosis), then depression; vertigo, tinnitus, excitement, confusion, convulsions, coma CVS: tachycardia Other: flushing, sweating, thirst, metabolic acidosis, fever, hemorrhage Auto chem, CV 2%. Interf: hemolysis (¯), Diflunisal () Price: [$$] LMS 12 Clinical toxicity: Method: Lab: Biochem SEDIMENTATION RATE, ERYTHROCYTE (WESTERGREN), ESR Use: Monitor therapy in inflammatory diseases and some malignancies. Specimen: Whole blood Expected values: Males: 0-6 mm/h Comments: TAT: Daily Black Females: 0-10 mm/h Asymmetric macromolecules (e.g. gamma globulins, fibrinogen) cause the most elevations. Normal range may be slightly higher in elderly patients. Lab: Hematol Price: [$] LMS 3 SEROLOGICAL TESTS see also VIRAL CULTURES Specimen: Serum Red Indicate phase: Acute phase (obtain where possible) or Convalescent (3-6w) Requisitions: Use PHL requisition #97-44 (07/98) except for 왔 Regional Virology Lab (CHEO)/CHEO Microbiol, n Biochem ✚ Tests also done in TM for transplant donors TAT 6h. For syphilis: use MOH form#1731-44 (94-10). CSF for syphilis: collect in Red top vacutainer (sent to PHL) For acute infections, include date of onset and clinical info 66 Tests available: Amebiasis Arbovirus Ascariasis ASO (CHEO Biochem) Bordetella pertussis Brucella California Encephalitis Chlamydia Coccidioides 왔 Cytomegalovirus (total, IgM) Echinococcus Eastern Equine Encephalitis 왔 Epstein Barr (see also EBV) Anti-HAV (Total, IgM) ✚ HBsAg ✚ Anti-HBs ✚ Anti-HBc (IgG+IgM) ✚ Anti-HBc (IgM) HbeAg Anti-HBe HDV (delta) HEV HCV ✚ Helicobacter pylori Histoplasma Anti HIV 1, 2 ✚ HIVp24Ag ✚ Anti-HTLV-I/II ✚ Legionella Leptospira Lyme disease 왔 Measles 왔 Mycoplasma pneumoniae Powassan Q fever Rickettsia Rocky Mountain Spotted fever n Rubella (IgG) St Louis Encephalitis Syphilis Toxocara 왔 Toxoplasma Trichinella Tularemia Typhus 왔 Varicella Zoster Western Equine Encephalitis SEX CHROMATIN, BARR BODIES see 2 Chromosomal Studies SEX HORMONE BINDING GLOBULIN not available SICKLE CELL SCREEN, HbS, Solubility test Use: Rapid method for the detection of hemoglobin S. Specimen: Whole blood Mauve Also order CBC, Film Comments: Does not distinguish between disease (homozygote) and trait (heterozygote). Positives confirmed with Hb electrophoresis. TAT: Stat, 1h; Routine, 1d Lab: Hematol Price: [$$] LMS 5 SODIUM, Serum, Na+ Specimen: Serum/plasma Ref Interval: 136-144 mmol/L Conversion factor: Method: Lab: Biochem SST/PST RS: 135-147 mmol/L mEq/L = mmol/L Auto chem, ISE, CV 1%. Interferences: lipemia (¯) unless cleared before analysis, marked hyperproteinemia (¯) Price: [$] LMS 5 Abbreviations: (complete list on page 4): ISE Ion-selective electrodes RS Riverside Campus 67 SODIUM, Urine Specimen: Random urine or 24h collected with no preservative Ref. Interval: 24h: 40-220 mmol/d Random urine in hyponatremia: <10 mmol/L suggests extrarenal loss >20 mmol/L suggests renal loss, hypoaldosteronism In oliguria: to distinguish between prerenal and acute tubular necrosis: Prerenal ATN U Na+ (mmol/L) <20 >40 Fractional Na clearance U Na+ ´ S Creat (unless on diuretics) S Na+ U Creat U osmolality (mmol/kg) <1 >1 >500 <350 U Cl - (mmol/L) <20 >20 TAT: stat, M-F for 24h collect Lab: Biochem Price: [$] LMS 5 SODIUM, Feces Specimen: Liquid fecal material TAT: Stat for random; Routine daily Lab: Biochem SOMATOMEDIN-C see INSULIN-LIKE GROWTH FACTOR STANDARD HEPARIN - see ANTI-Xa SUCROSE LYSIS TEST Use: Screen for Paroxysmal nocturnal hemoglobinuria. Do before Ham’s test. Specimen: Plasma Light blue Call Hematol (OC: 16216 OG: 78329) TAT: M-F, 1d Lab: Hematol Price: [$$] LMS 18 SYNOVIAL FLUID, MICROSCOPIC EXAMINATION for CRYSTALS Specimen: Synovial fluid Lab: OC Biochem/ OG Hematol Price: [$] TACROLIMUS, FK506, PrografÒ Specimen: Whole blood Mauve Therapeutic: Stable patients 5 – 20 µg/L (varies with transplant type, time (suggested): from last dose. Lower for long-term patients). Half life: 12h ± 4 for liver transplant, (21h ± 8 for healthy volunteers) Method: IA (Abbott IMxâ), CV 8% TAT: M-F, consult lab for stat Lab: OG Biochem Price: [$$] TELOPEPTIDES, C-TELOPEPTIDES, cTx Specimen: Serum/plasma Red/Mauve Collect between 12:00 -15:00 (marked diurnal variation) Restricted to Endocrinology, others consult Biochemist Ref Intervals: (95th percentile) 0.30 ug/L Method: TAT: 14d 68 IA (Roche Elecsysâ CrossLapsâ) Lab: OC Biochem Price: [$$] TESTOSTERONE, TOTAL replaced by TESTOSTERONE, FREE TESTOSTERONE, FREE Specimen: Serum Ref Interval: 20-29 y 30-39 40-49 50-59 ³ 60 SST/red Male Female 24.1– 94.8 pmol/L 20-59 y 25.0 – 89.3 ³ 60 23.5 – 81.7 22.5 – 80.4 21.5 – 74.3 0.5 – 8.1 pmol/L <6.4 Ooi et al. Clin Biochem 31:15-21 Conversion factor: Method: TAT: 7d ng/dL ´ 34.7 = pmol/L RIA (DPC Coat-A-Countâ). CV: 10% Lab: OC Biochem Price: [$$] LMS 100 THEOPHYLLINE, AMINOPHYLLINE Specimen: Serum/plasma SST/PST Draw peak concentration (postdose) 쐌 IV loading followed by infusion: 30 min after loading dose 쐌 PO: rapid dissolving preps: 2h post dose; slow release preps: 3-7h post dose Therapeutic: 55-110 umol/L Toxic conc: >110 umol/L. Consider dialysis at >300 umol/L Conversion factor: Half-life: Clinical toxicity: Method: TAT: M-F, 1d ug/mL ´ 5.6 = umol/L 7-11h CNS: restlessness, delirium, tinnitus, flashes of light, tremors, spasms, convulsions, coma; CV and respiratory collapse Other: fever, diuresis, dehydration, nausea/vomiting, coffee-ground vomitus AutoIA (Abbott AxSYMâ), CV 3%. Lab: Biochem Price: [$$] LMS 28 THROMBIN TIME Use: Determination of severe hypofibrinogenemia and presence of heparin-like anticoagulants, for diagnosis and monitoring of intravascular coagulation and fibrinolysis. Specimen: Ref Interval: Plasma 12-18s Lab: Hematol Light blue Price: [$] LMS 10 THYROGLOBULIN Specimen: Serum/plasma Red/Dark green/Mauve Sample at >6 w after thyroidectomy or 131I treatment Ref Interval: <128 pmol/L (tentative), post total thyroidectomy <2 pmol/L Conversion factor: Method: ng/mL ´ 1.515 = pmol/L AutoIA (Elecsysâ). Testing for Anti-TG interference available. TAT: 28d Lab: Biochem Price: [$$$] LMS 80 69 THYROTROPIN, THYROID STIMULATING HORMONE, TSH Specimen: Serum SST/red Ref Interval: 0.32-5.00 mU/L (2nd IRP 80/558) Conversion factor: Method: uU/mL = mU/L or mIU/L AutoIA (Abbott AxSYMâ), CV 5-8% TAT: M-F, 1d Lab: Biochem Price: [$] LMS 28 THYROTROPIN BINDING INHIBITORY IMMUNOGLOBULIN, TBII, TSI, LATS Use: Determining risk of neonatal hyperthyroidism in mothers with Graves’ disease; diagnosis of euthyroid Graves’ opthalmopathy. Specimen: Ref Interval: TAT: 21d Serum SST/red Restricted; consult Biochemist Normal <1.0 U/L, elevated >2.0 U/L Lab: HICL Price: [$$$$] THYROXINE BINDING GLOBULIN, TBG Specimen: Serum SST/red Ref Interval: 150-360 nmol/L TAT: 14d Lab: HICL Price: [$$] LMS 50 THYROXINE, FREE, FT4 Specimen: Serum/plasma SST/PST Ref Interval: Adult: 9.0-23.0 pmol/L Pregnancy: 1st trimester: 2nd trimester: 3rd trimester: Conversion factor: Factors affecting: Method: TAT: M-F, 1d 11.5-19.2 pmol/L 9.3-16.3 8.0-15.2 ng/dL ´ 12.87= pmol/L (¯) oral contraceptive and phenytoin use, following dialysis. () Heparin therapy (presence of NEFA). AutoIA (Abbott AxSYMâ), CV 5-10%, Interf:() autoantibodies. No interference from albumin or TBG. Lab: Biochem Price: [$$] LMS TINZAPARIN see ANTI-Xa TISSUE TYPING see HLA TOBRAMYCIN Specimen: Therapeutic: Toxic conc: Conversion factor: Half-life of drug: Method: TAT: M-F, 1d 70 Serum/plasma SST/PST State if pre-, postdose or random (peak: draw 30m post-infusion or 60m post-injection or oral dose) Predose <2 mg/L; postdose conc varies, based on use. Predose: >2 mg/L; postdose: >10 mg/L (guidelines only, consult Pharmacy) umol/L ´ 0.47 = mg/L 1.5h (to 15h, prolonged in renal failure) AutoIA (Abbott AxSYMâ), CV 5% Lab: Biochem Price: [$$] LMS 40 TRANSFERRIN Specimen: Serum Ref Interval: 1.7-3.6 g/L Conversion factor: Method: TAT: 7d SST/red mg/dL ´ 0.01 = g/L Immunonephel (Beckman), CV: 5% Interf: marked lipemia Lab: Biochem Price: [$$] LMS 12 TRANSFUSION REACTION INVESTIGATION (see Transfusion Med) Includes clerical check, visual specimen inspection, Direct Antiglobulin Test, appropriate laboratory investigation, review by designated transfusion medicine staff. Specimen: Comments: Post-transfusion Mauve (7mL) + Blood bag(s) Unused units will be re-crossmatched. No additional units of blood will be issued until investigation is completed. TAT: 1h (complicated case up to 3h) Lab: TM TRANSMISSIBLE DISEASE TESTING Tests Include: HBsAg, anti-HBs, anti-HBc (total, IgM), HCV, Anti-HAV (total, IgM), HIV p24 Ag, anti-HIV-1& 2, anti-HTLV-I/II, anti-CMV antibodies (total, IgM) Specimen: Comments: Red 10 mL, (not SST) HIV is performed only on organ/tissue donors and recipients. Confirmation is done by Public Health Lab. TAT: Routine 24-48h, Stat 4h Lab: TM TRICHOMONAS VAGINALIS Specimen: Vaginal swab (use sterile