Anesthesia Laboratory Medicine

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  1. Blood Urea Nitrogen (BUN)
    • Normal: 8-20mg/dL
    • Waste product from protein metabolism
    • Increased: Impaired Renal Function, Dehydration, CHF, AMI, high protein intake, GI blood
    • Decreased: Liver failure, malnutrition, over hydration, SIADH
  2. Serum Creatinine
    • Normal: 0.6-1.5mg/dL
    • Waste product of creatine phosphate in skeletal muscle
    • >2.0 = 50% nephron loss
    • >4.8 = 75% nephron loss
    • >10 = 90% nephron loss (ESRD)
    • Increased: Impaired renal function, chronic nephritis, muscle disease, CNF, shock
    • Decrease: Decreased muscle mass/ atrophy, inadequate dietary protein
  3. BUN/Creatinine Ratio
    Normal: 10-20:1Elevated: Resorption of Hematoma (increased protein), GI Bleed, obstructive uropathies, decreased tubular flow (CHF, cirrhosis, nephrotic syndrome)Normal: Dehydration (high values of both)
  4. Creatinine Clearance
    M: 95-135ml/minF: 85-125ml/minRate of creatinine clearance from kidneysMeasure of GFRDecreases 10% per decade after 50yo<10ml/min = dialysis
  5. Serum Osmolality
    Normal: 282-295mOsm/kgOsmotic concentration of fluid: dependent on active ions and moleculesIncreased: Renal disease, CHF, dehydration, diabetes insipidus, DM/hyperglycemiaDecreased: Sodium loss, SIADH, overhydration
  6. COX-1 Protective Effects
    Promotes gastric protection: + Gastric protection and - Gastric AcidPromotes platelet aggregation: + thromboxane formationPromote renal vasodilation: + renal prostaglandin formation
  7. COX-2 Protective Effects
    Promotes Renal Vasodilation: + Renal prostaglandin formationAdverse: Inflammatory, pain, and fever
  8. NSAID Drug Interactions
    • Decreased Effect of Anti-HTN and Diuretics: -GFR and + Renin Release
    • Acute Renal Failure: ACEIs, ARBs, B-Blockers
  9. Renal Blood Flow Regulation
    • Prostaglandins: Vasodilation of Afferent Arteriole (+GFR)- Blocked by NSAIDs
    • Angiotensin II: Vasoconstriction of Efferent Arteriole (+GFP)- Blocked by ACEIs, ARBs, and B-Blockers
  10. NMB & Reversal Agents
    • Cisatracurium: Hoffman Elimination
    • Rocuronium: Hepatic Metabolism
    • Vecuronium: 30% renal excretion
    • Neostigmine: 50% renal excretion
    • Edrophonium: 75% renal excretion
  11. Transaminases (ALT & AST)
    • ALT: 10-32 U/L
    • AST: 12-31 U/L
    • Over 100 U/L is significant
    • Released in response to injury
    • Does not predict severity of Liver disease
    • AST increased in skeletal/cardiac muscle injury
    • ALT is more specific for liver
  12. Albumin
    • Normal: 3.5-5.0 g/dL 
    • Half-life: 14-21 days
    • Indirect measure of  synthetic capacity
    • <2.5 d/dL may indicate severe disease
    • Low Albumin = more free drug
    • Low albumin: malnutrition, ascites, nephrotic syndrome
  13. Prothrombin Time
    • Normal: 10-12 sec
    • Half-Life: 6 hours
    • Good qualitative indicator of liver function
  14. Gamma-Glutamyl Transpeptidase (GGT)
    • Normal: 0-51 IU/L
    • Used for synthesis of Glutathione
    • Increased in alcoholism, phenytoin, and oral contraceptives
    • Sentitive to hepatocyte damage
    • Distinguish liver from bone disease when alkaline phosphatase is elevated
  15. Alkaline Phosphatase
    • Normal: 90-240 U/dL
    • Elevated: Obstructive liver/biliary disease, disease of rapidly growing bone, pregnancy,
