Dr. Irwan. Nilai Kritis

07-May-14

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Critical Value in

Clinical Chemistry

Irwan Idris

Nilai Kritis

adalah suatu hasil pemeriksaan lab

yang abnormal dan mengindikasikan

kelainan atau gangguan yang dapat

mengancam jiwa dan memerlukan

perhatian/ tindakan

PEDOMAN INTERPRETASI

DATA KLINIK KEMENKES 2011

07-May-14

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A Critical Value

Is defined as a value that represents a patho-

physiological state at such variance with

normal (expected values) as to be life-

threatening unless something is done

promptly and for which some corrective

action could be taken

Mayo clinic 2012

Regulation of Critical Values

The Joint Commission National

Patient Safety Goals

Documentation & read back

Define Critical Values and Critical Tests

CAP Checklists

Procedure, documentation, read

back, turnaround times

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Patient Safety

No Hospital Delayed (admin, nursing and Lab)

Stat test (TAT < 1 hour)

Report Critical Value Immediately

Regarded as Stat test (PIK Hospital)

New In-Patient

Emergency room

ICU & NICU

Test Result Depend on :

Patient Factor

Pre-analytical Variation

Biological Variation

Interference substances (HIL/metabolic

component)

Medicine

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Test Result Depend on :

Good Laboratory Practice

Quality Management System

Test Method

Reagent

Analytic variation < (good precision)

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Reference Range

Method

Reagent

Race

Age

Time of specimen collection

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Cirlulation 2011:124:2350-54

Cirlulation 2011:124:2350-54

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Cirlulation 2011:124:2350-54

System Causes of Troponin Elevation

Cardiovascular Acute aortic dissection , Arrhythmia, Hypotension

Heart failure, Hypertension

Cardiac inflammation

• Endocarditis, myocarditis, pericarditis

Infiltrative disease

• Amyloidosis, sarcoidosis, hemochromatosis, scleroderm

Myocardial Injury

Blunt chest trauma

Cardiac procedures

• Ablation, cardioversion, percutaneous intervention

Chemotherapy

Respiratory Acute PE , ARDS

Infectious/Immune Sepsis/SIRS , Viral illness, TTP

Gastrointestinal Severe GI bleeding

Nervous system Acute stroke (Ischemic stroke/ Hemorrhagic stroke)

Head trauma

Renal Chronic kidney disease

Endocrine Diabetes , Hypothyroidism

Musculoskeletal Rhabdomyolysis

Integumentary Extensive skin burns

Cardiac Biomarker,

September 8, 2010

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Critical Values – Current Issues

Communication

Contacting licensed caregiver (dr/nurse)

Hand offs of critical information

Documentation

TAT

Employee time (technologists & caregivers)

Laboratory Medicine of

Emory University

Critical Values – Current

Issues (2)

Defining Cutoff values

How are they currently determined ?

Are they appropriately chosen to reflect a

true critical situation

Should we have site /service specific

values ?

Laboratory Medicine of

Emory University

07-May-14

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How are critical cutoffs

determined ?

Medical Practice Committees

Experience

Usually represent diverse group of physicians with

unique perspectives

Specific clinical needs: eg. Special Programs

Understand the resources and limitations of the

system

Value: Clinician perspective

Caveat: “Critical” can become courtesy

Laboratory Medicine of

Emory University

Best Strategy for Determining Critical

Level

Compare to peers

Literature

Local, national

Medical input

Service groups

Medical Practice Committee

Laboratory Medicine of

Emory University

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Laboratory Medicine of

Emory University

Laboratory Medicine of

Emory University

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Standardization

Setting Limits (peer, local, national) Great start, need MPC input

Use Standard Templates Critical results called to and read back by ______ Date____

Time_____ by lab personnel _______.

Attempted to call critical result to ______ @______

Date____ Time_____ by lab personnel _______.