swab), place in transport medium TAT: 1-2d Lab: Microbiol Price: [$] TRICYCLIC ANTIDEPRESSANTS (TCA) QUANT see also TCA SCREEN Specimen: Serum/plasma Red (not SST or PST)/Mauve Restricted to Geriatric Unit and Psychiatry Therapeutic (nmol/L) Half-life of Drug Amitriptyline+Nortriptyline Results 300–900 17-40h Clomipraminea+metabolite 500–1300 15-62h Desipramine 470–1125 12-54h Doxepin+Nordopexin 540–900 17+6h Imipramine+desipramine 530–950 9-24h Nortriptyline 190–570 18-44h Protriptylinea 270–990 78+11h Trimipraminea 170–680 16-40h Comments: Toxic concentrations >1,700 nmol/L Method: Assayed by HPLC. aClomipramine (and des-methyl metabolite), trimipramine, protriptyline only by special request. Interferences: SST or PST (¯) Lab: OG Biochem Price: [$$$] TAT: 4d 71 TRICYCLIC ANTIDEPRESSANTS (TCA) SCREEN Use: Management of suspected overdose only. Specimen: Reported as: Clinical toxicity: Method: Lab: Biochem Serum/plasma Red top (not SST)/Mauve Restricted to ER, ICU, AMA Toxic:>300 ug/L (imipramine) 쐌 Actual conc varies with cross-reactivity of drug Present: 100 – 299 ug/L (imipramine). May indicate: 쐌 imipramine present in lower than toxic conc or 쐌 potentially toxic conc of other TCAs and related drugs with lower cross-reactivity. Negative: <100 ug/L (imipramine). Toxicity risk correlates with: QRS >0.1sec, cardiac arrhythmias and conduction defects, altered mental status (GCS <14), seizures, respiratory depression (<8/min or requiring support), systolic BP (<90 mmHg). AutoIA (AxSYM), CV 5% Assay detects following drugs (approx cross-reactivities): amitriptyline (90%), 10-OH amitriptyline (10%), clomipramine (45%, norclomipramine 50%), chlorpromazine (20%), cyclobenzaprine (50%), desipramine (90%), 2-OH desipramine (15%), diphenhydramine (60%), doxepine (35%), orphenadrine (5%), phenothiazine (5%), promethazine (10%), protriptyline (60%), trimipramine (60%). No/minimal cross-reactivity with carbamazepine, diazepam, fluoxetine, lorazepam, maprotiline, sertaline, trazadone. Price: [$$] TRIGLYCERIDES, TOTAL Specimen: Serum/plasma SST/PST Ref Interval: Fasting (12h): 0.55-1.70 mmol/L Conversion factor: Method: Comment: Lab: Biochem mg/dL ´ 0.011 umol/L Auto chem, CV 3%. Interferences: Glycerol (, assay does not blank for endogenous glycerol) See CWG guidelines under Cholesterol, High Density Price: [$] LMS 5 TRI-IODOTHYRONINE, TOTAL not available TRI-IODOTHYRONINE, FREE, FT3 Specimen: Serum/plasma SST/PST Ref Interval: 2.5-5.3 pmol/L Conversion factor: Method: TAT: 3d pg/mL ´ 1.536 = pmol/L AutoIA (AxSYMâ), CV 6%. Lab: OC Biochem Price: [$$] LMS 28 TRIMIPRAMINE see TRICYCLIC ANTIDEPRESSANT QUANT TROPONIN I not available, order Troponin T TROPONIN T, cTnT Specimen: Serum/plasma SST/PST Ref Interval: Clinical threshold for AMI<0.10 ug/L, normal <0.01 ug/L 72 Method: Comments: Lab: Biochem IA (Elecsysâ, 3rdGen), CV 6%; <0.01 ug/L value is highly reproducible. No interference by skeletal TnT. In ESRD especially diabetics (up to 1 ug/L;10% >0.2, 30%>0.1); CHF, other cardiac diseases, sepsis Price: [$$] TYPE AND CROSSMATCH (see Transfusion Med section) Use: Provide compatible units for transfusion Test includes ABO and Rh, Antibody screen , Compatibility Specimen: Comments: Mauve (7mL) Confirm patient identity; sign, date/time req For neonates - cord or maternal sample See Transfusion Med section. Repeat type/crossmatch may not be needed. TAT: Routine 1-3h, Stat 45min Lab: TM Price: [$] LMS 38 TYPE AND SCREEN (includes ABO and Rh group, Antibody screen) Use: Pretransfusion testing, patients with negative antibody screen will have blood assigned prior to issue. Specimen: Comments: Mauve (see Type and Crossmatch) If positive, two (2) units will be crossmatched automatically. TAT: Routine 1-3h, Stat 45min Lab: TM URATE, URIC ACID, Serum Specimen: Serum/plasma SST/PST Ref Interval: Male: 210-450 Female: 145-350 umol/L RS: 230-480 umol/L Conversion factor: Method: Lab: Biochem mg/dL ´ 59.5 = umol/L Auto chem, CV 3%. Interf: bilirubin (¯), mod. hemolysis (). Price: [$] LMS 6 URATE, URIC ACID, Urine Specimen: 24h urine, no preservative. NOT acidified. Ref Interval: 1.48-4.43 mmol/d Conversion factor: TAT: M-F, 1d mg/d ´ 0.006 = mmol/d Lab: Biochem Price: [$] LMS 5 UREA, Serum Specimen: Ref Interval: Serum/plasma 2.9-7.1 mmol/L Conversion factor: Method: Comment: Lab: Biochem BUN mg/dL ´ 0.36 = Urea mg/dL x 0.17 =mmol/L urea Auto chem, CV: 3% Prerenal failure - Creat:urea <12:1 Price: [$] LMS 5 UREA, Urine Specimen: Interpretation: 24h urine with no preservative. Excretion correlates with protein intake Conversion factor: Method: Lab: Biochem BUN mg/d ´ 0.036 = Urea mg/d x 0.017 = mmol/d urea Auto chem, CV: 3% Price: [$] LMS 6 SST/PST 73 URINE ANALYSIS Specimen: Random urine, preferably midstream. State time of collection. Specimen must arrive in lab within 4h (cellular Normal: WBC 3-5 /high power field (HPF); RBC 0-3 /HPF elements degrade on standing) Roche Diagnostics’ Chemstripâ 5L (pH, glucose, protein, blood and leukocyte esterase) avail in many wards. In the laboratory, Combur10 –Testâ is used. Specimen: Results: Random urine, to arrive in 4h if microscopy required Italicized results are within normal limits pH 5 Specific Gravity (SG) 1.005 –1.030 6 Protein Neg Equivalent to: Comments: Inteferences: Glucose Comments: Inteferences: Comments: Blood Equivalent to: Comments: Inteferences: Neg Neg 0.3 ++ 1.0 +++ 5.0 g/L 6 14 28 56 mmol/L + ++ 1.5 5 +++ >15 mmol/L acetoacetate Small Mod 5-10 ~50 Large ~250 RBC/uL Detects hemoglobin, hemolyzed RBCs and myoglobin (+) High SG, hypochlorite, microbial peroxidases (-) Vit C Equivalent to: Interferences: + 0.15 Most sensitive to acetoacetate. (+) captopril, mesna; phenylketones and phthalein cmpds may give red colour Neg Bilirubin Tr 9 Specific for glucose, does not detect other reducing sugars. Strips exposed to atmosphere (+) Equivalent to: Inteferences: 8 Test most sensitive to albumin (0.06 g/L); BJ proteins may not be detected. Quaternary ammonium cmpds (antiseptics, detergents), chlorhexidine (+), Strips exposed to atm (+) Neg Ketones 7 + ++ +++ 17 50 100 umol/L (+) Pyridium, Indican (yellow-orange/red colour), (-) Vit C Normal Urobilinogen Inteferences: Leukocyte (esterase) 17 68 135 203 umol/L (+) p-aminosalicylic acid Neg Equivalent to: Trace + ~25 ~100 ++ 500 WBC/uL Exposed strips may give false negative results Nitrite Lab: Biochem 74 Neg Pos Price: [$] LMS 2 (Microscopic exam) 5 (Dipstick) VALPROIC ACID Specimen: Serum/plasma SST/PST Draw trough level (12h after last dose) Therapeutic: 350-700 umol/L Toxic conc: >1000 umol/L Conversion factor: Half-life: Clinical toxicity Method: Lab: Biochem VANCOMYCIN Specimen: Therapeutic: Toxic conc: ug/mL ´ 6.9 = umol/L 9-15 h CNS: sedation, ataxia, headache, nystagmus, diplopia, asterixis, tremor, dysarthria, dizziness, coma; GI: diarrhoea, constipation AutoIA (AxSYMâ), CV 6% Price: [$$] LMS 35 Serum/plasma SST/PST State if pre-, postdose or random (peak: draw 30 min post-infusion or 60m post-injection or oral dose) Predose <10 mg/L Postdose 30-40 mg/L Predose: >15 mg/L Postdose >40 mg/L (guidelines only, consult Pharmacy) Conversion factor: Half-life: Clinical toxicity: Method: Lab: Biochem mg/L ´ 0.69 = umol/L 4-7.5h Skin rash, anaphylaxis, chills, fever, ototoxicity, phlebitis, pain at injection site, nephrotoxicity AutoIA (AxSYMâ), CV 6% Price: [$$] LMS 40 VANILLYLMANDELIC ACID, VMA, 4-OH-3-METHOXYMANDELIC ACID Specimen: 24h urine in 20 mL 6M HCl Avoid large amounts of caffeine during collection Restricted - available only by special request Ref Interval: Adults: Female: 9-36 umol/d Male: 12-44 umol/d Conversion factor: Method: TAT: 7d mg/d ´ 5.05 = umol/L HPLC Lab: OG Biochem Price: [$$$] LMS 60 VIRAL CULTURES, DIRECT DETECTION TESTS (EIA, Electron microscopy) see also SEROLOGY and individual virus Specimen: Serum, CSF, body fluids in Red vacutainer Swabs (eye, rectal, throat)- Virocult swab (Microbiol Lab) Nasopharyngeal suction, throat washings, stools in sterile screw- cap bottle Scrapings from skin, mucous membrane, lesions - Herpes collection kit (Microbiol Lab) Tissues Indicate date of onset and clinical condition on all reqs CMV: Collect urine, throat washings, tissues, CSF Coxsackie: TAT: 21d Collect CSF, rectal swab, stool, throat, vesicles Lab: CHEO Virology Price: [$$$] 75 VISCOSITY, SERUM (RELATIVE) Specimen: Serum (min 2 mL) Red x 2 Expected values: 1.5-2.0 (viscosity is compared to water at 37oC). TAT: 2d Lab: OC Imm/ OG Hematol Price: [$] VISCOSITY, WHOLE BLOOD Use: Hyperviscosity syndromes (bleeding, confusion, ¯ visual acuity, hearing) e.g. Waldenstrom’s macroglobulinemia, hyperglobulinemia. Specimen: Ref Interval: Whole blood Dark green Call Hematol Lab (OC:16216) prior to collection. 