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Result Authorisation – Correct or Not? Julie RYAN FAACB Chair SRAC AACB Healthscope Pathology
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Background Information Staff Result Validation Training in Biochemistry Competancy evaluation Process of Continuing Education Welcome
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Pre Analytical Issues Analytical Issues Post analytical Issues Focus on Potassium el al Plan of Action
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Right result Right Sample Right Patient Right Time Result Authorisation
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Patient Identifiers Sample Identifiers Sample Suitability Test suitability Pre Analytical Requirements
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Example 1 75 y o female, in ward. Date: 4,12 4,12 4,12 Time 03:00 06:00 08:35 Sodium 139 87 138 (135 - 145) mmol/L Potassium 3.4 2.0 3.8 (3.5 – 5.2) mmol/L Chloride 102 58 100 (101 - 110) mmol/L Bicarbonate 26 17 25 (22 - 35) mmol/L Urea 9.3 5.8 8.4 (3.5 - 10.0) mmol/L Creatinine 119 71 115 (40 - 85) umol/L Sample collected from IV site ? Dextrose infusion
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Example 2 45 y o male, in ward. Date: 27,3 27,3 26,3 Time 11:36 08:55 18:35 Sodium 137 135 138 (135 - 145) mmol/L Potassium 5.4 5.5 3.8 (3.5 – 5.2) mmol/L Chloride 102 105 100 (101 - 110) mmol/L Bicarbonate 31 23 25 (22 - 35) mmol/L Urea 11.0 8.7 8.4 (3.5 - 10.0) mmol/L Creatinine 78 51 115 (55 - 110) umol/L eGFR 79 >90 63 ml/min/1.73m2 Calcium 2.15 2.03 2.25 (2.10 – 2.60)mmol/L Magnesium 0.81 0.57 0.87 (0.70 – 1.10)mmol/L Phosphate 0.73 0.56 1.11 (0.80 – 1.40)mmol/L Albumin 24 16 26 (35 – 50) g/L Sample collected from IV site. Hb Change from 143 to 109 g/L also.
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Example 3 86 y o male, in ward. Date: 5,12 5,12 5,12 Time 23:00 06:54 02:24 Sodium 137 142 (135 - 145) mmol/L Potassium 4.8 3.7 (3.5 – 5.2) mmol/L Chloride 111 115 (101 - 110) mmol/L Bicarbonate 17 20 (22 - 35) mmol/L Urea 4.9 6.9 (3.5 - 10.0) mmol/L Creatinine 80 111 (55 - 110) umol/L Calcium 2.02 1.84 1.77 (2.10 – 2.60)mmol/L Magnesium 1.24 3.79 0.73 (0.70 – 1.10)mmol/L Phosphate 0.88 0.65 0.86 (0.80 – 1.40)mmol/L Albumin 28 19 23 (35 – 50) g/L Sample collected from IV site Mg infusion
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Example 4 59 y o male, in ward. Date: 21,11 Time 13:31 Sodium 164 (135 - 145) mmol/L Potassium >30.0 (3.5 – 5.2) mmol/L Chloride 151 (101 - 110) mmol/L Bicarbonate 4 (22 - 35) mmol/L Urea >107 (3.5 - 10.0) mmol/L Creatinine >1000 (55 - 110) umol/L Sample specimen check - Urine
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Example 5 64 y o Female, in ward. Date: 14,04 Time 11:22 Sodium 125 (135 - 145) mmol/L Potassium 7.2 (3.5 – 5.2) mmol/L Chloride 94 (101 - 110) mmol/L Bicarbonate 22 (22 - 35) mmol/L Urea 6.1 (3.5 - 10.0) mmol/L Creatinine 61 (40 - 85) umol/L TProtein 49 (60 – 80) g/L Albumin 28 (35 – 50) g/L Haemolysis 1+ Icterus 0 Lipaemia 3+ Sample specimen check – Intralipid Infusion
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Example 6 55 y o male, in AE Date: 14,4 Time 11:23 Sodium 143 (135 - 145) mmol/L Potassium 4.0 (3.5 – 5.2) mmol/L Chloride 109 (101 - 110) mmol/L Bicarbonate 28 (22 - 35) mmol/L Urea 5.2 (3.5 - 10.0) mmol/L Creatinine 59 (55 - 110) umol/L Calcium 2.10 (2.10 – 2.60)mmol/L Magnesium 0.69 (0.70 – 1.10)mmol/L Phosphate 0.87 (0.80 – 1.40)mmol/L Albumin 38 (35 – 50) g/L Sample issue ?