  16. Hemolysis/Gilberts
    • B: Elevated unconjugated
    • AST/ALT: N
    • Alk Phos: N
    • Albumin: N
    • PT: N
  17. Acetaminophen Induced Hepatitis
    • N-acteyl-p-aminophenol
    • Analgesic and antipyretic
    • Poor anti-inflammatory
    • 5-10% converted to NAPQI (detoxified by glutathione)
    • NAPQI causes hepatic damage
    • CYP 2E1 & CYP 3A4 Dependent
  18. Infiltrative Disease
    • B: Normal
    • AST/ALT: Normal or slightly elevated
    • ALP: Elevated over 4x (GGT, 5'N)
    • A: Normal
    • PT: normal
  19. Obstructive Jaundice
    • B: Both elevated
    • AST/ALT: moderate elevation
    • ALP: Elevated over 4x
    • A: Normal (unless chronic)
    • PT: Normal/ prolonged
  20. Alcoholic Hepatitis/Cirrhosis
    • B: Both elevated
    • AST/ALT: Over 2x (suggestive), Over 3x (diagnostic)
    • Alk Phos: Under 3x normal
    • Albumin: Decreased 
    • PT: Prolonged
  21. Chronic Hepatocellular Disease
    • B: both elevated
    • AST/ALT: Elevated <330 U/L
    • Alk Phos:Elevated less than 3x normal
    • Albumin: Decreased
    • PT: Prolonged
  22. Acute Hepatocellular Disease
    • B: Both elevated
    • AST/ALT: Elevated (ALT > AST)
    • Alk Phos: Elevated less than 3x normal
    • Albumin: N
    • PT: Usually N
  23. Bilirubin
    • Normal: Total < 1.1 mg/dL
    • Jaundice: > 2 mg/dL
    • Breakdown product of heme, myoglobin, cytochrome enzymes
    • Unconjugated (Indirect) bilirubin to conjugated (Direct) bilirubin for urinary excretion
    • Unconjugated bilirubin can lea to encephalopathy.
  24. Sodium
    Normal: 136-145mmol/L
  25. Hyponatremia
    • Due to water retention or water intake exceeds kidney excretion
    • Extracelluler hypotonicity causes cerebral edema, +ICP, 
    • Usually seen with hypo-osmolality
    • Exceptions: Addition of osmotically active solute (mannitol, glucose, glycine) and pseudohyponatremia (solid phase of plasma is increased from hyperlipidemia or paraproteinemic disorder)
    • Tx: Loop diuretic, withhold water, hypertonic saline (3% NaCl) only if significant symptoms, slowly treat chronic hyponatremia to avoid side affects (demyelination, quadriplegia, seizures, coma, death), ACEi for patients with hypervolemia due to CHF
  26. Hypernatremia
    • Seen with hyerosmolality and causes cellular dehydration/shrinkage
    • S&S: restlessness, muscular twitching, hyperreflexia, tremors
    • Dehydration of brain cells (hemorrhage), capillary and venous congestion, and venous sinus thrombosis
    • Tx: Hypovolemic (water replacement), hypervolemia (loop diuretic or possibly hemodialysis), euvolemia (water replacement)
  27. Potassium
    • Normal: 3.5-5 mmol/L
    • Major Intracellular Cation
  28. Hypokalemia
    • Signs: Cardiac (dysrhythmias) and neuromuscular (muscle weakness, cramps, paralysis, and ileus)
    • Tx: serious signs require IV K, correct prior to surgery (especially with other risk factors for dysrhythmias such as CHF or digoxin)
    • Anesthesia: avoid further decreases in K which may be caused by Beta agonists, insulin, glucose, bicarbonate, and diuretics, or by hyperventilation and respiratory alkalosis; it may cause prolonged action of muscle relaxants
  29. Hyperkalemia
    • S/S: chronic hyperkalemia may cause general malaise and mild GI disturbances. Acute/significant increases manifest as cardiac and neuromuscular changes (weakness, paralysis, nausea, vomiting, and bradycardia/asystole). 