2.7-5.3 cps TAT: M-F, 24 h Lab: Hematol Price: [$$] VITAMIN A not available, see CAROTENE VITAMIN B1 (thiamine), VITAMIN B6 (pyridoxine) – Consult Biochemist VITAMIN B12 Specimen: Ref Interval: Serum 150-675 pmol/L Conversion factor: Method: TAT: 7d ng/dL ´ 7.38 = pmol/L AutoIA (AxSYMâ); CV: 6%. Lab: Biochem Price: [$$] LMS 28 SST/red not heparinized plasma VITAMIN C see Ascorbic Acid VITAMIN D, 25-HYDROXY, 25OH D3 Specimen: Serum SST/red Ref Interval: 40-104 nmol/L, concentrations may be higher in summer Conversion factor: Method: TAT: 14d ng/mL ´ 2.6 = nmol/L RIA (DiaSorin), CV 10% Lab: OG Biochem Price: [$$] VITAMIN D, 1, 25-DIHYDROXY, 1, 25 OH D3 Use: Diagnosis of primary hyperparathyroidism, vit D deficiency in CRF. Specimen: Ref Interval: Serum SST/red Restricted to Endocrinology; others consult Biochemist 40-140 pmol/L, concentrations may be higher in summer TAT: 14d Lab: HICL Price: [$$$] VON WILLEBRAND FACTOR ANTIGEN Use: Differential diagnosis of Hemophilia A and von Willebrand’s disease, and detecting carriers of Hemophilia A Specimen: Ref Interval: Plasma Light blue ´ 3 Transport on ice Specify blood group. Also order Factor VIII and Ristocetin cofactor assays 0.60 – 2.00 U/mL TAT: 10d Lab: Hematol 76 Price: [$$] VON WILLEBRAND MULTIMER ASSAY Use: Sub-typing of von Willebrand’s disease Specimen: Plasma Light blue ´ 3 Transport on ice Restricted; consult Coagulation Lab (14190). TAT: 4 w Lab: Hematol Price: [$$$] XYLOSE ABSORPTION TEST Protocol: Call Phlebotomy (OC: 13424, OG: 78306) to arrange 25 g xylose loading dose. Specimen: Collect blood samples (SST/grey): 1h and 2h after load Collect urine for 5h following xylose dose Ref Interval: Serum: Peak conc (1h or 2h sample): 2.2 – 3.7 mmol/L Urine: 33 – 55 mmol/5h Conversion factor: Comments: TAT: 14d YEAST Specimen: TAT: days – 2w mg/dL x 0.067 = mmol/L Serum conc lower in elderly, urine excretion lower in renal impairment Lab: HICL Price: [$$] Blood in Aerobic BAC-T-ALERT bottle (if routine culture also requested, fungus will be cultured) CSF in Red vacutainer Skin, hair, nails black paper from Microbiol Lab - wrap securely (sent to PHL for analysis) All other specimens: sterile screw-cap container or sterile swab in transport medium Lab: Microbiol Price: [$$$] ZINC, PLASMA Specimen: Plasma Royal blue (from Biochem) Ref Interval: 9.8-20.2 umol/L Conversion factor: TAT: 14d ug/dL ´ 0.15 Lab: HICL Price: [$$] LMS 25 Abbreviations: (complete list on page 4): Laboratories/sites: Canadian Blood Services CBS Appendix (pages 89-102) 2 CHEO Children’s Hospital Automated Auto Hospital-in-Common Lab HICL Chem Chemistry Civic Campus OC Coefficient of Variation (Reproducibility) CV General Campus OG HPLC High performance Liquid Chromatography IA Public Health Lab PHL Immunoassay LMS Riverside Campus Labour, Management, Supplies (OHIP billing) RS RIA Transfusion Medicine TM Radioimmunoassay Room Temp RT Turnaround time (from time of receipt) TAT 77 78 TRANSFUSION MEDICINE (TM) The Transfusion Medicine Service of the Ottawa Hospital provides 쐌 Transfusion-related and serological tests (see main section under individual tests) 쐌 a full range of transfusion therapy - see Blood/Blood Products and Fractionated Products in this section. Locations Phone OC - Main Bldg basement 761-4328 24h (Stat coverage 23:00-07:00) OG - Ground floor, Rm 1451 737-8302 24h (Stat coverage 23:00-07:00) RS - Main floor laboratory 738-8214 Information Booklet Hours of operation Daily 07:00-23:00 From 2002 Oct Mon-Fri 07:00-20:00 An information pamphlet (English or French) on the use of human blood and blood components may be requested from Transfusion Medicine. TRANSFUSION MEDICINE POLICIES AND PROCEDURES (see also Product section under Blood Transfusion or the required product) Orders: 쐌 Use Requisition for Tranfusion Medicine - LAB 03 (Cat: 420175) for transfusion orders, products and tests. 쐌 If the patient has an Autologous card or a Caution/Transfusion card stating that he/she has antibodies, Transfusion medicine must be notified. Sample collection: 쐌 Patient must be identified before blood specimen collection for Type/Screen/Crossmatch. 쐌 The requisition must be signed by the person collecting the patient specimen, and dated and timed. Delivery of Blood Products 쐌 Blood products are picked up from Transfusion Medicine by designated hospital staff (porters, nurses, physicians, and residents). Person receiving product has to sign the Issue sheet. Transfusion procedure 쐌 Patients must be informed (document in patient’s chart) when they receive any blood product. Available alternate therapies should be discussed with the patient prior to the transfusion or injection of a blood product. Patients with low hemoglobin should not be transfused unless they are symptomatic. Despite screening for viral agents and careful crossmatching, blood transfusions still cause significant risk to the patient. 쐌 The issue sheet must be signed by two of the staff starting the infusion to verify the patient and blood product ID. Continued on next page 79 Documentation 쐌 Progress notes must be written to justify the transfusion of blood products and to document the clinical condition of the patient before, during and following transfusion, and any adverse reactions. TRANSFUSION REACTIONS: Stop transfusion immediately Inform TM. Investigations include clerical check, visual specimen inspection, direct antiglobulin test and other appropirate lab investigation. Designated TM medical staff will review. Lab tests: Comments: Type Send post-transfusion sample in Mauve (7 mL) and Blood bag(s) Untransfused units will be re-crossmatched. No additional units will be issued until investigation is completed. Signs/ Symptoms Usual Cause Febrile (most common) Fever, chills, rarely hypotension Urticarial (common) Urticaria, rarely Antibodies hypotension or to plasma anaphylaxis proteins, IgA antibodies Anaphylaxis (very rare) Bronchospasm or hypotension during/post transfusion Acute (intravascular) hemolytic Delayed (extravascular) hemolytic 80 Management Antibodies to Mild – may have unrelated cause leucocytes or 쐌 Treat with antipyretics, restart transfusion Severe – consider sepsis plasma 쐌 Stop transfusion and report to TM proteins 쐌 쐌 IgA def First reaction usually mild. Fever, hypotension, hemoglobinuria, bleeding, anxiety, chest pain, flank pain, ARF and/or DIC Usually ABO incompatibility, rarely due to other complementfixing antibodies Fever, malaise, ¯ Hgb, Indirect bilirubin, Urobili- nogen Destruction of donor red cells by IgG antibodies in recipient Stop transfusion Give antihistamine (PO or IM); if severe, epinephrine and/or steroids 쐌 Serological investigation not needed Prevention: antihistamine before transfusion; washed red cells if severe or recurrent. 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 Stop transfusion, report to TM Treat anaphylaxis Quantitate IgA and subtype IgA antibodies For future transfusions, IgA-deficient patients should receive washed blood or IgA deficient blood products Stop immediately Hydrate, treat hypotension with fluid replacement Induced diuresis Treat DIC – if renal failure is severe, dialyse Do not discard any tubing or blood bags. Report to TM for complete investigation. Monitor Hb, renal function, coagulation profile. No acute treatment needed usually. Report to TM – investigation for causative antibody. Type Signs/ Symptoms Usual Cause Management Transfusion related acute lung injury (TRALI) Dyspnea, pulmonary edema, normal pulmonary capillary wedge pressure HLA or leucocyte antibodies; usually donor antibodies 쐌 Circulatory overload Headache, dyspnea, CHF Large volume given quickly 쐌 Septicemia from infected blood Fever, chills, hypotension Contaminated blood product 쐌 쐌 쐌 쐌 쐌 쐌 Support blood pressure and respiration, may require intubation Report to TM (to quarantine remaining components from donor) Stop transfusion Give nasal oxygen, diuretics Stop transfusion immediately Support blood pressure Start antibiotics Return donor unit(s) and tubing to TM for bacterial culture. 