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Example 7 15 y o Female, in AE. Abdominal Pain Date: 11,03 Time 14:15 Sodium 138 (135 - 145) mmol/L Potassium 10.7 (3.5 – 5.2) mmol/L Chloride 105 (101 – 110) mmol/L Bicarbonate 28 (22 - 35) mmol/L Urea 2.9 (3.5 - 10.0) mmol/L Creatinine 57 (40 - 85) umol/L Glucose 2.6 (3.5 – 8.0) mmol/L Calcium 2.43 (2.10 – 2.60)mmol/L Albumin 28 (35 – 50) g/L BhCG <2.0 (0 – 5.0) IU/L Haemolysis 1+ Icterus 0 Lipaemia 0
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Example 8 41 y o Female, in AE. Date: 15,12 Time 03:10 pH 7.13 (7.35 – 7.45) pCO2 24 (35 – 45) mmHg pO2 33 (101 – 110 mmol/L Bicarbonate 8 (22 - 35) mmol/L Sodium 138 (135 – 145) mmol/L Potassium 4.5 (3.5 – 5.20 umol/L Chloride 111 (101 – 110) mmol/L Glucose 27.0 (3.5 – 8.0) mmol/L Cooximetry no results Sample specimen check – Lipaemic Sample
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Example 8 41 y o Female, in AE. Date: 15,12 Time 03:10 Sodium 133 (135 - 145) mmol/L Potassium 4.2 (3.5 – 5.2) mmol/L Chloride 104 (101 - 110) mmol/L Bicarbonate 8 (22 - 35) mmol/L Urea 4.2 (3.5 - 10.0) mmol/L Creatinine 81 (40 - 85) umol/L TProtein 46 (60 – 80) g/L Albumin 36 (35 – 50) g/L Haemolysis 1+ Icterus 0 Lipaemia 4+ Sample specimen check – Lipemia
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Order of Draw Correct Tube use Site of Collection Sample Mixing Post Collection Sample Collection
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Sample Tube Result Variation
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Due to Instrument Failure Due to Sample preparation issues Due to Calibration issues Due to QC issues Analytical Issues
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Example 1 49 y o Female, in AE. Date: 29,01 29,01 Time 10:01 09:38 pH 7.43 7.75* (7.35 – 7.45) pCO2 43 19 * (35 – 45) mmHg pO2 63 42 * (101 – 110 mmol/L Bicarbonate 28 26 (22 - 35) mmol/L Sodium 118 118 (135 – 145) mmol/L Potassium 3.2 3.2 (3.5 – 5.20 umol/L Chloride 82 82 (101 – 110) mmol/L Glucose 6.2 6.8 (3.5 – 8.0) mmol/L Lactate 4.2 3.6 (<1.3) mmol/L iCalcium 1.07 1.22 (1.15 – 1.27)mmol/L Sample speciman check – * Clot Detected in Sample