    • Tx: Immediately required if life-threatening dysrhythmias are present, CaCl2 or Ca-gluconate IV, K can be driven intracellularly by insulin, NaHCO3 and hyperventilation are adjuvant therapies, elimination of K by loop diuretic, saline infusion, or an ion exchange resin, dialysis if poor renal function
    • Anesthesia: Lower K immediately if surgery cannot be postponed, avoid succinylcholine, induction and maintenance drugs are okay, avoid respiratory or metabolic acidosis, IV fluids should be K-free (avoid lactated Ringer's and Normosol)
  30. Calcium
    • Normal: 9-11mmol/L
    • Regulated by PTH (increase bone resorption and renal tubular reabsorption), calcitonin (inhibits bone resorption), and vitamin D (augments intestinal absorption of Ca)
    • 1% of total body calcium is in the ECF (99% in bone)
  31. Hypocalcemia
    • Alkalosis reduces ionized Ca concentration 
    • S/S: CV and neuromuscular (paresthesia, irritability, seizures, hypotension, and myocardial depression)
    • Cause: PTH or Vitamin D disorders
    • Tx: IV Ca, may also have to replenish Mg, correct alkalosis, correct Ca before acidosis
    • Anesthesia: Minimize further Ca decrease (hyperventilation or bicarbonate may cause this), decrease in Ca due to massive transfusion of citrate containing blood)
  32. Hypercalcemia
    • Causes: Increased Ca absorption from GI, decreased renal excretion, and increased bone resorption
    • S/S: neurologic and GI (confusion, hypotonia, depressed deep tendon reflex, lethargy, abdominal pain, and nausea/vomiting)
    • Dx: hyperparathyroidism or cancer are common
    • Tx: Increase urinary Ca excretion and inhibit bone resorption/further GI absorption, 
    • Anesthesia: Restore Ca w/ IV volume and increase urinary excretion of Ca w/ loop diuretics (avoid thiazides), caution with NMBs
  33. Hematology Basics
    • Blood: 5L
    • Plasma: 3L
    • Cells: 2L
    • Cellular component: RBCs, WBCs, platelets
    • Bone Marrow: cell production
  34. RBC Count
    • Normal (M): 4.6-5.9x10^6/mm3
    • Normal (F): 4.2-5.4x10^6/mm3
    • Required for O2 and CO2 transport
    • Polycythemia: high altitude, athletes, COPD, cyanotic heart defect, polycythemia vera (PV)
    • Anemia: Secondary to decrease in number or Hb
    • Life Span: 4 months
    • Reticulocytes (immature): 0.5-1.5%(M); 0.5-2.5%(F)
  35. Hemoglobin (Hb)
    • Normal(M): 13-18g/dl
    • Normal(F): 12-16g/dl
    • Iron containing pigment (heme) bound to protein (global)
    • O2 carrying capacity proportional to Hb
    • Decreased Hb: RBC loss (blood loss, marrow suppression), Iron deficiency (hypo chromic)
  36. Hematocrit (Hct)
    • Normal(M): 45-52%
    • Normal(F): 37-48%
    • Percentage of RBC in plasma
    • About 3x Hb
  37. Mean Corpuscular Volume (MCV)
    • Normal(M): 80-90
    • Normal(F): 82-98
    • Size of RBCs
    • Normocytic: Acute Hemorrhage
    • Macrocytic: B12 and Folic Acid Deficiencies
    • Microcytic: Fe Deficiency, thalessemia
  38. Mean corpuscular hemoglobin (MCH)
    Normal: 27-31 picograms
  39. Mean corpuscular [Hemoglobin] (MCHC)
    Normal: 32-36%
  40. White Blood Cells (WBCs)
    • Total WBCs: 4000-10,000
    • Life Span: 13-20 days
    • WBCs fight infection: phagocytosis and antibodies (production, transport, and distribute)
    • Also called leukocytes
    • Destroyed in Lymphatic System
    • Immature cells called "bands" (3-5%)
  41. Leukocytosis
    • Increase in WBCs: Over 10,000
    • Neutrophilia, Basophilia, Eosinophilia
    • Lymphocytosis, monocytosis
