‘An approach to Clinical chemistry Sujiva Ratnaike FRCPA Chemical Pathologist + Test information © Adberay sa” ptologt and sei palo fx mre vas iesigtons ase ony cepted tbeatrs they are area antes ereatereaured rer = cpherneet fran fating dusien **Doctr's name legible) shone/eager + Computer requesting Wilame soon hoptaly Pre- analytical + Time of dy fenton Pre- analytical ~ TermesPre-analytical + Site of collection ‘Muse stated as relerence ranges ier = Venous mast bloods ~ Atrial bod gases ~capilary:new bors, eel rick for blood gases ucose, iter paper blood spt fr screening sean atl Orson point fare POC) Ike fucose monitors * Never ever colic blood from dip nes fom arms Into which aii renning sample + Sin ie orf nes ‘Need for corect sample fem 8— 18 ‘mit 30-97 cam 02 mmo 210-240 ‘Analysis and Turn Around Times (TAT) for results °F eqn he ase A Pegi Se Spey Reports + Telephone / pager: = Fortes mated “urgent” rent ta ar ented as “ene for patent ~ fet the doctor hs marked “phone/eaelc™ with + Routine reports on paper and /or compute termina: = Segle or cumulative = incur unts and eferen “feat narma popuston) ~ interpretive comments ges of anaites (fora AssistanceLaboratory Responsibility and Laboratory Accreditation Clinician Responsibility + he requesting nian response = tobe thouetul ad sensible about the tests requested ~ for receiving and acting onthe resus received + tewould be wise t avid eaing send equst foams or anyone ee orequest tess which may not be appropiate Flow charts for diagnosis Tables of causesRemember Physiology What has happened here? it ——o eee oo) kK = So ‘ Sone a : Se + How Is this unequal balance maintained? hat Wath appre ee? Taser SErEeE Sse ‘The effect of uncomplicated Potassium depletion on ‘the plasma potassium concentrationDiagnosis Needs many diferent investigations —] agree of Hepatilary ncrtore ‘An abnormal test result: maybe due to ‘many diferent disorders + sedguapesmaicernh ort Tapa aoa | WATS OTT fhe: ris sex Ast yes | "meee late vans tae | = & mee re Sw og of oak fo Ss wm Oh SS 7 BS Sate Sy Patterns within a set of results Patterns within a set of results a ee eee ioPatterns within a set of results ema Su teen Onmein Ne on Patterns within a set of results Patterns within a set of results rae vote nt conn mat 30-37 te so 28-17 nn e. ae “hen 53 loosen ana > Patterns within a set of results few “a ” Patterns within a set of results = a wos tim Fa Patterns within a set of results and change with tine ‘and treatment mae te aa Grommet 209 tee tots 32 mm a7Patterns within a set of resus Patterns within a set of results and changes with time ea eee alae aca ‘and treatment ee ee annem San geo Foempaum te ae Patterns within a set of results: Unusual pattern Patterns in time Greene Mo Oh Sip kw i Pattern in timePatterns in tine Nature's relationships are continuous + Plot of moving averages of patent plasma FT4 and Tsitfrom the Austin Pathology data base Nature’s relationships are continuous + Plot of moving averages of Oral Glucose Tolerance Test {0GT)Yastng plasma glucose and gleated haemoglobin {rom the Aust Pathology data base =) Nature's relationships i Sot tose ate [ ceuanath ==="Sodium and water balance Sujiva Ratnaike To remind you. Water is + eae aman = 270% man 2 Sop mexptwoner = 30 6089 woman Distribution: 8 tarred earcer (reese we) Fluid gain: 1 oad rd t= 2a hsp eta and a Fluid toss: Une = 15 fo, ork 150-300 Sart = ty owen 71) * SEeta cone heme 1 PEE ta ame Ogi ts ttn "Te Kidney and water hora ration aC) 804 5 inn rere Sr nari nae aa St) eng te rts ater AP, ne Taner ino permanente sro om