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Example 2 81 y o Male, in AE. Date: 30,11 30,11 Time 00:40 03:46 pH 7.33 7.30 (7.35 – 7.45) pCO2 37 36 (35 – 45) mmHg pO2 18 35 (101 – 110 mmol/L Bicarbonate 20 18 (22 - 35) mmol/L Sodium 137 137 (135 – 145) mmol/L Potassium 4.7 4.3 (3.5 – 5.20 umol/L Chloride 103 107 (101 – 110) mmol/L Glucose 24.1 18.9 (3.5 – 8.0 mmol/L Lactate 4.9 6.2 (<1.3) mmol/L Haemoglobin 107 122 (117 – 174) g/L Haematocrit 32 37 Sample Speciman check – Mixing of Sample
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Example 3 66 y o Female, in ICU. Date: 01,03 01,03 Time 17:54 07:56 pH 7.34 7.42 (7.35 – 7.45) pCO2 29 38 (35 – 45) mmHg pO2 74 50 (101 – 110 mmol/L Bicarbonate 16 25 (22 - 35) mmol/L Sodium <100 145 (135 – 145) mmol/L Potassium 2.5 3.9 (3.5 – 5.20 umol/L Chloride 65 116 (101 – 110) mmol/L Glucose <0.2 9.4 (3.5 – 8.0) mmol/L Lactate 0.9 1.7 (<1.3) mmol/L Haemoglobin 100 130 (117 – 174) g/L Sample Speciman check – Gas taken from IV site
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Example 4 86 y o male, in ward. Date: 03,06 03,06 Time 23:00 10:45 Sodium 133 (135 - 145) mmol/L Potassium 4.4 (3.5 – 5.2) mmol/L Chloride 98 (101 - 110) mmol/L Bicarbonate 28 (22 - 35) mmol/L Urea 5.4 (3.5 - 10.0) mmol/L Creatinine 59 (55 - 110) umol/L Calcium 2.34 1.57 (2.10 – 2.60)mmol/L Magnesium 0.82 (0.70 – 1.10)mmol/L Phosphate 0.98 (0.80 – 1.40)mmol/L Albumin 37 41 (35 – 50) g/L Instrument Error. Sample Repeated
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Example 5 42 y o Male, in ICU. Date: 21,01 21,01 21,01 Time 01:56 01:49 01:33 pH 7.28 7.25 7.25(7.35 – 7.45) pCO2 41 43 43(35 – 45) mmHg pO2 121 132 140(101 – 110 mmol/L Bicarbonate 19 19 19(22 - 35) mmol/L Sodium 134 134134(135 – 145) mmol/L Potassium 6.6 6.66.9 (3.5 – 5.20 umol/L Chloride 109 105 108(101 – 110) mmol/L Glucose 15.1 16.2 16.7(3.5 – 8.0) mmol/L Lactate 6.5 7.0 7.6(<1.3) mmol/L Haemoglobin 110 111 110(117 – 174) g/L Blood Gas Repeated ? Why
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Example 5 42 y o male, in ICU. Date: 21,01 21,01 21,01 Time 01:30 22:30 20:15 Sodium 140 138 139 (135 - 145) mmol/L Potassium 7.0 4.7 4.7 (3.5 – 5.2) mmol/L Chloride 109 111 105 (101 - 110) mmol/L Bicarbonate 20 15 23 (22 - 35) mmol/L Urea 8.8 7.9 9.0 (3.5 - 10.0) mmol/L Creatinine 148 140 152 (55 - 110) umol/L eGFR 39 42 38 ml/min/1.73m2 Calcium 1.83 1.60 (2.10 – 2.60)mmol/L Magnesium 0.63 0.61 (0.70 – 1.10)mmol/L Phosphate 2.19 1.92 (0.80 – 1.40)mmol/L Albumin 21 9 31 (35 – 50) g/L Post AAA Transfusion Packed Cells.
