Anesthesia Laboratory Medicine

• 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

• 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

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)

M: 95-135ml/minF: 85-125ml/minRate of creatinine clearance from kidneysMeasure of GFRDecreases 10% per decade after 50yo<10ml/min = dialysis

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

Promotes gastric protection: + Gastric protection and - Gastric AcidPromotes platelet aggregation: + thromboxane formationPromote renal vasodilation: + renal prostaglandin formation

Promotes Renal Vasodilation: + Renal prostaglandin formationAdverse: Inflammatory, pain, and fever

• Decreased Effect of Anti-HTN and Diuretics: -GFR and + Renin Release
• Acute Renal Failure: ACEIs, ARBs, B-Blockers

• Prostaglandins: Vasodilation of Afferent Arteriole (+GFR)- Blocked by NSAIDs
• Angiotensin II: Vasoconstriction of Efferent Arteriole (+GFP)- Blocked by ACEIs, ARBs, and B-Blockers

• Cisatracurium: Hoffman Elimination
• Rocuronium: Hepatic Metabolism
• Vecuronium: 30% renal excretion
• Neostigmine: 50% renal excretion
• Edrophonium: 75% renal excretion

• 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

• 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

• Normal: 10-12 sec
• Half-Life: 6 hours
• Good qualitative indicator of liver function

• 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

• Normal: 90-240 U/dL
• Elevated: Obstructive liver/biliary disease, disease of rapidly growing bone, pregnancy,

• B: Elevated unconjugated
• AST/ALT: N
• Alk Phos: N
• Albumin: N
• PT: N

• 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

• B: Normal
• AST/ALT: Normal or slightly elevated
• ALP: Elevated over 4x (GGT, 5'N)
• A: Normal
• PT: normal

• B: Both elevated
• AST/ALT: moderate elevation
• ALP: Elevated over 4x
• A: Normal (unless chronic)
• PT: Normal/ prolonged

• B: Both elevated
• AST/ALT: Over 2x (suggestive), Over 3x (diagnostic)
• Alk Phos: Under 3x normal
• Albumin: Decreased 
• PT: Prolonged

• B: both elevated
• AST/ALT: Elevated <330 U/L
• Alk Phos:Elevated less than 3x normal
• Albumin: Decreased
• PT: Prolonged

• B: Both elevated
• AST/ALT: Elevated (ALT > AST)
• Alk Phos: Elevated less than 3x normal
• Albumin: N
• PT: Usually N

• 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.

Normal: 136-145mmol/L

• 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

• 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)

• Normal: 3.5-5 mmol/L
• Major Intracellular Cation

• 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

• 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)

• 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)

• 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)

• 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

• Blood: 5L
• Plasma: 3L
• Cells: 2L
• Cellular component: RBCs, WBCs, platelets
• Bone Marrow: cell production

• 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)

• 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)

• Normal(M): 45-52%
• Normal(F): 37-48%
• Percentage of RBC in plasma
• About 3x Hb

• Normal(M): 80-90
• Normal(F): 82-98
• Size of RBCs
• Normocytic: Acute Hemorrhage
• Macrocytic: B12 and Folic Acid Deficiencies
• Microcytic: Fe Deficiency, thalessemia

Normal: 27-31 picograms

Normal: 32-36%

• 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%)

• 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

• WBCs: < 4,000
• Secondary to viral infections, bacterial infections, bone marrow disorders, drugs
• WBCs < 500: risk of fatal infection

• 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)

• Normal: 1-4% of WBCs
• Associated w/ Antigen-antibody rxns
• Granulocytes
• Increased: Allergic rhinitis, asthma, drug hypersensitivity
• Decreased: corticosteroid use

• 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

• 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

• Normal: 2-8%
• Largest cells in blood
• Phagocytosis
• Produce: Interferon, IL-1, TNF, Growth factors, 
• Increased: TB, malaria, monocytic leukemia, ulcerative colitis, regional enteritis

Normal: 98-106 mmol/L

Normal: 20-29mmol/L

• Normal: 25-35 sec
• Intrinsic
• Factors I,II,V,VIII,IX,X,XI,XII
• heparin Increases

• Normal: 12-14 sec
• Extrinsic 
• Factors: I, II, V, VII, X (Vitamin K)
• Coumadin/Warfarin increases

• Normal: 0.8-1.2
• Warfarin Therapy Target: 2-3
• Compares PT from one lab to another

• 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

• Normal: 7.35-7.45
• Intracellular: 7.0-7.3

Normal: 35-45mm Hg

Normal: 80-100mm Hg

• 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

• 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,

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)

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.