pcre get Tt sano nat npemeate ste ‘St emuront ve enc vote ase) Cctear terete nes ‘span eA? age marae ‘omnes sorcerer ot sa ta wea Ae osstrn noa conelatd nne coty or Son mcg as te, ey an a ig Sere ‘Hormonal Control of body water: The renin angiotensin system and ‘nt drei hermane (ADM) ‘so known 35 Arginine vasopressin (AVP) a ono romana cw 7 cmeeton tres ey Ieee re 99voume Norma ood volume in a tes ov pacwoens ‘ase bed. ‘rine snopes Sense Low effective blood volume Effective blood volume Noel blood volume in neem vselor volume Smaller load volume in normal ‘asta bed Tow effective blood Low effective blood volume: vasodilatation Effects of a low effective blood volume + Increases tubular sodium absorption = Low fractional excretion of socum (FEN) = tow urine Na <10 mmol. + Increases tubular rea absorption = High ureazereatinine ration plasma Notes Fractal extn out has ese aed SAD tesa by aes ‘Some definitions, Osmolality : mOsm/Ky “= Measured by the laboratory in pasma and urine + Major contour anaiyts in plasma? naval para oemaly 280 300 most + Major coniutor in urine ? ‘one ome Mma = SO moENKS sma = 1200 msm Digression + oblgitery volume of urine = 500 mi Neetu ‘Maximum out put of urine = 121 = E00 meonnySome definitions © Osmolarity mmol/L ~ Colulates fr plasma inthe ward as 1.86 (Na*) + urea + glucose mmol. * Osmolar gap = Norma: Osmelaty ~esmelarty 15, increased if unmeasured analyte 9, ebcohol ethylene glycol oers Some definitions : Hyperosmolalty and hypertonicity ‘Gonos wes srtcoescar "iOS a Seca crn St un 5 mal ok coat "seni ta eto amt mans Rice os ‘Approach and Investigations + The tory and examination are most inprtart Wi often mace the cause. * is best blood and une samples for vestigation are taken Before intervention, + Suggested intial investigations: = Plasma : UEC, glucose and osmolality = Urine Na", creBtnine ane osmalaity Pseudohyponatraemia 1 aetact of measurement + Pasa usuay assured tobe equivalent to plasma water Pasa has protein and pi but usually amounting to <7% in volume (we Ignore) ‘= tfhigh plasma tpi or protein fet 02715 hn a Do mma mere a lm acy exit rt chao ont me oom ne + Plasma osmolalty not afectes + heck soclum on tood gas analyser. Measurement based ion acy of Na: not aected by ip rete Hyponatraemia with Normo or hyperosmolality + ug aetna a mate oc + Ieee ato ype sate whee ater “rates he Fed, + Tecate eect gets fe peat ivimelt “Cortes Rem mene Ws gues S5I.5¢ + ower n hypeoums date: sates some eect ‘ear person. tie hyperremmarcometd fa volane mtb mine. Sena NEM 73209804 Investigation of Hypo-osmolar hponatraemia «© Suspected polyipsia Urine osmolality < 150 mosm/L urine Na >20 mmol/L. #9. Psychogenic polyipsia ‘Beer potomania ‘ Normal persons can handle up to 12 L water without water intoxication.Investigation of Fypo-osmolar hyponatremia i Afi Hyponatraemia : drug and hormone effects + Gucoceninis defeiney ‘Goer anc cons of OM seen Smo wr permit of cig a + Hypethyrien * ohcton roa Suacwse oe rma avy ADK (Cause of Hypernatraemia ‘Commonest cause by far: dehydration whatever ls Water deprivation le Water loss Renal Concentration defect ie Sg geen, mart ‘Seaton |. arr less ommecoans |. Skin oss ‘Sodium and water balance in the elderly “ena mass of nephrons and hence GFR decreased “lity to excrete water oad impares ‘+ Tubular concentrating abityimpatred: egos ADH sestity Mery erst toy ‘Reduction in renal capacty to retain sodium + Plasma renin aby and aldosterone reduced ‘Test mechanism impaired ' May not have access to water Salt and water balance the elderly (cont.) * Hyponatraemia (<130 mmol/L) ‘common