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15/09/2010 Results as follows: Digoxin3.1nmol/L(0.6 – 1.0) 16/09/2010: Digoxin>7.5nmol/L(0.6 – 1.0) Rx with Digibind Example 6
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Reference Intervals Reporting Format Collection Details Post Analytical Issues
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Example 1 81 y o Male, in ICU. Date: 30,01 30,01 30,01 30,1 Time 13:56 12:49 10:33 09:43 pH 7.15 7.19 7.19 7.25(7.35 – 7.45) pCO2 30 34 42 35 (35 – 45) mmHg pO2 249 114 24 106(101 – 110 mmol/L Bicarbonate 10 13 16 15(22 - 35) mmol/L Sodium 131 132137 135(135 – 145) mmol/L Potassium 7.5 6.85.2 4.9 (3.5 – 5.20 umol/L Chloride 107 106 109 109(101 – 110) mmol/L Glucose 17.4 16.1 13.1 13.2(3.5 – 8.0) mmol/L Lactate 6.9 4.6 4.0 3.9(<1.3) mmol/L Haemoglobin 92 106 84 87 (117 – 174) g/L Blood Gas Repeated Note pH K Lactate & Hb changes
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Example 2 81 y o male, in ICU. Date: 27,06 27,06 26,06 Time 23:50 03:50 20:15 Sodium 148 144 149 (135 - 145) mmol/L Potassium 3.6 4.0 4.3 (3.5 – 5.2) mmol/L Chloride 106 105 110 (101 - 110) mmol/L Bicarbonate 28 26 24 (22 - 35) mmol/L Urea 6.3 6.6 6.3 (3.5 - 10.0) mmol/L Creatinine 112 90 114 (55 - 110) umol/L eGFR 79 >90 63 ml/min/1.73m2 Calcium 2.23 2.27 2.05 (2.10 – 2.60)mmol/L Magnesium 0.72 1.28 0.74 (0.70 – 1.10)mmol/L Phosphate 0.83 0.93 1.93 (0.80 – 1.40)mmol/L Albumin 47 43 38 (35 – 50) g/L Report Printed 27,06 09:55
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Example 2 81 y o male, in ICU. Date: 27,06 26,06 26,06 Time 03:50 23:50 20:15 Sodium 144 148 149 (135 - 145) mmol/L Potassium 4.0 3.6 4.3 (3.5 – 5.2) mmol/L Chloride 105 106 110 (101 - 110) mmol/L Bicarbonate 26 28 24 (22 - 35) mmol/L Urea 6.6 6.3 6.3 (3.5 - 10.0) mmol/L Creatinine 90 112 114 (55 - 110) umol/L eGFR >90 79 63 ml/min/1.73m2 Calcium 2.27 2.23 2.05 (2.10 – 2.60)mmol/L Magnesium 1.28 0.72 0.74 (0.70 – 1.10)mmol/L Phosphate 0.93 0.83 1.93 (0.80 – 1.40)mmol/L Albumin 43 47 38 (35 – 50) g/L Report in Correct order
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Pre Analytical Issues Important Analyte Critical values Potassium
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Venepuncture technique Sample Container appropriate Transport at correct temperature Storage at correct temperature Pre analytical Issues K
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Due to Instrument Failure Due to Sample preparation issues Due to Calibration / QC issues Due to Patient Conditions Analytical Issues K
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Example 1 79 y o male, in AE. Date: 7,06 21,05 20,05 Time 09:50 13:50 10:15 Sodium 137 142 145 (135 - 145) mmol/L Potassium 7.9 4.4 4.3 (3.5 – 5.2) mmol/L Chloride 107 106 110 (101 - 110) mmol/L Bicarbonate 19 31 29 (22 - 35) mmol/L Urea 3.2 3.8 3.3 (3.5 - 10.0) mmol/L Creatinine 75 70 114 (55 - 110) umol/L Calcium 2.24 2.21 2.15 (2.10 – 2.60)mmol/L Magnesium 1.75 0.78 0.74 (0.70 – 1.10)mmol/L Phosphate 1.80 1.22 1.13 (0.80 – 1.40)mmol/L AST 56 23 33 (35 – 50) g/L HAEMOLYSED 4+