    • Process: 1. Acute infection/trauma/inflammation, 2.Colony Stimulating Factor (CSF), 3. Bone Marrow stimulation
    • WBC> 30,000: Massive infection or leukemia
  42. Leukopenia
    • WBCs: < 4,000
    • Secondary to viral infections, bacterial infections, bone marrow disorders, drugs
    • WBCs < 500: risk of fatal infection
  43. Neutrophils
    • Normal: 50-70% WBCs
    • aka Polymorphonucleocytes (PMNs)
    • Granulocytes
    • Primary defense: infection/stress
    • Left shift: Acute bacterial infection an increased neutrophils
    • Neutropenia: Typhoid, TB, viral infection, drugs (TCAs)
  44. Eosinophils
    • Normal: 1-4% of WBCs
    • Associated w/ Antigen-antibody rxns
    • Granulocytes
    • Increased: Allergic rhinitis, asthma, drug hypersensitivity
    • Decreased: corticosteroid use
  45. Basophils
    • Normal: 0.5-1.0% of WBCs
    • aka Mast Cells (granulocytes)
    • Contain heparin, histamine, and 5-HT
    • Increased: Leukemia, Hodgkin's
    • Decreased: corticosteroid, allergic reactions, infection
  46. Lymphocytes
    • Normal: 25-40% WBCs
    • B-Lymphocytes: Antibodies (produced and mature in BM)
    • T-lymphocytes: T4 Helper, Killer, Cytotoxic, T8 suppressor (produce in BM & mature in thymus)
    • Increase: Virus, TB, Lymphocytic Leukemia
    • Decrease: AIDS, Corticosteroids, Drugs
  47. Monocytes/Macrophages
    • Normal: 2-8%
    • Largest cells in blood
    • Phagocytosis
    • Produce: Interferon, IL-1, TNF, Growth factors, 
    • Increased: TB, malaria, monocytic leukemia, ulcerative colitis, regional enteritis
  48. Chloride
    Normal: 98-106 mmol/L
  49. Bicarbonate
    Normal: 20-29mmol/L
  50. Partial Thromboplastin Time (PTT)
    • Normal: 25-35 sec
    • Intrinsic
    • Factors I,II,V,VIII,IX,X,XI,XII
    • heparin Increases
  51. Prothrombin Time (PT)
    • Normal: 12-14 sec
    • Extrinsic 
    • Factors: I, II, V, VII, X (Vitamin K)
    • Coumadin/Warfarin increases
  52. International Normalized Ratio (INR)
    • Normal: 0.8-1.2
    • Warfarin Therapy Target: 2-3
    • Compares PT from one lab to another
  53. Platelets
    • Normal: 150,000-300,000 cells/uL
    • Thrombocytopenia: <100,000 cells/uL
    • Surgical Hemostasis: >50,000 needed
    • Spontaneous bleeding: <20,000 cells/uL
    • Life span: 9-11 days
  54. pH
    • Normal: 7.35-7.45
    • Intracellular: 7.0-7.3
  55. Arterial Carbon Dioxide Tension (PaCO2)
    Normal: 35-45mm Hg
  56. Arterial Oxygen Tension (PaO2)
    Normal: 80-100mm Hg
  57. Glucose
    • Normal (resting): 70-110mg/dL
    • HbA1c: <5.6%
    • Pre-Diabetic: 5.7-6.4%
    • Diabetic: >6.4%
    • Estimates: 5%=100,6%=125,7%=150, 1%=25mg/dL
  58. Magnesium
    • Normal: 1.5-2.5mEq/L
    • Hypomagnesemia: Anticipated dysrhythmias, similar symptoms to hypocalcemia, avoid diuretics (Mg follows Na excretion)
    • Hypermagnesemia: S/S @4-5mEq/L, exacerbated by acidosis,
  59. Acidosis
    Major adverse effects at a pH < 7.2 include decreased inotropy which may be increased in patients with LV dysfunction or myocardial ischemia or with sympathetic impairment (B-blockers or GA)
  60. Alkalosis
    Major adverse effects at pH > 7.6. Reflect impairment of cerebral and coronary blood flow due to arteriolar vasoconstriction. Associated decreases in Ca contribute to neurologic abnormalities. Increase in ventricular dysrhythmias and depresses ventilation.

Card Set Information

Anesthesia Laboratory Medicine
2015-09-01 06:03:20
Labs Values

Arterial Blood Gas Values
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