in the aged (711%) {Common in hogpal up to 50%) Prolonged use of diuretic @ common cause * Hypernatraemia (>150 mmol/L) 19% of elery subjects Decreases acces o water ini ot patents Loss due to fever osmotic duress | ‘Symptoms of hyponatremia Depend on sve and apy of fl of plasma som She n0-0s mat ase {Lower wes bade aus mae 1 apy ever th foe <0 rmoU > pnb sere cona 1 omese dit cues eer aon, 1 Shut sag i reac pres; hain possi, smote Adaptation Sty evatoghypnacena 1 an shodsorne he CP pies st at 1 Few smetoms‘Symptoms of hypernatremia + set and ore ceases >160 mea: ante et sore, ‘Sears song, mse meknes, onc + tana sen > voc nce "+ Tt may be abet fo commit: tered metal as, (hea moe + fpr a niger moat han hypenaeni Special sitatons + eur npg becae of Otte Ii (tl renege Correction of hypo and hypernatremia comection of hyponatremia. Grenier the bin natn ay preps a ono emeiation Corie mela) feared to ‘any * Sago: cone < Set 4a man orecton of hypernatremia ‘pen eth ten cn cota ey (etaing br mano + Langer er unknown ation, owe fa (03 mean et >12 tyes rao ono oa Name : Willam Sex M Age 37 Ward sus» + be 2406 sample oe 120, deloces maf ser setae Secon aru sare Ss ramam 4234 Irma 35-80 Otome bo frat 52107 Peatonte 24 ret 22-30 re 2 inmat 25~75 amenat: sage paerc Name : Louis Sex M Age 47 Ward 3 stn ‘O20 sae 1 Phama/soram mts at ge Sean be mot 13515 recum mat Giowe mot Bearonte 25 moot ve ue ral Cems 70 snail rte 7 ra) are 2» at 35-50 Femara 57-0968) “ Name : Kate Sex F Age 23 Ward emeseny sae Oa * Piaama/serum nts fe nge Sxn 120 mel 135-148 reason 52 Tame 35-50 Shore iret 92-107 exons Inmet 22-30 ‘ea femal 25-75 Cre ort 50-110 ose 3 mate 36-55 Oaenity ‘moan 20-300 Sedu re 30-300 Ormoainy Imani 100-1400 Name Marina Sex F Age 40 y Ward : Emerg cor * ee = * meName Bab Sex F Age 49. Ward ICU Name : Thelma Sex F Age 65 Ward 5 axsaosy om om 9g psa /serum mts Re ge Son ww rot 15-18 hone ° rot 82-107 Seanmmte 27 rma 22-30 Ue 18 Imma 25-75 Cestore 190 Crore 59-110 Guese 3 rat 35-55 nay mos 280-300 + spoturine eau 0 rest 30-300 Osnaty ‘moana 100-1680 Name Joy SexF Age 45. Ward Emery ne rene ns ewan = a "a 3s Name : Hazel Sex F Age 79 Ward certs pram serum nts Ra ge Sadun ma pat 15 15 Foam 42 rime 35-50 Chee ~ rot 92= 107 Crate 0 ret 50-10 Gono 23 somal 36-55 Gmociry 25 mos 20300 + speturne _—_ oem 100-400 Name Christina Sex F Age 69Y — Ward7 + ome 16051705 1805 1905 Tove 15350610 OWS IS Sei NSE 35m Ss roman 28 32 42 43 mall 35-50 Sone” 102 S02 105 mod 2-107 Recents 9M meal 2230 Wer Gd 18 4 56 moll 28-75 Cene "2&8 98 mat 50 Ho 36 O61 08S 0m molt G70-10 cote att rot Name : Robert Sex M Age 81 Ward enegeey some O88 1 sma /serum vate ge Seen pt ret 8S fami 48 forall 35-50 Remnonte sma 22-30 Cenore 155 molt 50-10, omony ‘moan 20-300, Seen rma 30-300 matty oem 80100Name Edna Sex Foye 7Oy Wards Name Carolyn Sex F Age27y Ward ICU ae ee eT + one ye yon 98 + Plasma serum ts et ope psa /serum ots Re age Ses tae 152ml 55 Seaun 54 156 mmol 135-145 remum 39 4534 mm 35-50 Poasium 30 41 malt 35-50 Clone 6 root 92107 Ones 12 Tomei 82-107 Beare 25 mt 2-30 Newer 16 16 ‘remy 22-30 ver as 2385 mel 25-75 re a 33 mall 25-75 Crnoone m0 m0 oma S00 Crate 7 malt 50-110 See "9 malt 38-55 cuore Th meal 36-8 ety = soem 280-500 Omouity 35 rome 280 300 + Oe + spot urine Sedu a0 mmol 30-300 Seu <0 rrmott_ 30-300 may me snosnitg 100 smote Py poem 300-100 References + Sng 6 Arena BH Ru an Exc rans Harz Prep ial Mle 17 Eton 208 + eas a sores Soom nce BH) Sooereres ‘+ Se and ans Doge ard Harggoant of ingore es Coen Open Swe 1+ 4. Ferate W ot a) Cn Encino Metab 2008;9(8):2981- $7