81 BLOOD AND BLOOD PRODUCTS Use TM requisition (LAB-03). Consult Hematologist if indicated. AUTOLOGOUS BLOOD TRANSFUSION Use: In elective surgeries, to eliminate risk of sensitization and transmissible diseases. Especially useful in patients who react adversely to allogeneic blood, have multiple alloantibodies or rare blood types To order: Product: Infusion: Physician to refer patient (OC: Autologous Prgm 798-5555 ext 17483, OG: Med Director, CBS 560 7271) Order Type and Screen (7 mL mauve, see Main section) 450 mL blood is collected from patient every 7d to a maximum of 4 units (35d). Phlebotomy is done at PAU (OC) or CBS (OG). Blood is collected in CPDA-1 and leucodepleted. Units are stored in TM at 4C until required, or discarded at expiry. See BLOOD TRANSFUSION below. BLOOD TRANSFUSION See Preamble for Policies and Procedures Use: Blood replacement. To order: Order Type & Screen New patients: send blood specimen. If antibody positive 2 units of blood will be crossmatched. Otherwise, blood is available within 5 min following an electronic cross-match. (This protocol has been adopted to increase blood availability by not reserving blood for patients not likely to require it). Patients with previous order: patients who have not been transfused in past 3m and are not pregnant, the stored sample (stored for up to 6m) can be used. Patients transfused in past 3m or pregnant, sample is stored for 72h only. For placenta previa patients, sample is stored for 1w. Preop requests: submit request on day before surgery, preferably before 18:00 as late orders can cause problems in patients with significant antibodies. State urgency: Routine (batch tested). State date and time blood is needed. Usually available in 2h, longer if antibodies present. ASAP (as soon as possible). These are given priority over routine and unspecified requests. Nursing unit is notified as soon as blood is ready. STAT (abbreviated) crossmatch: Blood is available within 45 min of receipt of patient’s sample for Type & Screen. Phone lab (OC: 14328; OG: 78302, RS 88214) when initiating request. Emergency uncrossmatched blood. To be used in life-threatening situations when patient cannot wait 45 min. Group-specific blood can be issued within 5 min. The attending physician or nurse designate must sign the request. A crossmatch is done on the issued blood and the nursing unit informed immediately should there be any incompatibility. Emergency O-negative blood. As above, used when patient sample cannot be obtained. It is issued immediately. Its use is discouraged, especially in non O-negative patients. It is rare and usually in short supply. Primary resuscitation 82 should aways start with normal saline or Ringer’s lactate. Infusion of cold stored blood may cause hyperkalemia and/or acidosis. Infusion: Use 19 gauge (or larger) needle and a Y-type administration set with 140-220 micron filter to remove large aggregates and fibrin. Change administration set with filter every 24h or after every 4 units. Air must never be introduced into the blood bag or adminstration set because of the risk of air embolism. Rate: 1.5-2h/unit and within 4h to reduce risk of bacterial proliferation and hemolysis occurring at RT. Rate depends on clinical condition of patient. Start slowly and increase rate if there is no reaction. Speeding infusion by use of pressure may contribute to hemolysis and should always be supervised by physician. Warming of blood: this is not necessary except in: · Extremely rapid and massive transfusion · Exchange transfusions in newborns · Patients with potent cold agglutinins. Strict control of warming procedures and equipment is required as RBCs may hemolyse at temperatures above 42C. Blood warmers should be tested before use, and temperature of blood monitored during infusion. Priming/flushing of IV line: do not use incompatible soln Calcium containing solutions (e.g. Ringer's lactate) promote clotting by counteracting the Ca-binding effect of citrate anticoagulant. Dextrose solutions may cause agglutination of RBC, ¯ RBC survival and cause acute hemolytic reaction. PCA (patient controlled anesthetic) pumps for delivery of narcotics are not permitted to run into lines delivering blood products. CRYOPRECIPITATE of ANTIHEMOPHILIC FACTOR/GLOBULIN Use:Treatment of hypofibrinogenemia (Fbg conc <2 g/L). For specific factor deficiencies, use viral inactivated concentrates. To order: Product: For new patients include order for Type & Screen (7 mL mauve) 1 unit (10 mL) cryoprecipitate contains 80 units F VIII and 250 mg fibrinogen. Avail: 30 min Infusion: Infuse within 4h of receipt at 200 mL/h CRYO SUPERNATANT PLASMA Use:Replacement fluid for plasmapheresis for TTP To order: To order: For new patients include order for Type & Screen (7 mL mauve) Plasma after cryoprecipitate is removed. Units of ~ 250 mL. Avail: 1h DIRECTED DONATIONS Use: Parental donation for neonates. To order: As for autologous blood transfusion. 83 EXCHANGE TRANSFUSION / CORDOCENTESIS Use: For treatment of severe hemolytic disease of newborn To order: Products: Order under “Other” Blood/Blood Components, stating purpose. Also order Type & Screen, Antibody screen, crossmatch of mother’s blood or cord blood (7 mL mauve) RBC from CMV negative, < 7d old is irradiated and reconstituted with AB fresh frozen plasma to a hematocrit of 0.60 (exchange transfusion) or 0.90 (cordocentesis). Avail: 1h FRESH FROZEN PLASMA Use: (a) Treatment of bleeding patients and those with multiple clotting factor deficiencies (PT >17s, PTT >50s) caused by liver disease, defibrination syndromes, massive transfusions using stored blood, (b) where specific clotting factor deficiency has not been established, and (c) plasmapheresis in TTP patients To order: Product: For new patients include order for Type & Screen (7 mL mauve). 1 unit (~200 mL) FFP contains all plasma clotting factors including labile factors (V, VIII) Avail: 1 h Infusion: Infuse ASAP after thawing at rate of 200 mL/h. Use within 24h. GRANULOCYTE TRANSFUSION Use:Treatment of severely neutropenic patients as temporary support, particularly if septic To order: Product: Consult Hematologist at 941-2108 (daytime) or 941-3061. The request must be booked through CBS Apheresis granulocyte preparation, stored at RT Avail: 3d Infusion: slowly over 2-4h (to avoid severe pulmonary reactions) IRRADIATED PRODUCTS Use: To reduce risk of graft- versus-host disease (GVHD) in susceptible immuno-compromised recipients, such as for use in intra-uterine transfusion, premature neonates of low birth weight or with known or suspected congenital immunodeficiency disorder, transplant recipients, acute leukemia or patients on high dose chemotherapy and in directed-donation products from first degree relatives or HLA-matched products. To order: Product: Order under “Other” Blood/Blood components. Blood and blood products irradiated to destroy lymphocytes. Avail: 6-8h Infusion: Transfuse within 30 min over 1.5-2h (no longer than 4h). PLATELET CONCENTRATE (RANDOM DONOR) Use:Treatment of bleeding due to thrombocytopenia (plt count <50 x 109/L) or prophylaxis in non-bleeding thrombocytopenic patients (<20 x 109/L). To order: 84 For new patients include order for Type & Screen (7 mL mauve). Units required: The average adult dose is 1 U/10 kg. Each unit should increase an adult’s platelet count by 5-10 x 109/L (1h post infusion). Product: 1 unit (50 mL) contains 5.5 x 1010 platelets. Units pooled prior to issue. Donor plasma should be compatible with recipient’s RBC. Avail: 30 min to 1h Infusion: Rapidly – 1unit in 5 min; pooled 6 units in 30 min PLATELETS from APHERESIS (SINGLE DONOR) Use:(a) BM transplant patients are transfused with irradiated, CMV neg single donor platelets, (b) patients refractory to random donor platelets due to HLA sensitization are transfused with HLA-matched single donor platelets. To order: Product: Attending physician to arrange with CBS for appropriate product and informing TM. For new patients include order for ABO/Rh Group/Crossmatch (7 mL mauve). Units required: 1 unit should increase an adult’s platelet count by 30-60 x109 /L. 1 unit (300 mL) contains 3 x 1011 platelets, equivalent to 5-6 units of random donor platelets. Donor plasma should be compatible with recipient’s RBC. Avail: Same day Infusion: Rapidly within 30 min RED BLOOD CELLS, DEGLYCEROLIZED Use:For patients with multiple antibodies to high frequency antigens To order: Product: Order under “Other” Blood/Blood component. Protocol as for BLOOD TRANSFUSION. Frozen RBC thawed and deglycerolized before infusion Avail: 24h Infusion: 1 unit in 1.5-2.0h, and within 4h. For details see BLOOD TRANSFUSIONS In case of infusion problems, return blood to TM. RED BLOOD CELLS, RED CELL CONCENTRATE Use:For patients with symptomatic anemia, anemia not responsive to therapy, for replacement of blood loss To order: Product: Protocol as for BLOOD TRANSFUSION. Units required: In an adult, 1 unit should increase hemoglobin by 10 g/L and Hct of 0.03. 