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Example 2 80 y o male, in AE Date: 15,10 Time 07:23 Sodium 150 (135 - 145) mmol/L Potassium 9.7 (3.5 – 5.2) mmol/L Chloride 114 (101 – 110) mmol/L Bicarbonate 19 (22 - 35) mmol/L Urea 42.2 (3.5 - 10.0) mmol/L Creatinine 386 (55 - 110) umol/L Calcium 2.19 (2.10 – 2.60)mmol/L Magnesium 1.18 (0.70 – 1.10)mmol/L Phosphate 3.58 (0.80 – 1.40)mmol/L Albumin 33 (35 – 50) g/L CRP 125.4 (<8) mg/L Haemolysis 3+ Sample Intravascular Haemolysis and Renal Impairment. Hb drop from 105– 64g/L
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Example 3 43 y o male, in ICU. Date: 21,01 20,01 Time 01:01 23:38 pH 7.25 7.10 (7.35 – 7.45) pCO2 43 42 (35 – 45) mmHg pO2 382 503 (101 – 110 mmol/L Bicarbonate 19 13 (22 - 35) mmol/L Sodium 134 134 (135 – 145) mmol/L Potassium 6.9 4.3 (3.5 – 5.20 umol/L Chloride 108 108 (101 – 110) mmol/L Glucose 16.7 22.2 (3.5 – 8.0) mmol/L Lactate 7.6 10.9 (<1.3) mmol/L Haemoglobin 110 68 (115 – 170) g/L Patient Post Transfusion
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Example 4 80 y o male, in AE Date: 16,02 Time 09:23 Sodium 144 (135 - 145) mmol/L Potassium 6.6 (3.5 – 5.2) mmol/L Chloride 112 (101 – 110) mmol/L Bicarbonate 20 (22 - 35) mmol/L Urea 33.4 (3.5 - 10.0) mmol/L Creatinine 276 (55 - 110) umol/L eGFR 18 ( >90 ) Calcium 2.19 (2.10 – 2.60)mmol/L Phosphate 2.58 (0.80 – 1.40)mmol/L Albumin 29 (35 – 50) g/L CRP 461 (<8) mg/L WCC 176.0 ( 4.0 – 11.0) x10^9/L Sample High WCC. Serum Used
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Example 7 48 y o Female, in AE. Muscle Weakness Date: 28,08 Time 08:55 Sodium 139 (135 - 145) mmol/L Potassium 1.8 (3.5 – 5.2) mmol/L Chloride 104 (101 – 110) mmol/L Bicarbonate 22 (22 - 35) mmol/L Urea 0.4 (3.5 - 10.0) mmol/L Creatinine 91 (40 - 85) umol/L Calcium 1.83 (2.10 – 2.60)mmol/L T Protein 49 (60 – 80) g/L Albumin 23 (35 – 50) g/L Lactate 9.3 ( 0.5 – 2.2) IU/L Haemolysis 0 Patient with Anorexia Nervosa
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Example 8 52 y o Female, in AE. Date: 26,08 Time 09:55 Sodium 125 (135 - 145) mmol/L Potassium 2.0 (3.5 – 5.2) mmol/L Chloride 74 (101 – 110) mmol/L Bicarbonate 35 (22 - 35) mmol/L Urea 3.8 (3.5 - 10.0) mmol/L Creatinine 68 (40 - 85) umol/L T Protein 57 (60 – 80) g/L Albumin 30 (35 – 50) g/L T Bilirubin 30 ( <18 ) umol/L GGT 391 ( <40 ) U/L Haemolysis 0 Patient with Vomiting
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Urine Spot Na <10 mmol/L K 7.0 mmol/L Cl <15 mmol/L Example 8
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Presentation a first look at Issues in Authorisation Provide some guidance about the common pitfalls of result verification Comparison with healthy patient results an invaluable tool Understanding of the processes involved in result production in the Biochemistry Laboratory All working towards: Final Comments
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Right result Right Sample Right Patient Right Time Final Comments
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Many thanks to the numerous people who have assisted in training Biochemists throughout the industry This includes representatives from the RCPA, AACB, various companies who produce and maintain the complex instrumentation used, and also the Educational Institutions providing graduates to staff Laboratories All invaluable to the Industry Acknowledgements
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