This template can be helpful for call times documented (time spent by staff)

Can not give up on the call, need clear escalation policy Laboratory Medicine of

Emory University

A Critical Value

Validation the result (I and II level)

In patient

Inform the user (doctor, nurse)

Record the name of doctor or nurse in charge

Repeat the result by user

PIK Hospital

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A Critical Value (2)

Out Patient : Inform the doctor

Record the name of doctor

Repeat the result by user

Walk in Inform the patient

Record patient’s name

Repeat the result by patient

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Souce Result Ref. Range

RNICU/3010 Hemoglobin 6.10 g/dL LL 14-20

UGD-N Sodium (Na) 110.0 mmol/L LL 135 - 150

UGD-N pH 7.008 LL 7.38 - 7.44

UGD-N pCO2 5.5 mmHg LL 35 - 40

UGD-N HCO3 1.4 mmol/L LL 21 - 28

UGD-N Random Glucose 515.0 mg/dL HH 70 - 140

DIA-N Creatinine serum 22.3 mg/dL HH 0.8 - 1.5

RG6 Amonia 326.0 umol/L HH 11.0 - 32.0

ICU1/3002 Chloride (Cl) 120.2 mmol/L HH 98 - 107

ICU1/3001 Troponin I 1.03 ng/mL HH < 0.10

UGD-N Potasium (K) 1.3 mmol/L LL 3.5 - 5.0

RG5/7508 WBC 0.87 Th/uL LL 4.1-10.9

UGD-N Random Glucose 34.0 mg/dL LL 70 - 140

ICU1/3003 APTT 122.0 Second HH 30 - 44

ICU1/3002 Natrium (Na) 115.4 mmol/L LL 135 - 150

Parameter Critical Value Note

Ammonia > 100 mg/dl (59

mmol/l)

Risk of hepatic encephalopathy.

Comatose states do not usually occur

unless levels exceed 300 mg/dl (176

mmol/l).

Anion gap > 20 mmol/l. Indicative of ketoacidosis or

lactacidosis, uraemia, alcohol

consumption, salicylate intoxication,

poisoning from methanol or ethylene

glycol

Bilirubin > 15 mg/dl (257

mmol/l)

Hepatobiliary disease caused mainly by

hepatotropic viruses and thus of

infectious origin with risk of contagion.

Inorganic

phosphate

< 1.0 mg/dl

(0.32mmol/l)

> 9.0 mg/dl (2.9

mmol/l)

Muscle weakness, muscle pain, central-

nervous symptoms such as

disorientation, confusion, convulsions,

coma, respiratory insufficiency with

metabolic acidosis.

Occurs in acute tumour lysis syndrome

and in terminal renal failure.

eJIFCC:www.ifcc.org/ejifcc

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ANALYTE CRITICAL VALUES

Blood Gases, Adult

pH

pCO2

pO2

<7.20 or >7.58

<9 or >65 mmHg

<40 mmHg

Calcium, ionized <0.78 or >1.58 mmol/L

Calcium, total <6.0 or >13.0 mg/dL

Carbon Dioxide (Total) <10 or >40 meq/L

Glucose

Newborn (under 30 days old)

Adult

1. <40 or >200 mg/dL

2. <45 or >500 mg/dL

Glucose, CSF <20 mg/dL

Glucose, POCT

Newborn Adult

1. <50 or >200 mg/dL 2. <50 or >500 mg/dL

Magnesium <1.2 or >4.7 mg/dL

Osmolality < 250 or >350 mOsm/kg

Phosphate <1.0 mg/dL

Potassium <2.5 or >6.0 meq/L

Sodium <120 or >160 meq/L

Sodium, CSF <120 or >160 meq/L

Troponin I ≥0.40 ng/mL (first critical value per 48 hour period for each patient)

Dept of Lab. Medicine Washington Edu 2012

Conclusion

Determine Parameter and Cutoff for

Critical value should be :

Collaboration with medical staff (doctor & nurse)

Test method

Reagent

Compare to peers

Literature

Local, national

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Conclusion

Standard procedure to inform Critical

Value :

Procedure

Documentation

Read back

Turnaround times

Thanks you

For your attention