1 unit (300-350 mL) contains 200 mL red cell mass and Hct of 0.55 to 0.60. Avail: within 5 min of completion of type and crossmatch Infusion: 1 unit in 1.5-2.0h, and within 4h. In case of infusion problems, return blood to TM. 85 FRACTIONATION PRODUCTS: Use TM requisition (LAB-03). Consult Hematologist if indicated. ALBUMIN (5%, 25%) Use:(a) Correction of acute large scale loss of colloid (hypovolemic shock, burns, patients undergoing peritoneal surgery), (b) plasma exchange and plasmapheresis Product: 100 ml of 5% albumin (same concentration as plasma, 50 g/L) or 25% albumin stored at RT. Pentaspan can be use in place of 5% albumin. Avail: Same day Infusion: 1 unit in 1.5-2h, complete within 4h C1 ESTERASE INHIBITOR (HUMAN) Use:under investigation for management of acute attacks and short-term prophylaxis of hereditary angioneurotic edema (HANE) To order: Consult Hematologist at 941-2108 (daytime) or 941-3061, Emergency drug release required. FACTOR VII CONCENTRATE Use:Treatment of confirmed F VII deficiency in a single emergency To order: Product: Consult Hematologist at 941-2108 (daytime) or 941-3061. Emergency drug release required. Dose required: 5,000 U per bleed; 30,000 U per emergency Recombinant product Avail: Same day Infusion: 2 mL/min FACTOR VIII CONCENTRATE, ANTIHEMOPHILIC FACTOR, HEMOPHILE FACTOR Use: treatment of hemophilia A – prevention and control of hemorrhagic episodes To order: Product: For other products (recombinant F VIII, Hemophil M (Monoclonal F VIII), Porcine C), consult Hematologist at 941-2108 (daytime) or 941-3061. Hemophil M and Porcine C require emergency drug release. Lyophilized product stored refrigerated. To reconstitute, bring diluent to RT for 30 min. Do not refrigerate after reconstitution. Avail: 15 min Infusion: Infuse within 3h of reconstitution at 2 mL/min FACTOR VIII/VON WILLEBRAND FACTOR Use:Treatment of blood in severe von Willebrand disease (vWD), or in moderate vWD unresponsive to Desmopressin. To order: Product: Avail: same day 86 Consult Hematologist - emergency drug release required, call 941-2108 (daytime) or 941-3061. Humate ® (Aventis Behring) FACTOR IX CONCENTRATE Use:Treatment of F IX deficiency (Hemophilia B/Christmas Disease), congenital deficiencies of F II, VII and X. To order: Product: For BPL UK, recombinant F IX (Benefix) - consult Hematologist at 941-2108 (daytime) or 941-3061. Emergency drug release required for BPL. Lyophilized pool plasma derivative, rich in factors II, VII, IX and X. To reconstitute, bring diluent to RT for 30 min. Do not refrigerate after reconstitution. Avail: Same day Infusion: Infuse within 3h of reconstitution at 2 mL/min FACTOR XIII CONCENTRATE Use: Treatment and prevention of bleeding in congenital and acquired F XIII deficiency patients To order: Product: Consult Hematologist at 941-2108 (daytime) or 941-3061. Emergency drug release required. Fibrogammin®P Avail: Same day FIBRINOGEN CONCENTRATE Use: Treatment of bleeding disorders in hypofibrinogenemia. To order: Product: Consult Hematologist at 941-2108 (daytime) or 941-3061. Emergency drug release required. Haemocomplettan®P IMMUNE GLOBULIN, ANTI-CMV Use: Prophylaxis against CMV infection To order: Consult Hematologist at 941-2108 (daytime) or 941-3061. Emergency drug release required. Avail: same day IMMUNE GLOBULIN, ANTI-RSV Use: Prophylaxis against respiratory syncytial virus infection To order: Product: Order form from TM. Synagis is obtained directly from Abbott. RespiGam®, Synagis® Avail: same day IMMUNE GLOBULIN, ANTI-VARICELLA ZOSTER, VZIG Use: Varicella zoster prophylaxis To order: Product: Order under “Other” Fractionation Products Massachusetts Public Health Biological Laboratories Avail: 1-2d IMMUNE GLOBULIN, HEPATITIS B Use: Hep B prophylaxis, passive protection after exposure to hepatitis B virus Protocol: Product: Measure anti-HBs to determine immune status Units of 120 ug and 300 ug Avail: Same day 87 IMMUNE GLOBULIN, INTRAVENOUS, IV IG Use: Treatment of primary humoral immunodeficiency, ITP, allogeneic bone marrow transplant, Guillain-Barre syndrome To order: Product: Dose req: 0.2-0.5 g per kg x 5d Gamimune-N, Gammagard, Iveegam, IGIV Avail: Same day Infusion: start at 0.01 to 0.02 mL/kg/ min for 30 min. If patient tolerates it, increase to 0.08 mL/kg/min IMMUNE GLOBULIN, Rh(D) IMMUNE GLOBULIN, RhIg, Anti-D Use: (a) to prevent Rh(D) sensitization of Rh neg women at 28 w gestation and within 72 following birth of Rh pos child, abortion or stillbirth, (b) after transfusion of Rh(D) product positive product to a Rh(D) negative patient, (c) high dose WinRho may be used in ITP in Rh(D) positive patients. To order: Product: Include order for ABO/Rh Group and Antibody screen (7 mL Mauve) Physician responsible for requesting additional RhIg for postpartum patient with abnormal Kleihauer results. WinRho, HypRho, RhoGAM Avail: As soon as Type & Screen completed. For therapeutic abortions, within 30 d of negative antibody screen. PENTASPAN Use: colloid replacement, for plasma volume expansion in place of albumin Product: 250 mL and 500 mL plastic IV infusion bags. Totally synthetic. Avail: Same day PROTEIN C CONCENTRATE Use: Transfusions in Protein C deficient patients To order: Product: Consult Hematologist at 941-2108 (daytime) or 941-3061. Emergency drug release required. German product. Avail: 2d PROTHROMBIN COMPLEX Use: Bleeding disorders To order: Product: Consult Hematologist at 941-2108 (daytime) or 941-3061. Emergency drug release required. Prothromplex® TIM4 TISSUE BANK/BONE BANK Use: provide bone for surgery (mainly Orthopedic) To order: Product: 88 Contact TM OC (14328) Live donor bones (femoral heads), cadaveric bones Pos Neg ELISA (GPL or MPL) ELISA ELISA scr Ouchterlony Cardiolipin/ Phospholipid dsDNA Extractable nuclear Ag, ENA (SS-a/Ro, SS-b/La, Sm, RNP) Results Clinical Associations See Tissue Transglutaminase Endomysium Pos – Jo-1 Ouchterlony ENA (Jo-1) Histadyl tRNA synthetase Pos – Scl-70 Ouchterlony ENA (Scl-70) Topoisomerase 쐌 쐌 Polymyositis (~20%; predicts pulmonary involvement) Dermatomyositis Scleroderma (PSS) 60%, esp with extensive cutaneous or interstitial pulmonary involvement. MCTD, mild SLE SLE Pos – Sm Sjogren’s Pos – RNP Pos Ss-a/Ro, SS-b/La Strongly suggestive of SLE >500 Antibodies in low conc Possible SLE or other MCTD Possible SLE 50-500 Does not rule out SLE 30-50 <30 U/mL Strongly suggestive of SLE or antiphospholipid syndr >60 U/mL Generalized MG (>90%), Ocular MG (~60%) MG in remission (<40%) Likely SLE or antiphospholipid syndr 쐌 쐌 15-60 U/mL >0.4 nmol/L Test Radioreceptor assay Antibody Cholinesterase Receptor (ACRA) ANTIBODIES AGAINST TISSUES Ouchterlony screen Lupus anticoagulant (for antiphospholipid syndr) Further Testing APPENDIX 89 90 Antibody Test ELISA PR3/MPO specific screen Screen with formalin-fixed neutrophils Likely Goodpasture’s Graves’ (lower titres) 쐌 Pos Wegener’s granulomatosis Systemic vasculitis PR3 pos MPO pos Neg Possible ANA or atypical ANCA Systemic vasculitis Perinuclear (pANCA) Neg - not true pANCA Wegener’s granulomatosis Primary biliary cirrhosis Hashimoto’s (almost always pos and higher titres) 쐌 Observed in normals, esp women, aged Likely LE; if anti-DNA is neg, likely drug-induced LE Cytoplasmic (cANCA) Neg IFA with ethanol fixed at 1:20 dil Neutrophil cytoplasm (ANCA) 1:1600–1:25,600 <1:400 Pos >20 U 10–20 U (borderline) Likely SLE, CTD, systemic vasculitis (than Goodpasture’s) Goodpasture’s Goodpasture’s; possible systemic vasculitis, nephritis Pos Pos Clinical Associations Does not rule out Goodpasture’s Neg Results Pos Microparticle aggl ELISA quant ELISA screen IFA Mitochondrium IFA (mouse kidney) Microsome (Thyroid peroxidase) Histone Glomerular membrane (Anti-GBM) Further Testing MPO semiquant PR3 semiquant ELISA PR3/MPO specific screen Confirm with formalin- fixed neutrophils PR3/MPO specific screen Nil unless Anti-GBM if needed ELISA quantitation ELISA screen Biopsy 91 Celiac IFA using mouse stomach ELISA Smooth muscle Tissue Transglutaminase IgA (replaces Endomysial) Chronic active hepatitis IFA using mouse stomach Parietal cell Po Po <20 KEU/L Centromere Peripheral Nucleolar Speckled – Cytoplasmic Pos: homogenous s: – Rim s: Pernicious anemia or gastritis Anti-Scl-70 Anti-ENA screen, RF Anti-Scl-70 PSS CREST (Calcinosis, Raynaud’s, Esophageal hypomotility, Sclerodactyly, Telangiectasia) Anti-ENA screen Sjogren’s Anti-dsDNA MCT Anti-ENA, Anti Scl-70 Titre Anti-dsDNA, if neg, anti-histone and anti-ENA confirm with anti-tissue Ab SLE 쐌 쐌 쐌 Anti DNA, ENA if SLE suspected Further Testing SS, PSS SLE SLE unlikely (2% SLE are –ve) Systemic vasculitis Pos Neg Indirect Fluorescence assay at 1:40 dil on HEp-2 cells Clinical Associations p-ANCA positive, not MPO-specific Neg Results Nucleus Test MPO ELISA (Myeloperoxidase) Antibody ANCA (continued) 92 Speckled or nucleolar (90%) Scleroderma (Progressive systemic sclerosis, PSS) Anti-ENA Scl-70 (60%), predicts lung involvement; Sm (<1%), RNP (20%) SS-A/Ro (10-70%), SS-B/La (15-60%), Scl-70 (5%) Other immune complex nephritis and systemic diseases Lupus glomerulonephritis Renal vasculitis Necrotising nephritis Goodpasture’s Nephritis: Wegener’s Neg Pos Jo-1 (~20%), predicts lung involvement Pos (2%) RNP alone Sm (1%), SSa/Ro, SSb/La low, RNP (5%) (1%) (1-5%) Neg Polymyositis/dermatomyositis 16-50% Anti-dsDNA (70%), if neg, test Sm (30%), RNP (50%), Sm (30%), anti-histone and SSa/Ro (25-35%), SSb/La (15%), RNP (50%) anti-tissue Ab Rheumatoid arthritis Centromere Speckled Sjogren’s Syndrome (SS) CREST (Calcinosis, Raynaud’s, Esophageal hypomotility, Scleroderma, Telangiectasia) Speckled Nucleolar Mixed Connective Tissue Disease (MCTD) (homogeneous rim), speckled; (98%) Nucleolar (26%) ANA (HE p-2 IFA) Drug induced SLE Systemic Lupus Erythematosus (SLE) AUTOIMMUNE DISEASES Neg p-ANCA (~85%) c-ANCA ANCA GBM Neg >20U 10–20U 10–20U Other Tests ¯ CH100 during crisis Anti-histone ¯C3, ¯C4 + ¯ CH100 MPO PR-3 RF Anti-histone 쐌 쐌 CHROMOSOMAL and DNA STUDIES, MOLECULAR BIOLOGY, GENETIC STUDIES. Note: This list is provided for quick information of test availability in the region. The Eastern Ontario Regional Genetics Program (sited at CHEO) provides clinical assessment, diagnosis and counselling by medical geneticists. (Tel: 737-2275) Abbrev: CY=Cytogenetics, MG= Molecular Genetics LHSC – London, KGH – Kingston General, MUMC – McMaster, NYGH – North York General HSC – Toronto Hosp for Sick Children Specimens for CHEO must be accompanied by CYTOGENETIC (CY) or MOLECULAR GENETICS (MG) requisition; for provincial programs: complete MOH requisition. Testing is expensive, most tests are >$100 each Sample Use Lab TAT PRENATAL: Pregnant patients should be referred for Genetic counselling and testing as appropriate. 쐌 쐌 Constitutional chromosomal studies FISH Î Chorionic villus (sampled under U/S) 쐌 Ï 20 mg tissue dissected from maternal tissues 쐌 쐌 Advanced maternal age ( ³ CHEO Î10-14d 35y) CY Ultrasound abnormalities Ï24-72h (FISH) Enumerating chr 13, 18, 21, X and Y Ð Aminocentesis fluid: (sampled under U/S) Ð10-14d Ñ Cordocentesis (sampled under U/S) Ñ 5-7d POSTNATAL: 쐌 쐌 Constitutional chromosomal studies FISH Blood – dark green (10 mL) 쐌 Tissue biopsy in a-MEM with 1% Pen/Strep 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 CHEO Turner syndrome CY Klinefelter’s syndrome Psychosis/psychosexual disorders (males) Ambiguous genitalia/delayed puberty Aneuploidies (trisomy 13, 18, 21, others) Developmental delays, failure to thrive Multiple congenital anomalies, dysmorphia Mental retardation, seizures Screen for mosaicism 2-3w Chromosome breakage syndromes (e.g. Bloom, Fanconi, Ataxia telangietasia) 4-6w Microdeletions (e.g. Prader-Willi, Angelmen, DiGeorge/Miller-Dicker, William, Wolf-Hirshhorn, Cri du chat, retinoblastoma) (FISH) 2-4w Spontaneous abortions (>3x) 2-3w 93 쐌 쐌 Acquired chromosomal abnormalities FISH Sample Use Bone Marrow drawn in syringes, rinsed in Na heparin 쐌 Solid tissue in a-MEM with 1% Pen/Strep 쐌 쐌 쐌 Leukemia Lymphoma Solid tumours Post-transplant (monitor chromosome changes) Lab TAT CHEO CY Blood – Dark green (10 mL) Angelman Syndrome Mauve (10 mL) HNPCC (research only) ACD (10 mL) ´ 3 CHEO MG 3-4w Colon Cancer Loeb Inst Apo E2,3,4 Dyslipidemia - type III hyperlipidemia), (Alzheimer’s 8w E phenotyping) disease) OC Biochem Breast Cancer Ovarian Cancer CHEO MG 4-8w Ashkenazi Jewish Screen Canavan Disease CHEO MG 2w 4-6w Mauve (7 mL) keep at (PCR, replaces Apo room temp BRCA1/BRCA2 (research only) ACD (10 mL) ´ 3 Canavan disease Mauve (10 mL) 쐌 쐌 쐌 쐌 Charcot Marie Tooth Type 1A Mauve (10 mL) ´ 3 Peripheral neuropathy CHEO MG Charcot Marie Tooth X-linked Mauve (10 mL) ´ 3 Peripheral neuropathy – X-linked MOH LHSC Connexin 26 Mauve (10 mL) Unexplained prelingual deafness CHEO MG 4-6 w Cystic Fibrosis Mauve (10 mL) ´ 3 쐌 CHEO MG 2-3w 쐌 Cystic Fibrosis Congenital absence of the vas deferens Cystinosis Mauve (10 mL) CHEO MG 2-3w Factor VLeiden (R506E) (PCR) Mauve (4 or 7 mL) keep Thrombophilia (resistance of OG TT at RT. If blue tube activated Protein C) CHEO MG drawn, send plasma & packed cells. 2w Fragile X Mauve (10 mL) ´ 3 CHEO MG 2-3w Cystinosis Unexplained Developmental Delay MOH NYGH MG Friedreichs Ataxia Mauve (10 mL) FSHD Mauve (10 mL) ´ 3 Hemochromatosis Mauve (4 or 7 mL) (C282Y and H63D) Hemophilia A, B 94 Mauve (10 mL) 2w Facioscapulohumeral muscular dystrophy CHEO MG Elevated Ferritin, Hemochromatosis OG TT 2w CHEO MG 2-3w Hemophilia MOH KGH MG HLA-B*27 Sample Use Lab Mauve (4 or 7 mL) Ankylosing spondylitis OG TT 7-10d TAT Narcolepsy OG TT Bone marrow patients OG-TT 1-3 w (PCR-SSP) HLA-DRB1*1501 Mauve (4 or 7 mL) and/or DQB1*0602 7d (PCR-SSP) HLA-class 1 (PCR-SSP) Mauve (4 or 7 mL) HLA-Class II typing: Mauve (4 or 7 mL) 쐌 쐌 쐌 HLA-DRB DRB3/4/5 DQB1 Donors and recipient typing OG TT 1-3 w for bone marrow, renal, heart allo-transplantation; low and high resolution allele identification available. HLA typing of cadaveric donor Further HLA typing if After harvesting of organs, save 2-3 pieces necessary 3 4 cm of spleen – send in McCoy’s medium OG TT 8-12hr HNPP Mauve (10 mL) x 3 CHEO MG Huntington Disease (IT-15) gene ACD (10 mL) ´ 3 Hereditary neuropathy with liability to pressure palsies 4-6 w CHEO MG Leukemia and lymphoma gene translocations and rearrangements AML1-ETO fusion gene t(8;21) (RT-PCR) Mauve 4 or 7 mL BCL-IgH fusion genes, Mauve (10 mL) (PCR, for BCL6 RT-PCR) AML M1/M2 OG TT 2w BCL1 t(11;14) NonHodgkin’s lymphoma (BNHL), Mantle cell lymphoma (MCL) OG TT 2w BCL2 t(14;18) - BNHL, follicular lymphoma, diffuse large cell lymphoma OG TT 2w BCL6 t(3;14) – BNHL, diffuse OG TT large cell lymphoma, follicular lymphoma 2w Bone Marrow 1mL in Mauve Bone Marrow: 1mL in Mauve vacutainer Lymph node, tissue– fresh BCR-ABL fusion gene t(9;22) RT-PCR Mauve (4 or 7 mL) OG TT CML, ALL Breakpoints identified: M-bcr (b2a2, b3a2;P210) or m-bcr (e1a2; P190) 2w Bone Marrow: 1mL in Mauve CBFB-MYH11 fusion gene Inv(16)/t(16;16) (RT-PCR) Mauve (4 or 7 mL) AML M4Eo OG TT 2w E2A-PBX1 fusion gene t(1;19) (RT-PCR) Mauve (4 or 7 mL) B-lineage of ALL (FAB L1/L2/L3) OG TT 2w Bone Marrow: 1mL in Mauve Bone Marrow: 1mL in Mauve 95 IgH (FR3) gene rearrangement (clonicity) (PCR) Sample Use Lab Mauve (4 or 7 mL) Determine clonicity in B-cell neoplasms OG TT 2w Bone marrow: 1mL in Mauve TAT Lymph node or tissue: fresh NPK-ALK fusion gene t(2;5) (RT-PCR) Lymph node or skin Anaplastic large cell lymbiopsy – fresh, sent in phoma (ALCL) Workshop (45 mL RPMI, 45 mL McCoy’s 5A, 10 mL heat-inactivated FCS) or McCoy’s medium OG TT 2w PML-RARA fusion gene t(15;17) (RT-PCR) Mauve (4 or 7 mL) AML-M3 or acute promyelocytic leukemia (APL); S and L forms identified. (AML profile consists of PML, CBFB and AML1) OG TT 2w Bone marrow: 1mL in Mauve vacutainer TCR (ß and g) gene rearrangements (PCR) Mauve (4 or 7 mL) T-cell neoplasms, T-ALL OG TT 2w B-cell precursor ALL of child- OG TT hood 2w Bone Marrow: 1mL in Mauve Lymph node, tissue: fresh TEL-AML1 fusion gene t(12;21) Mauve (4 or 7 mL) Bone marrow: 1mL in Mauve Marfan syndrome Mauve (10 mL) Family studies only CHEO MG 6-8w MCAD Mauve (10 mL) or 1mg tissue Sudden infant death CHEO MG 1-2w MEN2 (ret protooncogene) Mauve (15 mL) or ACD Inherited medullary thyroid (15 mL) Ca, pheochromocytoma, Hirschsprung’s disease MTHFR (C677T) – Mauve (7 mL) methylenetetrahydrofolate reductase Muscular dystrophy – Becker, Duchenne Mauve (10 mL) ´ 3 Myotonic dystrophy Mauve (10 mL) ´ 2 Thrombophilia (homocysteinemia) MOH LHSC MG CHEO MG 2w MOH HSC MG Myotonia CHEO MG 3-4w Oculopharyngeal muscular dystrophy CHEO MG 1-2w Neurofibromatosis Mauve (10 mL) ´ 3 Type I OPMD 96 Mauve (10 mL) Sample Use Lab PKD autosomal dominant Mauve (10 mL) ´ 3 Autosomal dominant polycystic Kidney disease type 1 and 2, family studies only CHEO MG 6-8w Prader Willi syndrome Mauve (10 mL) CHEO MG 3-4w Prothrombin (G20210A) (PCR) Mauve (7 mL) keep at room temp CHEO MG 2w Rh D typing (PCR) 쐌 쐌 Amniotic fluid: 1.5-10 mL or Cord blood: Mauve (10 mL) AND Paternal blood: Mauve (10 mL) Thrombophilia ( prothrombin circulating levels). Fetal-maternal incompatibility CHEO 7-10 d [if earlier than 15w gestation, cells have to be cultured 3w prior to testing] MOH MUMC Sickle cell disease Mauve (10 mL) ´ 3 CHEO MG SMA, types I, II, III Mauve (10 mL) ´ 3 Spinal muscular atrophy Spinocerebellar ataxia Spinocerebellar ataxia type 1, MOH NYGH 2, 3, 6, 7, 8 MG Mauve (10 mL) TAT Thalassemia - a, ß Mauve (10 mL) ´ 3 2-3w MOH MUMC Prepared with the assistance of Drs HS Wang, N Carson, D Sengar, JG Donnelly 97 Serum ENZYMES: TISSUE SOURCES and HALF-LIVES @ Content relative to liver, # relative to heart, & relative to serum Kidney ALP@ CK# MM MB BB AST& ALT& GGT& LD& 0.35 <0.1 8-12% 0% 90% 4500 1200 7420 500 1400 130 614 7100 2850 Pancreas Liver 1.00 Spleen 0.60 < 0.1 Heart 0.12 1.0 74% 0% 76-87% 13-22% 500 145 U/g 26% 700 80 113 0-2% 7800 450 3 400 250 (500 U/g) Skeletal muscle 288 87 U/g (14 U/g) 5.3 99% <1% <1% 5000 300 5 500 45 23 Lung 0.52 < 0.1 16-35% 0-1% 64-84% Brain 0.17 1.2 0% 0% 100% 37 Sm Int 0.38 0.2 3% 1% 96% 70 0.5 2% 0% 98% Rectum RBC Adenylate kinase Placenta 0.5 19% 1% 80% Uterus 0.1 2% 2% 96% Prostate < 0.1 3% 3% 94% Bladder 0.3 2% 6% 92% Stomach 0.4 3% 3% 95% Salivary gl < 0.1 44% 0% 56% Serum Half-lives of other enzymes/proteins: ALP: ALT: Amylase: AST: CK: GGT: ß-hCG: LD: Lipase PSA: PAP: 98 Intestine <1h; Bone ~40h, Placenta 170h 2-6d 12–24h Cytoplasmic 20h; Mitochondrial 35h Total 12h; MM 20h, MB 10h, BB 3h 3-5d a: 2–6h ß: 12–36h LD1 4-5d; LD5 10h 2-3d a: 13–20h ß: 2.2–3.2d a: 0.5–2.5d ß: ~11d 15 7 1 1 32-120 1 1 99 5´ 쐌 10´ 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 15´ 20´ 50´ >100´ Upper limit of Normal MI, pulmonary embolism Myopathies, muscle trauma Extrahepatic obstruction Hemachromatosis Infectious mononucleosis Chronic active hepatitis Acute myocarditis Acute hepatitis Toxic hepatitis Heat Stroke 1° liver Ca Ac and subacute necrosis AST 쐌 쐌 쐌 쐌 쐌 쐌 Liver Ca - 1° and mets Alcoholic hepatitis Intrahepatic cholestasis Infectious mononucleosis Acute hepatitis Hepatic necrosis ALT Serum ENZYMES – CAUSES OF ELEVATION 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 CAH Cirrhosis Acute hepatitis Pancreatic Ca Chronic pancreatitis Liver mets Liver cirrhosis 1° liver Ca Biliary obstruction GGT 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 Familial Hepatotoxic drugs 1° Liver Ca Amyloidosis Adolescence Extrahepatic obstruction Paget’s disease Osteogenic sarcoma Ectopic ALP (Regan) ALP 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 Bowel infarction Complications of renal Tx Pancreatic trauma Inflammatory bowel disease Renal failure Pancreatic duct obstr Acute rejection of renal Tx Gastroenteritis Cholelithiasis Abdominal trauma Pancreatic Ca CBD obstruction Acute pancreatitis Pancreatic abscess Pancreatic pseudocyst Lipase 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 CK MD carriers Cocaine, heroin Hypothyroidism Post-seizures Parturition Myopathy (ßblockers, fibrates, statins, phenytoin, Li) Myositis Malignant hyperthermia Neuroleptic malignant syndr Muscular dystrophy Rhabdomyolysis 100 Subnormal Marginal 2´ Upper Limit of Normal 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 AST Sarcoidosis and infiltration GI malignancies CHF CVA Hyperthyroidism DM, DKA Alcoholic liver disease Chronic hepatitis Cirrhosis (1°, biliary) Liver mets Cholestasis, cholangitis Eclampsia (HELLP syndr) 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 ALT Post-prandial Physical training Phenothiazine B6 deficiency Daily alcohol use Statins Obesity Severe myopathy Resolving hepatitis 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 GGT Diabetes mellitus Hyperthyroidism Kidney disease Hyperlipidemia Fatty liver Drug OD Ca prostate Extrahepatic obstruction Alcohol use Obesity Drug induction Lung disease Familial RA Myocardial injury 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 ALP Diurnal variation Age Ketoconazole Hypophosphatasia Postprandial Drugs Intrahepatic biliary obstr Ethanol Estrogens Drugs – Li, phenobarb, phenytoin Osteomalacia Ambulation after immobiliz Pregnancy (3rd trimester) Infectious hepatitis Fanconi’s syndrome Hyperparathyroidism 쐌 쐌 쐌 Lipase Chronic pancreatitis DKA Opiates 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 쐌 CK Renal failure IM injections Surgery Macro CK Acute psychosis Drugs CK-BB – Ca UGS, gastrium; leukemia, lymphoma, sarcoma; severe brain injury Unaccustomed exercise Bruising Metabolic myopathy Persistent coughing FLUIDS (Ref: Glasser L, ed Kaplan/Pesce 1989) Pleural Fluids Physical Exudate Transudate Malignant Cloudy, clots Clear May be bloody > 1.015 < 1.015 SG pH Benign <6: leakage of gastric contents 7.4: not likely TB Protein (g/L) Fluid: serum ratio > 30 > 0.5 < 30 < 0.5 LD (U/L) Fluid: serum ratio > 200 > 0.6 Normal <0.6 Glucose (mmol/L) >7.3 in 50% of pts in 12% of pts ~ serum Synovial Fluid Normal Inflammatory Septic Volume (mL) 0.13-3.05 >3.5 >3.5 >3.5 Colour Clear, colourless Yellow–white Yellow–green Red–brown 2–100 10–>100 >5 >50 >75 >25 WBC (109/L) Neutrophils (%) Hemorrhagic Total Protein (g/L) 10.7-21.3 − − − − Glucose ~ serum <0.6 serum <0.6 serum ~ serum Negative Positive Negative Culture Cerebrospinal Fluid Cerebral infarction Hemorrhage Epilepsy Appearance Glucose Xanthochromic N Protein Bloody/xanthochr N N or N N N N / xantho N/¯ Fungal/bacterial inf N ¯ Viral infection N N N N/ CNS tumour Viral meningitis N N Xanthochromic N Hyperosmolar coma N N Hypoglycemia N ¯ N Trauma 101 102 Test Results Likely Diagnosis 쐌 쐌 PCT VP, HCP 쐌 VP, HCP 쐌 쐌 Plasma / Urine uroporphyrins EPP 쐌 PCT 쐌 쐌 VP, HCP Not EPP See above (fecal porphyrins) See above (Urine and plasma porphyrins) See above (fecal porphyrins) Erythrocyte fluorescence Feces: copro-I Urine: uro, heptacarboxyl-III, copro Plasma: heptacarboxyl-III See above (fecal porphyrins) Feces: copro (III>I) Feces: copro, proto, ± uro-I, copro (III>I) 쐌 쐌 쐌 AIP VP Feces: copro Feces: copro, proto HCP 쐌 In between attacks of HCP RBC: ¯ PBG deaminase RBC: ¯ PBG deaminase Urine: Uro-I, uro-III, copro-III, copro-I, hepta, hexa, penta 쐌 In between attacks of VP Further Testing/Confirmatory 쐌 쐌 In between attacks of AIP Not acute porphyria « Plasma / Urine uroporphyrins RBC protoporphyrin « RBC protoporphyrin PBG ALA PBG and ALA negative Hindmarsh JT et al. Clin Biochem 1999;32:609-19 AIP: acute intermittent porphyria, ALA: aminolevulinic acid; EPP: erythrocytic protoporphyria, HCP: hereditary coproporphyria, PBG: porphobilinogen, PCT: porphyria cutanea tarda, VP: variegate porphyria. Active skin lesions: erosions ± bullae Sun-induced urticaria or erythema Acute neurovisceral ± skin lesions Symptoms PORPHYRIA Investigation Abbreviation, Alternate names Abbreviations, alternate names 1,25 diOH D3 17 b-Estradiol 17-KGS 17-KS 17-OH P4 17-OH Prog 25OHD3 3'UTPT A1-AT, AAT ACE Acid serum ACRA ACTH ADH AFP Al ALP Alprazolam screen (urine) ALT Amitriptyline (quant) Amitriptyline screen AML1-ET Amobarbital screen (urine) ANA ANCA Angelman syndrome Anti-GBM Anti-HAV Anti-HBc Anti-Hbe Anti-HBs Anti-hemophiliac factor Anti-HIV 1, 2 Anti-HTLV-I/II Anti-TPO APC resistance APPT As ASO AST ATT B2GP1 Barbital screen (urine) BCL-IgH fusion genes BCR-ABL fusion gene Becker muscular dystrophy gene Beta-subunit BRCA gene BSAP BT Butabarbital screen (urine) C&S C1-INH C3 C4 See: Vitamin D, 1, 25 di-hydroxy Estradiol Not available Not available Hydroxyprogesterone Hydroxyprogesterone Vitamin D, 25-hydroxy Chromosomal studies (Appendix) Alpha-1 antitrypsin Comments 1, 25 di-hydroxyvitamine D3 17-ketogenic steroids 17-ketosteroids 17-hydroxy progesterone 17-hydroxy progesterone 25-hydroxyvitamin D3 Prothrombin gene Angiotensin converting enzyme Ham's test Anti-acetylcholine receptor antibodies Adrenocorticotropin Antidiuretic hormone, vasopressin Alpha-fetoprotein Aluminum Alkaline phosphatase Benzodiazepine Screen Alanine aminotransferase Tricyclic antidepressants quant Tricyclic antidepressant screen Chromosomal studies (Appendix) Barbiturates Screen Anti-nuclear antibodies Anti-neutrophil cytoplasmic antibodies Chromosomal studies (Appendix) Anti-glomerular basement membrane antibodies Serological tests Serological tests Serological tests Serological tests Factor VIII assay Serological tests Serological tests Anti-microsomal antibodies Activated Protein C resistence Partial thromboplastin time Arsenic Anti-streptolysin O antibodies Aspartate aminotransferase Anti tissue transglutaminase Anti-beta-2 glycoprotein I Barbiturates Screen Chromosomal studies (Appendix) Chromosomal studies (Appendix) Chromosomal studies (Appendix) Chorionic gonadotropin, beta subunit Chromosomal studies (Appendix) Alkaline phosphatase, bone specific Bleeding time Barbiturates Screen Cultures C1 esterase inhibitor Complement 3 Complement 4 Glomerular basement membrane antibodies Hepatitis A virus Antibodies Hepatitis B core antibody Hepatitis B e antibody Hepatitis B surface antibody Human immunodeficiency virus antibody Human T-cell lymphotrophic virus I, II antibody Activated partial thromboplastin time Beta-2 glycoprotein 1 Breast carcinoma Bone specific alkaline phosphatase Culture and sensitivities Abbreviation, Alternate names Abbreviations, alternate names Ca CA-125 cAMP Canavan disease Cannabis screen (urine) CBC CBFB-MYH11 fusion gene CCCG CD4 count CD4/CD8 ratio CEA CH100 Charcot Marie Tooth CK CK iso CK-MB Clomipramine (quant) Clomipramine screen Clot lysis time CMV Codeine Codeine screen (urine) COHb Conjugated bilirubin Connexin CPK CrCl CRP CsA CSF cTnT cTX Cystic fibrosis gene Cystinosis gene DAT Delta OD Depakene Desipramine (quant) Diazepam screen (urine) Dilantin Diphenhydantoin Doxepin (quant) dsDNA Duchenne muscular dystrophy gene E2 E2A-PBX1 fusion gene EBV ECC EG ENA ER-PR Ethanol, ETOH FBG Fe FEP See: Calcium Cancer Antigen 125 cyclic AMP Chromosomal studies (Appendix) Cannabinoid screen Complete blood count Chromosomal studies (Appendix) Creatinine clearance Flow cytometry Flow cytometry Carcinoembryonic antigen Complement, total hemolytic Chromosomal studies (Appendix) Creatine kinase Replaced by Troponin T Replaced by Troponin T Tricyclic antidepressants quant Tricyclic antidepressant screen Euglobulin Clot Lysis Cytomegalovirus Opiates Opiate Screen Carboxyhemoglobin Bilirubin, direct Chromosomal studies (Appendix) Creatine kinase Creatinine clearance C reactive protein cyclosporin A Cerebrospinal fluid Troponin T Telopeptides Chromosomal studies (Appendix) Chromosomal studies (Appendix) Direct antiglobulin test Amniotic fluid scan Valproate Tricyclic antidepressants quant Benzodiazepine Screen Phenytoin Phenytoin Tricyclic antidepressants quant Anti-dsDNA Chromosomal studies (Appendix) Estradiol Chromosomal studies (Appendix) Epstein-Barr virus Creatinine clearance Ethylene glycol Anti-ENA Estrogen-Progesterone receptors Ethyl Alcohol Fibrinogen Iron Free erythrocyte protoporphyrin Comments Creatinine clearance by Cockcroft Gault formula Total hemolytic complement Creatine kinase isoenzyme Creatine kinase - MB isoenzyme Creatine phosphokinase Cardiac troponin T c-telopeptides Change in OD at 450 nm Endogenous creatinine clearance Abbreviation, Alternate names Abbreviations, alternate names Fibrin stabilizing factor FISH FK506 FLM FNA Fragile X Fragmin Friedreichs Ataxia FSH FSHD FT3 FT4 G6PD GBM GC GGT GGTP Glycated Hb GTT H pylori Hb HbA1c HbA2 HBeAg HbF Hbg HbS HBsAg hCG HCV HCY HDLC HDV Hemochromatosis gene Hemoglobin Hemogram Hemophilia A factor Hemophilia B Hemophilia gene Hemophiliac inhibitor Heroin Heterophile antibodies HEV Hg hGH HIAA, 5HIAA HIT HIV HNPCC HVA Hydromorphone screen (urine) IBC iCa IFIX Ig See: Factor XIII Chromosomal studies (Appendix) Tacrolimus Fetal lung maturity Fine needle aspiration biopsy Chromosomal studies (Appendix) Anti-Xa Chromosomal studies (Appendix) Follicle stimulating hormone Chromosomal studies (Appendix) Triiodothyronine Thyroxine Glucose-6 phosphate dehydrogenase Anti-glomerular basement membrane antibodies Gonococcus Gamma glutamyl transferase Gamma glutamyl transferase Hemoglobin A1c Glucose Serological tests Complete blood count Hemoglobin A1c Hemaglobin Investigation Serological tests Hemoglobin Investigation Complete blood count Sickle Cell Screen Serological tests Chorionic gonadotropin, beta subunit Serological tests Homocysteine Cholesterol, High density lipoprotein Serological tests Chromosomal studies (Appendix) Complete blood count Complete blood count Factor VIII assay Factor IX Chromosomal studies (Appendix) Factor VIII or IX inhibitor Opiates Screen Infectious mononucleosis screen Serological tests Mercury Growth hormone Hydroxy-indole acetic acid Heparin induced thrombocytopenia Human immunodeficiency virus Chromosomal studies (Appendix) Homovanillic acid Opiate Screen Iron binding capacity Calcium, ionized free Immunofixation Immunoglobulin Comments Fluorescence in-situ hybridization Facioscapulohumeral muscular dystrophy Free triiodothyronine Free thyroxine Glomerular basement membrane Gamma glutamyl transpeptidase Glucose tolerance test Helicobacter pylori Hepatitis B e antigen Hemoglobin S Hepatitis B surface antigen Human chorionic gonadotropin Hepatitis C virus High density lipoprotein cholesterol Hepatitis D virus Hepatitis E virus Human growth hormone 5-hydroxy indole acetic acid Hereditary non-polyposis colorectal cancer Ionized calcium Abbreviation, Alternate names Abbreviations, alternate names See: IGF-1 Insulin-like growth factor 1 IgH (FR3) gene Chromosomal studies (Appendix) INR International normalized ratio IPS Maternal serum screening iPTH Parathyroid hormone Isopropanol Isopropyl alcohol Anti-extractable nuclear antigen antibodies Jo-1 K Potassium L/S ratio Not available, substitute with Fetal lung maturity LAP Leucocyte alkaline phosphatase score LATS Thyrotropin binding inhibitory immunoglobulin LC Light chains LD Lactate dehydrogenase LDH Lactate dehydrogenase LDLC Cholesterol, low density lipoprotein LH Luteinizing hormone Li Lithium LMWH Lp(a) Not available Marfan syndrome Chromosomal studies (Appendix) MCAD Chromosomal studies (Appendix) MEN2 Chromosomal studies (Appendix) Methanol Methyl alcohol MetHb Methemoglobin Mg Magnesium Monospot Infectious mononucleosis screen Monotest Infectious mononucleosis screen Morphine screen (urine) Opiate Screen MSS Maternal serum screening MTHFR Methylene tetrahydrofolate reductase MTX Methotrexate Muscular dystrophy gene Chromosomal studies (Appendix) Myotonic dystrophy Chromosomal studies (Appendix) Na Sodium NAP Leucocyte alkaline phosphatase score NAPA Procainamide Neurofibromatosis Type 1 Chromosomal studies (Appendix) NH3 Ammonia Nortriptyline (quant) Tricyclic antidepressants quant NPK-ALK fusion gene Chromosomal studies (Appendix) O fusion gene Chromosomal studies (Appendix) O2 sat Blood gases OB Occult blood OPMD Chromosomal studies (Appendix) Osmo Osmolality Oxazepam screen (urine) Benzodiazepine Screen Oxycodone screen (urine) Opiate Screen P4 Progesterone PA Procainamide Panel reactive antibody HLA antibody Paroxysmal Nocturnal hemoglobinuriaHam's test Pb Lead PBG Porphobilinogen PBG deaminase Porphobilinogen deaminase PE Protein electrophoresis Comments Integrated pregnancy screening Intact Parathyroid hormone Lecithin/sphingomyelin ratio Long acting thyroid stimulator Low density lipoprotein cholesterol Low molecular weight heparin Lipoprotein(a) Medium chain acyl-CoA dehydrogenase Multiple endocrine neoplasia 2 Neutrophil alkaline phosphatase score N-acetyl procainamide Hereditary neuropathy with pressure palsies Oxygen saturation Oculopharyngeal muscular dystrophy Abbreviation, Alternate names Abbreviations, alternate names Pentobarbital screen (urine) Phenobarbital screen (urine) PHLA PK PKD PML-RARA fusion gene PNH test PO4 PRA Prader Willi syndrome Prothrombin gene Prothrombin time Protriptyline (conc) Protriptyline screen PSA PT PTA PTH PTT RAST Retic count RF Rh D typing by PCR RNP Rothera's test Scl-70 Secobarbital screen (urine) Serax screen (urine) Serum lysis test SGOT SGPT Sickle cell disease SMA Smear Solubility test Somatomedin C SPE Spinocerebella ataxia SS-a/Ro SS-b/La T and B cell X-match TBG TBII TCA tCO2 TCR gene rearrangement TEL-AML1 fusion gene Temazepam screen (urine) TG Thalassemia THC Thyroid stimulating hormone TIBC Trimipramine (quant) Trimipramine screen See: Comments Barbiturates Screen Barbiturates Screen Lipolytic activity Post heparin lipolytic acitivity Pyruvate kinase Chromosomal studies (Appendix) Polycystic kidney disease Chromosomal studies (Appendix) Ham's test Phosphate Either: Panel reactive antibody or Plasma renin activity Chromosomal studies (Appendix) Chromosomal studies (Appendix) International normalized ratio Tricyclic antidepressants quant Tricyclic antidepressant screen Prostate specific antigen International normalized ratio Prothrombin time Factor IX Parathyroid hormone Partial thromboplastin time Radio-allergosorbent test Radioimmunosorbent test Reticulocyte count Rheumatoid factor Chromosomal studies (Appendix) Anti-extractable nuclear antigen antibodies Ribonuclear protein Ketones Anti-extractable nuclear antigen antibodies Barbiturates Screen Benzodiazepine Screen Ham's test Aspartate aminotransferase (AST) Serum glutamate-oxaloacetate transferase Alanine aminotransferase (ALT) Serum glutamate-pyruvate transferase Chromosomal studies (Appendix) Chromosomal studies (Appendix) Spinal muscular atrophy Film, blood Sickle Cell Screen Insulin-like growth factor 1 Protein electrophoresis Serum protein electrophoresis Chromosomal studies (Appendix) Anti-extractable nuclear antigen antibodies Anti-extractable nuclear antigen antibodies Flow cytometry Thyroxine binding globulin Thyrotropin binding inhibitory immunoglobulin Thyrotropin binding inhibitory immunoglobulin Tricyclic antidepressants Bicarbonate Total CO2 Chromosomal studies (Appendix) Chromosomal studies (Appendix) Benzodiazepine Screen Either: triglycerides or thyroglobulin Chromosomal studies (Appendix) Cannabinoid screen Tetrahydrocannabinoids Thyrotropin Iron binding capacity Total iron binding capacity Tricyclic antidepressants quant Tricyclic antidepressant screen Abbreviation, Alternate names Abbreviations, alternate names TSH TSI UA Valium screen (urine) Vasopressin Vitamin C VLCFA VLM VMA XTT Zn See: Thyrotropin Thyrotropin binding inhibitory immunoglobulin Urate Benzodiazepine Screen Antidiuretic hormone Ascorbic acid Fatty acids Human immunodeficiency virus Vanillylmandelic acid Xylose tolerance test Zinc Comments Thyroid stimulating hormone Thyroid stimulating immunoglobulin Uric acid Very long chain fatty acids Viral load monitoring Acknowledgements Contributors to the first edition (2000) and Peter Bunting, Susan Commons, Antonio Giulivi, Laurie MacDonald, Doris Neurath, Ruth Padmore, Baldwin Toye. This handbook is printed with partial support from Beckman Coulter Diagnostics, Canada